Diagnostics of Internal Medicine

Lection 1

Doctor and Patient a partnership

through dialogue
The art of interviewing
Meaning of signs, symptoms and
complaints

Patients assessment

Comprehensive assessment
Focused / or problem oriented assessment
Routine clinical check-up
Periodic physical examination

Patients Assessment
Comprehensive

Focused / or
problem oriented

First visit of a patient in

a hospital or office

Is appropriate especially
during routine or urgent
care visits

Complete physical examination

Provides
fundamental
and
personalized knowledge about the
patient;
Strengthens the clinicianpatient
relationship;
Provides
baselines
for
future
assessments;
Helps identify or rule out physical
causes related to patient concerns

Assesses symptoms restricted to a

specific body system;
Applies examination methods
relevant to assessing the concern
or problem as precisely and
carefully as possible.
Addresses focused concerns or
symptoms.

Routine clinical check-up, or periodic

physical examination
Purpose
screening and prevention of illnesses, blood
pressure measurement, assessment of central
venous pressure from the jugular venous pulse,
listening to the heart for evidence of valvular
disease, detection of hepatic and splenic
enlargement and the pelvic examination with
Papanicolaou smears.

I stage - open-ended questions

to hear the story of the
symptom in the patients own
words

II stage - more specific

questions to elicit the seven
features of every symptom

III stage - the yes-no questions

or pertinent positives and
negatives from the relevant
section of the review of
systems

The Seven Attributes of a Symptom

1. Location. Where is it? Does it radiate?

2. Quality. What is it like?
3. Quantity or severity. How bad is it? (For pain, ask for a rating
on a scale of 1 to 10.)
4. Timing. When did (does) it start? How long does it last? How
often does it come?
5.

Setting in which it occurs. Include environmental factors,

personal activities, emotional reactions, or other circumstances that
may have contributed to the illness.

6. Remitting or exacerbating factors. Is there anything that

makes it better or worse?
7. Associated manifestations. Have you noticed anything else that
accompanies it?

Patients Data
SUBJECTIVE

What the patient tells to

MD
Pain in a chest, discomfort,
palpitation, cough, numbness
etc

OBJECTIVE

What MD detects during

the examination
All physical examination findings age,
white/black, sex, height, weight, BMI,
BP, HR, respiratory rate, temperature
etc.

Comprehensive Adult Health History

Components
I. Identifying Data and Source of the History;
Reliability
II. Chief Complaint(s)
III. Present Illness
IV. Past History
V. Family History
VI. Personal and Social History
VII.Review of Systems

I. Identifying Data and Source of the

History; Reliability
Identifying data
-

Age
Gender
Occupation
Marital status

Source of the history

-

Patient (usually)
Family member or friend (can be)
Letter of referral
The medical record

Reliability

- Varies according to the patients memory, trust, and mood.

II. Chief Complaint(s)

The one or more symptoms or concerns causing the

patient to seek care
Doctor should make every attempt to quote the
patients own words. ( For example, My stomach
hurts and I feel awful. )
Sometimes patients have no specific complaints.

Report their goals instead. (For example, I have

come for my regular check-up or Ive been
admitted for a thorough evaluation of my heart.)

III. Present Illness

The Chief Complaint(s);

Description how each symptom developed;
Patients thoughts and feelings about the illness
Review of systems, called pertinent positives
and negatives.

May include medications, allergies, and habits of

smoking and alcohol, which are frequently pertinent to
the present illness.

Allergies

Medications
name, dose, route, and
frequency of use.

to medication, foods, insects, or

environmental factors (rash,
nausea, palpitation etc).

Present Illness
accompanied by
Tobacco use
type, amount, frequency,
duration. If someone has
quit, note for how long.

Alcohol and drug

use
Type, amount, frequency,
duration.

Principal Symptom
Should be well-characterized, with
1.Descriptions of location;
2.Quality;
3.Quantity or severity;
4.Timing, including:
a.onset, duration, and frequency
b.the setting in which it occurs;
c.factors that have aggravated or relieved the symptom
d.associated manifestations.
N.B. Chief Complaint(s) - indicate the presence or absence of symptoms relevant to the
differential diagnosis, which identifies the most likely diagnoses explaining the patients
condition.

Risk Factors
Should be revealed risk factors for diseases (for
example, risk factors for coronary artery disease in
patients with chest pain).
Age
Sex
Sedentary Lifestyle
Obesity
Genetics
Smoking

IV. Past History

1. Lists childhood illnesses:
- measles,
- rubella,
- mumps,
- whooping cough,
- chickenpox,
- rheumatic fever,
- scarlet fever,
- polio
2. Also include any chronic childhood illnesses.

