History Taking and Physical Examination_An Overview.pdf

History Taking and Physical Examination: An Overview Prepared and presented by Marc Imhotep Cray, M.D. Learning Objectives: By the end of this presentation the learner should be able:  To understand the general principles of the approaches to the patient  To describe the seven components of the comprehensive adult medical history  To explain the essential components of preparing for the physical examination  To describe the equipment required for the physical examination  To list the general sequence of the physical examination  To describe the four cardinal techniques used in preforming the physical examination Marc Imhotep Cray, M.D. 2 Approaches to Patient: General principles General Objectives When physician (or student) approaches a patient (pt.) there are four initial objectives: 1. Obtain a professional rapport with pt. and gain his confidence 2. Obtain all relevant information which allows assessment of illness, and provisional diagnoses 3. Obtain general information regarding pt., his background, social situation and problems  In particular it’s necessary to find out how illness has affected him, his family, friends, colleagues and his life 4. Understand pt.’s own ideas about his problems, his major concerns & what he expects from hospital admission, outpatient or general practice visit Marc Imhotep Cray, M.D. 3 Approaches to Patient: General principles(2) Specific objectives In taking a history (Hx) or making an examination (PE) there are two complementary aims: 1. Obtain all possible information about a pt. and his illness (a database) 2. Solve problem as to diagnoses Marc Imhotep Cray, M.D. 4 Approaches to Patient: GPs (2) Analytical approach  For each symptom (Sx) or sign (Sn) one needs to think of a differential diagnosis (DDx), and  of other relevant information (by history, examination or investigation) which one will need to support or refute these possible diagnoses Self-reliance  The student must take his own history, make his own examination and write his own clinical records Marc Imhotep Cray, M.D. 5 Approaches to Patient: GPs (3) What is important when you start?  At basis of all medicine is clinical competence  No amount of knowledge will make up for poor technique  It is essential to learn and practice the basic ABC of clinical medicine, introduced in this sequence:  how to relate to patients (communication skills)  how to take a good history efficiently, knowing which question to ask next and avoiding leading questions  how to examine patients in a logical manner, in a set routine which will mean you will not miss an unexpected sign  apply yourself  initially learn by rote which skills are appropriate for each situation Marc Imhotep Cray, M.D. 6 Differences Between Subjective & Objective Data Subjective Data Objective Data  What the patient tells you  What you detect during examination  The history, from Chief Complaint  All physical examination findings through Review of Systems  Also, laboratory test and other diagnostic/ investigative techniques Example: Mrs. G is a 54-year-old Example: Mrs. G is an older, over-weight white hairdresser who reports pressure female, who is pleasant and cooperative. over her left chest "like an elephant Height 5’4 weight 150 lbs., BMI 26, BP 160/ 80, sitting there," which goes into her HR 96 and regular, respiratory rate 24, left neck and arm. temperature 97.5 F Marc Imhotep Cray, M.D. 7  History Taking Here we describe the seven components of the Comprehensive Adult Health History: 1. Identifying Data and Source of the History 2. Chief Complaint(s) 3. Present Illness 4. Past History 5. Family History 6. Personal and Social History 7. Review of Systems Marc Imhotep Cray, M.D. 8  1. Identifying Data  Identifying data—such as age, gender, occupation, marital status  Source of history—usually patient, but can be a family member or friend, letter of referral or medical records  If appropriate, establish source of referral, because a written report may be needed Marc Imhotep Cray, M.D. 9 3. Chief Complaint (CC) /Reliability Varies according to the patient's memory, trust and mood The one or more symptoms or concerns causing the patient to seek care Marc Imhotep Cray, M.D. 10  3. Present Illness (HPI)  Amplifies Chief Complaint; describes how each symptom developed  Includes patient's thoughts and feelings about the illness  Pulls in relevant portions of the Review of Systems, called “pertinent positives and negatives”  May include medications, allergies, habits of smoking and alcohol, which are frequently pertinent to the present illness Marc Imhotep Cray, M.D. 11  4. Past History (PMH)  Lists childhood illnesses  Lists adult illnesses with dates for at least four categories:  Medical  Surgical  Obstetric/gynecologic  Psychiatric  Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety Marc Imhotep