IRFAN MIR Clinical Corelations

CLINICAL

CORRELATION

Prepared by

KICK THE CLINICAL CORRELATION

* Wt loss with relatively high food In take suggest DM, Hyperthyroidism, mal absorption, consider also binge eating (bulimia) with clandestine vomiting. * Poverty, old age, social isolation, physical disability, emotional or mental impairment, lack of teeth, ill fitting dentures, alcohol or drug abuse increase the likely hood of malnutrition.

* Tension and migraine headache are the most common kind of recurring headache. Progressively severe headache  the likely hood of tumor or other organic cause. Extreme severe headache suggest subarachenoid hemorrhage or meningitis.

* Nausea or vomiting are more common with migraine but also occur with brain hemorrhage and tumor. * Changing the position of head, cough, sneeze may increase the pain of brain tumor or sinusitis.

* Refractory error most commonly explain gradual blurring, high sugar food may also cause blurring of vision. * Sudden visual loss suggest retinal detachment, vitreous hemorrhage or occlusion of the central retinal artery.

* Slow central visual loss occurs in nuclear cataract, macular degeneration. Where as peripheral visual loss occur in advanced open angle glaucoma on other hand one side visual loss occur in hemianopsia and quadrantic defect.

* Moving specks or strands suggest vitreous floaters, where as fix defect (scotomas)suggest lesion in the retina or visual pathway. * Flashing lights or new vitreous floaters suggest detachment of vitreous from retina.

* Diplopia indicates the weakness or paralysis of one or more extra ocular muscles. Horizontal diplopia implicate the 3rd _{and 6}th _{CN. where as diplopia in}

one eye with other closed suggest a problem in cornea or lens. On other hand vertical diplopia implicate problem in 3rd _{and 4}th _CN.

* Hearing conduction loss result from problem in external and middle ear Where as sensori neuronal loss results from problem in inner ear, cochlear nerve & CNS.

* Person with sensory neuronal hearing loss have particular trouble understanding speech, and complain that other noisy environment make it worst.(where as noisy environment may help in conduction hearing loss.)

* Tinnitus is the common symptom increasing in frequency with age when associated with hearing loss and vertigo suggest Meniere,s disease. * Vertigo primarily point the problem in inner ear cochlear nerve or central connection.

* Enlarge tender lymph node in neck often accompany pharyngitis.

* A milky bilateral discharge from breast may be due to pregnancy or hormonal imbalance (Galactorrhea) where as non milky unilateral discharge suggest local breast dis.

* Anxiety is the most common cause of chest pain In children. Among organic cause costochondritis is most common.

* Pain over the sternum suggest angina pectoris. Where as finger pointing small area over heart suggest a non cardiac origin. A hand moving up and down from epigastria to neck suggest heart burn.

* Orthopnea suggest left ventrical failure or mitral stenosis but may also accompany obstructive lung dis.

* Paroxysmal nocturnal dyspnea describes as episode of sudden dyspnea and orthopnea that waken a pts from sleep. It suggest left ventricular failure or mitral stenos sand may be mimicking a nocturnal asmatic attack.

* Wheeze a musical respiratory sound suggest airway obstruction.

* Puffy eyelid and tight ring when associated with edema else where suggest, renal dis or hypoalbuminemia. * Cough is imp symptom of left side heart failure.

* Hemoptysis originating in the stomach is usually darker than that from the respiratory tract.

* Hemoptysis is extremely rare event in infant, children and adolescents seen most often in cystic fibrosis.

* Dysphasia pointing to chest suggest esophageal disorder where as dysphasia pointing to the throat may occur in either a transfer or esophageal disorder. * Dysphagia of solid food suggest mechanical narrowing (obstruction) of the esophagus. Where as dysphgia of both solid and liquid suggest disorder of esophageal muscles.(eg.peristalsis problem).

* Odynophagia describes as pain on swallowing. Sharp burning pain suggest mucosal inflammation vs. squeezing cramping pain suggest muscular cause. * Acute appendicitis exemplified both visceral perital pain. Early distention of inflamed appendix produce periumblical pain, which is gradually replaced by right lower quadrant pain due to inflammation of the adjacent perital peritoneum.

* Visceral pain is poorly localized where as perital pain is caused by inflamed peritoneum and is steady aching pain that is usually more severe than visceral pain and also more precisely localized over the involved structure, aggravated by movement or cough. Pt with this kind of pain usually prefer to stay still. * Pain of duodenal or pancreatic origin may be referred to back. Where as pain from biliary tree may refer to the right shoulder or right poet chest. * Pain from pleurisy or acute MI may be referred to the upper abdomen.

* Cramping (colicky) pain suggest the relationship to peristalsis.

* Gastric juice is clear or mucoid.brownish or blackish vomitus with food particle like coffee ground suggest blood. * the frequency of bowel movement in normal adult is from 3 times a day to twice a week.

* Occasionally constipation becomes complete with the passage of neither feces nor gas this is called OBSTIPATION it occur in intestinal obstruction. * Large diarrheal stool suggest disorder of small bowel or proximal colon. Where as small frequent stool with urgency to defecate suggest disorder of left

colon or rectum.

* Large yellowish or gray, greasy foul smelling and some time frothy and floating stool suggest steatorrhea (fatty stool) associated with mal absorption. * Relief by moving the bowel or by passing gas suggest a disorder in left colon or rectum. TENNESMUS suggest the problem in the rectum or anal canal. * Conjugated type hyperbilirubinemia is cause by viral hepatitis ,cirrhosis ,biliary cirrhosis drug induced homeostasis like oral contraceptives ,methyl testosterone ,chlorpromazine.

* ACHOLIC stool (stool with out bile) are common in viral hepatitis or obstructive jaundice. * Itching favors cholestatic or obstructive jaundice.

* Kidney pain felt at or below the costal margin posteriorly near the costovertebral angle may radiate anteriorly to ward the umbilicus.

* Kidney pain is produce by sudden distention of renal capsule is typically dull, aching and steady. Where as urethral pain is severe colicky pain that originate in costovertebral angle and radiate around the trunk into lower quadrant of abdomen and into upper thigh, testicle, or labium.

* Urethral pain results from sudden distention of ureter and associated distention of renal pelvis. * Bladder pain may cause supra pubic pain and is dull in quality and steady often due to infection.

* Sudden over distention of bladder often cause agonizing pain where as chronic bladder distention is usually pain less. * Prostetic pain fell in the perinium and occasionally in he rectum.

* Uretheritis and cystitis cause painful urination. * In women internal burning cause by arthritis or cystitis. * Urinary frequency suggest infection and irritation of bladder.

* In man pain on urination without frequency or urgency suggest uritheritis.

* urinary frequency with polyurea (day or night) suggest either a disorder of urinary bladder or impairment to flow or below the bladder neck. * Hematuria may cause by cystitis, malignancy, stone, trauma, tuberclosis, or acute glomerulonephritis.

* Drug that may color the urine are laxatives (phenolophthaline), metronidazole, phenazopyridine.

* Urinary incontinence (involuntary loss of urine) may occur when detrusor contraction are too strong, or poor general health or medication or environmental (functional incontinence).urinary incontinence also occur when intrauterine pressure is low (stress incontinence)or may be due to out let obstruction (over flow incontinence) which cause enlargement of bladder due to vol over load.

* Stress incontinence occur while cough sneeze or laugh.

* Hesitation ,dribbling ,or difficulty in start urine is commonly due to partial obstruction like BPH or urethral stricture. ---

* Normal menstrual discharge is dark red where as excessive flow tend to be bright red and may include clots (not true fibrin clot). * Amenorrhea refer to the absence of menstruation.

* Primary amenorrhea is failure to initiate menstruation.

* Secondary amenorrhea is cessation of menstruation after have establishing it .(pregnancy ,lactation & menopause are physiologic form of secondary type).

* Oligomenorrhea is infrequent menstruation common in first 2 year after menarche or menopause. * Polymenorrhea is frequent menstruation.

* Menorrhagia is increase amount and duration flow. * Metrorrhagia is intermenstrual bleeding.

* Postcoital bleeding occur after intercourse or douching.

* Secondary amenorrhea occur due to low body wt mal nutrition, anorexia nervosa, stress, chronic illness, hypothalamic pituitary ovarian dysfunction etc. * postcoital bleeding suggest cervical disease like polyps, cancer, or in older women atrophic vaginitis or endometrial cancer.

