PhysicalDiagnosis

Question 1

A postural dizziness (severe enough to stop the test) or an increase in heart rate of at least _ beats/minute has sensitivity of 97% and specificity of 96% for blood loss >630 mL.

Unless associated with _, postural hypotension of any degree has little value.

Answer 1

A postural dizziness (severe enough to stop the test) or an increase in heart rate of at least 30 beats/minute has sensitivity of 97% and specificity of 96% for blood loss >630 mL.

Unless associated with dizziness, postural hypotension of any degree has little value.

Question 2

Body fat “distributions” by waist circumference (WC) and waist-to-hip ratio(WHR) are much better markers for cardiovascular risk than the body mass index (BMI) alone.

In fact, a WC <100 cm practically _ _ _.

Answer 2

Body fat “distributions” by waist circumference (WC) and waist-to-hip ratio(WHR) are much better markers for cardiovascular risk than the body mass index (BMI) alone.

In fact, a WC <100 cm practically excludes insulin resistance.

Question 3

An acute difference in systolic pressure > _ mmHg between the two arms usually indicates _ _ (complicated by aortic regurgitation in cases of more proximal dissection).

If chronic, it indicates instead a subclavian artery _ or a subclavian _ syndrome.

Answer 3

An acute difference in systolic pressure >20 mmHg between the two arms usually indicates aortic dissection (complicated by aortic regurgitation in cases of more proximal dissection).

If chronic, it indicates instead a subclavian artery occlusion or a subclavian steal syndrome.

Question 4

An ankle-to-arm systolic pressure index (AAI) < _ identifies patients with angiographically proven occlusions/stenoses of lower extremities arteries with 96% sensitivity and 94–100% specificity.

Most patients with claudication will have AAI values between _ and _, whereas those with pain at rest will have values < _. Indexes <0.2 are associated with ischemic or gangrenous extremities.

Answer 4

An ankle-to-arm systolic pressure index (AAI) <0.97 identifies patients with angiographically proven occlusions/stenoses of lower extremities arteries with 96% sensitivity and 94–100% specificity.

Most patients with claudication will have AAI values between 0.5 and 0.8, whereas those with pain at rest will have values <0.5. Indexes < 0.2 are associated with ischemic or gangrenous extremities.

Question 5

Significance

Answer 5

chronic hypoalbuminemia

Paired, transverse, white nail bands in the second, third, and fourth fingers (Muehrcke’s lines) suggest chronic hypoalbuminemia, occurring in more than three quarters of patients with:

1. nephrotic syndrome (<2.3 gm/100 mL)
2. liver disease
3. malnutrition.

Question 6

Acrochordons: significance

Answer 6

IGT or type 2 DM

In a study of 118 subjects with acrochordons (skin tags), 41% had either impaired glucose tolerance or overt type 2 diabetes.

Question 7

Vitiligo: Trigger

Answer 7

10% have serologic or clinical evidence of autoimmune disorders;

1. hypothyroidism of the Hashimoto variety.
2. Diabetes,
3. Addison’s,
4. pernicious anemia,
5. alopecia areata, and
6. uveitis (Vogt-Koyanagi syndrome) also are frequent.

Question 8

Acanthosis nigricans: DxTrigger

Answer 8

20%: aggressive neoplasm

Of these, (GI) adenocarcinoma: 90% , Gastric cancer: 60%.

Most: obesity and insulin resistance.

Question 9

Jaundice in dark skinned patients

Answer 9

1. Ask the patient to look upward.
2. Inspect the inferior conjunctival recess.
3. Should be white in nonicteric subjects, since the brownish discoloration of these individuals is the result of sunlight exposure.

Question 10

Nonproliferative diabetic retinopathy: earliest signs

Answer 10

Earliest signs of nonproliferative diabetic retinopathy include microaneurysms and dot intraretinal hemorrhages, with progression of disease characterized by an increase in number and size of microaneurysms and intraretinal hemorrhages (both dot and blot).

Soft exudates are not as predictive, and hard exudates even less.

Question 11

Diagonal earlobe crease

Answer 11

Diagonal earlobe creases in adults are an acquired phenomenon and a significant independent variable for coronary artery disease. Hair in the external ear canal also seems to be associated with coronary artery disease.

Question 12

Centcor criteria

Answer 12

XFELA

(1) pharyngeal or tonsillar exudates,
(2) fever,
(3) tonsillar enlargement,
(4) anterior cervical and jugulodigastric lymph adenopathy
(5) absence of cough.

