BASIC CLINICAL SKILLS

Physical examination

A physical examination, medical examination, or clinical examination (more popularly known as a check-up or medical) is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This data then becomes part of the medical record.
[/color]http://en.wikipedia.org/wiki/Physical_examination
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Vital signs
Vital signs are measures of various physiological statistics, often taken by health professionals, in order to assess the most basic body functions. Vital signs are an essential part of a case presentation. The act of taking vital signs normally entails recording body temperature, pulse rate (or heart rate), blood pressure, and respiratory rate, but may also include other measurements. Vital signs often vary by age.
Primary four

There are four vital signs which are standard in most medical settings:
Body temperature
Pulse rate (or heart rate)
Blood pressure
Respiratory rate
The equipment needed is a thermometer, a sphygmomanometer, and a watch.
Though a pulse can often be taken by hand, a stethoscope may be required for a patient with a very weak pulse.

Normal human body temperature, also known as normothermia or euthermia, depends upon the place in the body at which the measurement is made, and the time of day and level of activity of the person. Despite what many schoolchildren are taught, there is no single number that represents a normal or healthy temperature for all people under all circumstances using any place of measurement.
Different parts of the body have different temperatures. Rectal and vaginal measurements, or measurements taken directly inside the body cavity, are typically slightly higher than oral measurements, and oral measurements are somewhat higher than skin temperature.
The commonly accepted average core body temperature (taken internally) is 37.0 °C (98.6 °F).
The typical oral (under the tongue) measurement is slightly cooler, at 36.8° ± 0.4°C (98.2° ± 0.7°F), and temperatures taken in other places (such as under the arm or in the ear) produce different typical numbers.[1] Although some people think of these numbers as representing the normal temperature, a wide range of temperatures has been found in healthy people.[2]

Human body temperature

In healthy adults, body temperature fluctuates about 0.5 °C (0.9 °F) throughout the day, with lower temperatures in the morning and higher temperatures in the late afternoon and evening, as the body's needs and activities change.[1]
The time of day and other circumstances also affect the body's temperature. The core body temperature of an individual tends to have the lowest value in the second half of the sleep cycle; the lowest point, called the nadir, is one of the primary markers for circadian rhythms.
The body temperature also changes when a person is hungry, sleepy, or cold.

Circadian rhythm

A circadian rhythm ( /sɜrˈkeɪdiən/) is any biological process that displays an endogenous, entrainable oscillation (occurs when rhythmic physiological or behavioral events match their period and phase to that of an environmental oscillation) of about 24 hours.
These rhythms are driven by a circadian clock, and rhythms have been widely observed in plants, animals, fungi and cyanobacteria. The term circadian comes from the Latin circa, meaning "around" (or "approximately"), and diem or dies, meaning "day". The formal study of biological temporal rhythms, such as daily, tidal (diurnal falls & rises), weekly, seasonal, and annual rhythms, is called chronobiology.
Although circadian rhythms are endogenous ("built-in", self-sustained), they are adjusted (entrained) to the local environment by external cues called zeitgebers, commonly the most important of which is daylight.
Zeitgeber (from German for "time giver," or "synchronizer") is any exogenous (external) cue that synchronizes an organism's endogenous time-keeping system (internal clock) to the earth's 24-hour light/dark cycle and 12 month cycle . The strongest zeitgeber, for both plants and animals, is light.

