Source: Jaideep S. Talwalkar, 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'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'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.
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
- Note the general state of health in the patient. Is the patient's appearance consistent with the stated age? Does the patient appear fit and healthy or weak and frail?
- Note their level of consciousness (e.g., awake, alert, or somnolent).
- Observe for signs of pain. Note facial expressions, guarded movements, diaphoresis, etc.
- Observe for signs of respiratory distress. Can the patient speak in complete sentences without difficulty? Is the patient "tripoding" (leaning forward with the arms supported)? Are visible accessory muscles of respiration being used?
- Observe for signs of emotional distress. Is the patient fidgeting excessively, exhibiting generalized psychomotor slowing, or crying? Is eye contact appropriate?
- Make note of clothing, jewelry, tattoos, grooming, hygiene, and any other features that may provide insight into the patient's medical, social, and emotional situation.
- 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.
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.
- 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).
- At each site examined, also note the degree of hydration (i.e. dryness or oiliness), turgor, and texture of the skin.
4. Mental status exam
- Observe the patient's appearance and behavior including posture, dress, facial expressions, motor activity, mannerisms, physical characteristics, and reactions to the questions asked during the exam.
- Note the fluency, rate, and volume of speech.
- Assess the patient's affect, including the range, appropriateness, intensity, and ability. The examiner's objective assessment of affect should be compared to the patient's subjective report of mood, which is obtained via direct inquiry.
- Evaluate the patient's thought process, which is composed of elements, such as level of organization, presence of tangentiality, loose associations, and "flight of ideas."
- Evaluate the patient'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.
- Note the patient'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.
- Use specific questions to assess for suicidality and homicidality.
5. Ancillary observations
- Certain examination locations offer opportunities to learn about a patient'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's life outside of the patient role.
- 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?
- 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'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.
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!
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Applications and Summary
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.
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