Exam Findings Flashcards
1
Q
Findings suggestive of pulmonary hypertension
A
Palpable P2 Right ventricular parasternal heave Loud second heart sound, may be split Presence of TR Fluid overload - eg elevated JVP, APO, hepatomegaly, peripheral oedema
2
Q
Active lupus on examination?
A
Systemic features such as temperature Active urinate sediment (urinalysis) Skin changes (alopecia, rash) Mucosal membrane ulcers Lymphadenopathy Tender joints
3
Q
Left iliac fossa
A
Faeces Carcinoma of sigmoid or descending colon Diverticular abscess Ovarian tumour or cyst Psoas abscess Hernia Transplanted kidney
4
Q
Valsalva - decreases preload
A
Most murmurs are softer - exceptions
Hypertrophic obstructive cardiomyopathy where the murmur is louder with valsalva.
Mitral valve prolapse where the murmur becomes longer with valsalva.
5
Q
Squatting (increased preload) and standing (decreased preload)
A
The murmur of mitral valve prolapse becomes longer and click occurs earlier in systole with standing, the reverse occurs with squatting.
6
Q
ART 2021
A
TAF/TFC (descovy) or TDF/FTC (Truvada)
plus
Integrase inhibitor (dolutegravir, bictegravir or raltegravir) or lamivudine/doluegravir
7
Q
Massive hepatomegaly?
A
Myelofibrosis Myelodysplasia Liver Mets or HCC CLD with fatty infiltration or hepatoma TR (pulsatille) / RHD
8
Q
Adult PCKD
A
BP, urine for haematuria and proteinuria
EVidence of anaemia
Hepatic cysts
3% - intracranial haemorrhage - screen with MRI, test relatives
9
Q
Causes of ascites
A
Cirrhosis (portal htn) Malignancy Heart failure TB Pancreatitis
10
Q
Hand Exam Presentation
A
Name and presentation
Diagnosis (if not sure - eg. symmetrical polyarthropathy for which I have many differentials)
Active/Not Active
Function
11
Q
Findings in a patient with portal hypertension?
A
Splenomegaly
Ascites
Prominent paraumbilical veins
Hx of oesophageal or rectal varices
12
Q
Finger clubbing in lung diseases
A
IPF
Bronchiectasis
Suppurative lung diseases
Lung cancer
13
Q
Gout -post hands
A
Tophi -elbows, ears, other joints
? underlying causes eg. CVS - BMI
14
Q
Tender RUQ
A
Acute hepatitis Rapid distensions HCC Abscess Obstruction/cholangitis
15
Q
Dominant v wave
A
TR
16
Q
Mild hepatomegaly?
A
All above plus hepatitis and cirrhosis and biliary obstruction and granulomatous and Hydatid and amyloid and HIV and ischaemia
17
Q
Anterior abdominal wall masses
A
Lipoma Sebaceous cyst Fibrous Malignant deposits Epugastric hernia Umbilical Incisional hernia Rectus sheets haematoma
18
Q
Liver description
A
Size - > 20cm = massive, 15-30 is moderate
Soft (normal), firm or hard (cirrhosis or malignancy)
Regular or irregular
Tender - congestion, infiltration, malignancy and/or active inflammation eg. Hepatitis
19
Q
OA
A
Nodal OA hands - other joints
2nd/3rd Joint –> ddx - RA, look at liver for haemachromatosis
20
Q
Hepatosplenomegaly
A
Haematological (myeloproliferative, lymphoma, leukaemia, pernicious anaemia, sickle cell anaemia)
Infiltration (amyloid, sarcoidosis)
Infection (viral hepatitis, EBV, CMV)
CTD
Portal HTN (due to CLD, budd Chiari, RHF)
Endocrine (acromegaly and thyrotoxicosis)
CLD with portal hypertension ( but liver usually small, if large suggests fatty liver)
hepatitis, haemachromatosis, HCC or infiltration
21
Q
Secondary - prevent recurrence
A
Sec prophylaxis at lower dose until CD4 > 200 for 6 months
- FLuconazole (cryptococal)
- Valganciclovir (CMV)
22
Q
HIV Issues
A
Adherence ART effects Comorbidities - ageing/frailty Lifestyle factors Psychosocial issues - mental health/housing/financial Transplant considerations
23
Q
Scleroderma joint findings
A
Nails - dilated capillary loops
Limited - cacinosis, dusty skin/chillblains, sclerodactyly, telangiectasia
Hand function
Skin- gottrens, heliotrope rash, shawl sign, mechanics hands
Chest - rash, pleural rubs, cardiac failure, pulmonary fibrosis
Abdomen- hepatosplenomegaly
Neurology - muscle weakness in dermato/poly or pred use
24
Q
Pelvis
A
Bladder
Ovarian tumour or cyst
Uterus
Small bowel obstruction
25
When you switch ART
```
Simplification of regimen
Enhance tolerability
prevent or mitigate drug-drug interactions
Food requirements
Pregnancy
Cost
```
26
Causes of an elevated CVP
```
RVF
TS or TR
Pericardial effusion/constrictive pericarditis
SVC obstruction
Fluid overload
Hyperdynamic circulation
```
27
Normal spleen position
Traube’s space - sixth rib superiority, left MAL laterally and the left costal margin inferiority
28
Differentiating spleen from a renal mass?
Spleen moves downward and medically with respiration
Spleen has a notch on its upper margin (only appreciated if size at least moderate
Spleen is not ballotable
Splenomegaly will cause dullness in traube’s space
29
primary prophylaxis HIV
Bactrim - Pneumocystis Jirovecci CD4 <200 and Toxo
Azithro -MAC CD4 < 75
Cease after 3 months after immune restoration, virologic suppression (HIV viral load <50)
30
Calculating disease activity
Number of swollen joints
Number of tender joints
(Synovitis is a swollen AND tender joint)
Inflammatory markers ie ESR and CRP
31
Functional status
Different to deformity or activity
Evaluation of simple tasks, gait and mobility
32
y descent
Sharp - severe TR, constritive pericarditis
Slow - tricuspide stenosis, right atrial myxoma
33
Causes of a diffuse goitre
```
Idiopathic
Puberty , pregnancy and post-partum
Graves
Thyroiditis - hashimoto's, subacute thyroiditis
Simple goitre (iodine def)
Drugs - iodine excess or drugs
Inborn errors of synthesis
```
34
Decompensated cirrhosis?
```
Oesophageal variceal bleeding
Hepatic encephalopathy
Ascites
SBP
HCC
Hepatorenal syndrome
Hepatopulmonary syndrome
```
35
Firm and irregular liver
HCC
Mets
Cirrhosis
Hydatid disease, granuloma (sarcoidosis), Amyloid, cysts
36
Massive splenomegaly
Common - myeloproliferative (CML/MF)
Rare - primary lymphoma of spleen, hairy cell leukaemia, malaria, leishmaniasis
37
Classification of ascites
Causes of high gradient?
```
High gradient (>11g) - transudate
Cirrhosis
Alcoholic hepatitis
Budd chiari or veno occlusive disease
Fulminant hepatic failure
Congestive heart failure, constructive pericarditis
```
38
RA Extra-articular
```
Rheumatoid nodules
Muscle weakness
Vaculitis
pleural disease - effusions/fibrosis/nodules (pericaridal)
Atlanto=axial
Nerve entrapments
Eyes - sjogrens/scleritis/episcleritis, scleromalacia perforans
Feltys- splenomegaly/neutropenia
anaemia/thrombocytopenia
OP - RF of inflammatory arthritis/steroid SEs
lymphoma
CA
```
39
Causes of low gradient ascites
Peritoneal carcinomatosis
TB
Pancreatic ascites
Nephrotic syndrome
40
Scleroderma - post hands
BP!!
Face- alopecia, anaemia, birdlike, telangiectasia, mouth opening diameter, dysphagia
Chest- skin/rubs/cardiac failure/pulmonary fibrosis
Abdomen - hepatosplenomegaly (rare)
41
Fundoscopy changes in HTN
1- Silver wiring
II - + AV nipping
III - + haemorrhages
IV - +papilloedema
42
HIV Hx
Dx, seroconversion, exposure
Current status: CD4/Viral load
prognostic indicators: CD4 nadir
Tx - current + prev, adherences, reasons for change, SEs
Cx - comorbidities
-ageing with HIV/medications
Psychosocial - transmission, mental health, STIS, D and A, Finance and housing, networl/support
43
Upper abdomen
```
Retroperitoneal lymphadenopathy
Left lobe of the liver
Abdominal aortic aneurysm
Carcinoma of the stomach
Pancreatic pseudo cyst
Gastric dilatation
SBO
```
44
Describing treatment HIV
Progressed through mono and dual therapy before commencing ART
Unable to recall agents, stable on 3rd regimen of..
