med 1.1.1 history taking and clinical decision making.pdf

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

The adrenaline and stress of an adventure are better than a thousand peaceful days. Paulo Coelho Paulo Coelho

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Alfredo Guzman, M.D.

History Taking and Clinical Decision Making

1.1.1 2 June

2014

THE VALUE OF HISTORY TAKING

Directs the focus of the physical exam

Often the basis for differential diagnosis (differential diagnosis are

done during Hx taking)

Keys

o Trust (respect, dress appropriately, etc.)

o Right questions (open/close ended Qs)

o Interpreting responses

o Knowing what to do next

Care begins simultaneously

FIRST IMPRESSIONS

Positive impression

Appearance

Confidence

Demeanor

Body language

ESTABLISHING THE PATIENT RELATIONSHIP

Avoid putting things on top of the bed

Invited guest or unwanted pest?

Respect person, space, property, family

Locate px/s

Introduce yourself handshake

Determine pxs desired name

Avoid disrespectful terms & voice tone

Consider age & culture

TIPS FOR EFFECTIVE HX TAKING

Types of questions

Open ended Qs

What seems to be bothering you today?

Close ended Qs- BEST

Is your chest pain sharp or dull?

Multiple choice Qs

Listen actively

o Act as if you are listening

o Repeat pxs statements

o Clarify if needed

o Take notes

o Display concern

o Confront w/ caution

o Explore CC in more detail

o Explore other complaints

Are they associated? Do they involve completely different body systems?

Subjective Data - What the px tells you

- the Hx,from CC through ROS

Objective Data

- What you detect during the examination

- All PE findings

Pain most common sx

THE HISTORY & PE: COMPREHENSIVE OR FOCUSED?

Comprehensive Assessment Focused Assessment

Is appropriate for new pxs in

the office/hospital

Is appropriate for established

pxs, especially during routine/

urgent care visits

Provides fundamental &

personalized knowledge about

the px

Addresses focused

concerns/symptoms

Strengthens the clinician-px

relationship

Assesses the specific body

sytems relevant to the pxs

concerns

Helps identify/ rule out physical

causes related to px concerns

Develops proficiency in the

essential skills of physical

examination

*We will do the Comprehensive Assessment since were newbies.

COMPONENTS OF THE HEALTH HISTORY *Bates

Identifying Data

Age, gender, occupation, marital status

Source of hx usually the px, but can be a family member/ friend, letter of referral, or the medical record

If appropriate, establish source of referral, because a written report may be needed

Reliability varies according to memory, trust, &

mood

Chief Complaint/s 1 sx/ concerns causing the px to seek

care

Hx of Present Illness

Amplifies CC, describes how each sx developed

Pxs thoughts and feelings about illness

Pulls in relevant portions of ROS (pertinent +s & -s)

Medications, allergies, habits (smoking, alcohol), w/c are frequently pertinent to the present illness

Past Medical Hx

Childhood illnesses

Adult illnesses w/ dates for medical, surgical, obstetric/gynecologic, psychiatric

Health maintenance practices: Immunizations, screening tests, lifestyle issues, home safety

Family Hx

Outlines/diagrams of age, health, age & cause of death of siblings, parents, & grandparents

Documents presence/absence of illnesses in family (HPN, CA disease, etc)

Personal & Social Hx

educational level, family of origin, current household, personal interests, lifestyle

Review of Systems

Documents presence/absence of common sx related to each major body system

ELEMENTS OF THE COMPREHENSIVE HEALTH HX

(GUIDELINES FOR HX TAKING & PE)

I. GENERAL DATA

To Identify px

TOPIC OUTLINE

I. The Value of History Taking

II. First Impressions

III. Establishing the Patient Relationship IV. Tips for Effective History Taking

V. The History & PE: Comprehensive or Focused?

VI. Components of the Health History VII. Elements of the Comprehensive Health Hx

(Guidelines for Hx Taking & PE) A. General Data

B. Chief Complaint (CC)

C. History of Present Illness (HPI) D. Past Medical History

E. Family History F. Personal/ Social History

VIII. Review of Systems

IX. Special Challenges and Common Pitfalls X. Physical Exam (Highlights)

XI. Clinical Decision Making


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Introduction to

Clinical Medicine

Informant indicate, ID & give estimate of accuracy (to

determine reliability of px)

Name, age, sex, marital status, nationality, religion, occupation,

birthplace, present address, number of admission in this

particular hospital, exact date of admission

Admissions include order & locxn of admission

ER NOT an admission

II. CHIEF COMPLAINT (CC)

Prolonged sx

May not be sx of a more serious disease

Only 1 CC

Single most critical concern to px

o What prompted you to seek consultation?

o What can I help you w/ today?

o W/c sys (origin) do you believe to be affected by this CC?

o Do you clearly understand the pxs complaint/s?

Record simple statement of pxs complaint in his own words, 1-

few words or phrase (non-verbatim)

Description of sx should be at the HPI

Multiple complaints

o If I could make 1 thing better for you, w/c would you want it

to be?

o Are the multiple complaints likely to be related?

o Will you need to address multiple issues?

o Could some of these be chronic issues?