IV. Past History continued

3. Lists adult illnesses (four categories):
a. Medical - Illnesses such as diabetes, hypertension,
hepatitis, asthma, and HIV; hospitalizations; number
and gender of sexual partners; and risky sexual
practices.
b. Surgical - Dates, indications, and types of operations;
c. Obstetric/Gynecologic - Obstetric history, menstrual
history, methods of contraception, and sexual
function;
d. Psychiatric - Illness and time frame, diagnoses,
hospitalizations, and treatments.

IV. Past History continued

4. Includes health maintenance practices such as
immunizations, screening tests, lifestyle issues, and
home safety

o Immunizations -

find out whether the patient

has received all the necessury vaccines and
record them.

o Screening tests

- review tuberculin tests, Pap

smears, mammograms, stool tests for occult
blood, colonoscopy and cholesterol tests, together
with results and when they were last performed.

Tetanus

Diphtheria
Pertussis
Polio

Hepatitis B

Mumps

Immunization

Rubella

Herpes Zoster

Varicella

Measles

Influenza and
Haemophilus
influenzae type B

Pneumococci

V. Family History
Outlines or diagrams age and health, or
age and cause of death, of each immediate
relative, including parents, siblings,
grandparents, children, and grandchildren.

V. Family History

continued

Review each of the following conditions and record

whether they are present or absent in the family:
Hypertension, Coronary artery disease, elevated cholesterol
levels, stroke, diabetes, thyroid or renal disease, arthritis,
tuberculosis, asthma or lung disease, headache, seizure
disorder, mental illness, suicide, substance abuse, allergies.
Reveal any history of breast, ovarian,

colon, or prostate

cancer.
Reveal any genetically transmitted diseases.

VI. Personal and Social

History
Personal history

- Documents presence or absence of

specific illnesses in family, such as hypertension or coronary

artery disease;
Social History

- Describes educational level, family of

origin, current household, personal interests, and lifestyle.

Stress
Home situation

(source, length,
duration)

Exercise
Type & frequency

Social
History
Diet
(daily food intake,
dietary supplements and/or
restrictions, use of
coffee, tea etc.)

Important life
experiences
(military service, job history,
financial situation, leisure
activities, religious affiliation
and spiritual beliefs)

Safety
measures
(use of seat belts,
bicycle helmets,
sunblocks, smoke
detectors etc)

VII. Review of Systems

Documents presence or absence of common symptoms related to
each major body system.
o Ask series of questions going from head to toe
o Questions should start with a fairly general question and
should be addressed to different systems.
Examples of questions:
How are your ears and hearing?
How about your lungs and breathing?
Any trouble with your heart?
How is your digestion?
How about your bowels?

Review of systems
General

Usual weight
Recent weight change
weakness
fatigue
fever

Review of systems: Skin

Rashes
Lumps
Sores
Itching
Dryness
Changes in color
Changes in hair or nails
Changes in size or
color of moles.

Review of systems:
Head, Eyes, Ears, Nose, Throat
(HEENT)

Head:
Headache,
Head injury,
Dizziness,
Lightheadedness.
Eyes:
Vision
Glasses or contact lenses
Pain & redness
Excessive tearing
Double or blurred vision
Spots & specks
flashing lights
Glaucoma & cataracts.

Ears: hearing, tinnitus, vertigo,

Nose and sinuses:

Frequent colds, nasal stuffiness,

discharge, or itching, hay fever,
nosebleeds, sinus trouble.

earaches, infection, discharge.

Throat (or mouth and pharynx):

Condition of teeth and gums, bleeding
gums, sore tongue, dry mouth, frequent
sore throats, hoarseness.

Neck: Swollen glands,

goiter, lumps, pain, or
stiffness in the neck.

Breasts: Lumps, pain, or

discomfort, nipple
discharge.

Respiration

Cough
Sputum (color, quantity)
Hemoptysis
Dyspnea
Wheezing
Pleurisy
Last chest x-ray.

Cardiovascular

High blood pressure

Rheumatic fever
Heart murmurs
Chest pain or discomfort
Palpitations
Dyspnea and orthopnea
Paroxysmal nocturnal dyspnea
Edema
Past electrocardiograms

Gastrointestinal

Trouble swallowing
Heartburn
Nausea & vomiting
Abdominal pain
Food intolerance
Excessive belching or passing
of gas

Stool color and size

Pain with defecation
Rectal bleeding or black or
tarry stools
Constipation and diarrhea
Jaundice

Peripheral vascular System

Intermittent claudication
Leg cramps
Varicose veins
Past clots in the veins
Swelling in calves, legs, or
feet
Color change in fingertips
or toes during cold weather
Swelling with redness or
tenderness.

