250 cases in clinical medicine

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History and examination of the cardiovascular system
I Mitral stenosis 3
2 Mitral regurgitation 8
3 Mixed mitral valve disease 12
4 Aortic regurgitation 13
6 Mixed aortic valve lesion 23
7 Mixed mitral and aortic valve disease 24
8 Hypertension 27
9 Atrial fibrillation 31
10 Palpitations 35
11 Slow pulse rate 37
12 Gallop rhythm 39
13 Angina pectoris 41
14 Acute myocardial infarction 45
15 Jugular venous pulse 52
16 Congestive cardiac failure 54
17 Infective endocarditis 57
18 Prosthetic heart valves 61
19 Tricuspid regurgitation 64
20 Mitral valve prolapse 65
21 Ventricular septal defect 67
22 Atrial septal defect 71
23 Hypertrophic cardiomyopathy 75
24 Patent ductus arteriosus 78
25 Pulmonary stenosis 80
26 Dextrocardia 83
27 Coarctation of aorta 84
28 Eisenmenger syndrome 88
29 Fallot's tetralogy 91
30 Absent radial pulse 93

31 Constrictive pericarditis 95
32 Permanent cardiac pacemaker/implantable cardioverter-defibrillator 97
33 Pericardial mb 100
34 Primary pulmonary hypertension 102
35 Ebstein's anomaly 104

History and examination of the nervous system
36 Bilateral spastic paralysis (spastic paraplegia) 115
37 Hemiplegia 119
38 Ptosis and Homer's syndrome 125
39 Argyll Robertson pupil 128

40 Holmes-Adie syndrome 130
41 Homonymous hemianopia 132
42 Bitemporal hemianopia 133
43 Central scotoma 134
44 Tunnel vision 135
45 Parkinson's disease 136
46 Cerebellar syndrome 143
47 Jerky nystagmus 146
48 Speech 147
49 Expressive dysphasia 151
50 Cerebellar dysarthria 152
51 Third cranial nerve palsy 153
52 Sixth cranial nerve palsy 156
53 Seventh cranial nerve palsy - lower motor neuron type 158
54 Tremors 161
55 Peripheral neuropathy 164
56 Charcot-Marie-Tooth disease (peroneal muscular atrophy) 166
57 Dystrophia myotonica 168
58 Proximal myopathy 171
59 Deformity of a lower limb 172
60 Multiple sclerosis 175
61 Abnormal gait 180
62 Wasting of the small muscles of the hand 182
63 Facioscapulohumeral dystrophy (Landouzy-D4j6rine syndrome) 183
64 Limb girdle dystrophy 185
65 Myasthenia gravis 186
66 Thomsen's disease (myotonia congenita) 190
67 Friedreich's ataxia 191
68 Motor neuron disease 193
69 Neurofibromatosis 196
70 Syringomyelia 199
71 Subacute combined degeneration of the spinal cord 202
72 Tabes dorsalis 205
73 Ulnar nerve palsy 207
74 Lateral popliteal nerve palsy, L4, L5 (common peroneal nerve palsy) 210
75 Carpal tunnel syndrome 212

77 Chorea 215
78 Hemiballismus 218
79 Orofacial dyskinesia 219
80 Internuclear ophthalmoplegia 220
81 Cerebellopontine angle tumour 222
82 Jugular foramen syndrome 224
83 Pseudobulbar palsy 226

84 Bulbar palsy 227
85 Wallenberg's syndrome (lateral medullary syndrome) 228
86 Winging of the scapula 230
87 Becker muscular dystrophy 231

