Case 2 - Blackout

Question 1

Differential Diagnosis of a blackout - it may fall into … or ….

Answer 1

Cardiac (Cerebral hypoperfusion) or neurological (cerebral dysfunction)

Question 2

Cardiac differentials of a blackout (5)

Answer 2

• Vasovagal ‘faint’
• Postural hypotension
• Arrhythmia
• Ischaemic
• Structural

Question 3

Neurological differentials of a blackout (4)

Answer 3

• Epilepsy
• Cerebrovascular disease
• Psychogenic
• Substance abuse

Question 4

What would you expect to see on examination (end of bed) in someone with myotonic dystrophy? (3)

Answer 4

• Bilateral ptosis
• Frontal balding
• Long apathetic face
  Also a slow-relaxing hand shake

Question 5

What AMTS is considered to be ‘confusion’?

Answer 5

Under 8/10

Question 6

AV block means it is …

Answer 6

Above the ventricles

Question 7

AV Block types

Answer 7

1st degree
2nd degree mobitz T1 (Wenckeback)
2nd degree mobits T2
3rd degree (complete)

Question 8

What block has an increased risk of becoming complete heart block?

Answer 8

Mobitz type 2

Question 9

AV block - 1st degree - what is seen on ECG?

Answer 9

PR interval is prolonged (over 200ms, over 5 small squares)

Question 10

AV block - 2nd degree Mobitz T1 (Wenckebach) what is seen on ECG?

Answer 10

PR interval gradually increased then a failed beat

Question 11

AV block - 2nd degree Mobitz T2 what is seen on ECG?

Answer 11

PR interval stays the same but there are dropped beats (may be 2:1, 3:1)

Question 12

AV block - Complete heart block - what is seen on ECG?

Answer 12

Complete dissociation between atria and ventricles - failure of AV node

Question 13

High-output vs low-output cardiac failure - HF with … ejection fraction?

Answer 13

High-output is also known as HF with preserved ejection fraction
Low-output is also known as HF with reduced ejection fraction

Question 14

High-output cardiac failure - causes (4)

Answer 14

• Hyperthyroidism
• Anaemia
• Pregnancy
• Other

Question 15

Low-output cardiac failure - causes (5)

Answer 15

• Valvular
• Hypertensive
• Ischaemic
• Arrhythmic
• Other

Question 16

Endocardial - cardiac failure

Answer 16

Valvular disease
(Endocarditis)

Question 17

Myocardial causes - cardiac failure (4)

Answer 17

Ischaemic
Hypertensive
Arrhythmic
Cardiomyopathy

Question 18

Pericardial causes - Cardiac failure (3)

Answer 18

• Effusion
• Tamponade
• Constrictive

Question 19

Congestive cardiac failure - how to diagnose (what investigations? 4)

Answer 19

BNP, ECG, CXR, ECHO

Question 20

Treatment for congestive cardiac failure (prognosis AND symptoms)

Answer 20

Beta-blocker and ACEi

Question 21

Treatment for congestive cardiac failure (symptoms only)

Answer 21

Furosemide - helps with pulmonary and peripheral oedema

Question 22

Weakness can be due to 4 types of problems…

Answer 22

• Upper motor neurone lesion
• Lower motor neurone lesion (E.g. trauma)
• Neuromuscular junction disorder (e.g. myasthenia gravis)
• Myopathy (e.g. duchenne muscular dystrophy)

Question 23

Proximal Myopathy - Signs and symptoms (gait, mobilising?)

Answer 23

• Waddling gait
• Can’t climb stairs
• Difficulty getting out of chair

Question 24

Proximal Myopathy - Is there wasting? Reflexes? Tone? Fasciculations? Sensation?

Answer 24

Wasting yes 
Reflexes normal
Normal /reduced tone
No fasciculations
Normal sensation

Question 25

Distal myopathy - … hand movement

Answer 25

Clumsy hand movement

Question 26

Congenital myopathies (3)

Answer 26

Duchenne muscular dystrophy (most severe) Becker muscular dystrophy (less severe) Myotonic dystrophy

Question 27

Metabolic myopathies

Answer 27

Hypokalaemia, thyroid, vitamin D deficiency

Question 28

Drug causes of myopathy - examples

Answer 28

Alcohol, long term steroids in proximal myopathy

Question 29

Myotonic dystrophy - is it dominant or recessive?

Answer 29

Autosomal dominant

Question 30

Myotonic dystrophy - can present with what cardiac conditions?

Answer 30

Cardiomyopathy and heart block

Question 31

Increased risk of developing what condition with myotonic dystrophy?

Answer 31

T2 DM

Question 32

What dementia do people with myotonic dystrophy tend to get?

Answer 32

Fronto-temporal dementia

Question 33

Unilateral ptosis - complete vs partial?

Answer 33

``` Complete = cranial nerve III palsy Partial = Horner syndrome ```

Question 34

Bilateral ptosis - may be … or as a result of a …

Answer 34

Congenital or a myopathy

Question 35

Horner syndrome is a symptom of …

Answer 35

Pancoast tumour (lung cancer at Alice’s)

Question 36

Dementia vs Delirium

Answer 36

Dementia - normal consciousness, chronic, day-to-day similar, worse at night Delirium - altered consciousness, acute, fluctuates, worse at night

Question 37

Reversible dementia examples

Answer 37

B12 deficiency, Subdural haematoma

Question 38

Dissociation of p-waves and QRS complexes =

Answer 38

Complete heart block

Question 39

Suddenly collapse with no warning signs but rapidly re-gains consciousness = …

Answer 39

Arrhythmic cardiac syncope

Question 40

Slow-relaxing handshake is seen in people with …

Answer 40

Myotonic dystrophy

Question 41

Stepwise deterioration is seen in which time of dementia?

Answer 41

Vascular dementia

Question 42

Visual hallucinations and fluctuation in function is seen in which type of dementia?

Answer 42

Lewy body dementia

Question 43

What drug can you add in severe heart failure for mortality and symptom benefit?

Answer 43

Spironolactone

Question 44

… disease is a specific form of fronto-temporal dementia with ‘knife-blade gyri’

Answer 44

Pick’s disease