Short Cases in Clinical Exams of Internal Medicine

185 Pages·2016·31.106 MB·English

by  Wanis Hamad Ibrahim, R. A. Malik

Contents
1. CardiovascularCases 1
HowtoExamineaPatientwithHeartDiseaseinthe
ClinicalExamination? 7
ImportantCluesRegardingCardiovascularCasesinthe
ClinicalExamination 5
MitralStenosis 6
MitralRegurgitation 8
AorticRegurgitation 10
AorticStenosis 12
PatientwithaProstheticHeartValve 14
VentricularSeptalDefect 76
EisenmengerComplex 17
AtrialSeptalDefect 78
Dextrocardia 79
AtrialFibrillation 20
InfectiveEndocarditis 27
2. RespiratoryCases 26
HowtoExaminetheRespiratorySystem? 26
BilateralBasalCrackles 28
IdiopathicPulmonaryFibrosisandInterstitialLungDisease 29
Bronchiectasis 31
CysticFibrosis 32
DullnessattheLungBase 33
PleuralEffusion 34
Pneumonectomy/Lobectomy 36
UnilateralLungFibrosis(Post-tuberculous) 37
ChronicObstructivePulmonaryDisease 37
3. AbdominalCases 41
HowtoExaminetheAbdomen? 41
ChronicLiverDisease 45
Hemochromatosis 50
PrimaryBiliaryCirrhosis 57
Jaundice 52
ThalassemiaMajor 56
AdultPolycysticKidneyDisease(APKD) 57
RenalTransplant 59
Hepatosplenomegaly 62
xiv ShortCasesinClinicalExamsofInternalMedicine
MassiveSplenomegaly 62
HepatomegalywithoutSplenomegaly 63
PrimaryMyelofibrosis 63
PolycythemiaVera 66
Ascites 67
LiverTransplant 72
4. NeurologyCases 76
HowtoPerformaNeurologicExaminationoftheLower
(orUpper)Limbs? 76
CommonLowerLimbNeurologicCases 78
Flaccid(LowerMotorNeuron)Paraparesis 78
SpasticParaparesis 79
MultipleSclerosis 82
SubacuteCombinedDegenerationoftheCord
(B12Deficiency) 84
TabesDorsalis 85
Friedreich'sAtaxia 86
MotorNeuronDisease 86
PeripheralNeuropathy 88
HereditarySensorimotorNeuropathy
(Charcot-Marie-Tooth) 97
Guillain-BarreSyndrome 92
CranialNervePalsies 93
ThirdCranialNervePalsy 94
SixthCranialNervePalsy 96
LowerMotorNeuronFacialPalsy 97
HypoglossalNervePalsy 98
InternuclearOphthalmoplegia WO
CerebellarSyndrome 707
MyastheniaGravis 703
MyotonicDystrophy 706
Parkinson'sDisease 708
Ptosis 770
Homer’sSyndrome 777
5. Endocrine,Rheumatology,ConnectiveTissue
andSkinCases 113
Graves’Disease 713
Acromegaly 718
Cushing'sSyndrome 122
Pseudohypoparathyroidism 124
TurnerSyndrome 127
DeformingArthritisoftheHands 728
Contents xv
AnkylosingSpondylitis 133
SystemicSclerosis 136
Takayasu'sArteritisPulselessDisease 140
Marfan'sSyndrome 141
Paget’sDiseaseoftheBone 144
Henoch-SchonleinPurpura 146
Dermatomyositis 149
HereditaryHemorrhagicTelangiectasia
(Osier-Weber-RenduDisease) 152
Neurofibromatosis“Type1"“vonRecklinghausen's
Disease” 154
DiabeticFoot,NeuropathyandArthropathy 156
CharcotJoint 158
6. FundusCases 161
FundusCasesintheClinicalExamination 161
DiabeticRetinopathy 162
HypertensiveRetinopathy 165
OpticAtrophy 165
Papilledema 166
RetinitisPigmentosa 167
CentralRetinalVeinOcclusion 169
Index 173

How to Present your Findings
to the Examiners?
In addition to the proper technique of physical examination and identification
of the correct findings, the way that candidates present their findings to the
examinerswillaffecttheoverallexaminer'simpressionabouttheperformanceof
thecandidatesandthefinalshortcasemark.Manycandidatesofhighstandardcan
failtheexaminationssimplybecausetheycannotconveythecorrectfindingsand
diagnosistotheexaminers.Presentingyourideastolistenersisanartinitself;and,
therefore,candidatesshouldpracticerepeatedlypresentingtheirclinicalfindings
totheirpeersorseniorcolleagues.Thecommontwoscenariosafteracandidate
completes physical examination of a patient are that either he/she is confident
aboutthediagnosisorhe/sheidentifiedthefindingsbutisnotconfidentaboutthe
exactdiagnosis(inthelatterscenario,thecandidateshas2or3possibledifferential
diagnoses).Iftheformerscenarioisapplicableandthecandidateisconfidentabout
thediagnosis(forexample,thecandidatefoundapansystolicmurmurofmaximal
intensityatthemitralarearadiatingtotheaxillasuggestiveofmitralregurgitation),
thenthecandidateshouldtellthediagnosisfirst andthen refer tothe findings.
