MEDICINE FOR FINALS

1
MEDICINE FOR FINALS
DR INDER MAINIE MAY 2002
2
CARDIOVASCULAR

• INTRODUCTION
• MAY I EXAMINE YOU?
• 45 DEGREES
• INSPECTION (SOB, SCARS, MALAR FLUSH, ANKLE
  OEDEMA)
• ALWAYS LOOK AROUND THE BED, INHALERS, OXYGEN,
  DIET DRINKS ETC

3
EXAMINATION

• LOOK AT THE HANDS
• FINGER CLUBBING
• CYANOSIS
• SPLINTER HAEMORRAGES
• PALE

4
PULSE

• RATE
• RHYTMN
• CHARACTER BRACHIAL/CAROTID
• VOLUME
• COLLAPSING PULSE

5
CAUSES OF IRREGULAR IRREGULAR PULSE

• ATRIAL FIBRILLATION, VES, ATRIAL FLUTTER WITH
  VAR BLOCK, CHB
• CAUSES OF AF
• ISCHAMIC HEART DISEASE
• RHEUMATIC HEART DISEASE
• THYROID
• NO CAUSE
• CARDIOMYOPATHY
• WPW
• INFECTION
• ASD

6
COLLAPSING PULSE

• AORTIC REGURG LOOK FOR CORRIGANS SIGN
• PDA
• PAGETS
• PREGNANCY
• RUPTURED ANEURYSM OF AORTIC SINUS
• FEVER
• ANAEMIA

7
RADIO-FEMORAL DELAY

• COARCTATION OF THE AORTA
• ASK WHILE EXAMINING THE PULSE CAN YOU CHECK FOR
  THIS

8
BLOOD PRESSURE

• ALWAYS REMEMBER TO ASK IF YOU CAN CHECK THE BLOOD
  PRESSURE

9
JVP

• INTERNAL JUGULAR
• BETWEEN THE TWO HEADS
• EQUAL TO PRESSURES IN THE RIGHT ATRIUM
• a WAVE ATRAL CONTRACTION
• v WAVE ATRIAL FILLING DURING VENTRICLAR
  SYSTOLE,TRICUSPID VALVE IS CLOSED

10
CAUSES OF A RAISED JVP

• HEART FAILURE ELEVATION, SUSTAINED HJR
• PE ELEVATED
• PERICARDIAL EFFUSION-ELEVATED, PROMINENT Y
  DESCENT
• CONSTRICTIVE PERICARDITIS-ELEVATED KUSSMAULS,
  PARADOXICAL RISE ON INSPIRATION
• AF NO a WAVES
• TRICUSPID STENOSIS- GIANT a WAVES
• TRICUSPID REGURG- GIANT v WAVES
• COMPLETE HEART BLOCK- CANNON WAVES

11
APEX BEAT

• LOOK FOR STERNOTOMY SCARS
• LOOK FOR THORACOTOMY SCARS
• POSITION AND CHARACTER
• CHECK FOR HEAVES OR THRILLS

12
HEART SOUNDS

• PALPATE THE CAROTID SIMULTANEOUSLY
• COMMENT ON I AND II OR ADDITIONAL
• MURMURS

13
MURMURS

• STENOSIS- APEX LEFT LATERAL USE THE BELL
• REMEMBER CHANGES IN BREATHING
• INSPIRATION RIGHT HEART MURMURS GET LOUDER
• EXPIRATION LEFT SIDE MURMURS GET LOUDER
• PANSYSTOLIC MURMUR APEX, AXILLA
• EARLY DIASTOLIC AORTIC REGURG 3RD ICS SIT FORWARD
  ON EXP

14
GRADING OF MURMURS

• 1. FAINT
• 2. FAINT BUT EASILY DETECTED
• 3. POMINENT BUT NOT LOUD
• 4. LOUD THRILL
• 5. VERY LOUD
• 6. LOUD WITHOUT CONTACT

15
REMEMBER

• LUNG BASES
• SACRAL OEDEMA
• HEPATOSPLENOMEGALY FAILURE
• PERIPHERAL PULSES

16
MITRAL STENOSIS

• MALAR FLUSH
• PULSE- IRREGULR IRREGULAR
• RAISED JVP
• TAPPING APEX NOT DISPLACED
• LEFT PARASTERNAL HEAVE(RIGHT VENTRICULAR
  ENLARGEMENT)
• LOUD 1ST HS
• OPENING SNAP

