B)#Main#symptoms#in#internal#medicine#and#their#most#common#causes##

!
1.#Qualitative#disturbances#of#consciousness.##
Definition!Consciousness:!overall!activity!oft!he!central!nervous!system.!Disturbance!of!
consciousness!are!the!consequence!of!damage!to!the!central!nervous!system.!
Qualitative!Disorders:!
!!Are!characterized!by!the!disorientation!in!time,!place,!and!person!
• Amentia:!is!a!disorder!of!perception!with!hallucination!and!motor!hyperactivity!
• Delirium:!is!a!more!serve!state!with!prevailing!visual!hallucinations!(small!animals),!
memory!disorders,!agitation,!or!sleepiness!
• Obnubilation!(blackout):!manifests!by!unconscious!action!of!the!patient!(patient!does!
not!remain!memory!from!this!state).!The!patient!still!retains!his!spatial!orientation!
but!is!unaware!of!his!her!activity.!(e.g.!Hypoglycaemia)!
!
2.#Quantitative#disturbances#of#consciousness.##
Quantitative!Disorders:!!
!!are!recognized!as!impaired!consciousness!
• Somnolence:!is!a!pathological!sleepiness!with!a!possibility!of!awaking.!Verbal!
answers!to!questions!are!correct;!reactions!are!slowed!down!
• Sopor:!is!a!more!serious!disorder,!with!no!reaction!to!verbal!stimuli.!Wakening!is!
restricted!to!painful!stimuli.!After!this!sort!of!stimuli!stops,!the!patient!returns!to!
original!state!of!consciousness.!!
• Coma!(unconsciousness):!most!severe!disorder;!reaction!to!painful!stimulus!is!
missing.!Gradually!the!reflexes!vanish,!including!pupil!and!cornea!reflexes!
• Syncope!(faintness):!is!a!shortLtime!loss!of!consciousness!caused!by!insufficient!blood!
supply!of!CNS!
!
!!Causes!of!disorders:!!
• Circulatory:!ischemia!haemorrhage,!embolism!of!CNS,!secondary!to!heart!failure,!
arrhythmia!
• Inflammatory:!meningitis,!brain!abscess!
• Intoxications:!alcohol!abuse,!drugs!
• Metabolic:!hyperL,!hypoglycaemia,!liver!or!kidney!failure,!hydration!disorderL
dehydration!
• Psychiatric!illness!
• Associated!with!injury,!tumours,!epilepsy!
!
!
!
3.#Syncope,#collapse,#orthostatic#hypotension.##
1.!Syncope!
!!brief!attack!of!loss!of!consciousness!due!to!circulatory!disturbance;!in!severe,!longer!
lasting!forms!of!syncope!patients!soil!themselves!(urine,!stool)!or!develop!seizures.!
Forms:!
• Vasovagal!syncope!(blackout):!!!
− due!to!short!bradyLarrythmia!or!brief!cardiac!still!stand,!difficult!to!record!
because!of!short!duration!
 − Diagnosis:!provoke!causeL!standing!for!a!long!time!in!hot,!poorly!ventilated!
areas!
− Causes:!pain,!anxiety,!sight!of!blood,!stimulation!o!hypersensitive!carotid!
sinus!!
− In!individuals!without!CVD!
• Exertional!Syncope:!
− Due!to!server!heart!diseases,!connected!with!sudden!physical!exercise!
(occurrence!of!weakness,!blackout!feeling,!actual!fainting)!
− Diagnosis:!should!be!meticulously!pursued!
− Causes:!aortic!stenosis!(without!limitation!of!exertional!dyspnea),!pulmonary!
artery!stenosis,!severe!pulmonary!hypertension!(without!shunting!btw!right!
and!left!heart!compartments)!
2.!!Collapse:!
!!sudden,!often!unannounced!loss!of!postural!tone,!mostly!not!accompanied!with!loss!of!
consciousness;!
− Causes:!cardiac,!seizures,!psychological!causes!
3.!Orthostatic!hypotension:!
!!common!form!of!postural!syncope!and!is!the!result!of!peripheral!autonomic!limitation!
− Due!to!sudden!fall!in!systemic!blood!pressure,!resulting!from!a!failure!of!
adaptive!reflexes!to!compensate!for!an!erect!posture!
− Symptoms:!dizziness,!blurring!of!vision,!profound!weakness,!syncope!
− Causes:!drugs,!which!lead!to!changes!in!intravascular!volume!or!tone!
!
4.#Shock#–#forms,#common#causes,#clinical#examination.##
Shock!=!a!lifeLthreatening!medical!condition!as!a!result!of!insufficient!blood!flow!throughout!
the!body.!It!accompanies!often!with!severe!injuries!or!illness.!It!can!lead!to!other!conditions!
such!as!lack!of!oxygen!in!body’s!tissue!(hypoxia),!cardiac!arrest!or!organ!damage;!
Types:!!
• Septic!Shock:!results!from!bacteria!multiplying!in!blood!and!releasing!toxins;!causes:!
pneumonia,!urinary!tract!infections,!skin!infections!(cellulitis),!intraLabdominal!
infections,!meningitis!
• Anaphylactic!Shock:!type!od!a!severe!hypersensitivity!or!allergic!reaction;!Causes:!
allergy!to!insect!stings,!medicine,!food!
• Cardiogenic!Shock:!happens!when!heart!is!damaged!and!unable!to!supply!sufficient!
blood!to!the!bod;!lead!to!heart!attack,!congestive!heart!failure;!!
• Hypovolemic!Shock:!is!caused!by!severe!blood!and!fluid!loss,!such!as!from!traumatic!
injury,!which!makes!the!heart!unable!to!pump!sufficient!blood!to!the!body,!severe!
anaemia!(leads!to!insufficient!oxygen!supply)!
• Neurogenic!Shock:!caused!by!spinal!cord!injury,!result!of!traumatic!accident!or!injury!
Causes:!!
• Heart!condition:!heart!attack,!heart!failure!
• Heavy!internal,!external!bleedings!
• Dehydration!
• Infection!
• Allergic!reaction!
• Spinal!cord!injuries!
• Burns!
 • Persistent!vomiting,!diarrheal!
Symptoms:!
• Low!blood!pressure!
• Rapid,!shallow!breathing!
• Cold,!clammy!skin!
• Rapid,!weak!pulse!
• Dizziness!or!fanting!
• Weakness!
Clinical!examination!–!treatment:!
• General:!
o Fluid!resuscitation!
o Medication:!Epinephrine!(norL),!dopamine!!!raise!BP!
o Test:!XLray,!blood!tests,!ECG)!
• Depending!type!of!Shock:!
o Septic:!antibiotics!
o Anaphylactic:!Epi,!steroid!medications,!sometimes!H2!blocker!
o Cardiogenic:!Heart!attack:!cardiac!catherization!(unblock!coronary!artery),!
congestive!heart!failure:!medicamentation,!transplantation!
o Hypovolemic:!fluid!administration,!blood!transfusion!
o Neurogenic:!often!irreversible,!fluids,!immobilization,!monitoring,!antiL
inflammatory!medicine,!surgery!!
