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General Plan of Patients

Examination


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Clinical semiology is the science that studies signs and

symptoms of disease, as are grouped into syndromes,with the goal of building diagnostics. Used as a workorder is known as clinical method. This method includes questioning,

physical examination, analysis of laboratory and diagnostic imaging. diagnosis treatment

The registration of this information is known as MedicalRecords.
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Interview (questioning)


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I. Identifications and vital statistics

Name,Date of birth,

Place of birth

Sex,Nationality,

Race,

Residence,Marriage status, Occupation

Source of information: patient, others

Interpreter


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Complains

Main complains (are typically for one orfew diseases), for example cough,dyspnea, pain in the chest can be present

in pneumonia and acute bronchitis

General complains (can be meet in manydiseases), for example fever, weakness

(fatique), headache can present in manydiseases


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History of the diseases (or

Anamnezis morbi)

Onset of the disease

Evolution of the disease

Previous treatment and efficacyPrevious investigations

Cause of the last excerbation

Cause of the present appearance in thehospital


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History of the life

(or Anamnesis vitae)

Essential biografical data


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Past history

Previous illnesses

Previous operations, injuries

Previous hospitalization

Infectious diseases

General health issues

Appetite, Body weight, Weight loss

Stool habits

Urine complaints


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Social history

Social status

Economy status

Marital status

Habits

Diet

SmokingAlcoholDrugs


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Family history

Parents, Siblings

Age and health

Death and causes

History of diseases

Hypertension, Hearth disease, Diabete

Obesity, Endocrine disorders

Tuberculosis, Syphilis, AIDS

Malignancies

Alcoholism, Mental disturbances, etc.


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Clinical examination

General examination

Pulmonary system

Cardiovascular system

Digestiv system

Urogenital system

Blood system

Endocrin system

Nervous system


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Physical examination

It is the process of examining the patients bodyto determine the presence or absence ofphysical problems

The goal of the physical examination is to obtainvalid information concerning the health of the

patient

The examiner must be able to identify, analyze,and synthesize the accumulated information into

a comprehensive assessment


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Important aspects of physical

examination---physician

Wash your hands, preferably while the

patient is watching

Washing with soap and water is an

effective way to reduce thetransmission of disease


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Sequential

Conducted in head to toe order: head ---neck---chest---abdomen---spine---

extremities---anal---genital---nervesystem

Patients tire quickly when asked to sit

up, lie down, turn on your left side,

sit up, lie down and so on


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examination---patient

The patient should be made ascomfortable as possible during theexamination

The patient should be properlydraped


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examinationWhere is the bed placed?

When possible, the examining table/bed besituated so that the examiner has access toboth sides of the patient

An ideal arrangement is to have the tablelocated in the center of the examining room


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examinationWhere does the examiner stand?

Stand right side of the bed

Exam with one righthand


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examinationThe examiner should continue speaking tothe patient

Showing care to his disease and answer topatients questions

It can not only release patients nervousness,but also help to establish the goodphysician-patient relationship


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Precaution to take

The use of gloves should provide adequateprotection when performing the physical

examination or when handling blood-soiled orbody fluid-soiled sheets or clothing

Gloves should be worn when examining anyindividual with exudative lesions or weepingdermatitis


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Precaution to take

Hands or other contaminated skin surfaces shouldbe washed thoroughly and immediately itaccidentally soiled with blood or other body fluids

All sharp items, such as needle, must be handledwith extraordinary care to prevent injuries

A patient may be in isolation or on specialprecautions if he/she is suffering from a contagiousdisease


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METHODS IN THE PHYSICAL EXAMINATION

General measures:

Inspection Palpation

Percussion

Auscultation

Smelling


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Physical Examination TechniquesInspection = observation of the client (may at times include useof penlight, otoscope, and/or ophthalmoscope)Palpation = use of touch to assess client Use light pressure first to assess body surface Next use deep palpation to assess underlying structures

