Chapter 20

1. Overview of Patient Examination

A complete patient examination consists of three core components:

• Health History: Subjective data regarding past and present health status.

• Physical Examination: Systematic examination of each body system.

• Laboratory and Diagnostic Tests: Objective tests to evaluate bodily functions and tissues.

Purposes of Examination:

• Determine overall health status.

• Establish diagnosis and prescribe treatment.

• Observe changes in illness following treatment.

• Early disease detection and health promotion.

• Prerequisites for employment, sports participation, summer camp, or school admission.

2. Key Medical Terminology

• Final Diagnosis: Scientific determination of a patient's condition based on health history, physical examination, lab tests, and diagnostic procedures; provides the logical basis for treatment and prognosis.

• Clinical Diagnosis: Tentative diagnosis based solely on health history and physical examination prior to receiving lab/diagnostic test results.

• Differential Diagnosis: Determination of which of two or more diseases with similar symptoms is causing the illness (e.g., performing a strep test to differentiate streptococcal sore throat from pharyngitis).

• Prognosis: Probable course and outcome of a patient's condition and prospects for recovery.

• Risk Factor: Physical or behavioral condition increasing the likelihood of developing a specific condition (e.g., smoking as a risk factor for lung cancer and heart disease).

• Screening Test: Test conducted on asymptomatic individuals for early detection of health conditions.

• Acute Illness: Illness characterized by sudden, rapid onset of severe symptoms that subside in a short period ($\le 6\,\text{months}$) (e.g., influenza, pneumonia, fractures).

• Chronic Illness: Illness characterized by symptoms persisting longer than $6\,\text{months}$, progressing slowly, and often manageable rather than curable (e.g., diabetes mellitus, hypertension).

• Therapeutic Procedure: Treatment performed to eliminate a condition or promote recovery (e.g., medication administration, ear irrigation).

• Laboratory Test: Clinical analysis of body substances to obtain objective data (e.g., urinalysis, blood glucose test).

• Diagnostic Procedure: Procedure performed to assist in diagnosis (e.g., electrocardiography, mammography, colonoscopy).

3. Adult Health Screening Guidelines

• Blood Pressure: Every year starting at age $3$.

• Cholesterol Levels: Every $4\,\text{to}\,6\,\text{years}$ beginning at age $20$.

• Cervical Cancer: Pap test every $3\,\text{years}$ (ages $21-29$); Pap test and HPV test every $5\,\text{years}$ (ages $30-65$).

• Blood Glucose Level: Every 3 starting at age $45$.

• Testicular Self-Examination: Monthly starting at age $15$.

• Fecal Occult Blood Test: Annually starting at age $45$.

• Colonoscopy: Every $10\,\text{years}$ starting at age $45$.

• Prostate Cancer Screening: Offered annually starting at age $50$ (for men with life expectancy $\ge 10\,\text{years}$).

• Mammography: Optional annual screening at ages $40-44$; annual screening for ages $45-54$; every $2\,\text{years}$ or annual screening for ages $55+$.

• Electrocardiogram (ECG): Baseline recording starting at age $40$.

4. Preparation of the Examining Room and Equipment

Room Preparation Guidelines

• Keep room free of clutter, well lit, well ventilated, and maintained at a comfortable temperature.

• Clean and disinfect examination tables, countertops, faucets, and door handles daily.

• Change table paper and replace disposable gowns and drapes between patients.

• Empty waste receptacles and biohazard containers in accordance with OSHA standards.

• Ensure all instruments are clean, functional, and organized for easy access before the examination.

Common Examination Equipment

• Sphygmomanometer: Measures blood pressure.

• Stethoscope: Auscultates internal body sounds (heart, lungs, bowel).

• Otoscope: Inspects external ear canal and tympanic membrane.

• Ophthalmoscope: Inspects internal eye structures.

• Speculum: Opens body orifices/cavities for viewing (e.g., nasal, vaginal).

• Percussion Hammer: Evaluates neurological reflexes.

• Tuning Fork: Tests hearing acuity.

• Tongue Depressor: Depresses tongue for mouth and pharynx examination.

5. Patient Preparation and Coaching

Patient Identification and Preparation

• Identify patient using full legal name and date of birth; avoid asking leading questions (e.g., "Are you Mary?").

• Measure and document vital signs, weight, and height.

• Instruct patient to void before exam (collect urine specimen if required).

• Provide clear disrobing and gowning instructions, maintaining patient privacy.

Patient Coaching Principles

• Focus on goal-oriented, practical information ("necessary to know" vs. "nice to know").

• Present information concisely; repeat and reinforce key points.

• Engage multiple learning styles (reading, listening, doing) using handouts, demonstrations, and discussions.

6. Mensuration (Weight, Height, and BMI)

• Mensuration: The process of measuring the patient.

• Balance Beam Scale Guidelines:

  • Ensure scale is balanced at zero before measuring.

  • Have patient remove shoes and heavy outer garments.

