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RACP CLINICAL EXAM > Shorts Masterset > Flashcards

Shorts Masterset Flashcards

1
Q

Prosthetic Valve

A

Features

  • IE
  • Haemolysis
  • Bleeding (warfarinisation)
  • Valve regurgitation/stenosis
  • Pulmonary HTN

Mitral Valve

  • S1
  • MS murmur (flow)
  • Look for pulmonary HTN
  • Pathology:
    • MS - non-displaced apex
    • MR - displaced apex/pulmonary HTN

Aortic Valve

  • S2
  • ESM with well functioning aortic valve replacement
  • AR = valve dysfunction
  • Pathology:
    • AS - non-displaced apex
    • AR - displaced apex/pulmonary HTN
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2
Q

Aortic Stenosis

A

Features

  • Pressure loaded apex beat
  • Soft S2
  • ESM loudest at aortic region on expiration, radiates to carotids

Aetiology

  • Degenerative calcific change
  • Biscupid valve
  • Rheumatic heart disease

Signs of Severity

  • Narrow pulse pressure
  • Low volume, anacrotic carotid pulse
  • Aortic thrill
  • Length, harshness and lateness of systolic murmur peak
  • Soft S2 or paradoxical splitting
  • S4
  • Signs of LV failure/pulmonary HTN

ECG

  • LVH

CXR

  • LV failure
  • LVH
  • Valve calcification

TTE

  • Valve area <1cm
  • Peak velocity >4
  • Gradient >40

Surgery

  • Symptoms - exertional angina, SOBOE, exertional syncope
  • Critical obstruction and severe LVH (even if asymptomatic)
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3
Q

Aortic Regurgitation

A

Features

  • Displaced, pressure loaded apex
  • Soft S2
  • Early descrendo diastolic murmurs, loudest on LSE on expiration and when seated

Aetiology

  • Valvular
    • Rheumatic
    • Congenital - biscupid valve VSD
    • Seronegative arthropathy - esp ank spond
  • Aortic root dilation
    • Marfan’s syndrome
    • Aortitis - seronegative arthropathy, RA, tertiary syphilis
    • Dissecting aneurysm
    • Age related

Signs of Severity

  • Wide pulse pressure
  • Collapsing pulse
  • Soft S2
  • S3
  • Long decrescendo diastolic murmur/Austin Flint murmurs (diastolic rumble by limitation of mitral inflow)
  • Signs of LVH/pulmonary HTN

ECG

  • LVH

CXR

  • Cardiomegaly
  • Aortic root dilation
  • Heart failure
  • Valve calcification

Surgery

  • Symptoms - SOBOE
  • Worsening LV function
  • Progressive LV dilation on TTE
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4
Q

Mitral Stenosis

A

Features

  • AF (chronicity)
  • Narrow pulse pressure (<20)
  • Malar facies/flush
  • Tapping apex beat
  • Loud S1 wirh opening snap in diastole
  • Mid-diastolic murmur with opening rumble
  • Loudest at apex, on expiration and left lateral
  • Signs of pulmonary HTN

Causes:

  • Rheumatic (women > men)
  • Severe mitral annular calcification (consider hypercalcaemia, hyperparathyroidism)
  • Mitral valve repair
  • Congenital

Signs of Severity

  • Narrow pulse pressure
  • Diastolic thrill at the apex
  • Early opening snap (owing to raised LA pressure)
  • Length of mid-diastolic rumbling murmur (persists as long as there is a gradient
  • Pulmonary HTN/LV failure

ECG

  • p mitrale/LA dilatation (biphasic in V1/V2)
  • AF (Sx of chronicity)
  • LV hypertrophy (S wave V1 and R in V5 >35mm)
  • RAD (severe)

CXR

  • Mitral valve calcification
  • LA dilation - double LA shadow, displaced L) main bronchus, big L) atrial appendage
  • Signs of pulmonary HTN - large central pulmonary arteries, pruned peripheral arterial tree

Surgery Indications

  • Exertional dyspnoea and falling valve area
  • Increasing right heart pressures
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5
Q

Mitral Regurgitation

A

Features

  • AF (chronicity)
  • Pressure loaded apex beat
  • Pansystolic murmur, loudest at apex and radiation to axilla, louder on expiration and valsalva (if MVP)
  • Mid-systolic click if MVP

