history and physical examination in general practice clinics of family medicine

1. Clinical approach
to case Hx and
general Ex
Mohammed Alghamdi
Family Physician
Ministry of Health,
Makkah Almukarramah
Joint Prog. of Family Medicine

2. ‫ـام‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ق‬‫م‬ ‫ـل‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ك‬‫ل‬
‫ـال‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ق‬‫م‬
• Emergency (ED)
• Urgent care (UCC) ambulatory clinic/walk-in
• Routine clinic (OPD) Clinic/OFFICE
• In-Patient (IPD)
(admission-progress-order-procedure-
operation-delivery-discharge …etc.)

3. Science + Art
• Communication Skills Vs. Science
• Physician tools …
• Effective communicator
• Knowledgeable
• Clinical ethics

5. Medical Ethics
• Autonomy
• Beneficence
• Confidentiality
• Do no harm (maleficent)
• Equality (justice)

6. SCFHS
publication
in Ethics

7. Clinical Approach
Problem Solving
Consultation
Counseling / Education

8. Clinical approach
• Problem solving process
• Inductive Reasoning Method
• Hypothetical-deductive method
• Consultation
• Communication Skills
• Innovative Model for Consultation

9. Inductive Reasoning Method
•Hospital approach
•Doctor centered
•Disease oriented

10. Hypothetical-deductive method
Stage I. Data Collection and Analysis of presenting and existing cues
Stage II. Hypothesis Formulation and Developing Professional
Diagnosis
Stage III. Hypothesis Testing
Stage IV. Diagnosis (Problem definition)
Stage V. Management options (CRAPRIOP)
Stage VI. Outcome Evaluation

12. Counseling

13. Counseling
It’s a patient interviewing as a diagnostic and
therapeutic procedure, which is a systematic process
of data-gathering designed to identify problems and
to arrive at a conclusion, leading ultimately to
treatment plan.

14. Models of Consultation
1. Bio-medical model.
2. Bio-psychosocial model.
3. Byrne and Long model.
4. Balint model.
5. Pendelton model.
6. Stott and Davis model.
7. Neighbour model.

15. Bio-medical and Biopsychosocial
•Hospital based
•Doctor centered
•Disease oriented
•First theories connecting the biological (physical)
dimension with psychological and social dimensions.

16. Byrne and Long model
• It provides the main skills to conduct successful patient-centered consultation
versus doctor-centered consultation.
• First theories to shift the center of the counseling from the doctor center to
the patient centered.

17. Byrne and Long model

18. 4. Balint Model 1/2
1. “The doctor as a drug”
Doctor can be therapeutic if he/she uses his expertise for reassurance. On the
other hand, he can be toxic if use high doses to make patient depend on him.
2. “Elimination by physical examination”
Physical symptoms need physical examination, as well as the assessment of
psychological symptoms. Inappropriate physical examination and repeated
investigations may reinforce the patient’s ideas that his symptoms are physical
ones whereas in fact they might be neurotic in origin.
3. “The child as a presenting complaint”
The patient might offer his/her child as an entry ticket whereas he/she might
have a marital or sexual problem.
Continue in next slide

19. 4. Balint Model 2/2
4. “Collision of Anonymity” (Inappropriate referral)
Inappropriate referral to avoid psychosocial problems dilutes the responsibility
where no body takes ultimate responsibility.
5. “Th e Mutual Investment Company”
The patient “presents” offers’ his, physical or psychological problems to the
doctor, while the doctor is rejecting them by stating “nothing is wrong” or
“quick reassurance” which leads usually to the failure of consultation.
6 . “The Flash” (The transparence and counter-transparence)
The point at which the doctor and the patient feel the real reason, the patient
“offers” with appropriate response.

20. 5. Pendleton Model
Pendleton has classified the consultation into seven steps:
1. To define the real reason for attendance (we can use ICE)
2. To consider other problems
3. To choose “with the patient” the appropriate action for each
problem.
4. To achieve a share of understanding
5. To involve the patient in the management
6. To use time and resources effectively
7. To establish and maintain doctor-patient relationship.
Considered the first theory of shared decision and patient involvement in the
care plane with a mutual agreement.

