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High Yield Flashcards

1
Q

Causes of a motor peripheral neuropathy

A
  • Diabetes
  • Multifocal motor neuropathy
  • Charcot Marie tooth
  • Spinal muscular atrophy
  • Motor neuron disease
  • CIDP (motor predom form)
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2
Q

Causes of a sensory peripheral neuropathy

A
  • Diabetes*
  • Alcohol*
  • Infiltrative (amyloid)*
  • Vasculitis *
  • Medications*: amiodarone, cisplatin, izoniazid
  • Paraprotein (MGUS)
  • Sjogren’s
  • B12 deficiency
  • Syphilis
  • = painful
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3
Q

Aortic stenosis signs of severity

A
  • Plateau pulse
  • Aortic thrill
  • Late peaking murmur
  • S4
  • LVF
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4
Q

Aortic stenosis indications for surgery

A

Severe = valve area <1cm2, gradient >40mmHg

  • severe plus symptoms
  • severe plus LV dysfunction
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5
Q

Mitral regurgitation signs of severity

A
  • LV dilation, displaced apex bear
  • Small volume pulse (very severe)
  • soft s1
  • early A2
  • S3
  • LVF
  • Pulmonary HT
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6
Q

Mitral regurgitation indications for surgery

A
  • Acute MR
  • NHYA III/IV sx
  • LV dysfunction but EF >30%
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7
Q

HOCM signs of severity

A

ECG: LVH, lateral ST and T wave changes, deep Q waves

TTE: asymmetrical hypertrophy with septal hypertrophy and systolic anterior motion of the mitral valve.

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8
Q

Aortic stenosis aeitiology

A
  1. Degenerative
  2. Bicuspid aortic valve
  3. Rheumatic
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9
Q

Mitral stenosis causes

A
  1. Rheumatic
  2. Severe mitral annular calcification (rare assoc hypercalcaemia and hyperPTH)
  3. After mitral valve repair
  4. Congenital
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10
Q

Mitral stenosis signs of severity

A
  • Small pulse pressure
  • Soft S1
  • Early opening snap (due to raised LA pressure)
  • Length of the mid-diastolic rumbling murmur
  • Diastolic thrill at apex
  • Pulmonary HT
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11
Q

Mitral regurgitation: causes

A

CHRONIC
- Degenerative disease
- Mitral valve prolapse
- Rheumatic
- Papillary muscle dysfunction (LVF, ischaemia)
- CTD: RA, AS
- Congenital (e.g. endocardial cushion defect)
ACUTE
- IE (e.g. perforation of anterior leaflet)
- MI (chorae rupture or papillary muscle dysfunction)
- Trauma
- Surgical

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12
Q

Aortic regurgitation: signs of severity

A
  • Collapsing pulse
  • Wide pulse pressure (>80mmHg)
  • Length of the decrescendo diastolic murmur
  • Third heart sound
  • Soft A2
  • LVF
  • Austin flint murmur (diastolic rumble due to regurgitant jet limiting mitral inflow)
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13
Q

Aortic regurgitation: causes

A
  • Rheumatic valvular disease
  • Congenital (biscuspid valve)
  • Seronegative arthropathy (AS)
  • Aortic root disease
    • Marfan’s
    • Aortitis (e.g. AS, RA, tertiary syphilis)
    • Dissecting aneurysm
  • IE
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14
Q

Tricuspid regurgitation: CFx

A
  • V waves in JVP
  • RV heave
  • Pansystolic murmur (maximal LSE and on inspiration)
  • Pulsatile liver
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15
Q

Tricuspid regurgitation: causes

A
  • Functional (RVF)
  • Rheumatic
  • IE
  • Congenital (Ebstein’s anomaly)
  • Tricuspid valve prolapse
  • Right ventricular papillary muscle infarction
  • Trauma
  • Ventricular pacemaker can lead to decoupling of leaflet
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16
Q

HOCM clinical features

A

AUSC: Ejection systolic murmur loudest at LSE which increases with release of valsalva manouvre
PULSE: sharp, rising and jerky. Rapid ejection by the hypertrophied ventricle early in systole is followed by obstruction caused by the displacement of the mitral valve into the outflow tract.
JVP: prominent a wave (due to forceful atrial contraction against a non-compliant right ventricle)
PALP: double or triple apical impulse (due to presystolic expansion of the ventricle caused by atrial contraction)

Dynamic manoeuvre: outflow murmur is INCREASED by the valsalva manoeuvre, standing, isometric exercise. DECREASED by squatting.

ECG: LVH, lateral ST and T wave changes, deep Q waves

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17
Q

HOCM causes

A
  1. Autosomal dominant with variable expressivity: sarcomeric heavy chain
  2. Idiopathic
  3. Friedreich’s ataxia
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18
Q

ASD CFx

A
  • RV enlargement (or normal)
  • Fixed splitting S2
  • ES murmur in pulmonary area
  • LV impulse palpable
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19
Q

Pulmonary stenosis CFx

A
  • Peripheral cyanosis due to low CO
  • JVP A waves due to RA hypertrophy
  • RV heave
  • Thrill over pulmonary area
  • Harsh ejection systolic murmur max in pulmonary area (increased on inspiration)
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20
Q

Pulmonary stenosis: signs of severity

A
  • Ejection systolic murmur peaking late in systole
  • Absence of an ejection click
  • Presence of S4
  • Signs of RV failure
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21
Q

Pulmonary stenosis causes

A
  • Congenital
  • Carcinoid syndrome
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22
Q

Mitral stenosis CFx

A

GENERAL: tachypnoea, mitral facies, peripheral cyanosis (if severe)
PULSE: normal or reduced in volume (due to reduced CO), AF (secondary LA enlargement)
JVP: prominent a wave (if pulm HT), loss of a wave (if AF)
PALPATION: tapping apex beat (palpable S1), RV heave and palpable P2 (if pulm HT present), diastolic thrill (rare)
ASCULTATATION: loud S1 (valve cusps wide at systole), diastolic decrescendo murmur at mitral area

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23
Q

Mitral regurg CFx

A

SYMPTOMS: dyspnoea (increased LA pressure), fatigue (decreased CO).
GENERAL SIGNS: tachypnoea
PULSE: normal or sharp upstroke due to rapid LV decompression, AF common
PALPATION: apex beat displaced, diffuse and hyperdynamic, pansystolic thril is occ present at the apex, parastenal impulse (LA enlargement behind RV)
ASCULTATION: soft or absent S1 (by end of diastole, LA and LV pressures have equalised and valve cusps drifted back together), LV S3 (due to rapid LV filling in early diastole), pansystolic murmur max at apex usually radiating to axilla

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24
Q

MVP CFx

A

Systolic click or clicks at a variable time (usually midsystolic)
High pitched late systolic murmur, commencing with the click and extending throughout the rest of systole

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25
Q

Aortic stenosis CFx

A

SYMPTOMS: exertional chest pain, dyspnoea and syncope
PULSE: plateau or small volume pulse
PALPATION:
- Apex beat is hyperdynamic
- Systolic thrill at the base of the heart
ASCULTATION:
- Harsh midsystolic ejection murmur (max over aortic and radiates to carotids; louder with pt sitting up and in expiration
- narrowly split or reversed S2 (delayed LV ejection)

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26
Q

Aortic regurgitation CFx

A

SYMPTOMS: exertional SOB, fatigue, palpations, exertional agina
GENERAL INSPECT: marfan’s, AS, seronegative arthropathy, argyl-robinson pupils
PULSE: collapsing, waterhammer, bisiferens (severe), prominent carotid pulse
BP: wide pulse pressure
PALP: hyperkinetic apex beat, diastolic thrill
ASCULTATION: soft A2, decrescendo high pitched diastolic murmur immediately after S2 loudest at 3rd and 4th intercostal space.

