Transcription

PATIENT HISTORY&PHYSICAL EXAMINATION

Making a diagnosis1. Anamnesis history taking2. Physical examination – inspection, palpation, percussion,auscultation, vital signs, weight, height3. Working diagnosis - preliminary dg., diff. dg. considerations4. Further diagnostic examinations – lab, endoscopy, X-ray, EKGetc.5. Final diagnosis6. Therapy

Making a diagnosis1. Anamnesis history taking2. Physical examination – inspection, palpation, percussion,auscultation, vital signs, weight, height3. Working diagnosis - preliminary dg., diff. dg. considerations4. Further diagnostic examinations – lab, endoscopy, X-ray, EKGetc.5. Final diagnosis6. Therapy

Patient history Generally– Summary of all data regarding the patient’shealth from birth to present.– Direct vs. indirect Rules:1.Create an atmosphere of confidence and trusta)b)c)2.3.PrivacyComfortable environmentEliminate haste/stressAsk open questionsLet the patient choose his/her own words

Patient history1.Personal data 2.3.Chief complaintSocial status 4. Skin, head, eyes, ears, nose, mouth, throat, respiratory tract, cardiovascular lymphatics, GIT, urinary tract, genitalia, locomotor, nervous, psychologicalstate, endocrine, allergiesNatural functions: voiding, defecation, eating habits/weight changes, sleepStimulantia 7.Family illnesses – parents, siblings, childrenPrior illnesses – in chronologic order. Duration, treatment, complicationsPresent illnesses – onset, symptoms, course of symptoms, present statusReview of systems 6.occupation, family, daily function, Medical historya)b)c)5.name, address, date of birth, referring physician, next of kinTobacco, alcohol, drug abuse etc.Medication All drugs, strength, doses, duration

Physical examination Basic methodsA. Inspection B.Palpation C.Pigmentation, asymmetry, oedemas, scarsLesions, erythemas, hematomas etcSkin, muscle tonus, temperature, moistureSuperficial vs. deepPain, massesPercussion Indirect percussion – “ finger on finger”Superficial vs. deepQuality of sound: resonance, hyperresonance, tympanity, flatness, dullnessBordersD. Auscultation E.Indirect – stethoscope with membrane and bellHeart, lungs, intestines, vesselsSmell Hygiene, ketoacidosis, alcohol, bad breath, foetor hepaticus

Physical examination General examination (general impression)– Mental state, voice, speech, nutrition, posture, walk Skin– Pigmentations, rashes, moisture, elasticity– Scars, hematomas, hemorrhages, erythemas Head–––––Direct percussion of skullCN V exit points – tenderness?CN VII – make grimacesCN XII – protrude tongueEyes: conjunctiva, pupils round and equal (CN III) – anisocoria?, symmetricaccommodation reflex and reaction to light, movements, eyelids– Mouth: teeth (prostheses), moist and clean mucosa and tongue, central cyanosis Neck–––––StiffnessVenous congestionPalpable gl. thyreoideaCarotid stenosisLymph nodes

Physical examination Thorax– Normal shape and movements, breathing– Breasts description in women 40 years Tenderness, masses, skin changes symmetry of areolae, discharge– Axilla Lymph nodes– Heart Normal heart sounds, clean tones, no murmurs, respiratory arrhythmia– Lungs Breathing sounds (stridor?) and frequency, resonant percussion, borders Auscultation sounds - alveolar vs. tubal breathing, wet or dry sounds, frictionmurmur Spine– Pain, stiffness, asymmetry – lordoses/ kyphoses/ scolioses– Ex. Schober’s distance test, Stibor’s distance test

Physical examination Abdomen– Symmetry: any signs of enlargements or masses? Hernia?– Dilated veins – caput medusae– Palpation: texture, tenderness/pain?, palpable spleen or liver? –borders, palpable masses or possible tumors? Appendicitis: Rowsing’s sign – palpation of LEFT hypogastriumPlenie’s symptom – percussion tenderness of right hypogastrium»––––Percussion: borders of liver/spleen, tympanites?, ascites?Direct percussion of flanks – kidney tenderness?Auscultation: intestinal soundsUrinary bladder

Physical examination Ext. genitalia– tumors, rash, discharge, pain– Testes Rectal exploration– normal tonus of sphincter, tumors– Prostata: size (walnut), shape, consistency– Brown faeces on glove

Physical examination Upper extremities– Radial pulse– Raynaud’s phenomenon (SLE)– Finger clubbing Lower extremities––––Pulse of a. dorsalis pedis and a. tibialis posteriorIschemia – diabetic microangiopathyEdema, varicose veinsLymphedema - elephantiasis

Physical examination BASIC NEUROLOGICAL EXAMINATIONA. Cranial nerves N. olfactorius: rarely examined, smellN. opticus: normal visual fields, read letters on table, ophtalmoscopyN. oculomotorius: round pupils, reaction to light and accommodationN. trochlearis: no ptosis, paresis, deviation, nystagmusN. abducens: no pareses, double vision, movements (follow the finger),normal saccadic movementsN. trigeminus: normal sensibility for pain and touch in all three branchesN. facialis: Asymmetry of face, normal force of muscles of forehead, eyes,nose, mouth. Sentral vs. peripheral paresisN. vestibulocochlearis: Normal hearing, conduction through air better thanthrough boneN. glossopharyngeus & vagus: normal voice, swallowing, elevation of uvulaand soft palateN. accessorius: turn head and lift shoulders symmetrically against resistanceN. hypoglossus: no deviations upon protrusion of tongue, normal speech

Physical examinationB. Mobility Bradykinesia, dyskinesia, akinesia, tremors Rigidity, spasticity, hypotonicityC.Force Muscle force over joints: shoulders, elbows, fist, hip, knee, ankleTempo and fine motor skillsD. CoordinationE. Reflexes F.Each sideBiceps, triceps, radialPatellar, achilles, plantarSensibility Normal sensibility for pain, touch and temperatureG. Balance and walking Normal walk, stand on heels and toes, rise up from crouching position