Part II Internal Medicine Examination Answers

7/31/2019 Part II Internal Medicine Examination Answers

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18-Functional examining of the respiratory system; methods X ray,bronchoscopy, respiratory failure etiology, pathogenesis, symptoms;

Introduce yourselfand explain the procedure. Ensure the patient is comfortable

and maintain the patients dignity.

Look at the patientfrom the end of the bed for:

general appearance

breathing ratepursed lip breathing

non-specific signs of illness, interest and interaction with surroundingsThen start with the hands: look for (for example)

clubbing (Ca bronchus, mesothelioma, bronchiectasis, lung abscess, fibrosingalveolitis,

cystic fibrosis, empyema/lung abscess)

peripheral cyanosis

nicotine stainingcoarse tremor/flap of CO2 retention (also causes bounding pulse)Look at the face for

central cyanosis (lips and tongue)

eyes (eg Horners syndrome)

Inspect the chest: position patient at 45 degrees, look for

respiratory rate

use of accessory muscles, wheezing

pattern of respiration - Cheyne-Stokes (alternating hyperventilation and apneoa,

which occurs in LVF, high altitude and raised intracranial pressure)

shape of the chest and scars - asymmetry (in collapse of fibrosis), increased antero-

posterior diameter (barrel chest) in COPD

Palpation

check position of mediastinum by feeling position of trachea between heads of

sternomastoid in suprasternal notch apex beat - feel for the furthest point down andout where the pulsation can be felt

lymph nodes in supraclavicular fossae

Chest Expansion: extend fingers, anchor fingertips laterally around the lower part

ofthe chest so thumbs are 2-4 cm either side of midline but raised up over sternum.

Assess extent and symmetry of movement of thumbs apart on inspiration.

Percussion: both sides of the chest at top middle and lower segments, including

axillae. The finger which is struck should be parallel to the floor. Percuss in the

intercostal spaces. Compare sides.

increased resonance: means more air and less solid in chest than normal -found in

pneumothorax, emphysemadecreased resonance: means more solid and less air in chest than normal -found

in effusion, solid lung-consolidation, collapse, abscess, neoplasm

Auscultation: Use the diaphragm (except above the clavicles, when you use the

bell). Listen at the top, middle and bottom of the chest and then in the axillae

(comparing like with like on opposite sides). Ask the patient to breathe through

their open mouth quite deeply. Breath sounds may be

vesicular

bronchial (gap between inspiratory and expiratory phases with prolonged

expiratory phase) - found in consolidation

reduced - in effusion, pneumothorax, collapse, emphysema


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Listen for added sounds and note if inspiratory or expiratory:

crackles: fine are caused by snapping open of tiny airways (occur in heartfailure);

medium and coarse - are caused by fluid in larger airways ( occur in pneumonia,

bronchitis and bronchiectasis)

wheezes: mean constricted airways - the higher pitched the wheeze, the greater is

the narrowing.

pleural rub: pleurisy

Vocal Resonance (VR) or Tactile Vocal Fremitus (TVF): Ask the patient to say99, whilst listening over the chest. Sounds are louder over areas of consolidation.

Compare both sides.At the end of the examination ask to see the sputum and

measure the peak flow.

X-Ray : refer to radiation, waves or particles that travel through the air like light or

radio signals. X-ray energy is high enough that some radiation passes through

objects (such as internal organs, body tissues, and clothing) and onto x-ray detectors

(such as film or a detector linked to a computer monitor). In general, objects that are

more dense (such as bones and calcium deposits) absorb more of the radiation from

the x-rays and dont allow as much to pass through them. These objects leave a

different image on the detector than less dense objects. Specially trained or

experienced physicians can read these images to diagnose medical conditions or

injuries.

Medical x-rays are used in many types of examinations and procedures. Some

examples include

x-ray radiography (to find orthopedic damage, tumors, pneumonias, foreign objects,

etc);

mammography (to image the internal structures of breasts)

CT (computed tomography) (to produce cross-sectional images of the body)

fluoroscopy (to dynamically visualize the body for example to see where to remove

plaque from coronary arteries or where to place stents to keep those arteries open)

radiation therapy in cancer treatment.Bronchoscopy: is a test to view the airways and diagnose lung disease. It may also

be used during the treatment of some lung conditions.You may have a bronchoscopy to help

your doctor diagnose lung problems. Your doctor will be able to inspect the airways or take

a biopsy sample.

Common reasons to perform a bronchoscopy are:

Lung growth, lymph node, atelectasis, or other changes seen on an x-ray or other imaging

test

Suspected interstitial lung disease

Coughing up blood (hemoptysis)

Possible foreign object in the airway

Cough that has lasted more than 3 months without any other explanation

Infections in the lungs and bronchi

Inhaled toxic gas or chemical

You may also have a bronchoscopy to treat a lung or airway problem, such as:

Remove fluid or mucus plugs from your airways

Remove a foreign object from your airways

Widen (dilate) an airway that is blocked or narrowed

Drain an abscess

Treat cancer using a number of different techniques

Wash out an airway (therapeutic lavage)
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Respiratory failure is a syndrome in which the respiratory system fails in one or

both of its gas exchange functions: oxygenation and carbon dioxide elimination. In

practice, it may be classified as either hypoxemic or hypercapnic.

