TOP 70 PACES CASES SUMMARISED SUMMARIES BY DR SUJIT VASANTH

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DIABETIC RETINOPATHY (41) microaneurysms, blot haemorrhages,
hard exudates (Background), circinates of hard exudate near macula, poor acuity
(Macular oedema), cotton wool spots, flame haemmorhages, leashes of new vessels,
photocoagulation scars (proliferative), vitreous haemorrhage/scars, retinal
detachment (advanced diabetic eye dx). may be bp, cateract. indications for referral:
all except background, refer background involving macula. indications for
photocoagulation: pre-proliferative (cotton wool spots, multiple blots, venous
beeding) or proliferative retinopathy.
RHEUMATOID ARTHRITIS (31) symetrical deforming arthropathy,
spindling of fingers. PIP, MCP swelling, DIP spared, muscle wasting, deformity, pain.
nodules at elbow/dorsum hand, ulnar deviation, nail fold infarcts, arteric lesions.
warmth and swelling sugests active inflam. swan neck, boutonnière deformity, Z
thumb, palmer erythema, anaemia, episcleritis, CVS/RESP signs. causes of anaemia:
chronic dx, nsaids, myelosupressive drugs, feltys, assoc pernicious
anemia. treatment: general (education, excercise, physio - thermal, splinting, diet),
NSAIDs, DMARDs (1st line: methotrexate, sulphasalazine, gold, penicillamine,
(hydroxy)chloroquin, 2nd line: azathioprine, cyclophosphamide, chlorambucil),
corticosteroids (7.5 mg/day with calcium, bisphophanates), biological agents.
EXOPTHALMOS (26) (protrusion of eye revealing sclera above lower lid on
forward gaze). bilateral asymetrical swelling of medial caruncle, congestion of lateral
canthus, and exopthalmos. look for pretibial myxoedema, thyoid acropachy. graves
malignant exopthalmos: may be eu/hypo/hyperthyroid with severe exopthalmos,
chemosis, exposure keratitis, corneal ulceration, painful opthalmoplegia (lateral,
upward and convergent). due to muscle infiltration, oedema, fibrosis. sight
threatening due to optic nerve pressure. Rx: steroids, tarsoraphy (scar), orbital
decompression, radiotherapy. Causes: hyperthyroid graves dx, euthyroid graves dx,
hypothyroid graves. asymetrical: cavernous sinus thrombosis, carticocavernous fistula
(pusatile), unilat: retroorbital tumour, orbital celulitis (Hertel
exopthalmometer) Treatment: lubricant eye drops, avoid smoking, wrap around
glasses, optimize thyroid status. radioiodine may worsen exopthalmos.
ACROMEGALLY (24) prominent supraobital ridges, large lower jaw,
exagerated wrinkles, full lips, malocclusion/prognathism, interdental spaces,
nose/tongue/ears enlarged, kyphosis, large doughy spade hands, thick skin, carpal
tunnel syndrome, excesive sweating, 1/3 hersuit, husky, cavernous voice, bitemporal
hemianopia. Others: shoe/hat size, bowed legs, rolling gait, gynaecomatia,
gallactorhoea, large/small testes, acne, greasy skin, skin tags (colonic polyps),
acanthosis nigricans, osteoarthrosis, prox muscle weakness, cardiomegally (bp,
cardiomyopathy), CN3 palsy. Associations: DM, bp, hyercaliuria, hypercalcemia (if
MEN1=pipa=pituitry, islet cell, parathyroid, adrenal), urolithiasis, hyperTG, diabetes
insipidus, hypopituitrism. Inv: IGF1, GTT absent GH supression, MRI pituitry, visual
fields, old photos, SXR, ant pit tests (short synACTHen, ITT, TSH, T4, oestadiol,
LH/FSH, testosterone, prolactin). Rx: trnasphenoidal/transfrontal hypophysectomy,
external irradiation, gold/yttrium implants, bromocriptine (no shrinkage),
somatostatin analogues (shink). cause:99% pit adenoma, 1% gangliocytoma
CHRONIC LIVER DISEASE (21) icterus, pigmentation, clubbing,
leuconychia, palmer erythema, Dupytrens, spider naevi, flapping tremor, scratch
marks, purpura, gynaecomastia, scanty body hair, small testes, hepatomegally,
splenomegally, ascites, ankle oedema, distended abdo veins flow away +/- cyanosis
from pulm-venous shunts. consider transplantation. causes alcohol, viral hepatitis,
autoimmune CAH, haemochromtosis, cryptogenic. other: cardiac failure, constrictive
pericarditis, Budd Chiari, 2ry billiary cirrhsis, drugs (methotrexate, mehydopa,
isoniazid, CCl4, amiodarone, aspirin, phenytoin, propylthiouracil, sulphonamides),
Wilsons dx, alpha1antitrypsin def, metabolic (galactosemia, tyrosinemia,
glycogenosis4)

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FIBROSING ALVEOLITIS (21) sob, clubbing, steroid purpura, reduced
symetrical expansion, fine inspiratory crackles (+/- cyanosis, dullnes lung base,
LTOT) causes cryptogenic, rheumatoid, conn tissue disorders (systemic sclerosis,
SLE, polymyositis, dermatomyositis, Sjorgens), ankylosing spondylitis, extrinsic
allergic alveolitis, asbestosis, silicosis, drugs (bleomycin,buslphan, nitrofurantoin,
amiodarone), radiation fibrosis, chemicals (Berylium, mercury), poisons (paraquet),
ARDS.
PROSTHETIC VALVES (17) Mitral valve prosthesis midline sternotomy, S1
prosthetic click, diastolic opening click +/- mid diastolic flow murmur, pansystolic
murmur/failure suggests leak. Aortic valve replacement midline sternotomy, normal
S1, systolic opening click, prosthetic S2 +/- systolic flow murmur, early diastolic
murmur/collapsing pulse suggests leak Complictions thromboemolism, haemorhage,
endocarditis, valve leak, dehiscence, Starr-Edwards ball embolus, valve obstruction
(thrombus/fibrosis), haemolysis.
