OSCE Revision Flashcards
anterior cerebral artery blockage will lead to weakness of
lower limb contralaterally
vascular dementia presentation
step wise progression
onset can be sudden or gradual
executive function deficits prominent early
mood disturbances and disorders are common
neuro deficits and gait problems early
later stages = psychosis, delusions, hallucinations, paranoia
can be alongside alzheimers
AIDP
acute inflammatory demyelinating polyneuropathy
most common variant of GBS - 95% cases
Weakly positive birefringent, rhomboid shaped crystals
Calcium pyrophosphate = pseudogout
how to measure lying and standing BP
patient lay down for 5/10 minutes
take BP
then stand and take BP at 1 min and 3 min
DVLA and stroke /TIA
group 1 - dont need to report. dont drive for 1 month and can drive if no sustained neuro deficits after 1 month
group 2 = 1 year cant drive
risk factors for vascular dementia
main = HTN
smoking, diabetes, hyperlipidaemia, obesity, hypercholesterolaemia
retinal detachment presentation
new onset floaters, photopsia (bright flashes), sudden onset progressing visual field loss - a dark shadow that moves inwards
RAPD if macula or >1/2 retina detaches
Smith’s fracture
Volar displacement of radius head
treatment of parkinsons disease
1) levodopa + dopa decarboxylase inhibitor
2) dopamine agonist
3) MAO-B inhibitor
presentation of bacterial conjunctivitis
mucopurulent secretions, red eye, stinging, FB feeling, mild/moderate pain, glued eyes upon waking, papillae under eye lid
Z shaped thumb
Sign of RA-MCPJ flexion and IPJ extension
Negatively birefringent, needle shape crystals
Monosodium urate = gout
co beneldopa
levodopa and Benserazide
features of vascular parkinsonism
gradual or step wise deterioration small vessel disease symmetrical predominantly leg symptoms 50% respond to leva dopa
prophylactic treatment for migraine
if > 2 headaches a month
propranolol, topiromate, amitriptyline
2nd line - sodium valproate, botox
Ankle joint bones
Tibia, fibula and talus
Radial inclination
Normal wrist has 25 degrees radial inclination
presentation of parkinsons disease
resting tremor rigidity bradykinesia - reduced arm swing, progressive reduction in amplitude of repetitive movements fixed facial expression reduced blinking hypophonia (quiet voice) micrographia (little writing) gait disturbance hyposmia non motor symptoms - ANS: orthostatic hypotension, constipation, inconinence, sleep disorders, intense dreams, dysphagia, memory/ concentration problems.
prophylaxis of further aacg attacks
laser peripheral iridotomy
amiodarone
used for cardioversions in atrial fibrillation
donepezil
cholinesterase inhibitor for dementia
delirium
acute onset, fluctuating confusion due to an underlying treatable cause
investigations for encephalitis
LP - PCR for HSV, VZV and enterovirus
MRI and bloods
blockage of middle cerebral artery will lead to weakness/sensory loss of
contralateral face and arm
signs of radial nerve palsy
wrist drop (no wrist extensors) sensory loss of central posterior arm and thumb
Bouchards nodes
PIP joint swelling in OA
side effects of levodopa
dyskinesia with long term use
impulse control disorder
on/off fluctuations
reduced effect with time
nausea, vomiting, hypotension, poor appetite, psychological problems, sleep problems, hallucinations
how does viral conjunctivitis present
no/mild pain, watery discharge, diffuse red injections, mild itching, gritty feeling, lymphoid follicules under eyelid, pre-auricular lymphadenopathy
aetiology of delirium
Constipation Hydration Infection Metabolic disturbance Pain Sleeplessness
Prescriptions Hyperthermia or pyrexia Organ dysfunction - renal/hepatic Nutrition - vitamin deficiencies Environmental Drugs
others: hypoxia, surgery, hypoglycaemia, B12 deficiency, traumatic head injury, encephalitis
managing difficult delirium
use verbal/non verbal techniques to deescalate
if needed
short term haloperidol 0.5mg oral or 1mg IM
(not in parkinsons or LB dementia)
or Lorazepam
acute angle closure glaucoma presentation
severe, rapidly progressing pain, brick red eye, progressive headache on affected side, vomiting, rapidly progressing visual loss, corneal clouding, haloes, v high iop, mid dilated fixed pupil
Bamboo spine
Seen in ankylosing spondylitis , Due to ossification of the annulosus fibrosis and interspinous ligaments
hypoactive delirium
lethargy
slowness with everday tasks
inattention
excessive sleeping
5 common malignancies that spread to bone
Thyroid, lung, breast, renal, prostate
secondary prevention for TIA
treat AF treat carotid stenosis treat HTN optimise diabetes lifestyle changes treat vascular risk factors
Carpal bones
Bones of the wrist - Scaphoid, lunate, triquetral, pisiform, Trapezium, trapezoid, capitate, hamate
how often should diabetic patients be screened for DR?
at diagnosis and then annually
what are the 3 essential meds you cant miss in hospital
parkinsons meds
anti epileptics
insulin
strongst predictors of stroke prognosis
age and severity of stroke
AMT 4
age
dob
place
year
iridocorneal angle
the angle involved in glaucoma
latanoprost
prostaglandin analogue that lowers pressure in the eye by increasing drainage of aqueous humour
used in glaucoma
Aflibercept
Anti VEGF injection - used for wet AMD and oedema in DR
DVLA and epilepsy
1st unprovoked seizure = 6 months for group 1, 5 years for group 2
epileptic seizure = 12 months for group 1, 10 years for group 2
cant drive during period of AED withdrawal/changeover and for 6 months post
ropinirole
dopamine agonist for PD rx
Volar displacement
Displacement of the distal radius towards the palm of the hand #
4AT assessment
Alertness
AMT 4
Attention - months from december backwards
Acute onset and fluctuating
> 4 = delirium
crescendo TIA
2+ in 1 week
classic gait abnormalities in parkinsons
small shuffling steps with stooped posture.
