Exam 1 Physical Diagnosis Objectives

From Iusmicm

• Note, much borrowed from generous, previous IUSM medical students.

Contents 1 Chapter 1 2 Chapter 2 3 Chapter 7 4 Chapter 9 5 Chapter 10 6 Chapter 11 6.1 Ear 6.2 Nose 7 Chapter 12 8 Chapter 13 9 Chapter 17

Chapter 1

• Apply the guidelines for using a medical interpreter when a medical interpreter is needed for a patient interview.
  • need to be trained in med. Terminology
  • same sex and age as patient
  • establish an approach with interpreter before talking to patient
  • speak and look at patient
  • do not expect word for word translation
  • ask interpreter about patient fears and expectations
  • use short questions
  • use simple language
  • keep explanations brief
  • avoid using "if", "would" and "could" questions and statements
  • avoid idiomatic expressions

• Define the “rule of 5 vowels” and use the 5 vowels in a patient interview.
  • AEIOU: audition, evaluation, inquiry, observation, understanding
  • audition: listen to story
  • evaluation: determine what is relevant
  • inquiry: ask appropriate questions
  • observation: importance of non-verbal communication
  • understanding: show empathy and signs that you understand and care

• Recognize the difference between a “symptom” and a “sign”.
  • A symptom is what a pt feels.
  • A sign is what a physician detects.

• Select the appropriate terminology and questions to begin a medical interview.
  • Greet with your name, ask their name, make eye contact, shake hands, smile, state your purpose and intent.

• Apply the use of open-ended questions when conducting a medial interview.
  • Start with open ended questions, focus down with direct questions.

• Apply the use of direct questions when conducting a patient interview.
  • ROS should be demarked with a transition statement explaining that you're not looking for simple yes or no answers.
  • Follow positive ROS responses with open ended and OPQRST questions.

• Discriminate patient symptoms using the O-P-Q-R-S-T mnemonic.
  • OPQRST:
    • onset (time, activity);
    • provoke / palliate (what makes it worse or better);
    • quality (characteristics like blurry, sharp, burning, deep, etc.);
    • radiation (does the symptom occur anywhere else or associate with any other symptom);
    • severity (1-10);
    • timeline
  • CLOSER:
    • characteristics (quality, severity)
    • location (and radiation)
    • onset (and duration)
    • symptoms associated
    • exacerbating factors
    • relieving factors

• Discriminate which questions to avoid and not use when interviewing a patient.
  • Avoid rapid-fire questions; "have you lost or gained weight or had any nausea or vomitting?"
  • Avoid medical jargon; "where you tachypnic when the pain started?"
  • Avoid leading or biased questions; "you don't have any heart problems do you?"

• Describe the parts of the medical history and include each part when writing a medical history.
  • Chief complaint
  • History of Present Illness
  • Past Medical History
  • Social History
  • Family History
  • Psychosocial and Spiritual History
  • Sexual and Reproductive History
  • Review of Systems

Chapter 2

• Describe the various responses to illness in a patient.
  • There are several major responses to illness, including: anxiety, depression, denial, projection, and regression.
  • Anxiety: characterized by uneasiness and a sense of impending danger
  • Depression: a chronic state of lowered mood
    • The most common reaction to illness and perhaps the most overlooked.
    • 20% of pts with major illnesses express depression (especially cancer pts).
    • Noted by brief answers, slow speech, and low volume.
    • Thoughts are negative, with lots of (perceived) inadequacy, defeat, and worthlessness.
  • Denial: acting and thinking a part of reality is not true.
    • Recall that denial is a defense mechanism used to guard against an inner tension that causes anxiety. Denial prevents the turmoil from producing overt anxiety.
    • The more acute the illness, the less room for denial; the more insidious the illness, the more denial.
    • May need to interview a reliable informant when denial is so severe accurate answers cannot be secured.
  • Projection: perceiving one's own emotions in another being
    • Recall that projection is a defense mechanism that guards against an inner tension and manifests as the pt perceiving their own emotion in the interviewer (fear, anger, for example).
    • A danger for the Doctor-Pt relationship.
  • Regression: an unconscious return to an earlier stage of physical or emotional development in which the pt was free from the demands of disease and was often gratified.
    • Regression is a defense mechanism.

