Ashraf Zaki Flashcards
1
Q
What is meant by “Body Mass Index”?
A
Weight (Kg) / Height (M)². Normally = 20-25.
2
Q
What are causes of “orthopnic position”?
A
Left-sided heart failure.
Tense ascites.
Mediastinal mass.
Severe emphysema.
3
Q
What are other decubiti you know?
A
Lateral: Lung abscess.
Pleurisy.
Trepopnea.
Squatting: Fallot’s tetralogy.
Leaning forwards (kneeling): Pericardial effusion.
Pericarditis.
4
Q
What is “Glasgow Coma Scale”?
A
A scale to assess conscious level. It depends on 3 parameters:
Eye opening (5 degrees).
Verbal response (5 degrees).
Motor response (5 degrees).
Scale of 3 is deep coma, scale of 15 is fully conscious, and variable levels of consciousness lie in between.
5
Q
Causes of disturbed conscious level (or coma)?
A
Hysterical.
Organic: Intracranial causes.
Extracranial causes.
6
Q
How to “differentiate” intra from extracranial causes of coma?
A
Intracranial causes are associated with signs of lateralization (unilateral or asymmetrical neurologic deficit).
7
Q
What are “extracranial” causes of coma?
A
CO₂ narcosis (respiratory failure).
Hepatic encephalopathy (liver cell failure).
Uremic encephalopathy (renal failure).
Hypoglycemic coma.
Diabetic Keto Acidosis (DKA).
Diabetic Hyperosmolar non-ketotic coma.
Electrolyte disturbance.
8
Q
What are “precipitating factors” for hepatic encephalopathy?
A
High protein diet.
G.I.T. bleeding.
Constipation.
Hypokalemia.
Rapid tapping of ascites.
Infection.
9
Q
What is the most important “treatment” of hepatic encephalopathy?
A
Enema.
Lactulose & Neomycin.
Protein restriction.
10
Q
What is normal HR?
A
60-100 beats/minute.
11
Q
What are causes of “sinus tachycardia”?
A
Exercise.
Emotional stress.
Fever.
Thyrotoxicosis.
Heart failure.
Sympathomimetics.
Parasympatholytics.
12
Q
What are causes of “sinus bradycardia”?
A
During sleep.
Obstructive jaundice.
Sympatholytics (e.g., beta-blockers).
Parasympathomimetics.
Athletes.
13
Q
What is meant by “pulse deficit”?
A
Apical HR (by auscultation) is > radial HR due to irregular rhythm.
14
Q
How to differentiate between irregular pulse of AF & that of extrasystoles?
A
AF: Pulse deficit > 10.
Cannot count 4 regular beats.
Increases with exercise.
Extrasystole: Pulse deficit < 10.
Can count 4 regular beats.
Decreases with exercise.
15
Q
What are causes of “big pulse volume”?
A
Aortic regurgitation (AR).
Anemia.
Aortic atherosclerosis.
A-V fistula.
Beri Beri (vitamin B₁ deficiency).
Severe bradycardia.
Paget’s disease (increased osteoclastic activity).
PDA & Truncus arteriosus.
Pregnancy.
Thyrotoxicosis.
Vasodilators.
Hypoxia.
16
Q
What are causes of “small pulse volume”?
A
Decreased filling: Hypovolemia.
Tachycardia.
Cardiac tamponade.
Constrictive pericarditis.
Decreased pumping: Cardiomyopathy.
Myocarditis.
Myocardial infarction.
Intracardiac obstruction: Stenotic lesions (AS, PS, MS, TS).
17
Q
What are causes of “variable pulse volume”?
A
Any irregular rhythm (e.g., AF).
Some regular rhythms: Pulsus alternans.
Pulsus paradoxus.
18
Q
What is meant by “pulsus alternans”?
A
Pulse whose volume alternates between normal and weak. It is caused by severe left ventricular failure (LVF).
19
Q
How to diagnose pulsus alternans by sphygmomanometer?
A
During measuring ABP, Korotkoff sounds will appear at first as if slow, but with continuing cuff deflation, sudden doubling of Korotkoff’s sounds rate will occur.
20
Q
What is the mechanism of pulsus alternans in severe LVF?
A
Due to heterogeneity of refractoriness of the failed myocardium.
21
Q
What is meant by “pulsus paradoxus”?
A
Inspiratory decrease in pulse volume. It is an exaggeration of normal. It is caused by: Constrictive pericarditis.
Cardiac tamponade.
COPD.
22
Q
How to diagnose pulsus paradoxus by sphygmomanometer?
A
Expiratory SBP > Inspiratory SBP by > 10 mmHg.
23
Q
What are abnormal pulse characters?
A
Water Hammer: AR.
Bispherience: DA, AR, HOCM.
Parvus et tardus (plateau): AS.
Pulsus alternans: Severe LVF.
Pulsus paradoxus: COPD.
Pulsus bigeminy: Digitalis toxicity.
Pulsus trigeminy: Digitalis toxicity.
24
Q
What is the syn. of W.H.P.?
A
Collapsing pulse (when DBP is low).
25
What are causes of unequal pulse volume?
In the lumen: Thrombus or embolus.
In the wall: Dissection or aortic arch coarctation.
Outside the wall: Pancoast tumor or unilateral cervical rib.
26
Unequality of pulse.. in volume or rate?
In volume.
27
What is meant by “radiofemoral lag”?
Unlike normal, simultaneous radial & femoral pulsation shows delay (lag) in the femoral pulse after radial due to interruption of descending aortic flow by: Coarctation.
Thrombosis.
Dissection.
28
Where you prefer to comment on arterial wall?
Brachial artery... if rigid, it may be atherosclerotic.
29
If dorsalis pedis pulse is felt, do you need to palpate posterior tibial artery?
Yes... because dorsalis pedis is not the continuation of posterior tibial, but the anterior tibial.
30
What is meant by “force & tension”?
Force: Least pressure needed to just occlude the pulse. It is a rough assessment of SBP.
Tension: Least pressure needed to feel the pulse. It is a rough assessment of DBP.
31
Why we use “palpatory” method before auscultatory method in measurement of ABP?
To avoid underestimation of SBP if “auscultatory gap” is present.
32
What is the normal ABP?
Systolic: 100–140 mmHg.
Diastolic: 60–90 mmHg.
33
What is the normal temperature?
36.5–37.2°C.
34
What is the difference between fever & hyperpyrexia?
Fever: > 37°C to 40°C.
Hyperpyrexia: > 40°C.
35
What are causes of puffiness of eyelids?
Chronic cough (e.g., COPD).
Angioneurotic (allergic).
Myxedema.
Renal failure (nephritic or nephrotic).
36
What are causes of red glazed tongue?
Iron deficiency.
Vitamin B₁₂ deficiency.
Liver disease.
Diabetes mellitus.
Anticancerous drugs.
37
What are causes of bad odor of the mouth?
Fetor hepaticus (liver cell failure).
Ammoniacal (renal failure).
Acetone (diabetes mellitus).
Alcoholic (alcoholism).
38
Define Jaundice?
Yellowish discoloration of skin and mucous membranes due to elevation of serum total bilirubin > 2.5 mg%.
39
What is the normal level of serum bilirubin?
0.8–1.2 mg% (up to 0.2 mg% direct).
40
Why we inspect jaundice in daylight?
Because yellow light lamps produce artificial jaundice.
41
Why we inspect jaundice in “sclera”?
Because sclera is rich in elastin, which has a high affinity for bilirubin, and because sclera is white.
42
What “other causes” of yellow skin?
Hypercarotenemia (palms and soles).
Renal failure (dirty yellow skin).
Jaundice.
