来源：Jaideep S.Talwalkar，MD、 内科、 儿科，耶鲁大学医学院，纽黑文，康涅狄格
对尸体的检查是医学实践的基础。自罗马帝国时代，医生描述了身体的特定部位功能改变与特定疾病的国家之间的联系并寻求进一步科学的了解，提高床边诊断。然而，在这个现代的增加内医疗诊断技术时代，它是重要的是考虑物理考试今天起的作用。它是被误导相信体检拥有所有的答案，并多已写入有关可疑实用程序的某些以前在高方面举行的演习。它同样被错误的建议那体检在现代病人接触中起作用很小。
体格检查仍然是一个有价值的诊断工具;有很多只可通过体格检查的诊断。由实验室或成像诊断很少这么做没有结果检出在床边。作为提供程序进行历史和物理，他们积极地生成和测试假说来解释病人的病情。一个收集的信息不可能取代需要测试，但坚定的假设在地方允许提供程序更明智地命令测试，这些测试的更好的提问。这，反过来，有可能给病人减少风险和节约成本的卫生保健系统。最后，体检在治疗关系中发挥重要的作用。通过参与体检的古老仪式，临床医师有机会发展融洽的关系 （通过展示的注意力和灵敏度） 和通过触摸蓄意和负责任的使用促进愈合。
This video demonstrates the role that physical examination plays in the modern patient encounter and has reviewed some critical steps to ensure the exam is carried out in a safe and sensitive manner. Important preparatory steps before the examination help to reduce risk of infection as well as patient and provider anxiety. Ensuring patient privacy and using gowns and drapes in a sensitive manner also makes patients feel more comfortable. A deliberate approach to the examination that is grounded in clinical reasoning is valuable to optimize efficiency and the predictive value of the exam. An organized approach to the maneuvers being performed minimizes the need for unnecessary patient repositioning. The specific maneuvers to be performed vary based on the clinical circumstance, but an examiner's efforts to maintain clear communication with attention to patient comfort should not vary.
The physical examination has played a vital role in patient care for millennia and should continue to do so even in the face of technological advances. Over the past forty years, multiple studies in various clinical settings have demonstrated that history and physical alone allow physicians to arrive at the correct diagnosis a great majority of the time. In almost all other circumstances, the information gained at the bedside allows the clinician to utilize clinical reasoning to judiciously order and interpret tests to make diagnoses. Given the recent emphasis on medical cost containment, patient safety, and access to services, bedside diagnostics remain inexpensive, widely available, and carry little risk of adverse effects.
Physical examination has been fundamental to the practice of medicine for centuries. Despite substantial advancement in medical instrumentation, physical examination remains a valuable diagnostic tool, and its importance cannot be overstated. As physicians assess history and conduct a physical, they gather information leading to a firm hypothesis, which promotes a more judicious approach to ordering tests and analysis of those tests. This, in turn, has the potential to reduce patient risk and health care costs.
This video will illustrate some of the important steps that every physician must take to ensure that the physical exam is carried out in a safe and sensitive manner.
A physical exam can be comprehensive or specific, but the overall steps before and during each exam remain the same. Let’s review these steps in detail.
First, the exam room should be prepared for the patient by disinfecting surfaces to be used during the examination. In addition, a physician should disinfect equipment like the stethoscope or the reflex hammer, which may be used during the exam. Before every exam, wash your hands with soap and water or apply topical disinfectant solution. If the patient is suffering from a known specific infection, then control precautions should be taken by obtaining the necessary protective equipment. Make sure that cuffs of the gloves cover the gown so that no skin is exposed.
Once the patient is seated in the room, knock on the door and ask for patient’s permission to enter the room. Introduce yourself and your role. Request the family members or friends who have accompanied the patient to step out of the room. This provides an important opportunity to speak to the patient alone. Ensure that the exam room curtains are drawn and doors are closed. While talking to the patient, general observations should be made regarding the patient’s health. These include, appearance consistency with the stated age, overall health, alertness, affect, thought content and organization, and perception.
After this initial conversation, determine what aspects of the examination are necessary. Ensure the patient is dressed appropriately for the planned exam. If necessary, provide the patient with a gown and drape and give them some time to change. After some time, knock on the door and ask for the patient’s permission to enter the room. Request the patient to occupy the exam table. Adjust the back of the exam table as needed to optimize your ability to perform maneuvers. The physical examination can be subdivided into the following components: general survey, measuring vital signs, examination of the neurologic functioning and mental status, examination of the head, eyes, ears, nose, throat, chest, lungs, lymph nodes, cardiovascular, abdomen, musculoskeletal, skin, genitourinary, and rectal. A chaperone may be necessary if a sensitive exam like genitourinary, rectal, or breast exams is to be conducted.
Explain the patient the physical exam that is going to be conducted and ask for their permission to proceed with the exam. “Now that I’ve explained what I am going to do, may I proceed with the examination?” Each exam consists of maneuvers employing the techniques of inspection, percussion, palpation, and auscultation, each of which is explored in detail in separate videos of this collection. You should strive to minimize patient repositioning by grouping maneuvers together that need to be performed in a particular position. After the exam is complete, request the patient to change back to regular clothing. It is optimal to wait until the patient is dressed again before offering advice and opinion. Subsequently, weighing how the presence or absence of particular findings affects disease probability and consolidating the information obtained from patient’s history and physical exam, one may decide to initiate a therapy or order additional testing in a deliberate and judicious manner.
You have just watched JoVE’s video on general approach to the physical examination.
This video reviewed the importance of physical examination in the modern patient encounter and demonstrated some critical steps to ensure the exam is carried out in a safe and sensitive manner. Important preparatory steps before the examination help to reduce risk of infection, and an organized approach to the maneuvers being performed minimizes the need for unnecessary patient repositioning.
Given the recent emphasis on medical cost containment, patient safety, and access to services, physical examination remains inexpensive, widely available, and carries little risk of adverse effects. As always, thanks for watching!
