Making the Physical Examination Count: What actually works in real consultations

This blog aims to help you, a busy healthcare professional (HCP), update your skills and keep your consultations relevant in today’s rapidly changing healthcare landscape.

In my previous post, “From Talking to Examining”, I explained the role of the physical examination during a consultation. However, understanding when and why to perform it is one thing; knowing how to do it is another.

Examination skills remain essential. A thorough physical examination not only confirms or supports a diagnosis but can also reveal unexpected findings, guide management decisions, and help build trust.

Let’s be honest: much of what we learn about examining patients seems better suited to textbooks than to fast-paced clinics or awkward patients. Conducting a thorough systemic examination can be time-consuming and is seldom necessary. In practice, HCPs focus on what is relevant.

This post explores what actually works, and why.

The examination starts before the physical examination

It begins the moment you meet the patient. How they look, sit, stand, move, talk and breathe tells you a lot.

Do they look pale, jaundiced, cyanosed, or flushed?
Are they in pain?
What’s their breathing like?
Can they speak properly?
Do they make sense?

You don’t need a checklist for this — just pay attention.

A Moment of Illustration

You see a 54-year-old man who says he feels tired all the time. He sits perched on the edge of the chair, leaning forward, speaking in short sentences. Before you’ve asked a single formal question, you can see he is ill and short of breath at rest. That early observation shapes everything that follows.

The Practicalities of a Professional Approach

Introduce yourself as if you care and ask permission:

“Hi, I’m [name]. Can I examine you so that we can figure out what’s going on?”

Wait for the answer. Then wash your hands visibly, which reassures more than you might realise.

Have essential equipment ready: stethoscope, pen torch, tendon hammer, measuring tape, otoscope/ophthalmoscope.
Adapt to the patient. Position them for comfort and safety, whether sitting, lying down, or in the left lateral position. Techniques differ for infants, children, older adults, people with disabilities, and those in pain.
Expose adequately but modestly. Request only the exposure you need, and cover the area again as soon as possible.
Be methodical yet flexible. Use insights from your conversation with the patient to choose your starting point, decide what to assess and what you hope to find, and stay alert for the unexpected.
Explain as you go. Say what you’re going to do and let them know they can stop you at any time. It takes ten seconds and changes the whole dynamic. But remember you are not a sports commentator.
Ask questions if necessary.

The classic “inspect, palpate, percuss, auscultate” routine is useful, but the real skill lies in knowing when to apply these techniques and in making the whole process feel natural, respectful, and useful for both of you.

Look first: really look

Before using your hands, pause. Not a hurried glance: look to observe, understand and interpret.

Inspection is free and underused. You’d be surprised how often the diagnosis is in plain sight: the way someone holds their shoulder, a subtle facial asymmetry, swollen ankles they haven’t mentioned, or a surgical scar they forgot to tell you about.

Compare paired parts, and if any part is designed to move, watch it move. Note:

Colour: jaundice, cyanosis, pallor
Response to pressure: blanching, capillary refill
Texture: scars, pitting
Contour: organomegaly, muscle wasting
Position: deformity, deviation
Movement: expansion, pain

If you find an unexpected abnormality, ask: “Have you noticed it? How long has it been present? What caused it?“

Feel with purpose, not as a routine

Superficial abnormalities are often visible and palpable, whereas deeper abnormalities may be palpable only in certain positions or actions, such as during deep inspiration.

Warm your hands first, and tell the patient what you’re about to do.
Look, then feel, move, and look and feel again. Palpation complements inspection, and both are more valuable together, at rest and in motion. When you lay hands on someone, make it count. Focus on the site of interest: you don’t need to touch everywhere “just in case.” Purpose and accuracy beat thoroughness for its own sake.
Start away from the painful area, gently at first, and go deeper only if necessary.
Use both hands and eyes efficiently: one hand examines while the other stabilises or distracts. Watch the patient’s face, not just your hands. Their expression often tells you more than their words.

With practice, you learn what normal feels like and notice when it isn’t.

If you find an abnormality, is it tender? Is it hard (like bone), firm (like cartilage), soft (like fat), pulsatile (like an artery) or compressible (like a vein)? What is its shape? Are the margins defined, smooth or irregular? Is it separate from nearby structures? Determine the anatomy: depth, location and proximity to known organs.

Listen and percuss where and when it matters

Auscultate at key points when needed: mainly the chest and over the major vessels, and sometimes the abdomen. Learn what normal sounds like in real people.

Percussion is helpful when the situation calls for it, such as when examining the chest or abdomen, or when you feel a large mass. Don’t listen or percuss just because “that’s what we were taught.”

Make use of technology

Point-of-care tools, such as pulse oximetry or handheld ultrasound, increasingly complement rather than replace the hands-on examination.

These devices work best when guided by what you already know, and what you have already seen and felt.

Adapt to accommodate

People don’t come in standard sizes or abilities. Sometimes you need to adapt. For example, someone in a wheelchair with severe kyphosis who can’t lie flat, or someone who communicates differently. If in doubt, ask.

“Would you rather stay in the chair?”

“What’s the easiest way for me to examine your chest?”

Most patients will tell you what works. Transferring someone onto a couch when it’s painful or unnecessary helps no one. Examining through clothes because it feels awkward to ask them to undress helps even less.

Know when to stop. If the patient is clearly uncomfortable or the findings won’t change management, wrap it up.

Take-home message

The usual advice is “see more patients.” True, but incomplete. Watch skilled clinicians examine people. Notice how they work quickly and efficiently, touch minimally, stay focused and adapt.

Practise the awkward parts (explaining, positioning, asking permission, looking) until they feel natural.

You don’t need to perform a perfect textbook exam every time. You do need to gather the information that matters, without making the patient feel like an object or missing the obvious.

That’s the real skill.

For a guide to key examination techniques, click: A Guide to Key Examination Techniques.

In the next post, I will discuss examination pitfalls.

I would value your thoughts:

When did you last undertake a full systematic examination?

What skills do you find most reliable?

If you’re interested in developing a more adaptive, patient-centred approach, you can read more here: