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Physical Examination Guide: ❖ In internal medicine you are going to be asked to do one of the following:
1. Respiratory exam: either anterior chest or posterior chest.
Contents: 2. Precordium exam.
3. Abdominal exam.
 Introduction……………………. 2 4. Maybe Hand and Neck examination.
 Anterior chest…………………. 3
 Posterior chest……………….. 4 ❖ The physical examination part of the OSCE exam is about 5-7 minutes, if you
 Precordium…………………..... 5 was practicing well during the rounds, you can finish it in about 3
 Abdomen………………………. 6 minutes & spend the rest of the time chatting with the examiner.
 Neck……………………………… 9 ❖ In the exam the patient will have findings, so be prepared & don't rush
 Hand…………………………… 9 the examination results as you memorized the normal results from your
 Summary…………………………11 studying.
❖ The examiner will focus on the technique & that you did all the steps,
Introduction: also the findings will have so little marks on them & will be easy to
identify (ex: wheezing, pansystolic murmur, prosthetic valve click,
❖ Before you start the physical examination you must address the organomegaly). So it’s gonna be easy to find (we are still 4th year
following: students not specialists).
1. Introduce yourself & take permission.
2. Ensure proper Patient privacy. (Also, hand washing, room lighting ✓ Remember inspect, palpate, percuss, auscultate and report findings.
& temperature…. etc.) ✓ Also remember that during examination speak while you do the
3. Proper position and exposure. (explained later by system) examination steps to let the examiner notice what you’re doing.
✓ In real life hand hygiene is a top priority before & after examining ( ‫الدكاترة بمتحنوا كثير طالب وممكن يكونوا تعبانين وما يركزوا معك لكل الخطوات‬
the patient. ‫عشان هيك حاول وانت تشتغل تحكي اشي بسيط عن الي بتعمله وبدون ما يوخذ منك وقت‬
‫)هيك بتضمن العالمة ان شاء هللا‬
❖ HOW do you introduce yourself & take permission?
▪ Eng: Hello I am Mohammad a 4th year medical student, would you allow
me to examine you.
‫ مرحبا انا محمد طالب طب سنة رابعة تسمحلي افحصك‬:Ara
✓ Notes:
- in the exam, there are 2 marks on introduction & permission so
make it a part of your practice during the rounds, so that you
don’t forget it.
- In exam (say it for letting the examiner know you’re
systematic): there is a good privacy, and proper lighting.

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Respiratory system: d) Chest expansion (must be symmetrical with at least 5 cm
expansion).
Anterior chest: e) Tactile vocal fremitus.
1. Introduce yourself & take permission. ✓ For the inspection at the right side to say there is no visible
2. Ensure patient privacy. pulsations you have to look from the same level of his chest, you
3. Position the patient at 30-45° angle & expose him above the
can’t say while standing you must lean down. ( ‫بالعربي قرمز مشان تقدر تشوف‬
umbilicus or above the waist. ‫)أي نبضات عصدر المريض‬
What to say in the exam: ✓ Also, don’t forget while inspecting scars
I will position the patient in the middle of the bed at 30-45° degree. to check under axilla for any later
thoracotomy scars or previous chest tube
4. Inspection: scars.
a) At the foot of the bed: chest symmetry & deformity.
Chest deformities examples: barrel shaped (COPD), pectus
excavatum, pectus carinatum.
b) At the right side: scars, skin lesions, dilated veins, visible
pulastions.
c) Respiratory rate & signs of respiratory distress.
▪ Respiratory rate can be taken from foot of the bed or from
the right side while distress signs from the right side.
(source: internal resident)
▪ Signs of distress: tachypnoea, using of accessory muscles, - Tracheal position: Gently place the tip of your right index finger into
retractions, cyanosis, audible wheezes or stridor without the suprasternal notch and palpate the trachea. This can be
uncomfortable; be gentle and explain what you are doing. (2 or 3
stethoscope. fingers method can be used)
d) Jugular veinous pressure. (if its elevated it’s a Pulmonary HTN - Chest expansion: Place your thumbs along each costal margin, your
sign.) hands along the lateral rib cage. As you position your hands, slide them
✓ Note: Mostly the examiner will tell to skip point "c and d " but you medially a bit to raise loose skin folds between your thumbs. Ask the
must mention it. patient to inhale deeply. Observe how far your thumbs diverge as the
thorax expands, and feel for the extent and symmetry of respiratory
5. Palpation: (start it by taking radial pulse and RR from right movement. (most used method by doctors & residents during my
side of the bed) rounds in internal)
a) Palpate the chest generally for any tenderness. (ask him for any - Tactile fremitus: use either the ball (the bony part of the palm at the
base of the fingers) or the ulnar surface of your hand. Ask the patient to
pain before you start). repeat the words ‫أربعة وأربعين أو تسعة وتسعين‬
b) Tracheal position (to detect Tracheal deviation). - Cricosternal distance and tracheal tug Dr.Momany said throw
c) Cardiac Apex beat (to detect lower mediastinal shift) &. (explained them to garbage.
in CVS)

