Clinical signs Flashcards
1
Q
What is ascites?
A
A pathological accumulation of fluid in the peritoneal cavity.
2
Q
What are the four main groups of causes of ascites?
A
- Fluid imbalance
- Chylous ascites
- Exudative ascites
- Nephrogenic ascites
3
Q
What are causes of fluid imbalance which can lead to heart failure?
A
- Cirrhosis
- CCF
- Myoedema
- Budd-Chiari syndrome
4
Q
What are causes of chylous ascites?
A
- Obstruction e.g. malignant lymphoma
- Iatrogenic - lymphatics transection
- Retroperitoneal lymph node dissection
5
Q
What are exudative causes of ascites?
A
- Exudate-secreting tumours
- Infections - e.g TB
- Inflammatory disease - e.g SLE
6
Q
What is Cullen’s sign?
A
Periumbilical ecchymoses.
8
Q
What is Grey Turner’s sign?
A
Ecchymoses or purple discolouration of the flanks.
9
Q
What is the mechanism behind Grey-Turner’s sign?
A
A hole in the abdominal fascia. A defect in the transversalis fascia allows blood from the posterior pararenal space to move to the abdominal wall musculature and the subcutaneous tissue
10
Q
What causes cullen’s sign?
A
Retroperitoneal haemorrhage - The retroperitoneum is connected to the gastro-hepatic ligament, then the falciform ligament, and finally to the round ligament (the obliterated umbilical vein), which tracks to the abdominal wall around the umbilicus. When a haemorrhage (from any cause) occurs, blood is able to move along these ligaments to the abdominal wall to produce ecchymoses
13
Q
What are other causes of Cullen’s sign, besides acute pancreatitis?
A
- Retroperitoneal bleeding
- Post surgery
- Anticoagulation
- Rectus sheath haematoma
- Ectopic pregnancy
- Ischaemic bowel
14
Q
What is erythema ab ignes?
A
Erythema caused by exposure to heat - in the context of chronic pancreatitis
15
Q
What is asterixis?
A
When the patient is asked to hold the arms extended with the hands dorsiflexed, a flapping hand movement that is brief, rhythmless and of low frequency (3–5 Hz) becomes apparent. Asterixis may be bilateral or unilateral.
16
Q
What conditions can cause asterixis?
A
- Liver disease – most common
- Chronic obstructive pulmonary disease
- Stroke – rare
17
Q
What is thought to be the mechanism behind hepatic flap?
A
Little is known about the mechanism - The net result of the pathology is the failure of the diencephalic motor centres in regulating tone between the agonist and antagonist muscles needed to maintain position and posture
18
Q
How often may bowel sounds be heard in a heatlhy individual?
A
5-35 times per minute
19
Q
What are causes of absent bowel sound?
A
- Intestinal obstruction
- Paralytic ileus of any cause
- Mesenteric ischaemia
- Pseudo-obsstruction
20
Q
Why are bowel sounds absent in bowel obstruction?
A
In a mechanical obstruction due to any cause (hernia, volvulus, adhesion), the intestines are pushing against a fixed object. The normal oscillatory movement of food and water is not happening (as in a blocked pipe), so no sound is produced.
If the obstruction continues, inflammation occurs and, if vascular supply is compromised, normal peristalsis may also stop.
21
Q
Why can bowel sounds be absent in infection?
A
Although not entirely explained, there is evidence that the lipopolysaccharides (LPS) present on Gram-negative bacteria initiate an inflammatory response in the intestinal smooth muscle layer, which then reduces smooth muscle contractility, causing an ileus
22
Q
Why can absent bowel sounds occur in hypokalaemia?
A
Potassium is needed for normal polarisation and repolarisation of muscle cells. Hypokalaemia causes a hyperpolarisation of muscle cells, reducing excitability of the neurons and therefore smooth muscle activity, leading to ileus.
23
Q
Why can bowel sounds be absent in a post-operative situation?
A
Post-operative ileus
Hypothesised to be a combination of manipulation of the small intestine and bacterial overgrowth, which both contribute to inflammation of the bowel which leads to ileus
24
Q
What is borborygmus?
