How to Perform a Thorough but Streamlined Medical Physical Exam

This is designed to help med students put the physical exam together. There is a lot to remember, and having a memorized, organized sequence can make sure it's quick and you don't miss any steps. The basic idea behind this system is a "down and back up" method, because doing everything in one swab from top down gets the musculoskeletal exam all mixed up with everything else. Memorize the whole thing and get fast at it, then when it's time to put it to use, skip what you don't need.

Steps

  1. 1
    Wash your hands before examining the patient.
  2. 2
    Introduce yourself to the patient, and record their height and weight.
  3. 3
    Gather a medical history of the patient. This can include questions based on lifestyle, diet, physical activity, etc.
  4. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 1
    4
    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.
  5. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 2
    5
    Otoscope --- Here you want to view the ear canal (and while you're at the ear, rub your fingers together to test hearing ... then head to Weber and Rinne if you suspect a problem); then the nares; then the oropharynx. Use the otoscope then to start the eye exam. Check pupillary reflex, then have them follow the light to check extra-ocular muscles. Finish the otoscope theme by bringing the light towards the nasal bridge and back to check accommodation.
  6. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 3
    6
    Stay with the eye for the next two --- give them a Snell test if you have the card handy, and pull the lower eyelids down to look at the conjunctival.
  7. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 4
    7
    Lymph node time. Check the neck, around the ears, then above the collar bone. It is also wise to feel the nodes in the armpits and groin too.
  8. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 5
    8
    Thyroid exam. Feel for the thyroid gland in the patient's neck. Ask them to swallow.
  9. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 6
    9
    Skin ... a) pallor? b) lesions?
  10. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 7
    10
    Arms vasculature, from proximal to distal ... a) pulses (brachial and radial); b) warmth of hands; c) hair on digits ("hair don't grow where blood don't flow"); d) capillary refilling under the fingernails.
  11. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 8
    11
    Head, neck, and arms got their first swipe. Let's head down to the thorax with a stethoscope as our reminder of next steps. First, lung exam. I do three spots on each lung in the back, and 1 on each lung in the front. Listen for any crackles, wheezes, or rhonchi.
  12. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 9
    12
    Now that you're in the front, might as well listen to the heart, right?
  13. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 10
    13
    Heart's done, but how's it working on the carotids??? Check them out with the bell of your stethoscope.
  14. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 11
    14
    Still on the stethoscope, have your patient lay flat and begin the abdominal exam by listening for bowel sounds in all four quadrants.
  15. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 12
    15
    Palpate the spleen and liver while the patient breathes in.
  16. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 13
    16
    Palpate the liver, spleen, kidneys, and aorta. Listen for an aortic bruit just above the navel
  17. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 14
    17
    While you're down there, feel for the femoral artery and inguinal lymph nodes.
  18. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 15
    18
    Now that the abdominal exam is done, sit them up and start on the deep tendon reflexes. I actually head back to the arms to get the biceps, triceps, and brachioradialis, and then when I'm done with the patellar and calcaneal, I'm down at the feet and can do some stuff down there ...
  19. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 16
    19
    Feet vascular exam, proximal to distal --- a) pulses (popliteal and dorsalis pedis); b) warmth assessment; c) hair on the toes? d) capillary refilling
  20. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 17
    20
    Diabetic foot exam --- assess fine touch and vibratory sense starting distally and moving approximately until they can feel it. Also, have them close their eyes and check for conscious proprioception by seeing if they can tell if you've moved their toes up as opposed to down.
  21. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 18
    21
    Okay, now we start heading back upwards, and we use the musculoskeletal exam to do it. I used to say, "Okay, I'm going to pull your leg up, but don't let me." I've found it's much faster to just say "push your leg down" and then oppose it. For ease of writing and reading, I'm going to write this out like that (so I oppose each of the following actions I'm telling the patient to do): "Lift your big toe up for me. Now lift your whole foot up. Now push down on the gas. Kick your leg out [I'm assuming the patient is sitting]. 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, I push down on the arms to check shoulder strength]. Stick your arms out in front of you and squeeze them together [pectorals]."
  22. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 19
    22
    I stay with the muscle theme as I head superiorly, but I am also heading into the unfinished cranial nerve exam. I say "shrug your shoulders" and "turn your head to the left, and now to the right" to test for the accessory nerve and its muscles. Next, "Smile real big for me. Show me your upper teeth. Puff your cheeks out. Say 'la la la ... mi mi mi ... ka ka ka' (cranial nerves XII, VII, and X respectively]. Close your eyes really hard and don't let me open them. Clench your jaw shut tight."
  23. Image titled Perform a Thorough but Streamlined Medical Physical Exam Step 20
    23
    I end on the cerebellar exam. Here's 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." I next do dysdiadochokinesis testing, I have them draw a stripe down their shin with the opposite heel, and I end by having them walk across the room if I have questions about gait.

Article Info

Categories: College University and Postgraduate