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1
Q

Features of aortic coarctation

A
  • Radio-radio delay
  • Radio-femoral delay
  • Differing blood pressures in each limb
  • Ejection systolic murmur at L sternal border
  • Weak femoral pulse
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2
Q

On examination you find:

  • Radio-radio delay
  • Radio-femoral delay
  • Differing blood pressures in each limb
  • Ejection systolic murmur at L sternal border
  • Weak femoral pulse

What is your differential?

A

Aortic coarctation

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3
Q

Investigations and findings for aortic coarctation

A

ECG:
- Normal or RVH or LVH

CXR:

  • Normal
  • Posterior rib notching
  • 3 sign
  • Cardiomegaly

Echo:
- Narrowing in aorta

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4
Q

Aortic coarctation is associated with …

A
  • Genetic syndromes e.g. Turners

- Bicuspid aortic valve

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5
Q

Features of aortic regurgitation

A
  • Quincke’s sign (capillary nail bed pulsations)
  • Collapsing pulse
  • Bounding pulse
  • Wide pulse pressure
  • De Musset’s sign (head bobs with pulse)
  • Diastolic ‘blowing’ murmur
  • Laterally displaced apex beat
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6
Q

On examination you find…

  • Quincke’s sign (capillary nail bed pulsations)
  • Collapsing pulse
  • Bounding pulse
  • Wide pulse pressure
  • De Musset’s sign (head bobs with pulse)
  • Diastolic ‘blowing’ murmur
  • Laterally displaced apex beat

Differential?

A

Aortic regurgitation

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7
Q

Investigations and findings for aortic regurgitation

A

ECG:

  • ST-T changes
  • LVH and LAD
  • conduction abnormalities

CXR:
- Normal or cardiomegaly

Echo:
- regurgitation

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8
Q

Features of aortic stenosis

A
  • Slow rising pulse
  • Narrow pulse pressure
  • Ejection systolic murmur, radiating to carotids
  • Heaving apex beat
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9
Q

On examination you find:

  • Slow rising pulse
  • Narrow pulse pressure
  • Ejection systolic murmur, radiating to carotids
  • Heaving apex beat

Differential?

A

Aortic stenosis

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10
Q

Differentials for ejection systolic murmur

A
  • Aortic stenosis
  • Aortic sclerosis
  • Coarctation of the aorta
  • HOCM
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11
Q

Differentials for pansystolic murmur

A
  • Mitral regurgitation
  • Ventricular septal defect
  • Tricuspid regurgitation
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12
Q

Investigations and findings for aortic stenosis

A

ECG:
- LVH

CXR:
- Calcification of aortic valve +/- pulmonary oedema, cardiomegaly

Echo:
- Aortic stenosis

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13
Q

Causes of aortic stenosis

A
  • Calcification (elderly)

- Bicuspid valve (young)

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14
Q

Complications of aortic stenosis

A
  • Infective endocarditis
  • Embolic disease
  • Haemolytic anaemia
  • LV failure
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15
Q

Differentials for an irregular pulse

A
  • AF
  • Atrial flutter
  • Ventricular ectopics (disappear on exercise)
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16
Q

Causes of AF

A
  • Heart disease
  • Diabetes
  • Thyroid disease
  • Alcohol abuse
  • Smoking
  • Certain cancers
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17
Q

Features of heart failure

A
  • Shortness of breath
  • Orthopnoea
  • Peripheral cyanosis/pallor
  • Delayed cap refill time
  • Narrow pulse pressure
  • Raised JVP +/- hepatojugular reflux
  • Neck vein distention
  • Displaced apex beat
  • S3 gallop rhythm
  • Bibasal fine crackles
  • Sacral and peripheral oedema
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18
Q

On examination you find…

  • Shortness of breath
  • Orthopnoea
  • Peripheral cyanosis/pallor
  • Delayed cap refill time
  • Narrow pulse pressure
  • Raised JVP +/- hepatojugular reflux
  • Neck vein distention
  • Displaced apex beat
  • S3 gallop rhythm
  • Bibasal fine crackles
  • Sacral and peripheral oedema

Differential?

