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Usefulness of the external Mangione S. Cardiac auscultatory skills of physicians-in-training: jugular vein examination in detecting abnormal central venous a comparison of three English speaking countries Am J Med pressure in critically ill patients Arch Int Med ; The Skin The Head List of Tables.
The techniques of physical examination and history taking that you are about to learn embody the time-honored skills of healing and patient care. Gathering a sensitive and nuanced history and performing a thorough and accurate examina- tion deepen your relationships with patients, focus your assessment, and set the guideposts that direct your clinical decision making Fig.
The quality of your history and physical examination lays the foundation for patient assess- ment, your recommendations for care, and your choices for further evaluation and testing. As you become an accomplished clinician, you will continually pol- ish these important relational and clinical skills.
The importance of establishing rapport. Your experience with history taking and physical examination will grow, and will trigger the steps of clinical reasoning from the first moments of the patient encounter: identifying symptoms and abnormal findings; linking findings to underlying pathophysiology or psy- chopathology; and establishing and testing a set of explanatory hypotheses.
Working through these steps will reveal the multifaceted profile of the patient before you. Paradoxically, the skills that allow you to assess all patients also shape the clinical portrait of the unique human being entrusted to your care. The skilled physical ing hypotheses for causality and testing. This chapter, revised in this edition, provides a guide to clinical proficiency in four critical areas: the Health History; the Physical Examination; Clinical.
The new Chapter 2, Evaluating Clinical Evidence, provides the analytic tools for eval- uating tests, guidelines, and the clinical literature that will ensure best prac- tices and lifelong clinical learning. Chapter 3, Interviewing and the Health History, completes the foundational chapters that prepare you for performing the physical examination.
You will learn the techniques of physical examina- tion in Chapters 4 through Each chapter is evidence based and includes citations from the clinical literature for easy reference so that you can con- tinue to expand your knowledge. Beginning with Chapter 4, sections on Health Promotion and Counseling: Evidence and Recommendations review cur- rent clinical guidelines for preventive care. It addresses basic and advanced interviewing techniques and the approach to challenging patients as well as cultural competence and professionalism.
As you acquire the skills of physical examination and history taking, you will move to active patient assessment, gradually at first, but then with growing con- fidence and expertise, and ultimately clinical competence.
From mastery of these skills and the mutual trust and respect of caring patient relationships emerge the timeless rewards of the clinical professions. Comprehensive Assessment Focused Assessment Is appropriate for new patients in the Is appropriate for established patients, office or hospital especially during routine or urgent Provides fundamental and personal- care visits ized knowledge about the patient Addresses focused concerns or symp- Strengthens the clinician—patient toms relationship Assesses symptoms restricted to a Helps identify or rule out physical specific body system causes related to patient concerns Applies examination methods rele- Provides a baseline for future assess- vant to assessing the concern or ments problem as thoroughly and care- Creates a platform for health promotion fully as possible through education and counseling Develops proficiency in the essential skills of physical examination.
As you can see, the comprehensive examination does more than assess body sys- tems. It is a source of fundamental and personalized knowledge about the patient that strengthens the clinician—patient relationship. Most people seeking care have specific worries or symptoms. The comprehensive examination provides a more complete basis for assessing these concerns and answering patient questions. For the focused examination, you will select the methods relevant to thorough assessment of the targeted problem.
Of all the patients with sore throat, for example, you will need to decide who may have infectious mononucleosis and warrants careful palpation of the liver and spleen and who, by contrast, has a common cold amenable to a more focused examination of the head, neck, and lungs.
The clinical reasoning that underlies and guides such decisions is discussed later in this chapter. What about the routine clinical check-up, or periodic health examination? Numerous studies have scrutinized the usefulness of the annual well-patient visit for screen- ing and prevention of illness, in contrast to evaluation of symptoms, without coming to a clear consensus. Various consensus pan- els and expert advisory groups have further expanded recommendations for examination and screening, which will be addressed in the regional examination chapters.
What about the newer evidence about the physical examination itself and its relationship to advanced diagnostic testing? Subjective Versus Objective Data As you acquire the techniques of history taking and physical examination, remember the important differences between subjective information and objective information, summarized in the table below.
