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

Observation occurs as a constant process during the clinical encounter. Many of the items listed in the procedure are typically done simultaneously and when opportunities present themselves. The procedure highlights the components of observation, but is not intended to suggest a preferred sequence.
1. General survey
<ol>
	<li>Note the general state of health in the patient. Is the patient&#39;s appearance consistent with the stated age? Does the patient appear fit and healthy or weak and frail?</li>
	<li>Note their level of consciousness (e.g., awake, alert, or somnolent).</li>
	<li>Observe for signs of pain. Note facial expressions, guarded movements, diaphoresis, etc.</li>
	<li>Observe for signs of respiratory distress. Can the patient speak in complete sentences without difficulty? Is the patient &#34;tripoding&#34; (leaning forward with the arms supported)? Are visible accessory muscles of respiration being used?</li>
	<li>Observe for signs of emotional distress. Is the patient fidgeting excessively, exhibiting generalized psychomotor slowing, or crying? Is eye contact appropriate?</li>
	<li>Make note of clothing, jewelry, tattoos, grooming, hygiene, and any other features that may provide insight into the patient&#39;s medical, social, and emotional situation.</li>
	<li>Note any signs of pathology that may be evident on general observation, such as skin lesions, abnormal fat distribution, hearing deficits, muscle atrophy, odors, etc.</li>
</ol>
2. Organ-specific observation
During the remainder of the physical examination, active observation is done with an examination of each organ system. For some organ systems, inspection requires the use of equipment (e.g., otoscope or ophthalmoscope). Refer to the videos for each organ system for specific details.
3. Skin exam
Detailed inspection is the main component of the skin exam. A complete skin exam includes inspection of all anterior, posterior, and lateral body surfaces and mucous membranes. Inspection of certain areas requires manipulation for examination to be performed. These areas include the hair, scalp, mastoid processes, posterior auricles, external auditory canals, nares, axilla, nails, palpebral conjunctiva, oral mucosa, inferior aspects of the breasts, skin underlying a pannus, surfaces of genitals, vaginal mucosa, and gluteal cleft.
<ol>
	<li>Note the color of the skin or mucosa at each site examined. Common findings include areas of hypo- or hyper-pigmentation, pallor (palpebral conjunctiva, palms, soles, and nailbeds), cyanosis (nailbeds, lips, and perioral), and jaundice (sclera, skin, and mucous membranes).</li>
	<li>At each site examined, also note the degree of hydration (i.e. dryness or oiliness), turgor, and texture of the skin.</li>
</ol>
4. Mental status exam
<ol>
	<li>Observe the patient&#39;s appearance and behavior including posture, dress, facial expressions, motor activity, mannerisms, physical characteristics, and reactions to the questions asked during the exam.</li>
	<li>Note the fluency, rate, and volume of speech.</li>
	<li>Assess the patient&#39;s affect, including the range, appropriateness, intensity, and ability. The examiner&#39;s objective assessment of affect should be compared to the patient&#39;s subjective report of mood, which is obtained via direct inquiry.</li>
	<li>Evaluate the patient&#39;s thought process, which is composed of elements, such as level of organization, presence of tangentiality, loose associations, and &#34;flight of ideas.&#34;</li>
	<li>Evaluate the patient&#39;s thought content and perceptions, though these are typically not completed by observation alone, and specific questioning may be required. Thought content encompasses obsessions, anxieties, phobias, somatic pre-occupation, delusions, and ideas of persecution, influence, and reference. Perceptions include hallucinations, de-realization, and de-personalization.</li>
	<li>Note the patient&#39;s cognitive function. Clues to abnormalities of attention, orientation, memory, judgment, and insight can emerge if the examiner is attuned to look for them, though the use of specific questions and validated instruments may be necessary to quantify deficits.</li>
	<li>Use specific questions to assess for suicidality and homicidality.</li>
</ol>
5. Ancillary observations
<ol>
	<li>Certain examination locations offer opportunities to learn about a patient&#39;s social supports, interests, and lifestyle. When visiting a patient in a space they are occupying for more than a few hours (e.g., hospital room, nursing home, home), note the presence (or absence) of decorations, get-well cards, family photos, books, etc. to gain an understanding of the patient&#39;s life outside of the patient role.</li>
	<li>When family members or friends are present with patients, observe the interpersonal dynamics. This opportunity for observation offers important information about the patient. Does the family member speak for the patient? Does the patient look to the family member before responding to questions?</li>
