Examination for the Long Case Flashcards
Cause of Clubbing
-Cyanotic heart disease
-Lung disease
Abscess
Bronchiectasis
Cystic Fibrosis
Dont say COPD
Empyema
Fibrosis
-Ulcerative Collitis + Inflammatory Bowel Disease(Crohn’s Disease)
-Biliary cirrhosis
-Birth Defects
-Infective Endocarditis
-Neoplasm(eg. Lung cancer or mesothelioma)
-Gastrointestinal malabsorption syndrome(Coeliac disease)
Lung expansion: Symmatrical but reduced
Chronic obstructive lung disease.
Interstitial lung disease.
Lung expansion: Asymmetrical and abormal
In unilateral lung disease, lung resection or pneumonectomy (paradoxical expansion may occur).
Unilateral lung transplantation with normal expansion of the transplanted lung and reduced expansion of the native lung.
Dull percussion
Lung consolidation/collapse.
Pleural effusion (stony dull).
Mesothelioma.
Differentiating lung collapse/consolidation from pleural effusion
- Increased vocal resonance
- Bronchial breath sounds
PHTN Findings
- Palpable thrill over Pulmonary area
- RV parasternal heave
- Loud P2, may be split
- TR
- Features of RVF: elevated JVP, lung crackles, hepatomegaly, peripheral oedema
TR Findings
- elevated JVP with prominent V wave and Y descent
- Pulsatile liver
- RV heave
- Features of pulmonary HTN
- PSM loudest at left lower sternal edge, loudest on inspiration
Commonly associated with MR and PHTN
Causes of AS
Degneration of bicuspid valve
Calcification
RHD
Moderate heptomegaly
15-20 cm
- As per massive DDx
- Haemachromatosis
- CML
- Lymphoma
- NAFLD
Mild Splenomegaly
1-2 cm
- PRV
- ET
- Haemolytic anaemia
- ITP
- CTD
- Sarcoid
- Amyloid
- Portal HTN
Gallavardin phenomenon
AS murmur heard at apex
In this phenomenon, the harsh murmur of aortic valvular stenosis may change in quality and become musical at the apex.
Causes of AR
Valve pathology
- RHD
- Congenital w/ or w/o VSD
- Cx of IE
Aortic root pathology
- Aortic root dissection
- Ank Spond
- Syphilitic aortitis
- Cx of Marfan’s
DDx hepatosplenomegaly
-CLD w/ Portal HTN (although liver usually small)
DDx massive hepatosplenomegaly
Myelofibrosis
Myelodysplasia
CML/CMML
DDx moderate hepatosplenomegaly
Myelofibrosis Myelodysplasia CML/CMML CLL Lymphoma
Indicators for decompensated cirrhosis
- Variceal bleed
- Hepatic encephalopathy
- Ascites
- SBP
- HC
- Hepatorenal or hepatopulmonary syndromes
Differentiating spleen from renal mass
- Spleen moves down and medially with respiration
- Spleen has a notch on upper margin
- Spleen not ballotable
- Cannot get above a spleen
TR
- elevated JVP with prominent V wave and Y descent
- Pulsatile liver
- RV heave
- Features of pulmonary HTN
- PSM loudest at left lower sternal edge, loudest on inspiration
Commonly associated with MR and PHTN
DDx for wide based gait
- Cerebellar ataxia
- Sensory ataxia
- Vestibular ataxia
- Frontal ataxic gait
AR signs of severity
- Wide pulse pressure with collapsing pulse
- S3
- Soft A2
- Austin Flint murmur
- LV enlargement
AS signs of severity
- A small volume, slow rising, plateau carotid pulse.
- The presence of an aortic thrill.
- A long late peaking ejection systolic murmur.
- The presence of an S4, indicating reduced compliance of the left ventricle.
- Paradoxical splitting of S2.
- The presence of left ventricular failure.
Gallavardin phenomenon
AS murmur heard at apex
In this phenomenon, the harsh murmur of aortic valvular stenosis may change in quality and become musical at the apex.