unsteadiness on turning
difficulty stopping - festination
tendency to fall
‘freezing’ in doorways/ patterned carpets
uveitis presentation
associated with systemic inflammatory conditions- especially ankylosing spondylitis.
dull orbital pain, red eye, reduced vision, synechia, flare, tearing, floaters, photophobia
apraclonidine
alpha 2 adrenergic agonist - used in glaucoma to lower IOP by stopping aqueous humour production
best AED for pregnancy
lamotrigine with folic acid 5 mg
posterior column syndrome
loss of proprioception/vibration/fine touch below the lesion. sensory ataxia and positive rhombergs
Methotrexate given with
Folic acid
most common vasculitis in adults , affecting branches of the external carotid
giant cell arteritis
pathway of spinothalamic tracts
decussates soon after entering spinal cord and ascends in contralateral side
gonioscopy
measures the angle between the cornea and iris
loteprednol
topical steroids eye drops
osteoporosis treatment
colecalciferol and calcium supplement
alendronic acid - bisphosphanate
co careldopa
levodopa and carbidopa
Pilon #
Severe # to ankle – usually from jumping from a large height
signs of common peroneal nerve palsy
Hx of kneeling
weakness of foot dorsiflexion (causing foot drop) and eversion
anomia
unable to identify objects
how to prevent stroke in patients with AF
warfarin (INR aim 2-3) or apixaban/dabigatran
PC of MS
optic neuritis, weakness or loss of sensation, ataxia, facial weakness, nystagmus, diplopia, vertigo, deafness, transverse myelitis, cognitive and psychological symptoms
treatment of optic neuritis
Iv methylprednisolone with GI protection
Leflunomide
DMARD
treatment for encephalitis
Benzylpencillin for bacterial meningitis
IV acyclovir for HSV encephalitis
pseudodementia
due to a functional cause
depression
psychogenic
or hysterical
seizure
abnormal excessive neuronal activity in the brain leading to impairment of normal cognitive function
frontotemporal dementia treatment
antidepressants
antipsychotics
differnetiate between essential tremor and parkinsons disease
DaTScan
imagies the dopamin reuptake in the basal ganglia.
normal in essential tremor and not in PD
Ranibizumab
anti VEGF - used for wet AMD and oedema in DR
pathophysiology of diabetic retinopathy
hyerglycaemia- ishaemia - neovasculisation - leaky vessels - haemorrhage and oedema
management for falls
treat underlying cause
optimise sight
optimise mobility - balance and strength training with physio
optimise enviroment - OT
optimise foot wear - podiatry
medication review and stop drugs increasing risk
check osteoporosis and treat
side effects of dopamine agonists
impulsive behaviours +++
sleepines, fainting, nausea, constipation, confusion, hypotension, headaches, psychological problems
the different patterns of MS
RRMS 80% cases - becomes SPMS IN 50% of these
PPMS 15% cases
stages of alzheimers dementia
1) mild cognitive impairment - short term memory loss (Temporal lobe)
2) mild AD - reading problems and poor object recognition (parietal lobe)
3) moderate AD - poor judgement, impulsivity, short attention (frontal lobe)
4) severe AD - vision problems (occipital lobe)
HAS BLED
- risk of bleeding on anticoag for AF
HTN
Abnormal LFTs/Renal function
Stroke
Bleeding
Labile INR
Elderly >65
Drugs/alcohol
optical coherence tomography
mandatory test for AMD diagnosis
image of cross section of the retina
todds paresis
transient paralysis following seizure
lasts 48hrs
chloramphenicol
topical eye drop antibiotic to treat bacterial conjunctivitis
epinastine
topical eye drop antihistamine for conjunctivitis
syncope
global cerebral hypoperfusion
Schatzker classification
Classifies tibial plateau fractures
secondary dementia
reversible dementias due to a medical condition
Volar tilt
Normal wrist has 10 degrees volar tilt
pathophysiology of lewy body dementia
pathology of LBD mimics idopathic parkinsons
lewy bodys are composed of protein alpha synuclein
Mason classification
Classifies radial head fracturs 1=undisplaced 2 = displaced 3=comminuted
Boutonnieres deformity
Sign of RA-Hyperextended DIPJ and hyperflexed PIPJ
side effects of MAO B inhibitors
headache, aching joints, indigestion, flu-like symptoms, depression
can worsen side effects of ldopa - sickness and dyskinesia
entacapone
a cOMT inhibitor
taken with ldopa will prevent its break down and have a longer effect
hypopyon
pus in anterior chamber
triad of normal pressure hydrocephalus
dementia
gait disorder
bladder instability
risk factors for ischaemic stroke
hypertension carotid stenosis AF contraceptive pill clotting disorder diabetes smoking ischaemic heart disease peripheral vascular disease polycythaemia
scleritis
painful, associated with systemic inflammatory conditions (especially RA), pain with eye movement, visual loss
triad of encephalitis
fever, headache and altered mental status
prognosis of delirium
2/3 recover
1/3 wont recover completely- die or need care home
treatment for viral conjunctivitis
1) topical antihistamine +/- artificial tears
2) topical steroids
3) topical ganciclovir if confirmed adenovirus
Foot bones
Talus, Calcaneum, cuboid, navicular, 3 x cuneiforms
GBS prognosis
normal = max disability at 4 weeks
20% will have persistent neuro problems (of which 50% will be severe)
3-7% mortality
20% can’t walk unaided at 6 months
tia management
aspirin 300mg
risk asses for stroke
secondary prevention
Hallux valgus
Bunion , The big toe turns into valgus (laterally) towards the other toes
Susceptible nerve in humeral neck fracture
Axillary nerve
Susceptible nerve in elbow fracture
Ulnar nerve
dorsal columns carry
sensation of fine touch, proprioception and vibration
