regurgitation.
• Collapsing pulse.
• Early diastolic murmur.
• Wide pulse pressure (need reading with heart beat).
• Dancing uvula.
• Dancing capillaries with beat.
Fasciculation • Normal when stick out tongue.
• To find pathology, leave tongue in mouth.
• LMN – Motor neuron disease – Fasciculation everywhere.
3. Face and others
Endocrine Grave’s, acromegaly, Cushing’s.
CVS Sternotomy (CABG), hyperlipidemia (arcus lipidus), central cyanosis, clubbing, congenital cyanotic heart diseases, Eisenmenger syndrome.
Neurology • Bell’s palsy : Absence of forehead wrinkles, nasolabial fold (7th).
• Ptosis, eyeball down and out (3rd).
Nephrology • CRF – Sallow face (lighter than tea colour), uremic breath.
• Nephrotic syndrome – Peri-‐orbital edema.
Hepatology Alcoholic cirrhosis – Ascites, gynecomastia, female public hair distribution.
Rheumatology • SLE – Butterfly rash.
• RA + Swan neck deformity + Dry eyes and mouth = Sjogren’s syndrome.
• Dermatomyositis – Heliotrope rash.
4. Hands and others
Hands • Acromegaly (spade like).
• Darkening of palmar creases (+ pigmentation in mouth) – ACTH, Addison’s disease. Unable to produce cortisol, so feedback is to increase the production of ACTH (same structure as MSH), leading to hyperpigmentation.
• Raynaud’s phenomenon : White à Blue à Pink -‐ The symptoms include several cyclic color changes
1. When exposed to cold temperatures, the blood supply to the fingers or toes, and in some cases the nose or earlobes, is markedly reduced; the skin turns pale or white (called pallor), and becomes cold and numb.
2. When the oxygen supply is depleted, the skin colour turns blue (called cyanosis).
3. These events are episodic, and when the episode subsides or the area is warmed, the blood flow returns and the skin colour first turns red (rubor), and then back to normal, often accompanied by swelling, tingling, and a painful "pins and needles" sensation.
-‐ In men, this phenomenon sometimes occurs in individuals who work with vibrating instruments.
-‐ In patients with systemic scleroderma, attacks are, in general, more frequent and more severe.
• Cervical spondylitis.
• Osler’s nodes (painful), Janeway lesions (painless).
• Ulnar claw – 4th and 5th fingers drawn towards the back of the hand at the first knuckle and curled towards the palm at the second and third knuckles.
• Dupuytren’s contracture in CRF – Fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully extended (straightened). Due to contractures of the palmar aponeurosis (or palmar fascia).
• Mixed CT disease ("Sharp's syndrome") -‐ Autoimmune disease.
-‐ Combines features of scleroderma, myositis, SLE, and RA (with some sources adding polymyositis, dermatomyositis, and inclusion body myositis), and is thus considered an overlap syndrome.
-‐ Commonly causes joint pain/swelling, malaise, Raynaud’s phenomenon, Sjögren's syndrome, muscle inflammation, sclerodactyly (thickening of the skin of the pads of the fingers).
-‐ Lichenification – Thick, leathery skin, usually the result of constant scratching and rubbing.
• Livedo reticularis
-‐ Mottled reticulated vascular pattern that appears like a lace-‐
like purplish discoloration of the lower extremities. The discoloration is caused by swelling of the medium veins (not small) in the skin, which makes them more visible. So it can be caused by any condition that makes venules swell.
-‐ Broad differential diagnosis, broadly divided into possible blood diseases, autoimmune (rheumatologic) diseases, cardiovascular diseases, cancers, and endocrine disorders.
SLE, anti-‐phospholipid syndrome, Sneddon's syndrome.
• Boutonniere deformity (“Button through button hole”)
-‐ Deformed position of the fingers or toes, in which the joint nearest the knuckle (PIP) is permanently bent toward the palm while the furthest joint (DIP) is bent back away (PIP hyperflexion with DIP hyperextension). It is commonly caused by injury or by an inflammatory condition like RA.
-‐ This flexion deformity of the proximal interphalangeal joint is due to interruption of the central slip of the extensor tendon such that the lateral slips separate and the head of the proximal phalanx pops through the gap like a finger through a button hole (thus the name, from French boutonnière
"button hole"). The distal joint is subsequently drawn into hyperextension because the two peripheral slips of the extensor tendon are stretched by the head of the proximal phalanx (note that the two peripheral slips are inserted into the distal phalanx, while the proximal slip is inserted into the middle phalanx). This deformity makes it difficult or impossible to extend the proximal interphalangeal joint.
