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