Medicine PACES Flashcards
List the cardiac causes of clubbing.
Infective endocarditis
Congenital cyanotic heart disease
Atrial myxoma
What causes the four heart sounds?
S1: mitral valve closure
S2: aortic valve closure
S3: rapid ventricular filling of dilated left ventricle
S4: atrial contraction against stiff ventricle
What murmur is caused by aortic stenosis?
Ejection systolic murmur loudest in the right 2nd ICS heart best when sitting forward and in end expiration
Radiates to the carotids
Soft S2 and presence of S4 indicates severity
How does aortic sclerosis differ from aortic stenosis on examination?
No radiation to the carotids
Normal pulse character
NOTE: HOCM is another differential for an ejection systolic murmur
List some causes of aortic stenosis.
Senile calcification
Bicuspid aortic valve (2% of population)
Rheumatic heart disease
What are the main symptoms of severe aortic stenosis?
Syncope
Angina
Dyspnoea (this carries worst prognosis)
List the echocardiogram features of severe aortic stenosis.
Pressure gradient > 40 mm Hg
Valve area < 1 cm^2
Jet velocity > 4 m/s
Outline the management of aortic stenosis.
General: MDT, optimise cardiovascular risk, monitor with regular follow-up/echos, treat angina (BB) and heart failure (ACEi + BB)
Surgical valve replacement
TAVI (effective in older/frail patients who are not fit for open repair)
Balloon valvuloplasty is an alternative to TAVI (NOTE: effect reduces after 1 year)
What are the benefits of TAVI compared to open repair?
Heart does not need to be stopped and heart-lung bypass is not necessary
Avoids large thoracotomy scar
Less strain on body (so better for frail patients)
NOTE: it is associated with a higher risk of stroke
What murmur is caused by mitral regurgitation?
Pansystolic murmur heard loudest at the apex in the left lateral position at end-expiration
Radiates to the axilla
What are some clinical signs of mitral regurgitation?
Displaced apex
Apical thrill
Quiet S1
Pansystolic murmur radiating to the axilla
S3 (rapid ventricular filling)
Look for valvulotomy scar
List some causes of mitral regurgitation.
LV dilatation (e.g. hypertension, connective tissue disorders)
Annular calcification
Rheumatic heart disease
Mitral valve prolapse
What are some echocardiogram features of severe mitral regurgitation?
Regurgitant volume > 60 mL
Systolic pulmonary flow reversal
Outline the management of mitral regurgitation.
General: MDT, risk factor modification
AF - rate control and anticoagulation
Reduce afterload (ACEi, BB, diuretics)
Valve replacement (if symptomatic)
What murmur is caused by aortic regurgitation?
High-pitched early diastolic murmur loudest at the lower left sternal edge when sitting forward in end-expiration
NOTE: can cause Austin-Flint murmur (rumbling mid-diastolic murmur due to regurgitant blood hitting the mitral valve)
List some causes of aortic regurgitation.
Bicuspid aortic valve
Rheumatic heart disease
Ankylosing spondylitis
Rheumatoid arthritis
Connective tissue disease (Marfan’s, Ehlers-Danlos)
Infective endocarditis
Type A aortic dissection
Outline the management of aortic regurgitation.
General: MDT, risk factor modification
Reduce afterload (ACEi, BB, diuretics)
Surgical valve replacement (if symptomatic or LV dysfunction)
What murmur does mitral stenosis cause?
Loud S1 (opening snap) and rumbling mid-diastolic murmur heard loudest at the apex in the left lateral position in end-expiration with the bell
Radiates to the axilla
What are some signs of mitral stenosis?
Malar flush (severe)
AF
Tapping apex beat (palpable first heart sound)
NON-displaced apex beat
Right ventricular heave
Blowing mid-diastolic murmur with presystolic accentuation (if not in AF)
NOTE: tends to be middle-aged women who had rheumatic fever in childhood
List some causes of mitral stenosis.
Rheumatic heart disease (MOST COMMON)
Senile degeneration
Endocarditis
Congenital
Outline the management of mitral stenosis.
Consider rheumatic fever prophylaxis (pen V)
AF rate control and anticoagulation
Surgical: percutaneous balloon valvuloplasty (FIRST LINE provided valve mobile and not calcified)
Alternative: valvotomy or replacement
NOTE a TOE to check for a left atrial mural thrombus should be performed before intervention
What is the Duckett-Jones criteria for rheumatic heart disease?
MAJOR
- joints (arthritis)
- carditis
- nodules subcutaneous
- erythema marginatum
- Sydenham’s chorea
MINOR
- Fever
- High ESR or CRP
- Arthalgia
- Prolonged PR interval
- Previous rheumatic fever
Rheumatic heart disease if 2 major or 1 major + 2 minor
Outline the management of rheumatic fever.
