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15 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Examine this patient's neck
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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 |
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What are causes of a diffusely enlarged goitre?
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1. Grave's disease
2. Iodine deficiency 3. Autoimmune thyroid disease 4. transient thyroiditis 5. idiopathic 6. congenital, inherited 7. iodine excess 8. pregnancy |
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What are the causes of thyrotoxicosis?
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1. Normal or increase radio-iodine uptake
(a) Grave's disease (b) Toxic adenoma, MNG (c) Hashimoto's thyroiditis (d) iodine induced (contrast/amiodarone) (e) TSH mediated - TSH secreting pituitary tumour - mutation in TSH feedback loop 2) Associated with low radio-iodine uptake (a) transient thyroiditis (viral, postpartum, amiodarone, radiation) (b) Thyroxine excess (b) post-partum thyroiditis |
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What are the causes of hypothyroidism?
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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 |
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This man has loss of libido, please examine for panhypopituitarism.
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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) |
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This patient has weight gain. Please examine for Cushing's syndrome.
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- 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 |
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What conditions mimic Cushing's and interferes with dexamethasone suppression test.
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alcholism
depression Obesity OCP induction of hepatic enzymes (phenytoin etc) |
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Please examine this patient for acromegaly.
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- 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. |
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Please assess this patient with Addison's disease.
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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 |
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Causes of Addisons Disease.
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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 |
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What are you differentials if no murmur is heard on cardiovascular exam?
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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 |
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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. early opening snap of first heart 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 |
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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 |
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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 |
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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 |
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