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DIgestive sysyem
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digestive system and respiratory system complete notes and short cut to remember techniques.
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INTERNAL MEDICINE NOTESPhysical exam
- Cardiac: Remember BALLS for S3 and S4: Bell-apex-light pressure-left side
- Pulmonary
- Bronchial breath sounds sound like you are breathing through a paper towel tube and
have expiratory phase > inspiratory phase. Normal in the central lungs, abnormal over
the periphery - suggest consolidation (loud or normal volume, bronchial breath sounds)
- Vesicular breath sounds - have inspiratory phase >> expiratory phase.
- Inspiratory wheeze - think upper airway pathology
CXR notes
- Framework
- Image quality - roneophrotictation, inspiration (5-7 anterior ribs above diaphragm),
penetration
- Penetration
- On PA, the thoracic spine disc spaces should be barely visible through the heart but no
bony details of the heart.
- On lateral, the spine should darken as you move caudally due to more air in the lung in
the lower lobes and less chest wall - top of the spine should be brighter
- Under penetrated → everything is bright. Over penetrated → everything is dark
- Orientation
- PA
- Assess for rotation by looking at the clavicular heads and seeing if they are
equidistant from the spinous process of the thoracic vertebral bodies.
- Rotation to the left can increase heart size, while rotation to the right can
decrease heart size. Makes sense if you think about the position of the
heart in the chest
- Assess for the adequacy of inspiration - anterior ends of 5-7 ribs should be
visible above the diaphragm in the mid-clavicular line. Less → incomplete breath
in, more than 7 → lung hyperexpansion (if hyperexpansion, the costophrenic
angle can be blunted and give the false impression of pleural effusion)
- If lung inspiration is inadequate, lungs will look denser - might look like
consolidation
- Silhouette sign
- Right upper lobe is against the ascending aorta, right middle lobe is
against the right atrium, right lower lobe is against the right
hemidiaphragm
- Left upper lobe is against the aortic arch, lingula is against the left
ventricle, left lower lobe is against the left hemidiaphragm and the
descending aorta
- Only bone can obliterate bone!
- Kerley B lines = thickened edematous interlobular septa. Caused by pulmonary
edema, lymphangitis carcinomatosa, malignant lymphoma, atypical pneumonia,
interstitial pulmonary fibrosis, sarcoidosis, pneumoconiosis
- Lateral xray:
- film is against the left chest → right sided structures (ribs) get magnified and
appear larger
, - Left hemidiaphragm is higher than the right (usually).
- Left hemidiaphragm disappears anteriorly but right hemidiaphragm does not. Can
only see part of the left hemidiaphragm because of the silhouette sign - heart sits
on top of it. Right hemidiaphragm will also continue posteriorly past the smaller
left ribs and end at the larger and more posterior right ribs
-
- Heart
- PA: Right border is right atrium (should almost be straight up and down), left border is left
ventricle. Lateral: posterior border is left atrium, anterior border is right ventricle.
- Enlargement
- Normal heart size is < 50% of the chest diameter on PA film and 25-30%
cranial/caudal length of the sternum - assuming adequate inspiration
- Left atrial enlargement: double density of the right heart border, prominent left
atrial appendage, angle of the carina is increased > 90 degrees because it lies
just above the left atrium
- Lung pathology
- Atelectasis: Increased linear density, the apex tends to be at the hilum. Can be
associated with lost volume → other structures will move in, e.g., elevated
hemidiaphragm, elevated horizontal fissure
- Cardiac pulmonary edema: cephalization of the pulmonary vessels, kerley B lines
(thickened, edematous interlobular septa), peribronchial cuffing, bat wing pattern,
increased cardiac size
- Pneumonia
- With lobar pneumonia, look for silhouette sign to dermine the lobe affected
- Contrast atectasis - pneumonia has normal or increased volume (not loss), not
centered at the hilum
- Pleural effusion - blunting of costophrenic angles and the pleural fluid will form a
meniscus with the chest wall
- Pneumothorax: Most easily seen at the apices on PA image
- Pulmonary embolism - most often the CXR is normal!
