Whole Patient Encounter May 13

Doorway Information

Relation to Daily Activities: Does it change with your daily activities, like postures, exertion, rest, sleeping, eating, Hunger?

PAST MEDICAL HISTORY Write Name, VS, CC, DDx & mnemonics Knock the Door 3 times, wait 3sec, Go!!! It’s Showtime!!

Introduce Yourself:

Doc: “Mr. Smith?” SP: Yes Doc: "Hi, I am Dr. …., the physician on duty today. It’s nice to meet you (Handshake) Doc: "Is everything ok in the room? SP: Yes Ok now just let me make you more comfortable" (Drape Pt.) Doc: "I hope you don't mind if I sit and take some notes as you speak" Doc: “So Mr. Smith, how can I help you today?” SP: …. “Oh I am sorry to hear that, I will do best to help you”

HISTORY OF PRESENT ILLNESS (HPI) Chief Complaint (cc) Use your mnemonics.

Ostcd LIQuR + AAA

Onset: When did it start? How did it start? Was it all of a sudden or gradually? Setting: What were you doing when it started? Timing: Is it worst in a particular time of the day? Course: Is it getting worse, better or just the same? Duration: Does it come and go? or it’s always there? How often does it come? For how long does it stay each time?”

Location: Can you show me where it hurts? Intensity: How bad is it, on a scale from 1 to 10, being 1 the mildest and 10 the worst pain? Does it interfere with your daily activities?”

Quality: Tell me how does it feel like? Is it sharp? dull? Stabbing? Crampy? Squeezing? Burning?

Radiation: Does it go/ shoot anywhere? Aggravating factors: What brings it on? What makes it worse

Alleviating factors: “What makes it better?” “What has worked for you so far?”

Associated symptoms: “Have you noticed anything else that occurs with it?”” Such us……” “Any thing that you may recall?”

Other CC different to pain:

Before PMH “Now I am going to ask you some questions about your past medical Hx” PAM HUGS FOSS P (PMH) (Déjà Vu) Doc: “Has it happened before?” When? How did you handle it? Did you take any medication? … Doc: “Do you have any other medical conditions?, like High blood pressure, Diabetes, high Cholesterol?... A (Allergies) Doc: “Are you allergic to anything, food or medicine?” M (Medication) Doc: “Are you taking any medications? Prescribed or over the counter? H (Hospitalizations, Surgeries, Injuries, Accidents, transfusions) Doc: “Have you ever been hospitalized? Any surgeries in the past? Any injuries or accidents? Have you ever received transfusions?” U (Urination) Doc: “Have you noticed any changes in your Urinary Habits?” G (Gastrointestinal) Doc: “What about in your Bowel Movements?” S (Sleep) Doc: “Are you sleeping ok?

Before Family Hx “Now I am going to ask you some qs about your Family’s health” “ F (Family Hx) Doc: Does anybody in your family have the same problem? Are there any medical conditions that run in your family? like Diabetes, High blood pressure, Cancer? “Are your parents healthy?” Before Obstetric Hx “Now I am going to ask you some qs about your Obstetric Hx Ok? O (Obstetric Hx) Doc: “When was your last menstrual period LMP? Was it regular? Doc: “How many times have you being pregnant? Any abnormalities or complications? Any miscarriages? At how many weeks? Doc: “How many children do you have? Are they healthy? Doc: “What are you using for birth control?”

Use Qs according to the CC ……… 1

Before Sexual History “Ok Mr. Smith, now I am going to ask you some very personal qs, but let me re-assure you that everything we talk will be kept confidential ok?” S (Sexual history) Doc: “Are you sexually active?” Doc: “In the last year how many sexual partners have you had? Are they male, female, or both?” Doc: “Have you noticed any changes in your sexual function? Doc: “Do you always use condoms?” “Have you ever had any STD Sexual transmitted disease? Did you get any treatment? And your sexual partner? Before Social History Doc: “Now let me ask you some qs about your lifestyle” S (Social history) L SODA WET L “Who do you Live with?” S “Do you smoke?” How many packs a day? For how many years? O “Do you drink Alcohol? What do you drink? How many glasses, beers a day, week? D “Do you use any recreational drugs? What do you use? When was the last time you had it? A “How is your appetite? How is your diet? Any recent weight changes? How many pounds? Over what period of time?” W “What kind of work do you do?” Is it stressful? E “How often do you exercise?” T “Have you recently traveled?”

Finishing Qs & Before Physical Exam “All right Mr. Lee thanks for answering all these questions. Now I’ll need to do your physical exam, so I’ll just wash my hands first. Do you have any questions for me?”

