Medical profession
Detailed Presentation by: Janos Lonovics MD
Diagnostic examinations
Medical history
Physical examination
Laboratory examination
Special examinations (US, CT, MR, Endoscopy, etc)
Consultations with other professionals
Treatment procedures
Medical treatment
Surgical treatment
Structure of a medical record
Medical history
Findings of the physical examination
Reports of the laboratory tests
Conclusions from special examinations
(US, CT, MR, Endoscopy etc)
Report and suggestions of the consultants
Diagnosis by (competent) attending physician
Notes on treatment (medications, interventions)
Progress notes
Discharge summary\
Medical diagnosis
Tentative diagnosis (at the end of the case history)
Provisional diagnosis (to begin the diagnostic work)
Working diagnosis (to put things on the right track)
Final diagnosis (if achieved)
PURPOSES OF THE PATIENT’S MEDICAL RECORD
LEGAL PURPOSES
Medical history - anamnesis
* Identifications and vital statistics
* Present illness and chief complaints
* Past history
* Social history
* Family history
Identifications and vital statistics
Name, Date of birth, Place of birth
Sex, Nationality, Race, Residence,
Marriage status, Occupation
Source of information: patient, others
Interpreter
Present illness and chief complaints
Heart of medical history
Searching for diagnostic clues (complaints, symptoms)
Accumulation of facts
Evaluation of facts
Preparation of hypotheses
Insist upon symptoms, do not accept patient’s diagnosis
Nature of symptoms
Quantification of symptoms
Chronology of symptoms
Current medication
Past history
Previous illnesses
Previous operations, injuries
Previous hospitalization
Infectious diseases
General health issues
Appetite, Body weight, Weight loss
Stool habits
Urine complaints
Family history
Parents, Siblings
Age and health
Death and causes
History of diseases
Hypertension, Hearth disease, Diabetes
Obesity, Endocrine disorders
Tuberculosis, Syphilis, AIDS
Malignancies
Alcoholism, Mental disturbances, etc.
METHODS IN THE PHYSICAL EXAMINATION
* Inspection
* Palpation
* Percussion
* Auscultation
* Smelling
o Heigh and weight
o Body temperature
o Blood pressure
o Rectal digital examination
o Eye (fundoscopic) examination
o Bimanual (gynecological) examination
o Basic neurological examination
INSPECTION
Inspection of the body as a whole
Motor activity
Body build
Anatomic malformation
Nutrition
Appearance of illness
Behaviour
Speech
LOCAL INSPECTION
Focuses observation on a single anatomic region
o Observation with unaided eyes
o Observation through special equipments
ophtalmoscope
otoscope, nasoscope
laryngoscope
bronchoscope
gastroscope, anoscope, colonoscope
thoracoscope, peritoneoscope
gonioscope
cystoscope
microscope
PALPATION
Palpation in the act of feeling by sense of touch
Physican’s hands perceives physical signs by his (her)
Tactile sense
Temperature sense
Kinesthetic sense of position and vibration
Sensitive parts of the hands
Tactile sense - the tips of the fingers
Temperature sense – the dorsa of hands
Vibratory sense – palmar base of the fingers
Sense of position and consistency – grasping fingers
Structures examined by palpation
All external structures
Solid abdominal viscera
Solid contents of hollow viscera
Lymph nodes
Thrombosed veins
Structures accesible through body orifices
Qualities elicited by palpation
Texture – the skin and hair
Moisture – The skin and mucosa
Masses – The size, shape, consistency, etc.
Precordial cardiac thrust
Crepitus – in bones, pleura, etc.
Tenderness – in all accesible tissues
Thrills – over the heart, and blood vessels
Vocal fremitus – over the lung
Special methods of palpation
Light palpation
Deep palpation
Ballottement
Fluctuation
Fluid wave
LIGHT ABDOMINAL PALPATION
* Ticklishness
* Direct Tenderness
* Rebound Tenderness
* Voluntary Rigidity of Muscle
* Involuntary Rigidity of Muscle
* Subcutaneous Crepitus
* Abdominal Masses
DEEP ABDOMINAL PALPATION – RUQ AND RLQ
* Liver
* Enlarged (Tender and Nontender) Gallbladder
* Enlarged Right Kidney
* Masses in Cecal Region
DEEP ABDOMINAL PALPATION – LUQ AND LLQ
* Spleen
* Enlarged Left Kidney (Ballottement)
* Masses in Sigmoid Region
Vibratory palpation of the lungs and pleura
Detection of vocal fremitus
PERCUSSION
A method of examination in which the surface of the body is struck to emit sounds that vary in quality according to the density of the underlying tissue
Methods:
* Bimanual, Mediate or Indirect
* Immediate or Direct
SONOROUS PERCUSSION
Its purpose to ascertain the density of the tissue
* Percussion Notes
Tympani – air-filled stomach
Resonance –air-filled lungs
Hyperresonance – emphysematous lungs
Dullness – blood-filled heart
Flatness - thigh
DEFINITIVE PERCUSSION
Its purpose to determine the size and borders of a structure
Lung borders: bases, apices
Size of the heart
Size of the liver and spleen
Size of the distended gallbladder
Level of ascites fluid
Sizes of different masses
Percussion map of the thorax
* Procedure of thoracic percussion
SUPRAPUBIC MASSES
* Distended Urinary Bladder
* Ovarian Cyst
AUSCULTATION
Act of hearing through the stethoscope
Skull – bruit
Neck – carotid artery, jugular vein
Lungs – breath sounds, rales, friction rub
Heart – valve sounds, rhythm, murmurs
Abdomen – bowel sounds, murmurs
Crepitus – bones, pleural layer
Auscultation of the lungs and pleura
Breath sounds
* Vesicular breathing
Vesicular breath sounds have a long inspiratory and a short expiratory phase
* Broncial breathing
Bronchial breath sounds have a short inspiratory and a long expiratory phase
* Bronchovesicular breathing
The two respiratory phases are about equal in duration
* Ashmatic breathing
Voice sounds
* Whispered pectoriloquy (Whispered voice sounds)
* Bronchophony (Spoken voice sounds)
ASK the patients to repeat the test word ”ninety-nine” or ”one-two-three”
COMPARE symmetric parts of the lung sequentially by stethoscope
* Are increased in:
Pulmonary consolidation
Pulmonary infarction
Pulmonary atelectasis
* Are diminished or absent in:
Pleural effusion
Pneumothorax
Thickened pleura
Alveoli filled with
Fluid, red and white cells
Pleural fluid or thickening
Adventitious sounds - Rales
* Moist Rales
Inspiratory crackels or crepitation
Bronchial rales (heard in both phases)
Moist fine or subcrepitant rales
Moist medium or crepitant rales
Moist coarse or gurgling rales
* Dry rales
Musical (sibilant) rales
Sonorous rales
Ronchus
* Pleural friction rub
* Special sounds in hydropneumothorax Succusion splash Falling drop sounds, etc.
