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Internal Med - Jesse > Clinical > Flashcards

Clinical Flashcards

0
Q

What is Pemberton’s sign?

A

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.

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1
Q

Lymph node exam - things to comment on

A 
Presence / Location
Size (>1cm is pathological)
Fixed/Mobile
Tenderness
Texture
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2
Q

What is Virchow’s node?

A

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

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3
Q

Murmurs - comment on:

A

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

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4
Q

How to best hear an S3

A

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.

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5
Q

Where is the apex of the heart normally located?

A

5th left intercostal space at the midclavicular line

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6
Q

Mitral stenosis murmur characteristics

A
  • 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”
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7
Q

What is de Musset’s sign?

A

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

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8
Q

Signs in aortic regurg

A

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)

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9
Q

Aortic insufficiency/regurg murmur

A
  • low freq (bell)
  • early diastolic
  • decrescendo
  • best heard in the third left intercostal space (patient sitting)
  • may radiate along the left sternal border.
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10
Q

Osteoarthritis types of nodes

A

Bouchard’s (PIP joints)

Heberden’s (DIP joints - closer to fingernail)

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11
Q

How to tell osteoarthritis from rheumatoid arthritis

A

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.

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12
Q

Scaphoid fracture is a risk for ________

A

Avascular necrosis

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13
Q

Pulses: comment on _______

A 
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
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14
Q

Aortic stenosis characteristics

A
  • pulsus parvus et tardus
  • Murmur (see other card)
  • sustained, heaving apex beat
  • A precordial thrill
  • narrowed pulse pressure
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15
Q

Aortic stenosis murmur

A
  • 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
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16
Q

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

A

Measure BP in both arms

17
Q

OPQRSTUVW

A

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?

18
Q

The 3 Cs of Hx and phys exam

A 
Confirm symptomology (eg OPQRST)
Causes (differential leads to pointed high-yield questions and exam)
Complications
19
Q

CAD syndromes

A 
Sudden cardiac death
STEMI
NSTEMI
Unstable angina 
(Stable angina)
20
Q

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

A

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

21
Q

Can’t have AFib and _____ at the same time

A

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

22
Q

Quality of murmurs

A

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

23
Q

Grading of murmurs

A

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.

24
Q

At start of cardiac exam, don’t forget…

A

Peripheral pulses, carotids, JVP

25
Q

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

A

Left-sided S3 and S4
Mitral murmurs, esp mitral stenosis

Place BELL on apical impulse

26
Q

How to accentuate aortic murmurs (esp chronic aortic regurg)

A

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

27
Q
  • Carotid pulse vs JVP

- the best vein to assess JVP

A

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)

28
Q

Aortic stenosis vs mitral regurg murmurs

A 
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
29
Q

How to distinguish COPD vs heart failure

A
  • 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.)

30
Q

VINDICATE

A 
Vascular
Infection
Neoplasm
Drugs
Idiopathic, inflammatory
Congenital
Autoimmune
Toxins
Endocrine
31
Q

Myotomes (C1-T1, L2-S4)

A 
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
32
Q

How to reverse heparin and LMW heparin

A

Heparin: reverse with protamine

LMW heparin: can’t reverse (have to wait 1-2 days)

33
Q

3 causes of proximal muscle weakness

A

Dermatomyositis
Polymyositis
Steroids

34
Q

4 causes of distal muscle weakness

A

Guillain-Barré
Viral
Paraneoplastic / Lambert-Eaton
CIDP

35
Q

Kussmaul’s sign?

A

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.

36
Q

Clubbing: 5 criteria

A

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

37
Q

Causes of nonpitting (2) and pitting edema

A 
Nonpitting = myxedema or lymphedema
Pitting = mostly everything else
38
Q

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

A 
Generalized edema:
CHF
Liver failure
Nephrotic
Malnutrition (leading to ascites) due to malabsorption
Hypothyroid (more rare)

Leg edema: above plus
Venous insufficiency

39
Q

Pulmonary exam: steps (7)

A

(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

Internal Med - Jesse (8 decks)

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