619 & 672 L 7/27 History and Physical Diagnosis, Communication

Subjective Elements of Gathering Information

chief concern

history of present illness

past medical history

family history

social history

review of systems

Subjective Data

elicitd from a patient’s description (or parent/guardian) rather than from physical examination

Chief Concern

given in the patient’s own words, be sure to record it as such

chief complaint, presenting problem, reason for seeking care

History of Present Illness Mnemonic

OLDCAARTS?

onset

location

duration

character (how does it hurt)

associated/aggravating factors

relieving factors

temporal factors

severity of symptoms

? what does the patient think is wrong

Past Medical History Mnemonic

MAISHIFT

medical illnesses/medications (prescription and otc)

allergies and reaction

immunizations

surgeries

hospitalizations

injuries

family history

travel (can you eliminate possible diagnosis based on where they have been)

Family History 1st Degree vs 2nd Degree

1st degree shared ½ of the genes with the person (sibling, parent), and should always be considered

2nd degree share at least ¼ of the genes with the person (grandchild, uncle), and should be considered when relevant

Social History Mnemonic

HORSSES

habits (tobacco, diet, sleep- what habits are contributing to the CC)

occupation (stress level, exposures, ability to follow-up)

relationships (dating, bullying, social, friends)

safety and safety of relationships

sexual history

environment (possible exposures)

spirituality

Social History Caveat

ensure that all social history questions are appropriate for the age range

Review of Systems

questions from multiple body systems during a full history, will help you find out if you missed anything and may jog the patient’s memory to disclose more information

STILL subjective

Full History

asking all of the intake questions, typically to a new patient

Focused History

covers only the questions that are pertinent to the presenting problem, used on either returning patients or new patients with a serious illness (full history should still happen if they are new, just later when they are stable or from a family member)

Role of Focused H&P

concentrates on presenting problem and/or most urgent need, develop a plan and indicate future H&P directives that includes education and prevention (colon screening)

SOAP Format

used to record a focused H&P
subjective, objective, assessment, plan

What can you do when you are stuck on a history taking?

recap what the patient has told you to confirm, for them to correct errors, and to jog their memory

Objective Information of Gathering Information (Physical Exam)

vital signs

head to toe physical exam

Objective Data

clinical observations that can be seen, heard, and measured including lab values and imaging results

Enhancement of Physcial Senses

stethoscope, ophthalmoscope, and otoscope are used in examination, but you are only as good as your skills regardless of price

4 Cardinal Principles of Physical Exam

inspection

auscultation

percussion

palaption

Inspection

cardinal principle of physical exam, begins when you walk into the room, includes a general overall feel and localized specific symptoms, depends on knowledge of examiner

What physical exam method is the most productive

inspection yields the greatest number of physical signs and the most number of diagnoses, but you must overcome personal bias

Auscultation

cardinal principle of physical exam, listening to patient with and without stethoscope

Auscultation Without Stethescope

patient’s voice (clear, raspy, hoarse), listening for breathing, coughing

Auscultation With Stethoscope

heart sounds, vessels sounds (bruits, hums), lung/breathing sounds, bowel sounds

Percussion

cardinal principle of physical exam, striking the surface of the body to emit sounds that vary in intensity according to the density of underlying tissue

What sounds might you hear in the percussion section of physical exam?

tympany (air filled stomach)

resonance (air filled lungs)

flatness (solid muscle)

Why do we use percussion in the palpation section of the physical exam?

locate lung bases (symmetry)

ascites (fluid in peritoneal cavity)

map out organ size (liver, bladder)

Palpation

cardinal principle of physical exam, ask for consent and explain purpose

evaluate tenderness, texture, temperature, tone, masses (consistency, location, mobility, pulsation), ballottement fluctuation, fluid wave

Using Scent in Physical Exam

you don’t have to smell them specifically, but certain smells can be prominent

breath, sputum, vomitus, urine

Head to Toe Physical Exam

ask for consent, make sure patient is comfortable and you respect their modesty while being as complete as possible

quickly establish if patient is stable or unstable to determine speed of assessment

Exam Sequence

divided by system

adjust for patient position

discuss findings as you go

Adjusting for Patient Position

seated, supine, and standing in a good order that adjusts for patient (especially if they can’t stand)

Special Circumstaces of Physical Exam

infants, children, adolescents, mobility restrictions, cultural differences, health literacy, challenging patients

Assessment

problem identification and hypothesis generation, include social items like tobacco use if you plan to address it in your plan

could be a final diagnosis, bit often is first a differential diagnosis

Problem Identification

first step of assessment, a problem is anything that will need further evaluation and/or attention, we identify problems to help create our differential diagnosis, can include medical symptoms and SDoH

ex: fever, rash, financial hardships

4 Steps of Making a Diagnosis After Identifying Problems

patter recognition*

sampling the universe (exhaustive measures)

using algorithms

hypothesis generation and testing**

Generating Valid Hypotheses

second step of assessment, consider at least three diagnoses for every disease (one or more that fit the presentation and one you cannot afford to miss)

critical thinking allows you to consider and discard a variety of possible diagnosis in your head

The Plan Mnemonic

FAMOUS

follow up

additional tests/referrals

medications

OMT

understanding of disease impact

self care

The Plan

the decisions you make as a physician to treat the patient, the plan should reflect a response to your assessment

Complete H&P Overview

subjective: chief concern, history of present illness, past medical history, family history, social history, review of systems

objective: vital signs, head to toe physical exam

assessment

plan

7 Essential Elements of Healthcare Communication

open the discussion

build the relationship

gather information

understand the patient’s perspective

share information

reach agreement on problems and plans

provide closure

Doctor Centered vs Patient Centered Communication

it takes a blend of dr’s knowing what information is important and controls dialogue and the patient telling their story

Open-Ended Questions

what brings you in today

can you tell me more about that

what else

then what happened

Closed-Ended Questions

where does it hurt

when did this start

have you had any fever

does anything make it feel better

Differential Diagnosis Mnemonic

VINDICATES

vascular

infection/inflammation

neoplasm/neurologic

drugs/toxins/degenerative

idopathic/iatrogenic

congenital/developmental/inherited

autoimmune/allergy/anatomic

trauma

endocrine/environmental exposure

social/psychiatric

Idiopathic

a medical condition with an unknown cause

Iatrogenic

a medical disorder, illness, or injury caused in the process of medical treatment