Académique Documents
Professionnel Documents
Culture Documents
Couplet stations
3. TAKE HX. FROM MAN WITH DYSPHAGIA
PEP: SHOWN BARIUM SWALLOW, DESCRIBE XRAY FINDING, GIVE DX, GIVE
WORKUP
5. EXAMINE YOUNG WOMAN WITH PURPURA AND EPISTAXIS
PEP: HX, DX, INVESTIGATIONS
6. EXAMINE 20 Y.O FEMALE WITH HYPERTENSION
PEP: DDX, INVESTIGATIONS, WHAT TO DO IF YOUR INVESTIGATIONS ARE
NORMAL
4. EXAMINE MAN WITH CALF CLAUDICATION
PEP: INTERPRET EKG, RISK FACTORS, INVESTIGATIONS
5. TAKE HISTORY FROM MAN WITH SOB AND SPUTUM
PEP: ER RX, INVESTIGATIONS, ADVICE RE: PREVENTION
1. A. 26 year old male refused life insurance because of elevated LFTs. Focussed
history.
B. Ddx, other tests would order.
5. HIV patient with increasing exercise intolerance and dyspnea, now dyspneic at rest.
Physical exam.
B: interpret CXRay, Ddx, Rx
1.
2.
4.
40s man presents with elevated AS T (200) and ALT (200) (ALP 110, bili 26) on
screening at time of insurance. Wants test repeated. 12 drinks on weekend. CAGE
equivocal. Never drank more. IV heroin as teens. Is a janitor at a hospital. Had
perinatal jaundice but nothing since. Previously healthy. Never transfused. No FMHx.
History only.
MEDICINE
PEP:
Head and Neck Exam / Examine Lymph Nodes above the diaphragm
Examination of LN's above diaphragm
- examine the following --> occipital, post auricular, pre-auricular, cervical chains
(posterior, superficial, deep), tonsillar, submandibular, submental, SUPRACLAVICULAR (inspire to feel properly)
--> EPITROCHLEAR (medial surface of arm, 3cm above the elbow),
AXILLARY
PEP - DDx lymphadenopathy
Infection - Bacterial, viral (mono, CMV, cat scratch, HIV), parasitic (toxo), spirochetal
(syphilis), mycobacterial (TB, MAC), fungal (actinomycosis, cryptococcosis
1. Hepatic bruit - high/turbulent flow over liver - hepatocellular ca, alc hepatitis
2. Hepatic friction rub - inflammation of liver
3. Venous Hum (epigastric) - soft humming noise with systolic and diastolic
components, indicates increased collateral circulation between portal and systemic
venous systems, as in hepatic cirrhosis
PEP - Viruses that cause hepatitis and 2 with fecal oral spread
- Hep A,B,C,D,E, EBV, CMV
- Hep A and E and transmitted thru fecal-oral spread, both of which do NOT cause
chronic hepatitis
10) Focused liver exam alcoholic
Hands
Clubbing, leuconychia (pale nail)
Dupuytrens contracture, palmar erythema, spider nevi, tattoos, hepatic flap, pallor, scratch marks,
generalized pigmentation
Eyes and face
Icterus, cyanosis, parotid enlargement, fetor hepaticus
Chest
Spider nevi, loss of axillary hair, gynecomastia
Abdomen
Splenomegaly, ascites, hepatomegaly, caput medusae
GU
Testicular atrophy, loss of pubic hair
Leg edema
- postrenal - BPH, stones (flank pain), urinary retention in past, Achol. meds, diabetes
Associated symptoms - dysuria, flank pain, obstructive urinary symptoms, abdo pain,
hematuria, foamy urine(protein)
Past medical history - past episodes, recent UTI (post strept GN)
meds - as above
PEP - admitting investigations
- CBC, lytes, BUN, creatinine, glucose, urate, Ca, Mg, Phosphate
- Urine microscopy, C/S, culture, electrolytes, osmolality, creatinine
- 24 hour urine collection for protein, creatinine, pH, osmolality
- abdominal ultrasound
- Foley In/Out
- important initial causes of oliguria to consider include :
- CHF, hemorrhage, pulmonary edema, sepsis
- lipid lowering agents - do fasting lipid profile, if total chol >5.5 or LDL > 2.6 HMG CoA reductase inhibitors
2. Pharmocotherapy
- thrombolysis if meets indications and no contraindications
- anticoagulation - aspirin, heparin/coumadin (3 months)
- beta blockers - reduce mortality
- ACE-inhibitors - reduce mortality, especially good if hx CHF
- nitrates - symptomatic control only
- Define primary, secondary and tertiary prevention
Primary Prevention - preventing disease before it occurs, thereby reducing the incidence
of disease (eg immunization, dietary recommendations)
Secondary Prevention - early detection of disease in an asymptomatic period before it
progresses and the treatment which may occur as a result of screening
Tertiary prevention - attempts to reduce complications by treatment and rehabilitation,
which are carried out primarily by the exsting health care system.
percussion breath
sounds
advent.
sounds
voice
sounds
pneumo
decr. over
affected
side
contralat
shift
hyper
resonant
decr.
absent
none,
none
possible
pleural rub
atelectasis
decr. over
affected
side
decr. or
absent
crackles,
bronchial
breath
sounds
above
level of
atelect.
may have
egophony
above
level of
atelectasis
Pre-renal
Volume depletion intake?
