the subject “internal medicine propedeutics” as an introduction into the clinics of internal...
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The subject “Internal medicine propedeutics” as an introduction into the clinics of internal medicine. Main methods of examination of patients. Anamnesis as a part of a case history. Inspection of a patient and its value in diagnostic process.
professor Serhiy M. Andreychyn
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Internal diseases
• one of the bigest branches of theoretical and practical medicine which studies the diseases of internal organs in there different clinical forms, reasons of occurrence, pathogenesis, preventive mintenance and therapy.
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Propaedeutic
• a word of the Greek origin and means the introduction or preliminary training
• the aim of department of internal medicine - the introduction into the main course of theraphy, studing of the students to elements of a therapeutic science
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Tasks of Internal Diseases Propaedeutics :
• to teach students of doctor’s technics or methods of examination
• studying of symptoms and syndromes which can find using different methods of examination - semiotics
• construction the diagnostic conclusions on the ground of data of examinations - methodic of diagnosis
• studying of the separate questions of internal diseases - nozologic forms in their classical, typical variant
• the main principles of internal diseases’ treatment
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General plan of patient’s examination
• questioning (inquiry) of a patient (interrogatio) - the most important method of examination of the sick person, which characteristic only for practical medicine. This method uses language as a way of people, an exchange of opinions and mutual understanding. Word is the powerful medical factor also.
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Enquiry patient
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General plan of the questioning (subjective examination)
• general information about a patient (pasport data)
• patient’s problems which he is suffered for - patient’s complaints (molestia aegroti)
• the main data about the disease, its onset duration - history of present illness (anamnesis morbi)
• the main data about patient’s life in a short form - patient’s life history
(anamnesis vitae)
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Scheme of patient’s inquiry
• Passport data• Surname, name, father’s name• Age• Marrital status, Sex• Education, Ocuppation• Place of employement• Profession (post)• Adress of close relatives• Date of admission
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Objective examination (status praesent objectivus)
studying of the separate organs and systems- respiratiry system, cardio-vascular system, digestive system, urinary system,endocrine system, nervous system and sense organs
• general examination (inspectio)• palpation (palpatio)• percussion (percussio)• auscultation (auscultatio)
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Paraclinic (additional) methods of patient’s examination:
• laboratory• obligatory: complete lood analysis, urine analysis, analysis
of feces for worm ova, wassermann test
• special:biochemical blood analysis,tests for estimation of immune system, sputum examination
• instrumental: ECG, spirography, ultrasound diagnostic, computer tomography etc.
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Semiotics
• the science about the signs of disease, which explaints the facts are received with the help of different methods of patient’s examinations
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Symptomatology
• the science that is engaged in studying of disease’s symptoms
• Symptom is the separate sign of disease • Syndrom is the group of symptoms, which help
pathogenetic connection • Anonatomic syndrome is the group of symptoms, which
correspond to structural changes of the organs• Functional syndrome is the group of functional
symptoms
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General semiotics
• includes• main signs - age, sex, the type of constitution
• the patient’s general conditions, posture, fase expression, gain, bearing, pain, temperature, dyapnea etc.
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Diagnosis
• is the doctors conclusion about the disease and patient’s condition expressed in modern medical science’s terms.
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Types of diagnosis
• According to the character and content: etiological, pathogeneticnosological, pathologic (post-mortem), anatomical, pathophysiological.
• Acording to the method of construction and substantiation• direct - recognition from a symptom to a disease
• differential - when several probable diseases are compared (diagnosis by exclusion)
• diagnosis «by observation» - in the case when a diagnosis is possible to make only after prolonged supervision of a patient
• diagnosis by treatment responce - may be made when positive responce or specific treatment is present.
