Cases in general internal medicine 3 Flashcards
What can NMJ be affected by
As well as antibdodies in myasthenia gravis,toxins too
Possible pathology in neurological diagnoses
- Vascular
- Infection
- Inflammation/Autoimmune
- Toxic/Metabolic
- Tumour/Malignancy
- Hereditary/congenital
- Degenerative
What do you want to examine for upper and lower limbs
- Inspection
- Tone
- Power
- Reflexes
- Coordination
- Sensation
- Gait
- Back
Compare UMN and LMN signs
UMN: increased tone, reduced power, hyperreflexia and upward plantar reflex
LMN: Reducedtone, reduced power, reduced reflexes
Cerebellar signs and what are these all affecting
Dysdiadochokinesia Ataxia (gait and posture) Nystagmus Intention tremor Slurred, staccato speech Hypotonia/Heel-shin test All affecting coordination of movement
Distributions of abnormal sensation and the affected anatomy that would cause this
- Cerebral cortex –> Hemisensory loss
- Spinal cord –> Level (e.g. umbilicus)
- Nerve root (radiculopathy) –> Dermatome(s)
- Monorneuropathy –> Specific area
- Polyneuropathy –> Glove & stockings
Toxic/metabolic causes of peripheral neuropathy what are the clues for each
- 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)
What is duloxetine, SE and mechanism of action
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.
Other causes of peripheral neuropathy other than toxic/metabolic
Infection (HIV)
Inflammation (vasculitis, CTD, inflammatory demyelinating neuropathy)
Tumour/malignancy (paraneoplastic, paraproteinaemia)
Hereditary (– Hereditary sensory motor neuropathy… high arched foot)
What are the causes of papilloedema vs papillitis
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
What papillitis and what might you see and what signs
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
Disturbances to which area of spinal cord will cause a spastic paraparesis
Corticospinal and spinothalamic tracts
Causes of spastic paraparesis
– Vascular – Infection – Inflammation (demyelination) • Transverse myelitis – Toxic/Metabolic • b12 – Tumour/Malignancy
What is TB in the spine known as
Potts disease is a form of tuberculosis that occurs outside the lungs whereby disease is seen in the vertebrae.
What things would indicate MS
- Two lesions
* Separated in time/space
What is meralgia paraesthetica and what is the cause
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.
Management of meralgia parasthetica
If persistent
Reassure • Avoid tight garments • Lose weight If persistent: – Carbamazepine – Gabapentin
What is radiculopathy
Disease of nerve roots
Example of radiculopathy
Example: Lumosacral
• Pain in the buttock,
radiating down the leg
below the knee (‘sciatica’)
Causes of compression of nerve roots in radiculopathy
Compression by
– Disc herniation
– Spinal canal stenosis
Features of parkinsons
Tremor, rigidity,
bradykinesia
Affects – Dopaminergic neurons
– Substantia nigra
Features of PSP (steele-richardson syndrome)= progressive supranuclear palsy
Parkinsonian features,
upgaze abnormality
Lewy body dementia
Features of Alzheimer’s
disease, Parkinson’s &
hallucinations
DDx for apparent confusion/reduced AMTS
• 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)
DDx for confusion/reduced conscioussness
• 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
How to assess GCS
• 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
AMTS confusion assessment
- DOB
- Age
- Time
- Year
- Place
- Recall (West Register Street)
- Recognize doctor/nurse
- Prime Minister
- Second WW
- Count backwards from 20 to 1
Causes of headache in the emergency department
• Meningitis • Subarachnoid haemorrhage • Giant cell arteritis – Polymyalgia rheumatica – (Shoulder girdle pain, stiffness, constitutional upset) • Migraine
How would you tell if it’s meningitis
• Fever, neck stiffness,
Kernig’s sign
How would you tell it’s SAH + what investigations
- Sudden onset
* CT, LP (xanthochromia)
How would you tell if it’s giant cell arteritis and what management
Why must you treat
> 50 years
• ESR, steroids (to prevent blindness), Biopsy
Differentiate presentation of giant cell and polymyalgia rheumatica
What is their treatment
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
How would you tell if it’s migraine
Throbbing, vomiting,
photo/phonophobia, FHx,
Aura
Management of stroke
< 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
Management of TIA
• Aspirin • Don’t treat BP acutely – unless > 220/120 or – other indication • ECG, Echocardiogram • Carotid Doppler • Risk factor modification
What makes guillain barre more likely
Back ache
You need to masure FVC
Causes of collapse
• Low glucose
• Heart – Vasovagal – Arrhythmia – Outflow obstruction – Postural hypotension
• Brain
– Seizure
How would you use the pin prick
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
What part of a confusion history would suggest that the confusion is NOT caused by a bleed
No headache (bleeding on brain normally very painful)
What is kernig’s sign? When is it positive and what does it indicate
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.
