Internal Medicine Case Study

[MAJ]

After knowing a lot of topics were produced here in this section of the forum which were dealing with HOW TO APPROACH PATIENT CLINICALLY , So that , we want over here in this thread to practice what we `ve been said them theioritically and to apply them now clinically for chosing some common cases in the MEDICAL FIELD seeing them frequently in the hospitals and they will be also COMMON IN THE ORAL EXAM , At the same time , these cases will be done for the students level according to their clinical year in which they are and it will be in progressive manner i.e. starting from simple cases to more complicated one and from practicing the history very well ending to the management .

Fourth year needed to be more oriented with history taking and physical exam with some differential diagnosis .

Fifth year , added to them the investigation wise with outlines of managements .

Sixth year , will be from A to Z completed case report .

After practicing the job , we will try to put QUIZ OF THE WEEK , to be solved completely by the students .

I will start with the first case and I`ll present it in brief ( I will leave some information hinded to discover them together ) and deal with it as a case study in the beginning .

Of course , we are waiting from all of you over here to share us presenting these cases and to be active with us and we are sure , the whole will get benefit from that .

:sun:

Ok , Let`s Start with the first one

This was an interview with a patient I saw him in the medical ward ( ?? unite ) , it was 2nd day of admission , he was stable at that time and lying comfortable in his bed .I introduced myself to him and I asked him poiletly to talk about his condition and he was very cooperative to take history from him . The following few lines are describing his illness .

Personal Data :

Mr. X , a 55 years old Saudi man , he is retiered , admitted to the medical ward ( ?? unite ) for 2 days through ER .

Chief compliant :

Chest Pain
Shortness Of Breath
At the time just immediately prior to the admission

History Of Presenting Illness :

Patient was ok until 2 days back , when he was with his friend sitting together on the sea in Jeddah to enjoy their time .

Suddenly the patient felt a sever central squeezing chest pain graded to 7 out of 10 according to the patient words . It was radiating to the left shoulder , lasting for about 10-15 minutes .

Before the attack , the patient heared bad news from his friend and the pain wasn`t relieved even by rest on that time and was still progressing in severity .

Assosciated with Shortness Of Breath ( SOB ) and patient could not wake except for 2-3 meters distant .

He brought to the hospital and ER management was taken place , then he admitted to the ward in which I meet him .

There was previous similar attacks ( about 3 times over the last 8 months ) but was very mild and turns a way immediately within half a minute .

Past Medical History ( PMH ) :

Pt. Is hypertensive ten years back .

Past Surgical History ( PSH ) :

Appendecectomy since 10 years in Al-Noor hospital .

Drug History :

He is taken captopril tablets twice daily .

Alleric History :

Not known to have an allergy .

Family History ( FH ) :

No similar complain in the family .

Social History :

He is married
Having 3 daughters and 2 sons
Living in Makkah in Al-Aziziyah
Appartement in the 4th floor of the building

Now !! Together we want to make a complete story and a complete history by asking and answering few questions , and after that we will write an ideal and completed form of history which you can use it in such complian .

So , step by step , let`s answer the questions here :


Questions :

1. Which system looks likely to be affected in this case ? and why ?

2. What things you should ask about it when you start to analyse any pain ?

3. What questions are missed in the history ?

4. What do you think the thing that made this patient severly ill this time ? and mention other precipitating factors that can worsen his condition ?

5. According to your suspicious about the diagnosis , what will relieve his condition ?

6. Do you have any idea about the diagnosis ?

7. What could be other differential diagnosis ?

:sun:

Finally, I hope that , the way I wrote the case study is very clear and simple especially for the beginners , and if there is any question , we will be here available together for solving them .

Waiting for your answers and discussion .

With My Best Wishes

:LL:

[dr_Lord]

Salam all;

Cool and nice job Doctora, I was trying to do similer thing but no one was active, looks like the vacation gives it's effects on us.

Let me try to answer your questions with my little experiences and without revising anything from outer sources exept my mind.

---

1. Which system looks likely to be affected in this case ? and why ?
A: Cardiovascular system. them symptoms on the chest pain seems like those occur with Ischemic Heart Diseases patients. also he is hypertinsive for long time and this is one of the factor associed with his age in his illness.

2. What things you should ask about it when you start to analyse any pain ?
A: you shouldda ask about the followings; onset, site, radiation, charecter, progression, severity, aggravating factors, relivaing factors, and associated symptoms.

3. What questions are missed in the history ?
A: is he smoker or not. and if yes, for how long and how many cig./day does he smoke.
did he consult a doctor for the past attacks? and did he take any drugs for them?

4. What do you think the thing that made this patient severly ill this time ? and mention other precipitating factors that can worsen his condition ?
A: the bad news put him under stress and increased his blood presure, and he is hyperttensive.
other precipitating factors includ: smoking, high blood cholesterol, obesity, lack of exercise, angiopathies (not sure), Diabetis.

5. According to your suspicious about the diagnosis , what will relieve his condition ?
sublengual nitroglisrein, aspirine, rest.

6. Do you have any idea about the diagnosis ?
Ischemic heart disease. (angina, MI).

7. What could be other differential diagnosis ?
Gastro esophageal regurgitation (umm, not likely to be her but causes central chest pain), pulmonary embolism (also cases chest pain and SOB), Aortic Aneurism, .....

----

this is my answers from mind honestly, I need quick revision soon coz looks that I'm getting old :aa:

Thank you So much Doc.MAJ for refreshing my mind. please check up my answers and mark them for me. my answers were from my عقلي الباطن.

I'm wating for my result :12:

Thanks again..

[MAJ]

Great dr.Lord

Thanx a lot for your response

Of course most of them are true, and the vacation will do nothing even without reading too much if we will work here together to make such things active and to fill the section with such real cases which we face them commonly in our daily clinically life .

Any way , you did very well , I know dr.Lord you know a lot from what I `ve been said but I`m just gonna add and discuss with you some things to show the others how could it be in systematic way when we answer these questions in the bed side teaching session or in the oral exam and how it could be the direction of the discussion in a case study ?

Also I `ll interfer between each question and another with other new question , just for practicing which types of questions could be asked in a complian like this one ?

I hope to continue with me and also I would like to see and hear from the other members any question or comment about this case , as we said , it is a case study , and at the end of the discussion , we will write the completed ideal write history about this case and also every question we asked about it here and modify it in a separate rearranged reply .

Only , keep on touch and be with us .

By the way , this sort of discussion is a common way to deal with in the oral or even in the written exam .

Ok .... Let us to continue :

Regarding Q1:

The next questions will be :

Q1a :Why it is not respiratory system ? although the patient having chest pain and SOB which are symptoms from respiratory system ?

Q1b :What are the typical characteristic features of anginal pain ?

Regarding Q3 :

Your answer is correct but we want to show the beginners how could it be formulated in a completed manner , there is a way we can follow it together preventing us to miss any thing and that is to start from the personal history and see what things you should ask in such case going down to HPI and PMH , PSH and so on , by this way , we will be more comprehensive to collect the answer related to this case .

So , let`s try again to do it together !!

:LL:

Q3 : What others are missed ?

Q3a : And what are the negatives symptoms which you have to say them here to role out any other differential ?

Regarding Q4 :

Same thing what I did it on the fourth year , I was confusing between the precipitating factors and risk factors .

:l:

When we are talking about risk factors of IHD , we can divide it to tow subgroups :
Modifiable RF & Non-modifiable RF (fixed)

The fixed one are :

Age, usually elderly pt.
Sex, usually male sex.
Family history.

Modifiable :

Smoking
Hypertension
Hypercholestrerolemia
Diabetes
Lack of escersise
Obesity

So, our pt, has here 3 RF .
Old age, male sex , hypertensive .

And the question here again will be :

Q4 : What are the precipitating factors of anginal pain ?

One of them is stress ( pt. Here heared a bad news prior to attack ) , what are the others ?

Regarding Q6 :

Q6a : How many types you know about the angina ?

Q6b : And could you differentiate here which type is this one in this patient and why ?

I think it is enough for now .

:LL:

I`m waiting for other replies .

Good Luck

:sun:

[dr_Lord]

Good morning all.

Doc.MAJ you didn't mark my answers :sad: I'm still waiting for my result.

I don't know.. do you want me to continue answering you or let others participate with us. we can keep answering and let the beginner students in clincal understand clearly how to arrange the the history in their minds.

I'm waiting for the replays..

[MAJ]

Hi every body

Dr.Lord , I said in my previous reply that , most of your answers are true , I just want put them together over here in a systematic way to show the beginners how can arrange their thinking in presenting and discussing such a case .

So , no need to mark your answers because already you are MASHALLAH professional in such things .

:LL:

About who will continue the answers !!!!

Yes dr.Lord , you can share us your experience and continue answering , may be the others from the beginners in the clinical years want to know first how these cases are going to be discussed over here , At the same time , they can also share us in solving these problems or if they are having any comment on it .

:sun:

We want to explain why we are handling this case by asking these questions to make the history at the end easy to be arranged and to make the student understand why is he asking these questions in this case .

And as I said , at the end of the discussion , we will try to put an ideal form of history for this patient with some of the important points related to it in a separate reply .
So , full history on such compliant will be handled as a guide to the students .

I hope I explained it very well .

Waiting .

:sun:

[Totti]

Asalam 3alekom

First of all thank u dr lord and dr maj for ur efforts in this section and am a beginner as u said but I hope that I can answer some questions

Why it is not respiratory system ? although the patient having chest pain and SOB which are symptoms from respiratory system ?
I think because the SOB caused by the chest pain and there are not any symptoms from respiratory system
Characterized by chest pain are radiating to the left shoulder


What are the typical characteristic features of anginal pain?
Acute chest pain radiate to left arm ,shoulder, neck or jaw characterized by squeezing

What others are missed ?
I think u missed general systemic review

: And what are the negatives symptoms which you have to say them here to role out any other differential ?
……………………………………………………………
True or false
:l:

What are the precipitating factors of anginal pain?
I think atherosclerosis and its complications (acute plaque change)


How many types you know about the angina ?
Stable, prince metal, unstable

And could you differentiate here which type is this one in this patient and why ?
unstable angina
because it occurred due to stress and the pain wasn`t relieved even by rest on that time and was still progressing in severity

هدا والله أعلم
and thanx again



:eye:
Totti

[dr_Lord]

Salam,

Welcome totti, nice to see you here joining us. Mashallah you doing good here. let me try to answer in my own words although they will be same as yours but in little different way.

------

Q1a :Why it is not respiratory system ? although the patient having chest pain and SOB which are symptoms from respiratory system ?
A: First I as totti said the charecter of the chest pain and its radiation give you quick hint to typical charc. features of anginal pain. also look carefully to the patients Hx. He is 55 years old man, hypertensive. is that related to the symptoms or not.
this makes you think more on CVS problems, when you first hear 'I had a chest pain' you will automatically think about different types of chest pain, and then you will analyse it by your qestions. after patient answers your questions about his HPI, you will start to think and arrang them in your mind quickly and try to mach his answers with different symptoms related to different diseases in your mind. This will be your first approach to differential diagnosis.

Q1b :What are the typical characteristic features of anginal pain ?
A: central retrosternal chest pain that radiates to the left arm and neck, comes on with exertion and relived by rest. (classical angina).
-

Q3 : What others are missed ?
A: systemic review. "totti answered at while I was thinking more about questions related to the Hx. you will get higher than me totti :o:"

Q3a : And what are the negatives symptoms which you have to say them here to role out any other differential ?
A: I didn't understand the question clearly. cough and spotum realated to respiratory sympoms. getting swetty and if the pain lasts longer (some houers and at rest) with nausea and vomitting will make us think more about Myocardial Infarction. sudden sever chest pain with SOB and fainting will make us think more about pulmonary embolism...etc. (I hope I the idea is clear ) :eye:
-

Q4 : What are the precipitating factors of anginal pain ?
A: sorry I got confused in my last answering thins question.
precipitating factors (factors that will make case getting worsen); cold, exertion, excitement, stress, anger, bad news...etc.
-

Q6a : How many types you know about the angina ?
A: Varient (stable) angina, Unstable angina, and decubitus angina (occures on lying down). "It's my 1st time to hear about prince metal type totti".

Q6b : And could you differentiate here which type is this one in this patient and why ?
A: agree with totti. "because it occurred due to stress and the pain wasn`t relieved even by rest on that time and was still progressing in severity".

----


See. Mashallah my answers were almost the same as totti but I tried to explain the way I was thinking when 1st read about the Hx.

O.K Doctora, I think we really need your comments about our answers.

catch ya soon :J:

Bye

[Totti]

thanx alot dr lord

:eye:

"It's my 1st time to hear about prince metal type totti


but about princemetal angina i had been taken in pathology this year with dr almosalamani.

and it has the same properties of decubitus angina ( as u said occured on lying dowen or sleep )


but i opened my notes of pathology and i found princemetal angina written there but i think am mistaken .




:sun:

Totti

[MAJ]

Good Evening

Really, I `m so happy to see this sort of discussion here with different levels of clinical years students .

Any way , totti , I appreciate your participation and as dr.Lord said , good trial to start with us in our clinical case .

About the whole answers , If I didn`t comment on it , that means they are true and I want to proceed to the next clinically related question .

At the end of discussion , we will conclude our work collectively .

And now , will continue our discussion :

:waa:

Regarding Q1a :

Q1a :Why it is not respiratory system ? although the patient having chest pain and SOB which are symptoms from respiratory system ?

Totti , yes , there is no respiratory symptoms other than SOB are associated with in this pt , but the thing which I want to clarify here is , sometimes the pt. comes to you complaining of ( C/O ) respiratory symptoms and originally his disease is cardiac in origin e.g. heart failure sometimes presented only with cough ( which is one of the resp symptoms ) , also chest pain sometimes represent respiratory problem , and that why , we should always in a case of chest or cardiac symptoms , we have to ask about both cardiopulmonary symptoms .

Dr.Lord , your analysis was very clear and comprehensive to different types of chest pain , I hope in the future u put cases with such different levels of chest pain and illustrate each disease with its specific character of chest pain .

Let`s conclude the answer :

This case is most likely to be cardiac in origin rather than chest for three reasons :

1. The typical characteristic features of anginal pain ( we well mention them in the next coming question ) is more related to CVS .

2. Presence of multiple RFs ( mentioned before ) .

3. Nature of the chest pain i.e.In respiratory problem chest pain , the pain usually is localized ,pleuritic , sharp , worsen by DEEP INSPIRATION and COUGH ( so in this way , u have to ask the pt. always with chest pain , is this pain increased or worsen by inspiration and cough or not ) to exclude other differential , And this will differentiate the chest pain from angina or MI .


Regarding Q1b :

Q1b :What are the typical characteristic features of anginal pain ?

100 / 100 True answers .

Characteristics of anginal pain :

Squeezing central ( retrosternal ) chest pain ( characteristic figure to see the pt. Putting his hands on center of chest with fisting them ) .

Usually precipitated by exertion .

Rapidly relieved by rest or sublingual nitroglycerine .

Radiates to the arms , shoulders and jaws .

Typical duration is from 2-10 minutes and can vary according to the type of angina .


Regarding Q3 :

Q3 : What others are missed in the Hx ?

PD , was completed and important positives in this case was , he is male and old age .

CC, was completed with its duration ( duration is very important to mention in each CC )

HPI , ok a lot of things are missed here :

By many ways , the student can organize his thinking to do his job in HPI , I find it very easy to analyse the CC here with every thing related to it according to the case i.e. in this case , we can analyse the CC , and moves to important positives ( the symptoms which pt. Come with ) and the important negatives ( symptoms which pt. Denies to have it but is very important to say them to exclude other differential ) and then to important RF , and of course hospitalization is very important to identify the severity of the disease . So ,

Analyses of CC
Important + ves and important - ves
Review of the most likely affected systems
RF
Hospitalization

Take it one by one :

Analyses of CC :

Chest pain was completely analysed

But SOB was deficient

So my next question will be :


Q3i : What questions you should ask in SOB pt. , analyse this symptom ?

Q3ii : What is the relation between the SOB and the distance the patient can walk for ?

Review of the most important affected systems :

We missed to review the important two related systems to exclude other differential which are CVS and RESPIRATORY system , as I said previously these symptoms confusing if the pt. Presented with , because some of them present to each other system .

Related question :


Q3iii : What are symptoms of CVS and respiratory , mention ?

NB : you can review these two systems in the systemic review but in each compliant we have to put in HPI the important positives and the important negatives .

RF & Hospitalization :

NB : you can put hospitalization & RF as DM ( diabetes mellitus ) , HTN ( hypertention ) & High lipid in PMH as well .

PMH , PSH , DRUG & ALLERGIC Hx :

Related question :


Q3iv : What are the routine questions we ask them here in these titles ?

FH , was completed but we have to be more specific e.g. ask about if there is any cardiac disease in the family .

Social History :

Forgot to put here if he is smoking or not and for how much and how many packet daily .

Next related question :

Q3v : Why I asked specifically in the social Hx about the housing in which floor they are living in this case ? could you analyse more ?

Systemic Review :

OF course , it is missed totally , so ,

Q3vi : What are the systems which should be reviewed routinely and what are their important symptoms ?

Regarding Q3a

Q3a : And what are the negatives symptoms which you have to say them here to role out any other differential ?

Totti & Dr. Lord , I `m sorry if I couldn`l deliver the message clearly , I hope now u understand the question from my previous talk , I mean by that the review of cardiopulmonary symptoms , what is there in the pt. And what is not ?

So let`s try again ,

Q3ai : Can you specify now which are the +ves & -ves symptoms of this pt ?

By the way , dr.Lord , MASHALLAH you have good thinking in analysis the complian .

Regarding Q4 :

Q4 : What are the precipitating factors of anginal pain ?

10 over 10 corrected answer .

precipitating factors of anginal pain :

Factors that will make case of the pt. getting worsen :

Cold
Exertion
Excitement
Emotional excitement as stress, anger & bad news...etc.


Regarding Q6a :

Q6a : How many types you know about the angina ?

Ok , both of you are correct , with some comment :

Types of angina :

Stable
Unstable
Decubitus
Prinzmetal`s


My next questions :

Q6ai : Which one of them called VARIANT ? and which one of them called CRESCENDO ?

Q6aii : Can you talk about them in one line or two for each one

Regarding Q6b :

Q6b : And could you differentiate here which type is this one in this patient and why ?

Absolutely right .

Unstable angina because it occurred due to stress and the pain wasn`t relieved even by rest on that time and was still progressing in severity .

My next question :

Q6bi : Which one of them has an increase risk with MI ?

:LL:

Finally I hope my way in the discussion is helpful .

I`ll try to be on time as much as I can .

:waa:

Waiting .

:sun:

[Totti]

Good Evening


Infact dr maj mashallah you are stupendous and thank you so much for your explaination .

:wooow:


and I'll give dr lord the chance to show us his talent and answering the questions ( am sure u have great talent and u can answer these questions )

:hp:


now dr lord the ball in your playground .
:eye:



am also waiting
:sun:

[dr_Lord]

Salaam and good morning all.

I just waked up and saw the replaies. Mashallah, Doctora you are making a good discussion and let us think more and more before we answer. Totti, that's not fair to leave me alone here :sad: . I'll try to answer what I can from my knowledg.
Lets start;

-------

Q3i : What questions you should ask in SOB pt. , analyse this symptom ?
A: ask also about when it was started (before or after the chest pain) and how long did it last? ask about its severity (complete blockage of his airway or just diffeculty in taking breathing). was it aggravated or relieved by any factors?
"Actually the same questions of pain can be asked for symptomes but with lettile differences". also when we have a CC with associated symptomes, you have to analyse the associated symptome completely in your HPI just as you did with the CC.

SOB or Dyspnoea defined as unexpected awareness of breathing due to decrease of complaince of lungs or increase resistence to air flow. But in cardiac duspnea is due to exertion or left ventricular failure due to ischemia, fibrosis...etc. so when we put in our mind after answering the questions on SOB here that it is related to the cardiac symptoms and the patient can't walk except for few meters.
(This is the way I would think in such cases).

Q3ii : What is the relation between the SOB and the distance the patient can walk for ?
A: The SOB was sever and the patient need exertion to walk, but the severity of the SOB prevented him to do minimal exertions. Here we have to know the definition of angina and the ischemic heart diseases in general. there is imbalance b/w the myocardial muscles need of O2 and the O2 supply to them. mainly due to coronary artery disease such as obstruction and spasm.
so as the patient increase his exertion, his myocardial muscles needs more and more O2 supply and that's why he need breath more without touched effect. and that's why when he rests, he decreases his demand to O2 and getting better. "that's up to my knowledge ":LL:

Q3iii : What are symptoms of CVS and respiratory , mention ?
A: when taking a Hx from a patient, you have two choices. after you finish HPI, even you ask about other symptom in the expected systems. or just leave them to be asked in the systemic review.
symptoms of CVS include:
Orthopnia, PND, Palpitation, Syncope, Cyanosis...etc.
Symptoms of respiratory include:
cough, sputum, hemoptysis, wheezing, night sweat...etc.
when ask these questions after HPI, you can include and exclude other diagnosis in your mind (as I described befor in Myocardial Infarction in my last replay). That how you make up your D/Dx.

Q3iv : What are the routine questions we ask them here in these titles ?
A: actually, when you think about some diagnosis, as here, ask what makes you ensure about it as the risk factors of angina. this will confurm your Dx.

Q3v : Why I asked specifically in the social Hx about the housing in which floor they are living in this case ? could you analyse more ?
A: Because we need to know if the patient do some exertions to reach his housing or not, does he walk to the mosque daily or not...etc.
You forgot to mention here if his using an elevator or use the stairs to reach his appartment.

Q3vi : What are the systems which should be reviewed routinely and what are their important symptoms ?
All other systems. ummmm, I'll leave the symptoms to be answered by TOTTI coz I feel so lazy :LL: .

Q3ai : Can you specify now which are the +ves & -ves symptoms of this pt ?
I gave hints in my last replay.

Q6ai : Which one of them called VARIANT ? and which one of them called CRESCENDO ?
A: Varient "Stable angina", and Crescendo "Unstable angina".

Q6aii : Can you talk about them in one line or two for each one?
A:
Stable: angina caused by coronary spasm, occures with exertions, relieved by rest or sublengual NitroGl.
Unstable: angina increases rapidly in it's severity, ocuures at rest. caused by subtotal obstruction by platelet-rich clot over a fissured atherosclerotic plaque. can be transformed to MI if the fissured plaque increased and caused complete obstruction of the coronary artery.
Decubitus: occures on lying down.

Q6bi : Which one of them has an increase risk with MI ?
A: Unstable angina.

------

I hope I could cover all of the points of the Hx, Totti don't forget your homework :o: .

Dr.MAJ. thank you for refreshing my knowledges. I wanna ask you, do you wanna contineu with the managment or not??

I hope every one got benifit from our discussions.

waiting to see how was my performnce :J: .


See ya soon :87:

:12: :12: :12:
Dr.Lord

[Totti]

Thank u Dr lord

my homewark


Q3vi : What are the systems which should be reviewed routinely and what are their important symptoms?
All other systems. ummmm, I'll leave the symptoms to be answered by TOTTI coz I feel so lazy

General:
Weight gain or loss, loss of appetite, fever, chills, fatigue, night sweats.

Head:
Headaches, dizziness, masses,

ENT :
Visual changes, eye pain, Tinnitus, vertigo, discharge, hearing loss.Nose bleeds, discharge, sinus diseases. Dental disease, hoarseness, throat pain.

Respiratory:
Cough, shortness of breath, sputum (color) , hemoptysis , chest pain , wheezing , night sweat , sneezing .

Cardiovascular:
Chest pain, orthopnea, paroxysmal nocturnal dyspnea; dyspnea on exertion, claudication, edema, palpitations , lower limb swelling , cyanosis , intermittent claudications , cold extremties , valvular disease.

Gastrointestinal:
Dysphagia, abdominal pain, abdominal distension , nausea, vomiting, hematemesis, diarrhea, constipation, melena , hematochezia .

Genitourinary:
Dysuria, frequency, hesitancy, hematuria, discharge , incontinence .
in female
Gravida/para, abortions, last menstrual period (frequency, duration), age of menarche, menopause; dysmenorrhea, contraception, vaginal bleeding, breast masses.

CNS:
Weakness, seizures, memory changes, depression, tremor , syncope , disturbance of gait.

Endocrine:
Polyuria, polydipsia, skin or hair changes, heat intolerance.

Rheumat:
Joint pain or swelling, arthritis, myalgias, stiffness, deformity.

Derma:
rash , pigmentation changes , pruritus.

Hematologic :
anemia , easy bruising , bleeding from any site .


very hard homewark
:o:



:sun:
Totti

[MAJ]

Alsslam 3laikum

Dr.Lord , you covered most of the points , I `ll just stop with you and our members in certain points .

Totti , you did your home work very well , will be included in our final discussion .

Proceeding

:O:

Regarding Q3i :

Q3i : What questions you should ask in SOB pt. , analyse this symptom ?

Same as you said , I`ll just add few things on it .

SOB analysis :

Duration ( when it was started and how long did it last )
Onset ( sudden , gradual , on & off )
Frequency
Aggravating factors
Relieving factors
Orthopnea
Paraxosmal Nocturnal Dyspnea ( PND )
Severity
On how many pillows pt. Can sleep on
Assosciated symptoms e.g. wheeze , cough , haemoptysis . chest pain

Related questions :

What is the meaning of Orthopnea ?

What is the meaning of PND ?

How can we assess the severity ( grading ) of dyspnea in cardiac affected patient ?

Regarding Q3v :

Q3v : Why I asked specifically in the social Hx about the housing in which floor they are living in this case ? could you analyse more ?

Absolutely correct answer .

We want to know is this patient suffers from SOB and chest pain on minimal , moderate or heavy exertion .

So , the possible questions which could be asked to assess the relation between the exertion on different distances and SOB with chest pain :

How far can you walk on the flat before experiences discomfort ?
Do you get discomfort climbing stairs or hills ?
Are you get comfortable when you are using elevator or climbing upstairs to reach your apartment ?
Can you walk to the mosque daily , is there any SOB you suffer from ?
Can you go to the bathroom nearest to your room ?

Regarding Q3ai :

Q3ai : Can you specify now which are the +ves & -ves symptoms of this pt

Ok , just to clarify them to put easily later on when we will write a complete form of history :

The +ve symptoms in this patient are :

Chest pain
SOB

The -ve one are :

No orthopnea , PND , palpitation , nausia or vomiting , H/O intermittent claudication , palpitation , syncopy or dizziness , no ankle edema or cold extremities .

No cough , sputum , haemoptysis , wheeze , hoarseness , night sweat or fever .

As we said review the cardiopulmonary systems together .

Regarding Q6ai :

Q6ai : Which one of them called VARIANT ? and which one of them called CRESCENDO ?

Confused a little bit

Variant is the prinzmetal`s angina
Crescendo is the unstable angina

Regarding Q6aii :

Q6aii : Can you talk about them in one line or two for each one?

Seems to You that you do not want to know about the Prinzmetal`s angina at all !! coz you didn`t hear about it at all !!

Ok , Totti , would you please search about the prinzmetal`s angina and give us few words about it coz you told us about it originally ?

:LL:

I hope that our members getting benefit from our discussion , and again I`m calling them to share us over here , or if they are having any question regarding the case .

:sun:

Finally , about your question dr.lord :

I wanna ask you, do you wanna continue with the management or not ??
Well , you know dr.lord , when I wrote this thread , I wanted originally to put the basic points to start with , beginning from the history , and emphasize mainly on the way how to write an ideal form of history sheat and to take it from a real patient , and to organize a real discussion on line as if it is occurs in the hospitals with our tutors .

But if you see and other members to proceed up to the management of this case , I`m ready to do that and arrange it for you .

:sun:

With my best wishes .

Waiting .

[Totti]

Good Evening

thank u Dr maj and I'll try to answer these questions with homework for Dr lord :122:


OK let's go


What is the meaning of Orthopnea ?
- form of dyspnea in which the person can breathe comfortably only when standing or sitting erect; associated with asthma and emphysema and angina pectoris.



What is the meaning of PND ?
- Episodic shortness of breath at night



Ok , Totti , would you please search about the prinzmetal`s angina and give us few words about it coz you told us about it originally ?
prinzmetal`s angina :
An unusual and uncommon form of angina in which pain is experienced at rest and sometimes while in bed rather than during activity. It is caused by total occlusion of proximal coronary arteries due to spasm. Most commonly seen during the night and accompanied by severe disturbances of the heart rhythm


now I'll leave this question as homework for Dr lord :15:

How can we assess the severity ( grading ) of dyspnea in cardiac affected patient ?

so good luck



:sun:
Totti

[dr_Lord]

Salam budies;

Let me see what is left in this topic. this is medicine, what ever you answer you won't make a full answer.

let's answer the questions quickly whith some explainations.

----

What is the meaning of Orthopnea ?
A: dyspnoea the occures when the patioent lies in supine position(e.g. lies on the bed without pillows) because redistributed interstetioal edema b/w the lower and upper zones of the lungs.

What is the meaning of PND ?
A: Sever dyspnoea that occures at night, wake the patient from his sleeping making him go to the window searching for air. it's a manifestation of left heart failure
another type which is Obstructive sleep apnoea (OSA) is an obstruction of the upper airway during sleeping which causes repetitive apnoea.

How can we assess the severity ( grading ) of dyspnea in cardiac affected patient ?
A: ..... I'll be honest with you, I don't know, may be I know it but can't remember it at the moment. what a shame on me :sad:

Prinzmetal's angina
angina that is caused by coronary artery spasm and results in angina that occures without provocation, usually at rest.

----

Totti, Mashallah you are following the right way. Cool beginnig for you, you don't have to go to the hospital for now, you need only to know idea how is going in medicine and how to start studying for it.. it's not diffecult but need lot of work and Hx taking and you will get experienced so soon inshallah. did you know now the way you think while taking the history and asking your questions??

we want the others to answer with us.
..

wating for the next questions from you Doctora :sun:

bye.

[MAJ]

Alssalam 3laikum

Congratulation , almost you covered the most important points you need them according to your level regarding the history .

:LL:

The question which was saying :

How can we assess the severity ( grading ) of dyspnea in cardiac affected patient of IHD ?

I know you know it , very simple , but may be my question is hinded to some extent .

Ok , I`ll try to make more understandable , I mean by this grading is that , how much the degree of the exertion ( doing activity ) can affect the degree of the severity of the disease either to up or down , Ok , I`ll make it more easy , it has 4 grades , mention ? now it came !!

So , let`s try to answer it again .

:sun:

One question also is missed during the discussion which is ;

What are the routine questions we ask them here in these titles ?

I meant by these titles the PMH , PSH , DRUG & ALLERGIC Hx .

:sun:

This is the last question in the history .

And by the end of this question , will reach to the whole data to write an ideal and a completed form of a history in a patient with IHD using our data giving in the history which already discuss about it .

So , we will write after answering the above questions ( very easy questions , will take five minutes ) the way how to write a history in your clerking sheat and consider yourself that you are presenting it in front of your examiner .

Totti , you are involved also to write the history of this patient , I want to see your first trial .

One thing left , I need to know if you want to complete the clinical examination , main invistigation and brief management about the case or not ? and by the end we well conclude our work in a separate reply and well right every thing about this case and even we can use it as a source to study from it , of course with mentioning the references we went through them during our discussion and also to write the names of the members who shared us and made this scientific discussion successful .

:sun:

I hope really to get a benefit from what we`ve been talked about it , and also I hope not to get boaring or tiered from that , I know you are in vacation , but the end result will be a successful clinically oriented life INSHALLAH .

Waiting from the whole to participate .

[Totti]

Good morning


How can we assess the severity ( grading ) of dyspnea in cardiac affected patient of IHD ?
am sorry I don’t know :sad:

What are the routine questions we ask them here in these titles ?

Past Medical History ( PMH ) :
Past diseases, DM "type, treatment " , hypertension, peptic ulcer disease, asthma , TB , myocardial infarction, cancer , rheumatic fever. Blood transfusion .

Past Surgical History ( PSH ) :
date , hospital , diagnosis , sequelae .

Drug History :
name , dose , duration , frequency .

Alleric History :
food , drugs , animal or occupational allergies .




The history

Mr. X, a 55 years old Saudi man patient, admitted to the medical ward for 2 days through ER.
Complaining of Chest Pain, Patient was ok until 2 days back when he start with Suddenly sever central squeezing chest pain graded to 7 out of 10 according to the patient words. It was radiating to the left shoulder, the pain wasn’t relieved even by rest on that time and was still progressing in severity lasting for about 10-15 minutes. The chest pain associated with Shortness Of Breath and patient could not wake except for 2-3 meters distant , there is a history of previous similar attacks , about 3 times over the last 8 months but was very mild and turns a way immediately within half a minute . the patient is known to have HTN since ten years back treated by captopril tablets twice daily , there is Appendecectomy since 10 years ago in Al-Noor hospital .he is Not known to have an allergy and there is No similar complain in the family , He is married ,having 3 daughters and 2 sons , living in Makkah in Al-Aziziyah in apartment in the 4th floor of the building . he is not suffer from any other symptoms .

[dr_Lord]

Hi all,

quick answer to the grading question.

G1: dyspnoea during unusually intense activity.
G2: dyspnoea during ordinary or normal activity.
G3: dyspnoea during activity less than the ordinary one.
G4: dyspnoea at rest. which is the one in this case.

I'll catch ya soon cause I have to sleep now.. I can't see the keybord infront of me.

bye bye.:12:

Dr.Lord

[MAJ]

Asslam 3laikum

Good trial totti , you gave us
المختصر المفيد , ما قل ودل
The next time , you will be much much better and you will see your progression and your improvement by your self INSHALLAH .

:LL:

I observed one thing on your history form , that is , it is the history presented by resident , specialists and consultant`s doctors , because that what they need briefly to give them the important positives and important negatives .

I presented a case today to my consultant in details starting by history , he was listening to me waiting to give him the only positives symptoms , but I did not , I was presenting a complete history as we`ve been learn systematically from our doctors , then I proceeded again in details to give him a full examination , during that time , I felt that he got boaring from me and from my presentation :122: and he said : Doctora , yes yes I know I know , give me only the positives and in brief , do not say every thing in details , we have a lot of patients . He did not even want to give him the important points in my presentation :l: .

The point which I want to emphysize on here is that , in your clinical years , you will learn how to present a good case in systematic way , completed from A to Z , because our university staff are academic one trying to make your thinking organized BUT when you go to the actual field in the hospitals without your university staff , you will feel a big differences , that is because they are not systematically oriented or may be due to other causes such as a lot of patients are there or the doctor him self doesn`t want a lot of talk or or .

So , the thing which I want to stress on it is that , we do not want to take the bad habits which are occurring from some doctors , when we work with them , trying to represent our self as much as we can as a good doctor .

Hopping To All The Best .

:sun:

[MAJ]

Now

Prepare your self

Be confident

Loudly speaking

And

Present the case in front of your tutor

:

:

:

:

Start

:sun:

Personal Data :

Mr. X , a 55 years old Saudi male , he is retiered , admitted to the medical ward ( CCU ) for 2 days through ER .

Chief compliant :

Chest Pain
Shortness Of Breath
At the time just immediately prior to the admission

History Of Presenting Illness :

Patient was well until 2 days back , when he was with his friend sitting together on the sea in Jeddah to enjoy their time .

Suddenly the patient felt a sever central squeezing chest pain graded to 7 out of 10 according to the patient words . It was radiating to the left shoulder , lasting for about 10-15 minutes .

Before the attack , the patient heared bad news from his friend and the pain wasn`t relieved even by rest on that time and was still progressing in severity .

Assosciated with Shortness Of Breath ( SOB ) , started suddenly , just immediately after the onset of chest pain , no relieving factors and the patient could not wake except for 2-3 meters distant .

He brought to the hospital and ER management was taken place , then he admitted to the CCU in which I meet him .

There was previous similar attacks ( about 3 times over the last 8 months ) but was very mild and turns a way immediately within half a minute .

There is no orthopnea , PND , palpitation , nausia or vomiting , H/O intermittent claudication , palpitation , syncopy or dizziness , no ankle edema or cold extremities , also no cyanosis and the patient can sleep on one pillow comfortable .

No cough , sputum , haemoptysis , wheeze , hoarseness , night sweat or fever .

PMH & PSH :

Pt. Is hypertensive ten years back and he is on Captopril 12.5 mg twice daily to be taken orally .
He is not diabetic .
Not known to has high blood lipid .
No H/O tuberculosis (TB) .
No H/O bronchial asthma (BA) .
No H/O receiving any blood transfusion (BT) previously .
Appendecectomy since 10 years in Al-Noor hospital .

Drug History :

Not receiving medication other than captopril .

Alleric History :

Not known to have an allergy to food , drug or sunlight .

Family History ( FH ) :

No similar complain in the family .
His father is hypertensive and died from a cerebrovascular event since 5 years .
His mother is diabetic and she is on oral hypoglycemic agents .

Social History :

He is married .
Having 3 daughters and 2 sons , all are healthy .
Educated up to secondary school .
Retiered .
Likes to sit continuously in front of the TV (lack of excersise) .
Not smoker Or Alcoholic .
Living in Makkah in Al-Aziziyah .
Appartement in the 4th floor of the building , feeling recently some difficulty climbing upstairs up till the third one .
No recent traveling history .

Systemic Review :

Head:
No headaches, dizziness .

ENT :
No visual changes, eye pain, tinnitus, vertigo, discharge, hearing loss .
No nose bleeds, discharge, sinus diseases.
No dental disease, hoarseness, throat pain.

Respiratory:
Reviewed already in HPI .

Cardiovascular:
Reviewed already in HPI .

Gastrointestinal:
No dysphagia, abdominal pain, abdominal distension , nausea, vomiting, hematemesis, diarrhea, constipation, melena , hematochezia , no loss of weight or appetite .

Genitourinary:
No dysuria, frequency, hesitancy, hematuria, discharge , incontinence .

CNS:
No weakness, seizures, memory changes, depression, tremor , syncope , disturbance of gait.

Endocrine:
No polyuria, polydipsia, skin or hair changes, heat or cold intolerance.

Rheumatology :
No joint pain or swelling, arthritis, myalgias, stiffness, deformity.

Dermatology :
No rash , pigmentation changes , pruritus.

Hematologic :
No H/O anemia , easy bruising or bleeding from any site .

:sun:

After that , the tutor will start the discussion with you :waa: .

Good Luck

[Totti]

<center>


شكرا جزيلا دكتورة وجزاك الله ألف خير وان شاء الله يكتب في ميزان حسناتك

بصراحة لقد قمت بمجهود عظيم
سألين الله العلي العظيم ان ينتفع بهدا الموضوع اكبر عدد ممكن

:12:

والشكر موصول اليك دكتور لورد على ماقمت به من مشاركات رائعة ومفيدة

:12:


فجزاكم اله عنا خير الجزاء



:sun:

أخوكم
Totti

[dr_Lord]

السلام عليكم

Well done doctora, Mashallah you completed the first important steps needed for our clinical years. I really advice all of the students to thoses threads and learn from our & their mistakes during first year. I really hope from the moderators to make it and my topics as a sticky in this section.

See, this was a sample of the Hx and the questions related to them. every single time you take a history from a patient you will get more and more experienced in how to ask the questions? what questions should be asked about the current symptoms and HOW TO THINK during all of that.
جزاكي الله كل خير ان شاء الله.

----

Dear totti, I have nothing to tell except that you are Inshallah going in the right side, contineu your work in this way and as my sister MAJ said, you feel the results by yourself. Mashallah it's more than a nice beginning with us here. والله يجزاك ويانا كل خير

----

One thing left , I need to know if you want to complete the clinical examination , main invistigation and brief management about the case or not ? and by the end we well conclude our work in a separate reply and well right every thing about this case and even we can use it as a source to study from it , of course with mentioning the references we went through them during our discussion and also to write the names of the members who shared us and made this scientific discussion successful .

for me, YES I do. and strongly recommend that to make this topic a complete source for the students. and why we don't write it in document file and put it the end??? just an idea.

I am waiting for the next steps to be taken, untill that I'm ready and glad to help..

:to:

With my best regards;
Dr.Lord

[Totti]

good evening

for me, YES I do. and strongly recommend that to make this topic a complete source for the students. and why we don't write it in document file and put it the end??? just an idea.

am agree with u Dr lord , it's a nice idea



and thanx again

:eye:
Totti

[MAJ]

Asslam 3laikum

Very nice to hear these great words from all of you .

Thonx a lot , i hope that , I did the first part very well as much as could .

Totti !!!!! do you have any clinical examination book for internal medicine ?

http://www.uqumed.com/vb/showthread.php?s=&threadid=2938

I`m caring to have a one because the next part of the case study will depend mainly on you and other members .

It will be an interactive session , we will do it together INSHALLAH .

:sun:

[Totti]

Good evening



Totti !!!!! do you have any clinical examination book for internal medicine ?

yes I have one .


I`m caring to have a one because the next part of the case study will depend mainly on you and other members .

O.K.

I hope that and thanx again



:eye:
waiting

[dr_Lord]

I`m caring to have a one because the next part of the case study will depend mainly on you and other members

In the name of ALLAH, I'm not included?? and will be only an obsever?? :waa:

Ummm, O.K I'll correct the mistakes and add comments of each answer in the next discussion. :eye:

Let's start the physical examination for this patient..:J:

[Totti]

aslalam 3alikom


Dr lord remember u said "that's not fair to leave me alone" ,


who will leave another alone now???????
:waa:




:sun:
Totti

[MAJ]

Good Morning

I`m really proud with our students in our university to have this sort of activity over here , aiming for learning and teaching for helping the others at the same time .

:sun:

Dr.Lord , why u r not included , who said that ????? I agree with totti in that , will leave him alone !!!!! how come ?????

:O:

So , in the third part , will leave you alone too !!!!!

:122:

We need your experience , participating , guiding , observing and correcting , whole together .

:sun:

Ok , before we will go to the next part , let me give some hint about it , I thought a lot how could we make this part really active part presented on line as if it is presented in the hospital in front of a real patient , And I `m very care to make this part useful and helpful at least 85 % , you know , it is the most important part , because it needs a real patient .

But , any way , we will try to make it a real one as much as we can together , and a part from that , we will concentrate more here on figures and photographs and how to illustrate the techniques of the physical examination on them with writing the correct procedures .

The source of these photographs could be taken from our books which we are study from after scanning and through them over here OR from any medical websites having these figures ( and a lot & a lot of a beauty photographs are there for learning porpuses ) .

During the discussion , we will also try to discuss some important clinically aspect points related to the system affected in this patient .

FINALLY , at the end of the discussion from this part , we will put a VIDEO illustrating the techniques and procedures for affected system , and by that way , we knew at that time how the procedure could be done and how to apply it , the remaining only to practice these techniques on your real patients in the hospital , OR , ANOTHER WAY YOU CAN DO IT IS TO APPLY IT ON ONE OF YOUR YOUNGEST SISTER OR BROTHER , dosen`t matter at all , even if it is on normal persons , because usually we have to know the normal before the abnormal one , so , only try , it is really very helpful .

