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The History of the Physical Exam and Diagnostic Techniques

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Reduce bodily processes to laws of physics and chemistry ... Fueled move to hospital-based medicine. Fueled specialization. Changed doctor's image ... – PowerPoint PPT presentation

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Title: The History of the Physical Exam and Diagnostic Techniques


1
The History of the Physical Exam and Diagnostic
Techniques
  • Hughes Evans, MD, PhD

2
Humoral Medicine
  • Importance of the history
  • Physical exam less important
  • Highly individualized
  • Stressed regimen, diet, climate, inheritance

3
Diagnosis before 19th century
  • Importance of the history
  • Gathered information about the body
  • Feeling the pulse
  • Examining the stool and urine
  • Assess external manifestations of illness
  • Internal workings not accessible and not
    interesting

4
Pulse taking, ancient China
5
Persian Medicine
6
Pulse taking, Renaissance
7
Dr. William Clysson, 1780
8
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9
Development of Phys. Exam
  • Percussion
  • Auscultation
  • Temperature
  • Blood Pressure
  • How did these reflect new ways of thinking about
    disease?
  • What was the impact on the dr/pt relationship?

10
Percussion
  • Leopold Auenbrugger
  • Inventum Novum, 1761
  • Wine cask
  • Localized disease
  • Neglected throughout 18th century

11
Percussion
  • Pros
  • Accuracy Precision
  • Identified alterations in internal organs, esp
    the chest
  • Objective evidence of disease
  • Related structural internal change to external
    symptoms
  • Cons
  • Went against humoral theory which held that
    disease was lack of balance, not local process
  • Manual process

12
Auscultation
  • Rene-Theophile-Hyacinthe Laennec
  • Paris Clinical School
  • On Mediate Auscultation, 1819
  • stethoscope

13
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14
Immediate Auscultation
  • Immediate or direct auscultation
  • Problematic in obese and female patients

15
Mediate Auscultation
  • Mediate or indirect
  • Use of stethoscope to augment sound
  • Stethoscope means chest and observe
  • A window in the breast through which we can see
    the precise state of things within.

16
Impact of Stethoscope
  • Correlation of sounds with pathology
  • Localize disease to an organ and tissue
  • Correlate symptoms with autopsy findings
  • New way of conceptualizing disease
  • Anatomy in a living patient
  • Understanding how disease evolves

17
Philosophical shift
  • Increased role of physical exam relative to
    history
  • Gave disease increased autonomy
  • Importance of localizing disease

18
Monaural and binaural models
19
Laennecs portable stethoscope
20
Thermometer
  • Carl Wunderlich
  • Germany
  • On the Temperature in Diseases, 1868
  • Based on 25,000 hospitalized patients

21
Impact of Thermometer vs Stethoscope
  • Quantitative information
  • More precise
  • Showed trends
  • Could be graphed and show change over time
  • Fever curves assisted in diagnosis, treatment,
    and prognosis

22
Wunderlichs fever curve
23
Reception of the Thermometer
  • Focus on disease instead of patient
    idiosyncracies
  • Reinforced notion of disease as process
  • Replace physicians sense of touch
  • Technical difficulties
  • Easily broken, not portable
  • Hard to calibrate
  • Expensive

24
Physicians sense of touch
  • Pros
  • Portable
  • Convenient
  • Mysterious
  • Art of Medicine
  • Symbol of laying on of hands
  • Status and professionalism
  • Cons
  • Qualitative
  • Less accurate
  • Difficult to communicate
  • Manual

25
Sphygmomanometer
26
Pulse diagnosis and BP
  • Revered part of medicine since ancient times
  • German physiologists in 1840s
  • Reduce bodily processes to laws of physics and
    chemistry
  • Use technology to measure these processes
  • The Graphic Method
  • Adapted physiological instruments for clinical use

27
Kymograph
  • Carl Ludwig
  • 1840
  • Apply physics to medicine
  • Change over time

28
Sphygmograph, 1880s
29
Sphygmomanometer
30
Sphygmomanometer
  • Measures BP by occluding the pulse and recording
    pressure at which pulse returns
  • Many designs
  • Modern design based on Scipione Riva-Roccis
    device

31
Sphygmomanometer
  • Scipione Riva-Rocci
  • 1896
  • Italy
  • Means pulse and measure
  • Adapted by Harvey Cushing
  • Uses in surgery first, then at bedside

32
Uses of BP technology
  • Monitor VS in surgery and at bedside
  • Objectify teaching
  • Consultation
  • Diagnosis and Treatment
  • Ancillary staff instructions
  • First used to identify shock later for
    hypertension

33
Cushings ether curves
34
Helmholtz Ophthalmoscope, 1850
35
Electrocardiograph
  • 1901, Einthoven
  • String galvanometer
  • Bulky, delicate, expensive
  • Initially used to study rhythm
  • Later discovered changes assocd w/ myocardial
    infarction

36
Electrocardiograph
37
X-rays
  • Wilhelm Roentgen
  • Professor of physics in Bavaria
  • 1895
  • Could show internal anatomy
  • Immediately accepted

38
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39
Xrays
40
Benefits of PE technology
  • Instruments more reliable than patients
  • Information from the disease itself
  • independent of the caprice or ignorance of the
    patient
  • Delegation of tasks
  • National Importance of Instruments of Precision
  • Artistry yielding to machinery
  • Useful in research

41
Medical Research
42
Concerns about PE technology
  • Patients wary
  • Doctors concerned that instruments made them
    appear less intellectual. Thinkers not tinkers
  • Fear of being duped by technology

43
Concerns about Med. Technology
  • Difficulty of adapting technology to medical
    practice
  • Convenience, durability, size, reliability,
    calibration
  • Price
  • House-calls

44
Concerns about medical technology
  • Increased cost of medicine

45
Concerns about medical technology
  • Dr/ Patient encounter became less personal

46
Impact on Medicine
  • Changed communication and learning
  • Emphasized accuracy
  • Stressed quantification
  • Increased autonomy of disease

47
Impact on education
  • Osler, inspection
  • Osler, palpation

48
Impact on education
  • Osler, percussion
  • Osler, auscultation

49
Impact on Medicine
  • Fueled move to hospital-based medicine
  • Fueled specialization
  • Changed doctors image

50
Image of the Doctor
51
Doctors as Body Mechanics
52
Larry Weeds SOAP note
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