Bed rest
Ben pen 1.2 mg IM for 10 days
Analgesia for carditis/arthritis: aspirin/NSAIDs
Consider oral prednisolone if CCF
Consider diazepam for chorea
Outline the secondary prevention of rheumatic fever.
900 mg Benzathine benzylpenicillin every 3-4 weeks IM for 10 years
What is the difference between acute and subacute endocarditis?
Acute: normal valves –> caused by S. aureus and S. epidermidis –> RF: IVDU, skin wounds, immunosuppression
Subacute: abnormal valves –> caused by S. viridans, S. bovis, HACEK –> RF: prosthetic valves, damages valves
List some clinical features of infective endocarditis.
Petechiae (common)
Splenomegaly (common)
Clubbing
Splinter haemorrhages
Janeway lesions
Osler’s nodes
Fever
Roth spots
Haematuria
Which murmurs are most commonly associated with infective endocarditis?
Mitral regurgitation
Aortic regurgitation
Outline the Duke criteria for infective endocarditis.
MAJOR
- +ve blood culture (typical organism in 2 cultures or persistently positive cultures)
- endocardial involvement (positive echo (e.g. vegetation), new valvular regurgitation)
MINOR
- predisposition (cardiac lesion, IVDU)
- fever
- emboli (e.g. Janeway lesions)
- immune phenomena (e.g. Osler’s nodes)
- +ve blood culture not meeting major criteria
For diagnosis: 2 major OR 1 major + 3 minor OR 5 minor
Outline the management of infective endocarditis.
Acute Severe: flucloxacillin/vancomycin + gentamicin IV
Subacute: benzylpenicillin + gentamicin IV
What might you see on general inspection of a patient with a valve replacement?
Audible valve click
Bruising (anticoagulation)
Warfarin alert bracelet
Anaemia
Midline sternotomy (CABG, open valve replacement) +/- saphenous vein sampling
Neck scars from line insertion
Femoral/radial scars from angiography
Name three different types of prosthetic valve.
Starr-Edwards - 3 artificial sounds
Tilting disc (Bjork-Shiley) or bileaflet (St. Jude) - 1 artificial sound
Bioprosthetic - normal heart sounds
NOTE: bileaflet valves are most commonly used
How might mitral valve replacements sound different from aortic valve replacements?
Aortic: Lub-Click (systolic flow murmur)
Mitral: Click-Dub (diastolic flow murmur)
What might a lateral thoracotomy scar be due to?
Mitral valve replacement
Mitral valvotomy
Coarctation repair
Blalock-Taussig shunt
What might leave a subclavicular scar in cardiology?
Pacemaker
ICD
What is a scar in the antecubital fossa of a cardiology patient suggestive of?
Angoigraphy
Which cardiothoracic procedures may be done through a midline sternotomy?
CABG
Aortic valve replacement
Mitral valve replacement
Outline the factors considered when deciding on a type of valve replacement.
METAL: durable, needs lifelong warfarin, better for young patients or patients who are already on warfarin (e.g. for AF)
PORCINE: less durable (10 years), no need for warfarin, better for elderly/at risk of haemorrhage
NOTE: porcine also known as Carpentier-Edwards valves
List some complications of valve replacement.
Thromboembolus
Bleeding (due to warfarin)
Bioprosthetic dysfunction and LVF (usually within 10 years but can be treated percutaneously by valve in valve)
Haemolysis
Infective endocarditis (S. viridans, S. epidermidis)
Atrial fibrillation (particularly mitral valve replacement)
How can any murmur be made louder in a patient?
Make them exercise
List some causes of atrial fibrillation.
Ischaemic heart disease
Valvular pathology (mainly mitral)
Rheumatic heart disease
Thyrotoxicosis
Pneumonia
PE
Post-op
Electrolytes (e.g. hypokalaemia)
Alcohol
Which investigations are useful for identifying a cause of AF?
FBC (infection)
U&E (K+)
TFTs (hyperthyroid)
Troponin
D-dimer
CXR (pulmonary oedema, pneumonia, calcified mitral valve)
Echo (valve pathology, LV function)
NOTE: important differential is multiple ventricular ectopics
How can ventricular ectopics be clinically distinguished from AF?
Exercise the patient
AF: pulse remains irregularly irregular
VE: as heart rate increases, pulse becomes regular (closes the window for ventricular ectopics)
What is the difference between paroxysmal, persistent and permanent AF?
Paroxysmal: < 7 days and self-terminates
Persistent: > 7 days and requires cardioversion
Permanent: > 1 year or when no further attempts to rhythm control are made
What CHADS-Vasc score requires warfarinisation?
