The History is the Patient telling us the Diagnosis, The Physical Examination is the Body telling us the Diagnosis.

Saturday, March 31, 2012

Written by Professor Dr Wong Yin Onn The Start of a Diagnostic Process The History

History taking is the foundation of the Clinical Art and the heart of the diagnostic process in Medicine. The medical history is the grand centerpiece, the big picture that provides a panoramic overview of the patient's entire illness - how it originated, how it grew and developed, and how it is at present.
It is primarily the medical history that tells the doctor which specific signs to look for, and what other subsequent investigations are needed to obtain the information he seeks. All other methods of diagnosis can be seen as auxiliaries to the medical history, which is the principal, or core diagnostic method.

Prof TJ Danaraj demanded a highly detailed history from his students, and a sloppy history will be met with a severe reprimand. Prof KK Toh recalled how a student who did a particularly poor job will be exiled from the Bedside teaching until he has personally apologised to the teacher and each student in the group, for he has wasted the precious learning time of the entire group and himself; and insulted the patient.

TJD will typically draw a long line across the blackboard with his chalk; the student will be asked as to describe in detail what happened on the Day1 when the first symptom appeared and then Day2 etc etc. Then what brought the patient to hospital, that precipitating event which made the patient seek admission, and subsequently what happened Day1 of admission, etc all the way to the present day.

We must pay close attention to the time course of the symptoms. How has symptom complex changed over time?

The natural history of the illness, its progression is of utmost importance in diagnosis. Today I am saddened that most students take lightly this "History of Present Illness (HPI)". In this era of instant coffee and maggi mee, the students compressed all this HPI into a few brief statements, losing much that it tells us. Always remember that The History is the Patient telling us the Diagnosis!

I tell my students to at the very least think of 5 common conditions that can explain for the Chief Complaint and HPI. For eg if the Complaint has been Chest Pain, then at the very bare minimum, think of 5 Common or Important conditions that can cause or fit the HPI. The Common include Ischaemic Heart Disease, the NOT TO BE MISSED include Acute Myocardial infarct, Aortic Dissection, Pulmonary Embolism, and Pnemothorax. The long list of others from GERD to Oesophageal spasm to Zoster is at the back of our minds. With this we review the Systems and LOOK at each system one by one comprehensively for possible symptoms and disorders that may not be spoken of by the patient in the HPI. In the HPI the patient volunteers his data, in the systemic review we enquire!

The focused review of systems bring out information that supports a certain diagnosis or helps gauge the severity of the disorder, or exclude the likelihood of a pathology.

Today, the systemic review often consists of mindlessly repeating a few lines that goes.... "Patient does not smoke, drink or take drugs of abuse. He has no sexual indiscretion". This is one extreme.
Any book on Clinical Methods will have a list of symptoms that comprised the definitive "Review of Systems." Some students actually memorized this list. This is the other extreme! But the Mindless recitation of this list is rather stupid: "I know that you are having chest pain, but I need to know if you have ever had an extra marital affair."
I smile to myself everytime I hear such well parroted lines at the wards, and realise that the student still has Not grasped the Art.

The Diagnostic process is time honoured, refined by the passage of time,
a distillate of Medical wisdom.
History taking and Physical examination remains the pillars of sound practise,
no matter how the machines have advanced.
The human touch, both the spoken word and the touch of the hand is as important as the pharmacopeia.
Even if the superb diagnostician may not need it, the suffering man does.
he consults a doctor, not a machine,
he seeks help, not the beeps of computers.

On complicated machines we now rely,
and use ear, tongue, eye and hand far too little.
We scan and sound everything,
and await with pious resignation the decree of the computer.
Clinical methods we tend to damn,
and the doctor now becomes a stranger to the patient.

The modern doctor is at ease with ECHOs and Scans,
but he forgets the symptoms and signs of diseases,
the patient now a nameless collection of body parts to be referred to organ specialists,
where once on a clinician's skills the matter rests.
But we have yet a machine that can measure Human pain and distress,
nor a computer that can counsel and relieve.

What ails a man from the symptoms and signs, a clinician can tell,
at the bedside he truly shines,
his conversation reassures the patient that he is the most important suffering being to this doctor,
his touch a soothing balm to the aching body.

TJD warned us that we are Doctors, NOT Technicians; and unless we continue to act as Human Doctors healing the sick Human being, the Technician will take over!

The History is the Patient telling us the Diagnosis,
The Physical Examination is the Body telling us the Diagnosis.
Both must be Complete.

The History is in a language both the Doctor and Patient understands,
The Physical Examination is in a language only the well trained doctor understands.

The Mathematics of Diagnosis is the Mathematics of PROBABILITY; what is the probability of disease A causing the symptom complex of this patient?
In the OSCE system of evaluation of our medical students at the end of the year, the student is asked at the end of his history taking... "What is your Provisional Diagnosis and Differential Diagnosis at the end of this interview?"

Effectively we are asking, what is the Probability of the diseases causing this illness from the highest to the Lowest!

Some symptoms provide us with valuable clues to the diagnosis, for eg

Fever, Chills, and Rigors! People! pls give me 5 important common causes.

One of my students saw a patient come in with Fever, Chills and rigors with abdominal discomfort and unilateral flank pain. From the history, he was able to quite accurately localise the source of infection which took the attending doctors a CT Chest and Abdomen to diagnose! The history and physical examination should give us a Working Diagnosis based on which we order the appropriate Investigations. It should not be that we do the Investigations to give us the working diagnosis!

The medical history and dialogue between the patient and his doctor is the heart of the doctor - patient relationship. It is here that the doctor establishes a rapport with his patient, and communicates to him/her his sincere caring and commitment to their recovery. This caring in itself has great therapeutic value.
The cold impersonality of modern medicine is anti-therapeutic, and dehumanising.

Sleeping a little too much?

Thursday, September 15, 2011

One of the patients that I encounter this morning during the Psychiatric Liaison round. 41 year old gentleman was referred to the PSY team for methadone replacement therapy. He is an ex heroin addict presented with 2 days history of altered consciousness and excessive drowsiness. The wife claimed that he was unusually sleepy and tired over the few days prior to admission. There were no documented fever, seizures, limb weakness. Systemic reviews of the cardio, respi, genitourinary system were unremarkable. FBC was normal with total WCC of 6x10^9. Comment on the CECT findings and I will post up what was reported by the radiologist.

Causes of 3 figure ESR

Friday, July 8, 2011

I was taught by my prof that there are 5 common causes of a 3 figure ESR:

1) Multiple Myeloma
2) Polymyalgia Rheumatica/Temporal Arteritis
3) SLE
4) TB
5) Advance Malignancy

Though these are common causes, they are not definite or exhaustive. I have actually came across a lady with rhrumatoid arthritis having an ESR of 120mm/hr.

This gentleman presented with 1 year history of chronic back pain that worsened over the past 4 months. His condition deteriorated 2 weeks prior to admission and he was unable to ambulate independently without the aid of crutches due to the pain. Multiple X-rays were taken and showed
His ESR was 114mm/hr. What's the diagnosis?


Tuesday, April 26, 2011

8 year old boy presented with arthralgia, abdominal pain, maculopapular rashes and renal impairment.


Friday, April 15, 2011



Monday, February 21, 2011

Courtesy of Dr Fadzli, Endocrine MO

1)Spend a few seconds in general inspection
2)Start off by examining the patient's hand, you notice that he has spade-like, sweaty hand, the skin is thickened and doughy.
3)Check for carpal tunnel syndrome(Phalen and Tinel Test)
4)Look at the face-check for prognathism(causing malocclusion of jaw), prominent supra-orbital ridges, wide inter-dental spaces and macroglossia
5)Offer to look for skin tag(molluscum fibrosum) at axilla
6)Look at lower limbs for pitting edema to suggest cardiac failure, look for evidences to suggest osteoarthritis of the knee, thicken heel pad
9)Check for proximal myopathy by asking patient to squat down
10)Assess the visual field to look for bitemporal hemianopia(acromegaly tends to be due to macroadenoma)

After eliciting all the positive signs, suggest to examiners you would like to complete your physical examination by
1)Check the blood pressure which is an indicator for active disease process
2)Check urine for glycosuria
3)Check fundus for DM/HPT changes
4)Examine the cardiovascular system for heart failure, neck for goitre and abdomen for hepatosplenomegaly

1)How do you confirm the diagnosis?
2)What are the modalities of treatment available?
3)How do you monitor treatment response?
4)Any endocrine syndrome which is associated with acromegaly?

Liver Atlas and Casebook

Wednesday, January 5, 2011

Was browsing through the book collection in the HDOK library and came across this book titled “Liver Atlas and Casebook” edited by our very Malaysian Director General of health, Dr Ismail Merican himself. I highly recommend this book for students like me out there as it highlights important concepts pertaining to the diagnosis and management of common diseases that affect one of the largest organs in our human body- the liver. On the other hand, this book compiles a number of complex cases, which were managed by the highly specialised team in our very own hepato-biliary excellence centre- Selayang hospital. Overall rating of 8/10 with high resolution pictures of specimens for an in depth understanding of the pathology of most liver diseases. Some of the important facts that I’ve gathered after finishing ¾ of the book.

  • The text book triphasic CT characterisation of HCC

Arterial enhancement as HCC derives its blood supply from the hepatic arterial circulation

Complete venous washout

  • HCC usually causes thrombosis of the portal vein and its branches. Jaundice is not a common presenting feature of HCC.
  • Diagnosis of HCC rarely depends on liver biopsy due to potential tumour dissemination that may convert a resectable lesion into a non resectable disease.
  • Among the common presentations of HCC is abdominal pain/discomfort usually felt as a dull sensation, awareness of abdominal mass/constitutional symptoms of appetite and weight loss. Jaundice and ascites develop in later stages of the disease, when present contraindicates surgery.
  • Serum AFP may be normal in up to a third of patients with HCC
  • Text book CT characterisation of FNH(Focal Nodular Hyperplasia)

Hyperdense vascular enhancement with central hypodensity (stellate scar)

  • FNH usually does not require intervention unless patient is symptomatic/ uncertain and suspicious for malignancy
  • The most common benign liver lesion-hepatic haemangioma that is usually picked up incidentally.
  • Leptospirosis is caused by “Leptospira Icterohaemorrhagiae”. Rats are common source of human infection. It can also infect cattle shoes and swine. Incubation period takes about 10 days (average)
  • Adolf Weil was the first person to document this disease and thus severe form of leptospirosis is also called Weil Syndrome.
  • Jaundice and haemorrhagic manifestation are not uncommon, hence the name “Icterohaemorrhagiae”
  • The leptospires, directly/through immune mechanism damage blood vessels, cause centrilobular necrosis of the liver, renal tubular dysfunction by causing interstitial nephritis and acute tubular necrosis. Diagnosis is based on serology with 1:800 being diagnostic.
  • Liver abscess usually shows up as a hypoechoic area with some debris within it. ( On ultrasonography)
  • K.Pneumonia has emerged as one of the most common pathogen responsible for liver absvess
  • Metastatic infections are commonly seen in patients with K.Pneumoniae liver abscess. They are


Septic Pulmonary embolism

Pulmonary abscesses

Cerebral abscesses

Purulent meningitis

Otitis media


Prostate abscess

Psoas muscle abscess

  • In a patient with abscesses in multiple sites, K.Pneumonia infection should always be considered as a possible cause
  • Polycystic disease of the liver is a benign condition which usually presents as an incidental finding or abdominal discomfort/pain/mass
  • Occasionally an infected cyst would present with pain and fever
  • In a patient with abscesses in multiple sites, K.Pneumonia infection should always be considered as a possible cause
  • Polycystic disease of the liver is a benign condition which usually presents as an incidental finding or abdominal discomfort/pain/mass
  • Occasionally an infected cyst would present with pain and fever