General Examination and Diagnostic Techniques

Question 1

Intensity of a murmur:

Answer 1

refers to the loudness of the murmur, and is graded according to the Levine scale, from 1 to 6

Question 2

Shape of a murmur:

Answer 2

refers to the intensity over time; murmurs can be crescendo, decrescendo or crescendo-decrescendo.

Question 3

Pitch of a murmur:

Answer 3

may be low, medium or high and is determined by whether it can be auscultated best with the bell or diaphragm of a stethoscope.

Question 4

Quality of a murmur:

Answer 4

refers to unusual characteristics of a murmur, such as blowing, harsh, rumbling or musical.

Question 5

Radiation of a murmur:

Answer 5

refers to where the sound of the murmur radiates. The general rule of thumb is that the sound radiates in the direction of the blood flow.

Question 6

Timing of a murmur:

Answer 6

refers to whether the murmur is a systolic or diastolic murmur.

Question 7

Location of a murmur:

Answer 7

refers to where the heart murmur is usually auscultated best.

Question 8

Acute Dyspnea in Adults (Mnemonic: PAOPPA):

Answer 8

1. Pulmonary embolism
2. Acute pulmonary edema: Pulmonary: Noxious gas inhalation, HAPE. Cardiogenic: Congestive Heart Failure
3. Obstructed airway (Foreign body, Epiglottitis)
4. Pneumothorax (Spontaneous)
5. Pneumonia
6. Acute asthma or COPD exacerbation

Question 9

Diagnosis for peripheral edema:

Answer 9

1. Heart failure and pericardial disease
2. Cirrhosis
3. Renal sodium retention
4. Nephrotic syndrome
5. Idiopathic edema
6. Drug-induced edema
7. Unilateral edema (venous insufficiency or thrombosis; lymphedema)

• age, aging, but can be caused by many other conditions, including CHF, trauma, alcoholism, altitude sickness, pregnancy, hypertension, sickle cell anemia, or merely long periods of time sitting or standing without moving. Some medicines (e.g. amlodipine, pregabalin) may also cause or worsen the condition.

Question 10

Hypoxia:

Answer 10

Hypoxia refers to a state in which oxygen supply is insufficient.

Question 11

Anoxia:

Answer 11

Hypoxia in which there is complete deprivation of oxygen supply is referred to as anoxia.

Question 12

Hypoxemia:

Answer 12

Hypoxemia and anoxemia refer specifically to states that have low or zero arterial oxygen supply.

Question 13

Causes of Hypoxia:

Answer 13

1. Respiratory hypoxia
2. Hypoxia secondary to high altitude
3. Hypoxia secondary to right-to-left extrapulmonary
   shunting
4. Anemic hypoxia
5. Carbon monoxide (CO) intoxication
6. Circulatory hypoxia

Question 14

When is the onset of cyanosis?

Answer 14

The onset of cyanosis is 5.0 g/dL of deoxyhemoglobin.

Question 15

Cyanosis is divided into two main types:

Answer 15

1. Central: around the core, lips, and tongue

2. Peripheral: only the extremities or fingers

Question 16

Tilt-table test:

Answer 16

• A tilt-table test involves changing a person’s positioning quickly and seeing how their blood pressure and heart rate respond.
• This test is ordered for people who have symptoms like a rapid heartbeat or who often feel faint when they go from a sitting to standing position.
• Doctors call this condition syncope.

Question 17

What is uncomplicated syncope?

Answer 17

Uncomplicated syncope (without seizures and a normal neurological exam)

Question 18

Presyncope:

Answer 18

Presyncope is a dizziness, severe weakness, blurred vision, which may precede a syncopal episode

Question 19

Palpitation def:

Answer 19

Palpitation is an abnormality of heartbeat that ranges from
- often unnoticed skipped beats or accelerated heartrate - to very noticeable changes accompanied by dizziness or difficulty breathing.

Question 20

Fever of unknown origin (FUO) - Definition:

Answer 20

1. Fever higher than 38.3°C on several occasions
2. Persisting without diagnosis for at least 3 weeks
3. At least 1 week’s investigation in hospital

Question 21

Causes of FUO:

Answer 21

1. Infections: e.g. abscesses, endocarditis, tuberculosis, and complicated urinary tract infections
2. Neoplasms: e.g. lymphomas, leukemia
3. Connective tissue diseases: e.g. temporal arteritis and polymyalgia rheumatica, Still disease, SLE, and RA)
4. Miscellaneous disorders: e.g. alcoholic hepatitis, granulomatous conditions), and undiagnosed conditions

Question 22

Syncope - diagnostic approach:

Answer 22

1. For people with uncomplicated syncope (without seizures and a normal neurological exam) computed tomography or MRI is not indicated.
2. CBC (anemia), ECG (arrhythmia)
3. The Tilt table test is performed to elicit orthostatic syncope secondary to autonomic dysfunction (neurogenic).
4. San Francisco syncope rule: used to isolate people who have higher risk for a serious cause of syncope. High risk is anyone who has:
   a. CHF
   b. Hematocrit <30%
   c. EKG abnormality
   d. Dyspnea
   e. Systolic blood pressure <90 mm Hg

Question 23

Palpitations - Management:

Answer 23

1. Reducing stress, anxiety, caffeine, alcohol and nicotine
2. Beta-blockers (increased epinephrine)
3. Treat arrhythmias

Question 24

Palpitations - General:

Answer 24

Palpitation is an abnormality of heartbeat that ranges from often unnoticed skipped beats or accelerated heartrate to very noticeable changes accompanied by dizziness or difficulty breathing.

• Palpitations are common and occur in most individuals with healthy hearts.
• Palpitations without underlying heart disease are generally considered benign.
• However, heart palpitations can be symptoms of illnesses such as coronary heart disease, asthma, or emphysema.

Question 25

Palpitations - causes:

Answer 25

1. Hyperdynamic circulation (valvular incompetence, thyrotoxicosis, hypercapnia, pyrexia, anemia, pregnancy).
2. Sympathetic overdrive (panic disorders, hypoglycemia, hypoxia, levocetirizine antihistamines, anemia, heart failure, mitral valve prolapse).
3. Cardiac dysrhythmias (premature atrial contraction, junctional escape beat, premature ventricular contraction, atrial fibrillation, supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, heart block).

Question 26

Headache - Differential Diagnosis:

Answer 26

• Acute Single Episode*
  1. With menginsm:
  a. Meningitis
  b. Encephalitis
  c. SAH
  2. Head injury
  3. Venous sinus thrombosis
  4. Sinusitis
  5. Tropical illness: malaria
  6. Acute glioma
• Recurrent Acute Attacks of Headache*
  1. Migraine
  2. Cluster headache
  3. Trigeminal neuralgia
  4. Reccurent (Mollaret) meningitis
• Headaches of Subacute Onset*
  1. Giant cell arteritis
• Chronic Headache*
  1. Tension
  2. Raised intracranial pressure
  3. Medication overuse headaches