43
Tabulate the difference between different types of Jaundice?
Type: Hemolytic, Obstructive, Hepatocellular.
Bilirubin: Indirect ↑, Direct ↑, Both ↑.
Color: Lemon yellow, Olive green, Orange yellow.
Urine: Normal → Dark, Dark, Dark.
Stool: Dark, Pale, Pale.
44
Define Cyanosis?
Bluish discoloration of the skin & mucous membranes due to elevation of reduced Hb > 5 gm% in arterial blood of underlying capillaries.
45
What are “causes” of central cyanosis?
Extensive pulmonary disease.
Right-to-left shunt (Fallot’s tetralogy, Eisenmenger’s syndrome, TGA).
Polycythemia.
Liver cirrhosis (VDM → opening of intrapulmonary arteriovenous shunts).
Chemical cyanosis (e.g., methemoglobinemia, sulfhemoglobinemia).
46
What are “causes” of peripheral cyanosis?
Cold weather.
Low cardiac output (vasoconstriction of skin).
Peripheral vascular disease.
Polycythemia.
47
What produces “combined” central & peripheral cyanosis?
Polycythemia.
Cardiogenic APE.
48
How to unmask peripheral cyanosis in a patient with combined central & peripheral cyanosis?
Cold hands.
49
Can severe anemia produce central cyanosis?
Never... as this is incompatible with life.
50
What is meant by 'Differential Cyanosis'?
Cyanosis of lower limbs but not upper limbs. It is caused by PDA with preductal coarctation or pulmonary hypertension.
51
Can peripheral cyanosis occur in the tongue?
No... because peripheral cyanosis is caused by blood stagnation, which cannot occur in the tongue due to:
Proximity to the heart.
Being a movable organ.
Lack of sympathetic supply (no vasodilation).
Being in a closed warm cavity.
52
What is the only case in which peripheral cyanosis can occur in the tongue?
Lingual vein thrombosis → localized cyanosis in the tongue.
53
What is the difference between central & peripheral cyanosis?
Central: Occurs in the tongue.
Warm hands.
Warming hands worsens cyanosis.
Arterial O₂ ↓.
O₂ therapy improves cyanosis.
Clubbing.
Polycythemia (primary & secondary).
Hypoxic hypoxia.
Peripheral: Does not occur in the tongue.
Cold hands.
Warming hands improves cyanosis.
Normal.
No effect.
No clubbing.
Primary.
Stagnant hypoxia.
54
What are causes of 'butterfly rash'?
Malar flush (mitral stenosis with pulmonary hypertension).
Systemic lupus erythematosus.
Myxedema.
Pregnancy (brown).
Pellagra (brown).
55
What are “causes” of congested non-pulsating neck veins?
Superior vena cava obstruction (SVC).
56
What are causes of congested non-pulsating neck veins?
Superior vena cava obstruction (SVCO).
Cardiac tamponade.
Severe heart failure.
57
What are differences between neck veins and carotid pulsations?
| **Neck Veins** | **Carotid** |
|--------------------------------|----------------------------------|
| Anterior triangle. | Posterior triangle. |
| Seen more. | Felt more. |
| Pulsatile: | Wavy: |
| - 1 wave/cardiac cycle. | - 2 waves/cardiac cycle. |
| - Main movement: outward. | - Main movement: inward. |
| - Movement: out-in. | - Movement: out-in & up-down. |
| Not changeable with maneuvers. | Changeable with maneuvers: |
| | - Position. |
| | - Compression. |
| | - Respiration. |
| | - Valsalva. |
| | - Hepatojugular reflux (1-minute test).
58
What are causes of carotid shudder (thrill)?
Aortic regurgitation (AR).
Aortic stenosis (AS) (propagated from A₁).
59
What are causes of spider nevi?
Liver disease.
Vitamin B₁₂ deficiency.
Pregnancy.
Normal.
60
What is the distribution of spider nevi?
Areas drained by the superior vena cava (SVC).
61
What is the mechanism of spider nevi?
Not known, but two theories:
- Estrogen theory.
- VDM.
62
DD of spider nevi?
Insect bite.
Campbell de Morgan’s spots.
Purpura.
Venous star.
63
Most important causes of gynecomastia?
Liver cirrhosis (↑ estrogen).
Digitalis (estrogen-like).
Spironolactone (antiandrogen).
64
How to diagnose gynecomastia?
Firm tender disc beneath the nipple.
65
What are causes of tender edema in lower limbs?
Traumatic.
Deep vein thrombosis (DVT).
Cellulitis.
66
Where we elicit pitting in LL edema first?
Medial malleolus.
67
How to elicit pitting of edema in thigh & abdomen?
Pinching.
68
If no ankle edema, does that mean that the patient has no edema?
No... sacral edema (not ankle edema) is present in bedridden patients.
69
What are causes of bilateral edema in lower limbs?
Causes that ↑ hydrostatic pressure in capillaries:
- Heart failure.
- Pregnancy (local cause).
- Orthostatic.
- Steroidal & non-steroidal anti-inflammatory drugs.
- Renal failure.
Causes that ↓ osmotic pressure:
- Long-standing protein malnutrition.
- Chronic liver disease.
- Protein-losing nephropathies (e.g., nephrotic syndrome).
↑ Capillary permeability:
- Angioneurotic.
- Vasodilators.
Lymphedema & myxedema.
70
What is the mechanism of clubbing?
Chronic toxemia or chronic hypoxia → irritation of the nail bed → proliferation of the nail bed.
71
What are types of clubbing?
Pale (toxic).
Blue (hypoxic).
72
What are grades of clubbing?
Grade I: Nail angle obliteration.
Grade II: Parrot peak.
Grade III: Drumstick.
Grade IV: Pulmonary osteoarthropathy (due to bronchial carcinoma).
73
What is the test that detects mild clubbing?
Fluctuation test.
74
What are cardiac causes of clubbing?
Subacute bacterial endocarditis (SBE).
Congenital cyanotic heart disease.
75
What are chest causes of clubbing?
Cryptogenic fibrosing alveolitis.
Suppurative lung syndrome.
Bronchial carcinoma.
Mesothelioma.
76
What are abdominal causes of clubbing?
Bilharzial polyposis.
Primary biliary cirrhosis.
Inflammatory bowel disease.
Steatorrhea.
77
What are causes of palmar erythema?
Liver cirrhosis.
Thyrotoxicosis.
Tuberculosis.
Reticulocytosis.
Rheumatoid arthritis.
Vitamin B₁₂ deficiency.
Pregnancy.
Prolonged ACTH therapy.
Normal.
78
What are causes of flapping tremors?
End organ failure:
- Liver cell failure (LCF).
- Renal failure.
- Respiratory failure.
79
What are causes of spooning of nails?
Iron deficiency anemia.
80
What are causes of white nails?
Hypoalbuminemia.
Normal.
81
What are cardiac causes of jaundice?
Right-sided heart failure → liver congestion.
Prosthetic valve → hemolysis of RBCs.
Pulmonary infarction.
82
Dupuytren’s contracture occurs with what?
Alcoholic liver cirrhosis.
Diabetes mellitus.
83
What produces precordial bulge?
Right ventricular enlargement... dating back to childhood... due to congenital or rheumatic heart disease.
84
Define apex of the heart?
Outermost, lowermost, palpable, visible, strong, pulsating point on the chest wall.
85
What are causes of out displacement of cardiac apex?
Right ventricular enlargement.
Extracardiac causes:
- Left lung fibrosis or collapse (pulling the heart).
- Right pleural effusion or pneumothorax (pushing the heart).
86
What shifts the apex of the heart out & down?
