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Jeffrey Connor

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Pitting oedema bilaterally

– congestive cardiac failure– chronic liver disease, enteropathy, malabsorption, beri-beri– nephritic syndrome– drugs ie Ca antagonist

Unilateral – DVT, tumour, LN

Non-pitting oedema

- hypothyroidism- lymphoedema

o infectiouso malignanto congenitalo allergyo Milroy

Ulcers

- Venous stasis- Arterial- ischemic- Malignant- BCC, SCC- Infection – Staphylococcus aureus, syphilis, TB, mycoplasma, fungal- Neuropathic- painless, penetrating- DM, syphilis, leprosy- Systemic- DM, pyoderma gangrenosum, RA, lymphoid, HA

LVF

- IHD- Volume overload ( AR, MR)- Pressure overload (AS, systolic HTN)- PPT FACTORS- anaemia, thyrotoxicosis, rapid arrhythmia

RVF

- LVF- IHD- Volume overload( ASD, tricuspid regurgitation)- Pressure overload (pulm stenosis, pulm HTN)

Acute Pericarditis

- infection – viral, Coxsachie A/B influenza, TB septicaemia, - Post-AMI

- Post-cardiotomy- Uraemia- CTD- SLE, RA- Hypothyroidism

Systemic HTN

- Primaryo Essential , idiopathic, ETOH, Sodium, OSA

- Secondaryo Renal- RAS, pyelonephritis, PCKD, DM, reflux, analgesic, GNo Endocrine- Cushings, Conn, phaechromocytoma, acromegaly, thyrotoxicosis,

hypothyroidism, hyperPTHismo Coarctationo Other- pregnancy, PCV, toxins, hypercalcemia

Pulmonary HTN

- Primary idiopathic- Secondary

o PEo Lung disease – COPD, OSA, interstitial lung diseaseo Cardiac- LVF, congenital heart disease with L to R shunto Kyphosis, scoliosis

Mitral Stenosis

- Rheumatic fever- Congential parachute valve

Mitral Regurgitation

- Acuteo AMIo IEo Spontaneous ruptureo Trauma/surgery

- Chronico MVP- myxodematous degeneration, ASD, HOCM,Marfanso Degenerateo Rheumatico Papillary muscle defect – LVF, AMIo Cardiomyopathy – HOCM, dilated, restrictiveo CTD- marfan, RA, AS

o Congenital

Aortic stenosis

- Rheumatic fever- Senile degeneration- Supravalvular obstruction, fibrous diaphragm

Aortic Regurgitation

- Chronic-o congenitalo CTD – Ehlers Danlos, Marfanso Rheumatic fevero Aortic root dilatationo Dissecting aneurysm

- Acute-o IEo Aortic root- marfans, dissecting aneurysm

Tricuspid Stenosis

- Rheumatic fever

Tricuspid Regurgitation

- Functional- Rheumatic fever- Tricuspid valve prolapsed- R ventricular papillary muscle defect- Congenital – Ebstein Anomaly

Pulmonary Stenosis

- Congenital - Carcinoid

Pulmonary Regurgitation

- Pulm HTN- IE- Balloon valvulotomy ( for pulm stenosis)- Congenital atresia

HOCM (AD) – sarcomeric heavy chain/troponin gene mutation a/w Friedrich Ataxia

DCM

- Idiopathic / ETOH- Post-viral- Postpartum- Drugs – Doxirubicin- Dystrophia myotonica- Haemochromatosis

RCM

- Idiopathic eosinophilic- Endomyocardial fibrosis- Infiltrative – amyloidosis, granulomas sarcoid

Acyanotic Heart disease ( L to R shunt)

- VSD ( congential /acquired)- Ebstein anomaly- ASD- PDA- Coarctation of aorta

Cyanotic Congenital heart disease

- Eisenmenger disease ( R to L shunt)- Tetralogy of Fallot ( VSD, overriding aorta, RV outlet obstruction, RVH)- Transposition of great arteries

Cardiac Ex

- Abdo- Liver, AAA, PVD, Fundoscopy, Urine, Temp charts

Haemoptysis

- Respiratory o Bronchial CAo Pneumoniao PEo Bronchiectasis

- Cardiaco LVFo Mitral Stenosis

- Bleeding diatheses

Dyspnoea

- Airway o Asthma, COPD, bronchiectasis, URTI, LRTI, cystic fibrosis

- Parenchymalo Pneumonia, Pulmonary fibrosis, tumour

- Pulmonary Circulationo PE, AVM, pulmonary HTN

- Chest wall and Pleurao Ascites, effusion, rib fracture, kyphoscoliosis, NMJ

- Cardiaco Aortic Stenosiso ACSo LVF-> APO, Mitral valve pathology, cardiomyopathy, constrictive pericarditis

- Metabolico Anaemiao DKAo Hypothalamic lesiono psychogenic

Abnormal breathing pattern

- Sleep apnoea (cessation of airflow for 10s 10 times a night)o Obstructive – obesity, enlarged tonsils, acromegaly, hypothyroidism

- Cheyne Stokes ( period of apnoea followed by hyperpnoea from delayed medullary receptors to blood gases)

o LVF, Brain damage, high altitude- Kussmauls’ ( air hunger)

o Metabolic acidosis, CRF/DKA- Hyperventilation

o Alkalosiso Tetany

- Ataxic ( Biot)- irregular timing and deptho Brain stem

- Apneustic- post inspiratory pause in breathingo Pontine damage

- Paradoxical Respiration ( abdomen sucks in with inspiration)o Diaphragmatic paralysis

- Stridor o Sudden

Anaphylactic Toxin Acute epiglossitis Inhaled foreign body Angioedema

o Gradual Infection- retropharyngeal abcess, tonsillitis Tumours – larynx and pharynx Haematoma Angioedema

Pneumonia

- Lobar – pneumococcal, H influenza, Staphylococcus aureus- Bronchopneumonia- bacteria, viral (influenza, adenovirus, measles, CMV)- Atypical pneumonia – Mycoplasma pneumonia,Chlamydia psittaci, pneumonia, Legionella,

Coxiella Burnetti, Bordetella Pertussis

Collapse

- Intraluminal – mucus, foreign body, aspiration- Mural- CA- Extramural- aortic aneurysms, lymphadenopathy