Symptoms are subjective concerns, or what the patient tells you. Signs are considered one type of objective informa- tion, or what you observe. Knowing these differences helps you group together the different types of patient information. These distinctions are equally impor- tant for organizing written and oral presentations about patients into a logical and understandable format. Subjective Data Objective Data What the patient tells you What you detect during the examination, laboratory information, and test data The symptoms and history, from All physical examination findings, or signs Chief Complaint through Review of Systems Example: Mrs.
As you will learn in Chapter 3, Interviewing and the Health History, when you talk with patients, the health history rarely emerges in this order. This restructuring organizes your clinical reasoning and provides a template for your expanding clinical expertise. As you begin your clinical journey, review the components of the adult health history, then study the more detailed explanations that follow.
The date is always important. Be sure to docu- ment the time you evaluate the patient, especially in urgent, emergent, or hospital settings. Identifying Data.
These include age, gender, marital status, and occupa- tion. The source of history or referral can be the patient, a family member or friend, an officer, a consultant, or the clinical record. Identifying the source of referral helps you assess the quality of the referral information, questions you may need to address in your assessment and written response.
Document this information, if relevant. This judgment reflects the quality of the information provided by the patient and is usually made at the end of the interview. Chief Complaint s. Present Illness. Always remem- ber, the data flow spontaneously from the patient, but the task of oral and written organization is yours. Each symptom mer- its its own paragraph and a full description. Also, list home remedies, nonprescription drugs, vitamins, mineral or herbal supplements, oral contraceptives, and medicines borrowed from family members or friends.
Ask patients to bring in all their medications so that you can see exactly what they take. If someone has quit, note for how long. Also included are any chronic childhood illnesses. For immunizations, find out whether the patient has received vaccines for tetanus, pertussis, diphthe- ria, polio, measles, rubella, mumps, influenza, varicella, hepatitis B virus HBV , human papilloma virus HPV , meningococcal disease, Haemophilus influenzae type B, pneumococci, and herpes zoster.
For screening tests, re- view tuberculin tests, Pap smears, mammograms, stool tests for occult blood, colonoscopy and cholesterol tests, together with results and when they were last performed.
If the patient does not know this information, written permission may be needed to obtain prior clinical records. Family History. Under Family History, outline or diagram the age and health, or age and cause of death, of each immediate relative including parents, grand- parents, siblings, children, and grandchildren. Review each of the following con- ditions and record whether they are present or absent in the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, as well as.
Ask about any history of breast, ovarian, colon, or prostate cancer. Ask about any genetically transmitted diseases. Personal and Social History. It should include occupation and the last year of schooling; home situation and significant others; sources of stress, both recent and long-term; important life experiences such as military service, job history, financial situa- tion, and retirement; leisure activities; religious affiliation and spiritual beliefs; and activities of daily living ADLs.
Baseline level of function is particularly See pp. The Personal and Social History includes quently assessed in older adults. Include sexual orientation and practices and any alternative health care practices. Avoid restricting the Personal and Social History to only tobacco, drug, and alcohol use. An expanded Personal and Social History personalizes your relationship with the patient and builds rapport.
You will learn to intersperse personal and social questions throughout the inter- view to make the patient feel more at ease. Health History, for discussion of the swelling in your ankles or feet? Start with a fairly general question as you address each of the different systems, then shift to more specific questions about systems that may be of concern. Keep your technique flexible. Remember that major health events discovered during the Review of Systems should be moved to the Present Illness or Past History in your write-up.
If the patient has only a few symptoms, this combination can be efficient. If there are multiple symptoms, however, this can disrupt the flow of both the history and the examination, and necessary note taking becomes awkward. Listed below is a standard series of Review-of-System questions. General: Usual weight, recent weight change, clothing that fits more tightly or loosely than before; weakness, fatigue, or fever.
Skin: Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge.
If hearing is decreased, use or nonuse of hearing aids. Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble. Throat or mouth and pharynx : Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness. Breasts: Lumps, pain, or discomfort, nipple discharge, self-examination practices.
Respiratory: Cough, sputum color, quantity; presence of blood or hemoptysis , shortness of breath dyspnea , wheezing, pain with a deep breath pleuritic pain , last chest x-ray. You may wish to include asthma, bronchitis, emphy- sema, pneumonia, and tuberculosis. Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea. Bowel move- ments, stool color and size, change in bowel habits, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea.
Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble; hepatitis. Peripheral vascular: Intermittent leg pain with exertion claudication ; leg cramps; varicose veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness. Urinary: Frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, blood in the urine hematuria , urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling.
Genital: Male: Hernias, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infections and their treatments. Sexual habits, interest, function, satisfaction, birth control methods, condom use, and problems.
Concerns about HIV infection. Female: Age at menarche, regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual tension. Age at menopause, menopausal symp- toms, postmenopausal bleeding. If the patient was born before , exposure to diethylstilbestrol DES from maternal use during pregnancy linked to cervical carcinoma. Vaginal discharge, itching, sores, lumps, sexually transmitted infec- tions and treatments.
Number of pregnancies, number and type of deliveries, number of abortions spontaneous and induced , complications of pregnancy, birth-control methods. Sexual preference, interest, function, satisfaction, any problems, including dyspareunia. Musculoskeletal: Muscle or joint pain, stiffness, arthritis, gout, backache.
If present, describe location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms e. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness.
Psychiatric: Nervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts. Past counseling, psycho- therapy, or psychiatric admissions.
Hematologic: Anemia, easy bruising or bleeding, past transfusions, transfusion reactions. Think through your approach to the patient, your professional Infancy Through Adolescence, for demeanor, and how to make the patient feel comfortable and relaxed. Reflect on your approach to the patient. Adjust the lighting and the environment. Check your equipment. Make the patient comfortable. Observe standard and universal precautions. Choose the sequence, scope, and positioning of examination.
Reflect on Your Approach to the Patient. As you greet the patient, iden- tify yourself as a student. Appear calm and organized even when you feel inex- perienced. It is common to forget part of the examination, especially at first. Simply examine that area out of sequence. It is not unusual to go back to the patient later and ask to check one or two items that you might have overlooked.
Beginners need to spend more time than seasoned clinicians on selected portions of the examination, such as the funduscopic examination or cardiac auscultation. Many patients view the physical examination with some anxiety. They feel vulner- able, physically exposed, apprehensive about possible pain, and uneasy about what the clinician may find.
At the same time, they appreciate your concern about their health and respond to your attention. With this in mind, the skillful clinician is thorough without wasting time, systematic but flexible and gentle, yet not afraid to cause discomfort should this be required. The skillful clinician examines each region of the body, and at the same time senses the whole patient, notes the wince or worried glance, and shares information that calms, explains, and reassures.
As a beginner, avoid interpreting your findings. As you grow in experi- ence and responsibility, sharing findings will become more appropriate.
If the patient has specific concerns, discuss them with your teachers. At times, you. Always avoid showing distaste, alarm, or other negative reactions. Adjust the Lighting and the Environment. Several environmental factors affect the caliber of your examination.
Awkward positioning makes assessing physical findings more difficult for both you and the patient. Take the time to adjust the bed to a convenient height but be sure to lower it when finished , and ask the patient to move toward you, turn over, or shift posi- tion whenever this makes the examination of selected areas of the body easier. Good lighting and a quiet environment enhance what you see and hear but may be hard to arrange.
Do the best you can. If a television interferes with auscultat- ing heart sounds, politely ask the nearby patient to lower the volume, and remember to thank the patient as you leave. Tangential lighting. It casts light across body surfaces that throw contours, elevations, and depressions, whether moving or stationary, into sharper relief. When light is perpendicular to the surface or diffuse, shadows are reduced and subtle undulations across the surface are lost Fig.
Experiment with focused tangential lighting across the tendons on the back of your hand; try to see the pulsations of the radial artery at your wrist. Check Your Equipment. Equipment necessary for the physical examination includes the following:. If you are examining children, the otoscope could allow pneumatic otoscopy. To get this fit, choose ear tips of the. Close nearby doors, draw the cur- tains in the hospital or examining room, and wash your hands carefully before the examination begins.
Draping the Patient. You will acquire the art of draping the patient with the gown or draw sheet as you learn each segment of the examination in the chapters ahead.
Redrape the right chest, then uncover the left chest and proceed to examine the left breast and heart. Adjust the gown to cover the chest and place the sheet or drape at the inguinal level. Courteous Clear Instructions. Make sure your instructions to the patient at each step in the examination are courteous and clear.
