Patient Interview+HTx+IPE (1) (1) PDF

The Medical Interview History Taking Introduction to Physical Examination Lecture Notes  Asst.Prof.Dr.Bülent Sezgin The Medical Interview Objectives  Understand why patient-doctor communication is key to a successful relationship  Learn basic communication strategies for an improved patient-docto...

The Medical Interview History Taking Introduction to Physical Examination Lecture Notes  Asst.Prof.Dr.Bülent Sezgin The Medical Interview Objectives  Understand why patient-doctor communication is key to a successful relationship  Learn basic communication strategies for an improved patient-doctor experience The Patient-Doctor Relationship  Class exercise:  Tell me about your most memorable positive experience with a doctor (when you were a patient) The Patient-Doctor Relationship  Class exercise:  Tell me your most negative experience The Patient-Doctor Relationship  What does being a doctor mean to you? Good doctor-patient communication is essential to good health care WHY IS SO ESSENTIAL ? Taking accurate history is: the most important tool you will use in diagnosing a medical problem ! Many times, you will be able to make a diagnosis based on the history alone ! 9% 8% 83% Diagnosis changed after investigation Diagnosis changed after physical examination Fig. Relative contribution of history, physical examination, and investigations to final diagnosis Medical knowledge is a science but on the contrary medical practice is an art.  Excessive medical knowledge is not everything  Learning from patients  Building confidence of patient  Make patient become more cooperative Rene Laennec (French physician) Listen to the patient. They are giving you the diagnosis  “The trouble with doctors is  not that they dont know enough,  but they don’t see enough” (DC Corrigan 1802-1880)  “Learn to see, learn to hear, learn to feel, learn to smell  By practice alone , you can become an expert”  (Sir William Osler) You have to sharpen your two abilities:  Observational ability non verbal clues being observed,  Descriptive ability describe patient documentation medico legal issues tracking information The interview The health history is important identify the person’s problems As a bridge to the next step in data collection Then The the physical examination. health history collects subjective data EXTERNAL FACTORS Ensure Privacy Aim for geographic privacy—a private room. If geographic privacy is not available, the “psychological privacy” afforded by curtained partitions (person feels sure that no one can overhear the conversation or interrupt. Refuse Interruptions. Establish rapport. Physical Environment  Set the room temperature at a comfortable level.  Provide sufficient lighting.  Reduce noise.  Remove distracting objects.  Maintain the distance between you and the patient (twice an arm’s length).  Arrange equal-status seating.  Both of you should be comfortably seated at eye level. Avoid sitting behind a desk or bedside table placed so it looks like a barrier.  Avoid standing. There are three phases to each interview: 1) an introduction, 2) a working phase, 3) a termination (or closing). If you are gathering a complete history, give the reason for this interview. INTRODUCING THE INTERVIEW Introduce yourself and state your role in the agency Shake hands Address the patient using his or her surname. Nonverbal Communications We and patients continuously display nonverbal communications Eye contact  Facial expression   Posture Head movement (shaking, nodding)  Interpersonel distance   Placement of the arms or legs (crossed, neutral or open) Moving closer  Making physical contact (conveys emphaty)  Body Language  Examination room configuration  Sitting/Standing  Eye level  Eye contact  Note taking  Posture  Hurried speech Body Language Patients notice more than you think 2/3 of communication is non-verbal Appropriate use of touch Your Role as an Observer  Nonverbal communication  May reveal more than patient’s words  Listen attentively and observe the patient closely  Detect a problem that might otherwise go unnoted 36-30  Apparent state of health acute or chronically ill, frail,robust,vigorous Your Role as an Observer  Level of consciousness awake,alert,interactive  Sign of distress Clutching the chest,pallor,diaphoresis,laboured breathing,wheezing,cough,protecting painful area General apperance  These may be clues to patients personality,mood,lifestyle and self guard  Stare of hyperthyroidism, depression, cultural? Odors of body and breath  Diabetes,uremia, liver failure Posture,Gait and motor activity  Heart failure,COPD  Dress, grooming and personal hygiene  Facial expression   Objectivity  Removing your own beliefs and values  Avoid judgmental attitudes  IV Drug Abuse  Education  Socioeconomic status  Language/Cultural differences  Sexual preference  Teenage pregnancy  Ageism THE WORKING PHASE  The working phase is the data gathering phase.  