Basics of patient presentations including history and physical
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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


Review of lung anatomy

Review of Lung Anatomy


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 pulmonary6

Physical Exam: Pulmonary

  • Posterior


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 musculoskeletal exam

Physical Exam: Musculoskeletal Exam


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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