Transudative pleural effusion

- Cardiac failure- Liver failure- Nephrotic syndrome- Hypothyroidism- Meigs’ syndrome (ovarian fibroma with ascites and effusion)

Exudative pleural effusion (>30g protein /l)

- Infection- subphrenic abscess, lung empyema, TB- Inflammatory- acute pancreatitis- Malignancy-- Infarction- Drugs- chemotherapy- Trauma- CTD- SLE, RA

Pneumothorax

- Spontaneous o Subpleural bullae ruptureo Emphysemao Asthma, lung abscess, bronchial CA, granulomas, fibrosiso Iatrogenic

Tension Pneumothorax

- Trauma- Spontaneous- Mechanical ventilation at high pressure

Bronchiectasis

- Congenitalo CF, hypogammaglobulinemia

- Acquiredo Childhood infections, pneumonia, localized disease, allergic aspergilosis

Emphysema

- Generalizedo Smoking (centrilobular)o Alpha1 AT deficiency (panacinar)

- Centriacinaro Smoking, bleb formation

Bronchitis

- Smoking- Recurrent infection

Pulmonary Fibrosis

- Upper lobe (SCHART) Silicosis, Coal’ pneumoconiosis, Histiocytosis, Ank Spondylosis, allergic aspergilosis, Radiation, TB

- Lower Lobe (RASCO)- RA, Asbestosis, Scleroderma, Cyptogenic fibrosing alveolitis, Other drugs- bleomycin, MTX, hydralazine, amiodarone, nitrofurantoin)

TB (Ghon focus with hilar lymphadenopathy and erythema nodosum)

Miliary TB- Spleen, liver, LN, kidneys, brains

CXR

- AIRWAY- Bones, soft tissue- Cardiac size- Diaphragm- Equal volume (ribs)- Fine detail pleura parenchyma- Gastric bubble- Hilum

Breast Lump

- Tendero Cysto Abscesso Fibroadenomao Inflammatory breast cancero Mastitiso Phyllodes tumour

- Non-tendero Fibroadenomao Cysto CAo Fat necrosis, galactocoeleo Firm irregular nipple discharge

Inflammatory

- Mastitis- mammary duct atresia, fat necrosis- fibrocysts

Respi Ex

- Cor Pulmonale (JVP, LL oedema) , Breast Exam, Abdo- liver ptosis, Bony tenderness- Peak flow, Spirometry, Urine, Temperature charts

Dysphagia

- Mechanical obstruction o Intrinsic – stricture, esophageal CA, esophagitis, pharyngeal web, Schatski ringo Extrinsic- goitre, mediatinal tumour,

- Neuromuscular motility- achalasia, diffuse esophageal spasm, scleroderma- Pharyngeal dysphagia-

o cricopharygenal dysfunction- Zenker diverticulumo neurological disorder- pseudobulbar, bulbar palsy, MG, myotonic dystrophy

Acute Upper GI bleed

- PUD- Acute peptic erosion- Mallory Weiss- Esophageal varices- Dieulafoy- CA- Trauma

Acute Lower GI bleed

- Angiodysplasia- Diverticular disease - Colonic CA , polyp- Haemorrhoid- Anal fissure- Massive upper GI bleed- - IBD- Ischemic colitis- Meckel diverticulum- Small bowel tumour- GB haemobilia

Diarrhoea

- Osmotic – lactulose intolerant- Secretory

o Infective- staph, vibrio, e. coli,o Hormonalo Villous adenoma

- Malabsorptive- steatorrhoea- Gut dysmotility- DM, thyrotoxicosis, IBS- Exudative- IBD, CA

Constipation

- Diet- Endocrine- hyperCalcemia, hypothyroid, phaechromocytoma, hypokalamia - Drugs- codeine, antidepressant, TCA, Ca++, AL+++- Neuro- Hirschsprung, ANS, MS- Obstruction- CA, LBO, volvulus, hernia

GI polyp and Cutaneous manifestation

- Peutz Jagher – pigmented macules on lips with hamartamatous polps- Gardner’s- cysts, fibromas, lipomas with adenocarcinoma, polyps, bone osteomata- Cronkhite- Canada- alopecia, glossitis, dystrophic nails with exocrine pancreas insufficiency,

diarrhoea

Hormone secreting tumour and Cutaneous manifestation

- Carcinoid- flushing, telangiectasia with diarrhea, hepatomegaly, wheeze, R heart failure- Systemic mastocytosis- telangiectasia with PUD, diarrhea, malabsorption, asthma, headache,- Glucagonoma- necrolytic ras with glossitis, LOW, and DM

Vascular disorder and cutaneous manifestations

- Hereditary haemorrhagic telangiectasia- telangiectasia with GI bleed, Nasopharyngeal bleed, Pulm AV fistula bleed, High CO heart failure

- Acanthosis nigricans- brown black skin papillomas and CA, and DM , acromegaly, PCOS, insulin resistance

- Dermatitis herpetiformis- pruritic vesicles with celiac disease- Zinc deficiency- red crusty scaly lesion with diarrhoea- Porphyria cutanea tarda- vesicles with alcoholic liver disease- Inflammatory bowel disease- pyoderma gangrenosum, erythema nodosum, clubbing, mouth

ulcers - Haemochromatosis- bronzing with hepatomegaly, chronic liver disease with DM, heart failure,

dementia, testicular atrophy- Systemic sclerosis- Raynaud, calcinosis, telangiectasia, sclerodactyl with GI reflux, dysmotility,

overgrowth and malabsorption- Pseudoxanthoma elasticum – plaques with bowel bleed- Blue rubber bleb- haemangiomas with bowel bleed- Dego( malignant atrophic papulosis)- papaules with perforation bowel infarct

Palmar erythema

- Chronic liver disease- Pregnancy - Thyrotoxicosis

- RA, - PCV, CML

Parotid enlargement

- Alcoholic liver disease- Mumps, HIV, EBV- Sarcoidosis- Lymphoma- Malnutrition- Sjogren

Gum hypertrophy

- Phenytoin, pregnancy, Scurvy, gingivitis, leukamia

Pigmented mouth lesion

- Heavy metal- lead, iron- Peutz jagher- Drugs, antimalarial, OCP, quinine- Addisons- Malignant melanoma

Fetor

- ETOH- Fetor hepaticus- Halitosis – dental decay- Ammoniacal – uraemia, CRF- Acetonic- DKA- Aldehyde- Cigarettes- Putrid

Mouth ulcers

- Aphtuous ulcer- Drugs- Trauma

Hepatomegaly

- Massiveo Malignancies- HCC, metastatic, leukaemia, lymphoma

o ETOHo Myeloproliferativeo R heart failure

- Moderateo Haemochromatosis, amyloidosiso Fatty liver secondary to obesity, alcohol, toxins, NASH, DM

- Mildo Hepatitiso Biliary obstructiono Hydatido HIV infection

Pulsatile liver- TR, HCC, Vascular abnormalities- SVC obstruction, AVM

Tender liver –

- Hepatitis- RHF, Budd Chiari- HCC- Abscess- Biliary Obstruction/ Cholangitis

Firm irregular liver

- HCC- Mets- Cirrhosis- Hydatid cysts granulomas, cysts, amyloid, lipoid

Gall bladder enlargement

- Jaundicedo CA of CBD, head of pancreas, Ampulla of Vater, Cholangiocarcinomao Mucocoele of GB

- Not jaundicedo Mucocoele or empyemao Cholangiocarcinomao Acute cholecystitis

Hepatosplenomegaly

- Chronic liver disease- portal HTN- Haem- Myeloproliferative, lymphoma, leukaemia, pernicious anemia, sickle-cell- Infection- acute viral hepatitis, EMV, CMV, HIV, toxoplasma, Brucellosis

- CTD- SLE, RA- Infiltrative- amyloid, sarcoid- Endocrine- acromegaly, thyrotoxicosis

RIF mass

- Appendiceal abcess- Malignancy- ovarian, carcinoid, bowel- Crohns- Hernia- Transplanted Kidney

LIF mass

- Faeces- Malignancy- Abscess- psoas- Amoebiasis- Hernia - Transplanted kidney

Upper abdomen mass

- LN- Liver- AAA- Pancreatic pseudocyst- CA- SBO

Pelvic – bladder, ovarian, uterus, SBO

Anterior abdominal mass

- Lipoma, sebaceous cyst, dermal fibroma, malignant SCC, melanoma- Hernia - epigastric, umbilical , incisional- Rectal sheath divarication- Rectus sheath haematoma

Ascites

- High serum : ascites albumino Cirrhosis ETOHo Fulminant hepatic failure

o CCF, constrictive pericarditisBudd Chiari

o Myxoedma, o Liver Mets

- Low serum: ascites albo Peritoneal carcinomatosiso TB o Pancreatic abscesso Nephritic syndrome

Solitary lump above inguinal ligament

- Inguinal hernia- Undescended testes- Cyst in canal of nuck- Hydrocoele- Iliac LN- Large femoral hernia

Solitary lump below inguinal ligament

- Saphenous varix- Femoral hernia- Femoral artery aneurysm- Psoas abscess- LN

PR mass

- Malignancy- uterine, ovary, prostatic, cervical, sigmoid, rectal CA- Polyp, anal polyp, diverticula,- Abscess- Endometriosis- Granuloma- FB

Acute abdomen

- Severe pain with peritonism, rigidity and prostrationo Perf PUD, viscuso Ruptured AAAo Severe pancreatitis

- Tenderness, rigidity o L

Pancreatitis Diverticulitis Splenic rupture Pyelonephritis Gastric distension abscess

o R Cholecystitis cholangitis Appendicitis PUD Pleurisy pneumonitis Hepatitis, gastritis, pyelonephritis

- RIF o Appendicitiso PUD perfo IBDo Meckel o Cholecystitis

- LIFo Colitiso Diverticulitiso Colonic CAo Pelvic ovarian, salpingitis

- Periumbilicalo Mesenteric ischaemia, appendix, SBO, pancreatitis

- Obs and Gynaeo Ectopic pregnancy, ovarian cyst rupture, salpingitis, uterine

- Infectiveo Sick contacto Travelo Water, food animals

Portal HTN

- Cirrhosis- Presinusoidal- portal vein compression, intravascular clotting, PCT, umbilical vein phlebitis- Intrahepatic – sarcoidosis, lymphoma, leukaemia, congenital hepatic fibrosis- Postsinusoidal- hepatic vein outflow obstruction, myeloproliferative, CA, OCP, pregnancy, HA,

constrictive pericarditis, CCF, schistosomiasis

Hepatic encephalopathy

- Acute liver failure- Cirrhosis- Portosystemic encephalopathy- Diarrhea, vomiting- GI bleed- Infection – UTI, Chest, Penumonia, SBP- Drugs – Sedatives- Metabolic- hypoglycaemia

Dysphagia

- Upper oesphageal web- Plummel Vinson a/w IDA, cricopharyngeal 0 Zenker Diverticulum- Lower Schatzki Ring

Malabsorption

- Lipolytic- CF, pancreatic insufficiency, chronic pancreatitis- Micellar- bile salts decreased from biliary obstruction, chronic liver disease, bacterial

overgrowth, terminal ilieitis- Mucosal- celiac, whipple disease, bowel ischemia, amyloidosis, HIV,hypogammaglobulinemia- Devliery defect- lymphagiectasia, abetaproteinemia, CA of lymphatics

Ulcerative colitis

- Liver- PSC, cirrhosis- Blood- Anaemia, HA- Joint- Arthritis- Derm/Skin- Pyoderma gangrenosum, erythema nodosum- Eyes- uveitis, scleritis, episcleritis

Crohns’s disease

- Liver- Bones osteomalacia, osteoporosis- Gut- malabsorption- Finger clubbing- Renal and GB stones

