CLINICAL DDx Flashcards
DDx of clubbing
CLUBBING
- Cardiac: congenital (R→L shunt), IE
- Lungs: Suppurative dis (abscess, empyema), bronchiectasis, IPF, CF, asbestosis
- Uncommon:
- Bronchogenic Carcinoma (not sml cell)
- Bilary cirrhosis
- Idiopathic (thyrotoxocosis)
- Not COPD
- GI: IBD, Cirrhosis (esp bilary cirrhosis as above), Coeliac
DDx splinter haemorrhages
- Trauma (occupation)
- IE (2* vasculitis in nail bed)
- Vasculitis - PAN, APS
- Sepsis, RA, haemotological malignancy, profound anaemia
DDx - BRADYCARDIA regular
- Physiological (sleep, increased vagal tone)
- Drugs
- Hypothyr (dec sympathetic activity)
- Hypothermia
- Raised ICP (effects central sympathetic outflow - late sign)
- 3rd deg AV or 2nd deg AV block
- MI
- Jaundice (severe 2* BR deposition in conducting system)
DDx - TACHYCARDIA - regular
- Hyperdynamic circulation (preg, thyrotoxicosis, anaemia, arteriovenous fistula, thiamine def - beriberi)
- CCF
- Constrictive pericarditis
- Drugs (sympathomimetics)
- Denervated heart (DM)
- Conduction: SVT, A.flutter 2:1/variable, VT, Multifocal atrial tachy
- Sinus (PE, MI, hypoxia, hypercapnia, myocarditis)
*
DDx - TACHYCARDIA - regular
- Hyperdynamic circulation (preg, thyrotoxicosis, anaemia, arteriovenous fistula, thiamine def - beriberi)
- CCF
- Constrictive pericarditis
- Drugs (sympathomimetics)
- Denervated heart (DM)
- Conduction: SVT, A.flutter 2:1/variable, VT, Multifocal atrial tachy
- Sinus (PE, MI, hypoxia, hypercapnia, myocarditis)
*
DDx - AF causes
- Structural HD (ageing, HTN) - specifically left atrial enlargement (MV dis)
- Thyrotoxicosis
- PE
- Sick sinus
- Myocarditis
- Acute insult (fever, hypoxia etc)
- ALCOHOL
DDx
PULSUS PARADOXUS
>10mmHg BP reduction on inspiration is assoc w/
1) constricive pericarditis
2) pericardial effusion
3) asthma
Ddx
POSTURAL HYPOTn
HANDI
- Hypovolaemia & hypopituatism
- Addisions
- Neuropathy (DM, amyloidosis, Shy-Drager)
- Drugs (inc TCA, antipsych)
- Idiopathic autonomic dysfxn
DDx - arterial pulse
COLLAPSING
- AR
- Hyperdynamic circulation
- PDA
- Peripheral arteriovenous fistula
- Arteriosclerotic aorta (elderly pts especially)
DDx - arterial pulse
SML VOL
- AS
- Pericardial effusion
DDx - arterial pulse
ALTERNANS
- LVF
- (alternating strong & weak beats)
- Could also be bigemny?
Ddx - JVP
ELEVATED JVP on INSPIRATION
(Kussmauls)
Opposite of what normally happens (best elicited at 90deg with pt mouth breathing) - caused by Limited RV filling
- Constrictive pericarditis
- Cardiac tamponade
- RV infarction
DDx - JVP
ELEVATED JVP
- RVF
- TS/TR
- Pericardial effusion/constrictive pericarditis
- SVC obstruction
- Fluid overload
- Hyperdynamic circulation
DDx
APEX BEATS
- Pb loaded: sustained forceful impulse (AS, HTN)
- Vol loaded: diffuse, displaced, non sustained (MR, dilated CM)
- Dyskinetic: uncooradianted, larger than normal area (LV dysfxn eg ant MI)
- Double impulse: 2 distinct beats w/ each systole (Hypertrophic CM)
- Tapping: (shouldnt usu feel heart sounds) - Mitral (Tricuspid rarely) stenosis
DDx
ABSENT apex beat
- Thick chest wall
- COPD
- Pericardial effusion
- Shock
- Dextrocardia (feel on right)
DDx
Parastenal impulse
Felt when heel of hand rested to left of sternum with fingers lifted just off chest - usu can’t feel pulse
RV enlargement (or severe LA enlargement)
Grade I if visible but not palpable
Grade III if can’t obliterate
DDx
Thrills
Turbulent blood flow indicates organic lesion
usu felt w/ flat of hand in time w/apex (systolic) or not (diastolic)
apex, left sternal edge (best of left lateral)
BASE of heart (aortic/pulm areas, upper chest wall)
- best sitting up learning forward fully expired
DDx - Murmurs
MITRAL AREA
Bell (low pitched) - diastolic murmur of MS, 3rd HS
Diaphragm (high pitch) - systolic murmur of MR, 4th HS
DDx - Split HS
Split S1 usu not heard (complete RBBB)
Split S2 as aortic closes prior to pulm 70% adults
- Heard in pulmonary area & along L) sternal edge on INSPIRATION
Wider in:
- RBBB (delayed RV depolarisation)
- Pulm stenosis (delayed RV ejection)
- VSD (increased RV vol load)
- MR (earlier AV closure due to more rapid LV emptying)
- Fixed splitting is in ASD
- Reversed splitting (wider on EXP) in LBBB, severe AS, coarction (or PDA)
DDx - heart sounds
LOUD S1
- MS
- Tachycardia
Occues when MV or TV remain wide open at end of systole & shut forcefully w/ onset ventricular systole
DDx - heart sounds
SOFT S1
- 1st deg HB (prolonged diastolic filling time)
- LBBB (delayed onset LB systole)
- MR (failure of leaflets)
DDx - heart sounds
LOUD S2
- HTN (loud A2)
- AS (loud A2)
- Pulm HTN (loud P2)
DDx - heart sounds
SOFT S2
- AS
- AR
DDx - heart sounds
3rd heart sound
- Gallop rhythm (KENTUCKY)
- low pitched - hear with bell (mid-diastolic)
- Physiological in kids/young adults
- Pathological assoc w/ reduced ventricular compliance
- LV S3 - louder at apex & on expiration
- Assoc w/ Inc CO (preg, thyrotoxicosis), LVF/LVH, AR, MR, VSD, PDA
- RV S3 - louder at L) sternal edge & on inspiration
- Assoc w/ RVF, constrictive pericarditis