differentials of headache
tension headache cluster migraine drug induced meningitis space occupying lesion GCA sinusitis acute glaucoma trigeminal neuralgia subarachnoid haemorrhage
Odontoid peg
Peg on C2 vertebrae
presentation of giant cell arteritis
temporal head ache, scalp tenderness, jaw claudication, upper limb pain on use, polymyalgia rheumatica, partial or complete visual loss, systemic symptoms
causes of orthostatic hypotension
hypovolaemia - haemorrhage /vomiting /diarrhoea /dehydration
iatrogenic - betablockers, diuretics, vasodilators, alcohol, antidepressants, phenothiazines
autonomic failure - diabetic neuropathy, Parkinson’s disease, spinal cord injury
vascular dementia pathophysiology
caused by multiple small cerebrovascular infarcts, small vessel disease and a single cerebrovascular accident
alzheimers dementia pathophysiology
amyloid plaques - clumps of amyloid and degenerated neurons neurofibrillary tangles (mostly made of tau proteins)
hyperactive delirium
agitation delusions hallucinations aggression wandering
proptosis
abnormal protrusion of eye/s
physiological tremor features
increased SNS stimulation e.g. due to stress
action tremor
Multiple sclerosis characteristics
1) formation of lesions/plaques - in white matter (optic nerve/brain stem/ basal ganglia/ spinal cord/ corpus callosum
2) destruction of myelin sheath - demyelination
3) inflammation - cell mediated ( a break in the BBB allows them entry into the CNS)
presentation of early macular degeneration
central vision loss (scotoma or poor acuity), reduced contrast sensitivity, light glare, metamorphopsia
myasthenia gravis
a neuromuscular autoimmune condition - caused by antibodies against nicotinic acetylcholine receptor
forehead sparing is seen in
UMN palsy
Ulnar deviation
At the MCP joints-Might develop to subluxation
presentation of allergic conjunctivitis
severe itch, tearing, diffuse redness, papillae present
otorrhoea
discharge from ear
POCs criteria
1 of 3 present
- isolated homonymous hemianopia
- LoC
- cerebellar or brain stem syndrome
pathophysiology of CPOAG
reduced aqueous humour flow through the trabecular meshwork - raised IOP - hydrostatic pressure on the optic nerve and compromise of vasculature causing ischaemia leads to retinal ganglion apoptosis
galantamine
cholinesterase inhibitor for dementia
Pre-patellar bursitis
Housemaids knee – able to flex and relatively pain free
optic neuritis presentation
peri orbital/retro occular pain - worse on movement, loss of visual acuity with scotoma, RAPD, loss of colour vision, optic disc swelling, perception of seeing light due to eye movement or pressure on eye, swelling of optic disc on fundoscopy
presentation of CRAO
sudden painless loss of vision, RAPD
pale oedematous retina and cherry red spot fovea (underlying choroid)
differentials for space occupying lesion
infection - abscess, empyema, granuloma (TB)
vascular - stroke/haemorrhage
neoplasm - primary or secondary (glioblastoma)
hydrocephalus
corticospinal tracts
lateral tract decussates in the medulla
anterior decussates in the cervical/thoracic spine
cholesteatoma presentation
painless otorrhea - frequent or unremitting
progressive conductive hearing loss
erosion into local structures may lead to vertigo, headaches and facial nerve palsy
recurrent otitis media
Lewy body dementia core features
- visual hallucinations
- REM sleep disturbance
- fluctuating cognition, attention and arousal
with 1+ cardinal features of parkinsonism
treatment of AACG
emergency
1. brinzolamide (carbonic anhydrase) with timolol (beta blocker) and brimonidine (alpha 2 antagonist)
most common cause of bacterial conjunctivitis
staphylococus
streptococcus
4 main factors that lead to development of pressure sore
interface material
shear
friction
moisture
aetiology of falls
DAME
Drug induced
Age related - vision/instability
Medical - acute illness/syncope/seizure/stroke
Environmental
herpes keratitis sign
dendritic/geographic ulcer
treatment of endophthalmitis
intravitreal antibiotic injection if bacterial
treatment for AF
rate control - beta blocker or rate controlling CCB
2nd line = combo
rhythm control if rate control not working: amiodarone or electrical conversion
aphasia
inability to comprehend or produce languange/communicate
Hydroxychloroquine
DMARD
which level in the spine separates lower and upper limb innervation
T6
what is 3:1 atrial flutter
the beat is only conducted to the ventricles every 3 atria beats
HR = 100bpm
keratitis presentation
odeama and opacification of the cornea, corneal ulcer, redness, pain, discharge, lid oedema, reduced vision, photophobia, high IOP
Management of hip OA
Total hip replacement
drugs which induce parkinsonism
dopamine receptor antagonists
metaclopremide
haloperidol
cyclizine
prochlorperazine
natalizumab
anti lymphocyte moniclonal antibody
used in very active MS
cyclizine
used to treat vertigo/motion sickness
Sulfalazine
DMARD – good for fertile women
cholesteatoma
presence of keratinising squamous epithelium (skin) is present in the middle ear as a result of TM perforation (90%) or retraction
treatment for dry amd
no treatment
stop smoking, diet changes - eat dark leafy greens and take zinc and antioxidant vitamin supplements
counselling, visual rehabilitation
Syndesmophytes
Due to ossification of annulosus fibrosis. Irregular in psoriatic arthritis and regular in ankylosing spondylitis
hard exudates
precipitates of proteins leaking from blood vessels
The fibula lies on the _______ side
Lateral
Rheumatoid factor
Rheumatoid arthritis marker
investigations for suspected epilepsy
bloods - fbc, inflammatory markers, U&Es, LFTs (GGT), glucose - toxicity screen?
