Clinical assesment

1. Clinical assesment Dr. Dini Sri Damayanti,MKes

2. Taking together the history, information from the physical examination and any investigations or tests, this should provide all the information needed to make a diagnosis (i.e. to identify the nature of a health problem).

3. New clinical students often feel embarrassed about asking about a patient’s feelings,expectations or concerns. Ask about these aspects in the same, matter-of-fact way as you ask about other aspects of the history. If you feel comfortable asking the questions, the patient is more likely to feel comfortable about answering.

4. Providing structure to the consultation 1. Know what information you need have the main headings of the history and lists of any systems-specific questions in front of you • 2. Take notes take brief notes during the consultation itself

5. Building the relationship 1. Develop rapport • accept the patient’s views and feelings non-judgementally • use empathy • be supportive • deal sensitively with embarrassing or disturbing topics, and pain 2. Involve the patient • share your thinking with the patient • explain the rationale for your questions • during physical examination, explain the process and ask permission

6. 3.Respond to the patient’s needs • e.g. if the patient seems in discomfort, or tired, or in pain, acknowledge this and respond appropriately - do not simply continue. 4. Use appropriate non-verbal behaviour • eye contact, facial expression, posture, position and move • vocal cues, e.g. rate, volume, tone

7. How to take a history Start by putting the patient at ease: • Greet the patient by name: "Good morning, Mrs Jones" • Introduce yourself and explain that you are a medical student. • Shake the patient's hand, or if they are unwell rest your hand on theirs. • Ensure that the patient is comfortable.

8. Standard history taking • Name • Address • Date of birth • Date of admission • Presenting complaint • History of presenting complaint • Previous medical history • Systems enquiry • Drug history and allergy • Family history • Social history • Conclusion/summary

9. History of presenting complaint If the history of the presenting complaint includes pain “SOCRATES” • Site - where exactly is this pain? • Onset - when did the pain start, did it start suddenly or gradually? • Character - describe the pain - sharp? knife-like? gripping? vice-like? burning? crushing?

10. • Radiation - does the pain spread anywhere? To the arm, jaw, groin etc? • Associations - is the pain accompanied by any other features? • Timing - does the pain vary in intensity during the day? • Exacerbating and relieving factors - does anything make the pain better or worse? • Severity - does the pain interfere with daily activities or with sleep?

11. Questions to ask about previous medical History General question: • Have you suffered from any previous illness? Medical • Ask about childhood illness and immunization • Have you had TB or whooping cough? • Have you ever been found to have high blood pressure? • Have you had rheumatic fever? • Have you ever suffered from epileptic seizures? • Do you get asthma (episodic breathlessness, usually with wheeze)? • Have you suffered from anxiety or depression? • Do you have diabetes?

12. Surgical • Have you had any operations in the past? Obstetric (where appropriate) • Have you had any pregnancies? • Were they normal? • Were there any complications such as hypertension and toxaemia,diabetes, Caesarian section?

13. Questions to ask patients about their general health: Cardiovascular and respiratory function • Do you have a cough? • Do you cough anything up? • Have you ever smoked? If so what, how many, and for how long? • Do you get short of breath? • Do you wheeze? • Do you get any chest pain? • Do your ankles swell?

14. Gastrointestinal function • Has there been any change in your appetite? • Has there been any change in your weight? • Have you suffered from nausea or vomiting? • Has there been any change in the character or frequency of your bowel movements? • Has there been any change in the colour or consistency of your stools? • Have you had any bleeding? - while vomiting (haematemesis) or melena

15. Genitourinary function • How often do you pass urine? • Do you have pain or burning on passing urine? • Do you have pain in the small of your back (renal angles)? • Is there any blood in your urine (haematuria)? • Do you have any sexual problems?

16. Specific questions for men • Do you have any penile discharge or venereal infection? • Do you have any difficulty starting to pass urine (hesitancy or urgency), maintaining the flow of urine (poor stream), or stopping the flow of urine (terminal dribbling)? Specific questions for women • Do you have any vaginal discharge? • When did your periods start? • Are your periods irregular?

17. • How often do your periods occur and for how long do they last? • Do you have heavy bleeding (menorrhagia) or do you pass clots during your period? • When did your periods stop (menopause)? • Have you had any bleeding since your periods stopped? • How many children have you had and when did you have them? • Did you have any complications during any pregnancy?

18. Musculoskeletal function • Have you any weakness in your arms or legs? • Do you have any stiffness in your joints or spine? • Do you have pain in your joints or spine? Neurological function • Do you have any headaches? • Have you had any dizziness (feeling of instability or rotation)? • Do you get ringing in your ears (tinnitus)? • Do you get abnormal sensations or tingling in your hands or feet (paraesthesia)?