Aetiology

  • Degenerative disease
  • Mitral valve prolapse
  • Rheumatic heart disease (men > women)
  • Papillary muscle dysfunction - ischaemia, LV failure
  • Connective tissue disease - RA, ank spond
  • Congential - endocardial cushion defect, parachute valve
  • Acute causes
    • IE
    • MI
    • Surgery
    • Trauma

Signs of Severity

  • Small volume pulse (very severe)
  • Displaced apex beat
  • Soft S1
  • S3
  • Early diastolic rumble
  • Signs of LV failure/pulmonary HTN

ECG

  • p mitrale
  • AF
  • RAD

CXR

  • LA dilation
  • LVH
  • Mitral annular calcification
  • Pulmonary hypertension

TTE

  • Possible aetiology
  • Severity
  • Associated valve or structural abnormalities

Surgery

  • Chronic MR - Class III/IV symptoms, LV dysfunction, progressive increase in LV dilation
  • Acute MR - haemodynamic collapse
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6
Q

Tricuspid Regurgitation

A

Features

  • JVP - v waves
  • RV heave
  • Pansystolic murmur, loudest LSE on inspiration
  • Pulsatile hepatomegaly
  • Pulmonary HTN
  • RV Failure - oedema, ascites

Aetiology

  • Functional - right ventricular failure
  • Rheumatic - rare
  • IE - right sided
  • Congenital - Ebstein’s anomaly
  • Right ventricular papillary muscle infarction
  • Trauma (steering wheel injury

ECG

  • RAD
  • Tall R waves V1-V2
  • p pulmonale

CXR

  • RV hypertrophy

Surgery

  • Symptomatic severe TR unresponsive to medical therapy
  • Consider if getting left sided surgery
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7
Q

Pulmonic Stenosis

A

Features

  • Peripheral cyatnosis (low cardiac output)
  • Reduced volume pulses
  • Giant a waves (right atrial hypertrophy)
  • RV heave
  • Pulmonic thrill (common)
  • ESM with ejection click, loudest at pulmonic area on inspiration
  • Presystolic pulsation of the liver

Aetiology

  • Congenital
  • Carcinoid syndrome
  • Rheumatic heart disease
  • Endocarditis

Signs of Severity

  • Late peaking systolic murmur
  • Absence of ejection click
  • S4
  • RV failure
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8
Q

Pulmonic Regurgitation

A

Features

  • Early diastolic descrescendo murmur, loudest at the pulmonic region with radiation to sternal LLB and on inspiration

Aetiology

  • Functional secondary to pulmonary HTN
  • Rheumatic heart disease
  • IE
  • Iatrogenic (post TOF repair, RH cath complications)

ECG

  • RV hypertrophy and strain
  • RAD
  • RBBB
  • AF

CXR

  • Prominent pulmonary vasculature
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9
Q

HOCM

A

Features

  • Sharp, rising, jerky pulse
  • JVP - prominent a wave
  • Double/triple impulse apex beat
  • Late ESM loudest at LSE, on valsalva and standing
  • Pansystolic murmur loudest at apex (from MR)

Aetiology

  • Genetic - including Fredrich’s ataxia, DMD

ECG

  • LVH and lateral ST and T wave changes
  • Deep Q waves in lateral leads
  • Conduction disease

CXR

  • LV enlargement (with hump along border)
  • No valve calcification

TTE

  • SAM
  • Asymmetrical hypertrophy of ventricular septum
  • Gradient of LVOT

Surgery (ICD)

  • Prior or sustained ventricular arrhythmias
  • Family history of SCD
  • Syncope suspected to be arrhythmic in nature
  • Massive LVH >30mm
  • LV apical aneurysm
  • LVEF <50%
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10
Q

Clubbing

A

Respiratory

  • Chronic suppurative lung disease (bronchiectasis incl. CF)
  • IPF
  • NSCLC
  • Mesothelioma
  • Mediastinal disease (eg thymoma, lymphoma, carcinoma)

Cardiac

  • Cyanotic congenital heart disease
  • IE

GIT

  • IBD
  • Cirrhosis
  • Coeliac disease

Other

  • Idiopathic
  • Thyrotoxicosis
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11
Q

