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in Short Cases
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Books IN HEALTH STUDIES SERIES
UNIVERSITY OF MALAYA PRESS
Hospital Management
Hematram Yadav
Practical Aspects of Acute Care
Chan Yoo Kuen, Ng Kwee Peng (editors)
Ear, Nose, Throat Colour Atlas Sypnopsis
Rahmat Omar, Prepageran Narayanan, Raman Rajagopalan
Basic Practical Peri-Anaesthesia
A. E. De/illean
Making Neurological Diagnosis at the Bedside
Chew Nee Kong
Notes on Family Health
Hematram Yadav
Erectile Dysfunction Multicultural Perspectives in Malaysia
Low Wah Yun, Siti Norazah ZUlkifli, Wong Yut Lin, Tan Hui Meng
Film Reporting for the Postgraduate Radiology Examination
Gnana Kumar, Basri ]ohan feet Abdullah & Fatimah Moosa
Emergencies ENT
Gopala Krishnan, Mohd Amin ]alaludin & Prepageran Narayanan
Physiological Basis for Explaining the Signs and Symptoms of
Endocrine Disorders
Lam Sau Kuen & Raji Subramanian
Seksualiti dan Kecederaan Saraf Tunjang
Tunku Nor Taayah Tunku Zubir & Low Wah Yun
Essential E.N.T
Prepageran Narayanan
Health Economics Issues in Malaysia
Syed Mohamed Al ]unid & Nabila Al-Sadat Abdul Mohsein (edsJ
Drugs of Abuse
Mustafa Ali Mohd, Mohamad Hussain Habil & Zahurin Mohamed
Health: Bridging the Gaps
Roziah Omar
Mental Health in Malaysia: Issues and Concerns
Edited by Amber Haque
X'PRESS
Revison
in Short Cases
Aids to undergraduate Medicine
Author
Chew Nee Kong
Lecturer/Consultant (Neurology)
MBBS (Malaya), MRCP (UK)
Department of Medicine
University of Malaya
Kuala Lumpur
Co-Author
Lim Kheng Seang
Clinical Specialist
Neurology Unit
MBBS (Malaya), MRCP (UK)
Department of Medicine
University of Malaya
Kuala Lumpur
Published by
University of Malaya Press
50603 Kuala Lumpur
Malaysia
http://umpress.um.edu.my
A Founding Member of Malaysian Book Publishers Association
(Founded in 1969) .
Membership No: 196906
Printed by
University of Malaya Press
50603 Kuala Lumpur
This book is specially dedicated to
my mother, Mdm. Lee Mau Nol, who has taught me what true love
is all about
v
~ARTI S
VI
CONTENTS
Foreword xi
Preface xiii
Acknowledgements xv
Memoir of Tan Sri Professor 1J Danaraj xvii
List of Contributors xix
How to use this book xx
SECTION 1 1
Chapter 1 Neurology 2
Case 1 Bifacial weakness 2
Guillain-Barre syndrome 2
Myasthenia gravis 2
Facioscapulohumeral dystrophy 3
Dystrophia myotonica 3
Case 2 Ophthalmoplegia 8
Ptosis 8
Diplopia 10
Case 3 Parkinsonism 11
Case 4 Cerebellar syndrome 14
CaseS Unilateral facial weakness 15
Case 6 Speech disorders 19
Case 7 Dysphasia 20
Case 8 Myelopathy 23
Multiple sclerosis 24
Case 9 Wasting of small muscles of the hand 26
Case 10 Tremor 28
Case 11 Pseudobulbar / bulbar palsy 29
Case 12 Proximal muscle weakness 30
Case 13 Stroke 33
vii
Case 18 Hypopituitarism 51
Case 19 Hypothyroidism 54
Chapter 3 Dermatology 57
Case 20 Erythema Multiforme, Stevens-Johnson syndrome and
Toxic Epidermal Necrolysis 58
Case 21 Pemphigoid / Pemphigus 59
Case 22 Neurofibromatosis 60
Case 23 Psoriasis / Psoriatic arthritis 63
SECTION 3 99
Chapter 4 Hematology 100
Case 24 Beta-Thalassemia major 100
Case 25 Lymphadenopathy 103
Case 26 Deep vein thrombosis 106
Case 27 Anemia 108
Case 28 Easy bruising 111
viii
Chapter 8 Infectious Disease 153
Case 46 Human immunodeficiency virus (HN) infection 154
References 197
Index 201
ix
FOREWORD
xi
PREFACE
All the illustrations in this book are taken from the original collection
of the authors and contribu·tors. Every patient, when recognizable
on his or her photographs, has given written permission for this
publication.
"I'm on my way to
SHAKE THE
WORLD!"
xiii
ACKNOWLEDGEMENTS
First and foremost, I would like to Dr Lim Kheng Seang for his kind
assistance in helping me to write this book.
xv
MEMOIR OF TAN SRI DATUK
PROFESSOR EMERITUS
TJ DANARAJ
"If you met a patient at the Emergency Room, who complained ofsevere chest
pain that was not relieved by two doses of IV Morphine, always consider the
possibility of dissecting aneunJsm of the aorta".
Those were his very own words that I have always remembered
since the memorable lecture back in 1991. I was a Final Year Medical
Student then. Being fresh and naIve, all of us were always very anxious
whenever a very senior Professor walked into the lecture hall,
especially when the Professor never smiled at us. We were worried
about giving stupid answers to his relentless questions. But gradually,
our fears subsided when he showed us the "fatherly" figure in him.
As he went through many, many interesting slides with us, we started
to enjoy his lectures.
He passed away on the 19th March 1996, at the age of 82. Despite this,
his presence has continued to be felt by all of us in the Faculty of
Medicine till today. Many medical students who have graduated from
this faculty have been inspired by this great man, and eventually
became excellent and prominent clinicians in the country.
xvii
He was Tan Sri Datuk Professor Emeritus Thamboo John Danaraj,
the founder of the Faculty of Medicine, University of Malaya. He
was the man who started it all, and made us as what we are today. I
am sure that God has blessed him with happiness and peace in
heaven.
The most important lesson that I learnt as a former medical student ill the
Faculty of Medicine, University of Malaya (1986-1991), is the very fact that
teaching Medicine is merely a secondary objective of academic staff; their
primary duty is to become the role models for all the medical students.
And that was exactly what Tan Sri Datuk Professor Emeritus Thamboo John
Danaraj had achieved.
xviii
·LIST OF CONTRIBUTORS
Department of Medicine (University of Malaya)
Professor Wan Azman Wan Ahmad MBBS (Mal), FRCP (Glas) / Professor
Dato' Goh Khean Lee KSD, DPMP, MBBS (Mal), MD (Mal), FRCP (Glas),
FACG, FAMM / Dr Chua Chin Jou MBBS (Mal), MMed (UM) / Dr Chee Kok
Han MBBS (Mal), MRCP (UK) / Dr Chong Wee Peng MBBS (Mal), MRCP
(UK) / Dr Imran Zainal Abidin MBBS (Mal), M.Med (UM) / Professor Liam
Chong Kin MBBS (Mal), FRCP (Lon) / Assoc Professor Alan Teh MBBS,
MRCP (UK) / Dr Gan Gin Gin MBBS (Aust), MRCP (UK) / Dr Loo Liew
Chean MBChB, MRCP (UK), DipDerm / Professor Tan Chong Tin MBBS
(Mel), FRCP, MD (Mal) / Assoc Professor Goh Khean Jin MBBS (Spore),
FRCP (Glas) / Professor Adeeba Kamarulzaman MBBS (Mon), FRACP / Dr
Tan Lian Huat MD (UKM), MMed (UM) / Professor Chan Siew Pheng MBBS
(Mal), FRCP (Edin) / Professor Rokiah Pendek MBBCh BAO (Ire), MRCP
(UK) / Dr Shireene Vethakkan MBBS (Mal), M.Med (UKM) / Professor Tan
Si YenMBChB (Edin),MD (Edin),FRCP (Edin),AM(Mal) / DrGan WeeHin
MBBS, MRCP (UK) / Dr Raveendran Ramachandran MBBS (Mal), MRCP
(UK),AM
Dr Ahmad Fauzi Md. Sharif MBBS (Mal), M.Opht (Mal) / Dr SMS Sendhil
Kumar MBBS (Karnataka) / Dr Norlina Ramli MBBS (Newcastle), MROpht
(Lon) / Faizah Othman (MLT)
Assoc Professor Gnana Kumar MBBS, MMed (Rad), FRCR / Assoc Professor
Norlisah Ramli MBBS (Mal), FRCR (Lon) / Dr Joazlina Zaleha Yusof MBBS
/ Nevehtha Kunaratanam Ultrasonographer (MLT)
xix
HOW TO USE THIS BOOK
~ Early starters (> one month before the exam) - read all 60 cases
Mm Late starters - read only the cases rated ....... and .......
mm Opportunists - quick revision on the day before the exam, read the
boxes: [l]
Cases (Paj1;e) Ratinj1; Cases (Paj1;e) Ratinj1;
1) Neurology
Bifacial weakness (2)
*
Interstitial lung disease (122)
Bronchiectasis (123) **
Ophthalmoplegia (8)
Parkinsonism (11) **
***
Pleural effusion (124)
6) Rheumatology ***
Cerebellar syndrome (14)
*** Rheumatoid arthritis (126)
***
Unilateral facial weakness (15)
Speech disorders / dysphasia (19) **
*
Ankylosing spondylitis (130)
Dermato- / Polymyositis (133) **
Myelopathy (23)
*** Scleroderma (134)
*
Wasting of small muscles of the
hands (26) * Systemic lupus erythematosus
(137) **
Tremor (28)
*** 7) Gastroenterology
Pseudobulbar / bulbar palsy (29)
Proximal muscle weakness (30)
*** Hepatomegaly (142)
Splenomegaly (143) ***
***
Stroke (33)
** Chronic liver disease (144)
***
2) Endocrinology
Acromegaly (38)
**
Abdominal masses (147)
Jaundice (48) **
***
Thyrotoxicosis (41)
*** Ascites (50)
**
Cushinj1;'s syndrome (44)
*** 8) Infectious Disease
Marfan's syndrome (48)
Hypopituitarism (51)
Hypothyroidism (54) ***
HIV infection (154)
9) Cardiology **
3) Dermatology
Eisenmenj1;er's syndrome (63)
Infective endocarditis (64) *
**
Erythema multiforme / Stevens-
Johnson syndrome / Toxic * Cardiac murmur (68)
***'
epidermal necrolysis (58)
Pemphij1;us / Pemphij1;oid (59)
Neurofibromatosis (60) ** Hypertension (73)
Atrial fibrillation (75) *
**
Psoriasis / Psoriatic arthritis (63)
4) Hematology ** Angina (77)
Acute myocardial infarction (179) **
**
Thalassemia major (00)
Lymphadenopathy (103) *** Prosthetic heart valves (80)
***
Deep vein thrombosis (06) **
**
10) Nephrology
Chronic renal failure (84)
***
Anemia (08)
*** Polycystic kidney disease (187)
*
Easy bruisinj1; (11)
5) Respiratory system * 11) Fundoscopy
Diabetic retinopathy (92) ***,
Asthma (16)
*** Hypertensive retinopathy (94)
*
Chronic obstructive airway disease
(17) *** Optic neuritis / Papilledema (195)
***
Bronchogenic carcinoma (19)
** Optic atrophy (196)
*
xx
..-
..o
c
SECTIONl -o
=
.
o
CHAPTER 1 - NEUROLOGY
-..
::
NEUROLOGY
• if you saw a patient with reduced facial expression, consider the following:
a) extrapyramidal disorder (parkinsonism) - tremor, good eye contact.
*
b) psydlogeflic disorder (depression) no tremor, poor eye contact
4
-.•
o
o
Family
history
Ptosis/
syndrome
absent
absent
absent
present
autosomal
dominant
present
autosomal dominant
absent
•c: ocular palsy
Umb proximal proximal distal shoulder girdle
weakness or distal bilateral scapular
~
~ winging
•c: Reflexes absent normal or reduced or normal
lI: brisk absent
•• Fatigability absent present absent absent
••
- Guilla ill· Barre sylldrome
•
-o
.•-.
•
• acute demyelinating peripheral neuropathy.
• autoimmune-mediated (post-infectious etiology - C. jejllm).
• predominantly motor deficits (mild or absent sensory signs).
• investigations:
- cerebrospinal fluid (t protein, normal white.cell count).
- nerve conduction study (J. conduction velocity).
• treatment· plasma exchange (PE), IV immunoglobulin (IVIG).
Myasthenia gravis
•
• autoimmune-mediated neuromuscular jW1Ction
GBSand VIP!
~
MG are
disorder. important
• preferentially involves the ocular, facial and bulbar causes of
muscles. acute
• associated disorders - diabetes mellitus, thyroto- neuromuscular
xicosis, thymic hyperplasia (65%) and thymoma respiratory failure
(15%). l'======'J
2
• investigations:
Edrophonium (Tensilon) test V1P~
Ach receptor antibody
Rept"titive nerve stimulation test (decremental response) Commonest
Blood glucose, thyrOid function causes of
Anti-striated muscle antibody (marker for thymoma) bifacial
cr thorax (thymic mass) weakness in
exam - MG
• treatment: and GBS
- symptomatic - anticholinesterase inhibitors.
-specific - steroid, thymectomy, PE, IVIG (the latter two for myastheruc CriSIS).
Facioscapulol11/Jlteral dl/strOplly (FSHD).
STEP2 Eyes -
no ptosis / ocular palsy ptosis / ocular palsy
normal
(absent) ( normal / bris~) J,. / absent
(+ winged (+ fatigability) (+ myotonia,
scapula) facial features)
( Guillain-Barre
syndrome Facioscapulo- ( Mya~thenia
-:nspect the
humeral
dystrophy
gravIs J Dystrophia
myotonica
<apular area.
Honest dISagr.... ment IS often a good sIgn of progr..... - Mahatma Gandhi
3
DYSTROPHIA mYOTOnlOA
Face Eyes
Froll/al bllldi'!3 _ Cataract
Waslingof Diabetic retinopathy
Umporn/is _ -
Bi/attral ptosis._
Bifncinl il't"OkntsS
Wasting of
1
mas~t('r __ NKk
:; Elongaftd!lIct- - Wasting of
-.•
o
o
Pouting /ot«r lip
FtuI:JyR
sternomastoid
muscles ("swan
neck")
c-• 7
Chest
1
o
-oc Gynecomastia
(hypogonadism)
.•
Gallop rhythm.
~ basal lung crac-
kles - cardiac
•.- t failure
2. 1
-.
III
,.---,-----."
/
/
/
4
CASE REPORTS
a
:$
...-
o•
•
•..
..
,0
o
Fig. 1.4 Myotonia lkl.l\l'd rt'l,lX,ll1un of mu~,It' ,lfll'r lonlr<1,lllHl
.-
o
5
:;
-•.
o
o
•
c
--•
1;
-.•"•
c
l:
•til
6
.•.
c
3
Fig. 1 8 \\ ht'll .lbdu, Img both .Hm~, Hlt' ~'.lpuLlt' rot<lit' up .md out ,md <<Ill b" 6
SO'C'n frolll tht, front b\ ex.lI1111lt r tilt' .1Ilgt'I-I\ IIlg .1f'I',MJl1le illl' b{lnc~ of
=:
the- ..houlder<; .Hl' proll1l11l'nt due Itl \\.l~llng of till' ,kltold ll1u<;,It'<; \1<;0 Ilotl'
till." \\ .l~tlT1\; of tIlt' P'" lor,ll,,, lll<llor hlllT<; ,llld tn, 'T" lllLl~( I,'~
..•
-eo
.
~
c
6
'c"'
••..
• -
-o..•
~
.'"'
If you can't imagine it. you can't do it - John F Kennedy
7
~ OPHTHALMOPLEGIA.
PTOSIS •
.. ~;(@>
... - =-
<;'
g I I
o
••• ~ "",," [N':,';::" I I ~$ I
I ~ pupil
N_'
"",,"
LM,;
pupil
1
I
.-...
c IAnhydrosiS! Bilateral Midbrain lesio~
Medical 3..1 HorneTs syndrome (l'Xtremely ra~)
cranial nerve (extremely ra~)
Horner's pillsy (eNP) -
o syndrome diabetes
mellitus
Pseudoptosis*
Surgical
Squint
J.. eye movement
Facial! bulbar weakness
HMyastheni~
gravis (MG)
]
I
J
Isolated 3'" eNP Progressive external
- posterior ophthalmoplegia
communie.tting J.Retinitis
"'Ie movement a
pigmmlosa (Keams-Sayre
artery (PCOM)
syndrome) I
aneurysm 3,4,6, eNPs I
- cavernous
sinus/superior
orbital fissure
Frontal balding
StelTlOlIlOl!itoid Ilempo-
ralis muscles wasting
~ Dystrop.hia
myotomca
1
syndrome Myotonia
Arefll'Xia 1 Miller-Fisher
Atax;a syndrome·'
VIP! Isolated 3rd CNP -
remember diabetes
~
mellitus and reOM ( Con~enital "Pseudoptosis - voluntary do:sure of
ptOSIS
aneurySm (check the ere to suppress diplopia,. i.~. in
lat~ral rectus y.
PUPILS!) -a variant o~i1lain-1larn
syndrome which is characterized by
ophthalmoplegia, arefle~ia and
ataxia,
8
CAIE REPORTS
...•
•
o
o
=
Those who d~re 10 fail miserably can achieve greatly - Roberl F Kennedy
9
DIPLOPIA.
6THCNP.
• other than 6th CNP (a lesion of the peripheral portion of the cranial nerve),
lateral rectus (LR) weakness can be due to a 6th cranial nucleus lesion in
the pons. The latter is suggested by a coexisting ipsilateral lower motor
neuron (LMN) facial weakness (the 7th eN winds around the 6th cranial
nucleus!) ± contralateral hemiparesis.
[ LR weakness J
:;
g r"ij;;;i;;;;~~;';~~;;~~~;;:I-...!Y~'::'_~1
Ipsilateral absence of corneal reflex,
LMN facial weakness and deafness J
Cere be 11 0 po n lin e,
angle tumor
I
.-•
o
c:
no I
Ipsilateral LMN facial weakness
[ ± contralateral hemiparesis
I yes I Pontine lesion (tumor,
1---'1 stroke, multiple sclerosis) I
I
o
..•-- no
-
III
"the hemiparesis and facial weakness are
on the same side of the body.
£nasopharyngeal carcinoma.
10
~ PARKINSONISM.
..•
Clinical diagnosis afPD
• asymmetrical signs of parkinsonism ::0
• no clinical evidence of PPS and secondary parkinsonism CI
• marked response to dopaminergic drugs
Treahllento!PD -!l
o
o
• early stage - dopaminergic drugs (e.g. dopamine agonists).
• late stage - surgery (deep brain stimulation / DBS, pallidotomy).
--o
• response to dopaminergic drugs and brain surgery is poor in PPS
(d. PO - good response). : :0
• long-term outlook of PPS is poorer (due to more aggressivecourse).
•-
::0
Wliy do yOIl /leed to recognize secondary parkillso/lism?
• some cases are treatable - WD (chelating agent), neuroleptic-induced
parkinsonism (withdrawal of neuroleptic).
