PACES NOTES INVESTIGATION AND MANAGEMENT
Subhankar Chatterjee, Kolkata 5/1/2017
From my experience it was obvious that in Station 1 and 3 examiners want to hear quick and sensible investigation and management plan, which most of us fail to utter in timely and systematic fashion. They have 4mins after we finish the case. The usual questions which they ask are as follows1. Tell me the positive clinical finings- You should take no more than 30-40 sec for this 2. What are the differential diagnosis- It may take some time as you may be interrupted if going in wrong direction. But never > 1min. 3. Which investigations would you do for this patient?- 40 sec 4. How do you manage the case? – Again Again 40-60 sec. If you have answered all of the above in correct manner, you may have further questions which will fetch you towards full marks. So, So, time management is very important. important. I have made this note for my third attempt of PACES, which I passed. During exam felt quite confident as I have rehearsed it many times with my friends, juniors and even before mirror. It might seem inadequate, but believe me, you have small time to answer each question. This is a template only made for me and not all inclusive. I request all future examinees to prepare their own such notes which might be more effective if made according to one’s own ability, memory and concept. At the end I have tried to simplify some Neurology scenarios in a schematic pattern, which helps in recognition during examination. Obviously this note carries contribution from all of my teachers, mentors, books and notes targeting PACES. Best of luck for PACES.
pattern
Respiratory system
1. COPD Sir, my INVESTIGATIONs include :
Blood for FBC to look for Polycythemia
Differential count, ESR, CRP- to look for signs of infection,
Chest x ray /HRCT to look for hyperinflation and Bulla
Pulmonary function test to look for Obstructive pattern with reduced DLCO
ECG and Echocardiography to rule out Cor pulmonale
Sputum microscopy and C/S to isolate any organism
6min walking test for functional assessment
Arterial blood Gas to decide about L TOT
My TREATMENT plan include:
General measures o
Stop smoking
o
Pulmonary rehabilitation ( Pt education, Nutrition, Psychological support, Physiotherapy)
o
Vaccination
Specific medical o
Bronchodilator- inhaled B agonist/ ICS/ LABA/LAMA
o
Antibiotic and systemic steroid for acute exacerbations
o
Mucolytics
o
LTOT
o
Diuretics and Phosphodiesterase inhibitors for Cor pulmonale
Surgeryo
Bulectomy/ Lung volume reduction
o
Lung transplant
2. Bronchiectasis
Investigation o
Blood-Differential count, ESR, CRP- to look for signs of infection, Imm unoglobin levels
o
Chest x ray /HRCT to look for Tram line appearance/Signet ring
o
Sputum microscopy and C/S to isolate any organism, particularly Pseudomonas
o
Pulmonary function test to look for Obstructive pattern
o
ECG and Echocardiography to rule out Cor pulmonale
o
6min walking test for functional assessment
o
Sweat test if suspect cystic fibrosis
Management
General measures
o
Stop smoking
o
Pulmonary rehabilitation ( Pt education, Nutrition, Psychological support, Physiotherapy, POSTURAL DRAINAGE)
o
Vaccination
Specific medical o
Mucolytics
o
Bronchodilator- inhaled B agonist/ ICS/ LABA/LAMA
o
Antibiotic- systemic / inhalational inhalational +/- Steroids
o
LTOT
o
Diuretics and Phosphodiesterase inhibitors for Cor pulmonale
Surgeryo
Lobectomy
o
Bronchial artery embolisation for hemoptysis
o
Lung transplant for cystic fibrosis
3. Pulmonary Fibrosis/ ILD/Rheumatoid lung Investigation a. Chest x ray – ray –to to look for bilateral interstitial reticulo nodular pattern. Loss of lung volume b. HRCT to look for subpleural reticulation and traction broncheitasis, basal honeycombing , ground glass patterns c.
Pulmonary function test to look for Restrictive pattern with reduced DLCO
d. Blood-Differential count for eosinophilia, ESR, CRP- to look for signs of infection e. Markers for Autoimmune profile, ACE level, Ca, f.
Brocnchoscopy and BAL /Sputum microscopy and C/S to rule out any organism
g.
ECG and Echocardiography to rule out Pulmonary HTN
h. 6min walking test for functional assessment i.
ABG to decide about LTOT
Management
General measures o
Stop smoking and toxic or allergic substances
o
Pulmonary rehabilitation ( Pt education, Nutrition, Psychological support, Physiotherapy)
o
Vaccination
o
LTOT
Specific medical o
Immunosupressive – Immunosupressive – Steroid Steroid for ground glass, Thalidomide, Cyclophosphamide,
o
Antifibrotic – Antifibrotic – Pirfenidone Pirfenidone for IPF ( UIP P attern on HRCT)
o
Diuretics and Phosphodiesterase inhibitors for Cor pulmonale
Surgeryo
Single or Double lung transplantation
4. Pleural effusion Investigation a. Chest x ray to look for blunt costophrenic and cardiophrenic angles b. CT thorax to look for any MASS c.
USG to rule out multisepted/ loculated effusion
d. Pleural fluid assessment for cellularity, protein, sugar, cultures, malignant cell, special tests. e. Blood-Differential count , ESR, CRP- to look for signs of infection, Albumin, Urea/ electrolytes to rule out any renal disease, LFT to rule out any liver disease f.
ECG and Echocardiography to rule out Pulmonary HTN/ cardiac decompensation
g.
Markers for Autoimmune profile
h. Pleural biopsy in refractory cases i.
