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42 Cards in this Set
- Front
- Back
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What are the signs of aortic stenosis?
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- slow rising, plateau, small volume pulse
- small pulse pressure difference - pressure loaded non displaced apex beat - aortic thrill - soft S2 - S4 - ESM - signs of LVF |
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What are the clinical signs of severity for aortic stenosis?
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1. small volume pulse
2. aortic thrill 3. S4 4. late peaking ESM 5. paradoxical splitting S2 6. LVF |
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What are the causes of an S3?
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1. Physiological
2. Dilated cardiomyopathy 3. AR 4. MR |
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What are the causes of an S4?
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1. AS
2. HOCM 3. Systemic hypertension |
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What are ways of differentiating between a JVP and carotid pulse?
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- non pulsatile
- double flicker - moves with respiration (falls with inspiration) - moves with position - accentuates with hepatojugular reflex - fills from above |
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What are the causes of thyrotoxicosis?, What are the causes of thyrotoxicosis?
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Normal or high radio-iodine uptake
1. autoimmune graves disease 2. Thyroid adenoma, multinodular goitre 3. Iodine induced (amiodarone, contrast) 4. Hashimoto's thyroiditis 5. TSH mediated (pituitary adenoma) Reduced radioiodine uptake: 1. thyroiditis: viral, postpartum, amiodarone induced, autoimmune 2. Exogenous: factitious |
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What are the signs of graves disease?
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Signs of hyperthyroidism:
- increased sweating, warm skin - tremor - thyroid acropachy, softening of nails, onycholysis - anemia - vitiligo - tachycardia - hypertension - high output cardiomyopathy - proximal myopathy - crush fractures - alopecia - Neuropsychiatric: insomnia, psychosis, emotional lability, - lid lag, lid retraction, thyroid stare - goitre +/- compressive Sx - low BMI - hyper-reflexia - high serum oestradiol (oligomenorrhoea, infertility, erectile dysfunction, gynaecomastia, reduced libido Signs specific for Graves: - diffusely enlarged vascular goitre with bruits and thrills - thyroid eye disease: proptosis, exopthalmos, chemosis, periorbital oedema, conjunctival injection, complex orbitopathy, corneal/conjunctival ulcerations, reduced visual acuity with optic neuropathy - myxoedema: infiltrative dermatopathy - raised, hyperpigmented, violaceous, orange-peel textured papules most commonly overlying the shins |
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What are the signs of thyroid eye disease?
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- hyperthryoidism: lid lag, lid retraction
- Grave's related: exopthalmus, proptosis, periorbital oedema, chemosis, complex orbitopathy, diplopia, corneal/conjunctival ulceration, optic neuropathy |
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What are the non-pharmacological management principles in cardiac failure?
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- multidisciplinary: doctors, heart failure nurses, dietitian, physiotherapist
- fluid restriction, daily weights - Low salt diet <2g - exercise - LOW - appropriate BMI - smoking cessation - cardiac rehabilitation |
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What are the pharmacological management principles in cardiac failure?
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Mortality benefit
- ACE-i - B-blocker - Spironolactone Symptomatic benefit - frusemide - digoxin Interventional - biventricular pacing - AICD - cardiac transplant |
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What are the radiological changes in RA?
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1. symmetrical joint space narrowing
2. symmetrical soft tissue swelling 3. periarticular erosions 4. periarticular osteopenia 5. subluxation with typical deformities |
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What are the radiological features of OA?
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1. asymmetrical joint space narrowing
2. osteophytes 3. subchondral sclerosis 4. subchondral cysts |
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What are the findings in third nerve palsy?
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1. Down and out pupil
2. ptosis 3. fixed dilated pupil |
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What are the clinical findings of COPD?
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1. Inspection:
- cachexia - increased work of breathing - accessory muscle use - hoover's sign (subcostal tug) - tracheal tug - CO2 narcosis: metabolic flap, bounding pulse, encephalopathic - nicotine staining - cyanosis - polycythemia (palmar erythema) - barrel chested (increased AP diameter) 2.hyperexpansion 3. hyper-resonant percussion 4. auscultation: prolonged expiratory phase, expiratory wheeze, quiet breath sounds 5. cor pulmonale |
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What are the causes of peripheral neuropathy?
