MEDICINE FOR FINALS

DR AJAY MAY 2008

CARDIOVASCULAR
INTRODUCTION MAY I EXAMINE YOU? 45 DEGREES INSPECTION (SOB, SCARS, MALAR FLUSH, ANKLE OEDEMA) ALWAYS LOOK AROUND THE BED, INHALERS, OXYGEN, DIET DRINKS ETC

EXAMINATION
LOOK AT THE HANDS FINGER CLUBBING CYANOSIS SPLINTER HAEMORRAGES PALE

PULSE
RATE RHYTMN CHARACTER BRACHIAL/CAROTID VOLUME COLLAPSING PULSE

CAUSES OF IRREGULAR IRREGULAR PULSE

ATRIAL FIBRILLATION, VES, ATRIAL FLUTTER WITH VAR BLOCK, CHB CAUSES OF AF
ISCHAMIC HEART DISEASE RHEUMATIC HEART DISEASE THYROID NO CAUSE CARDIOMYOPATHY WPW INFECTION ASD

COLLAPSING PULSE
AORTIC REGURG LOOK FOR CORRIGAN S SIGN PDA PAGETS PREGNANCY RUPTURED ANEURYSM OF AORTIC SINUS FEVER ANAEMIA

RADIO-FEMORAL DELAY
COARCTATION OF THE AORTA ASK WHILE EXAMINING THE PULSE CAN YOU CHECK FOR THIS

BLOOD PRESSURE
ALWAYS REMEMBER TO ASK IF YOU CAN CHECK THE BLOOD PRESSURE

JVP
INTERNAL JUGULAR BETWEEN THE TWO HEADS EQUAL TO PRESSURES IN THE RIGHT ATRIUM a WAVE = ATRAL CONTRACTION v WAVE= ATRIAL FILLING DURING VENTRICLAR SYSTOLE,TRICUSPID VALVE IS CLOSED

CAUSES OF A RAISED JVP

HEART FAILURE ELEVATION, SUSTAINED HJR PE ELEVATED PERICARDIAL EFFUSION-ELEVATED, PROMINENT Y DESCENT CONSTRICTIVE PERICARDITISELEVATED KUSSMAULS, PARADOXICAL RISE ON INSPIRATION AF NO a WAVES TRICUSPID STENOSIS- GIANT a WAVES TRICUSPID REGURG- GIANT v WAVES COMPLETE HEART BLOCK- CANNON

APEX BEAT
LOOK FOR STERNOTOMY SCARS LOOK FOR THORACOTOMY SCARS POSITION AND CHARACTER CHECK FOR HEAVES OR THRILLS

HEART SOUNDS
PALPATE THE CAROTID SIMULTANEOUSLY COMMENT ON I AND II OR ADDITIONAL MURMURS

MURMURS
STENOSIS- APEX LEFT LATERAL USE THE BELL REMEMBER CHANGES IN BREATHING INSPIRATION RIGHT HEART MURMURS GET LOUDER EXPIRATION LEFT SIDE MURMURS GET LOUDER PANSYSTOLIC MURMUR APEX, AXILLA EARLY DIASTOLIC AORTIC
RD

GRADING OF MURMURS
1. FAINT 2. FAINT BUT EASILY DETECTED 3. POMINENT BUT NOT LOUD 4. LOUD THRILL 5. VERY LOUD 6. LOUD WITHOUT CONTACT

REMEMBER
LUNG BASES SACRAL OEDEMA HEPATOSPLENOMEGALY FAILURE PERIPHERAL PULSES

MITRAL STENOSIS
MALAR FLUSH PULSE- IRREGULR IRREGULAR RAISED JVP TAPPING APEX NOT DISPLACED LEFT PARASTERNAL HEAVE(RIGHT VENTRICULAR ENLARGEMENT) LOUD 1ST HS OPENING SNAP

MITRAL STENOSIS
CAUSES- RHD TAPPING APEX BEAT -DUE TO ACCENTUATED 1ST HS OPENING SNAP OPENING OF A STENOSED VALVE PLIABLE, ABSENT IN DIFFUSELY CALCIFIED VALVE LOUD 1ST VALVES ARE MOBILE PRESYSTOLIC ACCENTUATION- SINUS RHYTMN DUE TO THE ATRIAL SYSTOLE WHICH INCREASES FLOW ACROSS A STENOTIC VALVE

