Medicine Clinical Examination Material

Spotters: for 20 marks         

1. 2. 3. 4. 5. 6. 7. 8. 9.

Clubbing Pallor Edema Thyroid Tinea Tremor Icterus Scabies Psoriasis

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Clubbing Unilateral Clubbing Anomalous aortic arch Aortic or subclavian artery aneurysm Brachial arteriovenous aneurysm or fistula PDA with PAH Recurrent shoulder dislocation Pancoast tumor Unidigital Median nerve injury Sarcoidosis Tophi

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Anemia Caused by Blood Loss  UGI

Bleed : NSAIDS such as aspirin  Gastric malignancy  Hemorrhoids  Menorrhagia

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Anemia Caused by Decreased or Faulty Red Blood Cell Production

  



1. Sickle cell anemia 2. Iron deficiency anemia 3. Vitamin deficiency : B12, Folate 4. Bone marrow and stem cell problems

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Iron deficiency anemia

    

 

An iron-poor diet, especially in infants, children, teens and vegetarians Metabolic demands of pregnancy and breastfeeding that deplete a woman's iron stores Menstrual loss Frequent blood donation Digestive conditions such as Crohn's disease or surgical removal of part of the stomach or small intestine Certain drugs, foods, and caffeinated drinks Hook worm infestation

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Megaloblastic anemia:

      

1. Pernicious anemia: Poor vitamin B-12 absorption 2. An intestinal parasite infection (Fish tape worm) 3. Surgical removal of part of the stomach or intestine, 4. Poor vegterians 5. Pregnancy, 6.Methotrexate, Phenytoin, alcohol abuse, 7. Intestinal diseases such as tropical sprue and gluten-sensitive enteropathy

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Session 11 Long case for 50 marks    

CVS Respiratory GIT CNS: Hemiplegia

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Session 111 Short case for 30 marks    

System specification: 15 mts GCOE & System examination No history No case sheet writing

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Session 1V Viva for 20 marks:  Instruments  Drugs  X-rays.  Clinical charts  ECG’s

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Instruments

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1. Ryle’s tube (Nasogastric tube)

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Assessment of position: Take empty syringe & blow air into the tube & AUSCULTATE for bubbling sounds in LHC.

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Indications 

Diagnostic  Evaluation

of upper gastrointestinal (GI) bleed (ie, presence, volume)  Aspiration of gastric fluid content  Identification of the esophagus and stomach on a chest radiograph  Administration of radiographic contrast to the GI tract 15-11-29

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Indications 

Therapeutic 





  

Gastric decompression, including maintenance of a decompressed state after endotracheal intubation, often via the oropharynx Relief of symptoms and bowel rest in the setting of small-bowel obstruction Aspiration of gastric content from recent ingestion of toxic material Administration of medication Feeding Bowel irrigation

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Contra indications  

Corrosive poisoning, Stricture, Kerosene poisoning Relative contraindications  Coagulation

abnormality  Esophageal varices or stricture  Recent banding or cautery of esophageal varices  Alkaline ingestion 15-11-29

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Complications:

  

Perforation Hemorrhage Respiratory arrest if entered into glottis

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2. Self retaining Foley’s catheter;

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Foley’s catheter 



A Foley’s catheter is retained by means of a balloon at the tip which is inflated with sterile water. The balloons typically come in two different sizes: 5 cc and 30 cc. They are commonly made in silicone rubber or natural rubber. Catheter diameters are sized by the French catheter scale (F). The most common sizes are 10 F (3.3mm) to 28 F (9.3mm).

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Indications:        

Urinary retention in neurogenic bladder, BPH, Immobilized patients like fracture pelvis or long bones Chronic debilitating illnesses Urine output monitoring in a critically ill or injured person Unconscious patients Bladder wash Imaging study of the lower urinary tract After surgery

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Foley’s catheter Contraindications:  Stricture Complications:  Sepsis  Hemorrhage  Perforation

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A Robinson catheter   

Flexible catheter Short term drainage of urine. No balloon on its tip and therefore cannot stay in place unaided.

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A Coudé catheter 





A Coudé catheter is designed with a curved tip that makes it easier to thread the catheter pass the prostate or obstructions in the urethral canal. A Coudé catheter tip may be provided with a balloon or not. An irrigation catheter has a separate lumen to carry irrigation fluid into the bladder. This is useful following endoscopic surgical procedures or in the case of gross hematuria. An external Texas or condom catheter is used for incontinent males and carries a lower risk of infection than an indwelling catheter.

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3. Endo tracheal tube

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Indications:

  



Induction of general anesthesia Artificial respiratory support in OP poisoning, drowning. Artificial respiratory support in neurological conditions like: CVA, GB syndrome, bulbar palsy, pseudo bulbar palsy & MND Artificial respiratory support in respiratory conditions like: bilateral pneumonia, ARDS, AECB, acute pulmonary edema & Cor Pulmonale.

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Inflation 

SHOULD BE INFLATED WITH AIR, NOT WATER BECAUSE IN CASE IT BURSTS THE PT. ASPIRATES THE FLUID & DROWNS HIMSELF.

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4. L.P NEEDLE:

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L.P NEEDLE: 

SIZE: (26G-22G) L80-150 mm; *USE: Used in subarachnoid puncture for spinal anesthesia

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Indications       

MENINGITIS SAH GB SYNDROME UNEXPLAINED COMA MYELOGRAPHY INTRODUCE DRUGS SPINAL ANAESTHESIA

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Contra indications 

 

RAISED ICT, (Fundus exam mandatory to R/O Papilledema) MARKED SPINAL DEFORMITY, LOCAL INFECTIONS & SUSPECTED CORD COMPRESSION.

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COMPLICATIONS:   



HEADACHE, INFECTIONS, MEDULLARY HERNIATION LEADING TO DEATH, INJURY TO BLOOD VESSELS, SPINAL CORD OR INTERVERTEBRAL DISC.

