approach to short cases - nigel fong · • there are no enlarged cervical lymph nodes or cachexia...
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APPROACH TO SHORT CASES
Nigel Fong 2014
GENERAL NOTES
• You can only find what you look for; you can only look for what you know.
• Examine with brain on, not brain off. Do not simply go through the steps. Have a schema in your mind to piece together the clues
• Peripheries - pick up clues Central – go through differentials
• Compare bilaterally if you can
• Speed but not haste
• Know what can come out: AMI patients do not turn up at OSCE! (But you must still know)
CLUBBING
Cardiovascular • Congenital cyanotic heart dx:
Tetrology of Fallot • Infective endocarditis
Respiratory • Cancer • Bronchiectasis, abscess • Fibrosis
Abdominal • Cirrhosis • Inflammatory bowel dx
(Ulcerative colitis / Crohn)
*COPD is NOT a cause 80%
Thyroid acropachy (Graves disease)
PRESENTATION: GENERAL APPROACH
Two ways to present
• Go through what you did then conclude (recommended)
• “Sir this patient has ____. I say this because…. “
What you need to present
• Diagnosis and clinical reasoning
• Etiology – any clues?
• Complications – look for them, did you find any?
• Requests
PRESENTATION: NOTES
• Present physical sign (consolidation) not diagnosis (pneumonia)
• Some words already imply a diagnosis (e.g. stony dull)
• Use the appropriate euphemisms
• Cancer
• HIV
• Leprosy
• Syphillis
• Alcoholic
= Mitotic lesion
= Retroviral disease
= Hansen disease
= Treponemal disease
= Ethanol use
PAEDIATRICS
Standard opening
• Effect on growth & development: “appears well thrived for age but I will like to plot height, weight, and occipitofrontal circumference against gender-specific progressive percentile charts”
• Any obvious dysmorphism?
CARDIOVASCULAR EXAM
• Valve: AR, AS, MR, MS, MVP, VSD, PDA
• Cardiac failure
• Atrial fibrillation
• Prosthetic valves
Standard list of complications
• Pulmonary hypertension
• Atrial fibrillation
• Congestive cardiac failure
• Endocarditis
CARDIO SHORT CASES
CASE 1
CARDIO SHORT CASES
CASE 1
• 60/M/Chinese
• Median sternotomy scar
• Respiratory distress, on O2 nasal prongs 5L/min
• HR 100 RR 30
• JVP elevated
• Apex 6th ICS anterior axillary line nil parasternal heave.
• S1 S2 nil murmurs
• Basal lung crepitations
• Peripheral edema
CARDIO SHORT CASES
PRESENTATION Sir, this patient has biventricular heart failure because:
• There is displacement of the apex beat to the 6th intercostal space in the anterior axillary line.
• There are bibasal crepitations indicating pulmonary congestion
• There is elevated JVP and bilateral pitting lower limb edema
Complication. Pt is in respiratory distress with tachypea and tachycardia. I do not note peripheral stigmata of infective endocarditis. Pulse is regularly regular with no AF.
Etiology. I note a median sternotomy scar which is most likely a past coronary artery bypass as I do not hear any prosthetic valves. The likely etiology of heart failure is ischemic heart disease / an old myocardial infarct.
Requests. I will like to take his blood pressure
CARDIO SHORT CASES
CASE 2
• 70/F/Chinese
• Comfortable at rest
• Median sternotomy scar.
