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
What is meralgia parasthetica ?
WHat is the treatment?
What is meralgia parasthetica ?
Compression of lateral femoral cutaneous nerve
What is the treatment?
Conservative treatment:
- Reassure
- Avoid tight garments
- Lose weight
Medical (if persistant)
- Carbamazepine
- Gabapentin
What is the sensory innervation of the hand?
median nerve: green - abductor brevis and
ulnar: blue -
Radial nerve: red - extensors weakness
What is radiculopathy?
What could it be caused by?
What is radiculopathy? Disease of the nerve roots
What could it be caused by?
- Disc herniation
- Spinal canal stenosis
What are the lumbosacral radiculopathy symptoms?
- Pain in the buttock,
- radiating down the leg below the knee (‘sciatica’)
What are the dermatomes of the arm?
60 year old man • Recurrent falls • Tremor at rest • Rigidity • More forgetful • Dysphagia • Micrographia • Limited upgaze
What is the most likely diagnosis?
A. Progressive supranuclear palsy
B. Lew body dementia
C. Stroke
D. Epilepsy
E. Alzheimer’s disease
What are parkinsonian features?
- Tremor, rigidity, bradykinesia
- Parkinsonian features, upgaze abnormality
- Features of Alzheimer’s disease, Parkinson’s & hallucinations
What are other conditions that give a Parkinsonian picture?
- Parkinson’s disease
- Dopaminergic neurons
- Substantia nigra
- PSP (Steele‐Richardson syndrome)
- Lew body dementia
A 55‐yr‐old man • Confusion & chest pain • No headache or neck stiffness • Recently moved to a new house. • Temp: 37oC • PR 110, BP 120/60 • Normal CVS/Resp/GI/Neuro exam
Initial tests:
- ECG: sinus tachycardia, widespread ST depression
- Urinalysis: NAD
- Blood glucose: 7.0 mmol/L
- WCC: 7
- CRP < 5
- CT head: NAD
What is the most likely cause of his confusion?
A. Vascular
B. Infection
C. Inflammation
D. Toxic/Metabolic
E. Tumour
What are causes of apparent confusion with a reduced AMTS?
WHat questions would you ask to exclude them?
- Post‐ictal - History of seizure?
-
Dysphasia
- Receptive or expressive (Other features of stroke/TIA)
-
Dementia
- Vascular (multi‐infarct) - History of IHD/PVD
- Alcoholic - History of IHD/PVD
- Alzheimer’s disease
- Inherited e.g. Huntington’s disease (HD) - History of IHD/PVD
-
Depressive pseudodementia
- Elderly, withdrawn, poor eye contact
- Precipitating factor
What are causes of confusion with reduced conscouisness?
- Hypoglycaemia
-
Vascular
- Bleed: Headache, collapse
- Subdural haematoma (Fall, fluctuating consciousness)
-
Infection
- ? Temp, ? Intracranial, ? Extra‐cranial
- Inflammation
- Malignancy
-
Metabolic/Toxic
- Drugs, U&Es, LFTs, Vitamin deficiencies, Endocrnipathies
What are the questions in the AMTS?
- DOB
- Age
- Time
- Year
- Place
- Recall (West Register Street)
- Recognize doctor/nurse
- Prime Minister
- Second WW
- Count backwards from 20 to 1
Describe the GCS scale and how it works
EYES*(4 letters*): 4
4 = Spontaneous
3 = Opens in response to voice
2 = Opens in response to painful stimuli
1 = Does not open
Verbal response (V - roman 5): 5
5 = Oriented
4 = Confused
3 = Words
2 = Sounds
1 = No sounds
MOTOR RESPONSE (5+1)
6 = Obeys commands
5 = Localizes pain
4 = Withdraws to painful stimuli
3 = Abnormal flexion
2 = Extension
1 = No movements
Someone presents in A& E with a headache what are your differentials?
What would be signs in the history?
- Meningitis - Fever, neck stiffness, photophobia
- Subarachnoid haemorrhage - sudden onset
- Giant cell arteritis - over 50 years old
- Polymyalgia rheumatica – (Shoulder girdle pain, stiffness, constitutional upset)
- Migraine- Throbbing, vomiting, photo/phonophobia, FHx, Aura
What test would you do for a Subarachnoid haemorrhage?
- CT
- LP (xanthochromia)
What test would you do for giant cell arteritis?
ESR
maybe a biopsy of temporal artery but negative doesn#t mean they don’t have it
What is the treatment for giant cell arteritis?
high dose corticosteroids
Bx
What sign would you see in menigism?
Kernig’s sign
Brunzinsky
How would you manage a stroke?
< 4.5 hours
CT: no haemorrhage
Thrombolysis (if no contraindications)
> 4.5 hours
CT head (exclude haemorrhage)
Aspirin (300mg), Swallow assessment
Maintain hydration, oxygenations, monitor glc
How do you manage a TIA
- Aspirin
- Don’t treat BP acutely
- unless > 220/120
- other indication
- ECG, Echocardiogram
- Carotid Doppler
- Risk factor modification
40 year old • Backache • LMN weakness • Admitted to HDU • Regular FVC • Cardiac monitor • IVIG
What is the most likely diagnosis?
Guillain‐Barre
B. Stroke
C. Cord compression
D. Cauda equina syndrome
E. Myasthenia gravis
What are causes of a collapse?
- Low glucose
-
Heart
- Vasovagal: sick sinus syndrome
- Arrhythmia: AF, IHC, SVT, VT, long QT, brigada, complete heart blick
- Outflow obstruction: HOCM, aortic stenosis
- Postural hypotension
- Brain – Seizure
What is amyloidosis?
deposition of abnormal protein in tissue that interfere with structure and function
- can be due to light chain deposition in myeloma
- chronic inflammation/ inflammation
Serum amyloid A protein
What is Pott’s disease?
TB affecting the spine
