I. Chapter one Overview: physical examination and history takinga. Focus vs comprehensiveComprehensive AssessmentFocused Assessment

-Is appropriate for new patients in the office or hospital-Provides fundamental and personalized knowledge about the patient-strengthens the clinician-patient relationship-helps identify or rule out physical causes related to patient concerns-Provides baselines for future assessmentscreates platform for health promotion through education and counseling-Develops proficiency in the essential skills of physical examination-Is appropriate for established patients, especially during routine or urgent care visits-Addresses focused concerns or symptoms-Assess symptoms restricted to a specific body system-Applies examination methods relevant to assessing the concern or problem as precisely and carefully as possible.

b. Know common concern in each systemi. c. Know differential diagnosis 101i. 7 attributes indicate the presence or absence of symptoms relevant to the differential diagnosis, which identifies the most likely diagnoses explaining the patients condition1. Each principal symptoms should be well-characterized, with descriptions of a. 1. Locationb. Qualityc. Quantity or severityd. Timing including onset, duration and frequencye. The setting in which it occurs;f. Factors that have aggravated or relieved the symptom g. Associated manifestationsd. Prepare physical exam i. Is objective data: it is important to note that the key to a throught and accurate physical examination is developing a systematic sequence of examination. As first, you may need notes to remember what to look for as you examine each region of the body; but with a few months of practice you will acquire a routine sequence of your own. ii. important to minimize the number of times you ask the patient to change position from supine to sitting, or standing to lying position. 1. Comprehensive physical exama. General survey: observe general state of health, height , build, sexual development, weight, posture, gait, dress , groom, hygiene, odors, facial expressions. LOCb. VSSc. Skind. HEENTe. Neckf. Backg. Thorax lungsh. Breast, axillae, epitrochlear nodesi. Anterior thorax and lungsj. Cardiok. Abdomenl. Lower extremitiesm. Peripheral vascular systemn. Musculoskeletal systemo. Nervous systemi. Mental status: patients orientation mood abnormal perceptions.ii. Cranial nervesiii. Motor system iv. Sensory systemv. Reflexesp. Rectal examq. Genital and rectal exam in womene. position suggest for each systemf. Techniques on examination: describes the initial steps of the physical examination: preparing for the examination, conducting the general survey, and taking the vital signs. i. Beginning the examination: setting the stage1. Reflect on your approach to the patient 2. Decide on the scope of the examination: comprehensive vs focused exam.3. Choose the examination sequence 4. Adjust the lighting and the environment 5. Make the patient comfortable. II. Chapter two Clinical reasoning, assessment and recording your findingsa. How to report (1st part of chapter) i. Documentation: 1. Remembereverything in a patients medical record is a legal document2. When using the patients own words to describe something, be sure to use quotation maks around the statement 3. Organize information properly and use medical terminology4. Documentation should be done according to hospital policyIII. Chapter three Interviewing and the health historya. Know advanced interview i. Challenging patients: the silent patient. The confusing patient. The patient with impaird capacity. The talkative patient. The angry or disruptive patient. The patient with a language barrier. The patient with low literacy or low health literacy. The hearing impaired patient. The blind patient. The patiet with limited intelligent. The patient seeking personal advise. The seductive patient. ii. SENSITIVE TOPICS: the sexual history. The mental heal history. Alcohol and prescribed and illicit drug use. Intimate partner and family violence. Death and dying. 1. REMEMBER IT IS ALWAYS IMPORTANT TO LISTEN TO THE PATIENT AND CLARFY THE PATIENTS CONCERNS. iii. Silent patient. Silence has many meanings and purposes. b. The challenging patient: interviewing patients may precipiatate a number of reactions and behaviors that are challenging, difficult, and sometimes even threatening. Your ability to handle these situations will evolve throughout your career.c. The silent patient. Patients frequently fall silent for short periods to collect thoughts, remember details or decide whether you can be trusted with certain information. The period of silence usually feels much lonver to the clinician than it does to the patient. d. Confusing patient. Some patients have multiple symptoms or somatization disorder. Focus on the meaning or function of the symptoms and guide the interview into a psychosocial assessment. At other times you may be baffled, frustrated, and confused. The history is vague and difficult to understand, and patients may describe symptoms in bizarre terms. e. AMS: some patients cant provide their own hisotries because of delirium, dementia, or other conditions. Others cant relate certain parts of the history. In such cases, determine whether the patient has decision making capacity, or the ability to understand information related to health, to make medical choices based on a reason and a consistent set of values and to declare preferences about treatments. Many patients with capacity, obtain their consent before talking about their health with others. Maintian confidentiality and clarify what you discuss with others. Your knowledge about the patient can be quite comprehensive, yet others may offer surprising and important information. Consider dividing the interview into 2 segmentsone with the patient and the other with both the patient and a second informant. f. Language barrier: the ideal interpreter is a neutreal, objective person trained in both languages and cultures. Avoid using family members or friends as interpreters: confidentiality may be violated. Make clear short and simple questions with interpreter. Speak directly to the patient.

