Principles of Medicine

1. PRINCIPLES
OF MEDICINE

2. APPROACH TO
EVALUATION OF
PATIENT

3. WHAT IS
EXPECTED OF
THE DOCTOR?

4. MEDICINE IS BOTH
SCIENCE AND ART
 SCIENCE
- technology based on science is the
foundation for solution to clinical
problems
- advances in biochemical methodology
and in biophysical imaging techniques
- innovations in therapeutic maneuvers

5.  ART
- ability to extract contradictory physical signs
- ability to discern and interpret laboratory data
- to know whether to treat or watch
- to determine when to pursue a clinical clue or
when to dismiss
- to decide which is of greater risk: treatment
or disease
 This combination of medical knowledge,
intuition and judgment is the art of medicine

6. “ Tact, sympathy and understanding are
expected of the physician, for the
patient is no mere collection of
symptoms, signs, disordered functions,
damaged organs and disturbed
emotions. He is human, fearful and
hopeful seeking relief, help and
reassurance.”
- Harrison’s Principle of Medicine

7. PATIENT – PHYSICIAN /
DOCTOR RELATIONSHIP
 Individuals whose problems often
transcends their complaints
 Whatever the patient’s attitude, the
physician needs to consider the
terrain in which an illness occurs – family and
social background
 Approach patients not as “cases” or “diseases”
 Primary objective is to discover the root of a
patient’s concern and do something about it

8. HOW TO
EVALUATE
I. PATIENT HISTORY
• “build” a history rather
than “take” one
OBJECTIVES:
• identify problems
• to establish a sense of the patient’s
reliability
• to consider the potential for intentional or
unintentional suppression or underreporting of
certain experiences

9. Setting for the interview:
 Make everyone as comfortable as
possible
 Make the patient your focal point
 Maintain eye contact and a
conversational tone of voice

10. STRUCTURE OF THE
HISTORY
1. General data
2. Chief complaint
3. History of present illness
4. Past medical history
5. Family history
6. Personal and social history
7. Review of systems

11.  GENERAL DATA
- identifies the name, date, age, gender,
race, occupation
 CHIEF COMPLAINT
- brief statement of the reason the
patient is seeking care
- direct quotes are helpful

12. History of Present
Illness (HPI)
a complete HPI will include
the following:
• chronologic ordering of
events
• state of health just before the onset of the
present problem
• complete description of the first symptoms
• possible exposure to infection, toxic
agents or other environmental hazards

13. • description of a typical attack, including
its persistence
• impact of the illness on the patient’s
usual lifestyle
• medications current and recent including
dosage as well as home remedies

14. Past Medical History
baseline for assessing the present complaint.
• general health and strength
• childhood illnesses: measles, mumps,
chickenpox, etc.
• major adult illnesses: TB, hepatitis,
diabetes, HPN, MI, any surgical or non-
surgical hospitalization
• immunizations

15. • serious injuries
• medications
• allergies and the nature of reactions
especially to medications
• transfusions: reactions, date and number
of units transfused

16. Family History
• blood relatives in the immediate or
extended family with illnesses with
features similar to patient’s
• include in the list of concerns: heart
disease, high blood, pressure, diabetes,
asthma, epilepsy, allergy, thyroid
disease, etc.
• history of cancer

17. Personal and Social History
• PERSONAL STATUS: birthplace, where
raised, home environment, education,
position in family, marital status,
hobbies and interests, sources of stress
and strain
• HABITS: nutrition and diet, regularity
and patterns of eating and sleeping,
quantity of coffee, tea, tobacco, alcohol,
extent of cigarette use reported in “pack-
years”

18. • SEXUAL HISTORY
• OCCUPATION: description and
duration of employment; exposures to
toxins (e.g. lead, arsenic, asbestos)
• RELIGIOUS AND CULTURAL
PREFERENCES

