MEDICINE

VIVA
LV
NOTES
.G
R
D Pune.
Dr.Gajanan L Vaidya
️
-

©
BJGMC
 ☆ Must know ☆

There is nothing New In this notes. Almost all points are there in practical books. So then Why
these notes?
The Whole Purpose of these notes is to compile the basic and must know Points about the
clinical cases that are asked in examinations Bcoz these points are scattered here and there in
Practical books. Also one problem which we face while taking History is that we take chief
Complaints quickly but we don't know or don't Remember what are the points which we have to
ask in Negative History to Rule out diffrentials. And this is what the examiner Expects from UG
student in the viva. If you don't Reach towards Dx it's ok, but whether you have asked Relevent
negative History or not is what the examiner is Interested in. The thing which is expected from u

V
in the viva is ur approach to the case i.e. How you will proceed to the case when u have 2-3

L
complaints, what negative History you will ask to Rule out the diftrentials.For Ex-U have been
alloted a case having Complaints of weakness of Both lower limb then u should have 5-10
questions Ready in ur mind. It should not happen that after chiet complaints u have to think that

G
what questions I have to ask, as you have only 45 min. to complete ur case along with

.
examination.
For UG there are 5-6 Cases (long) which are Surely asked for everyone, So u should

R
have list of questions Ready Related to these cases in ur mind, and you should ask it without
pause, it saves the time for examination and examiner get to know that the Relevent points

D
Regarding case has been asked. All the points Regarding the negative History has been

️
covered in these notes.
These notes also include potent questions which have been asked in Viva Repeatedly.

©
There are at least 30 questions on each case. To Reduce Workload to find answers, u can make
group af 4 people and divide questions among you. one person will get 7-8 questions and will
find their answers and write it on paper and in this way u will make another Notes in which all
the viva questions which you are going to encounter in ur viva will be with you along with their
written answer. So try to make grp wherever there is big stuff. It Saves a time a lot.These notes
also Includes Symptomatology. There R only 10-15 Symptoms which are commenty asked in
viva. We know the causes of cough, but examinar asks 'tell me 10 conditions where cough is
seen?' then we either become blank or may tell 3,4 conditions but not 10.
These notes also include some of the charts which are imp. from clinical point of view
and are asked in viva repeatedly.
Only the format of examination is given. The exact procedure, diffrent methods are not
given in these notes. You have to Read it from other clinical books.
 THE PREFACE
A year ago I wrote handwritten notes for viva
which got tremendous response from final year

V
MBBS students, so now the same notes have
been converted into text form.

G L
.
I am very much thankful to my parents, friends
and junior colleagues who really put their efforts

R
together and made this book possible.

D
©️
Suggestions and positive criticism is welcomed
to improve further. Wish you all the best.
For improvement of book send your suggestion
on vaidyagajanan181@gmail.com

- Dr. Gajanan Vaidya

BJGMC, PUNE
 INDEX

Sr. No Topic

LV
G
1 Paraplegia

.
2 Ascitis

R
3 Pleural effusion
4 Mitral Stenosis

️ D
5 Hemiplagia
6 Charts

©
7 Symptomatology

A.Fever
B. Dyspnea
C. Cough
D. Hemoptysis
E. Hematemes
F. Chest pain
G. Palpitation
H. Vomiting
I. Abdominal pain
J. Bleeding per Rectum
K. Headac
Case 1 Paraplegia

Chief complaints: low grade fever since 4 month

weakness in Both legs since 2 months
low back pain for last 3 months,

HOPI : pt. Was Symptomatically well 4 months back when he developed low grade fever... (Ask
all points about fever)
After 1 month of fever pt. Developed weakness in Both Legs. Patient noticed this when
he found. difficulty in getting up from sitting / squatting Position. He also gave H/0 slipping of

V
chappals..

L
H/0 associated Symptoms : ASK
1) H/0 LOSS of sensations

G
2) Retention of urine

.
3) Loss of B/B control

R
4) H/0 Vaccination:
→AntiRables Vaccine =GBS

D
measles

️
Mumps (Post vaccinal encephalitis)
Diphtheria

©
5)Loss of consciousness indicates Intracranial Actiology
6) Hlo Dysphagia, nasal Regurgitation,
diplopla, (Indicates CN involvement i.e MS or GBS)
dribbling of saliva
7)Weakness in upper limb (High cervical cord lesion)
8) Hlo flexor spasms ( Involvment of Rubrospinal tract)

HOW TO DIFFERENTIATE BETWEEN ATM AND GBS

ATM GBS
1.Loss of sensations. 1.No loss of sensations

2.B/B involvement with retention of urine 2. NO B/B INVOLVMENT

and constipation

3. 3. Ascending paralysis
 4.Girdle like sensation 4. Normal
Area of paraesthesia above girdle like
sensation

5.Brisk reflex 5. Jerks absent

(Absent in neural shock)

6.Extensor plantar 6.Flexor or absent

H/0 Aetiology:
1)Hlo trauma to spine
2)Hlo backache. (TB- spine, Extremadullary tumours)

V
3)Hlo chronic cough, expectoration, hemoptysls, wt. loss (TB.)

L
4) Hlo swelling over back ( Gibbus, cold Abscess)
5) Chronic alcholism (Peripheral Neuritis, central pontine mylinolysis)

G
6) Headache, Vomiting, convulsion (Intracranial SOL)

.
7) Wt loss , Anorexia and other constitutional symptoms suggestive of malignancy
bladder.

R
BLADDER

INVOLVED

️ D NOT INVOLVED

©
● ATM ● GBS
● TB SPINE ● DEMYELINATING DISEASES MND
● TUMOUR
● TRAUMA SPINE
● ANT.SPINAL ARTERY
THROMBOSIS

Past History
1) Waxing and wanning (MS)
i.e. episodes of weakness followned by Remission.