Other Special tests as required
Diagnosis of plerual effusion Clinically 500ml, x ray PA 300ml, x ray lat decubitus-180ml d ecubitus-180ml , USG 30ml Management: 1. Therapeutic Pleural drainage drainage if Symptomatic, infective ( empyema) 2. Treatment of the cause 3. Decortication/intrapleuarl thrombolytics for multiloculated effusion 4. Pleurodesis for refractory malignant effusion
5. Lobectomy / Pneumonectomy Pneumonectomy Investigation o
Chest x ray – ray –to to look for confirmation
o
CT thorax to look for underlying cause
o
Pulmonary function test to look for Obstructive
o
Blood-Differential count , ESR, CRP- to look for signs of infection,
o
ECG and Echocardiography to rule out Pulmonary HTN
o
Other Special tests as required
Management:
o
Supportive
o
Management of the original disease
Indication of Lobectomy o
Localized broncheictasis with massive hemoptysis
o
Lung abscess
o
Solitary pulmonary nodule
o
Trauma
o
Aspergiloma
o
NSCLC T3AN0M0
o
TB – TB – not not done now a days
Indication for Pneumonectomy Pneumonectomy
o
Massive Broncheictasis
o
Multiple lung abscess
o
Fungal infection Malignancy
o
Trauma
o
Bronchial obstruction with destroyed lung
o
Congenital lung disease
o
Malignant mesothelioma/ disseminated thymoma
Indication of lung transplant o
COPD
o
IPF
o
Cystic fibrosis
o
Alpha 1 antitrypsin deficiency
o
Primary pulmonary hypertension
6. OLD TB- Fibrothorax Investigation o
Chest x ray – ray –to to look for confirmation
o
CT thorax to look for underlying cause and look for other lung pathologies
o
Pulmonary function test to look for volume loss
o
Blood-Differential count , ESR, CRP- to look for signs of infection,
o
ECG and Echocardiography to rule out Pulmonary HTN
o
Sputum gram stain and culture to look for infection, AFB and NAAT to rule out TB
Management: 1. General
Smoking cessation/ Pulmonary rehabilitation
Specific
Bronchodilator
Early antibiotic therapy for suspected infection
7. Lung Consolidation ( d/d- Pneumonia/ Infarction/ mass) Investigation o
Chest x ray – ray –to to look for confirmation
o
CT thorax to rule out any mass lesion lesion
o
Blood- Septic screening -Differential count , ESR, CRP, PCT - to look for signs of infection, Urea/ electrolytesCURB 65,
o
ABG to look for hypoxemia/ hypercapnoea
o
Sputum gram stain and culture to look for infection, cytology for malignant cells
o
ECG and ECHO to rule out pulmonary embolism
o
Bronchoscopy with BAL for microbiology, cytology
o
If septic screen and embolism negative- send autoimmune profile
Management
General measures o
Stop smoking and toxic or allergic substances
o
Pulmonary rehabilitation ( Pt education, Nutrition, Psychological support, Physiotherapy)
o
Vaccination
Specific medical o
Pneumonia
Antibiotics/ Bronchodilator/ Mucolytics
o
Infarction
LMWH/ warfarin/ modification of risk factor
o
Mass
Chemo/ radiotherapy/ surgery
8. Lung collapse ( d/d Malignancy/ TB/Hilar L/N / Mucus plug) o
Chest x ray – ray – for for confirmation
o
CT thorax to rule out any mass lesion, Enlarged L/N
o
Blood- Septic screening -Differential count , ESR, CRPUrea/ electrolytes/ LFT / ACE level
o
ABG to look for hypoxemia
o
Sputum gram stain and culture to look for infection, cytology for malignant cells
o
Bronchoscopy to rule out any endobronchial growth, BAL for microbiology, cytology , Biposy , NAAT
Management
General measures o
Physiotherapy
o
Positive pressure ventilation
Specific medical o
Mucus plug
Bronchodilator/ Mucolytics/ Mucolytics/ Bronchoscopy and lavage
o
Malignancy
Chemo/ radiotherapy/ Bronchoscopy may need stenting
o
Others
Bronchoscopy and treatment of the cause , may need stenting
9. SVCO ( D/D-Malignancy/ mediastinal goiter/ thoracic aorta aneurysm/ mediastinal fibrosis) Investigations o
Chest x ray /CT thorax to rule out any mass lesion, Enlarged L/N
o
Blood- FBC/ Urea/ electrolytes/ LFT
o
ECG /ECHO
o
CT Angiography / venography
o
Brochoscopy with BAL for microbiology, cytology , Biposy ,
Management
General measures o
Elevation of head,
o
Positive pressure ventilation
Specific medical o
Steroids ( Dexamathasone) and diuretics
o
Radiotherapy/ chemothapy
o
SVC Stenting
Abdomen 1. CLD ( D/D Alcohol/ viral/autoimmune/ viral/autoimmune/ metabolic/drugs) metabolic/drugs) Investigation
USG abdomen for confirmation of diagnosis may proceed to triphasic CT of Liver
Severity-
o
Synthetic function
o
Renal function
o
Bilirubin
o
Serum ammonia
PT/INR, Albumin
To look for complication o
Full Blood count – count – anemia, anemia, thrombocytopenia( hyperspleenism)
o
USG/ AFP to rule out HCC
o
OGD
to look for varices
To look for etiology o
Alcohol and drug history
o
Metabolic profile ( NASH)
o
Viral markers
o
Cerulopasmin and urinary copper study( WILSON’S)
o
Ferritin (HH)
o
Liver biopsy( NASH, PBC, PSC)
o
AMA ( PBC) , ASMA, , IgG, Anti LKM ( AIH) ANCA (PSC)
o
Alpha 1 antitrypsin
Management
MDT
Treat underlying cause
o
Alcohol: abstinence
o
Viral hep- Anti virals ( B-Lamivutin, Entacavir, C- Sofosbuvir, Telapravir, Bocepravir)
o
HH- venesection, iron chelation
o
Wislson’sWislson’s- d penicilamine, Zinc
o
PBC- UDCA, Immunosuprressant, cholestyraimine, antihistamine
o
NASH- Weight reduction, Control of diabetes
Treat complication o
Varix- ABCDE, Ligation, Ligation, B blocker
o
Encephalopathy- rifaximin, treat precipitants
o
Ascites- Diuretics, paracentesis
o
SBP- Antibiotic, drainage
o
Hepatorenal- Albumin, Terlipressin
o
HCC- resection, embolization, transplant
Definitive management- LIVER Transplant
2. Ascites ( CLD, Malignancy, TB, Fluid overload, Vascular, Peritoneal dialysis peritonitis) Investigations
USG abdomen for confirmation of diagnosis
Ascetic fluid for SAAG, Cell count, type, , Sugar, Protein, Malignant cell, Culture
To look for etiology o
Alcohol and drug history
o
Metabolic profile ( NASH)
o
Viral markers
o
Cerulopasmin and urinary copper study( WILSON’S)
o
Ferritin (HH)
o
Liver biopsy( NASH, PBC, PSC)
o
Auto antibodies: AMA ( PBC) , ASMA, , IgG, Anti LKM ( AIH) ANCA (PSC)
o
Alpha 1 antitrypsin
o
AFP for HCC
o
Renal parameters and urinary protein for Nephrotic syndrome
o
ECHO for CCF/ CP/ RCM
o
Thrombophilia workup and CECT abdomen for Veno-occusive disease
Management:
General – General – Patient Patient education / salt and fluid restriction
Medical- Diuretics- Spironolactone, Furosemide
Treatment of SBP
Therapeutic paracentesis
3. Heptomegally ( D/D- Cirrhosis, Cancer, Cardiac, Cyst, Infection, Infiltration, Inflammation)
Investigation 1. confirmation of diagnosis- USG abdomen 2. Look for etiology o
Alcohol and drug history
o
Metabolic profile ( NASH)
o
Viral markers
o
Cerulopasmin and urinary copper study( WILSON’S)
o
Ferritin (HH)
o
Auto antibodies: AMA ( PBC) , ASMA, , IgG, Anti LKM ( AIH) ANCA (PSC)
o
Alpha 1 antitrypsin
o
AFP for HCC
o
ECHO for CCF/ CP/ RCM
o
Liver biopsy ( NASH, PBC, PSC)
3. Look for complications o
LFTs
o
PT, INR, Albumin
o
FBC with inflammatory markers
o
CECT ABDOMEN
Management: General-patient education , counseling, dietary modification, weight reduction Specific- treat the underlying cause
4. Spleenomegally ( D/D Infection/ hematological/ congestive/ inflammatory/ neoplastic/ infiltrative) Investigations: o
Confirmation: USG of Abdomen
o
Doppler study to look for portal vein thrombosis
o
FBC and inflammatory markers
o
PBS look for malaria, kala azar, he molysis
o
Bone marrow to look for myeloprolifearative disorders
o
JAK 2 mutation, Philadelphia chromosome
o
Auto immune screen for RA, SLE- (RF, Anti CCP, ANA)
o
Hemolysis screen- LDH, DCT, Bilirubin, haptoglobin, Hb electrophoresis
o
HIV
o
CXR for mediastinal enlargement
Management General: Patient education Specific : treat underlying cause. Spleenectomy for severe hyperspleenism. (Influenza/ Hemophilus/ pneumococcus, meningococcus vaccine needed after spleenectomy) Prophylactic Penicilline for at least 2 yrs.
5. Hepatospleenomagally Investigations: o
Confirmation: USG of Abdomen
o
Doppler study to look for portal vein thrombosis
o
FBC and inflammatory markers
o
PBS look for malaria, kala azar, he molysis
o
Bone marrow to look for myeloprolifearative mye loprolifearative disorders
o
JAK 2 mutation, Philadelphia chromosome
o
Auto immune screen for RA, SLE- (RF, Anti CCP, ANA)
o
Hemolysis screen- LDH, DCT, Bilirubin, haptoglobin, Hb electrophoresis
o
HIV
o
CXR for mediastinal enlargement, ACE level for sarcoidosis
Management General: Patient education Specific : treat underlying cause. Spleenectomy for severe hyperspleenism. (Influenza/ Hemophilus/ pneumococcus, meningococcus vaccine needed after spleenectomy) Prophylactic Penicilline for at least 2 yrs.
6. Heptospleenomegally Heptospleenomegally with Lymphadenopathy Lymphadenopathy ( d/d Lymphoma, leukemia in blast crisis, disseminated TB, SLE, sarcoidosis, Infectious Mononeucleosis syndrome, HIV) Investigations: o
Confirmation: USG of Abdomen
o
Doppler study to look for portal vein thrombosis
o
FBC to see leucocyte count count and inflammatory markers
o
PBS look abnormal cells
o
Bone marrow to look for myelo/ mye lo/ Lympho prolifearative disorders
o
Auto immune screen for RA, SLE- (RF, Anti CCP, ANA)
o
Lymph node biopsy if > 1month, > 1 region, > 1cm and not draining any infective focus
o
HIV serology
o
CXR for mediastinal enlargement, ACE level for sarcoidosis
o
LFTs, Renal parameters,
Management General: Patient education Specific : treat underlying cause
7. Jaundice +/_ hepato/ Hepatospleenoegally (DCLD, Hepatitis, Hemolytic disease, malignancy, infections) Investigations: o
Confirmation: LFTs
o
For etiology o
USG of Abdomen followed followed MRCP/ CT depending on USG USG findings
o
Viral markers
o
Autoimmune profile (AMA,ANA, ASMA, Anti LKM)
o
o
PBS look abnormal cells, spherocytes,
o
Hemoglobin electrophoresis, DCT to look for hemolytic diseases
o
HIV serology
FOR complication
8.
o
Coagulation profile
o
OGD for esophageal varices
o
Renal parameters
o
Septic screen
o
Ascitic fluid if any
Jaundice and Ascites +/_ hepato/ Hepatospleenoegally ( DCLD, , Malignancy ,Disseminated TB, Cardiac cirrhosis)
o
Confirmation: LFTs
o
For etiology
o
o
USG of Abdomen followed followed MRCP/ CT depending on USG USG findings
o
Viral markers
o
Autoimmune profile (AMA,ANA, ASMA, Anti LKM)
o
Ascitic fluid for Cellularity, SAAG, Malignant cell, Culture
o
Laparoscopy and peritoneal biopsy
o
Echocardiography
For complication o
Coagulation profile
o
OGD for esophageal varices
o
Renal parameters
o
Septic screen
Management General: Patient education Specific : treat underlying cause
9. Polycystic Kidney Investigation
USG abdomen for Confirmation and measuring the number of cysts
CBC to look for anemia/ polycythemia
Renal function, Calcium and phosphate to look for secondary hyperparatyroidism
Chest x ray to look for fluid overload
Urine dipstick to look for hematuria/ protein
LFTs to look for deranged liver function as there might be cysts in liver
Screening for cerebral aneurysm with patients having family h/o SAH @5yrs.
Genetic study for potential donors with no cysts on US
Echocardiography to look for MVP, AR
Management:
General o
Patient education and counseling about course of disease and complication
o
Attempt 3lit fluid intake per day to suppress ADH secretion
o
Screening of 1st degree relatives from the age f 20yr at least 3 cyst uni/ bilateral
o
Avoid contact sports/risk of trauma to abdomen
Specific medical o
ACEI for control of hypertension
o
Avoid nephrotoxic drugs
o
Antibiotics for UTI/ cyst infection
o
Renal replacement therapy
o
Indication of Nephrectomy
o
Recurrent infection
Uncontrolled hemorrhage
Suspected malignancy
Symptomatic mass effect
Extension of polycystic kidney into transplant site.
Management of Hematuria- bed rest, hydration and analgesia
10. Transplanted Kidney Investigations
USG Doppler to confirm diagnosis and assess graft
To check that the graft is working
o
FBC
o
Renal Function
o
Calcium and Phosphate
o
CXR for volume overload
o
ABG for metabolic acidosis
To look for complication of immunosupression o
Septic screen for patients with fever
o
Renal function/ LFT ( Cyclosporin )
o
Fasting lipid/ sugar ( tacrolimus)
o
Screen for opportunistic infection
o
Biopsy from transplanted kidney to look for Graft failure
Management
MDT
Patient education and counseling, c ompliance to immunosuppressant
Monitoring for toxicity of immunosuppressant
o
FBC, Renal parameters, LFT
o
Septic screen
o
Dermatology surveillance for PTLD
Treat acute presentation of sepsis with antibiotic/ Antiviral/ antifungal
Renal replacement therapy if graft function deteriorates despite adequate immunosupression o
Uremic encephalopathy
o
Pericarditis
o
Refractor fluid overload
o
Decompensated metabolic acidosis and hyperkalemia
Lower limb Weakness
Quadruplegia
Bilateral
UMN Unilateral stroke ask permission UL/Face
Examine neck Lower cranial Nv cerebreller Paraparesis/ paraplegia
Check Cerebeller Yes MS, Brainstem , Spino Cerebeller Ataxia Friedreich’s / B12 deficiency No
Check Sensory- Deficit Spinal Level Spinal Cord lesion Dissociated sensory loss Syringomyelia/ Ant Spinal AO No Sensory deficit
Fasciculation
Peipheral nerve pattern Pheripheral neuropathy + Pyramidal Pyram idal
parasagital meningioma Syringomyelia
MND
Heriditary/Tropical Spastic Paraparesis
Spastic Diplegia ( Cerebral Palsy)
Lower limb LMN LMN Cerebeller Alcohol, drugs
Sensory Deficit
Yes
NO
Polio Small wasted limb
Root Lesion
Peripheral nerve
Both root and nerve
Muscle hypertrophy
fasciculation
Cauda GBS CIDP Diabetic amyotrphy
Diabetes Alcohol HSMN B6/B12 Paraneoplastic CIDP Drugs
GBS/ CIDP
Muscle disease
Multifocal Motor NP MND
Both UMN and LMN Lower limb
No Sensory Loss- ALS Dissociated Sensory Loss- Syrings Absent KJ+ brisk AJ, Planter ↑= Conus lesion Absent ankle jerk + planter ↑↑ M- MS, MND o A- Ataxia Freidreich’s Freidreich’s , Cauda conus o S- SACD, Syphilitic taboparesis o o S- Spinal shock , stroke with PN
Affect only LMN Asymmetric, UL and LL Prominent fasciculation Autoimmune origin Anti GM 1 antibody Treatment IvIg, Rituximab and Immunosupressant
Foot drop
Ankle Jerk
Brisk
UMN
Lateral thigh and leg compartment & Dorsum of foot Usually unilateral H/O Pain EHL weakness
L5 radiculopathy
Present
Sensory loss
absent
S1 radiculopathy
Part of leg and Dorsum of foot Unilateral
No sensory loss Bilateral
Common peroneal nerve D/D HSMN / trauma/ diabetes Paraneoplastic
Myotonic dystrophy IBM
Cause of Pes Cavus
Unilateral
Bilateral
Polio
HSMN
Burn
mascular dystrophy
Taruma
spinal mascular atrophy Syringomyelia
Palpable nerve
HSMN Acromegally Leprosy CIDP Amyloidosis Neurofibromatosis
Sciatic nerve
Upper limb Weakness
Check LL
LMN and UMN
UMN Unilateral stroke ask permission LL/Face
Bilateral (D/D- bilateral stroke/MND/ PD/ Freidreich’s/ Freidreich’s/ cervical 1-4)
MND Examine neck any scar, kyphoscoliosis
Check Cerebeller Yes MS, Brainstem , Spino Cerebeller Ataxia, Wilson’s
Friedreich’s Friedreich’s
No
Check Sensory- No Sensory deficit
Fasciculation
Yes
MND
No Deficit Tremor
Spinal Level
Spinal Cord lesion
cervical myelopathy
Dissociated sensory loss
Peipheral nerve pattern
Multiple sclerosis
Syringomyelia/ Ant Spinal AO
Pheripheral neuropathy + Pyramidal
Yes PD
Upper limb LMN LMN Cerebeller Alcohol, drugs, Syrings,
Sensory Deficit
Yes
NO
Polio
