Fonte: Jaideep S. Talwalkar,MD, Medicina interna e pediatria, Yale School of Medicine, New Haven, CT
L’esame del corpo è fondamentale per la pratica della medicina. Fin dall’Impero Romano, i medici hanno descritto la connessione tra alterazioni in funzione di specifiche parti del corpo e stati di malattia specifici e hanno cercato di approfondire la comprensione scientifica per migliorare la diagnosi al capezzale. Tuttavia, in questa era moderna di crescente tecnologia all’interno della diagnostica medica, è importante considerare il ruolo che l’esame fisico svolge oggi. È fuorviante credere che l’esame fisico contenga tutte le risposte, e molto è stato scritto sulla discutibile utilità di alcune manovre precedentemente tenute in grande considerazione. È altrettanto fuorviante suggerire che l’esame fisico abbia un ruolo poco nell’incontro moderno con il paziente.
L’esame fisico rimane un prezioso strumento diagnostico; ci sono molte diagnosi che possono essere fatte solo con l’esame fisico. Una diagnosi fatta da laboratori o imaging viene raramente eseguita in assenza di risultati rilevabili al capezzale. Mentre il fornitore conduce una storia e fisica, stanno attivamente generando e testando ipotesi per spiegare le condizioni del paziente. Le informazioni raccolte potrebbero non sostituire la necessità di test, ma avere ipotesi solide in atto consente al fornitore di ordinare test in modo più giudizioso e porre domande migliori su tali test. Questo, a sua volta, ha il potenziale per ridurre il rischio per il paziente e risparmiare sui costi per il sistema sanitario. Infine, l’esame fisico svolge un ruolo fondamentale nella relazione terapeutica. Impegnandosi nel rituale dell’esame fisico, il clinico ha l’opportunità di sviluppare un rapporto (dimostrando attenzione e sensibilità) e promuovere la guarigione attraverso l’uso deliberato e responsabile del tatto.
This video demonstrates the role that physical examination plays in the modern patient encounter and has reviewed some critical steps to ensure the exam is carried out in a safe and sensitive manner. Important preparatory steps before the examination help to reduce risk of infection as well as patient and provider anxiety. Ensuring patient privacy and using gowns and drapes in a sensitive manner also makes patients feel more comfortable. A deliberate approach to the examination that is grounded in clinical reasoning is valuable to optimize efficiency and the predictive value of the exam. An organized approach to the maneuvers being performed minimizes the need for unnecessary patient repositioning. The specific maneuvers to be performed vary based on the clinical circumstance, but an examiner's efforts to maintain clear communication with attention to patient comfort should not vary.
The physical examination has played a vital role in patient care for millennia and should continue to do so even in the face of technological advances. Over the past forty years, multiple studies in various clinical settings have demonstrated that history and physical alone allow physicians to arrive at the correct diagnosis a great majority of the time. In almost all other circumstances, the information gained at the bedside allows the clinician to utilize clinical reasoning to judiciously order and interpret tests to make diagnoses. Given the recent emphasis on medical cost containment, patient safety, and access to services, bedside diagnostics remain inexpensive, widely available, and carry little risk of adverse effects.
Physical examination has been fundamental to the practice of medicine for centuries. Despite substantial advancement in medical instrumentation, physical examination remains a valuable diagnostic tool, and its importance cannot be overstated. As physicians assess history and conduct a physical, they gather information leading to a firm hypothesis, which promotes a more judicious approach to ordering tests and analysis of those tests. This, in turn, has the potential to reduce patient risk and health care costs.
This video will illustrate some of the important steps that every physician must take to ensure that the physical exam is carried out in a safe and sensitive manner.
A physical exam can be comprehensive or specific, but the overall steps before and during each exam remain the same. Let’s review these steps in detail.
First, the exam room should be prepared for the patient by disinfecting surfaces to be used during the examination. In addition, a physician should disinfect equipment like the stethoscope or the reflex hammer, which may be used during the exam. Before every exam, wash your hands with soap and water or apply topical disinfectant solution. If the patient is suffering from a known specific infection, then control precautions should be taken by obtaining the necessary protective equipment. Make sure that cuffs of the gloves cover the gown so that no skin is exposed.
Once the patient is seated in the room, knock on the door and ask for patient’s permission to enter the room. Introduce yourself and your role. Request the family members or friends who have accompanied the patient to step out of the room. This provides an important opportunity to speak to the patient alone. Ensure that the exam room curtains are drawn and doors are closed. While talking to the patient, general observations should be made regarding the patient’s health. These include, appearance consistency with the stated age, overall health, alertness, affect, thought content and organization, and perception.
After this initial conversation, determine what aspects of the examination are necessary. Ensure the patient is dressed appropriately for the planned exam. If necessary, provide the patient with a gown and drape and give them some time to change. After some time, knock on the door and ask for the patient’s permission to enter the room. Request the patient to occupy the exam table. Adjust the back of the exam table as needed to optimize your ability to perform maneuvers. The physical examination can be subdivided into the following components: general survey, measuring vital signs, examination of the neurologic functioning and mental status, examination of the head, eyes, ears, nose, throat, chest, lungs, lymph nodes, cardiovascular, abdomen, musculoskeletal, skin, genitourinary, and rectal. A chaperone may be necessary if a sensitive exam like genitourinary, rectal, or breast exams is to be conducted.
Explain the patient the physical exam that is going to be conducted and ask for their permission to proceed with the exam. “Now that I’ve explained what I am going to do, may I proceed with the examination?” Each exam consists of maneuvers employing the techniques of inspection, percussion, palpation, and auscultation, each of which is explored in detail in separate videos of this collection. You should strive to minimize patient repositioning by grouping maneuvers together that need to be performed in a particular position. After the exam is complete, request the patient to change back to regular clothing. It is optimal to wait until the patient is dressed again before offering advice and opinion. Subsequently, weighing how the presence or absence of particular findings affects disease probability and consolidating the information obtained from patient’s history and physical exam, one may decide to initiate a therapy or order additional testing in a deliberate and judicious manner.
You have just watched JoVE’s video on general approach to the physical examination.
This video reviewed the importance of physical examination in the modern patient encounter and demonstrated some critical steps to ensure the exam is carried out in a safe and sensitive manner. Important preparatory steps before the examination help to reduce risk of infection, and an organized approach to the maneuvers being performed minimizes the need for unnecessary patient repositioning.
Given the recent emphasis on medical cost containment, patient safety, and access to services, physical examination remains inexpensive, widely available, and carries little risk of adverse effects. As always, thanks for watching!
