HEAD TO TOE PHYSICAL EXAMINATION

Oct 24th

HEAD TO TOE PHYSICAL EXAMINATION

CHAPTER I
INTRODUCTION

1.1 Background
Physical examination or clinical examination is a process of a medical expert examining a patient’s body to find clinical signs of disease. The results of the examination will be recorded in the medical record. Medical records and physical examination will help in establishing a diagnosis and planning patient care.
Usually, physical examination is carried out systematically, starting from the head and ending with the limbs. After the main organ examination is examined by inspection, palpation, percussion, and auscultation, some special tests may be needed such as neurological tests.
With the clues obtained during the history and physical examination, the medical expert can compile a differential diagnosis, which is a list of possible causes of the symptoms. Several tests will be performed to confirm the cause.
A complete examination will consist of an assessment of the patient’s general condition and specific organ systems. In practice, vital signs or temperature, pulse and blood pressure examinations are always performed first.

CHAPTER II
DISCUSSION

2.1. Theory Concept
Physical examination is a head-to-toe review of every body system that provides objective information about the client and allows the nurse to make clinical judgments. The accuracy of the physical examination affects the choice of therapy received by the client and the determination of the response to that therapy. (Potter and Perry, 2005)
A physical examination is an examination of the client’s body as a whole or only certain parts that are considered necessary, to obtain systematic and comprehensive data, ensure/prove the results of the anamnesis, determine problems and plan appropriate nursing actions for the client. (Dewi Sartika, 2010)
The physical examination techniques used are:
1. Inspection
Inspection is an examination using the senses of sight, hearing and smell. A general inspection is carried out when meeting the patient for the first time. A general picture or impression of the health condition is formed. The examination then progresses to a local inspection that focuses on a single system or part and usually uses special tools such as an ophthalmoscope, otoscope, speculum and others. (Laura A. Talbot and Mary Meyers, 1997) Inspection is an examination carried out by looking at the body part being examined through observation (eyes or magnifying glass). (Dewi Sartika, 2010)
The focus of the inspection on each part of the body includes: body size, color, shape, position, symmetry, lesions, and protrusions/swelling. After inspection, it is necessary to compare the normal and abnormal results of one body part with another.
2. Palpation
Palpation is an examination using the sense of touch by placing the hand on a part of the body that can be reached by the hand. Laura A. Talbot and Mary Meyers, 1997)
Palpation is an examination technique that uses the sense of touch; hands and fingers, to determine the characteristics of tissues or organs such as: temperature, elasticity, shape, size, moisture and protrusion. (Dewi Sartika, 2010)
Things that are detected are temperature, moisture, texture, movement, vibration, growth or mass, edema, crepitation and sensation.

3. Percussion
Percussion is an examination that includes tapping the surface of the body to produce a sound that will help in determining the density, location, and position of the structure below it. (Laura A. Talbot and Mary Meyers, 1997)
Percussion is an examination by tapping a certain part of the body surface to compare it with other parts of the body (left/right) by producing sound, which aims to identify the boundaries/location and consistency of the tissue. Dewi Sartika, 2010)

4. Auscultation
Auscultation is the act of listening to sounds produced by various organs and tissues of the body. (Laura A. Talbot and Mary Meyers, 1997)

Auscultation is a physical examination carried out by listening to sounds produced by the body. Usually using a tool called a stethoscope. The things that are heard are: heart sounds, breath sounds, and bowel sounds. (Dewi Sartika, 2010)

In conducting a physical examination, there are principles that must be considered, namely the following:
a. Infection control
Including washing hands, wearing sterile gloves, wearing masks, and helping clients wear examination clothes if available.
b. Environmental control
That is, ensuring that the room is comfortable, warm, and well-lit to carry out a physical examination for both the client and the examiner. For example, closing doors/windows or curtains to maintain client privacy
1. Communication (explanation of procedures)
2. Client privacy and comfort
3. Systematic and consistent

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