HEPATOSPLENOMEGALLY (17) spleen enlarged..cm below costal
margin. Liver palpable ... cm below right costal margin. Check for anemia,
lymphadenopathy, chronic liver disease and renal enlargement. Causes:
myeloproliferative,lymphoproliferative (CLL, lymphoma), liver cirrhosis with portal
hyperension, infections (hepB/C, EBV, CMV), zoonoses (brucella,weils, toxplasma),
megaloblastic anemia, storge dx (gauchers, glycogen storage), amyloidosis,
sarcoidosis,budd chiari=hep vein thrombosis, infantile PKD. worldwide causes:
malaria, kala azar, schistosomiasis, TB. Bruit suggests hepatoma.
PNEUMONECTOMY (16) chest wall deformity, with flattened L side
associated ith L thoracotomy scar, L tracheal deviation, L expansion reduced,
percussion dull, breath sounds diminished. Bronchial breathing L upper zone due to
tracheal deviation. L lower lobctomy deformity chest, L lower ribs pulled in, L
thoracotomy scar, trachea central, apex displaced L, percussion dull L lower zone,
breath sounds diminished.Indications for pnumonectomy 25% non small cell ca (26% mort), solitary pulm nodule of uncertain cause, treatment unresponsive
bronchiectasis, TB in preantibioic era.
RETINITIS PIGMENTOSA (16) widespread scattering of black pigment
resembling bone spicules, the macula spared. There is tunnel vision and night
blindness. Associaions: cateracts, deaf mutism, mental deficiency. Other causes of
pigmentary degeneration Laurence Moon Biedl, Refsums dx, hereditary ataxia,
familial nuropathy, neuronal lipidoses (ceroid lipofuscinosis).
SYSTEMIC SCLEROSIS (15) middle aged female, skin smooth, shiny, tight
fingers and face. Raynaulds, atrophy of finger tips, telangectasias face, pigmentation,
nodules of calcinosis palpable on some fingers. other: skin ulcers, vitiligo, Sjorgens,
diffuse intersitial fibrosis (leading cause of death) Rx vasoilators. other systems:
CREST, renal (bp, failure), CVS (cardiomyopathy, effusion), muscle (myositis,
arthritis), intestinal hypermotility, PBC. Treatment: general (education, exercise,
lubricants), Raynauds (calcium ch blockers, ACEi, proscycline, calcitonin GRP),
oesophagus (PPI, prokinetics=cisapride), malabsoption (low residue diet,
supplements, rotational abx), renal (ACEi, steroids), pulm vasc dx
(vasodilators),fibrosis (dpenicillamine, corticosteroids).
POLYCYSTIC KIDNEY DISEASE (14) bilateral flank masses, bilaterally
ballotable, can get above them, percussion resonant, abdominal scars from
CAPD/cyst aspiration, AV fistula, uremic facies, hypertension, renal transplant,
parathyroidectomy. Complications: flank pain, bleeding, uti, nephrolithiasis,
obstrucive uropathy. Other features: berry aneurysm, mitral valve prolapse, renal cell
carcinoma. Genetics: PKD1 (Ch16, 85%, renal failure), PKD2 (Chr4, 15%), PKD3
rare. Liver cysts: rare in adult AD-PKD, common in infantile AR-PKD. Screening:
U/S and genetic testing at 20 years (inconclusive before 20), earlier if FH aneurysm,
signs renal dx. Bilateral renal enlargement: polycystic kidney dx, bilateral
hydronephrosis, amyliodosis, tuberous sclerosis, von Hippel Lindau disease.
MITRAL REGURGITATION (13) pulse regular, JVP not raised, no
ankle/sacral oedem unless cardiac failure, thrusting apex suggestng volume overload

behind ears. papillairy muscle dysfunction. lymphoproliferative.22). Other arthropathy: arthritis mutilans. onycholysis. may be widespread ronchi. pressure effect (acoustic neuromas CN5-8. meningioma. MV prolapse. some single others lobulated. there is a notch. ant eaflet over spine.SBE) NEUROFIBROMATOSIS (13) multiple (5+) neurofibromas. left parasternal heave. NW europe. sob. percussion is dull over left lower chest and mass. Causes: v. spinal nerve root. erhler danlos. cnnot get above it.. myelofibrosis). sessile pedunculated fibromata some soft others firm. hypertrophic cardiomyopathy. inspiratory clicks heard with unaided ear. endocardial fibrosis. azathioprine. uv light. sarcoid. cirrhosis (telangectasias/transfusion). SPLENOMEGALLY (13) mass left hypochondrium. 16./diuretics. PLEURAL EFFUSION (10) Pulse regular.. pitting of fingernails. myelofibrosis. intraarticular steroids. MR with pulm bp. possible systolic thrill. knees. trachea usually central. Soft S1. 15. mental retardation. tongue. ank spond treatment local sunlight. It moves diagonally cross abdomen. yellow nail. Analgesic anti inflam for arthropathy. Uncommon in Japanese. local steroids. pseudoarthrosis.. on lips. conjunctival telagactesias (bloody tears). hepatitis. Rheumatoid-like. OSLER WEBER RENDU (11) (heridatary haemmorhagic telangectasias) Telangectasias on face. dithranol. congenital (defomity. Treatment systemic: acitretin (retinoid). massive intrahepatic shunting Treatment: chronic oral Fe therapy. Indications surgry: SOBOE despite ACEI. lymphadenopathy and fibrosis). trunk. low dose finbrinolytic agents (aminocaproic acid). scalp. Chloroquin contraindicated worsens skin. Genetics: Autosomal dominant. cerebellar signs). Loud pansystolic murmur at apex radiates to axilla. serial echo progressive LV dilatation. 19. NFT2 (chr 22) bilateral acoustic neuroma BRONCHIECTASIS (12) underweight. cyanosed.Patches of psoriasis over bony prominemces particularly elbows. JVP normal.14. rheumatic heart dx.complications: GI haemorhhage. Plaques circular. lung cysts (honeycomb lung). causes: childhood infections (whooping cough. increased end systolic volume (> 30 ml/m2). red. some nail plates thickened. CLL). hemoptysis 2ry to pulm AV aneurysms. well difined edges. S3 suggests severe MR. epistaxis. diminished TVF. infective endocarditis. around mouth. N American Indians. calipotriol. cafe au lait spots. Causes: degenerative. hypogammaglobulibemiam. congenital (marfans. antimetabolites (sulphasalazine. oestrogens to induce squamous metaplasia of nasal mucosa. Marfans. 