Small wasted limb
Root Lesion Dermatomal loss
Peripheral nerve Gloves pattern
Both root and nerve both/ variable
Muscle hypertrophy fasciculation Proximal Distal/proximal
Brachial Neuritis CIDP GBS
Diabetes HSMN Alcohol CIDP Drugs B6/B12 Paraneoplastic
GBS/ CIDP
Fatigable
Yes MG LEMS
No Muscle ds
Multifocal Motor NP MND Cervical Spon
Affect only LMN Asymmetric, UL and LL Prominent fasciculation Autoimmune origin Anti GM 1 antibody Treatment IvIg, Rituximab and Immunosupressant
Small Muscle wasting of hand D/DMND, Cervical myelopathy, Syrings, combined median and ulnar nerve damage,Peripheral neuropathy( CMT) , C8T1 lesion ( cervical r ib, Pancoast tumor, trauma) 1. Handa. 5 movements of thumb 4 movements of fingers b. DTR c. Sensory d. Cerebeller
1 movement of little finger e. Lower limb/ cranial
WASTING OF HAND
Unilat stroke LMN
UMN
Bilateral MND Parkinson’s Ds Upper cervical
SENSORY Median and Ulnar nerve
No sensory loss
gloves pattern
Dermatomal pattern C8-T1
MND Polyneuropathy MMN Myotonic dystrophy Disuse atrophy RA Cachexia Look relevant IBM Spinal Cord Cervical Spondylosis Syringomyelia Syringomyelia Anterior Horn Cell Motor Neuron Disease Polio Spinal muscular atrophy Nerve Lesions Median Ulnar Peripheral Neuropathy Brachial Plexus C8-T1 Myopathy Myotonic Dystrophy Distal myopathy
Dissociated
P ancoast Syringomyelia Neurofibroma Cervical Rib Cervical myelopathy (+UMN) Brachial plexopathy
Look at back Test sensation over cap area, look for Horners Fasiculation of the tongue or other muscles, ?bulbar speech Examination of lower limbs Alone will not give wasting of all small muscles of the hand Should have a claw hand e.g. CMT – CMT – absent absent reflexes, forearms > hands, thickened nerves ? clubbed from lung ca, cervical ribs, Horner’s Appearance, weak neck muscles e.g. inclusion body myositis
cerebeller+ dorsal
Friedreich’s ataxia
3rd nerve Medical – Medical – DM, DM, MS, Basal meningitis, Vasculitis, GCA Surgical- Trauma, PCA aneurysm, tumor
Inspection- Complete ptosis, Lift the eyelid see eyeball down and out see pupil miosis/ mydriasis H Diplopia maximal on contalateral superior gaze Check – Check –
4, 6, V1
Disc- papiloedema, Retinopathy
Ispilat cerebeller
Contra pyramidal- weber’s
Associated syndromes
Caverous sinus syndrome- III, IV, V1, V2., VI + symatetic fibers horner’s
Orbital apex- II, III,IV, V1, VI
Superior orbital syndrome- III, IV, V1, VI
4th nerve Inspection: affected eye in higher than o ther in neutral position. H impairment of the affected eye adducted eye can’t look down. Diplopia maximum at looking down and away from the affected side and cover test that outer image from affected side.
INO
6th Nerve meningitis, Vasculitis, False localizing sign, sign, CP angle Mass Cause- DM, MS, Basal meningitis,
Approach inspection : Convergent strabismus H impaired abduction of affected eye Diplopia cover test ask which image disappear? Outer/ inner. Relavant 1. Associated 3rd , 4th – search Gaze palsy 2. Associated V1- Cavernous 3. 7th – Brain – Brain stem 4. 8th – CP – CP angle 5. Disc- DN/HTN/OA/papiloedema— DN/HTN/OA/papiloedema—false localizing sign 6. Long tract sign - Brain stem stem syndrome- Millard gubler’s syndrome VI+ VII+ contra hemiparesis
Important causes of cranial nerve palsy 1. Infection- basal meningitis 2. Infarction- stroke 3. Inflammation- MS 4. Trauma 5. Mononeuritis multiplex 6. Autoimmune condition 7. Diabetes
Relevant N- Nerve 1up and 1 down until normal I- Ipsilateral cerebeller C- Contralateral pyramidal E – Eye fundus for raised ICT
7th Nerve 1. UMN- stroke/ tumor/ demyelination/ trauma 2. B/L UMN— UMN—MND, pseudobulber palsy present jaw jerk, taste sensation preserved 3. LMN- Bell’s palsy, basal meningitis, Leprosy, sarcoid, Ramsay hunt , Lyme disease disease,, HIV 4. B/L LMN- GBS, b/L bell’s palsy 5. Muscle ds- MG, Muscular dystrophy, FSHD, Mitochondrial myopathy Approch a.
Parotid scar previous surgery
b. Hearing loss ( VIII), ipsilateral loss of facial sensation( V) CP Angle c.
Ipsilateral sixth , contralat hemiparesis medial pons
d. Ear herpes/ pox Ramsay Hunt e. Mastoiditis Base of skull f.
UMN with hemiparesis- MCA stroke
I would like to complete my e xamination with
corneal reflex,
otoscopy,
formal audiometry and
examination of upper and lower limbs.
Bulbar and Pseudobulbar palsy Pseudobulbar
UMN CN V, VII (IX, X,XII) Facial expression, mastication Bilateral degeneration of corticobulbar tracts Gag reflex, tongue spasticity Jaw jerk exagerated Spastic dysarthria “Daffy Duck” MS, MND
Bulbar
LMN CN IX, X,XII Diminished gag Tongue fasciculation, wasting Jaw jerk normal Unilateral – Unilateral – raspy raspy voice Bilateral – Bilateral – nasal nasal speech GBS, Stroke, MND
Myotonic Dystophy: Face
Loss of facial and neck musculature Frntotemporal balding Difficulty in opening opening eyes after firm closure Drooping mouth Dysarthria Cataract Low IQ
Hands Distal wasting and weakness LMN pattern Percussion myotonia NO Sensory loss Lower Limb Distal wasting and weakness LMN pattern Foot drop and high steppage gait Others GYnecomastia Cardiomyopathy, conduction block Esophagial dysmotility Hypoventilation Testicular atrophy
Autosomal Dominant ,CTG trinucleotide repeat sequence in DM 1=Chromosome 19 DM2= Chromosome 3
Investigation Dive bomber potential in EMG CPK mild elevation Muscle biopsy- variability in fiber size and fibrosis FBS and Hba1c, LFTs ECG to look for conduction block, Echo Genetic testing MRI brain brain atrophy Management Patient education and counseling May die prematurely Phenytoin may help myotonia myotonia Advice against General Anaesthesia
Ptosis Unilateral
With ophthalmoplegia
Third nerve palsy Mydriasis
Bilateral
Without ophthalmoplegia
Without ophthalmoplegia
With ophthalmoplegia
Horner’s syndrome Miosis Partial ptosis
Fatigable Myasthenia gravis
Non fatigable Mitocondrial myopathy CPEO Occulopharyngeal muscular dystrophy Miller fisher syndrome Neurotoxic snake bite
Myasthenia initial stage fatigable
Myotonic dystrophy Senile Congenital B/L Horner’s
Steps: 1. Inspection – Inspection – one one eye/ both eye, 2. Come near to the patient without thouching the patient complete / partial 3. Lift the eyelid see Pupil.
Miosis
Normal
Dilated
Hormer’s position of eyeball. down + out colour of iris
heterochromia
Position of eye Normal
please close eyes tightly for me please follow scheme of nerve palsy
follow scheme of Horner’ s
Cant close eye tightly
Myasthenia Gravis
Can close tightly but can’ can’t open
Myotonic dystrophy
Horner’s Syndrome
Central 1st order
Demyelination /Syringomyelia
No sweating in face, arm and trunk
2nd order
Trauma, surgery, pancoast , Lymph node, goiter
3rd order
cavernous sinus syndrome, carotid dissection
No sweating in facearm trunk normal Sweating normal
Sequence 1. Partial Ptosis ask to look up. 2. Lift the eyelid colour of iris ( congenital heterochromia), Ask to dim the light for pupil, light reflex 3. Eye movement H 4. Hands- Samll muscle wasting, clubbing, clubbing, nicotin staining staining 5. Neck- Scar, dressing, cervical rib palpate, Goiter, palpalte palpalte thyroid gland 6. Chest- Scar, Dressing, pancoast 7. Lower limb- if time allows Presentation I would like to complete my e xamination by testing sweating 1. Partial ptosis, which is overcome by voluntary upgaze 2. Apparent Enopthalmos 3. Miosis 4. Scar
Myasthenia Gravis Fetures
Fatigable ptosis Complex ophthalmoplegia Nasal speech Bulbar weakness— weakness—Nasal speech, poor swallow Proximal weakness UL>>LL Reflex/ sensory normal Look for sternotomy scar Look for features of immunosupession Cushingoid o Single breath count – count – FVC FVC Other autoimmune disease
LEMS
limb girdle weakness LL>>UL Rarely Ptosis and diplopia Diminished reflexes become brisk after exercise Associated with malignancy- SCLC Anti voltage gated Ca cannel antibody Autonomic dysfunction EMG shows “second wind” phenomenon Mx-3,4 Diaminopyridine and treatment of tumor
Investigation CBC, ESR CXR to look for mediastinal mass CT chest for thymoma Anti AChR antibody 85% Anti MuSK antibody 15% Vital capacity RNST >10% decrement on 3HZ Single Fiber EMG (most specific) Thyroid profile, CPK FBS Treatent Patient education and counseling Avoidance of precipitators Acute: IvIG/Plasma Exchange o Maintenance Acetylcholine esterase inhibitors o Immunosuppressant o Steroid o Azathioprine o MMF o Cyclophosphamide o
patients even if there is Thymectomy -For all patients no thymoma
Friedreich’s ataxia: ataxia: Pyramidal+ LMN+ Cerebeller+ Cerebeller+ Dorsal Column
Young adult adult with Kyphoscoliosis Kyphoscoliosis Pes cavus Pyramidal type of weakness in lower limb Planter Bilateral upgoing Peripheral neuropathyDiminished / absent reflex Posterior column sign Bilateral Cerebeller signs (Ataxia, Dysarthria, Dysarthria, nystagmus)
I would like to complete with HOCM Hearing difficulty aid Diabetes Low IQ Optic atrophy High arch palate Pacemaker Insulin prick mark
Investigation NCS- slowing of motor velocities Genetic analysis ECG ECHO Vitamin E level Functional MRI FBC, U/E/ FBS HbA1C MRI of brain and spinal cord VEP/ AER Audiomety Management MDT – MDT – Neurologist/ Neurologist/ geneticist/ genetic counselor/physiotherapist/ speech and language therapist/occupational therapist and social worker Hearing aid Symptomatic Antidepressant Pacemaker
Autosomal recessive GAA repeat Frataxin gene
Exam possibility= Spstic paraparesis / Imballance If asked Lower limb= Start from gait
Wasting+ pes cavus+ UMN + post column+ + absent jerk +cerebeller
If asked upper limb= See tremor in hand to rule out parkinson’s
if no
look for cerebeller signs
FSHD (mostly upper upper limb) limb) 1. Myopathic face Wasting & weakness of facial muscle D/D2. No Ptosis and eye movements are normal 3. Proximal muscle weakness and wasting 4. Superior margin of scapula are visible from front 5. Winging of scapula with positive Beevor sign 6. Foot drop 7. Hearing aid
Fasciculation cause
MND
Syringomyelia
Cervical myelopathy
Thyrotoxic myopathy
(MG/ MD)
HSMN
Electrolyte disturbance( hypokalemia, hypomagnesemia)
Proximal myopathy D/D- Cushing’s, Acromegally, Osteomalacia, Thyroid ds, PMR, PM, DM, MG, electrolytes, Drugs, Muscular dystrophies Station 3- MG, Muscular dystrophies
Station 5- others
Inspection:
Face- cushingoid/ acromegally/ myopathic face/ eye- for Graves
Neck – Neck – thyroid, thyroid, Scar,
Hands- clubbing
Legs- pretibial myxedema
Chest- thymectomy scar
Rash- DM
Gait- myopathic gait
Finish UL/ LL as per scheme in 5 min 1 min for relevant
MND Management General: Patient education, counseling, MDT, Patient autonomy for future choice, early involvement of palliative care Specific:
Symptom controla. Baclofen for spasticity b. Analgesia for pain c.
