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STUDENT INTRODUCTION

Welcome to the Physical Diagnosis Course for second year medical students! The major objective of this course is to learn the techniques of obtaining, recording, and organizing a complete medical history and thorough physical exam. The course runs concurrently with the pathophysiology seminars. Thus, as the course progresses, the medical knowledge base of each student is increasing in both theory and bedside application. By the end of this course you should feel comfortable performing each aspect of the physical exam. These are skills that you will continue to practice and refine during your clinical clerkships.

The course has several components in order to allow you to develop your skills in all aspects of the medical history and physical exam. Each week you will have a physical diagnosis session. The core experience will be two or three students with one instructor. During these sessions you will begin by having a discussion with your instructor who will review the physical exam components assigned for the session. You may be asked to practice physical exam techniques on one another, under your instructor’s guidance. Next, you will meet a patient who will be assigned for you to personally interview and examine. After you complete obtaining the history and performing the physical exam you will meet again as a small group to discuss your findings. At this point, your instructor will review important historical data and physical findings so that the accuracy of your technique can be verified. Each student is required to prepare a written history and physical for each session that will be reviewed by your instructor, corrected and discussed at the next session. Remember that understanding the correlation between historical and physical findings and the underlying changes in both anatomy and physiology is an extremely important component of this course.

Sample student/instructor session

2:30-2:45 review material and write-ups from previous session

2:45-3:30 discuss and practice new physical exam components for current session

3:30-5:00 each student obtains a history and performs a physical exam on their own patient

5:00-5:30 review findings

You will also have five small group workshops that will introduce the medical interview and several of the more challenging parts of the physical exam. These workshops will occur before your upcoming sessions with your instructor. You will have the opportunity to practice techniques within these workshops that will then prepare you for your sessions with your instructor and a patient.

You will have one skills practice sessions (OSCE) in which you will demonstrate components of the physical exam that you have already learned. You will be directly observed and get immediate feedback during this session. This is a teaching session, not an evaluation session, therefore you will not be graded. The schedules will be given out in December.

You will also have two sessions in which you will learn and practice the female breast and pelvic exam and the male genito-urinary and rectal exam with trained teaching associates. This schedule will be given out in February. The sessions will take place in evenings in March and April.

You will also have an OPTIONAL review session in which you will have the opportunity to review the various parts of the physical exam that you have learned to date with the Course Directors, Drs. Buckvar-Keltz and Wong.

The recommended textbooks for the course are A Guide to the Physical Examination by Bates, Textbook of Physical Diagnosis by Swartz, Diagnostic Examination by DeGowin and DeGowin, and The Medical Interview by Lipkin, Putman and Lazare. It is essential that you read the appropriate chapters for each weekly session. Note that videotapes are on reserve at the medical school library for your individual use.

SPECIFIC LEARNING OBJECTIVES

A. Knowledge: Each student should be able to describe:

1. The significant attributes of a symptom, including location and radiation, intensity, quality, temporal sequence (onset, duration, frequency), alleviating factors, aggravating factors, setting, associated symptoms, functional impairment, and patient’s interpretation of symptom.

2. The four methods of physical examination (inspection, palpation, percussion, and auscultation), including where and when to use them, their purposes, and the findings they elicit.

3. The physiologic mechanisms that explain key findings in the history and physical exam.

4. The diagnostic value of history and physical exam information.

B. Skills: Each student should be able to:

1. Use language appropriate for each patient.

2. Use non-verbal techniques to facilitate communication and pursue relevant inquiry.

3. Elicit the patient’s chief complaint as well as a complete list of the patient’s concerns.

4. Obtain a patient’s history in a logical, organized, and thorough manner.

5. Obtain, whenever necessary, supplemental historical information from other sources, such as significant others or previous physicians.

6. Demonstrate proper hygienic practices whenever examining a patient.

7. Position the patient and self properly for each part of the physical examination.

8. Perform a physical examination for a patient in a logical, organized, respectful, and thorough manner, giving attention to the patient’s general appearance, vital signs, and pertinent body regions.

