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YEAR 6: PACES > Medicine 3 > Flashcards

Medicine 3 Flashcards

1
Q

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

A

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

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2
Q

What are the main side effects of ciclosporin?

A

Nephrotoxic
Gingival hypertrophy
Hypertrichosis
Hepatic dysfunction

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3
Q

What are the main side effects of tacrolimus?

A

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

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4
Q

List some complications of dialysis.

A

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)

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5
Q

What is an AV fistula and how are they made?

A

Surgically created connection between an artery and a vein

  • Radio-cephalic at wrist (Cimino-Brescia)
  • Brachio-cephalic at elbow
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6
Q

What are the advantages and disadvantages of AV fistulas?

A

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)

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7
Q

List some complications of AV fistulas.

A 
Thrombosis and stenosis 
Infection 
Bleeding 
Aneurysm
Steal syndrome (reduced pulses, pallor, necrosis)
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8
Q

List some causes of chronic renal failure.

A 
Diabetes mellitus 
Hypertension 
Renal artery stenosis (mainly due to atherosclerosis)
Glomerulonephritis 
Connective tissue disease (SLE, SS, RA) 
Polycystic disease 
Drugs 
Pyelonephritis 
Multiple myeloma
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9
Q

What are the components of a renal screen?

A

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

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10
Q

List some complications of chronic renal failure.

A 
Cardiovascular disease 
Renal osteodystrophy (osteomalacia, osteporosis)
Fluid overload 
Hypertension 
Electrolyte imbalance (hyperkalaemia, acidosis) 
Anaemia
Restless legs 
Sensory neuropathy
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11
Q

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

A

Asymmetrical resting tremor (5 Hz)

Exacerbated by counting backwards

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12
Q

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

A

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

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13
Q

What are the four main Parkinson’s plus syndromes?

A

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

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14
Q

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

A

DAT scan

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15
Q

Outline the management of Parkinson’s disease.

A 
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)
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16
Q

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

A 
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)
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17
Q

List some side-effects of L-DOPA.

A 
Tardive dyskinesia
Acute dystonia 
On-off phenomena 
Psychosis 
Dry mouth 
Daytime sleepiness
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18
Q

What are the main features of multiple system atrophy

A

Autonomic dysfunction (postural hypotension)
Parkinsonism
Cerebellar ataxia

NOTE: Shy Drager syndrome is when the autonomic features predominate

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19
Q

What are the main features of progressive supranuclear palsy?

A

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

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20
Q

What are the main features of corticobasal degeneration?

A

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

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21
Q

What are the main features of Lewy Body dementia?

A

Dementia
Visual hallucinations
Fluctuating consciousness
Parkinsonism

22
Q

What are the main features of vascular parkinsonism?

A

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

23
Q

List some differentials for a tremor.

A

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

24
Q

What are some key features of a benign essential tremor?

A 
Autosomal dominant 
Occurs with movement 
Worse when anxious or with caffeine 
Doesn't occur during sleep 
Better with alcohol
25
Q

What are the main features of cerebellar pathology?

A 
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)

26
Q

List some causes of cerebellar disease.

A 
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)

27
Q

What are the key features of a cerebellar vermis lesion?

A

Ataxic trunk and gait

Normal arms

28
Q

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

A

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

29
Q

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

A

Occlusion of PICA or vertebral artery

NOTE: it is the most common brainstem vascular syndrome

30
Q

What are the main features of lateral medullary syndrome?

A

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

31
Q

What are the features of cerebellopontine angle syndrome?

A

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

32
Q

What are the main features of von Hippel Lindau syndrome?

A 
Renal cysts
Bilateral renal cell carcinoma 
Haemangioblastoma (often cerebellar)
Phaeochromocytoma 
Islet cell tumours
33
Q

What is Friedreich ataxia caused by?

A

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

34
Q

What are the main features of Friedreich ataxia?

A

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

35
Q

What are the main features of ataxia telangiectasia?

A

Progressive ataxia
Telangiectasia (conjunctivae, eyes, nose)
Propensity for infections
Lymphoproliferative disease

NOTE: it is an autosomal recessive disease with onset in childhood/early adulthood

36
Q

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

A 
Increased tone
Pyramidal distribution of weakness (LEG: extensors stronger than flexors; ARMS: flexors stronger than extensors)
Hyperreflexia
Extensor plantars
Weakness
Pronator drift
37
Q

List some causes of bilateral lower limb spastic paraparesis.

A 
Multiple sclerosis 
Cord compression/trauma
Cerebral palsy 
Aortic dissection 
Syringomyelia
38
Q

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

A

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

39
Q

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

A

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

40
Q

List some causes of cord compression.

A

Trauma (vertebral fracture)
Infection (epidural abscess, TB)
Malignancy
Disc prolapse

NOTE: MRI is the investigation of choice

41
Q

What are the main features of cauda equina syndrome?

A 
Back pain
Radicular pain down the legs 
Bilateral flaccid, areflexic lower limb weakness 
Saddle anaesthesia 
Urinary/faecal incontinence/retention 
Lax anal tone
42
Q

What are the cardinal signs of syringomyelia?

A

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

43
Q

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

A

Bamford classification

44
Q

What are the features of a total anterior circulation stroke?

A

Hemiparesis and/or hemisensory deficit
Homonymous hemianopia
Higher cortical dysfunction (dominant: aphasia, non-dominant: neglect/apraxia)

NOTE: this affects carotid/MCA and ACA territory

45
Q

What are the features of a partial anterior circulation stroke?

A

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

46
Q

What are the features of a posterior circulation stroke?

A 
Cerebellar syndrome (DANISH)
Brainstem syndrome (cranial nerves - facial weakness, nystagmus, dysphagia, dysarthria)
Homonymous hemianopia

NOTE: affects the vertebrobasilar territory

47
Q

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

A 
Pure motor (posterior limb of internal capsule)
Pure sensory (posterior thalamus) 
Mixed sensorimotor (internal capsule) 
Dysarthria
Ataxia hemiparesis (anterior limb of internal capsule)
48
Q

List some stroke mimics.

A 
Space-occupying lesion
Head injury
Hyper/hypoglycaemia 
Infection (encephalitis, meningitis)
Drugs (e.g. opiates)
49
Q

Outline the typical first presentation of multiple sclerosis.

A

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)

50
Q

Which investigations may be used in suspected multiple sclerosis?

A

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

YEAR 6: PACES (22 decks)

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