Clinical Q&A by Dr. M. Allam PDF

By Dr.\ M. Allam General 1- Points to comment on Pulse? 1. Rate 2. Rhythm 3. Volume 4. Equality (in volume) on both sides. 5. Special character. 6. Condition of the blood ves...

By Dr.\ M. Allam General 1- Points to comment on Pulse? 1. Rate 2. Rhythm 3. Volume 4. Equality (in volume) on both sides. 5. Special character. 6. Condition of the blood vessles 7. Preipheral pulsations. 2- DD between extra systole & AF? AF Extrasystole ( 5 ‫مقدرش اعد‬ (with S. tachycardia) ‫ضربات متتالية‬ ‫)منتظمة‬ Pulse Rhythm Occasional irregularity marked irregularity. Exercise May increase irregularity increased irregularity Pulse deficit 10 beats/min. Neck veins Normal with Occasional absent. A wave irregularity Heart sound Normal with Occasional Variability irregularity ECG P Premature beat followed Absent by compensatory pause 3- What are causes of big pulse volum? A- Big volume (Big pulse pressure = large amplitude) A.I. - P.D.A. - AV fistula Arteriosclerosis of the aorta Bradycardia in C.H.B. Hyperkinetic state 1  By Dr.\ M. Allam 4- What are causes of small pulse volume? B- Small volume (small pulse pressure = small amplitude)  Small stroke v. (low COP)  Shock: Thready pulse; weak & rapid  Tachycardia 5- What are causes of variable volume? 1- A.F 2- V. Tachycardia rd 3- 3 H,B, 6- What are causes of unequal pulse? a) Compressing from outside:  Cervical rib  Cervical L.Ns  Pancoast tumour b) Causes in arterial wall:  Aortic arch aneurysm  Coarcotation of aorta c) Causes occluding the lumen :  Thrombosis  Embolism 7- Special C.C.C. of pulse? 1- Water hammer pulse (collapsing pulse): 2- Plateau pulse = Anacrotic pulse:- 3- Pulsus paradoxus: 4- Pulsus deficit: 5- Pulsus alternans 6- Pulsus bigeminy 8- What is water hummer pulse? Def.: sharp ascending and sharp descending with high amplitude Causes of high pulse P. 2  By Dr.\ M. Allam 9- What is pulsus paradoxus? Def.: Marked drop in the systolic pulse during inspiration (more than 10 mm Hg) Causes: 1) Pericardial:- tamponade, constrictive or effusion 2) Severe congestive H.F. 3) COPD (especially severe asthma) Detection: by sphygmomanometery Measure B.P. during inspiration & during expiration. 10- What is Pulsus deficit? HR on apex > radial pulse Causes: A.F >10 beats/m Extrasystoles < 10 beats / m. 11- What is pulsus alternans? Def. Alternation of strong & weak pulse waves Causes:- Severe L.V.F. 12- what is pulsus bigeminy? Strong beat followed by weak beat then compensatory pause Causes:-  Ventricular premature beats  Digitalis toxicity  Myocarditis  Myocardial infarction 13- Causes of palpable artial wall?  Systemic atherosclerosis.  Focal arteriosclerosis:  Polyarteritis nodosa: grape like along course of the artery 14- Peripheral vascular ,,dorsalis pedis? Lateral to the extensor hallucis longus tendon against navicular bone on the dorsum of the foot. In the 1st interossus space 15- Femoral – radial pulse relationship? Femoral-radial pulse relationship: the femoral pulse is weaker & delayed when compared with radial pulse simultaneously in: 1. Coarctation of A. 2. Saddle embolus at the bifurcation of the aorta. 3  By Dr.\ M. Allam 16- Temperature terms? 1. Subnormal Temp. < 36.5 C0. 2. Fever > 37.2 C0. 3. Hypothermia = ≤ 35 C0. 4. Hyperthermia = > 41 C0. 17- Types of fever? Continuous: (Gram negative sepsis, CNS damage) Fluctuation: base line. Remittent: (Viral, TB) Fluctuation: >1C0 & > base line. Intermittent - Hectic: (Abscess- malaria) (‫)ساعات ساعات‬ Fluctuation: >1C0 & may reach the base line. Relapsing (cyclic, periodic): (Collagenosis, lymphoma, brucellosis, IMN & FMF) (‫)ايام ايام‬ Days of fever and days of normal. 18- Temperature – pulse relationship? i. Synchronization between rise in body temperature and pulse rate documented as: Each 1O  10 – 15 beats/m in HR a) Asynchronous form: Relative Tachycardia Relative bradycardia  HR more than expected for  HR less than expected for body temperature as body temperature as typhoid Myocarditis (Rh. F/Diphtheria). F/ meningitis. 19- Normal BP in adult measurement? Category Systolic BP Diastolic BP Optimal < 120 < 80 Normal = 180 > = 110 Isolated Systolic Hypertension grade I > 140-159 < 90 grade II > =160 < 90 4  By Dr.\ M. Allam 20- What are kortakoff phases? a. 1st sound heard. b. Sounds markedly decreased or may disappear (mistaken for D.) c. Sounds reappear (mistaken for S) d. Sudden muffling of the sounds e. Total disappearance of the sounds. 21- What are Uses of sphngmomanometer? (I) B.P. & pulse changes: 1- Measurement of B.P. 2- Determination of pulse pressure (S—D) 3- Detection of pulsus alternans 4- Detection of pulsus paradoxus 5- Detection of unequality of pulse in both sides (II) In some valvular disorders: 1- In coarctation of aorta: B.P. in arms more than B.P. in legs by more than 60 mm Hg (reversal of Hill's). 2- In A.I. : B.P. in leg is more than B.P. in arm by more than 60 mm by (Hill's sign) (III) Diagnostic tests: 1- Capillary fragility test (Hess test) 2- DVT: application of low pressure will cause severe pain in diseased leg 3- Diagnosis of tetany: Trousseau’s test (carpo- pedal spasm). 4- Walker's test for diagnosis of Myasthenia gravis. 22- What is body mass index? Weight can be determined by body mass index (BMI) which is derived from the formula Wt (Kg) / Ht(m)2 :  Normally it is "18-25" (average body built).  Underbuilt : < 18.  Overbuilt: 25-29.  Obesity: 30-39.  Morbid obesity: 40 or more. 5  By Dr.\ M. Allam 23- Where to detect pallor?  Inner aspect of lips  Skin of the face  Nails  Palm creases 24- What is jaundice, its types, its sites, its DD? Def. yellow discoloration of skin & mucous membranes due to increase level of bilirubin > 2.5 mg %. Sub clinical Jaundice:- Serum bilirubin = 1- 2.5 mg/dl. Site of examination: In sclera of lower fornix in the day light. DD of yellow discoloration of skin & sclera: 1- Atebrin 2- Hypercaroteinaemia (not in sclera) 3- Picric a. toxicity 4- Uraemia 5- Myxoedema 6- xanthomatosis. 25- Why tongue used for detection of cyanosis? a. Has no autonomic fibers b. Highly vascular c. Continuous exercise d. Warm site 26- What is the difference between decubitus, position ,attitude , and gait ? Decubitus – on lying e.g. orthopnia Position : onsiting e.g. squatting position Attitude : on standing e.g. flextion attitude in parkinsonism Gait : on walking e.g. cirumduction in Hemiplegia 27- What is orthopnea, its causes?  Def.: Semi setting position  Causes: 1- Heart:- Lt. Sided H.F.& Pericardial effusion. 2- Chest:- Br. Asthma & Emphysema 3- Increased intra abdominal pressure e.g. massive ascites. 