Hello hello
The greatest mistake in the treatment of diseases is that there are php,icians for the body and physicians
for the so"l, allho"gh the two cannot be separated - Plato
11
'ARKlnlon...
Look Jor etiology of
"This man has slowness of parkillSOllism!
movement and recent brain
surgery - examine him" Face/he;r,d
M.ask-/i~ facies
! blinking of eyes
Positive gJa~lIar tap
Monotonous speech
Vertical gaze palsy (PSp)
:;
Face/ head
Sllrgii:aJ scars
(DBS; palliclo-
i
•
Chest
-•
o
o
lamy) - Implantable pulse
generator Ilpc·
(DBS)
••
•
•.•-. t •
Lower limb
Upgoing plantar
...-.
o
(pyramidal sign
-MSA)
•
c H=d
.
•• &srin fmor
CogWheel rigidity
I,
Bradykil"esia Gait
- writing F~fillllllt
Finger-nose test Stooped poslliU
(cerebellar sign - ! arm swing
MSA) Shuffling gait
Turning "en bloc~
Gait ignition failure
Retropulsion
Excuse me Sir, I would
like to completE' my
examination by checking
the following:
Postural hypotension , ·the IPG:
• delivers electrical impulse to
(dysautonomia· MSA)
Family hist0\'Y of
neu.rological or liver
disorde,,(WO)
Neuroleptics
I
... I the basal ganglia
• resembles a permanent
cardiac pacennaker
• suggestive of PD (the only
indication for DBS at the
moment).
12
, CAIE REPORT.
..•
::0
C
o
o
=
::
..o-
:0:
::0
ii-
::0
The faults of others is easily perceived, but that of Ot1esoelf is difficult to per<;ei"e. BhagavadGita
13
~L-,C",E",R",E",B""EL",L",A",R-,-"SY""N"-D=R""O",M",,E~• •
"1.,. ,am per.... pe.. tunl..Iy..
•••
clulll...sy (staccato speedl)" Tnmk
Truncal
ataxia
Head
Nystagmus
Scanning/
staccato speech
I
Titubation LOWel" Limbs
Pendular knee
jerk
t Heel-shin test
:; Upper limb
-.•
o Finger-nose test:
- past pointing I
o (dysmetria)
- intentk.nal tremor
Dysdiadochokinesia
•
..•
o
Pronator drift
Rebound
phenomenon
Hypotonia
Gait
Broad If-se
Reeling 0
Tandem gail
e side
.•.
Onset Unib.ter~1 Bilateral
Acute Cerebellar infarct Encephalitis
(hours days> I hemorrhage Phenytoin toxicity
o Subacute
(days - w~ks)
Tumor" (primary
I secondary)
Tumor" (primary /
secondary)
Alcohol Commonest
Paraneoplastic cerebellar
syndrome (bronchogenic disorders in
carcinoma) exam - stroke,
Chronic Spinocerebellar ataxia tumor, SeA
(months - years) (SCA)··
14
D:B UNILATERAL FACIAL WEAKNESS •
~ote: The cells of the 71h cranial nucleus that innervate the upper half of face
:'rontalis and orbicularis Oculi muscles) receive corticobulbar fibers that
.:triginale from both sides of motor cortex. Thus, a uriilateral UMN lesion above
the 7th cranial nucleus (e.g. at the motor cortex or intemal capsule) will spare the
..:pper face. In contrast, a LMN lesion at or below 71h cranial nudeus (e.g. 71h
::
.::ranial nerve) causes weakness of both upper and lower halves of face.
••
~J look for associated neurological and physical signs to further pinpoint the
exact site of the lesion, I~
• STEP 2 - determine the etiology of the lesion.
Site of
lesion
Anatomical features Relevant signs Pathological
process i•
Pons 7th eN hooks around the Ipsilateral6ili and Stroke / tumor
6th cranial nucleus before
leaving the pons
7 th CN palsies
Contralateral
hemiparesis
/ Multiple
sclerosis E
Cerebella
-pontine
71h
8th
CN related to 5111, 61h,
CN and cerebellum
IpsilateraI5Ih,6th ,
7 th , 81h CN palsies
TUf(lor
(vestibular i
angle 7 1h CN enters internal and ataxia schwannoma, i
(CPA) auditory meatus meningioma)
•••
Petrous
part of
7 1h CN descends in facial
canal and expands to form
Vesicles at ear
and palate
Fracture, otitis
media,'Sell's ..•
:0:
temporal
bon,
the geniculate ganglion
Branches - greater
petrosal nerve, nerve to
stapedius
Deafness palsy, Ramsay
Hunt
syndrome
-
~
15
APPAOAON TO unnATIRAI 10WIR MOTOR nlURon
nOlA I WIAKnlU
I I
upper motor lower molor
neuron neuron
I
Hemiparesis Vesicles at yes (Ramsay Hunt
Hemianopia ear and l syndrome-
Parietal lobe throat
signs
Ino
:;
g I I
Parotid
y" Parotid tumor
.••
swelling / surgery /
o Carotid bruit Cardiovascular / scar trauma
Atrial
fibrillation
system normal Ino
..•
c Papilledema
Cardiac Optic atrophy eN 5, 6, 8,
murmur 9, 10 palsies y" CPA tumor
c I I Cerebellar (vestibular
schwannoma)
signs
:.: Space-occupying
•• ( SITOk.)
lesion (tumor / I no
••
- abscess)
Ipsilateral
y"
Pontine
lesion
-o eN 6 palsy
Contralateral (stroke I
tumor)
=: hemiparesis
••-
I no
.•-• Note: Neuromuscular and mus-
cular disorders do not have to be
Bell's palsy....
.-
considered as they usually cause
C
bilateral facial weakness.
16
RIGHT 10.. IR mOTOR nlURon
, VII'/ 11""'11,,,1',0'1 tt!
"This Illilll
has f'Kial
~ rAOIAI .EAKnEU lIll.... " I Ill' L'"nll\ll
• I asymmetry - examinne him" reflex (vestibular
~ •
schwannoma)
~
•
Right 5th, 81h, 9th
~
~
~
,. and 10th cranial nerve
palsies (right cerebello-
Parotid swelling /
scar (parotid tumor pontine angle tumor)
I I surgery / trauma)
~
: ; il I
Right 6th cranial
! t nerve palsy, left
~ hemiplegia (right
~ pontine [csi9" •
USE a torchlight to stroke / t~mor)
~ look fOT1Vesides in
i the car (Ramsay
l, Hunt syndrome)
No abnormalities as
~
•
mcntion~ f.;om 1 to 4
-+ right Bell's palsy
[
IInx. . . IIIOIJ 11.1.1111•• J.lIOIO•• IU
CASE REPORTS
:;
g
o
.•••.
••o
:
••
•o
-..•
!
•
..
E
~
PATIENT 2 ,\ 1,1ell \\ Ilh de uk LI( 1.11 d~\ rmndn ,mel h II l'M d"dfr1('~~
afler \lr,11 k\"r Imdm~~ I eft I \1:\ [.Hldl \\",lkrlt'~~, lC~Hh'~ ,II tlw It'll
<'xlt,rt1,lll,<H (11g 0;"" - <,;,... llon 2) Dla~nosls r~,llIhlll 1111111 'l/II,I'UII'I'
Progress SIll' 1Il1pnl\l'd dftt'r..l lOUP'" 01 A, \< 10\ lr ,mel f'r('dlll~ul(lllt
18
~ SPEECH DISORDERS.
Dysarthria
• defect in articulation of speech - slurring of speech
-••
• the content of speech is normal
•
Dysphonia
• impairment in production of voice (soft or hoarse voice) p
• the content of speech is normal 6
!:
~f it is dysarthria, try to detenni"e tile subhJpe:
"ote: Local (non-neurological) causes of dysarthria such as dentures and oral malignancy .-o.
Q
•
.-•.
.lre excluded from the present discussion.
Q
-JesseJackson
When you want to be honored by others. you l...am to hO<lOr them first - Salhya Sai Saba
19
DYSPHASIA
..o
• carry out a written instruction - "lift up your right hand and touch
>- your nose"
••
C
Clinical
features
Expressive
(Broca's)
dysphasia
Receptive
(Wernicke's)
dysphasia
Conductive
dysphasia
Nominal
dysphasia
.:--.;
• Spontaneous
'p""h
Non·fluent"
Telegraphic
Auent
Paraphasia
Auent
Paraphasia
Pauses
Lack nouns
•• Naming objects Impaired
Neologism
Impaired
Neologism
Impaired Impaired
Repetition Impaired Impaired Impaired Normal
Writing Impaired Impaired Impaired Pauses
Lack nouns
Site of lesion Left inferior Left superior Left arcuate Left temporal
frontal gyrus temporal gyrus fasciculus lobe
·in severe cases of expressive dysphasia, patients become mute.
20
( Speak to this patient
Would you like to ask this patient some questions?
Non-neurological
I Neurological
( Speech disorder )
I
Spontaneous speech
Comprehension
Naming objects
.
Repetition
Writing
..
C
( Dysarthriil ~ Dysphasia
I y" Hemiparesis
Hemianopia
o
o
e-
-.
I I Cortica I sensory
y"
Bulbar palsy
no
(Dysphonia )
signs
I ."...
Pseudobulbar palsy
Parkinsonian speech
Cerebellar dysarthria
y" I
Vocal cord palsy )
y"
Stroke
Space-occupying
lesion
..•-
~
CAIE REPORTS
Fi~. 7.1
.~nen one door 01 happiness doses, another opens, often we look so long 31 the dosed door that we do
not ..... the one tru.1 has been opened lor us - Helen Keller
21
:;
9
••o
•c
•
=
...•.
•
~
22
MYELOPATHY
=- Reflex c1wllges:
• lower motor neuron signs at the level of the cord lesion and upper motor
neuron signs below the level of the cord lesion. For example, a C5 cord
:t'sion causes inversion of biceps jerk - absent biceps jerk (CS) plus brisk
~upinator jerk (C6).
: Spllil/cterdysfullctioll:
..••
o•
• nt'urogenic bladder (look for urine catheter).
.: SCI/son; deficits
.1 complete transection of the spinal cord - all modalities of sensation are lost
-
~
o
below the level of the lesion.
=- Brown-Sequard syndrome - contralateral loss of pain and temperature
sensation, ipsilateral loss of proprioception (ipsilateral weakness as well).
: dissociated sensory loss:
• ~oss of pain / temperature sensation with preservation of proprioception-
syringomyelia, anterior spinal artery infarct.
-...•~
o
• loss of proprioception with preservation of pain / temperature sensation-
subacute combined degeneration, multiple sclerosis, tabes dorsalis. .•.
\'Vbat are the potential exam cases? "???.JllmmL...."
Acute (several hours to days)
• Trauma
• Transverse myelitis
• Spinal cord infarction / bleeding (AVM*)
•.lIteriovenous malformation.
-~nty yeaTS from now YOll will be mOTe disappointed by the things you dido·t dothan by the ones you
did do· Anonymous
23
Note: The causes of transverse myelitis are multiple sclerosis, yiral
infection and systemic lupus erythematosus.
•• • ••
MULTIPLE SCLEROSIS (MS)
•
• despite being a rare disease in Malaysia, MS is a favorite exam case!
• demyelinating disorder of the central nervous system,
• onset: 20-40 years, male: female ratio = 1 : 1.5,
• episodes of focal disorder of the optic nerves (blindness), spinal cord
(weakness, numbness) and brainstem (internuclear ophthalmoplegia,
cerebellar ataxia).
.
• investigations:
- cerebrospinal fluid study - t protein, presence of oligoclonal band.
- MRI brain / spinal cord (Fig. 8) .
-.•.
o
o
- evoked potential studies (prolonged latency in cortical response to sensory
stimulus).
--•-
o
signs of lesions at > one site in the central nervous system
• in the presence of only one clinical sign, laboratory evidence
(evoked potentials, MRI) of an additional lesion is required
.-•.
-.
!::
•
24
IIYEIOPATHY
This man has weakness VIP! Common causes
~
iJf legs - examine his of myelopathy in
:ower limbs" exam - trauma,
transverse
myelitis, tumor
Cranial neryes
C'\2 - optic atrophy,
\larcus-Gunn pupil
\!ultiple sclerosis) Upper limbs
::-':9,10, H, 12 (Motor Inversion of biceps /
-",uron disease) supinator reflexes
(cervical myelopathy)
Trophic ufcel(" ,1, pain
/ tem,peratu
scnsati~ syringo-
.-•
o•
-.
myelia)
oe-
t
•.
-..
legs - Inspection
'S dsting / faS<.'iculation Excuse me Sir, I
\lotor neuron disease) would like to
..:rille catheter -
~",urogcnic bladder
complete my
examination by
o
•
I
legs - Tone/ Power /
Reflex (ankle clonus)
checking'flie:
Spine-..-.deformity /
scar (trauma)
Ana~ tone f reflex
..
•
:-i~-pertoni'1. AND Steps 6-7
-yperreflexia - spasticity
:-iypotonia, hypo /
lleflexia - spinal shock
t
I Legs. Sensation
Spinal se~ry patterns:
legs. Sensation complete transection /
_ook for sensory level* al hemisection / dissociated
::'1.e TRUNK (if pain sensory loss
"",nsalion is lost up to L1
evel)
*Nipple . T4, subcostal margin - T8. umbilicus -
TID, inguinal line - TI2.
A nalural dealh is where you die by yourself wilhoula dOClor's help- Anonymous
25
~ WASTING OF SMAll MUSClES
OFTHEHAND •
( Unilateral ( Bilateral )
( Sensation
III
(Sensation )
:; I II I I
9 Median +
ulnar nerve I(C8-n '''-) lNo,m'l) (Glo",)
I (C8-n ,,,- Dissociated
sensory
~ distribution malomes millimes
loss
••
..o• Combined median Motor
+ ulnar nerve palsy
(trauma, Hansen's
neUfon
disease
( C8-Tl cord
lesion (tumor) )
.•.. disease)
•-
;;
C8-TI nerve roots
/ brachial plexus
lesions (trauma,
Predominantly
motor peripheral
neuropathy·
Syringomyelia
/ central cord
tumor
..o
! tumor)
••
• neuromuscular and muscular disorders are WPI•
not considered because the former does not
cause muscle wasting while the latter does
Wasting of small
not usually cause distal muscle wasting muscles of the hands -
• Motor neuron disease (MND) usually starts
remember MND :::::>
with unilateral weakness and wasting of the
LOOK for tongue
distal muscles fasciculation
16
CAn REPORT.
:
•.:;
6
=
!•-
I
=:
~•
F
.o
II
--•
It is a mathematical fact that fifty percent of all doctors graduate in the bottom half of their class·
Anonymous
27
TREMOR
Tremor amplitude
remains the same Action
throughout tremor -
movement Essential
No dysmetria tremor
Clinical features PO ET
Frequency 3-5 Hz 4 8 Hz
4
2B
~ PSEUDOBULBAR / BULBAR PALSY.
Clinical features
::Jriini.tion
Pseudobulbar palsy
Upper motor neuron paralysis
Bulbar palsy
Lower motor neuron
*
of muscles innervated by 9th, paralysis of muscles
10th, 11 'n and 12th cranial innervated by 9th, lOin, 11th
nerves and 12th cranial nerves
G.Ig reflex Brisk Absent
Tongue Small, spastic Wasting and fasciculation·
;"\" jerk Brisk Normal
~h Spastic ("hol fXl1ato") Nasal
E::notionallability Present Absent
c.~ Acute - stroke (commonest Acute - brain stem stroke,
cause) Guillain-Barre syndrome,
Chronic - Multiple sclerosis, Myasthenia gravis
Motor neuron disease Chronic - Motor neuron
disease, Syringobulbia ••
- asting and fasciculation of the tongue are
in chronic, and not in acute disorders
..;;!l1 VIP! Common cause of :;•
~
~~ing bulbar palsy (in which there is not
~">Ugh time to develop muscle wasting).
pseudobulbar /
bulbar palsy in exam - o
Molor neuron disease
~~~p:!p...~!X:l~~~~======'I =
,.
CASE REPORT
-••g
o
e--
••
- •
••
,•.
•
S
29
~ ,PROXIMAL MUSCLE WEAKNESS.
=
• metabolic myopathies are rare in exam because the muscle weakness generally
resolves rapidly with treatment of the underlying disorders.
•
I: VIP! Commonest causes of
l1lvestigatio1l of IIIl1scle disorders
•
•a • serum CK / thyroxine, cortisol. myopathy in exam -
muscular dystrophy and
..
• EMG studies - myopathic pattern.
inflammatory
• muscle biopsy; • myopathies,
a) PM, DM - inflammatory cells.
~
b) MDs - segmental necrosis and regeneration, dystrophin protein staining
(absent in DMD, J. in BMD).
•• • genetic study - dysrrophin gene mutation in DMD and BMD.
~
.• IXA. IOIRARIO
A 36-year-old man has proximal muscle weakness and normal reflexes /
,II
Comments: The diagnoses are PM and early stage of MDs (both often 1001
similar clinically). The absence of family history docs not exclude MDs (LGMD
and BMD arc recessively inherited). Pseudohypertrophy is not .always present i1
MOs. Tell the examiner that muscle biopsy will solve the diagnostic problem.
30
IL
CASE REPORT
'.
I=
.
6
::
I•
•
•
.i
!
D
...~
...
•
D
:a-,', waste your lime on jealousy. Sometimes you're ahead, sometimd you're behind. The riKe is long..
and in the end it's only with yourself. Mary Schmich
31
'ROXIIIRI .USCll IIIRKnl1l
"This lady has difficulty climbing
stairs / combing hairs - examine
her uppe'r" / lower limbs"
Face
-- Heliotrope rash
Gotlro l' sign (OM)
End i e facies
oil,
•
Excuse me Sir, I
would like to
complete my
examination by
Bifacfal weakness +
scapular ioging
(FSHD)
Bilateral ptosis +
facial weakness (MG'II)
9 asking--for.
o Family history
•• t
+
Mj),
••
Ste~id th apy
(CuShing s
Gait
syndrome)
::: Waddling
••
(Ml'J<)
I
~
;•
Upper / lower limbs·
Inspection
.--
Marke proximal
• mu~wasting t
o (advancetl sthge of
MDs - dlCBS: no
32
STROKE
UlCl/nar stroke
• ,;;mall vessel disease -lipohyalinosis of penetrating arterioles at the internal
capsule and basal ganglia.
• clinical diagnosis is based on:
101 absence of cortical signs (hemianopia, dysphasia).
:') preserved conscious level.
: .illlan action can be modified to some extent, but human nature can root be changed Abraham lincoln
33
c) characteristic neurological signs of lacunar infarction.
••o • not a specific and sensitive test for severe carotid stenosis (a severe stenosis
...•.
may not cause a bruit at all).
• a r1sk factor for ischemic stroke and coronary events.
Investigatioll ofstroke
VIP~
• Full blood count (hematological disorders)
• ESR (arteritis)
• Blood glucose (to exclude hypoglycemia*)
• ECG (atrial fibrillation), chest Xray
• Echocardiography (source of embolism) CT brain is the only
• cr scan brain (differentiates ischemic from way to differentiate
hemorrhagic stroke, bleeding into a tumor") cerebral infarct from
• MR Angiography, Carotid Doppler, Trans- hemorrhage with
cranial Doppler studies absolute reliability
• lllrombophilia, connective tissue screen - for
patients with no obvious risk factors for "two important differential
stroke (e.g. young stroke - < 45 years) diagnoses of stroke.