* Dysmenorrhea is pain with menstruation & usually felt a bearing down aching or cramping sensation in lower abdomen & pelvis.

* PMS is refer to several symptom in some women during day 4 to 10 before periods. It include tension, nervousness, irritability depression, mood swing ,wt gain, abdominal bloating, edema and tenderness of the breast, and headache. these symptoms in some may be severe and disabling.

* Amenorrhea followed by heavy bleeding suggest a threaten abortion, or dysfunctional uterine bleeding related to the lack of ovulation.

* Dyspareunia is pain on intercourse. vaginismus is involuntary spasm of muscle surrounding the vaginal orifice that make penetration painful or impossible. (vaginismus may physiological or psychological).

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* In erection disorder man cant attain or maintain erection that is adequate to complete the sexual activity. causes are organic psychogenic ,medication ,endocrine ,vascular, or Neurogenic.(a firm erection in any circumstances specially early in the morning

suggest erectile dysfunction is psychogenic). * Premature ejaculation is very common in young man.

* Reduce or absent ejaculation is less common & effect middle aged or older man, may be due to medication, surgery, neurologic deficit, or lack of androgen. * Lack of orgasm with ejaculation is usually psychogenic.

* Severe pallor of finger often followed by cyanosis and than redness indicate Reynaud,s dis or phenomenon.

* Aching cramping and possible numbness and severe fatigue that appears with walking and disappear with rest indicates intermittent claudicating. * Stretching or tearing of ligament called sprain.

* Pain in small joints are sharply localized than large joints. Pain in hip joint is specially deceptive felt in groin or buttock or some time in ant thigh or solely in knee .

* Hip pain felt in or near greater trochanter of the femur suggest trochantric bursitis. * Pain in only one joint suggest bursitis ,tendonitis, or monoarticular arthritis.

* Rheumatic fever early gonnococcal arthritis often have a migratory pattern of spread, where as rheumatoid arthritis typically shows progressive or additive pattern and is symmetrical.

* Usually severe and rapidly developing pain in a swollen joint not explain by injury suggest acute gouty or septic arthritis.( in children specially consider osteomyelitis that involve bone contigous to a joint)

* Pain in the joint with out with out objective evidence of arthritis such as swelling, tenderness, or warmth are called arthralgia.

* Stiffness after inactivity is common in degenerative joint dis but usually last only a few minutes .this is some time called gelling. where as Stiffness in rheumatoid arthritis and other inflammatory arthritis often last 30 min or longer.

* Stiffness also accompanies ,fibromyalgia $, and polymyalgia rheumatica.

* Tenderness, warmth and redness in a joint suggest acute gout , septic arthritis ,or possible rheumatic fever. * IMP CLUES IN MUSCULOSKELETAL DISORDER:

Butterfly rash on cheek---SLE

Scaly rash ,pitted nail ,psoriasis---psoriatic arthritis.

Few papules ,pustules ,vesicles on reddened base located on distal extremity ---gonococcal arthritis. An expanding erythmatous patch early in the illness---lyme,s dis.

Hives---serum sickness and drug reaction.

Erosion or scales on penis and crusting scaling papules on sole and palm---Reiter,s $ (Reiter’s $ also include arthritis uretheritis and conjunctivitis)

Maculopapular rash of rubella---arthritis of rubella Clubbing of finger nail---hypertrophy osteoarthropathy. Red blurring and itchy eyes with arthritis---Reiter’s $.

Preceding sore throat---acute rheumatic fever and gonococcal arthritis.

Diarrhea and abdominal pain---arthritis with ulcerative colitis or regional arthritis. Symptom of arthritis---Reiter’s $ or gonococcal arthritis.

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* In young people how loss consciousness temporarily consider vasodepressor syncope, hyperventilation, and tonic clonic seizures. Voices heard when passing out and coming suggest more vasodepressor syncope or hyperventilation.

* Cardiac syncope starts and stops suddenly common in older person.

* DYSESTHESIAS are distorted sensation in response to stimulus and may last longer than the stimulus it self. For example a person may perceive a light touch or a pin prick as a unpleasant burning or tingling.

--- * In pt with atherosclerosis anemia may decrease the threshold for angina pectoris or intermittent claudicating.

* Patient with severe anemia may have headache, dizziness ,vertigo, syncope ,anorexia ,nausea ,intolerance to cold, amenorrhea ,menorrhagia, loss of libido, impotency.

* Petechiae in skin and mucous mem and small bruises are common in pletelet disorder where as large bruises ,deep hematoma, hemarthrosis are seen in cloting disorder.

* Obesity, weakness, fatigue, easy bruising, ankle edema, decrease or absent menstruation, suggest Cushing,s $. where as weakness, wt loss, nausea, vomiting darken skin and symptom of postural hypotension suggest Addison dis (adrenal in sufficiency).

--- HEADACHES

* TENSION HEADACHES are aching and non painful tightness and pressure associated with anxiety ,tension, depression some time last weeks or month. * MIGRAINE HEADACHE are throbbing or aching often associated with nausea, vomiting, flash’s of light ,blind spot, sensory disturbance, relieve by dark quiet room some time last one to two days.

* TOXIC VASCULAR HEADACHE shows variable severity provoke by fever ,CO, hypoxia ,withdrawal of caffeine.

* CLUSTER HEADACHE one sided study ache high in the nose and behind and over the eye abrupt onset often 2 to 3 hours. associated symptoms are unilateral stuffy runny nose and reddening and teasing of eye.

* HEADACHE WITH EYE DISORDER are ache around and over the eye may radiate to the occipital. Causes are far sightedness, and astigmatism but not near sightedness. Pain relieve by resting other eye associated symptoms are sandy sensations in the eye and redness of conjunctiva.

* TRIGEMINAL NEURALGIA is sharp short brief lightening like recurrent severe pain may disappear for months. Pain typically occur over the distribution of the 3rd _{division of trigeminal nerve 5.}

* GIANT CELL ARTERITIS is chronic inflammation of cranial arteries often temporal and occipital arteries shows throbbing or burning often recurrent severe pain may persist weeks months associated symptoms are tenderness of scalp, fever, malaise, fatigue, muscular ache or stiffness and visual loss or blindness .

* CHRONIC SUBDURAL HEMATOMA shows steady ache of gradual onset weeks to month, often injury progressively severe but may be obscured by clouded consciousness. Associated symptoms are personality change, hemiparesis, injury is often forgotten.

* POST CONCUSSION $ shows rapid onset of steady or severe pain (throbbing) tend to diminish over months or years. Associated symptoms are poor concentration, giddiness (dizziness), vertigo, restlessness, tenseness, and fatigue.

* SUBARACHENOID HEMORRHAGE cause abrupt onset of severe generalized pain “worst of my life” .associated symptoms nausea, vomiting, possible loss of consciousness, neck pain.

* BRAIN TUMOR cause aching steady pain often brief, intermittent but progressive over time .associated symptoms are neurologic deficit, mental symptoms, nausea and vomiting may develop .aggravated by coughing sneezing or sudden movement of head.

--- VERTIGOS

* BENIGN POSITIONAL VERTIGO is sudden onset of vertigo with brief duration may persist for weeks. tinnitus is absent some time cause nausea and vomiting (hearing is not effected).

* VESTIBULAR NEURONITIS (acute labyrinthinitis) cause sudden onset of vertigos may durate hours to days, may recur. tinnitus is absent also shows nausea and vomiting.(hearing is not effected).

* MENIERE,S DIS cause sudden onset of vertigo last several hours to days may recur, shows sensorineuronal loss of hearing that improves and recur eventually progress to one or both sides. Tinnitus, nausea, vomiting, and fullness of effected side are associated symptoms.

* DRUG TOXICITY (amino glycoside, alcohol intoxication) shows acute onset of vertigo with hearing impairment of one side, tinnitus present . Associated symptoms are related to pressure on CN5 ,CN6, CN7.

* Atherosclerosis ,tumor ,multiple sclerosis, ischemia may also cause vertigo.

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* Pericarditis and pleural pain presents sharp knife like severe pain aggravated by breathing and changing position. It can be differentiate by; that pericarditis relieves by sitting where as pleural pain relieves by lying on the involved side.

--- * Dyspepsia shows symptoms similar to peptic ulcer disease but has no ulceration ,common in young age 20-29 yrs. * Duodenal ulcer may wake pt at night ,common in age 30-60 yrs ,it may recur.

* Gastric ulcer is common in older age.

* In peptic ulcer disease or dyspepsia pain occur at epigastria region and may radiate to back. * Pain in cancer of stomach is at epigastric region and do not radiate, common in age 50-70.

* Acute pancreatitis cause pain in epigastria region and may radiate to back pain aggravate by lying supine and relieve by leaning forward with trunk flexed. .where as chronic pancreatitis cause fibrosis of pancrease with epigastria pain radiating through the back, pain is typically steady and deep. Pancreatic cancer cause same symptoms. Remember only chronic pancreatitis shows diarrhea with fatty stool (steatorrhea) and DM.

* Biliary colic is sudden obstruction of cystic duct or common bile duct by gall stone produce steady aching not colicky of rapid onset and usually subside in few hours.

* Acute cholecystitis cause pain with gradual onset longer than pain in biliary colic and aggravate by jarring and deep breathing. * Acute diverticulitis pain is of gradual onset first crampy than steady ,cause initial brief diarrhea than constipation.

* Acute mechanical intestinal obstruction commonly cause by adhesion or hernia, cancer, diverticulitis the pain is typically crampy.

* Small bowel obstruction cause per umbilical pain, vomiting and constipation, V/S where as large bowel obstruction cause lower abdominal or generalized pain constipation (obstipation) first than vomiting.

* Acute arterial occlusion produce crampy pain first periumbilically than steady and diffuse cause vomiting, bloody diarrhea, constipation than shock. * Melena (black tary shiny stool) cause by peptic ulcer, gastritis, or stress ulcer, esophageal or gastric varices, reflex esophagi is, Mallory weiss tear. * Black non sticky stool may cause by ingestion of iron, Pepto-Bismol, licorice, and even chocolate cookie.

* Irritable bowel $ may cause small hard often with mucous stool, with period of diarrhea, abdominal cramping, stress aggravate it. where as constipation cause by cancer of rectum and sigmoid colon. Rectal cancer cause tennesmus abdominal pain bleeding and pencil shape stool.

* Fecal impaction is large firm immovable mass most often in rectum common in children.

* Diverticulitis, volvulus, intusseseption, and hernia may cause colicky abdominal pain, abdominal distention, and in intusseseption often current jelly stool(red blood +mucous).

* Red blood in stool may cause by cancer of colon, polyps, diverticula’s of colon , ulcerative colitis, infectious dysenteries, anal intercourse, ischemic colitis, hemorrhoids and anal fissure.

* Acute non inflammatory infectious diarrheas watery caused by viruses ,toxin produce by E. coli ,staph aureus and giardia lamblia cause cramping. * Acute inflammatory infectious diarrhea cause by invasion of organism in intestinal mucosa produce loose to watery diarrhea often with pus blood and mucous. Rectal urgency, cramping, tennesmus may occur.

* Chronic diarrhea:- Irritable bowel $ cause diarrhea which rarely wake the pt in night where as in ulcerative colitis and chrone dis diarrhea wake the pt in night .it also cause crampy pain, fever, anorexia, wt loss.

--- * Thirst is not present in polyurea if cause by excessive water in take. nocturia is usually absent in these cases.

* Burning on urination, urgency, some time gross hematuria is because of bladder inflamation (due to infection, tumor, stone, forign body etc ) . it shows frequency with out polyurea.

* Frequency with out polyurea may also cause by BPH, motor disorder of CNS like in stroke, urtheral stricture, peripheral neuropathy as in DM. it cause hesitancy in starting the urinary stream ,dribbling during or in the end of urination.

* Nocturia with high vol may cause by CRF, bed time alcohol or coffee.

* Stress incontinence :- in which urethral sphincter is weak (momentary leakage of small amount of urine occur with stress like coughing ,laughing ,sneezing when in upright position).on physical examination bladder is not detected, atrophic vaginitis may be evident desire of urination is not associated with pure stress incontinence. Common in women due to child birth and surgery, post menopausal atrophy of mucosa, or urethral infection. In man stress incontinence may follow prostate surgery.

* Urge incontinence :- In which Detrusor contraction are stronger than normal and over come normal urethral resistance. The bladder is typically small and cant be detectable on physical exam. ( it is basically due to decrease inhibition from cerebral cortex to detrusor contraction, common in strokes, brain tumor, dementia and lesion in spinal cord above sacral level. It may cause by hyperexcitability of sensory pathway due to infection tumor fecal impaction. Another possible mechanism is reconditioning of voiding reflex due to frequent voiding at low bladder vol, ( pseudo stress incontinence ).

* Overflow incontinence :- In which detrusor contraction are insufficient to over come urethral resistance. The bladder is typically large and tender on palpation even after the effort to void. It may due to obstruction of bladder out let as in BPH and tumor, nerve weakness at the level of sacral region, impaired bladder sensation that interrupt the reflex as in Diabetic neuropathy, also shows dribbling and decrease force of urinary stream.

* Functional incontinence :- this is functional inability to get the toilet in time due to impaired health or environmental conditions. eg, arthritis, weakness, poor vision, unfamiliar setting (look for physical or environmental clue ).

* Incontinence secondary to medication :- tranquilizers, anticholinergic, sympathetic blocker, and potent diuretics. * POLYURIA :-

* Decrease of ADH (diabetes insipidus), Nephrogenic diabetes insipidus (renal unresponsiveness to ADH) ,hypercalcemia, hypokalemic nephropathy, renal dis or drug like lithium results into polyurea, thirst, severe polydipsia, nocturia.

* Nocturia with high vol cause by excessive fluid intake, before bed time coffee, alcohol, chronic renal insufficiency, CHF, nephrotic $, hepatic cirrhosis with ascitis ,chronic venous insufficiency, and causes of polyurea.

* Nocturia with low vol may result from insomnia, pseudofrequency ( voiding with out real urge),and other causes of frequency with out polyurea. * FREQUENCY WITH OUT POLYUREA :

*  bladder sensitivity to stretch cause by inflammation due to infection, stone, tumor results into burning on urination frequent urgency with out polyurea and some time gross hematuria.

*  elasticity of bladder due scar or tumor also results into burning on urination, frrequent urgency with out polyurea and some time hematuria. * Motor disorder of CNS like stroke cause decrease cortical inhibition of bladder contraction cause frequent urgency with out polyurea.

* Impaired emptying of bladder with residual urine in bladder due to obstruction, BPH, urethral stricture, results into hesitancy in starting the urinary stream, straining to void, reduced size and force of stream, dribbling during and at the end of urination, and frequent urine with out polyurea. It also cause by loss of nerve supply to bladder due to accident or DM.

--- * ARTERIAL DISORDER :

* Pain occur in arteriosclerosis is fairly brief ,pain aggravate by work and relieve by rest in 1-3 min. pain usually occur in calf but may also felt in buttock, hip, thigh, and foot; depending on level of obstruction of large and middle size arteries.

* Persistent pain at rest which worst at night and aggravate by elevation of feet (as in bed) is due to ischemia. Sitting with leg dependent may provide relief. * Acute arterial occlusion due to embolism and thrombosis possibly superimposed on atherosclerosis cause distal pain of sudden on set involving the foot and leg may associated with absent distal pulses .

* VENOUS DISORDER :

* Clot formation and acute inflammation of superficial vein cause superficial thrombophlebitis which produce pain locally along the course of involved vein, which last day or longer. It is associated with local redness, swelling, tenderness, palpable cord and possible fever.

* Clot formation of deep venous vein cause deep venous thrombosis if pain present is usually in calf but process is most often painless and hard to determine.

* Chronic venous engorgement secondary to occlusion or incompetency of venous valve may result into diffuse aching of leg; pain aggravated by prolong standing and relieve by elevation of leg .It may shows chronic edema, pigmentation ,possibly ulceration.

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* Acute lymphangitis cause by acute bacterial infection usually streptococcus results into red streak on the skin with enlarge tender lymph node and fever. * Thromboangitis oblitrans (buerger,s dis) is inflammatory thrombotic occlusion of small arteries and vein in smokers result into intermittent claudication of the arch of foot (finger and toe) pain is fairly brief but recurrent may be worst at night, excersize aggravate it and rest gives relief. Associated symptoms are distal coldness, sweating, numbness, cyanosis, ulceration and gangrene at the tip of finger.