• Scleroderma, psoriasis, vasculitis.
• Tophaceous gout – A chronic form of gout. Nodular masses of uric acid crystals (tophi) are deposited in different soft tissue
areas of the body. Even though tophi are most commonly found as hard nodules around the fingers, at the tips of the elbows, and around the big toe, tophi nodules can appear anywhere in the body (e.g. ears, vocal chords, spinal cord).
• Digital gangrene -‐ Atherosclerosis.
-‐ Vasculitis.
-‐ IgA nephropathy (Berger's) – Primary IgA nephropathy is characterized by deposition of the IgA antibody in the glomerulus. There are other diseases associated with glomerular IgA deposits, the most common being Henoch-‐
Schönlein purpura (HSP), which is considered by many to be a systemic form of IgA nephropathy. HSP presents with a characteristic purpuric skin rash, arthritis, and abdominal pain and occurs more commonly in young adults.
• Marfan’s
-‐ Arachnodactyly (fingers are abnormally long and slender in comparison to the palm of the hand).
-‐ Hyperextensibility.
• Toxic shock syndrome (TSS)
-‐ Potentially fatal illness caused by a bacterial toxin.
-‐ Staphylococcus aureus and Streptococcus pyogenes.
-‐ Diffuse rash, intense erythroderma, blanching with subsequent desquamation, especially of the palms and soles.
-‐ Tampons and septicemia.
• Tylosis – Rare inherited disease characterized by excess skin on the palms and soles. Affected patients have a much higher probability of developing esophageal cancer than the general population.
• Nail-‐pitting – Psoriasis.
• Beau’s lines – Unwell.
• Koilonychia – Iron deficiency.
• Pigmentation of nails – Zidovudine. Bluish or brownish-‐black discoloration of nails may develop during the first month or two of zidovudine therapy and usually disappears within 2 months if the drug is discontinued. Discoloration may occur as longitudinal streaks or transverse bands.
• Charcot Marie Tooth
-‐ An inherited disorder of nerves (neuropathy) that takes different forms.
-‐ Characterized by loss of muscle tissue and touch sensation, predominantly in the feet and legs but also in the hands and arms in the advanced stages of disease.
-‐ Usually, the initial symptom is foot drop early in the course of the disease. This can also cause claw toe, where the toes are always curled. Wasting of muscle tissue of the lower parts of the legs may give rise to "stork leg" or "inverted bottle" appearance. Weakness in the hands and forearms occurs in many people later in life as the disease progresses.
-‐ Breathing can be affected in some; so can hearing, vision, and the neck and shoulder muscles. Scoliosis is common. Hip sockets can be malformed. Gastrointestinal problems can be part of CMT, as can chewing, swallowing, and speaking (vocal cords atrophy). A tremor can develop as muscles waste.
Clubbing
• Endocarditis.
• Congenital cyanotic heart disease.
• PDA complicated by Eisenmenger (only toes, distal to SCA).
• Bronchiectasis.
• Lung abscess.
• CA lung.
• Idiopathic lung disease.
• IBD.
• Liver disease.
• Thyrotoxicosis.
• Atrial myxoma
• Fibrous alveolitis.
* NOT in COPD.
Thenar muscles
Flattened – Median nerve palsy.
• Bilateral carpal tunnel
• Acromealgy
Chronic, slowly progressing, highly variable inherited multi-‐systemic disease.
• Stiff handshake, cannot let go.
• Sad, shabby, droopy face.
• Wasting of the face (triangular face, lower half of face sunken).
• Marked wasting of the neck muscles – May have floppy neck.
• Bilateral ptosis.
Rheumatoid arthritis
• Swan neck deformity – DIP hyperflexion with PIP hyperextension.
• Boutonniere's deformity
• Z deformity of thumb – Hyperextension of the interphalangeal joint, and fixed flexion and subluxation of the metacarpophalangeal joint.
• Finger ulnar deviation (MCP).
Hepatology
and nails • Palmar erythema – Liver failure, PRV, pregnancy, thyrotoxicosis.
• Terry’s nail (leukonychia, white nails) – Hypoalbuminaemia caused by nephrotic syndrome.
• Half and half nails ("Lindsay's nails")
-‐ Proximal portion of the nail white and the distal half red, pink, or brown, with a sharp line of demarcation between the two halves.
-‐ Chronic renal failure.
• Ehlers–Danlos syndrome (EDS)
-‐ A group of more than 10 different inherited disorders; all involve a genetic defect in collagen and connective-‐tissue synthesis and structure.
-‐ Can affect the skin, joints, and blood vessels.
Scarlet fever
• Caused by exotoxin released by Streptococcus pyogenes.
• Characterized by (1) Sore throat.
(2) Fever.
(3) Bright red tongue with a “strawberry” appearance – Inflamed red papillae.
Seen in Kawasaki disease, toxic shock syndrome, and scarlet fever. May mimic glossitis or B12 vitamin deficiency.
* Kawasaki disease – An autoimmune disease that manifests as a systemic necrotizing medium-‐sized vessel vasculitis and is largely seen in children less than 5 years of age. It affects many organ systems, mainly those including the blood vessels, skin, mucous membranes and lymph nodes; however, its most serious
(4) Characteristic rash.
-‐ Fine, red, and rough-‐textured. Blanches upon pressure.
-‐ Generally starts on the chest, armpits, and behind the ears.
-‐ Spares the face (although some circumoral pallor is characteristic).
-‐ Worse in the skin folds. These Pastia lines (where the rash runs together in the armpits and groin) appear and can persist after the rash is gone.
-‐ May spread to cover the uvula.
Reddened sore throat, a fever at or above 101 °F (38.3 °C), and swollen glands in the neck. The tonsils and back of the throat may be covered with a whitish coating, or appear red, swollen, and dotted with whitish or yellowish specks of pus. Early in the infection, the tongue may have a whitish or yellowish coating. Also, an infected person may have chills, body aches, nausea, vomiting, and loss of appetite.
Hansen’s disease/Leprosy
• Chronic disease caused by the bacteria Mycobacterium leprae and Mycobacterium lepromatosis.
• Primarily a granulomatous disease of the peripheral nerves and mucosa of the upper respiratory tract; skin lesions are the primary external sign.
• Left untreated, leprosy can be progressive, causing permanent damage to the skin, nerves, limbs and eyes. Contrary to folklore, leprosy does not cause body parts to fall off, although they can become numb or diseased as a result of infection; infection results in tissue loss, so fingers and toes become shortened and deformed as the cartilage is absorbed into the body.
69) On DOPES!
Dear Yin Ling,
We must not allow Dopeys in medicine! That is only allowed in the 7 dwarfs!
No apex beat felt -‐ WHY?
Remember DOPES
Dextrocardia (pls don't say this first!), Obesity,
Pleural/Pericardial effusion, Emphysema, Empyema Shock, Silly medical student
70) on Eating
Yin ling says I feed her too much at dinner and hence she is sleepy post dinner! True or false?
Is there a physiological basis?
Did your teachers in year 1 teach you well?
High-‐carb, high-‐fat foods (like most Msian meals esp my beloved Hokkien mee) trigger a neural response when it reaches the small intestine. Thats why your sleepiness is Not instant but after an hour or so.
That response, via the parasympathetic nervous system, focus on moving the intestines and digesting the food rather than study. Think of the python after
swallowing a chicken... it lies flat and unmoving like my med students!
A group of brain cells called orexin neurons are found in the hypothalmus and are very sensitive to glucose levels, which spike after a CHO meal. These neurons produce orexin, which moderates wakefulness in the brain.
But orexin isn't the only sleep-‐related neurohormone affected by food. As the quantity of food increases, so too is the amount of insulin released. The insulin increases the amount of seratonin and melatonin that flood the brain, two
chemicals associated with drowsiness (and, for that matter, happiness). Remember the Melatonin tablet sold at airports to help travellers sleep? Now you know also why when some people are stressed they EAT! Natural SSRI !
Hence we feel Happy after our CNY reunion dinner. Drinking tea helps to keep us awake. And we just want to slouch on the sofa and sing or chit chat or 'chill'
So what can the med student or post grad do to solve this dilemma? Easy. Give me the food. I can afford to sleep!
71) on Beta blockers and Hypoglycaemia
Dear Yin Ling,
What hypoglycemic symptom is not masked by beta blockers?
Symptoms and Signs of Hypoglycemia Autonomic: Loss of concentration Drowsiness
Dizziness Hemiplegia
Arrhythmias, Seizures, Coma, Death