NEBULIZERS

Nebulizers

Advantages Disadvantages

Provide therapy for patients who cannot use other

inhalation modalities (e.g. MDI and DPI)

Allow administration of large doses of medicine

Patient coordination not required

Effective with tidal breathing

Dose modification possible

Can be used with supplemental oxygen

Decreased

portability

Longer set-up and

Administration time

Higher cost

Electrical power

source required

Contamination

possible

URINOMETER

1.

2.

3.

Urinometer is an instrument used to measure the specific gravity of

urine.

There are three parts of urinometer. They are as illustrated in the

Figure above:

The float: It is the air containing part

Weight: The lower end of urinometer

Stem: It has calibrations with numbers marked to measure the

specific gravity.

Normal values of specific gravity are 1.003–1.030. It signifies the

relative mass density. Specific gravity of urine is a measure of

concentrating ability of kidneys and is determined to get information

about its tubular function.

Increased-Specific Gravity in Urine

Diabetes mellitus, nephritic syndrome, fever, and dehydration.

Decreased-specific gravity in urine

Diabetes insipidus, chronic renal failure (low and fixed at 1.010) due

to loss of concentrating ability of tubules, and compulsive water

drinking.

Isosthenuria

This is condition where there is fixed specific gravity. The specific

gravity of the urine remains at 1.010 regardless of the volume of

water consumption by the person. It occurs specifically in chronic

renal disease.

WESTERGREN TUBE

The Westergren method requires collecting 2 mL of venous blood into

a tube containing 0.5 mL of sodium citrate. It should be stored no

longer than 2 hours at room temperature or 6 hours at 4°C. The blood

is drawn into a Westergren-Katz tube to the 200 mm mark. The tube

is placed in a rack in a strictly vertical position for 1 hour at room

temperature, at which time the distance from the lowest point of the

surface meniscus to the upper limit of the red cell sediment is

measured. The distance of fall of erythrocytes, expressed as

millimeters in 1 hour, is the erythrocyte sedimentation rate (ESR).

Spotters

C H A P T E R

14

Fig. 14.1: Pallor. Fig. 14.2: Icterus. Fig. 14.3

Fig. 14.4: Pitting edema. Fig. 14.5: Clubbing. Fig. 14.6: Axilla

Fig. 14.9:

Fig. 14.7: Nonpitting type of pedal edema.

Fig. 14.8: Claw hand.

Fig. 14.10: Psoriasis. Fig. 14.11: Pityriasis versicolor (tinea versicolor). Fig. 14

Fig. 14.13: Erythema nodosum. Fig. 14.14: Scabies.

Fig. 14.1

Fig. 14.16: Acanthosis nigricans and skin

tags.

Fig. 14.17: Neurofibromatosis. Fig. 14.18: Café-a

Figs. 14.19A to C: (A) Adenoma sebaceum; (B) Ash leaf-shaped macule is a hypopigmented macule—oval at one end and pointed at

patches—tuberous sclerosis.

Figs. 14.20A to C: (A) Tinea corporis; (B) Tinea cruris; (C) Tinea manuum.

Figs. 14.21A and B: (A) Herpes zoster—dermatomal involvement; (B) Herpes zoster ophthalmicus.

Figs. 14.22A to C: Lesions of lepromatous leprosy. (A) Facial involvement; (B) Nodular lesions on ear; (C) Leon

Figs. 14.23A and B: (A) Pigmentation of palms; (B) Oral pigmentation in Addison’s disease.

Figs. 14.24A to D: Features of Cushing’s syndrome. (A) Cushing’s habitus, obesity, and moon facies; (B) Buffalo hump; (C an

Fig. 14.25: Thyromegaly.

Figs. 14.26A to D: (A and B) Exophthalmos (front and side view); (C) Infiltration of extraocular muscles in hyperthyroidism; (D) Eye si

(arrow).

Figs. 14.27A and B: (A) Acromegalic facies; (B) Thick and spade-shaped hands.

Fig. 14.28: Systemic lupus erythematosus— malar rash,

alopecia.

Fig. 14.29: Rheumatoid hand.

Fig. 14.30: Scleroderma facies.

Figs. 14.31A to C: Features of cirrhosis. (A) Palmar erythema with Dupuytren’s contracture; (B) Diminished facial hair with parotid

enlargement; (C) Gynecomastia.

Fig. 14.32: Parkinson’s hand tremors. Fig. 14.33: Parkinson’s facies.

A

n

n

e

x

u

r

e

s

C

H

A

P

T

E

R

1

5

1.

2.

3.

4.

•

•

•

•

A. MISCELLANEOUS TOPICS

List of miscellaneous topics which are discussed include:

History taking framework

Pedigree charts

Alcohol usage

Smoking

HISTORY TAKING FRAMEWORK

Eliciting a history from a patient is an essential part of being an effective

doctor. Books have been written about how to consult with patients and

there is no set “right way”. Eliciting a patient’s history does not need to be

done in a set order. Taking a history is not just going down a checklist of

symptoms.

It does include active listening to the patient, awareness of nonverbal

communication, with respect and support of their feelings. It is not just

information gathering from the patient; it is a two-way communication in

which you need to be aware of what and how you are communicating and its

impact on the patient.