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6. Percussion: b) Maintain quality & symmetry
a) Sites of percussion (bilateral) c) Comment on auscultation:
▪ Supra-clavicular area (lung apex) ▪ Air entry & its symmetry
▪ Lung fields anteriorly & laterally ▪ Vesicular or bronchial breathing
▪ Expiratory phase (Dr. Tareq Hmood said its important and
✓ Dr. Momany said its 6 points one for each the normal exp phase is 1/3 of the inspiratory phase, if its
lung lobe.. prolonged then there is problem)
▪ Added sounds (wheezing, crackles, pleural friction rub)
b) Maintain quality & symmetry: Examples:
▪ Quality: Strike the center of the middle phalanx of your left - In a normal patient you would comment: bilateral
middle finger with the tip of your right middle finger, using a symmetrical air entry, vesicular breathing, normal expiratory
phase with no added sounds.
loose "swinging movement of the wrist and not the forearm". - In an asthmatic patient: bilateral air entry, vesicular
▪ Symmetry: Percuss the anterior and lateral chest, comparing breathing, prolonged exp phase with expiratory wheezes heard
both sides. (remember you are always comparing both sides mostly over the left lung.
to find the abnormality..)
d) Vocal resonance:
How to comment on a normal patient? Normal Bilateral
resonant chest
▪ Ask the patient to repeat the words ‫أربعة وأربعين أو تسعة وتسعين‬
while you auscultate to assess the quality and amplitude of
vocal resonance.
✓ During percussion and 8. Cover the patient and thank him. (2 marks)
auscultation don’t forget the
lateral side to perform on it Posterior chest: same as anterior.
(ant or posterior chest in both
we do lateral side) as in the 1. Introduce yourself & take permission.
image here.. 2. Ensure patient privacy.
3. Position & exposure:
a) Exposure: same as anterior chest.
7. Auscultation: b) Position: the patient should be sitting upright; his arms should be
a) Listen to the chest anteriorly and laterally as the patient breathes folded across the chest with hands resting, if possible, on the
with mouth open, on the same areas of percussion. (mainly using opposite shoulders, this position swings the scapulae laterally and
Diaphragm of stethoscope except at the apex use the bell) increases access to the lung fields. (let him do this position when
you need to percuss and auscultate only..)
Listen: ✓ Note: ask the patient to sit at the side of the bed while you examine
- Anteriorly from above the clavicle down to the sixth rib.
- Laterally from the axilla to the eighth rib. him from the other side (back), but this is not always applicable, so
- Posteriorly down to the level of the 11th rib. just make him sit upright in the middle of the bed.

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4. Inspection: Cardiovascular system:
a) Symmetry.
b) Deformities: Spine: Kyphosis or scoliosis. Precordium:
c) Scars, skin lesions, dilated veins.
❖ A great rule for memorizing precordium examination steps is "3+3=6",
Normal patient: Symmetrical chest, no chest or spine deformities and no scars, it means 3 steps for inspection plus 3 steps for palpation and 6 steps for
skin lesions or dilated veins. auscultation. There is no percussion in precordium examination.
1. Introduce yourself, take permission & ensure privacy.
2. Position the patient at 45° angle & expose him above the waist.
3. Inspection: (3 steps)
a) Chest symmetry.
b) Chest deformity.
c) Scars (name, site) & visible pulsations also any cyanosis signs.
4. Palpation: (3 steps)
a) Apex beat & its position.
b) Parasternal heaves.
c) Thrills.
5. Palpation:
a) Palpate the chest generally for any tenderness.
b) Chest expansion (must be symmetrical with at least 5 cm expansion)
c) Tactile vocal fremitus.

