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Physical Assessment

Foundations & Skillscardinal techniquesvitals & BPHEENT · lung · heart · MSK

30-Second Snapshot

What it is:The hands-on half of every patient encounter. The interview (covered separately) tells you what to suspect. The physical exam is where you go confirm it, using four repeatable techniques applied system by system: inspection, palpation, percussion, and auscultation.

The core problem:Physical exam skills get graded two ways at once, and students only prepare for one. You can find every abnormal finding on a simulated patient and still lose most of the points, because on every rubric in this curriculum you only get credit for what you verbalize out loud. A silent, technically perfect exam scores like an exam you never did.

What you do about it:Learn the exam sequence for each system so well it's automatic (general survey → vitals → inspection → palpation → percussion → auscultation), and practice narrating every step as you do it. The narration isn't padding, it isthe graded product.

Worth knowing

A signis what you observe (crackles, edema, a murmur). A symptomis what the patient reports (dyspnea, pain). The exam generates signs, which become the Objectivesection of your SOAP note, sitting right below the Subjective history you already took. Same patient, same visit, two different kinds of evidence, and good clinical reasoning uses both.

The 4 Cardinal Techniques

Every system exam in this course, HEENT, lung, heart, MSK, is built from the same four moves, always in this order. Learn the order once and every checklist in this document becomes easy to remember.

TechniqueWhat it meansWhat it catches
1. InspectionLook, before you touch anythingSymmetry, color, visible effort, deformity, skin changes
2. PalpationFeel with your handsTenderness, masses, texture, temperature, pulses, chest expansion, edema
3. PercussionTap and listen to the resulting soundAir vs. fluid vs. solid tissue underneath (resonance vs. dullness)
4. AuscultationListen with a stethoscopeBreath sounds, heart sounds, bowel sounds, bruits
The order is tested, not just the content

Auscultation almost always comes last, after inspection and palpation, because pressing on an area first can change what you hear (bowel sounds especially). The one exception in this curriculum: the abdomen is auscultated before percussion and palpation for the same reason in reverse, but for the lung and heart exams here, the inspect → palpate → percuss → auscultate order holds.

Where this fits in the visit

A comprehensive assessment(new patient, baseline) means the full history plus a full head-to-toe exam. A focused assessment(established patient, acute complaint, short on time) means history and exam narrowed to the symptomatic system. Almost every skills exam in this program is a focused assessment built around one chief complaint, one body system.

Vital Signs

Vitals come right after the history, before the focused physical exam, and they're graded as their own block worth real points. They're also your fastest read on whether a patient is decompensating in real time.

VitalTechniqueNumbers that matter
Heart rateRadial, brachial, or carotid, never both carotids at once. Pads of index and middle finger, don't press too hard or you'll block the pulse. Regular rhythm: count 30 sec × 2. Irregular: count the full 60 sec.Tachycardia >100 bpm. Bradycardia <60 bpm.
Respiratory rateObserved for a full 60 seconds, immediately after the pulse check, fingers left on the radial artery so the patient doesn't know you're watching their breathing.Assess rate, rhythm, depth, andeffort, not just the number.
TemperatureOral (probe cover, under tongue, wait if the patient had anything hot or cold in the last 10–15 min), tympanic, axillary, rectal, or temporal.See conversion table below.
SpO₂Pulse oximeter, used whenever there's concern the patient isn't oxygenating well.See the pearl below on reading it in context.
Weight / height / BMIShoes and coat off, done together. BMI is calculated from the two. Waist circumference, waist-to-hip, or waist-to-height ratio add adiposity context BMI alone misses.-
Sitevs. oralNotes
OralbaselineFalsely low/high with recent food or drink
Rectal+0.7–0.9°F (+0.4–0.5°C)Highest reading of the group
Axillary−1.8°F (−1°C)Least accurate site
Temporal−0.5 to −1°F (−0.3 to −0.6°C)Increasingly common; some models auto-convert
TympanicvariableAngle the probe up and back >1 yr old, straight back <1 yr. Cerumen falsely lowers the reading.
Reading SpO₂ in context, not alone

The simulated cases in this course make the pattern obvious: an HF patient with crackles read 95%, a pneumonia patient with unilateral dullness read 95%, an asthma patient wheezing on exhale read 96%, but the COPD exacerbation, the one with accessory muscle use, RR 26, and HR 110, read 93%. The single number matters less than the pattern: a dropping sat plusa rising respiratory rate plusa rising heart rate means the compensation is starting to fail, not just that one number crossed a line.

