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Authors: Matthew B. Levit, Doctor of Pharmacy Candidate, Class of 2018 and Kristin Watson, Pharm D, BCPS-AQ Cardiology
Physical examination skills are an essential part of assessing and managing patients.1,2 Unfortunately, the use of physical examination has become a lost art for many practitioners given the widespread growth of other diagnostic tests. Over the past decade, pharmacy schools have shifted the focus of their curriculum to be more clinically oriented but vary in the breadth and depth of physical examination training and experiences offered in the didactic portion of the curriculum.1,2
Performing the physical examination is crucial to assessing a patient’s overall heath and can assist practitioners in making conscientious decisions regarding patient management. The Pharmacists’ Patient Care Process (PPCP) is a new five-step process that can be used as a framework to provide patient care services in any practice setting (See Figure 1).
The first step in this process is “collect”, where pharmacists should obtain the objective and subjective data necessary for completing the next step of the process – “assess.”3 Performing a physical examination of the patient is one way that pharmacists can ensure that they have all of the essential data necessary for making an accurate assessment. Pharmacists can conduct a limited or comprehensive physical examination in many patient care settings – permitted a private space is available – to identify potential etiology of a patient’s symptoms, determine the stability of the patient’s condition, and monitor the effects of a therapeutic intervention.
Competition based on scope of practice among other healthcare professionals may pose a challenge for pharmacists who perform physical examination. However, pharmacists can readily employ these skills in outpatient practice settings. For example, when a patient presents to an anticoagulation clinic, the pharmacist or supervised learner can determine the patient’s blood pressure and heart rate. By performing this assessment, patients may perceive that they are getting a comprehensive evaluation during their routine anticoagulation visit, building trust with their pharmacist as a provider of care. This also provides patients with an opportunity for regular blood pressure screenings, which can be used to guide further evaluation and treatment. Another example includes performing an auscultation of a patient’s lungs and assessment of lower extremity edema in a patient with heart failure who presents with increased shortness of breath. The use of the physical examination coupled with patient interviewing skills can enable the pharmacist to triage the patient for further care.
Pharmacists should receive training prior to performing physical examination, and this education should start in pharmacy school. Advanced pharmacy practice experiences (APPEs) and postgraduate residency training programs are opportunities where pharmacy learners can have physical examination skills reinforced or further enhanced. Pharmacists who are comfortable in conducting components of the physical examination can teach their skills to both trainees and colleagues.
The four basic physical examination techniques are inspection, palpation, percussion and auscultation.2,4 Inspection is observing patients for physiologically abnormal physical characteristics and behaviors. An example of inspection is visual examination of the abdomen and its movement with respiration. Palpation is using touch to assess for abnormalities including temperature of the skin or the presence of edema.4 Percussion is producing sound to determine the size of an organ or the presence of fluid. An example of percussion is assessing for ascites in the abdominal area.3 Auscultation is listening for sounds produced by the body via movement of organs and tissues. An example of auscultation is measuring blood pressure or listening to heart sounds.
With the current state of the healthcare industry, it is becoming more difficult for patients to receive preventative services that can impact their overall quality of life. Pharmacists are on the front line of health care; by integrating physical examination into their practice, pharmacists can help bridge this unmet need and help triage patients when more advanced care is required.
The following are a list of videos that the ATRIUM Cardiology Collaborative has completed, or that the authors have identified as resources for those wishing to reinforce prior physical examination training or to gain a better understanding of the findings reported by other providers. Note: subscriptions may be required for some of these materials.
|Components of the Physical Exam||Videos||Readings|
|Vital Signs||Blood pressure||Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood measurement in humans and experimental animals. Hypertension 2005;45: 142-161.|
|Heart Sounds||Normal heart sounds||Chizner MA. Cardiac auscultation: rediscovering the lost art. Curr Probl Cardiol 2008; 33:326-408.
Etchells E, Bell C, Robb K. Does this patient have an abnormal systolic murmur? JAMA. 1997; 277:564-71.
|Pulmonary Examination||Respiratory examination||Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung auscultation. N Eng J Med 2014; 370:744-51.|
|Lower extremity||Lower extremity physical examination||Boulton AJ, Armstrong DG, Albert, SF, et al. Comprehensive foot examination and risk assessment. Phys Ther. 2008; 88:1436-43.
McGee SR, Boyko EJ. Physical examination and chronic lower-extremity ischemia: a critical review. Arch Intern Med. 1998; 158:1357-64.
Kristin Watson, PharmD, BCPS-AQ Cardiology
Matthew Levit, BS
- Jones, M, Gokun, Y, Cain, J. al. Physical examination instruction in US pharmacy curricula. Curr Pharm Teach Learn. 2014; 6(1):340-47.
- Bolesta, S, Trombetta, DP, Longyhore, DS. Pharmacist instruction of physical assessment for pharmacy students. Am J Pharm Educ. 2011; 75(2):1-7.
- Joint Commission of Pharmacy Practitioners. Pharmacists’ Patient Care Process. https://www.pharmacist.com/sites/default/files/files/PatientCareProcess.pdf. 2014.
- Bickley, LS. (2013). Bates’ Guide to Physical Examination and History Taking (11th) Philadelphia: Lippincott Williams & Wilkins.
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