Intro to C E_ Sem3 2013.ppt

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Introduction to Clinical

ExaminationSemester 3 (Year 2)

2010/11

Why Learn Basic Clinical

Skills?

70-80% of diagnoses can be

made based on history alone.

90% of diagnoses can be made

based on history and physical

examination alone.

Expensive tests often confirm

what is found during the Hx andP/E.

The History and Physical

Examination

These skills are the foundation

of clinical practice and should beconsidered part of the basic

science of medicine.

“The precise and intelligent recogni t ion

and appreciat ion of m inor d i f ferences isthe real essential factor in all successful medical diagnosis.”

- Joseph Bell (1890)

The character of Sherlock Holmes wasbased on Dr. Bell, an English surgeon whotaught Arthur Conan Doyle during medical

school.

The Physical Examination

Clinical signs are ascertained by

direct examination.

Together with the medical history,

the physical examination aids indetermining the correct diagnosis

and devising the treatment plan.

This information is then recorded in

the patients notes

History and Physical

Examination

If a diagnosis cannot be made then a

provisional diagnosis may be

formulated, and other possibilities(the differential diagnosis) may be

added, by convention listed in order

of likelihood.

Physical Examination

The general examination, precedes

the examination of the other

systems – cardiovascular,

respiratory, abdominal, nervoussystem, musculoskeletal, thyroid, etc

In this year, you will be shown the

CVS, respiratory, CNS/PNS and

abdominal examination

Approach to Physical

Examination

A good physical examinationrequires a cooperative patient

Quiet, well-lit room (daylight

better than artificial light) Chaperones should be present

when a male doctor is

examining a female patient andduring pelvic and vaginalexaminations

Four major techniques thatmake up the physical exam(i.e., inspection, palpation,

percussion, auscultation).

These techniques are used in

combination during the P/E of each system to elicit physicalsigns (normal or abnormal)

Palpation -a method of examination inwhich the examiner feels an object todetermine its size, shape, firmness, or location -for example, palpating body parts

to check for swelling or disease.

Percussion - done by tapping on a surfaceto determine the underlying structure.

Auscultation - is the technical term for listening to the internal sounds of the body,usually using a stethoscope

The combination of physical signs

in each system allows the examining

physician to come to a diagnosis

Eg: stony dullness on percussion, in

combination with reduced vocal

fremitus & resonance, and

diminished breath sounds suggest

the presence of pleural effusion.

General examination

The general examination includes:

inspection of the general appearance

inspection of the hands for signs

associated with systemic disease

checking for pallor, cyanosis,

jaundice assessing hydrational status

assessing lymphnode regions

Examination

The physical exam begins when

you first meet your patient

Golden Rule:

“ Always use your eyes before you

use your hands – inspect,inspect, inspect…”

Examination

DOCTORS SHOULD BE OBSERVANT, LIKE ADETECTIVE

“CONAN DOYLE”

Look at the patients general appearance…at theface ,hands and body

Each examining system can be described usingfour elements;

- looking/inspection

- feeling/palpation

- tapping/percussion

- listening/auscultation

- assessment of function

Physical Examination -

inspection

As you approach your patientyou will notice the comfort level of your patient.

Is she sitting, standing, lying or assuming some other posture.

What is her apparent level of alertness?

First impressions…..

Decide how sick is your patient?

Is she well, sitting up and

talking?

Or ill totally not aware of her

surroundings?

Is she active or very still?

Does she appear to be

in distress?

Physical Examination -

inspection What about her demeanour or

affect? Is she cooperative?Depressed?

As you get closer to your patient youmay notice apparatus such asintravenous lines, surgical drains,Foley urinary catheter bags.

How is your patient’s color? Doesshe appear her age?

Weight,body habitus and

posture

Obesity,BMI >30.

Any wasting of muscles?

Tall?short? Always observe when the

patient walks into the

examination room.

As you approach even closer, makeyour patient comfortable byintroducing yourself in a professionalmanner and explaining what you will

be doing.

For example, you may say, “I am(NAME), a second year medical

student. I would like to interview youand then perform a physical examination. Is that alright withyou?”

Referring to the patient by his/her namewith appropriate title is preferable toaddressing as “Pak Cik/Mak Cik”…you aretheir doctor, not their nephew or niece.

Explain the planned examination.

Give the patient clear instructions to elicitcooperation with the exam

Give the patient feedback during the exam.(Examples: that sounds fine, ok, good,...etc.)

Be conscientious about draping the patientand not exposing any more of the patientthan is necessary for a complete andaccurate exam.

