PHYSICAL DIAGNOSIS

R. MICHAEL RODRIGUEZ, M.D.

ASSOCIATE PROFESSOR OF MEDICINE

VANDERBILT UNIVERSITY SCHOOL OF MEDICINE

COURSE STRUCTURE

• LECTURES MONDAY AND THURSDAY 1-2PM TUESDAY 8-12AM • TUTOR SESSIONS MONDAY 2:30-4:30 PM THURSDAY 2:30-4:30PM AFTER MIDTERM ALL TUTOR SESSIONS WILL BEGIN AT 1:00PM MANDATORY

• SURROGATE EXAMS MANDATORY

EXPECTATIONS

• DRESS• ALWAYS WEAR A WHITE COAT AND YOUR ID

WHEN YOU SEE A PATIENT• RESPECT – PEERS, INSTRUCTORS, PATIENTS,

HOUSEKEEPING, NURSES• BE ON TIME TO TUTOR SESSIONS

• THE HISTORY, PHYSICAL AND ASSESSMENT ARE TO BE HANDWRITTEN. YOU MAY USE A TEMPLATE FOR THE FILL IN THE BLANKS PORTION OF THE H&P.

CLASS ETIQUETTE

• NO FOOD IN CLASS• BE ON TIME• CELL PHONES OFF IN

CLASS• NO POP TOPS• FEEDBACK - E-MAIL

• ASK QUESTIONS • DISCUSS ISSUES• HELP YOUR

CLASSMATES • NOTIFY EDA OR ME

OF ANY PROBLEMS• RESPECT YOUR

TUTORS AND TEACHERS

• NOTIFY EDA OR ME IF YOU ARE GOING TO MISS A SESSION

HOW WILL YOU BE EVALUATED ON THE WARDS

• DO YOU RESPECT OTHERS?• ARE YOU DRESSED IN A PROFESSIONAL MANNER?• ARE YOU ON TIME?• ARE YOU PREPARED?• ARE YOU A TEAM PLAYER?• ARE YOU COMPASSIONATE?• ARE YOU CARING?• ARE YOU COMPULSIVE?• ARE YOU EASY TO BE AROUND AFTER A NIGHT

ON CALL?• ARE YOU HUMBLE?

GRADES

• TUTOR 1 EVALUATION 20%• TUTOR 2 EVALUATION 2O%• MIDTERM EXAM 20%• FINAL PRACTICAL EXAM 20%• FINAL WRITTEN EXAM 20%• UNEXCUSED ABSENCES FROM TUTOR OR

PATIENT SESSIONS WILL RESULT IN A PENALTY. • NOTE, THIS IS THE FIRST TIME YOU WILL BE

GRADED OBJECTIVELY AND SUBJECTIVELY

GRADING SCALE

HONORS

PASS

FAIL

WHY ARE WE HERE?THE OBJECTIVES

• TO TEACH YOU HOW TO OBTAIN A CLINICAL HISTORY.

• TO TEACH YOU HOW TO PERFORM A PHYSICAL EXAMINATION

• TO TEACH YOU HOW TO ORGANIZE THE INFORMATION .

• TO TEACH YOU HOW TO RECORD THE INFORMATION.

• TO TEACH YOU HOW TO PRESENT THE INFORMATION.

• THE ULTIMATE GOAL IS TEACH YOU HOW TO USE THIS INFROMATION TO HELP YOUR PATIENT.

• THIS IS THE BEGINNING

AS A STUDENT WHAT SHOULD MY GOALS INCLUDE ?

• DEVELOP INTERVIEWING SKILLS• DEVELOP THE SKILLS TO PERFORM A

COMPLETE HISTORY AND PHYSICAL EXAM

• BECOME PROFICIENT IN WRITING AND PRESENTING THE H&P

• BEGIN TO DEVELOP A DIFFERENTIAL DIAGNOSIS FOR SPECIFIC SYMPTOMS AND SIGNS

THE PHYSICIAN PATIENT RELATIONSHIP

THE ROLE OF THE PHYSICIAN IS TO CARE FOR AND COMFORT

• THE INFIRM • THE WEAK • THE SCARED • THE STRONG • THE DYING

IT IS THE HUMAN TOUCH AFTER ALL THAT COUNTS FOR MOST IN OUR RELATION WITH OUR PATIENTS.

