AbouttheAuthor
MANUELASTOICESCU
ConsultantInternalMedicinedoctor,PhD,AssistantProfessoratUniversityofOradea,FacultyofMedicineand Pharmacy MedicalDisciplinesDepartment, Romania
Education:Philology-HistoryHighSchool,Oradea,Chemistry Biology fieldHighschooldiploma
UniversityofMedicineandPharmacy“IuliuHatieganu”Cluj-NapocaFacultyofMedicineandPharmacy Romania-PhysicianUniversityofMedicineandPharmacy“IuliuHatieganu”Cluj-NapocaRomania-ResidencyInternalMedicine5years-Certificate-InternalMedicineSpecialistFeb1996 Oct2001
Pe ´ dagogietrainingdepartment,Cluj Napoca,Romania Psychope ´ dagogieCertificate. CertificateofEnglishlanguageproficiency
Residency InternalMedicineClujNapoca UniversityofMedicineandPharmacy”IuliuHatieganu” Cluj-NapocaRomania,DepartmentofMedicalSemiology,MedicalIIClinic ClujNapoca CityInternalMedicine Department,MedicalIIClinicClujNapocaCity.
AssistantProfessorattheUniversityofOradea MedicalSemiologyDepartment 2002 present.
ConsultantInternalmedicinedoctor 2006
Ph.D.thesis:"Hypertensionintheyoungpeople-clinicalfeatures", -publicationdateJul28,2010publicationdescriptionObtainedthetitleofdoctorofmedicineaccordingtothe OrderoftheMinisterofEducation,ResearchNr.4542on28.07.2010.publicationdescriptionPh.D.Thesis: "Hypertensionintheyoungpeople-clinicalfeatures",originalwork,Obtainedthetitleofdoctorofmedicine accordingtotheOrderoftheMinisterofEducation,Research,YouthandSportsNr.4542on28.07.2010.PhD
ConsultantInternalMedicinedoctor.PhD,AssistantProfessor,UniversityofOradea,FacultyofMedicineand Pharmacy,MedicalDisciplinesDepartment
DatesEmployed:Jan2001 Present2019;EmploymentDuration:18years8months;Location:Oradea-Romania
Shehasbeenaninvitedspeakerat56InternationalConferencesinUSandEurope,isOrganizingCommittee Member(OCM)inInternationalConferencesinUSandEurope,published20articlesinprestigiousjournalsinUS andisEditorialBoardMemberintwoprestigiousISSNjournalsinUS: JournalofDevelopingDrugs and Surgery: CurrentResearch.
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TheHistoryofthePatient
Thehistoryofthepatientrepresentsthefirstcontactanddiscussionofthephysicianwiththepatientandisvery important.Takingasuperficialhistorybecauseofalackoftimeisnotexcusablebecauseitcangeneratemistakes.A seriousandcarefulhistoryofthepatientwillaidinasuccessfuldiagnosis.Wemustalwaysaskafewtypicalquestions,whicharepresentednext.
Look at me how carefully I am talking to the patient and take notes!
InthefirstinstanceIwillaskaboutpersonalinformation:name,age,gender.
1.PERSONALDATA
Whatisyourname?
Howoldareyou?
Iobserveifthepatientisamanorawoman,becauseIknowthatsomediseasesaremorecommoninwomenand otherdiseasesappearmoreofteninmen.
2.PLACEOFBIRTHANDHOME(ADDRESS)
Wherewereyouborn? Wheredoyoulive?
Whatisyouraddress?Whatisyourphonenumber?
3.ALLERGY?
Iwillaskmypatientifheorsheisallergictoanydrugs. Iftheanswerisyes,IwillaskwhatdrugshavecausedallergyinthepastandIwillmarkitwithredcolorinthe personalpapersofthepatient.Veryimportant!Theadministrationofthesedrugsmusttobeavoidedtoprevent anaphylacticshock,Quinckeedema,orsuddendeath.
Forexample,Inoticed:
allergytoaspirin
allergytopenicillin
So,Iwillnevergivethispatientaspirinorpenicillin!
