anamnesis status generalis

Society’s Expectation• Physician must be :

• Altruistic• Knowledable• Skillful• Dutiful

achievement

• Basic Med. Skill

• Comunni-cation Skill

Medical Education• Learning Outcome

Basic Medical Skill

1. History Taking2. Physical Examination3. Technical Procedur4. Interpretation of the Results5. Clinical reasoning- deductive6. Emergency and critical care7. Communication Skills

Skills Laboratory

1. Communication Skills 2. Physical Examination Skills3. Therapeutic Skills4. Laboratory Skills

Faculty of Medicine GMU

Pre test Probability

- Prevalence - Ax- PD

Penunjang- Laboratorium - USG- Ro.- dsb

Post test Probability/Clinical Dx.

GoldStandard

Dx. pasti

Decision Analysis :Making Prognosis

Deciding Best Therapy

Clinical Diagnostic Strategies

• Aims :• Labels patient & classifies their illness• Identifies their likely fates or

prognosis

• Propels us toward spesific treatments• Do more good than harm

DISEASE

DERANGEMENT

Anatomic Biochemical Physiological Psycological

E/

The Illness

ExhibitSymptom

Sign

4 strategies of Clinical Dx.

Strategy # 1• = pattern recognition• = gestalt method (considering or

treating what a person experiences and believes as a whole and individual thing )

• Def :• The instaneous realization that patient’s

presentation conform to a previously learned picture/pattern of disease

Strategy # 1

• Auditary - the speech of patient• Odor :

• Diabetec acidosis• Liver failure• Lung abscess

Strategy #2• = the multiple branching method

• Algorithm• Triage

Strategy #3• = “Go do complete hystory &

physical “

• Hystory taking• Physical examination

Strategy #4• = Hypothetico-deductive strategy

• the earlist clues of the patients• Short list of potential Dx/action• History & Physical• Paraclinic(lab., x-ray etc)

From :• Colleague• Teacher

HYPOTHESIS Deduction/Reduce the list

HISTORY TAKINGDr. I Gede Arinton,SpPd,MKom,MMR

The Head of Internal MedicineMargono Soekarjo HospitalMedical Faculty UNSOED

PURWOKERTO

PATIENT DOCTORseekinghelp

to regainor

retain healthT A C K L I N G " T H E F I V E D S " O F H E A L T H :- D I S E A S E

- D I S C O M F O R T- D I S A B I L I T Y

- D E A T H-

D I S S A T I S F A C T I O N

set the stage for :

* making a diagnosis* determining prognosis* carrying out treatment

* promoting health* preventing disease

student learn skills

THE PATIENT'SMEDICAL HISTORY

* D E S C R I P T I O N O F P A T I E N T* C H I E F C O M P L A I N T* H I S T O R Y O F T H E P R E S E N T I L L N E S S* P A S T M E D I C A L H I S T O R Y* S O C I A L A N D O C C U P A T I O N A L H I S T O R Y* F A M I L Y H I S T O R Y* R E V I E W O F S Y S T E M S - - - > P D

History

Taking

Introduction

HISTORYTAKING

PhysicalExamination

Hypothesis

List ofProblem

Dx

• Lab• Special

THE TECHNIQUES OF SKILLED INTERVIEWING• Active listening• Adaptive questioning• Nonverbal communication• Facilitation• Echoing• Empathic responses• Validation• Reassurance• Summarization• Highlighting transitions

Identifying data

• Name• Age• Gender• Occupation• Marital status

CHIEF COMPLAINT • Definition :

• statement of the primary reason for the patient seeking medical attention, often stated in the patient's own words.

• The chief complaint could be :• a pain • a symptom of discomfort • a loss of usual function • troublesome bodily change • a psychiatric symptom

CHIEF COMPLAINT • Why do patients seek care at a

particular time? :1. the symptoms of the illness increase

to the point that they are unbearable and the patient realizes s/he needs help

2. anxiety 3. the symptom in the chief complaint is

sometimes a "ticket of admission" to the physician's office or emergency room;

HISTORY OF PRESENT ILLNESS• an elaborated description of the

patient's chief complaint. • The goal is :

• to obtain a coherent, orderly picture of how the patient's chief complaint developed,

• linking the chronological emergence of symptoms within the overall life circumstances of the patient.

HISTORY OF PRESENT ILLNESS• Most important part of the medical

history, providing the essential information for making the diagnosis.

