In 80% resolves in 18 months Clinically: flat topped papules purchase 1 mg prandin mastercard, discrete or coalescing discount 2 mg prandin mastercard. But also similar lesions common in normal kids Classically (but not invariably) seen with epilepsy and mental retardation (zits buy discount prandin 0.5mg on-line, fits and nit-twits) Autosomal dominant with variable penetrance, 50% are new mutations Prevalence? Dont call it Exfoliative Dermatitis meaning is unclear May have sudden onset over weeks or days. Therapeutic agent unknown Topical Steroids Double the concentration doesnt necessarily double the efficacy Potency related to receptor binding. History Introduction Data: Age Gravidity = total number of pregnancies Parity = # of deliveries (multiple births = 1 delivery but definitions vary). Include: Bleeding: Quantity (eg # of pads per day but ask why they change 1 per hour too much), double protection needed (eg tampon and pad), soaking through, etc Duration Quality. Teenagers will often give their period length as first day without bleeding to first day of bleeding check understanding Ovulation is 12 16 days before the start of the next period (determined by timing of the following period, not the prior period). Fertile for 5 7 days before ovulation If post-menopausal, when did periods stop and are there any symptoms Past gynaecological problems or procedures ? To avoid embarrassment, just ask straight Cigarette, alcohol and recreational drug use Occupation ? Check experiences with past exams Ensure chaperon if male Have available: light, additional light source and mirror for the patient Check bladder is empty Clear instructions to patient on what clothes to remove and position. Use narrow speculum for nulliparous, wider speculum for multiparous, and paediatric for child or sometimes post menopausal. If its left in then risk of chorioamnioitis, miscarriage or pre-term labour Mirena carries levonorgestrel (a progesterone) risk of implantation and lighter periods (Good for menorrhagia). Adverse effects are dose related give lowest dose that gives good cycle control. Contraceptive cover immediate Breakthrough bleeding is very common especially in the first 3 months. Can add 20 g estradiol every 24 hours, 12 hours after the usual pill, for one week. Little evidence that its not safe to continue to menopause Progesterone Only Pill (PoP) = Mini-pill Cervical mucus hostile to sperm (G Type mucus) + prevent ovulation in some + tubal motility. Small risk of follicular cyst (one that doesnt pop) pain with full bladder or rectum Worst side effect: erratic bleeding. For post-partum contraception see Six Week Check, page 374 Contraindications: History of ectopic pregnancy, breast cancer, liver disease or enzyme inducing drugs Must be taken same time each day (+/- 3 hours). Safe again after 2 days of restarting the pill Depot progestogen: Safe, simple and effective (failure rate 0. Has been discussion of risk of prostate cancer best evidence says no association. Prophylactic cover if suspected Suspicion of Abuse or Interpersonal Violence It is common and victims are high users of health services Epidemiology: 20% of women report sexual abuse before 16, full intercourse reported by 4%. Ever had bruises or had to stay in bed Sexual: Did anything sexually frightening happen to you as a child or young adult, have you ever been made to participate in sexual activity that made you feel uncomfortable. If very recent then nil- by-mouth and collect all urine and toilet paper until forensic examination. Rarely Turners syndrome or testicular feminisation Secondary amenorrhoea: when periods stop for > 6 months, except for pregnancy: Hypothalamic-pituitary-ovarian causes common. If withdrawal bleed following, then there is enough oestrogen to produce an endometrium Ovarian causes are uncommon: Polycystic ovarian syndrome, tumours, premature menopause Hyperthyroidism oestrogen breakdown Investigation: Pregnancy Test -ive 5 day progesterone challenge: +ive withdrawal bleed? Diagnosis of Reproductive and Obstetrics 345 exclusion Oligomenorrhoea: infrequent periods: common in the young and the nearly menopausal. Most often on ovaries and uterosacral ligaments Chronic and progressive: inflammation and local haemorrhage fibrosis and scarring Incidence: 10 15% of reproductive age. Patients usually in mid 30s early 40s, nulliparous Common in infertility and chronic pelvic pain Aetiology theories: Retrograde menstruation homologous grafts Genetics: 7 fold risk if +ive family history. Usually earlier and more severe disease Symptoms: classic triad = pelvic pain, deep dyspareunia, dysmenorrhoea. Also irregular bleeding, infertility (scars fallopian tubes) On exam: tender, retroverted uterus Confirmation by laproscopy. Red brown