Presentations Flashcards
Ischaemia vs hypoxia
Ischameia is lack of blood flow to provide adequate oxygenation and lads to tissue hypoxia = reduced oxygen
What does VGEF respond to?
Ischaemia, hypoxia and inflammation
What is neovascularisation
Proliferation adnd migration of endothelila cells to form new vessel
How are retinal vessels different from normal vessles
- Absence of sympathetic nerve supply
- Autoregulation of blood flow
- Presence of blood-retinal barrier
Why does high blood pressure affect vision so much?
Renal vessels are different
- Absence of sympathetic nerve supply
- Autoregulation of b;lood flow
- Presence of blood-retinal barrier
HPTN therefore transferred directly t retinal vessels
What sign is found exclusively in diabetic of all the retinopathies eg not in hypertensive?
Microaneurysms
Red flag head and neck cancers
- Stridor
- New persistent nefck lump,
- dysphagia,
- unilateral odynophagia,
- middle ear effusion - elderly, cancer is post nasal space - eustachian tube drainage blocked
- Asian people more likely to have sinonasal cancers - watch for
- referred ear pain, smoking is risk factor
- over 45
- Persitent = over 2 weeks
- Laryngeal
Red flags in back pain
- Sphincter/ gait distrubance
- Progressive motor loss
- Saddle anaesthesisa
- Non-mechanical pain at rest
- Fevere or weigth loss
- Under 20 or over 50
- Thoracic pain
- Prev history cancer
- HIV/immuosupresssion
How investigate a neck lump?
- US with biopsy
- MRI neck with contrast - soft tissue disease
- High resolution CT neck with contrast - thyroid cartliage
- CT chest - mets
- Panenodoscopy under GA
What is a PEG
Percutaneous gastrostomy
Red flags in hoarseness
- Persistent sore throat/odynophagia
- Persistent dysphagia
- Persistent unilateral otalgia
- Persisten cough/SOB
- Has he lost weight?
Signs of CNIII involvement
- Eye down and out (MR, IR, SR, IO)
- Mydriasis )pupillary constriction)
- Ptosis (levator palpebrae superiosis)
CNVI sign
- Diplopia on R gaze (LR)
Causative agent of mastoiditis often is
Strep pneumoniae
What disease do you avoid haloperidol in?
Parkinsons/Lewy body dementia as causes parkinsonism, dysphagia and increased risk of stroke
What is a dol?
deprication of liberty dafeguards
Medications causing deliriym
- Anitcholinergic meds - TCAs amitryptilline, oxybutynin, tolteroidine
- Furosemide, codeien, digoxin, tramadol, warfarin, nifedipine, metoclopramide
- Sedatives - benzos
- Opioid analgesics - dose
- Anti-parkinsonian drugs - LDopa, dopamine antagonists
What is the investigation for vestibular schwannoma?
MRI
Discharging ear with pain differntials
- Otitis externa or media
- Foreign body
Discharging ear without pain differentials
Chronic suppurative otitis media (CSOM) woth perforation
cHRONIC INFECTION
cholesteatoma
Function of the larynx
Protext AW
Phonation
Regulate air flow into lungs
Most common to most ommon causes of hoarseness
- Infective laryngtiis
- Viral
- Fungal - steroid inhalers
- Laryngopharyngeal reflux
- Vocal cord polyps + nodules
- Neuromuscular conditions
- Vocal cord paralysis - vagus/RLN issues, intrinsiv muscle issues, cricoarytenoid joint issues
- Cancer - layrngeal - voice box (H+N, distal affeting vagus/RLN)
What is an early sign of epiglotitis ?
Hoarse voice
H influenzae
Why is hoarse voice significant in malignancy?
Commonest and often only sign of laryngeal cancer
Cerebellar signs
Dysdiodokinesia
Ataxia
Nystagmus
intention tremor
Slurred speech
Hypotonia
Which motor neurone lesions are atrophy and fasciculations seen in?
LMN
What is tone like in UMN vs lMN?
UMN - spasticity
LMN - Reduced
What are reflexes like in UMN or LMN lesions?
UMN - brisk
LMN - diminished
Whcih tremors are asymmetrical?
Parkinsonism, intention
What tremor worsens with stress and improves with rest?
Essential - symmetrical
What is most common tremor seen in parkinsonism?
Pill rolling
What happens to parkinsonian tremor at rest and on cognitive task?
Cognitive task - induces
Rest worsens
Which side of body is intention tremor on?
Ipsilateral to damage
When is intention tremor induced?
At end of purposeful movement ie finger to nose test
In which tremor would DANISH symptoms also be experienced?
Intention
What would EARLY AUTONIMIC SYMPTOMS suggest with coarse tremor?
MS -
orthostatic hypotension, erectile dysfunction, bladder disturbance, odd nocturnal breathing patterns
What would early hallucinations and coarse tremor suggest?
