2010

INTERNAL MEDICINE I
LOG BOOK FOR
INTERNAL MEDICINE

PERSONAL
INFORMATIONS:

NAME: QASIM HUSSAIN

ALHALEIMI

AC:207002113.

4TH YEAR MEDICAL

STUDENT.

Group : C1

COLLEGE OF MEDICINE IN
AL AHSSA
CONTENTS: Pages

Logbook cases ………………………………………………………………………………………………… 3

Summary of logbook ………………………………………………………………………………………….. 4

-NEUROLOGY (1st , 2nd WEEK):……………………………………………………………………………..5-16

1. Bedside teaching.

-History& examination.

2. Case Reports.

-INTERNAL MEDICINE A (3rd , 4th WEEK):……………………………………………………………….17-39

1-Case Reports.

2-Activities

1-Respiratory

Bedside teaching (History & examination & some investigation).

2-Cardiology.

-Activities

3-Heamtology.

Sickle cell disease (History & examination)

4-Musculoskeletal .

Examination

-INTERNAL MEDICINE B(5th WEEK):……………………………………………………………………..40-48

1. Bedside teaching.

2. Case Report.

Page3
Nos Diagnosis of Patients seen Date Presented to faculty
.

1
Cerebrovascular Stroke 4-4-2010 Dr.Khalid salam

Systemic Lopus Erythematosus 6-4-2010 Dr.Khalid salam

2

SCD VOC 10-4-2010 Dr.Khalid salam

3

4 24-4-2010 Dr.Amr Darwish

SCD VOC

5 28-4-2010 Dr.Naushad Abdie

SCD VOC

6 1-5-2010 Dr.B Surendra

DM type 1

7 3-5-2010 Dr.Imad AL-Khaufi

Pulmonary COPD

8 5-5-2010 Dr.Abdulmajeed AL-ballat

Pulmonary COPD

9 8-5-2010 Dr. Ahmed Melhem

SCD VOC

Epilepsy, previous Chronic Kidney

10 9-5-2010 Not presented
disease

Bilateral Renal stones, Dr .Mohammad Salah

11 12-5-2010
hydronephrosis Kheder
Page3
 COLLEGE OF MEDICINE IN AL-AHSA

CLASS IV YEAR

LOG BOOK FOR HOSPITAL ROTATION

SUMMARY

1. No. of Patients examined : 10 SHARED

2. No. of case histories presented : 10 SHARED

3. Ward Attendance : All

4. No. of assignments completed : No assignment is introduced by the doctor

5. Lectures attended : All the lectures

Name & Signature of faculty : Name & signature of student:

Qasim Hussain
AL-Haleimi
Page3

NEUROLOGY
 1-BEDSIDE TEACHING

Introduction:

During the two weeks rotation in KFH 5th floor we have been searching for neurological cases but we only see 3
cases. One of them have been discharged in the end of the first week. These cases are one of headache, one of UMNL,
and one of epilepsy.

In these cases the doctor was mentioning the important physical finding especially in the case of UMNL. And some
of the important points in history taking specially for neurological cases. These are some points or highlights
mentioned by the doctor:

History taking:

-In personal information: we should mention if the patient is right handed or left handed, age of the patient to predict
the case of the patient symptoms(Some of the diseases have more than one cause and these causes are age oriented for
example most of the diseases that occur in childhood are either genetic or idiopathic).

-In chief complaint: should be in "patient words”.

-History of the present illness: Should describe pre-, inter-, & post- to the case.

-Past history: specially for diseases related to the present complaints.

-Social & family history : is important specially in genetic diseases.

-Drug history : is important specially in addicting drugs & for the side effect of these drugs for example (morphine in
sickle cell disease patient).

-Systemic review: for detection of physical findings.

Examination:

You should know that neurological examination is the longest examination system you will ever met & that it start
from the first appearance of the patient(while the patient is entering to your clinic) by observation of the gait and
posture of the patient. In examination the doctor was concerning about the examination that is elicited to have finding
in the admitted cases these includes: Facial nerve examination, Trigeminal nerve examination, Deep tendon
reflexes, & Planter reflexes. (in UMNL CASE).

Neurological Examination

Neurological examination universally is divided in to 5 parts:

1. Evaluation of higher mental or cognitive function.

This include evaluation of patient orientation & evaluation of memory

Evaluation of orientation to (time, place, & person) this could be elicited by asking the patient about the time
of hospital admission, were is he living, what is his name.

Evaluation of memory involve both recent & past memory: by asking the patient to recall some words, &
after a while ask him to rebate these words also.

2. Cranial nerve examination: set of instructions for cranial nerve exam is included as

Olfactory CN I Sensory: Test nasal passage patency and identification of odors.

1. Ask the patient to breathe in and out through the nose while the examiner occludes one nostril.
Page3

2. Repeat with the other nostril.

3. Once patency is established, ask the patient to close his eyes.
 4. Occlude one nostril, and ask the patient to inhale gently through the open nostril in close proximity to your
test odorants.
5. The patient should be asked first whether the odorant can be detected. If detectable, the odorant should be
identified by name.
6. If the patient fails at the task, the test should be repeated with at least one distinct odorant.
7. The test should be repeated for the opposite nostril using entirely new odorants.

Optic CN II Sensory: Test visual acuity and visual fields.

Visual Acuity (may be omitted)

1. Perform visual acuity eye examination with glasses or contacts, if appropriate. Test each eye separately using
an eye cover.
2. Have the patient stand 20 feet from the Snellen eye chart, or hold the Rosenbaum pocket card 14 inches away.
3. With one eye covered, ask the patient to read the lowest line on the chart possible. If the patient has difficulty,
ask him to read the one above.
4. Have the patient repeat the test covering the opposite eye.
5. Record the smallest line read, eg 20/40.

Visual Fields

1. The clinician and patient should face each other at close proximity, the clinician’s head level with that of the
patient.
2. Instruct the patient to close one eye, using the other to stare directly into the corresponding eye of the
clinician.
3. While the patient maintains a fixed gaze, the clinician will moves objects (e.g., clinician’s wiggling fingers)
from points behind the patient directly forward and into what should correspond to portions of the visual
fields.
4. The patient should be instructed to indicate verbally when the moving objects become visible.
5. For each eye, the clinician should assess at least six trajectories, corresponding to clock positions of 12:00,
2:00, 4:00, 6:00, 8:00, and 10:00.
6. Test for visual extinction on double simultaneous stimulation by asking the patient how many fingers he sees
when fingers are presented to both sides at the same time. In visual extinction, a form of hemi-neglect,
patients do not report seeing the fingers on the affected (usually left) side of the visual field, although they can
see fingers when they are presented to that side alone.
7. In comatose or uncooperative patients, visual fields can be tested roughly using blink-to-threat, in which the
examiner's fingers are moved rapidly towards the patient's eyes from each quadrant to see if a blink occurs.
Optic CN II and Oculomotor CN III Motor: Test pupillary reflex; observe eyelid movement.

1. Ask the patient to focus on an object in the distance.

2. Observe the diameter of the pupils in a dimly lit room.
3. Note the symmetry between the pupils.
4. Next, shine the penlight light into one eye at a time and check both the direct and consensual light responses
in each pupil.
5. Note the rate of these reflexes.
6. If they are sluggish or absent, test for pupillary constriction via accommodation by asking the patient to focus
on the light pen itself while the examiner moves it closer and closer to their nose.
7. Normally, as the eyes accommodate to the near object the pupils will constrict. End the evaluation of cranial
nerves II and III by observing the pupils in a well lit room and note their size and possible asymmetry.
8. Observe spontaneous movement of the eyelid during blink. Note if lagging or ptosis is present.

Oculomotor CN III, Trochlear CN IV, and Abducens CN VI Motor: Test visual tracking

1. The test should begin with simple observation of the eyes. When gazing at distant objects, the eyes of the
patient should operate in tandem. At rest, neither of the eyes should deviate from the midline horizontal
position.
Page3
 2. With the head of the patient vertically oriented and directly opposite the head of the clinician, the clinician
should place his finger (penlight) approximately 18 inches from a point directly between the eyes of the
patient.
3. Instruct the patient to follow the finger/penlight with his eyes without moving his head while you move the tip
of the finger/penlight through space, forming a large capital-H. The H should be sufficiently large as to force
the eyeballs to their extremes of motion.
4. At the completion of the H, the clinician should return the finger/penlight to the distant central location (i.e.,
directly in front of the patient).
5. Then the finger should be moved towards the patient, with the target being directly between the eyes. This
causes the eyes to cross, perhaps culminating in bilateral constriction of the pupils (i.e., accommodation-
related pupillary constriction).
6. Note extra-ocular muscle palsies and horizontal or vertical nystagmus.