Assess areas of pain/tenderness/discomfort lastPercussion= tapping fingers on the clients skin using shortstrokes to assess underlying structures to determinesize/density/locationAuscultation = use of hearing to assess client


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Inspection

Method of observation used during physical examination

First step in examining a patient or body part

It includes a general survey of the patients

mental status posture

body movement gaitbreath odor skin

speech stature

state of nutrition


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How to inspect

Make sure the room is in a comfortabletemperature

Use good lighting, preferably sunlight

Look and observe before touching

Completely expose the body part youare inspecting while draping the rest

Compare symmetrical body parts


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Hepatic coma


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Posture (or position in the bed)

Active

Passive ( for example coma)

Forced (for examplein brocnchial asthma)


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Skin AssessmentSkin characteristics Temperature

Compare upper and lower extremities, and bilaterallyExcessive warmth may indicate fever, whereas excessive coolnessmay indicate poor circulation, shock, or hypothyroidism

MoistureShould be warm and dry (but excessively dry skin may indicatedehydration)

ColorVaries per age, culture, ethnicityMongolian spots = blue-black areas that are sometimes present onthe lower back or buttocks of African American, Native American,and Asian babiesCapillary hemangiomas (stork bites) = small, irregular pink-redareas present around the face/neck of newborns


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Common Skin Color VariationsColor

VariationDescription Significance

Pallor Loss of pink/yellow tonesor extreme paleness inlight-skinned clientsLoss of red tones in dark-skinned clients

Poor circulation, low hemoglobin levelAssess via oral mucosa, conjunctiva, nail beds, solesof feet, palms of hands

Cyanosis Blue-gray coloration ofthe skin; ashen

Central cyanosis is R/T hypoxiaMay be seen in extremities after exposure toextreme cold

Jaundice Yellow-orange cast to theskin Associated with liver disordersAssess via sclera, oral mucosa, palms and solesFlushing Widespread, diffuse areaof redness Results from fever, excessive room temperature,sunburn, polycythemia, vigorous exerciseErythema A reddened area Associated with rashes, skin infections, prolongedpressure on the skinEcchymosis Bruised (blue-green-yellow) area Bruising may indicate physical abusePetechiae Tiny, pinpoint red or

reddish-purple spotsExtravasation of blood into the skinMay be associated with a disorder or medication


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Cyanosis


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Pallor


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Jaundice


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Types of jaundice

Mechanical

Hemolitic

Parenchymatus


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Erythema


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Petechiae


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Skin Assessment (contd)Skin characteristics (contd) -- Texture

Should be smooth and softMay be affected by exposure, age, endocrine disorder, and impairedcirculation

TurgorRefers to the elasticity of the skin, and indicates hydration statusSkin that takes 3 seconds or longer to return to its original position istermed tenting, and indicates dehydration

LesionsPrimary = result of disease or irritationSecondary = develops from primary lesions as a result of continuedillness, exposure, injury, or infectionEvaluate for size, shape, pattern, tenderness, pain, etc


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ASSESSMENT OF THE SKIN


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Skin characteristics (contd) --

EdemaExcessive amount of fluid in the tissuesCommon in congestive heart failure, kidney disease, peripheralvascular disease, or low albumin levelsPitting edema is graded on a 0 to +4 scale

Assessing Pitting EdemaTrac

eMinimal depression noted when pressure applied

+1 Application of pressure creates a depression of about 2 mm; no visibledistortion; rapid return of skin to position+2 Application of pressure creates a depression up to 4 mm in depth thatdisappears in about 10-15 seconds+3 Application of pressure creates a depression of approximately 6 mm in depththat lasts about 1-2 minutes; area appears swollen+4 Application of pressure creates a depression up to 8 mm in depth thatpersists for about 2-3 minutes; area is grossly edematous


