Signs of severity - AS
Peripheral - slow rising pulse, low volume carotid pulse - left heart failure - small pulse pressure Praecordium - pressure loaded apex beat. - aortic thrill - harsh late peaking ESM radiating to carotids - soft S2 - paradoxical splitting Investigations - LBBB, LVH, LV strain
Signs of severity - MS
Peripheral - mitral facies - small pulse pressure - prominent A wave Praecordium - tapping apex beat - soft S1 with early opening snap and long diastolic murmur - pulm HTN (loud P2, RV heave, TR) Investigations - atrial fibrillation, p mitrale
Signs of severity - MR
Peripheral - small volume pulse Praecordium - displaced apex beat - pansystolic murmur extending into diastole - soft S1, S3 present - Left ventricular failure / pulm HTN Investigations - atrial fibrillation - LV enlargement, left axis deviation, LA dilatation
Effect of valsalva and handgrip on murmurs
Valsalva - decreases preload
- AS softer
- HOCM louder, MVP click and murmur earlier
Handgrip - increases afterload
- AS, HOCM softer
- MR, AR louder
Signs of severity - AR
Peripheral - collapsing pulse, wide pulse pressure - bounding carotid pulse Praecordium - LV failure, displaced apex beat - Long diastolic decrescendo murmur +/- austin flint in left parasternal border - S3, Soft S2 Investigations - Aortic root dilatation - Dilated LV
Signs of severity - TR
Peripheral - Large V waves - Pulsatile liver +/- hepatopathy (jaundice) - Oedema Praecordium - RV heave, loud P2 - Pansystolic murmur louder on inspiration Investigations - RV dilatation - LFT derangement
Causes of ILD
Upper lobes
- Sarcoidosis / silicosis
- Coal pneumoconiosis
- Hypersensitivity pneumonitis
- Ankylosing spondylitis
- Radiation
- Tuberculosis
Lower lobes
- Rheumatoid arthritis
- Asbestosis
- Scleroderma
- Cryptogenic (IPF)
- Other (drug - amiodarone, mtx, bleomycin)
Causes of hepatomegaly
Cardiovascular - RHF Hepatic - NAFLD / alcoholic hepatitis - Viral hepatitis / DILI - Infiltrative (iron/amyloid/sarcoid) - Metastases or HCC - Cystic liver (ADPCKD) Haematological - Myeloproliferative disease - Lymphoma
Causes of splenomegaly
Portal hypertension - LHF / pulmonary hypertension / RHF - Cirrhosis - Portal vein thrombosis Haematological - CML, lymphoma, myelofibrosis - Thalassaemia - Haemolytic anaemia Infiltrative (amyloid or sarcoid) Infection (EBV/CMV) CTD (vasculitis, rheumatoid arthritis)
Features in Cushing Syndrome
Investigations?
Inspection - central obesity, bruising, poor wound healing
Peripheries - proximal myopathy, moon face, buffalo hump, acanthosis nigricans
Always check visual fields! (pituitary adenoma)
Hypertension
Steroid induced diabetes
Ix:
- Dexamethasone suppression test
- ACTH level
Features in Acromegaly
Investigations?
Treatment?
Features of active disease: - Sweating, skin tags, - Hyperglycaemia, hypertension - Organomegaly, hearing loss, CN palsies Check visual fields
Investigations
- IGF-1, glucose tolerance
- MRI pituitary
Treatment
- Adenoma resection
- Octreotide, pegovisant
X-ray findings in: Osteoarthritis Rheumatoid arthritis Gout Psoriatic arthritis Scleroderma SLE
OA: irregular joint space narrowing, osteophytes, subchondral sclerosis, gull wing
RA: regular joint space narrowing, juxta-articular osteopaenia and erosions, DIP sparing
Gout: lytic moth eaten lesions, marginal erosions, tophi
PsA: marginal erosions, pencil in cup deformities preferentially interphalangeal joints
Ssc: acro-osteolysis, erosions, calcinosis
SLE: non-erosive deformity
Causes of Horner’s Syndrome
Brainstem
- lateral medullary syndrome
- syringomyelia –> syringobulbia
- space occupying lesion
Preganglionic
- pancoast tumour (UL weakness)
- thyroid mass
Postganglionic
- carotid aneurysm
- carotid dissection
Higher Centres 4 lobes
Frontal
- proverb interpretation (concrete thinking)
- grasp/pout/palmomental
- gait (magnetic)
Parietal Dominant: - acalculia, agraphia, LR disorientation, finger agnosia - expressive/receptive dysphasia - agraphaesthesia, two point discrimination loss Nondominant: - dressing apraxia Both - sensory inattention
Temporal
- memory: short and long term
Occipital
- visual inattention
Causes of foot drop
- common peroneal nerve palsy (inversion/ankle reflex intact)
- sciatic nerve palsy (ankle reflex missing)
- L5 radiculopathy (inversion weakness)
- peripheral motor neuropathy (usually bilateral, stocking sensory loss)
- myopathy
- stroke (expect UMN signs)
Causes of myopathy
Hereditary/congenital
Acquired
- Polymyositis/dermatomyositis
- Alcohol
- Cancer / paraneoplastic
- Endocrine (cushings, hypothyroidism, acromegaly)
- Periodic paralysis
- Osteomalacia
- Drugs - steroid
- Sarcoid
Sarcoidosis
P: acute (lofgrens) vs subacute. Cough and systemic symptoms. Coincidental hilar adenopathy on imaging. Systemic sx: skin, eyes, peripheral neuropathy, cardiac, hypercalcaemia, lymphadenopathy
R: family history, non smoker
I: CXR, bloods - ACE, WCC (hypercalcaemia - check calcitriol), CT, biopsy required to confirm diagnosis. Spirometry
C: pulmonary, cardiac, renal, neurological dysfunction. Hypercalcaemia. Skin lesions.
M: If asymptomatic, ongoing surveillance 1st: prednisolone Steroid sparing: MTX, AZA Consider biologic
C/P: steroid side effects. End organ dysfunction and consideration of transplant.
Cystic Fibrosis
P: Often diagnosed at birth screening.
