Objective examination of the patient: methods and general information

Objective examination is an important step in collecting patient information. Allows you to get a general idea of ​​his mental and physical condition. This type of examination differs from the subjective one in that it allows you to assess the status of a person’s health and well-being in the current period of time from the point of view of a medical professional. Any medical student knows the basics of such a procedure and knows how to put this knowledge into practice. Objective examination methods are widely used in world medical practice. Often in an extreme situation, knowledge of such methods helps to navigate, prescribe effective treatment and save the patient's life.

Some general information

So, what is a subjective and objective examination of a patient?

The data obtained during the subjective examination are largely based on the assumptions of the patient himself regarding his state of health. This is what kind of pain he feels, what kind of ailments he is having, what diseases he suffered in childhood. Such information can only be provided by the patient himself, and no one else. In some cases (often with psychiatric deviations, when unconscious or unable to conduct a dialogue), a sick person is not able to provide such data. In this case, we are not talking about the possibility of subjective examination.

Sources of subjective information for the examination are:

• a patient;
• his family.

A nurse or doctor conducts a survey to collect information. In its course, one can observe the patient and coordinate data and non-verbal signals with the information that the patient broadcasts about himself. Already at this stage, you can get a lot of information. Subjective and objective examination of the patient are necessary steps in the diagnosis of any disease. During the conversation, it is also necessary to provide the patient with information about the medical and sanitary environment, possible treatment methods, and detention in a hospital.

An objective examination of the patient includes the following studies:

• somatoscopic;
• samatometric;
• physiometric studies.

These options differ from each other by the presence of tactile contact and the method of collecting information for further diagnosis.

Next, we will examine in detail each stage, and you will learn the algorithm for objective examination of the patient. This method is of the highest importance both for the doctor and for the rest of the medical staff, since it helps to make an overall picture of the patient's condition.

Order of conduct

First you need to carry out a general inspection. It consists in a visual assessment of the appearance of the patient. The color and condition of the mucous membranes, skin tone, legal capacity, speech, posture, gait, rashes and dermatitis. It is carried out in daylight or artificial lighting. This method does not provide for palpation or any bodily contact with the patient.

Then a detailed examination is carried out - it consists in examining each individual area of ​​the body. The head, face, neck, torso, hands, hairline, joints are alternately evaluated. Inspection should be carried out evenly in order to adequately compare the state of symmetrical parts of the body.

Be sure to evaluate the patient's motor activity:

• An active state is most often characteristic of patients with a mild course of the disease. They easily change their position on the couch, without any problems fulfill requests to get dressed or undress, there are no visible damages to the skin and mucous membranes. The speech is clear, the judgments are adequate. Even if the patient himself subjectively assesses his position as difficult, an analysis of his motor activity may report the opposite.
• Passive state is expressed in sharp weakness. Sometimes up to a coma. The speech is slow, quiet. Perspiration on the forehead, skin from pale to cyanotic. The mucous eye is yellow to bluish. The position on the couch is difficult to change, in some cases partial immobilization is possible. In a passive state, as a rule, hospitalization should necessarily follow and further monitoring of the patient takes place in a hospital setting.
• Forced - characterized by the complete inability to take one or another pose in connection with exacerbation of pain. Cough, vomiting, chills, sweating, fever, light-headedness, coughing, shortness of breath may occur. Visually immediately apparent manifestations of this condition. Answers questions with difficulty, often putting visible effort for this. Urgent hospitalization is necessary, in this state the patient is unacceptable to leave.

Constitutional type of patient

Important information in the process of visual general examination during an objective examination of the patient can be gleaned by assessing its constitutional type.

