Basics of Clinical Practise PDF 2022-2023

BASICS OF CLINICAL PRACTISE Prof.dr.Gordana Kamceva Mihailova FMN, UGD – Stip, 2022-2023 objective examination physical examination (Status praesens) It is important to prepare both yourself and your patient for the physical examination. As a clinician, you must take reasonable steps to ensure...

BASICS OF CLINICAL PRACTISE Prof.dr.Gordana Kamceva Mihailova FMN, UGD – Stip, 2022-2023 objective examination physical examination (Status praesens) It is important to prepare both yourself and your patient for the physical examination. As a clinician, you must take reasonable steps to ensure you can give the patient your undivided attention, in an environment free from interruption, noise or distraction. Always introduce yourself to the patient, shake hands and seek permission to conduct the consultation. Make sure you have the relevant equipment available and that you have observed local hand hygiene policies. At the very least, ensure screens or curtains are fully closed around a ward bed; where possible, use a separate private room to avoid being overheard. Seek permission from the patient to proceed to examination, and offer a chaperone where appropriate to prevent misunderstandings and to provide support and encouragement for the patient. Regardless of whether the patient is the same gender as the doctor or not, chaperones are always appropriate for intimate (breast, genital or rectal) examination. Chaperones are also advised if the patient is especially anxious or vulnerable, if there have been misunderstandings in the past, or if religious or cultural factors require a different approach to physical examination. If patients decline the offer, respect their wishes and record this in the notes. Tactfully invite relatives to leave the room before physical examination unless the patient is very apprehensive and requests that they stay. A parent or guardian should always be present when you examine children. The room should be warm and well lit; subtle abnormalities of complexion, such as mild jaundice, are easier to detect in natural light. The height of the examination couch or bed should be adjustable, with a step to enable patients to get up easily. An adjustable backrest is essential, particularly for breathless patients who cannot lie flat. It is usual practice to examine a recumbent patient from the right-hand side of the bed. Ensure the patient is comfortably positioned before commencing the physical examination. Seek permission and sensitively, but adequately, expose the areas to be examined; cover the rest of the patient with a blanket or sheet to ensure that they do not become cold. Avoid unnecessary exposure and embarrassment; a patient may appreciate the opportunity to replace their top after examination of the chest before exposing the abdomen. Remain gentle towards the patient at all times, and be vigilant for aspects of the examination that may cause distress or discomfort. physical examination • • The purpose of the physical examination is to look for the presence, or absence, of physical signs that confirm or refute the differential diagnoses you have obtained from the history. It refers to the following physical methods and skills that every doctor MUST know: inspectio palpatio percusio auscultatio • • Despite the great progress in knowledge and medical technology, these methods have retained their significant place, and often irreplaceable, in the treatment of each patient. They also enable an additional better and confidential relationship with the patient, and on the other hand, a quick and efficient direction of the diagnosis process and determination of the right disease or condition. 1.Inspection (INSPECTIO)  An initial method of physical examination that begins with the first contact with the patient.  The doctor uses his senses, which, supplemented by his experience, gather significant data.  Elements: - determining the general mental state, - the general characteristics of the patient's body, - his posture and behavior, - determining the presence of physical anomalies and atypical changes, - changes in the body constitution, - skin characteristics, - local changes in some parts of the body, - detection of certain facial expressions , tics, can also refer to an unusual smell.  It enables a correct and quick assessment of the patient's general condition. 2.Palpation (PALPATIO)  A physical method that uses the tactile property of the palms in contact with the body, where the balls of the fingers are known to be the most sensitive. It provides information on local anatomical changes, temperature, pain sensitivity, pulsations and vibrations.  Palpation should be performed on a naked body and in principle all parts of the body are accessible for it, respecting the intimacy and integrity of the patient.  They are most often used: a/ superficial b/ deep c/ palpation with two hands (bimanual) d/ palpation with tapping (ascites) e/ the palpation of the pulse of the available arteries f/ palpation of tremors (fremitus pectoralis, fremmisement cataire, trill). Palpation gives answers to which organs the obtained data refer to, the shape, consistency, fixation or mobility to the substrate or the environment, the characteristics of the surface. 