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					   Novak ch.1

Initial Assessment and
     Communication

         부산백병원 산부인과
              R2 박영미
Communication
   Good communication is essential to patient
    assessment and treatment

   The foundation of communication is based
    on key skills
       Empathy
       Attentive listening
       Expert knowledge
       Rapport


   Trust is the fundamental element
       Encourages the patient to communicate her
        feelings, concerns, thoughts openly, without
        withholding information
    Variables that affect patient status

   Many external variables are important in
    understanding the patient’s response to her
    care in both illness and health

       The patient’s significant others
            Her family, friends, personal relationships
       Psychological, genetic, biologic, social and
        economic issues
       Education, attitudes, understanding of human
        reproduction and sexuality, family history of
        disease
       Cultural factors, socioeconomic status, religion,
        ethnicity, sexual preference
        Communication skills
   Important aspects of the patient-
    physician interaction

     The words used
     The patterns of speech
     The manner in which the words are
      delivered
     Body language
     Eye contact
     (1) Physician-patient interaction

   The patient must feel that she is able to
    discuss her problems fully

   If the patient perceives that she participates
    in the decision and that she is given as much
    information as possible, she will react to the
    proposed treatment with lower anxiety and
    depression

   Patient communication and understanding
    and treatment outcome are improved when
    discussion with physicians are more dialogue
    than lecture.
     (1) Physician-patient interaction

   On the outcome of chronic illness, three
    characteristics – better health care outcomes

       Empathetic physician and more patient control of
        the interview

       Expression of emotion by both patient and
        physician

       Provision of information by the physician in
        response to the patient’s inquiries
     (1) Physician-patient interaction
   In studies of gender and language
      Male physicians
          Talk more than women
          Tend to take control & be more assertive
          Interruption, command, lectures

       Women’s speech is
            Silence, questions, proposals


   These patterns indicate the need to be
    attentive to their style of speech
       It may affect their ability to elicit open and free
        responses from their patients
                            (2) Style
   The techniques to help achieve rapport

       Use positive language
            agreement, approval, humor


       Build a partnership
            Acknowledgment of understanding
            Asking for opinions
            Paraphrasing
            Interpreting the patient’s words


       Ask rephrased questions

       Give complete responses to the questions
           (3) Strategies for improving
                  communication
   General guidelines for communication

    1. Listen more and talk less

    2. Encourage the pursuit of topics
       introduced by and important to patients

    3. Minimize controlling speech habits such as
       interrupting, issuing commands, lecturing

    4. Seek out questions and provide full and
       understandable answers
       (3) Strategies for improving
              communication

5. Become aware of discomfort in an interview,
   recognize when it originates in an attempt by the
   physician to take control, and redirect that
   attempt

6. Assure patients that they have the opportunity to
   discuss their problem fully

7. Recognize when patients may be seeking
   empathy and validation of their feelings rather
   than a solution. Sometimes all that is necessary is
   to be there as a compassionate human being
          (3) Strategies for improving
                 communication

    An interview that permits maximum
     transmission of information to the physician

    1. Begin with an open-ended question

    2. As the patient begins to speak, pay attention not
       only to her answers but also to her emotion and
       general body language
       (3) Strategies for improving
              communication

3. Extend a second question or comment,
  encouraging the patient to talk

4. Allow the patient to respond without interrupting,
   perhaps by employing silence, nods, or small
   facilitative comments, encouraging the patient to
   talk while the physician is listening

5. Summarize and express empathy and
   understanding at the completion of the interview
History and physical
    examination
                             History
   Allow the patient to talk about her chief
    complaint

       Chief complaint is uppermost in the patient’s mind
        and the basis for the visit to the physician

       “then up to the time of this complaint, you felt
        perfectly well?”
            May elicit other symptoms that may antedate the chief
             complaint by days, months, or years

       “When did it begin?”
            Which will help in developing chronologic order in the
             patient’s story
                             History
       “what other problems have you noticed since you
        became ill?”
            May reveal other symptoms not yet brought forth in the
             interview


   A series of direct and detailed questions
    concerning the symptoms described by the
    patient

   The data described in the first two phases of
    the interview should now suggest several
    diagnostic possibilities
                         History

   These techniques may still fail to reveal all
    symptoms of importance to the present
    illness

       If they are remote in time and seemingly unrelated
        to the present problem

       The review of systems : a positive response
        should lead immediately to further detailed
        questioning
                           History
   Consider the following factors

       The probable cause of each symptom or illness,
        such as emotional stress, infection, neoplams

       The severity of the patient’s illness, as judged
        either by the presence of systemic symptoms,
        such as weakness, fatigue, loss of weight, or by a
        change in personal habits

       Determine the patient’s psychological reaction to
        her illness (anxiety, depression, irritability, fear) by
        observing how she relates her story as well as her
        nonverbal behavior
            Abdominal examination
   In supine position, relax as much as possible

   Inspection
       Signs of an intraabdominal mass, organomegaly,
        distention (ascites, intestinal obstriction)

   Palpation
       Evaluate the size and configuration of the liver,
        spleen, other abdominal contents

   Percussion
       To measure the dimensions of the liver
           Abdominal examination

