Parag-Notes for internal exam PDF

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Parag Notes computer written Nanna K. Melle and Madeleine Rydmarker 1) Cranial nerves examination: examination of all nerves reflexes (occulopalpebral corneal) afferents efferents of the reflexes everything from physiology lab manual vestibular examinations: a) blind walking, b) finger to finger c) ...

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ParagNotescomputerwritten

byNannaK.MellebyandMadeleineRydmarker    1)Cranialnervesexamination: ‐examinationofallnerves+reflexes(occulopalpebral+corneal) ‐afferents&efferentsofthereflexes ‐everythingfromphysiologylabmanual ‐ : a)blindwalking, b)fingertofinger c)fingertonose d)Barany(Hungarian) e)Rumberg+extendedRumberg  ‐ examinations: Knowhowtoexplain&performeach. Knowwhichofthemthatareexaminedtogether(CNIII,IV,VI) a)  •standatadistanceof fromthesubjectstanding .Thesubjectshould  .Theexaminerwhisper whichhavetobe .Onlyaccuraterepetitioncanbeaccepted. “Thesubjectrecognizeswhisperedspeechat3meters”. b)  •tocomparethe  Inahealthypersontheairconductionisbetterthantheboneconduction. •holdthe withitsshaftfirmlyonthe ,ipsilateraltothetested ear,andaskwhetherornothe/shecanhearit. ,  .Then  andinthiscasethe Ifthe  .). c)  •tocompare  • Thesubjectis askedwherehe/shecan whichwill  by ).Ifboneconductionisequalonbothsides,thediagnosiswillbeWeber infinite.Ifthe (Weber’stestdeviatestothis side)thatindicates  .

d) •to •

  .The .Thenthe .



2)Reflexesofthedeeptendon&theskin ‐knowthedifferentsegments •biceps:C5‐C6 •triceps:C6‐C7 •ulnar,radius:C7‐C8 •patella:L2‐L4 •ankles:L5‐S1 •abdomen:T7‐T12 •extremiter?:L2,L4 •plantar:S1,S2

 3)



‐knowallthetypes+knowhowtoperform ‐If ‐> . Reflexescausingdorsalflexofthebigtoe: a)Oppenheim b)Babinski c)Gordon d)Sheiter e)Madoc ‐handreflexes ‐Resolue,Mendel,Behtele 

.

4)Spinalcord ‐hitontheback,pushhead&shouldersdown,standontoes‐>↓ ‐tests: a) ( )cangiveriseto: •govess(dorsalflexoffoot) •brugged(dorsalflexofthetoe) b)Mennel1 c)Mennel2 d)Becherer(sitonachair&putthelegstogetheronanotherchair)

 

e)Trendelenburgposition 



 5)Rules&historytaking ‐Alwaysorganizetheevent’schronologically,notbytheageofthepatient,butbytheyear.

 6)

(deepveinthrombosis)

a) b)

 –

(puta ) •mechanism:inDVTthe ‐> inanalready ‐> ‐> Values:DVTproblemsruinthevalues.  c) the ‐> ?‐>  ‐Normal:from↑ ‐Abnormal:from↓ ‐Mechanism:Abnormalvalues=backflowofbloodfromdeep…  d)II:releasemanpetra ‐  ‐   e)Percussiontest: ‐percussonproximalpointofvein‐>abnormallyfeelitthedistal  f)Pertestest: ‐walkingtest   

Abnormalbreathingsounds: 1)Bronchialsound:wet‐>crackles(leftheartfailure) dry‐>wheezing 2)Crepitation–inspiration(pneumonia) 3)Crackle–insp+exp 4)Pleuralfriction(beginningofinflammation)

 

‐>



     





    Diagnostics  1)Historytaking  2)Physicalexamination:‐>Preliminarydiagnosis a)Inspection b)Palpation c)Percussion d)Auscultation

 3)Laboratory&instrumental(X‐ray,MRI,CT)  4)Differentialdiagnosis‐>Final(definitive)diagnosis •Finaldiagnosis: a)Main(principal)–e.g.acuteMI b)Complementary(additional)–e.g.hypertension,diabetesmellitus  Appearanceofdiseases:  1)Symptoms:seenbythepatient 2)Differentformsofsymptoms(alloccurringinpneumonia): ‐Initial‐>shaking,chill ‐General‐>weakness ‐Local‐>chestpain ‐Cardial‐>dyspnea ‐Accessory‐>fever