2/3 axilliary freckling. allergic bronchpulmonary aspergillosis. in navel. rib nochiing. silvery scaly surface. medulloblastoma. NFT1=von Ricklenhausen (chr 17). Mitral vave prolapse: post leaflet LSE. some mobile subcutaneously lumps others nodules along peripheral nerves. in 6 ICS. Lisch nodules=iris harmatomas. cystic fibrosis. oligo/mono artthropathy. hydroxyurea). bronchial obstruction (foreign body. TB). cirrhosis with portal hypertension. previous valvotomy for mitral stenosis. CN5 neuroma. localised crepitations. USA. frequent productive cough. I think this is a spleen enlarged at. chodrae rupture. non contractile capillaries cause prologed bleeding. annular calcification. Kartageners) . Genetics: aut dominant . buccal and nasal mucosa and fingers. renal art stenosis. lymphoproliferative (lymphoma. methotrexate. hypetkeratosis under them. complications: kyphoscoliosis.cm. coal tar. Large (4-8cm):myeloproliferaive (CML. sputum pot. carcinoma. intragluteal cleft. PUVA (psoralen and uv light). Incidence 5% Caucasian. infections (EBV. plexiform neuroma. finger clubbing. percussion stony dull at R/L base. ant axilliary lne. pulse dye laser NOT cautery. severe LV dilatation. 17. smoking related copd (common) PSORIASIS (12) (11) Asymetrical arthropathy involving mainly TIP. several gene defects possible. Japanese. pseudxanthoma elasticum). valvuloplasty +/annuloplasty preferable due to dec mort/no anticoagulation. retinal detachment/haemorrhage.Small (2-4 cm): myeloproliferative. measels. makaria/kala arar. cirrhosis with portal hypertension. epilepsy. sarcomatous change. VR and . 18. Anemia but no features of systemic sclerosis . Can also have: glioma. retinal harmatomas.expansion normal.large: CML (Ph chr t9.

Loud P3. Transudate (<30 g/l) cardiac failure. nitrofurantoin. tetanus. hoarse voice. cirrhosis. other living (74. hydralazine. hypothyroid facies. left thoracotomy scar. no lid lag. pneumonia. nephrotic syndrome.. Harsh ejection systolic murmur aortic area radiating to neck. 21. thyroid acropachy. Refsum's dx. thin. 73).Predominant AR regular pulse. slowly reacting reflexes. Lyme dx. mid dialstolic rumbling localised to apex. systemic sclerosis (chornic vasular/gi problems). Causes Exudate (>30 g/l. Difficult to transplant: HUS (recurrence possible. Loud S1. Apex in ant ax line 6ICS thrusting (volume overload). uremia. exophalmos (?chemosis. JVP not elevated. metronidazole. Previous thyroidectomy scar. sarcoidosis. glomerulonephritis.glove distribution. HLA matched cadaver (70. vincristine. 22. ethanbutol. in inspiration. esp if on cyclosporin). paraprotein. secondary malignancy. surgery indicated for stenotic symptoms. hypertensive renal dx. POEM syndrome) Motor causes: carcinomatous. Ex testing can be used except for severe AS. May be bronchial breathing over effusion. mesothelioma. small diffuse goitre with bruit. 10 yr outcome: HLA identicle living (88. basal collapse. other (guillin barre. early diastolic murmur LSE loudest on leaning forward. Diseases leading to transplantation: DM nephropathy. pulse regular with normal rate. gold. PAN. Tapping Apex. rheumatoid arthritis. Best treatment AV repair. (TB. soft A2. PERIPHERAL NEUROPATHY (9) impaired light touch. goitre. forcefull sustained heave (pressure overload). joint position and pinprick in a stocking +/. tachycardia. collapse/consolidation totally occluding distal airways. LDH >200) bronchial carcinoma. Thoracoscopy for either diagnosis and pleurodesis 20. early diastolic murmur LSE loudest on leaning forward. rare (myxoedema. sickle cell (increased crisis). Bilateral flank masses bimanually ballotable (or 1 mass and 1 nephrectomy scar). vibration. pulse irregular. Management: Cardiac catheter study gold standard. thyroidectomy scar. diptheria. AIDS). hyperthyroid graves usually female. Left parasternal heave. not displaced. BP low with low pulse pressure. aortic area and carotid. carcinomatous neuropathy. Apex thrusting (volume pverload). Systolic thrill apex. slow pulse. dialysis). TB. lymphoma. asbestos. Hypothyroid Graves: exopthalmos. 24. pretibial myxoedema. 5. lead. lv compromise in regurgitation. amiodarone.Management: Cardiac cath is gold standard. loud P2. in inspiration. cyclosporin). Apex palpable 1 cm left of MCL. Charcot Marrie Tooth. Euthyroid Graves:exopthalmos. pretibial myxoedema. SLE. in left lateral posn mid diastolic low rumble followed by opening snap.diminished breath sounds. palms not sweaty. Other causes of dullness at lung bases raised hemidiaphragm. hereditary ataxia. Pulse irregularly irregular. pansystolic murmur radiating axilla. no hand tremor. PE with infarction. It is likely that she has hyperthyroidism treated in the past (?thyroidectomy or radioactive iodine) now on inadequate throxine replacement alternatively Graves occasionally develops . Fullness in flanks. cystinosis and Farby's dx (continued dx activity). fidgety and nervous. BP. acromegaly. amyloidosis. apex 6 IC ant ax line. idiopathic. opthalmoplegia. Predominant MR with pulm hypertension left thoracotomy scar. swelling under scar RIF. 56). fine tremor of outstretched hands. lid lag. vit B def (alcoholics. porphyria. MIXED AORTIC VALVE DISEASE (9) Predominant AS Regular slow rising pulse (possibly bisferens). empeyema) Pleural bx: Abram's needle for tb/malignancy place in normal saline. Harsh systolic murmur aortic area radiating to neck. TRANSPLANTED KIDNEY (9) Usually assoc APKD. gradient on echo is unreliable in severe AR. soft S1loud pansystolic murmur LSE and or apex. Palpable rounded mass under the scar in RIF feels like kidney. GRAVES DISEASE (9) M:5F. 23. vitB12 def. sweaty palms. pleural thickening. JVP not raised. 56). arsenic posoning. causes: DM. thyroid acropachy. phenytoin. lateral tasoraphy). leprosy. opening snap. focal glomerulosclerosis (recurrence in graft common). JVP not raised. botulism. large volume and collapsing (possibly bisferens). drugs (isoniazid. chloramphenicol. poor nutrition. oxalosis (severe recurrence of stone dx). MIXED MITRAL VALVE DISEASE (9) Predominant MS malar flush.