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Differential diagnosis between

cardiac and renal edema

Cardiac Renal

Cyanotic Pallor

Occurs in the evening Occurs in the morning

Cold Warm

Hard Soft

Diuretics + Diuretics -

From lower extremities Diffuse


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Hi ti


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Hirsutism


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Allopecia


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Assessing the NailsCondition of Nail/Nail Bed Indications or ConcernsPale or cyanotic beds Circulatory or respiratory disorders that result in anemia orhypoxiaHalf-and-half nails Appears as a distal band of reddish-pink that covers 20-60% ofthe nail; caused by low levels of albumin or renal disease Mees lines Appears as transverse white lines in the nail bed; results fromsevere illnessSplinter hemorrhages Small hemorrhages under the nail bed that are associated withbacterial endocarditis or traumaBlack nails Related to blood under the nail--occurs after a local traumaWhite spots Zinc deficiencyClubbing Refers to an angle of the nail bed that is 180 or more (normal is

160); associated with hypoxic states (i.e. chronic lung disease)Spooning Iron deficiencyThickened nails Poor circulation or fungal infectionBrittle nails Hyperthyroidism, malnutrition, calcium and iron deficiencySoft, boggy nails Poor oxygenation

Cl bbi (COPD Ci h i


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Clubbing (COPD, Cirrhosis,

Congenital Valvular Lesions)

Janeway lesions and splinter hemorrages


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Janeway lesions and splinter hemorrages

(bacterial endocarditis)


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A l


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Acromegaly


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Assessing the EyesExternal structures PERRLA (pupils equal, round, reactive to light and accommodation) Conjunctiva: smooth, glistening , and peach in color Sclera: smooth, glistening, and blue-white in color Cornea: transparent, smooth, and moist

Visual acuity Snellen chart measures distance vision

Myopia = diminished distance vision Near vision measured by having client read newsprint from a distance

of 14 inchesHyperopia = diminished near visionPresbyopia = decrease in near vision due to the aging process


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Assessing the EarsOtic structures

External ear = collects and conveys sound waves; protects the middleear from the external environmentOtitis externa = infection of the outer ear that may result in a painfulauricle or tragus

Middle ear = consists of the tympanic membrane, eustachian tube, andthe ossicles; conducts sound waves from the external ear to the innerear

Otitis media = middle ear infection that may present as tendernessbehind the ear

Inner ear = hearing and equilibriumCerumen (ear wax) should be present, but should not occlude the ear canal May be black, dark red, gray, or brown in color


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Assessing the NoseSinus areas should be nontender uponpalpationNasal passages should be pink and moist, andfree from drainage or lesionsSeptum should be symmetricalAssess clients ability to breathe freely throughboth sides of the noseSense of smell is diminished in older adultsdue to atrophy of olfactory nerve fibers


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Assessing the Mouth and NeckBuccal mucosa should be smooth, moist, and pink:

Common Buccal/Oral VariationsCondition of Mouth/Oral

Mucosa Indications or ConcernsPaleness Anemia or inadequate oxygenationCanker sores Painful vesicles that erupt with allergies and stress Gingivitis Red, swollen or spongy, bleeding gingiva with receding gum lines;

tenderness may be present; this is a sign of periodontal diseaseParotitis Inflammation of the parotid salivary glandStomatitis Inflammation of the oral mucosaLeukoplakia Thick, elevated white patches that do not scrape off; may be

precancerous lesionsThrush White, curdy patches that scrape off and bleed caused by a fungal

infectionAphthous ulcers Small, painful vesicles with a reddened periphery and white/pale

yellow base; caused by viral infection, stress, or trauma


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Mouth and Neck Assessment (contd)Mouth/lips should be symmetrical

Assess for swelling or drooping Assess for difficulty swallowing

Assess teeth for dentures, obvious caries, loose teethTongue should be moist, symmetrical, slightly rough, smooth,pink, and freely movable Abnormal findings include deviation from midline; glossitis