3. Percussion (PERCUSIO)  A physical method in which one systematically taps, usually with the balls of the fingers, over a certain territory or organ, and in doing so, an appropriate return acoustic response is obtained.  Performance technique: INDIRECT PERCUSSION - casually placing the middle phalanx of the middle finger of the hand on the body (pleximeter) and on it with the last phalanx of the middle finger of the other hand bent, fast, short and sharp blows are performed from a distance of about 15 cm at a right angle, without holding the finger, and the movement is performed in the wrist. DIRECT PERCUSSION - when blows are performed with a finger or several fingers directly, without the intervention of a pleximeter. It is performed comparatively, on both sides symmetrically, most often during percussion of the lungs (orientational), and is also used for topographical purposes (topographical), to determine the boundaries of some organs or structures.  The tone obtained during percussion depends on the type and consistency of the underlying organs and structures. The resulting tone can be: • sonorous-like on percussion of healthy lungs; • dull-like opposite sound, obtained during percussion of consistent organs; • tympanic - sounds like a tambourine and quite musical, usually heard when percussing the abdomen over the intestines. • There are also transitional variants (hypersonic - stomach Traube's space) 4.Auscultation (AUSCULTATIO) • Indispensable physical method, especially during the examination of the cardiovascular, respiratory and to some extent the gastrointestinal system. • It is performed with a biauricular stethoscope (indirect auscultation), where the bell, with or without a membrane, is placed on the skin, and the sounds are transmitted through rubber hoses to the ears, thereby eliminating side sounds as much as possible. Auscultation is performed in a quiet comfortable environment. 3.1.GENERAL PHYSICAL EXAMINATION A) GENERAL INSPECTION  position-attitude of the patient: active/passive/forced;  mobility: actively mobile, passively mobile, immobile  state of consciousness: awareness, somnolence, sedation, coma; orientation in space, time and towards persons  constitution and nutrition (subcutaneous adipose tissue); TT and TV are measured and BMI (body mass index) and umbilical circumference (abdominal circumference measured at the height of the umbilicus-marker of central obesity) are calculated.  symmetry  muscle development (normal, atrophy, hypertrophy)  skin and mucous membranes: - Color: pale pink. Pathological: pale, icteric, cyanotic, greyish - Humidity: with normal heat and humidity. Dry pr. in hypothyroidism, dehydration, wet, sweaty and hot eg. in hyperthyroidism - Elasticity-turgor: normally preserved, (reduced elasticity e.g. in testicular edema, absent turgor in dry skin, hypothyroidism) - Pigmentation: hyperpigmented (eg Addison's disease, hypopigmented in vitiligo) - Rash: normally absent (if present: enanthema, exanthema, macular, papular, pustular, vesicular, etc.) • Haemorrhages: normally absent, if present describe the appearance (point-petechial, ecchymoses, hematomas) • Stretch marks: normally absent (obese, pregnant, Cushing's syndrome, puberty) • Hairiness: eutrichosis, (pathological: hypertrichosis-increased hairiness, hypotrichosis-decreased hairiness, alopecia areata-limited absence of hair, hirsutism-male-type hairiness in women) • Nails: brittleness, discoloration, white spots, deformities, bitten. • Lymph nodes in regions available for palpation: (if palpable, describe by shape, color of the skin above them, consistency, mobility in relation to the substrate or skin, painful sensitivity spontaneous or on palpation) • Specific smell; (e.g. in diabetic ketoacidosis, uremic syndrome, etc.) Evaluation of the general impression of the severity of the disease: healthy, light, medium, severe, vitally endangered patient. Examples of pathological changes in the nails https://www.yout ube.com/watch?v =SaBQc5zpCkM VITAL SIGNS  Body weight TT  Body height TV  BMI (body mass index) • >18.5 kg/m2 malnutrition • 18.5-24.9 kg/m2 normal nutrition • 25-29.9 kg/m2 nutrition • 30-39.9 kg/m2 obesity >40 kg/m2 morbid obesity  Umbilical circumference (marker of abdominal obesity) >80-88 cm in women/ >92-96 cm in men  Pulse (60-100, tachycardia, bradycardia)  Breathing (12-16, eupnea, tachypnea, bradypnea, hyperventilation, dyspnea, orthopnea)  Pain Body temperature  Body temperature can be measured in many locations of the body such as: • the forehead; • the ear (tympanic); • the armpit (axilla); • the mouth (oral). • the rectal (children) • the temporal (children)  Types of temperature • afebrile (36-37C) • subfebrile (37.2-37.5C) • febrile (37.5-38C) • high fever (>38C) • Temperature curves: 1. febris continua (It occurs in Typhus abdominalis in the second week of the