PCS: Overview of the History and Physical Dr. Harry Morris Tuesday, 8.17.

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**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 physical ii. How to begin the interview: 1. The approach to the interview 2. The process of the interview 3. Talk about the psychological things, real people with real problems iii. Techniques to establish the Chief Complaint, Present Illness, and Past History Types of Medical Encounters: a. New/Established Office Visits i. 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 properly ii. 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 Visits c. Admission to the Hospital d. Subsequent Visits in Hospital e. New/Established Nursing Home Visits f. Home Care Visits g. Checkups, sports physicals (more focused than a normal checkup), vaccinations, follow-up visits for previous problems, procedures h. H&Ps are usually done by 3rd year medical students. Sometimes an intern does it. The scope of your assessment depends on the type of visit (2 types) a. Comprehensive i. New patients ii. Provides fundamental and personalized info iii. Strengthens dr-pt relationship iv. Identify or r/o physical causes related to pt concerns v. Baseline for future vi. Platform for health promotion vii. The yellow card will have all the information to give a comprehensive physical. b. Focused i. All the focused visits are subsets of comprehensive physicals 1. ER chest pain= heart attack until proven other wise 2. Doctors office chest pain is not necessarily a heart attack ii. Established patients, routine or urgent visits iii. Addresses focused concerns or symptoms iv. Restricted to a specific body system v. Applies exam methods relevant to assessing the concern or problem as precisely and carefully as possible

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Components of a Note: Four Important Sections a. History i. Comprehensive vs Focused/problem focused b. Physical i. Comprehensive vs Complaint focused c. Assessment d. Plan e. All 4 sections must be completed Types of Information for History a. Subjective Data i. What the patient tells you 1. i.e. Patient telling you they have a chest pain 2. i.e. pain 3. i.e. saying they dont have diarrhea ii. The History from the Chief Complaint through Review of Systems iii. Symptoms? iv. The entire history (front part of the yellow card) is all subjective history b. Objective Data i. What you detect on the examination 1. i.e. Seeing the patient sweat (diaphoresis) ii. All physical findings 1. i.e. things we measure, smell, feel, lab tests, etc. iii. Signs? c. Structure of the Medical Note i. SOAP note are history/ physical assessment plan. It breaks down into subjective and objective findings. 1. S: Subjective information a. History 2. O: Objective findings a. Physical 3. A: Assessment a. Diagnosis/ Differential Diagnoses 4. P: Plan a. What need to be done. ii. Sequence of the Comprehensive History 1. See H+P Card and study it! a. Comprehensive Health History i. Identifying Data ii. Chief Complaint (s) iii. Present Illness 1. Seven dimensions of a symptom iv. Medications v. Allergies vi. Tobacco vii. Alcohol/Drugs viii. Past History (with 4 components) ix. Family History x. Personal and Social History xi. Review of Systems 1. Twenty Systems

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iii. ROS 1. General (Size up the patient, whether they look clean or oriented) 2. Skin 3. Head 4. Eyes 5. Ears 6. Nose 7. Throat 8. Neck 9. Breasts 10. Respiratory 11. Cardiovascular 12. Gastrointestinal 13. Urinary 14. Genital 15. Peripheral Vascular 16. Musculoskeletal 17. Neurologic 18. Hematologic 19. Endocrine 20. Psychiatric The Physical Examination: a. How it is documented, not how is it performed i. General Survey xiii. Breasts ii. Vital Signs xiv. Abdomen iii. Skin xv. Genitalia iv. Head xvi. Rectal v. Eyes xvii. Peripheral Vascular System vi. Ears xviii. Musculoskeletal vii. Nose xix. Nervous System viii. Throat 1. Mental Status ix. Neck 2. Cranial Nerves x. Lymph Nodes 3. Motor System xi. Thorax and Lungs 4. Sensory System xii. Cardiovascular 5. Reflexes b. So why do we do this?? i. Because: The health history is a conversation with a purpose: improve the wellbeing of the patient 1. Its all about the patient, not about us. 2. To establish a trusting and supportive relationship a. In the ER you dont have a long time to do this, but still need to establish professional relationship 3. To gather information 4. To offer information c. Clinicians do more than detective work i. Generating hypotheses about the nature of the patients concerns. ii. Test these hypotheses, ask for more information iii. Explore the patients beliefs about the problem 1. 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 them iv. Respond with understanding of the patients concerns

