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DPD 2020 > interactive cases in general internal medicine 4 > Flashcards

interactive cases in general internal medicine 4 Flashcards

1
Q

In an upper motor neurone lesion

describe the

TONE:

POWER
REFLEXES

A

TONE: increased (spasticity)

POWER (decreased)
​REFLEXES (increased)

plantar going up

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2
Q

In an lower motor neurone lesion

describe the

TONE:

POWER
REFLEXES

A

TONE: reduced (flacid)

POWER: reduced
REFLEXES: decreased

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3
Q

What does this patient have?

Diplopia (bilateral 6th) • Bilateral ptosis • Slurred speech • Dysphagia • Sluggish pupillary response to light • Descending symmetric muscle weakness • Multiple skin abscesses on arms & legs

A

Work through it:

Diplia is caused by damage to cranial nerve 3,4,6

Slurred speech and dysphasia: 9,10

The are not close together and it is therefore a problem with the neuromuscular junction

BOTULINUM TOXIN- IVDU user

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4
Q

What are cerebellar signs

A

dysdiadochokinesis

ataxia

nystagmus

intention tremor

Speech scanning and slurred

Heel-shin test positivity/ Hypotonia

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5
Q

How do you classify abnormal sensation and where could the pathology be?

A

Hemisensory loss - Cerebral cortex

Level (e.g. umbilicus) - Spinal cord

Dermatome(s) - Nerve roots (Radiculopathy)

Specific area - Mononeuropathy

Glove & stockings -Polyneuropathy

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6
Q

55 yr old man • Numbness & tingling in hands & feet • PMH: type 1 DM • On basal/bolus insulin • HbA1C: 50 mmol/mol • B12: 500 pg/ml (200 – 900) • eGFR: 90 • reduced Sensation to PP (glove & stocking distribution)

What would you prescribe?

A. Codeine

B. Duloxetine

C. Hydroxocobalamin

D. Paracetamol

E. Morphine

A

B. Duloxetine

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7
Q

What are causes of peripheral neuropathy?

What conditions would go under the different headings

A
  • Vascular
    • Vasculitis
  • Infection:
    • HIV
  • Inflammation/Autoimmune:
    • CTD
    • inflammatory demyelinating neuropathy
  • Toxic/Metabolic:
    • Drugs (Hx): metronidazole
    • Alcohol (high GGT &MCV)
    • B12 deficiency (Anaemia, high MCV)
    • Diabetes (Hx, glucose/ HBA1c)
    • Hypothyroidism (TFT’s)
    • Uraemia (U&E)
    • Amyloidosis (History of myeloma or chronic infection/inflammation)
  • Tumour/Malignancy:
    • Paraneoplastic
    • Paraproteinaemia
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8
Q

34 yr old woman • Weakness in legs • Blurred vision • Legs:increased tone, reduced power & brisk reflexes • reduced PP sensation in legs • Fundoscopy

What is the cause of her blurred vision?

A. Amaurosis fugax

B. Anterior uveitis

C. Papilloedema

D. Papillitis

E. Vitreous haemorrhage

A

D. Papillitis - painful

[Also known as optic neuritis]

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9
Q

What is a hereditary cause of peripheral neuropathy

A

– Hereditary sensory motor neuropathy

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10
Q

A man presents with this foot and peripheral neuropathy

What is the cause of his peripheral neuropathy?

A

Hereditary sensory motor neuropathy

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11
Q

What does optic neuritis present as?

A
  • Blurred optic disc margins
  • Blurred vision
  • Pain on eye movement
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12
Q

A patient presents with this?

  • Blurred optic disc margins
  • Blurred vision
  • Pain on eye movement

What does the patient have

A

Optic neuritis (papillitis)

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13
Q

What pathways could be affected in the spinal cord?

What symptoms would they produce?

What would could be the cause?

A

What pathways could be affected in the spinal cord?

  • Corticospinal
  • Spinothalamic tracts

What symptoms would they produce?

Spastic paraparesis

What would could be the cause?

  • Vascular
  • Infection: TB (Pott’s disease)
  • Inflammation (demyelination)
    • Transverse myelitis
  • Toxic/Metabolic: B12, suba
  • Tumour/Malignancy
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14
Q

In MS what is very important to make a clinical diagnosis

A

Two lesions

Separated in time/space

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15
Q

60 year old man • Pain & paraesthesia on anteriolateral thigh • PMH: Type 2 Diabetes • Metformin • HbA1C: 60 mmol/mol • BMI: 30 kg/m2 • decreased PP sensation anterolateral thigh

What is the most appropriate next step in his management?

A. Lose weight

B. Insulin

C. Statin

D. Aspirin

E. MRI Brain

A

A. Lose weight

Meralgia paresthetica

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16
Q

What is meralgia parasthetica ?

WHat is the treatment?

A

What is meralgia parasthetica ?

Compression of lateral femoral cutaneous nerve

What is the treatment?

Conservative treatment:

  • Reassure
  • Avoid tight garments
  • Lose weight

Medical (if persistant)

  • Carbamazepine
  • Gabapentin
17
Q

What is the sensory innervation of the hand?

A

median nerve: green - abductor brevis and

ulnar: blue -

Radial nerve: red - extensors weakness

18
Q

What is radiculopathy?

What could it be caused by?

A

What is radiculopathy? Disease of the nerve roots

What could it be caused by?

  • Disc herniation
  • Spinal canal stenosis
19
Q

What are the lumbosacral radiculopathy symptoms?

A
  • Pain in the buttock,
  • radiating down the leg below the knee (‘sciatica’)
20
Q

What are the dermatomes of the arm?

21
Q

60 year old man • Recurrent falls • Tremor at rest • Rigidity • More forgetful • Dysphagia • Micrographia • Limited upgaze

What is the most likely diagnosis?

A. Progressive supranuclear palsy

B. Lew body dementia

C. Stroke

D. Epilepsy

E. Alzheimer’s disease

A

progressive supranuclear palsy

22
Q

What are parkinsonian features?

A
  • Tremor, rigidity, bradykinesia
  • Parkinsonian features, upgaze abnormality
  • Features of Alzheimer’s disease, Parkinson’s & hallucinations
23
Q

What are other conditions that give a Parkinsonian picture?

A
  • Parkinson’s disease
    • Dopaminergic neurons
    • Substantia nigra
  • PSP (Steele‐Richardson syndrome)
  • Lew body dementia
24
Q

A 55‐yr‐old man • Confusion & chest pain • No headache or neck stiffness • Recently moved to a new house. • Temp: 37oC • PR 110, BP 120/60 • Normal CVS/Resp/GI/Neuro exam

Initial tests:

  • ECG: sinus tachycardia, widespread ST depression
  • Urinalysis: NAD
  • Blood glucose: 7.0 mmol/L
  • WCC: 7
  • CRP
  • CT head: NAD

What is the most likely cause of his confusion?

A. Vascular

B. Infection

C. Inflammation

D. Toxic/Metabolic

E. Tumour

A

carbonmonoxide poisoning

25
What are causes of apparent confusion with a reduced AMTS? WHat questions would you ask to exclude them?
* **Post‐ictal -** *History of seizure?* * **Dysphasia** * Receptive or expressive (*Other features of stroke/TIA)* * **Dementia** * Vascular (multi‐infarct) - *History of IHD/PVD* * Alcoholic - *History of IHD/PVD* * Alzheimer’s disease * Inherited e.g. Huntington’s disease (HD) - *History of IHD/PVD* * **Depressive** pseudodementia * *Elderly, withdrawn, poor eye contact* * *Precipitating factor*
26
What are causes of confusion with reduced conscouisness?
* **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, Endocrnipathies
27
What are the questions in the AMTS?
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
28
Describe the GCS scale and how it works
_EYES***(**4 letters*): 4_ 4 = Spontaneous 3 = Opens in response to voice 2 = Opens in response to painful stimuli 1 = Does not open _Verbal response (*V - roman 5*): 5_ 5 = Oriented 4 = Confused 3 = Words 2 = Sounds 1 = No sounds _MOTOR RESPONSE (5+1)_ 6 = Obeys commands 5 = Localizes pain 4 = Withdraws to painful stimuli 3 = Abnormal flexion 2 = Extension 1 = No movements
29
Someone presents in A& E with a headache what are your differentials? What would be signs in the history?
* Meningitis - Fever, neck stiffness, photophobia * Subarachnoid haemorrhage - sudden onset * Giant cell arteritis - over 50 years old * Polymyalgia rheumatica – (Shoulder girdle pain, stiffness, constitutional upset) * Migraine- Throbbing, vomiting, photo/phonophobia, FHx, Aura
30
What test would you do for a Subarachnoid haemorrhage?
* CT * LP (xanthochromia)
31
What test would you do for giant cell arteritis?
**ESR** maybe a biopsy of temporal artery but negative doesn#t mean they don't have it
32
What is the treatment for giant cell arteritis?
high dose corticosteroids Bx
33
What sign would you see in menigism?
Kernig’s sign Brunzinsky
34
How would you manage a stroke?
**CT:** no haemorrhage **Thrombolysis** (if no contraindications) _\> 4.5 hours_ **CT head** (exclude haemorrhage) **Aspirin** (300mg), Swallow assessment **Maintain hydration**, oxygenations, monitor glc
35
How do you manage a TIA
* Aspirin * Don’t treat BP acutely * unless \> 220/120 * other indication * ECG, Echocardiogram * Carotid Doppler * Risk factor modification
36
40 year old • Backache • LMN weakness • Admitted to HDU • Regular FVC • Cardiac monitor • IVIG **What is the most likely diagnosis?** Guillain‐Barre B. Stroke C. Cord compression D. Cauda equina syndrome E. Myasthenia gravis
guillain barre syndrome
37
What are causes of a collapse?
* **Low glucose** * **Heart** * **Vasovagal:** sick sinus syndrome * **Arrhythmia**: AF, IHC, SVT, VT, long QT, brigada, complete heart blick * **Outflow obstruction**: HOCM, aortic stenosis * **Postural hypotension** * **Brain** – Seizure
38
What is amyloidosis?
deposition of abnormal protein in tissue that interfere with structure and function 1. can be due to light chain deposition in myeloma 2. chronic inflammation/ inflammation **Serum amyloid A protein**
39
What is Pott's disease?
TB affecting the spine

DPD 2020 (48 decks)

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