MRCP Part 2 Flashcards
What are the causes of neuroleptic malignant syndrome?
Adverse reaction to anti-psychotics
Dopaminergic medications stopped abruptly
Metoclopramide and lithium
What is neuroleptic malignant syndrome caused by?
sudden reduction in dopamine activity, either from blockade of dopamine receptors or withdrawal of dopaminergic agents
Good prognostic features in MS
female sex
aged 20 - 30 at onset
relapsing-remitting (recovers in between)
sensory symptoms only
long interval between 1st two relapses
complete recovery between relapses
1st line drug of choice for prophylaxis in cluster headaches
verapamil
How can you get iatrogenic Creutzfeld-Jakob disease?
Previous neurosurgery using a dual graft - method of transmission of the prion protein
Postural headache but normal imaging
Idiopathic intracranial hypertension
MRI findings in multiple sclerosis
high signal T2 lesions
periventricular plaques
Dawson fingers (hyperintense lesions)
perpendicular to the corpus callosum
What is Stoke-Adams syndrome?
transient AV block and results in loss of consciousness
How do you assess suitability for a VP shunt in a patient with normal pressure hydrocephalus?
CSF infusion test demonstrates raised CSF outflow resistance
Prominent gait disturbance also points towards an increased likelihood of surgical success
Optic neuritis, longitudinal extensive cervical transverse myelitis with CSF negative for oligoclonal bands is …
Highly suggestive of neuromyelitis optica
Antibody = NMO-IgG or antibodies against aquaporin 4
Why does SAH cause a fever?
Blood being irritating to the meninges
Tremor which worsens on posture, head nodding and lack of cerebellar symptoms
essential tremor
CSF in Guillain-Barre syndrome
raised protein with normal white cell count
- albuminocytological dissocation
Cavernous sinus thrombosis involves which cranial nerves
6th nerve (abducens)
3rd and 4th nerve (occulomotor and trochlear)
Trigeminal nerve = hyperaesthesia of upper face and eye pain
Thrombectomy in acute brain stroke - time limit
6 hours from onset
6-24 hours considered if there is potential to salvage brain tissue
Drugs that may exacerbate myasthenia gravis
pencillamine
quinidine, procainamide
beta blocker
lithium
phenytoin
abx - gentamicin, macrolides, quinolones, tetracyclines
Memorable first occurence, attacks precipitated by touch or vibration and history of inappropriate dental treatment is a classical history of?
Trigeminal neuralgia
Parkinson’s disease vs Drug induced Parkinsonism
Drug induced is usually bilateral
Idiopathic Parkinsonism often presents asymmetrically
What is the on-off effect in Parkinson’s disease?
When levodopa becomes less effective over time
Gerst Mann syndrome is a tetrad of
acalculia
alexia
agraphia
R-L disorientation
finger agnosia
If only 1 lobe was affected in Wernicke’s aphasia
temporal lobe
Brain stem is made up of
midbrain - Weber, Benedict, Parinaud’s
pons - AICA
medulla - PICA
Vertical gaze is
ability to move eye up and down
Common peroneal nerve palsy vs L5 radiculopathy
Common peroneal nerve:
intact ankle inversion and flexion of big toe
sensory loss usually around lateral aspect of lower leg and dorsum of foot
- most common cause is trauma or compression at fibula head, classically by tight plaster casts
L5 radiculopathy:
- sensory loss is strip down the middle of the anterior lower limb
Facioscapulohumeral dystrophy features
facial muscles involved first - difficulty closing eyes, smiling, blowing
weakness of shoulder and upper arm muscles
abnormal prominence of borders of shoulder blades - ‘winging’
lower limb - hip girdle weakness, foot drop
Painful third nerve palsy
neurosurgical emergency
may indicate expanding posterior communicating artery aneurysm
needs urgent CT angiogram
manage = surgical clipping
- not happen quickly, risk of death from rupture or may be permanent ptosis and eye movement deficit
Late onset myasthenia gravis vs early onset with regards to thymus
Late onset - thymic atrophy
Early onset - thymic hyperplasia
Key points about Friedrich’s ataxia
progressive, limb and gait ataxia before 25 years
no deep tendon reflex, spasiticity, peripheral sensory neuropathy, dysarthria, difficulty swallowing, muscle weakness
equal sex incidence, AR
Most deaths are cardiac - LVH and ECG shows widespread T wave inversion
When would you not give dexamethasone in brain tumours?
