The Expert Clinician

A Guide to Examining a Person with a Disability

Many people who live with a disability have made necessary changes to their environment. Similarly, when we see them, we should make appropriate adaptations that respect their needs and ensure we examine them with care and professionalism.

Communication, Consent, and Professionalism

Patients with disabilities may have experienced rushed or disrespectful examinations in the past. 

Clear explanations, genuine listening, and flexibility rebuild trust. Use accessible language, allow extra time, involve supporters appropriately, and never make assumptions about capacity or ability. 

Preparation 

This is especially important when accommodating disability:

• Introduce yourself clearly, confirm identity, and explain the purpose of the examination in plain language.
• Obtain informed consent, checking understanding and involving carers or advocates when appropriate (while still addressing the patient directly).
• Ensure privacy, comfort, and accessibility: adequate space for a wheelchair or mobility aid, adjustable examination couch if available, good lighting, and a quiet environment.
• Chaperones remain important for intimate examinations regardless of disability.
• Wash or sanitise hands in the patient’s view and prepare only the equipment needed.
• Ask the patient (or carer) about the best way to transfer, position, or communicate before starting.
• Be prepared to examine in the chair, on a trolley, or in bed rather than insisting on a standard couch.

Adapt the examination

• Offer clear explanations of what you want to do and ask permission.
• Prioritise comfort and safety over a “complete” textbook examination.
• Expose only what is necessary and re-cover promptly.
• Ask the patient (or carer) how best to proceed—most people know what works for them.
• Explain every step using the patient’s preferred communication method.
• Compare sides whenever possible, adapting for asymmetry caused by the disability itself.
• Document both the findings and any adaptations or limitations so that colleagues understand the context and for future examinations.

Appear calm and flexible. Patients quickly sense whether their needs are being anticipated or treated as an inconvenience.

The Four Classic Techniques – With Adaptations

The core methods remain inspection, palpation, percussion, and auscultation, but each can be modified:

• Inspection. Allow extra time. Observe from the patient’s preferred position (sitting in a wheelchair, lying, or standing with support).
• Palpation. Use a lighter touch if the patient has allodynia, hypertonia, or joint instability. Warn before every contact.
• Percussion. May be limited by positioning; perform what is feasible and note limitations.
• Auscultation. Ensure the stethoscope can reach the chest or back; ask for assistance with clothing or positioning if needed.

Clinical Examples Highlighting the Techniques

Example 1: Wheelchair user with suspected heart failure

A 62-year-old woman who uses a wheelchair full-time presents with worsening breathlessness and leg swelling.

Transfer to a couch is performed only if essential and with the patient’s preferred method (hoist, standing transfer with assistance, or slide board).

• Inspection: Examine her in the wheelchair first. Look for raised jugular venous pressure (may require gentle head positioning), cyanosis, and dependent oedema.
• Palpation and percussion: Assess the apex beat and peripheral pulses while she remains seated if transfer is difficult or painful. Check sacral and heel areas for pressure injury.
• Auscultation: Listen to the heart and lung bases from the front and, if possible, lean her forward slightly with support to auscultate posteriorly. 

Document the clinical findings and any limitation caused by positioning or communication challenges.

Example 2: Patient with severe hearing impairment and possible pneumonia

A 78-year-old man who is profoundly deaf and communicates mainly by lip-reading and written notes has fever and cough.

Establish communication first: face him directly, speak clearly without exaggerating, use written instructions or a tablet if preferred, and confirm understanding.

• Inspection: Observe respiratory rate and effort; reduced chest expansion may still be visible.
• Palpation and percussion: Explain each step in writing or by gesture before touching. Percuss and compare sides systematically.
• Auscultation: Proceed as usual once consent is clear. Provide written feedback on findings afterwards if helpful.

Example 3: Patient with cognitive impairment and acute abdominal pain

An 84-year-old woman with moderate dementia is brought by her daughter because of new abdominal pain and reduced appetite.

With the patient’s permission, speak with the carer to understand the problem; otherwise, speak primarily to the patient. Use simple, calm language and allow extra time.

• Inspection: Look for facial grimacing, guarding posture, or reluctance to move.
• Auscultation: Listen early for bowel sounds.
• Palpation: Begin very gently, watching the face continuously for signs of pain rather than relying solely on verbal report. Guarding or rebound may still be detectable. Stop immediately if distress increases and reassess.

Example 4: Patient with hemiplegia after stroke and new focal neurological signs

A 70-year-old man with residual left-sided weakness is reviewed for possible further neurological deterioration.

Positioning for the examination should minimise risk of falls or shoulder injury on the hemiplegic side.

• Inspection: Observe spontaneous movement, posture, and facial symmetry while he is in his preferred position.
• Power testing: Assess the unaffected side first to establish a baseline, then the affected side using the MRC scale. Support the limb fully to avoid injury. Pronator drift can still be tested on the stronger side.
• Reflexes and tone: Test carefully; hypertonia or contractures may limit range. Use a tendon hammer gently.
• Sensation testing: May need simplified instructions or demonstration on the unaffected side first.

Example 5: Patient with visual impairment and joint pain

A 55-year-old woman who is registered blind presents with progressive knee pain. Allow the patient to keep a guide dog or white cane within reach if it provides reassurance.

• Offer verbal guidance throughout:“I am now going to feel around your right knee”.
• Inspection: Describe what you observe if relevant, but rely more on palpation for swelling, warmth, and crepitus.
• Palpation and movement: Guide the limb through active and passive range, explaining each movement. Compare both sides carefully.

Common Pitfalls and How to Avoid Them

• Assuming the disability explains all symptoms and therefore performing a limited examination.
• Failing to ask the patient about preferred positioning or communication methods.
• Examining through clothing or in a cramped space that restricts access.
• Relying solely on verbal responses when the patient has communication or cognitive difficulties. Watch facial expression and body language.
• Treating adaptations as optional rather than essential for accuracy and dignity.

Developing Inclusive Examination Skills

Skilled physical examination combines the classic techniques of inspection, palpation, percussion, and auscultation with the flexibility to accommodate different disabilities. When adaptations are made thoughtfully—as illustrated in the examples above—the examination becomes more accurate, more humane, and more effective for every patient.

Competence grows through practice, preferably supervised, with diverse patients. Ask for feedback from patients, disability advocates and experienced clinicians, and reflect on what worked or caused difficulty. 

Simulation can help, but real encounters conducted with curiosity, humility, and respect remain the best teacher.