SOCM Overview: Physical Exam and History Taking …slides.jsomtc.org/SOMPYL11/SOMPYL11.pdf · SOCM Overview: Physical Exam and History Taking ... Given a lecture in a classroom ...

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Slide 1JSOMTC, SWMG(A)

SOCMOverview: Physical Exam

and History Taking PFN: SOMPYL11

Hours: 3.0


Terminal Learning Objective Action: Communicate knowledge of “Overview: Physical Exam and History Taking"

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% IAW course standards on the formative quizzes and the Physical Exam Practical Test grade sheet


References

Bates’ Guide to Physical Examination And History Taking (11th edition; 2013; Lynn S. Bickley)

Evidence‐Based Physical Diagnosis (3rd

edition; 2012; Steven McGee)

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Reason

As a SOF medic, you may find yourself in austere environments that will limit your medical resources and test your diagnostic capabilities. Your ability to obtain patient history, perform a thorough physical exam and come to a correct diagnosis may save your patient's life.


Agenda

Identify the components of a Comprehensive Physical Exam

Communicate the Techniques of a Patient interview and Head‐to‐Toe Exam

Identify the basic concepts of evidence‐based medicine and clinical reasoning

Identify the components of a clear and accurate SOAP note


The Components of a Comprehensive Physical Exam

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Comprehensive Physical Exam

Determining the scope of your assessment

Comprehensive

• appropriate for new patients (provides baseline)

• can be time‐intensive

• suitable for enlistment screening (e.g., UW, FID, etc.) and special schools (e.g., MFF, scuba, Ranger, etc.)

Focused

• problem‐oriented assessment

• generally restricted to a specific body system

• applies same techniques as comprehensive exam



SOAP Format

Subjective

• interview (history) – all the patient tells you

• often under‐stressed!

Objective

• physical exam – your detections

•methodical approach to reduce omissions

Assessment – diagnosis (include differentials)

Plan – treatment (include follow‐up tests/visits)



Prepare for Success

Follow personalized sequence of exam

Check all equipment

Remain professional

Document everything

• this includes negative findings as well as positive

• assure modesty, privacy, and accountability

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Comprehensive Exam

Identification

Chief complaint(s)

History of present illness

Past medical history

Family history

Social history

Review of systems


Comprehensive Exam

Identification (ID)

Data

• age, gender, occupation, marital status

• primary physician and/or guardian if applicable

Source

• usually the patient

• can be family member, friend, medical records, etc.

Reliability – varies according to the patient's memory, trust, and mood


Comprehensive Exam

Chief Complaint (CC)

Reason for visit

• could be one or many

• could be simply for check‐up or screening

Should be brief

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Comprehensive Exam

History of Present Illness (HOPI/HPI)

Further develops CC

OPQRST

•Onset – general duration? (e.g., acute, chronic, etc.)

• Provocation/palliation – what makes it worse/better?

•Quality – “feels like…” (e.g., sharp, nauseating, etc.)

• Radiation – does it extend to other areas?

• Severity – 0 to 10 (for future reference)

• Time – how long? (possible intervals)


Comprehensive Exam

HOPI (cont.)

SAMPLE

• Signs/symptoms – associated with the CC

• Allergies – drug, food, environmental, etc.

•Medications – prescribed, OTC, supplements, etc.

• Past pertinent history – detailed history of CC

• Last oral intake – food & drink (include ETOH/H2O)

• Events leading up to illness/injury


Comprehensive Exam

Past Medical History (PMHx)

Past relevant illnesses/injuries

Past major illnesses

Childhood illnesses

Past surgeries

Immunizations

Current ongoing illnesses (e.g., DM, HIV, etc.)

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Comprehensive Exam

Family History (FHx)

Age/health or age/cause‐of‐death

• blood siblings

• parents

• grandparents

Presence/absence of specific illnesses

• could point to cause of CC

• examples: HTN, CAD, type 2 DM


Comprehensive Exam

Social History (SHx)

Living arrangements

Number of children (female: GPA)

Drug use

• includes tobacco, ETOH, recreational drugs, etc.

• includes quantity and frequency

Foreign travel

Recent activities/exposures

Sleep


ROS

Review of Systems (ROS)

Constitutional

• generally non‐specific

• weight loss, malaise, fever, fatigue, etc.

HEENT

• changes in vision can be a key indicator

• epistaxis, sinus pn, tinnitus, sore throat, etc.

CV

• heart – chest pn, orthopnea, palpitations, etc.

• peripheral – claudication, edema, etc.

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ROS

Resp

• association with CV could be unknown to pt

• coughing, wheezing, SOB, exercise intolerance, etc.

