* Part Ii Medical Viva

Front 1

What are the causes of an S3?

Back 1

1. Physiological
2. Dilated cardiomyopathy
3. AR
4. MR

Front 2

What are the causes of an S4?

Back 2

1. AS
2. HOCM
3. Systemic hypertension

Front 3

What are ways of differentiating between a JVP and carotid pulse?

Back 3

- non pulsatile
- double flicker
- moves with respiration (falls with inspiration)
- moves with position
- accentuates with hepatojugular reflex
- fills from above

Front 4

What are the signs of graves disease?

Back 4

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

Front 5

What are the signs of thyroid eye disease?

Back 5

- hyperthryoidism: lid lag, lid retraction
- Grave's related: exopthalmus, proptosis, periorbital oedema, chemosis, complex orbitopathy, diplopia, corneal/conjunctival ulceration, optic neuropathy

Front 6

What are the clinical findings of COPD?

Back 6

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

Front 7

What are the causes of peripheral neuropathy?

Back 7

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
-

Front 8

What are the features and causes of horners syndrome?

Back 8

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

Front 9

What are the clinical findings of COPD?

Back 9

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

Front 10

What are the causes of peripheral neuropathy?

Back 10

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
-

Front 11

What are the features and causes of horners syndrome?

Back 11

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

Front 12

What are the findings in Cushing's Syndrome?

Back 12

- 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

Front 13

What are the causes of clubbing?

Back 13

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

Front 14

What are the signs of aortic stenosis?

Back 14

- 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

Front 15

What are the clinical signs of severity for aortic stenosis?

Back 15

1. small volume pulse
2. aortic thrill
3. S4
4. late peaking ESM
5. paradoxical splitting S2
6. LVF

Front 16

What are the causes of hepato-splenomegaly?

Back 16

CHIICAT
1. CLD
2. Hematological disease: myeloproliferative, lymphoma, leukemia, pernicious anemia
3. Infiltration: amyloid, sarcoid
4. Infections
5. CTD - SLE
6. Acromegaly
7. Thyrotoxicosis

Front 17

What are the features of Chronic Liver Disease?
alcoholic liver disease?

Back 17

- 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

Front 18

What are the causes of pulmonary fibrosis?

Back 18

- 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

Front 19

What are the clinical features of acromegaly?

Back 19

- 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

Front 20

Causes of myopathy?

Back 20

- 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

Front 21

Causes of renal masses/enlargement?

Back 21

- benign cysts, APCKD
- malignant - RCC, mets
- infiltrates - sarcoid, myeloma
- infection - pyelonephritis, abscess
- hydronephrosis
- diabetic
- HIV

Front 22

What are the features of idiopathic parkinsons disease

Back 22

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

Front 23

What are the signs of aortic regurgitation?

Back 23

­- Pulse: Collapsing pulse / waterhammer pulse
 Wide pulse pressure
­- Palpation:
 Displaced apex beat, hyperkinetic
 Diastolic thrill on expiration and sitting forward
­- Auscultation:
 Soft A2
 High pitched decrescendo diastolic murmur immediately after 2nd HS (AV closure)
 Loudest at 3rd / 4th intercostal space
 Austin flint murmur: mid-diastolic rumble at apex due to shudder of anterior MV leaflet from regurgitant jet
 ESM often also present (AS without the signs – due to torrential flow across normal diameter valve as ventricular volume large)

Front 24

What are the clinical signs of severity for aortic regurgitation?

Back 24

­- Collapsing pulse
­- Wide pulse pressure
­- Long decrescendo murmur
­- S3
­- Soft A2 (AV closure)
­- Austin flint
­- Signs of LVF

Front 25

What are the signs of Mitral Stenosis?

Back 25

­- General: Tachypnoea, mitral facies, peripheral cyanosis
­- Pulse:
 Normal or reduced volume
 AF may be present
­- JVP:
 Normal or prominent A wave
 Loss of a wave with AF
­- Palpation:
 Tapping apex beat
 Right parasternal heave
 Palpable P2 if PHT
 Diastolic thrill (rare) in left lateral position
­- Auscultation:
 Low pitched, rumbling diastolic murmur
Best with bell with patient in left lateral position
 Loud S1 (cusps widely apart at onset of systole)
 Loud P2 if PHT
 Opening snap

Front 26

What are the clinical signs of severity for Mitral Stenosis?

Back 26

- Small pulse pressure
-­ Soft S1
­- Early opening snap (increased pressure)
­- Long diastolic murmur
­- Diastolic thrill
­- Signs of pulmonary HT: prominent a wave, RV heave, loud P2, pulm regurg, TR

Front 27

What are the signs of Mitral Regurgitation?

Back 27

­- Pulse:
 Normal or sharp upstroke
 AF common
 May be a compensatory tachycardia (decrease time for regurgitation)
­- JVP:
 Normal unless RVF
 A wave lost in AF
­- Palpation:
 Apex beat displaced,
 Diffuse, hyperdynamic pansystolic thrill at apex
 Right parasternal heave
­- Auscultation:
 Soft/absent S1
 Apical pansystolic murmur radiating to the axilla
 S3

Front 28

What are the clinical signs of severity for Mitral Regurgitation?

Back 28

-­ Small pulse pressure
­- Soft S1
­- Early opening snap (increased pressure)
­- Long diastolic murmur
­- Diastolic thrill
­- Signs of pulmonary HT: prominent a wave, RV heave, loud P2, pulm regurg, TR