PART ONE

SYMPTOMS AND SIGNS OF

VARIOUS DISEASES BY SYSTEMS

PROF. HYASINT JAKA

INTERNAL MEDICINE DEPARTMENT

Date: 11. Nov .2024 Monday

Time: 11.30-12.30
 6.18.7. COURSE CONTENT

Code Module name

LH TS AH IS PH TH Credits

MD301
Internal Medicine 44 7 3 8 10 72 7.2

Paediatrics and Child Health

MD302 44 7 4 8 10 73 7.3

Obstetrics & Gynaecology

MD303 38 7 4 6 13 68 6.8

General Surgery
MD304 48 7 2 10 12 79 7.9

Psychiatry
MD305 30 6 4 4 6 50 5.0

Total
204 34 17 36 51 342 34.2
MD301: INTERNAL MEDICINE

 Symptoms and signs of various diseases by

system
 History taking

 Introduction to physical examination

OBJECTIVES OF THE SESSION
At the end of the session a student will be
able to:
 Identify the symptoms and signs of various

diseases by systems
SYMPTOMS AND SIGNS OF VARIOUS
DISEASES BY SYSTEMS (1)
 Gastroenterology
 Neurology

 Geriatrics

 Nephrology

 Dermatology

 Rheumatology
SYMPTOMS AND SIGNS OF VARIOUS DISEASES BY SYSTEMS(2)

 Infectious diseases

 Cardiovascular Disease

 Respiratory disease

 Endocrinology
 Connective tissue disorders

 Haematology
PART TWO
HISTORY TAKING &
INTRODUCTION TO PHYSICAL EXAMINATION
OBJECTIVES OF THE SESSION
At the end of the session a student will be
able to:
 Demonstrate patient and doctor relationship
 Steps of making diagnosis
 Take history from an adult patient
 Make first and second summary
 Perform a physical examination (Respiratory,
abdominal, cardiovascular, and neurological
examination)
PATIENT DOCTOR RELATIONSHIP(1)

 Clinical methods are the skills Dr uses to

achieve the aim of excellence in clinical
practice
 Clinical methods are learned by a
combination of study and experience.
 The aim of consultation are the diagnosis and
understanding the nature of the patients
perception of the problem
PATIENT DOCTOR RELATIONSHIP (2)
 It requires knowledge of the disease and its
patterns of presentations and ability to
interpret signs and symptoms of the patient
 Appropriate skills are needed to elicit the
symptoms from the patients description and
conversation and signs by observation and
physical examination.
 You need knowledge, experience, and
confidence
PATIENT DOCTOR RELATIONSHIP (3)

 Every consultation should be taken seriously

and every patient should be evaluated
thoroughly
 Respect if the patient refuses to be examined
fully
STEPS IN MAKING DIAGNOSIS

1. Establish the clinical features by

 History
 Examination(clinical database)

2. Interpretation of the database in terms of

disordered function and potential causative
pathologies, whether physical, mental, social,
or combination

3. Make conclusion from your findings

HISTORY TAKING (ADULT PATIENT)(1)

QUESTION: Greet the patient , then ask the

patient:

What is the problem/the cause brought you to

Hospital? Can you describe it? Ask for
description of what has happened.
 Observe your patient
 Trust your patient and don’t interrupt
 Categorize the main symptoms and when making
notes, try to keep eye contact with the patient
HISTORY TAKING (ADULT PATIENT)(2)

Direct questions

Direct relevant questions are essential

especially when your patient did not describe
some key issues.
 Ask them when the patient has finished talking
 If you are not sure ask of something ask more
details
 Don’t use difficult words/vocabulary
 There are patients tend to exaggerate
HISTORY TAKING (ADULT PATIENT)(3)
 Stop yourself from showing an angry reaction
in your response when encounter angry,
distressed, tearful and difficult patients
 Speak to relatives and other close friends


HISTORY TAKING (ADULT PATIENT)(4)
6 Steps of history taking:
 Identification (Name, Age, address, marital

status, occupation, referral)

 Chief complaints

 History of presenting illness

 Review of other system

 Past medical/surgical history/menstrual

history
 Social and family history

SUMMARY 1
2. CHIEF COMPLAINTS(C.C)
 Symptoms always have physiological and
anatomical basis.
 If the patient had pain, fever and confusion you

should ask which one occurred first?

