Final Physical

FINAL EXAM
HEART
[Q.1.What is precordium
Precordium : the anterior surface of the chest

[IMP]
closest to the heart and aorta is termed the
precordium
Vertically : the second to the fifth intercostal space

Transversely : the right border of the sternum to
the left midclavicular line]
Extra.CONTENTS OF
Inspection
with tangential lighting
1.Precordial prominence and pectus

excavatum.
2.Apical impulse.
3.Abnormal precordial pulsation
Q.2Inspection- Apical impulse
Normal apical impulse
Displacement of apical impulse

Intensity and size of apical impulse
Inward impulse
Inspection- Apical impulse
[Q.3.Normal apical impulse.[IMP]

Location---in the left 5th intercostalspace
about 0.5 1.0 cm medial from the midclavicularline

Range ---no larger than 2.0 2.5 cm in diameter]
Displacement of apical impulse
Diaphragm
Mediastinum
Enlargement of the heart
Posture
Dextrocardia: 5-ICSRS
Inspection- Apical impuls- Displacement of apical impulse
Diaphragm
transverse position heart ---- upper;outward
Physiological factors: obesity;child;pregnacy
Pathological factors: massive ascites;huge tumor of abdominal cavity
vertical position heart ---- inferior;inner

Physiological factors: thin;high
Pathological factor: severe emphysema
Pulmonary
emphysema
8
Normal heart
[Q.4Mediastinum[MCQ]
one side pleural effusion or pneumothorax
---to the healthy side
one side atelectasis or pleural adhesion

---to the affected side]
gas
atelectasis
heart
pneumothorax
9
normal
Enlargement of the heart

right ventricular enlargement
left or slightly upper
left ventricular enlargement

left and inferior
LV & RV enlargement
left and inferior (both side dilatation)
10
Posture (Physiological factors)

Recumbent positionupper
Left lateral positionto the left 2-3cm
Right lateral positionto the right 1.0-2.5cm
11
Dextrocardia: 5-ICSRS
all signs described herein are located in the opposite hemithorax
mirror
A : normal heart
B : dextrocardia
12
Intensity and size of apical impulse

decrease
Physiological chest wall pachynsis
narrow intercostal space
pathological
myopathy (AMI, DCM)

pericardial effusion
constrictive pericarditis
emphysema
left side massive pleural
effusion or pneumothorax
increase
thin chest wall
broaden intercostal space
exercise ; excitation
LV hypertrophy
hyperthyroidism
fever
severe anemia
A feeble diffuse impulse ( more than 22.5cm in diameter) may suggest dilation
If the thrust is forcible, hypertrophy is suggested
13
Q,5.Inward impulse
Definition
Invagination of apical impulse when contract
Significance
adhesive pericarditis
prominent RV hypertrophy
14
Q.6THREE CONTENT OF
PALPATION
Palpation
Apical impulse and pulsation of

precardium
Thrill
Pericardial friction rub
Q.7Heaving apex
impulse[IMP]MCQ
---Definition Slow and forceful beat
in apex
lift finger tip often lasting up to the S2
---Significance: Sign of left ventricular
hypertrophy
Palpation -
Thrill
Definition:
Tiny vibrations felt by palm,somewhat similar

to the sensations on the throat of a purring cat
Mechanism: the flow of bloodnarrowed orifice
vorticesvibrationchest wall
thrill - high frequency
murmurs - low frequency
Significance: Signs of organic heart diseases
usually -- congenital heart disease
valvular stenosis
seldom -- valvular regurgitation
Key point: position
phase of cardiac cycle
clinical significance
17
Q.8Clinical significance of
thrill[MCQ FILLIN THE
BLANK
18
Location
phase
Disease
2 ICS-RS
2 ICS-LS
Systole
Systole
AS (RHD,CHD,senile)
PS (CHD)
3,4 ICS-LS
Systole
VSD (CHD)
Apex
Systole
MI (severe)
Apex
Diastole
MS (RHD)
2 ICS-LS
Continous
PDA[V.IMP]
Q.9Palpation - Pericardial friction rub
Seen:
acute pericarditis
Mechanism: rub of the visceral and parietal

layers of pericardial surface
Disappear: pericardial effusion

Position:
Phase:
precardium -4th ICS-LS[MCQ]

both phases of the cardiac cycle
Clearer: systolic period

sitting erect and leaning forward
the end of expiration
19
Q.1O.Percussion
---Aim: to determine the size and
shape of the heart
---Absolute dullness: contain no gas
Relative dullness : real size
20
Q.11Percussion
Contents of percussion
Method of percussion
Sequence of percussion
Normal border of relative cardiac dullness

Parts of cardiac border
Change and value of cardiac dullness
21
Q.12.Percussion- Method of percussion

Use mediate percussion
---patient in erect position
the pleximeter is vertical with the intercostal space
---patient in the recumbent position

the pleximeter is parallel with the intercostal space
22
Q,13Auscultation -- Auscultatory cardiac valve

areas .IMP
23
Mitral valve area

Pulmonary valve area
Aortic valve area
2 nd aortic valve area
Tricuspid valve area
(Apical area )
2 ICS-LS
2 ICS-RS
3rd ICS-LSErb area
4,5th ICS-LS
Pulmonic
valve area
Aortic valve
areas
2 nd aortic
valve area
Tricuspid
valve area
Mitral
valve area
Cardiac valve areas

24
Q.14Auscultation -- Contents
25
rate
rhythm
heart sound
extra heart sound
murmurs
pericardial friction sound
Auscultation Contents --
rhythm
Q.15.Cardiac rhythm
sinus arrythmia -- affected by breath
premature beat -- frequently 6 bpm
occasionally 6 bpm
bigeminy ; trigeminy
Q.16.[V.IMP]atrial fibrillation
absolute irregular rhythm
S1 intensity inequality
Pulse deficit
Pulse deficit : pulse rate is less than heart rate
26
Q.17heart sound-- 4 heart sounds.S3 AND S4 MECHANISM [IMP]
4 heart sounds
27
Q.18 Auscultation -- Order

Apical area
Pulmonary valve area
Aortic valve area
2 nd aortic valve area
Tricuspid valve area
MV---PV---AV1---AV2---TV
28
Normal adult apex beat is located

A. fourth intercostal space, the left medial
clavicular line 0.1 ~ 0.5cm
B. fifth intercostal space, left medial clavicular
line 0.5 ~ 1.0cm
C. fifth intercostal space, the right medial
D. fourth intercostal space, left medial
E. fifth intercostal space, the right medial
Normal adult range in diameter apex beat is

calculated as
A. 1.0 ~ 1.5cm
B. 1.5 ~ 2.0cm
C. 2.0 ~ 2.5cm
D. 2.5 ~ 3.0cm
E. None of the above
Apex beat exposition, the error is

A. pulsatile range of 1.0 ~ 1.5cm diameter
calculation
B. may be located within the fifth left
intercostal clavicle midline 0.5cm
C. can be located at the fourth intercostal
space
D. can be located in the sixth intercostal
E. posture, body position on the apex beat
influential
Displaced apex beat exposition, the error is

A. obese body who can be shifted to the apex
beat fourth intercostal
B. slender body who can move down apex beat
sixth intercostal
C. When the left ventricular apex beat under
increasing shift
D. When the right ventricle apex beat shifted to
the right
E. side of pleural adhesions, thickened, displaced
apex beat to the affected side
Precordial beat the error is

A. left sternal pulsating 3-4 intercostal seen in right
ventricular hypertrophy
B. xiphoid under pulsatile seen in right ventricular
hypertrophy, also found in abdominal aortic
aneurysm
C. 2nd intercostal space left sternal border systolic
pulsation seen in pulmonary hypertension
D. the right edge of the sternum second intercostal
systolic pulsation seen in aortic arch aneurysm
E. None of the above
Tremor discussion, the error is

A. systolic thrill at the apex touches found in two narrow
B. Where touches on clinical heart tremors may think organic
disease
C. palpation tremor noise can be heard in most parts
D. In the second intercostal sternum touches the right edge of
systolic thrill visible on the main narrow
E. In the second intercostal space left sternal border systolic thrill
touches found in pulmonary stenosis
Tremor discussion, the error is

A. systolic thrill at the apex touches found in two narrow
B. Where touches on clinical heart tremors may think
organic disease
C. palpation tremor noise can be heard in most parts
D. In the second intercostal sternum touches the right
edge of systolic thrill visible on the main narrow
E. In the second intercostal space left sternal border
systolic thrill touches found in pulmonary stenosis
Standard compatibility type questions

A. second intercostal space left sternal border systolic
thrill
B. left sternal border systolic thrill 3-4 intercostal
C. the second intercostal space left sternal continuity
tremor
D. apex diastolic tremor
E. sternum right edge of the second intercostal systolic
thrill
Aortic stenosis? Pulmonary stenosis?
Patent ductus arteriosus? Mitral stenosis?
ASCULTATION OF HEART
question
1 what do Extracardiac sounds include?
2 what are characteristics of heart murmur?
3 what are characteristics of heart murmur of
mitral stenosis(regurgitation) or aortic
stenosis(regurgitation) ?
4what is Austin Flint murmur?
5what is Graham Steell murmur?
1 what do Extracardiac sounds include?

B.Extracardic sounds In
A.Extracardiac sounds
diastolic period
in systolic period:
1.Early systolic ejection
sound
2) Middle and late
1.Gallop:
systolic clicks
2) Opening snap
3) Pericardial knock
Extracardiac sounds in systolic

period:
1) Early systolic ejection sound
Normal: presence
Abnormal : accentuate
Dilated great vessel, with

hypertention in it.
After S1, high in pitch.
PV
area:
PS
,
PH
inspiration, expiration
AV area: BP ,AS
2) Middle and late systolic clicks
In MVP
Valve, tandae chordea
redudent, floppy
Click: after S1, close to S2
best heard at apex
lower in pitch
Extracardic sounds In diastolic

period
1) Gallop:
Three or four sounds are
spaced to audibly
resemble the center of a
horse, the extra sounds
occurs after S2.
Protodiastolic gallop rhythm

S3 gallop, ventricular gallop rhythm.
S1 + S2 + pathologic S3
In early diastole, the blood

enters into ventricle from
atrium
in
failing
myocardium,
the
ventricular wall tension is
poor, produce vibration.
Reflex that the ventricular
function
Auscultation character of S3 gallop:
lower in pitch
After S2
Best heard at apex
S3 gallop: differ from normal S3
Occur in severe organic

heart disease
HR>100 bpm
The interval time between
S1 and S2 are almost
equal, mimicking quality,
normal S3 is nearer from S2
Normal S3 will disappear in
standing or sitting position
Late diastolic gallop

S4 gallop, atrium gallop
At late diastole, related to

atrial contraction.
when LVEDP compliance
Artial contraction
occur preceding S1, far from S2
low-pitch; best heard at apex
Tensity:
end
of
expiration(from LA)
end of inspiration (from
RA)
Occur in pressure overload,LVH,

in myocardial damaged ,and LV
compliance
such as BP, IHSS, CHD.
Summation gallop
Overlapping of S3G and S4G

while HR
2) Opening snap
In MS
In early diastole of LV, the
blood from LALV, the
opening MV suddenly
stopped make itself
vibration
After S2. Brief in duration.
High in pitch. Indicate a
flexible valve
3) Pericardial knock
In constrictive pericarditis
after
inflamation,
pericardial constricted,
the diastole of ventricle
was limited, produce the
vibration
of
ventrcular
wall.
0.1 after S2,
Loudest at apex.
Q.22 what are characteristics

of heart murmur?
Location:
Timing:
Quality
Radiation:
Intensity:
grading the intensity of heart murmur
PCG
3 what are characteristics

of heart murmur of mitral
stenosis(regurgitation) or
aortic
stenosis(regurgitation) ?
4what is Austin Flint
murmur?
1. Systolic murmur
1) MV area : produced by MI
Organic: RHD, MVP

