Common Presentations Flashcards
aortic stenosis
- signs/symptoms; slow rising pulse, narrow pulse pressure, heaving and undisplaced apex bear, harsh ejection systolic murmur with radiation to the carotids, signs of decompensation
- causes; bicuspid valve, rheumatic heart disease, senile calcification
- treatment; valve replacement if lv dysfunction or valve gradient >50mmhg at angiography or 60mmhg on echo
aortic regurgitation
- signs/symptoms; collapsing pulse, wide pulse pressure, thrusting displaced apex beat, high-pitched early diastolic murmur
- causes; rheumatic heart disease, bicuspid valve, infective endocarditis, aortic root dilation, inflammatoru causes including syphilis
- treatment; valve replacement based on symptoms and response to medical therapy
mitral stenosis
think af
- signs/symptoms; af, tapping undisplaced apex beat, loud s1, mid-diastolic rumbling murmur at apex in left lateral position, accentuated by exercise, malar flush, opening snap
- causes; rheumatic heart disease, congenital heart disease, carcinoid syndrome, sle
- treatment; antigcoagulation for af, percutaneous balloon valvuloplasty, valvotomy, valve replacement
mitral regurgitation
think af
- signs/symptoms; thrusting displaced apex beat, soft s1, loud pansystolic murmur radiates to axilla, best in left lateral position, signs of decompensation
- causes; rheumatic heart disease, ihd lv impairment and annular dilation, endocarditis, connective tissue disease, collagen disorders
- treatment; valve replacement surgery considered if nyha 2 and medical management failed
cabg
- internal mammary artery or long saphenous vein used as graft vessel
- midline sternotomy scar
prosthetic valves
- listen for metallic click and where it appears in each cycle
- assess if midline sternotomy scar and whether cabg was also performed
- may have been replaced percutaneously
- tissue vs mechanical
- look for signs of anticoagulation
mechanical
- starr-edwards, ball and cage
- bjork-shiley, pivoted single tilting disc
- st judes, double tilting discs
pacemaker/icd
-always assess upper chest and axilla for pacemaker/icd
tricuspid regurgitation
- look for tender pulsatile hepatomegaly
- af
- elevated jvp
- pansystolic murmur
causes
- congenital
- rheumatic heart disease, rare
- endocarditis
- carcinoid syndrome
- blunt trauma
- secondary to left heart failure
hocm
autosomal dominant myosin defect with family history of sudden cardiac death
manage with beta blockers, calcium channel blockers and icd insertion
- jerky peripheral pulse
- forceful apex beat
- ejection systolic murmur
coarctation
radial-radial or radial-femoral delay
- bp discrepancies
- systolic murmur
- weak femoral pulses
congenital or iatrogenic
associated with a bicuspid aortic valve in 50%
asd/vsd
- murmur
- maladie de roger
- vsd can progress to eisenmengers syndrome
dextrocardia
consider primary cilliary dyskinesia
eisenmengers
increased right sided pressure eventually leads to right-left shunt through vsd which is cyanotic
blalock-taussig shunt
used to partially correct tetralogy of fallot
- usually connects pulmonary arteries with right subclavian artery
pulmonary fibrosis
b - berylliosis r - radiation e - extrinsic allergic alveolitis a - ankylosing spondylitis/allergic bronchopulmonary aspergillosis s - silicosis/sarcoidosis t - tuberculosis
r - rheumatoid arthritis
a - asbestosis
i - idiopathic pulmonary fibrosis
d - drugs; belomycin, methotrexate, amiodarone, nitrofurantoin, hydralazine, busulphan
copd
- not fully reversible airway obstruction
- look for cor pulmonale, lung cancer, ihd and alpha 1 antitrypsin deficiency; neutrophil elastase
- mild >80% fev1, moderate 50-79% fev1, severe 30-49% fev1, very severe <30% fev1
bronchiectasis
characterised by;
- infection and bronchial oedema
- inflammation and remodelling, hypertrophy and tortuosity of airways and vessels, and neovascularisation
- difficulty clearing secretions and increased propensity to acute and chronic infection, and to haemoptysis
causes;
- genetic; cf, marfans, kartagener
- chronic lung disease eg copd
- connective tissue disease; third of ra patients
