Recognizing Signs and Symptoms

UNIVERSITY OF TENNESSEE

HEALTHSCIENCECENTER

Doctoring:

Recognizing Signs and Symptoms

(DRS2)

Topics:

Skin

Lymph

Sexual History

Chapter 7

September 17-21, 2007

DRS M-2 Grading System for 2007-2008

Chapter 6 August 13-17,2007

Topics: Neurologic exam

Mini-mental status

Monday Checklist2%

Preceptor2%

Master Clinicians2%

Standardized Patient Encounter

and Documentation (SPED)8%

14%

Chapter 7 September 17-21, 2007

Topics: Skin and lymph,

Sexual history

Monday Checklist2%

Preceptor2%

Master Clinicians2%

SOAP note assignment8%

14%

Chapter 8 October 22-26, 2007

Topics: Heart

Professionalism

Monday Checklist2%

Preceptor3%

Master Clinicians2%

Professionalism Assignment 1%

SOAP note assignment8%

16%

Chapter 9 February 4-8, 2008

Topics: Eye

Patients of different cultures

Monday Checklist2%

Preceptor3%

Master Clinicians2%

Rounding 1%

SPED8%

16%

Week 10March 17-20,2008

End-Of- Year Assessment 40%

40%

CLASS SCHEDULE

September 15-19, 2008

DRS2 Chapter 7

DateTimeEventPresenter(s)

Monday,1:00-1:30p Overview and ReviewDr. Beeman

9/15/081:30-3:00pSkin and Lymph

3:00-5:00pClinical Practice SessionsM-4s

Tuesday,8:00-5:00pCommunity Preceptor

9/16/08orSOAP NOTE assignment

Wednesday,8:00-5:00pCommunity Preceptor

9/17/08or SOAP NOTE assignment

Thursday,8:00-10:00aSmall GroupsMaster Clinicians

9/18/0810:00-11:00pSexual HistoryDr. Phillips

11:00-12:00pEnd of Week and SOAP ReviewDr. Beeman

12:00-1:00pBREAK

1:00-5:00pCommunity Preceptor

`

Friday,8:00-5:00pCommunity Preceptor

9/19/08

DRS
Chapter 7 / Monday
September 15 / Tuesday
September 16 / Wednesday
September 17 / Thursday
September 18 / Friday
September 19
8-12 AM / [PCC class time] / DRS Options
CP or SOAP*
[PCC self-study] / DRS Options
CP or SOAP*
[PCC self-study] / Small groups in GEB then entire class in A103 / DRS Option
CP*
[PCC small groups]
Break
1-5 PM / DRS Class Entire class in A103. Then small groups at 920 Madison, 7th Floor. / DRS Options
CP or SOAP*
[PCC self-study] / DRS Options
CP or SOAP*
[PCC self-study] / DRS Option
CP*
[PCC self-study] / DRS Option
CP*
[PCC small groups]

Community Preceptor (CP) – required for TWO of the DRS Option boxes.

*SOAP note assignment for one hour at assigned time

Tuesday or Wednesday at 920 Madison, 7th floor.

Deadline for Log is September 26, 2008

CHAPTER 7

ASSIGNMENTS, DUE DATES, AND GRADES

• Assignment: Clinical Practice Sessions Checklist and Documentation -

Attendance and participation in these small groups led by Senior Medical Students includes performing the examination skills according to a checklist and documenting the skills presented during the week.

Due Date: Monday afternoon – September 17, 2007.

Grade: 2% of your final grade.

• Assignment: SOAP Note - Interview and examine a standardized patient for 15 minutes to perform pertinent history and physical exam. Document the encounter in the following 10 minutes and orally present the patient information. This is an open book assignment. Feedback will be given after the note is written.

Place: Clinical SkillsCenter, 920 Madison, 7th Floor

Due Date: As scheduled – Tuesday or Wednesday of Chapter 7 – September 18-19, 2007. Times are posted on Blackboard and should be the same half-day as last time unless you have been notified.

Grade: 8% of your final grade.

• Assignment: Discussion about Patients with Master Clinicians -

Attendance and participation in these small groups led by the Master Clinicians includes role-playing the written cases and orally communicating patient information.

Due Date: Thursday morning – September 20, 2007.

Grade: 2% of your final grade.

• Assignment: Community Preceptor Log -

The Preceptor log includes information in the “box”, patient examination documentation, and the list of patients seen. Logs should be signed by the preceptor and placed in the Preceptor Log Box in the 920 MadisonBuilding 7th floor.

Due Date:Chapter 7 log is due bySeptember 28, 2007.

Grade: 2 % of your final grade. Make-up sessions are required if sessions are missed for any reason.

