Carte Semio Engl Modificata Final

The medical record and the reasons for correctly completing it
Chapter 1
1.1 The Medical Record and the Reasons for Correctly Completing It
Not only it is important, but it is also compulsory to register all of the information that we gather
about our patient in a medical record.
Firstly, we do this because the data obtained concerning our patient and his health state provide
important arguments for diagnosis. We may consult the clinical data and the laboratory findings from
the medical record later, whenever necessary to judge the findings in evolution.
Also, there are legal implications about this file, because we may have to prove that the patient
benefited entirely from our attention, care and support and also from decisions that were all based on
solid medical knowledge.
Last but not least, the medical file could be important for research, allowing prospective or
retrospective gathering of data.
Parts of the Medical Record
1. History
2. Physical examination
3. Laboratory tests and imaging studies
4. Diagnosis
5. Evolution
6. Treatment
7. Summary and recommendations
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1.2 The History
1.2.1 Identifying data:

- name
- age; this is an important piece of information for a diagnosis because many diseases are
generally age related; for example the essential hypertension is more frequent in patients older
than 40, while the secondary hypertension is more frequent in those younger than 40
- the sex of the patient is also related to some diseases; for example cholelithiasis is more
frequent in women, while ischemic heart disease is more frequent in men; hemophilia manifests
only in men
- race; sickle-cell anemia, a well-known genetic disorder, has been seen as most prevalent in
populations of sub-Saharan African ancestry, but is now known to also be common among
Latin-American, Indian, Saudi Arab, and Mediterranean populations
- place of birth and current residence: some diseases are more frequent in certain areas (e.g. goitre
in areas with a lack of iodine in water)
- marital status: certain infectious diseases develop in small collectivities (hepatitis A,
tuberculosis); also, the alimentary habits in families are important
- occupation may also be a risk factor for the development of certain diseases: varicose veins in
case of a job that requires prolonged orthostatic position, hypertension in case of stressful work,
pulmonary fibrosis in miners, bronchial asthma in case of exposure to chemicals
- religion may influence treatment of disease (or, in some cases, the refusal of treatment in certain
religions)
1.2.2 Presenting complaints (PC)
In this part, we have to ask the patient about the chief complaints-the most important symptoms or
signs that brought him/her to the doctor: “Why did you come to us?”
When possible, it is recommended to let the patient describe the situation in his own words, trying not
to suggest specific ways of describing.
If the patient can’t express what is wrong in a good manner, or if he enters in too many insignificant
details, it is better to obtain information by trying to lead the speech in the right way by asking specific
questions. These questions should be very short, clear and adapted to the level of knowledge the patient
has.
The questions will be asked either to the patient or to other people who know the patient and can give
valuable information (in this case, this part is sometimes called heteroanamnesis), with the aim of
formulating a correct diagnosis and providing medical care to the patient.
Medical histories vary regarding their depth and focus. For example, when taken inside an ambulance,
the history will typically be limited to important details. By contrast, a psychiatric history will
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frequently require taking exhaustive and deep details about the patient's life which are relevant to
formulating a management plan for a psychiatric illness.
A symptom is a medically relevant complaint reported by the patient or others familiar with the patient.
The most frequent symptom is pain; other examples of symptoms are: dyspnea (shortness of breath),
nausea, vertigo, dysuria (urinating with difficulty).
A sign is an objective expression of a disease which is ascertained by direct examination on the part of
medical personnel. Examples of signs are: pallor, jaundice, cough, fever.
In order to progress on the way to the diagnostic, we take details about general symptoms that the
patient presents, and then we question about specific symptoms.
We use open-ended questions if the patient’s own history is not comprehensive enough to guide us to a
correct diagnostic. We may negotiate a list of all issues, avoiding details.
The chief complaint(s) and other concerns will be mentioned.
We have to clarify the patient's expectations for this visit - ask the patient what has happened lately that
brought him for the medical control.
Then return to open-ended questions directed at the major problem(s).
We have to encourage the patient’s story with silence and our entire attention.
Focus to the diagnostic by summarizing all the data.
While writing in the medical record, we must translate the patient’s observations into medical words.
1.2.3 Short history of presenting complaint
This involves finding out more details about how everything started and how it progressed:
- When did this start?
- What happened next?
- Have you experienced something like that before?
- When did current symptoms first appear?
Direct questioning is used to ask specific questions about the diagnosis you have in mind or to exclude
other diagnosis on the differentials list. A review of the relevant symptoms or signs is done and
associated risk factors are considered.
Attributes of a symptom:
- Location (where is it?)
- Radiation (does it radiate?)
- Character or quality (what is it like?)
- Quantity and severity (how bad is it?)
- Timing (when did/does it start? How long does it last? How often does it appear?)
- Setting in which it occurs (environmental factors, personal activities, emotional reactions)
- Factors that make it better or worse
- Associated features
- Progression
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If presented with this/these symptoms to a doctor

- What diagnostic did he mention?
- What treatment did he recommend?
- Was the treatment correctly taken? Which were the results obtained?
How to approach a patient

- Give him your entire attention, encouragement and compassion
- Take care of his comfort (improved position in bed)
- Ask opening questions, listen actively and watch for clues to find out about important symptoms
and events
- Questions should proceed from the general to the specific
- Direct questions should not be leading questions
- Use language that is understandable and appropriate for the patient.
1.2.4 The past medical history (PMH) and past surgical history (PSH)
The past medical history and past surgical history will record all the medical events previously
experienced by the patient. He will be asked:
- Have you ever been to the hospital before? (when, where, why, etc).
- Do you suffer from any illnesses or conditions?
- Have you had any surgeries or procedures?
Childhood illnesses will be mentioned especially in young patients, if connected with present disease:
measles, rubella, mumps, whooping cough, chicken pox, scarlet fever, diphteria.
If the patient forgets or neglects certain topics, it is important to ask about:
- allergies to environmental allergens, foods or drugs
- hepatitis (or jaundice if the patient didn’t present to the doctor), tuberculosis, rheumatic fever,
hypertension & heart disease, asthma or chronic obstructive pulmonary disease, diabetes, stroke,
epilepsy
- accidents and injuries and resulting disabilities
- surgery: dental surgery or general surgery- data, diagnostic, behavior to anesthetics,
complications
The illnesses that happened in adulthood will be chronologically presented. Previous written
information may be used if available (medical prescriptions, medical documents).
We will try to find out if diseases have been treated at home or in a hospital. If it is known by the
patient, we have to note the exact diagnosis, the recommended treatment, for how long the treatment
was administered correctly by the patient and also, the side effects of the medication, if it was the case.
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Physiological Data for Women

1. Menstruation: age at first menarche; regularity, frequency, duration of periods; amount of
bleeding, bleeding between periods and intercourse, last menstrual period; discomfort or pain
before or during the periods.
Normally the interval between periods range from 24 to 32 days; the flow lasts 3-7 days;
Note if there has been present:
- Amenorrhea: the absence of periods (primary or secondary in pregnancy, lactation, menopause);
- Oligomenorrhea: infrequent periods;
- Polymenorrhea: abnormally frequent periods;
- Dysmenorrhea (pain and discomfort in menstrual period)
- Premenstrual syndrome.
2. Number of pregnancies, number of deliveries, number of abortions (spontaneous and induced);
complications of pregnancies; weight of the new-born (risk of diabetes in women which give
birth to children heavier than 4 kg)
3. Birth control methods
4. Last PAP, results ; Sexually transmitted disease treatments, Last HIV test
5. If it is the case, data about menopause: age at menopause, menopausal symptoms,
postmenopausal bleeding.
1.2.5 Family History (FH)
Family history is useful in assessing the patient’s risk for developing certain diseases. We may ask:
Is your family in good health? Are your parents alive, healthy or suffering of diseases? Which are those
diseases? If they are dead, which was the cause of death and at what age did that happen?
Ask the same questions for grandparents (and note only the diseases genetically or hereditary
transmitted- for example hemophilia, polyposys).
These questions will also be addressed concerning children and spouse, but will be supplemented with
information about infectious diseases.
We may mention diseases connected to certain habits or diets (hypertension, ulcer, chronic obstructive
airway disease) for those living in the same place.
It is possible that the patients forget, so we must ask about multi-factorial and polygenic (complex)
disorders (asthma, autoimmune diseases, cancer, diabetes, heart disease, hypertension, obesity, mood
disorders).
Some areas of the family history may need detailed questioning, for example to determine if there is a
significant history of heart disease or cancer.
We must be very careful when asking about a family history of malignancy: "I know this is difficult but
it is important for us to have the correct information..." On one hand, it may be useful to perform a
prophylactic screening in the family, but on the other hand we must not induce the idea of malignancy
especially in anxious patients.
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Physical Examination
1.2.6 Social history (SH)
Social history will detail social conditions that may be connected with diseases or risk factors for
disease:
- It is important to find out the conditions at home, how many persons are living together,
whether the patient lives in a house or an apartment, whether there are stairs and how many of
them (especially in the elderly)
- Occupation; are there difficult or dangerous conditions at work (exposure to chemicals, dust,
gas, heat or cold etc)?; duration of employment in those work conditions; unemployment may
be a source of stress and poor feeding
- Marital status; Spouse's job and health.
- Who visits - family, neighbors, general practitioner, nurse?
- The person needs special assistance? If the patient has limited mobility, are there walking aids
needed?
- Who does the cooking and shopping? Is there anything the patient can't do due to illness?
- Hobbies
- Sources of stress or anxiety
1.2.7 Habits
We ask questions concerning:
- Nutrition and diet; intake of salt, coffee, fat, sugar
- Sedentary or active life
- Alcohol, tobacco: How much? For how long? When did you stop? Quantify alcohol intake in
terms of grams and smoking in terms of number of cigarettes smoked in a day and number of
years of smoking. Frequently the patients may underestimate how much they drink and smoke,
so we sometimes have to increase the quantities declared, especially when there are physical
signs of abuse (eg rhinophyma).
- Recreational drugs, relationships and sexual history, sleep patterns.
1.2.8 Drug history (DH)

We must ask the patient if he takes any (regular) medication:
- if the answer is positive, we note the name and dosage
- are any of them over the counter drugs?
- any prescriptions?
- any herbal remedies?
- contraceptive pills?
- any known allergies?
- if none, record as no known drug allergies.
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Chapter 2
2.1 General data
The physical examination is the beginning of the physical contact between the patient and the
physician, who should take into account the following:
- most patients feel anxious when examined, that’s why we have to make them feel safe, secure and
very well taken care of
- a warm environment, with optimal lighting is needed while examining the patient; the
examination would be done better in a private room
- in the shortest time possible we have to examine the patient systematically, gently, while he is
undressed, in underwear; we have to make him understand that some discomfort may appear
while examining certain areas; in the meantime we should explain and reassure him of our entire
attention
- keep the patient informed to what we do, especially if he looks worried
- if symptoms are restricted to a specific body system we can use a less detailed examination; yet
we must not neglect the body as a whole- we might for instance discover an asymptomatic heart
murmure
- the right-side approach to the patient is considered the most appropriate: the jugular veins on the
right are more reliable for estimating venous pressure; the palpating hand is more comfortable on
the apical impulse; the right kidney is more frequently palpable than the left.
The recommended order for examining is:
a. General survey: observe the general state of health, stature and attitude, facial expressions,
reactions, state of awareness and level of consciousness
b. Vital signs: pulse, blood pressure, respiratory rate, body temperature
c. Skin: characteristics, lesions
d. Head: eyes, nose and sinuses, ears, mouth (lips, oral mucosa, gums, teeth, tongue), pharynx
e. Neck, the spine and muscles of the neck
f. Posterior thorax and lungs: inspect, palpate and percuss the chest; identify the level of
diaphragmatic dullness on each side; listen to the breath sounds, identify adventitious sounds,
listen to the transmitted voice sounds
g. Breasts, axillae
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h. Anterior thorax and lungs: inspect, palpate and percuss the chest; listen to the breath sounds,
identify adventitious sounds, listen to the transmitted voice sounds
i. Cardiovascular system: inspect and palpate the carotid pulsations; listen for carotid bruits;
observe the jugular venous pulsations; inspect and palpate the apex; listen to the normal or
abnormal heart sounds or murmurs
j. Abdomen: inspect, palpate, percuss and auscultate the abdomen; palpate the liver, spleen,
kidneys
k. Legs: musculoskeletal system, peripheral vascular system
l. Neurologic examination
m. Mental status
2.2 The parts of the physical examination:
2.2.1 Inspection
Inspection represents the first and very important part of examination based on the information
gathered by carefully regarding the patient. Even at first sight, only by looking at the patient, an
experienced doctor can recognize diseases like Parkinson, Basedow, acromegalia. Only by seeing a
patient, anemia, jaundice, cyanosis or obesity can be diagnosed.
The patient has to undress, keeping only the pelvic underclothing, and the females may cover their
chest with a towel at the beginning. The patient is sitting on the edge of the bed, unless the position is
contraindicated.
The doctor stays in front of the patient and examines all the body regions starting with the head and
finishing with the legs, moving to the either side as needed. Generally, in the beginning we examine the
skin, the head, the eyes, the nose and the sinuses, the mouth and pharynx, the neck, the spine and
muscles of the neck, the posterior thorax and lungs, the breasts, the axilla; then the patient lies down in
bed, the doctor comes to his right side and examines the anterior thorax and lungs, the cardiovascular
system, the abdomen and legs.
2.2.2 Palpation
Palpation allows the identification of tender areas, the assessment of observed abnormalities. It also
evaluates the volume, consistency and mobility of organs.
The doctor will have warm hands and watch the face of the patient while palpating, in order to detect
signs of discomfort or pain. In the beginning, the doctor uses a gentle palpation and then a stronger one,
using the tips or the pulps of the fingers or the palm of the hand.
The techniques are adapted to the examined area.
2.2.3 Percussion
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If the doctor is right-handed, he will hyperextend the middle finger of the left hand (the pleximeter
finger). Then he will press the distal interphalangeal joint firmly on the surface to be percussed. The
contact with any other part of the hand, which could disturb the vibrations must be avoided.
The right middle finger, partially flexed, relaxed, strikes the pleximeter finger with a quick, sharp, but
relaxed wrist motion. (fig.1)
The normal sounds generated by percussion are:
a. resonant sound: in the presence of air
- nontympanic resonance in the lungs
- tympanic resonance in certain areas of the abdomen
b. dullness: in airless tissues and organs such as the muscles, the heart, liver, spleen.
fig.1 Percussion of the abdomen
2.2.4 Auscultation
The auscultation uses the stethoscope, and it is a method that requires perfect silence in the
examination space.
It is important to avoid accidental contact between any part of the stethoscope and different objects
(hands, clothes), which could produce unwanted noises. The auscultation offers most information
on the respiratory and cardiovascular system. (fig.2)
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Fig 2. Auscultation of the thorax
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The Attitude (Position)
Chapter 3
The attitude describes the position, posture, in which the patient is laying in bed, giving information
especially in certain diseases. The attitude can be:
1. Normal, active, as of a normal person adopting a comfortable position.
2. Passive, in severe diseases, that make the patient lie in an indifferent position, as if unable to
stay otherwise
3. Forced (abnormal) position is a posture adopted by the patient in order to improve a certain
symptom.
a. Orthopnea: the patient is sitting up at the edge of the bed, upheld in his hands, or lies in bed
but uses some pillows to help him have his chest higher than the rest of the body. This is a
position adopted for avoiding or minimizing dyspnea in patients with heart failure or bronchial
asthma. (fig.3)
Fig. 3 Forced position Orthopnea
b. Lateral decubitus: lying in bed on the healthy part in the first part of a pleurisy (when the
pleura is inflamed), then on the involved side (when there is pleural effusion) may relieve pain
and dyspnea.
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c. “Knee-chest” or “Mahomedan position”: bringing down to one’s knees improves pain and
dyspnea in pericardial effusion (fig.4)
Fig.4 Forced position: “Knee-chest” or “Mahomedan position”
d. Ventral decubitus: the patient is bent and presses his epigastrium with his fist in peptic
ulcer, in order to relieve the pain.
e. “Gun-cock” position: patient is in lateral decubitus, with hyperextension of his head and his
calf flexed on the thighs, and the thighs flexed on the abdomen, which relieves the headache in
meningitis. (fig.5)
Fig.5 Forced position: “Gun-cock” position
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The Facies
Chapter 4
The Facies
The facial appearance (facies) is very characteristic for certain diseases, allowing the diagnostic (or at
least a high supposition for it) even at first sight.
1. Acromegalic face: in patients that have acromegaly, the head is elongated, with bony
prominence of the forehead, nose and lower jaw. The soft tissues of the nose, lips and ears are
also enlarged.
2. Cushingoid face: in patients with Cushing syndrome the face is round “as a moon”, with red
cheeks; in case of women: hirsutism, with excessive hair growth in the mustache and on the
chin.
3. Myxedematous face: in patients with severe hypothyroidism the face is puffy, with a dull
expression; the edema is present especially around the eyes and doesn’t pit with pressure. The
skin and hair are dry; the eyebrows are very thin or absent in the exterior part.
4. Hyperthyroidian face: in severe hyperthyroidia the eyes are widely open, as if “staring”, with
a bright look and bilateral exophtalmia.
5. Mitral face: in severe mitral stenosis the face is pale, but with cyanosis of the cheeks, lips and
nose.
6. Parkisonian face: in Parkinson disease the face has a decreased mobility, giving the appearance
of a mask, with decreased blinking and a characteristic stare.
7. “Butterfly like” face: in systemic lupus erythematosus an erythematous plaque is covering the
nose and the cheeks (creating the image of a butterfly).
8. Rhinofima: represents a big, deformed, lobated nose, characteristic in alcoholic patients.
9. Diabetic rubeosis: in diabetic patients there may appear a light red and round face.
10. Congestive face: in patients with high fever, particularly in case of pneumonia, the face is
intensely red.
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Height, weight and body mass index
Chapter 5
Height, Weight and Body Mass Index
5.1 The height

The height of the patient, which has variations according to age, sex and also to other individual factors
(genetic, hormonal, nutritional and environmental), will help especially in correlation with other data:
the patient’s body growth pattern over time, muscular development, sexual maturity rating, attitude.
The height growth is approximately uniform until adolescence, when it has a spectacular spurt. The
musculoskeletal proportions also vary in time, according to sex.
In the elderly the converse modifications are noticed, with the decrease of the height.
5.2 The weight

The normal weight is still a very controversial problem, influenced by medical reasons, but also by
other factors such as cultural and aesthetic preferences. Even the interpretation of lots of statistic
available data is prone to scientific discussions.
5.3 In order to harmonize all the arguments, there is an index that is mostly used called the Body
mass index (BMI), which is closely related to both the percentage of body fat and the total body fat.
Body mass index = Weight (kg) / Height (m2)
BMI = kilograms / meters2
Normal BMI: 18,5-24.9 kg/m2
5.4 Weight gain

Weight gain is an increase in body weight. This can be either an increase in muscle mass, fat deposits,
or body fluids.
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have
an adverse effect on health.
It is defined by body mass index (BMI) and further evaluated in terms of fat distribution via the waist–
hip ratio and total cardiovascular risk factors.
BMI is closely related to both the percentage of body fat and the total body fat.
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Height, weight and body mass index
- Overweight: 25-29.9 kg/m2

- Obesity Class I: BMI 30-34.9 kg/m2
Class II BMI 35-39.9 kg/m2
Class III BMI ≥40 kg/m2
Obesity increases the risk of many physical and mental conditions. These comorbidities are most
commonly shown in the metabolic syndrome, a combination of medical disorders which includes:
diabetes mellitus type 2, high blood pressure, high blood cholesterol, high triglyceride levels.
Weight gain is also associated with obstructive sleep apnea, certain types of cancer, and osteoarthritis.
As a result, obesity has been found to reduce life expectancy.
It is important to question the patient:
- how often he checks his weight
- when did the weight gain begin
- what was going on in the patient’s life during the periods of weight gain
- whether he tried to lose weight and what were the results
- whether his weight changed in the last year and in what manner.
5.5 Weight loss

