Presentation on theme: "After this lecture the students should understand: The philosophy of clinical examination The place of history taking and physical exam in the perspective."— Presentation transcript:
After this lecture the students should understand: The philosophy of clinical examination The place of history taking and physical exam in the perspective of professionalism The characteristics of clinical examination in infants and children The systematic of clinical examination in infants and children
What is the philosophy? Doctor as a professional must be aware that patients are looking for attention and help Patients primarily want to be examined by a respected doctor, NOT to be subjected as an object of technology
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 Francisco President of The American Surgical Association
The core clinical competencies 1.Patient care 2.Medical knowledge 3.Interpersonal and communication skills 4.Professionalism 5.Practice-based learning & improvement 6.Systems-based practice
What do patients usually want? Patients usually want to be respected as an individual; they are not numbers or even a member of a group of numbers
So what? Medicine is the science of uncertainties and the art of probabilities Personal and humane approach!!
Clinical exam in infants and children: Why special attention? A child is not a small adult! Keywords: growth and development Any information about history, physical, and laboratory / supporting exams should be judged in relation with the child’s stage of growth and development.
The diagnostic paradigm: History Physical Routine lab Special investigations
History (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)
Advances in medical knowledge & technology do not exclude the importance of clinical assessment Appropriate use of medical technology is based on thorough history & physical exam No laboratory or other exams are performed without appropriate clinical information No laboratory or other exams are interpreted without aligning with clinical condition Mastering clinical examination is a must for all doctors caring for patients, from GP to sub-specialist
Listen to them; they are telling you the diagnosis!!! History: ≥80% Supporting exam:5% Physical exam 10-20%
1.Patient’s identity 2.Chief complaint 3.Clinical course 4.Previous illness 5.History of maternal pregnancy 6.History of delivery 7.Feeding history 8.Immunization status 9.Growth and development 10.Family history 11.Environment Anatomy of history taking
Present Clinical course Birth Prenatal Birth Nutrition, immunization, growth & development Past history , 6, etc 11
Who provides the patient’s history? (determines your confidence to the information provided) Be patient, create a conducive atmosphere Use ordinary expression instead of medical terms Be sure that the history-giver understands your points Use history taking as a method for health education ALWAYS: make footnotes /remarks at the end of history taking Points to remember
1.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 epistaxis 2. A 12-year old boy, basketball player, suspected of suffering from radial fracture. Should complete history be obtained in all patients irrespective of their illness?
Remember It is the patient that should be treated; not the disease
In general similar to that in adults, i.e. to obtain accurate physical status irrespective of the approach Needs modification due to nature of infants & children: Start with inspection Followed by auscultation: abdomen & heart End with examination using equipment Physical examination
Steps in physical exam General condition Vital signs Anthropometric measurements Systematic exam
A. General condition 1. Consciousness: alert, apathetic, somnolent, soporous, comatous 2. Appearance: health, mild / moderate / severely ill, distressed 3. Color : pale, jaundiced, cyanotic 4. Specific facies: syndromes, facies cholerica, fish-mouth, facies leonina, Cooley’s facies
C. Anthropometric measurements 1. Body length / height: sitting, standing 2. Body weight 3. Head circumference 4. Arm circumference span 5. Abdominal circumference 6. Nutritional status: W/A, H/A, W/H (plot in standard normal curve NCHS)
D. Systematic examination Head and neck Chest Abdomen Genitals Extremities Skin, hair, lymph nodes Neurological
Use of stethoscope Use binaural stethoscope Bell-shaped side: for low & medium pitched sounds Membrane (diaphragm): for medium to high pitched sounds For heart exam use bell-shaped side first start without pressure, then with pressure End with diaphragm side
Common mistakes in performing examination History Fail to identify the patient first Make an incomplete history Provide a disorganized history Physical exam: Fail to describe general condition & vital signs first Incomplete description of features, e.g. pulse rate only or respiratory rate only without further characteristics
Developmental Approach to Physical Exam in Infants Perform uncomfortable parts of the exam last Complete the exam with the infant in the parents arm Keep the infants warm and covered Observe general appearance, respiratory rate and effort, overall color
Developmental Approach to Physical Exam in Toddlers Approach quietly, calmly and slow Complete the assessment wherever the child is comfortable Allow the child to play with your stethoscope Have a toy or something to distract the child Consider listening to parent or child’s toy to promote comfort
Developmental Approach to Physical Exam in School Age Clearly explain the plan and expectations before the examination Answers the child’s questions honestly Talk about topics of interest during the examination They may be modest, allow them to keep a gown on Include them in your history taking
Developmental Approach in Adolescents Questions should be directed at the adolescent and parent Be honest Ensure privacy during the examination and in sharing information Provide the adolescent with the opportunity to have the parent step out for history and/or examination Provide reassurance
Concluding remarks History taking and physical exam skills require good background knowledge and a sound human relation; as a part of medical practice, they are science and art The art of history taking and physical exam are by no means inferior to your scientific knowledge of the disease under investigation Respect the patient and the family if you want to be respected by them; by and large, respecting each other is the key for success in medical practice
How can you be a good examiner? THINK, PRACTICE, PRACTICE !!!