High Yield Flashcards

Question

Aortic stenosis CFx

Answer 1

SYMPTOMS: exertional chest pain, dyspnoea and syncope PULSE: plateau or small volume pulse PALPATION: - Apex beat is hyperdynamic - Systolic thrill at the base of the heart ASCULTATION: - Harsh midsystolic ejection murmur (max over aortic and radiates to carotids; louder with pt sitting up and in expiration - narrowly split or reversed S2 (delayed LV ejection)

Answer 2

SYMPTOMS: exertional SOB, fatigue, palpations, exertional agina GENERAL INSPECT: marfan's, AS, seronegative arthropathy, argyl-robinson pupils PULSE: collapsing, waterhammer, bisiferens (severe), prominent carotid pulse BP: wide pulse pressure PALP: hyperkinetic apex beat, diastolic thrill ASCULTATION: soft A2, decrescendo high pitched diastolic murmur immediately after S2 loudest at 3rd and 4th intercostal space. Note: may have associated systolic ejection flow murmur or as autin flint murmur (low pitched rumbling mid diastolic and presystolic murmur audible at apex)

Answer 3

JVP: large v waves, elevated if RHF PALPATION: right ventricular heave ASCULTATION: pansystolic murmur, max at lower edge of sternum that increases on inspiration ABDO: pulsatile, large and tender liver. May have ascities and pleural effusions LEGS: dilated, pulsatile veins

Answer 4

PALP: - Hyperkinetic displaced apex if the defect is large - Thrill at the left sternal edge. ASCULT: - Harsh pansystolic murmur max at the left sternal edge with a loud 3rd or 4th heart sound; louder on expiration. May have assoc MR. Murmur louder and harsher when the defect is small. Signs of severity: pulm HT, cyanosis Causes: - Congenital - Rupture in AMI - Tetraology of fallot (VSD, RV obstruction, overriding aorta) - Down's syndrome

Answer 5

UPPER LOBE: (SCHART) - Silosis, sarcoidosis - Coal workers pnuemoconiosis - Histiocytosis - Anklyosing spondylitis, allergic bronchopulmonary aspergillosis - Radiation - Tuberculosis LOWER LOBE: (RASCO) - RA - Abestosis - Scleroderma - Cryptogenic fibrosing alevolitis - Drugs (busulphan, bleomycin, nitrofurantoin, hydralazine, MTX, amiodarone)

Answer 6

GENERAL: dyspnoea, cyanosis, clubbing PALP: slightly reduced expansion ASCULT: fine late inspiratory or pan-inspiratory crackles Signs of associated CTD RFTs = reduced FVC and DLCO IPF on CT scan: traction bronchiectsis, honeyhombing

Answer 7

GENERAL: pursed lip breathing, barrel shaped chest, use of accessory muscles. PALPATION: reduced chest expansion (<5cm), hyperinflated chest PERCUSSION: hyperresonant BREATH SOUNDS: decreased, early inspiratory crackles Signs of RV failure in severe disease

Answer 8

SYSTEMIC: fever, cachexia, sinusitis (70%), clubbing, cyanosis (if severe) SPUTUM: voluminous, purulent, blood stained ASCULT: coarse pan-inspiratory or late inspiratory crackles over the affected lobe +/- wheeze If severe: copious sputum, clubbing, widespread crackles, signs of airway obstruction, signs of respiratory failure and cor pulmonale.

Answer 9

CONGENITAL: primary ciliary dyskinesia, cystic fibrosis, congenital hypogammaglobulinaemia ACQUIRED: infections in childhood, localised disease such as foreign body / bronchial adenoma / TB, allergic bronchopulmonary aspergillosis (proximal bronchiectasis) CT: tree in bud appearance, dilated thickened airway (tram tracking)

Answer 10

- Dull to percussion - Absent breath sounds - Decreased vocal resonance

Answer 11

TRANSUDATE: cardiac failure, hypoalbuminaemia (nephrotic syndrome, CLD), hypothyroidism, Meigs syndrome EXUDATE: pneumonia, neoplasm (bronchial carcinoma, metastatic carcinoma, mesothelioma), TB, pulmonary infarction, subphrenic abscess, acute pancreatitis, CTD, drugs (cytotoxics), irradiation, trauma HAEMOTHORAX: severe trauma, rupture of a pleural adhesion containing a blood vessel CHYLOTHORAX: trauma or surgery to the thoracic duct, carcinoma or lymphoma involving the thoracic duct EMPYEMA: pneumonia, lung abscess, bronchiectasis, TB, penetrating chest wound

Answer 12

Exudate= Pleural:serum protein >0.5 Pleural LDH >2/3 upper limit of normal Pleural:serum LDH >0.6

Answer 13

RESP: lung carcinoma (usually not SCLC), chronic pulmonary suppuration (e.g. bronchiectasis, lung abscess, empyema), idiopathic pulmonary fibrosis, asbestosis, cystic fibrosis, pleural fibroma or mesothelioma, mediastinal disease (e.g. thymoma, lymphoma, carcinoma). CVS: IE, cyanotic congenital heart disease OTHER: IBD, cirrhosis, coeliac disease, thyrotoxicosis (thyroid acropachy), brachial AV aneurysm or arterial graft sepsis (unilateral), neurogenic diaphragmatic tumours, familial or idiopathic, hemiplegic stroke (unilateral).

