Clinical Flashcards
What is Pemberton’s sign?
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.
Lymph node exam - things to comment on
Presence / Location Size (>1cm is pathological) Fixed/Mobile Tenderness Texture
What is Virchow’s node?
L supraclavicular node; strongly indicative of the presence of cancer in the abdomen, specifically gastric cancer, that has spread through the lymph vessels.
Murmurs - comment on:
Systole or diastole (diastole is always pathologic)
Intensity
Quality
Pattern (cresc, decresc, cresc-decresc, none)
Grading
Location
Radiation
How to best hear an S3
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.
Where is the apex of the heart normally located?
5th left intercostal space at the midclavicular line
Mitral stenosis murmur characteristics
- 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”
What is de Musset’s sign?
rhythmic nodding or bobbing of the head in synchrony with the beating of the heart, in general as a result of aortic insufficiency (regurg)
Signs in aortic regurg
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)
Aortic insufficiency/regurg murmur
- low freq (bell)
- early diastolic
- decrescendo
- best heard in the third left intercostal space (patient sitting)
- may radiate along the left sternal border.
Osteoarthritis types of nodes
Bouchard’s (PIP joints)
Heberden’s (DIP joints - closer to fingernail)
How to tell osteoarthritis from rheumatoid arthritis
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.
Scaphoid fracture is a risk for ________
Avascular necrosis
Pulses: comment on _______
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
Aortic stenosis characteristics
- pulsus parvus et tardus
- Murmur (see other card)
- sustained, heaving apex beat
- A precordial thrill
- narrowed pulse pressure
Aortic stenosis murmur
- 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
If aortic dissection is in differential, how do you test the BP?
Measure BP in both arms
OPQRSTUVW
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?
The 3 Cs of Hx and phys exam
Confirm symptomology (eg OPQRST) Causes (differential leads to pointed high-yield questions and exam) Complications
CAD syndromes
Sudden cardiac death STEMI NSTEMI Unstable angina (Stable angina)
For Dx of MI, need 2 of the following 3 findings:
Clinical Sx (eg chest pain etc)
Positive biochemical markers (eg troponins)
Abnormal ECG findings
Can’t have AFib and _____ at the same time
S4 (=atrial contraction causes blood to flow against less compliant ventricle - AFib has no atrial contraction)
Quality of murmurs
Blowing (usually regurg)
Harsh (usually obstruction)
Rumble (rare)
Grading of murmurs
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.
At start of cardiac exam, don’t forget…
Peripheral pulses, carotids, JVP
Murmurs accentuated by left lateral decubitus position - also how & where to listen
Left-sided S3 and S4
Mitral murmurs, esp mitral stenosis
Place BELL on apical impulse
How to accentuate aortic murmurs (esp chronic aortic regurg)
Sit up, lean forward, exhale completely, stop breathing in expiration.
- Carotid pulse vs JVP
- the best vein to assess JVP
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)
Aortic stenosis vs mitral regurg murmurs
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
How to distinguish COPD vs heart failure
- 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.)
VINDICATE
Vascular Infection Neoplasm Drugs Idiopathic, inflammatory Congenital Autoimmune Toxins Endocrine
Myotomes (C1-T1, L2-S4)
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
How to reverse heparin and LMW heparin
Heparin: reverse with protamine
LMW heparin: can’t reverse (have to wait 1-2 days)
3 causes of proximal muscle weakness
Dermatomyositis
Polymyositis
Steroids
4 causes of distal muscle weakness
Guillain-Barré
Viral
Paraneoplastic / Lambert-Eaton
CIDP
Kussmaul’s sign?
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.
Clubbing: 5 criteria
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
Causes of nonpitting (2) and pitting edema
Nonpitting = myxedema or lymphedema Pitting = mostly everything else
Generalized edema DDx (5) and leg edema (1 more)
Generalized edema: CHF Liver failure Nephrotic Malnutrition (leading to ascites) due to malabsorption Hypothyroid (more rare)
Leg edema: above plus
Venous insufficiency
Pulmonary exam: steps (7)
(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