4- marked obesity 6  By Dr.\ M. Allam 28- What is cyanosis, its types, its causes?  Def. & pathogcnesis: it is bluish discolouration of skin & m.ms, due to presence of more than 5 gm/dl reduced Hb.  Cyanosis is aggravated with ploycythaemia.  Site of exam: tongue, lips, hands; nails.  Examination in daylight is essential. Types: central, peripheral. Central cyanosis Peripheral cyanosis Blood ejected from heart (or lung) Blood ejected from heart is normal already contains more than 5gm% (normal amount of reduced Hb (stagnant reduced Hb (hypoxic hypoxia) hypoxia) Causes A- Cyanotic lung disease : A- Generalized decreased blood Flow : 1) Asphyxia 1- Polycythaemia: increased viscosity. 2) High altitude. 2- Marked decrease in C.O.P. 2) Lung diseases:- COPD, 3- systemic venous congestion : (RVF& fibrosis, collapse, Massive cardiac Tamponade) consolidation, Pneumothorax 4- shock or Pulmonary embolism 3) Pulmonary A-V fistula. 2- Congenital cyanotic H. dis. With B- Localized decrease in blood flow : Rt. To Lt. Shunt 1 - Cold temp. 2- Peripheral circulation disturbance (Raynaud's, Burger's, venous 3- Ploycythaemia. thrombosis & Arterial occlusion) 29- What is better to examine IJV or EJV & why? IJV is better than EJV due to  It runs in a direct continuity wz SVC  It has no valve  It dosent pierce deep facia  It is deep to sternomastoid so protected from external compression 30- Which is better to examine Rt IJV or Lt IJV ? RT ----- because Lt IJV is connected to SVC by the Lt innominate vein below which aortic arch passes & can compress it 7  By Dr.\ M. Allam 31- How to defferenciate between vein or artery in neck ex. Venous Arterial Lower Lateral to stemomastoid Medial to stemomastoid in post. Triangle. in ant. Triangle. Better seen than felt Better felt than seen Wavy: more than one wave One wave Have no Have an upper level upper level Disappear by pressure Disappear No by deep inspiration Postural changes Hepato-jugular (one minute No abdominal compression test) 32- What is normal waves ? A Wave:- Atrial contraction. C Wave :-  Elevation of the tricuspid valve at the start of ventricular contraction  Transmitted pulsation of carotid artery. X (Systolic Right atrial relaxation. collapse) V Wave :- Accumulation of venous blood in the right atrium during ventricular systole. 33- What is kussmaul sign? Kussmaul's sign:- Inspiratory filling of neck vein caused by berichardial disease 34- Whats normal jugular venous pressure? 2-3 cm H2O above sterna angle The angle of louis is about 5cm above Rt. A. at 45. C.V.P.= J.V. pressure [----] + 5cm = ---- cm H2O. Normal jugular venous pressure not more than 2 cm H2O Normal pressure in Rt. A. (central venous pressure) less than 7 H2O 8  By Dr.\ M. Allam 35- Causes of congested neck vein? B- Congested pulsating neck veins:  Right sided heart failure.  Tricuspid valve disease as T.I. & T.S.  Pericardial (effusion - Constrictive pericarditis).  Increased intrathoracic pressure (Massive pleural effusion \ Tension Pneumothorax / Emphysema).  Increased intra-abdominal pressure (Tense ascites / Pregnancy / Huge abdominal swelling).  Over transfusion = hypervolaemia  Hyperdynamic circulation. B- Congested non pulsating neck veins:  S.V.C. thrombosis causing complete obstruction.  Mediastinal syndrome causing complete obstruction.  Sever late constrictive pericarditis & pericardial effusion 36- Grades of clubbing, its ex.? Grade I: obliteration of the angle between nail and nail bed Grade II (parrot beak) Grade III (Drum stick) Grade IV (hypertrophic osteoarthropathy) Exam. 1- Look at fingers in profiles. 2- Window test (Schamroth's window test: pt's holds 2 index finger nails touching each together: if normal, will show a diamond- shaped window). 3- Fluctuation test at the nail base. 37- DD of generalized edema?  Cardiac edema with congested neck vein  Renal edema with periorbital puffness  Nutritional edema with sign of nutritional deficiencies  Hepatic edema with signs of L.T.F  Allergic edema with history of allergic manifestation (eczema, asthma) 9  By Dr.\ M. Allam Cardiology 1- What is NYHA classification of dysnea? NYHA classification of dyspnea I Dyspnea on more than ordinary effort II Dyspnea on ordinary effort III Dyspnea on sub ordinary effort IV Dyspnea on Rest 2- What is PND, mechanism? Dyspnea, cough + wheeze developed 1-2 hours after sleep spontaneously resolved called the Cardiac Asthma Mechanism of PND 1. Increased V.R. during sleep leading to aggravation of pulmonary congestion. 2. Absorption of oedema fluid into the circulation causing further increase in V.R. 3. Diminished Sympathetic activity during sleep causing reduction of cardiac contractility. 4. Night mares lead to tachycardia and elevation of BP. 5. Slipping down from high pillows.  PND is highly specific for cardiac cases  Diagnostic of left sided HTF  But we have to exclude B.A. 3- What are DD between cardiac asthma , bronchial asthma? Cardiac A. Bronchial A. Age - any age - young age Other symptoms + cardiac symptoms - chest symptoms Duration - short duration - long Time of attack 1 - 2 hrs after sleep - Early in the morning Relieved Spontaneously - Bronchodilators Dyspnea Inspiratory - Expiratory Sputum Frothy (may be blood - Thick. tinged) 4- Whats ascitis precox? Ascites precox = ascites before LL oedema in cases of pericardial & tricuspid diseases. 10  By Dr.\ M. Allam 5- Causes of jaundice in cardiac patient?  Associated viral infection.  Haemolytic Jaundice = pulmonary infarction or metallic valve  Hepatocellular Jaundice = hepatic congestion (cardiac cirrhosis)  Obstructed Jaundice = hepatic congestion obstruct the biliary tract 6- Causes of cardiac, non cardiac syncope? Cardiac syncope Exertional At rest Positional  Obstructive outflow  Adams-stocks  Ball and valve e.g. A.S. or HOCM.  Severe bradycardia embolus or tachycardia  Left atrial myxoma  Attacks of VF. Non cardiac syncope  Vasomotor syncope  Carotid sinus syndrome  Vasovagal attack  Orthostatic syncope??  Cerebral syncope: (embolism and hypertensive encephalopathy)  Hypoxic syncope: 7- What is Orthostatic syncope? Loss of reflex vasoconstriction of the blood vessels of lower limbs after standing Causes: 1. Autonomic neuropathy e.g. diabetic or uraemic neuropathy. 2. Huge varicose veins. 3. Hypovolaemia. e.g.: Haemorrhage or dehydration. 4. Weakness of the muscles of the lower limbs (muscle pump). 8- What is ortner sign? Left recurrent laryngeal nerve compression due to pressure = hoarseness of voice (Ortner'S). 