Patient introduction and communication
The examination always begins with establishing rapport. The physician collects biographical data: age, profession, place of work, as well as full name. Addressing the patient by their first and patronymic name is a mandatory requirement of medical ethics, demonstrating respect for the person. During the initial conversation, it is important to assess the internal picture of the disease — that is, to understand how the person subjectively perceives their condition and whether they realize the seriousness of the situation.
Patients with a medical background or those suffering from chronic pathologies for a long time require a special approach. When communicating with such "experienced" patients, it is quite permissible and even useful to use professional terminology and discuss the results of past hospitalizations in detail. It should also be remembered that today many people actively read popular medical literature. They may be well-informed about their problem, but the physician must take into account that the patient's own interpretation of symptoms does not always correspond to reality.
Detailed history taking and preparation for examination
A thorough history taking is the basis of the diagnostic minimum for a specialist in any field. The clinical picture of many chronic diseases becomes clear already at the stage of skilled questioning.
- Medication history: It is not enough simply to record the fact of taking medications. It is necessary to clarify specific drug names, dosages used, and the evaluation of the effectiveness of the therapy administered.
- Medical documentation: The physician is obliged to critically study all available extracts from inpatient and outpatient medical records, as data from previous examinations are of paramount importance.
- Deontological rules: The examination requires creating comfortable conditions. It is necessary to eliminate any external stimuli and obstacles to the conversation, and to prevent the patient from remaining in uncomfortable positions. A crucial ethical rule is to avoid unnecessary and prolonged exposure of the patient's body during the procedure.
Basic logical principles of physical examination
To ensure not a single important detail is missed, the clinical examination is built on two immutable rules that ensure data completeness.
1. The principle "From general to specific" Work begins with assessing the general condition (status praesens communis). The physician checks the level of consciousness, evaluates the body position in space, constitution (body type), facial expression, and performs thermometry and anthropometry. Only after this can one proceed to a targeted study of individual systems and organs.
2. The principle "From simple to complex" Within each system, a strict sequence of physical methods is observed:
- History taking and visual inspection (visus).
- Palpation (palpatio).
- Percussion (percussio).
- Auscultation (auscultatio).
Note: These methods can be organically combined. For example, when examining the digestive or respiratory system, you can immediately ask clarifying questions about dysphagia or epistaxis.
System-based examination algorithm
After assessing the general status, the physician proceeds to a detailed examination. The standard scheme includes the following stages in strict order:
- Skin and visible mucous membranes.
- Subcutaneous adipose tissue.
- Lymph nodes.
- Musculoskeletal system (bones, joints, muscles).
- Respiratory system.
- Cardiovascular system.
- Digestive tract.
- Hepatobiliary zone.
- Urinary system.
- Endocrine system.
- Nervous system and sense organs.
Within a specific system, the examination is always subject to strict anatomical and physiological logic:
- The lymphatic system is examined from top to bottom: occipital $\rightarrow$ submandibular $\rightarrow$ cervical $\rightarrow$ supraclavicular $\rightarrow$ axillary $\rightarrow$ cubital $\rightarrow$ inguinal lymph nodes.
- The respiratory system is evaluated along the path of airflow: nasal passages with paranasal sinuses $\rightarrow$ larynx $\rightarrow$ lower respiratory tract $\rightarrow$ lungs proper.
- The digestive system is studied in the proximal-distal direction: oral cavity (tonsils, teeth, tongue) $\rightarrow$ esophagus $\rightarrow$ stomach $\rightarrow$ small intestine $\rightarrow$ large intestine.
The final, verified diagnosis is always based on a comprehensive assessment: physical examination findings are necessarily compared with the results of modern laboratory and instrumental tests.
Briefly: answers to topical questions
What are the degrees of impaired consciousness when assessing a patient's general status?
When assessing a patient's general status, the following stages of impaired (depressed) consciousness are distinguished:
- Stupor — the ability to answer questions is preserved, but the answers are insufficiently meaningful.
- Obnubilation (drowsiness) — the threshold of perception for external stimuli is increased, mental processes are slowed, and orientation is incomplete. It is divided into moderate and deep obnubilation.
- Sopour — a deep stage of depression where response to verbal address is absent, but response to painful stimuli is preserved.
- Coma — deep central nervous system depression, complete loss of consciousness and reactions to any external stimuli. Depending on severity, moderate, deep, and terminal (transcendent) coma are distinguished.
What are the main types into which human constitution is divided when assessing body build?
When assessing body build, three main constitutional types are distinguished:
- Asthenic — characterized by the predominance of longitudinal dimensions over transverse ones, poor muscle development, long limbs, a narrow and flat chest with an acute epigastric angle.
- Normosthenic — distinguished by a proportional ratio of basic body dimensions, proper structure of the musculoskeletal system, and a straight epigastric angle (about 90°).
- Hypersthenic — characterized by a broad chest and an obtuse epigastric angle (greater than 90°).
What types of percussion are used when examining the respiratory system?
When examining the respiratory system, two main types of percussion are used:
- Comparative percussion — used to detect pathological changes in the physical properties of tissue (condensation, presence of fluid or air) by comparing the sound over anatomically identical, symmetrical areas of the lungs.
- Topographic percussion — used to determine the borders of an organ, their size, shape, and mobility. The technique consists of sequentially tapping areas of the chest until the character of the sound changes (e.g., from pulmonary to dull).
The logic of detailed system examination is easy to remember using the principles of "top to bottom" (for lymph nodes) and "along the physiological tract" (for respiration and digestion).
Class and exam questions
Do modern instrumental methods replace traditional physical examination?
No, the growth in the number of new methods does not negate the importance of traditional ones. Instrumental studies merely clarify and supplement the information a physician obtains during questioning and physical examination.
How to properly communicate with patients who have a medical education?
With medically trained patients, as well as patients with a long history of disease, it is advisable to use medical terminology and discuss the results of their past examinations in detail.
In what sequence are methods applied within a single system?
The principle "from simple to complex" is observed: questioning and visual inspection are performed first, followed by palpation, percussion, and, finally, auscultation.
What else to study on this topic
- Criteria for assessing the patient's general condition (status praesens communis)
- Methodology for forming the internal picture of the disease
- Specifics of analyzing inpatient medical record extracts
- Deontology in the Practice of an Internist
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