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LBH 2022 > Short case > Flashcards

Short case Flashcards

1
Q

COPD findings

A

Reduced breath sounds
Expanded lung fields

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2
Q

At what height do the lungs finish posteriorly?

A

T10

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3
Q

Description of crackles?

A

Fine or coarse
Crackles timing - pan, mid or end inspiratory
Crackle distribution

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4
Q

What causes coarse crackles

A

CCF (can also be fine)
Mucus

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5
Q

What is the ddx for lower lobe fibrosis?

A
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6
Q

What is the ddx for upper lobe fibrosis?

A
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7
Q

What is the normal liver span?

A

Normal liver span is 11-13 cm

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8
Q

Where is liver span measured?

A

At the mid clavicular line

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9
Q

What examination finding is expected in the presence of synovitis?

A

Boggy joint + tender

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10
Q

How do you differentiate Parkinson from Parkison-like gait?

A

Parkinsonism - festonant gait, loss of arm swing, tremor

Parkinsonian-like - posture will be more upright compared with the “hunched over” posture seen in Parkinson’s Disease

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11
Q

If the patient is unable to stand on heels, where is the defecit?

A

Foot drop (L5)

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12
Q

If the patient is unable to stand on toes, where is the defecit?

A

Weakness of calf muscles (S1)

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13
Q

Describe the Romberg test

A

Romberg +ve = steady with eyes open, unsteady with eyes closed

+ve Romberg (unsteady with eyes closed): Peripheral neuropathy (Usually with loss of proprioception)

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14
Q

What is the ddx for parkinsonian like gait?

A

“March a petit pas” (march of the little steps)

NPH
Multiple lacunar infarcts
PSP

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15
Q

Describe a Parkinsonian like gait

A

Small, shuffling steps
Several steps on turning

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16
Q

What are the causes of Romberg +ve gait?

A 
Vestibular gait (pt falls to one side)
Peripheral neuropathy, with predominantly posterior column involvement
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17
Q

Gait assessment - toes pointing toward each other. What is this typical of?

A

Toes pointing toward each other is typical of paraparetic gait

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18
Q

What gait is seen in cerebral palsy?

A

Bilateral spastic gait

(Knees together, small steps, abnormal posturing of hands)

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19
Q

What does pronator drift indicate?

A

Presence of an UMN lesion

(Pronators are stronger than supinators in UMN lesion)

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20
Q

Upper limb reflexes?

A

Biceps - C5
Brachioradialis - C6
Triceps - C7
Finger jerk - C8

21
Q

Diabetic retinopathy findings on fundoscopy?

A
  1. Non-proliferative
    - Cotton-wool spots or soft exudates: are nerve fibre layer infarcts.
    - Hard exudates are caused by lipid accumulation in or under the retina secondary to vascular leakage.
    - Intra-retinal haemorrhages and microaneurysms may also be seen.
  2. Proliferative
    - Neovascularisation may progress to fibrosis and retinal detachment
22
Q

Hypertensive retinopathy findings on fundoscopy? (Mild, moderate and severe).

A

Mild: narrowing of retinal arterioles also referred to as copper/silver wiring. Arteriovenous nicking or “nipping”.

Moderate: Haemorrhages, either flame or dot-shaped, cotton-wool spots, hard exudates, and microaneurysms.

Severe: Some or all of the above, plus papilloedema

23
Q

Which muscles does CN III innervate?

A

MR, SR, IR, IO
2/3rd levator palpebrae superiorsis
Pupillary meiosis

24
Q

Which muscles does CN IV innervate?

A

SO

25
Q

Which muscles does CN VI innervate?

A

LR

26
Q

Findings in CN III palsy?

A
  • Ptosis, inferolateral displacement of the ipsilateral eye.
  • Reduced adduction, elevation and depression of the affected eye.
  • A dilated non-reactive pupil (to direct or contralateral light reflex & accommodation). In diabetic mononeuritis pupillary sparing is often seen.
27
Q

Common causes of CN III palsy?

A
  • Tumours can compress the nerve anywhere along its path.
  • Cavernous sinus lesions.
  • Trauma.
  • Haemorrhagic or ischaemic stroke and demyelinating disorders that affect the nerve nucleus in the midbrain.
  • Mononeuritis multiplex e.g. diabetes (often with pupillary sparing).
  • Intracranial aneurysms, in particular posterior communicating artery aneurysms.
28
Q

Which nerves are involved in the pupillary light reflex?

A

Afferent limb is via the optic nerve (CN II)

Efferent limb is via the oculomotor nerve (CN III).

29
Q

What is the function of CN IV?

A

CN IV (trochlear nerve) is responsible for:

  • Depression of the eyeball, especially when the eye is adducted
  • Intorsion of the eyeball, especially when the eye is abducted.
30
Q

Findings in CN IV palsy?

A
  • Weakness of downward eye movement → vertical diplopia that is worse in the adducted eye position, but improved diplopia with head tilted to contralateral side (look to the nose then down).
  • Weakness of intorsion, in particular with eye abducted.
31
Q

Findings in CN VI palsy?