Answer 14

- Pleural effusion - Consolidation - Collapse (mucous plug, foreign body, airway obstruction, compression from external mass or lymph node) - Raised hemidiaphragm

Answer 15

- Tracheal deviation towards affected side - Lateral scar - Reduced chest expansion on affected side - Dull percussion + absent breath sounds + reduced vocal resonance in affected lower zone

Answer 16

``` # Liver - Alcoholic hepatitis - NAFLD - Malignancy (HCC or mets)* - Viral hepatitis - Haemochromatosis - Budd chiari - Polycystic liver # Haem - Myeloproliferative disease* - CML - Lymphoma # Infiltrative - Amyloid - Sarcoid # Right heart failure* # Infective - Hydatitid disease - HIV ``` * = causes massive hepatomegaly MASSIVE: metastases, alcoholic liver disease with fatty infiltration, myeloproliferative disease, RHF, HCC. MODERATE: above + haemochromatosis, haematological disease (CML, lymphoma), fatty liver (obesity, DM, toxins). MILD: above + hepatitis (viral, drugs), cirrhosis, biliary obstruction, granulomatous disorders, hydatid disease, amyloidosis and other infiltrative diseases, HIV infection, ischaemia.

Answer 17

``` # Haem: - myeloproliferative disease (PCRV, myleofibrosis) - malignant (CML, AML, lymphoma) - haemolytic anaemia (hereditary sphereocytosis, autoimmune heamolytic anaemia) # Infective (EBV, CMV, hepatitis) # CTD (RA, SLE) # Infiltrative (sarcoidosis, amyloidosis) # Portal hypertension and CLD ``` MASSIVE: CML, myelofibrosis, primary lymphoma of spleen, hairy cell leukaemia, malaria, kala-azar. MODERATE: above + portal hypertension, lymphoma, leukaemia (chronic or acute), thalassaemia, storage diseases (e.g. Gaucher's disease). SMALL: above + other myeloproliferative disorder (polycythemia rubra vera, ET), haemolytic anaemia, megaloblastic anaemia (rarely), infection (EBV, hepatitis, bacterial / IE), CTD (RA, SLE, polyarteritis nodosa), infiltration (amyloidosis, sarcoidosis)

