Outline of the educational case history in propaedeutics of internal diseases
Sections in the order expected by most academic departments. The generator uses this exact structure; if your department requires a specific format, upload it as a template.
- 1General patient data
Age (not date of birth), gender, occupation/profession (omit organization name), date and time of admission, department, referral source/delivery method, referring facility diagnosis, admission diagnosis. Do not include full name, address, or document numbers: use "Patient N."
- 2Complaints
Chief complaints with details (localization, character, intensity, radiation, duration, triggers, and relieving factors) along with general symptoms; complaints upon admission and at the time of examination.
- 3History of the present illness (Anamnesis morbi)
Onset and progression, initial symptoms, clinical course, previous medical consultations, prior diagnostic tests and treatments before admission along with their efficacy, as well as the reason and circumstances of hospitalization.
- 4Past Medical History (Anamnesis vitae)
- Brief biographical data, living conditions, and dietary habits
Birthplace and upbringing, education, housing and living conditions, dietary habits, physical activity.
- Occupational history
Profession, length of service, working conditions, occupational hazards (without naming the organization).
- Past medical history, surgeries, injuries
Childhood infections, chronic diseases, surgeries, trauma, tuberculosis, viral hepatitis, STIs, blood transfusions (with reactions).
- Bad habits
Smoking (duration, pack-years), alcohol (frequency, quantity), illicit drug use.
- Medication history
Regular medications taken by the patient (name, dose, frequency).
- Allergic history
Drug, food, and household allergen intolerance; type of reaction.
- Epidemiological history
Contact with infectious patients, travel outside the region/country over the past 6 months, parenteral interventions, bites, dietary history, contact with animals.
- Family history
First-degree relatives' medical history (CVD, diabetes mellitus, oncology, tuberculosis, psychiatric conditions).
- Obstetric and gynecological history
For women: menarche, menstrual cycle characteristics, menopause, pregnancies/childbirth/abortions.
- Insurance history
Certificate of incapacity for work (duration), disability group.
- 5Objective examination (Status praesens objectivus)
- General physical examination
General condition, level of consciousness, body position, physique, body type, height, body weight, BMI, body temperature; skin and visible mucous membranes, subcutaneous adipose tissue, edema, lymph nodes, muscles, bones, joints.
- Respiratory system
Chest inspection, respiratory rate, palpation (resistance, vocal fremitus), comparative and topographical percussion, auscultation (breath sounds, rales, crepitation, pleural friction rub), bronchophony, SpO2.
- Cardiovascular system
Inspection of the heart and neck vessels, apex beat, boundaries of relative cardiac dullness, auscultation (heart sounds, murmurs), pulse (rate, rhythm, volume, tension), blood pressure on both arms, peripheral arterial pulsation.
- Digestive system
Oral cavity, tongue, abdomen (inspection, superficial and deep palpation according to Obraztsov-Strazhesko, percussion, auscultation), liver dimensions according to Kurlov, gallbladder (symptoms), spleen, stool.
- Urinary system
Lumbar region inspection, kidney palpation, tapping sign (Pasternatsky's sign), urination, diuresis.
- Endocrine system
Thyroid gland (palpation, eye signs), subcutaneous fat distribution, secondary sexual characteristics.
- Nervous system and sense organs
Consciousness, orientation, sleep, memory, meningeal signs, focal symptoms, reflexes, vision, hearing.
- 6Preliminary diagnosis and its rationale
Identify syndromes based on complaints, history, and objective data, justify each; formulate a preliminary diagnosis.
- 7Examination plan
Laboratory and instrumental studies and consultations with the purpose of each: according to clinical guidelines of the Russian Ministry of Health (mandatory and as indicated).
- 8Results of laboratory and instrumental studies
All available results with dates (in a table where appropriate) and interpretation: what is normal, what is abnormal, and what it means. Unperformed/missing studies should be listed as "no data".
- 9Differential diagnosis
At least 2–3 diseases with a similar presentation: for each, common features and differences used to rule it out (based on this patient's data).
- 10Clinical diagnosis and its rationale
Formulation according to the classification from clinical guidelines and ICD-10 (code): underlying disease, complications of the underlying disease, comorbid conditions; rationale for each component.
- 11Etiology and pathogenesis
Etiology and pathogenesis of the disease in general and applied to this patient (risk factors, mechanisms of syndrome development).
- 12Treatment and its rationale
Regime, diet (table), non-pharmacological treatment, pharmacotherapy: drug (INN), dose, route, frequency, duration, and justification with reference to clinical guidelines; At the end: prescriptions in Latin (Rp.: … D. S. …) for 2–3 main drugs.
- 13Observation notes
prescriptions).
- 14Stage (discharge) epicrisis
Briefly: patient, age, date of admission, reason for admission, main examination results, clinical diagnosis, treatment performed and its effect, condition at the end of curation, recommendations.
- 15Prognosis and recommendations
Prognosis for life, for recovery, for working capacity (with justification); discharge recommendations and follow-up care according to clinical guidelines.
- 16References
formatted according to GOST R 7.0.100-2018.
How a case history in propedeutics differs from a therapeutic one
Propedeutics of internal diseases teaches examination methods, which is why the main section here is the objective examination (status praesens) by systems. Outcome of the work: syndromic diagnosis, i.e., a list of identified syndromes rather than a nosological diagnosis with treatment. Many departments ask to suggest a nosology at the end, but they evaluate primarily the path from findings to syndromes.
Examination outline that is being evaluated
- History taking: chief complaints and system review, history of present illness, past medical history (previous illnesses, harmful habits with pack-year calculation, occupational hazards, allergic and family history).
- General inspection: level of consciousness, posture, body type, height, weight, BMI, skin and mucous membranes, edema, lymph nodes, muscles, bones, joints.
- Respiratory, circulatory, digestive, urinary, endocrine, and nervous systems: inspection, palpation, percussion, and auscultation for each in the classic order.
- Laboratory and instrumental data with interpretation.
- Syndromes with a list of features for each and a syndromal diagnosis.
Common reasons for point deductions
The examiner expects specific numbers and bilateral comparison: lower lung borders along all lines on both sides, mobility of the lower lung edge, boundaries of relative cardiac dullness, Kurlov liver spans, pulse characteristics (rate, rhythm, volume, tension, symmetry, deficit), and apex beat (localization, area, amplitude, force, resistance). Normal findings must also be described: writing "unremarkable" instead of a full description is not accepted.
How to differentiate pulmonary syndromes based on physical examination findings
| Syndrome | Tactile fremitus | Percussion note | Respiration | Bronchophony |
|---|---|---|---|---|
| Pulmonary consolidation | increased | dull or flat | bronchial | increased |
| Pleural effusion | decreased or absent | flat | decreased or not audible | decreased |
| Pneumothorax | decreased or absent | tympanic | decreased or not audible | decreased |
| Increased lung compliance / hyperinflation | decreased | hyperresonant | decreased vesicular | decreased |
| Pulmonary cavity communicating with a bronchus | increased | tympanic | amphoric | increased |
For the cavity syndrome, the table describes a large, superficially located cavity; small and deep cavities may not be detectable on physical examination.
Sample case history in propaedeutics: respiratory system and syndromal diagnosis
Model example, fictitious patient. Patient N., 58 years old, complaining of a cough with rust-colored sputum, pain in the right hemithorax upon deep breathing and coughing, shortness of breath on exertion, and fever up to 39.2 °C with chills for the past 3 days.
Examination of the respiratory system
Inspection. Normosthenic, symmetrical chest, with the right hemithorax lagging behind in the respiratory cycle. Shallow breathing, respiratory rate 24 breaths per minute.
Palpation. Elastic chest wall. Tactile fremitus is increased on the right below the scapular angle, equal in other symmetrical areas.
Comparative percussion. Percussion note is dull below the scapular angle on the right along the scapular and posterior axillary lines; clear pulmonary resonance elsewhere. Topographic percussion: mobility of the lower border of the right lung along the mid-axillary line is decreased to 3 cm, left lung is 6 cm.
Auscultation. Bronchial breathing, loud fine crackles, and crepitation in the area of dullness; bronchophony is increased. Vesicular breathing over other areas, no pleural friction rub. SpO2 93%.
Identification of syndromes
- Pulmonary consolidation syndrome in the lower lobe of the right lung: lagging of the right hemithorax during respiration, increased tactile fremitus and bronchophony, dull percussion note, bronchial breathing, crepitation, loud moist crackles.
- Respiratory failure syndrome: dyspnea, respiratory rate 24 breaths per minute, SpO2 93%.
- Fever and intoxication syndrome: fever up to 39.2 °C with chills, weakness, heart rate 104 beats per minute.
- Pleuritic chest pain syndrome: pain in the right hemithorax, worsening with deep inspiration and coughing.
Syndromal diagnosis
Syndromal diagnosis of lobar pulmonary consolidation in the lower lobe of the right lung. Respiratory failure syndrome. Fever and intoxication syndrome. Pleuritic chest pain syndrome.
If the department requires a suspected nosology, write: "The identified syndromes are most characteristic of community-acquired pneumonia of the lower lobe of the right lung." To confirm, the plan should indicate chest X-ray in two projections, complete blood count, and sputum analysis. The ICD-10 code is not always required in propaedeutics; pneumonia with unspecified pathogen falls under category J18. Pneumonia severity and hospitalization criteria in internal medicine are assessed using scales such as CURB-65: these can be calculated in the clinical scales section.
Common mistakes in propaedeutics case histories
- Writing a nosological diagnosis and treatment plan directly instead of a syndromal diagnosis, without identifying syndromes.
- Naming a syndrome without listing its features, or scattering the features of a single syndrome across different sections.
- Writing "unremarkable" instead of a full description: missing lung and heart borders, or Kurlov liver spans in centimeters.
- Violating the examination sequence: systems described out of order, auscultation placed before percussion.
- Failing to compare symmetrical areas during comparative percussion and palpation.
- Describing the pulse only by rate, omitting rhythm, volume, tension, and symmetry.
- Perfunctory life history: omitting occupational hazards, pack-years, and allergic history.
- Contradictory data: dyspnea listed in complaints, but status shows a respiratory rate of 16 and vesicular breathing across all lung fields without explanation.
- Real patient data used in the identification section instead of anonymized data.
Compile your own internal medicine propaedeutics case history
The patient can be simulated for a specific condition, or you can upload your own clinical notes (text, handwritten photos, audio). Cross-checked with clinical guidelines, ICD-10 coding, and export to Word and PDF. 2 case histories per month for free.
Frequently asked questions
What is the structure of an internal medicine propaedeutics case history?
Administrative section (anonymized), chief complaints, history of present illness, past medical history, general inspection, system-by-system examination (inspection, palpation, percussion, auscultation), laboratory and instrumental data, identification of syndromes, and syndromal diagnosis. Details and section orders vary between departments, so always check your local guidelines.
What is a syndromal diagnosis and how does it differ from a clinical diagnosis?
A syndromal diagnosis lists the syndromes identified during the examination, such as pulmonary consolidation syndrome and respiratory failure syndrome. A clinical diagnosis names a specific disease with its classification, complications, and ICD-10 code. Propaedeutics focuses on the former, while the latter is taught in faculty and hospital therapy.
Where can I find a sample case history for students in propaedeutics?
This page breaks down an example of a respiratory system examination, highlighting syndromes and formulating a syndromic diagnosis. It is convenient to use as a structural template, but you must describe your own patient: the instructor will check that the physical examination findings match what they see in the actual patient.
Is treatment required in a propedeutics case history?
Most of the time no, or only briefly: propedeutics focuses on assessing the examination findings and syndromes. Some departments ask you to suggest a nosology and a further diagnostic plan. Check your department's guidelines for exact requirements.
How should a syndrome be described in a propedeutics case history?
Name the syndrome, indicate its localization if applicable, and list all signs that confirm it—from complaints, inspection, palpation, percussion, auscultation, and laboratory tests. Every sign must be described in the corresponding section of the physical status, otherwise the syndrome will appear fabricated.
Can an AI be used to write a propedeutics case history?
You can use an AI to understand the structure and draft the work, but you will have to defend it yourself. The generator follows a therapeutic scheme or your department's uploaded template, compiles text from your patient care notes (text, file, photo of handwritten notes, audio), and marks missing data as "not specified" rather than inventing findings. Do not include the patient's real full name, date of birth, address, or insurance policy in the prompt: this violates medical confidentiality (Art. 13 of Federal Law No. 323-FZ) and personal data regulations (152-FZ), so the patient identification section must be anonymized. Two case histories per month are available for free on any account, with 5 more on the "Maximum" plan.
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