Character: pan systolic
Harsh, Loud >3/6
Radiate to the left
axilla
Maneuver insp
exp
Relative murmur: Dilated LV

BP
Acute rheumatic
fever
Severe anemia
Character: soft, blowing,little radiation
Functional M:
Valve(-)
blood
flow faster
Fever
Anemia
Hyperthyroidism
2) AV areaAS
Organic: RHD
Character: Harsh, crescendodecrescendo,
radiateneck,
Thrill, S2
Relative:
Arteriosclerosis,
Dilation of aorta,
HP
2. Diastolic murmur
1) MV area
Organic: RHDMS
Apex, Mid-late diastolic
Rumbling, decrescendocrescendo
Thrill, S1, OS
Relative:
AI; Austin-Flint murmur

Pathophysiology : aortic regurgitation is often
associated with fluttering of the anterior leaflet
of the mitral valve , premature closure of the
mitral valve causingfunctionalmitral stenosis,
the abutment of the aortic regurgitant jet
against the trabeculated left ventricular
endocardium
The Murmur similar in pitch and timing to those
produced by organic disease of the mitral
valve Accentuation of S1 or P2 favors
organic mitral stenosis The opening snap of
the mitral valve is absent in Austin-Flint
murmur.
2) AV area AI rheumatic
decrescendo, sigh-like
best heard at aortic
second area
radiate to the left side of
the lower part of sternal
Q.6
Graham Steell
murmur
dilation of the pulmonic valve ring by

hypertension in the pulmonary circuit
quality and timing as the high-pitched
murmur of aortic regurgitation, less
loud , transmitted less widely,in the
second or third left interspace .
Heart Sounds P2 accentuated. A
Precordial thrust of the right ventricle.
Main symptom and sign of

common cardiovascular
diseases
question
1. The sign of mitral stenosis
2. The sign of Aortic Insufficiency
3. The sign of Pericardial Effusion
Q.1.The sign of mitral

stenosis
Inspection: Mitral Facies may be
present. The apical pulse may
extend to left side.
Palpation: diastolic thrill
(may be felt at apex)
Percussion: The cardiac dullness
extend to left in early stage and
later to right. The cardiac
silhouette is like a pear.
pear shape heart
Signs
Auscultation: Heart sounds
the first sound (S1) accentuated
The pulmonary second sound(S ) accentuated
2
and splitting
A mitral opening snap
(dispears when the mitral cusps rigid due to
calcification)
Signs
Auscultation: The murmur
1.diastolic murmur character

Location: at apex
Murmur property : a localized lowpitched rumbling diastolic murmur
Occur period : diastole (in the middiastole)
Heard best in the left lateral position
2.Graham Steels murmur (PA diastolic)
2.The sign of Aortic

Insufficiency
Inspection: Patients looks pale, the apical
impulse is diffuse and displaced
laterally or inferiorly.
Palpation: The apical impulse is displaced
laterally and inferiorly, lifting impulse
may be felt
(Heaving apex impulse)
Percussion:
The cardiac dullness is
enlarged laterally
and inferiorly
The cardiac waist is
decreased.
The cardiac silhouette
looks like a boot
Boot shape heart
Signs
Auscultation: The murmur
1)specific murmur:
Location and Occur period : aortic area or third
interspace left to sternum ,diastolic murmur
Murmur property : decrescendo sighing
The murmur transmitted to apex, and heard
clearly sitting erect and forward
2)Austin Flint murmur :relative MS (rumbling
eraly-mid diastolic murmur)
5 Signs V.IMP
Peripheral vascular signs

due to increased pulse pressure are as follow:
Moving of head with each heart beat
i.e. Musset sign
Carotid pulsation
Capillary pulsation
water hammer pulse
pistol shot sound and Duroziez dicrotic
murmur
(Femoral arteries or brachial artery )
3.The sign of Pericardial

Effusion
Inspection: The cardiac impulse decreases
or disappears. Jugular varicosity
Palpation: Apical pulsation reduce or
absent, with fast and small pulse,
paradoxical pulse may be present.
Percussion: Cardiac dullness is enlarged
bilaterally and changed with posture
flask shaped heart
Signs
Auscultation:
HR,diminution of intensity of cardiac
sound (S1/S2)
pericardial friction rub ( sometimes)
pericardial knock (occationally)
Ewarts sign is found.
Large effusion
Jugular varicosity
Liver enlargement
Paradoxical pulse
Pulse pressure
Kussmauls sign:
the filling of the jugular vein with inspiration
Ewart sign: VVV.IMP

Location: left infrascapular region
vocal fremitus--palpation
dullness -- percussion
bronchovesicular breath sound-- auscultation
the effusion is large enough to compress the left lower
lobe of the lung, causing consolidation or atelectasis
abdomen
Q,1The abdomen should be examined in the

following sequence:
inspection
auscultation
percussion
palpation
Q.2.Three signs help identify

ovarian cysts:
A. Careful
inspection of
the abdominal
profile reveals
two curves
instead of
one.
Three signs help identify ovarian cysts:
B. when a ruler is pressed transversely across

the abdomen, the pulsations of the
abdominal aorta are not transmitted with
free fluid. If the fluid is enclosed in a tight
cyst, the aortic pulsation will move the ruler
(the ruler test).
Tympanic sound
Tympanic sound
dulless
dullness
ovarian cyst
Ascites
C. In the supine position the

tympanitic intestines are pushed
superiorly, so the lower abdomen
Fluid wave
Either flank place one hand, tapping a flank
sharply with one hand then the other hand
receives an impulse.
Can detect ascites over 3000ml.
Abdomen hematochezia
hamatemesis consciousness
The level of consciousness is described in terms

of the patients apparent state of wakefulness
and response to stimuli.
1. Somnolence
Light degree of disorders of consciousness,
with an inability to sustain wakeful state, slow
arousal can be elicited by speaking to patient
or applying a tactile stimulus, and response
to spoken commands is correct, but the
patient is asleep again without stimulus.
2. Confusion
Being in deeper degree of disturbance of
consciousness than somnolence. The
patients keep simple mental functions,
but with disorientation
3. Stupor
Near to be unconscious. The patient can be
roused only by vigorous and repeated
stimuli, when left un-stimulated, quickly
drift back into a sleep-like state, and the
response to spoken commands is absent
and inadequate during arousal.
4. Coma
Serious disturbance of consciousness. The patient is

incapable of being aroused by external stimuli or inner
need. It can be divided into three stages:
(l) Mild coma or semicoma: Vigorous stimulation may
cause a stirring or moaning, reflexes are preserved,
ocular movements are obtainable.
( 2) Moderate coma: Vigorous stimuli may cause defensive
reactions, but the corneal reflex and papillary reflex
are decreased without rotation in eyeballs.
(3) Deep coma: Tone in limb muscles is diminished, no
reaction of all kind is obtainable, all reflexes are in
abeyance and vital signs are not stable.
5. Delirium
An acute confusional state is characterized
by increasing excitability. There is
manifest reduction in alertness and
psychomotor activity with disturbance of
orientation, with prominence of vivid
hallucinations and illusions and
veractivity, tremulousness, confused
language.
1.Repeated episodes of upper abdominal pain after

meals serving basic drugs can relieve tips
A.gastric ulcer
B.duedenal ulcer
C.esophagous ulcer
D.pancreatitis
E.chleccystitis
A
2.Women with sudden menupausal sudden

severe abdominal pain should first think
A.acute pylenephritis
B.liver rupture
C.rupture spleen
D.rupture of ectopic pregnancy
E.acute cystitis
D
3.Characteristics of appenendicitis
A.upper abdominal pain
B.tranfer of light lower abdominal pain
C.left lower abdominal pain
D.Right lower abdominal pain
E.abdominal pain
B
4.Epigastric pain and juandice were

visible at
A.peptic ulcer
B.pancreatic cancer
C.choleccystitis
D.pancreatitis
E.chronic gastritis
[B]
5.Repeated attacks of abdominal pain of empty stomach

or night pain,food or clothing basic drugs canrelieve
tips
A.choleccystitis
B.duodenal ulcer
C.gastric ulcer
D.pancreatitis
E.Hepatitis
[B]
6.Diagnosis of sudden xiphoid drill top

abdominal pain,most probably
A.intestinal ascariasis
B.cholelithiasis
C.Acute viral hepatitis
D.biliary ascariasis
E.cholecystitis
[D]
Female 65 years old,substernal burning pain in recent 3

years,often in postprandial lying motilium effectively
most probably
A.angina pectoris
B.pleurisy
C.gastric ulcer
D.duodenal ulcer
E.reflux esophangitis
[E]
8.Appear visible juandice ,bilirubin

,concentration in blood is
A.>1.7umol/L
B.>17.1 umol/L
C.>34.2umol/L
D.>68umol/L
E.>136umol/L
[C]
x.type.abdominal palpation content

inculeded
A.tenderness and rebounding pain
B.muscle tension
C.succesion
D.shiftng dullness
E.fluid thrill
[ABCE]
2.The following description about percussion of

abdomen which statement not true?
A.normal abdominal percussion are drum sound

B. A.normal abdominal percussion except
Spleen location ,more than for drum sound
C.gastrointestinal perforation expand absolute dullness
area
D. abdominal percussion drum sound including rash
sound .a sound
E.emphysema hepatic dullness
ACDE
Fill in the Blank

According to classification of etiology for juandice
A.hepatocellular juandice
B.cholestatic juandice
C.hemolytic icterus
C.congenital non hemolytic juandice
2.Pyloric over parts of hemorrhage not only

hasand..Below the pylorus
hemorrhage only
Hematemesis.
Melena.
melena
3.Acute diarrhea,acute onset course of disease

in.chronic diarrhea.
2 Weeks
More than 2 months
4.The most common cause of

haematemesis is
Peptic ulcer
Term.Haematemesis
Refer to patient vomiting because
upper gastrointestinal tract
[esophagous, stomach,duodenum,
jujanum after gastrojejunostomy,
Pancreas,biliary tract, ]
caused by acute hemorrhage
Q,50.Hematemesis, the vomiting of blood,

occurs after bleeding into the UGI tract-the esophagus,
stomach, or upper small bowel proximal to the ligament
of Treitz. Hematemesis may be bright red or darker as
a result of conversion of hemoglobin by gastric acid. It
is frequently associated with melena. Patients can
easily confuse it with hemoptysis ( coughing
up blood) , although the former is more common
2.diarrhea
Refers to increased frequency of
defecation,fecal matter thin or with
mucus,pus or undigested food.
Divided into acute and chronic
3.juandice
Since a serum bilirubin cause the
skin,mucous membrane and sclera
yellow signs and symtoms
4.Disturbance of
consciousness
Consciousness refers patient
unresponsive to things around
confusion or no response ,loss of
conciousness
.comlete loss of consciousness ,also
known as coma or unresponsive is
the most serious level of
consciousness
1.Peptic ulcer and acute perforation in patient with

abdominal any abnormal signs visual touch percussion
stethoscopy
1.isnpection.visual examination.plate belly

2.palpation.abdominal tenderness ,rebound
tenderness
3.percussion.hepatic dullness to shrink or
disappeard
4.auscultation.sound weaked or disappeard
Q.2Subregion
of the
Abdomen
Two systems have been used to describe

abdominal topography. One separates the
abdomen to four subregions, the other nine.
Most physicians prefer the former.
Nine
system
regions
The division into nine quadrants

by two horizontal lines and two
vertical lines
Hypochondrium
The upper horizontal line:

Through left and right costal
archs
The lower horizontal line:
Through left and right anterior superior
Iliac r.
iliac spine
Two vertical lines: two midclavicular
lines
Epigastrium
Hypochondriu
m
Lumbar
Lumbar
RegionUmbilical Region
Region
Hypogastrium
Iliac r.
1. Left Hypochondrium
2. Left Lumbar Region :
3. Left Iliac region:
4. Right Hypochondrium
5. Right Lumbar Region:
6. Right Iliac Region
7. Epigastrium:
8. Umbilical Region:
9. Hypogastrium
Subregion of the abdomen (Four regions)
the simpler division into

quadrants by an axial and a
transverse line through the
umbilicus
1.Right Upper
Quadrant RUQ
2.Right Lower
Quadrant RLQ
3.Left Upper
Quadrant LUQ
4.Left Lower
Quadrant LLQ
Q.3.HEMATOCHEZIA interegation
point
1.age,course of disease
2.etiology and incentives, such as whether there
are unclean diet,eating spicy food
history.where there is a history of
medication.blood in the
stool,color,character,relationship with
stool.estimation of the amount of blood in
the stool.the overall condition of the
patient.there is no fatigue,paLe
3.symptoms.there is no abdominal
pain,fever,tenesmus,abdominal
mass.mucocutaneous bleeding
4.after treatment .whether to check
occult
blood,colonoscopy,gastroscopy
5.in general
4.To describe the contents of liver

palpation
1.size
2.consistency
3.tenderness
4.pulsation
5.friction sound
6.liver thrill
Q.2The level of consciousness is described in

terms of the patients apparent state of
wakefulness and response to stimuli.
1. Somnolence
Light degree of disorders of consciousness,
with an inability to sustain wakeful state, slow
arousal can be elicited by speaking to patient
or applying a tactile stimulus, and response
to spoken commands is correct, but the
patient is asleep again without stimulus.
2. Confusion
Being in deeper degree of disturbance of
consciousness than somnolence. The
patients keep simple mental functions,
but with disorientation
3. Stupor
Near to be unconscious. The patient can be
roused only by vigorous and repeated
stimuli, when left un-stimulated, quickly
drift back into a sleep-like state, and the
response to spoken commands is absent
and inadequate during arousal.
4. Coma
Serious disturbance of consciousness. The patient is
incapable of being aroused by external stimuli or inner
need. It can be divided into three stages:
(l) Mild coma or semicoma: Vigorous stimulation may
cause a stirring or moaning, reflexes are preserved,
ocular movements are obtainable.
( 2) Moderate coma: Vigorous stimuli may cause defensive
reactions, but the corneal reflex and papillary reflex
are decreased without rotation in eyeballs.
(3) Deep coma: Tone in limb muscles is diminished, no
reaction of all kind is obtainable, all reflexes are in
abeyance and vital signs are not stable.
5. Delirium
An acute confusional state is characterized
by increasing excitability. There is
manifest reduction in alertness and
psychomotor activity with disturbance of
orientation, with prominence of vivid
hallucinations and illusions and
veractivity, tremulousness, confused
language.
Q. Gastroparesis
: can result from loss of

gastric tone following abdominal surgery or
inflammation, autonomic neuropathy as in
diabetes, vagotomy, or with chronic illness and
bed rest.
Inspection shows a greatly dilated stomach filling
the epigastrium, rarely reaching to the pelvis.
The mass is tympanitic and may have a
succussion splash.
Spine and nervous system
1.Kyphoscolosis as angulation in
adolescence are common
A.rachitis
B.rheumatid spondylytis
C.trauma
D.TB
E.prolapse of intervertebral disc
D
2.The common cause for gibus as

bending as
A.TB
B.rheumatid spondylytis
C.trauma
D. prolapse of intervertebral disc
E. rachitis
B
3.The largest and range activity of

spine
A.cervical and lumber
B.cervical and thoracic
C.only thoracic
D.lumber and sacral
A
4.Koilonychia causes are common

A.congenital heart disease
B.bronchiectasis
C.liver cirrhosis
D.iron deficiency anemia
E.lung abscess
D
5.Acropathy is commonb7nbthe
disease
A.bronchitic asthma
B.bronchodilation
C.chronic bronchitis
D.emphysema
E.myocardial infarction
B
6.Finger joint clostral form common in

disease
A.injury of ulnar nerve
B.progressive muscular atrophy
C.
D.rheumatid arthritis
E.Rheuma tid fever
D
7.Claw hand is common in disease

A. rheumatid arthritis
B.scerotin degeneration
C. Rheuma tid fever
D,Ulnar nerve injury
E.tenosynovitis
D
8.Floating patella test is checked

mainly
A.whether a patella was fractured
B.knee joint synovitis
C.articular cavity hydrops
D.knee jerk reflex
E.knee joint activity
C
9.Which combination is error

A.finger joint clostridial form-rheumatid
arthritis
B.clawhand-ulnar nerve injury
C.acromegaly-hypophysoma
D.elephanyiasis-lower extremity venous
thrombosis
E.floating patella phenomenon-knee auricular
cavity hydrops
D
1o.the cause of posture scoilosis are

A.false posture in the maturity of child hood
B.lower extremity is much shorter
C.prolapse of intervertebral cartilage
D.poliomylitic seqelae
ABCD
11.Lumbus sacro test positive lumber

intervertebral disc protrusion
A.pick up test
B.nerve stretching test
C.elevation test straight leg
D.rocking test
E.spurting sign
ABC
12.Abnormal gaits are caused by hip joint

disease are,.and
Lameness
Ducks step
dull
13.The common causes of organic scoliosis,

,..,.., and..
Congenital malnutrition
Muscular paralysis
Malnutrition
Chronic pachynsis pleura
adhesion of pleura
thoracocyllosis
15.The common deformities on feet are ..,

.,..,.and
Flat foot
Talipescavus
Equinus foot
Talipes calcaneus abnormalities
Cross foot pesvalgus
16.The common deformities of wrist

joint and wrist drop are
Ape palm
Claw hand
Fork deformity
Clubbed finger
koilonychia
17. Koilonychia is
A.nails concavity
B.Border cock nail thining
C.nail surface aspemy and clear cut
D.most seen in iron deficiency anaemia
E.less seen in rheumatic fever
ABCDE
18.Acropachy is common in the

disease
A.bronchiectasis
B.abscess of lung
C.cyanosis.congenital heart disease
D.subacute infection endocardium
E.malabsorption syndrome
ABCDE
19. Acropachy is
A.hyper plasia and hypertrophy at finger or toe
distal end
B.arch loss from foot to distal end of nail
C.nail surface asperity
D.common seen in lung abscess
E.single size acropachy is in subclavian artery
tumor
ABDE
2o.wrist joint paramorphia is seen in

A.tenosynovitis
B.ganglion cyst
C.epitenon fibrolipoma
D.inflammation and trauma of joint or soft
tissue
E.injury of ulnar nerve
ABCD
21.Unilateral edema legs can be seen

A.Thrombophebitis
B.limbs paralysis
C.blockage of lymph vessel
d.pressing outside veins
E.polyarteritis aorta
ABCD
22.CHARACTERS AND CLINICAL

SIGNIFICANCE OF KOILONYCHIA
Spoon nail is called koilonychias.

Characters is nails concavity
.Border cock nail thining
.nail surface aspemy and clear cut
.most seen in iron deficiency anaemia
.less seen in rheumatic fever and enychomyo
23.What is acropachy state clinical

significance
In this condition,the tips of the
bulbous,resembling the end the and
there is excessive curvature in all
Direction.the presence of clubbing finding
should prompt search for disease such as
1.pulmonary disease;lung abscess
bronchiectasis.and pulmonary
24.Tricep reflex contain

A.C 2,3
B.C 4,5
C.C5,7
D.C 7,8
E.C 5.T 1
D
25.Pathologic reflex is caused by

A.injury of spinal reflex arc
B.nervous system excitability
C.injury of basdal ganglia
D.injury of reticular formation of brain stem
E.impairment of pyramidal tracts
E
26.The typical manifestation of

ballinski sign positive
A.injury of spinal reflex arc
B.nervous system excitability
C.injury of basdal ganglia
D.injury of reticular formation of brain stem
E.impairment of pyramidal tracts
A
27.Shallow reflex include

Corneal reflex
Abdomen reflex
Cremastric reflex
Planter reflex
Anal reflex
28.Deep reflex include

A.Bicep jerk reflex
B.Radioperitoneal reflex
C.Knee jerk reflex
D.Achilles tendon reflex
E.planter reflex
ABCD
29.Sign of pyramidal tracts injury

A.abolition of one side abdominal reflex
B.tendon hyper reflexia
C.Babinski sign positive
D.neck rigiditry
E.lasegue sign positive
ABC
30.Meningeal irritation sign include

A.lasegue sign
B.kemig sign
C.brudzinski sign
D.neck rigidity
E.hoffiarin
BCD
31.Injury of ulnar nerve

A.acropachy
B.koilonychia
C.claw hand
D.finger joint fusiform shape
E.acromegaly
C
32.Infective endocarditis
A.acropachy
B.koilonychia
C.claw hand
E.acromegaly
A
33.Polyarthritis destrums
A.acropachy
B.koilonychia
C.claw hand
E.acromegaly
D
34.Adenolypophysis oncocytonia
A.acropachy
B.koilonychia
C.claw hand
E.acromegaly
E
35.Ischemic anemia
A.acropachy
B.koilonychia
C.claw hand
E.acromegaly
B
36.Feet sole flattened,central inside

touch the ground when erect
A.genu valgus
B.genu varum
C.pes varus
D.pes valgus
E.plate metatarsus and foot
E
41.Chronic adhesion of pleura and

increased thickness will induce
A.spine angular deformity

B.bowing deformity
C.hyperlordosis
D.posture scioliosis
E.organic scoliosis
E
42.Congenital posterior dislocation of

hip joint will induce

B.bowing deformity
C.hyperlordosis
E.organic scoliosis
C
43.TB of thoracic spine will induce

B.bowing deformity
C.hyperlordosis
E.organic scoliosis
A
44.Prolapsed disc will induce

B.bowing deformity
C.hyperlordosis
E.organic scoliosis
D
45.Rheumatid arthritis of spine will

induce
B.bowing deformity
C.hyperlordosis
E.organic scoliosis
B
46.Impairment of T 7-8 will induce

A.abolition of upper abdominal reflex
B. abolition of mid abdominal reflex
C. abolition of lateral abdominal reflex
D. abolition of bilateral abdominal reflex
E. abolition of one lateral abdominal reflex
A
47. Impairment of T 9-10 will induce

B
50.Acute abdomen will induce

D
51.Cremastric reflex
A.S 1,2
B.T 7,8
C.T 9,10
D.T 11,12
E.L 1,2
E
52. Abdominal reflex

A.S 1,2
B.T 7,8
C.T 9,10
D.T 11,12
E.L 1,3
B
53.Mid Abdominal reflex

A.S 1,2
B.T 7,8
C.T 9,10
D.T 11,12
E.L 1,4
C
54.Lower Abdominal reflex

A.S 1,2
B.T 7,8
C.T 9,10
D.T 11,12
E.L 1,5
D
55.Plantar reflex
A.S 1,2
B.T 7,8
C.T 9,10
D.T 11,12
E.L 1,5
A
56.Knee jerk reflex

