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Internal Medicine > Short cases > Flashcards

Short cases Flashcards

1
Q

Grading of finger clubbing

A

Grade 1: fluctuation and softening of nail bed
Grade 2: increase in the normal 160’ angle
Grade 3: accentuated convexity of nail bed
Grade 4: clubbed appearance of fingertip
Grade 5: shiny or glossy change in nail and adjacent skin with longitudinal striations

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2
Q

Causes of clubbing

A

> CVS

  • cyanotic congenital heart disease
  • infective endocarditis
  • aortic aneurysm
  • atrial myxoma

> Respiratory - ABCDE

  • abscess
  • bronchiectasis
  • cystic fibrosis
  • empyema
  • fibrosis (pulmonary)

> GIT

  • IBD
  • celiac disease
  • cirrhosis

> Endocrine

  • thyrotoxicosis
  • secondary hyperparathyroidism
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3
Q

Differential for Traube space dullness

A
  • Full stomach
  • Left sided pleural effusion
  • Splenomegaly
  • Proliferative growth in fundus of stomach
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4
Q

Characteristic of JVP which differentiate it from arterial occlusion

A
  • Visible but not palpable
  • Seen as biphasic wave in one heart beat
  • Decreases on inspiration
  • Can be occluded
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5
Q

Scars in the precordium

A
  • Median sternotomy scar: valve replacement, CABG, cardiac transplant
  • Pacemaker insertion scar
  • Posterolateral thoracotomy: pulmonary resection
  • Anterolateral thoracotomy: cardiac, pulmonary and oesophageal surgery
  • Axillary thoracotomy: pneumonectomy and pneumothorax operation
  • Scar for chest drain
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6
Q

Abnormal character of apex beat

A
  • Heaving (pressure loaded): aortic stenosis, systemic hypertension
  • Thrusting (volume loaded): mitral regurgitation, dilated cardiomyopathy
  • Tapping: mitral stenosis
  • Double impulse: hypertrophic cardiomyopathy
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7
Q

Causes of apex beat deviation

A
  • Left ventricle enlarge: laterally and inferiorly

- Right ventricle enlarge: medially

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8
Q

Causes of parasternal heave

A
  • Right ventricular enlargement

- Severe left atrial enlargement (pushes right atrium anteriorly)

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9
Q

Causes of thrills

A
  • Apical: left ventricular hypertrophy
  • Suprasternal: aortic stenosis
  • Lower left sternal edge: VSD
  • Upper left sternal edge: pulmonary stenosis
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10
Q

Causes of peripheral edema

A

> Pitting
Localized
- Increase capillary pressure/ venous congestion: venous thrombosis
- Increase capillary permeability: cellulitis, insect bites

Generalized

  • Increased plasma volume: renal failure, congestive cardiac failure
  • Reduce oncotic pressure: nephrotic syndrome
  • Increase capillary permeability: sepsis

> Non-pitting

  • Lymphedema 2” obstruction of lymphatic system: trauma, filariasis
  • Myxedema: Grave disease, hypothyroidism
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11
Q

Brief investigation for VSD

A
  • Confirm diagnosis: echocardiogram

- Ix for HF: BNP, CXR

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12
Q

Complication for VSD

A
  • Heart failure
  • Endocarditis
  • Eisenmenger syndrome
  • Arrhythmia
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13
Q

Scars in the abdomen

A
  • Kocher’s scar: open cholecystectomy
  • Midline: AAA repair, laparotomy
  • Lanz incision: appendicectomy
  • Left paramedian: colectomy
  • Pfannenstiel scar: C-section
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14
Q

Border of Traube’s space

A
  • Left 6th rib
  • Midaxillary line
  • Costal margin
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15
Q

Characteristic of spleen

A
  • Cannot get above it
  • Presence of splenic notch
  • Moves anteromedially with inspiration
  • Not ballotable
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16
Q

Splenomegaly causes

A
  • Infective: malaria, typhoid
  • Vessel congestion: portal hypertension, CCF
  • Malignancies: myeloproliferative disorders
  • Hemolysis: hemolytic anemia, thalassemia
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17
Q

Causes of hepatosplenomegaly

A
  • Infective: infectious mononucleosis, typhoid, HIV
  • Malignancies: CML, lymphoma
  • Portal hypertension
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18
Q

Causes of fasciculation

A
  • Motor neuron disease
  • Motor root compression
  • Peripheral neuropathy
  • Primary myopathy
  • Thyrotoxicosis
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19
Q

Types of hypertonia

A
  • Claps-knife: UMNL
  • Clonus: UMNL (abnormal if >5 contractions)
  • Cogwheel rigidity: Parkinsonism
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20
Q

Grading of reflex

A
  • 0: absent
  • 1: reduced
  • 2: normal
  • 3: increased
  • 4: greatly increased
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21
Q

Segmental level associated with each reflex

A
  • Biceps: C5, C6
  • Brachioradialis: C5, C6
  • Triceps: C7, C8
  • Knee jerk: L3, L4
  • Ankle jerk: S1, S2
  • Plantar reflex: L5, S1, S2
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22
Q

Conduction pathway for different type of sensation

A
  • Light touch: anterior spinothalamic
  • Pain: lateral spinothalamic
  • Vibration and proprioception: posterior column
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23
Q

Physiology behind Romberg’s test

A
  • To maintain postural stability, need 2 out of 3 components: vision, auditory, and proprioception
  • The visual component is eliminated as patient closes the eyes
  • If proprioception is impaired, auditory component alone is not sufficient -> feel unsteady
24
Q

Pattern of sensory deficit

A

> Sensory cortex: Contralateral hemisensory loss

> Internal capsule: Contralateral hemisensory loss

> Spinal cord
Anterior spinal artery syndrome
- Loss of pin prick
- Spared vibration and proprioception

Hemi cord transection (Brown-Sequad)

  • Loss of contralateral pinprick
  • Loss of ipsilateral vibration
  • Ipsilateral weakness

Posterior column

  • Loss of vibration and proprioception
  • Spared pin prick
  • Positive Romberg’s test
> Radiculopathy: dermatome
> Mononeuropathy: nerve innervation
> Polyneuropathy (eg: DM)
- Gloves and stocking
- Loss of proprioception
25
Q

Types of abnormal gait

A
  • Spastic gait: spinal cord lesion, multiple sclerosis, cerebral palsy
  • Hemiplegic gait: stroke, space occupying lesion
  • Parkinsonian gait
  • Waddling gait: proximal weakness (eg: Cushing’s syndrome, thyrotoxicosis, muscular dystrophies)
  • High-stepping gait: common peroneal nerve palsy
  • Cerebellar ataxic gait
  • Antalgic gait: arthritis
  • Trendelenburg gait: superior gluteal nerve lesion, neck of femur fracture
  • Sensory ataxia gait: multiple sclerosis, spinocerebellar degeneration
26
Q

Differential diagnosis of thyroid gland swelling

A

> Solitary

  • Grave’s disease
  • Thyroid adenoma
  • Dominant nodule of MNG
  • Thyroid cyst
  • Thyroid carcinoma

> Multinodular

  • Toxic multinodular goiter
  • Thyroid carcinoma
27
Q

Physical sign for acromegaly

A
  • Spade-like shape hands
  • Carpal tunnel syndrome
  • Acanthosis nigricans
  • Transfrontal scar
  • Prominent supraorbital ridge
  • Macroglossia and wide separates teeth
  • Gynecomastia
  • Organomegaly
28
Q

Complication of acromegaly

A
  • CVS: hypertension, IHD, CCF
  • GI: colorectal carcinoma
  • Endocrine: impaired glucose tolerance
29
Q

Causes of bronchial breath sound

A
  • Consolidation
  • Above fluid level of pleural effusion
  • Localized pulmonary fibrosis
30
Q

Cause of lung consolidation

A
  • Pneumonia
  • Malignancy
  • Pulmonary edema
  • Pulmonary hemorrhage
31
Q

Causes of ballotable kidney

A

> Unilateral

  • Renal cell carcinoma
  • Pyelonephritis
  • Renal abscess
  • Polycystic kidney disease (asymmetrical enlargement)
  • Hydronephrosis

> Bilateral

  • Polycystic kidney disease
  • Hydronephrosis
32
Q

Causes of splenomegaly

A
  • Infective: malaria, typhoid
  • Vessel congestion: portal HPT, CCF
  • Malignancies: myeloproliferative disorder
  • Hemolysis: hemolytic anemia, thalassemia, hereditary spherocytosis
33
Q

Differentiate liver and kidney in organomegaly

A

> Liver

  • Moves with inspiration
  • Dullness on percussion
  • Cannot get above the mass

> Kidney
- Resonance on percussion (retroperitoneal organ)

34
Q

Type of hemolytic anemia

A

> Inherited

  • Membrane defect: hereditary spherocytosis
  • Enzyme defect: G6PD, pyruvate kinase deficiency
  • Hemoglobinopathy: sickle cell disease, thalassemia

> Acquired

  • Immune mediated: hemolytic transfusion reaction, SLE, drugs
  • Non-immune mediated: prosthesis, malaria, HUS
35
Q

Cause of MR

A

> Chronic

  • Aging
  • RHD
  • Papillary muscle dysfunction

> Acute

  • Papillary muscle rupture due to MI
  • Infective endocarditis
36
Q

How to differentiate murmur in HOCM with aortic stenosis

A
  • HOCM: increase intensity when standing from sitting position/ Valsalva maneuver
  • Aortic stenosis: do not changes following Valsalva maneuver
37
Q

Causes of parkinsonism

A
  • Parkinson disease
  • Parkinson-plus syndromes
  • Neuroleptic drugs
  • Wilson’s disease
  • Cerebral palsy
38
Q

