A Practical Guide to Clinical Medicine

A comprehensive physical examination and clinical education site for medicalstudents and other health care professionals

Web Site Design by Jan Thompson, Program Representative, UCSD School of Medicine.Content and Photographs by Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center,San Diego, California 92093-0611. Send Comments to: Charlie Goldberg, M.D.

Introduction Breast Exam Write UpsHistory of Present Illness Male Genital/Rectal Exam The Oral PresentationThe Rest of the History The Upper Extremities Outpatient ClinicsReview of Systems The Lower Extremities Inpatient MedicineVital Signs Musculo-Skeletal Exam Clinical Decision MakingThe Eye Exam The Mental Status Exam Physical Exam Lecture SeriesHead and Neck Exam The Neurological Exam A Few ThoughtsThe Lung Exam Putting It All Together Commonly Used AbbreviationsCardiovascular Exam Medical Links ReferencesExam of the Abdomen

The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures.

Outpatient Clinics:Keys For Successful ParticipationAll components of patient care are being shifted from the in-hospital setting to outpatient clinics. Medicalstudent education has subsequently changed to more accurately reflect this current state of practice. Assuch, you will all undoubtedly spend a significant portion of the next few years (as well as time duringyour residency training) seeing patients/learning in the outpatient setting. In order to be successful, youwill need to adapt to this unique environment. The pace in clinic is less forgiving then on the inpatientservices. In the hospital, you can always go back later to talk with the patient. Outpatients, however, arescheduled to be seen in a finite period of time, with little consideration given for the chaos that can occurwhen visits overrun their allotted slots. What sort of impact does this have on you as a student? While youwill not be directly subjected to the pressures created by limited time and high patient volume, the samedoes not hold true for your preceptor. By extension, then, organization and time management will affectthe quality of your experience, as measured by the amount of time spent with the preceptor, teachingwhich occurs, and number of patients seen.

How then do you learn to function efficiently in clinic? Preparation is key. Most patients attendingoutpatient clinics have been seen previously in the healthcare system. Important information about thepatient is therefore frequently contained within the computer system, old charts, etc. In order to make bestuse of your time, you need to be aware of this information. I call this process "previewing" the patient anduse the accompanying preview sheet (at end of section) to collect data and prepare for the visit. Whenparticipating in a clinic, try the following:

1. Get to the clinic as early as possible so that you will have time to talk with the preceptor about yourrole/their specific expectations for you. Assuming that you will be performing the initial patient

evaluation on your own, ask the preceptor which patients he/she wants you to see.2. Obtain the charts for these patients and find a quiet place to review relevant historical information.

Ask the preceptor where additional patient information may be stored (e.g. computerized records,paper charts). When reviewing historical information, pay particular attention to:

a. The goal of the visit. If you are working with a sub-specialist and this is a first time referral,try to identify the question being asked by the referring provider. If it's a follow-up, determinewhich issues from the prior visit need to be addressed.

b. Any active issues which are being addressed in an ongoing fashion (i.e. medical problemswhich mandate continued reassessment and/or are in the process of being evaluated). Thiswould include problems such as coronary artery disease (which has a tendency to progress);diabetes; shortness of breath or fatigue of as yet undefined etiology, etc. Make note of theseproblems in the "active issues" section of the preview sheet . Past medical/surgical problemswhich tend to be static are noted in the PMH/PSH sections. If you are seeing a patient in ageneral medicine clinic, you'll need to pay attention to most of the active issues. Sub-specialists can obviously be a bit more selective, making note of only those problems thatmay be related to their field of interest. As such, preview sheets do not necessarily have to befilled out in their entirety.

c. Current medications.d. Past x-rays/studies/labs. Try to focus on those that you think would be relevant to the clinic

that you are attending (e.g. cardiology clinics will be interested in past echos andcatheterization reports; pulmonary clinics in PFTs, etc). This data is obviously quiteimportant. If you can't find the information that supports a purported diagnosis, make note ofthis as well, for it may represent one of the many instances where a patient has been labeledwith a disease in the absence of appropriate documentation.

It should take 5-10 minutes to preview a patient. You'll get better with more experience, particularly asyou develop a sense of what is truly relevant.

