principles of medicine prelim reviewer

7/29/2019 Principles of Medicine Prelim Reviewer

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PRINCIPLES OF MEDICINE PRELIM REVIEWER

HISTORY TAKING & PHYSICAL EXAMINATION

• Takes up 70% of diagnosis

• Remaining 30% is for diagnostic procedures

HISTORY

• Interview the patient

• Establish rapport with the patient

EPIDEMIOLOGY

• Study of prevalence of diseases in a certain

population

I. IDENTIFYING DATA or PATIENT’S PROFILE

• Name

• Age

• Sex

• Religion – reflects habits

• Marital status – reflects sexual habits

• Occupation – reflects stress levels

II. CHIEF COMPLAINT

• The reason why the patient seeks medical attention

• Main reasons:

o Pain or discomfort

o Observable changes from normal status

o Loss of function or dysfunction

• Use patient’s own words

III. HISTORY OF PRESENT ILLNESS

• Time

• Anatomic locations

• Quantity and quality of the symptom

• Aggravating and relieving factors

• Timing of symptom

• Associated signs and symptoms

• Absence of signs and symptoms

• Symptom’s response to therapeutic measures

IV. PAST MEDICAL HISTORY

• Previous hospitalizations

o Hypertension

o Diabetes

o Asthma

o Allergies/ hypersensitivity reactions

o Present medications

V. FAMILY HISTORY

• Ask for illness suffered by family members

• Proximity of family members

• History of communicable diseases with close family

relative

• Ask for hereditary diseases

o Hypertension

o Diabetes mellitus

o Presence or absence of malignancies

o Asthma

VI. PERSONAL AND SOCIAL HISTORY

• Habits – smoking, alcohol consumption, eating

• Environment

• Occupation

• Sexual history – sexual preference

VII. OB-GYN HISTORY

• Menarche

• Ob-gyn score

o GRAVIDA - # of times the woman got

pregnant

o PARITY - # of times the woman gave birth

• Birth control methods used

• LMP (last menstrual period)

o Ask for the first day

• FPAL

o F = full term

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o P = partial

o A = number of abortions

o L = number of live births

VIII. REVIEW OF SYSTEMS

• Start with constitutional symptoms (genera)

o Symptoms that do not pertain to a certain

system like: fever, body malaise, weight loss

• NERVOUS SYSTEM

o Ask for headache, dizziness, double vision

• RESPIRATORY SYSTEM

• CARDIOVASCULAR SYSTEM

• GASTROINTESTINAL SYSTEM

• GENITOURINARY SYSTEM

PHYSICAL EXAMINATION

• INSPECTION

• PALPATION

• PERCUSSION

• AUSCULTATION

I. GENERAL SURVEY

• Overall evaluation of the patient

• LEVEL OF CONSCIOUSNESS

• NUTRITIONAL STATUS

• MOOD/AFFECT

• PRESENCE OR ABSENCE OF CARDIOVASCULAR

DISTRESS

II. VITAL SIGNS

• BP

• RR

• PR

• Temp

Presence or absence of signs plays a big role in

determining if a patient’s low BP is normal

HYPERTENSION is easier to detect that HYPOTENSION

SKIN

• Use inspection and palpation

• Check for changes in normal or stable state

o COLOR

ERYTHEMA – inflammation

CYANOSIS – oxygenation

PALLOR – perfusion

o TEXTURE

o TURGOR

Elasticity

Ability of the skin to snap back

Best area to test: forhead

Test for: level of hydration

• Check for EVENTS

o Secondary lesions, trauma to the skin, cuts,

changes in consistency, changes in contour,

presence or absence of malaise, presence

or absence of masses

HEAD

• Normocephalic head

• Check for distribution of hair

• Check for normal contour of the head

• EYES

o Check for color of sclera

o Check for presence or absence of

ICTERESIA (yellowish sclera)

o Equally responsive pupils

o Palpebral conjunctiva must be pinkish in

color

o Presence or absence of corneal injection

Cornea is avascular so there mustnot be any corneal injection

• NOSE

o Check for septal deviations

• EARS

o Check for presence or absence of discharge

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NECK

• LYMPHADENOPATHICS

o Check for the triangles of the neck

o Check for thyroid enlargement

o Check for presence or absence of distended

neck veins

THORAX

• Check for absence or presence of PECTUS

CARINATUM (pigeon’s chest) or PECTUS

EXCAVATUM (depression towards external area)