Weight loss is a reduction of the total body mass, due to a mean loss of fluid, body fat or adipose tissue
and/or lean mass, namely bone mineral deposits, muscle, tendon and other connective tissue.
Underweight is defined by a BMI < 18.5 kg/m2 .
Unintentional weight loss occurs in many diseases and conditions, including some very serious
diseases:
- cancer is a very common and sometimes fatal cause of unexplained (idiopathic) weight loss.
About one-third of unintentional weight loss cases are secondary to malignancy. First to suspect
in patients with unexplained weight loss are gastrointestinal, prostatic, hepatobillary, pancreatic,
ovarian, hematologic or lung neoplasm
- AIDS can cause weight loss and should be suspected in high-risk individuals presenting with
weight loss
- gastrointestinal disorders are the most common non-cancerous cause of weight loss. Possible
gastrointestinal etiologies of unexplained weight loss are celiac disease, peptic ulcer,
inflammatory bowel disease, pancreatitis, gastritis, diarrhea
- infections; some infectious diseases can cause weight loss. These include fungal illness,
endocarditis, many parasitic diseases, and some other sub-acute or occult infections
- poor management of type 1 diabetes mellitus, hyperthyroidism.
- renal disease (frequent accompanied by poor or absent appetite, emesis and nausea),
cardiovascular disease (especially congestive heart failure), pulmonary disease, connective tissue
diseases, neurologic diseases, including dementia
In conditions of weight loss, we have to question the patient if the intake of food has diminished
proportionately, or whether it remained the same.
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Skin examination
In case of malnutrition there may appear other accompanying symptoms, often subtle and nonspecific:
weakness, cold intolerance, edema, pallor, dermatitis.
Chapter 6
Skin Examination
6.1 The color
The normal skin color depends on some particular and individual characteristics such as race, age,
content of melatonin, dermal blood supply.
Variations in skin color:
a. Brown:
- increased deposition of melanin: constitutional (rasial pigmentation), in case of long exposure to
sunlight, pregnancy- especially on the face, nipples, linea alba
- Addison’s disease- generalized or in exposed areas, parts pressed by tight clothing, axilae, palmar
creases
- hemochromatosis- generalized
- Peutz-Jegher’s syndrome: pigmented macules of 1-5 mm on lips, oral mucosa and fingers
b. Blue (cyanosis): in case of increased amount of deoxyhemoglobin (reduced hemoglobin) in the
blood, secondary to hypoxia; it may be:
a. peripheral (capillary)
- due to an increased tissue extraction of oxygen, in case of: exposure to cold environment, shock,
venous stasis (trombophlebitis, varices), acrocyanosis
- appears in nails, lips, or the affected area (the affected limb in case of trombophlebitis);
- cyanosed extremities are cold
- does not affect the tongue and oral mucosa.
b. central (arterial)
- it appears in heart or lung disease due to a reduction in the oxygen saturation of arterial blood
- the main causes: respiratory diseases (chronic obstructive pulmonary disease type B, pulmonary
embolism), cardiovascular diseases (heart failure, pulmonary edema, congenital heart diseases)
- cyanosed extremities are warm
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Skin examination
- it is generalized, therefore it also appears in buccal mucosa, tongue, lips, nails.

c. reddish blue: appearing in polycythemia in face, conjunctiva, mouth, hands, feet
d. yellow:
- jaundice: increased bilirubin levels in case of liver disease or red blood cell hemolysis; appears in
conjunctiva first, then in other mucous membranes, then may become generalized
- chronic uremia: pale-yellowish color because of retention of urinary chromogens, together with pallor
of anemia in case of chronic renal failure
e. decreased color (palor):
- anemia: decreased amount of oxyhemoglobin
- shock, syncope: decreased blood flow in superficial vessels
- peripheral artheriopathy : peripheral ischemia
f. decreased pigmentation: decrease or absence of melanin: albinism: congenital inability to
form melanin, vitiligo: acquired loss of melanin
6.2 Moisture
Normally the skin has a slightly moist surface.
Modifications:
- dryness: in hypothyroidism, congenital ichthyosis
- oiliness: in acne vulgaris
- excessive sweating: in fever, hypoglycemia, hyperthyroidism, shock.
6.3 Turgor
When lifting a fold of the skin between the thumb and forefinger and then releasing it, normally the
skin immediately restores the first appearance.
Turgor is decreased in case of dehydration.
6.4 Lesions of the skin
6.4.1 Primary lesions:

a. circumscribed, flat, nonpalpable changes in skin color: macule, patch
- The macule is small, up to 1 cm (e.g. petechia)
- The patch is larger than 1 cm (e.g. vitiligo)
b. palpable elevated solid masses: papule, plaque, nodule, tumor, wheal
- The papule is up to 0.5 cm (e.g. an elevated nervus).
- The plaque is a flat, elevated surface larger than 0.5 cm, often formed by the coalescence of
papules.
- The nodule is 0.5 to 1-2 cm, often deeper and firmer than a papule.
- The tumor is larger than 1-2 cm.
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Skin examination
- The wheal is a somewhat irregular, relatively transient, superficial area of localized skin edema
(e.g. mosquito bite).
c. circumscribed superficial elevations of the skin formed by free fluid in a cavity
within the skin layers: vesicle, bulla, pustule
- The vesicle is up to 0.5 cm, filled with serous fluid (e.g. herpes simplex)
The bulla is greater than 0.5 cm, filled with serous fluid (e.g. 2nd degree burn)
- The pustule is filled with pus (e.g. acne, impetigo).
6.4.2 Secondary lesions:
a. loss of skin surface: erosion, ulcer
- The erosion is the loss of the superficial epidermis (e.g. moist area after the rupture of a vesicle, as in
chickenpox)
- The ulcer is a deeper loss of skin surface that may bleed and scar (e.g. stasis ulcer of venous
insufficiency).
b. material on the skin surface: crust, scale
- The crust is the dried residue of serum, pus or blood (e.g. impetigo)
- The scale is a thin flake of exfoliated epidermis (e.g. dandruff, dry skin, psoriasis).
6.5 Vascular and purpuric lesions of the skin
6.5.1 Purpuric lesions of the skin

Purpura is the appearance of red or purple discolorations on the skin that do not blanch on applying
pressure. The difference of the its three forms of manifestation relies on its size:
- petechiae ≤ 3 mm,
- purpura 3–10 mm
- ecchymoses > 10 mm
They appear in bleeding disorders.
6.5.2 Vascular lesions of the skin
- telangiectasias (also known as spider veins) are small dilated blood vessels near the surface of the skin
or mucous membranes, measuring between 0.5 and 1 millimeter in diameter
- spider angioma: is a type of telangiectasis found slightly beneath the skin surface, often containing a
central red spot and reddish extensions which radiate outwards
- venous star: is a small red nodule formed by a dilated vein in the skin, often caused by increased
venous pressure such as in varicose veins
- cherry angioma: are cherry red papules on the skin containing an abnormal proliferation of blood
vessels.
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Skin examination
6.6 The venous collateral circulation
The venous collateral circulation is a particular type of dilatation of blood vessels on the abdomen or
anterior thorax, in case of obstruction of the blood flow through one of the three main veins: superior
vena cava, inferior vena cava and the portal vein.
a. The porto-cav type (caput medusae) appears like dilated cutaneous veins around the
umbilicus in liver cirrhosis and portal vein thrombosis.(fig.6a)
b. The inferior cavo-cav type appears mainly on the abdomen, being caused by ascites,
abdominal tumors (fig.6b)
c. The superior cavo-cav type appears on the superior part of the thorax, being caused by
an obstacle on the superior vena cava (most frequent mediastinal tumor). (fig.6c)
Fig.6 Venous collateral circulation

a. The porto-cav type
b. The inferior cavo-cav type
c. The superior cavo-cav type
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Edema
Chapter 7
Edema
Edema represents the accumulation of excessive interstitial liquid in the subcutaneous tissue, when the
movement of fluid out of the bloodstream exceeds the returning flow into the bloodstream.
An important sign that reveals edema is pitting edema. We press firmly but gently with the thumb for at
least 4-5 seconds and notice that there remained a depression caused by the pressure.
Causes of edema may be divided into:
a. General or systemic causes:

a. congestive heart failure:
- mechanisms: the decreased ability of the heart to accept venous blood increases the pressure in the
veins and capillaries, leading the fluid into the tissues; the impairment of renal blood flow; secondary
hyperaldosteronism; increased secretion of antidiuretic hormone; decreased oncotic pressure
- the edema first appears in the inferior part of the body (legs, feet), where the pressure is the highest;
- the edema is resorbed while lying down in bed (dorsal decubitus), that’s why the edema may
disappear or diminish until morning and increase during the day, being most prominent in the evening
- the edema is symmetrical
- the color of the skin is white in the beginning, but turns bluish (cyanotic) while the heart failure
progresses.
b. hypoalbuminemia
- mechanism: the decrease of the colloid osmotic pressure allows fluid to escape into the interstitial
space
- causes: cirrhosis, nephritic syndrome, nephrotic syndrome, severe malnutrition
- the color of the skin is white
- it is a pitting non-tender edema
- when the edema is caused by renal diseases the edema usually begins at face, especially in the
eyelids, mainly in the morning, after rest at bed in the night
- in cirrhosis and malnutrition the edema appears in dependent areas, then it becomes generalized
(anasarca);
- in cirrhosis ascites may appear first
c. excessive retention of salt and water:
20
Edema
- in case of administration of corticosteroids or estrogens, an excessive amount of water is retained, part

of it running into the interstitial space;
- the edema usually starts in the dependent areas and then becomes generalized.
b. Local causes:
- venous stasis (in case of thrombophlebitis or chronic venous insufficiency): the increased pressure in
the veins and capillaries produces run of fluids into the tissues; the edema is limited to the area of
blockage (often one leg)
- lymphatic stasis (in case of congenitally abnormal or obstructed lymph channels- by tumor or
inflammation): the edema is local, involving the affected area
- prolonged dependency (orthostatic edema, produced by prolonged sitting or standing without
sufficient muscular activity to promote venous flow) increases the pressure in the veins and capillaries;
it appears in dependent areas (eg the legs)
- inflammatory edema is accompanied by red, warm skin and pain.
c. Both general and local causes:

- increased capillary permeability (in case of allergies, burns) allows proteins to run into the
interstitial space, and together with them, they also attract fluids (by increasing the interstitial colloid
osmotic pressure). A particular form is angiooedema or Quincke's edema, in which the skin of the face
and the mucosa of the mouth, the tongue and/or throat, swell up in minutes or hours. The swelling can
also occur elsewhere, typically in the hands.
21
The hair and the nails
Chapter 8
The Hair and the Nails
8.1 The hair
While inspecting and palpating the hair, we note the quantity, distribution and texture.
Hirsutism is the increased growth of hair in women in those parts of the body where it does not
normally occur or is minimal - for example, a beard or chest hair.
Main causes: Cushing syndrome, polycystic ovary syndrome, tumors in the ovaries, congenital adrenal
hyperplasia, growth hormone excess (acromegaly), drugs: corticosteroids, phenytoin, certain anabolic
steroids.
Hypertrichosis is an abnormal amount of hair growth over the body.
It may be congenital or secondary (cancer, metabolic disorders, hormone imbalances such as
hyperthyroidism, or as side effect of certain drugs: minoxidil).
Alopecia represents hair loss that can be total, diffuse or in areas.
Main causes: fungal infection, traumatic damage, radiotherapy or chemotherapy, nutritional
deficiencies such as iron, autoimmune diseases.
8.2 The nails
While inspecting and palpating the fingernails and toenails we note the color, shape and lesions.
Leukonychia represents a white discoloration of the nails.
It may accompany hypoalbuminaemia in chronic liver disease.
In leukonychia punctata (the most common form of leukonychia) small white spots appear on the
nails.
In most cases, when white spots appear on a single or a couple of fingers or toes, the most common
cause is injury to the base (matrix).
Clubbing (also known as drumstick fingers and watch-glass nails) is a deformity of the fingers by an
increased convexity of the nail fold and thickening of the whole distal (end part of the) finger
(resembling a drumstick).
Clubbing of the fingers appears in:
22
The hair and the nails
a. Chronic respiratory diseases: suppurative lung disease (lung abscess, empyema,

bronchiectasis, cystic fibrosic), lung cancer, tuberculosis, arteriovenous fistula or
malformation, interstitial lung disease
b. Chronic cardiovascular diaseases: congenital cyanotic heart disease, infective
endocarditis, atrial myxoma
c. Other chronic diseases: malabsorption, Crohn's disease and ulcerative colitis, cirrhosis.
Koilonychia (spoon nails) is an abnormally of the nails (usually of the hand) which have lost their
convexity, becoming flat or even concave in shape. In a sense, koilonychia is the opposite of nail
clubbing.
It can be a sign of hypochromic anemia, especially iron-deficiency anemia (fig.7)
Fig.7 Koilonychia
Splinter hemorrhages are tiny blood clots that tend to run vertically under the nails. At first they are
usually plum-colored, but then darken to brown or black in a couple of days.
They associate with subacute bacterial endocarditis, scleroderma, trichinosis, systemic lupus
erythematosus (SLE), rheumatoid arthritis, antiphospholipid syndrome. (fig.8)
Fig.8 Splinter hemorrhages
23
The hematologic system
Chapter 9
The Hematologic System
9.1 Anemia
Patients with anemia may be asymptomatic for a long time, unless the decrease in hemoglobin is
sudden or severe. General complaints are: fatigue, headache, vertigo, nausea, amenorrhea, coldness and
numbness of the fingers.
If anemia becomes moderate or severe, it leads to dyspnea, palpitations, syncope, decreases the
threshold for angina pain, intermittent claudication or ischemic attacks.
In most cases mild anemia does not modify the physical examination. Moderate or severe anemia
presents with pallor of the nail beds, palmar creases and conjunctivae.
The iron deficiency anemia, which is the most frequent etiologic form of anemia, is accompanied by:
- atrophic glossitis
- angular cheilitis (scaling at corners of mouth)
- koilonychia (spoon nails).
Glossitis and peripheral neuropathy may be seen in vitamin B12 deficiency.
9.2 Bleeding
Spontaneous bleeding or bleeding with minor trauma may appear in bleeding disorders, that can be
congenital or acquired.
Most often bleeding disorders present with epistaxis or easy bruisability.
Inherited bleeding disorders (congenital diseases, such as hemophilia) are generally known and
reported by patients. They present with abnormal bleeding at an early age. Milder inherited
coagulopathies manifest only during significant hemostatic stress. A previous surgery or dental
extraction without bleeding is an important argument against an inherited disorder. The family history
is also very important in the diagnosis of an inherited bleeding disorder. Congenital bleeding disorders,
involving the clotting mechanism, are more frequent in men.
In case the bleeding disorder is acquired (especially recently), the patients note and report the changes
(eg: bleeding while brushing the teeth in chronic hepatitis).
24
The hematologic system
The medication history can also suggest the etiology of the bleeding disorder, such as the chronic use of
anticoagulants (warfarin) or platelet antiaggregants (aspirin). Certain antibiotics may associate with
immune-mediated platelet destruction.
Normal hemostasis requires:
- vasoconstriction following vascular injury
- platelet plug formation
- fibrin clot formation.
Disorders of the last two categories are most frequent involved in bleeding diseases.
A platelet disorder is suggested by superficial bleeding involving the skin, mucous membranes,
gastrointestinal and urinary tracts. Typical findings are:
- petechiae of the skin and mucous membranes
- small ecchymosis.
Bleeding occurs immediately after trauma, because the platelet plug isn’t properly formed.
Bleeding within the oral mucous membranes (wet purpura) increases the risk of more severe bleeding.
A clotting disorder is suggested by bleeding deep in the tissues, affecting mainly joints and body
cavities (e.g. pleura) and manifesting as:
- large ecchymosis
- deep hematomas (local masses of blood)
- hemarthroses (presence of blood in the joints), that lead in time to joint deformities.
Because platelet function is normal, bleeding may not appear immediately after trauma, but after
several hours or even days.
Bleeding due to a vascular defect resembles to to that caused by a platelet disorder and may associate
with it.
25
The temperature
Chapter 10
The Temperature
The normal temperature of an adult (measured in the mouth or in the axilla) is of average 36.3–37 °C.
Diurnal variations are normal, with the lowest value in the morning and the highest in the afternoon.
Modifications of this normal body temperature are:
1. hypothermia ≤ 35ْC
2. fever > 37ْC (with the particular case of low-grade fever 37-37,5 °C)
3. hyperpyrexia: ≥ 41.1ْC
Fever (also known as pyrexia or hyperthermia) is a common medical sign characterized by an
elevation of temperature above the normal range due to an increase in the body temperature regulatory
set-point. This increase in set-point triggers increased muscle tone and shivering.
As the temperature increases, a feeling of cold and shivering appears. Once the new temperature is
reached, a feeling of warmth is experienced.
Fever can be caused by many different conditions ranging from benign to potentially serious:
infections, cancer, immunologic diseases, hematological diseases, infarction, trauma (surgery, crushing
syndrome).
The pattern of temperature changes may occasionally guide the diagnosis:
1. Continuous fever: temperature remains above normal throughout the day and does not fluctuate
more than 1 °C in 24 hours, e.g. lobar pneumonia, urinary tract infection, brucellosis, typhoid
fever or typhus. A fast decrease of the fever is called “in crisis”, while a gradually end is called
“in lysis” (fig.9).
fig 9 Continuous fever

