The physical examination may be performed as a general survey in a person who has no particular complaint, or it may be a focused examination which follows the health history, and so is intended to determine or confirm a diagnosis. In order for the physical examination to provide the desired information, it is necessary that the patient be able to follow your instructions and cooperate in the examination. You must therefore be able to give clear instructions.

In a well patient who is simply having a routine check-up, the physical examination may cause little concern. However, the ill or injured patient may be concerned about additional pain or discomfort. You will need to reassure such patients, and also conduct your examination in a way which causes as little discomfort as possible.

Clinical procedures may be completely different in the country that your patient comes from, and you may have to modify your procedures or take extra time to gain your patient's cooperation. For example, in your patient's home country, there may be different customs regarding robing of patients. Patients may be more or less modest about disrobing than you would expect. There may even be particular cultural or religious restrictions about touching.

If you take a little time to explain what you intend to do, before you begin your examination, you are more likely to successfully gather the clinical information that you need. If you are clearly having difficulty explaining examination procedures, consider demonstrating on yourself or another member of the clinic staff. Once patients understand what is required or expected of them, you can move through the examination quickly and efficiently. A caring and professional attitude on your part will put your patients at ease, and help you to overcome the small difficulties which you may encounter.

Situation 1: A patient has come for a pre-employment physical examination. A health history has not revealed any indication of disease.

Nurse: Mr. Smith, I would like to get your height and weight first. Can you take off your shoes and stand on this scale.

Mr. Smith: Sure. Can I keep my socks on?

Nurse: Oh yes, and you can put on these slippers as soon as we're finished.

Nurse: Okay, Now, Mr. Smith, I would like to take your blood pressure and pulse. Is that alright? Would you like to sit here?

Mr. Smith: Certainly. (Mr. Smith begins to take off his shirt and undershirt.) Should I take off my undershirt?

Nurse: You can leave your undershirt on. Just remove your shirt.

Mr. Smith: Okay. Shall I take my wristwatch off?

Nurse: Yes, please take that off. I would like to check your pulse first. (Standing beside Mr. Smith, she palpates his radial artery with one hand, and places the other hand on his shoulder so that she can see her wrist watch.) You can just relax and breath normally.

The nurse writes the pulse and respiratory rate on Mr. Smith's chart.

Nurse: Okay, now I'll check your blood pressure. Can you remember what your blood pressure usually is?

Mr. Smith: (Joking) "Normal". That's all I know.

Nurse: (Releasing pressure in cuff.) One twenty over seventy-five - that's good. Okay, Mr. Smith, the doctor is going to listen to your chest, so I will get you to take off your undershirt now. Would you like a gown?

Mr. Smith: No, that's not necessary. Thank you.

Nurse: Okay, if you just wait a minute, the doctor will be right with you.

Patterns:

*I would like to
... get your height and weight first
... take your blood pressure and pulse
... check your pulse first

* Would you like
... to sit here
... a gown

* Can you take off your shoes and stand on this scale
* Can I keep my socks on
* Can you remember what your blood pressure usually is
* Can I / Can you ...

* You can
... put on these slippers as soon as we're finished
... leave your undershirt on
... just relax and breath normally

* Should I take off my undershirt
* Shall I take my wrist watch off
* Should I / Shall I ...

* I'll check your blood pressure
* I will get you to take off your undershirt now
* I will ...

* The doctor will be right with you

Situation 2: A young male athlete with a groin strain is being examined by a female athletic therapist.

Therapist: Okay Peter, the injury which you have described sounds like a psoas strain, but we will need to do an examination. Peter, I would like you to go behind the screen and change into these shorts.

Peter: Can I keep my shirt on?

Therapist: Yes, and you can keep your socks and underwear on. I just want you to take off your trousers and put on these shorts.

Peter changes into the shorts and then comes out from behind the screen.

Peter: Okay, now what?

Therapist: I would like you to lie on your back on this table with your knees bent a little bit. (Peter lies on the table.) I'll put this pillow under your knees so you can relax. Is that comfortable?

Peter: Yes, it feels more comfortable with my knees bent like that.

Therapist: Okay, Peter. I would like you to pull up your shorts on the right side so that I can see the top of your thigh. (The therapist motions as if pulling up shorts on herself so that the patient understands what to do.) Peter, I am going to press here slowly. Tell me right away if there is any pain. Okay?

The therapist palpates along the top of the pubic bone towards the ilium.

Peter: Ow! That feels pretty tender.

Therapist: Peter, I'm going to palpate a little further up. (She motions to indicate the direction in which she intends to palpate.) This shouldn't hurt, but tell me if it is unpleasant.

Peter: No, that feels okay. It's just down below, where you first touched, that is really painful. Can I play next week?

Therapist: That definitely looks like a psoas strain. We will tape that to make it feel better, but you won't be able to do any sports for at least a week or two.

Patterns:

* We will need to do an examination
* We need to do an examination
* We have to do an examination
* We... ... an examination
* I want
...to do an examination
...to examine you

* I would like you to ... go behind the screen
... lie on your back
... pull up your shorts

* I'll put this pillow under your knees
* I am going to press here slowly
* I'm going to palpate a little further up

* It feels more comfortable
* That feels pretty tender
* That feels okay
* That is really painful

* Tell me right away if there is any pain
* Please tell me if it is unpleasant

* Can I
... keep my shirt on
... play next week

* You can keep your socks and underwear on

Discussion:

1. In situation 1, the nurse tells the patient every procedure that she is going to perform before she performs it. What is the purpose of this?

2. In situation 1, the nurse asks Mr. Smith his blood pressure, before she actually measures it. Why do you think she did this?

3. In situation 1, the nurse offers Mr. Smith a gown when he removes his shirt. Is this normal in Japan and do you think that this was necessary?

4. In situation 2, the therapist uses gestures to show the patient what she wants him to do. Why do you think she used gestures?

5. In situation 2, both the patient and therapist might experience some embarrassment about the physical examination. How would you deal with this if you were the therapist?