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四川大学全英语授课专业课程大纲/Syllabus of English-Teaching
Program at SCU
诊断学/ diagnostics
Course Code:
Total Class Hours : 192
Course Name: Internal Medicine
Credit: 12
Textbook/Teaching material: Textbook of Physical Diagnosis(History and Examination)Health
Science Asia, Elaevier science
Course Objective: This course is designed for senior undergraduate students in the School of
clinical medicine. The basic theory and practice skills of diagnostics are covered. The intention is
that the material will provide a foundation for theoretical and applied introduction in diagnostics.
Course Description:：This course will introduce both theoretic and clinical skills of diagnostics.
We will introduce the semiology, physical examination, electrocardiogram, and other laboratory
methods for diagnosis. In the practice sessions, we will introduce how to set up the professional
values, and guide students to collect complete case history and get the ability of using standard
methods to conduct physic examination on patient and differential diagnosis.
Prerequisite：The prerequisite of this course includes, but is not limited to, the knowledge of,
anatomy, pathophysiology, pathology, pharmacology and medical imaging. Those who are not
familiar with these knowledge are encouraged to read related text books before hand.
Ways to engage students to the class：Pre-class assginments such as preparing lessons or solving
certain promblem will be given; In-class discussion will be conducted as often as possible;
After-class assignments will be passed out from time to time. These assignments will include both
problem solving and medical record writing. Besides, students are required to do some fundamental
clinical skills exercises now and then. The assignments will be graded by the teaching assistant, and
will be reviewed in the discussion sections.
Reference books:
[1] 欧阳钦, 临床诊断学（供 8 年制及 7 年制临床医学等专业用）, 人民卫生卫生出版社;
[2] Paula L. Stillman, 中英对照临床诊断学教程, 北京医科大学中国协和医科大学联合出版
社.
[3] 吕卓人//雷寒，Textbook of Diagnostics,诊断学(供临床基础预防口腔药学检验护理等专业
使用双语版医学英文原版改编双语教材)，科学出版社.
Grading
There will be one exam-a final exam. The final is close-book and close-note. The grading for the
course will be as follows: Assignments: regular grade 30%. Final exam: 70%.
Office Hour:
Wednesday: 14:30 to 17:00; And by Appointment.
Course Structure
1. Large Group Lectures
While many of the skills and issues related to professional development in diagnosis
are best learned in small groups, there are a number of topics which are introduced in
large group lectures. Although few lectures in medical school are required, we
encourage you to attend the diagnostic lectures. Taking time to prepare for clinical
practice while in the midst of basic science training is important work which we hope
will be of value to you now and which prepares you for more intensive clinical training
in your 3rd and 4th years.
2. Small Group Sessions
Topics for discussion at the sessions include interviewing techniques, experiences
during patient interviews, the emotional impact of contact with the patient, feedback on
write-ups, professional issues, adjustment to medical school.
Most of the teaching of the basic physical examination is done in small groups.
Prior to each small group session, the entire class will meet as a group in the large
lecture hall. We will review the section of the physical exam to be worked on that day
in lab. We will view the appropriate section of the video and discuss any key points
and helpful hints. We will also review how that portion of the physical exam is written
up in the medical data base. You will then go to your labs with a faculty member and
will review the exam, discuss any questions and practice that part of the exam on each
other in pairs. Models will be provided for the female breast.
3. Clinical Tutorials
The goals of the clinical tutorials are to provide you with the opportunity:
●to do complete "work ups" of patients - medical interview and complete physical
exam
●review history and physical exam findings at the beside
●to learn from the elements of the history and physical exams of your colleagues
●to practice oral case presentations
●to practice clinical reasoning
●to observe your College faculty interact with and examine patients.
4. Oral Case Presentations/Case Discussion
The clinical tutorials provide you with an opportunity to practice oral case
presentations and to review aspects of the clinical reasoning process. A good case
presentation involves thinking through the case and organizing the relevant
information into a concise presentation that succinctly contains all of the important
information. In order to do this, you must first figure out what you think is going on in
the case - you construct the case presentation with your final assessment of the case in
mind. In order to do a good case presentation you must have applied the clinical
reasoning process to the specific case material beforehand.
There are several ways to present case material depending on the purpose of the
case presentation. For the most part your oral case presentations will focus on a
detailed history of present illness including those portions of the past medical history,
family history, social history and review of systems that are relevant to the HPI; a very
brief summary of the other sections of the complete medical data base (PMHx, FHx,
SHx); and a focused description of the physical examination.
In addition to providing the opportunity to practice oral case presentation skills
and discuss the clinical reasoning process involved in specific cases, the discussions in
your clinical tutorials are also an opportunity to discuss issues related to the technical
aspects of interview skills and professional issues that arise in the course of your
clinical tutorials or other course or clinical experiences. These issues may include:
●difficult interview situations
●difficulty with the content or process of the interview
●relationships with patients
●difficult issues that arise in the interview
● relationships between members of the health care team (either observed or
experienced)
5. Write ups
We strongly suggest that you write up the medical data base (the history and
physical exam) as soon as possible, ideally within 48 hours of seeing your patient, for
several reasons. The first is that it is much easier to do the write up when the
information is fresh in your mind and you can do it much more quickly than if you
wait. The second is that next year when you are working up patients in your clerkships
you will have to have your note in the chart by the time you leave the hospital at the
end of the day (or the morning after your overnight call). It is very good practice to put
the basic history and physical exam data on paper as quickly as possible. You will
hand in your complete write up at your next clinical tutorial session (or you may send
it as an email attachment to your college faculty during the week).
