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Diseases Predilection by Gender

• Coronary heart disease, peptic ulcers, stomach cancer, bronchogenic carcinoma, and hemophilia are more common in males.
• Systemic lupus erythematosus (SLE) is more common in females, with over 90% of cases occurring in women, often starting at childbearing age.
• Females are more prone to thyroid disorders (thyrotoxicosis & Myxedema), bronchial adenoma, and gall bladder diseases (e.g., gallstones).

Diseases Related to Certain Occupations

• Lead workers are at risk of lead poisoning (plumbism), leading to anemia, nephropathy, hypertension, muscle and joint pain, mood disorders, headache, and infertility.
• Glass workers are prone to silicosis, causing interstitial pulmonary fibrosis.
• Radiologists may experience bone marrow depression, potentially leading to sterility.
• Asbestos workers risk developing asbestosis, causing interstitial pulmonary fibrosis and bronchogenic carcinoma.
• Aniline dyes exposure is linked to cancer of the urinary bladder.

Conduct of Clinical Examination

• Ensure privacy for examination, providing chaperones when appropriate.
• The room should be well-equipped for the examination.
• The examination couch or bed should be adjustable to help patients get up easily.
• Maintain a comfortable (warm) temperature in the room.
• Control noise level and other distractions, like phones.
• Have sufficient light source and well-lit conditions to detect subtle abnormalities of complexion easily.
• Seek permission sensitively and adequately expose areas to be examined while avoiding unnecessary exposure/embarrassment.
• Cover the rest of the patient with a blanket or sheet to prevent them from becoming cold.
• Avoid exhausting the patient due to prolonged physical examination or frequent changes in position.
• Remain gentle towards the patient and vigilant for aspects of the examination that may cause distress or discomfort.
• Acknowledge any anxiety or concerns raised by the patient during the consultation.

Sequence for Performing a Physical Examination

• A systematic examination includes:
• Inspection: Observing the patient for color changes, scars, or abnormal breathing/pulsation patterns.
• Palpation: Laying hands on the patient to palpate, or feel, for abnormalities.
• Percussion: Tapping on the body.
• Auscultation: Using a stethoscope to listen to the relevant system.

Gait and Posture

• Abnormalities of gait can be pathognomonic signs of neurological or musculoskeletal disease.
• Examples of gait abnormalities:
  • Hemiplegic gait: Occurs after a stroke.
  • Ataxic gait: Associated with diffuse cerebellar disease.
  • Parkinsonian gait: Characterized by the walk of little steps.

Posture (Position of the Patient)

• Orthopnea position: Patients with shortness of breath (dyspnea) prefer this position, which occurs when lying flat.
  • It's associated with left-sided heart failure, mitral stenosis, and tense ascites.
• Squatting position: Associated with Fallot's tetralogy.
• Opisthotonus position: Hyperextension of the neck and spine with flexion of the knee.
  • It's associated with Meningitis.
• Flat in bed supporting the abdomen with both hands, flexion of knee is associated with Peritonitis

Hands Examination: Nails

• Nails can be affected by both local and systemic diseases, skin diseases, and dermatophyte infection/onychomycosis (fungal infection), Psoriasis, Eczema, Lichen planus.
• Beau's lines are horizontal ridges/indentations that appear in the nail plate of all nails, typically following a systemic illness due to growth disturbances.
• Koilonychia refers to spoon-shaped nail plate deformity often associated with iron deficiency.
• Clubbing: early stages - the angle between the proximal nail and nail fold is lost., there may be swelling of the distal digits or toe in later stages
  • Causes include bronchogenic carcinoma, suppurative or fibrosing lung disease, cyanotic congenital heart disease, infective endocarditis, inflammatory bowel disease, as well as familial or idiopathic factors.
• Skin changes can indicate systemic disease.
  • Coarse skin and broad hands can be indicative of acromegaly.
  • Tight, contracted skin can be indicative of scleroderma.
  • Calcium deposits can be indicative of systemic sclerosis.