* Raynaud,s dis cause pain which is relatively brief but recurrent in one or more finger some time ulcer develop. Numbness tingling are common, exposure to cold aggravate it and warm environment gives relief.

* Acute cellulites and erythma nodosum mimic venous disorder (mistaken primarily for acute superficial thrombophlebitis).

* Acute cellulites is bacterial infection of skin and subcutaneous tissue result into diffuse swelling, redness and tenderness with enlarge lymph node and fever. There is no palpable cord, do not mistaken with superficial thrombophlebitis.

* Erythma nodosum a subcutaneous inflammatory lesion associated with variety of condition like pregnancy, acidosis, TB, streptococcal infection. Usually occur at ant surface of both lower legs manifest as raised red, tender, swelling with crops; with often malaise, joint pain, and fever. Do not mistaken with superficial thrombophebitis.

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* Rheumatoid Arthritis : - Chronic inflammation of synovial mem with secondary erosion of adjacent tissue (cartilage and bone) and damage to ligament and tendon. It progress to other joint symmetrically. Associated symptoms are swelling, tenderness, warm but seldom red. Stiffness is prominent after a period of inactivity, limited motion, weakness, fatigue, wt loss and low fever are common.

* Osteoartheritis is insidious onset of degenerative bone and cartilage dis. It progress to other joint but only one joint may be involve. Little swelling may be present it is seldom warm and red. Tenderness present with stiffness in morning & after inactivity may results into limited motion.

* Acute gout is an inflammatory reaction to micro crystal of sodium urate commonly occur with first metatarsophalangeal joint (base of big toe) rarely occur in other joints. It produce pain of sudden onset often at night after injury, surgery ,fasting, excessive food, alcohol intake. typically the joint is tender hot and red. motion is limited due to pain, fever may be present.

* Chronic tophaceous gout is accumulation of sodium urate in multiple joint and other tissue (tophi) with or without inflammation. Swelling present in joints, bursae, and subcutaneous tissue. Tenderness, warm, and redness may present with stiffness and limited motion. Pt may develop a symptom of renal failure, renal stone, and fever.

* Polymyalgia Rheumatica is dis of unclear nature seen in people in more than 50 yrs of age specially women may be associated with giant cell arthritis. Pain occur in muscle of hip girdle and shoulder girdle symmetrically. Pain may be insidious or abrupt even appearing over night. Shows no swelling warm or redness, but may be tender specially in morning. limitation of motion is usually none may shows malaise, sense of depression, anorexia, and wt loss. * Fibromyalgia $ is a wide spread musculoskeletal pain may accompany other dis (mechanism unknown). Pain shift unpredictably in response to immobility, excessive move, or chilling. Pain is chronic with ups and downs without swelling, redness and warm; symmetric tenderness not recognized until examination. Stiffness present specially in morning there is no limitation of motion.

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* Common lower back pain is often relieve by rest, common in teenage yrs to 40. Intervertibral disc is involve in many cases. Show percussion tenderness over spinous process.

* SCIATICA :- is redicular nerve root pain radiate down to one or both leg usually below the knee with numbness, tingling, and pain worsen by spinal movement (like bending, coughing, sneezing, leg raising).loss of sensation in dermotomal distribution, decrease to absent reflexes specially affecting the ankle jerk. Dermotomal sign and reflexes may be absent when one root is involved. usual causes are herniated intervertebral disc with contraction and traction of nerve root, spinal tumor, abscess.

* BACK PAIN OR SCIATICA WITH PSUEDOCLAUDICATION :- psuedoclaudication is a pain in the back or leg that worsen with walking and improve with flexing of spine or bending forward, causes include lumber stenosis which is combination of degenerative disc dis and osteoarthritis which narrow the spinal canal. common after age 60 (imp sign flexed posture).

* CHRONIC PERSISTENT LOW BACK STIFFNESS :- may cause by ankylosing spondilitis, chronic inflammatory poly arthritis common in young man. Where as diffuse idiopathic skeletal hyperostosis which effect middle age and older man. it manifest by loss of normal lumbar lordosis, muscle spasm, limitation of ant and lateral flexion and immobility of spine of middle and older age man.

* Aching nocturnal back pain unrelieved by rest usually case by metastatic malignancy from prostate , kidney, lung, breast, thyroid and multiple myeloma. Local bone tender may be present.

* Back pain referred from abdomen and pelvis is usually deep and aching, spinal movement is not painful, range of motion is not effected, common causes are peptic ulcer, pancreatitis, pancreatic cancer, chronic prostitis, endometriosis, dissecting aortic aneurysm, retroperitoneal tumor.

--- * Simple stiffness is acute episodic localize pain in the neck often appearing on awakening and last 1 - 4 day .

* Persistence dull aching in the back of the neck often spreading to occiput; common with postural strain, prolong typing, studying may also accompanying tension and depression when pain and tenderness are also present else where in the body consider fibromyalgia $.

* CERVICAL SPRAIN :- acute and often recurrent neck pain that are often more severe and last longer than simple stiff neck may precipitate by whip lash injury, heavy lifting or sudden movement. There is no dermotomal radiation.

* NECK PAIN WITH DERMOTOMAL RADIATION :- Is the neck pain as in cervical sprain but also radiate to dermotomal distribution(in arms, shoulder and back).the pain is typically sharp, burning and tingling in quality. Muscle spasm and tenderness with limited range of motion present. Pain increases with coughing, sneezing, and possible sensory loss with muscular atrophy. Causes include compression of one or more nerve due to herniated cervical disc or degenerative bone dis, Bony spurring, tumor or abscess.

* NECK PAIN WITH COMPRESSION OF CERVICAL SPINAL CORD :- In this neck pain present with associated symptoms of paralysis of leg, loss of sensation and position, vibration in leg, less commonly loss of temp and pain in leg, bibinski response +, the neck pain may be mild or even absent, possible causes are spinal cord compression due to herniated cervical disc, degenerative dis, bony spurring, trauma, abscess or tumor.

--- SYNCOPE AND SIMILAR DISORDER

* VASO DEPRESSOR SYNCOPE (common faint) :- Is a sudden peripheral vasodialation specifically in skeletal muscle with out compensatory rise in cardiac out put (BP falls). Causes are fatigue, hunger, hot humid environment which further precipitate by fear and pain. It manifest by restlessness, weakness, pallor, nausea, salivation, sweating, yawning. Always prompt return of consciousness occur when lying down.

* POSTURAL (ORTHOSTATIC) HYPOTENSION :- Syncope due to inadequate vasoconstriction reflex in both arteriole and veins with resultant venous pooling,  cardiac out put and decrease BP. Predisposing factors are peripheral neuropathies, or disorder of autonomic nervous sys, antihypertensive and vaso dialators, prolong bed rest. Prompt return to consciousness when person lying down..

* Postural (orthostatic hypotension may be cause by hypovolemia due to variety of situation eg, GI bleeding, diarrhea, vomiting, polyurea, dehydration, etc. it manifest by light headedness palpitation on standing. It improves on lying down.

* COUGH SYNCOPE :- occur due to  intrathorasic pressure due to severe paroxysm of coughing specially if person s muscular but prompt return to normal is usual.

* MICTURITION SYNCOPE :- occur usually in elder or adult man with nocturia precipitate by emptying the bladder after getting out of bed to void (mech is unclear). Prompt return to normal is usual.

* ARRHYTHMIAS :- too low < 35 - 40 B/min . or too fast > 180 B/min results into decrease cardiac out put. Prompt return to normal often occur. causes are organic heart problem, older age decreases the tolerance of abnormal rhythm.

* Aortic stenosis and hypertrophic cardiomyopathy when cause syncope is because vascular resistance falls but cardiac out put fail to rise. Onset is sudden which usually ends up with prompt return to normal.

* Myocardial infarction can cause syncope with sudden arrhythmias or  cardiac out put .

* massive pulmonary embolism cause syncope due to hypoxia or  cardiac out put .predisposing factors are deep venous thrombosis.

DISORDER RESEMBLING SYNCOPE

* Hypocapnia due to hyperventilation cause constriction of cerebral blood vesels .predisposing factor are anxiety, dyspnea, palpitation, numbness, tingling, chest discomfort, recovery is slow after hyperventilation ceases.

* Hypoglycemia disturbs cerebral metabolism with resultant epinephrine release and manifest by sweating, tremor, palpitation, hunger, headache, confusion, abnormal behavior, coma (true syncope is uncommon). Predisposing factors are metabolic disorder, insulin therapy, fasting.

* Hysteria fainting due to conversion disorder (mechanism is symbolic expression of an unexceptable idea through body language under stress full situation). It manifest as a slump to floor recovery may be prolong .

SIEZURES

** PARTIAL SEIZURES starts with focal manifestation indicate a structural lesion in cerebral cortex.

A. Simple partial seizures with motor symptom :- *Jacksonian seizures are tonic than clonic that start unilaterally in foot hand and face than spread to the other part of body on the same side but

maintain normal consciousness. Where as other motor seizures cause turning of head and eye to one side or tonic and clonic movement of one arm or

leg with out jacksonian spread but maintain normal consciousness.

B. Simple partial seizures with sensory symptoms :- Manifest as numbness tingling, simple visual, auditory and olfactory hallucination such as flash light,

buzzing or odor. Consciousness is normal.

C. Simple partial seizures with autonomic symptoms :- Manifest as funny feeling in the epigastrium cause nausea, pallor, flushing, light headedness but

normal consciousness.

D. Simple partial seizures with psychic symptoms :- Manifest as anxiety or fear, feeling of déjà vu or unreality, dreamy state, fear or rage, flash back experiences, more complex hallucination. Consciousness is normal.

** COMPLEX PARTIAL SEIZURES with simple partial seizures or with impaired consciousness. Automatism may develop. The seizures may or may not start with autonomic or psychic symptoms rather with impaired consciousness and person may appear confused. Pt may remember initial automatic or psychic symptoms but is Amnesic for rest of the seizures. Temporary confusion and headache mat appear.(Automatism include automatic motor behavior like chewing, smacking lips, walking about, unbuttoning cloths, or skilled behavior such as driving a car).

** PARTIAL SEIZURES THAT BECOME GENERALIZED :- It resembles clonic seizures (grand mal). Pt may not recall focal onset. 2. symptoms indicate a partial seizures that has become generalized that is recollection of an Aura and unilateral neurologic deficit during post tictal period.

** GENERALIZED SEIZURES :- it begins with bilateral body movement or impaired consciousness or both suggest bilateral cortical disturbance either hereditary or acquired. Tonic clonic (grand mal) usually starts in childhood or young adulthood. They are often hereditary but when starts after 30 yrs often toxic or metabolic in origin.

A. Tonic clonic seizures (grand mal) :- in which person losses consciousness suddenly and body stiffen into tonic extensor rigidity, breathing stops and person becomes cyanotic. Than a clonic phase of rhythmic muscular contractions follows, breathing resume and is often noisy due to excessive salivation. Tongue biting and urine incontinence may occur. After post tictal state (post seizure) confusion, drowsiness, fatigue, muscular aching and some time persistent but temporarily bilateral neurologic deficit such as hyperactive reflexes, bibinski response. The has amnesic during seizures and recall no Aura. B. Absence seizures :- A sudden breif lapse of consciousness with momentary blinking, staring, movement of lip and hands but no falling. Two types are recognized 1. Petit mal absence :---- last < 10 sec and stops abruptly, no aura recall .

2. Atypical absence :---- last > 10 sec post tictal cofusion occur.

C. Atonic seizures or drop attack :- sudden loss of consciousness but no movement occur. Either prompt return to normal or brief period of confusion occur.

D. Myoclonus :- sudden brief rapid jerks involving the trunk or limb associated with variety of disorder.

** PSEUDOSEIZURES :- these may mimic seizures but are due to conversion reaction (psychologic disorder). The movement may have personally symbolic significance and often don’t follow neuroanatomic pattern often variable post tictal state.

---

* Lethargic pts are drowsy but open there eye and look at you respond to question and than falls a sleep. Where as obtunded pts open there eye looked at you but respond slowly and are some what confused.

* Tense posture, restlessness, and fatigue suggest anxiety. * Crying, pacing, hand wringing, occur in agitated depression.

* Hopeless, slump posture, and slowed movement, occur in depression. * Singing, dancing, and expensive movement occur in manic episode.

* Grooming and personal hygiene may deteriorate in depression, dementia, and schizophrenia. * Excessive fastidiousness (overly difficult to please) seen in obsessive compulsive disorder. * One sided neglect occur from lesion of opposite prietal lobe cortex (usually non dominant side). * Anger, hostility, suspiciousness, or evasiveness occur in paranoid pt.

* Elation (fill with joy) and Euphoria (marked feeling of well being) occur in manic $. * Flat effect and remoteness occur in schizophrenia.

* Apathy (lack of emotion with detachment and indifference) occur in dementia, depression, and anxiety.. --- * Dysarthia refer to defective articulation (like bar with dar and pen with den).

** TESTING FOR APHASIA :- (disorder of language)

* Word comprehension :- ask pt one stage command (point to your nose), or two stage command (point your mouth than your knee). * Repetition :- ask pt to repeat a phrase of one syllabus word (no, if, and, but).

* Naming :- ask the pt names, like parts of watch. * Reading :- ask pt to read loud.

* Writing :- ask pt to write a sentence (a person who can write correct sentence does not have aphasia.). --- “VARIATION & ABNORMALITY IN THOUGHT PROCESS”

* Cercumstantiality :- speech characterize by indirection and delay in reaching the point because of unnecessary detail. Observe in obsessional person. (many people speak circumstantially with out mental disorder).

* Derailment (loosing of association) :- speech in which person shift from one subject to another that are unrelated or obliquely related without realizing that subject are not meaningfully connected. Observed in schizophrenics, manic episode and other psychiatric disorder.

* Flight of ideas :- an almost continuous flow of accelerated speech in which person changes abruptly from topic to topic and idea do not progress to sensible conversation, But speech changes are usually understandable association. found in mania.

* Neologism :- Invented and distorted word with new and highly idiosyncratic meanings observed in schizophrenia, psychotic disorder and aphasia. * Incoherence :- speech that is largely incomprehensible because of lack of meaningful connection. Shift of meaning occur with in clauses. It observed into

severely disturbed psychotic person usually schizophrenic.

* Blocking :- sudden interruption of speech In mid sentence or before completion of an idea, it may occur in normal people phenomenon may be striking in schizophrenics.

* Confabulation :- fabrication of facts or events in response to question, to fill in the gap in an impaired memory. Common in amnesia. * Perseveration :- persistent repetition of words and ideas. Occur in schizophrenic and other psychotic disorders.

* Echolalia :- repetition of the word and phrases of others ,occur in manic episode and schizophrenia.

* Clanging :- speech in which person chooses a word on the basis of sound rather than meaning , eg my beautiful eye in your tie. Occur In schizophrenia and manic episode.

--- * Thought process asses the logic, relevance organization, and coherence by word and speech.

* Thought content can provide more information about the pts idea or thought by asking question like ,what do you think about it in time difficult like that ? Or what do thing suppose to be done in that situation?. Etc.

** ABNORMALITIES OF THOUGHT CONTENT :

* compulsion :- repetitive behavior or mental act that a person feel driven to perform in order to produce or perform some future affair. Although expectation of such an effect is unrealistic. Compulsion often associated with neurotic disorder.

* obsession :- recurrent uncontrollable thoughts, images, or impulses that a person consider unacceptable and alien. Obsession often associated with neurotic disorder.

* phobias :- persistent irrigational fear accompanied by compelling desire to avoid the stimulus. Phobias are often associated with neurotic disorder. * anxiety :- apprehension, tension, fear, or uneasiness that may be focused (phobia) or free floating (a general sense of ill defined dread or impending doom). Anxiety often associated with neurotic disorder.

--- vs. ---

* feeling of unreality :- a sense that thing in the environment are strange, or unreal. Feeling of unreality is often associated with psychotic disorder. * feeling of depersonalization :- a sense that one self is different, changed , unreal, or has lost identity or become detached from one’s mind or body. Feeling of depersonalization is often associated with psychotic disorder.

* delusion :- false, fixed, personal belief that are not shared by others; delusion is often associated with psychotic disorder. - delusion of persecution

- grandiose delusion - delusion of jealousy

- delusion of reference :-person belief that external events, objects, or people have particular unusual personal significance .eg . Television might be commenting or giving instruction to a person.

- delusion of being controlled by out side forces.

- somatic delusion :- delusion of having a dis, disorder, physical defect. - systematized delusion :- cluster of delusion around single theme.

---

* Perception :- can be inquired by asking for eg when you heard those voices what did it says ? Or how did it make you feel ? ** ABNORMALITIES OF PERCEPTION :-

*illusion :- misinterpretation of real external stimuli. It may occur in grief reaction, delirium, acute and post traumatic stress disorder, and schizophrenia. * hallucination :- subjective sensory perception in the absence of relevant external stimuli. The person may or may not recognized the experiences as false. hallucination may be auditory, visual, olfactory, gustatory, tactile or somatic ( false perception associated with dreaming, falling a sleep, and on awakening are not classified as hallucination). Hallucination may occur in delirium, dementia (less commonly), post traumatic stress disorder, and schizopherenia. ---

* Insight :- is whether a pt is aware about his illness. Pt with psychotic disorder often lack insight into there illness. Denial of impairment may accompany some neurologic disorder. Always ask question like what bring u to the hospital ? What do u think is wrong to explain your illness or problem?

* Judgment :- assess pts response to family situation, job, use of money, interpersonal conflict. It can be assess by asking pt that how you will manage if you loss your job? Or what will you do if your class neighbor will threat you? Judgment may be poor in delirium, dementia, mental retardation, psychotic state. judgment can also be effected by anxiety, mood disorder, intelligence, education, socioeconomic state, and cultural values.

---

** COGNETIVE FUNCTION :-

* orientation :- can be determined by asking time, place, person. disorientation occur when memory or attention is impaired. as in delirium.

* attention :- test the pt ability to concentrate by adding, subtracting, spelling back ward, zip code, tel #, repeat number backward (person should be able to repeat at least 5 digit forward and 4 backward normally). Attention is poor in delirium, dementia, mental retardation, depression, anxiety and education.

* remote memory :- inquire about birthday. Anniversaries, social security, name of school attended, job, best friend’s name. remote memory impairment occur in late stage of dementia.

* recent memory :- is events of the day. Ask question about it and note if he is confabulating. Recent memory is impaired in dementia, delirium, amnestic disorder, anxiety, depression, and mental disorder.

* new learning ability :- give the pt 3 or 4 word and ask pt to repeat; than after three or five min ask pt to repeat the those words again. Normally person remember if not suffering from amnestic disorder.

--- ** HIGHER COGNETIVE FUNCTION :-

* information and vocabulary :- gives rough estimate but is fairly good indicator of persons intelligence. You can ask about name of president, governor, last 4 - 5 president large cities or countries, etc. information and vocabulary are usually effected in severely psychiatric disorder, and mental retardation. Where as in mild to moderate dementia information and vocabulary is fairly well preserved.

* calculating ability :- eg 9 x 4 = ? .poor performance is may be the sign of dementia, aphasia, education. Ask simple other calculations like charging 55 cents out of dollar how much you give back ?

* abstract thinking :- can be testing by two ways.

- proverbs :- ask pt what people means when says “ eye for an eye “ or “ squeaking wheel gets the grease “ or “ early to bed early to rise “ etc where as average pt should give abstract or semi abstract reason. (eye for an eye is concrete where as justice is an abstract reason).

- similarities :- ask pt about the similarities of things like how following are alike, pencil and a pen, helicopter and a plan, child and a dwarf etc. helicopter

and plane both fly is abstract but they both have tail is concrete.

* Concrete response is given by person with mental retardation, delirium, dementia, or a little education. Schizophrenics may respond concretely or with personal irrelevant or nonsense interpretation.

* constructional abilities :- can assess like copying figure like circle, triangle, rectangle, square, clock. If vision and motor ability is intact, poor construction ability suggest dementia or parietal lobe damage.

* mini mental state examination ( MMSE ) :-score < 24 increases the likelihood of dementia. (out of max score of 30, 24 - 30 consider normal). ---

** MOOD DISORDER :-

* major depressive episode :- in which depressed mood (irritable mood in children and adolescent), markedly diminish interest or pleasure are always present. Beside that pt may shows significant wt gain or loss, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue loss of energy, feeling of worthlessness or guilt, inability to concentrate, indecisiveness, recurrent thought of death or suicide ( or specific plan to attempt suicide ). In severe cases hallucination and delusion may occur. Major depressive episode usually last 2 weeks.

* manic episode :- in which distinct period of abnormally and persistently elevated, expensive, or irritable mood occur. During episode 3 of the following symptoms must present and persist at least for a week, inflated self esteem or grandiosity, decrease need for sleep, more talkative than usual, flight of ideas racing thoughts, distractibility, increase goal directed activity, or psychomotor agitation, excessive involvement in pleasurable high risk activity. In sever cases hallucination and delusion may occur.

* mixed episode :- last one week meet criteria for both manic and depressive episodes.

* hypomanic episode :- symptoms resemble those in manic episode but less impaired last less than a week.

* dysthymic disorder :- is depressed mood and symptoms over at least 2 yrs (1 yr in children and adolescent). Freedom from the symptoms last not > 2 mo.

* cyclothymic disorder :- is a numerous period of hypomanic and depress symptom that last for at least 2 yrs (1 yr in children and adolescent). Symptom free period is no more than 2 month at a time.

---

** ANXIETY DISORDER :- cause great distress and impaired function, affected one are not psychotic.

* panic disorder :- defined by recurrent, unexpected panic attack, period of intense fear or discomfort which develop abruptly and peak with in 10 min .panic attack include at least 4 of the symptoms, palpitation, sweating, trembling, shortness of breath or sense of smothering, feeling of chocking, chest pain or discomfort, nausea abdominal distress, dizziness fainting, feeling of unreality or depersonalization, fear of going crazy, fear of dying, paresthesia, chill or hot flashes.

* agoraphobia :- is anxiety about being in place or situation where escape may be difficult or help for sudden symptom may unavailable. Such situation are avoided or requires companion.

* specific phobia :- marked persistent fear of specific object, situation, eg dogs, injection. Specific phobia impaired the persons normal routine. * social phobia :- marked persistent fear one or more social or performance situation that involve exposure to unfamiliar people or scrutiny by others. Exposure create anxiety or possible panic attack and person avoid precipitating situation. Social phobia impair normal routine and relation ship. * obsessive compulsive disorder (OCD) :- involve obsession or compulsion that cause marked anxiety or distress. Pt recognize it as excessive and

unreasonable. OCD may interfere with persons normal routine and relation ship.

* acute stress disorder :- the traumatic event that threatened death or serious injury to one self or to other with resultant response of intense fear, helplessness or horror. During or immediately after this event person has at least 3 of the following symptoms. Numbness, detachment, absence of emotional responsiveness, reduce awareness of surrounding as in daze, feeling of unreality, feeling of depersonalization, amnesia for an event (imp part). The event is persistently reappeared. Person tries to avoid situation that provoke the memories of event. Symptoms occur with in 4 weeks of event and last 2 days to 4 weeks.

* posttraumatic stress disorder :- is traumatic event and fearful response and persistent experiencing of traumatic event as resembles acute stress disorder. Hallucination may occur, person tries to avoid stimuli that may provoke response. The disturbance cause marked distress, impair social and occupational functions. PTSD last more than month.

* generalized anxiety disorder :- excessive anxiety and worry which person find hard to control with at least 3 of the following symptoms; feeling restless, fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, insomnia or unsatisfied sleep. Generalized anxiety disorder impair social, occupational, and other imp functions.

---

* negative symptoms are flat affect, alogia (lack of content in speech), avolition (lack of interest, drive and ability to set and pursue goal), contiguous sign of disturbance must persist for at least 6 months.

** PSYCHOTIC DISORDER :- psychotic disorder impair reality testing.

* schizophrenia :- schizophrenia impairs major functioning at school, work, or in interpersonal relationship or self care. The person must manifest 2 of the following for a significant part of one month; these are delusion, hallucination, disorganized speech, disorganized catatonic behavior (psychomotor abnormalities like stupor, mutism, purposeless activity, bizarre posture, excited ), and negative symptoms.

* schizophreniform disorder :- has symptoms similar to schizophrenia but they last less than 6 months. Functional impairment may not be present unlike schizophrenia.

* schizoaffective disorder :- has a symptoms of both major mood disturbance and schizophrenia. The mood disturbance (depressed manic or mixed) is present during most of the illness and most of the time being concurrent with schizophrenic symptoms. During same period of time there must be delusion or hallucination for at least 2 weeks with out prominent mood symptom.

* delusional disorder :- characterized by non bizarre delusion that involve situation In real life such as having a disease or being deceived by lover. Delusion persist for at least a month, person functioning is not markedly impaired and behavior is not odd or bizarre. Symptom of schizophrenia is not present except tactile and olfactory hallucination.

* brief psychotic disorder :- in which one of the following psychotic symptom must be present; these are delusion, hallucination, disordered speech, frequent derailment or incoherence, grossly disorganized or catatonic behavior (psychomotor abnormality). The disturbance last at least one day but less than one month and person return to its prior function level.

* psychotic disorder due to medical condition :- prominent hallucination and delusion may be experienced during medical illness. ( for this Dx should not occur exclusively during the course of delirium)

* subs induced psychotic disorder :-prominent hallucination or delusion may be induced by intoxication or withdrawal from subs such as alcohol, cocaine, opioids etc. (for this Dx should not occur exclusively during the course of delirium)

--- * DELIRIUM AND DEMENTIA :-

*delirium :- is characterize by decrease level of consciousness, behavior decreased (somnolence) or increased (agitated or hypervigilence), hesitancy or rapid speech, disorganized incoherent thought process, delusion, illusion, hallucination often visual, impaired judgment, disoriented, unable to concentrate, and impair immediate and recent memory.

Causes are -- delirium tremens(alcohol withdrawal), uremia, acute hepatic failure, acute cerebral vasculitis, atropine poisoning.

* dementia :- is characterized by usually normal level of consciousness(until late in course), normal to slow may be inappropriate behavior, difficulty in finding words(aphasia), often flat depressed mood, impoverished thought process, delusion, hallucination, judgment impaired over the course of illness, Fair orientation and attention (until late in course),recent memory specially new learning impaired.

Causes -- vit B12 deficiency, thyroid disorder ---> causes reversible dementia

Alzheimer’s dis, vascular dementia ( due to infarct or trauma) ---> cause irreversible dementia. * Delirium may superimposed dementia some time.

SKIN, HEAD, AND NECK

* Very short stature found in turner’s $, achondroplasia, renal or hypopituitary dwarfism, where as long limbs in proportion to the trunk found in hypogonadism, marfan’s $.

* Generalized fat found in simple obesity, where as trunkal fat found with relative thin limb found in cushing’s $.

* Wt loss found in malignancy, DM, hyperthyroidism, chronic infection, depression, diuresis, successful dieting, anorexia nervosa, bulimia. * Pt with left heart failure prefer sitting up right, where as pt with COPD prefer leaning forward with arm braced.

* Fast frequent muscular movement found in hyperthyroidism, where as slowed activity found in my edema. * Cold intolerance found in hypothyroidism.

* Stare found in hyperthyroidism, where as immobile face found in Parkinson’s dis. * Hypothermia refer to below 35 degree C or 95 degree F of temperature.

* Hypothermia may cause by starvation, hypothyroidism, hypoglycemia.

* Dry skin (asteatosis) is flaky rough and often itchy. It is frequently shiny specifically on legs.

* Cyanosis depend in level of oxygen in arterial blood. If this level is low cyanosis is central if its level is normal cyanosis is peripheral. Central cyanosis is best identify in lips, oral mucosa, and tongue.

* Central cyanosis is cause by advanced lung dis, congenital heart dis, hemoglobinopathies.

* Peripheral cyanosis occur in venous obstruction, CHF(with pulmonary edema it may also be central). * Dryness, roughness of skin occur in hypothyroidism, where as oiliness occur in acne.

* Lift a fold of skin and note the ease with which it lift up (mobility), and speed with which it return to its place (turgor). * Decreased mobility of skin occur in edema and scleroderma and decreased turgor found in dehydration.

* Lichenification is thickening and roughening of skin with increased visibility of normal skin furrows, eg atopic dermatitis. * Excoriation is an abrasion of scratch mark. It may be linear or round as in scratched insect bite.

* Atrophy is thinning of skin with loss of normal skin furrows the skin look shinier and more translucent than normal eg arterial insufficiency. * Burrows of scabies look like short, linear or curved gray line and may end in the tiny vesicle ( burrow is slightly raised tunnel).

* Comedo refer to black head.

* Unlike jaundice carotene does not effect sclera which remains white.

* Increase in melanin may be due to Addison’s dis (hypofunction of adrenal cortex) or pituitary tumor. * Café-Au-lait spot in six or more in quantity of diameter >1.5 cm suggest neurofibromatosis.

* Spider angioma is fiery red with radiating legs almost never occur below the waist suggest liver dis, pregnancy, vit B deficiency, also occur in normal person.

* Cherry angioma has no radiating legs occur with increase age.

* Purpura (petechia 1- 3 mm, purpura are larger) suggest bleeding disorder and emboli to skin. * Ecchymosis (is of purple color) are often secondary to trauma, also seen in bleeding disorder.

* Basal cell carcinoma seldom metastasize initially a translucent nodule spreads leaving a depressed center and firm elevated border and telengiectatic vessel around it usually over age 40 in fair skin persons. Ulceration may occur.

* Squamous cell carcinoma occur in sun exposed skin look redden and firmer than basal cell carcinoma usually occur over age 60 in fair skin person. It may develop actinic keratosis.

* Actinic keratosis is superficial, flattened papule, covered by dry scale occur in fair skin old person. It is benign & may give rise to summons cell carcinoma. * Seborrheic keratosis is benign yellow to brown raised lesion that feel slight greasy, velvety, or warty, usually occur in trunk and face of older people or young black women.

* Clubbing of finger suggest chronic hypoxia due to cancer of lung etc.

* Terry’s nail are mostly whitish with a distal band of reddish brown suggest aging, liver cirrhosis, CHF, DM type 2. * Small pit in the nail may be a early sign of psoriasis but not specific.

* Beau’s lines in the nail are transverse depression associated with acute severe illness.

--- EYES, EAR, NOSE, MOUTH

* Palpable fissure is refer to opening b/w the eye lid.

* Muscle of eye movement :- superior rectus } 3rd _{CN superior oblique } 4}th _CN

Inferior rectus } 3rd _{CN lateral rectus } 6}th _CN

Medial rectus } 3rd _CN

Inferior oblique } 3rd _CN

* Vibration sound passes through the air transmitted to the ear drum to ossicles of the middle ear to the cochlea of middle ear to and than cochlea of inner ear.

* Sound passes from external ear to middle ear this is known as conductive phase, where as when sound passes from cochlea to cochlear nerve known as sensorineuronal phase.

* Air conduction describes normal conductive phase, where as bone conduction stimulate cochlea describe normal sensorineuronal phase. In normal person air conduction is more sensitive.

* Labyrinth with in the inner ear sense the position and movement of the head and help maintain balance.

* Submandibular gland opens on papillae via Wharton’s duct that lies on the each side of lingual frenum, where as each parotid gland empties into mouth near upper 2nd _{molar via stensen duct.}

* Ant triangle of neck is bound, above by mandibles, laterally by stern mastoid, and medially by mid line of neck. * Post triangle of neck is bound, interiorly by sternomastoid muscle, posterior by trapazius, & inferiorly by clavicle.

* Loss of accomodation power is called Presbyopia usually become noticeable in one’s 40 where as hearing loss in aging is called Presbycusis. * In elderly the lens continuous to grow it may push the Iris forward, narrowing the angle b/w Iris and Cornea and increase the risk of Narrow Angle Glaucoma.

* Lens thicken and yellow with age that’s why older people need more light to do fine work. * Fine hair found in hyperthyroidism where as coarse (inferior quality) hair found in hypothyroidism.

* Enlarge blind spot occur in condition affecting the optic nerve, eg glaucoma, optic neuritis & papilledema. (normal blind spot occur at 15 degree - temporal). * Abnormal protrusion of eye occur in grave’s dis or occular tumor.

