Exam 1 Physical Diagnosis Objectives
From Iusmicm
Revision as of 10:29, 9 March 2012 by 192.162.19.21 (Talk)
- Note, much borrowed from generous, previous IUSM medical students.
afizPK Enjoyed every bit of your post.Really looking forward to read more.
Contents |
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.
- Silent
- 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.
- Disabled
Chapter 6
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
- Inspection:
- 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
- Describe the actions and innervations of the eye and extraocular muscles.
- Identify the major symptoms of eye disease.
- 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.
- Apply the components of the physical examination of the eye to a patient.
- 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.
- Give a differential diagnosis based on symptoms and/or physical exam findings pertaining to the eye.
Chapter 11
Ear
- Describe the structure and innervations of the ear.
- External ear consists of pinna and external auditory canal
- The middle ear or tympanic cavity consists of connections to the mastoid antrum and nasopharyx through the Eustachian tube
- The tympanic membrane forms the lateral boundary of the middle ear, while the cochlea forms the medial boundary
- Sound is conducted from the tympanic membrane to the inner ear by the malleus, incus and stapes
- The tensor tympani [CN V] and the stapedius [CN VII] are also located in the middle ear
- The inner ear is the end-organ for hearing and equilibrium containing the semicircular canals, vestibule and the cochlea
- The hair cells of the organ of corti convert mechanical force into electrochemical signal
- 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.
- Hearing loss
- conductive: blocks transmission of sound waves in external canal or middle ear; caused by wax, effusions, foreign bodies
- sensorineural: inner ear structures, auditory nerve or brain stem are dibilitated; caused by prenatal rubella, and lots of other causes.
- Patients with sensorineural talk loudly, conductive speak softly.
- Vertigo: spinning or turning in position; can be otologic, neurologic, psychological, or iatrogenic.
- Meniere’s disease: severe paroxysmal vertigo as a result of labyrinthine lesions
- Tinnitus: sensation of hearing sound such as buzzing or ringing
- Otorrhea: bloody discharge associated with carcinoma or trauma
- Otalgia: pain related to inflammatory conditions or may be referred
- Itching: from primary disorder of external ear or discharge from middle ear
- Hearing loss
- Apply the components of the physical exam of the ear to a patient.
- Inspect external ear structures: tophi, “cauliflower ear” from trauma, cancer, discharge
- Palpate the external ear structures
- Auditory acuity testing: occlude one ear and speak softly into the other; use of 512Hz fork
- Rinne test: air conduction vs bone conduction using fork; placing stem on mastoid process compared against vibratory hearing; usually AC > BC [Rhine positive]
- Weber test: compares bone conduction in both ears by placing fork in middle of forehead; sound heard on ipsi side of conductive problem and contra side of a sensorineural problem
- Example: Rinne positive on both sides -> sensorineural problem; Rinne negative on one side identifies conduction problem on that side
- Otoscopic examination: pull posterior and superior and look at the canal and tympanic membrane (should be pearly gray)
- Injection: dilation of tympanic vessels
- Retraction pocket can indicate Eustachian tube blockage and decreased pressure
- Determination of mobility of tympanic membrane: also uses otoscope; useful for middle ear infection possibility (decreased movement will be detected if fluid present)
- 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. Interpret the symptoms of diseases of the ear and apply them clinically to patient.
- Acute otitis externa: p. aeruginosa
- Severe pain accentuated by manipulation of the pinna; lymphadenopathy; fever; normal tympanic membrane
- Summer time
- Bullous myringitis: localized form of external otitis
- Acute viral URI; severe pain; lesions on the skin of the deep external ear canal;
- Self-limited
- Acute otitis media: bacterial infection of the middle ear
- Usually in children;
- Pain, malaise, no pain on external manipulation, fiery red tympanic membrane;
- Winter
- Advanced acute otitis media: rupture of membrane
- Perforations can be central or marginal (more serious and may dispose to a cholesteatoma)
- May result from either otitis media or trauma
- Serous otits media:
- Adults with viral URIs or sudden atmospheric pressure changes
- Tympanic membrane appears yellowish-orange as a result of the amber-colored fluid
- Partial obstruction of the Eustachian tubes:
- Air bubbles or an air-fluid level in the middle ear
- Chronic otitis media: rupture and recurrent middle ear infections
- Foul-smelling, not usually painful
- Retraction pockets: chronic negative pressure within middle ear
- May progress to an acquired cholesteatoma
- Treat with T-tube (tympanostomy)
- Deafness:
- Child: conductive via cerumen, chronic/acute otitis media; sensorinueral via mumps, rubella
- Adult: conductive via tube blockage, viral myringitis, otosclerosis; sensorineural via Meniere’s, ototoxic drugs, acoustic neuroma
- Acute otitis externa: p. aeruginosa
- Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the ear.
Nose
- Describe the structure of the nose.
- Illustrate how the major symptoms of nose diseases are used to identify nose diseases.
- Interpret the symptoms related to the nose and apply them clinically to a patient.
- Apply the components of the physical exam of the nose to a patient.
- Clinically correlate the symptoms and physical exam findings pertaining to the nose for the following disease processes: allergic rhinitis, sinusitis, and nonallergic rhinitis.
- 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.
- Aphthous ulcer
Chapter 13
- Describe the topographical landmarks of the chest and utilize that knowledge to describe physical findings of the chest.
- Recognize the main symptoms of pulmonary disease and how these symptoms can identify disease.
- Interpret the symptoms of pulmonary disease and apply them clinically to a patient.
- Apply the components of the physical exam of the chest to a patient.
- Clinically correlate the symptoms and physical exam findings pertaining to the chest:
- Pulmonary Edema
- Pneumothorax
- Asthma
- Pneumonia
- Emphysema
- Pulmonary Embolism
- Pleural Effusion
- Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the chest.
Chapter 17
- Describe the topographical landmarks of the abdomen and utilize that knowledge to describe physical findings of the abdomen.
- Recognize where abdominal structures are located by topographical quadrants of the abdomen.
- Recognize the main symptoms of abdominal disease and how these symptoms can identify disease.
- Interpret the symptoms of abdominal disease and apply them clinically to a patient.
- Apply the components of the physical examination of the abdomen to a patient.
- Clinically correlate the symptoms and physical exam findings pertaining to the abdomen.
- Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings.
