anamnesis status generalis
DESCRIPTION
Anamnesis Status GeneralisTRANSCRIPT
Society’s Expectation• Physician must be :
• Altruistic• Knowledable• Skillful• Dutiful
achievement
• Basic Med. Skill
• Comunni-cation Skill
Medical Education• Learning Outcome
Basic Medical Skill
1. History Taking2. Physical Examination3. Technical Procedur4. Interpretation of the Results5. Clinical reasoning- deductive6. Emergency and critical care7. Communication Skills
Skills Laboratory
1. Communication Skills 2. Physical Examination Skills3. Therapeutic Skills4. Laboratory Skills
Faculty of Medicine GMU
Pre test Probability
- Prevalence - Ax- PD
Penunjang- Laboratorium - USG- Ro.- dsb
Post test Probability/Clinical Dx.
GoldStandard
Dx. pasti
Decision Analysis :Making Prognosis
Deciding Best Therapy
Clinical Diagnostic Strategies
• Aims :• Labels patient & classifies their illness• Identifies their likely fates or
prognosis
• Propels us toward spesific treatments• Do more good than harm
DISEASE
DERANGEMENT
Anatomic Biochemical Physiological Psycological
E/
The Illness
ExhibitSymptom
Sign
4 strategies of Clinical Dx.
Strategy # 1• = pattern recognition• = gestalt method (considering or
treating what a person experiences and believes as a whole and individual thing )
• Def :• The instaneous realization that patient’s
presentation conform to a previously learned picture/pattern of disease
Strategy # 1
• Auditary - the speech of patient• Odor :
• Diabetec acidosis• Liver failure• Lung abscess
Strategy #2• = the multiple branching method
• Algorithm• Triage
Strategy #3• = “Go do complete hystory &
physical “
• Hystory taking• Physical examination
Strategy #4• = Hypothetico-deductive strategy
• the earlist clues of the patients• Short list of potential Dx/action• History & Physical• Paraclinic(lab., x-ray etc)
From :• Colleague• Teacher
HYPOTHESIS Deduction/Reduce the list
HISTORY TAKINGDr. I Gede Arinton,SpPd,MKom,MMR
The Head of Internal MedicineMargono Soekarjo HospitalMedical Faculty UNSOED
PURWOKERTO
PATIENT DOCTORseekinghelp
to regainor
retain healthT A C K L I N G " T H E F I V E D S " O F H E A L T H :- D I S E A S E
- D I S C O M F O R T- D I S A B I L I T Y
- D E A T H-
D I S S A T I S F A C T I O N
set the stage for :
* making a diagnosis* determining prognosis* carrying out treatment
* promoting health* preventing disease
student learn skills
THE PATIENT'SMEDICAL HISTORY
* D E S C R I P T I O N O F P A T I E N T* C H I E F C O M P L A I N T* H I S T O R Y O F T H E P R E S E N T I L L N E S S* P A S T M E D I C A L H I S T O R Y* S O C I A L A N D O C C U P A T I O N A L H I S T O R Y* F A M I L Y H I S T O R Y* R E V I E W O F S Y S T E M S - - - > P D
History
Taking
Introduction
HISTORYTAKING
PhysicalExamination
Hypothesis
List ofProblem
Dx
• Lab• Special
THE TECHNIQUES OF SKILLED INTERVIEWING• Active listening• Adaptive questioning• Nonverbal communication• Facilitation• Echoing• Empathic responses• Validation• Reassurance• Summarization• Highlighting transitions
Identifying data
• Name• Age• Gender• Occupation• Marital status
CHIEF COMPLAINT • Definition :
• statement of the primary reason for the patient seeking medical attention, often stated in the patient's own words.
• The chief complaint could be :• a pain • a symptom of discomfort • a loss of usual function • troublesome bodily change • a psychiatric symptom
CHIEF COMPLAINT • Why do patients seek care at a
particular time? :1. the symptoms of the illness increase
to the point that they are unbearable and the patient realizes s/he needs help
2. anxiety 3. the symptom in the chief complaint is
sometimes a "ticket of admission" to the physician's office or emergency room;
HISTORY OF PRESENT ILLNESS• an elaborated description of the
patient's chief complaint. • The goal is :
• to obtain a coherent, orderly picture of how the patient's chief complaint developed,
• linking the chronological emergence of symptoms within the overall life circumstances of the patient.
HISTORY OF PRESENT ILLNESS• Most important part of the medical
history, providing the essential information for making the diagnosis.
