Name: clinical observation in physical exam
Uploaded: 2023-04-30T06:40:12.000Z
Duration: 5 min 2 s
Channel: JoVE

K12 Standards

new-york-state-science-learning-standards

New York State Science Learning Standards

High School

Life Science

Structure and Function

HS-LS1-3.

Observation and Inspection

Observación se produce como un proceso constante durante el encuentro clínico. Muchos de los elementos que aparecen en el procedimiento por lo general se realizan al mismo tiempo y cuando se presentan oportunidades. El procedimiento pone de relieve los componentes de la observación, pero no pretende sugerir una secuencia preferida.
1. general encuesta
<ol>
	<li>Tenga en cuenta el estado general de salud en el paciente. ¿La apariencia del paciente es consistente con la edad indicada? ¿Aparece el paciente apto y sano o débil y frágil?</li>
	<li>Tenga en cuenta su nivel de conciencia (p. ej., soñoliento, alerta o despierto).</li>
	<li>Observar signos de dolor. Nota expresiones faciales, movimientos vigilados, Diaforesis, etcetera.</li>
	<li>Observar signos de dificultad respiratoria. ¿Puede el paciente habla en oraciones completas sin dificultad? ¿Es el paciente "tripoding" (inclinarse hacia delante con los brazos apoyados)? ¿Se utilizan músculos accesorios visibles de la respiración?</li>
	<li>Observar signos de angustia emocional. ¿Es el paciente excesivamente inquieto, exhibiendo retraso psicomotor generalizado o llorando? ¿Es apropiado el contacto con los ojos?</li>
	<li>Tome nota de la ropa, joyas, tatuajes, aseo personal, higiene y cualquier otra característica que puede proporcionar la penetración en situación médica, social y emocional del paciente.</li>
	<li>Nota cualquier signo de patología que puede ser evidente en la observación general, tales como lesiones de piel, distribución anormal de la grasa, déficit de audición, atrofia muscular, los olores, etcetera.</li>
</ol>
2. órgano-específicas observación
Durante el resto del examen físico, observación activa se realiza con el examen de cada sistema del órgano. Para algunos sistemas de órganos, la inspección requiere el uso de equipo (por ejemplo,otoscopio y oftalmoscopio). Consulte los videos de cada sistema del órgano para obtener detalles específicos.
3. examen de la piel
Inspección detallada es el principal componente del examen de la piel. Un examen de piel completo incluye inspección de todas las superficies anterior, posterior y lateral del cuerpo y las mucosas. Inspección de ciertas áreas requiere manipulación de examen a realizar. Estas áreas incluyen el cabello, cuero cabelludo, procesos mastoides, aurículas posteriores, canales auditivos externos, nares, axila, clavos, conjuntiva palpebral, mucosa oral, aspectos inferior de los senos, la piel subyacente un pannus, superficies de los órganos genitales, mucosa vaginal y hendidura glútea.
<ol>
	<li>Observe el color de la piel o la mucosa en cada sitio examinado. Resultados comunes incluyen áreas de hipo - o hiper-pigmentacion, palidez (conjuntiva palpebral, palmas, plantas del pie y lechos ungueales), cianosis (lechos ungueales, labios y perioral) e ictericia (esclerótica, piel y membranas mucosas).</li>
	<li>En cada sitio examinado, también tenga en cuenta el grado de hidratación (sequedad o grasitud), turgencia y la textura de la piel.</li>
</ol>
4. examen de estado mental
<ol>
	<li>Observar el aspecto y comportamiento incluyendo postura, vestido, expresiones faciales, actividad motora, gestos, características físicas del paciente y las reacciones a las preguntas hechas durante el examen.</li>
	<li>Tenga en cuenta la fluidez, velocidad y volumen del habla.</li>
	<li>Evaluar el efecto del paciente, incluyendo la gama, pertinencia, intensidad y capacidad. Evaluación objetiva del examinador del afecto debe ser comparado con informe subjetivo del paciente del estado de ánimo, que se obtiene a través de consulta directa.</li>
	<li>Evaluar el proceso de pensamiento del paciente, que se compone de elementos, tales como nivel de organización, presencia de tangentiality, asociaciones flojas y "vuelo de ideas".</li>
	<li>Evaluar el paciente contenido de pensamiento y percepción, aunque estos por lo general no completan observación solamente, y preguntas específicas pueden ser necesario. Contenido de pensamiento abarca obsesiones, ansiedades, fobias, preocupación somática, delirios, y ideas de persecución, influencia y referencia. Percepciones incluyen alucinaciones, la realización y la personalización.</li>
	<li>Nota la función cognitiva del paciente. Pistas a las anormalidades de la atención, orientación, memoria, juicio y visión pueden surgir si el examinador es mirar para ellos, aunque el uso de preguntas específicas y de instrumentos validados pueden ser necesarios cuantificar los déficits.</li>
	<li>Usar preguntas específicas para evaluar tendencias suicidas y homicidality.</li>
</ol>
5. auxiliares observaciones
<ol>
	<li>Algunos lugares de examen ofrecen oportunidades para aprender acerca de ayudas sociales, intereses y estilo de vida del paciente. Al visitar a un paciente en un espacio que ocupan más de unas horas (por ejemplo, sala de hospital, hogar de ancianos, hogar), observe la presencia (o ausencia) de decoraciones, padeciendo tarjetas, fotos, libros, etc. para obtener un entendimiento de la vida del paciente fuera el papel de paciente.</li>
	<li>Cuando miembros de la familia o amigos con los pacientes, observar las dinámicas interpersonales. Esta posibilidad de observación ofrece información importante sobre el paciente. ¿El miembro de la familia habla para el paciente? ¿Hace la mirada paciente del miembro de la familia antes de responder a las preguntas?</li>
	<li>Preste atención a lo que se siente en presencia de la paciente, como esto puede resultar útil de diagnóstico, especialmente en términos de enfermedad psiquiátrica. Mientras que los proveedores deben ser conscientes de las trampas de la contratransferencia, si la sensación de que el paciente está provocando en ti no es típico o fácilmente explicada, puede una explicación subyacente en la salud mental del paciente. Por ejemplo, un poco característico sentimiento de tristeza en el clínico durante el encuentro puede llevar al clínico a considerar un diagnóstico de trastorno depresivo mayor.</li>
</ol>