88 Tetraplegia 233
89 Brown-Sdquard syndrome 236
90 Cauda equina syndrome 237
91 Torsion dystonia (dystonia musculorum deformans) 239
92 Epilepsy 240
93 Guillain-Barre syndrome 243 ~.
94 Multiple system atrophy 244
95 Neurological bladder 246
history and examination of tiic chest
96 Pleural effusion 251
97 Pleural rub 256
98 Asthma 258
99 Chronic bronchitis 261
100 Bronchiectasis 266
101 Cor pulmonale 269
102 Consolidation 271
103 Bronchogenic carcinoma 274
104 Cystic fibrosis 277
105 Fibrosing alveolitis 281
106 Pulmonary fibrosis 284
107 Pneumothorax 286
108 Old tuberculosis 288
109 Pickwickian syndrome 290
110 Collapsed lung 292
History and examination of the abdomen
111 Hepatomegaly 297
112 Cirrhosis of the liver 299
113 Jaundice 301
114 Ascites 304
115 Haemochromatosis 307
116 Primary biliary cirrhosis 310
117 Wilson's disease 313
118 Splenomegaly 315
119 Felty's syndrome 318
120 Polycystic kidneys 320
121 Transplanted kidney 324
122 Abdominal aortic aneurysm 327
123 Unilateral palpable kidney 329
124 Abdominal masses 330
General guidelines for examination of joints
125 Rheumatoid hands 336

126 Ankylosing spondylitis 340
127 Psoriatic arthritis 343

128 Painful knee joint 344
129 Osteoarthrosis 345
130 Gout 347
131 Charcot'sjoint 349
132 Still's disease 350

Examination of the thyroid
133 Graves' disease 355
134 Exophthalmos 359
135 Hypothyroidism 362
136 Multinodular goitre 367
137 Addison's disease 369
138 Acromegaly 372
139 Hypopituitarism (Simmonds' disease) 375
140 Gynaecomastia 377
141 Carpopedal spasm (post-thyroidectomy hypoparathyroidism) 379
142 Carcinoid syndrome 381
143 Obesity 382
144 Cushing's syndrome 385

145 Maculopapular rash 389
146 Purpura 390
147 Psoriasis 392
148 Bullous eruption 396
149 Henoch-Schoenlein purpura 399
150 Ichthyosis 401
151 Hereditary haemorrhagic telangiectasia (Rendu-Osler-Weber disease) 403
152 Herpes labialis 406
153 Herpes zoster syndrome (shingles) 408
154 Lichen planus 411
155 Vitiligo 412
156 Raynaud's phenomenon 415
157 Systemic lupus erythematosus 417
158 Phlebitis migrans 421
159 Erythema multiforme 423
160 Erythema ab igne 426
161 Hirsutism 428
162 Acanthosis nigricans 431
163 Lipoatrophy 433
164 Lupus pernio 435
165 Xanthelasma 439
166 Necrobiosis lipoidica diabeticorum 442
167 Radiotherapy marks 444

168 Tendon xanthomata 446
169 Eruptive xanthomata 448
170 Palmar xanthomata 450
171 Pseudoxanthoma elasticum 451
172 Rosacea 454
173 Dermatitis herpetiformis 456
174 Hairy leukoplakia 458
175 Kaposi's sarcoma 460
176 Peutz-Jeghers syndrome 463
177 Pyoderma gangrenosum 466
178 Sturge-Weber syndrome (encephalotrigeminal angiomatosis) 468

179 Acne vulgaris 470
180 Alopecia areata 472
181 Atopic dermatitis (eczema) 475
182 Venous ulcer 477
183 Arterial leg ulcer 478
184 Erythema nodosum 480
185 Fungal nail disease 482
186 Lichen simplex chronicus (neurodermatitis) 484
187 Nail changes 486
188 Onycholysis 489
189 Malignant melanoma 490
190 Seborrhoeic dermatitis 493
191 Molluscum contagiosum 494
192 Urticaria 496
193 Mycosis fungoides (cutaneous T-cell lymphoma) 498
194 Urticaria pigmentosa 500
195 Dermatomyositis 502
196 Scleroderma 505
197 Ehlers-Danlos syndrome 508
198 Tuberous sclerosis (Bourneville's or Pringle's disease) 511
199 Pretibial myxoedema 514

