Differential Diagnosis

PNEUMOTHORAX
A collection of free air in the chest outside the lung that causes the lung to collapse.

 Spontaneous pneumothorax is caused by
- rupture of a cyst or a small sac on the surface of the lung.
- fractured rib
- any penetrating injury
- surgical invasion of the chest, or may be deliberately induced in order to collapse the lungs
 Secondary pneumothorax :
- Cystic fibrosis

 Symptoms :
- Sudden onset of chest pain
- Tightness in the chest
- Shortness of breath
- Rapid heart rate, rapid breathing
- Cough
- Fatigue
- Cyanosis

CHOLECYSTITIS
Inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis.

 Upper abdominal pain, often radiating to the tip of the right scapula
 Nausea and vomiting

ANXIETY
 Generalized Anxiety Disorder
 Obsessive-Compulsive Disorder (OCD)
 Panic Disorder
 Post-Traumatic Stress Disorder (PTSD)
 Social Phobia (or Social Anxiety Disorder)
Symptoms :
 Excessive, ongoing worry and tension
 An unrealistic view of problems
 Restlessness
 Irritability
 Muscle tension
 Headaches
 Sweating
 Difficulty concentrating
 Nausea
 The need to go to the bathroom frequently
 Tiredness
 Trouble falling or staying asleep
 Trembling
 Being easily startled

PULMONARY EMBOLISM
A blood clot in the lung. It usually comes from smaller vessels in the leg, pelvis, arms, or heart.

 Chest pain : sharp, sudden onset, and is worse when taking a deep breath (referred to as pleuritic chest pain).
 Shortness of breath
 Anxiety
 Cough : dry, may be associated with blood.
 Sweating
 Passing out

HIATUS HERNIA
Hiatal hernia is an anatomical abnormality in which part of the stomach protrudes through the diaphragm and up into the chest.
 Vast majority of hiatal hernias are of the sliding type, and most of them are not associated with symptoms.
 The larger the hernia, the more likely it is to cause symptoms.
 When sliding hiatal hernias produce symptoms, they almost always are those of gastroesophageal reflux disease (GERD) or its complications.
 Patients with GERD are much more likely to have a hiatal hernia than individuals not afflicted by GERD.

PEPTIC ULCER
Generally caused by Helicobacter Pylori infection and non-steroidal anti inflammatory drugs (NSAIDs)
Symptoms:
 Epigastric pain
 Nausea
 Vomiting
 Dyspepsia, including belching, bloating, distention, and fatty food intolerance
 Heartburn
 Chest discomfort
 Anorexia, weight loss
 Hematemesis or melena resulting from gastrointestinal bleeding
 Dyspeptic symptoms
ESOPHAGEAL REFLUX
Gastroesophageal reflux disease (GERD) occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury (ie, esophagitis).
 GERD :
Heartburn
Regurgitation
Nausea

ESOPHAGITIS
Esophagitis is a common medical condition usually caused by gastroesophageal reflux.

Symptoms :

 Heartburn (dyspepsia)
 Symptoms often are maximal while the person is supine, bending over, wearing tight clothing, or has eaten a large meal.
 Upper abdominal discomfort, nausea, bloating, and fullness.
 Dysphagia
 Odynophagia
 Cough, hoarseness, wheezing
 Hematemesis.

OCP

Oral Contraceptive Pill--- aka "the pill"

what it contains???
- oestrogen and progestron

How to take the pill?
-contains 21 hormone pills and 7 inactive pills
- it adds up to 4 week if u didnt know^_^
-recommendation is to start on the first day of your period
- That way, she is instantly protected from pregnancy
- But, u can start anytime you want but you would need to wait for 7 days of taking the pills before u can have sex because that the time it takes to become effective
-oh the seven inactive pills are so that u still can have ur period
-if u dun wan to have period than jus keep taking the pills without using the inactive pill
- but u shud allow ur else to bleed every 3 months cause its only natural^_^ seriously yea just to keep u safe.

What does the pill do??
1) prevent ovulation
2) thickening of mucus in cervix to prevent entry of the "tadpoles"
3) changing the lining of the uterus to prevent implantation


Effectiveness
-99.5% !!!!!!!!!!! if u wan 100% jus abstain from SEX!!!