III. HISTORY OF PRESENT ILLNESS (HPI)

Explore CC in more detail

Explore other complaints

o Are they associated?

o Do they involve completely different body systems?

Complete, clear, & chronologic account of the problems

prompting the px to seek care

Include: o Onset of the problem

o Setting in w/c it has developed

o Manifestations

o Any treatments

Should reveal the pxs responses to his/her sx & what effect the illness has had on the pxs life

Medications

o Name, dose, route frequency of use

o Home remedies, nonprescription drugs, vitamins,

mineral/herbal supplements, oral contraceptives, meds

borrowed from family members/friends

Allergies

o Specific reactions to each medication (i.e. rash/nausea)

o Allergies to food, insects, or environmental factors

Tobacco use (pack-years)

o no. of packs/day x yrs of smoking = pack-yrs

o E.g. A person who has smoked 1 packs/day for 12 yrs has

an 18-pack-yr history (1 x 12 = 18)

o If someone has quit, note for how long

o Like Doc Tengco, married for 30 yrs. How many **ck years?

(Guzman, 2014)

Alcohol & drug use should always be indicated in HPI

Chronology

- provides structure for organizing data, particularly when multiple sx are present

Additional Qs related to temporal aspect of illness

o Frequency

o Periodicity

o Duration of typical episode

o Typical day/night

o Time of onset of sx (ask the last time he felt well)

Bodily locations of sx (& radiation if any)

Quantitative Qs

o Volume

o No

o Size

o Extent

Qualitative Qs

o Intensity

o Severity

o Comparison w/ previous experiences

Precipitating factors

Alleviating factors

Impact of illness on pxs life

o Relationships

o Exercise tolerance

o Ability to concentrate

o Athletic/leisure activities

Associated sx & info w/c might help in differential diagnosis:

o All items in pertinent system

o Qs provoked by abnormalities in PE

o Nonspecific manifestation of organic disease

o Qs provoked by etiologic possibilities

o Hx of test/procedure done to arrive at diagnosis

o Hs of previous diagnosis

o Med/drugs currently taking (religiously or not)

PQRST of Symptoms

Provocative/Palliative factors aggravates/relieves sx

Quality

Radiation common in pain

Severity (pain scale/grading) limit pxs activities

Timing onset of sx

The 7 attributes of a symptom

*Bates

(Provocative/Palliative) Remitting/ Exacerbating Factors

aggravated/relieved sx

Quality

(Radiation/) Location

Severity/ Quantity

Timing onset, duration, frequency

Setting in w/c it occurs

Associated manifestations

Pertinent positives & pertinent negatives designate presence/

absence of sx relevant to differential diagnosis

IV. PAST MEDICAL HISTORY (Paragraph form)

Health maintenance

o Immunizations

o Screening tests (e.g. Pap smears, mammograms)

Diagnosed childhood illnesses, medications taken

o HPN: highest, lowest, regular level; were diagnosed follow-

up consultations

Previous hospitalizations/surgical procedures, dates

reasons/indications, complications, blood transfusions, adult

illnesses

o Medical

Diabetes, HPN, Hepatitis o Surgical

Dates, indications, types of operation o Obstretic

Obstetric hx, Menstrual hx Birth control, Sexual function

o Psychiatric

Dates, diagnoses, hospitalizations, treatments

Previous accident & trauma

Paragraph form

Age, health or cause of death of parents, grandparents, uncles and aunts, and siblings (parents and siblings are the most important)

Family incidence of HPN, DM, TB. CA. mental disease, blood disorder

VI. PERSONAL/SOCIAL HISTORY

Paragraph form

Marital duration, health of partner

Place of birth and residence

Highest level of education

Habits: o Regularity of eating/sleeping o Exercise


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Introduction to

Clinical Medicine

o Coffee o Smoking (in pack years) o Drugs

Occupation (past and present work o Past and present work o Exposure to occupational disease o Duration of work

Personality Traits o Outgoing o Quiet o Moody

Weight o Usual weight o History of weight loss/gain

Type of residence where patient lives o Number of rooms and occupants o Water source o Fecal disposal

Neighborhood o Congested o Proximity to unusual place o Buildings

Nutritional history

REVIEW OF SYSTEMS

Documents presence or absence of common symptoms related to each major body system

Most ROS questions pertain to symptoms, but some also include diseases like pneumonia or TB

Start with general questions as you address each system (this focuses the patients attention), then shift to more specific questions about systems that may be of concern.