Interstitial Lung Disease

A
  • Idiopathic (LL)
  • Infective
    • Bronchiectasis (LL)
    • Aspiration (LL)
    • TB (UL)
  • Autoimmune
    • RA (LL)
    • Scleroderma (LL)
    • Ank spond (UL)
    • Sarcoidosis (UL)
  • Radiation induced (UL)
  • Drugs (LL) - bleomycin, MTX, nitrofurantoin, amiodarone
  • Toxins - smoking (LL), asbestosis (LL), heavy metals (LL), silicosis (UL)
  • Allergic - ABPA (UL)
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12
Q

Pleural Effusion

A

Lights Criteria (Exudative)

  • Pleural: serum protein > 0.5
  • Pleural LDH >165
  • Pleural:serum LDH > 0.6

Transudate

  • Cardiac failure
  • Nephrotic syndrome
  • Liver cirrhosis
  • Hypothyroidism

Exudate

  • Infection - pneumonia, TB, subphrenic abscess
  • Malignancy - lung carcinoma, metastatic carcinoma, mesothelioma
  • Connective tissue disease - RA, SLE
  • Sarcoidosis
  • Pancreatitis
  • Drugs - nitrofurantoin, chemo, drugs causing lupus
  • Radiation
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13
Q

Bronchiectasis

A
  • Infection
    • Recurrent aspiration
    • Childhood infection
    • TB/NTM
    • Recurrent bacterial infection
  • Connective tissue disease
    • RA
    • Sjogrens
    • IBD
  • ABPA
  • Immunodeficiency
    • HIV
    • Hypogammaglobulinaemia
    • Bronchiolitis post transplant
  • Genetic
    • CF
    • A1-antitrypsin deficiency
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14
Q

Renal Masses

A

Asymmetric Kidneys

  • PKD
  • Nephrectomy
  • Obstructive nephropathy
  • Congential
  • Renovascular disease

Bilateral Masses

  • PKD
  • Hydronephrosis
  • Acute renal vein thrombosis
  • Amyloidosis
  • Acromegaly

Unilateral Renal Masses

  • PKD
  • Hydronephrosis
  • RCC
  • Acute renal vein thrombosis
  • Solitary kidney
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15
Q

Chronic Liver Disease

A
  • Drugs - ETOH,
  • Metabolic - NAFLD
  • Infective - HBV/HCV
  • Autoimmune - hepatitis, PSC, PBC
  • Vascular - budd chiari syndrome
  • Infiltrative - Wilsons, haemochromatosis, amyloidosis, sarcoidosis
  • Hereditary - CF, a1-antitrypsin deficiency
  • Malignancy
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16
Q

Hepatomegaly

A

Massive

  • Metastatic malignancy/HCC
  • ETOH with fatty infiltration
  • Myeloproliferative disease (CML, myelofibrosis, PV, ET)
  • Right heart failure

Other Causes

  • Malignant as above
  • Fatty liver - NAFLD, ETOH, diabetes, obesity
  • Haematological: myeloproliferative, lymphoma
  • Infiltrative - amyloidosis, haemochromatosis, granulomatous, hyatid cyst
  • Infective - viral hepatitis, HIV
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17
Q

Splenomegaly

A

Massive

  • Myeloproliferative - myelofibrosis, CML
  • (Rare) Primary lymphoma of spleen, hairy cell leukaemia, malaria (kala-azar)

Other Causes

  • Haematological
    • As above
    • PV/ET
    • Lymphoma
    • Acute/chronic leukaemia
    • Thalassemia
    • Haemolytic anaemia
  • Portal hypertension
  • Infective
    • Viral - EBV, hepatitis
    • Bacterial - IE
  • Connective tissue disease
    • RA
    • SLE
    • PAN
  • Infiltration
    • Amyloidosis
    • Sarcoidosis
  • Storage disease
    • Gaucher’s disease
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18
Q

Hepatosplenomegaly

A
  • Chronic liver disease with portal HTN
  • Haematological - myeloproliferative, leukaemia, lymphoma, pernicious anaemia, sickle cell anaemia
  • Infection - acute viral hepatitis, EBV, CMV
  • Infiltration - amyloidosis, sarcoidosis
  • Connective tissue disease - SLE
  • Endocrinopathy - acromegaly, thyrotoxicosis
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19
Q