9- Causes of fever in cardiac patient? Endocardium: - Inf. Endocarditis. (serious) - Rh. fever (commonest) Myocardium: - Myocarditis Cardiac= - Myocardial infarction. Pericardium: - Pericarditis - Effusion. Vessels = - Thrombophlebitis - DVT Lung = - P. embolism - P. infection 11  By Dr.\ M. Allam 10- Value of chest ex. In cardiac case? Chest Cause Result Association Corpulmonale 1. Chest infection. Kartagner,s syndrome = 2. Pleural Bronchectasis + dextrocardia + effusion. absent frontal air sinus 3. Crepitations. 11- Value of abd ex. In cardiac case? Spleen 1- Palpable = cirrhosis 2- Palpable & tender = infective endocarditis Ascites 1- Normal sequels 2- Ascites precox = pericardial dis \ T.R. Liver 1- Palpable = Liver cirrhosis (Cardiac cirrhosis - B fibrosis) 2- Palpable + lender = congested liver = Rt HF / Pericardial diseases. 3- Palpable +tender + pulsating = pulsating liver = T.R. (systolic) /T.S. (diastolic) 12- What are Causes of pulsating liver?  T.R – T.S.  Highky vascular tumour  Transmitted from aorta 13- Causes of precordial bulge? indicates cardiac enlargement during childhood e.g. R.V. enlargement / pericardial effusion. 14- Area of palpation in cardiac case and its causes?  Supra sterna : AR , aortic aneurysm  Epigastric pulsation : - From tips of fingers : RV++ - From Rt side : hepatic - From behind : aortic  Aortic area : AS / aortic aneurysm / hypertention  Pulmonary area : PH +++  Lt parasternal : RV ++ 12  By Dr.\ M. Allam 15- What is apex? Apex = Outermost and lowermost visible and palpable part of the heart. 16- What are causes of absent apex? Absent apex: (OPERA):- Def:- Not visible or palpable apex even on left lateral position O Obesity. P Pericardial effusion \ Pleural effusion. E Emphysema R Rib "Under rib". A Anomalies "Dextrocardia". 17- Causes of diffuse apex ? Rt vent. ++++ 18- What are causes of shifted apex ? Down down and out  Viscero-ptosis  LV ++  Thin person 19- What are C.C.C. of apex & its causes? Hyperdynamic = forcible (In left lateral) Volume overload as A.R. / MR / VSD. Heaving = Sustained. Tension overload as systemic Hypertension / AS / A coarctation Slapping = papable S1 MS. 20- Causes of thrill in cardiac patient? Apical thrill a- Diastolic thrill in M.S. b- Systolic thrill in M.I. left parasternal thrill : VSD Basal thrill : AS 13  By Dr.\ M. Allam 21- What are signs of Rt vent enlargement ?  Apex : diffuse , systolic retraction ,shifted out  Lt parasternal thrill  Epigastric pulsation coming from fingertips  Precordial bulge  Large dullness of bare area  Stony dullness at lower sterna border 22- What are signs of Lt vent enlargement ?  Apex : shifted out & down 23- What are causes of volum overload on LV? AR – MR – VSD – PDA 24- What are causes of pressure overload on LV ? AS – aortic coarcotation - hypertention 25- Causes of Rt vent englagement ? Dilatation = volum overload eg TR – ASD Hypertrophy = pressure overload eg PS – PH 26- Causes of pulmonary hypertension ?  Lt sided HF  Extensive lung disease ( cor pulmonale )  Lt to Rt shunt due to lung plethora leading to revesal of the shunt = Eisinminger syndrome 27- Sign of pulmonary hypertention ?  Neck veins : Giant a wave  Inspection & palpation : - pulmonary pulsation - diastolic shock  Percussion : dullness on pulmonary area  Auscultation : - accentuated pulmonary component of S2 - Close splitting of S2 - Murmur of PR ( Graham steel murmur ) ealy diastolic soft murmur - Murmur of functional pulmonary stenosis ( ejection systolic ) - S4 on tricuspid area 28- Causes of accentuated 1st heart sound ?  MS  TS  Tachycardia  Hyperdynamic circulation 29- Additional sounds ? 14  By Dr.\ M. Allam 30- Whats ejection click? Def :- Opening of the normal aortic (or Pulmonary) valve is soundless while opening of the stenosed aortic (or Pulmonary) valve produce ejection click sound due to doming of this stenosed valve. C.c.c..: Clicky sound. Site : Aortic area (Al) Pulmonary area Causes : A.S. (Valvular)/ S. hypertension P.S. (Valvular)./PH++ NB, No ejection systolic click with subvalvular or Calcific A.S. 31- Whats opening snap? Def: - Snapy sound in M.S due to rigid periphery & pliable centre of the mitral valve in M.S. Timing: - Early diastolic / separated from S2 by the isometric relaxation phase / heard by cone Site: - Between M & T areas. Significance: - a. Diagnostic for M.S. b. Non calcified. c. Detect severity of M.S. (Diminished distance between O.S. & S2 = sever lesion). 32- What are investigation for cardiac patient? 1. Laboratory: - Urine/ stool/ blood/ others. 2. ECG 3. Images: -  X ray :- Plain or with Contrast  Echocardiography & Doppler.  C.T. / MRI. (limited for pericardial diseases or tumours) 4. Nuclear medicine as isotopic scan (for IHD) 5. Endoscopy 15  By Dr.\ M. Allam 33- What is the investigation of choice for valvular disease & why ? Investigation of choice: due to : simple, cheep, available, non invasive & highly diagnostic Echocardiography Doppler Indic Values Values 1/ Aetiology:- Rh (excessive fibrosis) For blood flow All cardiac cases congenital (ASD \ VSD) A) Direction :- regurge 2/ Lesion :- which valve B) pressure :- PH++ 3/ Severity:- see latter C) Velocity 4/ Effect :- Chamber ++ 5/ Complication:-  PH++  Calcification  Thrombosis 6/ Function:- Ejection fraction = St.V/EDV 34- Whats tight MS? Valve area (normal = 4-6 cm2) Tight MS = < 1 cm2 35- Heart surgary , valve replacement , complication ? Valve replacement Which valve is replaced? By a. History. b. Metallic H.S  S1 = Mitral.  S2 = Aortic. Function of the replaced valve:  No symptoms or signs of the disease.  Local examination i.e. no murmur. Complications of the replaced valve :-  Dysfunction  Haemolytic anemia.  Haemolytic jaundice.  Prosthetic valve endocarditis  anticoagulant use 16  By Dr.\ M. Allam 36- What is auscaltatory finding in AS ? H.S. :- S2 Murmur: Auscultation  Ejection systolic  Harsh  Over A1  Propagated: apex and carotid ‫طالع نازل‬  increase by leaning forword & expiration S2 37- What are peripheral signs of AR? H&N UL LL  Supra-sternal P.  WHP  Hill's sign  (Corrigan's sign)  High Pulse  Pistol-Shot  Systolic thrill over the carotid a. Pressure  Duroziez's Sign  De Musset's Signs (head nodding)  Capillary P DD: Parkinsonism & ataxia & hyst. 38- what are auscaltatory finding in AR ? H.S. :- S2 Murmur:- Auscultation  Early diastolic  Soft blowing  Over A2  Increase by inspiration S1 S2 17  By Dr.