• Check for changes in the usual curvature

• Check for symmetry of the ribcage

• Check for symmetrical expansion of the lungs

NORMAL BREATHING SOUNDS

• BRONCHIAL SOUNDS

o Sounds of traveling air in tubes

o Sounds dissipate after inhalation

• VESICULAR SOUNDS

o High-pitched, thin sounds

• BRONCHOVESICULAR SOUNDS

o Combination of bronchial and vesicularsounds

ABNORMAL BREATHING SOUNDS

• RALES

o Sounds of fluid in alveoli

o Gurgling sounds

• CRACKLES

o Sounds of fluid in bronchioles

o Sounds like crumpling paper

OBSTRUCTION SOUNDS

• WHEEZES

o Typical fine wheezing sound on small

bronchioles

o Found on ASTHMA

• RONCHI

o Obstructing very big airways

o Lower pitched & louder

PERCUSSION OF NORMAL LUNGS

• Detected 7cm down

•

Done on intercostals spaces

PERCUSSION OF ABNORMAL SOUNDS ON LUNGS

• Hyper resonance

PERCUSSION OF LUNGS WITH MASS OBSTRUCTION

• Dull sounds

HEART

• Check for presence or absence of murmurs

o Signs of obstruction of valves

o Check for rhythm

o Check for movement of precordium

o When there are heaves during systole,

there is enlargement of the left

ventricle

ABDOMEN

• Check for enlargement of viscera:

o Liver, spleen, stomach

• Check for presence of mass and tenderness

• Abdomen should always s be soft and not

board-like

• Check for SWELLING, TENDERNESS & ENLARGEMENT

SKIN

• Epidermis & dermis

• 1.3 – 2.3m2

• Functions:

o Protection against trauma and infection

o Thermoregulation

o Supports sensory receptors

EPIDERMAL LAYER

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• Stratum corneum

• Stratum lucidum

• Stratum spinosum

• Stratum granulosum

• Stratum basale

DERMAL LAYER

• Papillary layer 1/3

• Reticular layer 2/3

o Has a lot of nerves and blood supply

SUBCUTANEOUS TISSUE

• Adipose tissue

• Superficial fascia

HAIR

• CUTICLE – outermost layer of hair shaft

• CORTEX – middle layer

• MEDULLA – innermost layer

2 types of HAIR

• TERMINAL HAIR

o Dark, thick, pigmented hair growing on top

of the head, eyebrows, eyelashes, axilla and

genitals

• VELLUS HAIR

o Fine, non-pigmented

o Has arrector pili muscle (responsible for

goose bumps)

SEBACEOUS GLAND

• Gives oily secretion for lubrication and protection

SWEAT GLANDS

• Gives watery secretion for thermoregulation

• ECCRINE GLAND

o Scattered all over the body

• APOCRINE GLAND

o Found in genitals and axilla

HISTORY TAKING (SKIN)

CHIEF COMPLAINT

• PAIN

• PRURITUS

o Itching (mild pain)

• CHANGE FROM A STEADY STATE

•

DYSFUNCTION

o Hair loss, profuse sweating, oversecretion of

oil

PHYSICAL EXAM

• LOCATION and/or DISTRIBUTION

• ARRANGEMENT, PATTERN & SHAPE

o Linear, annular, serpenginous

• KIND OF LESION

o Primary or secondary lesions

• COLOR

KINDS OF LESIONS

• PRIMARY LESIONS

o PAPULE

Elevation on skin with a diameter

not greater than 5mm

o PLAQUE

Elevation on skin with a diameter

greater than 5mm

o VESICLE

Fluid-filled elevation on skin with a

diameter not greater than 5mm

o BULLAE

Fluid-filled elevation on skin with a

diameter greater than 5mm

o NODULE

Elevation on skin which is bigger

and deeper in origin

o PUSTULE

Pus-filled elevation on skin

o MACULE

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Pigmented skin lesion that is

circumscribed with a diameter not

greater than 5mm

o PATCH

Pigmented skin lesion that is

circumscribed with a diameter

greater than 5mm

• SECONDARY LESIONS

o Lesions that arise from Primary lesions

o EROSIONS

Epidermis is taken out with no

bleeding

o ULCER

Much deeper erosion into the

dermis

o FISSURE

Linear crack into the dermis

o LICHENIFICATION

Thickening of the dermis

Exaggeration of the furrows

Seen in PSORIASIS

o SCALING/SCALES

Dead skin cells still attached to the

epidermis

Eg DANDRUFF

o VEGETATION

Irregular shaped growth of the skin

Eg WARTS

o MACULOPAPULAR

Combination of elevated and flat

lesion

Folliculitis, measles

COLOR (normal)

