诊断学课程习题集

1、Outline for reviewing diagnosticsPart I Define the following terms:1. Continuned fever :Temperature is elevated and remains at the elevated level (39 -40 or more with diurnal fluctuation less than 1 . Seen in lobar pneumonia, typhus and typhoid.2. Remittent feverBody temperature is usually higher th

2、an 39 and temperature fluctuates greatly (morethan 2 within a 24-hour period but never falls to the normal level. Seen in septemia, serious pulmonary tuberculosis, purulent inflammation.3. Referred painPain sensation carried by visceral fibers can be interpreted as pain sensed by somatic fibers. Mix

3、ed message occurs at vertebral level (sharedcentral pathways. Pain felt in distant, unexpected well isolated somatic locations, ie. referred pain is the perception of sensory stimuli at a distance from its source, severe and precisely localized pain with tenderness, muscular rigidity and sensory sen

4、sitiveness. The characteristics of the pain should be reviewed in a systematic manner. e.g. acute cholecystitis causing diaphragmatic irritation with the patient feeling pain over the right shoulder top.4. CyanosisCyanosis is a bluish discoloration of the skin and mucous membranes resulting from an

5、increased quantity of reduced hemoglobin or of abnormal hemoglobin in the blood perfusing these areas. There are two principal forms of cyanosis: Central cyanosis, characterized by decreased arterial oxygen saturation due to lung or heart disease, e.g. Fallots Tetralogy. Peripheral cyanosis, most se

6、condary to a diminished capillary blood flow allowing more time for the removal of oxygen by the tissues, e.g. shock due to low cardiac output ; cutaneous vasoconstriction due to exposure to cold air or water.5. JaundiceA yellowing of the skin, sclera, and other tissues due to excess circulating bil

7、irubin.Mild jaundice, best seen by examining the sclera in natural light, is usually detectable when serum bilirubin reaches 2to 2.5mg/dL.It can bemainly divided into hemolytic, heptocellular, and obstructive jaundice6.PurpuraSpots or area of reddened skin 3-5mm in diameter caused by hemorrhages whi

8、ch does not blanch after pressure and may occur in hematological disorders, sever infection, vessel wall abnormalities, toxication of toxins or drugs.7. Paroxysmal nocturnal dyspneaThe patient awakes short of breath at night, but often obtain relief by sitting up for a period of time. In the most ad

9、vanced cases, the patients become acutely dyspneic, cyanotic and very frequently produce foamy sputum tinged with blood. Moist rales at the both lung bases, tachycardia, wheezing and bronchospasm, the markedly accentuated second heart sound in the pulmonic area. Mechanism:thepatient is already on th

10、e borderline of pulmonary edema. The result is an increase of pulmonary capillary pressure and pulmonary edema; Sensory awareness is depressed during sleep;severe interstitial and alveolar edema can accumulate ; Supine posture for sleep results in resorbtion of extracellular fluid into the intravasc

11、ular space, causing arise in filling pressure. The paroxysmal dyspnea is termed as cardiac asthma. It can be seen in the hypertensive heart disease and coronary heart disease.8. SyncopeA brief loss of consciousness is syncope and pressents a different group of diagnostic problems from those suggeste

12、d by coma. It occurs during transient diminution of the cerebral circulation or changes in the composition of the blood, as in hypoglycemia or hypocapnea. Impaired circulation of the brain may accur from ineffective cardiac action (myocardialinsufficiency or dysrhythmias, loss of peripheral resistan

13、ce in the vascular tree producing hypotension, or from vascular reflexes. The most common cause of syncope is the vasovagal, or vasodepressor, faint. Other considerations are cardiac dysrhymias(Adams-Stokesattacks-either tachy or bradycardia, seizure, anaphylaxis, autonomic dysfunction with orthosta

14、tic hypotension, pulmonary embolism, aortic stenosis, and cerebrovascular disease. 9. Disturbance of consciousnessConsciousness refers to set of neural processes that allow an individual to perceive, comprehend, and act on the internal and external environments. It consists of two components:awarene

15、ss and arousal (or wakefulness. Any injuries involving both bilateral diffuse cerebral cortex and /orbrain stem can cause disturbance of consciousness. It is divided into somnolence or lethargy, confusion, stupor and coma.10. ComaThe deepest state of unconsciousness in which the patient is motionles