high pitched wheeze=squawk. Graves can occur without eye signs and in elderly males. weight loss. systemic sclerosis. minimal hepatosplenomegally. dimples/depressions induced by percussion fill slowly (percussion myotonia of tongue/thenar eminence).cardiac catheterisation with LV angiography would be required to assess heamodynamic signifance of each lesion. axillary lymph nodes. Female propenderence assoc premature hair greying. aortic area and neck. pernicious anemia. Comments: Develops overtly in 2% RA. obliterative bronchiolitis (classucally dyspnoea. Organ specific autoimmune dx thyroid. Worsen in cold and excitement.. exertional dyspnoea. parasternal heave. sad. primary biliary cirrhosis. lifeless. In view of rheumatoid changes in the hands the likely diagnosis is fibrosing alveolitis associated wirg rheumatoid disease. usually FH of other 2. bronchiectasis. vasodilation. S1 loud. low glucose. premature ovarian failure. slow rising. Other features: cardiomyopathy. pulmonary arteritis. intellect/personality deterioration. progessing to honeycomb CXR. chronic active hepatitis. Can develop without hyperthyroidism . pulse irregularly irregular. expanded trinucleotine repeats Chr 19 myotonin protein kinas gene. systolic thrill at apex. hypoparathyroidism. ptosis (may be unilateral).Mixed aortic and mitral valve diseaseLeft thoracotomy scar. apex is heaving/lifting. massive confluent nodules in assoc with pneumoconiosis=Caplan syndrome). restrictive pattern. “can't keep stillâ€. Gold can induce same interstitial lung dx but reverses on discontinuing drug. shoulder girdle. cranial arteritis. difficulty opening eyes after firm closure. Hashimotos thyroiditis. progressive dyspnoea. Further investigation with echo leading to TOE +/. harsh ejection systolic murmuraortic area radiating to neck. myasthenia gravis. poor prognosis. wasting of facial muscles (temporalis. male frontal balding. early diastoli mumur just audible in aortic area and down LSE with patient sitting forward in expiration and opening snap followed by mid diastolic rumbing murmur localised to apex. slurred speech combined with tongue/pharyngeal myotonia. MIXED MITRAL AND AORTIC DISEASE (8) If 1 murmur found LOOK FOR 2ND MURMUR e. Autoimmune thyroid dx's: Grave's. Pretib mxyoedema develops usually after hyperthyroidosm treated esp with radioiodine. alopecia areata. other signs: fever. Autoimmune thyroiditis also assoc with Sjorgens. fibrosing alveolitis. proximal myopathy. palmer erythema. RHEUMATOID LUNG (8) possibly cyanosis and dyspnoea. When shaking hands difficulty releasing grip (feature of myotonia). it is not possible to determine major mitral valve lesion. Which lesion is dominant? Slow rising pulse suggests AS is the dominant aortic valve lesion. diagnosis by genetic test. diarhhoea. renal tubular acidosis. 27. systolic hypertension.autoimmune hypthyroidism. mixed conn tissue dx. intrapulmonary nodules (can become infected/cavitate/haemoptysis/rupture -> pneumothorax. all 3 fall under “hashitoxicosisâ€. testicula .g . polymyalgia rheumatica. quadreiceps. hyperinflation). enlarged intraorbital muscles. PFT reduced diffusion capacity and compliance. vitiligo. osteoperosis. WCC <5). subclinical in 50%. flow murmur. long lean. Addisons. regardless of thyroid statud pulse may be regular or irregular. course not linked to thyroid status. Ask some questions: heat intolerence. etc in the abt ax line. pansystolic murmur LLSE radiating to apex and axilla. masseter. atrophic myxoedema. fine thin hair with temporal recession. When making a fist unable to open it quickly especially repeatively. new bone formation (acropachy) on xray = soap bubbles. apical fibrobulous dx. sleepy expression). childhood choreoathetosis.Pulm Rheumatoid dx: pleural disease (exudate. spider naevi. shows anticipation (ancestors presenile cateracts). lymphocytic infiltration inc water and mucopolysacharide. 26. jvp not elevated. fatiguability. atrophic gastritis. Genetics: Aut dom. 25. MYOTONIC DYSTROPHY (8) Myopathic facies (drooping mouth. nervousness. sternomastoid. coarse spicules cf HPOA(=linear new bone formation). irritability. Fine inspiratory crackles aka crepitations on auscultation both bases. even radioiodine uptake with exception of nodules. onycholysis (Plummer's nails esp 4[SUP]th[/SUP] finger). increased apetite. chronic cough. menstrual symptoms. Investigations: thyrotrophin receptor Abs. hyperactive reflexes. Graves exopthalmos due to retrorbital fat. Rh F +ve. malar flush. DM. M>F.

