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| IMC Wiki | Case history, clinical findings – the patient's first consultation with their physician

Case history, clinical findings – the patient's first consultation with their physician

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A patient will consult a physician either as a preventive measure (medical checkup) or because of the appearance of certain symptoms of illness that they themselves, or their family, have noticed. These presumable signs of illness may be localized or not and they may be at an early or later stage. Generally speaking, treatment options and chances for favorable outcome are better the earlier the illness is detected. Many patients let as much time as possible pass before they consult their physician, thus reducing the possibility of a successful outcome.

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If the signs and symptoms listed here are observed, a physician should be consulted immediately. The physician is obliged to examine the patient and do everything possible to find out the reason for the patient's complaints. A wait-and-see approach is usually wrong.
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Localized signs of illness that the patient may recognize

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There are certain localized signs of illness that the patient may recognize and diagnose, such as "my stomach aches." Such symptoms are listed here. However, there are also localized symptoms occurring distant from their origin, e.g. back pain due to gallbladder disease.

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When the patient first consults their physician, they may appear healthy, both physically and mentally, and only complain about one symptom, such as problems with swallowing. On the other hand, the patient may be in a life-threatening situation, e.g. following a severe accident. This is the subject of the physician's first analytical approach. For more detailed information with regard to life-threatening conditions, please refer to the Polytrauma article. Furthermore, management of such situations will be described in more detail with regard to the affected organ (e.g. acute abdominal pain) in the following chapters.
If the patient's condition is not obviously acutely life-threatening, certain procedures should be followed, starting with the case history and clinical examination. The easiest cases are like this:
Case history: the patient has played soccer and has twisted their ankle so that it hurts and walking is a problem
Clinical examination: pain, swelling, signs of fracture (broken bone) of the lateral malleolus

However, in the normal course of events, a physician's life is not usually that easy.

Localized and generalized symptoms associated with diseases of and trauma to the body's systems

Primariy cellular lesions
Decreased vitality or physical ability, signs of viral infection, signs of tumor growth.

Primarily metabolic lesions
Generalized impaired function of all systems including the central nervous system (level of consciousness, cognitive function); pathological eating habits, weight gain or loss, aversion to certain foods, thirst, bad breath (halitosis), strongly smelling urine, muscle cramps.

Lesions primarily of tissue
Signs of inflammation, bleeding tendency, hemorrhage, muscular atrophy, chronic pain, anemia, polyglobulism, impaired function, lymphadenopathy.

Lesions of the immune system
Allergies, hypersensitivities, frequent infection, skin infection, enlarged spleen (splenomegaly), enlarged lymph nodes (lymphadenopathy), nocturnal sweats, attacks of fever, signs of generalized and localized organ infection, e.g. of the lung, signs of inflammation.

Lesions of regulatory organs and the endocrine and the autonomic nervous systems
Disturbed perception of hunger and thirst, excessive or lack of perspiration, weight gain or loss, anorexia, hyperorexia, shaking when hungry, tachycardia or bradycardia, exophthalmos, mental excitability or underexcitation/lethargy, amenorrhea, loss of libido, erectile dysfunction.

Lesions of the digestive system
Swallowing problems, (chronic) vomiting, (chronic) heartburn, hematemesis, retro-sternal pain and in the abdomen, chronic diarrhea or constipation, bloating, abdominal distension, incontinence, blood in or on the stools.

Lesions of the hepato-pancreatic system
Bloating, distended abdomen, enlarged liver (hepatomegaly), enlarged spleen (splenomegaly) pain in the right, middle or left upper abdomen, colicky pain, pain radiating to the back, whitish-gray stools, yellow coloration of the eyes or skin, brown urine, weight loss, signs of inflammation.

Lesions of the cardiovascular system
Chest pain, heart pain, back pain, angina pectoris, tachycardia, bradycardia, cardiac arrhythmias, variation in blood pressure, syncope, abnormal pulse rate, cardiac murmur, acute obstruction, chronic vascular disorder (e.g. in the legs), venous changes.

Lesions of the respiratory system
(Chronic) cough, permanent hoarseness, shortness of breath (respiratory distress), chest pain, dyspnea, (chronic) expectoration, audible respiratory sounds, stridor, increased, diminished, quick, deep, or flat breathing, cyanosis (of the lips, fingers), enlarged/pronounced cervical veins, cutaneous emphysema, blue and red face.