ROBERT TUTTLE MORRIS 1915

DO NOT TAKE THIS RESPONSIBILTY LIGHTLY

PHYSICAL*

LAB

HISTORY*

DIAGNOSIS

ASSESSMENT AND PLAN

YOUR GOALPHYSICIAN PATIENT RELATIONSHIP

PHYSICIAN PATIENT RELATIONSHIP

OBSERVE, RECORD, TABULATE, COMMUNICATE. USE YOUR FIVE SENSES…. LEARN TO SEE, LEARN TO HEAR, LEARN TO FEEL, LEARN TO SMELL, AND KNOW THAT BY PRACTICE ALONE YOU CAN BECOME EXPERT. MEDICINE IS LEARNED BY THE BEDSIDE AND NOT IN THE CLASSROOM. LET NOT YOUR CONCEPTIONS OF DISEASE COME FROM WORDS HEARD IN THE LECTURE ROOM OR READ FROM THE BOOK. SEE, AND THEN REASON AND COMPARE AND CONTROL. BUT SEE FIRST…

THAYER WS. OSLER THE TEACHER. BULLETIN OF THE JOHNS HOPKINS HOSPITAL 1919;30:198-200

3 rd YEARH&PA/P

H&P

PHYSICAL

HISTORY

INTERVIEW

WHY ARE INTERVIEWING AND PHYSICAL EXAMINATION SKILLS

IMPORTANT?

• THE HISTORY AND PHYSICAL REPRESENT THE FOUNDATION OF CLINICAL MEDICINE

• THE BOND BETWEEN YOU AND YOUR PATIENT BEGINS OR ENDS DURING THIS TIME. AS YOU DEVELOP AN IMPRESSION REGARDING YOUR PATIENT SO THEY WILL OF YOU.

THE INTERVIEW

A PRACTITIONER OF EXPERIENCE DOES NOT SEIZE THE PATIENT’S FOREARM WITH HIS/HER HAND, AS SOON AS HE/SHE COMES, BUT FIRST SITS DOWN AND WITH A CHEERFUL COUNTENANCE ASKS HOW THE PATIENT FINDS HIMSELF/HERSELF; AND IF THE PATIENT HAS ANY FEAR, HE/SHE CALMS HIM/HER WITH ENTERTAINING TALK, AND ONLY AFTER THAT MOVES HIS/HER HAND TO TOUCH THE PATIENT.

AULUS AURELIUS CORNELIUS CELSUS 25 BC – 50 AD

THE PHYSICIAN PATIENT RELATIONSHIP

• SOME FEEL THAT THE MEDICAL INTERVIEW IS YOUR MOST IMPORTANT SKILL! WHY?

POOR SKILLS • IMPEDE EFFICIENCY• PATIENT COMPLIANCE• PATIENT OUTCOMES • PATIENT SATISFACTION• ? INCREASE MALPRACTICE CLAIMS

MAYO CLIN PROC.2003;78:211-214

WHAT ARE THE FUNCTIONS OF THE MEDICAL INTERVIEW?

• TO GATHER INFORMATION

• TO FORM A RELATIONSHIP WITH THE PATIENT

• TO EDUCATE THE PATIENT

THE MEDICAL INTERVIEW: CLINICAL CARE, EDUCATION, AND RESEARCH. NEW YORK,NY:SPRINGER-VERLAG; 1995:3-19

OBTAINING A CASE HISTORY WHY?

• ALLOWS YOU TO OBTAIN FIRSTHAND INFORMATION REGARDING YOUR PATIENT’S ILLNESSS ( THE STORY), IT’S MANIFESTATIONS AS WELL AS IT’S NATURAL HISTORY.