• Physician works in partnership with the patient to develop an accurate and useful understanding of the illness in the patient's life.
HISTORY OF PRESENT ILLNESS• The Symptom
• Seven Core Dimensions:1. Location:
– Where is the problem located? Does it radiate?
– Can you take one finger and show me exactly where it hurts?
HISTORY OF PRESENT ILLNESS• The Symptom
• Seven Core Dimensions:2. Quality :
– What is it like? – How does it feel?– Before we go on further, can you
describe the pain in some more detail? Was it sharp or dull?Did it come and go or just stay there all the time?
HISTORY OF PRESENT ILLNESS• The Symptom
• Seven Core Dimensions:
3. Quantity/Severity:
– How bad is it?
– On a 1 to 10 scale, where 1 represents no pain and 10 represents the worst pain.
HISTORY OF PRESENT ILLNESS• The Symptom
• Seven Core Dimensions:4. Chronology/Timing:
– When did each symptom or problem begin?
– How did the events unfold? – How often does it occur?– Was this your very first episode of chest pain or
have you ever had chest pain before?What happened next?How frequently are you having the diarrhea?
HISTORY OF PRESENT ILLNESS• The Symptom
• Seven Core Dimensions:5.Setting/Context:
– What environmental factors, activities, emotional reactions or other circumstances may have contributed to or led up to the problem?
– Can you tell me what you are doing when you experience this chest pain?Is there anything else that comes to mind about the situations in which these headaches develop?
HISTORY OF PRESENT ILLNESS• The Symptom
• Seven Core Dimensions:6.Modifying Factors:
– What makes it better? What makes it worse?
– Can you tell me what tends to decrease the intensity of the pain?Have you tried any medications to control the diarrhea?Have you noticed anything that makes the pain worse?Is your shortness of breath worse when you lie down?
HISTORY OF PRESENT ILLNESS• The Symptom
• Seven Core Dimensions:7. Associated Symptoms/
Manifestations: – What other symptoms occur
preceding, coincidentally, or following the primary symptom?
– Pertinent positives and negatives – Organ specific review of symptoms– Do you have any other sensations or feelings
when you have these headaches?Did you notice any pain or discomfort in your jaw or left arm when you experienced the chest pain?
HISTORY OF PRESENT ILLNESS• Tips for Eliciting the HPI :
1.Types of Questions:• Open ended :
− Generally used at the beginning of the interview and throughout.
− " What is the pain like?“
− "Tell me about that".
HISTORY OF PRESENT ILLNESS• Tips for Eliciting the HPI :
1.Types of Questions:• Direct :
− To the point. − "What day did the pain start?" − "How many times have you had diarrhea
today?" • Designed :
− to get specific information about a particular point in the history
HISTORY OF PRESENT ILLNESS• Tips for Eliciting the HPI :
1.Types of Questions:• Multiple :
− To be avoided. − Questions like "Do you have any change in
bowel or bladder habits, blood in your stool or abdominal pain?"
− By the time you get to the end of the question, both you and the patient have forgotten exactly what you asked.
HISTORY OF PRESENT ILLNESS• Tips for Eliciting the HPI :
1.Types of Questions:• Laundry List:
− Somewhat similar to Multiple. − Useful in patients who have difficulty in describing
a symptom. − "Is the pain sharp or dull or burning or throbbing?" − Try the open ended "What is the pain like?" first.
HISTORY OF PRESENT ILLNESS• Tips for Eliciting the HPI :
2. Ways to Enhance Communication • Be sure the patient is comfortable. • Be sure you are ready to listen. • Introduce yourself • Be respectful of the patient (Call the patient
by his or her surname unless told otherwise)
HISTORY OF PRESENT ILLNESS• Tips for Eliciting the HPI :
2. Ways to Enhance Communication • Facilitate (These are phrases and gestures
that encourage the patient to tell the story, such as leaning forward, nodding your head, saying "go on", or "uh huh"
• Empathize (Put yourself in the patient's shoes. How would you feel?
HISTORY OF PRESENT ILLNESS• Tips for Eliciting the HPI :
2. Ways to Enhance Communication • Compassion • Silence • Confront and clarify (If something doesn't
make sense or is contradictory, ask the patient to make it clear
• Reflect or repeat what you have heard or understand back to the patient
HISTORY OF PRESENT ILLNESS• Tips for Eliciting the HPI :
2. Ways to Enhance Communication • Use summary statements occasionally • Use transition statements • Use a concluding question or statement :
− "Is there anything else you can think of?“− "Is there anything else that might be important?"
