Societys Expectation

Physician must be :

Altruistic
Basic Med.
Knowledable
Skill
Skillful achievement
Comunni-
Dutiful cation Skill
 Learning Outcome

Medical Education
Basic Medical Skill

1. History Taking
2. Physical Examination
3. Technical Procedur
4. Interpretation of the Results
5. Clinical reasoning- deductive
6. Emergency and critical care
7. Communication Skills
Skills Laboratory

1. Communication Skills
2. Physical Examination Skills
3. Therapeutic Skills
4. Laboratory Skills
Faculty of Medicine GMU
Pre test Probability

- Prevalence
- Ax
- PD
Penunjang
- Laboratorium
- USG Gold
- Ro. Standard
- dsb
Decision Analysis :
Making Prognosis
Deciding Best Therapy

Post test Probability/

Dx. pasti
Clinical Dx.
 Clinical Diagnostic
Strategies
Aims :
Labels patient & classifies their
illness
Identifies their likely fates or
prognosis

Propels us toward spesific

treatments
Do more good than harm
 E/

The Illness

Exhibit
DERANGEMENT
Symptom

Anatomic
Biochemical
Physiological
Psycological Sign

DISEASE
4 strategies of Clinical Dx.
Strategy # 1
= pattern recognition
= gestalt method (considering or
treating what a person experiences and
believes as a whole and individual thing )
Def :
The instaneous realization that patients
presentation conform to a previously
learned picture/pattern of disease
Strategy # 1

Auditary - the speech of

patient
Odor :
Diabetec acidosis
Liver failure
Lung abscess
Strategy #2

= the multiple branching method

Algorithm
Triage
Strategy #3

= Go do complete hystory &

physical

Hystory taking
Physical examination
 Strategy #4

= Hypothetico-deductive strategy

the earlist clues of the patients

Short list of potential Dx/action From :
History & Physical Colleague
Paraclinic(lab., x-ray etc) Teacher

HYPOTHESIS Deduction/
Reduce the list
HISTORY TAKING
Dr. I Gede Arinton,SpPd,MKom,MMR
The Head of Internal Medicine
Margono Soekarjo Hospital
Medical Faculty UNSOED
PURWOKERTO
 seeking
PATIENT help DOCTOR

to regain
or
retain health
TACKLING "THE FIVE DS" OF HEALTH:
- DISEASE
- DISCOMFORT
- DISABILITY
- DEATH
-
DISSATISFACTION
 set the stage for :

* making a diagnosis
* determining prognosis
* carrying out treatment
* promoting health
* preventing disease

* DESCRIPTION OF PATIENT
History * CHIEF COMPLAINT
* HISTORY OF THE PRESENT ILLNESS
* PAST MEDICAL HISTORY
Taking * SOCIAL AND OCCUPATIONAL HISTORY student learn skills
* FAMILY HISTORY
* REVIEW OF SYSTEMS --->PD

THE PATIENT'S
MEDICAL HISTORY
Introduction

HISTORY List of Physical

Problem Examination
TAKING

Hypothesis
Lab
Special
Dx
THE TECHNIQUES OF
SKILLED INTERVIEWING
Active listening
Adaptive questioning
Nonverbal communication
Facilitation
Echoing
Empathic responses
Validation
Reassurance
Summarization
Highlighting transitions
Identifying data

Name
Age
Gender
Occupation
Marital status
CHIEF COMPLAINT
Definition :
statement of the primary reason for
the patient seeking medical
attention, often stated in the
patient's own words.
The chief complaint could be :
a pain
a symptom of discomfort
a loss of usual function
troublesome bodily change
a psychiatric symptom
CHIEF COMPLAINT
Why do patients seek care at a
particular time? :
1. the symptoms of the illness
increase to the point that they are
unbearable and the patient realizes
s/he needs help
2. anxiety
3. the symptom in the chief
complaint is sometimes a "ticket of
admission" to the physician's
office or emergency room;
HISTORY OF PRESENT
ILLNESS
an elaborated description of the
patient's chief complaint.
The goal is :
to obtain a coherent, orderly picture
of how the patient's chief complaint
developed,
linking the chronological emergence
of symptoms within the overall life
circumstances of the patient.
HISTORY OF PRESENT
ILLNESS
Most important part of the
medical history, providing the
essential information for making
the diagnosis.
Physician works in partnership
with the patient to develop an
accurate and useful
understanding of the illness in
the patient's life.
HISTORY OF PRESENT
ILLNESS
The Symptom
Seven Core Dimensions:
1. Location:
Where is the problem located?
Does it radiate?
Can you take one finger and
show me exactly where it hurts?
HISTORY OF PRESENT
ILLNESS
The Symptom
Seven Core Dimensions:
2. Quality :
What is it like?
How does it feel?
Before we go on further, can you
describe the pain in some more
detail? Was it sharp or dull?
Did it come and go or just stay
there all the time?
HISTORY OF PRESENT
ILLNESS
The Symptom
Seven Core Dimensions:

3. Quantity/Severity:

How bad is it?