Note: may have associated systolic ejection flow murmur or as autin flint murmur (low pitched rumbling mid diastolic and presystolic murmur audible at apex)

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27
Q

Tricuspid regurgitation: CFx

A

JVP: large v waves, elevated if RHF
PALPATION: right ventricular heave
ASCULTATION: pansystolic murmur, max at lower edge of sternum that increases on inspiration
ABDO: pulsatile, large and tender liver. May have ascities and pleural effusions
LEGS: dilated, pulsatile veins

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28
Q

VSD CFx

A

PALP:
- Hyperkinetic displaced apex if the defect is large
- Thrill at the left sternal edge.
ASCULT:
- Harsh pansystolic murmur max at the left sternal edge with a loud 3rd or 4th heart sound; louder on expiration. May have assoc MR. Murmur louder and harsher when the defect is small.

Signs of severity: pulm HT, cyanosis

Causes:

  • Congenital
  • Rupture in AMI
  • Tetraology of fallot (VSD, RV obstruction, overriding aorta)
  • Down’s syndrome
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29
Q

Pulmonary fibrosis causes

A

UPPER LOBE: (SCHART)

  • Silosis, sarcoidosis
  • Coal workers pnuemoconiosis
  • Histiocytosis
  • Anklyosing spondylitis, allergic bronchopulmonary aspergillosis
  • Radiation
  • Tuberculosis

LOWER LOBE: (RASCO)

  • RA
  • Abestosis
  • Scleroderma
  • Cryptogenic fibrosing alevolitis
  • Drugs (busulphan, bleomycin, nitrofurantoin, hydralazine, MTX, amiodarone)
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30
Q

Pulmonary fibrosis: CFx

A

GENERAL: dyspnoea, cyanosis, clubbing
PALP: slightly reduced expansion
ASCULT: fine late inspiratory or pan-inspiratory crackles

Signs of associated CTD

RFTs = reduced FVC and DLCO

IPF on CT scan: traction bronchiectsis, honeyhombing

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31
Q

COPD: CFx

A

GENERAL: pursed lip breathing, barrel shaped chest, use of accessory muscles.
PALPATION: reduced chest expansion (<5cm), hyperinflated chest
PERCUSSION: hyperresonant
BREATH SOUNDS: decreased, early inspiratory crackles

Signs of RV failure in severe disease

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32
Q

Bronchiectasis: CFx

A

SYSTEMIC: fever, cachexia, sinusitis (70%), clubbing, cyanosis (if severe)
SPUTUM: voluminous, purulent, blood stained
ASCULT: coarse pan-inspiratory or late inspiratory crackles over the affected lobe +/- wheeze

If severe: copious sputum, clubbing, widespread crackles, signs of airway obstruction, signs of respiratory failure and cor pulmonale.

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33
Q

Bronchiectasis: Causes

A

CONGENITAL: primary ciliary dyskinesia, cystic fibrosis, congenital hypogammaglobulinaemia
ACQUIRED: infections in childhood, localised disease such as foreign body / bronchial adenoma / TB, allergic bronchopulmonary aspergillosis (proximal bronchiectasis)

CT: tree in bud appearance, dilated thickened airway (tram tracking)

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34
Q

Pleural effusion: CFx

A
  • Dull to percussion
  • Absent breath sounds
  • Decreased vocal resonance
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35
Q

Pleural effusion: causes

A

TRANSUDATE: cardiac failure, hypoalbuminaemia (nephrotic syndrome, CLD), hypothyroidism, Meigs syndrome
EXUDATE: pneumonia, neoplasm (bronchial carcinoma, metastatic carcinoma, mesothelioma), TB, pulmonary infarction, subphrenic abscess, acute pancreatitis, CTD, drugs (cytotoxics), irradiation, trauma
HAEMOTHORAX: severe trauma, rupture of a pleural adhesion containing a blood vessel
CHYLOTHORAX: trauma or surgery to the thoracic duct, carcinoma or lymphoma involving the thoracic duct
EMPYEMA: pneumonia, lung abscess, bronchiectasis, TB, penetrating chest wound

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36
Q

Pleural effusion: light’s criteria

A

Exudate=
Pleural:serum protein >0.5
Pleural LDH >2/3 upper limit of normal
Pleural:serum LDH >0.6

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37
Q

Clubbing causes

A

RESP: lung carcinoma (usually not SCLC), chronic pulmonary suppuration (e.g. bronchiectasis, lung abscess, empyema), idiopathic pulmonary fibrosis, asbestosis, cystic fibrosis, pleural fibroma or mesothelioma, mediastinal disease (e.g. thymoma, lymphoma, carcinoma).
CVS: IE, cyanotic congenital heart disease
OTHER: IBD, cirrhosis, coeliac disease, thyrotoxicosis (thyroid acropachy), brachial AV aneurysm or arterial graft sepsis (unilateral), neurogenic diaphragmatic tumours, familial or idiopathic, hemiplegic stroke (unilateral).

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38
Q

DDx dull percussion and reduced breath sounds

A
  • Pleural effusion
  • Consolidation
  • Collapse (mucous plug, foreign body, airway obstruction, compression from external mass or lymph node)
  • Raised hemidiaphragm
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39
Q

Pneumonectomy CFx

A
  • Tracheal deviation towards affected side
  • Lateral scar
  • Reduced chest expansion on affected side
  • Dull percussion + absent breath sounds + reduced vocal resonance in affected lower zone
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40
Q

Hepatomegaly causes

A 
# Liver
- Alcoholic hepatitis
- NAFLD
- Malignancy (HCC or mets)*
- Viral hepatitis 
- Haemochromatosis
- Budd chiari
- Polycystic liver
# Haem
- Myeloproliferative disease*
- CML
- Lymphoma
# Infiltrative 
- Amyloid
- Sarcoid
# Right heart failure*
# Infective
- Hydatitid disease
- HIV
  • = causes massive hepatomegaly

MASSIVE: metastases, alcoholic liver disease with fatty infiltration, myeloproliferative disease, RHF, HCC.
MODERATE: above + haemochromatosis, haematological disease (CML, lymphoma), fatty liver (obesity, DM, toxins).
MILD: above + hepatitis (viral, drugs), cirrhosis, biliary obstruction, granulomatous disorders, hydatid disease, amyloidosis and other infiltrative diseases, HIV infection, ischaemia.

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41
Q

Splenomegaly causes

A 
# Haem:
- myeloproliferative disease (PCRV, myleofibrosis)
- malignant (CML, AML, lymphoma)
- haemolytic anaemia (hereditary sphereocytosis, autoimmune heamolytic anaemia)
# Infective (EBV, CMV, hepatitis)
# CTD (RA, SLE)
# Infiltrative (sarcoidosis, amyloidosis)
# Portal hypertension and CLD

MASSIVE: CML, myelofibrosis, primary lymphoma of spleen, hairy cell leukaemia, malaria, kala-azar.
MODERATE: above + portal hypertension, lymphoma, leukaemia (chronic or acute), thalassaemia, storage diseases (e.g. Gaucher’s disease).
SMALL: above + other myeloproliferative disorder (polycythemia rubra vera, ET), haemolytic anaemia, megaloblastic anaemia (rarely), infection (EBV, hepatitis, bacterial / IE), CTD (RA, SLE, polyarteritis nodosa), infiltration (amyloidosis, sarcoidosis)

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42
Q

Hepatosplenomegally causes

A 
# Chronic liver disease with portal hypertension
# Haematological
- Myeloproliferative
- Malignant (lymphoma, CML, AML)
- Non-malignant (autoimmune haemolytic anaemia, hereditary spherocytosis, sickle cell anaemia, thalassaemia)
# Infection
- Viral hepatitis
- EBV, CMV
# Infiltative
- Amyloid
- Sarcoidosis
# Connective tissue disease
- SLE
# Endocrine
- Acromegaly
- Thyrotoxicosis
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43
Q

Causes of generalised lymphadenopathy

A
  • Lymphoma (rubbery and firm)
  • Leukaemia (CLL, ALL)
  • Malignant disease (metastases or reacitve changes usually causing asymmetrical, very firm nodules)
  • Infections: viral (CMV, HIV, EBV), bacterial (TB, brucellosis), protozoal (toxoplasmosis)
  • CTD (RA, SLE)
  • Infiltrations (sarcoidosis)
  • Drugs (phenytoin)
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44
Q

Chronic liver disease: CFx

A

HANDS: leuconychia, clubbing, palmar erythema, bruising, asterixis
FACE: jaundice, scratch marks, spider naevi, bruising, pectoral muscle wasting
CHEST: gynaecomastia, loss of body hair, bruising
ABDO: hepatosplenomegally, signs of portal hypertension, testicular atrophy
LEGS: oedema, muscle wasting, bruising

Two or more suggest cirrhosis: spider naevi, palmar erythema, splenomegaly, ascites, abnormal veins on abdomen.

