Internal Medicine Clinical Examination and Symptoms

History Taking

The most critical component of the medical examination process.

Focuses Attention

A benefit of history taking that directs the clinician to the affected body system(s).

Establish Rapport

The goal of putting the patient at ease and encouraging open dialogue during history taking.

Demonstrate Attentiveness

Making it clear to the patient that they have the clinician's undivided attention.

Professionalism

Avoiding the display of anger or shock at a patient's disclosures.

Enables Diagnosis

Symptomatology alone can be sufficient to diagnose conditions like epilepsy, migraine, or renal colic.

Severity & Progression

Insights provided by history taking regarding the temporal evolution of an illness.

Patient Narrative

Allowing patients to tell their story in their own words and sequence.

Non-Verbal Cues

Body language such as facial expressions, eye contact, and posture.

Active Listener

The principle that listening is as important as questioning in medical history taking.

Personal Data

The section of a medical history providing essential contextual information like age and occupation.

Chief Complaint

The main symptom(s) in the patient's own words that prompted medical care.

History of Present Illness

A detailed, chronological narrative of the current medical problem.

Past Medical History

A record of the patient's prior health, including chronic conditions and surgeries.

Social History

Explores the patient's environment, lifestyle, and social support.

Family History

Identifies potential genetic or environmental familial risks.

Age-specific diseases

Conditions like childhood infections or congenital anomalies that link to a patient's developmental stage.

Hemophilia

A sex-linked disease found in males.

Rheumatoid arthritis

A disease with a sex predilection for females.

Systemic lupus erythematosus

An autoimmune condition more common in females.

Occupation hazards

Risks like radiation exposure or asbestosis related to a patient’s work.

Schistosomiasis

An endemic disease commonly found in rural dwellers in certain geographic regions.

Pack-years

The unit used to document a patient's smoking history.

Chief Complaint Duration

The specific time frame of the main symptom, such as 'chest pain for $3\,\text{hours}$'.

Chief Complaint Chronology

Listing multiple complaints from the oldest to the most recent.

Dyspnea

A subjective feeling of difficulty breathing.

Grade I Dyspnea

Dyspnea occurring when doing more than the usual daily effort.

Grade II Dyspnea

Dyspnea occurring on doing the usual daily effort.

Grade III Dyspnea

Dyspnea occurring on doing less than the usual daily effort.

Grade IV Dyspnea

Dyspnea occurring at rest.

Paroxysmal Nocturnal Dyspnea (PND)

Attacks occurring $2-3\,\text{hours}$ after sleep with marked inspiratory dyspnea and cough.

Cardiac Asthma

Paroxysmal nocturnal dyspnea associated with wheezes due to bronchospasm.

Orthopnea

Dyspnea that increases on lying flat and is relieved by sitting.

Platypnea

Dyspnea that occurs on sitting and is relieved by lying down.

Trepopnea

Dyspnea that occurs when lying on one specific side.

Hering-Breuer reflex

Activation due to interstitial pulmonary edema leading to tachypnea.

Churchill-Cope reflex

Activation due to pulmonary venous congestion leading to dyspnea.

Hydrothorax

Mechanical compression of the lungs by fluid causing dyspnea.

Ischemic chest pain

Pain from conditions like angina, myocardial infarction, and aortic stenosis.

Aortic dissection

A non-ischemic cause of chest pain involving a tearing sensation.

Gastro-esophageal causes of chest pain

Conditions like reflux esophagitis that mimic cardiac pain.

Life-threatening causes of chest pain

Includes $MI$, pulmonary embolus, aortic dissection, and tension pneumothorax.

MI Pain Duration

Chest pain typically lasting $<30\,\text{minutes}$.

MI Pain Location

Pain characteristically felt in the retrosternal area.

MI Pain Radiation

Usually radiates to the lower jaw, medial aspect of the left arm, or medial $2\,\text{fingers}$.

MI Pain Aggravants

Includes effort, emotion, cold, and intercourse.

Palpation

Awareness of the heartbeat due to changes in rhythm, rate, or force.

Syncope

Sudden transient loss of consciousness with quick recovery due to cerebral hypoxia.

Vagal overactivity

The most common cause of simple fainting.

Cardiac Syncope

Syncope caused by arrhythmias, acute heart failure, or obstructed blood flow.