A.C 5,6
B.L 2,4
C.S 1,2
D.C 5,6
E.C 7,8
B
57.Tendon reflex
A.C 5,6
B.L 2,4
C.S 1,2
D.C 5,6
E.C 7,9
C
58.Bicep reflex
A.C 5,6
B.L 2,4
C.S 1,2
D.C 5,6
E.C 7,8
D
59.Tricep reflex
A.C 5,6
B.L 2,4
C.S 1,2
D.C 5,6
E.C 7,11
E
60.Radioperotoneal reflex
A.C 5,6
B.L 2,4
C.S 1,2
D.C 5,6
E.C 7,12
A
62.Shallow reflex include

Corneal reflex
Abdomen reflex
Cremastric reflex
Planter reflex
Anal reflex
63.Deep reflex include

Bicep jerk reflex
Tricep jerk reflex
Radioperitoneal reflex
Knee jerk reflex
Achilles tendon reflex
Electrocardiogram (ECG)
lesson 2

Wangxu
Normal ECG
P wave
PR interval
QRS complex
ST segment
T wave
QT interval
U wave
Explain phrase
transition zone
The precordial lead where the R and S waves are of
approximately equal amplitude is referred to as the transition
zone.
electrical axis
the mean orientation of the QRS vector with reference to the
six frontal plane leads. Normally, the QRS axis ranges from
-30-90.
P pulmonale
A positive component of the P wave in lead V1 or V2>1.5mm.
Another criterion is a P wave amplitude in lead , and aVF
0.25mm.
P mitrale
A terminal negative wave>1mm deep and >40ms wide for lead
v1 and >40ms between the first(right) and second(left) atrial
components of the P wave in lead ,or a P wave
duration>110ms in lead.
(1) P
wave:
represents
atrial
depolarization
(2) P-R interval 0.12s0.20s
3.QRS complex: represents
ventricular depolarization
QRS Duration 0.12 sec
4) T wave: ventricles repolarization
Electrical axis deviation
means Left, means right

the positive one decides axis
deviation.
Left Ventricular
Hypertrophy(LVH)
SV1 + R V5 or Rv6 >35mm (adults
over 35);
Right Ventricular
Hypertrophy(RVH)
A. Increased voltage
R/S ratio in V1 1.0;
R wave in V1>7mm tall;
R/S ratio in V5 or V6 1.0;
s wave in V5 or V6 >7mm deep;
B. Right axis deviation >+900.
C. ST depression and T inversion in V1or v3 avF
2.
summary
Normal ECG: P wave, QRS complex, T
wave,
U wave, PR interval, QT interval, ST
segment,
R-R (P-P)
Mean QRS axis
Clockwise and counterclockwise
rotation
Normal value and shape:
l Amplitude of waves or segment: P,
QRS, T, U
and S-T
ECG
Myocardial
ischemia
zhangjing
Summary
1.MYOCARDIAL ISCHEMIA AND
CHANGES OF ST-T
1. ST segment depression :
2.ST segment elevation:
3.T wave tall positive:
4.T wave inversion:
2.transmural ischemia
Basic changes of t wave
Ischemic T Waves.
Tall peaked T waves, often appear as
the earliest ECG sign of acute MI.
Then inverted T wave
Injuried ST-segment Elevations.
The ST segment elevated
necrotic (Pathologic) Q Waves.
the sudden developed Q wave may
indicate an acute MI.
3.Myocardial infarction
(1) Basic changes
T Wave Changes.
Within
the
first
few
hours
of
infarction,giant upright T wave may be
seen in the leads overlying the infarct.
Later inverted T wave is inscribed
ST-segment Changes.
The ST segment elevations are always
inscribed in the leads overlying the
infarct zone during acute myocardial
infarction
The
Abnormal
Complex.
Waves
And
QS
The abnormal Q waves and QS complex in

leads overlying the infarct zone are
4.Localization of myocardial
infarction
By observing the above infarct patterns in specific leads of the
ECG,one can localize anatomically the site of the infarction
Leads with Abnormal Q Waves
MI
V1 V4
I, aVL, V5 V6
location of
Anterior
Lateral
V1 V 6
Extensive Anterior
II, III, aVF
V7V8V 9( R in V1 )
Inferior
posterior
(2)Time course and ECG Changes

of myocardial Infarction
Acute period. ST elevation ,pathologic Q
wave,
T
wave
upright
or
inverted(hours---weeks)
Subacute period (T Wave Changes). The
elevated ST segments returns to
the baseline, abnormal
Q wave
persists.inverted T waves is getting
deeper and deeper. Then T wave
inversion lessens.finally t wave
does not change. It may be either
upright
or
inverted(weeks--months)
Old
myocardial
infarct
:A
definitive
diagnosis of old myocardial infarct
If the Q wave did not meet

diagnostic creteria for
abnormal Q wave ,ST
segment elevation and T
wave changes in specific
leads we also believe that it
is abnormal Q wave,we can
give a dignosis of
myocardial infarction
according to it
Differential diagnosis
1. Q-wave or non-Q-wave infarction
Necrosis of sufficient myocardial tissue may lead to
decrease R-wave amplitude or frank abnormal Q
waves in the anteroir or inferior
leads.previously,abnormal Q wave were considered
to be markers of transmural myocardial
infarction,while subendocardial infarcts were
thought not to produce Q waves.
1. Q-wave or non-Q-wave infarction
however, careful ECG-pathology correlative studies have
indicated that transmural infarcts may occur
without Q waves and that subendocardial infarcts
may sometimes be associated with Q
waves.therefore,infarcts are more appropriately
classified as Q-wave or non-Q-wave
5.abnormal Q wave
Physiologic or positional variants,ventricular
hypertrophy,hypertrophic cardiomyopathy
LUNGS
1.Collection of free air in the chest cavity

(thoracic cavity) that causes the
lung to collapse is hemothorax
2.Hyperresonance or tympany in the
upper part of the thorax, with
dullness inferiorly suggest
hydropneumothorax
3.Whispered pectoriloquy and

bronchophony are produced by
consolidation
4. CNS-depressant druges cannot
increase respiratory rate
1At rest, the normal respiratory rate in

adults per minute is between 12 to
20 cycle
2.Decreased oxygen delivery as a result
of severe anemia or hemorrhage
also leads to hyperpnea
6. Percussion affected factors contain:

thickness of thoracic
wall;;containing gas in
alveoli;calcification of costal
cartilage;hydrothorax ;alveolar
tesion.
7. Abnormal breath sounds include
:asthmatic or obstructive sounds;
amphoric breathing;
metamorphosing breathing
Normal Shifting range of bottom of

lung(cm):6-8
8.Vocal fremitus is increased in massive
consolidation
Hyperresonance can be heard during the

percussion of emphysema
9.A one way tissue valve permits

air to be forced into pleural
space during inspiration
and prevents its expulsion
during expiration is called
tension pneumothorax
10.Obstructive sleep apnea results from

obstruction of the extra thoracic
airway caused by relaxation of the
pharyngeal muscles and tongue
with persistence of ineffective
inspiratory efforts and terminating
with loud snort or snore.
11.On auscultation, adventitious sound
include
wheezes, rales and rhonchus.
12.Respiratory system examination

includes Inspection, palpation,
percussion and auscultation.
Egophony is a form of bronchophony in
which the spoken Eee is changed
to Ay which has a peculiar nasal
or bleating quality
tension pneumothorax:A one-way tissue

value permits air to be forced into the
pleural space during inspiration and
prevent its expulsion during expiration.
thus, the pressure in the cavity builds
up in excess of the atmosphere.
Pleural friction rub occur when inflamed,
unlubricated surfaces of pleurae rub
together during respiration. They are
characterized as the creaking of new
leather.
crackles result from the opening and

closing of alveoli and small airways
during respiration. It is produced
by air bubbling through fluid in the
distal small airways.
how many types of pneumothorax
Answer- Closed pneumothorax ; open
pneumothorax ; tension
pneumothorax ;
hydropneumothorax
What are the location and characteristics of

Bronchovesicular breath sound
Bronchovesicula breath sounds are
characterized by the two respiratory
phases are about equal in duration,
although expiration is frequently a bit
longer.
Location They are heard normally 1st, 2nd
intercostal space beside of sternum,
the level of 3rd, 4th thoracic vertebra
in interscaplar area, apex of lung.
What will you find in physical examination in patient with pleural

effusion?
Answer-
Inspection: Decreased chest wall motion (on affected

side)
Palpation: Decreased chest wall motion, decreased
tactile fremitus (on affected side); trachea pushed
to the opposite side and bulging of the intercostal
spaces.
Percussion: Stony dullness on percussion (affected
side)
Auscultation: Decreased breath sound (on affected
side).
What will be revealed in patients with the right

side tension pneumothorax by lung
examination?
Inspection: decreased breathing motion and
depth (affected side)
Palpation: decreased breathing motion, decreased
tactile fremitus (affected side); contralateral
shift of the trachea and bulging of the
intercostal spaces.
Percussion: flatness to percussion (affected side)
Auscultation: diminution of breath sounds over
the pneumothorax;
What are crackles

classified according to diameter
of the airway
Answer- Coarse; Medium; Fine; Crepitus
2.. classification of auscultation of
adventitious and abnormal voice
sound?
Adventitious sound areWheezes;Rhonchi ;Crackles or
rales
What are the types of abnormal voice sounds? Explain.

AnswerBronchophony: Normally, the spoken syllables are
indistinctly heard in the lungs. In the presence of
pulmonary consolidation, syllables are heard distinctly
and sound very close to the ear.
Egophony: This is a form of bronchophony in which the
spoken Eee is changed to Ay which has a
peculiar nasal or bleating quality.
Whispered pectoriloquy: Pulmonary consolidation transmits
whispered syllables distinctly, even when the
pathologic process is too small to produce bronchial
breathing. This sign is particularly valuable in
detecting early pneumonia, infarction and pulmonary
atelectasis
3.The symptoms and signs of bronchial

asthma?
Symptom, Expiratory dyspnea with wheezing
Signs. Expiratory dyspnea with wheezing
Orthopnea
Cyanosis
Severe sweat
Decreased movement of respiration
Decreased vocal fremitus
Hyperresonance
Rhonchi in full fields of lungs
1,.How to do the Percussion and auscultation?

