The previous chapters dealt with the individual organ systems and the history and physical examinations related to each of them. The purpose of this chapter is to help the student assimilate each of the individual examinations into one complete and smoothly performed examination.
Ideally, a complete examination is performed in an orderly, thorough manner with as few movements as possible required of the patient. Most errors in performing a physical examination result from a lack of organization and thoroughness, not from a lack of knowledge. Evaluate each part of the examination carefully before moving on to the next part. The most common errors in performing the physical examination are related to the following:
Errors in technique are related to lack of order and organization during the examination, faulty equipment, and poor bedside etiquette. Errors of omission are common in examinations of the eye and nose; auscultation of the neck vessels, chest, and heart; palpation of the spleen; rectal and genital examinations; and the neurologic examination. Errors of detection are those in which the examiner fails to find abnormalities that are present. The most common errors of this type involve thyroid nodules, tracheal deviation, abnormal breath sounds, diastolic murmurs, hernias, and abnormalities of the extraocular muscles. Errors in interpretation of findings occur most commonly with tracheal deviation, venous pulses, systolic murmurs, fremitus changes, abdominal tenderness, liver size, eye findings, and reflexes. The most common types of recording errors are related to descriptions of heart size and murmurs, improper terminology, and obscure abbreviations.
The following examination sequence is the one the author uses and is demonstrated in the DVD-ROM enclosed with this book. There is no right or wrong sequence. Develop your own approach. Just be sure that at the end of whichever technique you use, a complete examination has been performed.
In most situations, the patient will be lying in bed when you arrive. After introducing yourself and documenting a complete history, you should inform the patient that you are ready to begin the physical examination. Always start by washing your hands.
The reader is advised now to watch the video presentation on the DVD-ROM to review the complete physical examination of the man and the breast and pelvic examinations of the woman. The DVD-ROM will help you put the examination together.
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