Essential Examination 2nd Edition: MEDICINE Flashcards
(99 cards)
1
Q
What is exaggerated carotid pulse called and what is it a sign of?
A
Corrigan’s Sign
Sign of AR
2
Q
DDx for Submammary Scar
A
Mitral Valvotomy
Pericardial Window
3
Q
DDx Heave
A
Parasternal RVH
Apical LVH
4
Q
What veins are commonly harvested for CABG?
A
Saphenous Vein
Radial artery
Left Internal mammary artery
5
Q
How do you differentiate between different types of cyanosis?
A
Pure peripheral cyanosis causes COLD blue hands
Central cyanosis causes blue lips and tongue and when severe can causes WARM blue hands
6
Q
DDx for Peripheral Cyanosis
A
Peripheral Vascular Disease
Raynaud’s Syndrome
Heart Failure
Shock
7
Q
DDx for Central Cyanosis
A
Hypoxic Lung disease
Right to Left cardiac shunt. (cyanotic congenital heart disease, eisenmenger’s syndrome)
8
Q
Differential of an irregularly irregular pulse
A
AF
Ventricular ectopic beats
Complete heart block with variable ventricular escape.
9
Q
How do you differentiate between AF and Ventricular ectopic beats?
A
Can do an ECG
or
Exercise the patient- this will abolish ventricular ectopic beats but AF will remain
10
Q
Causes of an absent radial Pulse
A
Congenital- if this is the case it is normally bilateral
Arterial Disease
Arterial Embolism (perhaps due to AF)
Atheroma (usually subclavian)
coarctation of the aorta
Iatrogenic
Previous arterial line
Pervious cornonary angiography
Compression Cervical rib (specifically lost on abduction and external rotation of the shoulder-Adson's Sign)
11
Q
Causes of AF
A
- Ischaemic Heart Disease
- Rheumatic Heart Disease
- Thyrotoxicosis
- Pneumonia
- PE
- Alcohol
12
Q
What is Pulsus Paradoxus
A
It is not actually paradoxical but is an exaggeration of the normal BP response to inspiration which is a fall to such an extent that the pulse may not be able to be felt during insiration.
13
Q
Causes of Pulsus Paradoxus
A
- Cardiac Tamponade
- Constrictive Pericarditis
- Restrictive Cardiomyopathy
- Severe Obstructive Lung Disease
14
Q
What is Kussmauls sign?
A
A rise in JVP on inspiration (this is the opposite of normal)
Kussmauls sign occurs due to impaired RA filling
15
Q
Causes of Kussmauls sign
A
Kussmauls sign occurs due to impaired RA filling
- Cardiac Tamponade
- Constrictive Pericarditis
- Restrictive Cardiomyopathy
16
Q
Causes of a non-palpable apex beat
A
- Something is between your fingers and the apex
Adipose tissue (Obese Patient)
Air (Pneumothorax or emphysema)
Fluid (Pericardial or Pleural effusion) - Due to the apex not being in its normal position
Displaced (usually laterally in LHF)
Dextrocardia
17
Q
What is congestive Cardiac Disease?
A
CCF is biventricular failure i.e LHF and RHF
18
Q
Differential diagnosis for palpable Lymph Nodes
A
Infection (tender)
Malignancy (non tender)
19
Q
What is the name of the sign that is intercostal indrawing on inspiration
A
Hoovers sign
20
Q
When do you use whistering pectoriloquy?
A
In ares of increased vocal resonance or bronchial breathing
21
Q
Normal Examination findings for Consolidation
A
No mediastinal shift, Dull Percussion Note, Bronchial or reduced breath sounds, and increased vocal resonance.
22
Q
Normal Examination findings for Collapse
A
Mediastinal shift towards the collapse. Dull percussion note, reduced or absent breath sounds on ausculation, decreased or absent vocal resonance.
23
Q
Normal Examination findings for Effusion
A
Mediastinal shift away from effusion if large, (stony) dull percussion note, breath sounds were reduced or absent and vocal resonance is reduced or absent.