:sun:

Dr.Lord & Totti , our job this time needs a hard work to some extent , but the end result will be very satisfied INSHALLAH .

OK , are you ready , I`ll prepare for the next part very soon INSHALLAH , take a rest for a little period until that time .

Waiting From The Whole To Participate .

With My Best Wishes .

[Totti]

Good Morning


O.K dr maj am ready ,

Go ahead and am with u inshallah.


Thank u



:eye:
Totti

[dr_Lord]

Good afternoon all.

Totti, I didn't say that I'll leave ya alone, I'll protect your back and guide you. Don't worry, it's not gonna be diffecult and I'll do my best.

Doctora, looks that you'r plannin' to do Big, Hard, wounderful work right here. O.K it's really not easy to discuss about the clinical examination without a real patient and only write it over here, but your ideas will make a big difference.

I have a comment on what you said; ALWAYS, as a bigenner, practice on you friends and family how to do the Ex, الله يسلمهم من كل شر
You won't find findings on them but you will remember the steps for each system examined.

---
FINALLY , at the end of the discussion from this part , we will put a VIDEO illustrating the techniques and procedures for affected system

I think I can help ya in this part. let me check my database first :o:

---

well, shot vecation untill we get the orders from our intern. we are waiting and I'm really excited. :J:

c ya soon;
D r . L o r d

[MAJ]

Welcome Back

:hp:

PART 2 :-

After I took the history from the patient , I asked him kindly to examine him and the following clercking sheat was written in his file .

On Examination

Generally :

The pt. Looks well , not in pain , conscious , oriented , connected to right upper arm canula .

Head , Eyes , Ears , Nose & Throat :

No abnormality detected (NAD)

Vitally :

Blood Pressure (BP) : 140/90
Pulse (P) : 75
Respiratory Rate (RR) : 18
Tempreture (T) : 37

CVS :

Normal audible first and second heart sound with no added sounds .

Chest :

Vesicular , equal bilateral air entery with no added sounds .

Abdomen :

Soft, lax with no organomegaly and positive bowel sound .

Skin , Joints and Bones :

No rash .
No swelling .
No tenderness .
No redness .

CNS :

Grossly intact with normal power , tone and reflexes .

Lower Limb (LL) :

No LL edema .

:sun:

NB : This examination only presented by this way after the student is completing knowing the whole systems , so , he has the ability at that time to understand what these brief words meant by each system if the tutor asked about any one of them .

:sun:

[COLOR=red]Practicing The Examination :

Concerning our patient of unstable angina , we will concentrate mainly on Cardiovascular examination .

Cardiovascular Examination Outlines :

Systematically , the consequences of the cardiovascular examination including the general and specific part are :

I : Introduction
E: Environment
E: Exposure
P: Position
General Look ( appearance )
Vital Signs .
Hands
Pulsation
Blood Pressure
Face
Jugular Venous Pressure JVP
Praecordium
Back
Abdomen
Legs

So , that all what we will talk about it in our target system in the second part .

Practically , let`s know it together one by one :

First Step :

Now , you are in front of your patient and you finished already from your history and want to proceed for examination >>>> The next step will be highlighted down :

At the beginning of any examination , and before touching the patient , the student should follow certain things :

I : Introduction .
E: Environment .
E: Exposure .
P: Position .

And regarding these titles , practically , How Can We Do That i.e.

Q1. Practically demonstrate by verbal words how can you introduce your self to the patient in arabic ?

Q2. How can you arrange for the environment ?

Q3. How much you will ask the patient for exposure in our target system ?

Q4. And in which position you are trying to be on with this patient ?

Second Step :

When we talk about the CVS examination , We are examining the patient completely starting by generally related CVS and then the pericardial part of CVS :

Your patient on the bed on his right corrected position , and you want now to assess his general appearance or his general look ,

Q5. What things you want to emphesize ( comment ) on his general appearance ?

Third Step :

Very important after that to concern the vitals of the patient ( and that usually should be done in every system and not only in the CVS )

Pulse P
Blood Pressure BP
Temprature T
Respiratory rate RR

Regarding these vitals , generally :

Q6. What things you will assess in the P ? How much its normal range ? What u call it if increased & what u call it if decreased ? Give an illustrative verbal words with a patient his P is 75 ( comment by any finding u want to say )

Q7. What is the normal value of BP for normal patient ? What u call it if increased & what u call if it decreased ?

Q8. What is the normal range of T for normal patient ? What u call it if increased & what u call if it decreased ?

Q9. What is the normal range for RR in normal patient ? What u call it if increased ?

Clinical Points Of View :

QA. Mention some causes of TACHYCARDIA ?

QB. Mention some causes of BRADYCARDIA ?

:sun:

I think this dose is enough for today , trying to be digestable , I hope it is clear and easy to start with in our second part .

Freshy to work at the beginning of the week .

Hopping The Best To The Whole .

[Totti]

<center>
Good morning

sorry to late but just now i saw the new part .

O.K I 'll start now
بسم الله الرحمن الرحيم
نبدأ

Q1. Practically demonstrate by verbal words how can you introduce your self to the patient in arabic ?

السلام عليكم
كيف حالك ياعم...0
انا طالب في كلية الطب( مع اني ما أفضل اني أقول اني طالب طب عشان مايرفض زي ماسار معايا )0
وحابب افحصك شوية , ممكن؟


Q2. How can you arrange for the environment ?
by shaking his hand and giving good impression by smiling and putting my hand on his body.


Q3. How much you will ask the patient for exposure in our target system ?
I don't understand !!?!!
:?:


Q4. And in which position you are trying to be on with this patient ?
I have to exam the patient from the right side of the bed and the patient lying in bed at 45 degrees and his chest and neck are fully exposed .


Q5. What things you want to emphesize ( comment ) on his general appearance ?
well , ill , conscious , oriented ,
body built : normal , thin , obese , cachectic.
color : pale , jaundice, cyanosis , pigmentation .
presence of canula , catheter , O2 mask .


Q6. What things you will assess in the P ? How much its normal range ? What u call it if increased & what u call it if decreased ? Give an illustrative verbal words with a patient his P is 75 ( comment by any finding u want to say )
- rate of pulse , rhythm , radiofemoral delay , character and volume .
- b/w 60 and 100 beats per min .
- inc --> tachycardia and dec --> bradycardia.
- he has nomal pulse rate .


Q7. What is the normal value of BP for normal patient ? What u call it if increased & what u call if it decreased ?
- 140/ 90 mmHg
- inc -->hypertention , dec--> hypotention .


Q8. What is the normal range of T for normal patient ? What u call it if increased & what u call if it decreased ?
- b/w 36.6 to 37.2 degrees centigrade.
- inc--> hyperpyrexia , dec--> hypothermia.


Q9. What is the normal range for RR in normal patient ? What u call it if increased ?
- 14 breath per min
- inc--> tachypnoea.


QA. Mention some causes of TACHYCARDIA ?
-excercise , fever, pregnancy ,anaemia , CCF , salbutamol, atropine , thyrotoxicosis , pulmonary embolism, myocarditis,...etc.


QB. Mention some causes of BRADYCARDIA ?
- sleep , digoxin , hypothyrodism, hypothermia , MI , jaundice , alcohol , mitral valve disease ,...etc.


I was just trying and I hope that are correct.
:LL:



:eye:
Totti

[dr_Lord]

السلام عليكم ورحمة الله

Well well, so gittin' started without me huh??! :MM: . Sorry but I got busy last few days.
any way let's start, although Totti did a good job in his answers, but I'll add few things from the beginning and make a picture to what happins in the real life.

---

Q1. Practically demonstrate by verbal words how can you introduce your self to the patient in arabic ?
A: You are supposed to introduce yourself from the beginning of Hx taking.
1- اذا كانت مريضة فاطلب من ممرضة مرافقتك اولا .
2- اطرق الباب ، استأذن بالدخول.
3- القي السلام ، واجعل الابتسامة على وجهك ، فهي تحبب وتقرب المريض اكثر اليك
4- اسأل عن حال المريض ، كيف اصبح وكيف امسى .
5- الان عرف عن نفسك (يا عمي انا طالب بكلية الطب ، واحب استأذنك في بعض الاسئلة عن حالتك)
In the physical examination, after finishing Hx, ask the patient politly for examining him.
يا عم ، انا محتاج افحصك فحص بسيط وان شاء الله ما راح اتعبك معايا ولا اخذ من وقتك .
actually this part depind on YOU, how do you actually have the skills to talk and ask for somthing. what I saied was just an example.

Q2. How can you arrange for the environment ?
A: after taking the permission from the patient to examin him, you have to prepare the environment for his examination.
1- First close the cortain to allow privacy for the patient.
2- ALWAYS stand on the RIGHT side of the patient for the examination.
3- Adjust the hight of the bed to a level that makes you confortable during Ex.
4- make the right position of the patient depending on which system you wanna examin.

Q3. How much you will ask the patient for exposure in our target system ?
A: Our target system is CVS. we have to examin the chest, back, lower limbs and the base of the lung.
So, first we should expose the upper part of the body from the umbilicus and above includind the arms. then after finishing help the patient getting dressed again and expose the lower limps from the umbilicus to the foot.

Q4. And in which position you are trying to be on with this patient ?
Same as totti saied.

Q5. What things you want to emphesize ( comment ) on his general appearance ?
also totti answered it grately

Q6. What things you will assess in the P ? How much its normal range ? What u call it if increased & what u call it if decreased ? Give an illustrative verbal words with a patient his P is 75 ( comment by any finding u want to say )
nothing to add here on totti's answer. :eye:

Q7. What is the normal value of BP for normal patient ? What u call it if increased & what u call if it decreased ?
A: just to make it clear and perfect, Normal blood pressure is;
systolic: below 140.
diastolic: below 90.
usually 120/80.

Q8. What is the normal range of T for normal patient ? What u call it if increased & what u call if it decreased ?
A: Depends from where did you messure teh Temp. of the patient.
Normal:
-Mouth --> 36.8
-Axilla --> 36.4
-Rectum --> 37.3
Hyperthermia if increased and Hypothermia if decreased.

Q9. What is the normal range for RR in normal patient ? What u call it if increased ?
A: Normal b/w 14 and 18. if increased called tachpnoea.

QA. Mention some causes of TACHYCARDIA ?
QB. Mention some causes of BRADYCARDIA ?
Answered by totti.

Done, waiting for the next flood of qestions :LL:

[MAJ]

Asslam 3laikum

Totti , what u did is excellent , most of your answers were practically true , I appreciate your work .
Q1. Practically demonstrate by verbal words how can you introduce your self to the patient in arabic ?
السلام عليكم
كيف حالك ياعم...0
انا طالب في كلية الطب( مع اني ما أفضل اني أقول اني طالب طب عشان مايرفض زي ماسار معايا )0
وحابب افحصك شوية , ممكن؟


Tootti , I understand your point , yes there will be some patients refusing to be examined by a medical student , and this happened a lot with us especially at the beginning of the clinical years , but after that , once u r practicing how to talk and to deal with your patient making them trust on you , establishing a good doctor patient relationship , u will be more confident to say after that I`M A MEDICAL STUDENT , because u know now the patient will not refuse u , and on contrary , he will welcoming u to examine him .

