Clinical Examination Flashcards
Concepts to approach threatening topics
Normalizing questions
Symptom expectation and reduction of guilt
Symptom exaggeration
Familiar language when asking about behaviours
Purpose of normalizing questions?
Decrease patients embarrassment about feeling or behaviour
Purpose of symptom expectation?
Defuse admission of embarrassing behaviour
Purpose of symptom exaggeration?
Determine actual frequency of sensitive or shameful behaviour
Techniques to change topics?
Smooth transitions
Referred transitions
Introduced transitions
When to use smooth transitions?
To hint at something the patient just said
When to use referred transitions?
Hint at something mentioned earlier
When to use introduced transitions?
To pull a new topic from thin air
What are directive techniques?
Focused on seeking a particular answer or driven by motives of doctor.
Give e.g. of limit setting
I am going to interrupt you as there are a few things to cover.
Name some directive techniques
Limit setting Closed questions Question rephrasing Redirection Transition
Describe confrontation
Point out to a patient something which the doctor thinks the patient is missing or denying
Give e.g. of suggestive question
These voices are not from your head. Am I right?
What is functional analysis?
Attempts to explain and predict functions of a phenomenon by examining any relationships to the outcome.
What medical intervention can confirm a panic disorder?
Lactate provocation
Hyperventilation
CO2 inhalation
What inhibits panic attacks triggered by sodium lactate?
Benzos
TCAs
In which psychiatric diagnosis is infusion of amobarital (narcoanalysis) helpful?
Catatonia Stupor Muteness Repression Dissociation
What happens to organic conditions when infused of amobarbital?
They worsen
Why do non-organic conditions get better with infusion of amo-barbital?
Due to disinhibition, decreased anxiety or increased relaxation
What can be substituted for amo-barbital?
Benzos
Investigations for suspected encephalitis syndrome
NMDA receptor and voltage-gated K+ channel receptor auto-antibodies (IgG0
Investigations for porphyria
Spot urine sample for porphobilinogen during acute attack and 24 hour urine for porphyrins, porphobilinogen and delta-aminolevulinic acid
Investigations for Wilsons Disease
Serum ceruloplasmin
24 hour copper excretion test
Investigations for lysosomal storage disease
Skin biopsy
Genetic tests
Detection of serum alpha-galactosidase enzyme
Investigations for Homocystinuria?
Homocysteine in urine and blood
Molecular genetic testing
Investigations for metachromatic leukodystrophy
Arylsulfate A enzyme activity in WCCs or in cultured skin fibroblasts
Investigations in malnourishment
Serum homocystine and folate Vitamin B12 Niacin Trytophan Nicotinamide adenine Dinucleotide (NAD) and NADP
Difference between AIP and porphyria?
AIP does not present with rash
Onset of porphyria
18-40 years of age
What triggers AIP?
Oestrogens
Barbituates
Benzos
Diclofenac
Treatment for AIP
Haemin - reduces haem synthesis
important receptors involved in autoimmune encephalitis
Voltage gated K+ channel complex - LGI1, CASPR2, contactin-2 NMDA AMPA receptor GABA-B Glycine receptor
How do anti-NMDA receptor antibodies work?
Titre-dependent destruction of synaptic NMDAR through crosslinking and internalisation
Gender variability in anti NMDAR encephalitis?
80% are female
50% of women with it have underlying ovarian teratoma
How does psychosis with anti NMDAR first present usually?
Fever, headache, malaise
EEG in anti-NMDAR encephalitis?
Disorganized delta/theta activity
What to look for in MRI in anti-NMDAR encephalitis?
Medial temporal hyperintensity in hippocampi, frontobasal and insular regions in basal ganglia
How to confirm anti-NMDAR encephalitis?
CSF: lymphocytic pleocytosis, elevated protein and oligloclonal bands in 60%, anti-NMDAR antibodies.
Treatment of anti-NMDAR encephalitis
3 days of methylprednisolone PO/IV followed by PO prednisolone in association with 5 days of plasma exchange
Why must you not give antipsychotics in anti-NMDAR encephalitis?
Dystonic reactions and NMS-like syndrome can occur
What type of thyroid problem can cause cognitive impairment?
Low T4
When would EEG be required to diagnose dementia?
Rapid onset; may suggest CJD.
Need EEG and MRI
TFTs in patients with anorexia
Low T3
Low normal range T4
Normal TSH
(low T3 syndrome)
GI effects of anorexia
Delayed gastric emptying
Decreased colonic motility - secondary to chronic laxative misuse
Acute gastric dilatation - rare, secondary to binge eating
Haematological signs of anorexia
Moderate normocytic anaemia
Mild leucopenia with relative lymphocytosis
Thrombocytopenia
Electrolyte result of laxative misuse
Metabolic acidosis
Hyponatraemia
Hypokalaemia
Brain abnormalities resulting in anorexia
Enlarged cerebral ventricles and external CSF spaces (pseudo atrophy)
BMI for obesity
30 or greater
Most specific and sensitive test for detecting heavy alcohol use over 10 days
Carbohydrate deficiency test
What is Marchiafava syndrome?
Corpus callosum damage often due to alcohol misuse
Normal QTc for men
440ms
Normal QTc for women
470ms
Which recreational drugs increase risk of QTc prolongation?
Stimulants
Method of testing drug use aside from urine
Specific gravity in urine
How long is alcohol present in urine?
Up to 12 hours
How long is amphetamine present in urine?
Up to 48 hours
How long is benzo present in urine?
3 days depending on half life
How long does cannabis last in urine if occasional use?
Up to 3 days
How long does cannabis last in urine if high daily use?
Up to 4 weeks
How long does cocaine last in urine?
6-8 hours
How long does cocaine metabolite last in urine?
2-4 days
How long does codeine stay in urine?
48 hours
How long does heroin last in urine?
1-3 days
How long does methadone stay in urine?
3 days or more
How long does morphine last in urine?
2-3 days
How long does PCP stay in urine?
8 days
Which recreational drugs are associated with renal disease?
Cocaine
Heroin
Common renal dysfunction in black patients with drug misuse
Segmental glomerulosclerosis
Common renal dysfunction in white patients
Membranoproliferative glomerulonephritis
Plasma and urine osmolality in diabetes insipidues
Plasma: High (>295)
Urine: low
Plasma and urine osmolalities in psychogenic polydipsia?
Plasma: Low (<280)
Urine: Low
Plasma and urine osmolalities in SIADH
Plasma: low
Urine: high
At what Na level do symptoms of hyponatraemia occur?
Na <125
At what Na level can seizures and irreversible brain damage occur?
Below 110-115
Most common cause of Argyll-Robertson pupil
Diabetes
What is checker-board abdomen?
Multiple surgical scars in factitious disease
In which drug misuse is piloerection seen?
Opiate withdrawl
How can one rate Minor Physical anomalies?
Lane Scale
In what type of patients are Minor Physical Anomalies noted?
Developmental disorders
Which tuning fork is used to test auditory function?
512Hz
Which tuning fork is used to test peripheral neuropathy?
128 Hc
What type of diseases result in a positive Romberg test?
Polyneuropathies
Disease of dorsal column
Normal caloric testing result
On cold water testing, nystagmus noted to opposite side.
On warm water, nystagmus to same side
What are hard neurological signs?
Imapirments of basic motor and sensory functions that are localisable to pyramidal, extrapyramidal or cranial nerve systems.
what are neurological soft signs?
Non-localisable neurological findings thought to reflect neurodevelopmental aberrations when seen in psychiatric disorders.
Three groups of soft signs
Abnormalities of motor coordination, sensory integration and signs of cortical disinhibition
Signs of midline cerebellar dysfunction
Ataxic gait
Difficulty in maintaining upright posture
Truncal ataxia
What is the neocerebeullum?
Lateral cerebellar hemispheres
What does neocerebeullum control?
Movement of ipsilateral limb
What is the midline vermis involved in?
Control of truncal tone, speech and eye movements
What is the archicerebeullum?
Flocculonodular lobe
What does flocculonodular lobe do?
Vestibular functions
What part of the cerebellum controls vestibular functions?
Archicerebellum/flocculonodular lobe
How to test for ataxia
Tandem gait
Which type of tremor accelerates in pace on approaching the target
Intention tremor
What is dyssynergia?
Incoordination
What is dysmetria?
Past pointing
What is dysrhythmia?
Inability to tap and keep to a rhythm
What is dysarthria a sign of?
Diffuse involvement of cerebellum
What is the Brudzinski sign?
Flexion of hips and knees when you try to flex the neck
What is Kernigs sign?
Flexing one hip and knee and then extending knee with hip still flexed. If opposite knee flexes, this test is positive
What is another name of the straight-leg raising test?
Lasegue
Describe the straight leg raising sign
Passively flexing hip with knees straight while patient is in supine position.
Limitation of flexion due to hamstring spasm or pain indicates local irritation of lower lumbar nerve roots
Describe reverse straight leg raise sign
Passively hyperextending hip with knees straight while prone; limitation of extension due to spasm or pain in anterior thigh muscle indicates local irritation of upper lumbar nerve roots
Functions of cortical sensory system
Kinaesthetic sensation Stereognosis Graphesthesia Tactile localization Tactile 2 point discrimination on both sides of body
Which type of fibrillations are visible?
TOngue
Describe myoclonus
Brief <0.25 second muscle jerk, generalized.
What is myoclonus associated with
Generalized epilepsy
CJD
Severe Alzheimers
What is athetosis
Slow writhing spasms along long axis of limbs or body itself.
What is chorea
Quasi-purposeful movements affecting multiple joints with distal preponderance.
What lesion is chorea associated with?
Caudate
What is hemiballismus?
Violent flinging of half of body
What area of the brain is hemiballismus associated with?
Lesion of subthalamic nucleus
Give examples of primary reflexes
Glabellar tap Rooting Snout Sucking Palmomental
What are primary reflexes?
Absent in adults
What does primary reflex in adult suggest?
Possible frontal lobe damage
What are superficial reflexes?
Responses that indicate integrity of cutaneous innervation and corresponding motor outflow
What are the superficial reflexes?
Corneal and conjunctival
Abdominal
Cremasteric
Plantar
What controls corneal and conjunctival reflexes?
Afferent: 5th nerve
Efferent: 7th nerve
What is the abdominal reflex/
Drawing line away from umbilicus in diagonals of 4 abdominal quadrants. Normal reflex draws umbilicus towards direction of line.
Describe cremasteric reflex
Scratching medial surface of thigh to elicit scrotal contraction or lift.
Normal: elevation of ipsilateral testis.
What does lack of both positive and negative Babinski sign suggest?
Absence of cutaneous innervation in S1 or loss of motor innervation in L5
What is required for a deep tendon reflex?
Intact cutaneous innervation
Motor supply
Cortical input to corresponding spinal segment
Spinal roots of biceps reflex
C5, C6
Spinal roots of brachoradialis reflex
C6
Spinal roots of triceps reflex
C7
Spinal roots of patellar reflex
L2-L4
Spinal roots of Achilles reflex
S4
What type of lesion is a pseudobulbar palsy?
UMN lesion
What type of lesion is exaggerated jaw jerk?
UMN lesion
What type of lesion is bulbar palsy?
LMN
Which disease is frontal baldness associated with?
Myotonic dystrophy
Neurocutaneous signs of Tuberous Sclerosis
Dermatomal eruptions
Ash leaf macules
Ungual fibromas
Café au lait spots
Neurocutaneous signs of Neurofibroma
café au lait spots
Axillary freckling
Describe spastic dysarthria
Strained, hoarse voice
Hypernasality
Slow, imprecise articulation
Cause of spastic dysarthria
Bilateral UMN lesions