Semiology: Test 3 - the rest

thromboangiitiis obliterans inflammatory vascular disorder involving limbs occlusion of smal land medium vessels ischemia leading to gangreene and limb loss men aged 25-40 indian, korean, japanese, ashkenazi jews, SMOKING - must stop = tx

Buerger's disease

lung cancer, especially since most COPD patients are smokers

COPD patient with nail clubbing. What do you suspect?

Calcinosis cutis Raynaud's phenomenon Esophageal dysmotility Sclerodactyly Telangectasias 3 of 5 for CREST

CREST syndrome

Occurs when atrium contracts against a closed tricuspid valve, indicating *atrial-ventricular dissociation* A wave: atrial contraction phase

Cannon A waves

Increased intensity of right sided heart sounds during inspiration. *Can be used to differentiate mitral regurgitation from tricuspid regurgitation* Tricuspid insufficiency = positive Carvallo's sign Mitral insufficiency = negative Carvallo's sign

Carvallo's sign

*Unilateral:* -Stroke (exclude unilateral cord disease) *Bilateral:* -Toxin -Electrolyte disorder -Cervical cord disease -Neuropathy -Myasthenia Gravis -ALS

Causes of *Clinical Weakness:* Unilateral vs Bilateral

calcific aortic stenosis

Decreased A2

Aging Pulmonic stenosis

Decreased P2

Delayed conduction from atria to ventricles (1st degree AV block) Poor ventricular contraction *Calcified and immobile mitral valve* (mitral regurg)

Diminished S1

shortening of the finger flexors in the palm, may be idiopathic in origin but also associated with alcohol abuse and alcoholic cirrhosis.

Dupuytren's contractures

Results in *elevated pulmonary capillary pressure* and transudation of fluid into the interstitium and alveoli *Decreased lung compliance* from pulmonary edema Orthopnea Paroxysmal nocturnal dyspnea Dry cough and wheezing possible

Dyspnea of left-side heart failure

Prolactinoma -infertility -impotence, decreased libido -galactorrhea (rare in men) -visual field defects

Most common anterior pituitary tumor?

*Atherosclerosis*

Most common cause of aortic aneurysm?

rheumatic fever --> rheumatic heart disease

Most common cause of mitral stenosis?

IVDA: staph aureus Previously damaged valves: *Strep viridans* Mechanical valves: Staph epidermidis Colorectal cancer: strep bovis

Most common causes of *infective endocarditis*

1. Prolactinoma 2. Non-functional adenoma 3. Growth hormone producing tumor 4. Corticotroph adenoma (Cushing's disease)

Most common pituitary tumors in decreasing order

pulsatile uvula, indicative of *aortic regurgitation*

Muller's sign

-Carotid arteries -Iliac arteries -Renal arteries -Aorta (abdominal)

Where do you listen for bruits as evidence of atherosclerosis?

RBBB Pulmonic stenosis Pulmonary HTN Heard at 2nd intercostal space left of sternum

Wide S2 split (not physiologic)

-*Carpometacarpal squaring* (Arrow) -WILL BE ON THE TEST -NO sinovitis, warmth, or erythema

Wrist/Hand OA

Carpal Tunnel Syndrome DeQuervain's Tenosynovitis Inflammatory arthropathies -Rheumatoid -Psoriatic -Spondyloarthropathies

Wrist/Hand OA look-alikes

risks: smoking, males, t2dm, HTN, lipid disorders - intermittent claudication is prime sx - may develop foot ulcers/gangrene - unrelated to venous insufficiency - decreased pulses, rubor, skin atrophy w/ hair loss, pallor with elevation, bruit @ iliac/femoral artery stenosis - calf then quad pain

chronic arterial insufficiency - risks - complications - signs

PULSES NORMAL No association with gangrene

chronic veinous insufficiency - pulses - gangrene?

*Nasal pruritis:* (aka Wartenburg symptom) -Intense and unrelieved nasal pruritis has been associated with *brain tumor*, esp. with involvement of the floor of the 4th ventricle.

Itchy nose

No A wave (atrial contraction)

JVP changes during *atrial fibrillation*

Large and broad V wave (venous filling) that also occurs during X wave (where atrium should be relaxed). This is because the open tricuspid transmits pressure from the ventricle during systole

JVP changes during *tricuspid insufficiency/regurgitation*

Abnormally large A wave (atrial contraction phase)

JVP changes during *tricuspid stenosis*

A: *A*trial contr*A*ction X: Atrial Rela*X*ation V: *V*enous filling Y: Atrial empt*Y*ing C: bulging of tri*C*uspid during ventricular *C*ontraction

