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The Basics of a Physical Exam

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Most physical exams will begin with the patient being asked questions about their medical history and current situation including any problems or medications they are on.

Vital signs

Temperature

Temperature recording gives an indication of core body temperature which is normally tightly controlled (thermoregulation) as it affects the rate of chemical reactions.

The main reason for checking body temperature is to solicit any signs of systemic infection or inflammation in the presence of a fever (temp > 38.5 degrees C or sustained temp > 38 degrees C). Other causes of elevated temperature include hyperthermia. Temperature depression (hypothermia) also needs to be evaluated. It is also noteworthy to review the trend of the patient's temperature. A patient with a fever of 38 degrees C does not necessarily indicate an ominous sign if his previous temperature has been higher.  Temperature can be measured by: ear, axillary, oral, or rectal (most accurate although rarely done).

 

My doctor is old-fashioned. He makes me strip to my underwear right after I get into the room, and the last time was no different. I have to sit on the table while he starts the exam. After a few minutes he makes me flip over, and then pulls down my underwear, and sticks the greasy thermometer in my bottom. It's embarrassing to be lying there with a thermometer sticking out of my butt. He then removes my underwear completely and hands them to my mom before taking out the thermometer and I am left completely naked for the rest of the exam. It's really embarrassing being completely naked in front of your mom, a nurse, and a doctor who are completely clothed when you are 13. They all got a long look at my penis.

At the start of every school year, mom arranged for our physical exams for me and my sister. I hated seeing the date circled on the calendar and fearing what would inevitably take place. Our pediatrician - who I saw through high school - was a middle aged man who always made you undress to your panties even when I started to wear a bra. The nurse would tell me to remove my clothes and weigh me. Mom would be there unless I objected.  After some casual conversation with mom, the nurse would get out the thermometer, lube it, and approach me. I hated seeing the thermometer. The usually had me turn onto tummy and would make me lift up my hips lower my panties. As I got older, she usually made me get onto my side for the temp. I soon realized how much was showing while on my side. Without much warning, she quickly inserted it and held it there forever while talking to mom.
Even when it was my sister on the table, I remained anxious and wished I had on some clothes.


I was 12 years old and had come down with strep throat. My mom took me in to the doctor, and I was coughing like crazy. They took me back to the room and had me strip to my undies as was normal back then. The nurse came back in, and started taking my vitals. I had switched to oral temps at 9 years old which was a small victory and step towards growing up in my childhood mind. I had the same nurse every visit, named "Cherry B." She had a tattoo of a bee stinging a cherry on her arm. She was usually very nice.

On this day, she was a little curt. She took my blood pressure and all, I'm sure, but that part is pretty fuzzy. When it came time for the temperature, she very bluntly stated "I'm gonna go ahead and take your temperature in your bottom." I was crushed, shocked, and just knew that she was heard in the next room, as the walls were very thin. I kind of froze for a minute, and then she just as bluntly (and loudly in my mind) told me "go ahead and lay on your tummy and pull your undies down for me." I very slowly complied, and slid my undies just past my butt, like I did when I got shots. I always got my shots in the butt, and wasn't really that embarrassed by it, but this was totally different. This was taking my temperature like a baby and laying there with my butt on display for several minutes, not just a few quick seconds.

As she turned back around, she got a little more frustrated, saying "I need your undies all the way down." Another blow to my ego. I asked "how far" and she said "all the way down past your knees." So I slowly lifted up and complied, and felt everything flop out as I slid them down. My mom was there as she always was, not saying a word. Then I laid back down, and in went the old familiar cold, greasy thermometer. I was so ashamed. I kept coughing which slid the thermometer in and out, making me very aware of what was taking place. At one point I thought it fell out, and turned back to look. I saw the nurse holding the thermometer like an ink pen in place, staring right at my butt, and my mom was also staring. She told me "I need you to lie still, sweetie."


