MedicoPlexus
Notes for Propaedeutics of Internal Medicine
Gitty George
Introduction
Medical Diagnosis = the precise identification of the underlying state of disease using history taking, physical examination, imaging (X-ray, ECG, ultrasound, CT MRI etc.) and laboratory testing.
Differential Dx = an exhaustive list of probable diseases that have the same/similar clinical presentations.
Disease = a pathological process with its origin, ways of presentation, stages of progression, system incapacitation and prognosis.
Nosologic entity = clinically proven separate and unique combination of signs and symptoms.
Signs and symptoms = objective and subjective, clinical findings and complaints.
Syndromes = a combination of signs and symptoms, it is the most important in medical diagnosis.
Risk factors, diseases and syndromes = the triple face of the diagnostic process.
The Medical Record
Consists of the history taking and the physical examination (H & P)
- Subjective information: chief complaint (CC), history of present condition/illness (Hx), past medical history (PMH), family, social and occupational history, review of the systems (ROS).
- Objective information: signs, findings from the physical examination, selected diagnostic tests.
- Impression, diagnosis, assessment – after evaluation of all subjective and objective data.
Medical History – General
= it is an organised account of the events in the patient’s life that have relevance to his/her mental and physical health.
There are 2 purposes: medical (assistance in diagnosis, record for all medical staff and assist in teaching) and legal.
The medical history provides a suitable environment for the conduction of the patient interview.
Medical History – sequence of the components with an in-depth analysis of the component parts
- Vital statistics
- Name
- Sex
- Residence
- Age
- Place of birth
- Race
- Marital status
- Occupation
- Chief Complaint
- Present Illness
- Onset
- Duration
- Location
- Character of the discomfort
- exacerbation/remissions
- Course
- Previous treatment
- Previous episodes
- Past Medical History
- Medical history
- Paediatric history
- Surgeries
- Allergies
- Current medications
E. Psychosocial history
F. Family history
G. System review
General: any weight change, fever-chills, weakness, fatigue, sweating, night sweats
Allergies: sensitivities, drugs, vaccines, foods, pollens, chemical, eczema, asthma, hay fever, hives
- Skin: hair-nail, itching, rash/ulcer, pigment changes, lumps
- Head: headache, trauma, dizziness
- Eyes: last eye exam date, vision/glasses, blurring, photophobia, diplopia, scotoma, itching/watering, inflammation
- Ears: pain, discharge, vertigo, deafness, tinnitus, correction (aids)
- Nose: sinusitis, polyps, postnasal drip, epistaxis, obstruction, dysosmia
- Mouth: teeth, gums, breath, taste, pain, dentures, dental exam (date)
- Throat
- Neck: pain, swallowing, soreness, node enlargement, hoarseness, motion limitation
- Breast: lumps, discharge, pain
- Respiratory system: wheezing, dyspnea, hemoptysis, chest pain, cough, sputum, x-rays (date, where)
- Cardiovascular system: palpation, angina, dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND), edema, high BP, MI, exercise tolerance, cyanosis, phlebitis
- Gastrointestinal system: appetite, hernia, diarrhoea, jaundice, indigestion/heartburn, nausea/vomiting, pain, dysphagia, constipation, stool = shape+colour
- Genito-urinary system: dysuria, nocturia, hematuria, stones, pain, frequency, urgency, masses, incontinence, infection, discharge
- Gynaecological
- Locomotor+Musculoskeletal system: trauma, swelling, fractures, stiffness, abnormalities, limited motion, pain/arthritis,
- Endocrine system: goiter changes, glycosuria, exophthalmos, growth, hirsutism, diabetes, climatic intolerance
- Neuropsychiatric
General Survey
Apparent state of health
- acutely and chronically ill, frail, feeble, robust
- Depends on the outlook of the patient and consists of his level of consciousness and position in bed
- Patients may be in:
- Preserved apparent state of health state if wake, alert and responsive and taking active position in bed
- Imparied or poor apparent state of health if obnubilate, somnolent, soporous or comatose, and in passive or compulsory position in bed if in dyspnea, pain or anxiety
Levels of consciousness – awake, alert, responsive
Levels of consciousness impairment
- Obnubilation – dizziness-awake, adequate, responsive, sluggish
- Somnolence-sleepiness – sleepy, slow, non-adequate, responsive
- Sopor – not adequate, sleepy, partially responsive, tendon, corneal., pupil and gag reflexes
- Coma – total lack of unconsciousness, unresponsive, sensorium, conditional reflexes, voluntary motion, present – depressed breathing, cardiac activity, blood pressure, only sluggish pupil reflex (qualitative changes in consciousness)
- Delirium – awake, hyper-responsive, not adequate, hyperactive, aggressive
- Amentia – awake, not adequate, responsive, disorientated, cognitive impairment
- Signs of distress and position in bed – dyspnea, pain, anxiety
Signs of distress and position in bed – dyspnea, apin, anxiety
- Active position – normal locomotion in bed, self service
- Passive position – no active locomotion, only passive mobility, in situations of impaired consciousness and grace deterioration of apparent state of health
- Compulsory position
- Sitting – in pulmonary edema and cardiac asthma in acute heart failure
- Lying – in acute abdomen in severe pain and distress
Height and built
- Gigantism-tall: over 190cm in acromegaly, Kleinfelter syndrome, in Marfan syndrome
- Nanism-small: under 100cm, in various forms of dwarfism, in hypophysial nanism
Weight-emaciated, slender, obese
Emaciated:
- Inanition in anorexia neurosa, in stringe diets
- Cachexia in neoplastic disease
- Marasmus in seni and hypodynamic states
Obesity
- Brocca-Weight = height-100
- BMI-weight(kg)/height(m2)
- Normal: 20-24
- Overweight: 25-29
- Obesity: >30
- Moderate: >30
- Moderate: >35
- Severe: >40
Skin and mucous membranes – colour and lesions
Colour:
- Pale – anemia
- Cyanosis – reduced Hb >50g/l
- Central – respiratory failure
- Peripheral – heart failure
- Mixed – respiratory and heart failure
- Jaundice (icterus)
- Melanodermia
- Vitiligo
Skin Lesions – primary
- Macula – flat, non-palpable change in skin colour
- Teleangiectasia
- Hemorrhagic: petechia, purpura, ecchymoses, vibices, suffusions, sugilatio – vitropression
- Papule
- Urticaria
- Scales
- Plaque
- Vesicle
- Bulla
- Pustule
Skin lesions – others
- Xanthelasma
- Carcinoma of the skin
- Keloid
- melanoma
Dress, grooming and personal hygiene
Nails – onychomycosis, pigmentation, clubbing, arachnodactylia
Facial expression
Odors of body and breath
Posture, gait and motor activity
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