It involves your questions to the patient  Your responses to what he or she has said. There are two types of questions:  Open-ended questions  Closed (or direct) questions Each type has a different place and function in the interview. Active Listening Focus on what the patient is telling you ! Connecting the patients emotional state, encourge the patient to expand on feelings To understand a person’s experience Different than sympathy Empathy It requires Active listening Interest in patient’s experience Empathy is the capacity to feel patients feeling as your own Emphatic Responses To express emphaty:  Recognize the feelings  Elicit emotional content Empatic response deepens mutual trust! Empathy Sentences  “That must be very difficult for you to cope with?”  “This is completely understandable. Most people in similar circumstances would react just as you are.”  “I am sorry to hear that.”  “It must be hard for you, what are you unable to do as a result of the…(CC)”  “This can’t be an easy time for you, we’ll work together to get through this. Our goal is to facilitate communications without interruption Guided Questioning Let the patient talk ! ( Golden Moments 2 minute) Silence annoys us. Yes-no questions makes them feel more restricted and “passive” Moving from open ended to focused questions Elicit a graded response Techniques of Guided Questioning One question at a time Offering multipl choices Clarifying what the patient means Encouraging with continuers Using echoing from open ended to focused   An open-ended question asks for narrative information. It states the topic to be discussed, but only in general terms. Start with the most general questions: - What brings you today ? - How can I help you? Then still open but more focused questions: - Tell me more about your chest discomfort - What else ? - Where did you feel it ? - Did it travel anywhere ? - to which arm ? Closed or Direct Questions  Closed or direct questions ask for specific information. They elicit a one- or two-word answer, a “yes” or “no,” or a forced choice.  Use direct questions after the person’s narrative to fill in any details that he or she may have omitted.  when you need many specific facts Avoid leading questions ( contain suggested response) Is your pain like a pressure ? You dont have any blood in your stools , do you ? Patients response is cut short we need to adopt more neutral way “please describe your pain” Offering multipl choices Sometimes patients need help describing their symptoms. when we ask “ can you describe your pain” he maybe in difficulty to describe “which of the following words best describes your pain?” -sharp,pressing,burning, aching ?  Ask questions that require a graded response rather than a yes-no answer Elicit a graded response “how many steps can you climb before you get short of breath” “do you get short of breath climbing stairs” Which one is better? Graded response gives more spesific information While asking a series of questions  Ask one question at a time “Did you have any tuberculosis,pleurisy,asthma,bronchitis,pneumonia?” “do you have any of following problems” as you list each problem - pause - eye contact Clarification  Use the clarification response when the patient’s word choice is ambiguous or confusing Sometimes patients history is difficult to understand Its better to admit you confusion than to act like the story makes sense. “what did you mean?” “tell me exactly what you mean by ….?” Clarification reassures the patient that you want to understand his story. It builds relationship Facilitation  Your facilitative response encourages the patient to say more, to continue with the story, e.g., - posture - gestures - words - nodding head - remaining silent - Leaning forward - Making eye contact “mm-hmm,” “go on,” continue,” “uhhuh,”  or simply by nodding.  A reflective response echoes the patient’s own words.  Reflection involves repeating part of what the person has just said. Simply repeating the patients last words  Reflection Echoing demonstrates careful listening “the pain got worse and began to spread” “spread?” “I thought I was going die” “going to die?” “yeah just like the pain my father had when he had heart attack” Silence  Your silence communicates that the patient has time to think and organize what he or she wishes to say without interruption from you.  Silence also gives you a chance to observe the person unobtrusively and to note nonverbal cues. Confrontation This can focus on a discrepancy: “You say it doesn’t hurt, but when I touch you here, you grimace.” It can also focus on the patient’s affect: “You look sad” or “You sound angry.” Guided Questioning NARRATOR: Your goal with every patient is to establish trust and partnership by facilitating a dialogue. You’re looking to gain an understanding of your patient’s story. So, you’ll ask questions. Sometimes a yes-or-no answer can be informative. But often those types of closed-ended questions can limit the patient’s responses. CLINICIAN: Are you feeling okay today? PATIENT: Um… yeah. CLINICIAN: Is your back still bothering you? PATIENT: Uh… no, not really. NARRATOR: Closed-ended questions can actually shut down the patient’s answers. So, avoid using them to start the interview. Guided questioning gives you a better chance of eliciting the patient’s full story. One of the best techniques of guided questioning is to start with an open-ended question, that is, a general question that invites the patient to tell you their story. From this initial patient response, you can then move to more specific questions. General questions could be something like, ‘What brings you in today?’ or ‘How I can help you today?’ CLINICIAN: What brings you in today? PATIENT: Well, I’ve been feeling some discomfort in my chest. CLINICIAN: Can you tell me more about your chest discomfort? NARRATOR: And now you’re going to learn much more about the patient’s story. Another technique is simply repeating the patient's words, or echoing, which encourages the patient to elaborate on details and feelings. Echoing also demonstrates careful listening and establishes a subtle connection with the patient. PATIENT: It usually starts about right here… (gesturing to lower end/tip of breastbone). Right in the middle of my chest. CLINICIAN: In the middle of your chest? PATIENT: Yeah. It started about a month ago. CLINICIAN: A month ago, huh? PATIENT: Yes. It wasn’t that bad when it started, and I barely noticed it. But now it really bothers me. CLINICIAN: This discomfort you feel in your chest, it stays there and doesn’t move anywhere else, right? NARRATOR: And THAT is an example of a leading question. NARRATOR: Leading questions suggest a response that may or may not be true for the patient. In a patient–clinician relationship, you may be considered an expert, and patients might feel they should agree with you. Like this. CLINICIAN: So, this discomfort you feel in your chest, it stays there and doesn’t move anywhere else, right? PATIENT: Um… yeah. I guess that’s right. NARRATOR: It’s important to let the patient elaborate further on their concerns. In this scenario, continued use of open-ended questioning allows the patient to use their own words to describe the sensation. CLINICIAN: So, this discomfort you feel in your chest, could you describe what this sensation is like? PATIENT: Well, it’s not always the same. It’s like… I don’t know. It’s hard to describe. NARRATOR: Sometimes, however, patients need help in describing their symptoms. To minimize bias, you can offer a list of possible responses. CLINICIAN: Would you say that the chest discomfort is aching, sharp, pressing, burning, shooting?... Or something else? PATIENT: It’s definitely aching … and it burns sometimes too. NARRATOR: Although offering possible responses can be helpful, avoid asking multiple questions at the same time that may have different responses. CLINICIAN: What did you do when you felt this discomfort? Did you try anything to make it better? Did you take any medications or try any remedies? Did anything at all make it worse? PATIENT: Um…. NARRATOR: Can you remember all of the questions the clinician just asked? It’s more effective to ask one question at a time and to ask them in order of importance. CLINICIAN: What did you do to make the discomfort go away or make it feel better? PATIENT: I tried to eat something because I thought I was hungry. I didn’t really know what was going on. CLINICIAN: Did anything make it worse? PATIENT: No. Like I said, I didn’t really know what was going on. CLINICIAN: Did you take any medications? NARRATOR: Sometimes the patient may say something that you don’t quite understand. If that’s ever the case, don’t be afraid to ask for clarification. CLINICIAN: You said that when you were having the chest discomfort, you worry that you’re going to be joining your dad. What did you mean by that?” NARRATOR: When the patient is sharing, you can encourage them to say more with short phrases called “continuers.” PATIENT: Well, when my father was just a little older than me, he… (haltingly)…uhm… CLINICIAN: Yes…? PATIENT: …He died of a massive heart attack. NARRATOR: You can also use nonverbal communication to let your patient know you are actively listening. Your posture and gestures can encourage the patient to tell you more. Leaning forward… making eye contact… pausing and nodding your head are all cues that you are engaged and can help make the patient comfortable to continue. CLINICIAN: Go on… PATIENT: And I start to think about how the same thing might be happening to me. I mean…. CLINICIAN: I’m listening… NARRATOR: Using techniques of guided questioning can help you effectively and efficiently elicit and understand more of your patient’s story. Summary This is a final review of what you understand the patient has said. how you perceive the patient’s health problem or need. It also allows the patient to correct misperceptions.  