1 or more
How should a patient with acute AF presenting < 48 hours of onset be managed?
1st line: rhythm control (DC cardioversion or chemical cardioversion (flecainide or amiodarone))
Start LMWH
Rate control (BB, CCB, digoxin)
NOTE: rhythm control is first line in younger patients, first episode AF and when there is an obvious precipitant to the AF
Which medications should be used in the management of paroxysmal AF?
Prevention: bisoprolol or sotalol
Pill in the pocket: flecainide or amiodarone
How should patients presenting more than 48 hours after the onset of AF be managed?
3 weeks of warfarin (and rate control) before cardioversion
Can be done earlier if a TOE excludes a mural thrombus
List some contraindications of warfarin.
Bleeding tendency
Compliance issues (dosing/monitoring)
Risk of falls
Peptic ulcer disease
Pregnancy
List some complications of warfarin.
Bleeding
Osteoporosis
List some indications for permanent pacing.
Complete AV block
Mobitz type 2
Symptomatic bradycardia
Drug-resistant tachyarrhythmias
Biventricular pacing in chronic heart failure
What do the three letters in naming pacemakers mean?
1st: chamber paced (A, V, D)
2nd: chamber sensed (A, V, D)
3rd: response (inhibited, triggered, dual)
E.g. VVI: paces the ventricle but also senses intrinsic ventricular activity which would inhibit a pacing output
What are biventricular pacemakers used for?
Leads to both ventricles
Used for cardiac resynchronisation therapy in heart failure
NOTE: this aims to maximise the pumping action of the heart
List some complications of pacemakers.
Insertion:
- Bleeding
- Arrhythmia
Post-Insertion:
- Erosion
- Lead migration
- Pocket infection
- Malfunction
List some causes of heart failure.
LEFT: ischaemic heart disease, dilated cardiomyopathy, hypertension, mitral and aortic valve disease
RIGHT: LVF, cor pulmonale, tricuspid and pulmonary valve disease
Which main investigations are used in heart failure?
Blood test - BNP, FBC, U&E, glucose, urine
CXR - heart size, lung fields
ECG - rhythm, ischaemia, LVH
Echo - valves, ventricular function
Lipid and BP
Outline the management of chronic heart failure.
Risk factor modification
1st line: Beta-blocker + ACE inhibitor + loop diuretics (e.g. frusemide)
2nd line: add spironolactone
3rd line: consider digoxin
4th line: consider CRT
Final line: heart transplant
What cardiovascular signs should you check for in a patient with COPD?
Cor pulmonale
Raised JVP
Left parasternal heavy (RVH)
Tricuspid regurgitation
Ascites and pulsatile hepatomegaly
Peripheral oedema
What spirometry results would you expect to see in COPD?
Reduced FEV1
Low FEV1/FVC ratio (< 0.7)
Increased total lung capacity and residual volume
NOTE: bronchiectasis also gives an obstructive pattern
Which treatments can be offered to help people with COPD to stop smoking?
Specialist nurse and support programme
Nicotine replacement programme
Varenicline (partial nicotinic acetylcholine receptor agonist) and bupropion (noradrenaline-doparmine reuptake inhibitor)
List some causes of interstitial lung disease.
UPPER
- aspergillosis
- pneumoconiosis
- extrinsic allergic alveolitis
- TB
LOWER
- sarcoidosis
- toxins (amiodarone, nitrofurantoin, methotrexate, sulfasalazine, bleomycine)
- asbestosis
- idiopathic
- rheumatological (RA, SLE, systemic sclerosis)
What is the imaging modality of choice for interstitial lung disease?
High resolution CT
What spirometry results would you expect to see in a patient with pulmonary fibrosis?
FEV1: FVC ratio > 0.8
Low TLC
Low RV
Low FEV1 and FVC
What would you expect to hear on auscultation of the chest in a patient with bronchiectasis?
Coarse, wet crackles which may change once the patient coughs
May also hear a wheeze
Coughing may clear the wheeze if it is due to a mucus plug
ALSO: clubbing, copious sputum, features of cor pulmonale (raised JVP, loud P2)
List some causes of bronchiectasis.
ACQUIRED
Idiopathic (50%)
Post-infectious (pertussis, TB, measles)
Obstruction (tumour, foreign body)
Associated (RA, IBD, ABPA)
CONGENITAL
Cystic fibrosis
Kartagener’s syndrome
Young’s syndrome
Hypogammaglobulinaemia (CVIS, Bruton’s X-linked)
What are some causes of a transudative pleural effusion?
Congestive cardiac failure
Renal failure
Liver failure (hypoalbuminaemia)
Hypothyroidism
Meig syndrome
What are some causes of an exudative pleural effusion?
