Short cases Flashcards
Grading of finger clubbing
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
Causes of clubbing
> 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
Differential for Traube space dullness
- Full stomach
- Left sided pleural effusion
- Splenomegaly
- Proliferative growth in fundus of stomach
Characteristic of JVP which differentiate it from arterial occlusion
- Visible but not palpable
- Seen as biphasic wave in one heart beat
- Decreases on inspiration
- Can be occluded
Scars in the precordium
- 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
Abnormal character of apex beat
- Heaving (pressure loaded): aortic stenosis, systemic hypertension
- Thrusting (volume loaded): mitral regurgitation, dilated cardiomyopathy
- Tapping: mitral stenosis
- Double impulse: hypertrophic cardiomyopathy
Causes of apex beat deviation
- Left ventricle enlarge: laterally and inferiorly
- Right ventricle enlarge: medially
Causes of parasternal heave
- Right ventricular enlargement
- Severe left atrial enlargement (pushes right atrium anteriorly)
Causes of thrills
- Apical: left ventricular hypertrophy
- Suprasternal: aortic stenosis
- Lower left sternal edge: VSD
- Upper left sternal edge: pulmonary stenosis
Causes of peripheral edema
> 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
Brief investigation for VSD
- Confirm diagnosis: echocardiogram
- Ix for HF: BNP, CXR
Complication for VSD
- Heart failure
- Endocarditis
- Eisenmenger syndrome
- Arrhythmia
Scars in the abdomen
- Kocher’s scar: open cholecystectomy
- Midline: AAA repair, laparotomy
- Lanz incision: appendicectomy
- Left paramedian: colectomy
- Pfannenstiel scar: C-section
Border of Traube’s space
- Left 6th rib
- Midaxillary line
- Costal margin
Characteristic of spleen
- Cannot get above it
- Presence of splenic notch
- Moves anteromedially with inspiration
- Not ballotable
Splenomegaly causes
- Infective: malaria, typhoid
- Vessel congestion: portal hypertension, CCF
- Malignancies: myeloproliferative disorders
- Hemolysis: hemolytic anemia, thalassemia
Causes of hepatosplenomegaly
- Infective: infectious mononucleosis, typhoid, HIV
- Malignancies: CML, lymphoma
- Portal hypertension
Causes of fasciculation
- Motor neuron disease
- Motor root compression
- Peripheral neuropathy
- Primary myopathy
- Thyrotoxicosis
Types of hypertonia
- Claps-knife: UMNL
- Clonus: UMNL (abnormal if >5 contractions)
- Cogwheel rigidity: Parkinsonism
Grading of reflex
- 0: absent
- 1: reduced
- 2: normal
- 3: increased
- 4: greatly increased
Segmental level associated with each reflex
- Biceps: C5, C6
- Brachioradialis: C5, C6
- Triceps: C7, C8
- Knee jerk: L3, L4
- Ankle jerk: S1, S2
- Plantar reflex: L5, S1, S2
Conduction pathway for different type of sensation
- Light touch: anterior spinothalamic
- Pain: lateral spinothalamic
- Vibration and proprioception: posterior column
Physiology behind Romberg’s test
- 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
Pattern of sensory deficit
> 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
Types of abnormal gait
- 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
Differential diagnosis of thyroid gland swelling
> Solitary
- Grave’s disease
- Thyroid adenoma
- Dominant nodule of MNG
- Thyroid cyst
- Thyroid carcinoma
> Multinodular
- Toxic multinodular goiter
- Thyroid carcinoma
Physical sign for acromegaly
- Spade-like shape hands
- Carpal tunnel syndrome
- Acanthosis nigricans
- Transfrontal scar
- Prominent supraorbital ridge
- Macroglossia and wide separates teeth
- Gynecomastia
- Organomegaly
Complication of acromegaly
- CVS: hypertension, IHD, CCF
- GI: colorectal carcinoma
- Endocrine: impaired glucose tolerance
Causes of bronchial breath sound
- Consolidation
- Above fluid level of pleural effusion
- Localized pulmonary fibrosis
Cause of lung consolidation
- Pneumonia
- Malignancy
- Pulmonary edema