16、s and unresponsive to stimuli. It can be divided into light and deep coma depending on the severity.Light coma-primitive and disorganized motor response to painful stimuli. There is no response to attempts at arousal.“ loss of consciousness, can not be awaked by any strong verbal stimuli; Still be r

17、esponsible to strong painful stimuli. Occasionally, involuntary extremities movement, absence of abdominal reflex and presence of corneal reflex, light reflex, cough reflex, swallow reflex, tendon reflex and pyramid sign (ifexist, vital signs almost normal. ”Deep coma-absence of response to even the

18、 most painful stimuli absence of superficial reflexes, light reflex, cough reflex, swallow reflex, tendon reflex. Flaccid paralysis with respiration, circulation, and temperature dysfunctions.BMI:body mass index weight (kg/the square of height (m2. Obesity of WHO criteria:BMI>27(male,BMI>25(fe

19、male11. Compulsive positionIn order to relieve the pain, the patients are compelled or compromised to adopt certain special positions, eg. Orthopnea.12. OrthopneaPatients in respiratory distress, especially of cardiac origin, tend to sit upright clasping their knees or hanging their legs over the ed

20、ge of the bed.(inorder to increase the abilities of diaphragm and then give rise to the airflow of the lung elevated. Besides, this position can reduce blood flow return to the heart.13. Spider angiomaDilatation of the terminal branches of arteriole (thearterial spider in the skin mainly in the dist

21、ribution of superior vena cava such in face, neck, shoulders, fore arms, dorsum of the hands, and above the umbilicus. Spider angioma has a relation to the reduction of inactivation of estrogen in the liver. (resultfrom disordered metabolism of estrogens by the liverThey are common in acute and chro

22、nic hepatitis, hepatic cirrhosis.14. Liver palmRedness of the skin on thenar eminence and hypothenar eminence. It has arelation to the reduction of inactivation of estrogen in the liver. (resultfrom disordered metabolism of estrogens by the liverThey are common in acute and chronic hepatitis, hepati

23、c cirrhosis.15. Pulse deficitPulse deficit refers to the pulse rate is less than the ventricular rate Seen in atrial fibrillation in which the rhythm is irregular irregularity and the volume of each pulse is not the same.16. Pupil reflexesTesting the functional activities of the pupils. They consist

24、 of direct response to the light and a consensual reflex. Reduction or absence of the reflexes can be found in coma.17. Virchow lymph nodeEnlargement of left supraclavicular, Seen in intra-abdominal malignancy such as gastric or esophageal carcinoma.18. Jugular venous engorgementIn the position of s

25、itting or reclined at 45°to the horizontal, the occurrence of obvious jugular venous engorgement or distension suggests elevation of jugular venous pressure seen in right heart failure, constrictive pericarditis, pericardial effusion, obstruction of superior vena cava, etc.19. Hepatojugular ref

26、luxEngorgement of jugular vein become more severe due to hepatic congestion inright heart failure when the liver is pressed.20. Kussmaul respirationKussmaul respiration refers to deep and regular respiration. The patient has continuous increase in rate and depth of breathing. Seen in metabolic acido

27、sis21. Valsalva maneuverExerting expiration with closing of vocal cords after a deep inspiration Intrathoracic pressure Blood returning to heart ejectment in LV Murmur of IHSS ; of MR 22. Water hammer pulseRefers to sharp rise and fall pulse caused by pulse difference widened found in hypertyroidism

28、, aortic insufficiency, etc.23. Austin Flint murmur:The murmur is produced by relative mitral stenosis due toaortic regurgitation leading to overload of left ventricle during diastole and mitral valve kept in a semi-opened state. Its character :Mid-and late-diastolic, rumbling, crescendo, low freque

29、ncy, locally, short duration, S1 (-,OS (-,thrill (- . 24. McburneyMcburney s pointLocated in the right iliac fossa, ie, at one-third of the way along a line drawn from the right anterior superior iliac spine to the umbilicus. Tenderness of Mcburneys point found in acute appendicitis.25. MurphyMurphy

30、 s signIf pain is found in the gallbladder area,examiner should put his left hand on the lower lateral rib cage with the 4fingers scratching supriorly and the thrumb hooked under the angle of right costal margin and lateral border of rectus muscle. Ask patient breathe deeply and check to see if pati

31、ent stops breathing suddenly,changes facial expression,or complains of pain. The positive Murphys sign can be seen in acute cholecystitis.26. Bladder irritation syndromesyndrome:Frequent micturition, urgent micturition, and dysuria. They can be seen in infection of bladder, ureter, and prostate.27.