Trigeminal CN V Motor: Test temporal and masseter muscle tone and strength.
1. Palpate the masseter and temporalis muscles in a relaxed state.
2. Palpate the temporal and masseter muscles as client bites down hard.
3. Have client open mouth.
4. With mouth open, have client resist your attempt to close the mouth.

Trigeminal CN V Sensory: Test tactile sensation of the face.

1. Ask the client to close the eyes. Alternatively brush cotton across and lightly pinprick the
forehead, cheeks, and jaw on both right and left sides and ask the client to report "sharp" or "soft"
and the location to which it is applied.
2. Move across each division (forehead, cheeks, and jaw) and ask the client to report if the
sensation is the same or changes.
3. Test the corneal reflex. Note: use of contact lens may decrease response.
a. Ask the patient to look up and away.
b. From the other side, touch the cornea lightly with a fine wisp of cotton.
c. Look for the normal blink reaction of both eyes.
d. Repeat on the other side.

Facial CN VII Motor: Test facial expression symmetry to command; observe spontaneous expression.

1. Observe the face at rest, especially the nasal-labial folds and the eyes.
2. Starting from the top and working down, ask the client to do the following, noting any lag, weakness,
or asymmetry:
a. Wrinkle the forehead;
b. Raise the eyebrows;
c. Close both eyes tightly;
d. Show their teeth;
e. Purse lips or blow a kiss.
f. Smile

Facial CN VII Sensory: Test taste sensitivity of anterior two-thirds of tongue. Observe wetness of oral mucosa.

1. Using a cotton tip applicator, apply a solution that is sweet, salty, sour, or bitter, to one side then the other
side of the extended anterior tongue.
2. Have the client decide on the taste before pulling the tongue back into the mouth.

Glossopharyngeal CN IX Motor: Test function of the stylopharyngeus muscle.

Gently place your thumb and forefinger on either side of the thyroid cartilage.
Ask the client to swallow and feel for elevation of the larynx.

Glossopharyngeal CN IX Sensory: Test taste sensitivity of posterior one-third of tongue.

1. Using a cotton tip applicator, apply a solution that is sweet, salty, sour, or bitter, to one side then the other side
Page3

of the extended posterior tongue.

2. Have the client decide on the taste before pulling the tongue back into the mouth.
Glossopharyngeal CN IX Sensory and Vagus CN X Motor: Test the gag reflex.
1. Touch the back of the pharynx with a tongue depressor and watch the elevation of the palate. (Remember in
approximately 20% of normal individuals the gag reflex is minimal or absent.

Vagus CN X Motor: Test soft palate movement and vocal fold adduction during phonation.
Without tipping back the head, have the client open the mouth wide. Observe the soft palate symmetry. If
need be, use a tongue depressor to hold down the tongue blade.
Have the client say "ah" or "kah" while observing the rise of the palate. There should be little nasal air
escape.
1. Have the client sustain "ah" at a comfortable pitch and listen for vocal quality.
2. Have the patient sustain "ee" at a high pitch level, as this requires very close vocal fold adduction and tension.
3. Have the patient repeat "Methodist Episcopal" listening for phonatory and resonatory quality.

Vagus CN X Sensory: Observe any spontaneous coughing (to laryngeal irritant) during examination.

Accessory CN XI Motor: Test the function of the trapezius and sternocleidomastoid muscles.

1. Place your hands on the client's shoulders and ask her to shrug as your apply resistance by pressing down with
your hands.
2. Next ask the client to turn her head to one side as you once against resist the movement with your hand.
3. Repeat the head turn to resistance on the other side.

Hypoglossal CN XII Motor: Observe lingual appearance and mobility.

1. Have the client open her mouth and observe the tongue at rest, looking for atrophy and/or fasciculations.
2. Have the client protrude the tongue and then move it from side to side.
3. Have the client press her tongue as hard as possible against the buccal mucosa while you press against the
cheek with your hand.
4. Repeat with other side to compare relative strength of the two sides of the tongue.

3. Motor system examination.

Examination of the motor system includes:

-Observation for fasciculation, redness, twitches, hypertrophy, & wasting.

-Palpation for tenderness.

-Assessment of the muscle tone.

Different characters of muscle tone

1. NORMAL

2. INCREASED (SPASTICITY, COGWHEEL RIGIDITY, LEAD PIPE RIGIDITY)

3. DECREASED (FLACIDDITY)

-Assessment of the muscle strength & power.

Muscle strength is often rated on a scale of 0/5 to 5/5 as follows:

 0/5: no contraction
Page3

 1/5: muscle flicker, but no movement

  2/5: movement possible, but not against gravity (test the joint in its horizontal plane)

 3/5: movement possible against gravity, but not against resistance by the examiner

 4/5: movement possible against some resistance by the examiner

 5/5: normal strength

-Assessment of deep tendon reflexes.

GRADING OF TENDON REFLEXES

Deep tendon reflexes are often rated according to the following scale:

 0: absent reflex

 1+: trace, or seen only with reinforcement

 2+: normal

 3+: brisk

-(Hypo-reflexia or a-reflexia)Deep tendon reflexes may be diminished by abnormalities in lower motor neurons

-(Hyper-reflexia)Abnormally increased reflexes are associated with upper motor neuron lesions.

Reflex Main Spinal Nerve Roots Involved

Biceps C5,C6

Brachioradialis C5, C6

Triceps C6,C7,C8

Patellar L2-L4

Ankle S1, S2

-Planter reflexes & Babinski sign.

Planter reflexes anatomical consideration:

Planter reflex comprises of the afferent and efferent fibres in the tibial nerve and the L4-5 to S1-2 cord segments. The
reflexogenic area is the first sacral dermatome, with the receptor nerve endings being located in the skin on the sole of the foot.
The afferent fibres travel in the tibial nerve which is a branch of the sciatic nerve, to relay in the L4-5 to S1-2 cord segments. The
efferent fibres from the spinal cord travel back in the sciatic nerve which divides into two large branches just proximal to the
knee. Fibres supplying the toe flexors travel in the tibial nerve while those supplying the toe extensors travel in the peroneal nerve
to reach the foot. Injury or transection of the tibial nerve therefore, would interrupt the afferent and efferent arcs of the normal
plantar response, leaving the toe extensor muscles innervated. Interruption of the reflex arc can cause a diminution or absence of
the reflex.

Test the plantar response by scraping an object across the sole of the foot beginning from the heel, moving
forward toward the small toe, and then arcing medially toward the big toe.

 The normal response is downward contraction of the toes.

Page3
  The abnormal response, called Babinski's sign, is characterized by an upgoing big toe and fanning outward of
the other toes.

The presence of Babinski's sign is always abnormal in adults, but it is often present in infants, up to the age of
about 1 year. See the figures in adults & in children

Classical
babinski
sign

Babinski sign in healthy child

Other methods for planter responses include:

1-Chaddock’s sign: The stimulus is applied along the lateral aspect of the foot, below the external malleolus.

2 -Oppenheim’s reflex: Firm pressure is applied along the shin of the tibia from below the knee up to the ankle with
the knuckles of the examiner’s index and middle finger.

3- Gordan’s sign: The calf muscle is squeezed.

4- Schaefer’s sign: Squeezing the Achilles tendon.

5- Gonda’s sign: The fourth toe is pressed downwards and then released with a snap.

6- Stransky sign: The fourth toe is abducted maximally and then released suddenly.

7-Bing’s sign: Multiple pinpricks are given on the dorsolateral surface of the foot.

8- Moniz sign: The ankle is forcefully plantar flexed and then released.
Page3

9-Thockmorton sign: The dorsal aspect of the metatarsophalangeal joint of the great toe is percussed.
10- Strumpell sign: Forceful pressure is applied over the anterial tibial region.

11-Cornell sign: The dorsum of the foot is scratched along the inner side of the extensor tendon of the great toe.