Observación es un componente importante del paciente encontramos que comienza en el primer punto de contacto con el paciente. Observación se relaciona con información obtenida mediante el uso de los sentidos durante el examen y abarca hallazgos físicos así como las observaciones conductuales, situacionales y auxiliares. El estudio general, que debe ser una parte de cada encuentro paciente constituye un conjunto específico de observaciones. Observaciones adicionales ocurren durante cada parte de órgano-específicas de la e...

observación e inspección 

Fuente: Jaideep S. Talwalkar, MD, medicina interna y Pediatría, Facultad de medicina de Yale, New Haven, CT
Observación e inspección es fundamentales para el examen físico y comienza en el primer punto de contacto con un paciente. Mientras que la observación y la inspección son de uso frecuente alternativamente, es un término general que se refiere al uso cuidadoso de los sentidos para obtener información. La inspección es un acto limitado a lo que se puede observar visualmente y cuando se refiere a la examinación física, se refiere normalmente a resultados en la superficie del cuerpo, en lugar de comportamientos. Los médicos expertos utilizan todos sus sentidos para ayudar a obtener un entendimiento de sus pacientes, confiando en la visión, del tacto (percusión y palpación) y de la audiencia (percusión y auscultación) principalmente. Olor puede también proporcionar importante información de diagnóstico durante el encuentro paciente (p. ej., higiene personal, uso de sustancias o enfermedades metabólicas). Afortunadamente el sentido del gusto es en gran parte una reliquia histórica en medicina, aunque es interesante notar que la diabetes fue diagnosticada durante muchos siglos por el sabor dulce de la orina. A través de la experiencia, los médicos desarrollan un importante sexto sentido - el instinto de gut - que sólo puede ser adquirido a través de la práctica deliberada de habilidades clínicas en miles de pacientes durante muchos años. Instinto de tripa del médico, que se basa en gran parte en observaciones de cabecera, ha demostrado ser un fuerte predictor de enfermedad grave. Este video y otros de la colección video de habilidades clínicas son pasos en el camino a este nivel de dominio de aprendizaje.