CLOSING THE INTERVIEW “Is there anything else you would like to mention?” Give the person a final opportunity for self-expression. Then give a summary of  what you have learned during the interview. This is a final statement of what you and the patient agree his or her health state to be. Patient centered approach  At first, you will focus on gathering information But you will allow the patients story to unfold in its detailed form Recognise the patients - Personel feelings - Concerns - Emotions Clinician – centered approach Paternalistic Approach  More symptom focused  Doctor takes charge of interactions to obtain symptoms  Doctor tries to identify a disease  Ignore personel dimentions of the illness Listen to your patient. He is telling you the diagnosis ! Which approach we need to adopt ? Transitions   Tell them when you are changing directions Transitions help prepare patients for what comes next “ Now I’d like to ask some questions about your past health” “Before we move on to reviewing all medications ,anyting else left?” “I will step out for a few minutes. Please undress and put on this gown” Empowering the Patient The nurse-patient relationship is unequal Followings are contributing this power asymmetry:  Patients feel vulnerable  They may be in pain or worried about symptom  Differences of socioeconomic status But ultimately, patients are responsible for their own care All decisions should be taken together. Interview Check List OPENNING  Verbal introduction  Shake hands  Address patient as mr.,Mrs.,Ms  Put patient at ease  States goal of interview INFORMATION GATHERING  Questioning (uses open – to – closed cone)  Lets patient tell story without interrupting  Problem survey : what else  Redirects or interrupts ( if necessary) : maintains a chronological account  Segment summaries  Clarification : Let me see if I have this right  Transitional statement between interview sections : avoid abrupt changes Interview Check List (cont..) FACILITATION SKILLS  Eye contact  Open posture  Nods, mmhmm,repeating patients last statement (reinforce respond)  Use silence RELATIONSHIP SKILLS  Reflection : restating an expressed emotion  Legitimation : express understandability of patients emotion  Respect : treat patient at same level  Support/Partnership : willigness to work together PATIENT EDUCATION  Use simple language  Check patients understanding FLOW : it moves smoothly,key points summarized,smooth closure SOME TRAPS OF INTERVIEWING  Nonproductive, defeating verbal messages restrict the patient’s response.  They are obstacles to obtaining complete data and establishing rapport. Such statements as,  “Now don’t worry, I’m sure you’ll be all right” are courage builders that Providing False Reassurance relieve your anxiety and give you a false sense of having provided comfort.  However,for the patient these statements close off communication. they may think you trivialize their anxiety And effectively deny further discussion.  A person describes a problem to you,ending with, “What would you do?” If you answer, Giving Unwanted Advice “If I were you, I’d … ,”  you have shifted the resposibility for decision making from the patient to you.  The person has not worked out his or her own solution and has learned nothing about himself or herself. Using Authority  “Your doctor/nurse knows best” is a response that promotes dependency and inferiority. Using Professional Jargon  Use of jargon sounds paternalistic.  You need to adjust your vocabulary to the patient but should avoid sounding condescending. Using Leading or Biased Questions Asking such questions “You don’t smoke, do you?” implies that one answer is “better” than another.  Some examiners associate helpfulness with how much they talk. They think Talking Too Much they have met the patient’s needs. They think ‘The more I talk, the better I will be of help’ Just the opposite is true. Interrupting When you think  you know what patients will say, You interrupt and cut them off. The adult’s use of “why” questions Using “Why” Questions. usually implies blame and condemnation and puts the patient on the defensive. History Taking  Date and time of history: the date is always important, be sure to document the time you evaluate the patient especially in urgent, emergent, or hospital setting  Identifying data: age, gender, occupation, marital status Initial information  Source of history: usually the patient, but can be a family member or 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 the patient’s memory, trust, and mood CREATING INTIMACY Getting Started  Always introduce yourself to the patient  Make the environment as private and free of distractions as possible  If possible, sit down next to the patient  Remove any physical barriers (e.g. put down the side rail , computer screen..)  These simple maneuvers help to put you and the patient on equal footing Components of History Taking  Presenting Complaint ( Chief Complaint)  History of Presenting Complaint  Past Medical/Surgical History  Family History  Social History  System reviews Chief Complaint or Presenting Complaint  The patient's reason for coming to the clinician is usually referred to as the "Chief Complaint."  Open ended questions are a good way to start  These include: "What brings your here? How can I help you? What seems to be the problem?"   Focus on a single, dominant problem History of Presenting Complaint  When did the problem start ?  Since then, how has it progressed ?  Previous history of the problem  SOCRATES 1. Site * Where is the symptom exactly? Whether it is localised (concentrated in a small area) or diffuse (spread out over a wide area)? Ask the patient to point to the actual site on the body Bear in mind: Some symptoms are not localised. - Patients who complain of dizziness do not localise this to a specific site - Vertigo occasionally involves a feeling of movement within the head - Cough -Dyspnoea (shortness of breath), and -Weight change.  