Step-By-Step Guide
How to Propose the Elements of a Physical Exam
Dr. Mendoza would like you to propose the elements of the patient examination for Brian Johnson. After observing Dr. Shah’s patient interview, you will create a list of possible diagnoses to help you determine the elements Brian’s exam should include.
Review the interview with Dr. Shah and Brian to identify exactly what signs and symptoms Brian is experiencing, and then research what could have caused them. You then need to decide what should be included in Brian’s physical examination to explore all possible causes.
In the case of a sports injury involving a fall, the physician gathers information about such things as headache, dizziness, confusion/amnesia, stiff neck, and vomiting. The physical exam should also explore all possible consequences of the fall, such as a brain injury, a spinal column injury, a nerve injury, or something else, and determine if Brian is suffering any underlying complications because of his mishap.
Remember that, at this point, you are not creating a differential diagnosis because you don’t have the results of any tests. You are just creating a list of what might be wrong with Brian, and the elements that should be tested so that you can eliminate some elements and then create the differential. You’ll then order additional tests, if necessary, to come up with a working diagnosis and treatment options.
Getting Started
- Prepare to do your work on this task.
- Review Dr. Mendoza’s email and make sure you understand what you are being asked to do in this task. Also download the following file attached to his email:
- Patient Interview and Physical Examination Form—This form contains the triage nurse’s entries about vital signs, and Dr. Shah’s notes from the patient interview.
- If you haven't gone to the interview (by returning to the Read about your task section and clicking the "Go to Interview" button below Dr. Mendoza's email) already, do so now. You will have the ability to replay the video as often as you need.
- Download Dr. Shah's Interview Notes for review.
- Organize your team and create a plan for completing this task.
- In this task, you should create your own exam proposal first, and then meet as a team to gather together everyone’s ideas. As you did in the first case, you should develop a rough timeline to plan when you will do your individual work and when you will get together to synthesize this work for the team deliverable.
- If you need additional help organizing your team, please refer to the Teamwork section of the General Skills Resources located in the left menu.
Preparing the Examination Proposal
- Re-view the video and notes from Dr. Shah’s interview with Brian Johnson.
- As you work, take notes on any clinical findings with which you are presented. Specifically keep in mind:
- What symptoms Brian and his father mention.
- What questions Dr. Shah asks and how Brian responds.
Pay special attention to how Brian describes what happened to him when he fell, the pain and/or confusion he is experiencing, and specific things he mentions about difficulty moving any limbs.
- Research possible diagnoses in DATA using the clinical findings you have gathered to this point. Begin to compile a list of possible diagnoses that would explain the symptoms Brian presents.
- You are not trying to create a differential diagnosis yet. Instead, you are simply compiling information based on what you know of Brian’s condition so far, in order to determine the best way to gather the additional clinical findings you will need to create a well-informed differential diagnosis.
- In your notes, make a list of all the possible problems you think could be affecting Brian. Be sure you consider ALL his signs and symptoms.
- Review the Guide to Performing a Neurological Exam for detailed information regarding examination techniques physicians use to diagnose brain and spinal cord injuries.
- Determine which elements you propose to use in Brian’s patient exam.
- Using your list of possible diagnoses and the reference documents listed above, create a list of applicable exam techniques or elements. Research each potential exam element in DATA and use the Science Links for additional information.
- Write a rationale for each proposed element that:
- Describes what you believe that element will tell you about Brian’s injury, based on your research.
- Describes why you need the information the element can provide and how it will help you form a differential diagnosis.
Meeting to Exchange Feedback
- Meet with your teammates to discuss your findings and ideas. Take some time for each person to share highlights of his/her work.
- Come to a consensus on the proposed elements of the exam.
- Decide which elements your team is going to include in the Physical Examination Proposal.
- For this task, each team will submit one copy of the template. As a team, complete one Physical Examination Proposal that incorporates everyone’s ideas.
- For additional help, see the resources on Teamwork, especially the articles on collaborative group work and collaborative writing, in the General Skills Resources in the left menu.
- Submit your work to your mentor. Be sure to save all of your work, regardless of whether you submit it to the
mentor.
Diagnosis and Treatment Archive - Sports Medicine
What is the purpose of interviewing the patient?