250 cases in clinical medicine

CARDIOVASCULAR SYSTEM History and examination of the cardiovascular system I Mitral stenosis Mitral regurgitation Mixed mitral valve disease 12 Aortic regurgitation 13 Mixed aortic valve lesion 23 Mixed mitral and aortic valve disease 24 Hypertension 27 Atrial fibrillation 31 10 Palpitations 35 11 Slow pulse rate 37 12 Gallop rhythm 39 13 Angina pectoris 41 14 Acute myocardial infarction 45 15 Jugular venous pulse 52 16 Congestive cardiac failure 54 17 Infective endocarditis 57 18 Prosthetic heart valves 61 19 Tricuspid regurgitation 64 20 Mitral valve prolapse 65 21 Ventricular septal defect 67 22 Atrial septal defect 71 23 Hypertrophic cardiomyopathy 75 24 Patent ductus arteriosus 78 25 Pulmonary stenosis 80 26 Dextrocardia 83 27 Coarctation of aorta 84 28 Eisenmenger syndrome 88 29 Fallot's tetralogy 91 30 Absent radial pulse 93 31 Constrictive pericarditis 95 32 Permanent cardiac pacemaker/implantable cardioverter-defibrillator 97 33 Pericardial mb 100 34 Primary pulmonary hypertension 102 35 Ebstein's anomaly 104 NEUROLOGY 107 History and examination of the nervous system 36 Bilateral spastic paralysis (spastic paraplegia) 115 37 Hemiplegia 119 38 Ptosis and Homer's syndrome 125 39 Argyll Robertson pupil 128 40 Holmes-Adie syndrome 130 41 Homonymous hemianopia 132 42 Bitemporal hemianopia 133 43 Central scotoma 134 44 Tunnel vision 135 45 Parkinson's disease 136 46 Cerebellar syndrome 143 47 Jerky nystagmus 146 48 Speech 147 49 Expressive dysphasia 151 50 Cerebellar dysarthria 152 51 Third cranial nerve palsy 153 52 Sixth cranial nerve palsy 156 53 Seventh cranial nerve palsy - lower motor neuron type 158 54 Tremors 161 55 Peripheral neuropathy 164 56 Charcot-Marie-Tooth disease (peroneal muscular atrophy) 166 57 Dystrophia myotonica 168 58 Proximal myopathy 171 59 Deformity of a lower limb 172 60 Multiple sclerosis 175 61 Abnormal gait 180 62 Wasting of the small muscles of the hand 182 63 Facioscapulohumeral dystrophy (Landouzy-D4j6rine syndrome) 183 64 Limb girdle dystrophy 185 65 Myasthenia gravis 186 66 Thomsen's disease (myotonia congenita) 190 67 Friedreich's ataxia 191 68 Motor neuron disease 193 69 Neurofibromatosis 196 70 Syringomyelia 199 71 Subacute combined degeneration of the spinal cord 202 72 Tabes dorsalis 205 73 Ulnar nerve palsy 207 74 Lateral popliteal nerve palsy, L4, L5 (common peroneal nerve palsy) 210 75 Carpal tunnel syndrome 212 77 Chorea 215 78 Hemiballismus 218 79 Orofacial dyskinesia 219 80 Internuclear ophthalmoplegia 220 81 Cerebellopontine angle tumour 222 82 Jugular foramen syndrome 224 83 Pseudobulbar palsy 226 84 Bulbar palsy 227 85 Wallenberg's syndrome (lateral medullary syndrome) 228 86 Winging of the scapula 230 87 Becker muscular dystrophy 231 88 Tetraplegia 233 89 Brown-Sdquard syndrome 236 90 Cauda equina syndrome 237 91 Torsion dystonia (dystonia musculorum deformans) 239 92 Epilepsy 240 93 Guillain-Barre syndrome 243 94 Multiple system atrophy 244 95 Neurological bladder 246 RESPIRATORY SYSTEM 249 history and examination of tiic chest 96 Pleural effusion 251 97 Pleural rub 256 98 Asthma 258 99 Chronic bronchitis 261 100 Bronchiectasis 266 101 Cor pulmonale 269 102 Consolidation 271 103 Bronchogenic carcinoma 274 104 Cystic fibrosis 277 105 Fibrosing alveolitis 281 106 Pulmonary fibrosis 284 107 Pneumothorax 286 108 Old tuberculosis 288 109 Pickwickian syndrome 290 110 Collapsed lung 292 ABDOMEN 295 History and examination of the abdomen 111 Hepatomegaly 297 112 Cirrhosis of the liver 299 113 Jaundice 301 114 Ascites 304 115 Haemochromatosis 307 116 Primary biliary cirrhosis 310 117 Wilson's disease 313 118 Splenomegaly 315 119 Felty's syndrome 318 120 Polycystic kidneys 320 121 Transplanted kidney 324 122 Abdominal aortic aneurysm 327 123 Unilateral