출처: 자이딥 S. 탈와르,MD, 내과 및 소아과, 예일 의과 대학, 뉴 헤이븐, CT
관찰 및 검사는 신체 검사의 기본이며 환자와의 첫 번째 접촉 지점에서 시작됩니다. 관찰과 검사는 종종 상호 교환적으로 사용되지만 관찰은 정보를 얻기 위해 감각을 신중하게 사용하는 일반적인 용어입니다. 검사는 시각적으로 관찰 할 수있는 것으로 제한되는 행위이며, 신체 검사를 언급 할 때 일반적으로 행동보다는 신체 표면의 결과를 말합니다. 숙련된 임상의는 그들의 환자의 이해를 얻기를 돕기 위하여 그들의 감각을 모두 이용하고, 비전, 접촉 (타악기 및 심백), 청각 (타악기 및 심기) 주로. 냄새는 또한 환자 발생 시 중요한 진단 정보를 제공할 수있습니다(예:개인 위생, 약물 사용 또는 대사 질환). 다행히 맛의 감각은 주로 의학에서 역사적인 유물, 당뇨병 mellitus 소변의 달콤한 맛에 의해 많은 세기 동안 진단 되었다 는 것을 주의 하는 재미 있지만. 경험을 통해 임상의는 수년 동안 수천 명의 환자에 대한 임상 기술의 의도적 인 연습을 통해서만 얻을 수있는 중요한 여섯 번째 감각인 직감본능을 개발합니다. 주로 침대 옆 관찰에 기초한 임상의의 창자 본능은 심각한 질병의 강한 예측자인 것으로 나타났습니다. 이 비디오와 임상 기술 비디오 컬렉션의 다른 비디오는 이 수준의 숙달을 배우는 방법에 대한 단계입니다.
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 accounting for the bulk of the skin examination. In addition to direct observations of the patient, astute clinicians attend to information in the patient’s surroundings and social relationships, as well as the feelings that patients may evoke in them, as part of good patient care.
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!