If CNS lymphoma is suspected
CSF in Guillain Barre syndrome
normal white cells and glucose
raised protein
What vitamin excess can cause IIH?
Vitamin A excess
Meningitis which occurs as a complication of an ear infection is nearly always caused by
Streptococcus pneumoniae
Natalizumab and association with progressive multifocal leukoencephalopathy is found…
only in those who are JCV antibody seropositive
Parameter for ventilator support in GBS
FVC IS < 15-20ml/kg
Features of Lyme disease
- on CSF
- extra CNS features
lymphocytic pleocytosis in CSF
extra CNS features: arthralgia, peripheral neuropathy, 1st degree heart block
Myotonic dystrophy clinical features
Frontotemporal balding
Ptosis
Distal weakness
Depressed tendon reflexes
Myotonic (slow relaxation of muscles)
Lateral medullary syndrome
Wallenberg’s syndrome
occlusion of posterior inferior cerebellar artery
ataxia, nystagmus
ipsilateral: dysphagia, facial numbness, cranial nerve palsy
contralateral: limb sensory loss
What medication is containdicated for neuropathic pain if there is arrhythmias (particularly heart block)?
Amitriptyline
Scan findings in herpes simplex encephalitis
MRI - bilateral temporal lobe oedema
CT: medial temporal and inferior frontal changes
MRI findings for Alzheimer’s disease
medial temporal lobe atrophy
Axillary nerve injury
dislocation of shoulder joint, fracture of neck of humerus or serum and vaccine induced neuropathies
paralysis of abduction of the arm between 15 and 90 degrres, wasting of delotoid muscle and slight impairment of sensation over the oouter aspect of the shoulder
B12 deficiency is also known as
Cobalamin deficiency
Acephalgic migraine
experience aura without a headache
Anti-NMDA encephalitis classical features
prodromal headache followed by prominent psychiatric features
orofacial dyskinesia
insomnia
progression to seizures
Pontine haemorrhage
reduced GCS
paralysis
bilateral pin point pupils
MRI - hyperintense signals in the basal ganglia and thalamus
Creutzfeldt Jakob disease
Pneumothoroax and flying
fly 1 week after is complete resolution of pneumothorax after treatment
Thrombectomy in acute ischaemic stroke
extended target time of 6-24 hours may be considered
if CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
Ergotism
concomitant use of ergotamine and macrolide may cause ergotism
confusion, headache, seizure, psychosis and global vasoconstriction leading to critical limb ischaemia, cardiac ischaemia and bowel hypoperfusion
Carotid artery stenosis
male 50-99%
female 70-99%
that corresponds to same side of stroke
How soon do you consider for CEA?
considered for an urgent carotid endarterectomy within 14 days
Nerve conduction study:
normal conduction velocity
reduced amplitude
Axonal pathology
Nerve conduction study:
reduced conduction velocity
normal amplitude
Demyelinating pathology
Increased T2 and FLAIR signal intensity in putamen and head of caudate on T2 weighted MRI
14-3-3 protein on CSF
Sporadic Creutzfeld Jakob disease
EEG - interical epileptiform discharges
bilateral, symmetrical 3Hz spike and wave pattern
Absence seizure
Foster Kennedy syndrome
frontal lobe tumour
optic atrophy in ipsilateral eye
central scotoma in ipsilateral eye
papilloedema in contralateral eye
anosmia
Commonest cause of intracerebral infection due to penetrating/direct skull injury
Staphylococcus aureus
Lafora body disease
inherited progressive myoclonic epilepsy
Anton syndrome
bilateral occipital cortex infarction
no vision
pupillary responses are intact and fundoscopy is normal
visual evoked potentials and optokinetic nystagmus are absent
extensive lesions = in denial of their blindness
normal CT scan
need MRI with DWI to confirm diagnosis
Heterophile antibodies
Monospot test
indicates EBV (infectious mononucleosis)
Scrub typhus key points
South East Asia
black eschar is key diagnostic clue
treat with doxycycline
Antibiotics to use for the treatment of MRSA infections
vancomycin
teicoplanin
linezolid
Factors that can lead to elevated levels of azathioprine
drugs that inhibit xanthine oxidase - allopurinol
drugs that can also cause myelosuppression - sulphonamides, trimethoprim
reduced activity of TPMT
Profuse sweating associated with foul smell is typical of what infectious disease?
Brucellosis
‘hay-like’
What is the benefit of starting early antiretroviral treatment in HIV as opposed to deferring the treatment?
reduced risk of AIDs and mortality
Intensely pruritic, creeping, serpiginous erythematous cutaneous eruption that advances over time
cutaneous larva migrans
treat with ivermectin or albendazole
1st line treatment for chlamydia
doxycycline - 7 day course
Latent TB vs active TB
Latent TB = asymptomatic and non-infectious
positive tuberculin skin test or interferon-gamma release assay combined with normal CXR
Treat latent TB
3 months of isoniazid (with pyridoxine) and rifampicin
OR
6 months of isoniazid (with pyridoxine)
Norovirus testing
faecal or vomitus viral PCR
Most serious and frequent complication of typhoid
bowel perforation and haemorrhage
IgM antibodies in CSF against a flavivirus
Tick borne encephalitis
Viral haemorrhagic fever with exposure to caves/bats and primates
Marburg virus
Urethritis in a male
negative for gonorrhoea and chlamydia
?Mycoplasma genitalium
Syphilis tests
Non-treponemal: RPR and VDRL
negative after treatment
Treponemal: TP-EIA and TPPA
stays positive after treatment
Most common fungal infection of the CNS in patients with HIV
Cryptococcus neoformans
HHV 5
cytomegalovirus
- seen in post-transplant patients
Treat invasive diarrhoea - blood and fever with
ciprofloxacin
Measles in developing countries
2 doses of vitamin A
Treat plasmodium vivax
chloroquine and primaquine
Treatment for multi-drug resistnat TB
18-24 months of at least 5 drugs
Councilman bodies in liver
eosinophilic inclusion in liver
YELLOW FEVER
Prophylaxis for contacts in meningococcal meningitis
who gets meds?
close contact within 7 days before onset
Most common cause of meningitis in Saudia Arabia during Hajj
meningococcal meningitis type A
Rabies treatment after bite and healed
- not vaccinated
rabies immunoglobulin and full rabies vaccination schedule
river blindness = clouding of cornea
leopard print skin
onchocerciasis
Tx = ivermecthin
Main disadvantage of IGRA - interferon gamma release assay
unable to distinguish between active or latent TB
Manage staphylococcus aureus bacteraemia
IV flucloxacillin for 2 weeks
Main side effect of trastuzumab
cardiotoxicity
Drug to avoid in cocaine induced cardiovascular problems
beta blockers
risk of unopposed alpha-mediated coronary vasospasm
Medication that modifies diseases progression in idiopathic pulmonary fibrosis
decrease functional decline
prolong survival
reduce exacerbations
Pirfenidone and nintedanib
Distinguish chylothorax from pseudochylothorax
triglycerides - in chylothorax
cholesterol in pseudochylothorax
Angina management
Aspirin and statin
GTN spray
Beta blocker
Calcium channel blocker
Then B + C
Long acting nitrate
Ivabradine
Nicorandil
Ranolazine
add 3rd in whilst awaiting assessment for PCI or CABG
Prinzmetal’s angina
coronary artery spasm
pain at rest with ECG changes
ECG changes resolve as pain abates
normal or artery disease on angio
Avoid precipitants
CCB, nitrates and/or nicorandil
Chronic heart failure management
ACE inhibitor
Beta blocker
Aldosterone antagonist
SGLT2 inhibitors
Ivabradine - HR > 75, LVF < 35%
Sacubitril-valsartan - LVF < 35%
Digoxin - if coexisting AF
Hydralazine in combination with nitrate - Afro Caribbean patients
Cardiac resynchronisation - widened QRS on ECG
Posterior STEMI
recipricol changes in anterior leads V1 - V3
horizontal ST depression
tall, broad R waves
upright T waves
dominant R wave in V2
Trifascicular block
1st degree AV block
RBBB
LAD
Abx for prostehtic valve caused
blind therapy
caused by sthaphylococci
vanc, rifampicin and low dose gent
Coved ST elevation in leads V1-V3
Brugada syndrome
sustained non-displaced apical impulse on cardiology clinical examination
left ventricular hypertrophy
ECG - deep S waves in V1 and V3 and tall R waves in V5 and V6
Deeply inverted or biphasic T waves in V2-V3
Wellen’s syndrome
high risk of critical LAD stenosis
Valve disease associated with PCKD
mitral valve prolapse
Native valve endocarditis caused by staphylococci
Flucloxacillin
SVT management in asthmatics
verapamil
Kussmaul’s sign
paradoxical elevation of JVP on inspiration
Causes of constrictive pericarditis
radiotherapy
TB
chronic pericarditis
definitive management = surgical pericardial stripping
ECG shows T wave inversion in V1-3 with epsilon wave
Arrhythmogenic right ventricular cardiomyopathy
Chlortalidone
Thiazide like diuretic
Hydralazine with nitrate in Afro Caribean patients with HF
improves prognosis
Stages of HTN
1 = 140/90 OR 135/85
2 = 160/100 OR 150/95
Severe = >180 or >120
Tall
long fingered
downward lens dislocation
Learning diifculty
DVT
Homocystinuria
Definitive treatment for constrictive pericarditis
Pericardiectomy
Broad complex tachycardia
VT
Shock
Amiodarone
Lidocaine - not in LV impairment
DO NOT USE VERAPAMIL
Drug therapy fails:
EPS
ICD
Argyll Robertson Pupil
bilateral small pupils
don’t constrict in response to light
contrict when focusing on a nearby object
3 cardinal features of Lewy Body Dementia
visual hallucinations
fluctuating confusion
features of Parkinsonism
Alleviate cognitive impairment in Lewy Body Dementia
donepezil
Agitation in Parkinson’s disease
1st line - Quetiapine
2nd line - Clozapine
Best way to differentiate between delirium and dementia
confusion assessment method
Cyclophosphamide in granulomatosis with polyangiitis
increased risk of bladder cancer
- TCC
Cryptosporidiosis
protozoal cause of diarrhoea in immunocompromised
Dx = modified Ziehl Neelsen stain (acid fast stain) of stool may reveal charactersitic red cysts of cryptosporidium
Mx
- if HIV - then start HAART
- nitazoxainde
- rifaximin if severe disease
Cimex lectularius
Bed bugs
Sarcoptes scabiei
scabies
Best method to assess for strongyloides stercoralise eradication
repeat serology
post to pre treatment titre ratio of < 0.6 = good indicator of treatment success
Trypanosomiasis
rhodesiensi vs gambiensi
both Africa
acute = rhodesiense
chronic = gambiense
Urethritis in a male
negative for gonorrhoea and chlamydia
Mycoplasma genitalium
treat with doxycycline 100mg bd for 7 days
Immunosuppressed with no immunity to measles then exposed
Immunoglobulin following exposure
- within 72 hours but can be done until 6 days post exposure
Management of hepatitis B
1st line = Pegylated interferon-alpha
Lyme disease and doxycycline contraindicated
contraindicated in pregnancy
- give amoxicillin
Flu management in immunosuppressed
zanamivir
Zika virus and pregnancy
avoid pregnancy for at least 8 weeks after travel to Zika area
Fentanyl to morphine
75 patch = 180mg of morphine
100 patch = 240mg of morphine
Most common side effect of checkpoint inhibitors
dry, itchy skin and rashes
Most common chemotherapy regime for small cell lung cancer
etoposide
cisplatin
Treatment for small bowel bacterial overgrowth syndrome
rifaximin
co-amoxiclav or metronidazole also effective
Chromosomal changes associated with poor prognosis in CLL
deletion of short arm of chromosome 17 - del 17p
African trypanosomiasis types and key points
Gambiense = West Africa
CHRONIC
Rhodiesiense = East Africa
ACUTE