nodules on surface of ovaries and pelvic structures, and other sites (appendix, peritoneal scars, etc). Can develop large cysts, lined by endometrial stroma and glands and containing changed blood (chocolate cysts). Fix either in 95% ethyl alcohol for 20 - 30 minutes or cytofix sprayed from 20 30 cms. Can stop if > 5 years with no sex (this bit not in the guideline) Screening should be yearly for 2 years from 20 (some advocate starting earlier if > 2 years since commencing regular sex but as cancer in this age group is very uncommon, its not good screening practice. If cysts have smooth internal epithelium likely to be benign Borderline (20%): mucinous tumour of borderline malignancy. No atypia, minimal risk of carcinoma Complex hyperplasia: More crowded gland with budding and infolding. With atypia, 5% progress to carcinoma th th 354 4 and 5 Year Notes Complex hyperplasia with atypia: crowded, folded gland in which the lining cells are pleomorphic with loss of polarity and increased nuclear cytoplasmic ratio. If 6 weekly cycle, add 2 weeks (ovulation set by end of cycle not beginning) Date it well. See History, page 338 Actively treat any infection Any chronic infections (eg Herpes) Polycystic ovaries, uterine abnormality or surgery risk Gynaecological cancer: pregnancy hormones may exacerbate the disease Contraceptive history talk about restarting after pregnancy Smear history: last smear date, any abnormal Past Medical and Surgical History (and maybe very brief systems review): History of hypertension (any signs of renal disease? Reassure, small meals and stress Headaches, palpitations and fainting due to peripheral dilation. Give fibre and lots of fluid Reflux oesophagitis rd Backache in 3 trimester Carpal tunnel syndrome (due to fluid retention) Itchy rashes Ankle oedema almost universal. At 20 weeks up to umbilicus Lie and presentation from 32 weeks Fetal heart: use Doppler (mum can hear it too). Is the baby transverse or longitudinal Measure fundal height Find poles to determine lie Where is the back: Feel laterally (brace hand other side), then walk hands across. Score of fetal heart rate, breathing movements, fetal movement, fetal tone and amniotic fluid volume. Serum levels, maternal age and gestational age are used to calculate the risk of neural tube defects and chromosomal abnormalities classification as high risk (eg 1:50 for Down) or low risk (1:2700 for Down). If mosaic, skin cells in fetus closer to the babies karyotype than placental cells Amniocentesis: from 14 weeks (10 13 weeks 5% miscarriage). Culture amniotic cells for 2 3 weeks detects chromosomal abnormalities and neural tube defects. Difficult if anterior placenta or oligohydramnios Cordocentesis (Percutaneous umbilical blood sampling): from 18 weeks. These people to be chosen by the Abortion supervisory committee, with a view to expeditious access by any woman seeking an abortion. Supervisory committee also appoints/approves counselling services Ethics: Why is killing wrong: Violates the moral integrity of the entity killed It has negative consequences Evidences moral flaws in the killer Reasons for killing: to end suffering, to protect the innocent, lesser of two evils, to express societal condemnation Different views of the moral status of the fetus: Fetus has the same moral status: absence of a dividing line between a baby and a fetus does not show lack of difference Fetus has no moral status: Is seeking an abortion for trivial reasons wrong? Associated with preterm delivery Incomplete abortion: cervix is dilating, more pain, heavier bleeding. Usually active management to remove fetus Causes: None found most common Chromosomal abnormalities Hormonal imbalance: eg failure of corpus luteum to produce enough progesterone Maternal illness, abnormalities of the uterus (eg cervical incompetence), immunological factors Recurrent miscarriage = loss of 3 or more consecutive pregnancies, occurs in < 1% Ectopic pregnancy = Any implantation outside the uterine cavity. Atypical some initially have a fetus proliferation proliferating trophoblast Little invasive potential 10% invasive, Most have metastasised at Choriocarcinoma 5% diagnosis. Risk factors: Maternal age > 35 years Family history of diabetes Previous macrosomia, unexplained still birth Obesity Glycosuria on two or more separate occasions. Aiming for pretty tight control Insulin used if unable to control levels, or evidence of macrosomia. Even if tightly controlled, 4 5% risk of congenital abnormalities (2* general population). Aspirin (blocks thromboxane production preferentially make prostacyclin), antihypertensives, anticonvulsant prophylaxis (Magnesium sulphate). Have to stabilise before delivery Delivery is the only cure (although > half of fits occur post partum).