9. Adapt the scope and focus of the history and physical exam appropriately to the medical situation and the time available.

C. Attitudes: Each student should:

1. Recognize the essential contribution of a pertinent history and physical examination to the patient’s care by continuously working to improve these skills.

2. Establish a habit of updating historical information and repeating important parts of the physical exam during follow-up visits.

3. Demonstrate consideration for the patient’s feelings and cultural and social background whenever taking a history and performing a physical exam.

PHYSICAL DIAGNOSIS COURSE REQUIREMENTS 2005-2006
All students are expected to attend EVERY scheduled session for the course. This includes:

13 core instructor/patient sessions
5 Workshops
1 Skills Practice sessions (the physical exam OSCE)
2 Teaching Associate sessions (the female breast and pelvic session and the male GU and rectal session)
1 Pediatric session
1 Final Observation session

Attendance
One EXCUSED absence (death in family, illness) from the core instructor/patient sessions is allowed if necessary. You must inform the course coordinator of this absence within one week of the absence. More than one absence will need to be made up; contact Dr. Buckvar-Keltz or Dr. Wong to arrange make-up sessions.

Write-up requirement
Students are expected to hand-in write-ups to their instructors for EACH core instructor/patient session to be read, corrected, and returned by their instructors. (See ARCHIVES for sample write-up) In addition, each student must hand-in a total of FIVE CORRECTED WRITE-UPS to the Physical Diagnosis Course Coordinator by the following due dates:

· TWO Write-Ups due by the week of January 9, 2005

o The Course Coordinator will be collecting these write-ups outside of the Coles Seminar Rooms before the beginning of your workshop during that week.

· THREE Write-Ups due by the week of March 27, 2005

o The Course Coordinator will be collecting these write-ups at the Physical Diagnosis Course Office in Old Bellevue, C and D Building, room D401.

“Corrected” means the write-ups that the students have gotten back from their instructor have comments on them. Students do not need to edit the write-ups based on their instructor's comments.

Grading
The course is graded Pass/Fail. You will receive a passing grade contingent upon completion of all of the above.

SYLLABUS OF WEEKLY PHYSICAL DIAGNOSIS SESSIONS

1. Week of October 17^th: Medical Interview Workshops

READING: Medical Interview Chapter(s)

LOCATION: Coles Seminar Rooms 1-4

2. Week of October 24^th: The Medical Interview Instructor/Patient session

LOCATION: Instructor Designated Meeting Place

The instructor will review how to elicit a medical history. The instructor and students will then interview one patient together. The instructor will also review vital signs, including sphygmomanometer use. Each student will compose an individual history write-up, to be handed in at the next session.

3. Week of October 31^st: HEENT Instructor/Patient session

READING: Head, Eyes, Ear, Neck and Throat Chapter(s)

LOCATION: Instructor Designated Meeting Place

Write-ups from the prior week will be collected. The instructor will review the HEENT exam with the students. Each student will be assigned a patient. The instructor will introduce the patient to the student, who will obtain a complete history, check the vital signs, and perform a HEENT exam. The instructor should observe the student during part or the entire interview. Each student will compose an individual write-up, to be handed in at the next session. Please note this is an introductory session to the use of the ophthalmoscope and otoscope. All students will have additional sessions during their clerkship orientation at the end of second year.

4. Week of November 7^th: Neurological Exam Workshops

READING: Neurological Chapter(s)

LOCATION: Coles Seminar Rooms 1-4

5. Week of November 14^th: Neurological Exam I Instructor/Patient session

LOCATION: Instructor Designated Meeting Place

The instructor will critique prior write-ups and collect new write-ups. The instructor will review the mini-mental status exam and cranial nerve exam, with demonstration on students and/or suitable patients. Each student will then be assigned a patient for complete history, with physical to include vital signs, HEENT, mini-mental status exam and cranial nerves. The instructor will observe the student during part of the patient encounter. At the end of the session, the instructor will confirm the physical findings on each patient with the students. Each student will compose an individual write-up to be handed in at the next session.