This does not mean that exposure mustnecessarily be limited, as you are toexamine the patient completely andaccurately and professionally

Wash your hands and dry them prior to(and after) examining the patient

General examination:

Appearance

Hands Eyes

-part of every systemic examination

General appearance

FACIES

Specific diagnosis can be made

by just looking at a patient’s

Some facial characteristics are

so typical of certain diseases

that they immediately suggest

the diagnosis….so calleddiagnostic facies……

Important diagnostic facies

Acromegaly

Cushingnoid

Down syndrome

Marfanoid Myxoedemetous

Thyrotoxic

Parkinsonism

Inspection - face

Acromegaly

Acromegaly - hands

Down syndrome

Cushing’s syndrome

Inspection – hands and nails

CLUBBING -increase in the soft tissue of the distal part of the

fingers or toes.

CAUSES

1) Cardiovascular

-cyanotic congenital heart disease,IE2) Respiratory

-lung carcinoma

-bronchiectasis,lung abscess,emphyema

-lung fibrosis

3) Gastrointestinal

-cirrohis,IBS,Coeliac disease

4) Thyrotoxicosis

5) Familial

clubbing

Blue nails-cyanosis,wilson ds Red nails-polycythaemia,CO poisoning

Yellow nails- yellow nail syndrome

Splinter haemorrhages-IE,vasculitis

Koilonychia-iron def anaemia,fungalinfection,raynauds

Onycholysis-thyrotoxicosis,psoriasis

Leuconychia-hypoalbuminemia

Nailfold erythema-SLE

Terry’s nails-CRF,cirrhosis

Beau’s lines

The location of Beau's lines half way up the

nail suggests illness 3 months ago.

Beau’s lines

In 1846, Joseph Honoré Simon Beau

described transverse lines in the substance

of the nail as signs of previous acute

illness. The lines look as if a little furrow

had been plowed across the nail. Illnessesproducing Beau's lines include the

following:

Severe infection;

Myocardial infarction;Hypotension, shock;

Hypocalcemia; and

Surgery.

Plummer-Vinson syndrome

Psoriasis

Inspection – hands

CYANOSIS

Blue discolouration of the skin and mucousmembranes;it is due to the presence of deoxygenated haemoglobin in the superficial bloodvessels.

Occurs when there is more than 50g/L of

deoxygenated haemoglobin in the capillary blood. Types-central and peripheral

Central cyanosis- abnormal amount of deoxygenated haemoglobin in the arteries and thata blue discolouration is present in parts of the bodywith good circulation.eg;tongue.

Peripheral cyanosis-occurs when blood supply to aparticular part of body is reduced,eg;lips in coldweather becomes blue but the tongue is spared.

cyanosis

Inspection – eyes

PALLOR Deficiency of haemoglobin can

produce pallor of the skin.

Should be noticeable especiallyin the mucous membranes of

the sclera if the anaemia issevere- Hb of less than 7g/L.

Facial pallor can also be seen inpatients with shock, due to thereduction of cardiac output.These patients usually appear cold and clammy and

significantly hypotensive.

Causes of anaemia

MICROCYTIC ANAEMIA

1) Iron deficiency anaemia

-chronic bleeding

-malabsorption

-hookworm

-pregnancy

2) Thalassemia minor

3) Sideroblastic anaemia

4) Longstanding anaemia of chronicblood loss

Macrocytic anaemia

Megaloblastic bone marrow

1)Vitamin B12 defiency due to

-pernicious anaemia

-gastrectomy-tropical sprue

-ileal disease;crohns disease,ileal resection

-fish tapeworm

-poor diet in vegetarians

2) Folate deficiency due to-dietary defiency in alcoholics

-malabsorption

-increased cell turnover

eg;pregnancy,leukemia,chronic haemolysis-anti folate drugs – phenytoin,methotrexate,sulphasalazine

non megaloblastic bone marrow

-alcohol,cirrohis of the

liver,hypothyroidism,myelodysplasticsyndrome

Normochromic anaemia

Bone marrow failure

-aplastic anaemia

-ineffective haematopoiesis

-infiltration

• Anaemia of chronic disease

-chronic inflammation

-liver disease

-malignancies,chronic renal failure

• Haemolytic anaemia

JAUNDICE

It is the yellowish discolourationof a patient’s skin and sclerae

that results from

hyperbilirubinemia. It happens when the serum

bilirubin level rises twice above

the normal upper limit.

It is deposited in the tissues of

the body that contains elastin.

jaundice

Hydration

Mild-2.5L deficitmild thirst,dry mucous membranes,concentrated urine

Moderate – 4L deficit

as above with moderate thirst,reduced skinturgor (especially the arms, forehead,chest andabdomen), tachycardia

Severe – 6L

-great thirst,reduced skin turgor and decreasedeyeball pressure

-collapsed veins,sunken eyes,posturalhypotension,oliguia

Skin & mucous membranes

Oral cavity

The teeth and breathCheck the oral cavity looking for

MOUTH ULCERS

- apthous, drugs and trauma

-gastrointestinal disease;inflammatory bowel disease,coeliacdisease

-rheumatological;