Technique of Percussion
Bimanual
Mediate
Pleximeter: distal interphalangeal joint of left middle finger
Plexor: right middle finger tip
(The examiner holds the plexor finger partly flexed and rigid and delivers
the blow by bending only the wrist, so the weight of the hand lends
momentum ensuring repetitive blows of equal force. The wrist must
be relaxed and neither the elbow nor the shoulder should be moved.
After the stroke, the plexor should rebound quickly from the
pleximeter to avoid damping the vibrations. Usually, two or three
staccato blows are struck in one place, and then the pleximeter is
moved elsewhere for a second series of blows to compare the
sounds)
Immediate
striking the body surface directly with finger hand or reflex hammer the
procedure is called direct or immediate percussion.
auscultation
Seek a quiet room, which should be warm to eliminate
shivering as a cause of muscle sounds. Preferably,
have the patient sit.
Demonstrate how you wish the patient to breathe through the
mouth, deeper and slightly more forcefully than usual.
Start listening with the stethoscope diaphragm anteriorly at
the apices and work downward, comparing symmetrical
points sequentially. Then listen to the back, starting at
the apices and working downward.
At all points on the chest, identify the breath sounds, whether
vesicular, bronchovesicular, bronchial, asthmatic,
cavernous, or absent, by their quality and pitch.
Normal breath sound

Tracheal breath sound
Bronchial breath sound
Larynx, suprasternal fossa, around 6th, 7th
cervical vertebra, 1st, 2nd thoracic vertebra
Bronchovesicular breath sound
1st, 2nd intercostal space beside of sternum, the
level of 3rd, 4th thoracic vertebra in
interscaplar area, apex of lung
Vesicular breath sound
Most area of lungs
Write in short about physical examination of respiratory

system?
The Physical examination in respiratory system can be
divided into 4 different stages:InspectionObserves the patient's respiratory rate and signs of
respiratory distress which include:
Cyanosis;Pursed-lip breathing;Chest wall movement equal or
not;Accessory muscle use including the scalene and
intercostal muscles.Intercostal indrawing.Decreased
chest movement on the affected side.An increased
Jugular venous pressure indicating possible right heart
failure.Chest wall abnormalities. Example, Kyphosis,
Scoliosis
Tracheal deviation is also examined.
PalpationTracheal deviation, whether trachea is in

centered or not, indicating
enlargement or collapse of a lung
field.Respiratory expansion
indicating whether lung expansion
is equal or not.Tactile fremituspatient asked to say ninety-nine,
use ulnar aspect of the hand to feel
the changes in sound conduction.
PercussionPercussion is performed with the middle finger

striking the middle phalanx of the other
middle finger of the other hand. The sides
of the chest are compared. This is
performed symmetrically on all lung fields,
on the anterior, posterior and axillary
chest walls.
Dullness indicates consolidation.
Stony dullness indicates pleural effusion,
mass.Hyper-resonance suggests a
pneumothorax
AuscultationAuscultates the respiratory sounds over

the lung fields through a
stethoscope. While patient is
breathing, note normal breath
sounds and any abnormalities
breath sound. Adventitious sound
are- Wheezes;Rhonchi ;Crackles or
rales.
MIDTERM
Q.1Diarrhea
Conception
Diarrhea means increase in the frequency of

bowel movements and increase m stool
liquidity and in some cases, increase in
daily stool weight ( >200 g/d). Duration of
diarrhea less than 2 weeks is acute
diarrhea. Chronic diarrhea refer to
diarrhea with the duration exceeding 2
months.
Q.1.Pathlogy and sort of

infective fever or causes
of
infective
fever
Infective fever-------most common cause
bacterial
viral
rickettsial
fungal
para sitic
Q.3.Patterns of fever
Continuous fever
Remittent fever
Intermittent fever
Undulant fever
Relapsing fever
Episodic fever
Pel-Epstein fever
Continuous fever
temperature: 39-40 ,days or weeks;diurnal variation 0.5-1.0
disease: typhoid,acute pneumonia

diurnal temperature variation is a meteorological term that relates
to the variation in temperature that occurs from the highs
and lows during the day.
Remittent fever
temperatrue 38 , diurnal variation

2 no normal temerature
disease:sapraemia,acute rheumatic fever,
acute infectious endocarditis
Intermittent fever
suddenly reach climax,continue several
hours, suddenly fall to normal,
intermission 1-several days
disease:malaria, acute pyelonephritis
Undulant fever
slowly reach 39 ,slowly return to
normal. (repeate the rhythm)
disease:brucellosis,tumor
Relapsing fever
suddenly reach 39 , continue several
days,suddenly drop to normal. bout
every 5-7days
disease:spirochetes infection
Episodic fever
last for days or longer,then without fever for

at least 2 weeks
disease:familial periodic fever
Pel-Epstein fever
continuous or remittent fever boust several
days
disease:Hodgkin disease
Q.5mcq
GRADES OF FEVER
Grade
(oral reading)
low-grade fever:37.3-38
middle-grade fever:38.1-39
high-grade fever:39.1-41
hyperthemia: 41
Q.6mcq
1 normal rang: 36-37
2 higher: late afternoon,evening
maximum 8:00-10:00 pm
lower: morning
minimum 3:00-4:00 am
3measure pathway
rectum (higher 0.3-0.5)
mouth
axilia (lower 0.2-0.4)
Q.7FUOfever of unknown
origin
Diagnosis criteria:
mcq
the illness last at least 3 weeks;
38.3 repeatedly;
no diagnosis after 1 week hospitalization

Causes:
noninfectious inflammatory disease;
infections;
malignancies(hematologic);
50% unexplained[episodic fever
Q.8.TYPES OF EDEMA
Localized edema
.Generalized edema:
Edema
Clinical
occurrence
.Q.9.Localized edema
cause:local vein or lymphatic return

disturbance or capillary permeability
disease:Inflammation infection
insufficency of the venous valves
chemical or physical injuries
arteriovenous fistulas
site:above the diaphragm--superior

vena cava obstruction
below the diaphragmjugular venous
press ,portal vein hypertension,loss of
venous tone drugs
.Q.10.TYPES OF Generalized edema:
cardic edema
renal edema
hepatic edema
nutritional edema(protein losing conditions)
drug(corticosteroid,NSAID)
Q.11Cardic edema
DIFFERENCE BETWEEN
Symptoms:chest distress,short breath,dyspnea
Site:lower limbs
Disease right heart failure
Dyspnea: Difficult or labored breathing;
shortness of breath. Dyspnea is a sign of
serious disease of the airway, lungs, or hear
Q.12renal edema
Symptoms hematuria proteinuria
Site: eyelid legs
Disease: nephrotic syndrome
hematuria, or haematuria, is the presence of
red blood cells (erythrocytes) in the urine.
Proteinuria) means the presence of an excess
of serum proteins in the urine.
Q.13hepatic edema
Symptoms: anorexia,vomitting,liver function
test abnormal
Site: first lower limbs,then spread all over the
body, ascites is most common
Disease cirrhosis,chronic liver disease
Q.15.Browny edema:
chronic edema of the legs leads to
fibrosis of the subcutaneous tissues
and skin,so they no longer pit on
pressure.
Hematuria
Q.16Type or kind of hematuria
microscopic hematuria
defined as 4 erythrocytes per high-powered field on a spun
urine specimen occult blood
gross hematuria
bloody urine ,indicates sufficient red blood cells to discolor
the urine (1ml blood/1L urine)
Q.17Causes of glumerular
hematuria
diastrophic erythrocyturia---glomerular
hematuria
glomerular disease: acute glomerulonephritis,
nephrotic syndrome,
hematuria
4.Urinary system disease
diastrophic erythrocyturia---glomerular hematuria
glomerular disease: acute glomerulonephritis, nephrotic
syndrome,
orthomorphic erythrocyturia---non-glomerular hematuria
non-renal source: infarct/papillary necrosis, trauma , pyelitis,
stones, renal tumours/ infection/tuberculosis,
kidney injury of drugs
(e.g.,sulfonsmides, nonsteroidal, antiinflammatory drug or
mannitol),
renal infarction.
post renal: Ureteric/bladder stone; ureteric /bladder/
prostate cancers;
Q.20VOLUME OF URINE
oliguria <400ml /d
anuria <100ml/d
polyuria>2500ml /d
Q.21
Specific gravity1.015-1.025
Urine PH. 6.5
proteinuria>150mg/24hr
10cm in length
5cm in width
4cm in thickness
134 ~ 148g in
weight
Q.23Common symptoms OF
RESPIRATORY SYSTEM
Cough
Expectoration
Hemoptysis
Chest pain
Dyspnea
Cyanosis
263
Q.24 Cough
A cough is a sudden, forceful, noisy
expulsion of air from the lungs.
It is a protective reflex but excessive
coughing is harmful to humans body.
264
Expectoration
Q.30The attributes of
sputum
Bloody Sputum (Hemoptysis,next class )

Bloody gelatinous sputum
Rusty Sputum
Purulent Sputum
Stringy Mucoid Sputum
Frothy Sputum
Broncholiths
265
Bloody gelatinous sputum

Currant-jelly sputum
Copious quantities of tenacious ,bloody
sputum are almost pathognomonic for pneumonia
caused by klebsiella pneumoniae or streptococcus
pneumoniae
266
Rusty Sputum ( Prune-juice Sputum)

Purulent sputum containing changed blood pigment is typical of pneumococcal pneumonia but it
is frequently preceded by small amounts of frank blood.
Stringy Mucoid Sputum

Increased mucous production and formation of mucous plugs occur in asthma; during resolution
of an acute attack, retained mucous is mobilized.
Frothy Sputum ( Pulmonary Edema)

Fluid from the pulmonary capillaries enters the alveoli and is expectorated. A thin secretion
containing air bubbles, frequently colored with hemoglobin , is typical of pulmonary edema. Both
acute lung injury and left ventricular failure produce this sign.
267
Purulent Sputum
Inflammatory cells, predominately polymorphonuclear leukocytes, enter the airways and
alveoli in response to lower airway infection.
Colour:yellow (general bacterial), green (aeruginosus Bacillus), or Grey or black (dust inhalation).
Amounts:Small amounts acute bronchitis, pneumonia during resolution, small tuberculous

cavities or lung abscess. Copious purulent sputum suggests lung abscess, bronchiectasis, or
bronchopleural fistula communicating with an empyema. Many lung abscesses do not yield
much sputum because their bronchial communications are inadequate for complete drainage
Odor :Fetid sputum suggests anaerobic infection and/or lung abscess.
Bronchiectasis:200 to 500 ml/d. On standing, bronchiectatic sputum typically separates into three
layers,with mucus on top separated by clear fluid from pus on the bottom. (or upper: frothy,
middle: serofluid or serofluid pus,lower: necrosis substance)
bronchopleural fistula :Copious sputum from a patient with signs of pleural effusion suggests
268
Q.31 CONCEPT.Broncholiths
Occasionally, calcified particles are found in the sputum
either by the patient or the physician. These are usually
broncholiths, derived from calcified lymph nodes eroding
the bronchi or from calcareous granulomas in silicosis,
tuberculosis, or histoplasmosis. Their discovery may
explain the source of pulmonary hemorrhage
269
Q.32Hemoptysis
Definition: Spitting or coughing of blood is
hemoptysis.
The blooding region: anywhere from the nose to the
lungs .
The amount varies from blood-strained sputum to several

hundreds ml pure blood
Mild: 100ml/d
Moderate: 100-500ml/d
Severe: >500ml/d, or 100-500/time

270
Q.34.Distinguished hemoptysis from

hematemesis
Hemoptysis
Hematemesis
Causes
Pulmo or cardiac
digestive system
Previous symptoms
Cough, chest tightness
Nausea, vomiting
Spit up
Cough up
Vomited
Color
Bright red
Dark red
Mixture
Sputum, frothy
Gastric contents
pH
alkalinity
acidity
Tarry stools
Negative/ positive
positive
Post-bleeding
Sputum with blood
No sputum
271
Q.36.TYPES OF Bloody
Sputum
Blood in the sputum usually impresses patients enough to
bring them to the physician. The first problem is to
identify the anatomic site of hemorrhage.
Blood-Streaked Sputum is usually caused by inflammation in
the nose, nasopharynx, gums, larynx, or bronchi.
Sometimes it occurs only after severe paroxysms of
coughing and may be attributed to trauma.
Pink Sputum usually results from blood mixing with secretions
in the alveoli or smaller bronchioles; it most frequently
occurs in pneumonia or pulmonary edema.
272
Massive bleeding occurs with erosion of a bronchial

artery by cavitary pulmonary tuberculosis,
aspergilloma, lung abscess, bronchiectasis,
pulmonary infarction, pulmonary embolism,
bronchogenic carcinoma or a broncholith.
Goodpasture syndrome Alveolar Hemorrhage, does
not produce bloody sputum in all cases.
mitral stenosis. Not infrequently,frank bleeding from
the lungs occurs in
273
39.Nausea
A sensation of upper abdominal discomfort and
urge to vomit. May be associated with
the symptoms of vagus nerve excitation:
such as pale skin, sweating , salivation ,
hypotension and bradycardia.
Nausea, upper abdominal discomfort and urgency Yu Tu feeling. May be accompanied by

vagus nerve symptoms such as pale skin, sweating, salivation, hypotension and bradycardia,
vomiting often a prelude
40.Vomiting
Vomiting is a phenomenon which forces the
contents in stomach or part of small
intestine excreting through a strong
contraction of the stomach from the
esophagus and mouth.
Vomiting is forcing part of the stomach or small intestine by a strong contraction of the stomach contents
through the esophagus, mouth and excreted phenomenon.
Q.41 Nausea an
vomiting
I Etiology
Q.1
1.Reflexe vomiting
1)Irritation of pharynx: Smoking, severe cough