19. • Have you noticed changes in your sense of hearing, smell, taste,vision? • Have you any incontinence of urine or stools? • Do you get depressed? • Do you get anxious?

20. Drug history and allergies • What drugs, homoeopathic and herbal medicines and/or health foods do you take? - and in what dose? • What other therapies do you have? - Physiotherapy? Occupational therapy? Malaria prophylaxis? • Do you have any allergies? • Have any medicines ever upset you?

21. Family history • Are your father, mother, brothers, sisters alive? - If they have died, at what age did he/she/they die? What did he/she/they die of? • Do they have any current illnesses? • Do any illnesses run in your family?

22. Social history • Who is at home with you? • Are you single, married, widowed or divorced? • Is your partner healthy? • How many children have you got? • Are your children healthy? • What is your occupation?

23. • Do you have any financial worries? • Do you smoke? - If so, how may per day/week? • Have you ever smoked? - Why did you give up? • Do you drink alcohol? - If so, how many units per day/week? • Have you been abroad? - If so, where? • Do you have pets? • If mobility is a problem: What is your home like? Do you have to manage stairs? What facilities have you got?

24. Ending Consultation 1. When you are satisfied that you have completed the history-taking, tell the patient that you have covered everything that you need to. 2. Check that the patient has nothing more to add. 3. Summarise the information and check that it is complete and accurate.

25. 4. Explain what will happen next (e.g. you will pass the information on to the doctor,whether they are going to be seen soon by the doctor etc.) 5. Thank the patient and leave immediately after concluding the interview.

26. General Tips on How to Perform an Examination To begin the Examination • Wash your hands • Introduce yourself (full name and role) • Greet the patient with their title and surname, and check you are using their preferred form of address • Explain what you would like to do and obtain consent for the examination

27. • Then position the patient appropriately (45 degrees for cardiovascular and respiratory, flat for abdominal) • Then expose the relevant part of the patient ensuring as much privacy as possible. • Perform a general inspection from the end of the bed.

28. During the Examination • Have a methodical approach to examination. Although each system is slightly different the standard order is: • Inspect • Palpate • Percuss • Auscultate

29. PRINCIPLES OF THE PHYSICAL EXAMINATION

30. GENERAL SURVEY • Exam begins the minute you first see the patient • Exam continues throughout your patient interaction

31. OBSERVATION WEALTH OF INFORMATION!!!!

32. STATURE

33. HEALTH STATUS

34. WEIGHT

35. PERSONAL HYGIENE

36. SKIN COLOR /LESIONS

37. BREATH/ODOR

38. MOOD/ATTITUDE

39. WHEN WE PERFORM A PHYSICAL EXAM WE USE

40. TECHNIQUES OF THE PHYSICAL EXAMINATION • VISUAL INSPECTION • PALPATION • PERCUSSION • AUSCULATION

41. VISUAL INSPECTION • INSPECT CAREFULLY ALL AREAS OF EXAM • DOCUMENT BOTH NORMAL AND ABNORMAL FINDINGS

42. PALPATION

43. PALPATION • TEXTURE • SIZE • CONSISTENCY • CREPITUS • MASSES • EXAMPLE – TAKING A PULSE, HEAD AND NECK EXAM

44. PERCUSSION

45. PERCUSSION • USE OF THE HANDS AND FINGERS • STRIKING ONE OBJECT AGAINST ANOTHER

46. AUSCULATION

47. AUSCULATION • LISTENING FOR SOUNDS PRODUCED BY THE BODY • BLOOD PRESSURE, INTESTINAL SOUNDS

48. To end the Examination 1) Consider whether you need to examine any system in more depth (e.g. a full examination of joints in a patient with rheumatoid arthritis). 2) Re-examine any aspect that you are unsure about. 3) Inform patient that you have completed your examination. Thank them and help them get dressed. 4) Wash hands once more.

49. After the consultation has finished and you have left the patient: a) Write a two line summary of what you found in the history and examination b) Offer a differential diagnosis list for the presenting complaint if the diagnosis has not been fully established. c) Make a problem list which will include the present complaint, other illnesses and other personal, psychological or social factors which affect this illness. d) Consider what tests (biochemical and radiological) are required to confirm or establish the diagnosis. e) Consider what treatment should be given to the patient. f) Consider what/if arrangements are needed to hand over the patient’s care to another team. f) Reflect how the consultation was performed including points to consider for future

50. Terima Kasih