24
Q
Normal Examination findings for Pneumothorax
A
Mediastinal shift away from pneumothorax (if tension). Hyper-resonant percussion note, reduced or absent breath sounds. Vocal resonance is reduced or absent.
25
Normal Examination findings for Pneumonectomy
Mediastinal shift towards the removed lyng. Dull percussion note, ansent breathsounds and vocal resonance.
26
What are the indications for Pneumonectomy/ Lobectomy
1. Bronchogenic Carcinoma (25% of non-small cell carcinoma is resectable)
2. Bronchiectasis
3. Trauma
4. TB
27
What is differential diagnosis for Pleural effusion?
1. Rasied Hemidiaphragm- due to phrenic nerve palsy ( thoracic surgery, trauma, malignancy)
28
Signs of hyperinflation
```
Reduced cricosternal distance and tracheal tug.
Increased A-P diameter
Intercostal indrawing (Hoover's sign)
Apex beat not palpable
Hyper-resonant percussion note.
```
29
What is dilated veins on the abdomen a sign of?
Portal Hypertension
| [dilated veins on the abdomen a.k.a Caput Medusa}
30
How many spider naevia is considered normal?
<5
31
What is a maneuvere to feel the spleen?
repeat with pt on right hand side with your left hand gentle pulling pts left lower ribs forward.
32
Name Abdominal Scar 1
| PICTURE
Kocher's scar (Sub costal)
| Used for open cholecystectomy.
33
Name Abdominal Scar 2
| PICTURE
Right Para-median Laprotomy Scar
34
Name Abdominal Scar 3
| PICTURE
Midline laprotomy
35
Name Abdominal Scar 4
| PICTURE
Nephrotomy
| PCKD, Renal Transplant
36
Name Abdominal Scar 5
| PICTURE
Gridiron/ McBurneys
Used for appendectomy
(Now the lanz scar is commonly used, it is in the same place but horizontal, thought to look better cosmetically)
37
Name Abdominal Scar 6
| PICTURE
Laproscopic
Various uses inc. cholecystectomy, appendectomy, and gynaecologyical procedures
38
Name Abdominal Scar 7
| PICTURE
Left Paramedian Scar
Anterior Resection of the Rectum
39
Name Abdominal Scar 8
| PICTURE
Pfannenstiel Scar
Total Abdominal Hysterectomy
Caesarian Section
40
What are the common sites for AV fistulas
Wrist: Radio-Cephalic fistula. A.K.A cimino fistula
| Antecubital fossa: Brachio-Cephalic (or Brachio basilic)
41
Where are the most common sites for a parathyroid implanation scar?
Wrist,
| Shoulder
42
What is the name of the catheter for peritoneal dialysis
Tenckhoff Catheter
43
Differential Diagnosis of LIF Mass
Renal Transplant
Loaded colon
Diverticular Mass
Colorectal Carcinoma
Ovarian Pathology
44
Differential Diagnosis of RIF mass
Renal Transplant
Appendix Mass
Crohns Disease (Inflammed, matted small intestine)
Caecal carcinoma
Ovarian Pathology
45
Differential Diagnosis of Bilateral Englarged Kidneys
1. PCKD
2. Bilateral Hydronephrosis
3. Amyloidosis
46
Differential Diagnosis of Unilateral Englarged Kidney
1. Hydronephrosis
2. Renal Cell Cancer
3. Renal Cyst
47
What muscle are you testing when you get patient to open jaw against resistance?
Cranial Nerve V- Motor
Pteryoid Muscles
Jaw will deviate towards side of weakness
48
What muscle are you testing when you get patient to clench jaw?
Masseter and temporalis Muscles
49
What is Bell's sign?
Up gaze on attempted Eye Closure
50
Other than motor, what are the other functions of the facial nerve?