GI exam

- Hernia, PR, vomitus and stools, urine, temp, CVS for ascites

Acute renal failure

- Pre renalo Shock

Fluid loss, bleed, vomit, diarrhea, Cardiogenic schock

o Renovascular- dissection, atheroma, emboluso Hepatorenal syndrome

- Intra renalo Renal tubular acidosis- ischemia, toxins, drugs, and rhabdomyolysiso Tubulointerstitial disease – drugs PPI, sulphonamide, cyclosporine A, urate or Ca

depositso Myelomao Primary renal disease –Vasculitis,GN, CTDo Pyelonephritis

- Post Renalo Urethral obstruction

Calculi Blood clot Sloughed papilla Trauma Phimosis, paraphimosis

o Bladder neck Calculi Blood clot Prostate hypertrophy, CA

o Bilateral ureteric obstruction Blood clot, pyogenic debris, calculi, retroperitoneal fibrosis, uterine prolapsed,

tumour, surgery

Rapidly progressive renal failure

- Urinary tract obstruction- RPGN- Bilateral RAS- Scleroderma- Malignant HTN- HUS

Chronic renal failure

- Diabetes- GN

- HTN- Analgesics- Reflux- PCKD- Obstruction- Amyloid

Asterixis

- Chronic liver disease- Cardiac failure- Respiratory failure – CO2 narcosis- Renal – uraemia- Metabolic- hypoglycaemia, hypokalamia, hypomagnesium, Barbiturate

Unilateral palpable kidney

- RCC- Hydronephrosis- PCKD- Solitary cyst- Acute Renal vein thrombosis- Pyelonephritis, xanthogranulomatous ones, abscess- Compensatory single kidney

Bilateral palpable kidney

- PCKD- DM- RCC, hydronephrosis, renal vein thrombosis, bilaterally- Infiltrative- amyloid lymphoma- acromegaly

Proteinuria

- Renalo Nephrotic syndrome

- Non renalo Exercise, fever, HTN, CCF, burns, blood transfusion, Post Op, ETOH

- Orthostatico DM, HTN, decreased renal function

Nephrotic Syndrome

- Primaryo MCDo Membranouso Focal segmental Glomerular sclerosis

- Secondaryo Drugs- penicillamine, NSAIDS, probenecids, Gouto Systemic- lupus, DM, amyloidosiso Carcinoma- lymphoma, Multiple Myelomao Infection- hep B, Co Allergy- bee, vaccines

Glycosuria

- DM- Salicylates, ascorbic- Renal glycosuria- Fanconi syndrome- proximal renal tubular disease

ketonuria

- DKA- starvation

Positive blood dipstix

- haematuriao Renal – GN, PCKD, Pyelonephritis, RCC, malignant HTN, renal infarcto Renal tract- cystitis, calculi, bladder tumour, prostatism, urethritis

- Haemoglobinuriao MAHA, March HA, Prosthetic heart valves, PNH, cold agglutinin

- Myoglobulinuriao Rhabdomyolysis

Muscle infarct Excessive contraction Convulsion Viral myositis Drugs ETOH snake, statins Idiopathic

WCC in urine- Pyuria – UTI inflammation

Casts

- Hyaline – normal mucoprotein with 1 or 2 RBC WCC

- Granular casts- abnormal cylindrical granular casts from proteinuria- Red cell cast – primary glomerular disease- WCC casts- bacterial pyelonephritis, GN, kidney infarct, vasculitis- Fatty casts suggestive of nephrotic syndrome

Genital lesion

- ulcero HSV, Syphiliso Malignancy SCCo Chancroido Behcets syndrome

- non ulceratingo balanitis- reiters, poor hygieneo veneral wartso primary skin condition- psoriasis

Scrotal mass

- hydrocoele- varicocoele- inguinal hernia- testicular tumous- cyst in epididymis, hydatid, Morgagni- Epididymitis- Spermatocoele

Renal Exam

- Back nephrectomy scar, oedema , LL oedema, Urine, Temperature, BP lying and standing, Fundoscopy- HTN and DM, rash-livedo reticularis

Ecchymoses

- Thrombocytopenia- Coagulation disorders

o Acquiredo Congenital

Petechiae

- Thrombocytopenia- Platelet dysfunction- Bleeding in small vessel

Generalised lymphadenopathy

- Infection- Malignancy- Infiltrative- CTD- Drugs

Localised lymphadenopathy

- Infection- Malignancy

Splenomegaly

- Massive- Moderate- Mild

Anaemia

- Microcytic hypochromico IDA

Chronic blood loss ( GI, menses) Malabsorption Hookworm infection

o Thalassaemiao Sideroblastic anaemiao Pregnancyo Long standing ACD

- Normocytic normochromico Bone marrow failure –

aplastic anaemia - drugs, irradiation, ineffective haematopoiesis - myelodysplasia infiltration- lymphoma, leukaemia, sarcoidosis, myelofibrosis

o Haemolytic anaemia – Autoimmune, Warm/cold antibody, PNH, March, Microangiopathic HA, Heart valves, DIC

o Anaemia of chronic disease Malignancy, RA, SLE, TB, IBD, endocrine

- Macrocytico Megaloblastic

Folate def Diet deficiency esp in ETOH Increased cell turnover in pregnancy, chronic inflammation Drugs- MTX, phenytoin, valproate

B12 def Diet Malabsorption Celiac Terminal ilieum Crohns Gastrectomy, Pernicious anemia

o Non megaloblastic ETOH, cirrhosis Hypothyroidism Reticulocytosis, marrow infiltration, Myelodysplasia Myeloproliferative syndromes

Pancytopenia

- Aplastic anaemia- Marrow infiltration - Acute leukaemia

PRV

- Idiotpathic- Secondary

o Increased EPO RCC, PCKD HCC Cerebral haemangiomas Uterine fibroma

o Decreased O2 Chronic lung disease Sleep apneoa

Congenital cyanotic heart disease CO poisoning High Altitude

o Relative dehydration

Thrombocytosis

- >400o Haemorrhage, o Surgeryo Post splenectomyo IDAo Chronic inflammatoryo malignancy

- >800o Myeloproliferative o Post splenectomyo Malignancy

Hodgkin

- Reed Sternberg cells - LN discrete rubbery, painless, large superficial nodes- LOW, fever- Hepato Splenomegaly- Organ infiltration – lung, bone, spinal cord, nodularskin

Non Hodgkin

- LN >1 site- Hepatosplenomeglay- Less common LOW, FEVER- Extranodal spread, arise elsewhere

Haem Ex

- Bone tenderness, lung effusion, Liver, Spleen, - Neurological exam LL- Temperature, Urine(blood, bile), PR exam* blood, Fundi(haemorrhage, infection)

