Short case discussion of - PowerPoint Presentation

1. Short case discussion of Sherlock Holmes and his friend , Dr. Watson, will help us appreciate the “pearl of acute observation”. Short case dialogue between Sherlock Holmes and his assistant Dr. Watson.Sherlock Holmes requests his friend and assistant, Dr. Watson to inspect his client Mr. Wilson.Dr Watson. “ Altogether, on my inspection of Mr. Wilson, there was nothing remarkable about the man save his blazing red head, and the expression of extreme discontent “. Sherlock Holmes. “Beyond the obvious facts that he has at some time done manual labor, and that he has done a considerable amount of writing lately, that he has been in China, I can deduce nothing else." Mr. Wilson "How did you know all that, Mr. Holmes?" he asked. "How did you know, for example, that I did manual labor’.."Your hands, my dear sir. Your right hand is quite a size larger than your left. You have worked with it, and the muscles are more developed." “But the writing?" "What else can be indicated by that right cuff so very shiny for five inches, and the left one with the smooth patch near the elbow where you rest it upon the desk?" "Well, but China”? "The fish that you have tattooed immediately above your right wrist could only have been done in China”. “In addition, I see a Chinese coin hanging from your watch-chain, the matter becomes even more simple”

2. Sherlock Holmes, “Take away message” .Watson. You did not know where to look, and so you missed all that was important.“I can never bring you to realize the importance of sleeves, the suggestiveness of thumb-nails, or the great issues that may hang from a boot-lace.”This is a classical demonstration of Sherlock Holmes expertise in using his skill of physical examination, contemplation and judgment for correct diagnosis.Clinical clues, pouring out of our patients face, hands, chest and abdomen “Are not invisible but remain unnoticed” We , physicians at our encounter with the patient hear and look at the patient but unfortunately we don’t listen and see 3.Look means (only ) to direct your eyes in a particular directionSee  means to notice or become aware of (someone or something) by using your eyesHear  means to be aware of (sound) through the ear.Listen  means to pay attention to someone or something in order to hear what is being heard or said. 3.* https://www.britannica.com/dictionary/eb/qa/see-look-watch-hear-and-listen

3. Physical examination “Short case of cardiology”.What are the physicians requirements for optimal physical examination ?The single most useful device for optimal performance of the physical examination is an extraordinary curious & conscious mind. Next most useful is mastery of the techniques of observation, palpation, percussion, auscultation and contemplation. Less, but important are the tools required for the examination . By Asadullah Kundi.

4. 4Introduction.“Detection of clinical signs is not question of sensitive fingers, ears or eyes but more conscious mind “(Harrison)The first and most important part of clinical examination is curious observation..Don’t look at the patient , see and watch the patient. Examination of the cardiovascular or respiratory system does not start with the stethoscope.We should learn to observe. *See before you lay on your hands. You may get valuable information from the facies, skin coloration, gait.Few disorders may be immediately apparent at the first glance.You need to acquire mastery over the inside out of observations to be made at encounter with patient.

5. Short case cardiology (Sequence of examination ).Introduce yourself , explain the procedure and ask permission to examine.  Disinfect and warm your hands.1 General appearance. 2. Vitals.3. Skin and mucous membrane .4 .Steps/ Sequence of examining each region .Upper extremities Head, ears and ENT (HEENT ).Neck.Thorax (Chest, Lungs , and cardiovascular).Abdomen.Lower extremities 5. Contemplation .

6. General appearance.At very first eye contact with patient , ask yourself following queries about his/her general appearance.Is he/she comfortable or distressed ?Is he/she short of breath, has difficulty in talking ?Built, obese or * thin and tall.?Any obvious deformity ?^^ Clues of specific facies ?*Check clinical signs of Marfan syndrome .Thumb and wrist signs .Pectus carinatum/excavatum . An increased arm span–to–height ratio that is > 1.05 . A reduced upper-to-lower segment ratio < 0.85.^^ Look for signs of expected disease eg Acromegaly , Myxoedemetous . Thyrotoxic

7. https://heart.bmj.com/content/88/1/97Illustration of few clinical signs of Marfan syndrome. Thumb and wrist signs

8. Illustration of few clinical signs of Marfan syndrome.An increased arm span–to–height ratio that is > 1.05 .

9. https://teachmesurgery.com/cardiothoracic-surgery/thoracic/disorders-of-the-chest-wall/https://teachmesurgery.com/cardiothoracic-surgery/thoracic/disorders-of-the-chest-wall/Pectus carinatum, also known as pigeon chest, Pectus excavatum, also known as sunken chestIllustration of few clinical signs of Marfan syndrome.

10. Short case of cardiology(Continued ).Vitals.Pulse rate and rhythm. If irregular count the heart rate.Thumb of the examiner should not be used to feel the pulse. His own strong pulse might be mistaken for the patient's . Blood pressure.Respiratory rate.Temperature.