26
The temperature
2. Intermittent fever: elevated temperature is present only for some hours of the day and becomes
normal for remaining hours, e.g., malaria, kala-azar, septicemia. In malaria, there may be a
fever with a periodicity of 24 hours (quotidian), 48 hours (tertian fever), or 72 hours (quartan
fever, indicating Plasmodium malariae). These patterns may be less clear in travelers (Fig.10).
fig 10 Intermitent fever
3. Remittent fever: temperature remains above normal throughout the day and fluctuates more than
1 °C in 24 hours, e.g., infective endocarditis (Fig.11).
fig 11 Remittent fever
27
The temperature
4. Pel-Ebstein (undulant) fever: a specific kind of fever associated with Hodgkin's lymphoma,
being high for one week and low for the next week and so on (Fig.12).
Fig 12 Pel Ebstein fever
Febricula is an old term for a low-grade fever, especially if the cause is unknown, no other symptoms
are present, and the patient fully recovers in less than a week.
Repeated low grade-fever (37-37,5 °C) may also accompany serious or chronic diseases (such as
cancer, connective tissue disease, chronic infections).
Hyperpyrexia is a fever with an extreme elevation of body temperature greater than or equal to 41.5
°C. It is considered a medical emergency as it may indicate a serious underlying condition or lead to
significant side effects.
Possible causes: intracranial hemorrhage (the most common cause), sepsis, Kawasaki syndrome,
neuroleptic malignant syndrome, drug effects, serotonin syndrome, thyroid storm, viral infections
(roseola, rubeola, enteroviral infections).
Infections are the most common cause of fevers, however as the temperature rises, other causes become
more common.
28
The head and the neck
Chapter 11
The Head and the Neck
11.1 Headache
Headache is an very common symptom, defined as pain anywhere in the region of the head or neck. It
can be a symptom of a number of different conditions of the head and neck.
A primary headache isn't a symptom of an underlying disease, but may be caused by overactivity of
pain-sensitive structures of the head, possibly with a genetic predisposition of experiencing it.
The most common primary headaches are:
1. Cluster headache: severe pains that occur together in bouts
2. Migraine (with and without aura) tends to be pulsating in character, affecting one side of the head,
associated with nausea, disabling in severity, and usually lasts between 3 hours and 3 day
3. Tension-type headache is usually bilateral; may be generalized or localized to the back of the head
and upper neck or to the frontotemporal area; it appears gradual, lasts a variable time, is often recurrent
or persistent over long periods; it is frequently associated with anxiety, tension, depression
4. Trigeminal autonomic cephalalgia
5. Hemicrania continua (continuous headache on one side of the head).
Some primary headaches can be triggered by lifestyle factors, including alcohol, certain foods, such as
processed meats that contain nitrates, changes in sleep or lack of sleep, incorrect posture, skipped
meals, stress.
Secondary headache is a symptom of a disease that can activate the pain-sensitive nerves of the head.
Many conditions, varying greatly in severity, may cause secondary headaches:
- dental pathology, acute sinusitis, ear infections, glaucoma
- dehydration, hangover
- encephalitis, meningitis, stroke, intracranial hematoma, intracranial hypertension of any cause,
brain arteriovenous malformation, brain aneurysm, brain tumor, carotid or vertebral dissections,
concussion, post-concussion syndrome
- influenza, toxoplasmosis
- side effect to lots of drugs, including overuse of pain medication, monosodium glutamate
- panic attacks, trigeminal neuralgia
- cervical spondylosis
We must careful ask the patient whether the discomfort is one-sided or bilateral and whether it is steady
or throbbing.
The chronological pattern is the most important attribute of the headache. The patient should describe
whether the pain has recently appeared or whether it is a chronic, recurring one. Again an important
29
aspect is whether an old chronic pain has recently changed its character. He must describe the moment
of the day when the pain reappears and whether there are associated symptoms.
We must also ask the patient if coughing, sneezing or changing the position of the head affects the
headache.
11.2 The eyes:
We have to ask about visual disturbances and their onset (sudden or gradual).
Gradual blurring may be caused by refractive errors but also by diabetes.
Hyperopia (farsightedness) causes difficulties with close work; same difficulties appear with
presbyopia (aging vision); myopia causes problems in correctly dealing with objects in distance
(myopia)
Diplopia (double vision) indicates a weakness or paralysis of one or more extraocular muscles.
Scotoma is an area of partial alteration in the field of vision consisting of a partially diminished or
entirely degenerated visual acuity that is surrounded by a field of normal vision.
Inspect the position and alignment of the eyes, inspect eyebrows, eyelids, lacrimal apparatus,
conjunctiva and sclera, conjunctiva, cornea, iris, lens; compare pupils and test their reactions;
extraocular movements;
Exophthalmia is the protrusion of the eye anteriorly out of the orbit. It can be :
- bilateral : in thyrotoxicosis (Graves' disease)
- unilateral : in orbital tumor; complete or partial dislocation from the orbit is also possible from
trauma or swelling of surrounding tissue resulting from trauma.
Enophthalmia is the term that describes eyes that are abnormally sunken in the orbit. It can be:
- bilateral: severe dehydration, peritonitis
- unilateral: Horner’s syndrome (Claude Bernard-Horner syndrome): unilateral enophtalmia, ptosis
of the superior eyelid, miosis, sometimes accompanied by decreased sweating (anhidrosis) of the
face on the same side.
Xanthelasma is a sharply demarcated yellowish deposit of fat underneath the skin, usually on or
around the eyelids.
It may have a hereditary component, but where there is no family history of xanthelasmata, they
usually indicate high cholesterol and may correlate with a risk of atheromatous disease.
The sclera
Normal white color of the sclera can turn to:
- yellow- in jaundice
- red –in inflammations, polyglobulia
The cornea
Cornea is normally bright and transparent. Abnormal findings could be:
- arcus senilis corneae is a white or gray opaque ring in the corneal margin; it is quite commonly
present in the elderly. It can also appear earlier in life as a result of hypercholesterolemia
30
- Kayser-Fleischer ring is a brownish-yellow ring visible around the corneo-scleral junction; it consists
of copper deposits and is a sign of Wilson’s disease
Xerophthalmia is the abnormal dryness of the eyes that can be caused by:
- deficiency in vitamin A
- aging, poor lid closure, scarring from previous injury
- autoimmune diseases: rheumatoid arthritis, Sjögren's syndrome (in which it is accompanied by
xerostomia), radioiodine therapy.
The conjunctiva examination of the inferior lid gives us details in:
- anemia: pale color
- conjunctivitis: redness and edema
- subconjunctival hemorrhage: a red area that will turn to yellow and then disappear in days.
11.3 The nose
We ask and notice if there is rhinorrhea (nasal discharge), often associated with nasal stuffiness; they
may occur with sneezing, watery eyes, itching;
Possible causes:
- viral infections,
- allergic rhinitis (often accompanied by itching), symptoms being in relation to seasons or certain
environment
- vasomotor rhinitis
- oral contraceptives, reserpine and alcohol
Epistaxis means bleeding from the nose and it may have:
- local causes (trauma, inflammation, tumors, foreign bodies)
- general causes: bleeding disorders
11.4 The mouth and the pharynx
11.4.1 Abnormalities of the lips
Herpes simplex is a viral disease caused by herpes simplex virus type 1 and type 2.
It may produce recurrent vesicular eruptions of the lips and surrounding tissues. Then will develop a
small cluster of blisters, and as these are breaking, a crust will be formed, with healing in 10-14 days.
Primary orofacial herpes is easily recognized in patients with no previous history of lesions and contact
with a person with known HSV-1 infection. The multiple, round, superficial oral ulcers are frequently
accompanied by acute gingivitis.
31
Cheilitis is the inflammation of the lips that may include the perioral skin, the border and/or the labial
mucosa. The skin and the vermilion border are more commonly involved, as the mucosa is less affected
by inflammatory and allergic reactions. There are many recognized types and different causes:
- local causes that induce dryneness, also lip licking, biting or rubbing habits
- general causes: nutritional deficiencies (iron, B vitamins, folate), hematologic diseases, cancer,
HIV infection, immunologic diseases
Angular stomatitis is the inflammation of one both of the corners of the mouth. It is a type of cheilitis
(inflammation of the lips).
Causes
- local causes: infection with Candida, certain bacteria (such as Staphylococcus aureus, β-
hemolytic streptococci) or a combination of them
- irritation contact dermatitis
- nutritional deficiencies of vitamins or minerals: iron deficiency or deficiency of B vitamins
- systemic disorders: anorexia nervosa, granulomatosis Sjögren's syndrome, Crohn's disease,
ulcerative colitis
- drugs may cause angular cheilitis as a side effect, by various mechanisms: drug induced
xerostomia (to isotretinoin, indinavir), primary hypervitaminosis A, recreational drugs
(cocaine, methamphetamines, heroin and hallucinogens)
- allergic contact dermatitis
Angioedema is a diffuse, non-pitting, tense swelling of the dermis and subcutaneous tissue of the face
around the mouth, the mucosa of the mouth and/or throat and the tongue. It develops rapidly, over a
period of minutes to hours and it disappears in 1-2 days.
If the larynx is involved it can cause life-threatening asphyxiation.
It is classified in:
- Hereditary angioedema has three forms, all of which are caused by a genetic mutation inherited
in an autosomal dominant form
- Acquired angioedema: immunologic, nonimmunologic, or idiopathic
It is usually caused by allergy and it occurs together with other allergic symptoms and urticaria, or it
can also occur as a side effect to certain medications, particularly angiotensin converting enxyme
inhibitors.
Chancre is a painless firm buttonlike lesion (that will ulcerate and get a crust), formed during the
primary stage of syphilis, approximately 21 days after the initial exposure to Treponema pallidum. The
chancre may look like a carcinoma or a crusted sore; it is better to use glove for palpation in case of
these appearances.
Chancres transmit the sexually disease of syphilis through direct physical contact. The ulcers usually
form on or around the penis, vagina, but also mouth and anus. Chancres may diminish between four to
eight weeks without any treatment.
Peutz–Jeghers syndrome (hereditary intestinal polyposis syndrome) is a genetic disease characterized
by the development of benign polyps in the gastrointestinal tract and hyperpigmented macules on the
32
lips and oral mucosa (melanosis). The prominent pigmented spots can also be found on the face, fingers
and hands.
The risks associated with this syndrome include a strong tendency of developing cancer in multiple
sites.
11.4.2 Abnormalities of the buccal mucosa
Aphthous ulcer is a common form of benign and non-contagious mouth ulcer. It is characterized by
the repeated formation of small, round or oval white ulcers in the mouth, surrounded by a halo of red
mucosa.
It is a very common condition, affecting up to 20% of the general population.
They periodically occur as single or multiple ulcers and heal completely between attacks. Symptoms
range from minor pain, to interfering with eating and drinking, and more severe forms may be
debilitating.
The cause is not entirely clear and it is thought to be a multifactorial disease- a genetic predisposition
with possible triggers: nutritional deficiencies, local trauma, stress, hormonal influences, allergies.
Oral thrush is determined by accumulation of Candida albicans on the lining of the mouth.
It causes creamy white lesions, usually on the tongue or inner cheeks; the lesions can be painful and
may bleed. Sometimes oral thrush may spread to the roof of the mouth, gums, tonsils or the back of the
throat.
Although oral thrush can affect anyone, it's more likely to occur in:
- people with dental disease
- prolonged antibiotic or corticosteroids therapy
- gastrointestinal disorders: Celiac disease, inflammatory bowel disease (Crohn's disease,
ulcerative colitis)
- neutropenia
- nutritional deficiencies: vitamin B12, folic acid and iron
- immunocompromised states (eg HIV, cancer)
Oral thrush is a minor problem in healthy persons, but in the case of a weakened immune system,
symptoms of oral thrush may be severe and difficult to control.
11.4.3 Abnormalities of the gums and of the teeth
Gingivitis, which is the inflammation of the gum tissue, is a non-destructive periodontal disease.
It appears like redness and swelling of the margins of the gums; the normal stippling decreases or
disappears. Gums are tender or painful to the touch. Gums are bleeding spontaneously or after brushing
and/or flossing. Halitosis may add as well.
a. The most common form of gingivitis has a local cause, being the response to bacterial biofilms
(plaque) adherent to tooth surfaces
33
b. Non-plaque-induced gingival lesions may be:

- of genetic origin, or caused by:
- bacterial, viral, fungal infections
- traumatic lesions
- systemic conditions: hepatic and gastrointestinal diseases (chronic liver disease, Crohn’s disease,
ulcerative colitis, gastroesophageal reflux disease) hematologic disorders (anemias, histiocytosis),
connective-tissue disorders (Sjögren syndrome, Kawasaki disease), respiratory diseases (Wegener
granulomatosis, Sarcoidosis), multisystem conditions (amiloidosis), side effects to drugs (nonsteroidal
anti-inflammatory drugs, nicorandil, angiotensyne-converting enzyme inhibitors, calcium-channel
blockers, diuretics, antidepressants, beta-blockers, inhaled corticoids), HIV infection, cutaneous
diseases (psoriazis, acanthosis nigricans)
In the absence of treatment, gingivitis may progress to periodontitis, which is a destructive form of
periodontal disease.
Periodontitis is a set of inflammatory diseases affecting the periodontium, involving progressive loss
of the alveolar bone around the teeth, and if left untreated, can lead to the loosening and subsequent
loss of teeth.
Lead or bismuth line is a bluish black line appearing on the gums, about 1 mm from the gum margin,
in case of chronic lead or bismuth poisoning.
Melanin pigmentation is a brownish pigmentation of the gums that is normally appearing in blacks
and other dark-skinned persons; a similar pattern is present in Addison’s disease.
Hutchinson’s teeth are a sign of congenital syphilis. The teeth are smaller and more widely spaced
than normal and have notches on their biting surfaces.
A sore or painful tongue may have
- local causes: tongue injuries like accidentally biting the tongue, oral infection, aphthous ulcers,
herpes simplex virus; oral thrush, basically caused by Candida, tongue ulcer, poorly fitting
dentures, tongue cancer, neuralgia, prolonged smoking, chewing
- general causes: infections, cancer, disorders related to the digestive system, immune and
metabolic diseases
The accompanying symptoms are a burning sensation in the mouth, palate, lips, gums and tongue,
excessive thirst and a loss of the sensation of taste, a bitter or metallic taste in mouth.
11.5 The ears:
Pain in the ear suggests a problem in the external or middle ear but may also be referred from other
structures in the mouth, throat or neck.
We have to question about hearing; in case of any hearing loss we must ask if it involves one or both
ears, and if it started suddenly or gradually;
There are two basic types of hearing impairment:
- conduction loss (results from problems in the external or middle ear)
- sensori-neural loss (resulting from problems in the inner ear)
34
Tinnitus, which means a perceived sound with no external stimulus, may accompany hearing loss.
Vertigo is a type of dizziness, where there is a feeling of motion when one is stationary.
The symptoms are due to a dysfunction of the vestibular system in the inner ear. It is often associated
with nausea and vomiting as well as difficulties standing or walking.
Vertigo is classified into either peripheral or central depending on the location of the dysfunction of the
vestibular pathway.
The most common causes are:
- benign paroxysmal positional vertigo
- vestibular migraine
Less common causes: Ménière's disease, vestibular neuritis. Excessive consumption of ethanol
(alcoholic beverages) can also cause notorious symptoms of vertigo
We have to note whether there is discharge from the ear (in case of acute or chronic otitis media).
11.6 The thyroid gland
Inspection
- normal aspect in a thin person: the thyroid is slightly visible below the cricoid cartillage (usually
not visible)
- a diffuse enlargement is called goiter
Palpation
Attempt to locate the thyroid isthmus by palpating between the cricoid cartilage and the suprasternal
notch.
Use one hand to slightly retract the sternocleidomastoid muscle while using the other to palpate the
thyroid. Ask the patient to swallow as you palpate, feeling for the upward movement of the thyroid
gland.
Note the size, shape, consistency, tenderness, mobility or presence of nodules.
35
The lymph nodes
Chapter 12
The lymph nodes
Lymph nodes are located throughout the body, but visible and palpable only when they are superficial
and are enlarged or swollen.
Lymph nodes are regional, and each group corresponds to a particular region of the body and reflects
abnormalities in that region:
- The cervical area
- The axillary area
- The arms and the legs
Their shape is round or oval; their size depends on their location and cause of enlargement: e.g. the
preauricular lymph nodes are very small (1-2 mm), while the inguinal nodes are large (up to 20 mm).
In order to palpate the lymph nodes we use the pads of the index and middle finger, moving the skin
over the underlying tissues in each area. The patient has to relax, with the neck slightly flexed forward
and, if needed, towards the side of the examination.
The lymph nodes in the area of the head and of the neck :
- occipital- at the base of the skull
- posterior auricular- behind the ear
- preauricular- in front of the ear
- submaxillary- midway between the angle and the tip of the mandible; if present, they are
generally smaller and smoother than the submaxilary gland (which can be bilaterally palpated
(felt) inferior and posterior to the body of the mandible, moving inward from the inferior border
of the mandible near its angle with the head tilted forward)
- submental- in the midline, a few centimeters behind the tip of the manible
- cervical chain- superficial to the sternomastoid and along the anterior edge of the trapezius
- supraclavicular- deep in the angle formed by the clavicle and the sternomastoid. (fig.13)
36
The lymph nodes
pre-auricular
posterior auricular
occipital
submaxillary
submental
cervical chain
supraclavicular
Fig 13 Lymph nodes in the area of the head and of the neck
The axillary lymph nodes:

- the most frequently palpable are the central group, located high in the axilla, midway between
the anterior and posterior axillary folds
- the pectoral (anterior) group, placed along the lower border of the pectoralis major;
- the subscapular (posterior) group, placed along the lateral border of the scapula
- the lateral group placed along the upper humerus.
The epitrochlear nodes are located on the medial surface of the arm, 2-3 cm above the elbow.
The inguinal nodes:
- the horizontal group: below the inguinal ligament
- the vertical group: in the superior and interior side of the thigh.
Lymphadenopathy defines an abnormality of the lymph nodes in size, number or consistency and is
often used as a synonym for swollen or enlarged lymph nodes. It frequently represents a benign self-
limited process, but may also be the present in severe diseases. For a normal person, an occasionally
and transient adenopathy may have 5-20 mm. But dimensions larger than 10 mm general require further
investigations.
If a lymph node is found, there should be described:
- the site: localized to one region or generalized
37
The lymph nodes
- the size: large size suggests lymphoma or leukemia

- consistency: toughness suggests cancer
- tenderness- present in inflammations
- mobility on underlying structures and overlying skin: immobility suggests cancer, with the
exception of chronic lymphatic leukemia, when they may be mobile.
Associated data may help the diagnostic:
- weight loss, night sweats suggest lymphoma, cancer or tuberculosis
- sore throat suggests mononucleosis or pharyngitis
- genital lesions suggest syphilis
- history of drug use or high-risk sexual behavior suggest HIV.
In patients older than 50 the malignant etiology is ≥ 50%, while in those younger than 30 the benign
etiology is present in ≥ 80%.
Causes of lymphadenopathy:
1. Generalized:
- reactive to infections: toxoplasmosis, mononucleosis, tuberculosis, cytomegalovirus, secondary
syphilis, HIV
- tumoral: acute and chronic lymphocytic leukemias, Hodgkin and non-Hodgkin lymphoma,
metastasis
- autoimmune etiology: systemic lupus erythematosus, rheumatoid arthritis
- storage diseases: Gaucher and Niemann-Pick
- sarcoidosis
- hypersensitivity reaction.
2. Localized
- reactive to: acute infection (e.g., bacterial or viral), or chronic infections (tuberculosis)
- carcinomatous metastasis
- the beginning of diseases which will later develop generalized lymphadenopathy (eg lymphomas).
There are special diseases to consider for any of the particular location:
a. Cervical adenopathy: mononucleosis, lymphoma, pharyngitis, toxoplasmosis, sarcoidosis
b. Supraclavicular adenopathy: mediastinal or pulmonary malignancy (right) , abdominal
malignancy (left)
c. Inguinal adenopathy: syphilis, herpes simplex, lymphogranuloma, chancroid.
d. Bilateral epitrochlear adenopathy: secondary syphilis
e. Unilateral adenopathy proximal to a bite or scratch: cat-scratch disease.
38
The musculoskeletal system
Chapter 13
13.1 Symptoms and signs
13.1.1 Pain
a. Pain in the joints
Joint pain is a common complaint in medical practice and may result from one of several known
causes.
Joint pain or arthralgia, can occur in one or more joints. It may result from different types of injuries,
infections, autoimmune diseases, tumors of the joint, gout, bone diseases.
b. The low back pain:
Low back pain (or lumbago) is a common musculoskeletal disorder affecting 80% of people at
some point in their lives.
Lower back pain may be classified by the duration of symptoms as:
- acute (less than 4 weeks)
- sub acute (4–12 weeks)
- chronic (more than 12 weeks).
Causes:
The majority of lower back pain comes from benign musculoskeletal problems, and they are called
‘non specific low back pain” (due to muscle or soft tissues sprain or strain, particularly in instances
where pain suddenly arose during physical loading of the back, with the pain lateral to the spine).
The differential diagnosis includes many other less common conditions.
a. Mechanical: apophyseal osteoarthritis, degenerative discs, Scheuermann's kyphosis,
spinal disc herniation, thoracic or lumbar spinal stenosis, spondylolisthesis, fractures
b. Inflammatory: seronegative spondylarthritides, rheumatoid arthritis, epidural abscess or
osteomyelitis
c. Neoplastic: bone tumors (primary or metastatic), intradural spinal tumors
d. Metabolic: osteoporotic fractures, osteomalacia, ochronosis, chondrocalcinosis
e. Psychosomatic: tension myositis syndrome
f. Paget's disease, Referred pain: pelvic/abdominal disease, prostate cancer, posture.
13.1.2 Stiffness
39
Stiffness represents a reduced range of motion of a painful joint that may appear in osteoarthritis,
rheumatoid arthritis, ankylosing spondylitis.
It is common after inactivity in degenerative joint diseases, but disappears in several minutes. In
inflammatory arthritides (eg rheumatoid arthritis) it lasts 30 minutes or longer.
13.1.3 Swelling
Swelling of the joint is caused by an increase of fluid in the joint or in the tissues that surround the
joints. Appears more frequent in: osteoarthritis, rheumatoid arthritis, gout, ankylosing spondylitis,
infectious arthritis, joint injuries.
13.2 The examination of the musculoskeletal system
1. There are examined the active movements, that are performed by the patient, and the passive
ones, that are performed by the examiner. A decreased range of motion is found in: arthritis,
inflammations of the tissues around the joint, fibrosis of the joint or around it, ankylosis
2. Signs of inflammation: swelling, tenderness, heat, redness
- swelling of the joint: synovitis, fluid in the joint, trauma
- tenderness: arthritis, tendonitis, bursitis, osteomyelitis
- heat: if it is associated with tenderness and thickned synovium, it suggests rheumatoid arthritis
- redness: together with tenderness suggests arthritis or rheumatic fever
3. Crepitation is the palpable or audible crunching produced by the movement of a joint or tendon;
suggests an inflamed joint or osteoarthritis
4. Deformities: in rheumatoid arthritis
5. The condition of the surrounding tissues: subcutaneous nodules in rheumatoid arthritis or
rheumatic fever
6. Muscular strength: muscular weakness and atrophy in rheumatoid arthritis
7. Symmetry of involvement: the involvement of one joint increases the likelihood of bacterial
arthritis; rheumatoid arthritis typically involves several joints, symmetrically distributed
We have to examine the temporo-mandibular joint, the hands and wrists, the elbows, the shoulders and
related structures, the ankles and feet, the knees and hips, the spine.
40
The respiratory system
Chapter 14
14.1.1 Chest pain

Chest pain or discomfort in the chest- frequently considered as heart disease, may often originate in
other structures as well:
14.1.1.1 Respiratory diseases

a. Pulmonary embolism is a blockage of the main artery of the lung or one of its branches by a
substance that has traveled from elsewhere in the body through the bloodstream (embolism);
Symptoms of pulmonary embolism are:
- sudden-onset dyspnea (shortness of breath)
- tachypnea (rapid breathing)
- chest pain of a "pleuritic" nature (worsened by breathing)
- cough and hemoptysis (expectoration of blood)
In severe cases there may appear:
- central cyanosis: blue discoloration, usually of the lips and fingers, but also the oral mucosa
- collapse and circulatory instability.
b. Pneumonia:
Is a sharp pain of “pleuritic” type (experienced during deep breaths or coughs or worsened by
them).
In infectious pneumonia the following are associated:
- dry cough in the beginning, then producing, brown, greenish or yellow sputum; sometimes
hemoptysis (expectoration of blood or blood material from the lungs)
- dyspnea (shortness of breath) is also common, with a high respiratory rate (tachypnea)
- loss of appetite, fatigue, headache, nausea, vomiting, mood swings, joint pains or muscle aches
- high fever that may be accompanied by shaking chills, sweaty and clammy skin
- tachycardia
- the face is flushed and herpes is often present.
41
c. Pleurisy (the inflammation of the pleura) presents with chest pain while inhaling and exhaling
(between breaths, there is almost no pain), shortness of breath, dry cough, fever and chills.
The sharp, fleeting pain in the chest is worsened by coughing, sneezing, moving and breathing,
especially deep breathing. In some cases, pain may extend from the chest to the shoulder. When the
accumulation of fluid appears (pleural effusion), the pain usually disappears. As fluid accumulates, it
puts pressure on the lungs, compressing and interfering with their normal function, causing or
worsening shortness of breath.
d. Pneumothorax represents the presence of air in the pleural space, usually unilateral.
The chest pain has the “pleuritic” character and is accompanied by dyspnea (whose degree depends on
the amount of the air in the pleura).
Non-respiratory causes of chest pain are important for the differential diagnosis:
14.1.1.2 Cardiovascular causes

a. Stable angina pectoris typically presents with chest pain located across the anterior chest, radiating
in the left shoulder, arm, hand and last two fingers, with constrictive character, precipitated by activity;
symptoms decrease in several minutes when stopping activity or taking nitroglycerine.
b. Acute coronary syndrome:
- unstable angina pectoris: the symptoms are very much alike stable angina pectoris, but changed or
worsened
- myocardial infarction: chest pain has also similar qualities as angina pectoris, but it is more severe, it
often appears at rest, lasts longer (20 min-several hours), is not alleviated by rest or by nitroglycerine,
but by morphine.
c. Aortic dissection presents with typically sudden, excruciating pain in the chest but is often also felt
in the back. Distinctive symptoms of aortic dissection: pulses in the arms and legs are diminished or
absent, it may cause a heart murmur, is frequently accompanied by syncope, hemiplegia, paraplegia.
d. Pericarditis (inflammation of the pericardium) has sharp or dull pain located in the center of the
chest and sometimes extends over the left shoulder; deep breathing, lying down, or swallowing may
make the pain worse. Sitting up and leaning forward may improve it.
14.1.1.3 Chest wall diseases: Tietze's syndrome, spinal nerve problem, fibromyalgia,
radiculopathy, breast conditions, herpes zoster.
14.1.1.4 Psychological causes, hyperventilation syndrome
14.1.1.1.5 Gastrointestinal diseases: gastroesophageal reflux disease, hiatus hernia,
neuromuscular disorders of the esophagus, functional dyspepsia, ulcer
14.1.2. Dyspnea
Dyspnea (shortness of breath) is a nonpainful, but uncomfortable awareness of breathing.
42

a. respiratory causes: chronic obstructive pulmonary disease, bronchial asthma,
pneumonia, diffuse infiltrative lung disease, pulmonary embolism, airway obstruction,
pulmonary fibrosis, alveolitis, sarcoidosis, pneumoconiosis, lung cancer, pleurisy
pneumothorax.
b. cardiovascular causes: left heart failure, mitral valve disease, pericarditis,
cardiomyopathy, pericarditis.
c. non-cardiorespiratory diseases: severe obesity, acidosis (renal failure, diabetic
ketoacidosis), neuromuscular diseases (polyomielitis, myasthenia gravis, amyotrophic
lateral sclerosis), ankylosing spondilitis, kyphoscoliosis, drug-induced respiratory
depression, increased intracranial pressure, anxiety with hyperventilation
Its severity must be evaluated according to the patient’s everyday activity.
Degrees of dyspnea
1 - dyspnea on heavy exertion
2 - dyspnea on moderate exertion
3 - dyspnea on slight exertion
4 - dyspnea at rest.
Clinical forms of dyspnea
Acute dyspnea is defined as severe shortness of breath that develops over minutes or hours.
Chronic dyspnea develops in weeks or months, being more severe in time if untreated.
Tachypnea: is an increase in the respiratory rate > 20/minute (normal respiratory rate: 14-18/min); it
may normally appear after effort, otherwise it appears in cardiovascular, some respiratory diseases
(such as pneumonia, pleurisy), and in non-cardiorespiratory diseases (such as anemia).
Bradypnea: is a decrease in the respiratory rate ≤12/minute; it is present in bronchyal asthma, drug-
induced respiratory depression, increased intracranial pressure.
Orthopnea is shortness of breath (dyspnea) which occurs when lying down, and improves upon sitting
up.
Patients with orthopnea sleep propped up in bed or sitting in a chair. Orthopnea helps breathing in
asthma because offers an easier function of the accessory respiratory muscles in this position.
Orthopnea is due to increased distribution of blood to the pulmonary circulation while recumbent in
case of left ventricular heart failure and/or pulmonary edema.
Other forms of dyspnea:
Cheyne-Stokes breathing: periods of increasingly deep breating alternate with periods of apnea (no
breathing); appears in heart failure, renal failure, drug-induced respiratory depression, brain damage.
Ataxic breathing (Biot’s dyspnea): unpredictible irregularity; it appears in respiratory depression,
brain damage.
Kusmaul breathing is a deep sighing inspiration and expiration appearing in ketoacidosis.
Obstructive sleep apnea is that type of sleep disorder in which pauses in breathing or periods with
shallow or infrequent breathing during sleep appear.
43
The pause in breathing, called an apnea, can last from at least ten seconds to several minutes, and may
occur 5 to 30 times or more an hour.
The abnormally shallow breathing event is called a hypopnea. In sleep apnea a block to airflow
appears, despite respiratory effort. Snoring is common. Patients with sleep apnea are rarely aware of
having a form of difficulty in breathing, even upon awakening. Symptoms may be present for years (or
even decades) before the diagnosis.
14.1.3 Cough
Cough is a sudden and often repetitive occurring reflex which helps clearing the large breathing
passages from secretions, irritants, foreign particles and germs.
The cough reflex consists of three phases: an inhalation, a forced exhalation against a closed glottis,
and a violent release of air from the lungs following opening of the glottis.
Cough is an important defense mechanism that plays a major role in maintaining the integrity of the
airways.
Cough is commonly triggered by mechanical or chemical stimulation of receptors in the pharynx,
larynx, trachea and bronchi. Cough receptors also exist in the nose, paranasal sinuses, external auditory
ear canals, tympanic membranes, parietal pleura, esophagus, stomach, pericardium and diaphragm.
The most frequent causes of cough are:
- laryngitis, tracheobronchitis, chronic bronchitis, asthma, bronchiectasis, viral and bacterial
pneumonia, pulmonary tuberculosis, lung abcess, endobronchial lesions (benign: bronchial
adenoma, carcinoid tumor, malignant: bronchogenic carcinoma, metastatic cancer), foreign body in
the airways, interstitial lung diseases, hypersensitivity pneumonitis, chronic interstitial pneumonia,
chronic aspiration, pleurisy, pneumothorax
- congestive heart failure, pericarditis, mitral stenosis, pulmonary emboli
- sarcoidosis, tumors of the neck, thyroid disorders
- gastroesophageal reflux disease
- treatment with angiotensin converting enzyme inhibitors
- psychogenic/habitual cough, irritating particles, chemicals or gases
- chest trauma
The cough may be:
- dry and irritating (e.g. in pleurisy, laringytis, external compression of the airways, pericarditis,
mitral stenosis)
- productive of sputum (e.g. in chronic bronchytis) or hemoptysis (e.g. in tuberculosis)
14.1.4 Expectoration (sputum)
Sputum represents matter (mucus) that is expelled through coughing from the lower airways.
44
Sometimes it is mixed with saliva, which can then be spat from the mouth. The best sputum samples
used for microbiological examination should contain very little saliva because this can contaminate the
sample with oral bacteria.
Sputum can be:
- white, milky, or opaque (mucoid) – that may suggest a viral infection
- whitish, sticky, with small particles like “pearls” in brochial asthma
- foamy white - may come from obstruction or even edema.
- rusty colored – in pneumococcal pneumonia
- mucopurulent (yellow-green)- containing a mixture of mucus and pus caused by bacterial infection
- completely purulent (e.g. in lung abcess)
- frothy pink - in pulmonary edema
- bloody - often found in tuberculosis (hemoptysis)
Large amount of purulent sputum is eliminated in bronchiectasis and lung abcess.
14.1.5 Hemoptysis
Hemoptysis is the expectoration (coughing up) of blood or of blood-stained sputum from the bronchi,
larynx, trachea, or lungs.
The most frequent conditions involving hemoptysis are:
- bronchitis, pneumonia, lung neoplasm, tuberculosis, bronchiectasis, pulmonary embolism, lung
abscess
- sarcoidosis, aspergilloma, histoplasmosis, coccidioidomycosis
- presence of a foreign body in the respiratory tract
- cystic fibrosis
- anticoagulant use, bleeding disorders.
Rarer causes include: hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome),
Goodpasture's syndrome, Wegener's granulomatosis.
Blood-laced mucus from the sinus or nose area can be sometimes be misidentified as symptomatic
of hemoptysis.
Cardiac diseases that may be accompanied by hemoptysis are: congestive heart failure, mitral
stenosis.
The origin of blood (coming from the airways or from the digestive tube) can be identified by some
characteristics:
- in case of origin in the respiratory tract (hemoptysis): the color is bright red, foamy, expelled by
coughing, mixed with sputum, the patient has a history of respiratory diseases
- in case of origin in the digestive tube (hematemesis) the color is dark red (looks like “coffee-
grounds”), eliminated by vomiting, mixed with food, the patient has a history of digestive diseases
14.1.6 Wheezing
45
Wheezing is a high-pitched musical respiratory sound (that ressembles whistling) that may be
audible both to the patient and to the others; the sound is variable with breathing, being most
prominent during expiration.
The sound is generated by gas flowing through narrowed or irregular airways. Generally, wheezing
is due to asthma, but a variety of other conditions may present with it, such as: chronic obstructive
pulmonary diasease, anaphylaxis, congestive heart failure, pneumonia.
A special type of wheeze is stridor. Stridor is a shorter, crowing sound which is often evident
during inspiration and expiration, but which is louder and longer during inspiration.
It is loud enough to be audible without the aid of a stethoscope. Stridor is almost universally
associated with mechanical or functional narrowing of the larynx or of the subglottic airways.
14.2 The examination of thorax and lungs
The patient must be undressed, examined in good light.

Inspect, palpate, percuss, auscultate and compare one side to the other.
We must examine the posterior thorax and lungs while the patient is in sitting position. When the
patient lies down, we examine the anterior thorax and lungs.
We examine:
- The patient’s color; note cyanosis
- The shape of the fingernails; note clubbing in chronic diseases
- The position of the trachea
- Evidence of respiratory distress
Observe the rate, rhythm, depth and effort of breathing.
14.2.1 Examination of the posterior chest
14.2.1.1 Inspection
The thorax in the normal adult is wider than it is deep (its lateral diameter is larger than its
anteroposterior diameter) (fig 14).
46
Fig.14 Normal chest
Examine the shape of the chest and the way in which it moves.
Localization of findings depends on their relation with the ribs, the vertebrae, and also with the
following guiding lines:
- the vertebral line (along the spinous processes)
- the scapular line (vertical from the inferior angle of the scapula)
- the posterior axillary line (vertical from the posterior axillary fold) (fig.15,16).
Deformities or asymmetries of the thorax
a. the barrel chest: has an increased anteroposterior diameter (fig.17)
b. thoracic kyphoscoliosis: abnormal spinal curvatures and vertebral rotation deform the chest.
We look for eventual abnormal retractions of the interspaces during inspiration: retraction in severe
asthma, chronic obstructive pulmonary disease or upper airway obstruction.
Note whether there is impairment in respiratory movement or unilateral lag or delay in that movement.
Vertebral line
Scapular line
Fig.15 Posterior chest

47
Posterior axillary line
Midaxillary line
Anterior axillary line
Fig.16 Right lateral chest
Fig.17 The barrel chest
48
14.2.1.2 Palpation
The palpation will be performed on both sides, symmetrically, from the apices to the lung bases.
We identify the spinous processes of the vertebrae: when the neck is flexed forward the most prominent
process is usually that of the 7th cervical; if two processes appear equally prominent, they are the 7th
cervical and 1st thoracic
Palpation helps:
 identification of tender areas in case of inflamed pleura
 assessment of observed abnormalities such as sinus tracts in tuberculosis or actinomycosis
 assessment of respiratory expansion: place thumbs about at the level of and parallel to the 10th
ribs, hands grasping the lateral rib cage; watch the divergence of the thumbs during inspiration
and feel for the range and symmetry of respiratory movement (fig.18). Unilateral decrease or
delay in chest expansion may appear in pulmonary fibrosis, pneumonia, pleural effusion or
fibrosis, unilateral bronchial obstruction
 assessment of tactile fremitus.
The tactile fremitus is a vibration perceptible on palpation that is transmitted through the
bronchopulmonary system to the chest wall when the patient speaks. The patient is asked to say
“ninety-nine” and the examiner appreciates the vibrations in symmetrical areas. The tactile fremitus is
more prominent in the interscapular area than in the lower lung fields and more prominent on the right
side than on the left
Modifications of the tactile fremitus may give information on some possible diseases:
 it may be decreased or absent when the transmission of the vibrations from the larynx to the
chest surface are stopped by: acute or chronic obstruction of the airways (COPD: chronic
obstructive pulmonary disease), pleural effusion, pleural thickening (fibrosis), pneumothorax.
 it is increased in lobar pneumonia.
49
Fig.18 Palpation of the thorax
14.2.1.3. Percussion
We determine whether the underlying tissues are air-filled, fluid-filled or solid; it penetrates only 5-7
cm into the chest.
There are five percussion notes: flatness, dullness, resonance, hyperresonance, tympany:
 Flatness: extremely dull sound produced by very dense tissue such as muscle, bone or large
pleural effusion
 Dullness: produced by encapsulated tissue such as liver or spleen or lobar pneumonia
 Resonance: produced by airfilled lungs (normal lung sound)
 Hyperresonance: sound heard over a gas-filled area such as an emphysematous lung or crisis of
asthma (generalized hyperresonance) or pneumothorax (unilateral hyperresonance)
 Tympany: drumlike sound produced by an air-filled organ, such as the air chamber of the
stomach or large pneumothorax.
The percussion of the thorax is performed in symmetrical locations from the apices to the lung bases.
We percuss to identify the lower border of the lungs which is normally found at the level of the 10th
thoracic spinous process; it may descend to the 12th process with deep inspiration. (fig.19)
50
The lower
border of the lung
descends with
deep inspiration
Fig.19
14.2.1.4 Auscultation
a. Normal breath sounds:

- vesicular breath sound: over most of both lungs
- tracheal breath sound: over the trachea in the neck
b. Adventitious (added sounds):
- fine crackles (rales): soft, high-pitched, very brief- in lung disease (such as pneumonia) and
congestive heart failure
- coarse crackles (rales): louder, lower in pitch, not quite so brief- in chronic bronchitis, bronchial
asthma
- wheezes: high pitched; hissing or shrill quality- in chronic bronchitis, bronchial asthma
- rhonchi: low pitched; snoring quality- in chronic bronchitis, bronchial asthma
- pleural rub: in pleurisy
14.2.2 Examination of the anterior chest
14.2.2.1 Inspection
The guiding lines on the anterior part of the thorax are:

- the midsternal line (vertical, in the middle of the sternum)
- the midclavicular line (vertical from the midpoint of the clavicle)
- the anterior axillary line (vertical from the anterior axillary fold). (fig.20)
51
Midsternal line
Left midclavicular line
Left anterior axillary line
Fig.20 Important lines on the anterior chest
Note whether there are:

- deformities/ asymmetries
- abnormal retractions of the interspaces during inspiration
- impairment in respiratory movement.
Deformities of the thorax:
- the barrel chest: has an increased anteroposterior diameter (fig.17)
- the funnel chest: has a depression in the lower portion of the sternum (fig.22)
- the pigeon chest: the sternum is displaced anteriorly, increasing the anteroposterior diameter.
(fig.23)
The inferior border of the lung

meets the 6th rib on the
midclavicular line and
the 8th rib on the midaxillary
line
Fig.21 Anterior chest
52
The funnel chest

Fig. 22 (Pectus excavatum)
The pigeon chest

Fig.23 (Pectus carinatum)
14.2.2.2 Palpation:
Palpate and compare symmetrical areas of the lungs to obtain:

- an identification of tender areas
- an assessment of observed abnormalities
For further assessment of respiratory expansion place thumbs along each costal margin, hands along the
lateral rib cage; watch the divergence of the thumbs during inspiration and feel for the range and
symmetry of the respiratory movement
Find the sternal angle (angle of Louis), which is adjacent with the 2nd rib.
There is also assessed the tactile fremitus, comparing both sides; fremitus is usually decreased or absent
over the precordium.
53
14.2.2.3 Percussion:
The percussion of the anterior and lateral chest is also performed in symmetrical locations from the
apices to the lung bases.
On the left hemythorax the heart normally produces an area of dullness to the left of the sternum from
the 3rd to the 5th interspaces
On the right hemythorax: the normal liver dullness starts with the 5th interspace or the 6th rib at the
midclavicular line, and the 8th rib at the midaxillary line.
14.2.2.4 Auscultation
a. Normal breath sounds:

- vesicular breath sound: over most of both lungs; breath sounds are usually louder in the
upper anterior lung fields
- tracheal breath sound: over the trachea in the neck
b. Adventitious (added sounds): same as in the posterior thorax
If present, locate them on the chest wall and note whether they clear with deep breathing.
54
The cardiovascular system
Chapter 15
15.1 Symptoms and signs in cardiovascular diseases
15.1.1 Chest pain or chest discomfort
15.1.1.1 Cardiovascular causes
a. Stable angina pectoris

Angina pectoris, commonly known as angina, is chest pain due to ischemia of the heart muscle,
generally due to obstruction or spasm of the coronary arteries.
Also known as effort angina, this refers to the more common understanding of angina related to
myocardial ischemia.
The typical presentation of stable angina is that of:
 chest pain that is located retrosternal or across the anterior chest
 typical location for the referred pain: the left shoulder, arm, hand and last two fingers
 constrictive character
 precipitated by activity (running, walking, etc.) with minimal or non-existent symptoms at rest;
angina is also precipitated by emotional stress, by eating big meals and by cold temperatures
 the symptoms decrease in several minutes (1-3 minutes, up to 10 min) following the cessation
of precipitating activities and it stops when activity resumes. The chest pain that lasts only a few
seconds is normally not angina;
 it is relieved also by nitroglycerine in several minutes.
Atypical locations for referred pain: the epigastrium (upper central abdomen), back, neck, jaw.
This is explained by the concept of referred pain, and is due to the spinal level that receives visceral
sensation from the heart, simultaneously receiving cutaneous sensation from parts of the skin specified
by that spinal nerve's dermatome, without an ability to discriminate the two.
Patients with atypical angina may complain of chest discomfort rather than actual pain. The discomfort
is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation.
Pain may be accompanied by breathlessness, sweating and nausea in some cases.
b. Acute coronary syndrome: unstable angina pectoris, myocardial infarction ("heart attack”)
55
Unstable angina (also named “crescendo angina") is a form of acute coronary syndrome, defined as
angina pectoris that changes or worsens.
It has at least one of these features:
 is a new onset angina (i.e., within the prior 4–6 weeks)
 it occurs at rest (or with minimal exertion), usually lasting >10 min
 it is severe and/or
 it occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than
previously).
Symptoms of Myocardial infarction usually appear gradually, over several minutes and they are rarely
instantaneous.
Chest pain is the most common symptom of acute myocardial infarction and is often described as a
sensation of tightness, pressure, or squeezing.
Chest pain has similar qualities as angina pectoris, but:
 is more severe,
 often appears during rest
 lasts longer (20 min-several hours)
 is not alleviated by rest
 is not alleviated by nitroglycerine, but by morphine.
Associated shortness of breath (dyspnea) occurs when the damage to the heart limits the output of the
left ventricle, causing left ventricular failure and consequent pulmonary edema.
Other symptoms include:
- diaphoresis (an excessive form of sweating)
- weakness, light-headedness
- nausea, vomiting
- palpitations
- loss of consciousness (due to inadequate cerebral perfusion and cardiogenic shock)
- sudden death (frequently due to the development of ventricular fibrillation).
c. Aortic dissection (dissecting aneurysm or dissecting hematoma is an often fatal disorder in which
the inner layer of the aortic wall tears)
It presents with pain— typically sudden, excruciating pain, often described as tearing or ripping.
Most commonly, the pain is felt across the chest but is often also felt in the back between the shoulder
blades. The pain frequently travels along the path of the dissection as it advances along the aorta.
Distinctive symptoms of aortic dissection:
- in about two thirds of people with aortic dissection, pulses in the arms and legs are diminished or
absent
- a dissection that is moving backward toward the heart may cause a murmur
- is frequently accompanied by syncope, hemiplegia, paraplegia
d. Pericarditis (inflammation of the pericardium)
The chest pain is sharp or constantly dull.
It may be located in the center of the chest and sometimes extends over the left shoulder.
56
Deep breathing, lying down, or swallowing may make the pain worse. Sitting up and leaning forward
may improve it.
Associated symptoms: mild fever, weakness, fatigue, shortness of breath, coughing, hiccups.
The type of chest pain that occurs with pericarditis differs from angina, which usually becomes worse
with exertion but does not change with deep breathing.
15.1.1.2 Respiratory causes:

Pulmonary embolism, pneumonia, pneumothorax, pleurisy- detailed in chapter 14.
15.1.1.3 Chest-wall diseases:

a. Costochondritis or Tietze's syndrome - a benign and harmless form of osteochondritis often
mistaken for heart disease. It causes pain and tenderness in and around the cartilage that connects the
ribs to the sternum. Pressing on a few points along the edge of the sternum often results in considerable
tenderness in those small areas. If the pressure of a finger causes similar chest pain, it's unlikely that a
serious condition, such as a heart attack, is the cause of the chest pain.
b. Fibromyalgia, radiculopathies
c. Breast conditions
d. Herpes zoster
15.1.1.4 Psychological causes: panic attack, anxiety, depression, hypochondria

15.1.1.5 Hyperventilation syndrome often presents with chest pain and a tingling sensation of the
fingertips and around the mouth.
15.1.1.6 High abdominal pain
High abdominal pain may radiate to the inferior part of the chest, as in gastrointestinal diseases:
- gastroesophageal reflux disease, hiatus hernia, achalasia, neuromuscular disorders of the
esophagus
- gastric dyspepsia
- peptic ulcer.
15.1.2 Palpitations
Palpitations are described as an unpleasant awareness of the heart beat.

They don’t always mean heart disease, as they may appear in healthy persons in certain circumstances
(e.g. after running, after a big effort).
It is also possible that very serious arrhythmias (such as ventricular tachycardia) may not be not
perceived as palpitations.
The person experiencing palpitations may not be aware of anything apart from the abnormal heart
rhythm itself. In other cases, palpitations can be associated with symptoms such as dyspnea, vertigo.
Depending on the type of rhythm problem, these symptoms are transient or prolonged.
57
Actual blackouts or near blackouts, associated with palpitations, often indicate the presence of
important underlying heart disease. A very important guide to the diagnosis is the patient’s description
of the palpitations. The approximate age at which the person first noticed palpitations and the
circumstances under which they occur are of significance.
The way in which they start and stop (abruptly or not), whether they are regular or not, and
approximately how fast the pulse rate is during an attack are also important aspects.
Another helpful piece of information is whether the person has discovered a way of stopping the
palpitations.
Palpitations may be attributed to one of these causes:
a. Hyperdynamic circulation (valvular incompetence, thyrotoxicosis, hypercapnia, pyrexia,
anemia, pregnancy)
b. Sympathetic overdrive (panic disorders, hypoglycemia, hypoxia, anemia, heart failure,
excessive smoking or consumption of coffee, tea, alcohol )
c. Cardiac dysrhythmias or arrhythmias.
Cardiac dysrhythmia (also known as arrhythmia) is a term for any of a large and heterogeneous
group of conditions in which there is an abnormal electrical activity of the heart; the heart is beating
irregular, regular but faster or slower than normal.
The heart beats may be too fast (tachycardic) or too slow (bradycardic) and may be regular or
irregular.
In order to evaluate what type of dysrhythmia is it, we have to determine the heart rhythm:
α Regular
 fast (heart rate > 100/min), called tachyarrhythmias, in: sinus tachycardia, atrial or nodal
tachycardia, atrial flutter with a regular ventricular response, ventricular tachycardia
 normal (heart rate 60-80/min)- in: normal sinus rhythm
 slow (heart rate <60-80/min), called bradyarrhythmias, in: sinus bradycardia, second-degree
heart block, complete heart-block
β Irregular
 rhythmically or sporadically irregular: in premature contractions (of atrial, nodal or
ventricular origin), or in sinus arrhythmia
 totally irregular: atrial fibrillation or atrial flutter with a varying block
d. Anxiety
15.1.3 Dyspnea
Dyspnea or shortness of breath is an uncomfortable awareness of breathing that is inappropriate to the

circumstances. It can appear at rest or during exercise.
Other definitions of dyspnea include "difficulty in breathing", "disordered or inadequate breathing",
"uncomfortable awareness of breathing", or simple "breathlessness".
Acute breathlessness is defined as severe shortness of breath that develops over minutes to hours.
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Chronic breathlessness develops on over weeks or months, being more severe in time if untreated.
Its severity must be evaluated according to the patient’s everyday activity.
Degree of dyspnea
1 - dyspnea while performing difficult activities (climbing the stairs or walking in a hurry)
2 - dyspnea while performing moderate activities (walk slower than most persons of their age
or stop after 15 minutes of walking)
3 - dyspnea while performing even less than ordinary activities (stops after walking 20-100
m); comfortable only at rest
4 - dyspnea while performing minimal activity such as getting dressed; too dyspneic to leave
the house.
1. cardiovascular causes: left-sided heart failure, mitral stenosis, aortic stenosis, cardiomiopathy,
constrictive pericarditis, acute myocardial infarction
2. pulmonary causes: chronic obstructive pulmonary disease, bronchial asthma, pneumothorax,
pneumonia, diffuse infiltrative lung disease, pulmonary embolism
3. non-cardiorespiratory diseases: severe obesity, severe anemia, metabolic acidosis (renal failure,
diabetic ketoacidosis), neuromuscular diseases, drug-induced respiratory depression, increased
intracranial pressure, anxiety with hyperventilation.
Orthopnea
Orthopnea is a special type of shortness of breath (dyspnea) which occurs when lying down, and
improves upon sitting up.
Patients with orthopnea sleep propped up in bed (with many pillows) or sitting in a chair.
Orthopnea is due to increased distribution of blood to the pulmonary circulation while recumbent in
case of left ventricular heart failure and/or pulmonary edema.
Paroxysmal nocturnal dyspnea
Paroxysmal nocturnal dyspnea is the most severe form of dyspnea, appearing in severe forms of heart
failure, valvulopathies or cardiomyopathies. It has two forms:
a. Cardiac asthma
b. Pulmonary edema
a. Cardiac asthma is defined as sudden, severe shortness of breath at night that awakens a person from
sleep, often with coughing and wheezing.
Cardiac asthma commonly occurs several hours after a person with heart failure has fallen asleep. It is
often relieved by sitting upright, but not as quickly as simple orthopnea.
Paroxysmal dyspnea is caused by increasing amounts of fluid entering the lung during sleep. This fluid
typically rests in the legs, filling interstitial spaces in the peripheral vascular system (peripheral edema)
during the day, when the individual is upright. At night, in recumbent position, this fluid is reabsorbed
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and increases total blood volume and blood pressure, leading to pulmonary hypertension in people with
underlying left ventricular dysfunction.
Cardiac asthma is a symptom of heart failure and other associated conditions such as mitral stenosis,
aortic stenosis and insuficiency.
The patient describes episodes of sudden dyspnea and orthopnea that wake him up, accompanied by
wheezing and coughing.
b. Pulmonary edema is the most severe form of paroxysmal nocturnal dyspnea, being the expression
of fluid accumulation in the lungs caused by a cardiovascular disease.
It leads to impaired gas exchange and may cause respiratory failure. It is due to failure of the heart to
remove fluid from the lung circulation (cardiogenic pulmonary edema).
A noncardiogenic pulmonary edema is also described, caused by a direct injury of the lung
parenchyma.
Symptoms of pulmonary edema include very severe dyspnea, hemoptysis, excessive sweating, anxiety,
pale skin.
A classic sign of pulmonary edema is the production of pink frothy sputum.
It can lead to coma and death due to severe complications of hypoxia.
15.1.4 Cough
In cardiovascular diseases cough is mainly nonproductive. It is frequently a neglected symptom in

patients with cardiovascular disease in contrast to more definite and impressive symptoms such as
shortness of breath and chest pain.
In the beginning, cough associated with mild heart failure will be transient, but as the heart failure
becomes more severe, the cough becomes chronic, irritant and a very unpleasant symptom, one of the
main causes of sleep disorders.
It may associate with:
- purulent sputum in case of associated respiratory infection
- pink frothy sputum in case of pulmonary edema
- hemoptysis in congestive heart failure, mitral stenosis, pulmonary embolism.
15.1.5 Pain in the arms and legs
Pain in the arms and legs may be caused by:
15.1.5.1 Arterial disorders:

a. Peripheral artery disease
Arteriosclerosis obliterans represents the peripheral ischemia due to obstruction of middle-sized or
large arteries by arteriosclerosis. It presents as:
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1. Intermittent claudication: muscle pain (ache, cramp, numbness or sense of fatigue) classically in
the calf muscle, which occurs during exercise and is relieved by a short period of rest.
Signs of ischemia of the lower extremity arteries:
- decreased temperature, decreased pulse
- pallor when limb is raised and redness when it is returned to a "dependent" position
- atrophic changes, loss of hair, shiny skin.
2. Rest pain is a severe ischemia that appears even at rest. It is described as a distal pain, in the
toes or forefoot.
b. Acute arterial occlusion is caused by embolism or thrombosis, possibly superimposed on
arteriosclerosis. It is described as a severe distal pain, usually involving the foot and the leg and
accompanied by coldness, paresthesias, loss of sensation, paleness and lack of pulse in an extremity and
later blue skin in the affected limb.
15.1.5.2 Venous disorders:

a. Varicose veins:
- dilated tortuous veins, present on the calf or the thigh
- they become more visible in standing posture (it is possible to miss them when the patient is in a
supine position)
b. Chronic venous insufficiency:
- chronic venous engorgement secondary to venous occlusion or incompetence of venous valves
- diffuse aching of the leg increasing during the day, especially after prolonged standing
- in time it associates with edema, cyanosis in dependency, chronic pigmentation, possible
ulceration when complicated
c. Superficial thrombophlebitis
- in an acute inflammation of a superficial vein
- it presents local redness, swelling, tenderness, a palpable cord, possibly fever
d. Deep venous thrombosis
- caused by a clot formation in a deep vein
- it presents as phlegmatia alba dolens or phlegmatia coerulea dolens:
pain in the calf (but sometimes painless), swelling of the foot and calf and local calf tenderness
- the color of the limb is normal in phlegmatia alba dolens and cyanotic in phlegmatia coerulea
dolens.
3. Acute lymphangitis:
- acute bacterial infection spreading up the lymphatic channels
- red streaks on the skin, with tenderness, enlarged lymph nodes and fever
4. Thromboangiitis obliterans (Berger’s disease)
- occlusion of small arteries and veins occurring in smokers
- presents with intermittent claudication or rest pain
- associated signs: distal coldness, sweating, numbness, cyanosis; possible ulceration and
gangrene at the tips of fingers or toes
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5. Raynaud’s disease
- episodic spasm of the small arteries
- distal portions of pain of one or more fingers
- color changes in the distal fingers: severe pallor followed by cyanosis and redness
15.2 The physical examination of the cardiovascular system
15.2.1 The heart:
15.2.1.1 Inspection and palpation:
The apical impulse (a brief systolic beat) which may not be visible in supine patient and is often easier
to detect in the partial left lateral decubitus position. If it can’t still be detected, the patient should
completely exhale and stop breathing for a few seconds.
Obesity, a very muscular chest wall, or an increased anteroposterior diameter of the chest may make it
undetectable.
In other cases, despite change of position, the apical impulse remains hidden behind a rib cage.
Normal apical impulse has the following characteristics:
- location: in the 5th interspace on the midclavicular line;
- diameter: less than 2.5 cm and occupies only one interspace in the supine patient; it may
be larger in the left lateral decubitus position
- amplitude: small, feels like a gentle tap
- duration: the first two thirds of systole or even less
Modifications of the apical impulse:
- location may be displaced to the left and possibly downward in case of ventricular
hypertrophy
- amplitude may be increased in normal young persons, especially because of excitement or
exercise; it is abnormal increased in pressure overload of the ventricle (such as systemic
hypertension, aortic stenosis) or in volume overload of the ventricle (aortic or mitral
regurgitation)
- duration: a contraction approaching the second heart sound indicates left ventricular
enlargement.
15.2.1.2 Percussion: cardiac dullness in the 3rd, 4th, 5th and possibly 6th interspaces
15.2.1.3 Auscultation:
a. Locations:
- the mitral valve: the midclavicular line in the 5th interspace
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- the tricuspid valve: lower left sternal border

- the pulmonary artery (pulmonic region): the 2nd left interspace close to the sternum
- the aortic space (aortic area) the 2nd right interspace close to the sternum, but also aywhere from
the right 2nd interspace to the apex
- Erb’s space: the left sternal border in each interspace from the 3rd to the 5th (fig.24).
b. Patient positions:
- supine, with the upper body raised by elevating the head of the bed to about 30ْ
- onto the left side, which brings the left ventricle closer to the chest wall; place gently the bell of
the stethoscope on the midclavicular line in the 5th interspace ; best position to make the
diastolic murmur audible in mitral stenosis
- the patient is sitting up, leaning forward, exhaling completely and he stops breathing, which
increases or brings out aortic murmurs; listen along the left sternal border and at the apex, with
a periodic pause for the patient to breath.
the angle of Louis, near the 2nd rib
the aortic area: 2nd right interspace
the pulmonic area: 2nd left interspace
Erb’s space
the mitral valve area: 5th interspace
the tricuspid area: lower left sternal border
Fig. 24 Areas of auscultations of the heart
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c. The heart rate

If the rhythm is regular, count for 15 seconds and multiply by 4; if it is unusual fast or slow, count for
60 seconds;
If rhythm is irregular (for example in atrial fibrillation or frequent premature contractions) the rate
evaluated by cardiac auscultation may be higher than that one counted in the radial pulse, because not
all the heart beats may be detected peripherally.
d. The rhythm:
The rhythm may be regular or irregular:
α Regular
- fast (heart rate > 100/min), called tachyarrhythmias, in: sinus tachycardia, atrial or nodal
tachycardia, atrial flutter with a regular ventricular response, ventricular tachycardia
- normal (heart rate 60-80/min)- in: normal sinus rhythm, atrial flutter with a regular ventricular
response,
- slow (heart rate <60-80/min), called bradyarrhythmias, in: sinus bradycardia, second-degree heart
block, complete heart-block
β Irregular
- rhythmically or sporadically irregular: in premature contractions (of atrial, nodal or ventricular
origin), or in sinus arrhythmia
- totally irregular: atrial fibrillation or atrial flutter with a varying block
e. The heart sounds

- The first heart sound (S1); has a mitral (M1) and a tricuspid (T1) component, that is why it is
louder in the mitral and tricuspid area
- The second heart sound (S2); has an aortic (A2) and pulmonic (P2) component, that is why it is
louder in the aortic and pulmonic area. (fig.25)
Normal variations of heart sounds

- S2 is louder at the base of the
heart (aortic and pulmonic areas)
- S1 is louder in the apex
Fig.25 Normal first and second heart

sound
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Accentuated S1 in:
- physiological: in
tachycardia,
conditions with increased
cardiac output (effort, anemia)
- mitral stenosis
Diminished S1 in
- first degree heart block
- mitral regurgitation,
congestive heart failure
Fig. 26 Modifications of the first heart sound
Extra sounds in systole: the systolic click of mitral valve prolapse. (fig.27)
Fig. 27 The systolic click of mitral valve prolapse
Extra sounds in diastole:

- opening snap of stenotic mitral valve (in mitral stenosis)
- a physiologic third heart sound (S3, frequently in children, but may persist up to 35-40)
- a pathologic third sound (S3, ventricular gallop) in myocardial failure, mitral
regurgitation
- a pathologic fourth sound (S4, atrial gallop) may appear in normal persons: athletes,
elderly, but also in increased stiffness of the myocardium (hypertensive heart disease, coronary
artery diasease, aortic stenosis, cardiomyopathy) (fig.28)
65
Fig. 28 A pathologic third and forth heart sound
f. Systolic and diastolic murmurs- are characterized by: timing, shape, location of maximal intensity,
radiation, intensity, pitch, quality.
Heart murmurs are distinguishable from heart sounds by their longer duration.
They are attributed to a turbulence in the blood flow.
- It is possible that they have no pathologic meaning, for example in anemia, but they may also
mean heart disease, such as in:
- an abnormally narrowed (stenotic) valvular orifices
- the incompetence of a valve, causing regurgitation of the blood in a retrograde direction.
The mydsystolic heart murmurs are the most common types of murmurs and are associated to the
ejection. They can be pathologic, physiologic and innocent.
1. The innocent murmurs are not associated with any physiologic or structural abnormality that can
be detected. They result from turbulent blood flow that is probably created by the left ventricular
ejection of the blood into the aorta. For these murmurs, there is no evidence of cardiovascular disease.
 Location: the 2nd to the 4th left interspaces between the left sternal border and the apex
 Radiation: little
 Intensity: Grade 1 to 2, possibly 3
 Aids: it usually decreases or disappears on sitting
 Associated findings: None (normal splitting, no ejection sounds, no diastolic murmurs and no
palpable evidence of ventricular enlargement)
2. The physiologic murmurs are caused by a turbulence that is resulted from a temporary increase
in blood flow. Conditions that predispose to this type of murmur: pregnancy, anemia, fever,
hyperthyroidism.
The characters of the murmur are similar to the innocent ones.
 Associated findings: Possible signs of a likely cause, that disappear once the condition is cured.
3. The pathologic murmurs appear secondary to a structural cardiovascular abnormality.
The aortic stenosis (fig. 29) appears due to a significant stenosis of the aortic valve that causes
turbulence through impaing blood flow across the valve and that increases the afterload on the left
ventricle.
 Location: the right 2nd interspace
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 Radiation: often to the neck and down the left sternal border, even to the apex
 Intensity: sometimes soft, but often loud, with a trill
 Aids: heard best with the patient sitting and leaning forward
 Associated findings:
- A2 decreases as the stenosis worsens. A2 may be delayed, merging with P2 to form a single
expiratory sound or causing paradoxical splitting.
- An aortic ejection sound, if present, suggests a congenital cause.
The pansystolic (holosystolic) heart murmurs are pathological. They can be heard when blood
flows from a chamber of high pressure to one of lower pressure through a valve or through other
structure that should be closed. The murmur begins immediately with S1 and continues up to S2.
1. Mitral regurgitation (fig. 30) appears when the mitral valve fails to close fully in systole. This
causes the blood to regurgitate from the left ventricle to the left atrium, causing a murmur. This leakage
creates a volume overload on the left ventricle, with subsequent dilatation and hypertrophy.
 Location: the apex
 Radiation: to the left axilla, less often to the left sternal border
 Intensity: soft to loud
 Aids: unlike the murmur of tricuspid regurgitation, it does not become louder in inspiration
 Associated findings: S1 is often decreased and an apical S3 reflects the volume overload on the
left ventricle.
The diastolic heart murmurs almost always indicate heart disease.

