Psych / Neuro Flashcards

Question

Meningitis & encephalitis - presentation? causes? Ix? Mx?

Answer 1

Meningitis: * Presentation: headache, fever, photophobia, neck stiffness * Causes: * Bacterial – **N. meningitides, S. pneumo** (TB; neonates/elderly – GBS/Listeria/E.coli) – Listeria also more common in _alcoholics_ * Viral – enterovirus (Coxsackie, echovirus), mumps, HSV2 * Fungal – cryptococcus neoformans (chr) * Ix: A-E, **BC**, CT head, **LP** (CT first, if raised ICP --\> LP would cause coning) * Kernig sign - flex knee & hip to 90 degrees --\> extend knee (painful & limited extension) * Brudzinski sign - raise head while flat --\> hip & knee flexion * Mx: bacterial – **IV ceftriaxone** ± amoxicillin (Listeria - neonate/elderly) * **IM BenPen** for possible meningococcal infection (rash) in GP setting before sending to the hospital * Viral – supportive (self-limiting) * Altered consciousness (encephalitis?) --\> add _IV acyclovir_ Encephalitis: * Presentation: headache, fever, seizures, drowsiness, confusion (viral _HSV1_ affects temporal lobes --\> affecting consciousness) * Ix: BC, CT head, LP * Mx: **IV acyclovir** ± anti-convulsants

Answer 2

Postural imbalance/swaying: * When eyes open & closed = Cerebellar ataxia * When eyes are closed = sensory ataxia (somatosensory nerve affected) * Dorsal column loss: Tabes dorsalis (syphilis), SCDC (B12), MS * Sensory peripheral neuropathy

Answer 3

Dark matter middle (cell bodies = synapses) --\> white matter on the outside (neurone tracts) Sensory pathways (ascending - goes up): * **_Dorsal columns_** (posterior) - **fine touch, vibration, proprioception** * Sensory receptors - _1st order neurone_ up spinal column along ipsilateral side * At the **medulla oblongata** - synapses with _2nd order neurone_ that crosses the midline (decussation) * At the **thalamus** synapses with _3rd order neurone_ to the **Primary Somatosensory cortex** * **_Spinothalamic tracts_** (anterior) - **pain & temperature** * **Nociceptors** (pain) - _1st order neurone_ to **Substantia Gelatinosa** within grey matter of spinal cord * Synapses with _2nd order neurone_ & immediately crosses midline (decussation) to ascend spinothalamic tract * *NOTE: spinothalamic tracts decussate at the level the neurone enters the spinal cord* * At the **thalamus** synapses with _3rd order neurone_ to the **Primary Somatosensory cortex** * (Spinocerebellar tracts (lateral) - proprioceptive info to cerebellum) Motor pathways (descending - goes down): * **_Corticospinal tracts_** (anterior = trunk, neck, shoulders; _lateral - limbs_) - **voluntary motor control** (from primary motor cortex) * From the **Primary Motor Cortex** - _UMN_ goes to the **Medulla** and crosses over (decussation) * At the **anterior horn** for each spinal level synapses with _LMN_--\> muscle * NOTE: at any spinal level will be LMNs exiting the spine and UMNs that travel down further before synapsing with their respective LMN * SO *cord pathology above the level of Cauda Equina --\> some UMN & LMN signs*

Answer 4

Def: tendency to have recurrent, unprovoked seizures * Seizure = episodes of abnormal uncoordinated excessive brain activity * Provoked seizures = consequence of inf/drugs * Unprovoked = epilepsy * Definition of epilepsy: ≥2 unprovoked seizures >24hrs apart OR ≥1 unprovoked seizure AND probability of further seizures OR Dx epilepsy syndrome Types: * **Generalised** (whole brain): * Tonic-clonic, Tonic, Atonic, Myoclonic --\> Tx: _Na Valproate_ (AVOID in girls/women of childbearing age) * Absence (EEG - spike & wave pattern, Jeavons syndrome - myoclonic absence/eyelid myoclonia) --\> Tx: _Ethosuximide_/Na Valproate * **Focal** - aware (conscious) OR impaired awareness (impaired consciousness) * Tx: _Lamotrigine_ General management: * First seizure clinic - while waiting avoid trigger factors (sleep, caffeine, alchohol), stop driving and avoid dangerous activities + shower > bath * Drugs see above * For women: * Contraception - medroxyprogesterone acetate inj or IU methods (Cu-IUD or LNG-IUS), other methods interact with epilepsy meds * Pregnant - risk to child but dangerous to stop meds - avoid Na Val if at all possible Status epilepticus = \>5mins/repeated seizures without full recovery in between * 1st - IV lorazepam 4mg --\> repeat * 2nd - phenytoin infusion * 3rd - general anaesthesia * If no IV access --> buccal midazolam (or rectal diazepam) * Recovery position once seizure stop