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• According to time when a disease was identified
• early diagnosis - a disease was identified at its beginning
• late diagnosis - a disease was identified late
• postmortem diagnosis - is put at pathanatomical section
• by degree of reliability
• provisional diagnosis - is used during examination of a patient as a working hypothesis
• preliminary diagnosis - is formed after the first examination of a patient which includes inquiry and physical examination of separate organs and systems
• final clinical diagnosis - is formed after complete examination of a patient
• doubtful or indeterminate diagnosis - in heavy cases when it is dificult to confirm the diagnosis
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Diagnostical mistakes
• Caused by a disease - a disease is unknown or rare, symptons are abcent, clinical pattern resembles other diseases
• caused by a patient - when it is not possible to take anamnesis, anamnesis is wrong or distorted because of simulation, when it is not possible to perform objective examination, presence of concomitant diseases
• caused by a doctor - insuficient knowledges, inattentiveness, excessive confidence, overestimation of ata of examination
• caused by circumstances - noise, insufiient lighting, the room is not addopted for examination of patients
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Medical deontology
• A science about interrelations of a doctor and persons which participate in general clinical process• a doctor - a patient• a doctor - patient’s relatives• a doctor - medial and junior
medical personell• a doctor - a doctor• a doctor - a law (public
prosecutor’s office)• a doctor - insurance medical
company (medical experts)
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Complaints
• Patient’s complaints• the group of distinct complaints - in marked chandes in internal organs
(cough, dyspnoe, vomiting, pain, edema, elevation of body temperature)• the group of undistinct complaints - in chronic diseases or functional
disorders (pain of uncertain location and character, a patient «feels heart» etc)• the group of multiply, detalised and uncertain complaints (neurotic
complaints)• according to content complaints are devided on:• complaints on morphological changes (change of shape, position, appearance
of separate parts of a body)• complaints on functional disorders (disorders of function - dyspnoe,
diarrhoea)• complaints on pathological ffelings (psychical experiences) - pain, bad
feeling)
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Scheme questioning the patient
• Passport date
• Last name, first name, middle name
• Age
• Marital Status
• Sex
• Nationality
• Education
• Home
• Place of work
• Job Title (position)
• Address immediate family
• Date of admission to hospital
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Anamnesis morbi
• History of present illness• onset of a disease
• futher course of a disease
• performed diagnostical measures
• treatment in the past, its efficiency
• cause of the disease on patient’s own opinion
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Life history
• Place of birth, living conditions in childhood, children’s diseases
• professional way
• living and financial conditions
• marrital status at present time
• diseases of the past
• harmful habits
• heredity concerning to father’s and mother’s lines
• allergological anamnesis
• expert anamnesis
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General inspection
• Evaluation of patient’s general condition
• Estimation of condotion of conscioussness
• patient’s position
• body built (habitus) - constitution, high, body weight)
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Patient’s bearing and gate in Bechterev’s disease
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• Inspection of a head• Inspection of a face• Inspection of eyes and eyeleads• Inspection of a nose• Inspection of oral cavity• Tongue• Inspection of a neck• Inspection of skin• Mucous membranes o eyes, lips, oral cavity• Subcutaneous fat tissue• Edema• Puffiness• Lymph nodes• Muscles• Bones• Joints
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Acrocyanosis
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Vitiligo
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Herpes labialis
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Petechial rash
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Erythema annulate
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Inspection of conjunctive
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Baldness
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Constitution
• This is the group of functional and morphological peculiarities o an organism which are formed due to congenital and acquired properties, and determine patient’s reaction on exo- and eddogenous influences.• asthenic
• hypersthenic
• normosthenic
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Gigantism and nanism
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Alimantary obesity
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Abdominal type of obesity
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Obesity in patient with Cushing’s disease
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Quincke’s edema of the lower lip
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Inspection of a tongue (brown-yellow cover)
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Facial expression
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Jaundice
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Inspection of a face (mitral stenosis)
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Acromegaly
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Hyperthyreosis
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Moon-shaped face in Cushing’s disease
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Hytothyreosis
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Rinoscleroma
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Зоб
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Anisocoria
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Renal edema on the lower eyeyleads
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Oral moniliasis
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Goiter
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Large goiter
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Nodular goiter
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Swelling of neck veins
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Cachexia
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Kyphoscoliosis
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Gynaecomastia
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Ascites
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Strias in Cushin’s disease
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Rheumatoid arthritis
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Gout
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Dupuitren’s contracture
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Palmar hyperpigmentation in Addison’s disease
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Trophic ulcers
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“Clubbing fingers”
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