Sign UMN Lesions LMN Lesions

Weakness Yes Yes

Atrophy No Yes

Fasciculatio No Yes
n

Reflexes Increased Decreased

Tone Increased Decreased

4. Sensory system examination.

-FINE TOUCH

-PIN PRICK SENSATION

-TEMPERATURE SENSATION

-POSITION SENSATION

-VIBRATION SENSATION

-ROMBERG TEST

CORTICAL SENSATIONS

-TACTILE LOCALIZATION.

-TWO-POINT DISCRIMINATION.

-STEROGNOSIS.

-GRAPHAESTHESIA.

5. Cerebellar system examination.

-TEST FOR SPEECH (SCANNING SPEECH).

-EXAMINATION OF EYES FOR NYSTAGMUS (PENDULAR NYSTAGMUS).

-EXAMINATION FOR GAIT.

-TANDOM WALK.
Page3

-FINGER TO NOSE COORDINATION (ATAXIC).

 -RAPID ALTERNATING MOVEMENTS (SLOW).

-TEST FOR REBOUND

-HEEL TO SHIN COORDINATION (ATAXIC).

-EXAMINATION FOR TONE (HYPOTONIA).

Pseudobulbar palsy: bilateral impairment of the function of the lower cranial nerves IX, X, XI and XII which control
the muscles of eating, swallowing and talking. It is the result of an upper motor neuron lesion to the corticobulbar
pathways in the pyramidal tract.

Causes:

• Vascular causes: Bilateral hemisphere infarction

• Degenerative disorders: motor neuron disease
• Inflammatory disorders: Multiple sclerosis
• Malignancy: High brain stem tumors
• Metabolic
• Brain trauma

Common symptoms:

-Dysphagia.

-Uncontorlled loughing or crying.

Common signs:

-Speech problems slow, thick.

-Gag reflex

-Tongue is small, & stiff.

-Jaw jerk is brisk.

-UMNL.

Page3

2-CASE REPORT
 Presented to Dr. Khaled Sallam
CASE: CerebroVascular Stroke Date: Sunday- 4 /4/2010

We do an examination on Indian patient with right side paralysis because the patient is unable to talk. Examination
was specified in the positive signs of the patient.

General examination:

Middle age, male patient, alert, not oriented to time, place and person, comfortable, and connected to O2 ventilation
receiving IV nutrition, and urinary catheter.

Neurological Examination:

The patient was unable to talk .

Receptive aphasia was the only explanation found in the patient(Unable to understand what is said to be done).

Cranial nerve examination:

We examine facial 7th cranial nerve – UMNL

Trigeminal 5th nerve shows no abnormality in sensation, but some rigidity in the muscles of mastication.

The patient swallowing is affected by pseudobulber palsy so he is receiving IV fluids.

Motor functions:

Loss of the tone, power, in the right side.

No movement limitation.

Deep tendon reflex:

Exaggerated at the right side – UMNL

Planter reflex:

1- Babinski's sign

2-Oppenheim's sign: applying pressure to the medial side of the tibia.

3-Chaddock's sign: stroking the lateral malleolus.

4-Gonda's sign: flexing and suddenly releasing the 4th toe.

5-Gordon's sign: squeezing the calf muscle.

The planter reflex was positive in the right side.

Summary of the case:

The patient was diagnosed of stroke located in the brainstem especially in the pons.

Presented to Dr. Khaled Sallam

Page3
Case : SLE Date: Tuesday 6 /4/2010

Identification data:

Mohammed Al-Swilem is a 15 year old, Saudi male, workless, living in Al- Twether in Al-Hassa, smoker, and right
handed patient.

Chief complaints:

The patient referred from Al-Jaffer hospital before 7 days C/O difficulty in breathing and generalized weakness 4
weeks prior to his admission.

History of presenting illness:

The patient is a known case of SLE (Systemic Lobus Erythmatuses). The patient was in his usual state of health since 4
weeks prior to his admission. The difficulty in breathing was sudden in onset, continuous and progressive, increased
by effort and not relive by rest. The dyspnea is not severe because the patient able to climb stairs for 2 door. The
dyspnea not associated with palpitation, chest pain, wheeze, cough, fever, and heartburn. Regarding previous attack
this is the first attack.

Past history:

The patient had a past history of anemia. No past surgical history, no blood transfusion.

Drug history:

Unknown.

Family history:

Unknown.

Social history:

The patient live with his parent . He smokes 3 cigarette/day. He had very bad relationship with his family.

Review of systems:

CNS: no history of headache, no history of dizziness, no history of paralysis.

CVS: no history of peripheral edema, no history of palpitations, no history of hypertension.

RS: no history of fever, no history of dyspnea, no history of cough, no history of hemoptysis.

UT: there is a history of burning sensation in urination, no history of urine change.

Note:The doctor said : this patient is a mentally retarded and not cooperative.

On Examination:

- General appearance: young male, thin patient, alert, oriented to time, place and person, comfortable, and not
connected to anything. Butterfly face is not sow apparent.

-Vital signs: we did not do it.

-General Examination:
Page3

The head (face):

There is a pallor, the ear is low sited ( sign of mental retardation), no jaundice

Neck:

-Cervical lymph node ( submental, submandibular, pre-auricular, post-auricular, occipital lymph nodes, anterior
group, and posterior group of lymph nodes) are not palpable .

-JVP- we don't do it.

The chest:

No Gynaecomastia , no chest abnormality, no scars, no swelling, no hair loss.

Nails:

There is a pallor, no cyanosis, no clubbing, no koilonychias.

Palm of the hand:

There is a pallor, no Palmar erythema.

Dorsum of the hand:

No muscle wasting, no sign of inflammation or swelling.

The arm:

No bruising, no muscle wasting, no Scratch marks.

Elbow:

Pre trochlear lymph node is not palpable.

Axillae:

Anterior, posterior, medial, lateral, and apical lymph node ( right and left side) are not palpable.

Lower limb:

Dorsalis pedis, and posterior tibial arteries are palpable, no bruises, no scratch marks, no edema.

Neurological Examination:

All 12 cranial nerve were intact.

We do a deep tendon reflex and the result was normal.

In summary: the case was diagnosed with SLE that mainly affect the joint but it may affect any organ system in the
body so the patient was registered for monitoring the cause of dyspnea.

Presented to Dr. Khaled Sallam

Case: Sickle cell disease VOC Date: Saturday 10 /4/2010

Page3

Identification data:
Hassan Al-Qarash is a 30 year old, Saudi male, workless, living in Al-mahdood in Al-Hassa and originally from
there, married with 2 offspring, smoker.

Chief complain:

The patient admitted through ER since last Thursday, C/O pain in the right foot 1 day prior to his admission.

History of presenting illness:

The patient is a known case of SCD. The patient was in his usual state of health till 1 day prior to his admission when
he started to complain of sudden onset, continuous and progressive pain affecting whole right foot after waking from
sleep. The pain was localized and severe ( 6 out of 10 according to the patient). It is not aggravated by anything, but
relieved by flexing the knee.

Past history:

No history of past medical and surgical illnesses. There is a history of blood transfusion, 7month ago.

Drug history:

Morphine in crisis in the hospital.

He take folic acid, 1 tablet/day.

Family history:

His parents are relatives, carrier, he has 4 brother out of 11 with SCD.

Social history:

He is smoker, 20 cigarette/ day from 5 year.

Review of systems:

CNS: no neurological sign is detected.

CVS: no palpitation, no chest pain, no dyspnoea, no lower limb edema.

RS: no dyspnoea, no wheezes, no chest pain.

UT: no mecturation abnormality, no history of painful erection, no polyuria, no urinary frequency.

MS: no movement abnormality, no leg ulcers, no fasiculations, no muscle atrophy.

In summary:

The case was previously diagnosed of SCD, he was diagnosed in this admission of having vaso-occlusive crisis,
specially in the right limb.

INTERNAL MEDICINE B(3RD,4TH WEEK)

1-Case Reports:
Page3

Presented to Dr. Amr Darwish

Case: Sickle cell disease Date:Saturday- 24/4/2010

Identification data:

Ahmad Hassan Al-Dandan is a 18 year old, Saudi male, student, single, living in Al-Rashdia in Al-Ahssa, non-smoker.

Chief complaint:

The patient admitted through ER since 5 day C/O leg and low back pain.

History of presenting illness:

Patient is a known case of sickle cell anemia. Patient was on his usual state of heath till two days prior to his
admission. The pain is gradual in onset, continuous and progressive, in right leg and lower back, localized, so severe
( grade 10 out of 10 according the patient), aggravated by

We don't ask about character, associated symptom like pain is it with movement of the leg or not, is there any
swelling, weight loss.

Past history:

The patient is a known case of sickle cell anemia.

The patient had previous attack similar to this but not so severe like this.

No history of cardiac disease, no history of hypertension, or DM.

No history of transfusion or exchange of blood.

No history of surgical operations.

Drug history:

Folic acid , analgesic drug when needed not regular.

Family history: No disease in the family with familial tendencies.

Social history: non smoker, non alcoholic, no drug addict, living with his family with low socioeconomic class.

Review of system:

No finding of special importance.

MS: no leg ulcers, no swelling in the joints, no discoloration, no limitation of movement.

US: no frequency urination, no priapism, no polyuria, no urine discoloration, no urinary incontinence.

GI: No abdominal tenderness, no hepatomegaly, no splenomegaly, no pain in the abdomen, no diarrhea, no

constipation, no vomiting, no hematemesis, no melena.

CNS: No faintness, no headache, no numbness, no tingling.

RS&CVS: No chest pain, no dyspnoea, no wheezes, no cough, no hemoptysis, no orthopnoea, no PND, no palpitation,
no lower limb swelling.

In summary:

The case was diagnosed of vaso-occlusive crisis in the leg treated by oxygen therapy, analgesia, in severe cases
Page3

morphine drug is used.

 Presented to Dr.Naushad Abdie

Case: Sickle Cell Anemia Vaso-occlusive crisis Date: Wednesday 28-4-2010 AD

Personal Data:

Hussan Al-Rashed is a 29 year old, Saudi, male, working in Al- Jobbail(Royal company in Jobbail & Yunbbo), living
in Al-Faisalia, married without children, non smoker.

Chief Complaints:

The patient is admitted through ER since 6 days C/O:

Knee and shoulder pain since 4 days.

History of presenting Illness:

The patient is a known case of SCD. He was in his usual state of health till 4 day prior to his admission. The pain
started when he arrive from his travel to Al-maddina by the Bus. The pain was gradual in onset, continuous and
progressive, localized in the right knee and shoulder, like hummer hitting in character, not so severe that do not
interfere with daily activity, aggravated by waking and relief by flexing the knee. The knee and shoulder was movable,
no swelling, no ulcer, no fever, and no associated cough. There is a previous attack of chest pain, 3 years ago.

Past history:

Surgical Mass removal at the center of the chest 27 year ago

Blood transfusion 12 year ago at Aramco hospital

No history of medical illnesses.

Drug history:

The patient take folic acid, as a no regular treatment ( 1tablet/month), no regular follow up, and the disease was under
control.

Family history:

The parent of the patient is relatives (Consinguinious marriage), carrier to Sickle cell anemia, and he had 4 brother
with SCD.

Social history:

Non-smoker

Systemic review:

RS:No respiratory problem

CNS: no headache, no loss of sensations

General: the patient is alert, oriented to time, place and person ,there was no ulcer, no fever
Page3

Vital signs: temperature, pulse, BP, respiratory rate all are normal.
Hand : there is a palor, no cyanosis, no clubbing, no koilonychias.

Neck: lymph node are not palpable, trachea is in the center ,neck is movable, JVP normal.

Eye: there is a palor, no jaundice.

Mouth: No cyanosis, no whitish pigmentation, no tongue fasiculations

Feet: no edema, no ulceration , no loss of sensation.

CVS: no palpitation.

In summary:

The patient was diagnosed of having SCD VOC , managed by oxygen therapy, analgesic drugs.

Presented to Dr. Bathulas M Surendra

Case: Diabetes Mellitus Date: Saturday 1/5/2010

Identification data:

Abdullah Al-Ausheer is a 13 year old, Saudi male, student, living in Al-Battaliah village in Al-Hassa , non-smoker.

Chief complain:

The patient admitted through ER yesterday C/O excessive thirst, and increase urinary frequency 10 days prior to his
admission.

History of presenting illness:

The patient was in his usual state of health till 10 days prior to his admission when he experience to develop excessive
thirst, and increase urinary frequency. The patient visit Al-Battaliah health center 4 days ago for the same symptoms
but the diagnosis was unknown. Yesterday the patient monitor his blood glucose level at home and the level was 321
mg/dl, then the patient admitted to ER by his father. The amount and frequency of urination increase in a term of 6
time/day. ( Ask about associated symptom like urinary tract infection " fever, burning sensation in urination, urgency,
hesitancy, hematuria, color of urine)

Past history:

The patient had a past history of G6PD, 1year ago, diagnosed at Bin Jalawy hospital. There is no past surgical
history.

Drug history:

Folic acid, no regular treatment, no regular follow up.

Family history:

His grandfather, his aunt, and his cousin had DM type I .

Social history:

The patient is a student in intermediate school, non-smoker, living with his parents.
Page3

Review of systems:
General:

The patient is fully conscious oriented to time, place, & person, so cooperative, with no abnormality.

Gait is normal.

Normal tempreture.

Head : no signs of inflammation, redness, no blurred vision & retinopathy, no sunken eye, no conjunctivitis, no
jaundice, no dilated veins, hair distribution is normal.

Neck: Normal JVP, appearent carotid pulsation, no thyroid swelling, no lymph node enlargement, trachea is
centralized.

Limbs: No clubbing, koilionychea, no leukonychea, no pallorness, no edema, no skin turger, no tremors.

Chest: No scars, no spine abnormality, normal hair distribution as in under puberty patient, no dilated veins.

Abdomen : no hematemesis, no melena, no vomiting, no heartburn, no epigastric pain, no diarrhea, there is polyuria,
& frequency of urination.

CNS: no neuronal defect, no tremors, no numbness, no tingling sensation, no seizures, or fits, no faintness, no
syncope, no headache.

CVS: no palpitation, no lower limb edema, no dyspnoea, no PND, no orthopnoea, no syncope, no chest pain.

RS: no dyspnoea, no wheezes, no crepitation, no crackles, no chest pain, no cough, no hemoptysis.

MS: no swelling of joints, no limitation in the movement.

GUS: no blood in urine, normal color urine, no tenderness in the lower abdomen, no dysuria, no anuria.

In Summary:

The patient was diagnosed of having DM type 1 managed by insulin injection, the patient was being educated about
the disease importance of regular treatment or compliance & exercise , food intake regulation, glucose monitoring by
glucometer.

Presented to Dr. Imed Alkhoufi

Case: Mild Pulmonary COPD Date: Monday- 3/5/2010

Page3

Identification data:
Ali Essa, is a 56 year old, Saudi male, jobless, living in Al-Mazra in Al-Ahssa, married with 7 child, non-smoker.

Chief complain:

The patient admitted through ER since 4 days C/O difficulty in breathing 7 days prior to his presentation.

History of presenting illness:

The patient is a known case of DM and hypertension. The patient was in his usual state of health till 7 days prior to
his admission when he started to C/O sudden onset, continues and progressive dyspnea when he was sleeping that
awake him from sleep. It is aggravated by dust and not relive by any medicine. It is associated with sudden onset
cough, and small amount, yellow tengent sputum. It is not associated with fever ,heartburn, palpitation, and chest
pain.

Past history:

This is the 1st admission for the patient. The patient had a past history of DM, 12 years ago, and hypertension, 4 years
ago. No past surgical history, no past history of blood transfusion.

Drug history:

He take anti-hypertensive drug 1tablet/day, oral hypoglycemic drug 2tablet/day. The treatment are taken regularly.
No history of drug or food allergy.

Family history:

His father died since 27 year ago, and his mother died from MI. He has 7 healthy child.

Social history:

He is living with his sons, not dependant to any one, he is not educated, non smoker, workless.

Systemic Review:

General: The patient appear conscious self oriented sitting in the bed in semi-sitting position, not appear as in pain,
appear as obese, without asites, no redness in the body, no cyanosis, no jaundice.

