PD Lecture 1_Medical History JD rev 8 2023.pdf

Physical Diagnosis Dr. Joseph M Daleo DPA PA-C 631-665-1600 ext. 66348 Room 201 [email protected] Let's get acquainted PAM 431 Textbooks ◼ ◼ ◼ ◼ ◼ ◼ Bates Guide to Physical Examination and History Taking latest edition 13th Bickley, J.B. Lippincott, latest edition Bates Pocket Guide to Ph...

Physical Diagnosis Dr. Joseph M Daleo DPA PA-C 631-665-1600 ext. 66348 Room 201 [email protected] Let's get acquainted PAM 431 Textbooks ◼ ◼ ◼ ◼ ◼ ◼ Bates Guide to Physical Examination and History Taking latest edition 13th Bickley, J.B. Lippincott, latest edition Bates Pocket Guide to Physical Examination and History Taking Current Medical Diagnosis & Treatment, Lange Series, McGraw Hill, Most recent edition. Medical Spanish Made Incredibly Easy, Lippincott, latest edition PA school made ridiculously easy 4th edition #tooeasy PAMN 431 PD LEC Evaluation ◼ ◼ ◼ ◼ ◼ ◼ ◼ ◼ ◼ ASSESSMENT AND GRADING The student will be evaluated in the LECTURE component on the basis of: Exam #1- Lectures 1-5 33.3% Exam #2- Lectures 6-8 33.4% Quizzes 1-10 averaged 33.3% 100% There is no make up offered for the lecture component of this course NOTE: An average below 80% in lecture is considered failing, failing the lecture component will result in also failing the laboratory component of this course. What is “Physical Diagnosis”? 1. 2. 3. 4. Taking the Medical History Performing the Physical Examination Formulating an Assessment Creating a Plan Overview of Physical Examination and History taking Comprehensive evaluation (Full H/P) ◼ Focused evaluation (SOAP Note) ◼ ◼ The written Hx and Physical reports you will do for the lab portion of class are a combination of both types, Full H/P and SOAP notes. Others notes will be completed through the I human portal/EMR. There will be an identified problem area or C/C for most reports. Comprehensive Assessment – Full History Is appropriate for new patients in the office or hospital ◼ Provides fundamental and personalized knowledge about the patient ◼ Strengthens the clinician–patient relationship ◼ Helps identify or rule out physical causes related to patient concerns ◼ Provides baselines for future assessments (foundation) ◼ Creates platform for health promotion through education and counseling ◼ Develops proficiency in the essential skills of physical examination ◼ Focused Assessment - could be SOAP note ◼ Is appropriate for established patients, especially during routine or urgent care visits ◼ Addresses focused concerns or symptoms ◼ Assesses symptoms restricted to a specific body system ◼ Applies examination methods relevant to assessing the concern or problem as precisely and carefully as possible The Medical History Past Medical Hx ◼ Past Surgical Hx ◼ Medications name –dosage – frequency ◼ Allergies – reaction and severity ◼ Health Maintenance – screening tests – immunizations etc. ◼ Family History ◼ Social History – Smoking , ETOH, Drugs, Occupation ◼ GYN Hx – Sexual Hx ◼ Review of Systems ◼ History taking ◼ Subjective information – What the patient tells you – influenced from personal feelings ▪ This is the history – “It hurts when I laugh” or “my ribs really hurt” ◼ Objective information – Observable findings – visible and measurable ▪ Physical examination findings – Cervical Adenopathy – Ecchymosis overlying the right side at the mid axillary line at approximately ribs 3 and 4. ▪ Lab tests – CBC revealing leukocytosis ▪ Radiographic findings – Oblique fractures of lateral right sided ribs 3 and 4. The Physical Exam General Assessment ◼ Vital Signs ◼ Skin ◼ Head, Eyes, Ears, Nose, Mouth, Sinuses and Throat ◼ Neck ◼ Chest, Heart and Lungs ◼ Abdomen and Pelvis ◼ The Physical Examination Musculoskeletal System ◼ Peripheral Vascular System ◼ Nervous System and Mental Status Exam ◼ Breast and Genitalia ◼ Rectum ◼ Techniques of