Question 13

Multiple white, warty, corrugated, and painless plaques on the lateral margins of the tongue

Answer 13

Multiple white, warty, corrugated, and painless plaques on the lateral margins of the tongue (hairy leukoplakia) represent an Epstein-Barr–induced lesion typical of HIV infection, even though this can also occur in severely immunocompromised organ transplant patients. If present, it carries a worse prognosis for HIV progression.

Question 14

Reversible SVC obstruction by raising arm

Answer 14

Pemberton’s maneuver (reversible superior vena cava obstruction caused by a substernal goiter being “lifted” into the thoracic inlet as a result of arm raising) is a nonspecific finding that may be encountered in patients with substernal thyroid masses, lymphomas, or upper mediastinal tumors.

Question 15

Thyroid nodule size: detectability

Answer 15

The average size of a thyroid nodule detected on exam is 3 cm. In fact, the larger the nodule, the more likely its detection (with <1 cm nodules being missed 90% of the time; <2 cm nodules 50% of the time)

Question 16

Hyperthyroidism: useful signs

Answer 16

1. lid retraction (likelihood ratio [LR] = 31.5),
2. lid lag (LR = 17.6),
3. fine finger tremor (LR = 11.4),
4. warm skin (LR = 6.7),
5. tachycardia (LR = 4.4).

Findings more likely to rule out hyperthyroidism:

1. normal thyroid size (LR = 0.1),
2. heart rate <90/minute (LR = 0.2)
3. no finger tremor (LR = 0.3).

Older hyperthyroid patients exhibit more anorexia and atrial fibrillation; more frequent lack of goiter; and overall fewer signs, with tachycardia, fatigue, and weight loss in more than 50% of patients (and all three in 32%).

Question 17

Hypothyroidism: signs

Answer 17

1. Bradycardia (LR = 3.88),
2. abnormal ankle reflex (LR = 3.41), and
3. coarse skin (LR = 2.3).

No single finding, when absent, can effectively rule out hypothyroidism.

Question 18

Utility of CBE

Answer 18

Clinical breast exam (CBE) has low sensitivity for the detection of breast masses, high specificity.

Accuracy that can be increased by (1) longer duration of exam (at least 3 minutes per breast); (2) higher number of correct steps (a systematic and vertical search pattern, thoroughness, varying palpation pressure, use of three fingers, finger pads, and circular motion); and (3) examiner experience (previous training with silicone models).

Question 19

Arterial upstroke quality: significance

Answer 19

A brisk arterial upstroke + widened pulse pressure: aortic regurgitation (AR).

Brisk arterial upstroke + normal pulse pressure: indicates:

1. MR
2. VSD
3. HOCM

either the simultaneous emptying of the left ventricle into a high pressure bed (the aorta) and a lower pressure bed (like the right ventricle in patients with ventricular septal defect, or the left atrium in patients with mitral regurgitation) or hypertrophic obstructive cardiomyopathy (HOCM).

Question 20

Pulsus alternans: significance

Answer 20

severe LV dysfunction

The alternation of strong and weak arterial pulses despite regular rate and rhythm (pulsus alternans) indicates severe LV dysfunction, with worse ejection fraction and higher pulmonary capillary pressure. Hence, it is often associated with an S3 gallop.

Question 21

Visible neck veins in the upright position: significance

Answer 21

CVP > 7

Visible neck veins in the upright position indicate a central venous pressure >7 cmH2O and thus are pathologic.

Question 22

Significance of JVD and S3

Answer 22

In chronic heart failure, jugular venous distention represents an ominous prognostic variable, independently associated with adverse outcomes, including risk of death or hospitalization. The presence of S3 is similarly (and independently) associated with increased risk.

Question 23

end-inspiratory crackles: sensitivity, specificity

Answer 23

Presence of either end-inspiratory crackles or distended neck veins has high specificity (90–100%) but low sensitivity (10–50%) for increased left-sided filling pressure due to either systolic or diastolic dysfunction

Question 24

Abdominojugular reflux: sensitivity, specificity

Answer 24

Positive abdominojugular reflux has equally high specificity (but better sensitivity, 55–85%) for increased left-sided filling pressure.

S3 gallop, downward and lateral displacement of the apical impulse, and peripheral edema also have high specificity (>95%) but low sensitivity (10–40%).

