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| ==Overview== | | ==Overview== |
| Tetralogy of Fallot is associated with [[cyanosis]], [[clubbing]], a [[thrill]] and a harsh [[systolic ejection murmur]] over the left sternal border.
| | Patients with tetralogy of Fallot usually appear small due to a [[failure to thrive]]. [[Physical examination]] of [[patients]] with tetralogy of Fallot is usually remarkable for [[cyanosis]], [[systolic]] [[Palpation of the precordium|thrill]], [[systolic ejection murmur]], and [[Clubbing]]. |
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| ==Physical Examination== | | ==Physical Examination== |
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| ===Appearance of the Patient=== | | ===Appearance of the Patient=== |
| * The patient may be small due to a [[failure to thrive]]. Patients may be found in squatting position (compensatory mechanism). | | * Patients with tetralogy of Fallot usually appear small due to a [[failure to thrive]] |
| | | *Patients may be found in squatting position (compensatory mechanism) |
| ===Skin===
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| * [[Cyanosis]] may be present.
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| ===Eyes===
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| * Retinal vessels engorgement may be present.
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| ===Heart===
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| ====Palpation====
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| * A [[thrill]] may be present at left sternal border.
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| * A right ventricular impulse may be prominent.
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| ====Auscultation====
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| =====Heart Sounds=====
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| * First heart sound ([[S1]]) is normal
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| * Second heart sound ([[S2]]) is single as [[P2]] is absent.
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| =====Murmurs=====
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| * A harsh [[systolic ejection murmur]] best heard at the left sternal border is usually present. The loudness and length of [[systolic murmur]] is inversely proportional to the severity of [[right ventricular outflow tract obstruction]] ([[RVOTO]]). In other words as the RVOTO worsens, the murmur softens. The more cyanotic the patient, the softer the murmur.
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| * As the [[RVOTO]] progresses towards occlusion the right ventricular blood is diverted to left ventricle through [[ventricular septal defect]]. This causes the pulmonic murmur to become shorter and softer. [[P2]] is faint and delayed in mild [[cyanosis]] and inaudible in severe [[cyanosis]].
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| * A diastolic murmur may be heard due to [[aortic regurgitation]].
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| ===Extremities===
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| * [[Clubbing]]
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| * [[Cyanosis]] is most prominent at [[lip]]s and nail beds.
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| Physical examination of patients with [disease name] is usually normal.
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| OR
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| Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
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| OR
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| The presence of [finding(s)] on physical examination is diagnostic of [disease name].
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| OR
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| The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
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| ===Appearance of the Patient===
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| *Patients with [disease name] usually appear [general appearance].
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| ===Vital Signs=== | | ===Vital Signs=== |
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| *High-grade / low-grade fever
| | *[[Tachycardia]] with regular pulse |
| *[[Hypothermia]] / hyperthermia may be present
| | *Tachypnea |
| *[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse | |
| *[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
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| *Tachypnea / bradypnea | |
| *Kussmal respirations may be present in _____ (advanced disease state)
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| *Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
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| *High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]
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| ===Skin=== | | ===Skin=== |
| * Skin examination of patients with [disease name] is usually normal.
| | * [[Cyanosis]] may be present |
| OR
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| *[[Cyanosis]] | |
| *[[Jaundice]]
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| * [[Pallor]]
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| * Bruises
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| <gallery widths="150px">
| | ===HEENT=== |
| | | * Retinal vessels engorgement may be present |
| UploadedImage-01.jpg | Description {{dermref}}
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| UploadedImage-02.jpg | Description {{dermref}}
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| </gallery>
| | === Neck === |
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| ===HEENT===
| | * Neck examination of patients with tetralogy of Fallot is usually normal. |
| * HEENT examination of patients with [disease name] is usually normal. | |
| OR
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| * Abnormalities of the head/hair may include ___
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| * Evidence of trauma
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| * Icteric sclera
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| * [[Nystagmus]]
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| * Extra-ocular movements may be abnormal
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| *Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
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| *Ophthalmoscopic exam may be abnormal with findings of ___
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| * Hearing acuity may be reduced
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| *[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
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| *[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
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| * [[Exudate]] from the ear canal
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| * Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
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| *Inflamed nares / congested nares
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| * [[Purulent]] exudate from the nares
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| * Facial tenderness
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| * Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
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| ===Neck=== | | === Lung === |
| * Neck examination of patients with [disease name] is usually normal.
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| OR
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| *[[Jugular venous distension]]
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| *[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
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| *[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
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| *[[Thyromegaly]] / thyroid nodules
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| *[[Hepatojugular reflux]]
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| ===Lungs===
| | * Pulmonary examination of patients with tetralogy of Fallot is usually normal. |
| * Pulmonary examination of patients with [disease name] is usually normal. | |
| OR
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| * Asymmetric chest expansion OR decreased chest expansion
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| *Lungs are hyporesonant OR hyperresonant
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| *Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
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| *Rhonchi
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| *Vesicular breath sounds OR distant breath sounds
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| *Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
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| *[[Wheezing]] may be present
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| *[[Egophony]] present/absent
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| *[[Bronchophony]] present/absent
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| *Normal/reduced [[tactile fremitus]]
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| ===Heart=== | | ===Heart=== |
| * Cardiovascular examination of patients with [disease name] is usually normal.
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| OR
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| *Chest tenderness upon palpation
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| *PMI within 2 cm of the sternum (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
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| *[[Heave]] / [[thrill]]
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| *[[Friction rub]]
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| *[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
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| *[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
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| *[[Heart sounds#Third heart sound S3|S3]]
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| *[[Heart sounds#Fourth heart sound S4|S4]]
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| *[[Heart sounds#Summation Gallop|Gallops]]
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| *A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the stethoscope
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| ===Abdomen===
| | * A [[thrill]] may be present at left sternal border. |
| * Abdominal examination of patients with [disease name] is usually normal.
| | * A right ventricular impulse may be prominent. |
| OR
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| *[[Abdominal distension]] | | * First heart sound ([[S1]]) is normal |
| *[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
| | * Second heart sound ([[S2]]) is single as [[P2]] is absent. |
| *[[Rebound tenderness]] (positive Blumberg sign)
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| *A palpable abdominal mass in the right/left upper/lower abdominal quadrant | |
| *Guarding may be present
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| *[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]] | |
| *Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
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| ===Back===
| | * A harsh [[systolic ejection murmur]] best heard at the left sternal border is usually present. |
| * Back examination of patients with [disease name] is usually normal. | | *The loudness and length of [[systolic murmur]] is inversely proportional to the severity of [[right ventricular outflow tract obstruction]] ([[RVOTO]]). |
| OR
| | *In other words as the RVOTO worsens, the murmur softens. |
| *Point tenderness over __ vertebrae (e.g. L3-L4) | | *The more cyanotic the patient, the softer the murmur. |
| *Sacral edema | | * As the [[RVOTO]] progresses towards occlusion the right ventricular blood is diverted to left ventricle through [[ventricular septal defect]]. |
| *Costovertebral angle tenderness bilaterally/unilaterally | | *This causes the pulmonic murmur to become shorter and softer. |
| *Buffalo hump | | *[[P2]] is faint and delayed in mild [[cyanosis]] and inaudible in severe [[cyanosis]]. |
| | * A diastolic murmur may be heard due to [[aortic regurgitation]]. |
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| ===Genitourinary=== | | === Abdomen === |
| * Genitourinary examination of patients with [disease name] is usually normal.
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| OR
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| *A pelvic/adnexal mass may be palpated
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| *Inflamed mucosa
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| *Clear/(color), foul-smelling/odorless penile/vaginal discharge
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| ===Neuromuscular===
| | * Abdominal examination of patients with tetralogy of Fallot is usually normal. |
| * Neuromuscular examination of patients with [disease name] is usually normal. | |
| OR
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| *Patient is usually oriented to persons, place, and time
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| * Altered mental status
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| * Glasgow coma scale is ___ / 15
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| * Clonus may be present
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| * Hyperreflexia / hyporeflexia / areflexia
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| * Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
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| * Muscle rigidity
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| * Proximal/distal muscle weakness unilaterally/bilaterally
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| * ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
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| *Unilateral/bilateral upper/lower extremity weakness
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| *Unilateral/bilateral sensory loss in the upper/lower extremity
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| *Positive straight leg raise test
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| *Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
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| *Positive/negative Trendelenburg sign
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| *Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
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| *Normal finger-to-nose test / Dysmetria
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| *Absent/present dysdiadochokinesia (palm tapping test)
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| ===Extremities=== | | ===Extremities=== |
| * Extremities examination of patients with [disease name] is usually normal.
| | * [[Clubbing]] |
| OR
| | * [[Cyanosis]] is most prominent at [[lip]]s and nail beds |
| *[[Clubbing]] | | |
| *[[Cyanosis]] | | |
| *Pitting/non-pitting [[edema]] of the upper/lower extremities
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| *Muscle atrophy
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| *Fasciculations in the upper/lower extremity
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