CM 2 Exam

Left lower parasternal heave

Located at left parasternal 3 and 4 intercostal spaces Palpate w/ hand parallel to sternum Nl in children, thin adults Right ventricular hypertrophy

Eye exam

Look for anisocoria Observe direct and consensual pupillary response bilaterally Check for accommodation

Single S2

Loss of A2 or P2 Severe aortic stenosis or regurg Congenital absence of pulmonary valve

Medullary lesion

Loss of ipsilateral face sensation Hoarseness and dysphagia Loss of contralateral pain and temp from body May have vestibular dysfunction and fall toward side of lesion (ipsilateral cerebellar dysfunction; inferior cerebellar peduncle) if upper medulla Negative Romberg sign Mayhave Horner's syndrome

Flaccidity

Loss of muscle tone causing limb to be loose or floppy Guillain-Barre or LMN lesion

Aphonia

Loss of voice

Anterior chest abnormalities

Pectus excavatum Pectus carinatum

Nerve trauma

Peripheral nerve mononeuropathy Weakness and atrophy in peripheral nerve distribution, sometimes with fasciculations Sensory loss in the distribution of that nerve Decreased DTRs

Diabetes, alcoholism lesions

Peripheral nerve polyneuropathy Bilateral distal weakness and atrophy, sometimes with fasciculations Sensory deficits in stocking-glove distribution Decreased DTRs

Left Ventricular Impuse

Point of Maximal Impulse Location: 4th or 5th intercostal space, midclavicular line Diameter <=2 cm Amplitude: Brisk and tapping Duration: <=2/3 systole

Sensory ataxia

Polyneuropathy or posterior column damage Gait is unsteady and wide-based Pts throw their feet forward and outward and bring them down, first on the heels and then on the toes with double tapping sound They watch ground for guidance when walking With eyes closed they cannot stand steadily with feet together and staggering gait worsens

S3 heart sound

Low pitched sound occurring in early diastole; during rapid ventricular filling period after mitral and tricuspid valve opening High pressures and abrupt deceleration of inflow across mitral valve at end of rapid filling Auscultate w/ bell, light pressure Left-sided: heard at apex in left lateral decubitus position Right-sided: heard along lower left sternal border or below xiphoid w/ pt supine; louder on inspiration Normally audible in children, young adults and pregnancy Older: indicates ventricular failure or increased early diastolic ventricular pressure and volume Causes: decreased myocardial contractility, HF, volume overloading of ventricle--mitral or tricuspid regurg

Hydrocephalus induced secondary Parkinsonism

Lower-body parkinsonism MRI showing possible contusion

Toxin induced secondary Parkinsonism

Manganese, MPTP, mercury, methanol, EtOH, CO Exposure hx

NYHA Class IV

Pts w/ cardiac disease resulting in inability to carry on any physical activity w/o discomfort. Sx of heart failure or anginal syndrome may be present at rest. Any activity increases discomfort Objective: evidence of severe CVD

Relative afferent pupillary defect

Marcus Gunn pupil Checking for CN II or III damage

Elevated a wave

Resistance to right atrial emptying, at or beyond tricupsid valuve - Pulmonary HTN - Rheumatid tricuspid stenosis - Pulmonic stenosis - Right atrial mass or thrombus - RV hypertrophy

Panic Attack

Sx: May be indistinguishable from angina; often dx after negative eval for ischemia heat disease; often assoc w/ palpitations, sweating, anxiety ECG: nl CXR: nl

Bacterial Pneumonia

Sx: Pleuritic chest pain; onset in mintues to hours; fever; chills; cough; purluent sputum; often dyspnea and tachycardia; signs of consolidation (dullness to percussion, egophony, bronchophony) ECG: NL CXR: Consolidation

Tension Pneumothorax

Sx: Significant SOB, hypoTN, neck vein distension; unilateral diminished breath sounds and hyperresonance to percussion; sometimes subcutaneous air Trachea and mediastinum deviate to opposite side ECG: Nl CXR: Collapse lung; tracheal deviation

Angina pectoris

Sx: Substernal, constricting; transient, effort related; relieved by nitro ECG: local ST depression, occasional elevation CXR: Nl

Pulmonary Embolism

Sx: Sudden onset, pleuritic chest pain; dyspnea; tachycardia; sometimes mild fever, hemoptysis; shock if severe; risk for venous thrombosis; deteremine probability w/ Wells Criteria: low --nl D-dimer to exclude dx, Intm/high--ventilation-perfusion scan or spiral CT ECG: Nonspec, occasional RV strain CXR: nl or opacity +/- small pleural effusion

Pyuria

>3 WBCs/HPF Most often UTI Negative urine culture--viral or mycobacterial infection Sterile pyuria also noninfectious interstitial nephritis w/ leukocyte casts Eos in pts w/ acute kidney injury cause by drug-induced interstitial nephritis, RPGN, prostatitis, renal atheroemboli, small-vessel vasculitis

Microscopic hematuria

>=3 RBC/HPF Location of bleed needs to be ID for guide studies Glomerular hematuria--presence of dysmorphic RBCs, esp w/ blebs: acanthocytes Transient glomerular bleeding after vigorous physical activity Non-glomerular bleeding--isomorphic, nl RBCs, absence of proteinuria

Spinocerebellar ataxia

AD inheritance Begins early in life Ataxia predominates Assoc w/ Parkinsonism

Headache causes

Acute glaucoma Analgesic rebound Brain tumor Cluster Giant cell arteritis Meningitis Migraine Post-concussion headache Sinusitis Subarachnoid hemorrhage Tension Trigeminal neuralgia

Pulsus Alternans

Amplitude alternates from beat to beat even though rhythm is regular; detected by sphygmomanometry Usually accompanied by left-sided S3 - Left ventricular failure