\ M. Allam 40- What is aucaltatory finding in MR ? S1 S2 HS:- S1 muffield Murmur: (Pan systolic)  Auscultation pansystolic  Soft (80%) / Harsh (20%)  Over M (apex)  Propagated: Axilla (ant. Leaflet) and Sternum (post. Leaflet)  Increased by Left lat / exercise 41- What is aucaltatory finding in TR ? S1 S2 HS:- S1 muffled Auscultation Murmur:  pansystolic  Soft  Over T (apex)  Increased by inspiration (Karvaullo's sign) 42- What is auscaltatory finding in MS ? Site: S1 S2 At or inside the apex Character: rumbling. Propagation: localized Murmur Increased By Left lateral or exercise Timing:- mid-diastolic with presystolic accentuation which lost in AF 18  By Dr.\ M. Allam Chest 1- What is the surface anatomy of the lung ? a. Apex: a point 3cm above the medial 1/3 of the clavicle. b. Anterior border: Oblique line From apex to a point at the middle of sternal angle passing through sterno clavicular joint then the line descends vertically. Vertical line Rt. Lt. th To the 6 costal To the 4 costal cartilage where it deviates to cartilage the left (cardiac notch). Then continues down ward to the 6th costal cartilage  Inferior border :: th  6 rib in MCL. th  8 rib in MAL. th  10 rib close to vertebral column. d. Posterior border: A vertical line drawn upwards from the (10th rib) close to V.C. upwards along the side of V.C up to the apex. 2- What is the surface anatomy of the trachea ?  From 6th cervical vertebra to 4th thoracic vertebra (angle of lewis).  10 cm length (Upper 1/2 in the neck and lower 1/2 in the chest). 3- What is the surface anatomy of the lung fissures ? a. Oblique fissure: (Both lungs) ‫النهاية‬ ‫المنتصف‬ ‫البداية‬ th MCL == 6 costo- Extends obliquely downward and T3 chondral junction forward along the course of 6th rib posteriorly (MAL) b. Transverse fissure: ‫النهاية‬ ‫البداية‬ th th 6 rib at the MAL. Sternal end at 4 costo-chondral junction laterally 19  By Dr.\ M. Allam 4- What is the SLS ? 1) Suppurative Lung Syndrome (SLS): Definition:- Group of diseases charchterised by cough & expectoration of  Big amount (profuose). (Ps)  Purulent.  Postural.  ± Foetid. These diseases are : 1. Lung abscess. 2. Bronchiectasis. [Cavitary syndrome] 3. Infected lung cyst. 4. Empyaema with bronchopleural fistula. 5- What is corepulmonale? & its causes ? Right ventricular hypertrophy and / or RVF due to chest disease, on top of healthy left side. Acute:  tension pneumothorax  Massive pulmonary embolism Subacute:  multiple small pulmonary emboli Chronic:  hypoxic: COPD  oblitrative: fibrosis,bilharzial corepulmonale  restrictive : severe skeletal deformity 6- What are the c.c.c. of cough? Brassy:- tracheal causes (metalic form ======mediastinal synd.). Bovine:- Lt. RLN paralysis (hollow). Barking:- hysterical. Paroxysmal:- Whooping cough - Cavity syndrome - B.A. + Pharyngeal, laryngeal and auditory irritation. 7- What are the commenst causes of chronic cough? 1. Chronic bronchitis. 2. S.L.S. 3. Bronchial carcinoma. 4. Pulmonary -> T.B. / pneumoconiosis & sarcoidosis. 5. Post-nasal discharge as chronic sinusitis. 20  By Dr.\ M. Allam 8- What are the complications of chronic cough? Thoracic Extra thoracic Ms. (chest) pain. Eye puffness. Fracture rib (stress fracture) Subconjunctival hge. Pneumothorax. Emphysema. Hernia. Haemoptysis. Prolapse 9- What are the different type of expectoration ( sputum)? 1 Frothy (serous)  Pulmonary oedema (pink frothy sputum)  Pulmonary venous congestion,  Broncho alveolar carcinoma 2 Mucoid  Chronic bronchitis  Bronchial asthma. 3 Purulent  abscess and bronchiectasis Mucopurulent  any form of broncho pulmonary infection 4 Rusty  Peumonia. (altered blood pigment) Golden brown 5 Chocolate  Amebic lung abscess (Anchovy Sauce). 6 Red-current jelly  Bronchial carcinoma. 7 Caseous  TB == nummular sputum (coin like) 8 Black  Inhalation of carbon 10- What are the types of true haemoptysis and its cause ? True:- Below the vocal cord Deffrantiated by investigations False:- Above the vocal cord (laryngoscopy) True haemoptysis Type Causes Frothy blood tinged A.P.O. Blood stained Acute infection - bronchogenic carcinoma Blood streaked Ch. bronchitis - bronchogenic carcinoma T.B. Red current jelley bronchogenic carcinoma (blood +sputum + hg. debris) Rusty (golden Lobar pneumonia browen) Frank T.B. - P. embolization - bronchectasis sicca haemorrhagica. 21  By Dr.\ M. Allam 11- What are the difference between haemoptysis and haematemesis? Haemoptysis Haematemesis Preceded by Cough Nausea & vomiting During - Contents Frothy Food - Colour Bright red Dark (‫)لون البن المحروق‬ Alkaline. Acidic - PH Followed by Blood tainged sputum Melena. 12- What is Bronchiectosis Sicca Haemorrhagica? Special type of bronchictasis caused by TB charachterized by frank haemoptysis. Explained as; TB usually affects the apical part of the lung, with good drainage so, presented with Dry cough and Frank haemoptysis. 13- What are the main causes of haemoptysis? 1. M.S.& L.V.F. 2. Pulmonary T.B. 3. Acute bronchitis. 4. Bronchiectasis. 5. Bronchial adenoma & carcinoma. 6. Pulmonary embolism. 14- What are causes of paroxysmal dyspnea? A = Asthma (bronchial / cardiac / uraemic) H = Hysterical L = Laryngismus stridulus. A = allergic alveolitis. M = Myesthenia gravis / mediastinal syndrome. 15- What are causes of acute dyspnea? 1- Hypoventilation: obstruction (br. asthma) or restriction (pneumothorax) 2- Impairment of diffusion: cardiac asthma (APO) 3- Hypoperfusion: pulmonary embolism 22  By Dr.\ M. Allam 16- What are causes of jaundice in chest case? Hepatocelleular: - in core-pulmonale (liver congestion). Haemolytic: - in pulmonary infarction. Obstructive : - in bronchial carcinoma (liver metastasis). 17- What are causes of LL oedema in chest case? 1. R. V. F: core pulmonale. 2. Hypo-albuminemia: Excessive expectoration for along time or Frequent aspiration ofempyema. 3. Nephrotic syndrome due to renal amyeloidosis in chronic SLS 4. Acid-base disturbance in COPD (increased CO2) 18- What are causes of tender chest? Tenderness according the site Over sternum:-leukaemia Over spaces:- empyaema Over ribs:- fracture or osteomylitis Rt side:- amaebic liver abscess 19- What are causes of congested neck veins in chest case?  Cor- pulmonale.  Massive pleural effusion or pneumothorax.  Chronic obstructive pulmonary disease. Mediastinal syndrome 20- What are causes of clubbing in chest case? Chronic suppurative lung disease. Bronchogenic carcinoma. Chronic obstructive pulmonary disease. Interstitial lung fibrosis. Mesothelioma. 21- What are the value of cardiac examinations in chest case? CAUSE RESULT Association  Pulmonary congestion,  Core pulmonale Kartagner’s  Pleural effusion. syndroms  Lt. sided failure (BBC) 23  By Dr.\ M. Allam 22- What are causes of hepatomegaly in chest patient? 