1_Internal Medicine UKI New

7/17/2019 1_Internal Medicine UKI New

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Internal Medicine

Donnie Lumban Gaol



• Barbara Bates

Guide to physical examination and history

taking

• Lynn S. Bickley

Bates’ guide to physical examination and

history taking



Diagnosis an in!ured mosaic



Medical examination

• Patient history

• Physical examination

• Laboratory and instrumental examination





Patient history

". Introduction

1.Chief complaint(s)

cute !S chronic



Patient history

". Introduction

#. $hie% complaint&s'

". Present illness



(resent illness

• Location

• )uality

•)uantity or se*erity• +iming &onset, duration, %re-uency'

• Setting in hich it de*eloped

• /actors that aggra*ated or relie*ed• 0ssociated mani%estations

• +reatments



Patient history

". Introduction


1. (resent illness#. Past history



(ast history

• Most important diseases in chronological

order &hospitalisations'

• 2perations, in!uries, accidents

• 0llergies &drug, %ood, pollens etc.'

• +rans%usion&s'

• Screening tests



Patient history

". Introduction


1. (resent illness3. (ast history

$. Current health status



$urrent health status

• Social circumstances

• 2ccupation &recent and past'

• 4n*iromental ha5ards &home, school, orkplace'

•Diet &incl. be*erages'• 0lcohol and illicit drugs &type, amount, %re-uency, duration o%use'

• +obacco &type, amount, duration'

• $urrent medication

• 4xercise and leisure acti*ities

• Sleep patterns

• Sexual history



Patient history

". Introduction



6. $urrent health status

%. &amily history



/amily history

• (arents, siblings, spouse, children, other relati*es age7 age and cause o% death7 health status7 important

diseases

• 2ccurence o% Diabetes 8ypertension, heart diseases, stroke In%ecti*e diseases Malignant diseases

$oagulation disorders (sychiatric diseases, alcoholism, drug addiction Symptoms like those the patient



Patient history

". Introduction




9. /amily history'. Reie of organ systems



Reie of organ systems

• General

General status

:sual eight, eight change

/atigue

/e*er

• 0ccording to organs• Skin, 8ead, 4yes, 4ars, ;ose, Mouth, ;eck,

Breasts, <espiratory, $ardiac, Gastrointestinal,

:rinary, Genital etc.



Patient history

". Introduction




9. /amily history=. <e*ie o% organ systems



skin

• $olor

• +urgor

• +emperature

• Moisture



skin



nail





Dorsalis pedis pulse Posterior tibial pulse

(eripheral (ulses



4ye

• Inspection• 4xamine (upil





4ye signs in 8yperlipidaemia

C*R+,- RCS /+0,-S20



;4$>

• Inspect

• (alpate Lymph ;ode











;eck



(alpation? +racheal 0lignment



+racheal 0lignment

0bnormalities• (neumothorax shi%ts to una%%ected side

• (leural 4%%usion shi%ts to una%%ected side

• /ibrosis or 0telectasis shi%ts toardsa%%ected side

• (ulmonary consolidation no shi%t



• Inpect thyroid gland





(alpation %rom the %ront



I% the thyroid gland is enlarged,

listen o*er the lateral lobes ith a stethoscope

to detect a bruit.



Diffuse ,nlargement

0 di%%usely enlarged gland includes the isthmus and the lateral lobes, but there are no discretely

nodules.

$auses include Gra*es’ disease, 8ashimoto’s thyroiditis, and endemic goiter .



2ultinodular 3oiter

+his term re%ers to an enlarged thyroid gland that contains to or more identi%iable nodules. Multiple

nodules suggest a metabolic rather than a neoplastic process, but irradiation during childhood, a

positi*e %amily history, enlarged cer*ical nodes, or continuing enlargement o% one o% the nodules

raises the suspicion o% malignancy.



Single +odule

0 clinically single nodule may be a cyst, a benign tumor, or one nodule ithin a multinodular gland,

but it also raises the -uestion o% a malignancy.

(rior irradiation, hardness, rapid groth, %ixation to surrounding tissues, enlarged cer*ical nodes, and

occurrence in males increase the probability o% malignancy.





















+82<0@ and +he Lung



$hest +opography?

0nterior $hest

$h t + h



$hest +opography?

Lateral $hest

$h t + h



$hest +opography?

(osterior $hest

/iss res



/issures?



Location o% Lobes



(hysical 4xam +echni-ues

• 2bser*ation

• (alpation

•(ercussion• 0uscultation



• 0racheal Displacement to? same side ith olume loss &e.g.,

atelectasis'

opposite side ith opposing pressure&e.g., large pleural e%%usion, pneumothorax'

• udible +oise4 Stridor

Ahee5e

Aithout stethescope



• Cyanosis

• Aith right heartfailure

&cor pulmonale'

especially ith

expiration, see?

enlarged tender

li*er

neck *eindistention



(ectus 4xca*atum



(ectus 4xca*atum



(ectus carinatum



(alpation? Cocal /remitus

• BIL0+4<0L comparison

o% *ocal *ibrations

• Increased ith al*eolar

consolidation

• Decreased ith

increased distance

beteen lung and chest

all (neumothorax, (leural

e%%usion



(ercussion ;otes

• <esonance normal

• Dullness increased density

0telectasis, al*eolar %illingconsolidation,

pleural e%%usion, %ibrosis

• 8yperresonance decreased density

8yperin%lation &$2(D', (neumothorax



• I;S(4$+I2;E de%ormities, slope o% ribs,

retraction or bulging o% interspaces,

asymmetry, rate and rhythm

• (0L(0+I2;E masses, excursion, tactile%remitus, tenderness

• (4<$:SSI2;E locali5e organs, %luid,

masses, diaphragmatic excursion, hyperEresonance &seen in pneumothorax and o*er

gastric air bubble'

4*aluation 2% $hest



4*aluation 2% $hest

4xpansion

• Should be symmetrical• 0;+4<I2<E thumbs in midline, hands along rib cage?

spread ith inhalation

• (2S+4<I2<E thumbs midline about parallel to +#"?

as abo*e• Look %or bulging or retraction o% intercostal spaces

• Lag or impairment o% thoracic mo*ement suggests

underlying disease or in!ury to lung or pleura



+actile /remitus

• (alpate ith the palm o% your hand

• Cibrations transmitted to the chest all

• <epeat FH or FoneEonEoneH

•I+CR,S,DE o*er large bronchi orareas o% consolidated lung &air replaced

by a solid or exudate'



• 5S,+0 or D,CR,S,D6 %aint *oice,

obstructed airay, or by %luid, air &$2(D,

pneumothorax', or solid tissue in the

pleural space & like the heart or ane%%usion', thick chest all



(ercussion

• D--+,SSE o*er areas o% fluid or solid

tissue &heart in L interspaces 3E9'

ieElobar pneumonia, e%%usion, hemothorax,atelectasis



• 7P,RR,S*++C,

ieE $2(Dasthma &due to hyperin%lation'

bilateral and diffuse

• (neumothoraxEusually unilateral



0uscultation

• #stE stick it in your ears

• Deep breaths through the mouth

• Don’t hyper*entilate the patient• Listen to one hole cycle in each spot

• $ompare sides %rom apex to base

• Breathe hard and %ast i% sounds are

-uiet

E(eds? FBreathe like a puppy dogH

B th S d



Breath Sounds

• +ormal breathing is -uiet and e%%ortless,

inaudible ithout stethescope

• <ate #6E1" per min, occasional sigh

• 5ronchialE normally o*er manubrium.

L2:D, high pitched, 4xpiration InspEiration&Darth Cader'

• 5ronchoesicular E #E1nd intercostal

spaces and interscapular areas• !esicular E most o% lung. So%t, lo pitched,

Insp longer than 4xp sound



0bnormal Sounds

• ,3*P*+7E spoken F4H becomes F0H

• 5R*+CI- 5R,0 S*+DS6 normal

o*er trachea but heard in periphery

abnormal &exp J insp, and higherpitched exp'

• 8eard in consolidated or compressed

areas o% lung , as in upper le*els o% pleurale%%usion &better transmission'



More 0ltered Sounds

• 5R*+C*P*+7E *oice sounds louder

and clearer than usual &better

transmission o% highEpitched sounds'



2thers

• CRC8-,SE &aka FralesH' heard in

pneumonia, $8/, %ibrosis, and the bases

o% some elderly, bedridden and normals

• R*+CIE Sonorous, secretions in largeairays

• 9,,:,SE musical, mainly expiratory, in

asthma and $2(D



More

• P-,R- R56 In%lamed pleura mo*e

!erkily due to %riction. Locali5ed, loEpitched

and o%ten FtoEandE%roH. 2%ten disappears

hen e%%usion de*elops• S0RID*R6 due to upper airay

obstruction, most o%ten laryngeal. BiE

phasic or mainly inspiratory. $ould beemergency i% associated ith retractions or

cyanosis



$84S+ @<0K







Le%t LL (neumonia

Percussion?

Vocal sounds?

Fremitus?

Auscultation?

8 h



8emopneumothorax

Percussion?

Breath sounds?

Vocal sounds?

Fremitus?

L l l 4%% i



Large pleural 4%%usion

What would vocalsounds be like here?



atelectasis

Percussion?

Vocal sounds?

Fremitus?

Auscultation?



(ulmonary 4dema

Percussion?

Vocal sounds?

Fremitus?

Auscultation?

