9

The
Physical
Exam
Now it’s time to get into the physical exam portion of our encounter. We’ve

discussed the details of the interview at great length and by now you should have a very

good idea of everything you should be doing throughout the encounter in order to ensure

that you get as many points as possible, both on the CIS and ICE components of the exam.

The goal of the physical exam is of course to gather even more information about

the patient’s current status and should be based on the chief complaint. Remember that

for the sake of this exam, there is most likely going to be one main system that needs to

be examined. Something very important to keep in mind however is the fact that you

should also perform a very basic heart and lung exam for each encounter, assuming that

neither the heart nor the lungs is the system requiring a more thorough examination. If

the lungs require a thorough examination, then stick to a basic heart exam and a thorough

lung exam. If the heart requires a thorough exam, then stick to a basic lung and a

thorough heart exam.

Proper draping during the physical exam

Ensuring that the patient is properly draped and has a lap towel is extremely

important, so when you walk into the room this needs to be one of your initial

observations. Check to ensure that the patient is wearing the gown, and check to see that

they have a small towel or blanket on their lap. If either of these is missing and/or not in

place, you should get to them right away.

Properly exposing the area to be examined

It’s important to remember that the area you’re examining, whether it is the chest,

back, or abdomen, should be exposed during and only during the time of examination.

Of course, it is also important that you do not overexpose the patient and make them feel

uncomfortable, so keep that in mind at all times. For example, if you’re examining the

heart of a female patient, she will be wearing a bra or other supportive device to cover

her breasts; you don’t want to remove this item of clothing. Additionally, when

examining the heart of a female patient, if you need to listen to the mitral valve, it is in

your best interest to ask the patient to lift her left breast, not to try and move it yourself.

This is typically common sense however I want to be sure that this mistake isn’t made

during your exam.

One of my favorite physical exam tips to share with students has to do with

exposing the chest during the exam. When you are ready to examine that anterior chest,

which you will do during almost all cases, you are required to expose the patient’s chest.

Most students tell the SP they need to access the chest and then they move the gown

down themselves. Instead of doing this yourself and risking potentially making the SP

feel uncomfortable, make your life easier and let the patient know that you’d like them
to lower the gown themselves. This would sound something like this: “Mrs. Smith, I need

to listen to your heart now, would you mind lowering your gown as far as you’re

comfortable so I can access your heart?”. And when you do this, it does a couple of very

important things: 1) It shows the SP that you’re concerned for their comfort, and 2) It

lowers the risk that you’ll accidentally touch them in an inappropriate way.

As soon as you’re finished with an exposed area, you must cover it back up. This

is something that I’ve seen so many students forget time and time again. Therefore, make

it a habit to ask the patient to cover back up immediately after you’ve finished the

examination of that particular area. If you’ve finished the cardiovascular examination

and you need to now examine the abdomen, you want to cover up the chest before

moving onto the abdomen (i.e. Cover up each area as soon as you’re done with that

particular exam, don’t wait until the end of the entire exam to cover everything up).

Knowing what physical exams need to be performed

This is by far one of the most common issues students have when it comes to the

physical exam component of the exam. Students are often times lost when it comes to

figuring out which areas need to be examined based on the chief complaint. The real

problem here is that there’s nothing out there that teaches students the theory of the CS

exam in a way that simplifies things and makes it super easy to navigate. Therefore, I’m

going to give you a very simple strategy that you can use in order to ensure that you

never screw up the physical exam portion of the exam, as well as ensure that you have

confidence in yourself to make the right decisions.

The first step is remembering to always do a basic heart and lung exam, meaning

a quick auscultation of the four valves of the heart and four quadrants of the upper back
when listening to the lungs. This is of course assuming that your case doesn’t involve

either the heart or the lungs. If you’re dealing with a cardiovascular case, then you’d do

a basic lung exam and a thorough heart exam. If you’re dealing with a pulmonary case,

you’d do a basic heart exam and a thorough pulmonary exam. The basic heart and lung

exams are done when neither of these systems is the main system requiring your

attention. I also recommend doing this at the very beginning of your physical exam so

that you can take those twenty to thirty seconds to think about what you need to do as

part of your thorough exam.

Breakdown strategy for the physical exam

As with every other area of the exam we’ve discussed thus far, we can also apply

a strategy to our physical exam in order to make things as simple as possible. The

following is a step-by-step strategy that you can put in place to ensure that you navigate

these four to six minutes as efficiently and perfectly as possible:

1) Ask the SP permission to begin the PE

2) Wash your hands (use this time for rapport-building)

3) Tell the SP exactly what you’re going to do and be sure that you have their

permission prior to starting

4) With each different part of the exam, explain what you’re doing so that they feel

comfortable the entire time

5) Once finished, thank the SP for allowing you to perform the exam

The overwhelming majority of the time you’re only going to have to focus on one

system, however there are some instances when you’ll need to do a bit more. For example,

if you’re examining a patient that you believe to have hypothyroidism, you need to
examine the thyroid, which is part of the HEENT exam, but you also need to check

reflexes since hypothyroidism can present with decreased DTRs, which can be used to

support your differential. In this instance, you don’t need to do a thorough neurological

exam when checking the DTRs, you simply need to use your knowledge to recognize

what exams should be done in order to get you as much information as possible. When

more than one system comes into play, such as in the hypothyroidism example, make

sure that your main exam focuses on the primary issue, which is the thyroid, and

recognize which system that belongs to; in this case it is the HEENT system, and thus the

HEENT exam should be your primary focus. The secondary system to examine is the

neurological system however remember that you only need to do specific maneuvers that

will get you the information you need for your support. This strategy should apply to

any case whereby more than one system needs to be examined. Remember, the primary

goal is to perform the system-specific exam that is causing the issue, and the secondary

exam will be done if another system can provide you with important additional

information.

