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Comprehensive Introduction to History and Physical Exam

Learn the components of a routine history and physical exam, from vital signs to neurological assessments. Practice in outpatient and inpatient settings, including documentation. Contact physicians for preceptorship scheduling.

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Comprehensive Introduction to History and Physical Exam

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  1. Introduction to History and Physical Exam Robert Woodward, MD MBA Program Coodinator Clinical Practice Preceptorship

  2. Goal and Objectives • Goal: • To introduce the student to the history and physical exam • Objectives: • The student shall be able to recognize components of the routine history and physical exam • The student shall feel comfortable observing a physical exam in the preceptor’s office

  3. Inpatient Chief Complaint History of Present Illness Past Medical History Social History Review of Systems Outpatient (SOAP note) Subjective Objective Assessment Plan History

  4. Vital Signs BP, RR, Temp, Pulse ? Pain Scale General Appearance Age, nutrition, clean, etc HEENT and Neck Pulmonary and Thorax Cardiovascular Abdominal Peripheral Vascular Musculoskeletal Neurological Genital/Rectal Breasts and Axillae Components

  5. Vital Signs • Pulse- Take radial pulse and count beats for 1 min • Respiratory Rate- Count Respirations for 1 min • Temperature- In adults, use oral thermometer! • Blood Pressure

  6. Blood Pressure Cuff

  7. Otoscope

  8. Normal Eardrum

  9. Ophthalmoscope

  10. HEENT and Neck • Head –inspect and palpate • Ears- external and internal • Eyes- inspect, check fundi, pupil reflexes, peripheral vision • Nose- inspect and palpate • Throat- inspect with light and tongue depressor • (brush your teeth) • Neck- feel for lymph nodes and thyroid

  11. Pulmonary • Lungs- 3 lobes on right, 2 on left • Inspection (to look) for deformities • Palpation (to touch) for masses, vibration • Percussion (to tap on) • Cut your finger nails • Auscultation (to listen to a body part with a stethoscope) both front and back

  12. Auscultation • Lung • Alternate both sides and go down the back and do lower lateral areas • Test for Bronchophony- “99”-loud and clear • Normal is muffled and indistinct through chest wall • Test for Ergophony “EE”- sounds like “AY” • Normal is a muffled long “E” sound • Whispered Pectoriloquy- whispers heard clearly • Normal is faint and indistinct

  13. Auscultation

  14. Cardiac Exam • Inspection • Palpation for Point of Maximum Impulse or Thrills • Auscultation • Aortic, Pulmonic, Tricuspid, Mitral areas • S1, S2, murmurs, gallops, rubs

  15. Abdominal Exam • Inspection • Auscultation**** • Percussion • Light and Deep Palpation • Liver Span, Spleen • Special tests • Eg. for appendicitis

  16. Musculoskeletal Exam • Inspection • Tone • Palpation • Range of Motion • Passive and Active • Strength

  17. Neurological Exam • Mental Status (Mini Mental Status Exam) • Cranial Nerves I-XII • Muscle Tone • Strength • Reflexes- Bicep, Tricep, Brachioradialis, Knee, Ankle • Sensation- Pain, Cold, Soft Touch, Vibration • Higher Cerebral Function • Cerebellar Function- Coordination

  18. Contact Physicians • Schedule visit in: • October • November/December • January/February • March/April • Get White Jacket • Consider getting stethescope

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