Clinical Exam Flashcards by Nick Bradfield

Signs of severe AS

PP AT LP 4 PS2 LVF

1 Plateau pulse (slow upstroke).
2 Aortic thrill (very important sign of severe stenosis).
3 Lateness of the peak of the systolic murmur.
4 Fourth heart sound (S4).
5 Paradoxical splitting of S2 (delayed left ventricular ejection and aortic valve closure).
6 Left ventricular failure (a late sign).

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Signs of severe MR?

SPELL 123

Small-volume pulse 
Pulmonary HTN 
Early diastolic rumble
LV enlargement
LV failure
Soft S1
Early A2
S3

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Causes of apical predominant fine crepitations?

S = silicosis, sarcoidosis
H = histiocytosis X
A  = ankylosing spondylitis, allergic bronchopulmonary aspergillosis 
T = tuberculosis

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Causes of basal predominant fine crepitations?

RAMIS
R = RA
A = asbestosis
M = Meds (busulfan, bleomycin, nitrofurantoin, hydralazine, methotrexate, amiodarone)
I = IPF
S = Scleroderma, SLE

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Causes of clubbing

Cardiovascular
• Cyanotic congenital heart disease
• Infective endocarditis

2.	Respiratory
•	Lung carcinoma
•	Chronic supportive lung disease: bronchiectasis, abscess, empyema
•	Idiopathic pulmonary fibrosis
•	Cystic fibrosis
•	Asbestosis 
•	Pleural mesothelioma

Gastrointestinal
• Cirrhosis
• Inflammatory bowel disease
• Coeliac disease
Thyrotoxicosis

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Signs of pulmonary hypertension

Pulse: Low volume pulse
JVP: prominent a wave
Praecordium: right ventricular heave, palpable P2
Auscultation: ejection systolic click, loud P2, S4
Signs of right ventricular failure

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Vocal resonance over consolidation is normal or increased or decreased?

Increased

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Vocal resonance over pleural effusion is normal or increased or decreased?

Decreased

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Causes of massive hepatomegally

HAMR M

Hepatocellular carcinoma
Alcoholic liver disease with fatty infiltration
Myeloproliferative disease
Right heart failure
Metastases

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Causes of moderate hepatomegally

FACH
Fatty liver disease
Amyloid
CML
Haemochromatosis

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Causes of mild hepatomegally

a. Hepatitis
b. Biliary obstruction
c. Hydatid disease
d. HIV infection

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Causes of hepatosplenomegally

CHICIE
• CLD with portal hypertension
• Haem: e.g. myeloproliferative, lymphoma, leukaemia, thalassaemia, sickle cell
• Infection, e.g. acute viral hepatitis, EBV, CMV
• Connective tissue , e.g. SLE
• Infiltration, e.g. amyloid, sarcoid
• Endo: eg Acromegaly, Thyrotoxicosis

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Signs of portal hypertension

Splenomegaly
Collateral veins
Ascites

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Causes of massive splenomegally

Primary MMM

Chronic myeloid leukaemia
Myelofibrosis
Malaria
Primary lymphoma of the spleen

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Causes of moderate splenomegally

PLLTS

Portal hypertension
Leukaemia (acute or chronic)
Thalassaemia, sickle cell anaemia

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Causes of mild splenomegally

ICHI
• Infection: EBV, hepatitis, infective endocarditis
• CTD: RA, SLE, PAN
• Haemolytic anaemia
• Infiltrations: e.g. amyloid, sarcoid

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Lateral medullary syndrome signs

Ipsilateral (I HAN 5,9,10)
* Horner’s syndrome
* Ataxia
* Nystagmus (to the side of the lesion)
* Cranial nerve V (pain and temperature), IX and X

Contralateral
* Pain and temperature loss over trunk and limbs

Non-lateralised
Vertigo
Dysarthria
Dysphagia
Dysphonia

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Causes of motor-predominant peripheral neuropathy

Diabetes mellitus
Guillain-Barre syndrome and CIDP
Hereditary motor and sensory neuropathy (Charcot-Marie-Tooth)
Acute intermittent porphyria
Lead poisoning
Multifocal motor neuropathy

