Spotters: for 20 marks

1.
2.
3.
4.
5.
6.
7.
8.
9.

Clubbing
Pallor
Edema
Thyroid
Tinea
Tremor
Icterus
Scabies
Psoriasis

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MUN FP Academic Ha

Clubbing
Unilateral Clubbing
Anomalous aortic arch
Aortic or subclavian artery aneurysm
Brachial arteriovenous aneurysm or fistula
PDA with PAH
Recurrent shoulder dislocation
Pancoast tumor
Unidigital
Median nerve injury
Sarcoidosis
Tophi

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MUN FP Academic Ha

Anemia Caused by Blood Loss

UGI

Bleed : NSAIDS such as aspirin

Gastric malignancy
Hemorrhoids
Menorrhagia

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MUN FP Academic Ha

Anemia Caused by Decreased or

Faulty Red Blood Cell Production

1. Sickle cell anemia

2. Iron deficiency anemia
3. Vitamin deficiency : B12,
Folate
4. Bone marrow and stem cell
problems

15-11-29

MUN FP Academic Ha

Iron deficiency anemia

An iron-poor diet, especially in infants, children,

teens and vegetarians
Metabolic demands of pregnancy and
breastfeeding that deplete a woman's iron stores
Menstrual loss
Frequent blood donation
Digestive conditions such as Crohn's disease or
surgical removal of part of the stomach or small
intestine
Certain drugs, foods, and caffeinated drinks
Hook worm infestation

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MUN FP Academic Ha

Megaloblastic anemia:

1. Pernicious anemia: Poor vitamin B-12

absorption
2. An intestinal parasite infection (Fish
tape worm)
3. Surgical removal of part of the stomach
or intestine,
4. Poor vegterians
5. Pregnancy,
6.Methotrexate, Phenytoin, alcohol abuse,
7. Intestinal diseases such as tropical
sprue and gluten-sensitive enteropathy

15-11-29

MUN FP Academic Ha

Session 11
Long case for 50 marks

CVS
Respiratory
GIT
CNS: Hemiplegia

15-11-29

MUN FP Academic Ha

Session 111
Short case for 30 marks

System specification: 15 mts

GCOE & System examination
No history
No case sheet writing

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MUN FP Academic Ha

Session 1V
Viva for 20 marks:
Instruments
Drugs
X-rays.
Clinical charts
ECGs

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MUN FP Academic Ha

Instruments

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10

1. Ryles tube (Nasogastric tube)

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11

Assessment of position:
Take empty syringe & blow air
into the tube & AUSCULTATE for
bubbling sounds in LHC.

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12

Indications

Diagnostic
Evaluation

of upper gastrointestinal
(GI) bleed (ie, presence, volume)
Aspiration of gastric fluid content
Identification of the esophagus and
stomach on a chest radiograph
Administration of radiographic contrast
to the GI tract
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MUN FP Academic Ha

13

Indications

Therapeutic

Gastric decompression, including maintenance of

a decompressed state after
endotracheal intubation, often via the oropharynx
Relief of symptoms and bowel rest in the setting
of small-bowel obstruction
Aspiration of gastric content from recent
ingestion of toxic material
Administration of medication
Feeding
Bowel irrigation

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MUN FP Academic Ha

14

Contra indications

Corrosive poisoning, Stricture,

Kerosene poisoning
Relative contraindications
Coagulation

abnormality
Esophageal varices or stricture
Recent banding or cautery of
esophageal varices
Alkaline ingestion
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15

Complications:

Perforation
Hemorrhage
Respiratory arrest if entered
into glottis

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16

2. Self retaining Foleys catheter;

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Foleys catheter

A Foleys catheter is retained by means

of a balloon at the tip which is inflated
with sterile water. The balloons
typically come in two different sizes: 5
cc and 30 cc. They are commonly made
in silicone rubber or natural rubber.
Catheter diameters are sized by the
French catheter scale (F). The most
common sizes are 10 F (3.3mm) to 28 F
(9.3mm).

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MUN FP Academic Ha

18

Indications:

Urinary retention in neurogenic bladder,

BPH,
Immobilized patients like fracture pelvis
or long bones
Chronic debilitating illnesses
Urine output monitoring in a critically ill
or injured person
Unconscious patients
Bladder wash
Imaging study of the lower urinary tract
After surgery

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MUN FP Academic Ha

19

Foleys catheter
Contraindications:
Stricture
Complications:
Sepsis
Hemorrhage
Perforation

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20

A Robinson catheter

Flexible catheter
Short term drainage of urine.
No balloon on its tip and therefore
cannot stay in place unaided.

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21

A Coud catheter

A Coud catheter is designed with a curved

tip that makes it easier to thread the catheter
pass the prostate or obstructions in the
urethral canal. A Coud catheter tip may be
provided with a balloon or not.
An irrigation catheter has a separate lumen to
carry irrigation fluid into the bladder. This is
useful following endoscopic surgical
procedures or in the case of gross hematuria.
An external Texas or condom catheter is used
for incontinent males and carries a lower risk
of infection than an indwelling catheter.

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22

3. Endo tracheal tube

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23

Indications:

Induction of general anesthesia

Artificial respiratory support in OP
poisoning, drowning.
Artificial respiratory support in
neurological conditions like: CVA, GB
syndrome, bulbar palsy, pseudo
bulbar palsy & MND
Artificial respiratory support in
respiratory conditions like: bilateral
pneumonia, ARDS, AECB, acute
pulmonary edema & Cor Pulmonale.

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24

Inflation

SHOULD BE INFLATED WITH

AIR, NOT WATER BECAUSE IN
CASE IT BURSTS THE PT.
ASPIRATES THE FLUID &
DROWNS HIMSELF.

