Clinical Assessment: Symptoms, Signs, and Diagnostic Insights

Posted on Sep 22, 2025 in Medicine & Health

Gastrointestinal Disease Symptoms and Signs

Acute appendicitis, pancreatitis, dyspepsia, esophageal disturbances (pyrosis, regurgitation, odynophagia, dysphagia), gastroduodenal ulcers, gallbladder colic, reflux esophagitis, gastrointestinal tract (GIT) pain, viral hepatitis, hepatic steatosis, diverticulitis, anorectal lesions, and cholecystitis are common conditions.

Abdominal Pain Differentiation

Abdominal pain is differentiated according to Maratka and Jones zones. Types include:

  • Somatic: Localized pain.
  • Visceral: Poorly localized pain.
  • Colic: Severe pain that comes and goes in waves.
  • Rhythmic: Pain occurring during or related to meals.

Bleeding Manifestations

Signs of bleeding can include:

  • Caput Medusae: Dilated veins around the umbilicus (portal hypertension, flow toward legs).
  • Inferior Vena Cava (IVC) Obstruction: Venous flow toward the head.
  • Hemorrhoids.
  • Melena (dark, tarry stools).
  • Hematemesis (vomiting blood).

Common GI Symptoms

Other frequent gastrointestinal symptoms include:

  • Flatulence.
  • Diarrhea.
  • Constipation.
  • Meteorism: Abdominal distension due to excessive gas in the bowels, producing tympanic sounds on percussion.

Other GI Symptoms

Additional symptoms include:

  • Vomiting.
  • Stool Changes: Such as acholia (absence of bile pigment in stool) or steatorrhea (fatty stools).
  • Nausea.

Head Examination Findings

Skull Inspection

Observe skull type and posture:

  • Mesocephalic: Normal skull.
  • Brachycephalic: Shortened anterior-posterior diameter.
  • Dolichocephalic: Elongated anterior-posterior diameter.
  • Microcephaly: Abnormally small head.
  • Macrocephaly: Abnormally large head, potentially due to hydrocephalus, Paget’s disease, or caput quadratum.
  • Oxycephaly: Malformed, pointed skull.

Facial Appearances and Associated Conditions

Characteristic facial features can indicate underlying conditions:

  • Febrile: Flushed face, common in fever.
  • Pallida: Pale face, common in sepsis and rheumatic fever.
  • Myxedematous: Yellow, doughy skin with periorbital edema.
  • Mitralis: Vermilion blush with a cyanotic hue.
  • Abdominalis: Sunken eyes, pointed nose, dry lips, common in peritonitis.
  • Cushingoid: Round, moon-like face due to hyperproduction of adrenal cortical hormones (Cushing’s disease).
  • Nephritica: Pale face with eyelid edema.
  • Acromegalica: Enlarged nose and tongue, prominent supraorbital ridges due to increased growth hormone.

Types of Facial Paralysis

Paralysis can manifest as:

  • Upper Motor Neuron: Often due to stroke.
  • Lower Motor Neuron (Facial Nerve): Inability to wrinkle the forehead, one eye cannot close.
  • Central: Slanted mouth, inability to whistle.

Skull Percussion and Palpation

Pain on percussion or palpation may indicate conditions like sinusitis.

Skull Auscultation

A bruit (abnormal sound) may be heard in cases of intracranial aneurysm.

Eyelid Abnormalities

Eyelid findings include:

  • Swelling: Associated with blepharitis, kidney disease, or myxedema.
  • Pigmentation: Seen in Addison’s disease and thyrotoxicosis.

Eyeball Movement Assessment

Assess eyeball movement by following a finger (1mm) with the head in a fixed position:

  • Squinting (Strabismus): Oculomotor muscle paralysis or paresis, which can be divergent (eye deviates laterally) or convergent (eye deviates medially).
  • Nystagmus: Repetitive and rapid involuntary eyeball movements, either vertical or horizontal.

Sclera Color Changes

Scleral discoloration can indicate:

  • Yellow: Icterus (jaundice).
  • Blue: Osteogenesis imperfecta.
  • Brown Spot: Melanin deposits.

Cornea and Iris Findings

  • Arcus Senilis: A white or gray band around the circumference of the cornea.
  • Iris: Observe for mydriasis (dilated pupils) or miosis (constricted pupils).