Answer 5

Presentation * Disc herniation - acute unilateral radiculopathy (pain & numb in specific dermatome/weakness in muscle group) * Straight leg raise +ve * Worse on flexion (bending over/sitting) * Spinal stenosis - insidious neurogenic claudication (intermittent back pain worse on walking/standing) ± pain radiating down leg/leg paraesthesia * RFs: rev back injury/surgery, manual labour * Worse on extension (standing/walking) Ix: * Disc herniation - erect lumbar x-ray & MRI spine * Spinal stenosis - plane x-ray, MRI (T2-weighted) Mx: surgical decompression

Answer 6

**Cerebellar** signs _ipsilateral_ **Motor nerves** travel laterally in brainstem & cross @medulla **Dorsal columns** are _posterior_ & cross @medulla **Spinothalamic tract** is _anterior_ in spinal cord & cross in spinal cord Localisation: * **Cortical** - UMN pyramidal signs (hypertonia, hyperreflexia, babinski) * **Basal ganglia** - rigidity, tremor, bradykinesia * **Cerebellar** - DANISH (dysdiadokokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia) * **Nerve root** (dermatome/myotome)/single nerve - LMN signs (hypotonia, hyporeflexia, fasciculations, wasting, sensory loss)

Answer 7

**_LMN_** presentation = muscle pathology * Face: * Myopathic facies (sunken cheeks, bilateral ptosis, expressionless) * Wasting of facial & muscles of mastication * Frontotemporal balding * Distal wasting, weakness w/ loss of ankle jerks * Associations: cataracts, dysphagia, cardiac (cardiomyopathy, heart block), DM, hypogonadism (gynaecomastia/testicular atrophy) * Exam - failure of immediate relaxation after voluntary contraction * _Percussion myotonia_ - tap thenar eminence and thumb contracts * Slow-releasing grip - SHAKE HANDS (or make a fist and then spread fingers quickly or squeeze eyes shut and open quickly) Ix: * Conservative: _full functional assessment_ (incl. SALT), lung function tests (NM resp insufficiency), ECG/echo (CMO/HB), slit lamp (cataracts) * Bloods - BM (DM assoc), _CK_, genetic testing * Imaging & invasive: * Electromyography (EMG) - 'dive-bomber' potentials * Muscle/nerve biopsy Mx: MDT approach * Phenytoin for myotonia, weakness has no Tx * Genetic counselling - AD w/ genetic anticipation (trinucleotide repeat - worse severity/earlier presentation with each generation) * Avoid _statins_ (can cause myopathy)

Answer 8

Bilateral: * **MG** * **Myotonic dystrophy** * Tabes dorsalis (syphilis) = Argyll-Robertson pupil Unilateral: * 3rd nerve palsy (down & out, dilated, ptosis) * Horner's syndrome (ptosis, meiosis, anhydrosis)

Answer 9

**Myasthenia Gravis** * Def: * Chr AI disorder of post-synaptic membrane of NMJ in skeletal muscle * _Abs to AChR_ on post-synaptic membrane * Presentation: * **_Muscle fatiguability incl dysphagia_**, rarely SoB * **Eyes** - _bilateral ptosis_ (and compensatory increased frontalis muscle activity = raised eyebrows), diplopia * Face - dysarthria (slurred speech), facial paresis * _Curtain sign_ - when raising one upper eyelid the other one drops down * Assoc: **thymomas** (in the chest) * Ix: * Abs: **AChR** (on post-synaptic membrane), MUSK abs * Serial pul funct tests (FVC & negative inspiratory force) * NOTE: do not wait for ABG findings - late in course * CT-chest (for thymoma) * Mx: * **Acetylcholinesterase inhibitors** (Pyridostigmine) + IS (azathioprine) * IVIG/Plasmapheresis * Surgery - thymectomy * **Myasthenic crisis** = acute respiratory failure - FVC \<1L, negative inspiratory force (NIF) ≤20cm H2O, need mechanical ventilatory support * Accessory muscle use indicates sign inspiratory muscle weakness * Weak cough indicates sign expiratory muscle weakness * ABG often shows hypercapnia before hypoxia * Low threshold for endotracheal intubation (rapid deterioration of bulbar & resp muscles) * Mx: _intubation + mechanical ventilation_ (& Mx above) **Lambert-Eaton Myasthenic Syndrome (LEMS)** * Def: rare AI disorder of NMJ * Pre-synaptic membrane _Ab to voltage-gated Ca-channel_ receptors * 40% occur as paraneoplastic disorder assoc w/ SCLC * Presentation: * Limb weakness - proximal legs --\> proximal arms e.g. waddling gait * **STRONGER WITH USE** (vs MG get's weaker with use) * Hyporeflexia, NO eye involvement (compared to MG) * Autonomic disturbance - **_dry mouth_** (& orthostatic hypotension, sweating, GI & urinary problems, visual blurring, sexual dysfunction) * Associated with: _small cell lung cancer (SCLC)_ * Ix: * Nerve conduction studies, EMG, serial PFTs * Ab testing (Voltage-gated Ca-channels & AChR-abs) * CT chest (SCLC) * Mx: MDT support * Tx underlying cause, Amifampridine * IVIg/plasma exchange * Supportive care