Hypoxemic respiratory failure (type I) is characterized by an arterial oxygen

tension (PaO2) lower than 60 mm Hg with a normal or low arterial carbon dioxide

tension (PaCO2). This is the most common form of respiratory failure, and it can beassociated with virtually all acute diseases of the lung, which generally involve fluid

filling or collapse of alveolar units. Some examples of type I respiratory failure are

cardiogenic or noncardiogenic pulmonary edema,pneumonia, and pulmonary

hemorrhage.

Hypercapnic respiratory failure (type II) is characterized by a PaCO2higher than

50 mm Hg. Hypoxemia is common in patients with hypercapnic respiratory failure

who are breathing room air. The pH depends on the level of bicarbonate, which, in

turn, is dependent on the duration of hypercapnia. Common etiologies include drug

overdose, neuromuscular disease, chest wall abnormalities, and severe airway

disorders (eg, asthma andchronic obstructive pulmonary

disease[COPD]).Respiratory failure may be further classified as either acute or

chronic. Although acute respiratory failure is characterized by life-threatening

derangements in arterial blood gases and acid-base status, the manifestations of

chronic respiratory failure are less dramatic and may not be as readily apparent.

Acute hypercapnic respiratory failure develops over minutes to hours; therefore,

pH is less than 7.3. Chronic respiratory failure develops over several days or

longer, allowing time for renal compensation and an increase in bicarbonate

concentration. Therefore, the pH usually is only slightly decreased.The distinction

between acute and chronic hypoxemic respiratory failure cannot readily be made on

the basis of arterial blood gases. The clinical markers of chronic hypoxemia, such as

polycythemia or cor pulmonale, suggest a long-standing disorder.Etiology : These diseases can be grouped according to the primary abnormality and

the individual components of the respiratory system (eg, CNS, peripheral nervous

system, respiratory muscles, chest wall, airways, and alveoli).A variety of

pharmacologic, structural, and metabolic disorders of the CNS are characterized by

depression of the neural drive to breathe. This may lead to acute or chronic

hypoventilation and hypercapnia. Examples include tumors or vascular

abnormalities involving the brain stem, an overdose of a narcotic or sedative, and

metabolic disorders such as myxedema or chronic metabolic alkalosis.

Common causes of type I (hypoxemic) respiratory failure include the

following:

COPD

Pneumonia

Pulmonary edema

Pulmonary fibrosis

Asthma

Pneumothorax

Pulmonary embolism

Pulmonary arterial hypertension

Pneumoconiosis

Granulomatous lung diseases

Cyanotic congenital heart diseaseBronchiectasis


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Acute respiratory distress syndrome (ARDS)

Fat embolism syndrome

Kyphoscoliosis,Obesity

Common causes of type II (hypercapnic) respiratory failure include the

following:

COPDSevere asthma

Drug overdose

Poisonings

Myasthenia gravis

Polyneuropathy

Poliomyelitis

Primary muscle disorders

Porphyria

Cervical cordotomy

Head and cervical cord injury

Primary alveolar hypoventilation

Obesity-hypoventilation syndrome

Pulmonary edema

ARDS

Myxedema

Tetanus

Symptoms : Respiratory failure is accompanied by a number of symptoms including:

Bluish coloration of the lips or fingernails

Confusion or loss of consciousness

Fainting or change in level of consciousness or lethargy

FatigueIrregular heart rate (arrhythmia)

Rapid breathing (tachypnea) or shortness of breath

Dangerous Symptoms :

Bluish coloration of the lips or fingernails

Change in level of consciousness or alertness, such as passing out or

unresponsiveness

Rapid heart rate (tachycardia)

Respiratory or breathing problems, such as shortness of breath, difficulty breathing,

labored breathing, wheezing, not breathing, or choking

Physical Examination :Asterixis may be observed with severe hypercapnia.Tachycardia and a variety of arrhythmias may result from hypoxemia and acidosis.

Cyanosis, a bluish color of skin and mucous membranes, indicates hypoxemia

Dyspnea, an uncomfortable sensation of breathing, often accompanies respiratory

failure.

Both confusion and somnolence may occur in respiratory failure. Myoclonus and

seizures may occur with severe hypoxemia. Polycythemia is a complication of long-

standing hypoxemia.

Pulmonary hypertension frequently is present in chronic respiratory failure.

Alveolar hypoxemia potentiated by hypercapnia causes pulmonary arteriolar

constriction. If chronic, this is accompanied by hypertrophy and hyperplasia of theaffected smooth muscles and narrowing of the pulmonary arterial bed.
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Lab Tests: A complete blood count (CBC) may indicate anemia, which can contribute

to tissue hypoxia, whereas polycythemia may indicate chronic hypoxemic

respiratory failure.