GI

• common: diarrhea, constipation, abd pn, anorexia, etc.

• red flags: hematemesis, hematochezia, melena, etc.

GU

•male: testicular pn, decreased force of stream, etc.

• female: LMP, dysmenorrhea, contraception, etc.

• both: incontinence, dysuria, hematuria, etc.


ROS

MSK

• symptoms often change over time

• pn, decreased ROM, stiffness, joint swelling

Integ

• should include recent minor abrasions/lesions

• pruritus, rashes, eczema, excessive dryness, etc.

Neuro

• symptoms may appear in other systems

• HA, seizures, disequilibrium, higher mental functions, numbness/weakness/paresthesia, etc.


ROS

Psych – depression, anxiety, sleep patterns, etc,

Endocrine

• thyroid – sweating, cachexia, skin/hair, etc.

• diabetes – polydipsia, polyuria, polyphagia, etc.

• adrenal – orthostatic symptoms, etc.

Blood/lymph – prolonged/excessive bleeding, petechia, etc.

Allergic/immune – unusual sneezing, swollen lymph nodes, rhinorrhea, etc.

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The Techniques of a Patient Interview and Head‐to‐Toe Exam


Interviewing Techniques

Approaching an Interview

Review medical records

• this may require leg‐work

• have medical records translated if necessary

• ensure you properly continue patient records



Approach (cont.)

Prepare clinical setting

• safe setting for yourself/patient is priority

• ensure proper lighting

• prepare any privacy requirements

• procure an interpreter if necessary (medical knowledge is preferred)

• procure a chaperone if necessary

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Difficult Patients

Different levels of education/capacity

• include low literacy, vision/hearing impaired, etc.

• explain in simple terms, but avoid being perceived as condescending

• pts with medical knowledge can be a challenge

Altered compliances

• can range from silent pts to angry pts

• informed consent is ethical, not just U.S. law



Difficult Topics

Remain objective and non‐judgmental

Sexual history

• especially sensitive in women (but not exclusively)

• attempt to isolate pt if guardian is present

Mental health history

• can be perceived as a stigma

• emphasize confidentiality (esp. in teammates)

• in poor countries, this frequently presents as a Hxof “communicating with the spirit world”



Difficult Topics (cont.)

Alcohol and illicit drug use

Family violence

•maintain cultural awareness

• be perceptive of key indicators

injuries that are unexplained, recurring, inconsistent with Hx, etc.

these do not always indicate abuse!

Death and the dying patient (5 stages)

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Cultural Differences

Imperative: maintain self & cultural awareness!

• local culture dictates acceptable behavior

•mistakes can quickly lead to lost rapport

Can differ greatly amongst people & areas

• area studies should include differences in culture

•many differences can occur within a small area



Cultural Differences (cont.)

Culture – the total of inherited ideas, beliefs, values, and knowledge, which constitute the shared bases in a society

Ethics – the rules of conduct recognized in respect to a particular culture

Morals – the personal and variable principles of right and wrong


The Techniques of a Head‐to‐Toe Exam

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Head‐to‐Toe Exam Techniques

Inspection

Auscultation

Palpation

Percussion



Inspection (appearance, behavior, mvmt)

Physique, posture, contours, clothing

Symmetry, deficits, patterns, color

Facial expression, mood, eye movements

Manner of speaking & potential guarding

Gait & off‐setting movements

Respiratory variations

Tremors, tics, spasms



Auscultation

Not restricted to the lungs and heart!

Stethoscope

• diaphragm

primarily transmits high‐pitched frequencies

generally ideal in almost all situations

• bell – primarily transmits low‐pitched frequencies

• highly dependent on the model of stethoscope and operator expertise

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Palpation

Elevation/depression/deformities

Temperature

Tenderness

Lymph nodes

Pulses

Crepitus in the joints

Contours & sizes of organs/masses



Percussion

Results vary greatly by patient and expertise

Technique

• use of a plexor to tap/strike the pleximeter

• evokes a subtle sound wave (e.g., resonance, dullness, etc.)

Only appropriate in quiet, controlled settings



Notes on IAPP/IPA/etc.

Generally follow the rule “least invasive to most invasive”

Order of progression differs depending on the system being examined

• lungs – inspection, auscultation, palpation, palpation

• abd – inspection, auscultation, light palpation, deep palpation, percussion of liver span

•msk – inspection, palpation, active ROM, passive ROM, against resistance

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Head‐to‐Toe Exam

General Survey / Vital Signs

Skin, Hair, & Nails

Musculoskeletal

Neurological

Head, Ears, Eyes, Nose, & Throat (HEENT)

Thorax and Abdomen

Reproductive



General Survey / Vital Signs

General appearance

• begins the moment you encounter the pt

• note level of consciousness

Apparent state of health

• skin color

• build

• body symmetry

• dressing, grooming, and hygiene



General Survey / Vital Signs (cont.)

