anamnesa1.ppt

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Curriculum VitaeNama

LahirAlamat

Istri

Anak/Mantu/Cucu

Pendidikan

Pekerjaan

Pendidikan Tambahan

:

::

:

:

:

:

:

I Gede Arinton

Singaraja, 1 Januari 1950Jl. Pramuka 249 Purwokerto

1

5/2/3

1. dr. umum FK. UNUD 1977

2. dr. SpPD FK. UNDIP 1987

3. MKom STIBBi Jkt 1999

4. MMR UNSUD 2005

5. KGEH FK. UI 2007

6. Doktor Ilmu Kedokteran UNDIP 2008

Bag. Penyakit. Dalam RSUD. Margono

Soekarjo/FKIK Unsud Purwokerto1. Pelatihan Endoscopy di RSU dr.

Hasan Sadikin Bandung.

2. International Endoscopy Workshop

2007, Jakarta 57 April 2007.

3. Training Endoscopy Showa

University Yokohama 2009


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The Diagnostic Framework

To carefully observe the phenomena of life in all its phases, normal andperverted, to make perfect that most difficult of all arts, the art ofobservation, to call to aid the science of experimentation, to cultivate thereasoning faculty, so as to be able to know the true from the falsetheseare our methods.

Sir William Osler

Don't strain for arrangement. Look and put down and let your sensibility bethe sieve.

Theodore Roethke

. . .the framing of hypotheses is the most difficult part of scientific work,

and the part where great ability is indispensable. So far, no method hasbeen found which would make it possible to invent hypotheses by rule.Usually some hypothesis is a necessary preliminary to the collection offacts, since the selection of facts demands some way of determiningrelevance. Without something of this kind, the multiplicity of facts isbaffling.

Bertrand Russell


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Introduction Why is Diagnosis Important?

Ax & PE - basis Dx hypothesis generation

Accurate Dx. - precedes 3 tasks central to the

healing professions:

explanation, prognostication, and

therapy.

To answers 3 patient's fundamental questions:

1. What is happening to me and why?

2. What does this mean for my future?

3. What can be done about it and how will that

change my future?

Failure Dx -> to progress from curable to

incurable.


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Introduction

Clinician :

Takes experience,

Knowledge of the medical literature,

Good judgment, and

an understanding of the fundamentals of clinical

epidemiology and decision making.


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Introduction Diagnosis = the process of discovering a

patients underlying disease.

Step Diagnostic Process:

1. Based on probability

2. Pattern recognition

3. History taking4. Develop Hypotheses

5. Physical Examination

6.Make a Problem List

7.Generate a Differential Diagnoses8.Test the Hypotheses

9. Modify Your Differential Diagnosis

10. Repeat Steps 3 to 9

11. Make the Diagnosis


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DISEASE

DERANGEMENT

Anatomic

Biochemical

Physiological Psycological

E/

The Illness

Exhibit

Symptom

Sign

4 strategies of Clinical Dx.


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Pre test Probability

- Prevalence

- Ax

- PD

Penunjang- Laboratorium

- USG

- Ro.

- dsb

Post test Probability/

Clinical Dx.

Gold

Standard

Dx. pasti

Decision Analysis :Making Prognosis

Deciding Best Therapy

Step.1. Base on Probability


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Step 2. pattern recognition

= gestalt method (considering ortreating what a person experiences andbelieves as a whole and individual thing )

Def :

The instaneous realization that patients

presentation conform to a previously

learned picture/pattern of disease


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Step 2. pattern recognition

Auditary - the speech of

patient

Odor :

Diabetec acidosis

Liver failure

Lung abscess


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Strategy #2

= the multiple branching method

Algorithm

Triage


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Strategy #3

= Go do complete hystory &physical

Hystory taking Physical examination


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Strategy #4

= Hypothetico-deductivestrategy

the earlist clues of the patients

Short list of potential Dx/action

History & Physical

Paraclinic(lab., x-ray etc)

From :

Colleague

Teacher

HYPOTHESIS Deduction/

Reduce the list


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HISTORY TAKINGDr. I Gede Arinton,SpPd,MKom,MMR

The Head of Internal Medicine

Margono Soekarjo Hospital

Medical Faculty UNSOED

PURWOKERTO


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PATIENT DOCTORseeking

help

to regain

or

retain health

T A C K L I N G " T H E F I V E D S " O F H E A L T H :

- D I S E A S E- D I S C O M F O R T

- D I S A B I L I T Y

- D E A T H

-

D I S S A T I S F A C T I O N


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set the stage for :