You should write up the history of a hospitalized patient as if you are at the point
of their admission. You can include at the end of your HPI a section called "hospital
course" that covers what has occurred since admission. After the case discussion in
your clinical tutorial, you should have a general idea of the appropriate differential
diagnosis or clinical reasoning issues involved in your patient's case. Based on this you
should be able to do a simple branching diagram that reflects this reasoning and
differential and should do some focused reading in the appropriate textbook (usually
one of the major internal medicine texts).
●Medical interviewing
understand the purpose and function of the medical interview
● understand
the concept of the patient’s narrative and its importance in
patient-centered interviewing
●learn questioning skills, including ways of asking about sensitive material
●learn to respond to and deal with patient’s emotions
●participate in an interview of a "standardized patient"
●develop questioning skills in relation to specific populations and situations such as:
adolescent patients
pediatric patients
difficult interviews
●
human sexuality
HIV/AIDS
substance abuse
●Physical exam
learn basic techniques of adult physical examination
●demonstrate these skills in front of a faculty observer
●learn the advanced head and neck exam
●
●Medical data base/Documentation
learn to organize and write-up a complete medical data base
learn to construct a problem list
●understand the Problem Oriented Medical Record
●
●
Clinical Record
1. Master the basic framework of clinical record:
●General information of Patient
Patient’s basic data: patient’s full name, sex, age and occupation, date of admission, and the date of
recording case report, et al.
● History
①Chief Complaint
②History of Present Illness
③Past Medical history
④Review of Systems
⑤Personal History
⑥Marital History
⑦Menstrual and reproductive History
⑧Family History
● Physical Examination
● Lab. Exam and Other Special Exams
● Abstract of the Case
● Impression and Signature
2. Be familiar with the skills for writing chief complaint and history of present illness; the main
points for whole physical examination record
3. Recognize the writing skills for accuracy, fluency, clearness and standardization, especially the
process of occur, development, treatment and response of disease.
Vital signs
1. Equipment Needed
A thermometer
A watch displaying seconds
Sphygmomanometer
A stetescope
2. General Considerations
● Measure body temperature
Body temperature can be measured in several different ways
Learn how to measure the axillary body-temperature with a nercury thermometer.
The patient should not have had alcohol, tobacco, caffeine, or performed vigorous
exercise within 30 minutes of the exam.
● Measure respiratory rate
Best done immediately after taking the patient's radial pulse. Don’t announce that
you are measuring respirations.
Count breaths for 30 seconds and multiply this number by 2 to yield the respiratory
rate per minute.
The depth and thythm of respitation should also be noticed.
● Measure pulse
Learn how to measure the patient’s pulse and record the rate and rhythm.
Note whether the pulse is regular or irregular and intensity.
● Measure blood pressure
Learn how to use the Sphygmomanometer correctly.
Learn how to measure blood pressure.
Note positions of the patient , the cuff and the blood-pressure meter.
Blood pressure should be taken in both arms at the first visit.
Record the blood pressure as systolic over diastolic ("120/75 mmHg" for example).
Head
1. Head
Observe scars, lumps, rashes, hair including color, density, lustre and distribution, or
other lesions.
Look for facial asymmetry, involuntary movements, or edema.
Palpate the entire skull to identify any areas of tenderness or deformity.
2. Eyes
Test for near vision and visual acuity.
Observe cornea, sclera, conjunctiva and lacrimal puncta.
Evaluate extraocular muscle function.
Learn how to check pupillary direct and consensual response to light.
Learn how to check for convergence and accommodation.
3. Ears
Obeserve and palpate the auricles and the mastoid processes for tenderness or
deformity.
Learn how to evaluate auditory acuity.
4. Nose
Observe and palpate external nose.
Observe nasal vestibule without otoscope.
Press accessory sinuses of nose for tenderness.
5. Mouth
Observe lips, teeth, gums, tougue and floor of mouth under the tougue.
Learn how to use a wooden tongue blade and a good light source to inspect the
inside of the patients mouth including the mucosa and the posterior oropharynx
includng tonsils.
Note edema, ulcers , neoplasm, etc.
Neck
1. Neck
Inspect the neck for asymmetry, scars, or other lesions.
Palpate the neck to detect areas of tenderness, deformity, or masses.
Be familiar with locations of the various lymph node groups and learn how to
palpitate facial and cervical lymph nodes for size, number, hardness, mobility,
tenderness and so on.
2. Thyroid Gland
Inspect the neck looking for the thyroid gland. Note whether it is visible and
symmetrical.
Learn how to palpate the thyriod gland for the size, symmetry, position of the lobes
and presence of any nodules or masses.
Palpation for the thrill and auscultation for the bruit.
3. Carotid artery
Learn how to palpate carotid artery.
4. Trachea
Learn how to palpate reachea to determine its position.
Skin
1. Inspect and palpate the hair nail. Note color, density, lustre and distribution of hair.
2. Inspect and palpate skin of face and neck to evaluate the color, moisture, turgor and
texture of the skin.
3. Note the scars, lumps, rashes, tenderness and other lesions,
4. Some slides shown for abnormal skin.
Chest
1. Purpose and Requirement
●Understand how to use the technique of inspection, palpation, percussion and
auscultation in the examination of the chest.
●Understand the causes and the mechanisms of the normal and the common abnormal
signs, and their clinical significance.
2. Content
● The topographic landmarks of the chest surface
● Skeletal landmarks: Louis’ angle, suprasternal notch, supraclavicular fossae,
infrasternal angle, xiphiod process, intercostal space, costovertibral angle.
● Artificial vertical landmarks: midsternal line, midclavicular line, anterior, posterior
and midaxillary line, midspinal line, scapular line.
● Topographic description of location for any positive physical findings. The best way
of describing location is by using horizontal line first, and then a vertical line to locate
the finding precisely.
● Physical examination
Inspection
● The patient’s facial expression, posture, neck and the configuration of the chest.
● The sharp and symmetry of the chest. The ratio of the anteroposterior (AP) diameter
to transverse diameter (normal is 1 to 1.5)
● Measure respiratory rate, breathing motion and depth, abnormal breath patterns.
Palpation
● Palpate trachea and evaluate position of the trachea.
● Palpate for the tenderness, chest excursion, pleural friction rubs
● Check for tactile fremitus
Percussion
● Two methods for percussion of the chest: Mediate percussion and immediate
percussion
● The normal distribution of percussion sounds over the lung field
● Percuss supraclavicular fossae: The apices of the lungs
● Percuss the lower margins of the lungs: Usually done in the midclavicular lines,
midaxillary lines and scapular lines of both sides, and the lower margins are 6th, 8th and
10th intercostal spaces respectively.
● Defect diaphragmatic movement at scapular lines
Auscultation
● Normal breath sounds: tracheal, bronchial, bronchovesicular and vesicular breath
sound.
the normal locations, intensity and characters of each breath sound
● Differentiate normal from abnormal breath sounds: including bronchial and
bronchovesicular breath sound heard in any areas of the lungs that normally have
vesicular breath sound, as well as, increased, decreased, or absent breath sound
● Adventitious breath sound
rales and rhonchi: the etiological factors, characters and classification
● Pleural friction sounds: the common area for auscultation
● Vocal audible resonance
● The common abnormal signs of the chest in patients with pulmonary diseases.
Pneumonia, pneumothorax, pleural effusion, emphysema, and pulmonary atelectasis
Breasts and Axillae
1.Inspect breasts for asymmetry or other abnormalities (both male and female exam)
2.Continue inspection while patient places hands on hips and presses in and while she
clasps her hands and presses them together over the head (Patient replaces gown
leaving it loosened around the neck and lies on examining table; the drape covers legs
and abdomen. Examiner stands on patient's right side).
3.Expose one breast at a time and have patient place corresponding hand behind her
head.
4.Inspect skin of breast and areola
5.Palpate all breast tissue covering the entire breast and axillary tail systematically,
either using concentric circles or radial spokes from the center outward, using the pads
of the fingers.
6.Examine the nipple and attempt to express fluid from it.
7.Lower the patient's arm, and palpate the axilla using the right hand for the left axilla
(and vice versa) and supporting the patient's arm with your opposite hand.
8.Replace the gown on the first side, expose the other breast, and repeat the
examination of the breast and axilla on this side.
9.Male breast exam includes inspection (1 above) and palpation of breast tissue against
the chest wall with the patient sitting or lying down. Examination of the axillae is the
same in men and women.
Heart
1. Specific Symptoms
●Chest pain
Objectives, the students should be able to
●Understand the common causes of chest pain.
●Remember questions which should be asked during history taking.
●Differentiate angina from chest pain caused by other causes.
●Palpitations
Objectives, the students should be able to
●Understand the common causes of palpitations
●Remember questions which should be asked during history taking
●Dyspnea
Objectives, the students should be able to
●Understand the common causes of dyspnea.
●Describe the clinical features of Paroxymal nocturnal dyspnea, Dyspnea on exertion
and Trepopnea.
●Syncope
Objectives, the students should be able to
●Understand the common causes of syncope.
●Remember questions which should be asked during history taking.
●Fatigue
Objectives, the students should be able to
●Understand the common causes of fatigue.
Remember questions which should be asked during history taking.
●Dependent edema
Objectives, the students should be able to
●Remember questions which should be asked during history taking.
●Differentiate edema caused by congestive hear failure from edema caused by other
causes.
●Hemoptysis
Objectives, the students should be able to describe the clinical features of hemoptysis
caused by mitral stenosis.
2. Physical Examination
●Inspection
Objectives, the students should be able to
●Understand what to be observed during inspection, including :general appearance, the
skin, the nail, the facies, the eyes, the mouthes, the neck, the chest configuration, the
extremities.
●Describe the clinical significance of the abnormal appearances.
●Blood pressure Assesment
Objectives, the students should be able to
●Understand the principles of blood pressure assessment.
●Determine blood pressure by palpation and auscultation .
●Rule out orthostatic hypotention, supravavular aortic stenosis, cardiac tamponade.
●The Arterial Pulse
Objectives, the students should be able to
●Determine the cardiac rate and cardiac rhythm from the palpation of the arterial pulse.
●Understand how to palpate the carotid artery and evaluate the characteristics of the
pulse.
●The Jugular Venouse Pulse
Objectives, the students should be able to
●Determine the jugular wave form and estimate the jugular venouse pressure.
●Evaluate the hepatojugular reflux.
●Percussion
Objectives, the students should be able to understand how to percuss the heart′s
borders.
●Palpation
Objectives, the students should be able to
● Understand how to palpate the point of maximum impulse, localized motion,
generalized motion, thrills.
●Understand the clinical significances of these examinations.
●Auscultation
Objectives, the students should be able to
● Discribe the standard auscultation positions, the location of the five cardiac
areas:aortic, pulmonic, tricuspid, mitral and the erb′s area.
●Describe any murmur present and pericardial rubs.
●
●Examination for Edema
Objectives, the students should be able to test for edema.
3. Clinicopathologic Correlations
Objectives, the students should be able to understand the clinical significances of the abnormalities
of the first and second heart sound, systolic clicks, diastolic opening snap, murmurs.
Abdomen
1. Common symptoms of abdominal disease
Abdominal Pain
Purpose and Requirement
Understand the causes, the mechanisms and the key points of diagnosis of pain.
Understand the location, localization, character, radiation and nature of pain, the time
of occurrence and factors that aggravate or alleviate the symptoms, accompany
symptoms and physical signs.
Be familiar with referred pain.
Content
Introduction: abdominal pain is a common cause for consultation. The underlying problem can
often be identified by considering which structures normally lie at the site of the pain.
Abdominal pain may result from the following causes:
Epigastric pain
Lower oesophagus: oesophagitis, malignancy. Stomach: peptic ulcer, gastritis. pancreas:
Pancreatitis, malignancy.
Right hypochondrial pain
Biliary tree: biliary colic, cholecystitis, cholangitis. liver: hepatitis, malignancy, abscess, right
Ventricular failure. subphrenic space: abscess.
Left hypochondrial pain
Spleen: traumatic rupture, infarction (sickle cell disease). pancreas: pancreatitis, malignancy.
subphrenic space: abscess.
Central abdominal pain
Pancreas: pancreatitis, malignancy.
Small/large bowel: obstruction, perforation, intussusception, ischaemia, Crohn's disease,
lymphoma irritable bowel syndrome, adhesions.
Lymph nodes: mesenteric adenitis, lymphoma. Abdominal aorta: ruptured aortic aneurysm.
Right lilac fossa pain
Terminal ileum: Crohn's disease, infection (tuberculosis), Meckers diverticulum.
Appendix: appendicitis, carcinoid syndrome, lumour.
Caecum/ascending colon: diverticulitis, paracolic abscess, ulcerative colitis, malignancy.
Ovary/fallopian tubes: malignancy, ectopic pregnancy, pelvic inflammatory disease.
Left lilac fossa pain
Sigmoid/descending colon: diverticulitis, paracolic abscess, ulcerative colitis, malignancy.
Ovary/fallopian tubes: malignancy, ectopic pregnancy, cyst (bleeding or torsion), pelvic
inflammatory disease.
Loin pain
Kidneys:malignancy, pyelonephritis, polycystic disease.
Ureters: colic due to stone or clot.
Suprapubic pain
Bladder: urinary tract infection, acute urinary retention.
Uterus/adnexae: pelvic inflammalory disease, endometriosis.
Other causes of abdominal pain
Anxiety.
Myocardial infarction: usually inferior myocardial infarction causing epigastric pain.
Lower lobe pneumonia: ipsilateral hypochondrial or sometimes loin discomfort.
Porphyria.
Diabetic ketoacidosis.
Addison's disease.
Sickle cell crisis.
Lead poisoning.
Henoch-Sch6nlein purpura.
History in the patient with abdominal
When a patienl presents with abdominal pain, the first priority is to determine whether he or she
has an 'acute abdomen' requiring urgent admission to hospital. The history should focus on the pain
itself and then associated symptoms.
Change in Bowel Habit
Purpose and Requirement
Understand the concept and the mechanisms of diarrhea.. the common causes and
character of acute and chronic diarrhea.
Be familiar with the causes and character of constipation.
Content
Introduction: Always ask about the patient's normal bowel habit as there are considerable
differences between people,usually varying from three times a day to once every 3 days. It is
important to note a change in bowel habit as this is more commonly associated with pathology.
Diarrhoea
Medical causes:
Infective: Bacterial, Viral: rotavirus, Protozoa.
Osmotic causes of diarrhoea.
Secretory causes of diarrhoea.
Bile salt malabsorption.
Inflammatory causes of diarrhoea.
Causes of malabsorption.
Increased motility.
Constipation
Medical causes:
Low-fibre diet.
Poor bowel habit.
Endocrine causes: hypothyroidism and hyperparathyroidism.
Metabolic causes: hypokalaemia, hypercalcaemia, and uraemia.
Neurological causes: paraplegia and multiple sclerosis.
Irritable bowel syndrome (often a mixed picture with diarrhoea and constipation).
Medications: anticholinergic agents, opiates, diuretics, verapamil, psychotropics, and
disopyramide.
Prolonged bed rest or immobility.
Dehydration.
Psychogenic causes, e.g. depression, agitation.
Others: amyloidosis and scleroderma.
Surgical causes of constipation include:
Perianal disease, e.g. fissure, thrombosed
haemorrhoids.
Intestinal obstruction due to a mass, e.g. carcinoma of the rectum/sigmoid colon.
Pelvic mass including pregnancy.
Outlet delay: rectocele, rectal intussusception, rectal prolapse.
Colomc stricture, e.g. diverticulitis and Crohn's disease.
Hirschsprung's disease (aganglionic segment of the rectum, usually presenting in the first
years of life).
Postgastrectomy (although this usually causes diarrhoea).
Postoperative pain.
History in the patient with change in bowel habit
Normal bowel habit (note interindividual variation).
Onset: sudden or chronic. Infectious diarrhoea is usually of acute onset.
Frequency of defecation.
Stool appearance: formed, loose or watery; colour; volume; do the stools float?
Drugs: antacids, laxatives, cimetidine, digoxin, antibiotics, alcohol.
Tenesmus (a sense of incomplete voiding).
Smell: offensively malodorous in malabsorption; characteristic smellof melaena.
Foreign travel.
Contact with diarrhoea sufferers.
Relationship to food.
Stress.
Associated features, e.g. pain, fever, vomiting, weight loss.
Symptoms of thyrotoxicosis.
Nocturnal diarrhoea: autonomic neuropathies from diabetes mellitus.
Sexual history.
Haematemesis and Melena
Purpose and Requirement
Understand the character and clinical significance of rectal bleeding.
Be familiar with hematochezia , tenesmus and melena .
Content
Introduction: Haematemesis is the vomiting of fresh (bright red) or altered ('coffee ground')
blood. Melaena is the production of black, tarry stools, and is due to bleeding from the upper
gastrointestinal (GI) tract of more than 100 mL of blood. GI bleeding is an emergency, and
treatment may need to be initiated before a diagnosis has been made.
The differential diagnosis of haematemesis andmelaena includes the following:
Peptic ulcer disease: the commonest cause.
Erosive gastritis: implicated in about 20% of upper GI bleeds.
Mallory-Weiss tears.
Oesophagitis/hiatus hernia.
Ruptured oesophageal varices.
Vascular abnormalities: may cause upper or lower GI bleeding.
Gastric neoplasms: about 5% of upper GI bleeds.
History in the patient with Haematemesis and Melena
The history may have to be taken after initial resuscitation procedures. It is important to determine
whether the blood has been vomited or coughed. Haematemesis may be due to blood swallowed
from the nasopharynx or mouth. You must ask about the following:
Non-specific symptoms of GI blood loss.
Weight loss and anorexia: carcinoma.
Current drugs: aspirin, nonsteroidal antiinflammatory drugs.
Symptoms of chronic blood loss.
Heartburn: oesophagitis.
Intermittent epigastric pain relieved with antacids.
Sudden severe abdominal pain: perforation.
Dysphagia or odynophagia (pain on swallowing).
Chronic excessive alcohol intake: oesophageal varices.
Enquiry into the causes of liver failure.
Retching especially after an alcohol binge: Mallory-Weiss tear.
Family history: inherited bleeding disorders.
A past history of GI bleeds and their cause.
Jaundice
Purpose and Requirement
Understand classification, mechanisms, etiology and clinical manifestation of
jaundice.
Content
Introduction: Jaundice (icterus)is the yellow discoloration of the skin, sclera and mucosae, which
is detectable when serum bilirubin concentrations exceed approximately 30 umol/L.
Differential diagnosis:
Prehepatic jaundice results from increased bilirubin production, caused by abnormal RBC
breakdown (haemolysis).
Hepatic: Acute hepatocellular damage, Chronic hepatocellular damoge.
Posthepafic: Extrahepatic obstruction, Intrahepatic obstruction
History in the patient with Jaundice
The following factors should be assessed when obtaining a history in a patient with jaundice:
Pruritis, dark urine and pale stools: underlying cholestasis.
Duration of illness:
Abdominal pain:
Fevers or rigors: cholangitis.
Full recent drug history: particularly paracetamol, oral contraceptive pill.
Alcohol consumption: acute alcoholic hepatitis,cirrhosis.
Infectious contacts: hepatitis A.
Recent foreign travel to areas of high hepatitis risk.
Recent surgery.
Intravenous drug abuse, tattoos, homosexuality .
Occupation: sewage workers are at an increased risk of leptospirosis.
Family history of recurrent jaundice: inherited haemolytic anaemias and Gilbert's syndrome.
2. Physical Examination
Purpose and Requirement
Understand inspection, auscultation, percussion, palpation of abdomen. The key
point is palpation of abdomen, especially its method and contents.
Be familiar with the common physical signs and its clinical significance.
Content
Inspection
Scars: previous surgery or trauma.
Distension.
Obvious mass: including movement with respiration.
Bruising: Cullen's (paraumbilical)and Grey Turner's (flanks) signs in acute pancreatitis.
Dilated veins: inferior vena cava (venous flow is upwards).
Caput Medusae: portal hypertension (venous flow is away from the umbilicus).
Pulsation: abdominal aortic aneurysm.
Striae: pregnancy or Cushing's syndrome.
Node: umbilical nodule is a metastasis from intra-abdominal malignancy.
Peristalsis: if visible this indicates an obstruction.
Palpation
Before you touch the patient, ask if they are tender anywhere and start palpation away from that
area. Feel gently in each of the four quadrants, noting tenderness or masses. Then feel more deeply
in each quadrant to determine the characteristics of any mass found .
Percussion
Always percuss from resonance to dullness. Use percussion to determine the size of the liver and
spleenstarting at the chest, moving inferiorly.
Auscultation
Bowel sounds may be normal, increased, and absent.
Arterial bruits: may be heard over stenosed vessels such as renal arteries.
Venous hum in the epigastrium: portal hypertension.
Friction rubs:
Succussion splash: pyloric stenosis.
3. small group
Content
●Students practice inspection, auscultation, percussion, palpation of abdomen with
each other under teacher’s guidance.
●Bedside teaching
Study the common and important physical signs, including peptic ulcer,
cholecystitis, hepatomegaly, splenomegaly, ascites, mass and alteration of bowel
sounds, et al. learn how to detect the above physical signs, and explain its clinical
significance.
● Kinescope, abdominal physical examination and common abdominal abnormal
physical signs.
proteinuria and haematuria
Grasp the Definition of proteinuria and haematuria (visible/ macroscopic haematuria, or
invisible/ microscopic haematuria)
Grasp the classification of proteinuria
Be familiar with the further investigation to diagnosis of Proteinuria and haematuria
Recognize. differentiation diagnosis of haematuria
I OBJECTIVE: TO UNDERSTAND THE DIFINITION OF PROTEINURIA AND
HAEMATURIA
Moderate amounts of low molecular weight protein do pass through the GBM. These proteins
are normally reabsorbed by tubular cells so that less than 150 mg/day appears in urine. As shown in
Box 17.21, larger amounts indicate renal damage; any renal disease or injury may cause proteinuria.
Proteinuria is usually asymptomatic, although large amounts may make urine froth easily.
Relatively minor leakage of albumin into the urine may occur transiently after vigorous
exercise, during fever or UTI and in heart failure. Such proteinuria does not reach nephrotic levels
and tests should be repeated once the stimulus is no longer present. Occasionally, proteinuria
occurs only during the day, and the first morning sample is negative. In the absence of other signs
of renal disease, such 'orthostatic proteinuria' is usually regarded as benign
Low molecular weight proteins may also appear in the urine in larger quantities than 150
mg/day, indicating failure of reabsorption by damaged tubular cells, i.e. 'tubular proteinuria'. This
can be demonstrated by analysis of the size of excreted proteins or by specific assays for such
proteins (e.g. β2-microglobulin, molecular weight 12 kDa). The amounts of such protein rarely
exceed 1.5-2 g/24 hours, and proteinuria greater than this almost always indicates significant
glomerular disease. The amount of protein in urine should be quantified to guide further
investigations . Quantification in a 24-hour urine collection is the gold standard, but these
collections are arduous and often inaccurate. Use of the protein/creatinine (mg/mmol) ratio in
single samples makes allowance for the variable degree of urinary dilution and can allow
extrapolation of 24-hour values. Changes in this ratio give valuable information about the
progression of renal disease.
In many types of renal disease, the severity of proteinuria is a marker for an increased risk of
progressive loss of renal function. There is circumstantial evidence that protein in the glomerular
filtrate is toxic to the kidneys, and treatments that are effective at lowering the risk of progression
of renal failure (e.g. angiotensin-converting enzyme (ACE) inhibitors in diabetic nephropathy) also
reduce proteinuria.
Extremities (Neuromuscular)
[Patient sits facing examiner; gown fastened in back, drape over leg. Examiner stands in
front of patient.]
1.Inspect skin, muscles, and joints of upper extremities.
2.Test upper extremity motor strength* and joint mobility:
●grip strength
●finger abduction (spread fingers against resistance), thumb opposition against resistance
●wrist flexion and extension against resistance
●elbow flexion and extension against resistance
●shoulder abduction and adduction against resistance
●test shoulder mobility - arms overhead in diving position
3.Test for upper extremity drift or tremor: patient holds arms outstretched, palms up, first
with eyes open, then with eyes closed.
4.Inspect skin, muscles, and joints of lower extremities.
5.Test lower extremity motor strength* and joint mobility:
●ankle flexion and extension against resistance
●knee flexion and extension against resistance
●hip flexion against resistance
6.Check for edema** by pressing with your thumb over the lower anterior tibia for 5
seconds; observe and palpate lightly for an imprint.
7.Palpate the dorsalis pedis and posterior tibial pulses with the pads of the fingers and
compare sides.
*Remember that while you do the muscle strength exam during the extremity, or
neuromuscular exam, it is written up in the neurologic exam under motor exam. This is
true of the cranial nerve exam which is performed during the head and eye exams but
written up in the neurologic exam under cranial nerve exam.
**Examination for edema done during the extremity exam is often written up with the
cardiac exam.
Neurologic Exam
[Gown is now fastened again at the neck; patient is sitting with the drape over lap;
examiner stands in front of patient]
1.If a mydriatic was used to dilate the patient's eyes, you would perform the
fundoscopic exam at this time (described in eye exam section vb above).
2.Using the reflex hammer, test the biceps reflex bilaterally in the antecubital fossa,
while supporting the patient's forearm; test the knee jerk reflexes by tapping the
hammer just below the patella; test the ankle reflexes by striking the achilles tendon;
grade on a four-point scale.
3.Test the plantar (Babinski) response by stroking the lateral aspect of the sole of foot
from the heel towards the toes and across the ball of the foot.
[Patient stands, drape is discarded]
4.Have the patient walk across the room, observing gait and balance and noting arm
swing.
Male Genitalia
1.Put on examining gloves and have patient lift gown.
2.Retract the foreskin of the penis, and examine the glans, corona, meatus; examine
and palpate the shaft of the penis and "milk" the urethra for discharge.
3.Examine the scrotum; palpate the testes and epididymis gently between the thumb
and forefinger; feel for the spermatic cord.
4.Examine for hernias bilaterally by using the index finger to carry a fold of scrotal
skin into the inguinal canal and asking the patient to bear down or cough.
Rectal Examination
[Patient turns and leans over the examining table]
1.Spread the patient's buttocks and examine the anal orifice.
2.Using lubricating jelly, press the forefinger gently against the anus, then insert it into
the rectum, noting sphincter tone.
3.Palpate the prostate anteriorly, feeling both lateral lobes and median sulcus or raphe.
4.Rotate the finger clockwise and counterclockwise 180 degrees to palpate the rectal
mucosa.
5.While the patient strains downward, withdraw the finger and give the patient tissues
for wiping; if stool is present on the glove, note the color and perform a test for occult
blood.
Electrocardiography（ECG）
1.To know the principle of ECG, master the concept of common leads
2.Be familiar with clinical application and clinical significance of ECG examination
3.Master the normal graphics performance of ECG waves, normal value and clinical significance.
4.Master operating methods of common ECG and connection methods of limb and chest leads.
5.Master the analysis method of heart rate
6.Master graphic-sequenced interpretation of ECG
(a) P wave analysis
(b) PR interval analysis
(c) QRS wave analysis
(d) ST segment analysis
(e) T wave analysis
(f) Other common abnormal ECG
Chapter 1
Basic knowledge of ECG
Section 1 The First Sight of ECG
To know the principle of ECG, master the concept of common leads
Section 2 Configuration and Representation of Waves & Segments in ECG
Master the normal graphics performance of ECG waves, normal value and clinical
significance.
Section 3 Graphics-sequenced interpretation of ECG
Master the method of Graphics-sequenced interpretation of ECG
Section 4 Calculating Heart Rate in Regular or Irregular Rhythm
Master how to calculate heart rate
Chapter 2
P Wave
Section 1 Sinus P Wave
Master characteristic manifestation of normal sinus P wave, abnormality in frequency,
voltage and duration of sinus P wave.
Section 2 Non-sinus P Wave
Master characteristic manifestation of premature atrial contraction, atrial escape beat,
premature junctional contraction, junctional escape beat.
Section 3 P Wave Absence Junctional Premature Contraction
Master characteristic manifestation of sinus arrest, atrial flutter, atrial fibrillation
Section 4 Common Types of Tachycardia with Narrow QRS Complex
To know the analysis principle of Tachycardia with Narrow QRS Complex
Chapter 3
PR Interval
Section 1 The Normal PR Interval
Master the concept of PR interval, normal value and clinic significance.
Section 2 Abnormal PR Interval
1.Prolonged PR interval: First/Second(Type I and II)/High/Third AVB
Master different characteristic manifestation of each AVB.
2.Shortened PR interval: Pre-excitation Syndromes
Master characteristic manifestation of WPW syndrome
Chapter 4
QRS Complex
Section 1 Normal QRS Complex
Be familiar with forming principle of normal QRS complex and its characteristics
manifestation.
Section 2 Abnormal QRS Complex
1. Abnornality in QRS complex voltage:
Master characteristic manifestation of left/right ventricular hypertrophy.
To know the characteristic manifestation of low voltage.
2. Abnornality in QRS complex axis deviation
Master the analysis principle of axis deviation
3. Wide QRS complex
Master characteristic manifestation of premature ventricular contraction and
ventricular escape beat.
To know the characteristic manifestation of ECG recognition with artificial pacemaker.
Master characteristic manifestation of left/right bundle branch block.
Be familiar with characteristic manifestation of left anterior/posterior fascicular block.
Section 3 QRS-Absent Tracing
Master characteristic manifestation of ventricular flutter and ventricular fibrillation.
Section 4 Pathologic Q waves
Master the concept of pathologic Q waves. Be familiar with the analysis principle of
pathologic Q waves.
Section 5 Common Types of Wide Complex Tachycardia
To know the analysis principle of Tachycardia with wide QRS Complex.
Chapter 5 ST Segment
Section 1 Normal ST Segment
Master the concept of normal ST segment.
Section 2 Abnormal ST Segment
1. ST segment elevation: Master characteristic manifestation of myocardial infarction
(Master the position and time of myocardial infarction); To know with early
repolarization syndrome and acute pericarditis.
2. ST segment depression: Master characteristic manifestation of myocardial ischemia;
Be familiar with pre-excitation syndromes and ventricular hypertrophy related ST
segment change.
Chapter 6 T Wave
Section 1 Normal T Wave
Be familiar with characteristic manifestation of normal T wave.
Section 2 Useful Methods for Analyzing T Wave
To know the basic method for analyzing T wave
Chapter 7 Other Common Abnormal ECGs
To know the basic characteristic manifestation of prolonged QT Interval.
Master characteristic manifestation of hyperkalemia and hypokalemia.
Be familiar with characteristic manifestation of electrical alternans.
Renal Function
Grasp the Evaluation for Urine Regular Test.
Grasp the Evaluation for Renal Function: BUN, Crea, Uric Acid and Ccr
Be familiar with the result of other Renal Function Evaluation :Renogram and Renal Imagine.
Recognize the clinical significance for renal biopsy.
Renal function
I OBJECTIVE: TO UNDERSTAND THE GENERAL PRINCIPLE AND THE METHODS
USED TO MEASURE RENAL GLOMERULAR FUNCTION.
A. Measurement of the varied functions of the kidney depends almost entirely on the
application of the principle of conservation. For substances that are not synthesized or
metabolized by renal tissue, the amount entering the kidney via the renal artery equals the amount
leaving in the renal vein and ureter. Similarly, the amount entering the nephrons by filtration and/or
secretion equals the amount leaving by reabsorption and/or excretion. The use of this principle
provides the means for indirectly measuring renal blood flow, glomerular filtration rate, and the
rates of tubular reabsorption and secretion of various substances.
B. Renal plasma flow can be determined by the principle of conservation and the use of a
substance that is not synthesized or metabolized by the kidney. For example,
para-aminohippurate(PAH). Unit for RPF is ml/min.
C. The total plasma volume filtered by the glomeruli per unit time (GFR) can be measured by
the use of the conservation principle and a substance that is freely filtered but is not
reabsorbed or secreted, so that the amount excreted equals the amount filtered. Glomerular
filtration rate is the gold standard test of renal function
One such substance is inulin, a fructose polysaccharide with a molecular weight of approximately
5000. The amount of inulin filtered per unit time by the glomeruli equals the volume of plasma
filtered/time (GFR) times the plasma concentration (Pin). The amount exiting from the ureter per
unit time equals the urine flow rate (V) times the urine concentration (Uin). Since the tubular cells
do not add or remove inulin from the filtrate, the amount entering the nephrons equals the amount
exiting. Plasma and urine concentrations and the urine flow rate can be measured so that GFR can
be calculated (Amount entering = Amount leaving; so GFR x Pin=Uin x V; so GFR=Uin V/Pin). In
clinical , Nuclear medicine imaging (renal scan or isotope renography) can be used to estimate GFR.