Personal History
1)H/o Vegetarian[SACD]

Family History
1)H/o limb weakness in other member of family
2)SACD ( Vit B12 deficiency)
3)Lathyrism (Khesri dal= BOAA
Examination
(A) General Examination :
Built, nouishment,
Conscious, cooperative
Decubitus and attitude
Pulse, BP, RR (vitals)

(B)Systemic Examination

(a) Higher functions 1) Consciousness

2)Orientation (TPP)

V
3) Behaviour
4) Memory

L
5)Intelligenc
6) Speech

. G
7)Handedness
8) Agnosia/Apraxia

R
9) Perception
10) Emotional status

️
(b) Cranial Nerves (All12)

D
©
(c) Motor Examination (NTPCI) : 1)Nutrition
2) Tone
3)Power
4) Co-ordination
5)Involuntary movements

D )Reflexes :
1) Superficial
2) Deep
3) visceral
4) Primitive
E)Sensory Examination :

a)Superficial sensation: 1) Pain

2) Touch
3) Temperature
b)Deep Sensation: 1)Vibration
2) Pressure
3) Proprioception

c) Cortical sensation:
1) one point localisation

V
2) Two point discrimination

L
3)Stereognosis
4) Graphesthesia

G
5)sensory extinction (perceptual Rivalry)

.
6) Baragnosis

R
d)Peripheral Nerves Examination

️ D
Q)How do you like to Investigate Paraplegia?
Ans: 1) Blood → TLC, DLC, ESR, sugar, urea, creatinine

©
2) chest-X-Ray → TB
-Bronchogonte Carcinoma
→ metastasts -
3) X-Ray Spine - Caries Spine
-metastasis
- Fracture Or dislocation of Vertebrae

4) MRI or CT Scan To visualise details of spinal cord and disc prolapse

5) Lumbar puncture and csf examination

a) GBS:- Albuminocytological dissociation
b) multiple sclerosis:- oligoclonal bands csf electrophoresis.
6)Serum Vit B12 estimation
7)muscle enzymes, muscle Biopsy
8)NCV (Periphral Neuropathy, GBS)
Treatment:
A. General t/t:
a) Diet- Adequate nutrition and fluid
Alarm bell at bedside
b) Bladder- self retaining catheter under aseptic condition
Change catheter every 2- 3 wks
Urine c/s whenever needed
Rx of UTI (Antibiotics)
c) Bowel- laxatives for constipation
If needed manual, digital evacuation
d) Bed sores- developed due to loss of sensations

V
and increased blood supply

L
Skin should be kept dry and clean
Air/water cushioned bed

G
Tropic ulcers- cleaned with H2O2.

.
e) Physiotherapy of limbs
f) Drainage of cold Abscess

R
g) Laminectomy for Caries spine

D
h) Muscle spasm-

️
Treated By: Bactofone 5mg TDS
Tizanidine 2mg TDS

©
Botulinum toxin

B. Specific t/t:-
1. Potts spine-
- Traction in early stage
- Plaster jacket for immobilization
- ATT for 9- 11 months
2. ATM-
- High dose prednisone 1mg/kg/day × 2 wks
- High dose methyl prednisolone
3. GBS-
- IV Ig 0.4mg/kg/day for 5 days
- Plasmapheresis
 - Intubation and positive pressure ventilation when vital
capacity falls below 1L
4. Carcinoma/ Lymphoma-
- Treatment by chemotherapy/ radiotherapy
5. MND(ALS)-
- Riluzole 50mg BD( monitor LFT regularly)

Q) How would you differentiate between organic paralegia and hysterical

Paraplegia?
IN HYSTERICAL PARAPLEGIA:
1. Deep Reflexes are exaggerated or normal but never absent.

V
2. Plantar are never extensor

L
3. B/B involvement is rare
4. Sensory loss does not corrospond to anatomical distribution of nerves.

. G
( Hysterical pt may complain that sensations ate absent below knee, hip
or allow i. e keeping jt as demarcation point for sensation)

D R
Q) Mechanism of paraplegia by TB:
● Cold Abscess compressing Spinal cord

️
● Bone pieces compresing spinal cord

©
● Collapse of bodies of Vertebrae compressing spinal cord
● Intraspinal granulation formation
● Spinal artery vasculitis

VIVA Questions
1)Enumerate causes of paraplegia. In which case bladder involvement is seen?
2) causes of paraplegia with CN Involvment.
3)Intracranial causes of paraplegia
4)significance of Vaccination History in a case of Paraplegia. Enumerate
Vaccines having potential to coz Paraplegia
5)Different mechanisms by which TB causes Paraplegia
6) How is attitude of paraplegic Pt.
7)What is paraplegia in flexion and extention.
8)What is decerebrate and Decorticate rigidity
9)cause of Hyper and Hypotonia.
10) What is flexor spam
11) mass Reflexx
12)Causes of UMN and LMN Parplegia
13) Causes of Acute and gradual onset Paraplegla
14)Diffrence between conuss medullaris and cauda eqina syndrome
15) How will you diffrenciate extramedullay tumour from intramedullary
16)compressive and non compressive cause of Paraplegia
17)Causes of Quadriplegia.

V
18) Localisation of level of lesion in compressive mylopathy

L
19)Positive History and examination findings in fovour of GBS
20)Relation of Spinal segment with Vertebrae

G
21) Beevor's sign

.
22)diffrent methods of Ellicitation of planter Reflex

R
23) Various Responses in plantar Reflex.
24)What is Brown sequird Syndrome

D
25)What is Dissociated anesthesia

️
26) causes of thickened nerves.
27)What is Reinforcement effect

©
28) Enumerate Neurocutaneous Markers
29)Complications of paraplegia
30) Nerve supply of Bladder
31)Root value of all Reflexes
32)Perform Motor Examination in detail.
33) Diffrence between autonomous, automatic and uninhibited bladder.
 CASE 2. ASCITIS

CHIEF COMPLAINTS:

1) Distension of Abdomen
2)Breathlessness
3)Swelling of legs

HOPI

V
a) Hlo Associated Symptoms

L
1)No H/0 fever {peritonitis, Pancreatitis}

G
No H/o pain in abdomen

.
2) No H/o diarrhea {Protein loosing enteropathy}
3)No H/o Wheezing

R
No H/o cough {To make sure that Dyspnea is not due to Respiratory

D
cause}

️
No H/o chest pain
4)No H/o vomiting or constipation { Large Bowel obstruction by

