Expect to pee in a cup. An in-office urinalysis is a quick and inexpensive way to get a lot of information beyond urinary tract infection. For example it can rule-out overt diabetes or point to liver problems. Frothy urine can suggest congestive heart issues. Ketosis can suggest severe carbohydrate restriction. The pH should be slightly acidic — otherwise there may be something wrong with your stomach’s ability to produce stomach acid. Often when my patients have alkaline urine I ask them if they eat TUMS (or other acid blockers). Often they admit they do and we can have a conversation about how important stomach acid is for digestion.
Sometimes I have the patient undress and get into a gown right away. If they are shy or new to me, we’ll talk first. I ask about their sleep and food habits. I’ll ask about exercise. If it’s a new patient I ask about their grandparents’ and parent’s health to get a sense of their genetic risk factors. I’ll ask about their current job and living situation to determine whether any stressors there could be reduced.
Once they are sitting on the table, I start by tapping their knees with a reflex hammer, looking for that funny lower leg jerk. If it’s nice and brisk I know two things right away: they are absorbing their B vitamins and they probably don’t have a thyroid problem. This deep tendon reflex is indicative of nervous system health.
If the patient has told me they have chronic pain anywhere, I spend extra time in that area — whether it be head, or neck or knee or abdomen. While they are still sitting I take the blood pressure. Often I take it twice — in the other arm too. I listen to the heart and lungs. I firmly tap the kidneys at the mid-back, push all along the spine to see it there are stiff areas, or scoliosis. I peek thoroughly at the skin on the back, looking for weird looking moles or growths. If I see something that doesn’t pass the A-B-C-D-E dermatology test, I have it removed for biopsy. A = general appearance; B = borders; irregular is bad; C = color; multi-color is bad; D = depth, flat is rarely a problem; E = evolution; is this growing, has it grown since last year? Then I look in the ears, mouth, throat and up the nostrils. If the patient is lucky enough to have tonsils, I make sure they know how to perform “tonsil maintenance.” (Basically, regular gargling with Listerine or a home-made garlicky salt water mix). I use a flashlight sideways into the eyes to observe appropriate pupillary constriction. I check for lymph nodes around the back of the head, under the chin, along the neck, at the top of the collar bones and in the armpits. I gently check the thyroid gland right around the Adam’s apple. I do the seated portion of the breast check — for men and women — looking for dimpled or retracted skin, or obvious asymmetry. I take their temperature, which should be at least 97.8. I hardly ever find anyone with the “classic” temperature of 98.6 and I think this is because of world-wide pollutants and their effect on human metabolism (dials it down). A much lower temperature often indicates hypothyroidism.
Then I have the patient lie down, with a bolster under their knees to relax the abdomen. Before pressing into their belly, I listen with a stethescope, because I want to hear nice gurgling sounds all over. High pitched squeals are a bad sign — it may mean some part of the tube is pinched or obstructed. I press fairly deeply into the appendix area (lower right). I feel firmly under the left ribcage for the spleen — which I don’t want to feel because that would mean it’s enlarged or damaged. The spleen is responsible for recycling red blood cells, which last about 120 days. Then I feel up under the right ribcage for the liver and gallbladder. A sharp pain that radiates to the back may mean stones or sludge in the gallbladder. I can figure out the size of the liver fairly accurately by tapping over the right ribcage and listening for a hollow sound (guts) versus a dull sound (solid organ). I’m also looking at the skin quality over the abdomen. Lots of little spider veins or broken capillaries across the mid belly can signify liver distress. I’m looking also for moles that might be melanoma. I perform the lying down portion of the breast exam, starting with the armpit and methodically checking all the breast tissue, starting at a superficial level and pressing gently but firmly all the way to the chest wall. For women I make sure they know how to perform a good breast self exam — both breasts at the same time, looking for symmetry. Asymmetry in breast tissue for no reason (such as previous surgery) should always be brought to the doctor for an opinion.
Then it’s time for the pelvic exam. In a sexually experimenting woman, a PAP is important because she is at risk for cervical cancer caused by the STD Human Papilloma Virus (HPV). For women in long term, mutually monogamous relationships with a history of serveral “good” PAPs with that partner, the PAP is less important — unless the woman has a history of HPV. PAPs can be done every 5 years on a low-risk woman, but may need to be done every 6 months on a woman on the move with multiple partners. In the older woman, her risk is more for ovarian cancer. I spend several minutes feeling the uterus, checking for irregularities which are often fibroids, and also palpating (feeling) the ovaries, always trying to maintain eye contact so I can tell if I am inadvertently causing any discomfort. For a man, I will offer the digital-rectal exam (DRE) to check his prostate for lumps or asymmetry. In the younger man, age 15-30, I will give a testicular exam and make sure he knows to regularly perform testicular self-exam. Testicular cancer is most likely to occur in younger men.
When the patient gets up from the table, I measure their height and weight and calculate their BMI. I also take their waist measurement because that is an easy and reliable assessment of the dreaded abdominal fat, which also burdens the internal organs. For men I prefer waist size to be 40 inches or less and their BMI to be 26 or less unless they are massively muscular. For women I prefer waist size of 34 inches or less and a BMI of 27 or less. Ideal BMI is around 22. To calculate your basal metabolic index, take your height in inches, and square that number and write it down. Then calculate your weight in pounds and multiply by 703. When that bigger number is on the calculator, divide it by a smaller number: inches of height, squared. A number of 30 or above is considered obsese and puts the patient at much greater risk of diabetes, early cardiac death, painful joints and most cancers. The single most effective way to lose weight is to drastically reduce intake of refined carbohydrates and processed foods in general. If it comes in a box or is deep fried — don’t eat it.
I always allow time to review what my patients are eating. I ask them what comprises a typical breakfast, lunch, dinner and snacks. I find out how much water, and other fluids, they are drinking. Up to 2 beers or 2 glasses of wine for men, and 1 for women is OK. Less alcohol is better. I never encourage my patients to start drinking! If they smoke I make sure to spend time counseling them about quit options. Often the hardest part is needing to avoid friends who smoke, for a good long while.
As you can see, there is no way to perform a good physical exam in 7 or 10 minutes. A minimum of 25 minutes is required. I also train my patients to expect me to explain their lab results to them. It’s just not good enough to assume the patient won’t understand the lab results and only call them back if there is a problem. If I have drawn blood that goes out to a lab for analysis, I typically spend 10-15 minutes writing notes on the lab report explaining each item and what needs to happen next if there are abnormal values, and then mail a copy to my patient.
The US health care system will bankrupt us unless we all start taking more personal responsibility. Quit smoking. Eat vegetables and if possible grow your own. Don’t go for drugs as a first line of therapy. Drink mostly water or herbal teas. I believe my part in this equation is to help make my patients not only healthier, but also smart about how their bodies work and about optimal and individualized strategies for achieving good health. Everyone should leave their doctor’s visits with greater knowledge about themselves and about their treatment or health maintenance options. I recommend you go into your doctor’s office with a list of questions and do your best to not be interrupted or dismissed until you have answers.