Forexample,theexamineraskswhatyourdiagnosisis.Thetypicalanswershould
be:'Well,thispleasantgentlemanhasfeaturestosuggestmitralregurgitationas
evidencedbymuffledfirstheartsound,apansystolicmurmurofgrade3of5heard
bestatthemitralarearadiatingtotheaxilla'.Therearenosignsofheartfailureor
infectiveendocarditisandIwouldliketorequestechocardiographytoconfirmmy
findingsandassesstheseverityofthevalvelesion.Acandidatewhoisconfident
aboutcombinedaorticvalvedisease(stenosisandregurgitation)canprovidethe
followinganswer:'Well,thispleasantladyhasfeaturestosuggestcombinedaortic
stenosisandregurgitationasevidencedbyanejectionsystolicmurmurheardbest
intheaorticarea grade 3 of5 radiatingto the neckas wellasan early diastolic
murmurattheaorticarea.ThepatientseemstobeinheartfailureasIcouldhear
bilateralcracklesoverthelungbases.Thepredominantvalvularlesionseemstobe
aorticregurgitationasthepulseiscollapsingand,Icouldfindperipheralsignsof
aorticregurgitation.
Alternatively,the candidate may have established somefindings buthe/she
is not confident regarding thediagnosis.In other words, he/she is confused as
thefindingscouldfitmorethanonediagnosis.Inthatscenario,Isuggestthatthe
candidateshouldpresenthis/herfindingsfirst,andthensuggesta diagnosisand
justifyordefendhis/herthinking.Exampleofthis,acandidatefoundaharshsystolic
murmuroverthebase(aorticarea),butcould alsohearaloudmurmuroverthe
mitralarea,andisnotconfidentwhetheritisaorticstenosisormitralregurgitation.
Thetypicalcandidateanswerwillbe:'Well,Iexaminedthispleasantladywhohas
aholosystolicmurmurthatisbestheardovertheaorticarea;however,Icouldalso
hearthesamemurmurwiththesameintensityoverthetricuspidandmitralarea.
Althoughthemurmurisheardloudlyoverthemitralareaitdoesnotradiatetothe
xviii ShortCasesinClinicalExamsofInternalMedicine
axillaandIcouldhearradiationofthemurmurintheneck.Thismakesaorticstenosis
the most likely diagnosis in my mind;however, coexistent mitral regurgitation
needstoberuledoutbyechocardiography.Thepatientisnotinheart failureand
therearenosignsofinfectiveendocarditis'.Inthesecondscenario,theexaminers
usuallyask questionsthat canlead thecandidateto thecorrect diagnosis.Now
think what will be the candidate mark,if he/she stated that the diagnosis was
aorticstenosisandstopped,anditturnedtobemitralregurgitationorviceversa.
Thesecondimportantpointcandidatesneed to considerwhenpresentingtheir
findingsistoshowextremerespecttothepatient.A malepatient shouldalways
be referred to as pleasant gentleman and a female patient as pleasant lady.
Althougheachcandidateisgivenamarkbeforethenextcandidateisexamined,
theexaminationisacompetitionbetweencandidatesandexaminers,willusually
compareyourperformancetoothercandidates.Acandidatewhostartshisanswer
by:'Well,Iexaminedthispleasantgentleman/lady....'isdefinitelyconsideredmore
courteoustotheonewhostartsby:'Thispatientorthisoldwoman,etc.'Candidates
in clinical examinations are usually under tremendous anxiety and stress, and a
simplequestionbytheexaminermightbeinterpretedbytheanxious candidate
asatrickortrap.Alwaysthinksimpleandincase,youhaveadoubtastowhatthe
examinermeansbythequestion,donotjustgiveanyanswer,simplyrequestthe
examinerpolitelytorepeatorrephrasethequestion.
1
Cardiovascular Cases
HOWTOEXAMINEAPATIENTWITHHEART
DISEASEINTHECLINICALEXAMINATION?
(cid:127) Washyourhands.
(cid:127) Shakehandswiththepatient,introduceyourselfandtakepermission
(cid:127) Position the patient at a 45°angle and request the patient toremovetheir
upperclothes.
(cid:127) Informthepatienttoalertyouincaseyou causeanydiscomfortorpainto
him/herduringtheexamination.