17
MITRAL STENOSIS

• CAUSES- RHD
• TAPPING APEX BEAT -DUE TO ACCENTUATED 1ST HS
• OPENING SNAP OPENING OF A STENOSED VALVE
  PLIABLE, ABSENT IN DIFFUSELY CALCIFIED VALVE
• LOUD 1ST VALVES ARE MOBILE
• PRESYSTOLIC ACCENTUATION- SINUS RHYTMN DUE TO THE
  ATRIAL SYSTOLE WHICH INCREASES FLOW ACROSS A
  STENOTIC VALVE

18
COMLICATIONS

• LEFT ATRIAL ENLARGEMENT
• AF
• PULMONARY HTN
• TR
• RHF

19
SEVERITY

• NARROWER DISTANCE BETWEEN 2ND HS AND OS
• LONGER THE DIASTOLIC MURMUR

20
MITRAL REGURG

• PERIPHERAL PULSES- NORMAL JERKY DUE TO REDUCED
  SYSTOLIC EJECTION TIME SECONDARY TO A LARGE
  VOLUME OF BLOOD REGURG INTO LEFT ATRIUM
• APEX BEAT- DISPLACED
• 1ST HS SOFT
• 3RD HS
• PSM -gt AXILLA LOUDER ON EXP

21
CAUSES OF MR

• MITRAL VALVE PROLAPSE
• RHD
• LEFT VENTRICLAR DILATATION
• CORONARY DISEASE
• ANNULAR CALCIFICATION
• ENDOCARDITIS
• PAPILLARY MUSCLE RUPTURE
• CARDIOMYOPATHY
• CONNECTIVE TISSUE DISORDER
• TRAUMA
• MYXOMATOUS DEGENERATION

22
CAUSES OF PSM

• MR
• TR
• VSD
• HOCM

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AORTIC REGURG

• PULSE- LARGE VOLUME, COLLAPSING
• CORRIGANS
• APEX DISPLACED OUTWARDS, FORCEFUL
• EDM- LSE SIT FORWARD EXPIRATION

24
Aortic Regurgitation

• WIDE PULSE PRESSURE
• FEMORALS- PISTOL SHOTS(TRAUBES)
• TO AND FRO MURMUR (DUROZIEZS)
• CORRIGANS CAROTID PULSATION
• QUINCKES
• UVULA PULSATIONS (MULLERS)
• ARGYLL ROBERTSON PUPIL
• MARFANS
• ANK SPOND, RA

25
Causes Of Aortic Regurgitation

• RF
• HTN
• ATHEROSCLEROSIS
• ENDOCARDITIS
• SYPHILIS
• MARFANS
• RA
• ANK SPOND
• TRAUMA
• AORTIC DISSECTION

26
SEVERITY

• WIDE PULSE PRESSURE
• SOFT 2ND HS
• 3RD HS
• AUSTIN FLINT MURMUR
• LVF
• LONGER LOUDER

27
AORTIC STENOSIS

• LOW VOLUME SLOW RISING
• APEX- HEAVING, NOT DISPLACED
• SOFT 2ND
• EJECTION CLICK
• S4 MAY BE HEARD
• ESM
• NARROW PULSE PRESSURE
• REVERSE SPLITTING

