PRINCIPLES OF MEDICINE PRELIM REVIEWER HISTORY TAKING & PHYSICAL EXAMINATION Takes up 70% of diagnosis Remaining 30% is for

or diagnostic procedures

IV. PAST MEDICAL HISTORY Previous hospitalizations o o o o o Hypertension Diabetes Asthma Allergies/ hypersensitivity reactions Present medications

HISTORY Interview the patient Establish rapport with the patient

EPIDEMIOLOGY Study of prevalence of diseases in a certain population

V. FAMILY HISTORY Ask for illness suffered by family members Proximity of family members History of communicable diseases with close family relative Ask for hereditary diseases o o o o Hypertension Diabetes mellitus Presence or absence of malignancies Asthma

I. IDENTIFYING DATA or PATIENTS PROFILE Name Age Sex Religion reflects habits Marital status reflects sexual habits Occupation reflects stress levels

II. CHIEF COMPLAINT The reason why the patient seeks medical attention Main reasons: o o o Pain or discomfort Observable changes from normal status Loss of function or dysfunction

VI. PERSONAL AND SOCIAL HISTORY Habits smoking, alcohol consumption, eating Environment Occupation Sexual history sexual preference

VII. OB-GYN HISTORY Menarche Ob-gyn score o GRAVIDA - # of times the woman got pregnant PARITY - # of times the woman gave birth

Use patients own words

III. HISTORY OF PRESENT ILLNESS Time Anatomic locations

o Quantity and quality of the symptom Aggravating and relieving factors Timing of symptom Associated signs and symptoms Absence of signs and symptoms Symptoms response to therapeutic measures

Birth control methods used LMP (last menstrual period) o Ask for the first day

FPAL o F = full term

o o o

P = partial A = number of abortions L = number of live births

Use inspection and palpation Check for changes in normal or stable state o COLOR o o ERYTHEMA inflammation CYANOSIS oxygenation PALLOR perfusion

VIII. REVIEW OF SYSTEMS Start with constitutional symptoms (genera) o Symptoms that do not pertain to a certain system like: fever, body malaise, weight loss

NERVOUS SYSTEM o Ask for headache, dizziness, double vision

TEXTURE TURGOR Elasticity Ability of the skin to snap back Best area to test: forhead Test for: level of hydration

RESPIRATORY SYSTEM CARDIOVASCULAR SYSTEM

GASTROINTESTINAL SYSTEM GENITOURINARY SYSTEM

Check for EVENTS o Secondary lesions, trauma to the skin, cuts, changes in consistency, changes in contour, presence or absence of malaise, presence or absence of masses

PHYSICAL EXAMINATION INSPECTION PALPATION PERCUSSION AUSCULTATION HEAD Normocephalic head Check for distribution of hair Check for normal contour of the head EYES o o Check for color of sclera Check for presence or absence of ICTERESIA (yellowish sclera) Equally responsive pupils Palpebral conjunctiva must be pinkish in color Presence or absence of corneal injection PR Temp NOSE o EARS o Check for presence or absence of discharge Check for septal deviations Cornea is avascular so there must not be any corneal injection

I. GENERAL SURVEY Overall evaluation of the patient LEVEL OF CONSCIOUSNESS NUTRITIONAL STATUS MOOD/AFFECT PRESENCE OR ABSENCE OF CARDIOVASCULAR DISTRESS

o o

II. VITAL SIGNS BP RR

Presence or absence of signs plays a big role in determining if a patients low BP is normal HYPERTENSION is easier to detect that HYPOTENSION SKIN

NECK LYMPHADENOPATHICS o o o Check for the triangles of the neck Check for thyroid enlargement Check for presence or absence of distended neck veins

RONCHI o o Obstructing very big airways Lower pitched & louder

PERCUSSION OF NORMAL LUNGS Detected 7cm down Done on intercostals spaces

THORAX Check for absence or presence of PECTUS CARINATUM (pigeons chest) or PECTUS EXCAVATUM (depression towards external area) Check for changes in the usual curvature