1- Corepulmonale. 2- Hypoxic corpulmonale 4- Ptosed liver(emphysema) 5- Amoebic liver abscess 6- 2ry from Br. carcinoma. 7- Fatty changes (toxaemia) 8- Association. 23- What are causes of splenomegaly in chest patient? 1- Corpulmonale. 2- Hypoxic core pulmonale. 3- Miliary T.B. 4- Sarcoidosis. 5- Amyloidosis. 6- Associated. 24- What are MCL? MCL:-midway between the acromion process and sternoclavicular joint (as M Ing P) 25- What are the abnormal shapes of the chest? What are the C.C.C. of barrel chest? 1- Barrel chest: "Emphysematous" as in COPD  Antero posterior ≥ transverse.  Ribs : Transverse with wide I.C. spaces.  Thick shoulders.  Subcostal angle : wide.  Protrousion of the sternum  Kyphosis. 2-Funnel chest"Pectus excavatum" 3- Pigeon chest'pectus carniatum" Congenital or occupational. In Rickets. 4- Unilateral retraction: 5- Unilateral bulge: Fibrosis & collapse Pleura= effusion, penumothorax Chest wall= emphysema, tumours 26- Whats Trills sign? Prominent sternomastoid tendon on the shifted side (Trill's sign). 24  By Dr.\ M. Allam 27- Whats littins sign and its value? littin,s: The diaphragmatic shadow on chest wall.  Normally: in thin patients.  Its presence exclude: - Paralysis of the diaphragm. - Pleural effusion. 28- What are causes of tracheal shift? Tracheal shift to the same side of lesion to the opposite side of lesion Fibrosis, collapse Pleural effusion, pneumothorax, or pneumonectomy hydropneum-othorax or unilateral emphysema 29- What is TVF? What increase? What decrease? Def. : Vibrations of the vocal cord transmitted through air way & chest wall to be palpated on the chest wall. Causes of increased T.V.F. :  Consolidations.  Collapse with patent bronchus.  Cavity if superficial & surrounded by TVF reduced in any other chest diseases 30- What are causes of limited chest expansion? Causes:limitation of expansion in  Bilateral: COPD.  Unilateral: fibrosis & collapse.  Bilateral basal: bronchiectasis. Chest expands about 5-7 cm 31- What are causes of palpable rhonchi? COPD / Bronchial asthma 32- What are types of percussion notes ? Types of percussion notes: 1. Tympanitic: hollow viscus. e.g, normal traub's area. 2. Hyperresonance: emphysema and pneumothorax. 3. Resonance: normal lung. 4. Impaired note: pulmonary consolidation or fibrosis. 5. Dullness: pulmonary consolidation, pulmonary collapse & fibrosis. 6. Stony: pleural effusion. 1. Light percussion gives palpable rather than audible vibration. 2. Heavy percussion gives palpable and audible vibration. 25  By Dr.\ M. Allam 33- What is bare area? Its surface anatomy? When become resonant? When ++ in dullness? Anatomy:- Lt. 4th & 5th I.C. spaces from left border of the sternum to the left parasternal line. Normally:- Dullness (Blood). Abnormalities: 1. Resonant: - emphysema (the surest sign) - pneumothorax 2. Dullness of the bare area in : a. Collapse. b. Rt.V++ c. Pericardial effusion. Technique: (Light percussion) 34- What is surface anatomy of ( kronigs isthmus )? Bony border: - Ant.: Medial 2/3 of the clavicle - Post.: Medial 1/3 of the spine of the scapula. - Latral: A line connects 2 points : 1. Junction between medial 2/3 & lateral 1/3 of the clavicle. 2. Junction between medial 1/3 & lateral 2/3 of the spine of the scapula. - Medial: A line connects sternoclavicular joint and C7 Normally: Resonant. Abnormalities: Dullness in apical lesions as 1. T.B. 2. Pancost tumour. 3. Friedlender's pneumonia. 26  By Dr.\ M. Allam 35- Surface anatomy of (traubs area)? Causes of its dullness? When it increase in size? Def. : Area of the chest overlying the air bubbles at the fundus of the stomach. Anatomy: 1. 5th rib at MCL. 2. 9th rib at MAL. 3. Costal margin at MAL. 4. 8th costochondral junction. Normally: Tympanatic resonant (Air bubbles). Abnormalities: 1. Dullness : i. Above - Pleural effusion & pericardial effusion. ii. Down - Asictis, pregnancy & tumours. iii. Right - Hepatomegaly. iv. Left - splenomegaly. v. full stomach or gastric tumour. 2.Wide area: lobectomy, splenectomy, shrunken liver or dilated stomach. Technique: From out inward. 36- What are values of Tidal percussion? Differentiate supra from infra diaphragmatic dullness (see the lower table) Diaphragmatic movement:- measuring the distance between the lower border of pulmonary resonance in full inspiration and forced expiration at the back of the chest Normal: dullness at T10 changed to resonance by inspiration Abnormalities Infra diaphragmatic Reversed tidal Supra diaphragmatic percussion dullness above T10 resonant becomes dull dullness above T10 changed to on inspiration (didn’t change) resonance by (diaphragmatic paralysis) inspiration 37- What are normal muscles of inspiration?  Diaphragm  Intercostal muscles. 27  By Dr.\ M. Allam 38- What are normal muscles of expiration? no muscle as a passive processor 39- What are accessory muscles of inspiration?  Sternomastoid  Trapezius  Scalnii 40- What are accessory muscles of expiration?  Abdominal Ms  Latismus dorsalis  Lips 41- What is normal breathing and its C.C.C.? Vesicular breathing  Soft (rustling).  No gap.  Inspiration > Exp. 42- What are abnormal breathing sounds?  Vesicular breathing with prolonged expiration (harsh vesicular):- Obstructive aieway as; COPD.  Bronchial breathing (B.B.) in (3C3)  Consolidations.  Collapse with patent branchus.  Cavity if superficial & surrounded by consolidations. 43- Where B.B. is heard normal? On Trachia 44- What are types of B.B.? Subtypes of B.B. are Tubular, cavernous & amphorous. 45- What is Despin’s sign? Bronchial breathing below the level trachea (4th Thorcic vertebra) due to enlargment of interbronchial L.N. Causes:- * TB * Carcinoma 28  By Dr.\ M. Allam 46- What are C.C.C. of Rhonchi in COPD? Generalized (Bilateral). Insp. & Exp. But mainly expiratory. Changed with cough polyphonic 47- What are you mean by polyphonic?  Siblent: distal small bronchioles (high pitched)e.g. Br. asthma  Sonurn: central big bronchioles or bronchi (low pitched)e.g. ch. Bronchitis 48- What are C.C.C. of wheezes ( Ronchi ) in lung tumour? Localized, Monophonic, fixed 49- What are causes and types of crepitation? Fine Medium  Early  TB  Lung abscess pneumonia  Bronchiectasis. 50- What is opening snap of the chest? Early inspiratory crepitations may occur in COPD 51- What is pleural rub and its causes? And its D.D.? Def :It is a stitching friction gritty sound diappears by holding of breath. Causes: Pleurisy (dry or with effusion) D.D.:- Pericardial rub (with heart beats). Friction of the stethoscope:- diappears by firm pressure 52- What is Vocal resonance? Its methods? Def: It is vibrations of the vocal cord transmitted through airway and chest wall to be auscultated. Called voice sound  Diminished in all chest lesions except:- 3C3  Consolidations.  