Examination The cardinal techniques of examination Observation / Inspection ◼ Percussion ◼ Palpation ◼ Auscultation ◼ Assessment Diagnosis ◼ Problem List ◼ 21-year-old female with RLQ pain rule out appendicitis ◼ 50-year-old male with hypertension and hyperlipidemia ◼ Plan ◼ Medications - Bystolic 5mg, Crestor 40mg, ASA 81 mg QD ◼ Tests – CMP / Lipid panel ◼ Consultations - Cardiology ◼ Education and Follow up - low fat/sodium diet , RTO in one week The Medical History Identification ◼ Informant ◼ Source of Referral ◼ Reliability ◼ Chief Complaint ◼ History of Present Illness (HPI) story of the C/C ◼ Past Medical and Surgical History ◼ The Medical History What is the Role of the Clinician? Present and Identify Oneself Properly ◼ Communicate effectively ◼ Create Confidence ◼ Obtain Information ◼ Identify Problems ◼ Formulate Treatment Plan ◼ What are the Expectations of the Patient? Care, Compassion and Empathy ◼ Ability of Clinician to Listen and Explain ◼ Availability ◼ Professionalism – nonbiased ◼ Knowledge and Skill ◼ Relief of Pain and Suffering ◼ Infallibility and Perfection? ◼ How Should the Clinician Approach the Patient Have appropriate appearance ◼ Introduce yourself by name, title and position. ◼ Insure privacy and comfort ◼ Sit when possible, at same eye level about 3-4 feet away ◼ Make sure patient is appropriately draped ◼ Use nonmedical terminology ◼ Interviewing ◼ Good Communication is the Foundation of Excellent Medical Care ◼ Give the Patient time to Speak – The average clinician interrupts a patient within 18sec ◼ Symptoms: subjective sensations such as pain, chills or shortness of breath ◼ Signs: Objective findings such as increased heart rate or elevated blood pressure ◼ Signs and Symptom Complexes are associated with specific Diseases – RUQ pain which radiates to the back and worsens with eating = cholecystitis How to Obtain Accurate Information ◼ Objectivity ◼Reproducibility ◼ Precision Objectivity ◼ Remove one's own beliefs, prejudices and preconceptions. Non bias attitude ◼ Effective Listening and Feedback are the keys to being objective. ◼ Avoid Interpreting data too quickly Precision ◼ Words have different meanings to different patients (accuracy) “I’m extremely tired” ◼ “I feel dizzy” ◼ What is the patient really trying to say Reproducibility ◼ Different interviewers should be able obtain the same results. 1. Maximize objectivity – Don't jump to conclusions. 2. Maximize precision- What does the patient really mean ◼ Goal is to maximize objectivity and precision to produce accurate data. The Medical Interview Seven essential elements of communication in medical encounters Building the provider patient relationship ◼ Open the discussion ◼ Gather information ◼ Understand the patient’s perspective ◼ Share information ◼ Reach an agreement on problems and plans ◼ Provide closure ◼ How to Improve Communication Respect - admiration for someone or something elicited by their abilities, qualities, or achievements. ◼ Genuineness - truly being what something is said to be; authenticity ◼ Empathy - understanding and sharing the feelings of another ◼ Respect ◼ Value the individuals' traits and beliefs, be nonjudgmental. Show respect by…. ◼ Introducing yourself clearly ◼ Never use patients first name ◼ Arrange for comfort and privacy ◼ Sit at the patient's eye level ◼ Warn the patient before doing anything painful ◼ Let the patient know you hear them Genuineness ◼ Don’t pretend you are someone else. ◼ Introduce Your self as a Physician Assistant or PA student. ◼ Make the patient aware of your limited knowledge and responsibility ◼ Never give definite diagnoses or prognosis Empathy ◼ Listen to the total communication words, feelings and gestures. ◼ “I'm sure your daughter's problem has given you much anxiety.” ◼ “The death of someone close to you is hard to take.” ◼ “You must