Anticholinergic for drooling of saliva
d. Magnesium and Vitamin E for Fasciculation e. SSRI for depression
NIV
PEG
Riluzol – Riluzol – does does not improve symptom, does not prevent death. Prolong survival 3 month after 18 month therapy.
Cardiovascular Aortic Stenosis Cause
Median sternotomy scar
Bicuspid aortic valve
Congenital
Rheumatic fever
Supravalvular aortic stenosis
Degenerative in old people
Metallic valve replacement Tissue valve replacement CABG Corrective surgery of congenital heart Disease Heart transplant Thymectomy
Severity 1. Slow rising pulse 2. Narrow pulse pressure 3. Systolic thrill 4. Heaving apex 5. Soft S2 6. S4 7. Late peaking of long duration murmur 8. Pulmonary hypertension and congestion 9. Reverse spilt Investigation
FBC to look for anemia
Blood cultures for IE
LFTs to look for coagulation profile
Urine dipstick for hematuria
ECG to look for LV strain pattern pattern
X ray chest to look l ook for post stenotic dialatation of aorta, pulmonary congestion
Echocardiography Echocardiography to look for LV size and ejection function, valve area and and gradient
Coronary Angiography
Echo criteria for severe AS • Aortic valve area: < 1cm2 • Jet Velocity: > 4.0m/sec • Mean transvalvular pressure: > 40mmHg
Management General- patient education , counseling, vaccination, Rest Symptomatic AVR if syncope/ angina/ Af Asymptomatic-
IE prophylaxis for Dental, Genitourinary and Colonic procedure prophylaxis
Moderate/ severe stenosis undergoing other cardiac surgery
Gradient of > 40 mm Hg with any of the following o
LVEF < 50%
o
Abnormanl BP response on ETT
o
LVH > 15mm
o
VT
o
Valve area < 0.6 cm2
Aortic regurgitation
Cause Acute: Trauma Acute: Trauma , hypertension, Aortic dissection, rupture , Aortic root Abscess, IE , Chronic: Bicuspid aortic valve, Degeneration, Rheumatic, Marfan’s , Ehlar danolos syndrome, Aortitis – Aortitis – Syphilic/ Takayasu/RA/ Takayasu/RA/ SLE/ Ank Ank Spondylosis
D/D- Pulmonary regurgitation, Mitral Stenosis, Tricuspid stenosis, Severity
Wide pulse Pressure > 100
Displaced apex
Thrusting apex
Long duration murmur
Austin flint murmur diastolic murmur at apex without opening snap
LVF
Investigation
FBC to look for anemia
Blood cultures for IE
LFTs to look for coagulation profile
Urine dipstick for hematuria
ECG to look for LV strain pattern pattern
X ray chest to look l ook for Cardiomegally, pulmonary congestion
Echocardiography Echocardiography to look for LV size and ejection function, valve area and and gradient, aortic root size and dilatation
Coronary Angiography
Management General- patient education , counseling, vaccination, Rest, IE prophylaxis Specific include Medical: management of
Hypertension
Heart failure
PAH
Associated pathology
Surgical AVR for patient who are Symptomatic (angina/ Heart failure) Asymptomatic— Asymptomatic—patient undergo replacement if “Rule of 50” o
LV Ejection fraction <50%
o
Aortic root diameter > 50 mm
o
Pulse pressure > 100mm Hg
Mixed aortic Valve disease
Pulse Character Apex Pulse Pressure (May Ask)
Stenosis predominant Low volume, slow rising Undisplaced Low
AR predominant High volume Collapsing Displaced Wide
Prosthetic Aortic valve
Metallic click which coincides coincides with S2
No peripheral stigmata of IE
No sign of fluid overload
No sign of over anti coagulation Must mention if any
ESM flow murmur
Diastolic murmur murmur valvular dysfunction
Anemia Anemia blood loss due to anti coagulation, hemolysis, IE
Prosthesis function normal or not?
Diastolic murmur is due to malfunctioning Aortic prosthesis
Decreased intensity of closing click ( clot or vegetation)
Bioprosthetic
Age >70 yrs
Anticoagulation contraindicated contraindicated
Life expectancy shorter than life expectancy of valve
Advantage: No need need for warfarin, Safe in Child bearing age age and elderly
Disadvantage: Short life of prosthesis, due degeneration and calcification calcification
Complication
IE
Thromboembolism
Hemolysis
Valve dysfunction Heart failure
Over/under anti coagulation
Mitral Stenosis (D/D- left Arial Myxoma, Left Atrial Atrial thrombus, Austin flint Murmur) Cause
Rheumatic fever
Congenital
RA
SLE Carcinoid
Severity
Low pulse pressure
Early opening snap, Low S2 OS gap
Longer duration murmur
Pulmonary hypertension
Graham Steel Murmur
Echo criteria Grade Mild Moderate
MVA >1.5 cm2 1-1.5 cm2
Gradient <5 mm Hg 5-10 mm Hg
Severe
<1 cm2
>10 mm Hg
Investigation
FBC to look for anemia
Blood cultures for IE
LFTs to look for coagulation profile
Urine dipstick for hematuria
ECG to look for Atrial Fibrillation, left l eft atrial enlargement
X ray chest to look for Double Double right heart border, Left Atrial enlargement, enlargement, pulmonary congestion
Echocardiography Echocardiography to look for LV size and ejection function, valve area and and gradient,
Coronary Angiography
Management General- patient education , counseling, vaccination, Rest, IE prophylaxis Specific include
Medical: management of
asymptomatic – asymptomatic – IE prophylaxis and follow up o Symptomatic – Symptomatic – Heart failure/ atrial fibrillation and Pulmonary hypertension hypertension surgery Surgical indication : BMV/ CMC/ MVR o
o o o o
Hemoptysis Recurrent thromboembolic event despite anticoagulation Hoarseness of voice ( Ortner’s syndrome) Pulmonary hypertension
PBMV- wilkin’s score Low / minimal MR/ No thrombus in LA
Mitral Regurgitation ( D/D- MR/ MR/ TR/ VSD/ ASD) MR cause Acute: IE, Acute: IE, Papilary muscle dysfunction MI, Trauma Chronic- MVP, Chronic- MVP, Reumatic fever, Connective tissue disorder dilated LV ( functional MR),Post MI
Severity
Soft S1
S3, S4, Displaced apex,
Systolic thrill
Diastolic flow murmur
Pulmonary hypertension and congestion
Investigation
FBC to look for anemia
Blood cultures for IE
LFTs to look for coagulation profile
Urine dipstick for hematuria
ECG to look for Atrial Fibrillation, left l eft atrial enlargement, previous infarction
X ray chest to look for Double Double right heart border, Cardiomegally, pulmonary pulmonary congestion
Echocardiography Echocardiography (TTE/ TOE)to look for LV size and ejection ejection function, valve valve area and gradient,
Coronary Angiography
Management
General- patient education , counseling, IE prophylaxis, vaccination, Rest, Specific include Medical:
asymptomatic – asymptomatic – IE IE prophylaxis and follow up with echo cardiography
Symptomatic – Symptomatic – Anticogulation Anticogulation for Af or embolic phenomenon Diuretic , Beta blocker and ACE inhibitors Percutaneous – Percutaneous – Mitral clip device for palliation in inoperative cases of MVP
Surgical indication : Valve repair ( preferable) with with annuloplasty ring or or MVR
Asymptomatic patient LVEF LVEF <60% , LVESD > 45 mm
Symptomatic (NYHA III/ IV) despite medical management
Mixed Mitral Disease
Pulse Apex S1 Pulse Pressure (May Ask)
Stenosis predominant Low volume, Undisplaced Loud Low
MR predominant High volume Displaced Soft Wide
Prosthetic Mitral valve Must comment on Pallor, Valve function, Over anticoagulation, IE status
Systolic murmur pathological CC
s2
oc
flow murmur
Target INR- 2.5-3.5
Complication of valve
Operative mortality 3-5%
Late complication o
Thromboembolism 1-2% per year despite warfarin warfarin
o
Bleeding Fatal 0.6%, major 3%, minor 7% per anum on warfarin
o
Valve obstruction from thrombosis
o
Dehicence of valve
o
BIoprosthetic dysfunction dysfunction and LVF - usually within 10 yr
o
Hemolysis- mechanical in metal valve
o
Infective endocarditis
Early – Early – Staph Staph epidermiditis from skin
Late-Sterpto Viridans hematogenous spread
A second valve replacement needed to treat
Mortality of IE in prosthetic valve approx 60%
A fib for MVR
Investigations
FBC to look for anemia
Serial Blood cultures for IE
LFTs and coagulation profile to see adequacy adequacy
Urine dipstick for hematuria
ECG to look for Atrial Fibrillation, left l eft atrial enlargement,
X ray chest to look for Double Double right heart border, Cardiomegally, pulmonary pulmonary congestion
Echocardiography Echocardiography (TTE/ TOE)to look for LV size and ejection ejection function, valve valve area and gradient
Infective endocarditis Dukes criteria Major Blood culture- Typical organism in 2 blood culture and or
Minor
Pyrexia Predisposed valve- prosthetic Embolic phenomenon Immunologic/ vasculitis phenomenon- rash
Atypical organism in blood c/s Diagnose IE= 2 major/ 1 moajor+ 3 minor/ 5 minor
Echocardiography- abscess/ large vegetation/ dehiscence
Patients at risk
Patients with prosthetic valve, cardiac t ransplant
Acquired valvular heart disease with stenosis and regurgitation
Structural congenital heart disease a.
Including surgically corrected or palliated structural conditions
b. Excluding isolated ASD, fully repaired VSD/ PDA and closure device considered to be endothelialized
Hypertrophic cardiomyopathy
Previous episode of endocarditis
If patients at risk are undergoing a gastrointestinal or genitourinary procedure at site where infection is suspected, they should receive appropriate antibacterial therpy that includes cover against that cause endocarditis.
Patients at risk of IE should be a.
Advised to maintain good oral hygiene
b. Told how to recognize signs of IE and w hen to seek expert advice NICE do not advocate prophylaxis even for high risk pat ients whereas AHA recommends so.
Rheumatic fever
Streptococus pyogenes
Ducket Jones criteria 2 major / 1 major + 2 minor Major
Minor C Carditis E Erythema marginatum N nodules Subcutenous C Chorea E eryhtema marginatum R
Arthalgia Fever High ESR Raised WBC Prolong PR Previous Rheumatic fever
Treatment General and specific
Rest
High dose aspirin
Penicillin
Prophylaxiso
Primary
Penicilin V or clindamycin for 10 days
o
Secondary
Pencilin V for 5-10 yrs
