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This book recommends examining the patient from the patient's right side, moving to the opposite side or foot of the bed or examining table as necessary. This is the standard position for the physical examination and has several advantages compared to the left side: It is more reliable to estimate jugular venous pressure from the right, the palpating hand rests more comfortably on the apical impulse, the right kidney is more frequently palpable than the left, and examining tables are frequently positioned to accommodate a right-handed approach.

Left-handed students are encouraged to adopt right-sided positioning, even though at first it may seem awkward. It still may be easier to use the left hand for percussing or for holding instruments such as the otoscope or reflex hammer.

Often you will need to examine the supine patient. This may dictate changes in your sequence of examination. Some patients, for example, are unable to sit up in bed or stand. You can examine the head, neck, and anterior chest with the patient lying supine. Then roll the patient onto each side to listen to the lungs, examine the back, and inspect the skin. Roll the patient back and finish the rest of the examination with the patient again in the supine position.

Adjusting Lighting and the Environment. Surprisingly, a number of environmental factors affect the calibre and reliability of your physical findings. To achieve superior techniques of examination, it is important to "set the stage" so that both you and the patient are comfortable. As the examiner, you will find that awkward positions impair the quality of your observations. Take the time to adjust the bed to a convenient height (but be sure to lower it when finished!), and ask the patient to move toward you if this makes it easier to examine a region of the body more carefully.

Good lighting and a quiet environment make important contributions to what you see and hear but may be hard to arrange. Do the best you can. If a television interferes with listening to heart sounds, politely ask the nearby patient to lower the volume. Most people cooperate readily. Be courteous and remember to thank them as you leave.

Tangential lighting is optimal for inspecting a number of structures such as the jugular venous pulse, the thyroid gland, and the apical impulse of the heart. It casts light across body surfaces that throws contours, elevations, and depressions, whether moving or stationary, into sharper relief.

hen light is perpendicular to the surface or diffuse, as shown on the next age, shadows are reduced and subtle undulations across the surface are st. Experiment with focused, tangential lighting across the tendons on the back of your hand; try to see the pulsations of the radial artery at your wrist.

Promoting the Patient's Comfort. Your access to the patient's body is a unique and time-honored privilege of your role as a clinician. Showing concern for privacy and patient modesty must be ingrained in your professional behavior. These attributes help the patient feel respected and at ease. Be sure to close nearby doors and draw the curtains in the hospital or examining room before the examination begins.

You will acquire the art of draping the patient with the gown or draw sheet as you learn each segment of the examination in the chapters ahead. Your goal is to visualize one area of the body at a time. This preserves the patient's modesty but also helps you to focus on the area being examined. With the patient sitting, for example, untie the gown in back to better listen to the lungs. For the breast examination, uncover the right breast but keep the left chest draped. Redrape the right chest, then uncover the left chest and proceed to examine the left breast and heart. For the abdominal examination, only the abdomen should be exposed. Adjust the gown to cover the chest and place the sheet or drape at the inguinal area.

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To help the patient prepare for segments that might be awkward, it is con-ierate to briefly describe your plans before starting the examination. As s u proceed with the examination, keep the patient informed, especially 1 ien you anticipate embarrassment or discomfort, as when checking for the ^femoral pulse. Also try to gauge how much the patient wants to know. Is the patient curious about the lung findings or your method for assessing the liver or spleen?

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ake sure your instructions to the patient at each step in the examination e courteous and clear. For example, "I would like to examine your heart ow, so please lie down."

s in the interview, be sensitive to the patient's feelings and physical com-rt. Watching the patient's facial expressions and even asking "Is it okay?"

as you move through the examination often reveals unexpressed worries or sources of pain. To ease discomfort, it may help to adjust the slant of the patient's bed or examining table. Rearranging the pillows or adding blankets for warmth shows your attentiveness to the patient's well-being.

When you have completed the examination, tell the patient your general impressions and what to expect next. For hospitalized patients, make sure the patient is comfortable and rearrange the immediate environment to the patient's satisfaction. Be sure to lower the bed to avoid risk of falls, reapply any restraints you may have removed, and raise the bedrails if needed. As you leave, wash your hands, clean your equipment, and dispose of any waste materials.

The General Survey of the patient's build, height, and weight begins with the opening moments of the patient encounter, but you will find that your observations of the patient's appearance crystallize as you start the physical examination. The best clinicians continually sharpen their powers of observation and description, like naturalists identifying birds from silhouettes backlit against the sky. It is important to heighten the acuity of your clinical perceptions of the patient's mood, build, and behavior. These details enrich and deepen your emerging clinical impression. A skilled observer can depict distinguishing features of the patient's general appearance so well in words that a colleague could spot the patient in a crowd of strangers.

Many factors contribute to the patient's body habitus—socioeconomic status, nutrition, genetic makeup, degree of fitness, mood state, early illnesses, gender, geographic location, and age cohort. Recall that many of the characteristics you scrutinize during the General Survey are affected by the patient's nutritional status: height and weight, blood pressure, posture, mood and alertness, facial coloration, dentition and condition of the tongue and gingiva, color of the nail beds, and muscle bulk, to name a few. Be sure to make the assessment of height, weight, BMI, and risk of obesity a routine part of your clinical practice.

You should now recapture the observations you have been making since the first moments of your interaction and sharpen them throughout your assessment. Does the patient hear you when greeted in the waiting room or examination room? Rise with ease? Walk easily or stiffly? If hospitalized hen you first meet, what is the patient doing—sitting up and enjoying elevision? . . . or lying in bed? . . . What occupies the bedside table— agazine? . . . a flock of "get well" cards? . . . a Bible or a rosary? . . . an esis basin? . . . or nothing at all? Each of these observations should raise one or more tentative hypotheses about the patient for you to consider during future assessments.

Apparent State of Health. Try to make a general judgment based on observations made throughout the encounter. Support it with the significant details.

Acutely or chronically ill, frail, feeble, robust, vigorous

Level of Consciousness. Is the patient awake, alert, and responsive to you and others in the environment?

Signs of Distress. For example, does the patient show evidence of these problems?

If not, promptly assess the level of consciousness (see p._).

■ Cardiac or respiratory distress

Clutching the chest, pallor, diaphoresis; labored breathing, wheezing, cough

Wincing, sweating, protectiveness of painful area

Anxiety or depression

Height and Build. If possible, measure the patient's height in stocking feet. Is the patient unusually short or tall? Is the build slender and lanky, muscular, or stocky? Is the body symmetric? Note the general body proportions and look for any deformities.

Weight. Is the patient emaciated, slender, plump, obese, or somewhere in between? If the patient is obese, is the fat distributed evenly or concentrated over the trunk, the upper torso, or around the hips?

Whenever possible, weigh the patient with shoes off. Weight provides one index of caloric intake, and changes over time yield other valuable diagnostic data. Remember that changes in weight can occur with changes in body fluid status, as well as in fat or muscle mass.

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