Of these, only the S3 and the displaced apical impulse have a positive likelihood ratio (5.7 and 5.8, respectively).

Question 25

JVP: which jugular vein?

Answer 25

Right

The right internal jugular venous pulse is generally preferred for assessing right heart hemodynamics since the right internal jugular vein is in a direct line with the superior vena cava. On the other hand, the external jugular veins are more easily assessed than the internal jugular veins and can provide accurate results. We suggest examination of the right external jugular vein when the right internal jugular vein cannot be adequately visualized.

Question 26

The mean level of venous pressure normally declines during inspiration but the amplitude of the a wave increases. Lack of a decrease or an increase in jugular venous pressure during inspiration

Answer 26

Kussmaul sign

Numerous problems:

Constrictive or effusive pericarditis; other findings suggestive of chronic pericardial constriction include sharp y descent, diastolic left parasternal impulse, and pericardial knock. (See “Differentiating constrictive pericarditis and restrictive cardiomyopathy”.)

●Restrictive cardiomyopathy.

●Predominant right ventricular infarction; in patients with inferior or inferoposterior acute myocardial infarction, the presence of Kussmaul’s sign almost invariably indicates predominant right ventricular infarction [5,12,13].

●Severe right ventricular dysfunction

●Massive pulmonary embolism.

●Partial obstruction of the vena cavae.

●Right atrial and right ventricular tumors.

●Severe tricuspid regurgitation

●Occasionally tricuspid stenosis and congestive heart failure.

●Rarely cardiac tamponade.

Question 27

Hepatojugular reflux: duration of compression, positive test criterion

Answer 27

10 to 15 second, JVD increase of > 3 cm

Raising the legs or abdominal compression increases venous return and pressure.

1. applying firm, sustained pressure for 10 to 15 seconds over the upper abdomen while the patient is breathing quietly.
2. Normal: maneuver transiently increases jugular pressure by only approximately 1 to 3 cm.
3. In patients with right ventricular failure, however, sustained elevation of venous pressure usually greater than 3 cm is observed during continued compression (positive hepatojugular reflux).

Question 28

Abdominojugular reflux: significance

Answer 28

In patients presenting with dyspnea, an abdominojugular reflux argues in favor of bi-ventricular failure and suggests a PCPW >15 mmHg.

Negative: argues strongly against increased left atrial pressure

Question 29

PIC after MI

Answer 29

Ominous

Posturally induced crackles (PICs) after myocardial infarction (MI) carry an ominous sig-nificance, reflecting higher PCWP, lower pulmonary venous compliance, and higher mortality. After the number of diseased coronary vessels and the patient’s pulmonary capillary wedge pressure, PICs rank third as most important predictor of recovery after an acute MI.

Question 30

S3 and IHD: significance

Answer 30

Ischemic heart disease patients with S3 have a 1-year mortality that is much higher than those without it (57% versus 14%).

The same applies to a displaced apical impulse (39% versus 12%).

Question 31

Leg swelling without increased CVP: significance

Answer 31

1. bilateral venous insufficiency
2. noncardiac edema (hepatic or renal).

Question 32

Manouver for detecting LV dysfunction

Answer 32

The Valsalva maneuver

has excellent specificity and sensitivity (90–99% and 70–95%, respectively) for detecting left ventricular dysfunction, either systolic or diastolic.

supine or semirecumbent position and instructed to exhale forcefully against a closed glottis). Signs of adequacy include neck vein distension, increased tone in the abdominal wall muscles, and a flushed face. Maintain the strain for 10 to 15 seconds and then release it and resume normal breathing.

A modified Valsalva maneuver, which involves the standard strain (40 mmHg pressure for 15 seconds in the semirecumbent position) followed by supine repositioning with 15 seconds of passive leg raise at a 45 degree angle, has been shown to be more successful in restoring sinus rhythm for patients with SVT

lthough seldom used in current practice, the Valsalva maneuver has been evaluated in patients with heart failure and/or left ventricular dysfunction. Patients who are performing the Valsalva maneuver for diagnostic purposes in this setting should have continuous blood pressure monitoring along with continuous heart rate monitoring (single-lead telemetry is adequate here) during the maneuver. When non-invasively monitoring blood pressure responses using a blood pressure cuff, the cuff should be inflated to approximately 15 mmHg above the patient’s resting systolic blood pressure, and the investigator should auscultate the brachial artery throughout the maneuver and for 15 to 30 seconds afterward.