• Hypersthenic is characteristic of both men and women. Transverse dimensions prevail with a pronounced subcutaneous fat layer. such people look heavy, hard. Their body mass index, as a rule, is not lower than 28. The diaphragm is located high. The chest is wide and short, the peritoneum protrudes. The limbs are full - it is difficult to determine from them without palpation, swelling is this or the patient’s natural state. A characteristic feature of the structure of people with a hypersthenic constitutional type is that they have an internal organ that is one and a half to two times larger than people with an asthenic constitutional type. Prone to hyperhidrosis, perspiration, sweating.
• The asthenic constitutional type is characterized by a predominance of longitudinal over transverse dimensions. They look thin, dry, sinewy. The subcutaneous fat layer is minimal. Metabolism is usually fast. In some cases, they suffer from hyperthyroidism (you should visually evaluate the size of the thyroid gland - does it protrude on the patient’s neck and does it have characteristic "hyperthyroid" eyeballs). Growth is most often above average. The limbs are long, thin, with small muscle mass. The chest is narrow and long. The peritoneum is sunken, as a rule. Asthenics are characterized by active behavior and lively speech, often they exaggerate the data of subjective self-awareness, which can distort the picture of an objective examination of the patient.
• Normostenic - the average constitutional type between asthenic and hypersthenic. They are distinguished by the proportionality of physique, moderate muscle mass and the average level of subcutaneous fat. Most often have a cone-shaped chest. The length of the limbs corresponds to the body, you can immediately see the symptoms of excessive swelling (for example, in the tracks from socks or bracelets on the hands). They present the results of subjective self-awareness in a consistent and convincing manner.

The ability to distinguish one type from another will not help in recognizing the causes and symptoms of the disease, but it can bring diagnostic benefits. Asthenics are characterized by acute diseases of the respiratory system and digestive organs. People with a hypersthenic constitution often have metabolic diseases, thyroid and adrenal gland pathologies, atherosclerosis, cholelithiasis and liver problems. Normostenics often suffer from cardiovascular disease. Moreover, in connection with excellent health, they rarely go to the doctor: they endure microstrokes and pre-infarction on their feet.

Examination of the patient's gait during examination

The purpose of gait assessment is to localize the lesion and determine the severity of functional impairment. This method of objective examination of the patient is often used on an intuitive level.

Assessing the patient’s speed and pace of walking, average stride length and maintaining equilibrium at a distance of several meters is acceptable for outpatient practice.

According to the posture and the manner of holding a sick person, conclusions can be drawn about his general tone, the presence or absence of muscle tissue, the functioning of the nervous system and vestibular apparatus. Equal posture, fast and swift gait, free movements indicate a good condition of the body, the presence of vitality and legal capacity. If a person feels weak, if he is seriously ill or mentally depressed or afraid, the gait will be shaky, posture hunched over. In serious condition, the patient is not able to walk on his own and a few meters.

A specific gait (falling to one side, duck step, bear walk) is typical for the acute form of some neurological diseases - sciatica, vertebral hernia, sciatica, hemiplegia and others. With congenital dislocation of the hip joints, with fractures and dislocations of the ankles and feet, the gait is modified so much that the medical staff simply cannot but take into account a similar factor when conducting an objective examination of the patient. Observations do not have to be entered on an outpatient card - it’s easy enough for yourself to check the box for a later accurate diagnosis.

Characterization of the mental state of the patient during an objective examination

At the time of the survey and a detailed examination of the patient, it is important to give the correct characteristics to his mental state. To do this, one must carefully observe his manner of speech, gestures, and expression of his eyes, given out by information about his own well-being.

Features of subjective and objective examination of patients are such that the data on them may not coincide. Often this situation arises: the patient gives one information about his own sensations (pain, nausea, weakness and other symptoms). And the medical worker does not detect such conditions in him. What to do in this case, when the patient’s lie about his subjective well-being is obvious?

To date, there is no right to refuse hospitalization, so in any case, you will have to put the patient on record and continue to diagnose. But if there is a suspicion of incapacity, intoxication, drug delirium or a psychiatric spectrum disorder in a patient - should his passport data be checked in the database - is he not registered in the city PND? If the answer is yes, you should contact the relatives of the sick person or transfer him to hospitalization in the appropriate institution.

