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Pain on active movement v. pain on active and passive movement
- Pain on just active movement indicates a muscular disorder
- Pain on active and passive movement indicates a joint disorder
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First thing to rule out in a patient with monoarthritis
- Septic arthritis--needs to be treated immediately
- Characterized by a WBC count over 100,000
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Oligoarthritis v. polyarthritis
- Oligoarthritis--1 to 5 joints
- Polyarthritis--more than 5 joints
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DD for oligo/polyarthritis
- RA
- SLE
- Reactive arthritis/Reiter's
- IBD
- Psoriatic arthritis
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Morning stiffness in a patient with arthritis
Characteristic of inflammatory arthritis, as opposed to osteoarthritis. Caused by accumulation of fluid in joints after a long period of immobility.
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Schober's test
- Used to detect ankylosing spondylitis.
- Mark a line at the level of the PSISs
- Measure up 10 cm
- Ask patient to bend over and touch toes; distance between two lines should elongate by at least 4 cm
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Does DIP involvement indicate osteoarthritis or RA?
Osteoarthritis
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Extra-articular manifestations of RA
- Rheumatoid nodules, usually on extensor surfaces
- Pulmonary fibrosis
- Vasculites (renal disease, hepatic disease)
- Eye inflammation
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Livedo reticularis
A white, net-like pattern over an erythematous area. Indicative of APLA, which is associated with SLE.
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Bouchard's nodules
Firm, non-tender nodules on the PIPs
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Heberden's nodes
Firm, non-tender nodules over the DIPs
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Chronic diarrhae that does not manifest at night
May indicate IBS--an organic cause of diarrhea would also occur at night
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Patient presents with high palate, poor vision, and a heart murmur
`Marfans
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What disease causes patients to lose their eyebrows?
Leprosy
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Where can pain from lung disease be referred?
Shoulder
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Cause of central cyanosis
Right to left shunt
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Cause of peripheral cyanosis
Vasoconstriction or diminished blood flow in the periphery
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When is the a wave (jugular pressure) increased?
- The a wave indicates atrial contraction, and increases when pressure in the atrium increases:
- tricuspid stenosis
- AV block
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When is the v wave (jugular pressure) increased?
The v wave indicates right ventricular contraction, and gets bigger in tricuspid regurg, where the ventricle contracts against a higher volume of blood
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Kussmaul's sign
Increased JVP with inspiration. Goes with pulsus paradoxus, which may indicate constrictive pericarditis or cardiac tamponade.
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What is the correlation between the severity of a bruit, and degree of stenosis of an artery?
None exists
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How great a difference between the pulses on the right and left side does there need to be to indicate a pathology?
10 mm or more
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What is the definition of orthostatic hypotension?
A decrease of 20 or more in systolic bp and 10 or more in diastolic bp when someone stands up
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What does lateral displacement of the PMI indicate?
LV dilation
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What maneuver decreases venous return to the right heart?
Valsalva--increases intrathoracic pressure, which decreases the pull of the blood towards the heart
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When does the murmur of HCM increase?
- When there is less blood flowing through the heart, which allows the hypertrophic heart to contract more violently.
- Giving fluids to a patient with HCM will increase the volume of blood and decrease severity of symptoms. Inotropic agents would be a really bad idea.
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Holosystolic murmer with an S3
- Mitral regurg, if it does not become louder with inspiration
- Tricuspid regurg, if it does become louder with inspiration (associated with increased JVP and large v waves)
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Harsh, loud, holosystolic murmur with no S3
Probably VSD (might be mitral or tricuspid regurg)
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Crescendo-decrescendo systolic murmur
- Aortic stenosis
- Heard best with patient sitting up and leaning forward
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Crescendo-decrescendo systolic murmur of variable intensity that radiates to the apex, but not to the carotids
HCM
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What makes the systolic murmur of HCM increase or decrease?
- Increases with valsalva
- Decreases with squatting
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Early, decrescendo diastolic murmur that sounds like breath sounds
Aortic regurg
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Rumbling diastolic murmur
- Mitral stenosis
- Easier to hear with the patient in left lateral decubitus
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