Propaedeutics of intеrnаl medicine as аn introduction to

the clinic of internal medicine.

Questioning and physical examination of the patient.
Еthical and deontological aspects.
Hanna Kosova
Assistant of the department
of Propedeutic of Internal Medicine
“To study the phenomena of disease without books is to sail an
uncharted sea,
while to study books without patients is not to go to sea at all”
–Sir William Osler
Propaedeutics or propedeutics is a historical term for an
introductory course into a discipline: art, science, etc.
•Etymology: pro- + Greek: paideutikós
 The main areas of internal pathology
studied by the propaedeutic

 Semiotics- is the science of disease symptoms, the

mechanisms of their formation and the clinical
picture of the most common diseases.
 Medical diagnostic technique - teaching the
methods of physical examination of the patient.
 The general diagnostic methodology - the skills of
clinical thinking and logic to recognize disease.
 Propaedeutics of intеrnаl medicine

• The subject of propedeutics of internal diseases is

introduction to therapy and diagnosis of the most common
diseases of internal organs.
Propedeutics of internal diseases includes 2 main parts:
 general propeudeutics study basic principles and methods of
diagnosis of internal diseases
 special propeudeutics basis of diagnosis of most common
diseases of internal organs.
Main aims of the medicine

•prevention of disease
•treatment of disease
•alleviation of the patient ‘s suffering
 Diagnosis in medicine is the determination of the nature
of a disease.
Modern diagnosis combines:
• the taking of the patient's health history
• physical examination
• laboratory and instrumental examinations.
 All symptoms (signs of diseases) are divided
into subjective and objective symptoms.

Subjective symptoms such as Signs of the disease that are

pain or nausea are experienced revealed by the physician during
by the patient. These sensations his examination of the patient,
reflect objective changes that e.g. jaundice or enlarged liver,
occur in the patient's body. are objective symptoms of the
disease.
 Examination consists of two main parts

Subjective (interview, or inquiry,

taking of anamnesis)

Objective examination.
 Subjective examination (inquiry)

• The examination begins with an interview (inquiry, taking of

anamnesis).
The patient tells his complaints which often are of no less
importance than a thorough objective examination of the
patient. Some diseases are diagnosed almost exclusively by
the patient's complaints.
Contribution of various methods to the diagnosis of the disease.
Interview – with the help of questioning, up to 70% of correct
diagnoses are made.
Physical examination -even today, in the age of the latest technology,
it is impossible to overestimate the diagnostic value of physical
research methods., and a direct (physical) examination - examination,
tapping (percussion), feeling (palpation) and listening (auscultation)
belongs to another 20%.
Additional methods (laboratory and instrumental) - only 10% of the
diagnostic hierarchy is represented by additional research methods.
 The History and Physical Examination:
Comprehensive or Focused?
Comprehensive Assessment
• Is appropriate for new patients in the office or hospital
• Provides fundamental and personalized knowledge about the
patient
• examination • Strengthens the clinician–patient
relationship helps identify or rule
out physical causes related to
patient concerns Provides a
baseline for future assessments
• Develops proficiency in the
essential skills of physical
 Focused Assessment
• Is appropriate for
established patients,
especially during routine or
urgent, care visits
• Applies examination
• Addresses focused concerns methods relevant to
or symptoms assessing the concern or
• Assesses symptoms problem as thoroughly and
restricted to a specific body carefully as possible
system
 Differences Between Subjective and
Objective Data

Subjective Data
• What the patient tells you
• The symptoms and history, from Chief
Complaint through Review of Systems
 Differences Between Subjective and
Objective Data

Objective Data
• What you detect
during the
examination,
• laboratory
information, and
test data
• All physical
examination
findings, or signs
 The Comprehensive Adult
Health History

 Identifying data and source of the history; reliability

 Chief complaint(s)
 Present illness
 Past history
 Family history
 Personal and social history
 Review of systems
 The Fundamentals of Skilled Interviewing

• Active listening. Empathic responses.

• Guided questioning.
• Nonverbal communication.
• Validation.
• Reassurance.
• Partnering.
• Summarization.
• Empowering the patient.
 The Sequence and Context of the Interview

 Reviewing the clinical record.

 Setting goals for the interview.
 Reviewing your clinical behavior and appearance.
 Adjusting the environment.
 The Sequence and Context of the Interview

The Sequence of the Interview:

1. Greeting the patient and establishing rapport.
2. Taking notes. Establishing the agenda for the interview.
3. Inviting the patient’s story. Identifying and responding to
emotional cues. Expanding and clarifying the patient’s story.
4. Generating and testing diagnostic hypotheses.
5. Sharing the treatment plan.
6. Closing the interview and the visit.
7. Taking time for self-reflection.
Tactics of questioning

1. ACTIVE- Dialogue
The doctor asks questions - the
patient answers

2. PASSIVE
Patient monologue
• The interview is more than just a series of questions;
it requires a highly refined sensitivity to the patient’s
feelings and behavioral cues.
• The interviewing process that generates the patient’s
story is fluid and draws on numerous relational skills
to respond effectively to patient cues, feelings, and
concerns.
 Ethical aspects of questioning

When questioning the patient, it is necessary to remember the basic ethical

principles.
Coming into first contact with a patient, it is necessary, from the first words,
to create an atmosphere of benevolence, friendliness, participation and
availability to provide assistance.

Inattention, indifference or even more dismissive tone are unacceptable in

treating a sick person!!!