2. Onset (setting in which symptom occurs) Sudden onset, gradual onset What were you doing when it started?  Environmental factors  Personel activities  Emotional reactions  Severe breathlessness that wakes a patient from sleep is very suggestive of cardiac failure.  Asthma may occur in florist shop or near a pet 3. Character  Ask the patient to describe what they mean by the symptom; to describe it's character.  * If the patient complains of dizziness, does this mean the room spins around (vertigo), or is it more a feeling of impending loss of consciousness  * Does indigestion mean abdominal pain, heartburn, fullness after eating, or a change in bowel habit.  * If there is pain, is it stabbing, dull, sharp, boring, cramp-like, or burning. 4. Radiation  Determine if the symptom (if localised) radiates (spreads to a specific location, or in a specific direction). This mainly applies if the symptom is pain.  Certain radiation patterns are typical of certain conditions, or even diagnostic (.eg the nerve root distribution , cardiac pain) 5. Associated Symptoms  What else did you notice ? Have you felt anything else that have popped up around the same time?  Fever  Nausea  Sneeze  Stuffed nose 6) Timing & Duration - How long has this condition lasted? - Is it similar to a past problem? If so, what was done at that time? When your symptom first began? When was the last time you felt entirely well? (For patients with long-standing symptoms), ask why they decided to see the doctor at this time. 7. Exacerbating and Relieving Factors   Anything makes their symptom worse? The slightest movement may exacerbate - the abdominal pain of peritonitis - the pain in the big toe caused by gout  Anything makes the symptom better? (For example, the pain of pericarditis may be relieved when a patient sits up heartburn from acid reflux may be relieved by drinking milk or taking antacids) 8. Severity Severity is subjective.  The best way to assess severity is to ask the patient whether the symptom interferes with normal activities or sleep.  Severity can be graded from mild to very severe.  * A mild symptom is one the patient can ignore  * A moderate symptom cannot be ignored, but doesn't interfere with daily activities  * A severe symptom interferes with daily activities  * A very severe symptom markedly interferes with daily activities  Alternatively, pain or discomfort can be graded on a 10-point scale from 0 (no discomfort) to 10 (unbearable) Example for SOCRATES  The pain began 1 month ago and only occurs with activity in Gym  It rapidly goes away with rest within 5 minutes  When it does occur, it is a steady pressure focused on the center of the chest that is roughly a 5 (on a scale of 1 to 10).  Over the last week, it has happened 6 times while in the first week it happened only once.  The patient has never experienced anything like this previously and has not mentioned this problem to anyone else prior to meeting with you.  As yet, they have employed no specific therapy. Past Medical History: Start by asking the patient if they have any medical problems If you receive little/no response:     Have they ever received medical care? Tell me what medication you are on ? Have they ever undergone any procedures, X-Rays, CAT scans, MRIs or other special testing? Ever been hospitalized? If so, for what? MJHDS : Please dont be alarmed, I need to ask you some routine questions  Myocardial Infarction, Jaundice, Hypertension, Diabetes, Stroke Past Surgical History  Were they ever operated on, even as a child?  What year did this occur?  Were there any complications?  If they don't know the name of the operation, try to at least determine why it was performed  Encourage them to be as specific as possible. Medications:  Do they take any prescription medicines? If so, what is the dose and frequency?  It's important to ascertain if they are actually taking the medication as prescribed.  If patients are, in fact, missing doses or not taking medications altogether, ask them why this is happening. (side effect ?)  Ask about over the counter or "non-traditional" medications. Allergies/Reactions:  Have they experienced any adverse reactions to medications?  The exact nature of the reaction should be clearly identified  Anaphylaxis, for example, is a life threatening reaction and an absolute contraindication to re-exposure to the drug  A rash, however, does not raise the same level of concern Family History:    Are your parents still alive and well ? How old were they when they died? Did they suffer any significant illness? Heritable illnesses among first or second degree relatives ( are there any disease that run in the family ?) Coronary artery disease, diabetes and certain malignancies Find out the age of onset of the illnesses Also ask about any unusual illnesses among relatives, perhaps revealing evidence for rare genetic conditions. Social History: SMOKING  Have you ever smoked cigarettes?  If so, how many packs per day and for how many years?  If you quit, when did this occur?  