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Basics of Patient Presentations Including History and Physical. AFAMS Residency Orientation. Objectives. Learn the different types of presentations Master the techniques necessary to properly present a patient Obtaining a History and Physical

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basics of patient presentations including history and physical

Basics of Patient PresentationsIncluding History and Physical

AFAMS Residency Orientation

objectives
Objectives
  • Learn the different types of presentations
  • Master the techniques necessary to properly present a patient
  • Obtaining a History and Physical
  • Understand purpose of each physical exam maneuver
obtaining a history
Obtaining a History
  • Ask questions focused on the patient’s chief complaint
  • Questions shouldn’t be too specific
  • Allow the patient to fully answer the question
  • Your last question should be “Is there anything else that I didn’t specifically ask you about?”
formal presentations
Formal Presentations
  • 7 minutes or less
  • Requires
    • Style
    • Substance
  • No time wasted on superfluous information
  • Follows standard template from history to assessment / plan
types of presentations
Types of Presentations
  • New Patient
    • History, Physical, Assessment and Plan
  • Follow Up
    • Patient presented on a previous day
    • Abridged presentation referencing only major patient issues
  • Bedside
    • Ask the patient’s permission first
    • Student/resident presents to attending while standing next to the patient
new patient presentation
New Patient Presentation
  • History of Present Illness
  • Past Medical and Surgical History
  • Family and Social History
  • Medications and Allergies
  • Physical Exam Findings
  • Laboratory and Radiographic Findings
  • Differential Diagnosis
  • Assessment and Plan
new patient history of presenting illness
New Patient: History of Presenting Illness
  • Include symptom
    • Quality
    • Severity
    • Location
    • Duration
  • Last portion of History of Presenting Illness is review of systems
    • Complete head to toe review of any symptom the patient may have
new patient medical history
New Patient: Medical History
  • Past Medical History
    • Include the patient’s previous illness or diagnoses
  • Past Surgical History
    • Name of all previous procedures and surgeries
    • Include dates, indications, and complications
new patient further history
New Patient: Further History
  • Family History
    • Include any medical conditions affecting patient’s parents or siblings
  • Social History
    • Occupation
    • Alcohol use
    • Tobacco use
new patient medications and allergies
New Patient: Medications and Allergies
  • Allergies
    • Any medication allergies
    • Any major food or environmental allergies
  • Medications
    • Any current prescription medication
    • Herbal supplements
    • Over-the-counter medications
new patient physical exam
New Patient: Physical Exam
  • Head and Neck
  • Cardiovascular
  • Respiratory
  • Abdominal
  • Extremity
  • Musculoskeletal
  • Neurological
physical exam head and neck
Physical Exam: Head and Neck
  • Lymph Nodes
    • Cancer
    • Infection
  • Feeling for enlarged, warm, firm, or tender
  • Palpate all lymph node chains
physical exam head and neck1
Physical Exam: Head and Neck
  • Ear
    • External Exam (infection or cancer)
    • Internal Exam (infection)
  • Otoscope
    • Tympanic Membrane’s color, posterior structures, light reflex
physical exam head and neck2
Physical Exam: Head and Neck
  • Auditory Acuity
    • Sensorineural Defects
      • Weber Test
      • Rinne Test
    • Conduction Defects
      • Weber Test

WEBER

RINNE

physical exam head and neck3
Physical Exam: Head and Neck
  • Nose
    • Mucosal Color
    • Presence of Discharge
  • Sinuses
    • Maxillary Sinus
    • Frontal Sinus
    • Directly palpate and percuss sinuses
    • Examine for discharge
    • Tap teeth with tongue depressor (inflamed maxillary sinuses)
physical exam head and neck4
Physical Exam: Head and Neck
  • Oropharynx
    • Using light and tongue depressor have patient stick out tongue and say “Ah”
  • CN 9 dysfunction
  • Nutrition
  • Dental Hygiene
  • Infection
    • Peritonsillar

Abscess

physical exam head and neck5
Physical Exam: Head and Neck
  • Thyroid Exam
    • Goiter
    • Nodule
  • Methods of examination
    • Palpation
    • Observation
physical exam cardiovascular
Physical Exam: Cardiovascular
  • Three components to Cardiovascular exam
    • Observation
    • Palpation
    • Auscultation
  • Observation
    • Jugular Venous