!
5.#Fever#and#types#of#temperature#curves.##
=!fever!refers!to!an!abnormal!elevation!of!body!temperature!!
!!Bodytempreture!depends!on!the!balance!between!heat!production!by!the!body!
(metabolism,!muscular!activity..)!and!heat!loss!to!the!environment!through!the!skin!
(capillary!blood!flow!and!sweat).!This!balance!is!regulated!by!the!thermoregulatory!centre!
located!in!hypothalamus.!!
!!this!thermoregulatory!centre!could!be!affected!by!pyogenic!substances:!!
• Exogenous:!endotoxin!GL!bacteria!
• Endogenous!
• Originating!from!neutrophils:!free!pyrogens!during!phagocytosis!in!allergic!
reactions!(collagen!diseases,!tissue!necrosis)!
Classification:!
• Normal:!36L37!C!
• Subfebril:!elevated!up!to!38!C!
• Fever:!over!38!C!
• Hyperpyrexia:!40!C!
!!speed!of!temperature!increases!and!the!zenith!depend!on!the!etiology!of!the!disease,!as!
well!as!reactivity!of!the!organism!
!!children!react!to!same!disease!much!faster!and!with!greater!increase!in!temperature!than!
elderly!Types!off!temperature!curves:!
• Continuous!fever!(febris!continua):!steady!fever!above!38!C!with!a!diurnal!
amplitude!(fluctation)!of!not!more!than!1!degree;!typical!for!(untreated)!typhoid!
fever,!lobar!pneumonia!
 • Remittent!fever!(febris!remittens):!during!24h!the!temperature!fluctuates!by!
more!than!2!degrees!but!does!not!return!to!normal.!Prior!to!the!use!of!effective!
antibiotics!treatment!this!type!of!fever!used!to!be!typical!for!infections!
• Intermittent!fever!(f.!intermittens):!high!temperature,!which!during!the!day!falls!
to!normal!or!even!subnormal!levels.!This!type!is!present!in:!septicaemia,!in!
cholangitis,!pyelonephritis!
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• Recurrent!fever!(F.!recurrens):!also!relapsing!fever;!alternating!periods!of!fever!
with!periods!of!normal!temperature;!typical:!typhus!(borrelia)!

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6.#Headache,#vertigo.##
!!most!reasons!patient!seek!medical!attention!
!!diagnosis!management!based!on!a!careful!clinical!approach!
!
Primary!and!secondary!headache:!
• Primary:!!
o headache!and!its!associated!features!are!the!disorder!in!itself!
o caused!by!over!activity!of!or!problem!with!painLsensitive!structures!in!the!head!
o chemical!activity!of!the!brain,!nerves!or!blood!vessels!surrounding!the!skull,!or!
muscles!of!head!and!neck!can!play!a!role!
 o also!genetically!can!develop!headache!
o also!lifestyle!factors!trigger!headache:!alcohol,!certain!food!(nitrates),!changes!or!
lack!of!sleep,!poor!posture,!skipped!meals,!stress!

!
!
!
• Secondary:!!
o Symptom!of!a!disease!that!can!activate!pain!sensitive!nerves!of!the!head!
o caused!by!exogenous!disorders!
 !
o Origination:!!
• Pain!from!peripheral!nocireceptors!due!to!tissue!injury,!visceral!distension,!usw!
• Pain!because!of!damaged!or!activated!inappropriately!painLproducing!pathways!
or!damage!of!CNS!
Vertigo:!
=!dizziness,!sense!of!spinning!or!other!motion;!disease!(central!vertigo)!originating!from!the!
CNS.!Most!common!labyrinthine!dysfunctionL!from!simple!benign!positional!vertigo,!
precipitate!by!elevating!or!turning!the!head!–!to!chronic!recurrent!attacks!of!dizziness!with!
tinnitus!and!progressing!hear!loss!(Meniere`s!Syndrome)!
• Physiologic:!occurring!during!or!after!a!sustained!head!rotation!
• Pathologic:!due!to!vestibular!nuclei!and!their!connection!to!the!brain!stem,!
haemorrhagic!or!ischemic!insults!to!the!cerebellum!
• Other!causes:!CNS!tumours,!infection,!trauma,!Multiple!Scleroses!
!
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7.#Chest#pain.##
!!Complaints!of!chest!pain!or!chest!discomfort!raise!concern!about!heart!disease!but!often!
arises!from!structures!inn!the!thorax!and!lungs!as!well.!To!examine!this!symptom,!a!dual!
investigation!of!both!thoracic!and!cardiac!causes!is!necessary.!
• Sources!of!Chest!pain!and!related!causes:!
o Myocardium:!Angina!pectoris,!myocardial!infarction,!myocarditis!
o Pericardium:!pericarditis!
o Aorta:!dissecting!aortic!aneurysm!
o Trachea!and!large!bronchi:!bronchitis!
o Chest!wall,!including!musculoskeletal!systems!and!skin:!costachondritis,!
herpes!zoster!
o Esophagus:!reflux!esophagitis,!esophagal!spasm,!esophagal!tear!
o Extrathoracic!structures!(neck,!gallbladder,!stomach):!cervical!arthritis,!biliary!
colic,!gastritis!

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8.#Dyspnea#
=!shortness!of!breath,!is!a!painless!but!uncomfortable!awareness!of!breathing,!that!is!
inappropriate!to!the!level!of!exertion.!Thoroughly!assess!this!prominent!symptom!of!cardiac!
and!pulmonary!disease.!!
=!subjective!experience!of!breathing!discomfort!that!consists!of!qualitativly!distinct!
sensations!that!vary!in!intensity.!The!experience!derives!from!interactions!among!multiple!
physiological,!psychological,!social,!environmental!factors!and!my!indices!secondary!
psychological!and!environmental!response.!(American!Thoracic!society)!!
− Related!to!cardiac!or!pulmonary!conditions:!

!
• Cardiac!symptoms:!
o Paroxysmal!nocturnal!dyspnea!(PND):!occurs!at!night!or!when!patient!is!
supine.!This!position!increases!the!intrathoracic!blood!volume,!and!a!
weekend!heart!may!be!unable!to!handle!this!increased!load!!!congestive!
heart!failure;!Symptoms:!(similar!to!orthopnea)!need!for!using!more!pillows!
o Dyspnea!on!exertion!(DOE):!caused!by!chronic!congestive!heart!failure!or!
severe!pulmonary!!
o disease;!Symptoms:!can’t!walk!long!distances,!not!more!than!1!block.!!
!
9.#The#pathological#types#of#breathing.#
 • Eupnea:!Normal!respiratory!rate:!16L20!breaths!per!minute!
!!!physiological!can!be!changed!with!exercise!(change!in!number!of!breath!per!minute,!
depth,!regularity)!
• Tachypnea:!increased!breathing!rate!(frequency),!amplitude!(depth)!need!not!to!
change;!Sign!of!lung!disease;!also!occurs!in:!excitement,!nervousness,!fever,!exercise,!
hypoxia!(due!to!circulatory!insufficiency)!!
• Bradypnea:!decreased!number!of!breath!per!minute!