A
Frequent, loud, gurgling or ‘rushing’ bowel sounds that sometimes may be clearly heard even without a stethoscope.
25
Q
What are causes of borborygmus?
A
- Bowel obstruction
- IBD
- Food hypersensitivity
- Gastroenteritis
- Normality
- GI haemorrhage
26
Q
Why does borborygmus occur in intestinal obstruction?
A
When obstruction is present, the bowel increases peristalsis in an attempt to overcome the blockage.
27
Q
What are tinkling bowel sounds?
A
High-pitched ‘tinkling’ sound heard on auscultation of the abdomen that is often described as like pouring water into an empty glass.
28
When do tinkling bowel sounds occur?
Bowel obstruction
29
What is the following?
**Caput medusae** - Dilated veins of the abdominal wall, named after the snakes that made up the hair of the goddess Medusa in Greek mythology.
30
Whaat causes the following?
Any condition causing portal hypertension, e.g.:
* **Cirrhosis of the liver**
* **Severe heart failure**
* **Inferior vena cava obstruction**
* **Budd–Chiari malformation**
31
What is the mechanism behind caput medusa?
Portal hypertension causes backflow from the portal vein to the para-umbilical veins. The increased pressure and blood volume distend the veins.
32
How would you determine if caput medusae are being caused by IVC obstruction or portal hypertension?
**Occlusion of the vein** - Measure the flow of the vein below the umbilicus and use the following criteria:
* **Severe portal hypertension** - flow goes away from the umbilicus towards the feet.
* **IVC obstruction** - flow moves towards the head
Abdominal veins distend as they take blood back to the heart, bypassing the blocked IVC.
33
What is coffee ground vomit/haematemisis?
The vomiting of red blood or a coffee-ground-like substance. Haematemesis refers to the coughing up or vomiting of frank red blood.
34
What are causes of coffee ground vomit/haematemesis?
Upper GI bleed
* **Peptic ulcer disease**
* **Gastritis**
* **Oesophagitis**
* **Oesophageal varices**
* **Mallory–Weiss tear**
* **Vascular**
* **Tumour**
* **Vasculitis**
35
Why is coffee gorund vomit the colour and consistency that it is?
Coffee ground vomits owe their distinctive appearance to blood that has been oxidised by gastric acid, similar to malaena.
36
What does coffee ground vomit indicate?
It indicates that the blood and/or bleeding has been present for some time, and potentially is higher up in the gastrointestinal tract (i.e. the duodenum or stomach).
37
Why can haematemesis occur in peptic ulcer disease?
Inflammation and erosion of the normal mucosal surface into an underlying artery causes bleeding. Blood irritates the gut and is vomited back up.
38
What is the following?
**Erythema nosodum** - A skin disorder of acute onset with eruption of red, tender nodules and plaques, predominantly over the lower extremities, especially the extensor surfaces. It is a form of panniculitis
39
What are causes of the following?
* **Inflammatory bowel disease**
* **Infections** – streptococcal, tuberculosis, URTIs, yersiniosis
* **Sarcoidosis**
* **Rheumatological disorders**
* **Drug reactions** – usually sulfonamides and the oral contraceptive pill
* **Malignancies**
* **Pregnancy**
40
What is the mechanism behind erythema nodosum?
## Footnote
In theory, immune complexes form after exposure to an antigen and are deposited in venules around areas of subcutaneous fat and connective tissue. The subsequent inflammation causes the lesions.
Why the lesions appear so frequently on the shins has not been explained - suggested that a combination of a relatively meagre arterial supply combined with gravitational effects on venous system gravitational favour deposition in that area
41
What is voluntary guarding?
May be voluntary or involuntary in nature.
Voluntary guarding is the conscious contraction of the abdominal musculature, usually in response to fear of pain or anxiety.
42
What are causes of involuntary guarding?
Any cause of peritonism:
* **Inflammation of any visceral organ**
* **Abdominal infection**
* **Bleeding**
43
What is the following?
**Gynaecomastia** - A benign proliferation of glandular tissue in the male breast, clinically presenting as a firm disc of tissue underlying the nipple, which is at least 2 cm in diameter. Gynaecomastia usually develops bilaterally.