PAST MEDICAL HISTORY • is a record of the patient's past
experiences with illnesses and medical treatments-- information :• adds to the physician' s
understanding of the presenting problem or that leads to diagnostic possibilities to explain the current illness
• PMH often has a great impact on eventual patient management.
FAMILY HISTORY • a systematic exploration of the
presence or absence of illness in the patient's family- information may be helpful in diagnosing the patient's present illness or suggest possible risks for future disease.
PAST MEDICAL HISTORY • Core Elements of the PMH :
1. Childhood Illnesses: • Inquire about serious or chronic illnesses
2. Adult Illnesses: • illnesses in general inquire specifically
about common conditions3. Obstetric/Gynecologic History:
• Female patients • pregnancies and outcomes • miscarriages or abortions
PAST MEDICAL HISTORY • Core Elements of the PMH :
4. Psychiatric Illnesses: • hospitalizations, suicide attempts,
treatments (include dates)5. Surgeries:
• dates, indications, outcomes and complications.
6. Injuries/Trauma: • serious accidents or injuries (include
dates and complications)Hospitalizations:
PAST MEDICAL HISTORY • Core Elements of the PMH :
7. Medications: • hormone replacement and birth control
pils (include dosage and dosing regimen) 8. Allergies/Drug intolerance:
• medication, environmental and food allergies.
• medication side effects
PAST MEDICAL HISTORY • Core Elements of the PMH :
9. Transfusions: • transfusions of blood and blood products
(include dates, units and reactions).
10. Hazardous Exposures: • occupational and home exposures e.g.
any chemicals, dust or fumes at work or at home that might be dangerous?
FAMILY HISTORY • Core Element of the FH :
1. Parents, siblings, and children:
• health status, major illnesses, age at and causes of death
2. Other family members:• genetic factors : diabetes, CAD,
hypertension, cancers, lipid disorders, psychiatric illnesses including alcoholism
• Illnesses similar to the patient's
PHYSICAL EXAMINATION(PE)
INTRODUCTION
ERA OF HIGH TECHNOLOGY
PHYSICAL EXAMINATION ???
INTRODUCTION
• Proper performance of PE :• Routine ordering lab. Test & X-ray --guided by History Taking & PE
• interpretation of result lab.test, imaging, even biopsy -need PE
• Patient’s trust -- PE doctor
The process of examining the patient’s body to determine the presence or absence of physical problems. It includes :
inspection (looking)palpation (feeling)auscultation (listening)percussion (producing sounds )
DEFINITION
• Inspection :• Method of observation used during
physical examinations. Inspection, or
"looking at the patient," is the first step
in examining a patient or body part
Palpation is the method of "feeling" with the hands
during a physical examination Percussion is a method
of "tapping" on body parts with fingers, hands, or small
instruments
Auscultation is a method used to "listen" to the sounds of the body
by using a stethoscope.
HISTORY• Hippocrates (c.460-377BC) :
• the 'Father of Medicine' • by refusing to use gods to explain
illnesses and disease-a science rather than a religion.
• stressed the importance of observation
HISTORY• Leopold Auenbrugger:
• An Austrian physician• the inventor of percussion -by tapping on
the chest with the finger• the lungs wheel percussed, give a sound like a
drum • consolidated, as in pneumonia-= the thigh
is taped. • the heart -dull sound• injected fluid into the pleural cavity, -- by
percussion to tell exactly the limits of the fluid present
• He pointed out how to detect cavities of the lungs, and how their location and size might be determined by percussion
HISTORY• Jean-Nicholas Corvisart:
• Napoleon's personal physician• popularized percussion as a diagnostic
tool• With a picture -Cause of death
• Laenec:• The inventor of stethoscope-a
perforated wooden cylinder one foot long one end of a wooden -listening to the transmitted sound at the other end.
Laennec stethoscope
Piorry Stethoscope
Flexible Stethoscopes
BinauralStethoscopes
ElectronicStethoscopes
INTRODUCTION
•VITAL SIGN
•SYSTEMIC REVIEW
VITAL SIGN(VS)
INTRODUCTION• VS include the measurement of:
• Temperature• Respiratory rate• Pulse • Blood pressure
• provide critical information ("vital") about a patient's state of health.
INTRODUCTION• In particular, they:
• Can identify the existence of an acute medical problem.
• rapidly quantifying the magnitude of an illness
• how well the body is coping with the resultant physiologic stress.