Abnormalities in electrolytes such as potassium, magnesium, and phosphate may

aggravate respiratory failure and other organ function.

Measuring serum creatine kinase with fractionation and troponin I helps excluderecent myocardial infarction in a patient with respiratory failure. An elevated

creatine kinase level with a normal troponin I level may indicate myositis, which

occasionally can cause respiratory failure. In chronic hypercapnic respiratory failure,

serum levels of thyroid-stimulating hormone (TSH) should be measured to evaluate

the possibility of hypothyroidism, a potentially reversible cause of respiratory

failure.Instrumental Test :

Chest radiography is essential in the evaluation of respiratory failure because it frequentlyreveals the cause (see the images below). However, distinguishing between cardiogenic and

noncardiogenic pulmonary edema is often difficult. Increased heart size, vascularredistribution, peribronchial cuffing, pleural effusions, septal lines, and perihilar bat-wing

distribution of infiltrates suggest hydrostatic edema; the lack of these findings suggestsacute respiratory distress syndrome (ARDS).

Echocardiography need not be performed routinely in all patients with respiratory failure.

However, it is a useful test when a cardiac cause of acute respiratory failure is suspected.Thefindings of left ventricular dilatation, regional or global wall motion abnormalities, or severe

mitral regurgitation support the diagnosis of cardiogenic pulmonary edema. A normal heartsize and normal systolic and diastolic function in a patient with pulmonary edema would

suggest ARDS.Echocardiography provides an estimate of right ventricular function andpulmonary artery pressure in patients with chronic hypercapnic respiratory failure.

Pulmonary Functions Tests :Patients with acute respiratory failure generally are unable to

perform PFTs; however, these tests are useful in the evaluation of chronic respiratoryfailure.Normal values for forced expiratory volume in 1 second (FEV1) and forced vitalcapacity (FVC) suggest a disturbance in respiratory control. A decrease in the FEV1 -to-FVC

ratio (FEV1/FVC) indicates airflow obstruction, whereas a reduction in both FEV1 and FVCand maintenance of FEV1/FVC suggest restrictive lung disease.Respiratory failure is

uncommon in obstructive diseases when FEV1 is greater than 1 L and in restrictive diseaseswhen FVC is greater than 1 L.

Complications :Of acute respiratory failure may be pulmonary, cardiovascular,gastrointestinal (GI), infectious, renal, or nutritional.

Common pulmonary complications of acute respiratory failure include pulmonary

embolism, barotrauma, pulmonary fibrosis, and complications secondary to the use of

mechanical devices. Patients are also prone to develop nosocomial pneumonia. Regularassessment should be performed by periodic radiographic chest monitoring. Pulmonaryfibrosis may follow acute lung injury associated with ARDS. High oxygen concentrations and

the use of large tidal volumes may worsen acute lung injury.Common cardiovascular complications in patients with acute respiratory failure include

hypotension, reduced cardiac output, arrhythmia, pericarditis, and acute myocardial

infarction.

The major GI complications associated with acute respiratory failure are hemorrhage,gastric distention, ileus, diarrhea, and pneumoperitoneum. Stress ulceration is common in

patients with acute respiratory failure; the incidence can be reduced by routine use of

antisecretory agents or mucosal protectants.

Acute renal failure and abnormalities of electrolytes and acid-base homeostasis are

common in critically ill patients with respiratory failure. The development of acute renalfailure in a patient with acute respiratory failure carries a poor prognosis and high mortality.


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Nutritional complications include malnutrition and its effects on respiratory performance

and complications related to administration of enteral or parenteral nutrition. Complicationsassociated with nasogastric tubes, such as abdominal distention and diarrhea, also may

occur.

19- Aspiration and examining of pleural fluid;(KAITLARDA)

20- ECG rhythm disorders, disturbances in the conduction, pathological changesin patients with angina and myocardial infarction; (KAITLARDA)

21- Functional and instrumental methods of examining of the heartveloergometry, echocardiography, scintigraphy, catheterization with

angiography;(KAITLARDA)

22-Functional examining of the kidneys test for concentration and dilution of theurine, clearance tests; radiological tests diagnostic evaluation;(KAITLARDA)

23- Instrumental methods for examining of the alimentary tract gastroscopy,

The sequence of examining the abdomen changes according to the age and

cooperativeness of the child. Frequently all four types of assessments (inspection,

auscultation, percussion and palpation) are performed at different times. For example,

the medical practitioner may auscultate for bowel sounds following evaluation of heart

and lung sounds at the beginning of the examination when the child is quiet. Percussion

usually follows lung percussion, and palpation may be done toward the end of the

examination when the child is relaxed and more trusting of the medical practitional.

For descriptive purposes the abdominal cavity is divided into four compartments or

quadrants by drawing a vertical line midway from the sternum to the pubic symphysis

and a horizontal line across the abdomen through the umbilicus. This method of division

actually includes the pelvic cavity. Each section is designated as follows: Right upper

quadrant (RUQ), Right lower quadrant (RLQ), Left upper quadrant (LUQ), Left lower

quadrant (LLQ).

Percussion

Percussion of the abdomen is performed in the same manner as percussion of the lungs

and heart. Normally, dullness or flatness is heard on the right side at the lower costal

margin because of the location of the Liver. Tympany is typically heard over the stomach

on the left side and usually in the rest of the abdomen. An unusually tympanitic sound,

like the beating of a tight drum, usually breathing. However, it can also denote a

pathoilogic condition such as low intestinal obstruction or paralytic ileus. Lac of

tympany may occur normally when the stomach is full after a meal, but in other

situations it may denote the presence of fluid or solid masses.

Palpation


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Two types of palpation are performed, superficial and deep. In superficial palpation a

doctor lightly places the hand against the skin and feels each quadrant, noting any areas

of tenderness, muscle tone, and superficial lesions, such as cysts. Superficial palpation is

often perceived as "tickling" by the child. Which can interfere with its effectiveness, The

nurse can avoid this problem by having the child "help" with the palpation by placing

him with statements such as, "I am trying to feel what you had for lunch". Admonishing

the child to stop laughing only draws attention to the sensation and decreases

cooperation. Positioning the child in supinated position with the legs flexed at the hips

and knees helps relax the abdominal muscles.

Tenderness anywhere in the abdomen during superficial palpation is always noted.

There are two types of abdominal pain:

1. Visceral, which arises from the viscera or internal organs such as the intestines, and2. Somatic, which arises from the walls or linings of the abdominal cavity such as the

peritoneum.

Visceral pain is usually dull, poorly localized, and difficult for the patient to describe.

Somatic pain is generally sharp, well localized and more easily described. When

assessing abdominal pain, it is important to remember that the child will often respond

with an "all-or-none" reaction- either there is no pain or great pain. Therefore all aspects

of the examination must be carefully considered when ruling out conditions such as

appendicitis.

A special phenomenon called rebound tenderness, or Blumberg's sign, may be

performed if the child complains of abdominal pain. It is performed by pressing firmly

over the part of the abdomen distal to the area of tenderness. When the pressure is

suddenly released, the child feels pain in the original area of tenderness. This response is

only found when the peritoneum overlying a diseased visceral or organ is inflamed, such

as in appendicitis.

Deep palpation is used for palpating organs and large blood vessels and for detecting

masses and tenderness that were not discovered during superficial palpation. If the child

complains of abdominal pain, the area of the abdomen is palpated last. Normally,

palpation of the mid-epigastrium causes pain as pressure is exerted over the aorta, but

this should not be confused with visceral or somatic tenderness.

The doctor palpates the abdominal organs by pressing them with a free hand, which is

placed on the child's back. Palpation begins in the lower quadrants and proceeds

upwards. In this way, the edge of an enlarged liver or spleen is not missed. Except for


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palpating the liver, successful identification of other organs, such as the spleen, kidney,

and part of the colon, requires considerable practice with tutored supervision.

The lower edge of the liver is sometimes palpable in infants and young children as a

superficial mass 1 to 2cm (1/2 to inch) below the right costal margin (the distance issometimes measured in fingerbreadths). If the liver is palpable 3cm (1/4 inches) or 2

fingerbreadths below the costal margin, It is considered enlarged and this finding is

referred to a physician. Normally the liver descends during inspiration as the diaphragm

moves downward. This downward displacement should not be mistaken for a sign of

hepatomegaly. In older children the liver frequently is not palpable, although its lower

edge can be estimated by percussing dullness at the costal margin.

The spleen is palpated by feeling it between the hand placed against the back and the

one palpating the left upper quadrant. The spleen is much smaller than the liver and

positioned behind the fundus of the stomach. The tip of the spleen is normally felt

during inspiration as it descends within the abdominal cavity. It is sometimes palpable 1

to 2 cm below the left costal margin in infants and young children. A spleen that is

readily palpated more than 2cm below the right costal margin is enlarged and is always

reported for further medical investigation.

Other anatomical structures that are sometimes palpable in children include the cecum,

and sigmoid colon. The cecum is a soft, gas-filled mass in the right lower quadran. Thesigmoid colon is left as a sausage-shaped mass that is freely movable over the pelvic

brim in the left lower quadrant and is normally tender.

Although most of these structures are not routinely felt, one should be aware of their

relative location and characteristics in order not to mistake them for abnormal masses.

The most common palpable lower quadrant because with constipation the left colon fills

with stool and gas until the ileocecal valve is reached. The the cecum becomes distended,

causing pain, which may be erroneously associated with appendicitis.

Special methods of investigation

Laboratory examination

1. Routine blood examination

2. Urine tests (bile pigments, ketonuria)

3. Biochemical analysis (bilirubin total, unconjugated and conjugated bilirubin, protein,

cholesterol, AlAt, AsAt, amylase, trypsin and lipase)

4. Biochemical analysis of Urine for diastase.

Disorders

1. Syndrome of cholistasis increased level of total and conjugated bilirubin andcholesterol).


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2. Syndrome of cytolysis (increased level of AsAt, AlAt, LDG)

3. Syndrome of dysfunction of pancreas (increased level of amylase, trypsin, lipase)

4. Chain polymerizes reaction for virus of hepatitis A, B, C

5. Examination of feces for intestinal parasites (ascarides, lamblia cysts, enterobiosis)

6. Copogram

Indigested muscular fibers

Steatorrhea

Lientery

Bacteria in the feces

Instrumental methods of examination

1. Esophagogastroduodenoscpy

2. Ultrasound investigation

3. Intragastric pH-metry

4. Colonoscopy

5. Procto(sigmoido)scopy

6. Artificial contrast study of gastrointestinal system

7. Laparoscopy

8. Irrigoscopy and irrigography

9.Gastroscopy

A gastroscopy is a test where an operator (a doctor or nurse) looks into the upper part

of your gut (the upper gastrointestinal tract). The upper gut consists of the oesophagus(gullet), stomach and duodenum. The operator uses an endoscope to look inside your

gut. Therefore, the test is sometimes called endoscopy.An endoscope is a thin, flexible,

telescope. It is about as thick as a little finger. The endoscope is passed through the

mouth, into the oesophagus and down towards the stomach and duodenum.

Colonoscopy is a procedure used to see inside the colon and rectum. Colonoscopy can

detect inflamed tissue, ulcers, and abnormal growths. The procedure is used to look for

early signs of colorectal cancer and can help doctors diagnose unexplained changes in

bowel habits, abdominal pain, bleeding from the anus, and weight loss.

A rectoscopy is one of many components under endoscopy, which basically means

looking inside the body for medical reasons. The instrument used is called

an endoscope. This device goes inside the organ to properly observe from the inside.

A rectoscopy specifically is the endoscopy of the rectum, which is an organ used in

defecation. Essentially the endoscope is inserted into a place where the "sun don't

shine," so to speak.

Normal laboratory values of biochemical analysis of blood

Glucose 3.33-5.55 mmol/L

Bilirubin total 8.5-2.0 mcmol/L


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Unconjugated 2/3 of total

Conjugated 1/3 of total

Protein total 60.0-80.0g/L

ALT 0.1-0.75 mcmol/g/L

AST 0.1-0.45 mcmol/g/L

Amylase 16-32 dye units/L

A number of gastrointestinal disorders are caused by disturbances in motor function.

Some such as Hirschsprung's disease, produce typical signs of obstruction and are

alternately classified as obstructive disorders.

24- Laboratory tests in patients with liver diseases diagnostic evaluation;The diagnosis of liver diseases depends upon a combination of history, physical examination,laboratory testing and sometimes radiological studies and biopsy. Only a physician who knows

all of these aspects of a specific case can reliably make a diagnosis.Alanine aminotransferase (ALT)

ALT is an enzyme produced in hepatocytes, the major cell type in the liver. ALT is ofteninaccurately referred to as a liver function test, however, its level in the blood tells little about

the function of the liver. The level of ALT in the blood (actually enzyme activity is measured in

the clinical laboratory) is increased in conditions in which hepatocytes are damaged or die. Ascells are damaged, ALT leaks out into the bloodstream. All types of hepatitis (viral, alcoholic,

drug-induced, etc.) cause hepatocyte damage that can lead to elevations in the serum ALTactivity.

Aspartate aminotransferase (AST)AST is an enzyme similar to ALT but less specific for liver disease as it is also produced in muscle

and can be elevated in other conditions (for example, early in the course of a heart attack). AST

is also inaccurately referred to as a liver function test by many physicians. In many cases of liverinflammation, the ALT and AST activities are elevated roughly in a 1:1 ratio. In some conditions,such as alcoholic hepatitis or shock liver, the elevation in the serum AST level may higher than

the elevation in the serum ALT level.Alkaline phosphatase

Alkaline phosphatase is an enzyme, or more precisely a family of related enzymes, produced inthe bile ducts, intestine, kidney, placenta and bone. An elevation in the level of serum alkalinephosphatase (actually enzyme activity is measured in the clinical laboratory), especially in the

setting of normal or only modestly elevated ALT and AST activities, suggests disease of the bile

ducts. Serum alkaline phosphatase activity can be markedly elevated in bile duct obstruction or

in bile duct diseases such as primary biliary cirrhosis or primary sclerosing cholangitis.Gamma-glutamyltranspeptidase (GGT)An enzyme produced in the bile ducts that, like

alkaline phosphatase, may be elevated in the serum of patients with bile duct diseases.Elevations in serum GGT, especially along with elevations in alkaline phosphatase, suggest bile

duct disease. Measurement of GGT is an extremely sensitive test, however, and it may beelevated in virtually any liver disease and even sometimes in normal individuals.

Albumin

Albumin is the major protein that circulates in the bloodstream. Albumin is synthesized by the

liver and secreted into the blood. Low serum albumin concentrations indicate poor liverfunction.

Prothrombin time (PT)

Many factors necessary for blood clotting are made in the liver. When liver function is severelyabnormal, their synthesis and secretion into the blood is decreased. The prothrombin time is a

type of blood clotting test performed in the laboratory and it is prolonged when the bloodconcentrations of some of the clotting factors made by the liver are low. In chronic liver diseases,


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the prothrombin time is usually not elevated until cirrhosis is present and the liver damage is

fairly significant. In acute liver diseases, the prothrombin time can be prolonged with severeliver damage and return to normal as the patient recovers.Platelet countPlatelets are the smallest of the blood cells (actually fragments of larger cells known as

megakaryocytes) that are involved in clotting. In some individuals with liver disease, the spleen

becomes enlarged as blood flow through the liver is impeded.

Serum protein electrophoresisIn this test, the major proteins in the serum are separated in an electric field and their

concentrations determined. The four major types of serum proteins whose concentrations are

measured in this test are albumin, alpha-globulins, beta-globulins and gamma-globulins.

25 -Abdominal ultrasound, liver biopsy, CT scanning, MRI diagnostic abilities; ofthe methods;What is Ultrasound Imaging of the Abdomen?

Ultrasound imaging, also called ultrasound scanning or sonography, involves exposing part of

the body to high-frequency sound waves to produce pictures of the inside of the body.

Ultrasound examinations do not use ionizing radiation (as used in x-rays). Because ultrasound

images are captured in real-time, they can show the structure and movement of the body's

internal organs, as well as blood flowing through blood vessels.

Ultrasound imaging is a noninvasive medical test that helps physicians diagnose and treat

medical conditions.An abdominal ultrasound produces a picture of the organs and other

structures in the upper abdomen.A Doppler ultrasound study may be part of an abdominal

ultrasound examination.Doppler ultrasound is a special ultrasound technique that evaluates

blood flow through a blood vessel, including the body's major arteries and veins in the abdomen,

arms, legs and neck.

What are some common uses of the procedure?

Abdominal ultrasound imaging is performed to evaluate the:

kidneys liver gallbladder pancreas spleen abdominal aorta and other blood vessels of the abdomen

Ultrasound is used to help diagnose a variety of conditions, such as: abdominal pain or distention. abnormal liver function. enlarged abdominal organ. stones in the gallbladder or kidney. an aneurysm in the aorta.

Additionally, ultrasound may be used to provide guidance for biopsies.Doppler ultrasound images can help the physician to see and evaluate:

blockages to blood flow (such as clots). narrowing of vessels (which may be caused by plaque). tumors and congenital vascular malformation.

A liver biopsy is a procedure in which a small needle is inserted into the liver to collect a tissue

sample. The tissue is then analyzed in a laboratory to help doctors diagnose a variety of

disorders and diseases in the liver. A liver biopsy is most often performed to help identify the

cause of;
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Persistent abnormal liver blood tests (liver enzymes).

Unexplained yellowing of the skin (jaundice).

A liver abnormality found on ultrasound, CT scan, or nuclear scan.

Unexplained enlargement of the liver.

What is CT Scanning of the Body? CT scanningsometimes called CAT scanningis a noninvasive medical test that helps

physicians diagnose and treat medical conditions.CT scanning combines special x-ray

equipment with sophisticated computers to produce multiple images or pictures of the

inside of the body. These cross-sectional images of the area being studied can then beexamined on a computer monitor, printed or transferred to a CD.

CT scans of internal organs, bones, soft tissue and blood vessels provide greater clarity andreveal more details than regular x-ray exams.

one of the best and fastest tools for studying the chest, abdomen and pelvis because itprovides detailed, cross-sectional views of all types of tissue.

often the preferred method for diagnosing many different cancers, including lung, liver,kidney and pancreatic cancer, since the image allows a physician to confirm the presence of

a tumor and measure its size, precise location and the extent of the tumor's involvementwith other nearby tissue.

an examination that plays a significant role in the detection, diagnosis and treatment ofvascular diseases that can lead to stroke, kidney failure or even death. CT is commonly used

to assess for pulmonary embolism (a blood clot in the lung vessels) as well as forabdominal aortic aneurysms (AAA).

invaluable in diagnosing and treating spinal problems and injuries to the hands, feet andother skeletal structures because it can clearly show even very small bones as well as

surrounding tissues such as muscle and blood vessels.

