Putting It All Together

At the Start

At the first meeting, explain your level of training, and let them know that you may be more tentative than an experienced healthcare provider. The pressure and uncertainty you feel about your ability will fade as time, experience, and appropriate supervision help build your self-confidence.

The history and physical examination do not have to be completed in a special sequence or in the same sequence in which you will record them. They can be integrated to meet the needs of the patient or the demands of the moment. For example, if deviations from the expected physical findings are found, ask additional questions during the physical examination to expand or clarify historical information heard earlier. In this case, you are adapting to circumstance by using clinical judgment. This varies with the nature of the patient’s concern, the age, gender, and cultural background of the patient, and even findings during the physical examination.

The patient with a concern and a probable vulnerability may be uneasy, anxious, or even fearful ( Box 24.2 ). Patients evaluate you during the examination and gauge their anxiety by your manner, hesitations in speech, changes in facial expression, and time spent examining a part of their body. Some patients equate the gravity of the situation with the length of time you spend, but others equate length of time with thoroughness. One approach is to consistently provide an explanation about which part of the examination comes next and to be honest about any potential discomfort or pain and how long it will last. Check with your clinical supervisor before sharing your opinion about unexpected examination findings. Avoid inappropriate reassurance, and do not offer premature assumptions about unexpected findings.

Once you have obtained the basic history, assess urgency, the nature of the concerns, and the body systems involved. Then perform the physical examination, paying particular attention to the body systems of potential concern. You may need to ask more questions or even return to the physical examination to gather all of the needed information.

Do not assume that your initial list of differential diagnoses is certain. The patient may have an unusual presentation of a common problem, a common presentation of a rare condition, more than one disease process, a co-occurring emotional or social problem, a new illness superimposed on an existing one, or a combination of any of these factors. Do not ignore any fact or finding that does not fit your initial hypotheses or assume that a single diagnosis exists when two or more may be present. Do not squeeze findings to fit your initial hypotheses regarding the patient’s symptoms and fall prey to premature closure (see Clinical Pearl, “Respecting Your Instincts” ). With all pathophysiologic and psychosocial possibilities in mind and with probabilities and urgency dominant, constantly challenge yourself and resist being tightly bound by your initial impressions. See Chapter 4 for more information on clinical reasoning.

Accuracy

You and the patient have responsibility for the reliability of findings and observations, but yours is greater. Take the time with open-ended questions to ensure that the patient has the opportunity to report fully and accurately. Ask follow-up questions as needed. Several things can limit the patient’s ability to observe well and to report accurately:

• Sensory deprivation. A partial or total loss of any sense (e.g., vision, hearing, touch, taste, or smell) is clearly constraining. Do not expect the unaffected senses to be heightened. This may occur with some persons, but not all.

• Emotional constraints, apparent and unapparent. Patients who are psychotic, delirious, depressed, or otherwise seriously emotionally affected may confuse you. When you suspect this, carefully and objectively assess mental status during the history and physical examination.

• Language barriers. Patients may speak a language different from yours. Translation can be difficult in the best of circumstances, even when using a professional interpreter. Passing messages among three persons may potentially change the meaning and interpretation of important information, and confusion may be the result. Even using the same language may be a problem if the patient has a limited vocabulary, speaks English as a second language, or cannot read it very well.

• Cultural barriers. Consider the probable differences between you and the patient with candor and compassionate inquiry (see Chapter 1 ). Gender, race, and ethnicity may be obvious differences. Consider other barriers, such as the life experiences among persons who are overweight versus underweight, those with hearing impairment versus normal hearing, gravely ill versus well, transgender versus cisgender, and older versus younger. Display respectful curiosity by encouraging conversation about such differences. Uniformity is not part of the human condition.

Identify limitations that may affect accuracy and take the steps to enhance reliability. For example, the patient with a hearing impairment may need a response that facilitates communication such as use of a telephonic device for the deaf, loud language, written questions, sign language, or lip reading enhanced with good lighting, talking slowly, and keeping your lips visible to the patient. Remember that a person with hearing impairment cannot read lips through a mask and those with severe vision impairment cannot see your gestures.

Family, friends, or an emergency medical technician are a frequent resource for collateral information. If possible, make the patient aware that others are providing information. When possible, the patient should set the limits regarding information that can be shared. Autonomy and confidentiality are always in play.

At times a patient may be considered a “poor historian” because of life situations, disease state, limited cognition, indifference, or apathy. Other situations may involve patients with emotional or psychological problems that lead to distortions such as overstatements or understatements of reality. Each of these possibilities requires skill and sensitivity to obtain the most accurate information possible. Often collateral information or supporting information from previous health records is needed. Avoid using the descriptor “unreliable” in the health record because of its negative connotation.