Apparent state of health (cont.)

• facial expressions

• body odors

• posture, gate, motor capability

• signs of distress

Vital signs

• P/R/BP at a minimum! (don’t forget about qualities)

• consider SpO2, Temp, orthostatics, cap refill, and pain scale (if appropriate)

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Skin, Hair, and Nails

Skin

• correct lighting can be paramount!

consider amount and position

different types (i.e., natural vs. artificial)

• thorough inspection required

any little thing missed can be huge

check color, moisture, temp, texture, mobility/turgor, moles/lesions

• ensure patient modesty when appropriate



Hair

• include head and body

• note amount, pattern, distribution, texture, etc.

Nails

• include fingers and toes

• findings can be genetically, pathologically, and/or habitually related



HEENT

Head and face should be checked for general abnormalities and trauma

Eyes (including fundoscopy)

• visual acuity (OU, OD, and OS)

• shape and reactivity of pupils (before & after PERRL)

• extraoccular movements (EOM: LR6, SO4, R3)

• color and clarity of sclera

• fundus and microcirculation

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Ears, to include the tympanic membrane (TM), should checked for impaction and inflammation

Nose should be checked for patency and deviation

Throat should be examined for abnormalities

Also included mouth, teeth, and neck!


PMH Matters

Patient reports a history of going SCUBA diving 3 days prior. Patient states he completed one dive in salt water which was to 55 feet for 30 minutes.



Thorax and Abdomen

Chest and Lungs

• symmetry, work of breathing, and tenderness

• auscultation and percussion of multiple fields

Heart (CV)

• auscultation of rate, rhythm, and heart sounds

•manual blood pressure

• peripheral circulation and pulses

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Abdomen (Abd)

• Inspection of contours and abdominal muscle tone

• Auscultation of bowel sounds in multiple fields

• Light and deep palpation for aorta, liver, landmarks and abnormalities

• Percussion of liver span and possible for spleen

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Musculoskeletal (MSK)

Inspection and palpation of joints and landmarks

Active range of movement (ROM) & strength for all extremities/spine

Passive ROM & special tests



Neurological

Mental status – more than just A&Ox3!

Cranial nerves (CN I – XII)

Cerebellar function

Muscle tone and strength

Sensory perception

Applicable reflexes (e.g., DTRs, Babinski, etc.)



Reproductive

Breast – always have chaperone present

Female genitalia (see above)

• inspect and palpate external genitalia

• inspect internal genitalia with speculum and perform bimanual exam (don’t forget the anus)

Male genitalia

• inspect and palpate the dangling participles

• perform digital rectal exam (DRE)

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Key Points

Generally, focused PE will not require an examination of most of the organ systems

The ability to recognize “normal” helps to catch the “abnormal”

Findings may present differently in healthy patients (i.e., “normal” is only relative to each individual)


The Basic Concepts of Evidence‐Based Medicine and

Clinical Reasoning

Patient History

Physical ExamDia

g.

Patient History

Physical ExamDiagnostics

"Normal" U.S. Healthcare Provider SOCM


Evidence‐Based Medicine

Evaluating Clinical Evidence

Patient history, physical exam findings, & diagnostic results are inherently imperfect

Gold standard

• the most accurate and precise test possible

• usually MRIs, arthroscopy, endoscopy, etc.

Alloyed gold standard

• best available test under constrained conditions

• SOCM often must rely on these tests/combinations

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Understanding the Evidence

Reliability

• indicates how well repeated measurements yield the same result

• often associated with the precision of a test

• intra‐observer reliability vs. inter‐observer reliability

Validity

• indicates how closely a given observation agrees with “the true state of affairs”

• often associated with the accuracy of a test



Validity (cont.)

• Sensitivity

identifies the proportion of people who test positive in a group of people known to have the disease or condition

“SnNout” – when sensitivity is high, a negative result rules out a disease/disorder

positive results may mean very little



Validity (cont.)