Jugular venous pulse

Pes Anserine Bursitis Meniscal injury

Knee OA lookalikes

*Jugular venous distension* that paradoxically occurs during inspiration, classically associated with: -*constrictive pericarditis* (classic association) -right ventricular infarction -massive PE -restrictive cardiomyopathy May also be seen in cardiac tamponade

Kussmaul's sign

*Both Strokes:* -Spare motor function of forehead, jaw and tongue (bilateral innervation of these areas) *Bell's palsy* -Muscle paralysis on one side of face -CN VII -Inability to close the eye

Lacunar & Cortical Stroke vs Bell's Palsy

-Occurs in 1-3% of general population and 15% of workers in manufacturing/tools that vibrate—NOT likely causative!!!! -Conditions that increase risk: *female, obesity, pregnancy, RA, OA, renal failure, DM, hypothyroid, aromatase inhibitors* -Typing has *not* been proven to be A/W CTS! -Symptoms include *NOCTURNAL aching wrist pain with sparing of the palm*; numbness and tingling in *median nerve* distribution, abduction weakness. -*Phalen's* (looks funny) & *Tinel's* (Tap) Tests

*Carpal Tunnel Syndrome* -Risk Factors -Sx -Nerve -Tests

Tests: -*CN V:* Sensation -CN VII: motor Touch Cornea (NOT Sclera) Abnormal: *Lesion in Pons*

*Corneal Reflex:* CN? Lesion Location?

-Due to swelling of renal capsule and elicited by percussion with medial aspect of fist. -*Acute pyelonephritis* -Hydronephrosis: →Unilateral: often due to *Kidney Stone* →Bilateral: Usually a bladder or urethra obstruction

*Costo-vertebral angle tenderness:* Cause & DDx:

*Hyperreflex:* -UMN problem -Hyperthyroidism *Hypo-reflex:* -Neuropathy -Motor neuron Dz -Neuromuscular junction (Myasthenia gravis)

*Deep Tendon Reflexes* -Hyper causes -Hypo causes

*1. Stocking-glove sensory neuropathy:* -Typically symmetric and correlated with poor glucose control. Foot ulcers over metatarsal heads (pressure points) and Charcot joints (repeated damage due to joint anesthesia). *2. Acanthosis nigricans:* -Hyperpigmented, velvety plaques *3. Necrobiosis lipoidica diabeticorum:* -Pretibial lesion occurring in < 1% of diabetics, it begins as a well-circumscribed plaque with waxy-appearing center with telangiectasia. *4. Retinal findings*

*Diabetic Findings:*

-*Cerebral Cortex* Processing of Sensation -*CONTRALATERAL* Number in hand: graphesthesia Object in hand: Stereognosis

*Discriminative Sensation* -Part of brain? -Side? -Tests?

Only done on *comatose patients* Tests integrity of: *-Brainstem* *-Semicircular canals* *-CN VIII* -No eye movement= brainstem damage (medulla-pontine junction), especially if after cardiac arrest or stroke -Follow up with ice water lavage of ear canals

*Doll's Eye Test* (Oculocephalic reflex)

Double peaked pulse which depends on whether the second peak occurs before or after S2 After S2: Dicrotic pulse due to *severe HF, pericardial tamponade, constrictive pericarditis* Before S2: Bisferiens pulse due to *hypertrophic obstructive cardiomyopathy (IHSS)*

*Double peaked pulse*

*Slurred Speech* Causes: -*Cortical Stroke* -*Cerebellar Dz* -*Peripheral Neuropathy*

*Dysarthria:* -Define -Causes

*Difficulty forming words* with preserved understanding. (Problem is OUTPUT) Cause: -Lesion in inferior frontal cortex (area of *Broca*)

*Expressive Aphasia* -Define -Cause

*ASD* and right ventricular failure

*Fixed S2 split*

-Caused by *uric acid crystal* deposition in joint -Begins acutely with intense pain and inflammatory joint finding. -90% of patients have *great toe* involvement. -Rarely occurs in premenopausal women.

*Gout*

-Common cause of hyperthyroidism due to *autoantibody* that stimulates thyroid hormone production. -May have *proptosis/ exophthalmos* (due to soft tissue accumulation behind globe) -Thyroid gland enlargement and *pretibial myxedema*

*Graves' disease:*

Often felt as *groin or buttock pain* that is exacerbated by weight bearing -*X-rays show joint space narrowing* and femoral or acetabular osteophytes

*Hip OA*

-Ptosis, miosis and anhidrosis, -Ipsilateral to pathologic involvement of *sympathetic chain* -Affected pupil reacts to light Etiologies include: -*Cancer* (e.g. lung cancer with spine mets) -*Spinal cord disease* -*Neck mass* -*Vascular aneurysm* and/or dissection

*Horner's Syndrome* -3 Sx -Causes

Ischemia-related *pain of the muscles of mastication* that occurs with chewing and relieved with rest; this is a specific finding for *temporal arteritis.*

*Jaw claudication*

-Autosomal dominant 2 or more of the 3 Ps: -Hyper*p*arathyroidism -Anterior *p*ituitary -Entero-*p*ancreatic tumors (e.g. insulinoma) (serum C-peptide levels are elevated with insulinoma)

*MEN 1*

-Diagnosed by the swinging light test -*Afferent pupillary abnormality* -The involved eye does not react to light directly but does constrict to light directed to the opposite eye (consensual response)

*Marcus Gunn pupil* -Test? Describe findings -Where is the problem?

-Pain usually occurs acutely and/or is associated with *trauma* -A/w *buckling and "locking" of knee* -Exam: tenderness over joint line, effusion (hemarthrosis) *McMurray +:* clicking felt when knee compressed and rotated during varus and valgus stress

*Meniscal injury*

*Resting tremor = Parkinson's disease:* -"Pill-rolling"; Suppressed with activity. *Intention tremor = Cerebellar disease:* -It appears with action and worsens as goal is reached. *Postural (or action) tremor = Hyperadrenergic state:* -Evident with action; Severe anxiety, hyperthyroidism, sympathomimetic drugs of abuse (e.g. amphetamine), alcohol and drug withdrawal, and essential tremor.

*Types of Tremors* & Cause

-*Atherosclerosis* -*Aortic coarctation proximal to subclavian artery takeoff* -*Aortic dissection* -*Subclavian steal syndrome* -Takayasu's arteritis

*Unequal Arm Pulses*

*Aortic regurgitation*, as well as other etiologies

*Waterhammer* or bounding pulse seen in:

*Pain due to dissection and partial or complete occlusion of arteries arising from the aortic arch, intercostal and lumbar arteries* -radiates to *back*, neck, and abdomen -severe and sudden onset

*dissecting aortic aneurysm*

Prolonged ischemia with irreversible myocardial necrosis often due to occlusive coronary thrombus -*>30 minutes* -Occurs at rest, often in the early morning -Not relieved by NTG Associated with n/v diaphoresis, weakness, light-headedness, syncope, dyspnea

*myocardial infarction*

A fall in systolic BP >20mmHg when going from supine to standing position, particularly if patient is symptomatic *Hypovolemia* *drugs* *prolonged bed rest* *autonomic neuropathy*

*orthostatic hypotension*

*Chest pain due to inflammation of pericardium* -infection, systemic diseases (autoimmune, uremia), malignancy, post MI (Dresssler), contiguous process, drugs -Sharp, knife-like pain -Pleuritic -Positional/postural -May radiate to back, shoulders, neck, epigastrium -May be associated with fever

*pericarditis*

Due to low pulse pressure CHF Hypovolemia *Severe aortic stenosis*

*pulsus parvus et tardus* (small and weak pulses)

*myocardial ischemia*, diagnosis mostly be history -Retrosternal/across anterior chest pain -Radiates to *shoulders, arms, neck, jaw, or abdomen* (dermatomes C8-T4) -Pressing, squeezing, tight, heavy, "gas" feeling -*<20 minutes duration* -*occurs with activity, relieved by rest or NTG* -may be associated with dyspnea, nausea, and diaphoresis

*stable angina*

*myocardial ischemia* with *pain at rest* -less responsive to medication -pathology: plaque rupture, hemorrhage, or thrombosis

*unstable angina*

*Rheumatoid Arthritis* -*Symmetric polyarthritis with prolonged morning stiffness* -Xrays reveal periarticular osteopenia, *erosions*, symmetric joint space narrowing -A/w elevated *RF and anti-cyclic citrullinated peptide (anti-ccp)* -RF more sensitive, anti-ccp more specific -BUT...30% of pts with RA have normal labs

-Define -Signs/Sx

Due to high pulse pressure *Aortic regurgitation* (insufficiency) Hyperdynamic states -pregnancy -hyperthroidism -exercise -anemia -Paget's disease of bone -wet beriberi (inadequate thymine/B1)

*Bounding pulse*

*-ROM limited on active and passive motion: Apley Scratch Test* *-Usually painless*, unless you have concomitant rotator cuff injury -Presents in patients with chronic shoulder problems; also seen in *Parkinson's disease* -Usually middle and *older adults*

*Adhesive Capsulitis/Frozen Shoulder*

-Reduced passive and active range of motion (ROM), usually painless; -*Apley Scratch Test* will reveal reduced ROM, and a positive Touchdown Sign is expected (inability to fully raise effected arm).

*Adhesive capsulitis:*

Alternating strong and weak pulses seen in *poor functioning left ventricle with systolic dysfunction*. Carries a poor prognosis

*Alternans pulse*

Pulse is weak and late, seen in *severe aortic stenosis*

*Anacrotic* or pulsus parvus et tardus

Used to normalize assessment of vessel stenosis across all systemic pressure levels. *Highest pedal pressure/highest brachial pressure* 1: normal 0.6: intermittent claudication 0.3: rest pain <0.2: impending gangrene

*Ankle/Brachial Index (ABI)*

Primary problem *naming objects* (this is present to some degree in most aphasias) Cause: -Lesion of *angular gyrus*

*Anomic aphasia:* -Define -Cause

*Quincke's pulse:* -Intermittent capillary bed flush with pressure to the nail bed *Corrigan's pulse (or water-hammer pulse):* -Bounding radial pulse that is accentuated by raising the wrist *Müller's sign* -Pulsatile uvula

*Aortic Regurgitation Findings:*

-*Early diastolic (decrescendo)* -*Blowing (high pitch)* -Best heard at 3rd and 4th left intercostal space (NOT where aortic valve is normally heard) or LLSB -Radiates to apex and left axilla Best heard during *exhalation* with patient sitting and leaning forward Others signs that may be present: bounding pulse S3 and S4 gallops midsystolic ejection murmur Signs of LV hypertrophy Austin Flint murmur (regurgitation murmur heard at the apex)

*Aortic regurgitation*

-The pupils are small and do not react to light, but do constrict (if closely examined) to the accommodation maneuver. -Damage to the *Edinger-Westphal* nucleus. -Classically diagnostic of *neurosyphilis* (tabes dorsalis), now more commonly seen in: -*Diabetes mellitus* -*Lyme disease* -*Multiple sclerosis*

*Argyll Robertson pupil* -Description -Causes

Primarily small vessel disease where atheroembolous plaques break loose (often from aorta) following a cardiac procedure. Biopsy shows *cholesterol crystals in vessel* Can cause: -*Livedo reticularis* (common early sign) -Blue toes -Renal failure -*Eosinophilia* -Dead bowel - worst outcome

*Atheroembolism* (cholesterol embolization) -define -list what it causes

-Proximally, tendonitis results from impingement or instability *-Pain aggravated by lifting*, pulling or repetitive overhead movements *-Tenderness to palpation along the bicipital groove* with the arm slightly externally rotated is suggestive of tendonitis

*Biceps Tendonitis*

Rhythmically irregular rythm, alternating strong (normal) and premature beats. PACs and PVCs *Digoxin toxicity*

*Bigeminal pulse*

-Unusual finding that signals neuromuscular weakness Disorders to consider include: -*Myasthenia gravis* -Miller-Fisher variant of Guillain-Barre syndrome -Botulism.

*Bilateral ptosis:*

Abnormal condition where palpation of pulse shows two peaks per cardiac cycle Associated with *IHSS (idiopathic hypertrophic subaortic stenosis)* aka obstructive hypertrophic cardiomyopathy Most easily palpated in brachial and femoral arteries (peripheral arteries)

*Bisferiens pulse*

-*Holosystolic murmur* -Best heard at apex -Radiates to the *axilla* not so much LSB or base -*S3 gallop may be present* with increased and prolonged apical impulse (due to dilated LV) -S1 diminished Does NOT increase with inspiration (negative Carvallo's sign) May cause *increased splitting of S2* as majority of blood leaves the ventricle through the mitral valve and not the aorta ---- Differentiate from mitral regurg by: -Location (LSB is tricuspid, apex is mitral) -Radiation (to sternum is tricuspid, axilla is mitral) -Intensification with inspiration (tricuspid intensifies, mitral does not)

*Mitral insufficiency (regurgitation)*

*Mid to late rough diastolic murmur* or *rumble with presystolic accentuation* (accentuation due to atrial kick) Best heard at *apex* with bell at left lateral position, in *left lateral decubitis position* Usually heard *after exercise* or *during exhalation* minimal radiation Associated with *sharp S1* and *opening snap (short, high pitched early diastolic sound corresponding to the mitral valve opening)* Most common cause: rheumatic heart disease

*Mitral stenosis*

-Renal Cell Carcinoma -Polycystic Kidney disease -Xanthogranulomatous Pyelonephritis -Angiomyoplipoma (tuberous sclerosis)

*Palpable Kidney DDx:*

*Venous thromboembolus (usually from DVT) that crosses a patent foramen ovale (or ASD) to lodge in the arterial circulation* Can be caused by PE, which increases pulmonic artery pressure (due to increased pulmonary vascular resistance), increases pressure in right ventricle and atrium, which can open a propatent foramen ovale

*Paradoxical embolization*

Seen in *Cardiac tamponade*

*Paradoxical pulse*

Occurs on *expiration* instead of inspiration which is physiologic *LBBB* *Aortic stenosis* Aortic valve is always delayed, but during inspiration both the aortic and pulmonic are delayed so they sounds together

*Paradoxical splitting of S2*

-L5/S1 *Extension=Babinski:* UMN disease, including: -Cortical stroke -Spinal cord Dz -B12 deficiency -Severe intoxication -Post-ictal state

*Plantar Reflex* -Extension=_______ -Causes

Coarctation occurs in the aortic arch before the left subclavian branch, so right arm pulse will be stronger than left Most cases of coarctation are post-ductal

*Pre-ductal aortic coarctation*

PRONATION & Drop: *Stroke with UMN lesion* Arm Rises: *Cerebellar or proprioception*

*Pronator Drift:*

Regular rhythm but with alternating strong and weak pulse *Left ventricular failure* (systolic problem)

*Pulsus alternans*

Decrease in systolic BP by >10mmHg during inspiration *cardiac tamponade* (classic association) constrictive pericarditis COPD Severe asthma

*Pulsus paradoxus*

Fluent speech devoid of meaning due to lack of comprehension of language (*Politician/ Car salesman*) Cause: -Lesion in superior temporal lobe (*Wernicke's area*)

*Receptive aphasia*

-Tests proprioception -*Posterior column* -Stand with eyes closed 20-30 seconds If fail, confirm with vibratory on foot

*Romberg Test*

In severe *aortic valve regurgitation*, Rosenbach's sign is the pulsation of the liver during systole and is caused by the high stroke volume in this disease state. Note that *severe tricuspid valve regurgitation* also causes hepatic pulsations in systole due to the backward regurgitant volume.

*Rosenbach's sign*

-*Most common cause of shoulder pain* seen in primary care (29%!) -Usually no history of trauma -*Night-time symptoms* are prominent -*Drop arm test:* the patient raises arm to 90 degrees of abduction and lower it slowly. A suddenly dropped arm is considered positive and suggestive of a rotator cuff tear.

*Rotator Cuff Tendonitis*

Due to *subclavian stenosis* producing ipsilateral retrograde vertebral artery flow Symptoms tend to involve *ischemia of the ipsilateral arm during work*, esp. overhead work, and posterior circulation cerebral ischemia (e.g. dizziness, vertigo, syncope, dysarthria, visual loss and diplopia).

*Subclavian steal syndrome*

-Facial plethora (red-blue discoloration and swelling) -Chest wall neovascularity (in chronic cases) -Jugular vein distention and papilledema (due to retinal vein hypertension) -Findings may be precipitated/accentuated by raising both arms (Pemberton's sign - large thyroid goiters inlet may also have this sign).

*Superior vena cava syndrome*

-Deep or diffuse pain -Pain on active and *passive movement* *-Limited range of motion* on active and passive movement -Swelling *-Crepitation* -Instability -Locking -Deformity

*Sx:* Articular

-Painful on *ACTIVE range of motion* -Focal tenderness in regions adjacent to articular structures -Have physical exam findings remote from joint capsule -Rare to have swelling, crepitus, instability, deformity

*Sx:* Nonarticular

-May involve different mechanisms: 1) *Low flow* states due to large artery occlusion 2) *Small emboli*, which can be from large artery or heart (two most common sources) 3) Lacunar TIA from *stenosis of a small penetrating vessel*. -The TIA may involve the anterior circulation (carotid arteries) or the posterior circulation (vertebral and basilar arteries), and the TIA symptoms will reflect such. -By definition a TIA resolves within 24 hours and identifies a patient at high risk of stroke. It is essential that these patients be evaluated promptly.

*Transient ischemic attack (TIA):* -3 mechanisms

-*Holosystolic murmur* -Best heard at LSB -Radiates to right of sternum and xiphoid, not the axilla -*Right sided S3 gallop may be present* with increased and prolonged right-sided apical impulse (due to dilation of RV) *Intensifies with inspiration (positive Carvallo's sign)* ---- Differentiate from mitral regurg by: -Location (LSB is tricuspid, apex is mitral) -Radiation (to sternum is tricuspid, axilla is mitral) -Intensification with inspiration (tricuspid intensifies, mitral does not)

*Tricuspid insufficiency (regurgitation)*

-Pain and tenderness over *greater trochanter* -Pain can radiate down thigh in some cases -Should do an Xray of this to ensure that there are no other processes contributing

*Trochanteric bursitis*

*DeQuervain's Tenosynovitis* -Traditionally occurs in a *woman 30-50 yrs old* -Exercise related involving extensive wrist and thumb action, *gripping/grasping like carrying small children *(parents or day care workers!) -*Tenderness at anatomic snuff box* -*Finkelsteins maneuver*

-Who -What -Test

Hyperdynamic states: exercise, anemia, *hyperthyroidism*, 3rd trimester pregnancy Mitral stenosis

Accentuated S1

assesses collateral circulation to hand through ulnar artery Compress ulnar and radial aa with clenched fist. Open fist, release ulnar, should refill Tests adequate collateralization by ulnar a.

Allen Test

Common in elderly, due to *calcium deposit and stiffening of aortic valve WITHOUT STENOSIS* (Same as aortic stenosis) -*midsystolic* -best heard at base -Radiates to LSB, apex, and neck *Different than stenosis*: -No alteration in S2 -No LV hypertrophy -No changes in carotid pulse

Aortic *sclerosis*

-*midsystolic (crescendo-decrescendo)* -best heard *at base of heart* -Radiates to LSB, apex, and neck Increases with patient sitting and leaning forward Others signs that may be present in AS (but not present in aortic sclerosis): -S4 gallop -LV hypertrophy -Diminished S2 -Paradoxical splitting of S2 -Pulsus parvus et tardus

Aortic *stenosis*

*Articular structures:* -Synovium, synovial fluid, articular cartilage, intraarticular ligaments, joint capsule and juxtaarticular bone *Nonarticular (periarticular) structures:* -Supportive extraarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, overlying skin Note that *articular does not = arthritis* (as a meniscal injury is an articular problem but not arthritis)

Articular vs nonarticular

Indicates *aortic regurgitation* but best heard at *apex* (regurg normally heard at LLSB or 3-4 left ICS) Due to regurgitant jet hitting the *anterior leaflet of the mitral valve* causing premature closure of the mitral valve. Sound is due to mixing of blood between anterograde flow through the mitral valve and retrograde flow through the aortic valve

Austin Flint murmur

Significant left atrial enlargement

Convex shadow on left side of CXR and double density

*Hollenhurst Crystal*

Eye sign of *cholesterol embolism*

Scale of I - VI I: very faint II: clearly heard III: very loud, NO THRILL (can't be felt) IV: Palpable thrill V: Heard with stethoscope barely on chest wall VI: Heard with stethoscope off chest wall

Grading of heart murmurs

*Grey-Turner:* Flank echymoses *Cullen:* Periumbilical echymoses Caused by movement of blood up through the retroperitoneum DDx: -*Ruptured AAA* -*Hemorrhagic pancreatitis* -*Ruptured Ectopic Pregnancy* -Other small vessel bleeding

Grey-Turner Sign and Cullen's sign -Differences -DDx

Left lower sternal pulsation suggesting *right ventricular hypertrophy*

Heave

Herberden's nodes help pick your nose -Both seen in *OA*

Heberden's and Bouchard's nodes

-Trochanteric bursitis -Sacroiliitis

Hip OA lookalikes

*Atrial thrombus embolizing* to the celiac and/or superior mesenteric artery (SMA)

History of heart disease and atrial fibrillation, presenting with acute abdominal pain out of proportion to normal exam

Mitral or tricuspid regurgitation

Holosystolic murmur possibilities?

Opening snap, associated with mitral stenosis, occurs in the same position as an S3 heart sound, but is high pitched S3 is indicative of an overloaded ventricle being filled and occurs in early diastole, but is a low pitched sound unlike the opening snap

How can you distinguish an *opening snap* of the mitral valve and an S3 heart sound?

*Amaurosis fugax:* -Transient *monocular vision loss* due to a small retinal artery embolism -Described as a "shade being lowered" in the involved eye. -Transient because infarction of the retina doesn't occur. -Very worrisome symptom often due to carotid artery stenosis and demands prompt evaluation.

I can't see out of one of my eyes!!!

Due to enlarged septal muscle that blocks aortic outflow tract and affects the *anterior mitral valve leaflet* -*midsystolic (crescendo-decrescendo)* -usually *harsh or rough* -Best heard in 3rd and 4th Left intercostal space -May radiate to apex and base (*no radiation to neck*) -*S4 gallop* -no pulsus parvus et tardus -sustained apical impulse *Increases with valsalva and standing* (decrease ventricular chamber size) *Decreases with squatting* (increases ventricular chamber size)

Idiopathic hypertrophic subaortic stenosis (IHSS)

*malnutrition* Look for other signs of malnutrition such as *atrophic glossitis, angular cheilosis, and esophageal web* Pica - eating of non-food stuffs Also ask about problems swallowing food or drink

If you have a patient with koilonychia, what should you suspect?

indicates enlarged left atrium

Increased *carinal angle*

HTN dilated aortic root

Increased A2

Pulmonary HTN dilated pulmonary root ASD

Increased P2

Due to *turbulent blood flow across pulmonic valve* and common in *children, young adults (innocent)* or *anemia, pregnancy, febrile illness, or hyperthyroidism (physiologic)* -*Midsystolic* (crescendo-decrescendo) -Best heard in *2nd and 3rd left intercostal space* -Minimal radiation -Usually *grade II* -Usually *blowing quality* Usually decreases in sitting position