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Painless:
Painful: - toxins: heavy metals - drugs: chemotherapy (bortezomib, thalidomide, taxanes, vinca alkaloids), amioarone, HAART, antibiotics (isoniazid, metronidazole), colchicine - B1, 6, 12 deficiency - diabetic - alcoholic - inherited - paraneoplastic - |
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What are the features and causes of horners syndrome?
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Clinical findings:
1. anhydrosis 2. partial ptosis 3. meiosis Causes: 1. central: brainstem infarct/haemorrhage, lateral medullary syndrome, syringobulbia, tumour 2. cervical myelopathy, syringomyelia 3. pancoast tumour 4. carotid aneurysm, dissection 5. cavernous sinus infilatration/compression |
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What are the features of lateral medullary syndrome?
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1. Horner's syndrome
2. sensory dissociation 3. CN 9 and 10 palsy 4. Cerebellar |
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What are the findings in Cushing's Syndrome?
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- Thin skin, easy bruising
- hypertension - proximal myopathy - alopecia - moon facies - altered mental state, psychosis - cataracts - hirsutism - acne - oral thrush - dorsocervical fat patds - vertebral crush fractures - central obesity - abdominal striae - hypogonadism (small testicular size) - urinalysis: glycosuria Look for causes: - visual fields - respiratory exam - abdominal adrenal masses |
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What are the causes of clubbing?
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1. cardiac: cyanotic congenital heart disease, subacute infective endocarditis, atrial myxoma
2. Resp: suppurative lung disease (abscess, bronchiectasis), ILD, NSCLC 3. GIT: celiacs, CLD, IBD 4. Others: pregnancy, idiopathic, thyroid acropachy |
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What are the causes of palmar erythema?
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1. pregnancy
2. CLD 3. polycythemia 4. hypothyroidism 5. alcohol |
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What are the causes of hepato-splenomegaly?
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CHIICAT
1. CLD 2. Hematological disease: myeloproliferative, lymphoma, leukemia, pernicious anemia 3. Infiltration: amyloid, sarcoid 4. Infections 5. CTD - SLE 6. Acromegaly 7. Thyrotoxicosis |
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What are the features of CLD?
alcoholic liver disease? |
- palmar erythema
- dupetreyns contracture (alcohol) - clubbing - metabolic flap - anemia - bruising - cachexia - proximal myopathy - encephalopathy - jaundice, icteric - hepatic fetor - spider nevi - gynaecomastia - spider nevi - caput medusa - splenomegaly - ascites - peripheral oedema Alcohol: - parotidomegaly - palmar erythema - dupetryen's contracture - AST > ALT |
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What are the clinical findings of malignancy?
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- fevers
- cachexia - fatigue - lymphadenopathy - BM infiltration: easy bruising, anemia, mouth ulcers - Skeletal mets: bony pain, crush fractures - lung: pancoast tumour, T1 wasting, HPOA, clubbing, pleural effusions - hepatosplenomegaly, ascites, jaundice, PR masses/prostatomegaly - peripheral neuropathy |
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Differential diagnosis of ataxic gait?
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1. Cerebellar
2. Sensory 3. Vestibular dysfunction |
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What is Rhomberg's sign?
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Examination:
- ask patient to stand with feet shoulder width, and close eyes - ask patient to stand with feet together and close eyes - positive rhomberg's sign is if there is postural instability on eye closure, indicating proprioception loss (notes: cerebellar and vestibular ataxia would be present regardless of eye closure) |
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What are the signs and severity of AR?
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1. Hyperdynamic state (Quinke's sign, waterhammer pulse, corrigan's pulse, uvular bobbing, head bobbing, pistol shot femorals, pulsatile liver and spleen
- wide pulse pressure difference - volume loaded displaced apex beat - soft S2 - S3 - early diastolic murmur with long duration, loudest sitting forward on full expiration at the LSE - Austin flint murmur - signs of pulmonary hypertension and LVF |
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What is your approach to warfarin counselling?
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- Discuss the indications (AF and CHADS2 score)
- Assess for contraindications - Discuss the initiation and requirement for frequent blood tests - Discuss the risk or adverse effects - Advise regarding management of bleeding - Avoid green leafy foods - Drug interactions- let all health professionals know about warfarin therapy |
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How would you assess malnutrition?