IV. Sensitive topicsa. The sexual history: I routinely ask all patients about their sexual function.i. When was the last time you had intimate physical contact with someoneDid that contact include sexual intercourseii. Do you have sedx with men women or both the health implications of iii. How many sexual partners have you had in the last 6 monthsiv. Because no explicit risk factors may be present it is important to ask all patients do you have any concernts about HIV or AIDS ask about routine condom useb. Mental health history:i. Ask open ended questions initially Have you ever had any problem with emotionalr or mental illnesses them more specific have you ever vistited a counserl or psycho therapist have you or a family member ever been hospitalized for a mental health problem?c. Alcohol and drug history:i. Clinicians should routinely ask about current and past use of alcohol or drugs, patterns of use, and family history. ii. CAGE QUESTIONS1. Have you ever felt the need to cut down on drinking 2. Have you ever felt annoyed by criticism of drinking3. Have you ever felt guilty about drinking4. Have you ever taken a drink first thinkg in the morning to steady your nerves or get rid of a hangover?d. Family violence: start with general normalizing questions : because abuse is common in many womens lives, ive begun to ask about it routinely. Are there times win your relationships that you feel unsage or afraid? Consider physical abuse in the following settings: i. If injuries are unexplained, seem inconsistent with the patients story, are concealed by the patient, or cause embarrassmentii. If the patient has delayed getting treatement for traumaiii. If there is a past history of repeated injuries or accidentsiv. if the patient or a person close to the patient has a history of alcohol or drug abusev. if a partner tries to dominate the interview, will not leave the room ,or seems unsually anxious or solicitouse. Death and the dying patient: work through your own feelings with the help of reading and discussion. Kubler-ross has described 5 stages in our response to loss or the anticipatory grief of impending death: denial and isolation, anger, bargaining depression or sadness, and acceptance. These stages may occur sequentially or overlap in different combinations.i. Dying patients rarely want to talk about their illnesses all the time, nor do they wish to confise in everyone they meet. Give them opportunites to talk and then listen receptively, but be supportive if they prefer to stay at a social level. Understanding the paiteints wishes about treatment at the end of life is an iimportant clinician responsibility. Even if discussions of death and dying are difficult, you must learn to ask specific questions. Ask bout DNR status. f. Society and ethics: cultural humility.i. Culture is a system of shared ideas, rules and meanings that influences how we view the world, experience it emotionally, and behave in relation to other people. ii. Ethnicity iii. Clinicials are increasingly challenged to adopt cultureal humility which is a process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflextive practitioners. This process includes the difficult work of examining cultural beliefs and cultural systems of both patients and providers to locate the points of cultural dissonance or synergy that contribute to patients health outcomes. iv. We have a 3 point frame work in a clinician-patient relationshiop1. Self awareness; as clinicians, we face the task of bringing our own values and biassees to a conscious level. Values are the standards we use to measure our own and others beliefs and behavioursa. Biases are the attitudes or feelings that we attach to perceived differences for example the way and individual relates to time, which can be a culturally determined phenomenon . 2. Enhanced commincation and learning from the patient. a. Maintain an open, respectful, and inquiring attitude. What did you hope to get from this visit. If you have established rapport and trust, patients will be willing to teach you. Be ready to acknowledge your ignorance or bias. 3. Collaborative partnershipsa. Communication based on trust, respect, and a willingness to reexamine assumptions heals allow patients to express concerns that run counter to the dominant culture. You, the clinician must be willing to listen to and validate these feelings, and not let your own feelings preven you from expliring painful areas. You also must be willing to reexamine your beliefs. b. g. Sexuality in the clinician-patient relationship. i. The emotional and physical intimacy of the clinician-patient relationship may lead to sexual feelings. If you become aware of such feelings, accept them as a normal human response, and bring them to the conscious level so they will not affect your behavior. ii. EthicalConsiderations: nonmaleficence: fist do no harmiii. Beneficence do goodiv. Autonomy patients have the right todetermine what is in their own best interestv. Confidentiality that we are oblicagated not to tell others what we learn from our patientsh. V. Chapter 4 beginning the physical examination: general survy, VSS, and paina. Common concern symptomsi. Changes in weightii. Fatigue and weaknessiii. Fever, chills, night sweats.iv. painb. BMIi. (Weight in lbs X700/ height in inches)/height in inches or weight in (KG)/ height in m^2ii. 1 inch=2.54 cm; 100 cm=1 meterc. Classification of BMIi.