In pediatric patients, CT is rarely used to diagnose tumors of the lung or pancreas as well as

abdominal aortic aneurysms. For children, CT imaging is more often used to evaluate:

lymphoma neuroblastoma kidney tumors congenital malformations of the heart, kidneys and blood vessels

Magnetic resonance imaging (MRI) is a type of scan used to diagnose health conditions

that affect organs, tissue and bone.

MRI scanners use strong magnetic fields and radio waves to produce detailed images of the

inside of the body.

An MRI scanner is a large tube that contains a series of powerful magnets. You lie inside the tube

during the scan.

MR imaging of the body is performed to evaluate:

organs of the chest and abdomenincluding the heart, liver, biliarytract, kidneys, spleen, bowel,pancreas and adrenal glands.

pelvic organs including the reproductive organs in the male (prostate and testicles) andthe female (uterus, cervix and ovaries).

blood vessels (MR Angiography). breasts. Physicians use the MR examination to help diagnose or monitor treatment for conditions

such as:

tumors of the chest, abdomen or pelvis. certain types of heart problems.
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blockages, enlargements or anatomical variants of blood vessels, including the aorta,renal arteries, and arteries in the legs.

diseases of the liver, such as cirrhosis and tumors, and that of other abdominal organs,including the bile ducts, gallbladder, and pancreatic ducts.

diseases of the small intestine, colon, rectum and anus.

cysts and solid tumors in the kidneys and other parts of the urinary tract. tumors and other abnormalities of the reproductive organs (e.g., uterus, ovaries,

testicles, prostate).

causes of pelvic pain in women, such as fibroids, endometriosis and adenomyosis. suspected uterine congenital abnormalities in women undergoing evaluation for

infertility.

breast cancer and implants. fetal assessment in pregnant women.

26- Functional examining of the endocrine system;

Thyroid Gland Examination :

GENERAL APPEARANCE:- Weight loss.

- Anxiety.

- Frightened facies (thyroid stare)

Hands :

Onycholysis (Plummers nails) particularly on the ring finger. Rarely seen in Gravesdisease.

- Thyroid acropachy (clubbing).

- Fine tremors (sympathetic over activity).

- Moisture & warmth (sympathetic over activity).

- Palmer erythema.

VITAL SIGNS:.RADIAL PULSE:

. Sinus tachycardia.

Collapsing character (high cardiac output).

Irregularly irregular: atrial fibrillation.

Regular with periods of irregularity: extrasystole.

.BLOOD PRESSURE.

.TEMPERATURE.

. RESPIRATORY RATE.

ARMS:

- Proximal myopathy (ask the patient to raise the arms above the head).

- Exaggerated reflexes (esp. in relaxation phase).

EYES :

XOPHTHALMOS (PROPTOSIS): Protrusion of the eyeball out of the orbit (occurs

bilaterally only in Graves disease).- Sclera visible below or all around the iris.

- Patient can look up without wrinkling the forehead.

- Difficulty in converging.

- Patient cannot close the eyelids.

- Eyeball is visible anterior to superior orbital margin.

CHEMOSIS : Thickening, crinkling, oedema & opacity of conjunctiva particularly

over the insertion of the lateral rectus muscle.


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CONJUNCTIVITIS:

CORNEAL ULCERATION: due to inability to close the eyelids.

OPTIC ATROPHY: due to optic nerve stretching.

OPHTHALMOPLEGIA: Patient cannot look upwards & outwards.

LID LAG: The upper eyelid cannot keep pace with the eyeballs as it follows a finger

moving from above downwards.LID RETRACTION: Sclera visible above the superior limbus of the iris.

LEUKOTRICHIA: White discoloration of the eyelashes.

NECK:

INSPECTION:

Look at the front & sides of the neck & decide if there is localized or general

swelling of the gland.

- Swelling (enhanced by asking the patient to swallow sips of water): Shape (nodular or diffuse). Movement during swallowing (only a goiter or thyroglossal cyst will rise during

swallowing).

Inferior border.- Scars (thyroidectomy scar).

- Prominent veins (over the upper part of the chest, often accompanied by JVP. Suggestretrosternal extension of the goiter thoracic inlet syndrome-).- Erythema of skin (in case of suppurative thyroiditis).

There is diffuse thyroid swelling that moves freely with swallowing & its inferior border

is visible.No scars, prominent veins or erythema of skin.

PALPATION: begun from behind.

- Size: look for the lower border, if absent, may be retrosternal extension).

- Site:- Shape:

Diffuse enlargement.

Solitary nodule:

- Location.

- Size.

- Consistency:

Soft: simple goiter.

Rubbery hard: Hashimotos thyroiditis.

Stony hard node: carcinoma, calcification in a cyst, fibrosis, or Riedels thyroiditis.Tenderness.

Mobility. Multinodular.

- Surface:

- Temperature: thyroiditis.

- Tenderness: Thyroiditis (subacute or rarely suppurative), bleeding into cyst or

carcinoma.

- Texture:

- Thrill: in thyrotoxicosis.

- Consistency: firm or stony hard.