* making a diagnosis

* determining prognosis* carrying out treatment

* promoting health

* preventing disease

student learn sk i l ls

THE PATIENT'S

MEDICAL HISTORY

* D E S C R I P T I O N O F P A T I E N T

* C H I E F C O M P L A I N T

* H I S T O R Y O F T H E P R E S E N T I L L N E S S

* P A S T M E D I C A L H I S T O R Y

* S O C I A L A N D O C C U P A T I O N A L H I S T O R Y

* F A M I L Y H I S T O R Y

* R E V I E W O F S Y S T E M S - - - > P D

History

Taking


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Introduction

HISTORY

TAKING

Physical

Examination

List of

Problem

Hypothesis

Dx

Lab

Special


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CHIEF COMPLAINT

Definition : statement of the primary reason

for the patient seeking medicalattention, often stated in thepatient'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


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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 realizess/he needs help

2.anxiety

3. the symptom in the chief complaintis sometimes a "ticket of admission"

to the physician's office or

emergency room;


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HISTORY OF PRESENTILLNESS 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.


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HISTORY OF PRESENTILLNESS Most important part of the

medical history, providing the

essential information for makingthe diagnosis.

Physician works in partnership

with the patient to develop anaccurate and useful

understanding of the illness in

the patient's life.


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Seven Core Dimensions1. Location: Where is the problem located?Does it radiate? Can you takeone fingerand

show meexactlywhere it

hurts?


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Seven Core Dimensions2. Quality : What is it like? How does it feel? Before we go on further, can

you describe the pain in some

more detail? Was itsharp or

dull?

Did itcome and goorjust stay

there all the time?


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Seven Core Dimensions3. Quantity/Severity: How bad is it? On a1 to 10 scale, where 1

represents no pain and 10represents the worst pain.


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Seven Core dimensions4. Chronology/Timing: When did each symptom or

problem begin? How did the events unfold? How often does it occur? Was this yourvery first episodeof

chest pain or have youever hadchest pain before?Whathappened next?

Howfrequentlyare you having the


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Seven Core Dimensions5. Setting/Context: What environmental factors,activities, emotional reactions orother circumstances may havecontributed to or led up to theproblem? Can you tell mewhat you are doingwhen you experience this chest

pain?Is there anything else that comesto mind about the situations in

which these headaches develop?


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Seven Core Dimensions6. Modifying Factors: What makes it better? What makes

it worse? Can you tell me what tends todecrease

the intensity of the pain?

Have you triedany medicationsto

control the diarrhea?

Have you noticed anything that makes

thepain worse?

Is your shortness of breath worse when

youlie down?


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Seven Core Dimensions7. Associated Symptoms/

Manifestations: What other symptoms occur preceding,coincidentally, or following the primary

symptom? Pertinentpositives and negatives

Organ specificreview of symptoms Do you have anyother sensationsorfeelings

when you have these headaches?

Did younoticeany pain or discomfort in your jaw

or left arm when you experienced the chest pain?


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HISTORY OF PRESENTILLNESSTips 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".


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HISTORY OF PRESENTILLNESS 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


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HISTORY OF PRESENTILLNESS Multiple :

To be avoided.

Questions like "Do you have any change

in bowel orbladderhabits, blood in your

stool or abdominal pain?"

By the time you get to the end of thequestion, both you and the patient have

forgotten exactly what you asked.


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HISTORY OF PRESENTILLNESS 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.


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HISTORY OF PRESENTILLNESS2. Ways to Enhance Communication Be sure the patient is comfortable.

Be sure you are ready to listen.

Introduce yourself

Be respectful of the patient (Callthe patient by his or her surname

unless told otherwise)


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HISTORY OF PRESENTILLNESS 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?


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HISTORY OF PRESENTILLNESS Compassion

Silence

Confront and clarify (If somethingdoesn'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


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HISTORY OF PRESENTILLNESS 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


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= is a record of the patient's pastexperiences 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.


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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.



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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



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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:



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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



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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?


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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 includingalcoholism

Illnesses similar to the patient's


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PHYSICAL EXAMINATION(PE)


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INTRODUCTION

ERA OF HIGH TECHNOLOGY

PHYSICAL EXAMINATION ???


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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


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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 )

DEFINITION


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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


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Palpation is the method

of "feeling" with the handsduring a physical examination

Percussion is a methodof "tapping" on body parts

with fingers, hands, or small

instruments

Auscultation is a method used to

"listen" to the sounds of the body

by using a stethoscope.