Behcet’s syndrome, Reiter -erythema multiforme

-infections; herpes zoster, simplex,syphilis

Behcets ulcers

Gum hypertrophy

phenytoin

pregnancy

scurvy(vitamin C deficiency;

gums become swollen, spongy,

red and bleed easily)

gingivitis; smoking

leukaemia

Pigmentation in the mouth

Heavy metals

lead, bismuth, iron;haemochromatosis there is bluegrey pigmentation in the hard

palate Drugs-antimalarials, OCPs

(brown/black pigmentationanywhere in the mouth)

Addison’s disease

Peutz-Jeghers syndrome

Malignant melanoma

ALOPECIA

Non-scarring

- alopecia areta

- scalp ring worm

- traction alopecia

Scarring- burns, radiation, lupoid

erythema, sarcoidosis

Alopecia areata

Traction alopecia

Alopecia totalis

lymphadenopathy, goitre

During palpation of lymph nodesthe following features should beconsidered;

SITE- localised or generalised?

- palpable lymph node areas are

epitrochlear,axillary,cervical andoccipital, supraclavicular, para-aortic, inguinal and popliteal.

Lymphadenopathy

CONSISTENCY- hard are suggestive of carcinoma

- soft may be normal

- rubbery may be due to lymphoma

TENDERNESS- acute infection of inflammation

FIXATION

- if fixed to the underlying structures itsmost likely malignant

OVERLYING SKIN- if inflammed then it’s suggestive of infection, tethered suggests carcinoma.

Cervical lymphadenopathy

CAUSES OF

LYMPHADENOPATHY

GENERALISED

- lymphoma

- leukemia

- infections- viral;infectious mononucleosis, CMV,HIV

- bacterial; tuberculosis,syphilis

- protozoal; toxoplasmosis

- connective tissue disease- infitration; sarcoidosis

- drugs;phenytoin

CAUSES OF

LYMPHADENOPATHY

Localized

Local or acute infection

Metastasis from carcinoma or

other solid tumour

Lymphoma

I ti l & h t

Inspection - general & chest

I ti l & h t

VITAL SIGNS

PULSE BLOOD PRESSURE

TEMPERATURE

RESPIRATORY RATE Should be assessed

immediately once you discover

that your patients unwell. They provide important basic

physiological information.

G l i d

General reminders

Treat patients as you would wantyourself or a family member to be

cared for.

This should cover not only the

technical aspects of health care

but also the quality and nature of your interpersonal interactions.

G l i d

General reminders

There is no substitute for being thorough inyour efforts to care for patients.

Performing a good examination andobtaining an accurate history takes acertain amount of time, regardless of your level of experience or ability.

In addition, get in the habit of checking theprimary data yourself, obtaining hardcopies of outside information, old records

for information, re-questioning patientswhen the story is unclear

G l i d

General reminders

Learn from your patients. In particular,those with chronic or unusual diseases willlikely know more about their illnesses thenyou.

Find out how their diagnosis was made,therapies that have worked or failed,disease progression, reasons for frustrationor gratitude with the health care system,etc.

Realize also that patients and their storiesare frequently more interesting then thediseases that inhabit their bodies.

Sem 3 Module Objectives

To perform history-takingrelevant to the system.

To perform systematic

physical examination relatedto the system involved.

To perform basic medical

procedures.

Module Objectives

The emphasis for Year 2 is on

ability to obtain a complete

history

ability to demonstrate the

correct examination techniques

|the recognition of NORMAL

physical findings

Module Objectives

Learn appropriate professional behavior and dress while conducting a physicalexamination

You will practice the various parts of thephysical exam on your classmates whowill act as your patient and you will actin turn as their patient

You may be taken to wards to examinereal patients

CSL Sessions

Format/activities of each session: 2.00 – 2.15 pm : Intro/Briefing & video

2.20 – 5.00 pm : History taking (role-play)& discussion

Physical examination &

presentation to mentor

Feedback from mentor

Clinical mentors must ensure that everystudent has the opportunity to activelyparticipate and be directly observed.

CSL Sessions

CSL session : RESP 1 History-taking: 2 students role-play

(1patient, 1 doctor) and present thehistory. Cases are discussed.

CSL session : RESP 2-3 Mentor demonstrates examination

technique

All students practice

Students perform physicalexamination and present findingsunder observation of mentor

CSL Sessions

CSL session : CVS 1 History-taking: 2 students role-play

(1patient, 1 doctor) and present thehistory. Case is discussed.

CSL session : CVS 2-3 Mentor demonstrates examination

technique

All students practice

Students perform physicalexamination and present findingsunder observation of mentor

CSL Sessions

Each student should have the opportunityto perform and present 1 CVS and 1 Respexamination during this module.

The emphasis is on correct technique andrecognition of normal physical findings.Students should posses 1 reference bookon clinical examination.

**Please practice on each other or patientsthroughout the year

Assessment is by OSCE (70%)andcontinuous assessment (30%)

Thank you.

Intro to C E_ Sem3 2013.ppt

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