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1
Q

Pes Cavus (Description + Pathology)

A

Description:
- High arch of the sole of foot, claw toes
- Some degree of atrophy of muscles

Pathology
- Long standing LMN peripheral neuropathy (think CMT)
- Freidrich’s ataxia
- Spinocerebellar problems

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2
Q

Charcot Marie Tooth

A

PES Cavus, foot drop, distal muscle atrophy in legs > arms, diminished reflexes, sensory neuropathy

Autosomal dominant
Suspect in people in 20s/30s
Type of Hereditary motor and sensory neuropathy
- Pes Cavus
- Foot drop due to weakness (high steppage gait, orthotics)
- Distal muscle weakness and distal atrophy in legs > arms (inverted champagne bottle) - below elbow and middle third of thigh
- Peripheral sensory neuropathy
- Diminished reflexes in the limbs

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3
Q

Neuropathies - Motor>Sensory

A
  1. ADIP/CIDP
  2. Neuromuscular junction disorders
  3. Motor neurone disease
  4. Hereditary motor and Sensory neuropathy (CMT)
  5. Diabetes Mellitus
    Rarer: Lead poisoning, acute intermittent porphyria, multifocal motor neuropathy
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4
Q

CIDP

A

Chronic Inflammatory demyelinating polyradiculoneuropathy

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5
Q

Neuropathies - Predominantly Sensory

A
  1. Diabetes Mellitus
  2. Paraneoplastic
  3. Paraproteinaemia
  4. Vitamin B6 intoxication
  5. Sjogren’s syndrome
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6
Q

Painful Peripheral Neuropathy

A
  1. Diabetes
  2. Alcohol
  3. B12 or B1 deficiency
  4. Drugs - chemotherapy, arsenic, thallium
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7
Q

Mononeuritis Multiplex Causes

A

Acute (Usually vascular)
1. Diabetes
2. Polyarteritis nodosa or Connective tissue disease

Chronic
1. Multiple compressive neuropathies (joint-deforming arthritis)
2. Sarcoidosis
3. Acromegaly

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8
Q

Fasiculations Causes

A
  1. Benign idiopathic
  2. Motor neurone disease
  3. Motor root compression
  4. Spinal Muscular Atrophy
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9
Q

Upper Trunk Palsy (C5/C6)

A

Loss of Shoulder movement and elbow flexion, hand in waiter’s tip position
Sensory loss over lateral arm and forearm, and over thumb

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10
Q

Lower Trunk Palsy

A

True claw hand with paralysis of all intrinsic muscles
Sensory loss along ulnar side of hand and forearm
Horner’s Syndrome

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11
Q

Ataxia + UMN signs

A
  1. Spinocerebellar ataxia
  2. Friedrich’s ataxia
  3. Demyelination such as MS
  4. Stroke or injury to brainstem and spinocerebellar tracts
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12
Q

Mixed Upper and Lower MN SIgns

A

Motor Neurone Disease
Syringomyelia
Multiple pathologies
Cervical myelopathy

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13
Q

Wasted Hand

A
  1. Peripheral Nerve lesions - Median, Ulnar, Brachial Plexus, CMT
  2. Anterior Horne Cell Disease (MND, Polio, SMA)
  3. Myopathy
  4. Spinal Cord Lesions
  5. Nutritional, disuse, ischaemia
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14
Q

Proximal Myopathy

A
  1. Drugs - Steroids, statins, fibrates
  2. Toxins - Alcohol
  3. Diabetic amyotrophy
  4. Thyroid disease
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15
Q

Myotonic Dystrophy

A
  • Frontal Baldness
  • Wasting of fascial musculature - temporalis/masseter, sternomastoid atrophy
  • Partial ptosis
  • Difficulty opening eyes after forceful closure
  • Palatal, pharyngeal and tongue involvement - dysarthria, nasally speech
  • Neck flexion weakness
  • Impaired handshake (grip myotonia w/ impaired relaxation)
  • Generalised weakness in voluntary muscles of arms and legs
  • Forearm muscle wasting
  • Thenar tap causes contraction + slow relaxation (percussion myotonia)
    May have subtle peripheral sensory neuropathy/foot drop
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16
Q

Fascioscapulohumeral dystrophy

A
  • Expressionless face
  • Similar to myotonic dystrophy without ptosis or frontal balding
  • Muscle weakness in face, shoulder, distal legs
  • Muscle atrophy in face - difficulty with eye closure, smiling, pursing lips
  • No ophthalmoplegia
  • Shoulder weakness due to scapula winging - get patient to press on wall
  • Biceps + triceps weakness but deltoid spared
  • Spared wasting of the forearm
  • Tibialis anterior muscle weakness is characteristic
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17
Q

Inclusion Body Myositis

A

Symmetrical proximal weakness. Asymmetrical distal weakness
- Classically - upper limb distal weakness, lower limb proximal weakness
Quadriceps particularly weak compared to other groups in legs
Forearm flexor weakness, handgrip weakness
Scalloping weakness in medial forearm
Distal DIP finger flexion weakness is often first sign
Can have weakness in eye closure. No oculomotor involvement

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18
Q

UMN Weakness: Face and arms > Legs

A

MCA Territory

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19
Q

UMN Weakness: Legs > Face and arms

A

ACA territory

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20
Q

Subcortical signs

A

Face/Arms/Legs equally effected
Pure motor stroke = lacunar lesion
Pure sensory = thalamic lesion
Mixed motor and sensory - Thalamus and Internal Capsule

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21
Q

Brown-Sequard

A

Ipsilateral UMN weakness. Ipsilateral vibration + proprioception deficit
Contralateral pain + temperature deficit
Ipsilateral LMN weakness and complete sensory loss at level of lesion

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22
Q

Syringomyelia

A

Begins asymmetrically
Atrophy in the neck, shoulder, arms, small muscles of hand
Sensory deficit in ‘cape’ distribution over shoulders, neck, trunk, distal hands
Clasically segmental LMN at level of lesion, UMN below lesion

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23
Q

Spinothalamic

A

Pain and Temperature

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24
Q

Corticospinal Tract

A

Muscle power

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25
Spinocerebellar
Unconscious proprioception
26
Dorsal Column
Conscious vibration, proprioception
27
Anterior Spinal Artery Infarct
Only dorsal comuln is intact (vibration + propcrioception) Motor, pain, temeprature deficity below lesion
28
Posterior Spinal Artery Infarct
Light touch, vibration, proprioception deficit below the lesion
29
Extra-Pyramidal
No direct control of motor cortex - Regulation of motor activity, muscle tone, emotional and associative movement
30
Pyramidal weakness
Weakness of UL extensors and LL flexors
31
Polio
Often unilateral, lower limbs effected LMN pattern. May have pes cavus No sensory involvement
32
Motor Neuron Disease
Mixture of UMN and LMN signs No sensory involvement Asymmetry in weakness Fasciculations Thenar eminence wasting (split hand) Bulbar + pseudobulbar signs Does not effect eye movement
33
UL Myotomes
Shoulder abduction - C5 (Axillar) Elbow Flexion - C5/C6 (Musculoskeletal) Elbow Extension/Wrist Extension - C6/C7 (radial) Wrist Flexion - C7/C8 (Median) Finger flexion/extension - C8 (Median/Radial) Finger abduction/adduction - T1 (Ulnar)
34
Orthotic
Peripheral Nerves issue
35
Femoral Nerve Injury
Motor - Hip flexion and knee extension Sensory - Medial aspect of thigh
36
Sciatic Nerve Injury
Motor - Weakness of Knee flexion, loss of power in all muscles below knee - foot drop Sensory - Below knee sensation and posterior thigh
37
Tibial Nerve Injury
Motor - Plantar Flexion, foot inversion Sensory - Sole of foot
38
Common Peroneal
Motor - Dorsiflexion (deep branch), eversion of foot (superficial branch) Sensory - Between big toe and second toe (deep), lateral aspect and dorsum of foot (superficial)
39
Foot Drop
L4/L5, Sciatic Nerve, Common Peroneal Nerve
40
Myasthenia Gravis
Ocular symptoms most common - Ptosis, diplopia, ophthalmoplegia Subtle facial weakness Bulbar weakness Limb girdle weakness Fatigability
41
Lambert Eaton
Proximal weakness, improvement with movement Areflexia Autonomic features (postural hypotension)
42
Cerebellar vs Dorsal Column Ataxia
Cerebellar - Gait present constantly, arm drift, past pointing, disdiadochokinesis. Normal sensation. Poor heel to shin. Nystagmus and slurred speech Dorsal Column - Gait worse when eyes closed. Sometimes dysdiadochokinesis, otherwise sensation reduced with vibration + proprioception
43
Friedreich's Ataxia
AR ataxic problem Atrophy of cerebellum and associated motor + sensory tracts, also involves peripheral nerves - Ataxic gait - BL cerebellar signs - Posterior column loss in the limbs - UMN signs in the limbs - Peripheral neuropathy - Pes Cavus - Cardiomyopathy + kyphoscoliosis + diabetes
44
Spinocerebellar Ataxia
AD or trigplet repeat - Ataxic gait - Nystagmus - Ataxic dysarthria - Loss of fine coordination - Truncal and peripheral incoordination
45
Multiple Cranial Nerve Palsies
Malignancy - Nasopharyngeal carcinoma Chronic meningitis Miller-Fisher Variant of AIDP Brain Stem Lesions Trauma Myasthenia Gravis
46
Bulbar Palsy
LMN IX, X, XII Tongue fasiculations + wasting Nasal speech Absent jaw jerk and gag reflex MND, AIDP, Polio, Brainstem infarct
47
Pseudobulbar Palsy
UMN IX, X, XII Tongue - Small, stiff, spastic Spastic dysarthria (hard and slow to get out words) Increased Jaw jerk, normal/increased gag reflex MND, Parkinsons, MS, PSP
48
Bilateral UMN signs
B12 deficiency Demyelination HSP Bilateral brain or spinal cord pathology MND Two diagnoses
49
UMN signs + Cranial Nerve Lesions
Motor Neuron disease Multiple sclerosis
50
Massive Hepatomegaly
1. Metastases 2. Alcoholic liver disease with fatty infiltration 3. Myeloproliferative disease 4. Right heart failure 5. Hepatocellular carcinoma
51
Moderate Hepatomegaly
Causes of massive hepatomegaly (Mets, alcohol + fat, myeloproliferative, RHF, HCC) and: 1. Fatty liver - obesity, DM, toxins 2. Haematological disease - CML, lymphoma 3. Haemochromatosis
52
Mild Hepatomegaly
Causes of Massive and Moderate 1. Hepatitis 2. Cirrhosis 3. Infiltrative and granulomatous disorders
53
Firm and irregular liver
1. Cirrhosis 2. Metastatic disease 3. Hyatid disease, granuloma, amyloid cyst
54
Tender Liver
1. Hepatitis 2. Rapid liver Enlargement - RHF, Budd-Chairi 3. Hepatocellular carcinoma
55
Pusatile liver
1. TR 2. HCC 3. Vascular abnormalities
56
Bilateral Renal Masses
1. Polycystic kidneys 2. Bilateral hydronephrosis 3. B/L RCC 4. B/L Renal Vein Thrombosis 5. Infiltration and acromegaly
57
Unilateral Renal Masses
1. Renal Cell Carcinoma 2. Hydronephrosis or pyonephrosis 3. Polycystic kidney 4. Acute renal vein thrombus
58
If suspect Polycystic Kidneys
1. Check for hepatomegaly 2. Check blood pressure 3. Look for anaemia (and ask for urinalysis) 4. Parietal drift 5. Mitral Valve Prolapse Ask about intracranial aneurysm screening
59
RIF Mass
1. Appendiceal abscess 2. Caecal carcinoma 3. Crohn's disease 4. Psoas abscess 5. Pelvic organ - ovarian tumour or cyst
60
LIF Mass
1. Faeces 2. Carcinoma of sigmoid or descending colon 3. Diverticular disease 4. Psoas abscess 5. Pelvic organ - ovarian tumour or cyst
61
Upper Abdominal Masses
1. Retroperitoneal lymphadenopathy 2. Abdominal aortic aneurysm 3. Carcinoma of stomach or transverse colon or pancreas
62
Massive Splenomegaly
1. Chronic myeloid leukaemia 2. Myelofibrosis 3. Lymphoma of spleen, hairy cell leukaemia, malaria
63
Moderate causes
1. Massive causes (Haem: Chronic myeloid leukaemia, myelofibrosis, lymphoma of spleen, malaria) 2. Portal hypertension 3. Lymphoma 4. Leukaemia 5. Thalassaemia
64
Mild Splenomegaly
1. Haem + portal hypertension 2. Other myeloproliferative disorders (PRV, ET) 3. Haemolytic anaemia 4. Megaloblastic anaemia 5. Infection (hepatitis, endocarditis, EBV), CTD (RA, SLE, PAN), infiltration
65
Hepatosplenomegaly
1. Chronic liver disease with portal hypertension 2. Haematological disease - myeloproliferative, lymphoma, leukaemia 3. Infection - viral hepatitis, glandular fever, CMV 4. Infiltration 5. CTD 6. Acromegaly 7. Thyrotoxicosis
66
Spleen vs Kidney
Spleen has no upper border Spleen is dull to percussion Spleen moves infero-medially on inspiration Splenic notch Spleen is not ballotable Friction rub occasionally over spleen
67
Kidney vs Spleen
Can get above a kidney Kidney resonant to percussion Kidney moves inferiorly on respiration No splenic notch Kidney is ballotable No friction rub
68
Upper Lobe Fibrosis
SCART-H - **S**ilicosis + Sarcoidosis - **C**oal Worker's Pneumoconiosis - **A**nk Spond related + Allergic Broncho-pulmonary aspergillosis - **R**adiotherapy - **T**uberculosis - **H**istiocytosis
69
Lower Lobe Fibrosis
BRASI-D - **B**ronchiectasis - **R**heumatoid Arthritis - **A**sbestosis - **S**cleroderma - **I**diopathic Pulmonary Fibrosis - **D**rugs: Methotrexate, Bleomycin, amiodarone, nitrofurantoin
70
Subacute Combined Degeneration of the Cord
UMN signs Extensor plantar response Peripheral Neuropathy causing loss of knee or ankle jerks Symmetrical posterior common loss

Will's Clinical Exam (5 decks)

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