basics of patient presentations including history and physical afams residency orientation

Basics of Patient PresentationsIncluding History and Physical

AFAMS Residency Orientation

Objectives

• Learn the different types of presentations

• Master the techniques necessary to properly present a patient

• Obtaining a History and Physical

• Understand purpose of each physical exam maneuver

Obtaining a History

• Ask questions focused on the patient’s chief complaint

• Questions shouldn’t be too specific

• Allow the patient to fully answer the question

• Your last question should be “Is there anything else that I didn’t specifically ask you about?”

Formal Presentations

• 7 minutes or less• Requires– Style– Substance

• No time wasted on superfluous information

• Follows standard template from history to assessment / plan

Types of Presentations• New Patient

– History, Physical, Assessment and Plan

• Follow Up– Patient presented on a previous

day– Abridged presentation

referencing only major patient issues

• Bedside– Ask the patient’s permission first– Student/resident presents to

attending while standing next to the patient

New Patient Presentation• History of Present Illness• Past Medical and Surgical

History• Family and Social History• Medications and Allergies• Physical Exam Findings• Laboratory and

Radiographic Findings• Differential Diagnosis• Assessment and Plan

New Patient: History of Presenting Illness

• Include symptom– Quality– Severity– Location– Duration

• Last portion of History of Presenting Illness is review of systems– Complete head to toe

review of any symptom the patient may have

New Patient: Medical History

• Past Medical History– Include the patient’s

previous illness or diagnoses

• Past Surgical History– Name of all previous

procedures and surgeries– Include dates,

indications, and complications

New Patient: Further History

• Family History– Include any medical

conditions affecting patient’s parents or siblings

• Social History– Occupation– Alcohol use– Tobacco use

New Patient: Medications and Allergies

• Allergies– Any medication allergies– Any major food or

environmental allergies

• Medications– Any current prescription

medication– Herbal supplements– Over-the-counter

medications

New Patient: Physical Exam

• Head and Neck• Cardiovascular• Respiratory• Abdominal• Extremity• Musculoskeletal• Neurological

Physical Exam: Head and Neck• Lymph Nodes– Cancer– Infection

• Feeling for enlarged, warm, firm, or tender

• Palpate all lymph node chains

Physical Exam: Head and Neck• Ear– External Exam (infection

or cancer)– Internal Exam (infection)

• Otoscope– Tympanic Membrane’s

color, posterior structures, light reflex

Physical Exam: Head and Neck

• Auditory Acuity– Sensorineural Defects

• Weber Test• Rinne Test

– Conduction Defects• Weber Test

WEBER RINNE

Physical Exam: Head and Neck

• Nose– Mucosal Color– Presence of Discharge

• Sinuses– Maxillary Sinus– Frontal Sinus– Directly palpate and

percuss sinuses– Examine for discharge– Tap teeth with tongue

depressor (inflamed maxillary sinuses)

Physical Exam: Head and Neck

• Oropharynx– Using light and tongue

depressor have patient stick out tongue and say “Ah”

• CN 9 dysfunction• Nutrition• Dental Hygiene • Infection– PeritonsillarAbscess

Physical Exam: Head and Neck

• Thyroid Exam– Goiter– Nodule

• Methods of examination– Palpation– Observation

Physical Exam: Cardiovascular

• Three components to Cardiovascular exam– Observation– Palpation– Auscultation

• Observation– Jugular Venous Distension

• IJ NOT EJ• Head at 45 degrees• Angle of Louis

Physical Exam: Cardiovascular

• Palpation– Palm on left sternal edge,

fingers extended– Point of Maximal Impulse

• Should be on mid-clavicular line, 5th intercostal space

• Duration of impulse• Thrill?

Physical Exam: Cardiovascular

• Auscultation– Never listen through

clothing– Know all four valvular

regions

Physical Exam: Cardiovascular

• Discern S1 and S2• Recognize systole and

diastole• When a murmur is

present– Systole vs. Diastole– Duration– Intensity– Associated Sounds

Physical Exam: Cardiovascular• Murmurs are graded

– I: Heard with careful listening

– II: Easily audible with stethoscope

– III: Louder than II– IV: As loud as III, but with

additional thrill– V: Audible with

stethoscope barely touching chest

– VI: Heard without stethoscope

Physical Exam: Pulmonary

• Four components of the pulmonary exam– Inspection / Observation– Palpation– Percussion– Auscultation

