Hi all, nice to meet you again… However, it is not nice to write such a boring, not arranged and slides-missed lecture!!! The topic of today is related to the surgical aspects that face the Dentist, more specifically, the Dental Surgeon. (As you noticed, the slides were -problem based questions-; the Dr. presented the case and tried “with us” to answer them!! he said that this is a new approach and its aim is to make us understand that in medicine there is something to be understood, and there is something to be written and another one to be practiced. It is not a normal lecture!!) However, the Dr. started with an introduction to the Physical Examination in general…
Physical Examination: ** How can we examine a patient?! Simply, physical examination starts with: st 1 : a good eye-contact between you and the patient. 2nd: a good approach by hands. 3rd: you should hear the patient. The “C/C” Chief Complaint of the patient and why he is coming to you whether you are in the hospital or in the out-patient clinic. When the patient starts to describe his reasons, you have to elaborate that C/C. Elaboration means: knowing more and more about this problem. Don’t go right and left with the patient about another problems that were out of his C/C when he comes to you. For example; the main complaint due to which many patients come is Pain. It may be neck pain, headache, chest pain, abdominal pain or pharyngeal pain. Take this pain and elaborate it: - Where is it located precisely? - What are the aggravating factors of this pain? - What are the relieving factors of this pain? - With what is it associated? So, you have to put questions about this subjective complaint. On the other hand, if the patient has another objective complaint such as a swelling in the neck, you have also to put a list of questions, for example: - When did this swelling in the neck start? - How does it increase with time? We will either find a way or make one! - HANNIBAL
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Is it painful or not? Is it associated with other findings or not? Who perceived this swelling, the patient or one of his family members? - What is the effect of this swelling on your psychological status? These are different questions that you should ask about the C/C. You should go through a systemic review with the patient. There are different questions starting system by system; the cardiovascular system, the respiratory system, the neurological system, the musculoskeletal system, the peripheral vascular system,.. etc. For example; regarding the cardiovascular system, ask the patient: - if he has a chest pain. - if he has any risk factor of cardiovascular diseases “atherosclerosis”, like Hyperlipidemia, Diabetes Mellitus, Homocystenemia, Smoking, Family history of previous Myocardial Infarction, Family history of previous brain infarction… These are the questions that you should ask and write about various systems. Usually you achieve a systematic systemic review. 4th: You should go for examining the vital signs of the patient like blood pressure, pulse rate, respiratory rate, level of consciousness and temperature. These are a mandatory and you should write down the findings of these vital signs. Once you terminate the C/C, the systemic review and the vital signs examination, you formulate a differential diagnosis about the C/C. A differential diagnosis means you put –in priority- the different pathologies which may be responsible for that C/C. For example; regarding the swelling of the neck your differential diagnosis may include: 1- a thyroid swelling. 2- a thyroglossal cyst. 3- a brachial cyst. 4- a lymph node enlargement. You put these differential diagnosis in priority. Now, you are going to physical examination. Physical examination means that you are looking for physical findings which confirm your way of thinking or exclude some pathologies that you need only a hint to exclude them. It also means that you start to have a real contact with the patient. Physical Examination pursue is a combination of the physical integrity and the psychological integrity of the patient. In order to Life is either a daring adventure or nothing! – Helen Keller
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examine a patient you must have a full permission from him first. Because you are a doctor you are allowed –by law- to evaluate the psychology concerning the pathology of the patient. Exactly the same –by law- you are allowed to examine (put your hands on) the abdomen, chest, breast, neck, genitalia, mouth, nose…etc. However, being allowed to look and feel doesn’t mean that you are allowed to exaggerate your allowance in evaluation of the patient. You have a limited time and a limited period of examining the patient. You are not allowed to spend half an hour to examine for example the neck of a patient, on the contrary, you get your findings from the 1st 3-5 mins. This is allowed by law that you are revealing signs which confirm your way of thinking. So, the physical examination should be precise and appropriate with convenience and acceptance of the patient. The patient doesn’t allow you to do per-rectal or per-vaginal for example, so you do need to have an agreement from him.
