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in 6 ICS, ant axilliary lne, possible systolic thrill, left parasternal heave, Soft S1, S3
suggests severe MR. Loud pansystolic murmur at apex radiates to axilla. MR with
pulm bp. Causes: degenerative, rheumatic heart dx, severe LV dilatation, MV
prolapse, papillairy muscle dysfunction, previous valvotomy for mitral stenosis,
infective endocarditis, annular calcification, hypertrophic cardiomyopathy, chodrae
rupture, congenital (marfans, erhler danlos, pseudxanthoma elasticum), endocardial
fibrosis. Indications surgry: SOBOE despite ACEI,/diuretics, increased end systolic
volume (> 30 ml/m2), serial echo progressive LV dilatation, valvuloplasty +/annuloplasty preferable due to dec mort/no anticoagulation. Mitral vave prolapse:
post leaflet LSE, ant eaflet over spine.
SPLENOMEGALLY (13) mass left hypochondrium, cnnot get above it, there
is a notch. It moves diagonally cross abdomen, percussion is dull over left lower chest
and mass. I think this is a spleen enlarged at..cm. Causes: v.large: CML (Ph chr
t9;22), myelofibrosis, makaria/kala arar. Large (4-8cm):myeloproliferaive (CML,
myelofibrosis), lymphoproliferative (lymphoma, CLL), cirrhosis with portal
hypertension.Small (2-4 cm): myeloproliferative, lymphoproliferative, cirrhosis with
portal hypertension, infections (EBV, hepatitis,SBE)
NEUROFIBROMATOSIS (13) multiple (5+) neurofibromas, sessile
pedunculated fibromata some soft others firm, some single others lobulated, some
mobile subcutaneously lumps others nodules along peripheral nerves, cafe au lait
spots, 2/3 axilliary freckling, Lisch nodules=iris harmatomas, retinal harmatomas, rib
nochiing, mental retardation, epilepsy, renal art stenosis. complications:
kyphoscoliosis, pressure effect (acoustic neuromas CN5-8, cerebellar signs), CN5
neuroma, spinal nerve root, sarcomatous change, lung cysts (honeycomb lung),
pseudoarthrosis, plexiform neuroma. Can also have: glioma, meningioma,
medulloblastoma. Genetics: aut dominant , NFT1=von Ricklenhausen (chr 17), NFT2
(chr 22) bilateral acoustic neuroma
BRONCHIECTASIS (12) underweight, cyanosed, sob, finger clubbing,
frequent productive cough, sputum pot, inspiratory clicks heard with unaided ear,
localised crepitations, may be widespread ronchi.. causes: childhood infections
(whooping cough, measels, TB), cystic fibrosis, bronchial obstruction (foreign body,
carcinoma, sarcoid, lymphadenopathy and fibrosis), hypogammaglobulibemiam,
allergic bronchpulmonary aspergillosis, Marfans, yellow nail, congenital (defomity,
Kartageners) , smoking related copd (common)
PSORIASIS (12) (11) Asymetrical arthropathy involving mainly TIP, pitting
of fingernails, onycholysis, some nail plates thickened, hypetkeratosis under
them.Patches of psoriasis over bony prominemces particularly elbows, knees, trunk,
scalp, intragluteal cleft, behind ears, in navel. Plaques circular, well difined edges, red,
silvery scaly surface. Other arthropathy: arthritis mutilans, Rheumatoid-like,
oligo/mono artthropathy, ank spond treatment local sunlight, uv light, coal tar,
dithranol, local steroids, calipotriol, PUVA (psoralen and uv light). Treatment
systemic: acitretin (retinoid), antimetabolites (sulphasalazine, methotrexate,
azathioprine, hydroxyurea). Analgesic anti inflam for arthropathy, intraarticular
steroids. Chloroquin contraindicated worsens skin. Incidence 5% Caucasian, NW
europe, USA. Uncommon in Japanese, N American Indians, Japanese.
OSLER WEBER RENDU (11) (heridatary haemmorhagic telangectasias)
Telangectasias on face, around mouth, on lips, tongue, buccal and nasal mucosa and
fingers. Anemia but no features of systemic sclerosis .complications: GI
haemorhhage, epistaxis, hemoptysis 2ry to pulm AV aneurysms, conjunctival
telagactesias (bloody tears), retinal detachment/haemorrhage, cirrhosis
(telangectasias/transfusion), massive intrahepatic shunting Treatment: chronic oral
Fe therapy, oestrogens to induce squamous metaplasia of nasal mucosa, low dose
finbrinolytic agents (aminocaproic acid), pulse dye laser NOT cautery. Genetics:
Autosomal dominant, several gene defects possible.. non contractile capillaries cause
prologed bleeding.