have been very sad.” Interviewing techniques ◼ ◼ Validation: recognition or affirmation that a person or their feelings or opinions are valid Reassurance: most often reassurance comes from the way you express yourself and how well the patient feels taken care of. ◼ Partnering: let the patient know you want to work with them on his/her health. ◼ Summarize: “let me make sure I got this right” Alert patient to the transitions. Let the patient know about topic changes Interviewing techniques ◼ Share the power: the provider-patient relationship is inherently unequal. Try to give your patients as much power as possible, because ultimately, they are the ones making choices and changes. – Evoke their perspective, be interested in them as people, not just a problem (the arm, the cough…), follow their leads, elicit and validate emotions, give them information, make your reasoning understandable to them and reveal the limits of your knowledge. Interviewing techniques ◼ Special cases – Altered capacity – Children – The silent patient – The talkative patient – The crying patient – The angry patient - Language barrier - Low literacy - Deaf/hard of hearing - Blind patient - Low intelligence - Personal advice seeker Advanced interviewing ◼ Using interpreters: – Various languages – Sign language Other interviewing thoughts Cultural sensitivity – Self awareness – Respectful communication – Collaborative partnerships ◼ Sexuality in clinician patient relationships - Sexual involvement with a patient affects or obscures the providers medical judgment and is inevitably harmful to the patient. Accordingly, sexual relationships between patients and physicians are uniformly considered unethical and a form of professional misconduct ◼ Ethics and professionalism – Primum non nocere: “1st do no harm” – Beneficence: “Do good” – Pt autonomy - The right of patients to make decisions about their medical care without their health care provider trying to influence the decision – educate the patient – Confidentiality ◼ Sensitive Topics Sexual History ◼ Mental Health ◼ Gender ◼ Alcohol and Drug use ◼ Family violence ◼ Death and dying ◼ The 6 P’s of Sexual HX ◼ ◼ ◼ ◼ ◼ ◼ Partners Practices Past History of STIs Protection Pregnancy Prevention/Reproductive Life Plan. Pleasure, Problems and Pride- explores sexual satisfaction, functioning, concerns, and support for one’s gender identity and sexual orientation Mental Health Any Family history of psychiatric disorders ◼ If patient has history of behavioral health issues question if they have been on medication in the past, any hospital admissions for treatment, any history of suicidal attempts ◼ Remember many everyday complaints can be related to mental health issues. ◼ Alcohol Hx ◼ ◼ ◼ ◼ ◼ “How much do you drink on an average day?” “How much do you drink in an average week?” “What kind of alcoholic drinks do you drink?” “Is there anything that makes you drink more or less in a day?” “How much do you spend on alcohol each week?” C.A.G.E Other Screening tools for Alcohol Abuse Alcohol Use Disorders Identification Test (AUDIT). ... ◼ AUDIT-C is a shortened version of the Alcohol Use Disorders Identification Test (AUDIT). ... ◼ Drug use What type of drug is being used and the route (injectable – PO- Snort- Smoke ) ◼ Is it occasional or daily? ◼ Many patients see this as recreational ◼ Is there a history of previous drug use? ◼ Screening Tools for Drug use Drug Abuse Screen Test (DAST, also known as DAST-10). ... ◼ NIDA Drug Use Screening Tool, also known as the NIDA Quick Screen. ... ◼ NIDA Modified Alcohol, Smoking, and Substance Involvement Screening (NM ASSIST) ◼ Family violence ◼ Clues to possible physical abuse – Inconsistent, unexplained injuries – Delayed treatment – Repeated injuries or “accidents” – Close family history or ETOH or drug abuse – Partner/family member dominates