Diagnostics

1. Introduction to Physical Diagnosis
Mahamed Ibrahim (MD,MPH)
October 17,2023

2. Introduction to clinical medicine
The care of suffering you need:
• Scientific knowledge of Medicine
• The technical skill and the human understanding.
• The practice of medicine therefore combines both art and science

3. The medical art
The medical art:
• The skill of interviewing the patient to elicit important information,
• The ability of using the senses to identify signs of abnormality on the
body, and
• Intuition and judgment to extract the relevant symptoms, signs,
laboratory data, and discard all the rest.

4. History
• A deep knowledge of the patient.
• the chronology of present disease.
• describes the uniqueness of the complaints of the patient,
• social and family background, and
• past illness contributing to the current problem etc.
• Physical examination of the patient without a good history will be
like looking for an object in darkness

5. Good history
• Gives a clue to the root of the problem
• Active search of signs of disease on the body of the patient fruitful
effort.

6. Examination of the patient involves:
• The use of senses of looking, touching, hearing, and smelling.
• A careful observation of the behavior, mood, and speech could put
some light into the diagnosis .

7. The art of critical thinking
• It involves asking questions
• when taking history,
• when forming lists of possible diagnosis or
• when planning diagnostic or therapeutic plan.
• This Socratic approach, question based learning is time honored and
very much alive in medicine to this day
• Clinical reasoning

8. • Laboratory results must be seen as supporting evidence.
• reliability of laboratory data depends on the equipment and the performer’s
ability.
• A careful communication, observation and study of the patient cannot
be replaced by laboratory studies.
• A wise clinician should be purposeful in ordering a test.

9. Patient care
• is an indispensable trait of a health professional
• Patient should be respect by being nonjudgmental
• Requires deep knowledge of the patient’s social and environmental
characteristics
• begins with the development of a personal relationship between the
patient and health professional
• In the absence of trust and confidence on the part of the patient, the
effectiveness of most therapies fails

10. Patient care
• A health professional should have integrity by making himself
available for help, expression of sincere concern, taking time to
explain the aspects of illness to the patient.
• How much a patient is told should depend on the individual ability and
capacity to deal with the possibility of imminent death.
• Gradual and not abrupt disclosure of bad news is the best strategy.

11. Summary of the Clinical methodology
1. Investigation of the chief complaint through history and physical
examination
2. Select from an array of diagnostic tests
3. Integrating clinical and laboratory data
4. Weigh risks and benefits of further diagnostic and therapeutic options
5. Present Final recommendation to the patient before initiating therapy

12. Ethical issues
• Knowledge about common ethical issues is
• Forcing an “ignorant” patient to receive treatment.
• from ethical point of view it is absolutely wrong.
• The duty is simply put as “to do the right thing not necessarily the
good one”, because the good thing may not always be right thing to
do.
• The right thing is done only when he knows the basic ethical issues
concerning clinical practice.
• Patient’s autonomy

13. Ethical issues
• Conflict of patient and physicians’ interest arises
• Gifts for or to prescribe drugs of a certain company, or
• Order unnecessary laboratory investigation
• Covering-up for the mistakes done by oneself or that of a colleague is
as unethical
• confidentiality

14. CLINICAL HISTORY AND PHYSICAL
EXAMINATION
Objectives
• To know the basic interview technique.
• To understand the basic components of patient history.
• To understand the basic components and steps in physical
examination.

15. The “ Classic” History Taking Sequence
The order are :-
• Identification
• Previous Admission
• Chief Complaints
• History of Present Illness
• Past Illness
• Functional Inquiry ( System
Review)
• Personal History
• Family History
• Physical Examination
• Summary
• Differential Diagnosis
• Discussion of Differential
Diagnosis

16. Interview technique
Requirements
• Comfortable place
• Ventilation
• Adequate light
• Introduction
• Comfort the patient/client and establish a good relationship.
• Remember: “a patient is a person not simply a case”.

17. Building Rapport
• Begin with a non-medical interaction.
• Create an atmosphere that is open and supportive.
• Practice “active listening”.
• Discuss a detailed agenda of what will occur.
• Answer questions using simple terms the patient can understand.

18. Communication Skills
• Maintain good eye contact.
• Use active listening and watch the patient’s nonverbal cues.
• Have warm and accepting body language.
• Rely on open ended questions.
• Avoid interrupting.
• Use summaries and reflections.

19. Non verbal skills
• Maintain an appropriate eye contact.
• Listen carefully.
• Stay as close to the patient as is culturally acceptable.

20. Verbal Skills
• Phrase your questions politely and respectfully.
• Use words that the patient understands.
• Make your questions specific.
• Avoid double questions at a time.
• Keep your questions free of moral judgments.
• Avoid leading questions.
• Ask patient permission in special circumstance (sexual history).

