Initial OSCE - Comprehensive Physical Examination

Introduction:

Time: 2 minutes

1. Introduction to Patient:
o Introduce yourself as the healthcare provider performing the comprehensive
physical exam today.
o Confirm the patient's identity using their name and date of birth.
o Explain the process: "Today, I'll be conducting a full physical examination, which
will involve inspecting, palpating, and assessing various parts of your body. This
will take approximately 30 minutes, and I'll explain each step as we go along."

General Overview:

Time: 3 minutes

3. Apparent State of Health:

o Observe and verbally note the patient's general appearance, including signs of
distress, consciousness, mood, and speech.
o Verbalization: "The patient appears well, alert & oriented x 3, and shows no signs
of acute distress. Dress is appropriate for the situation and personal hygiene is
good. Speech is clear, and mood is congruent with the affect and appears stable."
4. Posture and Gait:
o Ask the patient to stand and walk a few steps.
o Verbalization: "The patient’s posture is upright, and gait is steady without any
apparent abnormalities."
5. Memory:
o Assess remote and recent memory by asking about past significant events and
what they had for breakfast.
o Verbalization: "Remote and recent memory are intact."

Skin, Hair, and Nails:

Time: 3 minutes

6. Inspect and Palpate Skin:

o Inspect the skin for color, moisture, temperature, texture, mobility, turgor, lesions,
and edema.
o Palpate for abnormalities.
o Verbalization: "The skin is warm, dry, and of normal texture with good skin
turgor & mobility. Skin color is appropriate for ethnicity. No lesions or edema
noted."
7. Inspect & palpate Nails:
o Assess color, shape, and contour.
 o Verbalization: "Nails are pink with normal shape and contour. No clubbing or
abnormal findings."

Head and Face:

Time: 2 minutes

9. Inspect and Palpate Hair & Scalp:

o Check the scalp and hair for tenderness, lumps, and texture.
o Verbalization: "The scalp is free of lumps, scales or tenderness. Hair distribution
is normal with even texture."
10. Inspect Head and Face:
o Inspect the head and face for symmetry, contour, and any abnormalities.
o Verbalization: "The head/skull is normocephalic and atraumatic. No lumps,
edema, or tenderness.”
o (CN V-Trigeminal Nerve). Instructions: Ask the patient to clench their teeth
while palpating the temporal and masseter muscles for strength.
o Verbalization: "Temporal and masseter muscles are symmetric and strong.
Cranial nerve V is intact."
o Cranial VII- Facial Nerve. Instructions: Observe the symmetry of the face and
note any involuntary movements. Test facial nerve function by asking the patient
to smile, frown, and raise eyebrows.
o Verbalization: Facial expressions are symmetrical with no signs of involuntary
movements. Cranial VII is intact.

Eyes:

Time: 3 minutes

10. Inspect Eyes:

o Inspect external eye structures, including alignment, eyelids, lashes, and lacrimal
apparatus.
o Verbalization: "The eyes are symmetrically aligned, with no protrusion. Eyelids
& lashes are normal and the lacrimal apparatus shows no signs of excessive
tearing or swelling."
11. Inspect Conjunctiva, Sclera, Cornea, and Lens:
o Check color and any opacities.
o Example Verbalization: "Conjunctiva is clear, sclera white, and no opacities in the
lens and cornea is transparent."
12. Pupillary Reaction to Light and Extraocular Movements:
o Test pupillary reaction to light and accommodation (CN III -Oculomotor nerve)
and assess extraocular movements (CN III-oculomotor, IV-trochlear, VI-abducens
nerves).
o Instructions: Shine a light into each pupil to check for direct and consensual
reaction. Perform the accommodation test by having the patient focus on a distant
object and then on a near one (use finger or pen).
 o Verbalization: "Irises are evenly pigmented. Pupils are equal, round, reactive to
light and accommodation. Extraocular movements are intact. Cranial Nerves III,
IV, & VI are intact."
13. Visual Fields & Acuity
o Cranial Nerve II (Optic Nerve) – Visual Fields by Confrontation
o Instructions: Test visual fields by having the patient cover one eye and look
straight ahead while you wiggle your fingers in their peripheral vision.
o Verbalization: “Visual fields are intact bilaterally. Cranial nerve II is intact.”
o CN II – Visual Acuity (Near Vision w/ Rosenbaum Chart)
o Instructions: Have the patient hold the Rosenbaum chart at reading distance and
read the smallest line possible.
o Verbalization: “Near vision is 20/20 with the Rosenbaum chart.”
14. CN II – Red Reflex (Ophthalmoscopic Exam)
o Verbalization: “Normal red reflex is symmetrical and equal in color, size,
brightness, and shape in both eyes.”