34
CASE REPonTS
;;,"
I'"
Stand for 50mething or yOll will fan for anything _ Michelle Hornbuckle
35
ITROKE
Focus all C£rltra/ rleroous and
"This man had acute onset
of right hemiparesis - cardiwasCillar systems!
examine him~
-
Eyes
Polycythemia
FacejcraniJIII nerves Retinal emboli
Malar rash. (SLE'"'") Papilledema (tumor)
XDnthelasrrnJs .......
FQcia/~ """" .....
Dysphasia .......
Dysarthria
Ilemianopfll
Parielallobe signs • '«k
sensory inattention Carotid
:;
-••
bruit
o t
o Hillnd / foer;nm
I
Finger c1ubbing*
••
Vasculitis Chest
Bruising (cerebral Surgical
hemorrhage -
•
~
warC.rln)
Radial pulse •
"""
Heart
...•.
o atrial fibrillation
t
General
inspection
I
°i>osciousness
lltmip,lretic
limbs..- -
danglitrg lit tile
side
36
j
••III
o
2
•o-o
SECTION 1
.
•
o
CHAPTER 2 - ENDOCRINOLOGY
••
ill
•••
ENDOCRINOLOGY
ACROMEGALY
Treatment ofacromegaly
• pituitary surgery (the treatment of choice):
- the earlier tile surgery, the better is the cllancefor visual field recovery.
• pituitary irradiation - when surgery is contraindicated.
• drugs (bromocriptine, octreotide) - adjunctive therapy.
38
CAIE REPORT
•
I
39
110.0••••1"" .••D_O_O•••OIOGY
..r-
activity ofMlIller's muscle (the retraction and stare (;
smooth muscle within the upper • ~ft tissue involvement <»
eyelid). • rraptnsis
• lid lag and mild lid retraction (1-2 • ~xtraocular muscle weak-
mm)* are due to thyrotoxicosis per se. ness
• !;;omeal involvement
"='re marked lid retraction is due to GO.
• S.ight loss - optic nerve
compression (Werner SC)
'tIC ffldnif!!tatimlf of thyrotoxicosis
• high-output cardiac failure. • angina.
• atrial fibrillation. • thyrotoxic cardiomyopathy.
A hospital should also have a recovery room adjoining the cashier·sofl;.;e _Fraocis O·Walsh
41
Confinning the diag!Jos;s 0 thy.rotoxicos· Disorders associated with
• serum T4, 1'3. Grave's disease
• serum TSH (the best screening test). • Addison's disease
• Type 1 diabetes mellitus
Investigation otG..ca.v.e..'s dise..l!..s! • Hashimoto's disease
• TSH receptor antibody. • Pernicious anemia
• cr / MRI orbit - for patients with unila- • Myasthenia gravis
teral proptosis, particularly euthyroid, to • Hypokalemic periodic
exclude retro-orbital tumor. paralysis
• Vitiligo
Treatment of thyrotoxicosis
a) control symptoms - beta-blockers
b) restore euthyroidism VIP' 90% of patients
"9Q i) Grave's disease:
~. antithyroid drugs· high relapse rate (60%).
. with CO are
thyrotoxic wlrile
--
o
!!
iii) Toxic adenoma - radioiodine or lobectomy.
OASE REPORT
This thyrotoxic lady, who had previous thyroid surgery, complained of
~•.. intermittent ptosis and diplopia. Findings (Fig. 15.3 - Section 2): Extensive
vitiligo, left thyroid nodule, thyroidectomy scar, bilateral ptosis and
=,
ophthalmoplegia. Investigations: Positive Edrophonium lest and TSH
receptor antibody. Diagnosis: Autoimmune polyendocrine syndrome / APES
(Crave's disease, Myasthf/lia gravis, vitiligo).
I want to be remembered
as a true academician ..
42
THYROTOXIOOJII
... ExophUzalmA
Lid retract iOn~
Ophtha ~legia
Lid la
Visual acui •
osis
(optic ,newppathy)
Ptosis (assqgated ~
Myasthenia gravis) •
t !
• •=: o
6
•
=:
t
'f~, • =
S
2
i
e,..
-
k
Even if you are on the righllrack. you'll still get run over if you iust sit there - Will Rogers
43
~ CUSHING'S SYNDROME (CS) •
What is CS?
• clinical syndrome characterized by steroid excess
due to any cause. •
VIP!~
Causes of CS
• ACTH-depende1lt - Cushing's disease (CD)*, Commonest causes
ectopic ACTH syndrome** of c:s in clinical
• ACTH-independent - iatrogenic, adrenal practice: iatrogenic,
...
0
~
adenoma / carcinoma followed by CD
Q
Three steps;l1 the diag1lostic
approach to CS (refer to next page)
COllfinning the clinical diagllosis
Dfes
• serum cortisol (11 pm and 9
0 a) Clinical diagnosis am) - loss of diurnal rhythm
~. • based on a COlis/ella lion ofnew • t 24-hour urinary cortisol
A...!" symptoms and signs (weight gain, • low-dose / overnightdexame-
buffalo hump, purplish striae, thasone suppression test
f""OI
••
0
proximal myopathy, etc).
..-•.
0
c) Determining the etiology of CS
• high-dose DST
- presence of suppression suggests CD while
failure of suppression suggests either ectopic
WP!~
The approach to CS:
ACfH syndrome or adrenal tumor.
a) clinical diagnosis,
- helps in di!feretltiating CD from ectopicACfH b) biochemical
syndrome in cases of t serum ACTH. diagnosis, al/d c)
• not necessary in cases of .,1. serum ACTH detennining the
(adrenal tumor), in which the next investigation SOl/rce of cortisol
is CT / MRI adrenal gland.
• inferior petrosal sinus sampling (IPSS)* - another method of distingui-
shing CD from ectopic ACTH syndrome. lPSS is used when other
investigations (biochemical and imaging) fail to determine the source a
*blood samples are withdrawn simultaneously from the inferior petrosal venous
sinuses (which drain the pituitary gland) and a peripheral vein. A cenlral to
peripheral venous cortisol ratio of > 2:1 is diagnostic of CD.
44
CLINICAL APPROACH TO CUSHING'S SYNDROME
Clinical diagnosis of CS
cs
I.
tACfH
•g
High-dose OST
o
normal suppression lack of suppression
;o
Cushing's dise..se i
Pituita MRJ cr / MRI thorax, abdomen ;
~ole; Only SO% of pituitary microadenoma are visible on MR!.
•-
ACTH secretion.
=•
What is pS~lIdo-CS?
S
D
• non-endocrine disorders (depression, alcoho-
:;
lism) in which the presence of some clinical
features (e.g. weight gain) and biochemical
abnormalities (loss of diurnal rhythm, increased
The most reliable
signs that
distinguish CS from
••
24-hour urinary cortisol, false-positive low-dose pseudo-CS are skin
DS1) of CS leads to diagnostic confusion. atrophy, easy
• these hormonal abnormalities resolve with bruising and
alcohol abstinence or treatment of depression. proximal myopathy
Treahnellt ofes
• Cushing's disease - transphenoidal microodenomectomy, pituitary
irradiation, total bilateral adrenalectomy.
• ectopic ACTH secretion· surgical resection of tumor.
• adrenal adenoma / carcinoma - unilateral adrenalectomy.
FortulW knocks but once, rnisfort1,l1W has m..m Il'I<>n pa~ -jOl\ilthan Swift
45
CASE REPORTS
j
I
II
i.-
g
~
•i
.
o
46
CU'HlnG·' nnDRO ••
Look for etiology
"lltis patient has weight
Eyes" and complicatio11S
gain - examine him"
Cataract afCS!
Ilypetl.n.ive I
~ dia~~;etinopathy
Nttk
Buffalo hump
Supracla'1icular
fat ij
t
• ••III
o
o
;o
o
::
o
•
!-.
••
-..-
...
Wha!t'YH you do WIll ~ insi~ but il is Yf:rf impootant INt you do il - Mahatmll
Gl.ndhi
47
I!lJiID MAREAN'S SYNDROME (MS) •
Mofecularbasis aIMS
• genetic mutations in the fibrillin~l (FBN1) gene on chromosome 15 which
encodes the glycoprotein fibrillin, a protein that is important for the
structural integrity of the lens, aorta and other
connective tissues.
.J
g,
e)
Clinical manifestations ofMS
• major systems affected - skeletal, cardiovascular and
ocular.
"MARfAN'S"
i *posilive if the distal phalanges of the first and fifth digits of one hand overlap
.
~
when wrapped around the opposite wrist.
"positive if the thumb, when completely opposed within the clenched hand,
projects beyond the ulnar border.
:: A1anageJnentofA1S
• • annual Echocardiography ~ to monitor aortic diameter and mitral valve
function. Aortic dilatation and dissection are the major causes of morbidity
and mortality. Prophylactic aortic surgery prolongs survival.
• ophthalmic referral.
• genetic counselling.
--, .
CA" RIPORT
A 24-year-old tall and thin man presented with acute severe chest pain. He had
hypotension, profuse sweating and unequal radial pulses. There was no evidence
of pneumothorax on the chest Xray. cr scan thorax showed dissection of ti'e
aorta, extending from the ascending aorta to aortic arch.
48
mARnn's nnDRomE
i.~
••
The mediocre teocher tells. The good teacher "xplains. The superior teacher demonstrates.
The great teacher inspi...... - William Arthur Ward
49
.llrln·s nnDIO••
fl
,. 6 "Examine this patient's
cardiovascular system"
,
Face ~es
t-hgti-arc cd
palate S The tall man willI cJrc;t
Blue tu~ (pn~II.Pllotlwrax)
J...en! ublUxa-
tio
:;
9
o
••- t
g 3
=
•
root,
I•a
e • •
••~
••
t 1
~ •
•
I (iJ
0
•
• •
-dissecting aneurysm of
aorta.
"aortic regurgitation.
·"upper segment - from
the crown to the symphysis
•
Excuse me Sir, I woUfd like to complete my
examination by clie£klng the:
pubis, lower segment - Arm span: heigh ratio 1.05
from the symphysis pubis Upper segment: t J..er gment ratio'''''' < 0.85
to the floor. Family history
50
BD HYPOPITUITARISM.
Investigation ojhypopituitarism
• Hormones: pituitary~ ACll-I, TSH, LH, FSH, GH, prolactin.
target organs ~ cortisol, T4, estrogen, testosterone.
• Pituitary stimulation test: measurement of pituitary hormones after
administration of Gn~RH, insulin (to induce hypoglycemia) and TRH.
• Neuroimaging: MRI pituitary.
51
eAIE REPORT
;-
!
,
I
ti
::
i
52
HTPOI'ITIIT. . . . .
,,,
. llUJir
~;~'~~'",r -
scu;r--"
Eyes· 'c atrophy,
bitemporal hemia-
nopia I
High-pitched voice 11/'"
t
/
;' ~ ented
---:' \:
\,: -
c.
/
/
1 •Ii:
~/ ,
~
;,..
•,..'
t
\\.-1 r------...,
1 .••-.
•
\ Excuse me Sir, I wouJd
like to complete my
exam IftIthij
t checkl:ol1J
\Small tes
pubic /lair
ecHon
, • Postural
AND "
skin - impol
menses,
~)
features
.cortisoI. is needed for maintenance of
blood pressure.
:he mm who try 10 do aomething and filiI ant infmitdy bdtft ltwl those who try 10 do r>Othins and
SUCX'ftd - Uoyd Jc:-s
53
-
~ HYPOTHYROIDISM.
Causes ofhypothyroidism *
• Destruction - surgery, radioiodine WP!~
• Drugs. thionamides, lithium
• Enzymes deficiency· dyshormonogenesis "DEATH"
• Autoimmune Thyroiditis (Hashimoto's) Commonest cause
• Hypothalamic-pituitary disorders (tumor) of hypothyroidism
Q
•; ; • myopathy.
• pseudodementia.
• slow relaxation of ankle jerk.
• myxedema coma.
o
oa Cardiovascular manifesta tions ofhypothyroidism
• sinus bradycardia.
: • pericarditis I pericardial effusion.
elow-outputcardiac failure.
• hypercholesterolemia / coronary artery disease.
• aggravation of angina.
hrvestigation of'rypotltyroidism
• serum 1'3, T4, TSH.
• thyroid autoantibodies (anti-microsomal Ab, anti-thyroglobulin Ab)-
autoimmune thyroiditis.
54
HYflOTIIYROIDU.
Facel head
;\Iop«iQ,; cOra hairr'
Loss 0 II! lJlI~
rot'brows-.t - tomy
••
I"
•
Pmorbital rJ/illess"'-
\olnthel sma
Hoa f'Voice ••-
.~'
Deaf~
~facroglossja Ch",t o
o
t ,,-'" •
~
t
General ins~tion
• •o
-
!
i
!.Llhargi duil" look
Slow of movement
Carotene ia
Vitiligo ( uloimmune
disorders)
Anemia
Excuse m~irrLwoUld like to
complete m ex.IJIlination by
checking the folfowing:
Cerebellar gal
•
'.15k patient 10 kneel on a chair with Other symp of hypothyroi-
:eet dangling over the edge. dism (constJ tiora. depression.
m('fl()IThagia <j
55
.
9
Q
•!
Q
o
!.
SECTION 1
CHAPTER 3 - DERMATOLOGY
DERMATOLOGY
5•
• respiratory failure (tracheobronchial shedding).
• skin - superimposed infection. VIPSI'"
Investigation o/EM, SJS and TEN • target lesions are
• culture - urine, skin lesions and blood. characteristic of
• serology - Mycoplasma, Streptococcal, herpes EM
simplex. • drug history is
vital - antibiotics,
• chest Xray - pneumonia.
antiepileptics
Treatment 0/ EM, SIS and TEN
• withdraw the offending drugs!
• topical steroid / antibiotic, artificial tears, bum unit.
• systemic steroid - controversial.
• acyclovir for herpes simplex infection.
58
~ PEMPHIGUS I PEMPHIGOID.
.....,
~Illlology
Nikolsky', sign~
Intra idermal blister
Dire<:t f1uorescence-
Su idennal blisler
Direct fluorescence-
Sube idermal blister
Negative
epidermal staining of linear IgG and I or
intercellular cement C3 at denno-
with IgC,C3 epidermal junction
Circulating Circulating
antibodies to antibodies to
intercellular cement basement membrane
T~atment Responds to high Responds to lower Withdrawal of
dose of sn.-rold (l20- dose of steroid (40 offCllding agent
240 rng daily) mgdaily) Severe cases - steroid
If you try you may fail, if you don't try you're guaranteed to fail- Jesse Jackson
59
B1ID NEUROFIBROMATOSIS (NFl.
:-,
c
Lisch nodules: pigmented hamartomas that appear as dome-shaped structures on
the surface of the iris.
60
:1.
• cardiovascular - hypertension, renal artery
stenosis.
• endocrine - pheochromocytoma,
• neurological· optic nerve glioma*, cerebral
glioma, meningioma, mental subnormality,
e skeletal- kyphoscoliosis, pectus excavatum,
pseudoarthrosis-, short stature and bowing
of long bone (Fig. 22.1).
elungs - interstitial pulmonary fibrosis.
e malignant change of neurofibromas.
·commonest intracranial tumor associated with NF-l.
u a non,healing pathological fracture.
Diagnosis ofNF:
~afe-au-Iait spots WP!~
Axillary freckling
fibroma
ge - Lisch nodules "CAFE
~keletal (bowing of bone, SPOT" Fig. 22.1 Xray of right tibia
dysplasia) - bowing of the fibula and
,redigree (family history) pseudoarthrosis of lower
Optic Iumor (glioma) (Zhllo HQ) third of tibia / fibula.
* -.,-=3
eRIE REPORT
---
The greatest pl'l'!lOnallimitation is to befOUM not in the things you want to doan<! can't, but;n the
things you've nev..... ronsiderro. doing - Richard Bandler
61
.r·1
MThis patient had multiple
skin lesions since child-
hood - examine her'"
. m
do'"
. ,1
I
t I
(:: ing) FtuhlyR
iosis
~
t
Gener;tl inspection
Neurof m"
Plexi
neurofi
"'" Short ,
:I• osis
62
g:g PSORIASIS I PSORIATIC ARTHRITIS.
• chronic erythemato-squamous
skin disease characterized by ab- Diagnostic dues for PSA:
normal keratinocyte proliferation. VIP! • asymmetrical oligo-
~
• both sexes equally affected. art"'it;,
• age of onset: usually 20-30 years. • DIPJ involvement
• family history in one-third of cases. • positive family history
• rash and nail changes
Clinical types ofpsoriasis
.J) Plague psoriasis (Fig. 23.1-2 - Section 2) - erythematous lesions covered
by silvery scales seen at extensor surface of knees / elbows, trunk, sacral
area and scalp.
e) Nail psoriasis - nail pitting (Fig. 23.3 - Section 2), onycholysis (the nail
becomes detached distally from its plate), ridging and discoloration.
• asymmetrical oligoarthritis
• rheumatoid arthritis-like (Fig. 23.4 - Section 2)
• arthritis mutilans
• distal interphalangeal joints (OWJ) only (Fig. 23.5 - Section 2)
• spondylitis
No man is smart, .. ~c.pt by comparison 10 IhOSf' who know less • Edgar Watson Howe
63
Investigation ofpsoriasis
• skin biopsy - usually not needed (except VIP' Look hard
in erythrodermic psoriasis). . for hidden
~
• Xray - joint erosion / space narrowing, perios- p'mi'"'
plagues at
titis, osteolysis ("pencil-in-cup" appearance), natal deft,
resorption of tufts of distal phalanges, spondy- behind the
litis. ear and in the
hairline
Treatment ofpsoriasis
• skin lesions· topical ... Pitfalls in the diagllosis of PSA
(dithranol, tar, steroid), • psoriatic rash may precede, coexist with or
systemic (photochemo- follow the onset of arthritis - in the latter
therapy / PUVA). case, family history of psoriasis is
• Psoriatic arthritis - TNF suggestive of PSA
antagonists (improve • psoriasis may be hidden - natal cleft, below
symptoms, inhibit the breasts, umbilicus and behind the ear
radiologic progression). • nail changes may be the sole physical sign
» -
CAn REPORT
I
.
S
64
••
••
SECTION 3
so
!:
o
CHAPTER 4 - HEMATOLOGY
•.•..
:il
•...
HEMATOLOGY
•.
• ineffective erythropoiesis - a chain precipitates in red cell precursors-+
accelerated apoptosis --+ intramedullary death of red cells.
• hemolysis - a chain inclusions reduce the deformability of mature red
cells --+ interfere with their passage through splenic microcirculation -+
•- premature destruction.
•..
:
DiagtlOsis of BTmajor
• peripheral blood film*
• • absence of HbA, t HbF (> 70%)
..
i • BT trait in both parents
Diagllosis ofBTtrait
• peripheral blood film*
• t HbA,
*hypoehromic microcytic anemia, target cells and
basophilic stippling.
100
IrOIl overload in BTmajor
• etiologies· repeated blood transfusions and increased gastrointestinal
iron absorption.
