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Finals Revision Lectures > Mirza's Cases > Flashcards

Mirza's Cases Flashcards

1
Q

What lesion is down and out pupil?

A

3rd nerve palsy

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2
Q

What are the causes of a 3rd nerve palsy?

A 
Surgical = SOL, posterior communicating artery
Medical = Diabetes, HTN, MS
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3
Q

Does the pupil dilate early or late in surgical 3rd nerve palsy?

A

Early, due to the parasympathetic fibres running along the outside of the nerve

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4
Q

What investigations would you like in a 3rd nerve palsy?

A

Blood pressure and blood sugars to assess for medical causes

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5
Q

A patient has a unilateral ptosis on their right side, what are the differentials?

A

Horners = small pupil

Myasthenia = normal pupil

3rd nerve palsy = dilated pupil

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6
Q

Causes of a bilateral ptosis?

A

Myasthenia graves

Dystrophia myotonica

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7
Q

How would a 6th nerve palsy present?

A

Inability to abduct the affected sides eye

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8
Q

Causes of a 6th nerve palsy?

A

HTN, diabetes

MS

Raised ICP

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9
Q

What are the signs of raised ICP?

A

Earliest sign is loss of retinal vein pulsation, latest is papilloedema

Cushings triad = Bradycardia, HTN, irregular breathing

Reduced GCS

6th nerve palsy - gets pinched at the petrous temple bone

3rd nerve palsy

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10
Q

When do you get double vision in a 6th nerve palsy vs a 4th?

A

6th is when looking towards the affected side
Outer image comes from the affected eye, disappears on closing that eye .

4th is when looking down and inwards

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11
Q

Patient has hypertonia in both legs, reduced power, increased reflexes and clonus. Ddx?

A

Cord compression

Cervical spondylosis

MS

MND

CVA

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12
Q

What is spasticity vs rigidity?

A

Rigidity is the same throughout

Spasticity = clasp like, difficult to initiate then eases off. Extensors in lower limbs and flexors in upper limbs.

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13
Q

Patient has cord compression after our lower limb exam before, what else do we want to do and what questions should we ask?

A

Check sensory levels and examine upper limbs + cranial nerves

Examine sacral sensation

Ask: Any urinary incontinence, or faecal incontinence. Have they noticed any change in the sensation when weeing?

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14
Q

Ddx for wasting of the thenar and hypothenar eminences?

A

Bilateral:

  • Rheumatoid
  • Cervical spondylosis
  • MND
  • CMT
  • Syringomyelia

Unilateral:

  • Cervical rib
  • Pancoasts
  • Brachial plexus trauma
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15
Q

Three reasons for a CXR in a stroke patient?

A

Risk of aspiration pneumonia

Lung malignancy can metastasise to the brain

Enlarged heart = CCF and HTN

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16
Q

What are the features of neurofibromatosis 1?

Which chromosome affected?

A

Cafe au lait spots
Axillary freckling
Fibromas = subcutaneous, and plexiform
Eye = Lisch nodules (brown iris hamartomas)

Neoplastic change in 10% e.g. Phaeo’s, meningiomas
Orthopaedic scoliosis
IQ reduced
Renal = RAS = HTN

Chr 17

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17
Q

How many cafe au last spots is diagnostic and how big should they be?

A

6

> 15mm

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18
Q

What are the features of neurofibromatosis 2 and chromosome?

A

Bilateral acoustic neuroma = SNHL

Chromosome 22

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19
Q

Types of facial nerve palsy?

A

UMN is forehead sparing

LMN is everything:

  • Bells palsy = unknown aetiology
  • Ramsay hunt syndrome is reactivation of varicella zoster virus in the geniculate ganglion of CN8
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20
Q

What else to examine / ask about?

A

Change in taste as facial does anterior 2/3rds of the tongue (via the chord tympani branch of CN7)

Examine ear for any rash

Ask about any extremely loud sounds (hyperacusis due to the stapedius branch of CN7)

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21
Q

Extracranial branches of facial nerve?

A 
Temporal
Zygomatic
Buccinator
Marginal mandibular
Cervical branch
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22
Q

How do you localise a facial palsy?

A

If symptoms of CN7 + 6 = pons

If symptoms of CN7 + 5 + 8 = cerebello-pontine angle
- For cranial nerve 5 can test corneal reflex (afferent branch is trigeminal, so if both eyes don’t close it is this)

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23
Q

Types of CMT, and how to differentiate?

A

Hereditary sensory and motor neuropathy
Autosomal dominant

CMT1 = commonest, demyelinating lesion = velocity <38m/s

CMT2 = Axonal pathology, velocity >38m/s

24
Q

PC in CMT?

A

Often presents with small muscle wasting of the hands.
Walking difficulty = high stepping gait and foot drop

Reduced reflexes, muscle strength and sensation

Pes Cavus

25
Q

How does Friedrich’s ataxia commonly present?

A

Spina-Cerebellar degeneration = cerebellar signs e.g. ataxia

26
Q

Non-neurological signs of Friedrich’s ataxia?

A

Pes cavus
Cardiac = HOCM
DM

27
Q

How does MND commonly present?

A

Fasciculations

28
Q

Describe a psoriatic rash?

A

Salmon pink circular discoid patches, with silver discolouration on flexor surfaces and buttocks

29
Q

Where else would you examine for psoriasis?