Left ventricular enlargement.
87
Systolic bulge of the apex is caused by what?
Normal, or left ventricular enlargement.
88
Systolic retraction of the apex is caused by what?
Marked right ventricular enlargement.
89
What are localized and diffuse apices?
Localized: Well-defined, occupies 1 space (usually), caused by left ventricular enlargement or normal.
Diffuse: Ill-defined, occupies > 1 space, caused by right ventricular enlargement.
90
What are characters of the apex?
Normal: Gentle brief impulse.
Hyperdynamic: Forcible, non-sustained = Volume overload on LV.
Heaving: Forcible, sustained = Pressure overload on LV.
Slapping: Brief + palpable S1 = Mitral stenosis.
91
What produces thrill on the apex?
Systolic thrill = Mitral regurgitation (MR).
Diastolic thrill = Mitral stenosis (MS).
92
What is the cause of left parasternal uplift?
Right ventricular enlargement.
Marked left atrial dilatation due to severe MR.
93
What is the cause of pulmonary pulsation?
Pulmonary dilatation (pulmonary hypertension or left-to-right shunt).
94
What is meant by Diastolic shock?
Palpable S2 over the pulmonary area, caused by pulmonary hypertension.
95
What produces thrill on the cardiac base?
Systolic thrill over the pulmonary area = Pulmonary stenosis (PS).
Systolic thrill over the aortic area = Aortic stenosis (AS).
96
Causes of Epigastric pulsations?
From fingertips = Right ventricular enlargement.
From palm = Aortic pulsation.
From the right side = Hepatic pulsation.
97
Causes of Aortic pulsations?
Aortic regurgitation (due to big pulse volume).
Aortic aneurysm.
98
Most important cause of hepatic pulsation?
Tricuspid regurgitation (TR).
99
What is the difference between systolic and presystolic hepatic pulsation?
Systolic: Caused by TR, coincides with S1.
Presystolic: Caused by TS, precedes S1.
100
What are causes of invisible – impalpable apex?
Obesity.
Lies behind the rib.
Pleural effusion.
Pleural thickening.
Pneumothorax.
Emphysema.
Pericardial effusion.
Weak contraction.
Dextrocardia.
101
Causes of dullness outside the right sternal border?
Right atrial dilatation.
Other causes:
- Pericardial effusion.
- Chest causes (fibrosis, collapse, effusion).
- Dextrocardia.
- Aneurysm of the aortic root.
- Giant left atrium.
102
How to differentiate between pericardial effusion and pulmonary dilatation as a cause of dullness on the pulmonary area?
When we percuss the pulmonary area after the patient sits, it is turned to resonant in the case of pericardial effusion. This is due to reshaping of cardiac borders caused by the effect of gravity on the fluid. This may be termed shifting dullness.
103
What are causes of dullness outside cardiac apex?
Pericardial effusion & chest causes.
104
What are causes of enlarged bare area with stony dullness?
Right ventricular enlargement.
Pericardial effusion.
Chest causes (fibrosis, collapse, consolidation, effusion).
105
Where would you percuss the lower end of the sternum?
Right ½ of the lower end of the sternum.
106
What is the significance of stony dullness in the lower end of the sternum?
Significance: Huge right ventricle, pericardial effusion, chest causes.
Normal: Resonant by light percussion.
107
Percussion of the bare area is heavy or light?
Light percussion.
108
Using percussion, what is meant by Obliterated waist?
Dullness in the left 3rd space measures from the midline > ½ the distance between the midline and apex (about 4.5–5 cm). This means:
- Left atrial dilatation.
- Pulmonary dilatation.
- Pericardial effusion.
- Chest causes.
109
What is the extent of the bare area?
From the 4th–6th rib (4th & 5th space) & from the midline to the left parasternal line (2.5 cm in the 4th space & 5 cm in the 5th space).
110
What is meant by Tidal percussion?
After detecting dullness at the base of the right lung (using heavy percussion), we ask the patient to INSPIRE DEEPLY & repercuss. If turned to resonant = infradiaphragmatic dullness. If still dull, it may be:
- Supradiaphragmatic (1 space above is resonant).
- Diaphragmatic paralysis (1 space above is dull). (This is called reversed tidal percussion).
111
What are signs of right ventricular enlargement?
Apex: Diffuse, systolic retraction, shifted out.
Left parasternal uplift.
Epigastric pulsations coming from fingertips.
Precordial bulge.
Large & stony dull bare area.
Stony dullness at the lower sternal border.
112
What are signs of left ventricular enlargement?
Apex: Shifted out & down.
Hyperdynamic: If dilatation.
Heaving: If hypertrophy.
113
What are causes of volume overload on LV?
Aortic regurgitation (AR), mitral regurgitation (MR), ventricular septal defect (VSD), patent ductus arteriosus (PDA).
114
What are causes of pressure overload on LV?
Aortic stenosis (AS), aortic coarctation, hypertension.
115
Causes of right ventricular enlargement?
Dilatation: Volume overload (e.g., tricuspid regurgitation, ASD).
Hypertrophy: Pressure overload (e.g., pulmonary stenosis, pulmonary hypertension).
116
Causes of pulmonary hypertension?
Left-sided heart failure.
Extensive lung disease (= cor pulmonale).
Left-to-right shunt due to lung plethora leading to reversal of the shunt = Eisenmenger’s syndrome.
117
Signs of pulmonary hypertension?
Neck veins: Giant 'a' wave.
Inspection & palpation:
- Pulmonary pulsation.
- Diastolic shock.
Percussion: Dullness on the pulmonary area.
Auscultation:
1. Accentuated pulmonary component of S2.
2. Close splitting of S2.
3. Murmur of pulmonary regurgitation (Graham Steel murmur) due to dilatation of the pulmonary ring = early diastolic soft murmur.
4. Murmur of functional pulmonary stenosis (ejection systolic).
5. S4 on the tricuspid area.
118
Causes of accentuated 1st heart sound?
Mitral stenosis (MS).
Tricuspid stenosis (TS).
Tachycardia.
Hyperdynamic circulation.
Short PR interval (Cannon Sound).
119
Causes of variable S1?
Irregular rhythm.
120
What is the murmur of functional pulmonary stenosis?
Ejection systolic murmur.
121
What is S4 on the tricuspid area?
S4 heart sound detected in the tricuspid area.
122
What are the causes of an accentuated 1st heart sound?
Mitral stenosis (MS), tricuspid stenosis (TS), tachycardia, hyperdynamic circulation, short PR interval (Cannon Sound).
123
What are the causes of variable S1?
Irregular rhythm (e.g., atrial fibrillation), Cannon Sound (complete heart block).
124
What are the causes of a pansystolic murmur?
Mitral regurgitation (MR), tricuspid regurgitation (TR), ventricular septal defect (VSD).
125
What are the causes of an ejection systolic murmur?
Aortic stenosis (AS), pulmonary stenosis (PS).
126
What are the causes of diastolic murmurs?
Early diastolic: Aortic regurgitation (AR), pulmonary regurgitation (Graham Steel). Mid-diastolic with presystolic accentuation: Mitral stenosis (MS), tricuspid stenosis (TS).
127
Match the following: a. MS, b. MR, c. AS, d. AR
a → (4) Mid-diastolic rumbling with presystolic accentuation. b → (1) Pansystolic murmur – soft. c → (2) Ejection systolic harsh murmur. d → (3) Early diastolic soft murmur.
128
What is Carvallo’s Sign?
Murmur of tricuspid regurgitation (TR) becomes louder after deep inspiration.
129
What is the grade of a murmur associated with a thrill?
Grade > 4.
130
What is the grade of a murmur with no thrill?