Ineffective communication is the most common reason for complaints

against doctors. The majority of malpractice allegations arise from

communication errors. History taking:

Establishes the doctor-patient relationship

Explores the patient’s ideas and concerns about the illness and their

expectations of the doctor

Identifies the patient’s physical, psychological, and social environment

Often leads to diagnosis.

Respect Patient’s Confidentiality

Remember to introduce yourself and state the purpose of the interview and

approximate time needed.

What the patient will be discussing with you may be very personal to

them, so remember to stress that the interview is confidential.

•

•

•

1.

2.

1.

–

–

–

–

–

–

–

–

–

–

2.

Presenting Complaint

This is the opening question.

Some options include:

What has the problem been?

What made you go to the doctor?

Can you tell me how you came to be in hospital?

History of Presenting Complaint

This is the main part of the history and you will need to spend time

discussing this with the patient. Usually has two parts:

A description and exploration of the patient’s problem

How the problem affects the patients personally.

A description and exploration of the patient’s problems: Allow the

patient to tell you in his/her words; this can take a couple of minutes of

uninterrupted talk from the patient.

Allowing the patient to talk without interruption enhances patient

satisfaction and efficacy of the interview. They are likely to need verbal

and nonverbal encouragement from you to maintain the flow.

Next, think about trying to direct your line of questioning to test

diagnostic hypotheses at this stage. For example, with a patient who has

a chest pain, it is important to assess if the pain comes with exercise (if

you suspect they have angina).

You can ask some leading questions for clarification like:

When did the problem start?

Is it a new or old problem?

How often does it occur?

What starts it off?

How long does it last?

What makes is worse?

What makes it better?

Does anything else happen to you at the same time, before or after?

What medicines have you tried?

What effect have they had?

How the problem affects the patient personally: This should not be

forgotten! This also connects with the assessment of mental state,

particularly inquiring about symptoms of depression.

You can ask:

–

–

•

•

•

•

•

•

•

•

•

•

•

How has this illness affected you generally?

How does this make you feel overall?

It is important to find out about the patient’s own interpretation of their

illness. Of equal importance, patients will not be satisfied if their

concerns have not been listened to and addressed.

Systemic (or Functional) Enquiry

As illnesses affect different parts of the body and many illnesses may be

multisystemic, it is important to ask about connected symptoms.

You need to cover the following areas:

Respiratory systems: Dyspnea, wheeze, cough, sputum, hemoptysis, and

chest pain.

Cardiovascular systems: Chest pain, orthopnea, paroxysmal nocturnal

dyspnea, ankle swelling, palpitations, and intermittent claudication.

Gastrointestinal system: Abdominal pain, nausea, vomiting, hematemesis,

bowel habit, bleeding per rectum, and melena.

Urogenital system: Frequency, nocturia, polydipsia, loin pain, hematuria,

menarche, menopause, cycle, intermenstrual bleeding, and postcoital

bleeding.

Central nervous system: Headaches, visual disturbances, sleep, hearing,

tinnitus, lightheadedness, blackouts, fits, unsteady gait, weakness, and

paresthesiae.

Musculoskeletal: Myalgia, arthralgia, back pain, and joint swelling.

Psychiatric: The mental state examination will be taught more formally in

your psychiatric attachment. Remember, depression is common and may

often coexist with physical ill health.

Past Medical History

Always ask the patient if they have or have had any serious illnesses. It

includes:

Ask specifically about hypertension, ischemic heart disease, strokes or

TIAs, diabetes, asthma, jaundice, TB, and rheumatic fever

Surgeries

Blood transfusion

Hospital admissions.

Family History (FH)

•

•

•

•

•

•

•

•

•

•

•

This gives a clue to any predisposition to any illnesses and may highlight

specific concerns the patient may have about a certain disease. Ask the

patient if their parent(s) suffered from any illness, if not alive then ask what

they died from and at what age. Then ask similar questions about brothers

and sisters and children.

Social History/Personal History

This is a very important part of the patient’s history. Remember to ask about:

Social life

Diet

Alcohol

Smoking

Recreational drug use

Occupation.

It is also important to assess a patient’s “activities of daily living”. This is

an assessment of how much support a patient requires to live on a day-today basis.

It includes asking about:

Help with dressing

Help with washing/toileting

Heal with eating

Help with walking

Help with shopping.

Drug History

List all of the patient’s drugs and doses. Remember over the counter and

alternative medicines. Some patients can be quite vague about their tabletstry and persevere.

Drug Allergy

Identify any drug allergies the patient may have and details of what

happens, for example, rash or anaphylaxis.

For female patients—menstrual history and obstetric history.

Summary

At the end of presenting a history, you will often be asked to give a

summary. Prepare two to three sentences to summarize the patient’s

•

•

•

•

•

•

problems including, if you can give a provisional diagnosis or differential

diagnosis.

PEDIGREE ANALYSIS (FIGS. 15A.1 TO 15A.4, AND

TABLES 15A.1 AND 15A.2)

A pedigree chart displays a family tree, and shows the members of the

family who are affected by a genetic trait.

