Exam findings Flashcards
EXAM = Describe findings in aortic regurgitation and signs of severity
Findings =
- high pitched early diastolic crescendo murmur heard at mid sternal region or LLSE sitting forward in full expiration
Signs of severity
- Collapsing pulse
- Wide pulse pressure
- Soft S2
- S3
- Length of murmur
- Austin Flint murmur
- Signs of LV failure
EXAM = Describe findings in tricuspid regurgitation and signs of severity
Findings =
- pansystolic murmur, loudest at lower left sternal edge on inspiration
Signs of severity =
- pulsatile liver
- prominent v wave
- signs of RV failure
EXAM = Describe findings in mitral stenosis and signs of severity
Findings:
- Mid diastolic rumbling murmur
- tapping apex beat
Signs of severity =
- small pulse pressure
- early opening snap
- length of murmur
- diastolic thrill at apex
- pulmonary HTN
EXAM = Describe findings in aortic stenosis and signs of severity
Findings =
- ejection systolic murmur loudest over right second intercostal space and radiates to the carotids, louder with expiration
- Apex beat -> non-displaced, pressure loaded
Signs of severity =
- Narrow pulse pressure
- Low volume carotid pulse
- Soft S2
- Paradoxical split S2
- S4
- Thrill
- Signs of LV failure
EXAM = Describe findings in mitral regurgitation and signs of severity
Findings =
- pan-systolic murmur loudest at apex, radiating to axilla and loudest on expiration
- Apex beat -> displaced and volume loaded
Signs of severity =
- Small pulse volume (very severe)
- Soft S1, Split S2
- S3
- Pulmonary hypertension
- Evidence of LV failure
- Early diastolic rumble (flow murmur)
What are respiratory reasons to find clubbing on exam?
Idiopathic pulmonary fibrosis (IPF)
Bronchiectasis
Suppurative lung diseases
Lung cancer
What pathologies would cause tracheal deviation?
Collapse or fibrosis pulling TOWARDS site of pathology
Large effusion or other mass pushing AWAY
How would you differentiate between lung consolidation and effusion?
- Presence of bronchial breath sounds
- Increased vocal transmission/resonance (in consolidation)
What findings would be consistent with pulmonary HTN?
- Loud and palpable P2 in pulm area, may be split
- right ventricular parasternal heave.
- May be associated with tricuspid regurgitation + signs of RHF
What are signs of chronic liver disease you would look for on examination?
General / face :
- jaundice
- asterixis
- parotid enlargement (ETOH)
Hands:
- Pallor of the palmar creases.
- Finger clubbing (may be present in any of the chronic liver disease aetiologies, however the strongest association is with liver disease secondary to inflammatory bowel disease).
- Leukonychia
- Dupuytren’s contracture (in the presence of chronic liver disease is in keeping with alcohol related aetiology).
- Palmar erythema.
Chest
- JVP
- spider naevi
- gynecomastia
Abdomen
- HSM
- caput medusa
- ascites
Legs
- peripheral oedema
What is the normal liver span?
11-14cm depending on patient size
What constitutes splenomegaly?
What is massive splenomegaly?
1-2 cm mild splenomegaly
3-7 cm moderate splenomegaly
>7cm marked splenomegaly
What are the findings consistent with portal HTN?
HSM
Ascites
Caput medusa
What are indicators of decompensated cirrhosis?
Confusion / coma Fetor Jaundice Asterixis Ascites / SBP
How to differentiate between spleen and enlarged left kidney?
Spleen will move medially with inspiration, whereas kidney does not Spleen will have notch on upper margin Spleen is not ballotable Cannot get above a spleen Spleen will be dull in Traube's space
What hand exam findings are consistent with RA/ SLE?
Ulnar deviation MCP / wrist, Swan neck, Boutonniere, Z deformity of thumb
What hand exam findings are consistent with OA?
Heberden’s / Bouchard’s nodes
What hand exam findings are consistent with Psoriatic arthritis?
Sausage digits, dactylitis
How would you assess hand function in RA?
Grip strength
Key grip / turn the key
Open jar
Hand writing (or typing!)
What are key findings in back exam for spondyloarthropathies?
Occiput to wall distance
Spinal ROM and tenderness
Lateral flexion finger to floor distance (normal is fingers reaching distal crease of the knee)
Chest expansion (measure tape entire chest, unlike in respiratory evaluation)
Modified Schober’s test
What extra-articular manifestations would you look for in RA?
Extra articular findings =
Face - anaemia, parotids, dental caries
Chest - fibrosis, joint effusions, rubs
Abdomen - splenomegaly (Felty’s), stoma (if associated inflammatory bowel disease)
Lower limbs - pyoderma gangrenosum
What are hand examination features of limited systemic sclerosis?
calcinosis
dusky skin and chillblains to suggest history of Raynauds’ disease
Sclerodactyly
Telangiectasia
How do you differentiate between limited and systemic sclerosis?
Extent of skin involvement -> beyond elbows
Pulm HTN also more common in limited
What would you expect in haemachromatosis-associated OA?
Arthritis of second and third MCP joints particularly
Causes of Pulsus Bisferiens ?
- moderate - severe aortic regurgitation
- mixed aortic regurgitation and stenosis (predominant lesion aortic regurgitation)
- HCM
What is the classic murmur of MVP?
Midsystolic click followed by a late systolic murmur at apex
What are classic exam findings of HOCM?
How can you differentiate from AS?
Carotid pulse -> jerky
Apex beat -> double impulse
Auscultation at the left lower sternal edge typically reveals an ejection systolic murmur, with no carotid radiation
The ejection systolic murmur is louder on Valsalva and softer with hand grip.
Classical findings in ASD ?
Fixed splitting of the 2nd heart sound + ESM, best heard in the pulmonary area
May be associated with pulm HTN
Classical findings in VSD?
Holosystolic murmur maximal at LLSE, often accompanied by a palpable thrill in the third or fourth left intercostal space
*loudness of the murmur is inversely proportional to the size of the VSD.
What is Romberg’s sign used to evaluate?
To look for sensory ataxia from posterior column disease
- Positive if able to maintain balance with eyes open, but loses balance with eyes closed
(compensation via vestibular function and vision)
What are classic exam findings in CIDP?
LL symmetric sensorimotor neuropathy
- motor predominant
- both proximal and distal muscles with atrophy
- reduced/absent reflexes
LL findings in MS?
UMN signs:
- hyper-reflexia
- spasticity
- upgoing plantars
Differentials for bilat spastic gait?
- MS
- cord lesion
- Hereditary spastic paraplegia
- cerebral palsy
- bilat stroke
DDx for bilat foot drop
Peripheral motor neuropathy e.g. CIDP, CMT
Bilat stroke
MND
DDx for Parkinsonian gait?
Parkinsons
Parkinson’s Plus
Drugs
DDx for wide based gait?
Cerebellar ataxia
Sensory ataxia
Vestibular ataxia
What is Hoffman’s sign?
Hoffman sign = involuntary flexion movement of the thumb and or index finger when the examiner flicks the fingernail of the middle finger down.
= UMN lesion of ULs
What does 3rd CN innervate?
- 2/3rds of upper eyelid elevator
- Medial, inferior, superior recti muscles
- Pupillary meiosis
What are findings in 3rd CN palsy?
- Ptosis, inferolateral displacement of the ipsilateral eye.
- Reduced adduction, elevation and depression of the affected eye.
- A dilated non-reactive pupil (can be spared in diabetes)
What are DDx for 3rd CN palsy?
- Tumours -> compression
- Cavernous sinus lesions
- Trauma
- Haemorrhagic or ischaemic stroke and demyelinating disorders that affect the nerve nucleus in the midbrain.
- Mononeuritis multiplex e.g. diabetes (often with pupillary sparing)
- Intracranial aneurysms, in particular posterior communicating artery aneurysms
What is the function of the 4th CN?
- Depression of the eyeball, especially when the eye is adducted
- Intorsion of the eyeball, especially when the eye is abducted.
What are findings in 12th / hypoglossal nerve palsy?
- UMN -> Protrusion of tongue AWAY from side of lesion
- LMN -> protrusion TOWARD the side of the lesion
What is a complex ophthalmoplegia and what are DDx?
Complex ophthalmoplegia = where the abnormality cannot be explained by cranial nerve abnormality or a gaze palsy
DDx:
Myasthenia gravis.
Mitochondrial myopathies.
Graves eye disease.
How does transverse myelitis generally present?
- UMN findings below level affected
- sensory level
What are cardiac causes of clubbing?
Infective endocarditis
Cyanotic congenital heart disease
What are respiratory causes of clubbing?
Lung cancer Suppurative lung disease IPF CF Mesothelioma Mediastinal disease
Causes of HSM?
CLD + portal HTN Haematological disease Viral infection (CMV, EBV) CTD Infiltration