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FROIN SYNDROME  



Xanthochromia High protein content (Albumino cytological dissociation) In spinal block

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Liver biopsy; VIM SILVERMAN

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Indications        

1. Cirrhosis of liver 2. Hepatic malignancies 3. Granulomas; Tb, Sarcoidosis, Schistosomiasis 4. Metabolic & storage disorders; Wilson, Amyloidosis & Hodgkin’s 5. Reticulo – endothelial; leukemia’s, multiple myeloma & Hodgkin’s 6. Unexplained fever with hepatomegaly; amoebiasis, Tb, cholangitis & brucellosis 7. Unexplained jaundice 8. Chronic hepatitis

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Contraindication

 

    

Bleeding diathesis Protracted hepatocelllular jaundice become hepatic precoma may be precipitated. Infections Hydatid cyst , if suspected Haemangioma of liver , if suspected Chronic passive congestion of liver Gross ascites

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Complications

   

Hemorrhage Infection Injury Precipitation of hepatic coma

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Bone marrow aspiration & biopsy

Salah needle

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BONE MARROW BIOPSY NEEDLEKLIMA 16G 25MM Bone marrow aspiration  Removes a small amount of bone marrow fluid and cells through a needle put into a bone.  The bone marrow fluid and cells are checked for problems with any of the blood cells made in the bone marrow. 15-11-29

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A bone marrow biopsy A bone marrow biopsy  Removes bone with the marrow inside to look at under a microscope.  The aspiration (taking fluid) is usually done first, and then the biopsy

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Indications         

Thrombocytopenia Leukemia Anemias Multiple myeloma Polycythemia vera Hodgkin's lymphoma Non-Hodgkin's lymphoma Staging & plan cancer treatment Culture and sensitivity test of the bone marrow sample

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Indications             

Disseminated coccidioidomycosis Hairy cell leukemia Hodgkin's lymphoma Idiopathic aplastic anemia Multiple myeloma Neuroblastoma Non-Hodgkin's lymphoma Polycythemia Vera Primary amyloid Primary Myelofibrosis Primary thrombocythemia Secondary aplastic anemia Secondary systemic amyloid

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Investigation for fever of unknown origin (FUO)      

Autoimmune deficiency syndrome (AIDS), Tuberculosis Mycobacterium avium intracellulare (MAI) infections, Histoplasmosis, Leishmaniasis, Disseminated fungal infections. Furthermore, the diagnosis of storage diseases (e.g.. Niemann-Pick disease and Gaucher disease) Assessment for metastatic carcinoma and granulomatous diseases (e.g., sarcoidosis) can be performed.

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side effects 

    

Hemorrhage : concurrent anticoagulation therapy or underlying myeloproliferative / myelodysplastic syndrome, Needle breakage Infections Pain Anaphylactic reaction Laceration of blood vessels

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Contraindications





If there is a severe bleeding disorder : gross anemia or thrombocytopenia. skin or soft tissue infection over the hip

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IV needles

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Venous cannula   

Administration of intravenous fluids, Obtaining blood samples Administering medicines

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Complications

  

Septic Thrombophlebitis Hematoma Nerve Damage

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Adult Ambu-Bag Manual Resuscitators

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Digital Thermometer, 60 Second Digital Thermometer

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X – rays       

Pleural effusion Hydropneumothorax Consolidation Bilateral emphysematous lungs Cannon ball Secondaries Pericardial effusion / cardiomyopathy Dextrocardia

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Systematic Roentgenographic interpretation         

1) superior vena cava (2) ascending aorta (3) right atrium (4) inferior vena cava and cardiac fat pad (5) left subclavian vein and artery (6) aortic arch (7) pulmonary artery (8) left atrium (9) left ventricle

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Transudates meet none: 

 



Exudates must meet one or more of the following criteria, whereas transudates meet none: Pleural fluid/serum protein > 0.5 or absolute value > 3 g/dl. Pleural fluid/serum LDH > 0.6 or absolute value > 0.45 upper normal serum limit Pleural fluid specific gravity > 1.018

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Etiology of Transudative Effusions

Congestive heart failure Cirrhosis Nephrotic syndrome Peritoneal dialysis Superior vena cava syndrome Myxedema Atelectasis (early) 15-11-29

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Etiology of Exudative Effusions Para pneumonic Simple or Complicated Empyema Tuberculosis Other infections :Fungal or Parasitic Malignant  Metastatic disease Mesothelioma  Pulmonary embolism 15-11-29

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Etiology of Exudative Effusions  

 

Collagen vascular disease Rheumatoid arthritis Systemic lupus erythematosus Wegener’s granulomatosis Churg-Strauss syndrome Familial Mediterranean fever Abdominal disease Pancreatitis Subphrenic abscess Esophageal rupture Postoperative

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Etiology of Exudative Effusions 

Atelectasis Acute respiratory distress syndrome, (ARDS) Asbestos exposure Hemothorax Chylothorax Cholesterol effusions Drug reactions Dressler’s syndrome Meigs’ syndrome Uremia Sarcoidosis Yellow nail syndrome Radiation therapy Ovarian hyperstimulation syndrome

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Pulmonary metastasis

cannonball Secondaries

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pulmonary metastasis 





Patients with carcinoma of the pancreas and bronchus who have pulmonary metastases have a 5-year survival rate of less than 5% One half of the patients with lymphangitis carcinomatosis die within 3 months. Chemosensitive tumors, such as choriocarcinoma and testicular teratoma, have a better prognosis. An isolated pulmonary metastasis (eg, from colon or kidney) can be resected, with a 5year survival rate of 50%.

