SYNTHESIS & INTEGRATION

Jody P.15 year-old female

Friday, September 3rd 2010

Overview: The History and Physical

• Subjective– Chief Complaint– History of Chief

Complaint– Past Medical

History• Medications• Allergies

– Social History– Family History– Review of

Systems

• Objective– Vital Signs– Physical exam

• Assessment– Problem List– Differential Diagnoses– Diagnosis

• Plan– Lab Tests– Treatments

Subjective: Chief Complaint

• “I’m here with my mom for my sports physical. She is in the waiting room.”

Subjective: History of Chief Complaint

• “I am on the tennis team. I have played on the team for the past 2 years. I think I am pretty healthy except for a recent cold. I was seen in an urgent care 2 weeks ago, they said I had strep throat even though the swab test was negative.”

Subjective:

• When asking Jody about her past medical history, health-influencing behaviors, family and social history, she tells you:

Subjective:

• “I had chicken pox when I was 5. I don’t think I’ve had any shots since I was a baby. I’m not allergic to any medicines, but I did just finish some antibiotic for my throat. I have never been to the hospital or had surgery or anything like that, and I workout for tennis a lot and eat well. My family is healthy, but my dad has high blood pressure. I do drink alcohol sometimes on the weekends, but everyone does here in Athens. My boyfriend and I have had sex a few times, but most of the time we use a condom…wait, you don’t have to tell my mom about that last part, do you?”

Subjective: Review of Systems

• Negative, except as noted below:– General: “I’ve been pretty tired lately,

but maybe it’s because tennis conditioning has been tough.”

– HEENT: “I finished all of that antibiotic I told you about, but my throat still hurts.”

What should be the first piece of information in your objective section?

1. Medications the patient is taking

2. Recent lab values3. The patient’s general

appearance4. Vital signs5. Your assessment and

plan

Objective: Vital Signs

Height: 64 inchesWeight: 119 lbsTemperature: 100.4˚ F ( 38 C)Pulse: 90 bpmRespirations: 16 rpmBlood Pressure: 100/60 mmHg

Which of Jody’s vital signs is abnormal?

1. Blood pressure (100/60 mmHg)

2. Pulse (90 bpm)3. Respiratory rate

(16 rpm)4. Temperature

(100.4˚ F/38 C)

Objective: Fever

• Different sources give different parameters

• Elevation of body temperature that exceeds the normal daily variation

and• Occurs in conjunction with an

increase in the hypothalamic set point (e.g., from 37°C to 39°C)*

*Harrison's Principles of Internal Medicine, 17e 

Calculate Jody’s BMI (height 64 in., weight 119 lbs). She is

1 2 3 4 5

20% 20% 20%20%20%1. Underweight2. Normal weight3. Overweight4. Obese5. Not enough

information

BMI Calculation

BMI = (weight in pounds) (height in inches)2

Jody’s BMI = (119) (64) 2

x 703

x 703

Weight Status Category Percentile RangeUnderweight < 5th percentileHealthy weight 5th - < 85th percentileOverweight 85th - < 95th percentileObese ≥ 95th percentile

= 20.4

BMI Interpretation

Objective: Physical Exam

• A somewhat muscular, slender female, who is cooperative and appears in no acute distress.

Objective: Physical Exam

Head: Normocephalic; face is symmetrical without maxillary or frontal sinus tenderness

Eyes: Clear conjunctiva and sclera, 20/20 for near and far vision without glasses

Ears: External auditory canals patent and clear; pearly tympanic membrane without erythema or bulging

Objective: Tympanic Membrane

Objective: Physical Exam

Nose: Clear without dischargeThroat: Marked pharyngeal inflammation;

enlarged tonsils with white exudates, small petechiae on palate

Neck: Enlarged and tender anterior and posterior cervical lymph nodes; no restriction to active or passive range of motion

Objective: Oropharynx

Objective: Physical Exam

Heart: Rhythm regular without murmurs; no palpable thrills or unusual pulsations

Lungs: Clear to auscultation bilaterally; full rib excursion

Chest: Symmetrical; no tenderness

Objective: Physical Exam

Abdomen: No distention, bowel sounds present in all 4 quadrants. Spleen palpated 2 cm below costal margin, slightly tender. No hepatomegaly noted.