COMLICATIONS
LEFT ATRIAL ENLARGEMENT AF PULMONARY HTN TR RHF

SEVERITY
NARROWER DISTANCE BETWEEN ND 2 HS AND OS LONGER THE DIASTOLIC MURMUR

MITRAL REGURG
PERIPHERAL PULSES- NORMAL JERKY DUE TO REDUCED SYSTOLIC EJECTION TIME SECONDARY TO A LARGE VOLUME OF BLOOD REGURG INTO LEFT ATRIUM APEX BEAT- DISPLACED 1ST HS SOFT 3RD HS PSM -> AXILLA LOUDER ON EXP

CAUSES OF MR
MITRAL VALVE PROLAPSE RHD LEFT VENTRICLAR DILATATION CORONARY DISEASE ANNULAR CALCIFICATION ENDOCARDITIS PAPILLARY MUSCLE RUPTURE CARDIOMYOPATHY CONNECTIVE TISSUE DISORDER TRAUMA MYXOMATOUS DEGENERATION

CAUSES OF PSM
MR TR VSD HOCM

AORTIC REGURG
PULSE- LARGE VOLUME, COLLAPSING CORRIGANS APEX DISPLACED OUTWARDS, FORCEFUL EDM- LSE SIT FORWARD EXPIRATION

Aortic Regurgitation
WIDE PULSE PRESSURE FEMORALS- PISTOL SHOTS(TRAUBES) TO AND FRO MURMUR (DUROZIEZS) CORRIGANS CAROTID PULSATION QUINCKES UVULA PULSATIONS (MULLERS) ARGYLL ROBERTSON PUPIL MARFANS ANK SPOND, RA

Causes Of Aortic Regurgitation

RF HTN ATHEROSCLEROSIS ENDOCARDITIS SYPHILIS MARFANS RA ANK SPOND TRAUMA AORTIC DISSECTION

SEVERITY
WIDE PULSE PRESSURE SOFT 2ND HS RD 3 HS AUSTIN FLINT MURMUR LVF LONGER + LOUDER

AORTIC STENOSIS
LOW VOLUME SLOW RISING APEX- HEAVING, NOT DISPLACED ND SOFT 2 EJECTION CLICK S4 MAY BE HEARD ESM NARROW PULSE PRESSURE REVERSE SPLITTING

CAUSES OF AORTIC STENOSIS

RHEUMATIC DEGENERATIVE CALCIFICATION OF A BICUSPID VALVE

OTHER CAUSES OF ESM

PULM STENOSIS HOCM SUPRAVALVULAR STENOSIS

SYMPTOMS
FATIGUE ANGINA DYSPNOEA SYNCOPE DEATH

INVESTIGATIONS
ECG CXR ECHO CATH EST BE CAREFUL IF SYMPTOMATIC

TRICUSPID REGURGITATION
CAUSES
FUNCTIONAL
PULMONARY HTN CCF

RHD ENDOCARDITIS DRUG ADDICTS

VSD
PSM AT LSE LOUD P2 OF PULM HTN MAY HAVE CCF LOUDNESS DOES NOT MEAN SEVERE

CAUSES OF VSD
CONGENITAL RUPTURE AFTER MI 50% MAY CLOSE SPONTANEOUSLY COMPLICATIONS ARE
CCF AORTIC REGURG SBE PULM HTN

INFECTIVE ENDOCARDITIS
ANAEMIA CLUBBING SPLINTER HAEMORRAGES- EMBOLISM OSLER NODES- INFLAMMATION OF EMBOLI JANEWAY LESIONS PETECHIAE ROTH SPOTS SPLENOMEGALY HAEMATURIA DENTAL FBP- NORMOCYTIC NORMOCHROMIC ESR

COMLICATIONS OF SBE
CARDIAC FAILURE RENAL PAIN CEREBRAL ANEURYSMS MYCOTIC ANEURYSMS VALVE ABSCESS

HOCM
PULSE JERKY DOUBLE APICAL- LEFT VENTRICULAR HEAVE WITH PROM PRESYSTOLIC PULSE PSM- SOFTER ON SQUATTING 4TH HS FAMILY HISTORY