What increases chances of getting pregnant?
- more than 24 hours late in taking the pill
-on medication such as antibiotics, anti epileptic or drugs to treat tubercolosis
- using some CAM stuff eg St. John Worts
- Severe vomiting or diarrhoea within 2 hours of taking the drugs


Missing the Pill!!! *GASP* !!!!!
- If u took ur hormone pill less than 24 hours late after your break !!! Good news u are still safe and protected(keeping in mind the lil 0.05% chance)
- BUT if you are - more than 24 hours late taking your pill after the break
- or miss more than 2 pills in a week
- SO happen u missed 2 pills in the week but still couldnt resist and had unprotected sex than immediately take emergency contraceptives!! shud be effective for up to 5 days, but best if taken within 24 hours

Advantages
-effective
-period more predictable
-can relieve PMS^_^
-can improve acne
prevent ovarian cycst and ovarian cancer

disadvantages
-sore breast
-nausea
- mood changes

contraindication
- Deep vein trombosis
- liver disease eg. Hep
- over 35 and smoker
-focal migraines
-vaginal bleeding

Important thing to tell doctor
-breast feeding
- smoking
- over 40
- had breast cancer or uterus cancer
-have fam Hx of high BP diabetes or any other blood disorder
-plan to have surgery

Neurological History Taking and Examination of the Peripheral Nervous System

Neurological History Taking and Examination of the Peripheral Nervous System

TAKING A NEUROLOGICAL HISTORY

In addition to the normal history presenting complaint, there are specific closed questions that form a neurological systems review. These questions do not take the place of the detailed history you learned to take in semester one but rather add extra information specific to the neurological system. You should ask the patient if they have experienced the following:

Seizures or fits (convulsions)

- Partial seizure: Partial consciousness

Fainting

- Syncope

- Can be due to hypotension, hyperglycemia, excessive bleeding

Dizziness

- Vertigo / near syncope

- A defense mechanism: More blood flow to the brain when you lie down

Headache

- Can be common, tension, cluster or pre-menstrual headache

- Could be aggravated by chocolates or caffeine

- Hemiplegic migraine

- Left hemipligia, pathology appears to be on the right

- Medial cerebral artery affected

- In the morning: Could be due to raised intracranial pressure

- Tension Headache : After work

- Quality: Burst (Hemorrhage) , Throbbing ( Migraine/ Tension)

Paraesthesia (abnormal sensation) / Anesthesia ( Total loss of sensation)

Weakness

- Could be due to

- Vascular

- Stroke

- Metabolic

- Diabetes, Hypoglycaemia

- Polio

Gait or movement problems

Visual Disturbance

- Diplopia, blurred vision, Tunnel vision, Bitemporal hemianopia

Neck stiffness

- Could be due to inflamed meninges which cause headache

- Sinusitis

Head Injury with loss of consciousness (LOC)

- Subdural hematoma

- When someone is old, it could be caused by personality change

RISK FACTORS FOR PERIPHERAL NEUROLOGICAL DISEASE

Smoking

- Cerebroascular disease

Diabetes

- Neuropathy

Alcohol

- Tremors, Delirium tremens, Dementia myopathy, Subdural hematoma

Diet

- Pellagra, Peripheral neuropathy

Malabsorption

- Niacin deficiency, Thiamine deficiency

GENERAL PRINCIPLES OF PERIPHERAL NEUROLOGICAL EXAMINATION

LOOK

Muscle bulk, Wasting, Fasciculation (Sign of LML), Tremor, Spasm, Abnormal Movements, Skin Changes ( Hemifibronulus, cutaneous anglomata)

Tremor

- Described according to speed (fast/slow) and amplitude (fine/course)

-Physiological

- Pathological

- If slower, indication of liver, thyroid, neurological disease

-Parkinsonian

- slow and course

Guide to Use a Condom =)

-Introduce yourself and explain the procedure to the patient.
-3 C's (consent, confidentiality, COMFORT)
-Dont be SHY and EMBARRASED... (for girls)
-After your demonstration on fake penis, assess the patients understanding by asking them to do it again.