6. Percussion: (make him cross arms to percuss the intrascapular region)

▪ Percuss lung fields posteriorly & laterally, maintaining quality &
symmetry.
7. Auscultation:
▪ Listen over the same areas of percussion. - Apex beat: Locate it by lying your fingers on the chest parallel to the rib
a) Maintain quality & symmetry. spaces; if you cannot feel it, ask the patient to roll on to his left side.
Once you have found the apical impulse, make finer assessments with
b) Comment on the auscultation. your fingertips, and then with one finger then locate it. The apex beat is
c) Vocal resonance. normally in the fifth left intercostal space at, or medial to, the mid-
clavicular line.
- Heaves: Apply the heel of your right hand firmly to the left parasternal
8. Cover the patient & thank him. area and feel for a right ventricle heave. Ask the patient to hold his
breath in expiration.
- Thrills: Palpate for thrills at the apex and both sides of the sternum using
the flat of your fingers.

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 How to comment on a normal patient?
- Symmetrical chest with no deformities, no scars, no visible pulsations.
- Apex beat is located at 5th intercostal space on the mid clavicular line.
- No heaves or thrills.
- Normal S1, S2 with no murmurs

Bell vs diaphragm
5. Auscultation: (6 steps)
The bell of the stethoscope is more effective at detecting low-frequency
a) 4 cardiac areas with the sounds, including the mid-diastolic murmur of mitral stenosis.
diaphragm.
b) 4 cardiac areas with the bell (you The diaphragm of the stethoscope is more effective at detecting high-
must show the examiner when you alternate between frequency sounds, including the ejection systolic murmur of aortic stenosis,
diaphragm and bell of your stethoscope).
the early diastolic murmur of aortic regurgitation and the pansystolic murmur
c) Radiation toward carotid of mitral regurgitation.
arteries. (aortic stenosis)
d) Radiation toward axilla.
(mitral regurgitation) Gastrointestinal system:
e) Roll the patient on to their left side. Listen at the apex using light
❖ Regarding the OSCE exam, the question won't be "do abdominal
pressure with the bell to detect the mid-diastolic murmur of
examination for this patient!!"… It will be for eg. "perform the
mitral stenosis
inspection phase for this patient, palpation or auscultation!!"
f) Ask the patient to sit up and lean forwards, then to breathe out
fully and hold his breath. Listen over the left sternal 3rd Abdominal examination:
intercostal space (Erb's point) (lower left sternal border (3rd/4th intercostal space))
with the diaphragm for the murmur of aortic regurgitation. 1. Introduce yourself, take permission & ensure privacy.
2. Position the patient comfortably supine with the head resting on only
one or two pillows to relax the abdominal wall muscles. Expose him
from nipple to mid-thigh.
3. Inspection:
a) At the foot of the bed:
1) Contour (flat, distended, scaphoid).
6. Cover the patient & thank 2) Symmetry.
him. 3) Movement with respiration.
4) Central inverted umbilicus.
b) At the right side of the patient:
1) Comment on everything you see (hair distribution, scars, dilated
veins, skin lesions, visible pulsations or peristalsis).
2) Inspect hernial orifices (ask the patient to cough).

