Your Physical Exam: Below the Waist

After the physical exam above the waist is completed, the rest of the exam follows. For females, the pelvic exam and rectal exam are done next. The pelvic exam can also be done by a gynecologist, a doctor who specializes in female medicine. This depends on your preference and/or if your primary care doctor chooses to refer you. It is an examination of the female external(outer) genitalia (parts) and internal (inside)reproductive sexual parts. The first female exam should be done at any age if there are any symptoms. Routinely, the first pelvic exam is done once the female is sexually active (having sex) or 18 years of age. It is recommended that a third person or chaperone who is an authorized health professional should be in the room for this exam. Every health care setting should have chaperone policies in place for gynecology exams. This should always be presented as an option, if there is no policy or law. Furthermore, it should be offered to a patient for the full physical examination, especially if the physician is the opposite sex of the patient.

The assistant will help you get in position. Your legs will be placed in stirrups (foot holders) that are at the end of the table. You will then slide your hips down until the buttocks touch the edge of the table. Your legs will then be able to relax
apart. (Some doctors have more comfortable exam chairs.) For those who might not be able to do this, there is the frog-leg position. The heels are brought together while the legs are bent: the heels are, thus, brought as close as possible to the
buttocks, like frog legs. For persons not able to assume either of these positions, referral to a gynecologist is necessary. Please note also that you should not be put in this position until the doctor is ready to examine you. That’s just good manners on the doctor’s part. Once the exam begins, the doctor will instruct you when to lie down. You should also be informed when and where you will be touched during each part of the exam. The doctor will be wearing latex gloves to do this part of the exam. You may also request that a mirror be placed so that you can watch the exam.

There are five basic parts of the pelvic exam. The first part is the exam of the external genital area where the doctor inspects and palpates for any abnormalities. The second part of the exam is done using a tool called a speculum. This is for looking into the vagina and at the cervix. It resembles a fancy pair of tongs (or a pelican beak) and is either plastic or metal. Most doctors
will and should warm the speculum with water before use. This allows for easier passage of the speculum. In the closed position the speculum is then placed gently in the vagina and opened to keep the vagina walls apart. When this is done,the doctor is able to see the cervix. The third part of the exam involves doing a Pap smear, which is a screening test for cancer of the cervix. A thin wooden stick about the size of a popsicle stick(called a spatula) and a stick with a tiny (about quarter-inch) brush on the end are used to do the test. When gently rubbed against the cervix, they are able to pick up cells. The cell samples are then placed on a glass side or in a test tube, which is then sent to the lab. The speculum is then removed.
Part four is the bimanual exam, which includes palpation of the internal female organs. One or two fingers that have been lubricated are placed in the vagina, while the other hand presses
over the pelvic (lower abdomen) area. The uterus(womb) and ovaries (eggs)can be felt for any tenderness or masses. The last part of the exam is the rectovaginal exam. Using a clean lubricated glove, one finger is inserted into the vagina and a
second finger into the rectum. This is an important part of the exam for two reasons: to check the rectum for bleeding and masses, and to further palpate the female organs. A complete
pelvic exam includes a rectal exam. The stool is checked for blood by placing a sample of stool from the gloved finger in the rectum onto a special card (commonly called guaiac or Hemoccult cards). If there is no stool for the specimen, your doctor will give you cards with instructions on how to collect samples at home. Once completed, the cards are returned to the doctor to be checked for blood. This is a very important test. Small amounts of blood in the stool cannot be seen with the naked eye but can
be detected with this test.

The male genital exam is the equivalent of the female pelvic. The doctor inspects first. With gloved hands, the penis glans (tip) and shaft are checked. If the male is not circumcised, the
foreskin (extra skin) should be pulled back. Then each scrotal sac is palpated to check the testicles for any abnormal lumps or bumps. This is a good time for the doctor to show you how to do your own monthly scrotal exam. Next the famous “cough” test is done in standing position. This is to check for hernias and is done with the insertion of the examining finger into the scrotal
and inguinal (groin) area while the patient coughs. It is done on the right and left side. The rectal exam follows and is usually done with the doctor’s lubricated gloved index finger inserted into the rectum. In addition to checking the stool
for blood, the prostate gland (which makes male fluids) is also checked for size, tenderness, and masses. This is an important cancer screening test for men and should be done routinely after age 40.

