Always Smile

Pack Year = Number of pack of cigarettes smoked per day x Number of years of the person has smoked 1 pack = 20 cigarettes 1 pack year  = 1 pack per day for 1 year    (20 cigarettes per day for 1 year) = 2 packs per day for 0.5 year    (40 cigarette per day for 6 months) 1 pack year = 365.24 packs of cigarettes = 7305 cigarettes Example A male patient smoked 15 cigarettes per day for 40 years = 15/20 x 40 = 30 pack years Risk for development of bronchogenic carcinoma increases when pack years exceed 40 Example 20 cigarette per day for 40 years 40 cigarette per day for 20 years 80 cigarette per day for 10 years

Lumbar Puncture Procedure Indication Diagnostic Meningitis Therapeutic Administration of drugs Decrease intracranial pressure Guillain – Barré syndrome Contraindication Increased ICP Patients under anticoagulant therapy Procedure If patient is under anticoagulant therapy Heparin Stop the drug 4 days prior to the procedure Aspirin Stop the drug 7 days prior to the procedure Instruments Lumbar puncture needle 22 Gauge Anaesthesia Injection Lignocaine Sample collection 3 samples 10ml each sample Microbiology Histopathology If repeated procedure indicated After 5 days of the previous procedure Complication Brain stem herniation Post dural headache Due to decreased ICP Prevented by 1 hour lying down before getting up Prevented by administration of paracetamol, caffeine, blood (epidural patch) Bowel & bladder incontinence Nerve damage due to negative pressure Infection

Cardiovascular System Examination Inspection 1. Precordium 2. Apex impulse 3. Pulsation 4. Dilated veins over the chest wall 5. Scars and sinuses Palpation 1. Apex beat 2. Parasternal heave 3. Diastolic shock 4. Thrills Percussion 1. Left border 2. Upper border 3. Right border Auscultation 1. Heart Sound 2. Murmurs Systolic murmurs - mid systolic - late systolic - pan systolic - early systolic Diastolic - early diastolic - mid diastolic - late diastolic

Per Abdomen Examination Inspection Umbilicus Position - can be upward or downward due to ascites, pregnancy, mass Inverted/Everted Shape Swelling Discolouration Distance between xiphisternal and umbilicus Distance between umbilicus and pubic symphysis Palpation Percussion False negative shifting dullness seen in Tense fluid - fluid is unable to move freely Loculation of fluid Auscultation Bowel sound Hepatic bruit Splenic bruit Renal bruit Venous hump 

General Physical Examination Pallor Icterus Cyanosis Clubbing 1. Pulmonary Bronchogenic carcinoma, mesothelioma Lung abscess Bronchiectasis Tuberculosis with secondary infection Diffuse fibrosing alveolitis Empyema 2. Cardiac Infective endocarditis Cyanotic congenital heart diseases, Eisenmenger’s physiology Atrial myxoma 3. Alimentary Ulcerative colitis Crohn’s disease Cholangiolitic cirrhosis Biliary cirrhosis Hepato-pulmonary syndrome 4. Endocrine Myxedema Thyroid acroachy (thyroid nails of hyperthyroidism e.g. in Grave’s disease) 5. Miscellaneous Hereditary Idiopathic Unilateral: Pancoast tumor, subclavian and innominate artery aneurysm Unidigital: Traumatic or trophi deposit in gou Only in the upper limbs in heroin addicts due to chronic obstructive phlebitis

Respiratory System Examination Upper Respiratory Tract Nose Nasal septum Flaring Ala nasi Nasal discharge Bleeding Foreign body Pharynx Redness Tonsil enlargement Lower Respiratory Tract INSPECTION Shape of Chest AP and transverse diameter Rickets / Pigeon breast / Keeled chest / Pectus carinatum Funnel chest / Cobbler's chest / Pectus excavatum Barrel shape chest Hollowing, bulging, flattening or retraction Sub-costal angle Shoulders Spines Spinoscapular distance on both sidesb Respiratory Movement Respiratory rate  Rhythm Character Abdominal Thoracic Thoraco abdominal Abdomino thoracic Equality Accessory muscle of respiration Sternocleidomastoid Pectoralis major / minor Serratus anterior Serratus posterior superior Latissimus dorsi Intercostal retraction / fullness Mediastinum Trailes sign Apex impulse Miscellaneous Scars Sinuses Pulsations Dilated veins Shiny skin over lower chest (Empyema, ...

Cirrhosis of Liver Type of Cirrhosis Alcoholic cirrhosis Postnecrotic cirrhosis Biliary cirrhosis Cardiac cirrosis Congestive cardiac failure, accumulation of fluid .. Clinical Features Intermittent jaundice - biliary cirrhosis Splenomegaly due to portal hypertension Anaemia, leukopenia, thrombocytopenia due to hypersplenism Effect/Signs of Liver Cell Failure Alopecia Icterus Bilateral parotid gland enlargement Coma Spider naevi Gynaecomastia Jaundice Ascites Loss of sexual hair Testicular atrophy Liver flap Bleeding tendency Anemia Ankle oedema Portosystemic Anastomosis Esophagus Bare surface of liver Caput medusae Rectum - hemorrhoid Pathogenesis of Ascites Increase aldosterone level Hypoalbuminemia Portal hypertension Management of Hepatic Encephalopathy Improve bowel habit by laxatives such as Lactulose syrup Antibiotic such as metronidazole and rifaximine