Systemic Examination: Techniques Explained in Detail

1. INSPECTION

General Principles

• Requires good lighting, privacy, warmth, and adequate exposure of the body region
• Both a visual and olfactory tool
• Requires training to pursue and interpret keen observations
• Performed with the patient sitting (chest) or lying supine (abdomen)

What to Look For

• Symmetry and shape - kyphoscoliosis, pectus excavatum (sunken chest), pectus carinatum (pigeon chest), ankylosing spondylitis, gynecomastia, scars, or surgical defects
• Pattern of breathing - classic ventilatory patterns (Cheyne-Stokes, Kussmaul, etc.) that immediately hint at underlying illness
• Movement with respiration - lag or asymmetry of chest wall movement; a patient with peritonitis may show a rigid abdomen that does not move with breathing
• Skin signs - Grey Turner's sign (flank discoloration from retroperitoneal hemorrhage in severe acute pancreatitis or leaking AAA), Cullen's sign (periumbilical discoloration from blood tracking along ligamentum teres in pancreatitis or ruptured ectopic pregnancy), dilated veins, visible pulsations
• Abdominal contours - distension, visible peristalsis, bulging flanks (ascites gives a rounded symmetric contour), scaphoid appearance (peritonitis), hernias
• Olfactory clues - tobacco stains on teeth/fingers/clothing; ethanol odor on breath; ketone odor in diabetic crisis; foul smell of anaerobic lung abscess; sweet smell of Pseudomonas skin infection

Technique tip: The clinician should kneel so that the observer's eye is at the level of the patient's anterior abdominal wall - this is the best position to detect visible masses, peristalsis, and abdominal movement with respiration.

• Murray & Nadel's Textbook of Respiratory Medicine, p. 397
• Bailey and Love's Short Practice of Surgery 28th Edition, p. 1077

2. PALPATION

General Principles

• Must be performed systematically across all regions (nine regions of the abdomen)
• Hands must be warm (cold hands cause involuntary muscle spasm masking pathology)
• Begin in the region furthest from the site of pain and work toward it
• Watch the patient's facial expression constantly - it reveals discomfort before they verbalize it

Types of Palpation

• Light pressure using the whole palm (not fingertips)
• Forearm kept horizontal; movement only at the metacarpophalangeal joints, never at the interphalangeal joints - this avoids "poking" which elicits voluntary guarding
• Detects surface tenderness, guarding, skin temperature, obvious masses

• Used only if superficial tenderness allows
• Identifies organs (liver, spleen, kidneys) and deeper masses
• Palpation during respiration helps identify lower margins of the liver and spleen as they move with breathing

• Have the patient say "one, two, three" while the examiner's palms move from top to bottom across both hemithoraces
• Increased fremitus - consolidation (pneumonia): sound transmits better through solid lung
• Decreased fremitus - pleural effusion: sound transmission impaired by fluid
• The tracheal position is felt at the suprasternal notch - deviation suggests mediastinal shift
• Subcutaneous emphysema produces a characteristic "crackling" under the fingers (crepitus)

• Always search for: apical impulse (normally 5th intercostal space, midclavicular line), heaves, lifts, thrills (palpable murmurs), and palpable valve closure
• In severe COPD, cardiac movements are better felt in the subxiphoid region than over the precordium

Signs Elicited by Palpation

• Guarding - voluntary or involuntary contraction of abdominal wall over area of pain
• Rigidity - involuntary "board-like" hardness when underlying peritoneal inflammation becomes generalized
• Rebound tenderness - pain worse on sudden release of pressure (indicates peritoneal irritation; gentle percussion is an equally sensitive and less distressing alternative)
• Shifting dullness confirmation - doughy feel of the abdomen in tubercular peritonitis
• Bailey and Love's Short Practice of Surgery 28th Edition, p. 1077-1078
• Murray & Nadel's Textbook of Respiratory Medicine, p. 397

3. PERCUSSION

Technique

• The pleximeter finger (usually the middle finger of the non-dominant hand) is placed firmly flat on the body surface
• The plexor (striking finger - middle finger of the dominant hand) delivers a uniform, free, easy stroke onto the pleximeter
• The wrist movement is a quick snap, not from the shoulder or elbow
• The percussion note is heard but predominantly felt - requires a keen sense of vibration and minor changes in pitch
• Move systematically from resonant to dull zones for best sensitivity

Percussion Notes

Applications

• Normal over air = resonant
• Large pneumothorax = hyperresonant; tension pneumothorax = tympanitic
• Pleural effusion/pneumonia = dullness
• Three zones can be detected over a large pleural effusion moving downward: normal resonance (above fluid) → dullness (middle zone) → flatness (completely submerged zone)

• Distinguishes bowel gas (tympanic) from solid masses (dull) and free fluid
• Testing for ascites: percussion from umbilicus outward to flanks reveals flank dullness
• Shifting dullness: patient turned to one side - the border between resonance and dullness shifts as free fluid moves
• Fluid thrill: a tap on one flank is felt as a vibration on the opposite flank; an assistant's hand placed on the midline prevents transmission through the abdominal wall

• Extremely sensitive - if the patient winces on light abdominal percussion, peritonitis is likely
• Often preferred over rebound testing as it is less distressing to the patient
• Bailey and Love's Short Practice of Surgery 28th Edition, p. 1078
• Murray & Nadel's Textbook of Respiratory Medicine, p. 397

4. AUSCULTATION

The Stethoscope

• Diaphragm (flat side) - detects higher-pitched sounds (breath sounds, normal heart sounds S1 and S2, friction rubs)
• Bell (cup side) - detects lower-pitched sounds (S3, S4 heart sounds, diastolic murmurs)
• If the bell is pressed too firmly, the taut skin acts like a diaphragm and higher pitches are enhanced instead
• Keep stethoscope clean - it is a recognized vector of nosocomial infection; isopropyl alcohol (glycerin-free) wipes are preferred; bleach is used if C. difficile is possible

Respiratory Auscultation

• Stethoscope useful when chest X-ray is normal (wheezes in asthma, crackles in interstitial lung disease)
• Electronic stethoscopes offer noise reduction and amplification - useful in ICU or noisy environments, though magnitude of improvement over best acoustic models is small

Cardiac Auscultation

• Aortic area - 2nd right intercostal space, right sternal border
• Pulmonary area - 2nd left intercostal space, left sternal border
• Tricuspid area - 4th/5th left intercostal space, lower left sternal border
• Mitral area - 5th intercostal space, midclavicular line (apex)

Abdominal Auscultation

• Bowel sounds - normally low-pitched gurgles every 5-10 seconds
  • High-pitched, tinkling or "rushed" sounds = early mechanical obstruction (air and fluid rushing through a narrowed segment under pressure)
  • Absent / very infrequent = paralytic ileus or generalised peritonitis
• Bruits - heard over a stenosis (aortic bruit at midline, renal artery bruit in flank, iliac artery bruit in iliac fossa) - indicates turbulent flow through a narrowed vessel
• Succussion splash - a "water in a bottle" sloshing sound on shaking the patient; suggests gastric stasis from gastric outlet obstruction (retained food and fluid)
• Murray & Nadel's Textbook of Respiratory Medicine, p. 397-399
• Bailey and Love's Short Practice of Surgery 28th Edition, p. 1078

Summary: The Four Techniques Applied by System