frequent respiratory infection. panacinar ?iceterus.8) LOOK FOR RADIOTHERAPY TATOES Carcinoma bronchus with pleural effusion: Clubbing. auscultation: expiratory phase prolonged. thrombophlebitia migrans. encephalopathy. ? hepatomegally. hepatomegally). COPD = obstructive spirometry. Chest hyperinflated. wheezes are often heard if associated bronchial dx. dilataio superficial veins). Metastases and their effects (pain. Accessory muscles respiration. Tachypnoeic at rest. cerebellar degeneration. widespread expiratory ronchi (and may be coarse crepitations). lymph nodes palpable in R/L axilla. classical “blue bloaterâ€. dull percussion note. anemia (usually normoblastic. wasting of small muscles of R/L hand. polymyosistis. stridor (SVC obstruction. myosis. myotonia congenita (Rhomsens's dx) myotonia without other features of dyotonic dystrophy. alpha1atitrypsin deficiency (young. peripheral neuropathy. noctine staining. SIADH. no flapping tremor (unless severe hypercapnoea in which case fundi – papilloedema). Pancoast's syndrome:radiation burn to chest.pain over T1 dermatome (can be C8-T2). pulse 80 bpm. nicotine staining of fingers. suprasternal notch to cricoid distance reduced. resistant lung abscess or localised bronchiectasis. hard lymph node in R/L supraclaviculare fossa. Chronic Bronchitis male smoker. Non metastatic effects: HPOA wrists/ankles. Aut dom/recessive ion channelopathies. priximal myopathy. Possibly cor pulmanale if ankle oedema. possible Herculean appearance ?involuntary isometric exercise. trachea central. dysphagia). Forced expiratory time 8 seconds. Hyperinflated ches evidenced by use of accessory muscles on inspiration and tracheal tug. diabetes mellitus (end organ unresponsiveness to insulin). trachea central. Lobectomy: R/L thoracotomy scar. expansion mainly verticle. Trachea deviated to R/L. venous pressure not elevated (ankle oedema. pulse regular. Macloed's syndrome (Swyer-James rare unilateral emphysema following childhood bronchiolitis and subsequent impaired alveolar growth. centrally cyanosed. chronic bronchitis = cough productive of sputum on 3 months of the year in 2 consequtive years. Nicotine staining. coal dust (centrilobular emphysema – simple coal dust pneumoconiosis – only minor abnormalities of gas exchange). enopthalmos). dermatomyositis. hepatomegally if cor pulmanal present). 28. chest expansion normal. neurological signs).atrophy. clubbing. lip pursing. JVP not elevated. persussion stony dull at R/L base. Eaton Lambert syndrome). R/L Horner's syndrome (ptosis. tactile fremitus. Carcinoma of bronchus with radiation therapy : cachectic. suprasternal notch to cricoid distance reduced suggesting hyperinflation (normally >3 finger breaths). prolonged expiration. sensory loss +/. fixed engorgement of neck veins.Definitions: Emphysema = pathological diagnosis. suffused conjuntivae. trachea deviated R/L/ R/L chest expansion diminished. R/L lobectomy for removal of tumour. Normal refkexes. area of bronchial breathing. indrawing of lower ribs on inspiration due to flattened diaphragm. PTH. radiation burn R/L upper chest. lower zone. trachea central. percussion note resonant. anhydrosis. no lymph nodes. Complications : local effects: SVC obstruction (?oeema face/upper extremities. TVF and resonance increased over upper chest. 29. CARCINOMA BRONCHUS (0. chest signs normal. suffusion eyes. Percussion hypersonant obliterating cardiac and hepatic dullness. foggy city. vocal resonance and breath sounds all diminished over area of dullness. dust/fumes. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (8) Emphysema thin man “pink puffer†appearance. non bacterual thrombotic endocarditis. nicotine staining. breath sounds harsher. Expansion equal but reduced to 2 cm. expansion diminished R/L upper chest. pulse regular. Likely radiotherapy for carcinoma bronchus causing collapse and consolidation of /L upper lung. carcinoid). JVP nor elevated.PTHrP. tracheal tug. This is pancoast's syndrome due to apical carcinoma involving the lower brachial plexus and cervical sympathetic nerves. SOMETIMES decreased breath sounds over the upper/middle/lower zoneof R/L lung raises possibility of emphysematous bulla. Causes of empysema: smoking (assoc with chronic bronchitis mixed centrilobular and panacinar). gynaecomastia (?HCG secreting tumour?). stocky. ectopic ACTH. . percussion resonant. breath sounds quiet in classical emphyema.