The Potential for Error

We are all susceptible to error. A practitioner may palpate the same abdomen at different times on the same day and conclude that the liver span is somewhat different each time. Multiple healthcare providers may palpate the same abdomen on the same day and report different liver spans. This demonstrates the potential for error in each of us, and the same error may occur with many of the diagnostic tests ordered for our patients ( Box 24.3 ). Every observation has a certain sensitivity (i.e., the assurance that if a patient has an abnormal examination finding that it will be found) and specificity (e.g., the assurance that a healthy patient will not have the abnormal finding). No observation or test has 100% sensitivity and specificity. Candidly question yourself and seek confirmation from others when necessary to minimize your errors.

Uncertainty

The potential of error increases uncertainty and the healthcare provider’s discomfort. It is more comforting to think in a deterministic or mechanistic fashion, seeking certain and fixed knowledge and avoiding subjective impressions. We cannot always express our findings in numbers, and probabilities cannot be avoided, but we still try. For example, we use scales (assessment tools) that have several variables requiring a subjective judgment and the assignment of a fixed number to quantify each variable leading to a total score (consider the Glasgow Coma Scale and the Apgar score). That fixed number is really a pseudo-quantification, or proxy indicator of severity. Such scales may provide a false comfort in the apparent certainty of numbers. The mature clinician is one who is comfortable with probabilities and making decisions with a degree of uncertainty.

Examination Sequence

General Inspection

Begin the inspection as you greet the patient, looking for problematic signs. You can perform parts of your physical examination any time the patient is in your view, during the history, or even in the waiting room ( Fig. 24.1 ). If you go to the waiting room to invite the patient into your examining room, take a moment to observe the appropriateness of dress and grooming, manner of sitting, degree of relaxation, relationship with others in the room, and their degree of situational awareness. On this first greeting, you can take note of the manner with which you are met and the palm’s moistness when you shake hands. Remember not to squeeze too hard when the patient is unknown to you and may have arthritic, painful hands. Observe the gait as the patient walks with you, the luster of the eyes, and the expression of emotion. All of this contributes to your examination, along with the initial assessments of the following:

• Skin color

• Facial expression

• Mobility

  • Use of assistive devices

  • Gait

  • Sitting, rising from chair

  • Taking off coat

• Dress and posture

• Speech pattern, disorders, preferred language

• Difficulty hearing, assistive devices

• Stature and build

• Musculoskeletal deformities

• Vision problems, assistive devices

• Eye contact with examiner

• Orientation, mental alertness

• Nutritional state

• Respiratory problems

• Individuals accompanying patient

Preparation

After completing the interview, you or an assistant can instruct the patient to empty the bladder, remove as much clothing as is necessary, and put on a gown. Ask for a chaperone when appropriate. Modifications in the suggested sequence that follows are often necessary when the patient has disabilities ( Box 24.5 ).

Measurements

Patient measurements (e.g., height, weight, and temperature) may be taken by an assistant in advance. In some cases you as the examiner will obtain all measurements or repeat certain ones (e.g., blood pressure if the initial measurement was elevated). Height and weight are often measured on the way to the examining room, and body mass index (BMI) is calculated. Vital signs (temperature, pulse, respirations, blood pressure, pain assessment, and sometimes oxygen saturation) may be obtained at the start of the physical examination or during the body system assessment. Assessment of distance vision and hearing may be performed by an assistant or at a convenient time during the physical examination.

Patient Seated, Wearing Gown

Patient is seated on examining table; examiner stands in front of patient ( Fig. 24.2 ).

Head and Face

• Inspect skin characteristics.

• Inspect symmetry and external characteristics of eyes and ears.

• Inspect configuration of skull.

• Inspect and palpate scalp and hair for texture, distribution, and quantity.

• Palpate facial bones.

• Palpate temporomandibular joint while patient opens and closes mouth.

• Palpate and percuss sinus regions.

• Inspect ability to clench teeth, squeeze eyes tightly shut, wrinkle forehead, smile, stick out tongue, and puff out cheeks (CN V, VII).

• Test light-touch sensation of forehead, cheeks, chin (CN V).

Eyes

• External examination:

  • Inspect eyelids, eyelashes, and palpebral folds.

  • Determine alignment of eyebrows.

  • Inspect sclera, conjunctiva, and iris.

  • Palpate lacrimal apparatus.

  • Near vision screening: Rosenbaum chart (CN II)

• Eye function:

  • Test pupillary response to light and accommodation.

