Areas Of Weakness Flashcards
8mm pituitary tumour
GH secreting
ACTH secreting
13mm pituitary tumour
TSH secreting tumour.
Non-functioning tumour
Short stature and pale skin and lethargy
Pituitary adenoma resulting in hyposecretion
Ectopic ACTH secreting tumour
Small Cell carcinoma of lung RCC of kidney Adrenal tumours Glucocorticoid administration ACTH administration
Successful suppression with low dose DEXA
Normal
Glucose intolerance, weight gain, hypertension, increased infections.
Cushings
Proximal myopathy, fractures, weight gain with thin skin, and HTN
Cushings
Left homonymous hemianopsia is caused by
Lesion after optic chiasm in one optic tract (right side)
Large pituitary adenoma can cause
Diplopia due to CN3,4,6 compression.
Headache - bony structures and meninges.
Bitemporal hemianopsia - optic chiasm
Hydrocephalus
Hyperpigmentation, weakness, fatigue, poor appetite.
Postural hypotension.
Addison’s disease
Low cortisol, and sex hormones. Adequate aldosterone
Secondary hypocorticolism.
Low glucose Low salt Low steroids Hyperkalaemia Hyponatraemia
Addisonian crisis
Problem with spatial awareness, positioning
Lesion in parietal lobe
Non-dominant!!!
Problem with memory. Change in personality - more emotional
Smell dysfunction
Temporal
Auditory dysfunction
Temporal lobe
Language comprehension dysfunction
Wernicke’s area - located in the superior aspect of the dominant temporal lobe
Good comprehension, but difficulty with speech
Broca’s area - on the dominant side, frontal lobe
Sensory cortex
Parietal
Dysfunction with fine muscle control
Cerebellum
Agnosia
Damage to temporo-parietal cortex
Apraxia
Damage to premotor cortex
Can’t execute movement, despite physical strength
Amnesia
Bilateral temporal lobe damage
Damage to cerebellar communicantes causes
Contralateral pyramidal weakness.
Damage to cardio respiratory control arises where?
Reticular formation in brain stem.
Damage to sleep control arises where
Reticular formation in brainstem
Damage to balance control arises where
Reticular formation in brainstem
Where does loss of control of voluntary movement and posture originate? Which side
Basal ganglia
Lesions cause contralateral motor disorder
Nystagmus is caused by
Lesion in ipsilateral cerebellum
Ataxia is causes by
Ipsilateral lesion in cerebellum
What is positive Romberg’s sign?
Interruption of proprioceptive centres in cerebellum - sensory ataxia and:
DANISH (dysdiachokinesis, ataxia, nystagmus, intention tremor, slurred speech, hypotonia).
Characteristics of parkinsons
TRAP Tremor Rigidity Akinesia Hypertonia
What is the difference between upper and lower motor neuron weakness of the face.
The forehead is spared in unilateral UMN lesion to CN VII.
LMN lesion does not spare the forehead.
C5 root lesion leads to
Sensory loss in lateral arm
Biceps reflex loss
Motor loss in shoulder abduction and elbow flexion
Pt wakes with paresthesia and pain radiating to forearm. It is relieved by hanging down.
Which nerve is affected?
Median nerve
Gives paraesthesia in the palmar aspect of the first 3.5 digits.
Palmar trauma can damage a deep motor branch of a nerve, causing loss in medial 1.5 digits. Which nerve
Ulnar nerve.
Can also be compressed in cubital tunnel
This nerve can be compressed against the humerus leading to wrist drop
Radial nerve
Motor to brachioradialis.
Also when posterior interosseus nerve in forearm is damaged.
Sensory to dorsum of hand.
Which nerve controls the ankle reflex?
S1
Symptoms of ckd
Malaise Lethargy N+V Anorexia Insomnia, confusion, coma
What degree of uraemia is dangerous?
Above 40mmol/L in CKD is symptomatic.
>60 leads to cloudiness, myoclonuc twitches.
Stage 1 CKD
kidney damage with normal GFR
Stage 3 CKD
GFR 30-59 (moderate decrease)
Stage 2 CKD
Kidney damage with mild decrease (60-89)
Stage 4 CKD
GFR 15-29
Stage 5 CKD
Kidney failure.
GFR < 15.