Causes of positive Rombergs test
(Steady with eyes open, not steady with eyes closed)
- Posterior column lesion
- PN
- Vestibular dysfunction
Findings in Diabetic neuropathy
- Gait: Sensory ataxia
- Romberg’s positive
- Sensory loss in glove and stocking
- In severe cases motor weakness or loss of ankle jerk
Findings in CIDP
Symmetric, sensorimotor neuropathy, with predominant motor neuropathy, resulting in both proximal and distal muscle weakness
- Ataxic gait
- Positive Rombergs
- Glove and stocking distribution of sensory loss
- Reflexes generally absent or reduced
- Muscle atrophy/weakness
Less common:
-Asymmetric and/or sensory predominant forms
MS findings
UMN findings:
- Hyperreflexia
- Spacitity
- Up going plantar
- Occasionally reflexes are lost due to interruption of afferent motor reflex
- Cerebellar and sensory findings may be present
Pulsus bisferiens
Commonly due to:
- mod-severe AR
- Mixed AR and AS
- HOCM
Mitral Valve prolapse signs
Mid systolic click +/- mid systolic murmur of MR
DDx PArkinsonian like gait
-Parkinson like syndrome e.g surapnuclear palsy, drug induced parkinsonism
Posture is often more upright
DDx for wide based gait
- Cerebellar ataxia
- Sensory ataxia
- Vestibular ataxia
- Frontal ataxic gait
DDX asymmetric gait
- Unilateral spasticity e.g. motor stroke
- Unilateral cerebellar lesions
- Unilateral foot drop e.g. common peroneal nerve lesion, L5 lesion, unilateral stroke
Standing on toes
Assesses S1
Standing on heels
Tests L4/5
Causes of positive Rombergs test
(Steady with eyes open, not steady with eyes closed)
- Posterior column lesion
- PN
- Vestibular dysfunction
Clasp knife/spasticity
UMN lesion
Lead pipe/rigidity
Cogwheel rigidity
extra-pyramidal lesions
Knee Jerk
L3,4
Ankle jerk
S1,2
Findings in proximal myopathy
Muscle atrophy No fasciculations Normal Tone Normal reflexes Down going plantars Weakness in prox muscles
AR signs
- Wide pulse pressure
- Collapsing water hammer pulse
- Quinke’s sign
- Head bobbing
- Pistol shot femoral artery sounds
- Displaced apex beat
- Diastolic thrill at left lower sternal edge
- S3
- Diastolic murmur loudest at the left lower sternal edge on expiration
Austin flint murmur
mid diastolic murmur head at the apex in severe AR
AR signs of severity
- Wide pulse pressure with collapsing pulse
- S3
- Soft A2
- Austin Flint murmur
- LV enlargemen
MR Signs
- May have AF
- Displaced, dyskinetic apex beat
- PSM radiating to axilla
- Soft S1
- S3 due to turbulent LV blood flow
- Apical thrill
Causes of MR
- Mitral valve degeneration
- RHD
- IE
- Congenital heart disease
- Ruptured chordae tendinae
- Infarcted papillary muscles
- LV dilatation
MR signs of severity
- LV dilatation
- Soft S1
- PHTN
- Split S2
- S3
- Cx of LVF
- Small pulse volume
CAuses of MS
- RHD
LEss common
-Radiation
-Congenital MS
Signs of MS
- Malar flush
- JVP: prominant A wave
- Tapping apex beat
- Loud S1
- Opening snap
- Mid diastolic rumbling murmur
MS signs of severity
- Small pulse pressure
- Short distance between opening snap and S2
- Long diastolic murmur
- Presence of PHTN
- Apical diastolic thrill
Pulsus bisferiens
Commonly due to:
- mod-severe AR
- Mixed AR and AS
- HOCM
Mitral Valve prolapse signs
Mid systolic click +/- mid systolic murmur of MR
Signs of HOCM
-Jerky carotid pulse
-JVP possible prominent A wve
-Apex beat: double impulse
-Systolic thrill at left lower sternal edge
-ESM at left lower sternal edge, loudest on valsalva
-PSM of MR
-S4
-
ASD signs
- Fixed splittingof the 2nd HS
- ESM loudest in pulmonary area
VSD signs
Small:
- loud, high frequency systolic murmur, loudest at left lower sternal edge
- palpable thrill in 3rd or 4th left intercostal space
Large:
- Softer
- Holosystolic
