k1 (anamnesis & pemeriksaan fisis)
TRANSCRIPT
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Pediatric Clinical
Diagnosis
Sudigdo SastroasmoroDepartment of Child Health, Medical School
University of Indonesia, Jakarta
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What is the philosophy?
Doctor as a professionalmust
be aware that patients are looking for
attention and helpPatients primarily want to be
examined by a respected doctor, not to
be subjected as an object of technology
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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 fulltrust will require consistent professional conduct in medical
students, residents, and practitioners of medicine.
Dr. Haile Debas (2000)Dean, The University of California, San Francisco
President of The American Surgical Association
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If the above rules are followed, you, as a medical
student, and in the future a physician, should find yourprofessional life extremely rewarding.
When you were born,
you cried and the world rejoiced.
Live your life in such a manner
so that when you die the world criesand you rejoice.
Old Indian Saying
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Profession is a complex concept, the definition of
which has been attempted for centuries. It has
been studied and defined by many from a varietyof disciplines with some agreements, much
conflict, and some useful additions.
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Profession: a declaration, promise,commitment publicly announced
Professionand professionalismare words withelastic meanings.
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A Profession is
a recognizable occupation in which
practitioners have a degree of autonomy over
their work, are involved in working withsignificant applied theory, and work within a
framework of values and ethicswhich are
broadly agreed across the occupation.
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Components of professionalism
Competence
Accountability
AltruismCollegiality
Ethics
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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
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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
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So what?
Medicine is the science of uncertainties
and the art of probabilities
Personal and humane approach!!
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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, andlaboratory / supporting exams should be
judged in relation with the childs stage of
growth and development.
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History
(Anamnesis)
Auto-anamnesis: self reporting by the patientAllo-anamnesis: any information other than by patient
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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 withoutappropriate 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
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History: 80%
Supporting exam: 5%
Physical exam 10-20%
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1. Patients ID
2. Chief complaint boleh bukan berupa keluhan, misalnya mau vaksinasi, dirujuk dsb
3. Clinical coursesdah diobati sendiri/dokter, ada diagnosis
4. Previous illness5. History of maternal pregnancy
6. History of delivery
7. Feeding history
8. Immunization status9. Growth & development
10. Family history
11. Environment
Anatomy of history taking
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PresentClinical courseBirth
Prenatal
Birth
Nutrition, immunization, growth & development
Past history
123
4
5, 6, etc
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Who provides the patients history?
(determines your confidence to the information provided)
Be patient, make a conducive atmosphere
Use daily words instead of medical terms
Be sure that the history-giver understands your points
Use history taking as a method for health education
ALWAYS: make footnotes /remarks at the end of
history taking
Points to remember
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1. An 8-year old girl, 30 kg, 130 cm, 3rdgrade ofelementary school, repeatedly had good ranking in
class. She was brought to the clinic due to 3-day highgrade fever, stomach ache, & nosebleed
2. A 12-year old boy, basketball player, suspected ofsuffering from radial fracture
Should complete history be obtained in all
patients irrespective of their illness?
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Remember
It is the patientthat should betreated; not the disease
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In general similar to that in adults, i.e. to obtain
accurate physical status irrespective of the approachNeeds modification due to nature of infants & children:
Inspection
Auscultation abdomen & thorax Examination using equipments (misal : dengan
nasal speculum)
Physical examination
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Steps in
physical exam
General condition
Vital signs
Anthropometric measurements
Systematic exam
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A. General condition
1. Consciousness : alert, apathetic, somnolent,
sophorous, comatose
2. Appearance : healthy, mildly/moderately/severely ill, distressed
3. Color : pale, jaundice, cyanotic
4. Specific facies : syndromes, facies cholerica,fish-mouth, facies leonina,
Cooleys facies
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B. Vital signs
1. Pulse : rate, regularity, volume,
equality
2. Respiration : rate, regularity, pattern3. Blood pressure : of 4 extremities
(setidaknya sekali
selama hidup)4. Temperature : oral, axillary, rectal
Note: always describe complete pulse & respiration!
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C. Anthropometric measurements
1. Body length/height : sitting, standing
2. Body weight
3. Head circumference
4. Arm circumference
5. Abdominal circumference
6. Nutritional status: W/A, H/A, W/H plot in
standard normal curves(NCHS)
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D. Systematic examination
Head & neck
Chest
Abdomen
Genitals
Extremities
Skin, hair, lymph nodesNeurological
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Use of stethoscope
Use binaural stethoscope
Bell-shaped side : low-medium pitched
sounds Membrane (diaphragm): medium-high pitched
For heart examination:
Bell-shaped first
Without pressure, then with pressure
Membrane
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Common mistakes inperforming examination
History
Fail to identify the patient first
Make 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
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Put your notes in every element of physical exam
where appropriate
Example: The child was cooperative, fighting,
etc.
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Components of professionalism
Competence
Accountability
AltruismCollegiality
Ethics
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Patients preference
Evidence from
valid research
Physicians competence
EBM
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What is Evidence-based Medicine?
The conscientious, explicit, and judicious use of
current best evidence in making decisions about
the care of individual patients Pemanfaatan bukti mutakhir yang sahih dalam
tatalaksana pasien Integration of (1) physicianscompetence,
(2) valid evidence from studies,
and (3) patientspreference
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WHY EBM?
1. New evidence are continuously generated
2. We usually fail to get the new evidence
3. Our clinicalperformance deteriorates with
time (the slippery slope)4. Traditional CME does not improve clinical
performance
5. EBM encourages self directed learningprocess which should overcome the above
shortages
100%
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Years after graduation
Relative
% of
remainingknowledge
2 4 6 8 10 12
$
100%
THE SLIPPERY SLOPE
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Patient with
problem
Search the
evidence
Criticallyappraise
the evidence
Formulate
in answerablequestion
Applythe evidence
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Concludingremarks
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
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A great doctor.
Three young moms are chatting about their
3-year-old sons
Mrs. A.: John must be a great lawyer then. He argues
everything all the time with definitely terrificarguments for his age!
Mrs. B: Im sure Mike will become a cute engineer.He destroys every toys we gave, and reconstructsthem successfully. Yes, always! Fantastic!!
Mrs. C: No doubt, Greg is a typical great doctor. Howdo you know? Asked Mrs. A and B. He never
comes when called, Mrs. C explained calmly.
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