A
  • Heart failure
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19
Q

Features of hyperlipidaemia

A
  • Xanthomata
  • Corneal arcus
  • Xanthelasma
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20
Q

Causes/risk factors for hyperlipiademia

A
  • Lifestyle factors e.g. diet
  • Kidney disease
  • Diabetes
  • PCOS
  • Pregnancy
  • Hypothyroidism
  • Familial hypercholesterolaemia
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21
Q

Features of infective endocarditis

A
  • Fever
  • Finger clubbing
  • Splint haemorrhages
  • Janeway lesions
  • Osler’s nodes
  • Poor dental hygiene
  • New murmur
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22
Q

On examination you find:

  • Fever
  • Finger clubbing
  • Splint haemorrhages
  • Janeway lesions
  • Osler’s nodes
  • Poor dental hygiene
  • New murmur

Differential?

A

Infective endocarditis

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23
Q

Features of mitral regurgitation

A
  • Associated AF
  • Pansystolic ‘blowing’ murmur at apex, radiates to axilla
  • Thrusting, displaced apex beat
  • Pitting oedema
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24
Q

On examination you find…

  • Associated AF
  • Pansystolic ‘blowing’ murmur at apex, radiates to axilla
  • Thrusting, displaced apex beat
  • Pitting oedema

Differential?

