A good physical examination (heent) starts the moment you see the patient. Watch how they look and walk. While taking history, notice behavior, mood, and understanding. Be gentle, quick, and thorough.
Core rules
- Use a fixed sequence. Make a routine so you don’t miss steps.
- Go regional. Look at the problem area and nearby regions, not every system in full.
- Be fast but careful. Keep the patient comfortable.
- Adapt to the situation. Your style can change with the clinic/ward and the patient’s condition.
- Don’t delay treatment. If the patient is very sick, treat once you have enough info and don’t wait to finish a “complete” exam.
- Keep dignity and safety. Use privacy, consent, and a female attendant, nurse, or female student when a male doctor/student is examine the female patient.
HEENT = Head, Eyes, Ears, Nose, Throat—a standard part of the general physical examination and a common first step in clinic.
Quick Checklists
A) Typical clinic patient (walk-in)
When a patient comes to you look these five things;
- First look: appearance, distress, gait
- Vitals: pulse, BP, temperature, respiratory rate, oxygen saturation
- Focused history: main problem, duration, red flags
- Regional exam: inspect → palpate → percuss → auscultate the target area; include nearby joints/nodes
- Targeted screen if needed (cardio-resp, abdomen, neuro)
- Summarize & plan: working diagnosis, tests, and first steps
B) Unconscious or very ill
- Resuscitation first (ABC). Start life-saving steps now.
- Rapid exam: quick head-to-toe; pupils; check glucose if needed.
- Minimal data: vitals + key signs to decide.
- Treat immediately; do the rest after the patient is stable.
- Document alertness with GCS (E, V, M; 3–15). Example: GCS 12/15 (E3 V3 M6).
Writing up the exam
Examine regionally, but write under systems (e.g., CVS, RS, Abdomen, CNS). If a sign fits in many places, write it once where it makes the most sense.
General Physical Examination (GPE)
1) General appearance
See if the patient looks well, mildly ill, or severely ill, and how distressed they look.
2) Consciousness & orientation
Is the patient alert, confused, drowsy, or in coma?
If reduced, write a GCS score with E/V/M.
Look for:
- Alert – awake, answers appropriately.
- Confused – awake but disoriented.
- Drowsy – keeps falling asleep, needs voice to rouse.
- Stupor – only responds to painful stimulus.
- Coma – no meaningful response
Examples:
- Alert and oriented.
- GCS 12/15 (E3 V3 M6).
3) Posture & attitude (what the position tells you)
- Orthopnea (heart failure): wants to sit up because lying flat worsens breathlessness.
- Tripod position (severe airway tightness/COPD/asthma): leans forward and fixes shoulder girdle to recruit accessory muscles.
- Peritonitis: lies still to avoid pain.
- Severe colic (renal/biliary/intestinal): keeps changing position, restless.
- Meningitis : neck stiff or extended may resist flexion
4) Physique: build, height, weight
- Measure, don’t guess: height, weight, BMI.
- Track weight trends in edema, ascites, heart/renal disease.
- If body looks out of proportion, compare arm span vs height.
Examples for notes
- “Build average. Ht 168 cm, Wt 66 kg, BMI 23.4.”
- “Calculate BMI = weight(kg) / height(m)².”
- “Tall habitus; arm span 178 cm vs height 172 cm (+6 cm).”
- “Weight 74.2 → 72.8 kg in 48 h after diuresis.”
HEENT Examination (primary focus)
Order you can trust
Inspect → Palpate → Special tests (as needed). Keep it short and gentle.
Head & Scalp
- Look for swelling, rash, wounds.
- Palpate for tender spots or lumps.
Eyes
- Eyelids and conjunctiva: pale = anemia; red = inflamed.
- Sclera: white vs yellow (jaundice).
- Pupils: equal, round, reactive to light and (PERRLA) is ok.
- Do a quick visual field screen if vision is a concern.
Ears
- Inspect outer ear and area behind it.
- Ask about pain, discharge, hearing loss.
- If you have an otoscope, look at canal and eardrum.
Nose & Sinuses
- Check for blockage, crusting, bleeding.
- Press gently on frontal/maxillary sinuses for pain.
Throat & Mouth
- With light and tongue depressor, check lips, teeth, gums, tongue, tonsils.
- Look for redness, white patches, sores, swelling, or bad breath.
Neck, Thyroid, and Lymph Nodes
- Inspect the neck. Ask the patient to swallow; watch the thyroid move.
- Palpate the thyroid for size, lumps, tenderness; listen for a thyroid bruit if hyperthyroid is suspected.
- Lymph node examination: submental, submandibular, pre/post-auricular, occipital, anterior/posterior triangles, and supraclavicular.