- Relation to surrounding structures: tethering or fixation to overlying skin or

underlying tissues in thyroid carcinoma.- State of regional L.N: enlarged in carcinoma.


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- State of local tissues (due to malignancy infiltration by thyroid carcinoma):

Arteries: bruits over the carotids.

Veins: venous hum.

NOW, move to the front. Note the position of the trachea, which may displaced by a

retrosternal gland.

PERCUSSION: Percuss the upper part of the manubrium from one side to the other. Ifpercussion notes changed, this may indicate retrosternal extension.

AUSCULTATION:

Listen for a bruit over each lobe which occur in:

- Hyperthyroidism.

- Using of antithyroid drugs.

CHEST:

*Thoracic inlet obstruction Pembertons sign: by asking the patient to lift botharms as high as possible. Wait for few minutes:

-Congestion of the face (plethora).

-Cyanosis.

-Respiratory distress & inspiratory stridor.

-Neck venous distention (venous congestion).

*This occurs with retrosternal goiter or any retrosternal mass.

- Gynaecomastia (occasionally with thyrotoxicosis, or with panhypopituitarism).

- Systolic flow murmurs (due to cardiac output).- Signs of CHF esp. in elderly (precipitated by thyrotoxicosis).

THE LEGS:

* Look for pretibial myxoedema (bilateral firm elevated dermal nodules & plaques which

can be pink, brown, or skin colored).

-Due to accumulation of mucopolysaccharide.

-This is occurs only in Graves disease & not in hypothyroidism.*Test for proximal myopathy & reflexes in the legs.

DIABETES MELLITUS EXAMINATION:

If FBS 7.8 mmol/L. or the 2 hour postprandial BSL of 11.1 mmol/L or more in morethan one occasion.

- Primary: either type I or type II.

- Secondary: hormone induced state (acromegally, Cushings syndrome,phaeochromocytoma, and glucagonoma).

- Drugs: steroid, thiazide, phenytoin, the contraceptive pills, and diazoxide).

- Pancreatic disease (carcinoma, chronic pancreatitis, haemochromatosis).

GENERAL SYMPTOMS: Polyuria, polydiapsia, polyphagia, blurred vision, weakness,

tiredness, lethargy, infections, groin itch, weight loss, disturbance of conscious state,

rash (pruritis vulvae, balanitis).

GENERAL APPEARANCE:

-Evidence of dehydration (osmotic diuresis).

-Obesity (type II DM).

-Recent weight loss (evidence of uncontrolled glycosuria).

-Abnormal endocrine facies (acromegally, Cushings syndrome).-Pigmentation (haemochromatosis bronze diabetes).-Kussmals breathing Air Hanger (diabetic ketoacidosis)LOWER LIMBS:

INSPECTION:SKIN- Hairless & atrophied (small vessels vascular diseases & resultant ischemia).


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- Leg ulcers on the toes or any pressure areas- (ischemia, peripheral neuropathy).

- Skin infections boils, cellulitis & fungal infections ( glucose, ischemia).- Pigmented scar (late diabetic dermopathy).

- Necrobiosis Lipoidica Diabeticorum: over the skin & it is a central yellow scarred area,

which surrounded by a red margin when the condition is active.

- Insulin injection sites (usually in the thigh): may associated with localized fat atrophy&/or hypertrophy.

MUSCLE WASTING:

-Note any Quadriceps muscle wasting due to femoral nerve mononeuropathy. This is

called Diabetic Amyotrophy. KNEE:

- Rare Charcots joint : grossly deformed & disorganized joint due to loss ofproprioception or pain or both.

PALPATION :

Injection sites for fat atrophy or hypertrophy.

- Feel all peripheral pulses, temperature, and tests the capillary return if -(peripheral vascular disease).

NEUROLOGICAL EXAMINATION:

- Check for sensation, muscle power & tap reflexes.

UPPER LIMBS:

Nail: for signs of candidal infections.

-Inspect & feel for the injection sites over the forearm.

-Take blood pressure lying & standing autonomic neuropathy which may leads topostural hypotension.

FACE EXAMINATION:EYES:

Visual acuity, which may be:

-Permanent: due to retinal diseases.T-emporarily: due to disturbed the shape of the lens associated with hyperglycemia &

water retention.

EARS:

-Evidence of Malignant Otitis Externa caused by Pseudomonas Aeruginosa.-Facial nerve palsy (in 50 %).

MOUTH

-Evidence of candidal infections.

NECK & SHOULDERS:

-Examine carotid artery for evidence of vascular diseases.

-Check for the thickening of the upper back & shoulders (evidence of Scleroderma).

-Acanthosis nigricans (in insulin resistant cases).

CHEST : For signs of infections.

ABDOMEN: Palpate hepatomegally due to fatty infiltration or due to haemochromatosis.

27- Functional examining of bones and joints;(KAITLARDA)

Part II Internal Medicine Examination Answers

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