HM - general physical examination

what is propaedeutics and what are its 5 components?

• it is a set of initial knowledge and skills needed to assess a person, formulate clinical hypotheses, and guide the continuity of care

• medical history; physical examination; initial clinical reasoning; clinical communication; documentation

• anamnese, exame físico, raciocínio clínico, comunicação clínica e registro

what should be examined during the medical history taking? (anamnese)

chief complaint, history of present illness, personal and family history, medications, allergies, lifestyle habits, psychosocial aspects, and family context

what are the four classic methods of physical examination and what does the physical examination include in addition to diagnostic methods?

• inspection, palpation, percussion, and auscultation

• vital signs and general assessment

What aspects should be considered when preparing for a physical examination?

Patient positioning in bed, adequate lighting, privacy, head-to-toe orientation, overall impression, symmetry, integrity and functionality of the segments, proper documentation, and appropriate timing

What is a basic step before a physical exam?

wash the hands

What basic instruments can be used in a physical examination?

• stethoscope, sphygmomanometer, thermometer, flashlight, measuring tape, tongue depressor, cotton, scale, and anthropometer

What is ectoscopy?

It is the assessment of the patient as a whole before examining each system individually.

What items are evaluated in ectoscopy and what needs to be observed in each of them?

• general condition: Appearance of health, well-being, discomfort

• level of consciousness: Alert, sleepy, confused

• posture: Orthopnea, antalgic position, respiratory discomfort

• coloring: Paleness, cyanosis, jaundice

• hydration and nutrition: Turgor, nutritional status

• hygiene and clothing: Personal care, adapting to the environment

What is the sequence presented for ectoscopy?

general condition; conscience; facies; posture; mobility; nutrition; hydration; mucosal edema; apparent signs; vital signs

How do I register a patient with no general abnormalities on ectoscopy?

Patient in good general condition, conscious, oriented, responsive, hydrated, well-colored, afebrile to the touch, with no apparent signs of respiratory distress, ambulating without assistance (conferir)

Paciente em bom estado geral, consciente, orientado, contactuante, hidratado, corado, afebril ao toque, sem sinais aparentes de desconforto respiratório, deambulando sem auxílio