Fuente: Jaideep S. Talwalkar, MD, medicina interna y Pediatría, Facultad de medicina de Yale, New Haven, CT
Observación e inspección es fundamentales para el examen físico y comienza en el primer punto de contacto con un paciente. Mientras que la observación y la inspección son de uso frecuente alternativamente, es un término general que se refiere al uso cuidadoso de los sentidos para obtener información. La inspección es un acto limitado a lo que se puede observar visualmente y cuando se refiere a la examinación física, se refiere normalmente a resultados en la superficie del cuerpo, en lugar de comportamientos. Los médicos expertos utilizan todos sus sentidos para ayudar a obtener un entendimiento de sus pacientes, confiando en la visión, del tacto (percusión y palpación) y de la audiencia (percusión y auscultación) principalmente. Olor puede también proporcionar importante información de diagnóstico durante el encuentro paciente (p. ej., higiene personal, uso de sustancias o enfermedades metabólicas). Afortunadamente el sentido del gusto es en gran parte una reliquia histórica en medicina, aunque es interesante notar que la diabetes fue diagnosticada durante muchos siglos por el sabor dulce de la orina. A través de la experiencia, los médicos desarrollan un importante sexto sentido – el instinto de gut – que sólo puede ser adquirido a través de la práctica deliberada de habilidades clínicas en miles de pacientes durante muchos años. Instinto de tripa del médico, que se basa en gran parte en observaciones de cabecera, ha demostrado ser un fuerte predictor de enfermedad grave. Este video y otros de la colección video de habilidades clínicas son pasos en el camino a este nivel de dominio de aprendizaje.
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!