Vital Signs - Temperature

• Normal body temperature is 36.8 ±0.4 °C.
• Fever refers to a temperature more than 37.2 ºC or > 37.7 °C PM.
• Hypothermia is defined as a temperature of 35 ºC or less.
• Hyperthermia is defined as a temperature of 41 ºC or more.

Common Causes of Hypothermia

• Cold weather to Alcohol toxicity.
• Hypothyroidism, Adrenal insufficiency & Hypoglycemia may cause hypothermia.

Common Causes of Hyperthermia

• Heat stroke to Status epilepticus**.
• Thyrotoxic crises and Pontine hemorrhage** may cause hyperthermia.

Types of Fever

• Sustained fever: temperature remains above normal throughout a 24-hour period and does not fluctuate more than 1° Celsius in 24 hours.
  • It occurs in lobar pneumonia and urinary tract infections.
• Remittent fever: temperature remains above normal throughout the day and fluctuates more than 2° Celsius in 24 hours.
  • It occurs in Tuberculosis (TB) and Typhoid fever.
• Intermittent fever: temperature is only present for some hours of the day, and the rest of the time is normal.
  • It occurs in Malaria and Septicemia*.
• Cyclic fever (periodic or relapsing): fever on some days and normal on other days, occurring in bouts of several days alternating with afebrile periods.
  • It occurs in Malaria and Infectious Mononucleosis**.

Vital Signs - Pulse

Tachycardia (Rate > 100 beats/m)

• Causes of sinus tachycardia: Physiological stress, drugs, Thyrotoxicosis, Severe anemia & Heart failure.

Bradycardia (Rate < 60 beats/m)

• Causes of sinus bradycardia: Physiological sleep, drugs, Hypothyroidism, Obstructive jaundice & Increased Intracranial tension (ICT).

Vital Signs - Respiratory Rate

• Common terms in respiration penia Bradycardia: rate of breathing is less than 10 breaths/min.
• Tachypnea: rate of breathing greater than 20/min.
• Hyperpnea: inspiration are increased in depth and rate. Apnea: respiration ceases for several seconds.
• Hyperventilation: rate and depth of respiration increases.
• Hypoventilation: rate and depth of respiration decreases

Functional anatomy of immune system

• The immune system is an intricately linked network of lymphoid organs, cells, and proteins.
• Immune defenses are categorized into:
  • Innate immune response: Provides immediate protection.
  • Adaptive or acquired immune response: Takes longer to develop but is highly specific and provides long-lasting protection.

The Innate Immune System

• Innate defenses against infection include:
  • Anatomical barriers
  • Phagocytic cells
  • Soluble molecules: Complement and acute phase proteins, and natural killer cells.

Cells of Innate Immunity

• Neutrophils circulate in the blood and kill microorganisms non-specifically.
• Monocytes are precursors of tissue macrophages that differentiate and reside in peripheral tissues.
• Specialized populations of tissue macrophages include Kupffer cells in the liver, alveolar macrophages in the lung, mesangial cells in the kidney, and microglial cells in the brain.

The Complement System

• The complement system includes over 20 tightly regulated proteins that promote inflammation and eliminate pathogens.
• Complement proteins are produced in the liver and circulate in inactive form.
• Activation leads to formation of a membrane attack complex (MAC), causing lysis of cells/organisms.
• There are three pathways for activating complement cascade, all converging on activation of C3.

Activation of Complement Pathways

• The classical pathway is activated by binding of antigen-antibody complexes and is blocked by CI inhibitor (C1inh).
• The lectin pathway is activated by mannose-binding lectins binding to microorganisms, activating the pathway by binding C4.
• The alternative pathway is activated by bacteria through C3.
• C3 is pivotal in complement activation through all three pathways.