RESPIRATORY
INTRO SITTING POSITION SPUTUM CUP BREATHLESS WASTING ASYMMETRICAL BREATHING COUNT RESP

HANDS
CLUBBING CYANOSIS TAR BOUNDING PULSE ASTERIXIS TONGUE CYANOSIS EYES- PALLOR, HORNERS

EXAMINATION
LOOK FOR NECK VEINS CERVICAL LYMPH TRACHEA DEVIATION PALPATE MOVEMENTS OF BOTH SIDES VOCAL FREMITUS PERCUSSION AUSCULTATION

PLEURAL EFFUSION
LOOK FOR DECREASED MOVEMENT TRACHEAL DEVIATION ASPIRATION MARKS STONY DULL DECREASED VOCAL RESONANCE FIND THE UPPER LEVEL BRONCIAL BREATHING SIGNS OF RA, TAR, LYMPH NODES, RADIATION BURNS, MASTECTOMY

CAUSES OF DULLNESS
PLEURAL EFFUSION PLEURAL THICKENING CONSOLODATION COLLAPSE RAISED HEMIDIAPHRAGM

INVESTIGATIONS
CXR TAP SEND FOR PROTEIN, LDH, GLUCOSE, BACTERIOLOGY, CYTOLOGY PH IF EMPYEMA AMYLASE IN NG, PANCREATITIS, OESOPHAGEAL RUPTURE RHEUMATOID FACTOR

TRANSUDATE
NEPHROTIC SYNDROME CARDIAC FAILURE LIVER FAILURE HYPOTHYROID CONSTRICTIVE PERICARDITIS MEIGS

EXUDATE
CA SECONDARIES PNEUMONIA PE TB RA SLE LYMPHOMA MESOTHELIOMA

PROGNOSIS
POOR IN NG PEURAL FLUID
LOW GLUCOSE LOW pH

HAEMORRAGIC FLUID
PE NG TB

REMEMBER OCCUPATION
EG SHIP BUILDING

BRONCHIECTASIS
LOOK FOR SPUTUM CUP FINGER CLUBBING BILATERAL COARSE CREPS LATE INSP CREPS

BRONCHIECTASIS
DEF - CHRONIC NECROTIZING INFECTION OF THE BRONCHI AND BRONCHIOLES LEADING TO ABNORMAL, PERMANENT DILATATION OF THE AIRWAYS

CAUSES
PNEUMONIA MEASLES PERTUSSIS TB MECHANICAL OBSTRUCTION ASPERGILLOSIS KARTAGENERS CYSTIC FIBROSIS IDIOPATHIC

INVESTIGATION
FBP SPUTUM CXR CT

COMPLICATIONS
PNEUMONIA PLEURAL EFFUSION PNEUMOTHORAX SINUSITIS HAEMOPTYSIS BRAIN ABSCESS AMYLOIDOSIS

TREATMENT
POSTURAL DRAINAGE ANTIBIOTICS NEBS SURGERY

CONSOLIDATION
SPUTUM TACHYNOEA REDUCED MOVEMENT ON AFFECTED SIDE TRACHEAL CENTRAL DECREASED PERCUSSION BRONHIAL BREATHING CREPS

CAUSES
PNEUMONIA CARCINOMA PE

FIBROSING ALVEOLITIS
TACHYNOEA CLUBBING CENTRAL CYANOSIS BILATERAL BASAL FINE END INSP CREPS DO NOT DISAPPEAR ON COUGHING

SIGNS
HANDS - RA, SYSTEMIC SCLEROSIS FACE - RASH OF SLE MOUTH - DRY OF SJOGRENS PULMONARY HTN - a WAVE IN JVP, LEFT PARASTERNAL HEAVE AND P2 LOOK FOR CAUSES - DRUGS EG AMIODARONE