no significant gradient on echo). trivial MR. sphenoidal wing meningioma. Murmur quietens as dx progresse/cardiac failure. Aortic sclerosis: normal pulse. myasthenia gravis. acromegaly. opthalmoplegic migraine. arteriosclerosis. 32.e.Other causes of short systolic murmur: prolapsed mitral valve. Sysolic thrill aortic area. 4. Degenerative calicification (in elderly. acute nephritis. cotton wool exudates (this constitutes grade 3 retinopathy and a diagnosis of malignant (accelerated) hypertension even without papilloedema).occasionally leucoerythroblastic). ejection systolic murmur not harsh or loud.apices. eye fixed in down and out position (and there is angulated dipliopia. Congenital (worsen during childhood and adolescence due to calification). hypertrophic cardiomyopathy. JVP not raised (unless cardiac failure). opthalmoplegia predominant=vascular if ptosis/pupil changes prominent extriinsic compression). (MS missed AS severity unerestimated) need echo. AORTIC STENOSIS (7) Aortic stenosis: Pulse regular. meningovascular syphilis) 3[SUP]rd[/SUP] nerve palsy. consider valvotomy in young.. conn's. fungal (AIDS). Cavernous sinus (Sup orb fiss) total or subtotal opthalmoplegia often painful. Harsh ejection systolic murmur aortic area radiating to neck. OCCULAR PALSY (3. Causes mononeuritis multiplex. Indications for surgery: symptoms. AV nipping (all occur in aging. mononeuritis multiplex. renal (4% . PKD). lymphomatous. apex 1cm left of MCL 5ICS (i. hypothyroidism. 30. no thrills. . acute porphyria.. HYPERTENSIVE RETINOPATHY (0. soft A2 (or absent). acanthosis nigricans. barely palpable. This is complete (NB often partial) causes unruptured aneurysm of Post comm art (or int carotid) artery painful. may be tortuous. Rheumatic heart disease (often associated mitral valve dx or aortic regurg). 4. If phaeochromocytoma screen for MEN2 and von Hippel-Lindau in patient AND families. apex undiplaced. pressure gradient 50-60 mmHg lower if EF low. myasthenia gravis. lifting lids reveals divergent strabismus. Av block in calcific aortic stenosis/post aortic valve operation/pacemaker insertion. Causes: 1. Apex Normal or Slightly displaced unless cardiac failure) with forcefull sustained heave (pressure overload). 7) 6[SUP]th[/SUP] nerve palsy: convjivergent strabismus. TB. Blood pressure low normal with decreased pulse pressure. Causes of hypertension: essential (94%). endocrine 1% (cushing's. midbrain demyelinating lesion (intranuclear opthalmoplegia commoner).: ptosis. hypertension). OCP). This is aortic sclerosis (assoc with 50% inc death CVS risk. dilated pupil. Herpes zoster. worse on reading or going down stairs. sensory loss in CN5i (absent corneal reflex) due to . vascular lesions. carotids +/. cerebral tumour or raised ICP from any cause can cause 2ry hypertension (Cushing's reflex). may need simultaneous CABG. Beta blockers as temporising measure. paraseller neoplasm. neck and extremities). increased light reflex (copper/silver wiring). pre-eclampsia). only radiates faintly to neck. 31. 2. Look careflully for MS as both conditions obscure eachother. impairment lateral movement R/L eye. hyperPTH. angulated diplopia on looking down and out. 8) Narrow retinal arterioles (normal AV ratio 1:1). arythema gyratum repens (irregular wavy bands with marginal desquamation on trunk. (outermost image comes from affected eye). Flame haemmorhages and blot haemorrhage . there is papilloedema (cerebral oedema or malignant hypertension – haemorrhages and exudates not necessary). vascular lesion (contralateral hemiplegia = Webers synddrome. miscellaneous <1% (caorctation. carcinomatous lesions skull base) 4[SUP]th[/SUP] nerve palsy adducted eye cannoot look downwards causing “one above the other†diplopia. diplopia worse on looking R/L. pruritis. varying calibre. neoplasm (assoc ipsilateral facial palsy if pontine tumour. 3. This is grade 4 retinopathy. demyleinating dx.ejection click. Associated ejection click if valve bicuspid). small volume and slow rising. polycythemia. compression by aneurysm (ectatic basilar artery – uncommon). SKEW deviation (sometimes also seen in brainstem lesions). other (sabacute meningitis.?RAS. Bicuspid aortic valve (M 60's). A2 normal +/. stenosis usually mild). subacute meningitis (carcinomatous. phaechromocytoma. raised ICP false localising sign due to long course.

3. pregnancy). 2. no retrosternal extension.. recurrent emboli (anticoagulate most MS's even if sinus rhythm). R/L lobe more enlrged cf L/R. 5. phaeochromocytoma. Diagnosis in middle aged/elderlyy patient is likely to be simple multinodular goitre which is due to relative iodine deficiency in suscetible person. palms. variable strabismus. 4. Brief high pitched early diastolic whiff). loud P2. WORSENS ON REPITITION. Sjorgens.tumor compressing 3. hyperthyroid Graves (?bruit. Diffuse goitre firm. . absent=calcified mitral valve.g. paraaminosalysilic acid). diagnosis is mitrak stenosis with previous valvotomy. Multinodular suggests longstanding. 3. children/middle aged. papilliary carcinoma (commonest. check TFT's. tachycardia. FATIGUABILITY test eye movements wuth eyes held 1 position between movements. possible subtotal lobectomy. irregularly irregular pulse in rate and volume OR sinus rythm small volume pulse. Exopthalmic opthalmoplegia (upward and outward gaze most often reduced). simple goitre (euthyroid. Opening snap: nearer S2 = tighter stenosis. later life. deterioration due to AF unresponsive to med rx). loud S1. Myasthenia gravis (?ptosis. 3. s1 will be soft) Other signs: giant v waves (tricuspid incompitence). thyroid carcinoma: 1. 2. 5. amyloidosis. ?hypthyroid facies. diffusely enlarged goitre. MEN2a(sipple's) med ca thyroid. thyroid adenoma (variable radioiodine uptake). highly malignant). inc T4. supressive thyroxine. left parasternal heave. Regional lymph node spread. carcinoma. often resectable. treated Grave's dx (?exopthalmos +/. usually previous Hashimoto's. parathyroid hyperlasia (50%) MEN 2b(aka 3) med ca thyroid . Causes solitary nodule: 1. MS accentuated by exercise. SLE. leprosy. exopthalmos. anaplastic carcinoma (elderly. JVP not raised. PAN. toxic adenoma (hot nodule. snarling smile. phenylbutazoned. clinically euthyroid (check pulse. proximal muscle weakness. 6 as travel from cavernous sinus to SOF. thyroid cysts. opening snap absence of calcium in submitral apparatus on TOE. tremor. no strabismus. 5. ataxic nystagmus distguishes from bilat CN6 palsy). haemoptysis. follicular carconimoa (2[SUP]nd[/SUP] commonest. Hashimito's dx (usually micronodular. medullary ca (rare. jerks. no ankle or sacral oedema (unless in heart failure). 4. tendon reflexes). Ocular myopathy 33. sweaty palms. count to 50 – may superficially resemble 3[SUP]rd[/SUP] of 6[SUP]th[/SUP] nerve palsy. symetrical. Esp in young female desiring later pregnancy. cold on scan).. iodine xs. young adults. esp females ?puberty. 6. middiastolic low rumbling murmur (with presystolic accentuation if NSR). 5. lymph nodes. MITRAL STENOSIS (7) Malar flush. Causes of Mononeuritis multiplex: DM. localised to the apex heard loudest in left lateral position. apex indisplaced. GOITRE (7) 1) multinodlar goitre: multinodular goitre. pulmonary iedena without cause. lid lag). intranuclear opthalmoplegia (abduction impaired bilaterally. valvotomy criteria: mobile valve: louds S1. No lymph nodes. Lithium. weak nasal voice. Cavernous sunus syndrome. 4.4. There are signs of pulmonary hypertension. pulm oedema in pregnancy (emergency valvotomy). supressed TSH). goitrogens (e. 34. Graham Steele murmur (rare 2ry pulmary incompetence. 4[SUP]th[/SUP] n palsy. blood borne mets. sometimes ACTH. thyroid carcinoma (?hard. If no recent change asymptomatic observe 6-12 months otherwise FNAC. Rheumatoid. palpable nodule in multinodular goitre. tacy. contitutional upset. 2. feel pulse to assess thyroid status) Causes of diffuse goitre: 1. sarcoidosis. usually good prognosis). Lyme dx). 5. Tapping cardiac impulse (S1). Other causes ocular palsy: 1. take up/respond to radioiodine therapy. Wegeners.bruit. good prognosis. dyshormonogenesis (6 congenital enzyme defects all rare) solitary thyroid nodule check for lymphadenopathy. eu or hypothyroid). Churg Strauss. absence of MR. Indications for surgery/ valvuloplasty:symptoms limiting normal activity. radioiodine scan (cold = possible malignancy). secretes calcitonin. fair prognosis. sweating. opening snap. de Quervain's viral throiditis (tender. 2. recent change. left thoracotomy scar. often TSH dependent so responds to thyroxine. tremor lid lag. 6. rx surgery. no bruit. FNAC. absent radioiodine uptake . normal adduction or vice versa. 3. facial weakness. bradycardia. no bruit. relative iodine deficiency. without retrosternal extension (check for bruit. large rapidly expanding mass. 3. 4.

posterior fossa SOL (papilloedema e. R/L plantar is extensor. Ataxic dysarthria with explosive staccato speech. amyloidosis. This is R/L hemiplegia. genetic screening – prophylactic thyroidectomy or annual calcitonin check. papiklloedema. This patient has had R/L thoracoplasty for Rx of TB in pre-chemotherapy era.a. 2Ry to otitis media). dysphagia. Old TB is likely cause. R/L supraclavicular scar (+/crepitations). Peripheral neuropathy. inc susceptibility to infection. syringomyelia. neuropathy (calluses). optic neuritis. reduced/absent breath sounds at R/L base. causes of neuropathic ulcers: tabes dorsalis. embolism – AF. Both aut dom. loud crepitus accompanying movement which is of abnormal range. other (yaws. Feet cold. 3. paraneoplastic . headache. tactile (astereognosis=cant recognise by feel). foot pulses not palpable.g.g. facial movements. porphyria.with past-pointing. Patient has a R/L cerebellar lesion. it is likely underlying diabetes (?fundi). hereditory neuropathy. gait apraxia. apraxia (cannot execute despite normal power/coord) e. Little or no abnormality in limbs when tested on bed. evidence periph vasc dx. visual field testing may reveal R/L homonymous hemianopia. ataxia with eyes open evidenced by rapid alternating movements (dysdiadokinesia). pedular jerks. tabes dorsalis. brainstem vascular lesion. Diminished expansion. 2 toes previously amputated. autotopognosia (parts of own body). Loss of sensation to light touch. trunk. Patient has had phrenic crush for TB before the days of chemotherapy. premotor) Constructional apraxia (hepatic encephalopathy). Cerebellar vermis lesion: widebased cerebellar ataxia and robergism same eyes open and closed (cf sensory ataxia which is wirse eyes closed). Causes: 1. May be also R/L hemisensory loss. Contributing factors to DM foot: injury. atrophy. large vessel dx (ischemia. neurofibromatosis) 36. nuro abnormalties (mucosal neuromas. gangrene). etc). abscess e. abdominal reflex diminisghed on R/L side. Other cerebellar sugns: ipsilateral hypotonia. Charcot joint:relevent above plus ankle joint greatly deformed and swollen. dressing apraxia (usually r parietooccipital|). leprosy. mutiple sclerosis (?internuclear opthalmoplegia. Phrenic crush: Expansion diminished on R/L. heel-shin tetst impaired on R/L. auditory (only recognises voice if can see/touch). marfanoid. proximal myopathy.check bp. DIABETIC FOOT/CHARCOT JOINT (7) Diabetic foot ulcer on sole R/L foot (most commonly under head of 1st metatarsal). intention tremor (increased on approaching target). gait ataxic with tendency to fall R/L. progressive sensory neuropathy (familial. visual. vibration and pinprick in glove and stocking distribution. Charcot joint (neuropathic arthropathy – gross osteoarthrosis and new bone formation from repeated minor trauma without normal protective pain response causing painless joint destruction). ocular palsy. dysgraphia (writing). 4. R/L upper chest shows deformity with decreased expansion.g. 37. urine catecholamines. small vessel dx. CEREBELLAR SYNDROME (6) unilateral cerebellar lesion: Nystagmus to R/L. R/L arm and leg weak (without wasting).phaeochromocyto. serum calcium) 35. OLD TUBERCULOSIS (6) Thoracoplasty: Trachea deviated R/L. Brain tomour (?insidious onset.g. HEMIPLEGIA (6) R/L UMN facial weakness. dullness. Parietal lobe signs: agnosia (inattention) e. bruits). Finger-nose test impaired on R/L. rare late manifestation of Charcot-MarieTooth dxCauses of Charcot joint: DM. parietal.( Corpus collosum. cerebellar signs. Bronchial breathing and crepitations. normal concavity of transverse arch at head of metatarsals is lost. dyscalculia (calculating) – post parietal lobe. pigmentation. leprosy (worldwide). loss of hair lower legs which are shiny. murmurs. Thoracotomy scar posteriorly with evidence of rib resections. skew deviation eyes. RET oncogene. causes:-CVA (thrombosis. 38. maldistributed pressure and foot deformity. megacolon. posterior circulation nystagmus. progressive sensory neuropathy. neuropathic ulcer. 2. ?evidence of 1ry e. cryptogenic). Thick callous over pressure points of feet. intestinal ganglioneuromatosis. haemorrhage . increased tone.g. hyperreflexia. reduced power. Apex beat may be displaced to R/L. crackles at R/L apex suggesting R/L apical fibrosis. dyslexia (reading). dull percussion note. Apical TB trachea deviated R/L. Clubbing). tumor. pendular arm drift rebound.

