Flashcards in Mirza's Cases Deck (56):
What lesion is down and out pupil?
3rd nerve palsy
What are the causes of a 3rd nerve palsy?
Surgical = SOL, posterior communicating artery
Medical = Diabetes, HTN, MS
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
What investigations would you like in a 3rd nerve palsy?
Blood pressure and blood sugars to assess for medical causes
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
Causes of a bilateral ptosis?
How would a 6th nerve palsy present?
Inability to abduct the affected sides eye
Causes of a 6th nerve palsy?
What are the signs of raised ICP?
Earliest sign is loss of retinal vein pulsation, latest is papilloedema
Cushings triad = Bradycardia, HTN, irregular breathing
6th nerve palsy - gets pinched at the petrous temple bone
3rd nerve palsy
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
Patient has hypertonia in both legs, reduced power, increased reflexes and clonus. Ddx?
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.
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?
Ddx for wasting of the thenar and hypothenar eminences?
- Cervical spondylosis
- Cervical rib
- Brachial plexus trauma
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
What are the features of neurofibromatosis 1?
Which chromosome affected?
Cafe au lait spots
Fibromas = subcutaneous, and plexiform
Eye = Lisch nodules (brown iris hamartomas)
Neoplastic change in 10% e.g. Phaeo's, meningiomas
Renal = RAS = HTN
How many cafe au last spots is diagnostic and how big should they be?
What are the features of neurofibromatosis 2 and chromosome?
Bilateral acoustic neuroma = SNHL
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
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)
Extracranial branches of facial nerve?
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)
Types of CMT, and how to differentiate?
Hereditary sensory and motor neuropathy
CMT1 = commonest, demyelinating lesion = velocity <38m/s
CMT2 = Axonal pathology, velocity >38m/s
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
How does Friedrich's ataxia commonly present?
Spina-Cerebellar degeneration = cerebellar signs e.g. ataxia
Non-neurological signs of Friedrich's ataxia?
Cardiac = HOCM
How does MND commonly present?
Describe a psoriatic rash?
Salmon pink circular discoid patches, with silver discolouration on flexor surfaces and buttocks
Where else would you examine for psoriasis?
Scalp and behind the ears
Nails = pitting, onycholysis
What is the koebner phenomenon?
Purple lesions associated with scarring
RCA = sinus bradycardia, 1/2 HB
- LAD = Complete heart block
- MR due to papillary rupture
Triad of Parkinson's?
Pill rolling tremor
What're the Parkinson's plus syndromes?
MSA, corticobasal degeneration and PSP
Signs of PSP?
Supranuclear gaze and postural instability
Rocket sign, ask them to get up out of the chair and they shoot up
What three conditions make up MSA, and signs?
Autonomic dysfunction = postural hypotension, bladder dysfunction
Rigidity > tremor
Extra-articular features of rheumatoid?
Atlanto-axial instability due to weakening of the transverse ligament holding odontoid of C2 against anterior arch of C1
Splenomegaly in Felty's
Fibrosis and pulmonary nodules
Clinical features of Pagets?
Bowed legs, frontal bossing
What do people with Paget's die from?
High output heart failure
As bones become larger = bigger capillary network = big volume = big heart
If you have a mix of UMN, and LMN with no sensory what is it?
Causes of hypoglycaemia?
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
Causes of Addison's?
Autoimmune is commonest in UK
TB is commonest worldwide
Investigations for Addisons?
Lying and standing BP
Steroids IV hydrocortisone fast and fluids
Then long term hydrocortisone and fludrocortisone
What murmur is ejection systolic?
Syncope, exertion dyspnoea and angina
Radiates to carotids
Slow rising pulse, and narrow pulse pressure
Investigations for AS?
Mx for AS?
TTE is definitive
ECG = LAD and LVH (Tall R wave in V5/6, Deep S in V1/V2)
Cons = Diet, exercise, weight
Medical = Mx any co-morbidities
- Asymptomatic valve replacement if EF <50%
- low risk = aortic valve replacement
- high risk surgical patient = TAVR
Long term anticoagulation if mechanical valve aiming for 3-4
Long term IE prophylaxis
What is an EDM? What does it change to when severe?
Low pitched mid-diastolic murmur = AUSTIN FLINT
LVF = orthopnea, PND, exertion dyspnoea
Management of aortic regurgitation?
- EF > 50 = vasodilator therapy
Symptomatic or asymptomatic EF <50:
- Aortic valve replacement / TAVR
Radiates to axilla
Causes of aortic stenosis?
Valvular causes = True congenital defect, calcificaition, rheumatic fusion
Sub-valvular = LV hypertrophy
Causes of aortic regurgitation?
Acute = IE and aortic dissection
Chronic = Bicuspid valve and rheumatic heart disease
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
Investigations and management of MR?
Acute MR = Valvuloplasty or annuloplasty
Chronic - EF >60 = ACEI and BB
Chronic EF <60 / symptomatic = Medical and surgical
Opening snap, tapping apex
Low pitched rumbling
Investigations and Mx of mitral stenosis?
Ix = ECG:
- LAH = bifid p wave / p-mitrale
- Also see RVH due to pulmonary congestion = Tall R in V1/V2, deep S in V5/V6.
- Mild disease = No therapy
- Symptomatic = Valve repair / replacement
Late systolic murmur with systolic click?
Mitral valve prolapse (barlow syndrome)
Medical = Aspirin / warfarin, BB's
Surgical = Mitral valve repair