Part II Internal Medicine Examination Answers
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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)
http://www.nlm.nih.gov/medlineplus/ency/article/003416.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000065.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000128.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003073.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001353.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001353.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003073.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000128.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000065.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003416.htm -
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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.
http://www.localhealth.com/article/faintinghttp://www.bettermedicine.com/topic/fatigue/http://www.localhealth.com/article/shortness-of-breathhttp://www.localhealth.com/article/shortness-of-breathhttp://www.localhealth.com/article/shortness-of-breathhttp://www.localhealth.com/article/shortness-of-breathhttp://www.bettermedicine.com/topic/fatigue/http://www.localhealth.com/article/fainting -
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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)