3 Focused Physical Examination

Purpose and scope

A focused examination is guided by the clinical question, the patient’s history and symptoms, vital signs, and immediate concerns. It gathers objective findings to help refine clinical judgment; it is not a requirement to perform every maneuver in a routine sequence. Expand or redirect the examination when findings, risk factors, or changes in condition call for it.

The assessment should remain adapted to the patient’s needs and safety. The history and examination findings determine whether it stays focused, expands, or prompts urgent escalation.

Prepare and observe

Introduce yourself, confirm the patient’s identity, explain the examination and why it is relevant, and obtain permission. Provide privacy, good lighting, and a comfortable temperature. Expose only the area being examined and use draping.

Ask about pain, mobility limits, and preferences. Use an interpreter or communication aid when needed. Adapt positioning and pace to the patient’s age, distress, disability, fatigue, and clinical stability.

Observe the patient from the start and throughout the encounter. Note general appearance, alertness, posture, movement, work of breathing, and apparent discomfort while speaking with the patient. Ongoing observation can help identify urgent changes.

Record vital signs with their values and units, and consider measurement conditions and relevant baseline. Common measures include temperature, pulse, respiratory rate, blood pressure, and oxygen saturation; pain and other measures may be appropriate to the setting. Interpret measurements in context, including age, symptoms, medications, activity, and trends. Do not let a reassuring number override signs of deterioration.

Select examination techniques

Choose examination techniques that address the clinical question. Compare sides when appropriate, explain what you are doing, and check in about discomfort. When feasible, examine a painful area last. For sensitive or intimate examinations, explain the steps, obtain specific consent, and follow local chaperone and policy requirements.

Core techniques

• Inspection: Look systematically for asymmetry, color or skin changes, swelling, wounds, deformity, movement, and effort. Describe what is visible rather than inferring a diagnosis from appearance alone.

• Palpation: Assess tenderness, temperature, texture, pulses, movement, or swelling with the hands. Start gently, observe the patient’s response, and stop or modify the maneuver if pain or distress increases.

• Percussion: Tap the body surface to assess the character of underlying sounds. Use it when it contributes to the question being assessed, such as when examining the chest or abdomen.

• Auscultation: Listen with a stethoscope for relevant sounds, using a quiet environment when possible. Compare corresponding areas when useful. The order of techniques depends on the body region; for the abdomen, auscultation is generally performed before percussion and palpation.

Match the examination to the concern

The following are starting points, not fixed checklists. Adapt the examination to the patient’s symptoms, findings, tolerance, and condition.

Shortness of breath

Observe speech, respiratory rate and effort, posture, and skin or lip color. Examine the chest with inspection, palpation, percussion, and auscultation as indicated. Assess related findings, such as peripheral swelling, when relevant. Increased work of breathing or a change in mental status warrants prompt clinical attention.

Abdominal pain

Ask where the pain is and what worsens it. Inspect the abdomen, then auscultate before percussion and palpation. Begin gently away from the most painful area. Note tenderness, guarding, distention, or other observed findings. Adapt the depth and extent of the examination to the patient’s tolerance and condition.

Limb injury or weakness

Compare the affected side with the unaffected side when possible. Assess appearance, tenderness, movement, strength, sensation, and distal circulation as appropriate to the injury and the patient’s symptoms. Avoid maneuvers that could worsen a suspected injury.

Communicate and document findings

Use specific, objective language and include location, side, quality, and relevant measurements. Separate observed findings from interpretation. For example: “Respiratory rate 26 breaths/min; using accessory muscles; speaks in short phrases; breath sounds present bilaterally.” This is clearer than “breathing poorly.”

Explain findings to the patient in plain language, acknowledge uncertainty when present, and describe the next step. Document relevant positive and negative findings, the examination’s scope, and any limitation. Escalate concerning findings promptly according to the clinical setting and protocol.

Reassess and respond

Reassess when symptoms change, after an intervention, or when the clinical situation requires monitoring. Repeat the relevant examination elements and vital signs, then compare them with earlier findings and the patient’s reported symptoms.

Document the time, what was reassessed, the patient’s response, and any actions taken. Worsening findings or a poor response should prompt timely escalation. Reassessment intervals should follow the patient’s condition and local protocol.

• Focused physical examination