Principles of Diagnosis

The determination of what is wrong with a patient is called a diagnosis. Any disruption of normal body function is regarded as a disease. Structural changes associated with a disease are called lesions. Diseases may be classified into two broad categories:

organic: disease that has identifiable lesions.
functional: disease with no lesions.

The term pathology refers to the study of disease. A pathologist specializes in the diagnosis and classification of diseases. Etiology is the study of the causes of disease. Pathogenesis refers to how a disease progresses and develops. A pathogen is something that causes disease such as a virus or bacteria.

Diseases are often classified into the following general categories based on lesions or pathogenesis:

congenital & hereditary - results from developmental disturbances and may be genetic, intrauterine injuries, or a combination of these factors.
inflammatory - results from reaction to injurious agent, such as bacteria or virus, by inflammation or, may result from antibodies against own tissues (autoimmune disease).
degenerative - results from degeneration of tissues of the body. Examples include aging, arthritis, atherosclerosis.
metabolic - results from a disturbance of a metabolic process in the body. Examples include, diabetes, hypothyroidism, various hormonal disorders, and electrolyte imbalances.
neoplastic - results from abnormal cell growth and leads to formation of benign or malignant tumors.

Subjective symptoms of a disease are described as symptoms. They are what is reported to the clinician by the patient, for example, "I feel... hot, nauseated, pain, dizzy", etc. Objective findings by the clinician are termed signs. They are measurable findings such as temperature, blood pressure, posture, gait, behavior, and appearance. Once a diagnosis is made, a prognosis may be given which is a prediction of the eventual outcome of the disease. It may be given as excellent, good, fair, poor, or sometimes as a percentage based on research statistics.

HISTORY & PHYSICAL

H & P

Name:

Date:

DOB:

Age:

Race:

Sex:

Occupation:

Religion:

Birthplace:

Source of Referral:

Reason for Referral:

Source of History:

Reliability of Historian:

CHIEF COMPLAINT:

HISTORY of PRESENT ILLNESS:

PAST MEDICAL HISTORY:

General:

Childhood illnesses:

Adult illnesses:

Injuries:

Hospitalizations:

Surgeries:

Meds:

Allergies:

Immunizations:

Childhood B, MMR, DPT

Adult - Hepatitis B? Tetanus?, PPD? Hx of CXR?

Sleep - onset? maintenance? waking? snoring? sleepwalking? behaviors?

Nutrition - typical meals/times, cravings, recent weight loss or gain, appetite

SOCIAL HISTORY:

Marital Status:

Children:

Present Occupation:

Education:

Religious practices:

Hobbies:

Sexual History:

Water Supply:

Alcohol Consumption:

Drug Use:

Military Background:

Childhood:

Psychological:

Social Interaction:

Previous Employment History:

Occupational Exposures:

FAMILY HISTORY:

REVIEW OF SYSTEMS:

GENERAL: appropriate to stated age, sex and gender, changes in health lifestyle, appetite, chills, night seats or weight, leathery, malaise, fatigue.

SKIN: rashes, pruritis, jaundice, bruising, skin cancer, mole changes, changes in hair or nails or lesions, skin is intake an heals well.

HEAD: trauma, lumps, masses, tenderness, dizziness, H/A, syncope or seizures, face or scalp rashes.

EYES: photophobia, visual field changes, blurring, star burs, diplopia, spots, itching, discharge, excessive tearing, dry eyes, cataracts, glaucoma, current vision/uncorrected corrected?/last eye exam/vision is ? In R/L/both eyes with contact lenses or glasses?

EARS: hearing changes, tinnitus, pain, discharge, vertigo, OM?, hearing.

NOSE: discomfort, nosebleeds, frequent colds, nasal stuffiness, discharge, itching, hay fever, or sinus troubles.

MOUTH & THROAT: gum bleeding or swelling, oral pain, frequent sore throat, vocal changes or tooth loss, last dental exam.

NECK: pain, discomfort, lumps/swelling, diff. Swallowing or moving neck.

