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.
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.
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.
| Technique | What it means | What it catches |
|---|---|---|
| 1. Inspection | Look, before you touch anything | Symmetry, color, visible effort, deformity, skin changes |
| 2. Palpation | Feel with your hands | Tenderness, masses, texture, temperature, pulses, chest expansion, edema |
| 3. Percussion | Tap and listen to the resulting sound | Air vs. fluid vs. solid tissue underneath (resonance vs. dullness) |
| 4. Auscultation | Listen with a stethoscope | Breath sounds, heart sounds, bowel sounds, bruits |
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.
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.
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.
| Vital | Technique | Numbers that matter |
|---|---|---|
| Heart rate | Radial, 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 rate | Observed 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. |
| Temperature | Oral (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. |
| SpO₂ | Pulse oximeter, used whenever there's concern the patient isn't oxygenating well. | See the pearl below on reading it in context. |
| Weight / height / BMI | Shoes 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. | - |
| Site | vs. oral | Notes |
|---|---|---|
| Oral | baseline | Falsely 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 |
| Tympanic | variable | Angle the probe up and back >1 yr old, straight back <1 yr. Cerumen falsely lowers the reading. |
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.
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.
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.
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.
| Parameter | Rule |
|---|---|
| Bladder width | ~40% of upper arm circumference |
| Bladder length | ~80% of upper arm circumference |
| Cuff position | Bare arm, snug fit, lower border 2.5 cm above the antecubital crease |
| Stethoscope | Bell or diaphragm directly over the palpated brachial artery |
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.
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.
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.
| Region | Steps |
|---|---|
| Head | Inspection, palpation. |
| Eyes | Inspection 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. |
| Ears | External inspection and palpation (tug test), internal inspection with otoscope, hearing acuity (Weber and Rinne), Romberg for vestibular/balance function. |
| Nose | Inspection: tilt the head back, check for a deviated septum, assess nasal mucosa and turbinates. |
| Sinuses | Percuss and palpate the frontal and maxillary sinuses. |
| Mouth/Throat | Inspect lips, buccal mucosa, teeth and gums, tongue, and the oropharynx (tongue blade, have the patient say "ah"). |
| Neck/Lymph nodes | Inspection, palpation including the thyroid and the full lymph chain. |
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).
| Test | How | What it tells you |
|---|---|---|
| Weber | Quiet room, vibrating tuning fork placed on top of the head | Ask if the sound is heard equally, or lateralizes to one side |
| Rinne | Vibrating fork on the mastoid bone until the sound fades, then move the prongs in front of the ear canal | Normally 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.
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.
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.
| Step | What you do |
|---|---|
| Inspection | Cyanosis, clubbing, breathing pattern (symmetrical vs. labored), any accessory muscle use. |
| Palpation | Hands 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. |
| Percussion | 8 locations, compare side to side at each level before moving down. |
| Auscultation | Same 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. |
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.
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.
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.
| Step | What you do |
|---|---|
| Inspection | Cyanosis, visible point of maximal impulse (PMI). |
| Palpation | Locate the PMI, feel for thrills (a palpable vibration, like a murmur you can feel) and lifts. |
| Auscultation | Diaphragm 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. |
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.
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.
| Sound | Mechanism | Best heard | Normal or abnormal |
|---|---|---|---|
| S1 ("lub") | Closure of the mitral and tricuspid (AV) valves, start of ventricular contraction | Louder at the apex | Normal |
| S2 ("dub") | Closure of the aortic and pulmonic (semilunar) valves, start of ventricular relaxation | Louder at the base | Normal; physiologically splits with inspiration (aortic closes before pulmonic) |
| S3 | Passive, rushing blood into the ventricles just after S2 | Left lateral decubitus, with the bell | Normal in children/young adults. In older adults: an overly compliantventricle |
| S4 | Vibration of the ventricular wall from atrial contraction, right before the next S1 | Apex or lower left sternal border, with the bell | Always 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.
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.
| Cause | Mechanism |
|---|---|
| Stenosis | Valve narrows, blocks forward flow |
| Regurgitation | Valve fails to close fully, blood leaks backward |
| Prolapse | Leaflets don't meet properly and can bulge back into the chamber they should be sealing |
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.
Four letters, four steps, and unlike the other systems here it opens with a dedicated mini-history before you ever touch the patient.
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.
Limping or guarding, swelling, visible injury, scars, posture, gait, facial expressions. Always compare right to left. Watch the patient walk awayfrom you.
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.
Joint- and injury-specific maneuvers layered on top of the general exam once you have a working suspicion.
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.
| Joint | Movements to check |
|---|---|
| Shoulder | Flexion, extension, abduction, adduction, internal rotation, external rotation |
| Elbow | Flexion, extension |
| Wrist and hand | Flexion, extension, supination, pronation, adduction, abduction |
| Neck | Flexion, extension, rotation, lateral bending |
| Spine | Flexion, extension, rotation, lateral bending |
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.
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.
| Case | Percussion | Auscultation | Egophony | Edema | The tell |
|---|---|---|---|---|---|
| Heart failure | Normal | Crackles, bilaterallower lobes | Positive, bilateral | 2+ both shins | Bilateral findings plus peripheral edema plus orthopnea history = fluid, not infection |
| Pneumonia | Dullness, right lower lobe | Crackles, right lower lobe | Positive, right lower lobe | None | Everything localizes to one lobe. Unilateral + fever + dullness = consolidation |
| Asthma | Normal resonance | Wheezingon exhale, lower lobes | Negative | None | No dullness, no crackles, just wheeze. It's airway narrowing, not fluid or consolidation |
| COPD exacerbation | Dullness, upper andlower lobes | Crackles, upper and lower lobes | Positive, lower lobes | None | Diffuse findings plus accessory muscle use plus RR 26 plus HR 110 plus SpO₂ 93% = the whole system is compensating and starting to lose |
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.
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.
| Component | Points |
|---|---|
| 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-Reflection | 5 |
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 (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.