A Word About Style And Substance: You will all quickly recognize that clinical education is a very heterogenous experience, particularly as itapplies to outpatient medicine. Every physician with whom you work will have a different approach tohistory gathering, note writing, physical examination, diagnostic and therapeutic reasoning, etc. Thisactually makes perfect sense, as it reflects the fact that there are many ways of "skinning the clinical cat."That is, there is rarely a single, correct way to care for patients. Rather, there are usually a wide array ofacceptable approaches, any of which may be appropriate. For students, however, this "clinical richness"can be quite disorienting. Lessons learned in the morning may at times seem contradictory to that which istaught in the afternoon. Instead of viewing this as a negative, I would suggest that you look at it as a greateducational opportunity. The actual practice of medicine is as much about style as it is about science. Thiswill be one of the rare moments in your careers when you will get direct exposure to an array of clinicalapproaches, each of which is likely to be effective in its own right. During these years, you will have towork within the rules that govern a particular practitioner's clinic. While doing this, try to understand thelogic behind their practice patterns. Ask yourself if it makes sense and is therefore something which youshould permanaently incorporate into the style that you are trying to develop for yourself. Don't lose trackof the fact that this is the ultimate goal of these exercises.

Meeting with the Patient: After examining all of the data, begin the interview by confirming the reason for the visit. Then review allof the historical information that you've uncovered during the previewing process. This provides anopportunity to correct any misinformation/misperceptions that may have been generated. Additionalhistory taking is approached in the usual manner.

At the completion of the interview, leave the room and allow the patient to change into a gown. Returnand perform the physical examination, noting the vital signs as well as any pertinent findings on thepreview sheet so that you will not forget them. Each visit does not necessarily require a complete physical.

Frequently, a focused exam (e.g. a detailed knee evaluation in a patient complaining of pain in that area) isentirely appropriate. Remember, not every patient needs/requires a complete H&P. This would neither beefficient nor revealing. Instead, use your judgment and check with your preceptor for guidance. At the endof the exam, leave the room (or at least pull the curtain) to provide privacy while the patient changes backinto their clothes. Take a few moments to think about the information that you've gathered and use it togenerate a focused assessment and plan (see below). Depending on your preceptor's practice style, youmay either present the case in front of the patient or in private and then go in together to review thedetails.

The Note

At the end of the visit, the preview sheet contains all of the information that you've gathered both beforeand during the examination. In addition, it can include a brief assessment and plan for each problem (asdiscussed below). This leaves you with an inclusive reference document for use in writing your notes atthe end of the visit. It also provides a structured means of keeping track of information while at the sametime allowing you to focus your attention on the patient during the course of the H&P. The type of notewhich you write varies with the clinic and reason for the visit. For example, first time visits to an InternalMedicine Clinic are similar to a complete H&P (see that section of the Practical Guide for details).Follow-up notes or those for subspecialty clinics, on the other hand, are much more focused. I'd like tohighlight a few special features that I think are particularly relevant to outpatient visits:

Purpose of the visit: Mention at the top of the note why the patient has come to the clinic. This couldinclude: First visit for general care; or routine/scheduled follow-up; or add-on/urgent visit to address aspecific concern/issue; or sub-specialty visit to address a very particular problem; etc.

Medications: I generally review the medications that the patient is taking, and then list them at the top ofthe note. Medication confusion/non-compliance is a major clinical problem. By reviewing the list eachvisit, I can try to make certain that the patient is taking meds as prescribed. And, if there is confusion/aproblem with compliance, I can at least be aware of it and attempt to address it. To minimize confusion, Iwould suggest using the generic names for medications (in addition to listing the dosing strength andinterval).

Issues/Events: Rather then beginning with an "HPI" or "Subjective" section, I start outpatient notes bydescribing recent/important "Issues/Events." These can include:

a. Any new symptoms that the patient is experiencing (e.g. cough, low back pain, chest pain etc),which is described in the usual "HPI" format.

b. Specific concerns that the patient may have (e.g. patient initiated discussion about the role of cancerscreening test, cholesterol measurement, etc).

c. Review of data/symptoms of disease states that the patient is known to have. Patients with diabetes,for example, will usually record their blood sugars. This information can be mentioned here. Or, ifthe patient is known to have coronary artery disease, I might record presence or absence of angina,exercise tolerance etc in this section.

d. Events: This includes any important clinical happenings that have occurred since our last visit. Forexample, trips to the emergency room (including reason for visit and outcome), visits tosubspecialists, hospital admissions, out-patient procedures (e.g. radiology studies, invasive testing),etc.

An Issues/Events section is simply one way of organizing historical data in a user friendly/functionalfashion. Note that disease states which generally don't generate symptoms (e.g. hypertension) are notmentioned in the Issues/Events section, as their treatment is not usually directed on the basis of subjectivemeasures. In the case of hypertension, for example, thiswould be based on measured BP, which is anobjective value noted in the VS.