Observación e inspección 

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT
Observation and inspection is fundamental to ...

La observación y la inspección son fundamentales para cualquier examen clínico. Las observaciones generales comienzan en el primer punto de contacto con cualquier paciente y continúan durante todo el encuentro clínico, incluso mientras se tiene una conversación con el paciente. La inspección está más dirigida a un objetivo y se limita a lo que uno puede observar visualmente mientras examina partes específicas del cuerpo como la piel, los ojos o los oídos, a veces con la ayuda de un equipo especializado. Aquí, ilustramos las observaciones generales que un clínico debe considerar realizar durante cada encuentro clínico, seguidas de algunas consideraciones relacionadas con los pasos de la inspección visual. En primer lugar, repasemos algunos pasos generales de observación que un médico debe tener en cuenta cuando se reúna con cualquier paciente. Estas observaciones se pueden hacer en cualquier momento durante el examen. Durante la conversación inicial, cuando un paciente está explicando su enfermedad, observe el estado de su salud física y pregúntese: "¿La apariencia del paciente es consistente con la edad indicada? ¿El paciente parece estar en forma y sano o débil y frágil? ¿El paciente está despierto y alerta, o somnoliento? Al mismo tiempo, evalúe su estado mental y afecto, y examine si sus pensamientos están organizados. Durante la conversación, un médico también puede evaluar el contenido de pensamiento y las percepciones del paciente. Además, busque signos de angustia emocional, como inquietud excesiva o contacto visual inadecuado. Además, preste atención a la forma en que se siente en presencia del paciente, ya que esto puede resultar útil para el diagnóstico. Un sentimiento inusual de tristeza en el clínico puede llevar a considerar un diagnóstico de trastorno depresivo mayor. Además, durante la conversación, observe los signos de dolor observando las expresiones faciales y observando si el paciente exhibe movimientos cautelosos o signos autonómicos como la diaforesis. Además, observe la higiene, la ropa, el maquillaje, etc. del paciente para obtener pistas adicionales que puedan ayudar en el diagnóstico. Además, busque signos de dificultad respiratoria. Observe si el paciente habla en oraciones completas sin ninguna dificultad. Observe si el paciente está "trípode", es decir, inclinado hacia adelante con los brazos apoyados. Observe si se están utilizando músculos accesorios visibles de la respiración, lo cual es común en casos de dificultad respiratoria. En conjunto, estas simples observaciones pueden proporcionar una visión sustancial del estado físico y mental del paciente, y pueden ayudar en el diagnóstico de su enfermedad. Ahora que conoce las observaciones generales, echemos un vistazo a la inspección, que es fundamental para el examen físico completo y específico de un órgano. En primer lugar, explique al paciente el propósito de la inspección y obtenga su consentimiento. Como se mencionó anteriormente, esto implica observar visualmente las superficies del cuerpo para verificar si hay anomalías. Durante un examen completo de la piel, es necesario inspeccionar todas las superficies corporales anteriores, laterales y posteriores y las membranas mucosas. Observe el color de la piel o mucosa en cada sitio examinado. Los hallazgos comunes incluyen áreas de hipo o hiperpigmentación, palidez, cianosis e ictericia. Además, verifique el grado de hidratación, turgencia y textura. La mayoría de las inspecciones consisten en observar atentamente diferentes regiones de la superficie del cuerpo a simple vista. A veces, se requiere un equipo especial para la inspección de las estructuras inaccesibles a simple vista. Por ejemplo, un otoscopio es necesario para la inspección de las membranas timpánicas. Algunas áreas del cuerpo requieren inspección con manipulación. Por ejemplo, para el examen del cuero cabelludo, un médico puede tener que manipular el cabello del paciente para exponer la superficie. Anote los resultados de la inspección para cada sitio examinado, que se pueden combinar con las observaciones y el historial del paciente para predecir la enfermedad. Al final de cada examen, agradezca al paciente por su cooperación. Acaba de ver el vídeo de JoVE sobre las observaciones generales y la inspección durante un encuentro con un paciente. En conjunto, las habilidades de observación e inspección desempeñan un papel fundamental en el diagnóstico clínico. Aquí, revisamos un conjunto específico de observaciones que deberían ser parte de cada encuentro clínico. Además, hablamos de la inspección, que es un aspecto importante de cualquier examen físico y puede ayudar en el diagnóstico a pie de cama. Como siempre, ¡gracias por mirar!