Parkinsonism with lewy bodies
What drugs can cause a coarse tremor?
Anti-emetics - betahistine, metaclopramide
Antipsychotics
What motor symptoms are suggested with parkinsonism with coarse tremor?
Slowness of movement must be present
Difficulty turning in bed
Shuffling gait
Reduced arm swing
Non motor early signs o parkinsons
Loss of smell
Depression
Dream entactment or fragmented sleep
Nocturia, urinary urgency, constipation
What does essential tremor improve with
Alcohol, beta blockers
What is chorea
Involuntary irregular, non rhytmic, rapid and unsustained movements flow randomly from one part of body to other
Unpredicatble in timing, direction and distribution
What causes dystonia>
Agonist and antagonist muscles of body contract together -> twisted posture of limb neck or trunk
Involve same muscle groups
What is myoclonus?
Sudden, brief, jerks caused by muscular contraction - postive
or inhibition - negative eg asterixis
What is restless leg syndrome?
An unpleasant, crawling sensation in legs or arms, esp when sat and relaxing, prominent in the evening. Disappears when walking
What are tics
Abnormal, stereotypuc, repetitive movements (motr tics) or abnormal sounds (phonic tics). Temproray suppression but need to be released at some point
what movements are hyperkinetic
Myoclonus
TIc
Dystonia
Atacia
Chorea
Functional;
Hypokinetic movements
Bradykinesia
Resting tremor
Postural instability
Rigidity
Causes of parkinsonism
parkinsons disease
Lewy body dementia
Antipsychotics - block dopamine
PSP (PD plus vertical gaze palsy)
MSAA - PD with ANS problems
Features ass with headache that are red flags
- Fever
- Rash
- Photophobia
- Nausea and vomitting
- Papilloedema
- neurological deficit
- impaired consciousness
- Change in personality/behaviour
- Dizzy
- Seizures
- Visual symptoms
What is raised ICP ass with?
- Headache worse in morning
- Worse on postrual change eg bending forward
- Focal neurological symptoms
- Visual changes/obscuration - w posture often
What can a space occupying lesion cause
- Focal neurology
- seizures
- Altered behaviour
- Symptoms primary malignancy, often not headahce alone, Hx suggests raised ICP
What lesion is ass with valsalva manourvre
Posteroir
What headahce causes get worse on lying down
Space occupying lesion
Venous sinus thrombosis
What headahce cause gets worse ons tanding?
CSF leak
Primary causes of headache
Tension
Migraine
Cluster
Secondary causes of headache
Sinusitis
- Otitis media
- Medication withdrawel
- Menstrual headache
- Med overuse
- Cervical paraspinak tenderness
- Dental care
- Acute hydrocephalus
- Space occupying lesion
- Papilloedema -
- Giant cell arteritis - 50+
Signs of acute hydrocephalus
- ataxia, lethargy, confusion, vomitting
Symptoms of Giant cell arteritis
- Lateralising headache over weeks
- Sight threatening
- Amorosis fugax
- TIAs
- Temporal pain and tenderness
- Jaw claudication
- Visual disturbances and field defects eg floaters
Investigation giant cell artteritis
- Check ESR/doppler of temporal artery
What is giant cell arteritis?
systemic vasculitis of medium-sized and large-sized arteries
Autonomic and neurologica symptoms in cluster headahce
- Autonomic symptoms
- Nose run, sweat, red eyes, lacrimation
- Looks like an allergy
- Episodic
- Neuralgia
- Precipitated by touching
- Tingling etc
Symptoms of benigin intercranial HPTN -> raised ICP
- Autonomic symptoms
- Nose run, sweat, red eyes, lacrimation
- Looks like an allergy
- Episodic
- Neuralgia
- Precipitated by touching
- Tingling etc
What is the MRC muscle power scale score 1-5
0 = no contraction
1 = flicker or trace of contraction
2 = active movement with gravity eliminated
3 = active movement against gracity
4 = active movement against gravity and resistance
5 = normal power
Types of gait
Antalgic
Ataxic
Hemiplegic
High stepping
Trendelenbergs
Waddling
What is high stepping gait caused by?
Weakness of dorsiflexors - common peroneal damage or peripheral neuropathy
What can ataxia affect?
Eys - nystagmus, hypermetria
Speech - dysarthria, slurred speech
Limb movements - intention tremor, hypermetria aka past point and overshoot
Gait - broad based, wobbly
Indications for lumbar puncture
Sus meningitis
Sus SAH
Cpnfusion, meningeal malignancies. demyelinating disorders
Intrathecal meds administration
Treat hydrocephalus or benign intracranial HPTN
LP contraindications
Signs of raised ICP
Convulsions until stabilised
Shock
Abnormal clotting profile
Superficial infection voer LP site
Complications of LP
Post LP headahche
Infection
Bleeding
Cerebral herniation
Minor neurologic symtpoms such as radicular pain or numbeness
Late onset epidermoid tumours of thecal ssac
Back pain
What is the investgiation of choice for epilpesy?
MRI
Conditions do nerve conduction studies for
GBS
Charcot-marie tooth
Carpal tunnel
Neuropathy
Herniated disc
Sciatica
Path for movements in the brain
- Cortex
- Basal ganglia
- Cerebellum
- Nerve
- Muscle
Ascending peripheral polyneuropathy signs
- Symptoms start distally + progress proximally
- LMN signs
- Affect motor and sensory
Cervical cord compression signs
Bilateral UMN signs
- Brisk refleces
- reased tone
- Below leele of lesion
- Slow progressive spastic paraperesis
What reflex dermatome is S1
Ankle jerks
Knee jerks dermatome
L2, L3, L4
What dermatome does bicep jerks originate from?
C5
What jerks originate form C6
Supinator jerks
What jerk originates from C7
Triceps
Abdominal nerve roots
T8-11
What would a L cerebellar problem shpw?
- Contralateral UMN and sensory signs
- Language problem
- No movement disorder
Eg chorea, parkinsonism, hemibalismus
What classification is used for strokes?
Bamford
What does hyperkinesia originate from brain?
No negative feedback to the brain
Grey matter function
Most motor and sensory
Higher functions of brain
What matter does gross damage effect?
Grey
What is white matter
Myelinated axons, communication areas between brain
What matter do demyelinating diseases effect?
White
Function of basal gnaglia
Movement, posture, muscle tone,
Emotional learning/states, behaviours
What forms the lentiform nucleus?
Putamen and globus pallidus
What is the pleasure cnetre of the brain
Nucleus accumbens
What is the basal ganglia made up of?
Corpus striatum and amygdala
What part of brain senses fear and disgust?
Amygdala
What is corpus striatum split inot
Neostraitum - caudate nucleus, putamen
Paleostriatum - globus pallidus
what conditions affect the basal ganglia
Parkinson, huntnigtons
Function of the brainstem
Regulates cardiac and respiratory function
What can be used to verify brainstem death
Corneal and gag reflex absence
What arteyr stroke can cause locked in syndrome
Basilar
What is Guillian Barre syndrome
Demyelinating polyneuropathy autoimmune
Virus triggers immune system antibodies to attack nerves
What is indication for nerve conduction studies
- For paraesthesias - numb, tingling, burning
- Weakness arms/legs
When is MRI especially helpful in epilepsy
- <2 year presentation or adulthood
- suggestioon focal onset history, exam or EEG - unless clear evidence benign focal epilepsy
- Seizures continue in spite of first line medication
When is a EEG done in children/young adult s
-after second seizure in children/YA
-EEG is supportive, not used as diagnostic for epilepsy
Signs of Guillian Barre syndrome
Spreads up - painful paraesthesia from feet
Extreme weakness and areflexia
What test do in Guillian Barre syndrome to assess severity?
Spirometry - whether has reached repiratory muscles yet
Hwo can treat guillian Barre sundrome
Immunoglobulins
What viruses cause Guillian Barre syndrome?
Campylobacter GE, viral
Where does central dural sinus get venous drainage from?
Facial veins
Why do face, nose and tonsil infections pass into cranium?
Via cavernous sinus - ICA, CNs
Triangle of death - infection site
SPondylysis vs spondylisthesis
Spondylosis = arthritis of spine
Spondylisthesis = slipped disc
CURB 65
Confusion
- Not themselves = delirium
- Think clearly - feel a bit muddled
Urea >7mmol - urine output in GP - whiskey rather than water
Resp rate = 30 breaths/min
BP < 90 mmHg systolic, 60 diastolic
> 65 yrs
Memory assessments for dementia
Minicog
6CIT
MMSE - 10 qs
Which antibiotic reacts with statins
Clarithromycin
CENTOR criteria
- Tonsilar exudate
- Tender anterior cervical lymphadenopathy or lymphadenitis
- Histoy of fever over 28
- Absence of cough
- Each = 1 point
- 3/4 = likelihood 36-52% of isolating strep
Most common cause sore throat
Strep pygoenes/GABHS
FEVER PAIN index
- Temperature >38.5 degrees
- History of a fever
Purulence - swab, picture, inspect
Attend Rapidly - within 3 days after onset symptoms
Inflamed tonsils - severely
No cough or coryza - inflammation mucus membranes in nose
Each point is 1 point - max = 5, above 3 = =swab
General aches + pains - more systemic
What is the S1Q3T3 pattern
S wave in lead I - R shift of axis
Q wave and T wave inversion in lead III
What type of anaemia does alochol cause
Macrocyitc
