CLINICAL EXAMINATION METHODS ON PATIENTS


SUBJECTIVE EXAMINATION

Inquiry

Inquiry is used in everyday observation of the patient, and it is very important to have good interview technique. Sometimes information obtained

during interview is sufficient to correct preliminary conclusion.

The ability to elicit an accurate history from the patient is crucial. It is this history, which provides the basis for priorities in the clinical examination and subsequent investigation, and management. The style of obtaining a history leads to the therapeutic alliance between doctor and patient – so essential for establishing trust and satisfaction.

It should be remembered that some people are naturally better communicators that others. From the patient's perspective the most important component of the clinical examination is the explanation. Clinicians who are courteous and patient, appear interested, encourage patients and relatives to ask questions and to spend time explaining situation in a way, which is

understood, are judged to be 'good doctors', irrespective of their attributes.

Inquiry includes following aspects: general information (passport part) – name, date of birth, age, address, occupation, etc; patient's present

complaints; history of the present disease (anamnesis morbi); and past history (anamnesis vitae).


Present Complaints

It is important to establish the patient's presenting complaint or complaints. The patient needs to understand what is being said. Generally speaking, technical terms are best avoided. The public is becoming increasingly informed through the Internet and mass media, but their use of medical jargon does not necessarily mean they understand the terms. Similarly there are terms such as ´shock’, ʼnervous breakdown’, and ʻgastric flu', which need to be clarified, if used by the patient.

The presenting complaint, as described by the patient, is the body of the history. The main complaints, those are most pronounced and determine the clinic of the disease, should be first detected. As a rule, the patient firstly describes the main complaints. However, sometimes the patient complains of unimportant signs, and only additional questioning helps to evaluate the main complaints. Detailed description of each complaint should be given according to definite plan: location, intensity, character, course, duration,

frequency, radiation, associated symptoms, cause of onset, aggravating factors, and relieving factors.

The patient should be questioned then according to special scheme:

general condition (weakness, fever, skin itching, sweetness, changes of body weight), and then on organs and systems: nervous system (work capacity, mood, memory, attention, sleep, headache, dizziness, etc), senses organs (vision, hearing, etc), respiratory system (voice changes, pain in the chest during breathing, breathlessness, asthma, cough, expectoration of sputum and blood), cardiovascular system (pain in the heart, breathlessness, attacks of suffocation, palpitation, intermissions, edema), digestive system (appetite, thirst, swallowing, nausea, vomiting, epigastric pain, defecation, etc), urinary system (pain, urination, urine character), locomotor system (pain in the joints, muscles, etc). Inquiry should be started from the system on which are the main complaints.


Anamnesis Morbi

Anamnesis morbi or history of the present disease includes obtaining of following information: the time of disease onset (acute or gradual), the cause (if known), the first symptoms and their character, previous examination and results (if any), and treatment and results (if any).

Anamnesis morbi includes data concerning onset and progress of the present disease until the present. The patient should be asked about the first signs of the disease and their dynamics, about exacerbations, remissions and their duration, about possible previous examinations and treatment and their results in chronological order. And finally, the cause of the present hospitalization should be noted (exacerbation, verification of the diagnosis, etc).

Correctly collected anamnesis morbi can be helpful in identifying the present disease, because most of them have definite course; one symptom followed another in specific order and quite frequent the present complaints differ from the initial manifestation of the disease.


Anamnesis Vitae

Anamnesis vitae is past medical history of the patient in infancy, childhood, adolescence, and adulthood. The information obtained during collecting of the anamnesis vitae is very important for understanding of character, cause, and conditions of the disease's onset.

The past history involves biographical data: place of the birth (endemic diseases), the age of the parents, living conditions in childhood, education, profession, occupation, etc. Then the patient should be asked about his past diseases in childhood, adolescence, and adulthood (tuberculosis, cardiovascular, nervous, psychiatric, endocrine diseases, etc), and also about

possible traumas or operations.

Habits. Because of the extent to which smoking cigarettes, drinking alcohol, and narcotics contribute to disease, inquiries into these habits is often necessary. Patients tend to be defensive and are quite likely to deny or minimize their substance use. If there are clinical grounds for suspecting misuse, questioning has to be tactful but firm and persistent. It is important to determine whether the patient is a smoker, an ex-smoker or a lifelong non-smoker. If the patient smokes, the following information is required: form (cigarettes, cigars or pipe); quantity (number of cigarettes/cigars or amount of pipe tobacco per day), and duration. If the patient is an ex-smoker, the

length of time since the practice ceased should be noted. In smokers, the possibility of tobacco-related disease should be considered (cerebrovascular disease, tobacco amblyopia, carcinoma of the mouth, lung cancer, chronic obstructive pulmonary disease, ischemic heart disease, peptic ulceration, peripheral vascular disease).