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The Realm of Patient Assessment a. Integrate the essential elements of clinical care: i. Empathic listening 1. 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 backgrounds 1. Learn how to be open-minded a. 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 patient iii. The techniques for examining the different body systems iv. 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 Reasoning i. Identify abnormal findings ii. Localize findings anatomically 1. 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 process iv. Make hypotheses about the nature of the patients problem v. Test the hypotheses and establish a working diagnosis 1. Chest pain= MI 2. Headache= cerebral bleed 3. Cough= lung cancer vi. Develop a plan agreeable to the patient 1. 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 encounter 1. Patient is first a blind slate. viii. Caution: Jumping to conclusions 1. 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 reasoning 1. 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 physician i. Explore the patients beliefs about the problem ii. Respond with understanding of the patients concerns

PCS: Overview of the History and Physical Dr. Harry Morris Tuesday, 8.17.10, 8:00am-10:00am

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iii. 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 adaptable iv. Its difficult for doctors to dispel misinformation 1. i.e. not taking a drug because they knew someone who died from it d. Pointers i. Learn to organize patient information into the components of the History on the fly 1. 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 outline iii. New patients require a comprehensive H+P iv. Other patients may require a focused or problem-oriented interview v. You will adapt your interview to the setting and time available vi. 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 contexts vii. The order of the H+P should not dictate the exact sequence of the interview viii. The data flows spontaneously from the patient ix. Its your job to organize and document the data 1. The patients dont follow the order, you do. Getting Ready to Interview a. Taking time for self-reflection i. Learn from your experiences, good and bad ii. 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 why 2. 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 differences iv. We have our own bias, assumptions, and values v. Self-Reflection: continual part of professionalism vi. Deepens personal awareness to our work with patients b. Reviewing the Chart i. Before seeing the patient review the medical record ii. Check identifying information 1. Making sure you have the right patient 2. Orderlies can put patients beds in the wrong location iii. Current and past diagnoses and treatments iv. Medicines and Allergies v. Could this info be inaccurate 1. DKA vs BKA a. BKA= below the knee amputation b. 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 physical 3. Complete physical

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ii. It helps to orient you on your mission to complete the interview iii. Your goals and the patients goals may not be similar - strike a balance 1. 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 Environment i. Make the setting private and comfortable 1. Temperature, shutting the curtains, etc. ii. Ask permission to pull a privacy curtain iii. Move from a congested public area to a private room iv. Failure to consider these issues is disrespectful e. Taking Notes i. You are expected to make notes ii. Jot down short phrases, dates, specific illnesses iii. Write your chart note later iv. 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 patient 1. 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. Clinician Behavior and Appearance a. Consciously or not, you are sending signals b. The patient is observing you i. 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 understanding d. Guard against negative signals that betray disapproval, embarrassment, impatience, or boredom i. 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 them e. Caution against behaviors that condescend, stereotype, criticize, or belittle f. Patients prefer (and I insist on): i. Cleanliness, neatness, conservative dress, and a name tag 1. 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. Morris b. Dont make people think that you are someone that you arent ii. No fragrance 1. Physicians should not have a scent. Some patients are sensitive to strong scents.

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The Sequence of the Interview: a. Basic things you need to learn how to do i. Greeting the patient and establishing rapport ii. Inviting the Patients Story iii. Establishing the agenda for the interview iv. Expanding and clarifying the patients story v. Generating and testing diagnostic hypotheses vi. 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 interview b. Greeting the patient and establishing rapport i. Knock on the door (dont need to wait for them to say come in), greet the patient by name and introduce yourself ii. If possible, shake hands 1. Some cultures (i.e. Muslims) dont allow this iii. 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 room 1. 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. I s 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 attention 1. If you need to break that undivided attention, let the patient know c. Inviting the Patients Story i. Why is the patient seeking health care ii. The Chief Complaint iii. 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 interrupt v. Ask if there is anything else. 1. Ask focused questions 2. 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 actively 1. 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.

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Establishing the Agenda for the interview i. Your goals and patient concerns and questions must be addressed 1. 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 lump 2. 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 prioritize iii. 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. Expanding and Clarifying the Health History i. The Chief Complaint ii. The Present Illness iii. Understand the essential characteristics of complaints iv. Seven Attributes of a Symptom Generating and Testing Diagnostic Hypotheses i. What are the causes of the patients concerns? 1. Generate a hypothesis after you gather all the information in the yellow card ii. Recognizing pattern of disease iii. Specific attributes of disease iv. Use relevant items from the Review of Systems to gather more information v. Clinical Reasoning is a Science and an Art vi. Assessment 1. Working Diagnosis: The thing you think it is today, given the information you have a. File and document the information on paper and generate a hypothesis on what is wrong. b. Working diagnosis will change as you get more information 2. Differential Diagnosis: 3. Your plan is all the things that youre going to do address the patients concerns (therapeutics, diagnostics, or education) Creating a Shared Understanding of the Problem i. Disease/Illness Distinction Model 1. Disease- explanation that the clinician brings to the symptoms 2. Illness- how the patient experiences the symptoms ii. 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 that iii. Dont refer to patients by the diagnosis. Its disrespectful iv. Exploring the Patients Perspective: 1. The patients thoughts about the nature and the cause of the problem a. 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 problem a. 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.

