Short case Flashcards
COPD findings
Reduced breath sounds
Expanded lung fields
At what height do the lungs finish posteriorly?
T10
Description of crackles?
Fine or coarse
Crackles timing - pan, mid or end inspiratory
Crackle distribution
What causes coarse crackles
CCF (can also be fine)
Mucus
What is the ddx for lower lobe fibrosis?
What is the ddx for upper lobe fibrosis?
What is the normal liver span?
Normal liver span is 11-13 cm
Where is liver span measured?
At the mid clavicular line
What examination finding is expected in the presence of synovitis?
Boggy joint + tender
How do you differentiate Parkinson from Parkison-like gait?
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
If the patient is unable to stand on heels, where is the defecit?
Foot drop (L5)
If the patient is unable to stand on toes, where is the defecit?
Weakness of calf muscles (S1)
Describe the Romberg test
Romberg +ve = steady with eyes open, unsteady with eyes closed
+ve Romberg (unsteady with eyes closed): Peripheral neuropathy (Usually with loss of proprioception)
What is the ddx for parkinsonian like gait?
“March a petit pas” (march of the little steps)
NPH
Multiple lacunar infarcts
PSP
Describe a Parkinsonian like gait
Small, shuffling steps
Several steps on turning
What are the causes of Romberg +ve gait?
Vestibular gait (pt falls to one side) Peripheral neuropathy, with predominantly posterior column involvement
Gait assessment - toes pointing toward each other. What is this typical of?
Toes pointing toward each other is typical of paraparetic gait
What gait is seen in cerebral palsy?
Bilateral spastic gait
(Knees together, small steps, abnormal posturing of hands)
What does pronator drift indicate?
Presence of an UMN lesion
(Pronators are stronger than supinators in UMN lesion)
Upper limb reflexes?
Biceps - C5
Brachioradialis - C6
Triceps - C7
Finger jerk - C8
Diabetic retinopathy findings on fundoscopy?
- 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. - Proliferative
- Neovascularisation may progress to fibrosis and retinal detachment
Hypertensive retinopathy findings on fundoscopy? (Mild, moderate and severe).
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
Which muscles does CN III innervate?
MR, SR, IR, IO
2/3rd levator palpebrae superiorsis
Pupillary meiosis
Which muscles does CN IV innervate?
SO
Which muscles does CN VI innervate?
LR
Findings in CN III palsy?
- 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.
Common causes of CN III palsy?
- 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.
Which nerves are involved in the pupillary light reflex?
Afferent limb is via the optic nerve (CN II)
Efferent limb is via the oculomotor nerve (CN III).
What is the function of CN IV?
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.
Findings in CN IV palsy?
- 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.
Findings in CN VI palsy?
- Medial deviation of ipsilateral eye.
- Inability to look laterally (abduct).
Common causes of CN VI palsy?
- 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
Signs of severe AS?
- 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
Signs of severe MR?
- LV dilatation
- Soft S1
- Split S2
- S3
- Pulmonary hypertension
- LVF
- Small pulse volume (very severe)
- Early diastolic rumble
DDx: UMN findings - unilateral +/- sensory findings
- Stroke/other central lesions, cortical, subcortical, brainstem
- Spinal cord (Brown Sequard)
DDx: Bilateral UMN with sensory findings
- 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)
DDx: Bilateral UMN findings with NO sensory findings
- Cerebral palsy
- MND (should see a mix of UMN and LMN)
- Multiple CVAs, often lacunar
DDx: UMN findings in lower limbs with normal upper limbs
- 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)
DDx: UMN findings in lower limbs and LMN findings in upper limbs
- 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
DDx UMN signs + Ataxia (+/- sensory findings)
- Spinocerebellar degeneration
- MS
- Ataxic hemiparesis (lacune in upper pons/internal capsule)
- Arnold Chiari malformation
DDx LMN findings
- 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)
DDx: Absent ankle jerk + up-going plantar
- MND (UMN + LMN findings)
- Dual pathology – peripheral neuropathy + UMN lesion (sensory findings)
- Friedreich’s Ataxia
- Subacute combined degeneration (B12 deficiency)
DDx: Sensorimotor neuropathies
- Possible findings: areflexia with distal weakness + some sensory loss:
- Acute Guillan Barre
- CIDP
- Hereditrary sensorimotor neuropathy, eg. Charcot marie tooth
- 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)
UMN findings
- Spasticitiy, rigidity
- Hyperreflexia
- Loss of cortical sensations
- Normal nerve conduction.
- EMG: Decreased interference pattern and firing rate
- NO fasiculations
LMN findings
- Proximal (myopathy) or distal (neuropathy) weakness
- Hypotonia
- Fasiculations
- Hypo/areflexia
- Abnormal NCS
- EMG: large motor units, fasciculations and fibrillations
Causes of tracheal deviation to side of lesion?
Pneumonectomy
Lobar collapse
Pulmonary fibrosis
Causes of tracheal deviation away from the lesion?
Large pleural effusion
Tension pneumothorax
UIP CT Chest findings?
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