• Peripheral examination normal
• Apex beat 6th ICS anterior axillary line
• Murmur loudest at aortic area
• Basal lung crepitations
• No pedal edema
CARDIO SHORT CASES
LISTENING COMPREHENSION
CARDIO SHORT CASES
MURMURS
Systolic Diastolic
Ejection systolic
AS
Only Left sided murmurs are included here. Should be sufficient for MBBS. Left vs right: Left louder in inspiration, Right louder in Expiration (R-I-L-E)
Pan systolic
MR VSD
Late systolic
MVP
Early diastolic (Decrescendo)
AR
Mid diastolic + presystolic
accentuation
MS PDA
Continuous
What to describe Timing + Area + Pitch + Loudness + Dynamic maneuver
CARDIO SHORT CASES
MURMURS
Systolic Diastolic
Ejection systolic
AS
Pan systolic
MR VSD
Late systolic
MVP
Early diastolic (Decrescendo)
AR
Mid diastolic + presystolic
accentuation
MS PDA
Continuous
Aortic Stenosis This patient has a grade 3/6 ejection systolic murmur heard best at the aortic area, radiating to the carotids.
CARDIO SHORT CASES
MURMURS
Systolic Diastolic
Ejection systolic
AS
Pan systolic
MR VSD
Late systolic
MVP
Early diastolic (Decrescendo)
AR
Mid diastolic + presystolic
accentuation
MS PDA
Continuous
Mitral Regurgitation There is a blowing grade 2/6 pansystolic murmur best heard at the apex, radiating to the axilla.
CARDIO SHORT CASES
MURMURS
Systolic Diastolic
Ejection systolic
AS
Pan systolic
MR VSD
Late systolic
MVP
Early diastolic (Decrescendo)
AR
Mid diastolic + presystolic
accentuation
MS PDA
Continuous
Mitral Valve Prolapse This patient has got a mid systolic click and late systolic murmur best heard at the apex, radiating towards the axilla.
CARDIO SHORT CASES
MURMURS
Systolic Diastolic
Ejection systolic
AS
Pan systolic
MR VSD
Late systolic
MVP
Early diastolic (Decrescendo)
AR
Mid diastolic + presystolic
accentuation
MS PDA
Continuous
Aortic Regurgitation This patient has a decrescendo early diastolic murmur. It is high pitched, grade 3/6, and best heard at the left lower sternal edge with the patient leaning forward in full expiration”.
CARDIO SHORT CASES
MURMURS
Systolic Diastolic
Ejection systolic
AS
Pan systolic
MR VSD
Late systolic
MVP
Early diastolic (Decrescendo)
AR
Mid diastolic + presystolic
accentuation
MS PDA
Continuous
Mitral Stenosis This patient has a grade 2/6 rumbling mid diastolic murmur with presystolic accentuation, best heard over the apex with the bell and the patient in the left lateral position.
CARDIO SHORT CASES
OTHER ADDITIONAL HEART SOUNDS
Split S2 = Late RV emptying
• Physiological • Wide: RBBB, PS, VSD, MR • Fixed: ASD S3 = Volume load
• Physiological • LVF, dilatation
• AR, MR, VSD…
S4 = Stiff ventricle
• Systemic HTN • AS • Others
Systolic Diastolic
Early Late
Opening snap (MS)
Ejection click (AS/PS)
Midsystolic click (MVP)
CARDIO SHORT CASES
PAEDIATRICS
• Cyanosis – TOFl, transposition of great arteries, Eisenmengers
• Beware dextrocardia
• VSD more likely than MR
• Listen carefully for pulmonary stenosis murmur
• Listen carefully for fixed splitting of S2 --- ASD
• Look for Down’s syndrome! ASD common, AVSD pathognomic
CARDIO SHORT CASES
RESPIRATORY EXAM
• Infective: bronchiectasis, consolidation
• Collapse, lobectomy and pumonectomy
• Interstitial lung disease
• COPD
• Pleural effusion
RESPI SHORT CASES
CASE 3
• 70/M/Chinese
• Respi distress, SOB, on oxygen. Nebulizer at bedside
• Nicotine stained fingers, no clubbing or asterixes
• No cyanosis, no pallor, no oral candidiasis
• Barrel chested
• Parasternal heave, loud P2
• Percussion note resonant, loss of cardiac dullness
• Prolonged expiratory phase + ronchi
• Cervical lymph nodes not enlarged
RESPI SHORT CASES
CASE 3 Sir, this patient has COPD. I say this because
• He has chest hyperinflation with bilaterally reduced chest expansion and tracheal tug.