Education

Educación

JoVE Science Education

Clinical Skills

Habilidades Clínicas

Physical Examinations I

Exámenes físicos I

clinical observation in physical exam

Clinical observation is the starting point of a physical examination and begins at the first contact with a patient. Observation is a broad term for using the senses carefully to gather information. Inspection is a narrower term. It refers to what can be seen with the eyes, especially on the surface of the body, rather than to behavior.

Skilled clinicians use more than sight when they examine a patient. They also rely on touch, through palpation and percussion, and on hearing, through auscultation and percussion. Smell can add useful clues as well. It may point to poor personal hygiene, substance use, or metabolic diseases.

Taste is mostly a historical part of medicine. For many centuries, diabetes mellitus was even diagnosed by the sweet taste of urine. Over time, clinicians also develop a sixth sense, often called gut instinct. This skill comes from deliberate practice on thousands of patients over many years. It is based largely on bedside observations and can help predict serious illness.

Clinical Observation in Physical Exam

general approach to the physical exam

Why Physical Exams Still Matter

Physical examination remains an important part of medicine. Doctors have used the body exam for centuries to connect changes in body function with disease. Even with modern imaging and lab tests, the bedside exam still helps clinicians understand what may be happening in the patient. Physical examination is not a replacement for tests, and it does not answer every question. Some maneuvers that were once highly valued may have limited usefulness. Still, many conditions can only be found through...

observation and inspection

Clinical observation is the starting point of a physical examination and begins at the first contact with a patient. Observation is a broad term for using the senses carefully to gather information. Inspection is a narrower term. It refers to what can be seen with the eyes, especially on the surface of the body, rather than to behavior. Skilled clinicians use more than sight when they examine a patient. They also rely on touch, through palpation and percussion, and on hearing, through...

palpation

How Hand Position Guides Palpation

Palpation uses touch to collect diagnostic information during the physical exam. It is one of the ways a healthcare provider uses the senses to learn more about a patient. The part of the hand used for palpation changes depending on the body area being examined. Finger pads are best for fine detail. Their dense sensory nerves help the examiner feel small features, such as the borders of masses or lymph nodes. The back of the hand, also called the dorsal surface, gives a rough sense of relative...

percussion

Clinical Percussion and Body Sound

Clinical percussion uses tapping to create sound and help assess what lies beneath the body surface. It is a simple bedside technique that depends on the way sound changes when it travels through different tissues. The method began with Leopold Auenbrugger, an Austrian inn-keeper's son, who found that tapping beer barrels could help him take inventory. He later applied the same idea to patients in Vienna and published the first description of its diagnostic use in 1761. Jean-Nicolas Corvisart...