There are a lot of ways regarding the way to examine the patient. First, you have to examine the patient in a sitting position if he is able to be in that position. However, if he is unable to do so you can put him in a supine position. Supine position means: the patient is lying on the bed on his back. You start by taking the hands of the patient. Don’t jump to the neck immediately. The patient should feel your hand. You start by palpating the peripheral pulses like the radial pulse. Then you tell the patient that you are going to examine by “looking” while your eyes on the eyes of the patient to formulate an initial confidence and trust that you are going to understand and reveal the complaint of the patient. While you are looking at the eyes of the patient you start to examine the head, the neck, the supraclavicular region, the upper limb, the chest, the abdomen and the lower extremity. Usually and classically the physical examination is performed according to four cardinal criteria: 1- Inspection: you use your eyes. Look at the face, the neck, the chest, the abdomen, the upper and lower extremities. Look for swellings, changes in the color of the patient, presence of a wound, presence of an abscess….etc. You have to look for symmetry because the patient is divided into two parts. Once you terminate inspection you go to: 2- Palpation: usually in the areas that are available for palpation like the abdomen, the chest and the neck you palpate against an anatomical landmark. You don’t palpate haphazardly. Almost always while you are examining a patient look at the face of the patient especially at his eyes to see if he experiences pain while you are performing the physical examination. God’s delays are not God’s denials! – Anthony Robbins
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Palpation is divided into two components: - The superficial palpation: to reveal the presence of pain. - The deep palpation: to look for the presence of a mass because you press on the abdominal cavity, the axilla, the neck…etc. However, if you don’t have the anatomical landmark (like the clavicles in the thoracic outlet in the supraclavicular region) you cannot understand what you are feeling. If you don’t know the anatomy of the axilla, you will not know what is in the axilla. So, you should know the anatomical structures and landmarks because the objective pathology arises from an anatomical structure. For example, a lymph node enlargement arises from a group of lymph nodes. After palpation you come to: 3- Auscultation: the area of auscultation is the vascular axis in the neck or the abdominal cavity looking for up normal abdominal sounds or bruits. Every part in the abdomen is liable for auscultation which may reveal the presence of an up normal circulation of fluids. For example; if fluid goes from a high pressure system to a low pressure system you should hear a bruit. After auscultation you can perform: 4- Percussion: it is a small part of palpation. You perform percussion on an area looking for dullness (in case there are fluids) or resonance (in case there is air). These are the cardinal findings of physical examination; Inspection, Palpation, Auscultation and Percussion. After you end your physical examination, and add it to your systemic review and C/C, you will be able in 90% of the cases to formulate a proper diagnosis. However, if your differential diagnosis is misleading you may still have one or two diagnosis after the complete examination. To reach a final diagnosis you need the hint of diagnostic modalities; like x-rays, CTS, MRI, ECG or any available diagnostic modalities. Each diagnostic modality has specificity, sensitivity and accuracy which means that each one of the them has advantages and disadvantages. You will not get a proper diagnosis 100% per sue by a diagnostic modality. The sum of the C/C, the systemic review, the physical examination and the help of the diagnostic modality will aid in reaching a proper final diagnosis. For example; you may formulate that this patient has an abscess in the neck, lymph adenitis, or lymph node enlargement. It is the A man suffers before it is necessary, suffers more than is necessary! - Seneca
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right of the patient to have a final diagnosis. Don’t leave your patient confused by a lot of differential diagnosis. Patient’s confusion means physician’s weakness; if you are weak you confuse your patient. However, if you have a scientific foundation in your approach your patient will never be confused. I (the Dr.) see a lot of patients coming to the outpatient clinic and they are confused about certain pathology. For example; you may see a patient with a thyroid enlargement and sometimes he wants to undergo surgery and sometimes he doesn’t. He is confused and the decision is not based on a full explanation to the patient about the pathology he has. One important point is that you have to ask the patient to participate in the decisions regarding his health to be a part of the treatment in the management to have a good outcome. In other words, if your patient understands the pathology, you will have a high success rate of outcome of your