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42 Cards in this Set

  • Front
  • Back
What are the signs of aortic stenosis?
- 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
What are the clinical signs of severity for aortic stenosis?
1. small volume pulse
2. aortic thrill
3. S4
4. late peaking ESM
5. paradoxical splitting S2
6. LVF
What are the causes of an S3?
1. Physiological
2. Dilated cardiomyopathy
3. AR
4. MR
What are the causes of an S4?
1. AS
2. HOCM
3. Systemic hypertension
What are ways of differentiating between a JVP and carotid pulse?
- non pulsatile
- double flicker
- moves with respiration (falls with inspiration)
- moves with position
- accentuates with hepatojugular reflex
- fills from above
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 signs of graves disease?
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
What are the signs of thyroid eye disease?
- hyperthryoidism: lid lag, lid retraction
- Grave's related: exopthalmus, proptosis, periorbital oedema, chemosis, complex orbitopathy, diplopia, corneal/conjunctival ulceration, optic neuropathy
What are the non-pharmacological management principles in cardiac failure?
- multidisciplinary: doctors, heart failure nurses, dietitian, physiotherapist
- fluid restriction, daily weights
- Low salt diet <2g
- exercise
- LOW - appropriate BMI
- smoking cessation
- cardiac rehabilitation
What are the pharmacological management principles in cardiac failure?
Mortality benefit
- ACE-i
- B-blocker
- Spironolactone

Symptomatic benefit
- frusemide
- digoxin

Interventional
- biventricular pacing
- AICD
- cardiac transplant
What are the radiological changes in RA?
1. symmetrical joint space narrowing
2. symmetrical soft tissue swelling
3. periarticular erosions
4. periarticular osteopenia
5. subluxation with typical deformities
What are the radiological features of OA?
1. asymmetrical joint space narrowing
2. osteophytes
3. subchondral sclerosis
4. subchondral cysts
What are the findings in third nerve palsy?
1. Down and out pupil
2. ptosis
3. fixed dilated pupil
What are the clinical findings of COPD?
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
What are the causes of peripheral neuropathy?
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
-
What are the features and causes of horners syndrome?
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
What are the features of lateral medullary syndrome?
1. Horner's syndrome
2. sensory dissociation
3. CN 9 and 10 palsy
4. Cerebellar
What are the findings in Cushing's Syndrome?
- 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
What are the causes of clubbing?
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
What are the causes of palmar erythema?
1. pregnancy
2. CLD
3. polycythemia
4. hypothyroidism
5. alcohol
What are the causes of hepato-splenomegaly?
CHIICAT
1. CLD
2. Hematological disease: myeloproliferative, lymphoma, leukemia, pernicious anemia
3. Infiltration: amyloid, sarcoid
4. Infections
5. CTD - SLE
6. Acromegaly
7. Thyrotoxicosis
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
What are the clinical findings of malignancy?
- 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
Differential diagnosis of ataxic gait?
1. Cerebellar
2. Sensory
3. Vestibular dysfunction
What is Rhomberg's sign?
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)
What are the signs and severity of AR?
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
What is your approach to warfarin counselling?
- 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
How would you assess malnutrition?
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
What are the clinical findings seen in pulmonary fibrosis?
- 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
What are the causes of pulmonary fibrosis?
- 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
What is you approach to managing frequent falls?
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
What are the clinical features of acromegaly?
- 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
what are the causes of normocytic anemia?
- anemia of chronic disease
- acute bleed
- hemolytic anemia
- bone marrow failure, aplastic anemia
Causes of myopathy?
- 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
Causes of renal masses/enlargement?
- benign cysts, APCKD
- malignant - RCC, mets
- infiltrates - sarcoid, myeloma
- infection - pyelonephritis, abscess
- hydronephrosis
- diabetic
- HIV
What is your approach to management of obesity?
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
What are the causes of chronic cough?
Most common
- asthma
- postnasal drip
- GORD

Others
- whooping cough, post viral cough
- cancer
- ILD
- COPD
- heart failure
What are the features of idiopathic parkinsons disease and the parkinsons plus syndromes?
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)
-
What is your approach to managing refractory hypertension?
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
What questions would you ask in assessment of a patients diet?
- 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
Causes of pyramidal weakness and cerebellar signs in the limbs?
1. Spinocerebellar syndromes
2. Arnold chiari malformations
3. multifocal diseases - strokes, MS
What are the causes of ptosis?
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