For many patients, the Issues/Events section may be left blank (e.g. young, healthy patient presenting for

annual follow-up).

Examination findings, lab/x-ray results, and assessment/plan are written in the same fashion described inthe "Write-Ups" section of this guide.

A Few Other Thoughts: Some practitioners actually write or type their notes while simultaneously obtaining the history. Withtime, you may develop skills that allow you to do this without compromising your attempts to establishrapport and listen closely to the information that the patient is trying to convey. At this stage, however, Ibelieve that this approach is too distracting. Instead, pay attention to the patient while taking written notesof important details. These can later be typed into the formal note.

I should also mention that, in health care systems that use computerized records, there is a growingtendency for practitioners to "cut and paste" data into their notes. In particular, this may be done for labtests and radiology reports. I would discourage this practice (at least early in your careers) as it is a bitmindless. Rather, I would prefer you to look through the labs and studies, and ask yourself: "Why werethese tests done? What critical information do they make apparent?" Cutting and pasting a normal CBCinto your note (complete with the MCHC, RDW etc) requires no thought and contributes little importantinformation. I would much rather you review the labs, identify that the cbc was normal, and then simplymention "normal CBC" in the note. Similarly, if a study is abnormal, think about what particular elementsare amiss, and highlight them, which should present the data in a workable/usable format. It may takeexperience/practice before you figure out what it relevanat (and why), but at least the above system willforce you to think!

Some computer record systems make it possible to "cut and paste" another clinician's history into yournote. I would strongly discourage this, as the note is your opportunity to present the Hx as you saw it, toprovide your own spin to the story.

The Assessment and Plan: There are many ways of approaching clinical problems. You might find it helpful, particularly whendealing with complex clinical issues, to break each problem into its most basic elements, with a separateplan noted for each one. By identifying the most basic components of each problem, you will be lesslikely to miss important issues and be better able to devise the most inclusive/complete plan possible.Your ability to do this will obviously vary with your experience and knowledge base. However, thisgeneral approach applies to most clinical situations. Let's take, for example, a patient who presents withnew dyspnea on exertion who also has known coronary artery disease, CHF, hypertension andhyperlipidemia. Each one of these problems is related to the patient's cardiovascular system. However, ifyou were to address all of them under a single "cardiovascular" heading, there is a good chance that theassessment and plan would become jumbled and confusing. These problems could, instead, be brokendown as follows:

Assessment #1: Dyspnea on Exertion: Patient with mild decrease in exercise tolerance. No symptoms of angina (whichwas associated with left-sided chest pain in the past). No exercise induced desaturation noted duringobserved 3 minute walk in clinic. Nothing on exam to suggest CHF. Patient has significant smokinghistory, though not known to have COPD, and no current wheezing on exam (no past PFTs). Smokingalso puts patient at increased risk for pulmonary malignancy, though no other suggestive symptoms.Etiology of dyspnea not clear. In any case, not obviously debilitated by symptoms.

Plan #1:

1. Obtain PFTs2. Obtain CXR today3. CBC to r/o anemia as cause4. Re-Evaluate in clinic in 6 w (or patient will call sooner if symptoms worsen)... at that time will

consider repeat Exercise Tolerance Test to asses for ischemia/quantify exercise tolerance; alsoconsider repeat echo to reassess LV function.

Assessment #2: Coronary Artery Disease: Known coronary disease. Patient continues to be active without symptoms.

Plan # 2:

1. Continue aspirin and lopressor (beta blocker)2. Patient aware of symptoms suggestive of recurrent ischemia. If occur with activity, will repeat

Exercise Tolerance Test.

Assessment #3: CHF: Known depressed left ventricular function on basis past MI, with EF 30% by last echo. Nosymptoms for over 1 year since initiation of medical treatment.

Plan #3:

1. Continue Lisinopril (ace-inhibitor) 40 mg/d2. Continue lasix (diurectic) 40 mg/d3. Check potassium, creatinine today4. Repeat echo next year, unless symptoms/exam more clearly suggest worsening CHF

Assessment #4: Hypertension: Well controlled. End organ dysfunction (CHF and CAD) managed as above.

Plan #4:

1. Continue medical treatment as above

Assessment #5: Hyperlipidemia: LDL 80, HDL 40 both at target levels on Simvastatin (HMG-COA Reductase Inhibitor)20 mg/d.

