Physical Examination Principles and Observation

• Physical examination involves skills to perform and requires mastery.
• Four basic principles of physical examination: inspection, palpation, percussion, and auscultation

Four Basic Principles

• Inspection involves training the eyes for a systematic observation of the body.
• Palpation uses touch to determine skin characteristics, warmth, tenderness, pulses, and organ sizes
• Percussion is a tactile sensation involving a sharp blow to an area being examined to determine the structure of the underlying organ or tissue.
• Auscultation requires listening to sounds produced by internal organs to get data regarding any disease

Importance of Observation

• Examiners should observe general appearance, state of nutrition, body habitus, symmetry, posture, gait, and speech

Physical Appearance Indicators

• General appearance includes consciousness and grooming
• Chronic diseases are associated with poor nutrition, sunken eyes, and loose skin
• Body habitus can indicate certain disease states.
• Asthenic/ectomorphic patients are thin with poor muscle development
• Mesomorphic patients are athletic with good muscle and bone structure
• Hypersthenic/endomorphic patients are short and round with good muscle development, but may be overweight
• Asymmetry in the body's outward appearance should be noted, as it can indicate systemic diseases

Posture and Gait

• Posture and gait involve nervous and musculoskeletal systems coordination
• Speech patterns can provide information.

Orientation

• Orientation to person, place, and time can be assessed
• Difficulty answering orientation questions may indicate cognitive impairment

Inflammation signs

• Examiners should recognize the cardinal signs of inflammation which are swelling, heat, redness, pain, and disturbance of function
• These symptoms are a result of edema/congestion and increased blood flow that pressure the nerve fibres.

Examination Preparation

• You should complete the physical examination only after the history has been documented.
• Assemble equipment in a portable case.

Recommended equipment

• Stethoscope, otoscope, ophthalmoscope, penlight, reflex hammer, tuning forks (128 Hz and 512 Hz), safety pins, tape measure, and pocket visual acuity card
• Optional equipment: nasal illuminator and speculum.
• Available equipment: sphygmomanometer, tongue blades, applicator sticks, gauze pads, gloves, lubricant gel, guaiac card, vaginal speculum, and hand sanitizer.
• Use a new safety pin for each patient, or a broken wooden applicator stick as an alternative

Best practice of examinations

• Place equipment on the patient's night table or bed stand
• Adjust lighting, using daylight if possible
• Close curtains for privacy
• Adjust the bed to a convenient height
• Before the examination, wash hands in the patient's view.
• Patients should wear a gown; pajamas are acceptable for hospitalized patients.
• Allow patients to use pillows.
• Incorporate individual evaluations into the complete examination to limit patient movement

During the Examination

• Conduct physical exams by body regions, not systems, and evaluate multiple systems when examining a particular area.
• By convention, the examiner stands to the right of the patient.
• Even left-handed individuals should perform the examination from the right side, using the right hand.
• Only expose the areas to be examined at that time.
• A patient's privacy promotes a good doctor-patient relationship.
• Continue speaking to the patient to pursue history and tell them what is being done

Communications During Examinations

• Avoid phrases like, "That's good," "That's normal," or "That's fine."
• Not making such comments may lead the patient to think there is something wrong.
• Combining individual evaluations leads to a smooth examination.

Infection Prevention

• All health care team members who have exposure to patients are at risk of infection.
• Preventative measures involve understanding the possible ways infections may be transmitted to prevent infection spread in the hospital

Standards of Practice

• Adhere to guidelines from the CDC and OSHA
• Follow these guidelines in exposure situations
• Use universal precautions, treating blood/body fluids as if they are infected
• Blood is the primary source of HIV, HBV, and HCV infection
• Infection prevention should limit exposure and promote HBV vaccination
• Protective barriers includes gloves, gowns, masks, and eye protection
• Equipment use depends on the nature of the patient contact and body fluid
• Supplement routine infection prevention with handwashing and glove use
• Apply proper judgment and refer to guidelines.

Categories of transmission based precautions

• Standard precautions are recommended for all patients
• These include hand washing and using appropriate protective equipment
• Transmission-based precautions provide more guidelines to decrease pathogen transmission
• Airborne precautions deal with tuberculosis by using an N-95 mask and isolation
• Droplet precautions deal with respiratory issues that require surgical masks and gloves are mandatory
• Contact spread precautions deal with Clostridium difficile which requires the use of gown and gloves

Needlestick injuries

• Individuals should flush the area and seek assistance
• Hospitals must create a support system for individuals affected
• Postexposure prophylaxis for HIV and testing for Hepatitis B and C should be considered

Best Practices

• Medical workers are responsible for preventing disease transmission to patients.
• Wear gloves and postpone the contact with patients when sick

Overall Goal

• Gather valid patient information, and integrate that information into a comprehensive evaluation.
• Validity depends on clinical experience and reliable exam techniques
• False positives/negatives reduce technique precision.

Importance of reducing bias

• Recognize there for unconscious bias.
• An examiner's bias can influence findings.
• Clinicians should review concepts like sensitivity and specificity

Important terminology

• Sensitivity has positive test results in individuals with disease.
• Specificity is the frequency of negative results for those without the disease or condition
• Predictive values are characterized by disease positive test result frequency
• Lack of disease presence is shown with negative test results
• Techniques must be applied together to make an appropriate assessment

Practical Application

• High sensitivity techniques are able to rule out disease for a patient with a negative finding
• Techniques with high specificity can be used in coordination to disease if a patient is positive for a certain finding

Term roots

• Prefixes, suffixes and roots of medical terminology can assist with understanding complex words in the medical field
• An understanding of etymology and its usage can assist with the proper spelling of medical terms

This content discusses the four basic principles of physical examination: inspection, palpation, percussion, and auscultation, with a focus on the importance of observation and physical appearance indicators. It highlights how examiners should observe general appearance, state of nutrition, body habitus, symmetry, posture, gait, and speech to gather important information.