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Use Behavioral Activation as an opportunity to practice being mindful of potentially pleasurable experiences as they occur order 2mg prandin free shipping. Depression and self-criticism try to take away the kudos we deserve when we achieve something buy generic prandin 1 mg. Goal: When I want to achieve it: How I am going to do it: How I am going to measure it: What are possible barriers? This topic was chosen to help parents and guardians further understand depression in children and adolescents discount prandin 1mg on-line. By understanding and learning to recognize the presence of depression, the possible negative outcomes that this illness brings can be prevented or lessened. To be able to understand the presence of depression in children and adolescents, varying depressive symptoms experienced by different age groups were identified, including psychopathological symptoms, somatic symptoms and the gender difference symptomology of depression. This thesis also includes the prevalence of depression and the potential risk factors that contributed to the development of depression among children and adolescents. Specified in the risk factors were the genetic and biological vulnerability, environmental factors, negative life events, and the characteristics of the child and adolescent. These possible negative effects such as impairment of psychological and social functioning that may lead to poor self esteem, poor academic performance, and higher risk of suicide were contained in the thesis. Depression may also affect the family system, parent-child duo, and peer relationships as well. Possible interventions that are commonly used by professionals in the treatment of depression in children and adolescent were also discussed. The non-pharmacologic treatment includes play therapy, psychosocial therapy, family therapy, and cognitive-behaviour therapy while pharmacologic treatment involves the use of anti-depressant medications. The facts provided in the thesis were taken from several published scientific researched articles; therefore, the target groups that were included were from different conducted research studies. The target groups were children and adolescents, where both boys and girls were included. The information provided by this thesis will be published in Terveysnetti a webpage provided for the public viewer. Yet despite doing their best to provide and protect them, children may still encounter disappointments, frustrations, or real heartbreak. However, some children and adolescents seem to be constantly experiencing sorrow, hopelessness, and helplessness. Depression is an illness where the feelings of depression persist and intervene with the child or adolescent functional ability. Frequently, the first appearance of depression occurs during childhood or adolescence. Prolonged depressive episodes happen in an individual with dysthymic disorder (a milder depression that is constituted by an insidious onset and chronic course) that gradually progresses into major depression. The clinical spectrum of the illness can range from simple sadness to a major depressive disorder or sometimes to bipolar disorder (Son & Kirchner 2000, 2297). Although depression is common among children and adolescents, it is still frequently unrecognized or undetected (Son & Kirchner 2000, 2297). In many societies, depression has been considered as a major health problem, but the treatment seeking is rare, which mostly includes the non-western societies. People from traditional cultural backgrounds either deny psychological distress; interpret such distress as somatic illness or either take it as physical illness. Depression is treatable but depressed children and adolescents may present a different behavior than those of depressed adults. Hence, child and adolescent psychiatrists caution parents to be acquainted with the signs of depression in their children. The growing number of studies confirmed that depression commonly and persistently affects young people. With the high number of children and adolescents suffering from depression, up to 80% of them are not given any form of treatment (Beardslee et al. The pre-pubertal age depression rates for boys and girls are similar, and doubled in females after puberty. Another separate study in two regions of Finland (Vaasa region and Pirkanmaa) th th consisted of students from secondary school of 8 and 9 grade, revealed a total result of 17. Likewise, recent Finnish rating scale based studies estimated adolescent depression from 6% to 14% (Torikka et al. In the context of Finland, there is no evidence of vast increase in rates of depressive symptoms among the adolescents (Luopa et al. Separate studies of Chinese adolescents were reported to have score rates of 13% (Dong et al. In clinical presentation, it was validated that 3 year-old children have been diagnosed with major depressive disorder. Depending on the severity of depression, depressive disorder may also be accompanied by psychotic symptoms. In minors, such psychotic symptoms are usually manifested by a feeling of sinfulness, guilt, or failure. Persistent shows of suicidal or self-destructive theme in plays displayed by pre-schoolers, or a physically healthy child displaying disinterests in play are example signs of anhedonia (Luby 2002; Dopheide 2006, 234). Some developmental tasks of children can be accomplished through playing but the presence of anhedonia makes the child uninterested towards it, thus hinder developments (Murphy 2004, 19). Recognizing depressive symptoms in children age 8 and younger may not be easy because they are less likely to verbalize their emotions and instead show symptoms of anxiety (e. Somatic complaint such as intermittent abdominal pain is commonly seen in primary care offices (Murphy 2004, 19). Depressed children also array signs of irritability, temper tantrums, and other behavioural problems. Unlike adolescents with depression, children are less likely to experience delusion or make serious contemplation to commit suicide. Table 1 (see table 1 below), shows different age groups with their corresponding psychopathology and somatic symptoms. Age dependent psychopathological symptoms of depression (Mehler- Wex & Klch 2008, 150). For this reason, accurate diagnosis is important to successfully eradicate the illness. Depression caused by mental illness and medical condition must be properly differentiated (Murphy 2004, 28. At this stage of development, depressive symptoms are often dismissed or ignored as signs of adolescence or teenage behaviours. Any abnormal or unusual behaviour shown by them are often linked to the temporary phase that they are going through or occasional bad mood rather than suffering from depression. Females are at a higher risk of first onset of major depression from early adolescence until their mid-50s and have a lifetime depression rate of 1. Studies reported that girls are more depressed and more severely depressed than boys. In a Swedish high school study, the most common symptoms for the boys were sadness, crying and suicidal ideation. The study also concluded that for both the adolescent girls and boys, the most common reported characteristics of depression includes interpersonal (social withdrawal, irritability and loneliness) and thought processing symptoms (concentration and indecisiveness). However, although there were substantial evidences in the continuity of depression from adolescence to adulthood, the consistency in the result in the continuity from pre-pubertal to adulthood is less (Carlson & Kashani 1988; Klein et al. Follow-up studies in the group of pre-pubertal children generated varying results. In some studies, the results indicated that depressed children are at high risk of developing depression in adulthood while other results did not indicate evidence of increased risk except for other particular subgroups. The study concluded that the increase rate of depression in adulthood is usually associated with the depression experienced during childhood or adolescence. Although the child or adolescent mental impairment predicts mental health problems in early adulthood, the association is not adequately strong enough to recommend either early childhood or possibly early adolescent screening or intervention, thus, screening should be delayed until adolescent period. A first episode of depression increases the chance of experiencing a further episode (Kovacs et al.

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Health and safety legislation frequently deals with quantifable issues such as electromagnetic felds and toxic chemicals purchase prandin 2mg with visa. Similarly generic 1mg prandin free shipping, policy plays a role in helping to prevent mental disorders and to improve mental well-being in 12 Depression in the Workplace general prandin 1mg sale. Interventions should clearly be seen as an investment rather than a cost given the gross fnancial burden that impaired mental health poses today. These preventive measures can focus on education for stakeholders that encourages a workplace culture where mental health issues are addressed sympathetically and with the same sensitivity as somatic illnesses such as cancer. That said, it is not possible to quantify risks to mental health in the workplace in the same way as for toxins and radiation. What is considered an inappropriate level of stress by one person can be seen as motivating and enjoyable by another. Moreover, there are huge differences in work environments across different sectors. As such, it is not feasible to develop policy and legislation to regulate what psychosocial factors workers can be exposed to, irrespective of whether or not they have depression. The answer perhaps lies in legislation that supports better working conditions combined with provision of practical support for staff members who have depression or other mental illnesses. Policy can play a role in fostering creation of solutions that help to address depression in the workplace. It is often the simple, inexpensive initiatives that can have the greatest impact. Canadas Provincial Health Services Authority has created a toolkit for various stakeholders: for employees who are at risk of developing depression, for employers, for family members, and for treatment providers. This toolkit provides an integrated information source to attain a better outcome for all concerned. In Europe, however, there are insuffcient effective measures to address depression in the workplace. Current policies fail to consider employers and workplaces as partners to the healthcare system, and to date, there is no existing systematic approach to integrate employment in the management of mental health. The employee Social services staff The employer Healthcare professionals 13 Depression in the Workplace Conclusions Depression is a disease that is often invisible. Sufferers tend to hide the problem, and employers are ill-equipped to connect it to absenteeism and impaired performance among employees. Employers are therefore unlikely to recognise the impact it is having on their organisation. And it is appropriate that the European legislature considers pan-European support to help Member States address these issues. The European Union and its Member States shall ensure that workers are protected from inappropriate psychosocial risks in the workplace through employment policy and legislation. Policies and legislation that have a clear potential impact on mental health in the workplace should contain specifc measures to improve mental well-being, and at the minimum ensure the mental health of the workforce is not impaired. Outcome measures that help Member States and individual companies to assess the impact of any changes should be proposed. Examples of such measures include the Working Time Directives, posting of workers, corporate restructuring, and anti-discrimination law. Policy makers need scientifcally based outcome measures that can be used to assess work environments and measure the impact of interventions designed to reduce the impact of depression in the workplace. These measures need to be grounded in the available evidence and supported by expert opinion. Legislation needs to acknowledge the role employers have in improving each of the following: Prevention of onset of depression through improvements in the work environment. This can be through appropriate design of the workplace and its environment