Monoarthritis- Septic arthritis

o Haematogenous – staph , gonococcalo Penetrating trauma

- Traumatic- Gout, pseudogout- Haemarthroses- Seronegative arthropathy

Polyarthritis

- Acute- infection bacterial, viral- Chronic

o RA symmetrical involvement of wrist, MCP, PIP, cervical spine, knees, tarsalMTjointso OA symmetrical involvement of DIP PIP, MCP, AcroClavicular, kneeso Seronegative arthropathy asymmetrical affect SI, spine, hip knee

Ank spond Psoriatic Reiter;s

o Gout, pseudogouto CTD – SLE, RAo Infection- lyme , spiroochaetes

Raynaud’s Phenomenon

- Reflex- idiopathic, vibrational tools, cervical spondylosis- Arterial disease- embolism, buergers Thromboangitis obliterans, Trauma- CTD- scleroderma, SLE, PAN, RA, polymyositis- Haem- PCV, leukemia, cold agglutinin- Drugs- beta blockers, bergers disease, Vinyl Cl

Sjogrens

- Dry eyes and mouth- Chest infection- Kidneys RTA and diabetes insipidus- Atrophic vaginitis- Pseudolymphoma

Deforming polyarthropathy

- RA- OA- Tophaceous gout

- Sero-ve arthropathy arthritis mutilans- Infection – Lyme

Carpal Tunnel Syndrome

- Idiopathic- Obesity- Pregnancy- Repetitive work- DM, Hypothyroid, Acromegaly- MS- RA, gout, amyloidosis- Carpal bone osteomyelitis

Arthritis with nodules

- RA- SLE, rheumatic fever, sarcoidosis

RA exam

- Face – eyes and mouth for Sjogrens- Neck – TMJ, cervical spine tenderness and LN- Chest- chest infection, pericarditis, pleural effusions, pulmonary fibrosis, Caplans- nodules- Abdo-Felty- splenomegaly hepatomegaly- LL – inguinal LN, Peripheral neuropathy- Ankle Archilles tendon nodules

Gout Risk factors

- age- obesity- diet – ETOH, high fat, high purine, - drugs- thiazide, - Med conditions – PRV, CRF, IHD, DM, hypothyroidism

SLE exam

- Cushingnoid, psychosis- Hands - Forearm- Head and neck- alopecia, sjogrens, fundoscopy, butterfly rash, discoid rash, LN- Chest – pericarditis, effusion, Pulm HTN- Abdo- hepatosplenomegaly- HIPs- avascular necrosis- Legs- proximal myopathy, peripheral neuropathy, ulcers, oedema

- Urine, Temp, BP

Tethered skin and thickened

- CREST scleroderma- Mixed CT disorder- SLE- Eosinophilic fasciitis- Localized morphea- Chemical- PVC, bleomycin- GVHD- Silicosis

Vascultides

- Hypersensitivity – affects capillaries and venules a/w urticaria, purpura, livedo reticularis, HSP, digital infarcts

o CTD- SLE, RAo Infections- Hep Bo Drugs – Penicillin, propyluracil, Phenothiazineo Haem- essential cryoglobulinemiao Idiopathic

- Allergic granulomatosis Churg Strauss- small arteries- rhinitis, sinusitis, - Wegener’s Granulomatosis- arteries capillaries and venules- URTI, lung pneumonitis, Renal HTN,

RF, haematuria, Eyes- conjunctivitis, uveitis, skin- Polyarteritis nodosa – medium and small vessels with fibrinoid necrosis- digital gangrene

ulceration, Renal HTN, RF haematuria, GIT haematemesis, malaena, lung pneumonitis, CNS mononeuritis, retinal vasculitis, SKin

- Behcets’ syndrome- medium and small vessels- genital oral ulcers, uveitis, polyarthropathy, rash- Giant cell temporal arteritis with Polymyalgia rheumatic- large and medium arteries – tender

extracranial visual disturbances, sudden blindness, jaw claudication- Aortic arch Takayasu aortitis- aorta and branches- HTN, pulselessness, reverse coarctation

Neck swelling

- Midlineo Goitreo Thyroglossal cysto Submental LNo PTH gland

- Lateralo LN o Salivary gland – submandibular, parotido Skin- sebaceous cyst, lipomao Lymphaticso Pharynx- pouch , embryogenic remnants

Goitre

- Diffuseo Idiopathico Puberty /pregnancyo Thyroiditis – De quervain, Hashimotoso Simple goitre – Iodine defo Goitrogens- I excess , lithium, IV contrast, Vegetableso Congenital

- Solitary noduleo Benign – follicular adenoma, dominant nodule, MNGo Malignant- CA, lymphoma

Exopthalmos

- Bilateral- Graves- Unilateral- Tumour of orbit, Cavernous sinus thrombosis, pseudotumour, Graves

Thyrotoxicosis

- Graves Disease- MNG- Toxic adenoma- Initial thyroiditis- Postpartum- Drugs- thyroxine, phenytoin, lithium amiodarone- Secondary

o Pituitary o Hydatidiform moles

o Struma ovarii

Hypothyroidism

- Primary- with goitre –o Autoimmune – Hashimotos, o Drugs – Li, Amiodaroneo Congenitalo Endemic Iodine def

- Primary without goitreo Iatrogenic – radioactive iodine, thyroidectomyo Agenesiso Idiopathic atrophyo Unresponsive to TSH

- Secondary- pituitary- Tertiary- hypothalamic- Transient

o Thyroxine withdrawalo Postpartumo Subacute thyroiditis

Hypopituitarism

- Space occupying lesion- Iatrogenic- surgery, radiation- Trauma- Infarction- sheehans, pituitary apoplexy- idiopathic

Cushing’s

- primary –o adrenal neoplasia- adenoma, carcinomao adrenal hyperplasia

- secondaryo pituitary ACTH production – Cushing’s diseaseo SCLC- ectopic sourceo Iatrogenic-Steroid

Addisons

- Primaryo Autoimmuneo Infection TB HIVo Granuloma

o Heparino Malignancyo Haemochromatosiso Leucodystrophy

- Secondaryo Acute septicaemia, adrenectomy, abrupt cessation of steroid

Autoimmune Polyglandular syndrome

- Type Io Chronic mucocutaneous candidiasiso HypoPTHo Addisons

- Type IIo IDDMo Autoimmune thyroido MGo Pernicious anaemiao Primary gonadal failure