• The percussion note is resonant but there is a loss of cardiac and liver dullness.
• On ascultation, there is a prolonged expiratory phase with expiratory ronchi.
• There is a nebulizer by his side.
Etiology. His fingers are nicotine stained implying significant smoking history.
Complication.
• The patient is in respiratory distress. At rest on 5L/min of oxygen, he is tachypnic with RR of 30/min and uses his accessory muscles of respiration. There is no asterixes suggestive of CO2 retention
• There is loud P2 with left parasternal heave suggestive of right ventricular hypertrophy secondary to pulmonary hypertension.
• There is no clubbing, cervical lymph node enlargement, or cachexia suggestive of mitotic lesion
Requests. I will like to check temperature, examine his sputum, and check peak exp flow
RESPI SHORT CASES
REDUCED CHEST EXPANSION
Lobectomy Pneumonectomy
Effusion Pneumothorax
Diffuse Localized (always side of lesion)
Scar No scar COPD Interstitial
Lung dx
Collapse
Consolidation
RESPI SHORT CASES
REDUCED CHEST EXPANSION
Lobectomy Pneumonectomy
Effusion Pneumothorax
Diffuse Localized (always side of lesion)
Scar No scar COPD Interstitial
Lung dx
Collapse
Consolidation
TRACHEAL DEVIATION
To side of lesion Away from lesion None
RESPI SHORT CASES
PERCUSSION
Stony Dull = Pleural effusion
Dull = Consolidation, Collapse
Resonant = Normal, fibrosis
Hyperresonant = COPD, pneumothorax
The advantage of the respiratory examination is that you have both sides to compare!
RESPI SHORT CASES
LUNG SOUNDS
Breath Sounds Additional Sounds
Wheeze Vesicular Reduced Bronchial
Obstruction • COPD • Effusion • Pneumothorax • Collapse • Pneumonia
Consolidation
Crackles Stridor
Upper airway obstruction
Throughout resp cycle
Localized monophonic • Cancer
Musical • COPD • Asthma
Confirm ↑ vocal
resonance
Timing Coarse Fine (Velcro)
Early inspiratory Bronchiectasis Bronchitis, asthma
Late inspiratory Pulmonary edema Fibrotic dx
Expiratory COPD
RESPI SHORT CASES
RESPI SHORT CASES
COMBINED SIGNS
ABDOMINAL EXAM
• Chronic liver disease
• Hepatomegaly
• Splenomegaly
• Combinations
• Polycystic kidneys
• Transplanted kidneys
ABDOMINAL SHORT CASES
DDX OF ABDOMINAL MASSES
Liver Gallbladder
Colon
Liver Colon
Stomach
Spleen Stomach
Colon Pancreas (tail)
Colon Kidney Adrenal Ovary
Stomach Small intestine
Pancreas (body) Aorta
Colon Kidney Adrenal Ovary
Colon (cecum) Appendix
Hernia Transplant kidney
Bladder Uterus Rectum
Small intestine
Colon Small intestine
Hernia Transplant kidney
By the 9 quadrants
ABDOMINAL SHORT CASES
DDX OF ABDOMINAL MASSES
Characteristics of a liver
• Location: R hypochondrium
• Moves inferiorly on inspiration
• Dull on percussion
• Cannot get over
Characteristics of a spleen
• Location: L hypochondrium
• Moves inf/med on inspiration
• Dull on percussion
• Can palpate splenic notch
• Cannot get over
Characteristics of a gallbladder
• Location: R hypochondrium
• Moves inferiorly on inspiration
• Focal rounded mass
• Murphy’s sign
Characteristics of a kidney
• Location: flanks
• Bimanually ballotable
• Moves inferiorly on inspiration
• Resonant on percussion
• Can get over it
ABDOMINAL SHORT CASES
CASE 4
• 56/M/Chinese. Obvious abdo distention
• Peripheral: purpura, dupuytren contracture, gynaecomastia, pitting edema. No asterixes
• Face: Scleral icterus, parotidomegaly
• Abdo: L0 S4 K0, shifting dullness +ve
• No enlarged cervical lymph nodes
ABDOMINAL SHORT CASES
SAMPLE PRESENTATION Sir, this patient has chronic liver disease with splenomegaly and portal HTN.