Grade < 4.
131
What are peripheral signs of tricuspid regurgitation (TR)?
Systolic expansion of neck veins, systolic hepatic pulsations.
132
What are peripheral signs of aortic regurgitation?
3 Neck: 1. Visible carotid pulsation (Corrigan’s sign). 2. Systolic nodding of the head (De Musset sign). 3. Systolic thrill over the carotid artery (carotid shudder). 3 Upper Limbs: 1. Jerky pulsations felt in the palmar surface of the elevated arm (water hammer or collapsing pulse). 2. Wide pulse pressure (>60 mmHg) with low diastolic BP (<60 mmHg). 3. Digital pulsation or capillary pulsation (Quincke’s sign).
133
What is the definition of rheumatic fever?
It is a systemic inflammatory disorder characterized by affection of the collagen of various body structures secondary to streptococcal infection.
134
What are the criteria of rheumatic fever?
Major criteria:
1. Pancarditis: peri, myo, and endocarditis.
2. Fleeting arthritis: affects big joints > small joints, dramatic response to salicylates, never associated with chorea.
3. Subcutaneous (Aschoff’s) nodules.
4. Erythema marginatum: expands from the periphery & fades from the center.
5. Chorea: semi-purposeful jerky movements that occur proximally more than distally, more in females, and never associated with arthritis.
Minor criteria:
1. Fever.
2. Arthralgia (joint pain without clinical signs of inflammation).
3. Elevation of ESR, CRP, ASOT (rising rather than high).
4. Epistaxis.
5. Previous history of rheumatic fever (for rheumatic activity).
135
How to diagnose rheumatic fever?
It is diagnosed by the presence of 2 major criteria or 1 major + 2 minor criteria.
136
What is the difference between rheumatic fever, rheumatic heart disease, and rheumatic activity?
Rheumatic fever: It is the first attack of rheumatic fever.
Rheumatic heart disease: It is the scar left by rheumatic fever in the form of valvular affection.
Rheumatic activity: Rheumatic fever on top of rheumatic heart disease or the attack of rheumatic fever other than the first attack.
137
What is the treatment of rheumatic fever?
Prophylactic:
1. Long-acting penicillin (benzathine penicillin) 1,200,000 units/month or 21 days or 15 days.
2. Tonsillectomy.
Curative:
1. Complete physical & mental rest.
2. Diet: Salt restriction to avoid heart failure.
3. Drugs:
- Corticosteroids: Best for carditis, large dose, gradual withdrawal to avoid rebound.
- Salicylates: Best for arthritis, large dose.
- Antibiotics.
138
What are complications of rheumatic (valvular) heart disease (MS, AS, MR, etc.)?
1. Heart failure (right-sided or left-sided according to the cause).
2. Rheumatic activity.
3. Infective endocarditis.
4. Pulmonary hypertension (if left-sided heart failure, especially MS).
5. Deep vein thrombosis (DVT) & pulmonary embolism due to prolonged bed rest.
6. Arrhythmia (e.g., atrial fibrillation with MS that leads to left atrial thrombus, which may complicate with embolic manifestations, e.g., embolic hemiplegia).
139
What is the treatment of rheumatic (valvular) heart disease?
Treatment of complications:
- Heart failure:
1. Bed rest.
2. Salt restriction.
3. Drugs:
- Diuretics.
- Vasodilators (not in AS or MS).
- Digitalis.
- Rheumatic activity: As in rheumatic fever.
- Infective endocarditis: Antibiotics according to culture & sensitivity.
- DVT & pulmonary embolism: Heparin.
- Atrial fibrillation: Digitalis to reduce the rate, anticoagulation.
Treatment of the cause:
- Valve replacement: For calcific valve stenosis, severe valve incompetence, and double valve lesions.
- Valve repair: For valve incompetence.
- Valvotomy: Surgical or catheter balloon for valve stenosis.
140
Investigations of a cardiac case?
1. Chest X-ray: To detect:
- Chamber enlargement.
- Pulmonary congestion or edema.
2. ECG: To detect:
- Arrhythmia.
- Chamber enlargement.
3. Echocardiography: To detect:
- Chamber enlargement.
- Valvular affection (type, degree).
- Intracavitary masses (thrombus, tumor).
- Vegetations of endocarditis.
- Myocardial function (systolic, diastolic).
- Pericardial disease (effusion, constrictive pericarditis).
- Congenital abnormalities.
4. Cardiac enzymes (CPK, LDH): They increase in myocardial infarction.
5. Cardiac catheterization.
141
What are cardiac causes of jaundice?
1. Right-sided heart failure due to liver congestion & cirrhosis.
2. Pulmonary infarction.
3. Hemolysis of RBCs on a mechanical valve.
142
Cardiac causes of fever?
1. Rheumatic fever or activity.
2. Infective endocarditis.
3. Chest infection.
4. Myocardial infarction.
5. Deep vein thrombosis.
143
What is the surface anatomy of the right lung?
4 cm above the medial 1/3 of the clavicle → sternoclavicular junction → Angle of Louis in the midline → midline (6th rib) → midclavicular line (6th rib) → midaxillary line (8th rib) → scapular line (10th rib) → paravertebral line (10th rib).
144
What is the surface anatomy of the left lung?
As the right lung, but the midclavicular line is at the 4th rib.
145
What is the surface anatomy of the oblique fissure?
Starts at the 2nd thoracic spine & passes around the lateral chest wall to the midclavicular line at the 6th space, passing parallel to the medial scapular border, then the 5th rib in the midaxillary line.
146
What is the interscapular region formed of?
Apical segments of the lower lobes.
147
Examine lower lobes equals what?
Equals 'Examine the back.'
148
Surface anatomy of Kronig’s isthmus?
4 points:
1. Spine of C7.
2. Sternoclavicular junction.
3. Junction between the lateral 1/3 & medial 2/3 of the clavicle.
4. The middle of the scapular spine.
149
Describe Barrel chest?
Symmetrical.
Anteroposterior diameter > transverse diameter.
Wide subcostal angle.
Horizontal ribs.
Chest moves up & down as one unit due to overaction of accessory muscles of inspiration.
150
What is the cause of Barrel Chest?
Hyperinflation (e.g., emphysema).
151
What other symmetrical chest shapes?
Elliptical: Normal.
Pigeon: Rickets, severe respiratory distress since childhood (e.g., bronchial asthma), osteomalacia, Marfan’s syndrome.
Pectus excavatum: Congenital (shoemaker).
Alar (flat): Normal.
Kyphosis.
152
How to differentiate normal from abnormal hemithorax (bulge & retraction) clinically?
The side of restricted chest expansion is the abnormal one; it may be a bulge or retraction.
153
What are causes of unilateral chest bulge & retraction?
Bulge: Pleural effusion & pneumothorax.
Retraction: Lung fibrosis or collapse.
154
What are causes of abdominal respiratory movement?
Pleurisy.
Pleural effusion.
Intercostal muscle paralysis.
Ankylosing spondylitis.
Severe emphysema.
155
What are causes of thoracic respiratory movement?
Tense ascites.
Diaphragmatic paralysis.
Peritonitis.
156
What is the normal respiratory rate?
14–20 breaths/minute.
157
What are causes of bradypnea?
Increased intracranial tension.
Morphine toxicity.
Barbiturate toxicity.
158
What are causes of rapid deep breathing?
Metabolic acidosis (e.g., diabetic ketoacidosis, uremia).
Massive pulmonary embolism.
Exercise.
Emotional stress.
159
What are causes of rapid shallow breathing?
Extensive pulmonary diseases.
160
What are accessory muscles of inspiration?
Sternomastoids.
