How to perform a better physical exam

There is a trend in internal medicine to get away from doing complete physical examinations on each visit, with a minimalistic approach to a healthy patient.¹ I am not prepared to go that far just yet, but I have modified my examination in many ways over the years. Here are some gems I have unearthed.

REFERENCE

1. Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191.

1. The most important parts of the examination in infants and young children are the growth parameters (including comparing them to previous visits) and the developmental evaluation. The latter can be done with items such as blocks and crayons, and verbal interactions in the older child. Unfortunately, this is still not well taught in medical school and residency, which is why there is a reliance on questionnaires such as the Ages and Stages Questionnaires (ASQ) and the Parents’ Evaluation of Developmental Status (PEDS) instead.

2. After I have checked a baby’s pharynx and palate once in their life, I do not examine it with a tongue blade again if they are well and not reported to be snorers. Gagging with a tongue blade is the most uncomfortable part of the examination, and I have never seen an acquired cleft palate. I will use a tongue blade to move the lips and cheeks out of the way.

3. I still look in the ears of an asymptomatic child during the well check-up for 2 main reasons. The first is that the parents expect this, and they will be less confident in my skills if I do not. The second is that if I do not do it and the child gets an ear infection even 1 week later, the parents will assume it is because I missed it the first time. That having been said, I will not clean out the ears (another uncomfortable process) if I cannot get a good view of the tympanic membranes in a child without suggestive symptoms.

4. Getting a good oral examination on a young child is hard to do when they are sitting, as parents often cannot restrain the child adequately. It is better, if the child is small enough, to use the “dental view.” Face the parent knees to knees, and have the child lie on his back with his head on your lap and his torso on the parent’s. The parent can hold the arms while you control the head.

5. The most important part of the neurologic examination of an infant is tone. Mild hypotonia will often prove to be benign, but hypertonia is always a worrisome finding.

6. Babinski testing (which is uncomfortable to boot) and deep tendon reflex testing are not useful in the healthy child. After years and years of never having an unexpected finding, I have stopped doing them if the rest of the neurologic examination is normal. The exception is with older children, if I think they will find tapping on their knee to be amusing, as sometimes happens.

7. If you are going to test deep tendon reflexes, you should really use a neurologic hammer with the screw-on weight, and not the rubber triangle model. The proper technique for using the neurologic hammer is to let gravity pivot it for you, rather than swinging it yourself. This can be seen on YouTube at: bit.ly/utube-deep-tendon-reflexes.

8. In newborn visits, I like to demonstrate the Galant reflex for parents, in which stroking down the side of the back with a dressmaker’s wheel causes the hip to swing out to that side. Parents love watching their baby “dance,” much more than they do the Moro reflex.