Right 2nd intercostal pulsations

Ascending aorta aneurysm

Tachyarrhythmia

Assoc w/ palpations; suspicious in cases of syncope w/ no warning or prodrome Ventricular arrhythmias causing syncope usu in setting of structural heart disease (MI-assoc Vtach) or w/ fam hx of sudden cardiac death (long AT, Brugada); Extended ECG recording, event monitoring, or electrophysiologic studies to doc arrhythmia

Lipiduria

Assoc w/ various glomerular diseases, usu accompanied by heavy proteinuria Lipids may be seen w/ tubular epithelial cells or macrophages Lipids in hyaline casts = fatty casts Lipid particles in urine under polarized light for Maltese cross

Fragile X-associated tremor/ataxia syndrome

Ataxia, tremor, dementia Assoc w/ Parkinsonism

Bradyarrhythmia

May be assoc w/ sx of near-syncope or signs of diminished CO (persistent) Dx by ECG, extended electrocardiographic monitoring, or electrophysiologic studies Includes SA and AV node dysfunction; may be drug-induced (beta blockers, CCBs, antiarrhythmia drugs)

Obstruction to outflow

May be related to exercise or assoc w/ angina or heart failure Dx by PE, echo, or specialized testing Causes: aortic stenosis, hypertrophic cardiomyopathy, mitral stenosis, myxoma, pulmonic stenosis, massive PE, pulmonary HTN

Bigeminal Pulse

May mimic pulsus alternans; SV of premature beat is diminished in relation to that of nl beats; varies in amplitude accordingly - Normal beat alternating w/ premature contraction

Lateral femoral cutaneous nerve entrapment

Meralgia paresthetica Pain, numbness, and paresthesia over anterolateral thigh

Mitral Stenosis Murmur

Mid-late diastolic Low-pitched rumbling murmur at apex Heard best w/ bell in left lateral decubitus Early opening snap precedes murmur Loud S1, attenuated if calcified Sx: Fatigue, dyspnea, orthopnea, PND, ankle edema, palpitations due to afib Findings: edema, increased JVP, left parasternal drift

Tricuspid stenosis murmur

Mid-late diastolic Low-pitched, rumbling at lower left sternal border Increased with inspiration

Pulmonic Stenosis Murmur

Midsystolic Crescendo-decrescendo murmur at left 2nd interspace with radiation to neck and left shoulder Harsh Sometimes with thrill, increased w/ inspiration Early pulmonic ejection sound Widely split S2 Right ventricular impulse may be increased Right S4

Aortic Dissection

Sx: Sudden, severe, substernal, tearing pain; radiation to back; may have syncope stroke, or leg ischemia; age >55; Hx of HTN, prostration; aortic insufficiency Pulse or BP may be unequal in limbs ECG: Nonspec; LVH or inferior MI CXR: Widened mediastinal silhouette, pleural effusion, or both

Pneumothorax

Sx: Sudden, sharp, unilateral pleuritic chest pain; dyspnea; maybe diminished breath sounds; maybe subcutaneous air; asthenic habitus; tendency toward recurrence; often smoker or COPD pt Chest radiograph of CT for confirmation ECG: Nl CXR: Collapsed lung

Herpes Zoster

Sx: sharp, band-like pain (intense burning) in mid thorax (unilaterally, dermatomal distribution); linear, vesicular rash; pain may precede rash by several days; dysesthesia ECG: nl CXR: nl

Situational syncope

Syncope assoc w/ spec activities (micturition, cough, swallowing, defecation) Gen dx by hx alone

Orthostatic hypoTN

Syncope occurs on assuming upright position May be caused by hypovolemia, drugs, disorders of ANS (idiopathic hypoTN, Shy-Drager syndrome)

Aortic Stenosis Murmur

Midsystolic crescendo-decrescendo murmur Right 2nd interspace with radiation to neck and down left sternal border to apex Loud, harsh, with a thrill Heard best when pt is sitting, leaning forward Ejection click with mobile valve S2 decreases and paradoxical splitting as stenosis worsens S4 Sustained apical impuls w/ LV hypertrophy Carotid pulse may rise slowly and be weak

Carotid sinus hypersensitivity

Syncope precip by pressure on carotid sinus (tight collar, sudden turning of head( Gen dx by hx Carotid massage confirmatory

Hypertrophic Cardiomyopathy murmur

Midsystolic murmur Lower left sternal border w/ radiation to apex and sometimes base Increased w/ Valsalva, decreased w/ squatting S3 and/or S4 may be present Apical impulse may be sustained, minimally displaced Sx: exercised induced chest pain, palpitations, syncope, rare sudden death Brisk carotid upstroke, bisferiens pulse

Absent a wave

No atrial contraction - Afib (Absent in Atrial fibrillation)

Broca's aphasia

Non-fluent, slow, laborious, poor inflection and articulation, appropriate words and meaningful sentences, good comprehension, posterior frontal lobe

Plantar reflex

Normal = toes down Absent Abnormal or Babinski present

Pain related complications of Parkinson

Painful dystonia, pain due to mechanical factors, visceral painful sensations, primary central pain

Paradoxical Pulse

Palpable decrease in pulse's amplitude on quiet inspiration; systolic pressure decreased of >10 mmHg during inspiration - Pericardial tamponade - Exacerbations of asthma, COPD - Constrictive pericarditis

Epigastric pulsation

Palpable in thin pts, emphysemics May be transmitted aortic impulse

Aortic ejection click

Heard at base and apex Louder at apex Does not vary with respiration Causes: dilated aorta, aortic valve disease from congenital stenosis, bicuspid aortic valve

Pulmonic ejection click

Heard best in 2nd and 3rd left interspaces S1 is loud Intensity decreases with inspiration Causes: congenital pulmonic stenosis, pulmonary artery dilation; pulmonary HTN