Scalene.
Trapezius.
161
What is the aim of pursing of lips?
To keep intrabronchial pressure high, avoiding bronchial collapse during forced expiration.
This sign occurs with obstructive airway disease (e.g., COPD, bronchial asthma).
162
What is Litten’s sign?
Normally: A rippling shadow is seen down the lower intercostals following diaphragmatic descent during deep inspiration in thin individuals.
Litten’s sign: Unilateral absence of this shadow, caused by:
- Diaphragmatic paralysis.
- Lower lobar pathology or infradiaphragmatic pathology that interferes with diaphragmatic descent.
163
Importance of examination of cardiac pulsation in chest patients?
Invisible apex:
- Emphysema.
- Left-sided effusion or pneumothorax.
Causes of apical shift:
- Lesion pulling the heart: fibrosis, collapse.
- Lesion pushing the heart: effusion or pneumothorax.
Signs of pulmonary hypertension & right ventricular enlargement in a chest case may indicate cor pulmonale.
164
Causes of shifted trachea?
Lung fibrosis or collapse: shifted to the same side.
Pleural effusion or pneumothorax: shifted to the opposite side.
165
Causes of tender chest wall?
Pleurisy (lower axillary, beneath breasts).
Myositis.
Osteomyelitis.
Costochondritis (Tietze’s disease).
Thrombophlebitis (Mondor’s disease).
Leukemia (tender sternum).
Herpes zoster (unilateral, dermatomal).
166
Tactile vocal fremitus is increased by what?
Consolidation.
Cavitation.
Other causes:
- Collapse with a patent main bronchus.
- Upper level of pleural effusion.
167
Tactile vocal fremitus is decreased by what?
Obstructive airway disease (e.g., severe bronchial asthma, obstructive lung collapse).
Barrier (e.g., obesity, pleural effusion, pneumothorax).
Lung tissue destruction (e.g., emphysema, lung collapse).
168
Causes of palpable rhonchi?
Obstructive airway disease (e.g., bronchial asthma, COPD).
Foreign body.
Tumor.
Secretions.
169
What are causes of limited chest expansion?
Bilateral:
- Emphysema.
- Lung fibrosis.
Unilateral:
- Pleural effusion.
- Pneumothorax.
- Fibrosis.
- Collapse.
- Pneumonia.
170
What is Trail’s sign?
Unilateral bulge of the sternomastoid tendon due to marked tracheal shift.
171
Causes of dullness on the lung?
Fibrosis.
Collapse.
Consolidation.
Abscess.
Tumor.
172
Causes of stony dullness on the lung?
Pleural effusion.
173
What is meant by hyperresonant lung?
This means that dullness of the bare area and/or upper hepatic border is encroached by pulmonary resonance due to hyperinflation of the chest (e.g., emphysema, pneumothorax).
174
What are causes of dullness on Kronig’s isthmus?
1. Pancoast tumor.
2. Friedlander’s bronchopneumonia (Klebsiella pneumonia).
3. Tuberculous bronchopneumonia.
4. Apical lung fibrosis (e.g., tuberculosis).
5. Apical lung abscess (e.g., tuberculosis).
6. Apical lung collapse.
175
What are causes of dullness on 'Kronig’s isthmus'?
1. Pancoast tumor.
2. Friedlander’s bronchopneumonia (Klebsiella pneumonia).
3. Tuberculous bronchopneumonia.
4. Apical lung fibrosis (e.g., tuberculosis).
5. Apical lung abscess (e.g., tuberculosis).
6. Apical lung collapse.
7. Apical pleural thickening.
8. Apical encysted pleural effusion.
176
Surface anatomy of Traub’s area?
6th rib → left midclavicular line.
8th rib → left posterior scapular line.
9th rib → left midaxillary line.
11th rib → left midaxillary line.
177
What are borders of 'Traub’s area'?
Upper border: Lower border of the left lung.
Lower border: Left costal margin.
Left border: Anterior border of the spleen.
Right border: Lower border of the left lobe of the liver.
178
Contents of 'Traub’s area'?
Fundus of the stomach.
Left pleura.
179
Note of percussion of normal Traub’s area?
Tympanitic resonant.
180
Causes of dullness on Traub’s area?
1. Splenomegaly (< 3 times normal size).
2. Hepatomegaly (left lobe).
3. Ascites.
4. Pregnancy.
5. Pleural effusion.
6. Pericardial effusion.
7. Full stomach.
8. Fundal tumor.
9. Situs inversus totalis.
181
'Physiological' causes of dullness on Traub’s area?
Full stomach.
Pregnancy.
182
How to differentiate supradiaphragmatic (chest) causes from infradiaphragmatic (abdominal) causes of dullness on Traub’s area?
By tidal percussion.
183
How to differentiate 'pleural' causes from 'pulmonary' causes of dullness at the base of the left lung?
Percuss Traub’s area → dullness = pleural causes.
184
What are causes of enlarged Traub’s area?
1. Splenectomy.
2. Shrunken liver.
3. Pneumothorax.
4. Pneumoperitoneum.
5. Dilated stomach.
185
How to diagnose hydropneumothorax by percussion?
By shifting dullness technique using one of three methods:
1. From the back.
2. From the front (2 directions).
186
What are the causes of diminished intensity of breath sounds?
* Pleural effusion
* Shallow pneumothorax
* Obesity
* Severe bronchospasm
* Obstructive lung collapse & fibrosis
* Emphysema
187
Describe 'normal vesicular' breathing.
* Rustling
* Expiration = 1/3 of inspiration
* No gap between inspiration & expiration
188
Describe 'vesicular breathing with prolonged expiration'.
* Rustling
* No gap
* Expiration is prolonged (> inspiration) & usually wheezy
189
What are the causes of vesicular breathing with prolonged expiration?
1. Chronic bronchitis
2. Bronchial asthma
3. Emphysema
190
Describe bronchial breathing.
* Hollow
* Gap between inspiration & expiration
* Expiration = inspiration
191
What are the causes of bronchial breathing?
1. Consolidation
2. Cavitation (large, superficial, empty, connected to a bronchus)
3. Other causes:
* Collapse with a patent main bronchus
* Collapse with an obstructed main bronchus if apical due to direct conduction of bronchial sounds from the trachea
* Upper level of pleural effusion
* Open & tension pneumothorax
* Normal main bronchi & trachea
192
What is the classification of bronchial breathing?
* Tubular:
* Consolidation
* Collapse
* Cavernous:
* Cavity
* Amphoric:
* Cavity with a rigid wall
* Open or tension pneumothorax
193
What is the significance of the 'pitch' of rhonchi?
* Sibilant: Severe narrowing of the airway (especially distal small bronchi)
* Sonorous: Mild narrowing of the airway (especially central large bronchi)
* Polyphonic: Generalized narrowing of the airway
194
What is the significance of the 'length' of rhonchi?
* Long: Severe airway stenosis
* Short: Mild airway stenosis
195
What is the significance of 'timing' of rhonchi?
* Expiratory: Mild airway stenosis
* Inspiratory: Severe airway narrowing or secretions
196
What is the significance of 'distribution' of rhonchi?
* Generalized: Generalized airway stenosis (e.g., bronchial asthma, bronchitis, emphysema)
* Localized: Localized airway stenosis (e.g., foreign body, tumor, secretions)
197
What does it mean if rhonchi are cleared by cough?
Bronchial secretions
198
Why are 'bronchial asthmatic' rhonchi mainly peripheral?
Bronchial stenosis due to bronchial asthma is based on bronchospasm, which requires smooth muscles (more in peripheral bronchi)
199
Which has a higher possibility of risk, generalized rhonchi or localized rhonchi?