2)Gastroduodenal diseases: pyloric obstruction
3)Itestinal diseases: Acute appendicitis
4) Hepatic, biliary and pancreatic diseases: Acute
hepatitis, liver cirrhosis, hepatic congestion, acute and chronic cholecystitis,

pancreatitis and so on.
5) Diseases of peritoneum and mesentery: acute

peritonitis
6) Systemic diseases: Nephrolithiasis rupture of ectopic

pregnancy heart failure
Q.2
1)
2)
3)
4)
2. Central vomiting
(1) Diseases of nervous system

Encephalic inflammation, all kinds of cephalitis and
meningitis
Cerebral vascular disease such as cerebral hemorrage,
cerebral thrombosis
Skull and intracranial injury : Brain contusion or
intracranial hematoma
Epilepsies, especially status epilepticus.
(2) Systemic diseases: hepatic encephalopathy, DKA and
hypoglycemia
(3) Drugs: Such as digitalis and morphia
(4) Intoxication: Such as alcohol, heavy metals, carbon
monoxide,
(5) Mental Factors: gastrointestinal neurosis, hysteria, anorexia
Q.42
II
Pathogenesis
Q.43Vomiting is a complicated reflex including three stages:

1.nausea,2. vomiturition and 3.vomiting.
In the stage of nausea, tensility and peristajsis of stomsch
decrease, while tensility of duodenum increases with or
without reflux of duodenal fluid.
In the stage of vomiturition, the upper part of stomach relaxes
with transient contraction of gastric antrum
. In the stage of vomiting, the abdominal muscles tighten
against a relaxed stomach with an open sphincter. The
contents of the stomach are propelled up and out.
Vomiting is different from countercurrent regurgitation, in
which the contents of Lhe stomach reflow up through the
esopbagus and out of the mouth withoui nausea and
conuaction
of diaphragrn.
Q.44Mcq.CTZ & Vomiting center)

Vomiting center Side of the net structure outside the medulla oblongata
back test Accept the cerebral cortex, digestive, cardiovascular and
chemoreceptor trigger zone (CTZ)
CTZchemoreceptor trigger zone The fourth ventricle floor

Exogenous or endogenous chemicals Opioid morphine
digitalis metabolites
The center of vomiting is located in the medulla which

consists of two parts with different function. One is
neural reflex center-vomiting center, which is located
in the lateral medullary reticular formation in the
medulla. The other is chemoreceptor trigger zone at
the base of the fourth ventricle of the brain The
vomiting center receives afferent impulses from
digestive tract, pallium, inner ear vestibule, coronary
artery and chemoreceptor trigger zone, and executes
the vomiting action directly. The chemoreceptor
trigger zone has numerous dopamine D2 receptors,
serotonin 5-HT3 receptors, opioid receptors,
scetylcholine receptors, alnd receptors for substance
P. Stimulation of different receptors is involved
, in
different
pathways leading to vomiting.
,
( ) (
)
Clinical
Manifestation
of
Q.45
vomiting
1. The time of vomiting
2. The relationship with eating
3. The features of vomiting
4. Character of vomitus
1. The time of vomiting

Vomiting which occurs upon waking is often
induced by moming sickness, uremia,
chronic alcoholism, functional dyspepsia
or sinusitis. If the vomiting occurs at
night, the common cause is pyloric
obstruction.
2. The relationship with

eating
The vomiting occurs some time after dinner is
always caused by food poisoning,
especially for the collective patients.
Vomiting just after dinner may be
neuropathic vomiting. Lingering vomiting
(deferred vomiting) is defined as the
vomiting which occurs more than 1h after
dinner, which indicates decline of gastric
tensility. Vomiting after several meals is
often caused by pyloric obstruction .
3. The features of vomiting

Neuropathic or ICP vomiting are lack of nausea.
Projectile vomiting always indicates ICP.
4. Character of vomitus
The barmy or septic smell indicates retention of gastric juice and
food. Feculent vomitus occurs with lower intestinal
obstructive lesions. when the vomitus contains bile it
suggests the obstruction is located under duodenal papilla.
If the vomitus contains no bile it suggests the obstruction
is located upon the duodenal papilla. Vomitus with plenty of
acid fluid indicates duodenal ulcer or gastrinoma. Vomitus
without acid fluid is always due to cardia stenosis.
Obstruction of upper digestive tract can be determined
according to the quantity of vomitus, and the amount of
liquid loss can be estimated.
Q.46
Abdominal pain
Pathogenesis
1.Visceral pain
2. Somatic pain
3. Referred pain
1.Visceral pain
The pain results from stimulation of autonomic nerves
in the visceral peritoneum which surrounds
internal organs. The signal may be transferred to
the spinal cord via the sympathetic route.
Clinical presentations of visceral pain:
pain is poorly localized; intermittent, cramp or colicky
pain; accompanied by symptoms of vagal
excitation, such as nausea, vomitting and
diaphoresis.
2. Somatic pain
Stimuli occur with irritation of pariet&l
peritoneum, and sensations conducted
along peripheral nerves which can localize
pain better.
Clinical presentation of somatic pain: precisely
localized pain; pain described as intense,
constant; with local guarding or rigidity;
getting worse after coughing; or position
changes; may be caused by infection,
chemical irritation, or other inflammatory
3. Referred pain
Pain felt at a distance from iLs source The
diffuse pain arising from abdominal
visceral structures tends to be projected
to a more superficial region with the same
segmental innervation.
(3) Quality: Duodenal ulcer is related to hunger; liver cancer is

with persistent pain.
Characteristics of intestinal colic, biliary colic and renal colic
type
location
other manifestation
intestinal penumbilica, infraumbilical

vomiting, nausea, diarrhea, biliary
upper quadrant
jaundice, fever, Murphy's sign
renal
radiates to genitalia, groin
changes in urine testhematuria
right
Q,47juandice, also known as icterus, is yellowish

discoloration of the skin, sclerae and mucous membranes
caused by hyperbilirubinemia ( increased levels of
bilirubin in the blood). This hyperbilirubinemia
subsequently causes increased levels of bilirubin in the
extracellular fluids. Typically, the concentration of bilirubin
in the plasma must exceed 1.5 mg/dL, three times the
usual value of approximately 0.5mg/dL, for the coloration
to be easily visible.
Q.48Causes of juandice
Jaundice occurs when there is:

too much bilirubin being produced for the liver to remove
from the blood ( For example, patients with hemolytic anemia
have an abnormally rapid race of destruction of their red blood
cells that releases large amounts of bilirubin into the blood) ;
a defect in the liver that prevents bilirubin from being
removed from the blood, converted to bilirubin/glucuronic acid
(conjugated) or secreted in bile; or
blockage of the bile ducts that decreases the flow of bile and
bilirubin from the liver into the intestines. For example, the bile
ducts can be blocked by cancers, gallstones, or inflammation of
the bile ducts.
Q.49.Horner Syndrome or
unilateral miosis
Interruption of the cervical sympathetic chain
interrupts sym-pathetic innervation of the
eye and face
Accompanied by ptosis and anhydrosis on
affected side
Q,50.Hematemesis, the vomiting of blood,

occurs after bleeding into the UGI tract-the esophagus,
stomach, or upper small bowel proximal to the ligament
of Treitz. Hematemesis may be bright red or darker as
a result of conversion of hemoglobin by gastric acid. It
is frequently associated with melena. Patients can
easily confuse it with hemoptysis ( coughing
up blood) , although the former is more common
Q.51What is physical
examination?
It is a fundamental examining method,
proceeded by the sense organs such
as eyes, ears, nose and hands or
simple tools stethoscope and plexor.
1Inspection(sight and smell)

2Palpation (touch)
3Percussion (touch and hearing)
4Auscultation (hearing)
5Smell
1The methods of deep palpation and bimanual

palpation
2the method of indirect percussion
3The diagnostic significance of patients
excretion
Q;1The methods of deep

palpation and bimanual
palpation
Deep palpation
Suitable for: abdomen change and
neck, breasts,large muscle masses
depth :2 cm
Methods: deep slipping palpation
deep press palpation
ballottement
deep press palpation---tenderness pointy

one or two finger draw to each other, deep press on the point little by little
when examine the rebound tenderness,on the basis of deep press for a moment, uplift the hands
suddenly.To inqury the change of pain.
Cholecystic point Murphys sign

---acute cholecystitis
Appendix point McBurney point
---acute appendicitis
rebound tenderness
---acute
peritonitis
Ballottement with massive ascites

---liver
enlargement splenomegaly
Adducted three finger 70-90angle on the surface of abdomen for several
quick and powerful strike
Bimanual palpation
Suitable for: liver, spleen, kidney,

Methods: put left palm on the back of
the organ, then hold to the right hand to
make the organ between two hands.
bimanual palpation--liver and

spleen
2the method of indirect

percussion
indirect percussion
Methods
(1)press the palmar surface of the left long finger firmly
onto the body surface as a pleximeter, only the
distal phalanx should touch the wall, other fingers
slightly uplift.
the tip of the right long
finger strike a sharp blow on the distal
interphalangeal joint of the pleximeter as a plexor .
Indirect percussion
(2)The examiner holds the plexor finger flexed and

rigid and delivers the blow by bending only the
wrist;
the elbow and shoulder should not
move.
(3)After the stroke ,the plexor rebound quickly from
the pleximeter
(4)Struck two or three staccato blows in one place.
Suitable for: thorax , abdomen

Notices: environment is quiet
proper position
compare symmetrical site
change of percussion sound
proper strength
heart : vertical/ parallel intercostal space
Q.52percussion sound
VIP
also mcq
Resonance: airfilled lung (normal lung)

Dullness: percussion over the heart
when it is covered by lung
Tympany: percussion the gastric air
bubble
Flatness: percussion the heart/ liver
Hyperresonance: emphysematous lung
3The diagnostic significance

of patients excretion
smell
Definition: the act by judging the relationship
between abnormal smell
and disease.
Source of smell: breath,sputum,vomitus
feces, urine,pus
Sour smell of fermenting food retained

overlong from the vomitus --- pylorus
obstruction
A pungent odor of garlic on the breath --organic phosphorous poisoning
A sweet odor of rotting apples ---diabetic
ketoacidosis
Foul sputum --- bronchiectasis, lung
abscess
2.What are the features of

cardiac ischemia pain ?
Cardiac ischemia pain :
a dull,crushing retrosternal pain, often
radiating to the jaw or arms, building up
over a few minutes and may brought on
by exercise, emotion, or cold weather,
resolving on resting or with glyceryl
trinitrate(GTN).
1.the common causes of

chest pain [may be] not
( 1 ) Ask the location of the pain, confirmed
accepting the location of the pain as indicating
only that the source is somew-here in the six-dermatome band (the

myocardium, peric-ardium, aorta, pulmonary artery, mediastinum,
esopha-gus, gallbladder, pancreas, duodenum, stomach, or subphrenic
region).
(2) Ask the patient to state the intensity of the pain on a scale of 1 to 10.
(3) Shorten the list of possibilities by carefully searching for provocativepalliative factors and timing.
(4) Make appropriate tests to distinguish between the disorders on the
shortened list.
2.the common causes of

dyspnea
Cause
s
Respiratory system
Obstruction: asthma, COPD, tumor

Pulmo Diseases: pneumonia,
interstitial lung disease,
Chest wall or pleural disorders:
pleurisy, pneumothorax, trauma
neuro-muscles disorders : poliomyelitis
, myasthenia gravis)
Diaphragma movement disorder:
obviously elevated pressure in
abdominal cavity
Cardiovascular system
Heart failure
Pulmo embolism
Cause
s
Poisoning
ketoacidosis
Central nervous system
Cerebral tumor , trauma,

abscess, hemorrhage,
encephalitis, meningitis
hematological system
Severe anemia,
carboxyhemoglobinemia,
methemoglobinemia and
sulfhemoglobinemia, cyanide and
cobalt poisoning.
1.the manifestation of three

depression sign?
supraclavicular fossa
suprasternal fossa
intercostal space
Three depression sign