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History:
- diet intake - nutritional quality of food: red meat, vegetables, protein, dairy products - appetite intake - dysphagia - malabsorptive symptoms - comorbidities, chronic illness - cognitive and functional affects Examination: - BMI, waist circumference - Fe deficiency: pallor, koilonychia, angular stomatitis - B12: atrophic glossitis, peripheral neuropathy, pallor - Thiamine - dementia, Wernicke, kosakoff - Vit D - osteomalacia/osteoporosis - folate - pallor - Vitamin A: poor eyesight peripheral neuropathy, osteoporosis, osteomalacia, dementia, visual distrubance |
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What are the clinical findings seen in pulmonary fibrosis?
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- increased WOB
- cachexia - cyanosis - flap - crepitations - cor pulmonale - look for CTD diseases o Musculoskeletal pain o Weakness, fatigue o Fever o Joint pains or swelling o Photosensitivity o Raynaud’s phenomenon o Pleuritis o Dry eyes o Dry mouth |
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What are the causes of pulmonary fibrosis?
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- Idiopathic
- Non organic dusts: silicosis, coal miner's lung, asbestosis - Organic dusts (hypersensitivity pneumonitis): bird fancier's lung, mushroom workers lung, farmer's lung, chemical worker's lung - CTD: RA, scleroderma, Ank spond - Sarcoid - Iatrogenic: Drugs (amiodarone, methotrexate, bleomycin, nitrofurantoin), Radiation pneumonitis Upper lobs: SCART - Silicosis, Sarcoid - Coal miners - Ank Spond, ABPA - Radiation - TB Lower Zones: RASIO - RA - Asbestosis - Scleroderma - Idiopathic - Other drugs |
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What is you approach to managing frequent falls?
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History
- type of falls - injuries - intrinsic factors: Age, past history, gait and balance impairment, visual impairment, neurological comorbidities, cardiovascular comorbidities, osteoarthritis, drugs, alcohol - extrinsic factors: footwear, environmental - behavioural factors: impulsive, risk taking behaviour Examination - neurological examination - postural blood pressure - visual assessment - cognitive assessment - functional reach - timed up and go - rhombergs Management - multidisciplinary appraoch: geriatricians, physiotherapist, occupational therapist, +/- social worker, orthotist - Identify reversible risk factors - medication review - appropriate gait aid - functional assessment with appropriate equipment or home mods - social support - personal alarm - rehabilitation |
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What are the clinical features of acromegaly?
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- thick greasy skin
- sweating - spade like hands, enlarged feet - carpal tunnel, compressive neuropathy - proximal myopathy - hypertension - skin tags in axilla - acanthosis nigricans - frontal bossing - hirsutism, acne - macroglossia - gum hypertrophy with splaying of the teeth - prognathia - hoarse, deep voice - goitre - cardiomyopathy - organomegaly in abdomen - osteoarthritis, pseudogout - foot drop (compressive neuropathy) - heel pad thickening - urinalysis - glycosuria - BSL - PR - colonic polyps, evidence of fe def anemia - fundi for complications of diabetes or hypertension, or optic neuropathy Also look for signs of a pituitary adenoma - bitemporal hemianopia - hypogonadism - hypothyroidism - hypoadrenalism Signs of activity/untreated: - skin tag number - excessive sweating - presence of glycosuria, - increasing visual field loss, cranial nerve palsies 3, 4, 6, 7 - enlarging goitre - hypertension - symptoms: headache, increasing size of shoes, rings, dentures Complications: - diabetes - hypertension - atherosclerosis - thyroid - colonic malignancy, bleed - peripheral mononeuropathies |
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what are the causes of normocytic anemia?
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- anemia of chronic disease
- acute bleed - hemolytic anemia - bone marrow failure, aplastic anemia |
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Causes of myopathy?
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- Hereditary muscular dystrophy
- Congenital myopathies - rare - Acquired: PACE, PODS ----polymyositis, dermatomyositis ---alcohol ---Carcinoma ---Endocrine (hypothyroid, hyperthyroid, Cushings, Acromegaly, hypopituitarism) ---Periodic paralysis ---Osteomalacia ---Drugs (chloroquine, steroids, statins, fibrates) ---Sarcoid ---Myasthenia Gravis |
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Causes of renal masses/enlargement?