• Physician works in partnership with the patient to develop an accurate and useful understanding of the illness in the patient's life.

HISTORY OF PRESENT ILLNESS• The Symptom

• Seven Core Dimensions:1. Location:

– Where is the problem located? Does it radiate?

– Can you take one finger and show me exactly where it hurts?


• Seven Core Dimensions:2. Quality :

– What is it like? – How does it feel?– Before we go on further, can you

describe the pain in some more detail? Was it sharp or dull?Did it come and go or just stay there all the time?


• Seven Core Dimensions:

3. Quantity/Severity:

– How bad is it?

– On a 1 to 10 scale, where 1 represents no pain and 10 represents the worst pain.


• Seven Core Dimensions:4. Chronology/Timing:

– When did each symptom or problem begin?

– How did the events unfold? – How often does it occur?– Was this your very first episode of chest pain or

have you ever had chest pain before?What happened next?How frequently are you having the diarrhea?


• Seven Core Dimensions:5.Setting/Context:

– What environmental factors, activities, emotional reactions or other circumstances may have contributed to or led up to the problem?

– Can you tell me what you are doing when you experience this chest pain?Is there anything else that comes to mind about the situations in which these headaches develop?


• Seven Core Dimensions:6.Modifying Factors:

– What makes it better? What makes it worse?

– Can you tell me what tends to decrease the intensity of the pain?Have you tried any medications to control the diarrhea?Have you noticed anything that makes the pain worse?Is your shortness of breath worse when you lie down?


• Seven Core Dimensions:7. Associated Symptoms/

Manifestations: – What other symptoms occur

preceding, coincidentally, or following the primary symptom?

– Pertinent positives and negatives – Organ specific review of symptoms– Do you have any other sensations or feelings

when you have these headaches?Did you notice any pain or discomfort in your jaw or left arm when you experienced the chest pain?

HISTORY OF PRESENT ILLNESS• Tips for Eliciting the HPI :

1.Types of Questions:• Open ended :

− Generally used at the beginning of the interview and throughout.

− " What is the pain like?“

− "Tell me about that".


1.Types of Questions:• Direct :

− To the point. − "What day did the pain start?" − "How many times have you had diarrhea

today?" • Designed :

− to get specific information about a particular point in the history


1.Types of Questions:• Multiple :

− To be avoided. − Questions like "Do you have any change in

bowel or bladder habits, blood in your stool or abdominal pain?"

− By the time you get to the end of the question, both you and the patient have forgotten exactly what you asked.


1.Types of Questions:• Laundry List:

− Somewhat similar to Multiple. − Useful in patients who have difficulty in describing

a symptom. − "Is the pain sharp or dull or burning or throbbing?" − Try the open ended "What is the pain like?" first.


2. Ways to Enhance Communication • Be sure the patient is comfortable. • Be sure you are ready to listen. • Introduce yourself • Be respectful of the patient (Call the patient

by his or her surname unless told otherwise)


2. Ways to Enhance Communication • Facilitate (These are phrases and gestures

that encourage the patient to tell the story, such as leaning forward, nodding your head, saying "go on", or "uh huh"

• Empathize (Put yourself in the patient's shoes. How would you feel?


2. Ways to Enhance Communication • Compassion • Silence • Confront and clarify (If something doesn't

make sense or is contradictory, ask the patient to make it clear

• Reflect or repeat what you have heard or understand back to the patient


2. Ways to Enhance Communication • Use summary statements occasionally • Use transition statements • Use a concluding question or statement :

− "Is there anything else you can think of?“− "Is there anything else that might be important?"

PAST MEDICAL HISTORY • is a record of the patient's past

experiences with illnesses and medical treatments-- information :• adds to the physician' s

understanding of the presenting problem or that leads to diagnostic possibilities to explain the current illness

• PMH often has a great impact on eventual patient management.

FAMILY HISTORY • a systematic exploration of the

presence or absence of illness in the patient's family- information may be helpful in diagnosing the patient's present illness or suggest possible risks for future disease.

PAST MEDICAL HISTORY • Core Elements of the PMH :

1. Childhood Illnesses: • Inquire about serious or chronic illnesses

2. Adult Illnesses: • illnesses in general inquire specifically

about common conditions3. Obstetric/Gynecologic History:

• Female patients • pregnancies and outcomes • miscarriages or abortions


4. Psychiatric Illnesses: • hospitalizations, suicide attempts,

treatments (include dates)5. Surgeries:

• dates, indications, outcomes and complications.