* Underlying skin of eye brows with scalyness suggest seborrhea dermatitis. * Lateral sharpness of eyebrows suggest hypothyroidism.

* Blephanitis is inflammation of eyelid along with lid margin often with crusting or scaling.

* Excessive tearing may be due to increase production, impaired drainage, conjuctival inflammation, corneal irritation, nasolacrimal duct obstruction, or Ectropion (outward drop of lower eyelid).

* Normally reactive equal pupil is called Isocoria .inequality of less than 0.5 mm is consider normal however one should rule out Horner $, Occulomotor nerve paralysis, and tonic pupil.

* Pupilary inequality called Anisocoria.

* LIGLAG is when eye move from above downward found in hyperthyroidism.

* In paralysis of left 6th _{nerve, eye can conjugate in right lateral gaze but not in left lateral gaze.}

* In paralysis of left 4th _{nerve, left eye cannot look down left.}

* In paralysis of left 3rd _{nerve, ptosis, papillary dilatation occur, left eye look out ward in effort to look straight, also upward downward inward movement is}

impaired.

* In lidlag of hyperthyroidism, a rim of sclera is seen b/w the upper lid and Iris and the lid seems to lag behind the eye ball. * Poor convergence is also found in hyperthyroidism.

* Mydriatric drops are contraindicated in head injury, narrow angle glaucoma, coma.

* Absence of red reflex while using ophthalmoscope suggest cataract, detached retina, retinoblastoma (in children), artificial eye.

* In refractive error, light do not focus on retina. In Myopia light focus ant to retina; In hyperopia light focus post or behind the retina; Retinal structure in myopic eye look larger than normal while using ophthalmoscope.

* Enlarge cup in optic disc suggest chronic open angle glaucoma.

* The presence of venous pulsation at the optic disc suggest but does not prove that the CSF is normal. * In retinal examination arteries are light red and veins are dark red in appearance.

* Lesion of retina can be related to optic disc and are measured as disc diameter for eg cotton wool patches at 2 and 3 o’ clock, less than half disc diameter or more than one disc diameter or two times than disc diameter, etc.

* when optic nerve is damage, the sensory (afferent) stimuli to brain is reduced so the pupil respond less vigorously and become dilated. This respond is afferent papillary defect called Marcus gunn pupil. the opposite eye respond consensually.

* Occlusion of the branch of central retinal artery may cause horizontal (altitudinal) defect. - superior branch occlusion ---> lower eye field defect

- inferior branch occlusion ---> upper eye field defect (diagram here)

* Non tender swelling cover by normal skin-deep into the ear canal suggest Exostosis, these are non malignant over growth which may obscure the drum. * Red bulging drum occur in Acute purulent otitis media where as Amberdrum occur in serous effusion.

* Serous effusion of middle ear cause by otitis media(viral) ; or by sudden change in atmospheric pressure from flying or diving called Otitic Baro trauma. * Bullous myringitis is a viral infection characterize by painful hemorrhagic vesicle on tympanic mem. Shows blood tingled discharge from ear.

* Unusually prominent short process of Malleus or more horizontal short process of Malleus suggest a retracted drum. * WEBER TEST is the test for lateralization to find out the hearing loss from turning fork.

* With weber test sound can be hear in impaired ear suggest unilateral conductive hearing loss, where as if sound can be hear in good ear suggest sensorineuronal hearing loss .

heard longer through ear.

* In conductive hearing loss pts own voice tend to be soft, vs. where as in sensory hearing loss pts own voice tend to be loud. * RINNE TEST compare the air conduction and bone conduction by tuning fork.

* In viral rhinitis the nasal mucosa is reddened and swollen where as in allergic rhinitis it may be pale bluish or red. * In nasal septum fresh blood or crusting may suggest septal perforation, trauma, surgery, cocaine or amphetamine use. * Nasal polyps are pale semi translucent masses that usually come from middle meatus.

* Transillumination technique is useful in Dx of sinusitis.

* Redness of the gum occur in gingivitis where as black line of gum occur in lead poisoning. * Asymmetric tongue or deviated tongue suggest lesion of the 12th _CN.

* Failure to rise soft palate by saying Ah or yawn suggest 10th _{CN lesion. Also the uvula deviated to opposite side.}

* Enlargement of the supraclavicular node specially to the left suggest possible metastasize from thoracic and abdominal malignancy. * Tender node suggest inflammation where as hard and fixed node suggest malignancy.

* Small, mobil, discrete non tender node are frequently found in normal person.

* Tracheal deviation may signifies mass in the neck, mediastinal mass, telecasts or a large pneumothorax. * A localize systolic or continuous bruit may be heard in hyperthyroidism.

* Regurgitation of mucopurulent fluid from the punta of the eye with increase tearing suggest nasolacrimal duct obstruction. * Cushing $ (increase adrenal hormone) produce moon face excessive hair growth may be present in mustaches or chin.

* Myxedema (severe hypothyroidism) has puffy dull facies, periorbital edema that does not pit with pressure. Where as Hair and eye brows are dry coarse, with thin and dry skin.

* Chronic unilateral enlargement of parotid gland suggest neoplasm where as a chronic bilateral enlargement of parotid gland associated with obesity, diabetes, cirrhosis, etc.

* Ptosis is the drooping of upper eyelid suggest Myasthenia gravis, Horner $. Wt of herniated fat may cause senile ptosis. * Exophthalmos suggest Grave dis, hyperthyroidism, unilateral exophthalmos may suggest, tumor , inflammation of orbit. * Retracted eyelid or lid lag often suggest hyperthyroidism, it may occur in normal person.

* Epicanthal fold normal in many Asians it may also suggest Down $.

* Ectropion (outward turning of lower eyelid) and Entropion (inward turning of upper eyelid); common in elder may cause irritation or increase tearing. * Periorbital edema suggest allergy, local inflammation, myxedema and nephrotic $.

* Pinguewla is yellowish some what triangular nodule in the bulbar conjunctiva appear with aging and is harmless. * STY is the painful tender red infection look like pimple around follicle of eyelashes.

* CHALAZION is chronic inflammatory lesion meibomiam gland it usually point inside the eyelid and is painless. * Swelling b/w lower eyelid and nose suggest inflammation of lacrimal sac.

* Xanthelasma suggest hypercholesterolemia.

* Acute iritis, acute glaucoma, and sub conjunctival hemorrhage in which occular discharge is absent.

* Corneal Areus is thin grayish white arc or circle at the edge of cornea. It accompanies normal aging but not in black where as in young people corneal areus suggest possibility of hypolipoprotinemia.

* Corneal scar is superficial grayish white opacity secondary to old injury or infection.

* PTERYGIUM is triangular thickening of bulbar conjunctiva that grows slowly across the outer surface of cornea.

* when Anisocoria ( unequal pupil ) is greater in bright light, the larger pupil cannot constrict properly suggest trauma, open angle glaucoma, impaired parasympathetic nerve supply to eye, or coulometer paralysis. vs. where as when Anisocoric is greater in dim light the smaller pupil cannot dialate properly suggest Horner $, and interruption of sympathetic nerve fiber.

* Horner $ in which Iris is lighter than its fellow called Hetrochromia.

* Light in a good eye produce direct reaction to the eye and consensual reaction to blind eye where as light direct to blind eye cause no response to either eye.

* Small irregular pupil that do not react to light but do react to near effort indicate Argyll Robertsonian pupil it suggest neuro syphilis.

* The Physiologic cup is a small whitish depression in the optic disc from which the retinal vessel appear to emerge. Grayish spot often seen at its base. * Ring and crescent are not the part of optic disc and is normal variation.

* Medullated nerve fiber appear as irregular white patch with feathered margin obscure the disc edge and retinal vessel it has no pathological significance . * In optic atrophy tiny disc vessels are absent.

* Glaucoma may result into increased cupping (depression) of disc and atrophy.

* The retinal arteries are normally transparent; In HTN arteries wall thickened and become less transparent. * Papilledema in which venous stasis engorge and swell the vessel with resultant swollen disc and blurred margin.

* Copper wire arteries shows bright coppery luster when reflect to light and Silver wire arteries occur after narrowing of arteries with no blood visible in it both condition found in HTN.