 Fever 1/12
 Headache 1/52 and
 confusion 1/7
3. HISTORY OF PRESENTING
ILLNESS(HPI)
Any pain:
 Duration &Mode of onset

 Site& radiation,

 Character

 severity and timing

 Aggravation/relieving factor

 Associated symptoms and factors

 Current treatment
HISTORY OF PRESENTING
ILLNESS(HPI)(2)
 If the patient describes having pain, a helpful
mnemonic to remember is
 SOCRATES:
S - site,
 O - onset(gradual/sudden),
 C - character,
 R - radiation,
 A - associations (other symptoms),
 T - timing/duration,
 E - exacerbating /alleviating factors and
 S – severity.
 Which medications was given on the course
of illness
4. REVIEW OF SYSTEMS (ROS)

This part refers to the part one discussed on

previous session on symptoms:
 General: weight, sleep, energy
 GIT: Abdominal Pain/distension, yellow
eyes(jaundice)Loss of appetite, nausea,
vomiting, painful or difficult in swallowing,
Water-brush, flatulence, Diarrhea, constipation,
pain, jaundice, pain, malena stool, blood in stool
REVIEW OF SYSTEMS (ROS)(2)
 Genital Urinary System:
Painful
micturation.urgency,hesitance,dribbling, low
urine output blood in urine
 Nervous System: Confusion, convulsions,

headche, gait& speech disorders and others

 Respiratory System:

 Cough, breathing, wheezing, chest pain

REVIEW OF SYSTEMS (ROS)(3)
 Cardiovascular System:
Dyspnoea, Pain or tightness, palpitations,
cough, edema,dizziness, paroxisimal nocturnal
dyspnoea
 Hematology system:

bleeding tendencies, lymph node enlargement

 5.PAST MEDICAL/SURGICAL HISTORY &
MENSTRUAL HISTORY
Menstrual, obstetrical & gynaecological
history
 Women

 When suspecting abdominal pain, endocrine

diseases, and genitourinary symptoms

 LNMP

 Age at which menses begun/menopause

 Regular cycles(frequency and length)

 Pregnancies and

children(alive/death/abortions)
 Contraceptives uses
5.PAST MEDICAL/SURGICAL
HISTORY/MENSTRUAL HISTORY (2)

Past medical History:

 Ask any serious illness or operation/admissions

 When

 Why

 Which age

 What was done

6. SOCIAL AND FAMILY HISTORY(1)

Social History:
 Patients habits(her work/sexual/drug abuse/husband

or wife; any travel history

 Smoking (how many a day and for how many years)

 Alcohol( type/amount per day /duration)

 CAGE:
 C=Have you ever felt you ought to Cut down your drinking?
 A=Have people Annoyed you by criticizing your drinking
 Have you ever feel Gilt about your dinking?
 Have you ever had a drink first thing in the morning to
steady your nerves or get rid of a hangover (Eye opener)?
6. SOCIAL AND FAMILY HISTORY(2)

The family History

 Parents and other siblings

 Any familial diseases

 Ask if similar disease have occurred in the

family
 Consider informations from grand father and

grand mother both sides

 DROW A FAMILY TREE
 CASE STUDY 1

CASE:

A male patient is 46 years old, from

Mwanza, alcoholic, married and has 4
children. She was diagnosed with chronic
renal failure in 2022. He is the second
born in a family of 5 children.

He is working in the Geita Gold mines for

4 yrs.
ASSIGNMENT
Currently, the patient complained of

Difficulty in breathing 2/52

Epigastric pain 5/7
Rt sided weakness 5/7

Task
 write the History of the presenting illness,
Review of the system, past history, and Family
social history and first summary
C. PHYSICAL EXAMINATION
ELICITING SIGNS
I. GENERAL EXAMINATIO
 HEENT -Head ( hair texture and
distribution)
 -Eyes (pallor, jaundice)
 -Ears ( discharge)
 -Throat ( lips, oral mucosae,
swelling)
 Skin ( lesions and their description)