• Apnea:!temporary!cessation!of!respiration!
• Hyperpnea:!deepened!respiration!(increased!minute!volume!of!air!in!lungs)!
• Dyspnea:!shortness!of!breath!
• !CheyneLStokes!periodic!respiration:!breath!becomes!deeper!and!concurrently!faster!
and!noisier.!After!reaching!max.!amplitude!and!frequency,!breathing!regresses!by!
same!fall!in!amplitude!and!frequency,!then!stops!for!various!amount!of!time.!–>!
circle!repeats;!in!patient!with:!heart!failure,!uraemia,!severe!pneumonia,!increased!
intracranial!pressure!
• Biots!breathing:!irregular!breaths!of!varying!amplitude!alternate!with!apneic!pauses;!
in:!meningitis,!encephalitis,!decreased!sensitivity!of!respiratory!centre!
• Kussmaul`s!(acidic)!breathing:!deep!and!faster!(regular)!braething!with!increase!in!
minute!volume!of!inspired!air;!in:!diabetic!ketoacidosis,!metabolic!acidosis;!!
• Sighing!respiration:!normal!respiratory!rhythm!is!interrupted!by!a!long!deep!
inspiration,!usually!with!a!sigh!and!followed!by!prolonged!expiration;!in:!
neuroasthmatic!individual!
!
10.#Cyanosis#
=!Cyanotic!(bluish)!hue!of!the!skin!and!mucous!membrane!develops!if!the!amount!of!
reduced!haemoglobin!in!the!capillary!bed!is!at!least!50!g/l.!two!mechanism!are!possible:!
stagnation!of!blood,!fall!in!oxygen!saturation!in!arterial!blood!(below!85%)!
!!frequent!in!disease!of!respiratory!system.!In!chronic!lung!diseases!in!which!exchange!of!
gasses!is!impaired,!cyanosis!develops!if!oxygen!saturation!in!the!alveoli!decreases!and!the!
amount!of!reduced!haemoglobin!in!blood!increases!above50g/l.!
LL>!develops!in!patient!with!normal!or!increased!erys,!than!in!patient!with!anaemia;!!
Two!types:!
• Central!cyanosis:!!
o Develops!in!defective!oxygenation!of!blood!in!the!lungs!due!to!various!types!
of!respiratory!diseases!or!in!situation!with!low!partial!pressure!of!oxygen;!
o Diffuse!and!affects!equally!the!entire!skin!surface!and!mucous!membranes!!
o Saturation!of!oxygen!in!blood!is!reduced!in!lung!congestion!
o Typical!for:!congenital!heart!disease!with!right!to!left!shunting!of!blood!
• Peripheral!cyanosis!
o Caused!by!blood!stagnation!and!congestional!hypoxia!
o Occurs!when!reduced!blood!flow!through!capillary!bed!delivers!more!oxygen!
to!the!tissue,!therefore!more!haemoglobin!is!produced!then!can!be!
transported!out!of!the!congested!area.!
o Most!prominent!in:!acral!party!of!the!body!–!lips,!ear!lobes,!tip!of!nose,!finger!
tips!
o Characterized!by!:!congestive!heart!failure!of!right!ventricle!
o (patients!who!develop!in!addition!to!right!ventricular!failure,!pulmonary!
congestion,!peripheral!cyanosis!with!low!oxygen!saturated!blood!combine)!
 • less!common!form:!methemoglobinemia!
o !!increased!production!of!methhemoglobin!with!plasma!levels!exceeding!15!
g/l!
o characterized!by!pale!blue!or!brownish!hue,!can!be!congenital!or!caused!by!
number!of!toxic!agents!and!drugs!(nitrites,!nitrobenzene,!phenacetin,!aniline,!
sulphonamides)!
• sulfhemoglobin!cyanosis:!!
o develops!if!haemoglobin!is!converted!into!sulfhemoglobin!from!increased!
absorption!of!sulphides!in!the!gut!
o 5!g/l!can!cause!cyanosis!
!
11.#Oedemas#(swelling)#
=!defined!as!a!clinically!apparent!increase!in!the!interstitial!fluid!volume,!which!develops!
when!the!Starling!forces!(hydrostatic!pressure,!colloid!oncotic!pressure)!are!altered!so!there!
is!increased!flow!from!the!vascular!system!into!the!interstitium.!
L Edema!due!to!capillary!pressure!may!result!from!an!elevation!of!venous!pressure!
caused!by!obstruction!to!venous!and/or!lymphatic!drainage;!increase!in!capillary!
pressure!may!be!generalized,!as!occur!in!heart!failure,!or!it!may!be!localized!to!one!
extremity!when!venous!pressure!is!elevated!due!to!unilateral!thrombophlebitis!
L Starling!forces!may!be!imbalanced,!when!the!colloid!oncotic!pressure!of!the!plasma!is!
reduced!owing!to!any!factor!that!may!induce!hypoalbuminemia,!as!when!large!
quantities!of!protein!are!lost!in!the!urine!such!as!in!nephritic!syndrome,!or!when!
synthesis!is!reduced!In!a!severe!catabolic!state!
Types:!
• Development!from!local!processes!!!local!edema:!Thrombosis,!incompetence!of!the!
venous!valve,!disturbance!in!lymphatic!circulation!!
• Generalized!edema!(anasarca);!develops!if!there!is!accelerated!production!of!
interstitial!fluid,!eLg!in!Hypoalbuminemias!(nephritic!syndrome,!cirrhosis!of!the!liver,!
malignant!tumours),!in!increased!capillary!and!venular!permeability!
(glomerulonephritis,!acute!anaphylactic!reaction),!in!increased!filtration!pressure!on!
the!capillaries!
! ! !!generalized!cause:!increased!capillary!filtration!pressure,!activation!of!
RAAS!System!
Clinical:!!
• Important!to!recognize!that!quantity!of!the!subcutaneous!tissue!is!also!responsible!
for!development!of!edema!(massive!edema!already!present!in!older!people)!
• Severe!congestive!heart!failure!with!increased!venous!pressure!and!ascites!produce!
edema!
!
12.#Lymphadenopathy#
=!enlargement!of!the!lymph!nodes!
Types:!
• Localized!lymphadenopathy:!single!node!or!one!group!of!nodes!is!enlarged!!
• Generalized!lymphadenopathy:!enlargement!of!more!than!2!nonLcontiguous!lymph!
node!groups.!Causes!of!generalized!lymphadenopathy!include!infections,!
autoimmune!diseases,!malignancies,!histiocytoses,!storage!diseases,!benign!
hyperplasia,!and!drug!reactions!Infections!Generalized!lymphadenopathy!is!most!
often!associated!with!systemic!viral!infections.!
 • Consistency!of!lymphnode:!hard!–!tumour!metastasis,!elastic.!Lymphomas!
• Fast!enlarging,!painful!lymph!nodes!–inflammatory!processes!(lymphadenitis)!!
Causes:!
• Infectious!or!inflammatory!processes!which!can!be!acute!or!chronic,!local!or!general;!
• Malignant!hematologic!disease!(Hodgkin!disease,!nonLHodgkin’s!lymphomas,!
leukaemia’s)!