(cid:127) Startbyinspectingthe patientand thesurrounding.Allowsometimefora
quicksurveillanceofthepatientandtheirsurroundings.Thismaygiveyou
importantcluesaboutthepatientconditionanddiagnosis.Atallmarfanoid
habitus may suggest the diagnosis of aortic regurgitation due to Marfan's
syndrome.Inabilityofthepatienttomovehisorherneck(particularlywhile
examining the Jugular venous pressure (JVP) should raise the suspicion
of ankylosing spondylitis with associated aortic regurgitation. External
appearance of Down’s syndrome may suggest an atrioventricular septal
defect.Similarly,awomanwholooksshortwithawebbedneckmayindicate
thereasonforcardiovascularsystemexaminationiscoarctationoftheaorta
asacomplicationofTurner'syndrome.Apatientonanintravenousheparin
infusionmaysuggestatrialfibrillationorpresenceofametallicvalve.Apatient
whoisusingoxygenmaysuggestthediagnosisofheartfailure.Apatientina
semi-sittingpositionfromthestartwhoappearsinrespiratorydistressmay
suggestsignificantheartfailure,whileonelyingcomfortablyinaflatposition
atthestartoftheexaminationsuggeststhatsignificantpulmonaryedemais
unlikely.Lookforcyanosis,malarflushduetomitralstenosis,obviouspedal
edema,etc.
2 ShortCasesinClinicalExamsofInternalMedicine
(cid:127) Candidates may hear different instructions from different examiners such
as examine the cardiovascular system, examine the heart or examine the
precordium. Many candidates get confused whether to examine only the
precordiumorlookforperipheralsignsofcardiacdiseases.Isuggestthateven
iftheinstructionistoexaminetheheart,candidatesshouldstartbylooking
forperipheralsignsof cardiovasculardiseaseunlesstheyare redirectedby
theexaminerstoexamineonlyontheprecordium.Acommoncauseoffailure
iswhencandidatesmissimportantperipheralsignssuchasclubbingorsigns
ofinfectiveendocarditisinapatientwithvalvularheartdisease.
(cid:127) Hold the right hand of the patient and feel the pulse.Payattention to the
rhythmasanirregularpulsecanbeeasilymissedbytheanxiouscandidate.
Record the rate, rhythm, volume, anyspecial character, the presence of a
synchronous pulseon theotherarm and feelforradiofemoraldelay.Make
sure that the patient does not have shoulder pain before you check for a
collapsingpulse.
(cid:127) Examine the hands for clubbing, cyanosis, pallor, splinter hemorrhage,
JanewaylesionsandOsier’snodes(Figure1.1).
(cid:127) Movetothefaceandmouth.Examinetheeyesforpallor,cheeksformalar
flushofmitralstenosis,cyanosisanddentalcaries(Figure1.2).
(cid:127) Examine the neck for JVP, dancing carotid pulsations "Corrigan pulse” of
aorticregurgitation and thyroid gland (particularlyin a patient with atrial
fibrillation).
(cid:127) Followthe steps of inspection, palpation and auscultationto examine the
precordium.
(cid:127) Inspectforvisiblepulsations,shapeofthechest,pectusexcavatum(Figure
1.3)orcarinatum(Figure1.4).
(cid:127) Beforeyoustartpalpatingthechestaskthepatientifhe/shehasanypain.
-
VA
V
FIGURE1.1 Fingerclubbingandsplinterhemorrhageinapatientwithinfective
CardiovascularCases 3
FIGURE1.2 Facialappearanceinmitralstenosis
m
wr
FIGURE1.3 Pectusexcavatum
(cid:127) Feel for the apex beat; determine its location and character. Feel for a
parasternalheave,thrillandpalpablesecondheartsound.
(cid:127) Start listening at the apex and simultaneously place your free hand over
the carotid to enable you to time the heart sounds, this is essential. First
concentrate on the Erst and second heart sounds. Determine whether
they are normal in intensity, muffled or loud. Checkwhether the splitting
of second heartsoundis normal wide, or fixed. Once you heara murmur,
determinetheplaceinwhichyouhearthemurmuratitsmaximalintensity.
This is usuallythesite of origin of the murmur.For example, ifyou hear a
pansystolicmurmurloudestatthemitralarea,thatmurmurismostlikelyto
bedueto mitralvalvedisease.Determinealsothecharacter, radiation and
effect of respiration on the murmur. Once you finish listening to the four
areas, askthe patienttotilt totheleftlateralpositiontolistenfor the mid¬
diastolicmurmurofmitralstenosisthenaskthepatienttositforward,breath
outandholdbreathtoexamineforthemurmurofaorticregurgitation.Listen
carefullyovertheleftaxillaforradiationofthemitralregurgitationmurmur