- Note site, size, number, tenderness, consistency, mobility, matted vs discrete, and any sinus/discharge.
- If you suspect a retrosternal goiter, raise both arms: facial redness/neck vein swelling suggests a positive Pemberton sign.
Hands
Look at shape, size, and posture of hand
- Carpal spasm (hands flexed and fingers tight) posture suggests tetany.
- Very large, broad hands suggest acromegaly.
- Short 4th metacarpal (on making a fist): think Turner syndrome (female).
- Short 4th & 5th metacarpal : pseudo-hypo-parathyroidism.
Nails what to look for
- Pallor (pale nailbeds): low Hb (anemia). In healthy persons nails are pink but in anemia patients its yellow (pale nail beds, check conjunctiva too).
- Cyanosis (blue): low oxygen. if nail are blue that means there is less oxygen in the body suggest heart/lung disease.
- Koilonychia (spoon nails): iron deficiency. if nails easily break and they are thin and concave shaped it presents iron deficiency in the body
- Clubbing: bulbous ends, soft base, loss of nail angle; Schamroth test loses the diamond gap. Do a Schamroth’s test put index fingers of both hand together = normal = tiny diamond gap. if there is no space between both fingers = clubbing. Bulbous “drumstick” fingertips in late stage.
- Tip: Curved nails without angle loss = not clubbing.
- Splinter hemorrhages: vertical hemorrhagic streaks seen in manual workers or infective endocarditis
- Leukonychia: white patches in nail plates is normal; also in hypo-albuminemia
- Pitting: large number of small pits in nails occurs in psoriasis.
Write-up templates
- Normal: “Nails: normal color; no pallor/cyanosis; no koilonychia; no clubbing (Schamroth gap present); no splinters; no pitting.”
- With clubbing: “Nails: clubbing present loss of nail-fold angle, spongy base; Schamroth gap absent.”
- With anemia signs: “Nails: pallor present; no cyanosis; no clubbing; plan iron studies.”
Causes of clubbing
- Respiratory disease (lung abscess, bronchiectasis, empyema, lung cancer, fibrosing alveolitis)
- Cardiovascular disease (cyanotic heart disease like tetralogy of fallot, transposition of great vessel, infective endocarditis)
- Gastrointestinal tract disease (malabsorption syndrome, Crohn’s disease, ulcerative colitis, primary biliary cirrhosis)
Fingers
- Osler nodes: small, painful swellings on finger tips also in infective endocarditis due to vasculitis.
- Heberden nodes (DIP) & Bouchard nodes (PIP) bony swelling: osteoarthritis. Tip: Painful = Osler. Painless lesions on palms/soles are Janeway don’t confuse in viva.
- RA changes: swollen MCP/PIP, ulnar deviation, swan-neck, boutonnière, Z-thumb.
- Arachnodactyly: long, thin fingers (e.g., Marfan).
- Swan neck deformity ; hyper extension of proximal interphalangeal joint and fixed flexion of distal interphalangeal join
- Button hole; fixed flexion of proximal interphalangeal joint and extension of terminal interphalangeal joint ‘Z’ deformity of thumb.
Palm
See any;
- Color (pale; thenar/hypothenar): anemia or low oxygen perfusion
- Sweating overactive sympathetic tone (anxiety = cold; thyrotoxicosis = warm).
- Palmar erythema: redness of thenar and hypothenar that is common in liver disease, pregnancy, thyrotoxicosis, RA, OCPs. Tip: press and release → blanching with quick refill.
- Dupuytren contracture: thick cord in palm → ring/little finger flexion; links: alcohol use, diabetes, epilepsy meds, family history.
Vitals and core measures
Pulse
Note rate and regularity.
Blood pressure
Measure in every patient (at start or end just don’t forget).
Respiratory rate
Count for a full minute. Normal adult: 14–16/min.
Temperature
- Oral, axillary, groin, or rectal are the areas.
- Rectal ≈ 1.0°F higher than oral; oral ≈ 1.0°F higher than axillary.
- Don’t check oral temp right after hot/cold drinks.
Face: the fast look
- General facies: moon face (Cushing’s), mask-like (Parkinsonism).
- Puffiness (periorbital): renal causes, myxedema, angioedema. In right heart failure, facial puffiness appears mainly if the patient can lie flat.
- Eyes: exophthalmos, lid lag/retraction (thyrotoxicosis), xanthelasma (lipids), rash (SLE “butterfly”).