HyperPTH

- Primaryo Adenomao Hyperplasia producing high Ca++o CA

- Secondaryo CRF, low Ca++

- Tertiaryo Autonomous

Hypercalcemia

- Stones bones moans, and groans- Primary Hyper PTH- Malignancy- CA, bone mets, Multiple myeloma- Thiazide diuretics, Al+++, theophylline- Vit D excess- Sarcoidosis- Thyrotoxicosis- Renal failure- Milk Alkali syndrome

- Hypocalciuria, hypercalcemia

Hypocalcemia

- Primary hypoPTH- Low Vit D – malabsorption, diet def- CRF- Acute pancreatitis

MEN

- Type Io PTHo Pituitaryo Pancreatic islet

- Type IIo C ret geneo Medullary CA, HyperPTH, phaechromocytomao Thyroid, adrenal medulla

Hirsuitism

- PCOS- Adrenal- Cushings, Phaechromocytoma, CAH, Virilising tumour- Ovary tumous- Drugs- phenytoin, streptomycin, minoxidil, steroids- Acromegaly, Porphyria Cutanea Tarda

Gynaecomastia

- Increased estrogen production- Leydig, adrenal, bronchial CA, Liver disease, thyrotoxicosis starvation

- Decreased androgen production – Klinefelters, Orchitis- Testicular feminization- Drugs- oestrogen, digoxin, spironolactone, cimetidine

Diabetes Mellitus

- Type i- Type ii- Exocrine pancreas disease- chronic pancreatitis, CA, haemochromatosis, cystic fibrosis- Endocrine- acromegaly, Cushings, phaechromotcytoma, glucagonoma- Drugs Steroid, OCP, phenytoin, thiazide- Infection Coxsachkie CMV rubella,- Congenital Turner, Down, Klinefelters

DM exam

- PVD + Neuro- Hydration + mental state + obesity + Respiratory pattern + facies- PVD- Neuro- Finger- Arms- Face – eyes- Neck – carotid bruit- Chest DCM- Abdomen- fat atrophy, kidney, hepatomeglay- Eyes fundoscopy, Urine, oedema

Cushing’s Exam

- Facies- Hands – thinning of skin- Arms- BP- Face- eye- Neck- fat pads- Abdomen- adrenal mass- Legs- oedema, bruise , wound heal- Urine, Bony tenderness- Diabetogenic- Osteoporosis- Neuro- CTS, reflex, proximal myopathy

Thyroid Exam

- Thyroid stare, slowmentation, anxiety, sweating, plethoric- Hands- tremor, sweat, palmar erythema, hypercarotenemia, anaemia, jaundice- Nails- oncyholysis, acropachy- Arms- pulse, reflex and myopathy- Face- eyes opthalmoplegia, eyes signs lid retraction, lid lag, chemosis, conjunctivitis, periorbital

oedema, exopthalmos, proptosis, corneal ulceration- Neck LN, lump, swallow, drink water, poke tongue out- Bruits- Percuss goitre, auscultate, Pembertons sign- Chest- pericardial effusion, systolic flow murmur, gynaecomastia- Abdomen- ascites, - Legs- pretibial myxoedema

Vertigo

- Vestibular –BPPH, Vestibular neuronitis, acute labyrinthitis- Drugs - aminoglycoside- Meniere’s >50, vertigo tinnitus and deafness- Acoustic neuroma- deafness and tinnitus- Central causes- vertebrobasilar, TIA – diploplia, visual loss and ataxia

Weakness

- UMN- LMN- Muscle wasting- NMJ- Non organic

Tremors

- Parkinsons- Essential/ familial- Physiological- Intention – cerebellar

Dysphasia

- Receptive- Expressive- Nominal- Conductive

Dysarthria

- UMN and cerebellar extrapyrimidal - Parkinsons- Pseudobulbar- Bulbar- Mouth ulcer

Parietal Lobe

- Dominanto Gertsmann Agraphia, acalculia, L R disorientation, finger agnosia

- Non-dominanto Agraphaesthesiao Tactile extinction

o Sensory and visual inattentiono Astereognosiso Spatial neglecto Constructional dressing apraxia

Temporal Lobe

- Memory loss- confabulation Korsakoff- Upper lobe quadhemianopia- Dysphasia- Seizure

Frontal lobe

- Personality- Primitive reflex- Anosmia- Optic nerve compression- Leg weakness- Micturition control- Expressive dysphasia- Dysgraphia

Occipital lobe

- Visual homonymous hemianopia- Ataxia

Bilateral blindness

- Sudden onseto Occipital infarction, Optic nerve damage by methylalcohol

Unilateral

- Central vein thrombosis artery occlusion, temporal arteritis ischemic optic neuropathy, optic neuritis, migraine

- Amaurosis fugax

Gradual

- Cataracts- Glaucoma- Macula degeneration- Diabetic retinopathy- Optic nerve compression

- Drugs – tobacco ambylopia

Cataract

- Senile- Endocrine- DM, steroid- Congenital- - Ocular - glaucoma- Radiation, trauma

Papilloedema

- Space occupying lesion- Hydrocephalus- benign inctracranial HTN- HTN grade 4- Central vein thrombosis

Optic atrophy

- Chronic papilloedema- Optic nerve pressure- Glaucoma- Ischemia- Familial

Optic neuritis

- Multiple sclerosis- Drugs _ Ethambutol, chloroquine, ETOH nicotine- Metabolic –Vit B12 def- Ischemia – DM, atheroma, Temporal arteritis- Infective - EBV - Familial

Tunnel vision- glaucoma , papilloedema , syphilis

Enlarged blind spot- optic nerve enlargement

Central scotoma- degenerative ( Multiple sclerosis, ETOH, tobacco, vascular , nutritional

Unilateral field loss- optic nerve

Vascular

Bitemporal hemianopia – pituitary tumour on optic chiasm

Homonymous hemianopia

Upper Quad Homonymous hemianopia – temporal lobe

Lower Quad Homonymous hemianopia- parietal lobe

Eyes

- Absent reflex but accommodate – Argyll Robertson o Syphiliso Diabeteso Midbrain lesiono Ciliary ganglion lesiono Parinaud’s