Blood pressure responses following a Valsalva maneuver — The expected blood pressure response in normal subjects is divided into four phases (figure 1) [13]. Phases 1 and 2 occur during the active strain phase of the Valsalva maneuver, while phases 3 and 4 occur after the strain phase has been completed. The normal pattern of systolic blood pressure has been named the “sinusoidal” response.

●Phase 1 is characterized by a >15 mmHg rise in the patient’s systolic blood pressure that occurs at the onset of straining and typically lasts less than five seconds. Phase 1 occurs because of increased intrathoracic pressure.

●Phase 2 is typified by a return of the systolic blood pressure to baseline (below the 15 mmHg increase) during the remainder of the straining phase. Phase 2 occurs due to decreased venous return (leading to a decrease in stroke volume) and an increase in systemic vascular resistance. Relative tachycardia may occur during this phase [15].

●Phase 3 occurs after release of the strain and is distinguished by an abrupt fall in systolic blood pressure below baseline. Phase 3 occurs due to an acute decrease in intrathoracic pressure.

●Phase 4 follows and is identified by a secondary rise in systolic blood pressure >15 mmHg above baseline. Phase 4 occurs because of a reflex sympathetic response to the decrease in systolic blood pressure encountered during phase 3. Relative bradycardia may occur during this phase.

Whil

Question 33

Low cardiac index: physical sign

Answer 33

The PPP (proportional pulse pressure—arterial pulse pressure divided by the systolic blood pressure) has excellent sensitivity (91%) and specificity (83%) for identifying low cardiac index (CI).

A PPP <0.25 has a positive likelihood ratio of 5.4 for CI of 2.2 L/min/m2.

Question 34

CHF signs but clear lungs

Answer 34

Cardiac tamponade

Patients with distended neck veins, dyspnea/tachypnea, tachycardia, and clear lungs should be thought of as having tamponade; thus, their pulsus paradoxus must be measured

Question 35

A pulsus paradoxus > _ mmHg has good sensitivity and excellent specificity for tamponade. It also may be palpable.

Answer 35

A pulsus paradoxus >21 mmHg has good sensitivity and excellent specificity for tamponade. It also may be palpable.

Question 36

Constrictive pericarditis: physical sign but not of tamponade

Answer 36

A paradoxical increase in venous distention during inspiration (Kussmaul’s sign) is not a feature of tamponade but does occur in 30–50% of patients with “pure” constrictive pericarditis; 90% of patients with constrictive pericarditis also have a retracting apical impulse.

Question 37

Loud S1: trigger

Answer 37

MS

A loud S1 should always alert the clinician to the possibility of mitral stenosis and should thus prompt a search for its associated diastolic rumble.

Question 38

Physiologic splitting of S2 varies with:

Answer 38

Age

An audible physiologic splitting of S2 is age dependent, present in 60% of subjects younger than 30 and 30% of those older than 60.

Question 39

Wide splitting of S2

Answer 39

Wide splitting of S2 usually reflects a delayed closure of the pulmonic valve because of either a right bundle branch block or pulmonary hypertension.

Question 40

Fixed S2 split

Answer 40

ASD

S2 that remains audibly split throughout respiration, both in the supine and upright positions, with a consistent interval between its two components, argues in favor of an atrial septal defect.

Question 41

S2: paradoxical splitting

Answer 41

S2 that becomes audibly split only in exhalation, while remaining single in inspiration (paradoxical or reversed splitting), means pathology until proven otherwise. This is usually an increased impedance to left ventricular emptying (aortic stenosis, coarctation, or hypertension), a left bundle branch block, or a transient, left ventricular ischemia.

Question 42

Mechanism of physiologic S2 split

Answer 42

1. Inspiration causes preferential filling of the right ventricle (increased venous return to RA, decreased venous return to LA)
2. During inspiration, intrathoracic pressure decreases causes ncrease in venous return into right atrium.
3. Inspiration causes decrease in LA return because lungs are exposed to a further increase in the magnitude of negative pressure.
4. Simultaneously, there is a reduction in blood volume returning from the lungs into the left atrium (because of the vacuum surrounding the lungs, and PVR is lower because of lung expansion).
5. Since there is an increase in blood volume in the right ventricle during inspiration, the pulmonary valve (P2 component of S2) stays open longer during ventricular systole whereas the aortic valve (A2 component of S2) closes slightly earlier due to a reduction in left ventricular volume.
6. Thus the P2 component of S2 is delayed relative to that of the A2 component.
7. Only heard in the pulmonic area

During expiration, the chest wall collapses and decreases the negative intrathoracic pressure (compared to inspiration). Therefore, there is no longer an increase in blood return to the right ventricle versus the left ventricle and the right ventricle volume is no longer increased. This allows the pulmonary valve to close earlier such that it overlaps the closing of the aortic valve, and the split is no longer heard.

