Outlinesfor Internal Medicine

BackgroundInternal Medicine is, on one hand, an integral clinical course which links all the basic courses together. On the other hand, it provides a platform to learn and grasp knowledge for other clinical courses. So it is important to master the essentials, know well about the etiology, and to understand treatment principles, not only for this course itself, but for all clinical courses.

Big challengeWith the amazing development of biochemistry, biophysics, biostatistics, molecular biology, genetic engineering, and other bioscientific courses, the conception and extension of Internal Medicine is becoming more and more complicated. As a result, the methods and lectured contents are required to adapt to all the challenges.

AimPrimary task is to master basic theories for diseases and emergencies that commonly occurBe capable to collect history, perform systemic physical examination skillfully, & to understand significance of lab results as wellAble to make a primary diagnosis by integral analysis of all clinical information. Referred to treatment, they are required to master principles for management of common emergency & Diseases

Ethical education

Ethical viewpoints, despite divergences among different cultures, are something educated through the whole lecturing processAnyhow, treating patients with kindness and full respect is the same in different cultural background. Other personalities such as patience, prudence and diligence are important for a qualified doctor.

Therefore, quality education should be embodied in class lecturing and clinical practice Qualified doctors is The end aim for clinical medical educationWhats a qualified doctor?

Humanityplentiful knowledgeSkillful techniqueDiligence & IntelligencePrudence & PatienceAll above is my answer

MethodTheoretic lecture is important in class, for basic knowledgeComplemental form, practice for history collectingscene simulation-- is helpful to strengthen theoretic knowledge lectured in classClinical practice in hospital is a step for every student.

EvaluationEducation is evaluated by

Topic discussion in classHomeworkSectional, midterm and final exams.

Approach to patients with diseases of respiratory system

General principlesAlmost commonest diseases in the worldIn China, occurrence is 1st in rural areas, 4th in urban areas.Death rate is overall the 1st

Currently, occurrence of lung cancer and bronchi asthma increased quickly.COPD is still a very common diseasetuberculosis has the ascending trend. AIDS related opportunistic infection and malignancyNew epidemic diseases, such as SARS and bird flu, is inflamed all over the world

How to make a diagnosis Patients with RD have both common and specific presentationsA diagnosis, even more refined differential diagnosis, relied on symptoms, signs, radiographs, and other examinations

What can we get from history inquiryCommon symptomsDyspnea (shortness of breath) & cough, according to time course, divided into acute, subacute, and chronic

Acute (a period of hours to days): indicate asthma, pulmonary parenchyma infection, pneumothorax, or pulmonary embolus

2 Subacute (over days to weeks): exacerbation of airway diseases (asthma and bronchitis), a parenchymal infection or noninfectious inflammation with a relatively slow pace, AIDS related pneumocistis carinii pneumonia, mycobacterial or fungal pneumonia, Wegners granulomatosis, eosinophilic pneumonia

3. Chronic (months to years): COPD, chronic interstitial lung diseases, chronic cardiac diseases, which is characterized as exacerbation & remission.

Other common symptomsCough may indicate RD, but not useful for differential diagnosis. However, accompanied symptoms indeed helpful

Sputum: always give a hint to diagnosisHemoptysis: may originate from disease of parenchyma, airway vasculature. Subacute (over days to weeks): Chest pain

Hemoptysis: may originate from disease of parenchyma, airway, vasculature. Parenchymal diseases: localized diseases including pneumonia, lung abscess, tuberculosis, or infection with aspergillus (); diffuse diseases such as Goodpastures syndrome, idiopathic pulmonary hemosiderosis ()Airway diseases: acute or chronic bronchitis, bronchiectasis, cystic fibrosis, or neoplasmVasculature diseases: pulmonary thromboembolic disease or arteriovenous malformations

Other common symptomsChest pain

Always indicates the parietal pleura is involvedAccentuated by respiratory motion, referred as pleuriticCaused by primary pleural diseases such as neoplasm, inflammatory disorders; secondary to pulmonary parenchymal disorders such as pneumonia or pulmonary infarction