A

Mitral regurgitation

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25
Causes of mitral regurgitation
- IE - Post-MI - Ischaemic injury to left ventricle - Rheumatic heart disease
26
Features of mitral stenosis
- Malar flush - Neck vein distention - Diastolic 'low pitched rumbling' murmur at apex - Opening 'snap' - Tapping apex
27
On examination you find: - Malar flush - Neck vein distention - Diastolic 'low pitched rumbling' murmur at apex - Opening 'snap' - Tapping apex Differential?
Mitral stenosis
28
Features of tricuspid regurgitation
- Raised JVP with prominent V wave - Parasternal pansystolic murmur over LLSE, no radiation - Carvallo's sign (increased murmur on inspiration) - Pulsatile hepatomegaly - Peripheral oedema
29
On examination you find: - Raised JVP with prominent V wave - Parasternal pansystolic murmur over LLSE, no radiation - Carvallo's sign (increased murmur on inspiration) - Pulsatile hepatomegaly - Peripheral oedema Differential?
Tricuspid regurgitation
30
Factors to consider when deciding on valve replacement
- Patient preference - Symptom burden - Any decompensation e.g. heart failure - Severity of valve dysfunction on ECHO
31
Complications of prosthetic valve replacement
- Paravalvular leak - Obstruction (thrombus) - Subacute bacterial IE - Haemolysis (due to turbulence) - Valve failure
32
Pros and cons to mechanical heart valves
- Longer lifespan | - Requires anticoagulation
33
Pros and cons to biological heart valves
- Does not require anticoagulation - Preferred in women of child-bearing age - Less durable, shorter life span
34
Causes of left sided heart failure
- IHD | - Mitral or aortic valve disease
35
Causes of right-sided heart failure
- Left sided heart failure - Tricuspid or pulmonary valve disease - Cor pulmonale e.g. COPD, fibrosis, PE, OSA
36
Causes of finger clubbing
General: - Malignancy - Grave's disease Cardiac: - IE Respiratory: - CF - Bronchiectasis - Interstitial lung disease - Lung cancer GI: - IBD - Liver cirrhosis - Lymphoma - Coeliac disease
37
Features of asthma on examination
ACUTE FLARE: - Use of accessory muscles - Intercostal recession - difficulty speaking - tachycardia - tachypnoea - reduced chest expansion - hyper-resonant percussion - reduced air entry - prolonged expiration - widespread polyphonic wheeze CHRONIC DISEASE: - examination may be normal
38
On examination you find: - Use of accessory muscles - Intercostal recession - difficulty speaking - tachycardia - tachypnoea - reduced chest expansion - hyper-resonant percussion - reduced air entry - prolonged expiration - widespread polyphonic wheeze Differential?
Acute asthma
39
Investigations to consider in asthma
- Spirometry - PEF - ABG - Sputum culture - CXR
40
Management of asthma
- SABA PRN - ICS BD - switch to combi ICS LABA - LTRA
41
Features of COPD on examination
- Hyper-inflated chest - Use of accessory muscles - Agitation - Drowsiness - Tachypnoea - Tachycardia - Central cyanosis - Pursed lip breathing - Raised JVP - Tracheal tug - Reduced cricosternal distance - Decreased breath sounds - Decreased chest expansion - Wheeze on expiration - Inspiratory crackles
42
On examination you find: - Hyper-inflated chest - Use of accessory muscles - Agitation - Drowsiness - Tachypnoea - Tachycardia - Central cyanosis - Pursed lip breathing - Raised JVP - Tracheal tug - Reduced cricosternal distance - Decreased breath sounds - Decreased chest expansion - Wheeze on expiration - Inspiratory crackles Differential?
COPD
43
Investigations for COPD
- Sputum culture - CXR - Spirometry (obstructive pattern) - ABG
44
Management of COPD
- Smoking cessation - Pulmonary rehab - Immunisations - SABA/SAMA PRN - If asthmatic features: Add LABA and ICS - No asthmatic features: Add LABA and LAMA
45
Features of bronchiectasis on examination
- Productive cough - Finger clubbing - Coarse crackles which change on coughing
46
On examination you find: - Productive cough - Finger clubbing - Coarse crackles which change on coughing Differential?
Bronchiectasis
47
Investigations for bronchiectasis
- Sputum culture - CXR - CT thorax: signet ring - Spirometry: obstructive
48
Management of bronchiectasis
- Pulmonary rehab - Immunisations - Bronchodilators +/- ICS - Long term azithromycin - Mucolytics - Surgery
49
Features of pneumonia on examination