6. Week of November 21^nd: THANKSGIVING BREAK, NO PD SESSION

7. Week of November 28^th: Neurological Exam II Instructor/Patient session

LOCATION: Instructor Designated Meeting Place

The instructor will critique prior write-ups and collect new write-ups. The instructor will review the motor, sensory, cerebellar, and reflex exams, with demonstration on the students and/or suitable patients. Each student will then be assigned a patient for complete history, with physical to include vital signs, HEENT, and complete neurological examination. The instructor will observe the student during part of the patient encounter. At the end of the session, the instructor will confirm the physical findings on each patient with the students. Each student will compose an individual write-up to be handed in at the next session.

8. Week of December 5^th: Cardiovascular Workshops

READING: Cardiovascular Chapter(s)

LOCATION: Coles Seminar Rooms 1-4 (except on 12/6, Coles 304A, 304B, 305A, and 305B)

9. Week of December 12^th: Cardiac Exam Instructor/Patient session

LOCATION: Instructor Designated Meeting Place

The instructor will critique prior write-ups and collect new write-ups. The instructor will review the cardiac examination, including neck veins, cardiac inspection, palpation, percussion and auscultation. The instructor will arrange demonstration on a patient or, if practical, have students examine each other as part of the demonstration. Each student will then be assigned a patient for full history, with physical examination to include vital signs, HEENT, complete neurological examination, and cardiac examination. The instructor will observe the student during part of the patient encounter. At end of the session, the instructor will confirm the physical findings on each patient with the students. Each student will compose an individual write-up to be handed in at the next session.

10.    Week of December 19^th: NO PD SESSION

11.    Week of December 26^th: WINTER BREAK, NO PD SESSION

12.    Week of January 2^nd: Vascular Exam Instructor/Patient Session

(Note: Monday groups meet on Friday this week)

LOCATION: Instructor Designated Meeting Place

The instructor will critique prior write-ups and collect new write-ups. The instructor will review the vascular examination, with demonstration on students and/or suitable patients. Each student will then be assigned a patient for complete history, with physical to include vital signs, HEENT, complete neurological examination, and cardiovascular examination. The instructor will observe the student during part of the patient encounter. At end of the session, the instructor will confirm the physical findings on each patient with the students. Each student will compose an individual write-up to be handed in at the next session.

13. Week of January 9^th: Chest/Abdominal Workshops

READING: Chest and Abdominal Chapter(s)

LOCATION: Coles Seminars

SUBMIT: Write-Ups are due to the Course Coordinator prior to the beginning of your workshop session. She will be collecting them outside the Coles Seminar Rooms.

14. Week of January 16^th: Chest Exam Instructor/Patient Session

(Note: Monday groups meet on Friday this week)

LOCATION: Instructor Designated Meeting Place

The instructor will critique prior write-ups and collect new write-ups. The instructor will review the chest examination, with demonstration on students and/or suitable patients. Each student will then be assigned a patient for complete history, with physical to include vital signs, HEENT, complete neurological examination, cardiovascular examination, and chest examination. The instructor will observe the student during part of the patient encounter. At end of the session, the instructor will confirm the physical findings on each patient with the students. Each student will compose an individual write-up to be handed in at the next session.

15. Week of January 23^rd: OPTIONAL Instructor/Patient Make-Up Session or Review Session

LOCATION: Preceptor’s Desired Location

This session may be used as a make-up session for those instructor-students pairs that may have missed a session or in anticipation of a future absence. Alternatively, you may use this opportunity to meet with the Course Directors, Drs. Buckvar-Keltz and Wong, to review the various parts of the physical exam that you have learned to date.

16. Week of January 30^th: Abdominal Exam Instructor/Patient session

LOCATION: Instructor Designated Meeting Place

The instructor will critique previous write-ups and collect new write-ups. The instructor will review the abdominal examination, with demonstration on students and/or suitable patients. Each student will then be assigned a patient for complete history, with physical to include vital signs, HEENT, complete neurological examination, cardiovascular examination, chest examination, and abdominal examination. The instructor will observe the student during part of the patient encounter. At end of the session, the instructor will confirm the physical findings on each patient with the students. Each student will compose an individual write-up to be handed in at the next session.