Examination of the fundus
200 Diabetic retinopathy 518
201 Hypertensive retinopathy 523
202 Papilloedema 525
203 Optic atrophy 529
204 Retinal vein thrombosis 531
205 Subhyaloid haemorrhage 534
206 Retinitis pigmentosa 535
207 Old choroiditis 538
208 Cholesterol embolus in the fundus 539
209 Vitreous opacities 542
210 Myelinated nerve fibres 543
211 Retinal changes in AIDS 544

212 Retinal detachment 546
213 Age-related macular degeneration (senile macular degeneration) 548

Examination of the foot
214 Diabetic foot 554
215 Swollen leg l: deep vein thrombosis 556
216 Swollen leg Il: cellulitis 559
217 Clubbing 561
218 Dupuytren's contracture 563
219 Cataracts 565
220 Anaemia 567
221 Lymphadenopathy 569
222 Chronic lymphocytic leukaemia 573
223 Crohn's disease 575
224 Dysphagia 577
225 Diarrhoea 578
226 Marfan's syndrome 580
227 Nephrotic syndrome 583
228 Uraemia 585

229 Paget's disease 588
230 Parotid enlargement 591
231 Superior vena caval obstruction 593
232 Glass eye 595
233 Turner's syndrome 596
234 Yellow nail syndrome 598
235 Osteogenesis imperfecta 599
236 Down's syndrome 600
237 Late congenital syphilis 602
238 Arteriovenous fistula 603
239 Carotid artery aneurysm 605
240 Retro-orbital tumour 606
241 Achondroplasia 607
242 Breast lump 608
243 Gingival hypertrophy 612
244 HaemophiliaA 613
245 Klinefelter's syndrome 614
246 Macroglossia 616
247 Osteoporosis of the spine (dowager's hump) 618
248 Pressure sores (bedsores) 620
249 Sickle cell disease 622
250 Thrush 624

Index 627

1. Chest pain: exertional, at rest (when angina is present, comment on the Canadian Cardiovascular
Angina class, p. 42).
2. Shortness of breath: exertional, at rest (when dyspnoea is present, comment on the New York Heart
Association class, p. 2), paroxysmal nocturnal dyspnoea.
3. Palpitations (see pp 35-6)
4. Dizziness, pre-syncope, syncope.
5. Swelling of feet.

1. Introduce yourself: 'I am Dr/Mr/Ms ............ May I examine your heart?'.
2. Ensure adequate exposure of the precordium: 'Would you take your top off, please?'. However, be
sensitive of the feelings of female patients.
3. Get the patient to sit at 45 degrees - use pillows to support the neck.
4. Inspection: comment on the patient's decubitus (whether he or she is comfort-able at rest or obviously
short of breath); comment on malar flush (seen in mitral stenosis).
5. Examine the pulse: rate (count for 15 s), rhythm, character, volume; lift the arm to feel for the
collapsing pulse. Feel the other radial pulse simultaneously.
6. Comment on the scar at antecubital fossa (cardiac catheterization scars).
7. Look at the tongue for pallor, central cyanosis.
8. Look at the eye for pallor, Argyll Robertson pupil.
9. Examine the jugular venous pulse: comment on the wave form and height from the sternal angle.

Check the abdominojugular reflux.
10. Comment on any carotid pulsations (Corrigan's sign of aortic regurgitation).
11. Examine the precordium: comment on surgical scars (midline sternotomy scars, thoracotomy scars
for mitral valvotomy may be missed under the female breast).
12. Feel the apex beat - position and character.
13. Feel for left parasternal heave and thrills at the apex and on either side of the sternum.
14. Listen to the heart, beginning from the apex: take care to palpate the right carotid pulse
simultaneously so that the examiner notices that you are timing the various cardiac events.
· Always comment on the first and second heart sounds. Mention any additional heart sounds (Am J Med
1959; 27: 360).
· If you do not hear the mid-diastolic murmur of mitral stenosis, make sure you listen to the apex in the left
lateral position with the bell of the stethoscope.
· If you hear a murmur at the apex, ensure that you get the patient to breathe in and out - the examiner
will be observing whether or not you are listening for the variation in intensity with respiration.
· If you hear a pansystolic murmur, listen at the axilla (mitral regurgitant murmurs are conducted to the

