Physical Exam

Undressing and draping the patient for the exam.

Expose one part at a time. Use the drape effectively. Draping can be done as soon as you enter the room after introduction or be done just prior to the exam. Draping, in context of the CS simply means covering up the lower half of the patients body with a sheet (will be kept in the room for you) in order to cover the private area while examining the abdomen and/or lower extremities.

Order of exam:

Most patients would be in sitting position when you enter the room. In such case the usual order of exam should be as follows:


While in sitting position.

HEENT: Head Eyes Ear Nose Throat
PICCLEN: Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema, Neck vessels (JVD and Carotid bruit)

Front of chest and entire (upper and lower) back while in sitting position. Auscultate front and back next. For auscultation do not ask the patient to remove the bra. You can have help him/her untie the gown (say I need to look at your back now. Let me help you untie your gown) and listen around the bra. The next step is going to be making the patient lie down. Before you do so think if you need to do anything else in the sitting position. (e.g. In a respiratory case you can percuss the front and back of the chest, in a neuro case you can do rinne, webers, finger nose test, cranial nerves etc in sitting position). We are taught examination system wise but we have to preform them in a way that is most comfortable to the patient (usually you can not complete exam of one system all at once).


Then make the patient lie down. (remember to pull the foot board)

Drape appropriately and then examine the abdomen. Remember to auscultate the abdomen too. You would almost never need to go below the waist area. I feel it is okay to skip inguinal nodes and hernial orifices without a problem for the sake of this exam. Before you make the patient sit up think if you need to do any other tests in a lying position (e.g. for backache case I would do SLR-Straight Leg Raise test. In a neuro case one can do ankle jerks and plantar reflexes while lying down.)

I usually at some point during my exam make a note of SSS - Skin Skull and Spine.

Hygiene: Always wash your hands before touching the patient (or use gloves). Some people recommend cleaning your stethoscope with alcohol wipes prior to auscultation. I am not sure if it matters.

Don't forget to document all the exams that you performed. People commonly forget to document "No abnormality on ophthalmoscopy" or "No carotid bruit"

In summary for all patients you must do - PICCLEN, Heart auscultation and Lung auscultation. In most patients you would feel and listen to the belly. Rest of the exam depends on the presenting symptoms. In most cases you would also need to do a quick Neuro exam (mainly ocular movements, power, knee jerks, vision{finger counting}and hearing{finger rubbing})

Before the exam: Tell the patient "Mr. Smith now I need to do a quick physical exam. Is that ok with you?"

During the exam: Tell the patient every step that you do. Look at the following conversation to get an idea. There is no wrong way of doing it. Each patient will be different.

"Lets start top to bottom Mr Smith. Can you show me your tongue...That looks normal. Let me look at your throat at the same time...can you open your mouth wide and say Ahhh as I shine this light inside...Throat looks normal. I am goind to shine this light in your eyes too ok MR. Smith?... Pupils look normal. Now I need to feel you neck...No enlarged lymphnodes, thyroid gland feels normal, neck veins look normal... Now I am going to listen to heart. I need you to untie your gown in order to do that...Let me help you with that. Ok...Your heart sounds normal. Let me listen to your neck vessels at the same time...No abnormal sounds here too. Now I am going to have a look at your back. Your lungs sound clear, spine looks normal, there is no lump or fullness. Good. Can you lie down Mr. Smith so that I can examine your belly. Feeling for your Liver... And now for your spleen. Liver and spleen are normal and belly feels soft. Listening for your bowel sounds now...They are normal. So far so good Mr. Smith...Can you.... .....

Specific parts of the exam that commonly trouble the CS taker:

Mini Mental State Examination:

The MMSE is a series of questions and tests, each of which scores points if answered correctly. If every answer is correct, a maximum score of 30 points is possible. People with Alzheimer's disease generally score 26 points or less.
Remember the MMSE is not a test for Alzheimer's disease or any other cause of dementia. There are many other reasons why someone might score less than 26 points.
While it is not possible to do the entire test in the CS exam I feel doing the following tests is more than sufficient. You cannot score it but will only give you a rough idea. You can put "Mini Mental Scale Evaluation screen" in your plan in your patient note.
1) Orientation in Time: Ask "What month is it?"
2) Orientation in Place: Ask "What city are we in?"
3) Orientation in Person: Ask "Who am I?"
4) Memory: -"I'd like to test your memory. Please say these words: boat, egg and house"
-"Begin with 100 and count backwards by 7s" (Answer = 93, 86, 79, 72, 65)
-"Can you repeat the three words I told you earlier?"
4) "Name the following items" Point towards your pen.
5) Activity "Take a paper in your right hand, fold it in half, and put it on the table."
6) Activity Tell the patient to imitate drawing of two intersecting pentagons. "Can you make a figure similar to this one?"

I like to remember the MMSE as the test that tests "Time-Place-Person, Memory, Name and two activities" The activities being folding the paper and making the pentagons.

Rinne's and Weber's tests:

These should be done in all patients who complain of decreased hearing. These need not be done in all neuro patients.

Rinnes test : "Mr Smith, I am now going to test your hearing with these tuning forks. I will place the fork behind your ear and you should be able to hear the sound. I want you indicate to me when you stop hearing."

Repeat the same instructions for air conduction. Remember to use 512 fork. It is the shorter of the two. (Longer one is to test for vibration). And remember to test on both sides.Don't use the terms positive or negative Rinne's as they are confusing. Simply document AC>BC or BC>AC.

Webers "Mr Smith I am now going to place this fork on the middle of your forehead. Please indicate if you hear the sound equal in both ears and if not which side is louder"

Fundus and vision testing:

Fundus exam must be performed in patients with Hypertension, Diabetes, Headache, Visual Complaints and if time permits in all neuro cases. You have to at least pretend that you are using it correctly. You should see patient's left eye with your left and patient's right eye with your right. (In other words avoid kissing the patient on the lips!)

Detailed vision testing (with Snellen's Chart) is rarely indicated in Step 2 CS. In most cases documenting that the patient 'can count fingers at 6 feet' suffices. Six feet is about your own height! So keep your hands at about 6 feet and tell the patient to count your fingers. Commonest mistake made while doing this is testing for both eyes at the same time!!! You cannot do that. You must test each eye separately and the patient must be instructed to cover one eye with ipsilateral hand.

Taking vital signs:

Vital signs are already mentioned on the door. You do not need to measure them unless something different happens while you are in the room. (I haven't heard of an SP crashing during the exam!)