6. Injuries/Trauma: • serious accidents or injuries (include

dates and complications)Hospitalizations:


7. Medications: • hormone replacement and birth control

pils (include dosage and dosing regimen) 8. Allergies/Drug intolerance:

• medication, environmental and food allergies.

• medication side effects


9. Transfusions: • transfusions of blood and blood products

(include dates, units and reactions).

10. Hazardous Exposures: • occupational and home exposures e.g.

any chemicals, dust or fumes at work or at home that might be dangerous?

FAMILY HISTORY • Core Element of the FH :

1. Parents, siblings, and children:

• health status, major illnesses, age at and causes of death

2. Other family members:• genetic factors : diabetes, CAD,

hypertension, cancers, lipid disorders, psychiatric illnesses including alcoholism

• Illnesses similar to the patient's

PHYSICAL EXAMINATION(PE)

INTRODUCTION

ERA OF HIGH TECHNOLOGY

PHYSICAL EXAMINATION ???

INTRODUCTION

• Proper performance of PE :• Routine ordering lab. Test & X-ray --guided by History Taking & PE

• interpretation of result lab.test, imaging, even biopsy -need PE

• Patient’s trust -- PE doctor

The process of examining the patient’s body to determine the presence or absence of physical problems. It includes :

inspection (looking)palpation (feeling)auscultation (listening)percussion (producing sounds )

DEFINITION

• Inspection :• Method of observation used during

physical examinations. Inspection, or

"looking at the patient," is the first step

in examining a patient or body part

Palpation is the method of "feeling" with the hands

during a physical examination Percussion is a method

of "tapping" on body parts with fingers, hands, or small

instruments

Auscultation is a method used to "listen" to the sounds of the body

by using a stethoscope.

HISTORY• Hippocrates (c.460-377BC) :

• the 'Father of Medicine' • by refusing to use gods to explain

illnesses and disease-a science rather than a religion.

• stressed the importance of observation

HISTORY• Leopold Auenbrugger:

• An Austrian physician• the inventor of percussion -by tapping on

the chest with the finger• the lungs wheel percussed, give a sound like a

drum • consolidated, as in pneumonia-= the thigh

is taped. • the heart -dull sound• injected fluid into the pleural cavity, -- by

percussion to tell exactly the limits of the fluid present

• He pointed out how to detect cavities of the lungs, and how their location and size might be determined by percussion

HISTORY• Jean-Nicholas Corvisart:

• Napoleon's personal physician• popularized percussion as a diagnostic

tool• With a picture -Cause of death

• Laenec:• The inventor of stethoscope-a

perforated wooden cylinder one foot long one end of a wooden -listening to the transmitted sound at the other end.

Laennec stethoscope

Piorry Stethoscope

Flexible Stethoscopes

BinauralStethoscopes

ElectronicStethoscopes

http://www.antiquemed.com/laennec1.jpg

http://www.antiquemed.com/lp.jpg

http://www.antiquemed.com/p.jpg

http://www.antiquemed.com/flexible.jpg

http://www.antiquemed.com/al7.jpg

INTRODUCTION

•VITAL SIGN

•SYSTEMIC REVIEW

VITAL SIGN(VS)

INTRODUCTION• VS include the measurement of:

• Temperature• Respiratory rate• Pulse • Blood pressure

• provide critical information ("vital") about a patient's state of health.

INTRODUCTION• In particular, they:

• Can identify the existence of an acute medical problem.

• rapidly quantifying the magnitude of an illness

• how well the body is coping with the resultant physiologic stress.

INTRODUCTION

• In particular, they: • Are a marker of chronic disease

states (e.g. Hypertension)

• To use these values as the basis for management decisions.

VITAL SIGN :• Body temperature• Blood Pressure• Pulse Rate• Respiration Rate

Equipment Needed • A stethoscope • A blood pressure cuff • A watch displaying seconds • A thermometer

http://bcs.medinfo.ufl.edu/sample/images/vs-stethoscope.mov

General Considerations

• The patient should not have had :• Alcohol• Tobacco• Caffeine• Performed vigorous exercise within 30 minutes of the exam.