Collapse with patent bronchus.  Cavity if superficial & surrounded by consolidations. 29  By Dr.\ M. Allam Methods : patient say 99 1. Bronchophony:- in a loud voice. 2. Whispring pectrology :- by whispring. NB : Aegophony is beared in upper border of pleural effusion with nasal tone. 53- What are types of respiratory failure? Types of Respiratory failure:-  Type A = hypoxia (O2 < 60 mmHg). Type B = hypoxia & hpercapnia (O2 < 60 mmHg & CO2 > 50 54- Whats the investigation of choice for chest diseases ? COPD  Pul. Function test (obstructive). Fibrosis  Pul. Function test (Restrictive). Bronchiectesis  At past: Bronchography  And now : HRCT Cavity & Abscess  At past: convent. Tomography.  Now : C.T. Pleural effusion  Detection by plain x-ray  Encysted by U/S.  T.B. need Biopsy. 55- What are causes of COPD? 1- Irritation 2- Allergy 3- Infection 56- What are types of COPD?  Type A "Pink puffer" Diffusion defect (decreasing surface area of alveoli) Increased V/Q Hypoxaemia with normo or hypocapnia. Sensitivity of respiratory centre is normal (no hypercapnia) dyspnea  Type B "Blue Bloater" Obstructive hypoventilation V/Q imbalance Hypoxaemia & hypercapnia: Later on pulmonary hyper-tension & cor-pulmonale Hypercapnia decreases the densitivity of respiratory centre. This leads to absence of severe dyspnea. 30  By Dr.\ M. Allam 57- Value of pulse ex. In COPD? Tachycardia & big pulse volume hyperdynamic circulation of hypercapnia & hypoxaemia. Small pulse volume Severe pulmonary hypertension ± heart failure Pulsus paradoxus may be present in severe cases 58- Complication of COPD? Local Systemic  Respiratory failure  Cor pulmonale  Pulmonary infections  Right-sided heart failure  Bronchial obstruction  Left-sided heart failure  Pneumothorax  Thrombembolism  Complications of chronic cough  Erythrocytosis  Salt & fluid retention  Proteinuria  Peptic ulcer 59- What is meaning of (examine lower lobes )? It means (examine the back) 60- TTT broncjial asthma? Between attack:  Avoid antign  Corticosteroid (( oral )  Mast cell stabilizer ( ketofen ) Durig attack  O2 therapy  Bronchodilator ( salbutamol inhaler , aminophyline IV )  Mucolytic  Antibiotic 61- What is the most important investigation in COPD? Pulmonary function test by spirometery: 1- F.V.C. = 5 liters 2- FEV1 = 4 liters 3- TVC = FEV1\FVC < 75% 31  By Dr.\ M. Allam Abdomen 1- What is value of pulse ex. In abdominal case? Tachycardia & hyperdynamic circulation ( VDMs) Bradycardia:- in obstructive jaundice. 2- What are causes of congested neck veins in abdominal case? Tens ascites – pl. or pericardial effusion 3- What are causes of clubbing in abdominal case? - Crohn`s - Ulcerative colitis - Biliary cirrhosis - B. polyposis - Intestinal steatorrhea 4- what are signs of vascular decompensation (portal hypertension)? 1- Splenomegaly 2- Ascites 3-Portosystemic anastmosis as gastroesophageal varices 5- What are Manifestations of LCF (parenchymatous decompensation)? Fever (Low grade) Feotor hepaticus DD 4F Flapping tremors Fatigue Jaundice – D.D. Encephalopathy 3 imp. Ascites Skin changes White nails ( protein ) SEBCK Endocrinal - Gynecomastia - Testicular atrophy - Feminin pubic hair - Hyperaldostrenism Blood Anaemia (pallor) Bleeding tendency CVS Hyperdynamic circulation Kidny Hepato renal failure 32  By Dr.\ M. Allam 6- What are signs of ascites? Inspection : generalized abdominal distension wz : Fullness in flanks – umbilicus bulged and shifted down Palpation : transmitted trill Percussion : shifting dullness Auscultation : buddle sign Sonar : if clinically nt evident +- fullness in Dogls pouch in PV exam 7- What are definition, mechanism , distribution and DD of spider naevi ? - Central dilated arteriole with radiating capillaries (Looks like a spider) - Pressure on central arteriole leades to fadding - Releasing of pressure:- the blood refill the “legs of the spider - Distributed in the upper half of the body (course of SVC) Due to ++ vasodilator s eg NO D.D Level Pruritus Pressure Site Spider naevi Raised Not Fading SVC occurse Insect bite Raised Itchy No Exposed area Purpura Not Not Not LL (common) 8- What are causes of palmer erythema and its DD ? Redness of thaner, hyotheaner, distal ends of metacarpal bone, pulp of fingers with central pallor Causes:-  Pregnancy  Thyrotoxicosis  LCF.  Eoestorgen containing contraceptive pill 9- What are causes of obtuse sub costal angle ? Normal: acute to right (70-90) Obtuse:  Upper abdominal swelling for long time (HSM)  Ascites  Barrel shape chest 33  By Dr.\ M. Allam 10- What are causes of divercation of recti? Causes: chronic increase of the intra-abdominal pressure (HSM - ascities) + hypoproteinemia 11- What are causes of visible peristalsis?  Pyloric obstruction  intestinal obstruction  Very thin person 12- What are causes of abnormal distribution of supra pubic hair ? Normal:- triangular in male with apex directed upward (umbilicus) & horizontal in female Abnormal: as LCF:- feminine distribution Hypogonadism:- loss of hair 13- What are Abnormalities of external genetalia? Testicular atrophy -------- liver cirrhosis Scrotal edema ------------------ liver failure – nephritic Hydrocele --------- ascites Varicocele -----------intra abdominal tumour Bedded spermatic cord ---------- B 14- What are causes of gynaecomastia? Gynaecomastia: hyperplasia of the glandular component of male breast. Confirmed by pinching test as a disc (button like). Usually presented as a one sign of LCF or caused by spironolacton 15- What are causes of bulging abdomen? Symmetrical (6Fs) Asymmetrical Fat = obesity (sunken umbilicus) Organ swelling (HSM) Flatus = (gases) Ovarian or uterine tumor Foetus (comment on mass ??) Fluid = Ascites Full urinary bladder Fibroid tumour 16- What is difference between visible and dilated vein? a) Visible: straight, narrow and not raised b) Dilated: Tortuous, wide and raised above the level of the skin 34  By Dr.