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25

4. L.P NEEDLE:

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26

L.P NEEDLE:

SIZE: (26G-22G) L80-150 mm;

*USE: Used in subarachnoid
puncture for spinal anesthesia

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27

Indications

MENINGITIS
SAH
GB SYNDROME
UNEXPLAINED COMA
MYELOGRAPHY
INTRODUCE DRUGS
SPINAL ANAESTHESIA

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28

Contra indications

RAISED ICT, (Fundus exam

mandatory to R/O Papilledema)
MARKED SPINAL DEFORMITY,
LOCAL INFECTIONS &
SUSPECTED CORD
COMPRESSION.

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29

COMPLICATIONS:

HEADACHE,
INFECTIONS,
MEDULLARY HERNIATION
LEADING TO DEATH,
INJURY TO BLOOD VESSELS,
SPINAL CORD OR
INTERVERTEBRAL DISC.

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30

FROIN SYNDROME

Xanthochromia
High protein content (Albumino
cytological dissociation)
In spinal block

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31

Liver biopsy; VIM SILVERMAN

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32

Indications

1. Cirrhosis of liver
2. Hepatic malignancies
3. Granulomas; Tb, Sarcoidosis,
Schistosomiasis
4. Metabolic & storage disorders; Wilson,
Amyloidosis & Hodgkins
5. Reticulo endothelial; leukemias,
multiple myeloma & Hodgkins
6. Unexplained fever with hepatomegaly;
amoebiasis, Tb, cholangitis & brucellosis
7. Unexplained jaundice
8. Chronic hepatitis

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33

Contraindication

Bleeding diathesis
Protracted hepatocelllular jaundice
become hepatic precoma may be
precipitated.
Infections
Hydatid cyst , if suspected
Haemangioma of liver , if suspected
Chronic passive congestion of liver
Gross ascites

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MUN FP Academic Ha

34

Complications

Hemorrhage
Infection
Injury
Precipitation of hepatic coma

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35

Bone marrow aspiration & biopsy

Salah needle

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36

BONE MARROW BIOPSY NEEDLEKLIMA 16G 25MM

Bone marrow aspiration
Removes a small amount of
bone marrow fluid and cells
through a needle put into a
bone.
The bone marrow fluid and cells
are checked for problems with
any of the blood cells made in
the bone marrow.
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37

A bone marrow biopsy

A bone marrow biopsy
Removes bone with the marrow
inside to look at under a
microscope.
The aspiration (taking fluid) is
usually done first, and then the
biopsy

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38

Indications

Thrombocytopenia
Leukemia
Anemias
Multiple myeloma
Polycythemia vera
Hodgkin's lymphoma
Non-Hodgkin's lymphoma
Staging & plan cancer treatment
Culture and sensitivity test of the bone
marrow sample

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MUN FP Academic Ha

39

Indications

Disseminated coccidioidomycosis
Hairy cell leukemia
Hodgkin's lymphoma
Idiopathic aplastic anemia
Multiple myeloma
Neuroblastoma
Non-Hodgkin's lymphoma
Polycythemia Vera
Primary amyloid
Primary Myelofibrosis
Primary thrombocythemia
Secondary aplastic anemia
Secondary systemic amyloid

15-11-29

MUN FP Academic Ha

40

Investigation for fever of unknown

origin (FUO)

Autoimmune deficiency syndrome (AIDS),

Tuberculosis
Mycobacterium avium intracellulare (MAI)
infections, Histoplasmosis, Leishmaniasis,
Disseminated fungal infections.
Furthermore, the diagnosis of storage diseases
(e.g.. Niemann-Pick disease and Gaucher disease)
Assessment for metastatic carcinoma and
granulomatous diseases (e.g., sarcoidosis) can be
performed.

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MUN FP Academic Ha

41

side effects

Hemorrhage : concurrent
anticoagulation therapy or
underlying myeloproliferative /
myelodysplastic syndrome,
Needle breakage
Infections
Pain
Anaphylactic reaction
Laceration of blood vessels

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42

Contraindications

If there is a severe bleeding

disorder : gross anemia or
thrombocytopenia.
skin or soft tissue infection over the
hip

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43

IV needles

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44

Venous cannula

Administration of intravenous fluids,

Obtaining blood samples
Administering medicines

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MUN FP Academic Ha

45

Complications

Septic Thrombophlebitis
Hematoma
Nerve Damage

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MUN FP Academic Ha

46

Adult Ambu-Bag Manual

Resuscitators

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47

Digital Thermometer, 60 Second Digital

Thermometer

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48

X rays

Pleural effusion
Hydropneumothorax
Consolidation
Bilateral emphysematous lungs
Cannon ball Secondaries
Pericardial effusion /
cardiomyopathy
Dextrocardia

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49

Systematic Roentgenographic
interpretation

1) superior vena cava

(2) ascending aorta
(3) right atrium
(4) inferior vena cava
and cardiac fat pad
(5) left subclavian
vein and artery
(6) aortic arch
(7) pulmonary artery
(8) left atrium
(9) left ventricle

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50

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Transudates meet none:

Exudates must meet one or more of

the following criteria, whereas
transudates meet none:
Pleural fluid/serum protein > 0.5 or
absolute value > 3 g/dl.
Pleural fluid/serum LDH > 0.6 or
absolute value > 0.45 upper normal
serum limit
Pleural fluid specific gravity > 1.018

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52

Etiology of Transudative Effusions

Congestive heart failure

Cirrhosis
Nephrotic syndrome
Peritoneal dialysis
Superior vena cava syndrome
Myxedema
Atelectasis (early)
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53

Etiology of Exudative Effusions

Para pneumonic
Simple or Complicated Empyema
Tuberculosis
Other infections :Fungal or Parasitic
Malignant
Metastatic disease
Mesothelioma
Pulmonary embolism
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54

Etiology of Exudative Effusions

Collagen vascular disease

Rheumatoid arthritis
Systemic lupus erythematosus
Wegeners granulomatosis
Churg-Strauss syndrome
Familial Mediterranean fever
Abdominal disease
Pancreatitis
Subphrenic abscess
Esophageal rupture
Postoperative