• Specificity

identifies the proportion of people who test negative in a group of people known to be without a given disease or condition

“SpPin” – when specificity is high, a positive result rules in a disease/disorder

negative results may mean very little

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Test Findings

True positive – correctly identified (sick people correctly diagnosed as sick)

False positive – incorrectly identified (healthy people incorrectly diagnosed as sick)

True negative – correctly rejected (healthy people correctly identified as healthy)

False negative – incorrectly rejected (sick people incorrectly identified as healthy)



Predictive values

• based on the prevalence of a disorder in a defined population (i.e., can change in different AOs)

• “positive” predictive value – probability that a positive result reflects the condition being tested

• “negative” predictive value – probability that a negative result reflects a health individual


The Process of Clinical Reasoning in

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Clinical Reasoning

Identify the Problem

Develop a Hypothesis

Test the Hypothesis

Establish a Diagnosis (Dx and DDx)

Develop a Plan


Clinical Reasoning

Identify the Problem

Identify abnormal findings

Localize the findings anatomically

Interpret findings in terms of a probable process

Make hypotheses about the nature of the problem


Clinical Reasoning

Develop a Hypothesis

Select the most specific and critical findings

• e.g., "sudden pain in my right shoulder while throwing a football".

•match the findings against any conditions that could produce them

• e.g., pain could be caused by a muscle strain, early osteoarthritis, was there trauma involved, prior injuries, over use / repetitive use injury. Asking the right questions will help.

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Clinical Reasoning

Develop a Hypothesis (cont.)

Eliminate the diagnostic possibilities that fail to explain the findings

• e.g., which special tests will identify AC injury, torn labrum or rotator cuff injury? Patient has a positive O'Brian's test, relieved with 2nd test

• weigh competing possibilities

• statistical probability of a given disease by:

age, sex, ethnicity, habits, lifestyle, and locality


Clinical Reasoning

Develop a Hypothesis (cont.)

Weigh competing possibilities (cont.)

•initial onset of Injury / illnesse.g., patient had a shoulder injury at age 16. At age 21 while wrestling in college, experienced sudden sharp shoulder pain with a loud popping noise. Pain subsided after several weeks of rest and rehab. (Always, get a good history)


Clinical Reasoning

Give special attention to potentially life‐threatening and treatable conditions

minimize the risk of missing the “zebra”

rule of thumb for differential diagnoses

always include “worst case scenario"

Test the Hypothesis

Gather additional information through:

• history

• physical examination

• laboratory results

• radiology

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Clinical Reasoning

Establish a Diagnosis

Use highest level of explicitness and certainty that the data allows

• symptoms may be broad or limited

e.g., “repetitive use injury, cause unknown”

• explicit problems

e.g., “bicipital tendonitis, and torn labrum”

Include multiple differential diagnoses (DDX)


Clinical Reasoning

Develop a Plan

Must be logical management from the diagnosis

Specify further necessary steps

• ancillary testing

• consultation

• additions, deletions, or changes to medication


Clinical Reasoning

Develop a Plan (cont.)

Note any education that was provided

Remember to consult with the patient to ensure comprehension and compliance

The plan should always be within your scope of practice!

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The Components of Clear and Accurate Records


Clear and Accurate Records

Recording your Findings

An important adjunct to patient care

Will evolve with increased knowledge

Organization is essential

• order and readability for future providers

• include all details during the exam

builds your examining skills

extremely time consuming and often compromised due to workload



Checklist

Is the order clear?

•make the headings clear

• accent your organization with indentations and spacing

• arrange the “present illness” in chronologic order

start with the current episode

then fill in relevant background information

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Checklist (cont.)

Does the data included contribute directly to the assessment?

Are pertinent negatives specifically described?

Are there overgeneralizations or omissions of important data?

Is there too much detail?

Are phrases and short words used appropriately and is there unnecessary repetition of data?



Checklist (cont.)

Is the written style succinct? Are there excessive abbreviations? Are the abbreviations well known or customary for your “clinic?”

Are diagrams and precise measurements included where appropriate?

Is the tone of the write‐up neutral and professional?


The SOAP Note

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SOAP Note

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Questions?

Don't you wish everything in medicine was this obvious?


Terminal Learning Objective

Action: Communicate knowledge of “Overview: Physical Exam and History Taking"

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


Agenda

Identify the components of a comprehensive physical exam

Identify the Techniques of a Patient interview and Head‐to‐Toe Exam

Identify the basic concepts of evidence‐based medicine and clinical reasoning

Identify the components of a clear and accurate SOAP note

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Reason

As a SOF medic, you may find yourself in austere environments that will limit your medical resources and test your diagnostic capabilities. Your ability to obtain quality patient history, perform a systematic physical exam and come to a correct diagnosis may save your patient's life.


Break

SOCM Overview: Physical Exam and History Taking …slides.jsomtc.org/SOMPYL11/SOMPYL11.pdf · SOCM Overview: Physical Exam and History Taking ... Given a lecture in a classroom ...

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