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Pulmonary metastasis Primary Tumor  Choriocarcinoma 60  Melanoma56  Testis, germ cell12  Osteosarcoma15  Thyroid7  Kidney20  Head and neck5 15-11-29

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

Chest x-ray showing dextrocardia and right-sided gastric air bubble indicating the presence of both dextrocardia and situs inversus

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Pink puffer 





↑ Residual lung capacity and volume, ↓ Elastic recoil, ↓ Expiratory flow rate and diffusing capacity

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Pneumonia as seen on chest x-ray. Abnormal chest x-ray with consolidation from pneumonia in the Upper or inferior lobe

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X-ray chest showing pericardial effusion

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Causes of pericardial effusion may include:

  

   

Viral, bacterial, fungal or parasitic infections Inflammation of the pericardium due to unknown cause (idiopathic pericarditis) Inflammation of the pericardium following heart surgery or a heart attack (Dressler's syndrome) Autoimmune disorders, such as rheumatoid arthritis or lupus Waste product in the blood due to kidney failure (uremia) Hypothyroidism HIV/AIDS

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Causes of pericardial effusion may include:



  

 

Spread of cancer (metastasis), particularly lung cancer, breast cancer, leukemia, non-Hodgkin's lymphoma or Hodgkin's disease Cancer of the pericardium or heart Radiation therapy for cancer if the heart is within the field of radiation Chemotherapy treatment for cancer, such as doxorubicin (Doxil) and cyclophosphamide (Lyophilized Cytoxan) Trauma or puncture wound near the heart Certain prescription drugs, including hydralazine, a medication for high blood pressure; isoniazid, a tuberculosis drug; and phenytoin (Dilantin, Phenytek, others), a medication for epileptic seizures

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DRUGS:      

ATROPINE DOPAMINE PHENYTOIN FUROSEMIDE ADRENALINE DEXAMETHASONE

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ATROPINE USES: 

     

Stomach and intestinal tract disorders: peptic ulcers, diarrhea irritable bowel syndrome diverticulitis, colitis, or pancreatitis To control bed - wetting and frequent urination, Prevent motion sickness Treat alcohol withdrawal symptoms, Parkinson's disease Asthma Poisonings due to certain insecticides or plants.

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SIDE EFFECTS:

           

Flushing of the face, Headache, Blurred vision, Drowsiness, Increased sensitivity to light, Constipation Dry mouth Reduced sweating or thirst. Confusion, Tremors, Fast/irregular heartbeat, Difficulty urinating. Symptoms of an allergic reaction include: rash, itching, swelling, dizziness, trouble breathing.

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PRECAUTIONS:

  

  

Heart problems, Glaucoma stomach/abdominal/intestinal problems, Prostate or urinary problems, Contact lens wear, Allergies (especially drug allergies).

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Furosemide USES  Heart failure  Cirrhosis  Chronic kidney failure  Nephrotic syndrome  High blood pressure  Hypercalcemia 15-11-29

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SIDE EFFECTS:    

Low blood pressure Dehydration Electrolyte depletion (Na, K, Ca). Less common : jaundice, tinnitus, photophobia, rash, pancreatitis nausea diarrhea abdominal pain and dizziness

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Diuresis: Oral administration Onset: one hour Lasts: 6- 8 hours

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After injection Onset: 5minutes Lasts: 2 hours

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DOPAMINE INDICATIONS 

     

Hemodynamic imbalances present in the shock syndrome due to myocardial infarctions, trauma Poor Perfusion of Vital Organs & Low Cardiac Output: Hypotension: Inadequate COP Endotoxic septicemia open heart surgery Renal failure Chronic cardiac decompensation as in congestive failure.

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CONTRAINDICATIONS Pheochromocytoma.  Uncorrected tachyarrhythmia's or ventricular fibrillation. 

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SIDE EFFECTS Cardiovascular System: Ventricular arrhythmia (at very high doses), ectopic beats Tachycardia Anginal pain Palpitation Cardiac conduction abnormalities widened QRS complex Hypertension Vasoconstriction 15-11-29

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Adrenaline (Epinephrine) Injection 1:1,000 Minijet. Adrenaline (Epinephrine) 1mg per ml. Adults and children over 12 years: 0.5 ml (0.5 mg), administered slowly. The dose may be repeated every 5 to 15 minutes as needed. 15-11-29

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Indication of Adrenaline Injection:





Increased blood pressure, increased heart rate, increased air entry, increased blood glucose, stimulates cardiac activity Reduce allergic reactions by reducing inflammatory response caused by histamine.

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Pharmacodynamic properties 





Adrenaline is a direct-acting sympathomimetic agent exerting its effect on alpha- and betaadrenoceptors. Major effects are increased systolic blood pressure, reduced diastolic pressure, tachycardia, hyperglycaemia and hypokalaemia. It is a powerful cardiac stimulant. It has vasopressor properties and is a bronchodilator.

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Indication of Adrenaline Injection:

 



Anaphylaxis Acute angioneurotic edema with airways obstruction Acute allergic reactions (e.g. drug reactions, insect stings, food allergies).

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Contraindications

    

Hyperthyroidism Hypertension Ischemic heart disease Diabetes mellitus Closed angle glaucoma

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Undesirable effects 



Symptomatic adverse effects are anxiety, dyspnea, restlessness, palpitations, tachycardia, anginal pain, tremor, weakness, dizziness, headache, cold extremities, nausea, vomiting, sweating, local ischemic necrosis. Biochemical effects include inhibition of insulin secretion and hyperglycaemia even with low doses, gluconeogenesis, glycolysis, lipolysis and ketogenesis.