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55

Etiology of Exudative Effusions

Atelectasis
Acute respiratory distress syndrome, (ARDS)
Asbestos exposure
Hemothorax
Chylothorax
Cholesterol effusions
Drug reactions
Dresslers syndrome
Meigs syndrome
Uremia
Sarcoidosis
Yellow nail syndrome
Radiation therapy
Ovarian hyperstimulation syndrome

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56

Pulmonary metastasis

cannonball Secondaries

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57

pulmonary metastasis

Patients with carcinoma of the pancreas and

bronchus who have pulmonary metastases
have a 5-year survival rate of less than 5%
One half of the patients with lymphangitis
carcinomatosis die within 3 months.
Chemosensitive tumors, such as
choriocarcinoma and testicular teratoma,
have a better prognosis.
An isolated pulmonary metastasis (eg, from
colon or kidney) can be resected, with a 5year survival rate of 50%.

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58

Pulmonary metastasis
Primary Tumor
Choriocarcinoma 60
Melanoma56
Testis, germ cell12
Osteosarcoma15
Thyroid7
Kidney20
Head and neck5
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59

Chest x-ray showing

dextrocardia and
right-sided gastric
air bubble indicating
the presence of both
dextrocardia and
situs inversus

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60

Pink puffer

Residual
lung capacity
and volume,
Elastic
recoil,
Expiratory
flow rate and
diffusing
capacity

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61

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62

Pneumonia as seen on chest x-ray. Abnormal chest x-ray

with consolidation from pneumonia in the Upper or inferior lobe

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63

X-ray chest showing pericardial

effusion

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64

Causes of pericardial effusion may include:

Viral, bacterial, fungal or parasitic infections

Inflammation of the pericardium due to
unknown cause (idiopathic pericarditis)
Inflammation of the pericardium following
heart surgery or a heart attack (Dressler's
syndrome)
Autoimmune disorders, such as rheumatoid
arthritis or lupus
Waste product in the blood due to kidney
failure (uremia)
Hypothyroidism
HIV/AIDS

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65

Causes of pericardial effusion may include:

Spread of cancer (metastasis), particularly lung

cancer, breast cancer, leukemia, non-Hodgkin's
lymphoma or Hodgkin's disease
Cancer of the pericardium or heart
Radiation therapy for cancer if the heart is within
the field of radiation
Chemotherapy treatment for cancer, such as
doxorubicin (Doxil) and cyclophosphamide
(Lyophilized Cytoxan)
Trauma or puncture wound near the heart
Certain prescription drugs, including hydralazine,
a medication for high blood pressure; isoniazid, a
tuberculosis drug; and phenytoin (Dilantin,
Phenytek, others), a medication for epileptic
seizures

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66

DRUGS:

ATROPINE
DOPAMINE
PHENYTOIN
FUROSEMIDE
ADRENALINE
DEXAMETHASONE

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67

ATROPINE
USES:

Stomach and intestinal tract disorders: peptic

ulcers, diarrhea irritable bowel syndrome
diverticulitis, colitis, or pancreatitis
To control bed - wetting and frequent
urination,
Prevent motion sickness
Treat alcohol withdrawal symptoms,
Parkinson's disease
Asthma
Poisonings due to certain insecticides or
plants.

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SIDE EFFECTS:

Flushing of the face,

Headache, Blurred vision,
Drowsiness,
Increased sensitivity to light,
Constipation
Dry mouth
Reduced sweating or thirst.
Confusion,
Tremors,
Fast/irregular heartbeat,
Difficulty urinating.
Symptoms of an allergic reaction include: rash,
itching, swelling, dizziness, trouble breathing.

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PRECAUTIONS:

Heart problems,
Glaucoma
stomach/abdominal/intestinal
problems,
Prostate or urinary problems,
Contact lens wear,
Allergies (especially drug
allergies).

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70

Furosemide
USES
Heart failure
Cirrhosis
Chronic kidney failure
Nephrotic syndrome
High blood pressure
Hypercalcemia
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SIDE EFFECTS:

Low blood pressure

Dehydration
Electrolyte depletion (Na, K, Ca).
Less common : jaundice,
tinnitus, photophobia, rash,
pancreatitis nausea diarrhea
abdominal pain and dizziness

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Diuresis:
Oral administration
Onset: one hour
Lasts: 6- 8 hours

15-11-29

After injection
Onset:
5minutes
Lasts: 2 hours

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DOPAMINE
INDICATIONS

Hemodynamic imbalances present in the

shock syndrome due to myocardial
infarctions, trauma
Poor Perfusion of Vital Organs & Low Cardiac
Output:
Hypotension: Inadequate COP
Endotoxic septicemia
open heart surgery
Renal failure
Chronic cardiac decompensation as in
congestive failure.

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CONTRAINDICATIONS
Pheochromocytoma.
Uncorrected tachyarrhythmia's
or ventricular fibrillation.

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SIDE EFFECTS
Cardiovascular System:
Ventricular arrhythmia (at very high
doses), ectopic beats
Tachycardia
Anginal pain
Palpitation
Cardiac conduction abnormalities
widened QRS complex
Hypertension
Vasoconstriction
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Adrenaline (Epinephrine)
Injection 1:1,000 Minijet.
Adrenaline (Epinephrine) 1mg per
ml.
Adults and children over 12 years:
0.5 ml (0.5 mg), administered
slowly. The dose may be repeated
every 5 to 15 minutes as needed.
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Indication of Adrenaline Injection:

Increased blood pressure,

increased heart rate, increased
air entry, increased blood
glucose, stimulates cardiac
activity
Reduce allergic reactions by
reducing inflammatory response
caused by histamine.

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Pharmacodynamic properties

Adrenaline is a direct-acting
sympathomimetic agent exerting its
effect on alpha- and betaadrenoceptors.
Major effects are increased systolic
blood pressure, reduced diastolic
pressure, tachycardia, hyperglycaemia
and hypokalaemia.
It is a powerful cardiac stimulant. It has
vasopressor properties and is a
bronchodilator.