I put my head back down and tried to relax, and it seemed like it was taking forever. I prayed it would be over, and right on cue, the door popped wide open and the doctor barged in. "Oops....sorry." I was in a panic, as the door was wide open, and I stared at the doctor as if to say "you can leave now!" But, no, with the door completely open, he walked over to the nurse and whispered a few comments. I buried my face in my arms, not believing what was happening. Here I was a 12 year old, with my bare butt totally exposed, a nurse holding a thermometer in it, and the door wide open.

It probably wasn't as long as I thought, but he finally left saying "I'll be back in a few." Finally, a few seconds after he left she pulled the thermometer out. "Okay you can pull your undies up now." I raced for my undies and couldn't get them up fast enough. The rest of the exam was pretty routine, and I got the shot in the butt at the end as I almost always did. I slid my undies all the way down as my own kind of protest. I would show them it didn't bother me! But it did.

I walked out and was just sure everyone knew I had a thermometer up my butt. I was still greasy and had to walk funny. When we left, we drove back to my parents business, and they employed a married couple with two girls that lived in a trailer behind our store. Knowing I would see them (one was my age), I begged my mom not to tell them I got my temp taken in the butt. She laughed at first, but then I think she realized how embarrassing it was for me and said she wouldn't say anything. I rehearsed an entirely different visit in my mind over and over so I didn't slip up and tell anyone. When we got there I acted as casual as I could, but as soon as I felt it wouldn't be too obvious, I went to the bathroom to wipe all the grease up. It was like a mocking reminder that I had my temperature taken like a baby. I thought about moving my band aid to my arm, but thought my mom might spank me for lying and taking the band aid off, and I definitely didn't need another butt humiliation that day. The girls did ask if I got a shot and where I got it, and I sheepishly told them "in the butt". They giggled, but it wasn't as bad as knowing I had a thermometer stuck in it, too. Fortunately, they never asked about that.

I didn't even remember this story until I had started posting here, and one day it all came back. Rehearsing the phony story apparently worked for a while. I had remembered bits and pieces, but forgot it happened at 12, and slowly remembered the details. It was horrible when it happened, but I developed a fascination with rectal temps later on. As a teen, I would take my temp and relive the part about having to pull my undies "all the way down". This happened in the mid 80s, probably the last few years that glass thermometers were the norm.


After being switched to oral at 9, the rectal thermometer was used again at 12 because of my coughing. It was humiliating, and to make matters worse the doctor barged in in the middle of it and left the door open while he whispered something to the nurse. I was left with a greasy bottom and my ego deflated.


Rectal temperatures were always standard practice at the clinic. So when I was called back to the examination room, I knew the procedure. The nurse told me to undress to my underwear so she could check my vitals. The temperature check was always the last procedure after height, weight, and blood pressure readings. After these the nurse told me she needed me to lay on my tummy for the temperature check. I stood up on the steps at the end of the table, and then lowered myself down on my tummy. I remember the crinkly white paper as I lay down on the examination table. I felt the nurse lower my underwear to below my knees. She then went over to the refrigerator. I watched as she took a thermometer from a container. I could see it was a glass rectal thermometer with a pear-shaped bulb. I watched as she shook the thermometer down several times, then proceeded to the counter area

From there she opened a drawer, and took out a white tube. This was KY jelly. She gently squeezed the solution on the thermometer, and placed it back on the countertop. She then approached me, and said relax, this will not hurt. I felt her spread my bottom cheeks with her fingers. Then the cold feeling of the KY jelly touching my anal hole. I slightly clenched, then relaxed, as the nurse slowly inserted the pear-shaped bulb rectal thermometer inside my anal passage. I could literally feel the raised ridges on the rectal thermometer's outside number readings against my soft internal rectal skin. This feeling sent chills up my spine, and my penis continued to harden. The feeling was intense, as this nurse was in full control of my butt, as she steered the pear-shaped bulb rectal thermometer deeper into me.

Once inserted, she held the rectal thermometer in my bottom the entire session. Several times I remember feeling the nurse gently, and slightly withdraw, then twirl the rectal thermometer, and slowly reinsert it in my bottom. My rock hard penis felt like it would explode, as the chills rocketed throughout my body. There were moments where time seemed to stand still. The nurse then announced that it was time to check for the temperature reading. From this she spread my bottom cheeks with her fingers as before, and then slowly removed the rectal thermometer. I felt the raised ridges on the rectal thermometer's number readings as the pear-shaped bulb slowly was removed from my anal hole. The nurse then went over to the counter, and places the rectal thermometer in the sink. She grabs several tissues from another container, approaches me, then spreads my butt cheeks, and wipes the excess KY from my anal hole area, as I continue to lay still on my tummy.

