Your Physical Exam: Above the Waist

After your doctor has taken a thorough medical history, a complete physical exam (CPE) is performed. The doctor started your physical exam from the time you were greeted just by looking at you. Are you able to get up and shake hands? Are you able to sit back down? Is there a cane or walker lying beside you? Are you speaking clearly? Are you tearful? This and many other observations can tell the doctor a lot. So the physical has begun before the doctor puts a healing hand on you.

The head, eyes, ears, nose, and throat (HEENT) are usually inspected first. The doctor looks at the scalp for any hair loss or other abnormalities. Your head is palpated (touched and felt) to check for any lumps, swelling, or sore spots. The eyes are next. You will be asked to follow the doctor’s finger with your eyes up, down, left, right. This tests your eye muscles. Pulling down the lower eyelid and pulling up on the upper eyelid allows for inspection of the white of the eye and the eyelids. The eye reflex is checked by shining a light on the colored part of the eye and is done with the lights dimmed (or light off and door cracked). The doctor uses the ophthalmoscope (an instrument) to look inside the eye. The blood vessels and nerve to the eye can be seen. Certain abnormal findings in the eye indicate diabetes, high blood pressure, and other maladies. For any findings that are abnormal with the eye, you will be sent (“referred” is the
up-to-date term) to an ophthalmologist (eye specialist). Routine eye exams by the ophthalmologist may also detect some diseases that are known to progress toward blindness or other complications. Looking at and reading from an eye chart tests the vision.

Can you hear a whisper? How about a watch ticking? Faint noises close to the ears allow a doctor to check to see how well you can hear. Formal hearing tests (like audiometry) are done by an otolaryngology doctor, also known as the ENT (short for ear, nose, and throat) doctor. Hearing tests may also be done by hearing aid centers. The doctor uses the otoscope (the same instrument used for the eyes with an attachment made for looking in the ears) to look in the ear canal and at the eardrum. Using the same tool, each nostril and the mouth are inspected. A stick called a tongue blade is used to hold the tongue down when the doctor asks you to say “aaaaahhhhh.” This is done so that the throat and the rest of the mouth can be checked. This procedure also tests the nerve for the gagging reflex (part of the nervous system exam). A gloved finger may be used to palpate (touch) the inside of the mouth. Any problems here will earn you a referral to the ENT doctor or dentist. Now may be a good time to ask any questions about the exam thus far. Please wait for the doctor to remove the gloved hand first.

The neck exam is next. At this time the thyroid gland is palpated. This is best done while the doctor stands behind the patient and places the right hand around the right side of the neck and the left hand on the left side of the neck. If any swelling or lumps are noted, further blood tests and a thyroid and/or neck scan may be ordered by the doctor. The lymph node glands can also be checked at this time. They are located in the front, back, and sides of the neck. They are also in the armpit and groin and are checked with those parts of the body. The lymph nodes should not normally be enlarged. More blood tests and Xrays may be ordered if they are enlarged.

Inspection, palpation, and percussion (lightly tapping) as well as listening to the chest give the doctor a chance to check the lungs. The doctor listens with a tool called a stethoscope, which makes the sounds louder. It is placed on the bare skin (beware of the doctor who tries to listen on top of your clothes) starting at the top of your upper back moving from the left to right, or right to left, from the top to the bottom of the chest
while you take deep breaths. The same will be done on the chest.

Then the stethoscope will be placed over the heart on the left and right sides of the breastbone. These areas are where the heart valve sounds are heard best. You may also be
asked to do certain things like holding your breath or bearing down (as when having a bowel movement). This makes some murmurs easier to hear. Certain positions may also be better for hearing some heart sounds. Your doctor has been trained to listen for certain things. If any abnormal sounds are heard, more tests may be ordered. These may include an X-ray of the chest(CXR, for short) and heart tracing(electrocardiogram—EKG, for short). Usually these can be done in the office after completion of the exam. Depending on your complaints, symptoms, and the results of the CXR and EKG, you could require more tests that are not done in the primary care physician office.

The breast exam is also done at this time. The doctor will let you know exactly what is to be done. For female patients, it is recommended that a third person or chaperone be present when this exam is done. After the gown is lowered to the waist, the doctor looks at the breasts with the patient sitting up on the exam table. The breasts should look the same size (sometimes one can normally be a tad larger or smaller than the other) and shape with the nipple positioned centrally. The breast is also checked to make sure there is no abnormal swelling, lumps, skin discoloration, or skin changes. Next you will be asked to put your hands on your hips and then raise your arms above your head much like doing your own breast inspection in front of the mirror. The doctor will again look and examine for any abnormal places. While you lie down on the exam table, the doctor will palpate each breast up and down vertically from right to left or vice versa. Palpation in a circle from out to in is another technique used. Breast tissue under the arm is also checked. The nipples are then squeezed gently to check for any discharge. Deeper palpation of the axilla (armpit) is then performed to check the lymph node glands. These steps are then repeated on the opposite breast. Any abnormalities may warrant a
mammogram and/or sonogram and possibly a surgeon’s evaluation. Men should also receive a breast exam. This is a good time for the doctor to teach to do your own self breast exam (SBE).