- Interstitial pulmonary fibrosis - ground glass opacification, volume loss, linear opacities
- Hilar adenopathy: Inflammation (sarcoidosis, silicosis), cancer (lymphoma, metastasis,
bronchogenic carcinoma), infection (TB, histo, mono) - can be confused with enlarged
pulmonary vessels. The vessels appear to have smooth contours while adenopathy is
lumpy-bumpy
- TB: any time you suspect TB, also think of histo and blasto, though they are far less
common
- Masses in general: size, shape, location, extent & distribution, circumscription (sharp edges?),
density, homogeneity
- Tubes and lines
- NG tube - should be below the level of the diaphragm and at least 10 cm beyond the
gastro-esophageal junction. The tip should lie on the left - if it is midline, then it’s in the
duodenum - that’s a naso-enteric tube
- Endotracheal tube - should be 5 cm from the carina, with head neither flexed nor
extended. Minimal safe distance is 2 cm. With head flexion, the tube can move down 2
cm. With head extension, the tube can move up 2 cm.
- Central venous catheter tip - enters through the subclavian or jugular veins, travel to the
junction left subclavian vein and superior vena cava
,Health Maintenance
Men and Women
1) Varicella: adults > 60 yrs
Women
1.) Mammogram
a.) Women 40-50 yrs: every 1-2 years
b.) Women > 50: every year
2.) Cervical cancer
a.) First one at 21 yrs or w/in 3 years of sexual activity, then second one is one year later.
b.) If first two are negative → every three years until age 35
c.) Every 5 years until 65
3.) STDs - screen women for chlamydia and gonorrhea, everyone for HIV
4.) Osteoporosis
a.) DEXA scans for women starting at age 65
Men
1) AAA - > 65 yrs if ever smoked. Do w/ ultrasound
, OUTLINE OF STEP UP TO MEDICINE
Chapter 1: Cardiovascular System
Diagnosis of CAD
1. ECG
2. Stress tests: If positive → cardiac cath
a. Stress ECG - 75% sensitive if patients can get HR to 85% of max. Watch for ST
depression, HR, or ventricular arrhythmias
b. Stress echo - more sensitive than stress ECG. Can be used to dx CAD in the presence of
preexisting ECG abnormalities.
c. Enhance stress tests with IV radioisotopes (thallium 201) - helps to determine fixed vs.
reversible ischemia. But more expensive, radiation, and not helpful w/ LBBB
d. Pharmacologic stress tests - adenosine and dyridamole are vasodilators, also
dobutamine
3. Holter monitors for silent ischemia (portable ECG), syncope, dizziness
4. Cardiac catheterization with coronary angiograpy = gold standard for CAD
a. Cath: info on hemodynamics, intracardiac pressure, CO, O2 saturation.
i. Do if + stress test, angina that’s a diagnostic dilemma or occurs after MI or
despite medical therapy, severe symptoms, evaluate valvular disease, determine
need for surgery
b. Coronary angiography: can do PCI with stent or balloon at the same time!
Stable angina
● Treatment options in general:
○ Reduce risk factors
○ Meds:
■ Aspirin and beta blockers (atenolol, metoprolol with B1 > B2) have mortality
benefits.
■ Nitrates for angina.
■ Can add calcium channel blockers if beta blockers or nitrates aren’t enough, but
no mortality benefit.
■ If CHF → add ACE inhibitor or diurectics
○ Revascularization: improves symptoms, does not reduce risk of MI! Can do PCI
(angioplasty) or CABG.
● Treatment options for CAD by disease severity:
○ Mild disease: Normal EF, mild angina, single vessel. Aspirin, BB, nitrates. Consider
CCBs.
○ Moderate disease: Normal EF, moderate angina, two vessels. If symptoms w/ meds,
consider PCI or CABG
○ Severe disease: Decreased EF, severe angina, three vessels/left main/LAD. PCI or
CABG. Generally CABG is the standard for really bad disease, but PCI may be just as
good.
Unstable angina: treat like MI but no fibrinolysis
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