Introduction General Medicine
Question 1. Enumerate The Causes Of Clubbing.
Or
Enumerate The Causes Of Clubbing Of Fingers.
Or
Write Important Cause Of Digital Clubbing
Answer. Clubbing is a bulbous enlargement of the soft part of terminal phalanges with both transverse and longitudinal curving of nails.
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Causes of Clubbing Fingers
Pulmonary Disorders
- Suppuration of lung
- Bronchiectasis
- Lung abscess
- Suppurative pneumonia
- Tumors of lung
- Mesothelioma
- Primary lung cancer
- Metastatic lung cancer
General Medicine BDS 3rd Year Question and Answers
Disorders Cardiac
- Cyanotic congenital heart diseases
- Subacute bacterial endocarditis
- Atrial myxoma
Disorders of the Gastrointestinal System And Liver
- Inflammatory bowel disease
- Regional ileitis
- Ulcerative colitis
- Malabsorption syndrome
- Cirrhosis of liver
- Malignancy of liver
Disorders of Endocrine System
- Myxedema
- Thyroid acropachy
- Acromegaly
Miscellaneous
- Hereditary
- Idiopathic
- Unilateral: Pancoast tumor, subclavian and innominate artery aneurysm
- Unidigital: Traumatic or tophi deposit in gout
- Only in upper limbs in heroin addicts due to chronic obstructive phlebitis.
Grades of clubbing
- Grade I: Softening of nail bed because of hypertrophy of tissue at that site.
- Grade II: In addition to grade I changes, there is the obliteration of angle between the nail base and the adjacent skin of the finger.
- Grade III: In addition to grade II changes, the nail itself loses its longitudinal ridges, and becomes convex from above downwards and from side to side. The nails assume the shape of a “parrot’s beak” or the terminal segment may become bulbous like a “drumstick”.
- Grade IV: Finger changes are associated with hypertrophic pulmonary osteoarthropathy.
General Medicine BDS 3rd Year Question and Answers
Question. 2. Write a Short Note On Cyanosis.
Or
Write a Short Answer On Cyanosis.
Answer. Cyanosis is a bluish discoloration of the skin and mucus membrane due to reduced hemoglobin (more than 5 mg%) in blood.
Type of Cyanosis: Generally, there are four types of cyanosis
- Central cyanosis
- Peripheral cyanosis
- Cyanosis due to abnormal pigments
- Mixed cyanosis.
- Central Cyanosis
- It occurs because of poor oxygenation of blood in the lungs due to interference of the exchange of gases, i.e. oxygen and carbon dioxide in respiratory failure or pulmonary edema.
- Central cyanosis is also visible in some congenital heart diseases where deoxygenated blood from the right side mixes with the oxygenated blood from the left side.
This brings down the oxygen saturation of the blood. - Central cyanosis is visible under the surface of the tongue and mucous membrane of the oral cavity and palate.
- Peripheral Cyanosis
- It occurs because of the removal of oxygen from the blood when circulation is slow due to congestive cardiac failure or due to shock causing vasoconstriction.
- This can also occur in healthy people when extremities are very cold.
- It is visible in the lip, nail, tip of the nose, and lobule of the ear.
- Cyanosis Due To Abnormal Pigments
- Normal hemoglobin has iron in ferrous form.
In methemoglobinemia, iron is in the ferric form designated as methemoglobin.
Several substances like nitrite ingestion, sulfonamide, or aniline dyes oxidize hemoglobin to methemoglobin, but this is immediately reduced back to hemoglobin by methemoglobin reductase I or diaphorase.
If there is a defiiency of diaphorase I, methemoglobin circulates in the blood, causing cyanosis. - Sulfhemoglobin is an abnormal sulfur-containing substance, which is not normally present, but is formed by the toxic action of drugs and chemicals like sulphonamides, phenacetin, and acetanilide.
Sulfhmoglobin forms an irreversible change in the hemoglobin pigment that has no capacity to carry oxygen and causes cyanosis.
- Normal hemoglobin has iron in ferrous form.