Now it’s time to look, listen, tap, and feel the abdomen, the area many people refer to as the stomach. This is where the liver, spleen, kidneys, bowels, and female reproductive organs are located. With this lineup of important organs the doctor has a lot to check. This part of the exam is done in the supine (lying on your back) position. Looking at the abdomen for scars tells about anysurgery you may have had. Listening with the stethoscope for overactive or underactive bowel sounds and/or bruits (sounds made by abnormal blood flow through arteries when there is blockage) is next. By tapping and feeling, a doctor is able to check for enlargement of the vital organs listed and to make sure that there are no abnormal internal masses or swelling. At this time the groin is also checked for any enlarged lymph nodes. If there are any abnormalities, further tests will be ordered by the doctor.



Patient Handbook to Medical Care: Your Personal Health Guide
http://amzn.to/13m51UU FREE with kindle unlimited!

Women's Health Week Checkup

Ladies, it's time to schedule your routine screenings and appointments to include:

1. mammogram/ MRI for breast cancer
2. PAP smear & HPV test for cervical cancer
3. stool check for blood (fecal occult blood test, FOBT) for colorectal cancer
4. cardiology doctor for cardiovascular prevention(get EKG, ECHO, and thallium stress test if indicated)
5. bone density scan to check for osteoporsis
6. counseling for smoking cessation, alcohol/drug dependence, and domestic violence
7. evaluation for depression and other mental disorders if necessary
8. complete physical exam, and routine blood tests.

Get in 5 to 10 minutes of exercise a day at least and eat healthy! Laugh a lot and love a lot!

by J. L. Richardson, MD, family practice, author of Patient Handbook to Medical Care: Your Personal Health Guide.

www.mypatienthandbook.com

Missed Diagnosis - Oooops!

Doctors are missing diagnoses especially with cancer - OVER 50%!!

Are you getting the right treatment? A 2006 study* of 307 closed malpractice claims revealed that many missed or delayed diagnoses in outpatients lead to serious harm, some fatal. In this study, 30% resulted in death! Adverse outcomes occurred in 59%.

The most missed diagnoses were cancer (breast and colorectal primarily), infections, fracture, and heart attacks. Fifty-nine percent of errors were associated with cancer diagnosis - or should I say misdiagnosis? Most of these malpractice claims (59% again) showed that diagnostic errors were significant.

The most common reason for failure to diagnose was failure to order the right test (55%). The other reasons were:
-failure to follow up (45%)
-failure to obtain a complete thorough medical history and physical
exam (42%)
-wrong interpretation of medical tests (37%)
Some cases were cited where the doctor failed to check the test results, or to tell the patient the results.

This data is truly mind blowing! Though a small study, it carries a lot of weight. The percentages are phenomenally high! How can this be happening in the most medically advanced country in the world? The fact is, it's happening. It is more common than we think - hidden, not talked about. What can you do to keep it from happening to you?

Has your doctor discussed preventive tests for cancer detection? Of course, you should have a routine complete medical history and physical exam first. Using this information your doctor will know what tests you may need. If cancer runs in your family, you really want to consider preventive cancer screening.

The medical history and physical exam give your medical facts. Findings on physical exam may suggest cancer for which testing is needed. Some tests considered for routine cancer screening are:
-mammogram, MRI - breast cancer
-PSA (prostate specific antigen) - prostate
cancer
-colonoscopy - colon cancer
-stool blood check - colon cancer
-PAP smear - cervical cancer
-complete blood count - blood cancer
-CT or MRI scan - lung cancer, brain cancer
-pelvic sonogram - ovarian cancer
-body scan (neck to buttocks and in between) - body (this scan shows other things ,
too).

Screening tests save lives. Talk to your doctor. Be sure your doctor goes over the test results with you and explains EVERYTHING! Leave with your questions answered! Be sure to follow up with your doctor to prevent any delays.

Get a copy of your test results. That way you will know if you were told everything and that the information is accurate. Research your results and diagnosis. Things you don't understand, ask again. Getting a second (and sometimes tiebreaker third because you were told different things by each doctor!) opinion is a reasonable research tool, also.

Patients must be their own advocate and take charge of their health. Health maintenance and prevention are so important to one's quality of life. Make it an important part of yours. Remember to do your own monthly breast exams for both sexes, and monthly scrotal check for the males.

Great health is true wealth!

(*from AHRQ, Agency for Healthcare Research and Quality, publication "Research Activities" February 2007 from study in Annals of Internal Medicine, 10/3/06)

J.L. Richardson, M.D., is a family medicine doctor, patient advocate, and author of "Patient Handbook to Medical Care: Your Personal Health Guide".

Self Breast Exam Beats Breast Cancer

Here is a video from Healthination.com that shows how to do a self breast exam. Monthly exams could save your life.

http://healthination.com/Videos/Breast-Self-Exam