Objective: Splenomegaly

• Palpation of anything more than the tip below the costal margin

• Percussed as a dull sound in the lung or abdominal region

• Usually measure on deep inspiration

http://www.4to40.com/images/ayurveda/Splenomegaly/Splenomegaly.jpg

Objective: Physical Exam

Breasts: No masses, nipple discharge, or tenderness noted

Genital: Female; Tanner sexual stage IVRectal: Deferred

Objective: Female Tanner Stage

http://commons.wikimedia.org/wiki/File:Tanner_scale-female.svg

From Nelson’s Textbook of Pediatrics 2007

Objective: Male Tanner Stage

From: http://commons.wikimedia.org/wiki/File:Tanner_scale-male.svg

From Nelson’s Textbook of Pediatrics 2007

Objective: Physical Exam

Back: Cervical, thoracic and lumbar curvatures are normal; no scoliosis noted; range of motion is unrestricted in cervical, thoracic and lumbar areas

Extremities: No cyanosis, clubbing, edema or varicosities; no restriction to active or passive range of motion

Skin: No rashes or lesions present

Objective: Physical Exam

Neurological: Cranial nerves II-XII grossly intact bilaterally; biceps, triceps, patellar and Achilles deep tendon reflexes +2 bilaterally

Psychiatric: Affect and fund of knowledge appropriate; memory, insight and judgment intact

Assessment: Problem List

• What sort of things do you want to include on your problem list at this time?

Assessment: Problem list

• Pharyngitis• Enlarged spleen• Fever• Fatigue• Health maintenance

– Risky behaviors• Substance abuse• Sexual intercourse

– Immunizations• Parent/child communication issues

Assessment: Differential Diagnoses

• Pharygitis– Bacterial

• Streptococcal• Gonococcal

– Infectious mononucleosis

• Peritonsillar abscess

• Epstein-Barr Virus • Cytomegalovirus • T. gondii• HIV • Hepatitis • Rubella

• Adenovirus

Select your top differential:

1 2 3 4

25% 25%25%25%1. Gonococcal pharyngitis

2. Infectious mononucleosis

3. Peritonsillar abscess

4. Streptococcal pharyngitis

Infectious mononucleosis• Called the ‘kissing disease’• Most often caused by the Epstein Barr

virus• Virus infections pharyngeal cells and after

release of virons it spreads to other parts of the body

• Once you mount an immune response you are protected for life

• Monospot and EBV specific antibody tests confirm diagnosis

Signs and Symptoms of Mononucleosis

From-http://www.answers.com/topic/infectious-mononucleosis

Assessment: Diagnoses

• Pharyngitis: Infectious mononucleosis

• Childhood risky behaviors including sexual intercourse and substance use

• Deficient in recommended vaccinations

Plan: Lab Tests

• Initial decrease in white blood cell count followed by an increase in the proportion of lymphocytes– Many of which are atypical

• Monospot: heterophile antibodies agglutinate horse RBCs– Usually become positive within 4

weeks after onset of illness– Specific but often not sensitive in early

illness

Plan: Treatment

• Supportive management– Rest– Fluid hydration– Pain relief– Monitor for airway compromise

• Restriction from contact sports until splenomegaly has resolved

Plan: Treatment

• Vaccines recommended for adolescents:– Pertussis (whooping cough)– Meningococcal infections– Hepatitis B– Varicella (chicken pox)– Measles, mumps and rubella

*Other vaccines may be indicated based on individual patient needs

Plan: Treatment

• Discuss risky behaviors and possible consequences– Sexual activity in adolescents

• Pregnancy• STIs/STDs• Emotional development

– Harmful effects of alcohol and drug use• Cultural and behavioral factors have

the greatest influence on mortality

Minor Patient Confidentiality

• Jody asks to use the restroom before they leave, and while she is out of the room her mother approaches you:

“I think my daughter is having sex with her boyfriend, and as her mother I feel I have a right to know. Did she say anything to you?”

How do you answer Jody’s mother?

1 2 3 4 5

20% 20% 20%20%20%1. “She is, but she is using protection.”

2. “No, she said she hasn’t.”3. “I don’t know, I’m a

medical student.”4. “I’m sorry, but I can’t

discuss that issue with you at this time.”

5. “Probably, but you should ask her to be sure.”

Minor Patient Confidentiality

• Teens have certain legal protections, so you may treat them for certain things without their parents knowledge• Administration of birth control• Treatment for STI’s• Counseling on drugs and ethanol• Anything if child is emancipated

• Health professionals should always advise teens to have close communication with parents or guardians

Learning Objectives:

Review history and physical (H&P) formatSubjectiveObjectiveAssessmentPlan

Health maintenance for adolescentsMinor patient confidentiality