GUIDE TO PATIENT ENCOUNTER NO. 1: HISTORY-TAKING AND PHYSICAL EXAMINATION July 1, 2011 1.

The class will be divided into 25-26 groups, each composed of 4-5 students each. Each small group will be assigned to 1 clinical preceptor. 2. In this activity, your preceptor will engage your small group in an interactive discussion with demonstration and return-demonstration of History-Taking and Physical Examination with more emphasis on the Vital Signs, Head and Neck (overview only, because the more detailed approach is reserved for specific organ modules throughout the schoolyear), anterior thorax, posterior thorax and abdomen. You may skip the Neuro Exam because this will be discussed separately in a plenary lecture. 3. You are advised to study your official textbook Bates' Guide to Physical Examination and History Taking, Ninth Edition and review its video cd on PE. 4. Your first task is to make sure that your group is complete with all the materials which include a bp apparatus, stethoscope, penlight, and tongue depressors, otosope, and ophthalmoscope, necessary in taking the health history and performing a complete PE of a patient. 5. As a group, your next task is to elicit a complete health history from the invited patient. To make this activity more organized, it would be of help to divide the work among yourselves. For example, you may assign each member to ask about the chief complaint, HPI (this is the body of your history so more historians are needed here to invite the patients story), Past Med Hx, ROS, etc. It would be good too to take turns in your questioning and avoid asking the patient all at the same time. Be organized and observe proper sequencing. 6. Under the supervision of your clinical preceptor, your next task is to do a complete Physical Examination of an actual patient but due to time constraints, the following organ system PE may be waived if NOT INDICATED, and are therefore optional:
a. b. c. d. e. Ophtha: Tests of Vision, Visual Field Tests ENT: Auditory tests, Weber, Rinne, Romberg Complete Neurologic exam Genital and Rectal exams Musculoskeletal System

7. The following are the salient points in history-taking and physical examination which are expected of you:

HISTORY-TAKING In taking a patients health history, the student is expected to:

ATTITUDE Greet the patient Introduce self Verify patients identity Acknowledge patients companions Establish rapport Explain process of history taking Treat the patient with dignity and respect Thank the patient at the end of the interview KNOWLEDGE Gather general data Identify the chief complaint Elicit history of present illness Elicit past medical history Elicit family history Elicit review of systems SKILLS Begin by asking open ended questions Progress to focused questions Minimiz interrupting patient Ask questions using simple terms Ask clarificatory questions Clarify symptoms using PQRST: Precipitating/Provoking Quality Radiation Relieving Severity Timing

PHYSICAL EXAMINATION In performing a physical examination, the student is expected to:

ATTITUDE Explain process of physical examination Obtain consent for physical examination Respect patients privacy Explain before each action Conduct self with dignity

KNOWLEDGE AND SKILLS With the patient sitting,

General Survey and Vital Signs Observe the patients general state of health, height, weight, posture, motor activity, gait, dress, grooming, facial expressions, level of awareness Use appropriate technique in taking patients: BP HR RR Temperature SKIN Inspect, palpate the hair and nails, hands, upper extremities Head Examine the hair, scalp, skull and face Eyes When appropriate, check visual acuity, screen the visual fields; inspect the eyelids, sclera and conjunctiva of each eye; check pupillary reaction; assess extraocular movements When appropriate, inspect the ocular fundi with an ophthalmoscope Ears Inspect the auricles, canals and drums When appropriate, check auditory acuity

Nose and Sinuses Examine the external nose When appropriate, inspect the nasal mucosa, septum, turbinates with a light and a nasal speculum; Palpate for tenderness of the frontal and maxillary sinuses Throat (or mouth and pharynx) Inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils, pharynx Neck Inspect and palpate the cervical lymph nodes and thyroid glands Back and Posterior Thorax Inspect and palpate the spine and muscles of the back Posterior Thorax Inspect, palpate and percuss the posterior thorax Auscultate; listen to breath sounds, if indicated, listen to transmitted voice sounds Breasts and Axillae When indicated, in a woman, examiner inspects the breasts with her arms relaxed, then elevated, then with her hands pressed on her hip; inspects the axillae and feel for the axillary nodes Anterior Thorax Inspect, palpate, percusse the chest; Auscultate; listen to breath sounds, any adventitious sounds, and if indicated, transmitted voice sounds

With the patient lying supine,

Cardiovascular System Observe the JVP, carotid pulsations; when indicated, measure the JVP appropriately, listen to carotid bruits, when indicated; Inspect and palpate the precordium Note the location, diameter, amplitude and duration of apical impulse; Auscultate; listen at the apex, lower sternal border with the bell; listen at each auscultatory area with diaphragm Abdomen Inspect, auscultate, percuss abdomen; Assess the liver and spleen by percussion, then palpation Lower Extremities Examine the legs, palpates for pitting edema When indicated, palpate the femoral, popliteal pulses, inguinal lymph nodes Note any deformities, limitation of range of motion

8. Your final task is to submit an INDIVIDUAL type-written write-up on your patients history and PE (following the format taught to you by Dr. Michelle De Vera in her lecture ) on July 4, 2011, Monday, to be collected and submitted by your student beadle to our admin staff, Ms. Maricel Go not later than 12:00 pm. Thanks and good luck! Amiel C.E. Dela Cruz, MD Medicine Coordinator