General medicine: CL Lai Session 4

Question 1

Where is JVP?
How to differentiate IJV from ECA?

Answer 1

• between heads of SCM
• Easily occludible
• Changes with pressure on abdomen, respiration (inspiration it goes down), posture
• Usually has upper border (unless goes to jaw)
• Biphasic (a wave = atrial contraction, v= ventricular contraction)

Question 2

TR features

Answer 2

• Giant V wave
• Pulsatile liver
• Pansystolic murmur
• Murmur increases on inspiration (right sided lesion causes increased venous return)
• Parasternal heave
• P2 increased due to pulmonary hypertension (must happen before TR)
• Systolic ejection murmur at pulmonary area due to pulmonary hypertension

Question 3

How to differentiate small bowel vs large bowel diarrhea

Answer 3

• Small bowel is watery diarrhea, no blood, no mucus. Periumbilical pain.
• Large bowel is semi solid diarrhea, bloody mucus. Suprapubic pain. Subsides with defaecation. Colicky pain: cycles of 3-5 minutes pain returning to baseline due to peristasis.

Question 4

Cause of colicky pain?

Answer 4

Contraction of smooth muscle of hollow viscus
* Gut
* Uterus (in menstruation or labor)
* Urinary tract (ureteric colic in urolithiasis)
Normal cycles of 3-5 mins pain and return to baseline

Biliary colic: pain rises to max at 30 min to 1hour, fluctuates about the plateaum and subsides after about 6 hours

Question 5

Approach to diarrhea

Answer 5

• Acute (<2 weeks) or chronic (>2 weeks or recurrent)
• Large bowel or small bowel. Small bowel diarrhea: usually water (because it ix toxigenic. No damage to intestinal mucosa –> no blood, no mucus). Pain= periumbilical. Large bowel diarrhea = usally more solid –> blood and mucus may be possible –> pain in flanks or hypogastrium
• if chronic diarrhea: is it organic or functional
  Functional (IBS): patient never woken up by the urge to defaecate. Stress related: typically occurs in the morning. Blood is never present, unless there are hemorrhoids (easily excluded)
  Organic: DM can cause nocturnal diarrhea, hyperthyroidism, autonomic neuropathy, drugs

Chlorea: V. cholera toxin
Oral rehydration solution: mixture of saline and glucose. Facilitates substrate dependent uptake of sodium ions and water

Question 6

Signs of AR

Answer 6

• Corrigan pulse: rapid and forceful distension of arterial pulse with quick collapse
• Traube sign: systolic and diastolic sounds (pistol shots) over the femoral artery
• Quincke sign: capillary pulsation on light compression (half white) on nail bed
• De Musset sign: to and fro head bobbing