• Metastases!of!malignant!tumours!
!
Causes!of!localized!lymphadenopathy:!!
Occipital!!
• Rubella,!pyodermia!on!the!skull!
PreL!or!postauricular!
• Inflammation!and!suppuration!of!external!acoustic!meatus!
Submental!
• Cancer!of!lower!lip,!cancer!of!tongue!
Submandibular!
• Gingivitis,!periostitis!of!mandible,!cancer!of!pharynx!
Retromandibular!
• Chronic!acute!tonsillitis,!cancer!of!tonsils!
Cervical!
• Inflammation!or!tumour!of!rhinopharynx,!cancer!of!thyroid,!malignant!lymphomas!
Supraclavicular!
• Inflammation,!tumour!of!breast!
• Inflammation,!tumour!of!thyroid!gland!
• Left!side:!Virchow’s!gland!in!cancer!of!stomach!or!other!cancer!of!GIT!
Axillary!
• Inflammation!of!areas!of!the!arm!and!shoulder!
• Inflammation,!tumour!of!breast!
Inguinal!and!femoral!
• Inflammation!lower!extremities,!inflammation!urogenital!tract,!cancer!rectum,!
cancer!uterus!
Mediastina!lymphadenopathy!!
• Mediastina!nodes!drain!the!thoracic!viscera,!including!the!lungs,!heart,!thymus,!and!
thoracic!esophagus.!Because!these!nodes!are!not!directly!demonstrable!upon!
physical!examination,!their!enlargement!must!be!indirectly!assessed.!Supraclavicular!
adenopathy!is!often!associated!with!mediastinal!adenopathy.!Mediastinal!nodes!may!
cause!cough,!wheezing,!dysphagia,!airway!erosion!with!hemoptysis,!atelectasis,!and!
the!obstruction!of!the!great!vessels,!which!constitutes!superior!vena!cava!syndrome.!
Airway!compromise!may!be!life!threatening.!
• Mediastinal!lymphadenopathy!is!usually!a!sign!of!serious!underlying!disease.!More!
than!95%!of!mediastinal!masses!are!caused!by!tumours!or!cysts.!Lymphomas!and!
acute!lymphoblastic!leukaemia!are!the!most!common!etiologies!and!usually!involve!
the!anterior!mediastinum.!
Abdominal!lymphadenopathy!!
• Abdominal!nodes!drain!the!lower!extremities,!pelvis,!and!abdominal!organs.!
Although!abdominal!adenopathy!is!not!usually!demonstrable!upon!physical!
examination,!abdominal!pain,!backache,!increased!urinary!frequency,!constipation,!
and!intestinal!obstruction!secondary!to!intussusception!are!possible!presentations.!
 • Mesenteric!adenitis!is!thought!to!be!viral!in!etiology!and!is!characterized!by!right!
lower!quadrant!abdominal!pain!caused!by!nodal!enlargement!near!the!ileocecal!
valve.!Differentiating!mesenteric!adenitis!from!appendicitis!may!be!difficult.!
• Mesenteric!adenopathy!may!be!caused!by!nonLHodgkin!lymphoma!or!Hodgkin!
disease.!
• Typhoid!fever!and!ulcerative!colitis!are!other!etiologies!of!mesenteric!adenopathy.!
!
!
13.#Cough,#expectoration,#hemoptysis,#hemoptoe.##
a)!cough!
=!most!frequent!syndrome!in!respiratory!system;!it!is!a!reflex!initiated!by!irritation!of!the!
tussigenetic!zone!in!the!larynx,!bifurcation!of!the!trachea,!bronchi!and!parietal!pleura!
!!maintain!the!patency!of!airways!and!removes!pathological!products!and!foreign!objects!
• Dry,!unproductive!cough:!develops!if!there!is!no!material!to!be!removed!from!
airways;!L!acute!inflammation!processes!in!respiratory!tract,!pneumothorax;!pressure!
upon!bronchi!from!enlarged!structures!in!mediastinum;!incipient!left!heart!failure!
• Wet,!productive!cough:!accombined!by!expectorations!of!sputum;!!

!
b)!Expectorations!
=!Sputum,!which!can!be:!
• Serous:!watery,!thin,!frothy,!copious,!may!be!blood!tinged!–pulmonary!edema!
• Mucous:!glassy,!tenacious!–!acute!bronchitis,!!
• Mucopurulent:!yellowish,!greenish!–!bronchopulmonary!diseases!
• Purulent:!yellow,!greenish!–!bronchiectasis,!lung!abscess,!pulmonary!TB!
• Putrid:!typical!for!anaerobic!infections!
c)!Haemoptysis!!
=!Coughing!of!bloody!sputum!or!blood!!
• Occurs!in!diseases!of!pulmonary!parenchyma!(TB,!lung!cancer,!bronchiectasis,!lung!
abscess),!pulmonary!congestion!(particular!accompanied!with!mitral!valve!disease),!
pulmonary!embolism,!pulmonary!hypertension!
d)!hamptoe!
!=!Massive!expectoration!off!blood!
• Result!of!bronchopulmonary!disease;!in!cardiovascular!disease,!the!cause!is!rupture!
of!bronchial!vein!in!mitral!valve!disease!with!high!left!atrial!pressure!or!massive!
pulmonary!infarct!
!
14.#Fluidothorax,#pneumothorax,#pleural#punction#
Fluidothorax:!
• Fluid!in!pleural!space,!can!be:!exudate!(inflammatory),!transudate!(nonLinflammatory!
in!cardiac!failure),!hemorrhagic,!purulent!
• Distribution!influenced!by!gravity!and!elasticity!!
• Highest!elasticity!is!farthest!point!from!hilus!–>!most!fluid!!
• In!inflammatory!effusion!upper!border!has!a!convex!shape,!heart!and!mediastinum!
pushed!to!healthy!side!
• Only!effusions!over!200L400!ml!can!be!detected!by!phys.!Examination!
• Percussion:!dull!sound,!certain!resistance!
• Auscultation:!Vocal!fremitus!(vibration)!&!bronchophony!are!caudally!diminished!or!
absent!!
!
Pneumothorax:!!
• Air!in!pleural!space!
• Normally!negative!Pressure!inside!space,!that’s!why!visceral!pleura!follow!parietal!
during!respiration!!
• If!Pressure!is!equal!to!atmospheric!air,!lung!collapses!
1.a)!External!Pneumothorax:!e.g.!chest!injuries,!if!intrapleural!space!is!connected!with!
ambient!atmosphere!
!!b)!Internal!Pth:!e.g.!rupture!of!lung!cyst,!if!air!enters!b/w!2!pleural!layers!from!the!lung!
across!a!tear!in!visceral!pleura!
2.a)!Complete!Pth:!if!entire!lung!retracts!to!its!hilus!
!!!!b)!Partial!Pth:!only!partially!collapses!
3.a)!Closed!Pth:!in!lung!injuries!
!!!!b)!Open!Pth:!Communication!hole!remains!open!
