Physical Examination

Highlights

1. A physical exam is used to check patient overall health and make sure they don’t
have any medical problems that they are unaware of.
2. Make sure to tell patient Primary Care Provider about any medications they are
currently taking or have in the past. It’s helpful to prepare for the appointment by
gathering any documents relating to patient medical history.
3. This is patient chance to talk about any problems or symptoms they are experiencing
and get professional advice from their PCP.

A physical examination is a routine test that primary care provider (PCP) performs to
check patient overall health. A PCP may be a doctor, a nurse practitioner, or a physician
assistant. The exam is also known as a wellness check. Patient don’t have to be sick to
request an exam.

The physical exam can be a good time to ask patient PCP questions about their health or
discuss any changes or problems that they have noticed.

There are different tests that can be performed during physical examination.
Depending on the age or medical or family history, PCP may recommend additional testing.

A. The Purpose of an Annual Physical Exam

A physical examination helps your PCP to determine the general status of your health.
The exam also gives you a chance to talk to them about any ongoing pain or symptoms that
you are experiencing or any other health concerns that you might have.
 A physical examination is recommended at least once a year, especially in people over
the age of 50. These exams are used to:

 check for possible diseases so they can be treated early

 identify any issues that may become medical concerns in the future
 update necessary immunizations
 ensure that you are maintaining a healthy diet and exercise routine
 build a relationship with your PCP

These exams are also a good way to check cholesterol, blood pressure, and blood sugar
levels. These levels may be high without you ever showing any signs or symptoms. Regular
screening allows your PCP to treat these conditions before they become severe.

Your PCP may also perform a physical exam before a surgery or before beginning your
treatment for a medical condition.

B. How to Prepare for a Physical Examination

Make your appointment with the PCP of your choice. If you have a family PCP, they can
provide you with a physical examination. If you don’t already have a PCP, you can contact
your health insurance for a list of providers in your area.

Proper preparation for your physical examination can help you get the most out of your
time with your PCP. You should gather the following paperwork before your physical
examination:

 list of current medications you take, including over-the-counter drugs and any herbal
supplements
 list of any symptoms or pain you are experiencing
 results from any recent or relevant tests
 medical and surgical history
 names and contact information for other doctors you may have seen recently
  if you have an implanted device such as a pacemaker or defibrillator, bring a copy of the
front and back of your device card
 any additional questions you would like answered

You may want to dress in comfortable clothing and avoid any excess jewelry, makeup, or
other things that would prevent your PCP from fully examining your body.

C. How Is a Physical Examination Performed?

Before meeting with your PCP, a nurse will ask you a series of questions regarding your
medical history, including any allergies, past surgeries, or symptoms you might have. They
may also ask about your lifestyle, including if you exercise, smoke, or drink alcohol.

Your PCP will usually begin the exam by inspecting your body for any unusual marks or
growths. You may sit or stand during this part of the exam.

Next, they may have you lie down and will feel your abdomen and other parts of your
body. When doing this, your PCP is inspecting the consistency, location, size, tenderness,
and texture of your individual organs.

Your PCP will use a stethoscope — the listening device doctors typically keep around
their necks — to listen to various parts of your body. This could include listening to your
lungs while you take deep breaths and listening to your intestines.

Your PCP will also use the stethoscope to listen your heart to make sure there are no
abnormal sounds. Your PCP can evaluate your heart and valve function and hear your
heart’s rhythm during the exam.

Your PCP will also use a technique known as “percussion,” tapping the body like it is a
drum. This technique helps your PCP discover fluid in areas where it shouldn’t be, as well as
locate the borders, consistency, and size of organs.

Your PCP will also check your height, weight, and pulse.
 Be sure to communicate with your PCP if you have any concerns throughout the exam.
While you can always contact your PCP as needed, your physical examination is your private
time set up to ask questions about anything health-related. If you don’t understand any test
that your PCP is doing, don’t hesitate to ask questions.

D. Following Up After a Physical Examination

After the appointment, you are free to go about your day. Your PCP may be in touch
with you after the exam. They will generally provide you with a copy of your test results and
carefully go over the report. Your PCP will point out any problem areas and tell you anything
that you should be doing. Depending on what your PCP finds, you may need other tests or
screenings at a later date.
 DIALOGUE PHYSICAL ASSESSMENT

Nabila as a Doctor and Sarah as a Patient

Doctor : Good Morning, Mam. What is your name?
Patient : Good Morning, Doc. My name is Mrs Sarah.

Doctor : Hello Mrs Sarah, my name is doctor Nabila. I’m a doctor who practices at the clinic
today. How is your condition today, Mrs Sarah?

Patient : I am still feel the fever and dizzy doc.

Doctor : Have you got your breakfast today?

Patient : Yes doctor, I got my breakfast. I was ate a quarter plate of rice and side dishes. I was
drunk a glass of water before.

Doctor : Mrs Sarah, now I will do physical examination to you and measure your vital sign.

Patient : Yes, please doctor.

Doctor : For the first, I will measure your vital sign. I will fold your sleeve to make it easy then
i’ll take the manset of sphygmomanometer in your arm. And I will check now.

Patient : Why is measure vital sign necessary doc?

Doctor : Yes, because by measuring the vital sign, we will know your condition and assess the
function of your body today.

Patient : How is the result doc?

Doctor : Well, the result of your vital sign are your blood pressure is 130/80 mmHg.

Patient : That’s sound not good nurse.

Doctor : Now, I will continued to do physical examination to you.

Patient : Why you do physical assessment to me doc? Is it a necessary?

Doctor : Yes, of course Mrs Sarah.. Do the physical assessment is necessary. The purpose is to
find out how your current physical condition.

Patient : Yes, please doc.

Doctor : For the first, I will check on your conjunctiva. Could you open your mouth please! I
will saw condition of your mouth.

Patient : Yes, of course doc.

Doctor : Your lips mucosa look pale and dry. I suggest you drink a lot of water, because is
also important for you and for fluid balance your body.

Patient : Thank you for your suggest, doc..

Doctor : You’re welcome Mrs Sarah.. Now I will leave you, before I leave do you still have any
question or complaints?

Patient : No doctor.

Doctor : If you have a complaint, you can call me on doctor station and 30 minutes again, i will
come here to check your condition. I hope you get well son. Excuse me Mrs Sarah.

Patient : Thank you doctor.