• major cause of morbidity and mortality (cardiac events a.re the primary
cause of death).
Whatever you do, or dream you can, begin ii, boldness nos genius, power, and magic in it Johann
Wolfgang van Goethe
101
IITII-THlllIIUI•• 1I .1I.0R
t palU:reas)!
Co1rdiov_~/9Mlai
Gallop r6Jthrn. lung
:; basal craCJdes (cardio-
myopathy)
9
o
~
I
•• -• Abdome
-jo/;J;s;"nt axillary hair
•- t Hqxlt al
•-
(cxtramedul ary
hemalop,pe:isis·,
-•••-
~
H.....
Pallor p Imar
creases and nail bed
Finger U inS
(chro')ic liver
iron overtoatl,
Hepatitis B / q
Ma~ l plblomega/y
/ splenectomy scar
Subculmreous It,SU-
disease) lin mark
Desftrrioxrlllline
t infusion pump
Gener
Slaf/j:XTIHI
men/nil n
I
SllOrt S~f re
(hypopitUitarism)
Excuse me Sir, l would like to complete
my examination by chc<:king the
-increased erythropoietin following:
synthesis stimulates the Testicular atr~h '/; J sent pubic hair
(ormation of extramedullary (hypogonadis
erythropoietic tissues in the liver, Plasma gluco v
spleen and paravertebral area. Family history of anemia
102
tB:B LYMPHADENOPATHY.
oj characteristics ofLN
i) location
• local· inflammatory or malignant diseases in the associated lymphatic
drainage area.
• generalized· indicates the presence of systemic disease.
ii) tenderness - infection.
iii) hard LN, fixed and matted together· malignancy. ••
b) age
••...
• infectious mononucleosis - young adults. o
• Hodgkin's lymphoma - bimodal peak (20-30
years. after 50 years).
o
c) associated llistory
!:
Common causes
:c
•.•
of enlarged LN -
• fever, night sweat, weight loss -lymphoma. lymphoma,
• contact with cats - Toxoplasmosis. metastases, TB
• high risk behavior - HIV infection.
•III
••o
W1U11 are ti,e cal/ses of lympJ/{ulellopatlly?
lJifectio'l
??? Hhmm . .
.,•...
•
•
•
•
bacterial - pyogenic, tuberculosis
viral- infectious mononucleosis, I-IIV
parasitic - Toxoplasmosis
fungal - coccidioidomycosis
.
Infiltration
• benign - Sarcoidosis
• malignant - lymphoma, metastases
Immulle
• connective tissue disease
Drugs
• phenytoin
103
lI'nOIOH TO IY.I'HIDEnOl'nHY
...
Breast carcinoma Cellulitis
Bacterial infections of Sexually transmitted
arm (Staphylococcal, \, diseases (syphilis,
....o
I I: Streptococcal) chancroid)
Filariasis
Lymphoma
Carcinoma of
....•.
a GENERALIZED
HIV
TIC (Toxoplasmosis,
external genitalia
•.
...
Infectious mononu-
cleosis, !;;MV)
Lymphoproliferative
disorders u
Cormective tissue
disease FadzlyR
Phenytoin
104
CASE REPORT
•Ii
•
a
o
=
105
~ DEEP VEIN THROMBOSIS IDVT).
AA
Cfinicaljeatllres olDVT
• painful calf.
• swelling and tenderness of calf / thigh muscles.
VIP~
• cyanosis.
• dilated superficial veins. Risk factors for
• increased warmth. DVT - Virchow's
triad
Dif!eretttial diagnoses ofDVT
• cellulitis. • ruptured plantaris tendon.
• ruptured Baker's cyst. • calf hematoma - warfarin.
••
...-. COl/fimlillg tI,e diagnosis ofDVT
• D-dimer - a negative D-dimer test
result excludes the diagnosis of DVT
ffiAUMA
• Surgery or fracture (hip, knee)
•o probability of disease.
• Duplex ultrasonography - accurate
• Cardiac failure
• Prolonged immobilization
: for detecting proximal thrombus.
• Venography - gold standard investi-
• Pelvic obstruction
.••
labour-intensiveness and patient
• Malignancy
discomfort. • Surgery
Note: The pretest probability (likelihood) • Myocardial infarct
of the diagnosis of DVT is increased when
a there is presence of both typical signs of
• Estrogen / puerperium
• Thrombophilia U, protein C / S
DVT and risk factors.
/ anti-thrombin III)
• Antiphospholipid syndrome
Complications alDVT
• pulmonary embolism.
• post-thrombotic syndrome - chronic leg pain, swelling, venous stasis and
ulcers.
TreatmentofDVT
• symptomatic - pain relief, elevation of foot, elastic stocking.
106
- prevention of pulmonary embolism, recurrence of DVT and post- thrombotic
syndrome - anticoagulation with heparin followed by warfarin.
Prevention ofDVT
- compression stockings.
- suocutaneous heparin.
...
-leg exercise and early ambulation after surgery.
.
CAIE REPORT
....
:
••
..
o
o
=
1:11
,••.
.-..::l
•~
••o
~
Stude/Its remember this,
~
- Martin H. Fischer
A man may die, nal;o"" may rise and fall, but an idea liv'"5on John F. Kennedy
107
ANEMIA
I I I
HEMOLITIC BLOOD LOSS BONE MARROW FAILURE
"9o
.
lntracorpu5cular • Acute • Lack of essential
• Hereditary • Chronic nutrients - vitamin Bl2,
spherocytosis (l-lS) (resulting folate, iron
••
-
• Thalassemia in iron • Infiltration - leukemia,
.PNH* deficiency) metastases, fibrosis
• Inhibition - drugs,
Extracorpuscu/ar inflammatory process
•- • Autoimmune -
-
• Endocrine - hypothyroidism,
SLE**
•• • Physical agents -
prosthetic heart
hypopituitarism, renal
failure
• Hereditary. Thalassemia,
• valve
• Chemical agents -
sideroblastic anemia
drugs
• Infections - malaria, *paro:o:ysmal nocturnal hemoglobinuria.
sepsis **systemic lupus erythematosus.
108
( Further investigations of some types of anemia)
(: Microcytic anemi~
Serum iron, ferritin, 1lBC
=) Macrocytic anemi~
Serum vitamin B12 /
folate, red cell folate
Normal
iron,
J.iron
J. ferritin
J. iron
t ferritin
( J. vitamin B12 ( , folate
Iron deficiency:
deficiency:
Vegans
Pernicious anemia ••
04
Menstruation
Gastrectomy
Bacterial overgrowth
o
Bleeding (peptic I)
ulcer, cancer, varices)
Parasites (Hookworm) "differentiates pernicious anemia
from intestinal causes of vitamin B12
~
•:
_ _-=="===.:IIIlE.~==_~~
OAII RIPORTS
••-
PATIENT 1 Alcoholic man with lethargy for three months.
Findings: Anemia, smooth tOl/gue (Fig. 27.1 - Section 2) and signs of
chronic liver disease. Investigations: Hb 6.9 g / dl, .J,. MCV,.J,.
MCHC, .J,. serum ferritin / iron, t nBC, blood film - hypochromia,
microcytosis, pencil cells. Endoscopy - esophageal varices. Diagnosis:
Tron deficiency anemia due to chronic intestinal bleeding (esophageal varices).
PATIENT 2 This man was found to have these oral lesions (Fig. 27.2 -
Section 2) when he was investigated for hypochromic microcytic anemia.
Endoscopy showed small bowel polyps. Diagnosis: Peutz-Jeghers
syndrome (PJS) with chronic intestillal bleeding.
I got the bill for my surgery. Now ll<now whallhosoo doctors were we~ring masks for. J~mes H. Boren
109
"This patient has anemia
- examine him" Mout~
Eyes
Conjunctival pallor
Tinge of
jaundice
(hemolysis)
... Angular cheilitis,
smooth tongue /
atrophic glossitis (iron
deficiency)
Cum hype~trophy
(acute promye1ocytic
Fundus - hemorrhage leukemia)
•
(thr9mbocytopenia),
optic atrQphy
(pernicious anemia)
NeckL
:t t axilla
9 f-el:,ympll
o noii~
.-•
Fore,lrms} arms
•
~
••••
Bruisillg_ -
Epitr;;:chlear
lympH nodes
Abdomen
•- t Surgical scar -
ga~trectomy,
••• cholecystectomy
(hereditary
• (reas
Koilonychia
spherocytosis)
Hepafospleno-
megaly
Inguinal
t
J lymph nodes./
General inspection
Pallor
Thalassemic facies
Cachexia
(malignancy)
.I, . \ Legs
•
Areflexia, upgoing
plantar, proprio-
Excuse me Sir, I would like to complete ceptive loss
my examination'b}r checking the (pernicious anemia)
following: J
Fever (neutropenic sepsis)
Family history of anemia
Stool occult blood
Hematuria (coagulopathy,
thrombocytopenia)
110
EASY BRUISING
(Easy bruising) ••
VASCULAR
.
••
o
PLATELET DISORDERS
DISORDERS
COAGULOPATHY
o
• Increased destruction;
Idiopathic thrombocyto- • Steroid
• Liver disorders
• Dive
!:
penic purpura, DIVC", • Senile purpura • Drugs - heparin,
viral infection, drug • Hcnoch-Schonlcin warfarin •
(quinine) purpura • Hemophilia l!!
•.••-.
• Decreased production; • Scurvy
Leukemia, aplastic • Amyloidosis
anemia, viral infection
•-C'
• Abnormal function;
drug (aspirin)
*disseminalcd intravascular coagulation.
11 isn'l whal you hav... or who you are. or ",he.... you are. or ",hat you are doing thaI makes you happy or
unhappy. 11 is what you think aooul- Dale Camegie
111
EAIT IRUlllnG
Face/eyes ...
Alopcci (cytotoxic)
Conju~val pallor
1
Peno 'tal purpura
(am oldosis)
fundu5- hmlorrhage
(Ihromb<x'ytopenia)
1
:;
g
.•
o
t - Ch",t
Stn7TO
"',,-
my
rfarin
Forearms I arms
•• t
t;
•• 1
:-.
Butloclrj Legs
Purpura
(J-1enoch.
Schonlein
t
General
purpu@
insp!ction
Cusllin$oid
Cac~exja
1
(malignancy)
Excuse me Sir, I oule:yike to complete my
examination by checking tlie (ollowing:
Drugs - steroid, anlic~u1anl
51001 occult blocf (t~rombcicylopenia)
Hematuria (coagulopathy)
Family history ofbruismg (Hemophilia)
112
=:
;
-
=
c;
SECTION 3
..
•
o
••
CHAPTER 5 - RESPIRATORY
a..•
RESPIRATORY SYSTEM
!S3ESPIRATORY EXAMINATION.
:;;
oto'
••
1
....
-
t
,
Sit up, patient's
back f<wmg you -
•• FadzlyR
palpate for lymph
nod
Hands I forearm
c !lib mg; xanosis
1
•-
o Nico - "'stili ing
to'
Mant0UYr
•i Palpate fa<h pulsc·
.•
•
(bo~ding Hypercap-
nia) w He counting
respiratory rate
:;;
oto' t 1
••
.•-.
• t
Introduce
youtse~f
Shake the
1
Excuse me Sir,~ould like to
patient's hand complete my exa ination by
checkingUie:
-not necessary to count the radial pulse
rale. Fever chart, s~u urn pot
~'ask patient to breath in and inspect the
Peak ex . alo do rate
chest movement from the end of the bed.
114
'" Presenting your diagnosis to the examiner
:,.•
process movement shift note sounds resonance
Consolidation j. On affected No~ ""II Bronchial T Crackles
••-
side
Collapse t on affected
side
Towards
affected
""U .1.1 absent ,j. 1 absent None
side
Pleural
effusion
,j. on affected
side
Towards
opposite
Stony
dullness
,j. 1 absent ,j. 1 absent Pleural rub
~
.I. on affected
side
Towards t / absent t 1 absent Absent =
..,-.
Pneumothorax Normal Or
side opposite hyper-
side
,
~nant
Bronchial
asthma ,
Symmemcally None Normal Normal 1
,
Normal 1 Rhonchi
==
Vesicular
with ••
prolonged
expiratory
phase
a
Interstitial
lung disease ,
Symmetrically None Nonnal Nonnal T Fine
inspiratory
crackl.." :=
:
••-
Causes of lung collapse
• bronchogenic carcinoma
• tuberculosis
• bronchial adenoma
Causes of lung consolidation
• bacterial pneumonia
• bronchogenic carcinoma
• pulmonary infarct
.o•-
:0
:0
The mediocre teacher tells. The good teacher e"plains. The superior teacher demonstrates. The great
teacher inspires - William Arthur Ward
115
CASE 29 ASTHMA
OiagrlOs;s ofastllma
••2-
.-•.
Assessing ti,e clinical severity ofBA
Note: Pulsus paradoxus is not a reliable indicator of severe asthma becau.sc it correlates
poorly with peak flow reading. The generation of pulsus paradoxus requires deep
inspiratory effort, which may be absent in patients with severe muscle fatigue. Wheezing
can be absent in severe obstruction of airways.
116
~ CHRONIC OBSTRUCTIVE AIRWAY
DISEASE (COAD). ***
• eOAD is defined* as a disease state characterized by airflow limitatiOIl"U
tllat is /lot fully reversible. The airflow limitation is usually both progressive
and associated with an abnormal jnflammatory response of the lungs to
noxious particles or gases.
*GOLD (Global Initiative for Chronic Obstructive Lung Disease). The old defini-
tions Le. chronic bronchitis and emphysema arc no longer widely used nowadays.
**slowing of expiratory airflow as measured by spirometry.
*the only known genetic factor for developing eOAD. AAT is a protease inhibitor that
blocks the neutrophil elastase in the lungs.
117
OOID
"This man has chronic cough _ Tile presellce of wheezillg,
examine him'" prolonged expiration and
Ilyperillflated '"ngs indicQtG
~COAD
Neck
j JVP - ulmonale
USI! of muscles
of brratHfiis..-r- - -
:;
2
••-
.-
••
t
•
t
General inspection
Tachypnea
umg term oxygen
•
therapy
118
~ BRONCHOGENIC CARCINOMA (BC).
Histological types of Be
••
• squamous cell carcinoma (sqcc): 30-40%. VlP! Routinely
~
• adenocarcinoma (adc): 30-40%. IOOkfO'
• small cell carcinoma (sec): 2,0%. Horner's
elarge cell carcinoma (Icc): 5%. syndrome in
respiratory
examination
Some clinical!eahlres of Be
*apicaJ lung tumor with invasion of lower trunk (C8-TI) of brachial plexus (wasting of
small muscles of the hand), sympathetic chain (Horner's syndrome) and 2nd- 3rd ribs.
**symptoms or signs due to damage to organs that are remote from the site of primary
;
tumor or its metastases (mechanism - substances secreted by primary tumor). ;
'Lambert-Eaton Myasthenic syndrome - an autoimmune-mediated neuromuscular junc-
tion disorder caused by antibody directed to calcium channels in the presynaptic mem-
brane. The muscle weakness predominantly affects the proximal muscles while the
•p
extraocular muscle weakness is absent or mild (c.f. Myasthenia gravis). I:
!
o
InvestigatiotlofBC
• serum sodium, calcium.
• chest Xray - hilar mass or coin lesion, rib erosions, raised. hemidiaphragm .o
(phrenic nerve paralysis), lymphangitis carcinomatosis.
• pleural fluid cytology. .-o
•.
• bronchoseopy (+ washing and brushing) - endobronchial tumor.
• CT scan thorax / abdomen, bone sean - staging of BC
-lung function test - FEV , .
tl""e Ihe man thal Can smile in lTOl.lble. lhal can gatherslrenglh from dislress, and grow brave by
reflections _ Thomas Paine
119
CASE REPORT.
""
!!!
-••
fi
I
'- !-
!
o
-,8
;;
.
oc:
o
••
120
IROnOIlOGlnlO OIROlnO.1
"This man has hemoptysis and Look for signs ofprimary
weight loss - examine him" tumor, ITlt:dillstinnl spmui,
mrtastQSl5, PNS and Irmtmrnt
complicntions!
---
Tht: ciga,.rt~ smoking
'"Illn with QtlUia
1 ,.•
i
I
1
t I~
MartillA
•o
b
:;•
•-o
•
••
t 1
Excuse ilW-S • I would
General,· pection
like to comlJ:l te my exa·
c.-t. mination by.checking the:
Alopeci (hcmo- Fever chart, putum pot
therapy) History of oking
121
~ INTERSTITIAL LUNG DISEASE (ItO) • *
• fLD, also termed diffuse parenchymal lung diseases (DLPDs), are a group
of disorders that invlove the space between epithelial and endothelial
basement membranes.
Causes a/lLD
a) known causes
• drugs - amiodarone, busulphan
VIP!",
• connective tissue diseases (CfO) Common cause of
• occupational exposure - asbestos, silica ILD in exam - ILD
b) idiopathic pulmonary fibrosis (IPF) due to CTDs
c) granulomatous DPLD - Sarcoidosis (especially young
=
2
d) other forms ofDPLD adults)
••
.:-:
-
ClinicalleatE/res ofILD
• history:
- progressive cxertional dyspnea, dry cough.
- drugs, occupational/environmental exposure.
• physical findings:
- clubbing, inspiratory and fine basal crackles.
:
-a
•• - signs of pulmonary hypertension, cor pulmonale and CfOs.
Investigation ofILD
• chest Xray - bilateral basal reticulonodular shadows, "honeycombing".
:"•: _ lung function tests - arterial desaturation after exercise, restrictive pattern
(normal or t FEV 1/ FVC ratio), J. transfer factor.
•..-
-•
• CfO screen.
• high-resolution Cf (HRCI) - helps in diagnosis (e.g. characteristic changes
-.
•
are seen in IPF) and prognostication (demonstrates the extent of disease).
• bronchial lavage - the sampling of cells and non-cellular materials from
the lower respiratory tract can be diagnostic (e.g. lymphocytosis in drug-
induced lung diseases and inorganic particulate material in occupational
C
- lung diseases).
-lung biopsy - transbronchial biopsy and open lung biopsy (useful in Sar-
coidosis and ILOs due to ODs respectively).
Specific treatmentoflLD
• steroid I cyclophosphamide.
• treatment of underlyingcause.
Note: For case reports on ILD due 10 Rheumatoid Arthritis and Scleroderma,
please refer to Cases 35 and 38 respectively.
122
BRONCHIECTASIS
Etiology of brOlld,iectasis
••-..
• endobronchial obstruction - bronchial cause of bronchi-
adenoma I carcinoma ectasis - TB
• congenital- Kartagener's syndrome, • don't forget the
hypogammaglobulinemia (extremely sputum pot o
rare) (copious sputum)!
=
••o
SOlne complica NOlls ofbronch iectasis
• pneumonia.
• hemoptysis.
• cerebral abscess.
•o
• amyloidosis. •-•
..o
--
Tnvestiga tiOIl ofbrOJlc11iectasis
• sputum AFB / fungal culture.
• sputum culture - H, injluellzae", Ps. aerugillosa", Str. plleumolliae".
•-
• chest Xray - ring-like shadows (airways that are seen on end), tram lines
(airways that arc perpendicular to the Xray beam), focal opacities.
• Aspergillus precipitin test.
• high-resolution CT:
- the best tool for diagnosis of bronchiectasis.
- detects airways changes (e.g. dilatation) that are not visible on Xray.
There is nothing in the world SQ nlUch admlfed as a rna" who knows how to bear unhappiness with
courage-Seneca
123
~ PLEURAL EFFUSION (PEl.
/Ilvestigatioll of PE
• chest Xray / ultrasound / cr scan VIPS!'"
.
o==
••
- helps in finding the best site for pleural tap.
• pleural tap and fluid analysis
- protein, LDH
Exudate:
-
!:
- glucose (.!- in infection and malignancy)
- Gram stain, Ziehl-Neelsen stain
Protein> 30 g / 1
LDH>200IU / 1
..
~ cytology and clinical suspicion of tuberculosis or malignancy.
-•••• Types of
pleural flu.id
Transudate
Characteristics I laboratory
findings
Protein < 30 g II
Etiology
Cardiac failure
.-• Exudate
LDH<200lU/L
Pleural; serum LDH ratio < 0.6
Protein> 30 gil
LDH>2QOIU/L
Nephrotic syndrome
Chronic liver disease
Malignancy (primary I secondary)
Pncumonia
Pleural, serum LDH ratio ~ 0.6 Tuberrulosis
Pulmonary infarrlion
Connective tissue diseases
Hemorrhagic Malignancy
Pulmonary embolism
Trauma
Empyema Turbid, foul smelling Lung infection (pncumonia, abscess)
Centrifugt.>d pleural fluid - dear Chest trauma
supernatant Thoracic surgery
Subdiaphragmatic abscess
Chylothorax Milky fluid Malignancy (lymphoma)
(Fig. 34- Centrifuged pleural fluid- Trauma
Section 2) turbid supernatant
Increased triglyceride
124
-••.
••
•
o
SECTION 3 o
=
o
••
CHAPTER 6 - RHEUMATOLOGY :=
••
RHEUMATOLOGY
g ~":~ISES"
-•.
o
~4 of the following criteria; "RF RISES"
• Rheumatoid factor
• finger / hand joints involved for O?: 6 weeks
•..
Popular exam case is
• Rheumatoid nodules rheumatoid hand -
• !nvolvement of3 or mareiaint areas bilaterally
••
• ~tiffness (morning) ;:: 1 hour for ~ 6 weeks symmetrical,
--•
;::
•Iii
• .Eros'ions on Xray
• ~ymmetrical arthritis 2= 6 weeks
(Donnelly TIJ
126
W1l/1t is tile significance ofrlleumatoid factor (IV)?
• marked elevation of RF correlates closely with extra-articular features
(rheumatoid nodules, vasculitis, Sjogren's syndrome).
• does not correlate with activity of the arthritis!
Felty's syndrome
.
• seropositive RA + neutropenia + splenomegaly.
• serious infections, vasculitis. •
I I:
;:
Sjo:?,-ell's sylldrom
• association of keratoconjunctivitis sicca* (reduced
Serial values of RF
titers arc not useful
••
lacrimal secretion) and xerostomia (reduced in monitoring Cl
salivary gland secretion) with a connective tissue
disorder (usually RA).
progression of
arthritis
o
.-•=
• antj·Ro (S5-A) and anp-La (55-6) antibodies
are positive. /
*diagnosed using the Schirmer's filter p<!per lest; filter paper is placed at the lower
eyelid and the length of the wet column is measured· > 15 mm in normal and <: 5 I I:
=
mm in keratoconjunctivitis siccfI.
RAI Cl
Causes ofanemia ill
• anemia of chronic disease. • bleeding gastric ulcer (analgesic). -
l:I
• Felty's syndrome. • bone marrow suppression (cytotoxic).
•
Respiratorycomplicatiolls in RA
• pleuritis I effusion.
.:::;
=
• interstitial pulmonary fibrosis.
-
~
I(one advances confidently in the direction of his dreams, and endeavors to live the life which he has
imagined. he will mect with success unexpected in COmmOn hours _Henry David Thoreau
I 127
• rheumatoid nodules.
• iatrogenic - asthma (NSAID), interstitial fibrosis
(methotrexate). VlP!~
Some neurological complications ofRA Psoriatic arthritis
• carpal tunnel syndrome. may resemble RA -
• atlanto·axial subluxation - cervical myelopathy. look for psoriatic
• mononeUJitis multiplex. plagues at extensor
aspect of elbows
Specific treatmentofRA
• NSAIO· for rapid symptomatic relief.
• DMARDs (disease-modifying anti-rheumatic drugs) - start as soon as
diagnosis is made (within three months after onset of symptoms) e.g.
• CAn REPORT
!•
•
-••-
;:;
:=
•
a
.
•
.••
=
,,
128
RHEU.ATOID ARTHRITIS
Look for local (joint) I systemic
"This patient has chronic
mallifestations and iatrogellic
'-)oint pain - examine her"
--;::;::::__==,---__:ro:,mPlicationS!
Eyes
Episclcritis Precor<Jium
Sderomalad rforans)'" Mitra artic
KeralocoI£iunctivilis sicca regurg~tation
Cataract (steroid) Pericardial rub
Loua
J ••
t •
Elbow
Rheumat a nodule
Lungs
Pleural Ff.
Basal cral.;}des -
!o
Psoriati gues*
FadzlyR
interstitial
fibrosls .
6
C'
1
t pneumonia ~
••
'...
•••
o
(MePD -
IlJ
Joint erythema
Psoriatic Tylnem,
Palmar naW
I swelling
L~~r-=--:-:::::=-;-:::~:::~~
J ,"::•
Palpation Hoin -- •::;
movement
-
-
Neurological: Tinc1' 5 sign ~
Function: writing
t
Gene'ii'J.
Excuse me Sir, I would
• 1 like t~co~plete my .
lR~tion e:o;arn:tnation b ra"eckmg
eus aid the:
facie Urine wotein
(penicillamine, infection,
'Psoriatic arthropathy can amyloidosis)
mimic rheumatoid hand!
My grandfather onct' told me that there were two kinds of people' those who do the work and th"", who
take the credit. He told meto try to be in the first group; there waS much lesscompelltion _Indira Gandhi
129
~ ANKYLOSING SPONDYLITIS (AS). *
• typically affects young adults (age 30-40 years).
-M:Fratio=9:1.
• associated with HLA-B27 antigen.
Clinical featllres
-•.
o
o
• extra~articular features
- peripheral joints (hips, knees, shoulders)
- anterior uveitis
- apical lung fibrosis
••• - aortic regurgitation
-diarrhea ~
••
...-- Radiological filldings
-.
a
• sacroiliac joint erosion / sclerosis
• vertebral changes
- "squaring" of vertebra
.
~
- ossification of anterior longitudinalliga-
ment
- syndesmophyte formation
.-.
=
- "bamboo" spine
-
Fig. 36.1 Positive "occiput to wall" test - with
o the heels and back touching the wall, the patient
:;; is unable to touch the wall with the back of his
head (without raising the chin) due to the fixed
"Tile 7A '5
alAS"
c:
• flexion deformity of the cervical spine.
"indicates lumbar spine involvement if lumbar flexion
Anterior uveitis
does not increase by > 5 cm the distance betwen L5
(level of posterior iliac spine) and a point 15 cm Aortic regurgitation
above. Apical lung fibrosis
Achilles tendinitis
Specific treatment of AS Atlantoaxial subluxation
• NSAIDs, Tumor-Necrosis Factor antago- Amyloidosis
nists. Autoimmune bowel
disease
• Hiparthroplasty. (Smith M)
130
••
•••
•c;
o
=
-,..
o
g
.---
1got the bill for my surgery. Now I know what those doctors wert' wearing masks for - James H.1k>rt'n
131
InKYIOlinG "OnDTlITIl
"This patient has chronic
backache - examine him"
t p'Pi"»;ion
0
. t Pre<'ordiuD'l
Early diaStolic
murmur ('frtic
...•0 • Mil/tinA
rcgurgita ·on)
••. I
••
-..---...
t
Spine (standing)
Loss of lumb<l~ lordosis
Palpa - ve ~l
rmA~'
cr
I
a tende
..-•.
0
Redured vemcnt •
flexion / e tension /
lateral ne n
\
,\
Abdo~9
Hepat~enome.
galy (a:) loidosis)
,, ,,
Sdwbu's t t
0
~
--
•- "Occiput to wall"' t~t
•
\
Feet
I
C "pUSh on the sacrum t Achilles tendinitis
• with the heel of both
hands.
Planta fa8(!iitis
rJ
··these disorders,
;I
together with AS,
belong to the "
1\
I
spondyloarthropathies
(a group of
seronegative,
.
d
"
" Excuse me Sir, I ~Uld like to
complete m exa inalion by
inflammatory arthritis checking:
characterized by I-lip / knee ulder ;oinls
involvement of the Genitalia ratoderma
spine, peripheral blenorrhaglca..(fieiter's
arthritis and eT1thesiti!l). disease....)
I 132
B:D DERMATOMYOSITIS/POLYMYOSITIS. *
• inflammatory muscle disorders of unknown origin.
Features Polymyositis (PM) Dermatomyositis (OM)
Sex F>M F>M
Age adult childhood and adult
Rash no yes
Associated interstitial lung disease, interstitial lung disease,
conditions malignancy·, other
connective tissue diseases
malignancy·, other
connective tissue diseases
(
·common primary sites; lung and colon in men, breast and ovary in women.
Skin manifestations of OM
133
SCLERODERMA
• cri n
- proximal scleroderma (to metacarpopha·
:•
(At least the major or 2 or > minor
Fig. 38.3 Microstomia
criteria required for the diagnosis)
in scleroderma.
~thickening
• of the skin which is limited to fingers and not spreading proximal to the
metacarpophalangeal joints.
"'due to ischemia (Raynaud's phenomenon).
•
!
D
Clil/ical manifestations ofsclerodrnlla (Fig. 38.1·2· Section 2. Fig. 38.3)
CREST syndrome
• halcinosis, Kaynaud's phenomenon, fsophageal dysmotility, ~Ierodac·
dactyly, Ielangiectasia.
• associated with anti-eentromere antibody.
• better prognosis than scleroderma.
134
Rayllaud's phenomenoll (RP)
OwsesofRP, "COLD HAND"
• a syndrome of reversible
• Connective
peripheral ischemia usually tissue disease (scleroderma*)
occurring at the hands and feet, • Occupational (vibrating tool)
pre<:ipitated by cold. • Lupus erythematosus
• fingers tum white ~ cyanosed • Drugs (beta-blockers)
~ bright red (rewarming stage).
A good plan implemented today is better than a perfe.:t plan implemented tomorrow· George Pallon
135
'OI.IOD.I•• Ch...
Roman breast pi tight skin)
"'11tis patient Loud P2 (pull';'ff.Rhypertension)
has dysphagia Pericardial rub
- examine her'" Bibasal crackles (i rstitial fibrosis)
Abdomen
Sympathecto
Hcpatomega
primary bili
I
t palhy
H:mds
litis)
Fingerf
RaynaU;ld,"~~1
Sderod
Calcinosis I
Finger pulp
Excuse me-str, Iwould
Fixed flexio
like to eomp" my
Hand functi
examination
checking Ute:.
·demonstrated by difficulty in pinching up the \.:"
__
Blood P e
skin.
Urine - P nuria
-demonstrated by inability to insert patient's MlfrlinA
own Ihrt!C fingers into his / her mouth. Stool· stClitorrhea
~ SYSTEMIC LUPUS ERYTHEMATOSUS
(SLEl.
Diagllosis olSLE
• Oral ulcers
• Rash (malar)
"ORDER HIS ANA "
VIP~
• Discoid rash
• .Exaggerated photosensitivity
• Renal - proteinuria, cellular casts Diagnosis
• Hematological- hemolysis, leuko- / thrombocytopenia of SLE-
• !mmunological- LEcell, anti-dsDNA Ab, VDRL
• §erositis - pleuritis, pericarditis "ORDER
• Arthritis - non-erosive arthritis fflS
• Neurological- seizures, psychosis ANA"
• Antinuclear antibody (Donnelly TJ)
Note: American Rheumatic Association criteria - to make a diagnosis of SLE, any four
or more of the 11 criteria should be present, either simultaneously or serially.
137
• Focal proliferative glomerulonephritis
(GN). VIP! C-reactive protein:
~
• Diffuse proliferative GN. • normal ill flareo!
• MembranousGN. SLE
• Advanced sclerosis. • i in infection
AntipllospllOlipid syndrome
• a hypercoagulable state: recurrent venous + / - arterial thrombosis + / -
abortion in the presence of anti phospholipid antibodies.
• it may be primary or secondary (most commonly SLE).
AIltipllOSpllOlipid antibodies
• anticardiolipin antibody.
:; • lupus anticoagulant - an antibody interfering with the prothrombin
9 activator complex -+ prolonged PTT which is not corrected by addition
•2
of normal plasma (thus, excluding a factor deficiency). However, it is
associated with paradoxical thrombosis in vivo.
••
Mixed cOllllective tisslle disease
• features resemblingSLE, scleroderma and polymyositis in the presence
of high titers of anti-RNP (ribonucleoprotein) antibodies.
-
o
-
cyclophosphamide.
0 ... RIPORT
•• This 36-year-old Chinese lady complained of facial rash which worsened
e with sun exposure (photosensitivity). She also had alopecia and joint
pain. Findings: Blood pressure 180 / 120 mm Hg. Malar rash (Fig. 39 -
Section 2) and oral ulcers present. No ankle edema. Investigations:
Positive antinuclear factor, ,l. 0 / C4, tt anti-dsDNA antibody titer,
urine - deformed red cells ++, white cells ++, red cell casts ++, protein
+++.24 hours urine protein -1.2 g. Diagnosis: StE with IIephritis.
Progress: She responded to pulsed IV methylprednisolone followed by
oral prednisolone.
138
In
"11tis young Chinese lady
has facial rash and joint
pain - examine her'"
\ I /
-
- " :Jlf.
ill ...
JIjjl
/ Ch~l
Pcricarltial rub
Pleural rub / ••••
Face I head,.. -
Alop«iIl ........
Discoid rash
effusion
1 •
Phot05~fsthtlr Inlliar rash t
Eyes. -ranemu., soft Abdomen
.....e=
o
exudate....: Splenom~galy
Oral ulcers
Cervical lymph nodes /
Abdo . I
=
//
tendem
t MartinA
(peritonism)
$
•
1 •-o
E9
AimS
Vascu itis
t
/
Leg>
Proximah"eaJ(ness
Uvedo rcticularis·
-.•.
Ankle edema l:
Hands
•
..••=
(nephrotic syndrome)
Raynaud:s phenomenon Vasculitis
Arthritis
Nailfol i¢arcts
Periungual t:!)'lhema
1 •.•o
t
Gereral
Excuse me Sir, I would
like to compl\te my
....
c
inspection examination by
Cushingoid checking the:
Blood 'N"'
Urine p(.otein,
"?!'rsistent ~disn-bluc mottling of celt cas
:::e legs that tends to be worse in
:::Jld weather.
Refled upon your Pf"'S'I1II bloessinp, 01 wtue:h""nr man has many - not on your past IllJ5fOl1voe, of
which ,n men hlo,".,
1I01tW • O>arles Dkl:ens
139
:t
g
..•o
••..
••
...
co_____
~
'
•o
.••
•o
SECTION 3 -.
oco
..
••
GASTROENTEROLOGY
HEPATOMEGALY
-•.
o
o
•
"normal liver span: 6-10 em in women, 8-12 em in men.
Causes offlepatomegaly
--
c
•o
.-•
•
• Infection"
- viral hepatitis, abscess (amebic, pyogenic),
typhoid
• Infiltration
~P!~
ot
- benign - fatty liver Commonest
- malignant" - myelo- / lymphoproHferative causes of
~
•ot disorders, hepatoma, metastases
• Autoimmune -lupoid hepatitis
hepatomegaly in
exam - infection
•
•..o • Drugs / toxin - alcohol" and malignancy
.••.
• Congestion - congestive cardiac failure"
• Metabolic - Wilson's disease (rare)
z "commonest causes.
TENDER LIVER
• hepatitis • abscess, cholangitis
• acute biliary obstruction • acute congestion - cardiac failure
FRICTION RUB
• tumor
142
Is it a splee,,?
SPLENOMEGALY
•••
Mrmoriu tiltS...
~
• can't get above it • splenic notch
• dull to percussion • not ballottable
• descends inferomed.ially with inspiration
Causes ofsplenomegaly
1k
• Congestion<-
- congestive cardiac failure, portal hypertension
C'
•
~
.•
• Hemolytic anemia·
- Thalassemia, hereditary spherocytosis
-Infection"
"CHINA"
o
.•• ")
- bacterial- infective endocarditis, typhoid, typhus
•
- viral· CMV, infectious mononucleosis
• parasitic - malaria
-fungal
• Neoplasia<- - myelo-J Iymphoproliferativedisorders
-.
o
o
C'
-o..•
• Autoimmune· connective tissue disease
~
·commonest causes.
I learned a 1onlll'trW ago that minoI" SU'P"'· i$ ... ~ thn· do lrw opention on - . - . . . • • not yOll
• 8ill W"lton
].13
~ CHRONIC LIVER DISEASE.
.•••• • specific signs - caput medusae, venous hum (heard over umbilical
collaterals); anorectal varices.
• non-specific signs - ascites, splenomegaly.
.••
o
Complications ofchrollic liver disease
.. • HEpatic encephalopathy
144
1I1vestigatioll ofcllrollic liver disease:
VIPI'" -.
SOllle laboratory markers ofalcollOlic liver disease
• y-glutamyltransferase (GGl), t MeV. 0
• liver biopsy· Mallory's hyaline (not pathognomonic). 0
e-
ComlllOIl treahllellt modalitiesfor variceal bleeding
....
Injection
• blood transfusion. marks and
tattoo are
0
• endoscopic sclerotherapy / band ligation.
• intravenousoctreotide. suggestive of
chronic HBV / 0
Trea tmell t of flepa tic ellcepltalopa tlly
HeV infedion
-
..-•-.
0
• identify and treat precipitating factors.
• laxative -lactulose.
• oral neomycin - eradication of gut flora.
Fig. 42 A 36-year-old
intravenous drug
III
M -...
user with chronic
hepatitis B infection
- he was treated for
infected left leg ulcer
M
..
(left) secondary to
repeated intrave-
nous injection. He
also had rather
unique tattoos (right)
- another risk factor
for viral hepatitis.
Uve as if you were 10 die lomorrow Learn as if you were to live forever - Mahatma Gandhi
145
CHRonlO L1nR DISEASE
"Carry out a general
Look for etiology (lIId complicatiom
examination and then of chronic liver disease!
...
proceed to the abdomen"
Chest
Neck Spiders
Lymph nodes Absent 3lCiIlary hair
Gynecomastia
:;
Face
Sclera - jaundice
Xanthelasmas (PBC') /
/
Abdomen
I
KF Tint (Wilson's)
g Parotid swelling Hepatomegaly
o Splenomegaly
.•••
(alcoholism)
Ascites
Liver bruit / rub
t (hepaloma)
,J.. bowel sound
.-••
o
Forearm
Scratch marks
(1'1$0) ,,/
(SBP)
Caput MedllSilc
Absent pubic hair
--••
(viral hepatitis)
Brllis;"g~
(coagulopathy) I
Cl t
•~ • Hands I-- - -
o-
FillgtT du/>bh'g .....