The conversation should be deep, serious, sensitive and confidentiality

should be respected.
 Professional
Ethics in Patient Care

• Nonmaleficence or primum non nocere is commonly

stated as, “First, do no harm.” In the context of the
interview, giving information that is incorrect or ot really
related to the patient’s problem can do harm. Avoiding
relevant topics or creating barriers to open
communication can also do harm.
• Beneficence is the dictum that the clinician acts in the
best interest of the patient.
 Professional
Ethics in Patient Care

• Autonomy reminds us that informed patients have the right to make their
own clinical decisions. This principle has become increasingly important
over time and is consistent with collaborative rather than paternalistic
clinician– patient relationships.
• Confidentiality can be one of the most challenging principles. As a clinician,
you are obligated not to repeat what you learn from or know about a
patient. This privacy is fundamental to our professional relationships with
patients. In the flurry of daily patient care, it is all too easy to let something
slip. You must be on your guard. Note that some frameworks posit Justice as
the fourth critical principle, namely that all patients be treated fairly with
equitable distribution of health care resources
 Techniques of Interiew
• Moving from Open-Ended to Focused Questions. Your questions
should flow from general to specific
• Ask questions that require a graded response rather than a yes-no
answer.
• Be sure to ask one question at a time.
• Sometimes, patients need help describing their symptoms- offer
multiple-choice answers
• Clarifying What the Patient Means. Sometimes the patient’s
history is difficult to understand. It is better to acknowledge
confusion than to act like the story makes sense. To understand
what the patient means, you need to request clarification
 GENERAL INFORMATION

•First name and surname;

•Date of birth and age;
•Permanent address;
•Place of work and job;
•Occupation;
•The date of admission to the hospital;
•The way of admission to the hospital;
 PATIENT PRESENT COMPLAINTS
• Doctor have to ask about main complaints with
determination in the case history the chief and additional
ones.
• The next point is description of every complaint beginning
from the main one.
• Detailed descriptions
 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. Onset (setting in which symptom 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?
 Anamnesis morbi, or History of present disease

• Inquiry about the present disease, about its beginning and the subsequent
course to the present day, i.e. day of research of the patient, an anamnesis
of disease (Anamnesis morbi, or History of present illness).
• Exact answers should be obtained from the patient concerning the
following aspects of his present disease (anamnesis morbi):
• (1) the time of the onset of the disease;
• (2) the character of the first symptoms;
• (3) the course of the disease;
• (4) examinations and their results, if any;
• (5) treatment, if any, and its efficacy.
 Anamnesis morbi, or History of present
disease
The history of the present disease should include
information concerning the onset of the disease and its
development until the present. The patient's general
condition before the disease should first be determined and
the causes that might have provoked the disease
established wherever possible. The patient should be
questioned in detail about the first signs of the disease and
the chronology of their development (dynamics), about
relapses or exacerbations, remissions and their duration
 ANAMNESIS VITAE

Inquiring about past medical history

include:
•Chronic disease;
•Place of birth;
•Drinking habits
•Life conditions in the childhood;
•Relatives;
•Education;
•Marital status;
•Occupation;
•Obstetric history;
•Past disease in the childhood;
•Profession and living conditions;
•Past disease in adult;
•Allergic history
•Operations, traumas;
 ANAMNESIS VITAE
• Lists childhood illnesses
• Lists adult illnesses with dates for events
in at least four categories:
• medical (Illnesses such as diabetes,
hypertension, hepatitis, asthma, and
human immunodeficiency virus )
 surgical
 obstetric/gynecologic,
 psychiatric
 ANAMNESIS VITAE

Family History
Outlines health, or age and cause of death, of siblings, parents,
and grandparents.
Documents presence or absence of specific illnesses in family,
such as hypertension, diabetes, or type of cancer.
Personal and Social History
Describes educational level, family of origin, current
household, personal interests, and lifestyle
Allergies
including specific reactions to each medication, such as rash
or nausea, must be recorded, as well as allergies to foods,
insects, or environmental factors.
Tobacco use
including the type. Cigarettes are often reported
in packyears (a person who has smoked 1 and 1/2
packs a day for 12 years has an 18-pack/ year
history). If someone has quit, note for how long.
SI = number of cigarettes per day x number of
months in a year (12) IT> 120 = "heavy smoker",
SI> 140 = high risk of developing lung and heart
disease.
Alcohol and drug use should always be investigated
 INQUIRY ON SYSTEMS AND ORGANS

• After the analysis of complaints and anamnesis, it is

necessary to carry out a brief systematized survey of the
patient regarding the general features of his well-being, and
also reveal complaints that indicate the pathology of certain
organs and systems.
• Particular attention should be paid to those organs and
systems that were not mentioned when collecting complaints
and anamnesis.
Conducting an objective examination

1. Inspection
2. Feeling (palpation);
3. Tapping (percussion);
4. Listening (auscultation).
 Rules of the general examination
 A general inspection is carried out:
 According to a certain scheme (plan);
 In a separate room (observatory): warm, quiet, without
drafts, good, preferably natural lighting;
 Comfort for the patient and convenience for the doctor
are important;
 Rules of the general examination
 Review confidentiality is important (no outsiders);
 It is important to observe the principles of deontology
 Only in daylight or with a daylight lamp (it is difficult to detect
jaundiced skin and sclera under electric lighting);
 With direct and side lighting;
 Consistently exposing the patient's body;
 First, a general examination, then an examination of body parts
by region: head, face, neck, mucous membranes, hair, trunk,
limbs, skin, bones, joints.
 The definition and assessment is carried out:

 general condition;
 state of consciousness;
 position of the patient's body, posture, gait;
 facial expressions and features, eye changes;
 anthropometric data, physique and constitution;
 the smell of the patient's body and exhaled air;
 neck area, thyroid gland;
 skin and mucous membranes;
 lymph nodes;
 edema;
 muscular system;
 bone and joint system.