4.THEREASONFORHOSPITALIZATION
Thereasonforhospitalizationrepresentsthemainsymptomsaboutwhichthepatientcameforconsultation. Thereisalwaysamajorsymptom;thisistheleadingsymptom.Thepatientmayalsopresentwithothersymptoms. Thesemustbeputinorderperanatomyandsystem.
ExampleNo.1
- Syncopeistheleadingsymptom
- Dyspnea
- Chestpain
- Palpitations
ExampleNo.2
Hematuriaistheleadingsymptom
- Pollakiuria
- Dysuria
- Chills
- Fever
ExampleNo.3
- Hemoptysisistheleadingsymptom
- Dyspnea
- Chills
- Fever
ExampleNo.4
- Abdominalpain
- Nausea
- Vomiting
5.THEHISTORYOFTHECURRENTDISEASE
Inthissectionweneedtodescribeindetailthehistoryofthecurrentdiseaseofthepatient.First,weneedto specify:
Howdidthediseasestart?
Wasitsuddenorinsidious?
Howlongagodiditbegin?
Whatarethesymptoms?
Whatwasthepatient’sattitudetowardthedisease?
Hasthepatientpresentedhim-orherselftoadoctororstayedathome?
Didthepatientbeginmedicaltreatmentontheadviceofaphysicianordidheorshebegintreatmentalone?
Ordidthepatientnotfollowanytreatment?
Didheorshestartadrugtreatmentthathadaninfluenceonthedisease?
Wasthereimprovement,aggravation,oranyinfluence?
Isthisthefirstepisodeorhavetherebeenothersimilarepisodesinthepast?
Inthissectionitisnecessarytodescribeindetailtheactualhistoryofthepatientasregardswhatheorsheisbeing hospitalizedfor,ascompleteaspossible.
Ifthepatientcurrentlyhasmorethanonedisease,wehavetotakeahistoryofeachone,followingthesameelementspresentedbefore.
6.FAMILYHISTORY
Inthissectionweneedtodescribewhatdiseasesareinthepatient’sfamily.Whatdiseaseshavethemother,father, brothers,sistershad?Thisisbecausethereexistsariskforgenetictransmission,forexample,arterialhypertension, diabetesmellitus,cancersatvariouslocations,andgeneticdiseaseswithdominantorrecessivetransmission.These diseasesareimportantbecausethepatenthasageneticriskfordevelopingthesediseasesatanypointintime.
7.PERSONALPATHOLOGICALHISTORY
Inthissectionweneedtodescribeallthediseasesthatthepatienthadinthepastandalsosurgicalprocedures,in chronologicalorder,exceptforthecurrentillness.
8.PERSONALPHYSIOLOGICALANTECEDENTS
Inthissectionweneedtodescribeallthephysiologicalantecedentsinwomenregardingmenstrualcyclesand pregnancies.
Atwhatagedidthefirstcycle(menarche)occur?
Normalageisbetween12and14years.
Havemenstrualcyclesbeenregular?Oncepermonth?
Normalcycleis28days.
Howmanydaysdoestheflowtake?
Normalisbetween3and5days.
Howdoyouestimatetheamountofbloodlostduringthemenstrualcycle?
Normalisbetween300and500mLofblood.
Haveyoueverhadcycleslongerthan10days?
Thisiscalledmenorrhagia.Thisisspecificforuterinefibroids.
Haveyoueverhadbleedingbetweenmenstrualcycles?
Thisiscalledmetrorrhagia.Thisisspecificforuterinefibroids
Haveyouhadabnormalmenstrualcycleswithaquantitymorethan500mL?
Thisiscalledhypermenorrhea.Thisisspecificforuterinefibroids
Haveyouhadabnormalmenstrualcycleswithincreasedquantityandwithbloodclotsandprolongeddurationof morethan5days?
Thisisspecificforuterinefibroids.
Howdoyoudescribethecoloroftheblood?
Normalisfreshred.
Haveyoueverhadadarkbleedingthatlookslikecoffeeorcoffeegrounds?