It is often necessary to ask whether the patient teetotal or drinks alcohol. If he does then how much alcohol, frequency and what exactly (vine, beer, vodka) he drinks.


Family history. Information about the health of the patient's relatives (parents, sisters, brothers) is very important because some diseases are caused by hereditary factors. However it should be noted that predisposition to some disease not always provoke its development. Pathological heredity as a rule manifests under harmful environmental conditions (hypertension, atherosclerosis, cholelithiasis, etc). Inherited character of the diseases can vary widely. Some inherited disease may be observed only in one member of the family, or in offspring after several generations, or in family members of one sex (hemophilia).


Social history should include basic information about occupation and domestic arrangements. It is important to determine labor conditions, exposure to hazard, e.g, chemicals, mechanical (poise, vibration, high or low temperature, etc), foreign travels, and accidents. It is necessary to ask the patient about his living condition: type of home, size, owned or rented, illumination, if it is damp or dry, hygienic conditions, etc. The patient should also be asked about the nutrition: regularity, quantity (under eating, overeating), character of food (is the diet sufficiently rich in vegetables and fruits, is there meat or fatty food abuse or salt abuse, etc.).


Allergological history. It is necessary to detemine in the patient and his relatives possible allergic reactions to various food (strawberry, eggs, crabs, etc), cosmetics, odor, etc. It is important to reveal whether the patient has ever experienced an adverse reaction to a drug and, if so, to record the information prominently so that it is immediately obvious at any future presentation. Allergic reactions are quite varied: from vasomotor rhinitis, Quincke's edema to even anaphylactic shock. Failure to obtain and record an adverse reaction there may lead to serious illness or even death.



OBJECTIVE EXAMINATION

Objective examination of the patient is helpful to obtain information about status praesens - of the condition of the entire body and of the internal organs.

Examinations methods are divided into the main and auxiliary.

The main methods include systemic inquiry and physical examination. The time-honored sequence of physical examination is inspection, palpation, percussion and auscultation. These have to be integrated into the examination and can be altered as deemed necessary. For example, it may be advisable to listen to bowel sounds before palpating the abdomen, or percuss liver before it’s palpating. Although the tendency is to teach the technique of physical examination system by system, in practice these require to be integrated because this approach is less tiring to the patient.

The auxiliary methods include instrumental and laboratory methods of examination. These methods are called auxiliary because only after using the main methods physician decides which instrumental or laboratory method is necessary to verify preliminary diagnosis. Other specialists conduct the auxiliary examination.


General inspection

General patient's condition may be good, satisfactory, moderately grave, grave, extremely grave. The criteria of the patient's condition are the following clinical features: consciousness, posture, gait, the facial expression, weight, and mental condition.

Good patient condition is characterized by clear consciousness, active posture, free gait, sensitive facial expression, sufficient weight, and good mood. This condition occurs in patients with remission of chronic disease favorable course of a disease, or during recovery.


Satisfactory patient's condition (status morboacili) is characterized by clear consciousness, active or active with restriction posture, free or partial deranged (specific) gait, sensible facial expression, and adequate mental reaction. This condition occurs in patients with remission of prolonged chronic disease, or during recovery from acute disease.


Moderate condition (status ingravescens) is characterized by deranged consciousness, alteration of facial expression and posture (forced), uncertain gait, partial deranged mental state and may be observed in patients with recurrence of chronic disease, acute diseases, or due to the traumas and poisoning.


Grave condition (status morbogravi) is characterized by disorders of practically all clinical features: deranged consciousness, changed facial expression (fear, suffer, hopelessness, indifference). The patients have forced or passive posture, weight loss, edema, and inadequate mental state. Grave condition is observed in patients with infections and oncological dis- eases, heart failure, renal disorders, liver functions, abnormalities of nervous and endocrine systems, after operations, traumas.


Extremely grave condition (status gravissimus) is characterized by unconsciousness, passive posture, and indifferent facial expression and observed in the patient with coma, shock, and agony.


Consciousness (sensorium) may be clear or deranged. The criteria’s of consciousness condition are the following features: orientation to the surroundings, adequate answers, concentrated attention, reflexes, and pupil reaction to light.


Clear consciousness (sensorium lucidum) is characterized by adequate behavior, correct orientation to the surroundings, timely answer to the question, and preservation of all reflections.