- Confusion - Pyrexia - Accessory muscle use - Tachypnoea - Hypotension - Central cyanosis - Productive cough - Pleuritic chest pain - Dull percussion - Reduced breath sounds - Coarse crackles - Bronchial breathing - Pleural rub
50
On examination you find: - Confusion - Pyrexia - Accessory muscle use - Tachypnoea - Hypotension - Central cyanosis - Productive cough - Pleuritic chest pain - Dull percussion - Reduced breath sounds - Coarse crackles - Bronchial breathing - Pleural rub Differential?
Pneumonia
51
Components of CURB65 score
- Confusion - Urea >7 - RR >30 - BP <90/60 - Age >65
52
Investigations for pneumonia
- ABG - Sputum culture - CXR
53
Management of pneumonia
- CURB 0-1: 10 days PO amoxicillin OR doxycycline - CURB 2:10 days PO amoxicillin OR clarithromycin - Curb >3: 10 days co-amoxiclav + clarithromycin
54
Most common causative agents of pneumonia
- Adults: strep pneumoniae | - Elderly/associated lung disease: H. Influenzae
55
Features of pleural effusion on examination
- Dyspnoea - Signs of associated causative disease - Tracheal and mediastinal shift - Reduced chest expansion - Stony dull percussion - Diminished breath sounds - Decreased vocal resonance - Bronchial breathing
56
On examination you find: - Dyspnoea - Signs of associated causative disease - Tracheal and mediastinal shift - Reduced chest expansion - Stony dull percussion - Diminished breath sounds - Decreased vocal resonance - Bronchial breathing Differential?
Pleural effusion
57
Investigations for pleural effusion
- Pleuritic aspiration for biochemistry and culture: - Protein >30: exudate e.g. infection, cancer, inflammation - Protein <35: transudate e.g. fluid overload, organ failure - Empyema: low glucose, low pH - CXR
58
Management of pleural effusion
- Small: diuretics - Moderate: aspiration - Large: chest drain - Recurrent: pleurodesis
59
Features of pneumothorax on examination
- Tall, skinny males - Hyperinflation - Tachycardia - Dyspnoea - Reduced chest expansion - Hyper-resonant percussion - Decreased/absent breath sounds - Decreased vocal resonance - Subcutaneous emphysema
60
On examination you find: - Tall, skinny males - Hyperinflation - Tachycardia - Dyspnoea - Reduced chest expansion - Hyper-resonant percussion - Decreased/absent breath sounds - Decreased vocal resonance - Subcutaneous emphysema Differential?
Pneumothorax
61
Investigations for pneumothorax
- CXR
62
Management of pneumothorax
Depending on size and if it is primary/secondary: - Watch and wait with outpatient review - Aspiration - Chest drain insertion
63
Features of TB on examination
- Pyrexia/night sweats - Evidence of weight loss - Hoarse voice - Cough - Sputum - Tachycardia - Displaced trachea - Enlarged lymph nodes - Decreased chest expansion - Decreased breath sounds - Bronchial breathing - Extra-pulmonary signs
64
On examination you find: - Pyrexia/night sweats - Evidence of weight loss - Hoarse voice - Cough - Sputum - Tachycardia - Displaced trachea - Enlarged lymph nodes - Decreased chest expansion - Decreased breath sounds - Bronchial breathing - Extra-pulmonary signs Differential?
TB
65
Investigations for TB
- CXR | - Sputum culture, including acid fast bacilli (3 cultures including 1 early morning sample)
66
Management of TB
2 months: - Rifampicin - Isoniazid - Pyrazinamide - Ethambutol Further 4 months: - Rifampicin - Isoniazid
67
Examination findings for interstitial lung disease
- Laboured breathing - Dyspnoea - Dry cough - Finger clubbing - Central cyanosis - Reduced chest expansion - Dull percussion - Fine inspiratory bibasal crackles - Oedema
68
On examination you find: - Laboured breathing - Dyspnoea - Dry cough - Finger clubbing - Central cyanosis - Reduced chest expansion - Dull percussion - Fine inspiratory bibasal crackles - Oedema Differential?
Interstitial lung disease
69
Causes of interstitial lung disease
- Idiopathic pulmonary fibrosis - Drug-induced e.g. methotrexate, amiodarone - Associated with systemic disease e.g. sarcoid, connective tissue disease, ankylosing spondylitis, RA, SLE - Associated with occupational hazards e.g. asbestosis, pigeon fanciers, silicosis, coal workers
70
Investigations for ILD
- Spirometry: restrictive - CXR: reticular opacities - HRCT: honeycomb lung - Bronchiolar lavage Investigation of causes: - Urine dipstick: haematuria and proteinuria in vasculitis - Antibodies e.g. Anti-CCP, ANA
71
Management of ILD