to help support physical and mental well-being Early intervention to support recognition of depression and the impact of any cognitive symptoms on the employees performance; and from there, implementation of a plan to support recovery Promoting good mental health through sound management programmes for depression Providing support when mental health is at risk and focusing on early training to ensure a reduction in the overall impact of depression on individual companies Managing mental health issues by ensuring the availability of Employee Assistance Programmes and mental health services 4. Enterprises shall be encouraged to develop plans that reduce the impact of depression and its cognitive symptoms on the workplace. The cognitive symptoms of depression, such as lack of concentration, indecisiveness, and forgetfulness impose a signifcant burden on organisations by reducing an individuals productivity and encouraging absenteeism. Employers and employees need to be supported in their efforts to increase understanding and recognition of these symptoms. From there, employers will be better placed to develop and implement strategies to improve mental health at work for the beneft of the individual and the organisation. Responsibilities of employers and employees as they relate to depression and the workplace must be clearly delineated and communicated. Within policy there must be no ambiguity surrounding employer obligations to staff, and vice versa, as they relate to depression. This means employers and employees alike must understand fully their respective responsibilities in reducing the burden of depression in the workplace. Those framing policy should recognise that effective interventions will rely on a productive partnership between employers, employees, and other stakeholders. Encourage Member States to establish Mental Health Commissions to oversee mental health provisions in the workplace. Canada has provided a blueprint for this approach in the form of the Mental Health Commission of Canada and the Workplace Strategies for Mental Health programme. They take a holistic view of the various issues seeking solutions across health and employment policy. The remit of this commission could include the following: Ensure employers, employees, and other stakeholders fully understand their respective responsibilities and the possibilities for intervention in relation to depression and other mental illnesses in the workplace Create educational materials for use in the workplace and adaptable toolkits for organisations to help them develop their own internal strategies to address this issue Foster communication between groups responsible for health and employment policy to ensure concordance of policy from these groups as it relates to mental health. The function responsible for follow-up would be defned by the Member States, and equipped with instruments to recognise improvement, and to impose sanctions where there are shortfalls. Health policy must recognise the role healthcare professionals have in ensuring that patients with depression are treated according to established evidence-based guidelines. Healthcare professionals play a critical role in developing and maintaining treatment plans for their patients. They must continue to be empowered to combine clinical judgement with evidence-based recommendations as they support individual patients on their path to wellness. In addition, healthcare professionals need to recognise that interventions will often require consideration of the patients work situation with necessary adjustments incorporated into the treatment plan. Member states should develop national Mental Health Action Plans to reduce psychosocial risks in the workplace. Employers and employees will be positioned as equal partners in the implementation of these Action Plans. The structure will involve execution of a simple risk assessment, followed by practical advice to help improve the workplace environment if necessary. These Action Plans should specify goals and objectives for interventions that address risks in the workplace, including but not limited to psychosocial stressors. In addition, a suite of educational resources for different stakeholders could be included, and also provide the cost-beneft rationale to support such investment in different types and sizes of organisations. Policy makers need to engage professional medical societies to ensure there is a shared understanding of the impact of the day-to-day clinical management on wider public health. In addition, this kind of engagement can help ensure policy is based on evidence and expert insights from the medical and research communities. Thus the objectives of such engagement are: To ensure that new policy dovetails with the needs of clinicians to supply evidence-based standards of care to patients with depression To ensure political initiatives within this feld are indeed practical and have value in the real world To encourage a greater understanding within the medical profession of public health policies surrounding depression. In addition, to ensure that the most recent policies are refected in medical education programmes that are supported by the professional societies. Update legislation that supports workplace employee education to include advice on depression and overall mental health. Legislation must underscore the importance of educating employers, employees with depression, and the broader employee community on recognising problems that could indicate serious mental illness. These educational needs should also de-stigmatise depression and other mental illness in the workplace. The guidance will need to explain in simple terms how depression is a syndrome with cognitive symptoms that can affect an individuals ability to earn a living. Promote fnancial support for research to measure the impact of alliances between employers, healthcare professionals, employees, and families to improve the identifcation and care of depression among employees. A number of alliances in various forms have been created, which are to be encouraged with suitable capture of outcome measures. Interventions should measure the impact of initiatives on absenteeism and presenteeism using expert advice.

