Medicine 3

Question 1

What are the three main types of graft rejection and how are they different?

Answer 1

Hyperacute: within minutes, ABO incompatibility, thrombosis and SIRS
Acute Rejection: < 6 months, cell-mediated, fever and graft pain, reduced urine output, increased creatinine, responsive to immunosuppression
Chronic Rejection: > 6 months, gradual increase in Cr and proteinuria, interstitial fibrosis and tubular atrophy, not responsive to immunosuppression

Question 2

What are the main side effects of ciclosporin?

Answer 2

Nephrotoxic
Gingival hypertrophy
Hypertrichosis
Hepatic dysfunction

Question 3

What are the main side effects of tacrolimus?

Answer 3

Nephrotoxic (less than ciclosporin)
Diabetogenic
Cardiomyopathy
Neurotoxic (peripheral neuropathy)

Question 4

List some complications of dialysis.

Answer 4

Cardiovascular disease
Malnutrition
Infection (uraemic –> granulocyte dysfunction –> sepsis)
Amyloidosis (b2 microglobulin accumulation)
Renal cysts –> RCC
Issues with fluid balance (e.g. hypotension, pulmonary oedema)
Electrolyte imbalance

NOTE: specific complications of peritoneal dialysis include peritonitis, exit site infection, catheter malfunction, obesity (glucose in dialysate)

Question 5

What is an AV fistula and how are they made?

Answer 5

Surgically created connection between an artery and a vein

• Radio-cephalic at wrist (Cimino-Brescia)
• Brachio-cephalic at elbow

Question 6

What are the advantages and disadvantages of AV fistulas?

Answer 6

ADVANTAGES: high flow, low infection rate, low chance of stenosis
DISADVANTAGES: takes 6 weeks to arterialise, body image, must take care around area (e.g. shaving)

Question 7

List some complications of AV fistulas.

Answer 7

Thrombosis and stenosis 
Infection 
Bleeding 
Aneurysm
Steal syndrome (reduced pulses, pallor, necrosis)

Question 8

List some causes of chronic renal failure.

Answer 8

Diabetes mellitus 
Hypertension 
Renal artery stenosis (mainly due to atherosclerosis)
Glomerulonephritis 
Connective tissue disease (SLE, SS, RA) 
Polycystic disease 
Drugs 
Pyelonephritis 
Multiple myeloma

Question 9

What are the components of a renal screen?

Answer 9

Fasting blood glucose/HbA1c
ESR
Immune: ANA, complement, anti-GBM, ANCA, viral serology
Serum protein electrophoresis

Question 10

List some complications of chronic renal failure.

Answer 10

Cardiovascular disease 
Renal osteodystrophy (osteomalacia, osteporosis)
Fluid overload 
Hypertension 
Electrolyte imbalance (hyperkalaemia, acidosis) 
Anaemia
Restless legs 
Sensory neuropathy

Question 11

Describe the type of tremor seen in the early stage of Parkinson’s disease.

Answer 11

Asymmetrical resting tremor (5 Hz)

Exacerbated by counting backwards

Question 12

Aside from inspecting and assessing tone in the arms, what else should be done when assessing a patient with Parkinson’s disease?

Answer 12

Check eye movements (nystagmus, vertical gaze palsy, saccades)
Glabellar tap
Gait
Write a sentence (micrographia)
Lying-standing BP (autonomic dysfunction)

Question 13

What are the four main Parkinson’s plus syndromes?

Answer 13

Progressive supranuclear palsy
Multiple system atrophy
Dementia with Lewy bodies
Corticobasilar degeneration

Question 14

Which type of scan is used to diagnose Parkinson’s disease?

Answer 14

DAT scan

Question 15

Outline the management of Parkinson’s disease.

Answer 15

MDT, assess disability using UPDRS 
Physiotherapy
L-DOPA + carbidopra/benserazide 
Dopamine agonists (e.g. ropinirole, pramipexole) 
MAO-B inhibitors (rasagiline)
COMT inhibitors (tolcapone) 
Amantadine 
Anti-muscarinics (e.g. procyclidine)

Question 16

What are the main clinical features of Parkinson’s disease?

Answer 16

Resting tremor (4-7 Hz)
Rigidity (lead pipe) 
Akinesia
Postural instability 
Postural hypotension 
Sleep disorders 
Psychosis 
Depression 
Dementia
Shuffling gait 
Synkinesis (increase in tone when distracted with another movement)

Question 17

List some side-effects of L-DOPA.

Answer 17

Tardive dyskinesia
Acute dystonia 
On-off phenomena 
Psychosis 
Dry mouth 
Daytime sleepiness

Question 18

What are the main features of multiple system atrophy

Answer 18

Autonomic dysfunction (postural hypotension)
Parkinsonism
Cerebellar ataxia

NOTE: Shy Drager syndrome is when the autonomic features predominate

Question 19

What are the main features of progressive supranuclear palsy?

Answer 19

Vertical gaze palsy
Pseudobulbar palsy (speech and swallowing problems)
Postural instability
Parkinson’s disease (symmetrical, usually no tremor)

Question 20

What are the main features of corticobasal degeneration?

Answer 20

Unilateral parkinsonism (especially rigidity)
Aphasia
Apraxia
Alien hand syndrome (can’t control one hand)

Question 21

What are the main features of Lewy Body dementia?

Answer 21

Dementia
Visual hallucinations
Fluctuating consciousness
Parkinsonism

Question 22

What are the main features of vascular parkinsonism?

Answer 22

Sudden-onset
Worse in legs than arms
Pyramidal signs
Prominent gait abnormality

Question 23

List some differentials for a tremor.

Answer 23

Resting: parkinsonism
Intention: cerebellar
Postural (worse when arms outstretched): benign essential tremor, hyperthyroidism, alcohol withdrawal,

Question 24

What are some key features of a benign essential tremor?

Answer 24

Autosomal dominant 
Occurs with movement 
Worse when anxious or with caffeine 
Doesn't occur during sleep 
Better with alcohol

Question 25

What are the main features of cerebellar pathology?

Answer 25

``` Dysdiadochokinesia Ataxia Nystagmus (and saccades) Intention tremor (and dysmetria) Staccato speech Hypotonia ``` Other: ocular dysmetria, pendular reflexes (continues to swing after reflex), heel-shin ataxia, truncal ataxia (vermis lesion)

Question 26

List some causes of cerebellar disease.

Answer 26

``` Demyelination Alcohol abuse Infarction SOL (e.g. schwannoma) Inherited (Wilson's, Friedreich ataxia, ataxia telangiectasia, VHL) Epilepsy medication (phenytoin) Multiple system atrophy ``` NOTE: bilateral signs are likely to be due to more global pathology (e.g. alcohol as opposed to infarction)

Question 27

What are the key features of a cerebellar vermis lesion?

Answer 27

Ataxic trunk and gait | Normal arms

Question 28

What are the main differences between nystagmus caused by cerebellar pathology and vestibular pathology?

Answer 28

Cerebellar: fast phase towards lesion, maximal when looking towards lesion Vestibular: fast phase away from lesion, maximal looking away from lesion

Question 29

What is lateral medullary syndrome (Wallenberg syndrome) caused by?

Answer 29

Occlusion of PICA or vertebral artery NOTE: it is the most common brainstem vascular syndrome

Question 30

What are the main features of lateral medullary syndrome?

Answer 30

Ipsilateral anaesthesia or the face Contralateral anaesthesia of the body (pain and temp) Cerebellar signs: dysphagia, ataxia, nystagmus, vertigo

Question 31

What are the features of cerebellopontine angle syndrome?

Answer 31

Unilateral hearing loss Speech impediments Disequilibrium (loss of balance) Tremors NOTE: this can also be accompanied by classical cerebellar signs, CN 6-8 palsies Causes: vestibular schwannoma, meningioma, metastases, astrocytoma

Question 32

What are the main features of von Hippel Lindau syndrome?

Answer 32

``` Renal cysts Bilateral renal cell carcinoma Haemangioblastoma (often cerebellar) Phaeochromocytoma Islet cell tumours ```

Question 33

What is Friedreich ataxia caused by?

Answer 33

Autosomal recessive disorder of the mitochondria characterised by progressive degeneration of the dorsal columns, spinocerebellar tracts and corticospinal tracts Onset in teenage years and associated with HOCM and dementia

Question 34

What are the main features of Friedreich ataxia?

Answer 34

INSPECTION: Young adult, wheelchair, Pes cavus MOTOR: Bilateral cerebellar signs (ataxia, dysarthria, nystagmus), Leg wasting, Areflexia but extensor plantars SENSORY: Loss of vibration and proprioception Other: high-arched palate, optic atrophy, retinitis pigmentosa, diabetes mellitus, HOCM

Question 35

What are the main features of ataxia telangiectasia?

Answer 35

Progressive ataxia Telangiectasia (conjunctivae, eyes, nose) Propensity for infections Lymphoproliferative disease NOTE: it is an autosomal recessive disease with onset in childhood/early adulthood

Question 36

What are the main upper motor neurone signs seen on examination?

Answer 36

``` Increased tone Pyramidal distribution of weakness (LEG: extensors stronger than flexors; ARMS: flexors stronger than extensors) Hyperreflexia Extensor plantars Weakness Pronator drift ```

Question 37

List some causes of bilateral lower limb spastic paraparesis.

Answer 37

``` Multiple sclerosis Cord compression/trauma Cerebral palsy Aortic dissection Syringomyelia ```

Question 38

List some causes of mixed upper and lower motor neurone signs.

Answer 38

Motor neurone disease (ALS) Friedreich ataxia Subacute combined degeneration of the spinal cord (B12)

Question 39

Describe the pattern of UMN/LMN signs in cord compression.

Answer 39

LMN at level of lesion UMN below level of lesion NOTE: there will also be a sensory level, deep pain/radicular pain and potentially sphincter disturbance

Question 40

List some causes of cord compression.

Answer 40

Trauma (vertebral fracture) Infection (epidural abscess, TB) Malignancy Disc prolapse NOTE: MRI is the investigation of choice

Question 41

What are the main features of cauda equina syndrome?

Answer 41

``` Back pain Radicular pain down the legs Bilateral flaccid, areflexic lower limb weakness Saddle anaesthesia Urinary/faecal incontinence/retention Lax anal tone ```

Question 42

What are the cardinal signs of syringomyelia?

Answer 42

Dissociated sensory loss (loss of pain/temperature, preserved light touch/vibration) usually affecting upper limbs and chest Wasting/weakness of hands (may include claw hand) Loss of upper limb reflexes Charcot joints (shoulder and elbow) NOTE: may be caused by blocked CSF circulation in Arnold-Chiari malformation or masses, spina bifida, secondary to trauma

Question 43

Which classification system is used to identify the part of the cerebral circulation affected by a stroke?

Answer 43

Bamford classification

Question 44

What are the features of a total anterior circulation stroke?

Answer 44

Hemiparesis and/or hemisensory deficit Homonymous hemianopia Higher cortical dysfunction (dominant: aphasia, non-dominant: neglect/apraxia) NOTE: this affects carotid/MCA and ACA territory

Question 45

What are the features of a partial anterior circulation stroke?

Answer 45

2/3 of the TACS criteria (usually homonymous hemianopia and higher cortical dysfunction)

Question 46

What are the features of a posterior circulation stroke?

Answer 46

``` Cerebellar syndrome (DANISH) Brainstem syndrome (cranial nerves - facial weakness, nystagmus, dysphagia, dysarthria) Homonymous hemianopia ``` NOTE: affects the vertebrobasilar territory

Question 47

How do lacunar infarcts manifest and how does it relate to the part of the brain affected?

Answer 47

``` Pure motor (posterior limb of internal capsule) Pure sensory (posterior thalamus) Mixed sensorimotor (internal capsule) Dysarthria Ataxia hemiparesis (anterior limb of internal capsule) ```

Question 48

List some stroke mimics.

Answer 48

``` Space-occupying lesion Head injury Hyper/hypoglycaemia Infection (encephalitis, meningitis) Drugs (e.g. opiates) ```

Question 49

Outline the typical first presentation of multiple sclerosis.

Answer 49

Two episodes separated by time and space Tingling Eyes (optic neuritis - pain on eye movement and reduced central vision) Ataxia (and other cerebellar signs) Motor (usually spastic paraparesis)

Question 50

Which investigations may be used in suspected multiple sclerosis?

Answer 50

MRI (gadolinium-enhanced will show areas of active inflammation) LP (oligoclonal bands) Antibodies (anti-MBP) Visual evoked potentials (optic neuritis)