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Title: When the Moon Split: A biography of Prophet Muhammad (Peace be upon him) Author: Safiur-Rahman al-Mubarkpuri Subj. Lecture Notes Clinical Medicine provides a comprehensive, accessible introduction to the management and treatment of medical conditions. CLINICAL MEDICINE. Lecture Notes. John Bradley. Mark Gurnell. Diana Wood. 7th Edition. LN. Bradley, Gurnell & W ood. Lecture Notes. CLINICAL MEDICINE.


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Lecture Notes Clinical Medicine 7th Edition PDF Medical Students, Nursing Students, Prehospital Management of Acute STEMI [PDF] English, Medical. CLINICAL MEDICINE Bradley, Gurnell & Wood Lecture Notes 7th Edition Reviews of the previous edition ' this book tackles the vast subject that is clinical . Lecture Notes: Clinical Medicine, 7th Edition. John R. Bradley, Mark Gurnell, Diana F. Wood. ISBN: Oct , Wiley-Blackwell. pages .

The key to the book's success lies in the first part which is structured and styled very much in the manner of a manual on techniques of physical examination.

The book helps the examination candidates carry out an examiner's request to perform a specific examination and hence is an excellent preparation tool for OSCEs. Description of the clinical approach is built around the questions most commonly asked and is designed to get medical students to work systematically as if they have been practising medicine for years.

The second part of the book is a short textbook of medicine: Get A Copy. Paperback , pages. Published January 27th by Wiley-Blackwell first published December 23rd More Details Original Title. Other Editions 4. Friend Reviews. To see what your friends thought of this book, please sign up. To ask other readers questions about Lecture Notes , please sign up. Lists with This Book. This book is not yet featured on Listopia. Community Reviews.

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Report the most affected organ systems first.

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If the patient presents with diarrhea, present GI first, then go on to other organ systems. Do a complete physical exam of each organ system every time you see a patient, but only report a detailed exam for the organ systems related to the chief complaint and for abnormal findings in other systems. Each organ system ought to be examined in the same order: I. As a junior medical student, it is best to report On inspection on palpation on percussion on auscultation This way you will not forget any part of the examination and you will keep things in the correct order.

The only exception to this rule would be for the central nervous system.

Also for the cardiovascular exam we start out with the inverted J check radial pulse, blood pressure, and JVP, then proceed to I. Report the vital signs twice: once during the general exam, and then the appropriate vital signs for each of the organ systems that are investigated e. Summary 2 This summary is two sentences. The first one is a repetition of Summary 1.

The second sentence is a summary of the physical exam findings. You do not need to repeat the specifics of the exam findings if you are able to summarize them in a brief way. For example, if the patient has a respiratory exam with decreased tactile fremitus, stony dullness on percussion, and decreased breath sounds on auscultation, you can say that they have exam findings consistent with a pleural effusion.

Impression Your impression should take into account the chief complaint and all abnormal findings on the history and physical. It should include every diagnosis that you think the patient DOES have. The differential diagnosis should include other possibilities, but not things that you are fairly certain the patient has.

It is helpful if you explain your reasoning behind your impressions e. I think this patient has IDS because they have wasting, fever, and candidal infection.

You should give your reason for each impression and then give good differential diagnoses for each impression. Plan Your plan should include both investigations and treatments pharmacological and nonpharmacological. It is best to organize your plan by stating what investigations and treatments you want for each of your impressions, e. This will help you in the future because your plan will be the same every time you see that diagnosis.

General Examination Introduction The general examination is usually done in either sitting or lying position. Observation begins as soon as you see the patient as they enter the room, or as they are lying in bed. Move from general observation to specific inspection of different parts of their body Mental and emotional state What is their mental state? What is their body habitus? Do they have any swelling? Skin What is its color?

How far up the leg does it go? How severe is it? Oslers nodes, laneway lesions, palmar erythema Any abnormal movements?

What is the appearance of their shins and feet? Is there thyroid gland swelling?

Are there abnormal pulsations of the neck vessels? Inspect the neck for the pulsations of the internal jugular vein. Measure its height from the level of the sternal angle.

It should normally be less than 3 cm above the sternal angle. Checking for pulsus paradoxus: The systolic blood pressure normally decreases slightly during inspiration. Pulsus paradoxus is an abnormally large decrease in this normal variation. To check this, inflate a blood pressure cough as you normally would until you hear no sounds.

