A Practical Guide to Clinical Medicine
A comprehensive physical examination and clinical education site for medical students and other health care professionals
|Introduction||Breast Exam||Write Ups|
|History of Present Illness||Male Genital/Rectal Exam||The Oral Presentation|
|The Rest of the History||The Upper Extremities||Outpatient Clinics|
|Review of Systems||The Lower Extremities||Inpatient Medicine|
|Vital Signs||Musculo-Skeletal Exam||Clinical Decision Making|
|The Eye Exam||The Mental Status Exam||Physical Exam Lecture Series|
|Head and Neck Exam||The Neurological Exam||A Few Thoughts|
|The Lung Exam||Putting It All Together||Commonly Used Abbreviations|
|Cardiovascular Exam||Medical Links||References|
|Exam of the Abdomen|
The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures.
In the discussion that follows, illustrative examples are frequently included and have been set off from the text by means of quotation marks and italics.
Chief Complaint/Chief Concern:
The presentation begins with a one sentence description of the patient and the reason prompting their evaluation (i.e. the Chief Complaint). This is a teaser that sets the tone for the information to follow. It should not be too inclusive.
"Mr. H is a 50 year old male with AIDS who presents for the evaluation of fever, chills and a cough over the past 3 days."History of Present Illness (HPI):
"Mr. H has been HIV + since 1987; his CD4 count in June of '97was 150 and viral load approximately 50,000. Past opportunistic infections have included: PCP pneumonia 12/95; CMV retinitis 1/96; and Kaposi's Sarcoma first noted on his skin 1/96. He currently takes 3TC, AZT, and Indinavir, all of which he has been receiving for approximately one year. He also takes Bactrim Single Strength tablets on a daily basis, along with Fluconazole troches PRN for thrush. He claims to be 100% compliant with all of his medication. He is homosexual though he is currently not sexually active. He has never used intravenous drugs."This information is not, in a strict sense, part of the present illness. However, it providescritical information that will have a direct bearing on the listener's interpretation of this patient's active problem. Your ability to determine which background to incorporate into your HPI will improve with time and exposure. The details of the patient's acute problem are then presented:
"Until 1 week ago, Mr. H had been quite active, walking up to 2 miles a day without feeling short of breath. Approximately 1 week ago, he began to feel dyspneic with moderate activity. This progressed to the point that, 1 day ago, he was breathless after walking up a single flight of stairs. 3 days ago, he began to develop subjective fevers and chills along with a cough productive of rust-colored sputum. There was associated nausea but no vomiting. He has spent most of the last 24 hours in bed. He denies head ache, photophobia, stiff neck, focal weakness, chest pain, hemoptysis, abdominal pain, diarrhea or other complaints. There is no know history of asthma, COPD or chronic pulmonary condition. His current problem seems different to him then his past episode of PCP."
This section documents the course of the patient's most active problem. It concludes with a list of "pertinent negatives" that are meant to exclude, on the basis of history, other possible diagnoses that are known to have a similar symptom complex. In a patient with an HIV related illness, this review might actually be much more extensive than that provided above due to the diffuse, multi-organ system involvement that occurs with this disease. Note that the patient's baseline functional status is described, allowing the listener to gain some sense of the degree of impairment caused by the acute medical problem. If a patient is a poor historian, confused or simply unaware of all the details related to their illness, state this and move on. Historical information can be obtained from family, friends, etc. If this is the case, make sure that you note the source.
If, for example, a patient complains of both chest pain and shortness of breath, they may well be secondary to a single underlying process such as myocardial ischemia resulting in heart failure. When the problems are completely unrelated, the "dominant issue" (as determined by the presenter) is treated first, followed by a discussion of the secondary complaint. This can get quite complicated when multiple problems exist in parallel.
Review of Systems: The critical positive and negative findings discovered during a review of systems are generally incorporated at the end of the patient's history, as was done above. These questions are designed to uncover illnesses which might "travel with" the main problem and attempt to identify commonly occurring complications (e.g. hemoptysis can be a sequelae of pulmonary infection). The listener needs this information to help them put the remainder of the history in appropriate perspective. Any positive responses to a more inclusive ROS that covers all of the other various organ systems are then noted. The extent to which this is repeated is left to the discretion of the presenter. If it is completely negative, it is generally acceptable to simply state, "ROS negative."
Past Medical History: Note is made of any other past medical problems which the patient has that are not related to the current complaint. Those items mentioned above are not repeated.
"The patient's past medical history includes:
"Past surgical history is remarkable for:
"The patient takes the following medications:Smoking and Alcohol (and any other substance abuse): Cigarettes and alcohol are highlighted because their use is so widespread and the deleterious effects associated with prolonged exposure well documented. Any additional substance abuse (e.g. cocaine use, intravenous drugs, etc.) should also be mentioned.
AZT 300 mg, 1 PO, BID
Indinavir 750 mg, 2 PO, TID
3TC 150 mg, 1 PO, BID
Lansoprazole 20 mg, 1 PO, BID
Lopressor 50 mg, 2 PO, BID
Clotrimazole Troches 100 mg, 1 PO TID PRN
Naprosyn 250 mg, 1-2, PO, BID PRN
He has no allergies"
"Mr. H smokes 1 pack of cigarettes per day and has done so for 20 years. He drinks approximately 1 glass of wine per week. He denies any other drug use."Social/Work History: This includes a brief description of the patient's work and home environments. Sexual history, if relevant to the oral presentation would also be presented here. Any unusual work-related exposures should be noted.