Thisisspecificforuterinecarcinoma.
Haveyoueverhadbleedinglikejuiceinwhichmeatwaswashed? Thisisspecificforuterinecarcinoma.
Areyouinmenopause?Atwhatagedidmenopausebegin?
Normalageformenopauseisbetween45and50years.
Areyouinearlymenopauseorartificialmenopauseafterovariectomy,radiotherapy,orchemotherapy?Thisisa riskfactorforischemicheartdisease,becausethewomanhaslosttheprotectionofestrogenhormonesagainst atherosclerosis.
Haveyouhadbleedinginmenopause? Thisisspecificforuterinecarcinoma.
Haveyoubeenpregnant,andhowmanytimes?
Wasthedeliveryatnormaltime,9months,orearlyorlate?
Haveyouhadanyabortions,andhowmany? Weretheabortionsspontaneousorinduced? Whatdidyourbabiesweighafterdelivery?
Normalweightisbetween3and4kg.
Ababybiggerthan4kgisa“bigbaby”orhasmacrosomiaandrepresentsariskfactorfordiabetesmellitusofthe motherinthefuture.
Ababylessthan3kgispremature.
9.LIFECONDITIONS
Thelifeconditionsofthepatientareveryimportant. Especiallyimportantarethehousingconditions,eating,andtoxicconsumptions.
A.Thehousingconditions
Thehousingconditionsareveryimportantbecausepeoplespendmostoftheirtimeathome.Itisimportantto knowhowmanypersonsliveinaroomandhowmanyroomsareinthehouse.Theinfectiouscontagiousdiseases suchasviruses,pneumonia,andtuberculosisaretransmittedwhenthepeoplecohabit.
Anotherimportantconditionisthecleanlinessofthehouse.Isitacleanhouseornot?Isitanovercrowdedhouse ornot?Arepeoplelivingtogetherwithcats,dogs,aparrot?Becauseanimalscantransmitdiseasestothepersons wholivewiththeanimals.
Roomairconditioningisariskfactorforrespiratorytractinfectionsandallergiesaswell.
B.Eating
Aperson’sdietisveryimportant.Itmustbenutritionallybalancedinaccordancewiththephysicaleffort.A normaldietshouldbevariedandbalancedinthecontentofproteins,carbohydrates,lipids,andvitamins.Aunilateraldietexcessiveinglucosesandcarbohydratesrepresentsariskfactorfordiabetesmellitus.Aunilateraldiet increasedinanimallipidsrepresentsariskfactorfordyslipidemia,atherosclerosis,ischemicheartdiseases,angina pectoris,andheartattack.
Also,excesscaloriestogetherwithsedentaryhabitsareariskfactorforobesity,highbloodpressure,anddiabetes mellitus.Deficiencyindietleadstoweightloss.
Failuretoeatregularmealsisariskfactorfortheoccurrenceofgastritisandgastricorduodenalulcers.
C.Toxicconsumptions
Inthissection,thepatientshouldbeaskedaboutthetoxicconsumptionofalcohol,smoking,coffee,anddrugs.
Alcoholconsumption
Intermsofalcoholconsumptionthepatientshouldbeaskedhowoftenheorsheconsumesalcohol:everydayor occasionally?Thetruthisthatalcoholisoftennotrecognizedbythepersonconcerned;usuallythefamilyistheone whoinformsthedoctoraboutalcoholconsumption.
Itisimportanttoknowtheamountconsumedandwhatkindofalcoholicbeveragesareconsumed,hardalcohol orlightalcohol,likebeerorwine?
Personswithchronicalcoholconsumptionhaverisksformanydiseases,suchaschronicalcoholichepatitis,liver cirrhosis,gastricorduodenalulcers,mentalillnessessuchasalcoholicdementia,andothers.
Smoking
Smokingisanotherriskfactorformanydiseases.Itisreallyimportanttoaskthepatientatwhatageheorshe begansmoking(howlong?).Whattypeofcigarette,withfilterorwithoutfilter?Howoften?Daily?Howmanycigarettesperday?Pipesmokersareatriskforlipcancer.
