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

omprehensive assessment

!ocused " or pro#lem oriented assessment

$outine clinical chec%&up

Periodic physical e'amination

omplete physical e'amination
Provides fundamental and
personali(ed %nowledge a#out the
patient)
*trengthens the clinicianpatient
relationship)
Provides #aselines for future
assessments)
+elps identify or rule out physical
causes related to patient concerns
Comprehensive
Patients Assessment
Focused / or
problem oriented
First visit of a patient in
a hospital or office
Is appropriate especially
during routine or urgent
care visits
,ssesses symptoms restricted to a
specific #ody system)
,pplies e'amination methods
relevant to assessing the concern
or pro#lem as precisely and
carefully as possi#le-
,ddresses focused concerns or
symptoms-
$outine clinical chec%&up, or periodic
physical e'amination
Purpose
screening and prevention of illnesses, #lood
pressure measurement, assessment of central
venous pressure from the .ugular venous pulse,
listening to the heart for evidence of valvular
disease, detection of hepatic and splenic
enlargement and the pelvic e'amination with
Papanicolaou smears-
I stage - open-ended questions
to hear the story of the
symptom in the patients o!n
!ords
II stage - more specific
questions to elicit the seven
features of every symptom
III stage - the yes-no questions
or pertinent positives and
negatives from the relevant
section of the revie! of
systems
The *even ,ttri#utes of a *ymptom
1- Location. /here is it0 Does it radiate0
1- Quality. /hat is it li%e0
2- Quantity or severity. +ow #ad is it0 3!or pain, as% for a rating
on a scale of 1 to 14-5
6- Timing. /hen did 3does5 it start0 +ow long does it last0 +ow
often does it come0
7- Setting in which it occurs. Include environmental factors,
personal activities, emotional reactions, or other circumstances that
may have contri#uted to the illness-
8- Remitting or exacerbating factors. Is there anything that
ma%es it #etter or worse0
9- Associated manifestations. +ave you noticed anything else that
accompanies it0
Patients "ata
#$%&C'I(& )*$%&C'I(&
+hat the patient tells to
,"
Pain in a chest, discomfort,
palpitation, cough, num#ness
etc
+hat ," detects during
the e-amination
,ll physical e'amination findings age,
white"#lac%, se', height, weight, :MI,
:P, +$, respiratory rate, temperature
etc-
omprehensive ,dult +ealth +istory
omponents
I- Identifying Data and *ource of the +istory)
$elia#ility
II- hief omplaint3s5
III- Present Illness
I;- Past +istory
;- !amily +istory
;I- Personal and *ocial +istory
;II-$eview of *ystems
I- Identifying Data and *ource of the
+istory) $elia#ility

Identifying data
-
Age
-
Gender
-
ccu!ation
-
"arital status

)ource of the history

-
#atient $usually%
-
&amily member or friend $can be%
-
Letter of referral
-
The medical record

.eliability
-
;aries according to the patients memory, trust, and mood-
II- hief omplaint3s5

The one or more symptoms or concerns causing the

patient to see% care

Doctor should make every attempt to quote the

patients own words. $ &or exam!le' ("y stomach
hurts and ) feel awful.* %
Sometimes !atients have no s!ecific com!laints.

Report their goals instead. (&or exam!le' () have

come for my regular chec+,u!* or ()-ve been
admitted for a thorough evaluation of my heart-<5
III- Present Illness

The hief omplaint3s5)

Description how each symptom developed)

