Transcript Basics of Patient Presentation

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
• Understand purpose of each physical exam
maneuver
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
• 7 minutes or less
• Requires
– Style
– Substance
• No time wasted on
superfluous information
• Follows standard
template from history
to assessment / plan
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
• 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
• Include symptom
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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
• 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
• Family History
– Include any medical
conditions affecting
patient’s parents or
siblings
• Social History
– Occupation
– Alcohol use
– Tobacco use
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
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Head and Neck
Cardiovascular
Respiratory
Abdominal
Extremity
Musculoskeletal
Neurological
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 Neck
• Ear
– External Exam (infection
or cancer)
– Internal Exam (infection)
• Otoscope
– Tympanic Membrane’s
color, posterior
structures, light reflex
Physical Exam: Head and Neck
• Auditory Acuity
– Sensorineural Defects
• Weber Test
• Rinne Test
– Conduction Defects
• Weber Test
WEBER
RINNE
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 Neck
• Oropharynx
– Using light and tongue
depressor have patient
stick out tongue and say
“Ah”
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CN 9 dysfunction
Nutrition
Dental Hygiene
Infection
– Peritonsillar
Abscess
Physical Exam: Head and Neck
• Thyroid Exam
– Goiter
– Nodule
• Methods of
examination
– Palpation
– Observation
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: Cardiovascular
• Palpation
– Palm on left sternal edge,
fingers extended
– Point of Maximal Impulse
• Should be on midclavicular line, 5th
intercostal space
• Duration of impulse
• Thrill?
Physical Exam: Cardiovascular
• Auscultation
– Never listen through
clothing
– Know all four valvular
regions
Physical Exam: Cardiovascular
• Discern S1 and S2
• Recognize systole and
diastole
• When a murmur is
present
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Systole vs. Diastole
Duration
Intensity
Associated Sounds
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
• Four components of the
pulmonary exam
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Inspection / Observation
Palpation
Percussion
Auscultation
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
Physical Exam: Pulmonary
• Palpation
– Detecting Chest
excursion
– Tactile Fremitus will be
altered by pathology:
• Consolidation
• Pleural Fluid
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: Pulmonary
• Percussion
Percussion Technique
Physical Exam: Pulmonary
• Auscultation: first remember the location of
each lobe in the lung fields
• Anterior
Physical Exam: Pulmonary
• Posterior
Physical Exam: Pulmonary
• Normal breath sounds
– Vessicular
• Wheezes
– Mucosal edema
– Bronchoconstriction
– Inspiratory vs. Expiratory
• Rales or crackles
– Result of fluid
accumulation
Physical Exam: Abdomen
• Components of the
exam are
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Observation
Auscultation
Percussion
Palpation
• Always think
anatomically
Physical Exam: Abdomen
• Abdomen is divided into four quadrants
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: 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
• 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
• 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
• Examine nail
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Shape
Color
Deformity
Capillary Refill
Joint Deformity
Cyanosis
Radial pulse
Edema
Axillary Lymph Node
Physical Exam: Lower Extremities
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Femoral Pulse
Inguinal Hernia
Popliteal Pulse
Pedal Pulse
Edema
Knee joint swelling
Gangrene
Cellulitis
Physical Exam: Extremities
Palpation of Axillary
Lymph Nodes
Onychomycosis
Cellulitis
Gangrene
Joint Deformity
Cyanosis
Physical Exam: Musculoskeletal 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
• 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 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 Nerves
• CN 9: Glosopharyngeal
• CN 10: Vagus
• Together CN 9 and 10
raise the soft palate and
produce gag reflex
Physical Exam: Cranial Nerves
• CN 11: Innervates
muscles which permit
shrugging of shoulders
• CN 12: Responsible for
tongue movement
Physical Exam: Sensory
• Spinothalamics: detect
pain, temperature,
crude touch
• Dorsal Columns: detect
position, vibratory and
light touch
Physical Exam: Motor Assessment
• Observe muscle bulk
• Look for asymmetry
between extremities
• Examine major muscle
groups of upper and
lower extremities
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Biceps
Triceps
Deltoids
Quadriceps
Hamstrings
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
• 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
• Etiology of Symptoms
• Pathophysiology of
Disease
• Diagnosis Criteria
• Common Complications
• Differential Diagnosis
• Diagnostic Tests
• Treatment Options
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 Tips
• Try not read directly off
paper
• Presentation should be
as conversational as
possible
• Expect questions and
be prepared to answer
them
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