  • Lower calibration bar is in $50\,\text{lb}$ increments; upper bar is in $1\,\text{lb}$ and $\frac{1}{4}\,\text{lb}$ increments.

  • Read weight measurement to the nearest $\frac{1}{4}\,\text{lb}$.

• Weight Conversions:

  • Pounds to kilograms:     $\text{Weight in kg} = \frac{\text{Weight in lb}}{2.2}$     Example: $136\,\text{lb} \div 2.2 = 61.8\,\text{kg}$

  • Kilograms to pounds:     $\text{Weight in lb} = \text{Weight in kg} \times 2.2$     Example: $75\,\text{kg} \times 2.2 = 165\,\text{lb}$

• Height Measurement: Read to the nearest $\frac{1}{4}\,\text{in}$; convert to feet and inches:   $\text{Feet} = \frac{\text{Inches}}{12}$   Example: $64\,\text{in} \div 12 = 5\,\text{ft}\,4\,\text{in}$

• Body Mass Index (BMI) Categories:

  • Underweight: $< 18.5$ (Severely underweight: $< 16$; Moderately underweight: $16 - 16.9$ ; Underweight: $17 - 18.49$)

  • Healthy weight: $18.5-24.9$

  • Overweight: $25.0 - 29.9$

  • Obese Class I: $30.0 - 34.9$

  • Obese Class II: $35.0 - 39.9$

  • Obese Class III: $\ge 40.0$

7. Body Mechanics

• Definition: The use of correct muscles to maintain proper balance, posture, and body alignment during movement.

• Spinal Curvatures: Cervical, thoracic, lumbar, and sacral curvatures maintain spine resilience.

• Spinal Conditions: Degenerative disc disease (deterioration and hardening of intervertebral discs) and herniated discs (bulging or ruptured discs).

• Key Principles:

  • Maintain good physical posture; keep back straight and head erect.

  • Bend at knees and hips when lifting (never bend at the waist).

  • Lift using strong arm and leg muscles, holding objects close to body at waist level.

  • Avoid reaching farther than $14\,\text{in}\,\text{to}\,18\,\text{in}$ away.

  • Pivot the entire body to turn; avoid twisting the spine.

  • Maintain a wide base of support with feet $6\,\text{in}\,\text{to}\,8\,\text{in}$ apart.

8. Cultural Competence in Patient Care

• Cultural Awareness: Observing and acquiring knowledge of diverse cultural values.

• Cultural Sensitivity: Respect and appreciation for cultural diversity.

• Cultural Competence: Incorporating a patient's cultural background into health care delivery.

• Key Guidelines:

  • Respect patient beliefs regarding blood collection, dietary practices, and modesty.

  • Avoid cultural stereotyping.

  • Address patients formally by last name unless permitted otherwise.

  • Speak clearly and slowly in a normal volume for patients with limited English fluency.

  • Respect cultural lines of authority and eye contact preferences.

9. Patient Examination Positions

• Sitting: Examines head, neck, chest, upper extremities, and vital signs.

• Supine: Patient on back; examines head, chest, abdomen, and extremities.

• Prone: Patient on stomach; examines back and hip joint extension.

• Dorsal Recumbent: Patient on back with knees bent and feet flat on table; used for vaginal/rectal exams or patients with lower back discomfort in supine position.

• Lithotomy: Dorsal recumbent position with feet in stirrups; used for vaginal, pelvic, and rectal exams.

• Modified Left Lateral Recumbent (Sims): Patient on left side with right leg flexed sharply; used for rectal exams, flexible sigmoidoscopy, and enemas.

• Knee-Chest: Patient kneeling with chest and head on table, buttocks elevated; used for rectal and proctoscopic exams.

• Fowler: Table back elevated to $45^\circ$ (semi-Fowler) or $90^\circ$ (full Fowler); used for respiratory/cardiovascular patients or blood collection.

10. Wheelchair Transfer Guidelines

• Position wheelchair at a $45^\circ$ angle to table on patient's stronger side.

• Lock wheelchair brakes and fold back footrests.

• Wrap transfer (gait) belt snugly around patient's waist over clothing.

• Assist patient to standing position using proper body mechanics (legs bent, wide base of support, back straight).

• Pivot patient toward table, position knees against table edge, and lower patient gently into sitting position.

11. Physical Assessment Techniques

• Inspection: Visual observation of patient (color, symmetry, skin lesions, posture, gait, anxiety).

• Palpation: Examination of body structures using sense of touch.

  • Light Palpation: Gently depressing $\approx \frac{1}{2}\,\text{in}$ to detect tenderness.

  • Deep Palpation: Depressing with two hands to evaluate internal organs/lumps (e.g., bimanual pelvic exam).

• Percussion: Tapping body surface with fingers to produce sound vibrations indicating underlying organ density (dense organs produce dull sounds; air-filled organs produce hollow sounds).

• Auscultation: Listening to body sounds using a stethoscope (diaphragm for high-pitched sounds like lung/bowel; bell for low-pitched sounds like heart/vascular).