Specifics of a medical student's work with a patient
The beginning of clinical practice and patient care requires strict adherence to the interaction algorithm. Physical examination is inextricably linked with establishing proper contact.
The introduction algorithm includes the following steps:
- Introduction. The student must introduce themselves and must find out the patient's first and patronymic name.
- Subjective stage. A brief collection of complaints and clarification of anamnestic details are performed.
- Objective stage. Direct transition to the physical examination, which can be performed either fully or selectively, depending on the clinical situation.
The psychological aspect is a critical component. The patient should perceive the student not just as a learner, but as a full-fledged medical professional whose main goal is to provide help. It is this positioning that justifies the inevitable physical and psychological discomfort that the patient may experience during the examination, palpation, or other medical manipulations.
Concept, role, and diagnostic value
Physical methods occupy a central place in making a diagnosis. Their main task is to provide the clinician with objective data that replace the subjective information obtained during the interview.
The interview only allows for the formation of an initial diagnostic hypothesis. The physical examination, however, allows this hypothesis to be confirmed. The data obtained are of not only diagnostic but also prognostic and therapeutic significance, determining further patient management tactics.
The fundamental rule of this stage is the principle of targeting. Practice shows that many specific symptoms are detected only when the physician deliberately and purposefully looks for them, presupposing their possible presence based on the complaints.
Classification of main methods
The basic physical methods that a clinician performs without using complex devices (using only basic tools like a stethoscope to enhance hearing) include:
- Inspection (observation) — visual assessment of the patient's condition.
- Palpation (feeling) — using the sense of touch to assess the properties of tissues and organs.
- Percussion (tapping) — analysis of sound phenomena arising from tapping on the body surface.
- Auscultation (listening) — perception of sounds naturally produced during the functioning of internal organs.
Dynamic observation: time factor and therapy
The physical presentation of a disease is not static. The time factor is of immense importance: a whole range of clinical signs is completely absent at the onset of the disease and begins to manifest only in its later stages. Therefore, a single examination is often insufficient.
In addition, dynamic observation requires accounting for the impact of ongoing therapy. The physician must carefully monitor symptoms and remember the risk of developing iatrogenic conditions. Some objective changes may not be a manifestation of the progression of the underlying disease, but rather a side effect of prescribed medications.
Limitations of physical examination
Despite their importance, traditional methods (inspection, palpation, percussion, and auscultation) have a number of serious limitations:
- Unconscious state of the patient. In this situation, collecting an anamnesis is impossible. Physical methods combined with laboratory and instrumental data become the only available sources of medical information.
- Low informativeness. In a number of complex clinical situations, the capabilities of the physician's senses are exhausted, and traditional methods prove to have low efficacy.
- Priority of paraclinical methods. Sometimes the primary, life-saving information is provided exclusively by supplementary (paraclinical) research methods. A classic example: in the development of a coma, determining blood glucose levels becomes of paramount importance, which cannot be done using palpation or inspection.
Briefly: answers to topical questions
What is the purpose of internal organ percussion?
Percussion of internal organs is performed to determine their anatomical borders and identify pathological changes in tissues. Depending on the diagnostic tasks, the method is divided into two main types:
- Comparative percussion — performed to assess the state of underlying organs and identify pathological changes in the physical properties of tissue (induration, presence of fluid or air) by comparing the sound over strictly symmetrical areas.
- Topographic percussion — used to determine the borders of organs, their size, shape, and degree of mobility, as well as to identify the dimensions and localization of pathological formations.
What is understood by iatrogenesis during an objective patient examination?
During an objective examination and dynamic observation, iatrogenic manifestations should be understood as reactions and symptoms associated not with the disease itself, but with the actions of the medical worker or treatment:
- Psychogenic reactions — fear, irritation, psychoneurosis arising from failure to comply with deontological norms, including the use of incomprehensible or frighteningly ambiguous expressions in the patient's presence.
- Therapy-related symptoms — signs that may be a side effect of medications rather than a manifestation of the underlying disease.
What types and rules of palpation exist?
Superficial and deep palpation are distinguished, performed with warm hands with the patient in a specific position. The examination always starts from the area distant from the pain focus, moving from superficial palpation to deep palpation:
- Superficial (exploratory) palpation — performed without significant pressure to identify tenderness, muscle tension, hernias, and rectus abdominis diastasis; includes comparative and systematic stages.
- Deep palpation — designed to examine deeply located organs. The V.P. Obrazцов method includes a static phase (contact with the skin) and a dynamic phase (pressure and sliding off the organ).
What sounds are heard during lung auscultation?
During lung auscultation, sound vibrations are heard, which are divided into basic respiratory sounds and adventitious sounds. Sound phenomena are best evaluated during inspiration (inspirium), but expiration (expirium) also has diagnostic significance.
- Main sounds — vesicular, weakened, harsh, and bronchial breathing.
- Adventitious (additional) sounds — dry and moist rales, crepitation, and pleural friction rub. Special methodological techniques, such as the cough test, are used for the differential diagnosis of rales and crepitation.
To remember the sequence of classical methods, use the rule "OPPA": Observation (Inspection), Palpation, Percussion, Auscultation.
Class and exam questions
Exclusively after completing the subjective stage: introduction, gathering complaints, and taking the medical history.
Exclusively after completing the subjective stage: introduction, collecting complaints, and clarifying the anamnesis. The interview provides a hypothesis, and the physical examination provides objective data to confirm it.
This is a regularity according to which many clinical symptoms are discovered by a physician only when they specifically look for them, presupposing their presence beforehand.
This is a regularity according to which many clinical symptoms are discovered by a physician only when they specifically look for them, presupposing their presence beforehand.
Yes, if the patient is in an unconscious state. In such cases, the interview is impossible, and the diagnosis is made solely on the basis of physical, laboratory, and instrumental data.
Yes, if the patient is in an unconscious state. In such cases, the interview is impossible, and the diagnosis is made solely on the basis of physical, laboratory, and instrumental data.
What else to study on this topic
- Technique and rules for general and localized inspection
- Types of palpation (superficial, deep) and their purpose
- Physical principles of percussion and types of percussion sounds
- Rules for heart and lung auscultation
- Algorithm for differential diagnosis of iatrogenic complications
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