Uveitis

- Anterior iritis-o Idiopathico Sero-ve artrhpathyo IBDo DMo Granulomatosis- sarcoidosiso Infection

Gonococcal syphilis, Brucellosis, Toxoplasmosis, TB- Choroiditis (same as above)

Horner’s syndrome

- Malignancy, Lung, thyroid, brachial plexus- Trauma- Carotid arterial lesion- carotid aneurysm, cluster headache- Brainstem- vascular , tumour- Syringomyelia

Lateral Medullary Syndrome

- Nystagmus, Horner’s, Ipsilateral CN 5 , 9 , 10 , cerebellar- Contralateral pain and temp loss over limb

Fasciculation

- LMN- Motor root compression- Peripheral neuropathy – DM

- Primary myopathy- Thyrotoxicosis

Wasting of small muscles of hand

- Spinal cord – cervical spondylosis, trauma, tumour- Anterior horn cell disease- MND, polio- Root lesion – C8- Lower brachial plexus – thoracic outlet syndromes- Peripheral nerve lesion – median ulnar- Myopathy- Trophic disorder

Gait disorder

- Spastic – scissors gait, paraparesis- Parkinson’s – shuffling , festinating, propulsion, retropulsion, freezing- Hemiplegia- foot plantarflexed swing lateral- Cerebellar – broad based- Posterior column- loud slapping down - Footdrop- high stepping

o Common peroneal no Sciatic no Lumbasacral plexus o L4, 5o Peripheral motor disorder o Distal myopathyo MNDo Stroke

- Proximal myopathy- waddling- Prefrontal lobe- apraxia- hysterical

Anterior Cerebral –

- UMN leg - Incontinence- Cortical sensation of leg

Middle Cerebral

- UMN face and arm- Homonoymous hemianopia- Aphasia/non dominant hemisphere signs

Posterior cerebral

- Thalamus , occipital - Hemianaesthesia

Pseudobulbar palsy

- Both internal capsule- MS- MND

Bulbar palsy

- MND- GBS- Polio- Brainstem

Multicranial nerve

- Nasopharyngeal CA- Meningitis- GBS- Brainstem- Arnold Chiari- Trauma- Pagets disease- Mononeuritis multiplex

Peripheral Neuropathy

- Vitamin B6 excess, B12 def - Iatrogenic – phenytoin, amiodarone, cisplatinum, vincristine, nitrofurantoin- Infection Clostridium , syphilis, TB, leprosy- Inflammatory- Toxins- heavy metal, snake , box jellyfish,- Alcohol- Metabolic –hypothyroidism, CRF, DM- Idiopathic- Neoplasm- paraneoplastic syndromes- Connective tissue – RA , SLE- GBS- HSMN

Motor neuropathy

- GBS, Chronic inflammatory demyelinating polyneuropathy- HMSN- DM

Painful neuropathy

- DM- ETOH- B12 def- CA- Porphyria- Ar/Th poisoning

Mononeuritis multiplex

- Acute – Vascular PAN, DM, CTD- SLE RA- Chronic- sarcoid, acromegaly, infection – HIV, TB, Lyme

Spinal Cord compression

- Verterbral o Spondylosiso Trauma tumouro Prolapsedo Infection

- Outside durao Lymphoma, abscess

- Within durao Tumour, meningoma, neurofibroma

- Intramedullaryo Tumour, glioma, ependyoma, syringomyelia

Spinal cord syndromes

- Brown-sequard ipsilateral vibration loss, contralateral pain temp loss, with LMN at level and UMN below level

o Hemisectiono MSo Angiomao Traumao Post radiationo Myelitis

- Subacute combined degeneration- posterior column loss- ataxic gait, UMN symmetrical, knee reflex absent, optic atrophy, dementia

o B12 def- Spinothalamic loss

o Syringomyeliao Brown-sequardo Anterior spinal artery thrombosiso Lateral medullary o Small fibre peripheral neuropathy – DM, amyloid

- Dorsal columno Subacute combined degenerationo Brown Sequardo Sprinocerebellar degenerationo Multiple sclerosiso Tabes dorsaliso Peripheral neuropathy DM hypothyroidism

- Syringomyelia – central lesion with loss of pain and temp over cape distribution, UL amyotrophy, LL UMN

- Extensor plantar with absent knee and ankle jerko B12 defo Conus medullariso UMN + cauda equineo Syphiliso MND

Muscular dystrophies

- Duchenne- Becker- Lumb girdle- Fascio scapulohumeral- Dystrophica myotonica (AD)

HMSN

- Pes cavus- Distal muscle atrophy- Absent reflex- No sensory loss- Thickened nerves- Optic atrophy – AR pupils

Cerebellar disease

- Rostral vermis – ETOH

- Unilateral- o spaceoccupying lesiono ischaemiao MSo Trauma

- Bilateralo Drugs o ETOKo Hypothyroidismo Paraneoplastico MSo Traumao Arnold Chiari

- Friedrich Ataxiao Young, cerebellar signs, pes cavus, UMN in limbs, peripheral neuropathy, posterior

column loss, DM, optic atrophy- Spastic ataxia paraparesis (UMN and cerebellar sign)

o Marie spastic ataxia in adolescenceo MS, spinocerebellar, syphilitic Arnold Chiari, in young adulto MS, syringomyelia, infarction, meningoma in late

- Parkinsonismo Idiopathico Drugs- methyldopa, phenothiazine, antipsychotics haloperidol, DA antagonists

metoclopramideo Post infection- encephalitiso Toxin –CO, Mno Supranuclear Palsy – Steele Richardsono Shydragero Syphiliso Wilson’s disease

- Choreao Drugs – lveodopa, Phenothiazine, OCP, phenytoino Congenital – Huntingtono Infectiono Wilson’so Kernicteruso Vasculitiso Thyrotoxicosiso PCV , hyperviscosity

Cerebellum

- Disdiadochokinesis- Ataxia- Slurred speech- Hypertonia- Intention tremor- Nystagmus- Gait disorder