palpable kidney 329 124 Abdominal masses 330 RHEUMATOLOGY 333 General guidelines for examination of joints 125 Rheumatoid hands 336 126 Ankylosing spondylitis 340 127 Psoriatic arthritis 343 ~ 128 Painful knee joint 344 129 Osteoarthrosis 345 130 Gout 347 131 Charcot'sjoint 349 132 Still's disease 350 ENDOCRINOLOGY 353 Examination of the thyroid 133 Graves' disease 355 134 Exophthalmos 359 135 Hypothyroidism 362 136 Multinodular goitre 367 137 Addison's disease 369 138 Acromegaly 372 139 Hypopituitarism (Simmonds' disease) 375 140 Gynaecomastia 377 141 Carpopedal spasm (post-thyroidectomy hypoparathyroidism) 379 142 Carcinoid syndrome 381 143 Obesity 382 144 Cushing's syndrome 385 DERMATOLOGY 389 145 Maculopapular rash 389 146 Purpura 390 147 Psoriasis 392 148 Bullous eruption 396 149 Henoch-Schoenlein purpura 399 150 Ichthyosis 401 151 Hereditary haemorrhagic telangiectasia (Rendu-Osler-Weber disease) 403 152 Herpes labialis 406 153 Herpes zoster syndrome (shingles) 408 154 Lichen planus 411 155 Vitiligo 412 156 Raynaud's phenomenon 415 157 Systemic lupus erythematosus 417 158 Phlebitis migrans 421 159 Erythema multiforme 423 160 Erythema ab igne 426 161 Hirsutism 428 162 Acanthosis nigricans 431 163 Lipoatrophy 433 164 Lupus pernio 435 165 Xanthelasma 439 166 Necrobiosis lipoidica diabeticorum 442 167 Radiotherapy marks 444 168 Tendon xanthomata 446 169 Eruptive xanthomata 448 170 Palmar xanthomata 450 171 Pseudoxanthoma elasticum 451 172 Rosacea 454 173 Dermatitis herpetiformis 456 174 Hairy leukoplakia 458 175 Kaposi's sarcoma 460 176 Peutz-Jeghers syndrome 463 177 Pyoderma gangrenosum 466 178 Sturge-Weber syndrome (encephalotrigeminal angiomatosis) 468 179 Acne vulgaris 470 180 Alopecia areata 472 181 Atopic dermatitis (eczema) 475 182 Venous ulcer 477 183 Arterial leg ulcer 478 184 Erythema nodosum 480 185 Fungal nail disease 482 186 Lichen simplex chronicus (neurodermatitis) 484 187 Nail changes 486 188 Onycholysis 489 189 Malignant melanoma 490 190 Seborrhoeic dermatitis 493 191 Molluscum contagiosum 494 192 Urticaria 496 193 Mycosis fungoides (cutaneous T-cell lymphoma) 498 194 Urticaria pigmentosa 500 195 Dermatomyositis 502 196 Scleroderma 505 197 Ehlers-Danlos syndrome 508 198 Tuberous sclerosis (Bourneville's or Pringle's disease) 511 199 Pretibial myxoedema 514 FUNDUS 517 Examination of the fundus 200 Diabetic retinopathy 518 201 Hypertensive retinopathy 523 202 Papilloedema 525 203 Optic atrophy 529 204 Retinal vein thrombosis 531 205 Subhyaloid haemorrhage 534 206 Retinitis pigmentosa 535 207 Old choroiditis 538 208 Cholesterol embolus in the fundus 539 209 Vitreous opacities 542 210 Myelinated nerve fibres 543 211 Retinal changes in AIDS 544 212 Retinal detachment 546 213 Age-related macular degeneration (senile macular degeneration) 548 MISCELLANEOUS 553 Examination of the foot 214 Diabetic foot 554 215 Swollen leg l: deep vein thrombosis 556 216 Swollen leg Il: cellulitis 559 217 Clubbing 561 218 Dupuytren's contracture 563 219 Cataracts 565 220 Anaemia 567 221 Lymphadenopathy 569 222 Chronic lymphocytic leukaemia 573 223 Crohn's disease 575 224 Dysphagia 577 225 Diarrhoea 578 226 Marfan's syndrome 580 227 Nephrotic syndrome 583 228 Uraemia 585 229 Paget's disease 588 230 Parotid enlargement 591 231 Superior vena caval obstruction 593 232 Glass eye 595 233 Turner's syndrome 596 234 Yellow nail syndrome 598 235 Osteogenesis imperfecta 599 236 Down's syndrome 600 237 Late congenital syphilis 602 238 Arteriovenous fistula 603 239 Carotid artery aneurysm 605 240 Retro-orbital tumour 606 241 Achondroplasia 607 242 Breast lump 608 243 Gingival hypertrophy 612 244 HaemophiliaA 613 245 Klinefelter's syndrome 614 246 Macroglossia 616 247 Osteoporosis of the spine (dowager's hump) 618 248 Pressure sores (bedsores) 