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IVMS -ICM Introduction to Clinical Medicine-Phyical Diagnosis

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IVMS -ICM Introduction to Clinical Medicine-Phyical Diagnosis

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IVMS -ICM Introduction to Clinical Medicine-Phyical Diagnosis

  1. 1. Introduction to Clinical Medicine Physical Diagnosis Website: http://ivmsicm.blogspot.com/ 1
  2. 2. Introduction to Clinical Medicine Physical Diagnosis Marc Imhotep Cray, M.D. Companion Online Folder: IVMS-Physical Diagnosis Notes and Reference Resources
  3. 3. 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?
  4. 4. 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
  5. 5. Approach• Setting the stage• Introductions,• Build Rapport,• Recognize presence of significant others• How’s your reaction to STRESS??—• EMERGENCY SITUATIONS
  6. 6. 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?)
  7. 7. 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
  8. 8. 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
  9. 9. Watchful Eye and Ear-----• Speech• Facial Expressions…fear?/ stoic? Appropriate facial responses to communication?
  10. 10. Signs of Distress?• Address early on-----Note posture, Labored Breathing? Sweating? Trembling….Chills? Wincing?….Pain
  11. 11. PREPARING FOR THE EXAM• Wash Your Hands• Lighting• Equipment• Universal Precautions• Patient Comfort/Your Physical –Hygiene, Professional Presentation
  12. 12. The Science of Physical ExaminationVital SignsBlood 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.
  13. 13. BLOOD PRESSURE
  14. 14. 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
  15. 15. 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
  16. 16. Widened (high) pulse pressure (>40 mmHg)Pathophysiology in Isolated Systolic Hypertension Suggests reduced large artery vascular compliance Best Blood Pressure marker for cardiovascular risk
  17. 17. Widened (high) pulse pressure (>40 mmHg)• Causes – Isolated Systolic Hypertension – Aortic Regurgitation – Thyrotoxicosis – Patent Ductus Arteriosus – Arteriovenous fistula – Beriberi heart – Aortic Coarctation – Anemia – Emotional state
  18. 18. Narrowed pulse pressure (<30 mmHg)CausesTachycardiaSevere Aortic StenosisConstrictive PericarditisPericardial effusionAscites
  19. 19. 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.
  20. 20. 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
  21. 21. 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?
  22. 22. 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
  23. 23. Vital Signs• Clinical significance:• Temperature• Weight• Height
  24. 24. 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)

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