15. Using the diaphragm of your stethoscope, listen at the apex, below the sternum, along the left
sternal edge, the second right intercostal space and the neck (for ejection systolic murmur of aortic
stenosis, aortic sclerosis).
16. Request the patient to sit forward and listen with the diaphragm along the left sternal edge in the 3rd
intercostal area with the patient's breath held in expiration for early diastolic murmur of aortic
17. Tell the examiner that you would like to do the following: · Listen to lung bases for signs of cardiac
failure. · Check for sacral and leg oedema.
· Examine the liver (tender liver of cardiac failure), splenomegaly (endocarditis).
· Check the blood pressure.
· Check the peripheral pulses and also check for radiofemoral delay.

The New York Heart Association classification of dyspnoea:
Class l Asymptomatic (shortness of breath on unaccustomed exertion).
· Class ll: There is slight limitation of physical activity and patients develop shortness of breath on
accustomed exertion.
· Class III Marked limitation of physical activity; patients develop shortness of breath on activities of
daily living such as having a shower, etc.
· Class IV: Inability to carry out physical activity; shortness of breath at rest.

Rene Theophile Hyacinthe Laennec invented the stethoscope in 1816 and reported his early experience
with auscultation in a two-volume book published 3 years later (Laennec RTH 1821 A Treatise on the
Diseases of the Chest. London: T and G Underwood. Translated by and with a preface and notes by
John Forbes).

British physician Sir John Forbes (1787-1861) is best remembered for popularizing the stethoscope
among English-speaking doctors. Forbes was born in Banff in the north east of Scotland. He studied at
Marischal College, Aberdeen, before he went to Edinburgh where he received his medical education.
Forbes translated Laennec's monograph in English in 1821 and published his own book on the subject in
1824 (Forbes J 1824 Original Cases with Dissections and Observations Illustrating the Use of the
Stethoscope and Percussion in the Diagnosis of the Diseases of the Chest. London: T and G
Underwood). The latter included a brief biographical sketch of the Austrian physician Leopald
Auenbrugger and the first English translation of his essay (which was in Latin) on percussion. It also
contained a summary of Parisian physician Victor Collin's recent manual on cardiac physical diagnosis.

This patient developed dyspnoea and orthopnoea during pregnancy, please examine her.
This 55-year old patient has atrial fibrillation, please perform the relevant clinical examination.

· Symptoms of left-sided heart failure: exertional dyspnoea, orthopnoea, paroxysmal dyspnoea.
· Less frequent symptoms: haemoptysis, hoarseness of voice, symptoms of right-sided failure (these
symptoms are somewhat more specific for mitral stenosis).
· Obtain a history of rheumatic fever in childhood.

· Pulse regular or irregularly irregular (due to atrial fibrillation). · Jugular venous pressure (JVP) may be
raised. · Malar flush.
· Tapping apex beat in the 5th intercostal space just medial to midclavicular line. · Left parasternal heave
(indicating right ventricular enlargement). · Loud first heart sound.
· Opening snap (often difficult to hear; a high-pitched sound that can vary from 0.04 to 0.10 s after the
second sound, and is best heard at the apex with the patient in the lateral decubitus position).
· Rumbling, low-pitched, mid-diastolic murmur - best heard in the left lateral position on expiration. In
sinus rhythm there may be presystolic accentuation of the murmur. If you are not sure about the
murmur, tell the examiner that you want the patient to perform sit-ups or hop on one foot to increase
the heart rate. This will increase the flow across the mitral valve and the murmur is better heard.
· Pulmonary component of second sound (P2) is loud.