620 249 Sickle cell disease 622 250 Thrush 624 Index 627 HISTORY Chest pain: exertional, at rest (when angina is present, comment on the Canadian Cardiovascular Angina class, p 42) Shortness of breath: exertional, at rest (when dyspnoea is present, comment on the New York Heart Association class, p 2), paroxysmal nocturnal dyspnoea Palpitations (see pp 35-6) Dizziness, pre-syncope, syncope Swelling of feet EXAMINATION OF THE CARDIOVASCULAR SYSTEM Introduce yourself: 'I am Dr/Mr/Ms May I examine your heart?' Ensure adequate exposure of the precordium: 'Would you take your top off, please?' However, be sensitive of the feelings of female patients Get the patient to sit at 45 degrees - use pillows to support the neck Inspection: comment on the patient's decubitus (whether he or she is comfort-able at rest or obviously short of breath); comment on malar flush (seen in mitral stenosis) Examine the pulse: rate (count for 15 s), rhythm, character, volume; lift the arm to feel for the collapsing pulse Feel the other radial pulse simultaneously Comment on the scar at antecubital fossa (cardiac catheterization scars) Look at the tongue for pallor, central cyanosis Look at the eye for pallor, Argyll Robertson pupil Examine the jugular venous pulse: comment on the wave form and height from the sternal angle Check the abdominojugular reflux 10 Comment on any carotid pulsations (Corrigan's sign of aortic regurgitation) 11 Examine the precordium: comment on surgical scars (midline sternotomy scars, thoracotomy scars for mitral valvotomy may be missed under the female breast) 12 Feel the apex beat - position and character 13 Feel for left parasternal heave and thrills at the apex and on either side of the sternum 14 Listen to the heart, beginning from the apex: take care to palpate the right carotid pulse simultaneously so that the examiner notices that you are timing the various cardiac events · Always comment on the first and second heart sounds Mention any additional heart sounds (Am J Med 1959; 27: 360) · If you not hear the mid-diastolic murmur of mitral stenosis, make sure you listen to the apex in the left lateral position with the bell of the stethoscope · If you hear a murmur at the apex, ensure that you get the patient to breathe in and out - the examiner will be observing whether or not you are listening for the variation in intensity with respiration · If you hear a pansystolic murmur, listen at the axilla (mitral regurgitant murmurs are conducted to the axilla) 15 Using the diaphragm of your stethoscope, listen at the apex, below the sternum, along the left sternal edge, the second right intercostal space and the neck (for ejection systolic murmur of aortic stenosis, aortic sclerosis) 16 Request the patient to sit forward and listen with the diaphragm along the left sternal edge in the 3rd intercostal area with the patient's breath held in expiration for early diastolic murmur of aortic regurgitation 17 Tell the examiner that you would like to the following: · Listen to lung bases for signs of cardiac failure · Check for sacral and leg oedema · Examine the liver (tender liver of cardiac failure), splenomegaly (endocarditis) · Check the blood pressure · Check the peripheral pulses and also check for radiofemoral delay The New York Heart Association classification of dyspnoea: Class l Asymptomatic (shortness of breath on unaccustomed exertion) · Class ll: There is slight limitation of physical activity and patients develop shortness of breath on accustomed exertion · Class III Marked limitation of physical activity; patients develop shortness of breath on activities of daily living such as having a shower, etc · Class IV: Inability to carry out physical activity; shortness of breath at rest Rene Theophile Hyacinthe Laennec