21. Special verbal skills
• Facilitation
• Direction
• When a patient is confused
• To start out ideas
• Summarizing and checking out the facts.
• Empathy: when dealing with feeling.
• Reassurance: Shows accepting feelings and need not last long.
• Expressing partnership: commitment to help.

22. Adapting the interview to specific situations
• Interview across a language barrier: find an interpreter. Ideally a
neutral person who understands the language & culture.
• Interviewing a confused person: talk to a well informed family
member.
• Interviewing the disruptive, angry patient: stay calm, appear accepting
& DO NOT be confrontational. SECURITY!
• Sensitive topics: sexual history, mental health history, history of
substance abuse, family violence

23. Components of the history
1. Socio-demographic
Identification
• Full name
• Age, sex
• Address, Marital status
• Religion, occupation (Current and previous)
• Educational status
Historian
Referral paper if any.

25. Previous Admission
•List of hospitalization in the order they occurred
•Specify the date
•Name and location of the hospital
•Disease that led to admission
•Outcome as briefly as is possible, e.g.

26. Chief Complaints
•Those signs and symptoms which prompted the
patient to seek medical advice
•Duration of each sign and symptom
•More than one complaint, they should be listed
in the order of occurrence.

27. • 1990 (EC). Menilik II Hospital, Addis Ababa. Bleeding duodenal ulcer.
Discharged symptom free after transfusion of 2 units of blood.
• 1992 (EC). TAH, Addis Ababa. Newly diagnosed Diabetes Mellitus.
Discharged symptom free with daily dose oh human insulin30 unit SC.
• 1999 (EC). St. Paul’s’ Hospital. Addis Ababa. DKA. Discharged
symptom free with daily of human insulin 45 units sc in divided dose.

28. 2. The chief complaint
• Definition: The main reason that
brought the patient/ client to the
health care provider.
• Components:
• Type of complaint/s
• Duration
• Principles
• Should be short and clear
• Use patient’s own words

29. The chief complaint
• Example 1.
• Cough of two months duration
• Example 2.
• Shortness of breathing of three months and leg swelling of two
weeks duration

30. 3. History of Present Illness(HPI)
• Importance:
• Detailed narration of the chief complaint.
• Is the most important element to reach at the diagnosis and to
consider the differential diagnosis .

31. HPI
• Components:
• Details of the chief complaint
• Date of onset
• Mode or circumstances of onset abrupt or gradual
• Course and duration-maintain chronology
• intermittent or persistent
• short lived or constant
• steady or increasing in severity
• Associated symptoms
• E. g: For pain
• Character, location, type, radiation, exacerbating and relieving
factors, position dependency

32. Effect of Treatment
Patients may have taken drugs or other forms of therapy
Such drugs may not have been taken properly
May have adverse effects by themselves
May have worsened or alleviated the symptoms
May have had no effect whatsoever except
Treatment for disease other than the one under complaint should also
be fully recorded.

33. HPI
• Negative and positive statements
• Helps to rule in or rule out differentials
• Negative statement may be as important as a positive statement.
• Statements are expressed in terms of signs and symptoms but not
diseases
• Chronic illness relevant to the chief complaint-HTN, DM, STI, HIV
• Mode of arrival
• Tells you severity and urgency

34. 4. Past Illness
• Listing of illness unrelated to the present illness, experienced in the past
• Including childhood diseases
• Serious injuries and surgery not requiring hospitalization
• Accidents, operations, any chronic illnes
• Duration or date of event.
• Severity
• Treatment history and out come.
MEDICATION S
Previous Admissions: When, Where, Reason and out come. Maintain
chronologic order.

35. 5. Review of symptoms( functional inquiry)
• Purpose:
• Double check or reminder on points that may have been missed in
the HPI.
• Is a check list.
• Components:
• General- fever, weakness, weight change
• System systematically

36. Review of symptoms( functional inquiry)
• HEENT: head ache, trauma, ear discharge, sneezing, tearing, difficulty
of swallowing
• Lymphoglandular system(LGS): breast pain, lump, discharge, thyroid
function assessment, lumps in the armpits, groin,etc
• Respiratory: Cough, shortness of breathing, chest pain, wheezes
• CVS: dyspnea, orthopnea, paroxysmal nocturnal dyspnea(PND),
palpitation

37. Review of symptoms( functional enquiry)
• GIS: vomiting, nausea, pain, diarrhea
• GUS:
• Urinary symptoms: dysuria, urgency
• Genital symptoms: discharge, menstrual cycle
• LOC: muscular pain, swelling, joint
• Integumentary: discoloration, ulcer, rash
• CNS: memory, loss of consciousness, seizures, vision, weakness of
limbs, etc

38. Personal History
• Record the personal history as follows:
• Early development: place of birth and early homes, childhood
development, health and activities, social and economic status.
• Education: School history, achievements and failures.
• Social activities: Recreation and other activities
• Work record: Age begun, type of work, number of jobs (mention
success or failure regarding shift of jobs), industrial hazards and
exposures, present work.
• Environment: living conditions.
• Habits: Dietary, alcohol, tobacco,drugs,herbs (including
anthelmintics).
• Marital status: Health of wife (or husband), adjustment, number of

39. 6. Personal /Social history
• Developmental
• Education
• Marital status
• Sexual history
• Income, living condition
• Habits

40. 7. Family history
• Family status
• Parents, siblings, spouse and children’s health situation.
• If dead ask for the presumed cause of death
• Familial diseases: diseases with known inheritance pattern/s (
Mendelian or polygenic).
• Family disease: Tuberculosis, diabetes mellitus, hypertensive
disorders, migraine.