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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


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HISTORY

Leopold Auenbrugger: An Austrian physician

the inventor of percussion -by tapping onthe chest with the finger

the lungs wheel percussed, give a sound likea drum

consolidated, as in pneumonia-= the thighis taped.

the heart -dull sound

injected fluid into the pleural cavity, -- bypercussion to tell exactly the limits of thefluid present

He pointed out how to detect cavities of thelungs, and how their location and size might

be determined by percussion


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HISTORY

Jean-Nicholas Corvisart: Napoleon's personal physician

popularized percussion as adiagnostic tool

With a picture -Cause of death

Laenec:

The inventor of stethoscope-a

perforated wooden cylinder one footlong one end of a wooden -listening to the transmitted sound atthe other end.
http://www.antiquemed.com/flexible.jpghttp://www.antiquemed.com/p.jpghttp://www.antiquemed.com/laennec1.jpg


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Laennecstethoscope PiorryStethoscope FlexibleStethoscopes

BinauralStethoscopes

ElectronicStethoscopes
http://www.antiquemed.com/al7.jpghttp://www.antiquemed.com/flexible.jpghttp://www.antiquemed.com/p.jpghttp://www.antiquemed.com/lp.jpghttp://www.antiquemed.com/laennec1.jpg


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INTRODUCTION

VITAL SIGN

SYSTEMIC REVIEW


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VITAL SIGN

(VS)


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INTRODUCTION

VS include the measurement of:

Temperature

Respiratory rate

Pulse

Blood pressure

provide critical information ("vital")

about a patient's state of health.


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INTRODUCTION

In particular, they:

Can identify the existence of an

acute medical problem.

rapidly quantifying the magnitude of

an illness

how well the bodyis coping with the

resultant physiologic stress.


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INTRODUCTION

Are a markerof chronic disease

states (e.g. Hypertension)

To use these values as the basis for

management decisions.


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VITAL SIGN : Body temperature

Blood Pressure

Pulse Rate

Respiration Rate


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Equipment Needed A stethoscope

A blood pressure cuff

A watch displaying seconds A thermometer
http://bcs.medinfo.ufl.edu/sample/images/vs-stethoscope.mov


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General ConsiderationsThe patient should not have had : Alcohol Tobacco Caffeine Performed vigorous exercise

within 30 minutes of the exam.


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General ConsiderationsIdeally the patient should be:

sitting with feet on the floor

their back supported.

The examination room should be

quiet and the patient comfortable.


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General ConsiderationsHistory of :

hypertension;

slow, rapid or irregular pulse

and current medications

should always be obtained.


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General ConsiderationsIn addition :

peak expiratory flow,

oxygen saturation or

blood glucose level.

etc


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Temperaturecan 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


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Temperature Rectal(or "core")

Glass or electronic


Aural (in the ear)Electronic


axillary < acurrate rectal

Feveroral 100.5 F/38.5 C orabove.

Duration


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Duration

Pattern:

Intermitten Remitten

continue


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Pulse1. 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).


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Pulse3. Compress the radial artery with

your index and middle fingers.

Note : the rate, the regularity, and amplitudeof the pulse you are measuring.


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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.
http://bcs.medinfo.ufl.edu/sample/page03a.html


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Pulse

Contour

- Start with a swift upstroke----> the


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PulseThe pulse may be palpated of the

accessible arteries :

- a. radialis ------> very common- a. brachialis

- a. temporalis ---> anesthesiologist

- a. dorsalis pedis----> DM

- a. carotis -----> aortic pulse wave

Volume

Rate

Rhytm

Start with a swift upstroke > the

peak sys. press.--> followed by a more

gradual decline --->- approximately at

the end of v ent.sys. ---> sec. & normal

upstroke ( dicrotic wave) b y the closed

aortic valve

Norma l l y impapab le

( only by

sphygmograph)

wher pa lpab le

One wave in sys.

and one in dia.

Pulsus Bisferiens:

- 2 wave in sys.

In :

- AI + :

*AS moderate

* HSS

* Hyperthyroidism

Bounding or Collapsing Pulsus (

Corrigan, Water-Hammer pulse):

- upstroke-->ver y sharp

- downstroke -> precipitously

- pistol-shot sound

In :

- HT Ess.+ rigid aorta

- Hyperthyroidism

- Emotional state- AI

- PDA

- AV-fistule

Plateau pulse(Pulsus Tardus)

- upstroke-->gradual

- downstroke -> de layed

- be st appreciated in a. carotis

In :

- AS

Volume

P l Alt


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The pulse may be palpated of the

accessible arteries :- a. radialis ------> very common

- a. brachialis

- a. temporalis ---> anesthesiologist

- a. dorsalis pedis----> DM

- a. carotis -----> aortic pulse wave

Contour

Rate

Rhytm

Pulsus Altenans:

- Rythm

- Interval

- Pulse wave --->volume >>> & Sys.fall 10 mmHg.

