IVMS -ICM Introduction to Clinical Medicine-Phyical Diagnosis
Introduction to Clinical Medicine Physical Diagnosis Website: http://ivmsicm.blogspot.com/ 1
Introduction to Clinical Medicine Physical Diagnosis Marc Imhotep Cray, M.D. Companion Online Folder: IVMS-Physical Diagnosis Notes and Reference Resources
Introduction to Clinical Medicine Physical Diagnosis• How do I record all this information?• Goal of the Physical Examination?• How do I approach the patient• Conducting the general survey--• What am I looking for?• Vital Signs and why?• Organization of thoughts?
Goal of H & P?• To determine valid information concerning the health of the patient• What must I know?????• To be able to identify, analyze, and synthesize accumulated information into a Comprehensive Assessment
Approach• Setting the stage• Introductions,• Build Rapport,• Recognize presence of significant others• How’s your reaction to STRESS??—• EMERGENCY SITUATIONS
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?)
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
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
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• Wash Your Hands• Lighting• Equipment• Universal Precautions• Patient Comfort/Your Physical –Hygiene, Professional Presentation
The Science of Physical ExaminationVital SignsBlood Pressure (BP) --Arterial blood pressure is the lateral pressure exerted by a column of blood against arterial wall It is the result of cardiac output & peripheral vascular resistance.
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 vesselsDiastolic BP = lowest pressure in the arteries, dependent on peripheral vascular resistance
The Difference…. Systolic-Diastolic** Pulse Pressure** Normal pulse pressure Range: 30-40 mmHg The pulse pressure represents the ability of the body to circulate blood. It is calculated by taking the difference of the systolic and diastolic measurement, e.g., a person with a blood pressure measurement of 130/85 would have a pulse pressure of 45. A low pulse pressure means that blood will not be circulated. In normal people the pulse pressure remains fairly constant across all conditions, including when resting, tired or exercising
Widened (high) pulse pressure (>40 mmHg)Pathophysiology in Isolated Systolic Hypertension Suggests reduced large artery vascular compliance Best Blood Pressure marker for cardiovascular risk
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 connected in parallel is greater than the resistance of a single large vessel.
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
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?
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
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)