Keeping the Patient Informed. As you proceed with the examination, talk with the patient to see if he or she wants to know about your findings. Is the patient curious about the lung findings or your method for assessing the liver or spleen? When you have completed the examination, tell the patient your general impres- sions and what to expect next. Be sure to lower the bed to avoid risk of falls and raise the bedrails. As you leave, wash your hands, clean your equipment, and dispose of any waste materials.
Observe Standard and Universal Precautions. The Centers for Disease Control and Prevention CDC have issued several guidelines to protect patients and examiners from the spread of infectious disease. All clinicians examining patients are advised to study and observe these precautions at the CDC websites. Advisories for standard and methicillin-resistant Staphylococcus aureus MRSA precautions and for universal precautions are summarized below.
Standard and MRSA precautions. Standard precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat , nonintact skin, and mucous membranes may contain transmissible infectious agents.
Standard precautions apply to all patients in any setting. Handwashing is a standard precaution. Because hand hygiene practices have been shown to reduce the transmission of multidrug-resistant organisms, especially MRSA and vancomycin- resistant enterococcus VRE ,19 the CDC hygiene recommendations are repro- duced below.
White coats and stethoscopes also harbor bacteria and should be cleaned frequently. Key situations where hand hygiene should be performed include: a. Personal protective equipment.
Use soap and water when hands are visibly soiled e. Otherwise, the preferred method of hand decontamination is with an alcohol-based hand rub. Source: CDC. Guide to infection prevention in outpatient settings. Minimum expectations for safe care. May Accessed March 1, Universal precautions.
Universal precautions are a set of guidelines designed to prevent parenteral, mucous membrane, and noncontact exposures of health care workers to bloodborne pathogens, including HIV and HBV. Immunization with the HBV vaccine for health care workers with exposure to blood is an important adjunct to universal precautions. The following fluids are considered potentially infectious: all blood and other body fluids containing visible blood, semen, and vaginal secretions and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids.
Protective barriers include gloves, gowns, aprons, masks, and protective eyewear. All health care workers should follow the precautions for safe injections and prevention of injury from needlesticks, scalpels, and other sharp instruments and devices.
Report to your health service immediately if such injury occurs. As you begin the examina- tion, study the four cardinal techniques of examination. Plan your sequence and scope of examination and how you will position the patient. The physical examination relies on four classic techniques: inspection, palpation, percussion, and auscultation. You will learn in later chapters about additional maneuvers that are important in amplifying physical diagnosis, such as having the patient lean forward to better detect the murmur of aortic regurgitation or ballot- ing the patella to check for joint effusion.
Palpation Tactile pressure from the palmar fingers or fingerpads to assess areas of skin elevation, depression, warmth, or ten- derness, lymph nodes, pulses, contours and sizes of organs and masses, and crepitus in the joints. Percussion Use of the striking or plexor finger, usually the third, to deliver a rapid tap or blow against the distal pleximeter finger, usu- ally the distal third finger of the left hand laid against the surface of the chest or abdomen, to evoke a sound wave such as resonance or dullness from the underlying tissue or organs.
This sound wave also generates a tactile vibration against the pleximeter finger. Auscultation Use of the diaphragm and bell of the stethoscope to detect the characteristics of heart, lung, and bowel sounds, including location, timing, duration, pitch, and intensity. For the heart, this involves sounds from closure of the four valves, extra sounds from blood flow into the atria and ventricles, and murmurs. Auscultation also permits detection of bruits or turbulence over arterial vessels.
Sequence of Examination. The key to a thorough and accurate physi- cal examination is developing a systematic sequence of examination. Organize your comprehensive or focused examination around three general goals:. You will quickly see that some segments of the examination are best assessed when the patient is sitting, such as examination of the head and neck and the thorax and lungs, whereas others are best obtained with the patient supine, such as the cardiovascular and abdominal examinations.
As you review the Techniques of Examination on the following pages, note that clinicians vary in where they place different segments of the examination, especially examinations of the musculoskeletal system and the nervous sys- tem. Some of these options are indicated in red in the right-hand column. Suggestions for patient positioning during the different segments of the exam- ination are also indicated in the right-hand column in red.