Question 43

Loud ringing S2

Answer 43

A loud and ringing S2, rich in overtones and tambour like (“drum” in French), indicates a dilation of the aortic root. When associated with an aortic regurgitation murmur, it suggests Marfan syndrome, syphilis (Potain’s sign), or a dissecting aneurysm of the ascending aorta (Harvey’s sign).

Question 44

S3 absence

Answer 44

S3 is such an accurate predictor of systolic dysfunction (and elevated atrial pressure) that its absence argues in favor of an ejection fraction >30%.

Question 45

S3 during pre-op eval

Answer 45

In patients with congestive heart failure, S3 is the best predictor for response to digitalis and overall mortality. It correlates with high levels of B-type natriuretic peptide (BNP), and if associated with elevated jugular venous pressure, it predicts more frequent hospitalizations and worse outcome. S3 is also the most significant predictor of cardiac risk during noncardiac surgery. If preoperative diuresis is not instituted, it can also predict mortality. Finally, the presence of S3 in mitral regurgitation reflects worse disease (i.e., higher filling pressure, lower ejection fraction, and more severe regurgitation).

Question 46

S4 significance

Answer 46

S4 reflects an increase in late ventricular diastolic pressure (hence a diastolic dysfunction); but, in contrast to S3, it reflects normal atrial pressure, normal cardiac output, and normal ventricular diameter.

Question 47

S4: sensitivity for MI

Answer 47

S4 can be heard in as many as 90% of patients with MI, but eventually resolves. Presence of S4 at more than 1 month after MI does predict a higher 5-year mortality rate.

Question 48

Early systolic sound: signifies

Answer 48

An early systolic (ejection) sound indicates normal ejection of blood through an abnormal aortic valve (i.e., bicuspid), normal ejection of blood into a stiffened and dilated aortic root (i.e., hypertension, atherosclerosis, aortic aneurysm, or aortic regurgitation), or forceful ejection of blood into a normal aortic root (high output states like aortic regurgitation).

Question 49

Aortic ES in patient with AR: signifies

Answer 49

An aortic ES in patients with aortic regurgitation (AR) argues in favor of valvular AR, possibly due to a bicuspid valve.

Question 50

All right-sided auscultatory findings (except the pulmonic ejection sound) get louder on (Rivero Carvallo maneuver).

Answer 50

inspiration

Question 51

murmur that intensifies with Valsalva or squatting-to-standing is due to either

Answer 51

HOCM or MVP

Question 52

Benign functional murmur characteristics

Answer 52

systolic, short, soft (typically <3/6), early peaking

1. (never passing midsystole),
2. predominantly circumscribed to the base, and a
3. well-preserved and normally S2.
4. Otherwise normal cardiovascular exam ;
5. Often disappears with sitting, standing, or following Valsalva.

Question 53

“Bad” systolic murmur characteristics

Answer 53

1. Long, loud
2. late peaking,
3. nonlocalized,
4. soft-to-absent S2 that does not normally split.
5. Abnormal findings/symptoms (“bad” company).

Question 54

Aortic sclerosis murmur: significance

Answer 54

murmur of aortic sclerosis is the most common systolic ejection murmur of the elderly, affecting 21–26% of persons older than 65 and 55–75% of octogenarians and carrying a 40% increased risk of myocardial infarction.

Question 55

Murmur of AS: significance of Ejection click

Answer 55

Presence of an early systolic (ejection) click in aortic stenosis (AS) usually indicates a valvular AS, typically due to a congenitally bicuspid aortic valve.

Question 56

Some patients with AS may exhibit a dissociation of the systolic murmur into two components, with medium frequencies transmitted to the base and high frequencies to the apex, almost mimicking MR.

Answer 56

Gallavardin phenomenon

Question 57

Aortic stenosis murmur

Answer 57

In favor:

1. reduced/delayed carotid upstroke,
2. mid-to-late peak of the murmur
3. Soft-to-absent A2
4. Precordial thrill
5. Apical-carotid (or brachioradial) delay.