4.!Tension!(valve)!Pth:!air!enters!on!inhalation!but!cannot!escape!because!the!hole!closes!on!
exhalation;!Pressure!exceeds!atmospheric!P!and!increases;!right!sided!more!dangerous!
because!of!thin!walls!of!atrium/ventricle!and!sup.!Vena!cava!
L!Most!important!Percussion!(hyperresonant!or!metallic!character)!&!Auscultation!inaudible!
or!very!faint!
!
Pleural!Punction:!!
• Also!called!Thoracentesis!
• Invasive!procedure!to!remove!fluid!or!air!from!pleural!space!for!diagnostic!or!
therapeutic!purposes!
• Cannula,!or!hollow!needle!is!carefully!introduced!into!thorax,!generally!after!local!
anesthesia!
• Most!common!causes!of!pleural!effusions:!cancer,!congestive!heart!failure,!
pneumonia,!tuberculosis!
• Use!of!ultrasound!for!needle!guidance!can!minimize!complication!rate!!
• Interpretation!of!pleural!fluid:!transudate!vs.!exudate;!pH,!glucose,!cell!count!(white!
blood!cell!L>!indication!of!infection)!
!
15.#Fluidopericard,#tamponade#of#the#heard#
• Serous!fluid!secreted!by!serous!layer!of!pericardium!into!pericardial!cavity!
• Pericardium:!2!layers,!outer!fibrous!layer!and!inner!serous!layer,!which!has!two!
membranes!
• Fluid!is!similar!to!CSF,!also!serves!to!cushion!and!allow!some!movement!
• Reduces!friction!within!pericardium!by!lubricating!the!epicardial!surface!allowing!the!
membranes!to!glide!over!each!other!with!each!heartbeat!
• Composition:!high!concentration!of!lactate!dehydrogenase,!protein,!lymphocytes!
• Pericardial!effusion:!presence!of!excessive!fluid!can!be!confirmed!with!ECG;!large!and!
rapidly!accumulating!effusions!may!cause!cardiac!tamponade!
Cardiac!temponade!
• When!fluid!in!pericardium!builds!up!and!results!in!compression!of!heart!
• Symptoms:!Cardiogenic!shock,!shortness!of!breath,!weakness!and!cough!
• Common!causes:!cancer,!kidney!failure,!chest!trauma,!pericarditis;!other!causes:!
aortic!rupture,!hypothyroidism,!CT!disease!
• If!fluid!accumulates,!each!successive!diastolic!period!leads!to!less!blood!entering!
ventricles;!eventually!increasing!pressure!forces!septum!to!bend!in!towards!left!
ventricle,!leading!to!decrease!stroke!volume!
!
16.#Abdominal#Pain#
• Adequate!Stimuli:!Increased!Pressure!and!intraluminal!tension!in!GIT;!in!active!bowel!
contractions!to!overcome!organic!or!functional!obstructions!
• Two!kinds!of!pain:!!
• 1)!Somatic!(epicritic)L!sharp,!acute,!precisely!localized!
• 2)!Visceral!(protopathic,!primary)!–!without!distinct!localization,!midline!mainly!–!e.g.!
small!intestine!pain!around!umbilicus,!colon!–!from!umbilicus!to!hypogastrium!
• Colic!Pain!–!severe,!undulant!(comes!in!waves),!constrictive,!in!10!min!may!increase!
and!decrease!twice!
• Rhythmic!Pain!–!after!meal,!e.g.!in!peptic!ulcer!of!stomach;!may!appear!with!
periodicity!(either!in!1)Paroxysms,!several!times!a!year!but!short!or!in!2)Bouts,!once!a!
year!but!longer)!
Pain!Syndromes:!
1)!Purely!visceral:!often!associated!with!diarrhea,!vomiting;!!rhythmic,!dependent!on!meals;!
(more)!superficial!irritation,!typical!of!uncomplicated!gastric!ulcers!
2)!Visceral!syndrome!with!transmitted!pain:!continuous!pain!with!radiation;!deeper!
involvement!of!organ,!e.g.!inflammation!of!wall!of!the!diseased!organ;!gallstone!with!
mucosal!irritation!
3)!Somatic:!spread!of!disease!process!into!tissues!innervated!by!cerebrospinal!nerves;!e.g.!
perforating!appendicitis!
• Types!of!meals!and!food!important:!hours!after!fatty!mealL!gallbladder!colic;!fat!and!
proteinsLpancreatitis!! ! ! !
• Onset!of!Pain:!!
• Start!in!epigastrium!L>!right!hypogastrium!L>acute!appendicitis!
• Right!hypochondriumL>!r.!shoulder!L>!cholecystitis!
• Epigastric!Pain:!gastric!origin;!Navel!area:!pancreatitis;!L.!Hypogastrium:!diverticulitis!
of!sigmoid;!midabdomen!&!hypogastrium:!diseases!of!colon!
!
17.#Dysphagia#and#dyspepsia#
Dysphagia:!!
• Difficulty!swallowing,!usually!accompanied!by!transient!pressure!in!lower!throat!
• In!organic!disorders,!difficulties!in!swallowing!of!solid!food,!later!soft!and!liquid!
• In!functional!disorders,!difficulty!in!swallowing!liquids!first!
• Congestion/!blockage!of!esophagus!leads!to!feeling!of!fullness!and!pressure!behind!
lower!sternum!
• Narrowing!in!thoracic!sectionL>!chest!pressure,!shortness!of!breath!
• In!patients!younger!than!40!causes!are!peptic!esophagitis!&!achalasia!(inability!of!
esophagus!to!relax!during!passage!of!food);!over!40!L>!cancer,!peptic!esophagitis!
Dyspepsia:!
L!Disturbance!of!digestion!
L!Stomach!dyspepsia:!
• 1)!Fullness!and!pressure!in!epigastrium!
• 2)!Belching!(burping)!
• 3)!Heartburn!
• 4)!Regurgitation!–!sour!and!bitter!juices!from!partly!digested!food!are!regurgitated!
• 5)!Loss!of!appetite!!
• 6)!Upset!Stomach!
• 7)!Throwing!up!
Less!specific!symptoms:!foul!taste,!coated!tongue,!xerostomia!(lack!of!saliva),!bad!breath!
(halitosis),!Hiccups!(singultus),!teeth!grinding!(rumination)!
L!Intestinal!dyspepsia:!!
L!1)!Meteorism!(distension!of!abdomen)!
L!2)!Rumbling,!splashing!sounds!(Borborygmi)!
L!3)!Flatulence!
L!4)!Constipation/diarrhea!!
!
18.#Ileus#
• Disruption!of!normal!propulsive!ability!of!GIT!
• Symptoms:!Moderate,!diffuse!abdominal!discomfort;!Constipation;!abdominal!
distension;!nausea/vomiting;!vomiting!of!bile;!lack!of!bowel!movement!or!flatulence;!
excessive!belching!
 • Cause:!bowel!obstruction!or!intestinal!atony/!paralysis!
• Intestinal!paralysis:!side!effect!of!surgery;!certain!drugs;!injuries!and!illnesses!
(pancreatitis);!no!bowel!sound!are!heard!!