1. Aortic regurgitation (fig. 31) is caused by the leaflets of the aortic valve that fail to close
completely during diastole. In this way, the blood regurgitates from the aorta back into the left ventricle
and it results in a volume overload on the left ventricle.
 Location: the 2nd to the 4th left interspaces
 Radiation: if loud, to the apex or to the right sternal border
 Intensity: grade 1 to 3
 Aids: the murmur is heard best with the patient sitting, leaning forward, with breath held in
exhalation
 Associated findings: An ejection sound may be present. An S3 or S4, if present, suggest severe
regurgitation. The pulse pressure increases and arterial pulses are often large and bounding.
2. Mitral stenosis (fig.32) appears when the leaflets of the mitral valve thicken, stiffen and become
distorted from the effects of rheumatic fever, thus failing to sufficiently open in diastole. It has two
parts: a middiastolic component (during rapid ventricular filling) and a presystolic component (during
atrial contraction).
 Location: usually limited to the apex
 Radiation: little or none
 Intensity: grade 1 to 4
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 Aids: Placing the bell exactly on the apical impulse, turning the patient into a left lateral
position. It is better heard in exhalation.
 Associated findings: S1 is accentuated and may be palpable at the apex. Because of the
thickened and stiffened valve, an opening snap (OS) appears after S2, before the diastolic
murmur. Mitral regurgitation and aortic valve disease may be associated with mitral stenosis.
A midsystolic murmur (begins

after S1 and stops before S2)
Aortic stenosis
Fig.29 Mydsistolic murmur in aortic stenosis
A pansystolic (holosystolic)
murmur; starts with S1 and
stops with S2
Mitral insuficiency
Fig.30 Pansystolic murmur in mitral insuficiency
An early diastolic murmur

Starts with S2 and stops before S1
Aortic insuficiency
Fig.31 Early diastolic murmur in aortic insuficiency
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A diastolic murmur with:

- a middiastolic component
- a presystolic component
Mitral stenosis
OS is the opening snap of the mitral valve
Fig. 32 Opening snap and diastolic murmur in mitral stenosis
15.2.2 Blood pressure
The blood pressure should be taken in both arms at least once. Normally, there may be a difference of
5-10 mmHg.
Normal blood pressure: normal resting arterial pressure is a systolic reading less than 120 but greater
than 90 and a diastolic reading of less than 80 but greater than 60.
Hypertension is defined as a systolic pressure of 140 mmHg or greater and they diastolic blood pressure
of 90 mmHg or greater. What used to be considered gray areas between systolic readings of 120 mmHg
and 140 mmHg and diastolic readings of 80 mmHg and 90 mmHg are now the ranges that define what
is known as pre-hypertension. Hypotension is defined as a systolic pressure of less than 90 mmHg and
the diastolic blood pressure of less than 60 mmHg.
Normal blood pressure: 90/60mmHg- 120/80 mmHg
Pre-hypertension: 120/80-140/90 mmHg
Hypertension: >140/90 mmHg
15.2.3 The arterial pulse:
a.. The heart rate determined by using the radial pulse.

If the rhythm is regular, the heart rate is equal to that counted for the heart.
If rhythm is irregular (for example in atrial fibrillation or frequent premature contractions) the rate is
lower than that one evaluated by cardiac auscultation, because not all the heart beats may be detected
peripherally.
b. Amplitude and contour:
There must be evaluated:
69
- the amplitude of the pulse

- the contour of the pulse wave (normally the upstroke is smooth and fast and, almost immediately, the
first heart sound follows)
- variations of amplitude (from beat to beat or with respiration).
Take the pulse in the carotid, brachial or radial arteries.

First inspect the neck for pulsations. The carotid pulsations may be visible just medial to the
sternomastoid muscles.
Place the fingers on the carotid artery in the lower third of the neck (at the level of the cricoid
cartilage).
Avoid pressing on the carotid sinus (at the level of the top of the thyroid cartilage). Do not press on
both carotids at the same time (which may cause a reflex drop in pulse rate or blood pressure). Our
fingers must slowly increase the pressure until the maximum pulsation, then slowly decrease it until the
amplitude and contour can be best sensed. (fig.33)
Fig. 33 The pulse in the carotid
70
c. Inspect both arms:
Brachial artery
Ulnar artery
Radial artery
Fig. 34 Arteries of the arm

In order to palpate an arterial pulse, the artery has to be close enough to the body surface, which is the
case of the radial and brachial pulse for the arm.
Palpate:
- the radial pulse (on the flexor surface of the wrist laterally) (fig.35)
fig 35 The radial pulse
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- the brachial pulse (medial to the biceps tendon at the antecubital crease) and compare them in both
arms.
The pulse may be increased, normal, diminished or absent.
d. Inspect both legs

The femoral artery
The popliteal artery
The posterior tibial artery
Dorsalis pedis artery
Fig. 36
Palpate:
- the femoral pulse (below the inguinal ligament and about midway between the anterior superior iliac
spine and the symphysis pubis)
- the popliteal pulse (into the popliteal fossa)
- the posterior tibial pulse (behind the mideal malleolus of the ankle) (fig.37)
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Fig. 37 The posterior tibial pulse
- the dorsalis pedis pulse (on the dorsum of the foot, lateral to the extensor tendon of the great toe).
(fig.38)
Fig.38 The dorsalis pedis pulse
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15.2.4 Jugular venous pressure and pulses
The jugular venous pressure is the indirectly observed pressure over the venous system.
In order to visualize the internal jugular vein, the patient is positioned about to 30°, and the filling level
of the jugular vein is determined. In healthy people the filling level of the jugular vein should be less
than 3 centimetres above the sternal angle.
The jugular venous pulse is easiest to observe along the surface of the sternocleidomastoid muscle. It
cannot be palpated, the pulse felt in the neck is generally the common carotid artery’s pulse.
The internal jugular vein is distinguished from the carotid artery by:
- a decreased pressure during inspiration (physiologically, this is a consequence of the Frank–
Starling mechanism as inspiration decreases the thoracic pressure and increases blood
movement into the heart- venous return)
- rising with abdominal pressure
- increasing and decreasing with lowering and elevation of the head of the bed, respectively
- being compressible with direct pressure.
15.2.5 The abdominojugular test

The abdominojugular test, also known as hepatojugular reflex or reflux, is used as an alternate test for
measuring jugular venous pressure through the distension or swelling of the internal jugular vein.
The swelling of the internal jugular vein in the neck is observed while pressing firmly over the right
upper quadrant of the abdomen (over the liver) for 10–60 seconds with a pressure of 20 to 35 mm Hg.
15.2.6 Edema
Check for pitting edema and note the temperature of the feet and legs.
Edema is a consequence of congestive heart failure. It appears because of the decreased ability of the
heart to accept venous blood, which increases the pressure in the veins and capillaries, leading to run of
fluid into the tissues.
The edema first appears in the inferior part of the body (legs, feet), where the pressure is highest. It
disappears during the rest at bed in the night and increases through the day (being most prominent
before going to bed). It is often accompanied by cyanosis.
74
The digestive system
Chapter 16

16.1.1 Abdominal pain
Abdominal pain can be visceral pain, parietal pain or referred pain. It is a symptom associated with
transient and harmless disorders or serious disease.
The character of the abdominal pain (location, radiation, quality, quantity and severity, timing, setting
in which it occurs, factors that make it better or worse, associated features, progression) help in
establishing the diagnosis. (fig.38)
the liver
the aorta
inferior part
of the kidney
transverse colon
descending and
sigmoid colon
pregnant uterus
bladder
Fig. 38 The site of the pain gives information on the possible organ involved
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Many diseases can result in abdominal pain that can be caused by:
1. Gastrointestinal diseases:
a. Inflammatory diseases: gastroenteritis, peptic ulcer, appendicitis, gastritis, dyspepsia, esophagitis,
diverticulitis, Crohn's disease, ulcerative colitis
b. Obstruction: hernia, volvulus, post-surgical adhesions, tumors, superior mesenteric artery syndrome,
severe constipation, hemorrhoids
c. Vascular diseases: embolism, thrombosis, hemorrhage, abdominal angina, blood vessel compression
2. Bile system diseases:
a. Inflammatory diseases: cholecystitis, cholangitis
b. Obstructive diseases: cholelithiasis, tumours
3. Liver diseases: hepatitis, liver abscess
4. Pancreatic diseases: acute or chronic pancreatitis, cancer of the pancreas
5. Renal diseases: pyelonephritis, bladder infection, urolithiasis, urinary retention, tumors.
6. Vascular causes: renal vein obstruction
7. Gynaecological or obstetrical causes: pelvic inflammatory disease, ovarian torsion, menstruation,
endometriosis, ovarian cyst, ovarian cancer, ruptured ectopic pregnancy
8. Causes connected to the abdominal wall: muscle strain or trauma, muscular infection, herpes zoster,
tabes
9. Referred pain:
- from the thorax: pneumonia, pulmonary embolism, ischemic heart disease, pericarditis
- from the spine: radiculitis
- from the genitals: testicular torsion
10. Metabolic disturbances: uremia, diabetic ketoacidosis, porphyria, adrenal insufficiency, lead
poisoning, narcotic withdrawal
11. Blood vessels: aortic dissection, abdominal aortic aneurysm
12. Immune system diseseases: sarcoidosis, vasculitis, familial Mediterranean fever
13. Idiopathic: irritable bowel syndrome (affecting up to 20% of the population; it is the most common
cause of recurrent, intermittent abdominal pain).
The character of the abdominal pain together with associated symptoms or sign help the diagnostic.
Peptic ulcer:
- epigastric pain, may radiate in the back
- variable quality: burning, aching, pressing, hungerlike (“painful hunger” in duodenal ulcer)
- pain relieved by meals and reappears after eating (in 1-2 hours in gastric ulcer, in 3-4 hours in
duodenal ulcer); in duodenal ulcer pain may wake the patient at night
- sometimes connected to seasons: pain worsens in spring and autumn
- associated symptoms: nausea, vomiting, belching, bloating, heartburn, weight loss (especially in
gastric ulcer).
Gastric cancer:
- epigastric pain
76
- variable quality: burning, aching, pressing

- pain is not relieved by meals
- pain is not connected to seasons
- associated symptoms: nausea, vomiting, anorexia, weight loss, sometimes hematemesis
- persistent pain, slowly progressive and with a shorter history than in peptic ulcer.
Acute pancreatitis:
- violent epigastric pain, may radiate in the upper abdomen or in the back
- acute onset, persistent pain
- pain aggravated by lying supine and relieved by leaning forward
- associated symptoms: nausea, vomiting, abdominal distension, fever
- frequently, a history of alcohol abuse or gallstones
Chronic pancreatitis
- epigastric pain, may radiate in the back
- steady, deep quality
- chronic or recurrent course
- pain aggravated by alcohol, heavy meals, relieved by leaning forward
- complicated with decreased pancreatic function: steatorrhea (diarrhea with fatty stools), diabetes
mellitus
Billiary colic:
- epigastric pain or in right upper quadrant that may radiate in the right shoulder or scapula
- steady aching
- rapid onset in a few minutes, lasts hours and disappears gradually; often recurrent
- associated symptoms: anorexia, nausea, vomiting, agitation
Acute cholecystitis
- pain in the right upper quadrant, may radiate in the right shoulder or scapula
- steady aching
- gradual onset, with a longer course than in billiary colic
- aggravated by deep breathing
- associated symptoms: anorexia, nausea, vomiting, low fever.
Irritable bowel syndrome is a functional gastrointestinal disorder, with no known organic cause. It is
characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits. Diarrhea
or constipation may predominate, or they may alternate.
16.1.2 Dysphagia
Dysphagia represents difficulty in swallowing. The condition results from an impaired transport of
liquids, solids, or both, from the pharynx to the stomach.
Some patients have limited awareness of their dysphagia, so the lack of the symptom does not exclude
an underlying disease.
77
Dysphagia is classified into two major types:

1. oropharyngeal dysphagia and
2. esophageal dysphagia
1. Causes of oropharyngeal dysphagia include:
- cerebrovascular stroke, multiple sclerosis, myasthenia gravis, Parkinson's disease and parkinsonism
syndromes, amyotrophic lateral sclerosis
- xerostomia, radiation, neck malignancies
- neurotoxins (e.g. snake venom), eosinophilic esophagitis, pharyngitis, etc.
Some signs and symptoms of oropharyngeal dysphagia include difficulty or inabilty to control food or
saliva in the mouth, difficulty initiating a swallow, coughing, frequent pneumonia, unexplained weight
loss, nasal regurgitation.
2. Causes of esophageal dysphagia can be divided into:
a. Motor disorders: diffuse esophageal spasm, scleroderma, achalasia
b. Inflammatory causes: peptic esophagitis, Candida esophagitis
c. Mechanical causes:
- carcinoma of the esophagus or gastric cardia, esophageal leiomyoma
- external compression of the esophagus (such as obstruction by lymph node)
Esophageal dysphagia is almost always caused by disease in or adjacent to the esophagus but
occasionally the lesion is in the pharynx or stomach.
In many of the pathological conditions causing dysphagia, the lumen becomes progressively narrowed.
Initially only fibrous solids cause difficulty, but later the problem can extend to all solids and later even
to liquids.
The most common symptom of esophageal dysphagia is the inability to swallow solid food.
Functional dysphagia is defined in some patients as having no organic cause for dysphagia that can be
found.
16.1.3 Odynophagia
Odynophagia represents pain on swallowing in the mouth (oropharynx) or esophagus. It can occur with
or without dysphagia or difficult swallowing. This pain while swallowing can be described as an ache,
burning sensation or occasionally a stabbing pain that radiates to the back.
It can be caused by many conditions, including very hot or cold food or drink, drugs, ulcers and
mucosal destruction, upper respiratory tract infections, immune disorders, cancers, and motor disorders.
Candida esophagitis is the commonest cause of odynophagia.
Odynophagia often results in weight loss.
16.1.4 Dyspepsia
Dyspepsia refers to an impaired digestion.

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It is a medical condition characterized by:

- chronic pain in the upper abdomen
- heartburn (sense of burning or warmth felt retrosternally; it may radiate from the epigastrium to
the neck)
- upper abdominal fullness after meals and feeling full earlier than expected when eating
- excessive gas (frequent belching, abdominal bloating or distension)
- fullness and tenderness on palpation
Possible causes:
- gastroesophageal reflux disease or gastritis
- in a small minority, it may be the first symptom of peptic ulcer disease (an ulcer of the stomach
or duodenum) and occasionally cancer
- medication: calcium antagonists, nitrates, theophylline, bisphosphonates, corticosteroids and
non-steroidal anti-inflammatory drugs
Functional dyspepsia (previously called nonulcer dyspepsia is dyspepsia "without evidence of an
organic disease that is likely to explain the symptoms". Functional dyspepsia is estimated to affect
about 15% of the general population in western countries.
16.1.5 Nausea and vomiting
Nausea is a sensation of unease and discomfort in the upper stomach that often precedes vomiting.
The causes are:
- gastroenteritis, ulcer, gallbladder disease
- early stages of pregnancy, intense pain, emotional stress (fear), motion sickness
- medication: chemotherapy, general anaesthetic agents
- inferior myocardial infraction
- concussion or brain injury, brain tumor
- some forms of cancer
Vomiting is the forcible voluntary or involuntary emptying of stomach contents through the mouth
and sometimes the nose.
Possible causes:
1. Digestive tract diseases
- gastritis, gastroenteritis, gastroesophageal reflux disease, pyloric stenosis
- bowel obstruction, acute abdomen and/or peritonitis
- cholecystitis, pancreatitis, appendicitis, hepatitis
- food allergies, food poisoning
2. Sensory system and brain injury
- motion sickness, Ménière's disease
- concussion, cerebral hemorrhage
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- brain tumors, intracranial hypertension

- migraine
3. Inferior myocardial infraction
4. Metabolic disturbances
- hypercalcemia
- uremia, adrenal insufficiency
- hypoglycemia, hyperglycemia
5. Pregnancy
6. Drug reaction: alcohol, opioids, selective serotonin reuptake inhibitors,
many chemotherapy drugs
16.1.6 Regurgitation
Regurgitation is the raising of esophageal or gastric contents in the absence of nausea or retching.
Regurgitation is different from vomiting, although the two terms are often used interchangeably.
Regurgitation is the return of undigested food back up the esophagus to the mouth, without the force
and displeasure associated with vomiting. The causes of vomiting and regurgitation are generally
different.
The most frequent causes of regurgitation are:
- gastroesophageal reflux disease, ulcer, gastroenteritis, esophageal sphincter muscle disorder, pyloric
stenosis, Zenker's diverticulum, achalasia, hiatus hernia,
- bending forward , strong physical excercise
- collagenosis (scleroderma)
- diabetes mellitus, alcoholic neuropathy
16.1.7 Bowel dysfunction
16.1.7.1 Diarrhea is the condition of having three or more loose or liquid bowel movements per day
or as having more stools than normal.
It is a common cause of death in developing countries and the second most common cause of infant
deaths worldwide.
There are described:
1. Acute diarrhea
a. Noninflammatory infections: viruses, toxin-producing bacteria (such as Escherichia Coli ,
Staphylococcus aureus), Giardia lamblia
Characteristics:
- watery stools
- short duration, but lactase deficiency may lead to a longer course
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- associated symptoms: nausea, vomiting, abdominal pain