• Describe the variety of patient types and how to approach them during an interview.
  • Silent
    • Characteristics: shy, insecure, easily embarrassed normally or silent from fear of illness. May be depressed.
    • Approach: Use directed questions, not open-ended.
  • Over-talkative
    • Characteristics:
    • Approach: use courteous interruption followed by another direct question. Avoid open-ended questions.
  • Seductive:
    • Characteristics: many have personality disorder and have fantasy of intimacy with doctor.
    • Approach: Keep empathy and reassurance to minimum. Keep professional distance.
  • Angry
    • Approach: Realize reactions are to illness and not personal. Confront about anger and allow to vent, proceed slow, avoid interpretations and ask questions about present illness.
  • Paranoid
    • Characteristics: Reassurance tends to be threatening.
    • Approach: Complete questioning and don’t try to convince about false ideations. Avoid any anger.
  • Insatiable
    • Character: never satisfied.
    • Approach: Handle with firm, noncondescending approach. Use definite closing statement.
  • Ingratiating
    • Character: attempts to please interviewer.
    • Approach: Try to give “right” answer. Stress importance of accuracy
  • Aggressive
    • Character: often has personality disorder, easily irritated and can fly into rage.
    • Approach: Stay away from provoking anxiety early and establish rapport.
  • Help-rejecting
    • Character: seen many experts and no one can figure out what is wrong. Return saying suggestions didn’t work. New symptoms appear after one goes away. Blame “illness” for disappointments.
    • Approach: Use strong emotional support and gentile reasoning
  • Demanding
    • Character: Use intimidation and guilt to force others to take care of them. See self as neglected, may have outburst of anger and have power struggle with doctor.
    • Approach: Provide firm boundaries, elicit and set clear expectations.
  • Compulsive
    • Character: concerned about every detail, use projection
    • Approach: Provide detailed and specific info in a straight forward way
  • Dependent
    • Character: finds life hard without help. Need to care for closely, but they can take advantage of doctors by demanding time.
    • Approach: Be direct about limits without leaving rejected.
  • Masochistic
    • Character: go thru life suffering mentally, but don’t seek physical abuse or pain. Feel they self-sacrifice and handle illness well, but may feel threatened by recovery.
    • Approach: Don’t promise cures, attend to all aspects of illness.
  • Borderline
    • Character: personality disorder with instability, splitting, impulsiveness and unstable moods. Are always afraid, but may mask with anger.
    • Approach: Use lots of reassuring words.