Infection (e.g. pneumonia)
Cancer
Inflammation (RA, SLE)
Infarction (e.g. PE)
Trauma
What are Light’s criteria for an exudative pleural effusion?
Effusion: serum protein ratio > 0.5
Effusion: serum LDH ratio > 0.6
Effusion LDH is 0.6 x ULN
Effusion protein < 25 g/L = transudate
Effusion protein > 35 g/L = exudate
Between
What are some complications of Pancoast tumours?
Horner’s syndrome
Recurrent laryngeal nerve palsy
Clawing of the hand and wasting of interossei (due to brachial plexus injury (T1))
List some indications for lobectomy or pneumonectomy.
Non-disseminated bronchial carcinoma (90%)
Bronchiectasis
COPD
TB
NOTE: they both have a relatively high mortality
What are the main types of lung cancer and which is most common?
Non-Small Cell Lung Cancer (80%)
- SCC (35%) - smoking, central, PTHrP
- Adenocarcinoma (25%) - peripheral, less associated with smoking
- Large cell
Small Cell Lung Cancer (20%)
- highly related to smoking, central, ADH/ACTH
Which dermatological conditions are associated with lung cancer?
Acanthosis nigricans
Trousseau syndrome (migratory thrombophlebitis)
Aside from imaging, what other important test needs to be done before a patient is surgically treated for lung cancer?
Pulmonary function tests to assess fitness for surgery
Pneumonectomy is contraindicated if FEV1 < 1.2 L
Which organisms most commonly cause community-acquired, hospital-acquired and aspiration pneumonia?
CAP: pneumococcus, mycoplasma, haemophilus (COPD), chlamydia pneumophila, viruses
HAP: pseudomonas, staph aureus, Gram negative enterobacteriaceae (Klebsiella)
Aspiration: anaerobes
What is a thoracoplasty?
Old treatment for TB which involved surgically removing a rib in order to collapse the part of the lung affected by TB
List the main side-effects of medical TB treatment.
Rifampicin: orange urine, enzyme induction (reduced COCP efficacy), hepatitis
Isoniazid: peripheral neuropathy
Pyrazinamide: hepatitis, arthralgia
Ethambutol: optic neuritis (loss of colour vision)
Describe the different X-ray features of primary TB.
Ghon Focus: primary subpleural lesion
Ghon Complex: hilar lymphadenopathy + lung lesion
Ranke Complex: fibrosis and calcification of Ghon complex
Which investigations are used to diagnose TB?
Latent TB: IGRA assay, tuberculin skin test
CXR
3 x sputum samples (one in morning) - microscopy (Ziehl-Neelsen) and culture on Lowenstein-Jensen
PCR (identify rifampicin resistance)
What are the components of a liver screen?
FBC and LFTs (alcohol, macrocytic anaemia)
Hepatitis serology
Lipids (NASH)
Autoantibodies (ASMA, AMA, pANCA, ANA)
Immunoglobulins (high IgG in autoimmune hepatitis; high IgM in PBC)
Caeruloplasmin, ferritin, A1AT
Cancer (AFP, CA19-9)
What should patients with chronic liver failure be screened for?
Hepatocellular carcinoma: US + AFP
Varices: OGD
What grading system is used for Cirrhosis and what factors does it take into account?
Child-Pugh Grading System
Albumin
Bilirubin
Clotting
Distension (ascites)
Encephalopathy
How can the complications of chronic liver disease be managed?
Ascites: daily wt, fluid and Na restrict, diuretics, tap
Coagulopathy: Vit K, FFP, platelets
Encephalopathy: avoid sedatives, lactulose, rifaximin
Sepsis / SBP: tazocin or cefotaxime
Hypoglycaemia: dextrose
Hepatorenal syndrome: IV albumin + terlipressin
How might hepatic encephalopathy manifest?
Asterixis
Ataxia
Confusion
Dysarthria
Constructional apraxia
Seizures
NOTE: plasma ammonia will be high
How should hepatic encephalopathy be treated?
Lactulose (reduces nitrogen-forming bowel bacteria)
Rifaximin (kills intestinal microflora)
Outline the treatment of spontaneous bacterial peritonitis.
Cefotaxime or tazocin (until sensitivities known)
Long-term ciprofloxacin and beta-blocker (propranolol)
NOTE: diagnosed if > 250 PMN/mm^3 in ascitic fluid. Usual organisms are E. coli, Klebsiella and Streptococci
Outline how SAAG is used to differentiate causes of ascites.
SAAG > 11 g/L
- Cirrhosis
- congestive cardiac failure
SAAG < 11 g/L
- neoplasia
- inflammation
- infection (e.g. TB peritonitis)
- nephrotic syndrome
NOTE: portal hypertension = pressure > 10 mm Hg
Outline the management of ascites.