Additional historic informationCigarette smokingCurrent or pastThe intensity: number of packs per dayCOPD & lung neoplasm is most important complications resulted from smoking Interval since cessation: which is related to the risk of lung cancerOthers: spontaneous pneumothorax, respiratory bronchitis-interstitial pneumonia, eosinophilic granuloma of the lung or pulmonary hemorrhage (Goodpastures syndrome), etc

Additional historic informationExposure of other inhaled agentsThis may act via direct toxicity or through immune mechanismOccupational or avocationalInorganic dusts associated with pneumoconiosis (asbestos or silica dusts); organic antigens (antigen from mold or animal protein) associated with hypersensitivity pneumoniaAsthma always exacerbated by such exposure

Additional historic informationContact with special population infected with specific respiratory pathogens, such as TB, SARS or bird flu, etc

Additional historic informationCoexisting systemic diseases, Examples: rheumatic diseases, neoplasm, AIDSPrevious treatment of other diseases

Chemotherapy immunosuppressiveAdrenergic -receptor blockers airway obstructionACEI (Angiotensin-converting enzyme inhibitors) cough

Physical ExaminationPrinciplesSequence: inspection palpation percussion and auscultationNot only for apparent ascertaining abnormalities, but also for underlying lung diseases, that is from phenomena to reality, which is refined by analysis and syntheses of all signs

On inspectionRate and pattern of respirationDepth and symmetry of thoracic expansionRapid, labored or associated with accessory muscles: augmented demands or increased work of breathing (airway or parenchymal problems)Asymmetry expansion: unilateral obstruction of airway, parenchymal or pleural diseases, or phrenic nerve paralysisAbnormal thoracic cage: kyphoscoliosis, ankylosing spondylitis labored breathing, dyspnea

On palpationSymmetry of lung expansion, confirming findings by inspectionTactile fremitus: or none pleural fluid interposed between lung & chest wall, or obstruction of airway altering sound transmission; increase localized consolidation

On percussion and auscultationWe can have valuable findings for different conditions (table 1)

Table 1 Typical chest PE findings in selected conditions

ConditionPercussion FremitusBreath sndVoice transAdvent sndNormalResonanceNormalVesicularNormalAbsent* ConsolidDull IncreaseBronchial@BronchophonyCrackles# Consolid atelectasisDullDecreaseDecreaseDecreaseAbsentAsthmaResonanceNormalVesicularNormalWheezingInterstitialResonanceNormalVesicularNormalCracklesEmphysem HyperDecreasedDecreaseDecreaseAbsent or wheezingPneumothxHyperDecreaseDecreaseDecreaseAbsentPleural effusionDullDecreasesDecreaseDecreaseAbsent or friction rub

@: bronchophony, or whispered pectoliquuy, egophony*: with patent airway#: with blocked airway

Chest RadiographyMost commonly and always initial appliedEvaluation for patients with R. symptomsProvide evidence in cases free of symptomFurther information is required with CT

Solitary circumscribed densityNodule (

33-

SQ.CA-

37-

Localized opacification (infiltrate)Pneumonia: bacterial, atypical, TB, or fungalNeoplasmRadiation pneumoniaBronchiolitis obliterans with organizing pneumoniaBronchocentric granulomatosisPulmonary infarction

Diffuse interstitial diseaseIdiopathic pulmonary fibrosisPulmonary fibrosis with systemic Rheumatoid diseasesSarcoidosis (nodular disease)Drug induced lung diseasePneumoconiosis (dusty lung)Hypersensitivity pneumoniaInfection (pneumocystis (), viral pneumonia)Eosinophilic granuloma

32-

1mmCT

Diffuse alveolar diseasesCardiogenic pulmonary edemaARDS (acute respiratory distress syndrome)Diffuse alveolar hemorrhageInfection (pneumocystis, viral or bacterial pneumonia)Sarcoidosis

40-

alveolar Cell Ca.-

Diffuse nodular diseasesMetastatic neoplasmHematogenous spread of infection (Bacterial, TB, fungal)PneumoconiosisEosinophilic granuloma

71-

Silicosis

69-

4R4L5

Disturbance of respiratory functionDiscussed in another time

Other procedures in RDImaging studiesHistology or cytologyEndoscope-related techniques

