Fonte: Jaideep S. Talwalkar, MD, Medicina Interna e Pediatria, Yale School of Medicine, New Haven, CT
A observação e a inspeção são fundamentais para o exame físico e começam no primeiro ponto de contato com o paciente. Embora a observação e a inspeção sejam frequentemente usadas de forma intercambiável, a observação é um termo geral que se refere ao uso cuidadoso dos sentidos para obter informações. A inspeção é um ato limitado ao que se pode observar visualmente, e quando se refere ao exame físico, normalmente se refere a achados na superfície do corpo, e não a comportamentos. Médicos qualificados utilizam todos os seus sentidos para auxiliar na compreensão de seus pacientes, contando principalmente com visão, toque (percussão e palpação) e audição (percussão e auscultação). O olfato também pode fornecer informações diagnósticas importantes durante o encontro do paciente (por exemplo,higiene pessoal, uso de substâncias ou doenças metabólicas). Felizmente, o senso de paladar é em grande parte uma relíquia histórica na medicina, embora seja interessante notar que o diabetes mellitus foi diagnosticado por muitos séculos pelo sabor doce da urina. Através da experiência, os médicos desenvolvem um importante sexto sentido – o instinto – que só pode ser adquirido através da prática deliberada de habilidades clínicas em milhares de pacientes ao longo de muitos anos. O instinto do médico, que é baseado em observações de cabeceira, tem se mostrado um forte preditor de doenças graves. Este vídeo e os outros na coleção de vídeos de habilidades clínicas estão a caminho de aprender esse nível de domínio.
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!