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Indication of Adrenaline Injection:

Anaphylaxis
Acute angioneurotic edema with
airways obstruction
Acute allergic reactions (e.g.
drug reactions, insect stings,
food allergies).

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Contraindications

Hyperthyroidism
Hypertension
Ischemic heart disease
Diabetes mellitus
Closed angle glaucoma

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Undesirable effects

Symptomatic adverse effects are anxiety,

dyspnea, restlessness, palpitations,
tachycardia, anginal pain, tremor,
weakness, dizziness, headache, cold
extremities, nausea, vomiting, sweating,
local ischemic necrosis.
Biochemical effects include inhibition of
insulin secretion and hyperglycaemia
even with low doses, gluconeogenesis,
glycolysis, lipolysis and ketogenesis.

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Undesirable effects

cardiac arrhythmias leading to

ventricular fibrillation and
death,
Severe hypertension leading to
pulmonary edema and cerebral
hemorrhage

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83

EDEMA - UNILATERAL

DVT
VENOUS INSUFFICIENCY
CELLULITIS
TRAUMA
LYMPHATIC OBSTRUCTION (LO) BY PELVIC
TUMOR
REFLEX SYMPATHETIC DYSTROPHY (RSD)
MAY THURNER SYNDROME ; LEFT ILIAC
VEIN IS COMPRESSED BY RIGHT COMMON
ILIAC ARTERY
LOIASIS

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EDEMA UPPER EXTREMITY

SVC SYNDROME
DVT
LYMPHATIC OBSTRUCTION
REFLEX SYMPATHETIC
DYSTROPHY
EOSINOPHILIC FASCIITIS

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Edema lower extremity - CARDIAC

CHF (RIGHT SIDED)

PCE
PERICARDITIS
TR / TS / PS /
COR PULMONALE
VENOUS INSUFFICIENCY
VENOUS OBSTRUCTION
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NON - CARDIAC CAUSES

CIRRHOSIS
NEPHROTIC SYNDROME
CELLULITIS
PREMENSTRUAL FLUID RETENTION
VASODILATORS
CALCIUM CHANNEL BLOCKERS
NSAIDS
LYMPHATIC OBSTRUCTION
PET / ECLAMPSIA
MYXOEDEMA
FILARIASIS
EOSINOPHILIC FASCIITIS

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Pink puffer

Residual lung capacity and

volume,
Elastic recoil,
Expiratory flow rate and
diffusing capacity
Ventilatory/perfusionV/Q
mismatch 2 to emphysemarelated destruction of blood
vessels

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Pink puffer

Clinical: SOB, hyperventilation

ABGs :Usually near normal due to
compensatory hyperventilation;
arterial pO2 is in the mid-70s, pCO2
is low to normal;

PPs have tidal volume and

retraction of accessory
respiratory muscles.

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Blue bloater

Normal to Lung capacity,

Residual volume with airtrapping,
Expiratory flow,

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Blue bloater

Hypoxia
Hypercapnia
Heart failure (Right)
Hypertension (Pulmonary)

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Pink puffer / Blue bloater

Residual lung
capacity and volume,
Elastic recoil,
Expiratory flow rate
and diffusing capacity
Ventilatory/perfusion
V/Q mismatch 2 to
emphysema-related
destruction of blood
vessels

15-11-29

Normal to Lung
capacity,
Residual volume with
air-trapping,
Expiratory flow,
Blue : Cyanosis
Bloat : Distension

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92

15-11-29

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Pink puffer

A descriptor for a Pt with COPD and severe

emphysema, who have a pink complexion and
dyspnea; PPs have residual lung capacity and
volume, elastic recoil, expiratory flow rate
and diffusing capacity and a
ventilatory/perfusionV/Q mismatch 2 to
emphysema-related destruction of blood vessels
Clinical SOB, hyperventilation ABGs Usually near
normal due to compensatory hyperventilation;
arterial pO2 is in the mid-70s, pCO2 is low to
normal; PPs have tidal volume and retraction of
accessory respiratory muscles.

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Blue bloater

A popular term for the appearance of a Pt

with COPD with Sx of chronic bronchitis,
normal to lung capacity, residual
volume with air-trapping, expiratory
flow, and characteristic arterial blood gas
parameters PO2, PCO2, despite
normal diffusing capacity, cyanosis and
right heart failure, due to sleep apnea and
progressive chronic pulmonary HTN; with
time, it becomes indistinguishable from
other forms of COPD.

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Non palpable apex

Apex lying behind a rib
Obesity or thick chest wall
Pendular breast in elderly female
Emphysema ( COPD )
Pleural effusion ( lt )
Pericardial effusion
Constrictive pericarditis
Acute myocardial infarction
Pneumothorax ( /t )
Deformity of the chest ( gross kyphoscoliosis )
Thickened
pleura ( lt )MUN
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CLINICAL FEATURES IN VALVE LESIONS

M.S

M.R

SOB

EXERTIONAL
DYSPNOEA

EFFORT
INTOLERANCE

PALPITATIONS

A.S
ANGINA

PALPITATION

SOB

PULSATILE OR
THROBBING
SENSATION

SYNCOPE

PND

SOFT S1

HAEMOPTYSIS

HYPERDYNAMIC APEX

FATIGUE

APEX GOES DOWN &

OUTWARDS

ANACROTIC

SYSTOLIC THRILL

PULSUS PARVUS Vs
TARDUS

SYNCOPAL
ATTACKS
CLI. SIGNS

CLI.SIGNS

PSM ; HP / SB /
RADIATES LT. AXILLA &
INF. ANGLE OF
SCAPULA

LOW VOLUME
PULSE
TAPPING APEX

A.R

LOW VOLUME PULSE

CAROTID SHUDDER ;
SYSTOLIC THRILL IN
CAROTID ARTERY IS
FELT

ANGINA
SOB
FEATURES OF
LVF ;
ORTHOPNOEA,
PND
HIGH VOLUME
WATER
HAMMER PULSE

PALPABLE S1

HAEVING APEX

DIASTOLIC
THRILL

CONCENTRIC LVH

HYPERDYNAMIC
APEX

S2 MUFFLED

S1 ; SHORT,
SHARP,
ACCENTUATED

EDM HP/ SB/ DC

ESM; HARSH / CDC/

15-11-29

OS, MDM, PSA

GALLAVERDINS
MUN FP Academic
Ha
PHENAMENON ( MA )

98

Opening snap
Where sound

MS

S3
HF / chronic MR

Best audible

at lt. para sternal

at apex with bell

Pitch

high - pitched

low - pitched

Palpability

not palpable

often palpable

Timing

0.04 0.12 after s2

0.14 0.16

Treatment of HF

OS becomes louder

S3 vanishes

15-11-29

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99

AOTIC SCLEROSIS

In aged persons suffering from atherosclerosis with or

without HTN
Fibrosis , thickening & some calcification of bases of
the aortic valve cusps.
Give rise to harsh ESM
Normal volume pulse , normal A2 ,
Associated features of thickened peripheral arteries ,
kinked carotids , locomotor brachialis , suprasternal
pulsations , Xanthelasma around the eyes ,
Occasionally this calcification becomes excessive ,
produces severe aortic valve obstruction ; calcific
aortic stenosis

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100

Aortic stenosis differentiation

Supra
valvular
Elfin facies

Valvular
Click

Sub
valvular

Soft A2

A2 normal

Thrill
Radiation to
mitral area
Loud A2
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101

JVP

15-11-29

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JVP
A- wave
Right
atrial
contract
ion

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103

JVP

C wave
Bulging
of TV
into RA
(RVS)

A- wave
Right
atrial
contract
ion

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JVP

C wave
Bulging
of TV
into RA
(RVS)

A- wave
Right
atrial
contract
ion

X Descent
DDTV / RVS
Fall RAP
CA Relaxation

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JVP

C wave
Bulging
of TV
into RA
(RVS)

A- wave
Right
atrial
contract
ion

X Descent
DDTV / RVS
Fall RAP
CA Relaxation

V wave
RA filling
with the TV
closed
during RVS

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106

JVP

C wave
Bulging
of TV
into RA
(RVS)

A- wave
Right
atrial
contract
ion

X Descent
DDTV / RVS
Fall RAP
CA Relaxation

V wave
Y descent

S3

opening of TV , blood
flow to RA RV, leading
to a sudden fall of
pressure in RA

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RA filling
with the TV
closed
during RVS

107

JVP
A- wave
Right
atrial
contract
ion

15-11-29

A absent AF

MUN FP Academic Ha

108

JVP
A- wave
Right
atrial
contract
ion

A absent AF

Large or
giant A

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TS / TA /
RAM / PS /
PHTN
MUN FP Academic Ha

109

JVP
A- wave
Right
atrial
contract
ion

A absent AF

Large or
giant A
Cannon A
CHB / VT /
Ectopic
beats
15-11-29

TS / TA /
RAM / PS /
PHTN
MUN FP Academic Ha

110

A wave diminished

JVP
A- wave
Right
atrial
contract
ion

Tachycardia & prolonged PR interval

A absent AF

Large or
giant A
Cannon A
CHB / VT /
Ectopic
beats
15-11-29

TS / TA /
RAM / PS /
PHTN
MUN FP Academic Ha

111

C (TV cusp) wave

Impact of carotid artery adjacent to

jugular vein.
Retrograde transmission of positive
wave in the RA P/B RVS.
Bulging of TV in to RA.
Not seen clinically.

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X descent

X descent is obliterated by a
positive wave s wave
TR / Constrictive pericarditis
S wave fuse with C & V wave =
giant v wave.

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113

Rapid Y descent

Constrictive pericarditis
Severe heart failure
TR
Short Y descent: TS

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114

Kussmauls sign

Normally inspiration

lowers JVP
inspiratory collapse,

ITP falls & Increase blood flow in to thorax.

Increase

IPP in CP: Paradoxical increase in JVP on inspiration.

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115

Hepatojugular reflux

Normally

when pressure is applied over the abdomen for 30 seconds,

JVP ( venous return )

Due to capacity of normal myocardium to accommodate the extra VR

Sustained elevation of JVP more than 1 mt , failing heart cant compensate the extra VR

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116

LVF

LAF

SYS. HTN

MS

IHD

LAM

AMI

BALL VALVE
THROMBUS IN
THE LA

AR
AS

MITRAL ATRESIA

MR

RVF ( CCF )

RAF

COPD

TS

SEC. TO LSHD ( LVF /

LAF )

SEC . TO RVF

PS

R.A.MYXOMA

ASD / VSD / PDA

PHTN
PUL . EMBOLI
CMP

CMP

MYOCARDITIS

COA

RV INFARCTION

MYOCARDITIS
SEVERE
ANAEMIA

BERNHEIMS EFFECT;
RV PRESSURE CHANGES
RESULTS FROM LVH WITHOUT
DEVELOPING PHTN.
IVS HYPERTROPHIES FROM
LVH & PRODUCES
OBSTRUCTION TO RV
OUTFLOW & THUS MANIFESTS
AS A PROMINENT a WAVE IN
THE NECK VEIN WITHOUT
DEVELOPING RVH OR RVF.

VSD
PDA

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ACCELERATED HTN
SIGNIFICANT RECENT INCREASE IN BP LEVEL
ASSOCIATED WITH EVIDENCE OF VASCULAR
DAMGE ON FUNDOSCOPIC EXAMINATION
WITHOUT PAPILLOEDEMA.