b. Inflammatory infections: invasion of the intestinal mucosa by Salmonella, Shigella,
Campylobacter, invasive Escherichia Coli
Characteristics:
- loose to watery stools, often with blood, pus or mucus
- short duration or varying
- associated symptoms: abdominal pain, tenesmus, fever
2. Chronic or recurrent diarrhea:
a. Malabsorption syndromes:
- caused by infective agents: bacterial infections, viral infections, parasitic infections, intestinal
tuberculosis, HIV related malabsorption, tropical sprue, traveller's diarrhea, parasites (e.g. Giardia
lamblia, Ancylostoma duodenale and Necator americanus), Whipple's disease
- caused by mucosal abnormality: Coeliac disease, cows' milk intolerance, soya milk intolerance,
fructose malabsorption
- caused by digestive failure: pancreatic insufficiencies (cystic fibrosis, chronic pancreatitis, carcinoma
of pancreas, Zollinger-Ellison syndrome), bile salt malabsorption (terminal ileal disease, obstructive
jaundice, bacterial overgrowth)
- caused by structural defects: blind loops, inflammatory bowel diseases commonly in Crohn's Disease,
post-gastrectomy, post-vagotomy, gastro-jejunostomy, fistulae, diverticulae and strictures, infiltrative
conditions (amyloidosis, lymphoma, eosinophilic gastroenteropathy), radiation enteritis, systemic
sclerosis and collagen vascular diseases, ischemic bowel disease, short bowel syndrome, colon cancer
- caused by enzyme deficiencies: lactase deficiency, intestinal disaccharidase deficiency, intestinal
enteropeptidase deficiency,
- systemic diseases affecting gastrointestinal tract: celiac disease, hypothyroidism and hyperthyroidism,
Addison's disease, diabetes mellitus, hyperparathyroidism and hypoparathyroidism, carcinoid
syndrome, malnutrition, abeta-lipoproteinaemia
Characteristics in malabsorption diarrhea:
- defective absorbtion of fat and fat-soluble vitamins, with excessive excretion of fat (steatorrhea)
- the stools are typically bulky, soft, light yellow to grey, greasy or oily, sometimes frothy;
particular foul-smelling; usually may float in the toilet
- progressive onset
- associated symptoms: anorexia, weight loss, fatigue, abdominal distension, chronic abdominal
pain; expression of nutritional deficiencies: frequent respiratory infections (vitamin A), fractures
(vitamin D), bleeding (vitamin K), glossitis (vitamin B), edema (protein).
b. Osmotic diarrhea:
- drugs (e.g. orlistat) which inhibit the absorption of fat, osmotic laxatives;
- in healthy individuals too much magnesium or vitamin C or undigested lactose can produce
osmotic diarrhea and distention of the bowel;
- sugar alcohols such as sorbitol (often found in sugar-free foods) are difficult for the body to
absorb and, in large amounts, may lead to osmotic diarrhea.
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c. The irritable bowel syndrome usually presents with abdominal discomfort relieved by defecation and
unusual stool (diarrhea or constipation) for at least 3 days a week over the previous 3 months.
16.1.7.2 Constipation
Constipation is usually defined as fewer than three bowel movements per week. Severe constipation is
defined as less than one bowel movement per week. The number of bowel movements generally
decreases with age. Most of adults have 3-21 bowel movements/week, considered normal. The most
common pattern is one bowel movement a day, with variations according to daily diet.
It is important to distinguish acute (recent onset) constipation from chronic (long duration)
constipation. Constipation requires an immediate assessment if it is accompanied by “alarming”
symptoms such as rectal bleeding, abdominal pain and cramps, nausea and vomiting, and involuntary
loss of weight. The evaluation of chronic constipation is less urgent, particularly if simple measures
bring relief.
Constipation can alternate with diarrhea. This pattern commonly occurs as part of the irritable bowel
syndrome.
Constipation can be caused by the slow passage of digesting food through any part of the intestine, but
in most cases the slowing occurs in the colon. The most frequent causes of constipation are:
a. Medicaments:
- the most common offending medications include narcotic pain medications: codeine, oxycodone
and hydromorphone;
- antidepressants: amitriptyline and imipramine
- anticonvulsants: phenytoin and carbamazepine
- iron supplements
- calcium channel blocking drugs such as diltiazem and nifedipine
- aluminum-containing antacids
- the over-use of stimulant laxatives (eg, senna, castor oil, and certain herbs)
b. Habit: too often suppressing the normal urge of the bowel movement
c. Low fiber diet (fruits, vegetables, and whole grains)
d. Hormonal disorders: hypothyroidism, hyperparathyroidism, during the menstrual periods, high
estrogen and progesterone levels (even during pregnancy).
e. Conditions affecting the bowel: intestinal pseudo-obstruction, Hirschsprung's disease, Chagas
disease, cancer or benign causes of stricture of the colon, diverticulitis, sclerodermia
f. Metabolic conditions: diabetes mellitus
g. Neurologic disorders: Parkinson's disease, multiple sclerosis, and spinal cord injuries
h. Irritable bowel syndrome, painful anal lesions.
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16.1.8 Black and bloody stools
16.1.8.1 Melena;
Melena refers to the passage of black, sticky and shiny feces, with a tarry aspect.
It is associated with esogastrointestinal hemorrhage (a loss of at least 60 ml of blood, usually from the
esophagus, stomach or duodenum). The black color is caused by oxidation of the iron in hemoglobin
during its passage through the ileum and colon. Less commonly, when the intestinal transit is slow, the
blood may originate in the jejunum, ileum or in the ascending colon.
Bleeding originating from the lower gastrointestinal tract (such as the sigmoid colon and rectum) is
generally associated with the passage of bright red blood, or hematochezia.
Blood that originates from a high source (such as the small intestine), or bleeding from a lower source
that occurs slowly enough to allow for enzymatic breakdown is associated with melena. It is estimated
that it takes about 14 hours for blood to be broken down within the intestinal lumen, therefore if transit
time is less than 14 hours, the patient will have hematochezia, and if it is greater than 14 hours, the
patient will exhibit melena. Melena generally occurs if the source of bleeding is above the ligament of
Treitz. Although it is possible for melena to occur with bleeding from the right colon, blood from the
sigmoid colon and the rectum usually does not stay in the colon long enough for the bacteria to turn it
black.
Sometimes, bleeding from the gastrointestinal tract (upper or lower) will be so minimal that it will not
cause either rectal bleeding or melena. In such situations, blood can be found only by the use of special
tests done on samples of stool (test for occult blood).
The most common causes of melena are:
- peptic ulcer disease
- other cause of bleeding from the upper gastro-intestinal tract (gastritis, esophageal varices, and
Mallory-Weiss syndrome)
- anti-coagulants (such as warfarin) overdose
- tumors, especially malignant tumors affecting the esophagous, the stomach and, less commonly,
the small intestine; a very helpful sign in these cases of malignant tumours is hematemesis
- hemorrhagic blood diseases (e.g. purpura and hemophilia)
- rarely: blood swallowed as a result of a nose bleed (epistaxis)
- causes of "false" melena: iron supplements, bismut, and lead; in this case, stools are black, but
negative when tested for occult bleeding and with no pathologic significance
16.1.8.2 Rectal bleeding (hematochezia)
Rectal bleeding refers to the passage of red blood from the anus, often mixed with stools and/or blood
clots.
The severity of rectal bleeding varies widely.
a. Most episodes of rectal bleeding are mild and stop on their own.
83
b. In case of moderate bleeding, large quantities of bright or dark red blood often mixed with stools
and/or blood clots repeatedly pass.
c. In case of severe bleeding, a large amount of blood is eliminated by several bowel movements or by
a single bowel movement.
Moderate or severe rectal bleeding can lead to weakness, dizziness, fainting, and signs of low blood
pressure or orthostatic hypotension (with a drop in blood pressure when standing up after a sitting or
lying position).
The color of blood during rectal bleeding often depends on the location of the bleeding in the
gastrointestinal tract. Generally, the closer the bleeding site is to the anus, the brighter red the blood
will be. Thus, bleeding from the anus, rectum, and the sigmoid colon tends to be bright red, whereas
bleeding from the transverse colon and the right colon tends to be dark red or maroon-colored.
Common causes of rectal bleeding include:
- anal fissures, hemorrhoids,
- cancers and polyps of the rectum and colon, diverticulosis
- abnormal blood vessels (angiodysplasia)
- ulcerative colitis, ulcerative proctitis, Crohn's colitis, infectious colitis ischemic colitis, Meckel's
diverticula
The occult gastrointestinal bleeding refers to a slow loss of blood into the upper or lower
gastrointestinal tract that does not change the color of the stool. The blood is detected only by fecal
occult blood testing. Occult bleeding has many of the causes the rectal bleeding has and may result in
the same symptoms as rectal bleeding. For example, slow bleeding from ulcers, colon polyps, or
cancers can cause small amounts of blood to mix and be lost within the stool. It is often associated with
anemia that is due to loss of iron along with the blood (iron deficiency anemia).
16.1.9 Jaundice
Jaundice, also known as icterus, is a yellowish pigmentation of the skin, the conjunctival membranes
over the sclerae (normally white), and other mucous membranes, caused by hyperbilirubinemia
(increased levels of bilirubin in the blood).
This hyperbilirubinemia 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 0.5 mg/dL), for the coloration to be easily visible.
One of the first tissues to change color as bilirubin levels rise in jaundice is the conjunctiva of the eye, a
condition sometimes referred to as scleral icterus, although the sclera themselves are not "icteric", but
rather the conjunctival membranes that overlie them.
The icterus is divided into:
a. Pre-hepatic (hemolytic) jaundice, caused by an increased rate of hemolysis:
- certain genetic diseases expressed by an increasesd hemolysis: sickle cell anemia, spherocytosis,
thalassemia, glucose 6-phosphate dehydrogenase deficiency
- hemolytic uremic syndrome
84
- defects in bilirubin metabolism: Gilbert's syndrome, Crigler-Najjar syndrome.

In jaundice secondary to hemolysis, the increased production of bilirubin leads to the increased
production of urine-urobilinogen.
Bilirubin is not usually found in the urine because unconjugated bilirubin is not water-soluble, so, the
combination of increased urobilinogen in urine with no bilirubin (this still being unconjugated) is
suggestive of hemolytic jaundice.
b. Hepatocellular (hepatic) jaundice
Hepatocellular jaundice appears because cell necrosis reduces the liver's ability to metabolize and
excrete bilirubin.
It can be caused by:
- acute and chronic liver disease
- drug hepatotoxicity, alcoholic liver disease
- primary biliary cirrhosis leading to an increase in plasma conjugated bilirubin
- neonatal jaundice, occurring in almost every newborn as conjugation and excretion of bilirubin
is not fully mature until approximately two weeks of age
- rat fever (leptospirosis)
c. Post-hepatic
Post-hepatic jaundice, also called obstructive jaundice, is caused by an interruption to the drainage of
bile in the biliary system.
- gallstones in the common bile duct, strictures of the common bile duct, biliary atresia, ductal
carcinoma
- cancer of the head of the pancreas, pancreatitis and pancreatic pseudocysts.
In complete obstruction of the bile duct, no urobilinogen is found in the urine, since bilirubin has no
access to the intestine, and it is in the intestine that bilirubin gets converted to urobilinogen to be later
released into the general circulation.
In this case, the presence of bilirubin (conjugated) in the urine without urine-urobilinogen suggests
obstructive jaundice, either intra-hepatic or post-hepatic.
The presence of pale stools and dark urine suggests an obstructive or post-hepatic cause as normal feces
get their color from bile pigments. The serum cholesterol may increase, and there may appear severe
itching or "pruritus" because of the deposition of bile salts.
16.2 The physical examination of the abdomen

For descriptive purposes, the abdomen is divided into four or nine quadrants.
The disposition in four quadrants described by some authors is:
- right upper, right lower
- left upper, left lower
85
The disposition in nine quadrants is:

- right upper, right middle, right lower
- epigastric, umbilical, hypogastric or suprapubic
- left upper, left middle, left lower
Fig.39 The quadrants of the abdomen

The disposition in four quadrants The disposition in nine quadrants
16.2.1 Inspection
The patient has to lie comfortable in a supine position, with a pillow for the head, and relax. His arms
must be kept at the sides, or folded across the chest. If necessary, distract the patient with conversation.
We must describe:
a. The skin: scars (describe their location), striae (old silver striae are normal), dilated veins (normally
only a few small veins can be seen, describe if collateral circulation is present), rashes and lesions
b. The umbilicus: note signs of inflammations or hernia
c. The contour of the abdomen:
- symmetrical or not
- flat, rounded, protuberant (with fat, tumors, or ascitic fluid) (fig 40) or scaphoid (markedly concave or
hollowed)
86
Fig.40 Rounded, protuberant abdomen
- note if there are any local bulging (such as suprapubic bulge of distended bladder or pregnant uterus)
d. Peristalsis is normally seen in very thin people; increased waves in intestinal obstruction
e. Pulsations of the aorta can be normally seen in the epigastrium.
16.2.2 Palpation
We ask the patient to point to the painful area and examine it. Warm hands are needed.
Light palpation is helpful in identifying muscular resistance, abdominal tenderness, some superficial
organs and masses (fig 41)
Involuntary rigidity or spasm of the abdominal muscles indicates peritoneal inflammation.
Deep palpation is required to delineate abdominal masses. If found, their location, size, shape,
consistency, tenderness, pulsations and mobility must be registered (fig.42).
Examples of abdominal masses:
- physiologic: pregnant uterus
- inflammatory: diverticulitis of the colon, pseudocyst of the pancreas
- vascular: aneurysm of the abdominal aorta
- neoplastic: myomatous uterus, carcinoma of the colon or ovary
- obstructive: distended bladder.
87
Fig.41 Light palpation of the abdomen
Fig.42 Deep palpation of the abdomen
88
Assessment for peritoneal irritation: association of pain and tenderness, especially when associated
with muscular spasm, suggest inflammation of the parietal peritoneum.
Palpating the liver:

a. The normal liver often extends down just below the right costal margin, its soft consistency
makes it difficult to feel through the abdominal wall. It can be palpable sometimes, with no
pathologic meaning, up to 1 cm below the lower border of the rib cage. Place the left hand
behind the patient, parallel to and supporting the right 11th and 12th ribs. Place the right hand on
the patient’s right abdomen lateral to the rectus muscle, with the fingertips below the lower
border of liver dullness; ask the patient to take a deep breath and try to feel the liver as it comes
down to meet the fingertips. (fig.43)
Fig. 43 Palpating the liver
b. The “hooking technique”: standing to the right of the patient’s chest, place both hands on the
right abdomen below the border of liver dullness. Than press in the fingers and up toward the
costal margin. (fig.44)
89
Fig 44 Palpating the liver- the hooking technique
Palpating the spleen:

With the left hand, reach over and around the patient to support and press forward the lower left rib
cage. With the right hand, below the left costal margin, press in toward the spleen. Ask the patient to
take a deep breath.
Normally the spleen can’t be perceived by palpation. But in a small percentage of normal adults, the tip
of the spleen is palpable: eg a deep inspiratory descent of the diaphragm, or a low, flat diaphragm as in
obstructive pulmonary disease.
16.2.3 Percussion
The percussion of the abdomen is performed in all nine quadrants to assess the distribution of tympany
and dullness. Tympany usually predominates because of gas in the gastrointestinal tract. Dullness in
both flanks indicates further assessment for ascites.
a. the liver: measure the vertical height of liver dullness in the right midclavicular line (n 6-12 cm)
and in midsternal line (n 4-8 cm) (fig.45)
90
The vertical height of the liver

6-12 cm
4-8 cm
Fig.45 Percussion of the liver
b. the spleen: percuss the lowest interspace in the left anterior axillary line (if spleen size is
normal, the percussion note remains tympanitic)
Special maneuvers
1. Assess possible ascites:

a. Protuberant abdomen with bulging flanks suggests ascitic fluid
b. Percussion gives dullness in dependent area of the abdomen; percuss outward in several directions
Ascitic fluid (dullness) stays in the inferior part because of gravity, while the gas-filled loops of the
bowel (tympany) are on top (fig 46).
c. Test for shifting dullness
The patients is asked to turn to one side. We have to percuss and mark the borders again. In the absence
of ascites, the borders between tympany and dullness remain approximately constant.
In ascites, dulness shifts to the dependent side, while tympany shifts to the top (fig 47).
91
Tympany
Dullness
Fig.46 Ascites
tympany
dulness
Fig.47 Ascites
c. Test for a fluid wave

An assistant presses the edges of both hands firmly down the middle of the abdomen. This pressure
stops the transmission of a wave through the abdomen, if it has an increased volume because of the
adipose tissue.
We tap one flank with the fingertip and feel the impulse in the opposite flank if ascites is present (the
impulse is the impact of the wave transmitted inside the fluid from one flank of the abdomen to the
other one).
2. Assess possible appendicitis: localized tenderness anywhere in the in the right lower quadrant may
indicate appendicitis
3. Assess possible acute cholecistitis: Murphy’s sign- fingers of the right hand placed under the costal
margin at the point where the lateral border of the rectus muscle intersects the costal margin. The
92
patient is asked to breathe deeply. A positive sign is a sharp increase in tenderness with a sudden stop
in inspiratory effort.
4. Assess ventral hernias: ask the patient to raise both head and shoulders. The bulge of a hernia will
usually appear with this action.
5. Distinguish an abdominal mass from a mass in the abdominal wall: ask the patient to raise the head
and shoulders and look for the mass again. A mass in the abdominal wall remains palpable, while an
intraabdominal mass is obscured by muscular contraction.
16.2.4 Auscultation:
- Listen for bowel sounds and note their frequency and character. Normal sounds consist of clicks
and gurgles, occasionally borborygmi.
- Listen for bruits if the patient has high blood pressure. In a hypertensive patient, a bruit in the
upper abdomen suggests renal artery stenosis.
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The urinary tract
Chapter 17
The urinary tract
17.1.1 Kidney pain

Kidney pain is experienced at or below the costal margin posteriorly, near the costovertebral angle.
Pain caused by the kidneys tends to be sharp and severe.
Diseases that can cause kidney pain:
 acute or chronic pyelonephritis
 post streptococcal glomerulonephritis,
 polycystic kidney disease, simple kidney cysts
 urolithiasis (which may cause renal colic more often), ureteric obstruction
 renal infarction, renal tuberculosis, obstruction, urinary tract infections, tumors.
17.1.2. Renal or ureteral colic

Renal colic is a severe colicky pain with a sudden onset, caused by the distension of the ureter.
The pain originates in the costovertebral angle and radiates around the trunk into the lower quadrant of
the abdomen and possibly on into the upper thigh and testicle or labium.
The pain is colicky (comes in waves) due to ureteric peristalsis, which tries to overcome the obstacle
created by urinary lithiasis, most frequently.
It is often described as one of the strongest pain sensations felt by humans (being worse than
childbirth).
Depending on the type and size of the kidney stones moving through the urinal tract, the pain may be
stronger in the renal or bladder area, or equally strong in both.
Other symptoms that can occur with renal colic can include hematuria, dysuria, nausea and vomiting.
The most frequent causes are:
- Nephrolithiasis
- Papillary necrosis
- Chronic interstitial nephritis
- Medullary sponge kidney
17.1.3 Suprapubic pain

94
The urinary tract
Some of the common causes of suprapubic pain may include:

- cystitis, urinary tract infection, pyelonephritis
- acute urinary retention, urinary obstruction urethral obstruction, urethral stricture , urethral
injury
- bladder tumor, bladder rupture
- constipation, urinary retention
- pelvis fracture, abdominal trauma, symphysis pubis separation
- appendicitis, seminal vesiculitis, diverticulitis colon
- ovarian abscess, Mittelschmerz ("ovulation pain" or "midcycle pain"), dysmenorrhea
- acute prostatitis , pelvic abscess
17.1.4 Dysuria
Dysuria is a burning or pain sensation during urination. It may be felt at the opening to the urethra
or, less often, over the bladder (in the pelvis, the lower part of the abdomen just above the pubic
bone).
Common causes of dysuria :
1. Infections
- cystitis (more common in women), cervicitis
- epididymo-orchitis, prostatitis
- urethritis, vulvovaginitis
The most involved are nonsexually transmitted bacteria (mostly Escherichia coli), but also sexually
transmitted organisms (such as gonococcus, chlamydial infection, and trichomoniasis).
2. Inflammatory
- inflammatory connective tissue disorders (reactive arthritis or Behçet's syndrome)
- interstitial cystitis (noninfectious bladder inflammation)
- vulvar vestibulitis (increased vulvar sensitivity to pain)
3. Physical
- catheterization of the bladder
- obstruction of the bladder neck (for example, due to benign prostatic hyperplasia) or urethra (due
to strictures)
4. Other
- atrophic vaginitis or urethritis
- tumors.
17.1.5 Urinary urgency

Urinary urgency is a sudden, compelling urge to urinate. It is often associated with urinary
incontinence, polyuria, nocturia, and interstitial cystitis. It tends to increase with age. When
uncontrollable, it causes urge incontinence.
The common causes are:
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The urinary tract
- frequent and urgent urination are classic signs of a urinary tract infection; the inflammation
reduces the bladder's capacity to hold urine, that’s why even small amounts of urine cause
discomfort
- diabetes, pregnancy
- interstitial cystitis, administration of diuretics, overactive bladder syndrome, prostatitis, stroke
and other neurological diseases, urinary incontinence
- less common causes: bladder cancer, bladder dysfunction, radiation therapy.
17.1.6. Hesitancy in starting the urinary stream

In men with partial obstruction to urinary outflow from the bladder (most frequent in case of benign
prostatic hyperplasia), the following may develop: hesitancy in starting the urinary stream,
straining to void, reduced caliber and force of the urinary stream, dribling as they try to complete
the voiding process.
17.1.7 Polyuria is a significant increase in 24-hour urinary volume, roughly defined as exceeding 3
liters.
Polyuria often appears in conjunction with polydipsia (increased thirst), though it is possible to have
one without the other, and the latter may be a cause or an effect.
Polyuria may be physiologically normal in some circumstances, such as cold diuresis, altitude
diuresis, and after drinking large amounts of fluids.
Causes:
- the most common cause of polyuria in both adults and children is uncontrolled diabetes
mellitus, causing an osmotic diuresis
- other frequent causes are: primary polydipsia (excessive fluid drinking), central diabetes
insipidus and nephrogenic diabetes insipidus
- after supraventricular tachycardias or crisis of bronchyal asthma, during an onset of atrial
fibrillation, postural orthostatic tachycardia syndrome
- removal of an obstruction within the urinary tract
- chemical substances: lithium, diuretic medication; diuretic foods (foods and beverages
containing caffeine, such as chocolate, coffee, tea, and soft drinks; hot spicy foods; juices high
in acid; alcoholic beverages; high doses of vitamin B2 or of vitamin C
- chronic renal failure
- renal tubular acidosis, hypercalcemia, hyperthyroidism, hyperparathyroidism, hypopituitarism,
hypogonadism, Conn's disease (primary aldosteronism), acromegaly, pheochromocytoma,
Cushing's syndrome, Addison's disease
- cold diuresis (the occurrence of increased urine production on exposure to cold, which also
partially explains the immersion diuresis), high-altitude diuresis occurs at high altitudes ,
increase in fluid intake, especially water, psychogenic polydipsia
17.1.8 Nocturia (nycturia)