On a 1 to 10 scale, where 1 represents
no pain and 10 represents the worst
pain.
HISTORY OF PRESENT
ILLNESS
The Symptom
Seven Core Dimensions:
4. Chronology/Timing:
When did each symptom or problem
begin?
How did the events unfold?
How often does it occur?
Was this your very first episode of chest pain
or have you ever had chest pain before?
What happened next?
How frequently are you having the diarrhea?
HISTORY OF PRESENT
ILLNESS
The Symptom
Seven Core Dimensions:
5.Setting/Context:
What environmental factors, activities,
emotional reactions or other
circumstances may have contributed to
or led up to the problem?

Can you tell me what you are doing when

you experience this chest pain?
Is there anything else that comes to mind
about the situations in which these
headaches develop?
HISTORY OF PRESENT
ILLNESS
The Symptom
Seven Core Dimensions:
6.Modifying Factors :
What makes it better? What makes it
worse?

Can you tell me what tends to decrease the

intensity of the pain?
Have you tried any medications to control
the diarrhea?
Have you noticed anything that makes the
pain worse?
Is your shortness of breath worse when you
lie down?
HISTORY OF PRESENT
ILLNESS
The Symptom
Seven Core Dimensions:
7.Associated Symptoms/
Manifestations :
What other symptoms occur
preceding, coincidentally, or
following the primary symptom?
Pertinent positives and negatives
Organ specific review of symptoms
Do you have any other sensations or
feelings when you have these headaches?
Did you notice any pain or discomfort in
your jaw or left arm when you experienced
the chest pain?
HISTORY OF PRESENT
ILLNESS
Tips for Eliciting the HPI :
1.Types of Questions:
Open ended :
Generally used at the beginning of the
interview and throughout.
" What is the pain like?

"Tell me about that".

HISTORY OF PRESENT
ILLNESS
Tips for Eliciting the HPI :
1.Types of Questions:
Direct :
To the point.
"What day did the pain start?"
"How many times have you had diarrhea
today?"

Designed :
to get specific information about a
particular point in the history
HISTORY OF PRESENT
ILLNESS
Tips for Eliciting the HPI :
1.Types of Questions:
Multiple :
To be avoided.
Questions like "Do you have any change in
bowel or bladder habits, blood in your
stool or abdominal pain?"
By the time you get to the end of the
question, both you and the patient have
forgotten exactly what you asked.
HISTORY OF PRESENT
ILLNESS
Tips for Eliciting the HPI :
1.Types of Questions:
Laundry List:
Somewhat similar to Multiple.
Useful in patients who have difficulty in
describing a symptom.
"Is the pain sharp or dull or burning or
throbbing?"
Try the open ended "What is the pain like?" first.
HISTORY OF PRESENT
ILLNESS
Tips for Eliciting the HPI :
2. Ways to Enhance Communication
Be sure the patient is comfortable.
Be sure you are ready to listen.
Introduce yourself
Be respectful of the patient (Call the
patient by his or her surname unless
told otherwise)
HISTORY OF PRESENT
ILLNESS
Tips for Eliciting the HPI :
2. Ways to Enhance Communication
Facilitate (These are phrases and
gestures that encourage the patient to
tell the story, such as leaning forward,
nodding your head, saying "go on", or
"uh huh"
Empathize (Put yourself in the patient's
shoes. How would you feel?
HISTORY OF PRESENT
ILLNESS
Tips for Eliciting the HPI :
2. Ways to Enhance Communication
Compassion
Silence
Confront and clarify (If something
doesn't make sense or is contradictory,
ask the patient to make it clear
Reflect or repeat what you have heard or
understand back to the patient
HISTORY OF PRESENT
ILLNESS
Tips for Eliciting the HPI :
2. Ways to Enhance Communication
Use summary statements occasionally
Use transition statements
Use a concluding question or
statement :
"Is there anything else you can think of?
"Is there anything else that might be important?"
PAST MEDICAL HISTORY
is a record of the patient's past
experiences with illnesses and
medical treatments--
information :
adds to the physician' s
understanding of the presenting
problem or that leads to diagnostic
possibilities to explain the current
illness
PMH often has a great impact on
eventual patient management.
FAMILY HISTORY
a systematic exploration of the
presence or absence of illness
in the patient's family-
information may be helpful in
diagnosing the patient's present
illness or suggest possible risks
for future disease.
PAST MEDICAL HISTORY
Core Elements of the PMH :
1. Childhood Illnesses:
Inquire about serious or chronic
illnesses
2. Adult Illnesses:
illnesses in general inquire specifically
about common conditions
3. Obstetric/Gynecologic History:
Female patients
pregnancies and outcomes
miscarriages or abortions
PAST MEDICAL HISTORY
Core Elements of the PMH :
4. Psychiatric Illnesses:
hospitalizations, suicide attempts,
treatments (include dates)
5. Surgeries:
dates, indications, outcomes and
complications.
6. Injuries/Trauma:
serious accidents or injuries (include
dates and complications)
Hospitalizations:
PAST MEDICAL HISTORY
Core Elements of the PMH :
7. Medications:
hormone replacement and birth
control pils (include dosage and
dosing regimen)