general obs and lying and standing blood pressure
ECG
alzheimers dementia presentation
> 60 YO
memory loss most prominent
gradual onset with slow progressive decline
evidence of varying changes in planning, reasoning, speech and orientation
decline in ADLs
personality, mood and interests change - apathetic,irritable
Diclofenac
Nsaid
myasthenia gravis treatment
anticholinesterase inhibitors - e.g. nyostigmine
immunosuppressants e.g. prednisolone and azathioprine
Colchicine
2nd line in gout if nsaids are CI becoz of renal impairment
when is an MRI indicated for seizures ?
new onset seizures in adulthood
focal seizures
seizures not responding to medication
treatment of scleritis
ophthalmologist referral
systemic steroids/NSAIDs +/- topical antibiotics
Intracapsular# treatment
Cannulated screws for non-displaced fractures, Hemiarthroplasty for displaced NOF #s
csf analysis of bacterial meningitis
Appearance: Cloudy and turbid
Opening pressure: Elevated (>25 cm H₂O)
WBC: Elevated >100 cell/µL (primarily polymorphonuclear leukocytes (>90%))
Glucose level: Low (<40% of serum glucose)
Protein level: Elevated (>50 mg/dL)
management of migraine
1st line = NSAIDs, antiemetics (domperidone), sumatriptan/zolmitriptan
treatment of CPOAG
1) medical: pressure lowering eyedrops
latanoprost, timalol, brinzolamide, apraclonidine
2) laser trabeculoplasty - peripheral iridotomy
3) surgical - trabeculectomyor aqueous shunt
presentation of endophthalmitis
pain, decreased vision, hazy eye appearance, floaters, hypopyon, swollen eyelid
furosemide
loop diuretic
inhibits Na-K-Cl co transporter in the thick ascending loop of henle
Fat pad
Signe up blood and fat in the joint capsule
differentials for sudden loss of vision
acute angle closure glaucoma retinal detachment retinal artery/vein occlusion giant cell arteritis orbital cellulitis endophthalmitis vitreous haemorrhage optic neuritis wet AMD
concerns about abuse of vulnerable elderly should be reported to
hospital safegaurding team
consequences of malnutrition
delayed wound healing impaired immune response reduced mobility increased length of hosp stay depression/ reduced qol
parkinsons disease
slowly progressing neurodegenerative disease with early prominent death of dopaminergic neurons in the substantia nigra pars compacta.
this leads to dopamine deficiency in the basal ganlia - causing parkinsonism
GBS treatment
plasma exchange IV immunoglobulins Neuropathic pain relief DVT prophylaxis ICU admission for ventilation
pramipexole
dopamine agonist for PD rx
csf analysis of viral meningitis
Appearance: Clear
Opening pressure: Normal or elevated
WBC: Elevated (50 – 1000 cells/µL, primarily lymphocytes, can be PMN early on)
Glucose level: Normal (>60% serum glucose however may be low in HSV infection)
Protein level: Elevated (>50 mg/dL)
DR treatment
1) photocoagulation (thermal laser) of the macular and pan retinal areas. it occluded microaneurysms reducing leakage and therefore oedema
2) Intravitreal injections if macula oedema (anti VEGF)
3) intravitreal steroids for refractory disease
differentials for red eye
conjunctivitis scleritis episcleritis uveitis keratitis AACG trauma / foreign body dry eyes
presentation diabetic retinopathy
painless gradual decrease in central vision
may have sudden onset of floaters if harmorrhage
central causes of vertigo
migraine
brainstem ishcaemia
cerebellar stroke
multiple sclerosis
classic clinical findings for CPOA Glaucoma
raised IOP >21mmHg
increased cup:disc ration >0.6
or 0.2 discrepancy btwn both eyes
arcuate scotoma
cardinal symptoms of parkinsonism
rigidity
rest tremor
bradykinesia
intention tremor features
coarse
caused by cerebellar lesion = stroke/trauma/ MS/ chronic alcoholism /lithium
worse with goal directed movement
associated features = ataxia, gait instability, hypotonia, dysarthria, poor rapid movement , nystagmus
GBS
autoimmune inflammatory polyneuropathy leading to demyelination and axonal degeneration
FOOSH
Fall on out stretched hand
what are the geriatric giants (5 x I)
incontinence Instability/immobility Intellectual impairment Impaired homeostasis Iatrogenic - pressure sores/ constipation
dementia
disorder of mental processes marked by memory disorders, personality changes and impaired reasoning
Anti Epileptic Drugs
Sodium Valproate
Lamotrigine
treatment for wet amd
anti-VEGF (vascular endothelial GF) injections
given monthly for first 3 months
5 day course of abx eye drop post injection
frontotemporal dementia presentation
can present as one of 3 clinical pictures:
1) behavioural and personality changes presentation -
2) semantic presentation - progressive decline in the understanding of word meanings, but speech fluent
3) non-fluent presentation - speech not fluent.
