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DPD 2019 > Cases in general internal medicine 3 > Flashcards

Cases in general internal medicine 3 Flashcards

1
Q

What can NMJ be affected by

A

As well as antibdodies in myasthenia gravis,toxins too

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2
Q

Possible pathology in neurological diagnoses

A
  • Vascular
  • Infection
  • Inflammation/Autoimmune
  • Toxic/Metabolic
  • Tumour/Malignancy
  • Hereditary/congenital
  • Degenerative
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3
Q

What do you want to examine for upper and lower limbs

A
  • Inspection
  • Tone
  • Power
  • Reflexes
  • Coordination
  • Sensation
  • Gait
  • Back
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4
Q

Compare UMN and LMN signs

A

UMN: increased tone, reduced power, hyperreflexia and upward plantar reflex

LMN: Reducedtone, reduced power, reduced reflexes

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5
Q

Cerebellar signs and what are these all affecting

A 
Dysdiadochokinesia
Ataxia (gait and posture)
Nystagmus
Intention tremor
Slurred, staccato speech
Hypotonia/Heel-shin test
All affecting coordination of movement
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6
Q

Distributions of abnormal sensation and the affected anatomy that would cause this

A
  • Cerebral cortex –> Hemisensory loss
  • Spinal cord –> Level (e.g. umbilicus)
  • Nerve root (radiculopathy) –> Dermatome(s)
  • Monorneuropathy –> Specific area
  • Polyneuropathy –> Glove & stockings
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7
Q

Toxic/metabolic causes of peripheral neuropathy what are the clues for each

A
  • Drugs (Hx)
  • Alcohol (Hx, raised GGT and MCV)
  • Hypothyroidism (TFTs)
  • Amyloidosis (Hx of myeloma or chronic infection.inflammation)
  • B12 deficiency (anaemia and raised MCV)
  • Diabetes (Hx, glucose/HbA1C)
  • Uraemia (U&Es)
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8
Q

What is duloxetine, SE and mechanism of action

A

Duloxetine inhibits the reuptake of serotonin and norepinephrine (NE) in the central nervous system.

Used to treat:

  • depression and anxiety.
  • relieve nerve pain (peripheral neuropathy) in people with diabetes or ongoing pain due to medical conditions such as arthritis or chronic back pain.

Side effects
Nausea.
Dry mouth.
Sleepiness.

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9
Q

Other causes of peripheral neuropathy other than toxic/metabolic

A

Infection (HIV)

Inflammation (vasculitis, CTD, inflammatory demyelinating neuropathy)

Tumour/malignancy (paraneoplastic, paraproteinaemia)

Hereditary (– Hereditary sensory motor neuropathy… high arched foot)

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10
Q

What are the causes of papilloedema vs papillitis

A

Papilloedema is a sign of raised ICP.

Papillitis is a sign of inflammation of the optic nerve, and thus an inflammatory problem.

Papillitis will give you reduced visual acuity and partially reduced colour vision too, whereas papilloedema won’t.

Papillitis gives you a large central scotoma, papilloedema gives you large blind spot

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11
Q

What papillitis and what might you see and what signs

A

Optic neuritis (papillitis)
– Blurred optic disc margins
– Blurred vision
– Pain on eye movement

To distinguish papilloedema from papillitis.

IN PAPILLOEDEMA: NO PAIN ON EYE MOVEMENT, NO REDUCED VISUAL ACUITY

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12
Q

Disturbances to which area of spinal cord will cause a spastic paraparesis

A

Corticospinal and spinothalamic tracts

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13
Q

Causes of spastic paraparesis

A 
– Vascular
– Infection
– Inflammation (demyelination)
• Transverse myelitis
– Toxic/Metabolic
• b12
– Tumour/Malignancy
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14
Q

What is TB in the spine known as

A

Potts disease is a form of tuberculosis that occurs outside the lungs whereby disease is seen in the vertebrae.

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15
Q

What things would indicate MS

A
  • Two lesions

* Separated in time/space

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16
Q

What is meralgia paraesthetica and what is the cause

A

Compression of lateral
femoral cutaneous nerve

Tight clothing, obesity or weight gain, and pregnancy are common causes of meralgia paresthetica. However, meralgia paresthetica can also be due to local trauma or a disease, such as diabetes.

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17
Q

Management of meralgia parasthetica

If persistent

A 
Reassure
• Avoid tight garments
• Lose weight
If persistent:
– Carbamazepine
– Gabapentin
18
Q

What is radiculopathy

A

Disease of nerve roots

19
Q

Example of radiculopathy

A

Example: Lumosacral

• Pain in the buttock,
radiating down the leg
below the knee (‘sciatica’)

20
Q

Causes of compression of nerve roots in radiculopathy

A

Compression by
– Disc herniation
– Spinal canal stenosis

21
Q

Features of parkinsons

A

Tremor, rigidity,
bradykinesia

Affects – Dopaminergic neurons
– Substantia nigra

22
Q

Features of PSP (steele-richardson syndrome)= progressive supranuclear palsy

A

Parkinsonian features,

upgaze abnormality

23
Q

Lewy body dementia

A

Features of Alzheimer’s
disease, Parkinson’s &
hallucinations

24
Q

DDx for apparent confusion/reduced AMTS

A

• Post‐ictal –> Hx seizure
• Dysphasia –> other features of stroke/TIA
– Receptive or expressive
• Dementia
– Vascular (multi‐infarct) (–> Hx IHD/PVD)
– Alcoholic (–> signs of ETOH excess)
– Alzheimer’s disease
– Inherited e.g. Huntington’s
disease (HD)
• Depressive pseudodementia (–> elderly, withdrawn, poor eye contact & a precipitating factor)

25
Q

DDx for confusion/reduced conscioussness

A

• Hypoglycaemia
• Vascular
– Bleed: Headache, collapse
– Subdural haematoma (Fall, fluctuating consciousness)
• Infection
– ? Temp, ? Intracranial, ? Extra‐cranial
• Inflammation
• Malignancy
• Metabolic/Toxic
– Drugs, U&Es, LFTs, Vitamin deficiencies, Endocrinopathies

26
Q

How to assess GCS

A 
• Eyes (4)
4 = Spontaneous 
3 = Opens in response to voice
2 = Opens in response to painful stimuli
1 = Does not open 
• Verbal response (5)
5 = Oriented
4 = Confused
3 = Words
2 = Sounds
1 = No sounds
https://www.brainscape.com/profiles/3291997
• Motor response (6)
6 = Obeys commands
5 = Localizes pain
4 = Withdraws to painful stimuli
3 = Abnormal flexion
2 = Extension
1 = No movements
27
Q

AMTS confusion assessment

A
  1. DOB
  2. Age
  3. Time
  4. Year
  5. Place
  6. Recall (West Register Street)
  7. Recognize doctor/nurse
  8. Prime Minister
  9. Second WW
  10. Count backwards from 20 to 1
28
Q

Causes of headache in the emergency department

A 
• Meningitis
• Subarachnoid haemorrhage
• Giant cell arteritis
– Polymyalgia rheumatica
– (Shoulder girdle pain, 
stiffness, constitutional 
upset)
• Migraine
29
Q

How would you tell if it’s meningitis

A

• Fever, neck stiffness,

Kernig’s sign

30
Q

How would you tell it’s SAH + what investigations

A
  • Sudden onset

* CT, LP (xanthochromia)

31
Q

How would you tell if it’s giant cell arteritis and what management

Why must you treat

A

> 50 years

• ESR, steroids (to prevent blindness), Biopsy

32
Q

Differentiate presentation of giant cell and polymyalgia rheumatica

What is their treatment

A

Patients with polymyalgia rheumatica usually present with acute onset of stiffness and pain in the shoulder and pelvic musculature, which may be accompanied by fever, malaise, and weight loss. If untreated, polymyalgia rheumatica may result in significant disability.

Giant cell arteritis may manifest as visual loss or diplopia, abnormalities of the temporal artery such as tenderness or decreased pulsation, jaw claudication, and new-onset headaches.

Treat both with steroids (higher dose for GCA) until remission is achieved

33
Q

How would you tell if it’s migraine

A

Throbbing, vomiting,
photo/phonophobia, FHx,
Aura

34
Q

Management of stroke

A

< 4.5 hours
– CT: no haemorrhage
– Thrombolysis (if no
contraindications)

> 4.5 hours
– CT head (exclude 
haemorrhage)
– Aspirin (300mg), Swallow 
assessment
– Maintain hydration, 
oxygenations, monitor glc
35
Q

Management of TIA

A 
• Aspirin
• Don’t treat BP acutely
– unless > 220/120 or 
– other indication
• ECG, Echocardiogram
• Carotid Doppler
• Risk factor modification
36
Q

What makes guillain barre more likely

A

Back ache

You need to masure FVC

37
Q

Causes of collapse

A

• Low glucose

• Heart
– Vasovagal
– Arrhythmia
– Outflow obstruction
– Postural hypotension

• Brain
– Seizure

38
Q

How would you use the pin prick

A

First test if they know what sharp and dull is by swtiching the two sides.

Then just use the sharp end and get them to tell you when they feel it

39
Q

What part of a confusion history would suggest that the confusion is NOT caused by a bleed

A

No headache (bleeding on brain normally very painful)

40
Q

What is kernig’s sign? When is it positive and what does it indicate

A

Kernig’s sign is positive when the thigh is flexed at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful (leading to resistance).

This may indicate subarachnoid hemorrhage or meningitis.

DPD 2019 (30 decks)

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