Chorda Tympani: Supplies anterior 2/3 of tongue
| Stapedius--> Hyperacusis
51
Presentation of Cerebellopontine angle tumour
(Acoustic neuroma or meningioma) Mainly V, VII and VIII
corneal reflex if lost first (V)
Then Facial (VII) and Vestibulocochlear (VIII)
Then the rest of Facial (V)
Sometimes IX and X are involved
52
Presentation of Paget's disease of the bone
due to impingement of bone on nerves
V,VII, VIII- Trigeminal, facial and vestibulococclear
53
Presentation of Gradenigo's Syndrome
Complication of Otitis Media
CN V and VI (Trigeminal and Abducens)
54
Presentation of Syringobulbia
Bulbar Palsy (IX, X and XII- Glossopharangeal, Vagus, Hypoglossal)
VIII- vertigo and nystagmus
V- Facial Pain/ Sensory Loss
VII SPARING
They may have Horner's syndrome, may have syringomyelia
55
Presentation of Cavernous Sinus Thrombosis
II, IV and VI (VI most common)
V- Pain, particularly in ophthalamic division; corneal reflex may be lost
Also get headache, periorbital oedema and proptosis
56
Causes of ANY cranial nerve pathology
1. DM (due to microagiopathy of the vasa nervorum)
2. Stroke
3. MS
4. Tumour
5. Sarcoid
6. SLE
7. Vasculitis
57
Differential Diagnosis of Ptosis
Ptosis can be unilateral or bilateral
causes of Unilateral ptosis include CN III (Occulomotor nerve) palsy, Hormers Syndrome, and congenital
Causes of bilatral ptosis includes myasthenia gravis and myotonic dystrophy. It can also be congenital.
58
Features of CN III Palsy
1. Eyes deviated down and out
2. Ptosis
3. Dilated pupil if it is complete!
In Diabetic oculomotor palsy the pial vessels perfusing the parasympathetic fibres are unaffected by the diabetic microangiopathy so the pupil is spared and the palsy is partial.
59
What is the typical UMN posture in the upper limb?
Shoulder ADducted, elbow flexed, wrist flexed and pronated.
60
How do you interpret pronator drift
UMN weakness
| The hand that drifts down and pronates is the side with the problem.
61
What are the typical clinical features of upper motor neurone lesion
Tone is increased (Spastic), may have clonus, Reduced power, brisk reflexes with upgoing plantars. Reduced co-ordination.
62
What are the typical clinical features of lower motor neurone lesion
Tone is normal or decreased, the power is decreased, reflexes are reduced or absent, plantars are down doing, coordiation is normal and there may be muscle wasting and fasciculations.
63
What are the typical clinical features of extrapyramidal pathology?
The tone may be increased (rigid), power and reflexes are normal. Plantars are down going. coordiation is reduced.
May have a resting tremour, bradykinesia and postural instability.
64
What are the typical clinical features of cerebellar lesion
The tone is decreased, normal power and reflexes and down going reflexes. Co-ordiation is markedly reduced.
May have an intention tremour, hystagmus and cerebellar speech.
65
What is the typical UMN posture in the lower limb
hip and knee extended, foot plantar flexed and inverted.
66
What is the spignificant number of clonus beats
3+
67
What are the possible outcomes of a babinski reflex test?