Nose Examination

Assess size (e.g., large in acromegaly), form, and secretions. Nosebleeds can be due to uremia, bleeding disorders, or hypertension.

Respiratory System Findings

Pneumonia

Pneumonia is an infection that inflames air sacs in one or both lungs. Symptoms and signs can include:

  • Breathlessness.
  • Strengthened fremitus pectoralis.
  • Shortened percussion note.
  • Audible crepitations, later tubal breathing, followed by crepitations again, and progressive weakening of tubal breathing.
  • Strengthened bronchophony.

Acute Bronchitis

Acute bronchitis typically presents with:

  • No breathlessness.
  • Distant bronchial phenomena.
  • Normal fremitus pectoralis on both sides.
  • Full and bright percussion note.
  • Alveolar breathing, which can be dry or wet.
  • Unchanged bronchophony.

Chronic Bronchitis

Chronic bronchitis is characterized by:

  • Decreased elasticity of the lungs.
  • Prolonged expiration.
  • Hyper-resonant percussion.
  • Vesicular breathing with rhonchi and moist sounds.

Emphysema

Emphysema is a chronic lung disease caused by damage to the alveoli. Symptoms and signs include:

  • Barrel-shaped chest.
  • Weakened fremitus pectoralis.
  • Hyper-resonant percussion.
  • Weakened alveolar breathing.
  • Weakened bronchophony.

Patient History and Presenting Complaints

The medical history is a structured assessment conducted to generate a comprehensive picture of a patient’s health and health problems. It includes an assessment of:

  • Patient’s current and previous health problems.
  • Current and previous medical treatment.
  • Factors which might affect the patient’s health and their response to prevention or treatment of health problems.
  • Their family’s health history.

Direct History

This occurs when the physician obtains information directly from the patient.

Indirect History

This occurs when the physician obtains information from family members or other people accompanying the patient.

Building Rapport

To establish a trusting relationship, it is important to:

  • Eliminate haste and nervous tension.
  • Create privacy for the interview.
  • Create a comfortable environment.

A medical interview usually starts with vital statistics (age, occupation) and then continues with the current complaints (e.g., “What are your difficulties/complaints or symptoms?”).

Personal Data and Chief Complaints

This section includes personal details (name, etc.) and the primary reason for the patient’s visit.

Oral Cavity Examination

Lips

Observe lip color and condition:

  • Cyanotic: Indicates heart or lung disease.
  • Pallor: Suggests anemia.
  • Cheilosis/Angular Stomatitis: Painful, small ulcers in the labial corners, often associated with HSV1.

Tongue

Assess tongue movements (hypoglossal nerve involvement leading to glossoplegia paralysis), macroglossia (enlarged tongue, seen in acromegaly and myxedema), and the surface for food, bacteria, or debris.

  • Hunter’s Glossitis: Deficiency of B12, resulting in a flat tongue with atrophic papillae.
  • Xerostomia: Dryness of the mouth, making swallowing or talking difficult.

Oral Mucosa

Examine the oral mucosa for:

  • Thrush: Caused by Candida albicans.
  • Pigmentation: Such as in Addison’s disease.

Gingiva (Gums)

Gingival findings can include:

  • Scurvy: Due to lack of vitamin C.
  • Necrosis: Seen in acute leukemia or agranulocytosis.

Teeth and Jaws

Check the position of the jaws:

  • Prognathia: Protrusion of the maxilla.
  • Progenia: Protrusion of the mandible.

Also assess for malocclusion, number of teeth, and their quality.

Tonsils

Note if tonsils are enlarged or inflamed.

Mobility and Posture Assessment

Types of Mobility

  • Active: Patient can achieve a range of positions without assistance.
  • Passive: Patient is helpless in posture but requires assistance to move from one position to another.
  • Obligatory: Patient requires assistance with maintaining posture.

Gait Abnormalities

Patients with neurological disorders often exhibit changes in gait:

  • Parkinsonian Gait: Small steps, body leaning forward, tremor, and muscular rigidity.

Gait with Circumduction

In this gait, the lower extremity (extensor muscles) is extended at the knee joint, requiring the leg to move in a circular manner to the side. This is typical for hemiparesis or hemiplegia of one side of the body following a stroke.

Tremors

Hand tremors can be observed in conditions like thyrotoxicosis, presenting as shaking hands or arms.