Doc: “Ok Mr. Smith, now let me begin by…” HEENT - HEAD Inspection: Doc: “Ok Mr. Smith, now I am going to start by examining your head, let me look at your head first… Palpation: Doc: “Now I am going to press on some areas on your face, to examine your sinuses, please let me know if you feel any pain.” Conjunctiva: Doc: “Let me check your eyes, can you look up for me please?” TMJ: Doc: “Please bite really hard?” Cranial Bones: Doc: “Now I am going to press on some areas of your skull, if you have any pain just let me know please?” Lymph nodes: NECK

Doc: “Now I am going to check if you have any swollen glands, please let me know if you have any discomfort” Supraclavicular: “Please take a deep breath in, in, in…..out”

Thyroid Gland Doc: “I am going to examine the gland in front of your neck for that I need you to swallow when I ask you, do you need a glass of water? Please swallow? Ok, thanks” EYES:

Dr. Charito. “Grazie”

1) Pocket Snellen Chart

Doc: “Mr. Smith, could you please cover one eye and read the smallest line possible? now with the other eye?” 2) Visual Fields: Remove glasses (yours and pt’s), 2 feet std

Doc: “Could you please cover your right eye, and with your left eye look at my 2

nose only, when you see my finger moving, please say “yes” Doc: “Can you see this, what about here?” SP: Yes/No

Patient (L) Doc(R)

3) Pupillary Response to Light and Convergence Doc: “Mr. Smith, please look ahead, I am going to shine this penlight on your eyes?, Continue to look ahead, as I shine this light from the side” 1st: Look for the Direct Pupillary Reflex 2nd: Look for the Consensual Pupillary Reflex

4) EOM Function: Cardinal Position of Gaze:

Doc: “Mrs. Clark, I’d like you to follow my finger with your eyes only, please do not move your head, follow it out here, here…”, “Now, I want you to watch my finger carefully as I go very close” (Convergence Test) 5) Fundoscopy: Ophthalmoscope Remove yours and the patient’s glasses, prove the light.

Law Of The Right – Right / Left - Left: Doc: “Mr. Clark could you look to a fixed point on the wall please, I am going to check inside your eyes?”, thanks. EARS 1) Othoscope Doc: “Now I am going to check your ears, let me pull your ear first, do you feel any pain, now let me check inside, now the other. 2) Tuning Fork Test: Rinne and Weber Test Doc: “Now I am going to strike this tuning fork on my hand and place it on the back of your ear. Doc: “Can you hear this? Can you hear better now?

Rinne Test

Weber Test

Usually: AC > BC

Doc: Now I am going to place it on the top of your head. Do you feel anything? SP: Yes, vibration

Doc: s it the same in both sides? SP: Yes NOSE Doc: “Mr. X, could you please extend your neck? I am going to lift the tip of your nose to check inside” THROAT - MOUTH Doc: “Mr. X. could you open your mouth for me please?” “Stick out your tongue, move it side to side” (XII Cranial) Now I am going to place this tongue depressor, say Ah (IX and X) you can put your tongue back, thanks.

Cranial Nerves: I∅ II, III, IV, VI done√ “H” VIII. - Vestibulocochlear (auditory) done √ IX & X. - “Say Ah” done √ XII. Done√ V.

Trigeminal

Opht

&

Maxil

Mandible→ S & M

→

S

Sensory Function: forehead, cheeks and jaw Doc: “Mr. X, I’m going to take this gauze pad and touch some places on your face with it, please close your eyes” “Did you feel this… did it feel similar or not?”

VII. Facial Doc: “Smile

for

me

please?”

“Big

Smile” Doc: “Could you frown for me?” XI. Spinal Accessory Grab Pt’s shoulders Doc: “Could you push up your shoulders against my resistance?”

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Auscultation: “Now please, let me listen

LUNGS Doc: “Please let me untie your gown so I can examine your lungs” Palpation: Chest Excursion Doc: “Now I am going to hold your back, please take a deep breath, again, again, ok thanks” Tactile Fremitus: Doc: “Could you cross your arms in front? Please say 99 every time I place my hands?” 99?, again, again…”

to your bowel sounds” Liver Palpation: Look at the pt’s face expression. Light palpation: One hand. Doc: “Any tenderness here?”(6 points)

Check the reno ureteral points for pain. Deep Palpation: 2 hands, rolling motion.

