**Everything in bold is from the PowerPoint, writing in regular font are additional notes from class. **Be sure to read chapters 1-3 in the text book.

I. An Overview: History Taking and Physical Examination a. Objectives:i. Overview of the components of the comprehensive history and physicalii. How to begin the interview:1. The approach to the interview2. The process of the interview3. Talk about the psychological things, real people with real problemsiii. Techniques to establish the Chief Complaint, Present Illness, and Past HistoryII. Types of Medical Encounters:a. New/Established Office Visitsi. Initial hospital visit is usually more comprehensive. 1. Need to find out the reason why the patient came into the hospital. 2. No medical records, so the clinician needs to get all the information to be treated properlyii. Established visit, there is already working diagnosis. 1. Primary focus, which is a focused examination to get the patient better so they can be discharged b. ER Visitsc. Admission to the Hospitald. Subsequent Visits in Hospitale. New/Established Nursing Home Visitsf. Home Care Visitsg. Checkups, sports physicals (more focused than a normal checkup), vaccinations, follow-up visits for previous problems, proceduresh. H&Ps are usually done by 3rd year medical students. Sometimes an intern does it.III. The scope of your assessment depends on the type of visit (2 types)a. Comprehensivei. New patientsii. Provides fundamental and personalized infoiii. Strengthens dr-pt relationshipiv. Identify or r/o physical causes related to pt concernsv. Baseline for futurevi. Platform for health promotionvii. The yellow card will have all the information to give a comprehensive physical. b. Focusedi. All the focused visits are subsets of comprehensive physicals1. ER chest pain= heart attack until proven other wise2. Doctors office chest pain is not necessarily a heart attackii. Established patients, routine or urgent visitsiii. Addresses focused concerns or symptomsiv. Restricted to a specific body systemv. Applies exam methods relevant to assessing the concern or problem as precisely and carefully as possibleIV. Components of a Note: Four Important Sectionsa. Historyi. Comprehensive vs Focused/problem focusedb. Physicali. Comprehensive vs Complaint focusedc. Assessmentd. Plane. All 4 sections must be completedV. Types of Information for Historya. Subjective Datai. What the patient tells you1. i.e. Patient telling you they have a chest pain2. i.e. pain3. i.e. saying they dont have diarrheaii. The History from the Chief Complaint through Review of Systemsiii. Symptoms?iv. The entire history (front part of the yellow card) is all subjective historyb. Objective Datai. What you detect on the examination1. i.e. Seeing the patient sweat (diaphoresis)ii. All physical findings1. i.e. things we measure, smell, feel, lab tests, etc.iii. Signs?c. Structure of the Medical Notei. SOAP note are history/ physical assessment plan. It breaks down into subjective and objective findings. 1. S: Subjective informationa. History2. O: Objective findingsa. Physical3. A: Assessmenta. Diagnosis/ Differential Diagnoses4. P: Plana. What need to be done.ii. Sequence of the Comprehensive History1. See H+P Card and study it!a. Comprehensive Health Historyi. Identifying Dataii. Chief Complaint (s)iii. Present Illness1. Seven dimensions of a symptomiv. Medicationsv. Allergiesvi. Tobaccovii. Alcohol/Drugsviii. Past History (with 4 components)ix. Family Historyx. Personal and Social Historyxi. Review of Systems1. Twenty Systemsiii. ROS1. General (Size up the patient, whether they look clean or oriented)2. Skin3. Head4. Eyes 5. Ears6. Nose7. Throat8. Neck9. Breasts10. Respiratory11. Cardiovascular12. Gastrointestinal13. Urinary14. Genital15. Peripheral Vascular16. Musculoskeletal17. Neurologic18. Hematologic19. Endocrine20. PsychiatricVI. The Physical Examination: a. How it is documented, not how is it performedPCS: Overview of the History and Physical Dr. Harry MorrisTuesday, 8.17.10, 8:00am-10:00am

Class of 2014hanweihu@pcom.eduPage 12 of 12

i. ii. General Surveyiii. Vital Signsiv. Skinv. Headvi. Eyes vii. Earsviii. Nose ix. Throatx. Neckxi. Lymph Nodesxii. Thorax and Lungsxiii. Cardiovascularxiv. Breastsxv. Abdomenxvi. Genitaliaxvii. Rectalxviii. Peripheral Vascular Systemxix. Musculoskeletalxx. Nervous System1. Mental Status2. Cranial Nerves3. Motor System4. Sensory System5. Reflexesb. c. So why do we do this??i. Because: The health history is a conversation with a purpose: improve the well-being of the patient1. Its all about the patient, not about us.2. To establish a trusting and supportive relationshipa. In the ER you dont have a long time to do this, but still need to establish professional relationship3. To gather information4. To offer informationd. Clinicians do more than detective worki. Generating hypotheses about the nature of the patients concerns.ii. Test these hypotheses, ask for more informationiii. Explore the patients beliefs about the problem1. When a patient is sick, they bring in a lot of affect to their illness. a. Patient needs to get better in order to get back to work. 2. Need to develop the sense of understanding a patients issue and tailor a plan that is individualized to themiv. Respond with understanding of the patients concernsVII. The Realm of Patient Assessmenta. Integrate the essential elements of clinical care:i. Empathic listening1. Empathy is the ability to relate to someone without having experienced their problems. 