Gastro Intestinal Tract and abdominal symptoms

1)Dysphagia and odynophagia.

2)Heartburn and reflux

3)Indigestion

4)Flatulence

5)Vomiting

6)Anorexia

7)Constipation

8)Diarrhea

9)Alternation of bowel pattern

10)Abdominal pain

11)Abdominal distention

12)Weight loss

13)Hematemesis

14)Rectal bleeding

15)Malena

16)Jaundice

17)Itching

18)Urinary symptoms

Ref :Hutchison's clinical methods 24th edition

Perception of Dyspnoea

How do we perceive Dyspnoea

       Sensory afferent signals are transmitted to the brain. Simultaneously, the brain generates predictions about the sensations the body should be feeling. When comparison between predictions and sensory information shows a mismatch , a neuro - cortical feedback loop is involved and  dyspnoea is perceiced .

In short, Dyspnoea occurs when there is a mismatch between afferent and efferent signals ,whrn the need for ventilation is not being met by physical breathing.

Which part of the brain are involved in perception of dyspnoea

1. Anterior insula, posterior insula, mid insula,among which the right anterior insular cortex seems to be the most consistent structure across studies.
2. Higher brain structures including the anterior cingulate cortex and the orbitofrontal cortex
3. Brain stem nuclei and midbrain structures, such as the periaqueductal gray matter

REF: American Journal of Respiratory and Critical Care Medicine 

Nephrotic syndrome

 Nephrotic syndrome is defined by a triad of clinical features: oedema, substantial proteinuria (> 3.5 g/24 hours) and hypoalbuminaemia (< 30 g/L)

Reference: Ghai textbook of pediatrics

Diaphragmatic referred pain

Nerve supply of diaphragm

Motor supply - phrenic nerve 

Sensory supply

Central tendon- phrenic nerve(ventral rami of c3,c4 and c5

Peripheral- lower 5 intercoastal nerve

Referred pain-

Sensory fibers which supply the diaphragm and enter the cord at the C 3, 4 and 5 segments. This segment of the cord also supply's the supraclavicular nerves (medial, intermediate and lateral) via the cervical plexus. The lateral supra-clavicular nerve supply's the skin directly over the acromium process. Irritation of the diaphragm can be experienced as pain over the acromium process.

Borg dyspnoea score

 Borg Dyspnoea Score

•  Borg Dyspnoea Score is a self reported measures of one’s difficulty in breathing upon exertion

• Developed by Swedish researcher Gunnar Borg
• It is a categorical scale with a score from 0 to 10, where 0 represents no dyspnoea and 10 represents maximum dyspnea
• In Modified Borg Dyspnoea Score ,the scores are obtained at the end of the 6MWD test and reflect the maximum degree of dyspnea at any time during the walk test.
• These instruments also perform the function of outcome marker in patients undergoing pul rehabilitation

Reference: Crisafulli E, Clini EM. Measures of dyspnea in pulmonary rehabilitation. Multidiscip Respir Med . 2010;5(3):202–10

Apical Impulse

 APICAL IMPULSE

Normal :  Fifth left intercostal space at, or medial to the mid-clavicular line (halfway between the suprasternal notch and the acromioclavicular joint)
Absent : D(dextrocardia) ,O (obesity),P( pericardial effusion and tamponade ,pneumothorax,E ( emphysema,effusion)
Heaving : Forceful but undisplaced palpable apical impulse that noticeably lifts your hand . It is noted in LV Pressure overload - Left ventricular hypertrophy, as in hypertension , severe aortic stenosis or Coarctation of aorta
Hyperdynamic : Seen in LV volume overload - AR ,MR,VSD,PDA,High output states
Diffuse : Occupies more than 1 ICS
Seen in Left ventricular dilatation as in AR
Tapping : Represents a palpable
first heart sound seen in Mitral stenosis and is not usually displaced.
Double apical impulse : Hypertrophic cardiomyopathy.

How to Differentiate Hyperdynamic apical impulse and Heaving Apical impulse clinically
Hyperdynamic : Increased Amplitude,Occupy more than 1 intercostal space,Duration of more than >1/3rd but  <2/3rd of the systole
Heaving :
Increased Amplitude,Occupy more than 1 intercostal space,Duration of > 2/3rd of systole

Reference: Macleod's clinical examination -14th ed,Clinical Examination in Cardiology 

Pleural fluid: amount that can be drained at once

It is rec­ommended that no limit to be placed on the amount of pleural fluid withdrawn during a therapeutic thora­centesis. However, the procedure should be stopped if the patient develops more than minimal coughing, chest tightness, chest pain, or shortness of breath.

Measurement of Pulsus Paradoxus

  For patients without an indwelling arterial access, pulsus paradoxus is best measured with a manual sphygmomanometer and stethescope. Automatic blood pressure cuffs cannot accurately measure pulsus paradoxus. 

Assessment is made by inflating the cuff until all Korotkoff are absent, then very slowly releasing pressure from the cuff. The first sounds auscultated will be heard only during expiration, and this pressure should be noted. Next, as cuff pressure is dropped further, the pressure should be noted when Korotkoff sounds are heard during both inspiration and expiration. The variation between these 2 systolic pressure is what quantifies pulsus paradoxus. 

Colour coding for inhalers

 COLOUR CODING OF INHALERS

Blue🔵-Relievers

 Brown 🟤- Inhaled steroids.

Green🟢 - LABA

Yellow 🟡-Anticholinergics

Black⚫ - Long-acting anticholinergics

Red🔴-To keep in reserve

Reference :

Jayakrishnan B, Al-Rawas OA. Asthma inhalers and colour coding: universal dots. Br J Gen Pract. 2010 Sep;60(578):690-1. doi: 10.3399/bjgp10X515449. PMID: 20849698; PMCID: PMC2930224.