Against:

1. Lack of radiation to the right carotid artery.
2. Normal rate of rise of the arterial pulse argues also against the presence of significant AS, but only in the young.

Question 58

S4 in AS: significance

Answer 58

severe left ventricular hypertrophy

(with a transvalvular pressure gradient >70 mmHg), but only in younger patients (older subjects may already have a “normal” S4).

Question 59

Rheumatic MR vs MVP MR

Answer 59

Rheumatic: Plateau mitral regurgitation (MR) murmurs are more likely to be rheumatic,

MVP or papillary muscle dysfunction: start in midsystole and “grow” into S2

Question 60

Valvular AR vs “root” AR

Answer 60

Valvular AR: loudest over the Erb’s point (left parasternal area)

“root” AR is loudest over the aortic area (right parasternal area).

Question 61

S2 best auscultated at:

Answer 61

Erb’s point refers to the third intercostal space on the left sternal border where S2 heart sound is best auscultated.[4][5] Some sources in

Question 62

Austin Flint murmur

Answer 62

An apical diastolic rumbling murmur in pure aortic regurgitation.

Several mechanisms have been proposed:

1. fluttering of the mitral valve from the impingement by the aortic regurgitant jet,
2. relative (functional) mitral stenosis
3. regurgitant jets directed against the left ventricular free wall

Question 63

Tachypnea sensitivity for PE

Answer 63

92%

Tachypnea is so frequent in pulmonary embolism (92% of patients) that a normal respiratory rate argues strongly against the diagnosis.

Question 64

Platypnea: causes

Answer 64

Platypnea (an obligatory “supine respiration”) is usually due to a right-to-left shunt.

1. intracardiac or
2. intrapulmonary (common in cirrhosis from hepatopulmonary syndrome).

Question 65

Crackles and rhonchii that clear with coughing

Answer 65

Crackles (and rhonchi) that clear with coughing suggest airflow obstruction.

Question 66

Post-tussive crackles: signifies

Answer 66

Tuberculosis

Question 67

Bronchial breath sounds: significance

Answer 67

Consolidation

Bronchial breath sounds reflect patent airways in a setting of absent alveolar air, with replacement by media that better transmit higher frequencies, such as liquids or solids (consolidation).

If unaccompanied by crackles: pleural effusion.

Question 68

Inspiratory crackles: timing implications

Answer 68

1. early: bronchitis
2. mid-inspiratory crackles: bronchiectasis
3. Late: interstitial fibrosis or edema.

Question 69

Pneumonia: sequence of findings

Answer 69

1. First: crackles and diminished sounds
2. 1-3 days: bronchial breath sounds, egophony
3. Later: dullness to percusion

crackles and diminished breath sounds appear first; bronchial breath sounds and egophony develop 1–3 days after onset of symptoms (i.e., cough and fever), and dullness to percussion (plus increased tactile fremitus) occurs even later. This time lag usually allows for x-ray to preempt diagnosis, thus making exam often irrelevant.

Question 70

Wheezing: significance

Answer 70

Wheezing intensity does not correlate with severity of obstruction.

Only pitch and length of wheezes are useful predictors of airway narrowing. Higher-pitched and longer wheezes reflect worse obstruction.

Question 71

Bowel sounds: utility in intestinal obstruction

Answer 71

Useless

Bowel sounds lack sensitivity and specificity for intestinal obstruction, being decreased or absent in only one quarter of cases. Hence, they are clinically useless.

Question 72

Murphy’s sign: specificity and sensitivity

Answer 72

A painful arrest in inspiration triggered by palpation of the edge of an inflamed gallbladder (Murphy’s sign) is a good test for cholecystitis, with sensitivity and specificity of 50–80% (specificity usually a little higher than sensitivity).

Question 73

Splenomegaly: interpretation

Answer 73

(1) + hepatomegaly: primary liver disease with portal hypertension;
(2) + lymphadenopathy excludes primary liver disease and makes instead hematologic or lymphoproliferative disorders more likely;
(3) massive splenomegaly: myeloproliferative etiology

Question 74

Ascites volume detectable by physical exam

Answer 74

Combining all bedside maneuvers provides a good bedside tool for the diagnosis of ascites, with overall accuracy of 80%.

Volume necessary: (500–1000 mL) is much larger than that detected by ultrasound alone (100 mL).

