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Introduction to the Physical Examination

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  1. Introduction to the Physical Examination

  2. Today’s Agenda • Overview of course • Exam techniques and use of equipment • Vital signs

  3. Introduction to the Medical Profession • Not an introduction, but a beginning • A new type of learning experience • The study of the patient • The study of illness as opposed to disease

  4. IMP I Primary Care Externship Communication and Interviewing Physical Examination Clinical Decision Making - EBM IMP II Adv. Communication and Interviewing Physical Diagnosis Radiology, Laboratory and problem-solving Clinical Decision Making-EBM IMP is a two year course

  5. Student Goals: • To understand the underlying anatomy and physiology of the normal physical examination • To be able to perform a complete screening physical examination in a logical fashion with minimal discomfort to the patient. • To be able to recognize normal findings on the physical examination

  6. Expectations • Attendance • Participation • Professionalism • Honesty • Feedback • Attitude

  7. Physical Examination • Lecture series • Small group session • CSTAC

  8. Assessment • Multiple choice examination • Practical examination • History • Physical examination

  9. Basic Clinical Skills • 70% of diagnosis can be based on history alone • 90% of diagnosis can be made when the physical examination is added • Expensive tests often confirm what is found in the H&P

  10. “The major effort in becoming a diagnostician consists in acquiring the intellectual background to make his or her perceptions meaningful - in short, he or she must practice and study.” DeGowin and DeGowin

  11. Physical Examination:Two Tiers of Investigation • Screening or Comprehensive Examination • The foundation of clinical skills • Uses • Undifferentiated patient • New patient • Pt wishing a “complete” H&P

  12. Physical Examination:Two Tiers of Investigation • Extended or Problem-Focussed Examination • Physician follows leads • Usually involves an extended assessment of a system or region

  13. Knowledge Base Technical Skills Exam skills Use of equipment Perceptual Skills Sensory Interpretation Communication Skills Interpersonal Skills Physical Examination

  14. Knowledgebase • Normal examination • Anatomy • Physiology • Techniques • Equipment • Expected normal findings • Normal variations • Changes with age • Extrapolation to common abnormalities

  15. Learning the Physical Examination • A key to a thorough and accurate physical examination is developing a systematic sequence of examination

  16. Learning the Physical Examination • An important goal is to minimize the number of times you ask the patient to change positions

  17. Learning The Physical Examination • Systems Approach  Regional Approach • Small group sessions with preceptor • Lecture series • Reading Bates • Practice • Review session with SPs

  18. Format of Small Group Sessions: • Read material ahead of time • Use objectives as a guide • Do the practice questions and review with preceptor • Practice exam techniques • Use checklist as a guideline

  19. The Syllabus

  20. Lecture Schedule

  21. Small Group Sessions: • 1.Getting started • 2. HEENT, neck, lymph nodes • 3. Cardiovascular, peripheral vascular • 4. Chest, pulmonary • 5 Abdomen • 6 Neurological • 7. Musculoskeletal • 8.&9.Putting it all together • 10.Patients

  22. Practice Questions

  23. Checklist

  24. Checklist Explained Systolic blood pressure should be estimated the first time a patient's blood pressure is taken. This is done by palpating the brachial or radial arteries; after the pulse is palpated, slowly inflate the blood pressure cuff and note the blood pressure at which the pulse is no longer palpable.