28
CAUSES OF AORTIC STENOSIS

• RHEUMATIC
• DEGENERATIVE CALCIFICATION OF A BICUSPID VALVE

29
OTHER CAUSES OF ESM

• PULM STENOSIS
• HOCM
• SUPRAVALVULAR STENOSIS

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SYMPTOMS

• FATIGUE
• ANGINA
• DYSPNOEA
• SYNCOPE
• DEATH

31
INVESTIGATIONS

• ECG
• CXR
• ECHO
• CATH
• EST BE CAREFUL IF SYMPTOMATIC

32
TRICUSPID REGURGITATION

• CAUSES
• FUNCTIONAL
• PULMONARY HTN
• CCF
• RHD
• ENDOCARDITIS DRUG ADDICTS

33
VSD

• PSM AT LSE
• LOUD P2 OF PULM HTN
• MAY HAVE CCF
• LOUDNESS DOES NOT MEAN SEVERE

34
CAUSES OF VSD

• CONGENITAL
• RUPTURE AFTER MI
• 50 MAY CLOSE SPONTANEOUSLY
• COMPLICATIONS ARE
• CCF
• AORTIC REGURG
• SBE
• PULM HTN

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INFECTIVE ENDOCARDITIS

• ANAEMIA
• CLUBBING
• SPLINTER HAEMORRAGES- EMBOLISM
• OSLER NODES- INFLAMMATION OF EMBOLI
• JANEWAY LESIONS
• PETECHIAE
• ROTH SPOTS
• SPLENOMEGALY
• HAEMATURIA
• DENTAL
• FBP- NORMOCYTIC NORMOCHROMIC
• ESR
• BLOOD CULTURES
• ECHO/ TOE

36
COMLICATIONS OF SBE

• CARDIAC FAILURE
• RENAL PAIN
• CEREBRAL ANEURYSMS
• MYCOTIC ANEURYSMS
• VALVE ABSCESS

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HOCM

• PULSE JERKY
• DOUBLE APICAL- LEFT VENTRICULAR HEAVE WITH PROM
  PRESYSTOLIC PULSE
• PSM- SOFTER ON SQUATTING
• 4TH HS
• FAMILY HISTORY

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RESPIRATORY

• INTRO
• SITTING POSITION
• SPUTUM CUP
• BREATHLESS
• WASTING
• ASYMMETRICAL BREATHING
• COUNT RESP

39
HANDS

• CLUBBING
• CYANOSIS
• TAR
• BOUNDING PULSE
• ASTERIXIS
• TONGUE CYANOSIS
• EYES- PALLOR, HORNERS

40
EXAMINATION

• LOOK FOR NECK VEINS
• CERVICAL LYMPH
• TRACHEA DEVIATION
• PALPATE
• MOVEMENTS OF BOTH SIDES
• VOCAL FREMITUS
• PERCUSSION
• AUSCULTATION

41
PLEURAL EFFUSION

• LOOK FOR DECREASED MOVEMENT
• TRACHEAL DEVIATION
• ASPIRATION MARKS
• STONY DULL
• DECREASED VOCAL RESONANCE
• FIND THE UPPER LEVEL
• BRONCIAL BREATHING
• SIGNS OF RA, TAR, LYMPH NODES, RADIATION BURNS,
  MASTECTOMY

42
CAUSES OF DULLNESS

• PLEURAL EFFUSION
• PLEURAL THICKENING
• CONSOLODATION
• COLLAPSE
• RAISED HEMIDIAPHRAGM

43
INVESTIGATIONS

• CXR
• TAP
• SEND FOR PROTEIN, LDH, GLUCOSE, BACTERIOLOGY,
  CYTOLOGY
• PH IF EMPYEMA
• AMYLASE IN NG, PANCREATITIS, OESOPHAGEAL RUPTURE
• RHEUMATOID FACTOR

44
TRANSUDATE

• NEPHROTIC SYNDROME
• CARDIAC FAILURE
• LIVER FAILURE
• HYPOTHYROID
• CONSTRICTIVE PERICARDITIS
• MEIGS

45
EXUDATE

• CA
• SECONDARIES
• PNEUMONIA
• PE
• TB
• RA
• SLE
• LYMPHOMA
• MESOTHELIOMA

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PROGNOSIS

• POOR IN NG PEURAL FLUID
• LOW GLUCOSE
• LOW pH

47
HAEMORRAGIC FLUID

• PE
• NG
• TB

48
REMEMBER OCCUPATION
EG SHIP BUILDING
49
BRONCHIECTASIS

• LOOK FOR SPUTUM CUP
• FINGER CLUBBING
• BILATERAL COARSE CREPS
• LATE INSP CREPS

50
BRONCHIECTASIS

• DEF - CHRONIC NECROTIZING INFECTION OF THE
  BRONCHI AND BRONCHIOLES LEADING TO ABNORMAL,
  PERMANENT DILATATION OF THE AIRWAYS

51
CAUSES

• PNEUMONIA
• MEASLES
• PERTUSSIS
• TB
• MECHANICAL OBSTRUCTION
• ASPERGILLOSIS
• KARTAGENERS
• CYSTIC FIBROSIS
• IDIOPATHIC

