Physical examination: connect an observed sign with the clinical question
Physical examination provides observed data to build upon the history taken from the patient. Physical examination can direct future questioning and assessments. However, physical examination and the patient's symptoms and circumstances are inextricably linked. This guide will introduce the interpretation process as opposed to instructing the unaided performance of a physical examination.
A sign and a symptom describe different kinds of information
A symptom is based on the patient's subjective report of their experience. A sign is an observed finding recorded during assessment. Establishing this distinction allows both sources of information to be identified and described without determining which type of information has greater importance. In many instances, the patient's history directs which area(s) of the body to assess, and, conversely, findings from a physical examination can lead to additional questioning regarding timing, function, etc., as well as provide additional insight into previously reported symptoms.
To assist with your preparation for a written exam, create a hypothetical scenario describing discomfort and differentiate the patient's self-reported experience from the observations/findings recorded by a clinician. Avoid filling in gaps with assumptions. If the report does not indicate if a characteristic was evaluated, document that as unknown. An unmentioned feature is different from a finding documented as absent.
The person needs to understand the examination
Prior to conducting an examination, the clinician will explain what is going to occur and obtain appropriate informed consent. Privacy, comfort, and dignity are all aspects of this process. Certain examinations require a chaperone or special arrangements. The explanation should allow sufficient time for the patient to ask questions and/or request that the examination cease due to discomfort.
You can complete a training exercise explaining the procedure of an examination without physically completing it. Explain the purpose of the examination in plain English and explain how the patient will be positioned or engaged. Do not assume that previous discussion of symptoms constitutes permission to perform all possible examinations. What is necessary in terms of explanations varies according to local professional guidelines and specific circumstances.
One finding rarely supplies the whole account
Measurements or physical signs are interpreted together with the history, additional findings, and factors present while making the evaluation. There are multiple potential diagnoses that may result in the presentation of identical signs. Some findings are affected by posture/activity/method of collection. Therefore, a single observation requires more contextualization than simply identifying it as either normal or abnormal.
Compare two hypothetical scenarios that have the same findings but different histories. Why might the interpretation differ? What additional information would be useful? By doing so, you can help differentiate collecting evidence from confirming your preferred hypothesis. Additionally, excessive reliance on a familiar sign can distract from consideration of the wider clinical picture.
Documentation should distinguish evidence from interpretation
A clear record documents what was assessed and what was discovered, using terminology that another health care provider could comprehend. The interpretation of the results and subsequent action plan should be easily discernible. All uncertainty should remain apparent in the documentation. Documentation loses value when an overall term obscures specifics regarding what components of an assessment were completed and from what source(s) did the information come.
Complete each revised case by asking what additional information is still needed to address any remaining questions. Depending upon the assessment, the next steps might include taking additional history, ordering diagnostic testing, reviewing images/studies/treatment plans, initiating treatment, etc. A study guide cannot presume that an actual symptom can be safely ignored because one assessment finding appears reassuring. Someone with new or concerning symptoms should seek advice from an appropriate healthcare service.
Check your understanding
A short quiz, with an explanation after each answer.
Which statement describes a symptom?
Go back to the most difficult section you encountered and write down an explanation of the example without viewing that section again. Once you've reviewed your explanation check out the quiz again after some time has passed. Being able to articulate your rationale is far superior to knowing where you correctly placed answers on a test.