Answer 10

Hammertoes - bilateral, symmetrical, distal wasting of small muscles of feet * Advanced = dorsal guttering from distal wasting, wasting of _extensor digitorum brevis at inferior border of lateral malleolus_ * Similar can be seen in the hands = wasting of _first dorsal interosseus_ Sign of **Charcot-Marie-Tooth disease** aka hereditary motor & sensory neuropathy (HMSN)/peroneal muscular atrophy (PMA) * Hx ankle sprains & scoliosis * Motor & sensory losses (sensory milder) = classic peripheral neuropathy * LMN pattern of weakness: * Motor loss in anterolateral compartments of legs (ankle dorsiflexion & toe extension) * Absent reflexes (plantar reflexes show no response) * Sensory loss in _glove & stocking distribution_ bilaterally * Pes cavus ± palpable common peroneal nerve, thickened nerves @medial malleolus * High stepping (foot drop) & ataxic gait * Test for foot drop = _heel walking_ What do I need to check for? NO scars over fibula (would indicate peroneal nerve damage from trauma e.g. car accident) DDx: * _Common peroneal nerve palsy_ (inversion of foot normal) * Sensory peripheral neuropathy: B12-def (SACD), Alcohol, DM, Hypothyroid (vitiligo?), HIV, drugs * Motor peripheral neuropathy: lead poisoning Types: * **Type 1** - demyelination, AD * Type 2 - axonal, AD/AR * Type 3 - demyelination, AR & presents as infant Ix: full functional assessment, FHx, _nerve conduction studies_, genetic testing Mx: * Physio, walking aids with ankle & foot supports (e.g. foot splint)

Answer 11

Hand muscle wasting - _dorsal guttering_ = first to be affected in ulnar lesions * First dorsal interosseous (next to thumb) = ulnar nerve * Abductor policies brevis (thenar eminence) = median nerve * Weakness of both - suspect T1 radiculopathy * NOTE: ulnar nerve innervates most of the intrinsic muscles of hand except median nerve serves **LOAF**: 2 radial **L**umbricals, **O**pponenes pollicis, **A**bductor pollicis brevis & **F**lexor pollicis brevis **Ulnar nerve palsy** = _claw hand_ @rest (4th & 5th fingers in extension at MCP, flexion at PIP/DIP) * Commonest site of lesion = elbow (arthritis @wrist & elbow) * Froment's sign (weak adductor pollicis brevis --\> thumb flexion) = +ve if thumb arches to hold paper = _ulnar nerve palsy_ * **Ulnar paradox** - higher lesion causes lesser deformity as lower lesions spares flexor digitorum profundus (causes flexion at DIP) **Median nerve palsy** = _sign of benediction_ on asking to close hand (thumb, index finger can't close, middle finger can close partially) * Look for sensation over thenar eminence --\> if lost can't be carpal tunnel syndrome (still median nerve palsy but arises proximally to carpal tunnel) * Bilateral carpal tunnel syndrome causes: Acromegaly, Amyloid (periorbital purpura after sneezing), DM, Hypothyroid, pregnancy