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Slowly deflate the cuff until you hear the first Korotkoff sound only during expiration and note the blood pressure. Continue to decrease the blood pressure until you hear the first Korotkoff sound during both inspiration and expiration. Subtract this from the first pressure. If it is greater than 10 mm Hg difference, then the patient has pulsus paradoxus.

Respiratory What is the quality of the voice? If so, to what degree? What is the shape of the abdomen? Note any abnormal movements of the abdomen? In severely ill patients, the nervous system exam can be completed in the lying position Always perform the neurological exam systematically so that you do not omit anything. Note any deficits and the anatomic site of the neurologic lesion. For more comprehensive neurological exam, refer to Hutchinsons Higher Centers Mental State: Examination of the mental state overlaps with the field of psychiatry, and it includes examination of appearance, attitude, behavior, mood, affect, speech, language, thought process, thought content, perception, cognition, insight, and judgment.

For the an internal medicine doctor, you should at the very least observe the level of consciousness and orientation Level of Consciousness: In extremely ill patients consciousness can be quantified with the Glasgow Coma Scale GCS. Do they know who they are their name, age, date of birth , where they are city, hospital, floor , and when it is year, month, day, time Speech: Do they have dysarthria, expressive aphasia, or receptive aphasia? Memory: assess both short term and long term memory.

This is often omitted during a brief bedside exam. CN II Optic : Test visual acuity with Snellen chart at 6m, visual fields each quadrant one eye at a time with fingers moving test. Test pupils by shining light into eyes and checking for direct and symmetric reaction.

Check accommodation by bringing finger close to their face between their eyes.

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If the patient is sedated or comatose, touch cotton to the corneal surface to illicit bilateral blink corneal reflex. Palpate masseter and temporalis muscles as patient clenches teeth to assess motor function. CN VII Facial : Check movement of the upper face by having the patient raise their eyebrows and screw their eyes shut while you try to open their eyelids.

Check movement of the lower face by having the patient smile, bare teeth, and hold air in the cheeks while you tap on them.

You can also check taste with various solutions: sweet with sugar, salt with salt, sour with a citric acid, and bitter with quinine. CN VIII Vestibulocochlear : Test hearing with different volumes of speaking normal, whisper , and with rubbing your finger near their each ear individually. If a tuning fork is available, check Rinne and Weber tests. Check the vestibular function at the end of the neuro exam during the coordination, gait and balance assessment with the Romberg test, heel to toe walking, and DixHallpike test.

Ask the patient which is louder. Ask the patient whether the sound is heard in the midline or whether it is louder on one side CN IX Glossopharyngeal : Test for motor function by having patient stick their tongue out. Test for taste on the posterior part of the tongue and gag reflex.

CN X Vagus : As the patient says ah, confirm soft palate elevates and the uvula stays midline. Check for sternoclaidomastoid strength by placing hand on cheek and having patient turn their head against it.

Kernigs Sign: With the patient supine on the bed passively extend the patients knee on either side when the hip is fully flexed and look for patient spasm. Brudzinskis Sign: When forced flexion of the neck elicits a reflex flexion of the hips. Note any abnormal posture or abnormal movements tremor, pseudoathetosis, myoclonus, chorea, ballism, athetosis, dystonia, tics, tetany, cramps. Tone: Move the limb passively back and forth at different rates. Note any hypertonia, hypotonia, rigidity, or spasticity.

Testicle moves upward. Move it up or down and asking the patient to tell you which direction you moved it. Two Point Discrimination: Normally 2mm separation can be recognized as separate stimuli on the finger tips, but only 1cm separation on the bottoms of the toes Coordination, Gait, and Balance Coordination: Test when concerned about cerebellar injury o Finger to nose test: ask the patient to touch his nose and then the tip of your finger, held at arms length in front of the patients face using their index finger.

Then have patient walk heel to toe with their eyes first open, then closed. Inspection of the Hands This would normally be done and reported as part of the general examination unless ONLY a focused cardiovascular examination is done. Especially note any, cyanosis, finger clubbing, warmth of extremities, signs of infective endocarditis. Arterial Pulses Rate: Palpate the right radial artery. Rhythm: Note whether the rhythm is regular no missed or extra beats or irregular.