Generalised Lymphadenopathy

A
  • Lymphoma
  • Leukaemia (CLL/ALL)
  • Malignancy
  • Infection
    • Viral - CMV, HIV, EBV
    • Bacterial - TB, brucelliosis
    • Protozoal - toxoplasmosis
  • Connective tissue disease - RA, SLE
  • Infiltrative - sarcoidosis
  • Drugs - phenytoin
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20
Q

Rheumatoid Arthritis

A

Hands

  • Flexor tendon nodule
  • Palmar erythema
  • Symmetrical, DIP sparing
  • Swan neck (DIP flexed/PIP hyperextended)
  • Boutonniere (DIP hyperextended/PIP flexed)
  • Z deformity (IP flex, MP hyperext, CMC flex)
  • Volar subluxation of MCP
  • Ulnar deviation

Non-articular

  • C-spine: atlanto-axial sublux
  • Anaemia
  • Eye: episcleritis (painless), scleritis (painful)
  • Cardiac - pericarditis
  • Lungs - pleural effusion, pulmonary fibrosis
  • Abdo - splenomegaly
  • Nerves - carpal tunnel, mononeuritis multiplex
  • Skin - ulcers

Serology

  • RF
  • Anti-CCP

X-Ray

  • Loss of joint space
  • Periarticular osteopenia (loss of white shaft)
  • Periarticular soft tissue swelling (if active)
  • Marginal erosions
  • Ulnar subluxation
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21
Q

Psoriatic Arthritis

A

Features

  • Symmetrical if polyarthritis
  • Nail pitting, onchyolysis
  • Arthritis mutilans (shortening of the digits)
  • Dactylitis (sausage digit)
  • Tendon involvement
  • Spinal involvement

Extra-articular

  • Eyes: uveitis
  • Cardiac: aortic regurg
  • Resp: fibrosis
  • Tendons: enthesitis

X-Ray

  • “Pencil in cup” - central erosions, bone overgrowth
22
Q

Osteoarthritis

A

Features

  • Asymmetrical
  • Heberdon’s nodes - DIP (HD)
  • Bouchcards nodes - PIP (BP) = bony nontender hard swelling

X-Ray

  • Subchondral sclerosis
  • Subchondral cysts
  • Loss of joint space
  • Osteophyte
23
Q

Gout

A

Features

  • Tophi - 1st MTP, ankle, knee

Serology

  • Uric acid
  • Renal function

Synovial fluid - negatively birefringent urate crystals

X-Ray

  • Lateral erosions/punched out lesions
  • Overhang
  • Tophi - large soft tissue masses
24
Q

Calcium Pyrophosphate Deposition Disease (CPPD/Pseudogout)

A

Features

  • Oligoarticular - knee and wrist

Extra-articular

  • Haemochromatosis
  • Hypothyroidism
  • CKD

X-Ray

  • Chrondocalcinosis (calcium deposition within the articular cartilage)
  • Loss of joint space
  • Hook osteophytes
  • Tendon calcinosis
25
Q

Scleroderma

A

CREST - calcinosis, raynaud’s, esophageal dysmotility, sclerodactylyl, telangectasia

Features

  • Malabsorption
  • Bird-like facies

Hands

  • Sclerodactylyl
  • Digital ulcerations/pits
  • Raynauds (temperatures)
  • Tendon friction rubs at palms/wrist
  • Calcinosis
  • Joint tenderness/synovitis
  • Function - key test

Arms

  • Skin thickening (if distal to knee/elbow = limited)
  • “Salt/pepper” rash, hair loss
  • Proximal muscle weakness
  • Fistula/permacath
  • BP

Face

  • Anaemia
  • Alopecia
  • Skin tightening
  • Telangiectasia
  • Mouth opening (3 fingers)

Systemic

  • Skin tightening on chest
  • Cardiac - PAH, pericarditis, cardiac failure
  • Resp - ILD
  • Abdo - pulsatle liver

Investigations

  • Antibodies:
    • ANA (95%)
    • ENA
      • anti-SCL-70 (dxSSC - ILD)
      • anti-centromere Ab (LcSSc - protects against ILD/renal)
      • anti-RNA polymerase III (dcSSC - renal)
      • Anti-Th/To (rare - both; PAH)
    • ESR/CR
  • ESR/CRP - disease activity
  • RF/CCF (ddx)
  • Urine PCR/renal function
  • RFTs/TTE/ECG - PAH/ILD
  • Hand X-Ray - acro-osteolysis (loss of distal phalanx)
26
Q