Next, I’m going to outline the maneuvers that I’ve been teaching my students for years

as part the ‘system-specific’ exams. This means that for the sake of the CS exam, if you

know all of these maneuvers when performing each system’s exam, you should get the

points and the information that you need. One thing to keep in mind is that there’s not a

specific list of maneuvers that they’re looking for; simply a thorough exam. This means

that even if you have additional maneuvers that you’ve been using, that’s not a problem.

Simply keep in mind that ‘thorough’ is the most important component of the focused

exam.
The Cardiovascular exam:

Performing a thorough cardiovascular exam requires that each of the following

maneuvers is performed:

o Inspect & palpate

o Auscultation of the heart

o Auscultation of the carotids

o Check pulses in all extremities

o Check PMI (in left lateral decubitus position)

o Check for JVD in supine position

The Pulmonary exam:

Performing a thorough pulmonary exam requires that each of the following maneuvers

is performed:

o Inspect & palpate

o Auscultation of the lungs (posteriorly)

o Check lung expansion

o Percussion

o Fremitus (say ‘99’)

o Egophony
The HEENT exam:

Performing a thorough HEENT exam requires that each of the following maneuvers is

performed:

o Inspect the head

o Palpate the lymph nodes

o Palpate the sinuses

o Look into the eyes, ears, and nose

o Look into the mouth

o Look at the throat

o Palpate the thyroid gland

The Neurology exam:

Performing a thorough neurology exam requires that each of the following maneuvers is

performed:

o Mini mental status exam (if LOC or AMS is present)

o Cranial nerves 2-12

o Sensory in upper & lower extremities

o Motor strength in upper & lower extremities

o Deep tendon reflexes in upper & lower extremities

o Alternating hand test

o Romberg test (for balance assessment)

o Gait test
The Abdominal exam (GI, GU, OBGYN)

Performing a thorough abdominal exam requires that each of the following maneuvers

is performed:

o Inspect (do this 1st)

o Auscultate (do this 2nd)

o Percuss (do this 3rd)

o Palpate (do this 4th)

o Rovsing test

o Psoas test

o Obturator test

o Murphy’s test

The Musculoskeletal exam:

Performing a thorough musculoskeletal exam requires that each of the following

maneuvers is performed:

o Inspect & palpate

o Range of motion (compare affected side to unaffected side)

o Ensure an understanding of the MSK ‘special tests’ (Knee, shoulder, back,

wrist all have special tests)

The Special tests:
Several systems have ‘special tests’ that we must perform in order to get the

necessary information from the patient, as well as ensure that we get full points. Below

you will find a list of the common special tests that should be performed during the CS

exam.

HEENT: Weber & Rinne test, Brudzinski & Kernig tests

KNEE: Ballottement, McMurray, Anterior/Posterior drawer tests, Varus/Valgus stress

tests

WRIST: Phalen, Tinel tests

SHOULDER: Drop arm test, -can test

BACK: Straight leg test

How to properly document your PE findings

The PE findings are an area that most students don’t realize is a potential time-

saving section of the patient note. The reason why this is the case is because the physical

exam findings are for the most part going to be the same each time. Therefore, by

recognizing this and more importantly learning how to properly and quickly document

these findings in your patient notes, you can free up some time that can be directed

towards more challenging sections of the note, such as the HPI or the differential

diagnoses. My suggestion to you would be to practice typing all of the following physical

exam findings as many times as is needed to ensure that you can type them quickly and

without much thought. The faster you can type out your physical exam findings, the more

time you’ll free up for other parts of the patient note. Below you will find a list of all

physical exam findings that you should document when each of these types of cases

present themselves on the exam.

Documenting the HEENT findings:

Head: NC/AT

Eyes: EOMI, PERRLA, normal eye fundus

Ears: TM intact, no discharge, no tinnitus, no redness, no fullness

Nose: Nasal turbinates not congested

Mouth: No tonsillar erythema, exudates, or enlargement, good dentition

Neck: No JVD, normal thyroid, no lymphadenopathy, no carotid bruit

Documenting the Neurology findings:

CN 2-12 grossly intact, motor strength 5/5 in all muscle groups, DTRs are 2+ intact and

symmetric, sensation intact to sharp and dull, rapid alternating movement intact,

cerebellum intact

* If MMSE is done: AAOx3, good concentration

Documenting the Respiratory findings:

Inspection: No bruises, cuts, or scars

CTAB/L, no rales, rhonchi, wheezing, or rubs

Normal to palpation, no tactile fremitus, no dullness, whispered pectoriloquy negative,

egophony negative

Documenting the CVS findings:

+S1/S2, RRR, no MRG, no JVD, no pedal edema, pulses 2+ in all extremities

Documenting the Abdominal findings:

Soft, non-tender, non-distended, Murphy’s sign +/-, rebound tenderness +/-, Psoas sign

+/-, Rovsing sign +/-, Obturator sign +/-

Documenting the MSK findings:

ROM increased/decreased, sensation intact, motor strength intact, [special maneuver] +/-

Documenting the Extremities findings:

No deformity or trauma, +/- tenderness, ROM increased/decreased, muscle strength 5/5

in all groups, DTRs 2+ bilaterally, sensation intact to sharp/dull, no cyanosis, clubbing, or

edema