Signs of decompensated CLD

  • Asterixis
  • Encephalopathy
  • Ascites
  • Icterus
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45
Q

Chronic liver disease: causes

A
  • Alcohol
  • postviral hep B or C
  • NASH
  • drugs (methyldopa, chlorpromazine, isoniazid, niteofurantonin, PTU, MTX, amiodarone)
  • autoimmune
  • haemacheomatosis
  • Wilson’s disease
  • PSC
  • PBC
  • alpha 1 antitrypsin deficiency
  • cystic fibrosis
  • budd chiari syndrome
  • cardiac failure
  • idiopathic
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46
Q

Causes of portal hypertension

A
  1. Cirrhosis
  2. Other
    - Presinusoidal: portal vein compression (e.g. lymphoma, carcinoma), intravascular clotting (e.g. polycythemia), umbilical vein phlebitis
    - Intrahepatic: sarcoid, lymphoma or leukaemic infiltrates, congenital hepatic fibrosis
    - Postsinusoidal: hepatic vein outflow obstruction (budd chiari: idiopathic, myleloproliferative disease, tumour, PNH, OCP), veno-occlusive disease, constrictive pericarditis, CCF
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47
Q

Signs of portal hypertension

A
  • Splenomegally
  • Collateral veins (on abdomen or haematemesis)
  • Ascites
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48
Q

DDx ascites

A
  • Chronic liver disease
  • Malignancy (HCC or other abdo mets)
  • Fluid overload (nephrotic syndrome, right heart failure)
  • Infection (TB, SBP)
  • Vascular (budd chiari)
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49
Q

Approach to a PCKD

A
  1. Take BP (75% have hypertension)
  2. Examine urine for haematuria (haemorrhage into a cyst) and proteinuria (usually <2g/day)
  3. Looks for anaemia (from CKD) or polycythemia (due to high EPO). Hb usually higher than expected for degree of renal failure
  4. Note the presence of hepatic cysts (present in 30% of cases) and splenic cysts (rare).
    Subarachnoid haemorrhage occurs in 3% of pts

ASK:

  • FBE (anaemia)
  • UEC (renal function)
  • Abdominal US to see cysts on kidney and liver
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50
Q

Difference between kidney and spleen

A
  • Spleen has notch
  • Spleen dull to percussion
  • Cannot palpate above spleen
  • Spleen not ballotable
  • Spleen moves inferomedially with respiration
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51
Q

RA CFx

A

GENERAL: ?cushingoid appearance
HANDS: small joint symmetrical polyarthritis, DIP sparring, ulnar deviation, Z deformity of thumb, swan neck deformity, boutonniere deformity, volar subluxation of MCP joints.
ARMS: RA nodules
FACE: redness and dryness of eyes (sjogren’s syndrome in 10%), scleritis, dry mouth.
CHEST: pleural effusion, ILD, pericardial rub, valvular regurg (particularly aortic)
ABDO: splenomegaly (10%, consider Felty’s syndrome), hepatomegaly (MTX)
LL: stocking distribution peripheral neuropathy, cord compression (if atlanticoaxial disease), feet arthropathy, achilles tendon nodules

Other sites: elbows, upper cervical spine, knees, tarsal and metatarsophalangeal joints

Deformities:
Boutonniere = flexion of proximal interphalangeal joint and extension of distal interphalangeal joint of the hand.
Swan neck deformity = hyperextension at proximal interphalangeal joint and flexion at distal interphalangeal joint.
Z-deformity of thumb = hyperextension of the interphalangeal joint, fixed flexion and subluxation of the metacarpophalangeal joint

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52
Q

Psoriatic arthritis CFx

A

Monoarticular and oligoarticular arthritis of the hands and feet.
NAILS: oncholysis, pitting, ridging, hyperkeratosis.
SKIN: rash elbows and behind ears

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53
Q

OA CFx

A

Symmetrical

Heberden’s nodes (DIP), Bouchard’s nodes (PIP)

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54
Q

DDx deforming polyarthropathy

A

RA
Seronegative spondyloarthropathy (psoriatic arthritis, ankylosing spondylitis, Reiter’s disease)
Chronic tophaceous gout (rarely symmetrical)
Primary generalised OA

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55
Q

Scleroderma CFx

A

CREST = calcinonsis, Raynauds, oesophageal dysmotility, sclerodactyly, telangiectasia

GENERAL: bird like facies, weight loss
HANDS: calcinosis, atophy of distal tissue pulp (Raynauds), sclerodactyl, telangiectasia, dilated capillary loops, small joint arthopathy and tendon crepitus, fixed flexion deformity, hand function
BP
ARMS: skin tightening or thickening, pigmentation, vitiligo, hair loss, proximal myopathy
HEAD: alopecia, eyes (anaemia, difficulty with closing), mouth (puckered, difficulty opening), pigmentation, telangictasia, neck muscle wasting and weakness
DYSPHAGIA
CHEST: tight skin, cor pulmonale, pericarditis, failure, ILD
LEGS: skin lesions, vasculitis

Other: urine analysis (proteinuria), temp chart (infection), stool examination (steatorrhoea)

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56
Q

Hypothyrodism CFx

A

GENERAL: mental and physical sluggishness.
HANDS: peripheral cyanosis (reduced CO), cool and dry skin, yellow discolouration of palms due to hypercarotenaemia (slowed hepatic metabolism), palmar crease pallor (anaemia)
ARMS: proximal myopathy (rare), hung up biceps reflex (delayed relaxation)
FACE: thickened skin, alopecia, vitiligo (an assoc autoimmune disease), periorbital oedema, loss or thinning of outer third of the eyebrows, coolness of skin and hair
THYROID: may see goitre (due to oversecretion of TSH) if cause severe iodine deficiency, late Hashimoto’s disease, treated thyrotoxicosis, inborn errors of metabolism.
CHEST: pericardial effusion, pleural effusion
LEGS: non-pitting oedemea, delayed relaxation of LL reflexes (‘hung up’), peripheral neuropathy

Neuro associations: entrapment of nerves, delayed ankle jerk, muscle cramps. Less common: peripheral neuropathy, proximal myopathy, hypokalaemic periodic paralysis

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57
Q

Hyperthryoidism CFx

A

GENERAL: weight loss, anxiety
HANDS: fine tremor (sympathetic overactivity), onycholysis, thyroid acropathy (clubbing), palmar erythema, sweatiness/warmth
PULSE: sinus tachycardia or AF (shortened refractory period to do sympathetic drive)
ARMS: proximal myopathy, brisk reflexes
EYES: exophthalmos, proptosis (Cx= chemosis [oedema of conjunctiva and injection of sclera], corneal ulceration, optic atrophy, opthalmoplegia [infeior rectus lost first]), lid retraction, test for lid lag (descent of lid lags behind eyeball)
NECK: examine for thyroid enlargement (Graves = diffuse enlargement, subacute = tender thyroid). If thryoidectomy scar assess for hypoparathyroidism
CHEST: systolic flow murmurs, CCF
LEGS: pretibial myxodema (Graves), proximal myopathy and hyperreflexia

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58
Q

Causes of thyrotoxicosis

A

PRIMARY: Grave’s disease, toxic multinodular goitre, hashimoto’s thyroiditis in early stage, subacute thyroditis, post partum thyriditis, iodine induced

SECONDARY: pituitary (rare), hydatidorm moles or choriocarcinomas, struma ovarii, drugs (amiodarone)

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59
Q

Causes of hypothyroidism

A

PRIMARY:

  • Without goitre (decreased or absent thyroid tissue): idiopathic atrophy, treatment of thyrotoxicosis, agenesis or a lingual thyroid, unresponsiveness to TSH.
  • With a goitre (decreased thyroid hormone synthesis): chronic autoimmune disease (e.g. Hashimoto’s), drugs (lithium, amiodarone), inborn errors, endemic iodine deficiency

SECONDARY: pituitary lesions

TERTIARY: hypothalamic lesions

TRANSIENT: thyroid hormone withdrawn, subacute thyroiditis, post partum thyroiditis.