The packs per day multiplied by the number of years gives the PACK YEARS Example: 1/2 pack a day 10 years : 5 pack years 2 packs a day 20 years : 40 pack years ALCOHOL  Do they drink alcohol?  If so, how much per day and what type of drink?  Encourage them to be as specific as possible.  If they don't drink on a daily basis, how much do they consume over a week or month? DRUG ABUSE  Any drug use, past or present, should be noted.  Remind them that these questions are not meant to judge but rather to assist you in identifying risk factors for particular illnesses (e.g. HIV, hepatitis)  In some cases, however, a patient will clearly indicate that they do not wish to discuss these issues Respect their right to privacy and move on. Perhaps they will be more forthcoming at a later date. PERSONAL HISTORY  How social conditions affect his daily life ? ▪ What sort of work does the patient do? Do they enjoy it? Or hate it ? If retired, what do they do to stay busy? Any hobbies? Participation in sports or other physical activity? Where are they from originally? How thing are at home? İf they are getting along, ok, They need any extra support       This may help improve the patient-physician bond and gives the sense that you care about them   Refer back to during later visits, letting the patient know that you paid attention and really remember them Obstetric/ Menstrual History:  Menstrual regularity, problems?  Have they ever been pregnant?  If so, how many times?  Full term delivery  spontaneous abortion  therapeutic abortion Sexual History This is an uncomfortable line of questioning  Is the patient married? divorced?  Do they participate in sexual activity? With persons of the same or opposite sex?  Are they involved in a stable relationship?  Do they use any means of birth control?  Past sexually transmitted diseases? How to present the history  Smooth and concise  Key elements are presented  Anything irrelevant is omitted  Being succinct is crucial  Your colligue will only want to know the key facts The doctor/patient interview (SAMPLE)  Greeting ( good afternoon, my name is Dr. Ahmet  Personal History: please tell me your first and last name ?  Determine the patients age :how old are you?  Determine the patients occupation: what do you do for a living ?  Determine the patients chief complaint (CC): -How can I help you today? -What brings you in to see me today?  Determine the duration of the CC ? -when were you last feeling perfectly well ? -when did this problem start? -how long have you had this problem? Sample cont...  Assess any aggravating or relieving factors? - is there anything that makes this problem worse or better?  Determine the onset of CC : - Did this problem start slowly or did it come on quite suddenly?  Assess any pain associated with the problem: - is this problem causing you any pain? -can you describe the pain for me? -is it stabbing or burning ? -is it constant or intermittent? -is it throbbing or pounding? -is it sharp or dull? -on a scale of 1 to 10, how would you rank the pain? -is the pain disrupting your daily activities? -does the pain keep you awake at night? -does the pain radiate to any other part of your body?  Past ( and current) medical history: -do you have any current health problems, such as diabetes or high blood pressure? -how long have you had this condition? - are you seeing a doctor for this condition? - are you taking any medication for this condition? -how often do you take this medication? -have you had any recent illness or health problems other than the one that brought you in today? SAMPLE (cont...)  Family History: -Do your parents have any health problems?, How old are they? -I’m sorry to hear that, what was the cause of your mothers death, how old was she when she died? -Do you have any brothers and sisters? How old are they?, Do they have any health problems? -Are you married ?, do you have any children?,How old are they?,do they have any health problems? -is there a history of high blood pressure,cancer,asthma,diabetes...in your family? Sample (cont..)  Drug History: -are you taking any prescription medications? (pills,injections,inhalers...) -do you use any alternative treatments and remedies for any health problems? -are you taking any over-the-counter (OTC) medicines?  Allegies: - do you have any allergies? Things like food allergies or allergies to medications?  Social history (lifestyle): -do you smoke? -how much do you smoke? -how old were you when you started smoking? -do you drink alcohol? -how often and how much do you drink? SYSTEM REVIEW  GENERAL  Current state of health ( includes past medical problems relevant to the current state of health) Chest pain, pressure or tihghtness Palpitation Orthopnea Paroxysmal CARDIOVASCUL AR SYSTEM (cvs) nocturnal dyspnea (PND) Shortness of Pedal breath edema Cladication Varicous veins Hypertention History of rheumatic fever Hyperlipidemia Heart murmur Spesific questions (cardiovascular)  Can you show me where the pain is located?  Does the pain radiate to any other part of your body?  Do you get short of breath when you are active?  How long does the pain last?  What were you doing when the pain started?  