These are Standard Physical Exam Procedures, but please feel free to edit them according to your own rp style. This is just a guideline for assistance.
1. History || This is your chance to ask the patient about any complaints or concerns about their health. You quiz them about important behaviors, like smoking, excessive alcohol use, sexual health, diet, and exercise. You can also check on their vaccination status and update their personal and family medical history.
2. Vital Signs || These are some vital signs checked:
Blood pressure: less than 120 over 80 is a normal blood pressure. Doctors define high blood pressure (hypertension) as 140 over 90 or higher.
Heart rate: Values between 60 and 100 are considered normal. Many healthy people have heart rates slower than 60, however.
Respiration rate: Around 16 is normal. Breathing more than 20 times per minute can suggest heart or lung problems.
Temperature: 98.6 degrees Fahrenheit is the average, but healthy people can have resting temperatures slightly higher or lower.
3. General Appearance || Your can gather a large amount of information about them and their health just by watching and talking to them. How is your memory and mental quickness? Does your skin appear healthy? Can you easily stand and walk?
4. Heart Exam || Listening to their heart with a stethoscope, a doctor might detect an irregular heartbeat, a heart murmur, or other clues to heart disease.
5. Lung Exam || Using a stethoscope, listen for crackles, wheezes, or decreased breath sounds. These and other sounds are clues to the presence of heart or lung disease.
6. Head and Neck Exam || Opening up and saying “ah” shows off their throat and tonsils. The quality of their teeth and gums also provides information about their overall health. Ears, nose, sinuses, eyes, lymph nodes, thyroid, and carotid arteries may also be examined.
7. Abdominal Exam || Doctor’s can use a range of examination techniques including tapping the abdomen to detect liver size and presence of abdominal fluid, listening for bowel sounds with a stethoscope, and palpating for tenderness.
8. Neurological Exam || Nerves, muscle strength, reflexes, balance, and mental state may be assessed.
9. Dermatological Exam || Skin and nail findings could indicate a dermatological problem or disease somewhere else in the body.
10. Extremities Exam || Look for physical and sensory changes. Pulses can be checked in their arms and legs. Examining joints can assess for abnormalities.
(The next portion of the Exam can be opted out by the patient if they inform you they have had it done within the last year)
Male Physical Exam
Testicular exam: A doctor can check each testicle for lumps, tenderness, or changes in size. Most men with testicular cancer notice a growth before seeing a doctor.
Hernia exam: The famous “turn your head and cough” checks for a weakness in the abdominal wall between the intestines and scrotum.
Penis exam: A doctor might notice evidence of sexually transmitted infections such as warts or ulcers on the penis.
Prostate exam: Inserting a finger in the rectum lets a doctor feel the prostate for its size and any suspicious areas.
Female Physical Exam
Breast exam: Feeling for abnormal lumps may detect breast cancer or benign breast conditions. The doctor will also check the lymph nodes in the underarm area and look for visual abnormalities of the breasts.
Pelvic exam: The pelvic exam allows examination of the vulva, vagina, and cervix. Routine checks for sexually transmitted infections are often done. A Pap test can screen for cervical cancer.
Blood Work || Blood work will be done on a case by case basis and depends on things you find out about your patient during the exam.
There are no standard laboratory tests during an annual physical. However, some doctors will order certain tests routinely:
Complete blood count
Chemistry panel
Urinalysis (UA)
Unless symptoms already suggest a problem, however, these tests are unlikely to provide useful information.
A lipid panel (cholesterol test) is recommended every five years. Abnormal cholesterol levels increase the risk for heart attacks and strokes.