Normal GFR 100±20 ml/min
D In clinical for easilier measuring, we could use Creatinine Clearance Rate(Ccr) to estimate
GFR.
1. Calculation of CCr
a. 24 hour urine creatinine collection required
b. CCr = {urine creatinine (mg/mL) x volume (mL)}/{plasma creatinine (mg/dL) x
time (min)}
c. Normal CCr 125 mL/min/1.73m2 or ~80-100mL/min
2. Estimation of CCr
a. Men CCr (mL/min) ~ (140-Age) x (weight in kg)/(72 x serum creatinine)
b. Women CCr (mL/min) ~ equation above for men x 0.85
E Serum creatinine allows a good estimate of renal function. It is cheap and easy to do
with result coming out quickly. Use of serum creatinine may be inaccurate in patients
with: obesity, oedema, pregnancy, ascites, old age, very weak, exercise, al et.
F BUN also allows a good estimate of renal function.
 normal 8-25 mg/dL (adult)
 Major nitrogenous end product of PROTEIN and AMINO ACID catabolism
 Produced by LIVER and distributed throughout intracellular and extracellular fluid
 KIDNEYS – almost all urea is filtered out of blood by glomerular function. Some urea
reabsorbed with water but most is removed in urine
Increased BUN
 Amount of urea excreted depends on hydration of the patient
 LOW PRELOAD (dehydrated)
 LOW CARDIAC OUTPUT
 Diet high in protein (Tube feedings)
 GI bleeding
Can compare to creatinine to determine true renal dysfunction. Unlike the BUN, creatinine is
affected MINIMALLY by HEPATIC function and meat intake.
G New markers: β2 microglobinin(β2 -M), Cyctatin C
II OBJECTIVE: TO UNDERSTAND THE GENERAL PRINCIPLE AND THE METHODS
USED TO MEASURE RENAL TUBULAR FUNCTION.
A Concentration dilution test---Mosenthal test
B Test for urine osmol:600~1000mOsm/kgH2O
 Purpose = Assess the ability of kidneys to dilute or concentrate urine and identify ADH
abnormalities
 Increased values = “Kidneys are conserving water” -- dehydration, Addison's disease,
diabetes mellitus, diarrhea, hyperglycemia, hypernatremia cirrhosis,
Decreased values = overhydration, hyponatremia, hypocalcemia, aldosteronism, diabetes
insipidus
C Test for small molecules reabsorbing, e.g. urine β2 –M
D Normal 24 hour Urine Collection Values
Normal 24 hour urine creatinine 15-25 mg/kg
Normal 24 hour calcium <200 mg/day
Normal 24 hour citrate <320 mg/day
Normal 24 hour cysteine <200 mg/day
Normal 24 hour oxalate <44 mg/day
Normal 24 hour uric acid <600 mg/day
Normal 24 hour protein <150 mg/day
III.Other test related to urinary system
A Serum Uric Acid
 Uric acid is end product of protein metabolism and excreted by kidneys and bowels.
 Temporary increase in serum uric acid from ingestion of food high in purine (meat, fish),
strenuous exercise, or heavy alcohol ingestion will usually return to normal within 1 day
 Normal value: Male 3.6-8.5 mg/dL, female = 2.3 – 6.6 mg/dL
 Serum Uric Acid
 Purpose of test is to confirm the diagnosis of gout and helps detect renal impairment that
causes prerenal azotemia and renal failure
 Overnight fasting
 interfering factors: starvation, caffeine, vitamin C ingestion, high purine diet
B Non-Invasive Radiography
1. Abdomen
a. KUB Radiograph (Kidney, Ureter, Bladder); detects ~80% of renal stones
b. Poor for evaluation of other problems
2. Ultrasound: dilated pelvices, cysts, shadows of stones
3. CT: additional structures, shape, angiography (with iv contrast dye) .Spiral CT
angiography is "gold standard" for vessel assessment
4. MRI: vascular involvement of tumors
C. Invasive Testing
1.
2.
3.
4.
Vascular Angiography: IVP (intravenous pyelogram); very good for stones, obstruction
Retrograde Pyelogram: Ureters
VCUG: voiding cystourethrogram. Assess reflux nephropathy
Bladder Assessment: Cystogram, cystoscopy
D Renal biopsy
1. Renal biopsy is performed transcutaneously under ultrasound guidance.
2. It is particularly useful in the assessment of rapidly deteriorating renal function, nephrotic
syndrome, and assessment of transplanted kidneys.
3. It may be complicated by significant haematuria, pain, and, in the long term, arteriovenous
malformation.
4. Biopsy material should be evaluated by light microscopy, electron microscopy, and
immuno-fluorescence.
Body fluid
Understand the difference between transudate and exudates.
Liver function test
Purpose and Requirement
Understand the principle and clinical significance of liver function test, especially
the test of protein, fat and bilirubin metabolic function.
Understand the principle and clinical significance of serum enzyme and
homoenzyme.
Be familiar with the liver function.
Diagnosis reasoning
Purpose and Requirement
Understand the method and basic principle of clinical diagnosis thinking.
Reference books:
[1]Andreoli and Carpenter’s Ceceil Essentials of Medicine, 7th Edition;
[2]Sleisenger & Fordtran’s Gastrointestinal and Liver Disease 6th Edition
[3]Davidson’s Principles and Practice of Medicine 18th Edition