Physical Exam: Pulmonary• Observation

– General Comfort– Breathing Pattern

• Pursed Lips• Wheezing or gurgling

– Use of Accessory Muscles• Intercostals• Sternocleidomastoids

– Patient Color• Lips, Nail beds, face

– Position of Patient• Upright or leaning forward

Review of Lung Anatomy

Physical Exam: Pulmonary

• Palpation– Detecting Chest

excursion– Tactile Fremitus will be

altered by pathology:• Consolidation• Pleural Fluid

Physical Exam: Pulmonary

• Percussion– Normal: tapping on chest

produces resonant note– Fluid filled cavity

(consolidation or effusion): dullness

– Conditions that lead to air trapping (emphysema and PTX): hyper resonant

Physical Exam: Pulmonary

• Percussion

Percussion Technique

Physical Exam: Pulmonary• Auscultation: first remember the location of

each lobe in the lung fields

• Anterior

Physical Exam: Pulmonary

• Posterior

Physical Exam: Pulmonary

• Normal breath sounds– Vessicular

• Wheezes– Mucosal edema– Bronchoconstriction– Inspiratory vs. Expiratory

• Rales or crackles– Result of fluid

accumulation

Physical Exam: Abdomen

• Components of the exam are– Observation– Auscultation– Percussion– Palpation

• Always think anatomically

Physical Exam: Abdomen

• Abdomen is divided into four quadrants

Physical Exam: Abdomen

• Observation– Appearance of abdomen

• Distended• Flat• Symmetric or Asymmetric

– Prior surgical scars– Signs of Peritonitis

• Patient laying very still• In pain with minor

movements

Physical Exam: Abdomen

• Auscultation– Listen in all four

quadrants 15 seconds in each

– Bowel sounds• Present vs. Absent• How frequently?

– Renal Artery Bruits

Physical Exam: Abdomen Percussion

• Two solid organs produce dull sound– Liver– Spleen

• Look for production of pain with percussion

• Percussion can assist in determining source of abdominal distention– Fluid– Gas

Physical Exam: Abdomen Palpation• Always in a normal area

– If pain in RUQ, start in LLQ• Palpate lightly first• Then repeat with deeper

palpation• Palpate internal organs if

possible• Note pain or splinting• Palpate the aorta around

the umbilicus• Is there any fluid or

ascites?

Physical Exam: Upper Extremities

• Examine nail– Shape– Color – Deformity– Capillary Refill

• Joint Deformity• Cyanosis• Radial pulse• Edema• Axillary Lymph Node

Physical Exam: Lower Extremities

• Femoral Pulse• Inguinal Hernia• Popliteal Pulse• Pedal Pulse• Edema• Knee joint swelling• Gangrene• Cellulitis

Physical Exam: Extremities

Cellulitis Gangrene Cyanosis

Palpation of Axillary Lymph Nodes Onychomycosis Joint Deformity

Physical Exam: Musculoskeletal Exam

Physical Exam: Neurological Exam

• Can be a comprehensive or cursory exam

• Major Components– Mental Status– Cranial Nerves– Muscle strength, tone and

bulk– Reflexes– Coordination– Sensory Function– Gait

Physical Exam: Cranial Nerves• CN 1: Olfactory Sense• CN 2: Visual Acuity• CN 3, 4, 6: Extra-ocular

muscle movement• CN 4: Superior Oblique muscle

CN 6: Lateral RectusCN 3: Inferior oblique

Inferior rectus, superior rectus, and medial rectus

Physical Exam: Cranial Nerves• CN 5

– Motor: Temporalis and Masseter muscles

– Sensory• V1: Forehead• V2: Check• V3: Jaw

• CN 7– Most of the facial muscles

• CN 8: Acoustic Acuity– Weber– Rinne

Physical Exam: Cranial Nerves

• CN 9: Glosopharyngeal• CN 10: Vagus• Together CN 9 and 10

raise the soft palate and produce gag reflex

Physical Exam: Cranial Nerves

• CN 11: Innervates muscles which permit shrugging of shoulders

• CN 12: Responsible for tongue movement

Physical Exam: Sensory

• Spinothalamics: detect pain, temperature, crude touch

• Dorsal Columns: detect position, vibratory and light touch

Physical Exam: Motor Assessment• Observe muscle bulk• Look for asymmetry

between extremities• Examine major muscle

groups of upper and lower extremities – Biceps– Triceps– Deltoids– Quadriceps– Hamstrings

Motor Assessment• Assessment of muscle

strength• 0: No movement• 1: Slight flicker of muscle

movement• 2: Can voluntarily move, but

cannot overcome gravity• 3: Can overcome gravity,

but not applied resistance• 4: Can overcome gravity

and some resistance• 5: Normal

Follow Up Presentation

• 1-2 sentence summary of patient’s presentation and hospital course

• Explanation of past 24 hour events

• Physical Exam• Important Laboratory

and Radiographic Studies• Assessment and Plan

Questions You May Be Asked During the Presentation

• Etiology of Symptoms• Pathophysiology of

Disease• Diagnosis Criteria• Common Complications• Differential Diagnosis• Diagnostic Tests• Treatment Options

Miscellaneous Tips• Include only essential

facts in your presentation– Be prepared to answer any

questions with more detail

• Keep the same order and format for all presentations

• Be thorough with your differential diagnosis and treatment plan

Miscellaneous Tips

• Try not read directly off paper

• Presentation should be as conversational as possible

• Expect questions and be prepared to answer them

Conclusions

• A tremendous amount of information can be obtained by a properly conducted history and physical

• It is important to be an excellent presenter and be able to convey important information to other medical professionals