Patients thoughts and feelings a#out the illness

$eview of systems, called =pertinent positives

and negatives<-

"ay include medications' allergies' and habits of

smo+ing and alcohol' which are fre.uently !ertinent to
the !resent illness.
Present Illness
accompanied by
,edications
name, dose, route, and
fre>uency of use-
Allergies
to medication' foods' insects' or
environmental factors $rash'
nausea' !al!itation etc%.
'obacco use
ty!e' amount' fre.uency'
duration. )f someone has
.uit' note for how long.
Alcohol and drug
use
Type, amount, fre>uency,
duration-
Principal *ymptom
*hould #e well&characteri(ed, with
1- Descriptions of location)
1- ?uality)
2- ?uantity or severity)
6- Timing, including@
a- onset, duration, and fre>uency
#- the setting in which it occurs)
c- factors that have aggravated or relieved the symptom
d- associated manifestations-
/.0. 1hief 1om!laint$s% , indicate the !resence or absence of sym!toms relevant to the
differential diagnosis' which identifies the most li+ely diagnoses ex!laining the !atient-s
condition.
$is% !actors
*hould #e revealed ris% factors for diseases 3for
e'ample, ris% factors for coronary artery disease in
patients with chest pain5-

,ge

*e'

*edentary Lifestyle

A#esity

Benetics

*mo%ing
I;- Past +istory
1- Lists childhood illnesses@
-
measles,
-
ru#ella,
-
mumps,
-
whooping cough,
-
chic%enpo',
-
rheumatic fever,
-
scarlet fever,
-
polio
2. Also include any chronic childhood illnesses.
I;- Past +istory continued
2- Lists adult illnesses 3four categories5@
a- Medical & Illnesses such as dia#etes, hypertension,
hepatitis, asthma, and +I;) hospitali(ations) num#er
and gender of se'ual partners) and ris%y se'ual
practices-
#- *urgical & Dates, indications, and types of operations)
c- A#stetric"Bynecologic & A#stetric history, menstrual
history, methods of contraception, and se'ual
function)
d- Psychiatric & Illness and time frame, diagnoses,
hospitali(ations, and treatments-
I;- Past +istory continued
6- Includes health maintenance practices such as
immuni(ations, screening tests, lifestyle issues, and
home safety
o
)mmuni3ations , find out whether the !atient
has received all the necessury vaccines and
record them-
o
Screening tests , review tuberculin tests' #a!
smears' mammograms' stool tests for occult
blood' colonosco!y and cholesterol tests' together
with results and when they were last !erformed.
'etanus
/epatitis $
Influen0a and
/aemophilus
influen0ae type $
,umps
"iphtheria
Polio
,easles
.ubella
Pertussis
(aricella
/erpes 1oster
Pneumococci
Immuni0ation
;- !amily +istory
Autlines or diagrams age and health, or
age and cause of death, of each immediate
relative, including parents, si#lings,
grandparents, children, and grandchildren-
$eview each of the following conditions and record
whether they are present or a#sent in the family@

+ypertension, oronary artery disease, elevated cholesterol

levels, stro%e, dia#etes, thyroid or renal disease, arthritis,
tu#erculosis, asthma or lung disease, headache, sei(ure
disorder, mental illness, suicide, su#stance a#use, allergies-

$eveal any history of #reast, ovarian, colon, or prostate

cancer-

$eveal any genetically transmitted diseases-

;- !amily +istory continued

Personal history & Documents presence or a#sence of

specific illnesses in family, such as hypertension or coronary
artery disease)

Social History & Descri#es educational level, family of

origin, current household, personal interests, and lifestyle-
;I- Personal and *ocial
+istory
)ocial
/istory
/ome situation
)tress
3source, length,
duration5
Important life
e-periences
3military service, .o# history,
financial situation, leisure
activities, religious affiliation
and spiritual #eliefs5
&-ercise
Type C fre>uency
"iet
3daily food inta%e,
dietary supple&
ments and"or
restrictions, use of
coffee, tea etc-5
)afety
measures
3use of seat #elts,
#icycle helmets,
sun#loc%s, smo%e
detectors etc5

Documents presence or a#sence of common symptoms related to

each ma.or #ody system-
o
,s% series of >uestions going from =head to toe<
o
?uestions should start with a fairly general >uestion and
should #e addressed to different systems-
Eamples o! questions"

