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.”

- Harrison’s Principle of Medicine

PATIENT – PHYSICIAN /

DOCTOR RELATIONSHIP

Individuals whose problems often

transcends their complaints

Whatever the patient’s 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

patient’s concern and do something about it

HOW TO

EVALUATEI. PATIENT HISTORY

• “build” a history rather

than “take” one

OBJECTIVES:

• identify problems

• to establish a sense of the patient’s

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. General data

2. Chief complaint

3. History of present illness

4. Past medical history

5. Family history

6. Personal and social history

7. 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 patient’s

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 non-

surgical 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 patient’s

• 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 “pack-years”

• SEXUAL HISTORY

• OCCUPATION: description and

duration of employment; exposures to

toxins (e.g. lead, arsenic, asbestos)

• RELIGIOUS AND CULTURAL

PREFERENCES

Review of SystemsIdentify 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 HISTORIES1. 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

• The results should be recorded at the time they

are elicited

• Repeat the physical examination as frequently

as the clinical situation warrants

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

PARTS OF PHYSICAL

EXAMINATIONS

1. Measurement of Vital Signs: baseline

indicators of a patient’s 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 patient’s 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. Respect the patient.

2. Achieve the complimentary forces of

competence and compassion.

3. The art and skill essential to history

taking and physical examination are the

bedrock of care; technologic resources are

complements

4. The history and physical examination are

inseparable – they are one.

5. The computer cannot replace you, it is

what you do that builds a trusting, fruitful

relationship with the patient.

6. The relationship can be indescribably

rewarding.

THANK YOU!!!