• Ideally the patient should be:• sitting with feet on the floor

• their back supported.

• The examination room should be quiet and the patient comfortable.


• History of :• hypertension; • slow, rapid or irregular pulse• and current medications

should always be obtained.


• In addition :• peak expiratory flow, • oxygen saturation or • blood glucose level. • etc

Temperature

• can be measured is several different ways: • Oral

•Glass, paper, or electronic •Normal 98.6° F/37° C

• Axillary •Glass or electronic •Normal 97.6° F/36.3° C

Temperature• Rectal (or "core")

•Glass or electronic •Normal 99.6° F/37.7° C

• Aural (in the ear) •Electronic •Normal 99.6° F/37.7° C

• axillary < acurrate rectal • Fever oral 100.5° F/38.5° C or

above.

Pulse

1. Sit or stand facing your patient.

2. Grasp the patient's wrist with your free (non-watch bearing) hand (patient's right with your right or patient's left with your left).

Pulse

3. Compress the radial artery with your index and middle fingers.

• Note :• the rate, • the regularity, • and amplitude of the pulse you are measuring.

Pulse

• Count the pulse for 15 seconds - multiply by 4.

• Count for a full minute if the pulse is irregular.

• A normal adult heart rate is between 60-100 beats per minute.

http://bcs.medinfo.ufl.edu/sample/page03a.html

PulseThe pulse may be palpated of theaccessible arteries :- a. radialis ------> very common- a. brachialis- a. temporalis ---> anesthesiologist- a. dorsalis pedis----> DM- a. carotis -----> aortic pulse wave

Contour

Volume

Rate

Rhytm

- Start with a swift upstroke----> thepeak sys. press.--> followed by a moregradual decline --->- approximately atthe end of vent.sys. ---> sec. & normalupstroke ( dicrotic wave) by the closedaortic valve

Normally impapable( only by

sphygmograph)wher palpable

One wave in sys.and one in dia.

Pulsus Bisferiens:- 2 wave in sys.In :- AI + :

*AS moderate* HSS* Hyperthyroidism

Bounding or Collapsing Pulsus (Corrigan, Water-Hammer pulse):- upstroke-->very sharp- downstroke -> precipitously- pistol-shot soundIn :- HT Ess.+ rigid aorta- Hyperthyroidism- Emotional state- AI- PDA- AV-fistule

Plateau pulse(Pulsus Tardus)- upstroke-->gradual- downstroke -> delayed- best appreciated in a. carotisIn :- AS

The pulse may be palpated of theaccessible arteries :- a. radialis ------> very common- a. brachialis- a. temporalis ---> anesthesiologist- a. dorsalis pedis----> DM- a. carotis -----> aortic pulse wave

Contour

Volume

Rate

Rhytm

Pulsus Altenans:- Rythm- Interval- Pulse wave --->volume >>> & <<<In :- myocardial weakness

Pulsus Bigemini(Coupled Rythm):- Rythm Normal- Interval between member-->shorter

Normal

Pulsus Paradoxus:- Normal: Inspiration--->Sys.fall <10mmHg- Sys.fall >10 mmHg.- Cardiac tamponade

Inequality of Contralateral Pulsus :- Aneurysm- Partial Obstruction

Sinus Rythm : 60-100Sinus Bradycardia : < 60

- AV Block- Athlete

Sinus Tachycardia : >100:-

- Sinus Rythm : 60-100- Dysrythmia :

- Atrial fibrilation- Atrial Flutter- Extra systole

Respiration

• Best done immediately after taking

the patient's pulse.

• Do not announce that you are

measuring respirations.

Respiration

• Without letting go of the patient's wrist begin to observe the patient's breathing.

• Count breaths for 15 seconds multiply by 4

• In adults, N: 14-20 X/minute

Respiration

• Tachypnea- Rapid• Hyperpnea-->Deep : Kussmaul

• Bradypnea-->Slow

• Apnea ---- Absent

• Cheyne-Stokes-apneahyperpnea

Blood Pressure• The room should be quiet and

the patient comfortable. • Position the patient's arm so the

antecubital fold is level with the heart.

(It is best that the arm be support by an armrest or your arm.)

Blood Pressure• Center the bladder of the cuff over

the brachial artery approximately 2 cm above the antecubital fold. Position the patient's arm so it is slightly flexed at

the elbow.

Blood Pressure

• Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate of the systolic pressure.