Smokingisanimportantriskfactorforcardiovasculardiseasessuchasischemicheartdisease,anginapectoris, acutemyocardialinfarction,cardiacarrhythmias,andsuddendeath;respiratorydiseasessuchaschronictobacco bronchitis,COPD,andbronchus pulmonarycancer;anddigestivediseasessuchasgastriculcerorduodenalulcer.
Wemustconsiderthestateofthepassivesmoker.Thisisrepresentedbypeople innocentvictims who passivelyinhalecigarettesmokebecausetheyarearoundapersonwhosmokes.Themostinnocentvictimsarechildren.Passivesmokersareatriskfortheaforementioneddiseasesinapercentagealmostasgreatasactivesmokers! Theyoungertheageatwhichsmokingstarted,andthehigherthenumberofcigarettesaday,thehigheristherisk forthediseasesmentioned.
Coffee
Coffeeconsumptionhasbeenknownfromtheearliesttimes.Thissmalldailyviceispracticedaroundtheworld. Abuseofcoffeeconsumptioncancausepalpitations,tachycardia,irritability,nervousness,andinsomnia.Itisalsoa riskfactorfortheoccurrenceofhighbloodpressureanddangerousarrhythmias.
Drugs
Drugconsumptionrepresentsariskfactorfordangerousarrhythmias,myocardialinfarctionatayoungage,and suddendeath.Bacterialendocarditisrepresentsanotherriskafterdrugconsumption.Drugconsumptionmusttobe stopped,especiallybecausemanyvictimsareyoungpeople.
10.WORKINGCONDITIONS
Workingconditionsrepresentanotherimportantpartofthehistoryofthepatient.Manyriskfactorsarepresentat theworkplace.Forthisreasonitisveryimportanttoaskandtoknowtheprofessionofthepatient.Howmanyhours areworkedperday?Riskfactorsfromworkincludedust,humidity,andnoise.Doesthepatientworkduringthe night?Worksupplementaryhours?Howarehisorherrelationshipswithcolleagues?Relationshipwiththeboss? Everythingisimportant!
11.GENERALMANIFESTATIONS
Thehistoryofthepatientfinisheswithafewimportantquestionsregardinggeneralmanifestationssuchas:
Appetite
Theweightcurve
- increasing?
- decreasing?
- stationary?
Thestool
Theurine
Frequencyofurinationin24h?
Diuresis?
Sleep
Doyousleepduringthenight?
Doyouhaveinsomnia?
Thehistoryofthepatientisfinishedwiththesegeneralmanifestationquestions.
I'm really happy!
We're done with patient history!
“Eachpatientisunique.Wehavetopracticeapersonalizedmedicine”
“Semiologyisawindowthatopenstotheuniverseofinternalmedicine”
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Objectiveexaminationofthepatientisveryimportant.Thecorrelationbetweensymptomsafterpatienthistoryis takenandthesignsfromtheobjectiveexaminationperformedhelpedthedoctortoestablishtheclinicaldiagnosisof thepatient.
Toperformtheobjectiveexamination,thedoctorusesfourimportantmethodsthatweshalldiscuss:inspection, palpation,percussion,andauscultation.
Ineachchapter,thesefourmethodswillbeusedtostudytherespiratory,renal,cardiovascular,digestive,and bloodsystemsaswellasthemedicalsemiology.
1.1Inspection
Inspectionisthemethodbywhichthedoctorobservesthepatientusingonlyhiseyes,withouttouchingthepatient,andheiscarefulifhediscoversimportantsigns.Thecorrectinspectionofthebodymusttobegeneralizedby strippingtheclothesoffthepatientandshouldbeconductedinnaturallight.Forexample,intheimagebelow,what doyouobserveatsimpleinspection?
Wecanseeaswellingintheleftinguinalarea.Thereisanenlargedlymphnodeintheinguinalareathatoccurred inthecontextofavenerealdisease. Whatdoyouobserveatinspectionintheimagebelow?