=+ow are your ears and hearing0<

=+ow a#out your lungs and #reathing0<

=,ny trou#le with your heart0<

=+ow is your digestion0<

=+ow a#out your #owels0<

;II- $eview of *ystems
$eview of systems
Beneral

Dsual weight

$ecent weight change

wea%ness

fatigue

fever
$eview of systems@ *%in

$ashes

Lumps

*ores

Itching

Dryness

hanges in color

hanges in hair or nails

hanges in si(e or
color of moles-
.evie! of systems2
/ead3 &yes3 &ars3 4ose3 'hroat
5/&&4'6
4ead5

4eadache'

4ead in6ury'

7i33iness'

Lightheadedness.
8yes5

9ision

Glasses or contact lenses

#ain : redness

8xcessive tearing

7ouble or blurred vision

S!ots : s!ec+s

flashing lights

Glaucoma : cataracts.
Ears@ hearing' tinnitus' vertigo'
earaches' infection' discharge.
'hroat 5or mouth and pharyn-62
1ondition of teeth and gums' bleeding
gums' sore tongue' dry mouth' fre.uent
sore throats' hoarseness.
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$reasts2 Lumps, pain, or
discomfort, nipple
discharge-
4ec72 =*wollen glands,<
goiter, lumps, pain, or
stiffness in the nec%-
.espiration
ough
*putum 3color, >uantity5
+emoptysis
Dyspnea
/hee(ing
Pleurisy
Last chest '&ray-
Cardiovascular
+igh #lood pressure
$heumatic fever
+eart murmurs
hest pain or discomfort
Palpitations
Dyspnea and orthopnea
Paro'ysmal nocturnal dyspnea
Edema
Past electrocardiograms
8astrointestinal

Trou#le swallowing

+eart#urn

Fausea C vomiting

,#dominal pain

!ood intolerance

E'cessive #elching or passing

of gas

*tool color and si(e

Pain with defecation

$ectal #leeding or #lac% or

tarry stools

onstipation and diarrhea

Gaundice
Peripheral vascular *ystem

Intermittent claudication

Leg cramps

;aricose veins

Past clots in the veins

*welling in calves, legs, or

feet

olor change in fingertips

or toes during cold weather

*welling with redness or

tenderness-
Drinary *ystem
!re>uency of urination
Polyuria

Focturia

Drgency C incontinence)

:urning C pain during

urination
+ematuria
Hidney, suprapu#ic or flan%
pain
Hidney stones
Dreteral colic
In males, reduced cali#er or
force of the urinary stream,
hesitancy, dri##ling-
Ather *ystems
Musculos%eletal@ fractures, mialgias etc-
Psychiatric@ Fervousness, tension, mood, including
depression, memory change, suicide at
tempts, if relevant-
Benital system
;ascular system
Feurologic system
Endocrine system
+ematologic system
*uggested positioning while e'amination
$ecommended@
Beneral survey C ;ital signs
*%in@ upper torso, anterior and
posterior
+ead and nec%, including thyroid
and lymph nodes
Aptional@
Fervous system 3mental status,
cranial nerves, upper e'tremity
motor strength, #ul%, tone,
cere#ellar function5
Thora' and lungs
:reasts
Musculos%eletal@ upper e'tremities
ardiovascular, including G;P,
carotid upstro%es and #ruits,
*1, *1 murmurs, e'tra sounds
Lying su!ine' with head of bed
raised ;< degrees
ardiovascular, for *2 and
murmur of mitral stenosis
Lying on the left side' with
head of bed raised ;< degrees
ardiovascular, for murmur
of aortic Insuficiency
Sitting' leaning forward
!tional5
Thorax and lungs exam
,#domen e'am
:reasts and a'illae
Peripheral vascular
S+in lower torso and
e'tremities
Fervous system@ lower e'tremity
motor strength, #ul%, tone,
sensation) reIe'es) :a#ins%i reIe'-
Lying su!ine

