PRINCIPLES OF MEDICINE

APPROACH TO EVALUATION OF PATIENT

WHAT IS EXPECTED OF THE DOCTOR?

MEDICINE IS BOTH SCIENCE AND ART

SCIENCE

- technology based on science is the foundation for solution to clinical problems - advances in biochemical methodology and in biophysical imaging techniques - innovations in therapeutic maneuvers

ART - ability to extract contradictory physical signs - ability to discern and interpret laboratory data - to know whether to treat or watch - to determine when to pursue a clinical clue or when to dismiss - to decide which is of greater risk: treatment or disease This combination of medical knowledge, intuition and judgment is the art of medicine

 Tact, sympathy and understanding are expected of the physician, for the patient is no mere collection of symptoms, signs, disordered functions, damaged organs and disturbed emotions. He is human, fearful and hopeful seeking relief, help and reassurance. - Harrisons Principle of Medicine

PATIENT PHYSICIAN / DOCTOR RELATIONSHIP

Individuals whose problems often transcends their complaints Whatever the patients attitude, the physician needs to consider the

terrain in which an illness occurs family and social background Approach patients not as cases or diseases Primary objective is to discover the root of a patients concern and do something about it

HOW TO EVALUATE
I.

PATIENT HISTORY build a history rather than take one

OBJECTIVES: identify problems to establish a sense of the patients reliability to consider the potential for intentional or unintentional suppression or underreporting of certain experiences

Setting for the interview:

Make

everyone as comfortable as possible Make the patient your focal point Maintain eye contact and a conversational tone of voice

STRUCTURE OF THE HISTORY

1. 2. 3.

4.
5. 6. 7.

General data Chief complaint History of present illness Past medical history Family history Personal and social history Review of systems

 GENERAL DATA

- identifies the name, date, age, gender, race, occupation

CHIEF COMPLAINT

- brief statement of the reason the patient is seeking care - direct quotes are helpful

History of Present Illness (HPI)

a complete HPI will include the following: chronologic ordering of events state of health just before the onset of the present problem complete description of the first symptoms possible exposure to infection, toxic agents or other environmental hazards

 description of a typical attack, including its persistence impact of the illness on the patients usual lifestyle medications current and recent including dosage as well as home remedies

Past Medical History

baseline for assessing the present complaint. general health and strength childhood illnesses: measles, mumps, chickenpox, etc. major adult illnesses: TB, hepatitis, diabetes, HPN, MI, any surgical or nonsurgical hospitalization immunizations

 serious injuries medications allergies and the nature of reactions especially to medications transfusions: reactions, date and number of units transfused

Family History
blood relatives in the immediate or

extended family with illnesses with features similar to patients include in the list of concerns: heart disease, high blood, pressure, diabetes, asthma, epilepsy, allergy, thyroid disease, etc. history of cancer

Personal and Social History

PERSONAL STATUS: birthplace, where raised, home environment, education, position in family, marital status, hobbies and interests, sources of stress and strain HABITS: nutrition and diet, regularity and patterns of eating and sleeping, quantity of coffee, tea, tobacco, alcohol, extent of cigarette use reported in packyears

 SEXUAL HISTORY OCCUPATION: description and duration of employment; exposures to toxins (e.g. lead, arsenic, asbestos) RELIGIOUS AND CULTURAL PREFERENCES

Review of Systems
Identify the presence or absence of health-related issues in each body system. general constitutional symptoms head and neck lymph nodes: enlargement, tenderness chest and lungs: pain in respiration, dyspnea, wheeze, cyanosis breasts: development, pain, tenderness, discharge, lumps heart & blood vessels peripheral vasculature: thrombosis, thrombophlebitis, claudication

 GIT: heartburn, nausea, vomiting, hematemesis, regularity of bowels, constipation, diarrhea, flatulence, hemorrhoids musculoskeletal: joint stiffness, pain, restriction of motion, swelling, redness, bone deformity neurologic: syncope, seizures, weakness or paralysis, tremors, loss of memory psychiatric: depression, mood changes, difficulty concentrating, anxiety, agitation, suicidal thoughts

 female: menarche, pregnancies males: puberty onset, erectile dysfunctions, problem in emissions, testicular pain, libido, infertility

TYPES OF HISTORIES
1. Complete History makes you thoroughly familiar with the patient - most often recorded the first time you see the patient. 2. Inventory History related to but does not replace the complete history - it touches on the major points without going into detail 3. Problem (or focused) History taken when the problem is acute possibly life threatening 4. Interim History chronicles the events that have occurred since your last meeting with the patient

II. PHYSICAL EXAMINATION Physical signs are the objective and verifiable marks of disease and represent solid, indisputable facts Physical examination should be performed methodically and thoroughly The results should be recorded at the time they are elicited Repeat the physical examination as frequently as the clinical situation warrants

PARTS OF PHYSICAL EXAMINATIONS

1. Measurement of Vital Signs: baseline indicators of a patients health status PULSE may be palpated in several areas; however, the radial pulse is most often used - note their rhythm, amplitude while counting

 RESPIRATION observe the rise and fall of the chest - Count the respiratory cycles / minute - Note the depth of respiration and whether the patient uses accessory muscles BLOOD PRESSURE TEMPERATURE oral, rectal, axillary and tympanic - kinds: electronic and tympanic; infrared axillary thermometers for neonates

 OXYGEN SATURATION estimation of arterial oxygen saturation - A healthy person with no anemia or lung disease has O2 sat. of 97% - 99% PAIN because of its ubiquitous nature, its universality as a distress signal, it is more and more often being recognized as part of the vital sign.

2. Physical Assessment INSPECTION - process of observation - what is the patients gait - is eye contact made - is the patient dressed appropriately for the weather - color and moisture of the skin

 PALPATION - involves the use of the hands and fingers to gather information through the sense of touch - ulnar surface of the hand and fingers is the most sensitive area for distinguishing vibration - dorsal surface of the hand is best for estimating temperature

 PERCUSSION - involves striking one object against another to produce vibration and subsequent sound waves - the more dense the medium, the quieter is the percussion tone - percussion over air is loud, over fluid less loud and over solid areas soft

PERCUSSION TONES
TONE Tympanic Hyperresonant Resonant Dull Flat INTENSITY Loud Very loud Loud Soft to Moderate Soft PITCH High Low Low Moderate to High High QUALITY Drumlike Boomlike Hollow Thudlike Very dull Example where heard Gastric Bubble Emphysematous Lung Healthy Lung Liver Over Muscle

CORE VALUES
1. 2. 3.

4. 5.

6.

Respect the patient. Achieve the complimentary forces of competence and compassion. The art and skill essential to history taking and physical examination are the bedrock of care; technologic resources are complements The history and physical examination are inseparable they are one. The computer cannot replace you, it is what you do that builds a trusting, fruitful relationship with the patient. The relationship can be indescribably rewarding.

THANK YOU!!!