PEARLS for an Ultrasound Physical and Its Routine Use as Part of the Clinical Examination

Michael Wagner, MD; Janice Boughton, MD


South Med J. 2018;111(7):389-394. 

In This Article

PEARLS General Description

The PEARLS mnemonic represents the general windows into the body for probe positioning (Figure 2). We use many of the same probe positions as are used in the Extended Focused Assessment with Sonography for Trauma,[8] the Cardiopulmonary Limited Ultrasound Examination,[13] or the Rapid Ultrasound for Shock and Hypotension protocols.[16] Using these general windows, it is possible to diagnose numerous conditions beyond the targets of these protocols more accurately than the traditional examination, particularly in detecting abdominal pathology or determining the elusive "volume status" of a patient.

Figure 2.

General windows for probe positioning in the PEARLS examination. PEARLS, Parasternal, Epigastric, Anterior Lung, (and/or Apical), Right upper quadrant, Left upper quadrant, and Suprapubic.

Rather than looking for specific findings to complete a diagnostic algorithm for a single clinical scenario, we advocate for a scaled examination that becomes more comprehensive with examiner experience and training and can be adjusted to the clinical setting and scenario. PEARLS is not only a mnemonic for body region but also a method for growing one's POCUS skill set, the basics of which should be learned by all POCUS users and taught alongside other physical examination skills. We agree with Liu and colleagues that a cornerstone of a POCUS examination should be the assessment for fluid where fluid should not be (eg, pericardial effusion, pulmonary edema, pleural effusion, ascites),[19] which is paired frequently with an assessment of intravascular volume status by evaluating the inferior vena cava (IVC). Although the probe positions and views for beginners can be learned and performed rapidly (often in <3 minutes), how exactly to incorporate the findings clinically takes time and experience. For example, the detection of free abdominal fluid also can be helpful in patients without blunt trauma, but it will mean different things for the medical intensive care unit patient with sepsis compared with the clinic patient with new abdominal pain. As one grows in experience and training, however, using the same general windows, one can layer new views and diagnostic targets, tailoring them to the patient and the clinical scenario. Below, each component of the PEARLS examination is described briefly for both the beginner and the more experienced POCUS user. For more detailed descriptions, the reader is directed to the Appendix (

Although the PEARLS mnemonic serves as a useful memory aid to ensure a complete and thorough examination, it need not be performed in that order. Frequently we start by "going where it hurts," using the probe as an extension of the hand when palpating. Like reading chest x-rays and electrocardiograms, however, having a system helps ensure nothing is missed.

The PEARLS examination is meant to be performed routinely, whenever a thorough physical examination is indicated. There is great utility in detecting changes from baseline as part of a serial examination, particularly those in the hospital or with conditions that result in frequent hospitalizations (eg, heart failure). Regular practice allows PEARLS to be completed in <3 minutes, with some of our medical students completing the limited version in <2 minutes.

To integrate US it may be necessary to restructure the clinical encounter, moving into the examination earlier. During the US portion of the examination, the interview can continue, and the quality of the questions and the accuracy of the answers may be affected by the real-time visualization of the viscera. In our experience, taking the cardiac history is much more fruitful while looking together at the heart, and taking a social history while imaging the liver can be rather enlightening, sometimes opening doors for motivational interviewing.

Finally, it is important to take steps that ensure that the technology brings the physician and patient closer together. Turning the screen to face the patient and his or her family or having the patient hold the device while the clinician steers the transducer can help engage curious patients. Be mindful of things such as gel temperature and probe pressure. A brief explanation of the findings and how it does or does not affect your clinical decisions enhances patient satisfaction with the examination.