1. The jaundice syndrome.

Definition and classification

Jaundice is a yellowish pigmentation of the skin, the conjunctival membranes over
the sclerae (whites of the eyes), and other mucous membranes caused
by hyperbilirubinemia (increased levels of bilirubin in the blood). It is detectable
clinically when the serum bilirubin is greater then 50µmol/L.
There are many causes of jaundice. A simple anatomical classification is into:

 pre-hepatic causes- The pathology is occurring prior to the liver

 hepatic causes- The pathology is located within the liver.
 post-hepatic causes- The pathology is located after the conjugation of bilirubin in the
liver

However, alternative classifications are often used, particularly into causes based on
serum bilirubin changes:

 predominantly unconjugated hyperbilirubinaemia

 predominantly conjugated hyperbilirubinaemia

the symptom that is associated most frequently associated with jaundice or cholestasis is itching, ,
medically known as pruritus. It is the disease causing the jaundice that causes most problems
associated with jaundice.

2. The prehepatic jaundice .definition.causes. symptoms and signs

Jaundice in these cases is caused by rapid increase in the breakdown and destruction of the red blood
cells (hemolysis), overwhelming the liver's ability to adequately remove the increased levels of
bilirubin from the blood.

Examples of conditions with increased breakdown of red blood cells include:

malaria, sickle cell crisis, spherocytosis, thalassemia, glucose-6-phosphate dehydrogenase deficiency

(G6PD), drugs or other toxins, and autoimmune disorders

In haemolytic states the patients have a pale yellow colour to the skin and sclera (anemic look).
Total bilirubin= normal/increased
Unconjugated Bilirubin= increased
Conjugated Bilirubin in urine= not present
Urobilinogen= increased
Urine and Stool colour= Normal

3. The hepatic jaundice .definition.causes. symptoms and signs

Hepatocellular (hepatic) jaundice can be caused by acute or
chronic hepatitis, hepatotoxicity, cirrhosis and alcoholic liver disease. Cell necrosis reduces the
liver's ability to metabolize and excrete bilirubin leading to a buildup of unconjugated bilirubin in the
 blood. Other causes include primary biliary cirrhosis leading to an increase in plasma conjugated
bilirubin because there is impairment of excretion of conjugated bilirubin into the bile. The blood
contains abnormally raised amount of conjugated bilirubin and bile salts which are excreted in the
urine.
In hepatocellular and obstructive jaundice the skin and sclera are much darker due to excess of
unconjugated bilirubin, they may become orange or greenish in colour.
Total bilirubin= increased
Unconjugated Bilirubin= increased
Conjugated Bilirubin in urine= increased
Urobilinogen= increased
Urine colour= Dark
Stool colour= Normal

4. The posthepatic jaundice .definition.causes. symptoms and signs

Post-hepatic jaundice, also called obstructive jaundice, is caused by an interruption to the drainage
of bile in the biliary system. The most common causes are gallstones in the common bile duct,
and pancreatic cancer in the head of the pancreas. Also, a group of parasites known as "liver flukes" can
live in the common bile duct, causing obstructive jaundice.
In hepatocellular and obstructive jaundice the skin and sclera are much darker due to excess of
unconjugated bilirubin, they may become orange or greenish in colour.
Total bilirubin= increased
Unconjugated Bilirubin= Normal
Conjugated Bilirubin in urine= increased
Urobilinogen= Decreased
Urine colour= Dark
Stool colour= Pale

5. The hepatomegaly. Definition and causes.

Hepatomegaly is the condition of having an enlarged liver. It is a nonspecific medical sign having many
causes, which can broadly be broken down into infection, direct toxicity, hepatic tumours, or metabolic
disorder. Often, hepatomegaly will present as an abdominal mass.
The lower edge of the liver normally comes just to the lower edge of the ribs on the right side. The edge of
the liver is normally thin and firm. It cannot be felt with the fingertips below the edge of the ribs, except
when you take a deep breath. It may be enlarged if a health care provider can feel it in this area.
The liver is involved in many of the body's functions. It is affected by many conditions that can cause
hepatomegaly, including:
Alcohol use, Congestive heart failure, Glycogen storage disease, Hepatitis A, Hepatitis B, Hepatitis C,
Hepatocellular carcinoma, Niemann-Pick disease

6. The ascites causes, symptoms and signs.

Ascites term for an accumulation of fluid in the peritoneal cavity. Although most commonly due to
cirrhosis and severe liver disease can also be caused by heart failure, nephrotic syndrome, pancreatitis,
cancer.
Mild ascites is hard to notice, but severe ascites leads to abdominal distension. Patients with ascites
generally will complain of progressive abdominal heaviness and pressure as well as shortness of
breath due to mechanical impingement on the diaphragm.
Cirrhosis or fibrosis of the liver patients may also complain of leg swelling,
bruising, gynecomastia, hematemesis, or mental changes due to encephalopathy. Those with ascites due
to cancer may complain of chronic fatigue or weight loss. Those with ascites due to heart failure may also
complain of shortness of breath as well as wheezing and exercise intolerance.

7. The diarrhea. Definition and medical causes.

Diarrhea is an increase in the volume, wateriness or frequency of bowel movements. Diarrhea is defined
by the World Health Organization as having 3 or more loose or liquid stools per day, or as having more
stools than is normal for that person.
It occurs when not enough water is removed from the stool, making the stool loose and poorly formed. It
is often associated with gas, cramping and an urgency to deficate, if caused by infectious disease also
nausea and vomiting.
If large amounts of fluids and electrolytes are lost the person feels weak, blood pressure can drope
causing fainting, arrhythmias and other serious disorders.
Causes can be drugs and chemicals, infection with (viruses, bacteria, parasites), foodstuff, stress, tumours,
chronic disorders (irritable bowel syndrome, inflammatory bowel disease, malabsorption syndromes)

8. Symptoms and signs in acute intestinal obstruction.

In obstruction of the small bowel: abdominal cramps around the umbilicus and epigastrium, vomiting and
in complete obstruction a severe constipation (obstipation). In partial obstruction diarrhea can occur and
severe, steady pain suggests strangulation. Shock and oliguria can be present in in simple obstruction or
strangulation. Hyperactive, high-pitched peristalsis with rushes and cramps is typical.

In obstruction of the large bowel: Usually causes milder symptoms that develop more gradually then in
small bowel obstruction. Lower abdominal cramps unproductive of feces occur.

9. Symptoms and signs in acute appendicitis.

The classic symptoms are epigastric or periumbilical pain followed by brief nausea, vomiting and
anorexia. After a few hours the pain shifts to the right lower quadrant. Pain increases with cough and
motion. Urinary frequency and dysuria occur if the appendix lies adjacent to the bladder.
The signs are right lower quadrant direct and rebound tenderness locates at Mcburneys point.

10. Mitral stenosis:Physical examination of the heart.Auscultatory

Mitral stenosis is associated with four auscultatory findings: loud S1, loud P2 (part of S2), an opening
snap, and a diastolic murmur. Only the murmur is consistent. The loudness of S1 and S2 are affected by
 the patient’s body habitus, valve mobility, and pulmonary artery pressure. The still mobile mitral valve
that has been damaged by rheumatic fever creates a high frequency sound in early diastole. You can hear
the opening snap near the cardiac apex, but more easily appreciate it along the lower left sternal border.
As the severity of mitral stenosis increases, left atrial pressure rises. Rising left atrial pressure results in
mitral valve opening at earlier time points along the decline of left ventricular pressure during relaxation.
Therefore, the time from aortic valve closure sound to opening snap (often referred to as the A2-OS)
offers us a method for estimating the severity of the disease.

11. Mitral stenosis .Complications

Mitral stenosis is the narrowing of the mitral orifice wich disturbs the free circulation of blood from the
left atrium to the left ventricle.
Congestive heart failue: when the heart is weakened and cant pump enough blood to meet the body needs
Heart enlargement: mitral stenosis weakens the heart by damaging the left atrium.
Atrial fibrillation: heart rhythm irregularity due to stretching and enlargement of the heart
Blood clots: the atrial fibrillation can lead to blood clot formation in the left atrium.
Lung congestion: called pulmonary oedema due to blood and fluid backing up into the lungs.

12. Causes of mitral regurgitation

Organic: destructive lesion of the mitral valve.

Functional: dilatation of the ventricular myocardium and of the mitral orifice.
Mitral valve prolapsed: when the leaflets and supporting cords of the mitral valve weakens.
Damaged cords: damage to the cords that anchor the flaps of the mitral valve to the heart.
Rheumatic fever (accounts for 1/3) and endocarditis
Prior heart attack: heart attack can damage the area of the heart muscle supporting the mitral valve.
Congenital heart disease: some are born with a leaky mitral valve.
Detoriation of valve with age: occurs in some people after middle age.

13. Aortic valve regurgitation . Signs and Symptoms

Aortic regurgitation is when the valve between the left ventricle and the aorta doesn’t close tightly causing
blood pumped out of the heart to leak back into the heart.
Irregular heartbeats. Shortness of breath during effort and sometimes without any effort. Dyspnoea is a late
symptom followed by cardiac failure. Fatigue especially during effort.
Insufficient blood supply causing chest pain, low blood pressure causing fainting. Swollen feet and ankles.
Pulsation in head and neck with sometimes pulsating headache. Auricular noises.
Some peripheral signs are: Mussets, Fredrich-Muller, Traube, Durozier.
14. Pulmonary edema. Symptoms and signs.
Pulmonary edema is the accumulation of fluid in the lungs. It can be cardiogenic or noncardiogenic.
Cardiogenic pulmonary edema: Cardiac abnormalities that lead to an increase in pulmonary venous
pressure causes the hydrostatic pressure to increase and fluid exits the capillary at an increased rate resulting
in an interstitial or worse alveolar edema.
Noncardiogenic pulmonary edema: The hydrostatic pressure is normal but the lung water increases due to
damage of the pulmonary capillary lining.
Patients with alveolar edema are acutely breathless, wheezing anxious and perspiring profusely. They also
have a cough productive of frothy, blood-tinged (pink) sputum, which can be copious. The patient is
tachypnoeic with peripheral circulatory shutdown. There is tachycardia, a raised venous pressure and a
gallop rhythm. Crackles and wheezes are heard throughout the chest.

15. Thrombophlebitis. Symptoms and signs

Thrombophlebitis occurs when a blod clot causes inflammation in one or more of the veins, typically in the
legs but also occurring in the arms or neck. The affected vein may be near the surface of the skin causing
superficial thrombophlebitis or deep within a muscle causing deep vein thrombosis.
Warmth, tenderness and pain in the affected area. Redness and swelling. The pain occurs standing up and
disappears lying down. Homans maneuver (dorsal flexion of foot) produces pain in the calf and pain in
popliteal fossa in thrombophlebitis of the shank veins. Other manifestations tachycardia, Mahlers sign
(climbing pulse), Anxiety. The patient may also have fever.
Many people with deep vein thrombosis have no symptoms.

16. Differential diagnosis angina vs. myocardial infarction

Angina Myocardial infarction

Pain: mild or moderate intensity usually high intensity
Anxiety: absent or mild high
Duration: less than 20 min 20-30 min
Relief: nitrates and rest nope
precipitated by exercise or emotion patient has sensation of empending death
17. Atrial fibrillation. Description and ECG Criteria
There is chaotic atrial activity at high frequency (400-600 bpm). There is little or no mechanical activity of
the atria and few of the beats are conducted by the atrioventricular node, so the ventricular response is
totally irregular and may be slow or as rapid as 200 bpm.
The pulse is “irregularly irregular” on palpation and the ECG has absent P waves, wich are replaced by
irregular waves (f waves). The QRS rhythm is rapid and irregular. Untreated the ventricular rate is usually
120-180 per minute.

18. Diseases occurs more often in women

Diseases occur in women at a higher frequency. For example, gallstones are three to four times more
common in women than in men. migraine headaches, a ratio of three females to one male. Other conditions
which plague women more often than men include irritable bowel syndrome and urinary tract infections.
Urinary tract infections, including cystitis(bladder infection) and kidney infection(pyelonephritis) are
significant health problems that especially affect women. Kidney disease is a leading cause of high blood
pressure (hypertension). And, after age 50, hypertension is more common in women than in men meaning
also cardiovascular diseases.
Also more common in women than men are the autoimmune disorders (for example,multiple
sclerosis, Sjogren's syndrome, and lupus.
Osteoporosis, a condition in which bone density decreases, occurs in both men and women. Overall,
however, it is more of a major health concern for women. More women than men suffer eating disorders
(anorexia, bulimia etc). Also higher rate of depression.

19. Diseases occurs more often in men

Men are more prone to cancer especially prostate cancer, esophageal cancer, lip & throat cancer, lung
cancer and urinary bladder cancer. Liver cancer and liver disease is more likely to occur in men because
men tend to drink and smoke more. Men are twice as likely to develop liver cancer than women.
Alzheimers disease usually affect men more than women.

20. Diseases occurs exclusively in females

Conditions that affect women only. Conditions that have an effect on the uterus and vagina.
Conditions like uterine cancer, uterine polyp, uterine prolapse, Disorders with occurring during
pregnancy, ectopic pregnancy. Genetic disorders like Turners syndrome causing infertility. Pelvic
inflammatory disease causing infections of the uterus and the fallopian tubes.
21. Diseases occurs exclusively in males
Obviously, any condition affecting the male genitals are male-only conditions simply because these organs
are only found in males. Some examples are erectile dysfunction and premature ejaculation. Other
diseases are testicular cancer and cancer of penis. Hypospadias (whole under) or Epispadias (whole
over) the normal opening of the urethra, these are congenital diseases. Gynecomastia is the
development of breasts in men due to hormonal imbalance. Alport's Syndrome this is another
hereditary disease that only affects males. In this disorder, men will have an inflammation in the
capillaries within their kidneys, which is referred to as glomerulonephritis.

22. Influence of place of birth and residence

Age-adjusted mortality from cardiovascular diseases--and from ischemic heart disease, cerebrovascular
disease and hypertension-related disease--according to birthplace were estimated residents who came from
Eastern Europe, Sub-Saharan Africa and South Asia had a higher risk of mortality from most of the
cardiovascular diseases analysed. Women from North Africa and the Caribbean also had a higher risk of
cardiovascular mortality. A higher risk of mortality from ischemic heart disease was observed in persons
from the Middle East, and from cerebrovascular disease in those from Eastern Asia.
Rotavirus: Rotavirus is the most common cause of viral gastroenteritis worldwide. It kills more than
600,000 children each year, mostly in developing countries.
Shigellosis: Shigella infection causes an estimated 600,000 deaths worldwide every year. It is most
common in developing countries with poor sanitation.
Malaria: Malaria is a mosquito-borne disease that affects more than 500 million people annually, causing
between 1 and 3 million deaths. It is most common in tropical and subtropical climates and is found in 90
countries—but 90% of all cases are found in Sub-Saharan Africa.
Cryptosporidiosis: Cryptosporidiosis has become one of the most common causes of waterborne disease in
the United States in recent years; it is also found throughout the rest of the world
Japanese Encephalitis: Japanese encephalitis is a mosquito-borne disease endemic in Asia. Around 50,000
cases occur each year; 25% to 30% of all cases are fatal.