Localized rhonchi because it may be a tumor
200
What are the types of crepitations?
* According to timing:
* Early inspiratory = Bronchial disease
* Late inspiratory = Alveolar disease
* According to type & number:
* Coarse & scanty = Bronchial disease
* Fine (or medium) & profuse = Alveolar disease
* According to quality:
* Consonating = Lung tissue destruction (e.g., pneumonic consolidation)
* Non-consonating = Pulmonary edema
201
What are the causes of fine (or medium) late inspiratory crepitations?
1. Interstitial lung fibrosis
2. Left-sided heart failure (pulmonary congestion)
3. Pneumonic consolidation (medium, consonating)
4. Lung abscess (coarse late inspiratory)
202
What are the causes of early inspiratory (coarse) crepitation?
1. Bronchiectasis (mid-inspiratory)
2. Bronchitis
3. Bronchiolitis
4. Bronchial asthma
5. Acute pulmonary edema
203
What are the causes of pleural rub?
Pleurisy
204
What is D’Espine’s sign?
Bronchial breathing (or whispering pectoriloquy) below the body of T4 vertebra caused by conduction of the sound of bronchi at the carina through a large mediastinal mass (e.g., lymph nodes or tumor)
205
What are special tests in chest auscultation?
* D’Espine’s sign: Mediastinal mass
* Coin test: Pneumothorax
* Succussion splash: Hydropneumothorax
* Post-tussive suction: Lung abscess
206
What is meant by 'vocal resonance'?
While auscultating the chest, ask the patient to say '44' once in a clear normal voice and once in a whispering voice.
207
What are the investigations of a chest case?
1. Chest X-ray
2. Arterial blood gases
3. Sputum culture & sensitivity
4. Skin test
5. Analysis of pleural fluid
6. Respiratory function test
7. V/Q (ventilation/perfusion) scanning
8. Bronchoscopy
9. Bronchogram
208
What are manifestations of respiratory failure (Type II: O₂↓, CO₂↑)?
1. Central cyanosis
2. CO₂ narcosis
3. Tachypnea (>40/min = decompensated respiratory failure)
4. Others:
* Clubbing of fingers in chronic respiratory failure
* Working ala nasi (in pneumonia)
* Overaction of accessory muscles of respiration
* Flapping tremors
* May have bilateral pitting edema in lower limbs
209
What are the causes of cor pulmonale?
* Acute:
* Tension pneumothorax
* Massive pulmonary embolism
* Subacute:
* Showers of small pulmonary emboli
* Lymphangitis carcinomatosa
* Chronic:
* Hypoxic: COPD
* Obliterative: Fibrosis of the lung
* Restrictive: Severe skeletal deformity
210
What are the manifestations of cor pulmonale?
1. Manifestations of primary chest disease
2. Manifestations of pulmonary hypertension
3. Manifestations of right ventricular enlargement
4. Manifestations of right ventricular failure
211
What is the treatment of bronchial asthma?
| Between Attacks | During Attack |
|-----------------------------------|----------------------------------|
| 1. Avoid antigen. | 1. O₂ therapy. |
| 2. Corticosteroids (oral). | 2. Bronchodilators: |
| 3. Mast cell stabilizers: | - Aminophylline (IV). |
| - Intal. | - Salbutamol (inhaler). |
| - Ketotifen. | 3. Mucolytics. |
| 4. Antibiotics. | 4. Antibiotics. |
212
What are chest causes of jaundice?
1. Cor pulmonale
2. Pulmonary infarction
3. Anti-TB drugs (hepatotoxic)
4. Bronchogenic carcinoma with liver metastasis
5. Suppurative lung syndrome with liver amyloidosis
6. Associated liver disease
213
What are chest causes of edema in lower limbs?
1. Cor pulmonale
2. Hypoproteinemia due to:
* Recurrent tapping of pleural effusion
* Chronic expectoration
* Renal & liver amyloidosis secondary to suppurative syndrome
* Bronchogenic carcinoma with liver metastasis
214
What are causes of suppurative lung syndrome?
1. Lung abscess
2. Bronchiectasis
3. Empyema with bronchopleural fistula
215
What is the importance of pulse examination in a chest case?
1. Rate: Tachycardia caused by:
* β-stimulants in the treatment of bronchial asthma
* Hypoxia
2. Volume:
* Big: Vasodilation due to hypoxia
* Small: ↓ Cardiac output due to cor pulmonale
3. Character:
* Pulsus paradoxus in COPD or severe asthma
* Water hammer pulse due to vasodilation caused by hypoxia
4. Equality: Unequal pulse volume (e.g., Pancoast tumor)
5. Rhythm: Irregular (e.g., multifocal atrial tachycardia in COPD)
216
How to differentiate intraabdominal from extra-abdominal swelling?
Ask the patient to elevate their trunk unsupported:
* If swelling ↓ → Intraabdominal
* If swelling ↑↑ → Extraabdominal
217
How to differentiate between lipoma, hernia & varicose vein on the abdomen?
* Lipoma:
* No expansile impulse on cough
* Slippery edge
* Hernia:
* Expansile impulse on cough
* Reducible
* Varicosities:
* Expansile impulse on cough
* Thrill
218
What is the cause of a 'wide' subcostal angle?
Wide subcostal angle indicates chronic ↑ intra-abdominal pressure due to upper abdominal mass (e.g., hepatomegaly, splenomegaly, ascites, or emphysema)
219
What are causes of divaricated recti?
Chronic increase in intra-abdominal pressure (e.g., hepatomegaly, splenomegaly, tense ascites). It may be congenital.
220
What are causes of downward displacement of the umbilicus?
* Upper abdominal mass (e.g., hepatomegaly or splenomegaly)
* Ascites
221
What is the normal site of the umbilicus?
Midway between the symphysis pubis
222
What are the causes of divaricated recti?
Chronic increase in intra-abdominal pressure (e.g., hepatomegaly, splenomegaly, tense ascites). It may be congenital.
## Footnote
N/A
223
What are causes of downward displacement of the umbilicus?
* Upper abdominal mass (e.g., hepatomegaly or splenomegaly)
* Ascites
## Footnote
N/A
224
What is the normal site of the umbilicus?
Midway between the symphysis pubis and the xiphisternal junction.
## Footnote
N/A
225
What are causes of bulging of the umbilicus?
* Increased intra-abdominal pressure by tense ascites
* Umbilical & paraumbilical hernia
## Footnote
N/A
226
What is 'caput medusae'?
Dilated veins radiating away from the umbilicus, caused by reopening of the umbilical vein due to high pressure in the portal vein in cases of portal hypertension.
## Footnote
N/A
227
What makes an adult male have a 'feminine' hair distribution?
Liver cirrhosis due to lack of destruction of estrogen.
## Footnote
N/A
228
What are complications of scars?
* Keloid
* Pigmentation
* Delayed healing
* Sinus
* Bleeding
* Infection
* Surgical emphysema
* Incisional hernia
## Footnote
N/A
229
What are causes of 'stria alba'?
* Tense ascites
* Marked obesity
* Repeated pregnancy
* Severe dieting
* Healed stria rubra
## Footnote
N/A
230
What is the cause of 'stria rubra'?
Cushing’s syndrome.
## Footnote
N/A
231
What are medical causes of 'pruritus'?
* Obstructive jaundice
* Diabetes
* Uremia
* Bilharziasis
* Drug hypersensitivity
## Footnote
N/A
232
What is the cause of visible veins on the abdomen?
Tense ascites.
## Footnote
N/A
233
If there is a dilated vein (D.V.) below the umbilicus, how to differentiate its causes?