 She then went over to toss the tissues in the trashcan. After this she told me that she was done, that I could put my underwear back on, and the doctor would be in shortly. From this moment, I wished she would have examined me as she did prior with the rectal thermometer. I continue to go to the same clinic to this day. I watch as their staff increases as the town grows in size, and I look forward to my physical visit, with my rectal temperature taking nurse. She knows me personally, so maybe one day she will take my rectal temperature more often than the yearly physical visits. I already know the procedures.


Blood Pressure

The blood pressure is recorded as two readings, a high systolic pressure which is the maximal contraction of the heart and the lower diastolic or resting pressure. Usually the blood pressure is taken in the right arm unless there is some damage to the arm. The difference between the systolic and diastolic pressure is called the pulse pressure. The measurement of these pressures is now usually done with an aneroid or electronic sphygmomanometer. The classic measurement device is a mercury sphygmomanometer, using a column of mercury measured off in millimeters. In the United States and UK, the common form is millimeters of mercury, whilst elsewhere SI units of pressure are used. There is no natural 'normal' value for blood pressure, but rather a range of values that on increasing are associated with increased risks. The guideline acceptable reading also takes into account other co-factors for disease. Elevated blood pressure hypertension therefore is variously defined when the systolic number is persistently over 140-160 mmHg. Low blood pressure is hypotension. Blood pressures are also taken at other portions of the extremities. These pressures are called segmental blood pressures and are used to evaluate blockage or arterial occlusion in a limb (see Ankle brachial pressure index).


Pulse

The pulse is the physical expansion of the artery Its rate is usually measured either at the wrist or the ankle and is recorded as beats per minute. The pulse commonly is taken is the radial artery at the wrist. Sometimes the pulse cannot be taken at the wrist and is taken at the elbow (brachial artery), at the neck against the carotid artery (carotid pulse), behind the knee (popliteal artery), or in the foot dorsalis pedis or posterior tibial arteries. The pulse rate can also be measured by listening directly to the heartbeat using a stethoscope. The pulse varies with age. A newborn or infant can have a heart rate of about 130-150 beats per minute. A toddler's heart will beat about 100-120 times per minute, an older child's heartbeat is around 90-110 beats per minute, adolescents around 80-100 beats per minute, and adults pulse rate is anywhere between 50 and 80 beats per minute.



Respiratory rate

Varies with age, but the normal reference range is 16-20 breaths/minute.

Basic Biometrics

Height

Height is the anthropometric longitudinal growth of an individual. A statiometer is the device used to measure height although often a height stick is more frequently used for vertical measurement of adults or children older than 2. The patient is asked to stand barefoot. Height declines during the day because of compression of the intervertebral discs. Children under age 2 are measured lying horizontally.

Weight

Weight is the anthropometric mass of an individual. A scale is used to measure weight.

Body mass index, or BMI, is used to calculate the relationship between healthy height and weight and obesity or being overweight or underweight.

Medical professionals generally prefer to use the SI unit of kilograms, and many medical facilities have ready-reckoner conversion charts available for professionals to use, when patients describe their weight in non-SI units. (In the US, pounds and ounces are common, while in the UK stones and pounds are frequently used; in most other countries the metric system predominates.)



Pain

Because of the importance of pain to the overall wellness of the patient, subjective measurement is considered to be a vital sign. Clinically pain is measured using a FACES scale which is a series of faces from '0' (no pain at all showing a normal happy face) to '5' (the worst pain ever experienced by the patient). There is also an analog scale from '0' to maximum '10'. It is important to allow patients to make their own choices on a pain scale. Physicians and health care workers frequently understate patient pain.

Inoculations

No one enjoys getting shots, but they can prevent terrible diseases.

   
       

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