:hp:

Dr.Lord , really , I surprised from your answers MASHALLAH , you covered what is missed and stressed on certain important points, even u said some points was not in my mind although we practice it daily with our patients .

Q1. Practically demonstrate by verbal words how can you introduce your self to the patient in arabic ?
A: You are supposed to introduce yourself from the beginning of Hx taking.
1- اذا كانت مريضة فاطلب من ممرضة مرافقتك اولا .
2- اطرق الباب ، استأذن بالدخول.
3- القي السلام ، واجعل الابتسامة على وجهك ، فهي تحبب وتقرب المريض اكثر اليك
4- اسأل عن حال المريض ، كيف اصبح وكيف امسى .
5- الان عرف عن نفسك (يا عمي انا طالب بكلية الطب ، واحب استأذنك في بعض الاسئلة عن حالتك)
In the physical examination, after finishing Hx, ask the patient politly for examining him.
يا عم ، انا محتاج افحصك فحص بسيط وان شاء الله ما راح اتعبك معايا ولا اخذ من وقتك .
actually this part depind on YOU, how do you actually have the skills to talk and ask for somthing. what I saied was just an example.

Wonderful talk and that`s exactly what should be done by a good physician cereating a good doctor patient relationship preparing for examination , also the patient by this way , will trust the doctor more and more , and the doctor will be highly oriented ethically , and that`s what we need it actually from our muslim`s doctors .

:hp:

Dr.Lord , I have a question to you ,I know some books having a discrepancy in their normal values , and I just want to know the source from which book u broght the normal range of mouth temprature , because I know also as totti said , it is from 36.6-37.2 C , I want to know too which book is saying that ??

:?:

Now it is completed and actually nothing to add it from my side .

I said previously , this part will depend mainly on you our members , and your replies were wonderful .

As we did previously , at the end , we will finalize our discussion in one ideal form INSHALLAH , to be more easy for the students to follow it and will collect it in a file as doctor lord adviced .

Now

Proceeding >>>>>>

:sun:

Practicing The Examination

Fourth Step :

Took the vitals already , Now , you have the chance to begin systematically to examine the patient from the hand going up to the head and face , coming down to the heart >>>>>>>>>>>>>to the lower limb .

If I asked you to examine the hand ,

Q10. What are the important findings which you have to look for ? And what is its significant in our target system i.e. what it indicate for ? Would you please illustrate by a figure or a photograph for each ?

Q11. Finishing the examination from the right hand , what should you do next ? DON`T FORGET ?

Q12. How can you define clubbing ? Mention its grades ?

Q13. How can you define cyanosis ? How many types does it has ?

Fifth Step :

When you are going to assess the pulse ,

Q14. What are the pulses which you are going to feel them ? What are their anatomical points to identify them on the body ? How could you illustrate that by your hand (technique) ? Would you please demonstrate by an illustrative photographs for each ?

After feeling the pulse , and as totti answered in the previous reply , you should look for :

Rate NORMAL ( 60-100 )
Rhythm ( regular Or irregular )
Volume ( good Or not )
Condition of the vessel wall ( thick Or thin )
Presence Or absence of delay
Character, assess the collapsing pulse

Regarding ,

Q15. What is the meaning of the delay ? How many types you will assess when you are examining the radial pulse ? And if it present , what does it indicate ?

Q16. What is the meaning of the collapsing pulse ? What does it indicate ? Would you please illustrate the procedure accompanied with a photograph ?

Q17. Finishing to assess the pulse from the right side , what shall you do next ? DON`T FORGET ?

Q18. What precaution you should stress on it when you are examining the carotid pulse ? and why ?

Clinical Points Of View :

QC. Mention some causes of clubbing ?

QD. Mention some causes of cyanosis ?

QE. Mention some causes of irregular pulse ?

:sun:

Slightly hard work but the end result will be wonderful INSHALLAH .

Waiting .

[Totti]

assalam 3alikom

thank u Dr lord and Dr maj .


O.k

Q10. What are the important findings which you have to look for ? And what is its significant in our target system i.e. what it indicate for ? Would you please illustrate by a figure or a photograph for each ?
we look for presence and absence of
- clubbing of nails .
http://fordcrown.jeeran.com/i.jpg

- splinter haemorrhages in the nail bed .
http://fordcrown.jeeran.com/o.jpg

- Olser's nodes .

- janeway lesions.
http://fordcrown.jeeran.com/t.jpg

- tendon xanthomata ,
http://fordcrown.jeeran.com/Totti.jpg

- palmar xanthomata

- peripheral cyanosis, and nicotine discoloration.

*clubbing : indecate 1- cyanotic congenital heart diseas .
2- infective endocarditis.
*splinter haemorrhages : indicate 1- infective endocarditis.
2- (rare) PAN.
*Olser's nodes :indecate 1- (rare) infective endocarditis.
*janeway lesions :indecate 1- (rare) infective endocarditis.
*tendon xanthomata :indecate type 2 hyperlipidemia.
*palmar xanthomata : indecate type 3 hyperlpidemia.

Q11. Finishing the examination from the right hand , what should you do next ? DON`T FORGET ?
doing the same thing on the left hand.

Q12. How can you define clubbing ? Mention its grades ?
It is an increaase of the soft tissue of the distal part of the finger.
ITS GRADE:
common , un common , rare and unilateral clubbing (am not sure).

Q13. How can you define cyanosis ? How many types does it has ?
it is blue discoloration of the skin and mucosus membrane due to presence of deoxygenated haemoglobin in superficial blood vessels.
TYPES :
central , peripheral cyanosis and nicotine discoloration.

Q14. What are the pulses which you are going to feel them ? What are their anatomical points to identify them on the body ? How could you illustrate that by your hand (technique) ? Would you please demonstrate by an illustrative photographs for each ?
the arterial pulse , from radial artery at rh wrist.
http://fordcrown.jeeran.com/19395.jpg

QC. Mention some causes of clubbing ?
common:
- cyanotic congenital heart disease
- infective endocarditis.
- lung carcinoma .
- bronchiectasis
- lung abcess .
- empyema.
un common:
- cystic fibrosis
- asestosis .
- cirrhosis
- coeliac disease.
- thyrotoxicosis.
.....ETC
QD. Mention some causes of cyanosis ?
central cyanosis :
- decreased arterial O2 saturation as in high altitude.
- lung disease.
- right to left cardiac disease.
- polycuthemia.
- heamoglobin abnormalities.
periphral cyanosis :
- all causes of central.
- exposure to cold.
- reduced cardiac output , LVF.
- arteria or venous obstruction.



:d:
am so tired now , very long homework, I'll leave the rest to Dr lord
sorry but
<center>
قوما تعاونوا ما ذلوا

تحياتي
:eye:
Totti

[dr_Lord]

Good morning all.
Thank you doctora for your words, actually that what I learned after continuous intro. To patients.
Regarding to your question about the normal temp. that what learned from our tutors and you can find a table in Clinical Examination by Talley in page 22, Table 2.7. We can say that the patient have hyperthermia or fever if his mouth temp. exceeded 37.3. Got now guys??

O.K, now let’s see what we got for this replay.

--

Q10. What are the important findings which you have to look for ? And what is its significant in our target system i.e. what it indicate for ? Would you please illustrate by a figure or a photograph for each ?
A: in the hands we will start from the fingers looking for the followings;
1- Clubbing: which is an increase in the soft tissue of the distal part of the fingers or toes “Talley p 34”. Clubbing of the fingers occurs due to many causes from different systems, one of them is CVS in some cases of Cyanotic Congenital Heart Diseases “CCHD” and Infective Endocarditis.
2- Splinter Hemorrhage in the nail beds: caused by Infective Endocarditis.
3- Osler’s nodes: caused by Infective Endocarditis.
4- Tendon & Palmer Xanthomata: signs for hyperlipidemia type 2 & 3 respectively.

Q11. Finishing the examination from the right hand , what should you do next ? DON`T FORGET ?
A: Move directly to the other hand and COMPARE, Remember always that ALLAH gave us two sides and both have to be examined and compared by.

Q12. How can you define clubbing ? Mention its grades ?
A: It is an increase in the soft tissue of the distal part of the fingers or toes.
Grades: 4 grades
1- Loss of angle.
2- Parrots beak.
3- Drum stick appearance.
4- Histopulmonary Osteoarthropathy.

Q13. How can you define cyanosis ? How many types does it has ?
A: It’s a blue discoloration of the skin and mucus membrane due to presence of deoxygenated blood more than 50 g/L in the capillary blood.
Types are Central Cyanosis as in the tongue, and Peripheral Cyanosis as in the lips and peripheries.

Q14. What are the pulses which you are going to feel them ? What are their anatomical points to identify them on the body ? How could you illustrate that by your hand (technique) ? Would you please demonstrate by an illustrative photographs for each ?
A: Radial, Brachial, Carotid, Femoral, Popliteal, Posterior tibial and dorsalis pedis pulses.

Q15. What is the meaning of the delay ? How many types you will assess when you are examining the radial pulse ? And if it present , what does it indicate ?
A: Compare the radial pulses for both hands feeling them spontaneously. If one is delayed to the other, radial to radial delay present. Types are “Delay in Timing” and “Delay in Volume”. It indicates a large artery occlusion by an atherosclerosis plaque or aneurysm.

Q16. What is the meaning of the collapsing pulse ? What does it indicate ? Would you please illustrate the procedure accompanied with a photograph ?
N/A

Q17. Finishing to assess the pulse from the right side , what shall you do next ? DON`T FORGET ?
A: compare with the left side and look for “radial to radial delay” and “radial to femoral”.

Q18. What precaution you should stress on it when you are examining the carotid pulse ? and why ?
A: NEVER palpate both carotid arteries together as they provide much of the blood supply to the brain which is a vital organ and needs O2 and Nutrition continuously.

--
Clinical Points Of View :
QC. Mention some causes of clubbing ?
A:
1- CVS: CCHD and Infective Endocarditis.
2- Respiratory: Bronchiectasis and Lung Abcess.
3- GIT: Cirrhosis and IBD “Inflammatory Bowl Disease”.
See also Talley page 36, Table “3.3”.

QD. Mention some causes of cyanosis ?
A:
1- Central: Polycythemia and Decreased arterial O2 saturation by lung diseases or CCHD...etc.
2- Peripheral: Exposure to cold, reduced cardiac output, arterial obstruction…etc

QE. Mention some causes of irregular pulse ?
A: atrial fibrillation, sinus arrhythmia, drugs as digoxin…etc
--

Tptti did nice but uncompleted work
دكتورة ، صراحة تقلتي العيار شويتين المرة دي في الاسئلة :aa:

To be continued;
D r . L o r d

[MAJ]

دكتورة ، صراحة تقلتي العيار شويتين المرة دي في الاسئلة

:122:

Yah , u r absolutely right , seems to be like that .