Palmar erythema
.o-. Leukonychia
Dupuytren's
contracture
•• (alcoholism)
Liver flap'
o
t
General inspection I
Hyperpigmentation
(hemochromatosis)
E:o;(use me Sir, I would like to
Drowsiness (hepatic
complete my e:o;amination by
encephalopathy)
che(king the following:
*a form of myoclonus Testicular atrophy.
(NOT tremor). Constructional apra:o;ia·· (hepatic
··draw a five-pointed star. encephalopathy)
History - alcoholism. blood
'IIprimary biliary cirrhosis. transfusion. drug abuse
{Kayser-Fleischer ring.
146
~ ABDOMINAL MASSES.
Is it a kidney?
Ulli/literal
• renal cell carcinoma-
• acute pyelonephritis
• hydronephrosis·
• pyonephrosis
C\
•
~
•o
.
• renal abscess
• polycystic kidney (asymmetrical enlargement) Favorite exam
cases - polycystic
.••
Bilateral kidneys and
•
• polycystic kidneys·
• pyonephrosis
• hydronephrosis·
0111 ••
......
• ovarian tumor moid / descending
• transplanted kidney . . . .IDO.lnl. . . . colon
• carcinoma of • ovarian tumor
transverse colon
• transplanted kidney
• appendiceal abscess
1
PELVIS
• diverticular abscess
• f"""
• bladder
• ovarian tumor
• uterus (pregnancy,
tumor, fibroid)
Afte. two d.ys ,n lhe hospil.t r look a tum for thenu ..... _ w.e Fields
147
.
AUNDICE
•••
• yellowish discoloration of the skin, sclera and mucous membranes due
to bilirubin, a yellowish-orange pigment.
• usually clinically evident when serum bilirubin is more than 3 mg / dl
(51.3 umol / I).
Note: Carotenemia is yellowish discoloration of the skin but not the sclera and
mucous membranes. In addition, the urine color is normal.
:; Causes ofjarmdice
g HEPATOCELLULAR JAUNDICE
o
..•••• HEMOLYTIC
JAUNDICE""
• viral hepatitis·
• alcohol*
• drugs" - paracetamol, chlorpromazine
• autoimmune hepatitis
.••.
o
~
(JAUNDICE)
./
o
t
o•
..-.••.
CHOLESTATIC JAUNDICE
Extrahepatic dlOlestasis llltrahepatic dlO/estasis
a • gallstone- • liver metastases·
• pancreatic carcinoma" • primary biliary cirrhosis
• cholangiocarcinoma • sclerosing cholangitis
• pancreatitis • cholestatic form of
viral hepatitis *commonest causes.
148
InVESTIGATiOn or JAUnDICE
JAUNDICE
• Serum bilirubin - conjugated, unconjugated
• ALP, ALT, AST, GGT
• Urine bilirubin, urobilinogen
I
• conjugated ± uncon-
.-.
• unconjugated • conjugated hyper-
hyperbilirubinemia jugated hyperbiliru- bilirubinemia
• no bilirubinuria* hinemia • tt ALP and GGT
e-
• t urobilinogenuria • ASf I ALT > 1000 • bilirubinuria
IU/I • no urobilinogcn-
..
.o....
• normal liver enzymes
• bilirubinuria ± uria o
I urobilinogenuria
• t Retic count I
• -l- Hemoglobin
o-
CHOLESTATIC
HEPATOCELLULAR JAUNDICE
t JAUNDICE
HEMOLYSIS I e-
o<
t
• Peripheral
I • Viral hepatitis
screen (HAY,
HBV,HCVj
Ultrasound
I ERCP -..
blood film I
..-o
1:1
• Coomb's test
• Hemoglobin
I
• autoimmune No dilated Dilated bile
electrophoresis screen: ANF, bile ducts ducts
anti-smooth
muscle / anti-
I
intrahepatic
I
LKM antibodies** extrahepatic
biliary biliary
I obstruction obstruction
( No obvious diagnosis?
:\'ote: Liver biopsy helps in
?rognostication and making ( Liver biopsy)
diagnosis (e.g. autoimmune
,epatitis, primary biliary
~irrhosis) when blood and *unconjugatcd bilirubin is usually all
Jl1aging tesls cannot protein-bound and not waler-soluble:
,:>stablish a definitive thus, it cannol be excreted in the urine.
Jiagnosis. **anti-liver.kidney microsomal
anlibody.
Statistics are like a bikini. What they reveal is suggestive but what they conceal is vital
- Aaron Levenstein
149
ASCITES
Note: The causes of abdominal distension - fluid, fetus, fat, flatus and feces (5 F~
Causes ofascites
High gradient (SAAG '" or> 11 gIl) Low gradient (SAAG < 11 gIl)
:; Cirrhosis (especially with portal
hypertension)
Peritoneal carcinomatosis
o
~ Alcoholic hepatitis Peritoneal tuberculosis
o
.•••.
c
Cardiac failure
Budd-Chiari syndrome
Fulminant hepatic failure
Nephrotic syndrome
Serositis
Pancreatic / biliary ascites
.-••
o Note: The commonest cause of ascites is cirrhosis (90% of cases).
-•
o 5AAG < 11 gil do not (exudative ascites)
• the terms" exudate and transudate" are no longer
used because 5AAG is marc accurate in classifying
ascites
nephrotic
syndrome,
malignancy
andTB
- liver transplantation.
o
.••
Spontaneous bacterial peritonitis (SBP)
• usually occurs in the advanced stage of cirrhosis
• features - fever, abdominal pain,.l. bowel sound, altered mental status
..
o
~
• diagnosis - t ascitic polymorphs count (> 500 cells/ ul) in the
absence of a local infectious source (e.g. perforated viscus)
..
oe-
• treatment· third generation cephalosporin·
• poor prognostic sign"
.
·most cases of SBP are caused by Gram negative enteric bacteria (E. coli, Klebsiella).
"among those who survive the first episode of SBP, less than one·third survive another
year.
.-•
M
o
M
Hello brother.....
• Richard Sandler
A hypochondriac is one who has a pill fore"erylhing e~<:ept what ails him· Mignon Mclaughlin
151
ASOITES
"This gentleman has Look for dlronic liver disease
abdominal distension· Qnd portal hypertension!
examine him,"
N«.
Virchow's node (upper
abdominal malignancy)
t Jvp (cardiac failure,
constrictive pericarditis)
:;
•
Face
-
o
o
Sclera - jaundice
Parotid swelling
.•
•• (alcoholism) C hest
Gallop rhythm
(cardiac failure)
•
C
.••.
o
t
.. Abdomen
...•
Caput Medusae
Upward draining
superficial veins (~
/ Ive obstruction-)
t I
General
inspection
Jaundice
•
Malnourished
152
..o,•-.
.o-
..
c
SECTION 3
..••-..
l:I
•
o
••
CHAPTER 8 - INFECTIOUS DISEASE :=
••
GO
INFECTIOUS DISEASE
..o.
D Diagnosis ofHIV injection
• repeatedly positive HIV antibody lest (ELISA)
followed by a positive Western blot
..
;:
o
c
Diagnosis ofAIDS
• symptomatic: 23 AIDS-defining diseases (cerebral
Toxoplasmosis, TB (any site), extrapulmonary
Diagnosis of
AIDS- CD4
count < 200 cells
Cryptococcosis, CMV retinitis, KS, PCP, etc. I ul or the
• asymptomatic: CD4 count < 200 cells or CD4 presence of an
c percentage < 14 AIDS-defining
o illness
..
;:
o Complicatiolls ofHI V jJlfectioll
• remember that the specific complications can be predicted by knowing
-
C the stage of disease (i.e. the CD4 count).
CD4 cell count Organism Common manifestations
> 500 (cells / ull HIV Primary HIV infection
Persistent generalized lymphadenopathy
Aseptic meningitis
< 500 (c"lls I ul) Sir. pucl/l"o"ine.lf. iuj1".."::ae Community-acquired pneumonia
M.I"berculosis Pulmonary TB (PTB)
Candida spe<:ies Oropharyngeal/vaginal Candidiasi.>
HHV-S (KSHV) Kaposi's sarcoma (KS)
Varicella-zoster virus Shingles
Epstein-Barr \'irus Or"l hairy leukoplakia \OHL)
Non-Hodgkin'S lymphoma (NHL)
< 200 (cells / ull P".."mocysl;s car;"ii (PC) PC pneumonia (PCP)
Cryptosporidium Chronic diarrhea
< 100(0'115 / ul) Toxopll1sma geudi; Encephalitis
Cryl'focrxcus llroforllll1>15 Meningitis
M. fJd",rwl05;S Disseminated TB
M. a,'ium romplex (MAIC) Disseminated M.I1l';l/ln romplex
Cylomegalovirus «(MV) Retinitis, GIT disease, encephalitis
HIV Wasting syndrome, dementia,
I myelopathv
154
a) Some oral cOlllplicatiOlls ofHlV infection
Antiretroviral
••
~
•
.
Progrl'SSive multifocal
leukoencephalopathy
Diffuse encephalopathy
::;
Cryptococcal
meningoencephalitis·
CSF -Indian Ink I utex Ag Amphotericin
..•-o
::0
.-
Tuberculous CSF - PeR for TB I50niazid I
meningoencephalitis rifampicin
Viral encephalitis CSF - viral serology AcyelOI'ir
HIVdementia Bye",elusion Antiretroviral
"more often presents as chronic meningitis - headache without altered conscious level.
o::0
Chi/drl'/l..
155
c) Some denllQtological complications of HIV illfeetion
Disorders Physical findings Diagnosis Treatment
Herpes simplex Blisters I ulcers Tzanck smear Acyclovir
Oral, genital, rectal (multinucleated
epithelial giant cells)
Skin biopsy
Varicella~z05ter Blisters, dermatomal Clinical Acyclovir
Histoplasmosis Erythematous macules / Skin biopsy Amphotericin
papules, pustules
.....
Seborrheic Faint pink patches with Clinical Topical steroid
dermatitis waxy scales plus ketoronazole
OM Scalp, face, axilla, groin =~
-..
OM d) Some retinal compficatiolls ofHIV ill/eetio"
.-
III Retinal disorders
HIV retinopathy
Fundoscopic appear,J.nce
Cotton wool exudates,
Diagnosis
Clinical
Treatment
None -tend 10
.
hemorrhages, microilneurysms resolve
o Lack of progression spontaneousJy
.-
CMV retinitis Multiple granular, white dots Clinical Ganciclovir
o
OM
with hemorrhages
Follows vascular arcades,
resulting in triangular area of
..o
;:
Toxoplasma
retinochoroiditis
infection
Progressively enlarge
Whitening of retina
Relative absence of hemorrhages
Clinical Pyrimethamine
and sulfadiazine
..o-
Vitritis
OM
e) Some callses of lymphadmopathy
Consider HIV infection
ill HIV illfection
.
VIPI in - respiratory
• persistent generalized lymphadeno- (pneumonia, TB), focal
!: pathy. neurological
• tuberculous lymphadenitis. (Toxoplasmosis) and
• lymphoma, fungal infection. • cardiac (IVDU with
infective endocarditis)
lllvestigation of HfV infeetio" disorders
n) HIV-speciftc baseline tests
• CD4lymphocytecount and percentage.
• quantitative HIV RNA testing for viral load assessment.
156
• helps in making decision on primary prophylaxis againts GIs and
starting antiretroviral therapy.
$tT.p'leumOllille
<50
Any (positive tuberculin test
or history of exposure)
Any
Azithromycin
Isoniazid
Pneumococcal vaccine
a
..••-..
Hepatitis A or B Any Hepatitis A and B vaccine
'"the decision to treat asymptomatic patients with CD4 count> 200 cells / ul should be
•
made after considering the viral load and personal choice.
•::;
-=-_.. . .=..,-=""--,='!"'!~"'"-.~=--~=. .•-
CAIE REPORTS
..
o
is
Live as if you were 10 d.... lomorrow Learn as if ~·ou were 10 live forever. Mahatma Gandhi
157
•
••
~
fig 46.4 ( I br.un (U\ntr.l~tl'd) ~h(l\\mg
~
-
iIll
h~,) nng-l'nlMnlmg k''>JOll'> ,1\ the I,-fl
b,l"'ll g,mgll'l ,mel It'fl [ron!.ll loll(' (\\hllP
,HW\\ 1ll',Ic!"j
•o
~
.•-o
.-.
C
c
o
~
::c
-
158
HIY InnOTIOn
HExamine this patient's
Head/neck respiratory / neurological
Sinus tenderness / cardiovascular system H
(sinusitis)
Fundus (CMV
Mouth
retinitis, Toxo-
plasmosis scar, Candidiasis
...•
Herpetic lesions
soft exudates)
Aphthous ulcer
Orfliea/lymph
"od~ _ OHL
KS
Gingivitis 0
.-
1 0
c..
t Chest
Lung crackles
(PCP, TB)
.....•
II:l
Hands/ann
Tricuspid regurgi-
tation (infective
•
Tntfoo_ -
lllj«lioll mArk \.
(drug abuser) \
Onycholysis
•
•
endocarditis)
1 ...•--
•
(fungal infection)
,, Abdomen
Ilepatospleno- ...-•
0
t "
'\
,
c'
megaly
(fungal. Myro-
bacterium,
0
General inspection
Skill rash (herpes, lymphoma)
varicella·zoster, Inguinal
warts, KS, etc) ........ lymph nodes
Nutrition (wasting
syndrome)
Hemiparesis
(cerebral Toxoplas-
mosis)
.' I I
'. ,
L• .,
1
Proximal myopathy
Excuse me Sir, I would like to complete my Areflexia (peripheral
examination by checking the following:) .- neuropathy)
Genitalia (herpes simplex, warts, discharge) Upgoing plantars
Rectal ulcer (herpes simplex), fever (intracranial mass,
Mental status: depression, dementia myelopathy)
T'Iw faults of ol~ IS NSiI)' pn-crn'Pd. but tNt of ont'5elf ISd,ffic1llt topn«'l'-'! - BhlIg.o,·ad Cil.o
159
•
••
~
-a
~
..-
.•o
o
.-c.
.
o
••
-
ell
o
SECTION 3 o
=
...•
o
CHAPTER 9 - CARDIOLOGY .••
•
CARDIOLOGY
~RDIOVASCULAREXAMINATION.
Face Precordium '~_.... ~
Centr;al cyanosis Inspection - surgical scar
Polycythemia Palpation - apex beat,
Oral cavity - left parasternal heave,
dental hygiene, loud 52, thrill
:;
g
o
signs of HIV
infection
N~k
t
\
•
Precordium
Auscultation";
-
a
JVP - use torchlight!
Palpate carotid thrill
Apex - use hell, left lateral
position
•• LSE - breath in (fR)
.
Carotid artery - radiation
FadzlyR
Hands of murmur (AS)
Clubbing, cyanosis Sit up, bend forward, hold
o breath in expiration (AR)
.••- •
Stigmata of bjlcteria[
;: endocarditis
Radial pulse - rate,
rhythm, collapsing Lungs
•
!i
delay·, radial-radial
delay
t •
AbdQPten
-•
:0 HepalC)-> /
o Positio.n It spleQomegaly
~
-
a
•o•
Prop up the head of
bed to 45 d.egrees
t •
L<g'
Ankle edema
Introduce yourself
Shake the patient's
hand
162
~ EISENMENGER'S SYNDROME (ES). *
• a condition whereby a large left-ta-right shunt (ventricular septal defect /
VSD, atrial septal defect / ASD or with a patent ductus arteriosus I PDA)
causes severe pulmonary vascular disease and pulmonary hypertension
--+ leading to reversal of the direction of shunting --+ cyanosis (Fig. 47.1-2
- Section 2).
COlllplicatiOIlS olES
• hyperviscosity symptoms (headache, dizziness, visual
disturbance) - due to polycythemia
• hemoptysis - due to pulmonary infarction or rupture of
pulmonary arterioles / arteries
• cerebral infarction- due to paradoxicaJ embolism and
venous thrombosis
..o..
o-
• cerebral abscess IJ
• syncope - due to.!- cardiac output and atrial fibrillation
• right heart failure (;
• sudden death (cardiac arrhythmia)
=
Investigatioll of ES
• full blood count / hematocrit - degree of secondary polycythemia.
-.
OR
~
OR
• ECC - right ventricular hypertrophy, atrial fibrillation.
•..
• Chest Xray:
.
OR
- prominent central pulmonary arteries
- reduced markings ("pruning") of peripheral vessels
- right ventricular enlargement in ASD (nomal heart size in PDA and •
VSD).
• Echocardiography - shunt, increased right ventricular pressure. ..
~
BeWMeof the young doctor ~nd the old bdrber - Benjamin Franklin
163
J
IlIlnllIlnGER"S synDROIlE
,,
• t
a
c
~
. Hands
Finger dubbing and
Lungs
No crackles
.•".
•
~ cyanosis
• Differential clubbing
..•
c
/ cyanosis (PDA)
Radial pulse - small
volume, irregular Abdomen
c
~
..-.. (atrial fibrillation) Hepatomegaly
(right heart
failure)
L.",
•
Ankle edema
*toes are more clubbed and cyanosed than (right heart
the hands in PDA. failure)
164 (
I!lililD INFECTIVE ENDOCARDITIS (IE).
AA
Predisposing factors for IE
Mitral valve
• intravenous drug use (IVDU). VIP!
prolapse is the
• prosthetic valve. commonest
• chronic rheumatic valvular disease. predisposing
• mitral valve prolapse. cardiac lesion in
• nosochomial infection (intravenous line). native valve
endocarditis
Common pathogens in IE
• S. nurel/s", Str. viridulIs, Sfr. femiis, fungi. "'has be<:ome an increasingly
common cause of IE.
Clinical features of IE
• extmcardiac
a) systemic symptoms - fever, anorexia, weight loss, arthralgia. .
o
o
b) peripheral stigmata:
-
• splinter hemorrhages
• finger clubbing
• splenomegaly (mild)
-!:o
o
....-o
• Roth's spot - central pale area with surrounding
hemorrhage (Fig. 48.1 - Section 2)
• Osler's node ~ tender nodules on the finger pulp
• Janeway lesion - non-tender hemorrhagic macules on the
.....
palms and soles
::;
• cardiac - changing cardiac murmur, cardiac failure, pericardial rub.
Complications of IE o
..-.
• cardiac -congestive cardiac failure (infection-induced valvular damage),
oo
perivalvular extension of infection (new-onset bundle branch block or
..-.
atrioventricular block).
• neurological- stroke due to cerebral infarction (embolism) or hemorrhage
o
(rupture of mycotic aneurysm), cerebral abscess (cyanotic congenital heart
disease with paradoxical embolism).
• systemic embolism with abscess formation - spleen, liver, kidney.
Investigation of IE
• full blood count (normocytic, normochromic anemia, leukocytosis).
·ESR.
• urine - microscopic hematuria.
• blood culture - three samples from different sites in 24 hours.
• Echocardiography (transthoracic / transesophageal) - vegetations.