Answer 18

``` # Chronic liver disease with portal hypertension # Haematological - Myeloproliferative - Malignant (lymphoma, CML, AML) - Non-malignant (autoimmune haemolytic anaemia, hereditary spherocytosis, sickle cell anaemia, thalassaemia) # Infection - Viral hepatitis - EBV, CMV # Infiltative - Amyloid - Sarcoidosis # Connective tissue disease - SLE # Endocrine - Acromegaly - Thyrotoxicosis ```

Answer 19

- Lymphoma (rubbery and firm) - Leukaemia (CLL, ALL) - Malignant disease (metastases or reacitve changes usually causing asymmetrical, very firm nodules) - Infections: viral (CMV, HIV, EBV), bacterial (TB, brucellosis), protozoal (toxoplasmosis) - CTD (RA, SLE) - Infiltrations (sarcoidosis) - Drugs (phenytoin)

Answer 20

HANDS: leuconychia, clubbing, palmar erythema, bruising, asterixis FACE: jaundice, scratch marks, spider naevi, bruising, pectoral muscle wasting CHEST: gynaecomastia, loss of body hair, bruising ABDO: hepatosplenomegally, signs of portal hypertension, testicular atrophy LEGS: oedema, muscle wasting, bruising Two or more suggest cirrhosis: spider naevi, palmar erythema, splenomegaly, ascites, abnormal veins on abdomen. Signs of decompensated CLD - Asterixis - Encephalopathy - Ascites - Icterus

Answer 21

- Alcohol - postviral hep B or C - NASH - drugs (methyldopa, chlorpromazine, isoniazid, niteofurantonin, PTU, MTX, amiodarone) - autoimmune - haemacheomatosis - Wilson's disease - PSC - PBC - alpha 1 antitrypsin deficiency - cystic fibrosis - budd chiari syndrome - cardiac failure - idiopathic

Answer 22

1. Cirrhosis 2. Other - Presinusoidal: portal vein compression (e.g. lymphoma, carcinoma), intravascular clotting (e.g. polycythemia), umbilical vein phlebitis - Intrahepatic: sarcoid, lymphoma or leukaemic infiltrates, congenital hepatic fibrosis - Postsinusoidal: hepatic vein outflow obstruction (budd chiari: idiopathic, myleloproliferative disease, tumour, PNH, OCP), veno-occlusive disease, constrictive pericarditis, CCF

Answer 23

- Splenomegally - Collateral veins (on abdomen or haematemesis) - Ascites

Answer 24

- Chronic liver disease - Malignancy (HCC or other abdo mets) - Fluid overload (nephrotic syndrome, right heart failure) - Infection (TB, SBP) - Vascular (budd chiari)

Answer 25

1. Take BP (75% have hypertension) 2. Examine urine for haematuria (haemorrhage into a cyst) and proteinuria (usually <2g/day) 3. Looks for anaemia (from CKD) or polycythemia (due to high EPO). Hb usually higher than expected for degree of renal failure 4. Note the presence of hepatic cysts (present in 30% of cases) and splenic cysts (rare). Subarachnoid haemorrhage occurs in 3% of pts ASK: - FBE (anaemia) - UEC (renal function) - Abdominal US to see cysts on kidney and liver

Answer 26

- Spleen has notch - Spleen dull to percussion - Cannot palpate above spleen - Spleen not ballotable - Spleen moves inferomedially with respiration

Answer 27

GENERAL: ?cushingoid appearance HANDS: small joint symmetrical polyarthritis, DIP sparring, ulnar deviation, Z deformity of thumb, swan neck deformity, boutonniere deformity, volar subluxation of MCP joints. ARMS: RA nodules FACE: redness and dryness of eyes (sjogren's syndrome in 10%), scleritis, dry mouth. CHEST: pleural effusion, ILD, pericardial rub, valvular regurg (particularly aortic) ABDO: splenomegaly (10%, consider Felty's syndrome), hepatomegaly (MTX) LL: stocking distribution peripheral neuropathy, cord compression (if atlanticoaxial disease), feet arthropathy, achilles tendon nodules Other sites: elbows, upper cervical spine, knees, tarsal and metatarsophalangeal joints Deformities: Boutonniere = flexion of proximal interphalangeal joint and extension of distal interphalangeal joint of the hand. Swan neck deformity = hyperextension at proximal interphalangeal joint and flexion at distal interphalangeal joint. Z-deformity of thumb = hyperextension of the interphalangeal joint, fixed flexion and subluxation of the metacarpophalangeal joint

Answer 28

Monoarticular and oligoarticular arthritis of the hands and feet. NAILS: oncholysis, pitting, ridging, hyperkeratosis. SKIN: rash elbows and behind ears

Answer 29

Symmetrical | Heberden's nodes (DIP), Bouchard's nodes (PIP)

Answer 30

RA Seronegative spondyloarthropathy (psoriatic arthritis, ankylosing spondylitis, Reiter's disease) Chronic tophaceous gout (rarely symmetrical) Primary generalised OA

Answer 31

CREST = calcinonsis, Raynauds, oesophageal dysmotility, sclerodactyly, telangiectasia GENERAL: bird like facies, weight loss HANDS: calcinosis, atophy of distal tissue pulp (Raynauds), sclerodactyl, telangiectasia, dilated capillary loops, small joint arthopathy and tendon crepitus, fixed flexion deformity, hand function BP ARMS: skin tightening or thickening, pigmentation, vitiligo, hair loss, proximal myopathy HEAD: alopecia, eyes (anaemia, difficulty with closing), mouth (puckered, difficulty opening), pigmentation, telangictasia, neck muscle wasting and weakness DYSPHAGIA CHEST: tight skin, cor pulmonale, pericarditis, failure, ILD LEGS: skin lesions, vasculitis Other: urine analysis (proteinuria), temp chart (infection), stool examination (steatorrhoea)

Answer 32

GENERAL: mental and physical sluggishness. HANDS: peripheral cyanosis (reduced CO), cool and dry skin, yellow discolouration of palms due to hypercarotenaemia (slowed hepatic metabolism), palmar crease pallor (anaemia) ARMS: proximal myopathy (rare), hung up biceps reflex (delayed relaxation) FACE: thickened skin, alopecia, vitiligo (an assoc autoimmune disease), periorbital oedema, loss or thinning of outer third of the eyebrows, coolness of skin and hair THYROID: may see goitre (due to oversecretion of TSH) if cause severe iodine deficiency, late Hashimoto's disease, treated thyrotoxicosis, inborn errors of metabolism. CHEST: pericardial effusion, pleural effusion LEGS: non-pitting oedemea, delayed relaxation of LL reflexes ('hung up'), peripheral neuropathy Neuro associations: entrapment of nerves, delayed ankle jerk, muscle cramps. Less common: peripheral neuropathy, proximal myopathy, hypokalaemic periodic paralysis

Answer 33

GENERAL: weight loss, anxiety HANDS: fine tremor (sympathetic overactivity), onycholysis, thyroid acropathy (clubbing), palmar erythema, sweatiness/warmth PULSE: sinus tachycardia or AF (shortened refractory period to do sympathetic drive) ARMS: proximal myopathy, brisk reflexes EYES: exophthalmos, proptosis (Cx= chemosis [oedema of conjunctiva and injection of sclera], corneal ulceration, optic atrophy, opthalmoplegia [infeior rectus lost first]), lid retraction, test for lid lag (descent of lid lags behind eyeball) NECK: examine for thyroid enlargement (Graves = diffuse enlargement, subacute = tender thyroid). If thryoidectomy scar assess for hypoparathyroidism CHEST: systolic flow murmurs, CCF LEGS: pretibial myxodema (Graves), proximal myopathy and hyperreflexia

Answer 34

PRIMARY: Grave's disease, toxic multinodular goitre, hashimoto's thyroiditis in early stage, subacute thyroditis, post partum thyriditis, iodine induced SECONDARY: pituitary (rare), hydatidorm moles or choriocarcinomas, struma ovarii, drugs (amiodarone)

Answer 35

PRIMARY: - Without goitre (decreased or absent thyroid tissue): idiopathic atrophy, treatment of thyrotoxicosis, agenesis or a lingual thyroid, unresponsiveness to TSH. - With a goitre (decreased thyroid hormone synthesis): chronic autoimmune disease (e.g. Hashimoto's), drugs (lithium, amiodarone), inborn errors, endemic iodine deficiency SECONDARY: pituitary lesions TERTIARY: hypothalamic lesions TRANSIENT: thyroid hormone withdrawn, subacute thyroiditis, post partum thyroiditis.

Answer 36

GENERAL: characteristic face and body habitus with frontal bossing HANDS: spade-like hands (due to soft tissue and bony enlargement), increased sweating and warmth (increased metabolic rate), thickened skin, OA changes due to skeletal overgrowth, examine for median nerve entrapment (due to soft tissue overgrowth) ARMS: proximal myopathy, ulnar nerve thickening behind medial epicondyle BP check AXILLAE: skin tags (molluscum fibrosum), feel for greasy skin, acanthosis nigricans FACE: supraorbital ridge causing frontal bossing, thickened lips EYES: examine visual fields for bitemporal hemianopia, look in fundi for optic atrophy, angioid streaks (red brown streaks that emanate from the optic disk), diabetic changes and papilloedema, MOUTH: enlarged tongue, teeth splayed and separated NECK: enlarged thyroid CHEST: coarse body hair, gynaecomastica, arrhythmias, cardiomegally, CCF BACK: kyphosis ABDO: hepatic, splenic and renal enlargment, look for tesitcular atrophy. LL: OA in hips and knees. Foot drop due to common peroneal nerve entrapment Ask for: - urine ?glucose - rectal exam ?colonic polyps Signs of active disease: large number of skin tags, excessive sweating, glycosuira, increased visual field loss, enlarging goitre, hypertension.

Answer 37

GENERAL: dehydration, obesity, cushing's faecies, kussmaul's breathing LOWER LIMBS: - Inspect: necrobiosis, hair loss, pigmented scars, ulceration, superficial skin infection, diabetic dermopathy (small rounded plaques with raised borders lying in a linear fashion over the shins), injection sites on thighs, charcot's joints (grossly deformed joints due to loss of proprioception or pain) - Palpate: peripheral pulses, capillary return - Neuro ex: peripheral neuropathy, proprioception, reflexes, proximal myopathy UPPER LIMBS: - Nails: ?candida BP including postural drop FACE: - Eyes: visual acuity, look for argyll robertson pupils, examine retina, assess for opthalmoplegia (CN III palsy most common) - Ears: examine for signs of infection - Mouth: ?candida NECK: Carotid arteries palpate and ascultate CHEST: look for acanthosis nigricans ABDO: palpate for hepatomegally ASK: - Urinanalysis ?glucose, ?proteinuria

Answer 38

UL: flexors stronger than extensors LL: extensors stronger than flexors

Answer 39