8. Allergies/Drug intolerance:
medication, environmental and food
allergies.
medication side effects
PAST MEDICAL HISTORY
Core Elements of the PMH :
9. Transfusions:
transfusions of blood and blood
products (include dates, units and
reactions).

10. Hazardous Exposures:

occupational and home exposures e.g.
any chemicals, dust or fumes at work
or at home that might be dangerous?
FAMILY HISTORY
Core Element of the FH :
1. Parents, siblings, and children:

health status, major illnesses, age at

and causes of death

2. Other family members:

genetic factors : diabetes, CAD,
hypertension, cancers, lipid
disorders, psychiatric illnesses
including alcoholism

Illnesses similar to the patient's

PHYSICAL EXAMINATION
(PE)
 INTRODUCTION

ERA OF HIGH TECHNOLOGY

PHYSICAL EXAMINATION ???

INTRODUCTION

Proper performance of PE :
Routine ordering lab. Test & X-ray
--guided by History Taking & PE
interpretation of result lab.test,
imaging, even biopsy -need PE
Patients trust -- PE doctor
DEFINITION
The process of examining the patients
body to determine the presence or
absence of physical problems.
It includes :
inspection (looking)
palpation (feeling)
auscultation (listening)
percussion (producing sounds )
 Inspection :

Method of observation used during

physical examinations. Inspection, or

"looking at the patient," is the first

step in examining a patient or body

part
 Palpation is the method
Percussion is a method
of "feeling" with the hands
of "tapping" on body parts
during a physical examination
with fingers, hands, or small
instruments

Auscultation is a method used to

"listen" to the sounds of the body
by using a stethoscope.
HISTORY
Hippocrates (c.460-377BC) :
the 'Father of Medicine'

by refusing to use gods to explain

illnesses and disease-a science
rather than a religion.

stressed the importance of

observation
HISTORY
Leopold Auenbrugger:
An Austrian physician
the inventor of percussion -by tapping on
the chest with the finger
the lungs wheel percussed, give a sound
like a drum
consolidated, as in pneumonia-= the
thigh is taped.
the heart -dull sound
injected fluid into the pleural cavity, -- by
percussion to tell exactly the limits of the
fluid present
He pointed out how to detect cavities of
the lungs, and how their location and size
might be determined by percussion
HISTORY
Jean-Nicholas Corvisart:
Napoleon's personal physician
popularized percussion as a
diagnostic tool
With a picture -Cause of death
Laenec:
The inventor of stethoscope-a
perforated wooden cylinder one foot
long one end of a wooden
-listening to the transmitted sound
at the other end.
 Laennec Piorry Flexible
stethoscope Stethoscope Stethoscopes

Binaural
Stethoscopes

Electronic
Stethoscopes
INTRODUCTION

VITAL SIGN

SYSTEMIC REVIEW
VITAL SIGN
(VS)
INTRODUCTION
VS include the measurement of:
Temperature
Respiratory rate
Pulse
Blood pressure
provide critical information
("vital") about a patient's state
of health.
INTRODUCTION
In particular, they:
Can identify the existence of an
acute medical problem.

rapidly quantifying the magnitude

of an illness

how well the body is coping with

the resultant physiologic stress.
INTRODUCTION

In particular, they:

Are a marker of chronic disease

states (e.g. Hypertension)

To use these values as the basis

for management decisions.