Aswellingisobservedbehindtherightear.Thereisanenlargedlymphnodeinthispatientwithacutetonsillitis. Inthepreviousimages,youmustconsidertheexampleofpatientswhohaveaswellingareaindifferentregions, whereenlargedlymphnodesappearedinthecontextofdifferentdiseases.Soanexampleisthediscoveryof enlargedlymphnodesatpatientinspection,asshown,butofcoursewecanalsoobservemanyotherdifferent andvarioussignsattheinspectionoftheskin,eyes,oralcavity,analarea,andsoon.
Itisquiteimportantnottoignorehiddenareassuchastheoralcavityorgenitalareasasthevulva,vagina,and analareas.Thoughsomepatientsmaybeundulymodestaboutsuchobservations,theymustbeinformedthatin thesehiddenareastherecanbeveryimportantsignsthatcanbediscoveredatsimpleinspectionandpossibly savetheirlives.
1.2Palpation
Palpationisthesecondimportantmethodinobjectiveexamination.Inthismoment,thedoctoruseshishandto palpateandfeeltheformationorareatopalpate.Forexample,thedoctorcanusetwofingerstopalpate;intheimage below,wecanseehowthedoctorpalpatesthelymphnodesintheleftinguinalareaofthepreviouspatientwhohas venerealdisease.
Afterpalpation,thedoctorcanappreciatetheconsistenceofthelymphnodes:softorhard.Thisisveryimportant becausesoftlymphnodessuggestinflammatoryetiology,whereaslymphnodesthatarehardlikeastonesuggest malignantetiology.
Inaddition,itispossibletofeelthecontour,whethertheareaisregularorirregular,sensibility,temperatureofthe skin,andmanyotherimportantsigns.
Intheimagebelow,thedoctorpalpateswithtwofingersunderthemandibleontherightside,wherehetriesto feelandpalpatethelymphnodes.Thismethodusestwofingers,andthedoctorperformsaneasymovementof rotation.
Palpationofleftinguinallymphnodes
Inthiscase,thepatientinthepreviouspicturehadacutetonsillitiswithsecondarypusappearingatinflammatory lymphnodesunderthemandible.Forthisreason,intheimageabovethedoctorpalpatestheenlargedlymphnodes underthemandible,withdimensions2x1.5cm,withregularborders,round,softconsistency,mobility,andsensibilityatpalpation.Theserepresentthetypicalfeaturesofinflammatorylymphnodes.
Thecorrectmethodofpalpationofenlargedlymphnodesispresentedintheimageabove,withtwofingersand thedoctoreffectingsimple,easyrotatormovementstofeelallthefeaturesmentionedearlier:shape,dimensions, contour,consistence,mobility,andsensibility.Itisimportanttoknowallthesecharacteristicsbecausethesehelp ustoestablishtheetiologyofenlargedlymphnodes.
PalpationofthePrecordialArea Thrill
Heartfremitus(thrill)isfeltbypalpationwiththewholepalmontheprecordialareaandthechest.Intheimage above,weseethemethodofpalpationoftheprecordialareawiththewholepalmonthechestofthepatient,where thedoctortriestofeelthrill thisisthepalpationofvibrationsofincreasedintensityofheartmurmur,VorVI typicalinaorticstenosis becauseinthisvalve,diseaseappearstoincreasetheintensityofheartmurmurfrom thecardiovascularpathology.
Anotherimportantelementofthepalpationmethodiswhenthedoctorfeelsthrill thepalpationofvibrationsof increasedintensityofheartmurmurasinaorticstenosis.Themethodofpalpationoftheprecordialareaforthrillis shownintheimageabove.
Inthenextimages,wewillseethemethodofpalpationoftheposteriorthorax,wherethepatientisaskedtosay “99”or“33”whilethedoctorfeels,underthepalms,thevocalcordvibrationstransmittedtothechestwallofthe thorax.Thisistactilefremitus.
Palpationofdeepabdominalorgansisanotheradvantageofthepalpationmethod.Intheimagebelow,weseethe methodofpalpationofthespleen,forexample:
