APPROACH TO INTERNAL

MEDICINE CASES

Vince Edward C. Araneta, MD, FPAFP, CSPSH

 LEARNING OBJECTIVES

At the end of the unit topic, the students will be able to:

1. Review the basics of Physical Diagnosis, the Health History and Physical
Exam format

2. Practice a systematic approach in diagnosing cases in Internal Medicine

3. Demonstrate analytical and clinical reasoning skills in arriving at their

clinical impression and differential diagnoses.
 INTERNAL MEDICINE

• It is the medical specialty dealing with the prevention, diagnosis, and

treatment of internal diseases.

• Internists are physicians specializing in internal medicine, a discipline focused

on the care of adults emphasizing use of the best medical science available in
caring for patients in the context of thoughtful, meaningful doctor-patient
relationships
CPC PROPOSED FORMAT
• Identifying data
• Chief complaint
• History of present illness
• Past Medical and Surgical History
• Personal and Social History
• Pertinent positives/negatives of Medical History
• Review of Systems
• Vital signs and Physical Examination
CPC PROPOSED FORMAT
• Pertinent Physical examination findings
• Differential Diagnosis
• Diagnostic Work up
• Course in the ward/Clinical course
• Discussion
• Final diagnosis
 HISTORY TAKING PURPOSE
• Identify current problem and diagnosis
• Exclude life threatening condition
• Identify underlying medical problem
• Progression of a patient in the ward
• Response to treatment
• Any complication to the patient
HISTORY TAKING IN IM SALIENT POINTS

• The other elements that you must take but do not require you to present
unless needed:

▪ Occupation
▪ Address
▪ Date of admission
▪ Informant (only relevant in case where patient could not provide you the history in
cases of psychiatric disorders, altered mental status, loss of ability to provide
information)
HISTORY TAKING IN IM SALIENT POINTS

• Chief complaint might be a little tricky because a patient might present with
many complaints.

• Just remember that chief complaint is the MOST IMPORTANT REASON for
the patient to seek consult or come to the hospital.

• Limiting the chief complaint to not more than 3 symptoms may help you
focus to the most important and worrisome problem.
HISTORY OF PRESENT ILLNESS

• Making a provisional diagnosis

• Exclude the differential diagnosis

• Assess the severity of the disease

HISTORY OF PRESENT ILLNESS

• You should make a list of differential diagnosis based on the patient’s chief
complaint to give you an idea of what question you should ask in order to
obtain important information.

• The 7 attributes will help you ask the questions.

HISTORY OF PRESENT ILLNESS

• “LORD SANFARO”

• Location, Onset, Radiation, Duration, Severity, Aggravating Factor,

Nature, Frequency, Associated Symptoms, Relieving Factor, Offset.
PAST MEDICAL AND SURGICAL HISTORY

• Every disease uncovered need to have the following item:

❑Who and when was it diagnosed?
❑How was it diagnosed?
❑Currently on follow up at which care setting
❑What treatment the patient has undergone
❑When was the patient last admitted
❑Any known syndrome?
 DRUG HISTORY
• Ask for the patient if he has a medication box or list.

• It is important to elicit use of traditional medication.

• Any allergies to drug need also to be elicited.

• If patient using an inhaler, mention what type of inhaler and medication

(reliever vs. controller)
 DIET AND ALLERGIC HISTORY

• This is important. Most of the stable patient may consume normal

adult diet but in patient with specific illness, you need to pay
attention on this problem.
 FAMILY HISTORY

• Plays a big role if the disease has genetic element that can be
passed down.

• Take 3 generation family history. Spouse medical illness or any

diseases also in the household.

• Important as well to identify any relative who died before the age
45 as it may signify a heart problem.
SOCIAL HISTORY

• You can elaborate under a few category:

• Alcohol intake, smoking and sexual history (best to reserve
sensitive questions at the end of the interview)
• Financial history
• Social support
 REVIEW OF THE SYSTEM

• This is to ensure that you do not miss any symptom. Basically you
do not need to elicit all system but the system related to the
current presentation.

• It should be brief and close ended method.

 PHYSICAL EXAM
• After introducing yourself to your patient and obtaining a history of
both the present medical condition and the patient’s previous
medical history, you must decide what type of physical exam to
perform.

• The physical exam can help to augment the history you have
already obtained and can aid in developing a differential diagnosis
and treatment plan.
 PHYSICAL EXAM
• There are two basic versions of the physical exam to choose from:
the head-to-toe exam and the focused physical exam.

• As a general rule, the head-to-toe exam is reserved for trauma

patients when you aren’t sure what body system may be involved
based on the mechanism.
 PHYSICAL EXAM
• In contrast, the focused physical exam is limited to one or two body
systems or regions, and is based largely on the nature of the
patient’s complaint.

• Choose the focused physical exam when you already have a good
idea of what system may be involved in the patient’s present
illness.
 FIVE ASSESSMENT TIPS
1. KNOW WHEN TO USE THE FOCUSED EXAM
2. HAVE A DIFFERENTIAL DIAGNOSIS IN MIND
3. CONSIDER ADJACENT REGIONS
4. DOCUMENT POSITIVES AND NEGATIVES
5. EXPLAIN THE STEPS OF YOUR ASSESSMENT
General H&P Write Up Format
• I. History
• II. Physical Examination
• III. Labs and Studies
• IV. Problem List
• V. Assessment and Differential Diagnosis
• (mnemonic: CHOPPED MINTS)
• VI. Treatment Plan
Initial (Brainstorm) Problem List:

• This is the list you write on a note card to gather a complete list
in a random order.

• It’s an enumeration of all the abnormalities unveiled by the

history, physical exam, and studies.
Final (Official) Problem List:

• Reorganize the list into one that begins with the most severe
problem.

• One way to think about this is to consider what needs to be

corrected first so that you don’t kill the patient!
Assessment and Plan:

• The assessment is where you take each of the patient’s

problems and draw conclusions (with the possibility of grouping
problems together with a shared etiology).

• You should list justification for your most likely diagnosis.

Assessment and Plan:

• You should also explain why you are less suspicious of

alternative diagnoses.

• You should develop a diagnostic and therapeutic plan for the

patient, and your plan should incorporate acute and long‐ term
care of the patient’s most likely problem.
REFERENCES
• Bate’s Guide to History Taking and Physical Examination 12th Edition
• Harrison’s Principles of Internal Medicine 20th Edition
• https://m.oxfordmedicine.com/mobile/view/10.1093/med/97801908
62800.001.0001/med-9780190862800-chapter-1
• https://www.ems1.com/patient-assessment/articles/5-steps-to-an-
accurate-physical-exam-ZFOe5V8mCJRWIt1H/