UKRAINIAN MINISTRY OF PUBLIC HEALTH
Dnepropetrovsk State Medical Academy
«APPROVED»
At the methodological meeting of
the internal medicine propedeutics
department
Chief of the department
____________prof. Khomazuk T.A.
«
»
2013 y.
Guidelines
For Second-year Students of the Dentist Department
Subgect
Module №
Enclosure module №
Topic №4
Propedeutics of the internal medicine
Course
Faculty
2
Inquring patient and its role in assessment of general
patient’s condition.
Dnepropetrovsk- 2013
General purpose – to know the base principles of the general and special
nursing therapeutic patients, algorithm of the clinical investigation of patients, to
manage inquiring patient and summarize obtaining data.
Special purpose:
1. To know principles of the general and special nursing patients (personal
hygiene, feeding patient, measuring body temperature.
2. To use fundamentals of the medical deontology.
3. To form at educational and occupational activity the main principles of the
healthy life style and prevention of the harmful habits.
4. To learn general principles of the diagnostics of internal diseases. Methods
of the clinical examination of patients: inquiry, physical, additional, their
role in diagnostics.
5. To know definition of the symptom, syndrome, semiotics, diagnosis of the
disease and be able to recognize them during patient examination. To learn
the rules of recording patient cart.
6. To obtain patient history and assess it.
Topic content
Guidelines for clinical examination of patient.
Nursing is concerned with the care of people. Generally, the recipient of
nursing care is called a patient, that is, any person, well or ill, who is receiving
nursing care. A health care consumer is one who uses health care services. The
person giving nursing care is most often called the nurse. Nursing is becoming
increasingly health-oriented although the care of the sick is still one of its
important functions. Nursing is offered on a continuing basis. Care does not begin
and end in any one setting, such as the hospital. Rather, through all of life, during
health and sickness, nursing services are offered to help consumers maintain
healthful behavior, avoid and minimize disease and disability, and restore persons
to their best health potential. Although hospitals are the largest single employer of
nurses, they also work in schools, industries, private homes, community health
agencies, clinics, physicians' offices, convalescent and nursing homes, day care
centers, and so on.
Health care is the total of all services offered by the various health
disciplines. It is comprehensive and continuing in nature. A variety of health
personnel work interdependently and collaboratively to help meet the needs of
persons who enter the health care system. Each group of professionals has specific
skills and knowledge to offer the consumer of health care: the nurse offers care that
helps an individual achieve and maintain health; the physician focuses on
diagnosing pathological conditions and prescribes appropriate medical treatment;
the nutritionist plans appropriate care in relation to dietary needs; the physical
therapist offers rehabilitation services; and so on. The general term health
practitioner is often used to describe anyone engaged in the practice of dispensing
health care services. The question is often asked, who is the captain of a team
offering total health care? Any health practitioner may assume leadership,
depending on the needs of the consumer. For example, when a patient is acutely ill
and needs medical care, the physician may guide the team. Nurses assume
leadership when a person is being helped to maintain or regain his state of health
with various nursing intervention measures, such as health teaching, comfort
measures, and restorative support.
Comprehensive health care is generally considered to consist of four
services: the promotion of health, the prevention of disease, the detection and
treatment of disease, and rehabilitation. Each service is of major concern to nurses,
and the responsibilities of nurses are: colleting data on the patient’s physical
health; providing for personal hygiene; promoting exercise and activity; promoting
comfort, rest, and sleep; meeting nutritional and fluids needs; promoting urinary
and intestinal elimination; promoting respiratory functioning; promoting tissue
healing; the administration of therapeutic agents; providing basic life support;
caring for the patient with a terminal illness; entering information into patient
records. Collecting data on the person’s physical health usually include observing
general state of health, measuring height and weight, obtaining vital signs (body
temperature, pulse and respiratory rates, blood pressure), collecting specimens of
blood, urine and so on. Personal hygiene means measures of personal cleanliness
and grooming that promote physical and psychological well-being. These measures
include care of the skin, bathing the patient; oral hygiene; care of the hair, nails,
feet, eyes, ears and nose; perineal care; prophylaxis of the decubitus ulcers
(bedsores). The technical skills in the administration of therapeutic agents are also
of great importance. The drugs can be administered orally or sublingually; by
injection (intracutaneously, subcutaneously, intramuscularly, intravenously), by
intravenous infusion; topically (applications to the skin, throat, vagina or rectum;
instillations to the eyes, ears or nose). A patient’s record (or chart) is an agency’s
compilation of a person’s health care information. An accurate record serves as a
valuable means of communication among health practitioners.