auscultation

Stethoscope Sounds in Clinical Exam

Auscultation is a clinical exam method that lets a provider listen to sounds inside the body. Doctors use it to gather important diagnostic information from the chest, heart, abdomen, and blood vessels. For many years, auscultation meant immediate auscultation. In that method, the examiner placed an ear directly on the patient's skin. This approach was used for centuries, but it became less useful in nineteenth-century France because of social norms and poor diagnostic yield. René Laënnec...

proper adjustment of patient attire during the physical exam

proper-adjustment-of-patient-attire-during-the-physical-exam

Draping for a Better Physical Exam

Draping is an important part of a careful physical exam. It helps the provider examine the right body area while also protecting patient modesty. Good draping takes practice because the examiner must balance exposure with comfort. Correct technique also improves the accuracy of the exam. Skin lesions can be missed if inspection is done through clothing. Lung crackles may be reported by mistake when the chest is examined through a T-shirt, and subtle heart findings can be missed when...

blood pressure measurement

Manual Blood Pressure Reading Steps

Blood pressure reading uses an indirect method to measure the pressure of blood against vessel walls. Blood pressure, or BP, is a vital sign that is checked routinely in hospital and outpatient settings. It is one of the most common medical assessments performed around the world. The indirect method is non-invasive, safe, and easily reproducible, so it is used most often. BP can be measured automatically by oscillometry or manually by auscultation. Auscultation uses a sphygmomanometer, which...

measuring vital signs

Vital Sign Ranges and Patient Status

Vital signs are objective measurements that show a patient’s clinical status. The commonly accepted vital signs are blood pressure, heart rate, temperature, respiratory rate, and oxygen saturation. In many practices, pain is also treated as the sixth vital sign and is documented with the others. Pain is different from the other vital signs because it is a subjective measurement. That means the pain scale can vary from one patient to another. A vital signs assessment includes heart rate, blood...

respiratory exam i: inspection and palpation

respiratory-exam-i-inspection-and-palpation

Checking Breathing Distress by Exam

Respiratory exam starts with looking for breathing distress and feeling the chest. Shortness of breath is a common reason for both outpatient and inpatient evaluation. Early inspection can reveal fast breathing or cyanosis, which is a bluish color change that can signal low oxygen. If a patient shows respiratory distress, the situation needs urgent attention and oxygen therapy. In many cases, careful clinical examination can help identify lung problems without relying only on tests. This is...

respiratory exam ii: percussion and auscultation

respiratory-exam-ii-percussion-and-auscultation

Respiratory Exam: Lung Sounds and Percussion

Respiratory exam skills include percussion and auscultation of the lungs. These techniques help identify lung problems during a physical exam. Percussion uses tapping to assess the chest, and auscultation uses a stethoscope to listen for breath sounds. Percussion is a useful skill that is often skipped in routine clinical practice. When it is done correctly, it can help a physician detect underlying lung pathology. Auscultation can also give an almost immediate clue to several acute pulmonary...

cardiac exam i: inspection and palpation

Cardiac Exam I: Checking the Chest First

Cardiac exam inspection and palpation are the first steps in a careful heart assessment. These steps help a physician gather useful information before using a stethoscope. They are part of the core examination performed when a patient is first seen. Heart and circulatory disorders are common reasons for hospital admission. They can include conditions such as myocardial infarction and congestive heart failure. Because of this, learning a complete cardiac examination is important for any...

cardiac exam ii: auscultation

Listening for Normal and Abnormal Heart Sounds

Heart auscultation uses a stethoscope to listen to heart sounds and check for normal and abnormal patterns. For physicians, knowing how to hear these sounds and tell them apart is an essential skill. The sound heard at each spot on the chest relates to the closing of specific heart valves. The heart has two main sounds, called S1 and S2. S1 happens when the mitral and tricuspid valves, which are the atrioventricular valves, close after blood enters the ventricles. This marks the start of...

