Medical history and physical examination rapid review by Marc Imhotep Cray, M.D.

Identifying Data (ID) Name or initials Date of birth Medical record number

Chief Complaint (CC)  One-liner--why patient here--use patient's own words  How to write--patient’s age, occupation or sex, problem & duration

History of Present Illness (HPI) Story of patient’s chief complaint (CC) Story of any active/significant illnesses patient as which impact on HPI

History of Present Illness (HPI) Story of CC: logical complete chronological

History of Present Illness (HPI) Story of CC (How To Ask): start with open-ended questions fill in with focused questions

History of Present Illness (HPI) Story of CC

Describe symptoms in terms of: – location – quality – quantity (severity) – timing – setting – aggravating and/or alleviating factors – associated manifestations

History of Present Illness (HPI) Story of CC document: â&#x20AC;&#x201C; prior medical Dx/Rx â&#x20AC;&#x201C; significant positives or negatives

History of Present Illness (HPI) Story of CC Document patient’s understanding of his/her illness: – patient’s fears and concerns – impact of illness/treatment on patient, family

History of Present Illness (HPI) Story of CC • • • •

logical, complete, chronological open-to-closed questioning characterize symptoms document: – prior medical diagnoses/treatments – significant positives/negatives • patient's understanding of illness

Story of any active/significant illnesses patient has which impact on HPI 11

Past Medical History (PMH) Childhood illnesses Immunizations Adult illnesses Psychiatric illnesses or Hospitalizations Operations Injuries/accidents Obstetric history Transfusions 12

Adult Illnesses Dx & how made Rx Response & sequelae

Operations Why Kind When & sequelae

Obstetric History Number times pregnant Number live births Number abortions (spontaneous/induced)

Transfusions Where When Why Reactions/complications

Current Health Status (CHS) Current medications--name, dose, reason, SE Allergies/drug reactions Health screening Diet/sleep/exercise Habits--tobacco, alcohol, elicit Alternative Therapies

Psycho-Social History (PSH) Marital status Living conditions Employment Sexual history Significant life events Mental status

Family History (FH) Mother/father/siblings/children • age--health (if dead, why)

Significant illnesses that run in family

Review of Systems (ROS) Characterize patient's overall health status Review systems/symptoms from head to toe

Physical Diagnosis • • • • • • •

Goal of Physical Examination? How do I approach the patient Conducting general survey-What am I looking for? Vital Signs and why? How do I record all this information? Organization of thoughts?

The Four Cardinal Principles of Physical Examination: • • • •

Inspection Palpation Percussion Auscultation – “teach the eye to see, the finger to feel, and the ear to hear”---Sir William Osler – (what is the fifth?)

Maintain a “watchful eye” during the medical interview • General Survey--Note: • Level of Consciousness • Apparent State of Health---General appearance-Age Appropriate? • State of Nutrition--Wasting?,….. • Body Habitus

Watchful eye--• Grooming, Hygiene----children/ elderly--?neglect---home/environment? • Odors---ETOH?---ACETONE? • Symmetry---extremities disproportionate to trunk?….Body Markings? • Posture and Gait….Limp?/ Upright? Unbalanced? Pace? – Can be noted as patient walks towards exam room

Watchful eye and Ear----• Speech • Facial Expressions…fear?/ stoic? • Appropriate facial responses to communication?

Signs of Distress? • Address early on-----Note posture, Labored Breathing? Sweating? Trembling….Chills? Wincing?….Pain

Preparing For The Exam • • • •

Lighting Equipment Universal Precautions Patient Comfort

The Science of Physical Examination â&#x20AC;˘ Vital Signs Blood Pressure (BP) --Arterial blood pressure is lateral pressure exerted by a column of blood against the arterial wall â&#x20AC;˘ It is result of cardiac output & peripheral vascular resistance

BLOOD PRESSURE

Arterial pressure Arterial pressure  is pulsatile  is not constant during a cardiac cycle 1. Systolic pressure  is highest arterial pressure during a cardiac cycle  is measured after heart contracts (systole) and blood is ejected into arterial system 2. Diastolic pressure  is lowest arterial pressure during a cardiac cycle  is measured when heart is relaxed (diastole) and blood is returned to heart via veins 30

Arterial pressure (2) 3. Pulse pressure  is difference between systolic and diastolic pressures  most important determinant of pulse pressure is stroke volume  As blood is ejected from left ventricle into arterial system, arterial pressure ↑ b/c of relatively low capacitance of arteries  b/c diastolic pressure remains unchanged during ventricular systole, pulse pressure ↑ to same extent as systolic pressure  ↓ in capacitance, such as those that occur with aging process, cause ↑ in pulse pressure 4. Mean arterial pressure  is average arterial pressure with respect to time  can be calculated approximately as diastolic pressure plus one31 third of pulse pressure

What’s The Difference???-better yet What does it all mean? • Systolic BP = The Peak Pressure in arteries, regulated by Stroke Volume (SV) and compliance of the blood vessels • Diastolic BP = lowest pressure in arteries, dependent on peripheral vascular resistance

Techniques of Exam--BP • Which Cuff?…..Appropriate size. • What if I get a different reading in one arm vs. other? • Right arm BP--5-10mm> than left • Systolic BP in legs 15-20mm> than in arms Poiseuille’s Law: relates to fact that total resistance of vessels connected in parallel is greater than resistance of a single large vessel 33

Techniques of Exam-BP • How to Assess? • Normal Values & Changes from the Norm?…Adult, Infant, Pregnancy, Geriatric... • Clinical Significance?…Elevation-Hypertensive, …Low-Hypotensive…Orthostatic Changes

Techniques of Exam--Pulse • Pulse= denotes the heart rate & rhythm, condition of the arterial walls • How to Assess? • What do my readings tell me? Rapid? Slow?

Vital Signs… Respiratory Rate • Assessment and Techniques of exam?- *Assess w/o the patient being aware. • What is the Rate and Pattern? Increased rate(Tachypnea),? Increased Depth-(Hyperpnea)? Cheyne-Stokes?….etc

Vital Signs • • • •

Clinical significance: Temperature Weight Height

How do I write it all down? • • • • •

Complete Hx w/ ROS & PE + Labs. S.O.A.P Formats Problem Specific Maintaining Organization Remembering It All---Note as you go along---Less lost Data • Hospital Records, Specified Forms (Clinics, Hospitals etc.) • EHR (Electronic health record) 38

THE END

See next slide for links to tools and resources for further study.

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.)