PROGNOSIS
50% SURVIVAL AFTER 5 YEARS INCREASE RISK OF CA

ABDOMEN

EXAMINATION
LYING FLAT DO NOT EXPOSE GENITALIA COMFORTABLE LOOK AROUND THE BED

HANDS
CLUBBING LEUCONYCIA PALMAR ERYTHEMA DUPUTRYENS HEPATIC FLAP PIGMENTATION SCRATCH MARKS

EXAMINATION
NODES TONGUE EYES - JAUNDICE, XANTHELASMA ANAEMIA SPIDER NAEVIA ACANTHOSIS NIGRICANS GYNAECOMASTIA

EXAMINATION OF ABDOMEN
MOVEMENTS MASS VEINS PERISTALSIS HERNIA

ASK IF THERE IS ANY PAIN

PALPATION
KNEEL DOWN ALWAYS LOOK AT THE PATIENT SUPERFICIAL THEN DEEP ALL QUADRANTS

PALPATE
MASS - CHARACTERISTICS LIVER - PERCUSSION SPLEEN KIDNEYS LYMPH NODES HERNIAL ORFICES TESTICULAR ATROPHY

PERCUSSION
SHIFTING DULLNESS

AUSCULTATE
LIVER BRUIT BOWEL SOUNDS RENAL BRUIT

LEG OEDEMA PR

HEPATOMEGALY
SIZE TENDERNESS- CHF OR ACUTE HEPATITIS SURFACE - SMOOTH OR IRREGULAR PERCUSS AUSULTATE- ALCOHOLIC HEPATITIS OR CA FOR BRUIT

CAUSES
CHF CIRRHOSIS SECONDARIES INFECTIVE HEPATITIS MYELOPROLIFERATIVE DISORDERS SARCOID HAEMACHROMATOSIS PBC AMYLOID TUMOURS

CAUSES OF HEPATIC ENCEPHALOPATHY

INFECTION DIURETICS, ELECTROLYTE IMBALANCE DIARROHEA AND VOMITING SEDATIVES GI BLEED ABDOMINAL PARACENTESIS SURGERY

CAUSE OF ASCITES
LIVER FAILURE + PORTAL HTN SECONDARY HYPERALDOSTERONISM DECREASED METABOLISM OF ALDOSTERONE BY LIVER DECREASED METABOLISM OF ADH LOW ALBUMIN LYMPHATIC OBSTRUCTION

HAEMACHROMATOSIS
MALE PIGMENTED PALMAR ERYTHEMA AND SPIDER ANAEMIA JAUNDICE ASCITES HEPATOMEGALY LOSS OF SEXUAL HAIR TESTICULAR ATROPHY JOINT PAIN- PSEUDOGOUT CARDIOMYOPATHY DIABETES

INVESTIGATIONS
AUTOSOMAL RECESSIVE MOSTLY HLA-A3 CHROMOSOME 6 TRANSFERRIN INCREASED SERUM FERRITIN RAISED GENE TESTING LIVER BIOPSY

TREATMENT
VENESECTION

RISK
X200 RISK OF HEP CA

PBC
MIDDLE-AGED WOMEN CLUBBING PIGMENTED XANTHELASMA ICTERUS SCRATCH HEPATOSPLENOMEGALY

PBC
XANTHOMATA- JOINTS - SKIN FOLDS - AREA OF TRAUMA LOOK FOR OTHER AUTOIMMUNE DISEASES PROXIMAL MUSCLE WEAKNESS OSTEOMALACIA PERIPHERAL NEUROPHATHY AMA M2 OBSTRUCTIVE PICTURE LIVER TRANSPLANTATION

LOOK FOR
AUTOIMMUNE CONDITIONS PROXIMAL MUSCLE WEAKNESS DUE TO OSTEOMALACIA PERIPHERAL NEUROPATHY

PBC
ANTI-MITOCHONDRIAL ABS CURE IS TRANSPLANTATION

SPLENOMEGALY
DIFF FROM KIDNEY
KIDNEY BALLOTABLE NOTCH CANT GET ABOVE DULL TO PERCUSSION MOVES WITH RESP

LOOK FOR
LYMPH NODES ANAEMIA JAUNDICE PLETHORIC (PRV) SPLINTER HAEMORRAGES RHEUMATOID

CAUSES
CML MALARIA KALA-AZAR PRV MYELOFIBROSIS PORTAL HTN SARCOID AMYLOID ENDOCARDITIS INFECTIOUS MONONUCLEOSIS FELTYS CLL

KIDNEYS
LOOK FOR AV FISTULA LOOK FOR TRANSPLANTED KIDNEY 3RD NERVE PALSY ASSOC WITH POLYCYSTIC KIDNEY (BERRY) BP FHX ANAEMIA

