A systematic approach to the physical exam.

Medical students usually get trained in an organ system approach to the history and physical examination (PE).  While this is a good start to learn these new skills, it does have a few limitations:

  • Leads to a somewhat fragmented approach when faced with a patient
  • Students often have to do a “mental checklist” or a review of examination points, which makes it difficult to stay patient-centered
  • The patient is often asked to change positions several times during an examination, with the same part of the body examined repeatedly from the point of view of a different organ system; e.g. examining the neck for lymph nodes and goiter and then returning to it later to listen for carotid bruits; or having a patient lie down to do a straight leg raising test and then having them sit back up to check for the knee deep tendon reflex.  
  • When faced with distractions the student often forgets critical elements of the examination.

Ehsan Balagamwala (CCCLM Class of 2013) and Neil Mehta, MD FACP (Director, Education Technology, CCLCM) have worked together to create a this website that summarizes all the ROS and PE elements in a single mindmap with hyperlinks to educational multimedia on the web to supplement the resources already provided by the curriculum.  In addition, they have also organized the information into a systematic head to toe approach that integrates the different organ systems and is organized by elements that should be done with the patient in sitting, standing and supine position.  

Ref:
1.  Neil Mehta, Technology in (Medical) Education Blog at http://blogedutech.blogspot.com/2009/11/logical-flow-of-physical-exam.html
2.  Bonnie Darvis; Rethinking the value of the annual physical exam, ACP Internist, January 2010 http://www.acpinternist.org/archives/2010/01/annual.htm

Organ System Approach

This mindmap is organized by the various organ systems.  Click on any node to collapse or expand it.  Click on the red arrows within a node to launch a new multimedia resource.  These resources are hyperlinks to educational material on the World Wide Web and are not produced by the authors or the Cleveland Clinic Lerner College of Medicine.  If you are aware of any difficulties accessing these resources or are aware of other resources that should be included, please email [email protected]. This mindmap requires Java.  If you get errors or cannot see the mindmap, please download Java from here.  Another option is to use the Tree View.

click here to view

Head to Toe Approach

This mindmap is organized using a head to toe approach.  This is just a suggested approach used by the authors to make the examination more systematic, efficient and convenient for the patient.  You do not have to use this particular approach.  With experience, you can develop an approach that works better for you.   

We usually start the examination with the patient sitting on the exam table.  Then we proceed to the supine examination, and then ask the patient to get off the table and examine in the standing position. 

Click on any node to collapse or expand it.  Click on the red arrows within a node to launch a new multimedia resource.  These resources are hyperlinks to educational material on the World Wide Web and are not produced by the authors or the Cleveland Clinic Lerner College of Medicine.  If you are aware of any difficulties accessing these resources or are aware of other resources that should be included, please email [email protected]. This mindmap requires Java.  If you get errors or cannot see the mindmap, please download Java from here.  Another option is to use Tree View

click here to view

Tree View

This is a simpler view of the mindmap.  It is created with JavaScript and thus does not require Java.  It will work with most mobile devices and iOS devices (iTouch, iPod etc which do not support Java).

click here to view