Vary the need for additional questions depending on the patients age, complaints, general state of health, and your clinical judgment

ROS may uncover problems that the patient has overlooked (unrelated to present illness)

This section should be described in detail the signs and symptoms listed below to include o Duration o Severity o Provocative and palliative factors

System Signs and Symptoms

Head, Eyes, Ears, Nose, Throat (HEENT)

Head: headache, lumps, discomforts, head injury

Eyes: vision, use of glasses, eye pain

Ears: hearing, earache, discharge, tinnitus (ringing in the ears), vertigo

Nose: epistaxis (nose bleed), congestion, discharge

Throat: bleeding gums, dentition, dental caries, sore throat, hoarseness, masses in the neck, dysphagia (difficulty in swallowing) or odonophagia (pain produced by swallowing)

Integumentary Skin: rashes, pruritus (itching), dryness, lumps, sores

Hair: loss of hair, hirsutism (for women only excessive growth of hair of normal or abnormal distribution)

Respiratory Pain in chest, dyspnea (difficulty in breathing), cough, sputum (color, quantity), audible wheezing (breathing difficultly usually with whistling sound), hemoptysis (expectoration of blood from some part of the respiratory tract), night sweats, pleurisy (inflammation of the pleura nest to the lung, last chest x-ray, you may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis

Cardiovascular Palpitation (awareness of own heartbeat), orthopnea (inability to breathe except in an upright position - advance HF), paroxysmal nocturnal dyspnea, chest pain/discomfort, edema (abnormal excess accumulation of serous fluid in connective tissue or in serous cavity), easy fatigability, cyanosis (bluish or purplish discoloration), intermittent

claudications (cramping pain and weakness in the legs that disappears after rest, and is usually associated with inadequate blood supply to the muscle; pulikat), varicosities (prominence of the veins)

Gastrointestinal Nausea, vomiting, abdominal pain, change in bowel habits (describe bowel habits e.g. diarrhea, constipation), stools (color, consistency), frequency, melena (passage of dark tarry stools containing decomposing blood that is usually an indication of bleeding in the upper GIT), hematochezia (passage of blood in the feces that is usually an indication of bleeding in the lower GIT), hematemesis (vomiting of blood), jaundice, liver or gallbladder trouble, etc.

Hematemesis with hematochezia sever upper GI bleeding

Genitourinary Amount and frequency of urination, color, and character or urine, dysuria (difficult or painful urination), hematuria (presence of blood or RBC in the urine), anuria (40cc/day), oliguria (400cc/day), polyuria (>3L/day), nocturia (urination > 2x/night; may suggest polyuria), urinary retention, dribbling (continuous dripping or urine), incontinence (involuntary loss of urine), enuresis (bed wetting without incontinence)

Hematologic Pallor (paleness), bleeding gums (observed after brushing teeth), epistaxis, hematoma (mass of usually clotted blood that forms in a tissue, organ, or body space as a result of a broken blood vessel), hematemesis, melena, easy bruising, prolonged bleeding

Neuromuscular Memory loss, nervousness, insomnia, vertigo, movement disorders (tremors, convulsions, chorea, athetosis, etc.), joint pains, muscle weakness/paralysis, language/speech problems, sensorial changes (hypesthesia, hyposthesia, hyperesthesia, etc.)

Endocrine Cold or heat intolerance

s/sx of hyperthyroidism: weight loss, increased appetite, weakness, palpitations, diarrhea

s/sx of hypothyroidism: sluggishness, easy fatigability, hoarseness, complaint of coldness

s/sx of diabetes: weight loss, polyuria, polydipsia (excessive or abnormal thirst), polyphagia (excessive appetite or eating), pruritus, numbness of skin, recurrent pyogenic infection of the skin

Obstetric and Gynecologic

Menstrual history: menarche, menopause, regularity, duration and heaviness of bleeding, date of last period

Pregnancy: number of abortions, miscarriages, live births, methods of delivery, living children

Veneraal diseases

SPECIAL CHALLENGES

Interviewing patients may precipitate several behaviors and situations that seem particularly vexing or perplexing

Always remember the importance of listening to the patient and clarifying the patients concerns

SENSITIVE TOPICS

The right location o Does anyone present make the patient feel uncomfortable?

Gaining trust

Choosing appropriate words

Understand the patients feelings related to the sensitive nature Be professional

THE SILENT PATIENT

Short periods of silence may be normal

Allow time to collect thoughts


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Introduction to

Clinical Medicine

Provide reassurance and encouragement

Consider: o You have frightened the patient o You are dominating the discussion o You have offended the patient o There is a physical or mental disorder

THE OVERLY-TALKATIVE PATIENT

Allow patient to speak

If necessary, politely interrupt and focus the discussion

Focus on most critical issue

Ask specific, closed-ended questions

Summarize the patients story and move on Dont display impatience

THE ANXIOUS OR FRIGHTENED PATIENT

Look for signs of anxiety and fear

Try to alleviate concerns and develop trust

No false reassurance o Everything is going to be fine.

Identify the source of anxiety/fear

Understand the patients feelings o I dont know why youre so anxious.