BREAST: lumps, pain, or nipple discharge, last breast exam, last mammogram, findings on self-breast exams?

RESPIRATORY: wheezing, dyspnea, coughing, hemoptosis, asthma, TB, bronchitis, pneumonia, emphysema or shortness of breath, last CXR?

CARDIAC: chest pain, dizziness, orthopnea, edema, palpitations, weakness on exertion, known heart murmurs, HTN, last ECG.

CIRCULATORY: numbness, tingling, cold extremities, edema, wound healing.

LYMPHATICS: adenopathy, recurrent neck, axillary or groin tenderness.

GASTROINTESTINAL: abdominal pain, change in bowel habits, jaundice, hepatitis, gallstones, dysphagia, adynophagia, heartburn, hemorrhoids, tenesmus, constipation, diarrhea, nausea or vomiting, appetite, last BM frequency, frank blood/tarry stools.

URINARY: burning or pain upon urination, nocturia, polyuria, hematuria, incontinence, infections, kidney stones.

GENITAL: discharge, sores, pain or masses, Hx STDs.

GYNECOLOGICAL: age of menarche, regularity of menses, G0P000,

(see OB pg. For G/P status), sexually at?, ?# partners.

Last OB/GYN/PAP smear -/+. Gynecological or surgical procedures.

MUSCULOSKELETAL: redness, swelling, warmth, pain, discomfort, ROM.

NEUROLOGICAL: neurological deficit, vertigo, syncope, seizure activity, motor/sensory deficit, memory loss, LOC, gait change, speech, coordination.

ENDOCRINE: polydypsia, polyuria, polyphagia, temperature intolerance, glycosuria, hormone therapy, changes in hair, energy levels, sweat, skin.

HEMATOLOGICAL: anemia, bleeding tendency, easy bruising, lymphadenopathy, transfusions, blood disorders.

PSYCHOLOGICAL: suicidal or homicidal ideation, depression, anxiety, phobias, change in sleep patterns, drug or alcohol abuse, memory loss.

PHYSICAL EXAM/VITAL SIGNS:

GENERAL SURVEY: appearance/health, nourishment, grooming, posture & gait?, affect (explain: smiling, apathetic, etc.), CAO X 4, speech, motor activity tremor or shake, signs of distress.

SKIN: color, temp, moisture, cyanosis, mottling, same temperature, peripherally to centrally, hair distribution, texture and turgor, jaundice, clubbing, capillary refill, nail beds, buccal/conjunctival mucous membrane.

HEAD: shape, trauma?, pain on palpation, signs of injury or deformity, masses, nodules, tenderness, hair texture, distribution, hygiene, lesions of scalp, psoriasis, nits, lice, face symmetry, paralysis? skin problems?

EYES: conjunctiva, lid lag, strabismus, exophthalmos, PERRLA, nystagmus, EOM, visual acuity, corneas clear?

Fundoscopy: red reflex, retina, AV nicking, exudates, papilledema, lacrimal apparatus tenderness or exudate.

EARS: tragal palpation, deformity/pain to pinna, mastoid percussion, visible discharge, swelling. Otoscopic exam: external redness or edema, cerumen, light reflex, indurated, retracted, injected, perforations, hearing.

NOSE and SINUSES: deformity, patency, smell, pain, discoloration, swelling, septum midline, inferior and middle turbinates, ulcerations or polyps, frontal and maxillary sinus pain.

MOUTH: Inspection: lips, teeth, gums, deformity, lesions, ulcers. Buccal mucosa: lesions, sores, color. Teeth: present? Tartar, caries, gingivitis?

Soft and hard palate: symmetrical? Tongue: exudate, lesions, tongue midline, gag reflex, palatine rise, phonation deficit,. Soft palate: uvula, tonsils and oral pharynx exudates, parotid and submandibular glands pain or enlargement, Stensen's and Wharton's ducts abscess or stricture.