23. Illness caused by profession

Occupational lung diseases include asbestosis among asbestos miners and those who work with friable
asbestos insulation, as well as black lung (coalworker's pneumoconiosis) among coal miners, and
byssinosis among workers in parts of the cotton textile industry. Occupational asthma has a vast number
of occupations at risk.
Bad indoor air quality may predispose for diseases in the lungs as well as in other parts of the body.
Occupational skin diseases and conditions are generally caused by chemicals and having wet hands for long
periods while at work. Eczema is by far the most common, but urticaria, sunburn and skin cancer are also of
concern.
High-risk occupations include: Hairdressing, Catering, Healthcare, Printing, Metal machining, Motor
vehicle repair, Construction.
Carpal tunnel syndrome among persons who work in the poultry industry and information technology.
Lead poisoning affecting workers in many industries that processed or employed lead or lead compounds

24. Hereditary transmitted diseases

Is genetically determined illness transmitted from parent to child.
Huntington's Disease This hereditary disease is the result of a gene abnormality on
chromosome 4, where too much of a specific genetic code has been repeated. Persons with
Huntington's gradually develop writhing muscular movements, a change in behavior,
irritability, antisocial behavior, dementia and then depression.
AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE In this disorder, large cysts
develop in both kidneys, causing them to enlarge.
Marfan syndrome is a genetically transmitted disease in which a gene mutation leads to
abnormalities in the skeletal and cardiovascular systems as well as in the eyes.
Hemophilia is a hereditary disease that affects only males. It is caused by a decreased amount
of a substance called factor 8, which is needed for blood to clot.
Alport's Syndrome This is another hereditary disease that only affects males. In this disorder,
men will have an inflammation in the capillaries within their kidneys, which is referred to as
glomerulonephritis.

25. Transmitted dominant autosomal hereditary disease:

Only one mutated copy of the gene will be necessary for a person to be affected by an autosomal dominant
disorder. Each affected person usually has one affected parent. There is a 50% chance that a child will
inherit the mutated gene. Examples of this type of disorder are Huntington's disease, neurofibromatosis type
1, neurofibromatosis type 2, Marfan syndrome, hereditary nonpolyposis colorectal cancer, and hereditary
multiple exostoses, which is a highly penetrant autosomal dominant disorder.

26. Autosomal recessive hereditary disease transmitted

Two copies of the gene must be mutated for a person to be affected by an autosomal recessive disorder. An
affected person usually has unaffected parents who each carry a single copy of the mutated gene (and are
referred to as carriers). Two unaffected people who each carry one copy of the mutated gene have a 25%
chance with each pregnancy of having a child affected by the disorder. Examples of this type of disorder
are cystic fibrosis,sickle-cell disease, Tay-Sachs disease, Niemann-Pick disease, spinal muscular atrophy,
and Roberts syndrome.

27. Transmission of a hereditary predispositions

Genes are sections or segments of DNA that are carried on the chromosomes and determine specific human
characteristics, such as height or hair color. Because each parent gives you one chromosome in each pair,
you have two of every gene (except for some of the genes on the X and Y chromosomes in boys because
boys have only one of each) In many cases, a single defective gene is not sufficient to cause a disorder. Yet
many of the common diseases of adult life, such as diabetes mellitus, hypertension, schizophrenia, and most
common congenital malformations, such as cleft lip, cleft palate, neural tube defects, have a strong genetic
component to their occurrence. In these examples it is thought that a large number of genes each act in a
small but significant manner to predispose an individual to the genetic condition. Polygenic genetic
disorders are those which are caused by the impact of many different genes, each having only a small
individual impact on the final condition. Multifactorial traits are those which result from an interaction
between multiple genes and often multiple environmental factors.

28. Congenital diseases .definition.Ex

It is a disease or disorder that exists at birth, it can exist before birth and it may or may not be genetically
transmitted.
Congenital heart disease in babies is one of the common diseases and the number of children taking birth
with heart defects is increasing day by day. The congenital heart diseases occur due to underdevelopment of
heart or blood vessels near the heart. Sometimes, incomplete formation of the right or left side of the heart
causes severe heart related problems. The babies can be born with one ventricle with aorta and pulmonary
artery arising from the same ventricle.
Congenital Anemia is a common disease among the newborn babies and results from blood defects.
Inadequate production of RBCs or excessive destruction of RBCs or low level of healthy red blood cells
causes several kinds of complications in the babies.
Spina Bifida is a severe birth defect, which develops due incomplete growth of the spinal cord or the
coverings of the spinal cord. When the tissue surrounding the developing spinal cord of a fetus does not
close properly, it leads to Spina Bifida.
Cleft lip and palate is one of the most common birth defects in babies. The cleft lip and palate results when
the tissues forming the roof of the mouth and upper lip do not join before birth.
Congenital genetic disorders result from genetic abnormalities

29. Physiological personal history in women

Physiological history: information about the patient history of health and his habits.
History of presenting complaint
Past history: childhood illnesses, adult illnesses (medical, surgical, gynecological, psychiatric), health
maintenance (immunization, scrrening tests, life style issues etc), family history, personal and social history
(education, job, personal interests, lifestyle etc)
30. Pathological personal history Acute infectious diseases

Acute infections usually last a short time, but they can make you feel very uncomfortable, with signs and
symptoms such as tiredness, achiness, coughing. Acute appendicitis, Acute pancreatitis, Acute bronchitis,
Acute bacterial prostatitis, Acute rheumatic fever.
Important to identify data about the person and the source of history (parents, family etc). The chief
complaint(s) the symptoms making the patient seek care. The onset and duration of the illness including
developed symptoms. childhood illnesses, adult illnesses (medical, surgical, gynecological, psychiatric),
health maintenance (immunization, scrrening tests, life style issues etc), family history.

31. Present disease history. Debut .Ex

Amplify the chief complaints: describes how every symptom developed, when it started etc.
Includes patient’s thoughts and feelings about the disease.
Pulls in relevant portions of the review of the bodies different systems.
May include medications, allergies, habits of smoking and alcohol which are frequently pertinent to the
present illnes.

32. Conditions of Living and Working. Food

These diseases include heart disease, high blood pressure, stroke, some types of cancer, and diabetes.
Eating a diet that contains 5 to 9 servings of fruits and vegetables a day as part of a healthy, active lifestyle
lowers the risk for all of these diseases. Everyone has some degree of risk for developing diet-related
chronic diseases, and this risk increases with age. Lifestyle factors that contribute to increased risk for these
diseases include not eating enough fruits and vegetables, eating too many foods high in saturated fats (fried
foods, full-fat dairy products, fatty cuts of meat) and not getting enough exercise. Some food linked
diseases:
Calcium lower osteoporosis
Fiber increase cancer
Fruits, vegetables, lower cancer
Fiber lower coronary heart disease
Fat increase cancer
Saturated fat, cholesterol, increase coronary heart disease
Sodium increase hypertension

33. Conditions of Living and Working. Smokinng

Cancer
Best known, was lung cancer. However, it is now known that smoking is related to cancers in many parts of
the body including the: throat, mouth, larynx (voice box), oesophagus, lung, kidney, bladder, pancreas,
stomach, blood (leukaemia) and cervix.
Diseases of the Cardiovascular System
Cigarette smoking causes atherosclerosis - the hardening and narrowing of the arteries.
Diseases of the Respiratory System
The lungs of smokers are likely to become damaged. Damage of the lung tissue can lead to diseases such as
emphysema, which reduce the capacity of the lungs to extract oxygen from the air we breathe
Smoking and Pregnancy
Smoking affects every stage of the reproductive cycle.
Smoking harms your health in other ways. By suppressing your immune system you are more likely
to suffer from other diseases and infections

34. Conditions of Living and Working. Alcool intake

Excessive drinking both in the form of heavy drinking or binge drinking, is associated with numerous
health problems, including—
Damage to the central nervous system and peripheral nervous system can occur from chronic alcohol abuse

Chronic diseases such as liver cirrhosis (damage to liver cells); pancreatitis (inflammation of the pancreas);
various cancers, including liver, mouth, throat, larynx (the voice box), and esophagus; high blood pressure;
and psychological disorders.

Unintentional injuries, such as motor-vehicle traffic crashes, falls, drowning, burns and firearm injuries.

Violence, such as child maltreatment, homicide, and suicide.

Harm to a developing fetus if a woman drinks while pregnant, such as fetal alcohol spectrum disorders.

 Sudden infant death syndrome (SIDS).

 Alcohol abuse or dependence.

35. The percussion. The analysis criteria of the percussion sounds

Percussion is a method of tapping on a surface to determine the underlying structure and is used in clinical
examinations to assess the condition of thorax and abdomen.
In cardiac percussion the cardiac dullness often occupies a large area. Starting well to the left on the chest,
percuss from resonance toward cardiac dullness in the 3rd, 4th, 5th and possibly 6th intercostals space.
In percussion of the abdomen you will assess the amount and distribution of gas in the abdomen and
identify possible masses that are solid or fluid filled. It’s used to estimate the size of liver and spleen.
Note that any large area of dullness might indicate an underlying mass or enlarged organ. Percuss the lower
anterior chest, between lungs above and costal margins below. On the right, you will usually find the
dullness of the liver and on the left, the tympany thatoverlies the gastric air bubble and splenic flexure of the
colon.
In percussion of the posterior chest place your pleximeter finger firmly using the same percussion
technique in both areas. Percuss or strike twice in each location to more easily detect differences in
percussion. Percuss one side of the posterior chest and then the other at each level in a ladder-like pattern.
In percussion of the anterior chest you have to percuss the anterior and lateral chest, again comparing
both sides. The heart normally produces an area of dullness to the left of the sternum from the 3rd to the 5th
interspaces. Percuss the lung lateral to it. Dullness replaces resonance in accumulation of large amounts of
fluid or solid tissues in lung or pleural spaces.

36. Enlargement of lymph nodes and spleen

Lymphadenopathy. This is a condition where the lymph nodes become swollen or enlarged, usually
because of a nearby infection. Swollen lymph nodes in the neck, for example, can be caused by a throat
infection. Once the infection is treated, the swelling usually goes away. If several lymph node groups
throughout the body are swollen, that can indicate a more serious disease that needs further investigation by
a doctor. It could be due to infection, auto-immune disease, or malignancy.
Splenomegaly (enlarged spleen >12 cm). In healthy people, the spleen is usually small enough that it can't
be felt when you press on the abdomen. But certain diseases can cause the spleen to swell to several times
its normal size. Usually, this is due to a viral infection, such as mononucleosis. But in some cases, more
serious diseases such as cancer can cause it to expand. Splenomegaly is usually associated with increased
workload (such as in hemolytic anemias), which suggests that it is a response to hyperfunction. It is
therefore not surprising that splenomegaly is associated with any disease process that involves abnormal red
blood cells being destroyed in the spleen. Other common causes include congestion due to portal
hypertension and infiltration by leukemias and lymphomas. Doctors usually tell someone with an enlarged
spleen to avoid contact sports like football for a while because a swollen spleen is vulnerable to rupturing
(bursting). And if it ruptures, it can cause a huge amount of blood loss.

37. Alteration in nervous function

The symptoms of a nervous system problem depend on which area of the nervous system is involved and
what is causing the problem. Nervous system problems may occur slowly and cause a gradual loss of
function (degenerative), or they may occur suddenly and cause life-threatening problems (acute).
Symptoms may be mild or severe. Some serious conditions, diseases, and injuries that can cause nervous
system problems include:
Blood supply problems (vascular disorders).
Injuries (trauma), especially injuries to the head and spinal cord.

Problems that are present at birth (congenital).

Mental health problems, such as anxiety disorders , depression , or psychosis .

Exposure to toxins, such as carbon monoxide, arsenic, or lead.
 Problems that cause a gradual loss of function (degenerative). Examples include:
o Parkinson's disease .
o Multiple sclerosis (MS) .
o Alzheimer's disease .
o Huntington's disease .
Infections. These may occur in the:

Brain (encephalitis or abscesses ).

Membrane surrounding the brain and spinal cord (meningitis ).
 Overuse of or withdrawal from prescription and non-prescription medicines, illegal drugs , or
alcohol.
 A brain tumour .
Organ system failure.

Nutritional deficiencies, such as vitamin B1 (thiamine) or vitamin B12 deficiency.

38. Alteration in respiratory function Data connected with age

Data connected with age:
 In childhood, acute infections of the respiratory airways are more frequent;
 Tuberculosis is more frequent with teenagers (the first bacillary infection);
 Bronchic asthma, bronchiectasia, chronic bronchitis, pneumonia, bronchopulmonary cancer are
more frequent with adults;
 Pulmonary emphysema, bronchopulmonary cancer, bronchopneumonia are more frequent with the
elderly.

39. Alteration in respiratory function .Data connected with sex

Chronic bronchitis, bronchiectasia, pulmonary emphysema, broncho-pulmonary cancer are more

frequent in men.
Bronchic asthma, pulmonary embolism (secondary to thrombophlebitis), tuberculosis are more

frequent in women.

40. Alteration in respiratory function Data connected with profession

Pneumoconiosis is more frequent with miners. Silicosis and silicotuberculosis are more frequent
with people working in cement factories.
 Bronchitis, bronchic asthma and pneumoconiosis are more frequent with people working in textile
industry.
Respiratory diseases are more frequent with people working in glass industry, with furnace
workers and with people working in agriculture.
 Professional exposure to azbest can favorise pulmonary fibrosis.
 Instrumental musicians are more exposed to empysema.

41. Chest pains. Vertebro-medular causes

. Vertebro-medular causes
- Vertebral tuberculosis (Pott’s disease)
- Spine cancer (progressive pain), osteomyelitis; spondylosis
- Hernia of an intervertebral disc (compression of the nerve in the conjugation hole)
- Tabes (chronic luetical meningitis involving the posterior root of the spinal nerves with painful
crisis)
-

42. Chest pains. Repiratory causes

- Dry pleurisy or pleuritis: lancinating, sharp, unilateral pleuritic pain which is felt over the involved
area.
- Pleural effusion: the patient will lay down on the involved side to permit the uninvolved side to
have an more amplified inhaling.
- Purulent pleurisy: violent pleuritic pain and a very sensitive hemithorax. The patient will lay
down on the opposite side.
- Diaphragmatic pleurisy: very violent pleuritic pain, sometimes unbearable, located at the
diaphragmatic-costal insertion and affecting the intercostal and the phrenic nerve; sometimes the
pain can radiate in the abdomen;
phrenic neuralgia is characterized by hyper sensitivity when pressing the following areas:
- scalen spot (between the 2 sternocleidomastoidian ends)
- parasternal points
- diaphragmatic button (at the junction of the middle of the breast bone with the
extension of the tenth rib)
- Interlobal pleurisy: chest pain along the lung cleavage (scarf pain)
- Pneumothorax: very violent, dagger-like sensation, associated with anxiety, cyanosis, dyspneea,
weak and frequent pulse, diminished vesicular sounds and characteristic modifications on the
chest x ray.
- Lobal pneumonia: localised in the nipple region, lasting 2-3 days and then disappearing;
 - Pulmonary embolism: strong, violent pain, like a dagger, dyspneea, cough, cyanosis, tachycardia,
lypothymia and syncope.
- Pulmonary cancer: progressive pain, which in advanced stages becomes unbearable, doesn’t
respond to common medication; the site depends on the size and location of the tumor and on its
relation to the sensitive nerves.
- Pancoast – Tobias syndrome (syndrome of the pulmonary peak):
 malignant tumor of the lung apex which infiltrates the nervous plexues and the large
vessels.
 asthenia, anorexia, subfeverishness, dry cough, hemoptysis, cyanosis
 it can be associated with Claude Bernard- Horner Syndrome (enophtalmia, miosis
resulting from cervical sympathic compression).

43. The respiratory rhythm. Accelerating rhythm

- physiological (emotions, physical exercise)

- pathological
a) feverish conditions when the high temperature of the circulating blood excites
the respiratory centers
b) diseases which lead to a decrease in the amplitude of respiratory movement
(intercostal neuralgies, costal fractures, cifoscoliosis, respiratory muscles paralysis)
c) diseases which lead to a decrease of the lung’s breathing area (pulmonary
embolism, pulmonary edema, pleural effusions, pneumonia, pulmonary tumors)
d) large bleedings, CO intoxication
e) diseases of the cardio-vascular system
f) intraabdominal processes that limit the diaphragmatic excursions (ascites,
tumors)

44. The respiratory rhythm Bradypnoea.causes

It may be:- inhaling, exhaling, mixed .
a) Inhaling bradypnoea: decrease in the upper respiratory ways calibre, leading to obstructive
ventilatory disturbances.
Causes
- internal obstacles: the vocal cordes paresis, croup, pseudocroup, glotic oedema, laryngeal
tumours.
- external compression: neighbouring tumours, mediastinal tumours
b) Exhaling bradypneea - an obstacle stops the evacuation of the intrapulmonary air, creating a whistling
sound called wheezing.
Causes : - bronchic asthma in crisis
- chronic obstructive pulmonary disease (chronic bronchitis and pulmonary emphysema).
c) Mixed bradypneea: tracheal disorders (tumors).

45. Dyspnoea with disordered respiratory movements

a) Cheyne-Stokes breathing
- respiration with a progressive increased frequency; a superficial breathing which goes to a maximum
limit, then the respiratory movements progressively thin out to a complete apneea of 5 - 20 seconds, after
that the cycle is repeated.
b) Kussmaul breathing
- deep and noisy breathing with a frequency of 9 – 10 breathings per minute, followed by apneea
- causes: agony, diabetic acidosis, uremic and hepatic coma, methanol intoxication.
Biot breathing
- irregular type of breathing
- irregular and unpredictable rate, rhythm, and depth, usually slow rate
- causes: agony, cerebral tumours, meningitis, vascular diseases that affect the respiratory center.

46. Cough
The coughing reflex
- is a normal defense mechanism of the lungs that protects them from foreign bodies and excessive
secretions.
- has the following components: starting point, centripetal ways, centers, centrifugal ways.
Coughing can be:
 productive of sputum because of hypersecretion:
- in acute tracheo- bronchitis, broncho-pneumonia and pneumonia, bronchiectasia,
tuberculosis, abcesses.
 dry coughing: it is a cough without expectoration with a different timbre. It appears in laryngitis,
in the early stages of acute bronchitis or tuberculosis, pneumothorax, mediastinal tumors,
pulmonary cancer, pleuritis, foreign bodies.
Slow cough, progressive in adults and elderly is believed to result from intrabronhial tumors.
 The methalic – like timbre and very noisy cough results from irritation or paralysis of reccurent
nerve.
 Emetizant coughing – a very intense cough, that triggers the vomiting reflex appears in whooping
cough, severe tuberculosis.
  In pulmonary infarction - rebel cough, productive of adherent, viscous sputum with hemopthysis.
 Epiglottal diseases cause barking - like cough.

The sputum has a great diagnostical value:

 Rusty, brownish sputum appears in lobal pneumonia.
 Cranberry jelly - like sputum appears in the pulmonary cancer.
 Rich, purullent sputum appears in bronchiectasia.
 Fetid sputum appears in pulmonary abscess and gangrene.
Macroscopically we describe the quantiy, aspect, colour, smell.
a) The quantity depends on the nature of the pathological process, the evolution of the disease, the
intensity of the cough and the efficiency of the treatment.

47. The physical examination of the respiratory system. .The Attitude

 In pleuritis the patient takes the position of contralateral decubitus – antalgic position.
 In pleurisy the patient takes the position of homolateral decubitus – antidyspneeal position.
 In bronchic asthma, acute pulmonary edema, massive pneumothorax, the patient takes the ortopneea
position
 In bronchiectasia, the patient will lay on the same side as the bronchial dilatation thing which will
disfavour the secretions drainage to the coughing areas - an anticoughing position,
 patients suffering from dyspneea caused by respiratory diseases, present a modification in
mobility determined by the severity of the dyspneea:
- in case of moderate dyspneea the patient will move normaly.
- in case of severe dyspneea there appears a breathing uneasiness at the slightest movement.

48. The physical examination of the respiratory system.The facies

 vultuos facies - in pneumonia the facies is of a strong red colour, with shining eyes because of the
fever.
 the doll face (phtysical beauty) - in tuberculosis - pale face and red cheeks, which is more
accentuated on the tuberculose lung side.
 a pale face with an earth - like hue in pulmonary suppuration (bronchiectasia, pulmonary
abcess, pulmonary gangrene).
 infants suffering from bronchopneumonia - the beating of the nasal wings.
 inequality of pupils in malignant tumor of the pulmonary apex.
 cyanotic, bloated face with raincoat edema in superior vena cava compression syndrome
(compression by a mediastinal tumour, important
49. . The physical examination of the respiratory system The Psychic
Mood ???????
 generalised cyanosis of central type - obstructions of the upper or lower respiratory ways, pleuro-
pulmonary pathologic processes which reduce the ventilation area
 localised cyanosis of peripheral type – in patients experiencing compressive mediastinal process
 red-violet coloured skin, especially on the face – in chronic sufferings such as emphysema,
pulmonary sclerosis with secondary polyglobulia
 paleness after severe hemophysis
 eruptions that can be linked to respiratory diseases:
- labium herpes appears frequently in pneumonia
- erythema nodosum – hypodemic nodules of red violet colour, located exclusivelly on
the shank, with pressure sensitivity; they appear in sarcoidosis, primo-infection tuberculosis

Clubbing fingers are present in the following respiratory diseases:

 pulmonary tuberculosis
 broncho pulmonary cancer
 bronchiectasia
 pulmonary supuration, pulmonary sclerosis
 empyema

50. The physical examination of the respiratory system. The Subcutaneous

Cellular Tissue.
generalised edema (anasarca) appears in cardiopathy, nephrotic syndromes; liquid is present also in
the pleural cavity - hydrothorax.
raincoat edema appears in the obstructions of the superior vena cava by an expanding mediastinal
process
Quincke edema and bronchic asthma are both allergic processes in which the target organ is
different.
In Quincke edema the target is on the tegumentary and subcutaneous cellular tissue, while in bronchic
asthma it is at the bronchiole level.
This is why there appear allergic symptoms.

51. The physical examination of the respiratory system The Ganglions

A physical examination is generally sufficient for diagnosing a ganglion cyst. A doctor may also order
imaging tests such as an X-ray, ultrasound, or magnetic resonance imaging (MRI) in order to learn more
about the characteristics of the cyst and to rule out conditions such as arthritis and malignant tumors.
Confirmation of a ganglion cyst also may be aided by aspiration - when a doctor uses a syringe to gather
fluid from inside the cyst.

52. The physical examination of the respiratory system Collateral Circulation

 Collateral circulation: raincoat edema secondary to superior vena cava obstruction is associated with
superficial circulation (venectasia) on the anterior and lateral side of thorax, especially in the superior area.

53. The Physical Examination of the Upper Respiratory Ways . The nostrils The
nasal voice The sinus
The nostrils:
The most important thing to be observed is the nasal obstruction. The patients will breath orally, this
being a very important aspect, because the air is warmed and purified in the nose.
The nasal voice:
In order to determine the obstruction examiners ask the patient to breathe nasally while pressing
alternatively the nostrils. The nature of the obstacle will be determined with the nasal speculum.
The sinuses:
They can be the source of an inflammation which may result in a frontal headache. It is termed
sinusitis. If vivid sensitive reaction results when pressure is applied, acute sinusitis is suggested.

54. The Physical Examination of the Trachea

It is accessible only in the first segment.
The palpation:
The examiner is situated in front of the patient; he introduces his finger in the jugular fosseta and he
palpates the tracheal rings in order to identify them and to determine their consistency and the
position of the trachea.
The pleural pulmonary pathologic processes can deviate the trachea.
The timus pushes the trachea on the opposite side.
The adherences pull the trachea on the same side

55. The Physical Examination of the Thorax Attitude . nutritional state; the
colour of the skin and facies; oedema.)
1. INSPECTION
  Teguments for colour, scars of previous heart or lung surgery; swellings, marks and spots on the
skin (eruptions, collateral circulation, edema)
 Thorax conformation (normal, deformed)
 Respiratory type
 The frequency and amplitude of the respiratory movements
 Modification of the thorax during respiration
Thoracic teguments examination
- vesicles in the intercostal area suggests zona zoster.
- tiny vein dilatation on the top of the thorax in pulmonary peaks tuberculosis.
- located edema with a bucket appears in deep suppurations (empyema).

56. The Physical Examination of the Thorax Symetrical, Bilateral Deformations

The emphysematous thorax: The thorax is dilated and rigid like a barrel (always while inhaling) with an
antero-posterior diameter bigger or equal to the transversal one; The ribs are horizontal, the supra and
subclavicular areas protrude; Xyphoid angle is larger than ninety degrees, and the respiratory movements
are very weak.
The paralytic thorax: The antero-posterior diameter is smaller than the transversal one; The xyphoid angle
is under ninety degrees, the supra/subclavicular areas are deepened. Most of the cases are congenital, but it
can be secondary to tuberculosis.
The conoid thorax: The lower part of the thorax is very dilated due to a hepato or splenomegaly or an
ascitis.
The adenopatic thorax: The ganglion growth results in the dilatation of the upper part of the thorax.
Pectus excavatum (funnel chest) = localized depression of the lower end of the sternum or depression of the
whole length of the sternum.
Pectus carinatum (pigeon chest) = a localized prominence of the sternum and adjacent costal cartilages
often accompanied by indrawing of the ribs to form symmetrical horizontal grooves ('Harrison's sulci')
above the costal margin, caused by severe and poorly controlled childhood asthma, osteomalacia and
rickets.
The rickety thorax: Appears in the rickets, the sternum is protruded, the thorax seems twisted laterally;
along the sternum, thickenings develop, which are called costal rosary.

57. The Physical Examination of the Thorax Assymetrical Bilateral Deformation

 They are determined by the modifications of the vertebral column
 Kyphosis represents the curving of the column in a sagittal plan, with a forward concavity. When it is
very accentuated it is called guibus (huntch back).
Lordosis – the concavity is posterior.
Scoliosis – lateral deformation of the column.
 These modifications appear as a result of rickets, vertebral tuberculosis, vicious position of the
body in childhood.
c) Unilateral Deformations
- Retraction: pachypleuritis, massive atelectasis (the lack of air
in the thorax), extensive pulmonary fibrosis.
- Protruding or distension thorax: massive pleurisy,pneumothorax, massive intrathoracic tumors.

58. The Physical Examination of the Thorax .The

. respiratory movements
Normal:
In men the breathing is performed using the lower part of the thorax and the abdomen.
In women the respiration is performed using the upper part of the thorax.
Pathological:
Men breathe with the upper thorax in case of the existance of pleuro-pulmonary processes of
the basis (pleurisy, pneumonia) or abdominal tumours, ascitis, uni/bilateral diaphragmal paralysis.

Women breathe with the lower side of the thorax in case of pathological processes that interest the
upper part of the thorax or in rib fractures at this level.
The frequency and amplitude of the respiratory movements
Normal – both hemithorax participate simetrically, equal to the respiratory movements.
- frequency: 16-18 resp/min
- the amplitude depends on frequency (low when high frequency and viceversa)
Pathological:
- amplitude is reduced - bilateral in the case of bilateral pulmonary emphysema.
- unilateral if a main bronchi is obstructed and the lung does not
receive air, pachypleuritis, massive pleural collections, intercostal neuralgia
Modification of the thorax during respiration
Expansion during exhaling : general expansion in emphysema
localised expansion – empyema in which the pus creates a fistula and
passes in the subcutaneous tissue during exhaling
Retraction during inhaling (supraclavicular fossae, intercostal spaces, suprasternal and epigastric
area).
 Extreme increases in inspiratory work of breathing - negative pleural pressure: may be manifested by
inspiratory retraction of the suprasternal or supraclavicular notches or the intercostal spaces.

59. The Physical Examination of the Thorax .The

. percussion of the respiratory
system
 The percussion of the respiratory system consists of provoking vibrations in organs and tissues by the
repeated knocking on the surface of the body in order to estimate on acoustic basis the physical condition of
the organs.
 The last one used a digital-digital percussion (the indirect method), in which one of the fingers acts as a
pleximeter and the other one acts as a hammer.
The obtained sounds must be analysed taking into account the following: intensity, tonality, timbre.
 Percussion over a structure containing air within a tissue, such as the lung, produces a resonant, high
amplitude, lower pitched note.
 Percussion over a solid organ, such as the liver, produces a dull, low-amplitude, short duration note
sound without resonance.
 Percussion over a hollow air-containing structure, such as the stomach, produces a tympanic, high-
pitched, hollow-quality note.
Technique:
- the examiner places the middle finger of one hand firmly
against the patient’s chest wall, parallel to the ribs in an intercostal space
- the tip of the right middle finger of the other hand strikes a quick, sharp blow on the left finger on the
chest wall.
- the motion of the striking finger should come from the wrist and not from the elbow.
Percussion can be: a). Comparative
b). Topographical
a). The percussion of several anterior and posterior symmetric areas
b). The delimitation by percussion of two different organs. (e. g. the inferior side of the lung from the liver,
the inner side of the lung form the spleen).
The inferior limits of the pulmonary resonance (5 - 6 - 6 - 7 - 10)
- parasternal, the superior edge of the 5th rib;
- medioclavicular, the inferior limit of the 6th rib;
- axillar, the 7th rib;
- posterior, the 10th spinal vertebra
On the right it leaves space for the hepatic dullness, while on the left, from the 4th rib to the 6th, the
pulmonary resonance is replaced by cardiac dullness.
From the 6th rib downwards, the stomach is situated and there a tympanic sound will be obtained.
Laterally, on the left side, from the 9th rib down, the spleen dullness is situated.
Percussion is also used to detect diaphragmatic movement. The patient is asked to take a deep breath and
hold it. Percussion at the right lung base helps determine the lowest area of resonance, which represents the
lowest level of the diaphragm.
Below this level is dullness from the liver. The patient is then instructed to exhale as much as possible, and
the percussion is repeated.
With expiration, the lung contracts, the liver moves up, and the same area becomes dull; that is, the level of
dullness moves upward.

60. Pulmonary resonance

 The maximum intensity is on the anterior side, in the 2 – 3 intercostal areas.
 At the percussion of the breast bone, a resonant sound can be heard in the superior third part. The
breast bone acts here as pleximeter.
Pulmonary resonance is closely linked with:
- the physical condition of the vibrating organ or of the tissue.
- the shape and the resilience of the thorax (infants show a more intense pulmonary resonance than
adults do)
- the quantity and the pressure of the pulmonary air and the extension of the surface vibrating by
means of the power of the percussion.
For example: at moderate percussion there is a surface of 2 - 5 cm vibrating and 5 - 7 cm depth.
This means that there will be discovered by percussion those pleuro-pulmonary lesions that are
accessible as depth and those that influence the quantity or the pressure of the intrapulmonary air.

61. The percussion of the thorax

Percussion can be: a). Comparative
b). Topographical
a). The percussion of several anterior and posterior symmetric areas
b). The delimitation by percussion of two different organs. (e. g. the inferior side of the lung from the
liver, the inner side of the lung form the spleen).
The inferior limits of the pulmonary resonance (5 - 6 - 6 - 7 - 10)
- parasternal, the superior edge of the 5th rib;
- medioclavicular, the inferior limit of the 6th rib;
- axillar, the 7th rib;
- posterior, the 10th spinal vertebra
 On the right it leaves space for the hepatic dullness, while on the left, from the 4th rib to the 6th, the
pulmonary resonance is replaced by cardiac dullness.
From the 6th rib downwards, the stomach is situated and there a tympanic sound will be obtained.
Laterally, on the left side, from the 9th rib down, the spleen dullness is situated.
Percussion is also used to detect diaphragmatic movement. The patient is asked to take a deep breath
and hold it. Percussion at the right lung base helps determine the lowest area of resonance, which
represents the lowest level of the diaphragm.
Below this level is dullness from the liver. The patient is then instructed to exhale as much as
possible, and the percussion is repeated.
With expiration, the lung contracts, the liver moves up, and the same area becomes dull; that is, the
level of dullness moves upward.

62. The added sounds

They can appear in alveolas, bronchi or pulmonary excavations and are called rales (wheezes and crackles).
Others appear in the pleural cavity and they are called pleural rub.
The rales
 They prove the presence of a pathological secretion moved by the air flow.
 They are perceived better if the patient breathes orally.
 They are influenced by coughing.
 There are two types of rales: dry rales and humid rales.
Dry rales (wheezes)
- Caused by the presence of a viscous secretion in the bronchi
- These secretions create endobronchial strictures, which generate sonorous rales as the air passes
throw them.
- There are 2 types of dry rales:
-  The rales in the bronchi with a big calibre have lower tonality. They are called
monophonic rales (wheezes). They resemble snoring sounds.
-  The rales in the bronchi with a small calibre have a sharper tonality. They are called
polyphonic rales (wheezes) and they resemble the sound of the wind blowing.
- The dry rales can be auscultated in both phases of respiration.
- During inhaling the first rales heard are the monophonic ones, than the polyphonic.
- During exhaling, the order is viceversa.
- They appear in: -acute bronchitis
- -chronic bronchitis
 - -bronhic asthma
- -bronchiectasia

63. Humid rales (crackles): crepitations, bubbling crackles, cavernous

crackles .Defination.Caracters
Humid rales (crackles)
1. Crepitations
- sounds similar with those resulting from salt thrown in the fire.
- they can be reproduced: a tress of hair rubbed near the ear pavilion.
- are determined by a viscid secretion adherent to the alveolar walls
- the air enters the alveolus at the end of inhaling phase, it suddenly relaxes the alveolar walls and
generates crepitations.
- they can be heard better after coughing
- they can be heard only while inhaling
Crepitations are present in:

 lobal pneumonia:
- the crackles which appear in the first phase are called inducing crepitations
- the crackles which appear in the resorbtion phase of pneumonia are called returning
crepitations
2. Bubbling crackles.

 humid rales which resemble the crepitations but they are

bigger, inequal, discontinuous, and are heard during both respiration phases.
they are very mobile and they modify between two examinations
 determined by a liquid secretion moved by the inhaled air
 they sound like blowing in a glass of water with a straw.
There appear air bubbles.
 three types of bubbling crackles (depending on the calibre of the bronchi ):
thick crackles
middle crackles
smooth crackles (they are also called subcrepitant rales and they resemble the classical
crackles with the difference that they can be heard in both respiratory phases) .
The subcrepitant crackles appear in
acute pulmonary edema
bronchiolitis
bronchopneumonia
 lobal pneumonia
3. The Cavernous Rales.
- are generated by the presence of a liquid in a cavity which communicates widely with the drainage
bronchi.
- they can be perceived during both respiratory phases
- present in :
cavitary tuberculosis
pulmonary absses
evacuated hydatic cyst
bronchiectasia

64. Definition.The Pleural Rub. Characteristics

In case of pleuritis, a layer of fibrine covers the pleura resulting in a rough surface. The rub between parietal
and visceral pleura in dry pleurisy leads to a rub noise which resembles the rubbing of a piece of leather or
of silk.
Characteristics:
- discontinuity, intermittence
- circumscribed surface
- it can be heard during both respiratory phases, but it is heard better during inhaling.
- it becomes more ample if the patient breathes deeply
- it is not modified by coughing, allowing a differential diagnosis from rales
- it is modified in case of pressure with the stethoscope

65. The semiology of the renal system Anamnesis Age.

Age. On new-borns or in the first years of life there can be present the external malformations of the urinary
system: phimosis: the congenital contraction of the preputial ring; epispadias (exstrophy): the opening of the
urethra on the dorsal side of the penis, hypospadias: the opening of the on the ventral side of the penis.
On child prevail the congenital malformations, renal malformations, congenital hydronephrosis which
facilitates the urinary ascending infections. With maximum frequency in childhood is encountered the acute
glomerulonephritis secondary poststreptococcal to the increased incidence of the anginas with
streptococcus β-hemolytic and of the scarlet fever; it is rare under the age of five years and to the matures.
On adolescents the beginning of the sexual activity exposes to the apparition of the venereal urethral
infections, the most frequent being the gonococcic or nongonococcal urethritis, bacterial, fungal or
trichomoniasis which can evolve with complications: precocious (prostatitis on boys, metroannexitis on
girls); tardy (urethral cicatricial strictures); the clinic manifestations of the polycystic kidney; urinary
lithiasis; ascending urinary infections (cystitis, cystopyelitis); renal tuberculosis, chronic
glomerulonephritis; obstructive uropathies.

66. The semiology of the renal system .Anamnesis

. Sex
Sex. On men – acute diffuse glomerulonephritis is more frequent and is because of the hyperanabolisant
protidic effect of the adrogens and the forming of the antibodies.
On women the anatomical particularities of the female genitourinary system – short urethra – allows the
ascending access of the germs resulting from the level of the vulva and vagina, the pregnancy favors the
minor stasis, and the postabortum cand appear the acute renal insufficiency which has as a cause the toxico-
septic shock. On women, regardless of the age the chronic pyelonephritis is the most frequent cause of the

chronic renal insufficiency.

67. The semiology of the renal system .Anamnesis

. Place of birth and residence
The balkan nephropathy – the endemic tubulointerstitial nephritis – is spread in the balkan area, and the
etiology it seems to be given by the silicates (mineral water), cadmium and rather a toxine connected with
the physical environment.

68. The semiology of the renal system .Anamnesis

. Renal pathological heredity
being known as the autosomal remittance dominant in: polycystic kidney, Alport syndrome (the family
hemorrhage nephritis and hereditary with deafness); renal acidosis of distal type; hereditary osteodystrophy;
renal glycosuria; glycinuria; hyperprolinemia.
Through autosomal recessive remittance are present the following diseases:
cystinosis and the medulo-cystic disease.
The renal diseases correlated with anomalies of the X chromosome are:diabetes insipidus; Fabry disease
(diamino-phosphatidic thesaurismosis); Lowe syndrome (oculocerebrorenal syndrome); hypophosphatemic
rickets vitamin D resistant.
There is the possibility of remittance of the anomalies of form and seat of the kidneys such as: renal
agenesy; supranumerary kidney; ectopic kidney; molecular enzymatic dysplasias.

69. The semiology of the renal system .Anamnesis

. The personal physiologic
antecedents Acute infectious antecedents
Acute infectious antecedents: streptococcal anginas with streptococcus β-hemolytic A-12 favors the
continuous or intermittent penetration into the general circulation clamping at the level of the glomerular
capillaries andothelium and after a period of latency variable between 10-21 days determines the forming of
specific Ac; at glomerular level is produced a reaction Ag-Ac which produce the lesions characteristic for
the nephritis; scarlet fever, erysipelas, flu, staphylococci, septicemias, acute viral hepatitis, leptospirosis,
acute articulary rheumatism, endocarditis, rickettsias.

70. The semiology of the renal system .Anamnesis

. The personal physiologic
antecedents .Chronic infectious antecedents
can concern the renal system, from which the most encountered are: syphilis, tuberculosis (determines
bacillary nephropathy), colibacillosis accompanied by constipation (enterorenal syndrome) and chronic
angiocolitis are etiological factors of the nephropathies, infections of tonsilous centre, dental, sinousal,
othical representing a peculiar nephropathogen potential.

71. The semiology of the renal system .Anamnesis

. The personal physiologic
antecedents .Cardio-vascular antecedents
in evolution can affect the renal system through multiple mechanisms:
arterial hypertension (HTA) determines nephroangiosclerosis and chronic renal insuf
valvulopathies, such as mitral stenosis can produce renal embolism, renal infarct
artherosclerosis favors the development of the plaques of atheroma, stenosant, on one or both of the renal
arteries;
the congestive cardiac insufficiency can lead to acute renal insufficiency.

72. The semiology of the renal system .Anamnesis

. The personal physiologic
antecedents .Digestive antecedents
acutegastroenterocolitis, malabsorption syndrome, syndrome of the gastric evacuatory insufficiency,
intestinal occlusion can determine hypovolemias and severe dyselectrolytemias which can provoke acute
renal insufficiency. The chronic constipation favors the infections with E. Coli realizing the enterorenal
syndrome described by Heitz-Boyer.
The administration of nestheroidian antiinflammatories on diseased with hepatic cirrhosis can determine
the interstitial nephritie. Chronic hepatitis especially with C virus are accompanied by glomerulonephrities
and have on base an immune mechanism.

73. The semiology of the renal system .Anamnesis

. Work and life conditions
The workers who work on high temperatures blast furnace men, steel workers through the physic sustained
effort in conditions of high temperature, through the abundant perspirations lead to disorders of the
hydroelectrolytic equilibrium with extracellular dehydration which favors the disorder of the renal function
and the apparition of the renal acute functional insufficiency characterized by oliguria and the increment of
the sanguine urea.
The cold shortens the period of latency of the nephrities producing severe forms such as ”a frigore”
nephritis, ”nephritis of campaign”.
In the etiology of the nephropathies also intervene sometimes henogen factors such as mercury, plumbum,
phosphorus, gold salts, toxic endogen factors, acidosis states, degradation products of the intestinal
putrefaction as well as some medicines which lead to iatrogenic nephropathies.
Analgetic abuse especially the phenacetin as well as the sulphamids, barbiturates administered in high
dozes intervene in the genesis of some acute or chronic renal tubulo-intestinal lesions. The usage of the
tuberculostatics such as riphampicine can lead to the apparition of the renal acute insufficiency.
Among the favoring alimentary factors of the renal lithiasis there are the hypercalcic foods (milk, cheese
foods), foods rich in purines (chocolate) and the foods rich in oxalates (tomatoes, spinach).

74. The semiology of the renal system .Symptoms

. of local category .The pain,
The renal colic.
Pain is the most characteristic and frequent symptom of the renal pathology the prototype being represented
by the renal colic.
The renal colic or the nephritic colic is defined as a violent pain with sudden debut, more frequently
nocturnal under the form of a paroxistic attack as a stroke of a dagger localised in one of the lumbar
regions. The pain irradiates typically on the ureter’s tract, involving the illiac fossa, the inguinal region, the
small pelvis, the external genital organs and the antero-internal part of the thigh (fig. 17). On men in colic,
the testicle is retracted and sensitive to palpation. Sometimes the irradiation of the pain is atypical and is
localised on the line of the sciatic nerve. The starting mechanism of the renal colic is represented by the
stretching or swelling of the superior calyx urinary passages, renal pelvis and especially, of the ureters,
secondary to an obstacle in the trickling of the urine, that can be of mechanic type (calcule, clot) or
functional (spasm).

75. The physical examination of the renal system Disorders in urine emission
Pollakiuria
Pollakiuria – defines frequent urinations in small quantity and recognizes the following causes:
cystitis, tonus disorders and the reduction of the capacity of the urinary bladder, the tuberculosis of
 the urinary bladder, bladder neoplasm, diabetes mellitus, diabetes insipidus, adjacency affections,
pelvic inflammations, uterine tumours, renal colic, urethritis.

76. The physical examination of the renal system Painful urination

is characterized by urinations accompanied by pains located hypogastric or ureteral. Depending on the
moment of the pain apparition during the urination act this can be: initial – at the beginning of the urination
is characteristic for the prostate adenoma, posterior urethtritis; final – at the end of the urination under the
form of tenesmi which collaps once with the emission of the last urine drops, it is encountered in the
cystitis; total – throughout the urination encountered in urethrities (gonococcic) or the urethral polyposia;
posturination – in the pericyctitis.
The painful urination is associated sometimes by the pollakiuria, the peremptorily sensation to urinate,
dysuria

77. The physical examination of the renal system. Urine retention

The incapacity of the urinary bladder to empty its content defines the urine retention. It can be complete or
incomplete, and it can settle suddenly and intermittent (acute retention) or permanent (chronic retention).

78. The physical examination of the renal system Dysuria

Dysuria represents the difficult urination accompanied or not by pains, the urinations beign prolonged with
slow trickling, irregular.
Dysuria can be: initial, complete or final and can have the following causes: bladder (bladder tumours,
bladder calcules); extrabladder (pelvic tumours, medullar lesions); sub-bladder obstacles (prostate
adenoma, prostate cancer).

79. The physical examination of the renal system Nycturia.

Nycturia. The normal report between diurnal diuresis and the nocturnal is of 3:1, the equalisation or the
inversion of this report defines the nycturia, the diseased being awakened from sleep by the necessity to
urinate. The nycturia is a precocious symptom of the cardiac in sufficiency. Other causes of the nycturia are:
the tuberculous cystitis, prostate adenoma, renal hypertensive sclerosis, renal insufficiency which produces
the renal nycturia in which we encounter polyuria with low density, psychogene causes on diseased with
neuro-vegetative dystonia.

80. Disorders of the diuresis

In physiologic conditions, the urinary volume on 24 h is between 100-1500 ml, and the number of the
urinations per day is of 3-6, the urine being eliminated without effort and with a specific density which
variates between 1017-1025.
The urine volume depends on the volume of the liquids ingested and of the quantity of liquids eliminated
on other ways (tegumentous, respiratory system, on digestive level). The urinary volume oscilates in wide
limits, so that the increased contribution of liquids determines the increment of the diuresis, while the
decrement of the hydric contribution diminishes the diuresis. The disorders of the diuresis can appear under
three forms: polyuria, oliguria, anuria.

81. polyuria.Definitation;Causes
defines the elimination of a volume of over 200 ml urine/24 h and is produced through the next
mechanisms: increment of the glomerular filtrate. physiologic polyuria: through large contribution of
liquids, contribution of diuretic aliments, ”a frigore”, on positive or negative emotions; pathological
polyuria: in prolonged feverish states, after epileptic attacks, induced iatrogenic (cardiotonics, diuretics),
hyperthyroidism, after painful attacks (renal colic), after an episode of paroxistic tachycardia or of pectoral
angina. Another mechanism of producting the polyuria is the decrement of the tubular reabsorption of water
on the level of the proximal contorted tube, which determines consecutive osmotic diuresis. Is encountered
in: diabetes mellitus : the diuresis being of 3-6 l/24 h and is secondary to the renal elimination of glucose
active osmotic substance which determines the increased elimination of water, the polyuria being with
normal density; the diabetes insipidus: the diuresis being of 10-24 l/24 h discoloured, with low density and
is due to the defficiency of antidiuretic hormone; primary hyperparathyroidism: induced iatrogenic through
the administration of osmotic diuretics (Manitol).

82. Oliguria Definitation;Causes

defined as the reduction of the urine quantity under 500 ml emissioned over 24 hours and has on its base the
following mechanisms: the reduction of the glomerular filtrate through the reduction of the filtration area
and is encountered in the following affections: renal sclerosis, severe dehydration states, vascular collaps
with the decrement of the renal sanguine flux, cardiac insufficiency, arterial hypotension, post-hemorrhagic
states, as a reflex mechanism in the renal colic, edematous form of the nephrotic syndrome, acute and
chronic glomerulonephritis, pyelonephritis, tubulointerstitial nephropathies, uremic stage of the renal
chronic insufficiency, the specific urinary density of the urine is high (hypersthenuric).