procedure and treatment plan. However, if the patient doesn’t understand what you are going to do and what is the diagnosis, he will be confused and his expectation from your procedures is different from your expectation. So you have to put the patient at YOUR expectation. As a result, the patient will not face an up normal outcome and he will not oppose your decisions regarding the final diagnosis. I (the Dr.) noticed that some patients don’t understand the procedures and they expect that they will be relieved totally from the pain. This is due to a lack in the understanding between the physician and the patient because the physician doesn’t explain to the patient his accurate condition. For example, by a certain kind of malignancy we expect a survival rate of 60% by the end of 5 years according to the international criteria but the patient comes after 5 years with metastasis everywhere so we conclude that there are differences between the doctor’s expectations and the patient’s ones!!! (I didn’t get that example!!!). You have to explain to the patient each step you are doing. This helps you in management and understanding. Personally, I (the Dr.) don’t perform any kind of surgery without a full patient’s understanding about the whole procedure. I prefer waiting (if it is not an emergency or urgency) before doing the procedure till the patient knows about it like I do. For example, diabetes mellitus, diabetic foot, infection or a mass in the neck. This was a review of physical examination and how to perform and how to approach. I (the Dr.) think that because you are 4th year medical students are aware of everything and well-oriented and your approach is good. Besides, you have the attitude to deal with the patient. You need only experience to be more and more mature like your teachers in medical and dental schools. It is not the events of our lives that shape us, but our beliefs as to what those events mean! – Anthony Robbins 5
Now, we are going to start our topic. We shall start from the neck which is the 1st thing that faces you. We will start with the carotid bruit.
Carotid Bruit: Bruit means that when you perform auscultation you hear an up normal sound. Usually, the laminar flow which is normal has no sound. However, the bruit is due to an up normal stimulus on the vessel whether it is an artery or vein. It is not palpable. So, when you put your stethoscope on the neck of the patient you should hear nothing except the respiration of the patient because of the passages of air in the trachea and the bronchi. On the other hand, once you hear something on the carotid axis this means that there is a stenosis in the carotid vessels.
The objectives: -
Understand the significance of a carotid bruit found in an asymptomatic person and how and when to further evaluate him. For example, a patient comes to you and you put your stethoscope on his neck and you hear a bruit. He is asymptomatic and doesn’t complain from his neck, he just comes because a problem in his teeth. In this case what should you do? You have to answer these questions: 1- What is the significance of a bruit ? There is underlying stenosis in the artery or vein (which is in our example the carotid artery). 2- What are the symptoms of a carotid disease? It is true that the condition is asymptomatic, but it may reveal symptoms and you should ask the patient if he has for example a weakness in the contralateral part on the hand (was he handling something in his hand and suddenly he dropped it). Or in the ipsilateral if he has a sudden loss of vision for a while with a complete recovery.
- How should a patient with a carotid bruit be evaluated? For example, you have a patient with a carotid bruit which you discovered after your physical examination. The patient is asymptomatic that he doesn’t have transient ischemic attack which means transient neurological deficit. 1- What do you do for him? 2- What is the available treatment for carotid disease and what are the indications? Success truly is the result of good judgment. Good judgment is the result of experience; and experience is often the result of bad judgment! – Anthony Robbins 6
The problem-based questions (which is the way of the Dr’s slides) means that we are trying to assume what the patient will ask while he is dialing with the physician.
Let’s consider this problem (case): In your examination to evaluate an 80 years old gentleman for a pain in his right foot you discovered a left carotid bruit. He has type 2 diabetes mellitus and mild hypertension. He takes hypoglycemic agent for his diabetes mellitus and ACE inhibitor for his hypertension. He has history of headache, dizziness, difficulty in speaking and visual disturbances. He is right-handed. How should you behave? Would you treat his foot and ignore the carotid bruit? Or would you start with the carotid bruit first? Here the Dr. started to talk about his approach and mentioned many situations with different doctors and patients which make us conclude that you should never ignore a problem and you should always start to treat the more dangerous one even if you discover it by coincidence on physical examination and is not the main complaint of the patient.
