Pdr

• The techniques of physical examination and history taking embody the time-honored skills of healing and patient care
• Gathering a sensitive and nuanced history and performing a thorough and accurate examination deepen relationships with patients, focus assessment, and set guideposts for clinical decision making
• The quality of history and physical examination lays the foundation for patient assessment, recommendations for care, and choices for further evaluation and testing
• Experience with history taking and physical examination triggers steps of clinical reasoning from the first moments of the patient encounter
• Steps of clinical reasoning include:

  • Identifying symptoms and abnormal findings
  • Linking findings to underlying pathophysiology or psychopathology
  • Establishing and testing a set of explanatory hypotheses
• Determining the scope of patient assessment is crucial
• Physical examination begins with taking vital signs to validate subjective complaints of the patient
• Components of the Adult Health History include:

  • Identifying Data:
  • Age, gender, occupation, marital status
  • Source of history
  • Reliability
  • Chief Complaint(s)
  • Present Illness
  • Past History
  • Family History
  • Personal and Social History
  • Review of Systems
• Reliability of information provided by the patient is crucial and should be documented at the end of the interview
• Chief Complaint(s) should be quoted in the patient's own words
• Present Illness description should be clear and chronological, including onset, manifestations, and treatments to date
• Symptoms should be well characterized, including location, quality, severity, timing, aggravating or relieving factors, and associated manifestations
• Allergies and reactions to medications, foods, insects, or environmental factors must be recorded
• Tobacco use should be noted, including type and history of use
• Alcohol and drug use should be investigated as it can be pertinent to the presenting illness
• Past History should include childhood illnesses and adult illnesses in medical, surgical, obstetric/gynecologic, and psychiatric categories
• Health Maintenance practices such as immunizations and screening tests should be covered
• Family History should outline age, health, or cause of death of immediate relatives and record presence or absence of specific illnesses in the family
• Immunizations should be reviewed for diseases like tetanus, measles, influenza, and screening tests like Pap smears, mammograms, and cholesterol tests
• Written permission may be needed to obtain prior clinical records if the patient does not know their immunization or screening test history
• Family history:

  • Hypertension
  • Coronary artery disease
  • Elevated cholesterol levels
  • Stroke
  • Diabetes
  • Thyroid or renal disease
  • Arthritis
  • Tuberculosis
  • Asthma or lung disease
  • Headache
  • Seizure disorder
  • Mental illness
  • Suicide
  • Substance abuse
  • Allergies
  • Symptoms reported by the patient
• Ask about any history of breast, ovarian, colon, or prostate cancer
• Ask about any genetically transmitted diseases
• Personal and Social History:

  • Captures the patient’s personality and interests, sources of support, coping style, strengths, and concerns
  • Includes occupation and the last year of schooling
  • Home situation and significant others
  • Sources of stress, both recent and long-term
  • Important life experiences such as military service, job history, financial situation, and retirement
  • Leisure activities
  • Religious affiliation and spiritual beliefs
  • Activities of daily living (ADLs)
  • Lifestyle habits that promote health or create risk, such as exercise and diet
• • Include sexual orientation and practices
  • Avoid restricting to only tobacco, drug, and alcohol use
• Review of Systems (ROS):

  • May uncover problems that the patient has overlooked
  • Keep technique flexible
  • Major health events discovered during the Review of Systems should be moved to the Present Illness or Past History
  • Tips for Eliciting the Review of Systems:
  • Think about asking a series of questions going from “head to toe”
  • Draw on Review of Systems questions related to system(s) relevant to the Chief Complaint
  • For example: After a full description of chest pain, ask about high blood pressure, palpitations, shortness of breath, etc.
• • Nose and sinuses: Frequent colds, nasal stuffiness, discharge, itching, hay fever, nosebleeds, sinus trouble
  • Throat: Condition of teeth and gums, bleeding gums, dentures, last dental examination, sore tongue, dry mouth, etc.
  • Neck: “Swollen glands,” goiter, lumps, pain, or stiffness in the neck
  • Breasts: Lumps, pain, or discomfort, nipple discharge, self-examination practices
  • Respiratory: Cough, sputum, shortness of breath, wheezing, chest pain, etc.
  • Cardiovascular: High blood pressure, heart murmurs, chest pain, palpitations, shortness of breath, swelling, etc.
• • Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea, bowel movements, abdominal pain, etc.
  • Peripheral vascular: Leg pain, cramps, varicose veins, swelling, color change in fingertips or toes, etc.
  • Urinary: Frequency of urination, urgency, burning or pain during urination, blood in the urine, urinary infections, kidney or flank pain, etc.
  • Genital:
  • Male: Hernias, discharge from or sores on the penis, testicular pain or masses, sexual habits, interest, function, etc.
• • Female: Menstrual history, menopausal symptoms, vaginal discharge, itching, sores, number of pregnancies, sexual preference, etc.
  • Musculoskeletal: Muscle or joint pain, stiffness, arthritis, backache, swelling, redness, weakness, limitation of motion, etc.
  • Psychiatric: Nervousness, tension, mood, memory change, suicidal ideation, past counseling, etc.
  • Neurologic: Changes in mood, attention, speech, orientation, memory, headache, dizziness, weakness, paralysis, seizures, etc.
  • Hematologic: Anemia, easy bruising or bleeding, past transfusions, transfusion reactions
• • Endocrine: Heat or cold intolerance, excessive sweating, thirst or hunger, polyuria, change in glove or shoe size
• The Review of Systems:

  • General: Usual weight, recent weight change, clothing that fits more tightly or loosely than before; weakness, fatigue, or fever
  • Skin: Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles
  • Head, Eyes, Ears, Nose, Throat (HEENT):
  • Head: Headache, head injury, dizziness, lightheadedness
  • Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision, etc.
  • Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge
• Ethics are a set of principles crafted through reflection and discussion to define right and wrong
• Medical ethics guide professional behavior and are not static or simple
• Traditional maxims are embedded in the healing profession
• Building Blocks of Professional Ethics in Patient Care:
• Nonmaleficence or primum non nocere - "First do no harm"
• Giving incorrect information or avoiding relevant topics can do harm in an interview
• Beneficence is the dictum that the clinician needs to "do good" for the patients
• Autonomy reminds us that patients have the right to determine what is in their own best interest
• Confidentiality is fundamental to professional relationships with patients