UNIVERSITY OF SANTO TOMAS

Faculty of Medicine and Surgery

Department of Medicine
Clinical Clerkship Committee

CLINICAL CLERKS
REVALIDA REVIEW 2017

ALEXANDER D.S. JUSON, M.D.

Reference: Harrison’s Principle of Internal Medicine 19 th Edition

 GENERAL POINTS
• Stock Knowledge
• Enough sleep and food
• Bring the following:
– COMPLETE medical bag
– References: books, journals, etc
• During the Oral Revalida:
– Be SYSTEMATIC
– COMPLETE history and physical examination
– Differential Diagnoses
– Assessment and General Plan
 OUTLINE
• Chest discomfort
• Dyspnea
• Cough
• Fever
• Edema
• Abdominal pain
• Gastrointestinal bleeding
• Jaundice
• Abdominal swelling
• Anemia
CHEST DISCOMFORT
 Dyspnea
• American Thoracic Society defines dyspnea
as a subjective experience of breathing
discomfort that consists of qualitatively
distinct sensation that vary in intensity.
• Interplay of various factors
• Perceived only by the patient (symptom);
differentiate by subjective finding of
increased WOB
Mechanisms of Dyspnea
 Differential Diagnosis
RESPIRATORY CARDIAC
• Airways • Left heart
– Asthma – Coronary artery disease
– COPD – Cardiomyopathy
• Chest wall • Pulmonary vasculature
– Kyphoscoliosis – Pulmonary hypertension
– Myasthenia gravis, GBS • Pericardium
– Pleural effusion – Pericarditis
• Lung parenchyma – Tamponade
– Pneumonia
– Interstitial lung disease OTHERS
- Anemia
- Obesity
- CV deconditioning
 COUGH
• DIFFERENTIAL DIAGNOSIS
– By Duration
– By Cause
De Blasio, et al. Cough management: a practical approach. Cough 2011, 7:7  doi:10.1186/1745-
De Blasio, et al. Cough management: a practical approach. Cough 2011, 7:7  doi:10.1186/1745-
 FEVER
• Elevation of body temperature that exceeds
the normal daily variation and occurs in
conjunction with an increase in the
hypothalamic set point
• Differentiate from hyperthermia
 Fever Definition
• an AM temperature of >37.2°C (>98.9°F) or a
PM temperature of >37.7°C (>99.9°F).
• Normal daily temperature variation is
typically 0.5°C.

• Hyperthermia (Heat stroke)

– characterized by an uncontrolled increase
in body temperature that exceeds the
body’sability to lose heat.
 Hyper-pyrexia
• A fever of >41.5°C (>106.7°F)

• Extraordinarily high fever can develop in

patients with severe infections butmost
commonly occurs in patients with central
nervous system (CNS) hemorrhages
 DIFFERENTIAL DIAGNOSES
• BY CAUSE • BY DURATION
– Infectious – look for – Acute
FOCUS – Chronic
– Neoplastic • BY PATTERN
– Inflammatory – Persistent
– Remittent
– Intermittent
– Relapsing
 EDEMA
• clinically apparent increase in the interstitial
fluid volume
 Localized edema
• Obstruction to venous or lymphatic drainage
– Thrombophlebitis, chronic lymphagitis,
lyphadenectomy, filariasis
• Typical sites of edema
– Cardiac: legs, evening. Bed: pre-sacral.
Ascites
– Hypoalbuminemia: generalized.
Prominent eyelids and face in the morning
– SVC: face, neck, upper extremities
 ABDOMINAL PAIN
• DIFFERENTIAL DIAGNOSES
– By Location
– By Cause
GASTROINTESTINAL BLEEDING
• UPPER GI BLEEDING
LOWER GI BLEEDING
• Hemorrhoids
• Diverticula, vascular
ectasias
• Neoplasm
• Colitis
– infectious
– idiopathic inflammatory
bowel disease
 UGIB
• Variceal or Non-Variceal?
• Variceal: endoscopic ligation
– IV Vasoactive agents: octreotide
– Cautious BT
• Non-varicieal: IV PPI
 LGIB
• Hemorrhoids : most common
• Anal fissures: minor bleeding and pain
• Diverticular: abrupt, massive and painless,
right colon source
 Approach to GIB
• VS, Orthostatic hypotension
• CBC: hgb initially is not reflective until EVF
enters vascular space, happens up to 72
hours
• Melena: blood at least 14h and as long as 3-
5days
• Hematochezia: LGIB or massive UGIB
JAUNDICE
 ABDOMINAL SWELLING
• Flatus
• Fat
• Fluid
• Feces
• Fetus
• Fatal Growth
 Approach to Diagnosis
• History
– Malignancy: weight loss, night sweats and
anorexia
– Bowel obstruction, severe constipation or
ileus: nausea vomiting, last BM
– Aerophagia or increased intestinal gas
production: increased eructation and
flatus
 Physical Examination
• Lymphadenopathy (virchow’s node),
metastatic abdominal malignancy
• Cardiac: JVP, murmurs,
• Hepatic: spider angioma, palmar erythema,
caput medusae, gynecomastia
• 1500mL minimum amount of ascitic fluid
• Check for warmth, tenderness any signs of
infection
 Ascites in Liver Disease
• Portal hypertension, renal salt and water
retention
• Increased hepatic resistance
• Heaptic fibrosis, cirrhosis and decresed
eNOS
• Increased systemic NO  splanchnic
vasodilation, pooling of blood  sensed as
hypovolemia  renal retention, (SNS and
RAAS)
 Ascites in a non-cirrhotic patient
• Peritoneal carcinomatosis (mesothelioma,
sarcoma, gastric/colon/mets)
• Peritoneal infection (TB)
• Pancreatic disease (leakage of pancreatic
enzymes
ANEMIA
The Revalida
UNIVERSITY OF SANTO TOMAS
Faculty of Medicine and Surgery
Department of Medicine
Clinical Clerkship Committee

CLINICAL CLERKS
REVALIDA REVIEW 2017

ALEXANDER D.S. JUSON, M.D.

Reference: Harrison’s Principle of Internal Medicine 19 th Edition