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Internal Diagnosis II(
 Infernal Die, Too
)Larry WyattGet notes from bookstore -look carefully at the points marked with (TQ)
-
Organic
– problems in the organs or body
-
 Inorganic
– test all the organs and don’t know what’s wrong with the patient.
Treat your patients in a bio-psycho-social manner…
Hx and Physical
•
History: AMPLE, HISTORY, OPPQRST:
o
Allergy, Medication, Past medical hx, Last menses/meal, Event of complaint (illness)
o
Hospitalizations, Immunizations, Sugar diabetes/Social Hx, Tumors/Trauma, Operations, Review of systems, YouthIllnesses.
o
Onset, Palliative, Provocative, Quality, Radiation/Region, Setting/Site/Severity, Timing
•
Physical exam: Inspection, Auscultation, Percussion, Palpation
o
Auscultation done 2
nd
to keep from altering sounds (bowel sounds, etc.)
•
Pain in gut is primarily from distension.
•
Most tumors are painless, until they grow enough to distend the organ (as they are encapsuled, in the serosa).
•
The peritoneum is also pain producing, primarily due to inflammation.
•
2 primary reasons for pain in the gut:
o
Distension.
o
Irritation/inflammation of the peritoneum.
o
Both shown in
appendicitis
.
At onset, pain in appendicitis is diffuse (caused bydistension)
In 18-36 hours, the pain will migrate to the region of theappendix. Abdominal guarding begins.
If appendix ruptures – pain reduces substantially initially because the distension reduces.
However, within a few hours pain severely increases andgeneralized, and the abdomen becomes very rigid (muscle tension) as the pusand bacteria spread throughout the abdominal cavity (and abdominal sepsis begins).
Death CAN occur in this case.
•
Pitting Edema (of the leg)
o
Blood pooling on heel of the foot
o
Differential Dx:
Cardiovascular (most common)
•
Most likely CHF
Renal failure probably caused death (more common)
Hepatic (Maybe, but no jaundice present)
Renal dz
Thyroid dz
1
 
•
Clubbing (right hand)
o
Findings:
White male
40’s
Swelling at DIP
Enlarged nails (no splinter hemorrhage)
•
Psoriasis has pitted nails
o
Enlargement of the terminal tuffs (seen on x-ray)
o
AKA: Hypertrophic Osteoarthropathy (digital clubbing)
Lung disease because of hypoxia (most common)
Can be associated with GI and GU problemsA.M.P.L.E.-Allergies (wheat, soy, peanut, shellfish, iodine, meds)-Medications (what, how much, ? for, how long)-Past Medical “HISTORY”
-
Last Meal/Last Menstrual Period (1
st
day of mense) (onset)-Events of the present illnessO.P.P.Q.R.S.T.-Onset (what cause, when, how long it takes)-Provocative (what makes it worse)-Palliative (what makes it better)-Quality (sharp, dull, aching, intermittent, cramping, cholicing)-Radiation/Region of pain (where does it hurt)
-
Setting (when – time)/Site (where is it located)/Severity-Timing (when does it happen and how long does it last)
o
Constant = 24/7/365
o
Serious-Large smooth dome-shaped mass in the LUQ-Appears pale over lesion-Have pt do a sit up so that abdominal muscles contract-Incisional Hernia (past surgery)
o
Gets larger when she bears down and painful
o
Auscultation will hear bowel sounds
o
Feels like it is filled with air (like balloon)
o
Very mobile
o
When blood supply is lost to a hernia is call
strangulation
o
Tender 
o
Lateral debicutis
o
 HISTORY-Hospitalization-Injuries/Immunizations-Sugar Diabetes-Tumors/Trauma-Operations-Review of Systems
2Most Frequent Hernias
 
-Youth Illness10-Day rule
•
Can only take X-ray’s first 10 days of cycle (starting at 1
st
day of menses)
•
Unless chance Mom’s life is in danger or severe morbidity
•
History
[The History and Interviewing Process (06)]
o
Hospitalizations
When? What for? How long? What was outcome?
Recent surgery – mobilization/manipulation not recommended within 2 months. If doing sooner – call anddiscuss with their surgeon.
o
Injuries
When? What happened? What done? Outcome?
o
Sugar diabetes
Insipidus or mellitus (NIDDM or IDDM)
Look for increased adipose tissue in belly.
Remember DM causes microvasculopathy and microneuropathy.
•
Hence these Pt’s have a lot of GI/GU problems, such as renal problems.
o
Tumors
Lipoma is the most common, benign tumor.
Most common malignant tumor is skin cancer (basal cell carcinoma or melanoma).
o
Operations
In-patient as well as out-patient.
o
Review of Systems
o
Youth Diseases
Measles, Mumps, Rubella, Diptheria, Pertussus, Tetanus and chicken pox.
•
Physical Examination (abdomen)
o
Inspection
Symmetry, size, shape
•
If abdomen is distended (besides obesity): fluid and gas (or combination)
o
Look for fluid wave, etc. to check for fluid. Can detectdown to about 20 ml of excess fluid.
Puddle test
– pt on all 4 for a few minutes.
Percuss on Pt and listen for sound as percuss.Tough to do.
o
Percussion notes for excess gas are higher than for fluid.There will also be a palpatory difference (fluid is less “squishy” and rebounds less than gas)
Lumps, bumps, scars, ecchymoses (bruising)
•
Hernias are common “bumps”, for example.
•
Large scars used to be common for abdominal surgery, but with endoscopic surgery, can’t tell just byincisions or what it was at this point.
•
Pt with scar always has to bear down to look for hernia.
•
Laprocholecystecomy, hysterectomy, appendectomy scars most common.
o
Auscultation
Bowel sounds (5-35/minute) (listen for about 1 minute)
•
AKA Borborygmi
•
Relatively high pitched
use diaphragm
•
Very high pitched and get faster than 35/minute
sign of obstruction
•
 No bowel sounds
Paralytic (
Adynamic illeus
(blunt trauma, post operative)
•
Early bowel obstruction
Rapid sounds to force fecal bolus
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