Transcript MEDICINE
MEDICINE FOR FINALS DR INDER MAINIE MAY 2002 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, VE’S, 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 PERICARDITIS-ELEVATED KUSSMAULS, PARADOXICAL RISE ON INSPIRATION AF NO a WAVES TRICUSPID STENOSIS- GIANT a WAVES TRICUSPID REGURG- GIANT v WAVES COMPLETE HEART BLOCK- CANNON WAVES 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 REGURG 3RD ICS SIT FORWARD ON EXP GRADING OF MURMURS 1. 2. 3. 4. 5. 6. FAINT FAINT BUT EASILY DETECTED POMINENT BUT NOT LOUD LOUD THRILL VERY LOUD 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 2ND 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 CORRIGAN’S APEX DISPLACED OUTWARDS, FORCEFUL EDM- LSE SIT FORWARD EXPIRATION Aortic Regurgitation WIDE PULSE PRESSURE FEMORALS- PISTOL SHOTS(TRAUBE’S) TO AND FRO MURMUR (DUROZIEZ’S) CORRIGANS – CAROTID PULSATION QUINCKE’S UVULA PULSATIONS (MULLER’S) 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 3RD HS AUSTIN FLINT MURMUR LVF LONGER + LOUDER AORTIC STENOSIS LOW VOLUME SLOW RISING APEX- HEAVING, NOT DISPLACED SOFT 2ND 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 BLOOD CULTURES 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 tug 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 CAN’T 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 ITP 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 MUTIPLE MYELOMA 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 NEUROFIBROMATOSIS AXILLA FOR FRECKLES VISUAL ACUITY - GLIOMA ACOSTIS NEUROMA IRIS FOR LISCH NODULES KYPOSCOLIOSIS BLOOD PRESSURE LOOK FOR 6 OR MORE CAFÉ 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 - WERNICKE’S SUPERIOR TEMPORAL PARKINSONS EXPRESSIONLESS- HYPERMYMIA DROOLING PILL ROLLING BRADYKINESIA TONE- COG WHEEL GLABELLAR TAP - CONTINUE MYERSON’S 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 !