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Undesirable effects 



cardiac arrhythmias leading to ventricular fibrillation and death, Severe hypertension leading to pulmonary edema and cerebral hemorrhage

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EDEMA - UNILATERAL       



DVT VENOUS INSUFFICIENCY CELLULITIS TRAUMA LYMPHATIC OBSTRUCTION (LO) BY PELVIC TUMOR REFLEX SYMPATHETIC DYSTROPHY (RSD) MAY – THURNER SYNDROME ; LEFT ILIAC VEIN IS COMPRESSED BY RIGHT COMMON ILIAC ARTERY LOIASIS

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EDEMA – UPPER EXTREMITY    



SVC SYNDROME DVT LYMPHATIC OBSTRUCTION REFLEX SYMPATHETIC DYSTROPHY EOSINOPHILIC FASCIITIS

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Edema lower extremity - CARDIAC       

CHF (RIGHT SIDED) PCE PERICARDITIS TR / TS / PS / COR PULMONALE VENOUS INSUFFICIENCY VENOUS OBSTRUCTION 15-11-29

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NON - CARDIAC CAUSES            

CIRRHOSIS NEPHROTIC SYNDROME CELLULITIS PREMENSTRUAL FLUID RETENTION VASODILATORS CALCIUM CHANNEL BLOCKERS NSAIDS LYMPHATIC OBSTRUCTION PET / ECLAMPSIA MYXOEDEMA FILARIASIS EOSINOPHILIC FASCIITIS

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Pink puffer    

↑ Residual lung capacity and volume, ↓ Elastic recoil, ↓ Expiratory flow rate and diffusing capacity Ventilatory/perfusion–V/Q mismatch 2º to emphysemarelated destruction of blood vessels

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Pink puffer  



Clinical: SOB, hyperventilation ABGs :Usually near normal due to compensatory hyperventilation; arterial pO2 is in the mid-70s, pCO2 is low to normal;

PPs have ↑ tidal volume and retraction of accessory respiratory muscles.

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Blue bloater  



Normal to ↓ Lung capacity, ↑ Residual volume with airtrapping, ↓ Expiratory flow,

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Blue bloater    

Hypoxia Hypercapnia Heart failure (Right) Hypertension (Pulmonary)

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Pink puffer / Blue bloater    

↑ Residual lung capacity and volume, ↓ Elastic recoil, ↓ Expiratory flow rate and diffusing capacity Ventilatory/perfusion– V/Q mismatch 2º to emphysema-related destruction of blood vessels

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    

Normal to ↓ Lung capacity, ↑ Residual volume with air-trapping, ↓ Expiratory flow, Blue : Cyanosis Bloat : Distension

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Pink puffer 

A descriptor for a Pt with COPD and severe emphysema, who have a pink complexion and dyspnea; PPs have ↑ residual lung capacity and volume, ↓ elastic recoil, ↓ expiratory flow rate and diffusing capacity and a ventilatory/perfusion–V/Q mismatch 2º to emphysema-related destruction of blood vessels Clinical SOB, hyperventilation ABGs Usually near normal due to compensatory hyperventilation; arterial pO2 is in the mid-70s, pCO2 is low to normal; PPs have ↑ tidal volume and retraction of accessory respiratory muscles.

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Blue bloater 

A popular term for the appearance of a Pt with COPD with Sx of chronic bronchitis, normal to ↓ lung capacity, ↑ residual volume with air-trapping, ↓ expiratory flow, and characteristic arterial blood gas parameters–↓ PO2, ↑ PCO2, despite normal diffusing capacity, cyanosis and right heart failure, due to sleep apnea and progressive chronic pulmonary HTN; with time, it becomes indistinguishable from other forms of COPD.

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Non palpable apex Apex lying behind a rib Obesity or thick chest wall Pendular breast in elderly female Emphysema ( COPD ) Pleural effusion ( lt ) Pericardial effusion Constrictive pericarditis Acute myocardial infarction Pneumothorax ( /t ) Deformity of the chest ( gross kyphoscoliosis ) Thickened pleura ( lt )MUN 15-11-29

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CLINICAL FEATURES IN VALVE LESIONS M.S

M.R

SOB

EXERTIONAL DYSPNOEA

EFFORT INTOLERANCE

PALPITATIONS

A.S ANGINA

PALPITATION

SOB

PULSATILE OR THROBBING SENSATION

SYNCOPE

PND

SOFT S1

HAEMOPTYSIS

HYPERDYNAMIC APEX

FATIGUE

APEX GOES DOWN & OUTWARDS

ANACROTIC

SYSTOLIC THRILL

PULSUS PARVUS Vs TARDUS

SYNCOPAL ATTACKS CLI. SIGNS

CLI.SIGNS

PSM ; HP / SB / RADIATES LT. AXILLA & INF. ANGLE OF SCAPULA

LOW VOLUME PULSE TAPPING APEX

A.R

LOW VOLUME PULSE

CAROTID SHUDDER ; SYSTOLIC THRILL IN CAROTID ARTERY IS FELT

ANGINA SOB FEATURES OF LVF ; ORTHOPNOEA, PND HIGH VOLUME WATER – HAMMER PULSE

PALPABLE S1

HAEVING APEX

DIASTOLIC THRILL

CONCENTRIC LVH

HYPERDYNAMIC APEX

S2 MUFFLED

S1 ; SHORT, SHARP, ACCENTUATED

EDM HP/ SB/ DC

ESM; HARSH / CDC/

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OS, MDM, PSA

GALLAVERDIN’S MUN FP Academic Ha PHENAMENON ( MA )

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Opening snap Where sound

MS

S3 HF / chronic MR

Best audible

at lt. para sternal

at apex with bell

Pitch

high - pitched

low - pitched

Palpability

not palpable

often palpable

Timing

0.04 – 0.12 after s2

0.14 – 0.16

Treatment of HF

OS becomes louder

S3 vanishes

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AOTIC SCLEROSIS 



  



In aged persons suffering from atherosclerosis with or without HTN Fibrosis , thickening & some calcification of bases of the aortic valve cusps. Give rise to harsh ESM Normal volume pulse , normal A2 , Associated features of thickened peripheral arteries , kinked carotids , locomotor brachialis , suprasternal pulsations , Xanthelasma around the eyes , Occasionally this calcification becomes excessive , produces severe aortic valve obstruction ; calcific aortic stenosis

