Cases in general internal medicine 3

Question 1

What can NMJ be affected by

Answer 1

As well as antibdodies in myasthenia gravis,toxins too

Question 2

Possible pathology in neurological diagnoses

Answer 2

• Vascular
• Infection
• Inflammation/Autoimmune
• Toxic/Metabolic
• Tumour/Malignancy
• Hereditary/congenital
• Degenerative

Question 3

What do you want to examine for upper and lower limbs

Answer 3

• Inspection
• Tone
• Power
• Reflexes
• Coordination
• Sensation
• Gait
• Back

Question 4

Compare UMN and LMN signs

Answer 4

UMN: increased tone, reduced power, hyperreflexia and upward plantar reflex

LMN: Reducedtone, reduced power, reduced reflexes

Question 5

Cerebellar signs and what are these all affecting

Answer 5

Dysdiadochokinesia
Ataxia (gait and posture)
Nystagmus
Intention tremor
Slurred, staccato speech
Hypotonia/Heel-shin test
All affecting coordination of movement

Question 6

Distributions of abnormal sensation and the affected anatomy that would cause this

Answer 6

• Cerebral cortex –> Hemisensory loss
• Spinal cord –> Level (e.g. umbilicus)
• Nerve root (radiculopathy) –> Dermatome(s)
• Monorneuropathy –> Specific area
• Polyneuropathy –> Glove & stockings

Question 7

Toxic/metabolic causes of peripheral neuropathy what are the clues for each

Answer 7

• Drugs (Hx)
• Alcohol (Hx, raised GGT and MCV)
• Hypothyroidism (TFTs)
• Amyloidosis (Hx of myeloma or chronic infection.inflammation)
• B12 deficiency (anaemia and raised MCV)
• Diabetes (Hx, glucose/HbA1C)
• Uraemia (U&Es)

Question 8

What is duloxetine, SE and mechanism of action

Answer 8

Duloxetine inhibits the reuptake of serotonin and norepinephrine (NE) in the central nervous system.

Used to treat:

• depression and anxiety.
• relieve nerve pain (peripheral neuropathy) in people with diabetes or ongoing pain due to medical conditions such as arthritis or chronic back pain.

Side effects
Nausea.
Dry mouth.
Sleepiness.

Question 9

Other causes of peripheral neuropathy other than toxic/metabolic

Answer 9

Infection (HIV)

Inflammation (vasculitis, CTD, inflammatory demyelinating neuropathy)

Tumour/malignancy (paraneoplastic, paraproteinaemia)

Hereditary (– Hereditary sensory motor neuropathy… high arched foot)

Question 10

What are the causes of papilloedema vs papillitis

Answer 10

Papilloedema is a sign of raised ICP.

Papillitis is a sign of inflammation of the optic nerve, and thus an inflammatory problem.

Papillitis will give you reduced visual acuity and partially reduced colour vision too, whereas papilloedema won’t.

Papillitis gives you a large central scotoma, papilloedema gives you large blind spot

Question 11

What papillitis and what might you see and what signs

Answer 11

Optic neuritis (papillitis)
– Blurred optic disc margins
– Blurred vision
– Pain on eye movement

To distinguish papilloedema from papillitis.

IN PAPILLOEDEMA: NO PAIN ON EYE MOVEMENT, NO REDUCED VISUAL ACUITY

Question 12

Disturbances to which area of spinal cord will cause a spastic paraparesis

Answer 12

Corticospinal and spinothalamic tracts

Question 13

Causes of spastic paraparesis

Answer 13

– Vascular
– Infection
– Inflammation (demyelination)
• Transverse myelitis
– Toxic/Metabolic
• b12
– Tumour/Malignancy

Question 14

What is TB in the spine known as

Answer 14

Potts disease is a form of tuberculosis that occurs outside the lungs whereby disease is seen in the vertebrae.

Question 15

What things would indicate MS

Answer 15

• Two lesions

* Separated in time/space

Question 16

What is meralgia paraesthetica and what is the cause

Answer 16

Compression of lateral
femoral cutaneous nerve

Tight clothing, obesity or weight gain, and pregnancy are common causes of meralgia paresthetica. However, meralgia paresthetica can also be due to local trauma or a disease, such as diabetes.

Question 17

Management of meralgia parasthetica

If persistent

Answer 17

Reassure
• Avoid tight garments
• Lose weight
If persistent:
– Carbamazepine
– Gabapentin

Question 18

What is radiculopathy

Answer 18

Disease of nerve roots

Question 19

Example of radiculopathy

Answer 19

Example: Lumosacral

• Pain in the buttock,
radiating down the leg
below the knee (‘sciatica’)

Question 20

Causes of compression of nerve roots in radiculopathy

Answer 20

Compression by
– Disc herniation
– Spinal canal stenosis

Question 21

Features of parkinsons

Answer 21

Tremor, rigidity,
bradykinesia

Affects – Dopaminergic neurons
– Substantia nigra

Question 22

Features of PSP (steele-richardson syndrome)= progressive supranuclear palsy

Answer 22

Parkinsonian features,

upgaze abnormality

Question 23

Lewy body dementia

Answer 23

Features of Alzheimer’s
disease, Parkinson’s &
hallucinations

Question 24

DDx for apparent confusion/reduced AMTS

Answer 24

• Post‐ictal –> Hx seizure
• Dysphasia –> other features of stroke/TIA
– Receptive or expressive
• Dementia
– Vascular (multi‐infarct) (–> Hx IHD/PVD)
– Alcoholic (–> signs of ETOH excess)
– Alzheimer’s disease
– Inherited e.g. Huntington’s
disease (HD)
• Depressive pseudodementia (–> elderly, withdrawn, poor eye contact & a precipitating factor)

Question 25

DDx for confusion/reduced conscioussness

Answer 25

• Hypoglycaemia • Vascular – Bleed: Headache, collapse – Subdural haematoma (Fall, fluctuating consciousness) • Infection – ? Temp, ? Intracranial, ? Extra‐cranial • Inflammation • Malignancy • Metabolic/Toxic – Drugs, U&Es, LFTs, Vitamin deficiencies, Endocrinopathies

Question 26

How to assess GCS

Answer 26

``` • Eyes (4) 4 = Spontaneous 3 = Opens in response to voice 2 = Opens in response to painful stimuli 1 = Does not open ``` ``` • Verbal response (5) 5 = Oriented 4 = Confused 3 = Words 2 = Sounds 1 = No sounds https://www.brainscape.com/profiles/3291997 • Motor response (6) 6 = Obeys commands 5 = Localizes pain 4 = Withdraws to painful stimuli 3 = Abnormal flexion 2 = Extension 1 = No movements ```

Question 27

AMTS confusion assessment

Answer 27

1. DOB 2. Age 3. Time 4. Year 5. Place 6. Recall (West Register Street) 7. Recognize doctor/nurse 8. Prime Minister 9. Second WW 10. Count backwards from 20 to 1

Question 28

Causes of headache in the emergency department

Answer 28

``` • Meningitis • Subarachnoid haemorrhage • Giant cell arteritis – Polymyalgia rheumatica – (Shoulder girdle pain, stiffness, constitutional upset) • Migraine ```

Question 29

How would you tell if it's meningitis

Answer 29

• Fever, neck stiffness, | Kernig’s sign

Question 30

How would you tell it's SAH + what investigations

Answer 30

* Sudden onset | * CT, LP (xanthochromia)

Question 31

How would you tell if it's giant cell arteritis and what management Why must you treat

Answer 31

> 50 years | • ESR, steroids (to prevent blindness), Biopsy

Question 32

Differentiate presentation of giant cell and polymyalgia rheumatica What is their treatment

Answer 32

Patients with polymyalgia rheumatica usually present with acute onset of stiffness and pain in the shoulder and pelvic musculature, which may be accompanied by fever, malaise, and weight loss. If untreated, polymyalgia rheumatica may result in significant disability. Giant cell arteritis may manifest as visual loss or diplopia, abnormalities of the temporal artery such as tenderness or decreased pulsation, jaw claudication, and new-onset headaches. Treat both with steroids (higher dose for GCA) until remission is achieved

Question 33

How would you tell if it's migraine

Answer 33

Throbbing, vomiting, photo/phonophobia, FHx, Aura

Question 34

Management of stroke

Answer 34

< 4.5 hours – CT: no haemorrhage – Thrombolysis (if no contraindications) ``` > 4.5 hours – CT head (exclude haemorrhage) – Aspirin (300mg), Swallow assessment – Maintain hydration, oxygenations, monitor glc ```

Question 35

Management of TIA

Answer 35

``` • Aspirin • Don’t treat BP acutely – unless > 220/120 or – other indication • ECG, Echocardiogram • Carotid Doppler • Risk factor modification ```

Question 36

What makes guillain barre more likely

Answer 36

Back ache You need to masure FVC

Question 37

Causes of collapse

Answer 37

• Low glucose ``` • Heart – Vasovagal – Arrhythmia – Outflow obstruction – Postural hypotension ``` • Brain – Seizure

Question 38

How would you use the pin prick

Answer 38

First test if they know what sharp and dull is by swtiching the two sides. Then just use the sharp end and get them to tell you when they feel it

Question 39

What part of a confusion history would suggest that the confusion is NOT caused by a bleed

Answer 39

No headache (bleeding on brain normally very painful)

Question 40

What is kernig's sign? When is it positive and what does it indicate

Answer 40

Kernig's sign is positive when the thigh is flexed at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful (leading to resistance). This may indicate subarachnoid hemorrhage or meningitis.