interactive cases in general internal medicine 4 Flashcards
In an upper motor neurone lesion
describe the
TONE:
POWER
REFLEXES
TONE: increased (spasticity)
POWER (decreased)
REFLEXES (increased)
plantar going up
In an lower motor neurone lesion
describe the
TONE:
POWER
REFLEXES
TONE: reduced (flacid)
POWER: reduced
REFLEXES: decreased
What does this patient have?
Diplopia (bilateral 6th) • Bilateral ptosis • Slurred speech • Dysphagia • Sluggish pupillary response to light • Descending symmetric muscle weakness • Multiple skin abscesses on arms & legs
Work through it:
Diplia is caused by damage to cranial nerve 3,4,6
Slurred speech and dysphasia: 9,10
The are not close together and it is therefore a problem with the neuromuscular junction
BOTULINUM TOXIN- IVDU user
What are cerebellar signs
dysdiadochokinesis
ataxia
nystagmus
intention tremor
Speech scanning and slurred
Heel-shin test positivity/ Hypotonia
How do you classify abnormal sensation and where could the pathology be?
Hemisensory loss - Cerebral cortex
Level (e.g. umbilicus) - Spinal cord
Dermatome(s) - Nerve roots (Radiculopathy)
Specific area - Mononeuropathy
Glove & stockings -Polyneuropathy
55 yr old man • Numbness & tingling in hands & feet • PMH: type 1 DM • On basal/bolus insulin • HbA1C: 50 mmol/mol • B12: 500 pg/ml (200 – 900) • eGFR: 90 • reduced Sensation to PP (glove & stocking distribution)
What would you prescribe?
A. Codeine
B. Duloxetine
C. Hydroxocobalamin
D. Paracetamol
E. Morphine
B. Duloxetine
What are causes of peripheral neuropathy?
What conditions would go under the different headings
-
Vascular
- Vasculitis
-
Infection:
- HIV
-
Inflammation/Autoimmune:
- CTD
- inflammatory demyelinating neuropathy
-
Toxic/Metabolic:
- Drugs (Hx): metronidazole
- Alcohol (high GGT &MCV)
- B12 deficiency (Anaemia, high MCV)
- Diabetes (Hx, glucose/ HBA1c)
- Hypothyroidism (TFT’s)
- Uraemia (U&E)
- Amyloidosis (History of myeloma or chronic infection/inflammation)
-
Tumour/Malignancy:
- Paraneoplastic
- Paraproteinaemia
34 yr old woman • Weakness in legs • Blurred vision • Legs:increased tone, reduced power & brisk reflexes • reduced PP sensation in legs • Fundoscopy
What is the cause of her blurred vision?
A. Amaurosis fugax
B. Anterior uveitis
C. Papilloedema
D. Papillitis
E. Vitreous haemorrhage
D. Papillitis - painful
What is a hereditary cause of peripheral neuropathy
– Hereditary sensory motor neuropathy
A man presents with this foot and peripheral neuropathy
What is the cause of his peripheral neuropathy?
Hereditary sensory motor neuropathy
What does optic neuritis present as?
- Blurred optic disc margins
- Blurred vision
- Pain on eye movement
A patient presents with this?
- Blurred optic disc margins
- Blurred vision
- Pain on eye movement
What does the patient have
Optic neuritis (papillitis)
What pathways could be affected in the spinal cord?
What symptoms would they produce?
What would could be the cause?
What pathways could be affected in the spinal cord?
- Corticospinal
- Spinothalamic tracts
What symptoms would they produce?
Spastic paraparesis
What would could be the cause?
- Vascular
- Infection: TB (Pott’s disease)
- Inflammation (demyelination)
- Transverse myelitis
- Toxic/Metabolic: B12, suba
- Tumour/Malignancy
In MS what is very important to make a clinical diagnosis
Two lesions
Separated in time/space
60 year old man • Pain & paraesthesia on anteriolateral thigh • PMH: Type 2 Diabetes • Metformin • HbA1C: 60 mmol/mol • BMI: 30 kg/m2 • decreased PP sensation anterolateral thigh
What is the most appropriate next step in his management?
A. Lose weight
B. Insulin
C. Statin
D. Aspirin
E. MRI Brain
A. Lose weight
Meralgia paresthetica