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Synthesis & Integration. Friday, September 3 rd 2010. Jody P. 15 year-old female. Overview: The History and Physical. S ubjective Chief Complaint History of Chief Complaint Past Medical History Medications Allergies Social History
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Synthesis & Integration Friday, September 3rd 2010 Jody P. 15 year-old female
Overview: The History and Physical • Subjective • Chief Complaint • History of Chief Complaint • Past Medical History • Medications • Allergies • Social History • Family History • Review of Systems • Objective • Vital Signs • Physical exam • Assessment • Problem List • Differential Diagnoses • Diagnosis • Plan • Lab Tests • Treatments
Subjective: Chief Complaint “I’m here with my mom for my sports physical. She is in the waiting room.”
Subjective: History of Chief Complaint “I am on the tennis team. I have played on the team for the past 2 years. I think I am pretty healthy except for a recent cold. I was seen in an urgent care 2 weeks ago, they said I had strep throat even though the swab test was negative.”
Subjective: When asking Jody about her past medical history, health-influencing behaviors, family and social history, she tells you:
Subjective: • “I had chicken pox when I was 5. I don’t think I’ve had any shots since I was a baby. I’m not allergic to any medicines, but I did just finish some antibiotic for my throat. I have never been to the hospital or had surgery or anything like that, and I workout for tennis a lot and eat well. My family is healthy, but my dad has high blood pressure. I do drink alcohol sometimes on the weekends, but everyone does here in Athens. My boyfriend and I have had sex a few times, but most of the time we use a condom…wait, you don’t have to tell my mom about that last part, do you?”
Subjective: Review of Systems • Negative, except as noted below: • General: “I’ve been pretty tired lately, but maybe it’s because tennis conditioning has been tough.” • HEENT: “I finished all of that antibiotic I told you about, but my throat still hurts.”
What should be the first piece of information in your objective section? • Medications the patient is taking • Recent lab values • The patient’s general appearance • Vital signs • Your assessment and plan
Which of Jody’s vital signs is abnormal? • Blood pressure (100/60 mmHg) • Pulse (90 bpm) • Respiratory rate (16 rpm) • Temperature (100.4˚ F/38 C)
Objective: Fever • Different sources give different parameters • Elevation of body temperature that exceeds the normal daily variation and • Occurs in conjunction with an increase in the hypothalamic set point (e.g., from 37°C to 39°C)* *Harrison's Principles of Internal Medicine, 17e
Calculate Jody’s BMI (height 64 in., weight 119 lbs). She is • Underweight • Normal weight • Overweight • Obese • Not enough information
BMI Calculation BMI = (weight in pounds) (height in inches)2 Jody’s BMI = (119) (64) 2 x 703 = 20.4 x 703
Objective: Physical Exam • A somewhat muscular, slender female, who is cooperative and appears in no acute distress.
Objective: Splenomegaly • Palpation of anything more than the tip below the costal margin • Percussed as a dull sound in the lung or abdominal region • Usually measure on deep inspiration http://www.4to40.com/images/ayurveda/Splenomegaly/Splenomegaly.jpg
From Nelson’s Textbook of Pediatrics 2007 Objective: Female Tanner Stage http://commons.wikimedia.org/wiki/File:Tanner_scale-female.svg
From Nelson’s Textbook of Pediatrics 2007 Objective: Male Tanner Stage From: http://commons.wikimedia.org/wiki/File:Tanner_scale-male.svg
Assessment: Problem List What sort of things do you want to include on your problem list at this time?
Assessment: Problem list • Pharyngitis • Enlarged spleen • Fever • Fatigue • Health maintenance • Risky behaviors • Substance abuse • Sexual intercourse • Immunizations • Parent/child communication issues
Assessment: Differential Diagnoses • Pharygitis • Bacterial • Streptococcal • Gonococcal • Infectious mononucleosis • Peritonsillar abscess
Select your top differential: • Gonococcalpharyngitis • Infectious mononucleosis • Peritonsillar abscess • Streptococcal pharyngitis
Infectious mononucleosis Called the ‘kissing disease’ Most often caused by the Epstein Barr virus Virus infections pharyngeal cells and after release of virons it spreads to other parts of the body Once you mount an immune response you are protected for life Monospot and EBV specific antibody tests confirm diagnosis
Signs and Symptoms of Mononucleosis From-http://www.answers.com/topic/infectious-mononucleosis
Assessment: Diagnoses Pharyngitis: Infectious mononucleosis Childhood risky behaviors including sexual intercourse and substance use Deficient in recommended vaccinations
Plan: Lab Tests • Initial decrease in white blood cell count followed by an increase in the proportion of lymphocytes • Many of which are atypical • Monospot: heterophile antibodies agglutinate horse RBCs • Usually become positive within 4 weeks after onset of illness • Specific but often not sensitive in early illness
Plan: Treatment • Supportive management • Rest • Fluid hydration • Pain relief • Monitor for airway compromise • Restriction from contact sports until splenomegaly has resolved
Plan: Treatment • Vaccines recommended for adolescents: • Pertussis (whooping cough) • Meningococcal infections • Hepatitis B • Varicella (chicken pox) • Measles, mumps and rubella *Other vaccines may be indicated based on individual patient needs
Plan: Treatment • Discuss risky behaviors and possible consequences • Sexual activity in adolescents • Pregnancy • STIs/STDs • Emotional development • Harmful effects of alcohol and drug use • Cultural and behavioral factors have the greatest influence on mortality
Minor Patient Confidentiality • Jody asks to use the restroom before they leave, and while she is out of the room her mother approaches you: “I think my daughter is having sex with her boyfriend, and as her mother I feel I have a right to know. Did she say anything to you?”
How do you answer Jody’s mother? • “She is, but she is using protection.” • “No, she said she hasn’t.” • “I don’t know, I’m a medical student.” • “I’m sorry, but I can’t discuss that issue with you at this time.” • “Probably, but you should ask her to be sure.”
Minor Patient Confidentiality • Teens have certain legal protections, so you may treat them for certain things without their parents knowledge • Administration of birth control • Treatment for STI’s • Counseling on drugs and ethanol • Anything if child is emancipated • Health professionals should always advise teens to have close communication with parents or guardians
Learning Objectives: • Review history and physical (H&P) format • Subjective • Objective • Assessment • Plan • Health maintenance for adolescents • Minor patient confidentiality
