Complete Clinical Picture

How do you perform the examination in a way that is complete, makes sense and yet is not awkward or prolonged? Is it OK to mix together different areas of the exam or should each system be explored as a block? As I am sure you’ve already recognized, these and many other related questions are not easy to answer. Putting together a smooth exam is, in fact, quite challenging. There is no single right way to perform a complete physical. The goal is to generate a method that works for you. Any technique, however, should:

  1. Cover all aspects of the examination such that you have a reasonable chance of identifying any
    pathology that might in fact be present.
  2. Be readily reproducible, allowing you to perform the exam the same way all the time.
  3. Keep patient gymnastics to a minimum (i.e. limit the number of times that the patient
    has to get up and down).
  4. Link together sections which, although disconnected physiologically, are connected spatially.
    It makes sense, for example, to integrate the cranial nerve and head and neck examinations as both involve the same region of the body.
  5. Allow you to be efficient and perform the exam with an economy of movement (i.e. minimize the number of times that you pick up and put down instruments, move from one side of the patient to the other, etc.).

It may take a fair amount of time, thought and practice before you come up with a system that works for you. I encourage you to experiment while choreographing your own moves.

What follows is not an in-depth review detailing the specifics of each area of the exam. Rather, it is simply an outline of the “mechanical events” that make up a complete physical.

  1. Wash your hands.
  2. Have the patient change into a hospital gown and take a seat at the end of the examining table. If possible, spend a few minutes simply watching them.
  3. Determine the blood pressure in both arms.
  4. Count the pulse. Measure this at both radial arteries simultaneously. Following this, examine the hands and fingers.
  5. Respiratory rate is noted while counting the pulse. Temperature is measured at the same time.
  6. Feel for axillary lymph nodes.
  7. Examine the scalp and head for any superficial abnormalities.
  8. Feel for lymph nodes in the head and neck.
  9. Have patient raise eyebrows, wrinkle forehead, close their eyes and smile (CN 7).
  10. Check sensation to touch on face; Feel temporal and masseter muscles when jaw clenched (CN 5).
  11. Assess extra occular movements (cranial nerves 3, 4, & 6).

    Check visual fields and acuity (CN 2) if appropriate.
  12. Using ophthalmoscope, check pupillary response to light (direct and indirect). Look for red reflex. Examine external structures of the eye.
  13. Perform fundoscopy. When examining the left eye you will have to walk to the left side of the body.
  14. Examine the nose.
  15. Ask the patient to show their teeth and stick out their tongue. Using the otoscope, examine the oral cavity. (CN 9, 10, 12).
  16. Examine the outer and inner ears. You will again have to walk to the left side of the body to look at the left ear.

    Check hearing acuity, Weber, and Rinne (CN 8) if appropriate.
  17. Have the patient shrug their shoulders and turn their head from side to side (CN 11).
  18. Walk behind the patient and feel the thyroid gland.
  19. Palpate the spine.
  20. Observe, palpate, percuss and auscultate the posterior lung fields as well the right middle lobe and the lingula.
  21. Walk around to the front, ask the patient to lie down, and listen to the anterior lung fields.
  22. Look at the cardiac area of the chest. Then feel for the point of maximal cardiac impulse.
  23. Auscultate the heart.
  24. Have the patient turn their head to the left and assess for jugular venous distention.
  25. Palpate the carotids.
  26. Listen over the carotids.

    *Note….Steps 19 thru 25 can be performed without ever removing your stethoscope from your ears.
  27. Observe, auscultate, percuss and palpate the abdomen.
  28. Feel for inguinal adenopathy and asses femoral and then popliteal pulses.
  29. Examine the feet, looking for edema, ulcers, discoloration, etc. Check for dorsalis pedis and posterior tibial pulses.
  30. Ask patient to sit up.
  31. Assess for Babinski.
  32. Check achilles and patellar reflexes.
  33. Assess muscle bulk, tone and strength in lower extremities.

    Check sensation to pin prick, light touch, vibration, and position sense in feet and lower extremities if appropriate.
  34. Check biceps, triceps and brachioradialis reflexes.
  35. Assess muscle bulk, tone and strength in upper extremities.

    Check sensation in upper extremities, as described for lower extremities, if appropriate.
  36. Assess cerebellar function with finger to nose and heel to shin testing.
  37. Have patient stand and then walk. Observe gait. Check for Romberg’s Sign.
  38. For male patients, perform genital and rectal exam while they are standing.
  39. For female patients, perform pelvic exam.
  40. Wash your hands.

I have omitted the formal joint examination. If indicated, this can be done in concert with assessment of extremity strength towards the end of the exam.

This approach keeps the movement of the examiner to a minimum, limits the frequency with which the patient has to get up and down, allows exploration of neighboring areas of the body even if they are part of different organ systems, and is reasonably logical, thorough and efficient. There is a lot of room for flexibility.

Adapted, with permission from University of California, San Diego School of Medicine By Charlie Goldberg, M.D.