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 ✓ Note: ▪ surface: smooth or irregular
o to see visible pulsations you should bend your knees. ▪ edge: smooth or irregular
o For any scar mention its name & site. ▪ Consistency: soft or hard
How to comment on a normal patient? ▪ tenderness
- Symmetrical flat abdomen, moves with respiration & a central inverted ▪ whether it is pulsatile.
umbilicus.
- Normal male/female hair distribution, no scars, no skin lesions, no dilated
✓ Note: normally, on inspiration liver edge is palpable 1-3 cm below
veins, no visible pulsation, no visible peristalsis. the costal margin in the midclavicular line. But don’t worry if you
- Intact hernial orifices. can't feel it.
4. Palpation: ❖ Percussion: (liver span)
a) Ask the patient if there is any painful area. 1) Percuss downwards from the right 2nd intercostal space in the mid-
b) Superficial palpation, observing the patient’s face (eye contact) for clavicular line, listening for the dullness that indicates the upper
any sign of discomfort throughout the examination. Begin with light border of the liver.
superficial palpation away from any site of pain, using the palm of 2) Percuss upward from the right iliac fossa until you reach the
your hand not the finger tips. dullness.
c) Deep palpation. 3) Measure the distance between the 2 points. (Normal liver span 6-12
d) Organomegaly: cm).
1) Liver (liver edge + liver span)
2) Spleen Splenomegaly examination:
3) Both Kidneys 1) Place your hand on the right iliac fossa. Keep your hand stationary
e) Palpate hernial orifices. (ask the patient to cough) and ask the patient to breathe in deeply through the mouth
2) Move your hand diagonally upwards towards the left
Hepatomegaly examination: hypochondrium 1cm at a time between each breath the patient takes.
3) Feel for the splenic edge as it descends on inspiration.
❖ Palpation: (liver edge) 4) If you cannot feel the splenic edge, ask the patient to roll towards
1) Place your hand flat on the skin of the right iliac fossa. you and on to his right side and repeat the above. Palpate with your
2) Some examiners like to point their fingers up toward the patient’s right hand, placing your left hand behind the patient's left lower ribs,
head, whereas others prefer a somewhat more oblique position, in pulling the ribcage forward.
either case, press gently in and up.
3) Ask the patient to breathe in deeply through the mouth. ✓ Note: normally spleen isn't palpable, unless it is 3 times larger than
4) Feel for the liver edge as it descends on inspiration. normal size.
5) Move your hand progressively up the abdomen, 1 cm at a time,
between each breath the patient takes, until you reach the costal
margin or detect the liver edge.
6) If you feel a liver edge, describe:
▪ Size

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Kidneys examination: Bi-manual examination a) Percuss from the midline out to the flanks. Note any change
from tympany to dull.
❖ Palpation of the Left Kidney: b) Keep your finger on the site of dullness in the flank and ask the
▪ Place your left hand behind the patient’s back below the 12th rib and patient to turn on to his opposite side.
your right hand anteriorly over the upper quadrant. Firmly, but c) Pause for 10 seconds to allow any ascites to gravitate, then
gently, push your hands together as the patient breathes out. Now, percuss again. If the area of dullness is now resonant, shifting
ask the patient to breathe in deeply, feel for the kidney moving down dullness is present, indicating ascites.
between your hands. If this happens, gently push the kidney back
and forwards between your two hands to demonstrate its mobility. 2) Transmitted thrill:
This is ballotting, and confirms that this structure is the kidney. a) Place the palm of your left hand flat against the left side of the
❖ Palpation of the Right Kidney: patient’s abdomen and flick a finger of your right hand against
▪ Use your left hand to lift up from the back, and your right hand to the right side of the abdomen.
feel deep in the right upper quadrant, proceed as before. b) If you feel a ripple against your left hand, ask the patient to place
the edge of his hand on the midline of the abdomen. This
prevents transmission of the impulse via the skin rather than
through the ascites. If you still feel a ripple against your left
hand, a fluid thrill is present.
✓ Note: transmitted thrill is only detected in gross ascites.

❖ In an adult, the kidneys are not palpable. A normal left kidney is rarely
palpable. However, a normal right kidney may be palpable, especially
when the patient is thin.
✓ Note: ballottement is done when you feel an enlargement or a mass
in the kidney.
5. Percussion:
a) General percussion of the abdomen. ( 9 regions of the abdomen)
b) Shifting dullness.
c) Transmitted thrill.

