2After this lecture the students should understand: The philosophy of clinical examinationThe place of history taking and physical exam in the perspective of professionalismThe characteristics of clinical examination in infants and childrenThe systematic of clinical examination in infants and children
3What is the philosophy? Doctor as a professional must be aware that patients are looking forattention and helpPatients primarily want to be examined by a respected doctor, NOTto be subjected asan object of technology
4Dean, The University of California, San Francisco Professionalism should be taught in medical schools and during residencies. Currently, we do suboptimal jobs in medical schools and a poor job in residencies.We are, I believe, witnessing an improvement in public esteem and trust in the medical profession. Restoration of full trust will require consistent professional conduct in medical students, residents, and practitioners of medicine…….Dr. Haile Debas (2000)Dean, The University of California, San FranciscoPresident of The American Surgical Association
5The core clinical competencies Patient careMedical knowledgeInterpersonal and communication skillsProfessionalismPractice-based learning & improvementSystems-based practice
6What do patients usually want? Patients usually want to berespected as an individual;they are not numbers or evena member of a group of numbers
7So what? Personal and humane approach!! Medicine is the science of uncertaintiesand the art of probabilities
8Clinical exam in infants and children: Why special attention? A child is not a small adult!Keywords: growth and developmentAny information about history, physical, and laboratory / supporting exams should be judged in relation with the child’s stage of growth and development.
10History (Anamnesis) Auto-anamnesis: self reporting by the patient Allo-anamnesis: any information other than by patient (parents, caregiver, referring doctor, previous medical record, previous lab results, etc)
11Advances in medical knowledge & technology do not exclude the importance of clinical assessment Appropriate use of medical technology is based on thorough history & physical examNo laboratory or other exams are performed without appropriate clinical informationNo laboratory or other exams are interpreted without aligning with clinical conditionMastering clinical examination is a must for all doctors caring for patients, from GP to sub-specialist
12Listen to them; they are telling you the diagnosis!!! History: ≥80%Supporting exam: 5%Physical exam 10-20%Listen to them; they aretelling you the diagnosis!!!
13Anatomy of history taking Patient’s identityChief complaintClinical coursePrevious illnessHistory of maternal pregnancyHistory of deliveryFeeding historyImmunization statusGrowth and developmentFamily historyEnvironment
15Points to remember Who provides the patient’s history? (determines your confidence to the information provided)Be patient, create a conducive atmosphereUse ordinary expression instead of medical termsBe sure that the history-giver understands your pointsUse history taking as a method for health educationALWAYS: make footnotes /remarks at the end ofhistory taking
16Should complete history be obtained in all patients irrespective of their illness? A 8-year old girl, 30 kg, 130 cm, 3rd grade of elementary school, repeatedly had good ranking in class. She was brought to the clinic due to 3-day high grade fever, stomach ache, and epistaxis2. A 12-year old boy, basketball player, suspected of suffering from radial fracture.
17It is the patient that should be treated; not the disease RememberIt is the patient that should be treated; not the disease
18Physical examinationIn general similar to that in adults, i.e. to obtain accurate physical status irrespective of the approachNeeds modification due to nature of infants & children:Start with inspectionFollowed by auscultation: abdomen & heartEnd with examination using equipment
19Steps in physical exam General condition Vital signs Anthropometric measurementsSystematic exam
22C. Anthropometric measurements 1. Body length / height: sitting, standing2. Body weight3. Head circumference4. Arm circumference span5. Abdominal circumference6. Nutritional status:W/A, H/A, W/H(plot in standardnormal curve NCHS)
23D. Systematic examination Head and neckChestAbdomenGenitalsExtremitiesSkin, hair, lymph nodesNeurological
24Use of stethoscope Use binaural stethoscope Bell-shaped side: for low & medium pitched soundsMembrane (diaphragm): for medium to high pitched soundsFor heart examuse bell-shaped side firststart without pressure, then with pressureEnd with diaphragm side
25performing examination Common mistakes inperforming examinationHistoryFail to identify the patient firstMake an incomplete historyProvide a disorganized historyPhysical exam:Fail to describe general condition & vital signs firstIncomplete description of features, e.g. pulse rate only or respiratory rate only without further characteristics
26Developmental Approach to Physical Exam in Infants Perform uncomfortable parts of the exam lastComplete the exam with the infant in the parents armKeep the infants warm and coveredObserve general appearance, respiratory rate and effort, overall color
27Developmental Approach to Physical Exam in Toddlers Approach quietly, calmly and slowComplete the assessment wherever the child is comfortableAllow the child to play with your stethoscopeHave a toy or something to distract the childConsider listening to parent or child’s toy to promote comfort
28Developmental Approach to Physical Exam in School Age Clearly explain the plan and expectations before the examinationAnswers the child’s questions honestlyTalk about topics of interest during the examinationThey may be modest, allow them to keep a gown onInclude them in your history taking
29Developmental Approach in Adolescents Questions should be directed at the adolescent and parentBe honestEnsure privacy during the examination and in sharing informationProvide the adolescent with the opportunity to have the parent step out for history and/or examinationProvide reassurance
30ConcludingremarksHistory taking and physical exam skills require good background knowledge and a sound human relation;as a part of medical practice, they are science and artThe art of history taking and physical exam are by nomeans inferior to your scientific knowledge of thedisease under investigationRespect the patient and the family if you want to berespected by them; by and large, respecting eachother is the key for success in medical practice
31How can you be a good examiner? THINK,PRACTICE,PRACTICE!!!