Doc: “Any tenderness (pain) here? Here?” Doc: “I know it feels a little uncomfortable, but if you feel pain please let me know” Special palpation: Liver, Spleen. Liver Palpation

Doc: “Take a deep breath in … out” Percussion Auscultation Percussion: Doc: “I am going to tap on your back” Auscultation: Warm the Stethoscope Doc: “I am going to listen to your lungs, please open your mouth and take a deep breath, in and out through your mouth”, again, again…” “Ok, now breath normally, Thanks.” HEART Palpation: Doc: “Now please lean forward, let me check your heart” First, I am going to press on some areas on your chest to feel your heart impulse”

Aortic Area: 2° ICS (Left), Pulmonary Area: 2° ICS (Right) Tricuspid Area: 3° ICS (LLSB) Mitral area: 5° ICS & Midclavicular Left Line

Spleen

Special Tests

Murphy’s Sign → Cholecystitis

Doc: “I am going to press on the right side below your ribs to feel your liver, please take a deep breath in, in … out. Thanks.” Any pain?” SP: yes (+) Murphy Appendicitis

Mc Burney →

Doc: “Now I am going to press on the left lower side of your belly, please let me know if you feel any pain?” Rovsing's Sign.- (contra lateral pain)

Doc: “I am going to press on this side, where do you feel the pain, ? Rebound Tenderness.- pain when removing the pressure (Peritonitis)

Doc: “Now I am going to do a deep palpation, when do you feel more pain, now or now. Psoas sign.right thigh

Auscultation: On 4 cardiac areas Doc: “Please lean forward”

Left to the navel.

Pain on passive extension of the

Doc: “Mr. X, please lay on your left side, I am going to extend your right leg backwards while pressing on your right hip. Do you feel any pain?

“ABDOMEN” Inspection:

Doc: “Mr. X, let me uncover your belly to examine it” “Could you please turn your head to the other side & cough for me?”

Psoas Obturator Obturator sign. – Passive internal rotation of the flexed thigh

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Doc: “Mr. X, I am going to move your leg to the side while I press on the side of your knee, do you feel any pain?

Extremities Radial & Brachial Radial & Femoral Pulses: (if thinking on Coarctation of Ao) Popliteal Pulses: place thumbs on the patella.

Post Tibial Pulses: press malleolus

fingers against

Dorsalis Pedia Pulses:

“Neurological Exam”

Mental Status Cranial Nerves √ Sensory function Motor function - Reflexes - Cerebellar function

Mental Status Quick Minimental Doc: “Mrs. Smith, I am going to ask you few questions to asses your attention and memory ok?” Orientation: • Can you please tell me your full name? • What is the date today? • Can you tell me what city are we in? Where are you now? Memory: • Mrs. Smith please say these words: boat, table & pencil. (Immediate recall). I am going to ask you to recall these words later ok. Attention & Concentration: • Now spell the word "WORLD" backwards for me please? Language Test • Can you close your eyes put your hands together and bring them on to your belly and then on to your back? * Mrs. Smith I want you to recall the 3 words that I told you few minutes ago. (Delayed Recall) Spatial Ability: • Can you copy the following drawing?

Sensory Function: Position Sense: Proprioception Doc: “Mr. X, could you close your eyes and tell me where did I just touch you?”…….. Hand, foot, Doc: “Did that feel similar?” Hold the finger

Doc: “This is up and this is down” Doc: “Tell me, what is this?” SP………. Vibration: Use the Tuning fork Doc: “Close your eyes please? Do you feel anything?” What do you feel?”… Vibration

Doc: What about now? Doc: “Stronger now? Weaker? Or the same?” toes. Sharp and Dullness: Doc: “Close your eyes, this is dull and this is sharp” Doc: “What is this?” “Sharp or dull?” Upp & Low limbs

Reflexes DTR Biceps

Patella (Knee)

Achilles

Motor function Upper Limbs

Doc: “Grip my hand, don’t let me go… relax” Doc: “Make a fist. Don’t let me open, relax” Doc: “bring your arms in front, palms up like this, don’t let me push you down, now palms down, don’t let me push up… ok relax” Lower Limbs

Doc: “Push your legs forward against my resistance, now backwards…relax now ” Cerebellar function Finger to Nose Test Doc: “I am going here, please touch touch your nose”, while I move my positions” Romberg test

to place my finger my finger and then now do the same finger in different

5

Doc: Please stand still with feet together and open your arms aside . Close your eyes and balance yourself. Don’t worry I will be behind you in case you need some assistance. Examination of Gait Doc: “Walk towards me; now, on your toes, now on your heels”… thanks. “Walk, one foot in front of the other in a straight line”

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