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15 Cards in this Set

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Examine this patient's neck
Thyroid, LAD, SVC obstruction, carotid body tumour

1. Neck exam
- Inspect for scars, swelling, obvious facies of hyper/hypothyroidism
- swallow with water - rise up
- palpate from behind, get patient to swallow, look for retrosternal extension
- palpate for thrills, listen for bruits
- palpate the carotids
- palpate the trachea
- percuss for retrosternal extension
- Do pemberton's sign

2. Hyperthyroidism
- thin, anxious
- warm sweaty skin
- onycholysis (plummers nail)
- clubbing (thyropachy)
- tremor
- tachycardia
- proximal myopathy
- lid lag, lid retraction
- reflexes
- pretibial myxoedema
- high output cardiac failure
- hepatosplenomegaly
- chvostek's, trousseau's sign

3. hypothyroidism
- overweight, drowsy
- thin, pale, dry skin
- anemia
- peripheral cyanosis
- bradycardia
- carpal tunnel syndrome
- proximal myopathy
- delayed relaxation of the reflexes
- oedema - LL, periorbital
- loss of outer third of eyebrows
- periorbital xanthelasma
- swollen tongue
- hoarse or slow speech
- pleural/pericardial effusions
- peripheral neuropathy

4. Grave's Eye disease
- periorbital oedema
- conjunctival injection
- chemosis
- proptosis
- opthalmoplegia/orbitopathy (inferior oblique)
- reduced VA, pale disc
What are causes of a diffusely enlarged goitre?
1. Grave's disease
2. Iodine deficiency
3. Autoimmune thyroid disease
4. transient thyroiditis
5. idiopathic
6. congenital, inherited
7. iodine excess
8. pregnancy
What are the causes of thyrotoxicosis?, What are the causes of thyrotoxicosis?
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
What are the causes of hypothyroidism?
1) Primary
(a) Autoimmune Hashimoto's
(b) iatrogenic (radiation, surgery, RAI)
(c) Iodine (deficiency or excess)
(d) Drugs
- Lithium, interferon, amiodarone
- Drugs that interact with thyroxine (phenytoin, carbamazepine, cholestyramine, Fe salts)
(e) Infiltration (amyloid, haemochromatosis, scleroderma)
(f) transient thyroiditis

2) Secondary
- TSH deficiency (pituitary disease)

3) Tertiary
- TRH deficiency (hypothalamic disease)

4) Resistance to thyroid hormones (autosomal dominant mutation)

5) Consumptive hypothyroidism - T3 deoidinase excess
This man has loss of libido, please examine for panhypopituitarism.
1. ACTH
- postural blood pressure

2. GH
- short stature
- no secondary sexual characterisitics (gonadotrophin failure before puberty)
- fine skin wrinkles around eyes and mouth

3. TSH
- overweight, drowsy
- thin, pale, dry skin
- anemia
- peripheral cyanosis
- bradycardia
- carpal tunnel syndrome
- proximal myopathy
- delayed relaxation of the reflexes
- oedema - LL, periorbital
- loss of outer third of eyebrows
- periorbital xanthelasma
- swollen tongue
- hoarse or slow speech
- pleural/pericardial effusions
- peripheral neuropathy

4. LH, FSH
- lack of hair
- gynaecomastia
- loss of pubic hair
- testicular atrophy (N 15-20ml)

6. Prolactin
- galactorrhoea

7. Evidence of pituitary tumour
- bitemporal hemianopia
- optic atrophy
- cavernous sinus infiltration (CN III, IV, VI, V1/2)
This patient has weight gain. Please examine for Cushing's syndrome.
- altered mental state, psychosis
- moon facies
- cataracts
- plethora, telangiectasia
- hirsuitism, acne in women
- oral thrush
- dorsocervical fat pads
- kyphosis, crush fractures
- acanthosis nigricans
- proximal myopathy
- hypertension
- thin skin, easy bruising
- abdominal striae
- central adiposity

Look for signs of tumour
- bitemporal hemianopia, optic atrophy
- adrenal masses, adrenalectomy
- peripheral signs of lung cancer
- hyperpigmentation with ACTH dependent

