General Physical Examination Techniques

Physical examination is the systematic assessment of a patient’s body systems using the techniques of inspection, palpation, percussion, and auscultation — in that specific order (except for abdominal examination, where auscultation precedes palpation and percussion). For the DOH (UAE) licensure examination, you must demonstrate competence in a complete head-to-toe examination while maintaining patient safety, dignity, privacy, and clear communication throughout. The UAE’s diverse patient population means you will encounter individuals from many cultural backgrounds — always explain each step before performing it, use a chaperone when examining opposite-gender patients, and ensure proper draping at all times.

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🟢 Lite — Quick Review (1h–1d)

Rapid summary for last-minute revision before your exam.

The Four Techniques — In Order:

1. Inspection — Look (use vision, note smells)
2. Palpation — Feel (light → deep; use dorsum of hand for temperature, palmar surface for texture)
3. Percussion — Tap (direct or indirect; produces sounds: resonant, dull, tympanic, flat)
4. Auscultation — Listen (stethoscope; only after inspection and palpation are complete except abdomen)

Key Principles for UAE Practice:

Principle	Application
Privacy and dignity	Close curtains, door, provide gown; expose only area being examined
Chaperone policy	Always offer/use a chaperone for intimate examinations (breast, genital, rectal)
Hand hygiene	Wash hands before and after every patient contact (5 moments of hand hygiene)
Warm hands	Cold hands startle patients; warm them before palpation
Right-handed examiner	Stands on the patient’s right side
Document immediately	Never leave documentation until end of shift

⚡ Exam Tip: If asked to demonstrate a specific system examination (e.g., cardiovascular), ALWAYS start by measuring vital signs before examining that system. Skipping vital signs is a common exam failure.

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🟡 Standard — Regular Study (2d–2mo)

Standard content for students with a few days to months.

1. General Inspection (The First 30 Seconds)

The moment you enter the patient’s room, inspection has already begun. Assess:

• General appearance: Alert and oriented or distressed? Comfortable or in obvious pain?
• Nutritional status: Cachectic (wasted), obese, or normal? Bulging cheeks may indicate mumps (still seen in the Gulf); pedal oedema suggests cardiac or renal disease (common in UAE due to high salt intake in traditional diets)
• Skin colour: Pallor (anaemia — common in migrant workers in UAE), jaundice (liver disease, haemolytic conditions), cyanosis (cardiac or respiratory compromise), bronzing (Addison’s disease)
• Posture and gait: Antalgic gait (painful), shuffling gait (Parkinsonism), wide-based gait (cerebellar ataxia)
• Facial expression: Guarding, grimacing, flat affect
• Hygiene and grooming: Poor hygiene may indicate depression or inability to self-care

2. Vital Signs as the Foundation

Before any system examination, measure and record:

A. Temperature

• Normal: 36.5–37.5°C (97.7–99.5°F)
• Methods: Oral, axillary, tympanic (most common in UAE facilities), rectal (avoid unless necessary; contraindicated in cardiac patients due to vagal stimulation)
• Fever patterns: Continuous ( typhoid), remittent (most infections), intermittent (malaria — consider in returning travellers in UAE), cyclical (weekly in rat-bite fever)

B. Pulse (Radial Artery)

• Rate: 60–100 bpm (bradycardia <60; tachycardia >100)
• Character: Regular or irregular? If irregular, describe pattern (regularly irregular = respiratory sinus arrhythmia in young people; irregularly irregular = atrial fibrillation — common in elderly UAE nationals)
• Volume: Full/bounding (hypertension, anxiety), weak/thready (hypovolaemia, shock)
• Site: Radial (most common), carotid (only in cardiac arrest assessment — never in elderly due to carotid sinus sensitivity), brachial (blood pressure measurement)

C. Respiratory Rate

• Normal: 12–20 breaths/min
• Count for full 60 seconds (most accurate); do not tell patients you are counting as awareness changes breathing
• Depth: Shallow vs deep (Kussmaul breathing = deep and rapid, seen in diabetic ketoacidosis)
• Pattern: Cheyne-Stokes (alternating apnoea and hyperpnoea; seen in brainstem injury, severe heart failure), Biot’s breathing (irregular periods of apnoea; brainstem lesion)
• Stridor (high-pitched inspiratory sound — airway obstruction) vs wheeze (expiratory — lower airway)

D. Blood Pressure

• Normal: <130/80 mmHg (UAE DOH follows WHO/ISH guidelines)
• Hypertension is prevalent in Emirati population (estimated 30-40% of adults); ALWAYS use appropriate cuff size (too small = falsely high; too large = falsely low)
• Korotkoff sounds: Phase I (onset) = systolic; Phase V (disappearance) = diastolic (in UAE practice; some use IV)
• Orthostatic hypotension: Drop of >20 mmHg systolic or >10 mmHg diastolic on standing = significant; check in elderly and patients on antihypertensives