- To see exohthalmos stand behind patient, lift the upper lids, see if cornea moves beyond lower lid. in graves disease protrusion is unilateral and later it bilateral. orbital tumor also cause unilateral exophthalmos. Sclera above and below the cornea is not visible, but in thyrotoxicosis the sclera is visible due to lid retract also present in proptosis sclera. For lid lag ask the patient to look straight at your finger and then follow it downwards. Normally both eyeball and upper eyelid move together while in thyrotoxicosis upper eyelid may lag behind.
- Xanthelasmas are yellow plagues on eyelids due to deposition of lipids associated with hyperlipidemia but normal in elders with normal lipids.
- Color of skin: Redness on the cheeks (malar flush) can be due to mitral stenosis and normal in normal individuals too.
- Hirsutism excessive growth of hair on face (moustache and beard area), limbs and trunk in a female.
- Parotid swelling: mumps (often both sides) or tumor (one side).
- Lip: Pull the lower lip and look for bluish discoloration of its inner surface due to cyanosis.
- Tongue: Look for dryness (which is seen in dehydration and mouth breathers), pallor and cyanosis on the dorsum of the look tongue and if size is enlarged its acromegaly
Neck: thyroid, JVP, and nodes
Examine the neck for:
- Thyroid.
- Neck veins
- Lymph nodes
Thyroid
- There are 2 lobes of thyroid connected by isthmus enlargment of it is called goiter.
- Inspect extend the neck of patient and look for swelling on sides of trachea or front of it. Ask to swallow. If swelling is moving with laryngeal cartilage on swallowing is enlarged thyroid. also note thyroid size , unilateral or bilateral , diffuse or nodular.
- Palpate put both hands on the swelling and palpate. Ask the patient to swallow and note characteristics as swelling moves under fingers, size , diffuse , single or multiple nodules, consistency, tenderness.
- Retrosternal thyroid: thyroid can be totally or partially retrosternal. Lower limit of thyroid cannot be reached. When patient is asked to raise both arms above the head there will be stridor , face congested and neck veins become distended that is pemberton sign.
- Bruit a bruit sound (murmur like sound) may be audible if thyroid is hyperfunctioning. Ask the patient to hold his breath while auscultation is done by bell. it should not be confused with murmur radiating from heart, carotid bruit or venous hum.
Neck veins (JVP)
- Patient at 45°, head slightly turned left.
- Look along the right sternomastoid border.
- Measure height above the sternal angle; > 3 cm above it suggests elevation (≈ >8 cm above right atrium). Clinical methods use the sternal angle because it sits ~5 cm above the RA at most positions.
Lymph nodes
Lymph nodes of the neck are divided into following group;
- Submental (under the chin) nodes
- Submandibular (under the jaw) nodes
- Pre and postauricular nodes
- Occipital nodes
- Lymph nodes of posterior triangle behind the sternomastoid.
- Lymph nodes of anterior triangle.in front of the sternomastoid.
- Supraclavicular nodes
Method of Palpation; Stand behind the patient, flex his neck and push middle and ring fingers of both hands under the chin. Move the fingers backwards to palpate submental and submandibular groups. Then palpate in front and behind the auricle and over the occiput. Move your fingers downwards behind the sternomastoid towards clavicle for lymph nodes of posterior triangle. For palpation of supraclavicular fossa, push your fingers behind the clavicle Finally, move the fingers upwards between trachea and sternomastoid for lymph nodes of anterior triangle.
If lymph nodes are palpable Record the site, size, number, consistency, tenderness, mobility (to skin/under-structures), matted vs discrete, discharge/sinus.
Clues: If lymph nodes are tender = acute infection; matted together in TB; rubbery consistency in Hodgkin; hard in metastasis
Axillary nodes (six groups):
- anterior
- posterior
- lateral
- medial
- central
- apical
- Elevate patient’s arm above his head and push fingers of the left hand up in the axilla, palm facing patient’s chest. Bring back patient’s arm alongside his chest. Move your fingers downwards along the chest wall. If lymph nodes are enlarged, they will slip between your fingers and patient’s chest. Elevation of patient’s arm is necessary to reach the apex of the axilla. In this way apical, central and medial groups are palpated.
- For palpation of anterior group, hold anterior axillary fold between thumb and fingers of your left hand. For lateral group, place pafmar aspect of fingers of your right hand along the medial side of the humerus.
- For posterior groups of both sides, hold posterior axillary folds between thumb and fingers of your corresponding hand from behind the patient.
- When a group of lymph node is palpable, examine its drainage area.
Epitrochlear nodes: at the elbow (medial).
Inguinal nodes: along the groin crease if enlarged, examine the leg/genital drainage area too.
Lymph nodes are commonly enlarged due to disease of the drainage area. when you detect an enlarged lymph node, examine the drainage area of that lymph node to exclude any pathology. Examine scalp, face and oral cavity in case of cervical lymph nodes, upper limb in case of axillary lymph nodes and lower limb in case of inguinal lymph nodes.