RS: No chest pain, no wheezes, mild dyspnoea, no use of accessory respiratory muscles, & no cough.

CVS: there is a history of bradycardia, and palpitation, no dizziness.

CNS: there is a history of mild headache.

GI: no hematemesis, no melena, no vomiting, epigastric pain, no diarrhea, no constipation, no abdominal pain.

Renal: no dysurea, hematourea.

In summary:

The patient was diagnosed of having COPD, due to complication of hypertention, & DM, which is managed by
Oxygen therapy, compliance to medication of DM, & Hypertension, no specialized treatment for COPD is prescribed
till the time of taking the case.

Presented to Dr.Abdulmajeed AL-ballat

Case: Pulmonary COPD Date: Wednesday 05/05/2010 AD
Page3

Identfication Data:
Ali Yasine AL-Esmaeel is a 69 year old Saudi male, living in AL-Oion , in AL-AHSSA, retired ,married with 13
offspring, smoker.

Chief Complaint:

Gastric pain 3 weeks.

Difficulty in breathing 7 days.

Right abdominal Pain 3 days

History of Present illness:

The patient is a known case of Bronchial asthma, associated with chronic cough before 17 years. The patient was in
his usual state of health till 3 weeks prior to his admission when he experience left hypocondrial pain which is
gradual in onset,continuous spastic in character, aggravated by eating & relieved by fasting. After that about two
weeks the patient develop difficulty in breathing like compression in character associated with mild fever managed
in the house by nebulizer & analgesic drug, after few days the patient experience to develop acute right abdominal
pain which is acute, continuous progressive in character, aggravated by excessive breath & relieved by rest. This pain
is associated with generalized fatiguability that brought the patient to the hospital.

Hospital Course:

X-ray.

Generalized CT.

Past history:

No similar attack similar to this attack.

The patient is a known case of bronchial asthma & chronic cough.

No surgical interventions.

Drug history:

Nebulizer for asthma, & anti-cough medication.

Family History:

No history of any genetic disease in the family.

His wife has Rhomatism.

Social History:

The patient is smoker of 30 cigarette/day for 17 years. Retired living with his family in a poor socioeconomic class.

Systemic Review:

General: the patient is stable well oriented to time, place, & person. Sitting in the bed with no IV line, he has a history
f otitis media in the right ear. No sign of dehydration but the patient is so thin which explain the fasting.

CNS: No headache, no blurred vision, no tremor.

Page3

CVS: No palpitation, no chest pain, no lower limb swelling, there is no dyspnoea.

RS: No chest pain, no wheezes, no hemoptysis in cough.

GI: no diarrhea, no conistipation, no vomiting, there is a left flank pain, no hematemesis, no melena.

GUS: no problems in the urine color, amount, & frequency.

MS: do not have any limitation in the movement , no swelling.

In summary:

The patient was diagnosed of having COPD which is suspected by X-ray, and any other problem will be shown in the
CT scan.

2-ACTIVITIES

1-Respiratory

BEDSIDE TEACHING

History taking:

Specially in patients complaining of :

-Breathelessness & Dyspnoea.

-Chest pain.

-Cough.

-Hemoptysis.

-Wheezing or abnormal sounds from the chest.

-Production of Sputum.

History includes:

1) Personal history (identifying data and source of the history)

2) Chief complaint (s) in patient words & duration since the day of admission.

3) Present history description of the patient complaints including:

-Preterm complaints which means actions before to the starting of the complaints.

-Interterm complains & associated complains.

-Postterm complains.

In the complain itself describe:

-Site, onset, character, severity, radiation, associated symptom, duration, course, pattern, relieving factors, &
exacerbating factors.
Page3

4) Past medical history.

 -Allergy.

-History of cardiac disease.

-History of generalized metabolic disease.

-History of any surgical intervention.

5) Family history

-Genetic diseases.

-Multifactorial diseases (as cardiovascular disease & diabetes mellitus).

6) Social and personal history

-Smoking history and the type of smoking(shesha, tobacco, and so on)

-Alcohol history & the amount.

7) Occupational history

-Certain occupations are at high risk of developing some diseases of respiratory problems like pneumoconiosis.

8) Review of systems

General assessment includes:

-Voice problems which may indicate upper airway obstruction.

-Breathelessness.

-Clubbing which is usually either cardiac or respiratory causes.

-Cyanosis & pallorness.

-Chest shape (Normal, barrel shaped, Pectus excavatum, & pectus carinatum ).

-Use of accessory respiratory muscles (As in respiratory distress).

-Cervical venous pulses (JVP high or low).

-Lymph nodes.

-Trachea position.

-Redness of the face & temperature examination.

-Ocular problems Jaundice, conjunctivitis, & pallor.

9) Drug history and allergies.

-History of drugs allergy (Specially for aspirin, penicillin, & salfa drugs).

-Drugs that cause bronchoconstriction.

-History of corticosteroids.

Respiratory system examination:

1-Inspection.

-Appearance of the chest: scars, barrel shaped chest, spine abnormalities as kyphosis (bending forword), or scoliosis (lateral
Page3

bending) or both.

-Skin rashes like that in systemic lupus & herpes zostar.

-Movement of the chest better seen when the patient is lying and see from the foot of the bed abnormal area usually not moving or
moving less than the normal area.

-Venous pulses in the neck.

-Respiratory rate and rhythm normally 16 + or – (2).

-Respiratoy expansion at three level.

2-Palpation.

-Lymph nodes in the neck & the axilla.

-Swelling and tenderness.

-Trachea & the heart specially point of maximal impulse.

-Tactile vocal fremitus by asking the patient to said 44 in Arabic or 99 in English.

3-Percussion.

Notes:

First you have to differentiate between dull sound & resonant or tympanic sound.

Second you may detect a pain or tenderness.

-Over the clavicle:

The clavicle is divided in to three parts:

Over the lateral 1/3 percussion always revels dullness because over bony area.

Over the two other thirds there may be dullness or resonance.

-Over the 2nd intercostal space to 5th intercostal space usually resonant.

-Tidal percussion for localization of the upper border of hepatic dullness which should be correlated with respiration.

-Traubes’ area percussion.

Note: In pneumothorax percussion revels hyperresonant.

4-Auscultation.

By auscultation you listen to:

1-Breath sound:

-Bronchial (Inspiration sound = Expiration).

-Vesicular (Inspiration sound is 3 times Expiration).

-Bronchiovesicular.

-No air entery.

2-Adventitious sounds or additional sounds:

-Rhonchi and wheezes (Continuous sound).

Page3

-Crackles & Crepitations (Discontinuous sound).

Other investigations of respiratory system importance:

-Sputum examination:

-Mucoid.

-Forthy.

-Purulent.

-Bloodstained.

-Rusty.

-Lung function tests.

-Arterial blood gases.

-Chest x-ray.

2-Cardiology

Activites

First day observation of the doctor while he take history & perform the examination.

Cardiac symptoms includes:

Page3

-Dyspnoea.
-Syncope.

-Chest pain.

-Palpitation.

-Edema & swelling of the extremities.

-Cough.

-Hemoptysis.

Cardiac History:

-Personal information as before but we have to mention smoking or alcohol use.

-Chief complaints: in patient words & in timing order since day of admission.

- Present history description of the patient complaints including:

-Preterm complaints which means actions before to the starting of the complaints (Exercise or stress).

-Interterm complains & associated complains (for example: chest pain associated after that with breathlessness & dyspnoea).

-Postterm complains (Rest relieve the complains & feel want to sleep and rest) .

In the complain itself describe:

-Site, onset, character, severity, radiation, associated symptom, duration, course, pattern, relieving factors, & exacerbating
factors.

-Past medical & surgical history:

Cardiac surgery or disease.

Metabolic disease.

Any surgery when where and for what purpose.

Heamatological disease.

Respiratory disease.

Previous hospitalization.

-Family history:

Genetic disease in the family.

Anemia.

Diabetes Mellitus.

Any one in the family with cardiac disease.

- Social and personal history:

-Smoking history and the type of smoking(shesha, tobacco, and so on)

-Alcohol history & the amount.

-Stressfull conditions that leads to hypertension.

Page3

Drug history:
Drugs used ,when , for what condition the drug is prescribed, for how much period specially these drugs:

-ACE inhibitors.

-Digitalis & Sublingual tablets.