• There is splenomegaly extending 4cm below the costal margin. I say that it is a spleen because it is dull to percussion, moves inferiormedially with respiration, and I cannot get above it. It non-tender, firm and non-nodular.
• There is ascites with shifting dullness.
• The liver is not enlarged and the kidneys not ballotable.
Complication.
• There are stigmata of chronic liver disease including jaundice and gynaecomastia. There is also pitting edema of bilateral legs.
• There is no flapping tremor that would suggest hepatic encephalopathy
• There are purpurae suggesting clotting factor deficiency
• There are no enlarged cervical lymph nodes or cachexia suggesting mitotic lesion
Etiology. I note dupytren’s contracture and parotidomegaly. The likely cause for the chronic liver disease is ethanol use.
Requests. I will like to complete my examination by looking at the temperature chart for fever and performing a rectal examination for malena.
ABDOMINAL SHORT CASES
HEPATOMEGALY & SPLENOMEGALY CAUSE HEPATOMEGALY SPLENOMEGALY
Cancer Hematological +++ +++
HCC, mets +++, firm, irregular, may be tender
Yes, if there is resulting portal hypertension
Liver dx Cirrhosis
Ethanol +++
Hepatitis +, tender
Non alcoholic fatty liver ++
Biliary obstruction +
CVS dx Right heart failure +++
Tricuspid regurgitation +++, pulsatile
Haem Hemolytic anemia + ++
Malaria + ++
Others Endocrine: thyrotoxicosis, acromegaly Metabolic: haemochromatosis, Wilson’s, storage diseases, amyloid Inflammatory: CMV, SLE, sarcoid
ABDOMINAL SHORT CASES
DDX OF HEPATOSPLENOMEGALY
Enlarged liver +
• Pulsatile
• Nodular, firm
• Tender
• Obese
Splenomegaly > Hepatomegaly +
• Stigmata of chronic liver dx
• Cachexia
ABDOMINAL SHORT CASES
GALLBLADDER ENLARGEMENT
With jaundice
• Ca pancreas
• Unlikely to be gallstones – chronic cholelithiasis causes fibrotic gallbladder which does not enlarge easily
No jaundice
• Cholecystitis
• Ca gallbladder
• Mucocele, empyema
ABDOMINAL SHORT CASES
PAEDIATRICS
• Chronic liver dx – think biliary atresia
• Abdo scar – think biliary atresia post Kasai
• Hepatosplenomegaly – think thalassemia
ABDOMINAL SHORT CASES
CASE 5
• 60/F/Malay
• BKA left
• “No BP taking left arm”
• Ascites + shifting dullness
• Kidney ballotable bilaterally, R > L
• No scars
ABDOMINAL SHORT CASES
KIDNEY ENLARGEMENT
Bilateral
• ADPKD
Unilateral
• Neoplasm
• Hydronephrosis – obstructive vs malignant
• Cyst
ABDOMINAL SHORT CASES
NEURO QUESTIONS
1. In each of the following scenarios, localize the lesion, and describe how you would distinguish between the various differentials.
1. Right sided weakness + Left facial droop
2. Right sided weakness + Right facial droop
3. Bilateral lower limb weakness
4. Right-sided footdrop
5. Generalized muscle weakness
2. Your patient has a third nerve palsy. How do you proceed?
3. Distinguish between pyramidal and extrapyramidal hypertonia.
NEUROLOGY
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