- Avoid triggers - Smoking cessation - Pulmonary rehab - Consider anti-fibrotics e.g. nintedanib or pirfenidone - Consider LTOT - Consider corticosteroids
72
Examination features of PE
- Pyrexia - Tachycardia - Hypotension - Tachypnoea - Central cyanosis - Raised JVP - Potential causes e.g. scars from previous surgery (Examination may be normal)
73
On examination you find: - Pyrexia - Tachycardia - Hypotension - Tachypnoea - Central cyanosis - Raised JVP - Potential causes e.g. scars from previous surgery (Examination may be normal) Differential?
PE
74
Investigation of PE
- Well's score - D-dimer - CTPA
75
Management of PE
- Apixaban PO for 3 months
76
Features of lung cancer on examination
- Cachexia - Pallor - Koilonychia - Finger clubbing - Tar staining - Reduced chest expansion - Pleural effusion - Hepatomegaly - Endocrinology signs Examination may be normal
77
On examination you find: - Cachexia - Pallor - Koilonychia - Finger clubbing - Tar staining - Reduced chest expansion - Pleural effusion - Hepatomegaly - Endocrinology signs Examination may be normal Differential?
Lung cancer
78
Investigations for lung cancer
- Bloods including Ca - CXR - CT CAP - Bronchoscopy and biopsy - PET-CT
79
Indications for lobectomy
- Malignancy - COPD - Chronic lung disease - TB - Bronchiectasis
80
On examination you find: - Normal tone - Moderately reduced power in proximal upper limbs - Normal reflexes - Normal sensation - Normal coordination Differentials?
Proximal myopathy: - Dermatomyositis/polymyositis - Muscular dystrophy e.g. DMD, Becker's muscular dystrophy - Cushing's - Glycogen storage disorders - Mitochondrial disorders - Thyroid disease - Acromegaly - Drugs e.g. statins
81
Features of proximal myopathy on examination
- Normal tone - Moderately reduced power in proximal upper limbs - Normal reflexes - Normal sensation - Normal coordination
82
Investigations for proximal myopathy
- Lower limb neuro exam - TFTs - Antibodies (Anti-M2, Anti-Jo) - CK - Muscle biopsy
83
Features of myotonic dystrophy on examination
- Ptosis | - Distal limb weakness
84
On examination you find: - Ptosis - Distal limb weakness Differential?
Myotonic dystrophy
85
Investigations for myotonic dystrophy
- EMG: myotonia | - Genetic testing: mutations in CNBP and DMPK
86
Features of myasthenia gravis on examination
- Female - Middle-age - Unilateral ptosis - Normal cranial nerve examination
87
On examination you find: - Female - Middle-age - Unilateral ptosis - Normal cranial nerve examination Differential?
Myasthenia Gravis
88
Investigations for myasthenia gravis
- Ice pack test (ptosis should improve) - Antibodies: Anti-AchR and Anti-MuSK - CT chest: associated with thymoma - EMG: decreased amplitude with repetitive stimulation - Consider screening for autoimmune disease
89
Features of hemiplegia on examination
- Unilateral facial droop - Ipsilateral flexed upper limb - Increased tone, clonus, reduced power, hyperreflexia in ipsilateral leg - Contralateral leg normal
90
UMN lesion signs
Lesion in brain, brainstem or spinal cord: - Hypertonia: rigidity and spasticity - Pronator drift - Ankle clonus - Hyperreflexia - Positive Babinskis sign - Weakness - usually affects arm flexors and leg extensors - Decreased sensation - Abonormal gait - Coordination reduced in cerebellar lesions
91
On examination you find: - Unilateral facial droop - Ipsilateral flexed upper limb - Increased tone, clonus, reduced power, hyperreflexia in ipsilateral leg - Contralateral leg normal Differentials?
Hemiplegia: - Ischaemic stroke or TIA - Haemorrhagic stroke - Space occupying lesion - Demyelinating process e.g. MS
92
Investigations in hemiplegia
- Complete neuro exam - CT head - MRI brain/spine
93
Examination findings in peripheral neuropathy
- Sensory loss in hands - Reduced power on distal leg movements - Sensory loss from feet to knees - Normal tone, reflexes and coordination in legs
94
On examination you find: - Sensory loss in hands - Reduced power on distal leg movements - Sensory loss from feet to knees - Normal tone, reflexes and coordination in legs Differential?
Peripheral neuropathy
95
Causes of peripheral neuropathy
Mostly sensory (ABCDE): - Alcohol and diabetes (most common) - B12/folate deficiency - Chronic renal failure - Cancer (paraneoplastic syndrome) - Drugs e.g. isoniazid - Diabetes - Everything else e.g. vasculitides (SLE) Mostly motor: - Charcot-Marie-Tooth (hereditary sensory and motor neuropathy) - Guillain-Barre syndrome - Chronic inflammatory demyelinating polyneuropathy e.g. MS