GENERAL: alcohol abstinence, daily weight, fluid restrict (< 1.5 L), low sodium diet
DIURETICS: spironolactone, add frusemide if poor response
Therapeutic paracentesis with albumin infusion
Refractory ascites: TIPSS, transplant
Prophylactic ciprofloxacin for SBP prevention
List some signs of immunosuppressant use.
Cushingoid (steroids)
Skin tumours (e.g. actinic keratosis, SCC, BCC)
Gingival hypertrophy (ciclosporin)
Hypertension (ciclosporin, tacrolimus)
Fine tremor (tacrolimus)
What are the main indications for a liver transplant?
Cirrhosis
Acute liver failure (e.g. hepatitis A/B, paracetamol overdose)
Malignancy
Which stains should be used on a liver biopsy of a patient with cirrhosis?
Pearl’s stain (iron)
Rhodamine stain (copper)
PAS stain (A1AT)
Apple-green birefringence with Congo Red (amyloidosis)
Check for granulomata
List some differentials for splenomegaly.
Infection: EBV
Haematological: CLL, lymphoma, CML, myelofibrosis, splenic sequestration crisis
Infiltrative: amyloidosis, Gaucher’s disease
Other: malaria, leishmaniasis, portal hypertension, RA, SLE
List some causes of hyposplenism.
Splenectomy
Coeliac disease
Inflammatory bowel disease
Sickle cell disease
NOTE: hyposplenism is managed with immunisations (pneumovax, Hib, men C, annual flu) and daily antibiotics (Pan V or erythromycin)
List some complications of splenectomy.
Redistributive thrombocytosis (leads to VTE)
Gastric dilatation (transient ileus)
Left lower lobe atelectasis
Pancreatitis
Increased susceptibility to infection (encapsulated)
List some differentials for enlarged kidneys.
BILATERAL
- ADPKD
- bilateral RCC
- bilateral cysts (von Hippel Lindau)
- amyloidosis
UNILATERAL
- simple renal cyst
- renal cell carcinoma
- compensatory hypertrophy
What blood test results would you expect to see in a patient with renal failure?
Anaemia
Deranged U&E
Hypocalcaemia, high phosphate, high PTH (secondary hyper PTH)
Which gene most often causes polycystic kidney disease?
PKD1 gene on chromosome 16 (85%)
Remainder caused by PKD2 gene on chromosome 4
NOTE: patients with ADPKD should be screened for Berry Aneurysms with an MRA
List some causes of renal cysts.
Simple renal cysts (present in 1/3 over 60 yrs)
Dialysis-associated renal cysts (increased risk of RCC)
Tuberous sclerosis
Which paraneoplastic phenomenon can result from RCC?
EPO –> polycythaemia
PTHrP –> hypercalcaemia
Renin –> hypertension
ACTH –> Cushing’s syndrome
Amyloidosis
What are the most common indications for renal transplant?
Diabetic nephropathy
Glomerulonephritis
Polycystic kidney disease
Hypertensive nephropathy
Which assessments need to be carried out before renal transplantation?
Virology
Co-morbidities (anaesthetic fitness)
ABO
Anti-HLA antibodies
Haplotype (DR > B > A)
Pre-implantation cross-match
List some complications of renal transplantation.
Bleeding
Graft thrombosis or dysfunction
Infection secondary to immunosuppression (PCP, CMV)
Increased risk of other pathology (skin cancer, post-transplant lymphoproliferative disease, cardiovascular disease)
Recurrence of original disease
Urinary leaks
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)
What is internuclear ophthalmoplegia and what is it caused by?
Caused by damage to the medial longitudinal fasciculus which is responsible for allowing communication between the ipsilateral CN3 (adduction) and contralateral CN6 (abduction).
This leads to failure of adduction of the ipsilateral eye. Nystagmus in the abducting eye may be noted.
It is most commonly caused by multiple sclerosis (and stroke in older patients)
What is the difference between bulbar and pseudobulbar palsy?
Bulbar: lower motor neurone palsy of CN 9 to 12.
Pseudobulbar: upper motor neurone palsy affecting CN 5, 7, 9-12.
Both cause dysphagia and dysarthria but pseudobulbar palsy will also cause lack of facial expression, difficulty chewing and emotional lability.
NOTE: key difference is that bulbar palsy causes LMN signs (e.g. tongue fasciculations) whereas pseudobulbar causes UMN signs (e.g. exaggerated gag reflex)
What are the different types of motor neuron disease?