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118

MALIGNANT HTN

SEVERE AHTN WITH DIASTOLIC BP >

140mmHg WITH HAEMORRHAGE ,
EXUDATE & PAPILLOEDEMA WITH ONE
OR MORE OF THE FOLLOWING ;
1. RAPIDLY DETERIORATING RENAL
FUNCTION
2. CARDIAC DECOMPENSATION
3. HYPERTENSIVE
ENCEPHALOPATHY ( HEADACHE ,
VOMITING , CONVULSIONS & COMA )

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119

HAND IN SBE

CLUBBING
PALLOR
OSLERS NODE ( TENDER )
SPLINTER HAEMORRHAGE
JANEWAYS SPOT ( NON TENDER MACULOPAPULAR
LESIONS IN PALM )
PYREXIA
PETECHIAE
GANGRENE OF THE FINGERS

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120

OSLERS NODE

TENDER PAPULE
PIN HEAD SIZE TO PEA
PULP OF FINGERS , TOES & PALMS
DUE TO EMBOLISM OR ARTERITIS

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ROTH SPOT

YELLOWISH, ELLIPTICAL , FLAME

SHAPED HAEMORRHAGES WITH A
PALE CENTRE IN THE RETINA
DUE TO DEPOSITION OF
CIRCULATING IMMUNE COMPLEX
APART FROM SBE ARE ; APLASTIC
ANAEMIA , LEUKAEMIA , SCURVY.

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122

CAUSES OF VALVULAR LESIONS

M.R

M.S
RHEUMATIC

RHEUMATIC

PARACHUTE
MITRAL VALVE

MVP
PAPILLARY MUSCLE
DYSFUNCTION D/T IHD

CARCINOID
SYNDROME

RUPTURE OF
PAPILLARY MUSCLE IN
AMI

COLLAGEN
VASCULAR
DISEASE
MUCOPOLYSACCH
ARIDOSES

TRAUMATIC ; DURING
MITRAL VALVOTOMY
I.E , MYOCARDITIS
MARFANS

A.S
RHEUMATIC
BI CUSPID
AORTIC VALVE
CALCIFIC DGN OF
AORTIC VALVE
ASS. WITH FAMILIAL
HYPERCHOLESTER
OLAEMIA & MPS
FUNCTIONAL IN
SEVERE AR / TT /
SEVERE ANAEMIA

A.R
RHEUMATIC
TRAUMATIC
INFECTIVE
ENDOCARDITIS
BICUSPID A.V
ATHEROSCLERO
TIC
DISSECTION OF
AORTA
SYPHILIS
MARFANS SYN

SLE ( LIBMAN SACKS

ENDOCARDITIS )

ANKYLOSING
SPONDILITIS

RA

RHEUMATOID
ARTHRITIS

DCM
CONGENITAL

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PND

ACUTE LT . SIDED HEART FAILURE

AWAKENED FROM SLEEP / WITH A FEELING OF INTENSE
SUFFOCATION & CHOKING SENSATION
HE SITS UPRIGHT IN THE BED WITH THE LEGS HANGING BY
THE SIDE OF THE BED OR RUSHES TO OPEN WINDOW IN THE
HOPE THAT COOL FRESH AIR WILL RELIEVE HIM.
DYSPNOEA PROGRESSES WITH PROFUSE SWEATING
THESE ARE ACCOMPANIED BY DRY , REPETITIVE COUGH D/T
ACUTE INTERSTITIAL OEDEMA; WHEN THERE IS NO
COLLECTION OF FLUID IN THE ALVEOLI.
THE ATTACK SUBSIDE SPONTANEOUSLY WITHIN 30 MTS BUT
OFTEN PROGRESSES TO ACUTE PULMONARY OEDEMA.
APO ; COUGH NOW PRODUCTIVE WITH PROFUSE WATERY
PINKISH & FROTHY SPUTUM.

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124

Pulmonary hypertension

When the PAP > 30mmHg

Symptoms ; SOB / EASY FATIGUABILITY / DIZZINESS / SYNCOPE / CHEST
PAIN
SIGNS ; LOW VOLUME PULSE
a wave is prominent in jvp
Visible pulmonary artery pulsations in 2nd lics
Epigastric pulsations
Apex goes outwards
P2 diastolic shock, p2 palpable
Lt. parasternal haeve
Pulsation of pulmonary artery may felt
S1 audible
Pulmonary ejection click
ESM ; d/.t relative obstruction
Close splitting of s2 with loud p2
Graham steel murmur an EDM d/t functional PR
Rt. Sided s3 ( RV gallop ) heard at lower lt. sternal border

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Causes of pulmonary HTN

PASSIVE FROM LEFT SIDED HEART DISEASES LIKE

MS / MR / AS / AR
HYPERKINETIC ASD / VSD / PDA
VASOCONSTRICTIVE CHRONIC CORPULMONALE
OBSTRUCTIVE PULMONARY THROMBOEMBOLISM /
ACUTE CORPULMONALE
OBLITERATIVE SLE / PSS / PAN
NEUROHUMORAL OR IDIOPATHIC - PPH

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126

Jones Criteria (Revised) for Guidance in the

Diagnosis of Rheumatic Fever*
Major Manifestation
Carditis
Polyarthritis
Chorea
Erythema Marginatum
Subcutaneous Nodules

Minor
Manifestations
Clinical
Previous
rheumatic
fever or
rheumatic
heart disease
Arthralgia
Fever

Laboratory
Acute phase
reactants:
Erythrocyte
sedimentation
rate,
C-reactive
protein,
leukocytosis
Prolonged PR interval

Supporting Evidence
of Streptococal Infection
Increased Titer of AntiStreptococcal Antibodies ASO
(anti-streptolysin O),

others
Positive Throat Culture
for Group A Streptococcus
Recent Scarlet Fever

*The presence of two major criteria, or of one major and two minor criteria,
indicates a high probability of acute rheumatic fever, if supported by evidence of
Group A streptococcal nfection.

