IVMS -ICM Medical History and Physical Examination Overview

1. Medical History and Physical
Examination Overview
Website: http://ivmsicm.blogspot.com/
1

2. Medical History and Physical
Examination Overview
Marc Imhotep Cray, M.D.
Companion Online Folder:
IVMS-Physical Diagnosis Notes and Reference Resources

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. Identifying Data (ID)
Name or initials
Date of birth
Medical record number
4

5. Chief Complaint (CC)
 One-liner--why patient here--use patient's own
words
 How to write--patient’s age, occupation or sex,
problem & duration
5

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. History of Present Illness (HPI)
Story of CC:
logical
complete
chronological
7

8. History of Present Illness (HPI)
Story of CC (How To Ask):
start with open-ended questions
fill in with focused questions
8

9. History of Present Illness (HPI)
Story of CC
Describe symptoms in terms of:
– location
– quality
– quantity (severity)
– timing
– setting
– aggravating and/or alleviating factors
– associated manifestations
9

10. History of Present Illness (HPI)
Story of CC
document:
– prior medical Dx/Rx
– significant positives or negatives
10

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. 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
• patient's understanding of illness
Story of any active/significant illnesses patient
has which impact on HPI
12

13. Past Medical History (PMH)
Childhood illnesses
Immunizations
Adult illnesses
Psychiatric illnesses or Hospitalizations
Operations
Injuries/accidents
Obstetric history
Transfusions
13

14. Adult Illnesses
Dx & how made
Rx
Response & sequelae
14

15. Operations
Why
Kind
When & sequelae
15

16. Obstetric History
Number times pregnant
Number live births
Number abortions (spontaneous/induced)
16

17. Transfusions
Where
When
Why
Reactions/complications
17

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. Psycho-Social History (PSH)
Marital status
Living conditions
Employment
Sexual history
Significant life events
Mental status
19

20. Family History (FH)
Mother/father/siblings/children
• age--health (if dead, why)
Significant illnesses that run in family
20

21. Review of Systems (ROS)
Characterize patient's overall health status
Review systems/symptoms from head to toe
21

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. 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. Approach
• Setting the stage
• Introductions, Build Rapport, Recognize
presence of significant others
• How’s your reaction to STRESS??--
EMERGENCY SITUATIONS
24

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. 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. 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. Watchful eye and Ear-----
• Speech
• Facial Expressions…fear?/ stoic?
Appropriate facial responses to
communication?
28

29. Signs of Distress?
• Address early on-----Note posture, Labored
Breathing? Sweating? Trembling….Chills?
Wincing?….Pain
29

30. PREPARING FOR THE EXAM
• Lighting
• Equipment
• Universal Precautions
• Patient Comfort
30

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. BLOOD PRESSURE
32

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. The Difference….Systolic-Diastolic
• ** Pulse Pressure**
34

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. 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. 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. 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. Vital Signs
• Clinical significance:
• Temperature
• Weight
• Height
39

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