Guide to Clinical Examination/General Philosophy

The obvious goal of the medical exam is to find, define and explain the patient’s problems. The standardized convention for recording this exam is referred to as a S.O.A.P. note. This stands for SUBJECTIVE (history), OBJECTIVE (physical exam and supporting tests), ASSESSMENT (diagnosis) and PLAN (treatment). When the patient &/or the problem is new, the most valuable information will most likely be provided in the History. At the very least, the history will allow the clinician to get an idea of what is wrong with the patient. It will also allow the clinician to get an idea of what kind of testing should be performed on the patient to determine the injury/illness and what kind of care that the patient should receive.

Any problem should be defined with as many adjectives as possible. Every problem should be defined in terms of site, onset, timing (duration, recurrence, periodicity), character (description, severity), exacerbation or relief, associated symptoms and the results of prior treatment attempts. [see the P-Q-R-S-T mnemonic.] When records are available, it is also important to ask about the status (resolution?) of prior known problems. Each problem should be addressed in terms of its Anatomy, Physiology, Etiology and Function.

Most exams begin with documenting the reason that the patient is there at that time: the Chief Complaint. From there, the examiner can pursue a directed line of questioning concerning the history of this complaint. This is the S of SOAP and is recorded as such. This section should be very thorough. The O consists of a directed exam and results of indicated tests. Objective is what the examiner finds. The A is the diagnostic conclusion arrived at from the synthesis of the above information. Sometimes no precise diagnosis can be determined on the spot. In such cases, the A-portion of the record would be a Differential Diagnosis or a list of diagnoses to Rule Out (R/O). In such cases, the P-portion is the list of steps to better define the problem; likely more tests. If the A is a definitive diagnosis, then the P-portion will be the treatment planned. Explain all treatsment to be done. Remember that the plan might change as time goes on.

The above are the minimum elements of a proper exam and record. There are times when a more comprehensive approach is called for; at admission to hospital, for example, or at the intake exam for a new patient.

The additional elements of such a comprehensive exam include a Family History of Disease, a Social History (activities, hobbies, alcohol intake, smoking), a list of any known Allergies, prior Hospitalizations and Surgeries and any current medical problems under treatment. Occasionally, a history of childhood illnesses and immunizations may be pertinent as well. An area often overlooked in such history taking is a Work history or Occupation (this might shed light on the Etiology of the problem as mentioned above). When the Chief Complaint is of a physical nature as opposed to a disease, a traumatic injury for example, a brief statement as to the circumstances of the injury may prove very useful for record, statistical or even legal purposes. The statement might read something like “fractured leg, sustained while a passenger in a vehicle accident.” Such statements are especially valuable when the injury was sustained on the job.

When the Physical Exam is a comprehensive one, the examiner should be schooled to proceed in the same manner every time. Each and every area of the body must be observed and properly tested and the results recorded. If one always does the same exam, then when recording the results, one only need remember the abnormal findings and can safely record all other areas as WNL (within Normal Limits). One normally begins such an exam at the head and works down the body ending at the feet. Depending on personal preference and training, there are some minor exceptions to this head to toe approach. For example, the examiner might defer the neurologic exam of reflexes in the arms until he reaches the legs and picks up the reflex hammer. When recording the physical findings, normal values (WNL) should not be overlooked. They can sometimes be very helpful later in establishing the timing of the onset of a new problem.