VITAL SIGN :
Body temperature
Blood Pressure
Pulse Rate
Respiration Rate
Equipment Needed

A stethoscope
A blood pressure cuff
A watch displaying seconds
A thermometer
General
Considerations
The patient should not have had :
Alcohol
Tobacco
Caffeine
Performed vigorous exercise
within 30 minutes of the exam.
General
Considerations
Ideally the patient should be:

sitting with feet on the floor

their back supported.

The examination room should be

quiet and the patient comfortable.

General
Considerations
History of :
hypertension;

slow, rapid or irregular pulse

and current medications

should always be obtained.

General
Considerations
In addition :
peak expiratory flow,

oxygen saturation or

blood glucose level.

etc
Temperature

can be measured is several

different ways:
Oral
Glass, paper, or electronic
Normal 98.6 F/37 C
Axillary
Glass or electronic
Normal 97.6 F/36.3 C
Temperature
Rectal (or "core")
Glass or electronic
Normal 99.6 F/37.7 C
Aural (in the ear)
Electronic
Normal 99.6 F/37.7 C
axillary < acurrate rectal
Fever oral 100.5 F/38.5 C or
above.
Pulse

1. Sit or stand facing your

patient.
2. Grasp the patient's
wrist with your free
(non-watch bearing)
hand (patient's right
with your right or
patient's left with your
left).
Pulse

3. Compress the radial artery with

your index and middle fingers.
Note :
the rate,
the regularity,
and amplitude
of the pulse you are measuring.
Pulse

Count the pulse for 15 seconds

- multiply by 4.

Count for a full minute if the

pulse is irregular.

A normal adult heart rate is

between 60-100 beats per minute.
Pulse
 Contour

Pulse
- Start with a swift upstroke----> the
peak sys. press.--> followed by a more
gradual decline --->- approximately at
the end of vent.sys. ---> sec. & normal
upstroke ( dicrotic wave) by the closed
The pulse may be palpated of the aortic valve
accessible arteries : Normally impapable
( only by One wave in sys.
- a. radialis ------> very common sphygmograph) and one in dia.
- a. brachialis wher palpable
- a. temporalis ---> anesthesiologist
- a. dorsalis pedis----> DM Pulsus Bisferiens:
- a. carotis -----> aortic pulse wave - 2 wave in sys.
In :
- AI + :
*AS moderate
Volume * HSS
* Hyperthyroidism

Rate Bounding or Collapsing Pulsus (

Corrigan, Water-Hammer pulse):
- upstroke-->very sharp
- downstroke -> precipitously
Rhytm - pistol-shot sound
In :
- HT Ess.+ rigid aorta
- Hyperthyroidism
- Emotional state
- AI
- PDA
- AV-fistule

Plateau pulse(Pulsus Tardus)

- upstroke-->gradual
- downstroke -> delayed
- best appreciated in a. carotis
In :
- AS
 Volume

Pulsus Altenans:
- Rythm Normal
- Interval
- Pulse wave --->volume >>> & <<<
In :
- myocardial weakness
The pulse may be palpated of the
accessible arteries :
Pulsus Bigemini(Coupled Rythm):
- a. radialis ------> very common - Rythm Normal
- a. brachialis - Interval between member-->shorter
- a. temporalis ---> anesthesiologist
- a. dorsalis pedis----> DM Pulsus Paradoxus:
- a. carotis -----> aortic pulse wave - Normal: Inspiration--->Sys.fall <10mmHg
- Sys.fall >10 mmHg.
- Cardiac tamponade

Inequality of Contralateral Pulsus :

- Aneurysm
- Partial Obstruction

Rate

Sinus Rythm : 60-100

Sinus Bradycardia : < 60
- AV Block
Contour - Athlete
Sinus Tachycardia : >100:
-

Rhytm

- Sinus Rythm : 60-100

- Dysrythmia :
- Atrial fibrilation
- Atrial Flutter
- Extra systole
Respiration
Best done immediately after

taking the patient's pulse.

Do not announce that you are

measuring respirations.
Respiration
Without letting go of the
patient's wrist begin to observe
the patient's breathing.

Count breaths for 15 seconds

multiply by 4

In adults, N: 14-20 X/minute

 Respiration
Tachypnea- Rapid

Hyperpnea-->Deep : Kussmaul

Bradypnea-->Slow

Apnea ---- Absent

Cheyne-Stokes-
apneahyperpnea
Blood Pressure
The room should be quiet and
the patient comfortable.
Position the patient's arm so
the antecubital fold is level
with the heart.
(It is best that the
arm be support by
an armrest or your
arm.)
Blood Pressure
Center the bladder of the cuff over
the brachial artery approximately 2
cm above the antecubital fold.
Position the patient's arm so it is
slightly flexed at

the elbow.
Blood Pressure
Palpate the radial pulse and
inflate the cuff until the pulse
disappears. This is a rough
estimate of the systolic
pressure.
Place the stethoscope over the
brachial artery.
Blood Pressure
Inflate the cuff 20 to 30 mmHg
above the estimated systolic
pressure.

