Transcript Physical Examination and History Taking

Physical Examination
and History Taking:
Comprehensive
Assessment of the Adult
Practicum of Health Science
Technology
2009 - 2010
Objectives
At the end of this unit students will be able to:
 Organize patient’s health history
 Determine the sequence of physical
examination
 Identify techniques of examination for each
component of the physical examination
Patient Assessment:
Comprehensive or Focused?
Determining the Scope of Your
Assessment
Questions to ask yourself:
 What is the patient’s problem? What is their
chief complaint?
 Is it severe?
Consideration must be given to:
 Clinical setting
 Time available
Comprehensive Assessment
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Includes all the elements of the health
history
Complete physical examination
Is appropriate for new patients in the
office or hospital
Provides fundamental and personalized
knowledge about the patient
Strengthens the clinician – patient
relationship
Comprehensive Assessment
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Helps identify or rule out physical
causes related to patient concerns
Provides baselines for future
assessments
Creates platform for health promotion
through education and counseling
Develops proficiency in the essential
skills of physical examination
Focused Assessment or Problem
Oriented Assessment
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Is appropriate for established patients,
especially during routine or urgent care visits
Addresses focused concerns or symptoms
Assesses symptoms restricted to a specific
body system
Applies examination methods relevant to
assessing the concern or problem as
precisely and carefully as possible
Subjective Data
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What the patient tells
you
The history, from
Chief Complaint
through Review of
Systems
Objective Data
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What you detect
through observation
and obtaining
medical history
All physical
examination findings
Comprehensive Assessment of the
Adult
Health History
Contains 7 components:
1. Identifying Data and Source of the History
2. Chief Complaint
3. Present Illness
4. Past History
5. Family History
6. Personal and Social History
7. Review of Systems
Identifying Data
Identifying Data – demographics, ie. age,
gender, occupation, etc.
 Source of History – usually the patient, but
can be a family member or friend, letter of
referral, or the medical record
Note: Reliability of information varies
according to patient’s memory, trust, reason
for visit, and mood
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Date and Time Everything!!!
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Be sure to document the date and time that
you evaluate the patient, especially in
urgent, emergent, or hospital settings.
Chief Complaint
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The patient’s reason for coming to the
clinical setting today.
One or more symptoms or concerns that
caused the patient to seek medical care
Chief Complaint: Quote the Source
of Information!
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When possible quote the patient in their own
word. This means this should be written in
quotation marks.
If the patient is not the one you are
obtaining information from quote them.
History of Present Illness;
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Amplifies the Chief Complaint; describes
how each symptom developed
Includes patient’s thoughts and feelings
about the illness
Answers the question: What led the up to
the patient’s current state of health?
Chronologic account of progress of patients
symptoms
History of Present Illness
Narrative should include:
 The onset of the problem
 The setting in which it has developed
 Manifestations
 Treatments attempted
 Answers question: Did anything make it
better or worse?
History of Present Illness
Each principle symptom should be wellcharacterized, with descriptions of:
1.
Location
2.
Quality
3.
Quantity or Severity
4.
Timing, including onset, duration, and frequency
5.
Setting in which it occurs
6.
Factors that have aggravated or relieved the
symptoms
7.
Associated manifestations
History of Present Illness
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Medications should be noted, including
name, dose, route, and frequency of use. Be
sure to include home remedies and
alternative medicine practices, nonprescriptive drugs, vitamins, minerals,
herbal supplements, contraceptives
(women), and medicines borrowed from
family members or friends.
History of Present Illness
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Allergies (food, drugs, and environmental
factors) including specific reactions to each
identified.
Smoking, include substance and type. Note:
Cigarette use normally measured in ppd or
pack per day.
Alcohol and drug use should always be
investigated. Note amount, how often, and
for how long.