- Mixed Cyanosis
-
- Due to a combination of both factors, e.g. cor pulmonale due to pulmonary emphysema.
-
Four Types of Causes of Cyanosis
1. Central cyanosis
- Pulmonary causes
- Lobar pneumonia
- High altitudes
- Pneumothorax
- Multiple small pulmonary thromboembolism
- Chronic obstructive pulmonary disease
- Respiratory failure
- Severe acute asthma
- Cardiovascular Causes
- Cyanotic heart disease
- Acute pulmonary edema
- Cor pulmonale
- Arteriovenous fistula
- Abnormal hepatopulmonary syndrome
General Medicine BDS 3rd Year Question and Answers
2. Peripheral Cyanosis
- Congestive heart failure
- Exposure to cold
- Due to arterial obstruction
- Due to venous obstruction
3. Cyanosis Due to Abnormal Pigments
- Methemoglobin formation due to ingestion of sulphonamide and aniline dye
- Sulfhemoglobin formation due to sulphonamide, phenacetin
4. Mixed Cyanosis
- Acute left ventricular failure
- Mitral stenosis
Question3. Enumerate causes of central cyanosis.
or
Write important causes of central cyanosis.
Answer. The following are the causes of central cyanosis:
- Pulmonary Causes
- Lobar pneumonia
- High altitudes
- Pneumothorax
- Multiple small pulmonary thromboembolism
- Chronic obstructive pulmonary disease
- Respiratory failure
- Severe acute asthma
- Cardiovascular Causes
- Cyanotic heart disease
- Acute pulmonary edema
- Cor pulmonale
- Arteriovenous fistula
- Abnormal hepatopulmonary syndrome
Question.4. Enumerate the Causes of Cyanosis.
Answer.
Cyanosis is a bluish discoloration of the skin and mucus membrane due to reduced hemoglobin (more than 5 mg%) in blood.
General Medicine BDS 3rd Year Question and Answers
Type of Cyanosis: Generally, there are four types of cyanosis
- Central cyanosis
- Peripheral cyanosis
- Cyanosis due to abnormal pigments
- Mixed cyanosis.
Central Cyanosis
- It occurs because of poor oxygenation of blood in the lungs due to interference of the exchange of gases, i.e. oxygen and carbon dioxide in respiratory failure or pulmonary edema.
- Central cyanosis is also visible in some congenital heart diseases where deoxygenated blood from the right side mixes with the oxygenated blood from the left side.
This brings down the oxygen saturation of the blood. - Central cyanosis is visible at under the surface of the tongue and mucous membrane of the oral cavity and palate.
Peripheral Cyanosis
- It occurs because of the removal of oxygen from the blood when circulation is slow due to congestive cardiac failure or due to shock causing vasoconstriction.
- This can also occur in healthy people when extremities are very cold.
- It is visible in the lip, nails, the tip of the nose, and lobule of the ear.
Cyanosis Due To Abnormal Pigments
- Normal hemoglobin has iron in ferrous form.
- In methemoglobinemia, iron is in the ferric form designated as methemoglobin.
- Several substances like nitrite ingestion, sulfonamide, or aniline dyes oxidize hemoglobin to methemoglobin, but this is immediately reduced back to hemoglobin by methemoglobin reductase I or diaphorase.
- If there is a defiiency of diaphorase I, methemoglobin circulates in the blood, causing cyanosis.
- Sulfhemoglobin is an abnormal sulfur-containing substance, that is not normally present but is formed by the toxic action of drugs and chemicals like sulphonamides, phenacetin, and acetanilide.
- Sulfhmoglobin forms an irreversible change in the hemoglobin pigment that has no capacity to carry oxygen and causes cyanosis.
Mixed Cyanosis Due to a combination of both factors, for example, cor pulmonale due to pulmonary emphysema.