Answer 12

**Brain:** stroke, SOL, MS **Spinal cord**: MS, trauma, disc herniation/spinal stenosis, spinal cord infarct, syringomyelia * _MS_ - weakness & paraesthesia based on UMN demyelination, disseminated in **_time & space_** * Optic neuritis, periorbital pain, RAPD, INO (damage to medial longitudinal fasciculus) * Ataxia, vertigo, chr constipation, blaadder dysfunct * **Lhermitte's sign** - electric shock down back on neck flexion * **Unhthoff's phenomenon** - worsening of Sx with increased body temp e.g. exercise, hot shower * Ix: MRI (brain & spinal cord) + LP (oligoclonal bands), nerve conduction study (evoked potential) * Mx: methypred for flare, INF-b long-term * _Trauma_ - extremity weakness wo/ cortical signs/facial weakness e.g. hemisection of spinal cord (Brown-Sequard syndrome) - below level of lesion: * Ipsilateral hemiparesis & loss of vibration/proprioception * **Contralateral loss of pain & temperature** * At level of lesion - loss of sensation + flaccid paralysis of muscles supplied by this spinal cord segment * _Herniated disc/spinal stenosis_ - weakness at level of lesion & lower extremities + bladder/bowel dysfunction + sciatica * _Spinal cord infarct_ - occlusion of anterior spinal artery (complication of aortic surgery) * Affects anterior 2/3 spinal cord in affected segment * Sudden-onset bilateral flaccid paralysis --\> developing into spastic paralysis after several days * Loss of pain & temp * **Light-touch, vibration & proprioception-sense spared** (dorsal columns not involved) * _Syringomyelia_ - developmental disorder * Syrinx (cavity) grows from centre of spinal cord & spreads outwards * Normally affects cervical cord but can extend into brainstem * Early - bilateral loss of **pain & temp in cape-like distribution** affecting neck, shoulders, upper arms * Late - as syrinx expands anterior horn cells affected --\> bilateral flaccid paralysis **Anterior horn** (motor neurone lesions): MND, poliomyelitis * _Poliomyelitis_ - enterovirus infection attacking anterior horn cells * **1-2wks prodrome (fever, headache, N&V)** * Asymmetrical weakness + can develop years after inf (post-polio syndrome) + can take place after taking live-attenuated polio vaccine * MND * Mixed UMN/LMN presentation * Ix (exclude other causes): EMG/NCS, MRI - whole spine * Mx: no cure - MDT approach (SALT (swallowing), physio & OT) * Sx-control: * Quinine - muscle cramp * Anticholinergics e.g. hyoscine patches - drooling * Prognostic: * Riluzole - glutamate antagonist (extend life expectancy by 3-5 months) * NIV - if respiratory muscles no longer functioning **Neuropathy:** diabetic neuropathy * Polyneuropathy (multiple nerves): DANG My THeRAPIST * _**D**iabetic neuropathy_ (most common, T1/2) * Sensory - **glove & stocking** loss of sensation/paraesthesia * Motor - same distribution as above + CN palsies (3rd - pupil-sparing) * Autonomic - orthostatic hypotension, constipation, erectile dysfunction * **A**lcoholic neuropathy (2nd most common) * **N**utritional (B1/6/12 def) * _**G**BS_ (AIDP - acute inflam demyelin polyneuropathy) * AI demyelination of peripheral nerves * 2-4wks post-inf e.g. diarrhoea with C. jejuni * **Ascending weakness in distal lower extremities** over hrs/days (worst after 4wks) * Flaccid paralysis with reduced/absent deep tendon reflexes * Can involve diaphragm --\> resp failure * Bilateral facial nerve palsy * Difficulty swallowing --\> aspiration * Autonomic dysfunction - sweating, orthostatic hypotension, urinary retention * NOTE: _sensory Sx rare_ * Ix: * LP (high protein, normal WCC) * NCS & EMG (reduced conduction velocity) * Serum abs (anti-glycolipid abs) * Mx: * Monitor FVC \<1L, NIF \<20cm H2O --\> intubate + mechanical ventilation * Monitor BP --\> IV fluids for hypo, Labetalol for hyper * IVIG, plasma exchange * **M(y)**-edications (colchicine, cisplatin, isoniazid --\> niacin def) * **T**oxins (lead) * **He**reditary - _HMSN (CMT)_ * Progressive hereditary (AD) _motor & sensory_ neuropathy (HMSN) * Distal back & lower extremity weakness: * **Foot drop** (damage to common peroneal nerve) * **High-arch foot (pes cavus)** - does not flatten with weight-bearing * Scoliosis * ± pain & sensory loss (can lead to foot ulcers) * Ix: nerve conduction study + EMG, genetic testing (electrophoresis/FISH) * Mx: physio, walking aids, foot & heel-support * **R**enal failure (uraemic nephropathy) * **A**myloidosis * **P**orphyrias * **I**nf (HIV, syphilis) * **S**ystemic (hypothyroidism) * **T**umours (multiple myeloma) * Mononeuropathy (one nerve): * _Facial nerve palsy_ - not forehead-sparing, crying/sensitive to noise/abnormal taste (ant 2/3 tongue) * Idiopathic = Bell's palsy * Secondary: * Lyme disease * Ramsay-Hunt syndrome - HZV reactivation in the geniculate ganglion, causes painful eruption in auditory canal * Tumours - acoustic neuroma, parotid * Bilateral palsy - Sarcoidosis, GBS * Tx: treat cause or if Bell's palsy --\> pred within 72hrs Sx onset + eye protection * _Carpal tunnel syndrome_ - entrapment of median nerve in flexor retinaculum * Repetitive use of wrist --\> numbness & tingling in lateral 3 fingers (& 1/2 4th finger) --\> weakness of thenar muscles * Tinel's sign - tap nerve at wrist * Phalen's sign - reverse prayer sign for 60s * Ix: EMG, wrist USS, MRI wrist (imaging to detect SOL e.g. ganglion cyst) * Tx: immobiliser wrist (splint), CS injection, carpal tunnel release **Neuromuscular junction:** MG/LEMS * _Myasthenia gravis (MG)_ - AI condition where Abs attach to NMJ post-synaptic nicotinic AChR in skeletal muscle * **FATIGUABILITY** with use * Initial - oculobulbar weakness (diplopia, ptosis, dysphagia, nasal voice) * Chr: * Asymmetrical proximal limb muscle weakness * Resp muscle failure * Assoc w/ **thymic hyperplasia/thymoma** * NOTE: normal sensation, normal deep tendon & pupillary reflexes * Ix: * Serological testing: _AChR_, MUSK abs * Repetitive nerve stimulation (CMAPs decrease) * CT chest - thymoma * Monitoring with serial pul funct tests (FVC & negative inspiratory force) if suspect myasthenic crisis * Mx: * Acetylcholinesterase inhibitors (**Pyridostigmine**) + IS (azathioprine) * Surgery - thymectomy * Myasthenic crisis = acute respiratory failure - FVC \<1L, negative inspiratory force (NIF) ≤20cm H2O * Often trigger - meds/inf * Accessory muscle use/weak cough = sign. exp muscle weakness * Mx: intubation + mechanical ventilation (& Mx above) * IVIG/Plasmapheresis * Stop pyridostigmine (increases secretions --\> aspiration risk), stop trigger (meds) * Cholinergic crisis - same presentation as above (resp muscle weakness) BUT cause = excess pyridostigmine --\> overstimulation of AChR --\> eventually stop working * Pyridostigmine also binds to nicotinic receptors --\> cholinergic Sx - SLUDGE (Salivation, Lacrimation, Urination, Diarrhoea, GI cramps, Emesis) * Mx: intubation + mechanical ventilation * Atropine (anti-muscarinic) for Sx but does not address resp weakness * Reduce dose of pyridostigmine * _Lambert-Eaton myasthenic syndrome (LEMS)_ - AI condition where Abs target pre-synaptic voltage-gated Ca channels --\> reduces release of ACh from presynaptic vesicles * Proximal muscle weakness - **IMPROVES** with use * Reflexes reduced/absent, ± autonomic Sx * Assoc w/ SCLC, Hodgkin's lymphoma * Ix: * NCS, repetitive nerve stimulation (CMAPs increase) * Serological testing: **VGCC abs** * CT chest (SCLC) * Mx: Tx underlying cause, Amifampridine * IVIg/plasma exchange * Supportive care incl. intubation + mech ventilation (if resp compromise) **Myopathy:** dermatomyositis * Inflammatory: proximal muscle weakness & pain * Dermatomyositis - **skin rash (heliotropic rash & Gottron's papules)** * Polymyositis * Assoc: ILD - in 10% patients * Ix: CK, ab panel **(anti-Jo-1**, ANA) * EMG, muscle MRI + muscle biopsy * Mx: * Induction: CS (PO/IV) ± IVIg * Maintenance: IS (methotrexate/azathioprine) ± IVIg * Inherited: * X-linked - Duchenne's & Becker's muscular dystrophy * AD - Myotonic dystrophy * **Myopathic facies (facial wasting) + frontal balding** * Distal wasting & weakness + loss of ankle jerk * Assoc: cataracts, dysphagia, cardiac, DM, hypogonadism * Exam - failure of immediate relaxation after voluntary contraction * Percussion myotonia - thumb contracts tapping thenar eminence * Slow releasing grip on shaking hands * Ix: CK, genetic testing, EMG 'dive-bomber' potentials, muscle biopsy * Mx: MDT approach * Phenytoin for myotonia, weakness has no Tx * Genetic counselling - trinucleotide repeat -severity/earlier with each generation * Avoid statins (can cause myopathy) * Endocrine: * Hypothyroidism - proximal muscle weakness & pain, deep tendon reflexes decreased, myoedema (swelling on percussion) * Also possible in Addison's Cushing's, Vit D def * Meds - statins (proximal muscle weakness & pain), glucocorticoids (muscle weakness) * Ix: serum CK, TSH lvls, EMG