TECHNIQUE OF PHYSICAL EXAMINATION
The main clinical diagnostic methods include systematic interview,
inspection, palpation, percussion, auscultation, and measuring. Each patient should
be examined repeatedly. These methods are called main because only after having
applied them, the physician can decide what auxiliary methods (laboratory and
instrumental tests) should be used to establish or verify the diagnosis.
Interview. The art of history (anamnesis) taking is not easy. Some patients
forget to mention the most important symptoms while others dwell on unimportant
and irrelevant details. The history will therefore be incomplete if the patient is
allowed to tell the history of his illness by himself. Some patients may be shy and
do not readily talk about some diseases (e.g. venereal) or harmful habits
(alcoholism).
The physician must learn the art of correct and systematic inquiring. The
first step is to collect identifying information about the patient: his name, age,
place of birth, job and occupation. Age is important in the development of some
diseases, e.g. essential hypertension, atherosclerosis, and malignant tumours that
commonly develop in the aged. Occupation and social status of the patient are
often responsible for the onset of the disease (e.g. poisoning, chills, etc.).
The next step is a systematic and thorough functional inquiry of the patient
according to a predetermined scheme. Chief complaint or the reason for seeking
care should be determined. If the patient complains of retrosternal pain, the
character and exact location of this pain, its focus and intensity should be
determined; the time of the onset, and possible causes that provoked the pain
(strain, cough, taking food, etc.) should be established. The patient should be asked
which remedies remove this pain. Other associated complaints should also be
analyzed. The study of the chief complaints can lead the examiner to a conclusion
concerning the general character of the disease, e.g. high body temperature would
normally indicate an infectious process, cough and expectorated sputum indicate
possible disease of the lungs.
History of present illness (Anamnesis morbi) 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, about relapses or exacerbations, remissions and
their duration. If some other physicians examined the patient during an
exacerbation of the disease, the results of the examinations and treatment should be
studied. Motives for hospitalization should also be determined (exacerbation of the
disease, verification of the diagnosis, etc.). History of present illness gives
information about the character of the disease (acute or chronic).
Review of systems (Anamnesis communis) gives the physician information
concerning the condition of various organs and systems of the patient
(cardiovascular,
respiratory,
gastrointestinal,
genitourinary,
nervous,
musculoskeletal, etc.). The patient should be questioned according to a specially
outlined scheme. Changes in the patient's general state should be established first
(loss of weight, fever, weakness, edema, headache). Next is the most affected
system. Then some questions about each system should be included. For example,
the condition of cardiovascular system is established by asking the patient about
chest pain or distress, palpitations, dyspnea, orthopnea (number of pillows needed),
edema, claudication, hypertension and so on.
Life history (Anamnesis vitae) is often very important for establishing the
character, the cause, and conditions for the onset of the disease. It is a medical
biography of the patient in every period of his life (infancy, childhood,
adolescence, and maturity). Personal and social history should be taken first. It
begins with the general biographical information. Birthplace is important, because
some diseases (e.g. endemic goiter) usually predominate in one locality and are not
met in others. The patient should be asked if he was born at term, if there were
other children in the family, if he was breast fed or artificially; and if he had
marked signs of rickets during his childhood. It is necessary to find out if the
patient's physical and mental development was not retarded and what was his
progress at school.
The patient should inform the physician on his home conditions (separate
apartment, hostel, country house, illumination, the presence of dampness, if any,
hygienic conditions, etc.). The composition of the family is important: large or
small family, their health, well-being, income, etc. Malnutrition is an important
factor for the onset of some diseases. The patient should be asked if his diet is
sufficiently rich in vegetables, fruits, etc. The way in which the patient spends his
leisure time is also important. The patient should report on the time he sleeps, rests,
walks in the fresh air, what sports and exercises he goes in for, and what harmful
habits he has.