• Describe how disease can influence the type of patient response.
  • Disabled
    • Theme is mistrust of healthcare; response is assurance.
    • Sort out emotional problems for physical ones.
    • Smile and nice words help them cooperate.
    • Don’t like their routines changed.
    • If hearing impaired sit in front so they can read your lips or speak louder, write things down if needed.
    • If vision impaired: occasionally touch patient’s arm so they know where you are. Avoid non-verbals.
    • Developmentally delayed need guardian to give history.
  • Cancer
    • -5 major concerns: loss of control, pain, alienation, mutilation and mortality.
    • Doctor may be afraid of patient’s questions about death and patient feels rejected.
    • Doctor needs to recognize their limitations.
    • Allow patient to vent and promote dialogue.
  • AIDS
    • Fearful for life and being stigmatized which may result in delay of seeking care.
    • Denial is important and may fear doctors.
    • Fear worsened by anxiety of health care workers who care for them.
    • Unsympathetic rejection of AIDS patients leading to anxiety, hostility and depression.
    • Be supportive with out false sense of hope.
    • Give facts and make sure staff is educated.
  • Dyphasic
    • Impairment of speech and can’t arrange words correctly.
    • Always assume patient is aware if talking with them in the room.
    • Give patient pen and paper and or ask yes / no questions.
  • Psychotic
    • Impaired reality testing abilities and can’t communicate effectively.
    • May have hallucinations and delusions.
    • Remain calm and get assistance if violent episode.
    • May have Munchausen’s and be malingerers.
    • Many self injure.
  • Demented or Delirious
    • Demented are more confused out of their environment especially at night ("sundowning").
    • Fear is common. Be sensitive and allay their fears. Avoid question that may seem threatening to them.
    • Need mental status exam.
    • History may not reliable.
  • Acutely Ill
    • Need concise history and physical.
    • May need to interview while doing exam.
    • Finish interview after stable.
  • Surgical
    • Frightened even if calm appearance.
    • Feel helpless and out of control.
    • Lack of communication from surgeon makes worse.
    • Depression if loss of body part.
    • Allow time to release tension and feelings of loss during interview
  • Alcoholic
    • Feel castigated and alone. Alcohol is only friend.
    • Often ready to talk and may have low self esteem.
    • May be self destructive. May have fears of sexual inadequacy or homosexuality.
  • Psychosomatic
    • Psychological problems create physical ailments.
    • May be unaware of emotional distress.
    • Identify disorder, teach patient to cope with psych problems.
    • Somatization is unconscious and patients are really suffering. Acknowledge their suffering is real. Never say problem is in your head.
    • Use open ended questions to get insight.
  • Dying
    • Conscious of taking up doctor’s time and will start asking fewer questions.
    • Don’t avoid dying patients because of own fears.
    • Many fear process of dying more than death.
    • May have anger or guilt or resentment.
    • Envy healthy and deny imminent death.
    • May deny disease even when asked directly.
    • Most reach acceptance which may include apathy and withdraw.
    • Dying patient needs to talk to someone.
    • Appropriate response to an expression of grief may be period of silence.

Chapter 7

• Describe the “Four Principles of Physical Examination”, their importance, and clinical application.
  • Four principles are inspection, palpitation, percussion, and auscultation.

• Describe what the examiner should observe while taking a history and how to apply clinically when evaluating a patient.
  • General appearance: state of consciousness and personal grooming, distress? Groggy? Alert? Clean?
  • State of nutrition: sunken eyes, temporal wasting, loose skin, thin, frail
  • Body habitus:
    • Asthenic: a condition of weakness, feebleness, or loss of vitality
    • Ectomorphic characterized by a lean slender body build with slight muscular development
    • Mesomorph: intermediate to asthenic and ectomorphic
    • Hypersthenic or endomorphic: is short, round with good muscles, but weight problem
  • Symmetry
  • Posture and gait: foot drag? Shuffle?, limp?
  • Speech: slurred? Appropriate words? Hoarse? High pitched?

• Apply the “preparations for the physical examination” clinically when evaluating a patient.
  • Have all necessary equipment and place at bedside
  • Close curtains for exam
  • Wash hands – lather 10 seconds or use alcohol product in no visible soilage
  • Have patient wear gown
  • Do in order that requires least movement of patient
  • Perform exam from right side of patient
  • Expose only areas that are being examined at that time
  • Continue speaking to patient during exam

• Discriminate which comments to refrain from when performing the physical examination.
  • Avoid using "that's good", "normal", and "that's fine" as they may have unintended consequences with regard the pt's perception.

• Apply the precautionary guidelines for health-care workers from the CDC and OSHA and how to apply them when examining a patient.
  • Use gloves when doing physical exam or handling blood soiled or body fluid sheets
  • Wear gloves with patients with exudative lesions or weeping dermitis
  • Use fluid resistant gowns, masks and eye covers when doing procedures
  • Wash hands immediately if accidently soiled with blood or body fluids
  • All sharps must be handled with care
  • Don’t re-cap needles and dispose in puncture resistant containers
  • Use mouthpieces for mouth to mouth
  • Handle blood and body fluid samples with gloves
  • Clean and decontaminant soiled surfaces with disinfectant
  • Process reusable items according to recommendations
  • If sharps injury or exposure to blood or body fluid clean area immediately and report
  • All heath care workers should have Hep B vaccine
  • Responsibility of health care worker not to transmit their disease to patient

Chapter 9

• Describe and recognize common symptoms of diseases involving the neck: neck mass and neck stiffness.
  • Two most common physical findings are masses and stiffness.