Answer 13

**RFs:** * Exposure to high-intensity global UV radiation * Treatment w/ lipid-lowering agents, D-penicillamine (Tx for RA) * HIV, prev inf/vaccine **Presentation:** * Overall: insidious/acute symmetrical muscle weakness of proximal arm & leg --\> difficulty getting out of chair/climbing stairs * **Dermatomyositis** - _acute_, proximal muscle weakness + **rash**: * _Heliotropic rash_ (purple discolouration of upper-eyelids) * _Gottron's papules_ (erythema over knuckles) * **Polymyositis** - _subacute_, proximal muscle weakness, no rash * **Inclusion body myositis (IBM)** - _slowly_, proximal & **distal** muscle weakness + muscle atrophy (_quadriceps, distal wrist & finger flexor)_ * Assoc: * **ILD** - in 10% patients with dermatomyositis/polymyositis * Malignancy (ovarian, pancreatic, NH lymphoma, lung, bladder) * AI disease **Ix:** * Bloods: CK, ANA/myositis ab panel (anti-Jo-1) * Imaging: MRI of involved muscle, electromyogram (EMG), muscle biopsy Mx: * Induction: **CS** (PO/IV) ± IVIg * Maintenance: **IS** (methotrexate/azathioprine) ± IVIg

Answer 14

**CONGENITAL MIND** * **CONGENITAL** - mitochondrial * **M**etabolic - Cushing's, hypothyroidism * **I**nflammatory - _dermato/poly/inclusion body myositis_ * **N**euromuscular - _MG/LEMS_ * **D**ystrophy - Becker

Answer 15

Bilateral = **3Ms** * **M**S * **M**ND (normal sensation) * **M**yelopathy (sensory level) - SOL, cervical myelopathy, disc prolapse, transverse myelitis, syringomyelia Unilateral: * Intracranial - CVA, SOL, MS * Brainstem - MS * Spinal cord - trauma, SOL, haemorrhage

Answer 16

**Vasculitis** - GPA, EGPA, microscopic polyangiitis, polyarteritis nodosa **Rheum** - RA, SLE, Sjogren's, Sarcoidosis

Answer 17

**MND** **B12 - SCDC** (subacute combined degeneration of the spinal cord) Friedrich's ataxia (cause of cerebellar syndrome) * Most common inherited AR ataxia in UK * Degen disease affecting heart and nervous system - assoc w/ DM & cardiomyopathies * Onset before 20yrs * PC: unsteady gait +/- pes cavus/scoliosis -> prog ataxia, dysarthria (slurred speech), decreased proprioception/vibration-sense/muscle weakness Syphilitic tabo-paresis