( l 4d



(ulmonary 4dema

Kerley B lines

(septal lines)

Pleural effusions

Pleural effusions

Tracheal Shift TactileFremitus

Percussion BreathSounds

Spoken/Whispered

AdditionalSounds



Fremitus Sounds WhisperedVoice

Sounds

Normal none N, symmetric resonance vesicular N none

ChronicBronchitis

none N resonance vesicular N coarse crackles

IL! C"F none N resonance vesicular N fne crackles

Pneumonia none increased dullness b-vb broncho, e!o,w"

crackles #$, c%,whee&e rhonchi

Atelectasis to same side absent dullness absent absent none

#mph$sema none decreased hy"erresonance decreased decreased none

Asthma none decreased hy"erresonance decreased decreased whee&e rhonchi

Pleurale%usion

to o""osite side decreased dullness decreased' decreased' none

Pneumothora&

to o""osite side decreased hy"erresonance decreased decreased none

0bbre*iations?

; EE normal% EE %ine

$ EE coarse

bE* EE broncho*esicular

b EE bronchial

broncho EE bronchophony

ego EE egophony

p EE hispered pectoril-uy

Bronchial breath sound, bronchophony, egophony, and hispered pectoril-uy could be heard near the top o% a large e%%usion.







+entukan (unctum Maximum





2 ’



D2;’+









Ahat is the -uantity o% the sound +he rating system %or

murmurs is as %ollos?#=... $an only be heard ith care%ul

listening1=... <eadily audible as soon as the stethescope is applied to

the chest

3=... Louder then 1=

6=... 0s loud as 3= but accompanied by a thrill

9=... 0udible e*en hen only the edge o% the stethescopetouches the chest

==.. 0udible to the naked ear





(recordium 0uscultation



(recordium 0uscultation

8eart Sounds

• Bell lo pitched

sounds

• Diaphragm high

pitched sounds

• Mitral→ +ricuspid→

(ulmonary→ 0ortic

areas• S# &%irst heart sound'

• S1 Splitting &01, (1'





0bdominal 4xam



0bdominal 4xam

•Inspection•uscultation

•Percussion

•Palpate

percussion includes percussion

o% li*er span, light and deep

palpation, palpation o% li*er

edge, spleen tip, kidneys, and

aorta. +he abdominal exam is

done ith the patient supine at

"o

'rder of e&am is critical( AuscultateB#F')# palpatin*+

'rder of e&am is critical( AuscultateB#F')# palpatin*+

5D*2,+; Inspection



5D*2,+; Inspection

,-. Auscultation



Percussion ,-01,-2



(ercussion? the le%t and right abdomen should be

percussed abo*e and belo the umbilicus. Most

examiners ill percuss N or more areas.

Percussion: Liver span





bdominal Palpation



Palpation; Deeply< all $ =uadrants



2ne should use to hands. (ress

don around 6 cm

Palpation: Liver



(lace your < hand on the pt’sabdomen ell belo here you

percussed the li*er edge

Pal"ation o$ (iver) Alternative *ethod



Palpation; Spleen





<ight

lateraldecubitus

Palpation of 8idneys



<ight kidney &take a deep

breath, capture kidney,

exhale, sloly release kidney

Le%t kidney &take a deep breath,

capture kidney, exhale, sloly

release kidney'

ABDOMINAL EXAMINATION ABDOMINAL EXAMINATION

POSITIONINGPOSITIONING



POSITIONINGPOSITIONING

• 0bdomen can be di*ided in %our -uadrants• (atient should be lying on supine position


INSPECTIONINSPECTION



INSPECTIONINSPECTION

• Shape and mo*ements

• Scars

• Distension

Localised? mass, organomegaly Generali5ed? 9 /’s

• (rominent *eins &caput medusae'

• Striae

• Bruises• (igmentation

• Cisible peristalsis

Spider ;e*us



Spider ;e*us



Tête de Méduse, by (eter (aul <ubens &#=#N'

$aput Medusae



$aput Medusae


S S G



• (ain in <:)

• In%lammation o% gallbladder

&cholecystitis'• $our*oisierOs la

MURPHY’S SIGNMURPHY’S SIGN


BLUMBERG’S SIGN



• a.k.a. rebound tenderness

• (ain upon remo*al o% pressure rather than

application o% pressure to the abdomen• (eritonitis and or appendicitis

BLUMBERG’S SIGNBLUMBERG’S SIGN


MCBURNEY’S POINT



• #3 0SIS to umbilicus

• Location o% 0C in retrocecal position

• Deep tenderness &J acute appendicitis'

MCBURNEY’S POINTMCBURNEY’S POINT




PALPATION OF THEPALPATION OF THE LIVERLIVER



PALPATION OF THEPALPATION OF THE LIVERLIVER

#. Start palpating in the right iliac %ossa

1. 0sk the patient to take a deep breath in

3. Mo*e your hand progressi*ely %urther up the abdomen

6. +ry to %eel the li*er edge

Shi%ting Dullness



Shi%ting Dullness






PALPATION OF THEPALPATION OF THE SPLEENSPLEEN



PALPATION OF THEPALPATION OF THE SPLEENSPLEEN

#. <oll the patient toards you

1. (alpate ith your le%t hand hile using your le%t hand to

press %orard on the patient’s loer ribs %rom behind

3. /eel along the costal margin



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1_Internal Medicine UKI New