32、Muscle tone and muscle strengthMuscle tone is the continuous and passive partial contraction of the muscles. It helps maintain posture, and it declines during REM sleep.Muscle trength is measured by the ability to contract the muscle against force or gravity. The classic grading system scores as fol

33、lows:0/5,no contraction1/5,muscle flicker, no movement2/5,movement possible, but not against gravity3/5,movement possible against gravity, but not against resistance by the examiner4/5,movement possible against some resistance by the examiner5/5,normal strength28. Pyramid sign:This is a pathological

34、 reflex. Positive pyramid signs, or even only a single positive sign, indicate strongly the pyramid tract (corticospinaltract lesion (upper neuron lesion except the infant or the child which age lower than one and half years old who is too young to have incomplete development of nervous system. Comm

35、on used signs are as follows:Babinskisign, Oppenheim sign, and Gordon sign. They are performed in different way, however theyhave the same positive manifestations, that is the hallux dorsilflexes and the other fan out. (The Babinski response.29. Meningeal irritation signWhen the meninges is stimulat

36、ed by blood (SAH,or inflammatory substances (meningitis,the menegeal irritation signs presence (positiveincluding neck rigidity and head retraction, Brudziskis sign, and Kernig s sign.30. AnemiaAnemia is a state in which the amount of Hb or number of RBC is below under the normal limits. Clinically,

37、 mainly estimated by the level of Hb, <120g/Lin male, <110g/Lin female.31. Reticulocyte :Reticulocyte is denucleated form of late normoblast derived from late normoblast and its cytoplasm contains a network of reticulum stained blue (basophilic ribonucleoprotein.Normal range:0.5-1.5%(adult,2.0

38、-6.0%(newborn.Significance of ret. examination reflects hemotopoiesis function of bone marrow and special treatment effect.32. “ Shift to the leftleft” ” of neutrophilsShift to the left of neutrophils denotes the presence of bands, metamyelocytes and sometimes myelocytes in blood. Stab granulocyte /

39、segmentedgranulocyte than 1:13.Seen in pyogenic infection, chronic/acute myelocytic leukemia, acute blood loss/hemolysis, and with toxic granules.33. Auer bodyAuer body refers large, elongated, azurophilic granules that contain peroxidase, lysosomal enzymes, and large crystalline inclusions. Found i

40、n some patients with AML, occasional but normal phenomenon in fetal hematopoiesis.34. HematuriaHematuria is the presence of abnormal numbers of red cells in urine. Theoretically, no red cells should be found in the normal condition, but some find their way into the urine even in very healthy individ

41、uals. If three or more red cells of concentrated urine are found in every high power field under the microscope, the specimen is called hematuria.35. ProteinuriaProtein in urine>30mg/24h.It can be devided into physiological, glomerular, tubular, mixed, overflow, histic, accidental, functional, an

42、d postrual proteinuria. 36. KetouriaMetabolism materials-hydroxybutyric acid, acetone, diacetic acid formation and found in the urine, occurs in conditions in which there is incomplete metabolism of fat. It can be divided into diabetic ketonuria seen in diabetic ketoacidosis; and non-diabetic ketonu

43、ria in infants, children , toxic states with vomiting, diarrhoea; hyperemesis gravidity ; cachexia with vomiting; post-anesthesia vomiting; massive alcohol drinking etc.37. Renal thresholdElevated blood levels of glucose lead to similarly elevated levels in the glomerular filtrate, which then exceed

44、 8.88mmol /L (160mg/dl , and glycosuria results. This glucose level is called renal threshold for glucose. This reflects blood glucose level when renal reabsorption function is saturated when the blood glucoseconcentration.38. Glomerular filtration rate (GFRTestsThese are several tests for evluating