THE ANGRY OR HOSTILE PATIENT

Common feelings with stress or fear

Understand the source of these feelings

Respond in a professional and caring manner

Personal safety is a primary concern o Distance o Assistance o Firm but caring verbal and body language

THE INTOXICATED PATIENT

Irrational

Altered sense of right and wrong

May become violent

If patient is shouting o Increased potential for violent behavior o Listen o Dont respond back with shouting o Have assistance for safety

THE DEPRESSED OR SUICIDAL PATIENT

Know the warning signs

Explore the specific feelings of the patient o Be direct and specific o Question regarding thoughts of suicide or personal harm o Talk openly and specifically about suicide plans

THE PATIENT WITH CONFUSING BEHAVIOR OR HISTORY

The entire history does not add up

Assess mental status

Consider possible dementia or delirium o Identify cause of possible o Consider specific causes based upon behavior

Confabulation Multiple personalities

Patients with frontal love tumors may manifest with psychiatric symptoms o Ensure neurologic examination

THE PATIENT WITH LANGUAGE BARRIER

Extremely difficult to assess

Enlist friends or family to act as an interpreter

Use pre-established questions in the patients language Language lines

INTELLIGENCE AND LITERACY

Does the patient really understand your questioning?

o History may be inaccurate o Enlist friends or family

Can the patient actually read? o Read statements aloud to the patient

THE PATIENT WITH SENSORY DEFICITS

Hearing impaired o Does the patient read lips

Face patient, close to good ear Talk slowly and distinctly Sign language?

o Will a hearing aid help? Where is it?

Blindness o Voice and touch and critical o Establish relationship and trust early on

COMMON PITFALLS

Patients Impression

Choosing to ask a lot of questions to obtain a history without also directing initial care or performing a physical exam.

Not doing anything for me

Why are we wasting our time here?

Stop asking all these silly questions.

Using a tone of voice that sends the wrong message.

What is your problem today, Mrs. Jones?

Why did you call 911?

He thinks I call EMS for every little problem.

I must have called 911 and was not supposed to.

I think I am bothering these nice people.

Lack of respect for cultural, religious, or ethnic differences.

Why do you people use these home herbal medicines?

You have enough kids. You should consider birth control.

This person thinks I am a fool.

She laughs at the traditions of my culture.

He does not respect my personal decisions.

Poor choice of words or using technical terms.

How many years has your husband been taking these ACE-inhibitors?

Your wife is experiencing congestive heart failure.

What the heck is he talking about?

My wifes heart is failing?!?! Has her heart stopped yet?

Son, could you speak English?

SUMMARY

Obtaining the Hx guides the PE Hx-taking is accomplished along with the PE and therapies For emergent patients, the Hx-taking is delayed or never actually

obtained in the pre-hospital setting

THE PHYSICAL EXAM

The key to a thorough and accurate physical examination is developing a systematic sequence of examination.

An important goal is to minimize the number of times you ask the patient to change position

An initial assessment of the patient will have been made whilst taking the history. The general appearance of the patient will be your first observation.

GENERAL SURVEY

The survey continues throughout the history and examination. 1. State of awareness and level of consciousness

(drowsy, stuporous, lethargic, comatose) 2. Orientation to 3 spheres

(time/person/place) 3. General state of health 4. Build

(endomorph, mesomorph, ectomorph) 5. Sexual development 6. Posture, motor activity, and gait

(coordinated, uncoordinated, staggering, shuffling, stumbling, unable to walk alone, w/ assistive devices)

7. Signs of distress (pain, cardiorespiratory)

8. Skin color and lesions 9. Body habits 10. Degree of nourishment


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Introduction to

Clinical Medicine

(obese, cachexic, well-nourished) 11. Dress, grooming, and personal hygiene 12. Odors of the body or breath 13. Facial expressions

(calm, worried, restless, tense) 14. Manner of speaking and mood

VITAL SIGNS

The patient is sitting on the edge of the bed or examining table (unless contraindicated). 1. Height and weight

> Other anthropometric measurements (if indicated: BMI, WHR, MUAC)

2. BP (indicate if Sitting / lying / standing) 3. PR (indicate also if regular/irregular) 4. RR (indicate also if regular/irregular) 5. Temperature (if indicated: Oral / axillary / rectal)

SKIN

Continue your assessment of the skin as you examine other body regions. 1. Observe the skin of the face and its characteristics 2. Identify the presence of any lesion/s (location, distribution,

arrangement, type, and color) 3. Inspect and palpate the hair and nails 4. Skin color (pallor, jaundice, flushing, cyanosis); temperature (cold,

slightly warm, warm -local / systemic); turgor, moisture (very dry, sweaty , oily, moist in skin folds)

5. Study the patients hands

HEAD, EYES, EARS, NOSE, THROAT (HEENT)

HEAD

1. Configuration (normocephalic, masses, skull deformation, depressions)

2. Hair (fine, coarse, dry, breaks easily, color, normal distribution, bald spot, alopecia)

3. Scalp (clean, dandruff, lice, lesions)

EYES

The room should be darkened for the ophthalmoscopic examination to promote papillary dilation and visibility of the fundi. 1. Visual acuity, visual fields, color field, position and alignment 2. Observe the eyebrows and eyelids 3. Inspect the sclera, conjunctiva, cornea, iris, and lens 4. Compare the pupils and test their reactions to light 5. Extraocular movements 6. Inspect the ocular fundi 7. Demonstrate reflexes (corneal and pupillary) 8. Perform fundoscopy (disc, vessels, retina, and macula)

