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DPD 2020 > interactive cases in general internal medicine 4 > Flashcards

interactive cases in general internal medicine 4 Flashcards

1
Q

In an upper motor neurone lesion

describe the

TONE:

POWER
REFLEXES

A

TONE: increased (spasticity)

POWER (decreased)
​REFLEXES (increased)

plantar going up

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2
Q

In an lower motor neurone lesion

describe the

TONE:

POWER
REFLEXES

A

TONE: reduced (flacid)

POWER: reduced
REFLEXES: decreased

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3
Q

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

A

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

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4
Q

What are cerebellar signs

A

dysdiadochokinesis

ataxia

nystagmus

intention tremor

Speech scanning and slurred

Heel-shin test positivity/ Hypotonia

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5
Q

How do you classify abnormal sensation and where could the pathology be?

A

Hemisensory loss - Cerebral cortex

Level (e.g. umbilicus) - Spinal cord

Dermatome(s) - Nerve roots (Radiculopathy)

Specific area - Mononeuropathy

Glove & stockings -Polyneuropathy

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6
Q

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

A

B. Duloxetine

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7
Q

What are causes of peripheral neuropathy?

What conditions would go under the different headings

A
  • 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
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8
Q

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

A

D. Papillitis - painful

[Also known as optic neuritis]

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9
Q

What is a hereditary cause of peripheral neuropathy

A

– Hereditary sensory motor neuropathy

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10
Q

A man presents with this foot and peripheral neuropathy

What is the cause of his peripheral neuropathy?

A

Hereditary sensory motor neuropathy

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11
Q

What does optic neuritis present as?

A
  • Blurred optic disc margins
  • Blurred vision
  • Pain on eye movement
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12
Q

A patient presents with this?

  • Blurred optic disc margins
  • Blurred vision
  • Pain on eye movement

What does the patient have

A

Optic neuritis (papillitis)

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13
Q

What pathways could be affected in the spinal cord?

What symptoms would they produce?

What would could be the cause?

A

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
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14
Q

In MS what is very important to make a clinical diagnosis

A

Two lesions

Separated in time/space

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15
Q

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

A. Lose weight

Meralgia paresthetica

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16
Q

What is meralgia parasthetica ?

WHat is the treatment?

A

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
17
Q

What is the sensory innervation of the hand?

A

median nerve: green - abductor brevis and

ulnar: blue -

Radial nerve: red - extensors weakness

18
Q

What is radiculopathy?

What could it be caused by?

A

What is radiculopathy? Disease of the nerve roots

What could it be caused by?

  • Disc herniation
  • Spinal canal stenosis
19
Q

What are the lumbosacral radiculopathy symptoms?

A
  • Pain in the buttock,
  • radiating down the leg below the knee (‘sciatica’)
20
Q

What are the dermatomes of the arm?

A
21
Q

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

A

progressive supranuclear palsy

22
Q

What are parkinsonian features?

A
  • Tremor, rigidity, bradykinesia
  • Parkinsonian features, upgaze abnormality
  • Features of Alzheimer’s disease, Parkinson’s & hallucinations
23
Q

What are other conditions that give a Parkinsonian picture?

A
  • Parkinson’s disease
    • Dopaminergic neurons
    • Substantia nigra
  • PSP (Steele‐Richardson syndrome)
  • Lew body dementia
24
Q

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
  • CT head: NAD

What is the most likely cause of his confusion?

A. Vascular

B. Infection

C. Inflammation

D. Toxic/Metabolic

E. Tumour

A

carbonmonoxide poisoning

25
Q

What are causes of apparent confusion with a reduced AMTS?

WHat questions would you ask to exclude them?

A
  • 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
26
Q

What are causes of confusion with reduced conscouisness?

A
  • 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
27
Q

What are the questions in the AMTS?

A
  1. DOB
  2. Age
  3. Time
  4. Year
  5. Place
  6. Recall (West Register Street)
  7. Recognize doctor/nurse
  8. Prime Minister
  9. Second WW
  10. Count backwards from 20 to 1
28
Q

Describe the GCS scale and how it works

A

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

29
Q

Someone presents in A& E with a headache what are your differentials?

What would be signs in the history?

A
  • 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
30
Q

What test would you do for a Subarachnoid haemorrhage?

A
  • CT
  • LP (xanthochromia)
31
Q

What test would you do for giant cell arteritis?

A

ESR

maybe a biopsy of temporal artery but negative doesn#t mean they don’t have it

32
Q

What is the treatment for giant cell arteritis?

A

high dose corticosteroids

Bx

33
Q

What sign would you see in menigism?

A

Kernig’s sign

Brunzinsky

34
Q

How would you manage a stroke?

A

CT: no haemorrhage

Thrombolysis (if no contraindications)

> 4.5 hours

CT head (exclude haemorrhage)

Aspirin (300mg), Swallow assessment

Maintain hydration, oxygenations, monitor glc

35
Q

How do you manage a TIA

A
  • Aspirin
  • Don’t treat BP acutely
    • unless > 220/120
    • other indication
  • ECG, Echocardiogram
  • Carotid Doppler
  • Risk factor modification
36
Q

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

A

guillain barre syndrome

37
Q

What are causes of a collapse?

A
  • 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
38
Q

What is amyloidosis?

A

deposition of abnormal protein in tissue that interfere with structure and function

  1. can be due to light chain deposition in myeloma
  2. chronic inflammation/ inflammation

Serum amyloid A protein

39
Q

What is Pott’s disease?

A

TB affecting the spine

DPD 2020 (48 decks)

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