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Itisvitaltopatient ent relationship in this way has positive effects on and doctor satisfaction with the consultation adherence to treatment and health outcomes purchase 2 mg prandin mastercard. Closing the session Summarise:reviewtheconsultationandclarifythe Special circumstances plan of action prandin 1 mg lowest price; make a contract with the patient Certain circumstances demand a special approach to about the next steps generic prandin 1mg. Sequencing Maintain a logical sequence to the Involve the Share your thoughts to interview; use exible but ordered patient encourage patient interaction; organisation by signposting and explain your rationale for doing summarising. The medical interview 5 Breaking bad news Approach to communication skills assessment Prepare: ensure you have all the clinical details and know the facts; set aside enough time; Past papers: the format of the examination should encourage the patient to bring a relative or be available for review; look at the communication friend. In some examinations spective; do not overwhelm with information in the clinical scenario is available in advance of the rst instance; check repeatedly that the pa- the examination to allow preparation of content tient understands. Make a plan: explain what will happen next; give Make a plan: before you enter the station, have a hope but be realistic; conrm your role as a clear plan as to how you will approach the partner in care. Complexsituationsrequirethedoctor present and discuss the case, listen carefully to to use basic skills to a higher level. Preparation and the examiner and present the salient features in planning, listening to the patient, delivering informa- a clear and logical manner. Closureisalsoimport- ant, ensuring the patient knows what is happening and is clear about the next steps. Communication skills are usually ments should have been through appropriate 6 The medical interview Concrete experience Consultation with a patient Interview a simulated patient Role play Reflection Active experimentation Think about the consultation Try a different approach Observe a recorded consultation in a learning environment Give and receive feedback Abstract conceptualisation What will I do differently next time? Thecycleenablesthelearnertobuildonexistingknowledgeand skills, to take responsibility for their own progress and to use real life clinical and simulated encounters to promote further learning. Dyspnoea may be observed and outstretched abnormal movements, including tremor or paucity of T resting tremor of Parkinsons disease hands facial expression, should be noted. Many patients with ischaemic heart disease have few or no physical signs and a characteristic history of peripheral vascular disease may be elicited. Cardiac valvular Arterial pulses diseaseandseptaldefectsusuallygiverisetomurmurs which may be diagnostic. Syncope: on exertion postural The sternal angle is about 5cm above the left atrium when the patient is lying at 45. Past history: hypertension If neither is obvious: cerebrovascular disease peripheral vascular disease. Suspect a low level: unless the liver is tender, press congenital heart disease on the abdomen gently but rmly. The hepato- jugular reux (not reex) has no pathophysiolog- Medication: antihypertensives ical signicance; thesolepurposeofthis manoeuvre antianginal therapy is to demonstrate the vein and to show that it can be statins oral contraceptives and lled (i. Check if the ear lobes move with the cardiac cycle and sit the patient vertically Family history: ischaemic heart disease to get a greater length of visible jugular vein above diabetes the right atrium. A large a wave (corresponding with atrial systole) occurs when the right atrial pressure is raised, e. A cannon wave is a massive a wave occurring in left ventricular dilatation or tapping in nature, complete heart block when the right atrium con- suggesting the accentuated rst sound of mitral tracts against a closed tricuspid valve. There is no a wave in atrial brillation because A parasternal heave is present when there is right there is no atrial systole. A large v wave (corresponding with ventricular Thrills are palpable murmurs felt over the relevant systole) indicates tricuspid incompetence (usually area in systole or diastole. Use the bell of the stethoscope to examine low- pitched noises, especially diastolic murmurs at the Heart apex, and the diaphragm to examine high-pitched