-B-blocker.

-Diuretics.

-Drug allergy.

-Penicillin allergy.

-Salfa drug allergy.

Review of systems:

-General assessment:

-Breathelessness.

-Level of consciousness.

-Clubbing which is usually either cardiac or respiratory causes.

-Cyanosis & pallorness.

-Chest shape (Normal, barrel shaped, Pectus excavatum, & pectus carinatum ).

-Cervical venous pulses & their congestion (JVP high or low).

-Apex beat localization.

-Carotid pulsation.

-Signs of infective endocarditis.

-Brachial, Radial, Ulner, Femoral, Poplitial, Anterior, and posterior tibial, and dorsalis pedis pulsation in both sides.

-Vital signs (RR,Temp,Pulse,& Blood pressure in both arms).

-Edema of the extremities and their type (Bitting or non bitting) localized or generalized.

-Cardiac local Examination:

Inspection, palpation, & auscultation (Percussion is replaced by echocardiography).

-Inspection:

Exposure of the chest from the suprasternal nutch to the umbilical region.

Look for :

-Chest shape, dilated veins, scars of previous surgery, hair distribution in male patient, the breast size which may indicate
gynecomastia in male patient, nodules, erythema or pigmentations, pulsations specially in the apex.

-Palpation:

Look for pulsations & thrill by looking tengential:

A. Precordial:
Page3

1. Apex

Comments should be on:

 1. Site

2. size

3. force

4. duration

5. character

6. Radiation &Thrill

Localize the maximal point of impulse.

2. Left parasternal

3. Pulmonary

4. Aortic

B. Extraprecordial:

1. Suprasternal (S)

Causes of pulsation:

- Hyperdynamic circulation

- Aortic regurge

- Unfolding of aortic arch

- High aortic arch

2. Epigastric (E)

Sources of pulsations:

1- Abdominal aortic:

- Aortic aneurysm- aortic regurge- hyperdynamic circ

2- Right ventricular enlargement: in PH- PS

3- Hepatic: in right side HT

Auscultations:

1. First and second heart sounds (S1, S1)

- Intensity

- Splitting of S2

2. Third & fourth heart sound ( S3, S4 )

3. Addional sounds: clicks, Opening snap, rub

4. Murmurs

How to comment on murmur:

1. Timing (Systolic or diastolic)

Page3

2. Grade: (Intensity).
 3. Character: (Harsh- blowing- rumbling).

4. Site of maximal intensity.

5. Selective direction of propagation.

6. Dynamic auscultation: Effect of respiration (TR)

Best sites for hearing sounds & murmur

Grades of clubbing:

Grade I: Obliteration of nail angle

- Grade II: increased nail convexity

(parrot peak)

- Grade III: Nail soft tissue is swollen

(Drum stick).
Page3

- Grade IV: Hypertrophic pulmonary osteo-arthropathy

Subperiostal calcium deposition

Causes of clubbing:

1. Cardiac : - Cyanotic congenital HD

- Endocarditis

2. Pulmonary: - Bronchogenic carcinoma.

- Suppurative lung syndromes

(empyema, abscess, bronchiectasis, cystic fibrosis).

- Fibrosing alveolitis.

3. GIT: - Crohn's disease).

- Billiary cirrhosis of liver.

- Malabsorption, e.g. celiac disease.

4. Rare causes: - Familial.

Causes of raised JVP:

- Right ventricular failure: large v wave.

- Tricuspid regurge: large v wave.

- Tricuspid stenosis: large a wave.

- Pericardial effusion.

- Constrictive pericarditis.

Causes of non detectable apex:

• Chest wall: obesity.

• Pleura: effusion- pneumothorax.

• Left lung: emphysema.

• Pericardium: effusion.

• Myocardium: failure.

• Dextrocardia.

3-Hematology

Bedside teaching (History & examination of SCA)

History:

-Personal Information: name,age,gender,occupation,marital status,consinguinus marriage,day of

admission,Residency,take the premarriage testing.

Chief complaints:
Page3

The two major problems that brought the SCA patient to the hospital are:
1-Hemolytic anemia.

2-Tissue infarction due to vaso-occlusion (Which is the most common).

Usually the SCD patient come with one or two of these complaints:

Long-term complains due to hemolysis:

-Generalized fatigue.

-Increased susceptibility to infections (chest infection as pneumonia ,meningitis,osteomyelitis).

-Leg ulcers due to ischemia.

-Gallstones so some patient are having cholecystectomy.

-Aseptic necrosis of bones specially femoral head so patient may present with hip or pelvic pain.

-Blindness due to retinal detachment.

-Chronic kidney disease due to vascular abnormalitiy.

-Bossing of the skull and sometimes the sternum as a compensatory mechanism in infantile age to less than one year
of age.

Infarctions due to vaso-occlusion:

-Bone pain is the most common problem patients come with. It defer in child as well as in adults. In child the most
common bones affected are fingers & toes, while in adults legs,arms, and sometimes the back & the chest.

-Spleen infarction or autosplenectomy and spleenomegaly.

-Kidney disease presenting as hematuria which is more common in SCT leading to papillary necrosis of the renal
calysis.

-Mesentaric infarctions are not so common but may occur presented as acute abdomen.

-Chest pain is almost common due to pulmonary infarctions which may be exacerbated by dehydration, chilling, &
chest infection mainly streptococcus penumoniae.

-CNS stroke may occur in thrombosis.

-Penile disease known as priapism (Painfull erection).

Other manifestations not specific includes:

-Hepatomegaly.

-Jaundice.

-Delayed puberty.

-Non-healing ulcers in the legs.

History of the Presenting illness: detailed description of the patient complaints regarding:

-Site, onset, duration, pattern, course, character, severity, radiation, associated symptoms, relieving factors, &
exacerbating factors.
Page3

Past medical & surgical history:

-Any previous attack similar to this condition.

-Hip replacement.

-Cholecystectomy.

-Chest infection.

-Cardiac disease.

-Infectious diseases(malaria,& schestosomiasis, hepatitis).

-Endocrine disorders (Thyroid, or pituitary disease).

-Kidney disorders.

-Vaccination for pneumococcal, & meningococcal infection.

- Blood transfusion or exchange.

-Bone marrow transplantation.

-Splenectomy.

Drug History: Drug name, dosage, frequency, compliance,& side effect.

-History of drugs that cause hemolysis:

Extravascular Hemolysis

-Alpha-methyldopa & levodopa

-Diclofenac

-Ibuprofen

-Interferon alfa

-Mefenamic acid

-Penicillin(Carbenicillin,ampicillin,& methicillin)

-Procainamide

Intravascular Hemolysis:

-Acetaminophen

-Chlorpromazine

-Fluorouracil

-Hydrochlorothiazide

-Hydralazine

-Insulin
Page3

-Isoniazid
-Melphalan

-Phenacetin

-Probenacid

-Quinidine & Quinine (treatment for malaria).

-Rifampin

-Streptomycin

-Sulfonamides

-Sulindac

-Tetracycline

History of addicting analgesic drugs as morphine.

History of folic acid tablet which increase RBCs production as compensatory mechanism.

Family history:

-Genertic disease in the family.

-History of multifactorial disease.

-Consinguinus marriage.

-History of sudden infantile death.

Social history: Social habits of clinical importance, Social class, occupation, social problems

Living where, hows taking care of you, especially during the attack. How much your fond per month. Educational
level of the patient & his/her parents. Smoking , or alcohol.

Menstrual history:

Regular, disturbed, normal amount of blood, painfull menses (Dysmenorrhea) , last period, stoppage of menses in
elderly when (Amenorrhea) , pregnancy.

Review of systems:

General:

-Posture of the patient usually is important indicating pain.

-Hair distribution

-Eye discolorations:

Jaundice 80-90% of the SCA patients have at least a mild degree of jaundice.

Pallorness.

Red eye in conjunctivitis.

Page3

-Skin turger as a mild degree of dehydration.

-Generalized fatigability.

-Vital signs: RR, BP, P, & TEMP.

-Look for cyanosis.

-Carotid pulses,& JVP.

-Localize the apex beat.

-Look for clubbing.

RS:

-Chest shape.

-Trachea.

-Breath sounds.

-Detection of any adventitious sounds.