Cray, M.D. 12  Family History (FH)  Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents  Documents presence or absence of specific illnesses in family, such as hypertension, diabetes, coronary artery disease , etc. Marc Imhotep Cray, M.D. 13 Personal and Social History (PH & SH) Describes:  educational level  family of origin  current household  personal interests and  lifestyle/habits Marc Imhotep Cray, M.D. 14 Review of Systems (ROS)  Documents presence or absence of common symptoms related to each major body system  Review of systems (or symptoms) is a list of questions, arranged by organ system, designed to uncover dysfunction and disease can be applied in several ways: 1. As a screening tool asked of every patient that you encounters 2. Asked only of patients who fall into particular risk categories (e.g. reserving questions designed to uncover occult disease of prostate to men over 50) 3. To better define likely causes of a presenting symptom, as described in HPI section (e.g. patients w/a chief concern of "chest pain" would be asked detailed cardiac and pulmonary ROS)  What's the best way to use ROS? Makes sense if following hold true: o Questions asked reflect an array of common and important clinical conditions o These disorders would go unrecognized if patient was not specifically prompted o Identification of these conditions then has a positive impact on morbidity/mortality Marc Imhotep Cray, M.D. 15 The Comprehensive Adult Physical Examination Beginning the Examination: Setting the Stage  Before you begin the physical examination, take time to prepare for tasks ahead  Think through your approach to patient, your professional demeanor, and how to make patient feel comfortable and relaxed  Review measures that promote patient’s physical comfort and make any adjustments needed in lighting and surrounding environment See Physical Diagnosis: Approach to the Patient (66 CORE ESSENTIALS in sequence, as to not have patient reposition unwarranted.) Marc Imhotep Cray, M.D. 16 Equipment for Physical Examination  An ophthalmoscope and an otoscope • If otoscope is to be used to examine children, it should allow for pneumatic otoscopy  A flashlight or penlight  Tongue depressors  A ruler and flexible tape measure, preferably marked in centimeters  A thermometer  A watch with a second hand  A sphygmomanometer  A stethoscope with following characteristics: • Ear tips that fit snugly and painlessly. To get this fit, choose ear tips of proper size, align ear pieces with angle of your ear canals, and adjust spring of connecting metal band to a comfortable tightness • Thick-walled tubing as short as feasible to maximize the transmission of sound: approximately 30 cm (12 inches), if possible, and no longer than 38 cm (15 inches) • A bell and a diaphragm with a good changeover mechanism Marc Imhotep Cray, M.D. 17 Equipment for Physical Examination cont.  Gloves and lubricant for oral, vaginal, and rectal examinations  Vaginal specula and equipment for cytological and bacteriological study  A reflex hammer  Tuning forks, ideally one of 128 Hz and one of 512 Hz  Q-tips, safety pins, for testing two-point discrimination  Cotton for testing the sense of light touch  Two test tubes (optional) for testing temperature sensation  Paper and pen or pencil Marc Imhotep Cray, M.D. 18 PE: Summary of Suggested Sequence  General survey  CV, for murmur of aortic insufficiency  Vital signs Optional: thorax and lungs-anterior  Skin: upper torso, anterior and posterior  Breasts and axillae  Head and neck, including thyroid and  Abdomen lymph nodes  Peripheral vascular; Optional: skin-lower Optional: nervous system (mental status, cranial torso and extremities nerves, upper extremity motor strength, bulk, tone  Nervous system: lower extremity motor and cerebellar function) strength, bulk, tone, sensation; reflexes;  Thorax and lungs Babinskis  Breasts  Musculoskeletal, as indicated  Musculoskeletal as indicated: upper Optional: skin, anterior and posterior extremities Optional: nervous system, including gait  Cardiovascular, including JVP, carotid Optional: musculoskeletal, comprehensive upstrokes and bruits, PMI, etc.  