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ICSM Year 6 + edits > Finals - PACES > Flashcards

Finals - PACES Flashcards

1
Q

Cardiac - inspection

A

Scars / medications

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2
Q

Sternotomy scar

A

CABG / valve placement

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3
Q

Bruising

A

fall - cardiac origin with anti-coagulations
with Valves - metallic e.g. warfarin

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4
Q

Pitting oedema

A

evidence of cardiac failure

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5
Q

Observation cardiac

A

warfarin, bruising, sternotomy scar, saphenous graft scar, audible click, oedematous ankles

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6
Q

No scar

A

Valvular - Pulse, BP and heart sounds

AF - “”

CCF - JVP, lungs, oedema

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7
Q

Normal pulse and no warfarin

A

exclude AF

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8
Q

Auscultation - ESM

A

Aortic stenosis or aortic sclerosis

Pulse, BP, radiation & Apex beat

with no warfarin, normal pulse and no scar

check for CCF - JVP, lungs, oedema

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9
Q

Pulse character of aortic stenosis

A

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

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10
Q

Systolic murmur

A

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

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11
Q

Aortic stenosis

A

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

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12
Q
A
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12
Q

AS presentation

A

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

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13
Q

Sclerosis

A

does not radiate
assess AS and CXR - systolic murmur, early aortic stenosis

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14
Q

Causes of aortic stenosis

A

calcific degeneration
biscuspid valve - turners

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15
Q

Symptoms of AS

A

Syncope

Angina

Left-Ventricular Failure

Sudden Death

ASH - Angina, Syncope, Heart failure

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16
Q

Signs of severity of Aortic stenosis

A

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

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17
Q

Indications for surgery in AS

A

symptomatic

asymptomatic + LVEF < 50%

Mean transcalcular pressure gradient > 40mmHg, valve area <1cm2 or jet velocity > 5m/s

Concomitant CABG

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18
Q

Grading of murmurs

A

1 - audibe to expert

  1. just audible to non-expert
  2. clearly audible
  3. clearly audible with palpable thrill
  4. audible with stehoscope only lightly applied
  5. audible without stehoscope on chest
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19
Q

Valve replacement work through

A

Sternotomy scar - valve replacement - warfarin / heart sounds

CABG - Saphenous scar, tar staining, xanthelasma

assess AF and CCF as well

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20
Q

Sternotomy scar with warfarin

A

metallic valve - click, heart sounds, murmur, pulse regularity

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21
Q

Present metallic valve

A

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

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22
Q

Tissue valve presentation

A

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

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23
Q

Severe anaemia

A

cause of high output heart failure

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24
Q

Midline sternotomy

A

Pulse
Murmur
Scar
Heart Failure

DDX: tissue valve, CABG, congential cardiac disease repair

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25
Q

Types of valve replacements

A

Transcatheter aortic valve implantation (TAVI)
Tissue based
Metallic

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26
Q

Metallic vs tissue

A

M: click, warfarin, 20 yrs, flow murmur = hearing turbulence acorss valve Ok

T: regurgitant murmur only (no click), 10 yrs

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27
Q

Hypokalaemia

A

U waves - on ECG

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28
Q

Warfarin Targets

A

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

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29
Q

Stenotomy scar - CABG

A

normal pulse, no warfarin - CABG

no AF

Spahenous scar, tar staining, xanthelasma

no click on auscultation

could still be tissue valve replacement

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30
Q

Exclude tissue valve scar

A

saphenous scar

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31
Q

Bypass graft presentation

A

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

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32
Q

Indications for CABG

A

Left main-stem disease

2 or more vessel disease

Failure of medical management

Concomitant (aortic) valvular replacement

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33
Q

Types of grafts

A

great saphenous

internal thoracic (mammary) artery

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34
Q

Most common artery used for CABG

A

Internal mammary artery - access via same midline sternotomy scar

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35
Q

Medication post CABG

A

Conservative - smoking, diabetes, weight

Med - DUAP (aspiring + ticagrelor) for 12 months, aspirin alone after, specialist opinion, cardi-selective beta-blocker (bisoprolol), ACEi

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36
Q

Kussmual sign

A

Rasied JVP not fall with inspiration

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37
Q

No scar, no warfarin, normal pulse, pansystolic murmur

A

Mitral regurgitation - radiates to axilla (VSD)

Assess CCF as well - JVP, lungs, oedema

VSd and TR

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38
Q

Systolic murmur heard at apex

A

Mitral regurgitation

dilation of heart

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39
Q

Present mitral regurg

A

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

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40
Q

Causes of mitral regurg

A

chronic - myxomatous degeneration - collagen
functional (with LV dilatation)

Acute - infective endocarditis, (posteriomedial) papillary muscle rupture, posterior interventricular artery post inferior / posterior MI

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41
Q

Signs of severity of MR

A

displaced or thrusting apex beat
left ventricular failure

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42
Q

Cardiac failure

A

no scar
JVP, lungs, oedema

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43
Q

Raised JVP

A

right sided heart failure
congestive cardiac failure - both sides failing

normal = any diagnosis, left-sided heart failure

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44
Q

Signs of RHF

A

acute - rasied jvp, hepatojugular reflux, hepatomegaly

chronic - pedal oedema, sacral oedmea, ascites

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45
Q

Signs of LHF

A

acute/chronic - pulmonary oedema, poor peripheral perfusion, tachypnoea, tachycardia

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46
Q

Present cardiac failure

A

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

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47
Q

Causes of heart failure

A

rhf - mi, pe, infective endocaridtes
left ventricular failure, cor pulonale - mainly left failing

lvf - MI, IE (acute), Ischaemic cardiomyopathy, hypertensive cardiomyopathy and VHD (chronic)

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48
Q

CCF mx

A

conservative - smoking, long term oxygen

medical - bb, acei, underlying cause e.g. htn, afib

surgical - left ventricular assist devices

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49
Q

Cardiac exam mains

A

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

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50
Q

Perioeprative anticoagulation

A

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

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51
Q

Mercedes benz scar

A

thoracic - oesophageal surgery

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52
Q

Intital inspection Abdo

A

rooftop scar - liver transplant

bulging flanks - CLD

AV fistulae - renal transplant

abdominal swelling - organomegaly

leg rash - IBD

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53
Q

Swollen abodomen

A

jaundice - chronic liver disease - signs of decompensatino

(organo / mass) - palpation

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54
Q

Liver transplant scar

A

transplant failure

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55
Q

Signs of chronic liver disease

A

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

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56
Q

Specific liver signs

A

needle / tattoo - hep c virus

parotid swelling - alcohol

bronzed complexion / insulin injection sites - haemochromatosis

obesity / diabetes - non-alcoholic fatty liver disease

xanthelasma - cholestatic

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57
Q

CLD presentation

A

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

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58
Q

Causes of chronic liver disease

A

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

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59
Q

signs of decompensation of liver

A

coagulopathy, asterixis, ascites, worsening jaundice, hypoglycaemia

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60
Q

Cirrhosis complications

A

Portal hypertension - spleno, oesophageal varics, thrombcytopenia, rectal varices (PR bleed)
- splanchnic vasodilation - hepatorenal, hypervolaemia (hyponatreaemia)

Hepatocellular destruction (decompensation) - hepatocellular failure - encephalopathy, hypoalbuminaemia, hypoglycaemia

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61
Q

swollen abdomen with organomegaly

A

abdo palpation

pallor no jaundice

dullness in traubes space - splenomegaly - hepatomegaly, lymphnodes and chronic liver disease

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62
Q

Traubes space

A

dullness over lung / spleen overlap

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63
Q

Differntials of spleno

A

malaria (foreign travel) and leukaemia - CML (FBC and film)

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64
Q

Dull mass, moves with respiration and did not ballot

A

Not kidney

beyond midline = massive splenomegaly

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65
Q

Causes of splenomegaly

A

haem - CML, myelofibrosis, spherocytosis

Infective - malarai, ebv

Other - portal htn, infilration (amyloidosis), sarcoidosis

with hepatomegaly excludes - myelofibrosis, sphero and portal htn

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66
Q

Indications for splenectomy

A

traumatic rupture, idiopathic thrombocytopenia, spherocytosis

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67
Q

Prophyalxis post splenectomy

A

pneumococcus, meningococcus, haemophilus, influenzae B, penicillin V

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68
Q

Renal transplant

A

see AV fistula - then assess sacr, abdo, palpation

if fistula is active - renal failure

no thrill and a scar

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69
Q

renal transplant next steps

A

abdo palpation
signs of renal failure
insulin injection sites
cushingoid
skin malignancy

70
Q

Renal transplant scrs

A

bilateral scars
midline incisions

hockey stick scar - mayo robson incision - RIF

nephrectomy scar

71
Q

renal exam findings

A

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

72
Q

indications for renal transplant

A

diabetic nephropathy - insulin injection sites

ckd stage 5

pckdad - flank scars

glomerulonephritis

73
Q

Complications of renal transplant

A

rejection - renal failure

cushings - round face and bruises

skin malignancy - bcc and scc

ciclosporin - gum hypertrophy

74
Q

Signs of renal failure

A

scars: old av fistulate, neck line and peritoneal dialysis catheters

cachexia

pulmonary and peripheral oedema

pallor

75
Q

Stoma

A

IBD - young, pallor, ieostomy

diver - elderly, colostomy

malign - nil else

urostomy - stoma appearance

lumens on stoma

76
Q

Signs of IBD

A

young
pallor slim
oral ulceration
pyoderma gangrenosum and erytham nodosum
dgital clubbing
medications

77
Q

Hypercholestramiea

A

can cause cushingoid appearance

78
Q

Complications of IBD

A

scars from hickman lines - parenteral nutrition

cushingoid

gum hypertrophy and hypertesnion if ciclosporin

jaundice . ursodeoxycholic acid - PSC

hepato-splenomegaly from amyloidosis

79
Q

IBD features on presentation

A

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

80
Q

Extra intestinal IBD

A

eyes: episcleritis, posterior uveitis, scleritis
skin: pyoderma gangrenosum, erythema nodosum
other: clubbing, oligoarthitis, anaemia

81
Q

Complications of IBD

A

Crohns: strictures, obstruction, fistulae
colitis: toxic mega colon, colonic carcinoma, psc

82
Q

Indications for stomas in ibd

A

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

83
Q

types of stoma

A

crohns - de functioning loo ileostomy

uc - end ielostomy - from pan-proctocolectomy
diviersion ileostomy - ileal rectal pouch formation

84
Q

bilateral flank masses

A

pckd

asuculataion, bp and dip urine - renal failure sigsn

85
Q

how common is adpckd

A

1:1000
htn, utis, cyst haemorrhage, haematuria
end stage renal failure at 40-60 yrs

86
Q

Associations of adpckd

A

hepatic cysts

berry aneruysms

mitral valve prolapse

87
Q

bilateral renal masses causes

A

adpckd

bilateral renal cysts

bilateral renal cell carcinoma

bilateral hydronephrosis - chronic urinary retention

amyloidosis

tuberous sclerosis

88
Q

Main thing for abdo

A

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

89
Q

inspection for resp

A

creon - cystic fibrosis

ventlin - COPD (look for tar staining)

90
Q

rheumatoid signs

A

pulmonary fibrosis signs

91
Q

Creon

A

cystic fibrosis

92
Q

resp inspection

A

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

93
Q

No clubbing

A

copd - tar staining

effusion - percussion

early bronchiectasis

early fibrosis - asucultation

94
Q

no clubbing, normal breath sounds and percussion

A

copd - well controlled

could also be asthma

95
Q

signs of resp failure

A

oxygen

signs of rhf - cor pulmonale

96
Q

resp presentation features

A

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

97
Q

COPD diagnosis

A

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

98
Q

COPD causes

A

smoking

industrial dust exposure

alpha-1-antitrypsin deficiency (panacinar emphysema)

99
Q

COPD mx

A

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

100
Q

other copd mx

A

influenza, covid, pneumoccal vaccines

sympto relief - fans, physiotherapy and morphine

long term oxygen therapy

home nocturnal NIV

lung reduction surgery - for large bullae

101
Q

criteria for long term oxygen therapy

A

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

102
Q

clubbing assessment with dry cough

A

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

103
Q

PF signs:
1. mcp swelling
2. facial rash
3. thick skin bird beak nose
4. oral ulcers, abdo scars
5. grey skin
6. kyphosis

A
  1. rheumatoid
  2. SLE
  3. systemic sclerosis
  4. crohns
  5. amiodarone
  6. ankylosing spondylitis
104
Q

Points of PF

A

mcp hyperextension and pip swelling - rheumatoid
reduced expansion - restrictive
base and mid zone crackles - differential
jvp not raised and normal p2

105
Q

Causes of PF

A

Apical
- EAA
- AS
- Sarcoid
- TB
- Silicosis

Basal
- IPF
- Connective tissue
- asbestosis
- aspiration

106
Q

Drug causes of PF

A

amiodarone, nitrofurantoin, sulfasalazine

hypersenstivity, assciations and idiopathic

107
Q

opacification diagnosis

A

consolidation, fluid or fibrotic lung disease

if round - malignancy

108
Q

Mx of PF

A

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

109
Q

Chest asymmetry - look at end of bed

A

get patient to take two or three breaths

kypho-scoliosis - spine

effusion - percussion

lobectomy - scar

110
Q

chest asymmetry with scar

A

lobectomy

malignancy - tar staining

old tb - absent ribs, apical

111
Q

Old TB signs

A

scars, deformity, absent ribs
apical fibrosis with tracheal traction
crackles, bronchial breathing
dullness on percussion
reduced expansion
kyphosis - potts disease with fracture

112
Q

Treatments for old tb

A

reduce ventilation, therefor reduce PaO2 and TB growth

apical obectomy

thoracoplasty - rib removal

phrenic nerve crush - unilateral diaphragm paralysis

plombage

113
Q

Current tb

A

RIPE

ONLY
Hepatitis in everything as well

114
Q

Wet cough and huff

A

Bronchiectasis or pneumonia
signs of CF / sputum

115
Q

CF signs

A

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

116
Q

Cf signs to comment on

A

slim gastrosom, creon, poracath - cf signs for bronchiectasis

not clubbed

wet cough - bronch

117
Q

Cf treatment

A

conservative - postural drainage, active cycle breathing and nutrition

medical - creaon, fat soluble vitamins, immunisations, Dnase, antibiotics (prophylactic, iv courses, exacerbations)

surgival - lung transplant

118
Q

Non CF bronchiectasis

A

Post infectious - ABPA, measels, pneumonia, TB
Associations - RA, IBD, Sjogrens SLE,
congenital - CF, PCD, kartagener syndrome
Mechanical - foreign body, obstructing tumour

119
Q

Chest asymmetry with dullness

A

effusion - percussion
and lobectomy - scar

120
Q

Signs of Pleural effusion

A

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

121
Q

Bilateral vs unilateral pleural effusion

A

bilateral - failure

unitlateral - high protein - malignancy

122
Q

Pleural effusion presentation

A

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

123
Q

CXR pleural effusion

A

evidence for meniscus

dense cant see air behind it

124
Q

Chest drain indications

A

empyema
malignant pleural effusions
massive haemothorax
penumothoraces - large, secondary and failure of aspiration

125
Q

Causes of pleural effusion

A

transudate - cardiac, renal, liver, nephrotic syndrome

exudate - parapneumonic, empyema, malignancy, inflammatory pleuritis

126
Q

Lights criteria

A

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

127
Q

Main things resp

A

cough and huff
expose at start for thoracotmy scars
test for asterixis
observe at end of bed for asymmetry

128
Q

Lower motor neuron palsy

A

not spar eyebrows

129
Q

Initial inspection of neuro

A

catheter and walking aids - MS

flexed arm - post stroke

resting tremor - parkinsonism

facial asymmetry - bells palsy

130
Q

Abnormal gait

A

hemiplegia - pyrmaidal weakness

ataxia - cerebellar signs

parkinsonian - PD signs

foot drop - perihperal neuropathy

131
Q

Abnormal gait with flexed arm

A

hemiplegia - pyramidal weakness - medulla pyramids - corticospinal and corticobulbar tracts (injury to those causes upper motor neuron signs)

upper motor neuron signs

132
Q

Signs of pyramidal weakness

A

fixed flexion upper limb - stronger flexion muscles
fixed flexion lower limb - stronger extension muscles

circumducting gait

133
Q

Upper motor neuron signs

A

Hypertonia
Clonus > more than 5 beats
Hyperreflexia
Up going plantars - +ve babinski
signs are contralateral

pyramidal tracts of voluntary movement

134
Q

Common causes of UMN

A

stroke & SOL & MS if young patient

135
Q

post stroke additional signs

A

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

136
Q

Pronator drift

A

palms up: affected pyramidal tract sign will turn

137
Q

Post stroke additional signs

A

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

138
Q

What signs indicate bulbar involvement

A

9 10 11 cranial nerves - exaggerated gag and jaw jerk reflex - with UMN

139
Q

Grading of power

A

0 - none

1 - flicker

2 - moves with gravity neutralised

3 - moves against gravity

4 - reduced power against resistance

5 - normal

140
Q

Bamford classification

A

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

141
Q

Abnormal gait with slow shuffle

A

parkinsonianism - extrapyramidal signs

redueced arm swing and tremor as well

142
Q

Parkinsonism signs

A

Bradykinesia - slow movement

Rigidity - increased tone

Resting tremor

Can also get postural instability

mask face, lead pipe rigidity etc

143
Q

Gait signs of parkinsonism

A

shuffing, slow start, asymmetrical limited arm

144
Q

Face parkinsonism

A

expressionless, glabellar tap positive, slow, monotonous speech

145
Q

Other parkinsonism signs

A

asymmetircal, 3-5hz pill rolling tremor (gets worse when not thinking), bradykinesia, rigidity (not velocity dependent), cogwheel rigidity with synkinesis

146
Q

Lying and standing blood pressure

A

Multi-system atrophy

147
Q

eye movements

A

progressive supranuclear palsy

148
Q

higher cognititve function

A

corticobasal degeneration and lew body dementia

149
Q

Causes of parkinsonism

A

Idiopathic, MSA, Progressive supranuclear palsy, cortiocbasal degeneration, lewy body dementia, drug induced

150
Q

Parkinson plus syndrome

A

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

151
Q

Motor symptoms parkinsons

A

levodopa

if significant impacting quality of life - no-ergot dervied dopamin agonists

re assess in 6 months

152
Q

Abnormal gait, broad and unsteady

A

ataxia - cerebellar signs

think toddler walking

153
Q

Signs cerebellar

A

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

154
Q

Cerebellar signs and localisation

A

Cerebellar nystagmus - fast towards lesion and worse towards affected side

vestibular nystagmus - fast away from lesion and worse looking away

155
Q

Central cerebellar nystagmus

A

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)

156
Q

Cerebellar ares

A

vermis - truncal ataxia with minimal limb signs

hemisphere lesions - ipsilateral limb signs with less truncal involvement

157
Q

Cerebellar syndrome causes

A

young, female, spasticity, internuclear ophthalmoplegia - MS

older, afib, cabg scar and tar staining - stroke

chronic liver disease - alcohol

coarse facial features, gingivial hypertrophy - phenytoin

158
Q

MS

MS

A

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

159
Q

Most common causes of cerebellar syndrome

A

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

160
Q

internuclear ophthalmoplegia

A

lesion of medial longitudinal fasciculus - connect nuclei of III IV VI

ipsilateral: failure of aduction

contralateral: nystagmus when in abduction

can be bilateral

161
Q

MS treatment

A

mdt

disease modifying - interferon beta, galtiramer, alemtuzumab
reduce relapse rate

methylpred for acute

baclofen for muscle spasm

162
Q

Facial asymmetry

A

upper motor neuron - contralateral and preservation of frontalis

lower facial - ipsilateral and frontalis weakness
bells phenomenon - eyeballe rolls up on attempted eye closure

163
Q

facial palsy causes

A

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

164
Q

treatment of bells palsy

A

idiopathic no cause facial nerve

conservative eye protection
prednisolone < 72 hrs

anti-viral if shingles

165
Q

erythema migrans

A

lyme disease

bilateral lower motor neuron palsy

166
Q

causes of facial palsy

A

uni - herpes zoster, diabetes mononeuropathy, tumour

bilateral - gbs, lyme disease, sarcoid, mg, bells palsy

167
Q

Weakness lmn

A

fasciulations
wasting
hypotonia
hyporeflexia

168
Q

nmj lesion

A

fatiguability

169
Q

weakness with reduced reflexes and upgoing plantars

A

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

170
Q

bulbar involvment

A

swallowing

171
Q

Dual pathology LMN and UMN

A

MND
peripheral neuropatyha and stroke

conus medullaris lesion

b12§

172
Q

n

neurology tips

A

walk the patient
look at the back
test clonus
ask history
classify the lesion and type thensuggest underlying cause
MS never causes LMN signs

173
Q

Insepction gen surg

A

groin lump - hernia
oedmatous and pigmented legs - chronic venous insufficinecy

ICSM Year 6 + edits (28 decks)

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