Answer 18

Normal Pressure Hydrocephalus - distended ventricles distort central corona radiata (incl sacral motor fibres innervating legs/bladder) PC: elderly pt with slow progressing triad - unsteady gait, urinary incontinence, potentially reversible dementia * **Unsteady gait** - like parkinson's (bradykinetic, broad-based, shuffling) * **Urinary incontinence** (can be faecal) * **Potentially reversible dementia** - from distortion of perivetricular limbic system -> memory loss/bradyphrenia (slowing) NOTE: no papilloedema, normal opening pressure on LP Mx: 1. LP + clinical response to removing CSF 2. CT/MRI (enlarged ventricles with convolutional atrophy) + continuous external lumbar CSF drrainage over 3-4 days 3. VP shunt to drain excess CSF to abdomen where it can be absorbed

Answer 19

Depression * PC: * >2wks Sx, affecting functionality * DSM-5: 5/9 Sx including ≥1 core Sx (low mood, anhedonia) * Ix: PHQ-9/HADS * Mx: self-help books -> self-CBT/computerised CBT -> SSRI (Sertraline)/In-person CBT +/- CMHT/crisis team/IP * Mx for kids: CBT -> fluoxetine Anti-depressant medication Mx: * Start meds --> review in 2wks: * If no effect after further 4wks --> increase/change * If effective – continue for 6 months past no depressive Sx --> wean off over 4wks * After started meds – monitor depression w/ PHQ-9 * Switching anti-depressants - direct switch/cross-taper

Answer 20

MHA assessment: patient risk to themselves/others due to MH issue. 3-person decision-making (can’t do for family/friends): * Approved mental health professional (AMHP) – 95% social workers (not doctors), only person that can run/start assessment * One treating doctor (full license, previous acquaintance w/ patient e.g. GP OR S12 approved) * Independent doctor S12 approved Mental capacity act: * Understand, retain, weigh up and communicate decision * Decision-specific, in best interest, least restrictive of persons rights/freedom * Capacity assumed in general, unwise choices ≠ lacking capacity Deprivation of Liberties Safeguarding (DOLS): * For people in care homes/hospitals * Checks to ensure protection of those with DoL - appropriate/best interests * Commonly dementia-related Legal sections SUMMARY: * S2 – 28d detention for assessment (& treatment), 2 doctors (1 psychiatrist, 1 knows patient) + 1 AMHP --> can be appealed within 14 days * S3 – 6-month detention for forceful treatment (can extend), 2 doctors (1 psychiatrist, 1 knows patient) + 1 AMHP --> can be appealed within 14 days * S4 – outside hospital, emergency admission for 72hrs by 1 doctor + AMHP – no appeal * S5(2) – voluntary hospital patient, hold inpatient for 72hrs for assessment by doctor * S5(4) – hold inpatient for 6hrs for assessment by nurse * S17 – conditional leave from ward as inpatient at MH unit * S136 – police to remove patient from public space (requires warrant – 24hrs) * S135 – police to remove from home to place of safety (24hrs) * CTO (community treatment order) – after discharge from S3 with conditions in place for treatment

Answer 21

Hemiballismus - invol flinging motions of extremeties Caused by infarct/haemorrhage in contralateral subthalmic nucleus

Answer 22

**Schizophrenia** - most common form of psychosis (perceive/believe/interpret differently) PC: * Positive Sx - auditory hallucinations, delusions, disrupted speech * Negative Sx - self-neglect, social withdrawal, flat affect, demotivation Types: * Paranoid (most common) - hallucinations/delusions prominent * Hebephrenic - 15-25yrs, poor prognosis, fluctuating affect + fleeting fragmented delusions/hallucinations * Catatonic - stupor, posturing, wavy flexibility, negativism * Simple & residual - negative Sx predominant ICD-11: * **≥1 first rank Sx** (thought echo/thought insert/withdrawal/broadcasting/delusions of control/influence/passivity/delusional perception/auditory/sensory hallucinations) * Delusion - false/fixed/irrational belief firmly held despite evidence to contrary (not explained by pt's cultural/religious BG) * Hallucination e.g. auditory - sensory perception without stimulus * Passivity - external control of thoughts/feeling/actions * Thought disorder - insertion/withdrawal/broadcasting * **OR ≥2 other Sx** Mx: * ALL adults --> EIS (intense specialist outpatient service for 3yrs) * ALL get care-coordinator = main contact * Therapy: CBTp (psychosis CBT) * Meds & Physical health checks - bloods, ECG, weight – med SEs (T2DM, weight gain, BM supression) * 1st - atypical antipsychotic e.g. aripiprazole, olanzapine, risperidone * 2nd - typical antipsychotic e.g. haloperidol, chlorpromazine (EPSEs + hyperprolactinaemia common) * Tx-resistent (failure to respond to ≥2 antipsychotics, one atypical, each at therapeutic dose for ≥6wks) - Clozapine/combo -------------- -------------- **Schizoaffective disorder** - mood disorder + schizophrenia within days/same intensity * Delusions/hallucinations need to be present for ≥2wks without mood Sx + NOT DUE TO ORGANIC CAUSE/MEDS * Tx: Anti-psychotics + anti-depressants + therapy +/- ECT -------------- -------------- **Delusional disorder **- ≥1 delusion ≥1 month (DSM5)/≥3 months (ICD10) - not due to schizophrenia/organic/drugs * NOTE: Normal psychosocial functioning/ordered thinking * Emotional response/behaviour consistent with delusions * No auditory/visual hallucinations (can have olfactory/tactile) * No thought/mood disorder or flat affect * Tx: individual CBT, social skills training

