Medical Vivas Flashcards
What are the causes of a 3rd nerve palsy?
What question should you ask someone with a 3rd nerve palsy to narrow your differential?
Do pupils dilate early or late in a surgical 3rd nerve palsy?
What else would you like to measure in this patient?
Causes of a 3rd nerve palsy - (1,2,3 the most common and the reasonable response to a viva question)
1-Diabetes
2-Hypertension
3-Posterior cerebral artery aneurysm (Painful)
Further causes = Stroke, Compression of the nerve (space occupying lesion/tumour), Multiple Sclerosis, Trauma/bleed.
What question should you ask someone with a 3rd nerve palsy to narrow your differential?
“Is it painful?” - If the answer is yes then it’s likely to be a PCA aneurysm.
Do pupils dilate early or late in a surgical 3rd nerve palsy?
Early: parasympathetic fibres lie on the outside so are affected earlier by compression.
What else would you like to measure in this patient?
Blood pressure and BM as two common causes are diabetes and hypertension.
Causes of ptosis of the eye can be split into unilateral and bilateral. What are some unilateral causes and some bilateral causes of ptosis?
In a unilateral ptosis your diagnosis is informed by the size of the pupil: What would a unilateral ptosis with a small, normal or large pupil respectively indicate the diagnosis is?
What are some causes of a 6th nerve palsy?
Causes of ptosis of the eye can be split into unilateral and bilateral.
Unilateral
Horners’ syndrome
3rd nerve palsy
Myasthenia gravis
Congenital
Bilateral
Myasthenia gravis
Oculogyric crisis
(muscle weakness)
With a unilateral ptosis your diagnosis is informed by the size of the pupil:
Small – Horners’
Large - 3rd nerve palsy
Normal- Myasthenia gravis
6th nerve palsy (presenting with diplopia) causes?
- Diabetes
- Hypertension
- Multiple Sclerosis
- Raised ICP
Raised intracranial pressure presents with Cushings’ triad, what is Cushings’ triad?
What is the earliest sign of raised ICP in the fundus and why?
What are some other signs of raised intracranial pressure?
Cushings’ triad is a triad of bradycardia, hypertension and abnormal respiration.
The earliest sign of raised ICP in the fundus is loss of retinal vein pulsation, which is due to the increased pressure downstream. (N.B. papilloedema is a LATE sign of raised ICP)
Other signs of raised ICP are reduced GCS, 3rd nerve palsy, 6th nerve palsy(most commonly affected as it has the longest intracranial course)
What is the definition of cirrhosis?
What are some common causes of cirrhosis?
What are some less common causes of cirrhosis?
What are some signs of chronic liver disease on examination?
What are some signs of chronic liver diease on blood tests?
Cirrhosis is defined as scarring and fibrosis of the liver with regenerating nodules, which leads to a decrease in normal liver function.
Common causes of cirrhosis are alcoholic liver disease, chronic hepatitis B and C and non-alcoholic fatty liver diease.
Less common causes of cirrhosis can be split into:
Metabolic/congenital - Wilson’s disease, haemachromatosis, alpha-1-antitrypsin deficiency
Auto-immune - Primary biliary cirrhosis, primary sclerosing cholangitis and auto-immune hepatitis
Drugs - amiodarone, methotrexate.
Signs of chronic liver disease on examination: palmar erythema, clubbing, spider naevi, gynaecomastia, testicular atrophy, ascites, hepatomegaly.
Signs of chronic liver disease on blood tests: LFTs- deranged ALT AST, decreased albumin; Clotting - increased PT and increased INR,
Spot diagnosis - What are these, and what are they a manifestation of?
These are neurofibromas which are a sign of neurofibromatosis
What are some common causes of Pancreatitis?
Do you know a scoring system to evaluate the severity of an episode of pancreatitis?
What indicator is an independent predictor of the severity of an episode of pancreatitis?
What are some common causes of pancreatitis?
Acute (Appropriate answers in finals underlined)
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Malignancy / Mumps
Autoimmune
Scorpion sting (Brazilian scorpion Tityrus serrulatus… yeah no don’t say this in finals)
Hypertriglycerides or hypercalcaemia (TG>1000)
ERCP
Drugs ( Azathioprine, hydrochlorothiazide)
Chronic
Alcohol
Autoimmune
Hereditary (CF, familial pancreatitis)
A scoring system for pancreatitis is the modified Glasgow score which follows the mnemonic PANCREAS; a point is given for each criteria met, a score of 3 or more indicates a severe attack and ideally that patient should have an ITU review/ be monitored in ITU:
Pa02 <8 kPa
Age >55
Neutrophilia: WCC >15
Calcium <2 mmol/L
Renal function: Urea >16mmol/L
Enzymes: AST/ALT >200IU/L or LDH >600 IU/L
Albumin <32g/L
Sugar: Blood glucose >10mmol/L
CRP is an independent predictor, a higher CRP value predicts a more severe episode.
An 82 year old woman is brought in by an ambulance following a fall and a long lie.
How would you manage this woman?
What investigations would you order following initial management?
Have a look at the ECG below, what are the abnormalities seen?
On the background of the history with this ECG what is the diagnosis and how are you going to manage it?
Mx : ABCDE approach with fluid resuscitation.
Ix: Creatine kinase(Rhabdomyolosis is a concern in a long lie), blood glucose (was the fall caused by hypoglycaemia, or a hyperosmolar state?), U&Es(for electrolyte imbalances particularly hyperkalaemia), FBC(WCC for infection), troponin(Cardiac cause of syncope), ECG (cardiac cause and check for hyperkalaemic changes)
ECG: Shows a prolonged PR interval, broad and bizarre QRS complexes which merge with the preceding P wave and subsequent T wave and peaked T waves. This changes are in keeping with a severe hyperkalaemia.
Most likely diagnosis is hyperkalaemia secondary to rhabdomyolosis, Mx for hyperkalaemia is 10ml 10% calcium gluconate, 50 ml 50% dextrose and 10 units of insulin with nebulized salbutamol. This initial treatment is cardio-protective, changes such as the ones seen on the ECG indicate a severely high hyperkalaemia which might also need haemodialysis or haemofiltration, especially given the cause is most likely to be rhabdomyolosis.
