Starting the exam

After you’ve summarized the interview and thanked your patient for sharing their history, transition to performing the exam. Briefly describe the exam elements that will be done, ask if there are questions or concerns, and request permission to proceed.

For hospital H&Ps, you could say, “Next I’d like to do a physical exam. I’ll examine your head and neck, listen to your heart and lungs, check your abdomen, and test your nerves and muscles? What questions do you have before we start? Is there anything I can do to make you more comfortable?”

To maximize privacy, ask if your patient would like others to leave the room during the exam. Closing the privacy curtain around the patient and close the door to the room.

To maintain the rapport and relationship that you built during the interview, stay sensitive to your patient’s comfort as you perform the exam. Our hands may feel cold, some elements of the exam may be uncomfortable or confusing, and the power differential between clinician and patient may discourage people from speaking up. Carefully observe for any signs of discomfort or anxiety and check in frequently with your patient, adjusting your approach as needed.

Preparing your equipment

Organize your medical equipment so that you can move smoothly through your exam without fumbling for the next piece of equipment. For the Immersion exam, you will need

  • Blood pressure cuff
  • Penlight
  • Tongue blade
  • Vision card or vision screening app
  • Stethoscope
  • Reflex hammer

Observing general appearance

You’ll already have carefully observed your patient as you interviewed them. Take a conscious moment to pause and consider what you have seen. For example,

  • At first glance, do they look well or ill? This first impression of “sick” can help to establish the urgency of the situation.
  • Are there nonverbal cues suggesting anxiety, discomfort, or pain?
  • What is the level of consciousness? Is your patient alert, or are they sleepy or confused?
  • How do they use speech and language? Are there any unusual features that suggest a neurologic or mental health disorder?
  • Are there signs of poor nutrition, such as wasting around the temples or loose clothing or jewelry?
  • Are there signs of poor perfusion, such as confusion or in lighter skinned individuals, pallor of the skin?
  • Are there bruises or injuries that might suggest child abuse or intimate partner violence?

Sample documentation: General appearance

Each physical exam chapter contains sample documentation. In your notes, feel free to adapt the suggested language to your findings on exam.

General appearance: Well-appearing and comfortable

OR

General appearance: Fatigued appearing, slightly anxious

License

The Foundations of Clinical Medicine Copyright © by Karen McDonough. All Rights Reserved.