2. Need to be empathetic in order to understand the patients perspective.3. Not every patient is going to be your friend. a. Need to separate friendship from doctor-patients relationships, but can still develop a professional relationship with them. ii. The ability to interview patients of all ages, moods, and backgrounds1. Learn how to be open-mindeda. Might not look like you, different language, different age group, different culture, etc. b. Need to adapt your information gathering and relationship-building based on the patientiii. The techniques for examining the different body systemsiv. The process of clinical reasoning: ability to understand anatomy, physiology and mechanics of whats going on with the patient and then to generate potential causes and the ways to therapeutically intervene. 1. Clinical reasoning is all about which path you can exclude. a. The subjective part (listening to the patient) can help your objective reasoning. b. Clinical Reasoningi. Identify abnormal findingsii. Localize findings anatomically1. i.e. Pain in abdomen after eating fried chicken. Doctor thinks its a gallbladder problem, and asks questions (clinical reasoning) confirm problem. iii. Interpret findings in terms of probable processiv. Make hypotheses about the nature of the patients problemv. Test the hypotheses and establish a working diagnosis1. Chest pain= MI2. Headache= cerebral bleed3. Cough= lung cancervi. Develop a plan agreeable to the patient1. Need patient compliance in order for plan to work. 2. Need to make them understand why they need to say yes to a procedure because its better than the alternatives.vii. Begins within the first moments of a patient encounter1. Patient is first a blind slate.viii. Caution: Jumping to conclusions1. Can go down the wrong path and thus diagnose and treat them improperly. 2. Need to walk in and be open to what they are saying to you.a. Example: Police finds a staggering homeless person on the street and throw them in jail for being drunk. They are dead the next day because the homeless person was actually diabetic. ix. Expert physicians have difficulty explaining the process of clinical reasoning1. It comes from experience. 2. As you develop your own style of practicing medicine, youll become hardwired into doing this.3. Able to ask the right questions because you have seen thousands of patients. c. But there is more to it: To be an effective physiciani. Explore the patients beliefs about the problemii. Respond with understanding of the patients concernsiii. Everyone has different beliefs.1. Need to understand where they are coming from.a. People from Southeast Asia have different medical beliefs 2. Need to be adaptableiv. Its difficult for doctors to dispel misinformation1. i.e. not taking a drug because they knew someone who died from itd. Pointersi. Learn to organize patient information into the components of the History on the fly1. Patient will not follow the yellow card in order. 2. You need to be flexible in order to get all the information from the yellow card.ii. The interview will not necessarily follow the outlineiii. New patients require a comprehensive H+Piv. Other patients may require a focused or problem-oriented interviewv. You will adapt your interview to the setting and time availablevi. Understanding the content and relevance of the components of the comprehensive H+P allows you to choose the elements most helpful for addressing patient concerns in different contextsvii. The order of the H+P should not dictate the exact sequence of the interviewviii. The data flows spontaneously from the patientix. Its your job to organize and document the data1. The patients dont follow the order, you do.VIII. Getting Ready to Interviewa. Taking time for self-reflectioni. Learn from your experiences, good and badii. You will be a more successful physician if you can stop and think about why you are doing this, why the patient bothers you, etc. 1. Its your job as a physician to understand why2. Physicians are involved in a lot of sadness and happiness. It causes feelings. a. Need to acknowledge the feelings or else you run into situations where you follow a bad path (drinking, drugs). b. Its for your own self-preservation of what you feel when you get into