Hypertensive crisis

Defined as systolic ≥180 mmHg and/or diastolic ≥120 mmHg.Splits into hypertensive urgency and hypertensive emergency. Watch for severe headache, confusion, nausea/vomiting, blurred vision, faintness, agitation, chest pain, dyspnea, anxiety, nosebleeds, neuro deficits, or seizures riding along with the number, those symptoms are what push it from urgency toward emergency. Possible complications: encephalopathy, intracerebral hemorrhage, MI, acute HF, pulmonary edema, unstable angina, aortic dissection, preeclampsia/eclampsia, and acute kidney injury.

Orthostatic hypotension, the actual test

Definition:a sustained drop in SBP >20 mmHg or DBP >10 mmHg within 3 minutes of standing. How to do it:let the patient lie supine 3–10 minutes, take a BP, leave the cuff on, have them stand, retake the BP within 3 minutes. Symptoms to ask about: lightheadedness, visual blurring, unsteadiness, syncope.

Blood Pressure, the Technique That Gets Docked Most

More rubric points get lost here than almost anywhere else in the physical exam, because BP has more steps that are easy to skip under exam pressure than any other single vital.

Before you inflate anything

Cuff and placement

ParameterRule
Bladder width~40% of upper arm circumference
Bladder length~80% of upper arm circumference
Cuff positionBare arm, snug fit, lower border 2.5 cm above the antecubital crease
StethoscopeBell or diaphragm directly over the palpated brachial artery
Estimating systolic first avoids the auscultatory gap

Palpate the radial artery while inflating the cuff and note the pressure where the pulse disappears. Deflate quickly, wait 15–30 seconds, then re-inflate to that palpated number plus 30 mmHgfor the real reading. This does two things: it avoids patient discomfort from over-inflating blind, and it avoids underestimatingsystolic BP by missing an auscultatory gap, a silent interval that can sit between the true systolic and diastolic sounds. If you inflate too low, you'll hear the sound reappear inside the gap and call that number the systolic, when it's actually lower than the truth.

Alternate sites, when the arm doesn't work

Thigh:special cuff mid-thigh, patient prone, bladder on the back of the leg, stethoscope over the popliteal artery. Wrist/forearm:wrist at heart level, less accurate overall but useful for cone-shaped arms or excess soft tissue where a standard cuff won't seat properly.

HEENT Exam

Head, Eyes, Ears, Nose, Throat, and the neck/lymph nodes that drain them. One of the most checklist-dense exams in the curriculum because so many small structures each get their own step.

RegionSteps
HeadInspection, palpation.
EyesInspection including PERRLA(Pupils Equally Round, Reactive to Light and Accommodation), extraocular movements (EOMs, patient moves eyes while keeping head still), visual acuity via Snellen chart, confrontation testing.
EarsExternal inspection and palpation (tug test), internal inspection with otoscope, hearing acuity (Weber and Rinne), Romberg for vestibular/balance function.
NoseInspection: tilt the head back, check for a deviated septum, assess nasal mucosa and turbinates.
SinusesPercuss and palpate the frontal and maxillary sinuses.
Mouth/ThroatInspect lips, buccal mucosa, teeth and gums, tongue, and the oropharynx (tongue blade, have the patient say "ah").
Neck/Lymph nodesInspection, palpation including the thyroid and the full lymph chain.
Ear exam in depth: otoscope technique and the hearing tests

Otoscope technique:position the patient, attach an appropriately sized speculum, then straighten the ear canal by pulling the auricle up and back(adults) before inserting.

Hearing pathway split:conductive loss lives in the external or middle ear (wax, infection, perforated eardrum). Sensorineural loss lives in the inner ear (Meniere's disease, aging).

TestHowWhat it tells you
WeberQuiet room, vibrating tuning fork placed on top of the headAsk if the sound is heard equally, or lateralizes to one side
RinneVibrating fork on the mastoid bone until the sound fades, then move the prongs in front of the ear canalNormally air conduction outlasts bone conduction. Conductive loss:bone sound ≥ air sound. Sensorineural loss:air still outlasts bone, but overall hearing is reduced.

Romberg:feet together, eyes open, then closed for 30 seconds. Should stay upright with eyes closed (vision was compensating for a vestibular or proprioceptive deficit). Loss of balance with eyes closed is a positive test. Stand ready to support the patient.

Lymph node map, exact locations
  • Preauricular- in front of the ear
  • Posterior auricular- behind the ear
  • Occipital- base of the skull, posteriorly
  • Tonsillar- angle of the mandible
  • Submandibular- midway between the angle and tip of the mandible
  • Submental- just behind the tip of the mandible
  • Superficial cervical- superficial and anterior to the sternocleidomastoid (SCM)
  • Posterior cervical- along the anterior edge of the trapezius
  • Deep cervical chain- deep to the SCM
  • Supraclavicular- deep in the angle formed by the clavicle and the SCM
ABCDE for a suspicious mole

Asymmetrical shape, irregular Border, Changes in color, Diameter, Evolving. Any of these on a skin lesion found during a head inspection is a referral, not a "watch it" note.

Lung Exam

Runs the four cardinal techniques front to back, and it's the exam most likely to overlap with a cardiac chief complaint, so the checklist folds in an edema check that's really about the heart.

StepWhat you do
InspectionCyanosis, clubbing, breathing pattern (symmetrical vs. labored), any accessory muscle use.
PalpationHands on the patient's back, ask for a deep breath in, feel for symmetrical chest expansion. Also check for edema at the shins, since lower-lobe crackles and leg swelling together point toward the heart, not just the lungs.
Percussion8 locations, compare side to side at each level before moving down.
AuscultationSame 8 locations as percussion, side to side. Then a vocal resonance check: egophony, have the patient say a long "E" while you listen, if it sounds like "A" through the stethoscope, that's a positive test.
What egophony actually means

Positive egophony ("E" to "A" change) happens over consolidated lung tissue, fluid or inflammatory exudate transmits sound differently than normal aerated lung. It's a sign of the same process that causes dullness to percussion in the same area: something has replaced the air in that part of the lung. Hearing it in one focal area (versus diffusely) is what points you toward pneumonia over a more global process like heart failure.

Assessment tools that pair with a lung/cardiac complaint

mMRC(dyspnea severity, COPD), GINA(asthma control/severity), NYHA(heart failure functional class), CURB-65(pneumonia severity, disposition decision). Skills exam rubrics specifically ask you to pick the tool that matches the diagnosis, using the wrong one is an easy way to lose the assessment points even with a correct exam.

Heart Exam

The most sequence-heavy exam in the curriculum: 2 techniques for inspection/palpation, then auscultation multiplied across 4 valve areas × 2 stethoscope heads × 3 patient positions.

StepWhat you do
InspectionCyanosis, visible point of maximal impulse (PMI).
PalpationLocate the PMI, feel for thrills (a palpable vibration, like a murmur you can feel) and lifts.
AuscultationDiaphragm then bell, at each of 4 areas (aortic, pulmonic, tricuspid, mitral), in each of 3 positions: supine with the head at 30°, left lateral decubitus, and sitting forward after exhaling.
Why 3 positions, not 1

Each position exaggerates a different finding. Left lateral decubitus with the bellbrings out left-sided S3, S4, and mitral stenosis. Sitting forward after exhaling, diaphragm along the left sternal border and apexis the position built for hearing aortic regurgitation. Auscultating supine only will make you miss findings that only appear once gravity and chest wall geometry change.

Finding the PMI

The apical impulse, normally located in the 5th intercostal space at or near the midclavicular line.It marks the left border of the heart. It isn't always palpable, and when the heart is enlarged or the ventricle is volume-overloaded, it can be displaced lateral to the midclavicular line, a physical sign of cardiomegaly you can pick up without imaging.

S1 through S4, what each sound actually is
SoundMechanismBest heardNormal or abnormal
S1 ("lub")Closure of the mitral and tricuspid (AV) valves, start of ventricular contractionLouder at the apexNormal
S2 ("dub")Closure of the aortic and pulmonic (semilunar) valves, start of ventricular relaxationLouder at the baseNormal; physiologically splits with inspiration (aortic closes before pulmonic)
S3Passive, rushing blood into the ventricles just after S2Left lateral decubitus, with the bellNormal in children/young adults. In older adults: an overly compliantventricle
S4Vibration of the ventricular wall from atrial contraction, right before the next S1Apex or lower left sternal border, with the bellAlways suggests a stiff, less compliant ventricle

Mnemonic:S1-S2-S3 sounds like "Ken-tuck-y." S4-S1-S2 sounds like "Ten-nes-see." Say them out loud, the rhythm is the point.

Murmurs: mechanism, cause, and how to time them

A murmur is a whooshing sound from turbulent flow. Some are "innocent" in young adults with no structural cause. Graded by loudness and whether a thrill (palpable vibration) accompanies it.

CauseMechanism
StenosisValve narrows, blocks forward flow
RegurgitationValve fails to close fully, blood leaks backward
ProlapseLeaflets don't meet properly and can bulge back into the chamber they should be sealing
Systolic vs. diastolic, by feel plus listen

Palpate the carotid artery while you auscultate. The carotid upstroke occurs in systole, right after S1. A murmur that lines up with the upstroke is systolic. A murmur you hear after the upstroke has passed is diastolic. This is a faster, more reliable read under exam pressure than trying to count S1 vs. S2 timing by ear alone.

Symptoms a defective valve produces:shortness of breath, fatigue, reduced exercise capacity, heart failure, pulmonary hypertension, pulmonary or systemic edema, chest pain (angina), arrhythmias, blood clots. The valve lesion and the heart failure lecture aren't separate topics, a bad valve is one of the structural causes that starts the whole HF cascade.

Musculoskeletal Exam - HOPS

Four letters, four steps, and unlike the other systems here it opens with a dedicated mini-history before you ever touch the patient.

H

History

What happened, how long, where/when it hurts, what helps or worsens it, prior episodes. PMH: trauma, surgeries, skeletal deformities. FH: congenital abnormalities, scoliosis, arthritis. SH: nutrition, exercise, weight changes.

O

Observation

Limping or guarding, swelling, visible injury, scars, posture, gait, facial expressions. Always compare right to left. Watch the patient walk awayfrom you.

P

Palpation

Think about the anatomy under your fingers. Check the cardinal signs, feel for muscle tone, feel for crepitus. Compare sides, starting with the uninjuredside first so you know what normal feels like for this patient.

S

Special Tests

Joint- and injury-specific maneuvers layered on top of the general exam once you have a working suspicion.

The cardinal signs, from any inflamed or injured joint

Pain, redness, swelling, increased warmth, deformity, loss of function.The same six signs apply whether you're looking at a sprained ankle or an inflamed joint, and they're what you're actively screening for during both observation and palpation.

Range of motion, by joint

JointMovements to check
ShoulderFlexion, extension, abduction, adduction, internal rotation, external rotation
ElbowFlexion, extension
Wrist and handFlexion, extension, supination, pronation, adduction, abduction
NeckFlexion, extension, rotation, lateral bending
SpineFlexion, extension, rotation, lateral bending
Special tests: which ones you perform vs. which you just explain

Perform these:varus, valgus, knee drawer, straight-leg raise, sag test, ankle drawer, talar tilt, Thompson test, piano key test, empty can test, scratch test, Phalen test, flick test, thumb opposition, Tinel's sign.

Know what they test, but you're not performing them:McMurray's, Lachman's, Clark's sign, apprehension test. On a rubric, being able to explain what a test is checking for still earns credit even when you're not asked to physically demonstrate it.

Connecting Findings to a Diagnosis

The exam only matters if you can read the pattern it produces. These four presentations come straight from the simulated case library and show how the same lung exam produces four different pictures depending on what's actually wrong.

CasePercussionAuscultationEgophonyEdemaThe tell
Heart failureNormalCrackles, bilaterallower lobesPositive, bilateral2+ both shinsBilateral findings plus peripheral edema plus orthopnea history = fluid, not infection
PneumoniaDullness, right lower lobeCrackles, right lower lobePositive, right lower lobeNoneEverything localizes to one lobe. Unilateral + fever + dullness = consolidation
AsthmaNormal resonanceWheezingon exhale, lower lobesNegativeNoneNo dullness, no crackles, just wheeze. It's airway narrowing, not fluid or consolidation
COPD exacerbationDullness, upper andlower lobesCrackles, upper and lower lobesPositive, lower lobesNoneDiffuse findings plus accessory muscle use plus RR 26 plus HR 110 plus SpO₂ 93% = the whole system is compensating and starting to lose
The pattern behind the pattern

Notice what separates these: laterality(one lobe vs. both), sound type(crackles = fluid/exudate, wheeze = narrowed airway, dullness = something replacing air), and what rides along with it(edema points to the heart, fever and unilateral findings point to infection). You're not memorizing four cases, you're learning to read three or four data points together instead of chasing one abnormal finding in isolation.

What Skills-Exam Graders Actually Score

The Winter 2026 Skills Exam rubric for the lung/vitals station breaks down to 50 points, and where those points sit is not evenly distributed the way you'd guess.