  • Perform cover-uncover test and corneal light reflex.

  • Test extraocular eye movements (CN III, IV, VI).

  • Assess visual fields (CN II).

  • Test corneal reflexes (CN V), if indicated.

• Ophthalmoscopic examination:

  • Assess red reflex.

  • Inspect lens.

  • Inspect disc, cup margins, vessels, and retinal surface.

Ears

• External ear

  • Inspect surface characteristics, alignment, and placement.

  • Palpate auricle.

• Screen hearing with whisper test (CN VIII).

• Perform otoscopic examination.

  • Inspect canals.

  • Inspect tympanic membranes for landmarks, effusion, redness, bulging, and deformities.

• Perform Rinne and Weber tests.

Nose

• Inspect structure, position of septum.

• Determine patency of each nostril.

• Inspect mucosa, septum, and turbinates with nasal speculum.

• Assess olfactory function: Test sense of smell (CN I), when clinically necessary.

Mouth and Pharynx

• Inspect lips, buccal mucosa, gums, hard and soft palates, and floor of mouth for color, surface characteristics, and any other apparent abnormalities.

• Inspect oropharynx. Note anteroposterior pillars, uvula, tonsils, posterior pharynx, and mouth odor.

• Inspect teeth for color, number, and surface characteristics.

• Inspect tongue for color, characteristics, symmetry, movement, and strength (CN XII).

• Test gag reflex and soft palate rising with “ah” (CN IX, X).

• Perform taste test (CN VII, IX) when clinically necessary.

Neck

• Inspect for symmetry and smoothness of neck and thyroid.

• Inspect for jugular venous distention (also when patient is supine).

• Inspect and palpate range of motion; assess strength with resistance against examiner’s hand.

• Test shoulder shrug (CN XI).

• Palpate carotid pulses, one at a time (also when patient is supine).

• Palpate tracheal position.

• Palpate thyroid.

• Palpate lymph nodes: preauricular, postauricular, occipital, tonsillar, submaxillary, submental, superficial cervical chain, posterior cervical, deep cervical, supraclavicular, and infraclavicular.

• Auscultate carotid arteries and thyroid.

Upper Extremities

• Inspect skin and nail characteristics.

• Inspect symmetry of muscle mass.

• Observe and palpate hands, arms, and shoulders, including epitrochlear nodes, note musculoskeletal deformities.

• Assess joint range of motion and muscle strength: fingers, wrists, elbows, and shoulders.

• Assess pulses: radial, brachial.

Patient Seated, Back Exposed

Patient is still seated on examining table. Gown is adjusted so the back is exposed ( Fig. 24.3 ). Examiner stands behind the patient.

Back and Posterior Chest

• Inspect skin and thoracic configuration.

• Inspect symmetry of shoulders, musculoskeletal development.

• Inspect and palpate the scapula and spine.

• Palpate and percuss costovertebral angle.

Lungs

• Inspect respiration: excursion, depth, rhythm, and pattern.

• Palpate for bilateral chest expansion and tactile fremitus.

• Palpate for scapular and subscapular nodes.

• Percuss posterior chest and lateral walls systematically for resonance.

• Percuss to measure diaphragmatic excursion.

• Auscultate systematically for breath sounds. Note characteristics and adventitious sounds.

Patient Seated, Chest Exposed

Examiner moves around to the front of the patient ( Fig. 24.4 ). The gown is lowered to expose the anterior chest.

Anterior, Chest, Lungs, and Heart

• Inspect skin, musculoskeletal development, and symmetry.

• Inspect chest movement with respiration, patient posture, and respiratory effort.

• Inspect for pulsations or heaving.

• Palpate chest wall for stability, crepitation, and tenderness.

• Palpate precordium for thrills, heaves, and pulsations.

• Palpate left chest to locate apical impulse.

• Palpate for tactile fremitus.

• Palpate for axillary lymph nodes.

• Percuss systematically for resonance.

• Auscultate systematically for breath sounds.

• Auscultate systematically for heart sounds in all listening areas.

Patients With Female Breasts

• Inspect in the following positions: patient’s arms hanging loosely at the sides, extended over head or flexed behind the neck, pushing hands on hips, leaning forward from the waist.

• Perform chest wall sweep from clavicles to nipples.

• Palpate each breast using bimanual digital palpation.

• Palpate for axillary, supraclavicular, and infraclavicular lymph nodes (if not already performed).

Patients With Male Breasts

• Inspect breasts and nipples for symmetry, enlargement, and surface characteristics.

• Palpate breast tissue.

• Palpate for axillary, supraclavicular, and infraclavicular lymph nodes.