history and physical exam
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History and Physical Exam. HST 2. Rationale. - PowerPoint PPT PresentationTRANSCRIPT
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History and Physical Exam
HST 2
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Rationale
• Health care workers are on the front line of fighting the spread of infectious disease. One of the most important aspects of their job is accurately diagnosing a disease by collecting the right types of information from the patient. It is necessary to obtain an accurate patient history and physical examination.
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Objectives
• Student expectations:
• Record a simple patient history
• Perform a patient exam, focusing on pulse, temperature, and respiration.
• Diagnose illness by matching observed symptoms with diseases, using a checklist.
• Suggest appropriate course of treatment.
• Describe symptoms and risk factors of various infectious diseases.
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Key Points
• Information gathered while performing a history and physical on a patient helps the physician determine:
• Patient’s level of health
• Need for additional testing or examinations
• Tentative diagnosis
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• Preventive measures needed
• Type of treatment
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Length and Detail
• At times, the history may need to be in great detail.
• For example, when a patient goes to a specialist, the patient may be asked to fill out a very lengthy form about any problems in the past that indicate a pattern.
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• But, many times a simple history is all that is needed to give the physician a good idea about what is going on with the patient.
• This is the best way to treat it, such as a patient seeing a doctor for a sore throat or broken arm, for example.
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Common Components of H&P
• Chief complaint (CC) – a brief statement made by the patient describing the nature of the illness (signs and symptoms) and the duration of the symptoms, i.e. why the patient came to see the physician.
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• History of present illness (HPI) – detail each symptom and look at the order of the symptoms to occur and the length of each. Example: when did it start, describe the intensity, what makes it worse or better, what relieves it, etc.
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• Past History (PH) – all prior illnesses the patient has had and the date.
• Childhood diseases
• Surgeries
• Hospital Admissions
• Serious injuries and disabilities
• Immunization record
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• Allergies – all kinds, including any drug reactions they may have had.
• For women only: number of pregnancies, number of live births, date of last menstrual cycle.
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• Family History (FH) – the summary of the health status and age of immediate relatives (parents, siblings, grandparents, children); if deceased, the date, age of death, and cause.
• Hereditary diseases, such as cancer, diabetes, heart disease, kidney problems, mental conditions, infectious diseases.
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• Social and Occupational history (SH) –
• Information related to the type of job, where the patient lives, recent travels, occupational exposures, personal habits and lifestyle:
• Use of tobacco, alcohol, drugs, coffee
• Diet, sleep, exercise, hobbies
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• Marital history, children, home life, occupation, religious convictions
• Resources and support
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Physical Exam
• Usually performed by a physician.
• Part may be performed by a nurse, therapist, PA, or other person.
• Types:
• Inspection – visual observations of the body. Check for rashes, scars, bruises, signs of trauma, deformities, swelling.
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• Many times, for inspection, instruments are used for getting a better look, such as an otoscope or a tongue blade.
• Palpation – by applying the tips of the fingers, the whole hand, placing both hands to a body part to feel for abnormalities and noting any pain or tenderness.
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• Percussion – done by tapping the body lightly, but sharply, with the fingers when looking for the presence of pus, fluid or air / gas in a cavity.
• Percussion hammer can be used when checking the reflexes of a patient.
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• Auscultation – the process of listening to sounds produced internally. Generally, a stethoscope is used. Examples: listening to heart, lungs, abdomen.
• Mensuration – the process of measuring. Includes TPR, BP, Height and Weight.
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• Diagnostic Testing – testing to give the physician a better look at what is going on inside, most likely done after the other parts of the exam.
• Examples include lab work, X-rays, or more invasive procedures such as a heart cath.
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Preparing the patient for the exam
• Patients are usually asked to undress and put on a patient gown.
• Always drape the patients so that they are covered except for the area to be examined.
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Common examination positions:
• Horizontal recumbent (supine) – the patient lies flat on back, with or without a head pillow; legs extended, arms across chest or at sides.
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• Prone – the patient lies facedown, legs extended, face turned to one side and arms above head or along side.
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• Dorsal recumbent – the patient lies on back, knees flexed, soles of feet flat on bed.
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• Knee-chest – the patient is on the knees with chest resting on the bed. The thighs are straight up and down; the lower legs are flat on the bed. The face is turned to one side.
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• Sim’s (lateral) – the patient lies on the left side with the left arm and shoulder front-side down on the bed. The right arm is flexed comfortably. The right leg is flexed against the abdomen; the left knee is slightly flexed.
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• Fowler’s – the back rests against the bed, which is adjusted to a sitting position. the bed section is raised under the knees. A pillow is placed between the patient’s feet and the foot of the bed.
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• Lithotomy – the patient lies on their back. The knees are separated and flexed. Sometimes, the feet are placed in stirrups.
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• Anatomic position (vertical) – the patient stands upright with feet together and palms forward.
• Dangling (sitting) – patient sits upright on the side of the bed, facing the doctor. Feet are resting on a stool or dangling. This is the most common position for exam, depending on their chief complaint.
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Equipment
• The equipment needed for examination will depend upon the type of exam. Some commonly used instruments:
• Tongue depressor• Otoscope• Nasal speculum• Percussion hammer• Opthalmoscope
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• Stethoscope
• Sphygmomanometer (BP cuff)
• Tape measure
• Gloves
• Emesis basin
• Thermometer
• Cotton balls / antiseptic solution
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• Knife handle / blade
• Hemostat
• Curved scissors (Metzenbaum)
• Sponge forceps
• Tissue forceps
• Suture scissors
• Needle holder
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• Hypodermic needle / syringe
• Mosquito forceps
• Towel clips
• Towels
• Gauze strips
• Drape or sheet