What points from the history do you need to know? You should know about atherosclerosis. In the previous case it is obvious that the patient has atherosclerosis. For example, a patient comes to you complaining of his tooth and he suffers from hypertension and diabetes mellitus so in common sense you label this patient as “atherosclerotic patient”. He is liable to develop all the complications of atherosclerosis –atheroma- during anesthesia or during leaving the clinic without proper evaluation. He may develop infarctions; brain infarction or myocardial infarction, he may develop a lower limb emboli… To conclude, you have to know: - the patient is atherosclerotic. - He has lower limb pain due to atherosclerosis and narrowing in the vessels supplying it. - He has narrowing in the vessels supplying the brain. - He has narrowing in the coronary vessels which will always increase the probability to develop MI during anesthesia. These are the points that you need to be aware of from the previous case.
Now, what studies should be done? That patient is asymptomatic regarding the carotid and the heart problems. So, what are the prophylactic techniques that you can offer to him? You put the patient on a prophylactic treatment which offers antiI’m not discouraged because every wrong attempt discarded is another step forward! – Thomas Edison 7
complications of atherosclerosis. For example, if you don’t want to investigate the coronary arteries by catheterization or you don’t want to investigate the carotid systems both on the right and the left by angiography you merely give him Aspirin and anti-platelet therapy. This is the medical treatment.
What is the indication of operative intervention? Once you face a critical limb ischemia and the limb is threatened. In this case you should operate and do revascularization.
What is the best time of operation if it is indicated? Once you optimize the patient. Optimization: reaching the best results of the internal environment of the patient. However, there are no rigid standards, only relative ones. So, you improve the cardiac output, you improve the cardiac function, you improve the renal function, you improve the blood pressure (BP) and you improve the blood sugar (BS). Example: A patient with BP= 180/110, BS= 340 “unit” can’t undergo a surgery. We do optimization. We try to reduce his BP using medications to 140/80 (acceptable within the international range). We give him insulin, or oral hypoglycemic agents to reduce his BS to 135-140 “unit”. We may improve the heart function by improving the ejection fraction of the heart from 35 to 55…etc. So we optimize the physiological functions of the body.
Hypercalcaemia: Objectives: - Discussing and understanding the calcium homeostasis. You should go back to physiology and know about it. For example, calcium is a main component of the bone, it is excreted from the kidney and it is absorbed from the GIT. Theses processes are controlled by the parathormone and vitamin D. -
Understanding the symptoms and signs of acute and chronic hypercalcaemia. Chronic hypercalcaemia: is due to renal failure or an adenoma in the parathyroid glands. Acute hypercalcaemia: is due to ingestion or loading of calcium in the IV fluid or milk-alkali syndrome. Chronic hypercalcaemia may lead to deposits of calcium in the subcutaneous tissue and this will lead to a continuous etching. While the acute hypercalcaemia may lead to an up normality in the ECG and Give me a lever long enough and a prop strong enough. I can singlehandedly move the world! - Archimedes 8
arrhythmias because it interferes in the conductivity of the cells on the cellular level. - Discussing the differential diagnosis of hypercalcaemia. -
Discussing the evaluation and management of hypercalcaemia. Is it a great or a small problem? Should be corrected immediately or slowly? As a general rule, any chronic pathology needs time to be corrected.
Let’s discuss the following case: While evaluating a 60 years old woman for epigastric pain. The serum calcium is?? (Couldn’t hear, but it is raised). She has a long history of gastric discomfort for which she takes antacid. She also has a mild hypertension for which she takes hydrochlorothiazide. In your examination you find a small rubbery mass in the upper quadrant of her breast. What are the possible causes of hypercalcaemia? Bone Cancer! She has a palpable breast mass and she is 60 years old, so it is most probable that the mass is malignant and it metastasizes to the bone.
What other history information and physical findings would you like to know? - Calcium level. - Lymph node enlargement in the axilla and in supraclavicular region.
What is the next step? You have an objective finding not a subjective one. You formulate a diagnosis but how? By taking a biopsy from the mass in the breast.
The end Finally, after this boring lecture! I would like to greet all of the Dof3a! Besides, a special greeting to my friends: Nour, Maram, Abeer, Do3a2, Areej, Eman & Noor J… On the other hand, I would love to pass a special and BIG BIG THANKS through this lecture to my MOM & DAD… May God bless them… Ithar B. Jabr ☺ 5.11.2008 Some men see things as they are and say: “why?!” I dream of things that never were and say: “why not?!” – George Bernard Shaw 9