|Cardiology History Taking
- Weight loss - malabsorption, malignancy, chronic disease, Cachexia - malignancy
- Skin e.g. bronzed - Haemochromatosis
- Jaundice - Examine sclera if subtle. Raised bilirubin.
- Eyes: Kayser Fleischer ring - Wilson's disease: copper deposit in Descemet's membrane. Needs slit lamp Xanthelasma - Primary biliary cirrhosis
- Spider naevi - central arteriole with radiating vessels > 6 pathological
- Causes: Normal in Pregnancy, liver disease
- Tattoo or needle track marks: Consider Hepatitis B
- Lips : >Brown freckles Peutz-Jegher's syndrome (small bowel polyps). Telangiectasia - Osler weber rendu syndrome
- Finger clubbing GI causes - Inflammatory bowel disease
- Dupuytren's contracture, Palmar erythema - Liver disease
- Leuconychia "white nails" seen with a low albumin
- Spoon shaped Koilonychia - Iron deficiency
- Palmar erythema in chronic liver disease
- Asterixis - Flapping tremor seen with hepatic encephalopathy
- Supraclavicular nodes - Metastasis from the stomach or other gastrointestinal malignancy to left supraclavicular nodes "virchow's node" spreads there from lymphatic drainage of the thoracic duct
- Breath - Fetor hepaticus, Ketosis, Smell of alcoholic drinks (alcohol is actually a clear colourless odourless liquid. We smell the non-alcoholic additives of drink)
- Angular stomatitis - inflammation of the edge of the mouth due to - No teeth, Poorly fitting dentures, flossing, Candidal infection
- Parotid swelling and tenderness: Associated parotid swelling with VII nerve or lymph nodes suggests malignancy. Mumps parotitis may accompany orchitis
- Ulceration: Aphthous ulcers, Idiopathic, Recurrent painful ulcer. Commoner in females -
Exclude Iron, folate or B12 deficiency. Topical steroid may help and chlorhexidine mouth wash. Other causes are Coeliac disease, Crohn's disease ulcers, Traumatic - ragged-tooth, Viral e.g. HSV 1, Coxsackie A, HZV
- Leucoplakia (White patches) in the mouth - Squamous cell cancer (Smoking, alcohol, HIV, Betel nuts) - Indurated ulcers with rolled edges. Surgical excision.
- Lichen planus - premalignant
- Candida - Red sore margin of white patches seen in Diabetes, Immunocompromised, Inhaled steroids, Broad-spectrum antibiotics
- Hairly leukoplakia - Synonymous with AIDS. Also look for oesophageal candidiasis and oral mucosal lesions of Kaposi's sarcoma
- Oral pigmentation - Addison's disease, Peutz-Jegher's syndrome, Melanoma
- Gingivitis and dental caries - Suggests self-neglect perhaps alcoholism. Consider Vitamin C deficiency with bleeding gums. Vincent's angina - acute ulcerative gingivitis with bleeding and ulcers secondary to a spirochaete infection seen in immunocompromised. requires Metronidazole and nutrition and good oral care
- Gum hypertrophy - Phenytoin, Ciclosporin, Acute myeloid leukaemia
- Teeth - Dental caries are due to Streptococcus mutans, Erosion of teeth with Bulimia, Hutchinson's incisor (central notch in teeth) and Moon's molar seen with congenital syphilis
The tongue is a muscle whose function is Eating, Swallowing, Speech. It is attached to the hyoid bone and mandible. Histology: Covered in Stratified squamous epithelium. Motor control via Hypoglossal nerve - nucleus in medulla XIIth cranial nerve. Sensory: Touch sensation to the glossopharyngeal nerve. Motor and sensation is well represented in contralateral motor and sensory cortices. Taste anterior 2/3rds by facial nerve and posterior 1/3rd by glossopharyngeal. Tastes are sweet, sour, salt, bitter, uami
- Upper motor neurone - Spastic tongue points to the side of the weakness. Seen with Pseudobulbar palsy, Motor neurone disease.
- Lower motor neurone - Wasted, fasciculating tongue, Causes Motor neurone disease, Brainstem disease e.g. syringobulbia
- Malignancy - Squamous cell carcinoma
- Enlarged Tongue(Macroglossia): Acromegaly, Amyloidosis, Hypothyroid, Neurofibromatosis, Down syndrome.
- Smooth"beefy" tongue "Glossitis": B12 deficiency (Pernicious anaemia), Folate and Niacin deficiency, Iron deficiency
- Geographical tongue: Discrete areas without papillae on the tongue. Benign. Red lesions with distinct margins
Abdominal examination - Inspection
- Expose patient from xiphisternum to loin covering genitals. The patient should lie flat with one pillow and be relaxed. Go to the end of the bed and Inspect
- Is the patient comfortable or in pain
- Obese or cachexic or normal habitus
- Presence of surgical or other scars or striae - ensure you look in both flanks
- Different scars - Midline, Paramedian, Appendix scar
- Is there any swelling (consider the 5 F's) - Fluid - ascites or an ovarian cyst, Flatus, Faeces, Fat, Fetus
- Any visible pulsations e.g. AAA
- Dilated veins e.g. Caput medusae
- Herniae - Femoral (always check groin), Umbilical, Inguinal, Incisional
Gastroenterology Exam - Examining abdomen
Wash hands, Introduction and consent
- Abdominal pain: Ask about pain. Determine where pain maximal. take examine slowly and carefully.
- Pain is an important clinical sign and in real life will have to be expected in the process of an examination but should be minimised.
- Look for tenderness, Guarding, Rebound
- Start again in right lower quadrant and move towards the left Upper quadrant. Percuss along this line too and any dullness from the LUQ extending towards RLQ suggests enlarged spleen.
- Splenomegaly: Portal hypertension, Chronic myeloid leukaemia, Kala-azar, Amyloidosis
- Air should rise and fluid is heavier so the circumference should be dull and the umbilicus resonant if uppermost. The fluid and dullness shifts to the lowest point if the patient rolls onto the side. As the patient rolls over gaseous bowel rises and dullness moves to the periumbilical region
- Find by the process of ballottement which uses a hand behind and one in front of the kidney
- Consider checking when you think there is gastric outlet obstruction
- Abdomen is shaken and listen for fluid-like splashes in left Upper quadrant
- Systolic bruit on either side of umbilicus suggests Renal artery stenosis
- Bowel sounds : High pitched tinkling - obstruction, None - "Silent" - Acute abdomen
End of exam
- Most abdominal examinations should end (in finals) with a request and in real life with the intention to do per rectal and perineal examination in all cases with abdominal complaints.
- Testicular examination should be standard in males with abdominal symptoms. Testicular cancer should not be missed. Vaginal and perineal examination in female if a gynaecological problem is suspected. Request the presence of a chaperone