approach to short cases - nigel fong · • there are no enlarged cervical lymph nodes or cachexia...

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


AR


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


AR


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


AR


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


AR


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


AR


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


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


• Focal rounded mass

• Murphy’s sign

Characteristics of a kidney

• Location: flanks

• Bimanually ballotable


• Resonant on percussion

• Can get over it


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


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.


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


DDX OF HEPATOSPLENOMEGALY

Enlarged liver +

• Pulsatile

• Nodular, firm

• Tender

• Obese

Splenomegaly > Hepatomegaly +

• Stigmata of chronic liver dx

• Cachexia


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


PAEDIATRICS

• Chronic liver dx – think biliary atresia

• Abdo scar – think biliary atresia post Kasai

• Hepatosplenomegaly – think thalassemia


CASE 5

• 60/F/Malay

• BKA left

• “No BP taking left arm”

• Ascites + shifting dullness

• Kidney ballotable bilaterally, R > L

• No scars


KIDNEY ENLARGEMENT

Bilateral

• ADPKD

Unilateral

• Neoplasm

• Hydronephrosis – obstructive vs malignant

• Cyst


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

approach to short cases - nigel fong · • there are no enlarged cervical lymph nodes or cachexia...

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