(inflammation of the tongue); limited mobility; dry, furrytongue related to dehydration; black, hairy tongueassociated with fungal infections; swelling, nodules, orulcers

Palpate neck for tenderness/nodules, thyroid Inspect for swelling, ROM

L h d


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Lymph nodes


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Palpation of lymph nodes

Dimensions

Mobility

Tenderness

Confusion


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Lymph nodes


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Lymph nodes


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Thyroid gland


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Muscle system assessment


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Muscle system assessment (con' d)

Shape (development of muscle)

Tenderness

Mobility

Muscle power (tonus of muscles)


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Palpation of the bones and joints


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Assesssment of joints and bones

Shape

Dimensions

Temperature

Mobility

Very often joints are affected in diseases

of connective tissue ( rheumatic fever,lupus erythematosus (SLE), rheumatoidarthritis, sclerodermia, dermatomyositis)


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Rheumatic fever,


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ANTHROPOMETRY


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BODY MASS INDEX


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BODY MASS INDEX


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CELEBRITIES BMI

Ashley Judd: 5'7 125 bmi: 19.6Anna Kournikova, 5'8", 113 pounds, BMI 17.2Adriana Lima, 5'10", 125 pounds, BMI 17.9Britney Spears: 5'5", 105 bmi: 17.5Beyonce Knowles, 5'5", 150 pounds BMI 25Christina Aguilera: 5'2 100 bmi: 18.3Cameron Diaz, 5'9", 120 pounds, BMI 17.8Calista Flockhart, 5'6", 97 pounds, BMI 15.5

Denise Richards 5'6", 119 pounds, BMI 18.8Faith Hill, 5'8", 121 pounds, BMI 18.4Fiona Apple, 5'3", 105 pounds, BMI 18.6Gwyneth Paltrow: 5'9", 112 bmi: 16.5Giselle Bundchen, 5'11", 115 pounds, BMI 16Geri Halliwell, 5'2", 99 pounds, BMI 18.2Heidi Klum: 5'9 119 bmi:18Heather Locklear: 5'5", 105 bmi:17

Jennifer Lopez: 5'6", 120 bmi: 19.3Julia Roberts: 5'10", 120 bmi: 17.3James King, 5'9", 120 pounds, BMI 17.7

Jennifer Aniston, 5'6", 110 pounds, BMI 17.8Kirsten Dunst, 5'4", 100 pounds, BMI 17.2Katie Holmes, 5'8", 120 pounds, BMI 18Kate Moss, 5'7", 107 pounds, BMI 17.3Lisa Kudrow, 5'7", 123 pounds, BMI 18.8Mandy Moore, 5'8", 108 pounds, BMI 16.4

Mayra Hornbacher, 5"1, 52 pounds, BMI9.8Nikki Taylor: 5'10" 118 BMI 16.9Nicole Kidman: 5'10 120 bmi: 17.2Nicole Richie: 51 83 lbs bmi: 15.3Naomi Campbell, 5'10", 110 pounds, BMI15.8

Neve Campbell, 5'5", 123 pounds, BMI 20.5Pamela Anderson: 5'7 105 bmi: 16.4Paris Hilton, 5'8", 115 pounds BMI 17.5Reese Witherspoon: 5'6", 122 bmi: 19.6Salma Hayek: 5'7", 115 bmi: 18Sandra Bullock: 5'8", 110 bmi: 16.7Sarah Michelle Gellar: 5'3", 98 bmi: 17


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WAIST CIRCUMFERENCE

Waist circumference (distance around the waist)is a common measure used to check for fat heldaround the stomach. Having extra body fataround the stomachmore than 35 in (89 cm)

for women and more than 40 in (102 cm) formenincreases your risk of heart disease anddiabetes.

How to measure waist circumference: Place a

tape measure around your body at the top ofyour hipbone. This is usually at the level of yourbelly button, as shown in the picture above.


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WAIST CIRCUMFERENCE


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WAIST CIRCUMFERENCE


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