83. Anuria Definitation;Causes

etymologically signifies the complete retrenchment of the diuresis. In reality, the anuria is defined as the
decrement of the diuresis to less than 50 ml/24 h, value which cannot assure the urinary excretion and it
characterizes the renal acute insufficiency and the terminal stages of the renal chronic insufficiency. The
bladder sondage is negative. Unlike the polyuria and oliguria, the anuria is always pathologic but it can be:
transitory (in the reversible renal acute insufficiency) or definitive (in the irreversible renal acute
insufficiency and in the terminal stages of the renal chronic insufficiency).
The installation mechanisms of the anuria are: the retrenchment of the formation of urine on renal level –
secretory anuria (real); the existance of an obstacle for the urine trickling through the urinary superior
passages to the bladder – excretory anuria; or through both mechanisms – mixed anuria.

84. The physical objective examination of the renal system The facies teguments.
atitude .renal edema
The inspection can be general and of the lumbar region. The general inspection consists in the examination
of the facies, of the teguments, of the state of the patient, of the renal edema and of the nails. The facies is
edemaciated with palpebral matutinal edemas, with the pallor of the teguments and the eyes deepened
in the sockets, the cheeks sucked in the renal insufficiency that evolves with uremia; teguments:pale
especially on patients with glomerular syndrome, soiled in renal insufficiency, lesions from scratching due
to the uremic itchiness. atitude: state of agitation in the renal colic, passive in the renal chronic
insufficiency; renal edema – white, pale, because of the anaemia coexistant with the stretched out skin,
shining, thinned, transparent and less elastic which leaves the digital print (the sign of the bucket present) is
more pronounced in the morning during the day. While it expands on the level of the shanks, the lumbar
sacral region, abdominal wall, superior limbs and it can associate with hydrothorax, hydropericard, ascites;
nails – flat, white and opaque.

85. The physical objective examination of the renal system .the

. palpation.
. Normally, the kidneys are not accessible for the palpation. On emaciated persons it can be performed the
palpation in the profound inspiration on the inferior pole of the right kidney. The kidneys can be palpated in
the following situations: renal ptosis, nephromegalies. The renal ptosis is encountered more frequently on
women and it can be of three degrees: degree I – in which is palpated only the inferior pole of the kidney in
the profound inspiration; degree II - in which is palpated the entire kidney during the inspiration; degree III
- in which the kidney is palpated in the side and iliac fossa
The renal ptosis favorises the urinary infection, as well as the calcules formation.
The nephromegalies can present causes: unilateral: superior polar renal cyst, renal neoplasm, compensatory
hyperthrophy after nephrectomy; bilateral: the polycystic kidney, hydronephrosis, pyonephrosis.We will
decide further the classic technics of palpation of the kidney used in the medical practice.
Kidneys palpation can be performed in: dorsal decubital, lateral decubital, and in orthostatism; mono-
manual or bi-manual.
86. Palpation in dorsal decubital through Guyon’s method
Palpation in dorsal decubital through Guyon’s method: Technic: the diseased is settled in dorsal decubital
with the thighes semiflected on the abdomen for the relaxation of the abdominal musculature. The examiner
placed on the side of the kidney he wants to examine; if it is to be palpated the right kidney, the examiner
puts the left hand on the lumbar region, the posterios side with the tip of the fingers pointed in the
costovertebral angle, the right hand is layed on the anterolateral wall of the right hypochondrium with the
tip of the fingers pointed under the costal paralel prominant protuberant edge with the median line. The
diseased is solicitated to inhale profoundly the examiner by the approaching of the two hands through a
„bunding” maneuver tries to catch the kidney estimating the morphologic characterers: shape, consistency,
surface, mobility, lumbar contact characteristic sign for the renal origin of a solid palpated structure in this
topographic area.

87. Palpation in Israel method

Israel method: Technic: the diseased in the lateral decubital opposed to the kidney that needs to be
examined, the examiner puts one hand at the level of the lumbar region, and the other one anteriorly at the
level of the hypochondrium and the respective side solicitating the diseased to inhale profoundly. It is tried
the palpation of the kidney the same way as in the Guyon method.

88. Palpation in Glenard method

Glenard method. Mono-manual method with the diseased in dorsal decubital with the
thighes flexed on the abdomen. The examiner with one hand grips the diseased side with
the fingers placed dorsal, and the anterior thumb under the costal prominant protuberant
edge, and the other hand is placed on the anterior side of the abdomen in order to impede
the displacement of the kidney on the median line. In the profound inhale through the
approaching of the fingers from the lumbar region to the thumb we seek to katch the
kidney.

89. Painful spots in the renal diseases

The anterior spots are: superior painful spot – subcostal or superior ureteral, is situated at the juncture of the
horizontal line which goes through the umbilic with the vertical line which goes through the Mac-Burney
point the painful sensitiveness at the level of this point signifies the affection of the renal pelvis; middle
painful spot – middle ureteral supra-interspinous situated at the juncture 1/3 middle with 1/3 external of the
horizontal line which unites the two anterosuperior iliac crests; inferior painful spot – ureteral inferior, is
perceived, only by rectal touch.
The anterior spots are sensitive to palpation in ureteral calcules and inflammations.
Posterior spots: Guyon costovertebral spot located in the angle formed by the XII rib and the spinal
column; costolumbar spot – costomuscular – situated at the level of the angle it forms the XII rib with the
lateral edge of the lumbosacral musculature.

90. The percussion: Giordano sign

Giordano sign: the percussion of the lumbar region with the cubital edge of the hand the examiner having
the fingers unfolded. The Giordano sign is present if above the percussive region determines pain and is
encountered in: pyelonephritis, acute glomerulonephritis, perirenal abscess, renal lithiasis, renal infarct. In
case of renal tumour the percussion to percussion will have auditive sensation.
The percussion of the hypogastric region can emphasize an auditive sensation area with the concavity
oriented down, in the case of the bladder globule.

91. Physical analysis of urine

Urine volume. The urine quantity eliminated in 24 h (diuresis) vary according to the liquid contribution and
is different depending on sex, therefore on men the urinary volume is between 1000-1500 ml/24 h, and on
women is between 800-1500 ml/24 h the urine quantity eliminating in 3-5 urinations, the volume of each
urination being of 250-300 ml. The report between the diurnal urinations and the nocturnal ones is of 4:1
The determination of the urinary volume is made with the help of some graduated receptacles, in which is
ingathered the entire urine quantity from 24 h.
The urinary volume can be placed in wide limits of the normal diuresis or pathologic (see polyuria, oliguria
or anuria).
. Transparency. Physiologically the urine freshly emissioned is – clear, limpid, transparent. The urine losses
its transparency if it is kept for various hours on room temperature and is due to the precipitation of certain
salts (phosphates, oxalates, carbonates ecc.). The urine by cooling (approximately 4°C), it thicks under the
form of a cloud, because of the presence of the desquamated epithelial cells from the level of the urinary
ducts.
Pathologic modifications of urine’s transparency: thick urine – the causes can be discovered with the help
of the following tests: the clearness of the urine after adding a few drops of acetic acid certifies the
presence of phosphates; thick urine because of the pus it cleares on adding the NaOH 10% solution; the
clearness of the urine through heating pleads for the presence of the urates; the clearness of the urine after
adding hydrochloric acid pleads for the presence of calcium oxalates.
Milky aspect, opalescent is encountered in: lipuria which defines the elimination of the urine by lipids and
is present in the nephrotic syndrome; the chyluria which defines the presence of the lymph in the urine
secondary to the lymphatic flux disorder because of the obturation of the lymphatic passages appears in the
renal neoplasm, retroperitoneal adenopathies.
 . Color. Physiologically the urine has a bright yellow color, it being conditioned by the presence of
some physiologic pigment of renal origin (urochrome) or of extrarenal origin (biliary pigments,
urobilin). The bigger is the volume of the urine emissioned in 24 h the brighter is the color.
 Polyuria causes: diabetes mellitus, renal sclerosis, diabetes insipidus, renal chronic insufficiency.
 The lesser is the volume of the urine emissioned in 24 h, the darker is the color.
 Oliguria causes are: feverish states, acute pyelonephrities.
 The urinary pH influences the color of the urine as follows: the acid urine has a dark color; the
alkaline urine has a bright color.
 The color of the urine is pink-red in: hemoglobinuria, hematuria, myoglobinuria, porphyria or
induced medicamentary to: picric acid, acetylsalicylic acid.
 The color of the urine is white-thick in: pyuria, crystalluria, chyluria and green – biliverdin – in
the mechanic jaundice, iatrogenically induced (reserpine, amitriptyline
 Urinary pH is comprised between 5,8-7,7 and it vary with the nourishment. On a mixed
alimentary regime the reaction is moderate acid.
 After sustained physical effort or nourishment with a meat regime, on diseased with diabetes
mellitus or gout the urine has an acid reaction, while on a vegetarian-lacteous nourishment or on
persons with gastric hyperacidity, the urine becomes alkaline.
 The chemical examination for determining the urinary acidity is performed with the help of some
quick tests that use sticks with ready prepared reactives; the pH can be determined ionometrically
and colorimetrically.

92. Urine specific density

 For the evaluation of the density (specific weight) is used the urinometer, with densitometer
sensitive to values between 1000-1040, calibrated to the temperature of 15°C. The density of the
urine variates depending on the substances dissolved (urea, glucose, chlorides) and the volume of
the diuresis, the normal limits being comprised between 1005-1023.
 The decrement of the urine density is encountered in: high liquid contribution, renal chronic
inssuficiency, chronic pyelonephritis, diabetes insipidus.
 We refer to isosthenuria when the density of the urine is of over 1010, and to hypoisosthenuria
when the urinary density is under 1010. The increment of the urinary density is encountered when
in the urine there can be found active osmotic compounds, such as: glycosuria, proteinuria.
  The hyposthenuria, isosthenuria and hypoisosthenuria are signs of renal insufficiency. The specific
density of urine evolves in reverse to the volume of the urine, therefore in the oliguria the density
increases and in the polyuria the density decreases, except the diabetes mellitus, situation in which
the polyuria is accompanied by a increased density (>1030) because of the glycosuria.

93. Proteinuria.
Proteinuria. The urine normally, does not contain, only in very low quantities proteins (approximately 2-70
mg/liter) and which cannot be emphasized by usual methods (physiologic proteinuria). Physiologically the
glomerular capillary endothelium is permeable for crystalloids and proteins with molecular weight lower
than 60.000 daltons.
In pathologic conditions in case of the increment of the glomerular permeability are eliminated high protein
quantities with molecular weight higher such as: globulines with molecular weight of 150.000-190.000
daltons; fibrinogen with molecular weight of 700.000 daltons; serine and serum albumins with molecular
weight of 70.000 daltons.
Depending on the production mechanism are distinguished three types of proteinurias: pre-renal, renal or
post-renal.

94. Pre-renal proteinuria.Definitation;causes

Pre-renal proteinuria – in which the plasmatic proteins with low molecular weight <70.000 daltons traverse
the renal filter. These are: acetosoluble ovalbumins, hemoglobin, myoglobin and is encountered in the
following affections: multiple myeloma, hepatic cirrhosis, Waldenstrom macroglobulinemia, Hodgkin
disease.

95. The renal proteinuria.Definitation;causes

The renal proteinuria (real) is produced through the following mechanisms: the increment of the
permeability of the glomerular filtrate membrane and is given by: autoimmune mechanisms and/or
infectious such as acute diffuse glomerulonephritis, chronic glomerulonephritis, nephrotic syndromes; renal
hypoxia secondary either to a general hypoxia (proteinuria of effort, proteinuria of stasis), either to a local
hypoxia (arterial hypotension, thrombosis of inferior cava); through the decrement of the tubular
reabsorption of the proteins in: tubulopathies through exogen intoxications, microbial tubulopathies,
congenital tubulopathies (Fanconi syndrome); through the increment of the diffusion process through the
filtrating membrane in: cardiac proteinuria, orthostatic, of pregnancy, of effort and of trench.
96. Postrenal proteinuria . Definitation;causes
Postrenal proteinuria (fake) is due to the presence in the urine of certain protean substances which derive
from disintegrated elements, such as seminal prostatic substances, genital, pus and is encountered in: pyuria,
cystities, pyelities, urethrities or bleeding at the level of the urinary passages (renal pelvis tumours, tumours
of the urinary bladder), the polyposis of the urinary passages, the polyposis of the urinary bladder.
There are four clinical forms of proteinuria: orthostatic, of effort, which accompany certain nervous
affections and the feverish proteinuria.

97. Hematuria . Definitation;causes

Is defined as the presence of the red cells in the urine deriving from the kidneys and from the urinary
passages situated above the anterior urethra.
In physiologic conditions through the urine are eliminated 500-1000 red cells per minute,
respectively 500.000 red cells in 24 h.
The hematuria can be: macroscopic – the urine being of red bright color or thick, sometimes it contains
blood clots; microscopic – emphasized by the quantitative dtermination of the red cells present in the urine
through the Stansfeld test (normal between 0-1 red cells/mm3) or through the Addis-Hamburger
(pathologic > 1000 erythrocytes/minute).

98. Anemia: definition and classification.

Anemia may be defined as any condition resulting from a significant decrease in the total body
erythrocyte mass. Decrease of the total blood hemoglobin concentration, the rbc count, and the hematocrit.
Therefore, a pragmatic definition of anemia is a state which exists when the hemoglobin is less than 12
g/dL or the hematocrit is less than 37 cL/L.
Different ways to classify anemias
 Size and hemoglobin content of rbc
 Mechanism of its production

Classification according to size

 macrocytic normochromic : pernicious anemia, folic acid def. and chronic liver disease
 normochromic normocytic :acute blood loss, and hemolytic anemias
 microcytic normochromic : neoplastic
 microcytic hypochromic : Fe def. thalassemia, sideroblastic anemias

Classification according to mechanism

 Blood loss acute and chronic
 Excessive destruction of rbcs
 Decreased production of rbcs
99. Glycosuria
defines the presence of the glucose in the urine. Under normal circumstances, the urine does not contain
glucose, because it reabsorbes on the level of the renal tubes.
The increment of the glycemia > 160-180 mg/100 ml determines the elimination of the glucose through the
kidneys, by the exceeding of the transport capacity of the tubular cells. The glycosuria accompanied by
glycosuria characterizes the diabetes mellitus, the most frequent cause of the glycosuria. There is glycosuria
with hyperglycemia besides the diabetes mellitus, such as hyperthyroidism, hyperplasia or
corticosuprarenal tumours, cerebral tumours, hepatic diseases.
The glycosuria without hyperglycemia appears in: renal diabetes, infectious diseases, plumbum
intoxications, atropine.
Under evolutional report, the glycosuria can be: passing (after strong emotions, in the acute coronary
accident, endocrine diseases – hyperthyroidism, Cushing disease), or permanent (diabetes mellitus, renal
diabetes).
Glycosuria can be dosed by: qualitative methods: Trommer reaction, wih reagent bandelets (clinistix,
glucotest); quantitative methods: Fehling reaction, polarimetric examinations.

100. Ketonuria
is the presence of the ketonic elements in the urine. The ketonic elements are: acetone, acetylsalicylic acid,
β-hydroxybutyric acid.
The ketonic elements are present in the urine secondary to the lipidic metabolism disorder through the
incomplete catabolysis of the fat acids and are encountered in: diabetes mellitus metabollicaly
decompensated, post prolonged, inanition, alcohol ingestion.
The ketonic elements are emphasized either by the Legal reaction which is performed by adding 5 ml of
urine, few drops of ammonia and Legal reagent. The reaction is positive if on the limit for separation the
urine from the reagent appears a violet ring, either with the help of the Ketostix bandelets which use the
same reaction and the ketonic elements can emphasize rapidly

101. Urobilinuria.
The bilirubin appears in the hyperbilirubinemia in which prevails the concerted bilirubin. The urine has a
dark color, sometimes brown. It is emphasized with Lugol reagent.
Technique: 5 ml of urine are ingathered in a sterile test-tube, over which is added Lugol iodated solution, so
that the two liquids not to mingle. The reaction is positive if on the place of separation between the two
liquids appears a green ring.
Urobilinuria appears in: hepatocellular jaundice, mechnic jaundice.
102. Renal functional exploration
Urea – the normal values of the urea are of 20-40 mg% in conditions of normal contribution and protean
metabolism, and the urinary concentration between 20-40 g in 24 h.
The increment of the urea is encountered in: hyperprotein diet, digestive hemorrhages, tissular traumas,
corticotherapy. The decrement of the urea is due to: hypoproteic diet, hepatopathies, nephrotic syndrome. In
the incipient stages of the renal insufficiency a normal serum urea does not exclude a renal functional
deficit.
 Creatinine appreciates much more correctly the renal function (in comparison to the urea), being
very little influenced by extrarenal factors. The creatinine is generated in the muscular tissue from
the transformation of the creatine The creatinine is eliminated through the urine. Normal values on
adults are of 0,5-1,2 mg%. The values are dependant on the muscular mass, on sex.
 Between the number of functional nephrons and the level of the creatinine exists a relation of
reversed proportionality, the level of the creatinine being a good indication of the quality of the
functional nephrons. Values higher than 1,5 mg% or higher than 2 mg% show important
reductions of over 30% of the mass of nephrons. In the renal chronic insufficiency the increment
of the creatinine appears precocious and is independent from the protean content of the
nourishment. The increment of the creatinine is encountered in: ketoacidosis, after the
administration of Cimetidin, Trimethoprim. The decrement of the creatinine is encountered in:
diminution of the muscular mass, cachexia.
 Uric acid has the normal plasmatic concentration of 3,5-5 mg%, and the urinary eliminations are
dependent on this concentration and on the value of the glomerular filtrate.
 The hyperuricemy represents the increment of the values of the uric acid in serum precedes the
increment of the sanguine urea and it represents a disorder of renal elimination.
 The hyperuricemy is constant and compulsory it manifests in the renal insufficiency but it can be
present also when the renal function is maintained (primeval or secondary gout, leukaemia,
septicemia, saturnism, pneumonia).
 Sanguine pH. Under pathologic conditions the acido-basic equilibrium can modify in renal
affections which evolve with renal chronic insufficiency. The kidneys have an essential role in
maintaining the sanguine pH.
 Technique: the determination of the sanguine pH can be performed through the colorimetric
method with red-phenol or through the electrometric method. The normal values of the sanguine
pH = 7,3-7,4. The renal affections are accompanied by metabolic acidosis which knows the
following mechanisms: the decrement of the glomerular filter which is accompanied by the
increment of the phosphate and sulphate anions; the disorder of the tubulous function regarding
the formation of the bicarbonates and the release of the ions of H.
103. The renal radiological and imagistical exploration
Intravenous urography. Are used hydrosoluble iodates compounds, which are rapidly and selectively
eliminated through the kidney (Odiston, Triopac). The contrast substances are harmless if there are
observed the indications and contraindications. The injection after performing the iodine sensitivity tests
the most often test being the i.v one.
Ecography. Is the most used method for reno-urethral-vesical morphologic exploration, the ecography
being non-invasive. Is a method of exploration which uses ultrasounds, without contrast substance.
Computerized tomography. The investigation can be performed with or without iodined contrast
substance intravenously administered.
Nuclear magnetic resonance. Is a complementary method to the computerized tomography, is very
expensive.
Renal scintigraphy: is performed with the help of the radioactive isotops. The renal scintigraphy with Tc-
99 offers morphologic details, it can emphasize with great accuracy the presence of renal tumours, cysts,
abscesses.

104. Renal explorationThe renal biopsy Indications

It is an invasive exploration which consists of taking samples of bioptic material, with Franklin-Silverman
needle, it can be guided ecographically or on CT.
Indications:
- acute glomerulonephritis with fast progressive evolution
- nephrotic syndrome of the adult and on child that doesn’t respond to cortisonic treatment
- lupic glomerulonephritis
- asymptomatic proteinuria
- IRC with kidneys of normal sizes
- IRA
- renal transplant

105. Renal explorationThe renal biopsy Contraindications

Contraindications of the renal puncture:
Absolute: - patient’s refusal
- hemoragipary disorders
- surgical or congenital unique kidney
- polycystic kidney
 - hydronephrosis
- cyst, abscess, renal suppuration

Relatival: - advanced renal insufficiency

- renal artery aneurysm
- obesity
- HTA
- pregnancy
- severe anaemia
- massive edemas
- fever
- perinephretic abscess.

106. The syndrome of renal acute insufficiency (IRA) Clinically

.Paraclinically
Definition: complex of clinical signs, humoral and functional renal appeared as a result of a sudden and
total interruption of the urine formation on a previously healthy kidney, with evolution potentially
reversible.
From clinical point of view, the IRA has a clinical dramatic panel determined by the sudden increment of
the sanguine urea and the decrement of the creatinine’s clearance, oliguria with diuresis less than 400
ml/day.
The renal acute insufficinecy can be oligoanuric (oliguric when the diuresis is under 400 ml, and anuric
when the diuresis is under 100 ml), or non-oliguric, with the maintaining of the diuresis.
The IRA frequence is increased and does not have connection with age or sex.
Paraclinically: - increment of the hematocrit and of the proteins
- urea/plasmatic creatinine report higher than 20
- urine: - density = 1020
- normal sediment
- osmolarity 400mosm/kg H2O
- Na urinary under 10 mEq/l
- urinary urea/ plasmatic urea = 8
- excretion fraction of the Na under 1%

107. Chest discomfort Differential diagnosis of the chest pain:Cardiac

causes
Cardiac:
Ischaemic: stable angina, acute coronary syndrome (ACS), coronary vasospasm (Prinzmetal's
angina), hypertrophic cardiomyopathy, aortic stenosis.
Non-ischaemic: arrhythmias, aortic dissection, mitral valve disease,pericarditis.

108. Chest discomfort Differential diagnosis of the chest pain Noncardiac

causes
Respiratory: pneumothorax, pulmonary embolism, pneumonia,pleurisy, lung cancer.
Musculoskeletal: costochondritis, Tietze's syndrome, trauma, rib pain (including fracture, bone
metastases, osteoporosis), radicular pain, nonspecific musculoskeletal pain (e.g. fibromyalgia).
Breast disease.
Gastrointestinal: gastro-oesophageal reflux disease (GORD),oesophageal rupture, oesophageal
spasm, peptic ulcer disease,cholecystitis, pancreatitis, gastritis.
Skin: herpes zoster infection.
Psychological, e.g. anxiety, depression, panic disorder.
Others: sickle cell crisis, diabetic mononeuritis, tabes dorsalis.

109. Angina pectoris;definitation,;causes.description

Def. It is the symptomatic manifestation of myocardial ischemia.
Car. Angina is felt in the centre of the chest. The patient localizes and indicates the pain using the open hand
or a fist rather than the finger tip. It radiates to one or both arms, to the throat or jaw, to the back or
epigastrium.
Aggravating factors: exertion, emotional excitement, excersice after meal, cold weather.
Relieving factors: rest, warm up before excersice, trinitroglycerin
Duration of pain: usually less than 10-15 min

110. Types of angina

Unstable angina: is angina of recent onset or increasing severity, duration or frequency. Can easily develop
to myocardial infarction.
Nocturnal angina: indicating severe coronary disease it may occur due to increased venous return
produced by lying down.
Crescendo angina: is an unstable angina during which attacks are progressively more frequent each day.

111. Myocardial infarction definitation,.description

Commonly known as a heart attack, results from the interruption of blood supply to a part of the
heart, causing heart cells to die aka ischemia.
The cardiac pain is much more severe and prolonged and it persists despite taking trinitroglycerin. The pain
is located back from the sternum and it radiates to arm, epigastrium and neck.
Symptoms: sweating, nausea, vomiting, restless, breathless and distress causing a sensation of impending
death. Have to make differential diagnosis with gastrointestinal disease.
Diabetic patients and elderly may be dealing with painless or silent myocardial infarction.

112. Pericardial pain

The pain is localized on the back side of the sternum and it may radiate to left shoulder or back. It is
intensified by: respiration, exertion and changes in posture
relieved by: analgesics, non-steroidal anti-inflammatory drugs (NSAIDs)
The pain may be preceded by a viral illness. Pericardial rub may be present, it is an audible medical
sign used in the diagnosis of pericarditis

113. Aortic aneurysm dissection

It causes a very severe chest pain of sudden onset that is located in central chest area and radiating to the
back. It is sometimes associated with ECG changes, associated with autonomic symptoms such as sweating
and may cause syncope ( loss of consciousness) or focal neurological symptoms.
It is also accompanied by: hypertension, asymmetric pulses and bradycardia.

114. Breathlessness
Dyspnea, shortness of breat or air hunger is the subjective symptom of breathlessness. It is an abnormal
awareness of breathlessness. Left ventricular failure causes dyspnea due to edema of the lungs making the
lungs stiff thus increasing the respiratory effort.
Tachypnea (rapid breathing) is also present due to stimulation of pulmonary stretch receptors.
There are several types of dyspnea:
Exertion dyspnea-(in heart diseases) breathlessness sensation which appears at physical efforts which were
previously tolerated.
Dyspnea at rest
Paroxysmal nocturnal dyspnea
Acute pulmonary edema

115. Orthopnea and paroxysmal nocturnal dyspnea

orthopnoea is shortness of breath (dyspnea) which occurs when lying flat, causing the person to have to
sleep propped up in bed or sitting in a chair. Orthopnea is found when heart failure is advanced and rarely
occurs in the absence of dyspnea on effort. Lying flat increases venous return to the heart and in patients
with a failing left ventricle it may precipitate the pulmonary venous return and pulmonary edema.
Paroxysmal nocturnal dyspnea is a form of orthopnea that should be differentiated vs nocturnal asthma. It
is often described like suffocation while the patient gets out of bed. The patients open the window to relieve
the distress. It has associated cough producing frothy sputum wich may be streaked with blood.

116. Palpitations
Palpitations is an increased awareness of the normal heart beat or the sensation of slow rapid or irregular
heart rhythms. It is the sensation of the heart beating in the chest often used terms: thumping, jumping,
racing, pounding, fluttering and skipping a beat.
The normal heart beat: sensed in anxiety, excitement and exercise.
Premature beats: felt by a patient as a pause followed by a forceful beat with a sensation of the palpations
fading away.
Bradycardia: may be appreciated as slow regular or forceful beats.
Palpitation may be due to heightened awareness of the heart beating in sinus rythm, irregularities of the
heart, extra systoles or another arrhythmia.

117. syncope.definitation. causes

Syncope is the medical term for fainting described as a transient loss of consciousness due
to inadequate cerebral blood floow.
Causes: arrhythmia (tachycardia, profound bradycardia), aortic stenosis, pulmonary
stenosis, pulmonary embolism

118. Peripheral oedema. Causes of oedema

Peripheral edema is the swelling of tissues, usually in the lower limbs, due to the accumulation of fluids.
Heart failure results from salt and water retention due to inadequate renal perfusion an consequent
activation of the rennin angiotensin aldesteron system.
Causes:
Bilateral: heart failure, low blood protein level, thiamine deficiency, inferior vena cava obstruction, chronic
venous insufficiency
Unilateral: trauma, soft tissue infection, deep vein thrombosis, hemiplegia (paralysis of body parts)

119. Family history Past history ???????????????????????

Family history- Documents of specific illnesses in family, such as hypertension, coronary artery disease
etc.
- Outlines or diagrams age and health, or age and cause of death, of siblings, parents or grandparents.
In case of heart disease- many cardiac disorders have a genetic component: Marfans syndrome, type 2
diabetes, hypertension, ischemic heart disease etc.
Past history- Lists childhood illnesses (rheumatic fever, heart murmur)
- Lists adult illnesses in 4 catagories (medical, surgical, obstetric/gynecologic and psychiatric)
-Includes health maintenance practice such as immunizations, screening tests, life style issues etc.
The presence of- diabetes mellitus, obesity, thyrotoxicity, glomerulo nephritis is frequent in cardiovascular
disease. Infective endocarditis in dental work or bacteraemia.
Artherosclerosis more frequent in men and also cardiovascular diseases but after menopause the
cardiovascular diseases are equal for the women because of no more hormone protection.

120. Breathlessness,Syncope and dizziness

Dizziness is a term that is often used to describe two different symptoms: lightheadedness and vertigo.
Light-headedness is a feeling like you might faint. Vertigo is a feeling that you are spinning or moving, or
that the world is spinning around you.
Light-headedness occurs when your brain does not get enough blood. This may occur if:

 You have a sudden drop in blood pressure

 Your body does not have enough water (is dehydrated) because of vomiting, diarrhea, fever, and
other conditions
 You get up too quickly after sitting or lying down (this is more common in older people)

Light-headedness may also occur if you have the flu, low blood sugar, a cold, or allergies.

More serious conditions that can lead to light-headedness include:

 Heart problems, such as a heart attack or abnormal heart beat

 Stroke
 Bleeding inside the body
 Shock (extreme drop in blood pressure)

Vertigo may be due to:

  Benign positional vertigo, a spinning feeling that occurs when you move your head
 Labyrinthitis, a viral infection of the inner ear that usually follows a cold or flu
 Meniere's disease, a common inner ear problem

Other causes of lightheadedness or vertigo may include:

 Use of certain medications

 Stroke
 Multiple sclerosis
 Seizures
 Brain tumor
 Bleeding in the brain

121. Central cyanosis ;Definition.Causes

Cyanosis is the abnormal blue discoloration of the skin and mucous membranes, caused by an increase in
the deoxygenated haemoglobin level to above 5 g/dL. Patients with anaemia do not develop cyanosis until
the oxygen saturation (SaO2) has fallen to lower levels than for patients with normal haemoglobin levels,
and patients withpolycythaemia develop cyanosis at higher oxygen saturation levels.1Cyanosis can be
divided into either central or peripheral.
Central cyanosis:
Central cyanosis is caused by diseases of the heart or lungs, or abnormal haemoglobin
(methaemoglobinaemia or sulfhaemoglobinaemia).
Cyanosis is seen in the tongue and lips and is due to desaturation of central arterial blood resulting
from cardiac and respiratory disorders associated with shunting of deoxygenated venous blood into
the systemic circulation.
Patients who are centrally cyanosed will usually also be peripherally cyanosed.
Associated features of central cyanosis depend on the underlying cause and include dyspnoea and
tachypnoea, secondary polycythaemia, and bluish or purple discolouration of the oral mucous
membranes, fingers and toes. The hands and feet are usually normal temperature or warm, but not
cold unless there is an associated poor peripheral circulation.

122. Peripheral cyanosis Definition.Causes

Peripheral cyanosis:
Peripheral cyanosis is caused by decreased local circulation and increased extraction of oxygen in the
peripheral tissues.
Isolated peripheral cyanosis occurs in conditions associated with peripheral vasoconstriction and stasis of
blood in the extremities, leading to increased peripheral oxygen extraction, e.g. congestiveheart failure,
circulatory shock, exposure to cold temperatures and abnormalities of the peripheral circulation.
Features of peripheral cyanosis therefore include peripheral vasoconstriction and bluish or purple
discoloration of the affected area, which is usually cold. Peripheral cyanosis is most intense in nail beds and
may resolve with gentle warming of the extremity. The mucous membranes of the oral cavity are usually
spared.

123. Paleness Definition.Causes

Paleness (pallor in Latin) is abnormal loss of color from normal skin or mucous membranes due
to reduced amount of the blood in the skin arteries.
Causes: Anemia (blood loss, poor nutrition, or underlying disease), Shock, Frostbite, Chronic diseases
including infection and cancer, eating disorders, hypoglycemia etc.

124. The facies in cardiac failure

Although facial swelling may be seen with heart failure, other causes should in general be considered
(such low protein states or facial inflammation).Facial engorgement, pulsation in the neck
and face (tricuspid regurgitation), paleness.

Left-sided failure
Common respiratory signs are tachypnea and increased work of breathing. Rales or crackles throughout the
lung fields suggest the development of pulmonary edema. Cyanosis which suggests severe hypoxemia, is a
late sign of extremely severe pulmonary edema.

Additional signs indicating left ventricular failure include a laterally displaced apex beat (which occurs if
the heart is enlarged) and a gallop rhythm (additional heart sounds) may be heard as a marker of increased
blood flow, or increased intra-cardiac pressure. Heart murmurs may indicate the presence of valvular heart
disease.

Right-sided failure
Physical examination can reveal pitting peripheral edema, ascites, and hepatomegaly. Jugular venous
pressure is frequently assessed as a marker of fluid status, which can be accentuated by
eliciting hepatojugular reflux.

125. Murmurs .characters.intensity.iradiation.location

Murmurs are pathologic heart sounds that are produced as a result of turbulent blood flow that is sufficient
to produce audible noise. Most murmurs can only be heard with the assistance of
a stethoscope ("on auscultation").

A functional murmur or "physiologic murmur" is a heart murmur that is primarily due to physiologic
conditions outside the heart, as opposed to structural defects in the heart itself.

Murmurs can be classified by seven different characteristics: timing, shape, location, radiation, intensity,
pitch and quality.
 Timing refers to whether the murmur is a systolic or diastolic murmur.
 Shape refers to the intensity over time; murmurs can be crescendo, decrescendo or crescendo-
decrescendo.
 Location refers to where the heart murmur is usually auscultated best. There are six places on the
anterior chest to listen for heart murmurs; each of the locations roughly corresponds to a specific part
of the heart. The first five of the six locations are adjacent to the sternum. The six locations are:
 the 2nd right intercostal space
 the 2nd to 5th left intercostal spaces
 the 5th left mid-clavicular intercostal space.
 Radiation refers to where the sound of the murmur radiates. The general rule of thumb is that the
sound radiates in the direction of the blood flow.
 Intensity refers to the loudness of the murmur, and is graded on a scale from 0-6/6.
 Pitch can be low, medium or high and is determined by whether it can be auscultated best with the
bell or diaphragm of a stethoscope.
 Quality refers to unusual characteristics of a murmur, such
as blowing, harsh, rumbling or musical.

126. Blood pressure Definition.Causes

The pressure exerted by the blood against the walls of the blood vessels, especially the arteries. It varies
with the strength of the heartbeat, the elasticity of the arterial walls, the volume and viscosity of the blood,
and a person's health, age, and physical condition.
Physical exercise causes very major effects on the circulation. Due to the enormously increased blood flow
through the exercising muscle, the amount of blood pumped by the heart may increase four-fold, or in elite
athletes as much as six-fold.
Emotional stress can cause quite large increases in blood pressure. Prominent amongst the physiological
responses to stress is an increase in activity in the sympathetic nerves.
Postural changes exert stresses on the cardiovascular system requiring effective reflex responses to
constrict arteries and veins and stimulate the heart, to control blood pressure, maintain brain blood flow, and
prevent loss of consciousness.
Straining (the Valsalva manoeuvre) induces large and complex variations in blood pressure. The sort of
stresses that induce these changes include blowing against a resistance, lifting heavy objects, and straining
at stool.

127. Blood pressure classification

Classification of blood pressure for adults

 Category systolic, mmHg diastolic, mmHg

Hypotension < 90 < 60

Desirable 90–119 60–79

Prehypertension 120–139 or 80–89

Stage 1 Hypertension 140–159 or 90–99

Stage 2 Hypertension 160–179 or 100–119

Hypertensive Crisis ≥ 180 or ≥ 120

128. Secondary hypertension Causes

Secondary hypertension is a type of hypertension which by definition is caused by an identifiable

underlying secondary cause.
A number of conditions can cause secondary hypertension. These include:

Diabetes complications (diabetic nephropathy), Polycystic kidney disease, Glomerular disease,

Renovascular hypertension, Cushing's syndrome, Aldosteronism. Thyroid problems,
Hyperparathyroidism, Coarctation of the aorta. Sleep apnea. Obesity, Pregnancy, Medications and
supplements, Tumours.

129. Causes of secondary hypertension reno-parenchimatouse diseases:

Renal parenchymal disease is the most common cause of secondary hypertension (excluding obesity and
alcohol abuse), and is responsible for 2-5% of all cases of hypertension.
Causes: glomerular nephropathies, diabetic nephropathy, obstructive nephropathy, polycystic kidney,
tumours secrete rennin etc.
Renal parenchymal hypertension most probably represents the combined interactions of multiple
independent mechanisms: potential factors include impaired sodium handling leading to volume expansion,
perturbations of the renin-angiotensin system, alterations in endogenous vasodepressor compounds, and
possibly increased activity of vasoactive substances.

130. Causes of secondary hypertension reno-vascular diseases

Renovascular hypertension is a syndrome which consists of high blood pressure caused by narrowing of
the arteries supplying the kidneys (renal artery stenosis). Cause: Renal hypoperfusion leads to
hyperactivation of the renin-angiotensin-aldosterone axis, causing hypertension, renal artery
atheroma/arteriosclerosis. ,aneurysm or thrombosis of renal artery.

131. Causes of secondary hypertension .Endocrine diseases

Pheochromocytoma - caused by an excessive secretion of norepinephrine and epinephrine which promotes
vasoconstriction
Hyperaldosteronism (Conn's syndrome) - idiopathic hyperaldosteronism, liddle's syndrome (also called
pseudoaldosteronism), glucocorticoid remediable aldosteronism
Cushing's syndrome - an excessive secretion of glucocorticoids causes the hypertension
Hyperparathyroidism, Acromegaly, Hyperthyroidism, Hypothyroidism

132. Causes of secondary hypertension Cardiovascular diseases

Aortic Coarctation, or narrowing of the aorta is a congenital defect that obstructs aortic outflow leading to
elevated pressures proximal to the coarctation.
Malformed aorta, slow pulse, ischemia: these cause reduced blood flow to the renal arteries, with
physiological responses as already outlined. Aortic valve disease, Atherosclerosis.

133. hypotension Causes of hypotension

Low blood pressure (hypotension) is pressure so low it causes symptoms or signs due to the low flow of
blood through the arteries and veins. When the flow of blood is too low to deliver enough oxygen and
nutrients to vital organs such as the brain, heart, and kidney, the organs do not function normally and may
be temporarily or permanently damaged.
 Causes can be due to low blood volume, hormonal changes, widening of blood vessels, medicine side
effects, anemia, heart & endocrine problems.
Pregnancy. Because a woman's circulatory system expands rapidly during pregnancy, blood pressure is
likely to drop.

Heart problems. Some heart conditions that can lead to low blood pressure include extremely low heart
rate (bradycardia), heart valve problems, heart attack and heart failure.

Endocrine problems. An underactive thyroid (hypothyroidism) or overactive thyroid (hyperthyroidism)

can cause low blood pressure. In addition, other conditions, such as adrenal insufficiency (Addison's
disease), low blood sugar (hypoglycemia) and, in some cases, diabetes, can trigger low blood pressure.

Dehydration. Blood loss. Severe infection (septicemia). Severe allergic reaction (anaphylaxis). Lack
of nutrients in your diet.

134. Causes of tachycardia .defination

Tachycardia refers to a faster than normal resting heart rate - the heart rate of a resting or sleeping
individual is faster than it should be. In general, the adult resting heart beats between 60 and 100 times per
minute (some doctors place the healthy limit at 90).

 A reaction to certain medications

 Congenital (present at birth) electrical pathway abnormalities in the heart
 Congenital abnormalities of the heart
 Consuming too much alcohol
 Consumption of cocaine and some other recreational drugs
 Electrolyte imbalance
 Heart disease which has resulted in poor blood supply and damage to heart tissues,
including coronary artery disease (atherosclerosis), heart valve disease, heart failure, heart muscle
disease (cardiomyopathy), tumors, or infections.
 Hypertension
 Hyperthyroidism (overactive thyroid gland)
 Smoking
 Certain lung diseases

135. Causes of bradycardia definition

Bradycardia (is the resting heart rate of under 60 beats per minute, though it is seldom symptomatic until
the rate drops below 50 beat/min) is caused by something that disrupts the normal electrical impulses
controlling the rate of your heart's pumping action. Many things can cause or contribute to problems with
your heart's electrical system, including:

Damage to heart tissues, High blood pressure (hypertension), Heart disorder present at birth (congenital
heart defect), Infection of heart tissue (myocarditis), A complication of heart surgery, hypothyroidism,
Imbalance of electrolytes, mineral-related substances necessary for conducting electrical impulses,
Obstructive sleep apnea, the repeated disruption of breathing during sleep. Inflammatory disease (such as
rheumatic fever or lupus), Hemochromatosis, the buildup of iron in organs, Medications

136. Causes of irregular pulse

Sinus arrhythmia, Atrial extrasystoles, Ventricular extrasystoles, Atrial fibrillation, Atrial flutter with
variable response, Second-degree heart block with variable response.

137. Common causes of atrial fibrillation

Thyrotoxicosis, alcohol-related heart disease, infections following surgery especially cardiothoracic surgery
e.g urinary tract and respiratory infections, hypertension, cardiac failure, myocardial infarction.

138. Differences between carotid and jugular pulsation

1. The carotid pulse has only one descent, or collapse; the jugular often has two
2. The carotid descent is slow, whereas the jugular descent is rapid. If the fastest and greatest movement is a
collapse, or descent, it is a jugular pulse.
3. Firm pressure just above the clavicle will obliterate all but the highest pressure jugular pulsations but
will not affect carotid pulsations.
4. Inspiration may exaggerate jugular pulsations but will, if anything, diminish carotid pulsations
5. Sitting up will make the carotids appear higher in the neck, but the jugulars will appear lower in the
neck.

6. The carotid, if visible, is always easily palpable with firm pressure. The normal jugular is rarely palpable,
except as a slight fluttering sensation with light pressure. The jugular is relatively easily compressible.

7. The X' descent ends at the S2, whereas the carotid descent appears to begin with the S2.

8. Sudden abdominal compression makes the jugulars momentarily more visible but has no effect on the
carotids.

139. Bleeding from the digestive tract.Causes

Doudenal ulcer, Stomach ulcer, Erosion of duodenum, stomach or oesophagus, Oesophageal varices,
Abnormal blood vessels, Colon cancer, colon polyps, anal fissures, diverticulosis, inflammatory bowel
disease, Large bowel inflammation, internal hemorrhoids

140. Constipation.Defination.Causes
Refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful
defecation. Severe constipation includes obstipation (failure to pass stools or gas) and fecal impaction.
Acute constipation begins suddenly and conspicuously while chronic constipation begin gradually and
persist for months or years.
Causes for acute constipation: Acute bowel obstruction, Ileus, inflammation of the lining of the abdominal
cavity, Drugs with anticholinergic effects, metallic ions, opioids.
Causes for chronic constipation: Colon cancer, metabolic disorder, functional disorder, diet low fiber,
chronic laxative abuse

141. Dyspepsia Defination.Causes

Also known as upset stomach or indigestion, refers to a condition of impaired digestion. It is a medical
condition characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and
feeling full earlier than expected when eating.
Symptoms are poor apetite, nausea, constipation, diarrhea, flatulence, belching and loud intestinal sounds.
Causes: Stomach ulcer, Stomach cancer, Stomach inflammation (gastritis), duodenal ulcer

142. Fecal incontinence Defination.Causes

It is the loss of control over bowel movements. Involuntary excretion and leaking are common
occurrences for those affected.
Causes: Diarrhea, Fecal impaction, injuries to anus or spinal cord, rectal prolapsed, dementia, neurologic
injury from diabetes, tumours of anus, injuries to pelvis during childbirth.

143. Nausea and Vomiting Defination.Causes

Nausea is an unpleasant feeling that may include dizziness, discomfort in abdomen, unwillingness to eat
and sensation of needing to vomit.
Some common causes of nausea are motion sickness, dizziness, fainting, gastroenteritis (stomach
infection) or food poisoning. Side effects of many medications including cancer
chemotherapy, nauseants or morning sickness in early pregnancy. Nausea may also be caused
by anxiety, disgust and depression.
Vomiting is the forceful contraction of the stomach that propels its contents up the oesophagus and
out through the mouth.
Causes: Headache caused during a migraine attack is mostly associated with nausea and vomiting.
Motion sickness, benign postural vertigo, labyrinthitis or Meniere’s disease are a few of the
conditions in the inner ear that can cause vomiting.
When pressure increases inside the skull due to any injury or illness, vomiting may be caused.
Increase in the intracranial pressure leads to swelling in the brain due to trauma, infection
(encephalitis or meningitis) and tumor.
Abnormal electrolyte and level of water in the bloodstream can also cause vomiting resulting from
increase in intracranial pressure.
Certain kind of sound or smell can also stimulate centrally mediated nausea. This is termed as
Noxious stimulus.
Heat related conditions like heat exhaustion, dehydration or extreme sunburn can also cause
vomiting. Diabetes, Medications and medical treatments, Pregnancy

144. Regurgitation Defination.Causes

Regurgitation is the spitting up of food from the oesophagus or stomach without nausea or forceful
contractions of the abdominal muscles.
Causes: Regurgitation of tasteless fluid containing mucus or undigested food can result from a narrowing
or a blockage of the oesophagus. The blockage may be caused from acid damage to the oesophagus,
ingestion of caustic substances, cancer of the oesophagus or abnormal nerve control of the oesophageal
sphincter.

145. Hypersalivation:sialorrhoea Defination.Causes

It is the increase of quantity saliva secreted.
Causes: parotidis, stomatitis, ingestion of sour food, digestive parasitoses

146. Hyposalivation Defination.Causes

Is the decrease of saliva secreted due to dysfunction or inhibition of the salivary glands.
Causes: dehydration, Sjogren syndrome, salivary lithiasis and intoxications with: atropine, opiate
substances.

147. Oral- pharyngeal dysphagia Causes

It means difficulty when swallowing the food during the deglutition.
Causes: pharyngitis, glossitis, stomatitis, local ulcerations, pharyngeal phlegmon, lateropharyngeal
phlegmon, hydrophobia, tetanus, iron deficiency anemia

148. The gums.modifications

Occurs in chronic lead intoxication
Bismuth gingivitis: exhibits a grey black line in the gingival margin.
Saturnine gingivitis: exhibits a grey blue line on the free edge of the gums (Burtons sign)

Diabetic gingivitis: in diabetes mellitus is characterized by tumefied, bigger, red and slightly bleeding
gums.
Hypertrophic gingivitis: in pregnancy and leukaemia.
Acute herpetic gingivostomatis: due to simplex virus
Vincents gingivostomatitis: due to fusiform spirochetes
Ulcerous necrotic gingivitis: a necrotic lesion, bleeding from gums, putrid odour and satellite adenopathy
Haemorrhages: in thrombocytic purpura and acute leukaemia.