these encounters. c. The caregiver needs to take care of himself.iii. It is a challenge to be open and respectful toward individual differencesiv. We have our own bias, assumptions, and valuesv. Self-Reflection: continual part of professionalismvi. Deepens personal awareness to our work with patientsb. Reviewing the Charti. Before seeing the patient review the medical recordii. Check identifying information1. Making sure you have the right patient2. Orderlies can put patients beds in the wrong locationiii. Current and past diagnoses and treatmentsiv. Medicines and Allergiesv. Could this info be inaccurate1. DKA vs BKAa. BKA= below the knee amputationb. DKA= diabetic ketoacidosis c. Setting Goals for the Interview i. What type of interview is it? What do you expect to accomplish?1. Forms completion (work or school physicals)2. Sports physical3. Complete physicalii. It helps to orient you on your mission to complete the interviewiii. Your goals and the patients goals may not be similar- strike a balance1. Patient might come in to do multiple examinations, but there isnt a lot of time to complete everything they want. 2. But in order to do an effective examination, require more time. d. Improving the Environmenti. Make the setting private and comfortable1. Temperature, shutting the curtains, etc. ii. Ask permission to pull a privacy curtainiii. Move from a congested public area to a private roomiv. Failure to consider these issues is disrespectfule. Taking Notesi. You are expected to make notesii. Jot down short phrases, dates, specific illnessesiii. Write your chart note lateriv. Maintain eye contact, put down your pen 1. Nothing is worse for a patient as when someone is looking down while youre writing something. Its disrespectful. v. Face the patient1. Patients want eye contact. 2. Patient wont give out a lot of information if they feel that they arent being listened to. vi. Today the biggest problem is facing the computer in order to write down their information. 1. Make sure the patient understands that you need to take some time to put the information on to the computer, but then turn to them to give them your undivided attention. IX. Clinician Behavior and Appearancea. Consciously or not, you are sending signalsb. The patient is observing youi. First impressions means everything. ii. How do you appear to a patient so that youre displaying openness to them? 1. When you review yourself after standardized patient sessions, self reflect and be open to it. Think of what the patient probably thought of you.c. Posture, gesture, eye contact, and tone of voice can express interest, attention, acceptance, and understandingd. Guard against negative signals that betray disapproval, embarrassment, impatience, or boredomi. You will be asking sensitive questions. You need to be careful how to project the questions. Try not to give attitude.ii. Make them understand that it important for you to know the information to better treat theme. Caution against behaviors that condescend, stereotype, criticize, or belittlef. Patients prefer (and I insist on):i. Cleanliness, neatness, conservative dress, and a name tag1. Its really important that you have your name tap on because anyone can put a white coat on and do invasive things to patients. 2. Need to introduce yourself and your rank.a. Reference up hill: I am a third year medical student and Im working with Dr. Morrisb. Dont make people think that you are someone that you arentii. No fragrance 1. Physicians should not have a scent. Some patients are sensitive to strong scents. X. The Sequence of the Interview: a. Basic things you need to learn how to doi. Greeting the patient and establishing rapportii. Inviting the Patients Storyiii. Establishing the agenda for the interviewiv. Expanding and clarifying the patients story v. Generating and testing diagnostic hypothesesvi. Creating a shared understanding of the problem (s)vii. Negotiating a plan (includes further evaluation, treatment, education)viii. Planning for follow-up and closing the interviewb. Greeting the patient and establishing rapporti. Knock on the door (dont need to wait for them to say come in), greet the patient by name and introduce yourselfii. If possible, shake hands1. Some cultures (i.e. Muslims) dont allow thisiii. Explain who you are: 1. Hello, Mrs. Smith. Im John Doe. Im a first year medical student working with Dr. Jones. I would like to ask you some questions before Dr. Jones comes in to see you. Is that OK?2. Even as a doctor, ask Can I ask you what brought you in today?a. This asks permission to get information from the patient.iv. Acknowledge everyone in the room1. A lot of time the family or significant other is present and they can give vital information to do the diagnosis, especially if the patient is weak or incapable of giving a lot of information.v. Confidentiality issue: Im comfortable with