Lesions of the uropoietic system
Back pain radiating to the groin and the right, left, and middle lower abdomen; pain in the anus, fever, smelly and cloudy urine, thirst, anuria, polyuria, oliguria, hematuria, proteinuria (test strip), incontinence, disturbed micturition; attacks of raised temperature associated with these symptoms.

Problems with water and ion metabolism
Water loss (due to perspiration, diarrhea), symptoms of uropoietic lesions (see above); cardiac arrhythmia, muscle cramps, bad breath (halitosis), smelly urine, disturbance of consciousness, dry and wrinkled skin, dry mucous membranes, altered breathing (frequency, intensity, pathological rhythm).

Lesions of body cavities and the skin
Pathological forms and extensibility (e.g. chest wall depression), symptoms of disturbed organ function (see above).
Skin: edema, various eruptions, infection, itching, ulcers.
Skull: Disturbance of consciousness, intelligence, and memory, signs of infection, signs of trauma.
Chest: Pain, respiratory problems, signs of fracture.
Abdomen: Pain, pain on pressure, signs of trauma.

Lesions of the supporting apparatus and the locomotor system
Changes in the body's external appearance, postural abnormalities, weakness, mobility disorder, impaired joint function/mobility, unrest, paralysis, muscular atrophy, infection foci, palpable ulcers, pain in bones, joints, muscles, ligaments, back pain, pain in the shoulder and cervical column.

Lesions of sensory organs
Disturbed function (vision, hearing, smell, tasting), pain, dysasthesia, pupillary changes, speech disorders, disorders of balance, vertigo, noises in the ear (e.g. tinnitus), sudden loss of hearing, seizures, impaired coordination of the locomotor system, paralysis, sensory disorders.

Lesions of the central nervous system
Altered level of intelligence, impaired memory, headache, character changes, impaired attention, sleeping problems, abnormal behavior, psychological syndromes, signs of infection, stiff neck, paralysis, back pain, signs of increased cerebral pressure (eye symptoms, bradycardia), signs of problems with sensory organs (see above).

An example from the physician's everyday life

A 58-year old patient in good physical and mental condition consults their physician:

Physician's questions Patient's responses
Why are you here? abdominal pain, vomiting and loss of appetite since yesterday
Have you had these complaints before? no
Please describe your abdominal pain – is it constant or intermittent, and increasing in intensity? constantly increasing in intensity
Where exactly do you hurt with abdominal pain? it started in the middle abdomen, around the belly button, but has shifted to the right side of the abdomen
Did you have a temperature? no
Have you undergone surgery in the past? yes, because of inguinal hernia

Clinical examination Findings
palpation of the abdomen pain on pressure in the right lower abdomen
impression of the abdominal wall, sudden release rebound tenderness in the right lower abdomen
percussion of the abdomen, sound no pathological findings
auscultation of the abdomen, sound very loud peristaltic sounds
digital rectal examination (palpation of the rectum using a finger) right lateral pain on pressure

Both the case history and the clinical findings lead to the assumed diagnosis of acute appendicitis. This assumption is either confirmed obtaining more clinical findings that are typical for the disease, or excluded as far as possible.

Blood count leucocytes (14,000) (increase in the number of white blood cells)
Pulse quality slight tachycardia (100) (acceleration of heart rate)
Temperature increased rectal temperature (37.8°C)
normal axillary temperature (36.8°C)
Urine analysis no pathological findings

These are typical findings associated with appendicitis hence the diagnosis is pretty safe. Repeat palpation one hour later shows a clear increase in pain on pressure and rebound tenderness. Therefore, the decision for appendectomy (surgical removal of the appendix) is made and the case history and findings completed with the aim to obtain information about accompanying conditions, possible risk factors and contraindications.
For this purpose, the case history and clinical findings will be recorded in as much detail as possible using a software program specially designed to systematically record them: PDF form .

Software programs have been developed for both physicians' practices and hospitals and are tailored to individual speciality needs, such as laboratory analyses, X-ray examinations, etc. The findings can be displayed on screen and printed, and may be filed and stored as a paper or electronic health record.

