---

Decompensated Features of Chronic Liver Disease (CLD)

---

Definition of Decompensation

---

Clinical Staging (Baveno Classification)

---

Cardinal Features of Decompensation

1. Ascites (Most Common - 80%)

• Most frequent sign of decompensation; occurs at 7-10% per year in compensated cirrhosis
• Caused by portal hypertension + splanchnic vasodilation + sodium/water retention
• Clinical signs: increased abdominal girth, bulging flanks, flank dullness, shifting dullness
• Hyponatremia (serum Na <130 mEq/L) is present in ~25% of patients with cirrhosis and ascites - a marker of disease severity
• Complications: Spontaneous Bacterial Peritonitis (SBP) - infection without an obvious surgical source; Refractory ascites - unresponsive to diuretics, requires repeated paracentesis or TIPS

2. Variceal Hemorrhage

• Gastroesophageal varices present in ~50% of newly diagnosed cirrhosis
• Prevalence ranges from 40% (Child A) to 85% (Child C)
• Small varices bleed at ~5%/year; large varices bleed at ~15%/year
• Predictors: large variceal size, severe liver disease, red wale markings
• Presents as hematemesis, melena, or both
• Gastric varices (especially fundal) carry higher bleeding risk than esophageal

3. Hepatic Encephalopathy (HE)

• Brain dysfunction caused by liver insufficiency and/or portosystemic shunting
• Pathogenesis: Ammonia accumulates (due to portosystemic collaterals + decreased hepatic metabolism) → damages astrocytes (Alzheimer type II astrocytosis) → GABA-mediated cortical depression
• Also: manganese deposition in globus pallidus → impaired motor function
• Grades I-IV: from subtle personality changes/sleep disturbance → confusion → stupor → coma
• Precipitants: GI bleed, infection, constipation, sedatives, electrolyte imbalance, dehydration

4. Jaundice

• Results from inability to excrete bilirubin (liver insufficiency)
• In cholestatic disease (PBC, PSC), may reflect biliary damage rather than pure liver failure
• Accompanied by coagulopathy (prolonged INR) and hypoalbuminaemia

---

Secondary/Progressive Decompensation Features

5. Hepatorenal Syndrome (HRS)

• Functional renal failure in setting of advanced cirrhosis; no intrinsic kidney pathology
• Results from extreme splanchnic vasodilation → renal vasoconstriction → decreased GFR
• HRS Type 1 (AKI type): Rapid deterioration (creatinine doubles to >2.5 mg/dL within 2 weeks); very poor prognosis
• HRS Type 2: Slower, associated with refractory ascites

6. Spontaneous Bacterial Peritonitis (SBP)

• Infection of ascitic fluid without a surgical cause
• Diagnosis: ascitic fluid PMN count >250 cells/mm³
• Common organisms: E. coli, Klebsiella, Streptococcus
• Associated with 30-50% in-hospital mortality if untreated

7. Cardiopulmonary Complications

• Cirrhotic cardiomyopathy: High-output heart failure with decreased peripheral O₂ utilization
• Hepatopulmonary syndrome (HPS): Pulmonary capillary dilation → right-to-left shunt → hypoxemia (PaO₂ <80 mmHg, or increased A-a gradient)
• Portopulmonary hypertension (PoPH): Vasoconstrictive substances bypass hepatic metabolism → irreversible pulmonary HTN

8. Coagulopathy

• Decreased synthesis of clotting factors (II, V, VII, IX, X)
• Thrombocytopenia (from hypersplenism + decreased thrombopoietin)
• Results in prolonged PT/INR; bleeding tendency

9. Other Advanced Features

• Hepatocellular carcinoma (HCC): Can develop at any stage and precipitate/accelerate decompensation
• Acute-on-Chronic Liver Failure (ACLF): A distinct syndrome - acute deterioration on a background of cirrhosis, with organ failures; high short-term mortality
• Infection/Sepsis: Now recognized as a distinct stage in the natural history; poor survival even after infection clearance
• Muscle wasting/Sarcopenia and malnutrition: Progressive loss of muscle mass
• Hepatic hydrothorax: Transudative pleural effusion (usually right-sided) from ascitic fluid passing through diaphragmatic defects

---

Physical Signs of Decompensation

---

Prognostic Scoring

• Child-Turcotte-Pugh (CTP): Scores ascites, encephalopathy, bilirubin, albumin, INR (range 5-15). Child A (5-6) = good; Child C (10-15) = poor
• MELD/MELD-Na score: Incorporates creatinine, bilirubin, INR, and sodium - used for liver transplant prioritization

Median survival in compensated cirrhosis: 9-12 years. Median survival in decompensated cirrhosis: ~1.6-2 years. - Goldman-Cecil Medicine, Sleisenger & Fordtran's GI and Liver Disease

---

Liver Span - Normal Range and Abnormal Values

How to Measure Liver Span

• Upper border: Use heavy percussion from the mid-thorax downward in the MCL - the point where lung resonance changes to hepatic dullness marks the upper liver border (normally at the level of the right nipple, ~5th intercostal space)
• Lower border: Use light percussion (examiner's ear close to the abdomen) from the right lower quadrant upward - the point where tympany changes to dullness marks the lower border (normally at the right costal margin)
• Can also be percussed at the midsternal line and anterior axillary line
• Palpation of the lower border below the costal margin alone is unreliable for determining span - percussion is superior

---

Normal Liver Span by Percussion

Adult Values (Mid-Clavicular Line)

• Goldman-Cecil Medicine states: normal liver span in the MCL is 6 to 12 cm; a span <12 cm reduces the likelihood of hepatomegaly
• Clinical Methods (NCBI): mean percussion span is 7 cm (women) and 10.5 cm (men)

Average Liver Span by Percussion Line (Adults)

By Sex (Clinical vs Ultrasound - Research Data)

Note: Ultrasound consistently gives larger values than clinical percussion (statistically significant, p<0.001), because percussion underestimates the true hepatic extent.

Paediatric Values (by percussion, MCL - Johns Hopkins study)

---

Abnormal Values

Hepatomegaly (Enlarged Liver)

• Vascular/Congestive: Right heart failure, Budd-Chiari syndrome, cardiac cirrhosis
• Metabolic/Infiltrative: Non-alcoholic fatty liver disease (NAFLD), haemochromatosis, Wilson's disease, amyloidosis, glycogen storage disorders
• Infective/Inflammatory: Viral hepatitis (acute), hepatic abscess, schistosomiasis, malaria, infectious mononucleosis
• Neoplastic: Primary HCC, metastatic carcinoma (most common cause of massive hepatomegaly), lymphoma, haemangioma
• Cholestatic: Primary biliary cholangitis, primary sclerosing cholangitis
• Haematological: Sickle cell disease, thalassaemia, polycythaemia vera

• Smooth + tender = acute viral/alcoholic hepatitis, hepatic congestion (CCF)
• Hard + irregular = cirrhosis, malignancy
• Smooth + non-tender = early cirrhosis, fatty liver, infiltrative disease

Shrunken/Small Liver

---

Important Caveats

---

Clinical Pearl

"A liver edge felt up to 2 cm below the right costal margin is considered normal, but a normal-sized liver can be displaced downward by other abnormalities such as emphysema."

• Goldman-Cecil Medicine

---

GI Examination — MBBS Final Year Practical

---

1. GENERAL EXAMINATION (Before touching the abdomen)

• Built, nourishment, BMI
• Pallor (anaemia — GI bleed, malabsorption)
• Icterus / Jaundice
• Cyanosis
• Clubbing (IBD, cirrhosis, malabsorption)
• Koilonychia (iron deficiency), Leuconychia (hypoalbuminaemia)
• Lymphadenopathy — especially left supraclavicular (Virchow's node) = gastric ca
• Oedema (pedal — hypoalbuminaemia, portal HTN)
• Parotid enlargement (alcoholic liver disease)
• Fetor hepaticus
• Flapping tremor / Asterixis (hepatic encephalopathy)
• Gynaecomastia, testicular atrophy (CLD)
• Loss of axillary/pubic hair (CLD)

---

2. HANDS & UPPER LIMBS

• Palmar erythema (CLD, pregnancy)
• Dupuytren's contracture (alcoholic liver disease)
• Leuconychia (hypoalbuminaemia)
• Koilonychia (iron deficiency)
• Clubbing
• Asterixis (flapping tremor) — ask patient to dorsiflex wrists
• Spider naevi on arms/chest (CLD) — >5 above the nipple line is significant
• Muscle wasting

---

3. FACE & NECK

• Scleral icterus (jaundice)
• Conjunctival pallor
• Kayser-Fleischer rings (Wilson's disease — slit lamp needed)
• Angular stomatitis, glossitis (nutritional deficiency)
• Parotid enlargement
• Fetor hepaticus
• Virchow's node — left supraclavicular fossa
• JVP — raised in right heart failure causing congestive hepatomegaly

---

4. CHEST WALL (relevant)

• Spider naevi — >5 significant (CLD)
• Gynaecomastia
• Dilated veins on chest wall

---

5. ABDOMINAL EXAMINATION

A. INSPECTION (Patient supine, arms by side, knees slightly flexed)

• Scaphoid (sunken) — malnutrition, advanced malignancy
• Distended — ascites, obesity, organomegaly, gas, pregnancy (5 F's + 1 F: Fat, Fluid, Flatus, Faeces, Fetus + Fictitious)
• Localised bulge — organomegaly, hernia, mass

• Dilated veins:
  • Caput medusae (radiates from umbilicus) — portal HTN
  • Inferior vena cava obstruction (flow upward in flanks)
  • Superior vena cava obstruction (flow downward)
• Striae (silvery/white = old; purple = Cushing's)
• Visible peristalsis — gastric outlet obstruction, intestinal obstruction
• Scars (note operative, laparoscopic port scars)
• Umbilicus — inverted (normal) vs everted (ascites, obesity)
• Sister Mary Joseph nodule (periumbilical nodule = metastatic malignancy)
• Hernia — umbilical, inguinal, incisional
• Jaundice of skin
• Ecchymosis — Grey Turner's sign (flanks = retroperitoneal bleed/pancreatitis), Cullen's sign (periumbilical = same)

---

B. PALPATION

Superficial Palpation

• Tenderness (localise to quadrant)
• Guarding (voluntary vs involuntary)
• Rigidity (board-like = peritonitis)

Deep Palpation

• Deeper tenderness
• Masses (note: position, size, shape, surface, margins, consistency, mobility, tenderness, pulsatility, movement with respiration)

Liver Palpation

• Start RIF, move toward right costal margin
• Ask patient to breathe deeply
• Normal: liver edge may be felt up to 2 cm below right costal margin
• Note: size below costal margin, surface (smooth/nodular), edge (sharp/rounded/irregular), consistency (soft/firm/hard), tenderness
• Hepatomegaly = >2 cm below costal margin

Spleen Palpation

• Start RIF, move toward left costal margin (diagonally)
• Ask patient to breathe deeply
• Normal spleen: not palpable
• If not felt supine → palpate in right lateral decubitus position
• Splenic notch felt on medial border = confirms spleen
• Differentiate from left kidney: cannot get above it (spleen), moves with respiration, notch present, dull to percussion, bimanual ballotability absent

Kidney Palpation (Bimanual)

• Ballotable, can get above it, resonant (colonic gas over it), does not move with respiration much

Other Masses

• Murphy's sign (cholecystitis): arrest of deep inspiration on palpating RHC
• McBurney's point tenderness (appendicitis)
• Rebound tenderness (peritonism)
• Rovsing's sign (appendicitis)

---

C. PERCUSSION

Liver

• Liver span in MCL:
  • Normal: 6-12 cm

  • 12 cm = hepatomegaly

  • <6 cm = shrunken liver (cirrhosis/acute liver failure)
• Upper border: 5th ICS (MCL) / level of right nipple
• Lower border: right costal margin

Spleen

• Traube's space (left lower chest, bounded by 6th rib above, MAL laterally, left costal margin below) — normally resonant
• Dull Traube's space = splenomegaly or pleural effusion

Ascites

• Shifting dullness (most reliable clinical sign):
  • Percuss from umbilicus to flank - note where dullness begins
  • Patient turns to opposite side - wait 30 seconds
  • Re-percuss - if dullness shifts to dependent side = positive
  • Detects >500 mL of fluid
• Fluid thrill (large ascites >2L):
  • One hand on flank, flick opposite flank
  • Assistant places edge of hand in midline to dampen fat vibrations
  • Feel transmitted wave

General

• Tympanic over bowel (gas)
• Dull over solid organs/masses
• Obliteration of hepatic dullness = gas under diaphragm (perforation)

---

D. AUSCULTATION

• Bowel sounds:
  • Normal: 5-12/minute, gurgling
  • Absent: paralytic ileus, peritonitis
  • High-pitched/tinkling: mechanical obstruction
  • Hyperactive: gastroenteritis, early obstruction
• Bruits:
  • Over liver = hepatocellular carcinoma, hepatic arteriovenous fistula
  • Over aorta = aortic aneurysm
  • Renal bruits = renovascular HTN
• Venous hum in epigastrium/umbilicus = portal HTN (Cruveilhier-Baumgarten syndrome)
• Rub over liver/spleen = hepatic/splenic infarction, perihepatitis (Fitz-Hugh-Curtis syndrome)
• Succussion splash (heard 3+ hours after meals) = gastric outlet obstruction

---

6. GROIN & GENITALIA

• Inguinal lymph nodes (enlargement)
• Inguinal/femoral hernia
• Testicular atrophy (CLD)
• Scrotal oedema (ascites, hypoalbuminaemia)

---

7. RECTAL EXAMINATION (PR) — mention even if not performed

• Inspect perianal area: haemorrhoids, fistula, fissure, skin tags
• Tone of sphincter
• Palpate rectal wall — mass, tenderness
• Prostate in males
• Blood, mucus on glove

---

8. TO COMPLETE EXAMINATION

"To complete my examination, I would like to:

• Examine the hernial orifices
• Perform a per rectal examination
• Check external genitalia
• Examine the back and renal angles (costovertebral angle tenderness)
• Do relevant investigations: LFT, USG abdomen, endoscopy, ascitic tap, etc."

---

QUICK SUMMARY TABLE — What Examiner Will Ask

---

History Taking — Liver Pathology

MBBS Final Year Practical Exam

---

OPENING

"Good morning sir/madam. I am a final year MBBS student. I would like to ask you some questions about your illness. May I proceed?"

• Name, Age, Sex, Occupation, Address, Religion, Marital status, Date of admission

---

1. CHIEF COMPLAINTS

• Yellowish discolouration of eyes/skin (jaundice)
• Swelling of abdomen (ascites)
• Swelling of feet (pedal oedema)
• Pain/discomfort in right upper abdomen
• Nausea, vomiting
• Loss of appetite (anorexia)
• Weakness, fatigue
• Fever
• Altered behaviour / confusion (encephalopathy)
• Itching (pruritus — cholestatic)
• Dark urine / clay-coloured stools
• Haematemesis / melaena (variceal bleed)
• Weight loss

---

2. HISTORY OF PRESENTING ILLNESS (HOPI)

For each complaint ask: SOCRATES

---

A. JAUNDICE (if present)

• Sudden vs gradual
• Duration

• Colour of urine: dark (bilirubinuria = obstructive/hepatocellular) vs normal
• Colour of stools: clay/pale (obstructive) vs normal/dark
• Itching (pruritus) — prominent in obstructive/cholestatic jaundice

• Fever + rigors before jaundice → Charcot's triad = cholangitis (fever + jaundice + RUQ pain)
• Painless progressive jaundice → carcinoma head of pancreas
• Jaundice + anorexia + low-grade fever → viral hepatitis
• Jaundice + abdominal pain + vomiting + alcohol → alcoholic hepatitis
• Jaundice + weight loss + anorexia → malignancy
• Jaundice that waxes and wanes → haemolytic or stone disease
• Preceded by prodrome (malaise, nausea, low-grade fever 1-2 wks before) → viral hepatitis

---

B. ASCITES / ABDOMINAL SWELLING (if present)

• Onset: sudden or gradual
• Duration
• Rate of progression: rapid (malignancy, SBP) vs slow (cirrhosis)
• Symmetrical or asymmetrical
• Associated with:
  • Pedal oedema
  • Breathlessness (diaphragm splinting, hepatic hydrothorax)
  • Decreased urine output (hepatorenal syndrome)
  • Fever + abdominal pain → spontaneous bacterial peritonitis (SBP)
  • Weight gain
• Previous tapping (paracentesis) — how many times, how much drained
• Response to diuretics

---

C. PAIN ABDOMEN (if present)

• Site: Right hypochondrium / epigastrium / generalised
• Onset: sudden (perforation, bleed) vs gradual
• Character:
  • Dull aching (hepatomegaly, capsule distension)
  • Colicky (biliary colic — comes in waves, radiates to right shoulder/back)
  • Constant severe (cholecystitis, abscess, malignancy)
• Radiation: right shoulder/scapula tip (biliary/diaphragm irritation)
• Aggravating: fatty food (biliary disease)
• Relieving: posture, antacids
• Associated: fever, nausea, vomiting, jaundice

---

D. HAEMATEMESIS / MELAENA (if present)

• Amount of blood vomited (teaspoon/cup/bowl)
• Fresh red blood vs coffee-ground
• Melaena (black tarry stools) — confirms upper GI bleed
• Haematochezia (fresh blood PR) — lower GI or massive upper GI bleed
• Associated with known portal HTN, varices, previous episodes
• Precipitated by: alcohol binge, vomiting (Mallory-Weiss if after prolonged retching)
• Haemodynamic status: giddiness, palpitations, syncope

---

E. ALTERED SENSORIUM / CONFUSION (if present)

• Onset: sudden or gradual
• Fluctuating or constant (encephalopathy fluctuates)
• Precipitants:
  • GI bleed
  • Infection
  • Constipation
  • Excess protein intake
  • Sedatives / tranquillizers
  • Electrolyte disturbance
  • Dehydration
  • Renal failure
• Previous episodes
• Sleep disturbance (reversal of sleep-wake cycle — early HE)
• Change in personality, behaviour (family members' observation)
• Fetor hepaticus noticed

---

F. FEVER (if present)

• Duration, pattern
• Rigors/chills
• Associated with jaundice → cholangitis
• Associated with ascites → SBP
• Associated with tender hepatomegaly → amoebic/pyogenic liver abscess
• Evening rise of temperature → TB (also causes hepatomegaly)

---

G. PRURITUS (if present)

• Duration, generalised or localised
• Worse at night
• Relieved by scratching or not
• Suggests cholestatic jaundice (PBC, PSC, obstructive)
• Scratch marks on skin

---

H. WEIGHT LOSS & ANOREXIA

• Amount of weight lost (in kg) over what period
• Anorexia: specific aversion to fat (cholecystitis), meat (hepatitis), alcohol
• Associated fatigue
• Malignancy: rapid weight loss + anorexia + jaundice = red flags

---

3. PAST HISTORY

• Previous episodes of jaundice
• Previous liver disease / hepatitis (type A, B, C, E)
• Previous abdominal surgeries (cholecystectomy, splenectomy, hepatectomy, Whipple's)
• Blood transfusions (risk for HBV, HCV)
• Diabetes mellitus (NAFLD)
• Hypertension
• Tuberculosis (hepatic TB, anti-TB drug hepatotoxicity — RIPE drugs)
• Malaria (hepatomegaly, Blackwater fever)
• Sickle cell disease / haemolytic anaemia
• Known cardiac disease (right heart failure → congestive hepatomegaly)
• Wilson's disease / haemochromatosis (hereditary)
• Autoimmune disorders (AIH, PBC)
• Previous hospital admissions and treatment

---

4. DRUG HISTORY

• Always ask about herbal/traditional medicines (common in India, often not volunteered)
• Duration of drug use

---

5. PERSONAL HISTORY

Alcohol History (CAGE Questionnaire + Quantification)

• Have you ever felt you should Cut down on drinking?
• Have people Annoyed you by criticising your drinking?
• Have you ever felt Guilty about your drinking?
• Have you ever had a drink first thing in the morning (Eye-opener)?

2 or more YES = significant alcohol use disorder

• Type of alcohol consumed (country liquor, beer, wine, spirits)
• Amount per day (standard units): 1 unit = 10 mL pure alcohol
• Duration (in years)
• Daily vs binge drinking
• Last drink consumed (important for withdrawal risk)
• Hepatotoxic threshold: >80 g/day in men, >40 g/day in women for >5 years

---

Smoking / Tobacco

• Smoking (number of pack-years) — risk for malignancy
• Tobacco chewing

---

Diet History

• Vegetarian or non-vegetarian
• Fat intake (biliary disease)
• Protein intake (relevant in encephalopathy)
• Contaminated water / street food (Hepatitis A, E — faeco-oral)
• Raw shellfish consumption (Hepatitis A, E)
• Malnutrition

---

Sexual History (sensitively)

• Multiple sexual partners (risk for HBV, HCV, HIV)
• Commercial sex worker contact
• Homosexual behaviour (HBV risk)

---

IV Drug Use

• Intravenous drug abuse (major risk factor for HBV, HCV, HIV)
• Needle sharing

---

Occupation

• Healthcare worker (needle-stick injury, HBV/HCV risk)
• Exposure to chemicals/solvents (carbon tetrachloride, vinyl chloride = hepatotoxic)
• Farmer (Weil's disease/leptospirosis)
• Travel history (endemic areas for Hepatitis A/E, malaria, schistosomiasis, echinococcus)

---

Tattooing / Body Piercing / Ear Piercing

• HBV and HCV transmission risk

---

Menstrual History (in females)

• Last menstrual period (rule out pregnancy — AFLP, hyperemesis)
• OCP use (cholestasis, hepatic adenoma, Budd-Chiari syndrome)

---

6. FAMILY HISTORY

• Similar illness in family members:
  • Jaundice in siblings/parents (viral hepatitis clusters — Hep A/E outbreaks)
  • Haemolytic anaemia, sickle cell, thalassaemia
• Wilson's disease (autosomal recessive)
• Haemochromatosis (autosomal recessive)
• Alpha-1 antitrypsin deficiency (autosomal codominant)
• Hepatocellular carcinoma in family (HBV-related vertical transmission)
• Gilbert's syndrome (benign familial jaundice)

---

7. SOCIOECONOMIC HISTORY

• Socioeconomic status (lower = risk for Hep A/E, malnutrition, alcoholism)
• Housing — overcrowding (Hep A/E)
• Sanitation and clean water access
• Financial impact of illness
• Social support system (important for counselling in chronic disease)

---

8. IMMUNISATION HISTORY

• Hepatitis B vaccination status (3 doses)
• Hepatitis A vaccination
• Important for healthcare workers and contacts

---

CLOSING THE HISTORY

"Thank you for answering my questions. Is there anything else you would like to tell me that you think is important?"

• General examination
• Systemic examination (GI — as above)

---

QUICK POINTER TABLE — History Clues to Diagnosis

History Taking — Liver Pathology

(20-minute exam version)

---

BIODATA

---

CHIEF COMPLAINTS (with duration)

• Jaundice / Yellow eyes
• Abdominal swelling
• Pedal oedema
• RUQ pain
• Nausea, vomiting, anorexia
• Fever
• Dark urine / pale stools
• Haematemesis / melaena
• Confusion / altered behaviour
• Pruritus, weight loss, fatigue

---

HOPI

Jaundice

• Onset, duration, progressive or fluctuating
• Urine: dark | Stool: clay-coloured → obstructive
• Pruritus → cholestatic
• Fever + RUQ pain + jaundice → Charcot's triad (cholangitis)
• Painless + progressive + elderly → Ca pancreas
• Prodrome + contaminated water → viral hepatitis
• Alcohol + vomiting → alcoholic hepatitis

Ascites

• Onset, rate of progression
• Breathlessness, decreased urine output
• Fever + abdominal pain → SBP
• Previous tapping — how many times

Pain Abdomen

• Site, character (colicky = biliary; dull = capsule distension)
• Radiation to right shoulder (biliary)
• Aggravated by fatty food

Haematemesis

• Amount, fresh red vs coffee-ground
• Melaena present or not
• Giddiness / syncope (haemodynamic instability)

Confusion

• Fluctuating → hepatic encephalopathy
• Precipitants: GI bleed / infection / constipation / sedatives / electrolyte imbalance
• Sleep reversal (early sign)

---

PAST HISTORY

• Previous jaundice / hepatitis / liver disease
• Blood transfusions
• Abdominal surgeries
• DM (NAFLD), TB (drug hepatotoxicity), cardiac disease (congestive hepatomegaly)
• Malaria, sickle cell, haemolytic anaemia

---

DRUG HISTORY (hepatotoxic drugs)

• Anti-TB — INH, Rifampicin, PZA ← most important
• Herbal/Ayurvedic ← ask specifically
• NSAIDs (paracetamol overdose)
• Statins, Amiodarone, OCP
• Methotrexate, Valproate

---

PERSONAL HISTORY

• Cut down? | Annoyed? | Guilty? | Eye-opener? (≥2 = significant)
• Amount/day, duration, last drink
• Threshold: >80 g/day men, >40 g/day women for >5 yrs

• IV drug use / needle sharing
• Multiple sexual partners
• Blood transfusion / tattooing / piercing
• Healthcare worker (needle-stick)

---

FAMILY HISTORY

• Similar jaundice (Hep A/E outbreaks, Gilbert's)
• Wilson's disease / Haemochromatosis / α1-AT deficiency (AR inheritance)
• HBV (vertical transmission → HCC in family)

---

SOCIOECONOMIC HISTORY

• Overcrowding, poor sanitation → Hep A/E
• Financial status, social support

---

IMMUNISATION

• Hepatitis B — 3 doses given or not
• Hepatitis A

---

QUICK CLUE TABLE

---

End with: "To complete history I would ask about review of systems and then proceed to general and systemic examination."

History Taking — Respiratory Case

MBBS Final Year Practical Exam

---

BIODATA

---

CHIEF COMPLAINTS (in patient's words, with duration)

• Cough
• Breathlessness / Dyspnoea
• Chest pain
• Haemoptysis
• Fever
• Wheezing
• Hoarseness of voice
• Weight loss / Anorexia
• Swelling of face / neck
• Noisy breathing (stridor)

---

HOPI

1. COUGH

• Onset: Sudden vs gradual
• Duration: Acute (<3 wks) | Subacute (3-8 wks) | Chronic (>8 wks)
• Character:
  • Dry / non-productive → ILD, early LVF, ACE inhibitor, pleural effusion
  • Productive → bronchiectasis, COPD, lung abscess, TB
  • Brassy/loud → tracheal compression, laryngeal
  • Barking → croup (children), epiglottitis
  • Bovine (no explosive phase) → RLN palsy
  • Whooping → pertussis
• Timing:
  • Morning → bronchiectasis, COPD (daily morning mucopurulent)
  • Night → asthma, LVF, GORD
  • On lying down (orthopnoeic cough) → LVF, bronchiectasis
  • Positional (one side) → lung abscess, bronchiectasis
• Sputum (if productive):
  • Amount per day (bronchiectasis: copious, >200 mL/day)
  • Colour: white/clear (viral, asthma) | yellow/green (bacterial) | rust-coloured (pneumococcal pneumonia) | currant jelly (Klebsiella) | pink frothy (pulmonary oedema) | black (coal miners) | anchovy sauce (amoebic abscess)
  • Smell: foul/offensive → lung abscess, bronchiectasis
  • Three-layer sputum on standing → bronchiectasis
  • Blood in sputum → see haemoptysis

---

2. BREATHLESSNESS / DYSPNOEA

• Onset: Sudden vs gradual
• Grading (MRC scale):

• Character:
  • Episodic + wheezing → asthma
  • Progressive + chronic smoker → COPD
  • Sudden onset → pneumothorax, PE, acute asthma
  • Orthopnoea (flat position) → LVF, severe asthma
  • PND (wakes from sleep) → LVF, asthma (3 AM dip)
  • Platypnoea (worse on sitting up, better lying) → hepatopulmonary syndrome, ASD
  • Trepopnoea (worse on one side) → pleural effusion, unilateral lung pathology
• Diurnal variation: Worse in morning → COPD | Worse at night → asthma
• Precipitants: Exercise | Allergens | Dust | Cold air | Fumes | NSAIDs (aspirin-sensitive asthma) | Beta-blockers

---

3. CHEST PAIN

• Site: Localised vs diffuse
• Onset: Sudden (pneumothorax, PE) vs gradual
• Character:
  • Sharp, stabbing, worse on breathing/coughing → pleuritic (pleuritis, pneumonia, PE, pneumothorax)
  • Dull aching, constant → malignancy, mediastinal
  • Central crushing → cardiac (distinguish from respiratory)
  • Burning retrosternal → GORD
• Radiation: To shoulder (diaphragmatic pleuritis) | To arm/jaw (cardiac)
• Aggravating: Deep breathing, coughing, movement → pleuritic
• Relieving: Leaning forward → pericarditis / pericardial effusion

---

4. HAEMOPTYSIS

• Onset, duration, episodes
• Amount: Streaky | Cupful | Frank (>200 mL/24h = massive haemoptysis)
• Colour: Bright red (fresh) | Dark (old) | Pink frothy (pulmonary oedema — not true haemoptysis)
• Mixed with sputum or pure blood
• Associated with:
  • Cough + weight loss + evening fever → TB ← most common cause in India
  • Recurrent + copious sputum → bronchiectasis
  • Elderly + smoker + weight loss → lung carcinoma
  • Young + mitral stenosis → MS with pulmonary HTN
  • Sudden onset + pleuritic pain + risk factors → pulmonary embolism
  • Rusty sputum + fever + pleurisy → pneumococcal pneumonia
• Rule out: Haematemesis (mixed with food, pH acidic, melaena) | Epistaxis (blood from nasopharynx)

---

5. FEVER

• Duration, pattern
• Evening rise + night sweats + weight loss → TB (classic)
• High fever + rigors + rust-coloured sputum → pneumonia
• Low-grade + chronic cough → TB, malignancy
• Fever + pleuritic pain → pleuritis, empyema
• Recurrent fever + purulent sputum → bronchiectasis, lung abscess

---

6. WHEEZE

• Onset, episodic or continuous
• Precipitants: allergens, exercise, cold, fumes, drugs
• Relieved by bronchodilators → asthma
• Persistent unilateral wheeze (monophonic) → foreign body, tumour (fixed obstruction)
• Polyphonic diffuse wheeze → asthma, COPD
• Inspiratory stridor → upper airway obstruction (larynx, trachea)

---

PAST HISTORY

• Previous similar episodes (asthma — recurrent from childhood)
• Previous TB and treatment taken (duration, compliance, DOT)
• Previous hospitalisation / ICU admission for breathing difficulty
• Childhood respiratory illness (recurrent LRTI → bronchiectasis)
• Tuberculin test / Mantoux done previously
• Allergic disorders — eczema, allergic rhinitis, urticaria (atopic triad with asthma)
• Cardiac disease (LVF → pulmonary oedema, cardiac asthma)
• Malignancy elsewhere (lung mets)
• Surgery / immobilisation / long travel (DVT → PE)
• HIV status (TB, PCP, fungal infections)
• Diabetes (TB, mucormycosis, susceptibility to infection)

---

DRUG HISTORY

• Current inhalers — SABA, LABA, ICS, LAMA (type and frequency)
• Oral steroids — current / previous use
• Nebuliser use at home

---

PERSONAL HISTORY

Smoking (most important in respiratory history)

• Quantify in pack-years:

  Pack-years = (cigarettes per day ÷ 20) × years smoked

• Type: cigarettes | bidi | hookah | pipe
• Age started, duration
• Current smoker or ex-smoker (if stopped — when and why)
• >10 pack-years → significant risk for COPD, lung Ca
• Passive smoking — household exposure

Occupation (very important — always ask)

• Duration of occupational exposure
• Use of protective equipment (mask)

Residence / Environment

• Urban (pollution → COPD, asthma) vs rural
• Indoor cooking with biomass fuel / wood fire / cowdung cakes → COPD in women (common in India)
• Animal exposure at home (dog, cat, bird → allergic asthma, HP)
• Overcrowding → TB transmission
• Damp housing → mould → asthma

Diet

• Nutritional status (TB — malnourished)
• Alcohol (aspiration pneumonia, TB risk)

Travel history

• Endemic areas for TB, histoplasmosis, coccidioidomycosis
• Long-haul flights (PE risk)

Sexual history

• HIV risk (TB, PCP, CMV pneumonitis)

---

FAMILY HISTORY

• TB in household contacts (close contact = high risk)
• Asthma (strong genetic predisposition)
• Atopy — eczema, allergic rhinitis, food allergy in family
• Cystic fibrosis (AR — recurrent chest infections from childhood)
• Alpha-1 antitrypsin deficiency (AR — early onset emphysema)
• Malignancy (lung cancer family history)
• ILD (familial pulmonary fibrosis)

---

SOCIOECONOMIC HISTORY

• Overcrowding, poor ventilation → TB
• Low SES → malnutrition → TB susceptibility
• Biomass fuel use (major COPD risk in Indian women)
• Financial ability for treatment and follow-up
• Compliance with previous treatment (TB — very important)

---

IMMUNISATION HISTORY

• BCG vaccination (scar present or not) — TB
• Influenza vaccine (annually for COPD, elderly, immunocompromised)
• Pneumococcal vaccine (COPD, elderly, asplenic)
• COVID-19 vaccination

---

REVIEW OF SYSTEMS (quickly)

• CVS: ankle swelling, palpitations (cor pulmonale, PE)
• GIT: heartburn, regurgitation (GORD → chronic cough, aspiration)
• Neurology: any weakness (neuromuscular → respiratory failure)
• ENT: nasal discharge, post-nasal drip, sinusitis (upper airway → chronic cough)

---

CLOSING

"Thank you. Is there anything else you would like to tell me? I will now proceed to general and systemic examination."

---

QUICK CLUE TABLE

History Taking — Respiratory Case

MBBS Final Year Practical (Short Version)

---

BIODATA

---

CHIEF COMPLAINTS (with duration)

• Cough | Breathlessness | Chest pain | Haemoptysis
• Fever | Wheeze | Weight loss | Hoarseness

---

HOPI

1. COUGH

• Onset: Sudden vs gradual | Duration: Acute <3wks | Subacute 3-8wks | Chronic >8wks
• Character:
  • Dry → ILD, LVF, ACE inhibitor
  • Productive → COPD, bronchiectasis, TB, lung abscess
  • Bovine (no explosive phase) → RLN palsy
  • Barking → croup | Brassy → tracheal compression
• Timing:
  • Morning → COPD, bronchiectasis
  • Night → asthma, LVF
  • Positional → lung abscess, bronchiectasis
• Sputum:
  • Amount (>200 mL/day → bronchiectasis)
  • Colour: white/clear (viral) | yellow-green (bacterial) | rust (pneumococcal) | currant jelly (Klebsiella) | pink frothy (pulmonary oedema) | anchovy sauce (amoebic abscess) | foul smelling (abscess, bronchiectasis)
  • Three-layer on standing → bronchiectasis

---

2. BREATHLESSNESS

• Onset: Sudden (pneumothorax, PE) vs gradual (COPD, ILD)
• MRC Grading:

• Type:
  • Episodic + wheeze → asthma
  • Progressive + smoker → COPD
  • Sudden → pneumothorax, PE
  • Orthopnoea / PND → LVF
  • Platypnoea (worse sitting up) → hepatopulmonary syndrome
  • Trepopnoea (worse one side) → pleural effusion
• Precipitants: Allergens | Cold air | Exercise | Dust | NSAIDs | Beta-blockers
• Diurnal variation: Morning worse → COPD | Night worse → asthma

---

3. CHEST PAIN

• Pleuritic (sharp, worse on breathing/coughing) → pneumonia, PE, pleuritis, pneumothorax
• Dull/constant → malignancy, mediastinal
• Central crushing → cardiac (rule out)
• Radiation to shoulder → diaphragmatic pleuritis
• Relieved leaning forward → pericarditis

---

4. HAEMOPTYSIS

• Amount: streaky | cupful | massive (>200 mL/24h)
• Cough + weight loss + evening fever → TB ← most common in India
• Recurrent + copious sputum → bronchiectasis
• Elderly + smoker + weight loss → lung carcinoma
• Young + mitral stenosis → MS
• Sudden + pleuritic pain → PE
• Rusty sputum + fever → pneumococcal pneumonia
• Rule out: haematemesis, epistaxis

---

5. FEVER

• Evening rise + night sweats + weight loss → TB
• High fever + rigors + rust sputum → pneumonia
• Recurrent + purulent sputum → bronchiectasis / lung abscess
• Fever + pleuritic pain → empyema / pleuritis

---

6. WHEEZE

• Episodic + relieved by bronchodilator → asthma
• Monophonic unilateral → foreign body / tumour
• Polyphonic diffuse → asthma / COPD
• Inspiratory stridor → upper airway obstruction

---

PAST HISTORY

• Previous similar episodes / hospitalisation / ICU admission
• Previous TB — treatment taken, duration, compliance, DOT
• Atopic triad: asthma + eczema + allergic rhinitis
• Cardiac disease (LVF) | HIV/DM (TB susceptibility)
• Surgery / immobilisation / long travel → PE risk
• Childhood recurrent LRTI → bronchiectasis

---

DRUG HISTORY

• Inhalers (type, frequency, compliance, technique)
• Oral steroids — current/previous

---

PERSONAL HISTORY

• Pack-years = (cigarettes/day ÷ 20) × years smoked
• Type: cigarette / bidi / hookah | Active or ex-smoker
• Passive smoking at home

• Biomass fuel / wood fire / cowdung cooking → COPD in women (very common India)
• Overcrowding + poor ventilation → TB
• Pet/animal exposure → allergic asthma, HP

---

FAMILY HISTORY

• TB in household contacts
• Asthma / atopy
• Cystic fibrosis (AR — recurrent childhood infections)
• Alpha-1 antitrypsin deficiency (early emphysema)
• Lung malignancy

---

SOCIOECONOMIC HISTORY

• Overcrowding + poor ventilation → TB
• Biomass fuel use
• Treatment compliance (TB)

---

IMMUNISATION

• BCG scar present or not
• Influenza / Pneumococcal / COVID vaccines

---

QUICK CLUE TABLE

---

"To complete my history I will review other systems and proceed to general and respiratory examination."

Respiratory Examination

MBBS Final Year Practical Exam

---

1. GENERAL EXAMINATION

• Built, nourishment, BMI
• Breathlessness at rest — count RR, use of accessory muscles
• Cyanosis — central (tongue, lips) vs peripheral (fingertips)
• Clubbing — grades I-V
  • Causes: bronchiectasis, lung abscess, empyema, ILD, lung Ca, mesothelioma, cystic fibrosis
• Pallor (anaemia → dyspnoea)
• Icterus (pneumonia — haemolysis | liver-lung disease)
• Lymphadenopathy — cervical, supraclavicular (TB, malignancy)
• Pedal oedema (cor pulmonale — right heart failure due to lung disease)
• Hoarseness (RLN palsy — lung Ca, mediastinal mass)
• Fever (infectious cause)

---

2. HANDS

• Clubbing (grade and describe)
• Cyanosis (peripheral)
• Nicotine staining (smoker — yellow-brown staining of fingers)
• Fine tremor (CO₂ retention / salbutamol excess)
• Flapping tremor (asterixis) — CO₂ narcosis / type 2 respiratory failure
• Wasting of small muscles (Pancoast tumour → T1 root compression)
• Tar staining of fingers
• Pulse: tachycardia (infection, PE, cor pulmonale) | Pulsus paradoxus (severe asthma, cardiac tamponade — fall in SBP >10 mmHg on inspiration)

---

3. FACE & NECK

• Central cyanosis — lips, tongue, buccal mucosa
• Conjunctival pallor
• Plethoric face — polycythaemia (COPD)
• Pursed lip breathing — COPD (auto-PEEP to prevent airway collapse)
• Nasal flaring — respiratory distress
• Tracheal position — central / deviated (examine from front)
  • Deviated AWAY from lesion: pleural effusion, pneumothorax (tension)
  • Deviated TOWARD lesion: collapse, fibrosis, pneumonectomy
• JVP — raised in cor pulmonale, SVC obstruction
• SVC obstruction signs: Facial puffiness, engorged neck veins non-pulsatile, chemosis, dilated chest wall veins (blood flows downward) — lung Ca / mediastinal mass
• Cervical / supraclavicular lymph nodes — TB, malignancy
• Horner's syndrome (ptosis + miosis + anhidrosis + enophthalmos) — Pancoast tumour (apex lung Ca)
• Pemberton's sign — raise both arms above head → facial flushing + JVP rise + stridor = retrosternal goitre / superior mediastinal mass

---

4. CHEST EXAMINATION

Patient position: Sitting upright, chest fully exposed, arms relaxed

---

A. INSPECTION

• Symmetrical or asymmetrical
• Reduced on one side → pathology on that side
• Overall reduced → COPD, bilateral fibrosis

• Sternocleidomastoid, scalene → severe COPD, asthma
• Intercostal recession → airway obstruction, stiff lungs

• Normal: 12-18/min
• Tachypnoea (>20) → infection, PE, acidosis
• Bradypnoea (<12) → opioids, raised ICP

• Pursed lip (COPD)
• Kussmaul (deep, rapid — metabolic acidosis)
• Cheyne-Stokes (waxing-waning — LVF, raised ICP)
• Paradoxical breathing (abdomen goes in on inspiration) → diaphragm palsy

• Scars: thoracotomy, VATS ports, chest drain site, mastectomy
• Prominent veins on chest wall (SVC obstruction — downward flow)
• Visible pulsation (aortic aneurysm)
• Subcutaneous emphysema (surgical emphysema — crepitus on palpation)

---

B. PALPATION

• Central or deviated — use index finger in sternal notch
• Tracheal tug (downward pull on inspiration) → severe airflow obstruction, aortic aneurysm

• Place hands on front of chest / back, thumbs meeting at midline
• Ask to take deep breath
• Thumbs should move equally 3-5 cm apart
• Reduced unilaterally → effusion, pneumothorax, collapse, consolidation, fibrosis on THAT side
• Reduced bilaterally → COPD, bilateral fibrosis, bilateral effusion

• Normally 5th ICS, MCL
• Displaced (mediastinal shift)

• Place ulnar border of hand on chest
• Ask patient to say "99" or "one-one-one"
• Compare symmetrical areas

• Tenderness (rib fracture, pleuritis, costochondritis)
• Subcutaneous emphysema (crepitus — feels like bubble wrap)
• Lymph nodes (axillary, cervical)

---

C. PERCUSSION

• Liver dullness — right side; absent = emphysema / pneumothorax
• Cardiac dullness — left side
• Traube's space (left lower chest) — normally resonant; dull = splenomegaly / left pleural effusion
• Kronig's isthmus — band of resonance over shoulder (reduced in TB apical fibrosis)
• Grocco's triangle (paravertebral dullness on opposite side of effusion)

---

D. AUSCULTATION

• Ask patient to say "99" — auscultate
• Increased (same as TVF increased) → consolidation
• Bronchophony = loud, clear "99" over consolidation
• Whispering pectoriloquy = whispered "99" heard clearly → consolidation (most sensitive sign)
• Aegophony = "ee" sounds like "aa" (E to A change) → consolidation, top of effusion
• Decreased/absent → effusion, pneumothorax

---

5. CLINICAL PATTERNS — EXAM FAVOURITE

---

6. BACK OF CHEST

• Repeat inspection, expansion, percussion, auscultation
• Costophrenic angles percuss — dull = effusion
• Interscapular region (TB, bronchial breathing upper zones)
• Sacral oedema (cor pulmonale in bedridden)

---

7. TO COMPLETE EXAMINATION

"To complete my examination I would like to:

• Check SpO₂ and peak flow rate (PEFR)
• Examine the cardiovascular system (cor pulmonale, LVF)
• Look for pedal oedema
• Check lymph nodes — cervical, axillary
• Examine the abdomen (liver — hepatomegaly in cor pulmonale)
• Perform relevant investigations: CXR, spirometry, ABG, sputum AFB, CT thorax, bronchoscopy"

---

QUICK SIGNS SUMMARY

History Taking — CVS Case

MBBS Final Year Practical Exam

---

BIODATA

---

CHIEF COMPLAINTS (in patient's words, with duration)

• Chest pain / discomfort
• Breathlessness / Dyspnoea
• Palpitations
• Swelling of feet / legs
• Syncope / fainting
• Fatigue / easy fatigability
• Cough (cardiac)
• Cyanosis
• Fever (rheumatic / infective endocarditis)
• Joint pains (rheumatic fever)

---

HOPI

1. CHEST PAIN

• Onset: Sudden vs gradual
• Site: Retrosternal | Left chest | Epigastric
• Character:
  • Crushing / squeezing / tightening → IHD / ACS
  • Sharp stabbing + worse on breathing → pleuritic / pericarditis
  • Tearing / ripping, radiates to back → aortic dissection
  • Burning retrosternal → GORD (mimic)
  • Positional (relieved leaning forward) → pericarditis
• Radiation:
  • Left arm / jaw / neck → IHD
  • Right shoulder → pericarditis, diaphragm
  • Back (interscapular) → aortic dissection
• Duration:
  • <20 min, relieved by rest/nitrates → stable angina

  • 20 min, not relieved by nitrates → ACS / NSTEMI / STEMI

  • Seconds only → musculoskeletal / functional
• Aggravating:
  • Exertion → angina
  • Cold, emotional stress → angina
  • Inspiration → pleuritis, pericarditis
  • Lying flat → pericarditis (worse), GORD
• Relieving:
  • Rest + nitrates → angina
  • Leaning forward → pericarditis
  • Antacids → GORD
• Associated:
  • Sweating, nausea, vomiting → ACS
  • Palpitations + syncope → arrhythmia
  • Fever + new murmur → infective endocarditis
• Grading (CCS Angina):

---

2. BREATHLESSNESS / DYSPNOEA

• Onset: Sudden vs gradual
• NYHA Grading:

• Type:
  • Orthopnoea — breathless on lying flat, relieved sitting up; number of pillows used → LVF
  • PND (wakes from sleep, 1-2 hrs after sleeping, relieved sitting/standing) → LVF
  • Cardiac asthma (wheeze at night) → LVF
  • Sudden onset + pleuritic pain → PE (DVT, AF, post-surgery)
  • Progressive + exertional → CHF, valvular disease
• Precipitants: Exertion | Lying flat | Emotional stress
• Associated: Ankle swelling, cough with pink frothy sputum (acute pulmonary oedema)

---

3. PALPITATIONS

• Onset: Sudden or gradual
• Character:
  • Fast and regular → SVT, sinus tachycardia
  • Fast and irregular → AF ← most common
  • Slow and regular → complete heart block
  • Missed beats / extra beats → ectopics (PAC, PVC)
  • Pounding (awareness of heartbeat) → anaemia, anxiety, hyperthyroidism
• Onset and offset:
  • Sudden onset AND sudden offset → SVT (paroxysmal)
  • Gradual onset → sinus tachycardia, anaemia
• Duration: Seconds / minutes / hours / days
• Precipitants: Exercise | Caffeine | Alcohol | Stress | Thyroid drugs
• Associated:
  • Syncope / pre-syncope → VT, complete heart block, severe AS
  • Chest pain → ACS, SVT
  • Polyuria after episode → SVT (ANP release)
• Termination: Spontaneous | Valsalva | Required cardioversion

---

4. SYNCOPE / PRE-SYNCOPE

• Definition: Transient loss of consciousness due to global cerebral hypoperfusion
• Onset: Sudden (cardiac) vs preceded by prodrome (vasovagal)
• Precipitants:
  • Prolonged standing, hot environment, emotional stress, pain → vasovagal (most common)
  • On exertion → AS, HOCM, pulmonary HTN ← dangerous, always ask
  • On neck turning / tight collar → carotid sinus hypersensitivity
  • On urination / coughing / defaecation → situational syncope
  • Lying to standing → orthostatic hypotension
• Warning (prodrome):
  • Nausea, sweating, yawning, blurring before → vasovagal
  • No warning, sudden → cardiac (arrhythmia, AS)
• Duration of unconsciousness
• Recovery: Rapid (cardiac, vasovagal) vs prolonged (seizure — mimic)
• During episode: Injury, tongue bite, incontinence → seizure mimic
• Associated palpitations → arrhythmia

---

5. PEDAL OEDEMA

• Onset: Sudden vs gradual
• Bilateral vs unilateral (bilateral → cardiac/systemic; unilateral → DVT, lymphatic)
• Pitting vs non-pitting (pitting → cardiac, renal, hepatic; non-pitting → lymphoedema, myxoedema)
• Level: Ankle only | Up to knee | Up to thigh | Sacral (bedridden)
• Diurnal variation: Worse in evening, better in morning → cardiac oedema (gravity-dependent)
• Associated:
  • Breathlessness + orthopnoea → CCF
  • Ascites + jaundice → hepatic
  • Facial puffiness in morning → renal
  • JVP raised → cardiac / SVC obstruction
• Response to diuretics

---

6. FEVER / JOINT PAINS

• Age of onset (typically 5-15 years)
• Preceding sore throat / pharyngitis (2-4 weeks before) — Group A Streptococcus
• Joint involvement:
  • Migratory polyarthritis — large joints (knees, ankles, elbows, wrists)
  • Duration in each joint (days), complete resolution
• Fever: High grade, during acute phase
• Carditis: Breathlessness, palpitations, chest pain during acute episode
• Chorea (Sydenham's): Involuntary movements, emotional lability, in girls
• Skin: Erythema marginatum | Subcutaneous nodules
• Recurrent attacks → each attack damages valves further
• Treatment taken → Penicillin prophylaxis on or not
• Resulting valve lesion: MS most common → MR → AR → AS (in rheumatic heart disease)

---

7. COUGH (Cardiac)

• Dry, irritating, worse at night / lying flat → LVF
• Pink frothy sputum → acute pulmonary oedema
• Haemoptysis → MS (pulmonary HTN + pulmonary venous hypertension)

---

PAST HISTORY

• Previous episodes of chest pain / MI / angioplasty / CABG / stenting
• Previous rheumatic fever / joint pains / sore throats in childhood
• Known valvular heart disease / murmur detected before
• Previous infective endocarditis
• Hypertension (duration, treatment, control)
• Diabetes mellitus (major CVS risk factor)
• Dyslipidaemia / hypercholesterolaemia
• Previous stroke / TIA (thromboembolic — AF, valve disease)
• CKD (hypertension, CVD risk, uremic pericarditis)
• Thyroid disease (AF, cardiac failure, pericardial effusion)
• Congenital heart disease (childhood cyanosis, murmur since birth)
• Previous cardiac surgery / pacemaker / ICD / cardiac catheterisation

---

DRUG HISTORY

• Compliance with current medications
• Any recent changes in medications

---

PERSONAL HISTORY

Smoking

• Pack-years = (cigarettes/day ÷ 20) × years smoked
• Type: cigarette / bidi / hookah
• Current / ex-smoker (when stopped)
• Major independent risk factor for IHD

Alcohol

• Amount per day, duration
• Heavy alcohol → dilated cardiomyopathy, AF (holiday heart syndrome)
• Moderate → protective (HDL rise)

Diet

• High fat / salt diet (hypertension, dyslipidaemia)
• Dietary compliance in known HTN / DM / dyslipidaemia

Physical Activity

• Sedentary lifestyle → IHD risk
• Exercise-induced symptoms (angina, syncope → AS, HOCM)

Occupation

• Sedentary (IHD risk)
• High stress job
• Shift work (hypertension risk)
• Occupation that requires fitness clearance (pilot, driver — arrhythmia, syncope)

Sexual history

• HIV → cardiomyopathy, pericarditis, pulmonary HTN
• Syphilis → aortitis, AR, coronary ostial stenosis

---

FAMILY HISTORY

• IHD / MI — father <55 yrs, mother <65 yrs = premature family history (strong risk factor)
• Hypertension (familial tendency)
• Diabetes (familial)
• Sudden cardiac death in young family member → HOCM, long QT, Brugada, arrhythmogenic CMP
• Rheumatic heart disease in siblings
• Congenital heart disease (some familial — Marfan's, HOCM, bicuspid aortic valve)
• Dyslipidaemia — familial hypercholesterolaemia (xanthomas, premature IHD)
• Marfan's syndrome (AR aortic dilatation, AR, MVP, aortic dissection)

---

SOCIOECONOMIC HISTORY

• Low SES → rheumatic fever (overcrowding, poor sanitation, inadequate treatment)
• Penicillin prophylaxis affordability and compliance
• Dietary habits (high salt, fat)
• Stress and lifestyle
• Treatment compliance and follow-up

---

IMMUNISATION

• No direct cardiac vaccine but:
• Influenza + pneumococcal vaccines recommended in CCF / valvular disease patients

---

QUICK CLUE TABLE

---

"To complete my history I will review other systems and proceed to general and cardiovascular examination."

CVS Examination

MBBS Final Year Practical Exam

---

1. GENERAL EXAMINATION

• Built, nourishment, BMI
• Dyspnoea at rest — note RR, use of accessory muscles
• Cyanosis — central (lips, tongue) vs peripheral (fingertips)
  • Central from birth → congenital cyanotic HD
  • Central acquired → Eisenmenger's, severe LVF
• Clubbing — grades I-V
  • Causes: cyanotic CHD (TOF, TGA), infective endocarditis, rarely in CCF
• Pallor (anaemia → high output CCF; worsens existing CCF)
• Icterus (chronic CCF → hepatic congestion → jaundice)
• Oedema — bilateral pitting pedal oedema (CCF, cor pulmonale)
• Lymphadenopathy (infective endocarditis, rheumatic fever rarely)
• Fever (rheumatic fever, infective endocarditis)
• Built: Tall + long limbs + high arched palate → Marfan's (AR, MVP, aortic dissection)
• Short stature + webbed neck + wide carrying angle → Turner's (bicuspid aortic valve, coarctation)
• Down syndrome features → ASD, VSD, AVSD

---

2. HANDS

• Clubbing (grade and describe)
• Peripheral cyanosis (fingertips, nail beds)
• Splinter haemorrhages (linear, subungual) → infective endocarditis (also trauma)
• Osler's nodes (tender, red-purple nodules on finger pulps) → infective endocarditis (immune complex)
• Janeway lesions (non-tender, erythematous macules on palms/soles) → infective endocarditis (septic emboli)
• Koilonychia (anaemia → high output CCF)
• Xanthomata (tendon xanthomata on extensor tendons) → familial hypercholesterolaemia → IHD
• Nicotine staining (smoker → IHD risk)
• Arachnodactyly (long spider fingers → Marfan's)
• Pulse (detailed — see below)

---

3. PULSE (Extremely Important in CVS)

Examine radial pulse first, then brachial, then carotid

• Normal: 60-100/min
• Tachycardia >100 → CCF, AF, fever, anaemia, PE, hyperthyroidism
• Bradycardia <60 → complete heart block, beta-blockers, hypothyroidism, sick sinus

• Regular
• Regularly irregular → 2nd degree heart block (Mobitz I/II), bigeminy
• Irregularly irregular → AF ← most common cause

• High volume (bounding) → AR, hyperthyroidism, CO₂ retention, anaemia, PDA, AV fistula, pregnancy
• Low volume → AS, CCF, shock, tamponade, constrictive pericarditis
• Absent → peripheral arterial occlusion

• Both radials simultaneously → radio-radio delay (subclavian stenosis, aortic coarctation, Takayasu's)
• Radial vs femoral → radio-femoral delay → coarctation of aorta

• Both arms (difference >15 mmHg → subclavian stenosis, aortic dissection, Takayasu's)
• Postural drop (>20 mmHg systolic on standing) → orthostatic hypotension
• Pulse pressure:
  • Wide (>60 mmHg) → AR, PDA, hyperthyroidism
  • Narrow (<30 mmHg) → AS, cardiac tamponade, CCF

---

4. FACE & NECK

Face

• Malar flush (mitral facies) — bilateral dusky red discolouration of cheeks → severe MS (low CO + pulmonary HTN)
• Central cyanosis — lips, tongue, buccal mucosa
• Corneal arcus (white ring around cornea in young <40 yrs) → hypercholesterolaemia
• Xanthelasma (yellow plaques on eyelids) → hypercholesterolaemia → IHD
• High arched palate → Marfan's
• Low set ears, hypertelorism → congenital syndromes
• Pallor of conjunctiva

Neck — JVP (Very Important)

• Seen in right internal jugular vein (between heads of SCM)
• Fills from below (venous), not palpable, obliterated by pressure, varies with respiration (falls on inspiration)
• Normal level: <4 cm above sternal angle (= <9 cm above right atrium)

• Right heart failure (CCF, cor pulmonale)
• Cardiac tamponade
• Constrictive pericarditis
• SVC obstruction (non-pulsatile, no waveforms)
• Fluid overload
• TR, TS, PS

• Kussmaul's sign — JVP rises on inspiration (normally falls) → constrictive pericarditis, RV failure, cardiac tamponade
• Hepatojugular reflux (HJR) — press RUQ abdomen for 10 sec → JVP rises and stays raised → CCF (RV cannot accommodate extra venous return)
• Abdominojugular test — same as HJR

Carotid Pulse

• Character (slow rising vs collapsing — see pulse section)
• Carotid bruit → atherosclerosis, carotid stenosis
• Never compress both carotids simultaneously

---

5. CHEST — PRECORDIAL EXAMINATION

Patient: Supine at 45°, chest fully exposed

---

A. INSPECTION

• Left-sided bulge → childhood cardiomegaly (large left-to-right shunt — VSD, PDA)
• Right-sided bulge → right ventricular enlargement

• Apex beat — normally 5th ICS, MCL; visible in thin patients, hyperdynamic states
• Parasternal heave — left lower sternal border lifts with each beat → RV enlargement
• Epigastric pulsation → RV enlargement, aortic aneurysm, normal in thin patients
• Pulsation in 2nd right ICS → aortic aneurysm, post-stenotic dilatation
• Pulsation in 2nd left ICS → dilated pulmonary artery (pulmonary HTN, ASD)

• Midline sternotomy → CABG, valve replacement, congenital repair
• Left lateral thoracotomy → mitral valvotomy (closed), PDA ligation, coarctation repair
• Right lateral thoracotomy → right-sided procedures
• Infraclavicular → pacemaker / ICD (note the device bulge)
• Groin / wrist → cardiac catheterisation / angioplasty

• Pectus excavatum → MVP, Marfan's
• Kyphoscoliosis → cor pulmonale

---

B. PALPATION

• Normally: 5th ICS, MCL (midclavicular line)
• Locate by counting ribs from angle of Louis (2nd ICS) downward
• Displacement:
  • Lateral + downward → LV enlargement (volume/pressure overload)
  • Opposite side → massive pleural effusion, tension pneumothorax
  • Same side → collapse, fibrosis
• Character:

• Place heel of right hand on left lower sternal border
• Lifting / heaving against palm → RV enlargement
• Causes: pulmonary HTN, MS (RV pressure overload), ASD, PS

• Palpable murmur (indicates grade ≥4/6 murmur)
• Systolic thrill at apex → MR, VSD
• Systolic thrill at aortic area (2nd RICS) → AS
• Systolic thrill at pulmonary area (2nd LICS) → PS, ASD
• Diastolic thrill at apex → MS (rare, best in left lateral position)
• Continuous thrill at 2nd LICS → PDA

• Palpable P2 at 2nd LICS → pulmonary HTN
• Palpable S1 at apex (tapping apex) → MS

---

C. PERCUSSION

• Less important in CVS but done to:
• Cardiac dullness — right border (right sternal edge), left border (apex)
• Enlarged cardiac dullness → cardiomegaly, pericardial effusion
• Relative vs absolute dullness:
  • Relative (deeper) → true cardiac border
  • Absolute (superficial) → area not covered by lung
• Right border → right atrium (normally just right of right sternal edge)
• Left border → left ventricle (normally at MCL 5th ICS)

---

D. AUSCULTATION (Most Important Part)

• Routine: supine 45°
• Left lateral decubitus → mitral murmurs (MS, MR) louder at apex
• Sitting forward, held expiration → AR heard best at Erb's point

---

HEART SOUNDS

• Mitral + tricuspid valve closure
• Heard best at apex
• Loud S1 → MS (valve leaflets still mobile but stiff), tachycardia, thin patient
• Soft S1 → MR (valve doesn't close properly), calcified MS, prolonged PR, LVF
• Variable S1 → AF, complete heart block

• Aortic + pulmonary valve closure (A2 + P2)
• Heard best at base
• Splitting of S2:
  • Normal (physiological) splitting — widens on inspiration (increased RV filling → P2 delayed) → narrows on expiration
  • Wide splitting → RBBB, PS, MR (A2 early)
  • Fixed splitting → ASD ← pathognomonic
  • Paradoxical splitting → LBBB, AS, HOCM (A2 delayed — splits on expiration, closes on inspiration)
• Loud A2 → systemic HTN
• Loud P2 → pulmonary HTN (MS, Eisenmenger's, primary PH)
• Soft A2 → AS (calcified, immobile valve)
• Single S2 → severe AS or PS (one component absent)

• Early diastole — rapid ventricular filling phase
• Low-pitched, heard at apex with bell
• Pathological in adults >40 yrs → LVF, dilated CMP, MR, AR, VSD
• Physiological in children, young adults, pregnancy, athletes
• Cadence: "Kentucky" (lub-dub-ta)
• Best heard: Left lateral decubitus, apex, bell of stethoscope

• Late diastole — atrial contraction against stiff ventricle
• Low-pitched, heard at apex with bell
• Always pathological
• Causes: LVH (HTN, AS, HOCM), acute MI, ischaemia
• Cadence: "Tennessee" (ta-lub-dub)
• Absent in AF (no atrial contraction)

• Scratchy, to-and-fro, 3 components (systolic loudest)
• Pericarditis
• Heard best: Erb's point, leaning forward, held expiration
• Increases with pressure of stethoscope
• Transient — disappears if effusion develops

• High-pitched, early diastole, heard at apex / lower left sternal border
• MS (pliable leaflets snap open)
• Shorter A2-OS interval → more severe MS (higher LA pressure)
• Absent OS → calcified, immobile valve (very severe MS)

• High-pitched, early systole, just after S1
• Aortic ejection click (2nd RICS) → bicuspid aortic valve, aortic stenosis
• Pulmonary ejection click (2nd LICS) → PS, dilated pulmonary artery
• Pulmonary ejection click decreases on inspiration (unique — only click that does so)

• Mid systole at apex → MVP (mitral valve prolapse)
• Followed by late systolic murmur of MR

---

MURMURS

TIME — Systolic / Diastolic / Continuous LOCATION — Where heard best RADIATION — Where it goes GRADE — 1-6 (systolic) / 1-4 (diastolic) CHARACTER — Harsh / Blowing / Rumbling / Machinery Pitch — High / Low Effect of respiration — Louder on inspiration = right-sided (Carvallo's sign); louder on expiration = left-sided Dynamic manoeuvres — Valsalva, squatting, standing

---

---

---

6. ABDOMEN (in CVS context)

• Hepatomegaly — tender, smooth, pulsatile → CCF (pulsatile in TR)
• Hepatojugular reflux — press RUQ → JVP rises → CCF
• Ascites — shifting dullness (CCF, constrictive pericarditis)
• Splenomegaly → infective endocarditis (septic emboli), congestive splenomegaly
• Pulsatile epigastric mass → aortic aneurysm
• Renal bruits → renovascular HTN

---

7. PERIPHERAL VASCULAR

• Peripheral pulses — all 12 pulses (radial, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedis — bilateral)
• Absent / diminished → peripheral arterial disease, coarctation, Takayasu's
• Radio-femoral delay → coarctation of aorta
• Ankle-brachial index (ABI) — mention
• Buerger's test → peripheral arterial insufficiency
• Varicose veins / DVT signs → PE risk

---

8. PERIPHERAL SIGNS OF SPECIFIC CONDITIONS

Infective Endocarditis

• Splinter haemorrhages
• Osler's nodes (tender, finger pulps)
• Janeway lesions (non-tender, palms/soles)
• Roth's spots (retinal haemorrhages with pale centre — fundoscopy)
• Clubbing (subacute IE)
• Splenomegaly
• Haematuria (glomerulonephritis — dipstick)

AR (Aortic Regurgitation) — Peripheral Signs

MS (Mitral Stenosis)

• Malar flush
• Tapping apex beat
• Parasternal heave (RV)
• Raised JVP (if RHF)
• AF (irregularly irregular pulse)

---

9. TO COMPLETE EXAMINATION

"To complete my examination I would like to:

• Measure blood pressure in both arms
• Examine the fund (Roth's spots in IE, hypertensive retinopathy)
• Dipstick urine (haematuria in IE, proteinuria in HTN)
• Examine all peripheral pulses
• Perform relevant investigations: ECG, Echo, CXR, CBC, LFTs, RFTs, troponin, BNP"

---

QUICK SIGNS SUMMARY