Release the pressure slowly, no

greater than 5 mmHg per
second.
Blood Pressure
The level at which you begin to
hear Korotkoff sounds is the
systolic pressure.
Continue to lower the pressure
until the sounds muffle and
disappear. This is the diastolic
pressure.
Blood Pressure
Blood pressure should be taken
in both arms on the first
encounter. If there is more than
10 mmHg difference between
the two arms, make a note to
always use the reading from the
arm with the higher pressure.
Interpretation

BP should be taken in both

arms -- < 10 mmHg difference
retake the BP ----
"whhth hoht" hhhhht.
In situations auscultation is
not possible-SP by palpation
alone.
Interpretation

Classification :
Normal : < 140/< 90
Isolated Sys.HT : >140/<90
Mild HT : 140-159/90-99
Moderate HT : 160-179/100-109
Severe HT : 180-209/110-119
Crisis HT : > 209/> 119
PROBLEM BASED
LEARNING
Introduction

learning is a strategy for

learning basic science concepts

using problems from clinical

practice
Objective
introduce the student in a practical
setting to the thought processes
required for solving clinical
problems.
Specifically, we propose :
1. to promote active learning
2. to encourage students to think
creatively about medical problems
3. to integrate learning across the basic
science curriculum.
Organization

Internal Department :
Small Group 7-8 student + Tutor
Monday -decided cases
Wednesday --tutorial
Saturday -case report :
1. patient presentation
2. physical examination
3. laboratory findings
4. treatment and follow-up
 Case Report Form
LAPORAN KASUS
Nama Pasien : Nama :
Mahasiswa
Kelamin/Umur : NIRM :

Alamat : Nama Tutor : :

Ruang : Tanggal :

Dirawat sejak :
Case Report Form
I.
a. Keluhan Utama :
b. Masalah :
Case Report Form
II. Riwayat Penyakit sekarang, Riwayat Penyakit Dahulu dan
Riwayat Penyakit keluarga yang sesuai dengan keluhan utama
a. RPS
( Ingat 7 dimensi)

b. RPD :
Melanjutkan penyakit sekarang
Hubungannya dengan tindakan.

c. RPK
Penularan
Keturunan
Case Report Form
III. BUAT HIPOTESIS BERDASARKAN 1 DAN 2
SERTA TERANGKAN PEMBENARANNYA
(LITERATUR)
1.

2.

3.
Case Report Form
IV. TENTUKAN PEMERIKSAAN FISIK YANG
DIBUTUHKAN(LITERATUR)
Case Report Form
V. HALUSKAN HIPOTESIS DIATAS BERDASARKAN DUKUNGAN
DARI PEMERIKSAAN FISIK. JELASKAN BERDASARKAN
LITERATUR
1.

2.

3.
Case Report Form
VI. TENTUKAN KEBUTUHAN LABORATORIUM/PENUNJANG
YANG SESUAI(LITERATUR)

VII. BILA HASIL TELAH ADA HALUSKAN LAGI

HIPOTESIS(LITERATUR)
1.

2.

3.
Case Report Form
VIII. TENTUKAN TERAPI DAN FOLLOW-UP (TERANGKAN PEMBENARANNYA)

1.

2.

3.

4.

5.

IX. TENTUKAN PROGNOSIS BERDASARKAN KRITERIA

 Evaluation

Student Activities Yes No

Arrived on time for session.

Prepared assigned learning issue.

Integrated their contributions into session events rather than simply

reading from notes.
 Evaluation

Provided rationale/explanations for contributions;

avoids unsubstantiated opinion.

Admitted the limits of their knowledge (Is not afraid

to say I dont know.)

Asked for clarification/explanation of topics that are

unclear to them.

Was receptive to ideas and contributions of other

group members.
Evaluation

As part of their participation, connected/integrated
the basic science of the case with previously
acquiredknowledge.

Synthesized or summarized information for the
group.

Extended discussion beyond case objectives (e.g.,
broughtinnewresearchfindings.)

Demonstrated leadership (e.g., acted to keep the
group on task, monitored time, kept comments
focussedondiscussiontopic.)
Evaluation

Actively encouraged the input of

other group members

Additional Facilitator Comments: