k1 (anamnesis & pemeriksaan fisis)

8/12/2019 K1 (Anamnesis & Pemeriksaan Fisis)

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Pediatric Clinical

Diagnosis

Sudigdo SastroasmoroDepartment of Child Health, Medical School

University of Indonesia, Jakarta


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What is the philosophy?

Doctor as a professionalmust

be aware that patients are looking for

attention and helpPatients primarily want to be

examined by a respected doctor, not to

be subjected as an object of technology


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Professionalism should be taught in medical schools and

during residencies. Currently, we do suboptimal jobs in

medical schools and a poor job in residencies.

We are, I believe, witnessing an improvement in public

esteem and trust in the medical profession. Restoration of fulltrust will require consistent professional conduct in medical

students, residents, and practitioners of medicine.

Dr. Haile Debas (2000)Dean, The University of California, San Francisco

President of The American Surgical Association


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If the above rules are followed, you, as a medical

student, and in the future a physician, should find yourprofessional life extremely rewarding.

When you were born,

you cried and the world rejoiced.

Live your life in such a manner

so that when you die the world criesand you rejoice.

Old Indian Saying


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Profession is a complex concept, the definition of

which has been attempted for centuries. It has

been studied and defined by many from a varietyof disciplines with some agreements, much

conflict, and some useful additions.


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Profession: a declaration, promise,commitment publicly announced

Professionand professionalismare words withelastic meanings.


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A Profession is

a recognizable occupation in which

practitioners have a degree of autonomy over

their work, are involved in working withsignificant applied theory, and work within a

framework of values and ethicswhich are

broadly agreed across the occupation.


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Components of professionalism

Competence

Accountability

AltruismCollegiality

Ethics


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The core clinical competencies

1. Patient care

2. Medical knowledge

3. Interpersonal and communication skills

4. Professionalism

5. Practice-based learning & improvement

6. Systems-based practice


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What do patients usually want?

Patients usually want to be

respected as an individual;

they are not numbers or even

a member of a group of numbers


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So what?

Medicine is the science of uncertainties

and the art of probabilities

Personal and humane approach!!


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Clinical exam in infants

and children:Why special attention?

A child is not a small adult!

Keywords: growth and development

Any information about history, physical, andlaboratory / supporting exams should be

judged in relation with the childs stage of

growth and development.


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History

(Anamnesis)

Auto-anamnesis: self reporting by the patientAllo-anamnesis: any information other than by patient


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Advances in medical knowledge & technology do not

exclude the importance of clinical assessment

Appropriate use of medical technology is based on

thorough history & physical exam

No laboratory or other exams are performed withoutappropriate clinical information

No laboratory or other exams are interpreted without

aligning with clinical condition

Mastering clinical examination is a must for all doctors

caring for patients, from GP to sub-specialist


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History: 80%

Supporting exam: 5%

Physical exam 10-20%


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1. Patients ID

2. Chief complaint boleh bukan berupa keluhan, misalnya mau vaksinasi, dirujuk dsb

3. Clinical coursesdah diobati sendiri/dokter, ada diagnosis

4. Previous illness5. History of maternal pregnancy

6. History of delivery

7. Feeding history

8. Immunization status9. Growth & development

10. Family history

11. Environment

Anatomy of history taking


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PresentClinical courseBirth

Prenatal

Birth

Nutrition, immunization, growth & development

Past history

123

4

5, 6, etc


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Who provides the patients history?

(determines your confidence to the information provided)

Be patient, make a conducive atmosphere

Use daily words instead of medical terms

Be sure that the history-giver understands your points

Use history taking as a method for health education

ALWAYS: make footnotes /remarks at the end of

history taking

Points to remember


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1. An 8-year old girl, 30 kg, 130 cm, 3rdgrade ofelementary school, repeatedly had good ranking in

class. She was brought to the clinic due to 3-day highgrade fever, stomach ache, & nosebleed

2. A 12-year old boy, basketball player, suspected ofsuffering from radial fracture

Should complete history be obtained in all

patients irrespective of their illness?