165
Causes of culture-negative endocarditis
• prior antibiotic treatment. Diagnosis of IE
VIP! depends on a
• fastidious organisms - HACEK organisms
•
constellation of
(Hemophilus, Actinobacillus, Cardiobac- clinical,
terium, Eikenella and Kingella), fungi, laboratory and
Coxiella burnelii. imaging findings
• right-sided endocarditis.
• sampling error (culture taken during abacteremic phase).
--
o
o
• persistent bacteremia or fever despite optimal antibiotic therapy.
• extensive valve ring infection.
D
o
. • prosthetic valve endocarditis - especially $. aurellS.
• recurrent episodes of systemic embolism.
D
-..-- CASE AEPOAT
o
....
D
o
...-
o
.-
166
InnOTIYI EnDOOARDITIS
Chest
Sternol scar
Tricuspid ~ mitral
t
Hartas 1 forearm
MartinA
regurgitation
Pr~thctic ~ck
Lung crackles
Fingl!T d °rts __ (abscess, cardiac o
•!•
failure)
Splinter hemorrhage
Phlebitis (f')iectioll)«..
-
Unequlll radial pul
(systemic embolism) '\ o
o
=
t .S•-.
.-
<C
•
••
D
o
o
••
D
--
:::;
t
General inspection
Unkempt Excuse me Sir, l.w.mud like to complete
Malnourished my examinatio ecking the:
Hemiparesis (embolic Temperature c~
stroke) Urine - haematu .
Happiness is IlOt a sIal.. to arrive at. but a mannerof traveling· MargoT.. t Lee Runbeck
167
D:D CARDIAC MURMUR •
:; Abbreviations:
--o
o
III
AS .. aortic stenosis
AI{ ..aortic regurgitation
ASD .. atrial septal defect
eM .. continuous murmur
MR .. mitral regurgitation
MS .. mitral stenosis
05 = opening snap
PDA • patent ductus arteriosus
•• OM .. diastolic murmur
EDM ~ early diastolic murmur
PH • pulmonary hypertension
PR .. pulmonary regurgitation
o ESM - ejection systolic murmur rs .. pulmonary stenosis
.••
HeM = hypertrophic cardiomyopathy PSM '" pansystolic murmur
ICS .. intercostal space RlCS .. right intercostal space
JVP .. juguLar venous pulsation
RSE .. right sternal edge
.•
LlCS .. left intercostal space
51 = first heart sound
• LSE .. left sternal edge
LVF .. left ventricular failure
MOM .. mid-diastolic murmur
52 • second heart sound
TR '" tricuspid regurgitation
V5D .. ventricular septal defect
o
•I-II PSM
<I) Apex
Other features Etiology
••o MR NormailYP
Apical thrill
Murmur:
Acute - papillary muscle rupture (acute
myocardial infarct)
Chronic - mitral valve prolapse,
- blowing, high-pitched rheumatic heart disea5e, infective
- platl'<Iu-shaped endocarditis, ischemic heart di5ea5e, left
- radiates to axilla ventricular dilatation
_J. with inspir;otion
b)4L1CS
VSD ]VP - normal or r ("a" wave in PH) Congenital
lbriH at 4L1CS Rupture of interventricular septum (acute
Murmur: myocardial infarct)
- harsh, plateau-shaped
- radiates to RSE
- unchanged with inspir;otion
TR r JVP ("v" wave) PH
Pulsatile liver Rheumatic
Thrill at LSE Right-sided endocarditis (drug abusers)
Murmur:
- similar to MR but radiates to xiphoid
- t with inspir;otion
168
Look for raised Innocent murmur: VIP!
~
IVP C'v" wave) Systolic ejection
ill TR! murmur
Short duration
(< 50% of systole)
Soft
Supine position - best heard
Satisfactory ECG & CXR
MartillA Single 52 (Jarada! Z)
169
DM Other fealures Etiology
Q)MDMatn~.t
MS Tapping apex beat (palpable Sl) Rheumatic heart disease
Loud 51'
OS"
Murmur:
- rumbling, low-pitched
- presystolic accentuation'"
Austin-Flint murmur Absence of loud 51 and OS Fluuering uf the anterior
Murmur - blowing mitral vah-., lea net in AR
bJEDMnt LSE
AR l'eripheral signs (St.'" the following Acute - info:.::ti,·c
section) endocarditis, disse<;lion of
Murmur: aorta
- blowing. decrescendo Chronic - rheumatic heart
- high-pilched disease, MarIan'S syndrome.
- best heard with patient seated, ankylosing spondylitis
leaning forward and breath held in
•o• *the mitral valve is held open by the greatly raised left atrial pressure until the force of
the ventricular systole doses the valve.
--the high left atrial pressure forces the valve cusps apart but the valve cone is halted
abruptly; OS indicates mobile valve cusps.
•
=0
***caused by left atrial systole - absent when atrial fibrillation has occurred.
170
Assessment ofseverih) of valvular defects
Valvular Clinkal findings Echoc....diographk
defect findings
AS Anacrotic pulse' Valve gradient:> 50 nun
Narrow pulse pressure Hg. vah'e area < 0.8 cm 2
Thrill
54
Long and Late-peaking ESM"
Signs of LVF
AR Wide pulse pressure
Long duration of the EOM
53
Austin Flint murmur
SignsofLVF
MS Closeness of 05 to 52 (due to r".ised left atrial Valve area < 1 eml
pressure)
long duration of MOM o
MR
loud 52 (signs of PH)
left ventricular enI.~rgement (displaced apex beat) ••g
53
-o
...-
Signs of lVF
*a variant of pulsus Iffln'lIs ef trt,d,IS in which a notch is palpable on the upstroke of the o
pulse wave.
"the loudness of murmur docs not correlate with severity of AS - in severe AS, the
murmur may be soft due to LVF while in mild AS, the murmur may be loud.
o
Signs ofdOlllil/(lIIce iI/mixed mitral valve disease ••g
•-o
Features Dominant MS Dominant MR
Apex beat Tapping, not displaced Heaving and displaced
51 Loud Soft
53 Absent Present
••
c
Signs ofdo",illallce ill mixed aortic valve disease
Features Dominant AS Dominant AR
••
C
~
ESM at 2LlCS - innocent murmur, ASO, PS
ESM at 2RICS - AS, HCM, aortic sclerosis
MOM at apex - MS
EDM at LSE - AR, PR
CM -PDA
If )"Oll tTl' rOll may fait if you don't Iry you're guaranteed to fai]- Jcsse 'ackso"
171
AORTIO REGURGITATiOn (AR)
,.
Lens subluxation
Argyll-Robertson
pupil (rare)
Uveitis (imkylosing
spondylitis)
Fundus - Roth's spot
..
--"
0
0
Headl mouth
de Musser's sign
Corrigan's sign
High-arched
palate (Marfan's
syndrome)
Chest
EDMof AR
•
Austin-Flint
Dental caries murmur
a
••0 Basal crackles - LVF
•0
....
-• H~'"
t
Quincke's sign
Spine •
K)' phoscoliosis
(Marian's syndrome)
•
endocarditIS
•0"•
Arachnodactyly
.
-0• t Femoral artery
WPistol-shot" sound
Duroziez's sign
• General
inspection 1
Marfanoid
Excuse me Sir, I would like to
habitus complete my examination by
checking the:
Abdomen - splenomegaly
_====;--"""1
Blood pressuf€' - wide pulse
pressure
Temperature chart
Urine - hematuria
172
HYPERTENSION
Callses ofIryperlells;oll *
• Idiopathic (essential hypertension - 90% of cases)
• bNS disorders (Cushing's reflex)
• High-output stales
• ~ndocrine disorders - Cushing's syndrome, acromegaly,
thyrotoxicosis, Conn's syndrome. pheochromocytoma
• !::.oarctation of aorta
• ,Kidney disease - renal artery stenosis, glomerulonephritis,
chronic renal failure, polycystic kidney
• Acute stress "1 CHECK A BP"
• ,!!irth control pills and other drugs o
• rt'egnancy (Do"ntl/y Tl) ••
-o
1:1
...-o
Complica naIlS ofIlypertf!1lsiotl
• neurological· stroke (cerebral infarction, hemorr- VIP! Cau,""
•
hage), hypertensive encephalopathy. dementia. of
hyper-
• cardiac - ischemic heart disease. aortic aneurysm,
.•'".'
tension:
dissecting aneurysm of aorta, left ventricular
failure. "'I CHECK A Dr'"
•.•
• retina - hypertensive retinopathy.
• renal- chronic renal failure, malignant hypertension.
• peripheral vascular disease.
.-o
Illvestigatioll ofhypertension
• full blood count.
• urinalysis.
• fasting lipid profile.
• renal function, uric acid.
• electrolytes - hypokalemia (Conn's
/ Cushing's syndrome).
.
• ECG - left ventricular hypertrophy. • Chest Xray.
M Qnagement ofizypertension
• general measures -low salt diet, weight reduction, stop smoking, reduce
alcohol intake.
• specific treatment -thiazides, beta-blockers, ACE inhibitors.
• aim for: :5140 mm Hg systolic blood pressure and:5 85 mm Hg diastolic
blood pressure.
J\'oone .ppeanon OUr st.~ "nless lhedl~or h;u pl.Iad them l~ foro"rbe..wl - P;ln.mahang
YogaNlnda
173
HYPIRTlnJlon
N«k
- Carotid
bruit
:;
Face / eyes
XantheJasmas
Fundus - hypertensive
retinopathy Chest •
Displaced apex beal,
gallop rhythm, basal
g crackles - left ventri-
o
-• cular failure
II
•o
c
•
-.•••-
o
t Abdomen
•
pulses (coarctation
of aorta, dissecting
aneurysm of aorta)
Legs
Proximal myopathy
(Cushing's / Conn's
t syndrome)
Peripheral pulses
General inspection
Cushingoid
Acromegalic
Sallow (uremia)
Excuse me Sir,J would like to
complete my examination by
chfiking Ihe:
•
Blood pressure - supine / standing-
*heard anteriorly over the epigastrium.
Urinalysis - proteinwia
.oa postural drop In blood pressurt' is
characteristic of pheochromocytoma. Family history of hypertension
174
B:m ATRIAL FIBRILLATION IAF). Iele
Causes ofAF
Irregularly irregular
-!:
o
pulse
..
• atrial flutter with varying block.
Pulse deficit
Absent "a" wave in JVP •
Illvestigatio1l ofAF
Variable intensity of Sl ••-
.-.
• thyroid function test.
• ECG - absent P waves, "f" waves.
••-
• Echocardiography - valvular defects, left atrial thrombus, left atrial size.
• Holter monitoring - paroxysmal AF.
MallagemelltofAF
The true laboratory is the mind, where behind illusions we uncover the laws of truth I.e. Bose
175
ATRIAl n.AIIIATlon OAADIOIOGY
ITRIAI (lIRIIIATIOn
Look for etIOlogy Qfld
complicatiolls ofA F!
Face! eyes
Malar Rush (mitral
stenosis - rare)
Coiter Chest
Exophthalmos Mitral valvotomy scar
Murmur - mitral
stenosis
Variable intensity of Sl
t
Hands
Irregularly irregular
pulse I
Warm, sweaty palm
.
~
.
• obstructive jaundice. • nephrotic syndrome.
i cholesterol
• xanthelasmas, tendinous
.-
e-
:n the End. we will remember not the words of our enemies, but the silence of our friends Marlin Luther
King..Jr
177
AnGinA
NKk
Carotid bruit
(diffuse atheroma·
tous disease)
IVP
Chest •
53· (.1. LV compliance I
PSM· (papillary
muscle dysfunction)
fSM (aortic stenosis,
hypertrophic
cardiomyopathy)
Gallop rhythm, basal
crackles (LVF)
• Legs
•
Thickening of
Achilles tendon
Dorsalis pedis
(diffuse athero-
matous disease)
•
General
inspection
Obesity
Tachypnea
178
~ ACUTE MYOCARDIAL INFARCTION
(AMI).
The men who tr" to do something and fail arC infinItely bcll~r than those who try to do nothing and
succeed - Oalc Camegic
179
B:m PROSTHETIC HEART VALVE.
b) Bioprostheses
• heterograft -composed of porcine (e.g. Carpentier-Edwards) or bovine
tissue (pericardial or valvular) mounted on a metal support.
• homograft - preserved human aortic valves.
--
o
o
a
Caged-ball
Tilting-disk
Normal
finding
Click, ESM
Click, ESM, DM
Abnormal
finding
Aortic DM
Normal
finding
Click, ESM
Click, DM
Abnormal
findillg
Apical PSM
Apical PSM
••o Heterograft
prostheses
No dick
ESM
Aortic DM No click
ESM,DM
Apical PSM
.•
~ during the first three months after valve replacement (due to increased
o risk of thromboembolism during this period).
• homograft bioprosthetic valve - does not need anticoagulation.
180
CAn REPORT
o
••
-oo
D
!:
..l;
...•
.•-.
o
••
•
..
•::;=
•
In nothing do men mo,," nearly approach the gods than in giving heallh to men • Cicero
181
'ROITHETIO HIART YAIYI
Facel eyes
Anemia (bleeding due 10
warfarin, bacterial
endocarditis, hemolysis)
Tinge of jaundice
....!!
(hemolysis) Chest
Fundus - Roth's spot 5temotomy scar
Soft / absent
prosthetic click - valve
-oa t thrombosis
Abnormal murmurs
•o•
(valve dysfunction)
New or changing
murmur (bacterial
endocarditis)
Basal crackles - left
•
..•.
ventricular failure
!:
•• Hands I forearm
I
••o PlIrpum (it'OtfrrriIJ) ,
-.•
Stigmata of
bacterial
.•o.
~
endocarditis
t
Excuse me Sir, I would
like to complete my
•... General
examination by
checking the:
Temperature
inspection
Hemiparesis Splenomegaly
(embolic Urinalysis - hematuria
stroke)
182
....•
.o
SECTION 3 -!:o
.
o
CHAPTER 10 - NEPHROLOGY
..•:=-
".
NEPHROLOGY
Defillitions
***
• Azotemia - accumulation of nitrogenous products (chiefly urea)
in the blood, as indicated by raised serum urea and creatinine
• Uremia - manifestations of organ dysfunction associated with azotemia
• CRF - permanent reduction in glomerular filtration rate* / GFR
(5-25 mljmin) sufficient to produce detectable alterations in well-
being and organ function
:; • End stage renal failure ~ the final stage of CRF (GFR < 5 rnl/rnin)
-o
o
when patients cannot survive without transplantation or long
term dialysis
..•
•• *normal GFR, as measured by creatinine clearance, is 90-120 ml/min,
...--•-.. • hypertension.
• pyelonephritis.
• polycystic kidney disease.
uria, nocturia, thirst
-long standing diabetes mellitus or
hypertension
Complicatiolls ofCRF
• Physical examination
- band keratopathy (calcium deposi-
tion beneath corneaJ epithelium)
.-
o
o
• Electrolyte - hyperkalemia,
hypocalcemia, hyperphospha-
temia.
- peripheral.neuropathy
• Investigations
- normochromic anemia
•• • Cardiovascular - cardiac failure,
hypertension, accelerated
- shrunken kidneys on ultrasound*
- renal osteodystrophy on Xray
o atherosclerosis, pericarditis.
-in CRF due to diabetic nephropathy and
• Hematological- anemia,
amyloidosis, the kidneys are enlarged.
bleeding tendency (platelet
dysfunction).
• Neurological- drowsiness, seizure, peripheral neuropathy.
• Metabolic / endocrine - hyperlipidemia, renal osteodystrophy.
• Gastrointestinal- anorexia, nausea, vomiting, bleeding.
• Skin - pruritus**, pigmentation, easy bruising.
184
Causes ofallemia ill eRF
• reduced renal erythropoietin production. VIP! Common exam
case - right / left
~
• hemolysis and depression of erythropoiesis
iliac fossa mass
due to uremia. (transplanted
• gastrointestinal bleeding. kidney)
• marrow fibrosis (osteitis fibrosa of secondary
hyperparathyroidism).
Renalosteodystrop11y
• skeletal complications of CRF characterized by:
-osteomalacia, osteitis fibrosa (caused by hypocalcemia, hyperphosphatemia
and reduced synthesis of 1,25 -DHCC).
-osteoporosis.
- osteosclerosis (increased density at upper and lower ends of vertebra /
"rugger jersey" spine).
..•
••
Illvestigatioll ofCRF
• blood tests - full blood count, ESR, urea, creatinine, calcium, phosphate,
complements, autoantibodies.
• urine - microscopy, 24-hour protein, creatinine clearance.
-.
o
oCO
• renal biopsy.
• radiological - ultrasound kidneys, bone Xray: o
Illdications for dialysis COllservative mallagement ofESRF
• Anemia - erytluopoeitin
:;•
.o-
• symptomatic uremia
despite optimal treatment • Bone disease - calcium, vitamin D
• fluid overload not
responsive to diuretics.
• Cardiac failure - diuretic, antihypertensive
• Diet - low protein .••.
• resistant hyperkalemia.
• significant impairment in
• Electrolytes - t potassium
(resornium, dialysis)
"ABCDEF" .--.
quaHty of life. • Fluid restriction
••••• -
C
••
OAII REPORT
This 41-year-old lady had undergone renal transplantation for end-stage
renal failure. She was noticed to have these physical signs (Fig. 55 - Section
2) while returning to the outpatient clinic for follow-up. Diagnosis: GlIm
hypertrophy and hypertrichosis secondary to long-term Cyclosporill therapy,
Comments: Renal grafts arc placed in retroperitoneal site in either iliac fossa
Jdjacent to large peripheral vessels and the bladder. Life-long immuno-
"uppression (Cyclosporin) is required after renal transplant.
: got the bill for my surgery. Now I know whallhose doctors were wearing masks for James H, Boren
185
OHRonlC RlnAI rAnURI
~---,'"
Forearm
Scratch marks
Bruising (platelet
dysfunction)
Hypertrichosisu
retinopathy
Chest
Pericardial rub
Gallop rhythm
•
Basal lung crackles
Vasculitis Vertebr.1! tenderness
Artrr;ovellorrs fis/ll/a (renal osteodystroph~·1
:; - thrill
-•o
o
..•
: II
c:
.•••--
.-. Hands
Pallor
MHalf-and-haLf'" nails·
Leukonychia Abdomen
•c: Asterixis TOlchkJJjf catheter
Transplant SCilr
••o Tinel's sign (carpal
tunnel syndrome) Ballotlable kidney(s)
-oc:
•
Hepatosplenomegaly
(polycystic kidney)
Loin tenderness
•
: II General inspection
Prostalomegaly
•
Hiccups
*dislal nail brown or red, proximal half pink Excuse me Sir, I would like to
or white. complete my examination by
~*side effects of long-term Cyclosporin
chKking the following:
therapy for ren.:tl transplant.
Blood pressure, urinalysis
186
B:m AUTOSOMAL DOMINANT POLYCYSTIC
KIDNEY DISEASE IADPKDj • *
• one of the commonest hereditary disorders.
• autosomal dominant inheritance with full penetrance.
• characterized by formation and progressive enlargement of renal cysts.
• ultimately progresses to end-stage renal failure in late middle life.
..-
o
Establislling tile diagnosis ofADPKD
• family history.