❖ Ascites:
1) Shifting dullness:

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6. Auscultation: Neck examination: The best source is this video, and I think its
a) Bowel sounds: place your stethoscope diaphragm to the right of the more than enough-> https://youtu.be/TL5dnlefRnc?si=W47T1NW1jPAOVee2
umbilicus. Listen for 1 minute (normally 3-15 sounds).
b) Aorta: listen above the umbilicus over the aorta for arterial bruits.
c) Renal arteries: listen 2–3 cm above and lateral to the umbilicus for Hand Examination:
bruits from renal artery stenosis.
d) Listen for bruits over the iliac arteries & the femoral arteries. 1. Introduce yourself & take permission.
e) Listen over the liver for venous hum & friction rubs. 2. Ensure patient privacy.
f) Listen over the spleen for friction rubs. 3. Position & exposure( Sitting and expose patient’s hands, wrist and
✓ Note: points "a, b, c" are the main steps, and what you are going to elbows). Put his hand on a pillow and let him relax them.
be asked to do mostly. 4. Inspection:
a) General inspection: Perform a brief general inspection of the
7. Genitalia & rectal examination:
▪ Just tell the examiner that you want to examine the genitalia & do patient, looking for signs suggestive of underlying pathology:
DRE. ✓ Scars: may provide clues regarding
previous upper limb surgery. (eg...carpal
8. Cover the patient & thank him. tunnel scar)

Example 1 of a normal patient:

✓ Wasting of muscles: suggestive of disuse
- Palpation: non tender soft lax abdomen, no hepatomegaly (liver edge not atrophy secondary to joint pathology or a
felt & the span is 8 cm), spleen & kidneys were not palpable. lower motor neuron lesion.
- Percussion: tympanic abdomen with no signs of ascites. b) Close inspection for the Dorsal aspect of the hand:
- Auscultation: active/audible bowel sounds, no aortic or renal bruits.
✓ Hand posture (e.g. Dupuytren’s contracture, ulnar deviation secondary to
Example 2 of a normal patient:
- Palpation: non tender soft lax abdomen, no hepatomegaly (liver edge is rheumatoid arthritis)
smooth and felt 2 cm below the costal margin & the span is 9 cm), spleen & ✓ Scars & swelling.
kidneys were not palpable. ✓ Deformities (Bouchard’s nodes, Heberden’s
- Percussion: tympanic abdomen with no signs of ascites. nodes, Z-thumb, Swan neck deformity,
- Auscultation: active/audible bowel sounds, no aortic or renal bruits. Boutonnières deformity)
✓ Skin & nail changes. (Skin thinning or bruises, Psoriatic plaques, splinter
hemorrhages, nail pitting, onycholysis)
✓ Muscle wasting
c) Close inspection for the Palmar aspect of the hand:
✓ Hand posture
✓ Scars & swellings (e.g.. carpal tunnel surgery).
✓ Dupuytren’s contracture (involves thickening of the palmar fascia,
resulting in the development of cords of palmar fascia).
✓ Janeway lesions

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 ✓ Osler’s nodes ✓ Palpate the anatomical snuffbox for tenderness which is
d) Elbows: inspect for evidence of psoriatic plaques or rheumatoid suggestive of a scaphoid fracture.
nodules. f) Palpate the flexor tendon sheeths in the hands and fingers to detect
local swellings & tenderness, also feel for thickning in the palmar
5. Palpation:
fascia.
a) Finger clubbing
6. Movement:
▪ The joints of the hand and wrist should be assessed and compared.
▪ If the patient is known to have an issue with a particular hand, you
should assess the ‘normal’ hand first for comparison.
a) Active movement.
✓ Finger extension: Instructions: “Open your fist and splay
your fingers.”
✓ Finger flexion: Instructions: “Make a fist.”
✓ Wrist extension: Normal range of movement: 90º |
b) Radial pulse: Rate, rhythm(regular/irregular), Instructions: “Put the palms of your hands together and
character(strong, weak). Do it for both sides.. extend your wrists fully.”
c) Temperature: Assess and compare the ✓ Wrist flexion: Normal range of movement: 90º | Instructions:
temperature of the joints of both of hand using the “Put the backs of your hands together and flex your wrists
back of both your hands. fully.”
d) Metacarpophalangeal joint squeeze: Gently b) Passive movement. Starts at 4:53 in the video below
squeeze across the metacarpophalangeal (MCP) c) Power of grip.
joints and observe for verbal and non-verbal
signs of discomfort. Tenderness is suggestive of ➢ See this video for the techniques:
active inflammatory arthropathy. (https://youtu.be/0TQkZwZ-xQE?t=221)
e) Bimanual joint palpation: Bimanually palpate Figure 1 Metacarpophalangeal joint squeeze
the joints of the hand, assessing and comparing d) Thumb opposition: essential for an effective pincer grip, is
for tenderness, irregularities and warmth: performed by instructing the patient to “Touch the tip of your
✓ Metacarpophalangeal joint (MCPJ) thumb to the tip of each of your fingers”. (demonstrate fine
✓ Proximal interphalangeal joint (PIPJ) motor function in the hand).
✓ Distal interphalangeal joint (DIPJ)
✓ Carpometacarpal joint (CMCJ) of the thumb (squaring of the 7. Cover the patient & thank him.
joint is associated with OA)