11. Skin and mucous membrane Cyanosis.Clubbing.Pallor.Pigmentation.purpura /Ecchymosis.Dehydration.(Capillary filling test) . Peripheral (skin ) signs of endocarditis (Osler nodes, Janeway lesions, and splinter hemorrhages.)Crepitus, (subcutaneous emphysema )should be looked for in patient with thoracic trauma.

12. Osler's nodes are split pea–sized, erythematous, tender nodules located principally on the pads of the fingers and toesOsler's nodes are thought to be caused by localised immunological-mediated response. Multiple non-tender macular erythematous lesions, consistent with Janeway lesionsThe lesions are usually transient and clear in 1 to 2 days. Janeway lesions are thought to be caused by septic microemboli.. They are nontender, erythematous or hemorrhagic macular  lesions on the palms or soles.Multiple erythematous Janeway lesionsIllustration of few clinical signs of infective endocarditis. https://www.youtube.com/watch?v=2PCGWFEwlEc

13. Splinter hemorrhages look like thin, red to reddish-brown lines of blood under the nails. They run in the direction of nail growthIllustration of few clinical signs of infective endocarditis.

14. https://www.webeyeclinic.com/terminology-r/roth-spotsRoth Spots are multiple flame-shaped or round, oval shape retinal hemorrhages with white centered spots .There are many causes of them but in 80% of cases they are associated bacteremia that is caused by subacute bacterial infective endocarditis.Roth spot represents rupture of retinal capillaries with leakage of blood and the central white spot are caused by platelet aggregates.Illustration of few clinical signs of infective endocarditis.

15. Short case of cardiology. (Continued )Steps/ Sequence of examining each region . (Should learn , what to examine and how to examine).Upper extremities Head, ears, eyes, nose, and throat (HEENT ).Neck.Thorax (Chest, Lungs , and cardiovascular).Abdomen.Lower extremities

16. Steps/ Sequence of examining each region . (Should , learn what to examine and how to examine).Upper extremities. (Inspection and palpation).Tremor. Pulse volume and character. Radial - femoral delay. Deformity. Xanthoma ( Examine extensor aspect ). Head, ears, eyes, nose, and throat (HEENT ).Examine the conjunctiva and sclera. Xantholesma , Arcus juvenilis . Ear Crease sign. Mallampati sign. Dental hygiene.Neck.( Inspection , palpation and auscultation ). First auscultation followed by gentle palpation of Carotid artery. Inspection of JVP. Palpation and auscultation of thyroid.

17. To properly assess a patient's Mallampati score, the patient is seated in the upright position and opens their mouth while maximally protruding their tongue. Classically this exam is done without phonation.It is used to predict the ease of intubation. It can also be used to predict whether a patient might have obstructive sleep apnea..The scoring classification is as follows with visualization of: Class 1: soft palate, uvula and faucial pillarsClass 2: soft palate, majority of uvula and part of faucial pillars Class 3: part of soft palate, base of uvulaClass 4: hard palate onlyMallampati sign Frank's sign.May be associated with Coronary artery diseasehttps://www.sleepfoundation.org/sleep-apnea/mallampati-score

18. Short case of cardiology. (Continued )Thorax (Chest, Lungs , and cardiovascular) front.Inspection. Palpation. Auscultation.Inspection .Inspection of the chest should be done from side and foot end . Observe any obvious chest deformity ,scar etc.Precordial pulsations and chest movement during respiration are better seen by bending down with eyes at the level of chest.Palpation.Localize apex beat and its character. Pont of maximum Impulse (PMI ) and apex beat may be at different location.Palpation for third and fourth heart sound ,thrill and heave.

19. Auscultation (front of ) chestAuscultation. Sounds (S1,S2,S3,S4). Murmur.(Systolic, Diastolic, to and fro or continuous murmur). Pericardial rub.Apical (Mitral area) murmur radiation.. Left lower sternal border (Tricuspid area) radiation and effect of respiration. Upper left sternal border pulmonary area (Effect of respiration and character of S2) .Right upper sternal border Aortic radiation to neck.Cardiac auscultation is imperfect unless as well done in left lateral position.Dynamic Maneuvers (optional if indicated) . Standing ,Squatting, hand grip and valsalva.Auscultate breath sounds.Palpation and auscultation back of chest.Palpate for sacral edema.Auscultation of bruit (of collaterals ) in cyanotic and patient with Coarctation of aorta.Auscultate breath sounds.

20. Examination of abdomen and lower limb.Abdomen. Inspect for obvious pulsation (Before palpation ask for any tender spot.)Percuss and palpate Spleen and liver.( Pulsatile liver ). Auscultate for bruit (Aortic and Renal ). Lower limb. Peripheral Pulses. Edema, ulcer, temperature.Auscultate Femoral pulses* Check BP of lower limb if patient has peripheral vascular disease or Coarctation ( ABI ). Contemplation . Compile the finding for possible differential diagnosis with justification.