Urinary System

Frequency of urination
Polyuria
Nocturia
Urgency & incontinence;
Burning & pain during
urination
Hematuria
Kidney, suprapubic or flank
pain
Kidney stones
Ureteral colic
In males, reduced caliber or
force of the urinary stream,
hesitancy, dribbling.

Other Systems
Musculoskeletal: fractures, mialgias etc.
Psychiatric: Nervousness, tension, mood, including
depression, memory change, suicide at
tempts, if relevant.
Genital system
Vascular system
Neurologic system
Endocrine system
Hematologic system

Suggested positioning while examination

Recommended:
General survey & Vital signs
Skin: upper torso, anterior and
posterior
Head and neck, including thyroid
and lymph nodes
Optional:
Nervous system (mental status,
cranial nerves, upper extremity
motor strength, bulk, tone,
cerebellar function)
Thorax and lungs
Breasts
Musculoskeletal: upper extremities

Cardiovascular, including JVP,

carotid upstrokes and bruits,
S1, S2 murmurs, extra sounds
Lying supine, with head of bed
raised 30 degrees

Cardiovascular, for S3 and

murmur of mitral stenosis
Lying on the left side, with
head of bed raised 30 degrees

Cardiovascular, for murmur

of aortic Insuficiency
Sitting, leaning forward
Optional:
Thorax and lungs exam
Abdomen exam
Breasts and axillae
Peripheral vascular
Skin lower torso and
extremities
Nervous system: lower extremity
motor strength, bulk, tone,
sensation; reexes; Babinski reex.

Lying supine

OR

Musculoskeletal, as indicated
Optional: skin, anterior and posterior
Optional: nervous system, including gait
Optional: musculoskeletal, comprehensive

Women:
Pelvic and rectal examination
Lithotomy position - Lying
supine, with hips exed,
abducted, and externally
rotated, and knees exed

Men:
Prostate and rectal
examination
Left lateral decubitus Lying on the left side

Trendelenburg position the body is laid flat on the

back (supine position)
with the feet higher than
the head by 15-30 degrees

Reverse Trendelenburg
position
Is recommended in
morbidly obese patients

Sims position
Common uses Post partum perineal
examination
Per-rectal examination

Patient lies on their left

side
Patient's left lower
extremity is straightened.
Patient's right lower
extremity is flexed at the
hip, and the leg is flexed
at the knee.
The bent knee, resting
against bed surface or a
pillow, provides stability.

Fowler's position is a standard patient

position, that is used to
promote oxygenation via
maximum chest expansion
and is implemented during
events of respiratory
distress.
Fowler's position
facilitates relaxing of
tension of the abdominal
muscles, allowing for
improved breathing.

Fowler's position.
There are several types of
Fowler's positions: Low,
Semi, Standard, and High
Fowler's.
Low Fowler's position is
when the head of bed is
elevated 15-30 degrees,
Semi-Fowler's position is
30-45 degrees, Standard
Fowler's is 45-60 degrees,
and High Fowler's position
is 80-90 degrees.

Cardinal techniques of examination

Inspection
Palpation
Percussion
Auscultation

INSPECTION
Close observation of the
Details of the patients appearance
Behavior
Body and Eye movements
Facial expression & Mood
Body habitus
Skin conditions
Pharyngeal color,
Symmetry of thorax
Height of jugular venous pulsations
Abdominal contour
Lower extremity edema etc.

Palpation
Tactile pressure from the
palmar fingers or fingerpads to assess areas of
skin elevation, depression,
warmth, or tenderness,
lymph nodes, pulses,
contours and sizes of
organs and masses, and
crepitus in the joints.

Percussion
Use of the striking or plexor
finger, usually the third, to deliver
a rapid tap or blow against the
distal pleximeter finger, usually
the distal third finger of the left
hand laid against the surface of
the chest or abdomen, to evoke a
sound wave such as resonance or
dullness from the underlying
tissue or organs. This sound wave
also generates a tactile vibration
against the pleximeter finger.

Auscultation
Use of the diaphragm and bell
of the stethoscope to detect the
characteristics of heart, lung,
and bowel sounds, including
location, timing, duration,
pitch, and intensity.
For the heart, this involves
sounds from closing of the four
valves and flow into the
ventricles as well as murmurs.
Auscultation also permits
detection
of
bruits
or
turbulence
over
arterial
vessels.

