Medicine 3 Flashcards
What are the three main types of graft rejection and how are they different?
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
What are the main side effects of ciclosporin?
Nephrotoxic
Gingival hypertrophy
Hypertrichosis
Hepatic dysfunction
What are the main side effects of tacrolimus?
Nephrotoxic (less than ciclosporin)
Diabetogenic
Cardiomyopathy
Neurotoxic (peripheral neuropathy)
List some complications of dialysis.
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)
What is an AV fistula and how are they made?
Surgically created connection between an artery and a vein
- Radio-cephalic at wrist (Cimino-Brescia)
- Brachio-cephalic at elbow
What are the advantages and disadvantages of AV fistulas?
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)
List some complications of AV fistulas.
Thrombosis and stenosis Infection Bleeding Aneurysm Steal syndrome (reduced pulses, pallor, necrosis)
List some causes of chronic renal failure.
Diabetes mellitus Hypertension Renal artery stenosis (mainly due to atherosclerosis) Glomerulonephritis Connective tissue disease (SLE, SS, RA) Polycystic disease Drugs Pyelonephritis Multiple myeloma
What are the components of a renal screen?
Fasting blood glucose/HbA1c
ESR
Immune: ANA, complement, anti-GBM, ANCA, viral serology
Serum protein electrophoresis
List some complications of chronic renal failure.
Cardiovascular disease Renal osteodystrophy (osteomalacia, osteporosis) Fluid overload Hypertension Electrolyte imbalance (hyperkalaemia, acidosis) Anaemia Restless legs Sensory neuropathy
Describe the type of tremor seen in the early stage of Parkinson’s disease.
Asymmetrical resting tremor (5 Hz)
Exacerbated by counting backwards
Aside from inspecting and assessing tone in the arms, what else should be done when assessing a patient with Parkinson’s disease?
Check eye movements (nystagmus, vertical gaze palsy, saccades)
Glabellar tap
Gait
Write a sentence (micrographia)
Lying-standing BP (autonomic dysfunction)
What are the four main Parkinson’s plus syndromes?
Progressive supranuclear palsy
Multiple system atrophy
Dementia with Lewy bodies
Corticobasilar degeneration
Which type of scan is used to diagnose Parkinson’s disease?
DAT scan
Outline the management of Parkinson’s disease.
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)
What are the main clinical features of Parkinson’s disease?
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)
List some side-effects of L-DOPA.
Tardive dyskinesia Acute dystonia On-off phenomena Psychosis Dry mouth Daytime sleepiness
What are the main features of multiple system atrophy
Autonomic dysfunction (postural hypotension)
Parkinsonism
Cerebellar ataxia
NOTE: Shy Drager syndrome is when the autonomic features predominate
What are the main features of progressive supranuclear palsy?
Vertical gaze palsy
Pseudobulbar palsy (speech and swallowing problems)
Postural instability
Parkinson’s disease (symmetrical, usually no tremor)
What are the main features of corticobasal degeneration?
Unilateral parkinsonism (especially rigidity)
Aphasia
Apraxia
Alien hand syndrome (can’t control one hand)
What are the main features of Lewy Body dementia?
Dementia
Visual hallucinations
Fluctuating consciousness
Parkinsonism
What are the main features of vascular parkinsonism?
Sudden-onset
Worse in legs than arms
Pyramidal signs
Prominent gait abnormality
List some differentials for a tremor.
Resting: parkinsonism
Intention: cerebellar
Postural (worse when arms outstretched): benign essential tremor, hyperthyroidism, alcohol withdrawal,
What are some key features of a benign essential tremor?
Autosomal dominant Occurs with movement Worse when anxious or with caffeine Doesn't occur during sleep Better with alcohol
What are the main features of cerebellar pathology?
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)
List some causes of cerebellar disease.
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)
What are the key features of a cerebellar vermis lesion?
Ataxic trunk and gait
Normal arms
What are the main differences between nystagmus caused by cerebellar pathology and vestibular pathology?
Cerebellar: fast phase towards lesion, maximal when looking towards lesion
Vestibular: fast phase away from lesion, maximal looking away from lesion
What is lateral medullary syndrome (Wallenberg syndrome) caused by?
Occlusion of PICA or vertebral artery
NOTE: it is the most common brainstem vascular syndrome
What are the main features of lateral medullary syndrome?
Ipsilateral anaesthesia or the face
Contralateral anaesthesia of the body (pain and temp)
Cerebellar signs: dysphagia, ataxia, nystagmus, vertigo
What are the features of cerebellopontine angle syndrome?
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
What are the main features of von Hippel Lindau syndrome?
Renal cysts Bilateral renal cell carcinoma Haemangioblastoma (often cerebellar) Phaeochromocytoma Islet cell tumours
What is Friedreich ataxia caused by?
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
What are the main features of Friedreich ataxia?
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
What are the main features of ataxia telangiectasia?
Progressive ataxia
Telangiectasia (conjunctivae, eyes, nose)
Propensity for infections
Lymphoproliferative disease
NOTE: it is an autosomal recessive disease with onset in childhood/early adulthood
What are the main upper motor neurone signs seen on examination?
Increased tone Pyramidal distribution of weakness (LEG: extensors stronger than flexors; ARMS: flexors stronger than extensors) Hyperreflexia Extensor plantars Weakness Pronator drift
List some causes of bilateral lower limb spastic paraparesis.
Multiple sclerosis Cord compression/trauma Cerebral palsy Aortic dissection Syringomyelia
List some causes of mixed upper and lower motor neurone signs.
Motor neurone disease (ALS)
Friedreich ataxia
Subacute combined degeneration of the spinal cord (B12)
Describe the pattern of UMN/LMN signs in cord compression.
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
List some causes of cord compression.
Trauma (vertebral fracture)
Infection (epidural abscess, TB)
Malignancy
Disc prolapse
NOTE: MRI is the investigation of choice
What are the main features of cauda equina syndrome?
Back pain Radicular pain down the legs Bilateral flaccid, areflexic lower limb weakness Saddle anaesthesia Urinary/faecal incontinence/retention Lax anal tone
What are the cardinal signs of syringomyelia?
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
Which classification system is used to identify the part of the cerebral circulation affected by a stroke?
Bamford classification
What are the features of a total anterior circulation stroke?
Hemiparesis and/or hemisensory deficit
Homonymous hemianopia
Higher cortical dysfunction (dominant: aphasia, non-dominant: neglect/apraxia)
NOTE: this affects carotid/MCA and ACA territory
What are the features of a partial anterior circulation stroke?
2/3 of the TACS criteria (usually homonymous hemianopia and higher cortical dysfunction)
What are the features of a posterior circulation stroke?
Cerebellar syndrome (DANISH) Brainstem syndrome (cranial nerves - facial weakness, nystagmus, dysphagia, dysarthria) Homonymous hemianopia
NOTE: affects the vertebrobasilar territory
How do lacunar infarcts manifest and how does it relate to the part of the brain affected?
Pure motor (posterior limb of internal capsule) Pure sensory (posterior thalamus) Mixed sensorimotor (internal capsule) Dysarthria Ataxia hemiparesis (anterior limb of internal capsule)
List some stroke mimics.
Space-occupying lesion Head injury Hyper/hypoglycaemia Infection (encephalitis, meningitis) Drugs (e.g. opiates)
Outline the typical first presentation of multiple sclerosis.
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)
Which investigations may be used in suspected multiple sclerosis?
MRI (gadolinium-enhanced will show areas of active inflammation)
LP (oligoclonal bands)
Antibodies (anti-MBP)
Visual evoked potentials (optic neuritis)