BronchoscopyDiagnosis for bronchial tumor, TB, foreign body, Location for hemoptysis, etc

Imaging studiesRoutine RadiographyBronchographyComputed TomographyMagnetic Resonance ImagingScintigraphic ImagingPulmonary AngiographyUltrasound

Routine RadiographyPosterioanterior and lateral viewsIn some cases, need apical lordotic view for apical diseasePortable equipment for patients in emergency or not in erect position

BronchographyMore helpful for bronchial diseases, such as bronchiectasis, tumor, atelectasis, etc

Computed TomographyAdvantages over routine radiographyCross-sectioned images distinguish between densities superimposed in AP filmFar better at characterizing tissue density, distinguish subtle differences between adjacent tissuesProvide more accurate size assessmentParticular valuable in assessing hilar () or mediastinal diseases, in identifying diseases adjacent to chest wall or spine

Advantages over routine radiographyCross-sectioned imagesFar better at characterizing tissue densityProvide more accurate size assessmentParticular valuable in assessing hilar diseasesValuable in the staging of lung cancerIn identifying fatty or calcification area in nodulesWith help of contrast medium, distinguish vascular from nonvascular structures

Other special application Helical CT: allows the collection of continuous data over a large volume of lung during a single breath-holding maneuver, which is not accomplished by conventional CTCT Angiography: pulmonary emboli be found

Other special application High-Resolution CT: cross-section is even thinner, 1-2mm vs 10mm in conventional CT, also, image reconstruction is possible. Better recognition of subtle parenchymal & airway or interstitial D, such as bronchiectasis, emphysema, & diffuse parenchymal D, interstitial D including Idiopathic pulmonary fibrosis, Sarcoidosis, Eosinophilic granuloma, or lymphatic carcinoma

Magnetic Resonance ImagingLess well defined than that of CTAdvantages over CT

Restructed in saggital, coronary and transverse planes, so better for imaging abnormalities near lung apex, spine, and thoracoabdominal junctionBetter for imaging vascular structures without administration of contrast (vessels as hollow tubular structures)

Scintigraphic ImagingRadioactive isotypes administered intravenously or by inhalation, image obtained with a gamma cameraMost common use is ventilation-perfusion lung scanning pulmonary thromboembolismAnother use is the evaluation of lung function before and after surgery

Pulmonary AngiographyCatheter threaded into pulmonary artery, contrast media administrated to make angiographyVery helpful for Pulmonary embolism, which demonstrated either a defect in the lumen or an abrupt termination (cutoff sign)Less common indications for pulmonary arteriovenous malformation or arterial invasion by a neoplasm

UltrasoundNot useful for evaluation of pulmonary parenchymal diseases, because ultrasound energy dissipated rapidly in airBut for pleural diseases or used as a guide to placement of a needle for sampling or drainage

Collection of sputumMethods

Spontaneous expectorationInduced after inhalation of irritating aerosol (hypertonic saline), better for diagnostic studiesAppearance & qualityGram staining and cultureCytological staining

Histology and CytologyMethods for sampling

Collection of sputumPercutaneous needle aspirationThoracentesis: 1) palliation of dyspnea when large quantity of pleural fluid exists, 2) diagnostic sampling: routine biochemical analysis, cytologyBronchoscopy and mediastinoscopy

Endoscope related techniquesIncluding: bronchoscope, mediastinoscope, and thoracoscopeApplication

DiagnosisTherapies

DiagnosisVisual information, bronchoalveolar lavage, washing or brushing for cytology, endobronchial or peribronchial biopsy for histology, endoscopic aspiration for lymph node

Therapies

Endoscopic laser therapyCryotherapyElectrocautery Stent placement for obstructed airwayVideo-assisted thoracic surgery, thoracotomyAnd mediastinotomy as well

CurriculumRespiratory diseases Total 27

2-28 Preface3-04 Asthma3-07 COPD3-11 Lung cancer3-14 Pneumonia, Lung abscess3-18 Pulmonary TB3-21 Bronchiectasis, ARDS 3-25 Pleural diseases3-28 Respiratory failure