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The urinary tract
Nocturia means a frequent urination at night. It is the need to get up in the night to urinate, thus
interrupting sleep. Its occurrence is more frequent in pregnant women and in the elderly.
Two types of nocturia are described:
a. Nocturia with high volume, going together with almost every type of polyuria, especially with the
following causes:
- chronic renal failure
- diabetes (especially if it is not controlled and is accompanied by osmotic diuresis)
- congestive heart failure, hepatic cirrhosis with ascites, chronic venous insufficiency,
hyperparathyroidism
- habit (too much liquid intake before going to bed, usually the case in the young), diuretic drugs
b. Nocturia with low volume: urinary incontinence, bladder infection, interstitial cystitis, benign
prostatic hyperplasia, ureteral pelvic junction obstruction or prostate cancer.
17.1.9 Urinary frequency

Frequent urination is defined as the need to urinate more often than usual.
Causes:
a. Most causes of polyuria
b. Decreased capacity of the bladder:
- because of inflammation: cystitis, bladder stones, tumor, foreign body, prostatitis, vaginitis
- because of the decreased elasticity of the bladder wall: bladder cancer, scars (following
inflammation), radiation therapy to the pelvis, used to treat certain cancers
- because of decreased cortical inhibition of bladder contractions in stroke or other brain or
nervous system diseases with paralysis
c. Impaired emptying of the bladder, with residual urine:
- loss of sensory nerve supply to the bladder: diabetes
- mechanical obstruction of the bladder: enlarged prostate, pregnancy, tumor or mass in the pelvis
- overactive bladder syndrome, bladder dysfunction.
17.1.10 Polydipsia
Polydipsia is an abnormally high intake of water or other fluids, commonly associated with polyuria.
Causes:
- usually being a result of osmotic diuresis, polydipsia is characteristically found in diabetics as one of
the initial symptoms or in cases of uncontrolled by diet or medication diabetes
- change in the osmolality of the extracellular fluids of the body, hypokalemia, anticholinergic
poisoning
- decreased blood volume (as it occurs during major hemorrhage), and other conditions that create a
water deficit
- diabetes insipidus
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The urinary tract
17.1.11 Hematuria
Hematuria is the presence of red blood cells (erythrocytes) in the urine.
Red discolouration of the urine can have various causes:
1. Presence of red blood cells :
- macroscopic hematuria (can be seen with our eyes)
- microscopic hematuria (small amounts of blood, can be seen only on urinalysis or light
microscopy)
2. Presence of hemoglobin (only the red pigment, not the red blood cells)
3. Presence of other pigments
- myoglobin in myoglobinuria
- porphyrins in porphyria
- drugs such as sulfonamides, quinine, rifampin, phenytoin and phenazopyridine
The most common causes of hematuria are:
- urinary tract infection with viruses, other sexually transmitted diseases (particularly in women)
or some bacterial species including strains of Escherichia coli and Staphylococcus
saprophyticus
- kidney stones or ureter stones
- benign prostatic hyperplasia, in older men, especially those over 50
Less common causes of hematuria include:
- IgA nephropathy ("Berger's disease") - occurs during viral infections in predisposed patients
- trauma, tumors and/or cancer in the urinary system, for example in bladder cancer or in renal
cell carcinoma
- kidney diseases : nephritic syndrome (in post-streptococcal and rapidly progressing
glomerulonephritis), fibrinoid necrosis of the glomeruli (as a result of malignant hypertension)
- urinary Schistosomiasis, prostatitis, benign familial hematuria
- arteriovenous malformation of the kidney, bladder vesicle varices, march hematuria.
17.1.12 Urinary incontinence

Urinary incontinence is an involuntary loss of urine that has become a social or hygienic problem.
It is a common and distressing problem, which may have a big impact on the quality of life. Almost
always, urinary incontinence results from an underlying treatable medical condition but is under-
reported to medical practitioners.
Types:
a. Stress incontinence or effort incontinence, is due essentially to insufficient strength of the pelvic
floor muscles to stop losing urine while sudden coughing, sneezing or laughing (frequent in women)
b. Overflow incontinence: feeling of being unable to stop the bladder from constantly dribbling, or
continuing to dribble for some time
c. Structural incontinence: structural problems, usually diagnosed in childhood, can cause incontinence,
for example an ectopic ureter, fistulas (vesicovaginal, ureterovaginal) caused by obstetric and
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The urinary tract
gynecologic trauma or injury can also lead to incontinence; an irritated bladder by repeated urinary
infections
d. Functional incontinence occurs when a person recognizes the need to urinate, but cannot physically
make it to the bathroom in time due to limited mobility. Causes of functional incontinence: confusion,
dementia, poor eyesight, poor mobility, poor dexterity, unwillingness to go to the toilet because of
depression, anxiety or anger, drunkenness, or being in a situation in which it is impossible to reach a
toilet.
e. Transient incontinence is a temporary version of incontinence. It can be triggered by medications,
adrenal insufficiency, mental impairment, restricted mobility, and severe constipation, which can push
against the urinary tract and obstruct outflow.
Causes:
 polyuria (excessive urine production); polyuria generally causes urinary urgency and frequency,
but doesn't necessarily lead to incontinence
 caffeine or cola beverages also stimulate the bladder
enlarged prostate is the most common cause of incontinence in men after the age of 40
 prostate cancer
 drugs or radiation used to treat prostate cancer can also cause incontinence
 brain disorders: multiple sclerosis, Parkinson's disease, strokes and spinal cord injury can all
interfere with nerve function of the bladder.
17.2 Examination of the urinary system
17.2.1 Inspection
We may notice:
a. a distended bladder in case of retention of urine
b. an enlarged kidney may deform the flank of the abdomen.
17.2.2. Palpation
A tenderness in the costovertebral angle (posterior, between the 12th rib and the spine) is suggestive for
urolithiasis or urinary infection (fig 48).
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The urinary tract
Fig. 48 Palpate in the costovertebral angle
The right kidney:

Place the left hand behind the patient just below and parallel to the 12th rib, with fingertips just reaching
the costovertebral angle.
Place the right hand in the right upper quadrant, lateral and parallel to the rectus muscle and ask the
patient to take a deep breath. At the peak of inspiration press the right hand firmly and deeply below the
costal margin, trying to “capture” the kidney between the hands (fig 49).
A normal right kidney may be palpable especially in thin, well relaxed women.
Occasionally right kidney is located more anteriorly than usual and needs to be distinguished from the
liver. The edge of the liver, if palpable, tends to be sharper and to extend medially and laterally. The
lower pole of the kidney is rounded.
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The urinary tract
Fig.49 Palpating the kidney
The left kidney: the right hand used to lift from in back, the left hand to feel deep in the left upper
quadrant. A left kidney is rarely palpable if it is normal.
17.2.3 Percussion
If tenderness didn’t appear while palpating the costovertebral angle, we shortly strike the same area
with the ulnar border of the hand. If tenderness was present it has the same significance (urolithiasis or
urinary infection) (fig 50).
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The urinary tract
Fig 50 Percussion – Giordano sign
17.2.4 Auscultation
An arterial murmur can be heard near the umbilicus, on both sides, in case of renal artery stenosis.
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The nervous system
Chapter 18
The nervous system
18.1. The altered level of consciousness
Consciousness can be measured on a spectrum that ranges from full wakefulness to deep coma.
The altered levels of consciousness include the following conditions:
a. Confusion: the confused patient cannot properly process all the information from the surroundings.
The most noticeable symptoms are: apathy, drowsiness, disorientation especially to time. A severely
confused person can accomplish only very few simple commands.
b. Delirium is a common problem especially in the elderly. The signs of delirium are: disorientation
(which may be total, the patient even forgetting who he is), delusions and sometimes hallucinations.
People with delirium may become drowsy or less alert at times.
c. Obtundation is characterized by a lower level of alertness. The patient in this state often sleeps
much more than usual, and when awakened, remains drowsy and confused. Wakefulness can only be
maintained by continuously talking to the person, or through constant painful stimulation.
d. Stupor is characterized by unresponsiveness from which a person can be aroused only by vigorous
and repeated painful stimulation.
e. Coma: the patient appears to be asleep, but cannot be awakened. Reflexes may be absent, and the
legs and arms may be rigid. The respiration rate is usually slowed.
Causes of altered level of consciousness:
 traumatic brain injury
 infections: encephalitis and meningitis
 metabolic disturbances: diabetes, chronic renal failure, chronic liver failure, hydroelectrolytic
abnormalities
 drug exposure, alcohol intoxication, exposure to home or industrial chemicals
 structural abnormalities of the brain- tumors
18.2 Syncope
The syncope represents a sudden, usually temporary, loss of consciousness generally caused by
insufficient oxygen in the brain either through cerebral hypoxia or through hypotension, but possibly
for other reasons.
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The nervous system
A pre- or near-syncope is diagnosed if the individual can remember events during the loss of
consciousness (reports remembering dizziness, blurred vision, and muscle weakness, and the fall
previous to hitting the head and losing consciousness).
If the episode of dizziness and loss of vision wasn’t accompanied by falling, then it is considered a
syncoptic episode. Typical symptoms progress through dizziness, clamminess of the skin, a dimming of
vision or greyout, possibly tinnitus, complete loss of vision, weakness of limbs to physical collapse.
Syncope may be caused by:
a. The ischemia of the central nervous system; the respiratory system may contribute to oxygen levels
through hyperventilation
Typical symptoms of fainting: pale skin, rapid breathing, nausea and weakness of the limbs,
particularly of the legs. If the ischemia is intense or prolonged, limb weakness progresses to collapse.
Arterial disease in the upper spinal cord, or lower brain, causes syncope if there is a reduction in blood
supply, which may occur with extending the neck or after drugs given to lower blood pressure.
b. Vasovagal (situational) syncope is one of the most common types and it may occur in scary,
embarrassing or uneasy situations, or during blood drawing, coughing, urination or defecation.
c. The postural syncope is caused by a changing in the body posture.
d. The cardiac syncope is caused by:
 cardiac arrhythmias: bradyarrhythmias or tachyarrhythmias
 obstructive cardiac lesion: aortic stenosis and mitral stenosis are the most common examples;
rarely, cardiac tumors such as atrial myxomas can also lead to syncope
 relatively infrequent causes of syncope: acute myocardial infarction, ischemic event,
hypertrophic cardiomyopathy, acute aortic dissection, pericardial tamponade, pulmonary
embolism, pulmonary hypertension
 other cardiac causes: sick sinus syndrome; Adams-Stokes syndrome is a cardiac syncope which
may occur with seizures caused by complete or incomplete heart block; symptoms include deep
and fast respiration, weak and slow pulse and respiratory pauses that may last for 60 seconds
 orthostatic hypotension
 neurological syncope
 many other causes of syncope: hypoglycemia, emphysema, pulmonary embolism.
18.3 Seizures
Epileptic seizures are defined as transient symptoms of abnormal excessive or synchronous neuronal
activity in the brain.
The medical syndrome of recurrent, unprovoked seizures is termed epilepsy, but seizures can occur in
people who do not have epilepsy.
The source of the seizure within the brain may be:
a. Localized: partial or focal onset seizures:
- simple partial seizures: if consciousness is unaffected
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The nervous system
- complex partial seizure : if consciousness is affected

A partial seizure may spread within the brain, a process known as secondary generalization.
b. Distributed: generalized seizures, which are divided according to the effect on the body, but all
involve loss of consciousness. These include absence, myoclonic, clonic, tonic, tonic–clonic, and atonic
seizures.
c. Mixed seizures represent the presence of both generalized and partial seizures in the same patient.
The signs and symptoms of seizures vary depending on the type:
a. may cause involuntary changes in body movement or function, sensation, awareness, or behavior.
b. often associated with a sudden and involuntary contraction of a group of muscles and loss of
consciousness.
c. can also be as subtle as a fleeting numbness of a part of the body, a brief or long term loss of
memory, visual changes, sensing/discharging of an unpleasant odor, a strange epigastric sensation, or a
sensation of fear and total state of confusion.
d. can last from a few seconds to status epilepticus: a continuous group of seizures that is often life-
threatening without immediate intervention.
In about 20% of people who have a seizure disorder, seizures are preceded by unusual sensations
(called aura): abnormal smells or tastes, butterflies in the stomach, a feeling of déjà vu, an intense
feeling that a seizure is about to begin. A patient suffering a tonic–clonic seizure cries out, loses
consciousness and falls to the ground; often violently convulses appear, forcefully turns his head to one
side, clenches his teeth, bites his tongue, loses bladder control.
The seizures usually last 1 to 2 minutes. Afterwards, some people have a headache, are temporarily
confused, and feel extremely tired. These symptoms may last from minutes to hours. Most people do
not remember what happened during the seizure.
After the active portion of a seizure, there is typically a period referred to as postictal before a normal
level of consciousness returns.
Some people have seizures that are not noticeable to others. Some have absence seizures in which the
only clue that shows they are experiencing it can be rapid blinking, extreme confusion for a few
seconds or, sometimes, for hours.
Causes of provoked seizures include:
 sleep deprivation
 space-occupying lesions in the brain (abscesses, tumors), cavernoma or cavernous
malformation, head injury
 intoxication with drugs, for example aminophylline or local anaesthetics; normal doses of
certain drugs that lower the seizure threshold, such as tricyclic antidepressant; withdrawal from
drugs (anticonvulsants, antidepressants, and sedatives such as alcohol, barbiturates and
benzodiazepines)
 infection (encephalitis or meningitis), fever leading to febrile convulsions, metabolic
disturbances (hypoglycaemia, hyponatremia or hypoxia)
 seizures during (or shortly after) pregnancy can be a sign of eclampsia.
 haemorrhagic stroke , multiple sclerosis
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The nervous system
 posttraumatic stress disorder (after a traumatic event): a psychogenic non-epileptic seizure

18.4. Fatigue
Fatigue is defined as the lack of energy or strength and it is a very common symptom. The term
includes drowsiness (sleepiness), lethargy, tiredness, malaise or weakness (including muscular
weakness).
Sometimes the patient finds it difficult to define exactly whether he is tired, feels weak, fatigued, or has
other symptoms. Nevertheless, any type of fatigue may indicate not only a minor disease, but also a
serious medical condition and needs prompt medical investigation.
The following medical conditions are some of the possible causes of fatigue as a symptom:
overexertion, anxiety, pregnancy, infections, mononucleosis, hepatitis, viral infections and post-viral
syndrome, chronic infections, tooth abscess, anemia, Addison's disease, hypothyroidism,
hyperthyroidism, diabetes, hypoglycemia, hypotension, chronic fatigue syndrome, poor nutrition, low
magnesium level, heart failure, cancer, depression, myasthenia gravis, malnutrition, uremia,
inflammatory disorders, connective tissue diseases, certain medications: diuretics, beta blockers.
We have to use open-ended questions to explore the attributes of the patient’s fatigue. Helpful
information can be given by:
- a good psychosocial history
- a careful review of all systems
- an exploration of sleep patterns
18.5 Weakness
Weakness adds to fatigue a demonstrable loss of muscular power during a physical exam.
Causes:
 metabolic: Addison’s disease, hyperparathyroidism, hyponatremia, hypopotasemia,
thyrotoxicosis
 neurologic : amyotrophic lateral sclerosis, bell's palsy, cerebral palsy, Guillain-Barre syndrome,
multiple sclerosis, stroke
 primary muscular diseases: dermatomyositis, muscular dystrophy (Duchenne), myotonic
dystrophy
 toxic disorders: organophosphate poisoning (insecticides, nerve gas)
 other: anemia, myasthenia gravis, poliomyelitis.
18.6 Paralysis
Paralysis is the loss of muscle function in one or more muscles. Paralysis can be accompanied by a loss
of feeling (sensory loss) in the affected area if there is sensory damage, as well as motor.
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The nervous system
It is most often caused by damage in the nervous system (especially the spinal cord). Other major
causes are: stroke, trauma with nerve injury, poliomyelitis, amyotrophic lateral sclerosis, botulism,
spina bifida, multiple sclerosis, Guillain-Barré syndrome, drugs that interfere with nerve function.
18.7 Tremors
Tremors are involuntary, somewhat rhythmic, muscle contractions and relaxations involving
movements of one or more body parts.
It is the most common of all involuntary movements and can affect the hands, arms, eyes, face, head,
vocal cords, trunk, and legs. Most tremors occur in the hands. Characteristics may include a rhythmic
shaking in the hands, arms, head, legs, or trunk, a shaky voice, writing or drawing difficulty or
problems in holding and controlling tools, such as a fork. Some tremors may be triggered by or become
exaggerated during times of stress or strong emotions, when the individual is physically exhausted, or
during certain postures or movements.
Causes:
 neurological disorders: multiple sclerosis, stroke, traumatic brain injury, and a number of
neurodegenerative diseases that damage or destroy parts of the brainstem or the cerebellum
(Parkinson's disease being the one most often associated with tremor)
 use of drugs (such as amphetamines, caffeine, corticosteroids), alcohol abuse or withdrawal,
mercury poisoning
 infants with phenylketonuria, overactive thyroid or liver failure
 hypoglycemia ( associating palpitations, sweating and anxiety)
 lack of sleep, lack of vitamins, or increased stressdefficiencies of magnesium and thiamine
18.8 Paresthesias
Paresthesias are sensations of tingling, pricking, or numbness of a person's skin with no apparent long-
term physical effect. The manifestation of paresthesia may be transient or chronic.
a. Transient:
- paresthesias of the hands and feet are common symptoms of the hyperventilation syndrome and panic
attacks
b. Chronic paresthesia indicates a problem in the functioning of the neurons:
- in the elderly, paresthesia is often the result of poor circulation in the limbs, most often caused by
atherosclerosis that offers a poor supply of blood and nutrients to the nerves, or of a transient ischemic
attack
- vitamin deficiency and malnutrition, metabolic disorders: diabetes, hypothyroidism, and
hypoparathyroidism
- rheumatoid arthritis, psoriatic arthritis and carpal tunnel syndrome, chronic neck and spine problems,
multiple sclerosis, lupus erythematosus
- motor neuron disease, herpes zoster virus, demyelinating diseases: multiple sclerosis and Guillain–
Barré syndrome.
107

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The medical record and the reasons for correctly completing it

Parts of the Medical Record

1.2 The History

1.2.1 Identifying data:

1.2.2 Presenting complaints (PC)

1.2.3 Short history of presenting complaint

If presented with this/these symptoms to a doctor

How to approach a patient

Physiological Data for Women

1.2.5 Family History (FH)

1.2.6 Social history (SH)

1.2.8 Drug history (DH)

2.1 General data

2.2 The parts of the physical examination:

fig.1 Percussion of the abdomen

Fig 2. Auscultation of the thorax

Fig. 3 Forced position Orthopnea

Fig.4 Forced position: “Knee-chest” or “Mahomedan position”

Fig.5 Forced position: “Gun-cock” position

5.1 The height

5.2 The weight

5.4 Weight gain

- Overweight: 25-29.9 kg/m2

5.5 Weight loss

- it is generalized, therefore it also appears in buccal mucosa, tongue, lips, nails.

6.4 Lesions of the skin

6.4.1 Primary lesions:

6.5 Vascular and purpuric lesions of the skin

6.5.1 Purpuric lesions of the skin

6.6 The venous collateral circulation

Fig.6 Venous collateral circulation

a. General or systemic causes:

- in case of administration of corticosteroids or estrogens, an excessive amount of water is retained, part

c. Both general and local causes:

8.2 The nails

a. Chronic respiratory diseases: suppurative lung disease (lung abscess, empyema,

Fig.8 Splinter hemorrhages

fig 9 Continuous fever

fig 10 Intermitent fever

fig 11 Remittent fever

Fig 12 Pel Ebstein fever

11.2 The eyes:

11.3 The nose

11.4 The mouth and the pharynx

11.4.1 Abnormalities of the lips

11.4.2 Abnormalities of the buccal mucosa

11.4.3 Abnormalities of the gums and of the teeth

b. Non-plaque-induced gingival lesions may be:

11.5 The ears:

11.6 The thyroid gland

The axillary lymph nodes:

- the size: large size suggests lymphoma or leukemia

13.1 Symptoms and signs

13.2 The examination of the musculoskeletal system

14.1 Symptoms and signs

14.1.1 Chest pain

14.1.1.1 Respiratory diseases

14.1.1.2 Cardiovascular causes

Dyspnea (shortness of breath) is a nonpainful, but uncomfortable awareness of breathing.

The most common causes are:

14.1.4 Expectoration (sputum)

14.2 The examination of thorax and lungs

The patient must be undressed, examined in good light.