disease. The difference between the morning and evening temperature is not more than 1°C and is constantly high. Then it drops sharply) 2. febris remittens (Patients constantly have a high temperature. The difference between the highest and the lowest body temperature is greater than 1°C. The minimum temperature never drops to a normal value, for example Sepsis, Peritonitis acuta) 3. febris intermittents (occurs in malaria. Fever occurs every day with afebrile periods) 4. febris recurens (occurs in relapsing fever. Febrile and afebrile periods of several days occur) 4. febris hectica (or debilitating fever occurs during infections with highly virulent bacteria. There are high fluctuations in body temperature during 24 hours, several times. Each drop in temperature is accompanied by sweating, patients are weak, exhausted and dehydrated. The temperature it goes up to 40ºС, and goes down to subnormal) - Pulse (60-100/min, tachycardia, bradycardia) https://www.youtube.com/ watch?v=JmfABHbL-HM https://www.youtube.com/wa tch?v=xvlaQDMbz-4 Breathing (12-16/min, eupnea, tachypnea, bradypnea, hyperpnea, dyspnea, orthopnea) The act of breathing - respiration, consists of: Inspiration - inhalation of air into the lungs. It is an active phase that uses the respiratory muscles and lasts shorter; Exhalation - exhalation of air is a passive phase and lasts twice as long as inspiration; Pause between the two phases, and all three phases together make one respiration. Types of pathological breathing: Dyspnea Biot's respiration Cheyne-Stokes respiration Kussmail's breathing https://www.youtube.com/watch?v=oW9zJ8FdNNs BLOOD PRESURE Classification CP (mmHg) DCP (mmHg) Optimal <120 and <80 Normal 120-129 and/or 80-84 Highly normal 130-139 and/or 85-89 Hypertension Grade 1 Grade 2 Grade 3 140-159 160-179  180 and/or and/or 90-99 100-109 110 140 and <90 Isolated systolic hypertension Table 1. Classification of KP according to ESH/ESC Legend: CP = systolic CP, DCP = diastolic CP - Pain • Pain is defined as an "unpleasant sensory and emotional experience" accompanied by tissue damage. The feeling of pain is complex and multifactorial. Pain involves sensory, emotional, and cognitive processes, but may lack a specific physical etiology • Seven attributes: location, quality, quantity or severity (pain intensity is quantified through three scales: a visual analog scale and a numerical scale using numbers from 1 to 10 and a pain scale through facial expression), time, conditions at which occurs (environmental factors, personal activities, emotional reactions), factors of remission or exacerbation and related manifestations. • Types of pain: Receptor or somatic pain, Neuropathic pain, Psychogenetic pain and Idiopathic pain NORMAL GENERAL STATUS The patient is conscious, oriented in time, space and towards persons, occupies an active position in bed, is actively mobile, moderately nourished with preserved symmetry of the body, normal osteomuscular structure, eupnoic, afebrile, skin and visible mucous membranes normally discolored, with preserved turgor, lymph nodes in accessible regions are not palpated enlarged. 3.2.SPECIAL PHYSICAL EXAMINATION-SPECIAL STATUS HEAD SKULL: skull configuration, size, symmetry (relative to body, contralateral sides and relative to face), shape, hairiness, scars 1. CONFIGURATION: symmetrical, of normal size, proportional Deviations: microcephaly, hydrocephaly, brachycephaly, craniotabes, 2. HAIR - rarity, distribution, type of hair (male, female) Deviations: loss of beard and mustache in hypogonadism, appearance of beard and mustache in women - androgenization, hirsutism, hair thin, fine, soft hyperthyroidism, hair coarse, freckled, without shine - hypothyroidism, alopecia totalis (complete loss of hair), alopecia areata (patterned hair loss) FACE INSPECTION A. Symmetry of the face-asymmetry in facial nerve paralysis (VII); and it exists: 1. central facialis paralysis - lowered corner of the mouth in case of contralateral damage to the nerve in the brain, the eye closes on that side (ptosis) and the eyebrow is raised 2. peripheral facial paralysis (Belova) - there are no wrinkles on one half of the face, the eye is open, the corner of the mouth is lowered (due to damage to the nerve in the facial canal in the temporal bone on the same side) B. Mimicry-extinguished in parkinson's disease, neuroleptic drugs C. Color: icteric, pale-anemic, cyanotic, D. Existence of swelling: kidney diseases, allergies, tumors, E. Male-type hairiness in women PALPATION A. Valeove Points-pain in neuralgia of the n. trigeminus B. tragus-pain in diseases of the external ear C.mastoideus+percussion-pain in middle ear inflammation EYES:  eyeballs (bulbus oculi): shape, size, symmetry/asymmetry, exophthalmos, enophthalmos, coordination of movements, spontaneous movements (nystagmus);  eyelids (palpebrae)-rimae oculi: symmetry, width, swelling, redness;  whites (sclerae): change in color and what, hemorrhagic deposits, jaundice;  conjunctivae: hyperemic, anemic, petechiae, foreign body, pterygium, corneal reflex, lacrimation;  