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Variations


Diurnal variation in body temperature, ranging from about 37.5 °C from 10 a.m. to 6 p.m., and falling to about 36.4 °C from 2 a.m. to 6 a.m.
Temperature control (thermoregulation) is part of a homeostatic mechanism that keeps the organism at optimum operating temperature, as it affects the rate of chemical reactions. In humans the average internal temperature is 37.0 °C (98.6 °F), though it varies among individuals. However, no person always has exactly the same temperature at every moment of the day. Temperatures cycle regularly up and down through the day, as controlled by the person's circadian rhythm. The lowest temperature occurs about two hours before the person normally wakes up. Additionally, temperatures change according to activities and external factors.[3]
Normal body temperature may differ as much as 0.5 °C (0.9 °F) from day to day.
[ ]Natural rhythms
Body temperature normally fluctuates over the day, with the lowest levels around 4 a.m. and the highest in the late afternoon, between 4:00 and 6:00 p.m. (assuming the person sleeps at night and stays awake during the day).[4][1] Therefore, an oral temperature of 37.3 °C (99.1 °F) would, strictly speaking, be a normal, healthy temperature in the afternoon but not in the early morning.
Body temperature is sensitive to many hormones, so women have a temperature rhythm that varies with the menstrual cycle, called a circamensal rhythm.[3]
A woman's basal body temperature rises sharply after ovulation, as estrogen production decreases and progesterone increases. Fertility awareness programs use this predictable change to identify when a woman is able to become pregnant. During the luteal phase of the menstrual cycle, both the lowest and the average temperatures are slightly higher than during other parts of the cycle. However, the amount that the temperature rises during each day is slightly lower than typical, so the highest temperature of the day is not very much higher than usual.[5]
Hormonal contraceptives both suppress the circamensal rhythm and raise the typical body temperature by about 0.6 °C (1.1 °F).[3]
Temperature also varies with the change of seasons during each year. This pattern is called a circannual rhythm.[5] . People living in different climates may have different seasonal patterns.
Increased physical fitness increases the amount of daily variation in temperature.lor=red] increased age, both average body temperature and the amount of daily variability in the body temperature tend to decrease.[5] Elderly patients may have a decreased ability to generate body heat during a fever, so even a somewhat elevated temperature can indicate a serious underlying cause in geriatrics.
[edit]Variations due to measurement methods
Different methods used for measuring temperature produce different results.
Generally, oral, rectal, gut, and core body temperatures, although slightly different, are well-correlated, with oral temperature being the lowest of the four. Oral temperatures are generally about 0.4 °C (0.9 °F) lower than rectal temperatures.[1]
Oral temperatures are influenced by drinking, chewing, smoking, and breathing with the mouth open.
Cold drinks or food reduce oral temperatures; hot drinks, hot food, chewing, and smoking raise oral temperatures.[3]
Axillary (armpit), tympanic (ear), and other skin-based temperatures correlate relatively poorly with core body temperature.[5]
Tympanic measurements run higher than rectal and core body measurements, and axillary temperatures run lower.[5]
The body uses the skin as a tool to increase or decrease core body temperature, which affects the temperature of the skin.
Skin-based temperatures are more variable than other measurement sites.[5]
The peak daily temperature for axillary measurements lags about three hours behind the rest of the body.[5]
Skin temperatures are also more influenced by outside factors, such as clothing and air temperature.
[ Variations due to outside factors
Many outside factors affect the measured temperature as well. "Normal" values are generally given for an otherwise healthy, non-fasting adult, dressed comfortably, indoors, in a room that is kept at a normal room temperature (22.7 to 24.4 °C or 73 to 76 °F), during the morning, but not shortly after arising from sleep.
Furthermore, for oral temperatures, the subject must not have eaten, drunk, or smoked anything in at least the previous fifteen to twenty minutes, as the temperature of the food, drink, or smoke can dramatically affect the reading.
Temperature is increased after eating or drinking anything with calories. Caloric restriction, as for a weight-loss diet, reduces overall body temperature.[3]
Drinking alcohol reduces the amount of daily change, slightly lowering daytime temperatures and noticeably raising nighttime temperatures.[3]
Exercise raises body temperatures. In adults, a noticeable increase usually requires strenuous exercise or exercise sustained over a significant time.
Children develop higher temperatures with milder activities, like playing.
Psychological factors also influence body temperature:
a very excited person often has an elevated temperature.
Wearing more clothing slows daily temperature changes and raises body temperature.[3] Similarly, sleeping with an electric blanket raises the body temperature at night.[3]
Sleep disturbances also affect temperatures.
Normally, body temperature drops significantly at a person's normal bedtime and throughout the night. Short-term sleep deprivation produces a higher temperature at night than normal, but long-term sleep deprivation appears to reduce temperatures.[3]
Insomnia and poor sleep quality are associated with smaller and later drops in body temperature.[3]
Similarly, waking up unusually early, sleeping in, jet lag and changes to shift work schedules may affect body temperature.[3]

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Methods of Temperature measurement



A medical/clinical thermometer showing the temperature of 38.7 °C

Taking a patient's temperature is an initial part of a full clinical examination.
Sites used for measurement include:
In the anus (rectal temperature)
In the mouth (oral temperature)
Under the arm (axillary temperature)
In the ear (tympanic temperature)
In the vagina (vaginal temperature)
On the skin of the forehead
Over the temporal artery
In the gut (by swallowing a small thermometer)

The temperature reading depends on which part of the body is being measured.
The typical daytime temperatures among healthy adults are as follows:
Temperature in the anus (rectum/rectal), vagina, or in the ear (otic) is about 37.5 °C (99.5 °F)[8]
Temperature in the mouth (oral) is about 37.0 °C (98.6 °F)[4]
Temperature under the arm (axillary) is about 36.5 °C (97.7 °F) [8]

Normal human body temperature varies slightly from person to person and by the time of day. Consequently, each type of measurement has a range of normal temperatures.
The range for normal human body temperatures, taken orally, is 37.0±0.5 °C (98.6±0.9 °F).[4] This means that any oral temperature between 36.5 and 37.5 °C (97.7 and 99.5 °F) is likely to be normal.
The temporal artery is close to the surface of the skin and therefore accessible for reading. The temporal artery is linked to the heart by the carotid artery which is directly linked to the aorta. It forms part of the main trunk of the arterial system. So long as the patient’s blood flow is permanent and regular, the method allows precise measurement of the temperature.
[ Measurement devices

There is a risk of injury from cracking glass thermometers if too much force is applied by the teeth to hold them in place and the alcohol or mercury contents are poisonous.
This is avoided by the use of electronic thermometers which are made from solid plastic and use a metal (thermocouple) sensor.
A plastic thermometer strip placed on the forehead gives an approximate local reading, which depends to a great extent on
ambient (surrounding) air temperature and local circulation effects. Using a thermometer to record the temperature under the armpit is less affected by surrounding air temperature, but is still prone to diverge from true core temperature if there are alterations in blood circulation.
Since the year 2000, small ear thermometers have become available. It is thought that the eardrum closely mirrors core temperature values, and these devices work by detecting the infrared heat emission from the tympanic membrane. A measurement is quickly taken within one second, making them popular for use with children. While the electronic display of the temperature value is easier to read than interpreting the graduation marks on a thermometer, there are some concerns for the accuracy of ear thermometers in home use.[9]

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