Non-pharmacological management of Parkinson’s disease

A
  • Deep brain stimulation

- Surgical ablation of the overactive basal ganglia circuit

39
Q

Type of parkinsonism

A
  • Parkinson’s disease: loss of dopaminergic neurons in the substantial nigra, associated with Lewy bodies in the basal ganglia, brain stem and cortex
  • Secondary parkinsonism: vascular parkinsonism, drugs (eg: neuroleptic), Wilson’s disease
  • Parkinson-plus syndrome: progressive supranuclear palsy, multiple system atrophy, cortico-basal degeneration, lewy body dementia
40
Q

Investigation for ADPKD

A

> Confirm diagnosis

  • Renal profile
  • Ultrasound of kidney

> Screen complication

  • Ultrasound liver
  • CT angiography
41
Q

Management of ADPKD

A
  • ACE-I: treat HPT
  • Genetic counselling, family screening
  • Renal replacement therapy: if ESRF
42
Q

Diagnosis of ADPKD

A

> USS

  • 15-39: >=3 cysts
  • 40-59 >2 cysts in each kidney
43
Q

Lead pipe vs Cogwheel rigidity

A

> Lead pipe

  • More marked at elbow
  • Constant throughout the range

> Cogwheel

  • More marked at wrist
  • Jerky with tension felt intermittently
44
Q

PE finding for Parkinson’s disease

A

> General inspection

  • Mask-like facies
  • Monotonous speech

> Upper limbs

  • Lead pipe rigidity
  • Pill-rolling tremor
  • Cogwheel rigidity
  • Bradykinesia (ask to touch thumb with each finger)

> Face

  • Reduce eye blinking
  • Positive glabellar tap
  • +- vertical gaze palsy (in PSP)

> Complete the examination

  • Handwriting
  • Postural hypotension
  • Anosmia
45
Q

Complication of ADPKD

A
  • Hypertension
  • Frequent UTI, cyst infection
  • Renal calculi
  • Anemia
  • Berry aneurysm
  • Progression to ESRF
46
Q

Details about Parkinson plus syndrome

A

> PSP

  • Postural instability
  • Vertical gaze palsy
  • Rigidity of trunk > limbs
  • Speech and swallowing problems

> Multiple system atrophy

  • Autonomic features (eg: impotence, incontinence, postural hypotension)
  • Cerebellar + pyramidal signs
  • Rigidity > tremor

> Cortico-basal degeneration

  • Akinetic rigidity involving one limb
  • Cortical sensory loss
  • Apraxia

> Lewy body dementia

47
Q

Medication that cause parkinsonism

A
  • 1st gen antipsychotics
  • 2nd gen antipsychotics
  • Antiemetic and prokinetic medication
  • Dopamine-depleting agents
  • Valproic acid
48
Q

Investigation for Marfan’s

A
  • Slit lamp examination: lens dislocation, retinal detachment
  • Echocardiography: aortic root aneurysm
  • MRI of lumbosacral spine: dural ectasia
49
Q

Management for Marfan’s

A
  • Beta blocker: may retard aortic root growth (mechanism unsure)
  • Regular surveillance of aortic root diameter
  • Elective aortic root repair surgery when >5cm
50
Q

Hand sign of Marfan’s

A
  • Steinberg sign (Thumb): positive when thumb extend pass palm of hand
  • Walker-Murdoch sign (Wrist): thumb and fifth finger overlap
51
Q

Causes of interstitial lung disease

A
  • Cystic fibrosis
  • Radiation
  • Silicosis
  • Asbestosis
  • Scleroderma
52
Q

Investigation for interstitial lung disease

A

> Initial

  • Lung function test: restrictive airway pattern
  • CXR: reticulonodular shadowing

> Confirm diagnosis
- HRCT thorax

53
Q

Screening test for ADPKD patient

A
  • Screening for intracranial aneurysm (MRI)

- Recommended for age <65 with personal/ family history of aneurysm/ SAH

54
Q

Ergot vs Non-ergot dopamine agonist

A
  • Ergot-derived DA have been largely replaced by nonergot DA due to potential SE
  • Bromocriptine (Ergot) have increase risk of valvular HD
55
Q

What to do to increase the reflex response

A
  • Clench teeth

- Jendrassik maneuver (patient lock fingers together and pulls hard)

56
Q

PE finding of RA

A
  • Joint swelling
  • Stigmata of RA: Z thumb, swan neck, Boutonniere, ulnar deviation at MCP joint
  • Small muscle wasting
  • Carpal tunnel syndrome
57
Q

How to choose between bioprosthetic and mechanical valve

A

> Bioprosthetic

  • Last 10-15 years
  • Suitable for elderly patient
  • Lower risk of bleeding and thrombosis

> Mechanical

  • Last lifetime
  • Suitable for younger patient as do not need to undergoes additional surgery
  • However required anticoagulation and close monitoring of INR -> reduce QoL

Internal Medicine (12 decks)

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