319
The characteristic of jaundice

evoked by autoimmune
hemolytic anemia.
I. Hemolytic Jaundice
(1) Etiology : All hemolytic disease can cause
hemolytic jaundice.
Congenital hemolytic anemia: Hereditary
spherocytosis, thalassemia; Acquired
hemolytic anemia: autoimmune hemolytic
anemia, newborn hemolysis,
heterohemolysis, favism, paroxysmal
nocturnal hemoglobinuria.
(2) Clinical manifestations: The jaundice is mild,

often accompanied with symptoms of
hemolytic disease, e. g. fever, chill,
headache, lumbago, anemia and
hemoglobinuria, sometimes with acute renal
failure. And congenital hemolytic anemia is
accompanied by splenomegaly.
(3) laboratory findings: Include: Urine: no
bilirubin present, urobilirubin > 2 units
( except in infants where gut flora has not
developed) ; Serum : increased
unconjugated bilirubin.
Mononuclear
phagocyte system
HB
Circulation
blood
RBC HB
kidney
UCB
UCB
TB
CB
normal
CB/TB <15%-20%
UB urobilirubi
nUrobilinogen
hemoglobinuria
CB
urobilinogen
urobilinogen
hemolytic jaundice mechanism
urolilin
stercobilin
The feature of jaundice

of cirrhosis in
laboratory
examination
2. Hepatic Jaundice
(1) Etiology: Hepatic jaundice causes include

acute hepatitis, hepatotoxicity and
alcoholic liver disease, whereby cell
necrosis reduces the liver's ability to
metabolize and excrete bilirubin leading to
a buildup in the blood. Less common
causes include primary biliary cirrhosis.
Jaundice
seen in the newbom, known
as neonatal jaundice, is common, occurring
in almost every newbom as hepatic
machinery for the conjugation and
excretion of bilirubin does not fully mature
until approximately two weeks of age.
(2) Clinical manifestations: Color of the skin and

sclerae changes depend on the level of
bilirubin. When the bilirubin level is mildly
elevated, they are yellowish. When the
bilirubin level is high, they tend to be
brown. It often accompanied with
symptoms of hepatic diseases, e. g. fatigue,
anorexia, et al.
(3) Laboratory findings:Urine: conjugated

bilirubin present, urobilirubin > 2 units but
variable; Liver function tests are abnormal;
Serum: both CB and UCB are increased.
Mononuclear
phagocyte system
HB
Circulation
blood
RBC
kidney
UCB
CB
UCB
TB
CB/TB >30%-40%
UB
+
urobilinogen
CB
CB
urobilinogen
urolilin
urobilinogen
Hepatocellular jaundice mechanism
stercobilin
. Chief complaints
Difinition: These should consist of a list of one
or more symptoms that caused the
patient to seek attention and be followed
by the approximate duration in time units.
concepts
Symptoms
Difinition: A symptom is usually considered
to be an abnormal sensation that is
perceived by the patient.
Physical signs: Can be seen, felt, heard by
the examiner.
mcq
History of present illness

1.Onset and disease duration;
2.Characters of the main symptoms;
3.Cause of diaseases
4. Development and Evolution of the disease
5. Accompanying symptoms
6. The treatment process
7. The general situation in the course.
5. Past medical and surgical history

1) General Health
2) Chronic and Episodic Illnesses
a. Chronic Medical illnesses
b. Infectious Diseases
3) Operations and Injuries
4) Previous Hospitalizations
5) Allergic history
6) History of preventive inoculation
6. Family History
7. Social History
1) Place of Birth
2) Nationality and Ethnicity
3) Marital Status
4) Occupation
5) Military History
6) Gender Preference
7) Social and Economic Status
8) Habits
9) Violence and Safety
10) Prostheses and In-home Assistance
Fill In the blank

Carotid include
Aortic incompetence;
hypertension;
hyperthyroidism;
critical anemia
Thyromegaly scale division

degree: not visible but can be palpated
degree: can be visited and can be palpated
but not surpass sternocleidomastoideus
degree: surpass sternocleidomastoideus
Jugular include
a.Jugular vein distention
b.Jugular vein pulsation: tricuspid incompetence
fill in the blank

.Jugular vein distention
include:
1.Right congestive heart failure;
2.constrictive pericarditis;
3.hydropericardium;
4.superior vena cava obstruction syndrome
Blank
Constructions:incude
THYROID
isthmus; lateral lobes
What are VTAL

SIGNS
Vital signs are measurements of the body's most
basic functions.
body temperature
pulse
breathing
blood pressure
342
WEIGHT
What is Body-Mass
Index(BMI)
Body mass index is a calculation that uses your height and weight
to estimate how much body fat you have.
Too much body fat is a problem because it can lead to illnesses
and other health problems.
The formulae universally used in medicine produce a
unit of measure of kg/m2
BMI=mass(kg)/height(
m2)
343
WEIGHT
Body-Mass Index(BMI)
< 18.5 underweight
18.5 to 24.9 healthy
25 to 29.9 overweight *
30 to 34.9 grade 1 obesity
35 to 39.9 grade 2 obesity
>40 grade 3 (morbid obesity)
344
VARIATION IN BODY TEMPERATURE
normal temperature vip

The population range of this set point varies from
36.0-37.5 .
minimum temperature
3:00 to 4:00 a.m.
maximum temperature
between 8:00 and 10:00 p.m
345
BLOOD PRESSURE AND

PULSE PRESSURE
346
BLOOD PRESSURE AND PULSE PRESSURE
Arterial Blood Pressure

Blood pressure (BP) is the pressure exerted
by circulating blood upon the walls of
blood vessels, and is one of the principal
vital signs.
347
Measurement of Arterial Blood

Pressure
sphygmomanometer
348
Measurement of Arterial Blood

Pressure
The patient may be either sitting or lying in

the supine position. In some cases, the
pressure may be quite different with
changes in posture.
The patient should have been resting for
some time.
349

Bare the arm and affix the collapsed cuff snugly and
smoothly, so the distal margin of the cuff is at least
3cm proximal to the antecubital fossa. Rest the arm on
the table or bed with the antecubital fossa
approximately at the level of the heart.
350

Palpate for the exact location of the brachial arterial
pulse
Place the end of the stethoscope on the elbow
351

Inflate the cuff using the inflation bulb until the flow of
blood is cut off.
Open the valve slightly so the pressure drops gradually
while making observations by auscultation.
352
The pressure where the first sound was heard is the

systolic pressure and the last sound heard is the
diastolic pressure.
353
Variation in BLOOD PRESSURE AND PULSE

PRESSURE
normal blood pressure:

Less than 120 mm Hg systolic pressure and
Less than 80 mm Hg diastolic pressure
Hypertension (high blood
pressure) :
140 mm Hg or greater systolic pressure or
90 mm Hg or greater diastolic pressure
hypotension (low blood pressure):
Systolic pressure less than 90 mm Hg or
diastolic pressure less than 60 mm Hg
354
SKIN COLORATION
What are the causes of Cyanosis
Cyanosis is the blue color seen through

the skin and mucous membranes
when the reduced hemoglobin
concentrations in capillary blood exceed
4.05.0g/dL,0.51.5g of
methemoglobin, or 0.5g of
sulfhemoglobin. The amount of
oxyhemoglobin does not affect the color.
355
SKIN COLORATION
Types of Cyanosis
Generalized cyanosis is seen in the lips,

nail beds, ears, and malar regions.
356
SKIN COLORATION
Cyanosis
DDX(
differential diagnosis):
Local Cyanosis localized venous stasis or
arterial obstructions, Raynaud phenomenon,
extravasations of blood in superficial tissues.
Central cyanosis : Central cyanosis is often due
to a circulatory or ventilatory problem that
leads to poor blood oxygenation in the lungs.
357
Examination of paranasal
sinuses
frontal
sinus
sphenoid
sinus
sinus orifices
What is Suppurative paranasal

sinusitis vip
Accompanied viral upper respiratory infections
Obstruction of narrow sinus orifices leads to
accumulation of mucous which becomes
secondarily infected by bacteria leading to
suppurative sinusitis
Severe pain occur7-14 days after signs and symptoms of
an upper respiratory infections
What is
Maxillary sinusitis
Dull throbbing pain in cheek and in several of
the upper teeth on that side .
Thumb pressure localize
Distinguish: tooth pain
What is
Frontal sinusitis
Pain in the forehead above the supraorbital
This region elicit tenderness
What is Peripheral corneal opacity

( Kayser Fleischer ring)
A circular band of
goldenbrown pigment, 2mm
wide, is seen on the
posterior corneal surface
near the limbus
Accompanies the
neurologic manifestations
of hepatolenticular
degeneration
(Wilsondisease)
What is Lid sign in hyperthyroidism

[von graefe sign]
Rosenbach sign: termor of the closed eyelids
Mean sign :global lag during elevation
Griffith sign: lag of the lower lids during
elevation of globes
Boston sign : jerking of the lagging lid
Chest wall,thorax and breast

Questions
1 the landmarks and Imaginary lines of
chest wall .
2 rachitic rosary,pigeon breast(pectus
carinatum),harrison groove, funel breast,
barrel chest.
3 how to describe a mass in breast
Funnel Breast
The reverse of the pigeon breast, the lower
costal cartilages, inferior sternum and
xiphoid process are retracted toward the
spine.. Rickets and Marfan syndrome are
known causes.
Barrel Chest
Both the anteroposterior and transverse
dimensions of the thorax are enlarged, so
the arched ribs tend to form perfect
circles in cross section
Chest wall,thorax and breast

Barrel chest
The AP diameter is increased to as large as, or even greater than the
transverse diameter. The oblique degree of the rib becomes small, the rib
angle with spine is larger than 45.
Interspace becomes wider and full. The infrasternal
angle becomes wider with less respiratory
variation.
This situation can be
seen in severe
emphysema
patient, or elderly or
fat person.
Anatomic landmarks of chest

wall(anterior)
1.Manubrium of sternum
2.Gladiolus of sternum
3.2nd rib
4.2nd intercostal space
5.2nd costicartilage
6.Costochondral junctions
7.Sternal angle (Louis angel )
8.costal angel
9. suprasternal notch
10.xiphoid process
Anatomic landmarks of chest

wall(posterior)
1.The first thoracic spinal process
2.inferior angle of scapula
3.The eighth/seventh rib
4.Costolspinal angle
3 how to describe a mass in

breast
3.Masses (1)location
(2)size
(3) shape
(4) consistency
(5)tenderness
(6)mobility
(7)texture
Imaginary lines of chest wall