149. The tongue’s modifications

The mobility: decreased mobility can be caused by paralysis of hypoglossal nerve, tumours, cerebral
bleedings. The tongues trembling appears in mercury,alcohol intoxication or cerebral tumors.
Macrglossy: appears in congenital disorder, acromegaly, mixoedema, Quinncke oedema, tumour,
amyloidosis.
Microglossy: appears in paralysis of the hypoglossal nerve, tabes, bulbar disease
The aspect and coulour: The dry or fried tongue in dehydration by vomiting, diarrhea, diabetes mellitus
with acidosis. The loaded tongue in feverish disease. The scrotal tongue is hereditary but also in
congenital syphilis,
The geographic tongue has exfoliated superficial and depapillated areas wich irregularly alternate with
unexfoliated areas.
The strawberry tongue in scarlet fever.
Tongue ulcerations: can be mechanic, chemical, infectious and tumoral.

150. Causes of mouth ulcers

Inflammatory bowel disease, leucoplakia, lichen planus, candidosic, Kopliks spots, Malignant erosion.

151. The main types of angina

Erythematous angina: characterized by redness of the tonsils, isthmus, pharynx of the soft palate and
uvula. It has a microbian (streptococcus) and viral etiology.
Purulent angina: looks like erythematous anginain the beginning but develops creamy, white spots.
Phlegmomous angina: is the stage of tonsils abscess.
Herpes angina: occurrence of vesicles at the level of pharynx accompanied by erosion, ganglion
tumefaction. It appears in 2nd week of typhoid fever.
Pseudomembranous angina: appears in diphtheria, syphilis and red scarlet. The pharynx is hyperemic
exhibiting oedema and the tonsils exhibit a whitish detachable exudates which becomes adherent and
appears as a grey gray, opalescent, smooth false membranes which covers the tonsils then expands.
The ulcerous membranous angina (Plaut Vincent): accompanied by fever, pharyngeal pains, ulceration
and bleeding tonsils.
Necrotic angina: appears in leukaemia and agranulocytosis.

152. Painful swallowing in oesophagus disorders

The pain is perceived as a sensation of retrosternal constriction at different levels of the oesophagus or as a
sensation of distension. It iiradiates on a large, symmetrical area and it is accompanied by dysphagia and
regurgitation. This symptom is usually due to local infection: candida, herpes simplex.
Acid Reflux Disease, Esophagitis: Esophagitis, Esophageal Spasm, Sphincter Irregularities, Esophageal
Cancer
Other causes of esophagus pain include esophageal trauma, which could be physical or chemical.
Esophageal burns due to excessive consumption of highly acidic and spicy foods, radiation injuries to the
esophagus, esophageal tear etc.

153. Paraclinical examinations in oesophagus disorders

The X ray examination with Barium soloution may point out: mechanical obstructions (tumours,
diverticulum stenosis, oesophageal varicose)
The endoscopy with fiber optic endoscope visualizes the oesophagus with the location and the nature of
the pathological process
Biopsy may be performed as well as removal of foreign bodies and bleeding varicose.

154. Pain in the pyloric ulcer

The gastric pain is correlated to the meals (they are rhythmic depending on the nourishment) in duodenal
and gastric ulcer and allows us to establish the location of the ulcer. The ulcer pain is characterized by the
season periodicity, it is frequent in spring and autumn and it occurs especially in duodenal ulcer.
The pain is projected in the epigastrium, the middle third of the epigastrium area in gastric ulcer or pyloric
ulcer.
When the ulcer complicates the pain character changes. It becomes violent taking an antalgic position when
the ulcer is penetrating.

155. The haematemesis.causes

Is the vomiting of blood. Light red blood when it is recent and dark red, brownish or coffe like if the blood
remained in the stomach for a while.
Causes: gastrodoudenal ulcer, peptic ulcer, oesophagus cancer, gastric cancer
extra gastric causes: haemophilia, leukemia

156. differential diagnosis between the haematemesis and haemoptysis

Haemoptysis is the coughing of blood originating from the respiratory tract below the level of the larynx.
Haemoptysis should be differentiated from: Haematemesis - vomiting of blood from the gastrointestinal
(GI) tract.

Where is it from?
GI TRACT RESPIRATORY TRACT
Dark red or brown Bright red
In clumps Foamy, runny
Mixed with food Mixed with mucous
Acidic pH Alkaline pH
Stomachache, abdominal discomfort Chest pain, warmth or gurgling over the
Nausea, retching before and after chest
episode Persistent cough

157. Melena Defination.Causes

Melena refers to the black, "tarry" feces that are associated with gastrointestinal hemorrhage. In upper
digestive bleedings part of the blood is eliminated by the haematemesis and another part goes to the
intestine it is digested and eliminated by means of feces called Melena. Melena is blood partially digested.
The altered colour of the blood results from contact with hydrochloric acid in gastric juice to produce
hematin.
Cuases: The most common cause of melena is peptic ulcer disease. Other medical causes of melena
include bleeding ulcers, gastritis, esophageal varices, and Mallory-Weiss syndrome.

158. Palpation for detecting ascites

Palpation and percussion are used to evaluate ascites. A rounded, symmetrical contour of the abdomen with
bulging flanks is often the first clue. Palpation of the abdomen in the patient with ascites will often
demonstrate a doughy, almost fluctuant sensation. In advanced cases the abdominal wall will be tense due to
distention from the contained fluid. Gas-filled intestines will float to the top of the fluid-filled abdomen.
Thus, in the supine patient with ascites there should be periumbilical tympany with dullness in the flanks.
One should mark the level of dullness on the skin and then turn the patient on one side for a full minute. A
change in the level of dullness is termed shifting dullness and usually indicates more than 500 ml of ascitic
fluid. Another physical sign of ascites is demonstration of a transmitted fluid wave. The patient or an
assistant presses a hand firmly against the abdominal wall in the umbilical region. The examiner places the
flat of the left hand on the right flank and then taps the left flank with his right hand. In the presence of
ascites, a sharp tap will generate a pressure wave that will be transmitted to the left hand. Unfortunately, fat
will also transmit a fluid wave, and there are frequent false-positives with this test.

159. Hepatomegaly Defination.Causes

Hepatomegaly is the condition of having an enlarged liver. It is a nonspecific medical sign having many
causes, which can broadly be broken down into infection, direct toxicity, hepatic tumours, or metabolic
disorder. Often, hepatomegaly will present as an abdominal mass. Depending on the cause, it may
sometimes present along with jaundice.

160. Medical causes of hepatomegaly

Cirrhosis: the liver becomes enlarged, nodular and hard.
Hepatitis: hepatomegaly occurs in the icteric phase.
Liver cancer: cause irregular, nodular firm hepatomegaly with pain and peripheral oedema, ascites,
jaundice.
Hepatic abscess: hepatomegaly may accompany a fever (primary sign)
Amyloidosis: is a rare disorder may cause hepatomegaly and jaundice.
Leukemia and lymphomas: blood disorders cause hepato and spleno-megaly.
Mononucleosis infection: causes hepatomegaly with lymphoadneopthy and temperature fluctuations.

161. Paraclinical examination of liver (Biochemical tests of liver function)

These tests are used in differential diagnosis of jaundice:
urinary urobilin, plasma bilirubin, alkaline phosphates, serum aminotransferase, plasma proteins, plasma
prothrombin, gamma glutamyl transferase
In hepatitis: antibodies to the hepatitis A,B,C viruses can be detected in the blood.

162. Symptoms and signs in diseases of the biliary tract

The biliary dyspeptic syndrome is characterized by pain in the right hypochondrium.
The biliary colic is accompanied by nausea, vomiting, distension of the abdomen.
Biliary colic sudden obstruction of the cystic duct or common duct by stones cause a pain described as
severe aching, pressure sensation located in the epigastrium or right hypochondrium. It may radiate to the
right scapula or right shoulder. Vomiting occurs 75% of attacks.
Cholelithiasis (gallstones) are often asymptomatic. The pain is characterized by frequent episodes of
steady severe pain in epigastrium or right upper quadrant with radiation to right scapula.

163. The Murphy s sign

The physician palpates the right hypocondrium with the tips of the fingers in the sub hepatic region at the
level of the free edge of the tenth rib and they try to get deeper while the patient is asked to breathe deeply.
When the gallbladder is sensible the patient presents pain and the Murphy sign is positive.

164. Paraclinical examinations in diseases of the biliary tract

In acute cholecystitis: the WBC count is usually high, total serum bilirubin 1-4 mg%, serum
aminotransferase and alkaline phosphatase are often elevated.
Ultrasound and X ray to detect stones.
Oral cholecystography: This procedure depends on excretion of iodine compounds, detects dilatation of
the bile duct.
Intravenous cholangiography: to demonstrate the bile ducts.
Endoscopic retrograde cholangiopancreatography (IRCP): contrast fluid is injected down the cannula
and the whole biliary system is visualized.

165. The medical causes of splenomegaly

Abnormal red blood cells: Since the spleen filters abnormal blood cells and removes them from the
circulatory system, diseases that result in abnormal red cells will cause the spleen to enlarge. Sickle cell
disease,thalassemia, and spherocytosis are examples of diseases that form unusually shaped cells that
cannot easily maneuver through the small blood vessels and capillaries of the body.
Viral and bacterial infection: The spleen is involved in making cells that fight infection and part of that
response is to enlarge. This is commonly seen in viral infections such as infectious mononucleosis (caused
 by the Epstein Barr virus), AIDS and viral hepatitis. Examples of bacterial infections associated with
splenomegaly include tuberculosis, malaria, andanaplasmosis.

Splenic vein pressure/blockage: Blood enters the spleen through the splenic artery and leaves through the
splenic vein. If the pressure within the vein increases or if the splenic vein becomes blocked, blood cannot
leave the spleen and it may swell. Because of the relationship to liver blood flow,cirrhosis and portal vein
obstruction can cause complications with venous blood flow from the spleen. Congestive heart failure may
cause both the liver and spleen to swell because of increased venous pressure.

Cancers: Leukemias and both Hodgkins and non-Hodgkins lymphoma can cause the spleen to enlarge, as
can a variety of other tumors includingmelanomas.

Metabolic disease: Metabolic diseases that enlarge the spleen include Niemann-Pick disease, Gaucher's
disease, and Hurler syndrome.

166. Splenomegaly ,Complementary examination

Ultrasound examination
CT examination
Blood cell count
Sternal puncture
Examination of the liver function
Ganglionar biopsy

167. anemia Defination.Causes

Anemia may be defined as any condition resulting from a significant decrease in the total body
erythrocyte mass. Decrease of the total blood hemoglobin concentration, the rbc count, and the hematocrit.
Therefore, a pragmatic definition of anemia is a state which exists when the hemoglobin is less than 12 g/dL
or the hematocrit is less than 37 cL/L.

Red blood cells can be lost through bleeding, which can occur slowly over a long period of time, and can
often go undetected. This kind of chronic bleeding commonly results from the following:
Gastrointestinal conditions such as ulcers, hemorrhoids, gastritis (inflammation of the stomach), and cancer

Use of nonsteroidal anti-inflammatory drugs (NSAIDS) such as aspirinor ibuprofen

Menstruation and childbirth in women, especially if menstrual bleeding is excessive and if there are
multiple pregnancies.
The body may produce too few blood cells or the blood cells may not function correctly. In either case,
anemia can result. Red blood cells may be faulty or decreased due to abnormal red blood cells or the a lack
of minerals and vitamins needed for red blood cells to work properly. Conditions associated with these
causes of anemia include the following:

 Sickle cell anemia

 Iron deficiency anemia
 Vitamin B12 deficiency
 Bone marrow and stem cell problems
 Other health conditions

168. Microcytic anemia Causes

Microcytic anemia is a generic term for any type of anemia characterized by small red blood cells. The
normal mean corpuscular volume is 76-100 fL, with smaller cells (<76 fL) described as microcytic and
larger cells (>100 fL) as macrocytic.
Causes: iron deficiency anemia,by far the most common cause of anemia in general and of microcytic
anemia in particular, thalassemia, sideroblastic anemia, congenital or acquired, Hereditary spherocytosis,
lead poisoning (rare).

169. Normocytic anemia Causes

Acute blood loss, Anemia of chronic disease, Aplastic anemia (bone marrow failure), Hemolytic anemia.
Edocrine disorders (hypopituarism, hypothyroidism, hypoadrenalism).

170. Macrocytic anemia Causes

Megaloblastic anemia, the most common cause of macrocytic anemia, is due to a deficiency of
either vitamin B12, folic acid (or both). Deficiency in folate and/or vitamin B12 can be due either to
inadequate intake or insufficient absorption. Folate deficiency normally does not produce neurological
symptoms, while B12 deficiency does.
Pernicious anemia is caused by a lack of intrinsic factor. Intrinsic factor is required to absorb vitamin
B12 from food. A lack of intrinsic factor may arise from an autoimmune condition targeting the parietal
cells (atrophic gastritis) that produce intrinsic factor or against intrinsic factor itself. These lead to poor
absorption of vitamin B12.
Hypothyroidism,
Methotrexate, zidovudine, and other drugs that inhibit DNA replication.

171. Symptoms of anemia

While performing a complete physical examination, the physician may particularly focus on general
appearance (signs of fatigue, paleness), jaundice (yellow skin and eyes), paleness of the nail beds, enlarged
spleen(splenomegaly) or liver (hepatomegaly), heart sounds, and lymph nodes.

Symptoms of anemia may include the following:

Fatigue, shortness of breath, palpitations, looking pale.

Symptoms of severe anemia may include:

chest pain, angina, or heart attack, dizziness, fainting or passing out , rapid heart rate, Change in stool
color,or visibly bloody stools if the anemia is due to blood loss through the gastrointestinal tract, low
blood pressure, rapid breathing , pale or cold skin, yellow skin called jaundice if anemia is due to red
blood cell breakdown, heart murmur, enlargement of the spleen with certain causes of anemia

172. Anemia Complementary examinations

Complete blood count (CBC): Determines the severity and type of anemia.

Stool hemoglobin test: Tests for blood in stool which may detect bleeding from the stomach or the
intestines.

Peripheral blood smear: Looks at the red blood cells under a microscope to determine the size, shape,
number, and color as well as evaluate other cells in the blood.

Iron level: An iron level may tell the doctor whether anemia may be related to iron deficiency or not. This
test is usually accompanied by other tests that measure the body's iron storage capacity, such as transferrin
level and ferritin level.

Transferrin level: Evaluates a protein that carries iron around the body.

Ferritin: Evaluates at the total iron available in the body.

Folate: A vitamin needed to produce red blood cells, which is low in people with poor eating habits.

Vitamin B12: A vitamin needed to produce red blood cells, low in people with poor eating habits or in
pernicious anemia.

Bilirubin: Useful to determine if the red blood cells are being destroyed within the body which may be a
sign of hemolytic anemia.

Lead level: Lead toxicity used to be one of the more common causes of anemia in children.

Hemoglobin electrophoresis: Sometimes used when a person has a family history of anemia; this test
provides information on sickle cell anemia or thalassemia.

Reticulocyte count: A measure of new red blood cells produced by the bone marrow

Liver function tests: A common test to determine how the liver is working, which may give a clue to
other underlying disease causing anemia.

Kidney function test: A test that is very routine and can help determine whether any kidney dysfunction
exists.
Bone marrow biopsy: Evaluates production of red blood cells and may be done when a bone marrow
problem is suspected.