Posting of grades

The grades are posted on the Blackboard Grade Book by the beginning of the following DRS week (October 22, 2007).

Topics: SKIN AND LYMPH

SEXUAL HISTORY AND REVIEW OF SYSTEMS (ROS)

Reading for the week:

Coulehan and Block, 5th edition: Sexual history; Chapter 6, pp 106-117

Swartz, 5th edition: Skin, Chapter 8, pp137-192; Lymph, pp 195-202 and page 450

PREPARATION:

Review the website USMLE.org Step 2 CS for the nature of the patient encounter and sample SOAP note.

On Monday, bring your stethoscope. (Tongue blades, cotton balls and ear specula, otoscopes, and BP cuffs will be provided). Dress appropriately for practicing the physical examination on each other to include review of the VS, ENT, chest, abdomen, musculoskeletal exams and neurological exams.

SYNOPSIS:

A guiding lecture is followed by small group practice and review sessions. The first session follows the lecture and emphasizes the physical examination skills. Other opportunities for practicing skills include encounters with patients in the community preceptors’ office and with a standardized patient. The second small group session on Thursday morning with the Master Clinician emphasizes medical interviewing, communication issues, and pathophysiology. Additional topics will be discussed on Thursday morning. A review session will follow.

OBJECTIVES:

By the end of these sessions you will be able to:

• Recognize normal skin by inspection and palpation.
• After palpating for lymph nodes in all of the appropriate anatomical areas, identify a normal lymph node examination.
• By inspection and palpation of the skin, recognize the important aspects of a

Vascular rash

Malignant melanoma

• By palpation, recognize generalized lymphadenopathy
• Discuss etiologies of these three conditions.
• Document the skin and lymph examination.
• Appreciate how the skin and lymph node exams fit in with the rest of the physical exam.
• In the appropriate situation, perform and document a sexual history.

Checklist for Sexual History

• Are you sexually active?
• Do you have any pain related to your sexual activity?
• Are you satisfied with your sexual activity?
• Do you have any problems or questions relating to sex?

Skin Physical Examination Checklist

• SkinPlease circle one:

Inspect

The patient is sitting.Done Not Done

HeadDone Not Done

FaceDone Not Done

NeckDone Not Done

Upper extremitiesDone Not Done

Back Done Not Done

The patient is supine.Done Not Done

Trunk Done Not Done

Lower extremities Done Not Done

Patient rolls to reveal dorsal areas not already viewedDone Not Done

Palpation

Temperature with back of handDone Not Done

Moisture with finger tips Done Not Done

Turgor by tensing skin between thumb and index fingerDone Not Done

Lesions with finger tips (gloved hand if appropriate)Done Not Done

• Lymph nodes Please circle one:

Palpation

Finger tipsDone Not Done

Rolling motionDone Not Done

Look at face if tenderness suspectedDone Not Done

Check the following locations bilaterally:

PreauricularDone Not Done

PostauricularDone Not Done

OccipitalDone Not Done

SubmentalDone Not Done

SubmandibularDone Not Done

TonsillarDone Not Done

Anterior cervicalDone Not Done

Posterior cervicalDone Not Done

Supraclavicular

Examiner behind patient with fingers in supraclavicular fossaeDone Not Done

Patient instructed to take a deep breathDone Not Done

AxillaryDone Not Done

EpitrochlearDone Not Done

InguinalDone Not Done

PoplitealDone Not Done

Useful Descriptions

• Skin

Physiologic – clear, no rash, no lesions, good turgor, normal texture and

temperature

Pathologic –

General

Color – erythema, jaundiced, pale

Turgor – poor, tenting

Temperature – warm, cool

Moisture – dry, moist, oozy, crusty

Texture – thin, thick

Perfusion – poor capillary refill

Lesions –

Primary –

Nonpalpable – macule, patch

Palpable – papule, nodule, tumor, plaque, wheal

Palpable, fluid filled – vesicle, bulla, pustule

Miscellaneous – comedo, burrow, cyst, abscess, furuncle, carbuncle, milia

Secondary –

Below the skin plane – erosion, ulcer, fissure, excoriation, atrophy, sclerosis

Above the skin plane – scaling, crusting

Vascular skin lesions –

Blanching – erythema, telangiectasia, spider angioma

Nonblanching – petechiae, purpura, ecchymosis

Miscellaneous –

Scar, keloid, lichenification

Configuration – linear, iris, reticulated, etc.

Distribution – if multiple lesions, describe parts of the body affected

Palpation – firm, raised, moist, cystic, tender

ABCD – note symmetry, border characteristics (smooth, irregular with

notches), color and color variability, size (larger or smaller than a pencil eraser)

• Lymph nodes

Physiologic – no palpable nodes; or in children, shotty (<1 cm, movable and non tender) cervical and inguinal lymph nodes bilaterally.