Nerve Conduction Study Patterns

A

Demyelinating

  • DDx: MS, CMT, CIDP, Diabetes, paraprotein (MM)
  • Normal amplitude
  • Reduced velocity
  • Increased distal latency

Axonal

  • DDx: diabetes, toxins, metabolic, paraneoplastic
  • Reduced amplitude
  • Normal to mildly reduced velocity
27
Q

Myopathy

A

Hereditary

  • Duchenne’s Muscular Dystrophy (X-linked)
    • Affects only males
    • Calves and deltoids are hypertrophied early and weak later
    • Early proximal weakness
    • Tendon reflexes preserved in proportion to muscle strength
    • Severe progressive kyphoscoliosis
    • Dilated cardiomyopathy
    • CK high
  • Becker (less severe) muscular dystrophy
    • Less severe than Duchenne’s
    • Later onset and less rapidly progressive
  • Limb girdle muscular dystrophy (autosomal recessive)
    • Facial and pectoral girdle weakness
    • Hypertrophy of the deltoids
  • FSHD (autosomal dominant)
    • Often asymmetric
    • Polyhill sign (deltoid typically spared)
    • Remember to test scapular winging: flexion + wall press
    • Limited abduction + flexion
    • Subtle facial weakness (ask pt to whistle, close eyes tightly, puff out cheeks)
    • Foot drop
  • Distal dystrophies
    • Autosomal dominant disease (rare - causes distal muscle atrophy and weakness)
    • Myotonic dystrophy
  • Mitochondrial myopathy

Acquired

  • Inflammatory myositis - polymyositis, dermatomyositis
  • Drugs/Toxins - ETOH, steroids
  • Endrocinopathy - thyroid, Cushing’s, acromegaly, hypopituitarism
  • Autoimmune - sarcoidosis
  • Malignancy
  • Osteomalacia

Investigations

  • CK (highest in Duchenne’s)
  • EMG - small motor units (NCS - normal)
  • ECG - especially Duchenne’s and myotonic dystrophy)
  • Muscle biopsy
  • TTE - cardiac Ix

Differentials

  • Myasthesia Gravis
  • Motor neurone disease
  • Polyradiculopathy
28
Q

Peripheral Neuropathy

A

“DAM IT BICH”

  • Diabetes
  • Drugs + toxins - chemo (cisplatin), isoniazid, phenytoin, nitrofurantoin, amiodarone, heavy metals
  • Alcohol
  • Metabolic - uraemia, hypothyroidism, porphyria
  • Immune - GBS, CIDP
  • Tumour - lung (paraneoplastic)
  • B12/B6 deficiency
  • Idiopathic
  • Connective tissue - SLE/PAN
  • Hereditary
    • Charcot-Marie Tooth

Predominantly Motor (3C3D3M3P)

  • CIDP/GBS
  • Cauda equina
  • CMT
  • Dapsone
  • Diptheria
  • Diabetes
  • MG
  • MND
  • Multifocal motor neuropathy
  • Polio
  • Porphyria
  • Poisoning (lead)

Predominantly Sensory

  • Diabetes
  • Paraneoplastic/paraproteinaemia
  • Sjogrens
  • Syphilis
  • B12 deficiency/B6 intoxication
  • Idiopathic

Painful Peripheral Neuropathy

  • Diabetes
  • ETOH
  • Vitamin B12/B1 deficiency
  • Carcinoma
  • Porphyria
  • Arsenic/thallium poisoning
  • Hereditary

Investigations

  • FBC/eLFTs
  • ESR/CRP
  • HBA1c
  • TFTs
  • B12/Folate
  • Serum EPP, urine Bence Jones
  • ENA, ANCA
  • NCS + EMG
  • Nerve Biopsy
  • Genetic testing
29
Q

Myelopathy

A

Compressive

  • Syringomyelia
    • LMN UL, UMN LL
    • Dissociated sensory loss (loss of STT, preserved DCML)
    • Spinal level - go down not up
    • Caused by Arnold-Chiari, tumour, spinal cord injury, infection
    • Look for INO (C5), CN 9-12 (medulla involvement)
  • Spondylotic myelopathy (disc prolapse)
  • Neoplasm
  • Abscess

