Internal: Physical exam
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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
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
Oligoarthritis v. polyarthritis
- Oligoarthritis--1 to 5 joints
- Polyarthritis--more than 5 joints
DD for oligo/polyarthritis
- Reactive arthritis/Reiter's
- Psoriatic arthritis
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.
- 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
Does DIP involvement indicate osteoarthritis or RA?
Extra-articular manifestations of RA
- Rheumatoid nodules, usually on extensor surfaces
- Pulmonary fibrosis
- Vasculites (renal disease, hepatic disease)
- Eye inflammation
A white, net-like pattern over an erythematous area. Indicative of APLA, which is associated with SLE.
Firm, non-tender nodules on the PIPs
Firm, non-tender nodules over the DIPs
Chronic diarrhae that does not manifest at night
May indicate IBS--an organic cause of diarrhea would also occur at night
Patient presents with high palate, poor vision, and a heart murmur
What disease causes patients to lose their eyebrows?
Where can pain from lung disease be referred?
Cause of central cyanosis
Right to left shunt
Cause of peripheral cyanosis
Vasoconstriction or diminished blood flow in the periphery
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
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
Increased JVP with inspiration. Goes with pulsus paradoxus, which may indicate constrictive pericarditis or cardiac tamponade.
What is the correlation between the severity of a bruit, and degree of stenosis of an artery?
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
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
What does lateral displacement of the PMI indicate?
What maneuver decreases venous return to the right heart?
Valsalva--increases intrathoracic pressure, which decreases the pull of the blood towards the heart
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.
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)
Harsh, loud, holosystolic murmur with no S3
Probably VSD (might be mitral or tricuspid regurg)
Crescendo-decrescendo systolic murmur
- Aortic stenosis
- Heard best with patient sitting up and leaning forward
Crescendo-decrescendo systolic murmur of variable intensity that radiates to the apex, but not to the carotids
What makes the systolic murmur of HCM increase or decrease?
- Increases with valsalva
- Decreases with squatting
Early, decrescendo diastolic murmur that sounds like breath sounds
Rumbling diastolic murmur
- Mitral stenosis
- Easier to hear with the patient in left lateral decubitus
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