	<li>Pay attention to the way you are feeling in the presence of the patient, as this may prove diagnostically useful, especially in terms of psychiatric illness. While providers must be aware of the pitfalls of countertransference, if the feeling that the patient is triggering in you is not typical or easily explained, there may an underlying explanation in the patient&#39;s mental health. For example, an uncharacteristic feeling of sadness in the clinician during the encounter may lead the clinician to consider a diagnosis of major depressive disorder.</li>
</ol>
<div class="chapter_text" id="script_0">
	Observation and inspection are fundamental to any clinical examination. General observations begin at the first point of contact with any patient and continue throughout the clinical encounter, even while just having a conversation with the patient. Inspection is more goal-directed and it is limited to what one can observe visually while examining specific body parts like skin, eyes or ears, sometimes with the help of a specialized equipment.
	Here, we illustrate the general observations that a clinical should consider performing during each clinical encounter, followed by a few considerations related to the visual inspection steps.
</div>
<div class="chapter_text" id="script_1">
	First, let's go over some general observation steps that a clinician should keep in mind when meeting with any patient. These observations can be made anytime during the examination.
	During the initial conversation when a patient is explaining their illness, note the state of their physical health and ask yourself "Is the patient's appearance consistent with the stated age? Does the patient appear fit and healthy or weak and frail? Is the patient awake and alert, or somnolent?" Simultaneously, gauge their mental status and affect, and examine whether their thoughts are organized.
	During the conversation, a physician can also evaluate the patient's thought content and perceptions. In addition, look for signs of emotional distress like excessive fidgeting or inadequate eye contact. Also, pay attention to the way you are feeling in the presence of the patient, as this may prove diagnostically useful. An uncharacteristic feeling of sadness in the clinician may lead to considering a diagnosis of major depressive disorder. Furthermore, during the conversation, observe for signs of pain by looking at facial expressions, and by noting if the patient is exhibiting guarded movements or autonomic signs like diaphoresis. Also, note the patient's hygiene, clothing, make up, etc. for additional clues that might help in diagnosis. In addition, look for signs of respiratory distress. Note whether the patient speaks in complete sentences without any difficulty. Observe if the patient is "tripoding", which is leaning forward with the arms supported. Notice if visible accessory muscles of respiration are being used, which is common in cases of respiratory distress.
	Taken together, these simple observations can provide substantial insight into the patient's physical and mental status, and can help in diagnosis of their illness.
</div>
<div class="chapter_text" id="script_2">
	Now that you know about general observations, let's look at inspection, which is critical to comprehensive and organ-specific physical examination.
	First, explain the patient the purpose of inspection and obtain their consent. As mentioned earlier, this involves visually observing body surfaces to check for any abnormalities. During a comprehensive skin exam, inspection of all anterior, lateral, and posterior body surfaces and mucous membranes is necessary. Note the color of the skin or mucosa at each site examined. Common findings include areas of hypo- or hyper-pigmentation, pallor, cyanosis, jaundice. Also, check for the degree of hydration, turgor, and texture.
	Mostly inspection involves keenly looking at different regions of the body surface with naked eye. Sometimes, special equipment is required for inspection of the structures inaccessible to the naked eye. For example, an otoscope is necessary for the inspection of tympanic membranes. Some areas of the body require inspection with manipulation. Like, for scalp examination, a physician may have to manipulate through the patient's hair to expose the surface. Note the inspection results for each site examined, which can be combined with observations and patient's history to predict the illness. At the end of every exam, thank the patient for their cooperation.
</div>
<div class="chapter_text" id="script_3">
	You have just watched JoVE's video on general observations and inspection during a patient encounter.
	Taken together, observation and inspection skills play a critical role in clinical diagnosis. Here, we reviewed a specific set of observations that should be a part of every clinical encounter. Additionally, we discussed inspection, which is an important aspect of any physical exam and can assist in bedside diagnosis. As always, thanks for watching!
</div>