PERCUSSION OF ABNORMAL SOUNDS ON LUNGS Hyper resonance

PERCUSSION OF LUNGS WITH MASS OBSTRUCTION Check for symmetry of the ribcage HEART Check for symmetrical expansion of the lungs Check for presence or absence of murmurs o Signs of obstruction of valves Check for rhythm Check for movement of precordium When there are heaves during systole, there is enlargement of the left ventricle Dull sounds

NORMAL BREATHING SOUNDS BRONCHIAL SOUNDS o o o Sounds of traveling air in tubes o Sounds dissipate after inhalation o

VESICULAR SOUNDS ABDOMEN o High-pitched, thin sounds Check for enlargement of viscera: o o Combination of bronchial and vesicular sounds Liver, spleen, stomach

BRONCHOVESICULAR SOUNDS

Check for presence of mass and tenderness Abdomen should always s be soft and not board-like Check for SWELLING, TENDERNESS & ENLARGEMENT

ABNORMAL BREATHING SOUNDS RALES

o o Sounds of fluid in alveoli SKIN Gurgling sounds CRACKLES o o Sounds of fluid in bronchioles Sounds like crumpling paper

Epidermis & dermis 1.3 2.3m2 Functions: o o o Protection against trauma and infection Thermoregulation Supports sensory receptors

OBSTRUCTION SOUNDS WHEEZES o Typical fine wheezing sound on small bronchioles Found on ASTHMA

EPIDERMAL LAYER

Stratum corneum Stratum lucidum Stratum spinosum Stratum granulosum Stratum basale

CHIEF COMPLAINT PAIN PRURITUS o Itching (mild pain)

CHANGE FROM A STEADY STATE DYSFUNCTION o Hair loss, profuse sweating, oversecretion of oil

DERMAL LAYER Papillary layer 1/3 Reticular layer 2/3 o Has a lot of nerves and blood supply

PHYSICAL EXAM LOCATION and/or DISTRIBUTION ARRANGEMENT, PATTERN & SHAPE o Linear, annular, serpenginous

SUBCUTANEOUS TISSUE HAIR Adipose tissue Superficial fascia

KIND OF LESION o Primary or secondary lesions

CUTICLE outermost layer of hair shaft CORTEX middle layer MEDULLA innermost layer

COLOR

KINDS OF LESIONS PRIMARY LESIONS o PAPULE Elevation on skin with a diameter not greater than 5mm

2 types of HAIR TERMINAL HAIR o Dark, thick, pigmented hair growing on top of the head, eyebrows, eyelashes, axilla and genitals

PLAQUE Elevation on skin with a diameter greater than 5mm

VELLUS HAIR o o Fine, non-pigmented Has arrector pili muscle (responsible for goose bumps)

VESICLE Fluid-filled elevation on skin with a diameter not greater than 5mm

SEBACEOUS GLAND Gives oily secretion for lubrication and protection

BULLAE Fluid-filled elevation on skin with a diameter greater than 5mm

SWEAT GLANDS Gives watery secretion for thermoregulation ECCRINE GLAND o Scattered all over the body o

NODULE Elevation on skin which is bigger and deeper in origin

PUSTULE Pus-filled elevation on skin

APOCRINE GLAND o Found in genitals and axilla

MACULE

HISTORY TAKING (SKIN)

Pigmented skin lesion that is circumscribed with a diameter not greater than 5mm

YELLOWISH = CAROTENE

PATCH Pigmented skin lesion that is circumscribed with a diameter greater than 5mm

DIAGNOSTIC PROCEDURES GRAM STAINING o Bacterial

SECONDARY LESIONS o o Lesions that arise from Primary lesions EROSIONS Epidermis is taken out with no bleeding

10% KOH o Fungal, hyphae

GIEMSA/ WRIGHT STAIN o Viral

ULCER Much deeper erosion into the dermis

WOODS LAMP o Fungal, pseudomonas (fluorescent)

SKIN BIOPSY/ SKIN PUNCH o Best test for diagnosis

FISSURE Linear crack into the dermis CNS BRAIN

LICHENIFICATION Thickening of the dermis Exaggeration of the furrows Seen in PSORIASIS