• Risk!factors:!GIT!surgery,!electrolyte!imbalance,!diabetic!ketoacidosis,!
hypothyroidism,!spinal!cord!injury!
!
19.#Hematemesis,#melena,#hematochesis,#enterorhagia#
L!Acute!gastrointestinal!bleeding!(hemorrhage)!
1.!Hematemesis!–!vomiting!of!blood!
• In!large!hemorrhage!(from!esophageal!varices)!vomits!bright!red,!undigested!blood!
• In!gastric!hemorrhage!–!digested,!appearance!of!coffee!grounds!
• Hemoptysis!(hemoptoe)!–!blood!from!respiratory!system!
2.!Melena!–!digested!blood!in!feces!
• Tarry!black,!pasty!(semisolid),!sweetish!odor!
• Originates!in!upper!GIT!(esophagus,!stomach,!duodenum,!beginning!of!jejunum)!
• At!least!50L100ml!to!document;!lasts!3L4!days!
3.!Hematochezia!(!enterorrhagia)!!
• Fresh,!bright!red!blood!on!feces!or!mixed!with!feces!
• Fecal!blood!from!lower!GIT,!e.g.!ileum!and!(transverse)!colon!
• Common!in!hemorrhoids,!hemorrhagic!proctitis!(part!of!ulcerative!colitis),!nonL
stenosing!rectal!tumors!
• GIT!bleeding!may!be!documented!only!be!test!–!BENZIDINE!Test!
• Acute!bleeding!in!upper!GIT!
• Chronic!bleeding,!may!lead!to!iron!deficiency!anemia,!from!lower!GIT!
!
20.#Changes#of#the#stool,#disturbances#of#bowel#movements#
• Physiologically:!dark!brown,!solid,!formed,!cylindrical!!
• Constipation:!difficult!&!less!frequent,!feces!is!hard!
• Diarrhea:!evacuation!of!loose!or!watery!stools,!usually!multiple;!consistency!more!
important!than!frequency!
• A!low!frequency!of!diarrheal!stools!indicates!small!bowel!involvement!rather!than!
disorders!of!the!colon!
• Color,!consistency,!pathologic!admixtures!
• Copious!(reichlich),!light!yellowLbrown,!pasty,!greasy!feces!with!a!“buttery”!odor!
typical!for!Steatorrhea!!
• Whitish!or!grayish!stools!are!passed!in!acholia!(absence!of!fecal!bile!pigments)!
• If!bowel!passage!is!accelerated,!as!in!enteritis!or!after!laxatives!the!passage!of!very!
loose,!watery,!yellowLgreen!feces!represents!ileal!content!!
• Dysmicrobia!causes!yellow!(sour!fermentation)!or!darker!brown!(rotten!putrefaction)!
loose!stools!with!foul!odors!
!!
21.#Icterus#(Jaundice)#
• Yellow!discoloration!of!the!skin,!sclerae,!mucous!membranes!
• Occurs!if!plasma!bilirubin!exceeds!35!µm/l!
• Different!types:!lemonLyellow,!orangeLyellow,!oliveLyellow!depending!on!type!of!
plasma!elevation!
• Don’t!confuse!icterus!with!carotenemia!from!elevated!levels!of!carotenes!after!
ingestions!of!large!amount!of!carrots,!sclera!remain!white!!
 • Frequent!finding!in!diseases!of!liver!and!biliary!tract!
L!Metabolism!of!bilirubin:!!
! 1)!Production!of!bilirubin!from!hemoglobin!!
! 2)!Transport!to!the!liver!cells!
! 3)!Intracellular!transport!in!liver!
! 4)!Conjugation,!mainly!with!gulucuronic!acid!catalyzed!by!the!enzyme!! glucuronylL
transferase!
! 5)!Excretion!into!the!biliary!tree!(canaliculi)!
! 6)!Transport!by!intrahepatic!biliary!canaiculi!
! 7)!Transport!by!extrahepatic!biliary!ducts!
! 8)!Deconjugation,!reduction!in!the!gut!by!intestinal!bacterial!activity!
! 9)!Enterohepatic!circulation!of!stercobilinogen!
L>!Disturbance!of!any!of!the!steps!may!cause!jaundice!
L!!3!types:!Prehepatic/!hepatocellular/!cholestatic!
a)!Prehaptic:!
• Elevated!plasma!levels!of!UNCONJUGATED!bilirubin,!due!to!increase!supply,!e.g.!from!
hemolysis;!Gilbert’s!syndrome!(abnormality!in!bilirubin!conjugation)!
• Higher!stercobilin!and!stercobilinogen!in!feces!
!
b)!Hepatocellular:!!
• Hemoglobin!catabolism!is!normal,!intrahepatic!transport!of!bilirubin!and/or!
conjugation!is!disturbed,!e.g.!viral!hepatitis!
• Obstructive!component!due!to!cell!damage,!conjugated!bilirubin!cannot!completely!
be!excreted!
• Both!types!of!bilirubin!absorbed!in!the!blood!
• Feces!contains!little!stercobilinogen,!enteric!reabsorption!is!limited!
• Urine!contains!urobilinogen!
!
c)!Cholestatic:!!
• Blockage!of!secretion!at!boundary!b/w!liver!cell!&!biliary!system!
• Compression!of!small!intrahepatic!biliary!canals!
• Obstruction!of!the!choledochus!(by!stone!or!tumor)!
• In!all!cases!conjugated!bilirubin!cannot!be!excreted!into!gut,!absorbed!to!the!blood!
plasma!(documented!by!direct!diazo!reaction)!
• Conjugated!bilirubin!excreted!by!kidneys,!because!waterLsoluable!
• Feces!are!grayishLwhite,!enteric!reabsorption!of!stercobilinogen!absent,!so!no!
urobilinogen!in!urine!
• Associated!with!itiching!of!skin,!hyperlipidemia,!elevated!alkaline!phosphatase!levels!
in!plasma!
!
22.#Ascites,#abdominal#punction#(paracentesis)#
• In!liver!diseases,!in!decompensated!hepatic!cirrhosis!
• Follows!Starling’s!law!of!fluid!movement,!! ! ! !
! !!!!!!!!!!!!!!!!Forces!pushing!fluid!out!of!portal!circulation!into!peritoneal!cavity!
are:!blood!pressure!in!portal!capillaries!&!colloid!osmotic!pressure!of!peritoneal!fluid
! ! !!!!!!!!!!!!!
• Forces!keeping!fluid!inside!portal!circulation!are:!colloid!osmotic!pressure!of!blood!
plasma!&!intraabdominal!hydrostatic!pressure!
 • In!cirrhosis!both!parameters!are!disturbed,!portal!capillary!pressure!increased!due!to!
hypertension!and!colloid!osmotic!pressure!of!plasma!is!decreased!due!to!
hypoalbuminemia!!
• Other!factors:!increased!lymph!production!in!liver,!retention!of!sodium!due!to!
hyperaldosteronism!L>!increased!production!of!ADH!
• Amount!of!ascites!varies,!can!be!over!40!l!
• Ascitic!fluid!is!yellowish,!greenish,!clear,!with!low!concentration!of!protein,!low!
specific!gravity!
!