Four Types of Causes of Cyanosis
1. Central cyanosis
- Pulmonary causes
- Lobar pneumonia
- High altitudes
- Pneumothorax
- Multiple small pulmonary thromboembolism
- Chronic obstructive pulmonary disease
- Respiratory failure
- Severe acute asthma
- Cardiovascular causes
- Cyanotic heart disease
- Acute pulmonary edema
- Cor pulmonale
- Arteriovenous fistula
- Abnormal hepatopulmonary syndrome
2. Peripheral Cyanosis
- Congestive heart failure
- Exposure to cold
- Due to arterial obstruction
- Due to venous obstruction
3. Cyanosis Due to Abnormal Pigments
- Methemoglobin formation due to ingestion of sulphonamide and aniline dye
- Sulfhemoglobin formation due to sulphonamide, phenacetin
4. Mixed Cyanosis
- Acute left ventricular failure
- Mitral stenosis
Question.5.Describe Briefly Pulsus paradoxus.
Answer. The term pulsus paradoxus is used to describe a dramatic fall in blood pressure during inspiration,i.e. characteristic of *tamponade, pericardial constriction, and severe airway obstruction.
- When the systolic blood pressure falls less than 10 mm, the pulse is referred to as pulsus paradoxus.
- Pulsus paradoxus is the *exaggeration of the normal phenomenon.
Pulsus Paradoxes Mechanism
Pulsus paradoxus Causes
- Superior vena cava obstruction
- Lung conditions
- Asthma
- Emphysema
- Airway obstruction
Cardiac condition
- Pericardial effusion
- Constrictive pericarditis
- Severe congestive cardiac failure
General Medicine BDS 3rd Year Question and Answers
Question.6. Describe Briefly the Water Hammer Pulse.
Answer. It is also called as Corrigan pulse.
- A water hammer pulse is a large bounding pulse with an increased stroke volume of the left ventricle and a decrease in the peripheral resistance, leading to wide pulse pressure.
- The pulse strikes the palpating finger with a rapid, forceful jerk and quickly disappears.
- It is best felt in the radial artery with the patient’s arm elevated.
- It is described as having a water hammer quality because of its sudden impact and collapsing quality because it falls away so rapidly.
- The collapsing pulse is caused by the artery suddenly emptying as some of the blood flows from the aorta to the ventricle.
Water Hammer Pulse Causes
1. Physiological
- Fever
- Chronic alcoholism
- Pregnancy
2. High output states or syndrome
- Anemia
- Beri Beri
- Cor pulmonale
- Liver cirrhosis
- Paget’s disease
- Arteriovenous fistula
- Thyrotoxicosis
3. Cardiac lesions
- Aortic regurgitation
- Rupture of the sinus of Valsalva into the heart chamber
- Patent ductus arteriosus
- Aortopulmonary window
- Bradycardia
- Systolic hypertension
Question 7. How Will You Differentiate Arterial And Venous Pulse?
Answer.
Question.8. Enumerate The Causes Of Hematemesis.
Answer. Rapid loss of blood from a lesion in the esophagus, stomach, or duodenum above the level of the ampulla of Vater will result in vomiting of blood.
Hematemesis Causes
1. Common causes
- Duodenal ulcer
- Esophagitis
- Gastric erosion
- Varices
- Gastric ulcer.
2. Less common
- Carcinoma stomach
- Bleeding diathesis
- Aortic aneurysm
3. Rare cases
- Acute pancreatitis
- Angiomas
- Telangiectasia
- COPD
- Polycythemia vera
- Hypoparathyroidism.
Question.9. Write a Short Note On Hematemesis.
Answer. For definition and causes refer to Ans 8 of the same chapter.
Hematemesis Clinical Features
- Patient presents with vomiting of blood or complaint of passing the *tarry stools.
- Many patients with coffee-ground vomiting are present.
- In cases of severe hemorrhage, there may be fresh rectal bleeding or *giddiness and *syncope due to sudden hypovolemia.
- Hematemesis is mixed with food particles.
Hematemesis Management
General
- Put the patient on the bed.
- Arrange a fresh blood transfusion.
- Maintain nutrition and hydration.
- Pass a Ryle’s tube and do constant suction. In cases of suspected peptic ulcer an antacid in gel form is given too early.
Specific
- Treat underlying conditions appropriately.
- Once the crisis is over and the bleeding subsides, treatment is to be planned according to the basic disease. Druginduced hematemesis shall require symptomatic relief.
Question.10. Enumerate The Causes Of Hemoptysis.
Answer. Hemoptysis is defined as coughing out of the blood which includes stained sputum.
Hemoptysis Causes
1. Causes for true hemoptysis-Cardiac
- Mitral stenosis
- Aneurysm of aorta
- Left ventricular failure and primary pulmonary hypertension.
2. Respiratory
- Pneumonia
- Tuberculosis
- Bronchogenic carcinoma and adenoma
- Pulmonary embolism
- Lung abscess
- Bronchiectasis and other infections of the lung and bronchi
- Trauma to the airways and lung
- AV malformations.
3. Immunological
- Goodpasture’s syndrome
- Wegener’s granulomatosis
- Polyarteritis nodosa.
4. Bleeding disorders
- Thrombocytopenia
- Purpura
- Agranulocytosis
- Leukemia
- Hemophilia and anticoagulant therapy.
5. Iatrogenic
- The following bronchoscopy
- Lung biopsy
- Endotracheal intubation
- Anticoagulant therapy
6. Causes for pseudo hemoptysis
- Trauma of the mouth, pharynx and larynx
- Tuberculosis, syphilis, or pyogenic infection of the mouth,
pharynx and larynx. - Malignancy of mouth, pharynx and larynx
- Bleeding spongy gums in scurvy.
Question 11. How Will You Differentiate Hemoptysis From Hematemesis?
Answer.
Question.12. Outline The Investigation And Management Of Hemoptysis.
Answer. Hemoptysis is defined as the expectoration of blood from the respiratory tract, spectrum varies from blood streak of sputum to cough up or large amount of pure blood.
Hemoptysis Investigation
- Hemodynamic resuscitation and bronchoscopy are done.
- Chest radiograph for TB, pneumonia, tumor, pulmonary infarction.
- Full blood count and hematological tests.
- Bronchoscopy to exclude central bronchial carcinoma and to provide tissue diagnosis for the suspected.
- CT scan: For peripheral lesion investigation which is seen on chest radiograph.
Hemoptysis Management
- Establishing a diagnosis is a first priority.
- When hemoptysis is maintained, adequate gas exchange preventing blood from the spleen into the unaffected area of lung and avoiding asphyxiation is the highest priority.
- Keeping the patient at rest and partially suppressing the cough is helpful to subside bleeding.
- If the origin of blood is known and is limited to one lung, the bleeding lung should be placed in the dependent position so that blood is not aspirated to the affcted lung.
- Endotracheal intubation and mechanical intubation are necessary to maintain the airways.
- Balloon catheters and inflating balloons at the bleeding site are helpful in control of the bleeding.
- Laser phototherapy, embolotherapy, and surgical resection of the involved area of the lung are the other methods.
Surgical resection is done in lifethreatening hemoptysis.
Question.13. Enumerate the causes of Malena.
Answer. Malena is defined as the passage of dark-colored blood in stool.
Malena Causes
- Peptic ulcer
- Portal hypertension
- Typhoid fever
- Malignant GI tract
- Ulcerative colitis
- Bleeding diathesis, i.e. purpura, hemophilia, leukemia.
Question.14. Enumerate common causes of fever.
Answer.
Question. 15. How will you investigate a case of prolonged fever?
Answer. Following are the investigations that are carried out as important investigations in case of a prolonged fever:
- ESR platelet correlation: If ESR is more than 100 mm/hr with thrombocytosis, the following diseases can be thought of i.e.
- Tuberculosis
- Malignancy
- Connective tissue diseases. If ESR is less than 100 mm/hr with thrombocytosis, viral infection can be suspected.
- Assessment of alkaline phosphatase levels: If alkaline phosphatase levels are higher following infections are suspected, i.e. biliary tract infections, alcoholic hepatitis, primary and secondaries of the liver, hypernephroma, lymphoma, military tuberculosis, cytomegalovirus infection.
- Serological tests: They are helpful in assessing enteric fever, hepatitis, CMV infection, tularemia, secondary syphilis, brucellosis, fever, amoebiasis, and HIV.
- Imaging techniques:
- X-ray chest: In cases with prolonged fever when the initial Xray is normal, a second Xray must be taken after three weeks to rule out military tuberculosis.
- Ultrasound: Excellent imaging is done in thin individuals and poor imaging in obese individuals, SOL in the hepatobiliary tree of more than 1 cm and endocarditis vegetation of more than 2 mm can be detected.
- CT scan: Provide excellent imaging in obese patients.
SOL in the liver is more than 1 cm and the CNS lesion is more than 0.2 cm. - Radionuclide scans: 99mTcsulphur colloid is used for scanning the liver and spleen. 111Indium labeled leukocytes are used for the detection of intraabdominal mass.
Question 16. Write a short note on pedal edema.
Answer. Pedal edema is defined as swelling of feet and ankles caused by a collection of fluid in the tissues and is a possible sign of congestive heart failure.
Pedal Edema Causes Trauma.
Pedal Edema Clinical Features
- Swelling appears on the feet and ankles.
- Pittng type of edema is present.
- Obstruction of inferior vena cava.
Pedal Edema Treatment
- Sodium restriction is done.
- Diuretics should be used, i.e. spironolactone.
- Management of underlying disorder.
- ACE inhibitors are given.
- Leg elevation of patient.
Question 17. Enumerate the causes of hematuria.
Answer. Hematuria is defined as the presence of blood in urine.
Hematuria Causes
1. Glomerulonephritis
- Primary
- Mesangial proliferative
- Mesangiocapillary
- Berger’s disease
- Secondary
- Systemic lupus erythematosus
- Polyarthritis nodosa
- Infective endocarditis
- Others
- Alport’s syndrome
- Fabry’s disease
- Benign familial hematuria
- Interstitial disease
- Acute pyelonephritis
- Papillary necrosis
- Neoplasms
- Cystic disease
- Adult polycystic disease
- Medullary cystic disease
- Renal stones
- Trauma to kidneys
2. Ureter
- Stone
- Neoplasm
3. Urinary bladder
- Neoplasm
- Cystitis
- Stone
- Trauma or catheter-induced
- Schistosomiasis
4. Prostate
- Prostatitis
- Benign enlargement of the prostate
- Neoplasm
5. Urethra
- Injury
- Urethritis
6. Disorders of hemostasis
- Bleeding or coagulation disorders
- Anticoagulants
7. Systemic diseases
- Diabetes
- Amyloidosis
- Collagen disease
- Disseminated intravascular coagulation
Question.18. Write a short note on bronchial breathing.
Answer. Bronchial breathing is blowing or hollow in character, the inspiratory phase equals the expiratory phase and there is a pause between the two.
- Bronchial breathing may be low pitched (Cavernous) medium pitched or high pitched (tubular).
Low-pitched bronchial breathing is heard over moderately large cavities in the lung and in the case of open pneumothorax. - High-pitched or tubular breathing is heard where consolidation of the lung has occurred around small-sized bronchial tubes as in consolidation of the lung, lobar pneumonia, malignant disease, pulmonary infarction, and pleural effusion.
- Another variety of bronchial breathing is amphoric which is like blowing across a bottle and has a distinct ‘echo-like’ quality.
It is heard over a large cavity with a smooth wall or in the case of pneumothorax in direct contact with a bronchus.
Question.19. Write a short note on clubbing.
Answer. Clubbing is an enlargement of the distal segment of fingers and toes due to an increase in soft tissue.
Causes of Clubbing
1. Pulmonary disorders
- Suppuration of lung
- Bronchiectasis
- Lung abscess
- Suppurative pneumonia
- Tumors of lung
- Mesothelioma
- Primary lung cancer
- Metastatic lung cancer
2. Cardiac disorders
- Cyanotic congenital heart diseases
- Subacute bacterial endocarditis
- Atrial myxoma
3. Disorders of the gastrointestinal system and liver
- Inflammatory bowel disease
- Regional ileitis
- Ulcerative colitis
- Malabsorption syndrome
- Cirrhosis of liver
- Malignancy of liver
4. Disorders of endocrine system
- Myxedema
- Thyroid acropachy
- Acromegaly
5. Miscellaneous
- Hereditary Idiopathic
- Unilateral: Pancoast tumor, subclavian and innominate artery aneurysm
- Unidigital: Traumatic or tophi deposit in gout
- Only in upper limbs in heroin addicts due to chronic obstructive phlebitis.
Grading
- Grade I: Softening of nail bed due to the hypertrophy of tissue at that particular site.
- Grade II: In addition to grade I changes there is the obliteration of the angle of the nail bed
- Grade III: In addition to grade II changes there is swelling of the subcutaneous tissues over the base of the nail causing the overlying skin to become tense, shiny, and wet and increasing the curvature of the nail, resulting in parrot beak or drumstick appearance.
- Grade IV: Swelling of the fingers in all dimensions associated with hypertrophic pulmonary osteoarthropathy causing pain and swelling of the hand, wrist, etc., and radiographic evidence of subperiosteal new bone formation.
Question.20. Write a short note on drug fever.
Answer. Drug fever is a prolonged fever and belongs to any febrile pattern.
- In drug fever, there is relative bradycardia and hypotension. Pruritus, skin rash, and arthralgia may occur.
- It begins 1 to 3 weeks after the drug is started and persists for 2 to 3 days after the drug is withdrawn.
- Eosinophilia may be present.
- Almost all the drugs may lead to drug fever.
- Drugs that commonly lead to drug fever are sulphonamide, penicillin, iodide, antitubercular drugs, methyldopa, anticonvulsants, and propylthiouracil.
Question.21.Write important causes of pitting edema.
Answer Following are the causes of pitting edema:
- Ingestion of excessive salt
- Due to steroids
- Premenstrual
- Due to portal obstruction
- Due to obstruction of the inferior vena cava
- In beri beri
- Anemia and hypoproteinemia
- Epidemic dropsy
- Pregnancy
- Miscellaneous: Dermatomyositis, Raynaud’s
- phenomenon and old age
- If pitting remains for more than a minute most likely cause is congestion
- If pitting remains for 40 seconds it is caused by hypoalbuminemia
Question.22. Write a short note on causes and investigations of dysphagia.
Answer. Dysphagia is difficulty in swallowing.
Dysphagia Causes
1. Due to the narrowing of the esophagus
- Intrinsic, i.e. obstruction inside the esophagus
- Esophageal stricture
- Esophageal ulceration
- Congenital atresia of the esophagus
- Plummer Vinson syndrome
- Tumors either benign or malignant
- Tonsillitis
- Stomatitis
- Glossitis
- Esophagitis
- Pharyngitis
- Extrinsic, i.e. obstruction outside the esophagus
- Aortic aneurysm
- Retropharyngeal mass
- Mitral stenosis which leads to left atrial enlargement
- Thyroid gland enlargement which compresses the esophagus.
2. Motor Dysphagia:
- Paralysis of esophageal sphincter
- Esophageal spasm
- Cardiac achalasia.
- Paralysis of 9th and 10th cranial nerve nuclei
- Systemic sclerosis
- Poliomyelitis.
- Esophageal muscle weakness
- Myopathy.
- Neuromuscular paralysis
- Myasthenia gravis.
Dysphagia Investigations
- A complete hemogram is done to check for anemia
- Chest Xray should be done to check for tuberculosis, cardiomegaly, mediastinal enlargement
- Endoscopy of the esophagus helps in the detection of lesions and finding their cause
- Barium meal examination is carried out purely for the localization of lesions in the esophagus
- Esophageal manometry is carried out to assess motility disorders of the esophagus.
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