- Pulmonary hemorrhage
Causes of ballotable kidney
> Unilateral
- Renal cell carcinoma
- Pyelonephritis
- Renal abscess
- Polycystic kidney disease (asymmetrical enlargement)
- Hydronephrosis
> Bilateral
- Polycystic kidney disease
- Hydronephrosis
Causes of splenomegaly
- Infective: malaria, typhoid
- Vessel congestion: portal HPT, CCF
- Malignancies: myeloproliferative disorder
- Hemolysis: hemolytic anemia, thalassemia, hereditary spherocytosis
Differentiate liver and kidney in organomegaly
> Liver
- Moves with inspiration
- Dullness on percussion
- Cannot get above the mass
> Kidney
- Resonance on percussion (retroperitoneal organ)
Type of hemolytic anemia
> 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
Cause of MR
> Chronic
- Aging
- RHD
- Papillary muscle dysfunction
> Acute
- Papillary muscle rupture due to MI
- Infective endocarditis
How to differentiate murmur in HOCM with aortic stenosis
- HOCM: increase intensity when standing from sitting position/ Valsalva maneuver
- Aortic stenosis: do not changes following Valsalva maneuver
Causes of parkinsonism
- Parkinson disease
- Parkinson-plus syndromes
- Neuroleptic drugs
- Wilson’s disease
- Cerebral palsy
Non-pharmacological management of Parkinson’s disease
- Deep brain stimulation
- Surgical ablation of the overactive basal ganglia circuit
Type of parkinsonism
- 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
Investigation for ADPKD
> Confirm diagnosis
- Renal profile
- Ultrasound of kidney
> Screen complication
- Ultrasound liver
- CT angiography
Management of ADPKD
- ACE-I: treat HPT
- Genetic counselling, family screening
- Renal replacement therapy: if ESRF
Diagnosis of ADPKD
> USS
- 15-39: >=3 cysts
- 40-59 >2 cysts in each kidney
Lead pipe vs Cogwheel rigidity
> Lead pipe
- More marked at elbow
- Constant throughout the range
> Cogwheel
- More marked at wrist
- Jerky with tension felt intermittently
PE finding for Parkinson’s disease
> 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
Complication of ADPKD
- Hypertension
- Frequent UTI, cyst infection
- Renal calculi
- Anemia
- Berry aneurysm
- Progression to ESRF
Details about Parkinson plus syndrome
> 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
Medication that cause parkinsonism
- 1st gen antipsychotics
- 2nd gen antipsychotics
- Antiemetic and prokinetic medication
- Dopamine-depleting agents
- Valproic acid
Investigation for Marfan’s
- Slit lamp examination: lens dislocation, retinal detachment
- Echocardiography: aortic root aneurysm
- MRI of lumbosacral spine: dural ectasia
Management for Marfan’s
- Beta blocker: may retard aortic root growth (mechanism unsure)
- Regular surveillance of aortic root diameter
- Elective aortic root repair surgery when >5cm
Hand sign of Marfan’s
- Steinberg sign (Thumb): positive when thumb extend pass palm of hand
- Walker-Murdoch sign (Wrist): thumb and fifth finger overlap
Causes of interstitial lung disease
- Cystic fibrosis
- Radiation
- Silicosis
- Asbestosis
- Scleroderma
Investigation for interstitial lung disease
> Initial
- Lung function test: restrictive airway pattern
- CXR: reticulonodular shadowing
> Confirm diagnosis
- HRCT thorax
Screening test for ADPKD patient
- Screening for intracranial aneurysm (MRI)
- Recommended for age <65 with personal/ family history of aneurysm/ SAH
Ergot vs Non-ergot dopamine agonist
- Ergot-derived DA have been largely replaced by nonergot DA due to potential SE
- Bromocriptine (Ergot) have increase risk of valvular HD
What to do to increase the reflex response
- Clench teeth
- Jendrassik maneuver (patient lock fingers together and pulls hard)
PE finding of RA
- Joint swelling
- Stigmata of RA: Z thumb, swan neck, Boutonniere, ulnar deviation at MCP joint
- Small muscle wasting
- Carpal tunnel syndrome
How to choose between bioprosthetic and mechanical valve
> 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