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Remember

It is the patientthat should betreated; not the disease


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In general similar to that in adults, i.e. to obtain

accurate physical status irrespective of the approachNeeds modification due to nature of infants & children:

Inspection

Auscultation abdomen & thorax Examination using equipments (misal : dengan

nasal speculum)

Physical examination


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Steps in

physical exam

General condition

Vital signs

Anthropometric measurements

Systematic exam


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A. General condition

1. Consciousness : alert, apathetic, somnolent,

sophorous, comatose

2. Appearance : healthy, mildly/moderately/severely ill, distressed

3. Color : pale, jaundice, cyanotic

4. Specific facies : syndromes, facies cholerica,fish-mouth, facies leonina,

Cooleys facies


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B. Vital signs

1. Pulse : rate, regularity, volume,

equality

2. Respiration : rate, regularity, pattern3. Blood pressure : of 4 extremities

(setidaknya sekali

selama hidup)4. Temperature : oral, axillary, rectal

Note: always describe complete pulse & respiration!


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C. Anthropometric measurements

1. Body length/height : sitting, standing

2. Body weight

3. Head circumference

4. Arm circumference

5. Abdominal circumference

6. Nutritional status: W/A, H/A, W/H plot in

standard normal curves(NCHS)


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D. Systematic examination

Head & neck

Chest

Abdomen

Genitals

Extremities

Skin, hair, lymph nodesNeurological


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Use of stethoscope

Use binaural stethoscope

Bell-shaped side : low-medium pitched

sounds Membrane (diaphragm): medium-high pitched

For heart examination:

Bell-shaped first

Without pressure, then with pressure

Membrane


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Common mistakes inperforming examination

History

Fail to identify the patient first

Make an incomplete historyProvide a disorganized history

Physical exam:

Fail to describe general condition & vital signs firstIncomplete description of features, e.g. pulse rate

only or respiratory rate only without further

characteristics


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Put your notes in every element of physical exam

where appropriate

Example: The child was cooperative, fighting,

etc.


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Components of professionalism

Competence

Accountability

AltruismCollegiality

Ethics


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Patients preference

Evidence from

valid research

Physicians competence

EBM


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What is Evidence-based Medicine?

The conscientious, explicit, and judicious use of

current best evidence in making decisions about

the care of individual patients Pemanfaatan bukti mutakhir yang sahih dalam

tatalaksana pasien Integration of (1) physicianscompetence,

(2) valid evidence from studies,

and (3) patientspreference


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WHY EBM?

1. New evidence are continuously generated

2. We usually fail to get the new evidence

3. Our clinicalperformance deteriorates with

time (the slippery slope)4. Traditional CME does not improve clinical

performance

5. EBM encourages self directed learningprocess which should overcome the above

shortages

100%


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Years after graduation

Relative

% of

remainingknowledge

2 4 6 8 10 12

$

100%

THE SLIPPERY SLOPE


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Patient with

problem

Search the

evidence

Criticallyappraise

the evidence

Formulate

in answerablequestion

Applythe evidence


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Concludingremarks

History taking and physical exam skills require good

background knowledge and a sound human relation;

as a part of medical practice, they are science and artThe art of history taking and physical exam are by no

means inferior to your scientific knowledge of the

disease under investigationRespect the patient and the family if you want to be

respected by them; by and large, respecting each

other is the key for success in medical practice


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A great doctor.

Three young moms are chatting about their

3-year-old sons

Mrs. A.: John must be a great lawyer then. He argues

everything all the time with definitely terrificarguments for his age!

Mrs. B: Im sure Mike will become a cute engineer.He destroys every toys we gave, and reconstructsthem successfully. Yes, always! Fantastic!!

Mrs. C: No doubt, Greg is a typical great doctor. Howdo you know? Asked Mrs. A and B. He never

comes when called, Mrs. C explained calmly.


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