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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
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
26
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
27
DDx asterixis aka flapping tremor
CO2 retention --- usually sec to severe COPD hepatic encephalopathy hepatic encephalopathy uraemic encephalopathy drug encephalopathy --- anticonvulsants, barbiturates cardiac encephalopathy
28
DDx trachea displacement
towards side of lesion upper lobe collapse upper lobe cirrhosis pneumonectomy consolidation away from side of lesion pleural effusion tension pneumothorax
29
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
30
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
31
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
32
DDx bibasal crepitations
fine: pulmonary oedema interstitial lung disease coarse: bronchiectasis cystic fibrosis bibasal pneumonia
33
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
34
drugs that can cause cholestasis
flucloxacillin co-amoxiclav nitrofurantoin steroids sulphonylureas
35
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
36
what are the 8 groups of neck LNs lymph nodes
submental submandibular pre-auricular anterior cervical chain supraclavicular posterior cervical chain post-auricular occipital
37
where is the virchow's LN lymph node
it is the left supraclavicular group
38
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
39
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
40
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
41
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
42
how do you differentiate inguinal & femoral hernia
inguinal = medial to pubic tubercle femoral = lateral to pubic tubercle + below inguinal ligament
43
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
44
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
45
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
46
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
47
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
48
what is Courvoisier's law
enlarged gallbladder + jaundice = cancer of pancreas or obstruction to biliary tree >> gallstones
49
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
50
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
51
how do you examine an AV fistula
inspect surrounding skin location wrist = radiocephalic antecubital fossa = brachiocephalic or brachiobasilic fistula palpate: thrill auscultate: bruit

Medicine (18 decks)

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