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60
Q

CFx of acromegaly

A

GENERAL: characteristic face and body habitus with frontal bossing
HANDS: spade-like hands (due to soft tissue and bony enlargement), increased sweating and warmth (increased metabolic rate), thickened skin, OA changes due to skeletal overgrowth, examine for median nerve entrapment (due to soft tissue overgrowth)
ARMS: proximal myopathy, ulnar nerve thickening behind medial epicondyle
BP check
AXILLAE: skin tags (molluscum fibrosum), feel for greasy skin, acanthosis nigricans
FACE: supraorbital ridge causing frontal bossing, thickened lips
EYES: examine visual fields for bitemporal hemianopia, look in fundi for optic atrophy, angioid streaks (red brown streaks that emanate from the optic disk), diabetic changes and papilloedema,
MOUTH: enlarged tongue, teeth splayed and separated
NECK: enlarged thyroid
CHEST: coarse body hair, gynaecomastica, arrhythmias, cardiomegally, CCF
BACK: kyphosis
ABDO: hepatic, splenic and renal enlargment, look for tesitcular atrophy.
LL: OA in hips and knees. Foot drop due to common peroneal nerve entrapment

Ask for:

  • urine ?glucose
  • rectal exam ?colonic polyps

Signs of active disease: large number of skin tags, excessive sweating, glycosuira, increased visual field loss, enlarging goitre, hypertension.

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61
Q

Diabetes CFx

A

GENERAL: dehydration, obesity, cushing’s faecies, kussmaul’s breathing
LOWER LIMBS:
- Inspect: necrobiosis, hair loss, pigmented scars, ulceration, superficial skin infection, diabetic dermopathy (small rounded plaques with raised borders lying in a linear fashion over the shins), injection sites on thighs, charcot’s joints (grossly deformed joints due to loss of proprioception or pain)
- Palpate: peripheral pulses, capillary return
- Neuro ex: peripheral neuropathy, proprioception, reflexes, proximal myopathy
UPPER LIMBS:
- Nails: ?candida
BP including postural drop
FACE:
- Eyes: visual acuity, look for argyll robertson pupils, examine retina, assess for opthalmoplegia (CN III palsy most common)
- Ears: examine for signs of infection
- Mouth: ?candida
NECK:
Carotid arteries palpate and ascultate
CHEST: look for acanthosis nigricans
ABDO: palpate for hepatomegally

ASK:
- Urinanalysis ?glucose, ?proteinuria

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62
Q

Pyramidal weakness

A

UL: flexors stronger than extensors
LL: extensors stronger than flexors

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63
Q

Receptive dysphasia

A

Def: patient cannot understand, speaks nonsense

Aeit: leison (infarction, haemorrhage, tumour) in the dominant hemisphere in the posterior part of first temporal gyrus (WERNICKE’S AREA)

CFx:

  • Patient cannot understand or follow commands
  • Speech is fluent but disorganised
  • Cannot name objects or repeat ‘no ifs, ands or buts’
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64
Q

Expressive dysphasia

A

Def: patient understands but cannot speak properly

Aeit: posterior part of the dominant third frontal gyrus (BROCA’S AREA)

CFx:

  • Non fluent speech
  • May be able to name objects and repeat phrases
  • Can follow commands
  • If hemiparesis present UL>LL affected
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65
Q

Nominal dysphasia

A

Def: cannot name objects but other aspects of speech normal

Aeit: lesion of the dominant posterior temporoparietal area

CFx:
- May use long sentences to overcome not remembering specific words

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66
Q

Conductive dysphasia

A

Def: can follow commands but difficulty in repeating statements and naming objects

Aeit: lesion of the arcuate fasciculus and other fibres linking wernicke’s and broca’s areas.

67
Q

Parietal lobe dysfunction CFx

A

DOMINANT:

  • Acalculia (can’t do basic sums)
  • Agraphia (can’t write)
  • Left-right disorientation (show R then L hand, then touch R ear with L hand and L ear with R hand)
  • Finger agnosia (can’t name fingers)

NON-DOMINANT:

  • Graphaesthesia (can’t recognise numbers drawn on the skin)
  • Tactile extinction (can’t tell which side being touched when both sides touched)

GENERAL:

  • Sensory and visual inattention (get inattention on L side with R sided lesion)
  • Lower quandrantinopia
  • Astereogenesis (tactile agnosisa)
  • Two point discrimination
  • Dressing and constructional apraxia
  • Spatial neglect (incomplete clock drawing)
68
Q

Temporal lobe dysfunction CFx

A
  • Decreased short term memory (recall 3 objects)
  • Confabulation
  • Upper quadrantinopia
  • Receptive dysphasia if dominant lobe
69
Q

Frontal lobe dysfunction CFx

A
  • Personality change
  • Primitive reflexes (grasp [stroke palms, graps on side contralateral to the lesion], pout [stroke upper lip with tendon hammer induces pouting of lips])
  • Anosmia
  • Optic nerve compression-> atrophy (rare due to a space occupying lesion)
  • Gait apraxia
  • Leg weakness
  • Loss of micturition control
  • Expressive dysphasia
  • Concrete thinking (can’t interpret proverb)
70
Q

Occipital lobe dysfunction CFx

A
  • Homonymous hemianopia

- Alexia (can’t read)

71
Q

CN III palsy CFx

A

CFx:

  • Complete ptosis
  • Eye down and out (divergent strabismus)
  • Dilated pupil unreactive to direct light (if parasympathetic fibres affected, consensual reaction in the opposite normal eye is intact)
  • Unnreactive to accomodation

Motor function

  • Superior rectus
  • Inferior oblique
  • Medial rectus
  • Inferior rectus
72
Q

CN III palsy aeitology

A
  • CENTRAL: vascular lesions in brainstem, tumours, demyelination
  • PERIPHERAL: compressive lesions (usually aneurysm on PICA, tumour, orbital lesion), ischaemia (arteritis, DM, migraine)
73
Q

CN IV palsy

A

CFx:
- Can’t turn eye inward and down when eye adducted (eye when adducting rotates up ‘nasal upshoot’)

Motor function
- superior oblique (intorts eye / depresses eye when adducted, action depends on direction of movement)

Aeit:
- Isolated palsy rare, usually idiopathic or trauma

74
Q

CN VI palsy

A

CFx:
- Failure of lateral movement, maximum of looking to the affected side

Motor function
- lateral rectus

Aeit:
BILATERAL: trauma, Wernicke’s encephalopathy (opthalmoplegia, confusion and ataxia), mononeuritis multiplex, raised ICP

75
Q

Causes CN V palsy

A

CENTRAL (pons, medulla or upper cervical cord)

  • Vascular lesion
  • Tumour
  • Syringobulbia (fluid filled cavities)

PERIPHERAL (middle fossa)

  • Aneurysm
  • Tumour
  • Chronic meningitis

TRIGEMINAL GANGLION (petrous temporal bone):

  • Trigeminal neuroma
  • Meningioma
  • Fracture of the middle fossa
CAVERNOUS SINUS:
[Involve only opthalmic (V1) division and typically assoc with CN IV and VI palsy]
- Aneurysm
- Tumour
- Thrombosis

If only one division of CN V affected then it must be a post ganglionic lesion.
Dissociated sensory loss suggests a brainstem or upper cord lesion.

