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Medicine > Hx & Exam > Flashcards

Hx & Exam Flashcards

1
Q

syncope vs pre-syncope vs dizziness

A

syncope = transient LOC due to transient cerebral hypoxia

pre-syncope = transient sensation of weakness w/o LOC

dizziness = world spinning feeling

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2
Q

what is a collapsing pulse aka corrigan’s pulse or water hammer pulse

A

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

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3
Q

DDx chest pain

A

cardiovascular:
ACS
dissecting aneurysm
pericarditis

respi – pleuritic pain
pneumothorax
PE
lung ca

GI
GERD
diffuse oesophageal spasm

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4
Q

what is claudication + DDx

A

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)

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5
Q

what is levine’s sign

A

when a patient hunches forward and places a clenched fist over his chest

indicates cardiac ischaemia

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6
Q

causes of cyanosis

A

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

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7
Q

what are the stigmata of IE infective endocarditis

A

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

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8
Q

DDx irregularly irregular pulse

A

afib
VEB ventricular ectopic beats
complete heart block + variable ventricular escape

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9
Q

what are the 5 stages of finger clubbing

A

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

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10
Q

DDx finger clubbing

A

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

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11
Q

what is the JVP jugular venous P (vs carotid pulse)

A

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

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12
Q

DDx elevated JVP

A

elevated
right HF
vol overload
PE
constrictive pericarditis

elevated + reduced BP
tension pneumothorax
cardiac tamponade
massive PE
severe asthma

elevated + fixed
SVC obstruction

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13
Q

what should you see on hepatojugular reflux for JVP

A

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

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14
Q

what is apex beat + normal position

A

the most inferior & lateral point where palpating fingers are raised at each systole

normal position: 5th intercostal space along mid-clavicular line

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15
Q

how do you grade murmurs

A

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

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16
Q

what murmur would you expect to hear for aortic stenosis and mitral regurgitation

A

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

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17
Q

what are the symptoms to ask for lower limb arterial disease

A

intermittent claudication –> rest pain –> ulcers –> ulcers

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18
Q

What is Buerger’s Test

A

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

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19
Q

what are the signs of chronic venous insufficiency

A

(least serious)
oedema
venous eczema
haemosiderosis
lipodermatosclerosis
atrophie blanchie
ulceration — esp medial gaiter area
(most serious)

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20
Q

what is the trendelenburg/tourniquet test

A

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

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21
Q

where do you located the lower limb pulses

A

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

22
Q

presentation of critical limb ischaemia

A

6Ps
pain
pallor
pulselessness
perishingly cold
parasthaesia
paralysis

23
Q

how do you interprete ABPI ankle-brachial pressure index

A

> 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

24
Q

compare & contrast arterial & venous ulcers

A

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

25
Q

haemoptysis vs haematemesis vs nasopharyngeal bleeding

A

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

26
Q

DDx cough

A

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

27
Q

DDx asterixis aka flapping tremor

A

CO2 retention — usually sec to severe COPD
hepatic encephalopathy
hepatic encephalopathy
uraemic encephalopathy
drug encephalopathy — anticonvulsants, barbiturates
cardiac encephalopathy

28
Q

DDx trachea displacement

A

towards side of lesion
upper lobe collapse
upper lobe cirrhosis
pneumonectomy
consolidation

away from side of lesion
pleural effusion
tension pneumothorax

29
Q

what is trachea tug

A

when the trachea seemingly moves inferiorly with each inspiration

due to airflow obstruction — causing gross overexpansion of chest
usually sec to COPD

30
Q

what is fremitus + DDx of increased/decreased fremitus

A

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

31
Q

what is Hoover’s sign

A

indrawing of the lower ribs rather then expansion during inspiration

due to an overinflated chest that cant expand laterally – ie COPD

32
Q

DDx bibasal crepitations

A

fine:
pulmonary oedema
interstitial lung disease

coarse:
bronchiectasis
cystic fibrosis
bibasal pneumonia

33
Q

DDx pleural effusion

A

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

34
Q

drugs that can cause cholestasis

A

flucloxacillin
co-amoxiclav
nitrofurantoin
steroids
sulphonylureas

35
Q

what is GCS

A

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

36
Q

what are the 8 groups of neck LNs lymph nodes

A

submental
submandibular
pre-auricular
anterior cervical chain
supraclavicular
posterior cervical chain
post-auricular
occipital

37
Q

where is the virchow’s LN lymph node

A

it is the left supraclavicular group

38
Q

normal liver span + normal upper border of liver

A

normal liver span on physical exam: 12-15cm
normal liver span on MRI
female = 7-10cm
male = 8-12cm

39
Q

is suspect splenomegaly — what additional actions can be done to rule it out

A

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

40
Q

what are the complications of stomas

A

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

41
Q

what are the possible reasons for a loop/end ileostomy/colostomy/urostomy

A

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

42
Q

how do you differentiate inguinal & femoral hernia

A

inguinal = medial to pubic tubercle
femoral = lateral to pubic tubercle + below inguinal ligament

43
Q

difference between direct vs indirect inguinal hernia

A

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

44
Q

what are the signs of chronic liver disease

A

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

45
Q

DDx guarding vs rigidity vs rebound tenderness

A

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

46
Q

DDx hepatomegaly

A

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

47
Q

DDx large left kidney vs splenomegaly

A

(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

48
Q

what is Courvoisier’s law

A

enlarged gallbladder + jaundice = cancer of pancreas or obstruction to biliary tree&raquo_space; gallstones

49
Q

what is Murphy’s sign

A

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

50
Q

DDx ascites

A

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

51
Q

how do you examine an AV fistula

A

inspect
surrounding skin
location
wrist = radiocephalic
antecubital fossa = brachiocephalic or brachiobasilic fistula

palpate: thrill

auscultate: bruit

Medicine (18 decks)

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