Parkinson’s Exam

- Masklike facies , pill rolling tremor- Bradykinesia, rigidity- Gait festinating, shuffling, retropulsion, propulsion- Bradykinesia in twiddling and tapping- Tremor- Finger nose diminishes tremor- Cogwheel and lead pipe rigidity- Face – titubation, no blinking, dribbling- Glabellar tap- Monotonous speech- Upward gaze failure- Greasy - Orthostatic Hypotension- Writhing action, micrographia, dementia

Chorea – corpus striatum- non repetitive abrupt jerky involuntary

Hemiballismus- subthalamic – wild throwing of proximal joints

Athetosis – Putamen – slow sinous writhing movement of distal joint

Pseudoathetosis- proprioception loss

Dystonia – Putamen- Involuntary abnormal posture, focal segmental periodic, SE from levodopa, phenothiazine, metoclopramide, spasmodic torticollis

COMA

- Co2 narcosis- Overdose- drugs, ETOH, amphetamines, Barbiturates- Metabolic derangements- glucose, Na, Ca++, DKA, Vit B def, uraemia, hepatic encephalopathy,

hypothyroidism myxoedematous coma, thyroid storm- Apoplexy – trauma, seizures, DAI, stroke, Space occupying lesion, infection encephalitis,

meningitis

Delirium

- Drugs o Intoxication

Anxiolytic Digoxin, L dopa, ETOHo Withdrawal

ETOH Anxiolytic drugs

- Metabolic – Uraemia, liver failure, anjoxia, cardiac, electrolyte - Endocrine - DKA, Hypoglycaemia- Systemic infection – pneumonia, UTI, meningitis, septicaemia- Intracranial- space-occupying lesion- Head injury- DAI, trauma, Subdural haematoma, contusion, concussion- Nutrition – B 12 def, thiamine, nicotinic acid- Epilepsy –postictal

Dementia

- Vascular, Vitamin def- Infection, ICP- Trauma, Toxin ETOH, heavy metal- Anoxia – anaemia, CO poison, cardiac respi arrest- Metabolic- ICP- Nutrition – B12 def, folate, thiamine- Endocrine – Myxoedema, Addison’s- Degenerate- ALzhemier’s Parkinson, Huntington, Normal pressure hydrocephalus

Drug Reaction

Acne- steroids

Alopecia- chemotherapy

Pigment- hyperpigmented- steroids, quinine

Exfoliative dermatitis

- Eczema- Psoriasis- Drugs phenytoin, allopurinol- Pityriasis rubra pilaris- Lichen planus- Mycosis fungoides, leukemia, lymphoma- Pemphigus folliceus- Hereditary- Dermatophytosis

Urticaria – NSAIDS, radiodye, captopril, penicillin

Mobiliform- ampicilin, allopurinol

Photosensitive- sulphur, thiazide, PTZ, tetracycline, anticonvulsant

Drug-induced lupus- procainamide, hydralazine

Vasculitis- Propylthiouracil, Allopurinol, thiazide, penicillin, phenytoin

Skin Necrosis- warfarin

Drug precipitating Porphyria- ETOH, barbiturates, sulphur OCP

Lichenoid- Gold, antimalarial B blockers, Captopril

Fixed drug eruption- sulphonamide, tetracycline, barbiturates

Bullous – frusemide, penicillamine, clonidine

Erythema multiforme, nodosum

Toxic epidermal necrolysis- allopurinol, phenytoin, sulphonamide, NSAID

Pruritus

- Asteatosis- Atopic dermatitis

- Urticaria- Scabies- Dermatitis herpetiformis- Systemic conditions

o Cholestasiso CRFo Pregnancyo Lumphoma, o IDA, PRVo Endocrine, thyroid, carcinoid, DM

Skin Lump

- Sebaceous cyst, epidermoid cyst, papilloma, Moves when skin moves- Subcutaneous fats – lipoma over which skin moves- Muscle tendon tumour limited by contraction of muscle- Nerve press lump elicits paresthesias cannot be moved longitudinally but transversely- Bone- immobile- Fluctuant- Transilluminating

Erythrosquamous eruptions

- Psoriasis bright pink plaques with silvery scale- Atopic eczema diffuse erythema with fine scaling- Pityriasis rosea paler pink scaly macular on trunk- Nummular eczema round patch of dermatitis diffuse- Contact dermatitis ( irritant / allergic)- Dermatophyte infection with ringworm- Lichen Planus Purple, polygonal, Papules – PBC, GVHD, drugs, gold penicillamine- Syphilis flat red hyperkeratotic

Bullous eruption

- Viral blister- Bullous pemphigoid- Pemphigus vulagaris- Dermatitis herpetiformis- Porphyria cutanea tarda- Infection with impetigo ,dermatophyte, viral HSV, VZV

Pustular Crusted lesions

- Acne vulgaris- Impetigo- Foliculitis- Acne rosacea- Viral lesion- Pustular psoriasis- Drug eruptions- Dermatophyte

Dermal plaques

- Granuloma annulare- Necrobiosis lipoidica diabeticorum- Sarcoidosis- Erythema nodosum- SLE, scleroderma- TB, Leprosy

Erythema nodosum

- Infection strep, Leprosy, TB, Toxoplasmaosis, Yersinia, Chlamydia- Inflammation- IBD- Drugs- sulphur, estrogen, iodine, bromide- Malignancy- CTD – SLE, autoimmune – Behcets’ Sarcoidosis

Erythema multiforme

- Drug – sulphur, phenytoin, penicillin, NSAIDS- Infection – mycoplasma, histoplasmosis, - Malignancy, sarcoidosis

Diffuse hyperpigmentation

- Endocrine o ACTH, Addisons, OCP, Pregnancy, Thyroid, Acromegaly, Phaechromocytoma

- Metabolic- malabsorptiono Liver disease jaundiceo Renal failureo Porphyriao Infectiono CTD- SLE scleroderma, dermatomyositiso Drugso Radiation

Facial flushing

- Menopause- Food- Drugs- nifidepine- Systmic mastocytosis- Rosacea- Carcinoid- Autonomic dysfunction- Medullary CA of thyroid

Skin Tumours

- Benigno Wartso Molluscum contagiosumo Seborrheic keratosiso Dermatofibromao Neurofibromao Angiomao Xanthomao Solar keratosis

- Malignanto BCCo SCCo Melanomao Secondary deposits