CHRONICLES :CLINICAL EXAMINATION STILL MATTERS. PART II

PART II


CLINICAL EXAMINATION

ASKING

Once all the above is over, has come  the time of  a critical step. It’s about questioning the patient and  asking for more details and precision. Never has a practitioner asked too many questions. Keep asking. Ask for any or relevant details like about the beginning of symptoms. About, say, the location of a headache, at the forehead or in the occipital. Is there some dizziness or buzzing at the ear? What about his sight? Is the vision good? Where is located the painful area?  How does this pain present? What's the pain schedule? What does he do to fight the pain? What does exacerbate it? Many practitioners go even further. They want to know about the characteristics of the pain.   They also inquire about whatsoever symptoms, whether they worsen in the morning or at night.  Pain is usually more intense at night.

In family practice, practitioners inform themselves by asking questions from above to below, going up to down. They ask about the head and neck, along the ears, the nose, the throat, aka: ENT. Then, moving down, they review the pulmonary and cardiovascular system, inquiring about the lungs and heart, the color of sputum if there is some. Does the patient cough? They ask: do you breathe easily? Is there some uneasiness in breathing such as dyspnea?  Are you gasping for air? How many pillows do you lie on? Do you wake up at night with respiratory problems? Do you have to stop in walking? Referring to the digestive system, they end up questioning about the schedule for ingesting food.   How often do you eat? How much water do you take?  Do some food hurt you more than others one? What do you notice in your bowel movements? How often do you awake at night to pie?  Practitioners ask for the color of the excreta (feces, urines). The medical inquiring goes on, emphasizing the walking, the aspect and the size of the limbs. Is there some asymmetry? Are the members cold or is there some discoloration?  How do fingers or toes look like? Is there some numbness at the limbs and arms? In fact questioning depends upon many factors and aspects in medical practice. There is no standard rules and procedure... But, it pays off by making the review of systems, the so-called ROS from above to below.

  

Previously, the practitioner has been aware of the lifestyle of his patient, his occupation. A lot of diseases are reported to have been caused by occupational hazards such as asbestos. It’s well known that ailments linked to farming, typesetting, cattling and so forth   fall into the so-called occupational   diseases. Finally, the practitioner asks about vaccination status and weight loss or gain.

Heredity and Past history

Needless to say that grouping these details leads to the coming of light at the end of the tunnel.  Questioning a patient is helping as well in improving the relationship patient -doctor. Confidence and trust ensue and  convince that the practitioner aims at doing his best to help. The patient doctor dialogue is special, unique because the resulting openness benefits the both of sides. Clinicians have in the past become part of the family by sharing  deep-hidden secrets. Furthermore, as mentioned above, a good questioning is a hallmark of the quality of care the patient can expect from his physician.

Some clinicians and out-patients services keep a list ready to fill out at questioning. Reviewing these charts, one has the impression that they serve as guidelines and rules to follow in order to have an overhaul at clinical examination.  The review of systems (or symptoms) is a list of questions, arranged by organ system, designed to uncover dysfunction and disease. It can be applied in several ways.

Shortly put, when asking for details, the practitioner gets an overview not only about the current disease for which the patient came to medical office, but also about the past of patients, their lifestyle and how far they can allege to be safe, health speaking. 

FOOTNOTES

NEXT POST : THE 4 STEP CLINICAL EXAMINATION

CHRONICLES :CLLINICAL EXAMINATION STILL MATTERS .PART 1

CLINICAL EXAMINATION

PART 1

LISTEN & WATCH

Since machines have been in use in the management of medical issues, is clinical examination over for good? Let’s see how far patient-doctor relationship and a kind of  eye to eye contact can still challenges machines era. Let's get started with the listening step   LISTENING TO   In fact, in medical practice, the art of listening can be rewarding in many ways. But, what to listen to? Patient listening has become obsolete, people say, but listening to  still  worth. Listening   to the patient describing his or her illness is instrumental in the making of  the right diagnostic. A good practitioner is  first of all  a good listener. Keep in mind that patients are the only people involved in their suffering. Even crippled , they  can  identify the main  distressful area and help understand  how the pain itself manifests. Talking about pain, patients give valuable clues. Is it a localized pain or a moving one ? Thus , by listening to , a practitioner learns about the nature of  the illness , its schedule, by  example the way  gastric and duodenal ulcers, daily or nocturnal  fever behave. Actually,  by listening to patients mapping out their bodies, practitioners draw fine conclusions whether  about GI diseases such as gastric  pain  related  to ulcers  or  back pain reflecting pancreatitis or nephritis. Uneasiness in the swallowing refers  to esophageal diseases and only affected patients can guide doctors to this underneath troubled GI tract.   Let’s remain that appendicitis pain, even accompanied  by other symptoms, represent a classic topic so that the Mc Burney point  situated halfway  along the line joining pubic spine to the umbilicus, serves to settle its diagnostic.  The same goes for gallbladder diseases  when patients describe their pain traveling up to the shoulder. Shoulder pain in fact underlines gallbladder disorders or cholangitis, in particular among women. It is said by the way that the 4 Fs define gallbladder illness: Fat, Female, Fertile and Forties.  Breast diseases  also remain a good example. Breast tumor is first at all a patient discovery. How tumors behave would be pivotal in the following steps. Prostate hypertrophy  and the toll it takes on the urine flowing and nighttime sleep. are above all. a patient’s finding.  Mastering the  art of  listening in medicine   pays off most of the time. WATCHING Watching your patient also is critical in settling the diagnostic and later on the treatment. It brings a lot of information whether in looking at the so-called body language or linking gestures to what you’re listening to. Over time, practitioners improve their senses (attuned them), acquiring a kind of clinical intuition named clinical finesse. It was said that an obstetric maiden could forecast the sex of unborn nothing but by hearing the parturient crying.  The same goes for an extinguishing physician’s race famous for their accurate diagnostic. Watching thus is rewarding. Observe your patient everywhere. Note the color of the eyes, turning whiter in case of anemia. Also note the face’s asymmetry when Bell’s palsy or even a minor stroke is there. Asthmatics present with a tightening of the nostrils when fighting asphyxia or gasping for air.  Lips turning to violet and blue herald deep-troubled blood circulation. Try to observe how pupils react to light. Opium overdose or cocaine make pupils pinpoint while other narcotics cause midriasis, or pupil dilatation. If cervical veins dilate, think about heart problems.  The JVD is a hallmark of the right heart failure. Remain aware of some by sternum noise or murmurs revealing an underneath   cardio vascular disorder. Watching completes listening by adding what scientists, practitioners have learned over the years. If by listening we stand by hypothesis or probabilities range, watching would confirm or reject these presumptions.  Chest area refers to lungs and heart as well.  Esophageal disorders, gastric and mediastinum tumors also express themselves over there. Collateral circulation, sweating, hoarseness occur at the level of cervical dermatomes, like in the Horner’s syndrome. Fruit odor breathing announces the incumbent  keto-acidosis  in diabetes. Pulmonary abscess is always foul-smelling. High blood pressure sometimes gives a flushing look to the face, let alone injected sclerotic and even tense eyeball, also a finding in glaucoma. The saying: good clinicians can read diseases at the skin level sounds like an aphorism.   Observation can reveal the classical finger tremor of alcoholics deprived of vitamin B1, the exophthalmia of thyroid disorders. Ascites and the ensuing Caput Medusa refer to portal hypertension and subsequent esophageal varies ready to rupture. Skin change, whether by  its discoloration or strength  leads to blood, hydration and deep located disease. Pancreas cancer gives a yellow hue to the skin. Limbs become sometimes part of the clinical picture. Phlebitis, calf pain, edema add to the clinical status of older patients plagued with abdominal tumors. Keep also in mind that from the head to the toes ailments used to take a toll. Alopecia or loss of hair, nail fragility and discoloration represent only the visible part of the iceberg. Heart and lung diseases express themselves  at the fingers and nails, the so-called spoon nails of the French doctors. Sometimes a remote detail comes up longtime before people looks for  medical assistance. That’s why patients and doctors need a  throughout clinical examination. Medical examination  has a lot to do with patience, that is to say, time. (To be continued ) FOOTNOTES Some investigators  end up to these conclusions regarding clinical examination in the making of diagnostic compared to lab process and other devices : History alone: 19.8% and 19.3%. Physical examination alone: 0.8% and 0.5%.  (complete blood test, chemistry panel, urinalysis, ECG, chest radiograph) alone: 1.1% and 1.3%. History and physical examination in combination: 39.5% and 38.6%. History plus basic tests: 14.7% and 14.7%. History, physical examination, and basic tests in combination: 16.9% and 18.5%. Imaging studies: 6.5% and 6.1%. The authors’ conclusion: “We found that more than 80% of newly admitted internal medicine patients could be correctly diagnosed on admission and that basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases.”1 This conclusion made me happy. However, an editorialist raised some interesting points. Like me, he is a senior clinician, that is, a euphemism for older (he was a fellow in the 1950s, I was in the 1970s). He went further, suggesting “modern imaging techniques when used appropriately have made the diagnosis of the patient’s disease and management more timely and accurate. There is also no doubt that these imaging techniques are overused … these techniques increase the cost of medical care significantly. ” Older clinicians rely on the history and physical to a greater degree than younger clinicians. In fact, has the pendulum swung too far toward technology? As a result of eroding auscultation skills, many recent graduates can only make cardiac diagnoses by echocardiography.

A KEY VITAMIN : VITAMIN D

 A SUNLIGHT-BOUNDED VITAMIN

S

peaking of the way sunlight works at the skin level, one has to recall that as a traveling energy, light effect on skin depends on the wavelength like anywhere else. Sunlight keeps giving the skin a youthful glow, even though UV radiation is harmful with bad consequences. So said, light happily affects the skin through physiological and vital processes. The more interesting of the process  remains vitamin D synthesis.

Besides being a protective shield and a  visible ID oriented to  social life, human skin is the site of the sunlight-generated vitamin D. Vitamin D remains a crossroad of our health system, aiming at maintaining homeostasis balance. This sunlight –bounded   synthesis emphasizes the way human life among other things is related to sky-located energy.

A lot has to come again about  light regarding the role of this vitamin in  biology, a vital one, to tell the truth. Vitamin D synthesis starts at skin level when UVB hits the epidermal cells causing a change to a cholesterol molecule. Then, crossing the circulation, this new synthesized molecule goes to the liver before being transformed into the 25-hydroxyvitmin D. Let’s recall that there exists to types of vitamin D, the 25-OH D3 named the storage form and the 1-25(OH)2 D3, the active form. This last one has been elaborated through the kidney and is considered physiologically active, implying this way its hormonal function.  It is called calcitrol. This hormone intervenes in the regulation of Ca+ 2 and Po4 . Both of them are absorbed into the gut.

Given the overall function of calcitrol in human physiology via the parathyroids and the bones, it is regarded as a key hormone affecting the cardiac cycle as well as the basal metabolism through the thyroid function and  calcium and phosphate regulation. From this point of view  we can  ask   what would have  happened  to life if sunlight had failed to trigger the vitamin D synthesis. As put by the  PhD  Laurance Johnson,” the sunlight –generated hormone sustains health throughout the body”.

 FOOTNOTES 

 VITAMINE D  Photochemistry

Photochemical conversion of 7-dehydrocholesterol to previtamin D3

Thermal isomerization of previtamin D3 to vitamin D3

1 ) The transformation that converts 7-dehydrocholesterol to Vitamin D3 (cholecalciferol) occurs in two steps.

First, 7-dehydrocholesterol, is photolyzed by ultraviolet light in a 6-electron conrotatory electrocyclic reaction. The product isprevitamin D3.

Second, previtamin D3 spontaneously isomerizes to vitamin D3 (cholecalciferol) in an antarafacial sigmatropic [1,7] hydride shift. At room temperature, the transformation of previtamin D3 to vitamin D3 takes about 12 days to complete.

2 ) Vitamin D can be synthesized only via a photochemical process, so land vertebrates had to ingest foods that contained vitamin D or had to be exposed to sunlight to photosynthesize vitamin D in their skin to satisfy their body's vitamin D requirement

HOW DOES ASA WORK?

More About Aspirin and its anti-Cox effect....

Known already in Roman times and before in Egypt, acetyl salicylic acid, ASA plays a key role in relieving pain, but in our times, ASA has rather  a prevention function which consists of protecting vital organs a such as the heart and the brain.  According to Eric Metcaff, who wrote an interesting book on ASA, Mayo Clinic advices us to take 162 milligrams of ASA if we think we’re having a heart attack before calling 911. The same goes for the cerebral vascular accidents and ongoing  ischemic attacks .  In   post MI recovery, ASA participates as a  sentinel  among other  prescriptions .

  The American College of  Cardiologists  and the American Heart Association recommend 80 and 325 mg of ASA before and after surgery to prevent  blood clots formation. In a more empirically way, people are advised to have ASA ,even if they think they  are fine, to prevent heart and ischemic coronary disease.  From there, we can conclude that ASA have something to do with  blood circulation.

If you think so, you’re right. The main mechanism of ASA action is to improve and increase blood delivery where oxygen is in demand. To do so, ASA has the so-called anti-Cox effect, which stops arachidonic acid from  synthesizing  prostaglandins through an enzyme named cyclooxygenase. Prostaglandins, in the following step, would react with  platelets, those types of blood cells specialized in coagulation. Prostaglandins maybe   help  by raising our temperature in case of infection and generating pain to let us know something wrong is happening. But they  also favor the clustering of  these platelets aimed at  occluding  veins and arteries, hampering our circulation and reducing blood feeding in  some organs. It is there  that ASA acts. In keeping cyclooxygenase away, ASA   breaks the chain by reducing the amount of  prostaglandins, reducing thus the possibility of  clots formation. Blood keeps flowing free through   would be at risk organs.  Once Cox blocked,  prostaglandin is no longer synthesized .  This is the anti-Cox effect. Some authors add that ASA dilates vessels instead of constricting them, the way the platelets do. 

Footnotes:
According to MNT, Aspirin has also become increasingly popular as an antiplatelet - used to prevent blood clot formation - in long-term low doses to prevent heart attacks and strokes in high risk patients. Nowadays, aspirin is often given to patients immediately after a heart attack to prevent recurrence or cardiac tissue death

CHR0NICLES :HEART ATTACKS SYMPTOMS

HEART FAILURE SYMPTOMS

However, there are so many, alas!
Medicine also has something tricky as well. Although breathlessness is classic in the most heart symptoms,  it doesn't define by itself the main clinical details in the coming of a  heart failure condition.

Put simply, here are the main symptoms of the heart failure

• ·        Breathlessness at rest
• ·        On exertion
• ·        Suddenly from sleep
• ·        When lying flat
• ·        Wheezing
• ·        Cough
• ·        Haemoptysis
• ·        Fatigue
• ·        Poor exercise tolerance
• ·        Ankle swelling
• ·        JVP third heart sound
• ·        Lung crepitations    
•        Shortness of breath ( SOB)

ASA, THE WONDER DRUG...

Once upon a time, aspirin...

ACETYLSALICYLIC ACID

T

here is no internal medicine without ASA, a famous Haitian internist once told . From the mid 70s up to now, ASA has become so popular that in many households today there exists even some ASA pills carefully kept in safe place. Why do so many people use ASA even at small dose on a daily basis?

Salix Alba told to be charged
with Salicylic acid

         

ASA Chemical Structure

To get started in our journey through ASA world, listen first to what WIKIPEDIA wrote as an introduction:

Acetylsalicylic Acid was originally derived from Salicin the active ingredient in Willow bark. In certain parts of the world Willow bark had been used for centuries in folk medicine. In 1897 Felix Hoffmann, an employee of Fredich Bayer, first prepared aspirin which is now the active ingredient in over 60 over-the-counter medicines. Sometimes the name Bayer is used for this compound owing to their manufacturers name.

This drug is used today to lower fevers and reduce inflammation, especially those caused by rhumatic fever and arthritis.

It will thin the blood and therefore it will, in small doses prevent heart attack, stroke & unstable angina. Because of its ability to thin the blood Acetylsalicylic Acid will inhibit the formation of blood clots.

It`s most common use is to relieve headaches as well as muscle & joint pain. Acetylsalicylic Acid interferes with the bodys synthesis of specific POSTAGLANDINS. These compounds are produced by almost every tissue in the body and control the substances involved in the transmission of nerve impulses which participate in the body`s defences against infection. Postaglandins have been shown to bring on fever and play a major role in inflammation.

At present other uses of this drug are under investigation such as there usefulness in prevention of certain cancers and dangerously high blood pressure which sometimes can occur in pregnancy. It`s effectiveness in the relief of migraines is currently being looked into.

Remember the words: prostaglandins, blood clots

Formal Chemical Name (IUPAC)

Update by Karl Harrison

CHRONICLES:LIGHT,THE MEDICINE OF TOMORROW

  GLANCING AT LIGHT IN OUR BODY

light gazing stimulates your body to produce Vitamin D amongst many other vital substances. Vitamin D is more than a hormone in that it regulates the function of your master proof reader gene that controls all your other genes. It is essential for optimum health. Achieving optimum vitamin D levels will result in a DNA activation itself. Many diseases of the west have been shown to be corrected with vitamin D3 supplementation

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Light therapy for SAD and non seasonal forms of depression is thought to work by triggering the brain's production of serotonin, a neurotransmitter related to mood disorders. Other researchers think that light therapy may relieve depression or jet lag by resetting the body's circadian rhythm, or inner biological clock.

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 In dermatology, ultraviolet (UV) light therapy is used to treat rashes, psoriasis, other skin disorders, and jaundice. Outpatient treatment for psoriasis usually requires three treatment sessions per week until the skin clears, which takes about seven weeks.

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Light enters the eye through the pupil, which changes size depending on the amount of Light entering it. When there is very little Light, the pupil dilates; in bright Light, the pupil constricts. As Light enters the eye, it is focused by the lens, which adjusts its shape by means of the action of the muscles and ligaments of the ciliary body. The lens becomes fatter or flatter depending upon the distance to the object being focused on. The lens projects Light onto the retina, where special pigment absorbs the Light and forms a corresponding image."