180 - Dicrotic pulse

The dicrotic pulse has two palpable waves, one in the systole and one in diastole (Figure above). It usually denotes a very low stroke volume, particularly in patients with dilated cardiomyopathy.

A dicrotic pulse results from an accentuated dicrotic wave and tends to occur in patients with

*sepsis, 
*severe heart failure, 
*hypovolemic shock, 
*cardiac tamponade, and 
*aortic valve replacement.

179 - Pulsus Bisferiens

Pulsus bisferiens with both percussion and tidal waves occurring during systole. This type of carotid pulse contour is most frequently observed in patients with hemodynamically significant aortic regurgitation or combined aortic stenosis and regurgitation with dominant regurgitation. It is rarely appreciated at the bedside by palpation.

The bisferiens pulse, which has two systolic peaks (as shown in figure above), is characteristic of aortic regurgitation (with or without accompanying stenosis) and of hypertrophic cardiomyopathy .
In the latter condition, the pulse wave upstroke rises rapidly and forcefully, producing the first systolic peak ("percussion wave"). A brief decline in pressure follows because of the sudden midsystolic decrease in the rate of left ventricular ejection, when severe obstruction often develops.
This pressure trough is followed by a smaller and more slowly rising positive pulse wave ("tidal wave") produced by continued ventricular ejection and by reflected waves from the periphery.

178 - Bird facies

 

*A very small lower jaw is the commonest finding in Pierre Robin syndrome. But the growth of the mandible seems to normalize by the 5th year of life, it however gives a characteristic appearance called as "bird facies."

*The combination of a small lower jaw and the reverse tongue gives rise to acute breathing problems in a child because of airway blockage. Defects of the middle ear can lead to hearing loss. Speech defects are common in Pierre Robin syndrome because of the unusual higly placed poition of the tongue and the lower jaw.

HERE IS A LIST OF DIFFERENT TYPES OF FACIES IN DIFFERENT CONDITIONS :

1. Mask like facies = Parkinsonism.

2. Elfin facies = William's syndrome.

3. Moon facies = Cushing's syndrome.

4. Snarling facies = Myasthenia gravis.

5. Mitral facies = Mitral stenosis.

6. Ashen grey facies = Myocardial Infarction.

7. Mouse facies = Chronic Renal Failure (CRF)

8. Adenoid facies = Adenoid hypertrophy.

9. Leonine facies = Lepromatous leprosy .

10.  Bird facies = Pierre Robin syndrome.

11. Mongoloid facies = Down's syndrome.

12. Coarse facies = Most of the inborn errors of metabolism (IEM) viz. the muco- polysaccharidoses (MPS), mucolipidoses (ML), fucosidoses mannosidoses, sialidoses, aspartylglycosaminuria, generalised gangliosidosis(GMl ) and Austin's variant of metachromatic leukodystrophy due to multiple sulfatase deficiency (MLD-MSD) have similar appearing facies. 

13. Syphilitic facies = Congenital syphilis ( bull dog jaw)

 

177 - Leonine facies

A face that resembles that of a lion. It is seen in multiple conditions and has been classically described for Lepromatous leprosy as well as Paget's disease of bone. It is a dermatological symptom, with characteristic facial features that are visible on presentation and is useful for focusing on differential diagnosis.
  

Differential diagnoses include the following:

* Lepromatous leprosy
* Paget's disease of bone
* Mycosis fungoides
* Amyloidosis
* Lichen myxedematosus
* Actinic reticuloid
* Leishmaniasis (Post Kala azar dermal leishmaniasis)
* Lipoid proteinosis
* Progressive nodular histiocytosis
* Mastocytosis