Observation is an important component of the patient encounter that begins at the first point of contact with the patient. Observation relates to information gained by using one's senses during the examination and encompasses physical findings as well as behavioral, situational, and ancillary observations. A specific set of observations makes up the general survey, which should be a part of every patient encounter. Additional observations occur during each organ-specific part of the physical examination, with inspection ...

observation and inspection

Source: <a href="https://www.jove.com/author/Jaideep+S._Talwalkar">Jaideep S. Talwalkar</a>, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT
Observation and inspection is fundamental to physical examination and begins at the first point of contact with a patient. While observation and inspection are often used interchangeably, observation is a general term that refers to the careful use of one&#39;s senses to gain information. Inspection is an act limited to what one can observe visually, and when referring to physical examination, typically refers to findings on the surface of the body, rather than to behaviors. Skilled clinicians utilize all of their senses to assist with gaining an understanding of their patients, relying on vision, touch (percussion and palpation), and hearing (percussion and auscultation) primarily. Smell can also provide important diagnostic information during the patient encounter (e.g., personal hygiene, substance use, or metabolic diseases). Fortunately the sense of taste is largely a historical relic in medicine, though it is interesting to note that diabetes mellitus was diagnosed for many centuries by the sweet taste of the urine. Through experience, clinicians develop an important sixth sense - the gut instinct - that can only be gained through deliberate practice of clinical skills on thousands of patients over many years. The clinician&#39;s gut instinct, which is based largely on bedside observations, has been shown to be a strong predictor of serious illness. This video and the others in the clinical skills video collection are steps on the way to learning this level of mastery.

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

Observation and inspection are fundamental to any clinical examination. General observations begin at the first point of contact with any patient and continue throughout the clinical encounter, even while just having a conversation with the patient. Inspection is more goal-directed and it is limited to what one can observe visually while examining specific body parts like skin, eyes or ears, sometimes with the help of a specialized equipment.Here, we illustrate the general observations that a clinical should consider performing during each clinical encounter, followed by a few considerations related to the visual inspection steps.First, let's go over some general observation steps that a clinician should keep in mind when meeting with any patient. These observations can be made anytime during the examination.During the initial conversation when a patient is explaining their illness, note the state of their physical health and ask yourself "Is the patient's appearance consistent with the stated age? Does the patient appear fit and healthy or weak and frail? Is the patient awake and alert, or somnolent?" Simultaneously, gauge their mental status and affect, and examine whether their thoughts are organized.During the conversation, a physician can also evaluate the patient's thought content and perceptions. In addition, look for signs of emotional distress like excessive fidgeting or inadequate eye contact. Also, pay attention to the way you are feeling in the presence of the patient, as this may prove diagnostically useful. An uncharacteristic feeling of sadness in the clinician may lead to considering a diagnosis of major depressive disorder. Furthermore, during the conversation, observe for signs of pain by looking at facial expressions, and by noting if the patient is exhibiting guarded movements or autonomic signs like diaphoresis. Also, note the patient's hygiene, clothing, make up, etc. for additional clues that might help in diagnosis. In addition, look for signs of respiratory distress. Note whether the patient speaks in complete sentences without any difficulty. Observe if the patient is "tripoding", which is leaning forward with the arms supported. Notice if visible accessory muscles of respiration are being used, which is common in cases of respiratory distress.Taken together, these simple observations can provide substantial insight into the patient's physical and mental status, and can help in diagnosis of their illness.Now that you know about general observations, let's look at inspection, which is critical to comprehensive and organ-specific physical examination.First, explain the patient the purpose of inspection and obtain their consent. As mentioned earlier, this involves visually observing body surfaces to check for any abnormalities. During a comprehensive skin exam, inspection of all anterior, lateral, and posterior body surfaces and mucous membranes is necessary. Note the color of the skin or mucosa at each site examined. Common findings include areas of hypo- or hyper-pigmentation, pallor, cyanosis, jaundice. Also, check for the degree of hydration, turgor, and texture.Mostly inspection involves keenly looking at different regions of the body surface with naked eye. Sometimes, special equipment is required for inspection of the structures inaccessible to the naked eye. For example, an otoscope is necessary for the inspection of tympanic membranes. Some areas of the body require inspection with manipulation. Like, for scalp examination, a physician may have to manipulate through the patient's hair to expose the surface. Note the inspection results for each site examined, which can be combined with observations and patient's history to predict the illness. At the end of every exam, thank the patient for their cooperation.You have just watched JoVE's video on general observations and inspection during a patient encounter.Taken together, observation and inspection skills play a critical role in clinical diagnosis. Here, we reviewed a specific set of observations that should be a part of every clinical encounter. Additionally, we discussed inspection, which is an important aspect of any physical exam and can assist in bedside diagnosis. As always, thanks for watching!

Education

JoVE Science Education

Clinical Skills

Physical Examinations 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...

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

This collection provides a foundation for performing physical exams; with techniques ranging from measuring blood pressure or vital signs, to key pulmonary and cardiovascular physical examinations. 

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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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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