©
malignancy}

b)H/o complications

1) No H/o Hematemesis {Variceal bleed}

2) No H/o altered consciousness, {hepatic Encephalopathy}
change in behaviour and sleep Inversion
3)No H/o Yellowish discolouration { hepatic failure causes Jaundice}
4) No H/o oligourea { Hepato RenalSyndrome}

c) H/o Previous treatment

1)H/o medications
2) H/o Tapping
3)No H/o use of Herbal medications{ Heavy metals present in herbal
medications known to cause hepatocellular damage }
d) H/o Aetiology
1)H/o alcoholism
2) No H/o Previous blood transfurion
No H/o Recent tatoo marks {Hepatitis}
No H/o Drug abuse
3) No H/o fever, Cough, hemoptysis {TB}
4) No H/o bleeding per Rectum or alternate diarrhea and constipation (
malignancy, intestinal tb

V
Past History

Personal History

G L
.
Family Histoy

R
Examination

D
A) General Examination

️
● Decubitus
● Built, nourishment

©
● Temperature
● Pulse
● RR
● BP
● Pallor
● Oedema
● Lymphadenopathay
● Icterus
● Clubbing
● Cyanosis

B)SIGNS OF LIVER FAILURE

● Alopecia
● Loss of axillary and public hair
● Gynaecomastia in Male
 ● Breast atrophy in female
● Testicular atrophy
● Spinal naevi
● Palmar arythema
● White nails
● Flapping tremors
● Abdominal distension
● Dilated veins
● Menstrual irregularity

V
HEPATIC FACIES

L
● Icterus
● Hallowing of temporal Fassa

G
● Sunken eyes

.
● Loss of buccal pad of fat

D R
©️
C) SYSTEMIC EXAMINATION
1) Inspection:
● Shape
● Symmetry
● Umbilical
● Movements
● Pulsation
 ● Skin
● Scars and signs
● Hernia orifices- Ext. genitalia( hydrocele)
Renal angle tenderness
Supraclavicular fossa

2) Palpation:

a) Superficial-
● Temperature
● Tenderness

V
● Guarding and rigidity

L
b) Deep- ( by dipping method)

G
● liver

.
● Spleen
● Kidney

R
● Any other lump

D
3) Percussion of fluid

️
a) Fluid thrill :1500ml

©
b)Horse shoe dullness: 1000ml
c)shifting dullness: 500ml
d)Puddle sign: 120ml
e)USG: 50ml

(4) Auscultation
a) peristalsis
b) Arterial bruit { RAS,Vascular tumour of liver}
c) liver Rub
d) Splenic Rub

Q) How will you investigate a case of Ascitis

1) Routine Blood examination:- Hb, TLC, DLC, ESR,

Neutrophilia indicates Infection.
2) urine examination:- increased albumin indicates Nephrotic Syndrome
3)Stool for occult blood:- seen in malignancy and cirrhosis
4)Serum cholesterol:- increased in Nephrotic Syndrome
Decreased in cirrhosis of liver
5)Plama Proteins:- Low albumin seen in Naphrotic Syndrome.
6) USG Abdomen:- Best to Confirm Ascitis
It can detect as little as 30ml of Ascitic fluid.
7)Examination of ascitic fluid :-
8)Biopy of Virchows glands and other Palpable Lymph nodes:- seen in TB
and malignant Lymphoma
9) Tests of Portal Hypertension:-
10)Liver function tests:-

Q) How will you manage a case of Ascitis?

1. Rest in Bed

LV
G
2. Diet-

.
- Salt restricted diet
- 2000- 2200 Kcal/day

R
- High protein diet in pt of neuropsychiatric manifestations from

D
cirrhosis of liver

️
3. Diuretics-
- Spironolactone- ODC

©
100- 200mg/day produces hyperkalemia
If no good response then -
- Frusemide 40-80mg/day
- Combination of both
4. Water intake restricted to 1-1.5L daily.
5. Monitor regularly -
- Serum eectrolytes
- Serum creatinine
- Weight
- Abdominal girth
- Urine output
6. Salt free albumin infusion in Refractory cases
7. Paracentesis abdominis-
- In case of Respiratory distress and when accumulation fluid is rapid
 - Large volume Paracentesis is done in case of cirrhosis i.e 3-5L fluid
aspirated in one sitting with 6-8 g/L salt free albumin infusion

Viva Questions
1) what are causes of Distension of abdomen?
2)what causes Dyspnea in Ascitis?
3)what are diffrent conditions that present with Ascitis and edema of Leg
4)How will u diffrenciate edema of legs of cardiac orgin from that due to extra cardiac causes.
5)what are Various mechanism that contributes to formation of Ascitis in a chronic alcoholic pt.
6) What do you maen by Chronic alcoholic
7) How much gram of alcohol is present in each of 100ml of whisky, wine, Beer, Country liquor,

V
(8) Enummate causes of Homatomesis? How will you diffrenciate Hemoptysis from

L
Hematemesis
9) How will you diffrenciate malena from Hematochezia

G
10) significance of alteration of sleep Rhythm in a pt. of Ascitis.

.
11)Name some of the familial liver diseases.
12)Can there be Icterus in a case of Ascitis How will u examine for that. 13)What is hepatic

R
Encephalopathy? How will u treat that.
14) What are sites of Portosystemic shunts

D
15)Significance of Lymphadenopathay in a case of Ascitis.

️
16)signs of liver cell failure
17)what are manifestations of ↑ Estogen level.

©
18) What are spider nevi ? Enumerate the conditions where they are seen.
19)Significance of Dupytren's contracture
20)Describe umbilicus in Ascitis? what are causes of Inverted and Everted umbillas
Respectively
21) caput Medussae
(22)Divarication of Recti
23)What do u mean by Refractory Ascitis?
24)How do u Judge the amt. af fluld in peritoneal cavity?
25)Demonstrate in details the procedures of elicitation of presence of free fluid in peritoneal
cavity
26) what is child pugh score? what are it's Components? what it signifies 27)Causes of Portal
Hypertension
28)positive points in favour of Portal Hypertension.
29)Complications of Portal Hypertension How will theat portal HTN.
30)How will be the presentation of pt. of cirrhosis.
31)Causes of Ascitis.
32)In a case at Hepatomegaly or Splenomegaly how will u perform
fluid thrill
33)Complications at Ascitis.
34)Demonstrate flapping tremors, Name other conditions in which they
are seen.
35) Puddle sign
36) How will you diffrenciate Ascitis from ovarian cyst
37)Diffrenciate between transudative and exudative Ascitis
What is SAAG
38) causes of hemorrhagic Ascitis
39) Indications of Tapping and it's complications
40) causes of Ascitis with Hepatomegaly or Splenomegaly Respectively
41) stigmata of alcoholic cirrhosis
42) hepatic facies
43) why there is Anemia, Jaundice in pt of cirrhosis

