EM cases

Question 1

• 3rd nerve palsy causes

Answer 1

o	Causes
	Surgical 
	Medical
o	Common (PHD)
	DM
	HTN
	PCA aneurysm
	MS

Question 2

o Does the pupil dilate early or late in a surgical 3rd nerve lesion and if so why?

Answer 2

 Parasympathetic fibres lying on the outside are affected early

Question 3

o What else would you like to measure in a patient with a 3rd nerve?

Answer 3

 Diabetes - do BM

 Hypertension - measure BP

Question 4

• Ptosis on the right side and a small pupil -> HORNER’s

Answer 4

o	Causes
	Apical lung tumour
	3rd nerve palsy
	MG
o	Make sure to look at pupil -> BIG pupil = 3rd nerve, Small pupil = Horner’s, Normal sized = MG

Question 5

• 6th Nerve Palsy causes

Answer 5

	HTN
	DM
	MS
	Raised ICP
•	Longest intercranial nerve
•	Cushing’s triad
o	Abnormal respiration
o	Bradycardia
o	High BP
•	Papilloedema (late sign) - what is the earliest sign? Loss of retinal vein pulsation
•	3rd nerve palsy
•	Focal neurology
•	Seizures

Question 6

• Hypertonia, reduced power, increased reflexes (BOTH LEGS)

Answer 6

o Spastic paraparesis
o Spasticity and rigiditiy difference?
 Spasticity is increased tone at the beginning
 Ridigidity is increased tone throughout

Question 7

o What are the causes of bilater UMN?

Answer 7

	CORD compression
	Syringomyelia
	Cervical spondylosis / MS
	MND
	CVA

Question 8

o What questions would you like to ask this patient or any patient with spinal back pain with or without neurology?

Answer 8

 Bowel and bladder symptoms

Question 9

• Wasting of the small muscles of the hand?

Answer 9

o Bilateral
 RA
 Cervical spondylosis
 MND

	CMT
	Syringomyelia
	Bilateral cervical ribs
o	Unilateral (PBC)
	Pancoasts
	Brachial plexus trauma
	Cervical rib

Question 10

• This patient has weakness down his left side. Can you give me 3 reasons for a CXR in this patient? (ALE)

Answer 10

o Aspiration pneumonia
o Lung Ca
o Enlarged heart

Question 11

NF features

Answer 11

o Mode of inheritance - AD
o Types - NF1 (von Recklinkhausen) - chr17 and NF2
o NF1 - triad
 Neurofibromas, Lisch nodules (Iris hamartomas - little outpouchings in the Iris), café au lait spots (>6)
o NF2 - chr8
 Bilateral 8th nerve palsy, acoustic neuroma

Question 12

NF Cx

Answer 12

	What are the complications of neurofibromatosis?
•	HTML
o	HTN - with RAS
o	Thoracic kyphosis
o	Malignant change 10%
o	Learning difficulties 
	Crowe’s sign is freckling in the
•	AXILLA

Question 13

What is Bell’s palsy?

Answer 13

o Idipathic paralysis of the facial nerve
o LMN
o I would like to examine the ears for herpes zoster (herpes zoster of the geniculat ganglion = Ramsay Hunt syndrome) and acute otitis media
o The parotids (that’s how it spreads)
o Tongue and 2/3
hyperacusis?
o Sensitivity to high pitched sounds

Question 14

Bilateral parotid enlargement?

Answer 14

Sjogren’s, Sarcoidosis, stones, tumour?

Question 15

• Other than CCF, causes of raised JVP?

Answer 15

o	TR
o	Cardiac tamponade
o	Complete HB
o	SVCO
o	Pericardial effusion

Question 16

Signs of pHTN

Answer 16

• Loud P2
• L parasternal heave
• Graham Steele murmur (EDM due to pulm regurg)

Question 17

• Parkinsons questions

Answer 17

o What triad in PD?
 Bradykinesia, rigidity and tremor
o PD and parkinsonism?
 PD -> disease due to death of neurones…
 Parkinsonism, combination of these symptoms
o PPS syndromes?
 PSP
 MSA
 Shy drager
o What proportion of PD patients are depressed - about 50%

Question 18

o What do patients in Paget disease die of?

Answer 18

 High output cardiac failure
 Why do they get it?
• It’s a busy bone disease with a big capillary netwrk
 What proportion of pagets patients get osteosarcoma?
• 1%
 Other causes of bowing of legs