Eyelids Symmetry, edema/swelling [R / L], ptosis [R / L], entropion, ectropion

Periorbital Region

Edema, sunken, discoloration, xanthelasma, lesions

Conjunctiva Pinkish, pale, lesion, discharge, hemorrhage

Sclera Anicteric, subicteric, icteric, hemorrhage

Cornea & Lens Smooth, clear, lesions, opacity, arcus senilis, corneal reflex

Pupil Size Equal, unequal R ___mm L ___mm

Reaction to Light

Brisk, sluggish, fixed, unequal

Accommodation Uniform, unequal

Convergence Uniform, unequal

Visual Acuity Able to read newsprint with __ font size at __ distance with [R / L / both eyes], grossly normal, wears glasses / contact lenses, intact peripheral visual fields

EOM Coordinated, uncoordinated

Eyebrows Hair distribution

Lacrimal Duct Easy tearing, tenderness, discharge, inflammation

EARS

1. Inspect the auricles, canals, and drums 2. Auditory acuity

o If diminished, check lateralization: Weber test o compare air and bone conduction: Rinne test

3. Perform otoscopy, describe tympanic membrane

External Pinnae Normoset, symmetrical, tenderness, gross

abnormalities

External Canal Impacted cerumen, lesions

Discharge Foul-smelling, serous, purulent, mucoid, color, amount

Gross Hearing Normal, hearing problem [R L]

Weber Test(lateralization)

Positive, negative

Rinne Test Air conduction >/< bone conduction

NOSE AND SINUSES

1. Examine the external nose 2. Inspect the nasal mucosa, septum, and turbinates using a light and

a nasal speculum. 3. Palpate for tenderness of the frontal and maxillary sinuses

Nasolabial Fold

Symmetrical, shallow [R / L]

Septum Midline, deviated, perforated, polyps

Mucosa Pinkish, pale, reddish

Discharge Serous, purulent, mucoid, bloody

Patency Both patent, obstructed [R / L], masses / lesions

Sense of Smell

Sinuses Tender, nontender, result of transillumination

MOUTH AND PHARYNX/THROAT

You may wish to assess the cranial nerves during this portion of the examination

Lips Pallor, cyanosis, dryness / cracks, lesions, mouth sore, cleft

Tongue Midline, deviated [R /L], atrophy, fasciculations, lesions, color

Teeth Complete, missing, carries, dentures , braces/retainers

Gums Pinkish, pale, bleeding, tenderness

Mucosa Oral: Pinkish, pale, cyanotic Pharynx: Dull red, pale, cyanotic, with exudates: color

Palate Lesion, cleft

Uvula Midline, deviated [R / L]

Tonsils Inflammation: grade

Speech Intact, slurred, aphasic, others

Sputum Color, amount, others

Smooth muscle movements

Tongue moves side to side, gag relfex

NECK

1. Inspect and palpate the cervical lymph nodes 2. Note any masses or unusual pulsations in the neck 3. Feel for any tracheal deviation 4. Observe sound and effort of breathing 5. Inspect and palpate the thyroid gland. Note the size, shape,

consistency, bruit and movement upon swallowing (Move behind the sitting patient to feel the thyroid gland)

6. Scar

Trachea Midline, deviation [R /L]

Lymph Nodes Nonpalpable, palpable, enlarged, tender

Thyroid Nonpalpable, enlarged: unilateral/bilateral, discrete nodules, firmly attached, freely mobile

Others Normal ROM, neck rigidity, NVE at ____ masses: size, shape

BACK

Inspect and palpate the spine and muscles of the back

POSTERIOR THORAX AND LUNGS

1. Inspect and palpate the spine and muscles of the upper back 2. Inspect, palpate, and percuss the chest 3. Identify the level of diaphragmatic dullness on each side 4. Breath sounds 5. Adventitious sounds 6. Transmitted voice sounds (if indicated)

Inspiration Expiration


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Introduction to

Clinical Medicine

Ratio (IE ratio)

Inspection Pectus excavatum (hollowed chest), Pectus carinatum (pigeon chest), lesions

Breathing Pattern

Eupnea, hyperpnea, tachypnea, dyspnea, use of accessory muscles

Shape of Chest APL Ratio: ___AP ___L Barrel, funnel, pigeon, others

Chest Expansion

Symmetrical, decrease / lag [R / L]

Tactile Fremitus

Symmetrical, inc / dec at [R / L]

Vocal Fremitus Bronchophony, whispered pectoriloquy, egophony

Breath Sounds Vesicular over: most of lungs, [R / L], I/E, pitch: low / medium / high; absent Bronchovesicular over: 1

st& 2

nd ICS, I/E,

intrascapular, pitch: low / medium / high Bronchial over:manubrium, lobar pneumonia, I/E, pitch: low / medium / high

Adventitious Sounds

Rhonchi over, wheezes over, crackles / rales, pleural friction rub, stridor

Percussion Resonant [R / L], dull [R / L] over, hyperresonant [R / L] over

Excursion Diaphragmatic dullness at, respiratory excursion around

BREAST, AXILLAE, AND EPITROCHLEAR NODES

1. In a woman, inspect and palpate the breasts (in supine position) with her arms relaxed, then elevated, and then with her hands pressed on her hips.