* Bruit in the lungs
* Subcutaneous crepitus
* Bone crepitus
Interpretation of pulmonary and pleural findings Pulmonary consolidation
Dullness and increased vibration
* Percussion: dull or flat
* Breath sounds: bronchial
* Voice sounds: increased
* Rales: crepitation or subcrepitation
* Vocal fremitus: increased
Alveoli filled with
Fluid, red and white cells
Interpretation of pulmonary and pleural findings
Pleural fluid (Hydrothorax, Pyothorax, Hemothorax)
Dullness and diminished vibration
* Percussion: dull or flat
* Breath sounds: absent
or bronchial
* Voice sounds: absent
* Rales: absent
* Vocal fremitus: absent
* Tracheal deviation to the unaffected side
Pleural fluid
or thickening
Interpretation of pulmonary and pleural findings
Thickened pleura
Dullness and diminished vibration
* Percussion: dull or flat
* Breath sounds: absent
or bronchial
* Voice sounds: absent
* Rales: absent
* Vocal fremitus: absent
* Tracheal deviation to the affected side
Pleural fluid or thickening
Interpretation of pulmonary and pleural findings
Pneumothorax
Resonance or hyperresonance
Percussion: resonant hyperresonant or tympanitic
Breath sounds: diminished absent
Voice sounds: diminished absent
Rales: absent absent
Vocal fremitus: absent absent
Tracheal deviation: no yes
Interpretation of pulmonary and pleural findings
Hydropneumothorax
Resonance or hyperresonance
* Percussion: a. hyperresonant b. flat
* Breath sounds: absent
* Voice sounds: absent
* Rales: absent
* Vocal fremitus: absent
* Sucussion splash, shifting dullnes may be present
* Tracheal deviation to the unaffected side
Interpretation of pulmonary and pleural findings
Pulmonary edema
Resonance and Dyspnea
* Causes: left sided heart failure, pulmonary diseases, noxious gases
* Characteristics:
Cyanosis, dyspnea, frothy (bloody) sputum
Prolonged exspiratory phase, accompanied
with musical rales (may resemble to asthma)
Moist bronchial (gurgling) rales
Interpretation of pulmonary and pleural findings
Bronchial asthma
Resonance and Dyspnea
* Characteristics: Dyspnea (pts rising to sitting position) Unproductive cough
Anxiety expressed by facial muscles Prolonged exspiratory phase, accompanied
with musical and sonorous rales Wheezing may be heard at a distance
* Between attacks pts may be perfectly well
Auscultation of the heart
* Cardiac valve areas
Normal heart sounds
* First heart sound (S1): produced by vibration of the left ventricular muscle, during early v. systole
accentuated in mitral stenosis, fever, etc
diminished in pericardial effusion, etc
* Second heart sound (S2: A2, P2): produced by vibration of great vessels and closed valves
accentuated A2 in arterial hypertension
accentuated P2 in pulmonary hypertension
splitting of P2: may be normal or pathologic
Abdominal auscultation
Abdominal murmurs
Clinical occurence:
Aortic aneurism
Renal artery stenosis
Arteriovenous fistula in renal vessels
Abdominal auscultation
Peristaltic sounds
Increased peristalsis Abscence of sounds
early pyloric obstruction peritonitis
early intestinal obstruction mesenteric thrombosis
brisk diarrhea electrolite abnormality
spinal cord injury
advanced intest. obstr.
Abdominal auscultation
Succussion splash
The sound is produced by the combination of air and fluid in the stomach and intestine
* Clinical significance: obstruction in the stomach or anywhere in the gut gastric dilatation
It can be elicitated by moving the patient or by palpation of the viscera
Abdominal auscultation
Peritoneal friction rub
Its presence indicates peritoneal inflammation
carcinoma of the liver or liver abscess
splenic infartion or abscess
syphilitic or gonococcal hepatitis
after liver biopsy
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