15-11-29

MUN FP Academic Ha

100

Aortic stenosis differentiation

Supra valvular Elfin facies

Valvular Click

Sub valvular

Soft A2

A2 normal

Thrill Radiation to mitral area Loud A2 15-11-29

MUN FP Academic Ha

101

JVP

15-11-29

MUN FP Academic Ha

102

JVP A- wave Right atrial contract ion

15-11-29

MUN FP Academic Ha

103

JVP

C wave Bulging of TV into RA (RVS)

A- wave Right atrial contract ion

15-11-29

MUN FP Academic Ha

104

JVP

C wave Bulging of TV into RA (RVS)

A- wave Right atrial contract ion

X Descent DDTV / RVS Fall RAP CA Relaxation

15-11-29

MUN FP Academic Ha

105

JVP

C wave Bulging of TV into RA (RVS)

A- wave Right atrial contract ion

X Descent DDTV / RVS Fall RAP CA Relaxation

V wave RA filling with the TV closed during RVS

15-11-29

MUN FP Academic Ha

106

JVP

C wave Bulging of TV into RA (RVS)

A- wave Right atrial contract ion

X Descent DDTV / RVS Fall RAP CA Relaxation

V wave Y descent

S3

opening of TV , blood flow to RA – RV, leading to a sudden fall of pressure in RA

15-11-29

MUN FP Academic Ha

RA filling with the TV closed during RVS

107

JVP A- wave Right atrial contract ion

15-11-29

A absent AF

MUN FP Academic Ha

108

JVP A- wave Right atrial contract ion

A absent AF

Large or giant A

15-11-29

TS / TA / RAM / PS / PHTN MUN FP Academic Ha

109

JVP A- wave Right atrial contract ion

A absent AF

Large or giant A Cannon A CHB / VT / Ectopic beats 15-11-29

TS / TA / RAM / PS / PHTN MUN FP Academic Ha

110

A wave diminished

JVP A- wave Right atrial contract ion

Tachycardia & prolonged PR interval

A absent AF

Large or giant A Cannon A CHB / VT / Ectopic beats 15-11-29

TS / TA / RAM / PS / PHTN MUN FP Academic Ha

111

C (TV cusp) – wave 



 

Impact of carotid artery adjacent to jugular vein. Retrograde transmission of positive wave in the RA P/B RVS. Bulging of TV in to RA. Not seen clinically.

15-11-29

MUN FP Academic Ha

112

X descent 

 

X descent is obliterated by a positive wave s wave TR / Constrictive pericarditis S wave fuse with C & V wave = giant v wave.

15-11-29

MUN FP Academic Ha

113

Rapid Y descent    

Constrictive pericarditis Severe heart failure TR Short Y descent: TS

15-11-29

MUN FP Academic Ha

114

Kussmaul’s sign

Normally inspiration

lowers JVP inspiratory collapse,

ITP falls & Increase blood flow in to thorax.

Increase

IPP in CP: Paradoxical increase in JVP on inspiration. 15-11-29 MUN FP Academic Ha 115

Hepatojugular reflux

Normally

when pressure is applied over the abdomen for 30 seconds,

JVP ( venous return )

Due to capacity of normal myocardium to accommodate the extra VR

Sustained elevation of JVP more than 1 mt , failing heart can’t compensate the extra VR

15-11-29

MUN FP Academic Ha

116

LVF

LAF

SYS. HTN

MS

IHD

LAM

AMI

BALL VALVE THROMBUS IN THE LA

AR AS

MITRAL ATRESIA

MR

RVF ( CCF )

RAF

COPD

TS

SEC. TO LSHD ( LVF / LAF )

SEC . TO RVF

PS

R.A.MYXOMA

ASD / VSD / PDA PHTN PUL . EMBOLI CMP

CMP

MYOCARDITIS

COA

RV INFARCTION

MYOCARDITIS SEVERE ANAEMIA

BERNHEIM’S EFFECT; RV PRESSURE CHANGES RESULTS FROM LVH WITHOUT DEVELOPING PHTN. IVS HYPERTROPHIES FROM LVH & PRODUCES OBSTRUCTION TO RV OUTFLOW & THUS MANIFESTS AS A PROMINENT a WAVE IN THE NECK VEIN WITHOUT DEVELOPING RVH OR RVF.

VSD PDA

15-11-29

MUN FP Academic Ha

117

ACCELERATED HTN SIGNIFICANT RECENT INCREASE IN BP LEVEL ASSOCIATED WITH EVIDENCE OF VASCULAR DAMGE ON FUNDOSCOPIC EXAMINATION WITHOUT PAPILLOEDEMA.

15-11-29

MUN FP Academic Ha

118

MALIGNANT HTN 

  

SEVERE AHTN WITH DIASTOLIC BP > 140mmHg WITH HAEMORRHAGE , EXUDATE & PAPILLOEDEMA WITH ONE OR MORE OF THE FOLLOWING ; 1. RAPIDLY DETERIORATING RENAL FUNCTION 2. CARDIAC DECOMPENSATION 3. HYPERTENSIVE ENCEPHALOPATHY ( HEADACHE , VOMITING , CONVULSIONS & COMA )

15-11-29

MUN FP Academic Ha

119

HAND IN SBE

CLUBBING PALLOR OSLER’S NODE ( TENDER ) SPLINTER HAEMORRHAGE JANEWAY’S SPOT ( NON TENDER MACULOPAPULAR LESIONS IN PALM ) PYREXIA PETECHIAE GANGRENE OF THE FINGERS

15-11-29

MUN FP Academic Ha

120

OSLER’S NODE    

TENDER PAPULE PIN HEAD SIZE TO PEA PULP OF FINGERS , TOES & PALMS DUE TO EMBOLISM OR ARTERITIS

15-11-29

MUN FP Academic Ha

121

ROTH SPOT 





YELLOWISH, ELLIPTICAL , FLAME – SHAPED HAEMORRHAGES WITH A PALE CENTRE IN THE RETINA DUE TO DEPOSITION OF CIRCULATING IMMUNE COMPLEX APART FROM SBE ARE ; APLASTIC ANAEMIA , LEUKAEMIA , SCURVY.