• Place the stethoscope over the brachial artery.

Blood Pressure

• Inflate the cuff 20 to 30 mmHg above the estimated systolic pressure.

• Release the pressure slowly, no greater than 5 mmHg per second.

Blood Pressure

• The level at which you begin to hear Korotkoff sounds is the systolic pressure.

• Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure.

http://bcs.medinfo.ufl.edu/glossary/k.html#Korotkoff_sounds

Blood Pressure

• Blood pressure should be taken in both arms on the first encounter. If there is more than 10 mmHg difference between the two arms, make a note to always use the reading from the arm with the higher pressure.

Interpretation

• BP should be taken in both arms -- < 10 mmHg difference

• retake the BP ----"w t o t" thi e c a effec .

• In situations auscultation is not possible-SP by palpation alone.

http://bcs.medinfo.ufl.edu/glossary/w.html#white_coat_effect

Interpretation

• Classification :• Normal : < 140/< 90• Isolated Sys.HT : >140/<90• Mild HT : 140-159/90-99• Moderate HT : 160-179/100-109• Severe HT : 180-209/110-119• Crisis HT : > 209/> 119

PROBLEM BASED LEARNING

Introduction

• learning is a strategy for learning

basic science concepts using

problems from clinical practice

Objective• introduce the student in a practical

setting to the thought processes required for solving clinical problems.

• Specifically, we propose :1. to promote active learning 2. to encourage students to think creatively

about medical problems 3. to integrate learning across the basic

science curriculum.

Organization• Internal Department :

• Small Group 7-8 student + Tutor• Monday -decided cases• Wednesday --tutorial• Saturday -case report :

1. patient presentation2. physical examination3. laboratory findings 4. treatment and follow-up

Case Report Form LAPORAN KASUS

Nama Pasien : Nama Mahasiswa

:

Kelamin/Umur : NIRM :

Alamat : Nama Tutor : :

Ruang : Tanggal :

Dirawat sejak :

Case Report Form I.a. Keluhan Utama :b. Masalah :

Case Report Form II. Riwayat Penyakit sekarang, Riwayat Penyakit Dahulu dan

Riwayat Penyakit keluarga yang sesuai dengan keluhan utama

a. RPS ( Ingat 7 dimensi)

b. RPD : Melanjutkan penyakit sekarang Hubungannya dengan tindakan.

c. RPK Penularan Keturunan

Case Report Form III. BUAT HIPOTESIS BERDASARKAN 1 DAN 2 SERTA TERANGKAN PEMBENARANNYA (LITERATUR)1.

2.

3.

Case Report Form IV. TENTUKAN PEMERIKSAAN FISIK YANG DIBUTUHKAN(LITERATUR)

Case Report Form V. HALUSKAN HIPOTESIS DIATAS BERDASARKAN DUKUNGAN DARI PEMERIKSAAN FISIK. JELASKAN BERDASARKAN LITERATUR1.

2.

3.

Case Report Form VI. TENTUKAN KEBUTUHAN LABORATORIUM/PENUNJANG YANG SESUAI(LITERATUR)

VII. BILA HASIL TELAH ADA HALUSKAN LAGI HIPOTESIS(LITERATUR)

1.

2.

3.

Case Report Form VIII. TENTUKAN TERAPI DAN FOLLOW-UP (TERANGKAN PEMBENARANNYA)

1.

2.

3.

4.

5.

IX. TENTUKAN PROGNOSIS BERDASARKAN KRITERIA

Evaluation

Student Activities Yes No

Arrived on time for session.

Prepared assigned learning issue.

Integrated their contributions into session events rather than simply

reading from notes.

Evaluation Provided rationale/explanations for contributions; avoids unsubstantiated “opinion.”

Admitted the limits of their knowledge (Is not afraid to say “I don’t know.”)

Asked for clarification/explanation of topics that are unclear to them.

Was receptive to ideas and contributions of other group members.

Evaluation As part of their participation, connected/integrated the basic science of the case with previously acquired knowledge.

Synthesized or summarized information for the group.

Extended discussion beyond case objectives (e.g., brought in new research findings.)

Demonstrated leadership (e.g., acted to keep the group on task, monitored time, kept comments focussed on discussion topic.)

Evaluation

Actively encouraged the input of other group members

Additional Facilitator Comments:

anamnesis status generalis

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