General observations 24
Common abnormalities 24 Complexion 25 Movements 27 Sounds 26 Odours 28
Measurement of height, weight and temperature 29 Common abnormalities 29 State of hydration 32 Common abnormalities 32
The physical assessment
The hair 36
Common abnormalities 37 The skin 38 The history 40 Examination 41 Common abnormalities 41 The hands 46
Common abnormalities 46 The head 50
Common abnormalities 61 The neck 62
The thyroid gland 62 The breasts 64 Abnormal findings 67 Investigation 67
There is no one correct way or correct sequence of performing the physical examination. Some clinicians may start by examining that system which appears to be most affected; others may first examine the hands and others examine the patient from the feet upwards. It is best to develop one's own sequence and 'style' of examination rather than to follow' a rigid regime uncritically. This book does not attempt to describe the method of physical examination but rather to provide a satisfactory and effec-(ive method of examination. The purpose of this chapter is to describe the following:
• the significance of those general observations that can be made before formally examining the patient
• an assessment of height, weight, temperature and state of hydration
• the examination of the hair and skin
• the examination of the hands and head (which can be performed before asking the patient to undress)
• those other components of the examination which cannot be assigned to any single system. This includes examination of the lymphatic system and the breasts and an assessment of the endocrine system.
Physical signs may be easily missed during a routine examination unless the clinician looks specifically for them. The very concept of performing a complete physical examination is misleading and should be avoided except as an exercise in practising examination techniques. It is time-consuming and inappropriate to test every patient's sense of smell and colour vision and to always examine the abdomen for shifting dullness. Rut it is essential to perform these tests in certain circumstances. It follows that, once the history has been obtained, the clinician should consider what physical features may be present and then to examine the patient accordingly. A useful maxim is 'You only find what vou look for".
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