INTRODUCTION
• In particular, they: • Are a marker of chronic disease
states (e.g. Hypertension)
• To use these values as the basis for management decisions.
VITAL SIGN :• Body temperature• Blood Pressure• Pulse Rate• Respiration Rate
Equipment Needed • A stethoscope • A blood pressure cuff • A watch displaying seconds • A thermometer
General Considerations
• The patient should not have had :• Alcohol• Tobacco• Caffeine• Performed vigorous exercise within 30 minutes of the exam.
General Considerations
• Ideally the patient should be:• sitting with feet on the floor
• their back supported.
• The examination room should be quiet and the patient comfortable.
General Considerations
• History of :• hypertension; • slow, rapid or irregular pulse• and current medications
should always be obtained.
General Considerations
• In addition :• peak expiratory flow, • oxygen saturation or • blood glucose level. • etc
Temperature
• can be measured is several different ways: • Oral
•Glass, paper, or electronic •Normal 98.6° F/37° C
• Axillary •Glass or electronic •Normal 97.6° F/36.3° C
Temperature• Rectal (or "core")
•Glass or electronic •Normal 99.6° F/37.7° C
• Aural (in the ear) •Electronic •Normal 99.6° F/37.7° C
• axillary < acurrate rectal • Fever oral 100.5° F/38.5° C or
above.
Pulse
1. Sit or stand facing your patient.
2. Grasp the patient's wrist with your free (non-watch bearing) hand (patient's right with your right or patient's left with your left).
Pulse
3. Compress the radial artery with your index and middle fingers.
• Note :• the rate, • the regularity, • and amplitude of the pulse you are measuring.
Pulse
• Count the pulse for 15 seconds - multiply by 4.
• Count for a full minute if the pulse is irregular.
• A normal adult heart rate is between 60-100 beats per minute.
Pulse
PulseThe pulse may be palpated of theaccessible arteries :- a. radialis ------> very common- a. brachialis- a. temporalis ---> anesthesiologist- a. dorsalis pedis----> DM- a. carotis -----> aortic pulse wave
Contour
Volume
Rate
Rhytm
- Start with a swift upstroke----> thepeak sys. press.--> followed by a moregradual decline --->- approximately atthe end of vent.sys. ---> sec. & normalupstroke ( dicrotic wave) by the closedaortic valve
Normally impapable( only by
sphygmograph)wher palpable
One wave in sys.and one in dia.
Pulsus Bisferiens:- 2 wave in sys.In :- AI + :
*AS moderate* HSS* Hyperthyroidism
Bounding or Collapsing Pulsus (Corrigan, Water-Hammer pulse):- upstroke-->very sharp- downstroke -> precipitously- pistol-shot soundIn :- HT Ess.+ rigid aorta- Hyperthyroidism- Emotional state- AI- PDA- AV-fistule
Plateau pulse(Pulsus Tardus)- upstroke-->gradual- downstroke -> delayed- best appreciated in a. carotisIn :- AS
The pulse may be palpated of theaccessible arteries :- a. radialis ------> very common- a. brachialis- a. temporalis ---> anesthesiologist- a. dorsalis pedis----> DM- a. carotis -----> aortic pulse wave
Contour
Volume
Rate
Rhytm
Pulsus Altenans:- Rythm- Interval- Pulse wave --->volume >>> & <<<In :- myocardial weakness
Pulsus Bigemini(Coupled Rythm):- Rythm Normal- Interval between member-->shorter
Normal
Pulsus Paradoxus:- Normal: Inspiration--->Sys.fall <10mmHg- Sys.fall >10 mmHg.- Cardiac tamponade
Inequality of Contralateral Pulsus :- Aneurysm- Partial Obstruction
Sinus Rythm : 60-100Sinus Bradycardia : < 60
- AV Block- Athlete
Sinus Tachycardia : >100:-
- Sinus Rythm : 60-100- Dysrythmia :
- Atrial fibrilation- Atrial Flutter- Extra systole
Respiration
• Best done immediately after taking
the patient's pulse.
• Do not announce that you are
measuring respirations.
Respiration
• Without letting go of the patient's wrist begin to observe the patient's breathing.
• Count breaths for 15 seconds multiply by 4
• In adults, N: 14-20 X/minute
Respiration
• Tachypnea- Rapid• Hyperpnea-->Deep : Kussmaul
• Bradypnea-->Slow
• Apnea ---- Absent
• Cheyne-Stokes-apneahyperpnea
Blood Pressure• The room should be quiet and
the patient comfortable. • Position the patient's arm so the
antecubital fold is level with the heart.