Highly treatment experienced, now on a salvage combination of
45
Scleroderma - Hands
Diffuse (above elbow) /limited
Dilated capillary loops
Hand function
46
Dermatomyositis
Gottrens sign - scaly erythematous (direct over joints)
Heliotrope rash
Shawl sign
Mechanics hands (rough cracked skin fingers')
Calcinosis
Go to neuro power and resp exam!! (weakness + fibrosis)
47
Moderate hepatomomegaly?
```
Haemachromatosis
Myelodysplasia
CML
Lymphoma
NASH
```
48
Splenomegaly (frequency)
```
Portal HTN
Haematological malignancy
Infection
Congestion or inflammation
Primary splenic disease
```
49
Causes of tricuspid regurg
Right ventricular dilatation
IE on tricuspid valve
Pacemarker insertion or frequent trans-jugular cardiac biopsies
50
Causes of blast crisis
Found either in BM and peripheral blood
Skin or tissue infiltration
Acute leukaemia
51
Creps
Late/Pan inspiratory - fine - fibrosis, med- LVF, corase - bronchiectasis/retained secretions
Early inspiratory - COPD
52
Causes of generalised lymphadenopathy
```
Lymphoma
Leukaemia
Malignant disease
CTD (RA/SLE)
Infections (viral - CMV, HIV, infectious mononucleosis, bacterial - TB, toxo)
Infiltrations
Drugs - phenytoin
```
53
Poly cystic kidneys
Abdominal distension
Fullness of both loins
Palpable ballotable masses
54
Dominant A waves
Completed heart block
Paroxysdmal nodal tachycardia with retrograde atrial conduction
VT with retrograde atrial conduction of AV dissociation
55
Deforming polyarthropathy
RA
Seronegative
Gout
OA
56
Insp/Exp murmurs
Right sided murmurs are louder in inspiration i.e. tricuspid and pulmonary valve murmurs.
Left sided murmurs are louder in expiration i.e. mitral and aortic valve murmurs.
57
Causes of oedema
```
Drugs - CCB
Cardiac: CCF, Cor pulmonale, constrictive pericarditis
Renal: Nephrotic syndrome
Hepatic: Cirrhosis
Malbsorption/starvation
Protein losing enteropathy
Myxoedema
Cyclical oedema
```
58
Features of limited over diffuse scleroderma?
Skin involvement - no thickening over chest wall or upper arms
Pulmonary HTN - more in limited scleroderma
Hx of raynauds and reflux, telangiectasia and cal inlaid are often more seen in limited scleroderma
59
Causes of HTN
Essential - > 95%, Secondary < 5%
Renal - Renal artery atherosclerosis, fibromuscular disease, vasculitis, diffuse
Endocrine - Conn's (primary aldosteronism), Cushings (especially steroid rx)
17 and 11 beta hydroxylase defects
Phaeo, Acromegaly, Myxoedema, OCP
Coarctation of the oarta
Other - PCV, neurogenic, hyperCa, Alcohol, sleep apnoea
60
Causes of clubbing
```
Resp - Lung carcinoma, chronic pul - bronchectasis/abscess, empyema
IPF/asbestosis
CF
Pleural fibroma
Mediastinal disease
```
CVS - IE, cyanotic congenital heart disease
Other - IBD, cirrhosis, coleiac, thyrotoxicosis, neurogenic diaphragmatic tumours, familial, hemiplegic stroke
61
Tender hepatomegaly
```
Infections (acute hepatitis)
Vascular liver disease
Malignancy
Alcoholic hepatitis
Congestion
```
62
Pulsatile liver
TR
HCC
Vascular
63
Causes of hyposplenism
```
Splenic infarction
Splenic artery thrombosis
Infiltrative conditions
Coeliac disease
Autoimmune disease
```
64
RIF Mass
```
Appendices abscess
Carcinoma of caecum
Crohns (if abscess)
Ovarian tumour or cyst
Carcinoid tumour
Amoebiasis
Psoas abscess
Ileocaecal TB
Hernia
Transplanted kidney
```
65
Bilateral renal masses
Unilateral