By **milking test**: Rapid refilling:
- **From above → Portal hypertension.**
- **From below → Inferior vena cava obstruction.**
234
Where are the hernial 'orifices'?
1. Epigastric.
2. Umbilical.
3. Incisional.
4. Inguinal.
5. Scrotal.
235
What is the cause of 'visible peristalsis'?
Intestinal obstruction.
236
What is the importance of examining 'male genitalia' in an abdominal case?
1. Testicular atrophy → Liver cirrhosis.
2. Scrotal edema → Liver failure, nephrotic syndrome.
3. Hydrocele → Ascites.
4. Varicocele → Intraabdominal tumor.
5. Thick spermatic cord → Bilharziasis.
6. Sinus on the back of the scrotum → TB peritonitis.
237
What are the 'aims' of superficial palpation?
1. Detect:
- Superficial masses.
- Tenderness.
- Guarding.
- Rigidity.
- Thrill.
2. Prepare the patient for deep palpation.
238
What is the difference between 'guarding & rigidity'?
- **Guarding:** Localized contraction of the anterior abdominal wall (e.g., appendicitis, cholecystitis).
- **Rigidity:** Diffuse contraction of the anterior abdominal wall (e.g., peritonitis).
239
What are 'normally palpable' structures in the abdomen?
Lower hepatic edge.
Abdominal aorta.
Sigmoid colon.
Lower right renal pole.
Rectus abdominis.
Inguinal lymph nodes.
240
What are different methods of palpation of the liver and spleen?
1. Single-handed.
2. Two-handed.
3. Enforced (for thick/rigid abdomen).
4. Bimanual (for thick/rigid abdomen).
5. Hooking (for shrunken liver/impalpable spleen).
6. Dipping (in tense ascites).
241
What are points to 'comment on' for a palpable liver or spleen?
1. Size (cm or fingerbreadth).
2. Border (sharp/rounded).
3. Surface (smooth/irregular).
4. Consistency (soft/firm/hard).
5. Tenderness.
6. Pulsation.
7. Notch (spleen).
8. Pittiness (spleen).
242
What is liver 'span'?
Vertical distance in cm in the midclavicular line (MCL) between upper and lower liver borders.
- **Normal:**
- ♀: 8–10 cm.
- ♂: 10–12 cm (up to 15 cm).
243
What are causes of 'tender' liver?
Congested (e.g., right-sided heart failure).
Inflamed (e.g., hepatitis).
Malignancy infiltrating the capsule.
244
What are causes of 'multiple' splenic notches?
Multiple splenic infarctions.
Congenital.
245
What are causes of 'absent' splenic notch?
Adhesions.
Malignancy.
Congenital.
246
What is Mofti’s sign?
Pittiness of the spleen due to **chronic myeloid leukemia (CML)**.
247
Causes of 'pulsating' liver?
Tricuspid regurgitation (TR).
Tricuspid stenosis (TS).
Right ventricular failure (RVF).
248
What is the 'method' of renal palpation?
**Bimanual method:**
- Right hand in hypochondrium.
- Left hand in renal angle.
- Ask the patient to inspire deeply.
249
What is meant by 'Huge spleen'? & What are its causes?
**Huge spleen:** Crosses the midline.
**Causes:**
1. Congestive splenomegaly (portal hypertension due to bilharzial fibrosis).
2. Thalassemia major.
3. Chronic myeloid leukemia.
4. Chronic malaria.
5. Myeloproliferative disorders (polycythemia vera, myelosclerosis).
6. Kala-azar (leishmaniasis).
250
How to differentiate splenomegaly from a renal mass?
| **Renal Mass** | **Splenomegaly** |
|-------------------------------|---------------------------------|
| Ballottable. | Not ballottable. |
| Descends with late inspiration. | Descends with early inspiration. |
| Band of resonance across dullness. | Continuous dullness. |
| No notch. | Notch present. |
| Round lower pole. | Sharp anterior border. |
| Rarely crosses midline. | Can cross midline. |
251
What are causes of ascites?
| **Transudate** | **Exudate** |
|-------------------------------|---------------------------------|
| Right-sided heart failure. | Pancreatitis. |
| Nephrotic syndrome. | TB peritonitis. |
| Liver failure. | Malignancy. |
| Meig’s syndrome. | Ruptured viscus (blood). |
| Myxedema. | Budd-Chiari syndrome. |
252
Percussion of the abdomen is light or heavy?
Light, except for the upper liver border.
253
Why detect the upper liver border before palpating its lower border?
- Differentiate ptosis from enlargement.
- Estimate liver span.
254
How to detect 'earliest' splenomegaly?
Percuss the anterior axillary line (AAL) in spaces 8, 9, and 10 before and after deep inspiration:
- **Resonant → dull after inspiration = earliest splenomegaly.**
255
Why does the spleen enlarge towards the right iliac region?
Guided by the **phrenicocolic ligament**.
256
Causes of 'vertical enlargement' of the spleen?
1. Malignancy.
2. Ruptured phrenicocolic ligament.
257
Why flex the patient’s legs during deep abdominal palpation?
To relax superficial fascia (no deep fascia in the abdomen).
258
What is auscultated in the abdomen?
1. **Intestinal sounds:**
- ↑↑: Intestinal obstruction, diarrhea, thyrotoxicosis.
- ↓↓: Postoperative handling, long-standing obstruction, myxedema, verapamil.
2. **Venous hum:** Portal hypertension.
3. **Bruits:**
- Epigastric: Superior mesenteric artery stenosis.
- Umbilical: Aortic dissection.
- Subcostal: Renal artery stenosis.
- Iliac: Common iliac artery stenosis.
- Femoral: Femoral artery stenosis.
4. **Peritoneal rub:** Malignancy/infarction of liver/spleen.
5. **Scratch test:** Detect liver edge.
6. **Succussion splash:** Pyloric obstruction.
7. **Puddle sign:** Minimal ascites.
259
What are manifestations of liver cell failure?
1. Hepatic encephalopathy (↑ ammonia).
2. Jaundice.
3. Bleeding tendency (↓ prothrombin, thrombocytopenia).
4. Foetor hepaticus (methyl mercaptan).
5. Red glazed tongue (vitamin B₁₂ deficiency).
6. Spider nevi.
7. Gynecomastia (↑ estrogen).
8. Flapping tremors.
9. Palmar erythema.
10. Clubbing (primary biliary cirrhosis).
11. Ascites (hypoalbuminemia + portal hypertension).
12. Feminine hair distribution (↑ estrogen).
13. Bilateral pitting edema (hypoalbuminemia).
260
Investigations of a liver case?
1. **Liver enzymes:**
- ALT (↑ in acute liver disease).
- AST (↑ in chronic liver disease).
- GGT (specific for liver).
- Alkaline phosphatase (↑ in liver/bone disease).
2. **Bilirubin:** Total, direct, indirect.
3. **Plasma proteins:** Albumin, globulin, A/G ratio, AFP (↑ in hepatoma).
4. **Prothrombin:** Concentration/time.
5. **CBC:** Pancytopenia (hypersplenism).
6. **Urine/stool:** Bilharzial ova.
7. **Hepatitis markers:** B & C.
8. **Abdominal sonar/CT:** Ascites, liver/spleen abnormalities.
9. **Endoscopy:** Esophageal varices, peptic ulcer.
261
Causes (types) of liver cirrhosis?
1. Post-hepatitic (B, C).
2. Alcoholic.
3. Hemochromatosis.
4. Wilson’s disease.
5. Right-sided heart failure (cardiac cirrhosis).
6. Biliary cirrhosis.
262
Definition of liver cirrhosis?