Midsternal line
Midclavicular line
Posterior axillary line
Anterior axillary line
Midaxillary line
Scapular line
Posterior midline
important
resonance
Is a type of percussion sound usually found in
normal lung(air filled lung)
pleura
A thin serous mebrane around lungs and inner
walls of chest
Crepitis
It is medically term used to describe
grating,crackling or popping sound and
sensation expressed under the skin joints
or crackling sensation from subcutaneous sensation due to presence of
air
What are five kinds of Generalized edema:

cardic edema
renal edema
hepatic edema
nutritional edema(protein losing conditions)
drug(corticosteroid,NSAID)
Signs of pneumonothorax
1.Presence of air in pleural space
2.costal interspace in affected side are wider.
3.limited movement of affected side
4.decreases vocal fermitis
5.trachea and heart shift to opposite side
6.tympany
7.vesicular breath sound deceased or
disappear
Types of palpation for

abdomen
Single handed palpation
Rein forced palpation
Ballotment
Light palpation
Deep palpation
Bimanual palpation
What will reveal patient with

RS pleural effusion in
lung
examination
1.diminished breath sounds affected side
2. decreased movement of chest on affected
side
3.pleural rib in affected side
4.stony dullness to percussion on affected side
5.decrease vocal fermitis
6.decreased vocal resonance
7.there may be tracheal deviation toward left

side
8.there may be blunting of costophrenic angles
on chest radiography
mcq
increased heat production
decreased heat dissipation
failure of regulating system
Set point change
Temperature deviation
fever
Five kinds of diseases with Oxyhemoglobin

Deficiency that causes dyspnea
Anemia, carbon monoxide poisoning ( carboxyhemoglobinemia) ,
methemoglobinemia and sulfhemoglobinemia, cyanide and cobalt
poisoning.
383
Causes of Blood streaked

sputum
Inflammation in nose,Nasopharynx,Gums
Larynx or brochi
Sometimes
After severe paroxym of coughing
Lead to trauma
Method of palpation
Light palpation
Deep palpation
Bimanual palpation
..
Auscultation is used to examine the heart and
lung
Introduction(2)
Attributes of chest pain
Provocative-palliative (Influential) factors
Exertional, respiration, food intake, administration
Quality /feature
pricking /bursting /pressing /blunt/colic/distention/burning /stabbing/ crushing
/throbbing
Region /location
Severity
Timing/ Duration
Referred pain
angina pectoris
myocardial infarction
LYMPHATIC SYSTEM
EXAMINATION OF THE LYMPH NODES
The following characteristics of palpable
lymph nodes should be noted
number size consistency mobility te

nderness warmth and whether they are
discrete or matted together.
Diagnosis
mcq
Palpation of the Cervical Lymph Nodes m
Let the patient seat in a chair; stand behind the patient to

palpate the neck with your fingertips. Examine, the
various lymph node sites in sequence:
(1)submental, under the chin in the midline and on either
side.
(2)submandibular, under the jaw near its angle.
(3)jugular, along the anterior border of the
ternocleidomastoid.
(4)supraclavicular, behind the midportion of the clavicle.
Diagnosis
mcq
Palpation of the Cervical Lymph Nodes
(5)post sternocleidomastoid (posterior triangle), behind the

posterior border of the upper half of the
sternocleidomastoid.
(6)postauricular, behind the pinna on the mastoid process.
(7)preauricular, slightly in front of the tragus of the pinna.
(8)suboccipital, in the midline under the occiput and to

either side.
(9)pretrapezius, in front of the upper border of the

trapezius.
Diagnosis
vocal fremitus diminished or

absent
e.g. lung tissue is destroyed,
pleura thickened, pleura surface
are separated by air or fluid
Bronchial Breathing
It results from consolidation or compression of pulmonary
tissue , so it does not occur in the normal lung.
Characterize: have a short inspiratory phase and a long
expiratory phase
the sound is lofty tone, like our tongue contact palate ,then to
expire air; when inspiration the sound is higher than expiration;
have a short stop between the end of inspiration and begining
of expiration.
Chronic bronchitis with

emphysema
Signs
Barrel chest
Movement of respiratory
Vocal fremitus
Hyperresonance
The lower border of lungs downward
Shifting range of bottom of lung
Cardiac dullness area
Decreased vesicular breath sound
Prolonged expiration
Moist crackles and/or rhonchi (acute episode)
extra
THE MENTAL STATUS, PSYCHIATRIC, AND

SOCIAL EVALUATIONS
Abnormal Perceptions
Abnormal perceptions arising from primary injury to
the sensory organs and their pathways are often
negative or represent an exaggeration or distortion of
the normal sensory signal.
Abnormal perceptions arising in the processing centers
and cortex are more often complex.
395

SOCIAL EVALUATIONS
Abnormal Affect Mood
Feelings are the way we react emotionally to the

perceptions and events of our lives.
Normally we have a range of feelings
throughout the day and the intensity of our
feelings may vary over time, from periods or
relative intensity to periods of less intensity.
Abnormal extremes of feelings, either in degree
or duration, may indicate psychiatric
disorders.
396

SOCIAL EVALUATIONS
Abnormal Thinking
Thinking is the process by which we

connect and explain events to
ourselves and others. It is a relational
activity of great complexity.
disorders may be manifest by verbal
symptoms expressed by the patient or
by abnormal behaviors resulting from
the disordered thoughts.
397

SOCIAL EVALUATIONS
Abnormal Memory
Amnesia:Amnesia is a loss of memory. It

can be retrograde for events of the
past,or antegrade, the inability to
form new memories.I t can be either
global or selective for particular
events or domains of memory.
It is indicative of brain injury or
psychological disorder.
398

SOCIAL EVALUATIONS
Abnormal Behaviors
How we behave, our actions in private and public, is the
result of how we feel, how we think, and how we
perceive the constraints and rewards of the social
environment.
Behaviors which are consistently abnormal or unacceptable
are indicative of personality or psychiatric disorders.
399

SOCIAL EVALUATIONS
Thought Disorders
Schizophrenia and Other Psychoses: As the prototypical
psychosis, schizophrenia is now considered to
comprise a group of diseases that are probably
etiologically distinct
Primary psychotic disorders occur in adolescence

or young adult life.
Onset of psychotic symptoms at older ages should

raise concern about organic brain disease, drug
intoxication or withdrawal.
Schizophrenia involves problems in thinking, affect,
socializing, action, language, and perception.
400
Skin
texture
There characteristic feel of skin depends on a number of phsiologic
processes.
Softness, as provided by the layer of fat cells that abut
the lower portion of the dermis;
Moisture, as provided by water diffusion through the
skin and by sweating onto the surface of the skin
Lubrication, as provided by the sebaceous glands
Warmth,as provided by the circulation of the
internally warmed blood
The presence or absence of roughness, depending on
the amount of scale(keration) produced by the
epidermal cells.
401
HEIGHT
Abnormal Body Proportions
Marfan Syndrome (Arachnodactyly)
autosomal dominant disorder of connective tissue.

tall
extremely slender build
long and slender fingers;
pigeon breast or funnel breast,
hammer toes,
long, narrow skull.
Frequently, death occurs from dissecting aortic aneurysm.
402
LYMPHATIC SYSTEM
IMPORTANT REGIONAL
LYMPH NODE SYNDROMES
More limited, regional

lymphadenopathy may be an early
sign of a generalized desease, or might
represent regional or local disease.
Four specific syndromes involving
regional lymphadenopathy are worthy
of special consideration:
403
LYMPHATIC SYSTEM
Postauricular Nodes
Bacterial or herpetic
infections of the acoustic
meatus, rubella
Preauricular Nodes
Ulcerating basal cell carcinoma

,tuberculosis,.
404

SOCIAL EVALUATIONS
The distinction between what we classify as neurologic versus

psychiatric illness is a function of our understanding of brain
physiology and pathophysiology.
The distinction often rests on the presence of
identifiable structural, genetic, physiological, or
biochemical disorders in the neurologic category and
their absence in psychiatric disease.
Many psychiatric syndromes show genetic
predispositions and respond to medications that alter
brain function.
It is sufficient to recognize that the disorders we classify as
psychiatric, although representing disorders of brain function,
will be recognized by their clinical sings with abnormalities of
thought, mood, affect and behavior rather than specific tests of
brain structure and clinical laboratory testing.
405
LYMPHATIC SYSTEM
Mandibular Nodes
Afferents from
tongue,submaxillary
gland,submental
nodes,medial
conjunctivae,mucosa of lips
and mouth;
Submental Nodes
Afferents from central lower

lip,floor of mouth,tip of
406
Conjugated bilirubin is distinguished from the

bilirubin that is released from the red
blood cells and not yet removed from the
blood which is termed unconjugated
bilirubin
sphygmomanometer
It consists of a flat rubber bag enclosed in a

cuff of indistensible fabric or plastic.
A rubber pump inflates the bag with air and
tubing connects the pump to the bag and also
to a manometer, either mercury or aneroid,
to measure the applied air pressure in
millimeters of mercury.
The arm cuff should be at least 10cm wide,
for the thigh, a width of 18cm is preferable.
408
Vital sign
Examination of head
Chest pain
Arcus senilis
Chest pain

Final Physical

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Final Physical

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FINAL EXAM

Precordium : the anterior surface of the chest

Vertically : the second to the fifth intercostal space

1.Precordial prominence and pectus

Q.2Inspection- Apical impulse

Normal apical impulse

Displacement of apical impulse

Inspection- Apical impulse

[Q.3.Normal apical impulse.[IMP]

about 0.5 1.0 cm medial from the midclavicularline

Displacement of apical impulse

Inspection- Apical impuls- Displacement of apical impulse

vertical position heart ---- inferior;inner

Inspection- Apical impuls- Displacement of apical impulse

one side atelectasis or pleural adhesion

Inspection- Apical impuls- Displacement of apical impulse

Enlargement of the heart

left ventricular enlargement

Inspection- Apical impuls- Displacement of apical impulse

Posture (Physiological factors)

Inspection- Apical impuls- Displacement of apical impulse

Inspection- Apical impulse

Intensity and size of apical impulse

narrow intercostal space

myopathy (AMI, DCM)

Inspection- Apical impulse

Apical impulse and pulsation of

Tiny vibrations felt by palm,somewhat similar

Q.9Palpation - Pericardial friction rub

Mechanism: rub of the visceral and parietal

Disappear: pericardial effusion

precardium -4th ICS-LS[MCQ]

Clearer: systolic period

Normal border of relative cardiac dullness

Change and value of cardiac dullness

Q.12.Percussion- Method of percussion

---patient in the recumbent position

Q,13Auscultation -- Auscultatory cardiac valve

Mitral valve area

Cardiac valve areas

Q.17heart sound-- 4 heart sounds.S3 AND S4 MECHANISM [IMP]

Q.18 Auscultation -- Order

Normal adult apex beat is located

Normal adult range in diameter apex beat is

Apex beat exposition, the error is

Displaced apex beat exposition, the error is

Precordial beat the error is

Tremor discussion, the error is

Tremor discussion, the error is

Standard compatibility type questions

1 what do Extracardiac sounds include?

Extracardiac sounds in systolic

Dilated great vessel, with

2) Middle and late systolic clicks

Extracardic sounds In diastolic

Protodiastolic gallop rhythm

In early diastole, the blood

Auscultation character of S3 gallop:

S3 gallop: differ from normal S3

Occur in severe organic

Late diastolic gallop

At late diastole, related to

Occur in pressure overload,LVH,

Overlapping of S3G and S4G