Medicine Tips 5

Question 1

Pharyngeal pouch

Answer 1

Old men
Posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Dysphagia, regurgitation, aspiration, chronic cough

Question 2

Globus hystericus

Answer 2

Symptoms are often intermittent and relieved by swallowing

Painless

Question 3

Acute exacerbation of COPD

Answer 3

Infective causes - haemophilus influenzae (most common cause), streptococcus pneumoniae, moraxella catarrhalis
Ix - ABG, CXR, ECG, FBC, U&E, theophylline levels, sputum MCS, blood culture (if pyrexial)
Mx - oxygen therapy, nebulised bronchodilators, 30mg prednisolone PO for 7-14 days, antibiotics, chest physio, IV theophylline

Question 4

COPD Management

Answer 4

First line - SABA/SAMA
Second line - depends on FEV1
FEV1 > 50% - LABA (salmeterol) / LAMA (tiotropium)
FEV1 < 50% - LABA + ICS or LAMA
Persistent exacerbations - if taking LABA then change to LABA + ICS; otherwise LAMA + LABA + ICS

Question 5

Asthma Management

Answer 5

1 - SABA
2 - SABA + low dose ICS (400 mcg budesonide)
3 - SABA + low dose ICS + LRTA
4 - SABA + low dose ICS + LABA (+ LRTA depending on reaction to LRTA)
5 - SABA +/- LRTA (switch ICS/LABA for maintenance and reliever therapy (MART) that includes low dose ICS)
6 - SABA +/- medium dose ICS MART or LABA + medium dose ICS (400-800 mcg budesonide)
7 - SABA +/- LRTA + high dose ICS (>800 mcg budesonide) / theophylline

Question 6

Migraine management

Answer 6

Acute - oral triptan (nasal in teenagers) + paracetamol/NSAID (+ non-oral metoclopramide/prochlorperazine)
Prophylaxis - topiramate (males) or propranolol (females) + riboflavin -> gabapentin
Predictable menstrual migraine - frovatriptan 2.5mg BD or zolmitriptan 2.5mg BD/TDS

Question 7

Cluster headache

Answer 7

Intense sharp, stabbing pain around one eye (recurrent attacks ‘always’ affect same side) occurring once or twice a day, each episode lasting 15 mins - 2 hours
Clusters typically last 4-12 weeks, once a year
Pt is restless and agitated during an attack
Accompanied by redness, lacrimation, lid swelling
nasal stuffiness
M > F
Associated with smoking and triggered by alcohol
Acute mx - high flow oxygen + SC triptan
Prophylaxis mx - verapamil

Question 8

Neuroleptic malignant syndrome

Answer 8

Caused by antipsychotics
Young male pts
Onset usually in first 10 days of treatment or after increasing dose
Pyrexia, tachycardia, hypertension, hyporeflexia, lead pipe rigidity
Raised CK, leukocytosis
Mx - IV fluids, bromocriptine/dantrolene

Question 9

Serotonin syndrome

Answer 9

Caused by SSRIs, MAOIs, ecstasy/novel psychoactive stimulants
Presents in hours
Pyrexia, tachycardia, hypertension, hyperreflexia, clonus, dilated pupils
Mx - IV fluids, cyproheptadine/chlorpromazine

Question 10

Psychogenic nonepileptic seizures

Answer 10

Pseudoseizure
Pelvic thrusting, family member with epilepsy, more common in females, crying after seizure, do not occur when alone, gradual onset
Normal prolactin (prolactin is raised in a true epileptic seizure)
Differentiate from a true epileptic seizure with video telemetry

Question 11

Facial nerve

Answer 11

Supplies

• face - muscles of facial expression
• ear - stapedius
• taste - anterior two-thirds of tongue
• tear - parasympathetic fibres to lacrimal glands and salivary glands

Question 12

Causes of bilateral facial nerve palsy

Answer 12

Sarcoidosis
Guillain-Barre syndrome
Lyme disease
Bilateral acoustic neuromas (as in neurofibromatosis type 2)
Bell's palsy

Question 13

Causes of unilateral facial nerve palsy

Answer 13

Same as causes of bilateral facial nerve palsy (sarcoidosis, Guillain-Barre syndrome, Lyme disease, bilateral acoustic neuromas (as in neurofibromatosis type 2), Bell’s palsy) AND
Upper motor neuron - stroke, MS
Lower motor neuron - Bell’s palsy, Ramsay-Hunt syndrome (due to herpes zoster), acoustic neuroma, parotid tumours, HIV, multiple sclerosis, diabetes mellitus

Question 14

Unilateral UMN facial nerve palsy

Answer 14

Forehead sparing

Question 15

Unilateral LMN facial nerve palsy

Answer 15

Affects all facial muscles

Question 16

Acoustic neuroma

Answer 16

Unilateral sensorineural deafness/tinnitus
Bilateral acoustic neuromas in neurofibromatosis type 2
Features can be predicted by the affected cranial nerves
CN VIII - hearing loss, vertigo, tinnitus
CN V - absent corneal reflex
CN VII - facial palsy

Question 17

Meniere’s disease

Answer 17

Attacks of vertigo, tinnitus, sensorineural deafness and fullness of the ear

Question 18

Tuberous sclerosis

Answer 18

Autosomal dominant
Cutaneous features - depigmented ‘ash-leaf’ spots (fluoresce under UV light), roughened patches of skin over lumbar spine (Shagreen patches), adenoma sebaceum or angiofibromas (butterfly distribution over nose), fibromata beneath nails (subungual fibromata), café-au-lait spots
Neurological features - developmental delay, epilepsy (infantile spasms or partial), intellectual impairment
Other features - retinal hamartomas (dense white areas on retina (phakomata)), rhabdomyomas of the heart, gliomatous changes can occur in the brain lesions, polycystic kidneys, renal angiomyolipomata, lymphangioleiomyomatosis (multiple lung cysts)