Up going plantars
Down going plantars
Equivocal
68
Multi factorial aetiology of ascites in CLD
1. Portal hypertension
2. Hypoalbuniaemia
3. Salt and water retention secondary to RAAS activation
69
Differential diagnosis of hepatomegaly
2 Is, 2 Bs and 2Cs
```
Infection
Infiltration
Blood related
Biliary
Cancer
Congestion
```
Infectious causes include: viral hepatitis (HSM), EBV (HSM), Malaria (HSM), hepatic abscess
Infiltration: Sarcoid (HSM) Amyloid (HSM), fatty liver, haemochromatosis
Blood related: lymphoma (HSM), leukaemias (HSM) myeloproliferative disorders (HSM), haemolytic anaemia (HSM)
Biliary: PBC and PSC
Cancer: Primary HCC, metastatic deposits
Congestion: RHF, Tricuspid Regurgitstion, Budd-Chiari syndrome
Biliary
Cancer
Congestion
70
Differential diagnosis of hepatosplenomegaly
1. Infective: viral hepatitis, EBV, malaria
2. Infiltration: Sarcoid, Amyloid
3. Blood Related: Lymphoma, Leukaemia, myeloproliferative disorder, haemolytic anaemias
71
Differential Diagnosis of Ascites
SAAG
Transudate Causes
1. CLD (75% of ascites)
2. RHF
3. Volume overload
4. Hypoalbuniaemia
5. Constrictive pericarditis
Exudate Causes
1. INFECTION- SBP, TB
2. INFLAMMATION- pancreatitis
3. MALIGNANCY- luminal (stomach/ cancer), pancreas, liver, ovarian, lymphoma
72
Indications for dialysis in CRF
1. Progressive decline in renal function: usually CKD stage 5
2. Symptomatic uraemia despite conservative Rx
3. Renal bone disease
4. Pericarditis
5. Volume overload despite fluid restriction and diuretics
6. Hyperkalaemia despite Rx
73
Spleen vs Left Kidney
```
Can get hand above kidney
Percussion note is resonant over kidney
Kidney is balottable
Spleen has a notch
Spleen moves more on respiration
```
74
DDx Ankle Swelling
Ankle swelling can be broken down by the system implicating the ankle swelling: cardio, resp, GI, renal, endocrine or vascular
or can be broken down into pitting and non-pitting. and bilateral and unilateral.
Bilateral causes of
Pitting Oedema is caused by:
1. Rasied venous Pressure
- Chronic venous insufficiency
- Right Heart Failure
- Volume overload (e.g due to renal failure)
- Immobility
- Constrictive pericarditis
- Obesity (with associated Na and H2O retention)
- Pregnancy
2. Reduced Oncotic Pressure
- nephrotic syndrome
- cirrhosis/ liver failure
- severe malnutrition
- protein losing enteropathy (e.g. IBD)
- exfoliative dermatitis
3. Drug related
- CCBs
- Long term corticosteroid use
- NSAIDs
Non-Pitting Oedema
1. Lymphoedema
- primary (e.g. Milroy's disease)
- malignancy
- filariasis
- radiotherapy
- lymph node clearance
2. Hypothyroidism
3. Pre-Tibial Myxoedema (Grave's Disease)
Unilateral Causes of ankle swelling:
1. Acute DVT
2. Post Thrombotic Syndrome
3. Cellulitis
75
DDx of Finger Clubbing
Cardiovascular Disease: Cynotic congenital heart disease, IE, Atrial Myxoma
Respiratory Disease: Interstitial Lung Disease, Malignancy (Mesothelioma, Bronchial Carcinoma), Suppurative [PUS] Lung Disease (Bronchiectasis, Abcess, Empyema, Cystic Fibrosis)
GI Disease: IBD, Hepatic cirrhosis, GI lymphoma, Coeliac Disease.
76
What are the features of finger clubbing?
1. Increased fluctuance of the nail bed
2. Loss of nailbed angle
3. Increased longitudinal curvature of the nail
4. Drumbsticking
77
DDx Lymphadenopathy
1. Localised
- Acute Local infection
- Neoplastic (Local malignancy or solitary distant metastasis)
2. Generalised
- Acute Generalised Infection (EBV, HIV seroconversion)
- Chronic Infection (TB 'cold abcesses', syphilis, HIV)
- Neoplastic (Multiple distant metastases)
- Haemotological (Lymphoma, CLL)
- Systemic Disease (Sarcoidosis, SLE)
78
How can you tell lymphadenopathy apart?
Tender and Fluctuant: Acute Infection
Non-tender and rubbery: Lymphoma/ CLL
Non-tender and hard: Metastatic
79
What is Marcus Gunn Pupil more commonly known as?
Relative Afferent Pupilary Defect
80
What is the pathology of visual inattention?
Stroke on the contralateral side.
i.e Left sided inattention--> Right sided stroke
81
How do you know which eye is giving diplopia
Cover each eye in turn
If diplopia on looking to the side when the affected eye is covered lateral image disappears.
