PUBLICACIÓN DE PRIMERA VEZ SOLUCIONES CREATIVAS BAKE AND COOK

The preceding statements are excellent examples of transparency, describing what you are doing and why in order to open up what may otherwise be a “black box” for the patient. It is also easy for you, and reas- suring for the patient, to indicate that parts of your examination are nor- mal. It is usually not particularly helpful to comment on every little detail, but if you know the patient is concerned about a particular system, it is helpful to note your findings about that system right away. For the patient who presents with chest pain, a comment that the heart and lungs sound normal can be quite reassuring (the patient need not be bothered at this point with the information that the heart may sound normal even when there is heart disease).

Here is an example of a clinician-and-patient conversation during the physical examination, which involved listening to the lungs and heart and palpating the breasts and abdomen. Notice the clinician’s inclusion of a few ROS-type questions, education about breast self-examination, and attention to the patient’s comfort (e.g., “Tell me if I hit any sore places”) as parts of the body are examined.

Clinician Okay, I am just going to loosen this [unties gown in back]. How long have you been smoking?

Patient About 3 years.

And you want to quit?

Well, yeah, I’ve been thinking about it.

Take a deep breath. Okay, out, good, and again. … Good. Now I am going to ask you to slip your arms all the way out and I am going to listen to your heart. … Okay. Sounds good. Now I’m going to check your breasts. I want you to put your hands up like this [demonstrates] and I’m just going to look at them first to see if there are any bumps.

Uh mm.

Okay, have you ever tried examining your breasts?

No, not really.

We recommend that everyone do it once a month; the best time is right after your period has stopped. Do your breasts get sore before your period?

Yes.

Okay, well, that is why it is best to wait until after your period starts, when usually the lumpiness goes away and they’re not tender to touch. … I am going to ask you to just hold this up …

and I want you to put your arms up over your head. What you do when you are checking is to do exactly what I’m doing. … Go all around the outside of your breasts like this … up here is breast tissue and also up here … so you are going to go in kind of a circle like this … then spiral in until you get every part including under the nipple. Okay? Now I’d like you to lie down and we’ll check your breasts again. … We always check them in two positions. … And I am going to check your heart. … Do you have any indigestion or trouble with your bowels? Now tell me if I hit any sore places.

For the female patient, the pelvic examination is a particularly per- sonal and anxiety-producing experience. To alleviate your patient’s dis- comfort, explain clearly what you are about to do and what the patient is likely to feel. Ask the patient if she has had a pelvic examination before. Whether she has or not, it is very reassuring to say, “I’m going to pretend that this is your first pelvic examination and explain everything that I’m doing.” The less experience the patient has had, either with pelvic exam- inations or with you, the more reassurance she will need. You should first touch the patient’s inner thigh and then firmly but gently conduct the examination. You should describe the anatomy to the patient as you are doing the examination, another opportunity for transparency. As you become more experienced, you will be able to help her relax her muscles through your calm tone of voice, your gentle palpation, and your instruc- tions about deep, slow breathing.

Here is how one clinician introduced a patient (who had requested a diaphragm for birth control) to her first pelvic examination. Each step is described with a relaxing, almost hypnotic, tone of voice; gestures are slow and deliberate (no sudden moves); and the clinician continuously looks at the patient’s face to gauge her reactions.

Clinician The next thing I am going to do is a pelvic exam. These are all the things I normally use, but I may not use all of them on you. Okay. These are the slides on which the Pap test is done, and these are the little brushes that I use to do the Pap test. See how soft they are? And this also, which I will roll around the cervix just like that [demonstrating], see, it is not sharp. … We usually do a culture for infection at the same time.

Patient A culture?

Yes, and that is to check for infection. This instrument is cold, and that is really the worst thing about it. It is called a specu-

lum and this is inserted very gently into the vagina and then opened very gently like that [demonstrating] so that I can see your cervix and see that it is normal. Okay? [Patient nods.] What I will ask you to do is to put your feet into these things, which are called stirrups, these metal things, that’s good, and now I want you to pull yourself all the way down to the end of the table like that, and practically feel yourself like your bot- tom is coming off the end of the table. Okay? That’s fine. I am going to put this pillow under your head right there, okay, and I am going to shine a light on you so that I can see what I am doing and as I do things I will tell you what I am doing. Okay? Are you more or less comfortable?

I guess so.

All right, it is not very comfortable, that is true. Okay. Now what I am going to do is to look at the outside of you first. If you can just kind of relax, that’s good. Now what I am doing is check- ing the labia, or lips. Good. Now you are going to feel my finger at the edge of the vagina, feeling where your cervix is. Do you know what your cervix is?

No.

Okay, that is the opening to your womb or uterus. Okay, I am just kind of locating it first, and that is just my finger again. Okay, now you’re going to feel the cold metal which I tried to warm up a little bit, but usually it’s still cold. Is that okay?

Mm hmm.

Now I insert it just until I can see your cervix so that I can