- chronic inflammatory disease eg ibd
- chemical damage; recurrent acid reflux aspiration
- focal bronchial obstruction
- infection
- hypogammaglobulinaemia
- allergic bronchopulmonary aspergillosis
pneumonectomy/lobectomy
indications for lobectomy
- lung cancer; clubbing may suggest
- bronchiectasis; clubbing may suggest
- chronic lung abscess
- tb; peripheral calcified lymph nodes may suggest
- benign tumours
- fungal infections; life threatening haemoptysis due to aspergillus infection
- congenital abnormalities
other cause of thoracotomy scars
- oesophageal surgery
- heart valve replacement
- diaphragmatic repair
- thoracic aortic aneurysm repair
- anterior spinal tumour excision
- latissimus dorsi flaps
consider vats; video assisted thorascopic surgery, if small scars consistent with port entry
pneumonia
Streptococcus pneumoniae (pneumococcus)
- Accounts for 80% of cases
- Particularly associated with high fever, rapid onset and herpes labialis
- A vaccine to pneumococcus is available
Haemophilus influenzae
- Particularly common in patients with COPD
Staphylococcus aureus
- Often occurs in patient following influenza infection
Mycoplasma pneumoniae
- One of the atypical pneumonias, which often present a dry cough and atypical chest signs/x-ray findings
- Autoimmune haemolytic anaemia and erythema multiforme may be seen
Legionella pneumophilia
- Another one of the atypical pneumonias
- Hyponatraemia and lymphopenia common
Klebsiella pneumoniae
- Classically seen in alcoholics
Pneumocystis jiroveci
- Typically seen in patients with HIV
- Presents with a dry cough, exercise-induced desaturations and the absence of chest signs
assess using curb-65
pleural effusion
exudates
- infection; bacterial, pneumonia, mycobacterial
- malignancy; commonest cause in over 60s
- pulmonary embolism
- autoimmune; rheumatoid, lupus
- pancreatitis; may be haemorrhagic
- drugs
- post cabg
transudates
- cardiac failure; commonest cause overall and usually bilateral
- cirrhotic liver disease
- peritoneal dialysis
- nephrotic syndrome
- hypothyroidism
assess
- microscopy and culture
- cytology
- ph; <7.2 indicates the need for a chest drain in a parapneumonic effusion
- ldh and protein to characterise using lights criteria
lung cancer; especially pancoast
- squamous cell carcinoma 35%; PTHrp, clubbing, HPOA
- adenocarcinoma 30%; commonest in non-smokers
- small cell carcinoma 15%; ADH, ACTH, lambert-eaton myasthenic syndrome
- large cell carcinoma 10%
- other 5%
pulmonary oedema
- fluid in the alveolar spaces
- kerley b lines
- increased vascular shadowing in a bats wing distribution
- upper lobe diversion
- pleural effusions
sarcoidosis
systemic inflammatory granulomatous disease of unknown origin
respiratory
- Stage I: bilateral hilar lymphadenopathy (BHL) alone
- Stage II: BHL with pulmonary infiltrates
- Stage III: pulmonary infiltrates without BHL
- Stage IV: fibrosis
- skin
- heart
- eye
- nervous system
- blood
- bones, joints and muscles
- endocrine/exocrine
- gi/gu
hepatomegaly; painful/non-painful
- cirrhosis
- congestive cardiac failure
- neoplastic; secondary and primary eg heptatoma
- infective; acute viral hepatitis, liver abscess, hydatid cyst
- polycystic disease
- tricuspid regurgitation; pulsatile hepatomegaly
- budd-chiari syndrome
- haemochromatosis
- infiltrative; amyloidosis, sarcoidosis
splenomegaly
- hepatic cirrhosis with portal hypertension
- myeloprolferative disorders; cml, myelofibrosis
- lymphoma
- infections; bacterial endocarditis, infectious mononucleosis, viral hepatitis, malaria, kala-azar, brucellosis
- sle, ra; felty’s syndrome, scleroderma, sarcoidosis
- haemolytic anaemias
hepatosplenomegaly
- portal hypertension; cirrhosis, budd-chiari syndrome
- chronic myeloid leukaemia; pyrexia, anaemia, petechial rash, ecchymoses
- non-hodgkin’s leukaemia; lymphadenopathy, pyrexia
- infective endocarditis; pyrexia, vasculitic rash, heart murmur
- myelofibrosis; cachexia, petechiae
- infiltrative conditions; amyloidosis, gaucher’s disease
- granulomatous conditions; tb, sarcoidosis, gpa
- other causes; malaria, kala-azar, schistosomiasis
chronic liver disease
causes
- alcohol
- viral; eg. hep b/c, cmv, ebv
- metabolic; eg. nash, haemochromatosis, wilsons, alpha1 antitrypsin deficiency
- autoimmune; eg. hepatitis, pbc, psc
complications
- portal hypertension
- synthetic dysfunction
- hepatic encephalopathy
- hepatorenal syndrome
- hepatopulmonary syndrome
- hcc, esp in chronic hep b
renal failure; rrt
- haemodialysis; look for fistulae
- peritoneal dialysis; look for tunneled line or port
- renal transplant; look for scars
common causes of ckd
- diabetes
- glomerulonephritis eg iga nephropathy
- reflux nephropathy
- obstructive uropathy
- renovascular disease
- hypertension
- polycystic kidney disease
- others eg myeloma or amyloidosis
renal transplant
immunosupressive regimes
- prednisolone
- calcineurin inhibitor eg ciclosporin or tacrolimus
- antiproliferative agent eg mycphenolate or azathioprine
complications of renal transplant
- acute rejection
- chronic rejection
- opportunistic infection eg cmv
- malignancy, particularly skin cancer
- cardiovascular disease, hypertension and hyperlipidaemia
- recurrence of primary renal disease
pckd
autosomal dominant inheritance
differential
- bilateral hydronephrosis
- amyloidosis
- tuberous sclerosis
- von hippel-lindau disease
associations
- cysts of pancreas liver and spleen
- mitral valve prolapse and aortic regurgitation
- berry aneurysms and sa bleeds
- pkd-1/2 gene on chromosome 16
ultrasound is investigation of choice
post-operative abdo patient
complications of surgery
- shock
- haemorrhage
- wound infection
- dvt
- atelectasis
- urinary retention
- analgesia complications
- anastamotic leakage
- visceral structure perforation or damage
colorectal cancer surgery resections
- Caecal, ascending or proximal transverse colon = right hemicolectomy
- Distal transverse, descending colon = left hemicolectomy
- sigmoid colon = high anterior resection
- upper rectum = anterior resection (tme)
- low rectum = anterior resection (low tme)
- anal verge = abdomino-perineal excision of rectum
parkinson’s disease
- idiopathic parkinsons disease
- drug-induced parkinsonism eg. antipsychotics, metoclopramide
- progressive supranuclear palsy (tau)
- multi-system atrophy (alpha synuclein)
- lewy-body dementia (lewy bodies)
- vascular parkinsons
cerebellar examination
main causes of cerebellar symptoms
- stroke
- tumour
- degenerative
- congenital
proximal myopathy
causes
- duchenne muscular dystrophy
- thyroid disease
- parathyroid dysfunction
- addison’s diseasea
- cushings disease
- hypokalaemia
- dermatomyositis
- polymyositis
- statins and other drugs
- infections eg hiv
- polymyalgia rheumatica (muscle tenderness as well)
peripheral neuropathy
- Genetic diseases: Friedreich’s ataxia, Fabry disease,Charcot-Marie-Tooth disease, hereditary neuropathy with liability to pressure palsy
- Metabolic and endocrine diseases: diabetes mellitus, chronic kidney failure, porphyria, amyloidosis, liver failure, hypothyroidism
- Toxic causes: drugs (vincristine, metronidazole, phenytoin, nitrofurantoin, isoniazid, ethyl alcohol, statins), organic herbicides TCDD dioxin, organic metals, heavy metals, excess intake of vitamin B6 (pyridoxine). Peripheral neuropathies also may result from long term (more than 21 days) treatment with Linezolid (Zyvox).
- Adverse effects of fluoroquinolones: irreversible neuropathy is a serious adverse reaction of fluoroquinolone drugs
- Inflammatory diseases: Guillain–Barré syndrome,systemic lupus erythematosus, leprosy, multiple sclerosis, Sjögren’s syndrome, Babesiosis, Lyme disease, vasculitis, sarcoidosis,
- Vitamin deficiency states: Vitamin B12 (Methylcobalamin), vitamin A, vitamin E, vitamin B1 (thiamine)
- Physical trauma: compression, pinching, cutting, projectile injuries (for example, gunshot wound), strokes including prolonged occlusion of blood flow, electric discharge, including lightning strikes
- Effect of chemotherapy - see Chemotherapy-induced peripheral neuropathy
- Exposure to Agent Orange
- Others: electric shock, HIV, malignant disease, radiation, shingles, MGUS (Monoclonal gammopathy of undetermined significance).
multiple sclerosis
.
polio
.
mixed umn and lmn signs
- mnd
- friedrich’s ataxia
- conus medullaris
- scdc
- taboparesis
stroke
assess for;
- hemiplegia
- cortical signs; hemianopia, expressive or receptive dysphasia, sensor inattention
taci - hemiplegia, hemianopia and at least one other cortical sign
paci - hemiplegia and one other cortical sign
laci - lacunar infarct, hemiplegia without cortical signs
assess for posterior circulation infarcts concerning visual loss and cerebellar syndromes
essential tremor/postural tremor
.
myotonic dystrophy
.
syringomyelia
.
foot drop
L5 and common peroneal
charcot-marie-tooth
.
friedrich’s ataxia
.
spastic paraparesis
.
spina bifida
.
cerebral palsy
.
internuclear ophthalmoplegia
medial longitudinal fasciculus syndrome
- defect in adducion of the ipsilateral eye
- nystagmus in the contralateral eye
- double vision on looking away from the side of the lesion
- associated with multiple sclerosis
- steroids induce remission
relative afferent pupillary defect
.
bell’s palsy
.
field defects
.
myasthenia gravis
.
thyroid eye disease
.
horner’s syndrome
.
bulbar/pseudobulbar palsy
bulbar palsy; lmn
- nasal, atrophic, decreased jaw jerk, -ve gag
- vascular; meedullary infarct
- degenerative; mnd
- infective; gbs, lyme disease, polio
- malignant; brainstem glioma
- toxin; botulism
pseudobulbar palsy; umn, bilateral
- slow spastic, increased jaw jerk
- brainstem stroke; corticobulbar
- mnd
- ms
complex ophthalmoplegia
.
cerabello-pontine angle syndrome
.
cavernous sinus syndrome
Cavernous sinus syndrome is characterized by multiple cranial neuropathies. The clinical presentation includes impairment of ocular motor nerves, Horner’s syndrome, and sensory loss of the first or second divisions of the trigeminal nerve in various combinations. The pupil may be involved or spared or may appear spared with concomitant oculosympathetic and parasympathetic involvement. Various degrees of pain may be involved
jugular foramen syndrome
palsies of cranial nerves 9-11 with/without 12
caused by;
- glomus tumours
- meningiomas
- acoustic neuromas
hip oa; replacement
.
trendelenburg gait positive
weakness of the abductor muscles of the lower limb
trochanteric bursitis
.
knee oa; replacement
.
acl tear
.
knee ra
.
rheumatoid hands
.
dupuytrens contracture
flexion contracture of the hand due to a palmar fibromatosis
associated with;
- men
- smoking
- hand trauma
- manual work
- family history
- alcoholics
- epilepsy
- diabetes
- hiv
hand oa
.
ulnar/median/radial lesions
.
marfans syndrome
fibrillin-1 gene
scleroderma
Limited cutaneous systemic sclerosis
- Raynaud’s may be first sign
- scleroderma affects face and distal limbs predominantly
- associated with anti-centromere antibodies
- a subtype of limited systemic sclerosis is CREST syndrome: Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
Diffuse cutaneous systemic sclerosis
- scleroderma affects trunk and proximal limbs predominantly
- associated with scl-70 antibodies
- hypertension, lung fibrosis and renal involvement seen
- poor prognosis
Scleroderma (without internal organ involvement)
- tightening and fibrosis of skin
may be manifest as plaques (morphoea) or linear
Antibodies
- ANA positive in 90%
- RF positive in 30%
acj oa
.
painful arc syndrome
.
rotator cuff problems
.
apprehension test positive
.
ankylosing spondylitis
- seronegative arthopathy
- hla-b27
- bamboo spine
- dagger spine
- sacro-iliac fusion
spine; fusion
.
varicosities
dilated tortuous vessels of the superficial venous system
saphena varix
- A saphena varix is a dilation of the saphenous vein at its junction with the femoral vein in the groin. Saphena varix is a common surgical problem. Patient can present with a groin swelling due to saphena varix.
It displays a cough impulse and may be mistaken for a femoral hernia. However it has a bluish tinge and disappears on lying down. On auscultation a venous hum may be heard. It is frequently associated with varicose veins. Saphena varix can be easily diagnosed by ultrasound. Saphena varix shows flow on duplex ultrasonography.
previously stripped veins
.
arterial disease
- pallor
- pain
- paraesthesia
- pulselessness
- paralysis
- poikilothermia; cold
fem-pop bypass
.
fem-fem bypass
.
amputations
.
multi-nodular thyroid
.
graves’ disease
.
hypo/hyperthyroidism
.
single thyroid nodule/cyst
.
parotid tumour
.
post-breast surgery
.
fibroadenoma
.
fibrocystic disease of the breast
.
breast carcinoma
- suspensary ligaments of cooper
- triple assessment; clinical examination, fine needle biopsy, uss or mammography dependant on breast density
paget’s disease of the nipple
.
inguinal hernia
.
hydrocele
.
varicocele
.
testicular cancer
.
arterial ulcers
- small
- deep
- regular
- painful
- pressure areas
venous ulcers
- large
- shallow
- irregular
- painless
- medial gaiter region
neuropathic ulcers
think diabetes
inflammatory ulcers
pyoderma
infective ulcers
.
necrobiosis lipoidica
- shiny, painless areas of yellow/red skin typically on the shin of diabetics
- often associated with telangiectasia
colostomy
loop colostomy
- To defunction a distal segment of colon
- Since both lumens are present the distal lumen acts as a vent
end colostomy
- Where a colon is diverted or resected and anastomosis is not primarily achievable or desirable
ileostomy
both usually in right iliac fossa
loop ileostomy
- Defunctioning of colon e.g. following rectal cancer surgery
- Does not decompress colon (if ileocaecal valve competent)
end ileostomy
- Usually following complete excision of colon or where ileocolic anastomosis is not planned
- May be used to defunction colon, but reversal is more difficult
ileal conduit
urostomy formed from refashioned ileum
parastomal hernia
.
abdominal surgical scars
kochers - cholecystectomy rooftop/mercedes-benz - liver tranplant midline - aaa - laparotomy lanz incision - appendicectomy groin incision - inguinal hernia left paramedian - colectomy pfannenstiel - cystectomy - prostatectomy vertical groin incision - femoral artery - embolectomy
inguinal hernia
indirect; patent processus vaginalis
direct; defect in hesselbach’s triangle
- Medial border: Lateral margin of the rectus sheath, also called linea semilunaris
- Superolateral border: Inferior epigastric vessels
- Inferior border: Inguinal ligament, sometimes referred to as Poupart’s ligament
femoral hernia
- more common in females
- high risk of strangulation
- located below inguinal ligament lateral to the pubic tubercle
epigastric hernia
- Lump in the midline between umbilicus and the xiphisternum
- Most common in men aged 20-30 years
divarification of the recti
Diastasis of this muscle occurs principally in two populations: newborns and pregnant women. It is also known to occur in men.
umbilical hernia
Symmetrical bulge under the umbilicus
Associations
- Afro-Caribbean infants
- Down’s syndrome
- mucopolysaccharide storage diseases
usually resolve on their own by 3 years of age
paraumbilical hernia
Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus
incisional hernia
May occur in up to 10% of abdominal operations
spigelian hernia
Also known as lateral ventral hernia
Rare and seen in older patients
A hernia through the spigelian fascia (the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally)
sle
.
nf1/2
.
haemochromatosis
.
wilson’s disease
.
osteogenesis imperfecta
.
marfans syndrome
.
acromegaly
.
ehlers-danlos syndrome
.
cushing’s syndrome
.
addison’s
.
scleroderma
.
hereditary haemorrhagic telangiectasia
.
peutz-jeughers syndrome
.
sturge-weber syndrome
rare, port wine stain on face and neurological feature; most notably seizure activity from early age, associated with learning difficulty
tuberous sclerosis
autosomal dominant
Cutaneous features;
- depigmented ‘ash-leaf’ spots which fluoresce under UV light
- roughened patches of skin over lumbar spine (Shagreen patches)
- adenoma sebaceum (angiofibromas): butterfly distribution over nose
- fibromata beneath nails (subungual fibromata)
- café-au-lait spots* may be seen
Neurological features;
- developmental delay
- epilepsy (infantile spasms or partial)
- intellectual impairment
Also;
- retinal hamartomas: dense white areas on retina (phakomata)
- rhabdomyomas of the heart
- gliomatous changes can occur in the brain lesions
- polycystic kidneys
- renal angiomyolipomata
- lymphangioleiomyomatosis: multiple lung cysts
dermatomyositis
idiopathic inflammatory myopathy characterised by;
- heliotrope rash
- gottron’s papules
- muscle weakness; no pain
related to polymyositis
- anti-jo antibody
