Medicine 6 Flashcards
What are some key things that you should do when examining a patient with acromegaly?
Shake the patient’s hand feeling for doughy consistency and excessive sweating
Check blood pressure
Dipstick urine for glycosuria
Visual field testing for bitemporal hemianopia
Look at tongue and teeth
Examine cardiovascular system if time
Key questions: change in ring size, change in shoe size, changes in vision, ask for old photographs
How is acromegaly investigated?
IGF-1 levels
Glucose tolerance test and measure GH levels (should be undetectable in normal people)
Imaging: lateral skull X-ray, CT, MRI
What are the treatments for acromegaly?
Transphenoidal hypophysectomy
Pituitary irradiation
Medical (octreotide 100-200 mcg every 8 hours OR lanreotide monthly)
What are some key things that you should do when examining a patient with Cushing syndrome?
Examine face and skin looking for bruising and thin skin
Check blood pressure
Urine dipstick for glycosuria
Look for proximal myopathy (squat down and stand up) and abdominal striae
What are the main causes of Cushing syndrome?
Iatrogenic (exogenous steroids) - MOST COMMON
Pituitary adenoma (next most common)
Adrenal adenoma
Ectopic ACTH (small cell lung cancer)
Outline the treatment of Paget’s disease.
May not need treatment
Simple analgesia
IV pamidronate every 3 months (mainstay)
Regular oral alendronate
What are the main differences between the CSF findings of bacterial and viral meningitis?
Viral: clear, lymphocytes, normal glucose, normal/high protein
Bacteria: cloudy, neutrophils, low glucose, high protein
Which medication reduces vasospasm in subarachnoid haemorrhage?
Nimodipine
Describe the difference in the pathogenesis of pupil-sparing and non-pupil sparing 3rd nerve palsy.
Pupil-sparing: caused by diabetes mellitus, where damage to the vasa vasorum supplying the main trunk of the 3rd nerve causes ischaemia (but sparing of surrounding parasympathetic fibres)
NON-pupil sparing: caused by space occupying lesions (e.g. posterior communicating artery aneurysm) which put pressure on the parasympathetic fibres and the main trunk causing dilatation
Which key examinations should you do in a patient with suspected MS?
Fundoscopy - check for optic neuritis
RAPD
Check for UMN signs in other parts of the body
Check for cerebellar signs (cerebellum is often affected)
What causes clonus?
Hugely increased muscle tone (i.e. UMN sign)
List some poor prognostic features of MS.
Brainstem or cerebellar disease at onset
Onset over age of 40 years
Primary progressive MS
What are the main features of neurofibromatosis type 1?
Multiple (>5) cafe au lait patches Axillary or inguinal freckling Optic glioma Lisch nodules (hamartomas on iris) Other: meningioma, phaeochromocytoma, kyphoscoliosis, renal artery stenosis
NOTE: it is autosomal dominant (Chr17)
List some causes of lower motor neurone signs.
Motor neurone disease (also causes UMN signs)
Previous polio (destroys anterior horn cells)
Guillain-Barre syndrome
Peripheral nerve lesion (e.g. trauma around fibula causing footdrop)
List some causes of upper motor neurone signs.
Stroke
Multiple sclerosis
Brain tumour
Damage to spinal cord
What is a passive shoulder shrug used for?
Loss of swing of an arm is a sign of rigidity
This may be due to Parkinson’s disease or UMN lesion
What does a positive Romberg sign suggest?
The patient is heavily dependent on vision for balance (sensory ataxia)
i.e. proprioception in the feet is impaired (peripheral neuropathy)
What is an easy way of testing L4/5 and S1/2?
L4/5 - ask the patient to stand and raise their toes off the ground (like a penguin)
What gait abnormality would you expect to see in a patient with an UMN lesion?
Drags legs
Circumducts (unilatearl) or scissors (bilateral)
What gait abnormality would you expect to see in peripheral motor neuropathy?
Foot drop (high step)
What gait abnormality would you expect to see in patients with myopathy?
Waddling
Difficulty standing/squatting
Trendelenberg sign
What gait abnormality would you expect to see in patients with cerebellar disorders?
Ataxic - broad-based, variable cadence
What would an ataxic gait due to sensory impairment look like?
Broad-based
Stamping
Romberg sign positive
What gait abnormality would you expect to see in Parkinson’s disease?
Reduced arm swing
Stooped, shuffling gait
Freezing
Festination
Outline the MRC scale for grading muscle power.
0 - no movement 1 - flicker in muscle 2 - moves but not against gravity 3 - can overcome gravity 4 - weak but can overcome gravity 5 - normal
List the main reflexes tested in a limb neurological exam and the nerve roots involved.
Biceps (C5/6) Brachioradialis (C6) Triceps (C7/8) Knee (L3/4) Ankle (S1/2)
List some niche reflexes that you may be able to elicit in patients with upper motor neurone lesions.
Finger jerks
Hoffman reflex
Crossed adductors
Absent abdominal reflexes
Which sensory nerve is responsible for sensation at the nipple and belly button?
Nipple: C5/6
Belly Button: T10
NOTE: with cord lesions that cause a sensory loss up to a certain level - the level of the sensory loss is the lowest level the cord lesion could be at. Pain is a better sign for localising the lesion.
What is the difference in the pattern of neurological symptoms in extrinsic vs intrinsic compression of the spinal cord?
Extrinsic (disc prolapse): rising sensory level (hitting the outer most fibres first)
Intrinsic (syringomyelia): descending sensory level and may affect pain (hitting inner most fibres first)
At what level does the spinal cord end?
L1
Lesions below this will produced LMN signs
What are the main aspects of testing the cranial nerves involving the eyes?
Visual acuity Visual fields Pupillary responses Fundoscopy Eye movements
What conclusions can you draw from looking at the shoes of a neurology patient?
Laces - likely to be good upper limb function
Shoes are worn - the patient is walking
Shoes worn at the lateral front edges from circumducting legs (likely UMN lesion)
Shoes worn at the front - foot drop
Both shoes worn - bilateral problem
List some causes of ascending aorta aneurysms.
Aortic stenosis (post-stenotic dilatation)
Hypertension
Marfan syndrome
Syphilis
What does obscuring of the right heart border suggest?
Right middle lobe pathology
What does obscuring of the left heart border suggest?
Left upper lobe pathology (lingula)
List some causes of lobar collapse.
Mucus plugs in bronchiectasis
Tumour blocking the airway
Foreign body inhalation
Which cancers have a predilection for spreading to the lungs?
Breast
Renal
Thyroid
Choriocarcinoma
What is the difference between a mass and a nodule in terms of CXR interpretation?
Nodule < 3 cm
Mass > 3 cm
What is an important differential to consider in a CXR that looks like a pneumothorax?
Giant bulla
DO NOT PUT CHEST DRAIN IN
What is the 10-day rule with regards to using ionising radiation in women?
In women of child-bearing age, imaging of the abdomen/pelvis using ionising radiation should be restricted to the 10 days following the onset of menstruation (i.e. day 1-10 of the menstrual cycle)
NOTE: this can be overridden if their life is in danger
Outline the treatment of acute otitis externa and otitis media.
Otitis externa: topical antibiotics (e.g. sofradex)
Otitis media: 7-10 day course of amoxicillin
Mastoiditis: surgical decompression (cortical mastoidectomy)
NOTE: mastoiditis can lead to meningitis, facial nerve palsy, brain abscess and death
Outline the treatment of sudden sensorineural hearing loss.
Steroids (high dose)
Anti-virals (aciclovir)
Intratympanic steroid injections
How is facial nerve palsy treated?
High dose oral steroids (40-60 mg prednisolone)
Aciclovir 800 mg 5 per day
How is BPPV treated?
Epley manoeuvre
NOTE: it is tested for using the Dix-Hallpike manoeuvre
List some causes of vertigo.
Meniere's disease Acoustic neuroma Trauma Migraine Central causes (CVA, cerebellar tumour)
How is bacterial tonsillitis treated?
Penicillin V 500 mg QDS for 10 days
List some symptoms of quinsy.
Trismus Hot potato voice Anorexia Spiking fever Stiff neck Stertor
NOTE: needs drainage
What can cause a loud second heart sound?
Pulmonary or systemic hypertension
How is bronchial breathing different from vesicular breathing?
Vesicular: crescendo-decrescendo with no gap, inspiration longer than expiration
Bronchial: expiration same duration as inspiration with a gap in the middle
What does a low TLCO or Kco suggest?
Damage to lung parenchyma (e.g. fibrosis, emphysema)
NOTE: they are both a measure of the diffusion capacity of the lungs (TLCO is not adjusted for volume, Kco is adjusted for volume)