Look for signs of pituitary dysfunction

Ask for:
- urinalysis for glycosuria, proteinuria
- old photos to compare
- fundoscopy for diabetic/hypertensive retinopathy
What conditions mimic Cushing's and interferes with dexamethasone suppression test.
alcholism
depression
Obesity
OCP
induction of hepatic enzymes (phenytoin etc)
Please examine this patient for acromegaly.
- spade like hands
- hyperhydrosis, greasy skin
- carpal tunnel syndrome and other compressive neuropathyies
- proximal myopathy
- hypertension
- acanthosis nigricans
- skin tags
- frontal bossing
- prognathism
- acne and hirutism in women
- gingival hypertrophy and splaying of teeth
- macroglossia
- hoarse voice
- goitre
- high output cardiac failure
- organomegaly
- OA, pseudogout
- heel pad thickening

Look for evidence of pituitary tumour
- bitemporal hemianopia and optic atrophy
- hypogonadism or other pituitary dysfunction

Also ask for
- urinalysis for glycosuria, proteinuria
- rectal exam for polyps
- fundoscopy for diabetic/hypertensive retinopathy
- old photos to compare

Signs of activity
- excessive sweating
- skin tag number
- glycosuria
- worsening visual fields or cranial nerve palsies
- enlarging goitre
- hypertension
- headache
- increasing size of rings, shoes, dentures.
Please assess this patient with Addison's disease.
1. pigmentation (palmar creases, elbows, gums, buccal mucosa, genital, scars)
2. vitiligo - assoc with autoimmune disease
3. ear lobe calcification
4. postural hypotension

Ask for urinalysis for glycosuria, diabetes is a coexisting autoimmune disease
Causes of Addisons Disease.
1. Primary - Adrenals
- autoimmne
- Inherited
a) Polyglandular syndrome type 1: Addison's disease, hypoparathyroidism, mucocutaneous candidiasis
b) Polyglandular syndrome type 2: Addison's disease, T1DM, Hashimoto's/Grave's disease
- infectious - TB
- vascular - ischaemia, hemorrhage
- infiltrative - sarcoid, amyloid
- malignant, metastatic
- demyelinating
- drugs - ketoconazole, metyrapone, mitotane

2. Secondary - Pituitary or hypothalamic disease
Investigations
- Electrolytes: hyponatremia, hyperkalemia, metabolic acidosis, hypercalcemia
- hypoglycaemia
- Short synacthen test - synthetic ACTH given, lack of response is indicative
- plasma ACTH level
What are you differentials if no murmur is heard on cardiovascular exam?
1. Mitral stenosis (exercise and position)
2. ASD (listen for a fixed splitting)
3. mitral valve prolapse (perform valsalva)
4. Pulmonary hypertension
5. Constrictive pericarditis
what are causes of mitral stenosis?

What are the clinical signs of severity?
Causes
1) Rheumatic
2) Congenital

Signs of severity:
1. small pulse pressure
2. Essentuate S1 then opening snap is a high-frequency sound that introduces the middiastolic component of the rumble and occurs .03 to .14 second after the second sound
3.length of the mid diastolic murmur
4. diastolic thrill at the apex
5. Signs of pulmonary hypertension
- loud, palpable P2
- RV heave
- PR or TR
- elevated JVP - prominant a wave
What are the causes of mitral regurgitation?

What are the clinical signs of severity?
Causes:
1) Chronic
a) Functional - secondary to LVF, or LV dilatation/hypertrophy
b) Primary
- degenerative
- MVP
- rheumatic
- CTD
- congenital
2) Acute
a) infarct
b) post surgical
c) trauma
d) infective endocarditis

Clinical signs of severity
- small volume pulse
- displaced apex
- soft S1
- wide split S2
- S3
- early diastolic murmur
- LV failure
- Pulmonary hypertension
What are the causes of AR?

What are the clinical signs of severity?
Causes
1. Chronic
(a) Valvular: rheumatic, congenital, seronegative arthropathy
(b) Aortic root: Marfan's, aortitis, dissecting aneurysm, degenerative
2. Acute:
(a) Valvular: Infective endocarditis
(b) Aortic root: Marfan's hypertension, dissecting aneurysm

Signs of severity
1. Haemodynamic state/collapsing pulse
2. wide pulse pressure
3. displaced apex
4. early diastolic murmur long duration
5. soft S2
6. S3
7. Austin flint murmur
8. LV failure
What are the causes of AS?

What are the clinical signs of severity?
Causes:
1. Congenital
2. Degenerative
3. Rheumatic - rare

Signs of severity:
1. small volume pulse
2. aortic thrill
3. Duration and harshness of the ESM
4. S4
5. reverse splitting of S2
6. LV failure