Symptoms and Signs

A symptom is a departure from normal
function or feeling which is noticed by a
patient, indicating the presence of disease or
abnormality.
A symptom is subjective, observed by the
patient, and cannot be measured directly,
A sign is objectively observable.

Symptoms and signs

Nonspecific

Specific

Pathognomic

Pathognomonic sign
is a particular sign (characteristic for a particular
disease) whose presence means that a particular
disease is present beyond any doubt.

Some Cases of Symptoms

(only the person experiencing it, subjective)

Paresthesia feeling of tingling;

Fatigue or Exhaustion or Tiredness - feeling of tiredness;
Weakness or asthenia feeling of muscle weakness
Chest Pain or Chest Discomfort
Palpitations - an unusual awareness of the heartbeat.
("skipped beats, periods of rapid and/or irregular heartbeats).
Nausea or being Sick of Stomach - feeling of having an urge
to vomit.

Some cases of Symptoms (continued)

(only the person experiencing it, subjective)

Headache pain in head

Throat ache the same as Sore Throat - painful and
annoying feeling in throat.
Numbness and tingling - abnormal sensations that can
occur anywhere in the body, but are often felt in fingers,
hands, feet, arms, or legs.
Itching - is a sensation that causes the desire or reflex to
scratch.
Thirstiness - desiring to drink.
Hungriness - Experiencing a desire or need for food
Blurred vision - lack of sharpness of vision.

Some cases of Symptoms (continued)

(only the person experiencing it, subjective)

Burning urination burning feeling while urination.

Chills - feelings of coldness accompanied by
shivering.
Heartburn - an uncomfortable feeling of burning
and warmth behind the breastbone.
Insomnia, or Sleeplessness - sleep disorder in which
there is an inability to fall asleep or to stay asleep as
long as desired.
Sweating or Perspiration is the release of liquid from
the body's sweat glands. This liquid contains salt.

Dizziness

Lightheadedness

feeling like person

might faint

Vertigo

feeling that somebody is

spinning or moving, or that
the world is spinning around
somebody

Dyspnea

Shortness
of Breath

Air Hunger

an unpleasant sensation
of uncomfortable, rapid
or difficult breathing

Some Cases of Signs

(anyone can confirm the sign - objective)

Erythema redness of the skin;

Cyanosis - bluish discoloration of the skin (Central around the nose, lips, and tongue and Peripheral acrocyanosis, only the extremities or fingers);
Edema - swelling caused by fluid retention;
Fever the same as Pyrexia or Febrile response - an
elevation of body temperature above the normal range
of 36.537.5 C (97.799.5 F);
Aphasia or Mutism - Lack or absence of speech.
Halitosis or Bad Breath or Bed Odor bad smell from
mouth.

Some Cases of Signs

(continued)

(anyone can confirm the sign - objective)

Watery eyes - are when tears flow out of the eye and
roll down the cheek;
Exophthalmos or Exophthalmus - is a bulging of the
eye anteriorly out of the orbit;
Enophthalmos - is the posterior displacement of the
eyeball within the orbit;
Jaundice or Icterus - yellowish discoloration of skin;
Paleness, also known as Pale Complexion or Pallor is an unusual lightness of skin color compared with the
normal hue.

Some Cases of Similar Signs and Symptoms

Coughing - A reflex action of the body to remove
foreign material or mucus from the lungs and upper
airway passages;
Hemoptysis or Haemoptysis - the expectoration
(coughing up) of blood or of blood-stained sputum from
the bronchi, larynx, trachea or lungs.
Bleeding gums
Blisters - small raised areas that are filled with fluid and
located in the superficial layer of the skin.

Some Cases of Similar Signs and Symptoms

continued

Hyperhidrosis - is the condition characterized by

abnormally increased sweating/perspiration;
Hoarseness - is a harsh and rough voice.
Diarrhea - loose and watery bowel movements (stools).
Vomiting or Throwing up - is forcing the contents of
the stomach up through the esophagus and out of the
mouth.

Some Cases of Similar Signs and Symptoms

continued

Facial Flushing - unpredictably occurred red,

burning face in response to certain triggers such as
sun exposure, cold weather, spicy foods, wind, hot
drinks and skin-care products because of facial blood
vessel dilatation.
Tremor or Trembling involuntarily shaking,
typically as a result of anxiety, excitement, or frailty.
Erythema - redness of the skin or mucous
membranes, caused by hyperemia of superficial
capillaries.