invented the stethoscope in 1816 and reported his early experience with auscultation in a two-volume book published years later (Laennec RTH 1821 A Treatise on the Diseases of the Chest London: T and G Underwood Translated by and with a preface and notes by John Forbes) British physician Sir John Forbes (1787-1861) is best remembered for popularizing the stethoscope among English-speaking doctors Forbes was born in Banff in the north east of Scotland He studied at Marischal College, Aberdeen, before he went to Edinburgh where he received his medical education Forbes translated Laennec's monograph in English in 1821 and published his own book on the subject in 1824 (Forbes J 1824 Original Cases with Dissections and Observations Illustrating the Use of the Stethoscope and Percussion in the Diagnosis of the Diseases of the Chest London: T and G Underwood) The latter included a brief biographical sketch of the Austrian physician Leopald Auenbrugger and the first English translation of his essay (which was in Latin) on percussion It also contained a summary of Parisian physician Victor Collin's recent manual on cardiac physical diagnosis INSTRUCTION This patient developed dyspnoea and orthopnoea during pregnancy, please examine her This 55-year old patient has atrial fibrillation, please perform the relevant clinical examination SALIENT FEATURES History · Symptoms of left-sided heart failure: exertional dyspnoea, orthopnoea, paroxysmal dyspnoea · Less frequent symptoms: haemoptysis, hoarseness of voice, symptoms of right-sided failure (these symptoms are somewhat more specific for mitral stenosis) · Obtain a history of rheumatic fever in childhood Examination · Pulse regular or irregularly irregular (due to atrial fibrillation) · Jugular venous pressure (JVP) may be raised · Malar flush · Tapping apex beat in the 5th intercostal space just medial to midclavicular line · Left parasternal heave (indicating right ventricular enlargement) · Loud first heart sound · Opening snap (often difficult to hear; a high-pitched sound that can vary from 0.04 to 0.10 s after the second sound, and is best heard at the apex with the patient in the lateral decubitus position) · Rumbling, low-pitched, mid-diastolic murmur - best heard in the left lateral position on expiration In sinus rhythm there may be presystolic accentuation of the murmur If you are not sure about the murmur, tell the examiner that you want the patient to perform sit-ups or hop on one foot to increase the heart rate This will increase the flow across the mitral valve and the murmur is better heard · Pulmonary component of second sound (P2) is loud Remember The signs of pulmonary hypertension include loud P2, right ventricular lift, elevated neck veins, ascites and oedema This is an ominous sign of the disease progression because pulmonary hypertension increases the risk associated with surgery (Bt Heart J 1975; 37: 74-8) Note · · In patients with valvular lesions the candidate would be expected to comment on rhythm, the presence of heart failure and signs of pulmonary hypertension In atrial septal defect, large flow murmurs across the tricuspid valve can cause mid-diastolic murmurs The presence of wide, fixed splitting of second sound, absence of loud first heart sound, and an opening snap and incomplete right bundle branch block should indicate the correct diagnosis However, about 4% of patients with atrial septal defect have mitral stenosis, a combination called Lutembacher's syndrome DIAGNOSIS This patient has mitral stenosis (lesion) which is almost always due to rheumatic heart disease (aetiology), and has atrial fibrillation, pulmonary hypertension and congestive cardiac failure (functional status) QUESTIONS What is the commonest cause of mitral stenosis? Rheumatic heart