The Adaptive Immune System

• Characteristics of adaptive immunity:
  • Exquisite specificity
  • High adaptivity and can respond to an unlimited number of molecules.
  • Immunological memory and change from initial activation
• Components of adaptive immunity:
  • Humoral immunity: Involves production of antibodies by B lymphocytes.
  • Cellular immunity: Mediated by activated T lymphocytes that synthesize and release cytokines, directly killing target cells.

Cells of Adaptive Immunity

• Mast cells and basophils are bone marrow-derived cells playing a central role in allergic disorders.
• Mast cells reside predominantly in tissues, and basophils circulate in peripheral blood.
• Mast cells and basophils express IgE receptors that bind IgE antibody.
• Upon encountering specific antigen, cells release histamine and other mediators, increasing local blood flow and vascular permeability, stimulating smooth muscle contraction, and increasing secretion at mucosal surfaces

Natural killer cells

• Natural killer (NK) cells are large granular lymphocytes playing a role in defense against tumors and viruses.
• NK cells express surface receptors, recognizing human leucocyte antigen (HLA) molecules, remaining tolerant to healthy cells.
• NK cells can be activated by binding of antigen-antibody complexes to surface receptors, known as antibody-dependent cellular cytotoxicity (ADCC).
• Activated NK cells eliminate targets by secreting pore-forming proteins (perforin), secreting proteolytic enzymes (granzymes), or producing cytokines.

Immunoglobulins

• Isotypes/classes of immunoglobulins are 5 types, determined by the heavy chain: IgG, IgM, IgA, IgE & IgD.
• IgM is the first antibody produced in infections (within 5-10 days).
  • It is effective at agglutinating pathogens and activates the complement.
• IgG is the most abundant antibody, found in the blood and extracellular fluid.
  • It can cross the placental barrier and appears later than IgM (1-2 weeks later).
• IgA is highly effective at neutralizing toxin and is important for mucosal surface defense.
• IgE is mostly bound to mast cells, basophils and eosinophils, important in allergic reactions and against parasitic infection.
• IgD functions as a cell surface receptor.

Immune Deficiency

• The most useful indicator is recurrent infections.
  • Infections may be frequent, severe, or with unusual organisms/sites.
• Autoimmunity may be caused by failure of normal lymphocyte apoptosis.
• There is increased susceptibility to malignancy.

Types and Distribution of HIV

• HIV-1: Widely distributed, causes global HIV pandemic.
• HIV-2: Causes a similar illness to HIV-1 but progresses more slowly and is less transmissible, restricted mainly to western Africa.

Diagnosis and Investigations

• Screening Tests: ELISA test is used.
  • It detects p24 antigen and antibodies to both HIV-1 and HIV-2.
  • Two different immunoassays is sufficient to confirm infection.
• Confirmatory Tests: Western blot assays and Nucleic acid amplification tests (PCR) are used.
  • Nucleic acid amplification detect HIV RNA for diagnose infections in HIV-infected mothers also known as PCR test.
  • It is the most sensitive test for detecting infection in infants and diagnosis primary infection.

Viral Load and CD4 Counts

• CD4+ Count: Clinically indicates the amount of immune suppression.

  • The normal CD4 count is over 500 cells/mm3. - Decisions to start treatment(ART) can be used along with prophylaxis for opportunistic infections based results - The rate of decline in CD4 count is variable to opportunistic infections and clinical problems.

• HIV Viral Load: Tests how the number of HIV particles is in mL or milliliter of blood which is “copies.” - The progression in HIV is crucial to determine treatment/monitoring known as ART.

Clinical Examination in HIV Disease (Specific Oral Conditions)

• Oral Hairy Leukoplakia is a corrugated white plaque running vertically on the side of the tongue.
  • It is pathognomonic of HIV disease with risk factors.
    • Asymptomatic, no treatment required, the cause is EBV.
      • High dose of aciclovir can eradicate infection with reoccurence.

Classification of Hypersensitivity Diseases

• Includes Gell and Coombs Classification of Hypersensitivity Diseases, which includes these four types
• Includes Type, Mechanism, Example of disease exogeneous agent and autoimmune disease.