Swan neck deformity
Sign of RA-Hyperflexed DIPJ and hyperextended PIPJ
what is a significant orthostatic hypotension
a different of 20 mmhg btwn lying and standing BP
treatment of CRAO
firm occular massage
anterior chamber paracentesis and IOP reducing drugs
isosorbide mononitrate for dilation for dilation of retinal artery
manage underlying cause
rotigotine
dopamine agonist for PD rx
what are the 5 factors for Frieds frailty phenotype ?
weakness weight loss fatigue slowness reduced physical activity
episcleritis presentation
focal isolated red patch with tenderness over this area. mild watering.
associated in many cases with inflammatory disease - systemic vasculitis or CTDs
signs of AF
fatigue, palpitations, syncope, breathlessness, chest pain, stroke/tia
spinothalamic tract carries
crude touch, pain and temperature
photopsia
perceived flashes of light
treatment of MS
vit D supplements
Methylprednisolone 500mg for 5 days during relapse
for active disease (2 attacks in 2 yrs) = interferon beta or glatiramer acetate (both injections)
teriflunomide or demethyl fumurate may be preferred b/c oral
v. active disease = natalizumab
nerve conduction studies are used to diagnose
GBS peripheral neuropathy peroneal, radial, ulnar etc nerve palsies carpal tunnel spinal disc herniation
treatment of haemorrhagic stroke
return clotting levels to normal with vit k or prothrombin complex concentrate
metamorphopsia
distortion of lines - seen in macular degeneration
bells palsy is treated with
25mg OD steroidss for 10 days and eye care
severe non-proliferative (pre-proliferative) DR
multiple haemorrhages, exudates, cotton wool spots, venous beading, microaneurysms within all 4 quadrants
diagnosis of MS
CSF analysis - oligoclonal bands
MRI - type 1 - gadolinium contrast
need 2 DIS lesions and 2 DIT lesions evidence - either clinical or imaging or 1 yr neuro progression
glatiramer acetate
immunomodulating drug for MS
sub cutaneous injections OD
what is endophthalmitis
inflammation of the anterior or posterior chamber, usually exogenous cause - injections/trauma/surgery
how fast do the atria contract in atrial flutter
300 bpm
treatment of neuropathic pain in MS
carbamazapine
amitrityline
pregablin
dopa decarboxylase inhibitor
carbidopa or benserazide
stops too much dopamine being produced peripherally from ldopa
what is geographic atrophy
well demarcated areas of hypo/hyper pigmentation seem on the retina due to extensive and irreversible damage and death to retinal cells.
seen in advanced AMD
csf analysis of MS
Oligoclonal bands of IgG on electrophoresis (CSF and Serum)
Appearance: Clear
Opening pressure: Normal
WBC: 0 – 20 cells/µL (primarily lymphocytes)
Glucose level: Normal
Protein level: Mildly elevated (0.45 – 0.75 g/L)
GBS presentation
3 weeks after resp/GI infection (cambylobacter jejuni)
symmetrical progressive weakness and SL starting in lower limbs and moving upwards. Can lead to facial weakness, dysphagia and resp failure
csf analysis of subarachnoid haemorrhage
Appearance: Blood stained initially, then xanthochromia (yellowish) >12 hours later
Opening pressure: Elevated
WBC: Elevated (WBC to RBC ratio of approx 1:1000)
RBC: Elevated
Glucose level: Normal
Protein level: Elevated
brinzolamide
used to treat glaucoma
carbonic anhydrase inhibitor – block water flow into the eye, stopping aqueous humour production
panophthalmitis
inflammation of the entire eye
csf analysis of GBS
Appearance: Clear or xanthochromia
Opening pressure: Normal or elevated
WBC: Normal
Glucose level: Normal
Protein level: Elevated (>5.5 g/L)
essential tremor features
fine tremor onset with certain postures worse with voluntary movement improves with alcohol hereditary bilateral
apraxia
motor disorder
difficulty performing tasks or movements when asked
types of action tremor
essential tremor
physiological tremor
intention tremor
exclusion criteria for thrombolysis
subarachnoid haemorrhage recent trauma/head injury or surgery hx intracranial bleeding active bleeding inr 1.4 pregnant HTN >185/100 recent non compresive arterial punctre or LP
alteplase
recobinant tissue plasminogen activator
for thrombolysis in stroke/MI
precipitants for epileptic seizure
acute illness, poor sleep/jet lag, missing AED dose, excess alcohol, new meds, recreational drugs, GI disturbance, fatigue
keratitis management
corneal scraping for culture
topical antibiotics if bacterial
acyclovir/ganciclovir if herpes and same day ophthalm referral
causes of seizure
metabolic disturbance - hypoglycaemia, electrolyte disturbance, alcohol or drug intoxication, adrenal insufficiency
space occupying lesions
head trauma
stroke
medication
epilepsy
cortical dementia leads to ___________ memory impairment
severe
vascular dementia treatment
antiplatelet therapy (aspirin/clopidogrel)
lifestyle modifications
cholinesterase inhibitors - rivastigmine, donepezil, galantamine
BP control
statins
diabetic control
refractory epilepsy
failed to control seizures with 2 AEDs
orbital cellulitis treatment
IV antibiotics - vencomycin, clindamycin, cefotaxime
if failure to respond @48 hours - surgical drainage
treatment of ramsay hunt syndrome
acyclovir and steroids
CAM assessment
need 1 + 2 + 3/4 to be CAM +ve = delirium diagnosis
Acute onset and fluctuating
Inattention
Disorganised thinking
Conciousness altered
important electrolytes in falls
calcium
magnesium
potassium
TACs criteria
- unilateral weakness and sensory loss of face, arm + leg
- homonymous hemianopia
- higher cerebral dysfunction e.g. dysphasia
gonococcal conjunctivitis signs
severely purulent with eye lid swelling
what are the only 2 interventions which are proven to decrease risk of falls?
home hazard assessment
exercise programme to improve balance and strength
PACs criteria
2 of the 3 TACs criteria
- unilateral weakness and SL of arm, leg and face
- homonymous hemianopia
- higher cerebral dysfunction
characteristics of wet AMD
10% cases, advanced MD
fragile blood vessels grow in the subretinal space (between RPE and Bruchs) - leads to haemorrhage, exudate, irreversible damage
miller fisher syndrome
a variant of GBS - inflammatory neuropathy of the cranial nerves. leads to ophthalmoplegia
ganciclovir
topical anti viral eye drops for confirmed adenovirus conjunctivitis
stroke complications
haemorrhagic transformation DVT seizure orolingual edema - thrombolysis SE depression aspiration pneumonia brain oedema - raised ICP
Weber classification
Classifies based on the location of distal fibula fracture relative to the syndesmosis A = distal, B = at same level, C= proximal
csf analysis of tuberculosis
Appearance: Opaque, if left to settle it forms a fibrin web
Opening pressure: Elevated
WBC: Elevated (10 – 1000 cells/µL, Early PMNs then mononuclears)
Glucose level: Low
Protein level: Elevated (1-5 g/L)
presentation of CRVO
ischaemic = sudden painless loss of vision, RAPD
many haemorrhages in all 4 quadrants
treatment for essential tremor
propranolol or primidone
goldmann tonometry
measures IOP
presbyopia
gradual loss of focusing power due to loss of elasticity of the lens
treatment of CRVO
laser therapy - photocoagulation
anti-VEGF
steroids
causes of cardiovascular syncope
arrhythmia
structural cardiovascular disease - hypertrophic cardiomyopathy
structural pulmonary disease - pulmonary embolism
retinal detachment treatment
retinopexy: 1) a gas bubble is injected into the vitreous chamber and patient positioned so that the retinal break closes.
2) retinal-choroid adhesion induced around the edges of the tear using cryotherapy/laser or both
Jones fracture
at the base of the 5th metatarsal
ramsay hunt syndrome
herpes zoster infection of facial nerve
pc = facial droop, vertigo, tinnitus, facial rash/blisters, pain
dementia mortality
frontotemporal dementia - 8 years from diagnosis
lewy body dementia - 7 years post diagnosis
Colles fracture
Fracture of the head of the radius with dorsal displacement – towards back of the hand
Tension band wire
Surgical method to fix olecranon #s
signs of L5 root compression
foot drop, weakness of eversion and inversion and no ankle reflex
dopamine agonists
used for Parkinson’s treatment
pramipexole
ropinirole
rotigotine
management of cluster headaches
acute - subcut/nasal triptans
prophylaxis - verapamil and prednisolone before attack
ABCD2 score
risk of having a stroke after TIA Age >60 Blood pressure >140/90 Clinical features unilateral weakness or speech disturbance Duration <1 hr or >1 hr Diabetes
high risk >4- needs investigations within 24 hours
<4 needs within 1 week
treatment of status epilepticus
1) IV lorazepam -> IV diazepam -> buccal/IM midazolam
2) if no response in 10 mins - IV phenytoin
3) 2nd IV AED if not working - sodium valproate or lamotrigine
4) if no response at 30 mins from onset- sedation and ICU admission
prochlorperazine
anti emetic
dopamine 2 receptor antagonist
differentials for transient LoC
reflex syncope (vasovagal, carotid sinus hypersensitivity, situational) cardiovascular syncope - LoC due to reduced CO orthostatic hypotension
seizure
MUST score
tool to identify patients at risk of malnutrition
sarcopenia
reduced muscle mass in elderly
Chondrocalcinosis
Radiographic feature of pseudogout – calcifications in the joint space
differentials of Parkinsonism
- idiopathic
- drug induced
- vascular dementia
- essential tremor
- normal pressure hydrocephalus
bells palsy
LMN facial palsy
non-proliferative (background) DR
haemorrhages (dot and blot), microaneurysms, exudates and cotton wool spots outside of temporal arcades
confusion screen includes..
glucose LFTs UandEs B12/folate hemantics calcium FBC INR TFTs
CXR
Urine dipstick /culture
etiology of retinal artery occlusion
emboli - carotid or atria
thrombus
EEG
electroencephalograph
clinical signs of cataracts
no red reflex, reduced visual acuity and clouding of lens
Garden classification
For NOF# 1 – incomplete fracture, not displaced, 2- complete fracture not displaced, 3 – complete fracture partially displaced, 4- complete fracture completely displaced
keratitis
inflammation of the cornea
Galeazzi fracture
of distal radius with dislocation of the distal radio-ulnar joint
The 4 Rs of fractures
Resuscitation, Reduction, Restriction (immobilisation), Rehabilitation
LACs criteria
1 of the following
- pure sensory stroke
- unilateral weakness/SL of face/arm/leg
- ataxic hemiperisis
bloods for dehydration
hyponatraemia
raised urea
Heberdens nodes
DIP joint swelling in OA
normal IOP
10-21 mmHg
subcortical dementia leads to ___________ memory impairment
moderate
presentation of bells palsy
unilateral facial droop
hyperacusis - sensitivity to high pitch sounds
inability to close eyes
reduced lacrimation
agnosia
inability to interpret sensory input
e.g. visual agnosia
dopa decarboxylase
converts levodopa into dopamine
AED interactions to avoide
sodium valproate and lamotrigine
titrate carefully during swap over period
etiology of retinal vein occlusion
systemic disease - atherosclerosis, diabetes, hypertension
hypercoagulable state
glaucoma or retinal vasculitis
DSM 5 diagnostic criteria of Alzheimers dementia
significant cognitive decline in 1+ areas of cognition which impacts complex activities e.g. paying bills
+ memory loss
+ aphasia/ apraxia/ agnosia/ disturbance in executive function
+gradual progressive course
resting tremor features
4-6Hz pill rolling seen in parkinsonism improved with action usually apparent in 1 limb/1 side for months-years b4 becoming generalised
anti-vegf injection names
ranibizumab (lucentis)
aflibercept (eylea)
baclofen
treatment for spasticity
given to MS patients
signs of UMN
spasticity hyperreflexia pronator drift babinski upgoing clonus
management of ischaemic stroke
CT non contrast brain imaging
Thrombolysis with alteplase if within 4.5 hours of onset symptoms
Mechanical clot retrieval
aspirin 300mg for 2 weeks and then clopidogrel
start statins
CHADS VASC
-risk of having stroke with AF
Congestive heart failure Hypertension Age >65 or >75 Diabetes Stroke Vascular disease Female
rasagiline, selegiline
MAO B inhibitors
treatment for parkinsons
Susceptible nerve in humeral mid shaft fracture
Radial nerve
pathway of dorsal columns
ascends ipsilaterally and decusates in the brain
dysgraphia
unable to write or draw - clock drawing test
ACE 3
addenbrooks cognitive assessment - cognitive function test for assessment of dementia
diagnostic criteria for parkinsons disese
bradikenesia + resting tremor/ rigidity/ postural instability
exclude-vascular dementia, head injuries, neurleptic treatment, encephalitis, affected relative,sustained remssion, unilateral only after 3 yrs,
Allopurinol
1st line prophylactic treatment for gout
physical examination for patient with falls
neurovascular exam MSK exams of lower limbs cardiorespiratory cognition visual exam vestibular exam
treatment of giant cell arteritis
oral prednisolone or IV methylprednisolone
recurrent attacks - treat with methotrexate once weekly
Monteggia fracture
of proximal ulna with dislocation of the radial head
cotton wool spots
result of damage to the nerve fibres - due to an accumulation of axoplasmic material in the nerve layer
treatment of alzheimers
- supportive and environmental measures
- Cholinesterase inhibitors: Donepezil, Rivastigmine, Galantamine. delay progression by 6-12 months
- memantine if above not tolerated
investigations for optic neuritis
MRI of optic nerves
FBC, ESR, CRP
proliferative DR
neovascularisation at disc and elsewhere.
Charles Bonne syndrome
Sensory Deficits leads to hallucinations
rate limiting CCB
diltiazam or verapamil
peripheral causes of vertigo
BPPV menieres acoustic neuroma cholesteatoma vestibular neuritis
what are drusen
discrete yellow deposits between the RPE and Bruch’s Membrane. due to a build up of waste products usually removed by the RPE
treatment for bacterial conjunctivitis
simple infection will settle within 1-2 weeks
chloramphenicol
Clinical signs of scaphoid fracture
Pain in anatomical snuff box on palpation, pain on palpation of scaphoid tubercle, pain on telescoping of the thumb
rivastigmine
cholinesterase inhibitor for dementia
Closed reduction
Bones realigned without surgery
Brown sequard syndrome
hemisection
Ipsilateral loss of motor control and proprioception/fine touch/ vibration. contralateral loss of pain and temperature sensation
Anti-ccp
Rheumatoid arthritis marker
differentials of gradual loss of vision (5)
Refractive error cataracts age related macular degeneration diabetic retinopathy chronic primary open angle glaucoma
orbital cellulitis presentation
systemic fever/malaise, proptosis, pain with eye movement, diplopia, RAPD, restricted eye movement, blurred vision, oedema, erythema, blepharitis, conjunctivitis
if optic nerve involved - papilloedema and optic neuritis
Monosodium urate crystals
Build up in joints leads to gout
management of GCA
high dose steroids 60 mg ASAP
bloods and temporal artery biopsy
uveitis treatment
ophthalmology referral
steroid eye drops or peri/intraoccular injection
oral steroids if severe
treatment of allergic conjunctivitis
artificial tears, cool compress, sodium cromoglicate (mast cell stabiliser) and antihistamine (epinastine)
hypermetropia treatment
longsightedness - fixed with convex glasses
most common cause of viral conjunctivitis
adenovirus
Intertrochanteric # treatment
Dynamic hip screw
Commonest hip replacement
Cemented total hip replacement
teriflunomide
used to treat MS - oral med
re-feeding syndrome
nutrition reintroduced to severely malnourished patients can lead to potentially fatal shifts in electrolytes and fluid
differentials for bells palsy
acute otitis media choleostoma viral infection (EBV, CMV) GBS/ MS trauma or iatrogenic neoplasm - parotid malignancy
presentation of cataracts
gradual loss of vision, glare, haloes, sensitivity to light, faded colours
drugs with high anticholinergic burden
amitriptyline olanzapine oxybutynin quetiapine amantadine
convulsive status epilepticus
seizure > 5 mins or > 3 seizures in 1 hour
Calcium pyrophosphate crystals
Pseudogout
initial investigations for fall
bloods - BM, U&Es, FBC, inflam markers
ECG
bone profile
TFTs, B12, folate - peripheral neuropathy causes?
signs of LMN lesion
hyporeflexia
flaccidity
fasciculations
atrophy
characteristics of DRY AMD
90% cases, gradual progression
drusen are seen on fundoscopy
10-15% will develop wet amd
myopia treatment
short sightedness - fixed with concave glasses
Parts of a psychiatric history
Pc/HPC Past psychiatric history Past medical history Medications Family history Personal history - birth, early childhood - schools -higher education -qualifications -employment -relationships -psychosexual history -current living situations -forensic history Alcohol and drugs Premorbid personality
Diagnosis of depression (ICD 10 )
1) need 2 key symptoms: low mood, anhedonia, fatigue
2) other symptoms: appetite changes, sleep changes, poor concentration, agitation or retardation, low self confidence, guilt or self blame thoughts, suicidal thoughts
lasting > 2 weeks
4 symptoms = mild
5-6 = moderate
7+ = severe
organic causes of depression
medication - steroids, beta blockers, statins, progesterone, isotretinoin
chronic pain, hypothyroidism, Addison’s disease, MS, diabetes, cerebrovascular disease, alcohol and substance abuse
manic episode criteria
1) A 1 week+ period of expansive mood with abnormally elevated energy
2) severe enough to cause social/work impairment or hospitalisation or psychotic symptoms are present
3) 3 or more of the following: grandiosity, decreased need for sleep, more talkative, flight of ideas/racing thoughts, distractibility, increased goal directed activity/psychomotor agitation, excessive involvement in risky behaviours e.g business ventures/sex
hypomanic episode criteria
same symptoms as above
lasting over 4 consecutive days
uncharacteristic but not impairing functioning of patient
no psychotic symptoms
treatment for subthreshold depression
active monitoring
reassess in 2 weeks
provide info about depression
treatment for persistent subthreshold depression and mild-moderate depression
1st line = low intensity psychological intervention (CBT therapy)
only consider meds if patient has previous moderate/severe depression or this episode has lasted >2 yrs
2nd line = high intensity psychosocial intervention (CBT/IPT) OR an antidepressant
treatment for moderate-severe depression
antidepressant combined with high intensity psychological intervention
treatment for severe or resistant depression
consider inpatient care
when to consider ECT for depression?
need rapid response
life threatening depression
all other treatments have failed
fluoxetine
SSRI
venlafaxine
SNRI antidepressant
duloxetine
SNRI antidepressant
Mirtazapine
antidepressant
blocks alpha 2 receptor causing raised Na and 5HT
treatment with antidepressant - step wise approach
1) SSRI - start at half the dose and titrate up every 14 days
if no response after 4-6 weeks :
2) switch SSRI or start SNRI
3) mirtazapine
4) augmenting agent - antipsychotic/lithium
5) TCA
6) MAO-I
amitriptyline
TCA
what demographic factors increase a patients suicide risk
male older > 45 yo single/widowed/divorced social isolation living alone low income/ unemployed doctor/farmer Fhx of suicide/substance misuse/depression
what details about a suicide attempt increase a patients suicide risk
final acts preparation high perceived legality precaution against being found violent methods discovered by chance resists mediccal intervention downplaying the seriousness
which antidepressants are most likely to cause discontinuation syndrome
venlefaxine and peroxetine
organic causes of psychosis
delirium dementia temporal lobe epilepsy CNS infection brain injury/trauma metabolic disorder - vit b12 thyroid disease cushings syndrome high dose steroids huntingtons extreme fatigue alcohol/drug withdrawal hypoxia
treatment of 1st psychotic episode
1) 2nd gen oral antipsychotic
2) with psychological intervention e.g. family therapy or individual CBT
atypical antipsychotics
2nd gen
aripiprazole clozapine quetiapine olanzapine risperidone
MHA
section 2
allows for mental health assessment
lasts up to 28 days
signed by 2 doctors (1 approved) and 1 AMHP
patient can appeal within 14 days via specialist tribunal
MHA section 3
for treatment
lasts up to 6 months
signed by 2 doctors and 1 AMHP
can be challenged with tribunal
MHA section 4
emergency admission only for assessment signed by 1 doctor lasts 72 hours cant be appealed
MHA section 5 (2)
allows for an inpatient to be kept in hospital due to mental illness.
lasts 72 hours
can’t appeal
signed by responsible clinician
MHA section 5 (4)
emergency holding order for hospital inpatients
signed by 1 registered nurse
lasts 6 hours
cant be renewed
MHA section 135
emergency section to bring you from any premises (incl. home) to hospital
made by a police and doctor and AMHP
can be held for 72 hours
can’t be appealed
MHA section 136
emergency situation bring patient from public to hospital by police and doctor lasts 72 hours can't be appealed
akathisia
movement disorder
inner restlessness
extrapyramidal side effects
parkinsonism
dystonia
dystonia
acute dyskinesia