Have you ever had this pain before? Respiratory system  Cough  Sputum  Hemoptysis  Dyspnea  Pleuritic chest pain  Wheezing  Asthma  COPD  Sleep pattern (snoring, sleep apnea) Spesific questions (respiratory)  Is your cough worse in the morning, in the evenning or at night?  When is your cough at its worst?  Do you cough up any blood?  Is your cough dry or productive?  Are you short of breath?  Do you have any difficulty breathing?  How is your breathing? Gastrointestinal System (GI)  Weight gain or loss  Results of previous endoscopy and DRE  Nausea or vomiting  Diarrhea  Constipation  Hematemesis  Hematochezia  Melena  Change in stool caliber  jaundice  GER (reflux) Spesific Questions (gastrointestinal)  Can you show me where the pain is located?  Are there any foods that make the problem worse?  Do you have diarrhea? , how many times per day?  Have you noticed any blood in your stools?  Have you noticed any fat or mucus in your stools?  Have you noticed anything unusual in regard to your stools?  Do you have regular bowel movements ?  Can you describe your bowel movements to me? Genitourinary system  Dysuria  Hematuria  Nocturia  Urinary frequency  Polyuria  Hesitancy  Urgency  İncontinance  Vaginal discharge  Penil discharge Spesific Questions (genitourinar)  How often do you urinate each day?  Can you describe the appearance of your urine?  Do you feel any pain when you urinate?  Can you tell me about your urination habits?  Do you have any difficulty starting to urinate?  How often do you urinate during the nights?  Whats the color of your urine?  Does your urine appear to be dark or cloudy?  When did you have your last period?  Are your periods regular? Neurologic system  Headache  Diplopia  Blurred vision  Vertigo  Dizziness  Syncope  Seizures  Paresthesia  Tremor  Weakness  falls Spesific Questions (Headaches)  Can you show me where your head hurts?  When you have your hadaches, are you sensitive to bright light?  Can you describe the pain? Is it sharp and intense or dull and not so intense?  Do you feel any pressure?  How long have you been having headaches?  How do the headaches start?, slowly or suddenly?  How severe is the pain?, can you rank it for me on a scale 1 to 10 ?  Do your headaches make you nauseous?  Do any position help you headaches – lying down, standing, etc? Musculoskeletal system  Arthritis  Joint stiffness or swelling  Myalgia  Back pain hematologic  Bloodtype  Anemia  Easy bruising or bleeding  Lymph node enlargement Endocrin system  Polyuria  Polydipsia  Polyphagia  Cold or heat intolerance  Hirsutism  Galactorrhea  Central obesity  amenorrhea HEENT  Sinusitis  Postnasal drip  Nasal polyps  Epistaxis  Condition of teeth and gums  Ulcers in oral cavity  Sore throat  Change in voice  hoarseness .....(name), a.....year old.........(occupation), with is known......(significant PMH)was admitted via... (mode of presentation) days ago complaining of a.....(PC in patients own words) of in duration (time factor).  HPI began......ago when he noticed (at this point we need to start from the beginning of the history related to this current episode.It should be chronological and include SOCRATES.  Give a list of positive and negative risk factors relating to this current episode ( For chest pain hypertension,hypercholesterolaemia,diabetes mellitus,smoking,family history) Majority of time should be spent on the above.  Briefly mention PMHx, drug & allergy, FHx, SHx, any relevant findings on direct questioning Presentation of case simulation  Mr. Yönter Meray, a 35 years old research asistant  PC: Chest pain ‘’ tightness in his chest’’  HPI: Patient complains of substernal tightness that lasted 10 minutes ,radiating to his neck and jaw. Symptoms started 10 days ago after a funeral while running to catch the train. Patient reports sweating and nausea at the time.  PMHx: DM,denies heart issues medication: nytroglycerine,aspirin allergy. peanut  SHx : Smoke 5 pack year, social drinker, living with girlfriend,  FHx: Father died from heart attack, mother diabetic and brother diabetic & hipertension Beginning physical examination Focused or Comprehensive ? On most new patients or patients being admitted to the hospital, you will conduct a comprehensive physical examination. Equipment for Physical Examination Available in most patient care areas Sphygmomanometer Tongue blade Gloves Lubricant gel Vaginal speculum Required Stethoscope Oto/ophthalmoscope Penlight Reflex hammer Tuning fork 128 Hz Pin Tape measure Optional Nasal Iluminator Nasal speculum Tuning fork 512 Hz Textbook of Physical Diagnosis, history and examination, 2nd edition. Mark H Swartz, WB Saunders, Philadelphia The Comprehensive Physical examination               General survey Vital sign Skin Head, eyes, ears, nose, throat (HEENT) Neck Back Superior thorax and lungs Breast, axillae, and epitrochlear nodes Anterior thorax and lungs Cardiovascular system Abdomen Lower Extremities Nervous system Additional examination rectal examination in men  genital and rectal examination in women  Clinical examination Basic pattern:  Looking (inspection)  Feeling (palpation)  Tapping (percussion)  Listening (auscultation) 1. General survey  General state of health, height, build ,weight.  