41. 8. Nutritional History
• Dietary intake and preference
• Type
• Quality
• Amount

42. 9. Immunization History
• Vaccines in the EPI( Expanded Program in Immunization)
• Polio, DPT, BCG, Measles, Hepatitis B, H. influenzae
• Others : Meningitis, Influenza, pneumococal, rubella, etc

43. Physical Examination
The physical examination is the examination of the patient looking for signs
of disease
• 'Symptoms' are what the patient volunteers
• 'Signs' are what the physician detects by examination).

44. • Success in recording complete physical findings depends on a step-by-
step and systematic examination
• Depending on the system involved or suspected, negative reports are
as significant as positive ones
Physical Examination

45. Physical Examination
• Requirement:
• Illumination
• Good exposure
• Position
• Explanation
• Meticulous and gentle
• Goal: To obtain clinical information that advances diagnosis and is not
merely a token repetitive exercise of going through a set of given
tasks.

46. Physical Examination
• Instruments Required
The five senses!!!!!
Stethoscope
Reflex hammer, monofilament, tuning fork
Ophtalmoscope/ otoscope

47. The four cardinal methods
• Inspection
• Palpation
• Percussion
• Auscultation
• Should be strictly observed

48. Physical Examination
• General appearance:
• Healthy looking, sick looking, distressed
• Consciousness
• Nutritional status
• Vital signs:
• BP
• Pulse rate
• Temperature
• Respiratory Rate ± Oxygen saturation( SaO₂)
• Anthropometric measurements, BMI

49. H.E.E.N.T
HEAD
• Look for scars, lumps, rashes, hair loss, or other lesions
• Look for facial asymmetry, involuntary movements, or edema.
• Palpate to identify any areas of tenderness or deformity.
EARS
• Inspect the auricles and move them around gently.
• Ask the patient if this is painful.
• Palpate the mastoid process for tenderness or deformity.
• Insert the otoscope inspect the ear canal and middle ear structures noting
any redness, drainage, or deformity.
• Repeat for the other ear.

50. Eyes
• Inspect lid lag, ptosis, exophthalmoses, lacrimation, peri-orbital edema
and nystabmus
• Inspect conjunctival pallor, hemorrhage, scleral colour and pterygia
• Examine the fundi by using ophthalmoscope

51. Nose
• Tilt the patient's head back slightly. Ask them to hold their breath for
the next few seconds.
• Insert the otoscope into the nostril, avoiding contact with the septum.
• Inspect the visible nasal structures and note any swelling, redness,
drainage, or deformity.
• Repeat for the other side.

52. Throat
• Ask the patient to open their mouth.
• Using a wooden tongue blade and a good light source, inspect the
inside of the patients mouth including the buccal folds and under the
tougue
• Note any ulcers, white patches (leucoplakia), or other lesions.
• Inspect the posterior oropharynx by depressing the tongue and asking
the patient to say "Ah." Note any tonsilar enlargement, redness, or
discharge.

53. Glands
• Inspect the neck for asymmetry, scars, or other lesions.
• Palpate the neck to detect areas of tenderness, deformity, or
masses

54. Lymph Nodes
• Systematically palpate with the pads of your index and middle fingers for the various
lymph node groups.
• Preauricular - In front of the ear
• Postauricular - Behind the ear
• Occipital - At the base of the skull
• Tonsillar - At the angle of the jaw
• Submandibular - Under the jaw on the side
• Submental - Under the jaw in the midline
• Superficial (Anterior) Cervical - Over and in front of the sternomastoid muscle
• Supraclavicular - In the angle of the sternomastoid and the clavicle
• Axillary, ingunal
• Note the size and location of any palpable nodes and whether they were soft or hard,
non-tender or tender, and mobile or fixed.

56. Thyroid Gland
• Inspect the neck looking for the thyroid gland. Note whether it is visible and
symmetrical
• A visibly enlarged thyroid gland is called a goiter.
• Move to a position behind the patient.
• Move laterally from the midline while palpating for the lobes of the thyroid
• The normal gland is often not palpable
• Note the size, symmetry, and position of the lobes, as well as the presence of
any nodules

57. THANK YOU