Poor cardiac output (CHF, tamponade, MI, PE)
Sx:?DOE, orthopnea, PND, ankle edema
Precipitants: MI, HTN, valvular heart disease, congenital heart disease, pericardial disease,
cardiomyopathy, PE, fluid overload, sodium retention, salt overload, dysrhythmia, beta
blocker, renal disease, anemia, fever and infection, pregnancy, noncompliance with meds or
diet.
Risk: CAD, HTN, cardiomyopathy
Shock/sepsis fever, chills, focus of infection
Renal
Glomerular nephritides
Tubular interstitial pyelo, hypercalcemia
ATN recent surgery
Nephrotoxic agents antibiotics, contrast dye, anaesthetics, NSAIDs, chemo
Vascular problems emboli, renal vessel thrombosis
Post-renal
Obstruction stones, tumour, BPH, strictures, clots, retroperitoneal mass
Bladder rupture trauma
Pain description
Ever had any CP before?
Quality: heavy, burning, tightness, stabbing, pressure
Precipitating/ Aggravating: walking level/uphill - quantify, food, cold
Associated Symptoms
N, V, diaphoresis, palpitations, dyspnea, orthopnea, PND
PMH
Also, previous cardiac disease
Meds
Inspection
Face distress, nasal flaring, pursed lips
Cyanosis (frenulum/lips, finger/toes/nose)
Posture ( usually leaning fwd, elbows resting on knees)
Neck accessory muscles
Chest AP dia., deformities, indrawing, assymetry
Resp rate and pattern
Hands clubbing (not seen in emphysema), nicotine stains
Palpation
Trachea position and mobility
Chest excursion
Diaphragmatic excursion
Tactile fremitus
Percussion
Lungs hyperresonant? compare sides
Loss of cardiac dullness
Auscultation
Breath sounds
Vocal resonance
FET: normal individuals can empty their chest from full inspiration in 4 seconds or less. The end
point of FET is detected by auscultating over the trachea in the suprasternal notch. Prolongation
of the FET to more than 6 seconds indicates airflow obstruction
Dont forget R middle lobe, anterior and posterior chest
Trachea central
Impaired percussion note
Bronchial breath sounds
crackles
TIPS
Introduce yourself
History
Age
Gender ( males mostly seronegative)
Pain: worse with rest = inflammatory, other pain qs
Morning stiffness: >60 min = inflammatory, <30-60 min = non-inflammatory
Distribution of joint involvement
Symmetrical, asymmetrical
Large/small
Peripheral/central (spinal dist)
Upper/lower limbs
Temporal profile of disease activity (eg. OA slowly and steadily progressive, vs. gout, intermittent
exacerbations and remissions)
Degree of disability: functional capacity and ADLs
Treatment
Family history: AS, SLE, RA
PMH: DM, IBD, psoriasis, GU/GI infections, renal disease
Meds: diuretics, cyclosporin, hydralazine, procainamide, anticonvulsants
Extra-articular features: (too many to list! Constitutional, skin, mucous membrane lesions,
urethritis, Raynauds, conjunctivitis, GI, pleuropericardial pain, etc.)
Inflammato
ry
opaque
low
>2,000
Infectiou
s
opaque
low
>50,000
>25%
>50%
%PMN
<25%
<25%
multiple joint
OA: conservative (weight loss, PT, OT, rest); acetaminophen,
NSAIDs for inflammation, intraarticular steroids; surgical options
later
Vitals
CNS status: alert or decreasing LOC
Abdomen: + RECTAL for melena, OB positive blood
Signs of chronic liver disease
-r/o symptoms: fatigue, SOB, chest pain, palpitations, has her family commented
on her being pale or jaundiced
-look for cause:
ask about diet: B12 and iron (meats), folate (greens)
alcohol intake
medications: antacids decrease Fe absorption
source of bleeding (melena, hematochezia, menorrhagia, hematuria)
fevers, chills, nightsweats, weight loss
travel (malaria-endemia areaOK, I know this one is a stretch for asymptomatic)
past history of anemia: therapy employed, response to treatment
family history of anemia, jaundice, gallbladder disease, splenectomy
PMHx:
35 year old with abdo cramps and diarrhea for 2 weeks - History
ID:
HPI:
history of diarrhea:
quantify: volume, frequency (is it really diarrhea? defn: increase in fluidity and/
frequency)
quality: colour, consistency, presence of melena, hematochezia (blood =
cathartic)
associated symptoms: tenesmus, relief with defecation, urgency,
nausea/vomiting
history of cramps: OPPQRST
Onset: sudden vs gradual
Position: where are the cramps
Provocating/alleviating factors: foods, (chocolate, peppermint, caffeine), alcohol,
drugs, stress, activity, etc.
Quality: what do the cramps feel like (true crampy pain vs sharp/dull, etc)
Radiation of pain
Symptoms associated: fever, myalgias, weight loss, chills (and those above)
Temporal profile: progression of symptoms with time
risk factors for infectious: daycare worker/children at daycare, outbreaks
4 mechanisms of diarrhea
abnormal intestinal motility
increased permeability causing fluid/electrolyte secretion
impaired intestinal absorption
intraluminal nonadsorbable osmotically active solutes
Previous surgery:
-terminal ileal resection (no bile salt reabsorption)