Preparation for the Examination

The physical examination usually begins after the history has been documented. You should have a portable case designed to contain all the necessary equipment, which includes the items listed in Table 7-1.

Place the equipment on the patient's night table or bed stand. By laying out all the tools, you are less likely to forget to perform a specific examination. It is preferable to use daylight for illumination because skin color changes may be masked by artificial light. The patient's curtains should be closed for privacy at the start of the interview.

Before examining the patient, wash your hands, preferably while the patient is watching. Washing with soap and water is an effective way to reduce the transmission of disease. Be sure to lather for 10 seconds or more. If soap and water is not available, it is also acceptable to use an alcohol-based hand hygiene product unless there is visible soiling.

The patient should be wearing a gown that opens at the front or back. Pajamas are also acceptable. It is most important to consider the comfort of the patient. You should allow the patient the use of pillows if requested. This is one of the few relationships in which individuals are willing to expose themselves to a stranger after only brief contact.

It is important that you become facile in each organ system examination. Incorporate the individual evaluations into the complete examination with the least amount of movement

Table 7-1 Equipment for Physical Examination

Required

Optional

Available in Most Patient Care Areas

Stethoscope Oto-ophthalmoscope Penlight Reflex hammer Tuning fork: 128 Hz Safety pins* Tape measure Pocket visual acuity card

Nasal illuminator{ Nasal speculum Tuning fork: 512 Hz

Sphygmomanometer Tongue blades Applicator sticks Gauze pads Gloves Lubricant gel

Guaiac card for occult blood Vaginal speculum

*A new pin should be used for each patient as a precaution against transmission of the human immunodeficiency and hepatitis viruses. As an alternative, a broken wooden applicator stick may be used. {Attachment for the otoscope handle.

of the patient. Regardless of age, patients tire quickly when asked to ''sit up,'' ''lie down,'' ''turn on your left side,'' ''sit up,'' ''lie down,'' and so on. You should perform as much of the examination as possible with the patient in one position. It is also important that the patient never be asked to sit up in bed without support for any extended period.

By convention, the examiner stands to the right of the patient as the patient lies in bed. The examiner uses the right hand for most maneuvers of the examination. It is common practice that even left-handed individuals learn to perform the examination from the right side, using the right hand. Each of the subsequent chapters on organ systems discusses the placement of hands.

Although it is necessary for the patient to disrobe completely, the examination should be carried out by exposing only the areas that are being examined at that time, without undue exposure of other areas. When a woman's breast is examined, for example, it is necessary to check for any asymmetry by inspecting both breasts at the same time. After inspection has been completed, you may use the patient's gown to cover the breast not being examined. The examination of the abdomen may be done discreetly by placing a towel or the bed sheet over the genitalia. Examination of the heart with the patient in the supine position may be performed with the right breast covered. Respecting the patient's privacy goes a long way in establishing a good doctor-patient relationship.

While performing the physical examination, you should continue speaking to the patient. You may wish to pursue various parts of the history, as well as tell the patient what is being done. You should refrain from comments such as ''That's good'' or ''That's normal'' or ''That's fine'' in reference to any part of the examination. Although this is initially reassuring to the patient, if you fail to make such a statement during another part of the examination, the patient will automatically assume that there is something wrong or abnormal.

The following chapters discuss the individual organ system examinations. Chapter 22, Putting the Examination Together, then summarizes a method of combining all the individual evaluations into one smooth, continuous examination.

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