2. Note the size, symmetry, contour, color, edema, venous pattern, and dimpling of the breasts.

3. Note the size, shape, inversions, ulcerations, discharge, and tenderness of the nipple.

4. In either sex, inspect the axillae and feel for the axillary nodes. Feel for the epitrochlear nodes.

Symmetry Equal, unequal

Contour Masses [R / L], dimpling [R / L]

Skin Redness, edema, lesions

Tenderness Tender at, nontender

Nipple and Areola

Inversion, flattening / retraction, deviation to [R /L], edema

Lymph nodes

ANTERIOR THORAX AND LUNGS

1. Inspect, palpate, and percuss the chest. 2. Breath sounds, adventitious sounds, transmitted voice sounds (if

indicated)

CARDIOVASCULAR SYSTEM

Elevate the head of the bed to about 30 1. Observe the jugular venous pulsations, and measure the jugular

venous pressure in relation to the sternal angle. 1. Inspect and palpate the carotid pulsations 2. Listen for carotid bruits

HEART

1. Inspect and palpate the precordium (note thrills, point of maximal impulse).

2. Location, diameter, amplitude, and duration of the apical impulse 3. Listen at the apex and the lower sternal border with the bell of a

stethoscope. Ask the patient to roll partly onto the left side while you listen at the apex.

1. Listen at each auscultatory area with the diaphragm. 2. Listen for the first and second heart sounds 3. Listen for any abnormal heart sounds or murmurs. The patient

should sit, lean forward, and exhale while you listen for the murmur of aortic regurgitation.

Pericordial Area

Flat, bulging, normodynamic, hyperdynamic, tenderness, heaves / thrills, PMI at __

Jugular Veins Normal, distension: lying ___degrees, ___cm

Carotid Arteries

Easily palpable, diminution

Heart Sounds Faint, distinct S3 S4 S1__S2 at base; S1__S2 at apex Murmur, grade __ best heard at ____

Percussion Cardiac dullness from ___ to ___ ICS

ABDOMEN

Examine with the patient in supine. Examiner standing on the right side of bed.

Inspect, auscultate, palpate and percuss. 1. Inspection

Scars, striae, dilated veins, rashes, Umbilicus: contour, eversion, inflammation, hernia Abdominal contour: flat, scaphoid, globular, masses, pulsations

2. Auscultation

Bowel sounds, gurgles, bruits, Borborygmi 3. Palpation

Deep and light palpation for masses, areas of tenderness, ballottement, characterize mass (soft, hard, doughy) Assess the liver and spleen by percussion and then palpation. Try to feel the kidneys Palpate the aorta and its pulsations.

4. Percussion

Fluid, shifting dullness, areas of dullness (liver, spleen and other masses) Tympany, Traubes space. For suspected kidney infection, percuss posteriorly over the costovertebral angles.

Skin Dilated veins, striae, scar, rashes, lesions

Umbilicus Sunken, bulging, hernia

Configuration Flat, globular, protuberant, scaphoid Symmetrical, asymmetrical

Bowel Sounds Normoactive ____/min, hyperactive ____/min, hypoactive ____/min Absent, dull, medium, loud

Bruit Absent, present over _____

Percussion Tympanitic, hyperresonant over Dull over fluid wave shifting dullness

Palpation Muscle guarding Liver: tenderness, span CVA tenderness, rebound tenderness Splenic dullness Aorta: palpable, well-defined mass

Psoas Sign

Obturator Sign

Pregnant LMP ___wks Fundic Height ____cm Fetal Position and Lie: [R / L] ______________ Fetal Presentation ____________ , ballottement FHR: ______beats/min at _________

GENITALIA

1. MEN Patient is standing. Examiner seated on stool. Male penis Size, circumsized, urethral meatus, ulcers, scars, tenderness,

indurations, note scrotum and content, transilluminate; Hernia external inguinal ring

2. WOMEN Patient is supine in lithotomy position. Examiner seated during speculum exam and standing during

bimanual exam of uterus and adnexa. Female external genitalia Labia majora, minora, clitoris and urethral orifice Bimanual examination of vagina, cervix, uterus, adnexae,

rectovaginal pouch Obtain Pap smear.

RECTUM

Men: patient is lying on his left side; examiner standing Women: patient is supine in lithotomy position; examiner is

standing. Inspect anus and perianal area. Note lumps, inflammation and

rashes. Ask patient to strain down and note hemorrhoids, fissures and other lesions

Digital exam: note sphincter tone of anus, tenderness, nodules. Examine prostate, size, shape, consistency, nodularity and tenderness

PERIPHERAL VASCULAR SYSTEM

Upper: symmetry, nail beds, color Pulses: brachial, radial, ulnar Lower: symmetry, nail beds, color and edema; examine legs,

assessing three systems while patient is supine.


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-Pulses: femoral, popliteal, dorsalis pedis, posterior tibial, varicosities

MUSCULOSKELETAL SYSTEM

Evaluate each joint for: 1. Limitation of normal range of motion 2. Swelling 3. Deformity 4. Crepitation 5. Strength 6. Muscle atrophy By this time, you have made some preliminary observations of the

musculoskeletal system. Use these and subsequent observations to decide whether a full musculoskeletal examination is warranted.

