Clinical

Question 0

What is Pemberton’s sign?

Answer 0

Hands above head cause retrosternal goiter to come up and cause venous occlusion; face turns red.

A positive Pemberton’s sign is indicative of superior vena cava syndrome (SVC), commonly the result of a mass in the mediastinum. Although the sign is most commonly described in patients with substernal goiters where the goiter “corks off” the thoracic inlet, the maneuver is potentially useful in any patient with adenopathy, tumor, or fibrosis involving the mediastinum.

Question 1

Lymph node exam - things to comment on

Answer 1

Presence / Location
Size (>1cm is pathological)
Fixed/Mobile
Tenderness
Texture

Question 2

What is Virchow’s node?

Answer 2

L supraclavicular node; strongly indicative of the presence of cancer in the abdomen, specifically gastric cancer, that has spread through the lymph vessels.

Question 3

Murmurs - comment on:

Answer 3

Systole or diastole (diastole is always pathologic)
Intensity
Quality
Pattern (cresc, decresc, cresc-decresc, none)
Grading
Location
Radiation

Question 4

How to best hear an S3

Answer 4

A left-sided S3 is best heard in the left lateral decubitus position and at the apex of the heart. A right-sided S3 is best heard at the lower-left sternal border.

Question 5

Where is the apex of the heart normally located?

Answer 5

5th left intercostal space at the midclavicular line

Question 6

Mitral stenosis murmur characteristics

Answer 6

• best heard at the apex
• little radiation
• nearly holodiastolic
• low-pitched, decrescendo, and rumbling
• heard best with the patient in the left lateral decubitus position
• may be preceded by an “opening snap”

Question 7

What is de Musset’s sign?

Answer 7

rhythmic nodding or bobbing of the head in synchrony with the beating of the heart, in general as a result of aortic insufficiency (regurg)

Question 8

Signs in aortic regurg

Answer 8

Murmur (see other card)
low diastolic and increased pulse pressure
de Musset’s sign
Quincke’s sign (pulsation of the capillary bed in the nail)
Müller’s sign (pulsations of uvula)

Question 9

Aortic insufficiency/regurg murmur

Answer 9

• low freq (bell)
• early diastolic
• decrescendo
• best heard in the third left intercostal space (patient sitting)
• may radiate along the left sternal border.

Question 10

Osteoarthritis types of nodes

Answer 10

Bouchard’s (PIP joints)

Heberden’s (DIP joints - closer to fingernail)

Question 11

How to tell osteoarthritis from rheumatoid arthritis

Answer 11

RA: signs of inflammation (affected joints are swollen, warm, painful and stiff)
Stiffness/Pain worse early in the morning or following prolonged inactivity.
Stiffness typically lasts for more than an hour.
Gentle movements may relieve symptoms in early stages

OA: signs of inflammation and early morning stiffness are less prominent; stiffness typically less than 1 hour; movements induce pain caused by mechanical arthritis.

Question 12

Scaphoid fracture is a risk for ________

Answer 12

Avascular necrosis

Question 13

Pulses: comment on _______

Answer 13

Symmetry (both sides)
Rate (15s x 4 OR hi/med/low)
Rhythm (regular, irregularly reg/irreg)
Contour/pattern (1 or 2+ peaks)
Intensity/amplitude (wk/normal/strong)
Timing

Question 14

Aortic stenosis characteristics

Answer 14

• pulsus parvus et tardus
• Murmur (see other card)
• sustained, heaving apex beat
• A precordial thrill
• narrowed pulse pressure

Question 15

Aortic stenosis murmur

Answer 15

• systolic
• crescendo-decrescendo (i.e., ‘ejection’) murmur
• heard loudest at the upper right sternal border, at the 2nd right intercostal space
• radiates to the carotid arteries bilaterally

Question 16

If aortic dissection is in differential, how do you test the BP?

Answer 16

Measure BP in both arms

Question 17

OPQRSTUVW

Answer 17

Onset of pain (time, duration)
Provocation & Palliation (what makes it worse & better)
Quality
Region affected & Radiation
Severity
Timing & Treatments
U: How does it affect ‘U’ in your daily life?
V: Deja Vu: Has this happened before?
Worry: What do you think or fear that it is?

Question 18

The 3 Cs of Hx and phys exam

Answer 18

Confirm symptomology (eg OPQRST)
Causes (differential leads to pointed high-yield questions and exam)
Complications

Question 19

CAD syndromes

Answer 19

Sudden cardiac death
STEMI
NSTEMI
Unstable angina 
(Stable angina)

Question 20

For Dx of MI, need 2 of the following 3 findings:

Answer 20

Clinical Sx (eg chest pain etc)
Positive biochemical markers (eg troponins)
Abnormal ECG findings

Question 21

Can’t have AFib and _____ at the same time

Answer 21

S4 (=atrial contraction causes blood to flow against less compliant ventricle - AFib has no atrial contraction)

Question 22

Quality of murmurs

Answer 22

Blowing (usually regurg)
Harsh (usually obstruction)
Rumble (rare)

Question 23

Grading of murmurs

Answer 23

Levine scale: 1,3 are quieter,louder than S1/S2. 4-6 involve thrills.

1 The murmur is only audible on listening carefully for some time.
2 The murmur is faint but immediately audible on placing the stethoscope on the chest. Similar level as S1-S2.
3 A loud murmur readily audible but with no palpable thrill.
4 A loud murmur with a palpable thrill.
5 A loud murmur with a palpable thrill. The murmur is so loud that it is audible with only the rim of the stethoscope touching the chest.
6 A loud murmur with a palpable thrill. The murmur is audible with the stethoscope not touching the chest but lifted just off it.

Question 24

At start of cardiac exam, don't forget...

Answer 24

Peripheral pulses, carotids, JVP

Question 25

Murmurs accentuated by left lateral decubitus position - also how & where to listen

Answer 25

Left-sided S3 and S4 Mitral murmurs, esp mitral stenosis Place BELL on apical impulse

Question 26

How to accentuate aortic murmurs (esp chronic aortic regurg)

Answer 26

Sit up, lean forward, exhale completely, stop breathing in expiration.

Question 27

- Carotid pulse vs JVP | - the best vein to assess JVP

Answer 27

JVP is: 1 not palpable 2 biphasic 3 occludable (pressure on sternal end of clavicle) 4 height of pulsations changes with position 5 height of pulsation falls with inspiration 6 abdominojugular test (normal= JVP rises with abd pressure then falls after 1-2 beats; abnormal = sustained rise OR a fall of >=4cm) R internal jugular is best vein to assess JVP - direct to heart (R int jugular joins brachiocephalic v first)

Question 28

Aortic stenosis vs mitral regurg murmurs

Answer 28

``` AS -- MR 1 location: aortic area -- apex 2 radiation: neck -- axilla 3 shape: cresc-decresc -- holosystolic 4 pitch: medium -- high 5 quality: harsh -- blowing 6 assoc signs: AS: S4, decreased A2, pulsus parvus et tardis, ejection click, narrow pulse pressure MS: S3, decreased S1, laterally displaced & diffuse point of maximum impulse ```

Question 29

How to distinguish COPD vs heart failure

Answer 29

- Physical examination: lung and heart auscultation (crackles and extra heart sounds); JVP - Chest X-ray: edema in Heart failure; lungs are usually clear in COPD. - Brain natriuretic peptide (BNP): usually elevated in heart failure, whether or not COPD is also present. - Pulmonary function tests: One crude bedside test is peak expiratory flow. 150-200 mL or less = probably a COPD exacerbation; higher flows indicate a probable CHF exacerbation. - Echocardiogram: An ultrasound test of the heart that can evaluate the heart chambers, valves, and pumping strength. - Cardiac enzymes: can help Dx MI or excessive heart strain. (Might want to look this up a bit more.)

Question 30

VINDICATE

Answer 30

``` Vascular Infection Neoplasm Drugs Idiopathic, inflammatory Congenital Autoimmune Toxins Endocrine ```

Question 31

Myotomes (C1-T1, L2-S4)

Answer 31

``` C1,C2: neck flexion/extension C3: neck lateral flexion C4: shoulder elevation C5: shoulder abduction (deltoid) C6: elbow flexion and wrist extension C7: elbow extension and wrist flexion C8: thumb extension T1: finger abduction (interosseous) L2: hip flexion L3: knee extension L4: dorsiflexion L5: big toe extension S1: plantar flexion & eversion, hip extension S2: knee flexion S3,S4: anal wink ```

Question 32

How to reverse heparin and LMW heparin

Answer 32

Heparin: reverse with protamine | LMW heparin: can't reverse (have to wait 1-2 days)

Question 33

3 causes of proximal muscle weakness

Answer 33

Dermatomyositis Polymyositis Steroids

Question 34

4 causes of distal muscle weakness

Answer 34

Guillain-Barré Viral Paraneoplastic / Lambert-Eaton CIDP

Question 35

Kussmaul's sign?

Answer 35

Kussmaul's sign is a paradoxical rise in jugular venous pressure (JVP) on inspiration. It can be seen in some forms of heart disease and is usually indicative of limited right ventricular filling due to right heart failure. Cardiac conditions that may be associated with a positive Kussmaul's sign include right atrial myxoma, tricuspid stenosis, constrictive pericarditis, pericardial effusion, restrictive myocardopathy, and severe pulmonary hypertension. Overall, the commonest cause is severe right-sided congestive heart failure.

Question 36

Clubbing: 5 criteria

Answer 36

1 gestalt (just look at the nails and see if they're clubbed) 2 relative phalyngeal depth ratio: height at level of nail bed / height at DIP = higher than 1.0 3 hyponycheal angle greater than 180 - in normal individ it's usually less than 165 4 prox nail bed sponginess 5 shamroth sign

Question 37

Causes of nonpitting (2) and pitting edema

Answer 37

``` Nonpitting = myxedema or lymphedema Pitting = mostly everything else ```

Question 38

Generalized edema DDx (5) and leg edema (1 more)

Answer 38

``` Generalized edema: CHF Liver failure Nephrotic Malnutrition (leading to ascites) due to malabsorption Hypothyroid (more rare) ``` Leg edema: above plus Venous insufficiency

Question 39

Pulmonary exam: steps (7)

Answer 39

(Not necessarily in right order) 1 volume of breath sounds / air entry 2 symmetry (L-R, top-bottom) 3 length of insp and exp (insp 2/3, exp 1/3) 4 breath sounds (parenchymal) - vesicular, bronchovesicular, bronchial 5 adventitious sounds (insp or exp? Continuous or discrete? Wheezing, stridor, crackles - wet or dry?) 6 hands on chest wall to see rise and fall / expansion 7 percussion