Question 75

Egophony

Answer 75

“EEE” sound will be heard as a “AH”

A better way to differentiate between the alveolar and interstitial causes of crackles is to test for the presence of egophony. When alveolar filling is present, the “EEE” sound will be heard as a “AH” sound; however, in interstitial lung disease the “EEE” sound will be preserved.

Question 76

Wheezing in asthma

Answer 76

Polyhonic

The most frequent cause of wheezing is asthma, which results in polyphonic wheezing due to the dynamic variability in airway obstruction throughout the lung fields.

Question 77

Absent breath sounds

Answer 77

severe bullous lung disease, emphysema, pneumothorax, or pleural effusion.

Question 78

Stridor vs wheezing

Answer 78

Stridor is loudest during inspiration,

When compared to wheezing associated with small airway disease, stridor is loudest during inspiration, although it can be heard during expiration as well

Question 79

Consolidation vs pleural effusion: difference in exam

Answer 79

Consolidation: vocal transmission increased

Dullness to percussion can be seen with consolidation, atelectasis, and pleural effusion. With consolidation, voice transmission is increased during expiration so that one may hear whispered pectoriloquy or egophony. However, in both pleural effusion and atelectasis, breath sounds are diminished and there is no augmentation of voice transmission. Although this patient could have either atelectasis or pleural effusion, the lack of tracheal deviation points to pleural effusion.

Question 80

A 72-year-old male with a long history of tobacco use is seen in the clinic for 3 weeks of progressive dyspnea on exertion. He has had a mild nonproductive cough and anorexia but denies fevers, chills, or sweats. On physical examination, he has normal vital signs and normal oxygen saturation on room air. Jugular venous pressure is normal, and cardiac examination shows decreased heart sounds but no other abnormality. The trachea is midline, and there is no associated lymphadenopathy. On pulmonary examination, the patient has dullness over the left lower lung field, decreased tactile fremitus, decreased breath sounds, and no voice transmission. The right lung examination is normal. After obtaining chest plain film, appropriate initial management at this point would include which of the following?

Intravenous antibiotics

Thoracentesis

Bronchoscopy

Deep suctioning

Bronchodilator therapy

Answer 80

• subacute-onset dyspnea and an examination consistent with pleural effusion. Dullness to percussion can be seen with consolidation, atelectasis, and pleural effusion. With consolidation, voice transmission is increased during expiration so that one may hear whispered pectoriloquy or egophony. However, in both pleural effusion and atelectasis, breath sounds are diminished and there is no augmentation of voice transmission.

Although this patient could have either atelectasis or pleural effusion, the lack of tracheal deviation points to pleural effusion. Atelectasis would have to be of many segments to account for these findings, and such significant airway collapse would generally cause ipsilateral tracheal deviation.

Most appropriate next management step would be thoracentesis to aid in the diagnosis of the etiology and for symptomatic relief.

Question 82

affects the abductor pollicis longus and extensor pollicis brevis tendons at the point where they pass through a fibro-osseous tunnel (the first dorsal compartment) at the styloid process of the radius.

• noninflammatory thickening of both the tendons and the tunnel
• common cause of wrist pain, particularly among women between the ages of 30 and 50 years of age.

Answer 82

de Quervain tendinopathy

Question 83

Which test?

Answer 83

Finkelstein test for de Quervain tendinopathy

The examiner gently rotates the patient’s wrist ulnarly (arrow) while the patient’s fingers are folded over the thumb.

From Sheon, RP, Moskowitz, RW, Goldberg, VM, Soft Tissue Rheumatic Pain: Recognition, Management, Prevention. 3rd ed, Williams & Wilkins, Baltimore 1996.

Question 84

Finkelstein’s test: grasp the thumb and ulnar deviate the hand sharply.

If sharp pain occurs along the _ _ de Quervain’s tenosynovitis is likely.

Which tendons are affected?

Answer 84

distal radius

If sharp pain occurs along the distal radius de Quervain’s tenosynovitis is likely.

abductor pollicis longus and extensor pollicis brevis tendons

Question 85

Durkan’s test

Answer 85

1. Examiner presses thumbs over carpal tunnel and holds pressure for 30 seconds.
2. Positive: onset of pain or paresthesia in the median nerve distribution within 30 seconds.

Accuracy[edit]

Sensitivity: 87% to 91%

Specificity: 90% to 95%.

Question 87

Localized monophonic wheeze

Answer 87

Foreign body