21. 6. Stott and Davis Model (The expanded
model)
Besides dealing with the patient presenting problems, they expand
the consultation to 3 other functions:
1. Management of presenting problem.
2. Management of continuous problems.
3. Modification of help seeking behavior.
4. Opportunistic health promotion.

23. 7. Neighbour Model
1. Connecting (establish a relationship)
2. Summarizing (Physical, psycho. and social diagnosis)
3. Handing-over (management of presenting problem)
4. Safety-netting (anticipating care), consider also the red flags
5. House-keeping (taking care of yourself)
One type of models that considers the doctors aspect as well as the
patient aspect

24. Difficult
Consultations

25. Difficult Consultations
Around (10% - 20%) of daily consultations are difficult. These
difficulties are either due to:
1. Difficult patient
2. Difficult doctor
3. Difficult communication between the doctor and the patient
4. Difficult environment

26. Difficult patient can be:
1. Psychotic patient, suicidal patient etc.
2. Depressive patient.
3. Psychosomatic patient.
4. The talkative patient.
5. Patient who is difficult to talk and withdrawn.
6. Bereaved patient.
7. Angry patient.
8. VIP patient.
9. Others (demanding, manipulative, etc.)

27. Difficult doctor can be:
1. Doctor in a hurry.
2. Authoritarian doctor.
3. Passive (?? Submissive) doctor.
4. Angry doctor.
5. Alien doctor (from different culture).
6. Doctor who have psychological or social problems.

28. Difficult communications
1. Language difficulties.
2. Social class differences.
3. failed consultation due to different reason.
4. Tele-Medicine problems.

29. Difficult environment
1. Crowded clinic.
2. Poor organization.

30. Interviewing
techniques/tips

31. Interviewing techniques/tips
• Normalization
• Generalization
• Summarization
• Mirroring
• Paraphrasing
• Feedback
• Minimization
• Types of questions (open, closed)
• Non-judgmental
• Maximization (don’t want him to say it !!!)
• Leading questions

32. Let's take a break
“ house keeping !! “

33. Innovative
Model for
Consultation
Mix of the best of all

34. History
Hx
• Setting the clinic (you and the clinic)
• Introducing yourself
• Establishing relationship (rapport)
• DD x4
• CC x2
• HPI (e.g. SOCRATES) (ICEE)
• PH (Adult, Adolescent, Child, Elderly, Woman)
(medical, surgical, admissions, accidents, transfusion)
• SR
(CS, RS, GI, GU, OB, Skin, MSK, NS)
• MAIDSs
(medications, allergies, immunizations, diet, sport, sleep)
• SAD
(smoking, alcohol, drugs)
• Psycho - Social
• DEPRESSION
• FMHx
Never forget to give a summarized feed back
and share your finding with the patient

35. Physical
Examination
Ex
• ABC (primary and secondary survey) when and where?
• Vital signs X6 +Special V/S
• General appearance and Behavior (GAB)
• Head and Neck (HEENT)
• Chest, Cardio-Pulmonary
• Abdomen and Pelvis (Back/GU)
• MSK
• Foot Exam
• Neurology
• Psychiatry (MSE/MMSE)

36. Physical Ex/
procedural
setting
• Patient ID and brief Hx (why)
• Privacy
• Patient accompanies
• Chaperon
• Washing hands
• PPE
• Preparing tools
• Explain what you will do
• Take permission (verbal vs written consent?)
• Appropriate exposure
• Where does it hurt you !!!
• Never repeat painful maneuvers
• Help the patient on and off the examination table.
• Never begin a discussion while the patient is
partially undressed

37. (look) inspection
(feel) palpation
Percussion
Auscultation
special tests
+Move for MSK
• Head and Neck (HEENT)
• Chest, Cardio-Pulmonary
• Abdomen and Pelvis (Back/GU)
• MSK
• Foot Exam
• Neurology
• Psychiatry (MSE/MMSE)

38. Investigations
“Ivx”
• Acute setting :
• Pneumonia
• DKA / HHS
• MI
• …..etc
• Set of tests for any chronic disease:
• Asthma
• COPD
• CHF
• Pregnancy
• ……etc

39. Management
“CRAPRIOP”
because we are managing a
human being rather than
just a disease.
• Clarify, explain your diagnosis upon your finding
and the possibilities of management
• Reassure, be optimistic, look for the motivative
points, but be realistic with the important negative
points and never give a false hope.
• Advice, the non-pharmacological management,
e.g. lifestyle.
• Prescribe, the pharmacological management.
• Refer, as needed.
• Investigate, as needed.
• Observe, follow up.
• Prevent, disease prevention and health
promotion points.