"Mr. H works as an accountant for a large firm in Boston. He lives alone in an apartment in the city."Family History: Emphasis is placed on the identification of illnesses within the family (particularly among first degree relatives) that are known to be genetically based and therefore potentially inherited by the patient. This would include: history of coronary artery disease, diabetes, certain neoplasms, etc.
"Both of the patient's parents are alive and well (his mother is 78 and father 80). He has 2 brothers, one 45 and the other 55, who are also healthy. There is no family history of heart disease or cancer."Physical Exam: This begins with a one sentence description of the patient's appearance along with their vital signs. In general, only '+' findings are noted. It is also reasonable to mention the absence of certain things that the listener will find helpful in excluding particular diagnoses. If, for example, a patient has shortness of breath secondary to asthma, the presenter might mention that rales, elevated jugular venous pressure and an S3 were not present, indicating that congestive heart failure is an unlikely diagnosis. Some listeners expect the entire physical examination to be recounted, including "normal findings," particularly if the presenter is a student. The following exam is listed in more detail then is necessary. However, it should give you an idea of how abnormalities as well as "normal findings" are reported.
"Mr. H was seated on a gurney in the ER, breathing comfortably through a face mask oxygen delivery system. Breathing was unlabored and accessory muscles were not in use.Lab results, Radiological Studies, EKGs: In general, only lab values which are abnormal are mentioned. Similarly, if the interpretation of radiological studies and EKGs are directly relevant to the case, they are discussed.
- Vital signs were: Temp 102 Pulse 90 BP 150/90 Respiratory Rate 20 O2 Sat (on 40% Face Mask) 95%
- Head, Eyes, Ears, Nose, Throat: Pupils equal, round and reactive to light; Tympanic membranes pearly gray with cone of light well seen; Sclera anicteric; No thrush was noted; Mucosa was dry and without lesions; There was no appreciable adenopathy; Thyroid non-palpable; JVP was less then 5 cm.
- Lungs: Crackles and Bronchial breath sounds noted at right base. E to A changes present. No wheezing or other abnormal sounds noted over any other area of the lung. Dullness to percussion and increased fremitus was also appreciated at the right base.
- Cardiac: Rhythm was Regular. Normal S1 and S2. No murmurs or extra heart sounds noted.
- Abdomen: Symmetric appearing; soft, flat, non-tender; no palpable masses; well healed Right upper and lower quadrant incisions at sites of prior apppendectomy and cholycystectomy.
- Rectal Exam: Brown stool in rectal vault, guiac negative; no masses; prostate small, smooth and non-tender.
- GU: Testes descended bilaterally; no masses; no hernia; penis without lesions.
- Extremities: No evidence of clubbing, cyanosis or edema; Dorsalis Pedis and Posterior Tibial pulses 2+ and equal bilaterally.
- Skin: a 2x3 cm raised, purplish, non-tender, non-blanching area noted on left mid-shin; no other skin abnormalities identified.
- Neurologic Exam:Mental Status: Awake, alert, appropriate and completely oriented.
Cranial Nerves: 2 thru 12 tested and intact.
Motor: Strength 5/5 all extremities.
Cerebellar: Finger to nose well done.
Reflexes: 2+ at ankles, knees, biceps and triceps
Sensation: Intact to light touch and pin prick bilaterally; proprioception normal; vibration normal.
Ambulation: Normal gait; negative Romberg."
"Mr. H's lab work was remarkable for: White count of 18 thousand with 10% bands; Normal Chem 7 and LFTs. Room air blood gas: pH of 7.45/ PO2 of 55/PCO2 of 30. Sputum gram stain remarkable for an abundance of polys along with gram positive diplococci. CXR showed a dense right lower lobe infiltrate without effusion."Impression and Plan: This is your opportunity to summarize the important aspects of the history, physical exam and supporting lab tests and formulate a differential diagnosis as well as a plan of action that addresses both the diagnostic and therapeutic approach to the patient's problems.
"Mr. H is an HIV + male with a low CD 4 count and high viral load who presents with an acute pulmonary process. The rapid progression, focality of findings on lung exam and radiography, along with the sputum gram stain suggest a bacterial infection, in particular Streptococcal pneumonia. Other pathogens to consider include H Flu and, less commonly, Legionella. While he is certainly at risk for PCP, his presentation, compliance with PCP prophylaxis and statement that his current illness seems different then past PCP infection would argue against this as the etiologic agent. Mycobacterial infection also seems unlikely. Viral infections and neoplastic processes like CMV or Kaposi's Sarcoma of the lung do not generally give this clinical presentation. Furthermore, the data does not support the existence of either a primary cardiac or noninfectious pulmonary process.A Few Practical Tips:
The Current plan then is:
- Follow up on cultures of sputum and blood.
- Obtain sputum for silver staining to r/o PCP
- Begin treatment with IV cefuroxime; Hold off on empiric treatment for PCP.
- Continue O2,with goal to keep sats greater then 92%
- IV fluid replacement with Normal Saline at 125cc/H for next 24 hours to correct mild hypovolemia, with plan to reassess volume status at that time
- If patient does not show improvement (or worsens) and cultures are unrevealing, consider bronchoscopy as a means of making more definitive diagnosis."
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