Def: patient cannot understand, speaks nonsense Aeit: leison (infarction, haemorrhage, tumour) in the dominant hemisphere in the posterior part of first temporal gyrus (WERNICKE'S AREA) CFx: - Patient cannot understand or follow commands - Speech is fluent but disorganised - Cannot name objects or repeat 'no ifs, ands or buts'

Answer 40

Def: patient understands but cannot speak properly Aeit: posterior part of the dominant third frontal gyrus (BROCA'S AREA) CFx: - Non fluent speech - May be able to name objects and repeat phrases - Can follow commands - If hemiparesis present UL>LL affected

Answer 41

Def: cannot name objects but other aspects of speech normal Aeit: lesion of the dominant posterior temporoparietal area CFx: - May use long sentences to overcome not remembering specific words

Answer 42

Def: can follow commands but difficulty in repeating statements and naming objects Aeit: lesion of the arcuate fasciculus and other fibres linking wernicke's and broca's areas.

Answer 43

DOMINANT: - Acalculia (can't do basic sums) - Agraphia (can't write) - Left-right disorientation (show R then L hand, then touch R ear with L hand and L ear with R hand) - Finger agnosia (can't name fingers) NON-DOMINANT: - Graphaesthesia (can't recognise numbers drawn on the skin) - Tactile extinction (can't tell which side being touched when both sides touched) GENERAL: - Sensory and visual inattention (get inattention on L side with R sided lesion) - Lower quandrantinopia - Astereogenesis (tactile agnosisa) - Two point discrimination - Dressing and constructional apraxia - Spatial neglect (incomplete clock drawing)

Answer 44

- Decreased short term memory (recall 3 objects) - Confabulation - Upper quadrantinopia - Receptive dysphasia if dominant lobe

Answer 45

- Personality change - Primitive reflexes (grasp [stroke palms, graps on side contralateral to the lesion], pout [stroke upper lip with tendon hammer induces pouting of lips]) - Anosmia - Optic nerve compression-> atrophy (rare due to a space occupying lesion) - Gait apraxia - Leg weakness - Loss of micturition control - Expressive dysphasia - Concrete thinking (can't interpret proverb)

Answer 46

- Homonymous hemianopia | - Alexia (can't read)

Answer 47

CFx: - Complete ptosis - Eye down and out (divergent strabismus) - Dilated pupil unreactive to direct light (if parasympathetic fibres affected, consensual reaction in the opposite normal eye is intact) - Unnreactive to accomodation Motor function - Superior rectus - Inferior oblique - Medial rectus - Inferior rectus

Answer 48

- CENTRAL: vascular lesions in brainstem, tumours, demyelination - PERIPHERAL: compressive lesions (usually aneurysm on PICA, tumour, orbital lesion), ischaemia (arteritis, DM, migraine)

Answer 49

CFx: - Can't turn eye inward and down when eye adducted (eye when adducting rotates up 'nasal upshoot') Motor function - superior oblique (intorts eye / depresses eye when adducted, action depends on direction of movement) Aeit: - Isolated palsy rare, usually idiopathic or trauma

Answer 50

CFx: - Failure of lateral movement, maximum of looking to the affected side Motor function - lateral rectus Aeit: BILATERAL: trauma, Wernicke's encephalopathy (opthalmoplegia, confusion and ataxia), mononeuritis multiplex, raised ICP

Answer 51

CENTRAL (pons, medulla or upper cervical cord) - Vascular lesion - Tumour - Syringobulbia (fluid filled cavities) PERIPHERAL (middle fossa) - Aneurysm - Tumour - Chronic meningitis TRIGEMINAL GANGLION (petrous temporal bone): - Trigeminal neuroma - Meningioma - Fracture of the middle fossa ``` CAVERNOUS SINUS: [Involve only opthalmic (V1) division and typically assoc with CN IV and VI palsy] - Aneurysm - Tumour - Thrombosis ``` If only one division of CN V affected then it must be a post ganglionic lesion. Dissociated sensory loss suggests a brainstem or upper cord lesion.

Answer 52

UMN (supranuclear; forehead sparring): - Vascular - Tumours LMN (forehead not spared, when pt tries to shut eye get upward movement of eyeball and incomplete closure): - Pontine causes (often assoc with CN V and VI lesions): vascular lesions, tumours, syrringobulbia, MS - Posterior fossa: acoustic neuroma, meningioma, chronic meningitis - Petrous temporal bone: bell's palsy, fracture, ramsay hunt syndrome (herpes zoster), ottitis media, parotid gland tumour or sarcoidosis

Answer 53

CENTRAL: - Vascular lesions (lateral medullary infarction due to vertebral or posterior inferior cerebellar artery disease) - Tumours - Syringobulbia - MND PERIPHERAL (posterior fossa): - Aneurysms at the base of skull - Tumours - Chronic meningitis - Guillian-Barre syndrome

Answer 54

Unilateral III, IV, V, VI suggests carvenous sinus lesion.

Answer 55

Unilateral V, VII and VIII suggests a cerebellopontine angle lesion (usually tumour, acoustic neuroma)

Answer 56

Unilateral IX, X, and XI suggests jugular foramen lesion

Answer 57

Bilateral X, XI and XII - Bulbar palsy if LMN signs - Psuedobulbar palsy if UMN signs

Answer 58

Pseudobulbar palsy = bilateral UMN lesions of CN IX, X and XII CFx - Increased gag reflex - Spastic tongue - Increased jaw jerk - Spastic dysathria (speech) - Bilateral limb UMN (long tract) signs - Labile emotions Causes: - Bilateral cerebrovascular disease (e.g. both internal capsules) - Multiple sclerosis - Motor neurone disease

Answer 59

Causes: - Bilateral cerebrovascular disease (e.g. both internal capsules) - Multiple sclerosis - Motor neurone disease

Answer 60

Bulbar palsy = bilateral LMN lesions of IX, X and XII CFx: - Absent gag relfex - Absent or normal jaw reflex - Nasal speech - Normal emotions Causes: - MND - Guillain-Barre syndrome - Poliomyelitis - Brainstem infarction

Answer 61

Causes: - MND - Guillain-Barre syndrome - Poliomyelitis - Brainstem infarction

Answer 62

Due to interruption of the sympathetic innervation of the eye. CFx: - Partial ptosis (sympathetic fibres supply the smooth muscle of both eyelids) - Constricted pupil (miosis; due to unbalanced parasympathetic action) - Decreased sweating

Answer 63

1. Carcinoma of the apex of the lung (usually squamous cell carcinoma) 2. Neck - Malignancy e.g. thyroid - Trauma or surgery 3. Lower trunnk brachial plexus lesions - Trauma - Tumour 4. Carotid artery lesion - Carotid aneursym or dissection - Pericarotid tumours - Cluster headache 5. Brainstem lesion - Vascular disease (e.g. lateral medullary syndrome; see nystagmus to the side of the lesion, ipsilateral pain and temperature loss (CN V), CV IX and X lesions, ipsilateral cerebellar signs and contralateral pain and temperature loss over the trunk and limbs)

Answer 64

EYES: - Partial ptosis - Miosis - Check for drecrease in sweating FACE: - Check for signs of lateral medullary syndrome -- Nystagmus to side of the lesion -- Ipsilateral pain and temperature loss (CN V) -- CN IX and X lesions (uvula deviation [to side of lesion'] and gag reflex, cough) -- ipsilateral cerebellar signs -- contralateral pain and temp loss over trunk and limbs VOICE - Hoarseness may be from a recurrent laryngeal nerve palsy HANDS - clubbing - weakness of finger abduction (if present do resp exam concentrating on the apices for lung carcinoma) NECK - lymphadenopathy - Thyroid carcinoma - Carotid aneursym or bruit

Answer 65

0 Complete paralysis 1 Flicker of contraction 2 Movement possible when gravity excluded 3 Movement possible against gravity but not if any further resistance is added 4- Slight movement against resistance 4 Moderate movement against resistance 4+ Submaximal movement against resistance 5 Normal power

Answer 66

Radial nerve - C5-8 Motor (extends UL!) - Triceps - Brachioradialis - Extensor muscle of hand Sensation - Anatomical snuff box Cfx palsy - Wrist drop - Test for triceps involvement (if affected lesion is above the upper third of the arm)

Answer 67

Median nerve C6-T1 ``` Motor Wrist flexion Finger flexors Lumbricals (leyton Hewitt sign) Thumb abduction - front muscles of the forearm except flexor carpi ulnaris and ulnar half of flexor digitorum profundus - LOAF of hand -- Lateral two lumbricals -- Opponens pollicus -- Abductor pollicis brevis -- Flexor pollicis brevis ``` Sensation - Palmar aspect of thumb, index and lateral half of ring fingers Lesions: - At wrist (carpal tunnel) - - pen touch test to assess for weakness of abductor pollicis brevis (get patient to abduct thumb towards pen held by examiner) - - Palm sensation spared - At cubital fossa - - Look for loss of flexor digitorum sublimis; get patient to clasp hands together and look for index finger sticking out

Answer 68

Median nerve C6-T1 ``` Motor Wrist flexion Finger flexors Lumbricals (leyton Hewitt sign) Thumb abduction - front muscles of the forearm except flexor carpi ulnaris and ulnar half of flexor digitorum profundus - LOAF of hand -- Lateral two lumbricals -- Opponens pollicus -- Abductor pollicis brevis -- Flexor pollicis brevis ``` Sensation - Palmar aspect of thumb, index and lateral half of ring fingers Lesions: - At wrist (carpal tunnel) - - pen touch test to assess for weakness of abductor pollicis brevis (get patient to abduct thumb towards pen held by examiner) - - Palm sensation spared - At cubital fossa - - Look for loss of flexor digitorum sublimis; get patient to clasp hands together and look for index finger sticking out

Answer 69

Ulnar nerve C8-T1 Motor Finger abduction Finger addiction Digit 4 and 5 flexion - Supplies small muscles of the hand except LOAF - Flexor carpi ulnaris - Ulnar part of flexor digitorum profundis Sensation - Palmar and dorsal aspects of the little finger and medial half of ring finger Note ulnar nerve paradox where distal lesions cause greater deformity.

Answer 70

- Ulnar and median nerve lesion (ulnar nerve palsy alone causes a claw like hand) - Brachial plexus lesion (C8-T1) - Other neurological disease, e.g. syringomyelia, polio - Ischaemic contracture (later and severe) - Rheumatoid arthritis (advanced, untreated disease)

Answer 71

``` SPINAL CORD LESION - Syringomyelia - Cervical spondylosis with compression of the C9 segment - Tumour - Trauma ANTERIOR HORN CELL DISEASE - Motor neurone disease - Poliomyelitis - Spinal muscular atrophies ROOT LESION - C8 compression LOWER TRUNK BRACHIAL PLEXUS LESION - Thoracic outlet syndromes - Trauma, radiation, infiltration, inflammation PERIPHERAL NERVE LESIONS - Median and ulnar nerve lesions - Peripheral motor neuropathy MYOPATHY - Dystrophia myotonica (forearms more affected than hands) - Distal myopathy TROPHIC DISORDERS - Athropathies - Ischaemia, inc vasculitis - Shoulder hand syndrome ```

Answer 72

COMPLETE LESION (rare): - LMN signs affect the whole arm - Sensory loss (whole limb) - Horner's syndrome - Often painful UPPER LESION (Erb) C5-6 - Loss of shoulder movement and elbow flexion; hand held in waiter's tip position - Sensory loss over the lateral aspect of the arm and forearm LOWER LESION (Klumpke) C8-T1 - True claw hand with paralysis of all the intrinsic muscles - Sensory loss along the ulnar side of the hand and forearm - Horner's syndrome Cervical rib syndrome - Weakness and wasting of the small muscles of the hand (claw hand) - C8 and T1 sensory loss - Unequal radial pulses and blood pressure - Subclavian bruits on arm manoeuvering - Palpable cervical rib

Answer 73

1. Inflammation, autoimmune (more common upper brachial plexus) 2. Radiotherapy (more often upper brachial plexus) 3. Cancer (more often lower; usually painful, weakness and sensory loss present) 4. Trauma

Answer 74

Sensory - Lateral aspect of thigh No motor

Answer 75

Femoral nerve L2, L3, L4 MOTOR: - Knee extension - Absent knee jerk SENSORY: - inner aspect of thigh and leg

Answer 76

Sciatic nerve L4, L5, S1, S2 MOTOR: - All muscles below the knee and hamstrings SENSATION: - posterior thigh - lateral and posterior calf CFx palsy: - Foot drop - Knee jerk intact but ankle jerk and plantar responses absent

Answer 77

Common peroneal L4, L5, S1 MOTOR (branch of sciatic) - Anterior and lateral compartment muscles of one leg CFx palsy: - Foot drop - Intact reflexes - Inversion preserved - Minimal sensory loss over the lateral aspect of the dorsum of the foot NOTE: L5 palsy has weakness of knee flexion and loss of foot inversion as well as sensory loss in L5 distribution.

Answer 78

Hemiplegic gait = foot is plantar flexed and the leg is swung in a lateral arc

Answer 79

Spastic paraparesis = scissors gait

Answer 80

Parkinson's gait = hesistation in starting - Shuffling - Freezing - Festination - Propulsion - Retropulsion

Answer 81

Cerebellar = a wide based or reeling on a narrow base. The patient staggers towards the affected side if the lesion is unilateral.

Answer 82

Foot drop = high stepping gait

Answer 83

Proximal myopathy = waddling gait

Answer 84

Prefrontal lobe (apraxic) = feet appear glued to floor when erect, but move more easily when the patient is supine

Answer 85

Walk on toes = not possible if S1 lesion Walk on heels = not possible if L4 of L5 lesion causing foot drop

Answer 86

UMN lesion = lesion at level above anterior horn cell (e.g. cerebral cortex, internal capsule, brainstem, spinal cord) CFx: - Upper limb drift - Hyperrelfexia - Extensor (upgoing) plantar response - Pyramidal weakness (UL flexors strong, LL extensors strong) - No muscle wasting - Increased tone / spasticity (due to destruction of the corticoreticulospinal tract) Causes: VASCULAR: thrombosis, embolism, haemorrhage. Thrombosis of internal carotid artery (may hear bruit). COMPRESSIVE/INFILTRATIVE: tumours, false localising signs from raised ICP (typically see 6th nerve palsy due to 6th nerves long path). DEMYELINATING DISEASE: MS INFECTION: HIV

Answer 87

Anterior cerebral artery = leg>arm involvement Penetrating branches of MCA = lacunar infarct Internal carotid / MCA = aphasia or non-dominant hemisphere dysfunction, hemiplegia contralaterally to lesion, homonymous hemianopia. Posterior cerebral artery = homonymous hemianopia, no hemiplegia Basilar artery = quadriplegia Penetrating branches of basilar artery to brainstem = brainstem infarct PICA (posterior inferior cerebellar artery) = laterally medullary syndrome (ipsilateral facial sensation changes, contralateral body sensory deficits)

Answer 88

- Weakness (may be more pronounced distally>proximally, all muscles equally involved) - Muscle wasting - Normal tone - Reduced reflexes with normal or absent plantars - Fasciculations may be present LMN lesion = interruption of reflex arc, thus lesion of the spinal motor neurones, motor root or peripheral nerve

Answer 89

- Unknown pathophys but pathology in anterior horn cell,s motor nuclei of the medulla and descending tracts CFx: - Combination of UMN and LMN signs - Fasiculations almost always present - Muscle stretch reflexes usually present until late in disease - No objective sensory changes

Answer 90

CFx: - Distal part of nerves involved first due to distance from the cell bodies - Can be loss of sensation or motor function - Typically symmetrical glove and stocking loss to all modalities - Peripheral weakness may be present if motor nerve involvement - If motor without sensory involvement reflexes may be reduced but should not be absent

Answer 91

MM = separate involvement of more than one peripheral or cranial nerves by a single disease ACUTE: - Polyarteritis nodosa - Diabetes - CTD: rheumatoid arthritis, SLE CHRONIC: - Multiple compressive neuropathies - Sarcoidosis - Acromegally - HIV

Answer 92

Spinal cord lesion causes LMN AT THE LEVEL of the lesion and UMN BELOW LEVEL of lesion. Examples: - C5: LMN weakness and wasting of rhomboids, deltoids, biceps and brachioradialism. UMN affecting the rest of UL and LL. - C8: LMN weakness and wasting of instrinsic muscles of the hand. UMN signs in LL. - T10/T11: loss of lower abdominal reflexes and upward displacement of umbilicus. UMN in LL. - L5-S1: LMN weakness of knee flexion and hip extension (S1) and abduction (L5) plus calf and foot muscles. Knee jerks present, no ankle jerks or plantar responses. Anal reflex present. - S3-S4: no anal reflex, saddle sensory loss, normal lower limbs.

Answer 93

Brown sequard = half cord (coronally) affected (partial unilateral cord lesion) CFx: - Loss of pain and temperature sensation on the opposite side to the lesion - Loss of vibration and proprioception on the same side of the lesions - UMN BELOW the hemisection on the same side as the lesion, LMN AT the level of the hemisection on the same side Causes: - MS - Angioma - Trauma - Myelitis - Post radiation myelopathy

Answer 94

CFx: - Posterior column loss symmetrically-> ataxic gait - UMN signs in LL symmetrically - Absent ankle reflex but knee reflex may be exaggerated or absent - Peripheral sensory neuropathy - Optic atrophy - Dementia

Answer 95

Syringomyelia = central cavity in spinal cord CFx: - Loss of pain and temp over neck, shoulders and arms (like a cape) - Amytrophy (atrophy and areflexia) of the arms - UMN signs in lower limb

Answer 96

``` # MYOPATHY - Polymyositis / dermatomyositis - Muscular dystrophy (Becker, Duchenne, facioscapulohumeral musclar dystrophy) - Endocrine: cushing's, hypothyroidism, acromegally - Drugs (steroids, statins) # NEUROMUSCULAR JUNCTION DISEASE - myasthenia gravis - Lambert-Eaton syndrome # NEUROGENIC: - MND - Kugelberg-Welander disease - CIPD (motor predominant) ``` Myopathy on EMG = early recruitment Kugelberg-Welander disease = proximal muscle wasting and fasiculation due to anterior horn cell disease. Autosomal recessive.

Answer 97

- HEREDITARY MUSCULAR DYSTROPHY (Becker, Duchenne, facioscapulohumeral musclar dystrophy) - CONGENITAL MYOPATHIES - ACQUIRED MYOPATHIES (PACE) - - Polymyositis or dermatomyositis - - Alcohol, AIDS (HIV infection) - - Carcinoma - - Endocrine, e.g. hyperthyroidism, hypothyroidism, Cushing's syndrome, acromegaly, hypopituitarism - Periodic paralysis (hyperkalaemic, hypokalaemic or normokalaemic) - - Osteomalacia - - Drugs (clofibrate, chloroquine, steroids, zidovudine) - - Sarcoidosis

Answer 98

DUCHENNE'S (psuedohypertrophic) - Affects only males (sex-linked recessive) - Calves and deltoids: hypertrophied early, weak later - Proximal muscle weakness: early - Dilated cardiomyopathy # BECKER - Affects only males (sex-linked recessive) - Similar features to Duchenne's but less heart disease, a later onset and less rapid progression # LIMB GIRDLE - Males or females (autosomal recessive), onset in the third decade - Shoulder or pelvic girdle affected - Face and heart usually spared # FACIOSCAPULOHUMERAL - Males or females (AD) - Facial or pectoral weakness with hypertrophy of deltoids # Dystrophia myotonica (AD) - AD - Frontal baldness - Expressionless triangular facies - Atrophy of the temporalis muscle and partial ptosis - Difficulty releasing hands post contraction - Cataracts - Atrophy of sternomastoid - Cardiac failure - Proximal muscle wasting and weakness

Answer 99

FACE: frontal bossing, expressionless triangular facies, atrophy of the temporalis muscle EYES: partial ptosis, cataracts / lens disease NECK: atrophy of sternomastoid, weak neck flexion with normal extension UPPER LIMBS: shake hands and test for percussion myotonia (tapping over thenar eminence causes contraction and then slow relaxation of abductor pollicus brevis), arm wasting, UL weakness (forearms affected first), slow to release hand grip. No sensory changes CHEST: gynaecomastica, cardiomyopathy TESTES: atrophy LOWER LIMB: tibial nerves affected first ASK: test urine for sugar as assoc with T2DM

Answer 100

1. Pes cavus (short arched feet) 2. Distal muscle atrophy due to peripheral nerve degeneration - This dose not usually extend above the elbows or above the middle third of thigh 3. Absent relfexes 4. Slight or sensory loss in the limbs 5. Thickened nerves 6. Optic atrophy, Argyll Robertson pupils

Answer 101

- Muscle power decreases with use - Little muscle wasting and no sensory change TEST: - Oculomotor muscles by getting patient to sustain upgaze for one minute, look for progressive ptosis - Peek sign: test for orbicularis oculi weakness, ask pt to close eyes, if positive within 30 seconds the lid margin will begin to separate showing the sclera. - UL proximal girdle, ask pt to hold arms above the head and repeatedly press the abducted arms down until they weaken. Power will decrease with repeated muscle contraction. Look for thymectomy scar

Answer 102

- Occur on the same side of the lesion as most cerebellar fibres cross twice in the brainstem (on entry and exit to the cerebellum) CFx - Jerky horizontal nystagmus - Explosive, jerky or loud speech with irregular separation of syllables (get pt to say Bristish Constitution) - UL drift due to hypotonia of the agonist muscles (hypotonia due to loss of a facilitatory influence on the spinal motor neurones) - Intention tremor (increases as target is approached, due to loss of cerebellar connections in the brainstem) - Dysdiadochokinesis - Truncal ataxia - Gait-> patient will stagger towards affected side if there is a unilateral cerebellar hemisphere lesion

Answer 103

``` ROSTRAL VERMIS LESION (only LL affected) - Alcohol UNILATERAL 1. Space occupying lesion (tumour, abscess, granuloma) 2. Ischaemia (vertebrobasilar disease) 3. Multiple sclerosis 4. Trauma BILATERAL 1. Drugs- e.g. phenytoin 2. Alcohol (possibly due to thiamine connection) 3. Friedreich's ataxia 4. Spinocerebellar atrophy 5. Paraneoplastic syndrome 6. Multiple sclerosis 7. Trauma 8. Arnold-Chiari malformation (lower CN palsy, cerebellar signs in limbs, UMN signs in legs) 9. Large space occupying lesion, cerebellar disease 10. Hypothyroidism MIDLINE 1. Paraneoplastic syndrome 2. Midline tumour ```

Answer 104

Autosomal recessive 1. Bilateral cerebellar signs including nystagmus 2. Pes cavus, cocking of the toes, kyphoscoliosis 3. UMN in the limbs with absent reflexes 4. Peripheral neuropathy 5. Posterior column loss in the limbs 6. Cardiomyopathy 7. Diabetes mellitus 8. Optic neuropathy (uncommon) 9. Normal mentation

Answer 105

- MS - Spinocerebellar degeneration - Arnold chiari malformation (lower CN palsy, cerebellar signs in limbs, UMN signs in legs) - Syringomyelia - Ischaemia - Meningioma / tumour

Answer 106

Extrapyramidal disease with degeneration of the substantia nigria and its pathways leading to dopamine deficiency and an excess of cholinergic transmission CFx: GENERAL: - Mask like facies with few spontaneous movements GAIT (ask patient to rise from chair, walk, turn, quickly stop and start): - Shuffling gait (small steps with lack of arm swing.), difficulty initiating walking and difficulty stopping. - Bradykinesia (decrease in the speed and amplitude of complex movements); can test finger tapping and twiddling (rotating hands in front of the body) TREMOR: - Asymmetrical resting tremor; characteristic movement is pill rolling - Tremor decreases with finger-nose testing TONE: - Increased / cogwheel ridigity FACE: - Glabellar tap (continues to blink when forehead tapped) SPEECH: - Soft and monotonous EYES: - Weakness of upward gaze (if marked rigidity and paralysis of gaze consider PSP) BP: - Orthostatic hypotension WRITING: - Micrographia

Answer 107

1. Parkinsonian (resting tremor) 2. Postural/action tremor (present throughout a movement) - Idiopathic - Anxiety - Drugs - Familial - Thyrotoxic 3. Essential / familial 4. Intention tremor (cerebellar disease, increases towards target) 5. Midbrain tremor (abduction-adduction movements of upper limbs with flexion-extension wrists (usually associated with intention tremor)

Answer 108

Affected side dilates when light shone in (on repeated testing) ``` Causes: Pathology after optic chiasm - retinal artery occlusion - large retinal attachment - retinal vein occlusion - optic nerve (optic neuritis, MS, compression) ```

Answer 109

``` Demelinating E.g. diabetes, paraprotein, CMT, CIDP - decreased velocity - increased distal latency - normal amplitude ``` Axonal E.g. diabetes mellitus, toxins, metabolic, paraneoplastic - decreased amplitude - velocity normal >70%

Answer 110

Peroneal nerve (L4, L5, S1, S2) - Decreased eversion - Normal power at knee - Decreased sensation at dorsum of foot - Ankle reflex intact Sciatic nerve (L4-S3) - Flaccid foot, reduced eversion and inversion - Reduced flexion at knee - Decreased sensation posterior thigh and below knee - Intact knee jerk - Absent ankle jerk L4/5 nerve root - Reduced inversion and eversion - Normal knee power - Dermatomal sensory loss - Ankle jerk intact

Answer 111

- Myasthenia gravis - Mitochondrial disorders - Grave's disease - Multiple CN affected (mononeuritis multiplex, MS)

Answer 112

``` # Myopathic - Inclusion body myositis - Muscular dystrophies (FSH) # NMJ - Myasthenia gravis # Neuropathic (peripheral neuropathy with motor predominance) - Hereditary sensory and motor neuropathy - Spinal muscular atrophy (UMN) - CIDP (LMN) - Multifocal motor neuropathy (LMN) - Diabetes ```

Answer 113

UNILATERAL - Horner's syndrome - CNIII palsy - Myasthenia gravis BILATERAL - Myasthenia gravis - Senile - Eyelid oedema (infection, allergy) - Muscular dystrophy, e.g. oculopharyngeal MD

Answer 114

- Freidreich's ataxia - Idiopathic - Hereditary motor and sensory neuropathy - Neuropathies in childhood

Answer 115

- Thyroiditis (hashimoto's, subacute) - Post partum or pregnancy - Idiopathic - Iodine deficiency - Grave's disease - Lithium - Hormone synthesis errors

Answer 116

- MS - Toxins (amiodarone, ethambutol) - Metabolic - Autoimmune disease - Malignancy - Infective (syphillis, CMV, VZV)

Answer 117

- Nystagmus to the side of the lesion - Ipsilateral CN V, X and sometimes XI lesion - Ipsilateral cerebellar signs - Contralateral pain and temp loss over trunk Causes of lateral medullary syndrome - Ischaemia to lateral medulla secondary to vertebral artery or posterior inferior cerebellar artery

Answer 118

- Focal glomerulosclerosis - Membranoproliferative GN - Anti-GBM - IgA nephropathy

Answer 119

``` Warm (IgG and C3 +ve) - autoimmune lymphoma (NHL) - CTD - drugs - idiopathic Cold (C3 +ve) - glandular fever - mycoplasma infection - hepatitis C - If chronic: lymphoma, idiopathic ```

Answer 120

- Diabetes - Alcohol - Nutritional (B12, B6, folate) - Drugs (vincristine, cisplatinum, amiodarone, bortezimib, phenytoin, izoniazid) - AIDP / CIPD - Paraneoplastic syndrome - Amyloid, sarcoidosis - Hypothyroidism - Porphyria - Renal - Congenital

Answer 121

DAV CHAP - Diabetes - Alcohol - B12 def - Carcinoma - Arsenic - Porphyria

Answer 122

- Soft tissue swelling - Juxta articular osteopenia - Subluxation and ulnar deviation of MCP joints - Radial deviation at the wrist - Marginal erosions - joint space narrowing

Answer 123

- Subchondral cysts - Subchondral sclerosis - Joint space narrowing - Osteophytosis - may see erosions

Answer 124

- Pencil in cup deformity (marginal erosions + adjacent bony proliferation) - Small joint ankylosis (joint immobility / consolidation) - Osteolysis of phalangeal and metacarpal bone - Telescoping of digits and periostitis - Proliferative new bone at sites of enthesitis - Joint destruction

Answer 125

- Hindfoot eversion - Plantar subluxation at the metatarsal heads - Forefoot widening - Hallux valgus - Lateral deviation and dorsal subluxation of the toes

Answer 126

- Total cholesterol < 4 - LDL <1.8 - HDL >1 - Triglycerides < 2 If low risk - Total cholesterol < 5.5 - LDL < 4

Answer 127

- RA - Psoriatic arthritis - SLE (jacoud arthopathy) - MCTD

Answer 128

1. Volume overload (AR, MR, PDA) 2. Pressure overload (HT, AS) 3. Myocardial disease (IHD, dilated cardiomyopathy)

Answer 129

1. Volume overload (ASD, TR) 2. Pressure overload (PS, pulmonary HT) 3. Myocardial disease (cardiomyopathy secondary LHF, right ventricular infarction)

Answer 130

1. Volume overload (ASD, TR) 2. Pressure overload (PS, pulmonary HT) 3. Myocardial disease (cardiomyopathy secondary LHF, right ventricular infarction)

Answer 131

``` Hashimoto thyroiditis - Graves disease - Familial or sporadic multinodular goitre Iodine deficiency Follicular adenoma Colloid nodule or cyst Thyroid cancer ```

Answer 132

- Seven big squares V1 + V5 or V6

Answer 133

>15 benefit for transplant | Consider referral at 10-12

Answer 134

Biceps C5 (musculocutaneous n) Brachioradialis C6 (radial n) Triceps C7 (radial n)

Answer 135

- anti-GAD antibody positive (glutamine acid decarboxylase) - insulin antibodies - c peptide level (correlate to insulin level)

Answer 136

- Anti-Jo-1(assoc anti-synthetase synd) | - Anti-Mi-2 (dermatomyositis)

Answer 137

C-ANCA (anti-protinase 3) - granulomatosis with polyangitis P-ANCA (anti-MPO) - microscopic polyangitis - eosinophilic granulomatosis with polyangitis

Answer 138

- Pneumonectomy - Agenesis of lung - Pulmonary fibrosis - Lobar collapse

Answer 139

- Pleural effusion | - Tension pneumothorax