PHYSICAL DIAGNOSIS VANDERBILT UNIVERSITY SCHOOL OF MEDICINE

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PHYSICAL DIAGNOSIS R. MICHAEL RODRIGUEZ,
M.D. ASSOCIATE PROFESSOR OF MEDICINE VANDERBILT
UNIVERSITY SCHOOL OF MEDICINE
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COURSE STRUCTURE

• LECTURES
• MONDAY AND THURSDAY 1-2PM
• TUESDAY 8-12AM
• TUTOR SESSIONS
• MONDAY 230-430 PM
• THURSDAY 230-430PM
• AFTER MIDTERM ALL TUTOR SESSIONS
• WILL BEGIN AT 100PM
• MANDATORY
• SURROGATE EXAMS
• MANDATORY

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EXPECTATIONS

• DRESS
• ALWAYS WEAR A WHITE COAT AND YOUR ID WHEN YOU
  SEE A PATIENT
• RESPECT PEERS, INSTRUCTORS, PATIENTS,
  HOUSEKEEPING, NURSES
• BE ON TIME TO TUTOR SESSIONS
• THE HISTORY, PHYSICAL AND ASSESSMENT ARE TO BE
  HANDWRITTEN. YOU MAY USE A TEMPLATE FOR THE FILL
  IN THE BLANKS PORTION OF THE HP.

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CLASS ETIQUETTE

• NO FOOD IN CLASS
• BE ON TIME
• CELL PHONES OFF IN CLASS
• NO POP TOPS
• FEEDBACK - E-MAIL

• ASK QUESTIONS
• DISCUSS ISSUES
• HELP YOUR CLASSMATES
• NOTIFY EDA OR ME OF ANY PROBLEMS
• RESPECT YOUR TUTORS AND TEACHERS
• NOTIFY EDA OR ME IF YOU ARE GOING TO MISS A
  SESSION

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HOW WILL YOU BE EVALUATED ON THE WARDS

• DO YOU RESPECT OTHERS?
• ARE YOU DRESSED IN A PROFESSIONAL MANNER?
• ARE YOU ON TIME?
• ARE YOU PREPARED?
• ARE YOU A TEAM PLAYER?
• ARE YOU COMPASSIONATE?
• ARE YOU CARING?
• ARE YOU COMPULSIVE?
• ARE YOU EASY TO BE AROUND AFTER A NIGHT ON CALL?
• ARE YOU HUMBLE?

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GRADES

• TUTOR 1 EVALUATION 20
• TUTOR 2 EVALUATION 2O
• MIDTERM EXAM 20
• FINAL PRACTICAL EXAM 20
• FINAL WRITTEN EXAM 20
• UNEXCUSED ABSENCES FROM TUTOR OR PATIENT SESSIONS
  WILL RESULT IN A PENALTY.
• NOTE, THIS IS THE FIRST TIME YOU WILL BE GRADED
  OBJECTIVELY AND SUBJECTIVELY

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GRADING SCALE HONORS PASS FAIL
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WHY ARE WE HERE?THE OBJECTIVES

• TO TEACH YOU HOW TO OBTAIN A CLINICAL HISTORY.
• TO TEACH YOU HOW TO PERFORM A PHYSICAL
  EXAMINATION
• TO TEACH YOU HOW TO ORGANIZE THE INFORMATION .
• TO TEACH YOU HOW TO RECORD THE INFORMATION.
• TO TEACH YOU HOW TO PRESENT THE INFORMATION.
• THE ULTIMATE GOAL IS TEACH YOU HOW TO USE THIS
  INFROMATION TO HELP YOUR PATIENT.
• THIS IS THE BEGINNING

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AS A STUDENT WHAT SHOULD MY GOALS INCLUDE ?

• DEVELOP INTERVIEWING SKILLS
• DEVELOP THE SKILLS TO PERFORM A COMPLETE
  HISTORY AND PHYSICAL EXAM
• BECOME PROFICIENT IN WRITING AND PRESENTING THE
  HP
• BEGIN TO DEVELOP A DIFFERENTIAL DIAGNOSIS FOR
  SPECIFIC SYMPTOMS AND SIGNS

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THE PHYSICIAN PATIENT RELATIONSHIP

• THE ROLE OF THE PHYSICIAN IS TO CARE FOR AND
  COMFORT
• THE INFIRM
• THE WEAK
• THE SCARED
• THE STRONG
• THE DYING
• IT IS THE HUMAN TOUCH AFTER ALL THAT COUNTS
  FOR MOST IN OUR RELATION WITH OUR PATIENTS.
• ROBERT TUTTLE MORRIS
  1915
• DO NOT TAKE THIS RESPONSIBILTY LIGHTLY

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PHYSICIAN PATIENT RELATIONSHIP
PHYSICIAN PATIENT RELATIONSHIP
YOUR GOAL
ASSESSMENT AND PLAN
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OBSERVE, RECORD, TABULATE, COMMUNICATE. USE YOUR
FIVE SENSES. LEARN TO SEE, LEARN TO HEAR, LEARN
TO FEEL, LEARN TO SMELL, AND KNOW THAT BY
PRACTICE ALONE YOU CAN BECOME EXPERT. MEDICINE IS
LEARNED BY THE BEDSIDE AND NOT IN THE CLASSROOM.
LET NOT YOUR CONCEPTIONS OF DISEASE COME FROM
WORDS HEARD IN THE LECTURE ROOM OR READ FROM THE
BOOK. SEE, AND THEN REASON AND COMPARE AND
CONTROL. BUT SEE FIRST
THAYER WS. OSLER THE TEACHER. BULLETIN OF THE
JOHNS HOPKINS HOSPITAL 191930198-200
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(No Transcript)
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WHY ARE INTERVIEWING AND PHYSICAL EXAMINATION
SKILLS IMPORTANT?

• THE HISTORY AND PHYSICAL REPRESENT THE FOUNDATION
  OF CLINICAL MEDICINE
• THE BOND BETWEEN YOU AND YOUR PATIENT BEGINS OR
  ENDS DURING THIS TIME. AS YOU DEVELOP AN
  IMPRESSION REGARDING YOUR PATIENT SO THEY WILL OF
  YOU.

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THE INTERVIEW
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A PRACTITIONER OF EXPERIENCE DOES NOT SEIZE THE
PATIENTS FOREARM WITH HIS/HER HAND, AS SOON AS
HE/SHE COMES, BUT FIRST SITS DOWN AND WITH A
CHEERFUL COUNTENANCE ASKS HOW THE PATIENT FINDS
HIMSELF/HERSELF AND IF THE PATIENT HAS ANY FEAR,
HE/SHE CALMS HIM/HER WITH ENTERTAINING TALK, AND
ONLY AFTER THAT MOVES HIS/HER HAND TO TOUCH THE
PATIENT. AULUS AURELIUS CORNELIUS CELSUS 25 BC
50 AD
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THE PHYSICIAN PATIENT RELATIONSHIP

• SOME FEEL THAT THE MEDICAL INTERVIEW IS YOUR MOST
  IMPORTANT SKILL! WHY?
• POOR SKILLS
• IMPEDE EFFICIENCY
• PATIENT COMPLIANCE
• PATIENT OUTCOMES
• PATIENT SATISFACTION
• ? INCREASE MALPRACTICE CLAIMS

MAYO CLIN PROC.200378211-214
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WHAT ARE THE FUNCTIONS OF THE MEDICAL INTERVIEW?

• TO GATHER INFORMATION
• TO FORM A RELATIONSHIP WITH THE PATIENT
• TO EDUCATE THE PATIENT

THE MEDICAL INTERVIEW CLINICAL CARE, EDUCATION,
AND RESEARCH. NEW YORK,NYSPRINGER-VERLAG
19953-19
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OBTAINING A CASE HISTORY WHY?