Women: pelvic and rectal examination  Marc CV,Imhotep for S3Cray,and M.D. murmur of mitral stenosis  Men: prostate and rectal examination 19 Cardinal Techniques of the Physical Examination  Inspection  Palpation  Percussion  Auscultation Marc Imhotep Cray, M.D. 20  Inspection Close observation of details of patient's:  appearance  behavior, and movement such as facial expression  mood  body habitus and conditioning  skin conditions such as petechiae or ecchymoses  eye movements  pharyngeal color  symmetry of thorax  height of jugular venous pulsations  abdominal contour  lower extremity edema and  gait Marc Imhotep Cray, M.D. 21  Palpation Tactile pressure from the palmar fingers or finger pads to assess:  areas of skin elevation or depression  warmth, or tenderness  lymph nodes  pulses  contours and sizes of organs and masses and  crepitus in the joints Marc Imhotep Cray, M.D. 22  Percussion  Use of striking or plexor finger, usually third digit, to deliver a rapid tap or blow against distal pleximeter finger, usually distal third finger of left hand laid against surface of chest or abdomen, to evoke a sound wave such as resonance or dullness from underlying tissue or organs • This sound wave also generates a tactile vibration against pleximeter finger Marc Imhotep Cray, M.D. 23  Auscultation Use diaphragm and bell of stethoscope to detect characteristics of:  heart  lung and  bowel sounds including: location, timing, duration, pitch, and intensity • For heart this involves sounds from closing of four valves and flow into the ventricles as well as murmurs  Auscultation also permits detection of bruits or turbulence over arterial vessels Marc Imhotep Cray, M.D. 24 Comprehensive History and Physical Examination Capsule History of Present Illness (HPI) Vital Signs (VS) The Rest of the history: Eye Exam Past Medical History(PMH) HEENT Head and Neck Exam Past Surgical History (PSH) Lung Exam Medications (Meds.) Cardiovascular Exam Allergies/Reactions Exam of the Abdomen Social and Personal History: Breast Examination (Smoking, Alcohol, Drugs of abuse) Male Genital and Rectal Exam Obstetric (where appropriate) Exam of Upper Extremities Sexual Activity Exam of Lower Extremities Family History (FH) Musculo-Skeletal Examination Work/Hobbies/Other Neurological Examination Military Service Adult Review of Systems (ROS) See Physical Exam Checklists Marc Imhotep Cray, M.D. 25 The History and Physical Examination: Comprehensive or Focused? Comprehensive Assessment Focused Assessment  Is appropriate for new patients in office or  Is appropriate for established hospital patients, especially during routine or  Provides fundamental and personalized urgent care visits knowledge about patient  Addresses focused concerns or  Strengthens the clinician-patient relationship symptoms  Helps identify or rule out physical causes related  Assesses symptoms restricted to to patient concerns a specific body system  Provides baselines for future assessments  Applies examination methods  Creates platform for health promotion through relevant to assessing concern or education and counseling problem as precisely and carefully as  Develops proficiency in the essential skills of possible physical examination Marc Imhotep Cray, M.D. 26 Summary of the Diagnostic process Step 1: Take a History: Elicit symptoms and a timeline; begin a problem list. Step 2: Develop Hypotheses: Generate a mental list of anatomic sites of disease, pathophysiologic processes, and diseases that might produce the symptoms. Step 3: Perform a Physical Examination: Look for signs of the physiologic processes and diseases suggested by the history, and identify new findings for the problem list. Step 4: Make a Problem List: List ALL the problems found during the history and physical examination that require an explanation. Marc Imhotep Cray, M.D. 27 Summary of Diagnostic process(2) Step 5: Generate a Differential Diagnosis: List the most probable diagnostic hypotheses with an estimate of their pretest probabilities. Step 6: Test the Hypotheses: Select laboratory tests, imaging studies, and other procedures with appropriate likelihood ratios to evaluate your hypotheses. Step 7: Modify Your Differential Diagnosis: Use the test results to evaluate your hypotheses, eliminating some, adding others, and adjusting the probabilities. Step 8: Repeat Steps 1 to 7: Reiterate your process until you have reached a diagnosis or decided that a definite diagnosis is neither likely nor necessary. Marc Imhotep Cray, M.D. 28 Summary of Diagnostic process(3) Step 9: Make the Diagnosis or Diagnoses: When the tests of your hypotheses are of sufficient certainty that they meet your stopping rule, you have reached a diagnosis. If uncertain, consider a provisional diagnosis or watchful waiting. Decide whether more investigation (return to Step l), consultation, treatment, or watchful observation is the best course based upon the severity of illness, the prognosis, and comorbidities. Marc Imhotep Cray, M.D. 29  THE END See next slide for links to tools and resources for further study. 30 Sources and Further Study: Cloud Folders Introduction to Clinical Medicine I (ICM-1) Introduction to Clinical Medicine II (ICM-2) Bate’s Guide to the Physical Examination and History Taking, Lynn Bickley (with Video) DeGowin’s Diagnostic Examination, 9th Ed. Richard DeGowin,et al. Textbook of Physical Diagnosis: History and Examination, Mark Schwartz. (with Video) A Practical Guide to Clinical Medicine, Charlie Goldberg and Jan Thompson. (A PDF version of the website compiled by this presenter.) Marc Imhotep Cray, M.D. 31