cardiac exam iii: abnormal heart sounds

Heart Murmurs and Gallop Sounds

Heart murmurs and gallop sounds are abnormal heart sounds that can be heard during auscultation, or listening to the heart with a stethoscope. A good understanding of normal heart sounds is the first step in telling normal sounds apart from abnormal ones. Murmurs usually have a swishing quality and point to turbulent blood flow across a heart valve. Murmurs can happen because a valve is too narrow, which is called stenosis, or because blood leaks backward across the valve, which is called...

peripheral vascular exam

Assessing PAD and Venous Signs

Peripheral vascular disease can affect blood flow in the arms and legs, and careful exam steps help reveal signs of disease. Peripheral artery disease (PAD) is linked to cardiovascular and cerebrovascular complications. Risk factors include diabetes, hyperlipidemia, hypertension, and tobacco use. Symptoms may appear as limb claudication, which is cramp-like muscle pain that gets worse with activity and better with rest. Chronic venous insufficiency (CVI) can cause lower extremity swelling,...

peripheral vascular exam using a continuous wave doppler

peripheral-vascular-exam-using-a-continuous-wave-doppler

Bedside Doppler for Leg Blood Flow Checks

Peripheral vascular disease affects the arteries and veins outside the heart, and it is common in older adults. History and physical exam can suggest the diagnosis, but Doppler ultrasound is now a routine part of the bedside vascular exam. This lesson focuses on bedside assessment of peripheral arterial disease and chronic venous insufficiency with a handheld continuous wave Doppler. A handheld Doppler is a simple tool that sends and receives ultrasound at the same time. It detects changes in...

physical examinations i

Esta colección proporciona una base para realizar la exploración física; con técnicas que van desde la medición de la presión arterial o signos vitales, hasta la exploración pulmonar y cardiovascular.

Learn how clinicians use observation, inspection, touch, hearing, and smell during a physical exam, and why bedside clues can help detect serious illness.

Clinical Observation in Physical Exam | JoVE K12

Jaideep Talwalkar

Internal Medicine

Yale School of Medicine

Overview

General Observations

Considerations for Inspection

Summary

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Methylation at CpG dinucleotides is a chemical modification of DNA hypothesized to play important roles in regulating gene expression. In particular, the ...

Expression Profiling with Microarrays

Microarrays are important tools for profiling gene expression, and are based on complementary binding between probes that are attached to glass chips and ...

Density Gradient Ultracentrifugation

Density gradient ultracentrifugation is a common technique used to isolate and purify biomolecules and cell structures. This technique exploits the fact ...

F&#246;rster Resonance Energy Transfer (FRET)

F&#246;rster resonance energy transfer (FRET) is a phenomenon used to investigate close-range biochemical interactions. In FRET, a donor photoluminescent ...

detecting-environmental-microorganisms-with-polymerase-chain-reaction

Detecting Environmental Microorganisms with the Polymerase Chain Reaction and Gel Electrophoresis

Source: Laboratories of Dr. Ian Pepper and Dr. Charles Gerba - Arizona University
Demonstrating Author: Bradley Schmitz
Polymerase chain reaction (PCR) is ...

Gel Purification

Gel purification is used to recover DNA fragments after electrophoretic separation. DNA recovery from an agarose gel includes three basic steps: binding, ...

Detecting Reactive Oxygen Species

Reactive oxygen species are chemically active, oxygen-derived molecules capable of oxidizing other molecules. Because of their reactive nature, there are ...

Gene Silencing with Morpholinos

Morpholino-mediated gene silencing is a common technique used to study roles of specific genes during development. Morpholinos inhibit gene expression by ...

development-and-reproduction-of-the-laboratory-mouse

Development and Reproduction of the Laboratory Mouse

Successful breeding of the laboratory mouse (Mus musculus) is critical to the establishment and maintenance of a productive animal colony. Additionally, ...

Construct an explanation based on evidence for how the structure of DNA determines the structure of proteins which carry out the essential functions of life through systems of specialized cells.

HS-LS1-1.

Clinical Observation in Physical Exam

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