Postural Syncope

Syncope related to autonomic neuropathy, hypovolemia, or pregnancy.

Tussive syncope

Loss of consciousness triggered by coughing.

Acute Cough

A cough lasting $<3\,\text{weeks}$, often due to viral infection.

Chronic Cough

A cough lasting $>8\,\text{weeks}$.

Dry cough

Cough associated with tracheitis, pneumonia, or interstitial lung disease.

Mucoid sputum

Clear sputum common in chronic bronchitis without infection.

Yellow sputum

Indicates acute infection ($\text{live neutrophils}$) or asthma ($\text{eosinophils}$).

Green purulent sputum

Indicates chronic infection ($\text{dead neutrophils}$) as in bronchiectasis.

Rusty red sputum

The characteristic sputum of early pneumococcal pneumonia.

Watery pink sputum

A hallmark of pulmonary edema.

Bronchorrhea

The production of large volumes of sputum over weeks, seen in alveolar cell cancer.

Foul-smelling sputum

Indicates anaerobic infection such as a lung abscess.

Hemoptysis

The act of coughing up blood.

Bovine cough

A low-pitched, prolonged cough associated with left recurrent laryngeal nerve damage.

Wheezy Chest

High-pitched whistling sounds from narrowed small airways on expiration.

Morning wheeze

A symptom suggestive of $COPD$.

SOCRATES

A mnemonic for pain characterization: Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating factors, Severity.

RUQ Biliary Pain

Pain from cholecystitis, cholangitis, or biliary colic.

Epigastric Pain

Pain originating from gastritis, $PUD$, $GERD$, or the pancreas.

LUQ Splenic Pain

Pain caused by splenomegaly, splenic infarction, or splenic rupture.

Periumbilical Pain

Associated with early appendicitis or small bowel obstruction.

RLQ Gynecologic Pain

Pain from ovarian cysts, torsion, ectopic pregnancy, or $PID$.

Diffused Abdominal Pain

Pain linked to peritonitis, gastroenteritis, or $IBS$.

Colicky Pain

Intermittent, crescendo-decrescendo pain typical of renal or biliary colic.

Tearing Pain

Vascular pain characteristic of aortic dissection.

Projectile vomiting

Vomiting associated with pyloric stenosis or increased intracranial pressure.

Feculent vomiting

Vomiting material resembling feces, indicating distal intestinal obstruction.

Bile-stained vomiting

Vomiting originating distal to the ampulla of Vater.

Acute Diarrhea

Diarrhea lasting $<14\,\text{days}$.

Steatorrhea

Malabsorptive diarrhea characterized by fatty stools.

Nocturnal diarrhea

A sign of organic disease rather than $IBS$.

Obstipation

Severe or complete constipation with the inability to pass gas or stool.

Upper GI Bleed

Bleeding proximal to the ligament of Treitz, often presenting as hematemesis.

Hematochezia

The passage of bright red blood per rectum, indicating lower $GI$ bleeding.

Melena

Jet-black, tarry stools indicating altered blood from an upper $GI$ source.

Occult Bleed

Positive $FOBT/FIT$ with iron deficiency anemia.

Oropharyngeal dysphagia

Difficulty swallowing due to neurologic or muscular issues like stroke.

Odynophagia

Painful swallowing, often from infectious esophagitis.

Pre-hepatic Jaundice

Yellow discoloration from hemolysis with unconjugated hyperbilirubinemia.

Obstructive Jaundice

Greenish-yellow discoloration from bile flow obstruction.

Bilirubinuria

The presence of conjugated bilirubin in the urine, giving it a tea-colored appearance.

Transudative Ascites

Ascites with high $SAAG \ge 1.1$, often due to cirrhosis or heart failure.

Exudative Ascites

Ascites with low $SAAG < 1.1$, often due to infection or malignancy.

Murphy’s sign

Gasping for air on inspiration during gallbladder palpation, indicating acute cholecystitis.

Board-like rigidity

A sign of peritonitis and perforated viscus.

Sudden Onset

Symptoms developing in seconds to minutes, like pulmonary embolism.

Sub-acute Onset

Symptoms developing over $1-2\,\text{weeks}$.

Insidious Onset

Symptoms developing over months to years, like hypothyroidism.

Progressive Course

Symptoms that worsen steadily, such as metastatic cancer.

Stationary Course

Symptoms that remain unchanging over time.