Musculos%eletal, as indicated

!tional5 s+in' anterior and posterior

!tional5 nervous system' including gait

!tional5 musculos+eletal' comprehensive

OR
=omen5

#elvic and rectal e'amination

#ithotomy position $ Lying
supine, with hips Ie'ed,
a#ducted, and e'ternally
rotated, and %nees Ie'ed
"en5

#rostate and rectal

e'amination
#e!t lateral decu%itus $
Lying on the left side
&rendelen%urg position $
the #ody is laid flat on the
#ac% 3supine position5
with the feet higher than
the head #y 17&24 degrees
Reverse &rendelen%urg
position
Is recommended in
mor#idly o#ese patients

Patient lies on their left

side

PatientJs left lower

e'tremity is straightened-

PatientJs right lower

e'tremity is fle'ed at the
hip, and the leg is fle'ed
at the %nee-

The #ent %nee, resting

against #ed surface or a
pillow, provides sta#ility-
Sims position
ommon uses &

Post partum perineal

e'amination

Per&rectal e'amination
'owler(s position $
is a standard patient
position, that is used to
promote o'ygenation via
ma'imum chest e'pansion
and is implemented during
events of respiratory
distress-
Fo!ler9s position
facilitates rela'ing of
tension of the a#dominal
muscles, allowing for
improved #reathing-
'owler(s position-
There are several types of
!owlerJs positions@ Low,
*emi, *tandard, and +igh
!owlerJs-
Low !owlerJs position is
when the head of #ed is
elevated 17&24 degrees,
*emi&!owlerJs position is
24&67 degrees, *tandard
!owlerJs is 67&84 degrees,
and +igh !owlerJs position
is K4&L4 degrees-
ardinal techni>ues of e'amination

Inspection

Palpation

Percussion

,uscultation
I F * P E T I A F
lose o#servation of the

Details of the patients appearance

:ehavior

:ody and Eye movements

!acial e'pression C Mood

:ody ha#itus

*%in conditions

Pharyngeal color,

*ymmetry of thora'

+eight of .ugular venous pulsations

,#dominal contour

Lower e'tremity edema etc-

Palpation
Tactile pressure from the
palmar fingers or finger&
pads to assess areas of
s%in elevation, depression,
warmth, or tenderness,
lymph nodes, pulses,
contours and si(es of
organs and masses, and
crepitus in the .oints-
Percussion
Dse of the stri%ing or ple'or
finger, usually the third, to deliver
a rapid tap or #low against the
distal ple'imeter finger, usually
the distal third finger of the left
hand laid against the surface of
the chest or a#domen, to evo%e a
sound wave such as resonance or
dullness from the underlying
tissue or organs- This sound wave
also generates a tactile vi#ration
against the ple'imeter finger-
,uscultation
Dse of the diaphragm and #ell
of the stethoscope to detect the
characteristics of heart, lung,
and #owel sounds, including
location, timing, duration,
pitch, and intensity-
!or the heart, this involves
sounds from closing of the four
valves and flow into the
ventricles as well as murmurs-
,uscultation also permits
detection of #ruits or
tur#ulence over arterial
vessels-
*ymptoms and *igns

, symptom is a departure from normal

function or feeling which is noticed #y a
patient, indicating the presence of disease or
a#normality-

, symptom is su#.ective,

o#served #y the
patient, and cannot #e measured directly,

, sign is o#.ectively o#serva#le-

)ymptoms and signs
4onspecific )pecific Pathognomic
Pathognomonic sign
is a particular sign (characteristic !or a particular
disease) whose presence means that a particular
disease is present %eyond any dou%t.
*ome ases of *ymptoms
$only the !erson ex!eriencing it' sub6ective%

#aresthesia feeling of tingling)

&atigue or 8xhaustion or Tiredness & feeling of tiredness)

=ea+ness or asthenia feeling of muscle wea%ness

1hest #ain or 1hest 7iscomfort

#al!itations & an unusual awareness of the heart#eat-

3Ms%ipped= #eats, periods of rapid and"or irregular heart#eats5-

/ausea or #eing Sic+ of Stomach & feeling of having an urge

to vomit-
*ome cases of *ymptoms $continued%
$only the !erson ex!eriencing it' sub6ective%