(It is best that the arm be support by an armrest or your arm.)
Blood Pressure• Center the bladder of the cuff over
the brachial artery approximately 2 cm above the antecubital fold. Position the patient's arm so it is slightly flexed at
the elbow.
Blood Pressure
• Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate of the systolic pressure.
• Place the stethoscope over the brachial artery.
Blood Pressure
• Inflate the cuff 20 to 30 mmHg above the estimated systolic pressure.
• Release the pressure slowly, no greater than 5 mmHg per second.
Blood Pressure
• The level at which you begin to hear Korotkoff sounds is the systolic pressure.
• Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure.
Blood Pressure
• Blood pressure should be taken in both arms on the first encounter. If there is more than 10 mmHg difference between the two arms, make a note to always use the reading from the arm with the higher pressure.
Interpretation
• BP should be taken in both arms -- < 10 mmHg difference
• retake the BP ----"w t o t" thi e c a effec .
• In situations auscultation is not possible-SP by palpation alone.
Interpretation
• Classification :• Normal : < 140/< 90• Isolated Sys.HT : >140/<90• Mild HT : 140-159/90-99• Moderate HT : 160-179/100-109• Severe HT : 180-209/110-119• Crisis HT : > 209/> 119
PROBLEM BASED LEARNING
Introduction
• learning is a strategy for learning
basic science concepts using
problems from clinical practice
Objective• introduce the student in a practical
setting to the thought processes required for solving clinical problems.
• Specifically, we propose :1. to promote active learning 2. to encourage students to think creatively
about medical problems 3. to integrate learning across the basic
science curriculum.
Organization• Internal Department :
• Small Group 7-8 student + Tutor• Monday -decided cases• Wednesday --tutorial• Saturday -case report :
1. patient presentation2. physical examination3. laboratory findings 4. treatment and follow-up
Case Report Form LAPORAN KASUS
Nama Pasien : Nama Mahasiswa
:
Kelamin/Umur : NIRM :
Alamat : Nama Tutor : :
Ruang : Tanggal :
Dirawat sejak :
Case Report Form I.a. Keluhan Utama :b. Masalah :
Case Report Form II. Riwayat Penyakit sekarang, Riwayat Penyakit Dahulu dan
Riwayat Penyakit keluarga yang sesuai dengan keluhan utama
a. RPS ( Ingat 7 dimensi)
b. RPD : Melanjutkan penyakit sekarang Hubungannya dengan tindakan.
c. RPK Penularan Keturunan
Case Report Form III. BUAT HIPOTESIS BERDASARKAN 1 DAN 2 SERTA TERANGKAN PEMBENARANNYA (LITERATUR)1.
2.
3.
Case Report Form IV. TENTUKAN PEMERIKSAAN FISIK YANG DIBUTUHKAN(LITERATUR)
Case Report Form V. HALUSKAN HIPOTESIS DIATAS BERDASARKAN DUKUNGAN DARI PEMERIKSAAN FISIK. JELASKAN BERDASARKAN LITERATUR1.
2.
3.
Case Report Form VI. TENTUKAN KEBUTUHAN LABORATORIUM/PENUNJANG YANG SESUAI(LITERATUR)
VII. BILA HASIL TELAH ADA HALUSKAN LAGI HIPOTESIS(LITERATUR)
1.
2.
3.
Case Report Form VIII. TENTUKAN TERAPI DAN FOLLOW-UP (TERANGKAN PEMBENARANNYA)
1.
2.
3.
4.
5.
IX. TENTUKAN PROGNOSIS BERDASARKAN KRITERIA
Evaluation
Student Activities Yes No
Arrived on time for session.
Prepared assigned learning issue.
Integrated their contributions into session events rather than simply
reading from notes.
Evaluation Provided rationale/explanations for contributions; avoids unsubstantiated “opinion.”
Admitted the limits of their knowledge (Is not afraid to say “I don’t know.”)
Asked for clarification/explanation of topics that are unclear to them.
Was receptive to ideas and contributions of other group members.
Evaluation As part of their participation, connected/integrated the basic science of the case with previously acquired knowledge.
Synthesized or summarized information for the group.
Extended discussion beyond case objectives (e.g., brought in new research findings.)
Demonstrated leadership (e.g., acted to keep the group on task, monitored time, kept comments focussed on discussion topic.)
Evaluation
Actively encouraged the input of other group members
Additional Facilitator Comments: