Hx & Exam Flashcards
syncope vs pre-syncope vs dizziness
syncope = transient LOC due to transient cerebral hypoxia
pre-syncope = transient sensation of weakness w/o LOC
dizziness = world spinning feeling
what is a collapsing pulse aka corrigan’s pulse or water hammer pulse
it is when you raise the patient’s arm above their head
and feel their radial pulse
a high volume pulse rapidly hitting and then collapsing against the fingers can be felt
it is a sign of aortic regurgitation
DDx chest pain
cardiovascular:
ACS
dissecting aneurysm
pericarditis
respi – pleuritic pain
pneumothorax
PE
lung ca
GI
GERD
diffuse oesophageal spasm
what is claudication + DDx
claudication = unilateral/bilateral pain in calves, thighs or buttocks
DDx:
intermittent claudication
popliteal entrapment — only when walking not running
lumbar spinal stenosis — pain in calves + relieved when sitting down (spinal flexion) + exacerbated by spinal extension (eg. walking down hill)
what is levine’s sign
when a patient hunches forward and places a clenched fist over his chest
indicates cardiac ischaemia
causes of cyanosis
central cyanosis = blue lips + tongue
hypoxic lung disease
right-to-left cardiac shunt — cyanotic congenital heart disease
methaemoglobinaemia
peripheral cyanosis = blue hands
peripheral vascular disease
raynaud’s syndrome
HF
shock
what are the stigmata of IE infective endocarditis
4 signs that may suggest IE
roth spots = spots on the retina – white central core + surrounding haemorrhage
due to microembolism
only visible on fundoscopy
osler nodes: red + raised + tender lesions — pulps of fingers/toes or thenar/hypothenar eminances
janeway lesions: red + flat + painless lesions — on palm
splinter haemorrhages: linear haemorrhage parallel to long axis of nail
DDx irregularly irregular pulse
afib
VEB ventricular ectopic beats
complete heart block + variable ventricular escape
what are the 5 stages of finger clubbing
grade 1: increased fluctuation & softening of nail bed
grade 2: increase in normal 160 degree angle between proximal nail fold & nail bed
grade 3: increased convexity of nail
grade 4: clubbed or drumstick appearance of fingertips
grade 5: shiny/glossy changes in nail & adjacent skin + longitudinal striations of nail
DDx finger clubbing
CVS
cyanotic congenital heart disease
IE
respi
lung cancer
chronic pulmonary suppuration: bronchiectasis, lung abscess, empyema
idiopathic pulmonary fibrosis
(NOT COPD)
GI
cirrhosis —- esp biliary cirrhosis
IBD
coeliac disease
what is the JVP jugular venous P (vs carotid pulse)
column of blood extending backward from right atrium
indication of central venous P — increased CVP = increased JVP
feasible but non-palpable biphasic wave
a wave = atrial systole
v wave = venous filling
found between the 2 heads of SCM — the right internal jugular V
decreases w inspiration
rises w hepatojugular reflux
height changes w angle of patient
normal JVP <3cm — taken with patient lying at 45 degrees
DDx elevated JVP
elevated
right HF
vol overload
PE
constrictive pericarditis
elevated + reduced BP
tension pneumothorax
cardiac tamponade
massive PE
severe asthma
elevated + fixed
SVC obstruction
what should you see on hepatojugular reflux for JVP
normal: JVP elevates (>4cm) for duration of compression — falls within 2 cardiac cycles after P is released
+ve hepatojugular reflux: JVP remains elevated for >2 cardiac cycles after P is released
DDx: reduced ability to take transient increase in blood vol
HF
reduced RV compliance
what is apex beat + normal position
the most inferior & lateral point where palpating fingers are raised at each systole
normal position: 5th intercostal space along mid-clavicular line
how do you grade murmurs
grade 1: v.faint — only audible to expert + optimal conditions
grade 2: faint — only audible to expert + non-optimal conditions
grade 3: moderately loud
grade 4: loud + palpable thrill
grade 5: (systolic only) v.loud + palpable thrill + audible with stethoscope partly off the chest
grade 6: (systolic only) v.loud + palpable thrill + audible without stethoscope
what murmur would you expect to hear for aortic stenosis and mitral regurgitation
aortic stenosis: ejection systolic murmur + loudest in aortic region + radiating to carotids + increases with held expiration
mitral regurgitation: pansystolic murmur + loudest in mitral region + radiating to axillary area + increases with held expiration
what are the symptoms to ask for lower limb arterial disease
intermittent claudication –> rest pain –> ulcers –> ulcers
What is Buerger’s Test
process:
ask the patient to lie onto their side
slowly perform a straight leg raise —- wait for the point where the leg goes pale (ie guttering of the veins)
that angle between the leg and the horizontal = buerger’s angle
shallower angle = more severe peripheral vascular disease
what are the signs of chronic venous insufficiency
(least serious)
oedema
venous eczema
haemosiderosis
lipodermatosclerosis
atrophie blanchie
ulceration — esp medial gaiter area
(most serious)
what is the trendelenburg/tourniquet test
process:
ask the patient to lie flat
perform a straight leg raise — put leg on my shoulder
stroke the veins towards the groin – expedite vein emptying
once empty = apply tourniquet to upper thigh
ask patient to stand
look for varicosities filling for 10-15s then release tourniquet
before releasing tourniquet
no filling of varicose V = isolated sapheno-femoral junction incompetence
slow filling of varicose V = mixed sapheno-femoral junction & perforating V incompetence
where do you located the lower limb pulses
femoral: halfway between ASIS & pubic symphysis – below the inguinal ligament
popliteal: within popliteal fossa — between heads of gastrocnemius
posterior tibial: 2cm posterior & inferior to medial malleolus
dorsalis pedis:
draw line between medial & lateral malleolus — identify mid point
draw imaginary line from this mid point to 1st interdigital cleft
palpate along this line – just lateral to tendon of extensor hallucis longus
max: 1/3 distance down the line
presentation of critical limb ischaemia
6Ps
pain
pallor
pulselessness
perishingly cold
parasthaesia
paralysis
how do you interprete ABPI ankle-brachial pressure index
> 1.3: calcified vessel (non-compressable) — usually DM
1-1.3: normal
0.5-1: intermittent claudication
0.3-0.5: rest pain or critical limb ischaemia
<3: gangrene or ulceration
compare & contrast arterial & venous ulcers
venous ulcer; arterial ulcer
Hx
V = varicose V, DVT
A = intermittent claudication, rest pain
classic sites
V = medial gaiter region
A = feet, toes, lateral malleolus (ankle)
edges
V = sloped
A = punched out
exudate
V = alot
A = little
pain
V = not severe
A = painful
oedema
V = common
A = uncommon
assoc features
V = venous eczema, haemosiderosis, lipodermatosclerosis, atrophie blanche
A = trophic changes, gangrene
Tx
V = graduated compression dressing, Abx for infection
A = endovascular revascularisation, surgical revascularisation
haemoptysis vs haematemesis vs nasopharyngeal bleeding
haemoptysis = coughing up blood (ie from respiratory tract)
haematemesis = vomiting blood (ie from GIT)
nasopharyngeal bleeding = bleeding nose
preceded by
haemoptysis = coughing
haematemesis = N&V, dry retching
contents
haemoptysis = blood + sputum — frothy
haematemesis = blood + vomitus
DDx cough
acute cough
acute bronchitis or pneumonia
epiglottitis — if child
croup — if child
chronic cough – >2 months
PIBHR post-infectious bronchial hyperreactivity
asthma
GERD
chronic rhinosinusitis
COPD
productive cough
sputum
chronic bronchitis
bronchiectasis
haemoptysis
PE
lung ca
bronchiectasis
left HF or other causes of pulmonary oedema
vasculitic causes
DDx asterixis aka flapping tremor
CO2 retention — usually sec to severe COPD
hepatic encephalopathy
hepatic encephalopathy
uraemic encephalopathy
drug encephalopathy — anticonvulsants, barbiturates
cardiac encephalopathy
DDx trachea displacement
towards side of lesion
upper lobe collapse
upper lobe cirrhosis
pneumonectomy
consolidation
away from side of lesion
pleural effusion
tension pneumothorax
what is trachea tug
when the trachea seemingly moves inferiorly with each inspiration
due to airflow obstruction — causing gross overexpansion of chest
usually sec to COPD
what is fremitus + DDx of increased/decreased fremitus
vocal fremitus = vibrations created by the vocal cords
tactile fremitus = when those vibrations transmit to the chest wall
DDx
increased fremitus — air in lungs replaced by liquid or solids
lung consolidation
haemothorax
empyema
cells
decreased fremitus
increased air in lungs = pneumothorax
wall between lungs & chest wall = pleural effusion
increased thickness of chest wall = obesity
what is Hoover’s sign
indrawing of the lower ribs rather then expansion during inspiration
due to an overinflated chest that cant expand laterally – ie COPD
DDx bibasal crepitations
fine:
pulmonary oedema
interstitial lung disease
coarse:
bronchiectasis
cystic fibrosis
bibasal pneumonia
DDx pleural effusion
transudate (protein <30 g/L)
LV failure
vol overload
hypoalbuminaemia
Meig’s syndrome
exudate (protein >30 g/L)
infection: pneumonia, TB
infarction: PE