One large fixed pupil

Herniation of temporal lobe with compression of oculomotor nerve and midbrain

Psychiatric disorder (anxiety, depression, conversion disorder)

High incidence (24-35%) of psych disorders have been reported in pts w/ syncope

Mid-systolic clicks

High pitch Click usually followed by late systolic crescendo murmur from regurg Change their time within systole by bedside maneuvers Best heard with diaphragm Heard at or medial to apex, also lower left sternal border Causes: mitral valve prolapse, tricuspid valve prolapse

Pleural effusion/hemothorax

Hx: Hx of trauma or pneumonia PE: Dullness to percussion, absent breath sounds

Pneumothorax

Hx: Hx of trauma, pleuritic chest pain PE: Absent breath sounds, deviated trachea (tension)

Pericardial tamponade

Hx: Hx of trauma, preceding "flu" sx, collagen vascular disease PE: Jugular venous distension, clear lungs, pulsus paradoxus, hypoTN

Pulmonary HTN

Hx: May be idiopathic or related to other diseases, ie interstitial lung diease or cardiac shunts (ASD) PE: JVD, increased P2, fixed split S2, tricuspid regurgitant murmur, clear lungs or crackles depending on cause

Aspiration

Hx: Observed aspiration, sx start during or shortly after eating or vomiting Altered mental status or abnl gag reflex at baseline PE: Unilateral, and sometimes bilateral, crackles, more commonly on right, fever

Interstitial lung disease

Hx: Possible exposure hx (silica, asbestos, smoking); collagen vascular disease (scleroderma) PE: Possible clubbing (pulm fibrosis), dry crackles

Parkinsonism

Basal ganglia Bradykinesia, rigidity, and tremor Normal sensations Normal or decreased DTRs

Parkinsonian gait

Basal ganglia disorder Posture is stooped with flexion of head, arms, hips, and knees Pts are slow getting started; steps are slow and shuffling w/ involuntary hastening Arm swings are decreased and pts turn around stiffly Postural ctrl is poor (retropulsion)

Vocal cord dysfunction

Hx: Previous normal spirometry results, hx of immediate improvement following intubation PE: Stridor, clear lungs, nl cardiac exam

Panic attack

Hx: Rapid onset of chest pain, dyspnea that resolve w/o spec tx PE: Nl cardiac and pulmonary exams

Pulmonary embolism

Hx: Risk factors for thromboembolism, pleuritic chest pain, hemoptysis PE: Nl exam, possible unilateral leg swelling

Deconditioning

Hx: Situations leading to decreased exercise tolerance PE: Nl cardiac and pulm exams

COPD

Hx: Smoking hx, cough, sputum PE: Diminished breath sounds, wheezing, prolonged expiration, large chest

Asthma

Hx: episodic cough, chest tightness, related to exercise, nocturnal sx PE: Wheezing

Pneumonia

Hx: fever, cough, sputum PE: Fever, crackles, dullness to percussion

Anemia

Hx: hx of blood loss or hemolytic disease PE: Conjunctival pallor

Neuromuscular disease

Hx: known neuromuscular disease PE: Nl cardiac and pulm exams, neuromuscular findings

Tracheal stenosis, tracheomalacia

Hx: prolonged mechanical ventilation and intubation PE: Stridor, clear lungs, nl cardiac exam

Akathisia

Hyperkinetic Movement Clinical: Inner restlessness coupled with repetitive movements Causes: Parkinsonism, drug-induced acute or tardive akathisia, and restless leg syndrome

Hyperkinetic Right Ventricular Impulse

Causes: Anxiety, Hyperthyroidism, Severe anemia Location 3rd, 4th, or 5th left interspaces Diameter: Not useful Amplitude: Slightly more forceful Duration: Normal

Pressure Overload Left Ventricular Impulse

Causes: Aortic Stenosis, HTN Location: Nl Diameter: >2cm Amplitude: More forceful tapping Duration: Sustained (up to S2)

Volume Overload Left Ventricular Impullse

Causes: Aortic or Mitral Regurg, Cardiomyopathy Location: Displaced to the left and possibly downward Diameter: >2cm Amplitude: Diffuse Duration: Often slightly sustained

Volume Overload Right Ventricular Impulse

Causes: Atrial septal defect Location: Left sternal border, extending toward the cardiac border, also subxiphoid Diameter: Not useful Amplitude: Slightly to markedly more forceful Duration: Normal to slightly sustained

Cerebellar ataxia

Cerebellar disease Gait is staggering, unsteady, wide-based, with exaggerated difficulty on turns Pts cannot stand steady w/ feet together, whether eyes closed or open

Cerebellar stroke

Cerebellum Hypotonia, ataxia, nystagmus, dysdiadochokinesis, and dysmetria Normal sensation Normal or decreased DTRs

Cortical stroke

Cerebral cortex Contralateral weakness, spasticity, and sensory loss Increased DTRs No CN deficits

Dysarthria

Defect in muscular ctrl of speech apparatus

Corticobasal degeneration

Degenerative Parkinsonism Asymmetric spasticity and rigidity, alien limb movement, myoclonus

Multiple system atrophy

Degenerative Parkinsonism Ataxia, dysautonomia

Dementia with Lewy bodies

Degenerative Parkinsonism Demetia, hallucinations

Progressive supranuclear palsy

Degenerative Parkinsonism Early falls, impaired vertical eye movement

Idiopathic Parkinson disease

Degenerative Parkinsonism Rest tremor, rigidity, bradykinesia, and gait disturbance

Behavioral complications of Parkinson

Depression, anxiety, hallucinations/delusions, psychosis, compulsive/addictive behaviors, hypersexuality, passivity, apathy

