Name: why physical exams still matter
Uploaded: 2023-04-30T06:35:19.000Z
Duration: 5 min 21 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.

General Approach to the Physical Exam

1. Antes do encontro do paciente
<ol><li>Preparar a sala de exame para o paciente desinfetando superfícies tocadas pelo paciente anterior (por exemplo,tabela de exame); isso é normalmente feito pela equipe de suporte.</li>
	<li>Desinfete qualquer equipamento que você planeje usar durante o encontro (por exemplo,estetoscópio, martelo reflexo).</li>
	<li>Lave as mãos com água e sabão ou solução desinfetante tópica.</li>
	<li>Determine se são necessárias precauções específicas de controle de infecção para o encontro clínico (por exemplo,precauções de contato) e obtenha os equipamentos de proteção necessários.</li>
	<li>Tente acalmar suas próprias ansiedades, pois o paciente pode estar se sentindo vulnerável devido à doença. É provável que o paciente se sinta muito mais à vontade se você parecer calmo.</li>
</ol>2. Entre na sala
<ol><li>Bata na porta e peça permissão para entrar.</li>
	<li>Apresente-se e seu papel.</li>
</ol>3. Privacidade do paciente
<ol><li>Pergunte aos familiares que acompanharam o paciente para sair da sala. Isso proporciona uma importante oportunidade de falar com o paciente sozinho. Os pedidos dos pacientes para que os familiares permaneçam presentes devem ser geralmente respeitados.</li>
	<li>Certifique-se de que as cortinas da sala de exame estão fechadas e as portas estão fechadas.</li>
	<li>Determine se um acompanhante estará presente durante o exame, o que é bom se o paciente ou o provedor achar necessário. Isso é frequentemente feito de forma padrão para exames genitourinary, retal e feminino.</li>
</ol>4. Considere sua abordagem
<ol><li>Determine quais aspectos do exame você pretende realizar. Isso pode variar desde uma avaliação abrangente, como se pode fazer durante uma visita preventiva, até um exame mais focado com base em queixas de pacientes e sua suspeita clínica para doenças específicas.</li>
	<li>Seja focado ou abrangente, o exame deve ser realizado de forma deliberada e ativa, com atenção constante dada ao que se busca, e não apenas através de um processo rote/automático. Alcançar o estado em que se é capaz de focar nos achados, e não apenas no processo, requer muita prática.</li>
	<li>Planeje sua sequência de exames para otimizar a eficiência e o conforto do paciente. Você deve se esforçar para minimizar o reposicionamento do paciente, agrupando manobras que precisam ser realizadas em uma determinada posição. É útil ter um plano em mente antes de iniciar o exame.</li>
</ol>5. Traje do paciente
<ol><li>Certifique-se de que o paciente está vestido adequadamente para o exame planejado. Se necessário, forneça ao paciente um vestido e uma cortina.</li>
</ol>6. Outras considerações ambientais
<ol><li>Ajuste a altura da cadeira e da mesa de exame conforme necessário para otimizar sua capacidade de realizar manobras.</li>
	<li>Ajuste a iluminação e o ruído ambiente conforme possível.</li>
	<li>A abordagem convencional do exame coloca o examinador no lado direito do paciente.</li>
</ol>7. Componentes do exame
<ol><li>O exame físico é subdividido nos seguintes componentes regionais/anatômicos: levantamento geral; sinais vitais; cabeça, olhos, orelha, nariz, garganta (HEENT); pescoço; peito; cardiovasculares; para trás; abdômen; extremidades; neurológica; musculoesquelético; pele; peito; genitourinary; retal; linfonodos; estado mental. Há uma sobreposição substancial entre os componentes.</li>
	<li>Cada exame de componente consiste em manobras utilizando as técnicas de inspeção, percussão, palpação e auscultação, cada uma das quais é explorada em detalhes em vídeos separados. Modalidades mais novas, como o ultrassom diagnóstico de cabeceira, são cada vez mais incorporadas ao exame físico.</li>
	<li>Pergunte à permissão do paciente para prosseguir com o exame e nos principais pontos de transição durante o exame (por exemplo,"Agora que expliquei o que vou fazer, posso começar o exame?" e "Em seguida, gostaria de examinar seu coração").</li>
</ol>8. Raciocínio Clínico
<ol><li>O examinador deve pesar ativamente como a presença ou ausência de determinados achados afeta a probabilidade da doença. Médicos experientes fazem isso em tempo real durante o exame.</li>
	<li>Modifique o plano inicial de abordagem com base nos achados encontrados durante o exame. Por exemplo, enquanto um só pode ter planejado realizar uma simples auscultação dos pulmões, a presença de sons de respiração reduzidos em uma determinada área pode levar o examinador a utilizar técnicas especializadas (por exemplo,egofonia, fremitus vocal).</li>
	<li>A consolidação das informações obtidas durante a história (sintomas) e físicos (sinais) informa os próximos passos na gestão. O tratamento pode ser iniciado se a probabilidade de uma determinada doença for alta o suficiente, ou testes adicionais podem ser solicitados de forma deliberada e criteriosa.</li>
</ol>9. Terminando o exame
<ol><li>Faça com que o paciente volte a se vestir regularmente no final do exame.</li>
	<li>É ideal esperar até que o paciente esteja vestido novamente antes de oferecer seus conselhos e opiniões.</li>
</ol>