• ALLOWS YOU TO OBTAIN FIRSTHAND INFORMATION
  REGARDING YOUR PATIENTS ILLNESSS ( THE STORY),
  ITS MANIFESTATIONS AS WELL AS ITS NATURAL
  HISTORY.
• THE CONTACT AT THE BEDSIDE FIXES THE DISEASE IN
  YOUR MIND WHICH READING ALONE CANNOT DO.

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COMMON SHORTCOMING OF THE INTERVIEW PROCESS

• INTERRUPTION OF THE PATIENT ( WE INTERRUPT
  PATIENTS AN AVERAGE OF 18 SECONDS AFTER THE
  PATIENT BEGINS TO SPEAK) SO----
• WE DO NOT ALLOW THE PATIENT TO SHARE ALL OF THEIR
  CONCERNS

BECKMAN HB, FRANKEL RM. ANN INTERN MED. 1984
101692-696.
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BUILDING A RELATIONSHIP WITH YOUR PATIENT (PEARLS)

• P PARTNERSHIP
• E EMPATHY
• A APOLOGY
• R RESPECT
• L - LEGITIMIZATION
• S - SUPPORT

THE MEDICAL INTERVIEW CLINICAL CARE, EDUCATION,
AND RESEARCH. NEW YORK,NYSPRINGER-VERLAG
19953-19 PLATT FW, ET AL. ANN INTERN MED. 2001
1341079-1085
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PATIENT EDUCATION

• ASK - TELL - ASK

KELLER VF, CARROLL JG. PATIENT EDUC COUNS. 1994
23131-140
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THE FIRST INTERVIEW

• EXCITEMENT
• FRUSTRATION
• PATIENCE
• DETAILS
• COMPLETION

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WHAT DO I NEED TO DO TO PREPARE MYSELF PRIOR TO
THE INTERIEW?

• DRESS
• EQUIPMENT
• STRATEGIES
• AT THE BEDSIDE
• ENVIRONMENT
• INTRODUCE YOURSELF
• DEFINE YOUR ROLE
• BEGIN

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THE BASIC CONCEPT OF THE INTERVIEW AND PHYSICAL

• TO LEARN THE FACTS THAT LED THE PATIENT TO SEEK
  YOUR HELP (THE STORY).
• GIVEN THE INFORMATION, IT IS THEN YOUR
  RESPONSIBILITY TO ORGANIZE THE DATA INTO A FORMAT
  THAT ALL WILL UNDERSTAND (HP)
• DEVELOP A PLAN OF MANAGEMENT.

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THE INTERVIEW

• DO NOT BE JUDGEMENTAL
• BE COMPASSIONATE
• LISTEN
• DO NOT PUT PATIENTS ON THE DEFENSIVE
• BE GENTLE

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THE INTERVIEW

• BY THE END OF THE INTERVIEW YOU SHOULD HAVE A
  CLUE AS TO WHY THE PATIENT SOUGHT MEDICAL
  ATTENTION ( THE STORY) FROM THE INFORMATION
  GATHERED IN THE THE CC, HPI, PMH AND THE ROS.

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THE INTERVIEW

• FOCUS ON THE PATIENT
• ALLOW THE PATIENT TO SPEAK FREELY AND IN THEIR
  OWN WORDS
• THEY WILL USUALLY TELL YOU THE STORY
• TRY TO LEARN HOW THIS ILLNESS HAS AFFECTED THE
  PATIENT

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THE INTERVIEW

• HOW DO I REMEMBER WHAT THE PATIENT SAID? RECORD
  THE INFORMATION
• WHAT IF I FORGET THE ANSWER? ASK THE PATIENT
  AGAIN.
• ALLOW YOURSELF TIME AT THE END OF THE PHYSICAL
  EXAM TO ASK FOLLOW-UP QUESTIONS .

