Medical profession

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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