76
Q

Causes CN VII palsy

A

UMN (supranuclear; forehead sparring):

  • Vascular
  • Tumours

LMN (forehead not spared, when pt tries to shut eye get upward movement of eyeball and incomplete closure):

  • Pontine causes (often assoc with CN V and VI lesions): vascular lesions, tumours, syrringobulbia, MS
  • Posterior fossa: acoustic neuroma, meningioma, chronic meningitis
  • Petrous temporal bone: bell’s palsy, fracture, ramsay hunt syndrome (herpes zoster), ottitis media, parotid gland tumour or sarcoidosis
77
Q

Causes CN IX and X palsy

A

CENTRAL:

  • Vascular lesions (lateral medullary infarction due to vertebral or posterior inferior cerebellar artery disease)
  • Tumours
  • Syringobulbia
  • MND

PERIPHERAL (posterior fossa):

  • Aneurysms at the base of skull
  • Tumours
  • Chronic meningitis
  • Guillian-Barre syndrome
78
Q

Combined unilateral III, IV, V, VI palsy

A

Unilateral III, IV, V, VI suggests carvenous sinus lesion.

79
Q

Unilateral V, VII and VIII palsy

A

Unilateral V, VII and VIII suggests a cerebellopontine angle lesion (usually tumour, acoustic neuroma)

80
Q

Unilateral IX, X and XI palsy

A

Unilateral IX, X, and XI suggests jugular foramen lesion

81
Q

Bilateral X, XI and XII palsy

A

Bilateral X, XI and XII

  • Bulbar palsy if LMN signs
  • Psuedobulbar palsy if UMN signs
82
Q

Pseudobulbar palsy: CFx

A

Pseudobulbar palsy = bilateral UMN lesions of CN IX, X and XII

CFx

  • Increased gag reflex
  • Spastic tongue
  • Increased jaw jerk
  • Spastic dysathria (speech)
  • Bilateral limb UMN (long tract) signs
  • Labile emotions

Causes:

  • Bilateral cerebrovascular disease (e.g. both internal capsules)
  • Multiple sclerosis
  • Motor neurone disease
83
Q

Psuedobulbar palsy: causes

A

Causes:

  • Bilateral cerebrovascular disease (e.g. both internal capsules)
  • Multiple sclerosis
  • Motor neurone disease
84
Q

Bulbar palsy: CFx

A

Bulbar palsy = bilateral LMN lesions of IX, X and XII

CFx:

  • Absent gag relfex
  • Absent or normal jaw reflex
  • Nasal speech
  • Normal emotions

Causes:

  • MND
  • Guillain-Barre syndrome
  • Poliomyelitis
  • Brainstem infarction
85
Q

Bulbar palsy: causes

A

Causes:

  • MND
  • Guillain-Barre syndrome
  • Poliomyelitis
  • Brainstem infarction
86
Q

Horner’s syndrome CFx

A

Due to interruption of the sympathetic innervation of the eye.

CFx:

  • Partial ptosis (sympathetic fibres supply the smooth muscle of both eyelids)
  • Constricted pupil (miosis; due to unbalanced parasympathetic action)
  • Decreased sweating
87
Q

Horner’s syndrome causes

A
  1. Carcinoma of the apex of the lung (usually squamous cell carcinoma)
  2. Neck
    - Malignancy e.g. thyroid
    - Trauma or surgery
  3. Lower trunnk brachial plexus lesions
    - Trauma
    - Tumour
  4. Carotid artery lesion
    - Carotid aneursym or dissection
    - Pericarotid tumours
    - Cluster headache
  5. Brainstem lesion
    - Vascular disease (e.g. lateral medullary syndrome; see nystagmus to the side of the lesion, ipsilateral pain and temperature loss (CN V), CV IX and X lesions, ipsilateral cerebellar signs and contralateral pain and temperature loss over the trunk and limbs)
88
Q

Horner’s syndrome CFx

A

EYES:
- Partial ptosis
- Miosis
- Check for drecrease in sweating
FACE:
- Check for signs of lateral medullary syndrome
– Nystagmus to side of the lesion
– Ipsilateral pain and temperature loss (CN V)
– CN IX and X lesions (uvula deviation [to side of lesion’] and gag reflex, cough)
– ipsilateral cerebellar signs
– contralateral pain and temp loss over trunk and limbs
VOICE
- Hoarseness may be from a recurrent laryngeal nerve palsy
HANDS
- clubbing
- weakness of finger abduction
(if present do resp exam concentrating on the apices for lung carcinoma)
NECK
- lymphadenopathy
- Thyroid carcinoma
- Carotid aneursym or bruit

89
Q

Muscle power grading

A

0 Complete paralysis
1 Flicker of contraction
2 Movement possible when gravity excluded
3 Movement possible against gravity but not if any further resistance is added
4- Slight movement against resistance
4 Moderate movement against resistance
4+ Submaximal movement against resistance
5 Normal power

90
Q

Radial nerve

A

Radial nerve - C5-8

Motor (extends UL!)

  • Triceps
  • Brachioradialis
  • Extensor muscle of hand

Sensation
- Anatomical snuff box

Cfx palsy

  • Wrist drop
  • Test for triceps involvement (if affected lesion is above the upper third of the arm)
91
Q

Median nerve

A

Median nerve C6-T1

Motor
Wrist flexion
Finger flexors 
Lumbricals (leyton Hewitt sign)
Thumb abduction 
- front muscles of the forearm except flexor carpi ulnaris and ulnar half of flexor digitorum profundus
- LOAF of hand
-- Lateral two lumbricals
-- Opponens pollicus
-- Abductor pollicis brevis
-- Flexor pollicis brevis

Sensation
- Palmar aspect of thumb, index and lateral half of ring fingers

Lesions:

  • At wrist (carpal tunnel)
    • pen touch test to assess for weakness of abductor pollicis brevis (get patient to abduct thumb towards pen held by examiner)
    • Palm sensation spared
  • At cubital fossa
    • Look for loss of flexor digitorum sublimis; get patient to clasp hands together and look for index finger sticking out
92
Q

Median nerve

A

Median nerve C6-T1

Motor
Wrist flexion
Finger flexors 
Lumbricals (leyton Hewitt sign)
Thumb abduction 
- front muscles of the forearm except flexor carpi ulnaris and ulnar half of flexor digitorum profundus
- LOAF of hand
-- Lateral two lumbricals
-- Opponens pollicus
-- Abductor pollicis brevis
-- Flexor pollicis brevis

Sensation
- Palmar aspect of thumb, index and lateral half of ring fingers

Lesions:

  • At wrist (carpal tunnel)
    • pen touch test to assess for weakness of abductor pollicis brevis (get patient to abduct thumb towards pen held by examiner)
    • Palm sensation spared
  • At cubital fossa
    • Look for loss of flexor digitorum sublimis; get patient to clasp hands together and look for index finger sticking out
93
Q

Ulnar nerve

A

Ulnar nerve C8-T1

Motor
Finger abduction
Finger addiction
Digit 4 and 5 flexion
- Supplies small muscles of the hand except LOAF
- Flexor carpi ulnaris
- Ulnar part of flexor digitorum profundis

Sensation
- Palmar and dorsal aspects of the little finger and medial half of ring finger

Note ulnar nerve paradox where distal lesions cause greater deformity.