Inflammatory

  • Transverse myelitis
    • Anterior spinal artery occlusion
    • Infection - bacterial, viral)
    • NMO
    • Vasculitis
    • Demyelination (ie MS)
    • Radiation
  • Connective tissue disease
  • MS
  • Sarcoidosis
  • Paraneoplastic syndrome

Infection

  • Epidural abscess
  • Acute viral myelitis (enterovirus, flavivirus)
  • AIDS myelopathy
  • Syphilis (dorsal column)

Vascular

  • Spinal cord infarction
  • Vascular malformation
  • Epidural haematoma

Toxic

  • Subacute combined degeneration
  • Radiation myelopathy
  • Intrathecal chemotherapy
30
Q

Brown-Sequard Syndrome

A

Hemisection of the Cord

  • Ipsilateral LMN at level of lesion, UMN below the lesion
  • Contralateral STT below the lesion
  • Ipsilaretal DCML below the lesion
31
Q

Subacute Combined Degeneration

A
  • UMN in legs
  • Loss of DCML
  • Loss of ankle jerk (but hyper-reflexic in knees)
32
Q

Parkinson’s Disease

A

Features

  • Hypomimia
  • Masked facies
  • Slow blink rate (glabella tap)
  • Hypophonia
  • Gait - stooped, reduced arm swing (often asymmetric), short stride length/shuffling + note tremor –> festination, freezing, turning en bloc + multiple steps to turn
  • Tremor - rest, asymmetric pill rolling - comfortable posture + distract (eyes closed, count backwards)
  • Rigidity - cogwheeling, lead pipe (increase with coactivation; head turning, painting a wall)
  • Bradykinesia with decrement
  • May have duodopa running through PEG-J or subcut apomorphine pump); look for DBS battery
  • Other exam:
    • EOM (vertical first, PSP)
    • Cerebellar signs (MSA), lying/standing BP, postural instability
    • Other: writing (micrographia), Archimedes spiral (tremor), cognitive Ax (DLB)

Differential Diagnoses

  • Drugs
    • Typical and atypical antipsychotics - chlorpromazine, haloperidol, olanzapine
    • Metoclopramide
  • MSA
  • DLB
  • CBD
  • Vascular parkinsonism
  • Normal pressure hydrocephalus

Further Investigations

  • Drug history
  • MRI (if atypical features)
  • Trial of levodopa
33
Q

Myasthenia Gravis

A
  • Ptosis +/- weak EOM and orbicularis oculi
  • Fatiguability
    • Look at the ceiling for two minutes
    • Abduct the arms and push down every second, and see fatiguability

Investigations

  • Antibodies
    • Acetylcholine receptor antibodies
    • Anti-MuSK antibodies
  • Repeat nerve stimulation
  • Single fibre EMG
  • RFTs
  • CXR - r/o thymoma
34
Q

Myotonic Dystrophy

A
  • Frontal balding
  • Dull triangular facies
  • Temporalis, masseter and sternomastroid atrophy
  • Partial bilateral ptosis
  • Neck - SCM atrophy; flexion weak, extension normal
  • UL
    • Grip myotonia (shake hands)
    • Percussion myotonia (tap over thenar eminence –> contraction then slow relaxation of abductor pollicis brevis)
    • Wasting and weakness; especially of forearm muscles
    • Sensory changes with peripheral neuropathy
  • Gynaecomastia
  • LL if time

Investigations

  • Family history + genetic testing (DMPK)
  • Diabetes - urine sugar, HbA1c
  • ECG and TTE - CMP, MVP, SVT/AF
  • RFTs (restrictive)
  • Sleep study - disordered breathing
  • MMSE - cognitive deficit
  • EMG: dive bomber effect with needle movement in muscle at rest
35
Q

Fredreich’s Ataxia

A
  • Bilateral cerebellar signs including nystagmus and truncal ataxia
  • Dorsal column loss
  • UMN signs (but loss of ankle jerk due to weakness)
  • Distal weakness
    • Pyramidal - UL extensors, LL flexors d
  • Peripheral neuropathy
  • Optic atrophy
  • Pes cavus

Other Signs:

  • Cardiomyopathy
  • Diabetes
  • Hearing loss
  • Dysphagia
  • Kyphoscoliosis
  • Sleep disordered breathing