Left 2nd or 3rd intercostal pulsation

Dilated pulmonary artery

Left 2nd or 3rd intercostal pulsations

Dilated pulmonary artery

Abrupt standing

Diminished VR and preload

Small, weak pulses

Diminished pulse pressure, pulse feels weak and small, upstroke may feel slower, peak prolonged - Decreased Stroke Volume (HF, hypovolemia, severe aortic stenosis) - Increased Peripheral Resistance (exposure to cold and severe HF)

Aphasia

Disorder in producing or understanding language

Tremor

Hyperkinetic Movement Clinical: Repetitive oscillation of a body part that occurs at rest or with action or postural holding; intention tremor is an action tremor that increases toward the end of the action Causes: Resting: Parkinson; Action or postural: physiological tremor, essential tremor, midbrain and cerebellar tremor, dystonic tremor; Intention: cerebellar outflow tremor caused by disorders of cerebellum

Tic

Hyperkinetic Movement Clinical: Stereotyped, automatic, purposeless movements and vocalizations Cause: Tourette, cerebral palsy and other developmental delay syndromes, autism, Huntington

Myoclonus

Hyperkinetic Movement Clinical: Sudden, shock-like movements of an isolated body part Causes: Physiologic myoclonus, essential myoclonus, metabolic encephalopathy, postanoxic myoclonus, and progressive myoclonic epilepsy

Dystonia

Hyperkinetic Movement Clinical: Torsional movements that are partially sustained and produce twisting postures Causes: Idiopathic or primary dystonia, dopa-responsive dystonia, anoxic/hypoxic injury, trauma, postencephalitic dystonia, and drug-induced acute or tardive dystonia

Chorea

Hyperkinetic movement Random, quick, unsustained, purposeless movements that have an unpredictable flowing pattern Causes: Huntington disease, neuroacanthocytosis, postinfectious chorea, drug-induced chorea, vascular chorea, autoimmune chorea, chorea gravidarum

Brainstem, vertebral, or basilar artery branch stroke

Dysphagia, dysarthria, tongue/palate deviation and/or ataxia Crossed sensory/motor deficits

Aortic Regurgitation Murmur

Early diastolic High-pitched, blowing, decrescendo 2nd to 4th left interspace, radiation to apex Heard w/ diaphragm, pt sitting forward, exhaling Ejection sound may be present S3 and/or S4 if severe Apical pulse progressively stronger, wider, longer Increased pulse pressure, bounding, bisferiens pulse Midsystolic flow or Austin Flint murmur

Jugular venous pulse exam

Elevate head of bed Measure vertical height of blood column above level of sternal angle 3cm H2O above sternal angle or 5cm JVP Nl 2-4 gm Low pressure--reduced venous return High pressure--high filling pressure on right due to obstruction to venous emptying or right ventricular failure

Double impulse

Elevated end diastolic pressure Left ventricular hypertrophy, myocardial disease, non-compliant heart in any form of ischemia

Wide split varies with inspiration

Hypertrophic cardiomyopathy

Parkinsonism

Hypokinetic Movement Disorder Clinical: Akinesia/bradykinesia, rigidity, tremor at rest, postural instability, gait freezing, and flexion posture Cause: Parkinson disease, diffuse Lewy body disease, atypical neurodegenerative Parkinson-plus syndromes, hydrocephalus, vascular parkinsonism, neuroleptic-induced parkinsonism, Wilson disease, toxic effect of drugs

DTR scale

0 = absent 1+ = trace or seen only w/ reinforcement 2+ = normal 3+ = brisk 4+ = non-sustained clonus 5+ = sustained clonus

Mitral Valve Prolapse Murmur

Late systolic plateau Preceded by high-pitched apical click Responds to bedside maneuver while standing Sx: Palpitations, chest pain, rare syncope Findings: Normal carotid, jugular, precordial exam

Bulbocavernosus reflex

Anal sphincter contraction in response to squeezing glans penis or tugging on indwelling Foley catheter

qPolio, amyotrophic lateral sclerosis

Anterior horn cell Weakness and atrophy in segmental or focal pattern Fasciculations Normal sensations Decreased DTRs

Drug induced secondary Parkinsonism

Antipsychotics, antiemetics, metoclopramide, reserpine, lithium, tetrabenazine, or flunarizine Exposure hx

Sitting up and leaning forward

Aortic Regurg Pericardial sounds

S2 heart sound

Aortic and Pulmonic valves closing (A2 and P2) A2 is louder than P2 with wider radiation zone Louder at base Splitting normally present, increased w/ inspiration

Cardiac auscultation and surface anatomy

Aortic valve: 2nd right intercostal space Pulmonic valve: 2nd left intercostal space Mitral valvue: 4th and 5th left intercostal midclavicular line, also apex Tricuspid valve: 4th and 5th left intercostal space left lower sternal edge

PMI

Best seen in thin-chested pts Inside 5th intercostal mid clavicular point Palpated at 4th or 5th intercostal midclavicular line Single, brief systolic outward movement lasting < half of sytole

Retraction of chest wall

Biventricular hypertrophy or constrictive pericarditis

Cognitive complications of Parkinson

Bradyphrenia, confusion, dementia

Brainstem stroke

Brainstem Contralateral weakness and spasticity Cranial nerve deficits Increased DTRs

Heart click

Brief, high frequency sounds in systole, prominent at base, head best with diaphragm

Corneal blink reflex

CNV1 afferent CN VII efferent

Median nerve entrapment

Carpal tunnel syndrome Pain, numbness, and paresthesias over wrist, palm, thumb, and 2nd and 3rd fingers Difficulty with finger coordination Wasting of thenar eminence Weak grip

Pressure Overload Right Ventricular Impulse

Cause: Pulmonic stenosis, Pulmonary HTN Location: 3rd, 4th, or 5th interspaces, also subxiphoid Diameter: Not useful Amplitude: More forceful Duration: Sustained

Hyperkinetic Left Ventricular Impulse

Cause: anxiety, hyperthyroidism, severe anemia Location: Nl Diameter: ~2cm, though increased amplitude may make it seem larger Amplitude: More forceful tapping Duration: <2/3 systole

Huntington disease

Chorea, dystonia, psychiatric sx, dementia, ataxia Assoc w/ Parkinsonism

Familial amyotrophy-dementia-parkinsonism

Cognitive/behavioral change Extremity weakness, atrophy Rigidity, bradykinesia Assoc w/ Parkinsonism

Casts in urine

Composed of Tamm Horsfall glycoprotein matrix--secreted by epithelium of thick ascending limb of Henle Cells may be trapped Formed only w/in tubules = any cell is of renal parenchymal origin

Venous hum murmur

Continuous low pitched Heard above medial third of clavicles w/ radiation to 1st and 2nd interspaces Disappears w/ venous compression

PDA murmur

Continuous murmur Left 2nd interspace w/ radiation to left clavicle Loud, harsh, machine-like

Cremaster reflex

Contraction of cremaster muscle after stroking ipsilateral side of superior/inner thigh Absent w/: testicular torsion, UMN/LMN lesions, L1/2 spinal cord injury, ilioinguinal nerve injury

Abdominal reflex

Contraction of superficial abdominal muscles when lightly stroking abdomen Absence usu UMN lesion on absent side

Middle cerebral artery subcortical stroke

Contralateral face, arm, and leg weakness/sensory loss

Middle cerebral artery cortical stroke

Contralateral face, arm, and leg weakness/sensory loss Aphasia or neglect

Anterior cerebral artery stroke

Contralateral leg weakness

Posterior cerebral artery stroke

Contralateral visual field cut

DDx Acute Cough

Cough lasting <3 weeks Common cold or viral URI Lower respiratory tract infection--pertussis, M. pneumoniae, C. pneumoniae Bacterial sinusitis Rhinitis due to allergens or environment Asthma or COPD exacerbations Cardiogenic pulmonary edema Aspiration or foreign body Medication reaction PE

DDX Chronic cough

Cough lasting >6 weeks Upper airway cough syndrome Asthma GERD Eosinophilic bronchitis Bronchiectasis Medication rxn--ACEI Chronic bronchitis due to smoking

Midposition fixed pupils

Damage to midbrain

GERD

Ex: Recurrent, burning, substernal pain; radiating from epigastrium to throat; exacerbated by bending or lying down; relieved by antacids; may mimic angina ECG: nl CXR: nl

Friederich's sign

Exaggerated x wave or diastolic collapse of neck veins - Constrictive pericarditis

Forceful and Hyperdynamic PMI

Fast impulse w/ large amplitude that terminates quickly Volume work--exercise, hypermetabolic states, mitral/aortic regurg, VSD

Wernicke's aphasia

Fluent, rapid, effortless speech, good inflection and articulation, malformed/inverted words and meaningless sentences, impaired comprehension, posterior superior temporal lobe

Steppage gait

Foot drop assov w/ peripheral nerve disease Pts either drag feet or lift them high w/ knees flexed and bring them down with slap onto floor thus appearing to be walking upstairs Cannot walk on heels

NYHA Class I

Fxn: Pts w/ cardiac disease by w/o resulting limitation of physical activity Ordinary activity does not cause undue fatigue, palpitations, dyspnea, or anginal pain Objective: No objective evidence of cardiovasclar disease

NYHA Class III

Fxn: Pts w/ cardiac disease resulting in marked limitation of physical activity. Comfortable at rest. Less ordinary activity causes fatigue, palpitations, dyspnea, or anginal pain Objective: evidence of moderately severe CVD

NYHA Class II

Fxn: Pts w/ cardiac disease resulting in slight limitations of physical activity, Comfortable at rest, Ordinary physical activity results in fatigue, palpitations, dyspnea, or anginal pain Objective: Evidence of minimal cardiovascular disease

Laryngitis, laryngeal tumor, unilateral vocal cord paralysis

Hoarseness or whispered speech

Tricuspid Regurgitation Murmur

Holosystolic Blowing murmur Lower left sternal border, increased w/ inspiration Right ventricular dilation is common S3 sometimes audible along lower left sternal border JVP often elevated Large v waves in jugular vein

Mitral Regurgitation Murmur

Holosystolic Blowing murmur Radiates to left axilla S1 decreased, S3 when severe Left ventricular dilation common Sx: fatigue, SOB on exertion, palpitations Findings: laterally displaced apical impulse (vol overload)

Ventricular Septal Defect Murmur

Holosystolic Harsh murmur Lower left sternal border w/ radiation to right sternal border Sometimes with thrill

Cerebrovascular disease induced secondary Parkinsonism

Hx MRI showing stroke

Head trauma induced secondary Parkinsonism

Hx of head trauma Including pugilistic encephalopathy

Hepatocerebral degeneration induced secondary Parkinsonism

Hx of liver disease MRI changes in basal ganglia

Seizure disorder

Hx of seizure disorder may be present Findings: cyanosis, absence of pallor during episode, frothing at mouth, tongue biting, disorientation, postictal muscle aching or somnolence, age younger than 45, duration of unconsciousness >5 min Diaphoresis or nausea b/f event and postsyncopal orientation argue against seizure

Anaphylaxis

Hx: Allergen exposure PE: Urticaria, facial edema, wheezing

Myocardial infarction

Hx: Cardiovascular risk factors, chest pain, nausea, diaphoresis PE: S3 and/or S4, jugular venous distension, possible mitral regurgitant murmur, pulmonary crackles

Heart failure (acute)

Hx: Cardiovascular risk factors, paroxysmal nocturnal dyspnea PE: Jugular venous distension, S3, pulmonary crackles, possible murmur, edema

Hepatopulmonary syndrome

Hx: Cirrhosis, platypnea PE: Findings of chronic liver disease, nl pulm exam

Thyrotoxicosis

Hx: Heat intolerance, weight loss, nervousness PE: Possible goiter

Dyspnea eval for pulmonary causes

Hx: Hx of asthma, COPD, smoking; no know lung disease, but risk factors for pulmonary disease ROS: Wheezing, cough, current/past smoking hx, environmental exposures Assess med compliance, new exposure, timing of meds PE: Wheezing, increased AP diameter, distant heart souns, decreased breath sounds, prolong expiratory phase, drug lung crackles Dx studies: CXR, pulm fxn tests, High res CT

Pleural effusion/hemothorax

Hx: Hx of cancer, possible chest pain PE: Dullness to percussion, absent breath sounds

Dyspnea eval for cardiac causes

Hx: Hx of cardiac disease (CHF, ischemic cardiomyopathy, valvulopathy); no known heart disease, but risk factors for CVD ROS: exertional sx, chest pain, paroxysmal nocturnal dyspnea, orthopnea, asses diet and med compliance PE: JVD, hepatojugular reflex, lung crackles, cardiac S3, peripheral edema Dx studies: ECG, stress test if ischemic diesease suspected

Aortic stenosis

Hx: Hx of heart murmur, chest pain, syncope, dyspnea; hx of rheumatic fever; hx of aortic coarctation PE: Crescendo-decrescendo systolic murmur at right upper sternal border cardiac base w/ radiation to carotid arteries

Mitral regurgitation

Hx: Hx of heart murmur, mitral valve prolapse, or MI PE: Holosystolic murmur at cardiac base

Chronic constrictive pericarditis

Hx: Hx of pericarditis, possible chest pain PE: elevated jugular venous pressure, clear lungs, edema, tricuspid regurg, pulsatile liver

Mitral stenosis

Hx: Hx of rheumatic fever, heart murmur PE: Opening snap followed by diastolic murmur w/ presystolic accentuation

Dyspnea eval for neck thyroid cause

Hx: Hx of thyroid disease ROS: Weight loss, palpitations, diarrhea PE: Goiter, thyroid bruit Dx studies: Thyroid fxn testing

Vocal cord paralysis

Hx: Hx of thyroid or neck surgery PE: Single frequency wheezing localized to throat, dysphonia

Dysphonia

Impairment in volume, quality, or pitch of voice

Laryngectomy

Inability to produce vocal sound

Lesion in dominant hemisphere

Inability to use words symbolically

Bisferiens Pulse

Increased arterial pulse w/ double systolic peak - Pure aortic regurg, combined aortic stenosis and regurg, hypertrophic cardiomyopathy

Right sided murmur maneuvers

Increased intensity with inspiration

Spasticity

Increased muscle tone that is rate-dependent Tone is greater when passive movement is rapid and less when passive movement is slow Tone is also greater at extremes of movement arc--clasp-knife resistance Stroke--late stage, UMN lesion

Rigidity

Increased resistance that is rate-independent and persists throughout movement Parkinsonism Basal ganglia lesion

Isometric handgrip

Increases peripheral resistance and BP Left heart regurgitant murmurs intensify

Right 2nd intercostal pulsation

Indicates aneurysm of ascending aorta

Large reactive pupils

Ingestion of cocaine, amphetamine, or LSD

Cerebrovascular disease

Invariably assoc w/ neuro signs and sx Carotid Doppler US not indicated b/c ischemia of anterior cerebral circulation rarely causes syncope

Spinal cord lesion

Ipsilateral loss of touch, vibration, proprioception, and weakness Contralateral loss of pain and temp UMN signs below lesion LMN sings at lesion Possible: Brown-sequard, syringomyelia, tabes dorsalis, transverse myelitis, subacute combined degeneration

Cannon a wave

Large positive venous pulse during a wave; when atrium contracts against closed tricuspid valve during AV dissociation - Premature atrial/junctional/ventricular beats - Complete AV block - Vtach

S1 heart sound

Mitral and Tricuspid valves closing (M1 and T1) Just after QRS complex and nearly synchronous w/ upstroke of carotid pulse and apical impulse Usually louder at apex than base Some splitting may be evident -Increased S1: thin chest, hyperdynamic state, mitral stenosis -Decreased S1: thick chest wall, emphysema, poor left ventricular function Early mitral valve closure (1st degree AV block, AR)

Muscular dystrophy

Muscle Proximal weakness Normal sensation Normal or decreased DTRs

Wilson disease

Must be r/o in pts aged <50 Hepatic and psychiatric disease Tremor, dystonia, ataxia Assoc w/ Parkinsonism

Pinpoint pupils

Narcotic overdose

Parkinsonism, cerebellar disease, disorders of CN V, VII, IX, X, or XII

Nasal, slurred, or indistinct words Symbolic aspect of language intact

Kussmaul's sign

Neck veins rise in inspiration, rather than fall - Constrictive pericarditis - Pericardial tamponade - Right heart failure (acute R ventricular MI)

Mysasthenia gravis

Neuromuscular junction Muscle fatigability Normal sensation Normal DTRs

Right Ventricular Impuse

Not normally palpable beyond infancy Characteristics are indeterminate

Basilar artery stroke

Oculomotor deficits and/or ataxia Crossed sensory/motor deficits

Increased P2

P2 louder than A2 at pulmonic region Due to Pulmonary HTN, ASD R/o causes for decreased A2--mitral regurg, aortic regurg, low diastolic arterial pressure, severe immobile aortic valve disease

Paradoxical splitting

P2 precedes A2 Splitting decreases during inspiration Delayed aortic valve closure--LBBB, pre-excitation RV, RV pacing, premature RV beats Aortic stenosis