iris: scars, ulcerations, color, deposits (copper ring, arcus senilis);  pupil (pupil): size, shape, symmetry, equality, response to light, accommodation and convergence (SAC);  sight: wears glasses/lenses. EARS:  auricles: shape, size, symmetry, scars or trauma, other changes (eg tophi uric);  external ear canal: size, direction, patency, content;  tragus and antitragus  mastoid: tenderness;  hearing: orientation for hearing intensity (test with sat), symmetry, suddenness, deafness, wears a device. NOSE:  shape, size, symmetry, septal deviation, contents and epithelium of the nostrils, patency; MOUTH:  lips: symmetry, color (pale, livid, cyanotic), inflammatory processes, growths, ridges, scars, herpes;  oral cavity: mucosa and gums: color, bleeding, ulceration, aphthae, pigmentation, fetor ex ore;  language: color, size, deposits, symmetry  mucous membrane (deposits, atrophic, ulceration, deviation);  teeth: preservation, number, care, repair (fillings, bridges, prostheses), caries  palate (hard and soft),  uvula: mobility and condition of the uvula  pharynx: color, secretion, hypo or hypertrophy of the mucous membrane, swallowing reflex  tonsils: size, consistency, inflammation, deposits, crypts HEAD NORMAL FINDING • • • • Head with normal configuration, symmetrical, female/male hair type, palpable and percutaneously painful (in)sensitive, Tragus and Valle's points palpatively painfully insensitive, mastoid process palpatively and percutaneously painfully insensitive. Auricles of normal shape, ear canals passable without pathological content, bulbs normoposed, mobile in all directions, without nystagmus (and strabismus), pupils round, equal, centrally placed, with preserved reaction to light, accommodation and convergence, rimae oculi equal, symmetrical, sclera nacreous, conjunctiva moderately blood-stained, Lips pink, normally discolored and moist, buccal mucosa without pathological changes, tongue normally large, painless and moist, teeth healthy (repaired, artificial, appliances), gums without pathological changes, hard and soft palate without pathological changes, mucous membrane of the pharynx and tonsils without signs of hyperemia, swelling, exudation, with normal color and humidity, Face normal, symmetrical, of normal color, nose of normal appearance, symmetrical, passable, without side content. 3.3.SPECIAL PHYSICAL EXAMINATION-SPECIAL STATUS NECK Shape, symmetry, Active and passive mobility Blood vessels: congestion of neck veins, their pulsation; unusual pulsations of carotid arteries; Throat gland (thyroid gland) bimanual palpation in order to assess: enlargement, as a whole, asymmetric or as nodules, quality, mobility/congruence with the environment, on auscultation systolic murmur; Lymph nodes: anterior and posterior cervical, anterior/retro auricular, supraclavicular (size, quality, individuality or fusion, fixation to surrounding tissues, painful sensitivity, redness, fistulas or scars) Distribution of palpable lymph glands PALPATION PALPATION OF THE THYROID GLAND Inspect the neck from the front, noting any asymmetry or scars. Inspect the thyroid from the side with the patient’s neck slightly extended. Extending the neck will cause the thyroid (and trachea) to rise by a few centimetres and may make the gland more apparent. Give the patient a glass of water and ask them to take a sip and then swallow. The thyroid rises (with the trachea) on swallowing. • Palpate the thyroid by placing your hands gently on the front of the neck with your index fingers just touching, while standing behind the patient (see Fig.B). The patient’s neck should be slightly flexed to relax the sternocleidomastoid muscles. Ask the patient to swallow again and feel the gland as it moves upwards. • Note the size, shape and consistency of any goitre and feel for any thrill. • Palpate for cervical lymphadenopathy. • Percuss the manubrium to assess for dullness due to retrosternal extension of goitre. • Auscultate with your stethoscope for a thyroid bruit. A thyroid bruit (sometimes associated with a palpable thrill) indicates abnormally high blood flow and is most commonly associated with Graves’ disease. It may be confused with other sounds: bruits from the carotid artery or those transmitted from the aorta are louder along the line of the artery. NECK NORMAL FINDING • Cylindrical, symmetrical, actively and passively mobile, without pathological pulsations and noises of the carotid arteries, with regular palpation of the carotid pulse, thyroid gland with normal localization, size and consistency, mobile during swallowing, without enlarged neck lymph nodes, non-swollen neck veins. Links for watching – home work https://www.youtube.com/watch?v=gUWJ-6nL5-8 https://www.youtube.com/watch?v=y6ncm72-4Ak https://www.youtube.com/watch?v=nvl1qQfgzuw https://www.youtube.com/watch?v=ziaYBkgEZNU https://www.youtube.com/watch?v=TL5dnlefRnc https://www.youtube.com/watch?v=MkqCjH-BlMo https://www.youtube.com/watch?v=O_Iwwegw-ek https://www.youtube.com/watch?v=i4mv8LJQPNo https://www.youtube.com/watch?v=IwBEjEbU-Yw THANK YOU