Epileptic Convulsions

Observe and describe any epileptic convulsions.

Comprehensive Medical History Taking

Document all illnesses from birth to the current state, including:

  • Chronological History: Surgical procedures and accidents, their type, duration, treatment, and possible after-effects.
  • Childhood Disorders: Infections, allergies, particularly rheumatic fever.
  • Foreign Travel: Important for tracking certain infectious or parasitic diseases (e.g., Salmonellosis, Malaria, Hookworm).
  • Inheritable Diseases: Such as diabetes mellitus (DM), hypertension, cystic fibrosis, or sickle cell anemia.
  • Other Conditions: Tuberculosis, sexually transmitted infections (e.g., syphilis).

Cardiac Auscultation: Heart Sounds

Physiologically, two heart sounds (S1 and S2) are typically heard. In young children, pregnant women, and pathological conditions, third (S3) and fourth (S4) heart sounds may be audible.

The first heart sound (S1) coincides with the onset of systole, and the second heart sound (S2) marks the end of systole. The interval between S1 and S2 is short, while the interval between S2 and the subsequent S1 is longer. Systole duration is approximately one-third, and diastole is two-thirds of the heart cycle.

First Heart Sound (S1)

S1 occurs as the atria contract at the end of diastole, filling the ventricles with blood. As atrial musculature relaxes, ventricular pressure rises, causing the atrioventricular valves (mitral and tricuspid) to close. S1 follows approximately 50ms after the beginning of the QRS complex and lasts around 100ms.

Second Heart Sound (S2)

S2 is caused by the sudden cessation of reversing blood flow due to the closure of the aortic and pulmonary valves at the end of ventricular systole. As the left ventricle empties, its pressure falls below aortic pressure, causing aortic blood flow to reverse and close the aortic valve leaflets. Similarly, as right ventricular pressure falls below pulmonary artery pressure, the pulmonary valve closes. A split S2 can be associated with various cardiovascular conditions.

Third Heart Sound (S3)

S3 relates to a sudden, abrupt ending of ventricular distension in the initial phase of diastole. It is found mostly in left ventricular failure, patients with mitral incompetence, ventricular septal defect, or constrictive pericarditis.

Fourth Heart Sound (S4)

S4 relates to the distension of the ventricle caused by atrial systole. It is not necessarily a sign of heart failure and originates in the left ventricles.

Gallop Rhythm

A gallop rhythm is a combination of tachycardia with either S3 or S4. Tachycardia is defined as a heart rate greater than 120 beats/min. A gallop is not present if tachycardia is accompanied by a decrease in atrial pressure; it can be indicative of left ventricular heart failure.

Auscultation Areas

Heart sounds are typically auscultated at specific locations:

  • Aortic Area: Right 2nd intercostal space (DX-2IC).
  • Tricuspid Area: Right 5th intercostal space (DX-5IC).
  • Pulmonic Area: Left 2nd intercostal space (SX-2IC).
  • Mitral Area: Left 5th intercostal space (SX-5IC), also known as the apex.

ECG Findings in Coronary Artery Disease

Coronary syndrome refers to clinical conditions caused by the rupture of an atheromatous plaque within a coronary artery. If a patient presents with chest pain and ECG evidence of myocardial ischemia but a normal plasma troponin level (<0.04ng/mL), it indicates coronary syndrome due to unstable angina.

Unstable Angina and STEMI

  • Unstable Angina: Characterized by ST depression (ST segment is the isoelectric period between ventricular depolarization and repolarization, typically 80-120ms).
  • ST-Elevation Myocardial Infarction (STEMI): Diagnosed when there is ST elevation in ECG leads corresponding to the damaged part of the heart. This includes more than 1mm of ST elevation in at least two contiguous limb leads (e.g., III and aVF) or more than 2mm of ST elevation in at least two precordial leads. A new or presumably new left bundle branch block also indicates STEMI.

Subendocardial and Transmural Infarction

  • Subendocardial Infarction: Presents with ST depression and T-wave inversion.
  • Transmural Infarction: Presents with T-wave inversion, ST elevation, and a pathological Q wave.

ECG Wave Characteristics

  • T-wave: Represents repolarization of the ventricles, typically lasting 0.10-0.25 seconds with an amplitude less than 5mm.
  • Q-wave: A pathological Q-wave indicates an absence of electrical activity, often signifying necrosis.