Investigations

*

36
Q

Chorea

A

Hereditary

  • Benign familial chorea
  • Wilson’s disease
  • Huntingtons
  • Spinocerebellar ataxia

Acquired

  • Deep brain lesion
  • Drugs - phenytoin, carbamazepine, lithium, levodopa
  • Malignancy/paraneoplastic
  • Autoimmune - SLE, Sydenhams, rheumatic fever
  • Infections - syphilis, HIV, TB
  • Life - pregnancy, senility
37
Q

Ptosis

A
  • Normal Pupils
    • Senile ptosis
    • Myotonic dystrophy
    • FSHD
    • Ocular myopathy - mitochondrial
    • Thyrotoxic myopathy
    • MG
    • Botulism/snake bite
    • Congenital
  • Constricted Pupil
    • Horner’s syndrome
    • Tabes dorsalis
  • Dilated Pupil
    • 3rd nerve palsy
38
Q

Horner’s Syndrome

A
  • Carcinoma - lung, thyroid
  • Carotid artery dissection
  • Lateral medullary syndrome
  • Brainstem lesion
  • Retro-orbital lesion

Investigations

  • MRI Brain and spine
  • USS Neck
  • CT Chest
  • CTA - arch to circle of willis
39
Q

INO

A

Lesion at the MLF

  • Demyelination (eg MS)
  • Tumour
  • Vascular - thrombus
  • Trauma
  • Infective (bacterial, viral)
  • Toxin - ETOH, TCA, lithium
  • Hepatic encephalopathy
40
Q

Cranial Nerve Clusters:

  • Cavernous Sinus
  • Superior Orbital Fissue
  • Lateral Medullary Syndrome
  • CPA tumour
A

Superior Orbital Fissure

  • CN 3, 4, 6

Cavernous Sinus

  • CN 3, 4, 5, 6

CPA Tumour

  • CN 5, 7, 8

Lateral Medullary Syndrome (usually PICA infarct)

  • CN 5 - trismus due to masseter, ipsilateral pain and temp
  • CN 9 - dysphagia, dysarthria, dysphonia. Hoarse voice, absent gag
  • CN 10 - cough
  • Ipsilateral Horner’s
  • Ipsilateral cerebellar/vestibular
  • Contralateral pain and temperature of trunk and limbs
41
Q

One and a Half Syndrome

A

From lesion in dorsal pons (stroke, MS, tumour)

Horizontal gaze palsy to affected side, impaired adduction to other side

42
Q

Optic Neuropathy

A
  • MS
  • Toxic - ethambutol, ETOH, nicotine
  • Metabolic (B12)
  • Ischaemic - DM, temporal arteritis, atheroma
  • Infective - EBV
43
Q

Occulomotor Palsy

A

Central

  • Vascular (ie brainstem)
  • Demyelination (rare)
  • Tumour
  • Trauma
  • Idiopathic

Peripheral

  • Compressive
    • PCOM aneurysm
    • Raised ICP
    • Orbit lesions - superior orbital fissure
    • Basal meningitis
    • Nasopharyngeal carcinoma
  • Infarction - DM, arteritis
  • Trauma
  • Cavernous sinus lesion
44
Q

Abducen’s Nerve Palsy (CN VI)

A

Bilateral

  • Trauma (had injury)
  • Wernicke’s encephalopathy
  • Raised ICP
  • Mononeuritis multiplex

Unilateral

  • Central
    • Tumour
    • Stroke
    • Wernicke’s encephalopathy
    • MS (rare)
  • Peripheral
    • Diabetes, other vascular lesions
    • Trauma
    • Idiopathic
    • Raised ICP
45
Q

Supranuclear Palsy

A
  • Progressive supranuclear palsy
  • Parinaud’s syndrome (lesion in dorsal midbrain)
46
Q

Trigeminal Nerve Palsy (CN V)

A

Central (pons, medulla and upper cervical cord)

  • Vascular
  • Tumour
  • Syringobulbia
  • MS

Peripheral (posterior fossa)

  • Aneurysm
  • Tumour (skull base eg acoustic neuroma)
  • Chronic meningitis

Trigeminal Ganglion (petrous temporal bone)

  • Meningoma
  • Fracture of the middle fossa

Cavernous Sinus (Ax 3rd/4th/6th)