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Summary:
ANTERIOR CHEST
Introduce yourself & take permission
Position at 45° degree & expose above the waist
INSPECTION PALPATION PERCUSSION AUSCULTATION
1) At the foot of the bed: 1) Palpate the chest generally 1) Sites of percussion: Supra- 1) Listen to the chest anteriorly and
chest symmetry & for any tenderness. clavicular area, Lung fields laterally.
deformity. 2) Tracheal position. anteriorly & laterally 2) Maintain quality & symmetry
2) At the right side: scars, 3) Cardiac Apex beat. 2) Maintain quality & 3) Comment on auscultation: Air
skin lesions, dilated veins. 4) Chest expansion (must be symmetry entry, Vesicular or bronchial
3) Respiratory rate & signs symmetrical with at least 5 breathing, Added sounds
of respiratory distress. cm expansion). (wheezing, crackles, pleural
5) Tactile vocal fremitus friction rub).
4) Vocal resonance.

POSTERIOR CHEST
Introduce yourself & take permission
Position sitting upright & expose above the waist
INSPECTION PALPATION PERCUSSION AUSCULTATION
1) Symmetry. 1) Palpate the chest generally 1) percuss lung fields 1) Listen over the same areas of
2) Deformities: Kyphosis or for any tenderness. maintaining quality & percussion.
scoliosis 2) Chest expansion (must be symmetry. 2) Maintain quality & symmetry.
3) Scars, skin lesions, dilated symmetrical with at least 5 3) Comment on the auscultation.
veins. cm expansion). 5) Vocal resonance.
3) Tactile vocal fremitus

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 PRECORDIUM
Introduce yourself & take permission
Position at 45 degree & expose above waist.
INSPECTION PALPATION AUSCULTATION
1) Chest symmetry. 1) Apex beat & its position. 1) 4 cardiac areas with the diaphragm.
2) Chest deformity. 2) Parasternal heaves. 2) 4 cardiac areas with the bell.
3) Scars (name, site) & visible 3) Thrills. 3) Radiation toward carotid arteries. (aortic stenosis)
pulsations 4) Radiation toward axilla. (mitral regurgitation)
5) Ask the patient to roll to his left side; listen at the
apex with the bell for mid-diastolic murmur of
mitral stenosis.
6) Ask the patient to sit up and lean forwards, then to
breathe out fully and hold his breath. Listen over
the left sternal 3rd intercostal space (Erb's point)
with the diaphragm for the murmur of aortic
regurgitation.

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 ABDOMEN
Introduce yourself & take permission
Position supine & expose from nipple to mid-thigh
INSPECTION PALPATION PERCUSSION AUSCULTATION
1) At the foot of the bed: 1) Ask the patient if there is any 1) General percussion of the 1) Bowel sounds.
Contour (flat, distended, painful area. abdomen. 2) Aorta.
scaphoid), Symmetry, 2) Superficial palpation. 2) Shifting dullness. 3) Renal arteries.
Movement with 3) Deep palpation. 3) Transmitted thrill 4) iliac arteries & the femoral
respiration & Central 4) Organomegaly: Liver,,Spleen arteries
inverted umbilicus. & Both Kidneys 5) Liver & spleen.
2) At the right side: 5) Hernial orifices
Comment on everything
you see (hair distribution,
scars, dilated veins, skin
lesions, vis- ible
pulsations or peristalsis)
& Inspect hernial
orifices.

‫تم بحمد هللا‬ Done by:

‫محمد جرادات‬
‫فادي الغزاوي‬
‫عُال بني عامر‬
‫مصعب ح ّماد‬

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