Pathologic –describe size in centimeters and location of enlarged lymph nodes, note tenderness or overlying redness, note firmness or fluctuance, matted (attached to underlying structures).

Signs and Symptoms of Serious Skin Conditions:

Vascular Rash with Fever

Symptoms / Risks / Signs / Cause
Severe and acute or subacute with rapid deterioration of URI, headaches, irritability / Exposures, for example in dorms and barracks
Mid-winter / Fever, tachycardia, tachypnea, ill appearing, poor perfusion, petechial/purpuric rash / Meningococcemia
Headache, myalgias / Tick bite 5-10 days prior to symptoms, Southeastern US, summertime / Fever, petechial rash on palms and soles / Rocky Mountain Spotted Fever (RMSF)
Chills, night sweats, loss of appetite and weight, fatigue and malaise, bone pain, limp / Any age, exposure to benzene and ionizing radiation / Generalized lymphadenopathy, organomegaly, petechiae/purpura / Leukemia with fever

“Ugly” Skin Lesion

Symptoms / Risks / Signs / Cause
No systemic symptoms, “ugly” changing mole / Fair skin, family history, intermittent sun burns, advancing age (very rare in children) / Asymmetry, irregular and notched borders, variable color, >6mm in size,
firm regional lymph adenopathy / Malignant melanoma
No systemic symptoms, new nevi expected only through early adulthood / Normal to have 10 to 40 in number over face and body / Symmetric, regular borders, uniform in color, <6mm / Nevi, normal mole
Scratching, scab-picking, hair pulling, etc. / Stress / Various secondary lesions – ulcers, excoriations, etc. / Anxiety and obsessive/compulsive disorders

Generalized Lymphadenopathy

Symptoms / Risks / Signs / Cause
Flu-like illness / Promiscuity, unprotected sex, blood transfusion, OSHA breech / Fever, rash, generalized lymphadenopathy / Infection - HIV:
Persistent Generalized Lymphadenopathy (PGL)
Fever, fatigue and sore throat for several days / Adolescent, young adult, passed through saliva / Exudative pharyngitis, generalized lymphadenopathy,
splenomegaly / Infection – EBV: mononucleosis
Chills, night sweats, loss of appetite and weight, fatigue and malaise, bone pain, limp / Any age, certain chemical exposures,
exposure to ionizing radiation / Generalized lymphadenopathy, organomegaly, petechiae/purpura / Malignancy: Leukemia
Rashes, arthralgias, chest pain, fatigue, etc. / Young adult female, AA and Hispanic, drug induced / Fever, malar rash, generalized lymphadenopathy, arthritis, etc. / Collagen vascular disease:
Systemic Lupus Erythematosus (SLE)

MONDAY

September 17, 2007

LECTURE SERIES ON CLINICAL SKILLS

Participating Faculty: Gail Beeman, MD., M.H.P.E.

1:00–1:30PM GEB A103

Topics: Overview and Review

1:30-2:30PM GEB A103

Topic: Skin and Lymph

The Monday afternoon lecture will present the techniques for examining the skin and lymph nodes. Conditions that present serious illnesses will be discussed. Signs and Symptoms of common and severe diseases will be presented.

Slides are available for viewing on Blackboard

and handouts of them will be provided for this lecture.

CLINICAL PRACTICE SESSIONS

Educational Activities:

• Guided by the lectures, the reading assignments, and the checklists, practice physical examination of the skin and lymph nodes.
• Review the physical examination of the chest, abdomen, ears, nose, oral cavity, and pharynx, musculoskeletal, neurological system, and vital signs.
• Organize the format for case discussions on Thursday, September 21, 2006

Small Group Room Assignments

Depending upon the number of M-4s who have signed up to instruct, we will send you through in smaller groups than last year. This will give you more access to the M-4 to answer questions and instruct you, as needed. We have found that this system provides better instruction in less time. For this Chapter, males and females may be together in the same room. If you have any problem with this, please let Michael Holliday know when you arrive at the SkillsCenter.

• If you are male, report at 2:30 PM or directly after the lecture.
• If you are female report at 3:30 PM, (During the next week we will switch times.)

TUESDAY or WEDNESDAY

September 18-19, 2007

SOAP NOTE ASSIGNMENT DESCRIPTION

You will be assigned to a patient to perform a pertinent history and physical examination. The patient’s chief complaint will be a common one from the organ systems that have been covered so far in the course. The role play case discussions and the common signs and symptoms chart in your syllabi will help you prepare for this assignment.

Timing and activities for the assignment are as follows: (This is an open note and book assignment, but time will not allow for a lot of reading during the encounter.)

