2.2 Physical Assessment

The Four Techniques and the Abdominal Exception

Physical examination uses four techniques, generally in this fixed order: Inspection, Palpation, Percussion, Auscultation (IPPA).

• Inspection always comes first — look before you touch: symmetry, color, contour, movement, wounds
• Palpation assesses temperature, texture, moisture, tenderness, masses, crepitus, and organ size; use light palpation (about 1 cm) before deep palpation (about 4 cm), and palpate tender areas last
• Percussion elicits tones: resonance over air-filled lung, hyperresonance over hyperinflated lung (COPD, pneumothorax), dullness over consolidation or fluid (pneumonia, pleural effusion), flatness over bone or muscle, tympany over the air-filled stomach
• Auscultation with the stethoscope diaphragm for high-pitched sounds (breath sounds, normal heart sounds, bowel sounds) and the bell for low-pitched sounds (S3/S4 gallops, mitral stenosis murmur, bruits)

The abdomen is the one exception: inspect, then auscultate, then percuss, then palpate. Palpation and percussion before auscultation can stimulate or quiet the bowel and falsely alter bowel sounds. Document bowel sounds as absent only after listening for 5 full minutes; hyperactive high-pitched tinkling suggests early obstruction, while a silent abdomen late in obstruction or peritonitis is ominous. A similar logic applies to the painful or injured area: assess it last.

Vital Signs: Normal Ranges and Abnormal Patterns

Pain is routinely assessed as the 'fifth vital sign.' Fever patterns carry diagnostic meaning: sustained/continuous (stays elevated, minimal fluctuation — typhoid, pneumococcal pneumonia), intermittent (returns to normal at least once daily — abscess, some sepsis), remittent (fluctuates but never normalizes — infective endocarditis), and relapsing/recurrent (febrile episodes separated by days of normal temperature — malaria, Pel-Ebstein fever of Hodgkin lymphoma). Clinical pearl: temperature rises about 0.5-1°C from morning to evening, and an absent fever does not exclude sepsis in older adults or immunocompromised patients — hypothermia can be a sepsis sign.

Orthostatic Vitals and Pulse Pressure

Orthostatic (postural) vital signs evaluate volume status. Technique: the patient rests supine for 5 minutes, then measure BP and pulse; have them sit or stand and remeasure at 1 and 3 minutes. Orthostatic hypotension is a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing; a compensatory heart rate rise of ≥20-30 beats/min suggests volume depletion (hypovolemia, bleeding, dehydration) rather than autonomic dysfunction. Do not let a dizzy patient stand unassisted — this is a fall-risk maneuver.

Pulse pressure is systolic minus diastolic pressure; normal is roughly 40 mmHg (about 25-50% of the systolic value). A narrowed pulse pressure (<25% of systolic) signals reduced stroke volume — hypovolemic shock, severe heart failure, cardiac tamponade (with pulsus paradoxus, an inspiratory systolic drop >10 mmHg). A widened pulse pressure appears in aortic regurgitation, hyperthyroidism, fever, and — critically — increased intracranial pressure, where widening pulse pressure plus bradycardia and irregular respirations forms Cushing's triad, a late sign of impending herniation.

Review of Systems

The review of systems (ROS) is a subjective, head-to-toe verbal inventory distinct from the hands-on exam: general (fever, weight change, fatigue), skin, head/eyes/ears/nose/throat, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, neurological, endocrine, hematologic, and psychiatric. ROS findings are subjective data reported by the patient — do not confuse them with objective examination findings; ANCC items frequently test this distinction.

Functional Assessment: ADLs and IADLs

Functional status predicts discharge disposition, fall risk, and rehabilitation needs. Activities of daily living (ADLs) — assessed with the Katz Index — are bathing, dressing, toileting, transferring, continence, and feeding. Instrumental activities of daily living (IADLs) — the Lawton scale — cover shopping, cooking, managing medications, managing finances, using transportation, and using the telephone. Dependence in ADLs signals the need for hands-on assistance or skilled care; IADL deficits often surface first and indicate the patient cannot safely live alone even when physically independent.

General Survey Red Flags

The general survey begins the moment you see the patient and costs no equipment. Red flags to recognize immediately:

• Acute distress: tripod positioning, accessory muscle use, inability to speak full sentences (respiratory failure); clutching the chest with diaphoresis
• Appearance inconsistent with stated age, cachexia, or marked recent weight loss (malignancy, malnutrition)
• Pallor (anemia, shock), cyanosis (hypoxemia), jaundice (liver failure), diaphoresis (pain, hypoglycemia, ACS)
• Poor hygiene or inappropriate dress for the weather (cognitive impairment, depression, self-neglect)
• Asymmetry of facial expression, limb movement, or gait (stroke, neurological deficit)
• Odor: fruity breath (ketoacidosis), alcohol, fecal breath (bowel obstruction), ammonia (uremia)

Trap warning: document what you see, not conclusions — 'unkempt clothing, strong body odor' rather than 'poorly cared for.'

Measurement Technique Pearls

Technique errors are a favorite exam trap. Use a blood pressure cuff with a bladder width about 40% of arm circumference — a cuff too small falsely elevates the reading, one too large falsely lowers it; support the arm at heart level. Count respirations for a full 30 seconds and multiply by 2 (60 seconds if irregular), ideally while pretending to take the pulse, because patients alter their breathing when observed. With an irregular rhythm, count an apical pulse for 60 seconds; a difference between apical and radial rates is a pulse deficit, classic in atrial fibrillation. Take the temperature route appropriate to the patient — avoid oral temps in confused or post-oral-surgery patients and rectal temps in neutropenic or post-rectal-surgery patients.