V
43) why there is Anemia, Jaundice in pt of cirrhosis

L
44) how will u investigate a case of ascitis
45) how will u manage a case of ascitis
46) what is TIPPS

. G
D R
©️
 CASE 3. PLEURAL EFFUSION

CHIEF COMPLAINTS

- pain in Rit. lower chest and fever since 10 days

- Cough, Breathlessness since 5 days

HOPI :
A)ODP of present complaints:

V
chest pain in Pleural effusion is characteristically pleuritic chest pain.
PLEURITIC CHEST PAIN-

L
Pain increases with deep breathing
Sharp in onset but later becomes Dull in character

G
(Also seen in - Fracture rib

.
Chostochondritis)

R
B)

️ D
DRY COUGH EXPECTORATION

● Upper RTI ● Pneumonia

©
● Allergic cough ● Bronchitis
● Early TB ● Bronchiectasis
● Chronic TB

C) H/O associated complaints:

- H/O Dry cough since 5 days
- No H/Oexpectoration or Hemoptysis
- Hlo Breathlessness since5 days [white Grade]
- No Hlo Wheezing
- NO H/O PND

D) H/O Aetiology
In any Respiratory case we have to Rule out whether the causes is
infective or allergic.
Also Rule whether breathlessness is primary due to Respiratory
cause or is secondary to any other cardiac condition
 Also we have to determine which part of Respiratory system is
involved i. e lung parenchyama or Respiratory airways or pleura

1.Infection- H/O fever cough n Breathlessness

2.Allergy, Asthma- H/O Wheezing, sneezing and rhinitis
3.TB- H/O contact with TB patient
4.Cardiac cause - H/O Palpitation, Pedal Oedema, PND
5.Mediastinal Compression- H/O Dysphagia, hoarseness, Stridor
6.H/O OCCUPATION - Pneumoconiosis
7.SLE- H/O Skin Rash, Joint pain and swelling

Past History

LV
G
Personal History

family History

General Examination:

R.
️ D
-Built, Nourishment
- Pallor, Cynosis,Clubbing.

©
- Icterus
- Pulse
-RR./ Pulse (1:4)
-R.P JVP
- Cor Fulmonale
-Edema af Logs.
- Lymphadenopathy
-Stigmata of TB
-Spine kyphoscoliosis

Upper Respiratory tract Examination:

1)Nose
2)Oral cavity - Erythroplakia
leukoplakia
Tobacco stained teeth
3)sinuses for tenderness

LOWER RESPIRATORY TRACT EXAMINATION:

A ) INSPECTION:
● SHAPE
● SYMMETRY
● MOVEMENTS
● RESPIRATION- Rate
Rhythm
Duration of Both phases
● TRACHEAL DEVIATION (trails sign)

V
● APEX IMPULSE
● Skin,Scars, Sinuses and Dilated veins

L
B) PALPATION:

. G
1.Superficial -temp, tenderness
2.Measurements -

R
-AP-AP diameter.
-Transverse diameter

️ D
-AP/Transverse
-Hemithorax diameter

©
- Chest expansion
- Hemithorax expansion

3.Movements-
- upper anterior chest
- lower anterior chest
-Apex
- Suprascapular
-Interscapular
- Intra scapalar

4.tracheal Palpation-
-By two finger method
- By three finger method
5. Apex-beart
 6.Tactile vocal fremitus

C)Percussion :
1)Direct Percussion on clavice
2) Indirect Percussion-
-Ante chest wall
-Axilla
- Back- Suprascapular
Interscapular

V
Infrascapular

L
Apex

G
3)Special Percussion-

.
a)Tidal
b) shifting dullness

R
c) Coin Percussion

D)Auscultation

️ D
©
1)Normal Breath sounds
2) Abnormal Breath Sounds
3)Adventitious sounds (Rhonchi, Crepts, Pleural Rub )
4) Vocal Resonance
5)Succussion Splash

Q)How will you treat a case of Pleural effusion

-Rest in Bed & nutritious diet
-NSAIDS for chest pain.
-Aspiration of Pleural fluid if there is
Respiratory distress or Rapid Collection
-Chest Physiotherapy
-According to etiology
● Tuberculosis- -ATT,
 -Sometimes steroids are added to Prevent adhesion
of fibrosis
● Malignancy-
- Repeated aspiration of Pleural fluid
-Pleurodesis
- T/t of Carcinoma
● Hydrothorax -
-T/t of CCF
- T/t of Cirrhosis of liver

Viva Questions

LV
G
1)What is character of pleuritic chest pain.

.
2)What are diffrent causes of cough.

R
3)Where will you see Dry Cough and Expectoration ?
5) Define Dyspnoea. Grade it.

D
6)Define Orthopnea

️
7)What are causes of tachypnea and Bradypnea
8)Respiratory conditions with Raised JVP

©
9)Stigmata ot TB
10)Causes of Bulging chest wall and Intercostal Spaces.
11)Significance of Spine examination in RS
12)What are accessory Muscled of Respiration
13)Types of Breathing.
14) Detine Biots, kussmauls, chyne stokes Breathing
15)causes es of chest wall tenderness.
16)What are different types of Percussion notes and in which conditions they are
seen.
17)characteristics at vesicularr and bronchial Sounds
18)What are abnormal Breath Sounds
19)What are Adventitious sounds
20)Differentiate Between Stridor and wheeee
21)Differentiate Between pleural and Pericardial Rub.
22)What are Aegophony, whispering Pectoriloqy, 23)What is Skodaic Resonance
24)What is kronigs Isthumus
25) Define Traubes space & It's borders.
26)How will you differentiate whether the dullness on Rt. side is d/t enlarged liver
or is d/t Rt sided
Pleural effusion.
27)Trails sign.
28)Difference Between pleural effusion and Hydropneumothorax
29)Causes of Pleural effusion
30)Enumerate causes where trachea is shifted towards side of Pleural effusion
31)D/D of Pleural effusion and complications of Pleural effusion
32)Indications for thoracocentesis

V
33)Diffrence between transudative and exudative effusion

L
34)What is TVF and Conditions with increased and decreased TVF
35)Investigation and management of case of Pleural effusion

. G
D R
©️
 Case 4.Mitral stenosis

● Personal profile
● Chief complaints
● HOPI- ODP -H/O etiological factors
H/O Complications
H/O any previous treatment
● Past History
● Personal History
● Family History
● Examination

Chief Complaints:

LV
1) Breathlessness on walking since 10 months.