Posture, motor activity, and gait  Dress, grooming, and personal hygiene  Odors of the body or breath.  Facial expressions and note the manner, affect.  Manner of speaking  State of awareness  Level of consciousness. The patient is sitting on the edge of the bed or examining table, unless this position is contraindicated. You should be standing in front of the patient, moving to either side if needed. 2. Vital sign  Measure blood pressure.  Count the pulse  Count the respiratory rate.  If indicated, measure the body temperature.  Palpation Feeling with hands size consistency texture location tenderness of an organ or body part  The palpation of abdomen is particularly important  How to perform palpation The initial step  -distracting patients (conversation or questions)  The goal is muscle relaxation  -ticklish patient -ask the patient to flex the thighs and knees Types of palpation  Light palpation  Deep palpation deep slipping palpation bimanual palpation deep press palpation ballottement  Light palpation: resistance The degree of muscle rigidity or -voluntary muscle tightening - actual rigidity  Muscle spasm cannot be relaxed by voluntary effort Begin with area of farthest from the location of pain Light palpation  Using the flat part of the right hand or the pads of the fingers, not the fingertips  The fingers should be together  Sudden jabs are to be avoided  The hand should be lifted from one area to area instead of sliding over the abdominal wall  Rigidity is involuntary spasm of the abdominal muscles and is indicative of peritoneal irritation  Rigidity may be: diffuse (diffuse peritonitis) localized (over an inflamed appendix or gallbladder)  In patients with generalized peritonitis, the abdomen is described as “board-like” Light palpation to determine ; Deep palpation  organ size  abdominal masses  flat portion of the right hand  pressure gently but steadily The patient should breathe quietly through the mouth (keep arms at the sides) Deep palpation Bimanual palpation  Uses two hands on each side  Left hand over the back of organs to fix or elevate the organs.  It is employed during the processes of liver, spleen, kidney or abdominal masses examination Bimanual palpation Bimanual palpation Rebound tenderness  It is a sign of peritoneal irritation  palpating deeply and slowly in suspected area  Palpating hand is then quickly removed  Sensation of pain occurs  ( rebound tenderness) Percussion  “tapping” of body parts with fingers  -to evaluate the size, consistency, borders and presence of fluid in body organs  Percussion produces a sound that indicates the type of tissue within the organ  It is particularly important in examining the chest and abdomen  Tapping on the chest/abdominal wall  is transmitted to the underlying tissue,  reflected back,  and picked up by the examiner’s sense  The sound heard are depend on the air-tissue ratio  The vibrations enable us to evaluate the lung tissue to a depth of 5~6 cm Percussion It is used to detect -diaphragmatic movement Percussion - the size of heart - -edge of liver - -spleen (traube space) - - ascitis (shifting dullness) Percussion  It should be performed from upside to downside sequential  From one side to the other side  Comparison Depending on - composition of the tissue - amount of air - gas Quality of Percussion -distance from the skin surface Resonance Tympany Hyperresonance Dullness Flatness Resonance  Quality of Percussion over a structure containing air within a tissue (such as lung, higher-amplitude, lowerpitched note) Tympany  over a hollow air-containing structure (such as stomach higher-pitched, hollow quality note, pneumothorax,intestines)  Hyperresonance: the quality of sound is between the resonance and tympany. Such as (pulmonary emphysema) Quality of Percussion  Dullness: over a solid organ, such as the liver, produces a dull note without resonance. Dullness occurs when the air content of the underlying tissue is decreased and its solidity is increased.  Quality of Percussion Flatness: absolute dullness No air present in the underlying tissue (over the muscle of the arm or thigh) Sounds produced by Percussion Record of finding Quality Place of heard Resonance Hollow Normal lung Hyperresonance Booming Air-filled lungs Tympany Drumlike Abdomen Dullness Thudlike Liver Flatness Flat Muscle, bone Classification of “percussion notes”  Resonance   Hyperresonance   Emphysema Tympany   Normal lung percussion Abdominal cavity, stomach or pneumothorax Dullness  Liver dullness, diaphragmatic dullness,Hydrothorax, atelectasis  TRAIN YOUR EAR ON YOURSELF ! Auscultation  A method used to “listen” to the sounds of the body during a physical examination  Performed by listening through a stethoscope, and to evaluate the frequency, intensity, during, number and quality of sounds Normal Breath Sounds Bronchial  Bronchial breath sound   Larynx, suprasternal fossa, around 6th, 7th cervical vertebra, 1st, 2nd thoracic vertebra Bronchovesicular Bronchovesicular breath sound  1st, 2nd intercostal space beside of sternum, the level of 3rd, 4th thoracic vertebra in interscaplar area, apex of lung Bronchial Bronchovesicularr  Vesicular breath sound  Most area of lungs Thank You