disease What is the mechanism of tapping apex beat? It is due to an accentuated first heart sound What does the opening snap indicate? The opening snap is caused by the opening of the stenosed mitral valve and indicates that the leaflets are pliable The opening snap is usually accompanied by a loud first heart sound It is absent when the valve is diffusely calcified When only the tips of the leaflets are calcified, the opening snap persists What is the mechanism of a loud first heart sound? The loud first heart sound occurs when the valve leaflets are mobile The valve is open during diastole and is suddenly slammed shut by ventficular contraction in systole What is the mechanism of presystolic accentuation of the murmur? In sinus rhythm it is due to the atrial systole which increases flow across the stenotic valve from the left atrium to the left ventricle; this causes accentuation of the loudness of the murmur This may also be seen in atrial fibrillation and is explained by the turbulent flow caused by the mitral valve starting to close with the onset of ventricular systole This occurs before the first heart sound and gives the impression of falling in late diastole; it is, however, due to the start of ventricular systole What are the complications? · Left atrial enlargement and atrial fibrillation · Systemic embolization, usually of the cerebral hemispheres · Pulmonary hypertension · Tricuspid regurgitation · Right heart failure How does one determine clinically the severity of the stenosis? · The narrower the distance between the second sound and the opening snap, the greater the severity The converse is not true (Note This time interval between the second sound and opening snap is said to be inversely related to the left atrial pressure.) in tight mitral stenosis the murmur may be less prominent or inaudible and the findings may be primarily those of pulmonary hypertension ADVANCED-LEVEL QUESTIONS What are the investigations you would perform? ECG Broad bifid P wave (P mitrale); atrial fbrillation in advanced disease Chest radiography · Congested upper lobe veins · Double silhouette due to enlarged left atrium · Straightening of the left border of the heart due to prominent pulmonary conus and filling of the pulmonary bay by the enlarged left atrium · Kerley B lines (horizontal lines in the regions of the costophrenic angles) · Uncommonly the left bronchus may be horizontal due to an enlarged left atrium · Mottling due to secondary pulmonary haemosiderosis Echocardiography 2D and Doppler echocardiography is the diagnostic tool of choice for assessing the severity of mitral stenosis and for judging the applicability of balloon mitral valvotomy (N Engl J Med 1997; 337: 3241) · It is able to identify restricted diastolic opening of the mitral valve leaflets due to 'doming' of the anterior leaflet and immobility of the posterior leaflet · It also allows assessment of the mitral valve apparatus and left atrial enlargement · Echocardiography usually permits an accurate planimetric calculation of the valve area (Am J Cardiol 1979; 43: 560-8) · It can also be used to assess the severity of stenosis by measuring the decay of the transvalvular gradient or the 'pressure half-time', an empirical measurement (BrHeartJ 1978; 40: 13140) · The mean transmitral gradient can be accurately and reproducibly measured from continuous wave Doppler signal across the mitral valve with the modified Bernoulli equation · The mitral valve area can be non-invasively derived from Doppler echocardio-graphy with either the · · diastolic half-time method or the continuity equation The continuity equation should be used when the area derived from the half-time does not correlate with the mean transmittal gradient Doppler also allows estimation of pulmonary