G
2) Palpitations since 4 months

.
3) Repeated attacks of cough with expecoration
4)PND

R
5)Syncopal attacks

D
All the complaints may or may not be present. Explain the onset,Duration,progression of the

️
complaints that ore present in your case.

©
HOPI:

A)ODP

B)H/O Aetiology- Rule out 3 Aetiology

1.Rheumatic Fever-
Ask H/O fever and Joint pain, swelling in childhood

2.Cynotic Diseases-
Ask H/O Breathlessness, cynotic episodes, Squatting episodes
Bulged precordium on inspection

3. Cardiac syphilis-
Ask H/O exposure to venereal diseases and sore on Penis

4.H/O Thyrotoxicosis
 C)H/O Complications
In Current situation whether MS is Just Isolated MS or has become
complicated with it's Complications.

Ask Questionnaire About 6 Complications of Ms.

1] History S/O COF-
- H/O Breathlessness
-H/O Edema feet
-H/O Pain in Right Hypochondrium
-H/O Abdominal distention

2) History of Pressure effects-

-Hoarseness of voice due to Compression of RLN

V
-H/O Dysphagia due to compression of oesophagus due to

L
enlarged Rt atrium

3) H/O Subacute Bacteriall Endocarditis

. G
- H/O fever and petechial hemorrhages
- H/O embolic episodes such as Hemoptysis,Haematuria
Hemiplegia.

R
4) H/O Hemoptysis

️ D
5) Atrial fibrillation-
- Ask H/O embolic episodes i.e CVA
- intermittent claudication, pain in Abdomen

©
- Unconsciousness is due to CVA in MS with AF and
Syncope is due to low cardiac output due to Pulmonary Hypertension

6) H/O Recurrent Bronchopulmonary expectoration

D)H/O Previous treatment:

-Ask about current medications.
- H/O Rheumatie fever prophylaxis
- Ask About monthly injections of penicilin

PAST

PERSONAL
FAMILY

EXAMINATION :

General:

● Bulit, nouishment
● Pulse
● RR
● BP
● Temperature

V
● Pallor
● Oedema

L
● Lymphadenopathay
● Icterus

G
● Cyanosis

.
● JVP
● Apex-pulse deficit

R
Systemic-

D
- CVS

️
-RS
-Abdomen

©
CVS Examination :
1)Inspection:
1. Shape and Symmetry of chest
2. Precordium
3. Pulsations-
a)Apex impulse
b) lateral parasternal Pulsation
c) Epigastric pulsation
d)Supraclavicular Pulsation
e)Suprasternal Pulsation
f)Carotid Pulsations
4. Skin , sinuses, scar, dilated veins etc.
2) Palpation:
a) Mitral Area: ( Lt. 5th ICS)
- Apex beat
- Palpable heart sounds
- Thrills

b) Pulmonary Area: ( Lt. 2nd ICS)

- Pulsations
- Palpable heart sounds
- Thrills

c) Aortic area: ( Rt. 2nd ICS)

- Pulsations

V
- Palpable heart sounds

L
- Thrill

G
d) Tricuspid area: ( Lt.4th ICS)

.
- Pulsation
- Palpable heart sounds

R
- Thrills

D
e) Erb's area or neoaortic area:

️
( Lt 3rd ICS)

©
f)Carotid artery pulsations, thrill

g) Tracheal tug

3) Percussion:
● Lt. Border
● Rt. Border
● Base of heart

4) Auscultation: heart rate and rhythm

● Mitral area
● Pulmonary Area
● Aortic area
● Tricuspid area
Heart sounds, murmur(all points), other sounds at all areas to be heard.
RS Examination:
- No basal rales
- No evidence of Pleural effusion

Abdomen Examination:
- Liver , Spleen not Palpable
- No ascitis

Diagnosis:
RHD with MS with Pulmonary HTN, RVH and mild CCF in sinus rhythm.

V
Q) How will you investigate a case of MS.

L
1. Chest Xray :
a) PA view-

G
- mitralization of Lt. Border of heart

.
- Increase in trans. Diameter oh heart due to RVH
- Dilated Pulmonary arteries at hillman ( Pulmonary HTN)

R
- Kelly B lines:
Horizontal lines at base of lung in region of costoprenic angle

️
b) Lateral view-

D
Obliteration of retrosternal air space indicating RVH

2. ECG:

©
● P mitrale- wide and notched p wave
● RVH
● Absent P wave- AF

3. Blood:
● TLC and DLC
● ESR
● ASO titre

4.Echo:
● Chamber enlargement
● Area of Mitral orifice
● Lt. Atrial thrombus
TREATMENT:
● PERCUTANEOUS MITRAL BALLOON VALVOPLASTY
● MEDICAL TREATMENT:
1)Treatment of CCF -
- Restrictions of physical activity
- Salt restricted diet
- Diuretics
- ACE
- Dioxin
2) Antibiotics prophylaxis against Infective Endocarditis
3)Anticoagulation in presence of AF- Heparin , warfarin,
B- blockers , Amiodarone, CCB

V
4) Penicillin prophylaxis against rheumatic fever

VIVA QUESTIONS

G L
.
1)Enumerate causes of Breathlessness
2)How will you diffrenciate whether breathlessness is due to cardiac cause or

R
Respiratory cause.
3) NYHA grading of Dyspnea

️ D
4)Causes of palpitations
5) Define PND. Mechanism behind PND, why it Is Nocternal .Difference between

©
Orthopnea and PND.
6)Causes of chest pain
7) acquired causes of MS
8)Causes of AF
9)Why hemoptysis is seen in Cardiac condition(Mechanism). Enumerate the conditions
10) Pulse and JVP in details.
11) Howo will you differentiate whether the Oedema is due to cardiac or Renal or
hepatic cause
12)What are Cardinal Symptoms of CVS
13)Cardiac conditions with cyanosis . what is differential cyanosis
14) What are Cynotie Spells and why they Relieve on Squatting
15)Causes of Brady and tachycardia
16)Enumerate cyanotic Heart diseases. 17)What is apex beat.What are diffrent types of
Apex beat.
18)How will you measure BP (Both by Palpatory and auscultatory method)
19)What are korotkoffs Sound
20)Complications of MS
21)How will you grade murmur
23)what is apex-Pulse Deficit? what is its significance
24) D/D of Mitral diastolic murmur
25)what negative History you are going to ask in pt of mitral-stenosis / What could be
your approch when a pt. came with Complaints at Breathlessness,chest pain and
Palpitations
26)How will you manage a case of Ms
27)what X Ray Findings you are going to get in a case of MS
28) Enumerate at least 10 signs of Aortic Regurgitation
29)Causes and clinical Presentations of Pulmonary HTN
30)What are thrills e with which part of ur hand u are going to palpate e for thrill.

LV
. G
D R
©️
 CASE 5.HEMIPLEGIA

Chief Complaints:
● Weakness of right half of body since 10 days
● Inability to talk
● Dribbling of saliva from Rt. Side of mouth

HOPI:
1)ODP- no H/O double vision, Dysphagia, nasal Regurgitation ( chk CN)

2)H/O Aetiology-

LV
1. Cerebral haemorrhage- H/O headache, giddiness, nausea n vomiting

G
2. Hemorrhage, thrombosis, TIA- H/O HTN

.
3. TIA- H/O similar episodes in past which resolved in less than 24 hrs

R
4. Haematoma- H/O head injury
5. Heart diseases- H/O chest pain, palpitation, Breathlessness

D
6. RHD- H/O fever, Joint pains in past

️
7. Postepileptic , embolism- H/O Convulsions

©
8. Meningitis- H/O headache,fever,neck stiffness
9. Blood diseases- H/O bleeding from nose or gums or skin
10. TB- H/O cough expectoration and hemoptysis (tuberculoma, tb
meningitis, tb arthritis
11. Neurosyphilis- H/O ulcer on penis
12. OCP, anticoagulant- H/O taking drugs
13. Amniotic embolism- H/O Recent delivery
14. Mural thrombosis- pastH/O MI
 Thrombosis Embolism Haemorrhage
Time Early morning After exertion Post
stress,anxiety
Primordial + - -
Symptoms
Convulsions - Common -
Neck stiffness - - +
Develops Hours Seconds Seconds

V
within

L
Location of lesion:
1. Cortex( Incomplete Paralysis)-

. G
Monophagia
Aphagia

R
Apraxia

D
Agnosia

️
Astereognosis

©
Loss of tactile localisation, discrimination
2. Sub-Cortex- Absence of Cortical signs
Loss of postural sensibility
Impairment of tactile localisation and
discrimination
3. Internal capsule- complete Hemiplagia
Hemianaesthesia
Homo hemianopia
Global aphasia
UL- increased tone flexor
LL- increased tone extensor
4. Brainstem- Always crossed hemiplagia
 5. Mid brain and medulla- Quadriplegia
Coma
Chyne- takes breathing
Decerebrate rigidity

TONE-
1. HYPERTONIA-
● SPASTICITY- Pyramidal TRACT Lesion(UMN)

V
● RIGIDITY- Extrapyramidal tract lesion

2. HYPOTONIA-

G L
.
● LMN
● Cerebellar lesion

D R
©️
FACIAL NERVE INVOLVMENT

1. UMN LESION-
Contralateral face weakness sparing upper half of face as
it receives nerve supply bilaterally.

2. LMN LESION-
Weakness of whole of I/L face
 LV
. G
D R
©️

CROSSED HEMIPLAGIA
PAST TIA-
Repeated- Same area- Thrombosis
-Different area- Embolism
T/t- Anticoagulation therapy

VARIOUS CAUSES OF THROMBOSIS -

● Vegetation of IE
● HTN- Atherosclerosis
● Recent delivery

V
● Mural thrombus following MI

L
● OC Pills
● MS with AF

. G
LESION

D R AFFECTED ARTERY

️
1. BRAINSTEM Vertebrobasilar artery

©
2. Int. Capsule MCA
3. Cortex ● ACA- sudden involvement
-hallucinations
● MCA- Hemianaesthesia
Aphasia
● PCA- Visual disturbance
Visual
hallucinations

PAST HISTORY:
PERSONAL HISTORY:
● Non-veg- Increased Satu.FA- Increased LOL-
Atherosclerosis
● Pork meat- Neurocysticercosis
● Smoking-
Nicotine- Vasospasm and vasculitis cause
hypercoagulable state.

FAMILY HISTORY:

EXAMINATION:
SAME AS IN PARAPLEGIA
LV
. G
R
Q)How will you manage a case of heliplagia

D
● CT Scan of brain -

️
To Categorize stroke into either ischaemic or

©
haemorrhagic
● Blood- TC,DC,Blood sugar,urea,creatinine,total cholesterol,
electrolyte status
● ECG- myocardial ischaemia
Chamber enlargement
Atrial fibrillation
● ECHO- To identify source of emboli
TREATMENT-
● SUPPORTIVE MEASURES
● ANTI-OEDEMA MEASURES
● Care of CO-MORBID CONDITION

1. Pt should lie in a railed cot-

○ Insert ryles tube
○ Put self retaining catheter
○ Adequate nutrition
○ Nursing care

V
2. -20% Mannitil - 100 ml thrice daily

L
-Oral glucose 6tsf thrice daily
-Inj furosemide 40mg iv stat and when necessary

. G
-Inj dexamethasone if not hypertensive
3.T/t of HTN,DM,Stress ulcers

R
Hyperlipidemia- atorvastatin 80mg/day
4.Antiplatelet drugs-

️ D
Aspirin, clopidogril, pentoxyphilline
5.T/t of atrial fibrillation and valvular heart diseases.

©
6.Anticoagulant therapy-
Heparin and warfarin
Only of value in evolving stroke
7.Thrombolytic therapy- r-TPA
Beneficial Only if started within 3 hrs of ischaemic stroke
8.Physiotherapy
9.Rehabilitation-
Speech and occupational therapy
10.Care of Bowel bladder and bed sores
11. SAH
 VIVA QUESTIONS

1)significance of Handedness in a Hemiplagic case

2)Enumerate the causes of sudden onset and gradual onset
Weakness.
3)Define Motor, sensory and Global Aphasia.
4)In which cases of Hemiplagia bladder Involvment
is seen.
5)Differentiate between Drowsiness, Stupour and Coma

V
6)Risk factors for stroke

L
7)What is TIA what is it's significance.
8)Define RIND, PRIND

. G
9)What Is Todds palsy?
10)Enumerate drugs increasing Risk of Stroke

R
11)What is attitude of Hemiplagia Pt. Reason Behind that

D
12)How will you differentiate between UMN and LMN facial palsy.

️
Why upper face is spared in UMN facial palsy.

©
13)Define clasp knife Spasticity, cog-wheel Rigidity.
14)plantar Reflex. Different t Procedures and different
Responses.
15) Kernig's and Brudzinsky sign. Grade Power.
16) Perform Homiplagic gait,what are other types of gait.
17)Difference Bet UMN and LMN. What is crossed Hemiplegia
and it's site of lesion.
18)How will you find out level of lesion and involved artery In
Hemiplegia.
19)How will a diffrenciate between Hemiplagic and ischaemic
stroke.
20)Facial Nerve Examination in detail.
21) What are causes of stroke in young pt.
22)Common sites of Homorrhages in Hypertensive Hemorrhagic
stroke Enumerate cardiac diseases giving Rise to stroke
23)Importance of Headache in a diagnosis of Hemiplagic
24)Causes of Recurrent Hemiplegia
25)Enumerate Ascending and descending tracks & functions of
each
26)Functions of pyramidal and Extra Pyramidal tracts.
27)Difference Between meningisum and meningitis.

V
28)Draw circle of willis

L
29)Define Hoover's sign & its significance
30)What are neurocutaneous markers

. G
31)Perform CNS examination in details
32)How will u investigate and treat a pt of hemiplagia

D R
©️
 IMPORTANT CHARTS ASKED IN EXAM

1.GRADING OF DYSPNEA

A. NYHA CLASSIFICATION FOR CVS

● Grade 1- shortness of breath on unaccustomed exertion
● Grade 2- SOB on ordinary activities
● Grade 3- SOB on less than ordinary activities

V
● Grade 4- limitation of activities at rest

B. MRCC CLASSIFICATION FOR RS

G L
.
● Grade 1- Dyspnea while walking up small hill
● Grade2- person lags behind people of similar age while

R
walking on ground level

D
● Grade 3 - person has to stop for breathing after walking 100

️
yards

©
2. CHILD PUGH SCORE (ASCITIS)

Parameter Points- 1 2 3
Bilirubin <2(mg/dl) 2-3 >3
Encephalopat None 1-2 3-4
h
Ascitis None Mild Moderate
Albumin >3.5(g/dl) 2.8-3.5 <2.5
Prolongation <4 4-6 >6
of PT

CLASS A- 5-6
CLASS B- 7-9
CLASS C- >9
Minimum score- 5
Maximum score- 15

V
3.GRADING OF MURMUR ( Levines grading system):
Systolic murmur classified into 6 grades and diastolic murmur

L
upto 4 grades only.

● Grade 1- very or soft

. G
R
● Grade 2- soft
● Grade 3- moderately loud

️ D
● Grade 4- loud with presence of thrill
● Grade 5- very loud with associated thrill

©
● Grade 6- extremely loud and may be heard without stetho

4. GRADING OF MUSCLE POWER (MRCS)

● Grade 0- complete paralysis
● Grade 1- a flicker of contraction only
● Grade 2- movement with gravity eliminated
● Grade 3- movement possible against gravity
● Grade 4- movement against gravity plus some resistance
● Grade 5- Norma power
 SYMPTOMATOLOGY

1. FEVER-
● Normal Body Temp- 36° to 37.5°
● Hypothermia- < 35°
● Mild fever- 37.2° to 37.8°
● Moderate fever- 37.8° to 39.4°
● High fever- 39.4°to 40.5°
● Hyperpyrexia- >40.5°
LV
. G
R
FEVER HYPERTHERMIA

D
● Increase in ● No change in set point

️
hypothalamus set point

©
● Respond to ● No response
antipyretics

TYPES OF FEVER-

1. Continous- Fluctuation of <1°C over 24 hrs and never

touches baseline
Examples- Pneumonia, Meningitis, UTI

2. Intermittent - Only for some hrs of a day and Remission to

normal in remaining hrs
 - Touches baseline
- Three types:
a) Quotidian- everyday
Kala Azar, septisemia, pyemia
b) Tertian- On alternate day
P. Falciparum, P.vivax
c)Quartan- Every third day
P.malarie, P.Ovale
3. Remittent- Fluctuation of > 1°C in 24 hrs and never touches

V
baseline.

L
Examples- Typhoid, Infective Endocarditis

.
FEVER WITH CHILLS AND RIGORS:
G
EXAMPLES-

D R
️
● Malaria

©
● Abscess
● UTI
● SABE
● Pyelonephritis

CHILLS RIGORS
Subjective feeling of cold Shivering
Disappear on putting blanket Does not disappear
 ● Perl abstain fever- hodgekins Lymphoma, brucellosis
● Hectic- septicemia
● Step ladder pattern- Typhoid
● Camel hump fever- Kala Azar
● Black fever- Kala Azar
● Black water fever- Malaria

◇ PUO-

V
● Fever > 38.3°C on atleast 2 occasions

L
● Illness Duration of > 3 wks
● No known immunocompromized state

G
● Diagnosis remains uncertain after History, examination and

.
investigation

◇ Prolonged fever- > 2 Wks

D R
️
◇CAUSES OF FEVER-

©
1. Infection - bacterial, viral, parasitic, fungal
2. Neoplasm- CA Bone, pancrease, lung, hepatoma
3. Vascular - AMI Pulmonary embolism, pontine haemorrhages
4. Immunological- RA , SLE
5. Endocrine - Thyrotoxicosis, Addison disease
6. Metabolic- Acidosis,gout, dehydration

◇ HYPOTHERMIA-
1. Hypothyroidism
2. Hypopituitarism
3. Hypoglycemia
4. Ketoacidosis
 2. DYSPNEA:
Uncomfortable Awareness of one's own breathing
CAUSES:
A.Respiratory causes-
○ Airway obstruction
○ Bronchial asthama
○ COPD

V
○ Pulmonary Oedema

L
○ Pulmonary embolism

G
○ Pleural effusion

.
○ Pneumothorax

R
○ Bronchogenic CA

B. CVS CAUSES:

️ D
©
● AMI
● Valvular heart diseases
● LVF
● Co genital cyanotic Heart diseases

C. NEUROLOGICAL CAUSES:
● Respiratory Centre defec as in GBS,
syringobulbia, bulbar polio, MG.
3. COUGH-
Dry Cough Expectoration
Upper RTI Pneumonia
Allergic cough Bronchitis
Early TB Bronchiectasis

V
Chronic TB

A.RS Causes-

G L
.
● Laryngeal and pharyngeal:

R
- Laryngitis
- Pharyngitis

️ D
- Neoplasm

©
● Tracheobronchial :
- Tracheobronchitis
- Bronchial Asthma
- Bronchiectasis
- Bronchogenic ca
- Aspiration
● Lung-
- Pneumonia
- TB
- Lung abscess
- Pulmonary Oedema
 - Tropical eosinophilia
● Pleural-
- Pleural effusion
- Pneumothorax

B.CVS Causes-
● LVF
● Mitral Stenosis

V
● Aneurysms of aorta

G L
4. HAEMOPTYSIS-

R.
Expectoration of blood.

TRUE
️ D PSEUDOHAEMOPTYSI

©
HAEMOPTYSIS
Haemorrhage from Haemorrhage from nose,
lung,bronchial tree mouth, larynx, pharynx
and trachea
CAUSES-
A) RESPIRATORY CAUSE-
● Pneumonia
● TB
● Bronchogenic ca
● Pulmonary embolism
● Bronchiectasis

V
● Lung abscess

B) CARDIAC CAUSES-

G L
● LVF

R.
● Mitral Stenosis

D
● 1°Pulmonary HTN

©️
C) HEMATOLOGY CAUSES-
● Hemophilia
● Thrombocytopenia purpura
● Leukemia

D) IATROGENIC CAUSES-
Following-
● Bronchoscopy
● Lung Biopsy
● Endotracheal intubation
● Anticoagulant therapy
5. HAEMATEMESIS-
Vomiting of blood
Causes-
● Peptic ulcer
● Chronic gastritis
● Ca stomach
● Oesophageal varices

V
● Mallory Weiss Syndrome

L
● Drugs: Aspirin, anticoagulant, steroids

G
Q) How will you differentiate between hemoptysis and
haematemesis-

R.
Hemoptysis Haematemesis

️
1.Appear. of blood

D
Bright red and
frothy
Coffee ground
mixed with blood
2.Preceding
Symptoms ©
3.Ass. Symptoms
Coughing

Cough,
Vomiting

Abdominal pain,
expectoration Vomiting
4.Following day Fever, rusty Indigestion,
sputum giddiness, tarry
stool
5.Reaction of Alkaline Acidic
blood
6.CHEST PAIN:
Causes:
A.Cardiac-
● Angina
● AMI
● Pericarditis
● Infective Endocarditis

V
● Dissecting aorta

L
● Valvular heart diseases

B.Respiratory -

. G
R
● Pleurisy

D
● Pneumothorax

️
● Pulmonary embolism

©
● Pulmonary HTN
● Malignancy

C.Mucoskeletal-
● Rib Fracture
● Chostochondritis
● Vertebrae Collapse
 D.Miscellaneous -
● Oesophagitis
● Peptic ulcer
● Pancreatitis

7. PALPITATION-
Examples:
Physiologic High output Arrhythmias Miscellaneo

V
al states states us
Exercise Anaemia Atrial

G L Pheochromo

.
fibrillation cytoma

R
Excitement Thyrotoxicosi Extrasystole Hypoglycemi
s s a
Excessive

️ D
Beri-beri Paroxysmal

©
tea, coffee, tachycardia
alcohol
Anxiety Pagets Heart block
diseases

-
8. VOMITING:
A.Abdominal
● Gastric ulcer
● Peptic ulcer
● Colic
● Intestinal obstruction
● Appendicitis
● Pancreatitis

B.Cardiac-

LV
G
● MI
● Cardiac failure
C.Central-

R.
D
● Increased ICT

️
● Motion sickness

©
D.Metabolic-
● Pregnancy
● Haypercalcemia
● Diabetes
● Alcohol
E.Toxic-
● Viral Hepatitis
● Cholera
9. ABDOMINAL PAIN:
a) Acid Peptic diseases
b) Peritonitis
c) Pancreatitis
d) Abdominal TB
e) Amoebic liver abscess
f) Mesenteric ischaemia
g) Typhoid

V
h) Sickle cell crisis

L
i) Colic- intestinal

G
- Renal
- Biliary

R.
j) Rupture of aneurysm

D
10. BLEEDING PER RECTUM-

️
Causes:

©
A.Anal:
● Fissure
● Fistula
● Foreign body
B.Rectal:
● Piles
● Proctitis
C.Colic:
● Bacillary and amoebic dysentery
● Ulcerative colitis
● Carcinoma
 ● Polyps
D.Haematological:
● Anticoagulant therapy
● Blood dyscriasias

11. HEADACHE-
Causes:
A.Intracranial:

V
● Meningitis

L
● Aneurysms

G
● SAH
● Malignant HTN
● Metastasis

R.
D
● Subdural haematoma, granuloma, Abscess

️
B.Extracranial:

©
a. Vascular-
● Migraine
● Cluster headache
● Temporal arteritis
b. Skeletal-
● Pagets disease
● Torticollis
c. Referred pain-
● Sinusitis
● Eye strain
● Glaucoma
 LV
. G
D R
©️
 LV
. G
D R
©️