your sister staying in the room. Is that OK with you?vi. If the patient displays signs of discomfort, address that.1. If someone is crying in a room or doubling over in pain, address that.vii. Give the patient your undivided attention1. If you need to break that undivided attention, let the patient knowc. Inviting the Patients Storyi. Why is the patient seeking health careii. The Chief Complaintiii. Begin with an Open-ended question:1. What concerns bring you here today?2. How can I help you?3. Let them speak! iv. Dont interruptv. Ask if there is anything else.1. Ask focused questions2. If the patient goes on with a long list of problems, tell them to focus on the most important problems first, then next time youll cover the rest. vi. Listen actively1. When a patient sees that you are actively listening, the patient will be able to provide more info. vii. Use continuers 1. Nod head, Go on, I see, uh huh. 2. Patients have to know that the connections are there. d. Establishing the Agenda for the interviewi. Your goals and patient concerns and questions must be addressed1. Sometimes your goals will be different than the patients goals. a. i.e. If you want to get a pap smear lump and the patient wants to talk about a breast lump2. Need to make sure that at some point you connect with the patient. What are your concerts today?ii. The laundry list of complaints- need to prioritizeiii. Class question: When do you wash your hands?1. Kids are viral cesspools.2. It is better to do it early in SP lab.3. You can walk in and introduce yourself as youre washing your hands, or you can wash your hands after seeing the patient. Use common sense.e. Expanding and Clarifying the Health Historyi. The Chief Complaintii. The Present Illnessiii. Understand the essential characteristics of complaintsiv. Seven Attributes of a Symptomf. Generating and Testing Diagnostic Hypothesesi. What are the causes of the patients concerns?1. Generate a hypothesis after you gather all the information in the yellow cardii. Recognizing pattern of diseaseiii. Specific attributes of diseaseiv. Use relevant items from the Review of Systems to gather more informationv. Clinical Reasoning is a Science and an Artvi. Assessment1. Working Diagnosis: The thing you think it is today, given the information you havea. File and document the information on paper and generate a hypothesis on what is wrong. b. Working diagnosis will change as you get more information2. Differential Diagnosis:3. Your plan is all the things that youre going to do address the patients concerns (therapeutics, diagnostics, or education)g. Creating a Shared Understanding of the Problemi. Disease/Illness Distinction Model1. Disease- explanation that the clinician brings to the symptoms2. Illness- how the patient experiences the symptomsii. Really need to understand how you frame things to patients. 1. Need to understand how certain diseases affect your patients and help them around that. a. Find out what their limitations are and help them around thatiii. Dont refer to patients by the diagnosis. Its disrespectfuliv. Exploring the Patients Perspective:1. The patients thoughts about the nature and the cause of the problema. Ask the patient what they think is going on. Patients are right a lot of the time. 2. The patients feelings, especially fears, about the problema. i.e. Person not wanting to go on insulin because they knew someone who died after going on the treatment. b. Need to know why they object to certain treatments and work with them through that.c. Explain to the patient why the treatment is best for them, but dont force them into it.d. Listen to what the patient says and understand their concerns. Give them other options.3. The patients expectations of the clinician and health carea. Some patients think that the doctor can cure them, but sometimes we cant. b. Need to give the patient the reality of what the doctor can actually do.4. The effect of the problem on the patients life5. Prior personal or family experiences that are similar6. Therapeutic responses the patient has already hadh. Negotiating a Plan (Read the book on this)i. Further evaluationii. Physical examinationiii. Laboratory testsiv. Consultationsv. Imaging studiesvi. Treatmentvii. Behavior changesi. Planning for Follow-up and Closingi. Not always easy to end the interviewii. Give notice that the end is approachingiii. Make sure the patient understands the plansiv. Review the plan: So you will take the medicine as we discussed, get the blood test before you leave today, and make a follow-up appointment for 4 weeks. Do you have any questions about this?XI. Comprehensive History (See H+P Card)a. Sequence of the Comprehensive Health History:i. Identifying Dataii. Chief Complaint (s)iii. Present Illness1. Seven dimensions of a symptomiv. Medicationsv. Allergiesvi. Tobaccovii. Alcohol/Drugsviii. Past Historyb. Identifying