chapt -1-Basic.pptx what is analysis do us?

particular rhythmic abnormalities. These vital information(s) could help a
physician in the correct diagnosis vis-a-vis right choice of medicaments.
In short, any disturbance to the conductance of the electrical impulses in a perfect sequential and
orderly manner ultimately forms the basis of an arrythmia.
Fig. 11.1(b) shows the schematic diagram of the cardiac electrical activity. It is, however, pertinent to state here that the electrophysiology of the heart is overwhelmingly governed by the prevailing
transmembrane resting potential. Hence, the existing potential inside a Purkinje fibre cell at rest,
with regard to the outside, is found to be almost equal to 90 mV. Interestingly, the potential difference is
maintained by an active transport system (i.e., a pumping device) which essentially sustains a higher
extracellular Na+
concentration in comparison to the intracellular K+
level. It has been observed that
upon excitation, the prevailing voltage quite rapidly gets reversed to a positive voltage, most probably
spiking around + 30 mV. This situation gives rise to an extremely rapid spontaneous and simultaneous
movement of Na+
into the cell, just like a gate had all-of-a-sudden opened a channel (usually known as
a ‘gating mechanism’). Therefore, the recovery from excitation status gives rise to the gradual restoration of the ensuing ‘resting potential’ in various phases from 1 through 4.
Phase-4 : the resting potential is followed by the rapid depolarization and its reversal.
Phase-0 : gets started with a series of three repolarization phases, namely : Phase-1, 2 and 3.
Importantly, depending on the areas measured*, the distinct separation of phases are not quite
feasible ; and the prevailing voltages invariably alter amongst the major cell types of the heart, viz.,
Purkinje fibres**, AV-node, atrial cells, and the SA-node.
There are two types of influx, namely : (a) rapid influx ; (b) slow influx.
A. Rapid Influx.
The rapid influx of Na+ through the channels (or gates) during phase 0 results in the cell a rapid depolarization, which in turn “closes” the gate behind them to enable further
influx to occur.
B. Slow Influx.
The slow influx of Ca2+ gets triggered off to equalize (balance) the K+
loss
besides maintaining a proper relative voltage plateau as shown in Fig. 11.1(b). In fact, as the Ca2+ entry
slows down, the membrane potential becomes low very swiftly to the predepolarization levels (i.e.,
phase 4). Thus, in the heart muscle the elcetrical activity is coupled to a mechanical activity by Ca2+ as
the potential trigger.
An effective refractory period (ERP) [See Fig. 11.1(b)]. Comprising of several hundred milliseconds follows during which no further stimulus may propagate an impulse effectively. However, the
‘impulse initiation’ happens to be an inherent characteristic features of the cardiac fibres which evidently enables them to modulate action potentials almost spontaneously, and hence, the corresponding
impulses.
Anti-arrhythmic a

1. Chapter 1 Basic principles of patient interviewing

2. INTRODUCTION complete medical evaluation includes medical history physical examination appropriate laboratory or imaging studies analysis of data Diagnoses treatment plan

3. Factors in establishing rapport Introduce yourself in a warm, friendly manner • Maintain good eye contact • Listen attentively • Facilitate verbally and non-verbally • Discuss patients’ personal concerns

4. Components of comprehensive Medical History The conventional health history has several parts each with a specific purpose. Together, they give structure to your data collection and final record but they do not dictate the sequence of the interview. Be aware that you are not expected to cover everything in the same order in the consultation as in a subsequent case report (a concise summary, presented in a logical, linear manner).

5. Socio-demographic data The date and time of history taking Patient Identification The full name The Age and Sex Address Marital status Ethnic origin Religion Occupation (including before retirement) Level of education Provide some tentative suggestions as to what kind of person you are talking to and what the likely problems might be.

6. Source of referral Important especially when patients do not initiate their own visits (e.g. at a request of a police). It indicates that a written report may be important, and it helps you to understand the patient’s possible motivation . Source of the history It helps to assess the value and possible bias of the information. The source can be the patient, family, friends, police, a letter of referral, or the past medical record.

7. Clinical History — The clinical history of an adult patient has got the following contents in that order. Previous admissions Chief complaints History of present illness Past illness Functional inquiry (systemic review) Personal and Social history Family history Neonatal and obstetrical history is slightly different from this.

8. Previous Admissions — L ist of hospitalization in the order they occurred. In each case, specify the date, name and location of the health institution, the disease that led to admission and the outcome as briefly as possible. If detailed description is necessary this may be recorded under past illness. If it is related to the present illness, it should be described in the appropriate place in the history of the present illness.

9. Chief complaints – are the m ajor symptoms for which the patient is seeking care or advice. They should be written using the patient’s own words. The duration of the complaint should be specified . History of present illness – is a clear chronological account of the problems for which the patient is seeking care. This is a list of the main symptoms, either volunteered by the patient or elicited from them during the consultation.

10. For each problem/complaint, gather information about : Body location, quality and severity. Chronology , including when it first began, mode of onset and offset, duration, frequency , periodicity Abrupt or gradual, Intermittent or persistent, Short lived or constant. Setting – under what circumstances does it take place. Aggravating and alleviating factors, including treatment. Associated manifestations that occurs with the chief complaints. Overall course (steady or increasing in severity) and effect on normal activities. Any previous history of similar symptoms. Negative and Positive statements – must be expressed in terms of signs and symptoms but not diseases). Mode of arrival – signifies about the general condition of the patient.