Why you need to wear condom???
-reduce risk of pregnancy and of getting or pasing on a STD. (95-97% effective)

Condom care:
-always check expiry date.
-learn how to put in on and take off a condom before using one for the first time.
-store condoms in a dry,cool place away from direct heat.
-never use a condom more than once.
-only use water based lubricant with condoms. (oil-based lubricant can weaken condom and increase risk of breakage)

How to use a male condom:
-gently open the packet and take out the condom (dont tear it with your teeth/ fingenails). Check the condom is around the right wat by unrolling it slightly.
-squeeze the air out of the tip of the condom with yr thumb and forefinger and unroll t all the way down the erect penis.
-use water-based lubricant on the outside of the condom or around the partner's genital area.
-check that the condom is still on during sex. If it comes off, withdraw the penis and put on a new condom.
-after ejaculation, withdraw the penis while its still hard, holiding onto the condom at the base of the penis so that no semen leaks out.
-take off the condom, wrap it up and throw it in the bin, without letting it touch the partners genital area.


How to use female condom:
-carefully open the condom packet.
-hold the middle of the inner ring, squeeze the ring together and push the ring up into your vagina as far as it will go. When inserted correctly the inner ring should not cause any discomfort.
- the outer ring should remain ouside your vagina.
-after ejaculation, twist the outer ring to keep the semen inside and pull gently. Wrap the condom and throw it in the bin.

Pros:
-reduce risk of getting on STD's
-have no health risks
-widely available at a low cost.

Cons:
-must wear it before any genital contact occurs to be effective.
-REDUCED sensitivity.
-not suitable for people with an allergy to lubricant.

If condom fails:
Emergency contraception (EC) can be used, but effectiveness is significantly increased when taken within 24 hours. Can also be taken up to 5 days after intercourse however the effectiveness decrease as time passes.

Blood Pressure

A few things you need to know before you take blood pressure:

1) Obtain consent and introduction.
2) Explain the procedure.
3) Note down a few things:
What the person has ate, coffee, exercise, family history, strenuous activity before coming to the doctor, medication and smoking.
4) Locate the brachial and radial pulse, strap on and get the estimate of the systolic pressure.
5) Repeat second time and get the real systolic and diastolic pressure reading. Remember to mention the Korotkoff sounds while hearing the pulses.
6) Explain to the patient what the reading is. Not that readings may vary from gender and age etc etc.

According to the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH), high blood pressure for adults is defined as:

• 140 mm Hg or greater systolic pressure
  
  and
• 90 mm Hg or greater diastolic pressure

In an update of NHLBI guidelines for hypertension in 2003, a new blood pressure category was added called prehypertension:

• 120 mm Hg – 139 mm Hg systolic pressure
  
  and
• 80 mm Hg – 89 mm Hg diastolic pressure

The new NHLBI guidelines now define normal blood pressure as follows:

• Less than 120 mm Hg systolic pressure
  
  and
• Less than 80 mm Hg diastolic pressure

The Korotkoff sounds

The Korotkoff sounds are the sounds heard through the stethoscope as the pressure cuff deflates. The sounds are first heard when the cuff pressure equals the systolic pressure, and cease to be heard once the cuff has deflated past the diastolic pressure.

It is generally accepted that there are five phases of Korotkoff sounds. Each phase is characterised by the volume and quality of sound heard. The figure below illustrates these phases. In this example, the systolic and diastolic pressures are 120mmHg and 80mmHg respectively.



Phase 1

With the pressure cuff inflated to beyond the systolic pressure, the artery is completely occluded and no blood can flow through it. Consequently, no sounds are heard above the systolic pressure. At the point where cuff pressure equals the systolic pressure, a sharp tapping sound is heard. We recall that the blood pressure oscillates between systolic and diastolic pressure. At systolic, the pressure is great enough to force the artery walls open and for blood to spurt through. As the pressure dips to diastolic, however, the artery walls bang shut again. It is the closing shut of the artery walls that results in the tapping sound.

Phase 2

This phase is characterised by a swishing sound, caused by the swirling currents in the blood as the flow through the artery increases. Sometimes, if the cuff is deflated too slowly, the sounds vanish temporarily. This happens when the blood vessels beneath the cuff become congested, and is often a sign of hypertension. The congestion eventually clears, and sounds resume. The intervening period is called the auscultatory gap.

Phase 3

In this phase, there is a resumption of crisp tapping sounds, similar to those heard in phase 1. At this stage, the increased flow of blood is pounding against the artery walls.

Phase 4

At this point, there is an abrupt muffling of sound. The blood flow is becoming less turbulent. Some medical practitioners choose to record this point as the diastolic pressure.

Phase 5

This is the point at which sounds cease to be heard all together. The blood flow has returned to normal and is now laminar. The pressure cuff is deflated entirely and removed.