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NUMERO UNO:Symptoms and signs of GI diseases. Acutea appendicitis, pancreatitis, dyspepsia, esophageal disturbances (pyrosis, regurgitation, odynophagia, dysphagia), gastroduodenal ulcers, gallbladder colic, reflux esophagitis, pain of GIT, viral hepatitis, steatosis of liver, diverticulitis, anorectal lesions, cholecystitis. ABD PAINdifferentiated according Maratka and Jones zones, somatic (local), visceral (no location), colic (severe pain which comes and goes), rhythmic pain (during meal). BLEEDING: caput medusa (portal hypertension, flow toward legs), IVC obstruction (flow toward head), haemorrhoids, melena, hematemesis. FLATULENCE, DIARRHEA, CONSTIPATION, METEORISM (tympanic sounds if percussed, lot of air in bowels). VOMITUS, POOING(acholia, steatorrhea). NAUSEA. Examination of head. SKULL INSPECTION: type and posture: mesocephalic skull (normal), brachycephalic skull (shortened anterior-posterior diameter) and dolichocephalic skull (elongated a-p diameter), microcephaly (small), macrocephaly (large one, due to: hydrocephalus, paget’s disease and caput quadratum), oxycephaly (malformed skull). FACES: fibrillis (buring face, common x fever), pallida (pale face, common x sepsis and rheumatic fever), myxoedematosa (yellow, doughy skin with periorbital edema), mitralis (vermilion blush, cyanotic hue), abdominalis (common x peritonitis, sunken eyes, pointed nose, dry lips), Cushingoid (hyperproduction of adrenal cortical hormones, Cushings disease), nephritica (pale face, eyelid edema), acromegalica (increase of GH hormone, large nose/tongue, supraorbital ridges). PARALYSIS: upp. motor neuron (due to stroke), low (facal nerve), peripheral (unable to wrinke forehead, one eye can’t close), central (slanted mouth, no whistle). SKULL PERCUSSION/PALPATION : pain (sinusitis) AUSCULATION: bruit (can be heard in intracranial aneurysm). EYELIDS: swelling: blepharitis, kidney disease, myxedema; pigmentation: Addison’s disease and Thyrotoxicosis. EYEBALLS: movement after follow finger (1mm) and head in fixed position: squinting (oculomotor muscles paralysis,paresis, can be divergent so eye deviates to the side or convergent so towards the midline), nystagmus (vertical or horizontal, eyeballs move repetitively and rapid) SCLERA: yellow=icterus, blue=osteogenesis imperfecta, brown spot= melanin. CORNEA: arcus senilis: white/grey band around circumference of cornea IRIS: mydriasis (dilated) or miosis. NOSE: size (large=acromegaly), form, secretions: nosebleed due to uremia, bleeding disorders, hypertension). Examination of PNEUMONIA: infection that inflames air sacs in one or both lungs. Symptoms can include: breathlessness, fremitus pectoralis strengthened, percussion shortened, crepitations are audible and later tubal breathing, crepitations again, progressive weakening of tubal breathing, bronchophony strengthened. ACUTE BRONCHITIS: no breathlessness, distant bronchitis phenomena, fremitus pectoralis normal on both sides, percussion full and bright, alveolar breathing can be dry or wet, bronchophony unchaged. CHRONIC: decrease elasticity, prolonged expiration, percussion: hyper resonance, breathing: vascular, redhead and also moist. EMPHYSEMA: chronic lung disease caused by damage to alveoli. Symptoms: barrel-shaped chest, fremitus pectoralis weakened, percussion hypersonic, alveolar breathing weakened, broncohopny weakened.
NUMERO DUE: HT presentingcomplaints. The medical history is a structured assessment conducted to generate a comprehensive picture of a patient’s health and health problems. It includes an assessment of: patient’s current and previous health problems; current and previous medical treatment; factors which might affect the patient’s health and their response to prevention or treatment of health problems their family’s health. DIRECT HISTORY: when the physician obtains the information directly from the patient. INDIRECT HISTORY: when the physician obtains the information from family members or from other people that are accompanying the patient. To obtain a trustful relationship we have to: eliminate haste and nervous tension; create privacy for the interview; create a comfortable environment. Medical interview usually starts with the vital statistics (age, occupation) then continues with the current complaints (what are your difficulties/complaints, symptoms). PERSONAL DATA + CURRENT/CHIEF COMPLAINTS (name, etc + why you here?). Examination of mouth. LIPS colour: cyanotic patients (heart/lungs disease), pallor (anemia), cheilosis/angular stomatitis (painful,small ulcers in labial corners), HSV1.TONGUE movements (hypoglossal nerve -> glossoplegia paralysis), macroglossia (enlarged tongue, Acromegaly and Myxedema), surface of tongue for presence of food, bacteria, debris; Hunter’s glossitis (deficiency B12, tongue is flat, atrophic papillae), Xerostomia (dryness of mouth, difficult to swall or talk). ORAL MUCOSA: thrush (candida albicans), graphite spots (Addison’s disease). GINGIVA: scurvy (lack of vitamin C), necrosis (acute leukemia, agranulocytsosis) TEETH:check position of jaws: prognathia (protrusion of maxilla) and progenia (mandible), check malocclusion, number of teeths, quality. TONSILS:enlarged? Inflamed? Mobility and posture: Active (patient can get into range of positions without help), Passive (patient is hepless in posture, but need assistance to move from one position to another), Obligatory (patient need assistance with maintenance of posture). Mobility: patients with neuro disorders often exhibit these changes: GAIT: small steps, body leaning forward (Parkinsons), tremor and muscular rigidity. GAIT WITH CIRCUMDUCTION: LE (extensor muscles) are extended at the knee joint, hence has to move in a circular manor, to the side. Typical for hemiparesis or hemiplegia of one side of the body, following a stroke. TREMORS:hand tremors observed in Thyrotoxicosis; shaking hands/arms. EPILEPTIC CONVULSIONS.
NUMERO TRE: HT medical history: All illnesses from birth to the current state: CHRONOLOGICALLY: surgical procedures and accidents, their type, duration, treatment and possible after effects, CHILDHOOD DISORDERS: infections, allergies, particularly rheumatic fever,FOREIGN TRAVEL: for the ‘tracking down’ of certain infectious or parasitic diseases (Salmonellosis, Malaria, Hookworm), INHERITABLEDISEASE(DM, hypertension, cystic fibrosis, sicke cell anemia), OTHERS:tuberculosis, sexually transmitted infections (syphilis). Heart sounds: Physiologically 2 heart sounds are heard. In young children, pregnant women and pathological conditions, 3/4 heart sounds can be heard. 1st coincides with onset of systole, 2ndend of systole. Interval btwn 1-2 short, btwn 2-1longer. Systole duration is 1/3, diastole 2/3 of heart cycle. FIRST:atria contracts at the end of diastole, ventricles fill with blood; after it, at the moment of relaxation of atrial musculature, pressure in ventricles is higher: atrioven valves (M-T) close. 1st HS follows after 50ms after beginning of QRS complex. It lasts for around 100ms. SECOND: Caused by the sudden block of reversing blood flow due to closure of the aortic valve and pulmonary valve at the end of ventricular systole. As the left ventricle empties, its pressure falls below the pressure in the aorta, aortic blood flow quickly reverses back toward the left ventricle, catching the aortic valve leaflets and is stopped by aortic valve closure. Similarly, as the pressure in the right ventricle falls below the pressure in the pulmonary artery, the pulmonary (outlet) valve closes. A split S2 can be associated with several different cardiovascular conditions. THIRD:relates to a sudden, abrupt ending of ventricular distension in the initial phase of diastole. Found mostly in left ventricular failure, patients with mitral incompetence, ventricular septal defect or constrictive pericarditis. FOURTH:relates to the distention of the ventricle caused by atrial systole; is not a sign of heart failure, it originates in left ventricles. GALLOP: combination of tachycardia with 3 or 4 HS. >120/min is tachycardia. It is not present if tachycardia is accompanied by decrease in atrial pressure; it can be left ventricular heart failure. WHERE LISTEN?A-DX-2IC, T-DX-5IC, P-SX-2IC, M-SX-5IC. Heart: apex or pulmonary region. ECG – coronary heart disease, acute myocardial infarction: Coronary syndrome means a clinical conditions caused by the rupture of atheromatous plaque within a coronary artery. If patient has chest pain and there’s ECG evidence of myocardial ischaemia but normal plasma troponin level (<0.04ng/mL) is coronary syndrome due to unstable angina. In UNSTABLE ANGINA ST (isoelectric period in which ventricles are btwn depo and repo, 80-120ms) depression; in STEMI (ST elevation myocardial infarction) ST rise in the ECG leads corresponding to the part of the heart that is damaged; STEMI is diagnose when there is more than 1mm of ST elevation in at least 2 contiguous limb leads (III and VF) or more than 2mm of ST elevation in at least 2 precordial leads; also if there is sx bundle branch block. In SUB ENDOCARDIAL infarction: ST depression + T inversion, in TRANSMURAL: T inversion, ST elevation + pathological Q wave. T: repolarization of ventricles, 0.10-0.25 seconds, amplitude less than 5mm. Q: absence of electrical activity, necrosis.