Polycystic kidneys, hydronephrosis, acute renal vein thrombosis, amyloid, acromegaly
(rarely early diabetes/nephrotic syndrome if very thin)
Unilateral - RCC, hydronephrosis, polycystic kidneys, acute renal vein thrombosis, solitary
66
Massive hepatomegaly and splenomegaly
Myelofibrosis and myelodysplasia (CML/CMML)
67
X Descent
Absent
Exaggerated
Absent - AF
Exaggerated - acute cardiac tamponade, constrictive pericarditis
68
Causes of hypothyroidism
```
Primary
WITHOUT goitre
- idiopathic
- iodine 131 or surgery
- agenesis
- unresponsiveness to tSH
```
WITH a goitre
- chronic thyroiditis
- drugs - lithium/amiodarone
- endemic iodine deficiency
- iodine induced
- enzyme deficiency
Secondary -
- pituitary lesion
tertiary - hypothalamic
Transient - TSH withdrawn, subacute thyroiditis, postpartum
69
Post Hands - RA
```
BP
Face- anaemia/eyes/parotids/dental
Chest - fibrosis, effusions, rubs
Abdomen - splenomegaly, injection sites
Lower limbs - pyoderma gangrenosum
Other joints screening - eg. cervical spine
```
70
Postural Hypotension causes
```
Hypovolaemia
Addison's disease
Neuropathy
Drugs - vasodilators, anti-hypertensives
Idiopathic orthostatic hypotension (elderly,)
```
71
Moderate splenomegaly
Lymphoma
CLL
PRV
Portal hypertension (with CLD, liver may be small)
72
Diabetes Issues
```
Control - hypo/hyper
Adherence - diet/apt/foot care
Insight
CV Risk factors
Cx - renal/neuropathy/autonomic/hypos/eye sight/ulcers
Falls
Driving
peri-op mx
```
73
Moderate hepatomegaly and moderate splenomegaly
Same as massive
| Also CLL and lymphoma
74
Handgrip (increases afterload)
Most softer
| Louder in MR
75
Mild splenomegaly
PRV, ET, haemolytic anaemia, ITP
Connective tissue disorders (RA, SLE, PAN)
Sarcoidosis, amyloid
Portal HTN (with signs of CLD)
76
Causes of thyotoxicosis
```
Primary:
Graves
Toxic adenoma or multinodular goitre
Hashimotos (early), subacute thyroditis (transient), painfull or painless
Iodine indeuced
Excess T4 replacement
Post-partum (non tender)
```
Secondary - pituitary or ectopic TSH secreting tumour (rare), hydatiform mole, factitious
77
Wheeze
- Inspiratory
- Expiratory
Insp - asthma or upper airway obstruction
Exp - Asthma and COPD
Fixed inspiratory wheeze - monophonic, fixed bronchial obstruction
78
Post hands - spondyloarthropathies (or back ex)
Face- anaemia
Abdomen - stoma! ( IBD)
Back - Axial Disease
79
Rheumatoid arthritis
Rheumatoid nodules
Complications of treatment - cushingoid features, infection, injection site reactions
Hand exam - symmetrical deforming pillar thrips the, a deformity of thumb, ulnar deviation of wrist, swan neck, boutonnières
Extra articular- face (anaemia, parotids, dental caries)
Chest - fibrosis, effusions, rubs
Abdomen - splenomegaly, injection sites, stoma
Lower limbs - pyoderma gangrenosum
80
Pulsatile liver?
TR
HCC
Vascular
81
Lower lobe fibrosis?
Autoimmune - RA, scleroderma, SLE
Inhalation - asbestosis
Drugs - bleomycin, amiodarone, methotrexate
82
Upper lobe fibrosis
Autoimmune - ank spond, sarcoidosis
Inhalation- silicosis, coal workers pneumoconiosis
Infective - TB, ABPA, radiation
83
UIP Pattern
Honeycombing
Traction bronchiectasis
Reticular opacities - peripheral and lower lobe predominant
No atypical features
84
NSIP pattern
Ground glass opacity
Reticular opacity
Traction bronchiectasis
Diffuse - can have subpleural sparing