ComponentPoints
Introduction (knock, hand hygiene, name/title, purpose)3
Interview (chief complaint, symptom attributes, ROS, histories, allergies, med rec)16
Vitals (BP questions, BP technique, HR, RR, SpO₂, temperature)8
Physical Exam Skills(inspection, palpation, percussion, auscultation)10
Assessment/Plan & Professionalism (empathy, organized plan, correct assessment tool, dress, control of session)13 (+2 EC)
Self-Reflection5
The line that costs the most students points

The Physical Exam Skills section is prefaced with: "Please verbalize exam and results to receive full credit."That's not a suggestion. A student who does a flawless, correctly sequenced exam in total silence is, by the rubric, indistinguishable from a student who skipped it. Say what you're checking andwhat you find, in real time: "I'm palpating for symmetrical chest expansion... that's symmetrical" beats doing it silently and reporting a summary at the end.

Percussion and auscultation are worth the most for a reason

Percussion (3 pts) and auscultation (4 pts) outweigh inspection (1 pt) and palpation (2 pts) combined on this rubric. Both require 8 locations, bilateral, side-to-side comparisonto get full credit, so a rushed 4-location "good enough" pass through the lung fields is a guaranteed partial-credit outcome, not a rounding error.

What You Actually Say During the Exam

  • Before BP:"Have you exercised, had caffeine, or used nicotine in the past 30 minutes? Have you taken any medications today? What's your usual blood pressure?"
  • Starting the lung exam:"I'm going to look at your breathing pattern first, then I'll place my hands on your back and have you take a deep breath in."
  • During chest expansion palpation:"Take a deep breath in for me... good, that's symmetrical on both sides."
  • Before auscultation:"I'm going to listen to your lungs in a few different spots, front and back, comparing side to side."
  • The egophony ask:"Can you say a long 'E' sound for me while I listen?"
  • Before the heart exam repositioning:"I'm going to listen to your heart in a few different positions, lying back, on your left side, and then leaning forward, it helps me hear different sounds clearly."
  • Otoscope exam:"I'm going to gently pull your ear up and back so I can see the canal clearly, let me know if anything feels uncomfortable."
  • MSK palpation, uninjured side first:"I'll check your uninjured side first so I know what's normal for you, then we'll compare."
  • Reporting a normal finding out loud:"Your pupils are equal, round, and reactive to light and accommodation." Verbalizing the normal is worth exactly as much credit as verbalizing the abnormal.

High-Yield Recall Sheet

  • 4 cardinal techniques, in order:inspection → palpation → percussion → auscultation. Auscultation last so palpation doesn't distort what you'll hear.
  • Sign = observed by you. Symptom = reported by the patient.Signs feed the Objective section of a SOAP note.
  • Comprehensive= new patient, full history and exam. Focused= established patient, exam narrowed to the symptomatic system.
  • HR:tachycardia >100 bpm, bradycardia <60 bpm. Count 30 sec ×2 if regular, full 60 sec if irregular.
  • RRis checked right after the pulse, fingers still on the radial artery, without telling the patient, so they breathe naturally.
  • Temp conversions vs. oral:rectal +0.7–0.9°F, axillary −1.8°F, temporal −0.5 to −1°F.
  • Hypertensive crisis:SBP ≥180 and/or DBP ≥120.
  • Orthostatic hypotension:SBP drop >20 mmHg or DBP drop >10 mmHg within 3 minutes of standing.
  • BP cuff sizing:bladder width ~40%, length ~80% of arm circumference. Deflate at 2–3 mmHg/sec, round to the nearest 2 mmHg.
  • Estimate systolic by palpation first(inflate to where the radial pulse disappears, then +30 mmHg) to avoid underestimating BP in an auscultatory gap.
  • PMI location:5th intercostal space, at or near the midclavicular line. Lateral displacement suggests cardiomegaly.
  • S1 = mitral/tricuspid closure ("lub," loudest at apex). S2 = aortic/pulmonic closure ("dub," loudest at base).
  • S3 = "Kentucky"(overly compliant ventricle). S4 = "Tennessee"(stiff ventricle). Both heard best with the bell.
  • Murmur timing:palpate the carotid while auscultating. Murmur with the upstroke = systolic. Murmur after the upstroke = diastolic.
  • Positive egophony ("E" → "A")means consolidated lung tissue underneath, pairs with dullness to percussion in the same spot.
  • Bilateral lung findings + edemapoints to heart failure. Unilateral dullness + feverpoints to pneumonia. Wheeze with normal percussionpoints to asthma.
  • HOPSfor MSK: History, Observation, Palpation, Special tests. Always compare the injured side to the uninjured side, checking the uninjured side first.
  • Cardinal signs of joint injury/inflammation:pain, redness, swelling, warmth, deformity, loss of function.
  • On every graded rubric here, an unverbalized exam earns no crediteven if performed correctly. Narrate what you're doing and what you find, in real time.