NECK: deformity, trachea midline, pre auricular, post auricular, occipital, posterior cervical, superficial cervical, deep cervical, tonsilar, submandib, submental and supraclavicular lymph nodes tender? supple, ROM? Thyroid gland palpable/tender/goiter, diff. swallowing, carotid bruits, JVD.

LUNGS and THORAX: symmetrical chest rise, signs of distress, retractions, accessory muscle use, AP diameter, deformities or pain, expansion, Percussion, diaphragmatic excursion, Auscultation, Tactile fremitus, egophony, bronchophony.

BREAST: pain, discoloration, symmetrical, dimpling, tenderness, retractions, masses, "orange peel"

CARDIOVASCULAR: extremities temperature & moisture, radial, ulnar, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedis pulses +2? Sacral, pedal or other dependant edema, measure JVP, lifts or heaves. Palpation of aortic, pulmonic, left sternal border, tricuspid and mitral areas for lifts, heaves or thrills, PMI displaced? location? Auscultation of rate, S1 and S2, S3, S4, bruits, murmurs? Murmurs with patient L lateral, decubitus or sitting up or leaning forward.

ABDOMEN: contour, lesions, striae, spider veins, visible peristalsis. Bowel sounds. Bruits in aortic, renal, iliac, femoral. Percussion: liver span, splenic percussion. Light/deep palpation, liver palpable, spleen or kidneys palpable, CVA percussion. Rovsing's, McBurny's, psoas, Murphy's, Obturator sign. Bladder palpable?

GENITOURINARY:

Female: inspection for discharge, lesions, genital warts, pubic hair, symmetry, discoloration. Palpation: masses, enlargement or discharge from urethra, Skene's of Bartholin's glands. Vaginal canal: rugae, lesions, masses. Cervical os: color, closed, indurated, lesions? Bimanual: tender, firm, smooth? Cervix: discharge pain. Uterus: smooth, nodules, masses, lumps. Adnexal masses, tenderness.

Male: Circumcised/uncircumcised. Glands: ulcers, scars, nodules inflamm. Skin: excoriation, nits or lice. Milk urethral meatus. Palpation: tender, induration, corpus spongiosum, corpus cavernosum deformity, rupture. Scrotum: rashes, swelling, lumps, engorged veins. Testicles: smooth, firm, pain, spermatic cords, inguinal hernias.

RECTAL: lesions, warts, hemorrhoids, fissures, sphincter tone, palpation for lesions or internal hemorrhoids, stool, Gualac.

MUSCULOSKELETAL: Motor strength 5/5 all joints?

TMJ: Inspection, palpation, ROM, crepitus, pain or clicks, inflammation.

C SPINE: palpation, flexion, extension, lateral movement and rotation.

T/L-SPINE: tenderness, abnormal curvature, ROM, pain, crepitus

ELBOWS: ROM, pain, crepitus, palpate olecranon and medial and lateral epicondyles.

HANDS/WRISTS: MP, DIP, PIP aligned, pain, swelling, deformities, ROM.

HIPS: pain, ROM, Arock hips@, sacral stability?

KNEES: pain, deformities, swelling, warmth, ROM, Bulge sign, McMurphy's, Lachman's sign, patellar position and condition.

FEET/ANKLES: pain, metatarsophalangeal joint, swelling, deformities, ROM of ankles & toes.

NEUROLOGICAL: neuro deficit, atrophy, CN deficit I-XII {see below}. Bicep, tricep, brachioradialis, patellar deep tendon reflexes, Achilles reflexes +2? Muscle strength tests 5/5? Pain/temperature, vibratory/positional senses for upper and lower extremities, graphesthesia, stereognosis, heel to toe walking, gait, stationary, Rhomberg, Babinski.