  25. Learning Resources: Required Textbook: Bates. . A Guide to Physical Exam and History Taking. 9th ed. Philadelphia: Lippincott, 2005

  26. Examination Techniques and Equipment

  27. Examination Techniques and Equipment Objectives for each section: General Appearance Appreciate the importance of observation Exam techniques Inspection List what some examples of what to look for in general observation List a few conditions that are diagnosed from general inspection The type of lighting is best for observing couture Percussion Definition of percussion Types of percussion Uses of percussion The technique of percussion Be able to perform direct and indirect percussion The percussion notes and what they indicate Recognize percussion notes Be able to interpret physical exam findings based on percussion

  28. Examination Techniques: • Inspection • Percussion • Palpation • Auscultation

  29. Observation (Inspection): • Least mechanical part of the physical examination • Hardest to learn • Yields the most physical signs • More diagnoses are made by inspection than all others combined • Depends upon the knowledge of the observer

  30. How to Observe • Keep your eyes open • Keep an open mind • Ask questions • Learn what to observe • Reflect on what you have observed and look for what you may have missed

  31. Finished files are the re- sult of years of scientif- ic study combined with the experience of years.

  32. Observation • “Never mind,” said Holmes, laughing; “it is my business to know things. Perhaps I have trained myself to see what others overlook. If not, why should you come to consult me?” • “A case of Identity” from Adventures of Sherlock Holmes

  33. “The precise and intelligent recognition and appreciation of minor differences is the real essential factor in all successful medical diagnosis”- Joseph Bell, MD (1890) • The character of Sherlock Holmes was based on Dr. Bell, an English surgeon who taught Arthur Conan Doyle during medical school.

  34. Enhancing Your Powers of Observation • Learning physical examination techniques is all about becoming a better observer • A skilled clinician has enhanced powers of observation and the knowledge to use these observations in the care of patients

  35. “Don’t touch the patient - state first what you see; cultivate your powers of observation.”Sir William Osler

  36. “The student must teach the eye to see, the fingers to feel, and the ear to hear.”Sir William Osler

  37. Observation: • What you see • Know what to look for • What you hear (listening) • Olfactory diagnosis • What you feel emotionally

  38. Observation: Inspection • Least mechanical aspect of the physical examination • Hardest to learn • Yields the most physical signs • More diagnosis are made by inspection than all other techniques combined • Depends upon the knowledge of the observer

  39. Inspection • Begins when you first see the patient and ends when they leave • Systematic part of each component of the physical examination • Part of the mental status examination • Subtle observations probably account for “the sixth sense” of astute clinicians

  40. Inspection: General Appearance • State of consciousness • Signs of distress (sick or not sick?) • Apparent state of health • Skin:discoloration or obvious lesions • Dress, grooming, and personal hygiene • Facial expression • Gait and posture • Motor activity

  41. Dress, grooming, and personal hygiene

  42. Inspection: General Appearance • State of nutrition • Body habitus • Symmetry • Stated age vs. physiologic age • Mood, attitude, affect • Speech • Olfactory diagnosis • Bodily excretions (Effuvia)

  43. Olfactory Diagnosis: “Medical olfaction can often be an important aspect of clinical examination if clinicians approach patient encounters with an “open nose” as well as an open mind.” Hayden, GF: Olfactory diagnosis in medicine, Post Graduate Medicine, 1980

  44. Olfactory Diagnosis: “Characteristic patient odors accompany many diseases and intoxications, and their recognition can provide diagnostic clues, guide the laboratory evaluation, and affect the choice of immediate therapy.” Hayden, GF: Olfactory diagnosis in medicine, Post Graduate Medicine, 1980

  45. Diagnosis of certain diseases Fruity; acetone like = Diabetic ketoacidosis Urine-like = Uremia Inborn errors of metabolism Detection of ingestions or toxins Alcohol Tobacco Toluene Cyanide Detection of certain infections Anaerobic Necrotic material Inspection: Olfactory Diagnosis:

  46. Inspection: Bodily Excretions (Effluvia) • Video

  47. Inspection: Bodily Excretions (Effluvia) Urine, stool, sputum, vomitus, exudates, sweat Color, odor, constancy, or smell Examples: • Acholic (clay colored) stool of biliary obstruction • “Coffee ground” emesis of upper gastrointestinal hemorrhage • “Rusty sputum” of pneumococcal pneumonia • Melena the black tarry stool from an upper gastrointestinal hemorrhage has a distinct odor • “Uremic frost” of severe renal failure