Recommendations of the American Heart Association

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STEP I: Primary Prevention of Rheumatic Fever

(Treatment of Streptococcal Tonsillopharyngitis)
Agent

Dose

Benzathine penicillin G

600 000 U for patients

Mode
Intramuscular

Duration
Once

27 kg (60 lb)
1 200 000 U for patients >27 kg

or
Penicillin V
Children: 250 mg 2-3 times daily Oral
(phenoxymethyl penicillin) Adolescents and adults:
500 mg 2-3 times daily

10 d

For individuals allergic to penicillin

Erythromycin:
Estolate

20-40 mg/kg/d 2-4 times daily

(maximum 1 g/d)

Oral

10 d

40 mg/kg/d 2-4 times daily

Oral
(maximum
1 g/d) Heart Association
Recommendations
of American

10 d

or
Ethylsuccinate

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128

STEP IV : Secondary Prevention of Rheumatic Fever

(Prevention of Recurrent Attacks)
Agent

Dose

Benzathine penicillin G

Mode

1 200 000 U every 4 weeks*

Intramuscular

or
Penicillin V

250 mg twice daily

Oral

or
Sulfadiazine

0.5 g once daily for patients 27 kg (60 lb Oral

1.0 g once daily for patients >27 kg (60 lb)

For individuals allergic to penicillin and sulfadiazine

Erythromycin

250 mg twice daily

Oral

*In high-risk situations, administration every 3 weeks is justified and

recommended

Recommendations
of American
Heart
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Academic
HaAssociation

129

Duration of Secondary Rheumatic Fever

Prophylaxis
Category

Duration

Rheumatic fever with carditis and

residual heart disease
until (persistent valvar disease*)

At least 10 y since last

episode and at least
age 40 y, sometimes lifelong
prophylaxis

Rheumatic fever with carditis

but no residual heart disease
(no valvar disease*)

10 y or well into adulthood,

whichever is longer

Rheumatic fever without carditis

5 y or until age 21 y,
whichever is longer

*Clinical or echocardiographic evidence.

Recommendations of American Heart Association

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Antibiotic Regimens for Prophylaxis of Endocarditis in

Adults with High-Risk Cardiac Lesionsa,b

A. Standard oral regimen

1. Amoxicillin 2.0 g PO 1 h before
procedure
B. Inability to take oral medication
1. Ampicillin 2.0 g IV or IM within
1 h before procedure

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131

Antibiotic Regimens for Prophylaxis of Endocarditis in

Adults with High-Risk Cardiac Lesionsa,b

C. Penicillin allergy
1. Clarithromycin or azithromycin 500 mg PO 1
h before procedure
2. Cephalexinc 2.0 g PO 1 h before procedure
3. Clindamycin 600 mg PO 1 h before procedure
D. Penicillin allergy, inability to take oral
medication
1. Cefazolinc or ceftriaxonec 1.0 g IV or IM 30
min before procedure
2. Clindamycin 600 mg IV or IM 1 h before
procedure

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132

High-Risk Cardiac Lesions for Which Endocarditis

Prophylaxis Is Advised before Dental Procedures

Prosthetic heart valves

Prior endocarditis
Unrepaired cyanotic congenital heart disease,
including palliative shunts or conduits
Completely repaired congenital heart defects
during the 6 months after repair
Incompletely repaired congenital heart disease
with residual defects adjacent to prosthetic
material
Valvulopathy developing after cardiac
transplantation

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PATHOLOGICAL CONDITIONS

CONSOLIDATION
TOTAL COLLAPSE
PARTIAL COLLAPSE
FIBROSIS
CAVITY
PLEURAL EFFUSION
EMPYEMA
PNEUMOTHORAX
HYDROPNEUMOTHORAX
BRONCHIECTASIS

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CLINICAL FINDINGS

CHEST WALL
MOVEMENTS
MEDIASTINUM
PERCUSSION
BREATH SOUNDS
ADVENTITIOUS SOUNDS
VOCAL RESONANCE

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CONSOLIDATION

CHEST WALL ;
NORMAL
MOVEMENTS ;
DECREASED
MEDIASTINUM ;
CENTRAL
PERCUSSION ;
DULL
BREATH SOUNDS ; TUBULAR
ADV. SOUNDS ;
RALES
VR
;
WP +

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COLLAPSE

TOTAL COLLAPSE
C ; RETRACTION
M ; DECREASED
M ; SAME SIDE
P ; DULL
B ; ABSENT
A ; ABSENT
V ; ABSENT

15-11-29

PARTIAL COLLAPSE
C;N/
RETRACTION
M ; DECREASED
M ; SAME SIDE
P ; DULL
B ; TUBULAR
A ; RALES
V ; WP +

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137

FIBROSIS

RETRACTION
DECREASED
SAME SIDE

CHEST
MOVEMENTS
MEDIASTINUM

IMPAIRED
DIMINISHED
RALES
DIMINISHED

PERCUSSION
BS
ADV.
VR

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138

CAVITY

N / RETRACTION
DECREASED
CENTRAL / SAME SIDE
IMPAIRED / BOXY
AMPHORIC / CAVERNOUS
RALES
WP +

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139

PLEURAL EFFUSION

CHEST ; NORMAL
MOVE ; DECRESAED
MEDI. ; OPPOSITE
PERC. ; STONY DULL
BS
; ABSENT
AS
; ABSENT
VR
; ABSENT

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PNEUMOTHORAX

NORMAL CHEST
DECREASED MOVEMENTS
OPPOSITE SIDE DEVIATION
HYPER RESONANT
ABSENT / AMPHORIC B.S
ABSENT A.S
ABSENT V.R

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CLINICAL DIFFERENCES

PLE
N
D
O
STONY DULL
AB
AB
AB

15-11-29

PNT
N
D
O
HYPER RESONANT
AB / AMPHORIC
AB
AB

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142

EMPYEMA

BULGING / OEDEMATOUS
D
O
STONY DULL
AB
AB
AB

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143

HYDROPNEUMOTHORAX

N
D
O
SHIFTING DULLNESS
AB
SUCCUSSION SPLASH
AB

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144

BRONCHIECTASIS

N
D/N
C
N
VESICULAR
COARSE LEATHERY RALES
N

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DD OF PLEURAL EFFUSION

THICKENED PLEURA
EMPYEMA
PERICARDIAL EFFUSION
LIVER ABSCESS
BGC
SYNPNEUMONIC EFFUSION

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PLEURAL DISEASES
THICKENED PLEURA
LONG STANDING HISTORY
DEPRESSED I.C.S
NO SHIFT / SS OF MEDIASTINUM
DULL
DIMINISHED B.S

PCE
EMPYEMA
SEPTICAEMIA +
RED / SHINY / EDEMA OF
I.C.S

15-11-29

PLE
ACUTE
BULGING
OPPOSITE SIDE
STONY DULL
B.S ; ABSENT

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147

PCE / PLE

MEDIASTINAL SHIFT
DULLNESS POSTERIORLY
TRAUBE S AREA
HEART SOUNDS

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LIVER ABSCESS / Rt. PLE

DULLNESS HIGHEST POINT MCL /

AXILLA
TIDAL PERCUSSION
-/+
INTER COSTAL TENDERNESS + / -

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A.P

Vesicular Breath Sound:

I.P

E.P

Soft

and low-pitched.
Inspiratory sounds >
expiratory sounds.

Rustling
Transmit low frequency sounds
Dampens high frequency sounds

.
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Vesicular Breath Sound:

Active inspiration due to passage of

air in to the bronchi & alveoli F/B
without a pause by passive
expiration D/T Elastic recoil of
alveoli, which occurs maximally in
the early phase giving an apparent
impression of short expiration.

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151

Bronchovesicular Breath Sound

I.P

E.P

Intermediate

intensity

and pitch.
Inspiratory =
expiratory sounds
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Bronchial Breath Sounds

Very

loud & high-pitched

Sound close to the
stethoscope.
Gap between the inspiratory
and expiratory phases
Expiratory sounds >
inspiratory sounds.
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Bronchial Breath Sounds

Hollow
No rustling
Loud
High pitch
Transmit both HFS & LFS

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Bronchial Breath Sounds

Tubular : HP / HOLLOW /
CONSOLIDATION
ABOVE PLEURAL EFFUSION
CAVERNOUS:
AMPHORIC:

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Absent or Decreased Breath Sounds

ARDS: decreased breath sounds in late stages

Asthma: decreased breath sounds
Atelectasis: If the bronchial obstruction persists,
breath sounds are absent unless the atelectasis occurs
in the RUL in which case adjacent tracheal sounds may
be audible.
Emphysema: decreased breath sounds
Pleural Effusion: decreased or absent breath sounds. If
the effusion is large, bronchial sounds may be heard.
Pneumothorax: decreased or absent breath sounds

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Crackles (Rales)
soft (fine crackles) or loud (coarse crackles)
high (fine crackles ) or low (coarse crackles)
Discontinuous,
nonmusical, brief; more commonly heard on inspiration;
ARDS, asthma, bronchiectasis, bronchitis, consolidation,
early CHF, interstitial lung disease
May sometimes be normally heard at anterior lung bases after max.
expiration or after prolonged recumbency

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157

Crackles (Rales)

Crackles are discontinuous, nonmusical, brief

sounds heard more commonly on inspiration.
They can be classified as
Fine (high pitched, soft, very brief) or
Coarse (low pitched, louder, less brief).

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158

Crackles (Rales)

Coarse
Low pitched,
Louder,
Less brief

15-11-29

Fine
High pitched
Soft
Very brief

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159

EARLY INSPIRATORY CRACKLES

LP
EIC
NON PRESSURE DEPENDENT
SCANTY
Open of large AWs closed by
ATM during previous expiration.
Chronic bronchitis

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MIC

Lung abscess
BEC
CAVITY

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161

LIC

Delayed opening of AWs

Profuse
HP
Postural variation
Pulmonary edema & fibrosis

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162

Expiratory rales

Severe AW obstruction
Reopening of temporarily closed
by the ATM during expiration.

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Crackles

Crackles may sometimes be normally heard

at the anterior lung bases after a maximal
expiration or after prolonged recumbency.
The mechanical basis of crackles: Small
airways open during inspiration and
collapse during expiration causing the
crackling sounds.
Another explanation for crackles is that air
bubbles through secretions or incompletely
closed airways during expiration.

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Wheeze

Wheezes are continuous, high pitched, hissing

sounds heard normally on expiration but also
sometimes on inspiration.
They are produced when air flows through
airways narrowed by secretions, foreign bodies,
or obstructive lesions.
Note when the wheezes occur and if there is a
change after a deep breath or cough.
Also note if the wheezes are monophonic
(suggesting obstruction of one airway) or
polyphonic (suggesting generalized obstruction
of airways).
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Wheeze
High expiratory continuous sounds
normally heard on expiration;
Monophonic (obstruction of 1 airway)
Polyphonic (general obstruction);
Asthma , CHF, Chronic bronchitis, COPD, Pulmonary edema

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166

Rhonchi
Low expiratory continuous musical sounds
Similar to wheezes;
Imply obstruction of larger airways by secretions.

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167

Wheeze

Asthma
CHF
Chronic bronchitis
COPD
Pulmonary edema

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Pleural Rub

Pleural rubs are creaking or brushing sounds

produced when the pleural surfaces are
inflamed or roughened and rub against each
other.
They may be discontinuous or continuous
sounds.
They can usually be localized a particular
place on the chest wall and are heard during
both the inspiratory and expiratory phases.
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Mediastinal Crunch (Hammans sign)

Mediastinal crunches are crackles that

are synchronized with the heart beat
and not respiration.
They are heard best with the patient in
the left lateral decubitus position.
As with Stridor, mediastinal crunches
should be treated as medical
emergencies.
E.g. Pneumomediastinum
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170