Amyotrophic lateral sclerosis (50%) - UMN and LMN signs
Primary lateral sclerosis - mainly UMN signs (spastic leg weakness and pseudobulbar palsy)
Progressive bulbar palsy - only affects CN 9-12
Progressive muscular atrophy - LMN signs only, affects distal to proximal (best prognosis)
List some lower motor neurone signs.
Muscle wasting
Fasciculations
Hypotonia
Hyporeflexia
List some causes of LMN signs.
DISTAL: Charcot-Marie-Tooth disease, paraneoplastic, lead poisoning, GBS, botulism
PROXIMAL: muscular dystrophy, myositis, Cushing’s, thyrotoxicosis, diabetic amyotrophy, alcohol
UNILATERAL: polio, mononeuropathy
List some causes of peripheral sensory neuropathy.
Diabetes mellitus
Alcohol abuse
B12 deficiency
Chronic renal failure
Hypocalcaemia
Vasculitis
Drugs (e.g. isoniazid)
What features of diabetic neuropathy can be seen in the lower limbs?
Distal sensory loss (gloves and stockings)
Bilateral loss of ankle jerk (due to sensory neuropathy)
Mononeuritis multiplex (foot drop)
List some manifestations of autonomic neuropathy in diabetes mellitus.
Postural hypotension
Gastroparesis
Diarrhoea
Urinary retention
Erectile dysfunction
List the main features of Charcot-Marie-Tooth disease.
Pes cavus
Symmetrical distal muscle wasting (claw hand, champagne bottle led)
Thickened nerves
High stepping gait
Weak foot and toe dorsiflexion
Absent ankle jerk
Variable loss of sensation
List some differentials for bilateral ptosis.
Myasthenia gravis
Myotonic dystrophy
Congenital
Senile
Bilateral Horner’s (RARE)
Describe the typical presentation of Guillain-Barre syndrome.
Symmetrical ascending flaccid paralysis and sensory disturbance (paraesthesia)
Can cause autonomic neuropathy (labile BP)
NOTE: Miller-Fisher variant is characterised by ophthalmoplegia, ataxia and areflexia
Which muscles are weak in a facial nerve palsy?
Fronatlis (raising eyebrows)
Orbicularis oculi (scrunching eyes)
Orbicularis oris (smiling)
NOTE: UMN lesion spares frontalis and orbicularis oculi - if UMN then it may be due to a stroke so do other neuro exams
List some causes of facial nerve palsy.
Idiopathic (Bell’s palsy) - 75%
Vascular (stroke)
Multiple sclerosis
Space-occupying lesion
Vestibular schwannoma
Meningioma
Ramsay-Hunt syndrome
Parotid tumour
Sarcoidosis
Lyme disease
NOTE: patients may complain of hyperacusis due to paralysis of stapedius and aguesia (loss of taste)
What causes Ramsay-Hunt syndrome?
Reactivation of VZV in the geniculate ganglion of CN7
List some causes of Horner’s syndrome.
Multiple sclerosis
Pancoast tumour
Trauma (central line, carotid endarterectomy)
Cavernous sinus thrombosis
What are the main features of oculomotor nerve palsy?
Ptosis (LPS)
Eye points down and out (unopposed superior oblique and lateral rectus)
Dilated pupils
May have ophthalmoplegia and diplopia
List some causes of third nerve palsy.
MEDICAL: mononeuritis (DM), MS, midbrain infarction, migraine
SURGICAL: raised ICP (transtentorial herniation), cavernous sinus thrombosis, posterior communicating artery aneurysm
What is a Holmes-Adie pupil?
Dilated pupil with no response to light and sluggish response to accommodation
Benign condition, more common in females
Also known as myotonic pupil and usually presents with sudden-onset blurred vision. Aetiology unknown.
What are Argyll-Robertson pupils?
Small, irregular pupils
Accommodation intact
Reaction to light is lost
Atrophied and depigmented iris
Causes include neurosyphilis and DM (lesion in pretectal lesion)
What is an RAPD (Marcus Gunn pupil)?
Minor constriction to direct light
Dilatation when moving light to abnormal light (due to defect in the afferent pathway)
List some causes of RAPD.
Optic neuritis (MS)
Ischaemic optic/renal disease (central retinal artery occlusion)
Severe glaucoma
Direct optic nerve damage (trauma, tumour)
Retinal detachment (diagnosed with ultrasound B scan)
Severe macular degeneration
Retinal infection (CMV, herpes)
List some features of optic atrophy.
Reduced visual acuity
Reduced colour vision
Central scotoma
Pale optic disc
RAPD
Outline the visual pathway.
Retina
Optic nerve
Optic chiasm (nasal fibres decussate)
Optic tract
Lateral geniculate nucleus of thalamus
Optic radiation (superior field = temporal; inferior field = parietal)
Visual cortex
A lesion at what point in the visual pathway causes homonymous hemianopia?
Contralateral defect beyond the optic chiasm (retrochiasmatic)
A larger defect suggests a larger lesion or it’s closer to the chiasm
NOTE: examine for ipsilateral hemiparesis and cerebellar signs
Which visual defect might you see in a middle cerebral artery stroke?
Homonymous hemianopia
NOTE: MCA supplies the optic radiation in the temporal and parietal lobes
Which visual defect might you see in a posterior cerebral artery stroke?
Homonymous hemianopia with macular sparing (branch of MCA supplies the visual cortex)
NOTE: patients will not have hemiparesis but may have cerebellar signs
List some causes of monocular blindness.
Eye problem (e.g. cornea, vitreous, retina)
Optic nerve (optic neuropathy)
List some causes of bitemporal hemianopia.
Pituitary tumours
Craniopharyngioma (benign suprasellar tumour from Rathke’s pouch)
What could cause a negative Rinne’s test?
Negative = BC > AC
True: conductive deafness
False: complete sensorineural hearing loss
How is Weber’s test interpreted?
SNHL: lateralises to normal ear
Conductive: lateralises to abnormal ear
List some causes of conductive hearing loss.
Canal obstruction (wax, foreign body)
Tympanic membrane perforation: trauma, infection
Ossicle defects: otosclerosis, infection, fluid in middle ear
List some causes of sensorineural hearing loss.
Presbyacusis
Drugs (gentamicin, vancomycin)
Infection (meningitis, measles)
Tumour (vestibular schwannoma)
Alport syndrome (SNHL + haematuria)
Describe how dysphasia can be tested.
Nominal dysphasia: name three objects
Receptive dysphasia: three-stage command
Conductive dysphasia: repeat a sentence
What is the difference between dysarthria and dysphasia?
Dysarthria: impaired articulation of sound
Dysphasia: impairment of language
List some causes of dysarthria.
Mouth lesions
Pseudobulbar palsy
Bulbar palsy
Cerebellar lesion
Describe the different types of dysphasia.
Expressive: Broca’s area damage (inferior frontal gyrus) - non-fluent speech but comprehension intact
Receptive: Wernicke’s area damage (superior temporal gyrus) - fluent but meaningless speech, comprehension impaired
Conductive: arcuate fasciculus damage - comprehension intact, unable to repeat words/phrases
Which areas of skin tend to be affected by plaque psoriasis?
Extensors
Behind the ears
Scalp
Umbilicus
Sites of trauma (Koebner phenomenon)
Auspitz sign (pinpoint bleeding at site of scraping)
DDx: fungal infection, lichen planus, Bowen’s disease, dermatitis
List some different subtypes of psoriasis.
Plaque
Guttate (drop lesions after Strep infection)
Pustular (generalised or palmo-plantar)
Erythrodermic
Flexural
What are the five patterns of psoriatic arthritis?
Symmetrical polyarthritis
Asymmetrical oligoarthritis
DIP involvement
Arthritis mutilans
Psoriatic spondylopathy
List some complications of neurofibromatosis.
Epilepsy
Sarcomatous change
Scoliosis
Learning difficulty
List some causes of cafe au lait spots.
NF1
Noonan syndrome
McCune Albright syndrome (cafe au lait spots, polyostotic fibrous dysplasia and endocrinopathy (precocious puberty))
What are the main features of Peutz-Jeghers syndrome?
Autosomal dominant mutation of STK11 gene on chromosome 19
Leads to multiple mucocutaneous macules (on lips and oral mucosa) and GI hamartomatous polyps (can bleed/intussusception)
They have an increased risk of colorectal cancer
List some causes of erythema multiforme.
Infection (HSV, mycoplasma, other (TB, histoplasmosis, Yersinia)
Drugs (sulphonamides, NSAIDs, allopurinol)
Severe form is called Stevens-Johnson syndrome (with mucosal ulceration and liver failure)
DDx: tinea, discoid eczema
List some causes of erythema nodosum.
Systemic: sarcoidosis, IBD, Behcet’s disease
Infection: streptococcal, TB
Drugs: sulphonamides, OCP
NOTE: the pain begins before the skin changes
List some extra-articular features of rheumatoid arthritis.
Eyes: episcleritis, keratoconjunctivitis sicca
Heart: pericarditis
Lungs: pulmonary fibrosis
Abdomen: splenomegaly (Felty)
Urine: amyloidosis from chronic inflammation
Skeletal: atlanto-axial subluxation
Skin: rheumatoid nodules
Which surgical procedures might patients with rheumatoid arthritis undergo?
Carpal tunnel decompression
Tendon repairs and transfers
Ulna stylectomy
Arthroplasty
What are the main side-effects of methotrexate?
Bone marrow suppression
Hepatotoxicity
Pulmonary fibrosis
What is Jaccoud arthropathy ?
Chronic non-erosive reversible joint disorder occurring due to repeated bouts of arthritis commonly associated with SLE
Mimics rheumatoid arthritis but is caused by tendon contractures which are reducible on extension
Describe the pattern of symptoms seen in ankylosing spondylitis.
Back pain that is worst in the morning and improves with exercise
NOTE: check for extra-articular manifestations as well (e.g. aortic regurgitation, ankylosing spondylitis, Achilles tendinitis, apical fibrosis, amyloidosis)
List some risk factors for gout.
Obesity
Hypertension
Drugs (thiazides, cytotoxic)
Lymphoproliferative disorder
Chronic renal failure
Alcoholism
Diet - purine rich foods
What are the main risks of radioiodine treatment for hyperthyroidism?
May worsen thyroid eye disease
Patients become hypothyroid
What are the main risks of thyroidectomy?
Haematoma
Recurrent laryngeal nerve palsy
Hypothyroidism
Hypoparathyroidism
List some causes of macroglossia.
Acromegaly
Amyloidosis
Hypothyroidism
Down syndrome
List some causes of acanthosis nigricans.
Obesity and metabolic syndrome
Diabetes mellitus
Cushing syndrome
Acromegaly
Gastric cancer
Pancreatic cancer
Which conditions are associated with acromegaly?
Carpal tunnel syndrome
Diabetes mellitus
Sleep apnoea
Cardiovascular disease
List some complications of Cushing syndrome.
Osteoporosis
Hypertension
Cardiovascular risk
Diabetes mellitus
Immunosuppression
List some side-effects of steroid use.
MSK: proximal myopathy, osteoporosis
ENDO: HPA suppression, obesity, diabetes
METABOLIC: hypokalaemia, hypertension, fluid retention
IMMUNE: increased susceptibility to infection
CNS: depression, psychosis
EYE: cataracts, glaucoma
What is hemiballismus and what causes it?
Involuntary flinging movements of the extremities, usually isolated to one side of the body
Caused by damage to subthalamic nucleus (e.g. infarct, MS)
What are the exacerbating and relieving factors for benign essential tremor?
Exacerbating: anxiety, caffeine
Relieving: alcohol, sleep
NOTE: it is autosomal dominant
Which investigations may be useful in acute rheumatic fever?
Raised ASO titre
Positive throat cultures for group A streptococcus
What CXR features may be seen in long-standing untreated mitral stenosis?
Left atrial enlargement
Pulmonary haemosiderosis (iron deposition in the lungs due to haemolysis)
List some signs of aortic regurgitation.
Collapsing pulse (DDx: pregnancy, PDA, hyperthyroid)
Wide pulse pressure
Corrigan’s sign (visible neck pulses)
De Musset sign (head bobbing)
Quincke’s sign (nail bed pulsation)
Dynamic apex
Early diastolic murmur at left sternal edge
Systolic flow murmur
What is R wave progression on ECG?
The R waves get bigger from V1 to V6 which is a feature of a normal ECG
Patients with a history of ischaemic heart disease will NOT have R wave progression
What are some differentials for bundle branch block?
Ventricular ectopic
Ventricular tachycardia
NOTE: You cannot interpret ST elevation in patients with BBB
What are the main complications of right coronary artery and left coronary artery infarcts?
RIGHT: Heart block - RCA supplies the SA node and AV node
LEFT: Heart failure - most important in maintaining blood pressure
Describe the rhythm seen in the three types of heart block.
1st Degree: regular rhythm, fixed prolonged PR interval
2nd Degree type 1: irregular, gradually increasing PR interval
2nd Degree type 2: irregular, fixed PR interval, missed beats
3rd Degree: regular bradycardia
List some complications of MI.
Arrhythmia (VF and death)
Cardiac failure
Embolism
Aneurysm rupture
Pericarditis (early in full thickness MI or Dressler syndrome)
What ECG feature would be seen in a patient with a ventricular aneurysm?
Persistent ST segment elevation in the left sided leads
List some ECG changes seen in PE.
May be normal
Sinus tachycardia
Right ventricular strain
S1Q3T3
List some signs of heart failure.
S3 heart sound (may be the first sign)
Tachycardia
Tachypnoea
Wheeze (cardiac asthma)
Bilateral crepitations
Raised JVP
Ankle/sacral oedema
What is the mainstay of treatment in cardiogenic shock?
Dobutamine or dopamine in ITU (this has a stimulant effect on the heart through beta-1 agonism)