Informationi. Walk in, introduce yourself, wash your hands, and then check the identifying information. ii. Ask the patient for: 1. Date2. Time (of the interview)a. Because 3 hours later, their condition can completely change3. Patients Name4. Date of Birth5. *Referrala. Who referred them to the specialist6. *Source of Historya. i.e. if a grandmother give the history for a 5 year old. 7. *Reliabilitya. i.e. If the patient looks confused or alert.c. Chief Complainti. Attempt to quote the patients own words1. My stomach hurts and I feel awful.2. I have come for my regular check-up. 3. I have an earache.ii. The first sentence/item that the patient says. iii. The chief complaint doesnt have to be in wordsiv. It just summarizes why the patient is here. d. Present Illnessi. Should be a complete, clear, and a chronological account of the problems prompting the patient to seek care 1. This is the who, what, why, when, and where of the patients 2. Focuses on experiences and symptoms3. i.e. If patient broke out in a sweat, you note that they are diaphoretic but not short of breath. ii. Pertinent information1. Positives2. Negativesiii. Seven Attributes of Symptoms (COMMIT TO MEMORY)1. Location2. Quality (i.e. Burning chest pain, sharp pain, pressure on the chest)3. Quantity or Severity4. Timing (onset, duration, frequency)5. Setting6. Aggravating/Relieving Factors7. Associated Manifestations 8. Good histories have at least have 5 of the 7 attributes. 9. Examples:a. Headacheb. Chest paine. Medications:i. Name, dose, route, and frequency of useii. Rx, OTC, herbal, home remedies, vitamins, birth control pills, borrowed medsf. Allergies:i. Meds and the specific reactions1. Types of allergies: rash or anaphylaxisii. Foods, insects, airborneiii. Always do your allergies right after the medicationsiv. Do your history in an outline format when you do your notesg. Tobacco- current and past usei. Cigarettes reported in pack-years1. i.e. a pack a day for 10 yearsii. Cigars, chew, snuffh. Alcohol- current and past usei. Tell me about your use of alcoholii. What do you like to drink?iii. Does alcohol mean hard stuff? Beer and wine?iv. Ask the number of drinks they have1. Multiply the number of drinks by 2v. Have you ever had a problem with drinking?1. Dont want to give a former alcoholic cough medication with alcohol in it 2. Ask them Cage questions if they have a problem with drinking.a. Cage is a well-known instruments to identify problems drinkingvi. The Cage Questionnaire (4 questions)1. Have you ever felt the need to cut down on drinking?2. Have you ever felt annoyed by criticism of drinking?3. Have you ever felt guilty about drinking?4. Have you ever taken a drink first thing in the morning (eye-opener) to steady your nerves or get rid of a hangover?i. Drugs- current and past usei. How much marijuana do you use?ii. Cocaine, Heroin, Amphetamines?iii. Add or drugs to the Cage questionsiv. Any bad reactions?v. Job or family problems?vi. Adolescents and childrenj. The Historyi. Includes:1. Past History2. Family History3. Personal and Social History4. Review of Systemsii. Past History1. Childhood Illnessesa. For older patients, important illnesses, injuries, i. Chicken pox, measles, mumpsii. Significant illnesses, surgeries, hospitalized, asthmas, etc.iii. Dont ask about insignificant illnesses like strep throat.b. For pediatric patients, details-details-detailsi. All they have are childhood illnesses. 2. Adult Illnesses: drill these 4 itemsa. Medicali. Important illnessii. Systemic illnesses 1. Diagnosis, how long?iii. Drugs they have been onb. Surgical: type of surgery, when, why, how did you do?i. You had no surgery? So you havent had your tonsils, appendix, gall bladder removed. No wisdom teeth extracted? No hernia surgery?c. OB/gyni. FDLMP (first day of last menstrual period)ii. Birth controliii. Menarcheiv. Menopausev. Pregnancies, miscarriages, abortions, live birthsvi. Sexual history can be discussed at numerous points in the history (More on this later)d. Psychiatrici. Have you had any problems with anxiety, depression (or your nerves) in the past?ii. Dates?iii. Ever hospitalized?iv. Diagnosis, type of treatmentv. Ask simple questions first and then build up to details. XII. In Review: a. Objectives:i. Overview of the components of the comprehensive history and physicalii. How to begin the interview:1. The approach to the interview2. The process of the interviewXIII. Six Rules Doctors Need to Knowa. Dr. Robert Lambertsi. Musings of a Distractible Mindii. Bloggeriii. http://well.blogs.nytimes.com/2008/08/07/six-rules-doctors-need-to-know/b. Six Rules Doctors Need to Know:i. Rule 1: Patients dont want to be in your officeii. Rule 2: They have a reason to be in your office.iii. Rule 3: They feel what they feel.iv. Rule 4: They dont want to look stupid.v. Rule 5: They pay for a plan.vi. Rule 6: The visit is about them.