Ears

Time: 2 minutes

13. Inspect and Palpate Ears:

o Inspect the auricle and ear canal and inspect the eardrum using otoscope.
o Verbalization: "The auricles are symmetrical without deformities, lumps or lesion.
Ear canals are clear, no discharge, swelling, foreign bodies or cerumen. Tympanic
membranes are pearly gray with a visible cone of light."
14. CN VIII – Vestibulocochlear Nerve – Whisper Test
o Instructions: Ask the pt. to cover one ear and whisper (1,2,3) then the other ear
(4,5,6).
o Verbalization: Hearing is intact bilaterally. CN VIII is intact.

Nose and Paranasal Sinuses:

Time: 2 minutes

14. Inspect and Palpate Nose and Sinuses:

o Inspect the nose for symmetry and palpate the sinuses (frontal & maxillary).
o Verbalization: "The nose is symmetrical with no deformities. Nasal mucosa is
pink without any bleeding or exudates. Nasal patency (occlude one nostril &
breath in). Frontal & Maxillary sinuses are non-tender."

Mouth and Pharynx:

Time: 3 minutes

15. Inspect Mouth and Throat:

o Inspect lips, oral mucosa, gums, teeth, tongue, and pharynx.
 o Assess gag reflex and movement of the palate (CN IX, X).
o Example Verbalization: "Oral mucosa is moist and pink, teeth are in good
condition, and the gag reflex is intact."

Neck:

Time: 3 minutes

16. Inspect and Palpate Neck:

o Assess lymph nodes, trachea position, and thyroid gland.
o Check neck strength and shoulder shrug (CN XI).
o Example Verbalization: "No lymphadenopathy noted, trachea is midline, and the
thyroid gland is non-enlarged. CN XI is intact."

Thorax and Lungs:

Time: 4 minutes

17. Inspect, Palpate, and Auscultate Lungs:

o Inspect respiratory movement, palpate for tenderness, and auscultate breath
sounds.
o Example Verbalization: "Breath sounds are clear bilaterally with no adventitious
sounds. Respiratory movement is symmetric."

Cardiac:

Time: 3 minutes

18. Inspect, Palpate, and Auscultate Heart:

o Inspect and palpate carotid arteries, and auscultate using both the bell and
diaphragm.
o Identify and describe S1 and S2 sounds.
o Example Verbalization: "S1 and S2 are heard clearly without any murmurs. No
carotid bruits detected."

Abdomen:

Time: 3 minutes

19. Inspect, Auscultate, Percuss, and Palpate Abdomen:

o Inspect contour, auscultate bowel sounds, percuss, and palpate quadrants.
o Example Verbalization: "The abdomen is soft, non-tender, with normal bowel
sounds and no masses."

Extremities:
Time: 4 minutes

20. Inspect, Palpate, and Assess ROM and Strength:

o Inspect pulses, assess range of motion (ROM) and strength in upper and lower
extremities.
o Example Verbalization: "Peripheral pulses are 2+ and equal bilaterally. ROM and
strength are within normal limits."

Spine:

Time: 2 minutes

21. Inspect and Palpate Spine:

o Assess curvature and palpate spinous processes.
o Example Verbalization: "Spinal curvature is normal, and there is no tenderness on
palpation."

Neuro:

Time: 2 minutes

22. Assess Reflexes, Sensory, and Coordination:

o Test deep tendon reflexes, sensory perception, and coordination (Romberg test,
point-to-point movements).
o Example Verbalization: "Deep tendon reflexes are 2+ and symmetric. Sensory
and coordination tests are normal."

Conclusion:

Time: 1 minute

23. Wrap-Up:
o Thank the patient for their cooperation.
o Ensure the patient is comfortable and provide any necessary assistance.
o Wash your hands and document the findings promptly.

Final Notes:

 During each section, ensure verbalization of key findings to meet the rubric requirements.
 Utilize the index card only twice during the exam to avoid point deductions.
 Maintain a professional demeanor and ensure clear communication throughout the
examination.
This script is structured to guide you through the OSCE within the 30-minute time frame,
ensuring all aspects of the rubric are covered.