• THE CONTACT AT THE BEDSIDE FIXES THE DISEASE IN YOUR MIND WHICH READING ALONE CANNOT DO.

COMMON SHORTCOMING OF THE INTERVIEW PROCESS

• INTERRUPTION OF THE PATIENT ( WE INTERRUPT PATIENTS AN AVERAGE OF 18 SECONDS AFTER THE PATIENT BEGINS TO SPEAK) SO----

• WE DO NOT ALLOW THE PATIENT TO SHARE ALL OF THEIR CONCERNS

BECKMAN HB, FRANKEL RM. ANN INTERN MED. 1984; 101:692-696.

BUILDING A RELATIONSHIP WITH YOUR PATIENT (PEARLS)

• P – PARTNERSHIP

• E – EMPATHY

• A – APOLOGY

• R – RESPECT

• L - LEGITIMIZATION

• S - SUPPORTTHE MEDICAL INTERVIEW: CLINICAL CARE, EDUCATION, AND RESEARCH. NEW YORK,NY:SPRINGER-VERLAG; 1995:3-19

PLATT FW, ET AL. ANN INTERN MED. 2001; 134:1079-1085

PATIENT EDUCATION

ASK - TELL - ASK

KELLER VF, CARROLL JG. PATIENT EDUC COUNS. 1994; 23:131-140

THE FIRST INTERVIEW

• EXCITEMENT

• FRUSTRATION

• PATIENCE

• DETAILS

• COMPLETION

WHAT DO I NEED TO DO TO PREPARE MYSELF PRIOR TO THE

INTERIEW?• DRESS• EQUIPMENT• STRATEGIES

AT THE BEDSIDE• ENVIRONMENT• INTRODUCE YOURSELF• DEFINE YOUR ROLE

BEGIN

THE BASIC CONCEPT OF THE INTERVIEW AND PHYSICAL

• TO LEARN THE FACTS THAT LED THE PATIENT TO SEEK YOUR HELP (THE STORY).

• GIVEN THE INFORMATION, IT IS THEN YOUR RESPONSIBILITY TO ORGANIZE THE DATA INTO A FORMAT THAT ALL WILL UNDERSTAND (H&P)

• DEVELOP A PLAN OF MANAGEMENT.

THE INTERVIEW

• DO NOT BE JUDGEMENTAL

• BE COMPASSIONATE

• LISTEN

• DO NOT PUT PATIENTS ON THE DEFENSIVE

• BE GENTLE

THE INTERVIEW

BY THE END OF THE INTERVIEW YOU SHOULD HAVE A CLUE AS TO WHY THE PATIENT SOUGHT MEDICAL ATTENTION ( THE STORY) FROM THE INFORMATION GATHERED IN THE THE CC, HPI, PMH AND THE ROS.

THE INTERVIEW

• FOCUS ON THE PATIENT

• ALLOW THE PATIENT TO SPEAK FREELY AND IN THEIR OWN WORDS

• THEY WILL USUALLY TELL YOU THE STORY

• TRY TO LEARN HOW THIS ILLNESS HAS AFFECTED THE PATIENT

THE INTERVIEW

• HOW DO I REMEMBER WHAT THE PATIENT SAID? RECORD THE INFORMATION

• WHAT IF I FORGET THE ANSWER? ASK THE PATIENT AGAIN.

• ALLOW YOURSELF TIME AT THE END OF THE PHYSICAL EXAM TO ASK FOLLOW-UP QUESTIONS .

I WISH I HAD TO SPEAK OF THE VALUE OF NOTE TAKING. YOU CAN DO NOTHING AS A STUDENT IN PRACTICE WITHOUT IT. CARRY A SMALL NOTEBOOK WHICH WILL FIT INTO YOUR WAISTCOAT POCKET, AND NEVER ASK A NEW PATIENT A QUESTION WITHOUT NOTEBOOK AND PENCIL IN HAND.