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INVESTIGATION

• FBP
• SPUTUM
• CXR
• CT

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COMPLICATIONS

• PNEUMONIA
• PLEURAL EFFUSION
• PNEUMOTHORAX
• SINUSITIS
• HAEMOPTYSIS
• BRAIN ABSCESS
• AMYLOIDOSIS

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TREATMENT

• POSTURAL DRAINAGE
• ANTIBIOTICS
• NEBS
• SURGERY

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CONSOLIDATION

• SPUTUM
• TACHYNOEA
• REDUCED MOVEMENT ON AFFECTED SIDE
• TRACHEAL CENTRAL
• DECREASED PERCUSSION
• BRONHIAL BREATHING
• CREPS

56
CAUSES

• PNEUMONIA
• CARCINOMA
• PE

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FIBROSING ALVEOLITIS

• TACHYNOEA
• CLUBBING
• CENTRAL CYANOSIS
• BILATERAL BASAL FINE END INSP CREPS
• DO NOT DISAPPEAR ON COUGHING

58
SIGNS

• HANDS - RA, SYSTEMIC SCLEROSIS
• FACE - RASH OF SLE
• MOUTH - DRY OF SJOGRENS
• PULMONARY HTN - a WAVE IN JVP, LEFT PARASTERNAL
  HEAVE AND P2
• LOOK FOR CAUSES - DRUGS EG AMIODARONE

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PROGNOSIS

• 50 SURVIVAL AFTER 5 YEARS
• INCREASE RISK OF CA

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ABDOMEN
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EXAMINATION

• LYING FLAT
• DO NOT EXPOSE GENITALIA
• COMFORTABLE
• LOOK AROUND THE BED

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HANDS

• CLUBBING
• LEUCONYCIA
• PALMAR ERYTHEMA
• DUPUTRYENS
• HEPATIC FLAP
• PIGMENTATION
• SCRATCH MARKS

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EXAMINATION

• NODES
• TONGUE
• EYES - JAUNDICE, XANTHELASMA ANAEMIA
• SPIDER NAEVIA
• ACANTHOSIS NIGRICANS
• GYNAECOMASTIA

64
EXAMINATION OF ABDOMEN

• MOVEMENTS
• MASS
• VEINS
• PERISTALSIS
• HERNIA

65
ASK IF THERE IS ANY PAIN
66
PALPATION

• KNEEL DOWN
• ALWAYS LOOK AT THE PATIENT
• SUPERFICIAL THEN DEEP
• ALL QUADRANTS

67
PALPATE

• MASS - CHARACTERISTICS
• LIVER - PERCUSSION
• SPLEEN
• KIDNEYS
• LYMPH NODES
• HERNIAL ORFICES
• TESTICULAR ATROPHY

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PERCUSSION

• SHIFTING DULLNESS

69
AUSCULTATE

• LIVER BRUIT
• BOWEL SOUNDS
• RENAL BRUIT

70
LEG OEDEMAPR
71
HEPATOMEGALY

• SIZE
• TENDERNESS- CHF OR ACUTE HEPATITIS
• SURFACE - SMOOTH OR IRREGULAR
• PERCUSS
• AUSULTATE- ALCOHOLIC HEPATITIS OR CA FOR BRUIT

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CAUSES

• CHF
• CIRRHOSIS
• SECONDARIES
• INFECTIVE HEPATITIS
• MYELOPROLIFERATIVE DISORDERS
• SARCOID
• HAEMACHROMATOSIS
• PBC
• AMYLOID
• TUMOURS

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CAUSES OF HEPATIC ENCEPHALOPATHY

• INFECTION
• DIURETICS, ELECTROLYTE IMBALANCE
• DIARROHEA AND VOMITING
• SEDATIVES
• GI BLEED
• ABDOMINAL PARACENTESIS
• SURGERY

74
CAUSE OF ASCITES

• LIVER FAILURE PORTAL HTN
• SECONDARY HYPERALDOSTERONISM
• DECREASED METABOLISM OF ALDOSTERONE BY LIVER
• DECREASED METABOLISM OF ADH
• LOW ALBUMIN
• LYMPHATIC OBSTRUCTION