interview, will not leave room, or seems anxious Death and Dying ◼ ◼ ◼ ◼ ◼ Step 1. Initiating discussion Establish a supportive relationship with patient and family. Appoint a surrogate decision maker. Elicit general thoughts about end-of-life preferences. Step 2. Clarifying prognosis ◼ Be direct, yet caring. Be truthful, but sustain spirit. Use simple everyday language. ◼ Step 3. Identifying end-of-life goals ◼ ◼ Facilitate open discussion about desired medical care and remaining life goals. Recognize that as death nears, most patients share similar goals; maximizing time with family and friends, avoiding hospitalization and unnecessary procedures, maintaining functionality, and minimizing pain. ◼ Step 4. Developing a treatment plan ◼ ◼ ◼ ◼ ◼ ◼ Provide guidance in understanding medical options. Make recommendations regarding appropriate treatment. Clarify resuscitation orders. Initiate timely palliative care, when appropriate. The Medical History ◼ The beginning of the interview sets the atmosphere for the rest of the history and physical. ◼ Friendly Greeting ◼ Establish Privacy and ensure the patient is comfortable Interviewing ◼ Meeting the patient for the first time – Be professional, respectful and polite – Be in control without appearing condescending or judgmental ◼ Prepare – Review the medical record (vital signs, etc) – Review your own appearance and behavior – Adjust your environment and take notes Identifying ◼ Be able to correctly identify your patients – In hospital: at least 2 pt. identifiers ▪ Patients own words: Tell me your name, DOB, SS#, etc… ▪ Wrist bands, chart-> MRN agreement Source and Reliability ◼ Usually the patient – Include translators, family members, other medical providers; EMT/medics etc. • “Source: patient” ◼ How reliable is the information? – Is the patient able to accurately give a history • Alcohol, drugs, mental capacity, etc… • “Reliability: good” The Chief Complaint ◼ Main reason the patient sought medical help. ◼ “How Can I help you today?” ◼ “What brings you in today?” ◼ Usually recorded in the patients' own words. ◼ Include time frame ◼ “Chest Pain X 1 hour” History of Present Illness (HPI) ◼ Thorough elaboration of the chief complaint (Story of the C/C) ◼ Let the patient tell you what's wrong ◼ Start with open ended questions ◼ Then use more directed questions ◼ Finally closed ended questions Open Ended Questions ◼ Allows patient freedom to Talk “Tell me more about that.” “What was the pain like?” ◼ Minimal Facilitators “Uh Huh”, “go on”, etc. ◼ Nonverbal cues Head nodding, smiling “W” Questions More directed yet still open ended ◼ Where: is the pain ◼ What: does it feel like ◼ When: did it start ◼ Why: do you think it occurs ◼ Who: is affected by it ◼ How: is it altered by time of day, sleep, food, exertion etc. Direct and Closed Ended Questions ◼ Provide More detail ◼ Good in Emergencies ◼ Deter Laundry Lists Questions to Avoid ◼ Leading Questions ◼ Multiple Questions ◼ Yes/No questions with sensitive matters Interviewing Symptoms Description Date of Onset ◼ Character of complaint ◼ Mode of onset ◼ Course persistent or intermittent ◼ Duration of symptoms ◼ Location and radiation ◼ Relation to other symptoms ◼ Exacerbation and Remission ◼ Rate Pain 1-10 / Effect of Treatment ◼ Activities of Daily Living ◼ Pertinent negatives and positives ◼ OPQRST O – Onset ◼ P – Precipitating and Palliative ◼ Q – Quality ◼ R – Radiation ◼ S – Severity ◼ T – Temporal ( time) ◼ Summarization and Clarification ◼ Feed back information to the patient ◼ Helps uncover discrepancies The Chief Complaint CC ◼ A concise statement describing the reason for the encounter. The CC should be clearly reflected in the medical record for each encounter and is usually stated in the patient's words. History Of Present Illness A description of the development of the patient's