Distension

      • IJ NOT EJ
      • Head at 45 degrees
      • Angle of Louis
physical exam cardiovascular1
Physical Exam: Cardiovascular
  • Palpation
    • Palm on left sternal edge, fingers extended
    • Point of Maximal Impulse
      • Should be on mid-clavicular line, 5th intercostal space
      • Duration of impulse
      • Thrill?
physical exam cardiovascular2
Physical Exam: Cardiovascular
  • Auscultation
    • Never listen through clothing
    • Know all four valvular regions
physical exam cardiovascular3
Physical Exam: Cardiovascular
  • Discern S1 and S2
  • Recognize systole and diastole
  • When a murmur is present
    • Systole vs. Diastole
    • Duration
    • Intensity
    • Associated Sounds
physical exam cardiovascular4
Physical Exam: Cardiovascular
  • Murmurs are graded
    • I: Heard with careful listening
    • II: Easily audible with stethoscope
    • III: Louder than II
    • IV: As loud as III, but with additional thrill
    • V: Audible with stethoscope barely touching chest
    • VI: Heard without stethoscope
physical exam pulmonary
Physical Exam: Pulmonary
  • Four components of the pulmonary exam
    • Inspection / Observation
    • Palpation
    • Percussion
    • Auscultation
physical exam pulmonary1
Physical Exam: Pulmonary
  • Observation
    • General Comfort
    • Breathing Pattern
      • Pursed Lips
      • Wheezing or gurgling
    • Use of Accessory Muscles
      • Intercostals
      • Sternocleidomastoids
    • Patient Color
      • Lips, Nail beds, face
    • Position of Patient
      • Upright or leaning forward
physical exam pulmonary2
Physical Exam: Pulmonary
  • Palpation
    • Detecting Chest excursion
    • Tactile Fremitus will be altered by pathology:
      • Consolidation
      • Pleural Fluid
physical exam pulmonary3
Physical Exam: Pulmonary
  • Percussion
    • Normal: tapping on chest produces resonant note
    • Fluid filled cavity (consolidation or effusion): dullness
    • Conditions that lead to air trapping (emphysema and PTX): hyper resonant
physical exam pulmonary4
Physical Exam: Pulmonary
  • Percussion

Percussion Technique

physical exam pulmonary5
Physical Exam: Pulmonary
  • Auscultation: first remember the location of each lobe in the lung fields
  • Anterior
physical exam pulmonary7
Physical Exam: Pulmonary
  • Normal breath sounds
    • Vessicular
  • Wheezes
    • Mucosal edema
    • Bronchoconstriction
    • Inspiratory vs. Expiratory
  • Rales or crackles
    • Result of fluid accumulation
physical exam abdomen
Physical Exam: Abdomen
  • Components of the exam are
    • Observation
    • Auscultation
    • Percussion
    • Palpation
  • Always think anatomically
physical exam abdomen1
Physical Exam: Abdomen
  • Abdomen is divided into four quadrants
physical exam abdomen2
Physical Exam: Abdomen
  • Observation
    • Appearance of abdomen
      • Distended
      • Flat
      • Symmetric or Asymmetric
    • Prior surgical scars
    • Signs of Peritonitis
      • Patient laying very still
      • In pain with minor movements
physical exam abdomen3
Physical Exam: Abdomen
  • Auscultation
    • Listen in all four quadrants 15 seconds in each
    • Bowel sounds
      • Present vs. Absent
      • How frequently?
    • Renal Artery Bruits
physical exam abdomen percussion
Physical Exam: Abdomen Percussion
  • Two solid organs produce dull sound
    • Liver
    • Spleen
  • Look for production of pain with percussion
  • Percussion can assist in determining source of abdominal distention
    • Fluid
    • Gas
physical exam abdomen palpation
Physical Exam: Abdomen Palpation
  • Always in a normal area
    • If pain in RUQ, start in LLQ
  • Palpate lightly first
  • Then repeat with deeper palpation
  • Palpate internal organs if possible
  • Note pain or splinting
  • Palpate the aorta around the umbilicus
  • Is there any fluid or ascites?
physical exam upper extremities
Physical Exam: Upper Extremities
  • Examine nail
    • Shape
    • Color
    • Deformity
    • Capillary Refill
  • Joint Deformity
  • Cyanosis
  • Radial pulse
  • Edema
  • Axillary Lymph Node
physical exam lower extremities
Physical Exam: Lower Extremities
  • Femoral Pulse
  • Inguinal Hernia
  • Popliteal Pulse
  • Pedal Pulse
  • Edema
  • Knee joint swelling
  • Gangrene
  • Cellulitis
physical exam extremities
Physical Exam: Extremities

