Method of Cardiac Auscultation

Patient is asked to be in supine position or in propped up position if orthopnoea present. The conventional sequence of auscultation of areas - Mitral area - tricuspid area - pulmonary area - aortic area - second aortic area

One should start auscultating mitral area with bell, then with diaphragm of stethoscope. For better appreciation, patient can be put in left lateral position.

Mitral area
Search for abnormality of S1 and presence of S3, S4, Opening snap and mitral systolic and diastolic murmur, conduction of systolic murmur to axilla

Tricuspid area 
You should look for diastolic and systolic murmurs of tricuspid valve disease, augmentation with inspiration in the sitting position is noticed

Pulmonary area 
Identify the abnormality of S2, alteration in intensity and split, ejection click, systolic, diastolic and continuous murmur

Aortic area 
Ask the patient to be in the sitting posture ,leaning forward and breath held in expiration. Look for intensity of aortic component of S2, aortic, systolic and early diastolic murmur

Second aortic area 
Sometimes aortic events are better heard in the 2nd aortic area and the position of the patient is as above. 

Features of Posterior interosseous nerve injury

• A lesion of the PIN causes weakness of finger extension (finger drop) without wrist drop.
• The wrist deviates radially on extension due to weakness of the PIN innervated extensor carpi ulnaris  muscle with preservation of the main trunk innervated extensor carpi radialis longus muscle.
• Some of the fingers may be affected more than others most often the ring and small fingers are selectively dropped, producing an abnormal posture which will  superficially resembles an  ulnar griffe (pseudoulnar claw hand).
• Sometimes, cervical radiculomyelopathy will also selectively drop the ring and small fingers (Ono's hand, myelopathy hand, pseudopseudoulnar claw hand).
• A PIN lesion is not associated with sensory changes.
• Neuropathy of the superficial radial nerve will cause pain and alterations of sensation in its
• distribution; it may be injured by tight bands around the wrist 

Oral Manifestations of vitamin B12 deficiency

• Tongue may be large  called as Macroglossia
• Tongue may be smooth due to loss of papillae (Atrophic Glossitis)
• Tongue may show red patches on red lines on the ventrum (Moeller's glossitis)
• Tongue may be red and inflamed (Sore tongue)
• Angular cheilitis may be associated
• Oral ulcers may be seen

Anemia of chronic renal failure

• Anemia of chronic renal failure is normocytic normochromic, hypoproliferative anemia
• The level of anemia correlates with the severity of underlying renal failure
• The anemia is primarily due to a failure to produce adequate level of Erythropoetin and a reduction in red cell survival.
• Patients usually present with normal serum iron, TIBC & ferritin levels
• Erythropetin therapy is the mainstay of treatmentto improves anemia symptoms
• Dialysis typically has little effect with regard to correcting the anemia.
• Peritoneal dialysis (ambulatory) usually improves anemia while hemodialysis may cause an associated iron deficiency anemia
• Iron deficiency anemia may however be seen in some patients with CRF who are maintained on chronic hemodialysis due to loss through the dialysis procedure.