Clinical findings

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While the case history is taken during consultation between the physician and patient and/or members of their family where documents from prior examinations/diseases may also be helpful, it is far more time-consuming to obtain clinical findings which require activity by the physician, for example, retrieving information from diverse electronic health records. All findings are obtained following a clinical examination that is obligatory when a patient consults their physician for the first time.
  • The examination procedure should be adequate.
    • The diagnosis must be safe.
    • Serious accompanying diseases must be known to the physician.
    • An inappropriate examination program costs time and money:
Example:
Small program Big program
youthful sportsman
clear diagnosis
broken leg
no previous diseases
old woman
physical and mental decline
life-threatening symptom
respiratory distress of unknown origin

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The classical methods of clinical examination, ie percussion (percussive sound through the skin) and auscultation (sounds in underlying organs, e.g. of the heart), have not lost their relevance despite the development of modern technical devices. They initially build up the essential relationship between the physician and the patient.

Normal findings

Body:
Mediium height, medium weight, visible muscles, little subcutaneous fat, normal appearance of skin. Straight upright posture, all joints freely mobile both actively and passively, slim lower legs, no edema, no excessively enlarged veins, no venous stasis in the neck or legs. If the hands are held up to chin level, the veins in the back of the hand will empty.
Core body temperature (taken in the rectum): 36.5-37°C
Skin (peripheral, taken in the axilla): 0.2-0.5°C lower if taken over a period of several minutes.
The patient's habitus
is insignificant (pycnic, asthenic, athletic…).

Head:
Normal level of consciousness, attentiveness, no or minimal shaking/tremor, fixation of objects, arterial pulse equally palpable on both sides, normal vision, hearing, smell, sensation. No pain on palpation. Face is neither red nor pale, lips are normal reddish color.

Eyes:
The examiner is observed. The patient's eyes are clear, the pupils moderately dilated and narrow with light, there is no discoloration, they are white, glossy and moist. The eyes do not protrude conspicuously (proptosis or enophthalmos). In old age, the patient uses glasses for close vision.

Neck:
Slim neck, smooth borders, no protrusion, no enlargement of lymph nodes (lymphadenopathy) or thyroid gland (goiter), the neck veins are empty.

Chest:
Symmetrical, no protrusion, no depression, both sides are equal, symmetrical respiratory movement, the average respiratory frequency is 14 breaths/minute, uniform, inaudible inspiration and expiration.

Lungs:
Bilateral quiet vesicular breath sounds, distributed evenly and a little softer in the upper parts, normal pulmonary margins mobile bilaterally during respiration, odorless exhaled breath.

Heart:
Heart margins normal at percussion, clear first and second heart sound, no noise, resting cardiac frequency 60 to 80 contractions, resting blood pressure 80/120.

Abdomen:
Slim, muscles palpable under tension, abdominal wall is soft when relaxed. Margin of the liver barely palpable below the right costal arch with deep inhalation. Normally nothing can be palpated in the middle except the spinal column posteriorly, no hardened areas, no pulsations. In slim people, the spleen and kidneys are just palpable when the posterior abdominal wall is lifted. No hernia.
Rectal palpation: No resistance, no narrowness palpable.

Extremities:
Normal color of skin in all regions, no discolorations. No motor or sensory abnormalities. The pulse is palpable on both palmar sides of the wrist (radial pulse), in the angle of the elbow (antecubital fossa), the axilla, the groin, in the back of the knee (popliteal fossa) and on the dorsum of the foot (dorsalis pedis). Even warmth and dry/moist skin. No change from a supine to a standing position. No edema, no dilated veins. Odorless sweat. Both rough force and fine motor skills of the fingertips are normal and the same on both sides.

The physician uses all five senses in the clinical examination

Sight #pic#
With their eyes, the physician can assess the patient's outer appearance, facial expression, eyes, skin, color of the skin, muscles, subcutaneous fat, joints, posture, breathing, filling of blood vessels and many more things.

Touch #pic#
Surface temperature, moisture, elasticity, firmness, mobility, resistance, tumors, fluids etc. can be palpated.

Sound #pic#
Percussion: percussion sounds inform about the density of structures, e.g. associated with pneumonia, or of the pulmonary margins.

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Auscultation: this is a technique looking for normal and pathological sounds of the chest and abdomen, e.g. heart sounds using a stethoscope.
Both clinical findings and the case history are obtained following a system using computerized forms, and pathological deviations are explained in detail: PDF form .

Explanation of some terms used in such forms:

aphasia
apraxia
agnosia
anaphylaxis
fluctuation
cachexia
cyanosis
syndactyly
absolute arrhythmia
speech disorders and problems understanding what is said
inability to perform coordinated movements
inability to interpret sensory stimuli
serious allergic reaction
spilling movement of liquids
extreme weight loss
bluish discoloration of the skin and mucous membranes
condition wherein two or more digits are fused together
completely irregular heartbeat