Here are some features that can produce nervous tension or psychiatric spectrum disorders with an objective examination of the patient:

• posture: forced, intense, relaxed;
• gesticulation: nervous, angular, or its complete absence;
• appearance: spiteful - impaired communication (mental illness, defects in character and upbringing); frightened - panic, neurosis, suspiciousness;
• description of their own feelings: hypochondriacs often come up with many symptoms, the abundance and implausibility of which an experienced medical professional will immediately "figure out";
• look: defocused - indicates a possible intoxication or delirium; wet and boring - nervous tension and a symptom of some disorders of the psychiatric spectrum;
• cutesy and defiant behavior in women, rude and aggressive, inappropriate behavior in men also in most cases indicate the presence of mental disorders.

Detailed examination of the upper body

First you need to conduct a visual assessment of the patient's head - its size and shape. Excessive enlargement of the skull with asthenic constitutional type is characteristic of hydrocephalus. If the skull, on the contrary, is small in size, this may indicate microcephaly and mild or moderate mental underdevelopment. The sedentary position of the head (the patient practically does not twist his neck, his head is motionless) is characteristic of cervical spondylarthrosis, myositis. If the head is too mobile, it shakes finely and walks from side to side - perhaps the problem is Parkinsonism.

General objective examination of the condition and facial features of the patient:

• feminine facial features in men and courageous - in women most often indicate the presence of endocrine disorders or the use of hormonal prescription drugs;
• puffy, swollen face signals problems with the kidneys, ureters, bladder;
• febrile face indicates hyperemia of the skin;
• sparkling eyes, excited expression - infectious diseases;
• the so-called "Hippocratic face" (sunken eyes, pallor, drops of cold sweat on the forehead) - a complex course of diseases of the gastrointestinal tract;
• pronounced omission of the upper eyelid (ptosis) is a sign of damage to the nervous system.

Inspection of the oral cavity is carried out using a special sterile spatula. You should pay attention to the mucous membrane (are there Filatov-Koplik spots, ulcers and inflammation of the ducts of the salivary glands). The condition of the teeth will help draw conclusions about the general state of health and the degree of self-care. Carious teeth are a separate source of infections for the body. An objective examination of the dental patient also involves examination of the gums for bleeding, density, ulcers. The examination of the tongue matters: raspberry with smooth papillae - with various anemia; dry with cracks and brown coating - with severe intoxication of the body; the so-called “varnished” language is one of the symptoms of oncology of the organs of the gastrointestinal tract.

Auricles and external auditory openings are examined (rash and weeping behind the ears or purulent, bloody discharge from the ears is possible).

Examination of the scalp and condition of the hair:

• with anemia, they are brittle, split, dull;
• baldness speaks of a variety of endocrine pathologies;
• pediculosis, oily or dry seborrhea, skin lesions are also possible.

On the neck of the patient should pay attention to the condition of the carotid arteries, pulsation of the jugular veins. In their appearance, heart failure can be assumed. Swollen lymph nodes may indicate tuberculosis, leukemia. The thyroid gland can be enlarged due to endocrine diseases (hyperthyroidism, hypothyroidism, nodular goiter). An objective examination of the patient with laryngitis should begin with a visual examination of the neck and palpation of the lymph nodes.

Detailed examination of the patient's skin

Skin examination is recommended under natural light. the saturation of the shade of the skin depends on many factors: blood vessels, the amount of pigment, the thickness and transparency of the skin.

• Hyperemia inherent in the expansion of peripheral vessels. This condition is characteristic of fever, high fever, nervous strain. Erythremia (a constant presence in the vessels of red blood cells) is also a common cause of hyperemia. With unilateral pneumonia, hyperemia of the cheek is characteristic on the side of the localization of pneumonia.
• Pallor occurs with heavy blood loss, with iron deficiency anemia. A person often turns pale in a state of severe fright, shock.
• Cyanosis of the skin (cyanosis) is characteristic of patients with a high hemoglobin content in the blood. Also, this condition of the skin occurs with an exacerbation of some chronic lung diseases.
• With the accumulation of total bilirubin in the blood, the skin and eyeballs acquire a yellow tint. The people call this condition "jaundice." It appears with hepatosis, hepatitis of various etiologies and other chronic liver diseases in the acute stage. Also, yellowness of the skin is characteristic of poisoning the body with ethyl alcohol and synthetic drugs.
• In chronic adrenal insufficiency, the skin color becomes bronze.