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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 care a. 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 life 5. Prior personal or family experiences that are similar 6. Therapeutic responses the patient has already had h. Negotiating a Plan (Read the book on this) i. Further evaluation ii. Physical examination iii. Laboratory tests iv. Consultations v. Imaging studies vi. Treatment vii. Behavior changes i. Planning for Follow-up and Closing i. Not always easy to end the interview ii. Give notice that the end is approaching iii. Make sure the patient understands the plans iv. 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? Comprehensive History (See H+P Card) a. Sequence of the Comprehensive Health History: i. Identifying Data ii. Chief Complaint (s) iii. Present Illness 1. Seven dimensions of a symptom iv. Medications v. Allergies vi. Tobacco vii. Alcohol/Drugs viii. Past History b. Identifying Information i. Walk in, introduce yourself, wash your hands, and then check the identifying information. ii. Ask the patient for: 1. Date 2. Time (of the interview) a. Because 3 hours later, their condition can completely change 3. Patients Name 4. Date of Birth 5. *Referral a. Who referred them to the specialist 6. *Source of History a. i.e. if a grandmother give the history for a 5 year old. 7. *Reliability a. i.e. If the patient looks confused or alert. c.

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Chief Complaint i. Attempt to quote the patients own words 1. 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 words iv. It just summarizes why the patient is here. Present Illness i. 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 symptoms 3. i.e. If patient broke out in a sweat, you note that they are diaphoretic but not short of breath. ii. Pertinent information 1. Positives 2. Negatives iii. Seven Attributes of Symptoms (COMMIT TO MEMORY) 1. Location 2. Quality (i.e. Burning chest pain, sharp pain, pressure on the chest) 3. Quantity or Severity 4. Timing (onset, duration, frequency) 5. Setting 6. Aggravating/Relieving Factors 7. Associated Manifestations 8. Good histories have at least have 5 of the 7 attributes. 9. Examples: a. Headache b. Chest pain Medications: i. Name, dose, route, and frequency of use ii. Rx, OTC, herbal, home remedies, vitamins, birth control pills, borrowed meds Allergies: i. Meds and the specific reactions 1. Types of allergies: rash or anaphylaxis ii. Foods, insects, airborne iii. Always do your allergies right after the medications iv. Do your history in an outline format when you do your notes Tobacco- current and past use i. Cigarettes reported in pack-years 1. i.e. a pack a day for 10 years ii. Cigars, chew, snuff Alcohol- current and past use i. Tell me about your use of alcohol ii. What do you like to drink? iii. Does alcohol mean hard stuff? Beer and wine? iv. Ask the number of drinks they have 1. Multiply the number of drinks by 2 v. 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 drinking

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vi. 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? Drugs- current and past use i. How much marijuana do you use? ii. Cocaine, Heroin, Amphetamines? iii. Add or drugs to the Cage questions iv. Any bad reactions? v. Job or family problems? vi. Adolescents and children The History i. Includes: 1. Past History 2. Family History 3. Personal and Social History 4. Review of Systems ii. Past History 1. Childhood Illnesses a. For older patients, important illnesses, injuries, i. Chicken pox, measles, mumps ii. Significant illnesses, surgeries, hospitalized, asthmas, etc. iii. Dont ask about insignificant illnesses like strep throat. b. For pediatric patients, details-details-details i. All they have are childhood illnesses. 2. Adult Illnesses: drill these 4 items a. Medical i. Important illness ii. Systemic illnesses 1. Diagnosis, how long? iii. Drugs they have been on b. 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/gyn i. FDLMP (first day of last menstrual period) ii. Birth control iii. Menarche iv. Menopause v. Pregnancies, miscarriages, abortions, live births vi. Sexual history can be discussed at numerous points in the history (More on this later) d. Psychiatric i. Have you had any problems with anxiety, depression (or your nerves) in the past? ii. Dates? iii. Ever hospitalized? iv. Diagnosis, type of treatment v. Ask simple questions first and then build up to details.

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In Review: a. Objectives: i. Overview of the components of the comprehensive history and physical ii. How to begin the interview: 1. The approach to the interview 2. The process of the interview Six Rules Doctors Need to Know a. Dr. Robert Lamberts i. Musings of a Distractible Mind ii. Blogger iii. 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 office ii. 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.