inflammation: RA, SLE
malignancy: bronchogenic, mesothelioma
drugs that can cause cholestasis
flucloxacillin
co-amoxiclav
nitrofurantoin
steroids
sulphonylureas
what is GCS
it stands for glasgow coma scale
it is a scale to describe the extend of impaired consciousness
criteria —- 1 point each
eye opening — max 4
spontaneous = 4
to sound = 3
to pain = 2
none = 1
verbal response — max 5
orientated = 5
confused = 4
words only = 3
sounds only = 2
none = 1
motor response — max 6
obeys commands = 6
localising = 5
normal flexion = 4
abnormal flexion = 3
extension = 2
none = 1
interpretation
severe: 3-8
moderate: 9-12
mild/normal: 13-15
what are the 8 groups of neck LNs lymph nodes
submental
submandibular
pre-auricular
anterior cervical chain
supraclavicular
posterior cervical chain
post-auricular
occipital
where is the virchow’s LN lymph node
it is the left supraclavicular group
normal liver span + normal upper border of liver
normal liver span on physical exam: 12-15cm
normal liver span on MRI
female = 7-10cm
male = 8-12cm
is suspect splenomegaly — what additional actions can be done to rule it out
normal splenomegaly check: palpate from RIF to LUQ
2nd step: put left hand around the LUQ to push the spleen — then do the same
3rd step: ask patient to tilt to their right — then do the same
what are the complications of stomas
parastomal hernia: incisional hernia
stoma stenosis: narrowing or constriction of the stoma or its lumen
stoma necrosis
stoma retraction: stoma recedes at least 0.5cm below the skin surface
high output stoma: stoma output >1.5-2L over the last 24 hrs
what are the possible reasons for a loop/end ileostomy/colostomy/urostomy
loop ileostomy — for defunctioning of the distal bowel
obstruction – eg. malignancy
anus — eg. IBD
newly form bowel anastomosis
end ileostomy = total colectomy
loop colostomy = distal obstructing colorectal tumour
end colostomy
abdomino-perineal resection
hartmann’s procedure w rectum oversewn
urostomy = post-cystectomy
how do you differentiate inguinal & femoral hernia
inguinal = medial to pubic tubercle
femoral = lateral to pubic tubercle + below inguinal ligament
difference between direct vs indirect inguinal hernia
direct inguinal hernia: herniates through muscular defect of inguinal canal — Hasselbach’s triangle
indirect: herniates through internal ring of inguinal canal
(more common)
difficult to differentiate clinically
what are the signs of chronic liver disease
general inspection:
jaundice
hands
leuconychia – sec to hypoalbuminaemia
finger clubbing — sec to cirrhosis
palmar erythema
asterixis — if hepatic encephalopathy
skin
ecchymosis
spider naevi
chest
gynaecomastia
abdomen
hepatosplenomegaly
ascites
DDx guarding vs rigidity vs rebound tenderness
guarding: resistance to palpation due to contraction of abdominal muscles
(ie can overcome w reassurance + gentleness)
rigidity: constant involuntary reflex contraction of abdominal walls
indication: peritoneal irritation or inflammation
rebound tenderness: palpate the abdomen — pain on rapid release of hand
indication: peritonitis
DDx hepatomegaly
infective: viral hepatitis, EBV, CMV, HIV, malaria, abscess
genetic: haemochromatosis, wilson’s disease, alpha-1 antitrypsin deficiency
infiltrative: sarcoidosis, amyloidosis
hepatic: alcoholic liver disease w fatty infiltration, fatty liver
biliary: PBC, PSC
cancer
congestion: RV failure, tricuspid regurg, budd chiari syndrome
haematological: myeloproliferative disease, chronic leukaemia, lymphoma, haemolytic anaemia
DDx large left kidney vs splenomegaly
(left kidney; splenomegaly)
palpable upper border (ie can get above)
K: yes
S: no
palpable anterior notch
K: no
S: yes
movement on inspiration
K: inferiorly
S: infero-medially
on percussion
K: resonant – due to dilated loops of bowel anterior to it
S: dull
ballotable
K: yes – since retroperitoneal
S: no — unless gross ascites present
what is Courvoisier’s law
enlarged gallbladder + jaundice = cancer of pancreas or obstruction to biliary tree»_space; gallstones
what is Murphy’s sign
place hand on RUQ
ask patient to take deep breath in
when the inflamed GB presses on your hand – patient would catch his breath
indicates cholecystitis
DDx ascites
transudative (protein <30 g/L)
CLD (75%)
right HF
vol overload
hypoalbuminaemia
constrictive pericarditis
exudative (protein >30 g/L)
infection: SBP, TB
inflammation: pancreatiits
malignancy
how do you examine an AV fistula
inspect
surrounding skin
location
wrist = radiocephalic
antecubital fossa = brachiocephalic or brachiobasilic fistula
palpate: thrill
auscultate: bruit