If diplopia on looking down when the affected eye is covered lower image disappears.
If diplopia on looking up when the affected eye is covered upper image disappears.
82
Specific Causes of Olfactory Nerve Palsy
1. Trauma
2. Frontal Lobe Tumour
3. Meningitis
REMEMBER: All CN palsies can be caused by...
1. DM (due to microagiopathy of the vasa nervorum)
2. Stroke
3. MS
4. Tumour
5. Sarcoid
6. SLE
7. Vasculitis
83
Specific causes of optic Nerve Palsies
Monocular Blindness:
- Multiple Sclerosis
- Giant Cell Arteritis
Bitemporal Hemianopia
- Pituitary Adenoma
- Internal Carotid Artery Aneurysm
Homonomous Hemianopia
-Anything behind the chiasm (stroke tumour abscess)
REMEMBER: All CN palsies can be caused by...
1. DM (due to microagiopathy of the vasa nervorum)
2. Stroke
3. MS
4. Tumour
5. Sarcoid
6. SLE
7. Vasculitis
84
Specific Causes of Oculomotor (Third Nerve) Palsy
Parial: Pupil Spared
-Diabetes
Complete
- PCA aneurysm
- Raised ICP with tentorial Herniation
85
Specific Causes of Trochlear palsy
Single Palsy Rare
| Usually due to orbit trauma
86
Specific Causes of Trigeminal palsy
- Idiopathic
- Acoustic Neuroma
- Herpes Zoster
87
Specific Causes of Abducens palsy
1. Skull # involving petrous temporal bone
2. Nasopharyngeal carcinoma
3. Raised ICP (false localising sign)
88
Specific Causes of Facial Nerve Palsy
Divide into LMN (forehead affected) and UMN (Forehead spared)
LMN
1. Bells palsy
2. Malignany parotid tumour
3. Herpes Zoster: Ramsay hunt
4. Sarcoid (Often bilateral)
UMN
1. Stroke
2. Tumour
89
Specific causes of vestibulocochlear palsies
1. Excessive Noise levels
2. Menieres disease
3. Furosemide
4. Aminoglycoside antibiotics (genamicin)
90
Specific causes of bulbar palsies
LMN (bulbar palsy) and UMN (pseudobulbar palsy)
```
LMN:
1. MND
2. Diphtheria
3. Polio
4. Guillain Barre Syndrome
Syringobulbia
```
UMN:
1. MND
2. Bilateral strokes
3. MS
91
Which extraoccular muscles are supplied by CN 3?
Superior Rectus
Inferior Rectus
Medial Mectus
Inferior Oblique
92
Which extraoccular muscles are supplied by CN 4?
Superior Oblique
93
Which extraoccular muscles are supplied by CN 6?
Lateral Rectus
94
What is ophthlmoplegia?
Weakeness of the eye muscles.
| Can be external or internuclear
95
Differential Diagnosis of Opthalmoplegia.
1. Myaesthenia Gravis
2. Cranial Nerve Palsy (especially due to raised ICP and Cavernous sinus thrombosis)
3. Grave's Disease
3. Wernicke's encephalopathy (Particularly failure of upgaze)
4. Progressive Supranuclear Palsy (Vertical Gaze)
96
What is Internuclear Ophthalmoplegia
Disorder of conjugate lateral gaze caused by lesion in the medial longitudinal fasciculus.
This causes a failure of ADduction of eye on affected side
97
What happens in a left sided internuclear ophthalmoplegia?
Lateral gaze to left is normal. (Left eye is being ABducted)
On looking to the right however....
- The right eye ABducts normally
- The left eye fails to ADduct and remains looking straight ahead
- The right eye consequently displays nystagmus as it attempts to compensate.
N.B Convergence is preserved.
98
Differential Diagnosis of Internuclear Ophthalmoplegia
1. MS (almost always the cause if a young pt)
2. Stroke
3. Lyme disease and Tricyclic Antidepressant overdose are rare causes.
99
Where is the lesion in internuclear ophthalmoplegia?
medial longitudinal fasciculus
