Perform a Thorough but Streamlined Medical Physical Exam
Template:CopyeditbotThis 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
- Wash your hands before examining the patient.
- Introduce yourself to the patient, and record their height and weight.
- Gather a medical history of the patient. This can include questions based on lifestyle, diet, physical activity, etc.
- 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.
- 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.
- 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.
- 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.
- Thyroid exam. Feel for the thyroid gland in the patient's neck. Ask them to swallow.
- Skin ... a) pallor? b) lesions?
- 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.
- 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.
- Now that you're in the front, might as well listen to the heart, right?
- Heart's done, but how's it working on the carotids??? Check them out with the bell of your stethoscope.
- Still on the stethoscope, have your patient lay flat and begin the abdominal exam by listening for bowel sounds in all four quadrants.
- Palpate the spleen and liver while the patient breathes in.
- Palpate the liver, spleen, kidneys, and aorta. Listen for an aortic bruit just above the navel
- While you're down there, feel for the femoral artery and inguinal lymph nodes.
- 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 ...
- Feet vascular exam, proximal to distal --- a) pulses (popliteal and dorsalis pedis); b) warmth assessment; c) hair on the toes? d) capillary refilling
- 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.
- 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]."
- 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."
- 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.