The deranged consciousness develops due to different causes: disorders of cerebral or cardiac circulation; endogenic and exogenic intoxication, infectious aflictions; hormonal, mineral, metabolic abnormalities; and traumas of the brain.

The deranged consciousness is divided into two groups – depressed (stupor, sopor, сoma) and excited consciousness (imitative disorder, delirium).


Palpation

Palpation (L palpare - to touch gently) is the method of clinical examination, which is known from ancient times. Despite the wide use of modern instrumental methods of examination, palpation remains one of the main and important technique of the internal organ diseases diagnostics.


Palpation is used to determine the elasticity and dryness of the skin, to assess the condition of the subcutaneous fat, to detect edema. The size, consistency, tenderness, and mobility of the peripheral lymph nodes it is possible to determine by the help of palpation. Muscles development, the size of the joints, their tenderness or possible swelling, deformities, the presence of fluid in the articular capsule can also be revealed by palpation.

Palpation is widely used in the examination of the chest to detect its elasticity, tenderness, and vocal fremitus.

Apex beat location, and its properties presence of the chest thrill ("cat's purr 'symptom) can be detected in palpation of the precordium.

Palpation is very important in examination of the abdominal organ intestine, liver, gall bladder, spleen, etc.

Palpation technical differs depending on object and task of the examination. Surface and deep palpations are differentiated. Surface or tentative palpation is done by the tip of fingers very gently in order to reveal tenderness, muscular strain of the abdomen, for example. Deep or sliding palpation developed by Obraztsov-Strazhesko is used to examine deep located abdominal organs. Penetrative palpation is a variation of the deep one. Palpation can be done by one hand, or by two hands-so-called bimanual palpation.



Percussion

Percussion (L percutere - to strike through) is a method of physical examination, which was proposed by an Austrian physician Leopold Auenbrugger in 1761. Tapping various part of the body sets underlying tissues into motion, producing audible sounds. Percussion helps to determine whether the under- lying tissues are air-filled, fluid-filled, or solid.

Technique of the percussion for the right-handed person. Immediate and mediate percussions are distinguished. In immediate percussion, proposed by Obraztsov, the examined surface is tapped by plexor (hammer) the tip of the index finger of the right hand. The obtained sound is not intense, therefore, the index finger may be first held by the side of the middle finger and then release to make the sound louder. This method is rarely used today.


The sound obtained during mediate percussion is loud and distinct. The key points of the mediate percussion are the following:

1. Place your left hand on the examined surface.

2. Press the second phalanx of the middle finger (the pleximeter finger) tightly on the surface to be percussed.

3. Slightly flex middle finger of your right hand (the plexor finger).

4. With a quick and short wrist motion (without involving the forearm strike the pleximeter finger with the plexor finger.

5. Striking intensity should be uniform, and directed perpendicularly to pleximeter finger. (A short fingernail is required).

Loud, light, and lightest percussions are differentiated. Loud percussion is used to examine organs located deeply (the vibrations reach a depth of 4-7 cm), light percussion for examining superficial organs, their size and borders (the vibrations reach a depth of 2-4 cm). The lightest percussion technique is used to outline the boundaries of the absolute cardiac dullness.

Comparative and topographic percussion are distinguished. The aim of comparative perception is to compare the sounds on the symmetrical parts of the body. Topographic percussion is used to detect the borders, size, and shape of the internal organs.



Auscultation

Auscultation (L auscultare-to listen) means listening to the sound inside the body. Auscultation was first proposed by French physician Laennec in 1816; in 1819 this method was described and introduced into medical practice. Laennec also proposed an instrument, called a stethoscope that is used for auscultation. He described and named almost all auscultative sounds: bronchial and vesicular breathing sounds, crepitation, heart murmurs, and confirmed clinical significance of auscultation by checking its results during section.


Auscultation can be direct-by ear, or indirect-using stethoscope. The binaural stethoscope is now widely used. It is closed acoustic system where air serves as a transmitting medium for sounds. Phonendoscope differ from simple stethoscope as is it has a membrane covering the bell, which intensifies auscultative sounds.

Auscultation is one of the most important diagnostic techniques for examining the lungs, heart and vessels, blood pressure measuring by Korotkoff's method. Auscultation is used in obstetrical practice, for the study of digestive organs.

The key points of auscultation are the following:

1. The room should be silent and warm.

2. The patient should be undressed (clothing produce additional friction).

3. The skin should be hairless (hair producе additional friction) or hair may be wetted with water.

4. The bell of the stethoscope should be held with the thumb of the forefinger, and pressed firmly and uniformly to the patient's skin (however, not too strong).

5. The posture of the patient is different depending on the examined organs.


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