Surviving 4th Year Medicine

8/16/2019 Surviving 4th Year Medicine

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Surviving 4Surviving 4 thth Year: Year:A Guide to Clinical MedicineA Guide to Clinical Medicine

Here’s hoping you won’t have as difficult and miserable a time as I hadHere’s hoping you won’t have as difficult and miserable a time as I had

By:By:Methal Al-Bayat

Special Thanks to:Special Thanks to: Amani Al-Shayea

Maha Al-Madi

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You hear a lot of horror stories about medicine and some of them are true but aYou hear a lot of horror stories about medicine and some of them are true but alot of them are e aggerations and it’s these stories that made me absolutely hatelot of them are e aggerations and it’s these stories that made me absolutely hatethis course !along with the feeling that everyone else seemed to be learning andthis course !along with the feeling that everyone else seemed to be learning andma"ing good progress e cept me#$ but really I didn’t have to be that scared !%ustma"ing good progress e cept me#$ but really I didn’t have to be that scared !%usta little bit scared is enougha little bit scared is enough #& So$ here is the advice and teachings I wish I had#& So$ here is the advice and teachings I wish I had

"nown before I started the course$ hope they are of some help&"nown before I started the course$ hope they are of some help&You will notice that I focus mainly on physical e amination' that is because thereYou will notice that I focus mainly on physical e amination' that is because thereare a lot of notes on history ta"ing that are very good$ and most doctors will focusare a lot of notes on history ta"ing that are very good$ and most doctors will focusmainly on history and will completely ignore the physical e amination part or ifmainly on history and will completely ignore the physical e amination part or ifthey do ta"e the time to show you how to e amine$ there will be so many of youthey do ta"e the time to show you how to e amine$ there will be so many of youthat you will not be able to really see or understand what is going on !that wasthat you will not be able to really see or understand what is going on !that wasthe main problem for me I can hear what the doctors say but with (( other girls inthe main problem for me I can hear what the doctors say but with (( other girls inthe group I could never really see what was going on#&the group I could never really see what was going on#&

At the end$ I added my surgery case report to give you an idea of how to At the end$ I added my surgery case report to give you an idea of how tocomment on the history and physical e amination& )emember that in medicinecomment on the history and physical e amination& )emember that in medicineyou are re*uired to go into much more detail than in surgery$ so don’t follow myyou are re*uired to go into much more detail than in surgery$ so don’t follow mycase report e actly in medicine but it should give you some idea of how tocase report e actly in medicine but it should give you some idea of how tocomment on normal findings&comment on normal findings&

General AdviceGeneral Advice•• +icholas or Macleod’s, A very controversial topic$ everyone has an opinion$

here I’ll try to write the pros and cons of each boo"NicholasNicholas Macleod’sMacleod’s

•• oo"s scary•• A ./ of information•• +ot many pictures•• 0ery boring !sometimes

difficult to read#•• Most doctors prefer it•• 1sually it is enough for 2 th

year

•• oo"s friendlier •• ac"ing information !not everything in

+icholas is mentioned in this boo"#•• A ./ of picture and colors•• Shows how to perform some physical

e aminations•• +ot all the doctors follow it !a lot of

them haven’t even read it#•• /his year’s .S34 came from the

pictures here

5ersonally$ I preferred +icholas$ the tables in it are 04)Y good !I tried toincorporate as many tables as I could in here# and overall it is a very

comprehensive boo" !If you have time try to read both boo"s#•• Something that would really help is if you begin reading in the ( st semesterduring B3S and try to memori6e some of the tables in +icholas

•• 4*uipment !that you can’t be without#oo Sphygmomanometer !you can borrow one from the hospital$ but I

prefer to have my own#oo 5en torchoo /ongue depressors !sterile#

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oo )uler oo Stethoscopeoo Measuring tapeoo Alcohol swabsoo 3otton swabsoo /ooth pic"s

•• /he topics that you ABS. 1/4 Y have to "now for your clinical e am areoo S37oo Bronchial Asthmaoo 3.57oo 3hronic iver 7iseaseoo 7M 8 H/+ !although you will never get a patient in the e am with

only these complaints but you M1S/ "now them#oo IB7 !1lcerative 3olitis and 3rohn’s 7isease#oo 5neumonia !and 5ara pneumonic lesion#oo 70/

•• /he topics that you should "nowoo /halassemiaoo /boo MIoo 5leural 4ffusionoo ymphadenopathyoo 7iabetic 9etoacidosis

•• /he above are the most common topics that you might get in the oral e ambut of course if they don’t have enough patients some unluc"y students willget difficult cases as +euro and )enal but usually the doctors are nicer tothe students who get difficult cases

•• In the end you have to remember that ta"ing a good history$ "nowing somebasic information$ and performing a good physical e amination !even if youdon’t catch all the findings$ the way you do it is more important# will get youa passing grade

•• 4ach doctor has a specific way they want you to follow in history andphysical e amination and very rarely two doctors will agree on the samemethod so in the end do what you are most comfortable with&

•• Before starting the course I would advise you to loo" for an older S/174+/to teach you how to do a basic physical e amination and ta"e a history& Inmy opinion it is best to learn the basics from a student or an intern becausethe information and the method will be fresh in their minds and at the end of the course you’ll find that the best teachings are those given by your fellowstudents because they will be thorough and they will teach you everything!residents and consultants are either too busy to give you a completeteaching$ too tired of teaching$ or give you a lot of information that will beconfusing and beyond your level$ but don’t get me wrong some residentsgive 4:34 4+/ teachings and some students may teach you somethingincorrect$ but with me the students gave me the best teachings#

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•• /ry as hard as you can to get someone !a student or intern# to give youteachings of the ma%or systems !30S$ )esp$ 8 ;I/# B4 minutes to ta"e the history and do the physical e am$ I don’tmean to scare you but you have to be prepared for anything#

•• earn the basic formula for history ta"ing by heart so that you only need tota"e notes while the patient tal"s and then read your history from thesenotes without organi6ing it !in your final you will not have time to organi6e

your history$ you will have to present it to the doctors from your notes so5)A3/I34$ 5)A3/I34$ 5)A3/I34#& My advice to you is never rewriteyour notes so that you will learn how to read a history from your chic"enscratches and this practice will pay off in the final&

•• /ry to present a case in front of a doctor$ this will need coordination with therest of the members of your group$ try to wor" out a schedule with the groupdeciding who will present a case each day$ this way everyone will have achance to present and there won’t be one person who presents every time&

•• @hen you are presenting your case or having a discussion with your friendsor with the consultant in front of the patient$ spea" in 4nglish and +./ in

Arabic because you might be tal"ing a bout a disease that the patient does

not have but he might thin" that he has it& •• )ead 7r 9indy’s notes& /hey are in my opinion the best notes on history

and physical e amination& /hey are very comprehensive but you may li"e toadd some of your notes to them !from what doctors tell you and from whatyou read in boo"s# so that when the e am comes these notes will be all youneed to revise from &&/here is a note on history ta"ing by


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•• 5repare cases that match your level&


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b&b& @hen the patient was last !i&e& when the symptoms ( st appearedin life#

i&i& @hat were the symptoms at the time they ( st appeared !arethey different from what the patient presents with now,#

ii&ii& @hat was the patient doing at the time they appearediii&iii&

Mode of onset !sudden or gradual#&iv&iv& 3ontinuous or intermittentv&v& 7uration&vi&vi& 3haracter vii&vii& Site 8 radiationviii&viii&5recipitating factorsi &i & Aggravating factors

&& )elieving factorsi&i& Severityii&ii&


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oo @hen startedoo 5hysician or self-prescribed&oo History of allergies to food or drugs

••


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0isual disturbanceHearing problems !deafness$ tinnitus#Memory 8 concentration changes

oo )espiratory System7yspnea or shortness of breath !on e ertion,#

3ough@hee6eSputum production !color$ amount$ 8 character#Hemoptysis3hest pain associated with inspiration or cough

oo 3ardiovascular System3hest pain on e ertion7yspnea on e ertion 8 how much e ertion.rhopnea5aro ysmal nocturnal dyspnea5alpitation

3laudication An"le edemaoo ;astrointestinal System

.ral ulcers7ental problems7ysphagia+ausea 8 vomitingHematemesisIndigestionHeartburn

Abdominal pain

3hange in bowel habit3hange in color of stool 8 consistencyoo ;enitourinary System

7ysuria3hange in fre*uency+octuriaHematuriaIncontinenceHesitancy5oor stream or flow/erminal dribbling concerns men

1rethral discharge Abnormal bleeding0aginal discharge concerns women3ontraception

oo Musculos"eletal Systemoint pain$ stiffness$ or swelling

Mobility


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oo 4ndocrine SystemHeat or cold intolerance3hange n sweating5olydipsea

oo Hematological System

Bruising$ ( being mild 8 (> being the worst pain the patient hasever e perienced

♣♣ If there is claudication don’t forget to as" about claudication distance!04)Y 04)Y IM5.)/A+/#

♣♣ If there is any change in the symptoms the patient has A @AYS get atime-line !what started ( st$ when did it change$ were the ? symptomspresent together,#

♣♣ A @AYS as" about any diurnal variation in the symptoms !e&g& fever or

sputum#♣♣ If there is sputum production don’t forget to as" about the position of the

patient which increases it♣♣ If the patient had some investigations done before$ as" about the results

and if there was a follow-up appointment♣♣ +404) ma"e any assumptions$ say e actly what the patient said and if

you thin" you "now what the patient meant say Dmost probably&&&E !e&g& asic"ler tells you that he ta"es a small yellow pill every day$ 7.+’/ say thepatient ta"es


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♣♣ In social history$ as" specifically about the housing conditionsF is it a houseor an apartment, Is it owned or rented, How many floors, How manyrooms, How many people per room, 3arpeting, 5ets, &&&

♣♣ A @AYS "now why you are as"ing the *uestion !a lot of times thee aminer will interrupt you in the middle of the history and as" you why did

you as" the patient that *uestion$ so A @AYS "now the reason behind the*uestion#♣♣ 7.+’/ forget to mention the hospital course !i&e& what happened to the

patient after heCshe was admitted$ the progression of the symptoms$treatment$ investigations#

♣♣ 7.+’/


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oo +ailsoo" at their color !white$ yellow&&oo" for peripheral cyanosisoo" for pallor in the nail-beds

3hec" capillary refillF press the nail and watch the nail bed

become pale then release the pressure and watch the nailbed go bac" to its normal color$ it shouldn’t ta"e more than ?seconds if it ta"es longer it is abnormal$ chec" all (> fingersIf the patient has henna or nail-polish on$ you can’t commenton anything about the nails

oo


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disappears the patient doesn’t have palmer erythema but ifthe color remains then the patient has it#

oo @rist/enderness

oint deformity•• /remors

oo


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oo )emember to compare both arms•• Blood pressure

oo 9orot"off soundsI&I& 9 I is the pressure at which a sound is first heard over the

artery !the systolic pressure#

II&II& 9 II is the increase in the intensity of the sound as the cuff isdeflatedIII&III& 9 III is the decrease in the intensity of the soundI0&I0& 9 I0 is the muffling of the sound0&0& 9 0 is the disappearance of the sound !the diastolic pressure'

however it slightly underestimates the arterial diastolic bloodpressure$ but in 9 I0 is more accurate if there is severe aorticregurge and sometimes 9 0 is absent in normal people and 9I0 must be used#

•• Head 8 nec"oo Inspect the head and nec" commenting on any obvious

abnormalities !e&g& anthalasma$ swellings in the face and nec"&&oo Mention any obvious pallor or cyanosisoo 4yes

3hec" for pallor by as"ing the patient to loo" up and pullingthe lower eyelids down and loo"ing underneath them andcomparing their color with the color of your thumb nail beds3hec" for %aundice by as"ing the patient to loo" down whileyou pull their upper eyelids and loo" at the sclera for ayellowish discoloration& 7.+’/


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oo +ec"oo" for any obvious swellings

3hec" the carotid pulse below the angle of the %aw pressingagainst the sternocleidomastoid3hec" the %ugular venous pressure

•• As" the patient to lie at 2LP•• ocate the internal %ugular vein !starts between the

two heads of the sternocleidomastoid then goesbehind the muscle then medial to it and comes belowthe %aw and behind the earlobe#

•• /o ma"e sure that the vein doesn’t go above theearlobe as" the patient to sit up at Q>P

••


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is centrally located !if it slightly displaced to the right that isnormal#5alpate the thyroid gland from behind the patient with thepatient’s head slightly fle ed !if the thyroid is normal you willnot feel anything$ no one in medicine taught us how to

palpate the thyroid and no one as"ed us about it e cept 7r&Mona$ so I really don’t "now how to e plain this to you#•• Bac"

oo Since the patient is already sitting up e amine the bac" beforemoving on to the chest

oo As" the patient to sit up and cross his or her arms and hold up theirgown

oo InspectionSpinal deformitiesScarsSwellings

3hest movementsoo 5alpation

Before doing this as" the patient if there is any tendernessand if there is start palpating away from the tender area andthen palpate the area last@hile palpating as" the patient to tell you if there is anytenderness


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)emember to compare both sides at each percussion i&e&you start percussing from the left then you move to the samearea on the right then go to the ne t area below that !still onthe right side# then move to the same area on the left side!so you move li"e this

/idal percussion !only 7r& Mona mentioned this to us$ and Icouldn’t find it in any boo"$ this is what I understood from her but please MA94 S1)4 .< /H4 3.))43/ @AY /. 7./HIS# before starting as" the patient’s permission to drawmar"s on him

•• 5ercuss in the mid-clavicular line from the bac" !is itcalled the mid-clavicular line, I’m not sure' but itshould correspond to the mid-clavicular line in thebac"#

•• 5ercuss downwards until you reach an area ofdullness and "eep your finger over the area

•• As" the patient to ta"e a deep breath and hold it•• 5ercuss from the previously dull area downwards until

you find the new area of dullness•• Mar" the area•• As" the patient to e hale completely and hold his

breath•• 5ercuss upwards until you find the area of resonance•• Mar" it•• Measure the area$ normally it is L cm !I thin"#•• )epeat on the other side of the chest•• /his is done to chec" for any diaphragmatic paralysis•• .n the right side the liver interferes with it !but I’m not

e actly sure what it does to change the value#oo Auscultation

5lace your stethoscope at the same areas of percussion andlisten to breathing of the patient !the *uality of the breathing

bronchial or vesicular and the air entry/hen go bac" and place your stethoscope at the same areasof percussion again and as" the patient to whisper QQ in4nglish or 22 in Arabic and listen to the vocal resonance!vocal resonance and tactile vocal fremitus go hand in hand$if one is reduced the other will also be reduced +404) say

that one is reduced and the other is normal#•• 3hest !remember here you are e amining both the lungs and the heart#

oo InspectionScarsHair distribution7istended veins$ spider nevi$ any discolorations

Any s"eletal deformities.bvious pulsations

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3hest movementsoo 5alpation

As" the patient if there is any tenderness and start palpatingaway from that area and leave it for last

As you palpate loo" at the patient’s face and see if he is in

pain and as" him to tell you if there is any tendernessSame as for the palpation of the bac" Also palpate the ape beat !the most lateral and inferiorpoint at which pulsations can be felt#5alpate for thrills and parasternal heave !by placing yourhand on its side with your thumb pointing outwards and your small finger on the chest against the left sternal edge

oo 5ercussionSame things as for the bac" !e cept for the tidal percussion#

oo" at +icholas for the areas you should percussoo Auscultation

Same things as for the bac" Auscultation of the heart

•• Start with the diaphragm at the ape•• Move to the tricuspid area at the L th left intercostal

space at the edge of the sternum•• Move to the pulmonary area at the ? nd left intercostal

space•• Move to the aortic area at the ? nd right intercostal

space•• /hen listen at the same areas using the bell

•• Abdomen !proper e posure is from the nipple to mid-thigh but in our cultureit is until the symphesis pubis $ ma"e sure the patient is lying flat on his bac"with his arms at his side this is very important for proper e amination

oo InspectionStand at the foot of the bed

oo" for movements and type of breathingoo" at symmetry of the abdomenoo" at shape of the abdomenoo" at hair distributionoo" at the shape of the umbilicusoo" for any scars

7iscoloration0isible swellings0isible pulsations !for this you need to bend down until youreyes are at the same level of the abdomen#

oo 5alpation( st and foremost as" the patient if there is any area oftenderness so you can avoid it and leave it for lastSuperficial palpation

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•• You are feeling for rigidity$ guarding$ superficialtenderness$ and superficial masses

•• If there is no tenderness$ start palpating lightly at theright iliac fossa moving in a counter-cloc"wisedirection to the hypogastrium$ left iliac fossa$ left

lumbar region$ left hypogastrium$ epigastrium$ righthypochondrium$ right lumbar region$ and finallyumbilical region

•• A @AYS loo" at the patient’s face as you palpate tosee if you are causing any pain& /his is very importantand most doctors will tell you off if you don’t loo" atthe patient’s face

7eep palpation•• You are feeling for deep tenderness and deep masses•• 5alpate the same way as for superficial but applying

more pressure with your hand as you palpate

.rgan palpation•• /he liver

5alpate the liver by starting in the right iliac fossa andas"ing the patient to ta"e a deep breath

As the patient e pires move your hand upward$ youmust practice the timing of your movement with thee piration9eep moving upwards until the edge of the liver hitsyour e amining handMa"e a mental note of where the lower border is andproceed directly to percussing the liver

•• /he spleen5alpate the spleen by starting at the right iliac fossaand move upwards and medially towards theumbilicus !why do you start at the )I


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I honestly have no idea how to palpate for them&However$ it can be palpated by a bimanual method&


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• +ormally the abdomen is resonant but when there isascites there will be dullness in the flan"s !fluidaccumulating there with the patient supine#

• If there is dullness$ chec" for shifting dullnessStart percussing from the midline to the left flan" until

dullness is reached As" permission and mar" the area)oll the patient to the right side !i&e& towards you#@ait => sec to ( min@ith the patient still on the side$ percuss from themar"ed area !the area of dullness# towards themidline of the abdomen/he previously dull area should become resonant asthe fluid shifts towards the midline and a new area ofdullness should be found closer to the midline

• 3hec" fluid thrill

As" the patient to place his hand at the midline of theabdomen !with the medial side of the hand againstthe abdomen#$ this is to stop the conduction of thevibrations by the s"in of the abdominal wall5lace one hand at the side of the abdominal wall@ith the other hand flic" the abdominal wall on theother side of the abdomenIf there is massive ascites a thrill will be felt by theopposite hand

o AuscultationBowel sounds

• 5lace the stethoscope %ust below the umbilicus andlisten to the gurgling of the bowels

iver 8 spleen• 5lace the stethoscope over the two organs and listen

for a friction rub as the patient breathes0enous hum

• Best heard between the iphisternum and theumbilicus

Bruits• Heard over the liver if there is hepatocellular cancer • Heard in the renal arteries if there is renal artery

stenosis' listen on either side of the midline above theumbilicus

•• ower limbsoo Inspection

oo" for bruising$ scratch mar"s$ discolorationR1lcersSwellings

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0aricose veinsoo" at the toes for clubbing$ cyanosisoo" between the toes for ulcers$ infectionsRoo" for %oint deformities

oo 5alpation

5alpate the temperature of the legs and feet3hec" the capillary refilling of the toes in the same way youchec" the fingers3hec" for pitting edema by pressing the thumb for at least(L sec against the shaft of the tibia or (L cm from

the patella downward and put your finger on that point•• /hen wrap the measuring tape around the leg at the

point where your finger is and read the measurement•• )epeat the process with the other leg•• /hen repeat the same thing but this time instead of

measuring downwards go upwards to the thigh•• A difference greater than ( cm between the two legs

is significant

Cardiovascular Syste%Cardiovascular Syste%•• )ead the history from 7r 9indy’s notes you will find that they are enough•• 5hysical e amination

oo 5ositionF at 2LPoo ;eneralF

(&(& middle-aged male$ lying comfortably?&?& well-nourished or cachectic → malignancy

→ severe cardiac failure!enlarged liver$ anore ia$mesenteric vessels#

=&=& well-developed

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2&2& consciousL&L& ill-loo"ingM&M& not in distress !resp& distress → dyspnea#N&N& obviously pale → anemia !prosthetic heart vavle → hemolytic#

→ shoc"

→ faintingO&O& cyanosis → central !congenital heart disease with right to left

shunt#→ peripheralF reduced cardiac output as in heartfailure$ or arterial obstruction

Q&Q& %aundice → severe congestive cardiac failure → hepatic congestion → prosthetic heart valve inducing hemolysis

(>&(>& features of syndromes → Marfan’s → 7own’s

→ /urner’s((&((& others → connected to I0 line or wearing face mas" or eye

glasseso 0ital signs

(&(& temperature?&?& pulse=&=& blood pressure !sitting vs& standing#2&2& respiratory rate !tachypnea$ dyspnea#

o Hands@arm and moist3yanosed$ %aundiced$ or pale+o muscle wasting or nicotine staining

aneway lesions 8 .sler’s nodules !infective endocarditis#loo" for them on the pulps of the fingers and the thenar 8

hypothenar eminences3hoiloychia$ leu"onychiaSplinter hemorrhage → trauma

→ infective endocarditis → rheumatoid arthritis → polyarteritis nodusa

3lubbing → cyanotic congenital heart disease

→ infective endocarditis → unilateral !bronchial A0 aneurysm$ a illaryartery aneurysm#

/endon anthomata → type II hyperlipidemia5almer anthomata 8 tubeo-eruptive anthoma → type IIIhyperlipidemia


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o Arterial 5ulse)ate)hythm

)e gularity Bradycardia /achycardia)egular 5hysiological !athletes$ sleep&&

7rugs !digo in$ B-bloc"ers&&HypothyroidismHypothermiaSevere %aundiceIncreased intracranial pressure=rd degree A0 bloc" T ? nd degree A0bloc"Myocardial infarction

Hyperdynamic circulation

4 ercise or an iety


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3haracter → pulsus alternans !left ventricular failure# → collapsing pulse !aortic incompetence#

!patient with collapsing pulse will most li"elyhave wide pulse pressure systolic U diastolicV > or 2> WI’m not sure of the number e actlyX#

.ther palpable vessels → carotid → brachial !medial to biceps tendon# → femoral → popliteal → dorsalis pedis → posterior tibial

o Blood pressure Auscultatory gap !in healthy people#Systolic pressure varies between the arms by up to (> mmHgIn legs blood pressure is higher

7uring inspiration the systolic and diastolic pressures decreaseby up to (> mmHg5ulsus parado us is an e aggerated reduction of systolic 8

diastolic during inspiration !V (> mmHg#→ constrictive pericarditis→ pericardial effusion→ acute asthma !severe#

High blood pressure → V (2>-(2LCQ> mmHgMalignant blood pressure → V (=> mmHg T papilloedema5ostural hypotension → fall of V (> mmHg on standing or V (L

mmHg systolic3auses → hypovolemia

→ drugs !vasodilation$ diuretics&& → Addisson disease → hypopituritarism → diabetes mellitus → idiopathic

o /he face4yes

aundice5allor Stigmata of coronary disease → anthelasma

→ arcus senalis !or arcuscornealis#

Stigmata of infective endocarditis → petechia→ )oth’s spot !inretina#

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Mitral facie !rosy cheec"s and bluish tongue# occurs insevere mitral stenosisMouth

•• 7iseased teeth → infective endocarditis•• 3entral cyanosis•• Mucosal petechia → infective endocarditis•• High arched palate → Marfan’s syndrome !aortic and

mitral regurgitation#o +ec"

3arotid artery → pulse character 8 volume !table in+icholas#

05•• 3auses of increase → right ventricular failure

→ tricuspid stenosis or regurge → pericardial effusion or constrictive

pericarditis → S03 obstruction → fluid overload → hyperdynamic circulation

•• 7ifference between 0 8 carotid→ 05 more seen than felt→ pressure at the base of the nec" obliterates 05→ 05 decreases with inspiration→ 3arotid is medial to strenocleidomastoid while 05 islateral→

05 is more prominent on lying down→ 05 is wavy while carotid is pulsatile→ very high 05 causes pulsatile displacement of the ear lobes→ hepato%ugular refle increases 05 !if you press on theliver the 05 shoots up#

/hyroid → enlargemento 5raecordium

Inspection•• Scar → lateral thoracotomy scar !closed mitral

valvotomy# → median sternotomy scar !valve replacement$coronary artery bypass grafting

•• S"eletal chest deformities → pectus e cavatum !funnelchest#F Marfan’s !alter position of ape beat#

→ "yphoscolyosis !Marfan’s# → bulging

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•• 5acema"er bo → obvious pulsation under right or leftpectoral muscle

•• 0isible ape beat•• .ther visible pulsations → pulmonary area !severe

pulmonary hypertension#

→ aortic area !aneurysm of archof aorta or ascending aorta# → epigastric !right ventricularenlargement$ hepatic congestiondue to heart failure$ aorticpulsations$ or transmitted pulse# → left parasternal → nec" !suprasternal orsupraclavicular#

5alpation•• Ape beat

oo ocation→ normally in the left L th intercostal space slightlymedial to the midclavicular line→ displaced laterallyF ventricular enlargement$ largepleural effusion$ pneumothora $ scoliosis$ pectuse cavatum#

oo 3haracter → hyper"inetic !diffuse#F aortic or mitral incompetence$patent ductus arteriosus$ ventricular septal defect→ sustained !locali6ed$ not shifted#F left ventricular

hypertrophy !aortic stenosis$ systemic hypertension$coarctation of the aorta#→ tapping !palpable$ accentuated S($ not shifted#Fmitral stenosis$ tricuspid stenosis#

oo +ot palpable ape beatF poor techni*ue$ thic" chestwall$ emphysema$ pericardial effusion$ shoc"$de trocardia#

oo 5arasternal heaveF right ventricular enlargement$severe left atrial enlargement$ sometimes it may bedue to severe mitral regurge#

oo 5alpable tap of 5?F pulmonary hypertensionoo /hrills !organic murmurs#

→ apical thrills !left lateral position#SystolicF mitral incompetence$ ventricularseptal defect7iastolicF mitral stenosis

→ basal thrills !lean forward in full e piration#

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SystolicF aortic stenosis$ pulmonary stenosis$pulmonary hypertension7iastolicF aortic incompetenceJ can be non-cardiacF vascular goiter$ vascularmediastinal tumour$ A0 aneurysm

→ continuous !upper left sternal edge#F patent ductusarteriosus5ercussion !no need#

Auscultation•• Bell !low pitch# → S=$ S2$ mitral stenosis$ tricuspid

stenosis•• 7iaphragm → S($ S?$ clic"$ snap$ aortic incompetence$

mitral incompetence•• +ormal heart soundsS( → variable !atrial fibrillation$ atrial flutter#

→ loud !mitral stenosis$ tricuspid stenosis$tachycardia or short A0 conduction time e&g& anemia$hypertension$ an iety$ e ercise #→ soft !prolonged diastolic filling time ( st degreeheart bloc" $ delayed onset of left ventricular systole

left bundle branch bloc" $ mitral regurge#S? → loud aortic component !systolic hypertension$congenital aortic stenosis#

→ soft A? !calcified aortic valve$ aortic regurge#→ loud 5? !pulmonary hypertension#→ splitting

o Increased normal splitting !wider on inspiration#→ right bundle branch bloc"$ pulmonarystenosis$ ventricular septal defect$ mitralregurge

o


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)ight ventricular S= !left sternal edge$ louder oninspiration# heard in right ventricular failure$constrictive pericarditis$ tricuspid regurge$ pericardial"noc"

K S2 !late diastolic#

eft ventricular S2 !left lateral position$ when leftventricular compliance is reduced# heard in aorticstenosis$ systemic hypertension$ acute mitral regurge$ischemic heart disease$ advanced age)ight ventricular S2 !when right ventricularcompliance is reduced# heard in pulmonary stenosisand pulmonary hypertension

K summation gallop heard when there is rapid heart ratecausing superimposed S= 8 S2

•• Added soundsK opening snap

Mitral stenosis/ricuspid stenosisK systolic e%ection clic"

3ongenital aortic stenosis !louder in e piration#5ulmonary hypertension !louder in inspiration#

K non-e%ection systolic clic"Mitral valve prolapse

Atrial septal defectK pericardial rub !varies with respiration$ loudest whenthe patient sits up and breathes out#

pericarditis

K diastolic pericardial "noc"3onstrictive pericarditisK metallic sound

5rosthetic heart valve•• Murmurs !read 7r& A"htar’s note$ it is more than enough'

but here are some of the important ones you should"now#

Mitral stenosisK loud S(K loud 5?K opening snap

K low pitched rumbling diastolic murmur K late diastolic accentuation may occur K best heard in the left lateral positionK accentuated by e erciseMitral regurgeK soft or absent S(K left ventricular S=K pansystolic murmur

28


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K ma imal at the apeK radiating towards the a illaK accentuated by e ercise and hand grip

Aortic stenosisK reversed S?

K harsh mid-diastolic e%ection murmur K e%ection clic"K ma imal over the aortic areaK e tending over the carotid arteriesK loudest with the patient sitting up and in fulle pirationK accentuated with e ercise

Aortic regurgeK soft A?K de-crescendo high pitched diastolic murmur

oudest at the third 8 fourth left intercostal space

/ricuspid stenosisK diastolic murmur K accentuated by inspirationK loud S(K loud 5?K opening snapK low pitched rumbling diastolic murmur /ricuspid regurgeK pansystolic murmur K ma imal at the lower end of the sternumK increases on inspiration

5ulmonary stenosisK e%ection clic"K harsh loud e%ection systolic murmur K heard best in pulmonary areaK accentuated by inspirationK S2 may be present5ulmonary regurgeK decrescendo diastolic murmur K high-pitchedK audible at the left sternal edgeK increases on inspiration

oo

/he bac" ung bases•• Signs of heart failure

ate or pan-inspiratory crepitation5leural effusion

5itting sacral edema K severe right heart failureoo /he abdomen

4nlarged tender liver K congestion or right heart failure

29


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5ulsatile liver K tricuspid regurge Ascites K severe right or congestive heart failureSplenomegaly K infective endocarditis

oo ower limb4dema•• 5itting edema

3ardiac K congestive heart failure$ constrictivepericarditisHepatic K cirrhosis)enal K nephrotic syndrome;astrointestinal K malabsorption$ starvation

•• 5itting unilateral edema70/3ompression of large veins by tumor or lymph node

•• +on-pitting lower limb edemaHypothyroidism

ymphedemaK infections !filariasis#K malignant !tumor lymphatics#K congenital !lymphatic development arrest#K allergy

5eripheral vascular disease• )educed or absent pulses•


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K cardiac failureK prolonged immobili6ationK traumaK occult neoplasmK 7I3

K 3ontraceptive pillK pregnancy Acute arterial occlusion

• )esults from4mbolism from thrombus of the heart secondary to

K MIK dilated cardiomyopathyK atrial fibrillationK infective endocarditis

Sign of embolus in ma%or arteryK pain

K pulselessK paleK paraly6ed limb

0aricose veins• Inspection

/ortuous dilated branches of long saphenous in frontof the whole legBac" of lower leg for branches of short saphenousveinsSigns of venous stasisK inflamed

K swollenK pigmented• 5alpation

Hard leg veins K thrombosis/enderness K thrombophlebitis

• 3ough impulse test


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K basal cell carcinomaK s*uamous cell carcinomaK melanomaK lymphomaK "aposi’s sarcoma

InfectionK staph aureusK syphilitic gummaK /BK atypical mycobactK fungal+europathicK painless penetrating ulcer on sole of foot due toperipheral neuropathy !7M$ tabes$ leprosy#1nderlying systemic diseaseK 7M

K pyoderma gangrenosumK )h arthritisK lymphomaK hemolytic anemia !small ulcer over maleoli e&g&sic"le cell anemia#

&espiratory Syste%&espiratory Syste%•• )ead the history from 7r 9indy’s notes•• 5hysical 4 amination

oo 5osition K undressed to the waistoo ;eneral

Middle-aged$ lying comfortably@ell-nourished$ weight lossK /BK carcinomaK chronic bronchitisK emphysema@ell-developedK "yphoscoliosisK bronchiectasis+ot under distress$ or under respiratory distressK tracheal descent

K tachypneaK accessory muscles of respiration3onscious$ or confusion or comaK hypo iaK hypercapnea.bviously paleK anemia due to chronic hemoptysis3yanosed

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•• 3entral !tongue#oo 3.57oo ung diffusion defect !pneumonia#oo 5ulmonary A0 fistulaoo Massive pulmonary embolism

•• 5eripheraloo 3auses of central cyanosisoo S03 syndrome

aundice K cor pulmonale.bserve the symptoms•• 3ough

oo ac" of e plosive sound !hollow$ bovine sound#K vocal cord paralysis

oo Muffled$ whee6y K airflow limitationoo oose productive K chronic bronchitis$

bronchiectasis$ pneumoniaoo 7ry$ irritating K chest infection$ asthma$ carcinoma of

the bronchus$ left ventricular failure$ interstitial lungdisease$ A34 inhibitors

•• Sputumoo 5urulentoo Mucoidoo Mucopurulentoo @ith blood

•• Stridor !croa"ing noise$ loud on inspiration#oo Sudden onset

K anaphyla isK to ic gas inhalationK acute epiglotitisK inhaled foreign body

oo ;radual onsetK laryngeal or pharyngeal tumor K crico-arteroid rheumatoid arthritisK bilateral cord palsyK tracheal carcinomaK paratracheal compression by lymph nodesK post tracheostomy

••

Hoarsenessoo aryngitisoo )ecurrent laryngeal nerve palsy associated with lung

carcinomaoo aryngeal carcinoma

•• .thersoo 3onnected to I0 line or face mas"oo


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oo 3ushingoid featuresK steroid use in asthma or chronic bronchitisK ectopic A3/H secretion by bronchogenic !smallcell# carcinoma

•• 0ital signoo /emperature K any acute or chronic chest infectionoo 5ulse

/achycardiaK hypo iaK hypercapniaK cor pulmonale3ollapsing pulseK hypercapnia/achycardia 8 pulsus parado usK severe asthma

oo Blood pressureoo )espiratory rate

/achypnea ! V (2-( Cmin#K sign of dyspnea

•• Handsoo @arm 8 moist K hypo ia 8 hypercapniaoo 3yanosed$ %aundiced$ 8 paleoo @asting 8 wea"ness of small muscle of hand K infiltration of 3O 8

/( nerve root by lung tumor oo 5almer erythema

3.? retention)espiratory failure3.57

ung carcinomaoo +icotine stainingoo +ail

5allor K anemia9oilonychia K iron deficiency anemia

eu"onychia K hypoalbuminemia3lubbingK H5. !primary lung carcinoma$ pleural mesothelioma#K bronchogenic carcinomaK bronchiectasisK lung abscess 8 empyemaK pulmonary fibrosisK fibrosing alveolitisK /B !uncommon#Jchronic bronchitis 8 emphysema do +./ cause clubbing

oo


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oo oints•• 4ye

oo Anemiaoo aundiceoo Horner’s syndrome

Apical lung tumor !compress sympathetic nerve in the nec"#oo oss of sweatingoo 3onstricted pupiloo 5artial ptosis

•• Sinusesoo Its tenderness K sinusitis

•• Mouthoo )eddened pharyn 8 enlarged tonsils K 1)/Ioo /ongue K central cyanosisoo Bro"en or rotten tooth predispose to

K lung abscessK pneumonia

••


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K lung pathologyoo Bulging

K neoplastic lesionK aneurysmK cardiac enlargement

Shape of chestoo Barrel chest

•• Severe asthma•• 4mphysema•• /horacic "yphosis

oo 5igeon chest•• 3hronic childhood regular illness•• )ic"ets

oo


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K air in the mediastinumoo 5rominent veins

K S03 obstructionoo Breast

K gynecomastia indicates bronchogenic carcinoma

Movement of chest walloo Assess asymmetry of chest e pansion by inspectionoo 7ecreased unilaterally

K local pulmonary fibrosisK consolidationK collapseK pleural effusionK pneumothora

oo 7ecreased bilaterallyK 3.57K diffuse pulmonary fibrosis

K asthmaK emphysemaoo 5alpation

5lapate for oo 3utaneous or subcutaneous massesoo Subcutaneous emphysemaoo /enderness

K rib fractureK tumor invade chest wall

Ape beatoo 7isplaced toward side of lesion

K collapse of lower lobeK locali6ed pulmonary fibrosis

oo Away from side of lesionK pleural effusionK tension pneumothora

oo ImpalpableK hypere panded chest secondary to airflow limitation

3hest e pansionMeasuring ma imum chest e pansionoo L cm is normaloo (-? cm is abnormal/actile fremitusoo 77 of decreased /0<

•• /hic" s"in 8 musculature•• /hic" pleura•• 5leural effusion•• 5neumothora••


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•• Massive pulmonary edema•• Bronchial obstruction

oo 77 of increased /0<•• 3onsolidation•• ung collapse in intimate contact with trachea or

bronchi•• ung mass•• Heavy but not obstructive pulmonary secretions

oo 5ercussion)esonance

oo +ormal lungHyperresonance

oo 5neumothoraoo Acute attac" of bronchial asthmaoo 4mphysemaoo 3avity !/B cavity$ neoplastic cavity$ lung abscess#

7ullnessoo 3onsolidationoo 3ollapseoo


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K e*ual phasesK louder e pirationK gapK occurs in

ung consolidation

ocal pulmonary fibrosis5leural effusion3ollapsed lung

Intensity of breath soundsoo 7ecreased

•• 3.57•• 5leural effusion•• 5neumothora•• 5neumonia !consolidation#•• arge neoplasm•• 5ulmonary collapse•• 5ulmonary fibrosis

Added soundsoo )honchi !continuous whee6e#

•• ouder in e piration•• Inspiratory whee6e K severe airway narrowing•• High pitch K small airway•• ow pitch K large airway•• Heard in

Bronchial asthma !high pitch#3hronic bronchitis !low pitch#4mphysema3arcinoma of lungK locali6ed$ single *uality rhonchiK not clear with cough$ louder in inspiration

oo 3repitation !intermittent#•• 4arly inspiratory

Medium coarseK 3.57 !chronic bronchitis$ emphysema#K asthmaK carcinoma !locali6ed rhonchi#

•• ate or pan-inspiratory


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•• 3ontinuous or intermittent grating noise$ louder withdeep inspiration

•• 5leurisy K pneumonia0ocal resonance

•• Heartoo Increased 05oo Increased 5?oo ouder 5? K pulmonary hypertensionoo 3or pulmonale due to

K 3.57K pulmonary fibrosisK pulmonary thromboembolismK severe "yphoscoliosis

•• Abdomenoo iver ptosis

K 3.57oo Hepatomegaly

K secondary to deposit of lung carcinomaoo Ascites

K cor pulmonale•• .thers

oo 5emberton’s signS03 obstruction

K facial plethoraK inspiratory stridor K non-pulsatile elevation of 05

oo pneumococcus#oo Bronchial pneumonia !bacterial$ viralF influen6a$ adenovirus$

measles$ cytomegalovirus#oo 5rimary atypical pneumonia !mycolpasma pneumonia#

•• 3auses of collapseoo Intraluminal !mucus K asthma$ cystic fibrosis#oo Mural !bronchial carcinoma#oo 4 tramural !peribronchial lymphadenopathy$ aortic aneurysm#

•• 3auses of pleural effusionoo /ransudate

Heart failureHypoalbuminemia !nephrotic syndrome$ chronic liverdisease#HypothyroidismMeig’s syndrome

40


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oo 4 duate5neumonia+eoplasm/B5ulmonary infarction

Subphrenic abscess Acute pancreatitis3onnective tissue disease !S 4$ )h arthritis#7rugs !cytoto in#Irradiation/rauma

oo HemothoraSevere trauma to the chest)upture of pleural effusion containing blood vessel

oo 3hylothoraSurgery or trauma to thoracic duct3arcinoma or lymphoma of thoracic duct

oo 4mpyema5neumonia

ung abscessBronchiectasis/B5enetrating chest wound

•• 3auses of pneumothoraoo Spontaneous

Sub-pleural bullae rupture4mphysema with rupture of bullae

oo /raumatic)ib fracture5enetrating chest wall in%ury7uring pleural aspiration

•• 3auses of tension pneumothoraoo /raumaoo Mechanical ventilation at high pressure

•• 3auses of generali6ed emphysemaoo 4mphysema associated with chronic bronchitis 8 smo"ingoo Idiopathicoo Alpha-antitrypsin deficiency

•• 3auses of chronic bronchitisoo Smo"ingoo )ecent chest infection

•• 3auses cystic fibrosisoo 1pper lobe !S3HA)/#

SilicosisSarcoidosis

41


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3oal wor"er’s pneumoconiosisHistocytosis

An"ylosing spondylitis Allergic aspergillosis)adiation

/Boo ower lobe !)ASI.#

)A AsbestosisSclerodermaIdiopathic fibrosing alveolitis.therF drugs !busulphan$ methotre ate#

Gastrointestinal TractGastrointestinal Tract• )ead the history from 7r 9indy’s notes

oo 5ain radiation/o the bac"

5ancreatitis5erforating peptic ulcer

/o the shoulders7iaphragmatic irritation

/o the nec")efle esophagitis

• 5hysical e aminationoo 5osition 8 e posure !from nipple to mid-thigh lying flat with the arms by the

side#oo ;eneral

Young male$ lying comfortably on bed+ot in distress@ell-nourished

@ith anore iaKK MalignancyKK MalabsorptionKK Hypermetabolic state !thyroto icosis#KK 7ysphagia@ell-developedKK Sic"le cell diseaseKK

/halassemiaKK ;lycogen storage disease3onscious$ comatose$ or stuperousKK Hepatic encephalopathy

7ecompensated advanced cirrhosis !chronic liver failure#


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o iver cell damage → unable to remove to ins !amonia$mercaptans$ short chain fatty acids$ amines# → portosystemic shunting

.bviously paleIron deficiency anemiaKK MalabsorptionKK Blood lossMegaloblastic anemiaKK MalabsorptionHemolytic anemiaKK Hypersplenism

Anemia of chronic illnessaundiced !natural daylight 7.+’/


44/64

Severe long standing chronic liver diseaseS"in

5igmentationKK ;eneral s"in pigmentation

iver cirrhosis

HemochromatosisKK Addison type pigmentation !due to malabsorption#

+ipples5almer creases5ressure areasMouth

5euts- egher’s syndromeKK #Hamartoma of colon !=> #

KK 5resent withIntussceptionBleeding;I carcinoma

Acanthosis +igricansKK Blac" velvety color of epidermisKK 3an be in a illa or body folds li"e genital areasKK Associated with

;I carcinomaymphoma

7iabetes mellitus Acromegaly

Hereditary hemorrhagic telangectasia !)endu- .sler- @ebersyndrome#KK Multiple small telangectasia in lips$ tongue$ 8 s"inKK Associated with

A0 malformation in liver KK 5atient presents with

;I bleeding5ophyria 3utanea /ardaKK 0esicles in e posed areas of s"in 8 hand with scarringKK 7isorder of porphoryn metabolism → dar" urineKK Associated with

Alcoholismiver disease

Hepatitis 3Systemic sclerosisKK /ense tethering of s"in !hardening 8 thic"ening#KK Associated with

44


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;astro-esophageal reflu4sophageal motility disorders;I motility disorders

7ermatitis herpetiformisKK 5ruritic vesicles on "nees$ elbows$ 8 buttoc"sKK Associated with3eliac disease

.thers3onnected to I0 line

oo 0ital sign/emperature

;I infection


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iver cirrhosis5regnancy.ral contraceptives/hyroto icosis)heumatoid arthritis

5olycythemia7upuytren’s contractures

Manual wor"er Alcoholic cirrhosis


47/64

Arms$ nec"$ chest wall$ occasionally may bleed blanching withpressure on central arteriole3aused byKK iver cirrhosisKK /ransiently with viral hepatitis

KK 5regnancy A illary ymphadenopathy !L groups of lymph nodes#oss of a illary hair !sparse#

3ampbell de Morgan0enous stars !increase venous pressure#

oo


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1lcer KK ;um hypertrophy

5henytoin5regnancyScurvy

;ingivitiseu"emiaKK 5igmentation

Heavy metals7rugs !antimalarials$ oral contraceptives#

Addison’s disease5eut6- egher’s syndromeMalignant melanoma

KK 7ecayed


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KK ;eographic tongue0itamin B(? deficiency

KK ingua nigraIncrease "eratin bismuth

Mouth ulcers

KK 3ommon Aphthous7rugs !gold$ steroid#/rauma

KK 1ncommon;I

o 3rohn’s diseaseo 1lcerative colitiso 3eliac disease)heumatoid

o Beh"et’s syndromeo )eitre syndrome4rythema multiformeInfection

o 0iral !herpes 6oster$ herpes simple #o Bacterial !syphilis$ /B#Self-inflictedHI0

3andidiasis !thrush#KK ImmunocompromisedKK 5erson on broad spectrum antibiotics !"ills normal flora#

+ec"3ervical ymphadenopathy !left supraclavicular → virchow’s node#/roisier signKK 3ombination of virchow’s node 8 carcinoma of stomach

3hestSpider neviHair on chestMuscle wasting 8 fasiculations;ynecomastiaKK 3irrhosis

Alcoholic cirrhosis

3hronic obstructive hepatitisKK 7rugs7igo in3imitidine

KK Alcoholism without liver disease !damage of leydig cells of testis# Abdomen

InspectionKK


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;eneral abdomen distensiono


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o iver biopsyo aparoscopyo Iliostomy or colostomy5rominent veins

o Severe portal hypertension !caput medusa#o Inferior vena caval obstruction !flow towards the headStria

o Asciteso 5regnancyo )ecent loss of weighto @ide$ purple → 3ushing syndromeS"in lesion

o 0esicles of herpes 6oster o Sister oseph nodules → deposits of metastatic tumor in the

umbilicuso 1mbilical blac" eye !3ullen sign# → e tensive hemorrhagic

peritonitis or acute pancreatitiso S"in discoloration in flan"s !;rey-/urner sign# → severe

acute pancreatitisBruises 8 hemorrhages3autery mar"Superficial massesInguinal orfices

5alpationKK Superficial

Abdomen is soft 8 la → guarding 8 rigidity → peritonitis

+o area of tenderness which can be !appendicitis$cholecystitis$ peritonitis$ nerveousness#+o area of rebound tenderness → peritonitis+o palpable superficial mass

KK 7eep palpation+o palpable deep masses

KK .rgan palpationiver

;allbladder Spleen9idney5ancreas

AortaBowelBladder Inguinal lymph nodes/estes

Anterior abdominal wall

51


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Abdominal tumor

• iveroo /he liver is palpable 2 cm below the costal margin$ upper border is at the

level of the th rib in the mid-clavicular lineoo


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Budd-3hiari syndrome !congestion#Hepatic abscess

oo 5ulsatile liver /ricuspid regurgeHepatoma with hepatocellular carcinoma

0ascular abnormalityoo Soft smooth tender liver

Hepatitis3ongested liver

Budd-3hiari syndrome)ight heart failure

oo Hard 8 irregular MetastasisMacronodular cirrhosis

oo 77 of normal span$ palpable liver 5tosis

Asthma4mphysemaSubdiaphragmatic collection

)iedel’s lobe

• ;allbladder oo 5alpable below the right costal margin as it crosses the lateral border of the

rectus abdominus muscleoo A palpable gallbladder will be bulbous$ focal rounded soft mass that moves

with inspiration !downwards#oo 3auses of enlargement

@ith %aundice3arcinoma of the head of the pancreas3arcinoma of the ampulla of vater

@ithout %aundiceMucocele or empyema of gallbladder 3arcinoma of gallbladder !stone hard irregular surface#

Acute cholecystitisoo 3ourvoisier’s law

If the gallbladder is enlarged and the patient is %aundiced$ the cause isless li"ely to be gallstones$ rather a carcinoma of the pancreas or lower

biliary tree resulting in obstructive %aundice is li"ely to be present A gallbladder with stones is usually fibrosed$ not capable of enlargementoo Murphy’s sign !the patient catches his breath during inspiration while you

palpate the gallbladder# → if cholecystitis is suspectedoo L> of enlarged gallbladders are +./ palpable

• Spleenoo Spleenomegaly

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Massive3hronic myeloid leu"emiaMyelofibrosisMalaria9ala A6ar

5rimary lymphoma of spleen/ropical spleenomegaly

Moderate/he above causes5ortal hypertension

ymphomaeu"emia !acute or chronic#

/halassemiaStorage disease e&g& ;aucher’s disease

Mild/he above causes.ther myeloproliferative disordersKK 5olycythemia rubra veraKK 4ssential thrombocythemiaHemolytic anemiaMagaloblastic !rarely#InfectionKK 0iral

Infectious mononucleosisHepatitis

KK BacterialInfectious endocarditis

KK 5roto6oalMalaria

3onnective tissue diseaseKK )heumatoid arthritisKK S 4KK 5olyarteritis nodosaInfiltrationKK AmyloidKK Sarcoid

oo Spleenomegaly without portal hypertension3hronic active hepatitis5rimary bleary cirrhosis

Alcoholic hepatitisIdiopathic hemochromatosis

oo 7ullness in /raube’s areaSpleenomegaly4nlarged left lobe of the liver /umor of fundus of the stomach

54


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Massive pleural effusionSevere cardiomegally

oo HepatospleenomegalyHematological

ymphoma

eu"emia5ernicious anemiaSic"le cell disease

Infection Acute viral hepatitisInfectious mononucleosis3ytomegalovirus

Infiltration AmyloidSarcoid

3onnective tissue diseaseS 4

Acromegaly/hyroto icosis3hronic liver disease with portal hypertension

• 5ancreasoo 5ancreatic pseudocyst after acute pancreatitisoo )ounded swelling above the umbilicusoo /enseoo 7oes +./ descend with inspirationoo


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oo 5ercussion V dull

• Inguinal lymph nodesoo Along the inguinal ligamentoo Along the femoral vessels

• /estesoo /esticular atrophy → chronic liver disease

• Anterior abdominal walloo umps

ipomaSebaceous cysts7ermal fibromaMalignant deposit → melanoma or carcinoma4pigastric hernia1mbilical or para-umbilical herniaInguinal hernia)ectus sheath divarication)ectus sheath hematoma

• Abdominal massoo 5ositionoo Si6eoo 3onsistencyoo Shapeoo Mobility

Moves down with inspirationStomach/ransverse colon

iver Spleen;allbladder 9idney

+o movement with respiration5ancreas5ara-aortic lymph nodes

7escending colon3ecum1rinary bladder

oo Ability to get above the mass Able to

4nlarged "idney5yloric tumor

+ot able to

56


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4nlarged liver 4nlarged spleen

oo Ability to get below the mass Able to

3olonic mass

+ot able to1rinary bladder 1terus5elvic tumor

oo 3auses of mass in)ight iliac fossa

Appendicular abscess3arcinoma of the cecum3rohn’s disease5elvic "idney.varian tumor or cyst3arcinoid tumor

Amebiasis5soas abscessIliocecal /BHernia

eft iliac fossa


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KK /umor KK


59/64

o Metastasiso )ecent liver biopsyo iver infarcto iver abscesso ;onococcal perihepatitis

Spleeno Splenic infarct

KK Bruits Arterial systolic bruit over the liver o Hepatocellular carcinomao Acute alcoholic hepatitiso A0 malformation.ver enlarged "idney

o Hypernephromaower abdomen

o +arrowing of aorta or iliac arteryo Aortic aneurysm1pper abdomen

o )eferred from hearto +arrowing of small mesenteric vessels)enal bruits

o )enal artery stenosisKK 0enous hum !increase during inspiration#

/ypically heard between iphysternum 8 umbilicus → portalhypertension3ruveilhier- Baumgarten sign

o Association of venous hum at the umbilicus 8 dilatedabdominal wall veins → cirrhosis of the liver

5resence of venous hum or caput medusa suggest that thesite of portal obstruction is intrahepatic rather than in the portalvein itself

)ectal e amination

Surgery Case &eportSurgery Case &eportSunday$ May ?( st$ ?>>

I7I7

Mr& Humood is a ?2 year old single$ Saudi gentleman& He is originally from)iyadh but lives in Al-9hobar and wor"s as a guard in the 9ing >complaining of abdominal pain of about L hours duration&

History of 5resenting IllnessHisto ry of 5resenting Illness

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/he patient was apparently well until early /hursday morning around =F=> a&m&when he was wo"en from sleep by abdominal pain that was worst around theumbilicus& /he pain started suddenly$ was colic"y in nature$ and severe enoughto wa"e him from sleep& After a few hours the pain became worse in the right iliacfossa& It was e acerbated by movement and only relieved by an in%ection of

analgesics& /he pain was associated with pain and a burning sensation onmicturation as well as dar" urine& After the pain started$ the patient felt nauseousand anore ic$ and vomited three times$ but the vomiting didn’t relieve the pain&/he patient was constipated for ? days before the onset of the pain and remainedconstipated after its onset& /he patient was afebrile$ denied having diarrhea$rigors$ hematuria$ or discharge with the urine&

An appendectomy was done on > after which the painended and there were no complications after the operation&

5ast History5ast Histor y•• /raumaF none••

Blood transfusionF none•• MedicalF none !not "nown to have diabetes mellitus$ hypertension$ asthma$ orother illnesses#

•• SurgicalF none

7rug History7ru g History+one

Allergies Alle rgiesHe is allergic to dust !eye allergy# but no "nown allergies to foods or drugs&


61/64

o +o headacheso +o sensory nor motor disturbances

•• 4yeso +o vision disturbanceso +o discharge$ redness$ nor pain

•• 4arso +o hearing disturbanceso +o ringing$ discharge$ nor bleeding

•• +oseo +o disturbance in smello +o discharge nor bleeding

•• /hroato +o soarnesso +o difficulty nor pain in swallowing

•• 30So +o palpitationso +o chest paino +o an"le swellingo +o hypertensiono +o history of leg cramps$ no claudicationo +o history of varicose veins

•• )So +o couch$ sputum$ nor Hemoptysiso +o whee6ing nor dyspnea

•• Musculos"eletalo +o mylagia nor arthralgiao +o stiffnesso +o swelling over the %oints$ erythema$ nor tenderness

•• Hematological 8 )4So +o "nown blood diseaseso +o spontaneous bleeding nor bruisingo +o history of ymphadenopathy nor hepatosplenomegaly

•• S"ino +o change in color o +o itching nor rashes

61


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o +o history of cellulites

•• 4ndocrineC Metabolico +o heat nor cold intoleranceo +o change in sweatingo +o polydipsia

Monday$ May ?? nd$ ?>>5hysical 4 amination5h ysical 4 amination

•• ;eneralYoung male$ conscious and alert$ sitting comfortably on bed& @ell-developedand well-nourished& +ot in pain nor respiratory distress& +ot obviously pale$cyanosed$ nor %aundiced&

•• 0ital signs/emperatureF =N&?P

5ulseF O> beatsCminBlood pressureF (=>CN> mmHg within normal values)espiratory rateF ?> breathsCmin

•• Hands/he pulse is O> beatsCmin$ regular$ e*ual bilaterally$ of normal volume andcharacter$ no palpable vessel wall$ and no radiofemoral delay+ails are not pale nor cyanotic+o "oilonychias+o clubbing+o palmer erythema

•• Head 8 +ec"o 4yes

+o ptosis+o pallor nor %aundice+ormal movement in all directions

o Mouth+o peripheral nor central cyanosis+ormal color of gums$ no bleeding/onsils not enlarged

o +ec"+o palpable lymph nodes+o palpable masses+o thyroid swelling/rachea in central position

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•• 3hest e aminationo Inspection

Symmetrical chest movement+o scars nor deformities+o visible veins

o 5alpation+ormal chest e pansion and tactile vocal fremitus+o tenderness$ subcutaneous emphysema$ nor subcutaneous nodules+o enlarged a illary lymph nodes5alpable ape beat in L th intercostal space mida illary line

o 5ercussion+ormal resonant note on all parts of the lungs

o Auscultation

+ormal air entry0esicular breathing e*ual bilaterally+o added sounds+ormal vocal resonance on all parts of the lungs+ormal S ( T S ?+o added sounds

•• Abdominal e aminationo Inspection

)educed movement with respiration !thoracoabdominal respiration#L cm hori6ontal scar in the right iliac fossa that is not infected

+o dilated veins +o visible peristalsis+o visible pulsations+ormal hair distribution+o pigmentation of s"in+o swellings

o 5alpationSuperficial+o change in temperature+o rigidity

/enderness and guarding over the right iliac fossa /enderness K

7eep+ot done !patient refused#

o 5ercussion+ormal tympanic !wasn’t done on the right half of the abdomen as thepatient refused#

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o Auscultation+ormal bowel sounds+o bruits

o Scrotal 8 7igital )ectal 4 am+ot performed

•• ower limbs+o edema+o muscle wasting+o change in temperature+ormal sensation5oplitial$ posterior tibial$ and dorsalis pedis pulses were present

5roblem ist5roblem ist

Active Abdominal pain3onstipation7ysuria and burning sensation on micturation

Inactive+one

3linical Impression3linical Im pression/he patient had acute appendicitis which was treated with an appendectomy andhad no complications after the operation&

7ifferential 7iagnosis7ifferential 7ia gnosis•• Acute appendicitis•• Acute pyelonephritis•• )enal colic•• 3ystitis•• +on-specific mesenteric adenitis•• Mec"el’s diverticulitis•• 3rohn’s disease•• Mesenteric embolus•• )ight sided colonic diverticulitis•• Acute intestinal obstruction•• 5erforated peptic ulcer

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Surviving 4th Year Medicine