Common causes of enlarged nodes
- Infection or cancer in the drainage area
- Tuberculosis
- Lymphomas
- Leukemias
Feet and edema
Look for
- Hair loss and shiny skin (ischemia).
- Nail changes: clubbing, koilonychia, cyanosis.
- Edema: press firmly for 5 seconds over foot/shin (and sacrum if bedridden).
Types and causes
Pitting edema
- Generalized/bilateral
- Cardiac (more in lower body): right heart failure, constrictive pericarditis, pericardial effusion, IVC obstruction
- Renal (often more on face): renal failure, nephrotic syndrome
- Hypoproteinemia: cirrhosis (low albumin), malnutrition, malabsorption
- Localized: venous obstruction, immobility/paralysis, inflammation (cellulitis)
Non-pitting edema
- Lymphatic: filariasis, Milroy disease, post-surgery/irradiation
- Angioedema
- Myxedema
Here the skin is thick, the whole hand/foot is swollen (not like obesity where skin feels normal and the foot/hand may be spared).
State of hydration
In dehydration: sunken eyes, dry tongue, poor skin turgor (demonstrated by pinching a fold of skin between thumb and fingers; less reliable in elderly), fast pulse, low BP, low urine output.
Blood, skin, and color clues
Pallor
Check nails, palms, lower conjunctiva, dorsum of tongue. Strong vasodilation can mask anemia.
Cyanosis
Blue color appears when reduced hemoglobin ≥ ~5 g/dL in capillaries. Look at: nails, nose tip, ear lobes, inner lip, tongue.
- Peripheral cyanosis: nails/nose/ears blue; lips and tongue normal → low flow/cold/extraction; hands often cold.
- Causes: cold, severe hypotension, Raynaud, venous obstruction
- Central cyanosis:lips and tongue also blue → lung oxygenation problem or mixing of venous with arterial blood; patient often breathless.
- Causes: respiratory failure; cyanotic heart disease (TOF, TGA, Eisenmenger)
Jaundice
When bilirubin > ~2 mg%, skin and sclera turn yellow. Best seen in bright daylight and at the sclera. Differentiate from carotenemia: skin yellow but sclera white.
Subcutaneous emphysema
Skin feels crackly on touch (air under skin). Causes: chest injury/procedures, pneumothorax tubes, esophageal rupture, gas gangrene.
Hair distribution
Female pattern: pubic hair limited with a horizontal top border. Male pattern: triangle that points upward toward the navel. In cirrhosis, male pubic hair may look female-type; axillary hair may be lost. Hirsutism is excess hair in female (face, trunk, limbs).
Pigmentation patterns
- Addison disease: decreased production of cortisol by adrenal glands, there is dark brown pigmentation of exposed parts, axillae, palmar creases and recent scars. Bluish black pigmentation is also seen in buccal mucosa but it may be normal in Negroes
- Hemochromatosis: Generalized greyish-bronze color pigmentation.
- Chloasma: mask-like patches in pregnancy/OCP use.
- Café-au-lait: brown patches (e.g., neurofibromatosis).
- Albinism: total lack of melanin.
- Vitiligo: white + dark patches; linked with autoimmunity.
Sounds and odors
- Stridor: inspiratory whistling sound heard in upper respiratory tract obstruction. Wheeze is similar sound but occurs in expiration and is due to spasm of smaller airways. noisy inspiration (upper airway blockage).
- Wheeze: musical expiration (small airway spasm).
- Fetor hepaticus: In hepatic failure there is a sickly odor in the breath of the patient
- Acetone breath: In ketoacidosis there is a sweat smell in breath.
Skin lesion definitions
- Macule: flat color change
- Papule: small raised bump (<5 mm)
- Nodule: large raised bump (>5 mm)
- Vesicle: small clear blister (≤5 mm)
- Pustule: pus-filled vesicle
- Bulla: big blister (>5 mm)
- Wheal: puffy, from local edema
- Scale: flakes from the top skin layer
- Crust: dried fluid
- Purpura: bleeding into skin
- Petechiae: tiny (1–3 mm) red dots; don’t blanch
- Ecchymosis: big bruise
- Hematoma: soft, fluctuant blood collection
- Telangiectasia: small dilated vessels
- Spider nevus: central red dot with radiating lines; blanches from the center
- Campbell de Morgan spot: tiny, bright red, does not fade; common with age
- Erythema nodosum: tender red lumps on shins; causes include TB, strep, sarcoid, drugs
- Erythema marginatum: pink patches that join with pale centers; linked to rheumatic fever