Common causes of CKD
DM
Polycystic Kidney disease
Chronic pyelonephritis.
Obstructive uropathy.
Suspected CKD. What investigations?
Urinalysis, urine microscopy and biochemistry. Serum biochemistry (IgA?).
Secondary - US, CT. Biopsy if unexplained and renal size normal.
Palpable kidney
In hydronephrosis, carcinoma and transplantation (RIF).
Bladder palpable
retention, large stones, late tumour
Biochemical features of ARF
creatinine
loss of urinary output
Electrolyte disturbances in ARF
Hyperkalaemia Acidosis Hyponatraemia (overdrinking) Hypocalcaemia (less vit D). Hyperphosphataemia.
Patient with anorexia, N+V, pruritis and clouding of the mind. What is missing for ARF
Oligouria
Which are possible life-threatening features of AKI?
When it complicates non-renal organ failure.
Sepsis related AKI.
Uraemia (coma).
Pulmonary oedema may be a feature.
Hyperkalaemia can lead to cardiac arrhythmias.
blood in urine
associated with inflammatory processes
protein in urine
thickening/loss of filtration process
Features of VTE (DVT)
Pain Swelling of calves. Redness. Engorged. superficial veins. Temperature.
If in iliofemoral region - severe pain but often no other features.
If occlusion - bluish discoloration and severe oedema.
In 20-30%, thrombosis can spread without any clinical evidence.
Pain, swelling, redness and heat are also the features of cellulitis! Needs to be considered.
Superficial thrombophlebitis most commonly affects
the great saphenous vein
Causes of DVT
Triad of stasis, hypercoagulability, endothelial damage
RF for DVT
age, obesity, varicose veins, immobility, pregnancy, previous DVT/PE, thrombophilia, oestrogen therapy, trauma/surgery, maligancy, cardioresp failure, recent MI, acute infection, IBD, venous catheter etc
Well’s score criteria
Active cancer Bedridden > 3 days Calf swelling >3cm compared to other leg. Visible collateral veins. Entire leg swollen. Localised tenderness. Pitting oedema. Paralysis/paresis, previous DVT
Score higher than 1 should raise suspicion.
Max is 9.
Acute arterial ischaemia
6 P's Pain paresthesia paralysis pallor pulseless COLD!
Chronic, venous insufficiency (eg. in leg)
VVV LAPS Varicose veins Venous ulcers Venous stars Lipodermatosclerosis Atrophy Blanche Pitting oedema Scars
Shock with severe pulmonary HTN (S3 gallop). Sudden death
Massive PE
SOB, chest pain, pleural rub, local tenderness and some pleural effusion. No response to GTN
Acute pulmonary infarct - PE
tachycardia, tachypnoea, localised crackles, some pleuritic pain (if due to PE)
Acute PE without infarct
Pulmonary HTN or cor pulmonale, Raised JVP, S3
Multiple PE
Paracetamol to the liver is an
intrinsic hepatotoxin - causes predictable, dose-depentant liver damage
Which drugs can cause idiosyncratic drug reactions with the liver
Valproate (antiepileptic) NSAIDs Amiodarone (antiarrhythmic) Diclofenac Methyldopa (HTN) Isoniazid (TB) Halothane (GA) Methotrexate (chemo + immune suppression)
Drugs that induce fatty change in the liver
valproate and methotrexate
Drugs that can cause cholestasis
oestrogens
coamoxiclav and flucloxacillin
chlorpromazine
Liver tumours can be caused by which drugs
OCP
Steroids
Which drugs can cause liver necrosis
paracetamol
WHich drugs can cause hepatitis
isoniazid
methyldopa
NSAIDs
Features of acute tubular necrosis
Kidney enlarges, pales, markings are lost. Damage starts in cortex.
2 clinical phases:
1) oliguria (drop in GFR and non-selective reabsorption) - uraemia - pulm oedema - metabolic acidosis and hyperkalaemia
2) diuresis - inability to concentrate urine leads to uraemia, acid/base imbalance, loss of electrolytes and loss of fluid
10-14 days post drug exposure, patient becomes febrile. There is haematuria and proteinuria
Acute tubulointerstitial nephritis.
Particularly NSAIDs
Chronic pyelonephritis features
Fibrosis and distortion of the kidney parenchyma. Loss of nephrons and deep scars.
A patient is catheterised. What damage can occur
urethral stricture
Causes of urethral strictures
urethral damage:
catheterisation
infections (such as gonorrhea), invasive tumour
Clinical features of urethral stricture
urinary incontinence
Overflow incontinence.
Slow start, slow flow, slow finish.
Spraying/splitting urine?
Causes of ureteric obstruction
Pelvis - calculi, tumour, stricture
Intrinsic - calculi, tumour, clots
Extrinsic - pregnancy, tumour, retroperitoneal fibrosis
Patient has flank pain, n+v, difficulty passing urine, fevers and chills
Ureteric obstruction
Causes of AKI that can lead to failure
Renal artery thrombosis, massive hypotension, haemorrhage, burns (hypovolamia), D+V, pancreatitis, diuretics, MI, CCF, endotoxic shock, liver failure, drugs, pregnancy.
Pre-renal causes lead to acute tubular necrosis
Patient with severe leg cramps on exercise, resolves with rest. What signs is he likely to have
Intermittent claudication signs:
Stops patient from sleeping. Relieved by hanging foot down.
Possible ulceration/gangrene.
Cold, dry skin with hair loss.
Diminished pulses.
Positive Buerger’s test - angle at which the leg becomes pale when raised.
Bruits over major arteries
How is neuropathic pain different from ischaemic in the leg
Tingling and numbness, glove and stocking distribution.
Differentiate with Buerger’s test.
There may be hyperalgesia and allodynia.
an S1 lesion results in
Sensory loss in posterior calf, and lateral border of foot.
Ankle reflex lost.
Loss of plantar flexion.
There is usually dramatic onset during twisting or bending.
Which disease affects synovial joints and leads to loss of cartilage
osteoarthritis
What is the prevalence of affected joints in osteoarthritis
Hip - 25% over 75
Knee - 40% over 75
Characterise joint pain caused by osteoarthritis
worse after activity, relieved by rest, stiffening and pain after immobility.
Joint instability, loss of function.
Tenderness.
Crepitus on movement.
Limitation of range.
Joint effusion and swelling. Bony swelling and muscle wasting.
Where is the deep inguinal ring compared to vessels
Lateral to the inferior epigastric vessels
Where do direct inguinal hernias pass through
Through weakness in transversalis fascia.
Medial to inferior epigastric vessels
Scrotal continuation of hernia
More likely in indirect
Symptoms of an incarcerated hernia.
Bowel obstruction.
Constipation, distension, vomiting and pain.
Increased bowel sounds on auscultation.
Strangulation of hernia signs (inguinal)
Ischaemia leads to 4 signs of inflammation: Pain Redness Swelling Warmth
And Tenderness
Local consequences of Crohns
Ileal involvement - B12 malabsorption
Colon and small intestine cancer
Intestinal obstruction due to narrowing
Inflammation leading to adhesions and fistulae
Extracolonic manifestations of IBD
Eye - conjunctivitis and uveitis
Seronegative arthritis of spine and peripheral joints
Erythema nodosum
Pyoderma gangrenosum
Gallstones
Nephrolithiasis
Liver steatosis
Hormones counter-regulating hypoglycaemia
Glucagon - inadequate in diabetes
Adrenaline - may be absent in long term DM
Growth Hormone (negatively regulated by glucose) and cortisol may give small increase in blood glucose
Hypoglycaemia symptoms
When glucose below 3mmol
Adrenergic - sweating, tremor, palpitations
Pallor and cold sweat
Neuroglycopaenic - pale, drowsy, detached.
Agression, coma
Common symptoms suggestive of carcinoma of the colon, rectum and anus
Weight loss Bleeding/ iron deficiency Mass Colicky pain Obstruction
There can also be perforation, haemorrhage.
Red Flag - tenesmus and nocturnal need
Anal cancer presentation
Strongly associated with HPV
Pruritus ani
Bleeding
Discharge
Pain
Can have enlarged inguinal LN
How does chronic liver disease effect aldosterone and oestrogens.
Not degraded, leading to secondary hyperaldosteronism.
WHat is a varicocele
varicosities in the pampiniform plexus.
asymptomatic or a heavy, aching feeling.
What is a hydrocele
Collection of fluid within tunica vaginalis. (normally anterior to testis.)
Caused by trauma, tumour, infection.
There is scrotal swelling with or without pain.
What is a spermatocele
Epididymal cyst. Collection of spermatic fluid within epididymis. Usually painless, scrotal swelling.
Where does testicular torsion occur
Generally within tunica vaginalis.
How does epididymo-orchitis present
Infection from epididymis spreads to testis.
Orchitis causes swelling, and the pathogen paramyxovirus can cause infertility if bilateral. The pain is slower onset than torsion.
Testicular lump which is transilluminable
Hydrocele
A testicular lump that one cannot get above
Hernia
One testicular lump
hernia, spermatocele
multiple testicular lumps
tumour, hydrocele
What is the pattern of joint involvement in RA
chronic, symmetrical polyarthritis
What is the palindromic pattern of RA
monoarticular attacks lasting 24-48 hours
What is the transient pattern of joint involvement in RA
self-limiting disease, lasting less than 12 months and leaving no permanent joint damage
what is the remitting presentation of RA
active arhtritis for several years, before remission with minimal damage
What is the chronic, persistent pattern of RA
most typical.
IgM RF.
Relapsing and remitting course.
Seropositive for RF and anti-CCP antibodies is an indicator of greater joint damage
What time of the day is RA pain worst
morning. gets better with activity.
What are complications of RA
ruptured tendons, ruptured joints (Baker’s cyst), spinal cord compression
What are characteristic changes in RA
Rheumatoid nodules
Swan neck deformity
What are the extra-articular manifestations of RA
nodules in subcutaneous tissues around the joint.
Nodules in lung, nervous system, kidney and spleen
Describe MSK pain in the back and compare to organ pain
usually in lumbar region. Organ disease radiates to thoracic region.
Episodes short lived in MSK pain, whereas organ pain is constant and progressive.
Mechanical pain is helped by rest.
Disc prolapse causes neurological symptoms in lower leg.
What is shock
describes acute circulatory failure with inadequate or inappropriately distributed tissue perfusion resulting in generalized cellular hypoxia and/or an inability of the cells to utilize oxygen.
What are common causes of Type 2 respiratory failure
COPD, asthma, overdose
What management is given in type 2 respiratory failure
salbutamol through oxygen driven nebuliser, maintain airway
What are the blood gas abnormalities of severe asthma
Normal pCO2 with hypoxaemia suggests current deterioration.
In life-threatening, there will be high pCO2, severe hypoxia and low pH
What are markers of life-threatening asthma?
PEF < 33% silent chest cyanosis bradycardia/hypotension exhaustion
How does portal htn manifest
hepatosplenomegaly varices ascites hepatorenal syndrome encephalopathy
presentation of CAP
rapidly becomes ill, fever, pleuritic pain and dry cough.
Develops rusty-coloured sputum in a few days.
Affected side of chest moves less - breathing becomes rapid and shallow.
Anorexia and headache?
predisposing factors to CAP
following viral, hospitalized, alcoholics, bronchiectasis, bronchial obstruction, immunosuppressed, IVDU
Causes of hypovolaemic shock
haemorrhage
burn
massive dehydration
causes of septic shock
more commonly gram -ve bacteria
causes of cardiogenic shock
large MI, VT/VF mismatch, tamponade, massive PE
complications of varicose veins
thrombophlebitis - pain;
minor and major haemorrhages; venous ulcers and oedema are chronic signs.
Lipodermatosclerosis.
VVV LAPS
What are the main points of drainage of superficial veins into deep veins via perforator branches?
At saphenofemoral and saphenopopliteal junctions.
Clinical features associated with chronic liver disease
Poor clotting, ascites, jaundice, malaise, fatigue, hypertension, pain, haematemesis, anaemia, encephalopathy
What are symptoms and signs of tcc of the bladder?
Haemorrhage.
Recurrence is common.
Painless haematuria, obstructive symptoms, UTIs and sterile pyuria.
Nerve impingement and other metastatic symptoms.
What is the aetiology of bladder tcc
Uncommon under 40, males 4x as common
Clinical features of pleural effusion
Chest wall movement reduced on affected side.
Mediastinum shifted away.
Dull on percussion.
Systemic effects of COPD
Hypertension Osteoporosis Depression Weight loss Loss of muscle mass Cor pulmonale