PLEURAL EFFUSION (10) Pulse regular, JVP normal, trachea usually
central,expansion normal, percussion stony dull at R/L base, diminished TVF, VR and
diminished breath sounds. May be bronchial breathing over effusion. Causes Exudate
(>30 g/l, LDH >200) bronchial carcinoma, secondary malignancy, PE with infarction,
pneumonia, TB, mesothelioma, rheumatoid arthritis, SLE, lymphoma. Transudate
(<30 g/l) cardiac failure, nephrotic syndrome, cirrhosis. Other causes of dullness at
lung bases raised hemidiaphragm, basal collapse, collapse/consolidation totally
occluding distal airways, pleural thickening. (TB, asbestos, empeyema) Pleural bx:
Abram's needle for tb/malignancy place in normal saline. Thoracoscopy for either
diagnosis and pleurodesis
20.
PERIPHERAL NEUROPATHY (9) impaired light touch, vibration, joint
position and pinprick in a stocking +/- glove distribution. causes: DM, carcinomatous
neuropathy, vitB12 def, vit B def (alcoholics, poor nutrition, dialysis), drugs
(isoniazid, vincristine, nitrofurantoin, gold, ethanbutol, phenytoin, hydralazine,
metronidazole, amiodarone, chloramphenicol, cyclosporin), idiopathic, leprosy, other
(guillin barre, PAN, amyloidosis, AIDS), rare (myxoedema, acromegaly, sarcoidosis,
uremia, Lyme dx, tetanus, botulism, paraprotein, hereditary ataxia, Refsum's dx,
arsenic posoning, POEM syndrome) Motor causes: carcinomatous, lead, porphyria,
diptheria, Charcot Marrie Tooth.
21.
MIXED AORTIC VALVE DISEASE (9) Predominant AS Regular slow
rising pulse (possibly bisferens). JVP not elevated. Apex palpable 1 cm left of MCL,
forcefull sustained heave (pressure overload). Systolic thrill apex, aortic area and
carotid. Harsh ejection systolic murmur aortic area radiating to neck, soft A2, early
diastolic murmur LSE loudest on leaning forward, in inspiration. BP low with low
pulse pressure.Predominant AR regular pulse, large volume and collapsing (possibly
bisferens). JVP not raised. Apex in ant ax line 6ICS thrusting (volume overload).
Harsh systolic murmur aortic area radiating to neck, early diastolic murmur LSE
loudest on leaning forward, in inspiration. BP.Management: Cardiac cath is gold
standard, gradient on echo is unreliable in severe AR. Best treatment AV repair,
surgery indicated for stenotic symptoms, lv compromise in regurgitation. Ex testing
can be used except for severe AS.
22.
MIXED MITRAL VALVE DISEASE (9) Predominant MS malar flush, left
thoracotomy scar. Pulse irregularly irregular, JVP not raised. Tapping Apex, not
displaced. Left parasternal heave. Loud S1, pansystolic murmur radiating axilla, loud
P2, opening snap, mid dialstolic rumbling localised to apex. Predominant MR with
pulm hypertension left thoracotomy scar, pulse irregular. Apex thrusting (volume
pverload), apex 6 IC ant ax line, soft S1loud pansystolic murmur LSE and or apex.
Loud P3, in left lateral posn mid diastolic low rumble followed by opening
snap. Management: Cardiac catheter study gold standard.
23.
TRANSPLANTED KIDNEY (9) Usually assoc APKD. Fullness in flanks,
swelling under scar RIF. Bilateral flank masses bimanually ballotable (or 1 mass and 1
nephrectomy scar). Palpable rounded mass under the scar in RIF feels like
kidney. Diseases leading to transplantation: DM nephropathy, hypertensive renal dx,
glomerulonephritis. Difficult to transplant: HUS (recurrence possible, esp if on
cyclosporin), sickle cell (increased crisis), systemic sclerosis (chornic vasular/gi
problems), focal glomerulosclerosis (recurrence in graft common), oxalosis (severe
recurrence of stone dx), cystinosis and Farby's dx (continued dx activity). 5, 10 yr
outcome: HLA identicle living (88, 73), other living (74, 56), HLA matched cadaver
(70, 56).
24.
GRAVES DISEASE (9) M:5F, hyperthyroid graves usually female, thin,
sweaty palms, fine tremor of outstretched hands, tachycardia, fidgety and nervous,
small diffuse goitre with bruit, exophalmos (?chemosis, opthalmoplegia, lateral
tasoraphy), lid lag. Euthyroid Graves:exopthalmos, thyroid acropachy, pretibial
myxoedema, pulse regular with normal rate, palms not sweaty, no hand tremor, no lid
lag. Previous thyroidectomy scar. Hypothyroid Graves: exopthalmos, goitre,
thyroidectomy scar, pretibial myxoedema, thyroid acropachy, hypothyroid facies,
hoarse voice, slow pulse, slowly reacting reflexes.. It is likely that she has
hyperthyroidism treated in the past (?thyroidectomy or radioactive iodine) now on
inadequate throxine replacement alternatively Graves occasionally develops
sujitvasanth10Guest
SUMMARIES CONTINUED
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pigment, sun tanning, endocrine (ACTH therapy (e.g. Asthma), Cushings dx,
thyrotoxicosis, extopic ACTH), chronic debilitation (malignancy, malabsorption,
chronic infection esp TB, cirrhosis, uremia), pigments (haemochromatosis slate
grey, hepatosplenomegally, arhyria, chronic arsenic poisoning), drugs
(phenothiazines (blue-grey), antimalarials (blue grey), amiodarone (grey), cytotoxics,
minocycline (purple-blue bone and blue oral discoloration).