\ M. Allam 17- What are DD of visible vein below the umbilicus? Portal (caput medusa) Systemic (IVC obstruction) Site Central Peripheral Milking Filling away from umbilicus From down to up test 18- What are causes of scratch marking? Denotes pruritus usually with obstructive jaundice  Multiple, parallel and superficial  In accessible area 19- What are aims of superficial palpation? - To gain patent confidence - For tenderness or rigidity - Temperature - Superficial mass 20- What are assessments of musle tone in abd ex.? There are 3 reactions that indicate pathology:  Guarding: muscles contract as pressure is applied  Rigidity: rigid abdominal wall-indicates peritoneal inflammation  Rebound: release of pressure causes of pain 21- What are normal palpate structures? Normal palpate structures:  Sigmoid colon: LLQ – firm, narrow tube  Cecum and ascending colon: RLQ – a softer, wider tube  Pulsation’s of ascending aorta: midline in upper abdomen 22- What is Surface anatomy of the liver? (‫)مهم جدا‬  Lt – MCL 5 th  th Lt – MCL 5 intercostals space intercostals space  Lt 8th costal cartilage  Rt – MCL 5th rib  Midway between the xiphisterum & umbilicus  Rt – MAL 7th rib  Rt 9th costal cartilage  Rt – scapular 9th rib  Rt – MCL 1 inch below the costal margin  Rt – MAL 11th rib 35  By Dr.\ M. Allam 23- What are causes of tender liver? Congested ( rt sided HF ) Inflamed ( hepatitis ) Malignancy ( infilterating the capsule) 24- What is liver span? Vertical distance in cm in MCL between upper and lower border of liver Normally : 8- 12 cm ( up 2 15 ) 25- What is surface anatomy of spleen? : Lt hypochondrium  Under 9th, 10th & 11th ribs (long axis on 10th rib)  Medially: scapular line  Laterally: MAL 26- What are causes of hepatomegaly? Infective :  Viral ( hepatitis , CMV )  Bacterial ( pyogenic abscesses , typhoid )  Parasite ( malaria , bilharziases ) Malignant : * 1ry carcinoma * 2ry metastasis Hematological : * leukemia * lymphomas * thalasmia Metabolic :* amyloidosis * fatty liver * heamochromatosis Immunological : * systemic lupus * rhumatiod artharitis Congestive :* rt sided HF * venooclusive diseases * TR * TS 27- What are causes of splenomegaly ? Infective:  viral ( viral hepatitis , IMN )  bacterial ( infective endocarditis , septicemia , typhoid )  parasite ( malaria , schistomiasis ) Malignant :* lymphomas * splenic sarcoma Hematological : * leukemias * 1ry polythaiasemia Metabolic : * amyloidosis Immunological : * systemic lupus * rhumatiod artharitis Portal HTN 36  By Dr.\ M. Allam 28- What are causes of huge splenomegaly ? -B, Thalassemia - Malaria - Myeloid L. - Kala zar (not in egypt) -B - Polycythemia V. - Sarcoma 29- What are causes of multiple splenic notches? Multiple splenic infarction - congenital 30- What are causes of absent splenic notch? Congenital - malignancy - adhesions 31- What are DD between , spleneic swelling and lt renal swelling? ( ‫مهم‬ ‫)جدا‬ Splenic swelling Lt. renal swelling - I can't - I can insinuate my finger between costal margin & the swelling - Notch ( pathognomonic ) - No - Empty renal angle. - Full - No post balloatment - + ve post. Balloatment Surface : Smooth Rounded Edge : sharp Bossy No resonant Band of resonant 32- What are causes of ascitis? Transudate : Rt sided HF Nephritic Myxedema LCF Exudate : Pancreatitis TB peritonitis Malignant Buddd chiari syndrome 37  By Dr.\ M. Allam 33- What are Values of auscultation in abd ex.? Auscultation of the abdomen has a relatively minor role. For  Intestinal sound  Succession splash  Vascular sound (venous hum , arterial burite )  Buddle sign  Scratch test  Friction rubs 34- What are values of P-R ex. In abd ex.?  Sphincter: Loss of tone and patulous. (Cauda equina syndrome)  Contents: Hard impacted stools, Foreign body.  Rectal wall: Pelvic masses (Ovary, Uterus) in women.  Mucous membrance: Irregular, Mass. (Cancer), piles (complicated)  Prostate in men o Smooth, large, firm and non-tender. (Benign enlargement) o Hard, irregular nodule or fixed hard mass. (Cancer, Stone, Chronic prostatitis) o Large, boggy and tender. (Acute Prostatitis)  Stools; o Bloody: (Hemorrhoids, Bleeding rectal lesion) o Black: (Upper GI bleed, Iron, Some Antacids) 35- What are Investigations of liver case? Liver enzymes ( SGPT , SGOT , alkaline phosphatase ) Bilirubin (total, direct , indirect ) Plasma proteins ( albumin , alobulin , A/G ratio ) Hepatitis markers Abdominal sonar ( for HSM , ascitis ) Liver biopsy Endoscopy ( upper GIT endo for esophageal varices , lower GIT endo for piles and bilharzial polyps 36- What are Def & Causes (types) of liver cirrhosis? Def : degeneration – regeneration - loss of architecture wz fibrosis Types : 1- post hepatitis ( b & c ) 2- hemochromatosis 3- alcoholic 4- Rt sided HF = cardiac cirrhosis 5- billary cirrhosis 6- Wilson disease 38  By Dr.\ M. Allam 37- What are causes of portal HTN? Presinousoidal Portal vein stenosis portal vein thorombosis periportal fibrosis ( bilharziazi) Sinusoidal Liver cirrhosis Hepatitis Post sinusoidal Venooclusive disease Budd chiari syndrome IVC obstruction Constrictive pericarditis 38- What is Def of hypersplenism ? ++ phagocytic activity of spleen 39- What are Ttt of ascites ? Bed rest Diet ++ protein --- salt Salt free albumin & diuretics Tapping 40- Staging of hepato-spenomegaly in B or mixed case? Grade 1 : heoatomegally Grade2 : hepatospelenomegally Grade3 : splenomegally + shrunken liver Grade4 : as 3 + ascites 41- What are causes of stria alba? Tense ascitis - marked obesity – repeated pregnancy 42- What are causes of sria rubra ? ++ cortisone ( cushing syndrome 43- Why spleen enlarge toward Rt iliac region? Because of phrenico-colic ligament 44- Causes of vertical enlargement of spleen? Conginatelly absent – surgically rempved - huge spelenomegally - infelteration of ligament 39  By Dr.\ M. Allam 45- Causes of hematemesis ?  Rupture esophageal varices  Peptic ulcer  Gastric carcinoma  Bleeding tendency  Mallory weiss syndrome 40  By Dr.\ M. Allam Neurology 1- Function of UMN , LMN ? Upper motor neurons = pyramidal tract + extra pyramidal tracts  Initiate the voluntary movemrnt  Inhidits AHCs  Skillful movement  Control the sphincters ( mecturation & defecation ) Lower motor neurons  Perform voluntary movements  Viatality of musles & surrounding ( skin , hair , nails ) 2- DD between UMNL & LMNL? UMNL LMNL Weakness Paresis Paralysis Distr : Distri : Distal proximal Later Abductor adductor Progravity antigravity Tone Hyertonia Hypotonia Reflexes Hyerreflexia Hyporeflexia Wasting & trophic Absent Present changes Fasciculation Absent present 3- What is the meaning of cauda equine , conus medalaris , epiconus ? Cauda equine : lumbo-sacral roots that occupied the vertebral canal below L1 Conus medalaris : the last 3 segment s of spinal cord ( S 3,4,5 ) Epiconus : the 4 segments above conus medalaris ( L4 ,5 , S 1,2 ) 4- What are Effects of alcohol in neurological case ? Priphral neuropathy, tremors , amnesia & confabulation ( korsacove’s syndrome ) 5- What is Value of handedness in neurological case ? Lt handed people : 1/3 ----- dominant Lt hemisphere 1/3 ------- dominant Rt hemisphere 1/3 --------- bilateral 41  By Dr.