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How to Perform a Thorough but Streamlined Medical Physical Exam
This article describes a method of teaching medical students how to do a physical examination. It is designed to help them to remember every step required in a physical exam, as well as how to sequence them in an order that flows easily. The basic idea behind this system is a "down and back up" method. It is designed to be easier than combining everything into one sweep from the top down. Going from the top down tends to get the musculoskeletal exam all mixed up with other parts of the examination. If you memorize the exam in this format, you will get quicker through practice, ensuring that you do not miss any part of the exam.
Introduce yourself to the patient.If this is a new patient in your practice, put them at ease by first introducing yourself. Next, record their height and weight.
Gather a medical history of the patient.This should include questions about previous medical conditions, diet, physical activity or any history of family conditions, such as heart disease, diabetes or cancer.
Check the blood pressure and pulse.Use a blood pressure cuff and a stethoscope for the blood pressure, and measure the patient's pulse on the wrist with your fingers.
Use the otoscope.The otoscope is a medical device used to view the ear canal. While you are at the ear, you can check hearing by rubbing your fingers together for three to four seconds test hearing. If you suspect a hearing issue, you may consider further hearing tests. Using the otoscope, move to the nares, then onto the oropharynx. Next, use the otoscope to start the eye exam. Check pupillary reflex, by having them follow the light with their eyes, to check extra-ocular muscles. Finish the otoscope theme of the exam by bringing the light towards the nasal bridge and back to check nasal bridge accommodation.
Continue examining the eye.Give them a Snell test if you have the card handy. Next, pull the lower eyelids down to look at the conjunctiva.
Do a check of the lymph nodes.Check the neck, around the ears, and above the collarbone. It is also wise to feel the nodes in the armpits and groin area.
Proceed with a thyroid exam.Feel for the thyroid gland in the patient's neck. Ask them to swallow.
Examine the skin.Look for poor pallor or paleness. Check for any lesions.
Check the arm vasculature, from proximal to distal.Check:
- pulses (brachial and radial)
- warmth of hands
- hair on digits ("hair don't grow where blood don't flow")
- capillary refilling under the fingernails.
Move down to the thorax.Head, neck, and arms got their first swipe. With a stethoscope, head down to the thorax. Start with the lung exam. Starting at the back, position the stethoscope in three different spots of each lung area, then move to the front and listen to one area of each lung. Listen for any crackles, wheezes, or rhonchi.
Listen to the heart.Now that you are in the front, might as well listen to the heart, right?
Carry on to the carotids.The heart's done, but how about the carotids? Check them out with the bell of your stethoscope.
Start the abdominal exam.Have your patient lay flat and begin the abdominal exam by using the stethoscope to listen for bowel sounds in all four quadrants.
Palpate the spleen and liver.Palpate each while the patient breathes in.
Palpate the kidneys, and aorta.Listen for an aortic bruit just above the navel.
Finish the abdominal exam.Feel for the femoral artery and inguinal lymph nodes and any abnormalities.
Commence checking reflexes.Have the patient sit up and start on the deep tendon reflexes. Head back to the arms to get the biceps, triceps, and brachioradialis. When that is done continue with the patellar and calcaneal, going down at the feet.
Begin examining the feet.Start the foot vascular exam, proximal to distal.
- Pulses (popliteal and dorsalis pedis)
- Warmth assessment
- Hair on the toes
- Capillary refilling
Commence a diabetic foot exam.Assess fine touch and vibratory sense, starting distally and moving slowly until they can feel it. Also, have them close their eyes and check for conscious proprioception by seeing if they can tell if you have moved their toes up as opposed to down.
Start heading back upwards.Use the musculoskeletal exam to do it. Have the patient take a sitting position. Say, "push your leg down" and then oppose it. Test motion by opposing each of the following actions you tell the patient to do. Ask them to:
- "Lift your big toe up for me. Now lift your whole foot up. Now push down on the gas. Kick your leg out. Bring it back in. Squeeze your knees together. Now push them apart. Lift your leg off the table."
- "Grab my fingers and squeeze. Now make a muscle like Popeye. Straighten your arm out. Bend your arms and point your elbows to the side. (Here, you want to push down on the arms to check shoulder strength.) Stick your arms out in front of you and squeeze them together [pectorals]."
Stay with the muscle theme as you head superiorly.You are also heading into the unfinished cranial nerve exam. Say:
- "Shrug your shoulders."
- "Turn your head to the left. Now to the right." (Test for the accessory nerve and its muscles.)
- "Smile real big for me. Show me your upper teeth. Puff your cheeks out. Say 'la la la ... mi mi mi ... ka ka ka'." (This is to examine the cranial nerves XII, VII, and X respectively).
- "Close your eyes really hard and don't let me open them. Clench your jaw shut tight."
End with the cerebellar exam.Here is how it goes: "Stick your arms out, palms up, and close your eyes. Okay, now touch your fingers to your nose with your eyes still closed. Okay, open your eyes and touch your index finger to my index finger. Now bring it back to your nose, back to my finger, back to your nose, back to my finger." Next do dysdiadochokinesis testing. Have the patient draw a stripe down their shin with the opposite heel. End the examination by having them walk across the room, if you have questions about gait.
QuestionWhen do I have a nude exam?Top AnswererIt is rarely--if ever--necessary to disrobe completely for a medical exam.Thanks!
QuestionCan a women be examined like a man?wikiHow ContributorCommunity AnswerYes, a woman can receive a physical exam. No, it is not the same exam a man would have.Thanks!
QuestionWhat is dysdiadochokinesis testing?Top AnswererIt is a test of a muscle group's ability to perform rapid, alternating movements, such as repeatedly opening and closing a fist.Thanks!
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