- Flashcards
1
Q
Differentials for short stature
A
Down Syndrome
Turner Syndrome
Achondroplasia
Hypothyroidism prior to growth plate fusion
Hypopituitism
Systemic illness prior to growth plate fusion
2
Q
Complications of Down Syndrome
A
Cognitive impairment Congenital heart disease - ASD, VSD, MR, Tetralogy, PDA Gastro - duodenal atresia, hirschprung, Meckels, imperforate anus, coeliac disease Hypothyroidism T1DM AML/ALL Atlanto-axial instability Male infertility Alzheimers
3
Q
Complications of Marfans
A
Heart disease - aortic root aneurysm, AR, dissection, MV prolapse
Ocular - lens dislocation, myopia, retinal detachment
Musculoskeletal - hypermobility, dural ectasia
Restrictive lung disease
Hernia
4
Q
Causes of webbed neck
A
Turner Syndrome Noonan syndrome Klippel-Fleil syndrome Diamond-Blackfan anaemia Watson syndrome
5
Q
What are the causes of a widely split S2
A
ASD (fixed) VSD Mitral regurgitation Pulmonary stenosis RBBB
6
Q
When is the click of a prosthetic mitral valve heard?
A
In the place of the first heart sound
7
Q
When is the click of a prosthetic aortic valve heard?
A
In the place of the second heart sound
8
Q
What are the types of ASD?
A
Ostium secundum - site of foramen ovale
Ostium primum - ant/inferior aspect, involve MV and TV
Ostium venosus
Coronary sinus ASD
9
Q
What are the features of a cavernous sinus lesion?
A
Unilateral III, IV, VI nerve palsies Sensory loss in Va/b distribution Loss of corneal reflex Painful opthalmoplegia Visual loss Conjunctival congestion Papilloedema Retinal haemorrhage
10
Q
What are the causes of a 3rd nerve palsy?
A
Central - vascular, tumour, demyelination, trauma, idiopathic
Peripheral - compressive (aneurysm, tumour, nasopharyngeal carcinoma, orbital lesions, basal meningitis). Infarction, trauma, cavernous sinus lesion
11
Q
What are the indications for lobectomy/pneumonectomy?
A
Malignancy Localised bronchiectasis Lung reduction surgery for COPD Cystic fibrosis TB Lung abscess
12
Q
Causes of upper lobe fibrosis
A
Berylliosis Radiation Hypersensitivity pneumonitis ABPA Sarcoidosis TB Silicosis Coal workers pneumoconiosis Langerhans cell histiocytocisis Ankylosing spondylitis Psoriasis
13
Q
What are the causes of a cavitating lung lesion?
A
Infectious - S aureua, klebsiella, anaerobic infections, pseudomonas, TB, aspergilloma, histoplasmosis
Non-infectious - malignancy, GPA, rheumatoid nodule, caplan syndrome
14
Q
What are the ECG features of PE?
A
Sinus tachycardia Tall R wave in V1 Right ventricular strain RBBB T wave invesion V1-3 S1Q3T3
15
Q
Extra-articular features of ankylosing spondylitis
A
Uveitis Aortic regurgitation Mitral valve prolapse Reduced chest expansion Apical fibrosis Inflammatory bowel disease Plantar fasciitis Achilles tenditis
16
Q
What are the classic deformities of RA?
A
Ulnar deviation MCP subluxation Boutonnieres Swan neck Z deformity of the thumb
17
Q
What are the RA deformities seen in the foot?
A
Hallux valgus
Subluxation of MTP
Hammer toe
18
Q
What is the anatomy of a swan neck deformity?
A
Hyperextension at the PIP joint and then flexion at the DIP joint
19
Q
What is the anatomy of a boutonniere deformity?
A
Flexion at the PIP with hyperextension at DIP
20
Q
What is the anatomy of a z deformity?
A
Flexion at the IP joint and hyperextension at MCP
21
Q
What is the difference between episcleritis and scleritis?
A
Episcleritis is painless while scleritis is painful
22
Q
XR changes psoriatic arthritis?
