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How do you perform the examination in a way that is complete, makes sense, and yet is not awkward or prolonged? Is it okay to combine different areas of the exam, or should each system be explored as a block? Answering these questions and putting together a smooth exam can be challenging. Any approach should:
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Cover all aspects of the examination that are appropriate to the clinical situation.
Be readily reproducible, allowing you to perform it the same way each time.
Keep patient gymnastics to a minimum (ie, limit the number of times that the patient has to get up and down).
Link together sections that, although disconnected physiologically, are connected spatially. For example, you’ll note in the list provided that the cardiovascular exam is “interrupted” by the abdominal exam, which allows the examiner to move from the chest, to the abdomen, and then to the lower extremities.
Allow you to be efficient and perform the exam with an economy of movement (eg, minimize the number of times that you pick up and put down instruments, move from one side of the patient to the other).
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It will take time, thought, and practice before you come up with a system that works for you. You should experiment while choreographing your own moves. It may be helpful to practice by writing down the components of the exam in the order in which you plan to perform them. If you can write them from memory, you’re a step closer to gaining mastery of the flow.
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Recognize that when caring for patients, the exam is typically modularized, with physicians performing selected aspects (eg, cardiac, abdominal, pulmonary) to investigate particular symptoms and clinical scenarios. This is referred to as performing a hypothesis-driven exam (ie, you perform the exam that’s appropriate to the clinical moment). For example, evaluation of a 20-year-old with knee pain after an injury would be limited to a detailed lower extremity assessment, as exploring other regions (eg, heart, lungs) would be unlikely to reveal important information. Conversely, an older person with a chief concern of weakness, which has many possible explanations, would require a comprehensive evaluation. Knowing which examination module(s) to apply in particular situations will come with experience and practice.
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The checklist that follows includes all of the elements of a rather comprehensive exam and is a compilation of those presented at the end of most chapters. It describes an ordered flow, something you can refer to when thinking through and practicing these core elements. You can also choose to “extract” particular modules (eg, the cardiac and pulmonary exams) from this larger list, providing a road map for the flow of selected sections if you used them during specific clinical situations. Special tests, performed in particular clinical moments, are identified as such. History taking and ROS checklists accompany those chapters.
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Pelvic, breast, male genital, rectal, ...