Unfavourable labour conditions and industrial hazards (some harmful dusts)
are important, for they may cause bronchial asthma and chronic diseases of the
bronchi and lungs. Strong noise, vibration, high ambient temperature, drafts, and
cold (work in the open) can cause pathology. Industrial poisoning by mercury,
lead, carbon monoxide and other harmful agents, and also exposure to radiation
(improper safety measures) may also cause disease. The working schedule is also
important.
Past medical history should be established in chronologic order. Childhood
and major adult illnesses, surgery, serious injuries, immunizations and medications
are important. Some infectious diseases, such as measles or scarlet fever, do not
recur because of acquired immunity, while other diseases, such as rheumatism or
erysipelas, tend to recur. Rheumatism or diphtheria often provokes heart diseases.
Nephropathy often develops after scarlet fever. Contacts with infectious patients
are important, especially in the presence of epidemics (e.g. influenza).
Family history helps the physician to make a conclusion on the role of
hereditary factors in the development or origin of the disease. Ask if there are any
blood relatives in the patient’s family who have illnesses with features similar to
the patient’s illness. Determine the ethnicity; health; and the cause of death of
parents, including their ages at death. Establish whether there is a history of heart
disease, high blood pressure, cancer, tuberculosis, stroke, epilepsy, diabetes, gout,
kidney disease, thyroid disease, asthma and other allergic states, forms of arthritis,
blood diseases, sexually transmitted diseases, or any other familial disease.
Determine the health of patient’s spouse and children. If there is a hereditary
disease, such as sickle sell disease, inquire into the history of the grandparents,
aunts, uncles, siblings, and cousins. A pedigree diagram is often helpful in
recording this information.
Allergological anamnesis is very important. Some patients often develop a
pathologically heightened (or inverted) response of the immune system (allergy),
and this is essential in the pathogenesis of certain diseases of internal organs. It is
necessary therefore to determine whether the patient or his relatives had allergies,
especially to medications, but also to environmental allergens or foods. Strawberry,
eggs, canned crabs, and other foods may frequently act as allergen. Allergies in
man vary from vasomotor rhinitis, nettle rash or Quincke's edema to anaphylactic
shock.
Assessment of the anamnesis and visual examination data
1. Highlight pathological signs obtained by visual inspection
2. Indicate connection between anamnesis data and visual inspection data.
3. Suggest which system or organ could be affected according to get data.
Tests self-knowledge and skills that students acquire while exploring themes.
Situational tasks:
1. Subjective examination includes:
А.Visual inspection
В. Taking a body temperature
С*. Inquiring
D. Measuring blood pressure
Е. Measuring weight and height
2. Objective examination includes:
А. Laboratory investigation
В. X-ray examination
С. Ultrasound examination
D*. Palpation, percussion, auscultation
Е. Endoscopic examination
3. Additional investigation includes:
А. Visual inspection
В*. Full blood count
С. Pulse palpation
D. Additional inquiring patient’s relatives
Е. Auscultation of the abdomen
4. Which system should inquiring about organs and systems be begun from?
А. It is not matter
В. From cardiovascular system due to its importance
С*. From affected system according to patient’s complaints
D. From respiratory system particularly in winter
Е. From digestive system
5. What conclusions should be made after inquiring patient?
А. Assessment of the patient general condition
В. Form probable diagnosis
С*. Reveal affected system, acute or chronic disease course
D. Administer treatment
Е. Perform visual inspection
6. Which information does passport part include?
А. Character of the disease course
В*. Patient’s home address
С. Data about treatment
D. Prognosis of the disease
Е. Disease onset
7. What does anamnesis morbi include?
А. Patient’s age
В. Patient’s home address
С. Patient’s occupation
D*. Disease onset
Е. Features of heredity
8. What does anamnesis morbi include?
А. Patient’s age
В*. Character of the disease course
С. Allergic history
D. Patient’s home address
Е. Patient’s occupation
9. What does anamnesis morbid include?
А*. Previously administered treatment
В. Patient’s age
С. Family history
D. Patient’s occupation
Е. Harmful habits
10. What does anamnesis vitae include?
А. Patient’s age
В. Disease duration
С. Character of the disease course
D*. Allergic history
Е. Previously taken treatment
11. What does anamnesis vitae include?
А. Character of the disease course
В. Disease duration
С.* Family history
D. Taken treatment
Е. Patient’s age
12. What does anamnesis vitae include?
А. Disease duration
В.* Harmful habits
С. Taken treatment
D. Patient’s home address
Е. Patient’s age
13. What do harmful habits include?
А. Overeating
В.* Smoking
С. Winter-swimming
D. Yoga exercises
Е. Vegetarian
14. Which purpose is inquiring patient about organs and systems made with?
А For prognosis of the disease
В. For revealing disease onset
С. For characteristics of the disease course
D.* For revealing concurrent pathology
Е. For revealing harmful habits
15. Which purpose is anamnesis morbi made with?
А * For characteristics of the disease course
В. For revealing harmful habits
С. For discovering heredity changes
D. For discovering previous diseases
Е. For obtaining family history
16. Which purpose is patient’s occupation obtained with?
А. For establishing harmful habits
В. For characteristics of the disease course
С.* For discovering occupational diseases
D. For discovering previous diseases
Е. For revealing disease onset
17. What do harmful habits include?
A. Overeating
B. *Smoking
C. Winter-swimming
D. Yoga exercises
E. Vegetarian
18. Which system should inquiring about organs and systems be begun from?
A. It is not matter
B. From cardiovascular system due to its importance
C. *From affected system according to patient’s complaints
D. From respiratory system particularly in winter
E. From digestive system.
19. What conclusions should be made after inquiring patient?
A. Assessment of the patient general condition
B. Form probable diagnosis
C. *Reveal affected system, acute or chronic disease course
D. Administer treatment
E. Perform visual inspection
20. Which purpose is inquiring patient about organs and systems made with?
A. For prognosis of the disease
B. For revealing disease onset
C. For characteristics of the disease course
D. *For revealing concurrent pathology
E. For revealing harmful habits
21. If patient has abdominal pain you should ask him about…
A. Location
B. Character
C. Connection with meal
D. reliving factors
E. all mentioned above
22. Which symptoms appear in case of stomachic disorders?
A. Dysphagia, odynophagia, heartburn, chest pain, hematemesis
B. Nausea, vomiting, epigastric pain, hematemesis, early satiety
C. Diarrhea, constipation, abdominal swelling
D. Heaviness in the right subcostal region, nausea, bitter taste, vomiting
E..Northing from mentioned above
23. Which symptoms appear in case of intestinal disorders?
A. Dysphagia, odynophagia, heartburn, chest pain, hematemesis
B. Nausea, vomiting, epigastric pain, hematemesis, early satiety
C. Diarrhea, constipation, abdominal swelling
D. Heaviness in the right subcostal region, nausea, bitter taste, vomiting
E..Northing from mentioned above
24. What are the gastrointestinal symptoms?
A. Chest pain, cough, dyspnea, wheezes, haemoptysis.
B. Pain in the heart region, palpitation, intermissions, oedema
C. Headache, dizziness, dysphagia, nausea, vomiting.
D. Pain in the right subcostal region, bitter taste, brown urine, skin itching,
jaundice.
E. Back pain, dysuria, ishuria, eyes oedema, weakness.
25. What symptoms characterize biliary dyspepsia?
A. Dysphagia, odynophagia, heartburn, hematemesis
B. Nausea, vomiting, hematemesis, early satiety
C. Diarrhea, constipation, abdominal swelling
D. Heaviness in the right subcostal region, nausea, bitter taste, vomiting
E. Northing from mentioned above
26. What symptoms characterize intestinal dyspepsia?
A. Dysphagia, odynophagia, heartburn, hematemesis
B. Nausea, vomiting, hematemesis, early satiety
C. Diarrhea, constipation, abdominal swelling
D. Heaviness in the right subcostal region, nausea, bitter taste, vomiting
E. E.Northing from mentioned above
27. What are the cardiovascular symptoms?
A. Chest pain, cough, dyspnea, wheezes, haemoptysis.
B. *Pain in the heart region, palpitation, intermissions, oedema
C. Headache, dizziness, dysphagia, nausea, vomiting.
D. Pain in the right subcostal region, bitter taste, brown urine, skin itching,
jaundice.
E. Back pain, dysuria, ishuria, eyes oedema, weakness.
28. What feature does the pain at angina pectoris have?
A. Be caused by physical extension
B. Duration under 15 minutes
C. Constricting, feeling of heaviness
D. Radiate to the left hand and scapula
E..*All mentioned above
29. What are the cardiovascular symptoms?
A. Abdominal pain, nausea, vomiting
B. *Dyspnea, faint (syncope), palpitation, dry cough
C. Cough with rusty sputum, chest pain, dyspnea
D. Swelling abdomen, constipation, melena
E. Oedema, dysuria, haematuria
30. What feature does not the pain at myocardial infarction have?
A. *Prolonged, continuous > 20-30 min.
B. Severe, tight or burning.
C Relief at rest.
D. Does not respond to nitrates.
E. Radiate to both hands, jaws, neck.
31. What are the respiratory symptoms?
A. *Chest pain, cough, dyspnea, wheezes, haemoptysis.
B. Pain in the heart region, palpitation, intermissions, oedema
C. Headache, dizziness, dysphagia, nausea, vomiting.
D. Pain in the right subcostal region, bitter taste, brown urine, skin itching,
jaundice.
E. Back pain, dysuria, ishuria, eyes oedema, weakness.
32. Whistle and noise breathing with feeling breathlessness is named
A. *Dyspnea
B. Respiratory noise
C. Musical breathing
D Wheezing
E. All mentioned above
33. What are the respiratory symptoms?
A. Abdominal pain, nausea, vomiting
B. Heartburning, faint (syncope), palpitation
C.* Cough with rusty sputum, chest pain, dyspnea
D. Swelling abdomen, constipation, melena
E. Oedema, dysuria, haematuria
34. What are the cough causes?
A. Irritation of the larynx receptors
B. Irritation of the trachea and bronchus receptors
C. Irritation of the pleural receptors
D. *All mentioned above
E. Northing from above
35. If patient has clear, thick sputum it is named
A. *Mucoid
B. Purulent
C. Copious
D. Fetid
E. Hemoptysis
36. Sputum production that contains pus is described by what term?
A. *Purulent
B. Fetid
C. Copious
D. Colored
E. None of the above
37. Amount of cigarettes that patient smokes in a day multiply to number of
smoking years and divide to 20 (pack/years) use for calculating
A. Smoking history
B. cigarettes consumption
C. Smoking habit
D. Smoking abuse
E. *All mentioned above.
Recommended Reading:
1. Diseases and disorders : a nursing therapeutics manual / Marilyn Sawyer
Sommers, Susan A. Johnson, Theresa A. Beery.—3rd ed.
2. Учебное пособие для иностранных студентов медицинских вузов,
обучающихся на английском языке / Мостовой Ю.М, Демчук А.В.,
Константинович Т.В.-1-е издание. - Винница:, 2009.
3. Clinical Nursing Skills and Techniques: basic, intermediate and advanced.
The C.V. Mosby Company, 1986.-1296 p.
4. Clinical Skills and Assessment Techniques in Nursing Practice. Scott,
Foresman and Company, 1989.-1280 p.
5. Emergency Nursing: priciples and practice. The C.V. Mosby Company,
1985.-715p.
6. Instructor's Manual for Fundamentals of Nursing, J.B. Lippincott Company
Philadelphia, 1989.-120 p.
7. Nursing interventions and clinical Skills. Mosby — year Book, Inc., 1996.813p.
8. Nursing Procedures: Student Version. Springhouse Corporation,1992.-788
p.