Specific Cranial Nerve Tests:

CN I- Smell

CN II- Vision

CN III, IV, VI- EOM, pupillary responses, direct and consensual

CN V- corneal reflex, facial sensation, jaw opening, and bite strength

CN VII- eyebrows raise, eyelids close, smile, frown, pucker, and taste

CN VIII- auditory acuity bilaterally, Rinne/Weber test

CN IX, X- palatine elevation, swallow, phonation, gag reflex

CN XI- lateral head rotation, neck flex, shoulder shrug

CN XIII- tongue protrusion, strength of lateral deviation

DIAGNOSTIC TESTS

Diagnostic tests and procedures are classified as:

invasive - procedures that involve introduction of needles, catheters, or other instruments into the body.
noninvasive - procedures that entail little or no risk or discomfort to the patient. Examples are urinalysis or x-rays.

Categories of diagnostic tests include:

laboratory tests - blood and urine concentrations of substances; organ function tests
electrophysiological - electrocardiogram (ECG); electroencephalogram (EEG); electromyelogram (EMG); evoked potential (EP)
radioisotope (radionuclide) - radioactively labeled substances are used to measure function
endoscopy - instruments used to view the interior of the body; consist of some form of tube, a light source, and lenses; proctoscope, sigmoidoscope, laparoscope, etc.
ultrasound - high frequency sound waves that are mapped as they echo back from internal organs and tissues resulting in a picture of interior structure; commonly used to examine heart valves, gallstones, and the uterus during pregnancy among other uses.
x-ray (radiographic) - standard x-rays (e.g., chest to look for signs of pneumonia or TB, or bones for fractures, subluxations, alignment, etc.); mammogram; angiogram; arteriogram
computerized tomography (CT) - produces cross section x-ray pictures
magnetic resonance imaging (MRI)/functional MRI similar in appearance to CT however patient is not exposed to radiation but is exposed to strong magnetic fields and radiowaves. Patients with metal implanted in their body cannot undergo MRI. MRI produces more detailed image of tissues such as nervous tissues.
positron emission tomography (PET) - used to measure function by injecting patient with a substance such as glucose labeled with a positron emitting isotope and measuring the distribution and metabolism of that substance.
cytological/histological - Papanicolaou (Pap) smear; biopsy

TREATMENTS

While it is impossible to discuss every possible treatment available for patients, the types of treatment may be categorized generally as:

pharmacological - administration of pharmaceutical agents (drugs) that may be by prescription or over-the-counter (OTC) and given via injection (IM, SC, IV, IC), ingestion (tablet, capsule, caplet, or other solid form), inhaled, or absorbed (patches, creams, lotions, etc.). Drugs should be considered as the primary source of treatment in acute crisis situations where surgery is not indicated or as an adjunct to surgery, or if other forms of treatment have failed.
surgical - invasive procedure used to repair or correct damage or malformation of tissues/organs in the body in order to restore normal function. It should be considered as a last resort except in emergency situations (e.g., coronary bypass surgery, appendectomy, etc.).
psychotherapy - the use of various techniques whereby a patient gains insight into his or her illness, usually mental illness, and is able to understand and correct errors or defective thought processes producing or resulting from a condition. Cognitive, behavioral, and solution-focused techniques are the most commonly used methods today.
naturopathic - various natural treatments which include herbal and homeopathic medicines, nutritional therapy including orthomolecular medicine, acupuncture, environmental (photo, color, music, aromatherapy, and other forms of sensory therapies), relaxation, biofeedback, and other treatment approaches. It is particularly useful for chronic illness, non-life threatening conditions. In situations that call for pharmaceutical treatment initially, an attempt should be made to eventually place the patient on some form of naturopathic treatment either as an adjunct or replacement for drug therapy.

REVIEW QUESTIONS:

1. What are the five major categories of disease?

2. What is the difference between an organic and a functional disease?

3. What are the major categories or types of diagnostic tests?

4. What are the major categories or types of treatments?

5. If a patient had arthritis, what types of treatment(s) would you try and why?

6. Why should you do a complete H & P for every patient?

7. Why would asking about diet have anything to do with a patient with headaches?

8. Why would you ask a patient if he/she snores if they are coming to see you for hypertension?

9. Why would you want to know a patient's religious affiliation if they were going to have surgery?

10. What is the difference between allopathic and holistic approaches to healthcare?

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