11. Past illness: This includes important illnesses from infancy onwards. Childhood illnesses like measles, rubella, mumps, whooping cough, chicken pox, etc . Illnesses experienced during adult hood. Accidents and injuries, operations or procedures. History of chronic illnesses like hypertension, diabetes mellitus, epilepsy, tuberculosis, venereal diseases, etc. History of blood transfusion Each of these conditions should be described in terms of the approximate date of occurrence , the magnitude of the problem; place and duration of admission, what was given or done, and the out come of the problem.

12. Drug history – i nclude medications the patient is taking ( prescribed, OTC), and medications that the patient is known to be sensitive to. Drug history is needed because: Medication may be the cause of the presenting problem. Current medication may preclude the use of other medications. Provides an opportunity to review the need for taking medications and to find out whether the person is actually taking them. Identify side effects of the medications.

13. Personal – Social history include: Early development – place of birth and where the patient lived before, childhood development, health and activities. Education – school history, achievements, and failures. Marital status – whether the patient is married or not, history of extramarital sexual activity, or sexual promiscuity. Work Record – type of work and age begun, the income, number of jobs, success or failure regarding shift of jobs, occupational hazards, and attitudes to work, employers and work mates. Home surroundings – their sanitary condition, and the possible existence of over crowding or of loneliness, what pets are kept? etc. Habits – dietary history; history of substances like alcohol, tobacco, chat, etc. (quantify the daily alcohol and tobacco consumption).

14. Family history – provides information about the health status of immediate relatives, hereditary illnesses , and the emotional difficulties which may be the cause of symptoms or maladjustments of the patient. Causes and age of death of parents. Details about the health of siblings and children. Heart disease, hypertension, DM, asthma, allergies & ethnic origin.

15. Systems Review/Functional Inquiry – a traditional comprehensive sweep of all bodily systems, to identify any symptoms which may otherwise be missed. Symptoms which are important in making the diagnosis may only come to the surface at the end of a consultation: Either because they have been forgotten, Considered trivial by the patient , Even because the patient has been particularly worried (sometimes known as the ‘by the way doctor’ or ‘ hand-on-the-door’ symptom ). Running through the entire list for any given patient would exhaust both of the patient and the clinical student/clinician. Be selective – focus on the system related to the patient’s problem list and include others only if clearly related to the differential diagnosis . There is no need to repeat complaints already recorded in the HPI.

16. General – u sual weight, recent weight change, any clothes that fit more tightly or loosely than before, weakness , fatigue, or fever . H.E.E.N.T . (Head, Eye, Ear, Nose, Mouth and Throat ): Head – h eadache or injuries, dizziness, lightheadedness. Eyes – d ouble vision, blurring, photophobia, itching, pain, redness, excessive tearing, etc. Ear – h earing problem, tinnitus, vertigo, earaches, discharge. If hearing is decreased, use or nonuse of hearing aids. Nose and sinuses: – f requent colds, nasal stuffiness, discharge or itching; nasal bleeding , etc . Mouth and Throat : sore tongue, sore throat, and hoarseness of voice, dry mouth, oral thrush, dental carries, bleeding gums, dentures, if any, and how they fit, last dental examination, etc.

17. Lympho – glandular system Enlarged lymph nodes in the neck, groin, axilla. Breasts – lumps , pain, or discomfort; nipple discharge ; self-examination practices. Thyroid – g oiter with or without heat or cold intolerance. Testis – d escent of testis. Respiratory system – cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, chest pain, last chest x-ray. Personal history of asthma , bronchitis, emphysema, pneumonia, and tuberculosis (optional).

18. Cardiovascular system Dyspnea (including degree of exercise tolerance ), Palpitation, Orthopnea (number of pillows required), Paroxysmal nocturnal dyspnea Cough (dry or productive ), Hemoptysis, Chest pain, Syncope, Hypertension Leg swelling Results of past electrocardiograms or other cardiovascular tests.

19. Gastrointestinal Trouble swallowing, heartburn, appetite, nausea. Bowel movements , stool color and size, change in bowel habits Pain with defecation , rectal bleeding or black or tarry stools Hemorrhoids , Constipation, Diarrhea, Abdominal pain, Food intolerance, Excessive belching or passing of gas Jaundice , liver, or gallbladder trouble; hepatitis.

20. Genito – Urinary system – History of flank pain, polyuria, nocturia, pain on micturition, passage of blood retention stream of urine, change in color of urine, urgency, frequency, hesitancy, dribbling, incontinence, or passage of stone during urination . Male – h ernias , discharge from or sores on penis Testicular pain or masses Scrotal pain or swelling, history of STDS and their treatments Sexual habits, interest, function, satisfaction Birth control methods, condom use, and problems Concerns about HIV infection

21. Female – Age at menarche; regularity, frequency, and duration of periods; amount of bleeding; bleeding between periods or after intercourse; last menstrual period; dysmenorrhea; premenstrual tension . Age at menopause, menopausal symptoms, postmenopausal bleeding . Vaginal discharge, itching, sores, lumps, STDS and their treatments . Number of pregnancies, number and type of deliveries, number of abortions, complications of pregnancy, birth-control methods. Sexual preference, interest , function, satisfaction, dyspareunia Concerns about HIV infection.

22. Integumentary system (Skin, Hair and Nails) – r ashes , lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles. Musculo- skeletal system – b ony deformities, joint pain and /or swelling, limping , loss of function of limbs or joints, leg swelling . Central nervous system – h istory of fainting, seizures, weakness Paralysis, numbness or loss of sensation, tingling sensation Tremor or other involuntary movements , insomnia, poor memory Headache , disturbance of speech, disturbance of sphincter control, Delusion , hallucination, illusion, etc.