Past Medical History
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List childhood illnesses
List adult illnesses and surgeries with dates
Includes health maintenance practices such
as immunizations, screening tests, lifestyle
issues, and home safety
Hospitalizations
Psychiatric illnesses and time frame,
diagnoses, hospitalizations, and treatment
Immunizations - Find out whether the patient
has received vaccines for:
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Tetanus
Pertussis
Diphtheria
Polio
Measles
Rubella,
Mumps
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Hepatitis A
Hepatitis B
Pneumococci
Meningitis
Human Papilloma
Virus
Varicella
Influenza
Screening Tests
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Tuberculin skin tests
Pap smears
Mammograms
Stool tests for occult blood
Cholesterol tests
Sickle cell tests
HIV tests
Hepatitis A, B, C
Family History
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Outlines or diagrams age and health, or age
and cause of death of siblings, parents, and
grandparents
Documents presence or absence of specific
illnesses in family
Diseases/Conditions to evaluate
include the following:
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Coronary artery disease
Hypertension
Cerebrovascular Accident
(Stroke)
Diabetes
Cancer
Tuberculosis
Asthma
Mental Illness
Allergies
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Suicide
Alcoholism
Kidney Disease
Lung Disease
Hyperlipidemia
Arthritis
Headaches
Seizure disorder
Substance abuse
Liver disease
Personal and Social History
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Describes educational level, family of
origin, current household, personal
interests, and lifestyle
Captures the patient’s personality and
interests, sources of support, coping
style, strengths, and fears
Includes occupation and the last year
of schooling; home situation, and
significant others; sources of stress,
both recent and long term; important
life experiences,
Personal and Social History
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Conveys lifestyle habits that promote health
or create risk
Use of safety measures
Alternative health practices
Review of Systems
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Documents presence or absence of common
symptoms related to each major body
system
Think about asking a series of questions
going from head-to-toe
Start with fairly general questions about
systems that may be of concern based on
Chief Complaint and History of Present
Illness.
Review of Systems
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Make note, that you will vary the need
for additional questions depending on
the patient’s age, complaints, and
general state of health and your
clinical judgment.
Review of systems questions may
uncover problems that the patient has
overlooked, or may not be aware are
concerning.
General
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Weight
Weakness
Fatigue
Fever
Skin
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Rashes
Lumps
Sores
Itching
Dryness
Changes in color
Changes in hair or nails
Changes in color or size of moles
Head
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Headache
Head injury
Dizziness
Syncope
Vertigo
Lumps
Sores
Eyes
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Vision
Glasses or contacts
lenses; last
examination
Pain
Redness
Excessive tearing
Double or blurred
vision
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Spots
Specks
Flashing lights
Glaucoma
Cataracts
Itching
Decreased tearing
Ears
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Hearing
Tinnitus
Vertigo
Earaches
Infection
Discharge
Use of hearing assistive devices
Nose and Sinuses
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Frequent colds
Nasal stuffiness
Discharge
Itching
Hay fever
Nosebleeds
Sinus Infections
Throat (Mouth and Pharynx)
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Condition of teeth and gums
Bleeding gums
Dentures
Last dental examination
Sore tongue
Dry mouth
Frequent sore throats
Hoarseness
Neck
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Swollen glands
Goiter
Lumps
Pain
Stiffness
Breast
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Lumps
Pain
Nipple discharge
Self-Examination practices
Respiratory
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Cough
Sputum (color, quantity)
Hemoptysis
Dyspnea
Wheezing
Pleurisy
Chest X-Ray
Cardiovascular
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Heart conditions
Hypertension
Rheumatic fever
Heart murmurs
Chest pain
Palpitations
Dypnea
Orthopnea
Paroxysmal
nocturnal dyspnea
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Orthopnea
Paroxysmal nocturnal
dyspnea
Edema
Electrocardiograms
Echocardiograms
Past other
cardiovascular tests
Gastrointestinal
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Trouble swallowing
Heartburn
Decreased/Increased
appetite
Nausea/vomiting
Jaundice
Hepatitis
Bowel movements
Stool color, size, and
consistency
Change in bowel habits
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Pain with defecation
Rectal bleeding or black tarry
stools
Hemorrhoids
Constipation
Diarrhea
Abdominal pain
Food intolerance
Excessive belching or
flatulence
Liver or gallbladder problems
Peripheral Vascular
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Intermittent claudication
Leg cramps
Varicose veins
Deep vein thrombosis
Swelling in calves, legs, or feet
Color change in fingertips or toes during
cold weather
Swelling with redness or tenderness
Urinary
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Frequency of urination
Polyuria
Nocturia
Urgency