Examine the hands, arms, shoulders, neck, and temporomandibular joints.

Inspect and palpate the joints. Check their range of motion.

NERVOUS SYSTEM

The complete examination of the nervous system can be done at the end of the examination.

MENTAL STATUS

Assess the patients orientation, mood, thought process, thought

content, abnormal perceptions, insight and judgment, memory and attention, information and vocabulary, calculating abilities, abstract thinking, and constructional ability.

CRANIAL NERVES

Check sense of smell, strength of the temporal and masseter

muscles, corneal reflexes, facial movements, gag reflex, and strength of the trapezia and sternomastoid muscles.

MOTOR SYSTEM

Muscle bulk, tone, and strength of major muscle groups.

CEREBELLAR FUNCTION

Check rapid alternating movements (RAMs), point-to-point movements, such as finger-to-nose (F N) and heel-to-shin (H S); gait.

SENSORY SYSTEM

Pain, temperature, light touch, vibration, and discrimination. Compare right with left sides and distal with proximal areas on the

limbs.

DECISION MAKING IN CLINICAL MEDICINE

EVIDENCE-BASED MEDICINE describes the integration of the best available research

evidence with clinical judgment and experience in the care of patients.

changes with time, research, and evidence

CLINICAL REASONING The most important actions in medicine are not procedures or

prescriptions but judgments (diagnoses and treatment) Research on medical expertise is best developed in the area of

diagnostic decision making

CLINICAL DECISION MAKING 1. Use of cognitive shortcuts as a way to organize the complex unstructured material that is collected in the clinical evaluation.

2. Use of diagnostic hypotheses to consolidate the information and indicate appropriate management steps.

USE OF COGNITIVE SHORTCUTS Also called heuristics or rules of thumb a type of intuitive mental process that help solve clinical

problems with great efficiency

1. REPRESENTATIVENESS HEURISTIC DESCRIPTION ERRORS ENCOUNTERED

Clinician is searching for

the diagnosis for which the patient appears to be a representative

Makes use of the Patient history

Allows efficient , directed, and therapeutically productive Patient evaluation

Analogous to pattern recognition

Failure to consider the

underlying prevalence of 2 competing diagnoses

Failure to consider that a pattern based on a small number of prior observations will likely be less reliable than one based on larger samples

Example: A patient with pleuritic chest pain, dyspnea, and a low-grade fever. A clinician might consider acute pneumonia and acute pulmonary embolism to be the two leading diagnostic alternatives. Using the representativeness heuristic, the clinician might judge both diagnostic candidates to be equally likely , although doing so would be wrong if pneumonia was much more prevalent in the underlying population.

2. AVAILABILITY HEURISTIC DESCRIPTION ERRORS ENCOUNTERED

Involves judgments

made on the basis of how easily prior similar cases can be brought to mind

Recall bias Rare catastrophes and

more recent experiences are more likely to be recalled

Example: An experienced physician may recall a previous incident where he encountered a particular symptom. It would take some time for a novice practitioner to come up with a diagnosis.

3. ANCHORING HEURISTIC DESCRIPTION ERRORS ENCOUNTERED

Involves estimating a

probability by starting from a familiar point (anchor)

Powerful tool for diagnosis

Very accurate, greater precision and specificity

Looks at pretest probability and risk factors

Often used incorrectly Pretest probabilities

should be accounted for

Example: A doctor may judge the probability of Coronary Artery Disease to be very high after a positive exercise thallium test because the prediction has been anchored to the test result ("positive test = high probability of CAD" ). But prediction would be inaccurate if the clinical (pretest) picture of the patient being tested indicated a low probability of disease (e.g., a 30-year-old woman with no risk factors).

In Harrisons

4. SIMPLICITY HEURISTIC DESCRIPTION ERRORS ENCOUNTERED

clinicians should use

the simplest explanation possible that will account adequately for the patient' s symptom

How to compute for the Pack Years?

Pack Years = No. of cigarette pack/s per day x No. of years

he/she is

smoking

ex.

Pack years = 2 packs per day x 10 years of smoking

Answer = 20 pack years

Pack years = 10 cigarette sticks per day x 10 years of smoking

(Note: 1 pack = 20 cigarettes.)

Thus, 10 cigarettes = 0.5 pack per day

Answer = 5 pack years


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s or findings (Occam's razor).

USE OF DIAGNOSTIC HYPOTHESES Cognitive shortcuts play vital role in hypothesis generation Sets a context for diagnostic steps to follow Provides testable predictions Expert clinicians do not follow fixed pattern in Patient

examinations

Questions asked in the history and PE are driven by the hypothesis

Clinician is on a focused search mission Negative findings are as important as positive ones! Acuity of patients illness play important role in overriding

considerations of prevalence and other issues Non-acute conditions: prevalence of alternative diagnoses

should play more prominent role in Diagnosis hypothesis generation.

GENERATION OF DIAGNOSTIC HYPOTHESIS Errors can occur that can lead to serious consequences

patient can diverge from textbook symptoms and the potential consequences of being unable to adapt to the diagnostic process to real-world challenges.