Remember. The signs of pulmonary hypertension include loud P2, right ventricular lift, elevated neck
veins, ascites and oedema. This is an ominous sign of the disease progression because pulmonary
hypertension increases the risk associated with surgery (Bt Heart J 1975; 37: 74-8).

· In patients with valvular lesions the candidate would be expected to comment on rhythm, the
presence of heart failure and signs of pulmonary hypertension.
· In atrial septal defect, large flow murmurs across the tricuspid valve can cause mid-diastolic
murmurs. The presence of wide, fixed splitting of second sound,

absence of loud first heart sound, and an opening snap and incomplete right bundle branch block should
indicate the correct diagnosis. However, about 4% of patients with atrial septal defect have mitral
stenosis, a combination called Lutembacher's syndrome.

This patient has mitral stenosis (lesion) which is almost always due to rheumatic heart disease
(aetiology), and has atrial fibrillation, pulmonary hypertension and congestive cardiac failure (functional

What is the commonest cause of mitral stenosis?
Rheumatic heart disease.

What is the mechanism of tapping apex beat?
It is due to an accentuated first heart sound.

What does the opening snap indicate?
The opening snap is caused by the opening of the stenosed mitral valve and indicates that the leaflets are

pliable. The opening snap is usually accompanied by a loud first heart sound. It is absent when the valve
is diffusely calcified. When only the tips of the leaflets are calcified, the opening snap persists.

What is the mechanism of a loud first heart sound?
The loud first heart sound occurs when the valve leaflets are mobile. The valve is open during diastole
and is suddenly slammed shut by ventficular contraction in systole.

What is the mechanism of presystolic accentuation of the murmur?
In sinus rhythm it is due to the atrial systole which increases flow across the stenotic valve from the left
atrium to the left ventricle; this causes accentuation of the loudness of the murmur. This may also be
seen in atrial fibrillation and is explained by the turbulent flow caused by the mitral valve starting to close
with the onset of ventricular systole. This occurs before the first heart sound and gives the impression of
falling in late diastole; it is, however, due to the start of ventricular systole.

What are the complications?
· Left atrial enlargement and atrial fibrillation.
· Systemic embolization, usually of the cerebral hemispheres.
· Pulmonary hypertension.
· Tricuspid regurgitation.
· Right heart failure.

How does one determine clinically the severity of the stenosis?
· The narrower the distance between the second sound and the opening snap, the greater the severity.
The converse is not true. (Note. This time interval between the second sound and opening snap is
said to be inversely related to the left atrial pressure.)

in tight mitral stenosis the murmur may be less prominent or inaudible and the findings may be
primarily those of pulmonary hypertension.

What are the investigations you would perform?

Broad bifid P wave (P mitrale); atrial fbrillation in advanced disease.

Chest radiography
· Congested upper lobe veins.
· Double silhouette due to enlarged left atrium.
· Straightening of the left border of the heart due to prominent pulmonary conus and filling of the
pulmonary bay by the enlarged left atrium.
· Kerley B lines (horizontal lines in the regions of the costophrenic angles).
· Uncommonly the left bronchus may be horizontal due to an enlarged left atrium.
· Mottling due to secondary pulmonary haemosiderosis.

2D and Doppler echocardiography is the diagnostic tool of choice for assessing the severity of mitral
stenosis and for judging the applicability of balloon mitral valvotomy (N Engl J Med 1997; 337: 3241).