artery systolic pressure from the TR velocity signal and assessment of the severity of concomitant MR or AR Trans-oesophageal echocardiography is not required unless a question about diagnosis remains after transthoracic echocardiography Cardiac catheterization · · · · · Shows raised right heart pressures and an end-diastolic gradient from pulmonary artery wedge pressure (or left atrium if trans-septal puncture has been done) to the left ventricle Left and right heart cardiac catheterization is indicated when percutaneous mitral balloon valvotomy is being considered Cardiac catheterization is also indicated when there is a discrepancy between Doppler-derived haemodynamics and the clinical status of a symptomatic patient Coronary angiography may be required in selected patients who need intervention Exercise haemodynamics should be performed when the symptoms are out of proportion to the calculated mitral valve gradient area What is the normal cross-sectional area of the mitral valve? It ranges from to em2; turbulent flow occurs when this area is less than cm2 What is the area in 'tight' mitral stenosis? It is usually less than cm2 and consequently the gradient across the valve is >10 mmHg How would you manage the patient? · · · · Asymptomatic patient in sinus rhythm: prophylaxis against infective endocarditis only Mild symptoms: diuretics to reduce left atrial pressure and therefore symptoms Atrial fibrillation: (1) rate control (digitalis, beta-blocker or calcium channel blocker); (2) anticoagulants (Eur Heart J 1988; 9: 291-4) Moderate to severe symptoms or pulmonary hypertension is beginning to develop: mechanical relief of valve stenosis including (1) balloon valvotomy (N Engl J Med 1994; 331: 961-7; Br Heart J 1988; 60: 299-308) - percutaneous mitral balloon valvuloplasty is usually the procedure of choice when there is a non-calcified pliable valve; (2) surgery What are the indications for surgery? · · · Patients with severe symptoms of pulmonary congestion and significant mitral stenosis Patients with pulmonary hypertension or haemoptysis, even if minimally symptomatic Recurrent thromboembolic events despite therapeutic anticoagulation Which surgical procedures are used to treat mitral stenosis? Closed commissurotomy · · Closed mitral valvotomy - involves the use of mechanical dilators, inserted through the apex of the left ventricle It is complicated by mitral regurgitation, systemic embolization and restenosis Balloon valvuloplasty (a form of closed commissurotomy) - percutaneous trans-septal balloon mitral valvotomy (or valvuloplasty) Remember, percutaneous balloon dilatation of the mitral valve is a useful option in patients who are unable to undergo cardiac surgery, as in late pregnancy or when too ill (severe respiratory disease, non-mitral cardiac disease, multiorgan failure) Open commissurotomy Requires cardiopulmonary bypass and allows surgical repair of the valve under direct vision, resulting in more effective and safer valvotomy than the closed procedure Valve replacement Entails risks including thromboembolism, endocarditis and primary valve failure What factors determine the success of balloon valvuloplasty? ... monograph in English in 1821 and published his own book on the subject in 1824 (Forbes J 1824 Original Cases with Dissections and Observations Illustrating the Use of the Stethoscope and Percussion in. .. flush · Tapping apex beat in the 5th intercostal space just medial to midclavicular line · Left parasternal heave (indicating right ventricular enlargement) · Loud first heart sound · Opening snap... second sound and opening snap is said to be inversely related to the left atrial pressure.) in tight mitral stenosis the murmur may be less prominent or inaudible and the findings may be primarily