A

Scalp and behind the ears

Nails = pitting, onycholysis

Joints

30
Q

What is the koebner phenomenon?

A

Purple lesions associated with scarring

31
Q

MI complications?

A 
Short term:
- VF 
RCA = sinus bradycardia, 1/2 HB
- LAD = Complete heart block
- MR due to papillary rupture
- Dresslers

Long term:

  • Arrhythmias
  • MI
  • CCF
32
Q

Triad of Parkinson’s?

A

Bradykinesia
Pill rolling tremor
Rigidity

33
Q

What’re the Parkinson’s plus syndromes?

A

MSA, corticobasal degeneration and PSP

34
Q

Signs of PSP?

A

Supranuclear gaze and postural instability

Rocket sign, ask them to get up out of the chair and they shoot up

35
Q

What three conditions make up MSA, and signs?

A

Olivopontocerebellar atrophy
Shy-drager
Striatonigral degeneration

Autonomic dysfunction = postural hypotension, bladder dysfunction
Cerebellar signs
Rigidity > tremor

36
Q

Extra-articular features of rheumatoid?

A

Atlanto-axial instability due to weakening of the transverse ligament holding odontoid of C2 against anterior arch of C1

Nodules

Anaemia

Splenomegaly in Felty’s

Fibrosis and pulmonary nodules

37
Q

Clinical features of Pagets?

A

Bowed legs, frontal bossing
Joint pain
Hearing loss

38
Q

What do people with Paget’s die from?

A

High output heart failure

As bones become larger = bigger capillary network = big volume = big heart

39
Q

If you have a mix of UMN, and LMN with no sensory what is it?

A

MND

40
Q

Causes of hypoglycaemia?

A

SAILS Q

Sulphonylureas
Alcohol
Insulin OD
Liver disease
Sepsis
Quinines
41
Q

What is Addison’s and signs?

A

Primary adrenal failure = low cortisol so high ACTH

Low sodium and high potassium

Postural hypotension, vitiligo, hypoglycaemia, hyper pigmentation as excess ACTH = POMC

42
Q

Causes of Addison’s?

A

Autoimmune is commonest in UK
TB is commonest worldwide
Amylodiosis

43
Q

Investigations for Addisons?

Mx?

A

Lying and standing BP
Synacthen test
Glucose

Steroids IV hydrocortisone fast and fluids

Then long term hydrocortisone and fludrocortisone

44
Q

What murmur is ejection systolic?

Classic signs?

A

Aortic stenosis

Syncope, exertion dyspnoea and angina
Radiates to carotids
Slow rising pulse, and narrow pulse pressure

45
Q

Investigations for AS?

Mx for AS?

A

TTE is definitive
ECG = LAD and LVH (Tall R wave in V5/6, Deep S in V1/V2)

MDT
Cons = Diet, exercise, weight
Medical = Mx any co-morbidities

Surgical:

  • Asymptomatic valve replacement if EF <50%
  • Symptomatic
  • low risk = aortic valve replacement
  • high risk surgical patient = TAVR

Long term anticoagulation if mechanical valve aiming for 3-4
Long term IE prophylaxis

46
Q

What is an EDM? What does it change to when severe?

Signs?

A

Aortic regurgitation

Low pitched mid-diastolic murmur = AUSTIN FLINT

LVF = orthopnea, PND, exertion dyspnoea
Collapsing pulse
De Mussets
Quinckes

47
Q

Management of aortic regurgitation?

A

Severe asymptomatic:
- EF > 50 = vasodilator therapy

Symptomatic or asymptomatic EF <50:
- Aortic valve replacement / TAVR

48
Q

Blowing PSM?

Features?

A

Mitral regurgitation

Exertional dyspnoea
Angina
Radiates to axilla
Soft S1

49
Q

Causes of aortic stenosis?

A

Valvular causes = True congenital defect, calcificaition, rheumatic fusion

Sub-valvular = LV hypertrophy

50
Q

Causes of aortic regurgitation?

A

Acute = IE and aortic dissection

Chronic = Bicuspid valve and rheumatic heart disease

51
Q

Causes of mitral regurgitation?

A

Acute = papillary muscle rupture post-MI, IE, rheumatic fever

Chronic = Mitral valve prolapse, LV dilation (AR, AS, HTN, dilated cardiomyopathy) , calcification

52
Q

Investigations and management of MR?

A

Acute MR = Valvuloplasty or annuloplasty

Chronic - EF >60 = ACEI and BB

Chronic EF <60 / symptomatic = Medical and surgical

53
Q

MDM?

Signs?

A

Mitral stenosis

Dyspnoea
Angina
Opening snap, tapping apex
Low pitched rumbling

54
Q

Investigations and Mx of mitral stenosis?

A

Ix = ECG:

  • AF
  • LAH = bifid p wave / p-mitrale
  • Also see RVH due to pulmonary congestion = Tall R in V1/V2, deep S in V5/V6.

Echo

Mx:

  • Mild disease = No therapy
  • Symptomatic = Valve repair / replacement
55
Q

Late systolic murmur with systolic click?

A

Mitral valve prolapse (barlow syndrome)

Medical = Aspirin / warfarin, BB's
Surgical = Mitral valve repair
56
Q

Causes of heart failure?

A

Myocardial damage = Infarction, toxins e.g. anabolic steroids, infiltration

Finals Revision Lectures (2 decks)

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