• ultrasound / CT scan / MRI of kidneys - bilateral renal cysts in index
..
o
patient plus one parent.
• gene-linkage studies:
...-..
o
..
)) mutation of PKD-l gene on chromosome 16 (85-90% of cases) - protein
product is polycystin-l.
:") mutation of PKD-2 gene on chromosome 4 (5-10% of cases) - protein
product is polycystin-2,
· not widely available.
-indicated for at risk patients who have no demonstrable renal cysts on
imaging studies.
E"en' human bring.. 01 "'h;llfl'\'fl' ong"" 01 \\"h<olC.',-er Slahon. d-"e; ':""J"'d. W.. must NCh nospt'ct
otherse-~ .. s w"l'O'$pt'ct 0IJrw!,'e; _U lbanl
CASE REPORT
....-
-
II
"l:
c:
"-o
ill:
-
~.
o
ChildrelL
if has 10 be given to
otlll~rs first ...,
188
POlYCYSTIC KIDnEY DUEASE
I
t Abdomen
Hepatomegaly
Forearm FlldzlyR
(liver cysts)
\,
Arteriovenous
fistula
Splenomegaly
(splenic cysts) ...o
I~alpable kidneys
t
Loin tenderness
(infected cyst) ..
:c
o
~
o-..
I
General
inspection
Sallow
appearance
.::-
III
(CRF)
~
~
.....-
III
I'm very proud thai I'm smarl enough IOgellO the point _Harry Tl"\lman
189
~
-•
o
o
•...
.•
....
c
1:1
o
~
SECTION 3 ...o
o
o
••
CHAPTER 11 - FUNDOSCOPY :•
•
-
'"
FUNDOSCOPY
Non-proliferative DR (NPDR)
• Microaneurysms, hard exudates
• Dot and blot hemorrhages
Pre-proliferative DR (PPDR)"
• Venous beading, soft exudates
=:
..
• Intraretinal microvascular abnormalities (lRMA)
o
o Proliferative DR (POR)
o • Neovascularization of the retina, optic disc or iris
.•.
A • Fibrous tissue adherent to vitreous face of retina
c
• Retinal detachment
...-.
-venous beading.. soft exudates and IRMA are signs of retinal ischemia, and indicate the
c likelihood of progression 10 PDR.
TennillologJ)
..••
o
~
MicrOfllleurysl1ls - focal dilatations of retinal capillaries that appear as red
dots.
Dot and blot Izemorrlwge - rupture of capillary in the middle layers of retina.
-
A
Hard exudate-lipid material that leaked out from capillaries, appear as bright
yellow lesions with distinct margin.
VeJlOliS beading - sausage-shaped dilatation of the retinal vein.
Soft exudate - infarction of nerve fibers that appear as white lesions with
blurred margin.
IRMA - dilated capillaries that represent intra-retinal neovascularization.
Retinal edema - grayish areas of retinal thickening.
192
- contraction of fibrovascular tissue and vitreous
--+ focal elevation of the retina --+ tractional
retinal detachment.
b) vitreous or pre-retinal hemorrhage:
VlPI.
- the overlying vitreous contracts and pull on the The occurrence of
DR is directly
fragile new vessels. related to
c) rubeosis iridis and rubeotic glaucoma: duration of
- the new vessels block the anterior chamber diabetes mellitus
drainage angle.
ManagementofDR
• address the risk factors that worsen DR especially
poorly controlled diabetes
- aggressive glycemic control reduces the risk of DR
in Type 1 diabetes (Diabetes Control and Complica-
Risk factors for ...
C
worsening of DR: ::0
-.....
tions Trial) and Type 2 diabetes (United Kingdom • poor glycemic III
Prospective Diabetes Study). control o
• retinal photocoagulation: • hypertension o
-leads to regression of new vessels and reduces risk • diabetic nephro-
pathy
o
of visual loss.
• hyperlipidemia
How does retinal photocoaglilatiolllVork?
• destruction of ischemic retinal tissue --+ reduced oxygen consumption--+
-••
III
reduced hypoxic stimulus for production of angiogenic factors.
• it does not directly photocoagulatc the new vessels. .-•o
Diagllosis ofdiabetes melliflls
.-••
..o.•.
• fasting plasma glucose> 7.0 mmol /1 or
::0
• symptoms (polyuria, polydipsia,
unexplained weight loss) and random
plasma glucose> 11.1 mmol / lor
• plasma glucose> 11.1 nunol / Iafter a 75
g glucose load
•...
1love the rnan lhal can smile in lrouble. that can gather strenglh from distress, and grow brave by
renl'ctions· Thomas Paine
193
~ HYPERTENSIVE RETINOPATHY.
-
o
o • Grade 4 - papilledema
...
Note: Narrowing of retinal arterioles and arteriovenous nipping are not specific
D
c to hypertensive retinopathy - they are also seen in arteriosclerosis due to ageing.
.. Maligllallt hypertellsioJl
• severely elevated blood pressure accompanied by Grade 4 retinopathy (Fig.
.•o
:0: 58 - Section 2).
..- Papilledema
retinopathy
absent
retinopathy
may be present
..-.•
~ Arteriolar constriction absent present
Soft exudates + +++
C
...
Hard exudates +++ + (macular star)
Microaneurysms +++ +
Dot and blot hemorrhages +++ +
Flame-shaped hemorrhages + +++
:0:
New vessels present absent
194
~ OITIC NEURITIS / PAPILLEDEMA •
...
Pupils RAPO" RAPD"" Normal
Color vision Affected Affected Normal
Side ;,Heeted Unilatl'ral Unilateral Bilateral
Causes Multiple Hypertension Space-occupying lesion (tumor, c:
sclerosis Diabetes mellitus meningitis. abscess)
Temporal arteritis Hydrocephalus
Malignant hypertension
Central n:tinal \'enous occlusion1 ..o
a
o
o
"'visual acuity may be impaired in the late stage
(optic atrophy). VIP! The most :=
..-..
~~relative afferent pupillary defect (Marcus- important and
Cunn pupil).
'widespread retinal hemorrhages ("battle-
common cause
of papilledema
o
is raised ICP
field" fundus) - Fig. 59.1 (Section 2).
-------" ~ .. .........~._.-------
o
c:
.
•
CASE RIPORT.
.--.
::;
PATIENT 1 This HIV-infected man presented with headache. Findings:
Bilateral sixtll cralliailleroe palsy, both eyes - "onl/al visllal {lCliity {Iud
pupils, blurred optic discs margin (Fig. 59.2 - Section 2). Investigations: cr
..
brain - normal, lumbar puncture - CSF pressure of 47 em CSF, white cells
:: -.
....
240/ mm 3, 90% lymphocytes, glucose 1.6 mmol/I, protein 2.9 g/dl and
positive Cryptococcal antigen test. Diagnosis: CryptowcCllI mmi"gitis with
bilattrnl pllpilltdtma.
a
II
Comments: Always look hard for Sixth cramal nerve palsy (false locahzmg
sign) in any patient with papilledema.
Happmess" not a state toarrlveat, but a mann.,.,. of tra,·ehng· Margore! Lee Runb«k
195
OPTIC ATROPHY
WP!~
Unilnteral Bilateral
Compression· - raised Toxin - alcohol, tobacco
intracranial pressure OCP)
(tumor, chronic meningitis)
Demyelinating disorder Hereditary - Leber's The most
(multiple sclerosis) optic atrophy, Retinitis
~ important cause
..o
pigmentosa of optic atrophy
o Ischemia - ischemic optic Metabolic - vitamin 812
o neuropathy, central retinal deficiency
is raised Iep
artery occlusion
...
Q
c ·thc optic atrophy may be bilateral if there is generalized increase in ICP.
...• •
CAli RIPORTS
..•
~ PATIENT 1 This HIV-negative man with Cryptococcal meningitis
had initially presented with headache and fever for four weeks. On
admission, the only neurological abnormality was bilateral
o papilledema. Visual acuity and pupils were nannal. Progress: Two
f
o
months later, examination revealed bilateral optic atrophy (Fig. 60.1 -
Section 2), fixed and dilated pI/pi Is, and total blindness. Diagnosis:
Bilateral optic atrophy dlle to chronic meningitis (Cryptococcal).
Comments: Papilledema is usually seen during the early stage of raised lep
(particularly when there is sharp rise in IeP). With chronically raised lep, optic
atrophy gradually develops. In this patient, the development of optic atrophy
and blindness could have been prevented if ventriculoperitoneal shunt was
carried out during the first presentation.
1%
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Gel/eml Medicine
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Macleod J (Ed). Davidson's Principles and Practice of Medicine (14th Edition).
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ShipmanJJ. Mnemonicsand Tactics in Surgery and Medicine. London: Lloyd-
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Weatherall OJ et al (Eds). Oxford Textbook of Medicine. Oxford University
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Neurology
Adams RD, Victor M, Ropper AH: Principles of Neurology. New York:
McCraw-Hill,1997.
PattenJP. Neurological differential diagnosis. New Delhi: Narosa Publishing
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197
Dermatology
Adam BA. Current treatment in Dermatology. Kuala Lumpur: 5. Abdul
Majeed & Co, 1994.
Mackie RM. Clinical Dermatology: An Illustrated Textbook (2 nd Edition).
Oxford University Press, 1986.
Roujeau JC, Kelly JP, Naldi L, et al. Medication use and the risk of5tevens-
Johnson syndrome and toxic epidermal necrolysis. N Engl J Med 1995;
333, 1600-1607.
Cardiovascular system
Braunwald E (Ed). Heart Disease. A textbook of Cardiovascular Medicine.
Philadelphia: WB Saunders Company, 1980.
Brickner ME, Hillis LD, Lange R. Congenital Heart Disease in Adults (Second
of Two Parts). N Engl J Med 2000; 342(5): 334 342.
4
Carabello BA, Crawford FA. Yalvular heart disease. N Eng J Me<! 1997; 337(1):
32-41.
Falk RH. Atrial fibrillation. N Engl J Med 2001; 344(14): 1067 1078.
4
Hematology
Hoffbrand AY, Pettit JE. Essential Haematology (3rd Edition). Oxford:
Blackwell Scientific Publications, 1993.
Nephrology
Badani KK, Hemal AK, Menon M. Autosomal dominant polycystic kidney
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Rllelllllafology
HeIHwell PS, Taylor WJ. Classification and diagnostic criteria for psoriatic
arthritis. Ann Rheum Dis2oo5; 64: 3-8.
KHppelJA, Dieppe PA. Rheumatology (2 fld Ed). Yo12. London: Mosby, 2000.
Moll JMH, Wright V. Psoriatic arthritis. Semin Arthritis Rheum 1973; 3: 55-
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198
lllfectious Diseases
Guerrant RL, Walker DH, Weller PF. Tropical Infectious Diseases. Principle,
Pathogen and Practice. Philadelphia: Churchill Livingstone, 1999.
Respiratory
Medford A, Maskell N. Pleural effusion. Postgrad Med J 2005; 81: 702-710.
Pauwels RA, Buist AS, Calverley PM, et al. Global strategy for the diagnosis,
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NHLBI/WHOGloballnitiativc for Chronic Obstructive Lung Disease
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1256-76.
The British Thoracic Society / Scottish Intercollegiate Guideline Network.
British Guideline on the management of asthm<l. Thor<lx 2003; 58 (51):
il-i94.
199 •
•
INDEX
A Caput Medusae 146
Abdominal masses 147 Cardiac murmur 168
Acoustic neuroma see vestibular Cardiovascular examination 162
schwannoma Carotid bruit 34
Acromegaly 38,40,69 Cerebellopontineangle tumor 15,
Acute myocardial infarction 179 16,17
Cerebral hemorrhage 32,35
Alpha-l-antitrypsin deficiency 117
Anemia 108,110 Cerebral infarct 32
Charcot-Marie-Tooth disease 27
Angel wing sign see Facioscapulo-
Charcot's triad 148
humeral dystrophy
Chronic liver disease 109,144,146
Angina 177.178
Ankylosing spondylitis 130,132 Chronic obstructive airway disease
117,118
Antiphospholipid syndrome 138
Aortic regurgitation 130,170,172 Chronic renal failure 184,186
Peripheral signs 170 Chylothorax 80,124
Aortic sclerosis 169 Clubbing 115,117,119,121,122,
146,165
Aortic stenosis 169
Continuous murmur 170
Arachnodactyly 49
Ascites 144,150,152 Courvoisier's law 148
Asthma 116 CREST syndrome 134
Atrial fibrillation 175,176 Cushing's disease 44,46
Atrial septal defect 169 Cushing's syndrome 44.. 46, 47, 70
Atrophic glossitis 79
Autoimmune polyendocrine syn- D
drome 42. 70 Deep vein thrombosis 106,107
Autoimmune thyroiditis 54
Dermatomyositis see Inflammatory
Axillary freckling 60 myopathy
Dexamethasone suppression test 44
B Diplopia 10
Bamboo spine 131 Dissociated sensory loss 23
Bell's palsy 15,16 Dysarthria 19
Beta-Thalassemia major 78,100,102 Dysphasia 19,20, 32
Bitemporal hemianopia 38,53 Expressive 21
Bronchiectasis 123 Receptive 22
Bronchogenic carcinoma 119,121 Global 22
Brown-Sequard syndrome 23 Dysphonia 19
Buffalo hump 46 Dystrophia myotonica 2, 3,4, 5, 66
Myotonia 3, 5
C
Cafe-au-Iait 60,74
•
201
.
E Dermatological complications 156
Easy bruising 111, 112 Central nervous system com-
Eisenmenger'ssyndrome 87,163, plications 155
164 Oral complications 155
Erythema multi forme 58 Candidiasis 87
Essential tremor 28 Hairy leukoplakia 87
Exophthalmos 41 Retinal complications 156
Hyperlipidemia 177
Hypertension 173,174
r Hypertrichosis (Cyclosporin) 92, 185
Facial weakness Hypertrophic cardiomyopathy 169
Bifacial 2 Hypertrophic pulmonaryosteoar-
Unilateral 15,16,17 thropathy 118,121
Upper motor neuron versus lower Hypopituitarism 38,51,52,53,71,
motor neuron 15 lDO
Facioscapulohumeral dystrophy 2, Hypothyroidism 54
3,6,32
Angel wing sign 7
Popeye arm sign 7
I
Winging of scapulae 6 infectious disease 154
False localizing sign 10 Infective endocarditis 165,167
Fatigability Sl!f! Myasthenia gravis Inflammatory myopathy 30,32, 81,
Felty's syndrome 127 119,133
Innocent murmur 169
Intentional tremor 28
G lnterstitiaiiung disease 122,128,
CoUron's sign 82,133 135
Grave's ophthalmopathy 41,69 iron overload 101
Crave's disease 41,42
Guillain-Barre syndrome 2,3,5 I
Gum hypertrophy (Cydosporin) Janeway lesion 89,165,167
92,185 Jaundice 148
Gynecomastia 121,146
K
II Kaposi's sarcoma 86,156
Heliotrope Tash 83, 133 Koebner phenomenon 63
l-lepatomegaly 142
Hepatosplenomegaly 143
High-arched palate 49
I
Homer's syndrome 8,9,67,119,120, Lacunar stroke 33, 35
121 lambert-Eaton myasthenic syn-
Human immunodeficiency virus drome 119
infection 154 Language function 20
Lid lag / lid retraction 41
202
Lisch nodul<> ,::('\ 7A p
Livedo reticularis 139
Pancoast syndrome 119,120
Liver span 142
Papilledema 96,195
Lung
Paraneoplastic syndrome 119
Bibasal crackles 115
Parkinsonism 11,12
Collapse 115
Parkinsonism-plus syndrome 11
Consolidation 115
Parkinson's disease 11,13,28
Lymphadenopathy 103,104,156
Pemberton's sign 43
Lymphoma 105
Pemphigoid 59,73
Pemphigus 59,73
m Peutz-]egherssyndrome 79,109
Malar rash 86,137,139 Pituitary tumor 38,51,52
Marfan's syndrome 48,50 Pleural effusion 124
Miller-Fisher syndrome 8,9 Polycystic kidneys 147,187,189
Mitral regurgitation 168 Polymyositis sa Inflammatory myo-
Mitral stenosis 170 pathy
Mixed connective tissue disease 138 Popeye arm sign see Facioscapulo-
Moon facies 46 humeral dystrophy
Mongoloid facies 101 Portal hypertension 144
Motor neuron disease 27,29 Posterior communicating artery
Multinodular goiter 41 aneurysm 8, 9
Multiple sclerosis 24,196 Progressive external ophthalmople-
Muscular dystrophy 30,31,32 gia 8,9
Myasthenia gravis 2,3,6,32 Progressive supranuclear palsy 11,
Fatigability 6 13
Myelopathy 23,25 Proptosis see Exophthalmos
Myotonia see Dystrophia myotonica Prosthetic heart valves 180,182
Proximal muscle weakness 30,32
Pseudobulbar / bulbar palsy 29
n Pseudo-Cushing's syndrome 45
Nail pitting 63,77 Pseudohypertrophy 31,32
Neurofibroma 60,74 Psoriasis 63,76
Plexiform 75 Psoriatic arthritis 63,77
Neurofibromatosis 60,62,74 Ptosis 8,9,42,121
Nikolsky's sign 59 Pulmonary stenosis 169
Pulmonary regurgitation 170
o Pupils 8,9
Occiput-to-wall test 130
Ophthalmoplegia 8,9,42 R
Optic atrophy 38,53,97,196 Raised intracranial pressure 10,195,
Optic neuritis 195 196
Osler's nodes 165,167 Ramsay Hunt syndrome 15,16,18,
68
203
Raynaud's phenomenon 84,133, Toxic epidermal necrolysis 58
135.136 Toxoplasmosis 154,157
Renalosteodystrophy 185 Transplanted kidney 92, 147
Respiratory examination 114 Tremor 28
Retinopathy Tricuspid regurgitation 167,168
Diabetic 93, 192
Laser scar 95
Retinal detachment 94
y
Vitreous hemorrhage 94 Venbicular septal defect 168
Hypertensive 95,194 Vestibular schwannoma 15,18,60
Rheumatoid arthritis 80,126,129 Virchow's triad 106
Rheumatoid factor 127 Vitiligo 42, 55
,
Roth's spot 88,165
W
Waddling gait 31,32
Schober's test 130 Wallenberg syndrome 9
Sclerodactyly 84,134,136 Walker sign 48
Scleroderma 83,134,135,136 Wasting of small muscles of the hand
Secondary parkinsonism 11 26
Sensory level 23 Winging of scapulae see Facioscapu-
Serum-ascitic albumin gradient 150 lohumeral dystrophy
Sixth cranial nerve palsy 10
Sjogren's syndrome 127,134
Slow relaxation of ankle jerk 53,55
X
Speech disorder 19 Xanthelasmas 92, 146, 171
Spinocerebellar ataxia 14 Xanthomas 90, 171
Splenomegaly 143 Tuberous 91,171
Spontaneous bacterial peritonitis
151
Steinberg sign 48,49
Stevens-Johnson syndrome 58, n
Stroke 33,36
Superior vena cava obstruction 79,
119,120
Syringomyelia 27,68
Systemic lupus erythematosus 137,
139
T
Target lesion 58,72
Third cranial nerve palsy 8,67
Thyrotoxicosis 41,43
Toxic adenoma 41
204