45、 glomerular filtration function, including the determinations of plasma (serum urea, creatine and cystatin C, and renal clearance tests of certain substances39. Sinus rhythmThe impulse comes from the sinoatrial node. ECG characteristics of sinusrhythm (1P waves are present regularly (2Positive in ,

46、, aVF, V4-V6;Negative in aVR(3The frequency of sinus rhythm:60-100beats/min.40. Wenckebach phenomenonIn ECG of second-degree atrioventricular block (MobitzI type:Progressive PR interval prolongation prior to the blocked P wave, followed by a conducted beat witha shorter PR interval and then a repeti

47、tion of this cycle. This is called Wenckebach phenomenon.41. Mean QRS axis(Cardiacaxis:42. Pathological Q waveIn transmural myocardial infarction(myocardialinfarcting area >20-30mm or thickeness >5mm,Q waves are pathologic when they appear in a lead in which Q waves were previously not present

48、, or when the Q waves of normal septal depolarization become exaggerated (duration 0.04s, magnitude 1/4Rin the same lead.Part II Questions and answers.1. Describe the clinical significance of history taking.History taking is a process for doctor to obtain the medical history and information systemic

49、ally from the patient and related members. Integrity and accuracy of history have a great impact on diagnosis and treatment of the disease. The informations obtained by history inquiry for understanding the occurrence, development, diagnosis and treatment, past health state, previous illness etc. ca

50、n play an important role in making an accurate diagnosis. In fact, the diagnoses of some diseases can be basically established only by history taking. Instead, ignoring the inquiry will bring incomplete information, misunderstanding the exact condition, and cause misdiagnosis as well.2. Why should w

51、e take a history and conduct a physical examination in order to make an accurate diagnosisdiagnosis? ?1. Establishes a personal relationship of trust and respect between the patient and clinician necessary for good medical care. Clinical medicine refers to a matter of communication and quality of re

52、lationship decides doctors success or failure.2. Avoid the expensive laboratory tests and imaging studies, or false-positive results , which delay proper diagnosis.3. Large studies have shown that the history and physical examination are more sensitive and specific than imaging tests in most difficu

53、lt diagnostic situations. History taking and physical examination can provide about 50-80%informations for the diagnsosis.3. List the items of present illness history.Onset and duration, main characteristics, etiology and precipitation factors, development of the illness, associated symptoms, medica

54、tion and general conditions. 4. List the etiology and clinical classification of fever.(1Infective Fever :allinfections caused by bacteria, viruses , fungi , rickettsias, chlamydia, or parasites, etc.(2Noninfective Fever Absorption of aseptic necrotic substance caused by mechanical trauma, vascular

55、accidents e.g. myocardial, pulmonary, and cerebal infarctions, neoplastic diseases (eg.cancer,hematopoietic disorders Diseases due to immune mechanisms including the connective tissue diseases, drug fevers, and fever due to other immunologic abnormalities. Endocrine and metabolic disorders e.g. hype

56、rthyoidism Reduction of heat loss in the skin e.g. extensive (orgeneralizeddermatitis, chronic heart failure. Disorders which may involve cerebral thermoregulatory centers directly, such as brain tumors, intracranial hemorrhage or thrombosis, or heat stroke etc. Disturbance of autonomic nerve functi

57、on5. What is jaundice? How to get a history when the patient presented with jaundice?Jaundice:Accumulation of bilirubin in the bloodstream causes yellow pigmentation of the plasma,leading to discoloration of heavily perfused tissues. Clinically , hyperbilirubinemia appears as jaundice or icterus ,ye

58、llow pigmentation of the skin and scerae . It can bemainly divided into hemolytic, heptocellular, and obstructive jaundice.History taking:(1Determining jaundice; (2Onset and duration; (3Causes of illness and inducements /precipitating factors; (4Progression; (5Associated symptoms; (6 Others :pastmedical history; personal history, family history, etc.6. What are the etiology of hemoptysis?(1Bronchial disease(2Lung diseases(3Cardiovasculardiseases:(4Constitutionaldiseases:7. List the causes of chest pain.Cardiac origin:angina pectoris, stable angia, or unstable angia, or MINon-ca