15-11-29

MUN FP Academic Ha

122

CAUSES OF VALVULAR LESIONS M.R

M.S RHEUMATIC

RHEUMATIC

PARACHUTE MITRAL VALVE

MVP PAPILLARY MUSCLE DYSFUNCTION D/T IHD

CARCINOID SYNDROME

RUPTURE OF PAPILLARY MUSCLE IN AMI

COLLAGEN VASCULAR DISEASE MUCOPOLYSACCH ARIDOSES

TRAUMATIC ; DURING MITRAL VALVOTOMY I.E , MYOCARDITIS MARFAN’S

A.S RHEUMATIC BI – CUSPID AORTIC VALVE CALCIFIC DGN OF AORTIC VALVE ASS. WITH FAMILIAL HYPERCHOLESTER OLAEMIA & MPS FUNCTIONAL IN SEVERE AR / TT / SEVERE ANAEMIA

A.R RHEUMATIC TRAUMATIC INFECTIVE ENDOCARDITIS BICUSPID A.V ATHEROSCLERO TIC DISSECTION OF AORTA SYPHILIS MARFAN’S SYN

SLE ( LIBMAN – SACKS ENDOCARDITIS )

ANKYLOSING SPONDILITIS

RA

RHEUMATOID ARTHRITIS

DCM CONGENITAL

15-11-29

MUN FP Academic Ha

123

PND  



 





ACUTE LT . SIDED HEART FAILURE AWAKENED FROM SLEEP / WITH A FEELING OF INTENSE SUFFOCATION & CHOKING SENSATION HE SITS UPRIGHT IN THE BED WITH THE LEGS HANGING BY THE SIDE OF THE BED OR RUSHES TO OPEN WINDOW IN THE HOPE THAT COOL FRESH AIR WILL RELIEVE HIM. DYSPNOEA PROGRESSES WITH PROFUSE SWEATING THESE ARE ACCOMPANIED BY DRY , REPETITIVE COUGH D/T ACUTE INTERSTITIAL OEDEMA; WHEN THERE IS NO COLLECTION OF FLUID IN THE ALVEOLI. THE ATTACK SUBSIDE SPONTANEOUSLY WITHIN 30 MTS BUT OFTEN PROGRESSES TO ACUTE PULMONARY OEDEMA. APO ; COUGH NOW PRODUCTIVE WITH PROFUSE WATERY PINKISH & FROTHY SPUTUM.

15-11-29

MUN FP Academic Ha

124

Pulmonary hypertension                

When the PAP > 30mmHg Symptoms ; SOB / EASY FATIGUABILITY / DIZZINESS / SYNCOPE / CHEST PAIN SIGNS ; LOW VOLUME PULSE ‘a’ wave is prominent in jvp Visible pulmonary artery pulsations in 2nd lics Epigastric pulsations Apex goes outwards P2 – diastolic shock, p2 – palpable Lt. parasternal haeve Pulsation of pulmonary artery may felt S1 – audible Pulmonary ejection click ESM ; d/.t relative obstruction Close splitting of s2 with loud p2 Graham steel murmur – an EDM d/t functional PR Rt. Sided s3 ( RV gallop ) – heard at lower lt. sternal border

15-11-29

MUN FP Academic Ha

125

Causes of pulmonary HTN 

  

 

PASSIVE – FROM LEFT SIDED HEART DISEASES LIKE MS / MR / AS / AR HYPERKINETIC – ASD / VSD / PDA VASOCONSTRICTIVE – CHRONIC CORPULMONALE OBSTRUCTIVE – PULMONARY THROMBOEMBOLISM / ACUTE CORPULMONALE OBLITERATIVE – SLE / PSS / PAN NEUROHUMORAL OR IDIOPATHIC - PPH

15-11-29

MUN FP Academic Ha

126

Jones Criteria (Revised) for Guidance in the Diagnosis of Rheumatic Fever* Major Manifestation Carditis Polyarthritis Chorea Erythema Marginatum Subcutaneous Nodules

Minor Manifestations Clinical Previous rheumatic fever or rheumatic heart disease Arthralgia Fever

Laboratory Acute phase reactants: Erythrocyte sedimentation rate, C-reactive protein, leukocytosis Prolonged PR interval

Supporting Evidence of Streptococal Infection Increased Titer of AntiStreptococcal Antibodies ASO (anti-streptolysin O),

others Positive Throat Culture for Group A Streptococcus Recent Scarlet Fever

*The presence of two major criteria, or of one major and two minor criteria, indicates a high probability of acute rheumatic fever, if supported by evidence of Group A streptococcal nfection.

Recommendations of the American Heart Association

15-11-29

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127

STEP I: Primary Prevention of Rheumatic Fever (Treatment of Streptococcal Tonsillopharyngitis) Agent

Dose

Benzathine penicillin G

600 000 U for patients

Mode Intramuscular

Duration Once

27 kg (60 lb) 1 200 000 U for patients >27 kg

or Penicillin V Children: 250 mg 2-3 times daily Oral (phenoxymethyl penicillin) Adolescents and adults: 500 mg 2-3 times daily

10 d

For individuals allergic to penicillin Erythromycin: Estolate

20-40 mg/kg/d 2-4 times daily (maximum 1 g/d)

Oral

10 d

40 mg/kg/d 2-4 times daily Oral (maximum 1 g/d) Heart Association Recommendations of American

10 d

or Ethylsuccinate

15-11-29

MUN FP Academic Ha

128

STEP IV : Secondary Prevention of Rheumatic Fever (Prevention of Recurrent Attacks) Agent

Dose

Benzathine penicillin G

Mode

1 200 000 U every 4 weeks*

Intramuscular

or Penicillin V

250 mg twice daily

Oral

or Sulfadiazine

0.5 g once daily for patients 27 kg (60 lb Oral 1.0 g once daily for patients >27 kg (60 lb)