75
HAEMACHROMATOSIS

• MALE
• PIGMENTED
• PALMAR ERYTHEMA AND SPIDER ANAEMIA
• JAUNDICE
• ASCITES
• HEPATOMEGALY
• LOSS OF SEXUAL HAIR
• TESTICULAR ATROPHY
• JOINT PAIN- PSEUDOGOUT
• CARDIOMYOPATHY
• DIABETES

76
INVESTIGATIONS

• AUTOSOMAL RECESSIVE
• MOSTLY HLA-A3
• CHROMOSOME 6
• TRANSFERRIN INCREASED
• SERUM FERRITIN RAISED
• GENE TESTING
• LIVER BIOPSY

77
TREATMENT

• VENESECTION

78
RISK

• X200 RISK OF HEP CA

79
PBC

• MIDDLE-AGED WOMEN
• CLUBBING
• PIGMENTED
• XANTHELASMA
• ICTERUS
• SCRATCH
• HEPATOSPLENOMEGALY

80
PBC

• XANTHOMATA- JOINTS
• - SKIN FOLDS
• - AREA OF TRAUMA
• LOOK FOR OTHER AUTOIMMUNE DISEASES
• PROXIMAL MUSCLE WEAKNESS OSTEOMALACIA
• PERIPHERAL NEUROPHATHY
• AMA M2
• OBSTRUCTIVE PICTURE
• LIVER TRANSPLANTATION

81
LOOK FOR

• AUTOIMMUNE CONDITIONS
• PROXIMAL MUSCLE WEAKNESS DUE TO OSTEOMALACIA
• PERIPHERAL NEUROPATHY

82
PBC

• ANTI-MITOCHONDRIAL ABS
• CURE IS TRANSPLANTATION

83
SPLENOMEGALY

• DIFF FROM KIDNEY
• KIDNEY BALLOTABLE
• NOTCH
• CANT GET ABOVE
• DULL TO PERCUSSION
• MOVES WITH RESP

84
LOOK FOR

• LYMPH NODES
• ANAEMIA
• JAUNDICE
• PLETHORIC (PRV)
• SPLINTER HAEMORRAGES
• RHEUMATOID

85
CAUSES

• CML
• MALARIA
• KALA-AZAR
• PRV
• MYELOFIBROSIS
• PORTAL HTN
• SARCOID
• AMYLOID
• ENDOCARDITIS
• INFECTIOUS MONONUCLEOSIS
• FELTYS
• CLL
• ITP

86
KIDNEYS

• LOOK FOR AV FISTULA
• LOOK FOR TRANSPLANTED KIDNEY
• 3RD NERVE PALSY ASSOC WITH POLYCYSTIC KIDNEY
  (BERRY)
• BP
• FHX
• ANAEMIA

87
ABDOMINAL MASSES

• EPIGASRTIC -CA STOMACH
• -CA PANCREAS
• -AAA
• -RETROPERITONEAL LYMPHADENOPATHY

88
ABDOMINAL MASSES

• RT ILIAC FOSSA- CROHNS
• CA CAECUM
• LYMPH NODES
• TRANSPLANTED KID
• APPENDIX ABSCESS
• OVARIAN NG
• CARCINOID
• AMOEBIAS