• 15 minutes to perform the pertinent history and physical
• 10 minutes and desk space to complete a SOAP note
• 2-5 minutes to orally present the patients findings and your assessment and plan to the observer
• After the oral presentation, you will turn your paper in for grading and receive feedback according to the form included in this folder.

A learner-of-medicine senior to you will observe you during the patient encounter and the oral presentation. The observer will fill out a checklist, grade your note and presentation, and then give you oral and written feedback. Written comments from the Standardized Patient will be included in the feedback. The observer will assign a pass or fail to your performance. If a pass is assigned, then you will be awarded the maximum number of points for this assignment. If a fail is assigned, remedial work is required.

Reviewing the sample notes and patient encounters on the USMLE web site should give you an idea of the nature of this experience. USMLE.org and to Step 2 CS. This assignment will last about 45 minutes. Your time is posted on Blackboard and should reflect the half-day you signed up for earlier in the academic year.

Instructions for Oral Presentations

Doctor-to-Doctor Communication

1. Appropriate identifying statement about this patient.

“Mr. G is a 40-year-old man who works as a house painter.”

1. State the symptom that is the chief complaint. Note: this can be in medical terms or in the patient’s words.

“He comes in today with the complaint of shortness of breath.”

1. The HPI is a narrative; you are telling a story.

• Give all the attributes that you have. It usually takes at least four to make a diagnosis.

Bodily locationSetting (context)

Quality (or character)Aggravating factors

Quantity (or intensity or severity)Alleviating factors

Chronology (onset, duration, frequency)Associated manifestations

“He complained of this symptom for two weeks and it seems to be increasing in severity. He has a nighttime non-productive cough. He tried some over-the-counter remedies which did not work. I think they were antihistamines.”

• State pertinent positives and negatives. Sometimes absence of an attribute of a symptom has more diagnostic value than the presence of a symptom. As you know more pathophysiology you will use pertinent negatives more. This is not a review of systems (ROS). This is diagnostically pertinent information.

“He does not complain of chest pain. He does not have a runny nose. He has not had fever.”

1. Summarize the important parts of patient’s past medical history (PMH), family history (FH), patient profile (PP), habit history, and review of systems (ROS).

“Mr. G has a history of multiple admissions during the last decade for pneumonia. The last one was one month ago. He was treated with broad-spectrum antibiotics and was symptom-free prior to this illness. The others seemed to be acute illnesses from which he fully recovered. He has not been diagnosed with asthma. There is no related family history. His father who was a smoker died of lung cancer at age 50. Mr. G. does not smoke. As I mentioned earlier, he does breathe paint fumes on the job. Mr. G. is recently divorced. He was married for five years to a high school teacher. Prior to his divorce he was drinking heavily and lost his job as a salesman.”

1. Objective, observed physical examination findings follow the history. Start with a general observed description of the patient.

“Mr. G. looks healthy and appears normal weight. However, he has increased effort to breathe today.”

1. Report the physical findings both pertinent normal and abnormal in order – VS and BMI first followed by a head-to-toe description by organ systems.

“Mr. G’s respiratory rate is 30 per minute which is rapid. His other VS are within the normal ranges. Tympanic membranes are pearly gray bilaterally. Nose exam does not reveal any secretions. Lung findings show decreased breath sounds in the lower left lung field bilaterally. I do not appreciate any crackles or wheezes. Heart has regular rhythm and rate, no murmurs appreciated. PMI is at the 5th intercostals space mid-clavicular line. Distal extremities show strong pulses and no edema.”

1. Report available and pending pertinent laboratory and imaging studies. Be sure you know which tests are normal and which are abnormal.

“The O2 sat is 95%. So he doesn’t need O2 and is presently on his way down to X-ray for a PA and lateral chest film.”

1. Assess the patient. For now the assessment may be a summary of findings and/or a list of possible diagnoses.

“Mr. G. has an acute illness involving the respiratory system. This seems to be a reoccurrence of a similar illness suffered a few times over the last decade. Risk factors include inhaled paint fumes. I think he has either community acquired pneumonia or some kind of chemical pneumonitis.”

1. Later you will state a plan of action to include ordered studies, medication, referrals, etc,

Note: Be enthusiastic. Make it interesting. Your interpretations are important, but when describing personal information about the patient, be descriptive not judgmental.

Chapter 7, 2007

SOAP Note Assignment Feedback

M-2 Name: ______Date: ______

Overall: ___Pass (8 points)___ Fail (remedial work required)

15 MINUTES IN THE EXAMINATION ROOM

Outstanding ClearPassBorderline Clear Fail

History taking

Content of the medical history was satisfactory with the following comments: