PACES NOTES
PACES NOTES
INVESTIGATION AND MANAGEMENTINVESTIGATION AND MANAGEMENT
Subhankar Chatterjee, Kolkata 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 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 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
the case. The usual questions which they ask are as follows-1.
1. Tell me the positive clinical finings- You should take no more than 30-40 sec for thisTell me the positive clinical finings- You should take no more than 30-40 sec for this 2.
2. What are the differential diagnosis- It may take some time as you may be interrupted if going in wrongWhat are the differential diagnosis- It may take some time as you may be interrupted if going in wrong direction. But never > 1min.
direction. But never > 1min. 3.
3. Which investigations would you do for this Which investigations would you do for this patient?- 40 secpatient?- 40 sec 4.
4. How do you manage the case?How do you manage the case? – – Again 40-60 sec. Again 40-60 sec. If you have answered all
If you have answered all of the above in of the above in correct manner, you may have further questions which will fetch you correct manner, you may have further questions which will fetch you towardstowards full marks. S
full marks. So, time management o, time management is very imporis very important.tant.
I have made this note for my third attempt of PACES, which I passed. During exam felt quite confident as I have 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, rehearsed it many times with my friends, juniors and even before mirror. It might seem inadequate, but believe me, you have small time to
you have small time to answer each question.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 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
notes which might be more effective if made according to one’s own ability, more effective if made according to one’s own ability, memory and concept.memory and concept. At
At the the end end I I have have tried tried to to simplify simplify some some Neurology Neurology scenarios scenarios in in a a schematic schematic pattern, pattern, which which helps helps in in patternpattern recognition during examination.
recognition during examination.
Obviously this note carries contribution from all of
Obviously this note carries contribution from all of my teachers, mentors, books and notes targeting my teachers, mentors, books and notes targeting PACES.PACES. Best of luck for PACES.
Respiratory system Respiratory system
1.
1. COPDCOPD
Sir, my INVESTIGATIONs include : Sir, my INVESTIGATIONs include :
Blood for FBC to look for Blood for FBC to look for PolycythemiaPolycythemia
Differential count, ESR, CRP- to Differential count, ESR, CRP- to look for signs of infection,look for signs of infection,
Chest x ray /HRCT Chest x ray /HRCT to look for hyperinflation to look for hyperinflation and Bullaand Bulla
Pulmonary function test to look for Obstructive pattern with Pulmonary function test to look for Obstructive pattern with reduced DLCOreduced DLCO
ECG and Echocardiography to rule out Cor ECG and Echocardiography to rule out Cor pulmonalepulmonale
Sputum microscopy and C/S to isolate any organismSputum microscopy and C/S to isolate any organism
6min walking test for functional assessment6min walking test for functional assessment
Arterial blood Gas to decide about LArterial blood Gas to decide about LTOTTOT
My TREATMENT plan include: My TREATMENT plan include:
General measuresGeneral measures
o
o Stop smokingStop smoking o
o Pulmonary rehabilitation ( Pt education, Nutrition, Pulmonary rehabilitation ( Pt education, Nutrition, Psychological support, Physiotherapy)Psychological support, Physiotherapy) o
o VaccinationVaccination
Specific medicalSpecific medical
o
o Bronchodilator- inhaled B agonist/ ICS/ LABA/LAMABronchodilator- inhaled B agonist/ ICS/ LABA/LAMA o
o Antibiotic and systemic steroid for acute exacerbationsAntibiotic and systemic steroid for acute exacerbations o
o MucolyticsMucolytics o
o LTOTLTOT o
o Diuretics and Phosphodiesterase inhibitors for Diuretics and Phosphodiesterase inhibitors for Cor pulmonaleCor pulmonale
Surgery-
Surgery-o
o Bulectomy/ Lung volume reductionBulectomy/ Lung volume reduction o
o Lung transplantLung transplant
2.
2. BronchiectasisBronchiectasis
InvestigationInvestigation
o
o Blood-Differential count, ESR, CRP- to look for signs of infection, ImmBlood-Differential count, ESR, CRP- to look for signs of infection, Imm unoglobin levelsunoglobin levels o
o Chest x ray /HRCT Chest x ray /HRCT to look to look for Tram for Tram line appearance/Signet line appearance/Signet ringring o
o Sputum microscopy and C/S to isolate any organism, particularly PseudomonasSputum microscopy and C/S to isolate any organism, particularly Pseudomonas o
o Pulmonary function test to look for Obstructive patternPulmonary function test to look for Obstructive pattern o
o ECG and Echocardiography to rule out Cor pulmonaleECG and Echocardiography to rule out Cor pulmonale o
o 6min walking test for functional assessment6min walking test for functional assessment o
o Sweat test if suspect cystic fibrosisSweat test if suspect cystic fibrosis
ManagementManagement
o
o Stop smokingStop smoking o
o Pulmonary rehabilitation ( Pt education, Nutrition, Pulmonary rehabilitation ( Pt education, Nutrition, Psychological support, Physiotherapy, POSTURALPsychological support, Physiotherapy, POSTURAL
DRAINAGE) DRAINAGE)
o
o VaccinationVaccination
Specific medicalSpecific medical
o
o MucolyticsMucolytics o
o Bronchodilator- inhaled B agonist/ ICS/ LABA/LAMABronchodilator- inhaled B agonist/ ICS/ LABA/LAMA o
o Antibiotic- systemic Antibiotic- systemic / inh/ inhalational alational +/- Steroids+/- Steroids o
o LTOTLTOT o
o Diuretics and Phosphodiesterase inhibitors for Cor Diuretics and Phosphodiesterase inhibitors for Cor pulmonalepulmonale
Surgery-
Surgery-o
o LobectomyLobectomy o
o Bronchial artery embolisation for hemoptysisBronchial artery embolisation for hemoptysis o
o Lung transplant for cystic fibrosisLung transplant for cystic fibrosis
3.
3. Pulmonary Fibrosis/ ILD/Rheumatoid lungPulmonary Fibrosis/ ILD/Rheumatoid lung Investigation
Investigation a.
a. Chest x rayChest x ray – –to look for bilateral interstitial reticulo nodular pattern. Loss of lung volumeto look for bilateral interstitial reticulo nodular pattern. Loss of lung volume b.
b. HRCT to look for subpleural reticulation and traction broncheitasis, basal honeycombing , ground glassHRCT to look for subpleural reticulation and traction broncheitasis, basal honeycombing , ground glass patterns
patterns c.
c. Pulmonary function test to Pulmonary function test to look for Restrictive look for Restrictive pattern with reduced DLCOpattern with reduced DLCO d.
d. Blood-Differential count for eosinophilia, ESR, CRP- to look for signs of infectionBlood-Differential count for eosinophilia, ESR, CRP- to look for signs of infection e.
e. Markers for Autoimmune profile, ACE level, Ca,Markers for Autoimmune profile, ACE level, Ca, f.
f. Brocnchoscopy and BAL /Sputum Brocnchoscopy and BAL /Sputum microscopy and C/S to rule out microscopy and C/S to rule out any organismany organism g.
g. ECG and Echocardiography to rule out Pulmonary HTNECG and Echocardiography to rule out Pulmonary HTN h.
h. 6min walking test for functional assessment6min walking test for functional assessment i.
i. ABG to decide about LTOTABG to decide about LTOT Management
Management
General measuresGeneral measures
o
o Stop smoking and toxic or allergic substancesStop smoking and toxic or allergic substances o
o Pulmonary rehabilitation ( Pt education, Nutrition, Pulmonary rehabilitation ( Pt education, Nutrition, Psychological support, Physiotherapy)Psychological support, Physiotherapy) o
o VaccinationVaccination o
o LTOTLTOT
Specific medicalSpecific medical
o
o Immunosupressive –Immunosupressive – Steroid for Steroid for ground glass, Thalidomide, Cyclophosphamide,ground glass, Thalidomide, Cyclophosphamide, o
o Antifibrotic –Antifibrotic – Pirfenidone for IPF ( UIP P Pirfenidone for IPF ( UIP Pattern on HRCT)attern on HRCT) o
o Diuretics and Phosphodiesterase inhibitors for Diuretics and Phosphodiesterase inhibitors for Cor pulmonaleCor pulmonale
Surgery-
Surgery-o
4.
4. Pleural effusionPleural effusion Investigation Investigation
a.
a. Chest x ray to Chest x ray to look for blunt costophrenic and cardiophrenic angleslook for blunt costophrenic and cardiophrenic angles b.
b. CT thorax CT thorax to look to look for any for any MASSMASS c.
c. USG to rule out multisepted/ loculated effusionUSG to rule out multisepted/ loculated effusion d.
d. Pleural fluid assessment for cellularity, protein, sugar, cultures, malignant cell, Pleural fluid assessment for cellularity, protein, sugar, cultures, malignant cell, special tests.special tests. e.
e. Blood-Differential count , ESR, CRP- to look Blood-Differential count , ESR, CRP- to look for signs of infection,for signs of infection, Albumin, Urea/ electrolytes to rule out
Albumin, Urea/ electrolytes to rule out any renal disease, LFT to rule out any any renal disease, LFT to rule out any liver diseaseliver disease f.
f. ECG and Echocardiography to rule out Pulmonary HTN/ cardiac decompensationECG and Echocardiography to rule out Pulmonary HTN/ cardiac decompensation g.
g. Markers for Autoimmune profileMarkers for Autoimmune profile h.
h. Pleural biopsy in refractory casesPleural biopsy in refractory cases i.
i. Other Special tests as requiredOther Special tests as required
Diagnosis of plerual effusion Clinically 500ml, x ray PA 300ml,
Diagnosis of plerual effusion Clinically 500ml, x ray PA 300ml, x ray lat dx ray lat decubitus-180ml , USG 30mlecubitus-180ml , USG 30ml Management:
Management: 1.
1. Therapeutic Pleural draiTherapeutic Pleural drainage if nage if Symptomatic, infective Symptomatic, infective ( empyema)( empyema) 2.
2. Treatment of the causeTreatment of the cause 3.
3. Decortication/intrapleuarl Decortication/intrapleuarl thrombolytics thrombolytics for for multiloculated effusionmultiloculated effusion 4.
4. Pleurodesis for refractory malignant effusionPleurodesis for refractory malignant effusion
5.
5. Lobectomy / Lobectomy / PneumonectomPneumonectomyy Investigation
Investigation
o
o Chest x rayChest x ray – –to look for confirmationto look for confirmation o
o CT thorax CT thorax to look for to look for underlying causeunderlying cause o
o Pulmonary function test to look for ObstructivePulmonary function test to look for Obstructive o
o Blood-Differential count , ESR, CRP- to look Blood-Differential count , ESR, CRP- to look for signs of infection,for signs of infection, o
o ECG and Echocardiography to rule out Pulmonary HTNECG and Echocardiography to rule out Pulmonary HTN o
o Other Special tests as requiredOther Special tests as required
Management: Management:
o
o SupportiveSupportive o
o Management of the original diseaseManagement of the original disease
Indication of LobectomyIndication of Lobectomy
o
o Localized broncheictasis with massive hemoptysisLocalized broncheictasis with massive hemoptysis o
o Lung abscessLung abscess o
o Solitary pulmonary noduleSolitary pulmonary nodule o o TraumaTrauma o o AspergilomaAspergiloma o o NSCLC TNSCLC T3A3ANN00MM00 o
o TBTB – – not done now a days not done now a days
o
o Massive BroncheictasisMassive Broncheictasis o
o Multiple lung abscessMultiple lung abscess o
o Fungal infection MalignancyFungal infection Malignancy o
o TraumaTrauma o
o Bronchial obstruction Bronchial obstruction with with destroyed lungdestroyed lung o
o Congenital lung diseaseCongenital lung disease o
o Malignant mesothelioma/ disseminated thymomaMalignant mesothelioma/ disseminated thymoma
Indication of lung transplantIndication of lung transplant
o
o COPDCOPD o
o IPFIPF o
o Cystic fibrosisCystic fibrosis o
o Alpha 1 antitrypsin deficiencyAlpha 1 antitrypsin deficiency o
o Primary pulmonary hypertensionPrimary pulmonary hypertension
6.
6. OLD TB- FibrothoraxOLD TB- Fibrothorax Investigation
Investigation
o
o Chest x rayChest x ray – –to look for confirmationto look for confirmation o
o CT thorax CT thorax to look for underlying to look for underlying cause and look for cause and look for other lung pathologiesother lung pathologies o
o Pulmonary function test to look for volume lossPulmonary function test to look for volume loss o
o Blood-Differential count , ESR, CRP- to look Blood-Differential count , ESR, CRP- to look for signs of infection,for signs of infection, o
o ECG and Echocardiography to rule out Pulmonary HTNECG and Echocardiography to rule out Pulmonary HTN o
o Sputum gram stain and culture to look Sputum gram stain and culture to look for infection, AFB and NAAT to rule for infection, AFB and NAAT to rule out TBout TB
Management: Management:
1.
1. GeneralGeneral
Smoking cessation/ Pulmonary rehabilitationSmoking cessation/ Pulmonary rehabilitation
Specific Specific
BronchodilatorBronchodilator
Early antibiotic therapy for suspected infectionEarly antibiotic therapy for suspected infection
7.
7. Lung Consolidation ( d/d- Lung Consolidation ( d/d- Pneumonia/ Infarction/ mass)Pneumonia/ Infarction/ mass) Investigation
Investigation
o
o Chest x rayChest x ray – –to look for confirmationto look for confirmation o
o CT thorax CT thorax to rule out to rule out any mass lany mass lesionesion o
o Blood- Septic screening -Differential count , ESR, Blood- Septic screening -Differential count , ESR, CRP, PCT - to CRP, PCT - to look for signs of infection, Urea/ electrolytes-look for signs of infection, Urea/
electrolytes-CURB 65, CURB 65,
o
o ABG to look for hypoxemia/ hypercapnoeaABG to look for hypoxemia/ hypercapnoea o
o Sputum gram stain and culture to look Sputum gram stain and culture to look for infection, cytology for malignant cellsfor infection, cytology for malignant cells o
o ECG and ECHO to rule out pulmonary embolismECG and ECHO to rule out pulmonary embolism o
o Bronchoscopy with BAL for microbiology, cytologyBronchoscopy with BAL for microbiology, cytology o
Management Management
General measuresGeneral measures
o
o Stop smoking and toxic or allergic substancesStop smoking and toxic or allergic substances o
o Pulmonary rehabilitation ( Pt education, Nutrition, Pulmonary rehabilitation ( Pt education, Nutrition, Psychological support, Physiotherapy)Psychological support, Physiotherapy) o
o VaccinationVaccination
Specific medicalSpecific medical
o
o Pneumonia Pneumonia Antibiotics/ Antibiotics/ Bronchodilator/ Bronchodilator/ MucolyticsMucolytics o
o Infarction Infarction LMWH/ LMWH/ warfarin/ warfarin/ modification modification of of risk risk factorfactor o
o Mass Mass Chemo/ Chemo/ radiotherapy/ radiotherapy/ surgerysurgery
8.
8. Lung collapse ( d/d Malignancy/ TB/Hilar L/N / Lung collapse ( d/d Malignancy/ TB/Hilar L/N / Mucus plug)Mucus plug)
o
o Chest x rayChest x ray – – for confirmation for confirmation o
o CT thorax CT thorax to rule out any mass to rule out any mass lesion, Enlarged L/Nlesion, Enlarged L/N o
o Blood- Septic screening -Differential count , ESR, CRP-Blood- Septic screening -Differential count , ESR,
CRP-Urea/ electrolytes/ LFT / ACE level Urea/ electrolytes/ LFT / ACE level
o
o ABG to look for hypoxemiaABG to look for hypoxemia o
o Sputum gram stain and culture to look Sputum gram stain and culture to look for infection, cytology for malignant cellsfor infection, cytology for malignant cells o
o Bronchoscopy to rule out any endobronchial growth, Bronchoscopy to rule out any endobronchial growth, BAL for microbiology, cytology , Biposy , NAATBAL for microbiology, cytology , Biposy , NAAT
Management Management
General measuresGeneral measures
o
o PhysiotherapyPhysiotherapy o
o Positive pressure ventilationPositive pressure ventilation
Specific medicalSpecific medical
o
o Mucus plug Mucus plug Bronchodilator/ Mucolytics/ Bronchodilator/ Mucolytics/ Bronchoscopy Bronchoscopy and and lavagelavage o
o Malignancy Malignancy Chemo/ Chemo/ radiotherapy/ radiotherapy/ Bronchoscopy Bronchoscopy may may need need stentingstenting o
o Others Others Bronchoscopy Bronchoscopy and and treatment treatment of of the the cause cause , , may may need need stentingstenting
9.
9. SVCO ( D/D-Malignancy/ mediastinal goiter/ thoracic aorta aneurysm/ mediastinal fibrosis)SVCO ( D/D-Malignancy/ mediastinal goiter/ thoracic aorta aneurysm/ mediastinal fibrosis) Investigations
Investigations
o
o Chest x ray /CT thorax Chest x ray /CT thorax to rule out any mass to rule out any mass lesion, Enlarged L/Nlesion, Enlarged L/N o
o Blood- Blood- FBC/ Urea/ FBC/ Urea/ electrolytes/ LFTelectrolytes/ LFT o
o ECG /ECHOECG /ECHO o
o CT Angiography / venographyCT Angiography / venography o
o Brochoscopy with BAL for microbiology, cytology , Biposy ,Brochoscopy with BAL for microbiology, cytology , Biposy ,
Management Management
General measuresGeneral measures
o
o Elevation of head,Elevation of head, o
o Positive pressure ventilationPositive pressure ventilation
Specific medicalSpecific medical
o
o Steroids ( Dexamathasone) Steroids ( Dexamathasone) and diureticsand diuretics o
o Radiotherapy/ chemothapyRadiotherapy/ chemothapy o
Abdomen
Abdomen
1.
1. CLD CLD ( D/D Alcohol/ viral/a( D/D Alcohol/ viral/autoimmune/ metaboutoimmune/ metabolic/drugs)lic/drugs) Investigation
Investigation
USG abdomen for confirmation of diagnosisUSG abdomen for confirmation of diagnosis may proceed to triphasic CT of Liver may proceed to triphasic CT of Liver
Severity-
Severity-o
o Synthetic function Synthetic function PT/INR, PT/INR, AlbuminAlbumin o
o Renal functionRenal function o
o BilirubinBilirubin o
o Serum ammoniaSerum ammonia
To look for complicationTo look for complication
o
o Full Blood count –Full Blood count – anemia, thrombocytopenia( hyperspleenism) anemia, thrombocytopenia( hyperspleenism) o
o USG/ AFP to rule out HCCUSG/ AFP to rule out HCC o
o OGD OGD to to look look for for varicesvarices
To look for etiologyTo look for etiology
o
o Alcohol and drug historyAlcohol and drug history o
o Metabolic profile ( NASH)Metabolic profile ( NASH) o
o Viral markersViral markers o
o Cerulopasmin and urinary copper study( WILSON’S)Cerulopasmin and urinary copper study( WILSON’S) o
o Ferritin (HH)Ferritin (HH) o
o Liver biopsy( NASH, PBC, PSC)Liver biopsy( NASH, PBC, PSC) o
o AMA ( PBC) , AMA ( PBC) , ASMA, , ASMA, , IgG, Anti IgG, Anti LKM ( LKM ( AIH) AIH) ANCA (PSC)ANCA (PSC) o
o Alpha 1 antitrypsinAlpha 1 antitrypsin
Management Management
MDTMDT
Treat underlying causeTreat underlying cause
o
o Alcohol: abstinenceAlcohol: abstinence o
o Viral hep- Anti virals ( B-Lamivutin, Entacavir, C- Sofosbuvir, Telapravir, Bocepravir)Viral hep- Anti virals ( B-Lamivutin, Entacavir, C- Sofosbuvir, Telapravir, Bocepravir) o
o HH- venesection, iron chelationHH- venesection, iron chelation o
o Wislson’s- d penicilamine, ZincWislson’s- d penicilamine, Zinc o
o PBC- UDCA, Immunosuprressant, cholestyraimine, antihistaminePBC- UDCA, Immunosuprressant, cholestyraimine, antihistamine o
o NASH- Weight reduction, NASH- Weight reduction, Control of Control of diabetesdiabetes
Treat complicationTreat complication
o
o Varix- ABCDE, LigatiVarix- ABCDE, Ligation, B on, B blockerblocker o
o Encephalopathy- rifaximin, treat precipitantsEncephalopathy- rifaximin, treat precipitants o
o Ascites- Diuretics, paracentesisAscites- Diuretics, paracentesis o
o SBP- Antibiotic, drainageSBP- Antibiotic, drainage o
o Hepatorenal- Albumin, TerlipressinHepatorenal- Albumin, Terlipressin o
o HCC- resection, embolization, transplantHCC- resection, embolization, transplant
2.
2. Ascites ( CLD, Malignancy, TB, Fluid overload, Vascular, Ascites ( CLD, Malignancy, TB, Fluid overload, Vascular, Peritoneal dialysis peritonitis)Peritoneal dialysis peritonitis) Investigations
Investigations
USG abdomen for confirmation of diagnosisUSG abdomen for confirmation of diagnosis
Ascetic fluid for SAAG, Cell count, type, , Sugar, Protein, Malignant cell, CultureAscetic fluid for SAAG, Cell count, type, , Sugar, Protein, Malignant cell, Culture
To look for etiologyTo look for etiology
o
o Alcohol and drug historyAlcohol and drug history o
o Metabolic profile ( NASH)Metabolic profile ( NASH) o
o Viral markersViral markers o
o Cerulopasmin and urinary copper study( WILSON’S)Cerulopasmin and urinary copper study( WILSON’S) o
o Ferritin (HH)Ferritin (HH) o
o Liver biopsy( NASH, PBC, PSC)Liver biopsy( NASH, PBC, PSC) o
o Auto antibodies: AMA ( Auto antibodies: AMA ( PBC) , PBC) , ASMA, , IgG, Anti ASMA, , IgG, Anti LKM ( AIH) LKM ( AIH) ANCA (PSC)ANCA (PSC) o
o Alpha 1 antitrypsinAlpha 1 antitrypsin o
o AFP for HCCAFP for HCC o
o Renal parameters and urinary protein for Nephrotic syndromeRenal parameters and urinary protein for Nephrotic syndrome o
o ECHO for CCF/ CP/ RCMECHO for CCF/ CP/ RCM o
o Thrombophilia workup and CECT abdomen for Veno-occusive diseaseThrombophilia workup and CECT abdomen for Veno-occusive disease
Management: Management:
General –General – Patient education / salt and fluid restriction Patient education / salt and fluid restriction
Medical- Diuretics- Spironolactone, FurosemideMedical- Diuretics- Spironolactone, Furosemide
Treatment of SBPTreatment of SBP
Therapeutic paracentesisTherapeutic paracentesis
3.
3. Heptomegally ( D/D- Cirrhosis, Cancer, Cardiac, Cyst, Infection, Infiltration, Inflammation)Heptomegally ( D/D- Cirrhosis, Cancer, Cardiac, Cyst, Infection, Infiltration, Inflammation) Investigation
Investigation 1.
1. confirmation of diagnosis- USG abdomenconfirmation of diagnosis- USG abdomen 2.
2. Look for etiologyLook for etiology
o
o Alcohol and drug historyAlcohol and drug history o
o Metabolic profile ( NASH)Metabolic profile ( NASH) o
o Viral markersViral markers o
o Cerulopasmin and urinary copper study( WILSON’S)Cerulopasmin and urinary copper study( WILSON’S) o
o Ferritin (HH)Ferritin (HH) o
o Auto antibodies: AMA ( Auto antibodies: AMA ( PBC) , PBC) , ASMA, , IgG, Anti ASMA, , IgG, Anti LKM ( AIH) LKM ( AIH) ANCA (PSC)ANCA (PSC) o
o Alpha 1 antitrypsinAlpha 1 antitrypsin o
o AFP for HCCAFP for HCC o
o ECHO for CCF/ CP/ RCMECHO for CCF/ CP/ RCM o
o Liver biopsy ( NASH, PBC, PSC)Liver biopsy ( NASH, PBC, PSC)
3.
3. Look for complicationsLook for complications
o
o LFTsLFTs o
o
o FBC with inflammatory markersFBC with inflammatory markers o
o CECT ABDOMENCECT ABDOMEN
Management: Management:
General-patient education , counseling, dietary modification, weight reduction General-patient education , counseling, dietary modification, weight reduction Specific- treat the underlying cause
Specific- treat the underlying cause 4.
4. Spleenomegally ( D/D Infection/ hematological/ congestive/ inflammatory/ neoplastic/ infiltrative)Spleenomegally ( D/D Infection/ hematological/ congestive/ inflammatory/ neoplastic/ infiltrative) Investigations:
Investigations:
o
o Confirmation: USG of AbdomenConfirmation: USG of Abdomen o
o Doppler study to look for portal vein thrombosisDoppler study to look for portal vein thrombosis o
o FBC and inflammatory markersFBC and inflammatory markers o
o PBS look for malaria, kala azar, hePBS look for malaria, kala azar, he molysismolysis o
o Bone marrow to look for Bone marrow to look for myeloprolifearative disordersmyeloprolifearative disorders o
o JAK 2 mutation, JAK 2 mutation, Philadelphia chromosomePhiladelphia chromosome o
o Auto immune screen for RA, SLE- (RF, Anti CCP, ANA)Auto immune screen for RA, SLE- (RF, Anti CCP, ANA) o
o Hemolysis screen- LDH, DCT, Bilirubin, haptoglobin, Hb electrophoresisHemolysis screen- LDH, DCT, Bilirubin, haptoglobin, Hb electrophoresis o
o HIVHIV o
o CXR for mediastinal enlargementCXR for mediastinal enlargement
Management Management
General: Patient education General: Patient education
Specific : treat underlying cause. Spleenectomy
Specific : treat underlying cause. Spleenectomy for severe hyperspleenism.for severe hyperspleenism.
(Influenza/ Hemophilus/ pneumococcus, meningococcus vaccine needed after spleenectomy) (Influenza/ Hemophilus/ pneumococcus, meningococcus vaccine needed after spleenectomy)
Prophylactic Penicilline for at least 2 yrs. Prophylactic Penicilline for at least 2 yrs.
5.