Circles represent females and squares represent males.

Each individual is represented by: A Roman Numeral, which stands for

the generation in the family and a Digit, which stands for the individual

within the generation.

A darkened circle or square represents an individual affected by the trait.

A male and female directly connected by a horizontal line have mated and

have children.

Vertical lines connect parents to their children.

The “founding family” consists of the two founding parents and their

children.

Figs. 15A.4A to C: Pedigree illustrating autosomal dominant

transmission. (A and B) One parent is affected; (C) Both parents are

affected. Note that both males and females are affected equally.

Figs. 15A.2A to E: Pedigree illustrating mechanism of autosomal

recessive transmission. (A) Both parents are unaffected heterozygotes; (B

and C) One parent is sufferer (homozygous) and other is normal; (D) One

parent is sufferer and other is unaffected heterozygote; (E) One parent is

normal and other is an unaffected heterozygote.

Figs. 15A.3A to C: X-linked dominant transmission. Only females are

affected. Usually males who inherit the mutant allele die in utero. (A) Normal

male and affected female (sufferer); (B) Affected male and female; (C) Both

male and female are affected.

Figs. 15A.4A to D: Mode of X-linked recessive transmission. Note the

absence of male-to-male transmission. (A) Male is normal and female is a

carrier; (B) Male is sufferer and female is normal; (C) Male is a sufferer and

female is a carrier; (D) Male is normal and female is sufferer.

Table 15A.1: Examples of automosal dominant and autosomal recessive disorders.

System Autosomal

dominant disorder

Autosomal recessive disorder

Nervous Huntington disease

Neurofibromatosis

Tuberous sclerosis

Neurogenic muscular atrophies

Friedreich’s ataxia

Spinal muscular atrophy

Skeletal Marfan syndrome

Achondroplasia

Noonan syndrome

Alkaptonuria

Ehlers-Danlos syndrome

Metabolic Familial

hypercholesterolemia

Intermittent porphyria

Cystic fibrosis, phenylketonuria, lysosomal storage

diseases, galactosemia, hemochromatosis,

glycogen storage diseases

Hematopoietic Hereditary

spherocytosis

von Willebrand

disease

Sickle cell anemia, thalassemia

Renal Polycystic kidney

disease

Congenital adrenal hyperplasia

Gastrointestinal Familial polyposis Wilson’s disease

•

•

•

•

coli

Table 15A.2: Examples of x-linked recessive disorders.

System Related x-linked recessive disease

Musculoskeletal Duchenne muscular dystrophy

Blood

Hemophilia A and B

Glucose-6-phosphate dehydrogenase deficiency

Immune Agammaglobulinemia

Metabolic Diabetes insipidus

Nervous Fragile-X syndrome

ALCOHOL USE (TABLE 15A.3)

1 unit of alcohol contains 8 g of ethanol.

A conservative threshold of 14 units/week for both men and women is

considered safe.

The risk threshold for developing ALD is variable but begins at 30 g/day

of ethanol.

The average alcohol consumption of a man with cirrhosis is 160 g/day for

over 8 years.

Some of the risk factors for ALD are:

Drinking pattern: Liver damage is more likely to occur in continuous

rather than intermittent or “binge” drinkers, as this pattern gives the liver a

chance to recover. It is therefore recommended that people should have

at least two alcohol-free days each week.

Gender: The incidence of ALD is increasing in women, who have higher

blood ethanol levels than men after consuming the same amount of

alcohol. This may be related to the reduced volume of distribution of

alcohol.

Genetics: Alcoholism is more concordant in monozygotic than dizygotic

twins. The patatin-like phospholipase domain-containing protein 3

(PNPLA3) gene, also known as adiponutrin, has been implicated in the

pathogenesis of both ALD and NAFLD.

Nutrition: Obesity increases the incidence of liver-related mortality by

over five-fold in heavy drinkers. Ethanol itself produces 7 kcal/g (29.3

kJ/g) and many alcoholic drinks also contain sugar, which further

increases the calorific value and may contribute to weight gain.

Units of alcohol explained:

A UK unit is 10 milliliters (8 g) of pure alcohol

For example, most whisky has an ABV (alcohol by volume) of 40%.

1 liter (1,000 mL) bottle of this whisky therefore contains 400 mL of pure

alcohol. This is 40 units (as 10 mL of pure alcohol = one unit).

So, in 100 mL of the whisky, there would be 4 units.

And hence, a 25 mL single measure of whisky would contain 1 unit.

The maths is straightforward. To calculate units, take the quantity in

milliliters, multiply it by the ABV (expressed as a percentage) and divide by

1,000.

Fig. 15A.5: Description of one standard drink based on different beverages.

Table 15A.3: Amount of alcohol in an average drink.

Alcohol type % Alcohol by volume Amount Units*

Beer 3.5

9

568 mL (1 pint)

568 mL (1 pint)

2

4

Wine 10

12

125 mL

750 mL

1

9

‘Alcopops’ 6 330 mL 2

Sherry 17.5 750 mL 13

Vodka/rum/gin 37.5 25 mL 1

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•