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Medical History and Physical    Examination OverviewWebsite: http://ivmsicm.blogspot.com/                                 ...
Medical History and Physical     Examination Overview          Marc Imhotep Cray, M.D.           Companion Online Folder:I...
COMPONENTS OF THE MEDICAL HISTORY Identifying Data (ID) Chief Complaint (CC) History of Present Illness (HPI) Past Med...
Identifying Data (ID)Name or initialsDate of birthMedical record number                                4
Chief Complaint (CC) One-liner--why patient here--use patients own  words How to write--patient’s age, occupation or sex...
History of Present Illness (HPI)Story of patient’s chief complaint (CC)Story of any active/significant illnesses patient...
History of Present Illness (HPI)Story of CC:   logical   complete   chronological                                   7
History of Present Illness (HPI)Story of CC (How To Ask):   start with open-ended questions   fill in with focused quest...
History of Present Illness (HPI)Story of CCDescribe symptoms in terms of:      – location      – quality      – quantity (...
History of Present Illness (HPI)Story of CC   document:      – prior medical Dx/Rx      – significant positives or negativ...
History of Present Illness (HPI)Story of CC   Document patient’s understanding of his/her illness:      – patient’s fears ...
History of Present Illness (HPI)  Story of CC     •   logical, complete, chronological     •   open-to-closed questioning ...
Past Medical History (PMH)Childhood illnessesImmunizationsAdult illnessesPsychiatric illnesses or HospitalizationsOpe...
Adult IllnessesDx & how madeRxResponse & sequelae                             14
OperationsWhyKindWhen & sequelae                         15
Obstetric HistoryNumber times pregnantNumber live birthsNumber abortions (spontaneous/induced)                         ...
TransfusionsWhereWhenWhyReactions/complications                            17
Current Health Status (CHS) Current medications--name, dose, reason, SE Allergies/drug reactions Health screening Diet...
Psycho-Social History (PSH)Marital statusLiving conditionsEmploymentSexual historySignificant life eventsMental stat...
Family History (FH)Mother/father/siblings/children   • age--health (if dead, why)Significant illnesses that run in famil...
Review of Systems (ROS)Characterize patients overall health statusReview systems/symptoms from head to toe              ...
Physical Diagnosis•   Goal of the Physical Examination?•   How do I approach the patient•   Conducting the general survey-...
Goal of H & P?• determine valid information concerning the  health of the patient• What must I know?????• Be able to ident...
Approach• Setting the stage• Introductions, Build Rapport, Recognize  presence of significant others• How’s your reaction ...
The Four Cardinal Principles of         Physical Examination:•   Inspection•   Palpation•   Percussion•   Auscultation    ...
Maintain a “watchful eye” during      the medical interview• General Survey--Note:• Level of Consciousness• Apparent State...
Watchful eye---• Grooming, Hygiene----children/ elderly--  ?neglect----home/environment? Odors---  ETOH?---ACETONE?• Symme...
Watchful eye and Ear-----• Speech• Facial Expressions…fear?/ stoic?  Appropriate facial responses to  communication?      ...
Signs of Distress?• Address early on-----Note posture, Labored  Breathing? Sweating? Trembling….Chills?  Wincing?….Pain   ...
PREPARING FOR THE EXAM•   Lighting•   Equipment•   Universal Precautions•   Patient Comfort                               ...
The Science of Physical Examination• Vital Signs• Blood Pressure (BP) --Arterial blood  pressure is the lateral pressure e...
BLOOD PRESSURE                 32
What’s The Difference???-better yet        What does it all mean?• Systolic BP = The Peak Pressure in the  arteries, regul...
The Difference….Systolic-Diastolic• ** Pulse Pressure**                                 34
Techniques of Exam--BP• Which Cuff?…..Appropriate size.• What if I get a different reading in one arm vs  other?• Right ar...
Techniques of Exam-BP• How to Assess?• Normal Values & Changes from the  Norm?…Adult, Infant, Pregnancy,  Geriatric...• Cl...
Techniques of Exam--Pulse• Pulse= denotes the heart rate & rhythm,  condition of the arterial walls• How to Assess?• What ...
Vital Signs… Respiratory Rate• Assessment and Techniques of exam?-  *Assess w/o the patient being aware.• What is the Rate...
Vital Signs•   Clinical significance:•   Temperature•   Weight•   Height                                 39
How do I write it all down?• Complete Hx w/ ROS• S.O.A.P Formats• Problem Specific• Maintaining Organization• Remembering ...
