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Flashcards in Mirza's Cases Deck (56):
1

What lesion is down and out pupil?

3rd nerve palsy

2

What are the causes of a 3rd nerve palsy?

Surgical = SOL, posterior communicating artery
Medical = Diabetes, HTN, MS

3

Does the pupil dilate early or late in surgical 3rd nerve palsy?

Early, due to the parasympathetic fibres running along the outside of the nerve

4

What investigations would you like in a 3rd nerve palsy?

Blood pressure and blood sugars to assess for medical causes

5

A patient has a unilateral ptosis on their right side, what are the differentials?

Horners = small pupil

Myasthenia = normal pupil

3rd nerve palsy = dilated pupil

6

Causes of a bilateral ptosis?

Myasthenia graves

Dystrophia myotonica

7

How would a 6th nerve palsy present?

Inability to abduct the affected sides eye

8

Causes of a 6th nerve palsy?

HTN, diabetes

MS

Raised ICP

9

What are the signs of raised ICP?

Earliest sign is loss of retinal vein pulsation, latest is papilloedema

Cushings triad = Bradycardia, HTN, irregular breathing

Reduced GCS

6th nerve palsy - gets pinched at the petrous temple bone

3rd nerve palsy

10

When do you get double vision in a 6th nerve palsy vs a 4th?

6th is when looking towards the affected side
Outer image comes from the affected eye, disappears on closing that eye .

4th is when looking down and inwards

11

Patient has hypertonia in both legs, reduced power, increased reflexes and clonus. Ddx?

Cord compression

Cervical spondylosis

MS

MND

CVA

12

What is spasticity vs rigidity?

Rigidity is the same throughout

Spasticity = clasp like, difficult to initiate then eases off. Extensors in lower limbs and flexors in upper limbs.

13

Patient has cord compression after our lower limb exam before, what else do we want to do and what questions should we ask?

Check sensory levels and examine upper limbs + cranial nerves

Examine sacral sensation

Ask: Any urinary incontinence, or faecal incontinence. Have they noticed any change in the sensation when weeing?

14

Ddx for wasting of the thenar and hypothenar eminences?

Bilateral:
- Rheumatoid
- Cervical spondylosis
- MND
-CMT
- Syringomyelia

Unilateral:
- Cervical rib
- Pancoasts
- Brachial plexus trauma

15

Three reasons for a CXR in a stroke patient?

Risk of aspiration pneumonia

Lung malignancy can metastasise to the brain

Enlarged heart = CCF and HTN

16

What are the features of neurofibromatosis 1?

Which chromosome affected?

Cafe au lait spots
Axillary freckling
Fibromas = subcutaneous, and plexiform
Eye = Lisch nodules (brown iris hamartomas)

Neoplastic change in 10% e.g. Phaeo's, meningiomas
Orthopaedic scoliosis
IQ reduced
Renal = RAS = HTN

Chr 17

17

How many cafe au last spots is diagnostic and how big should they be?

6

>15mm

18

What are the features of neurofibromatosis 2 and chromosome?

Bilateral acoustic neuroma = SNHL

Chromosome 22

19

Types of facial nerve palsy?

UMN is forehead sparing

LMN is everything:
- Bells palsy = unknown aetiology
- Ramsay hunt syndrome is reactivation of varicella zoster virus in the geniculate ganglion of CN8

20

What else to examine / ask about?

Change in taste as facial does anterior 2/3rds of the tongue (via the chord tympani branch of CN7)

Examine ear for any rash

Ask about any extremely loud sounds (hyperacusis due to the stapedius branch of CN7)

21

Extracranial branches of facial nerve?

Temporal
Zygomatic
Buccinator
Marginal mandibular
Cervical branch

22

How do you localise a facial palsy?

If symptoms of CN7 + 6 = pons

If symptoms of CN7 + 5 + 8 = cerebello-pontine angle
- For cranial nerve 5 can test corneal reflex (afferent branch is trigeminal, so if both eyes don't close it is this)

23

Types of CMT, and how to differentiate?

Hereditary sensory and motor neuropathy
Autosomal dominant

CMT1 = commonest, demyelinating lesion = velocity <38m/s

CMT2 = Axonal pathology, velocity >38m/s

24

PC in CMT?

Often presents with small muscle wasting of the hands.
Walking difficulty = high stepping gait and foot drop

Reduced reflexes, muscle strength and sensation

Pes Cavus

25

How does Friedrich's ataxia commonly present?

Spina-Cerebellar degeneration = cerebellar signs e.g. ataxia

26

Non-neurological signs of Friedrich's ataxia?

Pes cavus
Cardiac = HOCM
DM

27

How does MND commonly present?

Fasciculations

28

Describe a psoriatic rash?

Salmon pink circular discoid patches, with silver discolouration on flexor surfaces and buttocks

29

Where else would you examine for psoriasis?

Scalp and behind the ears

Nails = pitting, onycholysis

Joints

30

What is the koebner phenomenon?

Purple lesions associated with scarring

31

MI complications?

Short term:
- VF
RCA = sinus bradycardia, 1/2 HB
- LAD = Complete heart block
- MR due to papillary rupture
- Dresslers

Long term:
- Arrhythmias
- MI
- CCF

32

Triad of Parkinson's?

Bradykinesia
Pill rolling tremor
Rigidity

33

What're the Parkinson's plus syndromes?

MSA, corticobasal degeneration and PSP

34

Signs of PSP?

Supranuclear gaze and postural instability

Rocket sign, ask them to get up out of the chair and they shoot up

35

What three conditions make up MSA, and signs?

Olivopontocerebellar atrophy
Shy-drager
Striatonigral degeneration

Autonomic dysfunction = postural hypotension, bladder dysfunction
Cerebellar signs
Rigidity > tremor

36

Extra-articular features of rheumatoid?

Atlanto-axial instability due to weakening of the transverse ligament holding odontoid of C2 against anterior arch of C1

Nodules

Anaemia

Splenomegaly in Felty's

Fibrosis and pulmonary nodules

37

Clinical features of Pagets?

Bowed legs, frontal bossing
Joint pain
Hearing loss

38

What do people with Paget's die from?

High output heart failure

As bones become larger = bigger capillary network = big volume = big heart

39

If you have a mix of UMN, and LMN with no sensory what is it?

MND

40

Causes of hypoglycaemia?

SAILS Q

Sulphonylureas
Alcohol
Insulin OD
Liver disease
Sepsis
Quinines

41

What is Addison's and signs?

Primary adrenal failure = low cortisol so high ACTH

Low sodium and high potassium

Postural hypotension, vitiligo, hypoglycaemia, hyper pigmentation as excess ACTH = POMC

42

Causes of Addison's?

Autoimmune is commonest in UK
TB is commonest worldwide
Amylodiosis

43

Investigations for Addisons?

Mx?

Lying and standing BP
Synacthen test
Glucose

Steroids IV hydrocortisone fast and fluids

Then long term hydrocortisone and fludrocortisone

44

What murmur is ejection systolic?

Classic signs?

Aortic stenosis

Syncope, exertion dyspnoea and angina
Radiates to carotids
Slow rising pulse, and narrow pulse pressure

45

Investigations for AS?

Mx for AS?

TTE is definitive
ECG = LAD and LVH (Tall R wave in V5/6, Deep S in V1/V2)

MDT
Cons = Diet, exercise, weight
Medical = Mx any co-morbidities

Surgical:
- Asymptomatic valve replacement if EF <50%
- Symptomatic
- low risk = aortic valve replacement
- high risk surgical patient = TAVR

Long term anticoagulation if mechanical valve aiming for 3-4
Long term IE prophylaxis

46

What is an EDM? What does it change to when severe?


Signs?

Aortic regurgitation

Low pitched mid-diastolic murmur = AUSTIN FLINT

LVF = orthopnea, PND, exertion dyspnoea
Collapsing pulse
De Mussets
Quinckes

47

Management of aortic regurgitation?

Severe asymptomatic:
- EF > 50 = vasodilator therapy


Symptomatic or asymptomatic EF <50:
- Aortic valve replacement / TAVR

48

Blowing PSM?

Features?

Mitral regurgitation

Exertional dyspnoea
Angina
Radiates to axilla
Soft S1

49

Causes of aortic stenosis?

Valvular causes = True congenital defect, calcificaition, rheumatic fusion

Sub-valvular = LV hypertrophy

50

Causes of aortic regurgitation?

Acute = IE and aortic dissection

Chronic = Bicuspid valve and rheumatic heart disease

51

Causes of mitral regurgitation?

Acute = papillary muscle rupture post-MI, IE, rheumatic fever

Chronic = Mitral valve prolapse, LV dilation (AR, AS, HTN, dilated cardiomyopathy) , calcification

52

Investigations and management of MR?

Acute MR = Valvuloplasty or annuloplasty

Chronic - EF >60 = ACEI and BB

Chronic EF <60 / symptomatic = Medical and surgical

53

MDM?

Signs?

Mitral stenosis

Dyspnoea
Angina
Opening snap, tapping apex
Low pitched rumbling

54

Investigations and Mx of mitral stenosis?

Ix = ECG:
- AF
- LAH = bifid p wave / p-mitrale
- Also see RVH due to pulmonary congestion = Tall R in V1/V2, deep S in V5/V6.

Echo

Mx:
- Mild disease = No therapy
- Symptomatic = Valve repair / replacement

55

Late systolic murmur with systolic click?

Mitral valve prolapse (barlow syndrome)

Medical = Aspirin / warfarin, BB's
Surgical = Mitral valve repair

56

Causes of heart failure?

Myocardial damage = Infarction, toxins e.g. anabolic steroids, infiltration