CVS:

-Palpation:

Carotid, suprasternal , epigastric , aortic , pulmonary, tricuspid, & mitral areas.

-Auscultation: S1,S2, splitting between aortic & pulmonary sounds with respiration.

-Any additional murmer and localize it in systole or diastole.

GI:

-Ask for any GI symptoms as constipation,diarrhea,vomiting,hematemesis,melena,heartburn,dyspepsia,dysphagia.

Inspection:

-Look for the abdomen shape (Countor) ,localize the umbilicus, look for the oral cavity ouder ,hygiene, whitish
discoloration of the cavity which suggest oral candidiasis, look below the tongue for cyanosis, look to the abdomen
for hernia femoral, inguinal, diaphragmatic,& umbilical. Look for scars, dilated veins.

Palpation:

Superfecial palpation for swelling & tenderness.

Deep plapation for organs liver,spleen,& kidneys.(Look for splenomegaly or hepatomegaly)

Percussion:

Liver span

Ascultation:

Intestinal prestalesis.

Aortic bruit.

Renal bruit.
Page3

GUS: ask for urine frequency (Nephrogenic diabetes insipidus) & color ,micturation pain, pripism(Painfull erection).
MS: ask for screening exam GALS(Gait, Arms, Legs, & Spine) for inspection ,palpation , & movements specially legs
& arms.

CNS: Ask the patient to walk around the room for gait assessment, perform cranial nerve examination, motor &
sensory system examination.

Types of Crisis in SCD patients:

-Painfull crisis (Vaso-occlusive crisis).

-Hemolytic crisis (Due to hemolysis of blood).

-Aplastic crisis (Mainly due to infection by Parvovirus B19).

-Sequestration crisis (Leading to splenomegaly & hepatomegaly).

Common Investigations for SCD:

Blood picture:

-Hemoglubin electrophoresis, hemoglobin level, & hematocrit.

-Reticulocyte count (for marrow function).

-WBC & DLC & Platelet count.

Serum bilirubin level s especially indirect bilirubin.

Some cases LP(Lumper Puncture) is done to rule out meningitis.

Indications for Blood Exchange in SCD patients:

-Recurrent vaso-occlusive crisis.

-Stroke.

-Priapism (Painfull erection).

-Acute chest syndrome.

-Presurgical preparation.

Guidelines for management of SCD patient :

-Rehydration.

-Oxygen therapy.

-Analgesia(In severe cases morphine is used)

In case of morphine poisoning naloxon as an antidote is prescribed.

Prognosis of SCD patient:

It depends on the stability of the patient, compliance to treatment & so on. With the standard medical care about
Page3

15% die by age of 20 & 50% by age of 40.

Important Notes:

-B12 deficiency leads to neurological manifestations while folic acid deficiency does not.

-B12 deficiency will appear after 3-5 years while folic acid will appear with in 2 months.

-Normal hemoglobin :

Female: 12-15 mg/dl.

Male: 13-17 mg/dl.

4-MUSCULOSKELETAL

Examination

Musculoskeletal Examination begins by screening test called GALS:

G : Gait.
Page3

A: Arms.
L: Legs.

S: Spine.

Any problem during the screening test should be noticed so examination will be concerned.

After that examination which include:

1-Inspection or observation.

2-Palpation or feeling.

3-Range of movement.

4-Some special tests

Inspection:

Redness, deformities, discoloration, shape of the spine, shape of the hand, shape of the shoulders, shape of the leg,
pattern of joint movement.

Palpation:

Swelling, tenderness from bone or joints.

Joint tenderness can be graded depending up on patient reaction to pressure between finger & the thumb:

Grade 1: The patient says the joint is tender

Grade 2: The patient winces

Grade 3: The patient winces and withdraws the affected part

Grade 4: The patient will not allow the joint to be touched

TENDON SHEATH CREPITUS

This is a grating or creaking sensation defined by palpating the tendon while the patient is asked to contract the
muscle tendon complex involved.

JOINT CREPITUS

Range of movement:

Estimate the range of movement wither active or passive movement and the degree of limitation.

Each joint alone.

Some special tests:

Straight leg raising test (nerve stretching test): determine whether there is evidence of nerve root irritation as a
consequence of prolapse of a lumber disc.

Procedure: With the patient supine, carefully elevate the extended leg at the hip. Normally, 80 - 90° of flexion is
Page3

possible.
Restriction of movement : spinal and hip disease.

Test for flexion deformity: With one hand flat between the lumbar spine and the couch, flex the normal hip fully to
the point of abolishing the lumbar lordosis. The spine will come down on to the hand, pressing it on to the couch.

TYPES OF ARTHRITIS

1) On the basis of number of joint involved

-Monoarthritis

-Infective arthritis

-Reactive arthritis

- Traumatic arthritis

-Crystal induced

-Oligoarthritis

-Reactive arthritis

-Psoriatic arthritis

-Poly arthritis

-Rheumatoid arthritis (Symmetrical)

2) On the basis of pathologic process

-Degenerative

-Inflammatory

How to differentiate between Degenerative & inflammatory arthritis?

Morning stifness

Involvement of the small joints of hands and feet

Sparing of distil interphalangeal joints( in Rheumatoid arthritis)

High Inflammatory markers (ESR , CRP)

Internal Medicine B(5th Week)

1-Bedside teaching

-Importance of every part in the history taking as before.

-Differential Diagnosis of cough:

1- Acute cough (Less than 3 weeks).

Page3

2-Chronic cough (More than 3 weeks).

Acute cough:

-URTI (Upper Respiratory Tract Infections).

-Bacterial Infections causing pneumonia.

-Whooping cough in children.

-Pulmonary embolus in severe cases leads to cough.

Chronic cough:

-Bronchitis & Bronchiactasis.

-In smoker patients COPD & Lung Cancer.

-Drugs specially ACEinhibitors (like captopril,enalapril) & B-blockers.

-Bronchial Asthma.

-GERD (GastroEsophgeal Reflux Disease).

-Post nasal Drip syndrome.

-Tuberculosis.

-Psychogenic cough.

-Congestive Heart failure & mitral stenosis.

Differential diagnosis of Melena(Black- tarry stool) 12-14 hours bleeding of 50-100cc of blood:

-Upper GI Bleeding 90%.

-Lower GI Bleeding10%.

Differential diagnosis of Hematocchesia(Blood per-rectum):

-Lower GI Bleeding 90%.

-Upper GI Bleeding10%:

Peptic ulcer due to:

-NSAIDs.

-Hb PYLORI causing (gastric ulcer, gastric cancer, or gastritis).

Esophageal varices.

Gastric erosions.

Esophagitis common causes:

-Viral infection.

-Candidiasis.
Page3

-NSAIDs.
-Steroids.

-Immunocompromised.

Esophageal adenocarcenoma.

Gasteroesophageal reflux disease.

Esophageal tearing.

Common causes of chronic gastritis:

-Autoimmune

-Bacterial mainly Hb pylori.

-Chemical as drugs mainly NSAIDs.

Common side effect of ACE inhibitors:

-Cough.

-Arrythmia.

-Hypotension in the first dose.

-Hyperkalemia in patient with renal impairment as in renal failure.

Contraindications for using ACE inhibitors:

-Hyperkalemia.

-Renal artery stenosis.

Note:

Portal pressure normally around 10 mm hg/l.

Causes of Red urination:

1-Pegmintation

2-Blood (Hematuria)

Pegmintation due to :

-Drug metabolites excretion refampine.

-Iron hemosiderosis(Iron offerload).

Blood(Hematuria)

-Intial urination lower urinary tract disease in urinary bladder or lower.

Page3

-Total urination it means kidney disease mostly glumeruler disease.

-Terminal urination is synchronized with bladder contraction so urinary bladder disease.

Extracorporeal shock wave lithotripsy (ESWL): is a procedure used to break down kidney stones less
than 2 cm

Indication: ESWL may be used on people with a kidney stone that is causing pain or blocking the urine flow. Stones
that are between 4 mm (0.16 in) and 2 cm (0.8 in) in diameter are most likely to be treated with ESWL.

ESWL may work best for kidney stones in the kidney, not in the ureter. It may be harder for ESWL to break up a stone
that has moved into the ureter.

Contraindication:

-Pregnancy.

-Hemolytic disorders.

-UTI, Kidney cancer.

-Kidney abnormality.