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IVMS -ICM Medical History and Physical Examination Overview

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  1. 1. Medical History and Physical Examination OverviewWebsite: http://ivmsicm.blogspot.com/ 1
  2. 2. Medical History and Physical Examination Overview Marc Imhotep Cray, M.D. Companion Online Folder:IVMS-Physical Diagnosis Notes and Reference Resources
  3. 3. COMPONENTS OF THE MEDICAL HISTORY Identifying Data (ID) Chief Complaint (CC) History of Present Illness (HPI) Past Medical History (PMH) Current Health Status (CHS) Psycho Social History (PSH) Family History (FH) Review of Systems (ROS) 3
  4. 4. Identifying Data (ID)Name or initialsDate of birthMedical record number 4
  5. 5. Chief Complaint (CC) One-liner--why patient here--use patients own words How to write--patient’s age, occupation or sex, problem & duration 5
  6. 6. History of Present Illness (HPI)Story of patient’s chief complaint (CC)Story of any active/significant illnesses patient as which impact on HPI 6
  7. 7. History of Present Illness (HPI)Story of CC: logical complete chronological 7
  8. 8. History of Present Illness (HPI)Story of CC (How To Ask): start with open-ended questions fill in with focused questions 8
  9. 9. History of Present Illness (HPI)Story of CCDescribe symptoms in terms of: – location – quality – quantity (severity) – timing – setting – aggravating and/or alleviating factors – associated manifestations 9
  10. 10. History of Present Illness (HPI)Story of CC document: – prior medical Dx/Rx – significant positives or negatives 10
  11. 11. History of Present Illness (HPI)Story of CC Document patient’s understanding of his/her illness: – patient’s fears and concerns – impact of illness/treatment on patient, family 11
  12. 12. History of Present Illness (HPI) Story of CC • logical, complete, chronological • open-to-closed questioning • characterize symptoms • document: – prior medical diagnoses/treatments – significant positives/negatives • patients understanding of illness Story of any active/significant illnesses patient has which impact on HPI 12
  13. 13. Past Medical History (PMH)Childhood illnessesImmunizationsAdult illnessesPsychiatric illnesses or HospitalizationsOperationsInjuries/accidentsObstetric historyTransfusions 13
  14. 14. Adult IllnessesDx & how madeRxResponse & sequelae 14
  15. 15. OperationsWhyKindWhen & sequelae 15
  16. 16. Obstetric HistoryNumber times pregnantNumber live birthsNumber abortions (spontaneous/induced) 16
  17. 17. TransfusionsWhereWhenWhyReactions/complications 17
  18. 18. Current Health Status (CHS) Current medications--name, dose, reason, SE Allergies/drug reactions Health screening Diet/sleep/exercise Habits--tobacco, alcohol, elicit Alternative Therapies 18
  19. 19. Psycho-Social History (PSH)Marital statusLiving conditionsEmploymentSexual historySignificant life eventsMental status 19
  20. 20. Family History (FH)Mother/father/siblings/children • age--health (if dead, why)Significant illnesses that run in family 20
  21. 21. Review of Systems (ROS)Characterize patients overall health statusReview systems/symptoms from head to toe 21
  22. 22. Physical Diagnosis• Goal of the Physical Examination?• How do I approach the patient• Conducting the general survey--• What am I looking for?• Vital Signs and why?• How do I record all this information?• Organization of thoughts? 22
  23. 23. Goal of H & P?• determine valid information concerning the health of the patient• What must I know?????• Be able to identify, analyze, and synthesize the accumulated information into a Comprehensive Assessment 23
  24. 24. Approach• Setting the stage• Introductions, Build Rapport, Recognize presence of significant others• How’s your reaction to STRESS??-- EMERGENCY SITUATIONS 24
  25. 25. The Four Cardinal Principles of Physical Examination:• Inspection• Palpation• Percussion• Auscultation – “teach the eye to see, the finger to feel, and the ear to hear”---Sir William Osler – (what is the fifth?) 25
  26. 26. Maintain a “watchful eye” during the medical interview• General Survey--Note:• Level of Consciousness• Apparent State of Health---General appearance--Age Appropriate? State of Nutrition--Wasting?,…..• Body Habitus 26
  27. 27. Watchful eye---• Grooming, Hygiene----children/ elderly-- ?neglect----home/environment? Odors--- ETOH?---ACETONE?• Symmetry---extremities disproportionate to trunk?….Body Markings?• Posture and Gait….Limp?/ Upright? Unbalanced? Pace? – Can be noted as patient walks towards exam room 27
  28. 28. Watchful eye and Ear-----• Speech• Facial Expressions…fear?/ stoic? Appropriate facial responses to communication? 28
  29. 29. Signs of Distress?• Address early on-----Note posture, Labored Breathing? Sweating? Trembling….Chills? Wincing?….Pain 29
  30. 30. PREPARING FOR THE EXAM• Lighting• Equipment• Universal Precautions• Patient Comfort 30
  31. 31. The Science of Physical Examination• Vital Signs• Blood Pressure (BP) --Arterial blood pressure is the lateral pressure exerted by a column of blood against the arterial wall. It is the result of cardiac output & peripheral vascular resistance. 31
  32. 32. BLOOD PRESSURE 32
  33. 33. What’s The Difference???-better yet What does it all mean?• Systolic BP = The Peak Pressure in the arteries, regulated by Stroke Volume (SV) and compliance of the blood vessels• Diastolic BP = lowest pressure in the arteries, dependent on peripheral vascular resistance 33
  34. 34. The Difference….Systolic-Diastolic• ** Pulse Pressure** 34
  35. 35. Techniques of Exam--BP• Which Cuff?…..Appropriate size.• What if I get a different reading in one arm vs other?• Right arm BP--5-10mm^ than left• Systolic BP in legs 15-20mm^ than in arms – $ Poiseuille’s Law: relates to the fact that the total resistance of vessels conncected in parallel is greater than the resistance of a single large vessel. 35
  36. 36. Techniques of Exam-BP• How to Assess?• Normal Values & Changes from the Norm?…Adult, Infant, Pregnancy, Geriatric...• Clinical Significance?…Elevation- Hypertensive, …Low- Hypotensive…Orthostatic Changes 36
  37. 37. Techniques of Exam--Pulse• Pulse= denotes the heart rate & rhythm, condition of the arterial walls• How to Assess?• What do my readings tell me? Rapid? Slow? 37
  38. 38. Vital Signs… Respiratory Rate• Assessment and Techniques of exam?- *Assess w/o the patient being aware.• What is the Rate and Pattern? Increased rate- (Tachypnea),? Increased Depth- (Hyperpnea)? Cheyne-Stokes?….etc 38
  39. 39. Vital Signs• Clinical significance:• Temperature• Weight• Height 39
  40. 40. How do I write it all down?• Complete Hx w/ ROS• S.O.A.P Formats• Problem Specific• Maintaining Organization• Remembering It All---Note as you go along-- -Less lost Data• Hospital Records, Specified Forms (Clinics, Hospitals, HMOs) 40

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