14/12/15 Interactive Cases in General Medicine 1

Question 1

What is Frank’s sign and what is it seen in?

Answer 1

Ear crease from tragus seen in coronary artery stenosis due to loss of dermal and elastic fibres

Question 2

59M longstanding HTN, SOBOE, normal ECG what is the diagnosis?

Answer 2

Stable angina due to coronary artery stenosis

Question 3

What do you need to know for any neurological diagnosis?

Answer 3

Where is the lesion (brain, brainstem, cerebellum, spinal cord, nerve roots, peripheral nerves, NMJ/muscle) and what is the lesion (VIITT: vascular, infection, immune/inflam, tumour, toxic/metabolic. Congenital, degenerative)

Question 4

Hemiparesis (contralateral)

Answer 4

Motor deficit in arm and leg of the same side, brain lesion cerebral cortex such as a stroke

Question 5

Paraparesis

Answer 5

Motor deficit in arms OR legs (upper or lower body), lesion in the spinal cord, at a particular level

Question 6

Radiculopathy

Answer 6

Nerve root lesion, backache, dermatomal

Question 7

Glove and stocking distribution

Answer 7

Peripheral neuropathy (BAD hypothyroidism), particular area mono/polyneuropathy

Question 8

Muscle fatigue, weakness

Answer 8

Myasthenia gravis, NMJ disease

Question 9

What is the gait like in a stroke?

Answer 9

Pyramidal gait: flexion of upper limbs, extension of lower limbs

Question 10

Hypotonia (flaccid paralysis) reduced power, hyporeflexia

Answer 10

LMN lesion, e.g. GBS

Question 11

Hypertonia (spastic), reduced power, hyperreflexia, upgoing plantars

Answer 11

UMN lesion, e.g stroke

Question 12

What are cerebellar signs?

Answer 12

DANISH
Dysdiadochokinesia 
Ataxia
Nystagmus
Intention tremor (finger, nose, finger)
Slurred/scanning/staccato speech
Hypotonia

Question 13

55M with numbness and tingling in hands and feet. T1DM on basal bolus insulin, HbA1c 50mM, normal B12, normal eGFR. How is his peripheral neuropathy treated? Other drugs for neuropathic pain?

Answer 13

Duloxetine is the first line treatment for peripheral neuropathy when renal function is normal. Amitriptylline (TCA), valproate, gabapentin, pregabalin (antiepileptic), transcutaneous electrical nerve stimulation

Question 14

Causes of peripheral neuropathy

Answer 14

VIITT: infection HIV, inflame vasculitis CTD, SLE (CIDP chronic inflammatory demyelinating polyneuropathy), toxic/metabolic DM, B12, alcohol, renal failure/uraemia, paraneoplastic manifestations, paraproteinaemia amyloidosis AL-AM-AA, hereditary res caves

Question 15

34F leg weakness, blurred vision. Legs: hypertonia, low power, hyperreflexia, reduced pinprick sensation. Blurred optic disc margins, what causes the blurred vision? What is the diagnosis?

Answer 15

Papillitis, inflammation of the head of the optic nerve. Blurred vision and pain differentiate this to papilloedema. Inflammation of nerves in CNS = MS

Question 16

Headache worse in the mornings

Answer 16

Raised ICP, papilloedema if seen

Question 17

Amaurosis fugax

Answer 17

Dark curtain descending, embolus in carotid arteries

Question 18

Anterior uveitis

Answer 18

Red, painful eye: sarcoid, Behcet, IBD extra intestinal manifestation

Question 19

Vitreous haemorrhage

Answer 19

Sudden loss of vision

Question 20

Spastic paraparesis causes

Answer 20

Spinal cord lesion: spinothalamic, corticospinal.
Anterior spinal artery occlusion
TB Potts disease
Transverse myelitis
B12 deficiency, tumours

Question 21

MS

Answer 21

2 lesions separated in time and space

Question 22

Meralgia paraesthetica

Answer 22

Compression of the lateral femoral cutaneous nerve, pain and paraesthesia in the anterolateral thigh. Reassure, lose weight, avoid tight garments. If persistent, carbamazepine and gabapentin for neuropathic pain. Mononeuropathy

Question 23

Sensory innervation of the hand

Answer 23

Median (3.5), ulnar (1.5), radial (thumb base)

Question 24

Radiculopathy

Answer 24

Disease of the nerve roots, e.g. lumbosacral. Sciatica = pain in the buttock radiating to below the knee. Compression by disc herniation, spinal canal stenosis

Question 25

60M recurrent falls, tremor at rest, rigidity, bradykinesia, limited up gaze, dysphagia, micrographia, limited upgaze

Answer 25

Progressive supra-nuclear palsy, Parkinsonian features with up gaze abnormality. Steel-Richardson syndrome. (DAergic neurons in substantia nigra)

Question 26

Features of Alzheimers, Parkinsons AND hallucinations

Answer 26

Lewy body dementia

Question 27

How should a stroke be managed?

Answer 27

If patient presents 4.5h and no haemorrhage, give 300mg aspirin (safe swallow assessment), hydration, O2, monitor glucose

Question 28

How should TIA be managed?

Answer 28

Aspirin, do not treat BP acutely unless >220/120. ECG, echo, carotid doppler (carotid endarterectomy), risk factor modification

Question 29

40M lower limb weakness and backache

Answer 29

Guillain Barre Syndrome, often post-infection. Need to monitor ECG, FVC regularly, IVIG treatment after admit to HDU

Question 30

Major causes of collapse?

Answer 30

Check glucose
Cardiac: VAOP vasovagal, arrhythmia, outflow obstruction (left AS/HOCM, right PE), postural hypotension
Brain: seizure