89
CAUSES OF PTOSIS

• UNILATERAL
• 3RD NERVE PALSY
• HORNERS
• MYASTHENIA
• CONGENITAL
• IDIOPATHIC

• BILATERAL
• MYASTHENIA
• DYSTROPHIA
• OCULAR MYOPATHY
• SYPHILIS
• CONGENITAL
• BILATERAL HORNERS IN SYRINGOMYELIA

90
HORNERS

• MIOSIS
• PARTIAL PTOSIS
• ENOPTHALMOS
• ANHYDROSIS

91
CAUSES

• PANCOAST TUMOUR
• CERVICAL SYMPATHECTOMY
• CAROTID ANERUYSMS
• SYRINGOMYELIA
• LESION OF BRAINSTEM
• TRAUMA

92
HOLMES- ADIE

• YOUNG WOMAN
• DILATED PUPIL
• PUPIL REACTS SLOWLY
• DECREASED REFLEXES
• BENIGN

93
DILATED PUPIL

• EYE DROPS
• 3RD NERVE
• HOLMES ADIE
• LENS IMPLANT
• DEATH
• SYMPATHETIC OVERACTIVITY

94
SMALL PUPIL

• OLD AGE
• EYE DROPS
• HORNERS
• ARGYLL ROB
• PONTINE
• NARCOTICS

95
DIABETIC EYES

• BACKGROUND RETINOPATHY
• PREPROLIFERATIVE
• PROLIFERATIVE

96
PAPILLOEDEMA

• SOL
• HTN RETINOPATHY
• BIH
• INCREASED ICP
• HEAD INJURY CAUSING CEREBRAL OEDEMA
• CO RETENTION
• THYROID
• VIT A INTOXICATION
• CENTRAL RETINAL VEIN THRMBOSIS
• MUTIPLE MYELOMA

97
OPTIC ATROPHY

• MS
• OPTIC NERVE COMPRESSION
• GLAUCOMA
• TOXINS
• ISCHAEMIA
• HEREDITARY
• PAGETS
• VIT B12 DEF

98
LOWER 7TH

• LOOK IN THE YEARS
• PAROTID GLAND ENLARGEMENT
• TASTE (INVOLVING CHORDA TYMPANI)
• HEARING (HYPERACUUSIS DUE TO STAPEDIUS)
• URINE - DIABETES

99
CAUSES OF BILATERAL

• GUILLAN BARRE
• SARCOIDOSIS
• MYASTHENIA MAY MIMIC

100
UNILATERAL PALSY

• LLS
• HERPES
• CEREBELLOPONTINE TUMOURS
• POLIO
• OTITIS MEDIA
• SKULL FRACTURE

101
DYSTROPHICA MYOTONICA

• SHAKING HANDS
• FRONTAL BALDNESS
• PTOSIS
• CATARACTS
• EXPRESSIONLESS

102
DYSTROP MYOTON

• TEST POWER
• DECREASED REFLEXES
• ASK ABOUT SWALLOWING
• URINE - GLUCOSE
• LOW IQ
• GYNAECOMASTIA
• TESTICULAR ATROPHY

103
DYSTROP MYOTONICA

• A D
• CARDIOMYOPATHY
• CHEST INFECTION

104
PROXIMAL MYOPATHY

• DIABETES
• CUSHINGS
• THYROID
• POLYMYOSITIS
• DRUG
• CARCINOMA
• OSTEOMALACIA
• HEREDITARY

105
WASTING SMALL MUSCLES OF THE HAND

• RHEUMATOID
• OLD AGE
• CERVICAL SPONDYLOSIS
• BILATERAL CERVICAL RIBS
• MND
• SYRINGOMYELIA
• CHARCOT
• GUILLAN
• NERVE PALSIES
• PANCOASTS

106
NEUROFIBROMATOSIS

• AXILLA FOR FRECKLES
• VISUAL ACUITY - GLIOMA
• ACOSTIS NEUROMA
• IRIS FOR LISCH NODULES
• KYPOSCOLIOSIS
• BLOOD PRESSURE

107
LOOK FOR

• 6 OR MORE CAFÉ AU LAIT
• 2 OR MORE NEUROFIBROMAS
• AXILLA FRECKLING
• OPTIC GLIOMA

108
SPEECH

• COMPREHENSION
• PUT OUT TONGUE
• SHUT YOUR EYES
• ORIENTATION
• TIME , DATE

109
SPEECH

• NAME FAMILIAR OBJECTS
• ARTICULATION
• MENTAL SCORE
• EXPRESSIVE - BROCA FRONTOPARIETAL
• RECEPTIVE - WERNICKES SUPERIOR TEMPORAL

110
PARKINSONS

• EXPRESSIONLESS- HYPERMYMIA
• DROOLING
• PILL ROLLING
• BRADYKINESIA
• TONE- COG WHEEL
• GLABELLAR TAP - CONTINUE MYERSONS SIGN
• WALK
• MICRGRAPHIA