Abdominal!punction:!!
• Paracentesis!–!peritoneal!cavity!is!punctured!
• Indications:!relieve!pressure!from!ascites;!diagnose!spontaneous!bacterial!peritonitis;!
diagnose!metastatic!cancer;!diagnose!blood!in!peritoneal!space!in!trauma!
• Paracentesis!for!ascites:!small!risk!of!infection,!excessive!bleeding!or!perforating!a!
loop!of!bowel!
• Risks!can!be!limited!by!ultrasound!guidance!
• For!ascites:!Patient!is!requested!to!urinate!before!the!procedure,!positioned!in!bed!
with!elevated!head!(45L60°)!to!allow!fluid!to!accumulate!in!lower!abdomen;!insert!
needle!2L5!cm!to!reach!fluid;!fluid!is!drained!by!gravity,!syringe!or!connection!to!
vacuum!bottle!
• Procedure!is!generally!not!painful,!Patient!does!not!require!sedation!!
• Contraindications:!the!risk!of!bleeding!may!be!increased!if!prothrombin!time!
>21seconds;!platelet!count!<50,000!per!cubic!millimeter!
• Relative!contraindications:!pregnancy,!distended!urinary!bladder,!abdominal!wall!
cellulitis,!distended!bowel,!intraLabdominal!adhesions!
!
23.#Disorders#of#urination,#dysuria,#hematuria,#pyuria,#anuria,#oliguria,#polyuria#
Dysuria:!difficulties!in!voiding!(diseases!with!involvement!of!urethra!&!bladder!particularly),!
hesitancy,!thin!stream,!dribbling,!may!have!to!push!to!maintain!flow,!obstruction!of!urethra!
or!neurogenic!bladder!(in!older!men!may!typically!indicate!prostatitis!or!prostatic!
hypertrophy)!
Hematuria:!blood!in!urine,!red!urine!may!be!from!other!than!blood,!e.g.!from!hemoglobin!or!
medications!
Pyuria:!urine!containing!white!blood!cells!or!pus,!sign!of!bacterial!UTI,!may!be!present!in!
older!patient!with!pneumonia!
Anuria:!virtually!no!urine!(less!than!50!ml/24h),!serious!condition,!invariably!indicates!severe!
kidney!damage!
Oliguria:!if!urine!output!despite!normal!intake!is!less!than!500!ml/24h;!may!be!a!sign!of!renal!
disease,!heart!failure,!hypovolemic!shock,!bilateral!ureteral!obstruction!
Polyuria:!increased!amount!of!urine!in!24h,!common!in!certain!kidney!diseases!due!to!
damage!to!their!concentrating!mechanism.!!
Most!frequently!in!diabetes!mellitus!due!to!osmotic!diuresis!caused!by!glycosuria.!Typical!for!
diabetes!insipidus!(lack!of!effective!ADH)!
!
24.#Changes#of#the#skin,#hair#and#nails#
L!Red!color!diffusely!distributed!over!the!skin:!!
• Increased!overall!blood!perfusion!(e.g.!sunburn);!! ! ! ! !!!!!!!!!!!!
• Central!nervous!influence!in!limited!redness!of!face,!neck,!chest!
 • Flush=!occurs!in!carcinoid!tumors!usually!with!liver!metastases! ! ! !
L!Pallor!(paleness)!of!the!skin!and!mucous!membranes:!!
• In!anemia,!vasomotor!paleness!in!fainting!(circulatory!insufficiency)!and!in!paroxysm!
of!hypertension! ! ! ! ! !
• Rheumatic!fever;!Hodgkin’s!disease!!
!
LCyanosis:!violet!to!bluish!coloration!of!skin!&!mucous!membranes;!occurs!when!level!of!
reduced!blood!hemoglobin!exceeds!50!g/l! ! ! ! ! ! !!!!!!!!!!!!
1)!Central!cyanosis:!!
• In!defective!oxygenation!of!blood!in!lungs!due!to!types!of!respiratory!diseases,!or!
when!low!partial!pressure!of!ambient!oxygen! !!!!!!!!!
• Saturation!of!blood!is!reduced!
• Typical!for!heart!diseases!with!right!to!left!shunting!of!blood!
• Is!diffuse,!affecting!entire!skin!surface!
2)!Peripheral!cyanosis:!!
• Caused!by!blood!stagnation!&!congestional!hypoxia!!
• Occurs!when!reduced!blood!flow!through!capillary!bed!delivers!more!oxygen!to!
tissues!L>!more!reduced!hemoglobin!is!produced!than!can!be!transported!out!of!
congested!area!
• In!congestive!heart!failure!of!right!ventricle!
• Most!prominent!on!the!acral!parts!of!the!body,!lips,!ear!lobes,!nose!tip,!finger!tips!!
• Local!type!of!peripheral!cyanosis!in!venous!obstruction!and!vasomotor!disturbances!!
Pigmentation!and!lack!of!pigment:!! ! ! ! ! ! !!!!!!!!!!!!!!!!!!!!!!!!
• Increased!melanin!deposits!in!creases!of!palms,!around!eyes,!neck,!in!Addison!
disease!on!oral!mucosa!! ! ! ! ! ! !
! !!!!!!!!!!!!!
• Gray!brown!pigmentations!first!develop!on!sunLexposed!areas!&!pressure!points!
(elbow)!L>!caused!by!hyperactivity!of!ACTH!and!melanocyteLstimulating!hormones!
due!to!loss!of!feedback!from!cortisol! ! ! !
! !!!!!!!!!!!!!!!!!!!!!!!!!!!!
• Pregnancy:!pigmented!spots!on!face,!hyperpigmentation!on!breast!nipples!and!linea!
alba! ! ! ! ! ! ! ! !
! !!!!!!!!!!!!!!!!!!!!!!!!!
• Lack!of!melaninL!diffuse!in!albinism!or!local!in!vitiligo!
Skin!eruptions!(Rashes!–!Erythemas,!Exanthemas):!!! ! ! ! !!!!!!!!!!!!!!
• Urticaria!is!a!sudden!or!repeated!eruption!of!pink!or!red!itchy!wheals!on!the!skin!
• Lupus!erythema:!on!face,!butterfly!appearance;!may!be!transient!and!have!reddishL
violet!color,!later!in!chronic!stages,!the!rash!become!atrophic!or!undergo!changes!of!
follicular!hyperkeratosis!
• Erythema!nodosum:!may!accompany!Tbc,!RF,!ulcerative!colitis,!drug!reactions;!
tender!to!painful,!slightly!elevated!nodules!(up!to!2cm),!bilaterally!on!extensor!side!
of!legs!
• Herpes!Zoster:!crop!of!small!vesicles!in!intercostal!spaces!by!neuralgic!pain;!coincides!
with!lymphoreticular!system!
Pathological!formations!(lesions)!!
• Osler’s!nodes:!present!in!infective!(subacute,!bacterial)!endocarditis,!small!(1cm)!
circular!subcutaneous!papules,!on!fingertips!&!pupls!particularly! !
 • RenduL!Osler’s!disease:!vascular!telangiectases,!mostly!on!lips,!tongue,!mucous!
membranes!of!mouth!and!nose!