For individuals allergic to penicillin and sulfadiazine Erythromycin

250 mg twice daily

Oral

*In high-risk situations, administration every 3 weeks is justified and recommended

Recommendations of American Heart 15-11-29 MUN FP Academic HaAssociation

129

Duration of Secondary Rheumatic Fever Prophylaxis Category

Duration

Rheumatic fever with carditis and residual heart disease until (persistent valvar disease*)

At least 10 y since last episode and at least age 40 y, sometimes lifelong prophylaxis

Rheumatic fever with carditis but no residual heart disease (no valvar disease*)

10 y or well into adulthood, whichever is longer

Rheumatic fever without carditis

5 y or until age 21 y, whichever is longer

*Clinical or echocardiographic evidence. Recommendations of American Heart Association

15-11-29

MUN FP Academic Ha

130

Antibiotic Regimens for Prophylaxis of Endocarditis in Adults with High-Risk Cardiac Lesionsa,b

 

 

A. Standard oral regimen 1. Amoxicillin 2.0 g PO 1 h before procedure B. Inability to take oral medication 1. Ampicillin 2.0 g IV or IM within 1 h before procedure

15-11-29

MUN FP Academic Ha

131

Antibiotic Regimens for Prophylaxis of Endocarditis in Adults with High-Risk Cardiac Lesionsa,b       

C. Penicillin allergy 1. Clarithromycin or azithromycin 500 mg PO 1 h before procedure 2. Cephalexinc 2.0 g PO 1 h before procedure 3. Clindamycin 600 mg PO 1 h before procedure D. Penicillin allergy, inability to take oral medication 1. Cefazolinc or ceftriaxonec 1.0 g IV or IM 30 min before procedure 2. Clindamycin 600 mg IV or IM 1 h before procedure

15-11-29

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132

High-Risk Cardiac Lesions for Which Endocarditis Prophylaxis Is Advised before Dental Procedures     



Prosthetic heart valves Prior endocarditis Unrepaired cyanotic congenital heart disease, including palliative shunts or conduits Completely repaired congenital heart defects during the 6 months after repair Incompletely repaired congenital heart disease with residual defects adjacent to prosthetic material Valvulopathy developing after cardiac transplantation

15-11-29

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133

PATHOLOGICAL CONDITIONS          

CONSOLIDATION TOTAL COLLAPSE PARTIAL COLLAPSE FIBROSIS CAVITY PLEURAL EFFUSION EMPYEMA PNEUMOTHORAX HYDROPNEUMOTHORAX BRONCHIECTASIS

15-11-29

MUN FP Academic Ha

134

CLINICAL FINDINGS       

CHEST WALL MOVEMENTS MEDIASTINUM PERCUSSION BREATH SOUNDS ADVENTITIOUS SOUNDS VOCAL RESONANCE

15-11-29

MUN FP Academic Ha

135

CONSOLIDATION       

CHEST WALL ; NORMAL MOVEMENTS ; DECREASED MEDIASTINUM ; CENTRAL PERCUSSION ; DULL BREATH SOUNDS ; TUBULAR ADV. SOUNDS ; RALES VR ; WP +

15-11-29

MUN FP Academic Ha

136

COLLAPSE        

TOTAL COLLAPSE C ; RETRACTION M ; DECREASED M ; SAME SIDE P ; DULL B ; ABSENT A ; ABSENT V ; ABSENT

 

     

15-11-29

PARTIAL COLLAPSE C;N/ RETRACTION M ; DECREASED M ; SAME SIDE P ; DULL B ; TUBULAR A ; RALES V ; WP +

MUN FP Academic Ha

137

FIBROSIS   

   

RETRACTION DECREASED SAME SIDE

CHEST MOVEMENTS MEDIASTINUM

IMPAIRED DIMINISHED RALES DIMINISHED

PERCUSSION BS ADV. VR

15-11-29

MUN FP Academic Ha

138

CAVITY       

N / RETRACTION DECREASED CENTRAL / SAME SIDE IMPAIRED / BOXY AMPHORIC / CAVERNOUS RALES WP +

15-11-29

MUN FP Academic Ha

139

PLEURAL EFFUSION       

CHEST ; NORMAL MOVE ; DECRESAED MEDI. ; OPPOSITE PERC. ; STONY DULL BS ; ABSENT AS ; ABSENT VR ; ABSENT

15-11-29

MUN FP Academic Ha

140

PNEUMOTHORAX       

NORMAL CHEST DECREASED MOVEMENTS OPPOSITE SIDE DEVIATION HYPER RESONANT ABSENT / AMPHORIC B.S ABSENT A.S ABSENT V.R

15-11-29

MUN FP Academic Ha

141

CLINICAL DIFFERENCES        

PLE N D O STONY DULL AB AB AB

15-11-29

       

PNT N D O HYPER RESONANT AB / AMPHORIC AB AB

MUN FP Academic Ha

142

EMPYEMA       

BULGING / OEDEMATOUS D O STONY DULL AB AB AB

15-11-29

MUN FP Academic Ha

143

HYDROPNEUMOTHORAX       

N D O SHIFTING DULLNESS AB SUCCUSSION SPLASH AB

15-11-29

MUN FP Academic Ha

144

BRONCHIECTASIS       

N D/N C N VESICULAR COARSE LEATHERY RALES N

15-11-29

MUN FP Academic Ha

145

DD OF PLEURAL EFFUSION      

THICKENED PLEURA EMPYEMA PERICARDIAL EFFUSION LIVER ABSCESS BGC SYNPNEUMONIC EFFUSION

15-11-29

MUN FP Academic Ha

146

PLEURAL DISEASES THICKENED PLEURA LONG STANDING HISTORY DEPRESSED I.C.S NO SHIFT / SS OF MEDIASTINUM DULL DIMINISHED B.S

PCE EMPYEMA SEPTICAEMIA + RED / SHINY / EDEMA OF I.C.S

15-11-29

PLE ACUTE BULGING OPPOSITE SIDE STONY DULL B.S ; ABSENT

MUN FP Academic Ha

147

PCE / PLE    

MEDIASTINAL SHIFT DULLNESS POSTERIORLY TRAUBE ‘S AREA HEART SOUNDS

15-11-29

MUN FP Academic Ha

148

LIVER ABSCESS / Rt. PLE 

 

DULLNESS HIGHEST POINT MCL / AXILLA TIDAL PERCUSSION -/+ INTER COSTAL TENDERNESS + / -

15-11-29

MUN FP Academic Ha

149

A.P

Vesicular Breath Sound: I.P

E.P

 Soft

and low-pitched.  Inspiratory sounds > expiratory sounds.   