I`m soooooo sorry for that totti & dr.lord .

I`ll put this observation in my consideration in the next time INSHALLAH .

Any way , my expression on your participation in this topic is the best .

:LL:

And to continue doing that , it is really need a time from you ,

Without boaring or loss of interest .

:l:

Because now , the whole topic is from you .

I`m only watching after I come back from my shift ,

Trying to be on time as much as I can , and

Preparing for the next part of questions .

So, PLEASE take your time in answering .

:sun:

جزاكم الله كل الخير على جهودكم

قال الشاعر

سيبقى الخط بعدي في الكتاب
وتبلى اليد مني في التراب
فياليت الذي يقرأ كتابي
دعا لي بالخلاص من الحساب

Hopping The Best To The Whole .

[dr_Lord]

Hello,

Continueing some missing points of my last replay.. I tried to get some pictures from the web for explaination and showing some valued informations.

---

Q14. What are the pulses which you are going to feel them ? What are their anatomical points to identify them on the body ? How could you illustrate that by your hand (technique) ? Would you please demonstrate by an illustrative photographs for each ?
A:
totti have already showed the one of radial pulsation and from where shouldda be felt.

for the brachial pulse:
Take the first two fingers of your right hand and place them on the front of your left elbow, slightly towards the inside. You should be able to feel your heart beat (pulse) with the light touch of your fingertips.
http://www.sti.upmc.edu/STI_Patient_web/sti/images/exercise.heartrate-02.jpg
"for more info., visite www.sti.upmc.edu"

and to feel the carotid pulse:
http://imc.gsm.com/integrated/BCS/keyframes/cv-carotid-pulse.jpg
N.B: Avoid compressing both sides a the same time. This could cut off the blood supply to the brain and cause syncope. Avoid compressing the carotid sinus higher up in the neck. This could lead to bradycardia and depressed blood pressure.
"for more info., visite www.imc.gsm.com"

for Femoral anatomy:
http://www.bartleby.com/107/Images/small/image550.jpg

to feel it:
http://mosquito.who.int/docs/images/hbsm_fig16.gif

the popliteal artery:
http://www.vh.org/adult/provider/anatomy/AnatomicVariants/Cardiovascular/Images0200/0225.jpg

for posterior tebial artery anatomy and palation of its pulse:
http://www.med.umich.edu/lrc/coursepages/M1/anatomy/html/surface/pulses/tibial_1.jpeg
http://www.latrobe.edu.au/podiatry/vascular/vascpics/colourpics/PTpalpate.jpg

and finally for the dorsalis pedise artery and pulse:
http://www.podiatry.curtin.edu.au/encyclopedia/vasdisease/Dorsi2.JPG
http://www.latrobe.edu.au/podiatry/vascular/vascpics/colourpics/DPpalpatetransverse.jpg

--
Q16. What is the meaning of the collapsing pulse ? What does it indicate ? Would you please illustrate the procedure accompanied with a photograph ?
A: Pulse, water hammer: A jerky pulse that is full and then collapses because of aortic insufficiency (when blood ejected into the aorta regurgitates back through the aortic valve into the left ventricle). This type of pulse was likened to a water hammer, a Victorian toy consisting of a glass tube filled partly with water or mercury in a vacuum. The water or mercury produced a slapping impact when the glass tube was turned over. Also called a Corrigan pulse or a cannonball, collapsing, pistol-shot, or trip-hammer pulse.
click here to visit the link (http://www.medterms.com/script/main/art.asp?ArticleKey=22974)

Ex: With the patient reclining, the examiner raises the patient's arm vertically upwards. The examiner grasps the muscular part of the patient's forearm. A waterhammer pulse is felt as a tapping impulse which is transmitted through the bulk of the muscles.
click here to visit the link (http://www.gpnotebook.co.uk/cache/-590348245.htm)

---

Well, I think that answers most of the remaining questions.. I hope the figuers did their work.

اسأل الله ان ينتفع الجميع بمشاركاتنا
wating for the comments.

الى اللقاء
د.لورد:12:

[MAJ]

Asslam Alaikum

Really , a wonderful work , now our discussion is an open book in front of the student and at the same time is a real case presented on line .

Dr.Lord & Totti , you completed your job although it was hard to some extent , but you did it very well .

The only few things that I think are missed in between due to large number of questions , I know it is my fault and for that reason I will search about them instead .

:waa:

Regarding Q10 :

A photograph for Osler`s Nodes was forgotten ????????

Regarding Q14 :

Remaining only to illustrate by hands how to feel the popliteal pulse ????????

Regarding Q15 :

Radiofemoral delay à Coarctation of the aorta .

Regarding Q16 :

What dr.lord mentioned about it is much clearer from what I`ll say it now , anyway , just to be familial with it , it is from Meckloud`s clinical examination saying that : Collapsing pulse is that , the peak of the pulse wave occurs early and is of brief duration followed by an equally rapid descent ( collapsing sensation ) for the same reason mentioned previously .

It is a sign of AORTIC REGURGE , very impo.

Remaining only to illustrate the procedure .

I know now which book most popularly used in our university for clinical examination study and I `ll try to concentrate on it during our discussion .

:?:

Now >>>> Ready To Proceed ,

Continue >>>>>>

:sun:

Practicing the Examination :

Sixth Step :

Ok , usually we are leaving this step to the end of the examination to complete examining the patient on lying down first , but any way , it is up to you .

Measuring the Blood Pressure is an important part of examination , and to obtain an accurate reading , certain aspects of the measurement must be understood (eventhough Bp can now be taken by machine which produce beeping noises and digital readouts) , Regarding :

Q19. In which positions you should measure the BP ?

Q20. What is the instrument usually you use it in the measuring of BP ?

Q21. Could you please put a photo for it ?

Q22. Illustrate it by a procedure ? if possible show us how you will wrap the cuff around the arm ?

Q23. How will you read your measurement i.e. interpretation of the reading ?

Q24. Is measuring BP in both arms should be equal ? and if it differed , for how much is it ?

Q25. What about the leg BP in relation to the arms ?

Q26. What is the Pulsus Paradoxus ? What is it indicating if present ?

Q27. What is the postural hypotension ?

Seventh Step :

Finishing from a complete hand examination going up to the face , Regarding ,

Q28. What things you should inspect for ? and what is the significant for each ? illustrate by a photos for some of them ?

Clinical Points Of View :

QF. Mention some causes of postural hypotension ?

:sun:

Many questions , but need to be answered in one and a half line , I hope that they seem to you as what I feel .

Good Luck .

[WaLeeD]

Assalamu3leikum dear doctors MAJ, LORD & TOTTI
Wallah Dear Sister Dr.MAJ you are doing a very very great Job
Just think about # of letters you've written here
:LL:
جزاكي الله الف الف خير على اللي تعمليه وحبك للخير
Dr. LORD & dear TOOTI are following you with a very high level of responsiveness, thaaanx very very much dear brothers
:12: :12:


It will take time to follow you since it is a very loooong subject
but i'll try my best to read it as faster as I can, coz i really want to join you. May you permit me Dr. MAJ ??? thaaanx

UmmmMm Doctorah i want to participate in answering the Qs



Q19. In which positions you should measure the BP ?
A19: In lying down position I think.

Q20. What is the instrument usually you use it in the measuring of BP ?
A20: the instrument is Sphegnomonometer.

Q21. Could you please put a photo for it ?
A21: I'll Look for it insha'allah

Q22. Illustrate it by a procedure ? if possible show us how you will wrap the cuff around the arm ?
A22: I'll wrap the cuff in a way that the 2 rubber tubes will descend anteriorly.

Q23. How will you read your measurement i.e. interpretation of the reading ?
A23: after I wrap the cuff, i'll press the rubber bag to rise up the level of the mercury up to 170 or 180 mmHg, then I leave the air to be out. I put the stethoscope under the cuff on an artery in the cubittal fossa, then i rise up the level of the mercury once again to the same level. I then bring it down till i hear the first beat, and that is the systolic BP, then i continue bringing it down till the beat soud disappear, and that is the diastolic BP.


UmmmmmMm Doctorah that is what i've now, but i'll be back tomorrow Insha'allah, May Allah bless your work . Thaaaanx

[MAJ]

Asslam alaikum

Welcome welcome dr.Ledo .

Very happy to see your reply over here, joining our team and attaching to it .

:hp:

Of course you can share without a request or permission for you and for the others too .

This is your forum and this section is your next coming life in the medical colleague and what you are doing here is for the benefit of the whole INSHALLAH .

Welcome to you again and waiting for your next participation .

:sun:

By the way ,

Where are you totti and Dr. Lord ????

:?:

Waiting for you too .

Hopping The Best To The Whole .

:sun:

[dr_Lord]

Good Morning All...

Sorry doctora, I just came from my shift in the ER. trying to practice cause this vecation cleaned up my mind completly :d:
-
Welcome Dr_Ledo, I've been wating for you and other members to start with us in this topic. welcome again :wooow: .
-
Doctora, our descusion her going so big and wonderful MASHALLAH, just look at the number veiwed. I really hope that it is usefull for everyone.
-

O.K Let's start our doctora's next flood of questions..

---

Q19. In which positions you should measure the BP ?
A: Routinely shouldd'a be take in 2 positions, i.e Lying and Standing. But usually doctors and nurses take it only in lying one. The standing position used to see if the patient suffers from postural hypotension.

Q20. What is the instrument usually you use it in the measuring of BP ?
A: It's called Sphygmomanometer .

Q21. Could you please put a photo for it ?
this is for the mercory one

http://www.orthodynamic.gr/images_prod/25120s.gif

and this is a small one with a watch reader
http://101.blood-pressure-monitors-online.com/bp117--400-fct.jpg

Q22. Illustrate it by a procedure ? if possible show us how you will wrap the cuff around the arm ?
A: The cuff is wrapped around the upper arm with the bladder centered over the brachial artery (1/3 of the way over the medial epicondyle). The cuff is fully inflated then deflated slowly untill the radial pulse returnes. The diaphragm of the stethoscope is placed over the brachial artery.

Q23. How will you read your measurement i.e. interpretation of the reading ?
A: Five different sounds will be heared as the cuff is slowly released. They are called the Korotkoff sounds and they are:
1-Korotkoff I the pressure at which a sound is first heared over the artery and it is the systolic pressure
2-KII where the sound increases in intensity.
3-KIII where the sound decreases.
4-KIV when becomes muffled (مكتوم).
5-KV when it disappeares (and it's the best measure for the diastolic pressure)

Q24. Is measuring BP in both arms should be equal ? and if it differed , for how much is it ?
A: ummmm. I remember that I've heared about it but really I can't remember.:?:

Q25. What about the leg BP in relation to the arms ?
A: Normally the systolic pressure is from 10 up to 20 mmHg higher than in the arms

Q26. What is the Pulsus Paradoxus ? What is it indicating if present ?
A: It's a strong reduction in the systolic BP more than 10mmHg during inspiration
It indecates that the patient may have any of the following: constrective pericarditis, pericardial effusion, or sever asthma.

