after this lecture the students should understand: the philosophy of clinical examination the place...
TRANSCRIPT
After this lecture the students should understand:
The philosophy of clinical examination The place of history taking and physical exam in the perspective of professionalismThe characteristics of clinical examination in infants and childrenThe systematic of clinical examination in infants and children
What is the philosophy?
Doctor as a professional must
be aware that patients are looking
for
attention and help
Patients primarily
want to be examined by a
respected doctor, NOT
to be subjected as
an object of technology
Professionalism should be taught in medical schools and during residencies. Currently, we do suboptimal jobs in medical schools
and a poor job in residencies.
We are, I believe, witnessing an improvement in public esteem and trust in the medical profession. Restoration of full trust will require consistent professional
conduct in medical students, residents, and practitioners of medicine…….
Dr. Haile Debas (2000)Dean, The University of California, San
FranciscoPresident of The American Surgical
Association
The core clinical competencies
1. Patient care
2. Medical knowledge
3. Interpersonal and communication skills
4. Professionalism
5. Practice-based learning & improvement
6. Systems-based practice
What do patients usually want?
Patients usually want to be respected as an individual; they are not numbers or even a member of a group of numbers
So what?
Medicine is the science of uncertaintiesand the art of probabilities
Personal and humane approach!!
Clinical exam in infants and children:
Why special attention?
A child is not a small adult!
Keywords: growth and development
Any information about history, physical, and laboratory / supporting
exams should be judged in relation with the child’s stage of growth and
development.
The diagnostic paradigm:
History
Physical
Routine lab
Special investigations
History(Anamnesis)
Auto-anamnesis: self reporting by the patient Allo-anamnesis: any information other than
by patient (parents, caregiver, referring doctor, previous medical record, previous lab results, etc)
Advances in medical knowledge & technology do not exclude the importance of clinical assessment Appropriate use of medical technology is based on thorough history & physical exam No laboratory or other exams are performed without appropriate clinical information No laboratory or other exams are interpreted without aligning with clinical condition Mastering clinical examination is a must for all doctors caring for patients, from GP to sub-specialist
Listen to them; they are
telling you the diagnosis!!!
History: ≥80%
Supporting exam:5%
Physical exam 10-20%
1. Patient’s identity 2. Chief complaint 3. Clinical course 4. Previous illness 5. History of maternal pregnancy 6. History of delivery 7. Feeding history 8. Immunization status 9. Growth and development 10.Family history11.Environment
Anatomy of history taking
PresentClinical courseBirth
Prenatal
Birth
Nutrition, immunization, growth & development
Past history
123
4
5, 6, etc
11
Who provides the patient’s history? (determines your confidence to the information provided)Be patient, create a conducive atmosphereUse ordinary expression instead of medical termsBe sure that the history-giver understands your pointsUse history taking as a method for health educationALWAYS: make footnotes /remarks at the end of
history taking
Points to remember
1. A 8-year old girl, 30 kg, 130 cm, 3rd grade of elementary school, repeatedly had good ranking in class. She was brought to the clinic due to 3-day high grade fever, stomach ache, and epistaxis
2. A 12-year old boy, basketball player, suspected of suffering from radial fracture.
Should complete history be obtained in all patients
irrespective of their illness?
Remember
It is the patient that should be treated; not
the disease
In general similar to that in adults, i.e. to obtain accurate physical status irrespective of the approach Needs modification due to nature of infants & children: Start with inspection Followed by auscultation: abdomen
& heart End with examination using
equipment
Physical examination
Steps in physical exam
General condition Vital signs Anthropometric
measurements Systematic exam
A. General condition
1. Consciousness : alert, apathetic, somnolent, soporous, comatous2. Appearance : health, mild / moderate / severely ill, distressed3. Color : pale, jaundiced, cyanotic4. Specific facies : syndromes, facies
cholerica, fish-mouth, facies leonina, Cooley’s
facies
B. Vital signs
1. Pulse : rate, regularity, volume, equality
2. Respiration : rate, regularity, pattern3. Blood pressure : of 4 extremities4. Temperature : oral, axillary, rectal Note: always describe complete pulse & respiration!
C. Anthropometric measurements
1. Body length / height: sitting, standing2. Body weight3. Head circumference4. Arm circumference span5. Abdominal circumference6. Nutritional status: W/A, H/A, W/H (plot in standard normal curve NCHS)
D. Systematic examination
Head and neck Chest Abdomen Genitals Extremities Skin, hair, lymph
nodes Neurological
Use of stethoscope
Use binaural stethoscope Bell-shaped side: for low & medium pitched sounds Membrane (diaphragm): for medium to high pitched sounds
For heart exam use bell-shaped side first start without pressure, then with pressure End with diaphragm side
Common mistakes in performing examination
HistoryFail to identify the patient firstMake an incomplete historyProvide a disorganized history
Physical exam: Fail to describe general condition &
vital signs firstIncomplete description of features,
e.g. pulse rate only or respiratory rate only without further characteristics
Developmental Approach
to Physical Exam in Infants
Perform uncomfortable parts of the exam lastComplete the exam with the infant in the parents arm Keep the infants warm and covered Observe general appearance, respiratory rate and effort, overall color
Developmental Approachto Physical Exam in Toddlers
Approach quietly, calmly and slowComplete the assessment wherever the child is comfortableAllow the child to play with your stethoscopeHave a toy or something to distract the childConsider listening to parent or child’s toy to promote comfort
Developmental Approachto Physical Exam in
School Age
Clearly explain the plan and expectations before the examinationAnswers the child’s questions honestlyTalk about topics of interest during the examinationThey may be modest, allow them to keep a gown onInclude them in your history taking
Developmental Approachin Adolescents
Questions should be directed at the adolescent and parentBe honestEnsure privacy during the examination and in sharing informationProvide the adolescent with the opportunity to have the parent step out for history and/or examinationProvide reassurance
Concluding
remarks History taking and physical exam skills require good background knowledge and a sound human relation;
as a part of medical practice, they are science and artThe art of history taking and physical exam are by no means inferior to your scientific knowledge of the disease under investigationRespect the patient and the family if you want to be respected by them; by and large, respecting each other is the key for success in medical practice
How can you be a good examiner?
THINK, PRACTICE,
PRACTICE,
PRACTICE!!!
Thank you