History and Physical Examination

Chapter 10 History and Physical Examination



Matthew J. Kapklein, MD, MPH



Introduction


A chapter on history and physical examination (H&P) in a medical text is a bit like a chapter on gravity and Newtonian physics in a book on aviation: they are the foundation on which the entire field is built. Everything we do as professionals, we do for a reason—or at least we should. The skilled technician knows what to do; the reflective practitioner knows why to do it. Good strategic planning is an important component of any endeavor and requires a mission statement as well as goals and objectives for achieving it. What follows is an attempt to place the pediatric H&P in this context, using the framework of the American Academy of Pediatrics’ (AAP’s) mission statement, goals gleaned from the Accreditation Council for Graduate Medical Education’s (ACGME’s) component skills in the six core competencies, and one author’s objectives. See Appendix 1 ACGME General Competencies for a complete listing of the competencies and their definitions from the ACGME.



Profession: Pediatrician



Mission: Attain optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults.

Activity: History and physical examination (H&P).


Patient Care



Goal 1: Gather essential and accurate information about patients.

Objectives: Most think of this as the primary goal of the H&P, with historical information obtained first (via interviewing) and examination findings later (via “laying hands”). In fact, history taking starts before the interview begins and continues after it ends. Likewise, the physical examination begins the moment you hear or see the patient and ends only when he/she is out of reach of your senses.


Before medical school, we live for decades during which we develop skills in reading people. You are allowed, even encouraged, to use those skills in addition to the ones you paid to learn. Indeed, these may tell you whether the time is even appropriate for information gathering or for immediate intervention, or both in tandem. An experienced pediatrician can, on entering a room and from several feet away, perform a large portion of a child’s examination without touching the child or entering his/her personal space. This is fortunate, because many of our patients do not like it when we touch them, or even get close.


Goal 2: Communicate effectively, and demonstrate caring and respectful behaviors with patients and their families.

Objectives: The key word here is demonstrate. You may respect or care a great deal about a patient and family, but if they cannot discern it, then as far as they are concerned you do not. Likewise, there may be times when, for a variety of reasons, we do not highly respect a particular family. At these times demonstrating that we do becomes even more important. It is easy to act our best when we feel good; the challenge is doing so when we do not.


“You never get a second chance to make a first impression,” which becomes harder to change as time goes on. Eye contact, posture, vocal tone, facial expression—these behaviors form others’ major impressions of you. Maya Angelou said, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” For many, any trip to a physician is anxiety provoking; the stress of a sick child compounds this anxiety exponentially. Feeling someone cares about them goes a long way toward making people feel better—which is, after all, what we are trying to do.


Goal 3: Make informed decisions about interventions based on patient information and preferences.

Objectives: Although most “decisions” made during this initial interaction are about navigating the interaction itself, it is also when you learn about the aforementioned “preferences.” You may be told outright what those preferences are; other times you must infer. The relationship between behavior and preferences may not be obvious. For example, if a family comes to you by ambulance, it could be because of perceived or actual degree of illness, lack of alternate transportation or ability to afford it, lack of consideration of alternatives, or any combination thereof. Each possibility reveals different familial concerns.


Goal 4: Perform a competent physical examination.

Objectives: Notice that this is separate from the goal of information gathering. Notice also that a “competent” examination is not necessarily the same as a “complete” one. The common rookie mistake is to do a comprehensive examination in every situation, irritating patients and delaying care. Examination is as much a matter of knowing what not to include as what to include. We must limit our violation of patients’ privacy without sacrificing their health. Even for the routine, screening well child visit, the “complete” examination is in context of what you are screening for. A note stating, “Soft, active bowel sounds, no rebound tenderness, no guarding” for the abdominal examination of a healthy child is largely irrelevant, because abnormalities in these areas matter more for acute problems (e.g., pain, vomiting). A screening examination concerns itself more with occult problems, with a note stating “no masses or organomegaly,” for example. masses or organomegaly, for example. Just as when you order laboratory tests, your examination should not be a “fishing expedition”—you should fish for something in particular.

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Related posts:

  1. Attention-Deficit/Hyperactivity Disorder (Case 1)
  2. Newborn Hearing Screen (Case 22)
  3. Pediatric Poisonings (Case 54)
  4. Note Writing

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on History and Physical Examination

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