  • Aneurysm
  • Thrombosis
  • Tumour

Other

  • Sjogren’s syndrome
  • SLE
  • Toxins
  • Idiopathic
47
Q

Facial Nerve Palsy (CN VII)

A

UMN

  • Vascular
  • Tumour

LMN

  • Pontine (Ax V/VI)
    • Vascular
    • Tumour
    • Syringobulbia
    • MS
  • Posterior fossa
    • Acoustic neuroma
    • Meningoma
  • Petrous temporal bone
    • Bell’s palsy
    • Ramsay Hunt syndrome
    • Otitis Media
    • Fracture
  • Parotid
    • Tumour
    • Sarcoid
  • Bilateral Disease
    • GBS
    • Bilateral parotid disease (eg sarcoidosis)
    • Mononeuritis multiplex (rare)
    • Myopathy and NMJ can mimic
48
Q

Vestibulocochlear Nerve Palsy (CN VIII)

A

Webers Test:

  • Conduction - localises to bad ear
  • Sensorineural - localises to good ear

Rinne’s Test

  • Sensorineural: AC > BC (positive)
  • Conduction: BC > AC (negative)

Sensorineural Deafness

  • Degeneration
  • Trauma (eg high noise exposure, fracture of petrous temporal bone)
  • Toxic (eg aspirin, ETOH, streptomycin)
  • Infection (eg congenital rubella/syphilis)
  • Tumour (eg acoustic neuroma)
  • Brain stem lesions
  • Vascular disease of internal acoustic artery

Conductive Deafness

  • Wax
  • Otitis Media
  • Otosclerosis
  • Paget’s Disease of bone
49
Q

Upper Limb Neuroanatomy

A

Myotomes:

  • Shoulder abduction: C5 (axillary)
  • Elbow flexion: C6 (musculocutaneous)
  • Wrist flexion: C7 (median)
  • Finger flexion: C8 (median)
  • Elbow extension: C7 (radial)
  • Wrist extension: C6 (radial)
  • Finger extension: C7 (radial)
  • Finger abduction/adduction: T1 (ulnar)

Reflexes

  • Supinator C5/6 (radial)
  • Biceps C5/6 (musculocutaneous)
  • Triceps C7/8 (radial)

Localising Radial Nerve Injury

  • If only elbow ext weak - C7
  • If elbow ext and all below weak - at spiral groove
  • If elbow and finger weak but normal brachioradialise - posterior interosseous
50
Q

Cause of Foot Drop

A
  • Common peroneal nerve palsy
  • Sciatic nerve palsy
  • Lumbosacral plexus lesion
  • L4/L5 root lesion
  • Peripheral motor neuropathy
  • Distal myopathy
  • Motor neurone disease
  • Precentral gyrus lesion

Test ankle jerk –> if absence, S1/sciatic nerve lesion suspected; if normal common peroneal/L5; if increased UMN/MND

Inversion is normal in common peroneal but absent in L5 radiculopathy (eversion is absent in both)

51
Q

Cerebellar Syndromes

A
  • Ischaemia
  • Drugs - ETOH, phenytoin, lithium, carbamazepine
  • Hereditary - Fredreich’s ataxia, spinocerebellar ataxia
  • Paraneoplastic (ovary, uterus, breast, HL, SCLC)
  • MS
  • Posterior fossa tumour

UMN (Spastic) + Cerebellar (Ataxic)

  • Fredreich’s ataxia
  • Spinocerebellar ataxia
  • MS
  • Infarction (upper pons, bilateral internal capsule)
  • Arnold Chiari
  • Syringomyelia
52
Q

Charcot Marie Tooth (HSMN)

A
  • Pes cavus (short high arched feet with hammer toes)
  • Distal muscle atrophy (from peripheral generation) –> inverted champagne bottle leg
  • Does not extend above the elbows or above the middle one third of the thighs
  • Areflexia/hyporeflexia (always show reinforcing manoeuvres)
  • Slight or not sensory deficits in the limbs
  • Thickened nerves
  • Foot drop –> high stepping gait, look for AFOs/Dictus bands
  • Bedside: opthalmoscope (optic atrophy)
  • Ix: NCS, genetics (PMP22), OT for functional assessment

RACP CLINICAL EXAM (8 decks)

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