Pupillary control

PNS: Pupillary constriction, Edinger Westphal nucleus--> CNIII travel--> ciliary ganglion--> sphincter pupillae muscle constricts SNS: Pupillary dilation; cortex in ciliospinal center--> travel through brainstem to spinal cord and exit through cervical sympathetic chain--> synapse at superior cervical ganglion--> travel through carotid plexus to orbit through CNV1--> dilator pupillae muscle dilates

Femoral nerve entrapment

Pain, numbness, and paresethesias of the medial thigh and anteromedial calf Weakness of quadriceps muscle (knee extension) Difficulty walking up and down stair, esp down Feeling knee give way Decreased patellar reflex

Ulnar nerve entrapment

Pain, numbness, and paresthesias in 4th and 5th fingers on palm side Weak grip Difficulty with finger coordination Muscle wasting

Radial nerve entrapment

Pain, numbness, and paresthesias of forearm, thumb side of dorsal hand, 2nd and 3rd fingers Difficulty extending elbow Difficulty extending wrist

Common peroneal nerve entrapment

Pain, numbness, and paresthesias over dorsal foot and lateral leg Slapping gain Foot drop Toes dragging while walking

Axillary nerve entrapment

Pain, numbness, and paresthesias over outer shoulder Shoulder weakness Difficulty lifting objects Difficulty lifting arm above the head

Sciatic nerve entrapment

Pain, numbness, and paresthesias ranging from lower back and upper buttock to back of the thigh and leg Decreased ankle reflex

Romberg test

Positive test seen in sensory ataxia Peripheral polyneuropathy or posterior column damage

Autonomic complications of Parkinson

Postural hypoTN, bladder and sexual dysfunction, constipation, sialorrhea, seborrhea, excessive sweating

Renal tubular epithelial casts

Produced by desquamation of eptihtelial cells assoc w/ acute tubular necrosis, proliferative glomerulonephritis, interstitial nephritis Broad, muddy brown casts = ATN Hyaline casts from Tamm-Horsfall glycoprotein increased in concentrated specimens Granular hyaline casts contain filtered proteins in pts w/ albuminuria or proteinuria Degenerated cellular casts--> granular--> waxy

Nephrotic Syndrome

Proteinuria: Usu >3.5 g/g Sediment: Bland, hyaline casts, lipiduria Clinical: hypoalbuminemia, hyperlipidemia, edema, hypercoagulability Glomerular path: Noninflammatory: Dysproteinemia: amyloidosis and multiple myeloma; diabetic nephropathy, minimal change disease, FSGS, Membranous, amyloid

Nephritic Syndrome

Proteinuria: variable, usu <3.5 g/g Sediment: Active, dysmorphic RBCs, RBC casts, Granular casts Clinical: HTN, oliguria, elevated serum creatinine, may have renal-dermal syndromes: SLE, Henoch-Schonlein purpura, ANCA-assoc vasculitis, cryoglobulinemia; low complement concentrations suggest lupus nephritis, postinfectious and membranoproliferative glomerulonephritis and mixed cryoglobulinemia Glomerular Path: inflammatory: Diffuse proliferative GN, Membranoproliferative GN, IgA nephropathy, Crecentic GN/RPGN

Horner's syndrome

Ptosis, miosis, anhydrosis Disruption of SNS to head

Large, Bounding Pulses

Pulse pressure increased; pulse feels strong and bounding; rise and fall may feel rapid, peak brief - Increased SV and/or decreased PR as in fever, anemia, hyperthyroidism, aortic regurg, AV fistulas, PDAs - Increased SV due to slow heart rates (bradycardia, complete heart block) - Decreased compliance of aortic walls (Aging, atherosclerosis)

Argyll Robertson pupil

Pupils will NOT constrict to light but WILL constrict to accommodation Hallmark of tertiary syphillis

UA specific gravity

Quantifies density Nl 1.003-1.035 Hyposthenuria--persistently low SG <1.007--loss of concentrating ability High urine SG may reflect appropriate response to water loss or dehydration or may indicated pathology of fluid retention Isosthenuria--excretion of fluid w/ fixed SG 1.010 regardless of hydration--Usu accompanies severe kidney damage

Paraneoplastic induced secondary Parkinsonism

Rapidly progressive Signs/sx of ataxia, encephalopathy, myoclonus

Hypothyroidism induced secondary Parkinsonism

Rare Resolves w/o tx

Anal wink reflex

Reflexive contraction of external anal sphincter upon stroking skin around anus Afferent - pudendal nerve Efferent - S2-4

DTRs

S1/2 = ankle/achilles L3/4 = patellar C5/6 = biceps and brachioradilis C7/8 = triceps

Left lateral decubitus

S3 S4 Mitral stenosis

Creutzfeldt-Jakob disease

Secondary Parkinsonism Rapidly progressive Signs/sx of ataxia, dementia, myoclonus, dystonia

Lateral displacement of PMI

Seen in enlarged heart, pleural effusion, right tension pneumothorax, left pulm fibrosis

Epigastric and subxiphoid movememnts

Seen w/ right ventricular hypertrophy, right ventricular dilation, AAA Nl in emphysema, children, scaphoid abdomen, very thin pts

UA blood analysis

Sensitive to intact erythrocytes, but will also yield positive for blood in hemoglobinuria or myoglobiuria >3 erythrocytes/HPF reported for positive, seek evidence of hemolysis or rhabdo

Large fixed pupils

Severe anoxia following cardiac arrest Overdose of TCA

Sleep related complications of Parkinson

Sleep fragmentation, restless leg syndrome, rapid eye movement behavior disorder, excessive daytime sleepiness, sleep-wake reversal, drug-induced sleep attacks

S4 heart sound

Soft low pitched sound just before S1, related to atrial systole Suggests decreased ventricular compliance caused by pressure overload, HTN, myocardial ischemia, aortic stenosis, hypertrophic cardiomyopathy Left sided: heart best at apex in left lateral position ("Tennessee") Right sided: heard along lower left sternal border or below xiphoid; often louder w/ inspiration Causes: atrial contraction generated in ventricle