15.
ABDOMINAL MASS (2, 4) Mass RIF: young, somewhat pale adult, freely
mobile 5x4 cm (measure) firm non-tender mass RIF. No abdominal organs enlarged,
no fitulae. This is Crohn's disease. Causes: illiocecal TB (?asian ?chest signs),
carcinoma caecum (?older person, non tender hard mass, lymph nodes, colonoscopy),
amoebic abscess (?travel), lymphoma (?hepatosplenomegally, lymph nodes
eksewhere, investigate CT), appendix abscess (investigate with US), ovarian tumour
(US, CT), ileal carcinoid (rare) Mass LIF: ekderly patient with freely mobile
6x5 mass in LIF, no organomegally. This is probably a diverticular
abscess usually tender. Investe with: US/CT. Causes: carcinoma colon
(non tender, hepatomegally, colonoscopy), ovarian tumour (US/CT),
faecal mass, amoebic abscess. Epigastric mass: round hard non tender mass
8x6 cm with ill defined edges in epigastrium. Does not move with respiration, no
hepatosplenomegally. Check for cervical lymph nodes ?Troisiers sign. Causes:
carcinoma stomach, (Troisier's sign, OGD), carcinoma pancreas (?icterus, ?
courvoisier's sign palpable gall bladder unlikely stones, needs CT), lymphoma
(generalised lymphadenopathy, splenomegally, needs CT). Pulsatile mass: vulsatile
abdominal mass (anterior and transverse) 6x4 cm palpable 2 cm above umbilicus
reaching to epigastrium. Femoral pulses palpable just before radials (i.e no
dissection), no bruits over mass or femorals., look for PVD in feet. Likely AAA
commonest cause atherosclerosis. Mass in upper abdomen: define size, shape,
consistency, get above?, bimanually ballotable?, moves with respiration?, tender?.
Must differentiate from renal mass, spleen or liver. Causes: carcinoma colon,
retroperitoneal sarcoma, lymphoma (generalised lymphadenopathy, spleen),
diverticular abscess (?tender),
16.
MARFAN'S SYNDROME (2) Tall with disproprtionatley long extremities
(pubis-sole > pubis-vertex), elongated fingers and toes (arachnodactyly), high arched
palate, long narrow face, span greater then height. Underdeveloped musculature,
hypotonia (+/- funnel/pigeon chest, pectus excavatum, kyphoscoliosis, flat feet, genu
recurvatum, hypertextendable joints, recurrent dislocations). Tremor of the iris
(iridodenesis) often only visible on slit lamp suggesting lens dislocation. May have
collapsing pulse, auscultate for AR (cystic necrosis of aortic media, disscetion can
occur) Other signs: heterochromia of iris, myopia, retinal detachment, cystic lung
disease (pnemothorax, bullae, apical fibrosis, aspergilloma, bronchiectasis), mitral
valve prolapse, aortic coarctation, bacterial endocarditis, inguinal/femoral hernia,
decreased subcutaneous fat, Meischer's elastoma (smooth nodules/papules in neck
skin). Discussion: Life expectency 40 years. beta blockade decreases development of
aortic complications in some patients. Aut dominant, fibrillin defect Chr
15q. Homocystinuria can appear similar (other abnormalities mental retardation,
malar flusj, osteoperosis, DOWNWARD lens dislocation (Marfans upgoing). Urine
cyanide-nitrprusside test positive).
17.