4eadache pain in head

Throat ache the same as Sore Throat & painful and

annoying feeling in throat-

/umbness and tingling & a#normal sensations that can

occur anywhere in the #ody, #ut are often felt in fingers,
hands, feet, arms, or legs-

)tching & is a sensation that causes the desire or refle' to

scratch-

Thirstiness & desiring to drin%-

4ungriness & E'periencing a desire or need for food

0lurred vision & lac% of sharpness of vision-

*ome cases of *ymptoms $continued%
$only the !erson ex!eriencing it' sub6ective%

0urning urination #urning feeling while urination-

1hills & feelings of coldness accompanied #y

shivering-

4eartburn & an uncomforta#le feeling of #urning

and warmth #ehind the #reast#one-

)nsomnia, or Slee!lessness & sleep disorder in which

there is an ina#ility to fall asleep or to stay asleep as
long as desired-

Sweating or #ers!iration is the release of li>uid from

the #odyJs sweat glands- This li>uid contains salt-
"i00iness
:ightheadedness (ertigo
feeling li7e person
might faint
feeling that somebody is
spinning or moving3 or that
the !orld is spinning around
somebody
"yspnea
)hortness
of $reath
Air /unger
an unpleasant sensation
of uncomfortable3 rapid
or difficult breathing
*ome ases of *igns
$anyone can confirm the sign , ob6ective%

8rythema redness of the s%in)

1yanosis & #luish discoloration of the s%in 3entral &

around the nose, lips, and tongue and Peripheral &
acrocyanosis, only the e'tremities or fingers5)

8dema & swelling caused #y fluid retention)

&ever the same as #yrexia or &ebrile res!onse & an

elevation of #ody temperature a#ove the normal range
of 28-729-7 N 3L9-9LL-7 N!5)

A!hasia or "utism & Lac% or a#sence of speech-

4alitosis or 0ad 0reath or 0ed dor #ad smell from

mouth-
*ome ases of *igns $continued%
$anyone can confirm the sign , ob6ective%

=atery eyes & are when tears flow out of the eye and
roll down the chee%)

8xo!hthalmos or 8xo!hthalmus & is a #ulging of the

eye anteriorly out of the or#it)

8no!hthalmos & is the posterior displacement of the

eye#all within the or#it)

>aundice or )cterus & yellowish discoloration of s%in)

#aleness, also %nown as #ale 1om!lexion or #allor &

is an unusual lightness of s%in color compared with the
normal hue-
*ome ases of *imilar *igns and *ymptoms

1oughing & , refle' action of the #ody to remove

foreign material or mucus from the lungs and upper
airway passages)

4emo!tysis or 4aemo!tysis & the e'pectoration

3coughing up5 of #lood or of #lood&stained sputum from
the #ronchi, laryn', trachea or lungs-

0leeding gums

0listers & small raised areas that are filled with fluid and
located in the superficial layer of the s%in-
*ome ases of *imilar *igns and *ymptoms
continued

4y!erhidrosis & is the condition characteri(ed #y

a#normally increased sweating"perspiration)

4oarseness & is a harsh and rough voice-

7iarrhea & loose and watery #owel movements 3stools5-

9omiting or Throwing u! & is forcing the contents of

the stomach up through the esophagus and out of the
mouth-

&acial &lushing & unpredicta#ly occurred red,

#urning face in response to certain triggers such as
sun e'posure, cold weather, spicy foods, wind, hot
drin%s and s%in&care products #ecause of facial #lood
vessel dilatation-

Tremor or Trembling involuntarily sha%ing,

typically as a result of an'iety, e'citement, or frailty-

8rythema & redness of the s%in or mucous

mem#ranes, caused #y hyperemia of superficial
capillaries-
*ome ases of *imilar *igns and *ymptoms
continued