باطنية عملي pdf - د.اسماعيل

Clinical Training

50 SLIDES

for third year students

Prepared by

Dr. Ismael Dawoud

Chairman

Department of Medicine

2016 - 2017

Look to sclera, skin and frenium of tongue.
Causes:
1.

Hemolytic: hereditary (spherocytosis, thalasemia, etc. Acquired: Drugs like

penecilln, methydopa, disease like SLE, Lymphoma).

2. Hepatocellular (increase liver enzyme: ALT, AST) like viral hepatitis, alcohol,

drugs (INH, rifampicine, etc)

Obstructive (increase ALP): stone in CBD, Ca head of pancreas, etc) pruritis

and deep jaundice.

Congenital non-hemolytic: like Gilbert syndrome.

Jaundice

Some causes:
Nutritional (B12, folic acid (macrocytosis), iron (MC/HC), etc.
Blood loss; acute and chronic.
Hemolysis.
Bone marrow suppression.

Anaemia

What theses pictures are demonstrating?

Clubbing of fingers and the first picture is also showing cyanosis.

Enumerate some causes:

Respiratory: Bronchiectasis, lung cancer, etc.

Heart: Cyanotic congenital heart disease.

GIT; e. g ulcerative colitis, Crohn’s disease, liver cirrhosis.

Schamroth’s test - Attach two corresponding
fingers by their nails. There is free space at
healthy fingers between them called
Schamroth’s window. There is no free space at
clubbing fingers.

What this picture is showing?

Bruising. Due to trauma or bleeding tendency

What this picture is demonstrating?

Ascites.

Mention 3 physical sign for diagnosis of ascites.

Abdominal distension with flat or everted umbilicus.

In percussion: Shifting dullness is positive (the most important sign): percuss from

midline toward either flank. At point of dullness turn the patient toward the

opposite side so the dullness change to tympanic.

Transmitted thrill of fluid wave become positive in tense ascites.

Diagnosis:

Abdominal striae

Causes:

Pregnancy, Obesity, Cushing’s

syndrome

What is the value of axillary examination?

For detection of the following:
Lymphadenopathy – malignancy / infection
Hair loss – malnourishment / iron deficiency anaemia
Acanthosis nigricans (darkened pigmentation) – GI
adenocarcinomas / obesity

What is the definition of precordium?

Precordium: area on anterior chest that covers heart and great vessels.

What are the ausculatatory areas of the heart?

Mitral area at apical area (5

intercostal /midclavicular).

Tricuspid area: Just to the left of lower sternal area.

Aortic area: base of the heart at 2

intercostal space just to the

right of sternum.

Pulmonary area: base of the heart at 2nd intercostal space just to

the left of sternum.

What is the picture diagnosis?

Koilonychia.

Cause: Iron deficiency anaemia.

What are the expected finding on inspection
during cardiac examination?

Comment on heart sounds:

The two major sounds heard in the normal heart sound like

“lub dub”. The “ lub” is the first heart sound, commonly

termed S1, and is caused by turbulence caused by the

closure of mitral and tricuspid valves at the start of systole.

The second sound,” dub” or S2, is caused by the closure of

aortic and pulmonic valves, marking the end of systole. Thus

the time period elapsing between the first heart sound and

second sound defines systole (ventricular ejection) and the

time between the second sound and the following first

sound defines diastole (ventricular filling).

What is the diagnosis?

White nail

Cause:

hypoalbuminaemia

Q: Define auscultation, mention two main stethoscope parts and
enumerate its purpose:

Auscultation:

is the term for listening to the internal sounds of the

body.

Auscultation

is performed for the purposes of examining;

1. the circulatory system and respiratory system (heart sounds and

breath sounds).

2. gastrointestinal system (bowel sounds).
The stethoscope comprises a bell and a diaphragm. The bell is most
effective at transmitting lower frequency sounds, while the diaphragm
is most effective at transmitting higher frequency sounds
Techniques

To optimize the effectiveness of auscultation the surroundings
should be:

1.Quiet - the ambient noise might interfere the heart and lung
sounds.

2.Warm - so that the patient feels comfortable while the upper
part of the body is being exposed. Also, it is to avoid shivering
that may add the noise.

3.Appropriate lighting - to allow good coordination between
visual and auscultatory findings.

What this clinical examination is demonstrating ?

This is auscultation for bowel sounds.

What other things which can be detected by abdominal auscultation?

Friction rub over spleen and liver (inflammation)

Arterial bruit (Aortic bruits – auscultate just above the umbilicus – AAA
Renal bruits – auscultate just above the umbilicus, slightly lateral to the

midline).

What is the importance of hand washing

and cleanliness before examining the

patient? Give two examples

How you can analyze pain as a common symptom in

every day practice? Enumerate and comment on one.

Mention the important questions about common

symptoms in cardiovascular, respiratory GIT and

genitourinary systems

The answer in next slides

Cardiovascular:
Ask about chest pain and its characters (ischemia,

pericarditis).
Ask about palpitation (SVT, atrial fibrillation, etc.)
Ask about waking up at night due to shortness of

breath (paroxysmal nocturnal dyspnea and pulmonary

oedema).
Respiratory:
Ask about cough and whether dry or productive of

sputum.
Ask about wheeze (bronchial asthma, bronchitis, etc.)
Ask about coughing of blood (TB, lung cancer, etc.).
Ask about shortness of breath.

GIT:

Ask about

dyspepsia

(indigestion): It is an upper abdominal discomfort. Many

causes : functional is the commonest cause , peptic ulcer, gastritis, cancer, etc.
Ask about

heart burn:

Burning sensation behind the sternum (retrosternal) due

to regurgitating (reflux) of stomach content to oesophagus in a disease called

gastroesophageal reflux disease (GERD ).
Ask about

abdominal pain

(Location: epigastric, lower abdomen, mid central,

etc.) , association and nature (constant or colicky).
Ask about a

recent change in bowel habit

(diarrhea, or constipation).

Ask about stool:
If it

containing

blood, mucus, food particles , etc.

Ask about

amount of stool (stool size):

small amount (in large bowel disease,

large sized stool usually in diseases of small bowel.
Bulky, offensive, greasy with difficulty in washing and floating stool in WC

indicates malabsorption syndrome.

What is hemoptysis? Enumerate some causes.

It is coughing of blood (mixed with sputum or pure blood)

Causes:

1. Pulmonary TB.
2. Bronchiectasis.
3. Carcinoma of lung.
4. Pulmonary infarction.
5. Mitral stenosis.
6. Blood disease.

What are the questions you like to ask a
patient who is presenting with SOB?

1. Onset (sudden or gradual.
2. Duration (hours, days, months, etc.)
3. Exertional (specify which kind of activity
provoke it ). or at rest.
4. Associated symptoms (cough, chest pain,
etc.).

What is orthodnea?

It is feeling dyspnic on laying down. It is

typically occur in left side heart failure

(pulmonary odema).

Enumerate the physical signs and symptoms of left side

heart failure:

The patient is feeling short of breath (dyspnea) and you

may see cyanosis, tachycardia and orthopnea in general

examination.
Apex of the heart may be displaced, Auscultation of chest

will reveal fine basal (at base of lungs posteriorly)

crepitation.

What are the features of right side heart failure:

Fatigue, cardiomegaly, raised JVP, bilateral pitting leg

oedema and may be features of ascites and pleural

effusion.

This picture demonstrating a patient

with heart failure

مهم جدا

Comment on site and character of cardiac apex:

Site:

(the most lateral and most inferior; normally in the 5th left

intercostal space in the mid clavicular line)

Displaced or not

Character :

The following are the common characters of apex:

thrusting displaced apex beat

is caused by

volume overload

: an active

large stroke volume ventricle eg

aortic or mitral regurgitation

or left to

right shunts.

sustained apex beat

is caused by

pressure overload

aortic stenosis

gross hypertension

tapping apex beat

mitral stenosis

diffuse pulsation asynchronous with apex beat

- left ventricular

aneurysm.

double or triple impulse

may occur in

hypertrophic obstructive

myopathy.

an impalpable apex beat

- obesity, overinflated chest, pericardial

effusion. Also consider dextrocardia

مهم جدا

Comment on types of murmurs in

Aortic stenosis (AS):

The murmur of aortic stenosis is typically a

mid-systolic ejection murmur

, heard best

over the “aortic area” or right second intercostal space, with radiation into the right

neck.

Aortic incompetence (regurgitation):

Early

Diastolic murmur.

Mitral regurgitation (MR):

Pan systolic murmur: usually best heard at the apex, with radiation into the axilla.

Mitral stenosis (MS):

Mid diastolic murmur.

Ventricular septal defect (VSD)

: It is usually best heard over the “tricuspid area”, or

the lower left sternal border.

What are the causes of MR?

A: Mitral valve regurgitation is usually either a

congenital

condition or a consequence of

rheumatic heart disease

marked left ventricular dilatation, acute infective

endocarditis, or papillary muscle dysfunction secondary to

acute or prior myocardial infarction.

Diagrammatically demonstrate the heart sounds and cardiac murmurs

and give one example for each systolic and diastolic murmurs.

A. See the diagram below. مهم

Example of systolic murmurs: MR and AS.

Examples of diastolic murmurs: MS and AI.

What are steps of chest examination:

INSPECTION.

PALPATION.

PERCUSSION.

AUSCULTATION.

What this picture is demonstrating?

A. Chest expansion in step of

palpation

What this picture is showing? Enumerate 3 causes.

A. Flapping tremor.

Type 2 respiratory failure.

Hepatic (liver) failure.

Renal (kidney) failure.

What are the things to be mentioned in pulse

examination?

Answer: Rate, rhythm, volume, character and

condition of vessel wall.

Give 2 examples of abnormal pulse rate:

مهم

Tachycardia: pulse rate (more than) > 100 beat /m, bradycardia:

pulse rate (less than)< 60beat/m

Give 2 examples of completely irregular (irregular irregularity)Pulse.

Atrial fibrillation (AF).

Multiple ectopic.

Give 3 causes of AF:

thyrotoxicosis, ischemic heart disease (IHD),

hypertension, etc.
Give 2 examples of small volume pulse: Heart failure (HF), Volume loss

(diarrhea, vomiting, anaphylaxis, burn, hemorrhage, etc.).

Give 2 causes of large volume

(bounding) pulse: Hyperdynemic

circulation: chronic anemia, thyrotoxicosis, pregnancy, fever, etc.

Give one example for pulse character

: Collapsing pulse due to e. g.

thyrotoxicosis.

What is the value of this examination?

Tongue examination

for sign of dehydrations,

anemia, cyanosis, etc.

What is this examination?
Answer: Examination of left supraclavicular node (Virchow’s

Node ). This drains the thoracic duct so an enlarged node

(Troisier’s Sign) may suggest metastatic cancer e.g. lung or

abdominal.

What this picture is demonstration?

Tracheal palpation:

feel between the heads of the

two clavicles for the trachea. If it is deviated, it

may suggest a tumour or pneumothorax

What is this?

This is anterior chest percussion (step 3 in chest examination):

10.Perform percussion on both sides, comparing similar areas on both

sides. You should start by tapping on the clavicle which gives an

indication of the resonance in the apex. Then percuss normally for the

entire lung fields. Hyper-resonance may suggest emphysema where as

dullness suggests consolidation such as in pneumonia, effusion or a

tumour. Be sure to perform this on the back as well.

What is this?

This is test for tactile vocal fremitus. Place the

medial edge of your hand on the chest and ask

the patient to say “99” in English or 44 in

Arabic Do this with your hand in the upper,

middle and lower areas of both lungs. This

again gives a suggestion of the constitution of

the tissue deep to your hand.

What is this?

Auscultation of lungs (step 4 ):

Do this in all areas of both

lungs and on front and back comparing the sides to each
other.

Listen for any reduced breathe sounds,

added sounds:

crackles

(crepitation), wheeze (rhonchi),

pleural rub.

Give 2 causes for crepitation (crackles):

Bronchiectasis, pneumonia.

Give 2 causes of wheeze (rhonchi):

Bronchial asthma, bronchitis.

Give 1 cause of pleural rub:

pleurisy (inflammation of two surfaces of

parietal and visceral pleura).
Give1cause of stony dullness on chest percussion: pleural

effusion(accumulation of free fluid inside pleural space).

What these pictures are demonstrating?

Dilated veins on abdominal wall due
to inferior vena caval obstruction.

Bilateral pitting leg oedema

Causes:

Heart failure

Nephrotic syndrome (renal)

Chronic liver disease and cirrhosis and

other causes of hypoalbuminaemia.

Some forms of chest

Barrel chest

emphysema

Pigeon chest

Asthma since

early

childhood

Pectus

excavatum

congenital

Scoliosis and

kyphosis

Unilateral leg swelling:

Causes: DVT, cellulitis, lymphatic

obstruction, ruptured baker cyst,

trauma.

How you can differentiate between enlarged spleen and enlarged

left kidney?

You can not get above spleen.

Spleen has a notch at medial side.

Percussion is dull over the spleen

Spleen is enlarged obliquely toward RIF.

Kidney is bimanually palpable while spleen can be palpable by

one hand.