Spinal cord trauma

Spinal cord Bilateral weakness and spasticity with sensory level Increased DTRs

Scissors gait

Spinal cord disease Gait is stiff Pts advance each leg slowly and the thighs tend to cross forward on each other at each step Steps are short Pts appear to be walking through water

Herniated disc

Spinal roots and nerves Weakness and atrophy in root-innervated distribution, sometimes with fasciculations Corresponding dermatomal sensory deficit Decreased DTRs

Wide splitting

Splitting during expiration, wider during inspiration Anything causing delayed conduction down R bundle--RBBB, pre-excitation of left ventricle, pacing of left ventricle, premature LV beats, pulmonary stenosis or pulmonary arterial HTN

Mitral Valve Prolapse maneuvers

Squatting delays click and murmur Standing moves them closer to S1

Spastic hemiparesis

Stroke assoc w/ corticospinal tract lesions Affected arm is flexed, immobile, and held close to side w/ elbows, wrists, and IP joints flexed Affected leg extensors spastic Ankle plantar-flexed and inverted Pts may frag toe, circle leg stiffly outward and forward or lean trunk to contralateral side to clear affected leg during walking

Paratonia

Sudden change in tone w/ passive ROM increase or decrease Dementia, bilateral hemispheric lesion

Forceful and Sustained PMI

Sustained throughout systole Pressure work--left ventricular hypertrophy, outflow obstruction, cardiac heart failure w/ reduced EF

Myocardial Infarction

Sx: Acute, severe, persistent, substernal, crushing pain; radiation to jaw or arm; S4 gallop; sometimes late systolic murmur; possible hypoTN; elevated troponin ECG: Local ST elevation or depression CXR: Possible vascular congestion or cardiomegaly

Esophagitis

Sx: Burning-type chest discomfort usu precipitated by meals and not related to exertion; often worse lying down, improved sitting ECG: nl CXR: nl

Aortic Stenosis

Sx: Chest pain w/ exertion, heart failure, syncope; typical systolic murmur at base of heart radiating to neck

Pericarditis

Sx: Constant or intermittent sharp (or dull or pressure), pleuritic pain; radiation along trapezius ridge; often aggravated by inspiration. swallowing, or supine position; relieved by sitting forward Pericardial friction rub ECG: Diffuse ST- segment elevation; PR-segment depression CXR: Possible enlarge silhouette

Acute Coronary Syndrome: Unstable angina, NSTEMI, STEMI

Sx: Frequent, by not always exertional chest pain; often not sharp or positional and radiates to both arms; not easily reproducible; possible S3 and elevated cardiac enzymes ECG: Dependent on type CXR: NL?

Pulmonary Artery Hypertension

Sx: Gradual onset; dyspnea, fatigue, edema ECG: Tall right precordial waves, right axis deviation, RV strain CXR: Prominent pulmonary arteries

Muscuoloskeletal (Muscle strain, costochondritis, fx)

Sx: Insidious onset; persistent, lasting hours to weeks; worsened by cough or deep breathing; diffuse focal tenderness; typically more reproducible; usu dx of exclusion

Esophageal Rupture

Sx: Intense retrosternal pain after vomiting/retching; often assoc w/ EtOH use; followed by rapid development of odynophagia, tachypnea, dyspnea, cyanosis, fever shock CXR: Pseudomediastinum

Posterior tibial nerve entrapment

Tarsal tunnel syndrome Pain, numbness, and paresthesia over the plantar surface of the foot

Brachial plexus entrapment and/or subclavian artery or vein

Thoracic outlet syndrome Pain, numbness, and paresthesias along ulnar aspect of forearm, hand, and 4th and 5th finger Swelling and pain in arm Episodic cramping of the hand, esp w/ arm elevation

Musculoskeletal complications of Parkinson

Truncal and neck flexion, falls and fractures, arthritis and other mechanical complications

Valsalva maneuver

Venous return to right heart transiently reduced, left falls after several beats Increases hypertrophic cardiomyopathy murmur All others decrease (mitral valve prolapse also increases?)

Elevated v wave

Ventricle contracts and tricuspid valve does not close well --> jet of blood shoots into R atrium - Tricuspid regurg: accompanied by pulsatile liver, pansystolic murmur increasing w/ inspiration

Thrills

Vibrations Grade intensity of mumurs Seen with loud murmurs (4/6)

Double Impulse

Visible over apical region in hypertrophic cardiomyopathy Second impulse from filling of enlarged ventricle in diastole

Midbrain lesion

Weakness, increased tone, hyperreflexia, and Babinski sign of contralateral body Weakness of contralateral lower half of face Eye looking down and out (CN III) on ipsilateral side

Pontine lesion

Weakness, increased tone, hyperreflexia, and Babinskin sign of contralateral body Weakness of ipsilateral half of face (CN VII) Horizontal gaze palsy when looking toward lesion (PPRF damage)

Fixed splitting

Widely split S2, not affected by respiration Suggests ASD Also Right HF or PulmHTN

Vasovagal syncope

Younger pts w/ presyncopal sx (lightheadedness, nausea, warmth, diaphoresis, blurred vision) Common triggers include micturition, defecation, cough, fear, pain, phlebotomy, prolonged standing

Jugular venous waveform

a wave - atrial contraction c wave - ventricular contraction (tricuspid bulges) x descent - atrial relaxation v wave - atrial venous filling y descent - ventricular filling

Opening snap

brief high-pitched diastolic sound; just after A2, but earler than S3 During initial downward movement of mitral valve just as valve begins to open Radiate to apex and pulmonic area of loud Best heard with diaphragm just medial to apex along lower left sternal border Cause: Mitral stenosis