Finals - PACES Flashcards
Cardiac - inspection
Scars / medications
Sternotomy scar
CABG / valve placement
Bruising
fall - cardiac origin with anti-coagulations
with Valves - metallic e.g. warfarin
Pitting oedema
evidence of cardiac failure
Observation cardiac
warfarin, bruising, sternotomy scar, saphenous graft scar, audible click, oedematous ankles
No scar
Valvular - Pulse, BP and heart sounds
AF - “”
CCF - JVP, lungs, oedema
Normal pulse and no warfarin
exclude AF
Auscultation - ESM
Aortic stenosis or aortic sclerosis
Pulse, BP, radiation & Apex beat
with no warfarin, normal pulse and no scar
check for CCF - JVP, lungs, oedema
Pulse character of aortic stenosis
slow rising pulse - blood moving slower rate due to stenosis - only in severe aortic stenosis
narrow pulse pressure - systolic similar to diastolic - 25% of difference between the two or less
Systolic murmur
loudest in upper chest = AStenosis/Sclerosis
(only) Heard at Apex = Mitral regurgitation
between heart sounds 1 and 2
AF - more likely to be mitral
tip: feel the subclavian artery above the clavicle
Aortic stenosis
radiates to carotids
slow rising
narrow pulse pressure
heaving apex beat - hypertrophied heart due to extra work
absent 2nd Heart sound
sclerosis is slight calcification
AS presentation
examined CV system
describe pulse - regular, slow rising pulse - haemodynamic effect
Apex beat - not displaced and normal character - no LVH
heart sounds - normal and had ESM murmur, intensity 3/6, loudest in the 2nd intercostal space on the right radiates to carotids - aortic flow murmur, loud but no thrill, no sclerosis
no features of cardiac failure - so signs consistent with aortic stenosis - good negative
history to assess symptoms of As and request echo to look for aortic pressure gradient - assess indications for surgery
Other differentials: ASD and pulmonary stenosis
Sclerosis
does not radiate
assess AS and CXR - systolic murmur, early aortic stenosis
Causes of aortic stenosis
calcific degeneration
biscuspid valve - turners
Symptoms of AS
Syncope
Angina
Left-Ventricular Failure
Sudden Death
ASH - Angina, Syncope, Heart failure
Signs of severity of Aortic stenosis
Narrow pulse pressure / slow rising pulse – much harder to pump
delayed closure of A2 or reveresed splitting
absent 2nd HS
heaving apex beat
features of CCF
symptomatic
Indications for surgery in AS
symptomatic
asymptomatic + LVEF < 50%
Mean transcalcular pressure gradient > 40mmHg, valve area <1cm2 or jet velocity > 5m/s
Concomitant CABG
Grading of murmurs
1 - audibe to expert
- just audible to non-expert
- clearly audible
- clearly audible with palpable thrill
- audible with stehoscope only lightly applied
- audible without stehoscope on chest
Valve replacement work through
Sternotomy scar - valve replacement - warfarin / heart sounds
CABG - Saphenous scar, tar staining, xanthelasma
assess AF and CCF as well
Sternotomy scar with warfarin
metallic valve - click, heart sounds, murmur, pulse regularity
Present metallic valve
midline sternotomy scar and there was warfarin at the bed side
metallic click heard with first heart sound and second heart sound was normal
mitral = first heart
aortic = second heart sound
look for AF
Tissue valve presentation
no audible sounds with a mid-line sternotomy scar
No scars on legs
No warfarin on the bedside
could also be Prevsious CABG using internal thoracic artery. or repair of congential cardiac disease
Severe anaemia
cause of high output heart failure
Midline sternotomy
Pulse
Murmur
Scar
Heart Failure
DDX: tissue valve, CABG, congential cardiac disease repair
Types of valve replacements
Transcatheter aortic valve implantation (TAVI)
Tissue based
Metallic
Metallic vs tissue
M: click, warfarin, 20 yrs, flow murmur = hearing turbulence acorss valve Ok
T: regurgitant murmur only (no click), 10 yrs
Hypokalaemia
U waves - on ECG
Warfarin Targets
biprothetic of aortic - nil (aspirin)
mitral - 2.5 (2-3) - 3 months of warfarin then aspirin
Aortic mechanical - 3(2.5-3.5) - life long
Mitral mechanical - 3.5 (3-4) - life long
Stenotomy scar - CABG
normal pulse, no warfarin - CABG
no AF
Spahenous scar, tar staining, xanthelasma
no click on auscultation
could still be tissue valve replacement
Exclude tissue valve scar
saphenous scar
Bypass graft presentation
CVS - tar staining on fingers, midline sternotomy scar and a scar over his left saphenous vein
Heart sounds normal
Look for finger pricks for T2DM
No features of CCF
Indications for CABG
Left main-stem disease
2 or more vessel disease
Failure of medical management
Concomitant (aortic) valvular replacement
Types of grafts
great saphenous
internal thoracic (mammary) artery
Most common artery used for CABG
Internal mammary artery - access via same midline sternotomy scar
Medication post CABG
Conservative - smoking, diabetes, weight
Med - DUAP (aspiring + ticagrelor) for 12 months, aspirin alone after, specialist opinion, cardi-selective beta-blocker (bisoprolol), ACEi
Kussmual sign
Rasied JVP not fall with inspiration
No scar, no warfarin, normal pulse, pansystolic murmur
Mitral regurgitation - radiates to axilla (VSD)
Assess CCF as well - JVP, lungs, oedema
VSd and TR
Systolic murmur heard at apex
Mitral regurgitation
dilation of heart
Present mitral regurg
normal pulse
apex beat displaced / not displaced
pansystolic beat heard at the apex - radiates to axilla
impact on patients life and CXR if CCF - patient centred approach
Causes of mitral regurg
chronic - myxomatous degeneration - collagen
functional (with LV dilatation)
Acute - infective endocarditis, (posteriomedial) papillary muscle rupture, posterior interventricular artery post inferior / posterior MI
Signs of severity of MR
displaced or thrusting apex beat
left ventricular failure
Cardiac failure
no scar
JVP, lungs, oedema
Raised JVP
right sided heart failure
congestive cardiac failure - both sides failing
normal = any diagnosis, left-sided heart failure
Signs of RHF
acute - rasied jvp, hepatojugular reflux, hepatomegaly
chronic - pedal oedema, sacral oedmea, ascites
Signs of LHF
acute/chronic - pulmonary oedema, poor peripheral perfusion, tachypnoea, tachycardia
Present cardiac failure
tar staining and short of breath at rest - say resp rate and heart rate
pulse and jvp raised xcm above sternal angle
apex beat displaced in x line
bibasal fine end inspiratory crackles and peripheral oedema present to mid thigh
basal crackles and peripheral oedemaa
do echo
Causes of heart failure
rhf - mi, pe, infective endocaridtes
left ventricular failure, cor pulonale - mainly left failing
lvf - MI, IE (acute), Ischaemic cardiomyopathy, hypertensive cardiomyopathy and VHD (chronic)
CCF mx
conservative - smoking, long term oxygen
medical - bb, acei, underlying cause e.g. htn, afib
surgical - left ventricular assist devices
Cardiac exam mains
leg scars
CCD
2/6 or 3/6 murmurs
thrill = 4/6
bruises suggestive of warfarin
speak to senior and get echo to confirm findings
take stethoscope on until diagnosis
Perioeprative anticoagulation
stop warfarin a week before, use LMWH until day before and then unfractionated heparin
get INR down to 1.5 surgery safe, high risk of clot, unfractionated is reversible
Mercedes benz scar
thoracic - oesophageal surgery
Intital inspection Abdo
rooftop scar - liver transplant
bulging flanks - CLD
AV fistulae - renal transplant
abdominal swelling - organomegaly
leg rash - IBD
Swollen abodomen
jaundice - chronic liver disease - signs of decompensatino
(organo / mass) - palpation
Liver transplant scar
transplant failure
Signs of chronic liver disease
dupetryens, palmar erythema
icteric sclerae, parotid swelling
clubbing
spider naevi - need 5 to be significant
caput medusae
gynaecomastia, ascites, splenomegaly
cachexia - malnourished
excoriations, brusing, lack of axillary hair
Specific liver signs
needle / tattoo - hep c virus
parotid swelling - alcohol
bronzed complexion / insulin injection sites - haemochromatosis
obesity / diabetes - non-alcoholic fatty liver disease
xanthelasma - cholestatic
CLD presentation
abdo system, cachectic and jaundiced
no asterixis - not encephalopathic
shifting dullness -ascites
soft abdomen - not SBP
dullness in traubes space - splenomegaly
unable to palpate liver edge - tense ascites
decompensated - ascites and jaundice
alcohol history and bloods - investigate cause
check clotting - test synthetic function
Causes of chronic liver disease
infective - hep b and hep c - serology
toxic - alcohol - history
metabolic - NAFLD, haemo, A1A, wilsons - ferritin, transferrin, a1at, caeruloplasmin
autoimmune - autoimmune hepatitis, psc, pbc, immunoglobulins and autoantibodies
signs of decompensation of liver
coagulopathy, asterixis, ascites, worsening jaundice, hypoglycaemia
Cirrhosis complications
Portal hypertension - spleno, oesophageal varics, thrombcytopenia, rectal varices (PR bleed)
- splanchnic vasodilation - hepatorenal, hypervolaemia (hyponatreaemia)
Hepatocellular destruction (decompensation) - hepatocellular failure - encephalopathy, hypoalbuminaemia, hypoglycaemia
swollen abdomen with organomegaly
abdo palpation
pallor no jaundice
dullness in traubes space - splenomegaly - hepatomegaly, lymphnodes and chronic liver disease
Traubes space
dullness over lung / spleen overlap
Differntials of spleno
malaria (foreign travel) and leukaemia - CML (FBC and film)
Dull mass, moves with respiration and did not ballot
Not kidney
beyond midline = massive splenomegaly
Causes of splenomegaly
haem - CML, myelofibrosis, spherocytosis
Infective - malarai, ebv
Other - portal htn, infilration (amyloidosis), sarcoidosis
with hepatomegaly excludes - myelofibrosis, sphero and portal htn
Indications for splenectomy
traumatic rupture, idiopathic thrombocytopenia, spherocytosis
Prophyalxis post splenectomy
pneumococcus, meningococcus, haemophilus, influenzae B, penicillin V
Renal transplant
see AV fistula - then assess sacr, abdo, palpation
if fistula is active - renal failure
no thrill and a scar
renal transplant next steps
abdo palpation
signs of renal failure
insulin injection sites
cushingoid
skin malignancy
Renal transplant scrs
bilateral scars
midline incisions
hockey stick scar - mayo robson incision - RIF
nephrectomy scar
renal exam findings
previous av fistula - not currently on dialysis
blood glucose marks - diabetes
oblique scar with mass - renal transplant
no peripheral oedema - not in renal failure
not cushingoid - side effect of steriods
asuculatiaion, bp and dip - for features of renal failure
indications for renal transplant
diabetic nephropathy - insulin injection sites
ckd stage 5
pckdad - flank scars
glomerulonephritis
Complications of renal transplant
rejection - renal failure
cushings - round face and bruises
skin malignancy - bcc and scc
ciclosporin - gum hypertrophy
Signs of renal failure
scars: old av fistulate, neck line and peritoneal dialysis catheters
cachexia
pulmonary and peripheral oedema
pallor
Stoma
IBD - young, pallor, ieostomy
diver - elderly, colostomy
malign - nil else
urostomy - stoma appearance
lumens on stoma
Signs of IBD
young
pallor slim
oral ulceration
pyoderma gangrenosum and erytham nodosum
dgital clubbing
medications
Hypercholestramiea
can cause cushingoid appearance
Complications of IBD
scars from hickman lines - parenteral nutrition
cushingoid
gum hypertrophy and hypertesnion if ciclosporin
jaundice . ursodeoxycholic acid - PSC
hepato-splenomegaly from amyloidosis
IBD features on presentation
pale and slim
no clubbing - IBD has clubbing
hernias or fistulae - post op complications
cushingoid - side effects of steroids
perianal disease exam - crohns sub type
disease activity - disease activity scores or monitoring
crohns disease activity index 0-600
Extra intestinal IBD
eyes: episcleritis, posterior uveitis, scleritis
skin: pyoderma gangrenosum, erythema nodosum
other: clubbing, oligoarthitis, anaemia
Complications of IBD
Crohns: strictures, obstruction, fistulae
colitis: toxic mega colon, colonic carcinoma, psc
Indications for stomas in ibd
crohns- failure of med mx, hospital, still symptomatics, bleeding, nutrition depleted e.g. low albumin, cachetic, weak
obstruction and fistulae
uc - failure of med mx, toxic megacolon: or malignancy
types of stoma
crohns - de functioning loo ileostomy
uc - end ielostomy - from pan-proctocolectomy
diviersion ileostomy - ileal rectal pouch formation
bilateral flank masses
pckd
asuculataion, bp and dip urine - renal failure sigsn
how common is adpckd
1:1000
htn, utis, cyst haemorrhage, haematuria
end stage renal failure at 40-60 yrs
Associations of adpckd
hepatic cysts
berry aneruysms
mitral valve prolapse
bilateral renal masses causes
adpckd
bilateral renal cysts
bilateral renal cell carcinoma
bilateral hydronephrosis - chronic urinary retention
amyloidosis
tuberous sclerosis
Main thing for abdo
expose at start
look at forearms and upper arms
always test for asterixis
observe from end of bed for distension / asymmetry
look for laproscopic surgery scars
inspection for resp
creon - cystic fibrosis
ventlin - COPD (look for tar staining)
rheumatoid signs
pulmonary fibrosis signs
Creon
cystic fibrosis
resp inspection
clubbing - pulonary fibrosis
A - abcess, B - bronchiectasis, C - cancer, D - defo not COPD, E - empyema, F - fibrosis
thoracotomy scar - old tb / bronchial carcinoma
sputum pot - bronchiectasis
No clubbing
copd - tar staining
effusion - percussion
early bronchiectasis
early fibrosis - asucultation
no clubbing, normal breath sounds and percussion
copd - well controlled
could also be asthma
signs of resp failure
oxygen
signs of rhf - cor pulmonale
resp presentation features
tar stain - copd
sternoceldimastoid hypertrophy and pursed lip breathing - chronic ventilaroy impairment
not clubbed and asterixs
hyperxaplended lungs and reduced breath sounds - copd features
jvp not raised and noraml p2 - no pul hypertesnion
low bmi
spirometry and exacerbation frequency
COPD diagnosis
chronic bronchitis - cough with sputum for most days for 3 months of 2 yrs
emphysema - permanent dilatation with destruction of alveolar walls distal to terminal bronchioles
spirometry - fev1/fvc is 0.7 and fev1 <80%
asthma is reversible on inhaler
COPD causes
smoking
industrial dust exposure
alpha-1-antitrypsin deficiency (panacinar emphysema)
COPD mx
conservative - smoking cessation
medical - saba / sama prn
then asthmatic features or not (previous, high eosinophil, varaition in fev1 at 400ml, diurnal variaion in peak flow)
- asthma - laba and ics
- not - laba and lama
severe exacerbation or 2 moderate exacerbation in 1 yr - laba, lama and ics
other copd mx
influenza, covid, pneumoccal vaccines
sympto relief - fans, physiotherapy and morphine
long term oxygen therapy
home nocturnal NIV
lung reduction surgery - for large bullae
criteria for long term oxygen therapy
non smoker - smoke ignites
PaO2 <7.3kPa in air
PaO2 < 8 with pulmonary htn - loud p2, raised jvp, TR and oedema (increase pressure of artery pressure in lungs - >20)
PaCO2 no rise excessiively on oxygen - assess type 2 rf (serial abg in community)
stop cor pulmonale occuring
clubbing assessment with dry cough
fibrosis - dry vs wet, auscultate, percussion - get patient to huff
malignancy - auscultate, percussion, tar stain
fine crackles distinguishes them - end inspiratory crepitations at the bases - then choose cause
PF signs:
1. mcp swelling
2. facial rash
3. thick skin bird beak nose
4. oral ulcers, abdo scars
5. grey skin
6. kyphosis
- rheumatoid
- SLE
- systemic sclerosis
- crohns
- amiodarone
- ankylosing spondylitis
Points of PF
mcp hyperextension and pip swelling - rheumatoid
reduced expansion - restrictive
base and mid zone crackles - differential
jvp not raised and normal p2
Causes of PF
Apical
- EAA
- AS
- Sarcoid
- TB
- Silicosis
Basal
- IPF
- Connective tissue
- asbestosis
- aspiration
Drug causes of PF
amiodarone, nitrofurantoin, sulfasalazine
hypersenstivity, assciations and idiopathic
opacification diagnosis
consolidation, fluid or fibrotic lung disease
if round - malignancy
Mx of PF
conservative - stop smoking, LTOT if criteria met
- immunosuppress inCTD
- pirfenidone or nintedanib
- lung transplant
prognosis
- honeycombing in IPF: 80% mortality at 5 yrs - destruction
- ground glass 80% survival at 5 yrs - inflammation
Chest asymmetry - look at end of bed
get patient to take two or three breaths
kypho-scoliosis - spine
effusion - percussion
lobectomy - scar
chest asymmetry with scar
lobectomy
malignancy - tar staining
old tb - absent ribs, apical
Old TB signs
scars, deformity, absent ribs
apical fibrosis with tracheal traction
crackles, bronchial breathing
dullness on percussion
reduced expansion
kyphosis - potts disease with fracture
Treatments for old tb
reduce ventilation, therefor reduce PaO2 and TB growth
apical obectomy
thoracoplasty - rib removal
phrenic nerve crush - unilateral diaphragm paralysis
plombage
Current tb
RIPE
ONLY
Hepatitis in everything as well
Wet cough and huff
Bronchiectasis or pneumonia
signs of CF / sputum
CF signs
bronchiectasis - clubbing - loss of nail bed angle
inhaler - pseudomonas treatment - TOBI - tobrimycin (only not IV)
thickened secretions throughout the body
insulin mx
recurrent iv ABs - port catheter
young and thin
gastrostomy
creon
port-a-cath
transverse abdo scar - failed to pass meconium at birth
PEP devices
Cf signs to comment on
slim gastrosom, creon, poracath - cf signs for bronchiectasis
not clubbed
wet cough - bronch
Cf treatment
conservative - postural drainage, active cycle breathing and nutrition
medical - creaon, fat soluble vitamins, immunisations, Dnase, antibiotics (prophylactic, iv courses, exacerbations)
surgival - lung transplant
Non CF bronchiectasis
Post infectious - ABPA, measels, pneumonia, TB
Associations - RA, IBD, Sjogrens SLE,
congenital - CF, PCD, kartagener syndrome
Mechanical - foreign body, obstructing tumour
Chest asymmetry with dullness
effusion - percussion
and lobectomy - scar
Signs of Pleural effusion
tar staining and clubbing - bronchial carcinoma
raised jvp - cardiac failure
widespread eoedma - hypo al
hand joint swelliung - ra
av-fistula - renal failure
spider naevi .ascites and dupytrens
Bilateral vs unilateral pleural effusion
bilateral - failure
unitlateral - high protein - malignancy
Pleural effusion presentation
R - tachypnoeic due to effusion
tar stain - risk factor bronchial carcinoma
stony dullness mid zone down - half chest unilateral
jvp normal - less liely transudcaive
temp - parapneumoni effusion
chest xr - look for mass
CXR pleural effusion
evidence for meniscus
dense cant see air behind it
Chest drain indications
empyema
malignant pleural effusions
massive haemothorax
penumothoraces - large, secondary and failure of aspiration
Causes of pleural effusion
transudate - cardiac, renal, liver, nephrotic syndrome
exudate - parapneumonic, empyema, malignancy, inflammatory pleuritis
Lights criteria
25-35 g protein
exudate suggest if
effusion albumin: plasma alubmin >0.5
ldh effusion / plasma ldh >0.6
effusion ldh ?2/3 upper limit of normal plasma ldh
Main things resp
cough and huff
expose at start for thoracotmy scars
test for asterixis
observe at end of bed for asymmetry
Lower motor neuron palsy
not spar eyebrows
Initial inspection of neuro
catheter and walking aids - MS
flexed arm - post stroke
resting tremor - parkinsonism
facial asymmetry - bells palsy
Abnormal gait
hemiplegia - pyrmaidal weakness
ataxia - cerebellar signs
parkinsonian - PD signs
foot drop - perihperal neuropathy
Abnormal gait with flexed arm
hemiplegia - pyramidal weakness - medulla pyramids - corticospinal and corticobulbar tracts (injury to those causes upper motor neuron signs)
upper motor neuron signs
Signs of pyramidal weakness
fixed flexion upper limb - stronger flexion muscles
fixed flexion lower limb - stronger extension muscles
circumducting gait
Upper motor neuron signs
Hypertonia
Clonus > more than 5 beats
Hyperreflexia
Up going plantars - +ve babinski
signs are contralateral
pyramidal tracts of voluntary movement
Common causes of UMN
stroke & SOL & MS if young patient
post stroke additional signs
pyramidal weakness (flex arm and extended leg)
walking aids
wasting / oedmatous affected side
increased tone and clonus
clasp knife spasticity - initial tone and then releases (velocity dependent)
VII palsy in upper motor neurone distribution
brisk reflexes and upgoing plantars
Pronator drift
palms up: affected pyramidal tract sign will turn
Post stroke additional signs
Bulbar involvement
gag swallow - aspiration and nutrition - PEG / NGT
visual fields and neglect - needed for bamford classification
blood pressure
pulse for AF
carotid bruit(anterior circulation stroke only)
risk factors key to tell examiner
What signs indicate bulbar involvement
9 10 11 cranial nerves - exaggerated gag and jaw jerk reflex - with UMN
Grading of power
0 - none
1 - flicker
2 - moves with gravity neutralised
3 - moves against gravity
4 - reduced power against resistance
5 - normal
Bamford classification
Total anterior circulation - hemiplegia, homonymous hemianopia, higher cortical dysfunction
Partial - 2 of 3
Lacunar circulation - hemi motor or hemi sensory stroke only
Posterior
NIHSS score more common - 11 modalities for severity of stroke
Abnormal gait with slow shuffle
parkinsonianism - extrapyramidal signs
redueced arm swing and tremor as well
Parkinsonism signs
Bradykinesia - slow movement
Rigidity - increased tone
Resting tremor
Can also get postural instability
mask face, lead pipe rigidity etc
Gait signs of parkinsonism
shuffing, slow start, asymmetrical limited arm
Face parkinsonism
expressionless, glabellar tap positive, slow, monotonous speech
Other parkinsonism signs
asymmetircal, 3-5hz pill rolling tremor (gets worse when not thinking), bradykinesia, rigidity (not velocity dependent), cogwheel rigidity with synkinesis
Lying and standing blood pressure
Multi-system atrophy
eye movements
progressive supranuclear palsy
higher cognititve function
corticobasal degeneration and lew body dementia
Causes of parkinsonism
Idiopathic, MSA, Progressive supranuclear palsy, cortiocbasal degeneration, lewy body dementia, drug induced
Parkinson plus syndrome
MSA - autonomic failure - postural hypotension, ED, atonic bladder, parkinsonism and cerebellar features
PSP - vertical gaze palsy (look down more than up), parkinsonism , early falls, MRI mickey mouse sign, poor response to L dopa
CBD
Motor symptoms parkinsons
levodopa
if significant impacting quality of life - no-ergot dervied dopamin agonists
re assess in 6 months
Abnormal gait, broad and unsteady
ataxia - cerebellar signs
think toddler walking
Signs cerebellar
ataxia - heel toe walk
scanning dysarthria speech
arms - rebound overshoot (lack of antagonistic muscle to stop overshoot), dysdiadochokinesia, hypotonia, hyporeflexia, past pointing and intention tremor
Cerebellar signs and localisation
Cerebellar nystagmus - fast towards lesion and worse towards affected side
vestibular nystagmus - fast away from lesion and worse looking away
Central cerebellar nystagmus
verticual and pendular
fast beat towards side of lesions
not relieved by fixation of gaze
other cerebellar signs
(peripheral - vestibular - horizontal and jerk, fast beat away from lesions, reudeced by fixation and no cerebellar signs)
Cerebellar ares
vermis - truncal ataxia with minimal limb signs
hemisphere lesions - ipsilateral limb signs with less truncal involvement
Cerebellar syndrome causes
young, female, spasticity, internuclear ophthalmoplegia - MS
older, afib, cabg scar and tar staining - stroke
chronic liver disease - alcohol
coarse facial features, gingivial hypertrophy - phenytoin
MS
MS
young female
catheter
walking aids and wheelchair
increased reflexes and spasticity
bilateral internuclear ophthalmopplegia
optic atrophy and relative afferent pupillary defect - loss of direct effect (might dilate instead)
only CNS so no LMS
Most common causes of cerebellar syndrome
inflammatory - MS
stroke
SOL
romberg - sensory ataxia (vision, proprioception and vestibular input - 2/3 to be working)
- stand and remove vision
- fall and dont try to correct themselves
dual with up motor neuron stroke and MS are the causes
internuclear ophthalmoplegia
lesion of medial longitudinal fasciculus - connect nuclei of III IV VI
ipsilateral: failure of aduction
contralateral: nystagmus when in abduction
can be bilateral
MS treatment
mdt
disease modifying - interferon beta, galtiramer, alemtuzumab
reduce relapse rate
methylpred for acute
baclofen for muscle spasm
Facial asymmetry
upper motor neuron - contralateral and preservation of frontalis
lower facial - ipsilateral and frontalis weakness
bells phenomenon - eyeballe rolls up on attempted eye closure
facial palsy causes
CS tract with 6th nerve - pons - stroke MS
v vi viii and cerebellar - cerebello pontine ngle - acoustic neurome
viii palsy - inner ear - cholesteatoma
parotid swelling - facial nerve - parotid tumou
examine auditory canal - vesciles ramsay hunt re activate chickenpox in cranial nerve
treatment of bells palsy
idiopathic no cause facial nerve
conservative eye protection
prednisolone < 72 hrs
anti-viral if shingles
erythema migrans
lyme disease
bilateral lower motor neuron palsy
causes of facial palsy
uni - herpes zoster, diabetes mononeuropathy, tumour
bilateral - gbs, lyme disease, sarcoid, mg, bells palsy
Weakness lmn
fasciulations
wasting
hypotonia
hyporeflexia
nmj lesion
fatiguability
weakness with reduced reflexes and upgoing plantars
motor neuron disease
fasciulations
increased tone
absent and brisk reflexes
upgoing plantars
bulbar or pseudo bulbar tongu
normal sensory examinations
either two pathologies or motor neuron disease
bulbar involvment
swallowing
Dual pathology LMN and UMN
MND
peripheral neuropatyha and stroke
conus medullaris lesion
b12§
n
neurology tips
walk the patient
look at the back
test clonus
ask history
classify the lesion and type thensuggest underlying cause
MS never causes LMN signs
Insepction gen surg
groin lump - hernia
oedmatous and pigmented legs - chronic venous insufficinecy