Palpation of Axillary Lymph Nodes

Onychomycosis

Joint Deformity

Cellulitis

Gangrene

Cyanosis

physical exam neurological exam
Physical Exam: Neurological Exam
  • Can be a comprehensive or cursory exam
  • Major Components
    • Mental Status
    • Cranial Nerves
    • Muscle strength, tone and bulk
    • Reflexes
    • Coordination
    • Sensory Function
    • Gait
physical exam cranial nerves
Physical Exam: Cranial Nerves
  • CN 1: Olfactory Sense
  • CN 2: Visual Acuity
  • CN 3, 4, 6: Extra-ocular muscle movement
  • CN 4: Superior

Oblique muscle

CN 6: Lateral Rectus

CN 3: Inferior oblique

Inferior rectus, superior

rectus, and medial rectus

physical exam cranial nerves1
Physical Exam: Cranial Nerves
  • CN 5
    • Motor: Temporalis and Masseter muscles
    • Sensory
      • V1: Forehead
      • V2: Check
      • V3: Jaw
  • CN 7
    • Most of the facial muscles
  • CN 8: Acoustic Acuity
    • Weber
    • Rinne
physical exam cranial nerves2
Physical Exam: Cranial Nerves
  • CN 9: Glosopharyngeal
  • CN 10: Vagus
  • Together CN 9 and 10 raise the soft palate and produce gag reflex
physical exam cranial nerves3
Physical Exam: Cranial Nerves
  • CN 11: Innervates muscles which permit shrugging of shoulders
  • CN 12: Responsible for tongue movement
physical exam sensory
Physical Exam: Sensory
  • Spinothalamics: detect pain, temperature, crude touch
  • Dorsal Columns: detect position, vibratory and light touch
physical exam motor assessment
Physical Exam: Motor Assessment
  • Observe muscle bulk
  • Look for asymmetry between extremities
  • Examine major muscle groups of upper and lower extremities
    • Biceps
    • Triceps
    • Deltoids
    • Quadriceps
    • Hamstrings
motor assessment
Motor Assessment
  • Assessment of muscle strength
  • 0: No movement
  • 1: Slight flicker of muscle movement
  • 2: Can voluntarily move, but cannot overcome gravity
  • 3: Can overcome gravity, but not applied resistance
  • 4: Can overcome gravity and some resistance
  • 5: Normal
follow up presentation
Follow Up Presentation
  • 1-2 sentence summary of patient’s presentation and hospital course
  • Explanation of past 24 hour events
  • Physical Exam
  • Important Laboratory and Radiographic Studies
  • Assessment and Plan
questions you may be asked during the presentation
Questions You May Be Asked During the Presentation
  • Etiology of Symptoms
  • Pathophysiology of Disease
  • Diagnosis Criteria
  • Common Complications
  • Differential Diagnosis
  • Diagnostic Tests
  • Treatment Options
miscellaneous tips
Miscellaneous Tips
  • Include only essential facts in your presentation
    • Be prepared to answer any questions with more detail
  • Keep the same order and format for all presentations
  • Be thorough with your differential diagnosis and treatment plan
miscellaneous tips1
Miscellaneous Tips
  • Try not read directly off paper
  • Presentation should be as conversational as possible
  • Expect questions and be prepared to answer them
conclusions
Conclusions
  • A tremendous amount of information can be obtained by a properly conducted history and physical
  • It is important to be an excellent presenter and be able to convey important information to other medical professionals
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