4o

You said:

please include detailed instructions

ChatGPT said:

ChatGPT

Certainly! Here’s a detailed script for the Objective Structured Clinical Examination (OSCE),
with explicit instructions to guide you through each step of the comprehensive physical
examination:

Script for OSCE - Comprehensive Physical Examination

Introduction:

Time: 2 minutes

1. Introduction to Patient:
o Instruction: Walk into the examination room confidently. Greet the patient with
a friendly, professional demeanor.
o Verbalize: “Good morning/afternoon, my name is [Your Name], and I’m a
[medical student/healthcare provider] who will be performing your physical
examination today.”
o Confirm Identity: Politely ask the patient to confirm their full name and date of
birth.
o Verbalize: “Just to confirm, could you please tell me your full name and date of
birth?”
o Explain the Procedure:
 Verbalize: “Today, I’ll be conducting a comprehensive physical
examination. This will include inspecting, palpating, and assessing various
parts of your body to ensure everything is functioning as it should. It
should take about 30 minutes. I’ll explain each step as we go along, and if
you have any discomfort or concerns, please let me know.”
o Ensure Comfort:
 Instruction: Ask the patient if they’re comfortable and ensure they’re
appropriately draped for modesty.
 Verbalize: “Are you comfortable? Please let me know if you feel any
discomfort during the exam.”
 2. Preparation:
o Instruction: Before proceeding, wash your hands thoroughly in front of the
patient to demonstrate good hygiene.
o Verbalize: “I’m just going to wash my hands before we begin.”
o Gloves: If necessary (e.g., for specific examinations or patient conditions), put on
gloves.
o Verbalize: “I’m putting on gloves for your safety and mine.”

General Overview:

Time: 3 minutes

3. Apparent State of Health:

o Instruction: Stand at an appropriate distance from the patient, observe their
general appearance, and note any immediate signs of distress or abnormal
behavior.
o Verbalize: “The patient appears well, alert, and oriented. No signs of acute
distress are observed. Speech is clear, and mood appears stable.”
4. Posture and Gait:
o Instruction: Ask the patient to stand up and walk a few steps, observing their
posture and gait.
o Verbalize: “Could you please stand up and walk to the door and back? I’ll be
observing your posture and the way you walk.”
o Observation: Pay attention to any abnormalities, such as limping or unsteady
gait.
o Verbalize: “The patient’s posture is upright, and gait is steady without any
apparent abnormalities.”
5. Memory:
o Instruction: Test the patient’s memory by asking about a remote event (e.g.,
“Can you tell me about a significant event in your life?”) and a recent event (e.g.,
“What did you have for breakfast today?”).
o Verbalize: “To assess your memory, could you tell me about an important event
from your past? And what did you have for breakfast today?”
o Assessment: Ensure the patient recalls these events accurately.
o Verbalize: “The patient’s remote and recent memory are intact.”

Skin, Hair, and Nails:

Time: 3 minutes

6. Inspect and Palpate Skin:

o Instruction: Ask the patient to expose their arms and legs for a skin examination.
Inspect the skin for color, moisture, temperature, texture, mobility, turgor, and
any lesions or edema.
o Verbalize: “I’m going to examine your skin now. Please roll up your sleeves and
pant legs.”
 o Palpation: Gently press on the skin to check for turgor and edema.
o Verbalize: “The skin is warm, dry, and of normal texture with good turgor. No
lesions or edema are noted.”
7. Inspect and Palpate Hair:
o Instruction: Inspect the scalp and hair by parting the hair in several areas to
check for tenderness, lumps, and texture.
o Verbalize: “I’m going to check your scalp now. Let me know if you feel any
tenderness.”
o Palpation: Gently palpate the scalp.
o Verbalize: “The scalp is free of lumps or tenderness. Hair distribution is normal
with even texture.”
8. Inspect Nails:
o Instruction: Look closely at the patient’s fingernails and toenails for color,
shape, and contour.
o Verbalize: “I’m going to check your nails now.”
o Observation: Ensure there is no clubbing, pitting, or abnormal coloration.
o Verbalize: “The nails are pink with normal shape and contour.”

Head and Face:

Time: 2 minutes

9. Inspect Head and Face:

o Instruction: Stand in front of the patient and inspect the head and face for
symmetry, contour, and any abnormalities.
o Verbalize: “I’m going to examine your head and face now.”
o Palpation: Palpate the temporal and masseter muscles while the patient clenches
their teeth to assess muscle tone and symmetry (Cranial Nerve V).
o Verbalize: “Please clench your teeth. I’m checking the muscles here.”
o Verbalize: “The head is normocephalic and atraumatic. Facial muscles are
symmetrical with no signs of involuntary movements.”

Eyes:

Time: 3 minutes

10. Inspect Eyes:

o Instruction: Stand in front of the patient and inspect the external structures of the
eyes, including the alignment of the eyes, eyelids, lashes, and lacrimal apparatus.
o Verbalize: “I’m going to inspect your eyes now.”
o Observation: Look for any signs of redness, swelling, or discharge.
o Verbalize: “The eyes are symmetrically aligned, with no signs of excessive
tearing or swelling.”
11. Inspect Conjunctiva, Sclera, Cornea, and Lens:
o Instruction: Gently pull down the lower eyelids to inspect the conjunctiva and
sclera. Use a penlight to inspect the cornea and lens.
 o Verbalize: “I’m checking the inner part of your eyes now. Please look up.”
o Observation: Ensure the conjunctiva is clear, the sclera is white, and the cornea
and lens are clear.
o Verbalize: “The conjunctiva is clear, sclera white, and there are no opacities in
the cornea or lens.”
12. Pupillary Reaction and Extraocular Movements:
o Instruction: Use a penlight to test the pupillary reaction to light and
accommodation (Cranial Nerve III). Ask the patient to follow your finger as you
move it in an "H" pattern to assess extraocular movements (Cranial Nerves III,
IV, VI).
o Verbalize: “I’m going to shine a light in your eyes to check your pupils’ reaction.
Then, please follow my finger with your eyes without moving your head.”
o Observation: Ensure pupils are equal, round, reactive to light, and
accommodation, and that extraocular movements are intact.
o Verbalize: “Pupils are equal, round, and reactive to light and accommodation.
Extraocular movements are intact.”

Ears:

Time: 2 minutes

13. Inspect and Palpate Ears:

o Instruction: Inspect the external ear, including the auricle and ear canal. Perform
the whisper test to assess auditory acuity (Cranial Nerve VIII).
o Verbalize: “I’m going to examine your ears now.”
o Palpation: Gently palpate the auricles and tragus for tenderness.
o Whisper Test: Stand behind the patient and whisper a word or number while
covering one ear at a time. Ask the patient to repeat what they hear.
o Verbalize: “The auricles are without deformities. Ear canals are clear, and
auditory acuity is intact bilaterally.”

Nose and Paranasal Sinuses:

Time: 2 minutes

14. Inspect and Palpate Nose and Sinuses:

o Instruction: Inspect the external nose for symmetry and any deformities. Palpate
the frontal and maxillary sinuses for tenderness.
o Verbalize: “I’m going to check your nose and sinuses now.”
o Palpation: Press gently on the frontal and maxillary sinuses.
o Verbalize: “The nose is symmetrical, and sinuses are non-tender.”

Mouth and Pharynx:

Time: 3 minutes
 15. Inspect Mouth and Throat:
o Instruction: Ask the patient to open their mouth wide. Inspect the lips, oral
mucosa, gums, teeth, tongue, and pharynx. Use a tongue depressor if necessary.
o Verbalize: “I’m going to examine your mouth and throat now. Please open your
mouth wide and say ‘ah.’”
o Assessment: Observe the movement of the soft palate and check the gag reflex
(Cranial Nerves IX, X).
o Verbalize: “The lips, oral mucosa, and gums are healthy, with no signs of lesions.
The teeth are in good condition, and the tongue and pharynx are normal.”

Neck:

Time: 3 minutes

16. Inspect and Palpate Neck:

o Instruction: Inspect the neck for symmetry and any masses. Palpate the lymph
nodes (preauricular, postauricular, occipital, tonsillar, submandibular, submental,
superficial cervical, deep cervical, posterior cervical, and supraclavicular) and
thyroid gland.
o Verbalize: “I’m going to check your neck now, including the lymph nodes and
thyroid gland.”
o Palpation: Ask the patient to swallow while you palpate the thyroid.
o Verbalize: “The neck is symmetrical with no palpable masses. The lymph nodes
and thyroid gland are non-tender and of normal size.”