Rustling Transmit low frequency sounds Dampens high frequency sounds

. 15-11-29

MUN FP Academic Ha

150

Vesicular Breath Sound:



Active inspiration due to passage of air in to the bronchi & alveoli F/B without a pause by passive expiration D/T Elastic recoil of alveoli, which occurs maximally in the early phase giving an apparent impression of short expiration.

15-11-29

MUN FP Academic Ha

151

Bronchovesicular Breath Sound I.P

E.P

Intermediate

intensity

and pitch. Inspiratory = expiratory sounds 15-11-29

MUN FP Academic Ha

152

Bronchial Breath Sounds  Very

loud & high-pitched  Sound close to the stethoscope.  Gap between the inspiratory and expiratory phases  Expiratory sounds > inspiratory sounds. 15-11-29

MUN FP Academic Ha

153

Bronchial Breath Sounds     

Hollow No rustling Loud High pitch Transmit both HFS & LFS

15-11-29

MUN FP Academic Ha

154

Bronchial Breath Sounds 

  

Tubular : HP / HOLLOW / CONSOLIDATION ABOVE PLEURAL EFFUSION CAVERNOUS: AMPHORIC:

15-11-29

MUN FP Academic Ha

155

Absent or Decreased Breath Sounds

  

 



ARDS: decreased breath sounds in late stages Asthma: decreased breath sounds Atelectasis: If the bronchial obstruction persists, breath sounds are absent unless the atelectasis occurs in the RUL in which case adjacent tracheal sounds may be audible. Emphysema: decreased breath sounds Pleural Effusion: decreased or absent breath sounds. If the effusion is large, bronchial sounds may be heard. Pneumothorax: decreased or absent breath sounds

15-11-29

MUN FP Academic Ha

156

Crackles (Rales) soft (fine crackles) or loud (coarse crackles) high (fine crackles ) or low (coarse crackles) Discontinuous, nonmusical, brief; more commonly heard on inspiration; ARDS, asthma, bronchiectasis, bronchitis, consolidation, early CHF, interstitial lung disease May sometimes be normally heard at anterior lung bases after max. expiration or after prolonged recumbency

15-11-29

MUN FP Academic Ha

157

Crackles (Rales)

   

Crackles are discontinuous, nonmusical, brief sounds heard more commonly on inspiration. They can be classified as Fine (high pitched, soft, very brief) or Coarse (low pitched, louder, less brief).

15-11-29

MUN FP Academic Ha

158

Crackles (Rales)

Coarse Low pitched, Louder, Less brief

15-11-29

Fine High pitched Soft Very brief

MUN FP Academic Ha

159

EARLY INSPIRATORY CRACKLES     



LP EIC NON PRESSURE DEPENDENT SCANTY Open of large AW’s closed by ATM during previous expiration. Chronic bronchitis

15-11-29

MUN FP Academic Ha

160

MIC   

Lung abscess BEC CAVITY

15-11-29

MUN FP Academic Ha

161

LIC     

Delayed opening of AW’s Profuse HP Postural variation Pulmonary edema & fibrosis

15-11-29

MUN FP Academic Ha

162

Expiratory rales  

Severe AW obstruction Reopening of temporarily closed by the ATM during expiration.

15-11-29

MUN FP Academic Ha

163

Crackles 





Crackles may sometimes be normally heard at the anterior lung bases after a maximal expiration or after prolonged recumbency. The mechanical basis of crackles: Small airways open during inspiration and collapse during expiration causing the crackling sounds. Another explanation for crackles is that air bubbles through secretions or incompletely closed airways during expiration.

15-11-29

MUN FP Academic Ha

164

Wheeze





 

Wheezes are continuous, high pitched, hissing sounds heard normally on expiration but also sometimes on inspiration. They are produced when air flows through airways narrowed by secretions, foreign bodies, or obstructive lesions. Note when the wheezes occur and if there is a change after a deep breath or cough. Also note if the wheezes are monophonic (suggesting obstruction of one airway) or polyphonic (suggesting generalized obstruction of airways). 15-11-29

MUN FP Academic Ha

165

Wheeze High expiratory continuous sounds normally heard on expiration; Monophonic (obstruction of 1 airway) Polyphonic (general obstruction); Asthma , CHF, Chronic bronchitis, COPD, Pulmonary edema

15-11-29

MUN FP Academic Ha

166

Rhonchi •Low expiratory continuous musical sounds •Similar to wheezes; •Imply obstruction of larger airways by secretions.

15-11-29

MUN FP Academic Ha

167

Wheeze     

Asthma CHF Chronic bronchitis COPD Pulmonary edema

15-11-29

MUN FP Academic Ha

168

Pleural Rub







Pleural rubs are creaking or brushing sounds produced when the pleural surfaces are inflamed or roughened and rub against each other. They may be discontinuous or continuous sounds. They can usually be localized a particular place on the chest wall and are heard during both the inspiratory and expiratory phases. 15-11-29

MUN FP Academic Ha

169

Mediastinal Crunch (Hamman’s sign)









Mediastinal crunches are crackles that are synchronized with the heart beat and not respiration. They are heard best with the patient in the left lateral decubitus position. As with Stridor, mediastinal crunches should be treated as medical emergencies. E.g. Pneumomediastinum 15-11-29

MUN FP Academic Ha

170