Doctor - Helper

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 9331 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

NEUROLOGY 107 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

RESPIRATORY SYSTEM 249 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

ABDOMEN 295 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

RHEUMATOLOGY 333 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

ENDOCRINOLOGY 353 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

DERMATOLOGY 389 145 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

FUNDUS 517 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

MISCELLANEOUS 553 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

ATRIAL FIBRILATION

Examine this patient's pulse.

· Palpitations. · Pre-syncope, dizziness. · Fatigue. · Dyspnoea. · Asymptomatic and atrial fibrillation is discovered incidentally. · History of ischaemic heart disease, hypertension, valvular heart disease, rheumatic heart disease,

COPD, congenital heart disease (atrial septal defect, ventricular septal defect), thyrotoxicosis (pp

355-9). · History of consumption of caffeine, digitalis, theophylline.

· Irregularly irregular pulse (patients are often digitalized and in slow atrial fibrillation). · Look for:

- malar flush (mitral stenosis)- mitral valvotomy scar

- warm hands, goitre, pretibial myxoedema (thyrotoxlcosis). · Elevated JVP without 'a' waves. · Varying intensity of first heart sound (the intensity is inversely related to the previous RR cycle

length; a longer cycle length produces a softer SI). · Pulse deficit, which is the difference between the rate of the apex and the pulse rate (because

varying stroke volumes result from varying periods of diastolic filling, not all ventricular beats produce

a palpable peripheral pulse). The pulse deficit is greater when the ventricular rate is high. · If you are not sure, tell the examiner that you would like to differentiate from ventricular ectopics by exercising the patient; after exercise, ventricular ectopics diminish in frequency whereas there is no

change in the rhythm of atrial fibrillation. · Look for the underlying cause:

-Examine the heart for mitral valvular lesion. -Check the blood pressure for hypertension. - Ask the patient for history of ischaemic heart disease. -Check the patient's thyroid status for thyrotoxicosis.

This patient has fast atrial fibrillation (lesion) which is commonly caused by ischaemic heart disease (aetiology). The patient is short of breath, indicating that he may be in cardiac failure (functional status). Read this recent review: N Engl J Med 2001; 344: 1067.

· Mitral valvular disease in the young and middle-aged. · Ischaemic heart disease or hypertension in the elderly. · Thyrotoxicosis (atrial fibrillation may be the only clinical feature in the elderly). · Constrictive pericarditis. · Chronic pulmonary disease.

Brain, leg, kidney, superior mesenteric artery, coronary artery and spleen.

If the patient is not in heart failure, exercise the patient; after exercise, ventricular ectopics tend to diminish in frequency whereas there is no change in the rhythm of atrial fibrillation.

Electrocardiogram P waves are absent. Fibrillatory or 'f' waves are present at a rate that may vary between 350 and 600 beats/minute and the 'f' waves vary in shape, amplitude and intervals. The RR interval is irregularly irregular. Narrow QRS complex with varying RR interval (regular unless there is an underlying ventricular conduction detect).

Echocardiogram Useful to determine left atrial size and left ventricular systolic function, and to exclude underlying valvular heart disease and intracardiac thromboemboli.

Test of thyroid function To exclude thyrotoxicosis.

Exercise treadmill When atrial fibrillation is precipitated by exercise.

Holter monitor Useful in paroxysmal atrial fibrillation to determine whether it was triggered by another arrhythmia such as when a premature atrial complex during a rapid paroxysmal atrial tachycardia may cause the immediate

onset of atrial fibrillation.

· Atrial fibrillation. · Multiple ventricular ectopics.

· Atrial tlutter with varying block. · Complete heart block (there is associated bradycardia).

In which congenital disorders is atrial fibrillation common? Atrial septal defect, Ebstein's anomaly.

Lone atrial fibrillation occurs itl the absence of cardiopulmonary disease or a history of hypertension and before the age of 60 years. Such patients have a low risk of stroke (0.5% per year).

How would you treat a patient with atrial fibrillation?