Plan #5:

1. Continue Simvastatin at current dose2. Check parenchymal liver enzymes (alt/ast), Creatinine Kinase today and in 6 months to assure no

toxicity.

Heath Care Maintenance: In a general medicine clinic, it's helpful to conclude each note with a Health Care Maintenance section.This includes age and sex specific screening tests as well as vaccinations that are otherwise easy to overlook.

For men this would include (roughly... the following are not necessarily the definitive guidelines):

Consideration for checking PSA (African-Americans beginning age over 40; Others over 50)Colorectal cancer screening (age over 50 and every 5-10 years thereafter)

For women:

Annual PAP smear (beginning at age of sexual activity)Annual Mammography (beginning at age 40 or 50)Colon Cancer Screening (with flex sig. or stool guaiac cards as above)? Bone Density Assessment (based on risk factors)

Vaccinations:

Flu Vaccine (annually)Pneumovax (age over 64 or those at risk)Tetanus (every 10 years)

Follow-up is mentioned at the conclusion of the note. Selecting the appropriate interval between visits isnot very scientific. As such, you will see wide variation among practitioners, varying with accuity ofillness, complexity of care, and experience of the clinician. Perhaps more important is identifying theappropriate situations for initiating contact as well as the preferred means of communication (e.g.,telephone, email, snail mail, etc.).

You will find samples of an initial/full clinic note, repeat visit note for the same patient, as well as acompleted preview sheet later in this section.

The system described above represents one particular organizational approach to outpatient care. There isa lot of room for variability.

BLANK PREVIEW SHEET

COMPLETED PREVIEW SHEET

SAMPLE CLINIC NOTE-- INITIAL VISIT

09/18/98

First visit to me for this 56 yo male, formerly cared for by Dr. M. He is to receive all medical care fromme, and sees no other/outside providers. MEDS: Supposed to be taking: Diltiazem 60 tid; Fosinopril 20 qd; Glyburide 10 bid; Metformin 500 bid; Aspirin325 qd; Gemfibrozil 600 bid; isordil 10 tid. Actually taking: Glyburide 5 tid; Aspirin 325 qd; Fosinopril 20 qd; Diltiazem 60 tid.

Allergies: None

Active Issues/Events:

1. DM: Known x 2y with poor control over that time (alcs around 10). Patient confused about meds.Claims has met nutritionist, but no education classes. No hypogly events. Has glucometer, but doesnot check finger sticks.

2. Chest Pain: Reports very brief episodes (ie lasting 1-2 seconds) of L sided chest discomfort. Notlike past mI. Not associated with activity. Can occur up to 3x/w. Then may not occur for weeks.Sometimes takes TNG for this, othertime not. No increase in frequency. S/P PTCA (?which vessel)in 93 at Sharp. . Presented at that time with new onset of severe cp, diaphoresis, sob. This was arelatively brief episode, with resolution of sx prior to angiogram. Unclear if his MI was at this timeor prior (though no similar sx prior). No episodes/sx CHF. Last ETT-Thal at VA 95...8 mets, fixedinf-septal defect; small distal inf-septal area reperfusion (5% of myocardium).

3. ER Visit: Went to the emergency room about 1 month ago after having fallen approximately 5 feetfrom a ladder, landing on right ankle, with significant associated pain.. Had x-rays done that werenegative for fracture (per patient). Pain in ankle now completlly resolved.

4.

PMH: Diabetes (details as above)CAD (details as above)HTNHyperlipidemia

PSH: S/P Appendectomy 88

Smoking: ETOH:Other substanceuse:

30 pack year, quit 10 years ago.2 beers per weekNone

SOC: Not working currently, though wishes to go back to work doing lightconstruction. Enjoys reading and hiking. Married x 15 years. Twochildren, ages 10 & 5, both well. Sexually active with wife, no problems with libido or erections.

Family: Father died from MI, age 50; mother alive, age 65, though Hx DM(onset 50), stroke age 60. One brother, two sisters all well. No familyHx cancer.