\ M. Allam 6- What is the meaning of onset and its types in neuro case? Onet: from beginging of symptoms until the establishment of the disease Types: acute ( less than 14 days ) or gradual ( 14days or more ) Acute: seconds ( dramatic eg emboulas or truma ) Minutes ( apoplectic e.g. Hge) Hours ( sudden e.g. thrombosis ) Days less than 14 ( rapid e.g. inflammation ) Gradual: degenerative D. ( diabetic PN ) or space occupying lesions ( tumors ) 7- Remittent course def ? The disese comes in attacks , and between attacks the Pt still diseased e.g. multiple sclerosis 8- What is meant by percipitancy ? Its indicate Partial Bilateral UMNL 9- Relationship between drug intake and neuro disease? PN -------- caused by isoniaside Myopathy ---------- caused by steroids ,choroquine Ataxia ------------ caused by phyntoin ( toxicity ) 10- What is the difference between aphasia & dysarthria ?? # aphasia abnormal formulation # dysarthria : abnormal articulation 11- Types of aphasia & dysarthria ? Aphsia  Sensory ( auditory & visual )  Motor : verbal brocs area area 44 Writing exners area area 45 dysarthria  Pyramidal tract --------- slurred speech  Ext. pyramidal tract ------- monotonous speech  Cerebellum --------- staccato speech 12- Causes of hypertonia? 1- Pyramidal tract lesion : spasticity ( clasp knife ) 2- Ext. pyramidal lesion : rigidity ( cog wheal or lead pipe ) 3- Myotonia 4- Meningeal irritation 42  By Dr.\ M. Allam 13- Causes of hypotonia? 1- Lesion of reflex arc Afferent = PN Center = MND Efferent =PN Effector = myopathy 2- Pst colum lesions 3- Cerebellar lesion except maris 14- Degree of musle weakness? 1- complete paralysis 2- Contraction without movement 3- active movement wz no aravity 4- active movement against gravity 5- active movement against resistant 6- normal power 15- What is Planter reflex center & normal response ? Center : S 1,2 mainly S 1 Normal response : planter flextion 16- What is meaning of +ve babiniski ? and what are its causes ? and other methods ? Abnormal response : Dorsi fleyion = +ve babinski Causes :  pyramidal tract lesion  infant below 1 yr  deep sleep  anathesia & coma Other methods : * struniskii * gonad * shadok * barada * oppenhem 17- Causes of equivocal response ?  LMNL at S 1  Hypotheia at S 1  Total paralisis of big toes  Marked deformity of the foot 43  By Dr.\ M. Allam 18- Abdominal reflex , center value ? Center : T 6 – T 12 Value :  In hemiplegia --- ½ lost  In para plegia ----- level  DS ---- early lost 19- Causes of hyper eflexia ? Pyramidal tract lesions Thyrotoxicosis Tetany Tension 20- Degree of reflexes ? 1- no reflex even by re-inforcemnt 0/1 reflex appear only by re- inforcemny 2- hyporeflexia 3- exagerated 4- brisky 5- clonus 21- Reflexes wz its center ? Deep reflexs UL LL Biceps C5,6 Knee L 2,3,4 Brachio – radialis C 5,6 Ankle S 1,2 Triceps C 6,7 Pathological reflex UL LL Suprasinatus C3,4 Patellar L 2,3,4 Finger flextion C8 , T1 Adductor L 4 Hofffman C8 , T1 Wartenberg C8 , T1 22- Sure sign of pyramidal tract lesion ?  Distribution of weakness  Hyper tonia  Hyper reflxia  +ve babinski  Pathological reflex  clonus 44  By Dr.\ M. Allam 23- Light reflex & accommodation reflex significance ? Afferent 2nd , efferent 3rd Significance : argyl Robertson pupil ( irregular , unqual ) which react to accommodation but dnt react to light reflex Causes : DM , D S , encephalitis 24- Causes of ptosis in neurological case ?  Oculomotor nerve paralysis ( complete ptosis , mydriasis , divergent squint  Sympathetic paralysis ( horner syndrome ) ( partial ptosis , myosis , anhydrosis , enophalmos ) 25- C.c.c. of nystagmus in cerebellar lesion ?  On fixation  Horizontal  Biphasic ( jerky )  Bilateral  Rapid phase toward the fixation point 26- Significance of jaw reflex ? Afferent & efferent : 5th cranial nerves If present : Bilateral , UMNL , level above the pons 27- Glabellar reflex ? Afferent & efferent : 7th cranial nerve Normally : blinking 4-6 times then stopped due to habituation Significance : Present --- UMNL Absent ------ LMNL Persistant ( no habituation ) parkinsonism 28- Nerve supply of tongue ? Motor : 12th cranial nerve ( hypoglossal ) Sensory :  ant 2/3 : - general 5th cr nerve -taste sensation : 7th cr nerves  Post 1/3 ------- 9th cranial nerve 45  By Dr.\ M. Allam 29- DD between extra & intra medullary compressio Intra-medullary as Extra- medullary as disc syringomyelia prolapsed , fracture vertebra , potts dis , trauma Painless Painfull Symmetrical Asymytrical Jacket of sensory loss Sensory level Early sphincteic affection Late sphinctric affection Late affection of saddle shape Early affection of saddle area area 30- How can you detect level in paraplegia ?  History of girdle painting  The sensory level  By abdominal; reflex T6 – T 12  From scar or tenderness at the back 31- Aetiology of hemiplegia & its level ? Aetiology :  Vascular ( mainly ) : embolus / he / thrombosis  Inflammatory  Congenital  Neoplastic  Hesterical Level  Cerebral : cortical / subcortical / capsular  Brain stem ( crossed hemiplegia  Spinal cord ( Brown –sequard syndrome 32- Whats NPLD I n diabetic patient ? Necropoiesis lipotic diabeticorum , and its skin lesion specific for diabetic Pt 33- Neurological complication of DM ?  Comas  Argyle robetson pupil  PC lesion  PN  SCD 46  By Dr.\ M. Allam 34- Causes of cerebellar ataxia ?  H.F. : friedrech & maris ataxia  Sympotomatic 2ry to - infection ( encephalitis )/ vascular / alcohol / tumours  Idiopathic : in old age 35- DD between fridrech ataxia & maris ataxia ? Friedrich ataxia Maris ataxia Component 1- Archi cerebellar lesion Neo cerebellar 2- Pyram tract Pyram tract 3- PN 4- PC Tone & reflexs Hypo Hyper Gait Drunken gait Scissoring gait Ataxia Mixed Pure cerebllar Association Present : ( pescavus , heart No associ dise ,) 36- Whats meant by Gower test , Gower sign , Gower disease ? Gower test : test for shoulder Tone Gower sign : climbing sign for pelvic girdle myopathy Gower disease : distal type of Myopathy 37- Causes of lost ankle preserved knee reflex ?  PN  Friedrech ataxia  SCD  Epicouns lesion  Cauda equine lesion of S1 38- Causes of lost ankle & exaggerated knee reflex ?  chorea Friedrich ataxia  SCD 39- Neurological diseases wz intact sensation ?  Muscle dis ( myopathy , myositis , myotonia )  MND  Maris ataxia  Poliomyelitis  Parkinsonism  Chora  HSP 47