It is worth paying attention to skin rashes: petechiae, urticaria, purpura, erythema, herpetic rash, acne.

With increased peeling of the skin, we can talk about strong and constant dehydration, about the violation of the water-salt balance. It is necessary to check kidney function.

Palpation during a detailed examination of the patient

The next step is palpation. This is a clinical method of subjective and objective examination of the patient using touch. In fact, this is obtaining conclusions about the patient’s state of health by feeling his limbs and peritoneum.

The room where the examination takes place should not be cold. It is advisable that the patient be dressed in comfortable clothes for him and be in a comfortable position, in a relaxed state. Palpating position - to the right of the patient.The hands of the palpating physician should be warm, the nails should not be pricked or scratched. Hard or traumatic movements are not permitted.

Types of palpation with a general objective examination:

• superficial is used to detect pathologies in the upper layers of subcutaneous fat;
• deep palpation is designed to study the shape and size of organs. Most often, this method is used to examine the size and density of the kidneys, liver, spleen, lymph nodes, stomach, intestines.

Lymph nodes in a healthy person are not palpable. They are soft, do not bulge above the surface of the skin. With their soreness and inflammation, an alarm should be raised. they should be palpated from top to bottom, standing in front and to the right of the patient.

Palpation of the abdominal region should be first superficial, then deep. It is carried out in the following sequence: sigmoid colon, blind section of the intestine, ascending and descending sections of the colon. then the stomach, gall bladder, liver, spleen, kidneys are palpated.

This method of objective examination of the patient can report the main cause of pain and malaise. Most often, after finding out the possible cause, the patient is hospitalized and the necessary tests are collected.

Rules for palpation

An objective examination of the patient with intestinal infections by palpation should be carried out strictly in rubber disposable gloves. According to hygiene standards, this is exactly the way (with gloves) and it should always be carried out. However, in extreme cases, when it comes to human life, many medical professionals neglect this rule.

If the palpating hands are too cold, this can cause a patient reaction, which will lead to a distortion of the objective examination data.

The skin and muscles are examined, taking them into a fold - sometimes it can be somewhat painful for the patient. Palpation of edema is carried out on the legs or ankles by strongly pressing the finger in the lower leg. If a pit remains at the site of pressing, this indicates the presence of serious edema, which could not be visible with a visual objective examination of the patient. With experience, real skill in recognizing edema comes to doctors.

Palpation is one of the main objective method of examining a patient, which can report a lot of information and contribute to the diagnosis of pathologies of internal organs already at the initial stage of examination.

Percussion and auscultation

Percussion is an analysis of percussion sounds that occur when striking the patient’s body surface. This is the final objective examination method. The physician needs experience in order to correctly interpret the nature of the oscillations of the organs and tissues under study. The quality and duration of sound depends on the amount of air in the tapped organ. If it is not there, the sound will be dull, somewhat dull. Percussion can be direct (when tapping is performed on the naked body) or indirect (tapping through a metal plate).

Auscultation is an examination method based on listening to the functioning of internal organs. This effectively helps to diagnose diseases of the heart, lungs, intestines. Auscultation is one of the most informative methods, but only if the doctor has the necessary experience and qualifications to decrypt the signals. It is carried out both with the help of a stethoscope, a phonendoscope, and simply with an open auricle.

Objective Nursing Examination of the Patient

Making nursing diagnoses is simplified and does not imply a more or less accurate diagnosis. Most often, this is simply recording an anthropological data (height and weight) of the patient and his main complaints on an outpatient map.

An objective nursing examination includes several activities:

• independent activity is simple and does not require specific instructions and reporting, includes the provision of first aid and psychological support to the patient, monitoring the progress of treatment;
• dependent activity is positioned as following the instructions of a doctor;
• interdependent is in interaction with other medical professionals.

Making nursing diagnoses is acceptable in some extreme cases. When staged, the nurse determines the patient’s condition and recommends him bed rest or provides first aid urgently.