Answer 23

ASR - transient disorder without other apparent mental disorder in response to exceptional physical/mental stress (if >1month ?PTSD) * Daze -> withdrawal/agitation * Mx: short course benzos, social support, reassurance Adjustment disorder (incl prolonged grief reaction) - subjective emotional distress affecting functioning during sign life chang (prolonged grief following death >6 months) * Mx: psych support +/- SSRIs PTSD - delayed/protracted response to catastrophic event, >1 month * PC: * Re-experiencing (flashbacks/nightmares) * Avoidance (reminiscent activities) * Autonomic hyperarousal (vigilent for threat, insomnia, difficulty concentrating) * Other: emotional numbing/depression/substance use/unexplained physical Sx * Ix: trauma screen questionnaire, referral to mental health services * Mx: DO NOT DEBRIEF * Mild (<4wks) - watchful waiting * >1 month - trauma-focused CBT * >3 months after non-combat trauma (severe) - eye movement desensitisation and reprocessing (EMDR) * 2nd line - NaSSA (mirtazapine)/SSRI/SNRI, 3rd line - anti-psychotic

Answer 24

Pseudo-hallucinations - false sensory perception in absence of external stimuli when affected has insight (is it is a hallucination) * Hypnagogic hallucination - transitioning from wakefulness to sleep * As part of grief response (e.g. seeing the deceased) Mx: reassure = normal + will not develop mental illness

Answer 25

>2wks, >1hr per day

Answer 26

Depression - PHQ9 Anxiety - GAD7 Both - HADS score

Answer 27

ASD - persistent deficits in social communication and social interaction across multiple contexts, starts <3yrs * Refer to CAMHS for Dx: **impaired social communication & interaction, inflexible thinking/ritualistic behaviour**, sensory hyperstimulation (loud noise/textures) * Spectrum: autism (triad, IQ <70, impaired language dev), high-functioning autism (IQ >70), asperger's (IQ>70, normal language dev) * Mx: * Young children (2-3y) - Applied behav analysis (ABA), picture exchange comm systems (PECS) * Older children - comm skills/psychoeducation + ABA (sexual/aggresion) ADHD - <12yrs, ≥2 settings, reduced functioning, ≥6 months * PC: inattention, hyperactivity, impulsive * Ix: ADHD assessment * Mx: * Watchful waiting for 10 days if persistent refer for ADHD assessment * Severe/failed Tx & ≥5yrs - methylphenidate 6wk trial (2nd - Lisdexamphetamine, all cardio toxic - baseline ECG) * NOTE: methylphenidate SEs - reduced hunger, difficulty sleeping, mood/seizures/cardiac complications (CIs: glaucoma, phaeo, hyperthyroid, psych hx, CV/cerebrovasc abn, FHx: cardiac issue/arrythmia/tourette's/epilepsy) Learning disability spectrum - mild (IQ 50-69), mod (IQ 35-49), severe (IQ <35) * Scores: WAIS for adults, WISC for children Tic disorder - Mx: clonidine (alpha 2 antag/atypical antipsychotic) Chronic insomnia - difficulty getting to/maintaining sleep on >3 nights/wk for ≥3 months * Ix: sleep diary * Mx: sleep hygeine, CBT-I, benzos short-term if daylight impairment

Answer 28

CAGE questionnaire (≥ excessive drinking): cut down, annoyed, guilt, eye opener Formal assessment tools: * AUDIT (alcohol use disorders identification test) - 16-19 harmful, ≥20 possible alcohol dependence * SADQ (severity of alcohol dependence questionnaire) - do if >15 on AUDIT -> 16-30 moderate, ≥31 severe * CIWA-Ar (Clinical institute withdrawal assessment for alcohol) - determines severity of withdrawal (determine next stage of Tx) * APQ - alcohol problems questionnaire (nature + extent of problems arisen from alcohol misuse) Assisted alcohol withdrawal - worst Sx in first 48hrs -->3-7 days to disappear * If >15 units/day OR >20 on AUDIT -> community-based assisted withdrawal * INPATIENT withdrawal if 30+ units/day OR ≥30 on SADQ, Hx of delirium tremens/withdrawal-related seizures, children (≤17yrs) * Meds: * Acute - Chlordiazepoxide/diazepam (if liver impaired - lorazepam) --> reduce dose over 7-10 days * After successful withdrawal - 6months of Acamprosate/Naltrexone (2nd - disulfiram)

Answer 29

SCOFF Questionnaire - ≥2 = possible ED * Sick (self-induced vom), Control (lost control of eating), One (lost >1 stone in 3m), Fat (think fat others think thin), Food (food dominates life) Anorexia nervosa * PC: * Restricted food intake > WL/low BMI * Fear of gaining weight/fat * Distorted view (think fat) * Ix: preg test, bloods (hormone profile, ESR, general), ECG +/- DEXA * Mx: * Admit if BMI <13/extreme WL/physical complications/high suicide risk (refeeding syndrome - low PO4/Mg/K/thiamine, Na/H2O retention) * Urgent referral to community ED service (CEDS) if BMI <15 (routine referral if 15-17) * Weight restoration target - 0.5-1kg weight gain/wk * Psychotherapy: MANTRA (Maudsley AN treatment in adults), CBT-ED, SSCM * Child - family therapy (2nd - CBT-ED) NOTE: Bulimia nervosa > binge eating if purging (being sick, laxatives, thyroid drugs) * Recurrent binge eating ≥1/wk ≥3 months * Mx: CBT-ED +/- SSRI

Answer 30

Antidepressants: Sertraline best * TCAs = cardiotoxic (in/out of pregnancy) but low-dose amitriptyline likely ok Antipsychotics - not teratogenic but may need induction of labour * Clozapine risk of neonatal agranulocytosis Mood stabilisers - low dose carbamazepine / lamotrigine safe * Lithium – neonatal thyroid, arrythmia, Ebstein’s anomaly * Na Valproate – neural tube defects (pregnancy protection programme to prevent) BENZOS – oral cleft, floppy baby syndrome Breastfeeding: * Recommended antidepressant = sertraline * Recommended antipsychotic/mood stabilisers = olanzapine/quetiapine (but sedating) * For sleeping = promethazine > benzos * Consider ECT

Answer 31

CNS TB - commonly caused by mycobacterium TB secondary to disease elsewhere in the body * PC: meningitis (headache, neck stiffness +/- focal neuro/tremor/vision changes over 2-3wks) or IC tuberculomas (slow growing focal lesion/raised ICP) * Ix: CSF analysis, CT/MRI head (oedema, hydrocephalus, basilar meningeal thickening, tuberculomas), 50% CXR abn Tx: * TB without CNS - RIPE (2 months) -> RI (4 months) * TB with CNS - RIPE (2m) -> RI (10 months)

Answer 32

ON - demyelinating inflam of optic nerve assoc w/ MS * PC: preceeding viral illness -> unilateral acute visual deterioration, change in colour perception, retro-orbital pain (worse on eye mov) * NOTE: Uhthoff's phenomenon - pain worse on exercise/heat, Pulfrich phenomenon - straight mov appears curved * O/E: pupilary light defect +RAPD (Marcus-Gunn pupil) + 1/3 have swollen optic disc * Ix: myelin basic protein, oligoclonal bands, high IgG index/synthesis rate in CSF = MS + MRI/visual evoked potentials can show optic nerve inflam * Tx: high-dose steroids

Answer 33

Facioscapulohumeral muscular dystrophy * Disease progresses from face downwards * Winging of scapula is characteristic sign

Answer 34

Definition: chr mental health disorder characterised by mania/hypomania + episodes of depression * Manic episode - ≥1wk abn elevated mood/irritability --> severe functional impairment/psychotic Sx (delusions of grandeur/aud hallucinations) * Hypomanic episode - ≥4d abn elevated mood/irritability --> decreased/increased function * Mixed episode - alternating mania/depression - ≥1wk (hypo)mania + 3 depressive Sx OR ≥2wk depression + 3 (hypo)manic Sx Classification - ≥2 episodes mood/activity disturbed: * Type 1 BAD (most common) - manic episodes + major depressive episodes * Type 2 BAD - recurrent depressive episodes + periods of hypomania * Rapid-cycling bipolar disorder - 4 depressive/manic/mixed episodes in 1 year DDx: cyclothymia (rapid mood swings) Mx: * Urgent referral to CMHT (non-urgent ref if hypomania) * CBT/family therapy * Mania pharm: stop anti-depressant, anti-psychotic (olanzapine), 2nd - alternative/dose change, 3rd - lithium/Na Val, 4th - ECT * Short-term benzos if severe behav issues * Bipolar depression pharm: if not on other meds fluoxetine + olanzapine (2nd - Quetiapine, 3rd - lamotrigine) * Long-term Mx: lithium - switch from acute meds 4wks post manic episode (2nd - Na Val/Olanzapine/Quetiapine) Drug monitoring: * Lithium - 0.4-1 therapeutic margin (>1.2 is toxic, 1.5 Sx, >2-life-threatening) - check lvls 5d after starting/changing dose (12hr after last dose), weekly until stable then 3m for first year then 6 monthly * Na Val - LFTs every 6 months * Lamotrigine - 10% benign rash, some develop SJS