Real clues should be distinguished from false traits High alert for clues that the initial Diagnosis may be wrong

MAJOR INFLUENCES ON CLINICAL DECISION MAKING 1. FACTORS RELATED TO PHYSICIANS PERSONAL

CHARACTERISTICS AND PRACTICE STYLE

influenced by physicians knowledge, training ,experience, recollection and interpretation of available medical evidence.

practice style also depends on the physicians specialization or area of expertise

specialists have more familiarity with specific drugs and processes in their area of expertise and are less likely to overreact to foreseeable problems in therapy

also influenced by opinion of influential leaders (need not to be doctors)

Defensive Medicine: Decision making is affected by the physicians perception about the risk of malpractice suit. Involves using tests and therapies with very small marginal returns to preclude future criticism

2. FACTORS RELATED TO THE PRACTICE SETTING relate to physical resources available physician-induced demand: refers to the remarkable ability

to accommodate to and employ the medical facilities available to them

also affected by availability of specialists and high tech facilities (e.g. mri, angiography suites, surgery program, etc)

3. FACTORS RELATED TO ECONOMIC INCENTIVES closely related to other two categories financial issues can exert both stimulatory and inhibitory

influences on clinical practice Fee-for-service: more work, more pay, doctors increase the

number of services Capitation: provides fixed payment per patient per year,

more patients but with fewer services provided Salary basis: receive the same amount regardless the

amount of work done

QUANTITATIVE METHODS TO AID CLINICAL DECISION-MAKING

Defining the available courses of action and estimating the likely outcomes with each

Assessing the desirability of the outcomes Expert clinical decision making can be appreciated as a

complex interplay of cognitive processes(to simplify and organize information) and physician biases (reflecting education, training and experiences) all shaped by external forces.

MEASURES OF TEST ACCURACY

The purpose of performing a test on a patient is to reduce uncertainty about the patient's diagnosis or prognosis and aid the clinician in making management decisions

The accuracy of diagnostic tests is defined in relation to an accepted "gold standard"

Sensitivity or True-Positive Rate proportion of patients with disease (defined by the gold

standard) who have a positive (new) test

reflects how well the test identifies patients with disease

Specificity or true-negative rate

proportion of patients without disease who have a negative test reflects how well the test correctly identifies patients without

disease

low probability of having the disease A perfect test would have a sensitivity of 100% and a specificity of 100% & would completely separate patients w/ disease from those without it.

Good Test: sensitivity specificity, then (+) test result = probability of having the disease Test yourself! sensitivity specificity, then (-) test result = _____ probability of having the disease

MEASURES OF DISEASE PROBABILITY AND BAYES

THEOREM there are no perfect tests. After every test is completed, the

true disease state of the patient remains uncertain

Bayes theorem: provides a mathematical way in quantitating this uncertainty from three parameters:

o pretest probability of disease

o test sensitivity

o test specificity

o likelihood ratio is the ratio of the probability of a given test result (e.g., "positive" or "negative") in a patient with disease to the probability of that result in a patient without disease

Table 3-1 Measures of Diagnostic Test Accuracy

Disease Status

Test Result Present Absent

Positive True-positive (TP) False-positive (FP)

Negative false-negative (fn) true-negative (tn)

Identification of patients with disease

True-positive rate (sensitivity) = TP/(TP + FN)

False-negative rate = FN/(TP + FN)

True-positive rate = 1 false-negative rate

Identification of patients without disease

True-negative rate (specificity) = TN/(TN + FP)

False-positive rate = FP/(TN + FP)

True-negative rate = 1 false-positive rate


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Positive test: the likelihood ratio is calculated as the ratio of the true-positive rate to the false-positive rate

[or sensitivity/(1 specificity)] o For example, a test with a sensitivity of 0.90 and a

specificity of 0.90 has a likelihood ratio of 0.90/(1 0.90), or 9. Thus, for this hypothetical test, a "positive" result is 9 times more likely in a patient with the disease than in a patient without it.

o Most tests in medicine have likelihood ratios for a positive result between 1.5 and 20. Higher values are associated with tests that are more accurate at identifying patients with disease.

Negative test: likelihood ratio is the ratio of the false negative

rate to the true negative rate [or (1 sensitivity)/specificity]

o The smaller the likelihood ratio (i.e., closer to 0) the better the test performs at ruling out disease

MEASURES OF DISEASE PROBABILITY Pretest probability of disease = probability of disease

before test is done o May use population prevalence of disease or more

patient-specific data to generate this probability estimate.

Posttest probability of disease = probability of disease

accounting for both pretest probability and test results. Also called predictive value of the test.

BAYES' THEOREM: Computational version

Posttest Probability = Pretest probability x test sensitivity Pretest probability x test sensitivity + (1- pretest probability) x test false- positive rate Example: [with a pretest probability of 0.50 and a "positive" diagnostic test result (test sensitivity = 0.90, test specificity = 0.90)]: Posttest Probability= _______(0.50) (0.90)________ (0.50)(0.90) +(0.50)(0.10)

= 0.90