Fonte: Jaideep S. Talwalkar, MD, e Joseph Donroe, MD, Medicina Interna e Pediatria, Yale School of Medicine, New Haven, CT
Para otimizar o valor preditivo do exame físico, o provedor deve realizar manobras corretamente. O uso adequado de cortinas é um componente importante para a realização correta de manobras de exame físico. Lesões cutâneas são perdidas quando a “inspeção” ocorre através da roupa, os estalos são erroneamente relatados quando os pulmões são examinados através de uma camiseta, e os achados sutis no exame cardíaco não são detectados quando a auscultação é realizada sobre roupas. Assim, as normas de boas práticas exigem o exame com as mãos ou equipamentos em contato direto com a pele do paciente (ou seja,não examinam através de um vestido, cortina ou roupa). Além de seu valor clínico, a técnica correta de draping é importante para melhorar o nível de conforto do paciente durante o encontro.
Como todos os outros aspectos do exame físico, é preciso pensamento e prática deliberados para encontrar o equilíbrio certo entre o draping, que é feito para preservar a modéstia do paciente, e a exposição, que é necessária para otimizar o acesso às peças que precisam de exame. Os estilos individuais de provedores no uso de vestidos e cortinas variam consideravelmente com base no local da prática, disponibilidade de recursos e disciplina dentro da medicina. Este vídeo fornece uma visão geral de algumas das técnicas mais comuns utilizadas, combinando técnicas que utilizam abordagens comuns de draping.
The sensitive use of gowns and drapes during the physical examination is important to strike a balance between patient comfort and exposure (Figure 1). The examination should not be compromised out of the clinician’s concern for patient exposure, since the proper use of draping allows for the proper exam to be performed in most clinical circumstances. Examination through clothing, sheets, or gowns is incorrect technique, though only the areas of the body being directly examined at a given time need to be exposed, and once an area has finished being examined, a clinician should replace the drape or clothing before moving on to the next area. An examiner shouldn’t reach under a gown or clothing to examine a patient, and they should enlist the patient’s help in moving the gown or drape throughout the exam, as this allows the patient to maintain some control over the degree of exposure. Letting the patient know what is about to be done before moving a gown or drape is also important, as proper communication puts the patient at greater ease. If a clinician has tied the gown during the exam, they should retie it before asking the patient to step down from the table. The handful of draping techniques demonstrated in this video can be used together for all the standard parts of the physical examination. As with all the other aspects of the physical examination, developing comfort and individual stylistic variations in draping technique takes deliberate practice.
The proper usage of any attire, including hospital gowns and drapes is an important component of correctly performing maneuvers during the physical exam.
Skin lesions can be missed when inspection occurs through clothing. Sounds can be misleading if the lungs are percussed through a t-shirt. And subtle findings on the heart exam can go undetected when auscultation is performed over apparel. Accordingly, the best practice standards call for examining with one’s hands or equipment in direct contact with the patient’s skin. Therefore, it takes deliberate thought and practice to employ appropriate usage of clothing, such that it preserves patient modesty, and allows sufficient access to the parts that need examination.
Certain regions can be examined while patient are wearing street clothing, while others regions can be more comfortably investigated if the patient is wearing gown and drapes. In this video, we’ll demonstrate considerations for each of these scenarios using examples of a few routine physical exams.
First, let’s go over the steps, which can be performed on patients wearing street clothing. The vital signs can be measured if you have access to the patient’s arms. For basic HEENT maneuvers, instruct the patient to remove any hats, eyeglasses, dentures-if a thorough exam of a patient’s oral mucosa in necessary, and hearing aids -if a thorough ear exam is necessary. But other than that these exams can be performed regardless of what a patient is wearing from the neck down.
If the patient is wearing loose-fitting clothing, the inspection and palpation of the neck and supraclavicular regions can be easily performed. In order to examine the abdomen, instruct the patient to lie down and ask them to roll down their pants and raise-up their shirt to provide optimal exposure. During vascular exam, raise the sleeves and the pant legs as necessary to access the pulse sites. Make sure that the footwear and socks are removed before testing the pedal pulses. The femoral pulse is usually not accessible in patients wearing street clothing. All aspects of the neurologic examination can be performed on a patient who’s wearing clothing that permits inspection and palpation of the extremities.