Examination of the musculoskeletal system(arms, legs, back), nervous system (including mental health), and skin mark the end of the complete physical. The extremities (arms and legs)are checked for symmetry (the same on both sides, and were being checked as you got on and off the exam table, to see if you required assistance or were using an assistive device such as a wheelchair,walker, or cane. Following instructions and answering the doctor’s questions during the exam allows for an indirect check of the nervous system. The skin can be inspected as each of the previous parts of the physical is done. Be sure to
have the doctor show you how to do your own self skin exam.

The inspection of the extremities continues as the doctor looks for scars, skin color change,edema (swelling), and effusions (joint swelling). The joints of the arms and legs are then tested for range of motion (actual movement) actively (movements done by patient) and passively (extremities are moved by the doctor). They are also checked for any tenderness, swelling, and
warmth or coolness. The strength, reflexes, and sensation(feeling)in the extremities are usually tested at this time or can be included in the neurologic(nervous system) exam. Strength is tested by resisting the doctor’s strength. Pushing the hand against the doctor’s hand, kicking the leg out, and gripping a finger with your hand are all relative tests of strength. The reflexes are checked with a reflex hammer at several places on
the arm (front and back of the elbow, above the wrist) and leg (below front of knee, back of ankle on Achilles’ tendon). Sensation can be checked using different items but is usually checked by light touch on the same parts of the arm or leg at
the same time. A sterile pin touched lightly on the area to be checked can also be used. Different areas of the body are touched while the patient’s eyes are closed and the doctor asks whether the touch feels the same on both sides or if a sharp or
dull feeling is experienced with the pin. Position sense is checked by being able to tell if your finger or toe is being held up or down with eyes closed. Vibration sense is tested on a finger or toe joint with a tool called a tuning fork (a six-inch
or so steel piece that vibrates when tapped lightly). Your job is to tell the doctor if it’s vibrating and when it stops. Finally, the extremities are checked for the pulses(circulation) in the arm and leg and for any vein abnormalities.

The rest of the neurological exam involves checking the way you walk, talk, and answer a few questions designed to check the mental state(such as where you are, the date, ability to identify a simple object). The cranial nerves(nerves involving the face and neck area) can also be checked now, if they were not included in the head and neck exam. During the back exam the doctor first looks at your posture. The shoulders and hips are checked for symmetry and deformities. The muscles of the neck, posterior thorax (chest), and lower back are palpated to check for any tenderness or spasm. Likewise, the bones of the spinal column are also checked. Movement of the neck and lower back is
done actively and passively in all directions of movement.

Please be reminded that the way the physical exam is done may vary from doctor to doctor. This is unimportant as long as a complete physical exam is done. Please note that the above
description of the CPE is quite generalized and does not include every specific detail. Book references for more detail include: "Bates Pocket Guide to Physical Examination and History Taking" by Barbara Bates, M.D., et al. (also available on CDROM
and VHS tape), and "Bedside Diagnostic Examination" by Drs. Elmer and Richard DeGowan. Many medical school curricula use
these references.

Once the physical exam is complete, the doctor and assistant will leave the room so you can get dressed. If an EKG (electrocardiogram — heart tracing) and X-ray are going to be done, you may be asked to get partially dressed (bottoms only) and keep the gown on. If blood has not been taken, that can be done at this time, too. Following these tests you will be able to get fully dressed. The doctor will then sit down with you in the office or exam room and discuss your symptoms,the physical findings (normal vs. abnormal), diagnosis, and whether any further tests or treatments are needed.

This is also the time for obtaining any prescriptions and to be told about any further tests or specialists whose expertise will be required. The doctor may also counsel you with information about your diagnosis and treatment, as well as any number of preventive healthcare topics. You may also be given handouts and booklets. Doctors may refer you to pertinent medical and patient education websites such as www.webmd.com. Email is becoming another way to talk with your doctor, in addition to phone calls, regular mail, and faxes. Prescriptions for medication are usually given to the patient at the end of the visit. Prescriptions are written orders for medicine that the doctor
has chosen for you. The patient should take these to the drugstore as soon as possible to stay well or to hasten recovery. Prescription medication must be dispensed by a licensed pharmacist. Some doctors fax or call the prescription in to your drugstore. Asking the doctor to do this for you will ensure you receive your medication promptly and will save you a trip to the drugstore. Some doctors are now using e-prescriptions
over the computer to send in patient prescriptions. By giving your doctor the number for the druggist you use, you will be able
to get a prescription filled in less time. You may also get prescriptions for medicine that can be bought over the counter—that is, without a pharmacist. Your pharmacist is the best person to help you with obtaining your medicine, discussing side effects and interactions, what the medicine is for, and so on. Be sure to discuss this with your doctor, too.

Best health!



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