 Neck palpate for any enlarged lymph nodes

i.e ( posterior/ anterior auricular,

submandibular, sub mental, cervical, and
supra clavicular nodes) while behind the
patient and any thyroid gland swelling.
GENERAL…..
 Inspect and palpate the spine and muscles
while behind the patient and rule out any
sacral edema.
 Move forward to examine the axillary

lymph nodes ( 5 groups; apical, anterior,

posterior, central and lateral group) the
epitrochlear lymph nodes in the cubital
region and the inguinal lymph nodes.
 Examine and feel for bilateral lower limb

pitting/ non pitting edema in the ankle, pre-

tibial and tibial region.
GENERAL EXAM..
 Finish with taking the vital signs,
particularly temperature in degrees
centigrade.
 Other vital signs like pulse rate, blood

pressure, and respiratory rate (can also be

recorded in their respective systems)

REPORTING
 When you are reporting the General

examination, report the positive signs first

then the important negatives of that system.
Vital signs should be reported here.
STEPS ON SYSTEMATIC EXAMINATION

 INSPECTION (use your eyes)

 PALPATION (use your hand to feel)

 PERCUSSION (use your hand to tap the

surface)

 AUSCULTATION (use your stethoscope)

NB: Neurological exam and cardiovascular

( some changes)
RESPIRATORY SYSTEM
 Points to note in General examination
 After obtaining consent, make sure the

patient’s chest is well exposed in a sitting

position.
 Breathlessness, Central/ peripheral cyanosis,

Clubbing, Intercostal recession, use of

accesory muscles for breathing, palpate for
lymph nodes.
CHEST…INSPECTION
 - Appearance of the chest ( scars, shape,
deformities)
 - Symmetry ( Anterior posterior diameter

with lateral diameter)

 - Chest expansion

 -Respiratory rate ( 14-16 breath/min)

CHEST…. PALPATION
 Position of the trachea
 Chest wall tenderness

 Cardiac impulse

 Chest expansion ( on the lower ribcage)

 Tactile vocal fremitus

CHEST…PERCUSSION
 The middle finger of the left hand is placed in
the intercostal space and the back of the
distal inter phalangeal joint is then struck
with the tip of the middle finger. The
movement is at the wrist joint rather than
the elbow joint.
 The normal tone is the Resonant note.

 Percuss on both sides of the anterior,

posterior, axillary regions and the supra

clavicular fossae over the apex of the lungs.
CHEST….AUSCULTATION
 Vesicular breath sounds
 Vocal fremitus

 Bronchial breath sounds ( consolidation,

airless)
 Added sounds
 Pleural friction rub ( pleurisy)

 Wheezes heard on expiration ( asthma/

COPD)
 Stridor heard on both inspi/expiratory

narrowing of the trachea or large airway

 Crackles ( coarse[bronchiectasis],

fine{intestitial fibrosis]
 ASSIGNMENT 2
 Assignment as part of continuous
assessment:

 Write short notes on the following;

 differences between COPD and asthma,

Bronchiectasis and interstisial fibrosis,

pleural effusion and pneumonia.
 PART THREE
P/ABDOMEN CARDIOVASCULAR,
AND NEUROLOGICAL
EXAMINATION
DIGESTIVE DISEASES EXAM
GENERAL EXAMINATION
 Head & mental state: Mental state, Jaundice,
Paleness
 parotid and lymph nodes, glands ,fetor

hepaticus, stomatitis, leucoplakia, ulcers,

telangiectasia, skin pigmentations, gingivitis,
bleeding, gum hypertrophy, candidiasis,
tongue atrophy.
 Examine for the scratch marks, wasting,

Hepatic flap, dupuytrens contractures,

clubbing, leuconychia, palmar erythema and
spider naevi, bruising. In the chest look for
gynecomastia, body hair.
ABDOMINAL EXAMINATION
 Inspection: Inspect for the abdominal distension,
scars, pigmentations, bruises, mass, visible
peristalisis and visible veins.
INSPECTION
PALPATION..
ABDOMINAL….
 Palpations: superficially for tenderness,
rigidity and deep palpation for spleen, liver,
kidney and fluid thrill. In case of any mass
in the abdomen, the site, tenderness, size,
surface, edges, consistency, mobility
pulsation and if you can go above the mass
should be examined.
 Percussion: Shifting dullness, the liver span,

and percussion of the spleen

 Auscultation: Examine the bowel sounds

and bruits
 Rectal examination: the examination

should be done to all patients over the age of

CAUSES OF
HEPATOSPLENOMEGALY

 Chronic liver diseases with portal

hypertension
 Hematological diseases (lymphoma,

leukemia, myeloproliferative diseases

 Infections like viral hepatitis, infectious

mononucleosis, cytomegalovirus
 Infiltration like amyloid and sarcoidosis.