If there is sinus arrhythmia, the heart rate will slow slightly whenever the patient breaths out.

Character: Palpate the right carotid artery on the neck at the angle of the right mandible. Check for symmetry between the right and left side, and for delay between the brachial and femoral pulses. Synchronicity: Is the radial pulse synchronous with both the contralateral radial pulse and the femoral pulsation? Radial, brachial, carotid, femoral, popliteal, and pedal pulses commonly assessed.

Blood Pressure Blood pressure should be checked first in the sitting position in both arms. Place the bell of the stethoscope over the brachial artery on the ventral surface of the elbow.

Normally it is less than 4cm vertically above the angle. Palpation Place your right hand on the patients left chest with the butt of the hand at the sternum and the fingers extending into the axilla Apex beat: the lowest most lateral point at which the cardiac impulse can be palpated. Normally located superior to the 5th intercostals space and medial to the midclavicular line. Double Thrust: A palpable 3rd and 4th heart sound Left Parasternal Thrust: Thrust appreciated just to the left of the sternum Thrill: Palpable vibrations on the chest wall Auscultation Technique Diaphragm of the stethoscope for high-pitched sounds Bell of the stethoscope to hear the low-pitched sounds.

Place the stethoscope in the four primary areas. Sounds 1st sound S1 closing of the mitral and tricuspid valves 2nd sound S2 closing of the aortic and pulmonary valves. Split S2 occurs during inspiration.

Occur during diastole after S2. Either one is called a gallop. This can be low-pitched, medium pitched, or high-pitched. Use one of the four main areas. Movement o Is the degree of expansion normal?

If asymmetrical, is it from congenital deformity, trauma, or other? What is the respiratory rate and rhythm? Note any areas of swelling or tenderness Note the position of the trachea: Feel with your second and fourth fingers on each edge of the sternal notch.

Use the 3rd finger to assess its position. Note any asymmetry during chest expansion: Face the patient and place the fingertips of both hands on either side of the lower ribcage, so that the tips of the thumbs meet in the midline in front of but not touching the chest. Observe the position of the thumb as with each breath.

Check tactile fremitus: Place the hands on the front of the chest with one hand on each side of the sternum. Have the patient say nane, nane or nyama, nyama and feel for any abnormalities. Repeat on the back of the chest. Not any increased, decreased, or asymmetrical fremitus. Percussion Note any hyperresonance increase in resonance or dullness reduction in resonance as well as any pain or tenderness on percussion.

Place middle finger of the left hand on the part to be percussed and press firmly against the surface of the chest. Use the tip of the right middle finger to strike the distal interphalangeal joint of the left hand Move your right hand at the wrist Make sure the right middle finger is bent so that it strikes the left finger at a right angle in a tapping motion Percuss on the two sides of the chest, moving back and forth between the Percuss over the clavicles, then three of four areas on the anterior chest wall, in the axillae, and three or four areas on the back of the chest 17 Auscultation Use correct technique o Use the diaphragm of the stethoscope not the bell o Ask the patient to take deep breaths through an open mouth o Listen in comparable positions on each side and compare them to each other Describe the breath sounds?

Are there any added breath sounds wheezes, crackles, stridor, pleural rub Are there any abnormalities in vocal resonance?

Use correct technique Have the patient repeat a phrase such as nani-nani Listen with the stethoscope to the sound of the vibrations being transmitted from the vocal cords into the chest.

Compare each point with a corresponding point on the other side of the chest. Determine if there is increased resonance louder, clearer sounds o Whispering pectoriloquy: when vocal resonance is so loud, that you can clearly hear a whispered phrase with your stethoscope at the chest wall o Aegophony: the nasal, bleating sound that the voice has when you listen overtop of a consolidation while a person speaks Remember that palpation, percussion and auscultation of the lungs should be performed and reported in all 7 lung areas on both right and left sides.

Supraclavicular anterior Supramammary anterior Inframammary anterior Axillary Suprascapular Posterior Intrascapular Posterior Infrascapular Posterior 18 Gastrointestinal System Exam Introduction Prepare the patient: position them supine and expose the patients abdomen from the xyphoid to the symphysis pubis.

Make sure to inspect the genitals after the abdomen. Movements of the abdominal wall.