Now, let’s go over the maneuvers to be performed while the patient is wearing a hospital gown. First, provide instructions to the patient on what to do with the gown, “In order to examine you today, I’m going to ask you to change into this gown. Keep it open in the back. You can leave your underwear on, but please remove your other clothing including your bra.” Let the patient know how long you’ll be gone and step out of the room while the patient changes. When you come back, knock on the door and ask for the patient’s permission to come in. Instruct the patient to sit on the exam table. Offer a drape to cover lap and legs for warmth. This drape will be used in subsequent maneuvers as well.
Now, let’s go over the appropriate gown use for the neck, anterior chest, and heart exams. Untie the gown at the back of the neck. Instruct the patient to lower the gown slightly at the shoulders to allow optimal examination of the lower neck and clavicles. Next, ask the patient to lower the gown a few inches further. This allows for adequate exposure of the anterior chest, lung zones, as well as the pulmonic and aortic regions of the heart. Further lowering the gown at the sternum allows for auscultation at the Erb’s point and the tricuspid area. When this portion of the exam is finished, replace the gown over the shoulders.
For examining the cardiac apex, instruct the patient to raise their gown to expose the left flank and upper left quadrant of the abdomen. To examine the mitral area, place the stethoscope in the fifth left intercostal space at the mid-clavicular line. Certain findings are best appreciated with the patient lying in the left lateral decubitus position. If the patient’s left breast is impeding access to this area, ask the patient to displace it with their right hand or you can use the back of your left hand to do the same. This position brings the left ventricle closer to the chest wall, which can accentuate S3, S4 and the murmur of mitral stenosis when using the bell.
For adequate exposure of the back region, move the folds of the gown laterally with the patient in the seated position. Displace the gown further, one side at a time, to allow for the lateral chest wall examination. During gait or standing range of motion, like forward flexion testing, hold the back of the gown together, so that the patient can concentrate on the movement and not worry about the gown falling off. After this portion of the exam, replace the gown to cover the back and retie the neck straps.
For abdominal, thigh and inguinal investigation, ask the patient to lie down at 0-30° angle, and place the drape to cover the patient’s legs and pelvis. Request the patient to lift the gown just below the chest level, simultaneously securing the drape. This technique is called “double draping,” which means simultaneous use of a gown and a drape. All standard aspects of the abdominal exam can be performed with this exposure, except for the percussion of the liver from the superior approach, which requires additional displacement of the gown on the right side to expose the lower chest. To assess the femoral artery and inguinal lymph nodes, move the drape medially, examine one side at a time and replace the drape before moving to the other side. Replace the gown when these maneuvers are finished being performed.
In order to examine the musculoskeletal system, ensure that the region of interest is exposed to permit inspection, palpation, and provocative maneuvers simultaneously. Exposure should also allow examination of the surrounding muscle groups and joints. For testing lower extremities, place the draping sheet between the patient’s legs, so that each leg and hip can be easily uncovered and directly examined, which limits the exposure of areas not being actively examined. Lastly, a complete skin examination requires sequential displacement of the gown to expose all areas of interest, while keeping other regions covered with the gown or drape.
At the end of the physical exam, thank the patient for their cooperation. Ask patients to change back into their clothing before initiating complicated discussions about diagnosis and treatment.
You’ve just watched JoVE’s video on sensitive and effective usage of attire during the physical exam. Here, we presented a handful of techniques for effectively working with patient’s clothing-be it “street” or “hospital”-that can be can be applied to all the standard parts of the physical exam.
It is extremely important to strike a balance between patient comfort, and exposure necessary for a thorough examination, and as with all the other aspects of the physical exam, developing the skill to appropriately manipulate the patient’s attire takes deliberate practice. As always, thanks for watching!