A
Enthesitis and marginal bone loss 'Pencil in cup' Bone proliferation Joint subluxation Interphalenx ankylosis Soft tissue swelling
23
Q
Psoriasis arthropathy patterns of involvement
A
Asymmetric oligoarthropathy primarily affecting DIP Symmetric polyarthritis (RA pattern) DIP arthritis Arthritis mutilans Spondylitis +/- sacroilitis
24
Q
XR findings in OA
A
Asymmetric joint space loss
Osteophyte formation
Subchondral sclerosis
Subchondral cyst formation
25
Why is the ptosis only partial in a Horners Syndrome?
Upper eyelid is controlled by levator palpebrae superioris (III nerve) and muller muscle (sympathetic fibres). A Horners syndrome affects the sympathetic fibres leading to a partial ptosis and alight elevation of the lower eye lid
26
What is the pathway of the sympathetic innervation of the eye?
Hypothalamus to brainstem to cord to T1 exiting to the cervical sympathetic chain ascending to superior cervical ganglion to the carotid plexus to the eye (muller muscle, pupil and sweat glands)
27
What is the pattern of anhidrosis in Horners Syndrome?
If central (1st order neuron) then affects ipsilateral face, arm and upper trunk. If 2nd order then ipsilateral face and there is no anhidrosis if affecting a 3rd order neuron
28
Causes of a unilateral ptosis?
3rd Nerve palsy
Horner Syndrome
Myasthenia gravis
Congenital
29
What are the causes of ptosis?
```
Normal pupils:
Senile
myotonic dystrophy
Fascioscapulohumeral dystrophy
Ocular myopathy eg mitochondrial
Thyrotoxic myopathy
Myasthenia Gravis
Botulism, snake bite
Congenital
Fatigue
With constricted pupils:
Tabes dorsalis
Horner Syndrome
Dilated pupils
3rd nerve palsy
```
30
Causes of bilateral anosmia
```
Upper respiratory tract infections
Meningioma of the olfactory nerve
Ethmoid tumours
Head trauma
Meningitis
Hydrocephalus
Congenital eg Kellmann syndrome
```
31
How to differentiate between an essential tremor and a parkinsons tremor?
Essential tremors are symmetrical, postural and can affect the head. When writing essential tremor will become larger and tremor is seen, with parkinsons the tremor stops and there is micrographia
32
What is the clinical pattern of charcot-marie-tooth?
Symmetrical distal motor and sensory neuropathy
33
What are the causes of pes cavus?
Local - burns, malunion, compartment syndrome,
Spinal - polio, trauma, tumours, syringomyelia,
Other - fredreichs ataxia, muscular dystrophy, spinal muscular atrophy, cerebral palsy, hereditary spasic paraparesis
34
Causes of thickened nerves
```
Hereditary motor and sensory neuropathy
Acromegaly
CIDP
Amyloidosis
Leprosy
Others - sarcoidosis, neurofibromatosis
```
35
What are small fibre sensory modalities?
Pain and temperature
36
What are large fibre sensory modalities?
Position and vibration
37
What are the causes of pulsatile liver?
Tricuspid regurgitation/pulmonary HTN
Hepatocellular carcinoma
Vascular abnormalities
38
What are the causes of tender hepatomegaly?
Hepatitis
Rapid enlargement eg right heart failure, budd-chiari syndrome
Hepatocellular carcinoma
39
What are the causes of a firm and irregular liver?
```
Cirrhosis
Metastatic disease
Polycystic liver disease
Hydatid disease
Granuloma
amyloid
Cysts
Lipoidoses
```
40
What are the causes of massive hepatomegaly?
```
Metastases
Alcoholic liver disease
Myeloproliferative disease
Right heart failure
Hepatocellular carcinoma
```
41
What are the causes of moderate hepatomegaly?
All the causes of massive hepatomegaly
Haemochromatosis
Haematological disorders - lymphoma, CML
Fatty liver disease
42
What are the causes of massive splenomegaly?
CML
Myelofibrosis
Primary lymphoma of spleen, hairy cell leukaemia, malaria
43
What are the causes of moderate splenomegaly?
```
Causes of massive splenomegaly
Portal HTN
Lymphoma
Leukaemia
Thalassaemia
Storage disease eg gauchers disease
```
44
What are the causes of hepatosplenomegaly?
```
Chronic liver disease with portal HTN
Haematological disease eg MPN, lymphoma, leukaemia, sickle cell anaemia,
Infection - hepatitis, EBV, CMV
Infiltrative - amyloidosis, sarcoidosis
Connective tissues - SLE
Acromegaly
Thyrotoxicosis
```
45
Which eye movement directions are affected in 3rd nerve palsy?
Eye is down and out
| Cannot adduct or completely elevate
46
What nerve roots supply each reflex?
```
Biceps - C5-6
Brachioradialis - C5-6
Triceps - C6-7
Knee - L3-4
Ankle jerk - S1-2
```
47
What are the features of an ulnar nerve palsy?
Claw hand (extension deformity lateral 2 fingers)
Wasting of intrinsic muscles of hands expect LOAF
Weakness of finger abduction and adduction
Sensory loss of 5th and medial 1/2 4th fingers
Froments sign
48
What are the causes of an ulnar nerve palsy?
At elbow - fractures, arthritis, compression
At wrist - tumours, ganglion, fracture, aberrant artery
Mononeuritis multiplex
49
What is Froments sign?
Hold a piece of paper between the thumb and the lateral aspect of the 2nd finger. Normally thumb is flat, in ulnar nerve palsy it bends due to weakness of thumb adduction
50
What are the causes of a predominately sensory peripheral neuropathy?
```
Diabetes
ETOH
Metabolic - Hypothyroidism, uraemia
Nutritional - B12, B6
Malignancy - paraneoplastic, paraprotein
Drugs - chemotherapy, TB medications
Autoimmune - sjogrens, vasculitis
Idiopathic
```
51
Causes of predominately motor peripheral neuropathy?
```
Guilllain-Barre, Chronic inflammatory demeylinating polyradiculopathy
Charcot Marie Tooth
Acute intermittent porphyria
Diabetes
Lead poisoning
Multifocal motor neuropathy
```
52
What are heberdon and bouchards nodes?
Bony swelling associated with osteoarthritis. Heberdons nodes are at the DIP joint and bouchards nodes are at the PIP joint
53
How can you differentiate the cause of facial sensory loss?
Corneal reflex. In cortical sensory loss the corneal reflex is intact, in trigeminal pathology it is lost
54
Where is the lesion in upper quadrant homonyous hemianopia?
Temporal lobe - think stroke, mass, trauma and surgery
55
Where is the lesion in lower quadrant homonyous hemianopia?
Parietal lobe - think stroke, mass, trauma and surgery
56
What is the pattern of subacute degeneration of the cord?
Upper motor neuron signs in the lower limbs with absent ankle reflexes and extensor plantar response and peripheral neuropathy causing loss of ankle +/- knee jerks
57
Causes of extensor plantar response with absent ankle reflexes?
```
Subacute degeneration of the cord
Conus medullaris lesion
Combination of UMN lesion with cauda equina or peripheral neuropathy
Syphilis (taboparesis)
Friedreichs ataxia
Diabetes
Leukodystrophy
```
58
Signs of severity MR
```
LV enlargement/displaced apex beat
Pulmonary HTN
S3
Early diastolic rumble
Soft S1
Early A2
Small volume pulse
LV failure
```
59
Indications for surgery in MR
Acute MR with heamodynamic compromise
Class III and IV symptoms
LV dysfunction
60
Causes of MR
Chronic - degeneration, MV prolapse, rheumatic heart disease, papillary muscle dysfunction, connective tissue disease
Acute - IE, MI, Surgery, trauma
61
Murmur of AR
Crescendo - decrescendo murmur over the left sternal edge loudest on expiration and sitting forward. May have associated diastolic rumble at apex and ejection systolic murmur
62
What are the signs of severe AR?
```
Collapsing pulse
Wide pulse pressure
LV failure
S3
Soft A2
Long murmur
Austin flint murmur
```
63
What are the causes of AR?
Acute - IE, dissection, HTN
Valvular - rheumatic, congenital, seronegative arthropathy
Aortic root - marfans, aortitis, dissecting aneurysm, age
64
What is the murmur of MS?
Opening snap, Mid-diastolic murmur at the apex louder on expiration, left lateral position and exercise
65
What are the signs of severity of MS?
```
Small pulse pressure
Early opening snap
Length of murmur
Diastolic thill at apex
Pulmonary HTN
```
66
What are the causes of cerebellar dysfunction
```
Drugs and toxins esp ETOH
Structural - trauma, masses, CVA, Arnold-Chiari,
Genetic - Friedrichs ataxia
Inflammatory - MS, paraneoplastic
Metabolic - hypothyroidism
```
67
What are the causes of unilateral cerebellar signs?
```
MS
Masses
Trauma
CVA
Paraneoplastic
```
68
Cerebellar signs
```
Staccato speech
Nystagmus
Broken eye pursuit
Truncal ataxia
Intention tremor
Hypotonia
Dysmetria - pass pointing
Dysdodichokinesia
Rebound
Abnormal heal shin
Abnormal foot tapping
Pendular reflexes
Ataxic gait
```
69
Investigations for MND
NCS/EMG - fasiculations, acute and chronic deinervation
CT/MRI if unclear diagnosis
Spirometry
Early morning ABG
Barium swallow and speech path assessment
Cognitive screening
70
Features to distinguish a spleen from a kidney
```
No palpable upper edge
Spleen has a notch
Moves inferolateral with inspiration
Dull to percussion
Not ballotable
```
71
What is a brown sequard syndrome?
Unliateral disease of the spinal cord. Causes UMN weakness and dorsal column loss on the ipsliateral side and spinothalamic sensory loss on the contralateral side. Causes include trauma, disc, tumours, inflammation
72
What is the difference between bulbar and pseudobulbar palsy?
Bulbar is lower motor neuron and can be unilateral or bilateral. Pseudobulbar palsy is upper motor neuron and must be bilateral.
73
What are the causes of a bulbar palsy?
LMN - MND, basilar ischaemia, syringobulbia, brainstem tumour, polio, GBS, neurosyphilus, subacute meningitis
NMJ - myasthenia, botulism
Muscular - muscular dystrophy, polio
74
What are the causes of a pseudobulbar palsy?
```
MND
Bihemispheric vascular disease
Brainstem tumour
MS
Trauma
```
75
What is an INO?
Internuclear opthalmoplegia. Due to damage to the medial longitudinal fasciulus. Means that the affected eye cannot adduction when gaze is moved to the contralateral side however when unaffected eye is covered there is a normal range of movement. There may be nystagmus of the unaffected eye.
76
What is seen in bilateral INO?
Neither eye is able to adduct past the midline on contralateral gaze. When each eye is covered eye movements return to normal
77
What are the causes of bilateral LMN weakness?
CIDP - symmetric motor predominant, can have sensory components
Motor neuron disease - UMN and LMN signs
Multifocal motor neuropathy - asymmetric distal>proximal
Polio - usually very asymmetric/unilateral
Spinal muscular atrophy - symmetric proximal weakness with only LMN signs
Other peripheral neuropathy - distal, sensory involvement
78
What type of speech is seen in cerebellar disease?
Scanning speech - irregular and staccao. Imprecise consonants with omissions and distortions
79
What type of speech is seen in bulbar palsy?
Imprecise nasal speech, weak and low volume
80
What type of speech is seen in pseudobulbar palsy?
'donald duck like' high pitched and slow with a harsh, strained voice
81
What are the speech patterns of expressive dysphasia? Where is it located?
Brocas area, posterior 3rd gyrus frontal lobe. Non-fluent speech with frustration. Comprehension intact, may be able to repeat with difficulty, unable to name. Able to read, dysgraphia.
82
What are the speech patterns of receptive dysphasia? Where is it located?
Wernikes area, posterior part of the 1st temporal gyrus. Fluent incomprehensible speech, oblivious. Unable to complete any part of the speech exam. Able to write but content impaired
83
What are the speech patterns of conductive dysphasia? Where is it located?
Arcuate fasciculus in temporal lobe. Fluent but incomprehensible speech. Able to follow commands but not repeat, name, read or describe. Dysgraphia
84
What are the causes of nominal aphasia?
Lesion in the angular gyrus (temporal lobe). Can also be seen in recovery of another aphasia, encephalopathy and pressure due to mass effect
85
What are the findings of a radial nerve palsy?
Wrist drop with weakness in wrist and MCP flexion. Weakness in supination. Weakness in elbow extension if lesion above spiral groove.
Sensory loss over anatomical snuff box
Triceps reflex loss if above spiral groove
86
Causes of carpal tunnel?
```
Idiopathic
Arthropathy eg RA
Endocrine - hypothyroidism, acromegaly
Pregnancy
Trauma and overuse
```
87
What are the signs of a median nerve palsy?
Wasting of the thenar eminence
Weakness of thumb abduction, flexion and opposition
Loss of sensation over the palmar aspect of the1st 3 1/2 fingers
88
What is Ochsners clasping test?
Patient clasps hands together. In a medial nerve palsy above the level of the cubital fossa the index finger is unable to flex
89
How to differentiate an ulnar nerve lesion from a C8 nerve root/lower brachial plexus lesion?
Sensation loss in an ulnar nerve lesion is the 5th and medial aspect of the 4th finger and the thenar eminence is not wasted. In a C8/lower brachial plexus lesion the sensory loss extends above the wrist, there is wasting of the thenar eminence and there is weakness of abductor policis brevis
90
What are the causes of wasting of the small muscles of the hands?
1. Nerve lesions - ulnar, median, brachial plexus, motor peripheral neuropathy
2. Anterior horn cell
3. Myopathy
4. Spinal cord lesion
5. Trophic disease
91
What are the features of Friedreichs ataxia?
Upper motor neuron pyramidal weakness
Dorsal column loss (vibration, proprioception)
Bilaterally cerebellar signs
92
What is the pattern of pyramidal weakness?
Upper motor neuron signs
Flexion stronger than extension in upper limb
Extension stronger than extension in lower limb
93
What is a relative afferent pupillary defect?
When there is a unilateral optic nerve lesion then the affected pupil dilates when a light is swung between the eyes from the unaffected to affected eye
94
What is the surgical sieve?
```
Malignant
Vascular
Inflammatory
Infective
Trauma
Iatrogenic
Congenital
Nutritional
Metabolic
```
95
What are the causes of INO?
```
MS
Brainstem lesions
Wernikes encephalopathy
SLE
Miller Fisher syndrome
```
96
What are the causes of a foot drop?
```
Common peroneal nerve lesion
L4/5 nerve root lesion
Sciatic nerve
Lumbosacral plexus
Peripheral motor neuropathy
Distal myopathy
Motor neuron disease
Precentral gyrus lesion
```
97
How to differentiate between a common peroneal nerve and L4/5 nerve root lesion?
Common peroneal nerve will have weakness in dorsiflexion and eversion, preserved inversion and ankle jerk. L4/5 nerve root lesion will also have weakness in inversion and hip abduction. Sensation is lost over the dorsum of the foot and lateral leg, in L4/5 lesions this extends more proximally.
98
What is the clinical picture of a sciatic nerve lesion?
Weakness of knee flexion and all muscles below the knee. Preserved knee reflex, loss of ankle and plantar reflexes. Sensation loss posterior thigh and all below the knee.
99
What is the clinical picture of a femoral nerve lesion?
Weakness of knee flexion and slight hip flexion weakness. Preserved adductor strength. Loss of knee jerk and sensory loss inner aspect of thigh and leg.
100
What are the causes of peripheral neuropathy + proximal weakness?
Paraneoplastic conditions
Alcohol
Connective tissue disease
101
What are the causes of myopathy?
Hereditary myopathies
Congenital myopathies
Drugs and toxins eg steroids, alcohol, chloroquinine
Neoplastic - carcinomas, paraneoplastic
Inflammatory - polymyositis, dermatomyositis, connective tissue disorders
Endocrine - thyroid, acroegaly, cushings, hypopituitism, periodic paralysis, osteomalacia
Infiltrative - sarcoidosis
102
What are the causes of proximal weakness?
Myopathic
neuromuscular junction
Neurological - MND, polyradiculopathies
103
What is myopathic facies?
Lean, lifeless, expressionless facial features. Seen is facio-scapulo-humeral dystrophy, myotonic dystrophy
104
What is the clinical pattern of myotonic dystrophy?
```
Myotonia
Distal wasting and weakness
Facial weakness and wasting, myotonic facies
Frontal balding
Mild peripheral neuropathy
Hypogonadism
Cardiac disease
```
105
What are the non-muscular complications of myotonic dystrophy?
```
Diabetes
Cardiomyopathy
Valvular heart disease
Arrhythmias and conduction deficits
Hypogonadism
Gotire
Mild intellectual disability
```
106
What are the clinical features of a cerebellopontine angle lesion?
CN V, VII, VIII +/- CN IV palsies
| If late then lower cranial nerves and cerebellar signs
107
What are the causes of cerebellopontine lesions
```
Acoustic neuromas
Meningiomas
Haemangioblastomas
Granulomas
Nasopharyngeal carcinoma
Basilar artery aneurysm
Metastasis
```
108
What is the Child-Pugh classification
Bilirubin, ascites, encephalopathy, prolonged PT, albumin
A - score 5-6
B - score 7-9
C - >10
109
What are the differentials of renal masses?
```
Polycystic kidneys disease
Hydronephrosis
Renal cell carcinoma
Acute renal vein thrombosis
Amyloid, lymphoma and other infiltrative conditions
Acromegaly
```
110
What are the causes of generalised lymphadenopathy?
```
Lymphoma
Leukaemia
Malignancy
Infections eg mononucleosis, CMV, HIV, TB, toxoplasmosis
Connective tissue disease
Infiltrative - sarcoidosis
Drugs - phenytoin
```
111
What are the causes of a diffuse goitre?
```
Idiopathic
Puberty, pregnancy, postpartum
Graves disease
Thyroiditis
Simple goitre (iodine deficiency)
Toxins - iodine excess, lithium
Inborn errors of thyroid hormone synthesis
```
112
What is the examination picture of eisenmengers syndrome?
Pulmonary HTN with central cyanosis
113
What are the causes of Eisenmengers syndrome?
Shunt reversal due to high right heart pressures
- ASD
- VSD
- PDA
114
What are the complications of Eisenmengers syndrome?
```
Haemoptysis
Right heart failure
Paradoxical embolism
Infective endocarditis
Sudden death
Polycythaemia and hyperviscosity
Thrombosis
Bleeding
```
115
What is lights criteria?
Used to differentiate transudative and exudative pleural effusions.
Pleural protein: serum protein >0.5
Pleural LDH: serum LDH >0.6
Pleural LDH >2/3rds upper limit of normal of serum LDH
116
What are the causes of bronchiectasis?
```
Cystic fibrosis
Recurrent infections
Ciliary dyskinesis including kartagners syndrome
Yellow nail syndrome
Immunodeficiency
HIV
Rheumatological - SLE, RA
Allergic bronchopulomary aspergillosis
```
117
What are the causes of superior vena cava syndrome?
```
Lung cancer
Retrosternal tumours - lymphoma, thymoma
Retrosternal goitre
Massive mediastinal lymphadenopathy
Aortic aneurysm
```
118
What is the clinical picture of a complete brachial plexus lesion?
LMN weakness of whole arm
Sensory loss whole arm
Horners syndrome (only if lesion in proximal part of lower plexus)
119
What is the clinical picture of an upper trunk brachial plexus lesion?
Waiters tip positioning
LMN shoulder and elbow flexion weakness
Sensory loss lateral aspect of arm and thumb
120
What is the clinical picture of a lower trunk brachial plexus lesion?
True claw hand with paralysis of all intrinsic muscles
| Sensory loss along medial aspect of hand and forearm
121
What are the complications of polycystic kidney disease?
```
Cyst haemorrhage
Cyst infection
Cyst torsion
Renal stones
Nocturia
Subarachnoid haemorrhage
Aortic regurgitation
Mitral valve prolapse
```
122
What are the causes of a 6th nerve palsy?
Bilateral - trauma, wernikes, raised ICP, mononeuritis multiplex
Unilateral
Central - Vascular, tumour, wernikes, MS
Peripheral - Diabetes and other vascular lesions, trauma, idiopathic, raised ICP