Gynaecomastia must be differentiated from adipomastia/lipomastia (pseudogynaecomastia), which refers to fat deposition without glandular proliferation (i.e. adipose tissue rather than true breast tissue).
44
What are causes of gynaecomastia?
* **Physiological**
* **Drugs**
* **Radioiotherapy**
* **Hepatic cirrhosis**
* **Hypogonadism of any cause**
* **Hyperthyroidism**
* **Re-feeding syndrome**
* **Testicular tumours**
* **Renal failure/dialysis dependence**
* **Congenital abnormalities**
45
What drugs can cause gynaecomastia?
* **Cimetidine**
* **Digitalis**
* **Spironolactone**
* **Methyldopa**
* **Captopril**
* **Calcium channel blockers**
* **Chemotherapeutic agents**
46
What are the general mechanisms behind gynaecomastia development?
* **High levels of circulating oestrogen**
* **Increases in the oestrogen : testosterone ratio**
* **Androgen insensitivity**
47
What are causes of haematuria?
* **Kidney stones**
* **Malignancy**
* **Trauma to the urinary tract (e.g. infection or instrumentation)**
* **Glomerulonephritis** – nephritis syndrome
* **IgA nephropathy**
* **Goodpasture’s syndrome**
* **Vasculitis**
* **Interstitial nephritis**
* **Polycystic kidneys**
* **Papillary infarction**
48
What is hepatic encephalopathy?
Refers to an array of symptoms resulting from acute or chronic liver failure:
* **Forgetfulness**
* **Decreased cognitive function**
* **Confusion**
* **Altered sleep–wake cycle**
* **Irritability**
* **Asterixis**
* **Decreased level of consciousness**
* **Can have coma**
49
When can hepatic encephalopathy be caused by?
Acute or chronic renal failure
50
What mechanisms are thought to contribute tot he development of hepatic encephalopathy?
* **Portal hypertension**
* **Inability to metabolise ammonia**
* **Increased manganese**
* **Increased GABA**
* **Increased benzodiazapine like substance**
51
What is hepatic foetor?
A sweet/musty odour emanating from the breath
52
When does hepatic foetor occur?
Hepatic failure
53
What is the mechanism behind hepatic failure?
Due to the failing liver’s inability to metabolise bacterially degraded methionine and mercaptan dimethyl sulfide, these substances pass through the lungs and are exhaled, producing a distinctive smell. Trimethylamine has also been implicated as a cause of the odour
54
What is a hepatic venous hum?
Low-pitched hum heard over the liver when auscultating with the bell of the stethoscope.
55
What can cause a hepatic venous hum?
* **Portal hypertension**
* **Large haemangioma**
* **Hepatoma**
56
What is the mechanism behind a hepatic venous hum?
A hepatic venous hum occurs with portal hypertension as the blood flows into the lower-pressure systemic system via collateral vessels from the higher-pressure portal system, creating a continuous and appreciable noise
57
What is hepatomegaly?
An enlarged liver – usually larger than 13 cm in diameter from the superior to inferior border. Commonly found using percussion over the chest and abdomen with palpation of the lower liver border.
58
What are groups of causes of hepatomegaly?
* **Infective**
* **Infiltrative**
* **Neoplastic**
* **Metabolic**
* **Vascular**
59
What are infective causes of hepatomegaly?
* **EBV**
* **Hep A, Hep B**
* **Malaria**
* **Liver cysts**
* **Liver abscess**
60
What are infiltrative causes of hepatomegaly?
* **Sarcoidosis**
* **Haemochromatosis**
* **Amyloidosis**
61
What are neoplastic causes of hepatomegaly?
* **Hepatocellular carcinoma**
* **Tumour mets**
* **Haemangioma**
* **Leukaemia**
* **Lymphoma**
* **Haematoma**
62
What are metabolic causes of hepatomegaly?
* **Fatty liver**
* **Storage disease**
63
What are cardiovascular causes of hepatomegaly?
* **Heart failure**
* **Budd-Chiari syndrome**
64
What are the general mechanisms involved in hepatomegaly?
One or a combinaiton of:
* **Increased vascular engorgement**
* **Inflammation**
* **Deposition and expansion due to non-liver cells/materials**
65
Why does hepatomegaly occur in CCF?
In congestive heart failure pressure backs up into the venous system due to ineffective filling or forward outflow, leading to a congested and engorged liver.
66
Why does hepatomegaly occur in infection?
Inflammation and swelling
67
Why does hepatomegaly occur in infiltrative disorders such as sarcoidosis and haemochromatosis?
These lead to the deposition of material in the liver, increasing its size. Similarly, primary or secondary malignancy enlarges the liver via tumour cell proliferation and inflammation.
68
Why do you get hepatomegaly in Budd-Chiari syndrome?
This involves an occlusion of veins draining the liver to the heart (i.e. from the hepatic venules, through the hepatic vein to the right atrium). The backup of pressure from the blockage back to the liver causes hepatic engorgement.
69
What are kayser-Fleisher rings?
Brown/blue rings at the periphery of the cornea
70
What can cause kayser-Fleisher rings?
**More common**
* Wilson’s disease
**Less common**
* Chronic active liver disease
* Primary biliary cirrhosis
* Multiple myeloma
71
What is the following?
**Leuconychia** - Complete whitening of the nail plate. This is an example of Terry's nails - nail is white proximally and brown distally
72
What is the following?
**Leuconychia** - complete whitening of the nailbed
73
What are causes of the following?
* **Hereditary**
* **Injury to nail base**
* **Hypoalbuminaemia**
* **Protein-losing enteropathies**
* **Hepatic cirrhosis**
* **Chronic renal failure**
* **Congestive heart failure**
* **Diabetes mellitus**
* **Hodgkin’s lymphoma**
74
What is Mcburney's point tenderness?
A point of maximum tenderness on palpation located one-third of the distance from the right anterior superior iliac spine to the umbilicus
75
What condition(s) is Mcburney's Point associated with?
Appendicitis
76
What is the mechanism behind the presentation of Mcburney's point tenderness?
McBurney’s point is said to be the most common surface location of the appendix.
When the appendix becomes inflamed such that it is no longer in the lumen of the bowel the peritoneum becomes locally irritated and tender.
77
What is the following?
Black, tarry, foul-smelling stools.
78
What are causes of maleana?
GI haemorrhage/bleed
* **Peptic ulcer disease**
* **Oesophageal varices**
* **Oesophagitis**
* **Gastritis**
* **Mallory–Weiss tear**
* **Neoplasm**
79
What is the mechanism behind malaena?
Bleeding from any cause in the upper gastrointestinal tract can result in melaena. It is often said that bleeding must begin above the ligament of Treitz; however, this is not always the case.
The black, foul-smelling nature of the stool is due to the oxidation of iron from the haemoglobin, as it passes through the gastrointestinal tract.
80
What is the following?
**Apthous ulcer** - A painful open lesion anywhere within the oral cavity.
81
What are causes of the following?
* **Trauma**
* **Stress**
* **Toothpaste**
* **Iron deficiency/Folate deficiency/Vitamin B12 deficiency**
* **Food hypersensitivity**
* **Humoural/immunological**
* **Inflammatory bowel disease**
* **Behçet’s disease**
* **SLE**
* **HIV/AIDS**
* **Nicorandil**
82
What are the following?
**Muerke's Lines** - Two white bands that run parallel to the lunula across the width of the nail. They are smooth and not raised. Normal-appearing pink nail-bed tissue is seen between the two white lines.
83
What are causes of the following?
* **Hypoalbuminaemia**
* **Diseases causing serious metabolic stress**
* **Chemotherapy treatment**
* **Infection**
* **Trauma**
84
What is murphy's sign?
As the examiner palpates the abdomen below the right subcostal margin, the patient is asked to take a deep breath in and, if on doing so, is caught by sudden pain, this is Murphy’s sign.
85
What is murphy's sign a sign of?
Cholecystitis
86
What is the mechanism behind murphy's sign?
On deep inspiration the lungs expand, pushing the liver downwards so the inflamed gallbladder is pushed onto the examiner’s pressing hand, causing an unexpected sharp pain.
87
What is the obturator sign?
Pain on internal rotation of the thigh.
88
What is the mechanism behind the obturator sign?
The inflamed appendix lies in contact with the obturator internus muscle. When the leg is rotated, the obturator moves and the appendix is stretched and irritated.
89
What is oliguria?
Although not easily observed as a sign, urine output can be enquired about and a routine fluid balance check is included in the review of many conditions. Oliguria is described as less than 400 mL urine output per day in adults and less than 0.5 mL/kg/hr in children.
90
What is anuria?
Anuria refers to urine output of less than 100 mL per day in adults.
91
What are pre-renal causes of oliguria/anuria?
* **Dehydration**
* **Blood loss**
* **Sepsis**
* **Cardiac failure**
* **Burns**
* **Drugs**
* **Anaphylaxis**
92
What are renal causes of oliguria/anuria?
* **Acute tubular necrosis**
* **Drugs**
* **Toxins**
* **Glomerulonephritis**
* **Vascular** - renal artery thrombosis
* **Interstitial nephritis**
93
What are post-renal causes of oliguria/anuria?
* **Bladder outlet obstruction**
* **Bilateral ureteric obstruction**
94
What is the following?
**Palmar erythema** - symmetrical and slightly warm reddened area on the thenar and hypothenar eminences of the palm. May have a mottled appearance or blanch when pressed. It is not associated with pain, itch or scaling. It May involve the palmar aspect of the fingers and proximal nail folds
95
What are primary causes of palmar erythema?
* **Hereditary**
* **Pregnancy**
* **Senility**
96
What are secondary causes of palmar erythema?
* **Chronic liver disease**
* **Autoimmune disease**
* **Endocrine** - hyperthyroidism
* **Neoplastic causes**
97
What is thought to be the mechanism behind the development of palmar erythema in chronic liver disease?
## Footnote
There is decreased metabolism and clearance of androstenedione, which allows for greater peripheral conversion to oestrogen. Raised circulating levels of oestrogens, oestradiol-to-testosterone ratio or free oestrogen lead to increased vascularity of the palms.
An alternative theory is that damaged local autonomic nerves and vasoconstrictor reflexes cause the erythema. The precipitating damage is caused by dysfunction of arteriovenous anastamoses which are present in cirrhotic patients.
98
What is pruritis?
**Itchyness** - Scratch marks manifest as a sign related to an underlying symptom, pruritus, which is the sensation of itchiness. The absence of scratch marks in hard-to-reach places (e.g. between the shoulder blades) when they are present on the rest of the body may be an indication of severity of itch.
99
What are hepatobiliary causes of pruritis?
* **Infectious hepatitis**
* **Biliary obstruction**
* **Primary biliary cirrhosis**
* **Primary sclerosing cholangitis**
* **Drug-induced cholestasis**
100
What are renal causes of pruritis?
CKD
101
What is the psoas sign?
The patient experiences pain on passive extension of the thigh
102
What is the psoas sign indicative of?
* **Appendicitis**
* **Psoas abscess**
103
What is the mechanism behind the psoas sign?
If the appendix is in a retro-caecal position, it may be in contact with the psoas muscle. Therefore, movement of this muscle will irritate the inflamed appendix, causing pain. A similar process occurs with a psoas abscess.
104
What is the following seen in?
**Pyoderma gangrenosum**
* Idiopathic: 25–50% of cases
* Inflammatory bowel disease: up to 50% of cases
* Rheumatological disease
* Paraproteinaemia
* Haematological malignancy
105
What is rebound tenderness?
The clinician presses hard on the abdomen and then quickly removes their hand (i.e. the pressure). The patient feels sudden pain on the release of pressure rather than the preceding palpation.
106
What can cause rebound tenderness?
Any cause of peritonitis
107
What is the mechanism behind rebound tenderness?
When the abdomen is pushed down and then quickly released, the peritoneum rebounds and, if it is inflamed, the rebound movement will activate pain sensory fibres.
108
What is involuntary guarding?
A constant involuntary contraction of the abdominal musculature where the abdomen is literally ‘rigid’ to palpation. There will also be tenderness present.
