intro to c e_ sem3 2013.ppt
TRANSCRIPT
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Introduction to Clinical
ExaminationSemester 3 (Year 2)
2010/11
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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.
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The History and Physical
Examination
These skills are the foundation
of clinical practice and should beconsidered part of the basic
science of medicine.
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“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.
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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
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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.
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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
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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
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Physical Examination
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)
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Physical Examination
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
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Physical Examination
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.
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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
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Approach to Physical
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…”
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Approach to Physical
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
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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?
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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?
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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?
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Weight,body habitus and
posture
Obesity,BMI >30.
Any wasting of muscles?
Tall?short? Always observe when the
patient walks into the
examination room.
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Physical Examination
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?”
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Physical Examination
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.)
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Physical Examination
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
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Physical Examination
General examination:
Appearance
Hands Eyes
Mouth
Feet
-part of every systemic examination
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General appearance
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FACIES
Specific diagnosis can be made
by just looking at a patient’s
face.
Some facial characteristics are
so typical of certain diseases
that they immediately suggest
the diagnosis….so calleddiagnostic facies……
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Important diagnostic facies
Acromegaly
Cushingnoid
Down syndrome
Marfanoid Myxoedemetous
Thyrotoxic
Parkinsonism
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Inspection - face
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Acromegaly
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Acromegaly - hands
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Down syndrome
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Cushing’s syndrome
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Inspection – hands and nails
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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
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Inspection – hands and nails
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clubbing
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Nails
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
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Inspection – hands and nails
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Inspection – hands and nails
Beau’s lines
The location of Beau's lines half way up the
nail suggests illness 3 months ago.
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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.
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Inspection – hands and nails
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Plummer-Vinson syndrome
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Psoriasis
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Inspection – hands and nails
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Inspection – hands
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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.
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cyanosis
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Inspection – eyes
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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.
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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
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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
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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
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Normochromic anaemia
Bone marrow failure
-aplastic anaemia
-ineffective haematopoiesis
-infiltration
• Anaemia of chronic disease
-chronic inflammation
-liver disease
-malignancies,chronic renal failure
• Haemolytic anaemia
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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.
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jaundice
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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
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Skin & mucous membranes
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Skin & mucous membranes
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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
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Behcets ulcers
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Gum hypertrophy
phenytoin
pregnancy
scurvy(vitamin C deficiency;
gums become swollen, spongy,
red and bleed easily)
gingivitis; smoking
leukaemia
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Pigmentation in the mouth
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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
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HAIR
ALOPECIA
Non-scarring
- alopecia areta
- scalp ring worm
- traction alopecia
Scarring- burns, radiation, lupoid
erythema, sarcoidosis
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Alopecia areata
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Traction alopecia
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Alopecia totalis
NECK
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NECK
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.
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Lymphadenopathy
SIZE
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.
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Cervical lymphadenopathy
CAUSES OF
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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
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CAUSES OF
LYMPHADENOPATHY
Localized
Local or acute infection
Metastasis from carcinoma or
other solid tumour
Lymphoma
I ti l & h t
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Inspection - general & chest
I ti l & h t
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Inspection - general & chest
I ti l & h t
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Inspection - general & chest
I ti l & h t
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Inspection - general & chest
VITAL SIGNS
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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
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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
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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
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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.
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Sem 3 Module Objectives
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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
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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
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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
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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
OR
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
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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
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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
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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%)
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Thank you.