- Cardiac tamponade

Inequality of Contralateral Pulsus :

- Aneurysm

- Partial Obstruction

Sinus Rythm : 60-100

Sinus Bradycardia : < 60

- AV Block

- Athlete

Sinus Tachycardia : >100:-

- Sinus Rythm : 60-100

- Dysrythmia :

- Atrial fibrilation

- Atrial Flutter

- Extra systole


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Respiration Best done immediately after

taking the patient's pulse.

Do not announce that you aremeasuring respirations.


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Respiration Without letting go of the

patient's wrist begin to observethe patient's breathing.

Count breaths for 15 secondsmultiply by 4

In adults, N: 14-20 X/minute


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Respiration Tachypnea-Rapid Hyperpnea-->Deep : Kussmaul Bradypnea-->Slow Apnea ----Absent Cheyne-Stokes-apneahyperpnea


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Blood Pressure The room should be quietand

the patient comfortable. Position the patient's arm so

the antecubital fold is levelwith the heart.

(It is best that the

arm be support by

an armrest or your

arm.)


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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.


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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 thebrachial artery.

Blood Pressure


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Inflate the cuff20 to 30 mmHgabove the estimated systolicpressure.

Release the pressure slowly, nogreater than 5 mmHg per

second.

Blood Pressure


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The level at which you begin tohearKorotkoff sounds is the

systolic pressure. Continue to lower the pressure

until the sounds muffle and

disappear. This is the diastolicpressure.

Blood Pressure
http://bcs.medinfo.ufl.edu/glossary/k.htmlhttp://bcs.medinfo.ufl.edu/glossary/k.html


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Blood pressure should be taken inboth 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 higherpressure.


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Interpretation BP should be taken in both arms

-- < 10 mmHg difference

retake the BP ----"white coat"

effect.

In situations auscultation isnot possible-SP by palpationalone.
http://bcs.medinfo.ufl.edu/glossary/w.htmlhttp://bcs.medinfo.ufl.edu/glossary/w.htmlhttp://bcs.medinfo.ufl.edu/glossary/w.htmlhttp://bcs.medinfo.ufl.edu/glossary/w.html


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Interpretation Classification :

Normal : < 140/< 90

Isolated Sys.HT : >140/ 209/> 119


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PROBLEM BASED

LEARNING


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Introduction

learning is a strategy for

learning basic science concepts

using problems from clinical

practice


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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.


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Organization

Internal Department :

Small Group 7-8 student + Tutor

Monday -decided cases

Wednesday --tutorial

Saturday -case report :1. patient presentation

2. physical examination3. laboratory findings

4. treatment and follow-up


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Case Report Form

LAPORAN KASUS

Nama Pasien : Nama

Mahasiswa

:

Kelamin/Umur : NIRM :

Alamat : Nama Tutor : :

Ruang : Tanggal :

Dirawat sejak :


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Case Report Form

I.

a. Keluhan Utama :

b. Masalah :


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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


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Case Report Form

III. BUAT HIPOTESIS BERDASARKAN 1 DAN 2

SERTA TERANGKAN PEMBENARANNYA

(LITERATUR)

1.

2.

3.

C


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Case Report Form

IV. TENTUKAN PEMERIKSAAN FISIK YANG

DIBUTUHKAN(LITERATUR)

C R t F


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Case Report Form

V. HALUSKAN HIPOTESIS DIATAS BERDASARKAN DUKUNGAN

DARI PEMERIKSAAN FISIK. JELASKAN BERDASARKAN

LITERATUR

1.

2.

3.

C R t F


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Case Report Form

VI. TENTUKAN KEBUTUHAN LABORATORIUM/PENUNJANGYANG SESUAI(LITERATUR)

VII. BILA HASIL TELAH ADA HALUSKAN LAGIHIPOTESIS(LITERATUR)

1.

2.

3.

C R t F


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Case Report Form

VIII. TENTUKAN TERAPI DAN FOLLOW-UP (TERANGKAN PEMBENARANNYA)

1.

2.

3.

4.

5.

IX. TENTUKAN PROGNOSIS BERDASARKAN KRITERIA

Evaluation


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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


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Evaluation

Provided rationale/explanations for contributions;

avoids unsubstantiated opinion.

Admitted the limits of their knowledge (Is not afraidto say Idont know.)

Asked for clarification/explanation of topics that are

unclear to them.

Was receptive to ideas and contributions of other

group members.

Evaluation


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Evaluation

As part of their participation, connected/integrated

the basic science of the case with previously

acquired knowledge.Synthesized or summarized information for the

group.Extended discussion beyond case objectives (e.g.,

brought in new research findings.)Demonstrated leadership (e.g., acted to keep the

group on task, monitored time, kept comments

focussed on discussion topic.)

Evaluation


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Evaluation

Actively encouraged the input of

other group members

Additional Facilitator Comments:
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