ABDOMINAL MASSES
EPIGASRTIC -CA STOMACH -CA PANCREAS -AAA -RETROPERITONEAL LYMPHADENOPATHY

ABDOMINAL MASSES
RT ILIAC FOSSA- CROHNS CA CAECUM LYMPH NODES TRANSPLANTED KID APPENDIX ABSCESS OVARIAN NG CARCINOID AMOEBIAS

CAUSES OF PTOSIS
UNILATERAL 3RD NERVE PALSY HORNERS MYASTHENIA CONGENITAL IDIOPATHIC BILATERAL MYASTHENIA DYSTROPHIA OCULAR MYOPATHY SYPHILIS CONGENITAL BILATERAL HORNERS IN SYRINGOMYELIA

HORNERS
MIOSIS PARTIAL PTOSIS ENOPTHALMOS ANHYDROSIS

CAUSES
PANCOAST TUMOUR CERVICAL SYMPATHECTOMY CAROTID ANERUYSMS SYRINGOMYELIA LESION OF BRAINSTEM TRAUMA

HOLMES- ADIE
YOUNG WOMAN DILATED PUPIL PUPIL REACTS SLOWLY DECREASED REFLEXES BENIGN

DILATED PUPIL
EYE DROPS 3RD NERVE HOLMES ADIE LENS IMPLANT DEATH SYMPATHETIC OVERACTIVITY

SMALL PUPIL
OLD AGE EYE DROPS HORNERS ARGYLL ROB PONTINE NARCOTICS

DIABETIC EYES
BACKGROUND RETINOPATHY PREPROLIFERATIVE PROLIFERATIVE

PAPILLOEDEMA
SOL HTN RETINOPATHY BIH INCREASED ICP HEAD INJURY CAUSING CEREBRAL OEDEMA CO RETENTION THYROID VIT A INTOXICATION CENTRAL RETINAL VEIN THRMBOSIS

OPTIC ATROPHY
MS OPTIC NERVE COMPRESSION GLAUCOMA TOXINS ISCHAEMIA HEREDITARY PAGETS VIT B12 DEF

LOWER 7TH
LOOK IN THE YEARS PAROTID GLAND ENLARGEMENT TASTE (INVOLVING CHORDA TYMPANI) HEARING (HYPERACUUSIS DUE TO STAPEDIUS) URINE - DIABETES

CAUSES OF BILATERAL
GUILLAN BARRE SARCOIDOSIS MYASTHENIA MAY MIMIC

UNILATERAL PALSY
LLS HERPES CEREBELLOPONTINE TUMOURS POLIO OTITIS MEDIA SKULL FRACTURE

DYSTROPHICA MYOTONICA
SHAKING HANDS FRONTAL BALDNESS PTOSIS CATARACTS EXPRESSIONLESS

DYSTROP MYOTON
TEST POWER DECREASED REFLEXES ASK ABOUT SWALLOWING URINE - GLUCOSE LOW IQ GYNAECOMASTIA TESTICULAR ATROPHY

DYSTROP MYOTONICA
AD CARDIOMYOPATHY CHEST INFECTION

PROXIMAL MYOPATHY
DIABETES CUSHINGS THYROID POLYMYOSITIS DRUG CARCINOMA OSTEOMALACIA HEREDITARY

WASTING SMALL MUSCLES OF THE HAND

RHEUMATOID OLD AGE CERVICAL SPONDYLOSIS BILATERAL CERVICAL RIBS MND SYRINGOMYELIA CHARCOT GUILLAN NERVE PALSIES PANCOASTS

NEUROFIBROMATOSIS
AXILLA FOR FRECKLES VISUAL ACUITY - GLIOMA ACOSTIS NEUROMA IRIS FOR LISCH NODULES KYPOSCOLIOSIS BLOOD PRESSURE

LOOK FOR
6 OR MORE CAF AU LAIT 2 OR MORE NEUROFIBROMAS AXILLA FRECKLING OPTIC GLIOMA

SPEECH
COMPREHENSION
PUT OUT TONGUE SHUT YOUR EYES ORIENTATION TIME , DATE

SPEECH
NAME FAMILIAR OBJECTS ARTICULATION MENTAL SCORE EXPRESSIVE - BROCA FRONTOPARIETAL RECEPTIVE - WERNICKES SUPERIOR TEMPORAL