5. HepatospleenomagallyHepatospleenomagally Investigations:
Investigations:
o
o Confirmation: USG of AbdomenConfirmation: USG of Abdomen o
o Doppler study to look for portal vein thrombosisDoppler study to look for portal vein thrombosis o
o FBC and inflammatory markersFBC and inflammatory markers o
o PBS look for malaria, kala azar, hePBS look for malaria, kala azar, he molysismolysis o
o Bone marrow to look for myeBone marrow to look for myeloprolifearative disordersloprolifearative disorders o
o JAK 2 mutation, JAK 2 mutation, Philadelphia chromosomePhiladelphia chromosome o
o Auto immune screen for RA, SLE- (RF, Anti CCP, ANA)Auto immune screen for RA, SLE- (RF, Anti CCP, ANA) o
o Hemolysis screen- LDH, DCT, Bilirubin, haptoglobin, Hb electrophoresisHemolysis screen- LDH, DCT, Bilirubin, haptoglobin, Hb electrophoresis o
o HIVHIV o
Management Management
General: Patient education General: Patient education
Specific : treat underlying cause. Spleenectomy
Specific : treat underlying cause. Spleenectomy for severe hyperspleenism.for severe hyperspleenism.
(Influenza/ Hemophilus/ pneumococcus, meningococcus vaccine needed after spleenectomy) (Influenza/ Hemophilus/ pneumococcus, meningococcus vaccine needed after spleenectomy)
Prophylactic Penicilline for at least 2 yrs. Prophylactic Penicilline for at least 2 yrs.
6.
6. HeptospleenomHeptospleenomegally egally with with LymphadenopLymphadenopathyathy
( d/d Lymphoma, leukemia in blast crisis, disseminated TB, SLE, sarcoidosis,
( d/d Lymphoma, leukemia in blast crisis, disseminated TB, SLE, sarcoidosis, Infectious MononeucleosisInfectious Mononeucleosis syndrome, HIV)
syndrome, HIV) Investigations:
Investigations:
o
o Confirmation: USG of AbdomenConfirmation: USG of Abdomen o
o Doppler study to look for portal vein thrombosisDoppler study to look for portal vein thrombosis o
o FBC to see leucocyte counFBC to see leucocyte count t and inflammatory and inflammatory markersmarkers o
o PBS look abnormal cellsPBS look abnormal cells o
o Bone marrow to look for myeBone marrow to look for myelo/ Lympho prolifearative disorderslo/ Lympho prolifearative disorders o
o Auto immune screen for RA, SLE- (RF, Anti CCP, ANA)Auto immune screen for RA, SLE- (RF, Anti CCP, ANA) o
o Lymph node biopsy if > 1month, > 1 region, > Lymph node biopsy if > 1month, > 1 region, > 1cm and not draining any infective focus1cm and not draining any infective focus o
o HIV serologyHIV serology o
o CXR for mediastinal enlargement, ACE level CXR for mediastinal enlargement, ACE level for sarcoidosisfor sarcoidosis o
o LFTs, Renal parameters,LFTs, Renal parameters,
Management Management
General: Patient education General: Patient education Specific : treat underlying cause Specific : treat underlying cause
7.
7. Jaundice +/_ hepato/ Hepatospleenoegally (DCLD, Hepatitis, Hemolytic disease, Jaundice +/_ hepato/ Hepatospleenoegally (DCLD, Hepatitis, Hemolytic disease, malignancy, infections)malignancy, infections) Investigations:
Investigations:
o
o Confirmation: LFTsConfirmation: LFTs o
o For etiologyFor etiology o
o USG of Abdomen folloUSG of Abdomen followed wed MRCP/ CT depending on UMRCP/ CT depending on USG findingsSG findings o
o Viral markersViral markers o
o
o PBS look abnormal cells, spherocytes,PBS look abnormal cells, spherocytes, o
o Hemoglobin electrophoresis, DCT to look for hemolytic diseasesHemoglobin electrophoresis, DCT to look for hemolytic diseases o
o HIV serologyHIV serology o
o FOR complicationFOR complication o
o Coagulation profileCoagulation profile o
o OGD for esophageal varicesOGD for esophageal varices o
o Renal parametersRenal parameters o
o Septic screenSeptic screen o
o Ascitic fluid if anyAscitic fluid if any
8.
8. Jaundice and Ascites +/_ hepato/ Hepatospleenoegally ( DCLD, , Malignancy ,Disseminated TB, CardiacJaundice and Ascites +/_ hepato/ Hepatospleenoegally ( DCLD, , Malignancy ,Disseminated TB, Cardiac cirrhosis)
cirrhosis)
o
o Confirmation: LFTsConfirmation: LFTs o
o For etiologyFor etiology o
o USG of Abdomen folloUSG of Abdomen followed wed MRCP/ CT depending on UMRCP/ CT depending on USG findingsSG findings o
o Viral markersViral markers o
o Autoimmune profile (AMA,ANA, ASMA, Anti LKM)Autoimmune profile (AMA,ANA, ASMA, Anti LKM) o
o Ascitic fluid for Cellularity, SAAG, Malignant cell, CultureAscitic fluid for Cellularity, SAAG, Malignant cell, Culture o
o Laparoscopy and peritoneal biopsyLaparoscopy and peritoneal biopsy o
o EchocardiographyEchocardiography o
o For complicationFor complication o
o Coagulation profileCoagulation profile o
o OGD for esophageal varicesOGD for esophageal varices o
o Renal parametersRenal parameters o
o Septic screenSeptic screen
Management Management
General: Patient education General: Patient education Specific : treat underlying cause Specific : treat underlying cause
9.
9. Polycystic KidneyPolycystic Kidney Investigation
Investigation
USG abdomen USG abdomen for Confirmation and for Confirmation and measuring the number of cystsmeasuring the number of cysts
CBC to look for anemia/ polycythemiaCBC to look for anemia/ polycythemia
Renal function, Calcium and phosphate to look for secondary hyperparatyroidismRenal function, Calcium and phosphate to look for secondary hyperparatyroidism
Chest x ray to Chest x ray to look for fluid overloadlook for fluid overload
Urine dipstick to look for hematuria/ proteinUrine dipstick to look for hematuria/ protein
LFTs to look for deranged liver LFTs to look for deranged liver function as there might be cysts in liverfunction as there might be cysts in liver
Screening for cerebral aneurysm Screening for cerebral aneurysm with patients having family h/o SAH @5yrs.with patients having family h/o SAH @5yrs.
Genetic study Genetic study for potential for potential donors with donors with no cysts no cysts on USon US
Echocardiography to look for MVP, AREchocardiography to look for MVP, AR
Management: Management:
GeneralGeneral
o
o Patient education and counseling about course of disease and complicationPatient education and counseling about course of disease and complication o
o Attempt 3lit fluid intake per day to Attempt 3lit fluid intake per day to suppress ADH secretionsuppress ADH secretion o
o Screening of 1Screening of 1stst degree relatives from the age f 20yr at least 3 cyst uni/ bilateral degree relatives from the age f 20yr at least 3 cyst uni/ bilateral o
o Avoid contact sports/risk of trauma to abdomenAvoid contact sports/risk of trauma to abdomen
Specific medicalSpecific medical
o
o ACEI for control of hypertensionACEI for control of hypertension o
o Avoid nephrotoxic drugsAvoid nephrotoxic drugs o
o Antibiotics for UTI/ cyst infectionAntibiotics for UTI/ cyst infection o
o Renal replacement therapyRenal replacement therapy o
o Indication of NephrectomyIndication of Nephrectomy
Recurrent infectionRecurrent infection
Uncontrolled hemorrhageUncontrolled hemorrhage Suspected malignancySuspected malignancy Symptomatic mass effectSymptomatic mass effect
Extension of polycystic kidney into transplant site.Extension of polycystic kidney into transplant site.
o
o Management of Hematuria- bed rest, hydration and analgesiaManagement of Hematuria- bed rest, hydration and analgesia
10.
10. Transplanted KidneyTransplanted Kidney Investigations
Investigations
USG Doppler to confirm diagnosis and assess graftUSG Doppler to confirm diagnosis and assess graft
To check that the graft is workingTo check that the graft is working
o
o FBCFBC o
o Renal FunctionRenal Function o
o Calcium and PhosphateCalcium and Phosphate o
o CXR for volume overloadCXR for volume overload o
o ABG for metabolic acidosisABG for metabolic acidosis
To look for To look for complication of immunosupressioncomplication of immunosupression
o
o Septic screen for patients with feverSeptic screen for patients with fever o
o Renal function/ LFT ( Cyclosporin )Renal function/ LFT ( Cyclosporin ) o
o Fasting lipid/ sugar ( tacrolimus)Fasting lipid/ sugar ( tacrolimus) o
o Screen for opportunistic infectionScreen for opportunistic infection o
o Biopsy from transplanted kidney to look for Graft failureBiopsy from transplanted kidney to look for Graft failure
Management Management
MDTMDT
Patient education and counseling, cPatient education and counseling, c ompliance to immunosuppressantompliance to immunosuppressant
Monitoring for toxicity of Monitoring for toxicity of immunosuppressantimmunosuppressant
o
o FBC, Renal parameters, LFTFBC, Renal parameters, LFT o
o Septic screenSeptic screen o
o Dermatology surveillance for PTLDDermatology surveillance for PTLD
Renal replacement therapy if graft Renal replacement therapy if graft function deteriorates despite adequate immunosupressionfunction deteriorates despite adequate immunosupression
o
o Uremic encephalopathyUremic encephalopathy o
o PericarditisPericarditis o
o Refractor fluid overloadRefractor fluid overload o
Lower limb Weakness Lower limb Weakness
Quadruplegia Bilateral
Quadruplegia Bilateral UMNUMN Unilateral Unilateral stroke stroke ask permission UL/Face ask permission UL/Face Examine neck Examine neck Lower cranial Nv Lower cranial Nv cerebreller cerebreller Paraparesis/ paraplegia Paraparesis/ paraplegia Check Cerebeller
Check Cerebeller Yes Yes MS, Brainstem , Spino Cerebeller Ataxia MS, Brainstem , Spino Cerebeller Ataxia Friedreich’s / B12 deficiency
Friedreich’s / B12 deficiency No
No
Check
Sensory-Check Sensory- Deficit Deficit Spinal Level Spinal Level Spinal Cord lesion Spinal Cord lesion Dissociated sensory loss
Dissociated sensory loss Syringomyelia/ Ant Spinal AOSyringomyelia/ Ant Spinal AO No
No Sensory Sensory deficit deficit Peipheral Peipheral nerve nerve patternpattern Pheripheral neuropathy + Pyram Pheripheral neuropathy + Pyramidalidal
Fasciculation
Fasciculation parasagital parasagital meningiomameningioma Syringomyelia
Syringomyelia MND
MND Heriditary/Tropical Spastic Heriditary/Tropical Spastic Spastic Spastic Diplegia Diplegia ( ( Cerebral Cerebral Palsy)Palsy) Paraparesis
Lower limb LMN
Lower limb LMN Cerebeller Cerebeller Alcohol, drugs Alcohol, drugs
Sensory Deficit Sensory Deficit
Yes NO
Yes NO PolioPolio
Small wasted limb Small wasted limb
Root
Root Lesion Lesion Peripheral Peripheral nerve nerve Both Both root root and and nerve nerve Muscle Muscle hypertrophy hypertrophy fasciculationfasciculation Cauda
Cauda Diabetes Diabetes GBS/ GBS/ CIDP CIDP Muscle Muscle disease disease Multifocal Multifocal Motor Motor NPNP GBS
GBS Alcohol Alcohol MNDMND
CIDP HSMN
CIDP HSMN
Diabetic
Diabetic amyotrphy amyotrphy B6/B12B6/B12
Paraneoplastic Paraneoplastic CIDP
CIDP Drugs
Drugs Affect Affect only only LMNLMN
Asymmetric, UL and LL Asymmetric, UL and LL Prominent fasciculation Prominent fasciculation Autoimmune origin Autoimmune origin Anti GM 1 antibody Anti GM 1 antibody Treatment IvIg, Treatment IvIg, Rituximab and Rituximab and Immunosupressant Immunosupressant Both UMN and LMN
Both UMN and LMN Lower limbLower limb
No Sensory Loss- ALSNo Sensory Loss- ALS
Dissociated Sensory Loss- SyringsDissociated Sensory Loss- Syrings
Absent KJ+ brisk AJ, PlanterAbsent KJ+ brisk AJ, Planter ↑↑= Conus lesion= Conus lesion
Absent ankle jerk + planterAbsent ankle jerk + planter ↑↑↑↑
o
o M- MS, MNDM- MS, MND o
o A- Ataxia Freidreich’s , Cauda conusA- Ataxia Freidreich’s , Cauda conus o
o S- SACD, Syphilitic taboparesisS- SACD, Syphilitic taboparesis o
Foot drop Foot drop
Ankle Jerk Ankle Jerk
Brisk
Brisk Present Present absentabsent
UMN
UMN Sensory Sensory loss loss S1 S1 radiculopathy radiculopathy Sciatic Sciatic nervenerve
Lateral
Lateral thigh thigh and and leg leg compartment compartment Part Part of of leg leg and and No No sensory sensory lossloss &
& Dorsum Dorsum of of foot foot Dorsum Dorsum of of foot foot BilateralBilateral Usually
Usually unilateral unilateral UnilateralUnilateral H/O Pain
H/O Pain EHL weakness EHL weakness
L5
L5 radiculopathy radiculopathy Common Common peroneal peroneal nerve nerve Myotonic Myotonic dystrophydystrophy D/D
D/D HSMN HSMN / / trauma/ trauma/ diabetes diabetes IBMIBM Paraneoplastic
Paraneoplastic
Cause of Pes Cavus Cause of Pes Cavus
Unilateral Bilateral
Unilateral Bilateral
Polio HSMN
Polio HSMN
Burn
Burn mascular mascular dystrophydystrophy
Taruma
Taruma spinal spinal mascular mascular atrophyatrophy Syringomyelia Syringomyelia Palpable nerve Palpable nerve HSMNHSMN AcromegallyAcromegally LeprosyLeprosy CIDPCIDP AmyloidosisAmyloidosis NeurofibromatosisNeurofibromatosis
Upper limb Weakness Upper limb Weakness
Check LL
Check LL UMNUMN Unilateral Unilateral stroke stroke ask permission LL/Face ask permission LL/Face
LMN
LMN and and UMN UMN Bilateral Bilateral ((D/D-D/D- bilateral stroke/MND/ PD/ bilateral stroke/MND/ PD/ Freidreich’sFreidreich’s/ / cervical cervical 1-4)1-4)
MND MND
Examine neck
Examine neck any scar, kyphoscoliosis any scar, kyphoscoliosis
Check
CheckCerebellerCerebeller Yes Yes MS, Brainstem , Spino Cerebeller Ataxia, Wilson’sMS, Brainstem , Spino Cerebeller Ataxia, Wilson’s
Friedreich
Friedreich’s’s NoNo
Check Sensory
Check Sensory-- No No Sensory Sensory deficit deficit FasciculationFasciculation YesYes MNDMND No No Deficit Deficit Tremor Yes Tremor Yes PD PD Spinal
Spinal Level Level Dissociated Dissociated sensory sensory loss loss Peipheral nerve Peipheral nerve pattern pattern Multiple Multiple sclerosissclerosis
Spinal
Spinal Cord Cord lesion lesion Syringomyelia/ Syringomyelia/ Ant Ant Spinal Spinal AO AO Pheripheral Pheripheral neuropathy neuropathy + + PyramidalPyramidal
cervical myelopathy cervical myelopathy
Upper
Upper limb limb LMNLMN Cerebeller Cerebeller Alcohol, drugs, Syrings, Alcohol, drugs, Syrings,
Sensory Deficit Sensory Deficit
Yes NO
Yes NO PolioPolio
Small wasted limb Small wasted limb
Root
Root Lesion Lesion Peripheral Peripheral nerve nerve Both Both root root and and nerve nerve Muscle Muscle hypertrophy hypertrophy fasciculationfasciculation Dermatomal
Dermatomal loss loss Gloves Gloves pattern pattern both/ both/ variable variable Proximal Proximal Distal/proximalDistal/proximal
Brachial
Brachial Neuritis Neuritis Diabetes Diabetes GBS/ GBS/ CIDP CIDP Fatigable Fatigable Multifocal Multifocal Motor Motor NPNP CIDP
CIDP HSMN HSMN MNDMND
GBS
GBS Alcohol Alcohol Cervical Cervical SponSpon
CIDP CIDP Drugs Drugs B6/B12 B6/B12 Paraneoplastic Paraneoplastic Affect only LMN Affect only LMN Asymmetric, UL and LL Asymmetric, UL and LL Prominent fasciculation Prominent fasciculation Yes No
Yes No Autoimmune Autoimmune originorigin
MG
MG Muscle Muscle ds ds Anti Anti GM GM 1 1 antibodyantibody LEMS LEMS Treatment IvIg, Treatment IvIg, Rituximab and Rituximab and Immunosupressant Immunosupressant
Small Muscle wasting of hand Small Muscle wasting of hand
D/D-
D/D- MND, MND, Cervical Cervical myelopathy, myelopathy, Syrings, Syrings, combined combined median median and and ulnar ulnar nerve nerve damage,Peripheral damage,Peripheral neuropathy(neuropathy( CMT) , C8T1 lesion ( cervical r
CMT) , C8T1 lesion ( cervical rib, Pancoast tumor, trauma)ib, Pancoast tumor, trauma) 1.
1. Hand- Hand-a.
a. 5 5 movements movements of of thumb thumb 4 4 movements movements of of fingers fingers 1 1 movement movement of of little little fingerfinger b.
b. DTR DTR c. c. Sensory Sensory d. d. Cerebeller Cerebeller e. e. Lower Lower limb/ limb/ cranialcranial WASTING OF HAND
WASTING OF HAND
Unilat
Unilat stroke stroke LMN
LMN UMN UMN BilateralBilateral MND MND
Parkinson’s Ds Parkinson’s Ds Upper cervical Upper cervical SENSORY SENSORY
Median and Ulnar nerve Median and Ulnar nerve
No
No sensory sensory loss loss gloves gloves pattern pattern Dermatomal Dermatomal pattern pattern C8-T1 C8-T1 Dissociated Dissociated cerebeller+ dorsalcerebeller+ dorsal
MND
MND Polyneuropathy Polyneuropathy PP ancoast ancoast SyringomyeliaSyringomyelia Friedreich’sFriedreich’s MMN
MMN Neurofibroma Neurofibroma ataxiaataxia
Myotonic
Myotonic dystrophy dystrophy Cervical Cervical RibRib Disuse atrophy
Disuse atrophy RA RA Cervical myelopathy Cervical myelopathy (+UMN)(+UMN) Cachexia
Cachexia Look Look relevant relevant Brachial Brachial plexopathyplexopathy IBM
IBM
Spinal Cord Spinal Cord Cervical
Cervical Spondylosis Spondylosis Look Look at at backback Syringomyeli
Syringomyelia a Test Test sensation sensation over over cap cap area, area, look look for for HornersHorners Anterior Horn Cell
Anterior Horn Cell Motor
Motor Neuron Neuron Disease Disease Fasiculation Fasiculation of of the the tongue tongue or or other other muscles, muscles, ?bulbar ?bulbar speechspeech Polio
Polio Spinal
Spinal muscular muscular atrophy atrophy Examination Examination of of lower lower limbslimbs Nerve Lesions
Nerve Lesions Median
Median Alone will Alone will not not give give wasting wasting of of all all small small muscles muscles of of the the handhand Ulnar
Ulnar Should have Should have a a claw claw handhand Peripheral
Peripheral Neuropathy Neuropathy e.g. e.g. CMTCMT – – absent reflexes, forearms > hands, thickened nerves absent reflexes, forearms > hands, thickened nerves Brachial Plexus C8-T1
Brachial Plexus C8-T1 ? clubbed from lung ca, cervical ribs, Horner’s? clubbed from lung ca, cervical ribs, Horner’s Myopathy
Myopathy Myotonic
Myotonic Dystrophy Dystrophy Appearance, Appearance, weak weak neck neck musclesmuscles Distal
3
3rdrd nerve nerve
Medical
Medical – – DM, MS, Basal meningitis, Vasculitis, GCA DM, MS, Basal meningitis, Vasculitis, GCA Surgical- Trauma, PCA aneurysm, tumor
Surgical- Trauma, PCA aneurysm, tumor Inspection
Inspection- Complete ptosis, Lift the eyelid- Complete ptosis, Lift the eyelid see eyeball see eyeball down and out down and out see pupil see pupil miosis/ mydriasis miosis/ mydriasis H
H Diplopia maximal on contalateral superior gaze Diplopia maximal on contalateral superior gaze Check
Check – –
4, 6, V14, 6, V1
Disc- papiloedema, RetinopathyDisc- papiloedema, Retinopathy
Ispilat cerebellerIspilat cerebeller
Contra pyramidal- weber’sContra pyramidal-weber’s
Associated syndromes Associated syndromes
Caverous sinus syndrome- Caverous sinus syndrome- III, IV, V1, V2., VI + symatetic fibersIII, IV, V1, V2., VI + symatetic fibers horner’shorner’s
Orbital apex- Orbital apex- II, III,IV, II, III,IV, V1, VIV1, VI
Superior orbital syndrome- III, IV, V1, VISuperior orbital syndrome- III, IV, V1, VI
4
4thth nerve nerve
Inspection: affected eye in higher than o
Inspection: affected eye in higher than o ther in neutral position.ther in neutral position. H
H impairment of the impairment of the affected eye adducted eye can’t look affected eye adducted eye can’t look down. Diplopia maximum at looking down anddown. Diplopia maximum at looking down and away from the affected side and cover test that outer image from affected side.
away from the affected side and cover test that outer image from affected side.
INO INO
6
6thth Nerve Nerve
Cause-Cause- DM, MS, Basal meninDM, MS, Basal meningitis, Vasculitis, gitis, Vasculitis, False localizing signFalse localizing sign, CP angle Mass, CP angle Mass Approach
Approach
inspection : Convergent strabismus inspection : Convergent strabismus H
H impaired abduction of affected eye impaired abduction of affected eye Diplopia Diplopia cover test cover test ask which image disappear? Outer/ inner.ask which image disappear? Outer/ inner. Relavant
Relavant 1.
1. Associated 3Associated 3rdrd , 4 , 4thth – – search search Gaze palsyGaze palsy
2.
2. Associated V1- CavernousAssociated V1- Cavernous 3.
3. 77thth – – Brain stem Brain stem
4.
4. 88thth – – CP angle CP angle
5.
5. Disc- DN/HTN/OA/papiloedemaDisc- DN/HTN/OA/papiloedema——false localizing signfalse localizing sign 6.
6. Long tract sign Long tract sign - Brain s- Brain stem syndrome-tem syndrome- Millard gubler’s syndromeMillard gubler’s syndrome VI+ VII+ contra hemiparesisVI+ VII+ contra hemiparesis
7
7thth Nerve Nerve
1.
1. UMN- UMN- stroke/ stroke/ tumor/ tumor/ demyelination/ demyelination/ traumatrauma 2.
2. B/L UMNB/L UMN——MND, pseudobulber palsyMND, pseudobulber palsy present jaw jerk, taste sensation preserved present jaw jerk, taste sensation preserved 3.
3. LMN-LMN- Bell’s palsy, basal Bell’s palsy, basal meningitis, Leprosy, sarcoid, meningitis, Leprosy, sarcoid, Ramsay hunt , Lyme diseaRamsay hunt , Lyme diseasese, HIV, HIV 4.
4. B/L LMN-B/L LMN- GBS, b/L bell’s palsyGBS, b/L bell’s palsy 5.
5. Muscle ds- MG, Muscular Muscle ds- MG, Muscular dystrophy, FSHD, Mitochondrial myopathydystrophy, FSHD, Mitochondrial myopathy Approch
Approch a.
a. Parotid scarParotid scar previous surgery previous surgery b.
b. Hearing loss ( VIII), ipsilateral loss of facial sensation( V)Hearing loss ( VIII), ipsilateral loss of facial sensation( V) CP Angle CP Angle c.
c. Ipsilateral sixth , contralat hemiparesisIpsilateral sixth , contralat hemiparesis medial pons medial pons d.
d. Ear herpes/ poxEar herpes/ pox Ramsay Hunt Ramsay Hunt e.
e. MastoiditisMastoiditis Base of skull Base of skull f.
f. UMN with hemiparesis- MCA strokeUMN with hemiparesis- MCA stroke I would like to complete my e
I would like to complete my examination withxamination with
corneal reflex,corneal reflex,
Important causes of cranial nerve palsy Important causes of cranial nerve palsy
1.
1. Infection- basal meningitisInfection- basal meningitis 2.
2. Infarction- strokeInfarction- stroke 3.
3. Inflammation- MSInflammation- MS 4.
4. TraumaTrauma 5.
5. Mononeuritis multiplexMononeuritis multiplex 6.
6. Autoimmune conditionAutoimmune condition 7.
7. DiabetesDiabetes
Relevant Relevant
N-N- Nerve Nerve 1up and 1 1up and 1 down until down until normalnormal
I-I- Ipsilateral cerebellerIpsilateral cerebeller
C-C- Contralateral pyramidalContralateral pyramidal E
otoscopy,otoscopy,
formal audiometry andformal audiometry and
examination of upper and lower limbs.examination of upper and lower limbs.
Bulbar and Pseudobulbar palsy Bulbar and Pseudobulbar palsy
Pseudobulbar Bulbar
Pseudobulbar Bulbar
UMNUMN
CN V, CN V, VII VII (IX, (IX, X,XII)X,XII)
Facial expression, masticationFacial expression, mastication
Bilateral degeneration of corticobulbar tractsBilateral degeneration of corticobulbar tracts
Gag reflex, tongue spasticityGag reflex, tongue spasticity
Jaw jerk exageratedJaw jerk exagerated
Spastic dysarthriaSpastic dysarthria
“Daffy Duck”“Daffy Duck”
MS, MNDMS, MND
LMNLMN
CN CN IX, IX, X,XIIX,XII
Diminished gagDiminished gag
Tongue fasciculation, wastingTongue fasciculation, wasting
Jaw jerk normalJaw jerk normal
Unilateral –Unilateral – raspy voice raspy voice
Bilateral –Bilateral – nasal speech nasal speech GBS, Stroke, MNDGBS, Stroke, MND Myotonic Dystophy: Myotonic Dystophy: Face Face
Loss of facial and neck musculatureLoss of facial and neck musculature
Frntotemporal baldingFrntotemporal balding
Difficulty in opDifficulty in opening eyes ening eyes after firm closureafter firm closure
Drooping mouthDrooping mouth DysarthriaDysarthria CataractCataract Low IQLow IQ Hands Hands
Distal wasting and weakness LMN patternDistal wasting and weakness LMN pattern
Percussion myotoniaPercussion myotonia
NO Sensory lossNO Sensory loss
Lower Limb Lower Limb
Distal wasting and weakness LMN patternDistal wasting and weakness LMN pattern
Foot drop and high steppage gaitFoot drop and high steppage gait
Others Others
GYnecomastiaGYnecomastia
Cardiomyopathy, conduction blockCardiomyopathy, conduction block
Esophagial dysmotilityEsophagial dysmotility
HypoventilationHypoventilation
Testicular atrophyTesticular atrophy
Autosomal Dominant ,CTG trinucleotide repeat Autosomal Dominant ,CTG trinucleotide repeat sequence in sequence in DM 1=Chromosome 19 DM 1=Chromosome 19 DM2= Chromosome 3 DM2= Chromosome 3 Investigation Investigation
Dive bomber potential in EMGDive bomber potential in EMG
CPK mild elevationCPK mild elevation
Muscle biopsy- variability in fiber size andMuscle biopsy- variability in fiber size and
fibrosis fibrosis
FBS and Hba1c, LFTsFBS and Hba1c, LFTs
ECG to look for conduction block, EchoECG to look for conduction block, Echo
Genetic testingGenetic testing
MRI brain brain atrophyMRI brain brain atrophy
Management Management
Patient education and counselingPatient education and counseling
May die prematurelyMay die prematurely
Phenytoin may Phenytoin may help mhelp myotoniayotonia
Ptosis Ptosis Unilateral Bilateral Unilateral Bilateral With ophthalmoplegia With ophthalmoplegia Without Without ophthalmoplegia
ophthalmoplegia With With ophthalmoplegiaophthalmoplegia
Without Without
ophthalmoplegia ophthalmoplegia
Third nerveThird nerve
palsy palsy Mydriasis Mydriasis MyastheniaMyasthenia initial stage initial stage fatigable fatigable Horner’s syndrome Horner’s syndrome Miosis Miosis Partial ptosis Partial ptosis Fatigable Fatigable
Myasthenia gravisMyasthenia gravis
Non fatigable Non fatigable MitocondrialMitocondrial myopathy CPEO myopathy CPEO OcculopharyngealOcculopharyngeal muscular dystrophy muscular dystrophy
Miller fisherMiller fisher
syndrome syndrome
Neurotoxic snake biteNeurotoxic snake bite
MyotonicMyotonic dystrophy dystrophy SenileSenile CongenitalCongenital B/L Horner’sB/L Horner’s Steps: Steps: 1.
1. InspectionInspection – – one eye/ both eye, one eye/ both eye, 2.
2. Come near to the Come near to the patient without thouching the patientpatient without thouching the patient complete / partial complete / partial 3.
3. Lift the eyelidLift the eyelid see Pupil. see Pupil.
Miosis
Miosis Normal Normal DilatedDilated
Hormer’s Hormer’s
position of eyeball. down + out position of eyeball. down + out colour
colour of of iris iris Position Position of of eye eye NormalNormal
heterochromia
heterochromia please please close close eyes eyes tightly tightly for for me me pleaseplease
follow scheme of nerve follow scheme of nerve palsy
palsy follow scheme
follow scheme of Horner’ s
of Horner’ s Cant Cant close close eye eye tightly tightly Can Can close close tightly tightly but but cancan’’t opent open
Myasthenia
Horner’s
Horner’s SyndromeSyndrome
Central 1
Central 1ststorder order Demyelination Demyelination /Syringomyelia /Syringomyelia No No sweating sweating in in face, face, arm arm and and trunktrunk
2
2ndndorder order Trauma, Trauma, surgery, surgery, pancoast pancoast , , Lymph Lymph node, node, goiter goiter No No sweating sweating in in facefacearm trunkarm trunk
normal normal 3
3rdrdorder order cavernous cavernous sinus sinus syndrome, syndrome, carotid carotid dissection dissection Sweating Sweating normalnormal
Sequence Sequence
1.
1. Partial PtosisPartial Ptosis ask to look up. ask to look up. 2.
2. Lift the eyelidLift the eyelid colour of iris ( congenital heterochromia), Ask to dim the light colour of iris ( congenital heterochromia), Ask to dim the light for pupil, light reflexfor pupil, light reflex 3.
3. Eye movement HEye movement H 4.
4. Hands- Hands- Samll muscle wasting, clubSamll muscle wasting, clubbing, nicotin staininbing, nicotin stainingg 5.
5. Neck- Scar, dressing, Neck- Scar, dressing, cervical rib palpate, Goiter, palpcervical rib palpate, Goiter, palpalte thyroid glandalte thyroid gland 6.
6. Chest- Scar, Dressing, pancoastChest- Scar, Dressing, pancoast 7.
7. Lower limb- if time allowsLower limb- if time allows Presentation
Presentation
I would like to complete my e
I would like to complete my examination by testing sweatingxamination by testing sweating 1.
1. Partial ptosis,Partial ptosis,which is overcome by voluntary upgazewhich is overcome by voluntary upgaze
2.
2. Apparent EnopthalmosApparent Enopthalmos 3.
3. MiosisMiosis 4.
Myasthenia Gravis Myasthenia Gravis
Fetures Fetures
Fatigable ptosisFatigable ptosis
Complex ophthalmoplegiaComplex ophthalmoplegia
Nasal speechNasal speech
Bulbar weakness—Bulbar weakness—Nasal speech, poor swallowNasal speech, poor swallow
Proximal weakness UL>>LLProximal weakness UL>>LL
Reflex/ sensory normalReflex/ sensory normal
Look for sternotomy scarLook for sternotomy scar
Look for features of immunosupessionLook for features of immunosupession
o
o CushingoidCushingoid
Single breath count –Single breath count – FVC FVC
Other autoimmune diseaseOther autoimmune disease
LEMS LEMS
limb girdle limb girdle weakness weakness LL>>ULLL>>UL
Rarely Ptosis and diplopiaRarely Ptosis and diplopia
Diminished reflexes become brisk afterDiminished reflexes become brisk after
exercise exercise
Associated with malignancy- SCLCAssociated with malignancy- SCLC
Anti voltage gated Ca cannel antibodyAnti voltage gated Ca cannel antibody
Autonomic dysfunctionAutonomic dysfunction
EMG shows “second wind” phenomenonEMG shows “second wind” phenomenon
Mx-3,4 Diaminopyridine and treatment ofMx-3,4 Diaminopyridine and treatment of
tumor tumor Investigation Investigation CBC, ESRCBC, ESR
CXR to look for mediastinal massCXR to look for mediastinal mass
CT chest for thymomaCT chest for thymoma
Anti AChR antibody 85%Anti AChR antibody 85%
Anti MuSK antibody 15%Anti MuSK antibody 15%
Vital capacityVital capacity
RNST >10% decrement on 3HZRNST >10% decrement on 3HZ
Single Fiber EMG (most specific)Single Fiber EMG (most specific)
Thyroid profile, CPKThyroid profile, CPK
FBSFBS
Treatent Treatent
Patient education and counselingPatient education and counseling
Avoidance of precipitatorsAvoidance of precipitators
Acute:Acute:
o
o IvIG/Plasma ExchangeIvIG/Plasma Exchange
MaintenanceMaintenance
o
o Acetylcholine esterase inhibitorsAcetylcholine esterase inhibitors o o ImmunosuppressantImmunosuppressant o o SteroidSteroid o o AzathioprineAzathioprine o o MMFMMF o o CyclophosphamideCyclophosphamide
ThymectomyThymectomy -For all pa-For all patients tients even if there iseven if there is
no thymoma no thymoma
Friedreich’s ataxia
Friedreich’s ataxia: : Pyramidal+ Pyramidal+ LMN+ CeLMN+ Cerebeller+ rebeller+ Dorsal Dorsal ColumnColumn
Young adult Young adult with Kyphoswith Kyphoscoliosiscoliosis
PPes cavuses cavus
PPyramidal type of weakness in lower limbyramidal type of weakness in lower limb
PPlanter Bilateral upgoinglanter Bilateral upgoing
PPeripheral neuropathyeripheral neuropathyDiminished / absentDiminished / absent
reflex reflex
PPosterior column signosterior column sign
Bilateral Cerebeller signs Bilateral Cerebeller signs (Ataxia, Dysarthri(Ataxia, Dysarthria,a,
nystagmus) nystagmus)
I would like to complete with I would like to complete with
HOCMHOCM
Hearing difficultyHearing difficulty aidaid
DiabetesDiabetes
Low IQLow IQ
Optic atrophyOptic atrophy
High arch palateHigh arch palate
PacemakerPacemaker
Insulin prick markInsulin prick mark
Autosomal recessive GAA repeat Frataxin gene Autosomal recessive GAA repeat Frataxin gene
Investigation Investigation
NCS- slowing of motor velocitiesNCS- slowing of motor velocities
Genetic analysisGenetic analysis
ECG ECHOECG ECHO
Vitamin E levelVitamin E level
Functional MRIFunctional MRI
FBC, U/E/ FBS HbA1CFBC, U/E/ FBS HbA1C
MRI of brain and spinal cordMRI of brain and spinal cord
VEP/ AERVEP/ AER
AudiometyAudiomety
Management Management
MDT –MDT – Neurologist/ geneticist/ genetic Neurologist/ geneticist/ genetic
counselor/physiotherapist/ speech and counselor/physiotherapist/ speech and
language therapist/occupational therapist and language therapist/occupational therapist and social worker
social worker
Hearing aidHearing aid SymptomaticSymptomatic AntidepressantAntidepressant PacemakerPacemaker
Exam possibility= Spstic paraparesis / Imballance Exam possibility= Spstic paraparesis / Imballance If asked
If asked Lower Lower limb= limb= Start Start from from gaitgait Wasting+ pes cavus+ UMN + post column+ + absent jerk Wasting+ pes cavus+ UMN + post column+ + absent jerk +cerebeller+cerebeller If asked upper limb= See tremor in
If asked upper limb= See tremor in hand to rule out parkinson’shand to rule out parkinson’s if noif no look for cerebeller signslook for cerebeller signs FSHD
FSHD (mostly u(mostly upper limbpper limb)) 1. Myopathic face
1. Myopathic faceWasting & weakness of facial muscleWasting & weakness of facial muscle D/D- D/D- (MG/ (MG/ MD)MD) 2. No Ptosis and eye movements are
2. No Ptosis and eye movements are normalnormal 3. Proximal muscle weakness and wasting 3. Proximal muscle weakness and wasting 4. Superior margin of scapula are visible from 4. Superior margin of scapula are visible from frontfront 5. Winging of scapula with positive Beevor sign 5. Winging of scapula with positive Beevor sign 6. Foot drop 6. Foot drop 7. Hearing aid 7. Hearing aid Fasciculation cause Fasciculation cause MNDMND SyringomyeliaSyringomyelia
Cervical myelopathyCervical myelopathy
HSMNHSMN
Electrolyte disturbance( hypokalemia, hypomagnesemia)Electrolyte disturbance( hypokalemia, hypomagnesemia)
Proximal myopathy Proximal myopathy
D/D-D/D- Cushing’s, Acromegally, Osteomalacia,Cushing’s, Acromegally, Osteomalacia, Thyroid ds, PMR, PM, Thyroid ds, PMR, PM, DM, MG, electrolytes, Drugs, Muscular dystrophiesDM, MG, electrolytes, Drugs, Muscular dystrophies Station
Station 3- 3- MG, MG, Muscular Muscular dystrophies dystrophies Station Station 5- 5- othersothers Inspection:
Inspection:
Face- cushingoid/ acromegally/ myopathic face/ eye- Face- cushingoid/ acromegally/ myopathic face/ eye- for Gravesfor Graves
NeckNeck – – thyroid, Scar, thyroid, Scar,
Hands- clubbingHands- clubbing
Legs- pretibial myxedemaLegs- pretibial myxedema
Chest- thymectomy scarChest- thymectomy scar
Rash- DMRash- DM
Gait- myopathic gaitGait- myopathic gait
MND MND
Management Management
General: Patient education, counseling, MDT, Patient autonomy for
General: Patient education, counseling, MDT, Patient autonomy for future choice, early involvement of palliative carefuture choice, early involvement of palliative care Specific:
Specific:
Symptom control-Symptom
control-a.
a. Baclofen for spasticityBaclofen for spasticity b.
b. Analgesia for painAnalgesia for pain c.
c. Anticholinergic for drooling of salivaAnticholinergic for drooling of saliva d.
d. Magnesium and Vitamin E for FasciculationMagnesium and Vitamin E for Fasciculation e.
e. SSRI for depressionSSRI for depression
NIVNIV
PEGPEG
Cardiovascular
Cardiovascular
Aortic Stenosis Aortic Stenosis Cause Cause Bicuspid aortic valveBicuspid aortic valve
CongenitalCongenital
Rheumatic feverRheumatic fever
Supravalvular aortic stenosisSupravalvular aortic stenosis
Degenerative in old peopleDegenerative in old people
Severity Severity
1.
1. Slow rising pulseSlow rising pulse 2.
2. Narrow pulse pressureNarrow pulse pressure 3.
3. Systolic thrillSystolic thrill 4.
4. Heaving apexHeaving apex 5.
5. Soft S2Soft S2 6.
6. S4S4 7.
7. Late peaking of long duration murmurLate peaking of long duration murmur 8.
8. Pulmonary hypertension and congestionPulmonary hypertension and congestion 9.
9. Reverse spiltReverse spilt Investigation
Investigation
FBC to look for anemiaFBC to look for anemia
Blood cultures for IEBlood cultures for IE
LFTs to look for coagulation profileLFTs to look for coagulation profile
Urine dipstick for hematuriaUrine dipstick for hematuria
ECG to look ECG to look for LV for LV strain patterstrain patternn
X ray chest to lX ray chest to look for post stenotic dialatation of aorta, pulmonary congestionook for post stenotic dialatation of aorta, pulmonary congestion
EchocardiographEchocardiography to look for LV y to look for LV size and ejection function, valve area ansize and ejection function, valve area and gradientd gradient
Coronary AngiographyCoronary Angiography
Echo criteria for severe ASEcho criteria for severe AS
• Aortic valve area: < 1cm2
• Aortic valve area: < 1cm2 • Jet Velocity: > 4.0m/sec • Mean • Jet Velocity: > 4.0m/sec • Mean transvalvular pressure: > 40mmHgtransvalvular pressure: > 40mmHg
Management Management General-
General- patient education , patient education , counseling, vaccination, counseling, vaccination, RestRest Symptomatic AVR if syncope/ angina/ Af
Symptomatic AVR if syncope/ angina/ Af
Asymptomatic-Median sternotomy scar Median sternotomy scar
Metallic valve replacementMetallic valve replacement
Tissue valve replacementTissue valve replacement
CABGCABG
Corrective surgery of congenital heartCorrective surgery of congenital heart
Disease Disease
Heart transplantHeart transplant
IE prophylaxis for Dental, IE prophylaxis for Dental, Genitourinary and Colonic procedureGenitourinary and Colonic procedure prophylaxis prophylaxis
Moderate/ severe stenosis undergoing other Moderate/ severe stenosis undergoing other cardiac surgerycardiac surgery
Gradient of > 40 mm Hg with any of the followingGradient of > 40 mm Hg with any of the following
o
o LVEF < 50%LVEF < 50% o
o Abnormanl BP response on ETTAbnormanl BP response on ETT o
o LVH > 15mmLVH > 15mm o
o VTVT o
o Valve area < 0.6 cmValve area < 0.6 cm22
Aortic regurgitation Aortic regurgitation
Cause Cause
Acute:
Acute: Trauma , hypertension, Aortic dissection, rupture , Aortic root Abscess, IE Trauma , hypertension, Aortic dissection, rupture , Aortic root Abscess, IE ,, Chronic:
Chronic: Bicuspid Bicuspid aorticaortic valve, Degeneration, Rheumatic, Marfan’s , valve, Degeneration, Rheumatic, Marfan’s , Ehlar danolos syndrome,Ehlar danolos syndrome, Aortitis
Aortitis – – Syphilic/ TakayasSyphilic/ Takayasu/RA/ SLE/ Au/RA/ SLE/ Ank Spondylosisnk Spondylosis
D/D-D/D- Pulmonary regurgitation, Mitral Stenosis, Tricuspid stenosis,Pulmonary regurgitation, Mitral Stenosis, Tricuspid stenosis, Severity
Severity
Wide pulse Pressure > 100Wide pulse Pressure > 100
Displaced apexDisplaced apex
Thrusting apexThrusting apex
Long duration murmurLong duration murmur
Austin flint murmurAustin flint murmur diastolic murmur at apex without opening snapdiastolic murmur at apex without opening snap
LVFLVF
Investigation Investigation
FBC to look for anemiaFBC to look for anemia
Blood cultures for IEBlood cultures for IE
LFTs to look for coagulation profileLFTs to look for coagulation profile
Urine dipstick for hematuriaUrine dipstick for hematuria
ECG to look ECG to look for LV for LV strain patterstrain patternn
X ray chest to lX ray chest to look for Cardiomegally, pulmonary congestionook for Cardiomegally, pulmonary congestion
EchocardiographEchocardiography to look for LV y to look for LV size and ejection function, valve area ansize and ejection function, valve area and gradient, aortic root sized gradient, aortic root size
and dilatation and dilatation