Skin, veins, and pigmentation of the abdomen. Groin, penis, and scrotum: Note any swelling or abnormal position.

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Palpation Mould the hand to the abdominal wall. Use gentle firm pressure. Ask the patient to take a deep breath to make detection of organs easier.

Use a logical sequence to avoid missing anything. Left kidney: Not normally palpable unless it is low in position or enlarged. If the lower pole is felt, it is rounded firm swelling between the right and left hands bimanually palpable and can be pushed from one hand to the other Spleen: Not normally palpable, unless it is enlarged two to three times its size o Minor enlargement: firm swelling with smooth, rounded borders o Considerable splenomegaly: firm swelling, beneath left subcostal margin, in the left upper quadrant of the abdomen, moves downwards on inspiration, is not bimanually palpable, upper border cannot be felt, notch sometimes felt in the lower medial border Right kidney: Lower pole is commonly palpable in thin patients, smooth, rounded swelling which descends on inspiration and is bimanually palpable.

Liver o Describe the enlargement of the liver as centimeters of enlargement below the costal margin use a ruler if possible. At the height of inspiration the breathing stops with a gasp as the mass of an acutely inflamed gallbladder is palpated which is exquisitely tender o Courvoisiers Law: in the presence of jaundice a palpable gallbladder makes gallstone obstruction of the common bile duct unlikely Urinary bladder: Normally not palpable. Note the width of the aorta. Can you feel the inferior edge of the mass, or does it disappear into the pelvis?

Can it be moved by palpation? Does it have side to side mobility? Does this pulsation come from the mass or is it transmitted by the mass? Feel for any guarding o Involuntary reflex contraction of the muscles of the abdominal wall o Determine if this is truly involuntary, or if it is voluntary contraction Feel for rigidity Board-like abdomen Feel for rebound tenderness o Palpate slowly and deeply over the abdomen o Release the palpating hand, and observe to see if the patient experiences severe pain o o Percussion Define the boundaries of abdominal organs and masses Liver o o o o o Start anteriorly, at the 4th intercostal space in the midclavicular line.

The note should be resonant because you are over the lung at this height.

Move vertically downward the chest wall as you percuss The note will become dull at about the intercostal space as you move over the liver The dullness extends down to the lower border at or just below the right subcostal margin o Normal liver height is 12cm to 15cm Spleen: Normally not able to discern splenic size based on percussion.

Percussion is used to confirm splenic enlargement as it protrudes into the abdominal space. Urinary bladder: Normally not able to find with percussion. Can be dull to percussion just over the pubic bone when the bladder is enlarged from urinary retention.

Other Masses: Use percussion and the change from resonance to dullness to measure the size of masses in the abdomen. Palpation the digital rectal exam o Place lubricant on the gloved index finger of the right hand o Place the pulp of the finger not the tip flat on the anus o Press firmly and slowly, flexing the finger in a slightly backwards direction o Feel the tone of the sphincter.

Normally it grips the finger firmly o Feel for the shallow groove just inside the anal canal which marks the dividing line between the external and internal sphincter o Push the finger into the rectum o Sweep the finger through a degree circle at 2,5 , and 8cm inwards o Repeat this as the finger is withdrawn o Feel for thickening or irregularity of the wall of the canal o Feel anteriorly in men for the rectovesicular pouch, the seminal vesicles normally not palpable , and the prostate o Feel for any boggy, hard, or irregular swelling o Feel the each lateral lobe of the prostate and the median sulcus and determine whether it is rubbery and firm or abnormal boggy, hard, irregular, nodular o In women feel for the cervix, the pouch of Douglas o Inspect the finger after withdrawing 23 Common Procedures Procedure Documentation Before you begin stop and confirm: correct procedure, correct site, no contraindications.

After you finish, document the procedure in the patients file: date, time, procedure, indication, site, technique, quantity and quality of specimen, complications.The book is divided into two sections: Part 1 focuses on the clinical examination of each body system, and Lecture Notes on Clinical Medicine has a long-standing reputation for excellence and is a must-have in the run-up to final examinations and throughout the clinical years.

This book is not yet featured on Listopia. Either one is called a gallop. CN X Vagus : As the patient says ah, confirm soft palate elevates and the uvula stays midline. Lecture Notes : Emergency Medicine 4th Ed.

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