PARKINSONS
EXPRESSIONLESS- HYPERMYMIA DROOLING PILL ROLLING BRADYKINESIA TONE- COG WHEEL GLABELLAR TAP - CONTINUE MYERSONS SIGN WALK MICRGRAPHIA

RHEUMATOID
SUBLUXATION OF MCP SWAN NECK BOUTONNIERES Z DEFORMITY SUBLUX AT WRIST NAIL FOLD INFARCTS PALMAR ERYTHEMA

RHEUMATOID ARTHRITIS
MUST CHECK FOR NODULES SEROPOSITIVE AGGRESSIVE PERFORM SIMPLE TASKS EXAMINE OTHER JOINTS

ANAEMIA
CHRONIC DISEASE PERNICIOUS ANAEMIA FELTYS NSAIDS

PULMONARY
NODULES EFFUSION FIBROSIS CAPLANS BRONCHIOLITIS OBLITERANS

EYES
EPISCLERITIS SCLERITIS SCLEROMALACIA SICCA SJOGRENS

ANK SPOND
? MARK POSTURE PROTUBERANT ABDOMEN ASK HIM TO TURN WHOLE BODY TURNS STAND AGAINST A WALL SCHOBERS TEST

LOOK FOR
IRITIS ANTERIOR UVEITIS AORTIC REGURG APICAL FIBROSIS ACHILLES TENDINITIS

GENETIC
HLA-B27 40% SEVERE DISEASE

SCLERODERMA
TIGHTENING OF HANDS TELANGICTASIA PSEUDOCLUBBING VITILIGO JOINT FOR ARTHRITIS PINCHED NOSE DIFF OPENING MOUTH

ASK ABOUT
DYSPHAGIA RAYNAUDS DRY EYES SWALLOWING BREATHING - FIBROSIS

GOUT
ASYMMETRICAL LOOK AT 1ST MTP , HELICES, OLECRANON, ACHILLES NEGATIVE BIFRINGENT DISORDER OF PURINE METABOLISM

THYROID
HANDS - SWEATING, TREMOR, WARM SCARS PALMAR ERYTHEMA PULSE NODES GOITRE SEAT UPRIGHT EXOPTHALMOS PALPATE ,WATER

EXAMINE FOR
SIZE MOBILITY TEXTURE TENDERNESS PEMBERTONS SIGN - RAISE ARMS FOR COMPRESSION PERCUSS FOR RETROSTERNAL BRUITS - GRAVES

EYES
LID LAG VON GRAEF SIGN EXOPTHALMOS LID RETRACTION DALRYMPLES SIGN EXTRAOCCULAR MOVEMENTS CORNEAL INVOLVEMENT PROXIMAL MUSCLES SKIN PRETIB MYXOEDEMA

CUSHINGS
MOON FACE BRUISES HIRSUTISM PLETHORIC BUFFALO HUMP STRIAE PROXIMAL MUSCLE WEAKNESS

ASK ABOUT
STEROIDS DIABETES BP LOOK FOR RA , ASTHMA VISUAL FIELDS

CAUSES
STEROIDS PITUITARY ADENOMA- PIT DISEASE ADRENAL CA ADRENAL ADENOMA ECTOPIC CA

ACROMEGALY
FACE SWEATING LARGE HANDS CARPAL TUNNEL PROM SUPRAORBITAL RIDGES LARGE NOSE AND LIPS PROTRUSION OF LOWER JAW WIDE TEETH

LOOK FOR
MACROGLOSSIA VISUAL FIELDS ACANTOSIS NIGRICANS ORGANOMEGALY JOINTS- CHONDROCALCINOSIS KYPHOSIS BP DIABETES OLD PHOTOGRAPHS

HYPERTENSIVE FUNDUS
GRADE 1 SILVER WIRING GRADE 2 AV NIPPING GRADE 3 HAEMORRAGES (FLAME) +EXUDATES GRADE 4 - PAPILLOEDEMA

DIABETIC EYES
BACKGROUND/PREPROLIFERATIVE HAEMORRAGES (MICROANEURYSMS) + EXUDATES PROLIFERATIVE MALIGNANT RETINOPHATY NEOVASCULARISATION NEW VESSELS

GOOD LUCK !