Brain and brainstem 12 cranial nerves 31 PNS

SCALING/SCALES Dead skin cells still attached to the epidermis Eg DANDRUFF

4 LOBES

BRAINSTEM Pons, medulla, cerebellum WHITE MATER periphery GRAY MATER center POSTERIOR HORN sensory ANTERIOR HORN motor Reflex o o Afferent posterior horn Efferent anterior horn

VEGETATION Irregular shaped growth of the skin Eg WARTS

MACULOPAPULAR Combination of elevated and flat lesion Folliculitis, measles

COLOR (normal)

CSF flows up to S2 SUBARACHNOID ends at lower border of L1

RED = OXYHEMOGLOBIN BLUE = DEOXYHEMOGLOBIN DARK COLOR = MELANIN

HISTORY (CNS) CHIEF COMPLAINT

PAIN o Headache (cephalalgia)

GLOSSOPHARYNGEAL o o Sensory: posterior 1/3 of tongue Gag reflex

DYSFUNCTION o o Motor loss/ weakness Anesthesia (sensory loss)

VAGUS o Gag reflex

Dizziness Loss of consciousness

SPINAL ACCESSORY o o Trapezius shoulder shrug Sternocleidomastoid (SCM) turn head with resistance

GENERAL SURVEY Level of consciousness/ coherence Orientation

HYPOGLOSSAL o Stick out tongue

Assess function of the patient MUSCLE MOTOR TESTING (MMT) 0/5 = no contraction/ no tone 1/5 = with little contraction Use Snellens Chart 2/5 = with movement but not against gravity 3/5 = can overcome gravity 4/5 = can overcome gravity but not resistance 5/5 = can overcome gravity and resistance Test pinpoint sensations with PINS and BRUSHES SKIN OF THE FACE (intact) Compare left and right Cervical and cranial nerves Graded in %

CHECK THE 12 CRANIAL NERVES OPTIC o

OLFACTORY o Check smelling sensation

OCCULOMOTOR o Extraoccular movements

TROCHLEAR o o Extraoccular movements Superior Oblique

TRIGEMINAL o o V1, V2, V3 Clenching of teeth

BELLS PALSY Paralysis of one side of the face Muscular branches of facial nerve are involved Facial nerve (CN VII) is affected o Peripheral nerve dysfunction

ABDUCENS o o Extraoccular movement Lateral rectus

FACIAL o o o Mixed nerve Sensory : anterior 2/3 of tongue Facial expression

Caused by: o o o Infection: may be viral or bacterial Inflammation: secondary to trauma Compression: by a mass

ACOUSTIC/ AUDITORY

MRI TRIGEMINAL NEURALGIA Facial pain Involving sensory branches of trigeminal nerve Most often occurs in V2 and/or V3 Etiology: o o Inflammatory process Often times occur in one side of the face Checks the integrity of soft tissues Cannot see hard tissues Cerebral infarcts (decomposition of tissues)

Spinal Cord makes extensive use of MRI Compression of nerves and swelling of spinal cord

LUMBAR PUNCTURE/ SPINAL TAP Infection= WBC Hemorrhage = RBC Detect through cytology o Aids in histologic diagnosis

CEREBROVASCULAR ACCIDENT Residual effects: o o Weakness/paralysis of muscles Sensory loss

Do puncture between L4 & L5

Blockage of Circle of Willis (blood supply of the brain) EPIDURAL HEMATOMA Do CT scan Can also be done with Xray

AXONS comprise the spinal cord MOST COMMON ENCOUNTERED IN CVA CORTICOSPINAL motor o o o Efferent Voluntary movements Starts from precentral gyrus

CT scan is always fone before lumbar puncture is done in order to prevent herniation of the brainstem

SPINOTHALAMIC sensory o o Decussate in medulla Responsible for pain, temperature, crude touch -Rosette Go 072410

POSTERIOR COLUMNS sensory

Receptors in the periphery are in the axons of the spine Motor pre-central gyrus Sensory post-central gyrus Broadmans Area 312 sensory CT scan Checks the density of hard tissues Checks for MASSES Better used for detection of Cerebral Hemorrhages Detects extravassated blood