10 Top Tips to Carry Out a Medical Examination
Patients like being examined. It makes them feel they have had a complete assessment. So, if in doubt, do an examination – even if brief and focussed.
1. Prepare yourself
- Look smart(ish) or at least look like a doctor. It does give the patients a sense that you are taking the examination seriously. Tie up any long hair
- Wear nothing below the elbow – including watches
- Prepare equipment: Ensure you have all necessary equipment, such as stethoscopes, blood pressure cuffs, and otoscopes, and that they are in good working order. If you knwo you are going to perform a PR be ready with glove and gel, for example. It wastes time to ask a nurse to get you the equipment and looks unprofessional.
5Ps – XXXX poor plannning leads to poor performance”
2. Respect patient dignity
- Ensure the patient is comfortable and exposed only as necessary for the examination
- Maintain a professional demeanor and respect their modesty
- For male doctors, and a female patient, always (always) have a female chaperone – unless it is an emergency.
3. Start with a thorough medical history: Take a detailed medical history before beginning the physical examination. This will help you focus your examination and identify potential areas of concern. Now wash your hands. Perform hand hygiene before and after the examination to prevent the spread of infection.
4. Introduce yourself properly with a medical diagnostic handshake.
5. Use a systematic approach: Develop a consistent approach to the examination, such as starting at the head and working your way down, to ensure you don’t miss anything important.
What’s the blood pressure (BP)? It is always relevant”
6. Observe carefully. And use all your senses to observe the patient’s general appearance, posture, gait, presence of pain, and any other abnormalities. What are they reading? Why?
Observation (all senses) is 90% of medicine”
7. Explain what you’re doing: Inform the patient what you’re doing and why, and ensure they’re comfortable with the examination
8. Be gentle and considerate: Be mindful of the patient’s comfort and pain levels, and adjust your examination accordingly. If they are older, place a pillow under their head if you lie them down.
9. Document your findings: Accurately record your findings, including any abnormalities or notable negatives.
10. Correlate findings with history: Consider the patient’s history and symptoms when interpreting your examination findings, and seek additional information or consultation if necessary.