96
Examination findings for MS
- Young adult females - Lhermitte's sign - Urthoff's phenomenon - Autonomic signs e.g. urinary incontinence - Internuclear ophthalmoplegia - Optic neuritis - Sensory disturbances in upper limbs - Increased tone and ankle clonus - Reduced leg power - Hyperreflexia in legs - Impaired heel-shin coordination - Impaired proprioception and light touch - Foot drop
97
On examination you find: - Young adult females - Lhermitte's sign - Urthoff's phenomenon - Autonomic signs e.g. urinary incontinence - Internuclear ophthalmoplegia - Optic neuritis - Sensory disturbances in upper limbs - Increased tone and ankle clonus - Reduced leg power - Hyperreflexia in legs - Impaired heel-shin coordination - Impaired proprioception and light touch - Foot drop Differential?
MS
98
Investigations for MS
- MRI brain/spinal cord: demyelinating lesions - LP: oligoclonal bands Diagnosed using McDonald criteria: must have multiple lesions separated in space and time
99
Management of MS
- Physiotherapy - Baclofenac for spasticity - Analgesia for neuropathic pain - IV methylprednisolone for flares - Dimethyl fumarate/Interferon beta and alemtuzumab for maintenance if >2 relapses in last 2 years
100
Examination findings for Parkinsonism
- Myerson's sign on glabella tap - Reduced facial expression - Slow monotonous speech - Resting tremor in upper limbs - Increased tone with cog-wheeling - Bradykinesia - Micrographia - Normal power, reflexes, sensation and coordination in arms - Increased tone in legs - Normal power, reflexes, sensation and coordination in legs - Gait: difficulty initiating walking, shuffling gait, reduced arm swing, multiple steps to turn around
101
Management of Parkinson's disease
- Physiotherapy - Support groups - Dopamine agonists e.g. bromocriptine - L-DOPA with peripheral dopa decarboxylase inhibitor
102
On examination you find: - Myerson's sign on glabella tap - Reduced facial expression - Slow monotonous speech - Resting tremor in upper limbs - Increased tone with cog-wheeling - Bradykinesia - Micrographia - Normal power, reflexes, sensation and coordination in arms - Increased tone in legs - Normal power, reflexes, sensation and coordination in legs - Gait: difficulty initiating walking, shuffling gait, reduced arm swing, multiple steps to turn around Differential?
Parkinsonism
103
Causes of Parkinsonism
Parkinson's disease (usually asymmetrical signs): idiopathic destruction of the substantia nigra Parkinson's plus syndromes (usually symmetrical signs): - Multi-system atrophy: Parkinsonism plus postural hypotension, cerebellar signs - Progressive supra-nuclear palsy: vertical gaze palsy - Corticobasal degeneration: apraxia, alien hand Drug induced Parkinsonism e.g. antipsychotics Lewy Body Dementia: dementia precedes Parkinsonism features
104
Features of MND on examination
- Age >40 - Strained, slow speech - Head drop - Stooped posture - Weakness - Painful muscle spasms - Muscle atrophy - Hyperreflexia - Spastic, unsteady gait - Foot drop - Sensation intact
105
On examination you find: - Age >40 - Strained, slow speech - Head drop - Stooped posture - Weakness - Painful muscle spasms - Muscle atrophy - Hyperreflexia - Spastic, unsteady gait - Foot drop - Sensation intact Differential/
MND
106
Management of MND
- Riluzole BD: prolongs survival | - Symptomatic relief e.g. nutritional support
107
Differentials for ptosis
- Large lid lesion e.g. tumour, oedema - Myotonic dystrophy - Myasthenia gravis - 3rd nerve palsy - Horner's syndrome (damage to sympathetic pathway)
108
LMN lesion signs
Lesion in grey matter of spinal cord at level of synapse or injury to axons leaving spinal cord - Hyporeflexia - Hypotonia: flaccid paralysis - Fasciculations - Muscle wasting - Weakness: usually more focal, follows nerve root or peripheral nerve distribution - Normal coordination - Decreased sensation
109
Features of cerebellar disease on examination
- Dysdiadochokinesia - Ataxia - Nystagmus - Intention tremor - Slurred speech - Hypotonia and hyporeflexia - Past-pointing
110
On examination you find: - Dysdiadochokinesia - Ataxia - Nystagmus - Intention tremor - Slurred speech - Hypotonia and hyporeflexia - Past-pointing Differential?
Cerebellar disease e.g. stroke

Finals OSCEs (1 decks)

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