Degeneration, regeneration, loss of architecture, and fibrosis.
263
Portal hypertension: Causes?
1. **Pre-sinusoidal:** Portal vein thrombosis, bilharzial fibrosis.
2. **Sinusoidal:** Liver cirrhosis.
3. **Post-sinusoidal:** Budd-Chiari syndrome, IVC obstruction, constrictive pericarditis.
264
Definition of hypersplenism?
↑ Phagocytic activity of the spleen.
265
Treatment of ascites?
1. Bed rest.
2. Diet: ↑ protein, ↓ salt.
3. Salt-free albumin + diuretics.
4. LeVeen shunt.
5. Tapping.
266
Causes of splenomegaly?
1. **Infective:**
- Parasitic (bilharziasis, kala-azar).
- Chronic (malaria, TB).
- Acute (endocarditis, septicemia).
2. **Inflammatory:** SLE, rheumatoid arthritis.
3. **Malignant:** Lymphomas.
4. **Hematological:** Leukemias, polycythemia.
5. **Metabolic:** Amyloidosis.
267
Causes of hepatomegaly?
1. Early cirrhosis.
2. Inflammatory (hepatitis, abscess).
3. Neoplastic (hepatoma, metastasis).
4. Hematological (leukemia, thalassemia).
5. Congestive (right heart failure).
6. Metabolic (fatty liver, amyloidosis).
7. Biliary obstruction.
268
Grades of bilharzial hepatosplenomegaly?
Grade I: Hepatomegaly.
Grade II: Hepatosplenomegaly.
Grade III: Splenomegaly + shrunken liver.
Grade IV: Grade III + ascites.
269
Causes of hematemesis (≈ melena)?
1. Ruptured esophageal varices.
2. Peptic ulcer.
3. Gastritis.
4. Gastric carcinoma.
5. Bleeding tendency.
6. Mallory-Weiss syndrome.
270
What is the 'Pyramidal tract' pathway?
Cortex (area 4) → Corona radiata → Internal capsule → Brainstem → Crosses midline at medulla → Anterior horn cells (contralateral).
271
What is a peptic ulcer?
A peptic ulcer is a sore that develops on the lining of the stomach, small intestine, or esophagus.
272
What is gastritis?
Gastritis is the inflammation of the stomach lining.
273
What is gastric carcinoma?
Gastric carcinoma is a type of cancer that occurs in the stomach.
274
What is a bleeding tendency?
A bleeding tendency refers to an increased likelihood of bleeding due to various medical conditions.
275
What are criteria of Lower motor neurone lesion?
1. Paralysis.
2. Hypotonia.
3. Hyporeflexia.
4. Wasting.
5. Fasciculation (if AHCs or motor Cr. Nuclei irritation).
276
What are criteria of Lower motor neurone lesion?
1. Paralysis. 2. Hypotonia. 3. Hyporeflexia. 4. Wasting. 5. Fasciculation (if AHC_s or motor Cr. Nuclei irritation).
277
What are criteria of Upper motor neurone lesion?
1. Paralysis. 2. Hypertonia. 3. Hyperreflexia. 4. No or mild wasting. 5. No trophic changes.
278
What is nerve supply of tongue?
Motor: Hypoglossal nerve (XII). Sensory: - Anterior 2/3: - Taste: Facial nerve (VII). - General sensation: Trigeminal nerve (V). - Posterior 1/3: - Taste: Glossopharyngeal nerve (IX). - General sensation: Glossopharyngeal nerve (IX).
279
What are sure signs of bilateral pyramidal tract lesion?
1. Appearance of jaw reflex. 2. Precipitancy.
280
What is meant by Gower’s test – Gower’s sign & Gower’s disease?
1. Gower’s test: Test for shoulder girdle TONE. 2. Gower’s sign: Climbing sign for pelvic girdle myopathy. 3. Gower’s disease: Distal type of myopathy.
281
What is grading of muscle power?
(0): Complete paralysis. (1): Contraction but no movement. (2): Movement with gravity. (3): Movement against gravity. (4): Movement against gravity & some resistance. (5): Full strength.
282
What is grading of deep reflex?
| Grade | Description |
|---|---|
| (0) | - Absent = Areflexia. |
| | + Present only with re-enforcement. |
| (1) | + Just present = Sluggish. |
| (2) | ++ Normal = Brisk. |
| (3) | +++ Exaggerated = Very brisk = Hyperreactive. |
| (4) | ++++ Clonus.
283
What is inverted supinator reflex?
Components: 1. Lost biceps reflex (C_{5-6}). 2. Exaggerated triceps reflex (C_{6-7}). 3. Abnormal brachioradialis reflex (flexion of fingers). Lesion: At C_5.
284
What are causes of Babineski sign?
Babineski sign: (extensor response) - Definition: Dorsiflexion of big toe (± fanning of other toes). - Cause: 1. Δ (± Extra Δ) tract lesion. 2. Deep sleep, deep coma, or deep anesthesia. 3. Infants < 1 years.
285
What are causes of equivocal plantar reflex?
Absent (equivocal) response: Destruction in: - Receptor: . Thick skin. . Cold skin. - Centre: Lesion in S1. - Afferent: Peripheral neuropathy. - Efferent: LMNL. - Pyramidal: Shock stage of UMNL. - Musculoskeletal: foot deformity.
286
What are causes of hyperreflexia?
1. UMNL. 2. Thyrotoxicosis. 3. Tetany. 4. Hysterical. 5. Drug addiction.
287
What are causes of hyporeflexia?
1. LMNL. 2. Posterior root affection. 3. Cerebellar ataxia. 4. Chorea. 5. Myxedema (delayed reflex). 6. Hypothermia.
288
What are causes of lost ankle, preserved knee reflex?
1. Friedrech’s ataxia. 2. SCD. 3. Peripheral neuropathy. 4. Epiconus lesion. 5. Cauda equina lesion of S1. 6. Holmes - Adies myotonic pupil.
289
What are causes of lost ankle, exaggerated knee reflex?
1. Friedrech’s ataxia. 2. Pellagra. 3. SCD.
290
What are sure signs of pyramidal tract lesion?
Sure sign of pyramidal tract lesion: 1. Babineski sign. 2. Clonus. 3. If bilateral: - +ve jaw reflex (pathological reflex). - Precipitancy.
291
What are causes of hypotonia?
1. Lower motor neurone lesion (LMNL). 2. Shock stage of upper motor neurone lesion. 3. Cerebellar ataxia. 4. Rheumatic chorea. 5. Peripheral neuropathy. 6. Posterior column lesion. 7. Hysterical.
292
What is the difference between rigidity & spasticity?
| | Spasticity | Rigidity |
|---|---|---|
| Site of lesion | Δ tract lesion | Extra Δ tract lesion. |
| Pattern | Clasp knife | Lead pipe Cog wheel |
| Distribution | 1. Distal > proximal. 2. Antigravity muscles. a. Flexors of UL. b. Extensors of LL & trunk. c. Adductors. | 1. Proximal > distal. 2. Flexors. |
| Deep reflexes | Hyperreflexia | Hyporeflexia |
293
What is the root value of the following reflexes?
1. Biceps: C_{5-6}. 2. Triceps: C_{6-7}. 3. Brachioradialis: C_{5-6}. 4. Knee: L_{2-3-4}. 5. Ankle: S_{1-2}. 6. Adductor: L_4. 7. Patellar: L_{2-3-4}. 8. Jaw: Trigeminal. 9. Glabellar: Facial. 10. Corneal & Conjunctival: C_{15-7}. 11. Pharyngeal: C_{19-10}. 12. Palatal: C_{15-10}. 13. Plantar: S_1.