Thorax and Lungs:

Time: 5 minutes

17. Inspect Thorax:

o Instruction: Ask the patient to sit upright and expose their chest. Inspect the
thorax for symmetry, respiratory effort, and any deformities.
o Verbalize: “I’m going to examine your chest and lungs now. Please sit upright.”
o Observation: Ensure the chest rises symmetrically with respiration.
o Verbalize: “The thorax is symmetrical with normal respiratory effort.”
18. Auscultate Lungs:
o Instruction: Using your stethoscope, auscultate the anterior and posterior lung
fields in a systematic pattern. Ask the patient to take deep breaths through their
mouth.
o Verbalize: “I’m going to listen to your lungs now. Please take deep breaths in
and out through your mouth.”
o Observation: Listen for any abnormal sounds such as crackles, wheezes, or
rhonchi.
o Verbalize: “Breath sounds are clear bilaterally with no adventitious sounds.”
19. Percussion of Lung Fields:
o Instruction: Percuss the anterior, posterior, and lateral lung fields.
 o Verbalize: “I’m going to tap on your chest to check the resonance of your lungs.”
o Observation: Ensure resonance is normal and symmetrical.
o Verbalize: “Percussion reveals normal resonance over lung fields.”

Cardiovascular System:

Time: 5 minutes

20. Inspect Precordium:

o Instruction: Ask the patient to lie down and expose the chest. Inspect the
precordium for visible pulsations.
o Verbalize: “I’m going to examine your heart now. Please lie down.”
o Observation: Look for any visible apical impulse or abnormal pulsations.
o Verbalize: “The precordium is without visible pulsations or heaves.”
21. Palpate Precordium:
o Instruction: Palpate the precordium to assess the point of maximal impulse
(PMI) and any abnormal movements.
o Verbalize: “I’m going to feel your chest now to assess your heart’s movement.”
o Observation: Palpate in the areas of the aortic, pulmonic, tricuspid, and mitral
valves.
o Verbalize: “The point of maximal impulse is located at the fifth intercostal space
in the midclavicular line.”
22. Auscultate Heart:
o Instruction: Using your stethoscope, auscultate the heart in the four key areas:
aortic, pulmonic, tricuspid, and mitral valves. Listen for heart sounds, murmurs,
or abnormal rhythms.
o Verbalize: “I’m going to listen to your heart now. Please breathe normally.”
o Observation: Identify S1 and S2, and note any abnormal sounds like murmurs or
extra heart sounds.
o Verbalize: “Heart sounds S1 and S2 are heard with regular rhythm and no
murmurs detected.”
23. Palpate Peripheral Pulses:
o Instruction: Palpate the radial, brachial, femoral, popliteal, posterior tibial, and
dorsalis pedis pulses.
o Verbalize: “I’m going to check your pulses now.”
o Observation: Assess pulse strength and symmetry.
o Verbalize: “Pulses are strong and symmetrical in all extremities.”

Abdomen:

Time: 5 minutes

24. Inspect Abdomen:

o Instruction: Ask the patient to lie flat and expose the abdomen. Inspect for
symmetry, distention, scars, or any abnormal pulsations.
o Verbalize: “I’m going to examine your abdomen now. Please lie flat and relax.”
 o Observation: Ensure the abdomen is flat and symmetrical with no visible
abnormalities.
o Verbalize: “The abdomen is flat, symmetrical, with no visible scars or
pulsations.”
25. Auscultate Abdomen:
o Instruction: Auscultate the abdomen in all four quadrants using the diaphragm of
your stethoscope to listen for bowel sounds.
o Verbalize: “I’m going to listen to your abdomen now.”
o Observation: Ensure bowel sounds are present and normal.
o Verbalize: “Bowel sounds are present and normal in all quadrants.”
26. Percussion of Abdomen:
o Instruction: Percuss all four quadrants of the abdomen to assess tympany and
dullness.
o Verbalize: “I’m going to tap on your abdomen now to check for any abnormal
sounds.”
o Observation: Tympany should predominate with some dullness over solid
organs.
o Verbalize: “Percussion reveals normal tympany with some dullness over the
liver.”
27. Palpate Abdomen:
o Instruction: Palpate the abdomen lightly first, then deeply, in all four quadrants.
o Verbalize: “I’m going to gently press on your abdomen now. Let me know if you
feel any discomfort.”
o Observation: Check for tenderness, masses, or organomegaly.
o Verbalize: “The abdomen is soft, non-tender, with no palpable masses or
organomegaly.”
28. Assess Liver and Spleen:
o Instruction: Palpate the liver by placing your hand under the right costal margin
and asking the patient to take a deep breath. Palpate the spleen similarly under the
left costal margin.
o Verbalize: “I’m going to check your liver and spleen now. Take a deep breath for
me.”
o Observation: Ensure neither organ is enlarged.
o Verbalize: “The liver and spleen are not palpable, indicating normal size.”