109
What is the mechanism behind involuntary guarding?
Inflammation of the peritoneum stimulates a reflex arc resulting in the contraction of the abdominal muscles
110
What is Rovsing's sign?
When the left lower quadrant is palpated, the patient feels pain in the right lower quadrant
111
What is rovsing's sign caused by?
Traditionally appendicitis; although theoretically inflammation of any organ in the right lower quadrant may elicit Rovsing’s sign.
112
What is the following?
**Scleral icterus** - Yellow discolouration of the sclera.
113
What is the cause of the following?
Jaundice
114
What is the mechanism behind the development of the following?
Hyperbilirubinaemia leads to bilirubin deposition in the sclera
115
What is the following?
**Sialadenosis** - A persistent enlargement of the parotid gland (and occasionally submandibular salivary glands). It is neither inflammatory nor neoplastic in origin. Clinically, sialadenosis is palpable as a soft, bilateral, symmetrical and non-tender enlargement of the parotid glands.
116
What conditions are associated with the following?
* **Diabetes mellitus – rare**
* **Malnutrition**
* **Alcoholism**
117
What are the following (when put under pressure, they blanch then refill from the centre outwards)?
**Spider naevi** - Skin lesion consisting of a central arteriole with thread-like vessels (said to resemble a spider’s legs) radiating outwards. Blanching occurs when the spider naevus is compressed by hand, and refilling occurs from the central arteriole outwards when released. Naevi can vary in size from a pinhead to 5 mm in diameter
118
What are causes of spider naevi?
* **10–15% of healthy adults and young children**
* **Alcohol-related liver disease**
* **Hepatitis B and C**
* **Pregnancy**
* **Oral contraceptive pill and other oestrogen formulations**
* **Thyrotoxicosis**
119
What are infectious causes of splenomegaly?
* **EBV**
* **Viral hepatitis**
* **Septicaemia**
* **Typhoid**
* **CMV**
* **Toxoplasmosis**
* **TB**
* **Subacute endocarditis**
* **Malaria**
* **Leishmanaiasis**
120
What are haematological causes of splenomegaly?
* **Myeloproliferative disorders**
* **Lymphoma**
* **Leukaemia**
* **Congenital** - hereditary spherocytosis
* **Autoimmune haemolysis**
* **Megaloblastic anaemia**
121
What is steatorrhoea?
Stools that are foul-smelling, soapy, bulky and oily in appearance. Quantitatively defined as stool fat greater than 7 g of fat per day. Patients may describe the faeces as difficult to flush down the toilet and very foul-smelling
122
What can cause steatorrhoea?
* **Thyrotoxicosis**
* **Coeliac disease**
* **Inflammatory bowel disease**
* **Drugs (e.g. lipase inhibitors)**
* **Alteration of anatomy of upper GI tract post surgery**
* **Cirrhosis of the liver**
* **Giardia lamblia infection**
* **Blocked bile ducts**
* **Lymphatic obstruction**
* **Whipple’s disease**
* **Biliary tree disease**
123
What is the mechanism behind steatorrhoea?
An inability to break down (luminal), absorb (mucosal) or transport (post-absorptive/lymphatic) fats cause steatorrhoea. The increased fat load in the faeces causes diarrhoea by an osmotic effect.
124
What is the following?
Areas of skin with irregular bluish/purple bands or stripes. The colour of striae may change over time and fade.
125
What can cause the following?
* **Obesity and weight gain**
* **Cushing’s syndrome**
* **Pregnancy**
* **Puberty**
* **Steroid therapy**
126
What GI problems can uveitis be associated with?
IBD
127
What is the following?
Clubbing
128
What are causes of the following?
* **C**yanotic heart disease/**C**rohn's
* **L**ung disease - ABCDEF
* **A**bscess
* **B**ronchiectasis
* **C**F
* **D**ON'T SAY *_COPD_*
* **E**mpyema
* **F**ibrosis
* **U**lcerative colitis
* **B**iliary cirrhosis
* **B**irth defect
* **I**nfective endocarditis
* **N**eoplasm
* **G**I malabsorption syndrome (coeliac)