Este vídeo demonstra o papel que o exame físico desempenha no encontro moderno do paciente e tem revisto algumas etapas críticas para garantir que o exame seja realizado de forma segura e sensível. Importantes passos preparatórios antes do exame ajudam a reduzir o risco de infecção, bem como a ansiedade do paciente e do provedor. Garantir a privacidade do paciente e usar vestidos e cortinas de forma sensível também faz com que os pacientes se sintam mais confortáveis. Uma abordagem deliberada para o exame que está fundam...

abordagem geral para o exame físico

Fonte: <a href="https://www.jove.com/author/Jaideep+S._Talwalkar">Jaideep S. Talwalkar</a>, MD, Medicina Interna e Pediatria, Yale School of Medicine, New Haven, CT
O exame do corpo é fundamental para a prática da medicina. Desde o Império Romano, os médicos descreveram a conexão entre alterações em função de partes específicas do corpo e estados específicos da doença e têm procurado aprofundar a compreensão científica para melhorar o diagnóstico de cabeceira. No entanto, nesta era moderna de aumento da tecnologia dentro dos diagnósticos médicos, é importante considerar o papel que o exame físico desempenha hoje. É equivocado acreditar que o exame físico contém todas as respostas, e muito tem sido escrito sobre a utilidade questionável de certas manobras anteriormente realizadas em alta consideração. É igualmente equivocado sugerir que o exame físico desempenha pouco papel no encontro moderno do paciente.
O exame físico continua sendo uma ferramenta de diagnóstico valiosa; existem muitos diagnósticos que só podem ser feitos por exame físico. Um diagnóstico feito por laboratórios ou imagens raramente é feito na ausência de achados detectáveis ao lado da cama. À medida que o provedor conduz um histórico e físico, eles estão ativamente gerando e testando hipóteses para explicar a condição do paciente. As informações coletadas podem não substituir a necessidade de testes, mas ter hipóteses firmes em vigor permite que o provedor peça testes de forma mais criteriosa e faça melhores perguntas desses testes. Isso, por sua vez, tem potencial para reduzir o risco ao paciente e economizar custos para o sistema de saúde. Finalmente, o exame físico desempenha um papel crítico na relação terapêutica. Ao se engajar no ritual de exame físico, o médico tem a oportunidade de desenvolver relacionamento (demonstrando atenção e sensibilidade) e promover a cura através do uso deliberado e responsável do toque.

Abordagem Geral para o Exame Físico

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT
The examination of the body is fundamental to ...