LMN FACIAL PALSY (2) On the R/L side there is paralysis of upper and
lower face, so the eye cannot be closed (or can be easily opened by examiner; cannot
bury eyelashes), the ee turns up on attempted closure (Bell's phenomenon) and
unable to to raise R/L eyebrow. Corner of mouth droops, nasolabial fold smoothed
out, volunatary and involunatey movements of mouth paralysed on R/L.(lips and
tongue drawn opposite side). Look for heerpes in ear/on neck (trigeminal, cervical,
occipital). Causes: 1. Bells palsy, 2. Ramsay Hunt syndrome (herpes zoster on ext
aud meatus and geniculate ganglion taste ant 2/3 tongue lost +/- palatal lesions)
Facial weakness includes frontalis (raise eyebrows), corrugator superficialis (frown),
orbicularis oculi (close your eyes tight). Taste preserved in mild Bell's palsy (swelling
nerve in facial canal), more severe taste lost, stapedius paralysis causes
palpitations, angina, dizziness, syncope often after cessation after exercise (decreased
CO or VT) cf aortic stenosis DURING exercise. ECG normal in 25%, tall QRS midprecordial leads, septal hypertrophy (Q inf and lat precordia; ;eads), LAD. CXR
normal or left atrial enlargement. Echo: asymetrical septal hypertrophy, systolic
anterior motion of mitral valve leaflet. HCM = aut dom various myosin genes, often
de novo, variable penetrance, offer 1[SUP]st[/SUP] deg relarives screening. Risk
factors of poor outcome: syncope, FH sudden death, poor bp response to exercise,
ventricular arrythmiad, outflow tract gradient >40 mmHg, septal thickness >18 mm.
Treatment: beta blockers, rate limiting calcium antags, septal ablation, myomectomy,
pacing (ICD for high risk individuals).
21.
TARDIVE DYSKINESIA (2) Elderly patient with chronic schizophrenia
with stereotyped tic-like orofacial dyskinetic (involuntary movements) including lip
smaking, chewing, pouting and grimacing. There may be choreoathetoosis of limbs
and trunk. It is likely patient on sustained phenothiazine treatment for at least 6
months. tardive = not occuring till 3 months. Discussion: Condition often persists
even after drug withdrawn. Neuroleptics that ihibit dopamine: phenothiazines
(chlorpromazine), butyrophenones (haloperidol), substituted benzamides
(metoclopromide), reserpine, tetrabenazine. other neuoleptic induced
extrapyramidal reactions: acute dystonia (soon after starting drug e.g. oculogyric
crisis), akathasia (restlessness, unease), Parkinson's syndrome (tremor less common,
responds to anticholinergics rather than Ldopa)
22.
LUNG TRANSPLANT (2) Successful lung transplant: young man
(major operative procedure for severe chronic respiratory problem) not breathless at
rest, RR=12, bilateral clubbing, midline sternotomy, equal expansion bilaterally,
precussion and breath sounds normal. I suspect cystic fribrosis with successful double
lung transplant. Bronchiolitis obliterans syndrome: middle aged woman with
right lung transplant increasingly breathless over last few months. RR=18. Oxygen
2l.min nasal cannulae, bilateral clubbing, features of Cushing's syndrome, right
thoracotomy scar, reduced exapnsion both lungs, left base dull to precussion, fine
inspiratory crackles to mid zones left lung, few scattered inspiratory squeeks right
lung. Suggest lung transplant for pulmonary fibrosis, there may have been recurrent
episodes of acute rejection now developed borchiolitis obliterans syndrome requiring
large doses of steroids and continuous oxygen therapy. Spirometry recording book,
may be on active transplantation list llok for a bleeper.Inidcations for Lung
transplant: pulmonary hypertension:primary, or secondary to systemic disease
and Eisenmengers syndrome. Restrictive lung disease: pulmonary fibrosis
(idiopathic, secondary to connective tissue disease, sarcoidosis, chronic allergic
alveolitis), Obstructive lung disease (emphysema, alpha1antitrypsin deficuency,
Langerhans cell granulomatosis, lymphagioleiomyomatosis. Suppurative lung
disease includes cystic fibrosis, bronchiectasis.Complications: perioperative (e.g.
Graft dehiscence), infection: viral (CMV, HSV, bacterial, fungal Candida,
Aspergillus, other pneumocystis), rejection hyperacute (within hours), acute
(common 1-2 episodes in first 6 months\0, bronchiolitis obliterans syndrome
progressive obstruction rapid progression, poor survival. Acute rejectiion=non
productuve cough, dyspnoea, malaise, irreversible airflow obstruction, reduced TLC
and gas transfer. No effective treatment immuosuppressives commonly tried.
Consider retrasplantation, drug side effects azathioprine, cyclosporin,
corticosteroids.
23.
CHOREOATHETOSIS (2) Brief, jerky, abrupt, quasi purposeful involuntary
movements (do not integrate into a coordinated act). Movements flit to dofferent
parts of body randomly, present at rest, accentuated by activity preventing relaxation
and distorting movement, general air of restlessness, unable to protrude tongue (darts
in and out), abnormal posturing of hands (wristr flexed, fingers hyperextended at
MCP joints). When the upper limbs are raised there is pronation of the forearm. This
is chorea. Causes: sydenham chorea (5-15 yrs old, ?heart murmur, 1/3 Hx
Rheumatic fever, may occur during preg or OCP), huntingtons chorea (often lower
limbs, dancing gait, dementia, age 30-40, family history), drug induced chorea