• Spide!nevi:!in!liver!cirrhosis,!particularly!on!skin!of!ant.!Chest!and!epigastrium!
Skin!hemorrhage!(bleeding!into!the!skin)!
• Pinpoint!size,!minute!bleedings!–!petechiae,!typical!for!diseases!with!increased!
platelets!or!defective!platelets;!as!well!as!in!damage!of!vessel!wall! !
• In!larger!areas!–!suffusions!or!ecchymoses!
• Collection!of!blood!that!extends!into!deeper!tisssues:!hematoma!
Skin!moisture!
• Increased!skin!wetness!(perspiration)!in!RF!and!hyperthyroidism!!
• Night!sweats!in!tuberculosis!and!malignant!lymphoma,!l.!ventricular!failure!
• Cold!sweats:!hypoglycemia,!circulatory!collapse,!nervousness!
Skin!turgor!
• Slow!smoothing!of!fold!after!pinching!skin!L>!dehydration!
• Diabetic!ketoacidosis!from!polyuria!due!to!osmotic!diuresis,!hyperventilation!from!
acidosis!
Edema!
• Accumulation!of!fluid!in!interstitial!space!
• Localized!or!generalized!!
• Following!mechanisms!play!a!role:!!
• 1)!Increased!filtration!pressure!in!capillaries!which!pushes!intravascular!fluid!out,!into!
interstitial!space!!
• 2)!Decreased!oncotic!pressure!of!plasma!proteins!
• 3)!Concentions!of!electrolytes,!mainly!sodium,!tends!to!bind!water!
• 4)!Condition!of!vessel!wall!
• 5)!Condition!of!lymphatic!channels!
• Some!or!all!of!above!may!combine!for!pathogenesis!of!edema!
• Inspection!and!Palpation!of!Edema:!skin!above!is!taut,!shiny,!nonLinflammatory!
• Fluid!accumulates!in!lowest!part!of!the!body!usually!
• Also!accumulates!in!body!cavities,!peritoneal!(ascites),!pleural!(hydrothorax),!
pericardial!(hydropericardium)!
• Generalized!Edema!–!anasarca,!most!frequently!in!r.!heart!failure,!in!certain!kidney!
diseases,!hypoproteinemia,!liver!cirrhosis!!
!
Changes!of!hair:!!
• Secondary!sexual!characteristics;!may!often!be!encountered!in!endocrine!disorders!
• Decrease!in!body!hair!in!cirrhosis!of!liver;!limited!hair!loss!in!thyroid,!ovarian,!
pituitary!gland!disorders!
• Total!loss!of!hair:!alopecia!diffusa;!in!circumscribed!areas:!alopecia!areata!
Changes!of!nails:!
• Increased!brittleness,!separation,!breakage!of!nails!encountered!in!thyroid!disorders,!
iron!deficiency!anemias!
• Spheric!nails:!convex!watch!glasses!associated!with!clubbed!fingers!in!congenital!
cyanotic!heart!diseases,!pulmonary!diseases;!may!accompany!subacute!bacterial!
endocarditis,!inherited!anomaly!!
• Flat!nails:!planinychia!or!concave!nails!associated!with!iron!defieciency!anemia,!along!
with!brittle!nails!
!
25.#Obesity#(types,#causes,#complications,#health#consequences)#
L!Obese,!if!weight!exceeds!his!or!her!“optimal”!weight!by!10%;!broca!rule:!weight=!height!
minus!100!!
1)!Types!
• Body!mass!index:!weight/height2!
• 25L30!kg/m2!L>!overweight;!30L35!kg/m2!class1!obesity;!35L40!kg/m2!class2;!>40!
class3!
2)!Causes!
• Excessive!food!energy!intake!and!lack!of!physical!active!–!most!cases!
• Genetics!–!e.g.!PraderLWilli!syndrome!
• Medical!reasons!–!e.g.!hypothyroidism,!Cushing’s!syndrome,!growth!hormone!
deficiency!
• Psychiatric!illness!
• Insufficient!sleep,!endocrine!disruptors,!decreased!variability!in!ambient!
temperature,!decreased!rates!of!smoking!
3)!Complications/!Health!consequences!
• 2!broad!categories:!those!attributable!to!effects!of!increased!fat!mass!(osteoarthritis,!
obstructive!sleep!apnea)!or!increased!number!of!fat!cells!(diabetes,!cancer,!CVD,!
nonLalcoholic!fatty!liver!disease)!
• Increases!in!body!fat!alter!body’s!response!to!insulin,!leading!to!insulin!resistance!
• Proinflammatory!state!
• CardiologyL!e.g.!coronary!heart!disease,!high!blood!pressure,!abnormal!cholesterol!
levels!
• Endocrinology!–!e.g.!menstrual!disorders,!diabetes!mellitus!
• Neurology!–!e.g.!stroke,!dementia,!Ms!
• PsychiatryL!e.g.!depression,!social!stigmatization!
• Rheumatology!and!Orthopedics!–!e.g.!poor!mobility,!osteoarthritis,!low!back!pain!
• Dermatology!–!e.g.!stretch!marks,!lymphedema,!cellulitis!
• Gastroenterology!–!e.g.!cholelithiasis,!reflux!disease!
• Oncology!–!e.g.!gallbladder,!pancreatic!
• Respiratory!–!e.g.!obesity!hypoventilation!syndrome,!asthma!
• Urology,!Nephrology!–!e.g.!erectile!dysfunction,!chronic!renal!failure!
!
26.#Weight#loss,#Cachexia,#and#anorexia#
1)!Weight!loss:!!
• Loss!of!body!fats,!body!fluids,!muscle!atrophy!or!combination!
• Malnutrition,!disease!processes,!changes!in!metabolism,!hormonal!changes,!
medications,!reduced!appetite!
• Malnutrition!can!affect!every!function!of!human!body:!immune!response,!wound!
healing,!muscle!strength,!renal!capacity,!thermoregulation,!menstruation!
• Related!to!specific!diseases:!COPD,!cancer,!HIV,!celiac!disease,!inflammatory!bowel!
disease,!pancreatitis,!renal!disease,!cardiac!disease!
2)!Cachexia!
• Loss!of!weight,!muscle!atrophy,!fatigue,!weakness,!significant!loss!of!appetite!
• Differs!from!starvation!in!part!because!it!involves!a!systemic!inflammatory!response!
• Often!seen!in!endLstage!cancer,!congestive!heart!failure,!MS,!Parkinson’s!disease…!
• Gastrointestinal!and!pancreatic!cancers!have!highest!frequency!!
• Mechanism!of!development!–!inflammatory!cytokines!TNF!alpha,!IFN!gamma,!IL6!
3)!Anorexia!
• Decreased!sensation!of!appetite!
• Anorexia!nervosaL!people!see!themselves!as!overweight;!weigh!frequently,!eat!only!
small!amounts,!only!certain!food,!exercise!a!lot,!force!to!vomit!
• Complications:!Hypokalaemia!(drop!in!potassium!in!blood),!osteoporosis,!infertility,!
heart!damage,!no!menstruation!!