With practice, you will develop your own sequence of examination, keeping the need for thoroughness and patient comfort in mind. At first, you may need notes to remind you what to look for, but over time, this sequence will become habit- ual and remind you to return to segments of the examination you may have skipped, helping you to be complete.
This is the standard position for the physical examination and has several advantages compared with the left side: Esti- mates of jugular venous pressure are more reliable, the palpating hand rests more comfortably on the apical impulse, the right kidney is more frequently palpable than the left, and examining tables are frequently positioned to accommodate a right-handed approach.
Left-handed students are encouraged to adopt right-sided positioning, even it may seem awkward. The left hand can still be used for percussing or for holding instruments such as the otoscope or reflex hammer. Review the proposed physical examination sequence in Figure , which meets the three goals of patient comfort, minimal changes in positioning, and efficiency. General survey Optional: skin—lower torso and extremities Nervous system: lower extremity Vital signs motor strength, bulk, tone, Skin: upper torso, anterior and posterior sensation; reflexes; Babinski reflex Head and neck, including thyroid and lymph nodes Musculoskeletal, as indicated Optional: nervous system mental status, Optional: skin, anterior and posterior cranial nerves, upper extremity motor strength, bulk, tone, cerebellar function Optional: nervous system, including gait Thorax and lungs Optional: musculoskeletal, comprehensive.
Breasts Women: pelvic and rectal examination. Musculoskeletal as indicated: upper extremities Men: prostate and rectal examination.
Each symbol pertains until a new one Abdomen appears. Two symbols separated by Lying on the left side a slash indicate either or both positions. Examining the Patient at Bedrest. Often you will need to examine a patient at bedrest, especially in the hospital, where patients frequently cannot sit up in bed or stand.
This often dictates changes in your sequence of examination. You can examine the head, neck, and anterior chest with the patient lying supine. Then, roll the patient onto each side to listen to the lungs, examine the back, and inspect the skin. Roll the patient back and finish the rest of the examination with the patient again supine. Note posture, set of the patient encounter and con- motor activity, and gait; dress, grooming, and personal hygiene; and any odors tinues throughout the history and of the body or breath.
Vital Signs. Measure the blood pressure. Count the pulse and respiratory The patient is sitting on the edge of rate. If indicated, measure the body temperature. Stand in front of the patient, moving to either side as needed. Observe the skin of the face and its characteristics. Assess skin moisture or dryness and temperature. Identify any lesions, noting their location, distribu- tion, arrangement, type, and color. Inspect and palpate the hair and nails. Continue your assessment of the skin as you examine the other body regions.
Head: Examine the hair, scalp, The room should be darkened for skull, and face. Eyes: Check visual acuity and screen the visual fields. Note the the ophthalmoscopic examination. Observe the eyelids and inspect the sclera This promotes pupillary dilation and and conjunctiva of each eye. With oblique lighting, inspect each cornea, iris, and visibility of the fundi.
Compare the pupils, and test their reactions to light. Assess the extraocular movements. With an ophthalmoscope, inspect the ocular fundi. Ears: Inspect the auricles, canals, and drums. Check auditory acuity.
If acuity is diminished, check lateralization Weber test and compare air and bone conduction Rinne test. Nose and sinuses: Examine the external nose; using a light and a nasal speculum, inspect the nasal mucosa, septum, and turbinates. Many new and updated photographs and illustrations support the text, and figures are now numbered for easy identification and reference.
Rewritten chapter on evaluating clinical evidence clarifies key concepts to ensure student understanding. Revised and expanded chapter on the skin, hair, and nails includes new dermatology photographs and provides the framework for assessing common lesions and abnormalities.
Updated behavior and mental status chapter now references DSM Significantly revised information on obesity and nutrition counseling; cardiovascular risk factor screening and new clinical guidelines; new screening guidelines for breast cancer, colon cancer, Papanicolau smears, and stroke risk factors; updated information on STIs; new geriatric assessment tools; and much more.
New life cycle content, including an increased emphasis on cardiovascular health promotion and child development; updated pregnancy topics such as weight gain, substance abuse, and intimate partner violence; and new information on the older adult, including frailty, immunizations, cancer screening, cognitive decline and dementia screening, and a new algorithm for falls prevention.
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