PE: Overweight male, NAD154/81 76 wt 208HEENT:NormalLungs: CTAC/V: s1 S2 no S3 S4 1/6 sem c/w aortic sclerosisABD: Soft, nt, no massesRectal: Brown stool, g neg; prostate nt, no nodulesGU: Testes descended bilat, nt, no masses; no herniaExt: no c/c/e

Labs andStudies of Note:

09/98: T Chol 344, TG 651, HDL 48 (NOT FASTING), Cr 1, Glu268, LFTS nl; UA + Protein, Alc 9.8

1/98: A1c 10, Glu 300

R Ankle Xray 8/98: neg

ASSESSMENT/PLAN:

1. DM: Very poor control and very poorly informed, though willing to learn.Not actually taking metformin and on wrong dosing regimen for glyb.Ned to readdress all areas of care.P:

Will arrange DM teachingGlyburid 10 bidNo metformin for now (he's not taking it in any case). Assessresponse to glyburide and then add back...will also allow forsimpler regimen, at least initially.Instructed to take fs 1x/d, alternating btwn pre-breakfast andpre-dinnerHas proteinuria...on ace-i... addressing better control as aboveHad eye exam 6m ago.

2. CAD/ChestPain:

Not sure what these 1-2 second episodes of chest discomfort are.They do not sound anginal. Not a worrisome pattern, given fact thatno increase in frequency, not with activity. However, patient is not thebest historian and certainly does have CAD.P:

Will arrange for ETT-Thal to better quantify ex tol, assess forworrisome ischemiaD/C DiltiazemStart atenolol 25Cont asaGiven bottle for fresh TNG s1, in case...D/C isordil (not actually taking, anyway)

3. HTN: Suboptimal controlP:

D/C DiltiazemFosinopril and atenolol as above

4. Hyperchol: Can't interpret lipids in setting non-fasting state.P:

Repeat profile on 12 hour fastD/C gemfibrozil (he is not taking it anyway)Would benefit from statin if LDL > 100...also would certainlybenefit from better glycemic control... to be addressed as above.

5. HCM: Tetanus and Pneumo Vax 97.P:

Address ? Colorectal CA screning, PSAon f/u visit.

F/U: 1 Month

SAMPLE CLINIC NOTE-- FOLLOW-UP VISIT

10/30/98

F/U visit for this 56 year old male, last seen by me 9/18.MEDS: Glyburide 10 bid; Aspirin 325 qd; Fosinopril 20 qd; Isordil 10 tid; Atenolol 25 qd.

Active Issues/Events:

1. DM: Taking glyburide as directed. Also brings finger stick log, which reveals AM readings (pre-breakfast) 180s, PM readings (pre-dinner) 200-210. No hypoglycemic episodes. Attended first of 4DM education sessions and met with nutritionist. Repeat hemoglobin A1C obtained last week = 9.

2. CAD: Just underwent ETT with Thallium (/98. Achieved 8 met workload without becomingsymptomatic. Thallium reealed fixed inf-interal defect. No areas of ischemia. Has been workingdoing light construction and has had no chest pain, so, other. Has not used any sub-lingual TNG.Denies PND, orthopnea, leg swelling.

No other complaints.

PE: Well appearing, NAD150/90 76 wt 210HEENT: no JVDLungs: CTAC/V: s1 s2 no s3 s4 1/6 sem c/w aortic sclerosisABD: Soft, nt, no massesExt: no c/c/e; no ulcers

LABS: Fasting lipids 10/22/98: T Chol 270, TG 300, HDL 40, LDL 170.

ASSESSMENT/PLAN:

1. DM Better control now that taking glyburide as directed though still sub-optimal. Appears compliant. Following thru with DM classes.P:

Continue glyburide at 10 bidAdd Metformim...start with 500 qam x 1 week; then 500bid...aware of side effects (i.e. GI sx) and will call if intolerable.Continue with DM education program.Check hemoglobin A1C in 3 months.Continue keeping finger stick glucose log...can take readingspre-breakfast one day alternating with pre-dinner the next.Has proteinuria but already on ACE-I (fosinopril 20).

2. CAD/ChestPain:

ETT reveals no ischemia at reasonable work load. Still with BP towork with.P:

Increase atenolol to 50 qd.Continue asa 325 mgD/C Isordil as no evidence of ischemia on ETT or chest pain

3. HTN: BP still up. Compliant with meds.P:

Meds as described under CADIf high on f/u, increase Fosinopril to 40 - target BP 130/80

4.Hyperepidemia:

LDL above target of 100 in patient with known CAD.P:

Start Simvastatin 20 mg qhs.

Baseline alt/ast, ck nl (as of 8/98). Repeat alt/ast in 3 mRepeat fasting profile in 3m. Increase Simva to 40 if not attarget at that time.Patient aware of other side-effects (e.g. myositis, GI upset).Will care if they occur.

5. HCM: Vax up to date. Discussed PSA and flex sig and wishes to proceed.P:

Obtain PSA todaySubmit consult for flex sig.

F/U: With me 3 M

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