Pain:  1)Type:dull,burning,colic,launcinating 2)Site:abdominal(example) 3)Spread:irradiation 4)Periodicity:duration,frequency 5)Relievingfactors:medicine,rest 6)Exacerbitingfactors 7)Associatedfactors  Signs: ‐seenbythepatient/physician ‐Jaundice,cyanosis,hyperpigmentation,subcutaneousedema ‐symptoms&signsareusuallyconnectedtoanorgansystem  Cardiovascular: 1)Signs: ‐cyanosis ‐wideneckveins 2)Symptoms: ‐retrosternalpain ‐palpitation(fast,poundingheartbeat) ‐dyspnea  Respiratorysystem: 1)Signs: ‐cyanosis ‐changesinshapeandmovementofchestwall ‐clubbingfingers? 2)Symptoms: ‐chestpain ‐dyspnea ‐caugh ‐haemoptysis(coughingblood)   GItract: 1)Signs: ‐lostofweight ‐meteorism

‐enlargedliver,spleen,gallbladder ‐icterus(jaundice) ‐spidernaevus(smallreddotsonthechest) ‐caputmedusae 2)Symptoms: ‐abdominalpain ‐vomiting ‐diarrhea ‐constipation ‐dysphagia ‐anorexia

    Historytaking 1)Presentcomplains:theorderisnotimportant,everythingshouldbeasked a)Cardiovascularsystem: •4mainquestions:‐chestpain ‐shortnessofbreath(SOB) ‐Edema,swollenlegs ‐Nycturia(excessiveurinationatnight (fatigue,palpitation) !!!Ifchestpain,weshouldaskifnitratesweretakencauseitdilates thecoronariesand↓ thepain.  b)Respiratorysystem:‐SOB ‐painduringbreathing(sharppain‐>pleuritis) ‐dyspnea ‐coughing:productive(sputum–color,changesofsputumwithbody position)/unproductive.Bronchiectasis–chronicwideningofthebronchiinbronchiolisdue to ‐sputum ‐fever(subfebrility) ‐anydrugs  c)GIsystem:‐appetite ‐weight ‐constipation ‐diarrhea

‐motionsmotility ‐heartburn ‐vomiting ‐nausea ‐dailydefecation:color,consistency,haematocasia,malaena ‐painrelievedorincreasedaftereating(stomachcancer?Duodenalulcer?) connectedtodefecation(pancreatitis?)  d)Urinarysystem:‐frequencyofurination ‐painbeforeurination,duringorafter ‐color ‐howmuchdothepatientdrinkaday ‐difficultywithurination ‐smell ‐paininback(kidneys…?) ‐frequencyofmycturia ‐urinevolumereduction ‐acutepyelonephritis(inflammationinrenalpelvis)   e)Neurology:‐memoryproblems ‐blackouts ‐confusion ‐dizziness ‐tiredness/sleepinghabits ‐depression ‐headache  f)Endocrinesystem: g)Skeletalsystem:

  2)Pastmedicalhistory:chronologicalorder ‐operations ‐hospitalization(whenapersonhasbeen/istreatedinahospital) ‐immunization(processwhenapersonbecomesimmune/resistantagainsttoaninfectious disease–vaccination) 

3)Drughistory ‐allergy

‐currentmedications:frequency,dose 

4)Social: ‐work,howoften? ‐pastwork ‐education ‐home ‐exercise ‐smoking ‐alcohol ‐drugs ‐diet

 5)Familyhistory: ‐tellmeaboutyourdad,mum,siblings,children ‐hypertension,diabetes,infarcts? 

6)Physicalexamination: a)Inspection b)Palpation c)Percussion d)Auscultation !!!Inabdominalexamination:Inspection,auscultation,palpation,percussion. Becauseduringtheauscultationwewillhearifnormalbowelmovementispresent. 

7)Generalexamination: a) b) c) d) e)

ofthepatient ):Moderatelypigmented.Abnormalities. :Edema.Turgoroftheskin. : . .Checktheeyes,mouth.  f)Throat:Moderatelybloodfilledandintact g)Teeth:Replaced,wellaligned. h) :usually– . Checkenlargement,tenderness,mobilityofthe:submandibular,submental,supraclavicular, parasternal,axillary,inguinallymphnodes. i)Genitals:Morphologicallyintact. j) ?ULusuallyinvolvestumors.

 iscontracted. k)

Insitting,lyingpositionelevateahandsothem.pectoralis .Tenderness? .Symmetric/asymmetric.

 

8)Compulsoryexaminations: a)BMI:kg/m² ‐Underweight:30  b)Bodytemperature: ‐Normal:36‐37°C ‐Subfebrility:37‐37.5°C ‐ = ofthebodytemperature, . Ifthetemperaturedoesn’tchangein1°C/day‐>febriscontinua. Ifthetemperaturechangesmorethan1.5°C,butthelowesttemp.doesnotreachthe normaltemperature‐>febrisremittent. Ifthetemperatureraisesmorethanorequalto1.5°C,buttheminimaltemperaturereaches thenormalvalue‐>febrisintermittens.(likeinsepsis)  c)Waiscircumference:becauseofabig(fat)abdomen ‐Normalfemale:80cm ‐Normalmale:94cm ‐Moderatefemale:80‐88cm ‐Moderatemale:94‐102cm 

  Practical: Symptomsof : 1)  2) :notlife‐threatening. 3) :

. –dangerous

Notoccurringduringeffort,butisalwayspresent‐>coronography‐>stent? *  . 4)Differenttypesofanti‐..?...pills intopdose‐>noresponse‐>Dopplerofneuralart? Maybeof Ischemiashrinksthekidneys. CT,Doppler,Abdominaecho.??? : ‐Adrenaladenoma‐> ,but . Whyatrialfibrillation? ‐ dueto  ‐  ‐  Samesymptoms:themedicationofHFdidn’twork.Hehadhypoproteinemia.Steroidswere given. ‐!!pulsusdeficiens:lessperipheralpulsefrequencythanthepulseovertheheart.Thisis oftenseeninatrialfibrillation. HeartPP‐PeripheralPP=pulsusdeficiens     Auscultation: 1)Basicbreathingsounds: Thepatternofnormalbreathsoundsarecreatedbytheeffectofbodystructuresonair movingthroughairways. a)Vesicular:(normal)aresoft,blowingorrustlingsoundsnormallyheardthroughoutmost ofthelungfields.Thesoundsarenormallyheard   b)Bronchial:arepresentoverthelargeairwaysintheanteriorchestnearthe2ndand3rd intercostalsspaces.Areheardoverthebodyofthesternum.Thesesoundsaremoretubular andhollowsounding.Thesesoundsareloudandhighinpitchwithashortpausebetween inspirationandexpiration.Expirationsoundslastlonger. ‐Wetbronchialsound:cracklesduringinsp.&exp. ‐Drybronchialsound:wheezingduringinsp.&exp. c)Tracheal:areheardovertrachea.Thesesoundsareharshandsoundlikeairisbeingblown throughapipe. d)Bronchovesicular:areheardintheposteriorchestbetweenthescapulaeandinthe centerpartoftheanteriorchest.Mostlybetweenthe1stand2ndintercostalsspace.These soundsaresofterbuthaveatubularquality.Thesoundsareaboutequalduringinspiration andexpiration.

2)Addedbreathingsounds: a)Crepitating(characteristiccrackingorpoppingsoundduringinspiration):maybeasignof fracture. ‐wecanmimicacrepitatingsoundifwerubourhair–similarsound. ‐isheardinpneumoniaduetoaccumulationoffluidinthealveoli. b)Crackling(formlycalledrales):high‐pitchedshort,crackling,poppingsoundsheardduring theendofinspirationandisnotclearedbycoughing. Canbeheardoverthelowerlobeofthelungs.Ismoreaudibleincaseofpneumonia. c)Pleuralfrictions:inthebeginningofaninflammation,beforemuchexudatesaccumulates betweenthetwopleura’s.Thetwopleurasrubuponeachothertomakeacertainsound.

Anginasymptoms: ‐painincreasesafterphysicalactivity ‐  ‐  ‐  *Askaboutthe: ‐arrhythmiaabsoluta ‐pulseamplitudeisirregularanddistanceisirregular ‐ejectionfractionisabnormal‐>congestion‐>dyspnoeaischaracteristicafterphysical activityinischemicheartdiseases.  ‐kidneypainisnotcorrespondingtophysicalactivitywhilespinalcordoriginisrelatedto physicalactivity. ‐chronicalcoholismus:>40gforwomen >60gformen  

Heartfailuresymptoms: 1)  2)  3) : ‐ .Aboveanklethenascendingtoscrotum.??? Ifthepatientisinbed,pressabovesacrum. After forsometime,the ‐  ‐   •Recorder:2nd,5thintercostalsspace 

.

Apicalthrust(apexbeat):heartmovestowardsthethoracicwallandproduceasound. ‐alwaysstandonthepatientsrightside.

‐usingametacarpophalangealjointwefindthesitefortheapicalthrust. Usuallyitsinthe5thintercostalsspace,1fingermediallyfromthemidclavicularline. 

: ‐signof ‐> ‐ifthe  ‐ifthe ‐> / Rightpneumo/hydrothoraxpushesthehearttotheleft. ‐ifthethrustis ‐>  ‐ drop‐2leatherpiecesrubbedtogether‐> ‐synchromancywithheartmovementofifpericarditis ‐synchronancywithrespirationmovementifpleuritis   

 



X‐rayevaluation  1)Printedfilm 2)Fluoroscopy: ‐theheartcanbeseenmoved ‐ ???– ‐ ???‐

isinjectedwhichis .Putthecatheterto…of ???.

. 



X‐rayfeatures  “

or

”‐ ,

and

.

”–   •Betweenesophagusandthevertebralcolumnthereare2fingersdifferenceinmitral configuration.The .Wecangive . Holzknecht. •In – mulates,life‐threatening.        



Patients:

1stpatient ‐Pain? •Localisedinleftleg,duringworking, •Whendiditstart?Howlongdiditlast? 2yearsagohehadanulcerformation. 3weeksagoitstartedagain.Thefeverwasabout38degrees. Thereisedemaonhisleftankle.Hehashadedemafor2years. Therewasrednesssurroundingtheulcer •Diabetic?Forhowlong?(askingbecauseofdiabeticneuropathy) *Neuropathy=pathologyoftheperipheralnerves *Diabeticneuropathy=neuropathyassociatedwithdiabetes •Anysensationdisturbance? Yesdoesn’tfeelthelegifthereisunfeltpressure‐>circulation↓‐>necrosis‐>untilbone‐> osteomyelitis(infectionsofthebone/bonemarrow) Diabetescanleadtomicro&macropathy‐>atherosclerosis‐>ischemic 

            Lung  In .(?) ‐linesofthelungs: a)midclavicular



b)midscapular  ‐whatcanchangethechestwallshape? • ‐>pigeon/chickenbreast:sternumisdepressed •   1)Percussion ‐soundsvaryaccordingtodensitiesofunderlyingtissues ‐direct:directlywithfingersonthorax.Notsoinformative. ‐indirect:mediatefingerontheintercostalsspace.Onlythedistalphalanxshouldtouchthe wall. ‐tympanicsound:overthegastricandabdominalregionsbecausetheyareairfilled.  Whydowepalpatethethorax? ‐tofind  ‐to observedintheinspection ‐to  



 ‐ If If

      

&

‐>putthe :in :

 



ParagNotes!

ECG ‐ ‐

Rythm Ifthe

:

(causeof

) ‐ ‐ ‐ ‐ ‐ ‐

. QTinterval ‐wave  aVR aVFadditionalleads=Goldbergerleads aVL 

Leftaxisdeviation:Highervoltageinlead Rightaxisdeviation:Highervoltageinlead! 

Whatdowelookforininspectionoftheheart? 1. 2. 3. 4.

Apexbeat Epigastricbeat DistendedJugularveins Cyanosis



AsthmaBronchiale Exogenousandendogenous ‐ ‐

IgE↑inplasma Familyhistory

Bronchiolitis:Weezingsound(drybronchialsound) TypeIIdiabetes:Higherrisksofinfections,fataroundtheabdomen Emphysemicchest: ‐ ‐ ‐

Hypersoundwhenpercussing Cyanosis,periodiccyanosis Jugularveinsdistention



‐ ‐

Percussionsounds Diaphragmmovementisnotsogood

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Inischemicheartdisease,thepaininthechestgetsworseduringphysicalactivity Drilling(?)Backpain:Maybeaorticaneurism,itissharpandcontinuousandnotrelievedby anythingbutapainkiller. DysbasiaorClaudications(limping):Paininlegsafterveryshortphysicalactivity. Dysbasticofclaudicationindex:4if4meterswalkevokethepain(onlyarterialabnormalities –Ischialisskeletalmuscle) “Thesepatientswillprobablyhaveheartproblems,too,becausethesameatherosclerosis willbepresentintheheart,too.”Wikipedia 

Nephrology Insteadofrenalfailurewesaychronickidneydisease. ‐ ‐ ‐

Endocrine–EPO,Renin,D.activation Clearance–Detoxification,pH,volumeregulator GFRcanbejudgedbycreatineclearance

StagesofChronicKidneyDisease(fromtheinternet,thispersondoesnothaveagood handwriting…) Inchronickidneydisease,thekidneys don'tusuallyfailallatonce.Instead,kidneydisease oftenprogressesslowly,overaperiodofyears.Thisisgoodnewsbecause,ifCKDiscaught early,medicationsandlifestylechangesmayhelpslowitsprogressandkeepyoufeeling yourbestforaslongaspossible.Withearlydiagnosis,itmaybepossibletoslow,stop,or evenreverseCKD,dependingonthecause.TheNationalKidneyFoundation(NKF)recently publishedinformationonthestagesofChronicKidneyDisease(CKD).Inthetablebelow,the "GFRlevel,"orglomerularfiltrationrate,isameasureofhowwellyourkidneysarecleaning yourblood.YourdoctorcancalculateyourGFR,basedonaformula. InStage1andStage2CKD,thereareoftenfewsymptoms.EarlyCKDisusuallydiagnosed whenthereis:     

Highbloodpressure Higherthannormallevelsofcreatinineorureaintheblood Bloodorprot...