Q27. What is the postural hypotension ?
A: A fall of more than 15mmHg in systolic BP or 10mmHg in diastolic BP on STANDING position.

Q28. What things you should inspect for ? and what is the significant for each ? illustrate by a photos for some of them ?
A:
Sclera: look for jaundice --> in sever congestive cardiac failure and hepatic congestion.
Xanthelasma around the eyes --> Type 2 & 3 hyperlipidaemia.
Mitral facies --> pulmonary HTN, low cardiac output as in sever mitral stenosis.
Mouth --> look for the followings:
a- High arched palate --> Marfan's syndrome.
b- Teeth --> if diseased or bad oral hyogin as a sourse of organisms cause infective endocarditis.
c- Tongue --> Central cyanosis.



Clinical Points Of View :
QF. Mention some causes of postural hypotension ?
A:
1- Hypovolaemia (e.g. dehydration).
2- Drugs (e.g. Diuretics).
3- Addison's disease.
4- Hypopituitarism.
5- Autonomic neuropathy.
6- Idiopathic orthostatic hypotension. (rare)

N.B :in such a question, when asked to mention causes of something. Start with the commenst then the least common then to the rare causes. Don't start with the rare causes. you will gather more marks by that except if the examiner asked you specificly about the rare causes.

---

Done, (and Dr.Lord is done too :d: )

Thanx for attending with us :12:

[MAJ]

Asslam alaikum

Ok !!!! Good !!!!

So , consuming our times in practicing before starting the new year , any way , very good to chose the ER to practice in , Know why ???? a big world in the ER is greatly different from the word or from the OPD ( out patient department ) and also a lot of benefit things to be learned only there .

Not only that , the exposure for the patients in the ER is highly surprising you in many things , whether if it is socially , ethically , psychologically or or ,,,, and the kinds of problems there make you sometimes to know and to learn also how to deal with them .

For example , you may expose to a patient putting you in a trouble without doing any thing for him , he just wanna to see , examine , reassure , discharge him before the others , Imagine in the ER how many patient you have , you are not looking only for one patient , you are seeing a lot of patients as a flush for sometimes .

One of them went to the head of the department complaining on me and on my senior , no , also he complained on the whole medical staff :122: because we were busy with a critical case and because that patient as that time wanted to be requested for the invistigation for his child although his child was seen and examined from my senior and also he was stable patient , and after a while I surprise from the ER head of the department coming to speak to me :?: , I was a lone at that time and actually at the beginning I didn`t get the point which he is talking about because he was talking to me by an indirect way about the compliant of that person , but finally I understood the situation after a frequent request to him to illustrate more and to elaborate more , I just was saying to him : doctor please I don`t understand you , would you please tell me what is the problem exactly which I did to talk to me by this way ?? :O: ?? Ooh Noooo , that person was saying tourble things on us , I tried to explain the situation for the doctor although I don`t know the patient and didn`t touch him at all .

So I don`t know the patient , I didn`t touch him , I didn`t see him , I didn`t talk to him , although he complained , but at the end ALHAMDULLAH every thing was cleared up , Unfortunatly my senior doctor was not explained the condition very well to him and make him worry to wait more although he waited only for few minutes .

:LL:

Long story , but the message here is in the ER , really it is a very large society , every day you will learn how to deal with the patients there and how to deal with its problems even from your mistakes .

We will have a separate topic INSHALLAH on the ER problems , I hope to share us and other members from your experiences from practicing there .

:sun:

Ok , I just wanted to deviate slightly from our talk in this long subject because I felt it is boaring for you to some extent , any way , we have a little to finish INSHALLAH .

Now , back to our topic

The only thing left in the previous part is for Regarding Q24 :

The systolic Bp may normally vary between the arms by up to 10 mmHg .

In the legs , the Bp is normally higher than in the arms .

Dr,Ledo , very nice to start with us .

Dr.Lord , good job , well done .

I`m still preparing for the next part .

Hopping The Best To The Whole .

[dr_Lord]

Hello there

Actually doctora in ER you have to have skills in dealing with 2 PROBLEMS; the disease or case and the patient himself as you said. But it's great in practicing how to do procedures and how to get quick skills.

from my side, I think that it's really great to have an elective in ER especially for surgery and trauma, but as a job or speciality you have to think twise again caz you will distroy your own life by the shifts.

however, I really liked my team and I think I'm gonna cry at the end of my elective :waa: . I'll miss them all.

anyway, I'm waiting for the next part to be started..

bye :12:

[WaLeeD]

<center>

AssaLamu3laiKuM dears.

Thanx dr. Lord for your nice words

Me ToooOooO dear Doctorah MAJ, waiting for the next prat. i'm really soo intrested. And i'll try to apply more medical English in my answers inestead of using my bad general English
:o:

من فين جبت انا كلمة
Rubber tubes
:l: :l:

Sorry Deeeeears
:15:

[dr_perfecta]

Wow ............what a great wonderful things here ............

it's really impressive...............
sorry ...I really would like to be present so often but the hospital I'm working in is making my internship very BURDENSOME


any way up till the next time i see u I eave u with this advice .........the first impression u give to the pt is the most important step in interviwing you pt so make sure to make it good........when u first see ur pt great him say
السلام عليكم
shake ue pt hands it he or she from the same gender as u r

look proffessenal
then in inviting the pt story make sure to show ur understanding...use the verbsl and non verbal comunications........

i hope that make sense to u
thanx see u soon

[dr_Lord]

Salam

































Where is everybody?? is it the end of this discusion???

[MAJ]

Waalikum Asslam

:?:

Of course not Mr.Lord

Our discussion still to be continued

Never ever , I`ll not leave it INSHALLAH until we will finish it together and presenting it in a good form as we`ve been said previously .

I just was slightly busy in the last period because of my consultant giving to me in every day a topic I have to prepare it before , to present it in front of him after finishing the round team .

And we are preparing for exam too :waa: , gray for us to pass , one week only left .

Any way , dr.Lord , I`m really very happy to be active and interesting to follow this subject .

I hope to get benefit from it to the whole greatest students in our university and also to our brothers visiting and sharing us from other universities .

Ok , my consultant forgot today to ask me about the topic and i forgot too to remind him , coz there was a lot of patients in our team have to be seen , so that i`ll not prepare a new one today :hp: i`ll present the same topic .

Now >>

Let`s work

Back to our topic ,

:sun:

Practicing The Examination :

Eighth Step :

Of great important to elicit the JVP and to differentiate it from the carotid arterial pulse in the neck region during the examination of the cardiovascular system .

Regarding the JVP ,

Q29. What is the significant to measure the JVP ?

Q30. Which vein actually do you measure ?

Q31. What is the course of this vein i.e. anatomy ?

Q32. How can you measure it i.e. illustrate the procedure , and if you can to show it by a photograph ?

Q33. You are looking for what when you are assess the JVP ?

Q34. What is its normal value ? and what indicating if it is raised ?

Q35. If you can not assess the pulsation , then what should you do ?

Q36. How could you differentiate between the vein in the neck and the carotid artery?

Q37. Talk about the waveform of the JVP in brief and its relation to the heart sounds and cardiac cycle ?

Clinical Points Of View :

QG. Mention some causes of elevated central venous pressure ?

QH. Mention some causes of a dominant a wave , Cannon a wave , Do0minant v wave , X descent , Y descent ?

By the way , QH is important in MCQs too .

Tow sessions left to finish from the second part INSHALLAH .

Waiting for our team to answer the questions .

[Totti]

Q29. What is the significant to measure the JVP ?
It tells us about right arterial and right ventecular function .


Q30. Which vein actually do you measure ?
internal jugular vein .

Q31. What is the course of this vein i.e. anatomy ?
It is medial tothe sternomastoid muscle.


Q33. You are looking for what when you are assess the JVP ?
height and character


Q34. What is its normal value ? and what indicating if it is raised ?
height: 3 cm above the zero point , if it is raised --> tis is a sign of right ventricular failure or of volume overloads .


Q36. How could you differentiate between the vein in the neck and the carotid artery?
the J.V is visible but not palpable , it has coplex wave form , it moves on respiration , and it is at first obliterated and then filled from above when light pressure is applied at the base of the neck.


Q37. Talk about the waveform of the JVP in brief and its relation to the heart sounds and cardiac cycle ?
There are two positive waves in the normal JVP . the first is called the a wave and concides with right arterial systole . it is due to arterial contraction . the a wave also concides withe the first heart sound and precedes the carotid pulsation . the second impulse is called the v wavw and is due to arterial filling , in the period when the tricuspid valve remains closed during ventricular systole . between the a and v waves there is a trough cused by arterial relaxation . this is called the x descent . it is interrupted by the c point which is due to transmitted carotid pulsation , and concides with tricuspid valve closure . following the v wave , the tricspid valve opens and rapid ventricular filling occure ; this result in the y descent.


QG. Mention some causes of elevated central venous pressure ?
- right vntricular failure
- tricuspid stenosis
- pericardial effusion
- constictive pericarditis
- S.V.C obstruction
- fluid overload
- hyperdynamic circulation .


QH. Mention some causes of a dominant a wave , Cannon a wave , Do0minant v wave , X descent , Y descent ?

* a dominant a wave:
- tricuspid stenosis
- pulmonary stenosis
- pulmonary hypertension

* Cannon a wave :
- compelet heart block
- paroxysmal nodal tachycardia with retrograde arterial conduction
- ventricular tachycardia with retrograde arterial conduction

* Do0minant v wave :
- tricuspid regurgitation

* X descent :
- absent --> arterial fibrillation
- exaggrated --> acute cardiac temponade , constictive pericarditis

* y descent :
- sharp : severe tricuspid regurgitation , constictive pericarditis
- slow : tricuspid stenosis , right atrial myxoma

[dr_Lord]

Salam..

طيب دكتورة ،،، انتهينا؟؟؟

[MAJ]

Walikum Asslam

THE GIVING MIND of the forum

We are here , you escaped for a long time

any way , really i was busy in the previous period

i`m so sorry

but still i`m on my words ,

we will finish it as we planned to it before inshallah !!!!!

or if you want to direct the rest of the discussion

It doesn`t matter

You are MASHALLAH master now

we will be here all together

Of course totti , ledo and the others will be with us

Good Luck

:sun:

[dr_Lord]

OOOh god, really you've embarrassed me doc. THANK YOU and I realy appreciate it.

I'm sorry but I was busy with the courses we take wich needs some attention. any way I'm quite sure that the students of 4th year will share us from now on and they can make it :wooow: .


or if you want to direct the rest of the discussion
NO, for sure you will be our director since you are our intern mashallah and your knowledge & experiences are more MASHALLAH.

----

So, We will be wating. just finish your work and come to manage us here..


bye bye