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- benign cysts, APCKD
- malignant - RCC, mets - infiltrates - sarcoid, myeloma - infection - pyelonephritis, abscess - hydronephrosis - diabetic - HIV |
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What is your approach to management of obesity?
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Causes
- Lifestyle (sedentery, diet) - metabolic: Cushings, hypothyroidism - inherited - drugs: antipsychotics, antiepileptics, HAART Consequences: - Accelerated atherosclerosis - Dyslipidaemia - diabetes - hypertension - sleep disordered breathing - restrictive ventilation defects - fatty liver - FSGS - Osteoarthritis - Psychological Management - lifestyle factors initially (evidence for short term LOW) - Diet: low fat, low calories< 1500kcal, low salt<2g - exercise: mod workload for 30mins most days of the week - involve dietitian, family, exercise trainer - Review regularly, aiming weight loss of 10-15% - Pharmacological therapy (limited benefit): orlistat (fat binder, Cx GIT/steatorrhoea), fentomene (appetite suppressant Cx cardiomyopathy), topiramate (off label), metformin (if have insulin resistance) - bariatric surgery (evidence for long term weight loss): lap banding, sleeve gastrectomy, gastric bypass |
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What are the causes of chronic cough?
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Most common
- asthma - postnasal drip - GORD Others - whooping cough, post viral cough - cancer - ILD - COPD - heart failure |
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What are the features of idiopathic parkinsons disease and the parkinsons plus syndromes?
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1. Idiopathic parkinsons disease:
- asymmetrical onset - tremor - bradykinesia - abnormal gait: hesistancy, freezing, stooped, festinating, shuffling, reduced arm swing, wide arc turns - rigidity - postural intability, retropulsion, propulsion - mask like facies - siallorhoea - soft monotous voice - anosmia - micrographia - dementia - frontal release signs: Palmar grasp, palmomental reflex, rooting reflex, sucking reflex, snout reflex, glabellar reflex - look for dyskinesias 2nd medication 2. Parkinsons Plus: (a) - |
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What is your approach to managing refractory hypertension?
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1. Medication history and compliance
2. Assess for secondary causes: - Conn's, CAH, hyperaldosteronism - Cushings - Acromegaly - phaechromocytoma - thyroid - OSA - coarctation - Renal artery stenosis - CRF - APKD - medications: steroids, OCP, immunosuppressants (Tacrolimus) - pregnancy 3. Complications: (a) acute: retinopathy, stroke, encephalopathy, flash APO (b) chronic: - retinopathy - atherosclerosis - hypertrophic cardiomyopathy - hypertensive nephrosclerosis - AAA 4. Examination: - BP both arms, postural BP - pulses: radio-radio, radio-femoral - Cushings - Acromegaly - renal bruits - abdominal masses (phaeochromocytoma) - Complications: retinopathy, carotid bruits, PVD, hypertrophic cardiomyopathy 5. Investigations: - ambulatory BP monitoring to confirm - investigate for secondary causes: early morning cortisol/salivary cortisol, UEC, renin:aldosterone levels, urinary metanephrines 6. Management: - low salt diet - exercise - appropriate weight loss - quit smoking - pharmacological: ACEI, ARBs, thiazides, BB, CCB, centrally acting, - monitoring: home BP, office BP, adherence |
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What questions would you ask in assessment of a patients diet?
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- number of meals
- snacking - source of food, who prepares - eating out, take away, fast food - types of food: high salt, high fat - insight into the concepts of caloric monitoring, low salt diet - alcohol, soft drinks - comfort foods |
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Causes of pyramidal weakness and cerebellar signs in the limbs?
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1. Spinocerebellar syndromes
2. Arnold chiari malformations 3. multifocal diseases - strokes, MS |
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What are the causes of ptosis?
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1. Neurogenic:
- third nerve palsy, - horners syndrome 2. Myogenic: - myasthenia gravis, - myopathy, - myotonic dystrophy, - congenital 3. Mechanical - trauma - eyelid oedema - inflammation of eyelid - neoplastic 4. Neurotoxic: - envenomation - chronic opioid abuse |