   Auscultation
       To ascertain the nature of the bowel sounds
       Intestinal obstruction
         : rushes, as well as the occasional high-pitched
           sound
       Ileus
         : less frequent bowel sounds but at the same
           pitch as normal bowel sounds
              Pelvic examination
   Empty the bladder

   In lithotomy position

   Draped properly

   The examiner’s Rt or Lt
    hand is gloved

   The pelvic area is
    illuminated well
                (1) External genitalia
   Inspect the skin, hair, contour, swelling
       Mons pubis, labia majora, labia minora, perineal
        body, anal region

   Separate the labia majora,
    Inspect the epidermal and mucosal
    characteristics and anatomic configuration
       Labia minora
       Clitoris
       Urethral orifice
       Vaginal outlet (introitus)
       Hymen
       Perineal body
       anus
                      (2) Introitus

   Instruct the patient to bear down

   Cystocele
       Bulging of the anterior wall of the vagina


   Rectocele or Enterocele
       Bulging of the posterior wall of the vagina


   Bulging of both
       may accompany a complete prolapse of the uterus
             (3) Vaginal and cervix
   Inspection using a speculum should always precede
    palpation
   Select the proper size of speculum, warmed and
    lubricated
                 (3) Vaginal and cervix
   Inspect the vagina for the following

       The presence of blood
       Discharge
            To detect trichomoniasis, monilia, clue cells
            To obtain cultures for gonococci, chlamydiae
       Mucosal characteristics
            Inflammatory – redness, swelling, exudates, ulcers,
             vesicles
            Neoplastic
            Vascular
            Pigmented – bluish discoloration of pregnancy
            Miscellaneous – endometriosis, traumatic lesions, cyst
       Structural abnormalities (congenital or acquired)
                  (3) Vaginal and cervix
   Inspect the cervix

       Unusual bleeding from the cervical canal
            Evaluation for cervical or uterine neoplaisa
       Inflammatory lesions
            Mucopurulent discharge from the os
            Redness, swelling, superficial ulcerations of the surface
       Polyps
            From the surface of the cervix projecting into the vagina
            From the cervical canal
       Carcinoma
            Similar in appearance to an inflammation
            Biopsy should be performed
            (4) Bimanual palpation

   One hand on
    the lower
    abdominal wall

   The other hand,
    the fingers
    (usually two) in
    the vagina

   The other hand,
    the fingers in
    the vagina and
    rectum
    (rectovaginal
    examination)
              (4) Bimanual palpation

   Introduce the well lubricated index and middle
    finger into the vagina at posterior aspect near
    the perineum
       Test the strength of the perineum
          Cystocele, rectocele, Ut prolapse




   Advance the fingers along the posterior wall
       Abnormalities or tenderness
              (4) Bimanual palpation

   Evaluate the body of the uterus
    -> Press the abdominal hand, very gently
       downward, sweeping the pelvic structures
       toward the vaginal fingers
       Position
       Architecture, size, shape, symmetry, tumor
       Consistency
       Tenderness
       Mobility

   Evaluate the cervix for position, architecture,
    consistency, tenderness
              (4) Bimanual palpation

   Intravaginal finger : explore the anterior,
    posterior, lateral fornices

   Outline the adnexa
       Vaginal fingers in the Rt or Lt lat fornix
       Abdominal hand on the Rt or Lt lower quadrant
       A normal tube & a normal ovary is often not
        palpable
       Adnexal mass : location relative to the uterus &
        cervix, consistency, tenderness, mobility
              (4) Bimanual palpation

   Rectovaginal-abdominal examination
       Insert the index finger into the vagina
       Insert the middle finger into the rectum
       The other hand on the infraumbilical region
       Higher exploration of the pelvis


   Intact hymen
       Rectal-abdominal technique
                Pediatric patients
   The examiner should be familiar with the
    normal appearance of the prepubital genitalia
       The normal unestrogenized hymenal ring and
        vestibule
         : mildly erythematous

   Examination technique must be tailored to the
    individual child based on age, size, comfort
    with the examiner
       A young child
          : frog-leg position in the examining table
       Very young girls (toddlers or infants)
          : held in their mother’s arms
       The knee-chest position
                Pediatric patients

   Examination with the use of anesthesia
       Some children who have been abused
       Particularly traumatic previous examinations
       Unable to allow an examination
              Adolescent patients
   An adolescent should have a pelvic
    examination
       If she has had intercourse

       If the results of a pregnancy test are positive

       If she has abdominal pain

       If she is markedly anemic

       If she is bleeding heavily enough to compromise
        hemodynamic stability
               Adolescent patients

   Before a first pelvic examination

       A brief explanation of the planned examination

       Instruction in relaxation techniques

       The use of lidocaine jelly as a lubricant
              Adolescent patients

   Confidentiality is an important issue in
    adolescent health care
       Interviewed alone, without a parent in the room



   Should be asked
       If she has engaged in sexual intercourse

       If she used any method of contraception

       If she feels there is any possibility of pregnancy
                      Follow up
   Patients with no evidence of disease
       Counseled regarding health behaviors and the
        need for routine care

   Patients with signs and symptoms of a
    medical disorder
       Discussed about further assessments and a
        treatment plan

   The physician must determine
       Whether she is equipped to treat a particular
        problem
       Whether she should be directed to another health
        professional

				
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posted:4/30/2011
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