40. Chronic
Patient
Follow-up
4Cs
• Confirmation and staging
• Compliance (review and side effects)
• Control
• Complications

42. Case Scenario
• Patient is in the waiting room…. What you will do before
calling her?
Setting the clinic, organize the clinic, call the nurse, be self
ready, read her file if available.
• She is heading to your clinic/office, what should you do
now?
Welcoming and observing, she looks fatigued and little pet
overweight.
• Now she is setting and waiting for you to start, how would
you start the counseling?
Established a good patient-doctor relationship (rapport) by
Introducing yourself and get to know her by asking the
DDx4 in a friendly way e.g. how would you like me to call
you? (40 years old, married with one child 15 yo,
unemployed, general Edu)
• After establishing rapport, how would you ask about the
reason of the visit?
What seems to be the problem? How can I help you? ‫كيف‬
‫اساعدك‬ ‫اقدر‬/‫اخدمك‬
Once she tells you, now you have the reason of the visit
and you must reformulate it to her scientifically
(paraphrasing) to confirm it and be sure you got her right
then ask about the duration of it, (CCx2) she might have
more than one CC and you must to confirm each one with
the duration of it.

43. I have fatigue and weakness
since long time can't
remember since when, but
I feel it is getting worse by
time specially the last 3
months …
• HPI (site, onset, character, referral, association, timing, esx/rel
factors, severity) + ICEE
E.g. Generalized fatigue, onset long time but progress in the last 3
months, fatigue and subjective weakness, no referral, associated
with clod intolerance and constipation and hair thinning and
irregular period)
• PH (Adult, Adolescent, Child, Elderly, Woman)
(medical, surgical, admissions, accidents, transfusion)
• SR
(CS, RS, GI, GU, OB, Skin, MSK, NS)
• MAIDSs
(medications, allergies, immunizations, diet, sport, sleep)
• SAD
(smoking, alcohol, drugs)
• Psycho - Social
• DEPRESSION
• FMHx
Never forget to give a summarized feed back
and share your finding with the patient

44. 40 YOF
medically free
c/o Syx. of
hypothyroidism
• How would you start the Ex?
• ABC (primary and secondary
survey)
• Vital signs X6 +Special V/S
• General appearance and Behavior
(GAB)
• Head and Neck (HEENT)
• Chest, Cardio-Pulmonary
• Abdomen and Pelvis (Back/GU)
• MSK
• Foot Exam
• Neurology
• Psychiatry (MSE/MMSE)
Never forget to give a summarized feed back
and share your finding with the patient

45. What
investigations
do you need?
• CBC
• CMP
• Thyroid
• Do you need imaging?
• Do you need physiological
investigations?
• As a screening !!
After reviewing the tests results Never forget to give a
summarized feed back and share your finding with the patient

46. 40 YOF confirmed
hypothyroidism
with no other
problem, Mx?
• Clarify, explain your diagnosis upon your
finding and the possibilities of management
• Reassure, be optimistic, look for the motivative
points, but be realistic with the important
negative points and never give a false hope.
• Advice, the non-pharmacological
management, e.g. lifestyle.
• Prescribe, the pharmacological management.
• Refer, as needed.
• Investigate, as needed.
• Observe, follow up.
• Prevent, disease prevention and health
promotion points.

47. After 1 month of
starting thyroxine,
she came for
follow up (4Cs)
• Confirmation and staging
• Compliance to ttt plan
(review Meds and side effects)
• Control
• Complications

48. Important further point not covered in this
lecture
• Breaking bad news
• Family structure and cycle.
• Medical Ethics
• Emergency case approach
• SaudiMED-FM 2020
• Review physical examination.
• A lot of roleplays and real clinical practice.

49. MCQs
and there are a lot of other
important books too
Doctor-Patient Issues chapter
(pretest family medicine)

50. Cases and
scenarios

51. OSCE/SOE

52. good background
to start reading
in FM

53. Contact me at:
• WhatsApp: 055840072
• Email: dmgh85@gmail.com
Ask me
anything