Long case Flashcards
What are the differential diagnoses for massive hepatomegaly?
Myelofibrosis
Myelodysplasia
Liver metastases
Hepatocellular carcinoma
Chronic liver disease with fatty infiltration or hepatoma
Tricuspid regurgitation (pulsatile hepatomegaly)
What size defines moderate hepatomegaly and massive hepatomegaly?
Normal liver: 11-14 cm
Moderate hepatomegaly: 15-20 cm
Massive hepatomegaly: >20cm
What are the differential diagnoses for moderate hepatomegaly?
As for massive hepatomegaly. Plus: Haemochromatosis Myelodysplasia CML Lymphoma NAFLD
What are the differential diagnoses of mild hepatomegaly?
Any/all of the causes of moderate or massive hepatomegaly
What are the differential diagnoses for marked splenomegaly?
Myelofibrosis
CML
Myelodysplasia
What are the differential diagnoses for moderate splenomegaly?
Lymphoma
CLL
PRV
Portal hypertension (with CLD, liver may be small due to cirrhosis)
What are the differential diagnoses for mild splenomegaly?
PRV, ET Haemolytic anaemia ITP Sarcoid, amyloid Portal hypertension, with signs of CLD
What are the possible causes of hepatomegaly in CLD?
Chronic liver disease with portal hypertension is a possible differential, however the liver would be shrunken with cirrhosis
Hepatomegaly in chronic liver disease suggests:
- Fatty liver (NAFLD or EtOH related)
- Hepatitis
- Haemochromatosis
- Hepatocellular carcinoma or infiltration
- Infiltrative disorders include: lymphoma, amyloid, connective tissue disorders
What are infiltrative disorders that may affect the liver, causing hepatomegaly?
Amyloid
Sarcoid
Connective tissue disorders
What are the differential diagnoses for massive hepatomegaly and marked splenomegaly?
Myelofibrosis
Myelodysplasia (CML, CMML)
What are the differentials for moderate splenomegaly and moderate hepatomegaly?
Same as for massive (myelofibrosis, CML, CMML)
with the addition of:
CLL
Lymphoma
What are the findings in a patient with portal hypertension?
Ascites Bleeding/varices/purpura/thrombocytopaenia Caput medusae Diminished liver Enlarged spleen
What are the indicators of decompensated cirrhosis in a patient with chronic liver disease?
Albumin Bilirubin Coagulopathy/Thrombocytopaenia Distension (abdo) ie ascites Encephalopathy Flap
Recent variceal bleeding
What features differentiate the spleen from a left renal mass?
- Spleen: moves down and medially with respiration. Renal mass: moves down but NOT medially with respiration.
- Spleen: has a notch on its upper border. (Splenic size needs to be at least moderate for the notch to be appreciated).
- Spleen: is not ballotable. Renal mass is ballotable.
- Enlarged spleen: Cannot palpate above the spleen.
- Splenomegaly will cause dullness in traube’s space.
What are the margins of Traube’s space?
Superior: Left sixth rib
Lateral: Left mid axillary line
Inferior: Left costal margin
Name three abdominal findings that would be expected in a patient with PCKD?
Abdominal distension
Fullness of both loins
Palpable ballotable masses
What are some of the hand and upper limb findings that should be considered as part of the abdominal examination?
- Blood pressure
- AFib - may suggest EtOH aetiology of chronic liver disease
- Pallor of palmar creases or palmar erythema
- Finger clubbing - may be present in any of the CLD aetiologies, however the strongest association is with liver disease secondary to inflammatory bowel disease
- Leukonychia
- Dupuytren’s contracture (in the presence of CLD is in keeping with EtOH related aetiology).
- Urochrome staining of the fingers - seen in patients with advanced kidney disease
- AV fistulaeand/or inactive permacath
- Flap/asterixis
- Tremor (Calcineurin use in renal tx patients)
- Transplant scars
- Cushingoid features
Name some head and neck findings that may be relevant to the abdominal examination
Pallor and jaundice
Spider naevi
Lymphadenopathy, (suggestive of an underlying haematological condition)
JVP examination (TR as cause of hepatomegaly, assessment of volume status)
Parotidmegaly (in the presence of CLD is in keeping with alcohol related aetiology)
Name some chest findings that may be relevant to the abdominal examination
Gynaecomastia - secondary to chronic liver disease
or secondary to the use of spironolactone in patients with chronic liver disease
Spider naevi
Systolic murmurs - adjectives
Pan, Ejection (harsh, musical), Midsystolic
Diastolic murmurs - adjectives
Early decrescendo, mid-diastolic/rumbling
Heart murmur description
- Systolic or diastolic
- Where is it loudest, and where does it radiate?
- How loud is it? How long is it? Where is the peak?
- How does the murmur change with respiration?
- Are additional manoeuvres required? (Valsalva, hand grip)
- How many murmurs?
- Does S1, S2, additional HS fit with diagnosis/severity?
Indications for valsalva manouvre
If you suspect HCM (Ej SM at LLSE not radiating)
What is Gallavardin’s phenomenon?
The Gallavardin phenomenon is a clinical sign found in patients with aortic stenosis. It is described as the dissociation between the noisy and musical components of the systolic murmur heard in aortic stenosis. The harsh noisy component is best heard at the upper right sternal border radiating to the neck due to the high velocity jet in the ascending aorta. The musical high frequency component is best heard at the cardiac apex.[1]
Which murmurs are systolic?
Pansystolic (mitral or tricuspid regurgitation)
Ejection systolic (aortic stenosis or HOCM, maybe harsh, musical)
Midsystolic (mitral valve prolapse).
Which murmurs are diastolic?
Early decrescendo (aortic or pulmonary regurgitation) Mid-diastolic/rumbling (mitral stenosis with possible pre-systolic accentuation if in sinus rhythm).
Aortic stenosis: features on examination that indicate at least moderate severity? (6)
- Carotid pulse: Small volume, slow rising, plateau carotid pulse.
- Aortic thrill.
- Murmur:
- Long late peaking ejection systolic murmur.
- A loud murmur (grade 4 or greater) has a high specificity for severe AS
(However, most patients with severe stenosis have a grade 3 murmur, and many have only a grade 1 or 2 murmur). - The presence of an S4, indicating reduced compliance of the left ventricle.
- Paradoxical splitting of S2.
- Left ventricular failure
