Short Case

Question 1

Signs of severity - AS

Answer 1

Peripheral
- slow rising pulse, low volume carotid pulse
- left heart failure
- small pulse pressure
Praecordium
- pressure loaded apex beat.
- aortic thrill
- harsh late peaking ESM radiating to carotids
- soft S2
- paradoxical splitting
Investigations
- LBBB, LVH, LV strain

Question 2

Signs of severity - MS

Answer 2

Peripheral
- mitral facies
- small pulse pressure
- prominent A wave
Praecordium
- tapping apex beat
- soft S1 with early opening snap and long diastolic murmur
- pulm HTN (loud P2, RV heave, TR)
Investigations
- atrial fibrillation, p mitrale

Question 3

Signs of severity - MR

Answer 3

Peripheral
- small volume pulse
Praecordium
- displaced apex beat
- pansystolic murmur extending into diastole
- soft S1, S3 present
- Left ventricular failure / pulm HTN
Investigations
- atrial fibrillation
- LV enlargement, left axis deviation, LA dilatation

Question 4

Effect of valsalva and handgrip on murmurs

Answer 4

Valsalva - decreases preload

• AS softer
• HOCM louder, MVP click and murmur earlier

Handgrip - increases afterload

• AS, HOCM softer
• MR, AR louder

Question 5

Signs of severity - AR

Answer 5

Peripheral
- collapsing pulse, wide pulse pressure
- bounding carotid pulse
Praecordium
- LV failure, displaced apex beat
- Long diastolic decrescendo murmur +/- austin flint in left parasternal border
- S3, Soft S2
Investigations
- Aortic root dilatation
- Dilated LV

Question 6

Signs of severity - TR

Answer 6

Peripheral
- Large V waves
- Pulsatile liver +/- hepatopathy (jaundice)
- Oedema
Praecordium
- RV heave, loud P2
- Pansystolic murmur louder on inspiration
Investigations
- RV dilatation
- LFT derangement

Question 7

Causes of ILD

Answer 7

Upper lobes

• Sarcoidosis / silicosis
• Coal pneumoconiosis
• Hypersensitivity pneumonitis
• Ankylosing spondylitis
• Radiation
• Tuberculosis

Lower lobes

• Rheumatoid arthritis
• Asbestosis
• Scleroderma
• Cryptogenic (IPF)
• Other (drug - amiodarone, mtx, bleomycin)

Question 8

Causes of hepatomegaly

Answer 8

Cardiovascular 
- RHF
Hepatic
- NAFLD / alcoholic hepatitis
- Viral hepatitis / DILI
- Infiltrative (iron/amyloid/sarcoid)
- Metastases or HCC
- Cystic liver (ADPCKD)
Haematological
- Myeloproliferative disease
- Lymphoma

Question 9

Causes of splenomegaly

Answer 9

Portal hypertension
- LHF / pulmonary hypertension / RHF
- Cirrhosis
- Portal vein thrombosis
Haematological
- CML, lymphoma, myelofibrosis
- Thalassaemia
- Haemolytic anaemia
Infiltrative (amyloid or sarcoid)
Infection (EBV/CMV)
CTD (vasculitis, rheumatoid arthritis)

Question 10

Features in Cushing Syndrome

Investigations?

Answer 10

Inspection - central obesity, bruising, poor wound healing
Peripheries - proximal myopathy, moon face, buffalo hump, acanthosis nigricans
Always check visual fields! (pituitary adenoma)
Hypertension
Steroid induced diabetes

Ix:

• Dexamethasone suppression test
• ACTH level

Question 11

Features in Acromegaly
Investigations?
Treatment?

Answer 11

Features of active disease: 
- Sweating, skin tags,
- Hyperglycaemia, hypertension
- Organomegaly, hearing loss, CN palsies
Check visual fields

Investigations

• IGF-1, glucose tolerance
• MRI pituitary

Treatment

• Adenoma resection
• Octreotide, pegovisant

Question 12

X-ray findings in:
Osteoarthritis
Rheumatoid arthritis
Gout
Psoriatic arthritis
Scleroderma
SLE

Answer 12

OA: irregular joint space narrowing, osteophytes, subchondral sclerosis, gull wing

RA: regular joint space narrowing, juxta-articular osteopaenia and erosions, DIP sparing

Gout: lytic moth eaten lesions, marginal erosions, tophi

PsA: marginal erosions, pencil in cup deformities preferentially interphalangeal joints

Ssc: acro-osteolysis, erosions, calcinosis

SLE: non-erosive deformity

Question 13

Causes of Horner’s Syndrome

Answer 13

Brainstem

• lateral medullary syndrome
• syringomyelia –> syringobulbia
• space occupying lesion

Preganglionic

• pancoast tumour (UL weakness)
• thyroid mass

Postganglionic

• carotid aneurysm
• carotid dissection

Question 14

Higher Centres 4 lobes

Answer 14

Frontal

• proverb interpretation (concrete thinking)
• grasp/pout/palmomental
• gait (magnetic)

Parietal
Dominant: 
- acalculia, agraphia, LR disorientation, finger agnosia
- expressive/receptive dysphasia
- agraphaesthesia, two point discrimination loss
Nondominant:
- dressing apraxia
Both
- sensory inattention

Temporal
- memory: short and long term

Occipital
- visual inattention

Question 15

Causes of foot drop

Answer 15

• common peroneal nerve palsy (inversion/ankle reflex intact)
• sciatic nerve palsy (ankle reflex missing)
• L5 radiculopathy (inversion weakness)
• peripheral motor neuropathy (usually bilateral, stocking sensory loss)
• myopathy
• stroke (expect UMN signs)

Question 16

Causes of myopathy

Answer 16

Hereditary/congenital

Acquired

• Polymyositis/dermatomyositis
• Alcohol
• Cancer / paraneoplastic
• Endocrine (cushings, hypothyroidism, acromegaly)
• Periodic paralysis
• Osteomalacia
• Drugs - steroid
• Sarcoid

Question 17

Sarcoidosis

Answer 17

P: acute (lofgrens) vs subacute. Cough and systemic symptoms. Coincidental hilar adenopathy on imaging. Systemic sx: skin, eyes, peripheral neuropathy, cardiac, hypercalcaemia, lymphadenopathy

R: family history, non smoker

I: CXR, bloods - ACE, WCC (hypercalcaemia - check calcitriol), CT, biopsy required to confirm diagnosis. Spirometry

C: pulmonary, cardiac, renal, neurological dysfunction. Hypercalcaemia. Skin lesions.

M:
If asymptomatic, ongoing surveillance
1st: prednisolone
Steroid sparing: MTX, AZA
Consider biologic

C/P: steroid side effects. End organ dysfunction and consideration of transplant.

Question 18

Cystic Fibrosis

Answer 18

P: Often diagnosed at birth screening.