19. Review of Systems
Identify the presence or absence of health-related
issues in each body system.
• general constitutional symptoms
• head and neck
• lymph nodes: enlargement, tenderness
• chest and lungs: pain in respiration, dyspnea,
wheeze, cyanosis
• breasts: development, pain, tenderness,
discharge, lumps
• heart & blood vessels
• peripheral vasculature: thrombosis,
thrombophlebitis, claudication

20. • GIT: heartburn, nausea, vomiting,
hematemesis, regularity of bowels,
constipation, diarrhea, flatulence,
hemorrhoids
• musculoskeletal: joint stiffness, pain,
restriction of motion, swelling, redness,
bone deformity
• neurologic: syncope, seizures, weakness
or paralysis, tremors, loss of memory
• psychiatric: depression, mood changes,
difficulty concentrating, anxiety,
agitation, suicidal thoughts

21. • female: menarche, pregnancies
• males: puberty onset, erectile
dysfunctions, problem in emissions,
testicular pain, libido, infertility

22. TYPES OF HISTORIES
1. Complete History – makes you thoroughly
familiar with the patient
- most often recorded the first time you see
the patient.
2. Inventory History – related to but does not
replace the complete history
- it touches on the major points without
going into detail
3. Problem (or focused) History – taken when
the problem is acute possibly life threatening
4. Interim History – chronicles the events that
have occurred since your last meeting with
the patient

23. • The results should be recorded at the time they
are elicited
• Repeat the physical examination as frequently
as the clinical situation warrants
II. PHYSICAL EXAMINATION
• Physical signs are the objective
and verifiable marks of disease
and represent solid, indisputable
facts
• Physical examination should be
performed methodically and
thoroughly

24. PARTS OF PHYSICAL
EXAMINATIONS
1. Measurement of Vital Signs: baseline
indicators of a patient’s health status
• PULSE – may be palpated in several
areas; however, the radial pulse is
most often used
- note their rhythm, amplitude while
counting

25. • RESPIRATION – observe the rise and
fall of the chest
- Count the respiratory cycles / minute
- Note the depth of respiration and
whether the patient uses accessory
muscles
• BLOOD PRESSURE
• TEMPERATURE – oral, rectal,
axillary and tympanic
- kinds: electronic and tympanic; infrared
axillary thermometers for neonates

26. • OXYGEN SATURATION – estimation
of arterial oxygen saturation
- A healthy person with no anemia or lung
disease has O2 sat. of 97% - 99%
• PAIN – because of its ubiquitous nature,
its universality as a distress signal, it is
more and more often being recognized
as part of the vital sign.

27. 2. Physical Assessment
• INSPECTION
- process of observation
- what is the patient’s gait
- is eye contact made
- is the patient dressed appropriately
for the weather
- color and moisture of the skin

28. • PALPATION
- involves the use of the hands and
fingers to gather information through
the sense of touch
- ulnar surface of the hand and fingers
is the most sensitive area for
distinguishing vibration
- dorsal surface of the hand is best for
estimating temperature

29. • PERCUSSION
- involves striking one object against
another to produce vibration and
subsequent sound waves
- the more dense the medium, the
quieter is the percussion tone
- percussion over air is loud, over fluid
less loud and over solid areas soft

30. PERCUSSION TONES
TONE
Tympanic
Hyperresonant
Resonant
Dull
Flat
INTENSITY
Loud
Very loud
Loud
Soft to Moderate
Soft
PITCH
High
Low
Low
Moderate to High
High
QUALITY
Drumlike
Boomlike
Hollow
Thudlike
Very dull
Example
where heard
Gastric
Bubble
Emphysematous
Lung
Healthy
Lung
Liver
Over
Muscle

31. CORE VALUES
1. Respect the patient.
2. Achieve the complimentary forces of
competence and compassion.
3. The art and skill essential to history
taking and physical examination are the
bedrock of care; technologic resources are
complements
4. The history and physical examination are
inseparable – they are one.
5. The computer cannot replace you, it is
what you do that builds a trusting, fruitful
relationship with the patient.
6. The relationship can be indescribably
rewarding.

32. THANK YOU!!!