Burning or pain during
urination
Hematuria
Urinary infections
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Kidney or flank pain
Kidney stones
Ureteral colic
Suprapubic pain
Incontinence
Reduced urinary
stream
Hesitancy
Dribbling
Genital: Male
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Hernias
Discharge from or sores on the penis
Testicular pain or masses
Scrotal pain or swelling
History of sexually transmitted diseases and their
treatments
Sexual habit, interest, function, satisfaction, birth
control methods, condom use and problems
Concern about HIV infection or exposure
Genital: Female
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Age of onset of menarche, regularity, frequency,
and duration of menstrual cycle; amount of
bleeding; bleeding between cycles or after
intercourse; last menstrual period; dysmenorrhea;
premenstrual syndrome
Age at menopause, menopausal symptoms, post
menopausal bleeding
If the patient was born before 1971, exposure to
Diethylstilbestrol (DES) from maternal use during
pregnancy because it has been linked to cervical
cancer
Genital: Female
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Vaginal discharge, itching, sores, lumps, sexually
transmitted diseases and treatments
Number of pregnancies, number and type of
deliveries, number of abortions (spontaneous and
induced), complications of pregnancy, birth
control methods
Sexual preference, interests, function, satisfaction,
any problems, including dyspareunia
Concerns about HIV infection or exposure
Musculoskeletal
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Muscle or joint pain
Stiffness
Arthritis
Gout
Backache
If present, describe location or affected joints or muscles,
any swelling, redness, pain, tenderness, stiffness, weakness,
or limitation of motion or activity; include timing of
symptoms duration, and any history of trauma
Neck or low back pain
Joint pain with systemic features such as fever, chills, rash,
anorexia, weight loss, or weakness
Psychiatric
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Nervousness
Tension
Mood
Including depression
Memory change
Suicide attempts
Neurologic
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Changes in mood,
attention, or speech
Changes in
orientation, memory,
insight, or judgment
Headache
Dizziness
Vertigo
Syncope
Blackouts
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Seizures
Weakness
Paralysis
Numbness or loss of
sensation
Tingling or “pins and
needles”
Tremors or involuntary
seizures
Hematologic
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Anemia
Easy bruising or bleeding
Past transfusions
Transfusion reactions
Endocrine
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Thyroid conditions
Heat or cold intolerance
Excessive sweating
Excessive thirst or hunger
Polyuria
Change in glove or shoe size
Beginning the Evaluation: Setting
the Stage
Preparing for the Physical
Examination
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Reflect on your approach to the patient
Adjust the lightening and the environment
Make the patient comfortable
Check your equipment
Choose the sequence of examination
Reflect on Your Approach to the
Patient
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Be straightforward
Identify yourself
Appear calm, organized, and competent, even if
you feel differently
Reassure the patient – when evaluating the area
involved in the chief complaint, assure the patient
that you may spend additional time assessing this
area, but it is not necessarily because you find
anything abnormal
Reflect on Your Approach to the
Patient
DON’T WASTE TIME!!!
 Be systematic in your assessment of the patient
while ensuring that appropriate draping is
maintained
 Examine each region of the body, and at the same
time think of the patient as a whole, noting
discomfort, or anxiety
 Communicate with the patient, and let them know
what you are going to do BEFORE doing it.
Adjust the Lightening and the
Environment
SAVE YOUR BACK!!!
 Adjust the bed waist high
BE SURE TO LOWER IT AFTER
ASSESSMENT IS COMPLETED!
 Ask the patient if you may lower the
television or radio volume if the sound is
interfering with your assessment
 When performing the assessment make sure
good overhead lightening is utilized
Equipment for the Physical
Examination
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Ophthalmoscope
Otoscope
Flashlight or penlight
Tongue depressors
Flexible tape measure, preferably marked in
centimeters
Thermometer
Watch with a second hand
Sphygmomanometer
Stethoscope
Equipment for the Physical
Examination
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Gloves
Reflex hammer
Tuning forks
Q-tips, safety pins, cotton swabs
Small notebook
Black pen, #2 pencil
CHECK YOUR EQUIPMENT
PRIOR TO ENTERING THE
PATIENT’S ROOM. MAKE
SURE YOU HAVE
EVERYTHING YOU NEED TO
COMPLETE YOUR
ASSESSMENT PRIOR TO
ENTERING THE PATIENT’S
ROOM.
Make the Patient Comfortable
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Showing concern for privacy and patient
modesty must become ingrained in your
professional behavior
Be sure to close nearby doors and draw
curtains in the hospital or examination room
PRIOR to beginning physical examination
Your goal is to visualize one area of the body
at a time
Make the Patient Comfortable
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Prepare the patient for the examination by briefly
describing what you are going to do PRIOR to
starting the evaluation and removing the drapes
As you proceed with the examination, continue to
be conscious of the patient’s comfort level, and
keep them informed about what you are doing, or
about to do.
