ANSWER
The process of evaluating objective anatomic findings through observation, palpation, percussion, and auscultation is known as a physical examination. The data must be carefully integrated with the patient’s history and pathophysiology. Furthermore, it is a one-of-a-kind situation in which both the patient and the physician know that the interaction is intended to be diagnostic and therapeutic. A thorough physical examination should yield 20% of the information required for patient diagnosis and management.
Visit: The Context
Almost always, medical history about the patient is available during the physical examination. There may be no history or only brief recordings of acute events in rare cases. Speech, gestures, habits, gait, and manipulation of features and extremities can provide helpful information for a physical examination. Interactions with family and staff are frequently revealed. Cyanosis, jaundice, and pallor are examples of pigmentary changes. Diaphoresis, blanching, and flushing can all reveal information about vasomotor tone, mood, or physiologic abnormalities. Pictures, books, magazines, and personal objects at the bedside can show details about the patient’s habits, interests, and relationships.
Visit: Physician-Patient Interaction
Aside from the hospital room and office, physical examinations can occur in various other settings where privacy and quiet are challenging. The physician’s best tool for setting the tone for the physical examination is to communicate respect and genuine concern for the patient’s well-being. The patient should be addressed politely and asked to perform the examination maneuvers, which is far preferable to using imperative language such as “I want you to…” Patients should expect unpleasant parts of the examination.
It is unnecessary to maintain a continuous conversation with the patient during the examination, aside from explanations and reassurance. Try not to embarrass the patient. Ensure that draping material is used appropriately and that personal areas are not overexposed. An abrupt end to an examination may diminish the value of the doctor-patient relationship and destroy its therapeutic content. A summary of relevant findings may benefit the patient, who may require reassurance about what has and has not been discovered.
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Visit: The Materials
A curious and sensitive mind is the most helpful device for optimal physical examination performance. Mastering observation, palpation, percussion, and auscultation techniques are the next most beneficial skill. The tools required for the examination could be more critical (Table 4.1).
Table 4.1 shows the equipment needed for the physical examination.
Table 4.1: Physical Examination Equipment Required.
Visit: The Examination
Because the environment influences the quality of the physical examination, it is prudent to plan for quiet and privacy, darkening the room for parts of the study and patient and examiner comfort.
The examination should be conducted systematically, with the patient shifting positions as little as possible (Table 4.2). Regional studies, however, must allow the physician to determine the integrity of the various organ systems. For example, during a head and neck examination, the physician must identify the vascular, neurologic, lymphatic, skeletal, and integumentary components and relate them to their counterparts in other body regions. It would be time-consuming to examine the vascular system in its entirety, followed by a thorough neurologic examination and then the different organ systems in turn. When reviewing an anatomic region, the observer must be alert to the appearance of any abnormality and question the morphologic aspects of the abnormality as well as its clinical significance at the time.
Positions of the Patient and Examiner During the Physical Examination (Table 4.2).
Table 4.2: Patient and Examiner Positions During the Physical Exam.
The general physical examination can take many different forms depending on the circumstances. Typically, the examiner evaluates body regions broadly, looking for abnormalities. History-based clues indicate the need for a more precise and detailed examination of a given system. A thorough physical examination will frequently include the sequence shown in Table 4.3.
Physical Examination Steps (Table 4.3).
Table 4.3: Physical Examination Procedures.
The clinically significant physical examination is a malleable entity that should adapt to the patient’s needs. Periodic health examinations, like most hospital admission examinations, must be comprehensive. In contrast, most patients presenting with symptoms of an upper respiratory tract infection or a urinary tract infection will not benefit from a thorough physical examination.
Proceed to: Conclusion
The physical examination is an integral part of a process that runs from the history of the current illness to the therapeutic outcome. Laboratory tests should be largely confirmatory if the history and physical examination are adequately linked by the physician’s reasoning abilities. However, if the physical analysis is performed in a perfunctory and superficial manner, it can be the weakest link in this chain. Understanding a physical abnormality’s pathophysiologic mechanism is critical for accurate diagnosis and management. Failure to distinguish and know the origin of carotid bruits and transmitted sounds of valvular origin, for example, can be fatal.
As disease knowledge evolves, physical examination techniques develop as well. Astute physician is constantly reviewing and expanding their repertoire of physical examination techniques.
Assessing the physical examination in terms of sensitivity and specificity is difficult. The presence or absence of historical information and coexisting physical findings frequently influences the interpretation of isolated physical findings. For example, determining whether clubbing of the fingers is present or absent has significant interobserver variability and is influenced by the patient’s clinical appearance.
Several studies have investigated the validity of the physical exam as a diagnostic tool. When looking at specific isolated findings, interobserver and intraobserver variability was introduced. For example, the presence or absence of râles is more likely to be agreed upon by multiple observers and on repeated exams by a single blinded observer than the graded intensity of breath sounds. Physical exam techniques are ineffective in determining the presence or absence of ascites in patients with known liver disease. However, bedside auscultation measurement of forced expiratory time has shown low interobserver variability in trained observers and is clinically helpful in determining the degree of airway obstruction.
Because of the wide range of variability in observing many physical signs, the following guidelines for reporting and interpreting physical findings can be followed.
The emphasis should be on dichotomous variables (such as the presence or absence of râles) rather than graded variables (i.e., the intensity of breath sounds).
Some physical signs (for example, finger clubbing) range from obviously average to abnormal. The findings that represent the extremes, rather than the “borderline” cases, should be highlighted.
Recognizing physical findings with a high degree of interobserver variability is critical. Percussion detection of diaphragmatic movement and detection of moderate or small amounts of ascitic fluid are two examples. These findings should be downplayed in favor of those that are more reproducible.
Taking advantage of the body’s “symmetry” is advantageous. Differences in breath sounds auscultated between similar areas of the right and left lung are far more clinically significant than a general decrease in breath sounds.
If these points are remembered, the physical exam will play its proper role in the patient’s care. In addition to a thorough history and a means for the physician to interact physically with the patient.
QUESTION
You will perform a history of a peripheral vascular problem that your instructor has provided you or one that you have experienced and perform a peripheral vascular assessment. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided.
Peripheral Vascular System Assignment
Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.
Save your assignment as a Microsoft Word document. (Mac users, please remember to append the “.docx” extension to the filename.)