1 UKRAINIAN MINISTRY OF HEALTH CARE UKRAINIAN ACADEMY OF MEDICINE AND DENTISTRY INTRODUCTION TO CLINICAL MEDICINE (PROPEDEVTIC OF THE MEDICINE) WITH PATIENT CARE EDUCATIONAL MATERIALS FOR INDEPENDENT STUDY WITH TESTS AND EXPLANATIONS INCLUDED FOR SECOND YEAR DENTAL FACULTY STUDENTS POLTAVA, 2007 2 Contents Contributors Preface Lesson1 Physician-Patients Relationship and Professional Deontology. Basic Components of the Medical History. The Physical Examinations Lesson 2 The Respiratory Tract Examination Lesson 3 The Cardiovascular System Examination Lesson 4 The Gastrointestinal System Examination Lesson 5 The Kidney Examination Lesson 6 Approach to Patients with Hematological Diseases Lesson 7 The Endocrine System Examination Lesson 8 Approach to Patients with Immune System, Connective Tissue and Joints Diseases Comprehensive exam Literature 3 Contributors: Igor P. Kajdashev M.D., Ph. D, Professor Head of the Department of Internal Medicine, UKRAINIAN ACADEMY OF MEDICINE AND DENTISTRY Michael S. Rasin M.D., Ph. D., Professor Professor of the Department of Internal Medicine UKRAINIAN ACADEMY OF MEDICINE AND DENTISTRY Preface Beginning students of medicine and dentistry must acquire a set of skills that prepare them to become clinicians. This includes establishing rapport and a therapeutic relationship with the patient, basic interviewing, the specific conduct and content of medical data collection (the history and the physical examination), formulation of a problem list and diagnostic hypotheses, documentation and record-keeping, and communication with others involved in the patient's care. An introduction to these skills during the first years of medical school focuses on the basics of data collection and information synthesis rather than the specifics of disease, diagnosis, and treatment-that is, the emphasis is on process rather than specialized content. There are many fine texts that provide detailed discussions of the medical history and physical examination. This instruction is not intended to replace these comprehensive approaches but rather to summarize methods and outline the basic principles essential to data collection. The authors of this book have all been involved in teaching the Introduction to Clinical Medicine course at the Ukrainien Academy of Medicine and Dentistry. Their experience has informed the problem based approach used in this book. This book is structured to allow students to review a set of skills that will enable them to approach undifferentiated medical problems systematically and with confidence in preparation for clinical clerkships. I. Kajdashev, M. Rasin 4 Lesson 1 Physician-Patients Relationship and Professional Deontology Basic Components of the Medical History Introduction to the Physical Examination Physician-Patients Relationship and Professional Deontology Adopting a set of values and a professional identity is an important part of a professional education. There are many rites of passage that comprise the transformation of a layperson into a medical professional. These involve an increase in knowledge, a change in identity, as well as a familiarity with the events that define the profession (e.g., anatomy and dissection of the human body, access to intimate information about patients, and performance of invasive procedures). 1. Intimate information. Patients often share intimate information with clinicians about family difficulties, sexual relationships, and fears about disability and death. It is important that student-clinicians develop strategies for responding appropriately to the patient's needs as well as their own. 2. Lack of legitimacy. Students often feel that they are somehow just "playing" at being clinicians and that the patients with whom they work might just as well share intimate information; the person in the next bed. This is often compounded by "looking young" and having patients question their role as student-clinicians. This is one of the most difficult rites of passage in becoming a clinician. Students can manage these situations by: a. Explaining their stage of training and level of responsibility-for example, "l am a medical student, and I am here to interview you as part of our medical history course. b. Developing confidence about data collection skills and an awareness that new important information may be discovered. 3. Conflict between education and patient care. Some students feel a tension between educational objective and providing patient care. They are often concerned that they using patients" when they repeat examinations that are clinically unnecessary. However students should not overlook the fact that: a. They may discover something new and important. b. Most patients are pleased that they have something worthwhile to teach students. Many patients appreciate the extra attention and benefit from the additional time that students spend listening to their histories. 4. Patients with self-inflicted problems. Frequently, clinicians encounter patients who have acquired diseases or disabilities from high-risk behaviors, such as alcohol abuse, resulting in liver failure; heavy cigarette consumption, resulting in emphysema or lung 5 cancer; and intravenous drug use, resulting in endocarditis, osteomyelitis, or acquired immune deficiency (AIDS). While these patients may engender feelings of anger or frustration in health professionals, they still require sensitive and medically appropriate care. 5. Patients with terminal illness. Student-clinicians must explore their feelings about dying so that they can better attend to terminally ill patients and their families. The commonest reactions to death and dying are: a. Withdrawal from the patient to avoid emotional involvement or sadness about impending loss b. Anger over "treatment failure" c. Feelings of inadequacy in caring for the patient d. Denial 2. Distancing. Stepping aside and trying to view a given situation objectively can provide perspective. Distancing is an important coping strategy, which medical students must acquire early, so that they can analyze their interactions with patients, peers, and preceptors. 3. Self-control. Learning to control immediate emotional reactions is important for functioning well in clinical encounters. Although the immediate emotional response to a situation may not be appropriate to communicateto the patient, it should always be analyzed and discussed (see I E 1, 4). 4. Seeking social support. Developing support systems is important so that the student- clinician does not feel completely isolated and can engage help during the stressful periods of medical education. 5. Positive reappraisal. Reframing a stressful situation to determine the areas of learning is another positive strategy. 6. Confrontation. Examining the causes of discomfort or seeking clarification from faculty about areas of conflict can help students to deal positively with stress. Students often need to learn how to approach confrontation in an assertive rather than aggressive way.c. While many students chose medicine because of a desire to work with people, they often feel more isolated in the first 2 years than at any other point in their lives. 2. CONFIDENTIALITY A. Definition. All communication between patient and clinician is privileged and legally protected. Without the written consent of the patient, this information may be shared only with individuals who are involved in the patient's care. B. Maintenance of confidentiality. Confidentiality is one of the key elements of the profession of medicine and the delivery of health care. 1. Use of initials or anonymity. To preserve confidentiality, it is standard practice to use either initials or general descriptors (e.g., L. K. is a 55-year-old female Caucasian postal worker with a 10-year history of hypertension) in the presentation of case information. 2. Professional exchange of information. It is standard and appropriate practice that 6 information obtained from the patient may be shared with other health professionals under specific circumstances. a. Patient care. Other professionals involved in the ongoing care of patients may need to know information collected from the patient by another professional. In this instance, the name of the patient is necessarily used. b. Educational purposes. When patients agree to participate in an educational activity, confidential ity should be maintained in any verbal or written presentation, using initials or general descriptors as described above. 3. Patient's family and friends. Information collected from patients should not be shared with their tamiA or friends unless the patient indicates that this is acceptable. A demand from a ramilk member to knov, about drug use or sexual behavior of an adolescent child or a spouse s a*~oical example of the t~pe of conflict that ma~ occur. PATIENT PERSPECTIVE. To provide appropriate care, clinicians must have an understanding of the perspective patients bring to the health care encounter. A. Social context. Patients and clinicians are influenced by and act on the expectations of the society of which they are a part. 1. Sick role. In 1951, Parsons, a sociologist, developed a theoretical perspective on the functional meaning of being sick in Western societies. From his perspective, illness is a socially undesirable state, which prevents a person from performing ordinary tasks and roles and which must be remediated as soon as possible. There are four major components to the sick role, two "rights" and two "duties." a. Rights of the sick role (1) Recognition that the sick