17. Week of February 6^th: Physical Exam OSCE

LOCATION: Manhattan VA Clinic Areas (Exact location will be announced)

This session is designed for students to practice their skills in parts of the physical exam. In pairs, students will rotate through four different stations taking turns to obtain a complete history and perform different parts of the regional exam on an actual patient with an abnormal physical finding while being observed by a faculty observer. The faculty observer will then provide feedback on the students’ performance and review the abnormal finding. These are teaching sessions and students’ performance will not be graded. Specific OSCE instructions will be given out along with the schedule in January.

18. Week of February 13^th: Musculoskeletal Workshops

READNG: Musculoskeletal Chapter(s)

LOCATION: Coles Seminars

19. Week of February 20^th: Musculoskeletal Exam Instructor/Patient session

(Note: Monday groups meet on Friday this week)

LOCATION: Instructor Designated Meeting Place

The instructor will critique prior write-ups and collect new write-ups. The instructor will review the musculoskeletal examination, with demonstration on the students or suitable patients. Each student will then be assigned a patient for complete history, with physical to include vital signs, HEENT, complete neurological examination, cardiovascular examination, chest examination, abdominal examination, and musculoskeletal examination. The instructor will observe the student during part of the patient encounter. At the end of the session, the instructor will confirm the physical findings on each patient with the students. Each student will compose an individual write-up to be handed in at the next session.

20. Week of February 27^th: Complete History and Physical Instructor/Patient session**

LOCATION: Instructor Designated Meeting Place

The instructor will critique prior write-ups and collect new write-ups. Then, the instructor will concentrate on the individual needs of each student, fine-tuning history taking and physical examination techniques. The instructor will observe the student during part of the patient encounter. At the end of the session, the instructor will confirm the physical findings on each patient with the students. Each student will compose an individual write-up to be handed in at the next session.

21. Week of March 6^th: Complete History and Physical Instructor/Patient session**

LOCATION: Instructor Designated Meeting Place

22. Week of March 13^th: Complete History and Physical Instructor/ Patient session **

LOCATION: Instructor Designated Meeting Place

The instructor will critique prior write-ups and collect new write-ups. Then, the instructor will concentrate on the individual needs of each student, fine-tuning history taking and physical examination techniques. The instructor will observe the student during part of the patient encounter. At end of session, the instructor will confirm the physical findings on each patient with the students. Each student will compose an individual write-up to be handed in at the next session.

23. Week of March 20^th: NO PD SESSION

24. Week of March 27^th: Complete History and Physical Instructor/Patient session

LOCATION: Instructor Designated Meeting Place

SUBMIT: Write-Ups are due to the Course Coordinator prior to the beginning of your session. She will be collecting them at the Physical Diagnosis Course Office in Old Bellevue, C and D Building, room D401.

The instructor will critique prior write-ups and collect new write-ups. Then, the instructor will concentrate on the individual needs of each student, fine-tuning history taking and physical examination techniques. The instructor will observe the student during part of the patient encounter. At the end of the session, the instructor will confirm the physical findings on each patient with the students. Note: Students do not compose a write-up based on today’s patient encounter.

25. Week of April 3^rd: Final Observation Instructor/Patient session

LOCATION: Instructor Designated Meeting Place

The students will be assigned to a different instructor this week (schedule to be emailed). This week, the session will be divided, with each student assigned one and a half-hours to perform a complete history and physical examination while being observed by the instructor. The instructor will critique each student’s technique of taking a thorough history and performing a precise physical examination, and corroborate the accuracy of all the physical findings. The instructor fills out the student evaluations and submits them by fax, (212) 263-8234, or by e-mail, amy.hsieh@med.nyu.edu.

** Pediatrics Session instead of one of these sessions

In addition, there will be two evening teaching associates’ sessions, one on the female breast and pelvic exam and one on the male GU and rectal exam. These will take place during the months of March and April. The schedule will be given out in January.