Causes of sensory-predominant peripheral neuropathy

Diabetes mellitus
B12 deficiency
Paraproteinaemia
Carcinoma (e.g. lung, ovary, breast)
Sjogren’s syndrome
Vitamin B6 intoxication
Syphilis

Signs of subacute combined degeneration of the cord

• Symmetrical dorsal column loss (vibration and position sense) 
- Sensory ataxic gait
• Symmetrical UMN signs in lower limbs 
- absent ankle reflexes
• Peripheral sensory neuropathy
• Optic atrophy (occasionally)
• Dementia (occasionally)

Scleroderma antibodies

Limited = anti-centromere = pHTN (T in limited, centromere, pHTN) Centromere = CRESTomere

Diffuse = anti-scl70 = ILD (DILS)

Causes of a tender liver?

Hepatitis
Rapid liver enlargement – right heart failure, Budd–Chiari syndrome
Hepatocellular carcinoma

Causes of a firm and irregular liver?

Cirrhosis
Metastatic disease
Lipoidoses
Amyloid
Granuloma
Hydatid cyst

Causes of a pulsatile liver?

Tricuspid regurgitation
Hepatocellular carcinoma
Vascular abnormalities

Cavernous sinus syndrome?

CN 3/4/6 (motility) V1, V2 (sensation) Horner's

Secondary causes of hypertension?

RECOM • Renal: renal artery stenosis, diffuse renal disease • Endocrine: Cushing's, Acromegally, Conn's, Phaeochromycytoma • Co-arctation of the aorta • OSA • Meds/drugs/pharm: methamphetamine, cocaine, pseudoephidrine,

Arthropathy of the hands predominantly affecting PIP. Top differentials?

RA and SLE

Arthropathy of the hands predominantly affecting DIP. Top differentials?

OA. Psoriatic arthritis. Gout

Examination findings of malnourishment

Loss of subcutaneous fat in the triceps and biceps | Muscle wasting with hollowing of the temples and marked prominence of the clavicle

Signs of internuclear ophthalmoplegia

On contralateral gaze: - Ipsilateral eye fails to adduct - Contralateral eye has nystagmus But convergence is intact

ECG features of MR

P mitrale (broad, bifid P waves in lead II) AF Right axis deviation

ECG features of AS

LVH voltage criteria (7 large squares V1 + V5/V6 or R in aVL > 11 mm) LBBB Left axis deviation

Apex beat in AS

Pressure loaded (forceful and sustained)

Apex beat in MR

Volume loaded (forceful NOT sustained)

Causes of a pan systolic murmur?

MR MVP TR VSD

Causes of an ejection systolic murmur?

AS Aortic sclerosis HOCM ASD PS

Defining features of decompensated cirrhosis?

Jaundice Hepatic encephalopathy Ascites Variceal bleeding

TTE features of severe AS?

Valve area <1 cm2 Peak velocity >4 m/s Mean gradient >40 mm

Lights criteria

Exudate is defined by any of the following: Pleural fluid protein to Serum protein ratio >/= 0.5 Pleural LDH to serum LDH ratio >/= 0.6 Pleural LDH >/= 2/3 ULN for serum

Signs of activity in acromegaly?

SHE DIG - Skin tag number - Hypertension. Headache - Excessive sweating. Enlarging goitre - Development of cranial nerve palsies III, IV, V, or VI - Increasing visual field loss or increasing ring size, shoe size or dentures - Glycosuria

UIP features

Basal Honeycombing Sub-pleural reticular opacities Traction bronchiectasis

NSIP features

GG opacities Sub-pleural sparing reticular opacities Traction bronchiectasis

Mnemonic for social history in long case

H FAMS AS EILSH 1/2/5 Home Family ADLs Mobility Supports Alcohol Smoking Education Income Legal Sexual Hobbies Where do you see yourself in 1/2/5 years?

Mnemonic for ROS in long case

4Fs, CC, SET Falls Fractures Food Feelings Cognition Continence Sleep Exercise Tolerance