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BEGINNING THE EXAMINATION: SETTING THE STAGE

Important Areas for Examination

■ Reflect on your approach to the patient

■ Decide on the scope of the examination

■ Choose the examination sequence

■ Adjust the lighting and the environment

■ Make the patient comfortable

Before you begin the physical examination, take time to prepare for the tasks ahead. Think through your approach to the patient, your professional demeanor, and how to make the patient feel comfortable and relaxed. Review the measures that promote the patient's physical comfort and make any adjustments needed in the lighting and the surrounding environment. Make sure that you wash your hands in the presence of the patient before beginning the examination. This is a subtle yet much appreciated gesture of concern for the patient's welfare.

Approaching the Patient. When first examining patients, feelings of insecurity are inevitable, but these will soon diminish with experience. Be straightforward. Let the patient know you are a student and try to appear calm, organized, and competent, even when you feel differently. If you forget to do part of the examination, this is not uncommon, especially at first! Simply examine those areas out of sequence, but smoothly. It is not unusual to go back to the bedside and ask to check one or two items that you might have overlooked.

As a beginner, you will need to spend more time than experienced clinicians on selected portions of the examination, such as the ophthalmoscopic examination or cardiac auscultation. To avoid alarming the patient, warn the patient ahead of time by saying, for example, "I would like to spend extra time listening to your heart and the heart sounds, but this doesn't mean I hear anything wrong."

Over time, you will begin sharing your findings with the patient. Clinicians have different approaches as to how and when this occurs. As a beginner, you should avoid interpreting your findings. You are not the patient's primary aretaker, and your views may be conflicting or in error. As you grow in ex-?erience and responsibility, sharing findings will become more appropriate. ' the patient has specific concerns, you may even provide reassurance as you ^finish examining the relevant area. Be selective, however—if you find an unexpected abnormality, you may wish you had kept a judicious silence. At times, you may discover abnormalities such as an ominous mass or a deep oozing ulcer. Always avoid showing distaste, alarm, or other negative reactions.

Scope of the Examination: How Complete Should It Be? There is no simple answer to this common question. Chapter 1 provided some guidelines to help you choose whether to do a comprehensive or focused examination. As a general principle, a new patient warrants a complete examination, regardless of chief complaint or setting. You may choose to abbreviate the examination for patients making routine office visits or seeking urgent care. A more limited examination may also be appropriate for patients with symptoms restricted to a specific body system or with patients you know well.

A comprehensive examination does more than assess the body systems. The physical examination is a source of fundamental and personalized knowledge about the patient and strengthens the clinician-patient relationship. Most people seeking health care have specific worries or symptoms. The physical examination helps to identify or rule out related physical causes. It gives information for answering patient questions and serves as a baseline for future comparisons. The physical examination also provides important opportunities for health promotion through education and counseling, and increases the credibility and conviction of the clinician's reassurance and advice. Furthermore, students must repeatedly perform such examinations to gain proficiency, and clinicians need ongoing practice to maintain their skills. How to best divide the usually limited time allotted to a patient visit between listening, discussion, or counseling on the one hand, and the physical examination on the other, takes both judgment and experience.

For the focused examination, select the methods relevant to assessing the problem as precisely and carefully as possible. The patient's symptoms, age, and health history help determine the scope of your examination, as does your knowledge of disease patterns. Out of all the patients with sore throat, for example, you will need to decide who may have infectious mononucleosis and warrants careful palpation of the liver and spleen and who, in contrast, has a common cold and does not need this examination. The clinical thinking that underlies and guides such decisions is discussed in Chapter 18.

What about the need for a periodic physical examination for screening and prevention? The utility of the comprehensive physical examination for the purposes of screening and prevention of illness, in contrast to evaluation of ymptoms, has been scrutinized in a number of studies. Studies have validated umber of physical examination techniques: blood pressure measurement, ssessment of central venous pressure from the jugular venous pulse, listen-ig to the heart for evidence of valvular disease, the clinical breast examination, detection of hepatic and splenic enlargement, and the pelvic examination with Papanicolaou smears. Recommendations for examination and screening have been further expanded by various consensus panels and expert advisory groups. Bear in mind, however, that when used for screening (rather than assessment of complaints), not all components of the examination have been validated as ways to reduce future morbidity and mortality.

Choosing the Examination Sequence, Examining Position, and andedness. Remember that the sequence of the comprehensive or

Ha focused examination should maximize the patient's comfort, avoid unnecessary changes in position, and enhance the clinician's efficiency. In general, move from "head to toe." An important goal for you as a student is to develop your own sequence of examination with these principles in mind. For example, avoid examining the patient's feet or genital areas before checking the face or mouth.

Turn back to Chapter 1, pp._, to review a suggested examination sequence, and look over the outline of such a sequence below.

THE PHYSICAL EXAMINATION: SUMMARY OF SUGGESTED SEQUENCE

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