mcleaod 25

12 ASSESSING PATIENTS: A PRACTICAL GUIDE 2 The clinical examination A routine ‘screening’ clinical examination (see Clinical tool: The 20-step clinical examination) is required in most patients. Some Box 2.3 Sexual history questions • Do you have a regular sexual partner at the moment? • Is your partner male or female? • Have you had any (other) sexual partners in the last 12 months? • How many were male? How many female? • Do you use barrier contraception – sometimes, always or never? • Have you ever had a sexually transmitted infection? Box 2.2 Non-prescribed drug history • What drugs are you taking? • How often and how much? • How long have you been taking drugs? • Any periods of abstinence? If so, when and why did you start using drugs again? • What symptoms do you have if you cannot obtain drugs? • Do you ever inject? • Do you ever share needles, syringes or other drug paraphernalia? • Do you see your drug use as a problem? • Do you want to make changes in your life or change the way you use drugs? elements of the clinical examination that have traditionally been considered routine are only required in specific circumstances. These include examination of the fundi, rectum, genitalia, breasts and individual joints. 1. Assess general demeanour, appearance, movements, odour, nutrition and hydration. 2. Record routine observations, including temperature, pulse, BP, RR and SpO 2 . 3. Examine the hands: temperature, capillary refill, colour, nails, tremor, asterixis and joints. 4. Feel the radial and brachial pulses. 5. Inspect the face and eyes (Tables 2.2 and 2.3). 6. Examine the mouth: dental hygiene, cyanosis, tonsillar inflammation, ulcers, blisters, candidiasis. Position the patient at 45° 7. Assess the height and waveform of the JVP and feel the carotid pulse. 8. Inspect and palpate the trachea: check centrality and cricosternal distance. 9. Inspect and palpate the praecordium. 10. Auscultate the heart. 11. Examine the lung fields from the front. Sit the patient up at 90° 12. Inspect the trunk (front and back) for rashes, moles, spider naevi, scars etc. 13. Palpate for lymphadenopathy and goitre; check for bony/renal angle tenderness, sacral oedema. 14. Examine the lung fields from the back. Lay the patient flat 15. Examine the abdomen and hernial orifices. 16. Examine the legs: • Inspect for swelling, colour, rashes, skin changes. • Feel for pitting, temperature, pulses, capillary refill. Clinical tool: The 20-step clinical examination

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ASSESSING PATIENTS: A PRACTICAL GUIDE2

The clinical examinationA routine ‘screening’ clinical examination(seeClinicaltool:The20-stepclinicalexam-ination)isrequiredinmostpatients.Some

Box 2.3 Sexual history questions

• Doyouhavearegularsexualpartneratthemoment?

• Isyourpartnermaleorfemale?

• Haveyouhadany(other)sexualpartnersinthelast12months?

• Howmanyweremale?Howmanyfemale?

• Doyouusebarriercontraception–sometimes,alwaysornever?

• Haveyoueverhadasexuallytransmittedinfection?

Box 2.2 Non-prescribed drug history

• Whatdrugsareyoutaking?

• Howoftenandhowmuch?

• Howlonghaveyoubeentakingdrugs?

• Anyperiodsofabstinence?Ifso,whenandwhydidyoustartusingdrugsagain?

• Whatsymptomsdoyouhaveifyoucannotobtaindrugs?

• Doyoueverinject?

• Doyouevershareneedles,syringesorotherdrugparaphernalia?

• Doyouseeyourdruguseasaproblem?

• Doyouwanttomakechangesinyourlifeorchangethewayyouusedrugs?

elements of the clinical examination thathavetraditionallybeenconsideredroutineareonlyrequiredinspecificcircumstances.These include examination of the fundi,rectum, genitalia, breasts and individualjoints.

1. Assessgeneraldemeanour,appearance,movements,odour,nutritionandhydration.

2. Recordroutineobservations,includingtemperature,pulse,BP,RRandSpO2.

3. Examinethehands:temperature,capillaryrefill,colour,nails,tremor,asterixisandjoints.

4. Feeltheradialandbrachialpulses.5. Inspectthefaceandeyes(Tables2.2and

2.3).6. Examinethemouth:dentalhygiene,

cyanosis,tonsillarinflammation,ulcers,blisters,candidiasis.

Position the patient at 45°

7. AssesstheheightandwaveformoftheJVPandfeelthecarotidpulse.

8. Inspectandpalpatethetrachea:checkcentralityandcricosternaldistance.

9. Inspectandpalpatethepraecordium.10. Auscultatetheheart.11. Examinethelungfieldsfromthefront.

Sit the patient up at 90°

12. Inspectthetrunk(frontandback)forrashes,moles,spidernaevi,scarsetc.