WIILIAM OSLER 1903

THE STUDENT LIFE

THE INTERVIEW - RULE OF FIVE VOWELS

A - AUDITION

E - EVALUATION

I - INQUIRY

O - OBSERVATION

U - UNDERSTANDING

TYPES OF QUESTIONS

• OPEN - INTERVIEW BEGINS WITH AN OPEN QUESTION - ALLOWS THE PATIENT TO DISCUSS THEIR ILLNESS

• CLOSED

HAVE YOU HAD A COUGH?

TYPES OF QUESTIONS

• BE CAREFUL HOW YOU ASK THE QUESTION - DO NOT ASK THE QUESTION IN SUCH A WAY THAT THE ANSWER IS IMPLIED

• YOU HAVE NOT TRAVELED HAVE YOU?

• HAVE YOU TRAVELED?

TYPES OF QUESTIONS

• SPEAK IN LAYMANS TERMS

• HAVE YOU EVER RECEIVED MECHANICAL VENTILATION

• HAVE YOU EVER BEEN ON A BREATHING MACHINE

TYPES OF QUESTIONS

• DUPLICATION - YOU MAY REPEAT A QUESTION TO CLARIFY A POINT

• HOWEVER DO NOT REPEAT THE QUESTION IN SUCH A WAY THAT THE PATIENT BELIEVES THAT YOU HAVE NOT BEEN LISTENING

THE INTERVIEW QUESTIONS TO AVOID

• YES-NO QUESTIONS

• SUGGESTIVE QUESTIONS

• WHY

• AVOID MULTIPLE SIMULATANEOUS QUESTIONS

• BUSY - MAKE QUESTIONS CONCISE AND EASY TO UNDERSTAND

THE INTERVIEW TECHNIQUES

• SILENCE

• FACILITATION – “GO ON”, “HMM”

• CONFRONTATION - OBSERVATION

• INTERPRETATION - INFERENCE

• REFLECTION - MIRRORS

• SUPPORT - INTEREST

• PACING

INTERVIEWING TIPS NONVERBAL BEHAVIORS

• BODY LANGUAGE

• EYE CONTACT

• ENCOURAGEMENT

• PHYSICAL CONTACT

• HABITS

• POSITIONING

SIGNS AND SYMPTOMS

• SYMPTOMS - THIS IS WHAT THE PATIENT FEELS

• CONSTITUTIONAL SYMPTOMS FEVER

WEAKNESS

• SIGNS – PHYSICAL FINDINGS -WHAT THE EXAMINER DISCOVERS

AN APPROACH TO A SYMPTOM THE SEVEN ELEMENTS

• BODILY LOCATION• QUALITY• QUANTITY• CHRONOLOGY• SETTING• AGGRAVATING OR ALLEVIATING

FACTORS • ASSOCIATED MANISFESTATIONS

I HAVE A COUGH

• ARE YOU COUGHING UP ANYTHING, IF SO WHAT?

• HAVE YOU HAD A RUNNY NOSE?• DO YOU SMOKE?• DO YOU HAVE ANY PAIN? - IF SO WHEN?• WHEN DID IT BEGIN? • WHEN DOES IT OCCUR?• WHAT MAKES IT BETTER OR WORSE?• WEIGHT LOSS, NIGHT SWEATS

REMEMBER

• HOW LUCKY YOU ARE TO CARE FOR PATIENTS.

• ALWAYS HONOR THE PHYSICIAN PATIENT RELATIONSHIP. NEVER TAKE IT FOR GRANTED.

• LEARN YOUR SKILLS WELL

PERFECT THEM WITH TIME

REMEMBER

• TO ALWAYS USE YOUR SENSES FIRST, DO NOT SUBSTITUTE TECHNOLOGY FOR YOUR EYES, EARS AND HANDS.

• ALWAYS BE ETHICAL AND RESPECTFUL

• YOU ARE THE HEIRS TO CENTURIES OF KNOWLEDGE