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I WISH I HAD TO SPEAK OF THE VALUE OF NOTE
TAKING. YOU CAN DO NOTHING AS A STUDENT IN
PRACTICE WITHOUT IT. CARRY A SMALL NOTEBOOK WHICH
WILL FIT INTO YOUR WAISTCOAT POCKET, AND NEVER
ASK A NEW PATIENT A QUESTION WITHOUT NOTEBOOK AND
PENCIL IN HAND. WIILIAM OSLER 1903
THE STUDENT
LIFE
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THE INTERVIEW - RULE OF FIVE VOWELS

• A - AUDITION
• E - EVALUATION
• I - INQUIRY
• O - OBSERVATION
• U - UNDERSTANDING

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TYPES OF QUESTIONS

• OPEN - INTERVIEW BEGINS WITH AN OPEN QUESTION -
  ALLOWS THE PATIENT TO DISCUSS THEIR ILLNESS
• CLOSED
• HAVE YOU HAD A COUGH?

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TYPES OF QUESTIONS

• BE CAREFUL HOW YOU ASK THE QUESTION - DO NOT ASK
  THE QUESTION IN SUCH A WAY THAT THE ANSWER IS
  IMPLIED
• YOU HAVE NOT TRAVELED HAVE YOU?
• HAVE YOU TRAVELED?

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TYPES OF QUESTIONS

• SPEAK IN LAYMANS TERMS
• HAVE YOU EVER RECEIVED MECHANICAL VENTILATION
• HAVE YOU EVER BEEN ON A BREATHING MACHINE

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TYPES OF QUESTIONS

• DUPLICATION - YOU MAY REPEAT A QUESTION TO
  CLARIFY A POINT
• HOWEVER DO NOT REPEAT THE QUESTION IN SUCH A WAY
  THAT THE PATIENT BELIEVES THAT YOU HAVE NOT BEEN
  LISTENING

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THE INTERVIEW QUESTIONS TO AVOID

• YES-NO QUESTIONS
• SUGGESTIVE QUESTIONS
• WHY
• AVOID MULTIPLE SIMULATANEOUS QUESTIONS
• BUSY - MAKE QUESTIONS CONCISE AND EASY TO
  UNDERSTAND

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THE INTERVIEW TECHNIQUES

• SILENCE
• FACILITATION GO ON, HMM
• CONFRONTATION - OBSERVATION
• INTERPRETATION - INFERENCE
• REFLECTION - MIRRORS
• SUPPORT - INTEREST
• PACING

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INTERVIEWING TIPS NONVERBAL BEHAVIORS

• BODY LANGUAGE
• EYE CONTACT
• ENCOURAGEMENT
• PHYSICAL CONTACT
• HABITS
• POSITIONING

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SIGNS AND SYMPTOMS

• SYMPTOMS - THIS IS WHAT THE PATIENT FEELS
• CONSTITUTIONAL SYMPTOMS FEVER
• WEAKNESS
• SIGNS PHYSICAL FINDINGS -WHAT THE EXAMINER
  DISCOVERS

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AN APPROACH TO A SYMPTOM THE SEVEN ELEMENTS

• BODILY LOCATION
• QUALITY
• QUANTITY
• CHRONOLOGY
• SETTING
• AGGRAVATING OR ALLEVIATING FACTORS
• ASSOCIATED MANISFESTATIONS

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I HAVE A COUGH

• ARE YOU COUGHING UP ANYTHING, IF SO WHAT?
• HAVE YOU HAD A RUNNY NOSE?
• DO YOU SMOKE?
• DO YOU HAVE ANY PAIN? - IF SO WHEN?
• WHEN DID IT BEGIN?
• WHEN DOES IT OCCUR?
• WHAT MAKES IT BETTER OR WORSE?
• WEIGHT LOSS, NIGHT SWEATS

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REMEMBER

• HOW LUCKY YOU ARE TO CARE FOR PATIENTS.
• ALWAYS HONOR THE PHYSICIAN PATIENT RELATIONSHIP.
  NEVER TAKE IT FOR GRANTED.
• LEARN YOUR SKILLS WELL
• PERFECT THEM WITH TIME

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REMEMBER

• TO ALWAYS USE YOUR SENSES FIRST, DO NOT
  SUBSTITUTE TECHNOLOGY FOR YOUR EYES, EARS AND
  HANDS.
• ALWAYS BE ETHICAL AND RESPECTFUL
• YOU ARE THE HEIRS TO CENTURIES OF KNOWLEDGE