 Connective tissue diseases example systemic

lupus erythematosus
CARDIOVASCULAR EXAM
GENERAL EXAM
 Difficulty in breathing, cyanosis, facial
swelling, finger clubbing(4 stages), splinter
hemorrhage, oslas node, lower limb edema
(pitting)

 Pulse rate and heart rate take the difference

(>10 is pulse deficit) (presence of pulse ,
symmetry,rate, rhythm, volume and
character)
JUGULAR VENOUS PRESSURE
 JVP= Reflects central venous/ right atria
pressure
REVISE CARDIAC CYCLE
LOCATIONS FOR AUSCULTATION
APEX
AUSCULTATION….
FINDINGS
 HEAVE
 THRILL

 S2 AND S2 SOUNDS

 PERICARDIAL RUB

 MURMUS (DIASTOLIC OR SYSTOLIC)

NEULOROGICAL
EXAMINATION
GENERAL EXAM
 Level of consciousness, Facial symmetry
 Glasgow coma scale with a total score of 15.

EYES 4 VERBAL 5 MOTOR 6

 Neck stiffness

 Kerning sign

 Brudzink sign
1. HIGHER CENTRES

 Orientation to people, place and time

 Speech ( Brocus area for motor function,

Wernikie’s area for sensory function)

 Memory (short and long term)
2. CRANIAL NERVES
 1. olfactory test both nostrils separately
 2. optic nerve - Acuity (Snells chart 3m,6m

away
 - Field ( Direct confrontation
test
 3. oculomotor (pupils constriction n

accomodation), 4. trochlear, 6. abducent –

Extra ocular muscles, eye movements SO4
AL3 LR6
 5. trigeminal opthalmic, maxillary (sensory)

mandibular ( mixed) muscles of mastication

 7 facial nerve (mixed) motor muscles of

facial expression, sensory anterior 2/3 of the

2. CRANIAL NERVES……
 vestibulo cochlear- hearing
 9. glossopharyngeal nerve ( posterior 1/3

of the tongue), gag reflex sensory

 10. vagus nerve- gag reflex motor, uvula

symmetry
 11. Spinal accessory nerve (Shrug the

shoulder)
 12. hypoglossal nerve ( tongue protrusion)
3.MOTOR EXAM
 Muscles which are supposed to be examined
are:
 upper limb: abductors, elbow flexors, wrist

extensors,
 Lower limb: hip flexors, knee extensors and

foot dorsal flexors (Kleyweg et al., 1991).

MOTOR PHYSIOLOGY
MUSCLE POWER GRADING
REPORTING…
4. SENSORY EXAM
SENSORY…
Test for sensation to:
 Lateral spinal thalamic tracts (Pain & and

temperature) …. Test by applying Pinprick &

hot objects
 Anterior spinothalamic tracts ( crude touch &

pressure)…
 Posterior column: vibration, joint position

sense
5. COORDINATION
 6. Co ordination
 Upper limbs- Finger to nose test,

dysdiochokinesis
 Lower limbs – heel sheen test


6. GAIT
 High stepping gait- peripheral neuropathy
 Swinging outward gait- hemiplegic

 Wide-based gait- cerebellar lesion

 Shuffling gait- parkinsonism

D. SECOND SUMMARY
Should be 7-8 lines which consist of positive
and important negatives which identified
from history (Disease, risk factors and
complications) and physical exam
MARKING A DIAGNOSIS FROM SIGNS
AND SYMPTOMS
 Taking an appropriate history of symptoms
and collecting relevant data
 Make a first summary

 Physical examination (General and

systemic)
 Make a second summary

 Generating a provisional and

differential diagnosis
 Investigation

 Treatment