Musculoskeletal System:

Time: 4 minutes

29. Inspect Joints and Muscles:

o Instruction: Inspect the major joints (shoulders, elbows, wrists, hips, knees, and
ankles) for symmetry, swelling, or deformities. Observe muscle bulk and tone.
o Verbalize: “I’m going to examine your joints and muscles now.”
o Observation: Ensure there is no swelling, deformities, or muscle atrophy.
o Verbalize: “The joints are symmetrical with no swelling or deformities. Muscle
tone is normal.”
 30. Palpate Joints:
o Instruction: Palpate each joint to assess for tenderness, warmth, or crepitus.
o Verbalize: “I’m going to feel your joints now. Let me know if you feel any pain.”
o Observation: Ensure the joints are non-tender, with no abnormal warmth or
crepitus.
o Verbalize: “The joints are non-tender with no warmth or crepitus.”
31. Range of Motion (ROM):
o Instruction: Ask the patient to perform active range of motion exercises for each
major joint.
o Verbalize: “I’m going to assess your range of motion now. Please follow my
instructions.”
o Observation: Ensure the patient has full ROM without pain.
o Verbalize: “The patient has full range of motion in all joints without pain.”

Neurological System:

Time: 5 minutes

32. Assess Mental Status:

o Instruction: Assess the patient’s mental status by asking questions about
orientation, memory, and judgment.
o Verbalize: “I’m going to ask you a few questions to assess your mental status.
What is today’s date? Where are you right now?”
o Observation: Ensure the patient is alert and oriented to person, place, and time.
o Verbalize: “The patient is alert and oriented to person, place, and time.”
33. Cranial Nerves:
o Instruction: Test all cranial nerves (I–XII) through various tasks (e.g., smell test
for CN I, facial movement for CN VII, shoulder shrug for CN XI).
o Verbalize: “I’m going to test your cranial nerves now.”
o Observation: Ensure all cranial nerves are intact.
o Verbalize: “All cranial nerves are intact.”
34. Motor System:
o Instruction: Test muscle strength by asking the patient to push against your
resistance in the upper and lower extremities.
o Verbalize: “I’m going to test your muscle strength now. Push against my hand.”
o Observation: Ensure muscle strength is 5/5 in all extremities.
o Verbalize: “Muscle strength is 5 out of 5 in all extremities.”
35. Reflexes:
o Instruction: Test deep tendon reflexes (biceps, triceps, patellar, Achilles) and the
Babinski reflex.
o Verbalize: “I’m going to test your reflexes now.”
o Observation: Ensure reflexes are normal and symmetrical.
o Verbalize: “Reflexes are 2+ and symmetrical. The Babinski reflex is negative.”
36. Sensory System:
o Instruction: Test sensation to light touch, pain, and vibration in various areas
(hands, feet, legs).
 o Verbalize: “I’m going to test your sensation now. Please tell me when you feel
this.”
o Observation: Ensure sensation is intact and symmetrical.
o Verbalize: “Sensation is intact to light touch, pain, and vibration in all tested
areas.”
37. Coordination and Gait:
o Instruction: Ask the patient to perform coordination tasks (finger-to-nose, heel-
to-shin) and observe their gait as they walk across the room.
o Verbalize: “I’m going to test your coordination and gait now. Please follow my
instructions.”
o Observation: Ensure the patient performs tasks accurately and has a steady gait.
o Verbalize: “Coordination is intact, and gait is steady.”

Final Steps:

Time: 1 minute

38. Conclude the Examination:

o Instruction: Thank the patient for their cooperation and explain that the
examination is complete.
o Verbalize: “Thank you for your cooperation. The examination is now complete.
Do you have any questions?”
39. Documentation:
o Instruction: Record all findings from the physical examination in the patient’s
medical record.
o Note: Ensure documentation is thorough and accurate.