Observe noises and the precordium generally. Internal Pericardial friction rub: low-pitched and scratchy; jugular heard over the lower sternum; varies with posture and vein breathing. Checkforradiationofaorticstenoticmurmurstothe A full cardiovascular history should be taken, focusing carotid area. Coarctation of the aorta: radial-femoral arterial standing or severe hypertension. Best existent connective tissue or other heard with patient sitting forwards in disorders expiration Mitral stenosis Mid or late rumbling diastolic murmur Turn patient on left side (and at apex; presystolic accentuation if exercise) to accentuate murmur. Often atrial brillation Opening snap if valve pliable Mitral incompetence Pansystolic at apex Radiation to axilla; often heard parasternally Mitral prolapse Midsystolicatapex. Patients with peripheral vascular disease may com- Check individual waves and intervals plain of:. In chronic lung dis- ease, the availability of sophisticated radiology and Count respiratory physiology can be used to conrm the diagnosis and monitor disease progress. When examining the back of the chest, ask the Key featuresof the history in a patientwithrespiratory patient to put their hands on their hips to facilitate disease are shown in Table 4. Palpation The anterior surface markings of the lungs are shown Examination in Fig. Key abnormalities detected on examination of the Palpate for chest are shown in Table 4. Patients who have had a single small haemoptysis, no other symptoms and a normal Haemoptysis chest X-ray (postero-anterior and lateral) should have Aetiology: common afollow-upchestX-rayafter12months. Afullhistoryandclinicalexaminationwill usually identify pulmonary infarction, foreign body,. Middle Oblique ssures run along the line of the fth/ sixth rib; a horizontal ssure runs from the Lower Lower fourth costal cartilage to the sixth rib in the mid-axillary line. Anteriorly you are listening mainly to upper lobes and on the right the middle lobe. Gastrointestinal causes Left ventricular failure may produce cyanosis that is partlycentral(pulmonary)andpartlyperipheral(poor. Cyanosis is a clinical description which refers to the sulphonamides, primaquine or nitrites. Central cyanosis is usually caused by the presence of an excess of reduced haemoglobin in the respiratory system capillaries. The normal arterial values are: If the tongue is not cyanosed but the nger nail beds. PaO2 1013 kPa (values fall with age) are, the cyanosis is peripheral and secondary to. Physiological shunt (venous admixture): deoxygen- shunts ated blood passes straight to the left heart without. The arterial PaO2 is not signicantly improved by the administration of Causes of hypoxaemia oxygen. Normal values for all these tests vary with age, sex and size and appropriate nomograms should be consulted. Volume expired in the rst second is the forced fusion or alter the balance between them. Correction must be made for haemoglobin concen- Relaxed (slow) vital capacity may provide a better tration, because transfer factor varies directly with measure of trapped gas volume in chronic airways haemoglobin. Metabolic abnormalities including acute A scheme for examination of the abdomen is shown in diabeticketoacidosisandchronichypercalcaemiamay Fig. Look before palpation, have warm hands abdomen, careful history-taking and examination and palpate gently so as to gain the patients con- forms a vital part of the initial management. Ask the patient to let viduals withchronic disease, the historyshould dictate youknowifyouarehurtingthem. Percuss the liver and spleen areas to avoid missing Inspect the eyes and conjunctivae for the lower border of a very large liver or spleen. The upper border is in the fourth to fth intercostal Palpate for lymphadenopathy space on percussion. The liver may be of normal size but low because of hyperinated lungs in chronic obstructive airway Abnormal masses disease. Palpate for abnormal masses particularly in the epigastrium (gastric carcinoma) and suprapubic Spleen region (bladder distension, ovarian and uterine. The spleen enlarges diagonally downward and monly palpable in the left iliac fossa. Check for ascites: examine for shifting dullness by patient lying on the right side with the left leg exed noting a change in percussion note with the patient and abducted. Consider Paracentesis may occasionally be required for the reliefofseveresymptoms;repeatedparacentesisleads.

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