• RED = OXYHEMOGLOBIN

• BLUE = DEOXYHEMOGLOBIN

• DARK COLOR = MELANIN

• YELLOWISH = CAROTENE

DIAGNOSTIC PROCEDURES

• GRAM STAINING

o Bacterial

• 10% KOH

o Fungal, hyphae

• GIEMSA/ WRIGHT STAIN

o Viral

• WOOD’S LAMP

o Fungal, pseudomonas (fluorescent)

• SKIN BIOPSY/ SKIN PUNCH

o Best test for diagnosis

CNS

• Brain and brainstem

• 12 cranial nerves

• 31 PNS

BRAIN

• 4 LOBES

BRAINSTEM

• Pons, medulla, cerebellum

• WHITE MATER – periphery

• GRAY MATER – center

• POSTERIOR HORN – sensory

• ANTERIOR HORN – motor

• Reflex

o Afferent posterior horn

o Efferent anterior horn

• CSF flows up to S2

• SUBARACHNOID ends at lower border of L1

HISTORY (CNS)

CHIEF COMPLAINT

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• PAIN

o Headache (cephalalgia)

• DYSFUNCTION

o Motor loss/ weakness

o Anesthesia (sensory loss)

•

Dizziness

• Loss of consciousness

GENERAL SURVEY

• Level of consciousness/ coherence

• Orientation

o Assess function of the patient

CHECK THE 12 CRANIAL NERVES

• OPTIC

o Use Snellen’s Chart

• OLFACTORY

o Check smelling sensation

• OCCULOMOTOR

o Extraoccular movements

• TROCHLEAR

o Extraoccular movements

o Superior Oblique

• TRIGEMINAL

o V1, V2, V3

o Clenching of teeth

• ABDUCENS

o Extraoccular movement

o Lateral rectus

• FACIAL

o Mixed nerve

o Sensory : anterior 2/3 of tongue

o Facial expression

• ACOUSTIC/ AUDITORY

• GLOSSOPHARYNGEAL

o Sensory: posterior 1/3 of tongue

o Gag reflex

• VAGUS

o Gag reflex

•

SPINAL ACCESSORY

o Trapezius – shoulder shrug

o Sternocleidomastoid (SCM) – turn head

with resistance

• HYPOGLOSSAL

o Stick out tongue

MUSCLE MOTOR TESTING (MMT)

0/5 = no contraction/ no tone

1/5 = with little contraction

2/5 = with movement but not against gravity

3/5 = can overcome gravity

4/5 = can overcome gravity but not resistance

5/5 = can overcome gravity and resistance

Test pinpoint sensations with PINS and BRUSHES

SKIN OF THE FACE (intact)

• Compare left and right

• Cervical and cranial nerves

• Graded in %

BELL’S PALSY

• Paralysis of one side of the face

• Muscular branches of facial nerve are involved

• Facial nerve (CN VII) is affected

o Peripheral nerve dysfunction

• Caused by:

o Infection: may be viral or bacterial

o Inflammation: secondary to trauma

o Compression: by a mass

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TRIGEMINAL NEURALGIA

• Facial pain

• Involving sensory branches of trigeminal nerve

• Most often occurs in V2 and/or V3

•

Etiology:

o Inflammatory process

o Often times occur in one side of the face

CEREBROVASCULAR ACCIDENT

• Residual effects:

o Weakness/paralysis of muscles

o Sensory loss

• Blockage of Circle of Willis (blood supply of the brain)

AXONS comprise the spinal cord

MOST COMMON ENCOUNTERED IN CVA

• CORTICOSPINAL – motor

o Efferent

o Voluntary movements

o Starts from precentral gyrus

• SPINOTHALAMIC – sensory

o Decussate in medulla

o Responsible for pain, temperature, crude

touch

• POSTERIOR COLUMNS – sensory

Receptors in the periphery are in the axons of the

spine

Motor – pre-central gyrus

Sensory – post-central gyrus

Broadman’s Area 312 – sensory

CT scan

• Checks the density of hard tissues

• Checks for MASSES

• Better used for detection of Cerebral Hemorrhages

• Detects extravassated blood

MRI

• Checks the integrity of soft tissues

• Cannot see hard tissues

• Cerebral infarcts (decomposition of tissues)

Spinal Cord makes extensive use of MRI

•

Compression of nerves and swelling of spinal cord

LUMBAR PUNCTURE/ SPINAL TAP

• Infection= ↑ WBC

• Hemorrhage = ↑ RBC

• Detect through cytology

o Aids in histologic diagnosis

• Do puncture between L4 & L5

EPIDURAL HEMATOMA

• Do CT scan

• Can also be done with Xray

CT scan is always fone before lumbar puncture is done

in order to prevent herniation of the brainstem

-Rosette Go 072410

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principles of medicine prelim reviewer

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