94
Q

Causes of a claw hand

A
  • Ulnar and median nerve lesion (ulnar nerve palsy alone causes a claw like hand)
  • Brachial plexus lesion (C8-T1)
  • Other neurological disease, e.g. syringomyelia, polio
  • Ischaemic contracture (later and severe)
  • Rheumatoid arthritis (advanced, untreated disease)
95
Q

Causes of small muscle wasting

A 
SPINAL CORD LESION
- Syringomyelia
- Cervical spondylosis with compression of the C9 segment
- Tumour
- Trauma
ANTERIOR HORN CELL DISEASE
- Motor neurone disease
- Poliomyelitis
- Spinal muscular atrophies
ROOT LESION
- C8 compression
LOWER TRUNK BRACHIAL PLEXUS LESION
- Thoracic outlet syndromes
- Trauma, radiation, infiltration, inflammation
PERIPHERAL NERVE LESIONS
- Median and ulnar nerve lesions
- Peripheral motor neuropathy
MYOPATHY
- Dystrophia myotonica (forearms more affected than hands)
- Distal myopathy
TROPHIC DISORDERS
- Athropathies
- Ischaemia, inc vasculitis
- Shoulder hand syndrome
96
Q

Brachial plexus lesions

A

COMPLETE LESION (rare):

  • LMN signs affect the whole arm
  • Sensory loss (whole limb)
  • Horner’s syndrome
  • Often painful

UPPER LESION (Erb) C5-6

  • Loss of shoulder movement and elbow flexion; hand held in waiter’s tip position
  • Sensory loss over the lateral aspect of the arm and forearm

LOWER LESION (Klumpke) C8-T1

  • True claw hand with paralysis of all the intrinsic muscles
  • Sensory loss along the ulnar side of the hand and forearm
  • Horner’s syndrome

Cervical rib syndrome

  • Weakness and wasting of the small muscles of the hand (claw hand)
  • C8 and T1 sensory loss
  • Unequal radial pulses and blood pressure
  • Subclavian bruits on arm manoeuvering
  • Palpable cervical rib
97
Q

Brachial plexus lesion causes

A
  1. Inflammation, autoimmune (more common upper brachial plexus)
  2. Radiotherapy (more often upper brachial plexus)
  3. Cancer (more often lower; usually painful, weakness and sensory loss present)
  4. Trauma
98
Q

Lateral cutaneous nerve of the thigh

A

Sensory
- Lateral aspect of thigh

No motor

99
Q

Femoral nerve

A

Femoral nerve L2, L3, L4

MOTOR:

  • Knee extension
  • Absent knee jerk

SENSORY:
- inner aspect of thigh and leg

100
Q

Sciatic nerve

A

Sciatic nerve L4, L5, S1, S2

MOTOR:
- All muscles below the knee and hamstrings

SENSATION:

  • posterior thigh
  • lateral and posterior calf

CFx palsy:

  • Foot drop
  • Knee jerk intact but ankle jerk and plantar responses absent
101
Q

Common pernoeal nerve

A

Common peroneal L4, L5, S1

MOTOR (branch of sciatic)
- Anterior and lateral compartment muscles of one leg

CFx palsy:

  • Foot drop
  • Intact reflexes
  • Inversion preserved
  • Minimal sensory loss over the lateral aspect of the dorsum of the foot

NOTE: L5 palsy has weakness of knee flexion and loss of foot inversion as well as sensory loss in L5 distribution.

102
Q

Hemiplegic gait

A

Hemiplegic gait = foot is plantar flexed and the leg is swung in a lateral arc

103
Q

Spastic paraparesis gait

A

Spastic paraparesis = scissors gait

104
Q

Parkinson’s gait

A

Parkinson’s gait = hesistation in starting

  • Shuffling
  • Freezing
  • Festination
  • Propulsion
  • Retropulsion
105
Q

Cerebellar gait

A

Cerebellar = a wide based or reeling on a narrow base.

The patient staggers towards the affected side if the lesion is unilateral.

106
Q

High stepping gait

A

Foot drop = high stepping gait

107
Q

Waddling gait

A

Proximal myopathy = waddling gait

108
Q

Feet glued to floor gait

A

Prefrontal lobe (apraxic) = feet appear glued to floor when erect, but move more easily when the patient is supine

109
Q

Heel and toe walking

A

Walk on toes = not possible if S1 lesion

Walk on heels = not possible if L4 of L5 lesion causing foot drop

110
Q

UMN CFx

A

UMN lesion = lesion at level above anterior horn cell (e.g. cerebral cortex, internal capsule, brainstem, spinal cord)

CFx:

  • Upper limb drift
  • Hyperrelfexia
  • Extensor (upgoing) plantar response
  • Pyramidal weakness (UL flexors strong, LL extensors strong)
  • No muscle wasting
  • Increased tone / spasticity (due to destruction of the corticoreticulospinal tract)

Causes:
VASCULAR: thrombosis, embolism, haemorrhage. Thrombosis of internal carotid artery (may hear bruit).
COMPRESSIVE/INFILTRATIVE: tumours, false localising signs from raised ICP (typically see 6th nerve palsy due to 6th nerves long path).
DEMYELINATING DISEASE: MS
INFECTION: HIV

111
Q

Stroke syndrome patterns

A

Anterior cerebral artery = leg>arm involvement

Penetrating branches of MCA = lacunar infarct

Internal carotid / MCA = aphasia or non-dominant hemisphere dysfunction, hemiplegia contralaterally to lesion, homonymous hemianopia.

Posterior cerebral artery = homonymous hemianopia, no hemiplegia

Basilar artery = quadriplegia

Penetrating branches of basilar artery to brainstem = brainstem infarct

PICA (posterior inferior cerebellar artery) = laterally medullary syndrome (ipsilateral facial sensation changes, contralateral body sensory deficits)

112
Q

LMN CFx

A
  • Weakness (may be more pronounced distally>proximally, all muscles equally involved)
  • Muscle wasting
  • Normal tone
  • Reduced reflexes with normal or absent plantars
  • Fasciculations may be present

LMN lesion = interruption of reflex arc, thus lesion of the spinal motor neurones, motor root or peripheral nerve

113
Q

MND

A
  • Unknown pathophys but pathology in anterior horn cell,s motor nuclei of the medulla and descending tracts

CFx:

  • Combination of UMN and LMN signs
  • Fasiculations almost always present
  • Muscle stretch reflexes usually present until late in disease
  • No objective sensory changes
114
Q

Peripheral neuropathy CFx

A

CFx:

  • Distal part of nerves involved first due to distance from the cell bodies
  • Can be loss of sensation or motor function
  • Typically symmetrical glove and stocking loss to all modalities
  • Peripheral weakness may be present if motor nerve involvement
  • If motor without sensory involvement reflexes may be reduced but should not be absent
115
Q

Mononeuritis multiplex causes

A

MM = separate involvement of more than one peripheral or cranial nerves by a single disease

ACUTE:

  • Polyarteritis nodosa
  • Diabetes
  • CTD: rheumatoid arthritis, SLE

CHRONIC:

  • Multiple compressive neuropathies
  • Sarcoidosis
  • Acromegally
  • HIV
116
Q

Spinal cord lesion CFx

A

Spinal cord lesion causes LMN AT THE LEVEL of the lesion and UMN BELOW LEVEL of lesion.

Examples:

  • C5: LMN weakness and wasting of rhomboids, deltoids, biceps and brachioradialism. UMN affecting the rest of UL and LL.
  • C8: LMN weakness and wasting of instrinsic muscles of the hand. UMN signs in LL.
  • T10/T11: loss of lower abdominal reflexes and upward displacement of umbilicus. UMN in LL.
  • L5-S1: LMN weakness of knee flexion and hip extension (S1) and abduction (L5) plus calf and foot muscles. Knee jerks present, no ankle jerks or plantar responses. Anal reflex present.
  • S3-S4: no anal reflex, saddle sensory loss, normal lower limbs.
117
Q

Spinal cord brown sequard syndrome CFx

A

Brown sequard = half cord (coronally) affected (partial unilateral cord lesion)

CFx:

  • Loss of pain and temperature sensation on the opposite side to the lesion
  • Loss of vibration and proprioception on the same side of the lesions
  • UMN BELOW the hemisection on the same side as the lesion, LMN AT the level of the hemisection on the same side

Causes:

  • MS
  • Angioma
  • Trauma
  • Myelitis
  • Post radiation myelopathy
118
Q

Spinal cord syndromes: subacute combined degeneration of the cord (Vit B12 deficiency)

A

CFx:

  • Posterior column loss symmetrically-> ataxic gait
  • UMN signs in LL symmetrically
  • Absent ankle reflex but knee reflex may be exaggerated or absent
  • Peripheral sensory neuropathy
  • Optic atrophy
  • Dementia
119
Q

Central cord CFx (e.g. syringomyelia)

A

Syringomyelia = central cavity in spinal cord

CFx:

  • Loss of pain and temp over neck, shoulders and arms (like a cape)
  • Amytrophy (atrophy and areflexia) of the arms
  • UMN signs in lower limb
120
Q

Causes of proximal muscle weakness

A 
# MYOPATHY
- Polymyositis / dermatomyositis
- Muscular dystrophy (Becker, Duchenne, facioscapulohumeral musclar dystrophy)
- Endocrine: cushing's, hypothyroidism, acromegally
- Drugs (steroids, statins)
# NEUROMUSCULAR JUNCTION DISEASE 
- myasthenia gravis
- Lambert-Eaton syndrome
# NEUROGENIC:
- MND
- Kugelberg-Welander disease
- CIPD (motor predominant)

Myopathy on EMG = early recruitment

Kugelberg-Welander disease = proximal muscle wasting and fasiculation due to anterior horn cell disease. Autosomal recessive.

121
Q

Causes of myopathy

A
  • HEREDITARY MUSCULAR DYSTROPHY (Becker, Duchenne, facioscapulohumeral musclar dystrophy)
  • CONGENITAL MYOPATHIES
  • ACQUIRED MYOPATHIES (PACE)
    • Polymyositis or dermatomyositis
    • Alcohol, AIDS (HIV infection)
    • Carcinoma
    • Endocrine, e.g. hyperthyroidism, hypothyroidism, Cushing’s syndrome, acromegaly, hypopituitarism
  • Periodic paralysis (hyperkalaemic, hypokalaemic or normokalaemic)
    • Osteomalacia
    • Drugs (clofibrate, chloroquine, steroids, zidovudine)
    • Sarcoidosis
122
Q

Causes of muscular dystrophy

A

DUCHENNE’S (psuedohypertrophic)
- Affects only males (sex-linked recessive)
- Calves and deltoids: hypertrophied early, weak later
- Proximal muscle weakness: early
- Dilated cardiomyopathy
# BECKER
- Affects only males (sex-linked recessive)
- Similar features to Duchenne’s but less heart disease, a later onset and less rapid progression
# LIMB GIRDLE
- Males or females (autosomal recessive), onset in the third decade
- Shoulder or pelvic girdle affected
- Face and heart usually spared
# FACIOSCAPULOHUMERAL
- Males or females (AD)
- Facial or pectoral weakness with hypertrophy of deltoids
# Dystrophia myotonica (AD)
- AD
- Frontal baldness
- Expressionless triangular facies
- Atrophy of the temporalis muscle and partial ptosis
- Difficulty releasing hands post contraction
- Cataracts
- Atrophy of sternomastoid
- Cardiac failure
- Proximal muscle wasting and weakness

123
Q

Dystrophica myotonia CFx

A

FACE: frontal bossing, expressionless triangular facies, atrophy of the temporalis muscle
EYES: partial ptosis, cataracts / lens disease
NECK: atrophy of sternomastoid, weak neck flexion with normal extension
UPPER LIMBS: shake hands and test for percussion myotonia (tapping over thenar eminence causes contraction and then slow relaxation of abductor pollicus brevis), arm wasting, UL weakness (forearms affected first), slow to release hand grip. No sensory changes
CHEST: gynaecomastica, cardiomyopathy
TESTES: atrophy
LOWER LIMB: tibial nerves affected first

ASK: test urine for sugar as assoc with T2DM

124
Q

Hereditary motor sensory neuropathy CFx

A
  1. Pes cavus (short arched feet)
  2. Distal muscle atrophy due to peripheral nerve degeneration
    - This dose not usually extend above the elbows or above the middle third of thigh
  3. Absent relfexes
  4. Slight or sensory loss in the limbs
  5. Thickened nerves
  6. Optic atrophy, Argyll Robertson pupils
125
Q

Myasthenia gravis CFx

A
  • Muscle power decreases with use
  • Little muscle wasting and no sensory change

TEST:

  • Oculomotor muscles by getting patient to sustain upgaze for one minute, look for progressive ptosis
  • Peek sign: test for orbicularis oculi weakness, ask pt to close eyes, if positive within 30 seconds the lid margin will begin to separate showing the sclera.
  • UL proximal girdle, ask pt to hold arms above the head and repeatedly press the abducted arms down until they weaken. Power will decrease with repeated muscle contraction.

Look for thymectomy scar

126
Q

Cerebellar disease CFx

A
  • Occur on the same side of the lesion as most cerebellar fibres cross twice in the brainstem (on entry and exit to the cerebellum)

CFx

  • Jerky horizontal nystagmus
  • Explosive, jerky or loud speech with irregular separation of syllables (get pt to say Bristish Constitution)
  • UL drift due to hypotonia of the agonist muscles (hypotonia due to loss of a facilitatory influence on the spinal motor neurones)
  • Intention tremor (increases as target is approached, due to loss of cerebellar connections in the brainstem)
  • Dysdiadochokinesis
  • Truncal ataxia
  • Gait-> patient will stagger towards affected side if there is a unilateral cerebellar hemisphere lesion
127
Q

Causes of cerebellar disease

A 
ROSTRAL VERMIS LESION (only LL affected)
- Alcohol
UNILATERAL
1. Space occupying lesion (tumour, abscess, granuloma)
2. Ischaemia (vertebrobasilar disease)
3. Multiple sclerosis
4. Trauma
BILATERAL
1. Drugs- e.g. phenytoin
2. Alcohol (possibly due to thiamine connection)
3. Friedreich's ataxia
4. Spinocerebellar atrophy
5. Paraneoplastic syndrome
6. Multiple sclerosis
7. Trauma
8. Arnold-Chiari malformation (lower CN palsy, cerebellar signs in limbs, UMN signs in legs)
9. Large space occupying lesion, cerebellar disease
10. Hypothyroidism 
MIDLINE
1. Paraneoplastic syndrome
2. Midline tumour
128
Q

Fredreich’s ataxia CFx

A

Autosomal recessive

  1. Bilateral cerebellar signs including nystagmus
  2. Pes cavus, cocking of the toes, kyphoscoliosis
  3. UMN in the limbs with absent reflexes
  4. Peripheral neuropathy
  5. Posterior column loss in the limbs
  6. Cardiomyopathy
  7. Diabetes mellitus
  8. Optic neuropathy (uncommon)
  9. Normal mentation
129
Q

Causes of spastic and ataxic paraparesis (UMN + cerebellar signs)

A
  • MS
  • Spinocerebellar degeneration
  • Arnold chiari malformation (lower CN palsy, cerebellar signs in limbs, UMN signs in legs)
  • Syringomyelia
  • Ischaemia
  • Meningioma / tumour
130
Q

Parkinson’s disease CFx

A

Extrapyramidal disease with degeneration of the substantia nigria and its pathways leading to dopamine deficiency and an excess of cholinergic transmission

CFx:
GENERAL:
- Mask like facies with few spontaneous movements
GAIT (ask patient to rise from chair, walk, turn, quickly stop and start):
- Shuffling gait (small steps with lack of arm swing.), difficulty initiating walking and difficulty stopping.
- Bradykinesia (decrease in the speed and amplitude of complex movements); can test finger tapping and twiddling (rotating hands in front of the body)
TREMOR:
- Asymmetrical resting tremor; characteristic movement is pill rolling
- Tremor decreases with finger-nose testing
TONE:
- Increased / cogwheel ridigity
FACE:
- Glabellar tap (continues to blink when forehead tapped)
SPEECH:
- Soft and monotonous
EYES:
- Weakness of upward gaze (if marked rigidity and paralysis of gaze consider PSP)
BP:
- Orthostatic hypotension
WRITING:
- Micrographia

131
Q

Causes of tremor

A
  1. Parkinsonian (resting tremor)
  2. Postural/action tremor (present throughout a movement)
    - Idiopathic
    - Anxiety
    - Drugs
    - Familial
    - Thyrotoxic
  3. Essential / familial
  4. Intention tremor (cerebellar disease, increases towards target)
  5. Midbrain tremor (abduction-adduction movements of upper limbs with flexion-extension wrists (usually associated with intention tremor)
132
Q

Relative afferent pupillary defect

A

Affected side dilates when light shone in (on repeated testing)

Causes:
Pathology after optic chiasm
- retinal artery occlusion 
- large retinal attachment
- retinal vein occlusion 
- optic nerve (optic neuritis, MS, compression)
133
Q

Nerve conduction studies peripheral neuropathy

A 
Demelinating 
E.g. diabetes, paraprotein, CMT, CIDP
- decreased velocity
- increased distal latency 
- normal amplitude

Axonal
E.g. diabetes mellitus, toxins, metabolic, paraneoplastic
- decreased amplitude
- velocity normal >70%

134
Q

Foot drop DDx cause

A

Peroneal nerve (L4, L5, S1, S2)

  • Decreased eversion
  • Normal power at knee
  • Decreased sensation at dorsum of foot
  • Ankle reflex intact

Sciatic nerve (L4-S3)

  • Flaccid foot, reduced eversion and inversion
  • Reduced flexion at knee
  • Decreased sensation posterior thigh and below knee
  • Intact knee jerk
  • Absent ankle jerk

L4/5 nerve root

  • Reduced inversion and eversion
  • Normal knee power
  • Dermatomal sensory loss
  • Ankle jerk intact
135
Q

Complex opthalmaplegia causes

A
  • Myasthenia gravis
  • Mitochondrial disorders
  • Grave’s disease
  • Multiple CN affected (mononeuritis multiplex, MS)
136
Q

Causes of distal muscle weakness

A 
# Myopathic
- Inclusion body myositis
- Muscular dystrophies (FSH)
# NMJ
- Myasthenia gravis
# Neuropathic (peripheral neuropathy with motor predominance)
- Hereditary sensory and motor neuropathy
- Spinal muscular atrophy (UMN)
- CIDP (LMN)
- Multifocal motor neuropathy (LMN)
- Diabetes
137
Q

Causes of ptosis

A

UNILATERAL

  • Horner’s syndrome
  • CNIII palsy
  • Myasthenia gravis

BILATERAL

  • Myasthenia gravis
  • Senile
  • Eyelid oedema (infection, allergy)
  • Muscular dystrophy, e.g. oculopharyngeal MD
138
Q

Causes of a pes cavus

A
  • Freidreich’s ataxia
  • Idiopathic
  • Hereditary motor and sensory neuropathy
  • Neuropathies in childhood
139
Q

Causes of a diffuse goitre

A
  • Thyroiditis (hashimoto’s, subacute)
  • Post partum or pregnancy
  • Idiopathic
  • Iodine deficiency
  • Grave’s disease
  • Lithium
  • Hormone synthesis errors
140
Q

Causes of optic neuritis

A
  • MS
  • Toxins (amiodarone, ethambutol)
  • Metabolic
  • Autoimmune disease
  • Malignancy
  • Infective (syphillis, CMV, VZV)
141
Q

Lateral medullary syndrome CFx

A
  • Nystagmus to the side of the lesion
  • Ipsilateral CN V, X and sometimes XI lesion
  • Ipsilateral cerebellar signs
  • Contralateral pain and temp loss over trunk

Causes of lateral medullary syndrome
- Ischaemia to lateral medulla secondary to vertebral artery or posterior inferior cerebellar artery

142
Q

Glomerulonephritis likely to reoccur post transplant

A
  • Focal glomerulosclerosis
  • Membranoproliferative GN
  • Anti-GBM
  • IgA nephropathy
143
Q

Causes of autoimmune haemolytic anaemia

A 
Warm (IgG and C3 +ve)
- autoimmune lymphoma (NHL)
- CTD
- drugs
- idiopathic
Cold (C3 +ve)
- glandular fever
- mycoplasma infection
- hepatitis C
- If chronic: lymphoma, idiopathic
144
Q

Causes of a peripheral neuropathy

A
  • Diabetes
  • Alcohol
  • Nutritional (B12, B6, folate)
  • Drugs (vincristine, cisplatinum, amiodarone, bortezimib, phenytoin, izoniazid)
  • AIDP / CIPD
  • Paraneoplastic syndrome
  • Amyloid, sarcoidosis
  • Hypothyroidism
  • Porphyria
  • Renal
  • Congenital
145
Q

Causes of a painful peripheral neuropathy

A

DAV CHAP

  • Diabetes
  • Alcohol
  • B12 def
  • Carcinoma
  • Arsenic
  • Porphyria
146
Q

X-ray changes in RA

A
  • Soft tissue swelling
  • Juxta articular osteopenia
  • Subluxation and ulnar deviation of MCP joints
  • Radial deviation at the wrist
  • Marginal erosions
  • joint space narrowing
147
Q

X-ray changes OA

A
  • Subchondral cysts
  • Subchondral sclerosis
  • Joint space narrowing
  • Osteophytosis
  • may see erosions
148
Q

X-ray changes psoriatic arthritis

A
  • Pencil in cup deformity (marginal erosions + adjacent bony proliferation)
  • Small joint ankylosis (joint immobility / consolidation)
  • Osteolysis of phalangeal and metacarpal bone
  • Telescoping of digits and periostitis
  • Proliferative new bone at sites of enthesitis
  • Joint destruction
149
Q

Findings in foot RA

A
  • Hindfoot eversion
  • Plantar subluxation at the metatarsal heads
  • Forefoot widening
  • Hallux valgus
  • Lateral deviation and dorsal subluxation of the toes
150
Q

Cholesterol targets

A
  • Total cholesterol < 4
  • LDL <1.8
  • HDL >1
  • Triglycerides < 2

If low risk

  • Total cholesterol < 5.5
  • LDL < 4
151
Q

Significant reforming polyarthropathy

A
  • RA
  • Psoriatic arthritis
  • SLE (jacoud arthopathy)
  • MCTD
152
Q

Causes of LVF

A
  1. Volume overload (AR, MR, PDA)
  2. Pressure overload (HT, AS)
  3. Myocardial disease (IHD, dilated cardiomyopathy)
153
Q

Causes of RHF

A
  1. Volume overload (ASD, TR)
  2. Pressure overload (PS, pulmonary HT)
  3. Myocardial disease (cardiomyopathy secondary LHF, right ventricular infarction)
154
Q

Causes of RHF

A
  1. Volume overload (ASD, TR)
  2. Pressure overload (PS, pulmonary HT)
  3. Myocardial disease (cardiomyopathy secondary LHF, right ventricular infarction)
155
Q

Causes of goitre

A 
Hashimoto thyroiditis
- Graves disease
- Familial or sporadic multinodular goitre
Iodine deficiency
Follicular adenoma
Colloid nodule or cyst
Thyroid cancer
156
Q

LVH voltage criteria

A
  • Seven big squares V1 + V5 or V6
157
Q

Meld score for transplant

A

> 15 benefit for transplant

Consider referral at 10-12

158
Q

Upper limb reflexes

A

Biceps C5 (musculocutaneous n)

Brachioradialis C6 (radial n)

Triceps C7 (radial n)

159
Q

Factors suggesting type 1 / latent autoimmune diabetes

A
  • anti-GAD antibody positive (glutamine acid decarboxylase)
  • insulin antibodies
  • c peptide level (correlate to insulin level)
160
Q

Antibodies in myositis

A
  • Anti-Jo-1(assoc anti-synthetase synd)

- Anti-Mi-2 (dermatomyositis)

161
Q

Antibodies in vasculitis

A

C-ANCA (anti-protinase 3)
- granulomatosis with polyangitis

P-ANCA (anti-MPO)

  • microscopic polyangitis
  • eosinophilic granulomatosis with polyangitis
162
Q

Tracheal deviation towards

A
  • Pneumonectomy
  • Agenesis of lung
  • Pulmonary fibrosis
  • Lobar collapse
163
Q

Tracheal deviation away

A
  • Pleural effusion

- Tension pneumothorax

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