2-Case Report

Presented to Dr Ahmed Melhem

Case: Sickle cell disease VOC Date :Saturday- 8/5/2010

Identification data:
Page3
Ahmad Jawad Bou-Hussan, is a 16 year old, Saudi male, student, living in Al-Battaliah in Al-Hassa, not married, and
non-smoker.

Chief complaint:

The patient admitted through ER yesterday C/O pain in the low back and right foot 2 hours prior to his admission.

History of presenting illness:

The patient is a known case of SCD. The patient was in his usual state of health till 2 hours prior to his admission
when he started to C/O low back and right foot pain. The pain was sudden in onset, continuous and progressive,
thrombing in character, mild to moderate ( 4/10 according to the patient), not aggravated by anything, and relive by
drug intake (Folic acid medication). The pain is not associated with swelling or redness, and not related to movement.

Past history:

No history of medical illnesses. There is a history of knee replacement, and blood transfusion, 6 years ago, in KFH.

Drug history:

The patient take analgesics as voltaren, or paracetamol, and folic acid as needed. He follow up regularly, and the
disease is controlled. The patient give a history 1 visit/year, the last one was in 8 months ago, for the same complaint,
and managed by voltaren and paracetamol.

Family history:

His parent are relatives, both are carrier. He has 1 brother out of 3 with SCD, and one sister out of 5 with SCD and
G6PD.

Social history:

He is a student in intermediate school, non-smoker, not married, living with his parents in their house, with middle
income class.

Review of system:

CVS: no palpitation, no chest pain.

RS: no cough, no sputum, no fever.

CVS: No headache, no dizziness.

GIT: no diarrhea, no constipation.

On Examination:

- General appearance: young male, thin patient, alert, oriented to time, place and person, comfortable, and not
connected to anythings.

-Vital signs:

Pulse: 62, regular, forced, arterial wall not felt, radio-femoral synchronize.

BP: 130/60 mmHg

Temp.: 36.4 degrees C

Page3

RR: 20 breath/min.
-General Examination:

The head (face):

There is a pallor, mild jaundice

Neck:

-Cervical lymph nodes are not palpable .

-JVP- we don't do it.

-Trachea is centralized.

-No thyroid swelling.

-Carotid pulse is normal.

The chest:

No Gynaecomastia, no chest shape abnormality, no scoliosis, no lordosis, no kyphosis.

Axillae:

Anterior, posterior, medial, lateral, and apical lymph node ( right and left side) are not palpable.

Nails:

There is a pallor, no cyanosis, no clubbing, no koilonychias.

Palm of the hand:

There is a pallor, no Palmar erythema.

Dorsum of the hand:

No muscle wasting, no sign of inflammation or swelling.

The arm:

No bruising, no muscle wasting, no Scratch marks.

Elbow:

Pre-trochliear lymph node is not palpable.

Lower limb:

Dorsalis pedis, and posterior tibial arteries are palpable, no bruises, no scratch marks, no edema.

Abdominal Examination:

-Liver span = 6cm ( normal)

-Spleen and kidney is not palpable.

-No renal bruit.

-Normal prestalysis, no mesenteric obstruction.

Page3
 This case is Not presented

Case: Epilepsy & previous Chronic Kidney Disease(CKD) DATE:09/05/2010 AD

Personal Information:

Hassan Al-Herz is 24 year old, saudi male patient, graduated from College of technology last year, living in AL-
Maslakh, single, with no habits of clinical importance.

Chief complaints:

He was admitted to the ER since 6 days c/o

Sudden loss of consciousness 1-2hours

History of presenting Illness:

The patient is a known case of CKD with urinary incontinence since birth . He was in his usual state of health till the
same day of admission when he started to develop mild headache with no visual disturbances while he is setting in the
bed. After a while he walk near to the bedroom door & set down . He started to loss his conscious level & alertness
without any sensation of chest pain, palpitation,or blurred vision. This loss of consciousness was gradual in onset,
associated with decrease in alertness level. When he was taken to the hospital by his brother he experience some
degree of seizures with no sphincter lossness, & no discoloration. In the hospital the patient suddenly recover from
his state with urine incontinence ,& no other symptoms of the previous one.

Past History:

Bed sour plastic surgery before 2 months in KFH.

Previous attack similar to this before 3 months with no diagnosis.

Blood transfusion before a year.

Ventricular peritoneal shunt since birth.

Open vertebral disc surgery(Spina bifida) in the low back since 3 days after birth.

Drug History:

No history of drugs exept muscle relaxant during the attack in the hospital.

Management received in the hospital ( Hospital course):

-Normal saline IV.

-O2 inhalation.

-Muscle relaxant.

Family History:

His parents are relatives with DM in both parents, His family composed of 18 person including him 7 suns & 11
daughters. No one has the same similar attack except the daughter of his sister.

Social History:

The patient is living with his family with good economic class, with no social habit of clinical importance.
Page3

Systemic review:
CNS: Headache, & loss of consciousness, mild seizures.

CVS: No dyspnoea, no palpitation, no swelling of the extremeties.

RS: Mild degree of breathlessness leading to use of inhalation sometimes.

GI: Uncontrolled defecation, no heartburn, no diarrhea, no conistipation.

GUS: dysuria, normal yellow color, having urinary incontinence.

Examination:

General:

The patient is conscious ,alert, oriented to time place & person.

Head:

Hair is normal not thin, Eye shows no signs of jaundice,conjunctivitis, littile pallor, Word articulation is difficult.

Neck: centralized trachea, JVP not clear, no swelling, no redness, hair distribution is normal.

Chest: normal chest shape, no scars, heart sounds are normal felt good.

Upper limb:

No swelling ,normal development ,with good sensation, & motor function.

Lower limb:

Defective in both in there development in the lower part with loss of sensation but reflexes are there.

Vital signs:

P: 86 beat/min.

BP: 150/110 mmhg.

RR: 14 B/Min.

Axillary Temp:36.6 degrees C.

Summary of the case:

The patient is known case of CKD, previous attack of epilepsy, congenital anomalies like spinabifida, loss of
sensation of the lower extremeties leading paraplegia, managed in the hospital by O2 ventilation, muscle relaxant,
& IV Saline.

Presented to Dr .Mohammad Salah Kheder

Case: Bilateral Renal stone, hydronephrosis.

Date: 12-05-2010 AD
Personal Information:
Page3
Radhy is a 30 years, Saudi male patient, married with 2 child, typewriter, living in Al-Hassa,
ex-smoker.

Chief Complaints:

The patient admitted through ER since 2 days C/O loin and groin pain in both side and red
urine 1 month prior to his admitssion.

History of presenting Illness:

The pain is stitching in character, more in the right side, intermittent and progressive relive
by compression and analgesic (Ibuprofen), associated with burning urination, urine dropping,
urgency, hesitancy, and red urine in the initiation part of urination, and bilateral lower limb
edema.

Past history:

The patient had similar attack 9 years ago, treated by ESWL(Extracorporeal shock wave
lithotropsy) .

Hypertension 8 years ago.

No history of blood transfusion.

Drug history:

Hypertension is mild treated by IV drug mainly frusemide. No history of drug allergy. There is
a history of food allergy like egg, fish , watermelon causing diarrhea and pigmentation in the
arms.

Family history:

His uncle had similar condition, his mother has HTN and IHD. His father died in RTA. His
brother has DM type II control by dietary restriction.

Social History:

The patient graduated from secondary school, and work in ministry of Education as
typewriter.

Systemic Review:

General: The patient is so cooperative conscious oriented to time place & person, sitting in
the bed, with no pain.

Head: no any sign of clinical importance.

Neck: no enlarged lymph node, no swelling, trachea is centralized.

Chest:

-RS: the patient experience some sort of dyspnea while he is sleeping that awake him.

This dyspnoea also occur while walking more than the dialy activity.

-CVS: no palpitation , no chest pain, no dyspnoea, no hemoptysis

Page3

Abdomen: no vomiting, no hematemesis, no melena, no flank tenderness.

UPPER Limb: no sign of cyanosis, no clubbing, no tremors.

Lower Limb: no edema.

In Summary:

The patient is a known case of chronic renal stone that has relapse in this time bilaterally &
will be treated by ESWL intervention next saterday due to hypertension.

THE END

Page3