· It is able to identify restricted diastolic opening of the mitral valve leaflets due to 'doming' of the anterior
leaflet and immobility of the posterior leaflet.
· It also allows assessment of the mitral valve apparatus and left atrial enlargement. · Echocardiography
usually permits an accurate planimetric calculation of the valve area (Am J Cardiol 1979; 43: 560-8).
· It can also be used to assess the severity of stenosis by measuring the decay of the transvalvular
gradient or the 'pressure half-time', an empirical measurement (BrHeartJ 1978; 40: 13140).
· The mean transmitral gradient can be accurately and reproducibly measured from continuous wave
Doppler signal across the mitral valve with the modified Bernoulli equation.
· The mitral valve area can be non-invasively derived from Doppler echocardio-graphy with either the

diastolic half-time method or the continuity equation. The continuity equation should be used when
the area derived from the half-time does not correlate with the mean transmittal gradient.
· Doppler also allows estimation of pulmonary artery systolic pressure from the TR velocity signal and
assessment of the severity of concomitant MR or AR.
· Trans-oesophageal echocardiography is not required unless a question about diagnosis remains
after transthoracic echocardiography.

Cardiac catheterization
· Shows raised right heart pressures and an end-diastolic gradient from pulmonary artery wedge
pressure (or left atrium if trans-septal puncture has been done) to the left ventricle.
· Left and right heart cardiac catheterization is indicated when percutaneous mitral balloon valvotomy
is being considered.
· Cardiac catheterization is also indicated when there is a discrepancy between Doppler-derived
haemodynamics and the clinical status of a symptomatic patient.
· Coronary angiography may be required in selected patients who need intervention.

· Exercise haemodynamics should be performed when the symptoms are out of proportion to the
calculated mitral valve gradient area.

What is the normal cross-sectional area of the mitral valve?
It ranges from 4 to 6 em2; turbulent flow occurs when this area is less than 2 cm2.

What is the area in 'tight' mitral stenosis?
It is usually less than 1 cm2 and consequently the gradient across the valve is >10 mmHg.

How would you manage the patient?
· Asymptomatic patient in sinus rhythm: prophylaxis against infective endocarditis only.
· Mild symptoms: diuretics to reduce left atrial pressure and therefore symptoms.
· Atrial fibrillation: (1) rate control (digitalis, beta-blocker or calcium channel blocker); (2)
anticoagulants (Eur Heart J 1988; 9: 291-4).
· Moderate to severe symptoms or pulmonary hypertension is beginning to develop: mechanical relief
of valve stenosis including (1) balloon valvotomy (N Engl J Med 1994; 331: 961-7; Br Heart J 1988;
60: 299-308) - percutaneous mitral balloon valvuloplasty is usually the procedure of choice when
there is a non-calcified pliable valve; (2) surgery.

What are the indications for surgery?
· Patients with severe symptoms of pulmonary congestion and significant mitral stenosis.
· Patients with pulmonary hypertension or haemoptysis, even if minimally symptomatic.
· Recurrent thromboembolic events despite therapeutic anticoagulation.

Which surgical procedures are used to treat mitral stenosis?

Closed commissurotomy
· Closed mitral valvotomy - involves the use of mechanical dilators, inserted through the apex of the
left ventricle. It is complicated by mitral regurgitation, systemic embolization and restenosis.
· Balloon valvuloplasty (a form of closed commissurotomy) - percutaneous trans-septal balloon mitral
valvotomy (or valvuloplasty). Remember, percutaneous balloon dilatation of the mitral valve is a
useful option in patients who are unable to undergo cardiac surgery, as in late pregnancy or when too
ill (severe respiratory disease, non-mitral cardiac disease, multiorgan failure).

Open commissurotomy
Requires cardiopulmonary bypass and allows surgical repair of the valve under direct vision, resulting in
more effective and safer valvotomy than the closed procedure.

Valve replacement
Entails risks including thromboembolism, endocarditis and primary valve failure.

What factors determine the success of balloon valvuloplasty?

Document Outline
  • 1 Cardiology.pdf
  • 2 Neurology.pdf
  • 3 Respiratory.pdf
  • 4 Abdomen.pdf
  • 5 Rheumatology.pdf
  • 6 Endocrine.pdf
  • 7 Dermatology.pdf
  • 8 Fundus.pdf