Type I

• In this, the Mechanism is IgE-mediated mast cell degranulation.
  • Example of exogenous agent: Allergic disease --Example of Autoimmune disease:None described.

Type II

• In this, the Mechanism is Binding of Antigen cell by IgG or IgM antibodies on cell surface causing killing. - Example of exogenous agent:ABO blood transfusion reaction Hyperacute transplant rejection --Example of Autoimmune disease::Autoimmune haemolytic anaemia Idiopathic thrombocytopenic purpura Goodpasture's disease

Type III

• In this, the Mechanism is is Binding of IgG or IgM antibodies antigens to trigger complex to activate complement pathway. - Example of exogenous agent: serum sickness,f Farmers lung. --Example of Autoimmune disease::Systemic lupus erythematosus Cryoglobulinaemia

Type IV

• In this, the Mechanism isactivated T cells, and phagocytes. - Example of exogenous agent:Acute cellular transplant rejection Nickel hypersensitivity --Example of Autoimmune disease::Type 1 diabetes Hashimoto's thyroiditis

Type I Hypersensitivity (Allergy)

• Etiology: The most common is hygiene due to infection affecting early stage development. - In sanitation, (hygiene) and health the decrease exposure of infection leads to many health effect.
• Genetic Factors: Has can make an impact and has positive family history.

Common Causes of Systemic Allergic Reactions

• Anaphylaxis: Has IgE reactions to a number of mast cell degranulations. - The increased risk, particularly in poorly controlled patients. - IV administration of drugs (penicillin, other antibiotics), antisera, & IV anesthetic agents - Insect stings (Bee venom, Wasp venom) - Ingestion of certain foods (Peanuts, milk, eggs, soy products, fish and shellfish) - Chemicals - Latex can affect the allergic reactions

• Anaphylactoid include but aren't limited to : Aspirin and NSAIDs orRadiocontrast media and Physical: Exercise, Cold. -Idiopathic can also lead to 20%.

Management for Allergic Patient

• Avoid Allergen: This should be avoided with all necessary specialist dietitians in the medical industry as an important factor.. - Antihistamines: can the effect with prophylaxis against with treatment.

• Glucocorticoids: in minimizing diseases and affecting those topical sides will reduce to allergic diseases. - Adrenaline (epinephrine): Will injectable self adrenaline will act saving due to anaphylaxis.

Angioedema

• Pathophysiology:Angioedema is swelling of submucous and subcutaneous tissues. - The underlying mechanism is degranulation of mast cells (IgE mediated -allergic). - Angioedema may occasionally be mediated by local bradykinin concentration .

• In hereditary Angioudena is fatal with laryngeal obstruction with infection and dental procedures.

Autoimmune Diseases

• Is present with immune system action by self tissue.
• Autoimmune Disease: Affects major in adults and affecting the diseases.
• Fails in immune system from system recognizing of selfs.

Autoimmune feature and damage

• Are clinical and variable -Localized and localized in specific types of non organs --Has hypersensitivity. --Has etiogy by immuno,genetic, hormonal, and environmental related

Autoimmune Linkage

• Has HLA class II antigens and genetic variation is caused in lymph response.
• Also may cause by Streptoccocal, and Cardia glycoprotein.

Tests

• Antibodies rheumatoid are used to test, diagnose, monitor or autoimmune related patients The increase in activation C4 levels and leads to less C4/ C3 counts and classical measure.
• Cryoglobulin - tests and directed antibodies/immuno levels is used when complex has cold,purpur, rash and arthralgia Immunes and complex with higher sensitivities.

Disease and Management

In disease, manage with diseases and autoimmune affects the follow use: The use of Glucocorticoids and immunosuppresive. biologic agent:targets and for all agents which affect it autoimmune problems or disease and some conditons require immunosuppression to a disease. Gluten use involves auto immune and withdrawal to dietary for thyronix related functions