Innocent and physiologic systolic murmur

A couple joints= OA Lots of joints= RA

Local or widespread Arthritis

arachnodactyly mitral valve prolapse skin striae aortic root dissection Risk of aortic dissection, get annual exam

Marfan's syndrome

*Class I*: No limitation or symptoms with normal physical activity *Class II*: Slight limitation with symptoms occurring with normal physical activity *Class III*: Marked limitation with less than ordinary activity causing symptoms, but no sx at rest *Class IV*: Unable to engage in physical activity, symptoms may be present at rest

NYHA classifications

<6-8 cm H2O (or <3cm above sternal angle) 1 mmHg = 1.3 cm H2O

Normal JVP

Is a congenital open channel between the aorta and the pulmonary artery Continuous (machine-like) murmur best heard in the *2nd left intercostal space* radiating to the left clavicle

Patent ductus arteriosus - heart murmur?

Due to inflammation of the pericardial sac (pericarditis) Usually *3 short, scratchy and high pitched components best heard in the 3rd left intercostal space*. Sounds correspond to atrial contraction, ventricular systole, and early diastolic filling May increase during *exhalation* with the patient sitting and leaning forward (same as aortic regurgitation)

Pericardial friction rub

*visual:* amaurosis fugax (painless, transient monocular vision loss) *retinal exam:* Hollenhorst crystal *peripheral sx:* leg claudication

Peripheral vascular disease: a) visual changes c) retinal exam finding b) peripheral symptoms

Pain just below *knee at anteromedial* aspect of tibia that occurs when *exercising* or climbing stairs Pes anserine bursa is tender to palpation

Pes Anserine Bursitis

Normal splitting of S2 that is *increased during inspiration* (Pulmonic valve closes late) Negative intrathoracic pressure increases blood flow to RA and lung expansion increases pulmonary interval

Physiologic splitting of S2

*Hypertrophic*: Strong PMI that is prolonged and can fill the hand *Dilated*: weak PMI that may be displaced laterally and increased in size *Normal*: mid clavicular line, or slightly medial

Point of Maximal Impulse (PMI) changes in hypertrophic or dilated cardiomyopathy

Aortic regurgitation Mitral stenosis

Possible *diastolic murmurs*

Pulmonic/Aortic stenosis Mitral/Tricuspid regurgitation VSD Aortic sclerosis Idiopathic hypertrophic subaortic stenosis (IHSS) Innocent/Physiologic

Possible *systolic murmurs*

Connective tissue disorder (EDS, Marfans, LDS) Aortic dissection Tertiary syphilis Aortitis (e.g. ankylosing spondylitis) Rheumatic heart disease Infective endocarditis Bicuspid valve (can causes both regurg and stenosis)

Possible causes of *aortic regurgitation* (7)

*Polyarteritis Nodosa* -*Hep B* -HTN -Young -Many organs involved (*lungs spared*) -Skin lesions -String of Pearls -Tx: Corticosteroids & cyclophosphamide

Presents with: -HTN -abdominal pain -Young adult -Hematuria & High Cr -Neuro disturbances

*1. Cerebellar ataxia:* -Wide-based, unsteady, lateral veering (*MS, tumor*) *2. Sensory ataxia:* -"Stamp and stick" gait as described by Ramsay Hunt; looks at ground (*B12 deficiency, tabes dorsalis*(neurosyphilis)) *3. Festinating:* -Shuffling steps with rigidity; lower body appears to be chasing upper body ( *Parkinson's*) *4. Steppage* or equine: -Inability to dorsiflex foot (trauma to *peroneal nerve, Charcot-Marie-Tooth*)

Problems with *Gait* & cause

Appreciated by palpation in the *left 2nd ICS* and associated with *pulmonary artery dilation* usually due to pulmonary htn

Pulmonary impulse

Heard in *early diastole* at the end of the rapid filling phase *S3 gallop* - sounds like "Ken-----tu-cky" Caused by *forcing of blood into a dilated and overloaded ventricle* because walls of ventricle are stretched tight and act like a drum Best heard at *apex* (left) or *xyphoid* (right) with *bell* (low pitched sound) Normal (physiologic) in children, adolescent, 3rd trimester pregnancy, anemia, febrile states, or hyperthyroidism Abnormal is always indicative of serious myocardial dysfunction

S3 heart sound

Heard in *late diastole* during atrial contraction sound is like a percussion sting played on the drums after a bad joke: "ba-DUM bump." (Ten-ne------see) Caused by sudden tensing of ventricular musculature and chordae tendinae during atrial contraction into the ventricle and is *indicative of decreased ventricular compliance* Often heard in hypertrophied ventricle as a result of *long-standing hypertension* Best heard at apex (LV) or lower left sternal border with bell (low pitched, low intensity sound)

S4 heart sound

Non-functional adenoma -visual field cuts, compression of other structures -possibility of spontaneous infarction/hemorrhage

Second most common anterior pituitary tumor?

Biceps tendonitis Rotator cuff tendonitis Frozen shoulder

Shoulder OA look-alikes

Pericardial rub Patent ductus arteriosus

Sounds that may be systolic, diastolic, or both

*Cortical strokes* (blood to outer brain) -80% due to ischemia (*Carotid arteries*) -Unilateral deficit in the *middle cerebral artery territory* -Usually have *combined motor and sensory deficits* -Face and hand often involved together; *leg spared* *Lacunar Stroke:* (blood to deep brain) -Occlusion of small penetrating vessel serving the white matter fiber projections -Often *pure motor* OR *pure sensory* deficits that may involve leg, hand and face

Stroke (CVA): *Cortical vs Lacunar*

a rare multi-system genetic disease that causes benign tumors to grow in the brain and on other vital organs such as the kidneys, heart, eyes, lungs, and skin.

What is tuberous sclerosis?

Growth hormone producing tumor causing acromegaly -characteristic face and hands -macroglossia -DM -heart failure -visual field defects

Third most common anterior pituitary tumor?

*Blowing*: high pitched *Harsh*: low pitched *Musical*: sea gull

Three possible *qualities* of heart murmurs

*Midsystolic*: crescendo-decrescendo (diamond) *Holosystolic*: pansystolic, plateau *Late systolic*: crescendo *Early diastolic*: decrescendo *Mid-diastolic*: decrescendo *Late diastolic*: CREScendo

Timing of heart murmurs and the dynamic of each -3 in systole -3 in diastole

*Internuclear ophthalmoplegia:* (INO) -Failure to adduct Cause: (Damage to the medial longitudinal fasciculus) -Brainstem stroke (unilateral) -*Multiple sclerosis* (bilateral) -Diabetes, others

Trying to look to her left

*CN VI palsy:* Abducens -Failure to abduct *Cause:* Increased intracranial pressure: -*Meningitis* -Tumor -Meningeal process -Cavernous sinus process -Diabetes -Vascular Dz with focal ischemia to pons

Trying to look to his left

*CN III Palsy:* Oculomotor -Eye deviated laterally and inferiorly (*down and out*) -May also have *Dilated pupil and ptosis*. Causes: -*Uncal herniation* (greatest fear) -Diabetes -Infarct (*aneurysm*) -Tumor

Trying to look up

Lymph nodes in the head and neck. Tonsillar is often inflamed Describe *size* and *quality* of the nodes. Also if they are *tender* or not Malignant nodes are often rock hard and fixed to underlying structures

What must be described when discussing lymph nodes?

Complete heart block - irregular rhythm (A-fib)

Varying S1

*Palmomental:* Stroking thenar imminence produces contraction of mentalis muscle (raise upper lip) *Suck:* Sucking movement elicited with touching or stroking lips *Snout:* Puckering or protrusion of lips elicited by percussion *Grasp:* Unrecognized stroking of palm produces grasp of fingers

What *abnormal reflexes* exist in someone with a *frontal lobe* pathology? (Alzheimer's dementia) aka *Frontal Release signs*

S4

What abnormal heart sound is never heard in atrial fibrillation?

Congenital heart disease Hepatic cirrhosis IBD

What are the common non-pulmonary causes of nail clubbing?

Chronic hypoxic conditions -COPD -CF -Lung cancer -Interstitial lung disease

What are the common pulmonary causes of nail clubbing?

a) *end of toe* - arterial b) *ankle* - chronic venous insufficiency c) *pressure points* - neuropathic

What causes ulcer at the: a) end of toe b) ankle c) pressure points of foot

4+: bounding *3+: normal* 2+: diminished 1+: diminished Absent: no palpable pulse, *should attempt to auscultate with doppler stethoscope*

What is a normal pulse character? What should be done if pulses are absent?

A connective-tissue disease related to polymyositis (PM) that is characterized by inflammation of the muscles and the skin. While DM most frequently affects the skin and muscles, it is a systemic disorder that may also affect the joints, the esophagus, the lungs, and the heart

What is dermatomyositis?

Relatively common congenital anomaly (1% of population) that *increases risk of infective endocarditis and aortic dissection* NOT associated with Marfan's syndrome, so no Fibrillin-1 genetic testing is indicated

bicuspid aortic valve

sausage digit (dactylitis)

spondyloarthropathy