E. Oxygen Saturation (SpO₂)

• Normal: 95–100% on room air
• <94% = hypoxaemia (requires supplemental oxygen per UAE DOH oxygen therapy protocol)
• <90% = severe hypoxaemia (medical emergency)
• Note: Pulse oximetry may be inaccurate in poor perfusion, dark nail polish (common in Gulf region — remove polish before reading), or carbon monoxide poisoning (SpO₂ reads falsely normal because co-oximetry cannot distinguish carboxyhaemoglobin from oxyhaemoglobin)

3. System-by-System Examination

A. Cardiovascular Examination

• JVP (Jugular Venous Pressure): Measure with patient at 45°. Elevated JVP (>3cm above sternal angle) suggests right heart failure or fluid overload — increasingly common in UAE due to high-salt traditional diets
• Precordial examination: Palpate apex beat (5th intercostal space, midclavicular line); heaves (right ventricular hypertrophy); thrills (turbulent flow — associated with VSD, mitral regurgitation)
• Auscultation: Listen at all 5 valvular areas. Focus on S1 and S2 (split S2 is normal on inspiration), added sounds (S3 gallop = heart failure; S4 = stiff ventricle — hypertensive heart disease), murmurs (timing — systolic vs diastolic; character — blowing, rumbling; radiation; maneuvers that change them)

B. Respiratory Examination

• Inspection: Barrel chest (COPD — common in UAE due to high smoking rates including shisha); tracheal deviation (tension pneumothorax = emergency)
• Palpation: Chest expansion (asymmetrical = collapse, pleural effusion); tactile vocal fremitus (increased over consolidation, decreased over pleural effusion)
• Percussion: Dullness over consolidation (lobar pneumonia is still prevalent in UAE) or pleural effusion; hyperresonance over pneumothorax or emphysema
• Auscultation: Breath sounds (vesicular, bronchial); added sounds — crackles (pulmonary oedema, pneumonia), wheezes (asthma, COPD — both very common in UAE due to desert dust and air quality), pleural rub

C. Abdominal Examination

• Order for abdomen is different: Inspect → Auscultate → Percuss → Palpate (because palpation and percussion can alter bowel sounds)
• Auscultation: Listen for bowel sounds (absent = paralytic ileus, increased = early obstruction); bruits over renal arteries (hypertensive patients)
• Organomegaly: Palpate liver (normally not palpable below costal margin; if palpable, measure in cm below costal margin), spleen (normally not palpable; if palpable, think haematological malignancy, malaria exposure), kidneys (ballotable)

D. Neurological Examination (Mini-Mental State Examination — MMSE)

• Orientation: Time (day, date, month, year) and place
• Registration: Recall 3 objects immediately and after 5 minutes
• Attention: Serial 7s or spell “world” backwards
• Language: Naming, repetition, written command, written sentence
• Praxis: Copy a intersecting pentagon design
• Score: 30/30 normal; <24 indicates cognitive impairment

4. Documentation

Document findings systematically using objective, descriptive language. Avoid interpretive statements:

• ❌ “Patient has pneumonia”
• ✅ “Increased tactile vocal fremitus over right lower lobe; dull to percussion; bronchial breath sounds and late inspiratory crackles auscultated over right lower lobe”

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🔴 Extended — Deep Study (3mo+)

Comprehensive coverage for students on a longer study timeline.

5. Specific Examination Considerations in the UAE Context

A. Infectious Disease Precautions The UAE has experienced outbreaks of MERS-CoV (Middle East Respiratory Syndrome Coronavirus), and the region is endemic for brucellosis, tuberculosis, and hepatitis B and C. Standard precautions apply to ALL patients — assume every patient is potentially infectious:

• Hand hygiene (5 Moments — WHO)
• PPE based on risk assessment
• Safe injection practices
• Sharps disposal (UAE has strict needlestick injury protocols)
• Respiratory hygiene/cough etiquette

B. Cultural Considerations in Examination

• Modesty: Female Muslim patients may prefer female healthcare providers for intimate examinations. Always offer a same-gender examiner or chaperone. Do not force examination — explain the clinical necessity calmly
• Permission: Always ask before removing any item of clothing; explain why it is necessary
• ** Pain assessment:** Some Arab patients may have different pain expression norms — use a visual analogue scale with faces and provide Arabic translation
• Eye contact: Direct eye contact may be considered disrespectful by some patients from certain Arab or Asian cultures — be culturally sensitive
• Gulf Region Specific Pathologies: Practice pattern recognition for conditions prevalent in the Gulf: familial Mediterranean fever (FMF), diabetes mellitus and its complications, metabolic syndrome, vitamin D deficiency (very high prevalence in veiled women due to limited sun exposure), renal disease

C. Documentation and Legal Requirements DOH (UAE) requires:

• Informed consent for all examination and procedures — written consent for invasive procedures
• Documentation of all findings without bias or personal opinion
• All nursing notes must be countersigned by a licensed nurse or physician as appropriate
• Incident reports for any adverse events (falls, medication errors, needlestick injuries)

Exam Watch: DOH examiners frequently set up scenarios where a patient refuses an examination or procedure. The correct answer is ALWAYS to respect the patient’s autonomy, explain the clinical implications of refusal, document the refusal, and inform the physician. Never proceed against a patient’s will.

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