A
  • Medial deviation of ipsilateral eye.
  • Inability to look laterally (abduct).
32
Q

Common causes of CN VI palsy?

A
  • Tumours can compress the sixth nerve anywhere along its path. Acoustic neuromas can affect the 6th nerve.
  • Elevated intracranial pressure, a false localising sign.
  • Trauma.
  • Haemorrhagic or ischaemic stroke and demyelinating disorders that affect the nerve nucleus in the pons.
  • Mononeuritis multiplex e.g. diabetes
33
Q

Signs of severe AS?

A
  • Aortic thrill
  • Soft S2
  • Carotid pulse: small volume, plateau, slow up-rise
  • Apex beat: pressure loaded
  • Loud murmur (Grade 4) is very specific for severe AS
  • LV failure
34
Q

Signs of severe MR?

A
  • LV dilatation
  • Soft S1
  • Split S2
  • S3
  • Pulmonary hypertension
  • LVF
  • Small pulse volume (very severe)
  • Early diastolic rumble
35
Q

DDx: UMN findings - unilateral +/- sensory findings

A
  • Stroke/other central lesions, cortical, subcortical, brainstem
  • Spinal cord (Brown Sequard)
36
Q

DDx: Bilateral UMN with sensory findings

A
  • Spinal cord compression (look for sensory level)
    • If affecting arms and legs = cervical levels + look for bowel/bladder problems
  • MS (sensory findings variable and may have cerebellar findings)
  • B12 deficiency (UMN + Peripheral neuropathy)
  • Multiple CVAs
  • Arnold Chiari malformation (cerebellar signs also)
37
Q

DDx: Bilateral UMN findings with NO sensory findings

A
  • Cerebral palsy
  • MND (should see a mix of UMN and LMN)
  • Multiple CVAs, often lacunar
38
Q

DDx: UMN findings in lower limbs with normal upper limbs

A
  • Cerebral palsy (may selectively affect the lower limb fibers)
  • Spinal stenosis below cervical spine (cervical spine stenosis may present with selective lower limb signs and sparing of the upper limbs)
  • Parasagittal tumours, meningiomas
  • Hydrocephalus
  • Hereditary spastic paraparesis (sensory findings often mild)
39
Q

DDx: UMN findings in lower limbs and LMN findings in upper limbs

A
  • Cervical syringomyelia - with sensory findings
  • Cervical lesions with nerve roots affected in upper limbs and cervical spine stenosis causing UMN findings in lower limbs - with sensory findings
40
Q

DDx UMN signs + Ataxia (+/- sensory findings)

A
  • Spinocerebellar degeneration
  • MS
  • Ataxic hemiparesis (lacune in upper pons/internal capsule)
  • Arnold Chiari malformation
41
Q

DDx LMN findings

A
  • LMN lesions: anywhere from Anterior Horn cells + distally (ie. nerve root, plexus or peripheral nerves).
  • LMN findings with no sensory loss:
    • Polio (often with underdeveloped limb, if occurring in childhood)
  • LMN findings plus sensory loss:
    • Peripheral nerve
    • Nerve root compression
    • Cauda Equina syndrome
    • Plexopathies
  • Peripheral neuropathies (sensorimotor)
42
Q

DDx: Absent ankle jerk + up-going plantar

A
  • MND (UMN + LMN findings)
  • Dual pathology – peripheral neuropathy + UMN lesion (sensory findings)
  • Friedreich’s Ataxia
  • Subacute combined degeneration (B12 deficiency)
43
Q

DDx: Sensorimotor neuropathies

A
  • Possible findings: areflexia with distal weakness + some sensory loss:
    • Acute Guillan Barre
    • CIDP
    • Bilateral familial neuropathy (CMT)
  • Possible findings: areflexia with sensory involvement and little motor loss:
    • Diabetes
    • EtOH
    • Drugs eg. vincristine
    • CKD
    • Paraneoplastic
    • Vitamin B12 (may have UMN findings also, eg. up-going plantar)
44
Q

UMN findings

A
  • Spasticitiy, rigidity
  • Hyperreflexia
  • Loss of cortical sensations
  • Normal nerve conduction.
  • EMG: Decreased interference pattern and firing rate
  • NO fasiculations
45
Q

LMN findings

A
  • Proximal (myopathy) or distal (neuropathy) weakness
  • Hypotonia
  • Fasiculations
  • Hypo/areflexia
  • Abnormal NCS
  • EMG: large motor units, fasciculations and fibrillations
46
Q

Causes of tracheal deviation to side of lesion?

A

Pneumonectomy

Lobar collapse

Pulmonary fibrosis

47
Q

Causes of tracheal deviation away from the lesion?

A

Large pleural effusion

Tension pneumothorax

48
Q

UIP CT Chest findings?

A

Usual interstitial pneumonia (UIP) is a histopathologic and radiologic pattern of interstitial lung disease, which is the hallmark pattern for idiopathic pulmonary fibrosis (IPF).

Findings of UIP on CT Imaging:

  • Lung volume loss
  • Peripheral septal thickening with a craniocaudal gradient (worse at bases)
  • Bronchiectasis
  • Honeycombing

LBH 2022 (10 decks)

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