• Interpret the signs and symptoms of diseases involving the neck: neck mass and neck stiffness.
  • If there is associated pain with a mass in the neck, an acute infection is likely.
  • Consider the age of the patient:
    • Thyroglossal cyst occurs with patients under the age of 20, while thyroid disease occurs in older patients
  • Consider the location of the mass:
    • Lateral masses are more commonly neoplastic
    • Midline masses are not associated with neoplasms but hyperplasia
    • Superior masses correlate with head / neck tumors
    • Inferior masses correlate with breast / stomach masses
  • Neck stiffness is usually cause by spasm of the cervical muscles and commonly causes tension headaches.
  • Depression is a common symptom of head and neck disease.

• Apply the components of the physical exam of the neck to a patient.
  • No special equipment is required, and the patient is seated facing the examiner
  • Inspection: position, scalp, masses, eyes, veins, nodularity
  • Auscultation for carotid bruits
  • Palpation: along muscles and major lymph node tracts using pads of fingers from posterior to anterior; thyroid gland

• Clinically correlate the symptoms and physical findings for the following disease processes: hyperthyroidism, hypothyroidism, thyroid nodules.
  • Inspection:
    • Proptosis: forward displacement of the eyes from thyroid dysfunction or orbital mass
    • Thyromegaly: Graves’ disease causes bilateral proptosis and thyromegaly
    • Thyroglossal duct cysts: are smooth, firm and midline
    • Venous distention and nodularity may be associated with a goiter
  • Palpation:
    • Tender nodes are associated with inflammation, whereas firm nodes are associated with malignancy
    • Thyroid
      • Two methods for palpating the thyroid: anterior and posterior
      • Rarely felt in it's healthy state.
      • Hardness is associated with cancer or scarring
      • Tenderness is associated with acute infections or hemorrhage
      • Enlargement warrants auscultation
      • A to-and-fro bruit of the superior pole highly suggests a toxic goiter
    • Supraclavicular nodes: important; enlarged nodes can be felt with inspiration

• Using the symptoms and / or physical exam findings pertaining to the neck, generate a diagnosis and a differential diagnosis.
  • Grave’s Disease: proptosis, heat intolerance, hyperhidrosis, anxiety, insomnia, hyperpigmentation, palpitations, sweats, erythema, etc.
  • Plummer’s Disease: toxic adenomatous goiter – frequently see atrial fibrillation
  • Malignant thyroid nodule: male, one nodule, no FHx, change in voice, prior radiation for H/N
  • Benign nodule: female, >1 nodule, FHx of benign thyroid disease, no voice change
  • Hypothyroidism: weight gain, fatigue, chilly, lethargy

Chapter 10

1. Describe the actions and innervations of the eye and extraocular muscles.
2. Identify the major symptoms of eye disease.
3. Interpret the symptoms of the major diseases of the eye and apply them clinically to a patient: loss of vision, eye pain, diplopia, tearing or dryness, discharge, and redness.
4. Apply the components of the physical examination of the eye to a patient.
5. Clinically correlate the symptoms and physical exam findings pertaining to the eye for the following disease processes: visual field defect, red eye (acute conjunctivitis, acute iritis, narrow-angle glaucoma, and corneal abrasion), diabetes, hypertension, and papilledema.
6. Give a differential diagnosis based on symptoms and/or physical exam findings pertaining to the eye.

Chapter 11

Ear

1. Describe the structure and innervations of the ear.
2. Identify the major symptoms of ear disease and how these symptoms can identify diseases involving the ear: hearing loss, vertigo, tinnitus, otorrhea, otalgia, and itching.
3. Interpret the symptoms of diseases of the ear and apply them clinically to a patient.
4. Apply the components of the physical exam of the ear to a patient.
5. Clinically correlate the symptoms and physical exam findings pertaining to the ear for the following disease processes: conductive and sensorineural hearing loss, otitis media. Serous otitis media, otitis externa, and vertigo.
6. Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the ear.