Make sure that your instructions to the patient at
each step in the examination are clear, and
courteous.
Make the Patient Comfortable
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Be sensitive to the patient’s feelings and physical
comfort
When you have completed the examination, show
your attentiveness, by rearranging the patients
pillows, or adding blankets for warmth; make sure
their immediate environment is to their
satisfaction
Be sure to lower the bed completely, and make
sure side rails are up and call bell is in the patient’s
reach
As you leave be sure to WASH YOUR HANDS!
Choose the Sequence of the Examination:
Work from Head-to-Toe!
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8.
General Survey
Vital Signs
Skin
Head
Neurological System
Cardiovascular
Respiratory
Breast and Axillae
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10.
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13.
Abdomen
Peripheral Vascular
Musculoskeletal
Optional: WomenPelvic and Rectal
Examination
Optional: Men –
Prostate and Rectal
Examination
Cardinal Techniques of Examination
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Inspection
Palpation
Percussion
Auscultation
Inspection
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Close observation of the details of the
patient’s appearance, behavior, and
movement.
Palpation
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Tactile pressure from the palmar fingers or
fingerpads to assess areas of skin elevation,
depression, warmth, or tenderness; lymph
nodes; pulses; contours and sizes of organs
and masses; and crepitus in the joints.
Percussion
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Use of the striking or plexor finger, usually
the third, to deliver a rapid tap or blow
against the distal pleximeter finger, usually
the third finger of the left hand laid against
a surface of the chest or abdomen, to evoke
a sound wave such as resonance or dullness
from the underlying tissue or organs.
Auscultation
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Use of the diaphragm and bell of the
stethoscope to detect the characteristics of
heart, lung, and bowel sounds, including
location, timing, duration, pitch, and
intensity
Standard and MRSA Precautions
Based on the principle that ALL blood, body fluids,
secretions, excretions except sweat, nonintact skin, and
mucous membranes may contain transmissible infectious
agents
 Apply to all patients in any setting
 Hand hygiene
 Use of gloves, gowns, and mouth, nose and eye protection
 Respiratory hygiene and cough etiquette
 Patient isolation criteria
 Precautions relating to equipment, toys, and solid surfaces,
and handling of laundry;
 Safe needle injection practices
Universal Precautions
Set of guidelines designed to prevent transmission of
HIV, hepatitis B and C, and other bloodborne
pathogens when providing first aid or health care.
The following fluids are considered potentially
infectious:
 All blood and other body fluids containing visible
blood
 Semen
 Vaginal secretions
 Cerebrospinal fluid
 Synovial, pleural, peritoneal, pericardial, and
amniotic fluids
Protective Barriers
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Gloves
Gowns
Aprons
Masks
Protective eyewear
Hats
Shoe covers
Positioning for the Examination
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Be conscious of how often you ask the
patient to change positions during the
physical examination
Utilize your examination sequence with the
goal of minimizing how often you ask the
patient to change position.
Medical Terminology
Instructions
Define the following terms in your interactive
note book. Utilize KIM technique with the
K = Key word/ key term; I = Information/
Definition; and M = Memory Cue –
something that will help you to remember
the term. Maybe a picture, word, or phrase.
Terms
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Comprehensive
Assessment
Focused Assessment
Subjective Data
Objective Data
Identifying Data
Chief Compliant
History of Present
Illness
Past Medical History
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Family History
Personal and Social
History
Review of Systems
Ophthalmoscope
Otoscope
Tongue Depressor
Thermometer
Sphygmomanometer
Stethoscope
Terms
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Inspection
Palpation
Percussion
Auscultation
Standard Precautions
Universal Precautions
Methicillin-resistant staphylococus aureus
Medical Abbreviations
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S – Subjective
O – Objective
CC – Chief Compliant
HPI – History of present illness
PMH – Past medical history
ROS – Review of systems
ETOH – Alcohol
PPD – tuberculin skin test
ppd – packs per day (cigarette smoking)
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HIV – Human immunodeficiency virus
HBV – Hepatitis B virus
ADLs – Activities of dialy living
HEENT – Head, Eyes, Ears, Nose, Throat
CDC – Centers for Disease Control and
Prevention
MRSA – Methicillin – resistant
Staphylococcus aureus
VIP of the Week
Ibn al-Haytham
Instructions: Research this person and write the
following in your interactive notebook.
 Who is he?
 What significance does he have to medicine or
science?
 How can I utilize his contribution in my
profession?
 How does his contribution affect the world?
Questions