Attempt to restore slow ventricular rate: · In the hypertensive patient use calcium antagonists (verapamil, diltiazem). · In thyroid disease use a beta-blocker (e.g. propranolol). · In ischaemic heart disease use a beta-blocker or diltiazem, verapamil. · In heart failure use digoxin or verapamil. · In hypertrophic cardiomyopathy use a beta-blocker or calcium antagonists. · In those who are intolerant of or do not respond to drugs, radiofrequency catheter ablation of the

atrioventricular node (with a cardiac pacemaker) may provide symptomatic relief; however, it does not

change the risk of systemic emboli or the need for anticoagulation (N Engl J Med 1999; 340: 534). · More recently, radiofrequency ablation of the pulmonary veins has been shown to be effective in

paroxysmal atrial fibrillation when the ectopic focus is in the pulmonary veins.

Attempt to restore sinus rhythm by cardioversion if the following conditions apply: · Left atrial size by echocardiogram is less than 4.5 cm (left atrial size >4.5 cm is not associated with

long-term maintenance of sinus rhythm). · Short duration of the arrhythmia (acute atrial fibrillation is likely to remain in sinus rhythm). · Drugs used to restore sinus rhythm or prevent recurrence include quinidine, procainamide,

disopyramide, propafenone, sotalol, fiecainide, amiodarone and ibutilide (N Engl J Med 2000; 342:913-20; Circulation 1996; 94:1613).

Anticoagulation with warfarin is advised for certain patients': · Undergoing cardioversion (electrical or drug). · With underlying mitral valve disease. · In left ventricular failure.

· With cardiomyopathy. · Above the age of 60 years.

Procainamide, disopyramide or quinidine for 2-3 days restores sinus rhythm in up to 30% of patients.

Non-rheumatic atrial fibrillation is an important risk factor for stroke, even though it is recognized that only 80% of strokes in such patients the heart. All patients with non-rheumatic atrial fibrillation should be anticoagulated with warfarin unless there are contraindications (Br J Hosp Med 1993: 50: 452-7).

· A novel surgical technique, the Maze procedure, has recently been described in which multiple incisions are made in the atria to prevent re-entrant loops (Clin Curdiol 1991; 14:827 34). This procedure is highly effective in preventing atrial fibrillation: only one patient out of 65 suffered a

·

·

· ·

·

clinical recurrence of the arrhythmia three or more months after the procedure. Although the long-term outcome is not known, it remains a promising procedure when atrial fibrillation is not controlled by medical therapy or in those cases complicated by recurrent thromboembolism.

· The 'corridor' procedure effectively isolates both the left and right atrium, leaving a strip of myocardium connecting the sinus node to the atrioventricular node. This procedure does not prevent atrial fibrillation but isolates the fibrillating atria. Although a 70% 'cure' rate is reported, sequential atrioventricular contraction is not restored (with the consequent haemodynamic effects and the risk of thromboembolism).

It is the occurrence of supraventricnlar arrhythmias, usually atrial fibrillation anti atrial flutter, folk)wing an acute alcoholic binge in chronic alcoholics. These are usually transient.

It was James Mackenzie, a Scottish general practitioner working in Burnley, England, utilizing an ink-polygraph to record and label jugular venous pulses, who pioneered the deciphering of normal and abnormal cardiac rhythms. His key observation that the jugular 'a' wave disappeared in a patient who went from a normal to an irregular rhythm provided the first insight into the mechanism of atrial fibrillation. In 1924, Willem Einthoven (1860-1927) of Leyden University, The Netherlands, was awarded the Nobel Prize for his discovery of the mechanism of electrocardiography (Am J CardJo11994;7:]: 384-9).

In 1909, Lewis in England and Rothberger and Winterberg in Vienna, taking advantage of Einthoven's newly developed string galvanometer, were the first to establish electrocardiographically that auricular fibrillation was the cause of pulsus irregularis perpetuus.

Rodney Falk is Professor of Cardiology at Boston University. He trained in England and his main interests are amyloidosis and atrial fibrillation.

بسم الله الرحمن الرحيم



اكبر مفاجأت موافى 2010

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تسجيلات كورس مراجعه قصر العينى 2010
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أول حصه
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RHEUMATOLOGY
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بدء الدكتور بــ SCHEME و اهميته فى امتحانات النظرى و الشفوى ثم RA بالطريقتين الرأسيه و الافقيه

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تانى حصه
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Hepatology

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بين جانب الخير ( النص اليمين ) و جانب الشر ( النص الشمال ) لدكتور موافى و هو قاعد على الكرسى الهزاز فى البلكون انتظروا و اعرفوا ازاى الهيباتولوجى كله يخلص فى حصه 5 ساعات و نص و مش شرط جانب الخير ينتصر

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