O exame físico tem sido fundamental para a prática da medicina há séculos. Apesar do avanço substancial na instrumentação médica, o exame físico continua sendo uma valiosa ferramenta diagnóstica e sua importância não pode ser exagerada. À medida que os médicos avaliam a história e realizam um exame físico, eles coletam informações que levam a uma hipótese firme, que promove uma abordagem mais criteriosa para solicitar exames e análises desses testes. Isso, por sua vez, tem o potencial de reduzir o risco do paciente e os custos de saúde. Este vídeo ilustrará algumas das etapas importantes que todo médico deve seguir para garantir que o exame físico seja realizado de maneira segura e sensível. Um exame físico pode ser abrangente ou específico, mas as etapas gerais antes e durante cada exame permanecem as mesmas. Vamos revisar essas etapas em detalhes. Primeiro, a sala de exames deve ser preparada para o paciente desinfetando as superfícies a serem usadas durante o exame. Além disso, o médico deve desinfetar equipamentos como o estetoscópio ou o martelo de reflexo, que podem ser usados durante o exame. Antes de cada exame, lave as mãos com água e sabão ou aplique solução desinfetante tópica. Se o paciente estiver sofrendo de uma infecção específica conhecida, as precauções de controle devem ser tomadas obtendo o equipamento de proteção necessário. Certifique-se de que os punhos das luvas cubram o vestido para que nenhuma pele fique exposta. Assim que o paciente estiver sentado na sala, bata na porta e peça permissão ao paciente para entrar na sala. Apresente-se e apresente seu papel. Solicite aos familiares ou amigos que acompanharam o paciente que saiam da sala. Isso oferece uma oportunidade importante de falar com o paciente sozinho. Certifique-se de que as cortinas da sala de exames estejam fechadas e as portas fechadas. Ao falar com o paciente, observações gerais devem ser feitas sobre a saúde do paciente. Isso inclui consistência da aparência com a idade declarada, saúde geral, estado de alerta, afeto, conteúdo e organização do pensamento e percepção. Após essa conversa inicial, determine quais aspectos do exame são necessários. Certifique-se de que o paciente esteja vestido adequadamente para o exame planejado. Se necessário, forneça ao paciente um avental e uma cortina e dê-lhe algum tempo para se trocar. Depois de algum tempo, bata na porta e peça permissão ao paciente para entrar no quarto. Solicite ao paciente que ocupe a mesa de exames. Ajuste a parte de trás da mesa de exame conforme necessário para otimizar sua capacidade de realizar manobras. O exame físico pode ser subdividido nos seguintes componentes: levantamento geral, medição dos sinais vitais, exame do funcionamento neurológico e estado mental, exame da cabeça, olhos, ouvidos, nariz, garganta, tórax, pulmões, gânglios linfáticos, cardiovascular, abdômen, musculoesquelético, pele, geniturinário e retal. Um acompanhante pode ser necessário se um exame sensível, como exames geniturinários, retais ou de mama, for realizado. Explique ao paciente o exame físico que será realizado e peça permissão para prosseguir com o exame. "Agora que expliquei o que vou fazer, posso prosseguir com o exame?" Cada exame consiste em manobras empregando as técnicas de inspeção, percussão, palpação e ausculta, cada uma das quais é explorada em detalhes em vídeos separados desta coleção. Você deve se esforçar para minimizar o reposicionamento do paciente agrupando as manobras que precisam ser executadas em uma posição específica. Após a conclusão do exame, solicite ao paciente que volte a usar roupas normais. É ideal esperar até que o paciente esteja vestido novamente antes de oferecer conselhos e opiniões. Posteriormente, ponderando como a presença ou ausência de achados específicos afeta a probabilidade da doença e consolidando as informações obtidas a partir da história e do exame físico do paciente, pode-se decidir iniciar uma terapia ou solicitar exames adicionais de maneira deliberada e criteriosa. Você acabou de assistir ao vídeo de JoVE sobre a abordagem geral do exame físico. Este vídeo analisou a importância do exame físico no encontro moderno com o paciente e demonstrou algumas etapas críticas para garantir que o exame seja realizado de maneira segura e sensível. Etapas preparatórias importantes antes do exame ajudam a reduzir o risco de infecção, e uma abordagem organizada das manobras que estão sendo realizadas minimiza a necessidade de reposicionamento desnecessário do paciente. Dada a ênfase recente na contenção de custos médicos, segurança do paciente e acesso aos serviços, o exame físico permanece barato, amplamente disponível e apresenta pouco risco de efeitos adversos. Como sempre, obrigado por assistir!

Education

JoVE Science Education

Clinical Skills

Habilidades Clínicas

Physical Examinations I

Exames Físicos I

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 physical examination, and diagnoses made with labs or imaging usually begin with findings from the bedside.

As a provider performs the history and physical, they form and check ideas, or hypotheses, about the patient’s condition. These ideas help guide which tests to order and which questions to ask next. That can make testing more focused, reduce risk for the patient, and help lower health care costs.

The physical exam also supports the therapeutic relationship. By using careful and respectful touch, the clinician can show attention and sensitivity. This process can build rapport and may help promote healing during the patient encounter.

Why Physical Exams Still Matter

general approach to the physical exam

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 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...

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 coleção fornece uma base para a realização de exames físicos, com técnicas que vão desde a aferição da pressão arterial ou sinais vitais até exames físicos pulmonares e cardiovasculares.

Learn why the physical exam remains a key part of medicine, from bedside diagnosis and hypothesis testing to building patient trust and rapport.

Why Physical Exams Still Matter | JoVE K12

Jaideep Talwalkar

Internal Medicine

Yale School of Medicine

Overview

General Steps During Any Physical Examination

Summary

Characteristics of Life

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Proteins: From Genes to Degradation

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explant-culture-for-developmental-studies

Explant Culture for Developmental Studies

Explant culture is a technique in which living cells or tissues are removed from an embryo for continued development outside of the organism. This ex vivo ...

DNA Methylation Analysis

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.

Why Physical Exams Still Matter

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