Systematic Physical Assessment
On this page
Direct answer
Order matters in physical assessment: except over the abdomen, every region is examined by inspection, palpation, percussion and auscultation, in that sequence, moving head to toe (cephalocaudal) so nothing is omitted. The abdomen reverses the middle steps — inspect, then auscultate, then percuss and palpate — because palpating first stimulates peristalsis and alters the bowel sounds you are about to hear. Assessment is continuous and comparative, side against side, performed with the health history in hand, and scaled to the situation: a comprehensive admission head-to-toe, a focused recheck or an emergency rapid survey. Before touching the patient: explain, identify yourself, provide privacy and draping, warm your hands and instruments and ensure good light.
What you must remember
- The four techniques: inspection (look before you touch, in good light), palpation, percussion, auscultation — the abdomen alone swaps to inspect-auscultate-percuss-palpate.
- Percussion notes: resonance over normal lung, hyperresonance in emphysema and pneumothorax, tympany over air-filled bowel (the normal abdomen), dullness over the liver, pleural fluid and consolidation, flatness over muscle and bone.
- Palpation depths: light palpation to about 1 centimetre for skin, tenderness and superficial masses; deep palpation to about 4 centimetres, bimanual if needed, for organs and deep masses.
- Stethoscope halves: diaphragm for high-pitched sounds (breath sounds, S1-S2, bowel sounds), bell for low-pitched ones (S3, diastolic murmurs, bruits).
- Types of assessment: complete or comprehensive (admission), focused or problem-centred, episodic or follow-up, shift assessment, and the emergency primary survey.
- Preparation courtesies: expose only the area being examined, keep the patient warm and draped, use standard precautions, and examine the painful area last.
- Chaperone rule: a chaperone is provided for breast, genital and rectal examination — and whenever the patient requests one — with its presence documented.
- Compare sides: every finding is judged against the opposite side; asymmetry, not the absolute finding, raises the flag.
Walking an admission head-to-toe
Admission of a 40-year-old with uncontrolled diabetes. The general survey begins while you take the history — level of consciousness, speech, posture, hygiene, nutrition, distress: inspection of the whole person before any region. Then systematically: head (skull, hair, face), eyes (conjunctiva for pallor, pupils and reactions), mouth and throat; neck (lymph nodes, thyroid, jugular veins); chest — inspect the breathing pattern, palpate for tenderness and expansion, percuss for the note, auscultate vesicular breath sounds and any crackles; heart — inspect for scars and oedema, palpate the apex beat, auscultate S1 and S2. At the abdomen the order flips: inspect, auscultate bowel sounds patiently (absence needs several minutes of listening), percuss for shifting dullness, then palpate lightly before deeply. Finish with limbs (pulses, oedema, calf tenderness), a brief neurological screen, and — because the admission reason demands it — a monofilament foot examination for peripheral neuropathy. Document immediately; the examination is only as good as its record.
Where marks are lost
Two slips dominate. First, the abdominal order — palpating before auscultating — which MCQs frame as "which technique comes second over the abdomen" (auscultation). Second, matching percussion note to tissue: tympany belongs over air-filled bowel, dullness over liver and fluid, resonance over lung, hyperresonance over a pneumothorax or emphysematous chest; the exam application is dullness at a lung base signalling effusion or consolidation. Remember also that the painful area is examined last, and that a patient in pain or distress earns a focused examination now and the full survey later — technique never overrides tolerance.
Frequently asked questions
Why is the abdominal examination order different?
Inspect, auscultate, percuss, then palpate: palpation and percussion stir peristalsis, so listening first preserves the true bowel sounds.
Which percussion note is expected over a normal lung?
Resonance; hyperresonance suggests emphysema or pneumothorax, while dullness points to consolidation or pleural fluid.
How deep is light palpation?
About one centimetre, for skin texture, tenderness and superficial masses; deep palpation reaches about four centimetres for organs and deep masses.
When is a chaperone required during examination?
For breast, genital and rectal examination, whenever the patient requests one, with the chaperone's presence documented.
What are the main types of health assessment?
Complete (admission), focused or problem-centred, episodic follow-up, shift and emergency assessments — chosen by the clinical situation.