present illness. The HPI is usually a chronological description of the progression of the patient's present illness from the first sign and symptom to the present. ◼ HPI tells the story of the C/C (chief complaint) ◼ Points on HPI ◼ First sentence can include such things as age sex race along with pertinent past medical history ◼ Second sentence includes where patient is presenting to and restates the chief complaint with time frame ◼ The third sentence starts with patient states… And goes on to include pertinent information ◼ Last sentence includes pertinent negatives ◼ Try to combine pertinent information in sentences Examples of HPI ◼ 48-year-old white female with PMHX of T2DM presents to ER complaining of right upper quadrant pain after eating a cheese pizza this afternoon. She claims the pain is 8/10 and radiates to her upper back. Denies and N/V/D, fever , chills, or other complaints. The Medical History ◼ ◼ ◼ ◼ ◼ ◼ ◼ ◼ Past Medical history Family History Social History Occupation Lifestyle Support Systems Sexual History Review of Systems Past Medical History ◼ ◼ ◼ ◼ ◼ ◼ ◼ ◼ ◼ Serious Illnesses Hospitalizations Surgical Procedures Accidents and Injuries Obstetrical History Allergies Current Medications Including Herbals Immunizations Screening tests Family History ◼ Include Parents, Siblings, Children and grandparents ◼ Mother 65 Alive and Well ◼ Father 72 MI, History of IDDM Family History Diagram Social History Habits- ETOH, Smoking, Drugs, Caffeine ◼ Travel ◼ Marital Status / Support Systems ◼ Occupational History ◼ Home Situation including pets ◼ Diet ◼ Daily Activities and Exercise ◼ Sexual History ◼ Smoking Alcohol and Drugs ◼ Ascertain amount and frequency ◼ Don’t use yes or no questions ◼ “How many years have you been smoking?” ◼ “How many beers do you drink a day?” ◼ “How much marijuana do you smoke?” ◼ Quantify smoking Tobacco in pack years Smoking (Pack Years) Pack Years ◼ A way to measure the amount a person has smoked over a long period of time. It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, 1 pack year is equal to smoking 1 pack per day for 1 year, or 2 packs per day for half a year, and so on. Support Systems ◼ Is the patient married? ◼ Does the patient live alone ◼ Is there family or friends available to help ◼ May need to arrange health services Occupation ◼ What jobs has the patient held? ◼ Any exposure to fumes, chemicals, radiation or noise? ◼ Explore temporal relations to current medical problems. Home Situation ◼ Does the patient live alone? ◼ Any pets? ◼ Stairs to climb? Nutrition and Diet ◼ Typical days meals, snacks, times ◼ Proportion of red meats, fats, fiber, salt and caffeine intake Activity and Exercise ◼ Is patient sedentary? ◼ Type and frequency of exercise. Sexual History Sexual function essential to most patients lives. Many emotions are involved: Depression, anxiety and anger. ◼ ◼ Sexual dysfunction may be due to underlying illness. ◼ “Do you have any concerns about sexual functioning?” ◼ Many girls/boys your age have questions about birth control. Travel Hx Does patient travel out of the country or even other states regularly/ recently ◼ How often and for how long ? ◼ When was the last time you traveled ? ◼ *Increased possibility of infectious disease* Contact Tracing Goals of Contact Tracing To interrupt ongoing transmission and reduce spread of an infection ◼ To alert contacts to the possibility of infection and offer preventive counseling or prophylactic care ◼ To offer diagnosis, counseling and treatment to already infected individuals ◼ If the infection is treatable, to help prevent reinfection of the originally infected patient ◼ To learn about the epidemiology of a disease in a particular population ◼ Review of Systems General ◼ Skin hair and Nails ◼ Head ◼ Eyes ◼ Ears ◼ Nose nasopharynx ◼ Sinuses ◼ Review of Systems Mouth and throat ◼ Neck ◼ Breast ◼ Cardiorespiratory ◼ – Break up into Cardiovascular and Respiratory Gastrointestinal ◼ Genitourinary ◼ Menstrual and Obstetrical ◼ Review of Systems Nervous System ◼ Musculoskeletal ◼ Hematological System ◼ Endocrine System ◼ Psychiatric ◼ General Recent weight loss or gain ◼ Loss of appetitive ◼ Generalized weakness ◼ Fever, chills or night sweats ◼ Skin, hair and Nails Texture ◼ Excessive dryness or sweating ◼ Discolorations ◼ Pigment changes ◼ Changes in hair distribution ◼ Head Headaches ◼ Vertigo ◼ Head Trauma ◼ Eyes Visual disturbances ◼ Lacrimation ◼ Photophobia ◼ Pruritus ◼ Last Eye exam ◼ Ears Deafness ◼ Pain ◼ Discharge ◼ Tinnitus ◼ Vertigo ◼ Nose, Nasopharynx and Sinuses Discharge ◼ Epistaxis ◼ Obstruction ◼ Pain ◼ Mouth and Throat Bleeding Gums ◼ Sore throat ◼ Dental Hygiene ◼ Last Dental Exam ◼ Neck Localized Swelling or Stiffness ◼ Pain ◼ Breasts Lumps ◼ Discharge ◼ Pain ◼ Last Mammogram ◼ Cardiorespiratory Dyspnea- hard to breathe ◼ Orthopnea –SOB when lying flat ◼ Paroxysmal Nocturnal Dyspnea -SOB that wakens the PT ◼ Edema ◼ Cough ◼ Hemoptysis ◼ Chest pain ◼ Cardiorespiratory Palpitations ◼ Syncope ◼ Wheezing ◼ Gastrointestinal Appetite ◼ Intolerance to certain foods ◼ Nausea and vomiting ◼ Dysphagia ◼ Pyrosis- heartburn ◼ Flatulence ◼ Eructation- belching ◼ Abdominal Pain ◼ Gastrointestinal Diarrhea ◼ Jaundice ◼ Changes in bowel habits ◼ Hemorrhoids ◼ Tenesmus- cramping rectal pain ◼ Stool Guaiac/Colonoscopy/Sigmoidoscopy ◼ Genitourinary Frequency ◼ Nocturia ◼ Urgency ◼ Hesitancy ◼ Oliguria- minimal urine output ◼ Pyuria- presence of white cells/pus ◼ Genitourinary Incontinence ◼ Pain ◼ Sexual history ◼ Last prostate Exam and PSA Level ◼ Menstrual and Obstetrical Date of Last normal Period ◼ Interval between periods ◼ Duration and amount of flow ◼ Menarche- first menses ◼ Dysmenorrhea- painful menses ◼ Menorrhagia- heavy menstrual bleeding ◼ Post Coital bleeding ◼ Vaginal Discharge ◼ Menstrual and Obstetrical Dyspareunia- painful sexual intercourse ◼ Menopause (HRT) ◼ Obstetrical History ◼ G#P# - gravida, para G - total # of pregnancies P - total # of delivered pregnancies T - total # of term deliveries (after 37 weeks) P - total # of preterm deliveries (20-36 weeks) A - total # of abortions/miscarriages (before 20 weeks) L - total # of living children * Note: for T-P-A twins count as one number, but for L they count as two ◼ Example G2P2 ◼ Taking OB History Using GTPAL ◼ https://youtu.be/wH7-LtQx9eI Nervous System Seizures ◼ Numbness and Paresthesia ◼ Ataxia- lack of muscle control ◼ Loss of Strength ◼ Change in cognition, mental status or memory ◼ Musculoskeletal Muscle and joint pain ◼ Deformity ◼ Swelling ◼ Erythema ◼ Peripheral Vascular System Intermittent Claudication ◼ Coldness ◼ Trophic Changes ◼ Varicose veins ◼ Hematological System Anemia ◼ Easy bleeding or bruising ◼ Lymph node enlargement ◼ Endocrine system Polyuria / Polyphagia / Polydipsia ◼ Heat or cold intolerance ◼ Goiter ◼ Psychiatric Depression ◼ Anxiety ◼ Suicidal/homicidal Ideations ◼ Have you ever seen a mental health professional ◼ All this info…now what? ◼ Recording your findings – Charting - EHR – HIPAA -health insurance portability and accountability act (1996) ◼ Assessment and Plan – Clinical reasoning – EBM- evidence based medicine Steps in clinical reasoning SOAP Note Recording your findings Medical history example (Bates) ◼ Electronic Medical Record EMR Core functions of EHR ◼ ◼ ◼ ◼ ◼ ◼ ◼ ◼ Health Information and Data. ... Results Management. ... Order Entry/Order Management. ... Decision Support. ... Electronic Communication and Connectivity. ... Patient Support. ... Administrative Processes. ... Reporting and Population Health Management. EHR Review Of Symptoms Tips for Taking a Great History ◼ https://youtu.be/4wfjSfoHwl4 The Physical Examination …more to come #TooEasy