Nose

1. Describe the structure of the nose.
2. Illustrate how the major symptoms of nose diseases are used to identify nose diseases.
3. Interpret the symptoms related to the nose and apply them clinically to a patient.
4. Apply the components of the physical exam of the nose to a patient.
5. Clinically correlate the symptoms and physical exam findings pertaining to the nose for the following disease processes: allergic rhinitis, sinusitis, and nonallergic rhinitis.
6. Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the nose.

Chapter 12

• Know the structures of the oral cavity and pharynx.
  • 
  • 

• Know the functions of the pharynx.
  • Subdivisions: nasopharynx, oropharynx, hypopharynx.
  • Fxn: provides swallowing, speech, and an airway.

• Know the important symptoms of disease of the oral cavity.
  • Ulceration, bleeding, mass, halitosis, xerostomia (dry mouth).

• Apply the components of the physical exam of the oral cavity and pharynx to a patient.
  • See cd.

• Clinically correlate the signs and symptoms of the following conditions:
  • Aphthous ulcer
    • Single canker sore. Most common acute oral ulcer.
    • Relatively superficial w/ raised borders. On buccal or labial mucosa.
  • Herpetic ulcer
    • acute multiple ulcers, associated w/ vesicles.
    • On mucocutaneous junction, hard palate, or gingivae.
    • Crusting when bullae break.
  • Chancre
    • Painless, single lesion on lips or tongue.
    • Lesion w/o central necrotic material.
    • May have tender lymphadenitis.
  • Squamous cell carcinoma:
    • Single indurated sore on lips, tongue, mouth floor, or tongue (esp. on lateral borders)
    • Erythroplakia of mouth floor and soft palate.
    • Raised border, absence of necrotic material in crater.
    • May have painless lymphadenopathy in neck.
  • Candidiasis
    • Burning tongue, inside of cheek or throat.
    • Whitish pseudomembrane.
    • Peeled off to reveal raw, red area that may bleed.
  • Erythroplakia
    • Painless, red area.
    • Granular, red papules that bleed.
  • Leukoplakia
    • Painless, white area.
    • Hyperkeratinized. Can’t be scraped off.
    • Looks like flaking white paint. Often speckled w/ red spots.
    • If associated with adenopathy, could be malignancy.
  • Lipoma
    • Painless mass on inner surface of cheek or tongue.
    • Yellowish, soft, freely mobile.
  • Lichen planus
    • Usually no symptoms.
    • Erosive form causes burning sores on inner cheeks and tongue.
    • White reticulated papules bilaterally in lace-like pattern.
    • Erosive form is hemorrhagic, ulcerated w/ possible white areas or bullae.
    • May have pseudomembrane covering.
  • Mucocele
    • Intermittent painless swelling of lower lip, or inside cheek.
    • Slightly bluish.
    • Dome-shaped, freely-mobile cystic lesion.
  • Hairy Tongue
    • Gagging sensation.
    • Large brown or black painless lesion on top of tongue.
    • Elongation of filiform papillae and color change.

Chapter 13

1. Describe the topographical landmarks of the chest and utilize that knowledge to describe physical findings of the chest.
2. Recognize the main symptoms of pulmonary disease and how these symptoms can identify disease.
3. Interpret the symptoms of pulmonary disease and apply them clinically to a patient.
4. Apply the components of the physical exam of the chest to a patient.
5. Clinically correlate the symptoms and physical exam findings pertaining to the chest:
   1. Pulmonary Edema
   2. Pneumothorax
   3. Asthma
   4. Pneumonia
   5. Emphysema
   6. Pulmonary Embolism
   7. Pleural Effusion
6. Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the chest.

Chapter 17

1. Describe the topographical landmarks of the abdomen and utilize that knowledge to describe physical findings of the abdomen.
2. Recognize where abdominal structures are located by topographical quadrants of the abdomen.
3. Recognize the main symptoms of abdominal disease and how these symptoms can identify disease.
4. Interpret the symptoms of abdominal disease and apply them clinically to a patient.
5. Apply the components of the physical examination of the abdomen to a patient.
6. Clinically correlate the symptoms and physical exam findings pertaining to the abdomen.
7. Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings.