1St Semster Q finals Flashcards
- Scheme of medical history
- I. The patient identification data (ID).
- II. Medical history
- III. Physical examination
- IV. Scheme of investigation
- V. Investigation data
- VI. Сlinical diagnosis
- VII. Treatment.
- Anamnesis.
-DF : The patient interview (anamnesis – Greek.,
расспрос – Rus.) usually referred to as the history.
* The medical history is the foundation upon which diagnosis and treatment are made. Without a medical history, the clinician works in a vacuum.
–COMPONENTS OF THE (ADULT) MEDICAL
HISTORY (The patient interview) :
* I. Introductory information (identifying data) – ID.
* II. Chief complaint – CC.
* III. History of the present illness – HPI. :
* Beginning of the illness, First manifestations
* Possible reasons of its origin (in the opinion of the patient)
* Development of symptoms
* Sequence, reinforcement, weakening or disappearance earlier appeared or appearance of new disease’s symptoms
* Seeking medical help, examination and treatment before
* Description of present worsening of a patient condition
* IV. Life history:
* 1.Past medical history – PMH
* 2. Family history – FH.
* 3. Psychosocial history – PSH.
* 4. Medications and habits – MH.
* VIII. Review of systems – ROS.
- General examination of the patient (position, constitution, skin)
-Positions :
1-Forced position during a bronchial asthma attack :
the patient takes forced sitting position leaning with his hands on the back of a chair, edge of a bed, his knees, etc. This position gives a possibility to fix the shoulder girdle and to switch additional respiratory musculature, specifically, muscles of the neck, back and breast enabling expiration
2-Forced position during cardiac asthma attack:
During cardiac asthma attack and pulmonary edema caused by blood congestion in lesser circulation circle vessels the patient is eager to take vertical (sitting) position with legs dropped down which decreases blood inflow to the right cardiac chambers and gives a possibility to unload lesser circulation circle to some extent (orthopnea position)
-Constitution :
1-Normosthenic type :
is characterized by correct habitus with proportional parts of body, well-developed somatic musculature, correct chest shape with costal angle approaching straight angle
2- predominant body development in length,
muscles are weakly developed,
shoulders are sloping,
long neck,
the chest is narrow and flat
epigastric angle is narrow (less than 90°).
the ribs are oblique
the scapulae do not adjoin the chest tightly.
3-Hypersthenic type. :
predominant body development in width;
medium height or lower,
enhanced nutrition,
muscles are well-developed.
shoulders are wide, neck is short.
the abdomen is enlarged in volume.
the chest in is wide,
epigastric angle is obtuse (over 90°),
the ribs are located more horizontally
————————
-Skin
—-1-color:
-there are 5 types we can distinguished while we examine the patient :
1- Paleness = -anemias - peripheral circulation pathology:
2-Redness = 2-1peripheral vessels dilation: fever 2-2erythrocytosis, polycythemia
3-Cyanosis (bluish) = :
3-1Central cyanosis – diffuse, warm: develops in result of insufficient blood oxygenation in the lungs in various respiratory organs diseases
3-2. Peripheral cyanosis (acrocyanosis), cold : appears in case of slowing down of peripheral
circulation, in venous congestion in patients with cardiac insufficiency.
3-3. Limited, local cyanosis :develops in result of peripheral veins congestion due to their compression with tumor,
4-Jaundice ; three kinds of jaundice are distinguished = :
1. parenchymal (in hepatic parenchyma lesion);
2. mechanical (in obturation of common bile duct with a concernment or its compression with a tumor);
3. hemolytic (in enhanced hemolysis of erythrocytes)
5-Bronze (brown) = Bronze (brown) skin color is usually seen in adrenal insufficiency.
—-2- humidity (moisture) :
–they are several types :
1-Moderate (normal)
2-Excessive (sweating) – diabetes mellitus (especially when blood sugar is low)
3- Dry (dryness) -renal failure, skin diseases
4-Peeling - , «uremic powder»
—-3-elasticity (turgor):
1-Decrease in elasticity of skin - patients of old age, dehydration (vomiting, diarrhea).
2-Increase in turgor and tension of skin - liquid delay.
—–4-skin rashes and lesions
–Hemorrhagic:
1-petechiae,
2-ecchymosis,
3- purpura
–Non-hemorrhagic:
1-erythema (including erythema nodosum),
- General examination (subcutaneous fat, edema, lymph nodes)
1- Subcutanous fat :
1-development (moderate, weak, excessive),
2-largest deposition sites,
3-presence of edema,
4-thickness of the fat fold at the lower angle of the scapula and on the abdomen at the level of the navel
——(obesity) ; Primary (exogenous constitutional, or alimentary-metabolic) obesity based on energetic imbalance (absolute or relative increase of energy income with food or decrease of its waste due to hypodinamia)
–the opposite of the obesity is the chexcia
——————————–
2-Edema :
1-Prevalence(local, general)
2-Sites (extremities, abdomen, face)
3-Degree of severity (pastiness, severe)
4-Consistency(soft, dense)
5- Skin color in edema sites
-Local edema :
the main causes :
1. regional lesion of venous outflow
2-. acute inflammatory reaction of skin and subcutaneous fat
3-. local cutaneous allergic reaction, Quincke’s edema.
-Diffuse or general edema : in cardiac, renal and other visceral organs diseases
are, caused by combination of lesions of numerous
mechanisms taking part in water-electrolytic balance
in the organism.
ex : Ascites = is the accumulation of fluid in the peritoneal cavity ( renal )
ex: Hydropericardium is the accumulation of fluid in the pericardial cavity
Hydrothorax = is the accumulation of fluid in the pleural cavity
—The following methods are used for disclosure of peripheral edemas:
1. palpation method
2. follow-up of bodymass dynamics;
—————————–
3- Lymph nods
–Normally peripheral lymph nodes :
present round or oval formations from 5 to 20 mm in size. They are not elevated above the skin level and that is why not disclosed during examination.
–location of lymph nodes :
1. Pre-auricular 2. Posterior auricular 3. Tonsillar 4. Submaxillary
5. Submental 6. Cervical 7. Supra- and subclavian 8. Anconeal (elbow) and
9. Inguinal
– we should exam the lymph nodes for distinguish :
a) size b) shape c) consistency d) painless
e) movability f) adhered
—-diseases : there are two types
1- Diffuse, systemic lymph nodes lesion
-inflammatory changes (for example, in certain infections)
2. local enlargement of regional lymph nodes
-inflammatory (local suppurative processes)
- Types of impaired consciousness.
– Three grades of consciousness disturbance are distinguished :
1. Torpor : is a state of stunning out of which the patient may be taken out for a short time by speaking to him. The patient is poorly oriented in the surrounding situation, answers the questions slowly and late
2- Sopor (sleep) : is more pronounced consciousness disturbance. The patient does not react to surrounding people, although sensitivity, including pain sensitivity, is preserved, reacts to examination.
3-Coma :
consciousness and response to external stimuli (pain,
etc.) are completely absent.
Complete muscle relaxation and loss of reflexes are observed.
Regulation of vital functions (breathing, circulation) are
damaged, but saved.
Thus, in coma there is a complete unconsciousness, loss
of sensitivity and movements.
-Types comatose states
alcoholic coma
hypoglycaemic coma
diabetic (hyperglycaemic) coma
hepatic coma
uremic coma
epileptic coma
- The face of the patient with various diseases.
-they are several types :
1-Facies mitralis : (face of a patient with mitral valve stenosis)
2-Acromegaly :The increased growth hormone of acromegaly produces enlargement of both bone and soft tissues. of the head
3-Facies nephritica : (face of a patient with renal diseases) pain, puffy, with upper and lower eyelids edema,
4-Facies leonine : (face of patient with leprosy)
5-Facies Corvisari : is characteristic for patients with pronounced cardiac insufficiency..
6-Facies micsedemica : face of a patient with thyroid gland hypofunction (myxedema).
7-Facies Basedovica : (face of a patient with thyrotoxicosis): anxious, exasperated or frightened face expression is marked,
8-hirsutism facies : Face of a female patient with hirsutism developed due to excessive testosterone in the organism
- Fever and its types.
— In a healthy human being body temperature
fluctuates in a narrow range: from 36,0°C to 37,0°C.
1-Continued fever (febris continua): long-term body
temperature increase with diurnal fluctuations not
exceeding 1°C.
2-Remittent fever (febris remittens): long term body temperature increase with diurnal fluctuations exceeding 1°C.
3-Intermittent fever (febris intermittens): high fever changed by normal body temperature (below 37°С) for 1-2 days and then rising again up to 38-40°С.
4-Hectic fever (febris hectica): sufficient temperature increase up to 39-41°С (more often by the evening) changed by normal temperature within 24 hours. Increase of temperature is accompanied by pronounced chill, and its increase - by emaciating sweating
- Complaints of patients with respiratory diseases.
1-Main (specific)symptoms:
1.Cough ( dry or productive of sputum )
2.Sputum
3.Breathlessness
4.Chest pain
5.Haemoptysis
6.Wheeze
2- Nonspecific- Fever, Chills, Sweating, Weakness,
working ability.
- Data of general examination of patients with respiratory diseases
1-forced posation
2-Cyanosis (bluish) = :
2-1Central cyanosis – diffuse, warm: develops in result of insufficient blood oxygenation in the lungs in various respiratory organs diseases
2-2. Peripheral cyanosis (acrocyanosis), cold : appears in case of slowing down of peripheral
circulation, in venous congestion in patients with cardiac insufficiency.
2-3. Limited, local cyanosis :develops in result of peripheral veins congestion due to their compression with tumor,
3-Static examination of the chest :
-thorax shape
- symmetry of the chest
-distortion in terms of restriction or enlargement of one side: increase of one side -exudative pleurisy (hydrothorax), pneumothorax,
-decrease of one side -pulmonary fibrosis, obstructive atelectasis
1. Emphysematous or barrel
pronounced swelling or flattening in the
supraclavicular area
horizontal ribs and intercostal spaces increase
rib angle greater than 90º
an increase in the cross and especially
anteroposterior chest size
2. Paralytic- tuberculosis, chronic abscess
Thorax is flattened from front to back
anteroposterior size is about ½ the size of the frontal
Retraction of supra- and subclavian spaces
Expressed wide intercostal spaces
Epigastric angle is less than 90
3. Rachitic (keeled) thorax : (compressed from sides, sternum sharply protruding - chicken breast)
4. Funnel chest and chest cobbler: congenital anomaly (changing the shape of the sternum, the lower
part of the impression or oblong recess at the upper and middle part of the sternum - navicular thorax)
- Palpation of the chest. Tactile fremitus (normal, increased, decreased, absent)
NB!healthy person the chest is symmetrycal during inspiration and expiration
-Resistance of the chest :
- opposite the property of elasticity;
- causes:
1. emphysema of the lungs,
2. ossification of ribs in the elderly,
3. fluid in the pleural cavity,
4. tumors of the pleura
—Vocal (tactile) fremitus :
-Decreased
* 1. hydrothorax
* 2. pneumothorax
* 3. fibrothorax (thickening of pleura
* 4. obturative atelectasis
* 5. emphysema of the lungs
* 6. thick chest (obesity)
-Increased
* 1. consolidation of the lung tissues - lobar pneumonia;
* 2. empty cavity presence in the lungs;
* 3.compressive atelectasis
* 4. thin chest
- Comparative percussion of the lungs. Percussion notes, reasons of abnormal percussion notes.
-Purrcation notes :
1-Resonant note : Normal lung
2-Dull : Pleural effusion, presence of hepatic tissue, consolidation, pleural thickening
3-Stony dull (flat)
4-Hyporesonant
5-Hyperresonant : Pneumothorax, COPD
6-Tympanic
- Topographic percussion of the lungs. .
-Determining:
* 1) the upper borders of the lungs
* 2) the lower borders of the lungs
* 3) variation mobility of the lower border of the lung
-Rules:
* percussion - quiet
* from clear to dull percussion note
* the finger-pleximeter parallel to the border of the organ
* the border is marked by the edge of the pleximeter
directedtoward the zone of the more resonant sound
* percussion carried out at the ribs and intercostal space
-Lungs topographic percussion abnormalities (lower lung borders) :
1-Elevation
* Shrinking of the lung
* Thickening of pleura
* Exudative pleuritis and hydrothorax
* High diaphragm
* Flatulence
* Ascites
2-Depression:
* Emphysema
* Asthma
* Chronic obstructive pulmonary disease (COPD)
- Lungs auscultation data (vesicular breath and its changes in pathology, pathological bronchial breath).
-The mechanism of formation vesicular breath sounds:
is caused by vibration of extending elastic alveolar walls, heard during the whole inhalation. In the first third of exhalation.
1-Increased vesicular breathing :
* Thin chest wall, Puerile breathing in children, hyperventilation
2-Weakening of vesicular breathing : extrpolumonary causes such as : dysfunction of res muscles , thikning of chest wall ,chet truma , olural effeusion , penumotorax , emphysema ,fibrothorax
-Pathological bronchial breathing :
1.cavitary (in presence of large pulmonary cavities) – amphoric
2.infiltrative (inflammation, tumour, infarction)
3.compressive atelectasis (in exudative pleuritis above the fluid border),
- Adventitious respiratory sounds – crackles, wheezes, pleural crackles (rub)
1- Crackles :
1.1 Wet crackles : Inspiratory and expiratory (wet) crackles
occur during inspiration and expiration,
when air passes through the pathological
liquid, forming bubbles. causes - pathology of the
bronchi and trachea (bronchitis,)
1.2 Fine crackles : Late inspiratory (fine) crackles are associated with the appearance in the alveoli a small amount of viscous secretions (transudate, exudate, blood) causes - pneumonia, alveolitis,
2-wheezing :
* are caused by of air flow through narrowed small bronchi in bronchial asthma, emphysema and COPD.
* better heard on expiration, especially forced.
3-pleural crackles (rub) : pleural pathology (inflammation)
* Is heard during both phases of respiration,
* Is localized to a small area of the chest,
* Does not change after coughing,
* Aggravated by pressure with a stethoscope on the chest wall,
* The sound is caused by the two inflamed surfaces of the
pleura rubbing against each other during
respiration and disappears when sufficient fluid accumulates
to separate the two layers of the pleura.
- Complaints of patients with diseases of the cardiovascular system.
*Pain: - coronarogenic (ischaemic) – angina pectoris
- non-coronarogenic - cardialgia
*Interruptions in the work of the heart and palpitation
*Shortness of breath (dyspnea), suffocation
*Edema
*Coughing, hemoptysis
*Headache
*Dizziness, flickering flies before the eyes
*Syncope
- Data of general examination of patients with cardiovascular diseases. Heart palpation (apex beat, cardiac (right ventricular) beat).
1-Apex beat :
*Location in the V intercostal space, 1,5 cm medial to the
mediaclavicular line
*Mechanism: due to the impact of the apex of the heart on
the chest wall
*Pathology: “Negative push” - with adhesive
(constrictive) percarditis
-Shift of apex beat :
1.Left shift:
§ On the left side (3-4 см)
§ Dilation and hypertrophy of LV
§ Dilation of RV
§ Fluid or air in right pleural cavity Shift of apex beat
2.Right shift:
§ Lying on the right side (1-1,5 см)
§ Pleuro-pericardial commissures
3.Disapperas :
§Left-sided hydrothorax
§Hydropericardium
4.Negative: (constrictive pericarditis)
-Features of apex beat :
Area
- normal 1-2 см2
- >2 см2 - increased (LVH, thin chest, wide intercostal spaces, mediastinal tumor)
- <1 см2 - narrow (thick or edematous subcutaneous fat, narrow intercostal spaces, emphysema)
> 3 см2 LV dilation
-Amplitude: - high (exercise, anxiety, thyrotoxicosis, fever) - low
-Force: - increased (LVH) - decreased
-Resistance – high in LVH
————————————
2-Cardiac (right ventricular) beat:
*Location in the III - IV intercostal space to the left of the sternum extends to
the epigastric region
*Mechanism - reduction of enlarged right ventricle
- Heart percussion (relative and absolute (total) cardiac dullness borders - normal and pathological).
-Percussion of the heart :
1.Detection of atrial and ventricular dilation
2.Detection of vessel bundle dilation
-Detection of relative dullness :
1. Right border:
Is formed by RA (right atrium)
Localized along right sternal line (right sternum edge or 1 cm laterally
-Pathology :
* Dilatation and hypertrophy of the right ventricle or right atrium:
1. mitral stenosis
2. mitral insufficiency
* Mediastinal displacement to the right:
1. left-sided hydrothorax
2. left-sided pneumothorax
3. right obstructive atelectasis
2-Left border:
Is formed by LV
Is detected after palpation of apex beat
Is located 1-2 cm medialy from left midclavicular line
Fits in with apex beat
-pathology :
.Dilatation and hypertrophy of the left ventricle:
1. aortic incompetence
2. aortic stenosis
3. arterial hypertension
.Mediastinal displacement to the left:
1. right-sided hydrothorax
2. right-sided pneumothorax
.Horizontal position of the heart:
1.high diaphragm level (obesity, flatulence, ascites)
3. Upper border:
Is formed by LA appendage
Is percussed 1 cm laterally from sternal line
Is located along the 3rd rib
-Pathology :
Dilatation and hypertrophy of the left atrium:
* 1. mitral stenosis
* 2. mitral valve incompetence
- Auscultation of the heart - heart sounds normal and abnormalities.
-Sounds can be listened to (by auscultation) and recorded by
phonocardiography (PCG) :
I sound (S1) - systolic Norm
II sound (S2) - diastolic Norm
III sound (S3) - diastolic
IV sound (S4) - diastolic
–
* After S1, there is a small pause (0,2 seconds) corresponding to the period of expulsion of blood into the vessels
* After S2, there is a large pause (0,43 sec), corresponding to the flow of blood from the atria into the ventricles
* S1 with a small pause is the systole of the ventricles
* S2 with a large pause is the diastole of the ventricles
————
–Decrease of both sounds :
-Causal causes
1. Obesity
2. Muscle hypertrophy
3. Swelling of the chest
4. Emphysema of the lungs
5. Hydrothorax
-Heart Causes
1. Myocarditis
2. Cardiomyopathies
3. Myocardial dystrophy
4. CHD (coronary heart disease)
5. Myocardial infarction
–increase both : When improving their conduct:
1. Asthenic type of constitution
2. Cachexia
3. Exercise stress
4. Tachycardia
5. Thyrotoxicosis
6. Anemia
- Auscultation of the heart - heart murmurs
-Murmur : A heart murmur is a sound made by turbulent blood flow
within the heart.
-Causes :
* Folding valve flaps - stenosis
* Incomplete closure of the valve opening - insufficiency
* The presence of anomalous holes in the heart:
- atrial septal defect;
- ventricular septal defect
* Rapid of blood flow
* Low blood viscosity
–Correspond to the listening points of sounds:
* Mitral defects (MV) - the apex of the heart
* Aortic defects (AV) - II intercostal space on the right
* Vices of the PV - II intercostal space to the left of the
sternum
* Vices of the tricuspid valve (TV) - at the base of the xiphoid process
-Description of murmurs:
*Timing in the cardiac cycle (systolic, diastolic)
*Location
*Radiation
*Duration
*Intensity
—-Differences in functional and pathological murmur :
1-Functional
*Normal structure of valve
*Only systolic
*Without radiation
*Quiet, soft
*Grade 1-2/6
*Normal S1, S2
*Variable, short
*Causes: - fever
- fast blood flow
- thyrotoxicosis
- low viscosity
- anemia
2-Systolic murmur Properties :
- Listens between S1 and S2 Etiology
- With stenosis of the AV and PV
- With insufficiency of MV, TV - regurgitation
- It has a decreasing character, which depends on the
decrease in the pressure gradient
- Carried out on the current of blood
Types
2.1) Functional (in unchanged valves due to increased blood flow):
– anemia;
– thyrotoxicosis;
– fever
2.2) Pathological:
– Aortic stenosis (maximum in
the 2nd point)
– Pulmonary trunk stenosis
– Hypertrophic cardiomyopathy
3-Diastolic murmur :
Properties
- Auscultate between S1 and S2
- It is always organic
-Etiology :
*Stenosis of atrio-ventricular valves:
- Mitral stenosis
- Tricuspid valve stenosis
*Semilunar valves regurgitation
- Aortic valve insufficiency
- Pulmonary valve insufficiency
4-Extracardiac murmurs :
4.1 Friction of the pericardium
4.2 Pleuropericardial
- Arterial pulse, its properties are normal and pathological.
-Df :Pulse is the rhythmical vibration of the arterial walls caused by contractions of the heart, blood discharge into the arterial system, and changes in pressure in this system during systole and diastole.
* Pulse wave is transmitted due to the ability of arterial walls to distend and collapse.
–Properties of arterial pulse :
* Symmetry:
symmetrical/asymmetrical
* Rhythm: regular/irregular
* Pulse rate:
- normal (60-90 per min)
- bradicardia (<60 per min)
- tachycardia (>90 per min)
* Pulse pressure:
- pulsus durus (hard or high-tension pulse)
- pulsus mollis (soft)
- normal pulse
* Volume of pulse:
- pulsus plenus (full)
- ulsus vacuus
* Pulse amplitudea.
- pulsus magnus (high pulse)
- pulsus parvus (small pulse)
- pulsus filiformis (thready)
- Blood pressure measurement. Diagnostic meaning.
Category Systolic BP Diastolic BP
Optimal <120 and <80
Normal 120-129 and/or 80-84
High normal 130-139 and/or 85-89
1st degree AH 140-159 and/or 90-99
2nd degree AH 160-179 and/or 100-109
3rd degree AH ≥180 and/or ≥110
ISH* ≥140 and <90
- Complaints of a patient with diseases of the esophagus, stomach and intestines
1-Easophgial
*Dysphagia : narrow of easophegial
*Belching :
* Heartburn
*Esophageal vomiting
* Pain when swallowing
*Bad breath
* Bleeding
——
2-Stomach :
* Pain in epigastric
* Dyspepsia: nausea, vomiting, belching, changes in appetite
*Gastrointestinal bleeding
*Weight loss
- Complaints of patients with diseases of the liver and gallbladder.
Pain
Dyspeptic complaints
Fever
Itch (pruritus)
Yellowness of the skin
Discoloration of urine and feces
- Abdominal exam, light palpation of an abdomen.
-first the tequnic :
1. The palm of the right hand is laid flat on his stomach
2. Using your II. III. IV. V fingers gently press on the abdominal wall, feeling her tension
———————-
1-The first method - palpation of symmetrical area:
left iliac region
- the right iliac region
-the left-hand side region
- right side region
- left upper quadrant
- right upper quadrant
- epigastrium left
- epigastrium on right
———————
2-The second method - palpation counterclockwise;
- the left iliac region
- the left side region
- left upper quadrant
- the right upper quadrant
- the right side region
- the right iliac region
- parumbilical region