111
RHEUMATOID

• SUBLUXATION OF MCP
• SWAN NECK
• BOUTONNIERES
• Z DEFORMITY
• SUBLUX AT WRIST
• NAIL FOLD INFARCTS
• PALMAR ERYTHEMA

112
RHEUMATOID ARTHRITIS

• MUST CHECK FOR NODULES SEROPOSITIVE AGGRESSIVE
• PERFORM SIMPLE TASKS
• EXAMINE OTHER JOINTS

113
ANAEMIA

• CHRONIC DISEASE
• PERNICIOUS ANAEMIA
• FELTYS
• NSAIDS

114
PULMONARY

• NODULES
• EFFUSION
• FIBROSIS
• CAPLANS
• BRONCHIOLITIS OBLITERANS

115
EYES

• EPISCLERITIS
• SCLERITIS
• SCLEROMALACIA
• SICCA
• SJOGRENS

116
ANK SPOND

• ? MARK POSTURE
• PROTUBERANT ABDOMEN
• ASK HIM TO TURN WHOLE BODY TURNS
• STAND AGAINST A WALL
• SCHOBERS TEST

117
LOOK FOR

• IRITIS
• ANTERIOR UVEITIS
• AORTIC REGURG
• APICAL FIBROSIS
• ACHILLES TENDINITIS

118
GENETIC

• HLA-B27
• 40 SEVERE DISEASE

119
SCLERODERMA

• TIGHTENING OF HANDS
• TELANGICTASIA
• PSEUDOCLUBBING
• VITILIGO
• JOINT FOR ARTHRITIS
• PINCHED NOSE
• DIFF OPENING MOUTH

120
ASK ABOUT

• DYSPHAGIA
• RAYNAUDS
• DRY EYES
• SWALLOWING
• BREATHING - FIBROSIS

121
GOUT

• ASYMMETRICAL
• LOOK AT 1ST MTP , HELICES, OLECRANON, ACHILLES
• NEGATIVE BIFRINGENT
• DISORDER OF PURINE METABOLISM

122
THYROID

• HANDS - SWEATING, TREMOR, WARM
• SCARS
• PALMAR ERYTHEMA
• PULSE
• NODES
• GOITRE
• SEAT UPRIGHT
• EXOPTHALMOS
• PALPATE ,WATER

123
EXAMINE FOR

• SIZE
• MOBILITY
• TEXTURE
• TENDERNESS
• PEMBERTONS SIGN - RAISE ARMS FOR COMPRESSION
• PERCUSS FOR RETROSTERNAL
• BRUITS - GRAVES

124
EYES

• LID LAG VON GRAEF SIGN
• EXOPTHALMOS
• LID RETRACTION DALRYMPLES SIGN
• EXTRAOCCULAR MOVEMENTS
• CORNEAL INVOLVEMENT
• PROXIMAL MUSCLES
• SKIN PRETIB MYXOEDEMA

125
CUSHINGS

• MOON FACE
• BRUISES
• HIRSUTISM
• PLETHORIC
• BUFFALO HUMP
• STRIAE
• PROXIMAL MUSCLE WEAKNESS

126
ASK ABOUT

• STEROIDS
• DIABETES
• BP
• LOOK FOR RA , ASTHMA
• VISUAL FIELDS

127
CAUSES

• STEROIDS
• PITUITARY ADENOMA- PIT DISEASE
• ADRENAL CA
• ADRENAL ADENOMA
• ECTOPIC CA

128
ACROMEGALY

• FACE
• SWEATING
• LARGE HANDS
• CARPAL TUNNEL
• PROM SUPRAORBITAL RIDGES
• LARGE NOSE AND LIPS
• PROTRUSION OF LOWER JAW
• WIDE TEETH

129
LOOK FOR

• MACROGLOSSIA
• VISUAL FIELDS
• ACANTOSIS NIGRICANS
• ORGANOMEGALY
• JOINTS- CHONDROCALCINOSIS
• KYPHOSIS
• BP
• DIABETES
• OLD PHOTOGRAPHS

130
HYPERTENSIVE FUNDUS

• GRADE 1 SILVER WIRING
• GRADE 2 AV NIPPING
• GRADE 3 HAEMORRAGES (FLAME) EXUDATES
• GRADE 4 - PAPILLOEDEMA

131
DIABETIC EYES

• BACKGROUND/PREPROLIFERATIVE HAEMORRAGES
  (MICROANEURYSMS) EXUDATES
• PROLIFERATIVE MALIGNANT RETINOPHATY
• NEOVASCULARISATION NEW VESSELS

132
GOOD LUCK !