magaloblastic – pernicious anemia. lymphoreticular malignancy). periorbital puffiness and pallor). relaxation of ankle jerks (and other reflexes) is delayed and slow. achiles tendon and pressure points). hypertension these cause an association with DM and IHD. Skin rough. mention drug hx. cyclosporin). also ethanbutol. olecranon bursa. no palpable goitre. telangectasia conjunctivae. shape (oval.cerebellar syndrome (clubbing. nodule=larger papules. constipation (occasionally presents to surgeons). ataxia telangactasia (recessive progressive ataxia. cachexia. surface (scaling or eroded). GI ulcer. RASH OF UNCERTAIN CAUSE (6) Rash description routine. pulse. diarrhoea. Indictations for prophylaxis if: recurrent. 2. etc). 3. Other causes of cerebellar ataxia: hypothyroidism (?facies. alcoholism. food and high purines). base and secretion. circular. distribution. tiredness and depression. Associations: obesity. not raised. Monomorphic or pleomorphic. crusting. secondary features (lichenification. Sinuses possible. mild form in siimple hypothyroidism). paper thin skin). papule=raised. TOPHACEOUS GOUT (6) Asymetrical swelling small joints of hands and feet. pes cavus. carpal tunnel syndrome. 6 features. sulphinpyrazone) drugs started 2-3 weeks after acute episode (otherwise prolong acute attack. face. dry and inelastic with distinct yellowish tint (carotenemia). <1cm. myxoedema=accumulation hyaluronic acid binding water in dermis Hasimoto's thyroiditis. hard of hearing. Consider biopsy. abdo pain). colour (erythema. treatment: avoid aspirin causes uric acid retention unless v high doses. pustules (contain puss). decease alcohol. ask patient some questions: deafness and hoarse voice. hoarse voice. 1ry/2ry amennorhea (younger). obesity. reflexes). patient likely to have Grave's dx treated with radioiodine or thyroidectomy (scar) and is now hypthyroid (occasionally Grave's sponteously progresses to hypothroidism). Hypothyroid Grave's dx as above + exopthalmos. Visual survey. 39. colchicine (SE: nausea. Allopurinol or uricosuric (probenecid. ulcers have: shape. annulaar). generalised non pitting swelling subcutaneous tissues. crusts . croaking. macule. as above + symmetrical firm. 2[SUP]nd[/SUP] line: intrarticular/systemic steroids. Tophi on helix of ear and some of the tendon sheaths (esp ulnar surface forearm. 40. pseudodementia. Occasional severe deformity. hyperlipidemia. Dermatology terms: macule=flat curcumscribed. HYPOTHYROIDISM (6) myxoedema Overweight. how you would differentiate. Paradoxically tophi indicate dec frequency. Other feature: anemia (normochromic Fe deficient due to atrophic gastritis. circumscribed. scales. Other symptoms: CNS disorders: peripheral neuropathy. chronic arthritis. 41. 1. tophi. choreoathetosis. Discussion: DD.e. myxoedematous facies (thickened and coarse facial features. Significance of tophi Tophus proportional severity and duration. alcoholic cerebellar degeneration (nutritional). slow movements. fine micornodular goitre. scars. trigger further episides). edge. vesicles=small well defined fluid collections (bullae=large vesicles). skin. radiotherapy field marks. cerebellar ataxia. etc). Adequate exposure. menhorhagia (middle aged). character (papule. 4. . tingly. anticonvulsant toxicity (esp phenytoin nystagmus). surrounding skin (scratch marks. abx for infection. nicotinic acid. wt loss.Complications: renal dx. Emolients. 6.causes of 2ry uricemia: drugs (esp thiazides. Freidrich's ataxia (?scoliosis. carpal tunnel. severity cf non tophacouus. renal dx. likely diagnosis is Hasimotos thyroiditis (assoc autoimmine dx). absent ankle jerks). pyrimadal and dorsal colum signs. Patient has myxoedema (look for assoc autoimmune dx). severe heart failure). chronic renal failure. Rx 1[SUP]st[/SUP] line NSAIDs (except if CRF. may be loss of outer third of eyebrow (not reliable). low IgA infections. 5. normo-uricaemia not achieved by lifestyle – i. thinning of hair which is dry and brittle. angina unmasked once rx started. young with hyperuricemia FH renal/heart dx. drop attacks. weals=circumscibed elevations itchy. 5. size. epipepsy. Large tophi may have area of necrosis exuding pasty/chalky monosodium urate crystals. ocular apraxia. myeloproliferative and lymphoproliferative disorders (cell tunover preformed purines). Slow pulse (give rate). vesicle. floor. pigment). cold intolerence. tophi formation in perarticular tissues.

Glaucoma (?pathological cupping). macronodular cirrhosis (after hep B with widespread necrosis). Look for cause: high arched palate. ulcerative colitis. etc. Well defined disc edge suggests not 2ry to papilloedema (yellow grey disc blurred margins). DM). etc). large volume.preipheral cyanosis (+/. Serial echoes. S3/murmur. amyloidosis (? rheumatoid artritis or other chronic dx). Raynaud's phenomenon. Comments: should check B12. Pagets dx .g. Other signs: de Mussett sign (head nods). louder on expiration. Causes: Rheumatic fever. PBC (?middle aged female. apex thrusting (volume overload) in ant axilliary line. Autoimmune thyroiditis presents as case 1 or 2. longstanding hypertension (aortic dilatation. Other causes of hepatomegally: infection (hep A/B. lymphoproliferative (?lymph nodes). diabetes mellitus (?fundi). evidence of primary).pain. then rapidly alternate pupil and will slowly dilate). radionuclear angiography. sarcoidosis (?erythema nodosum. HEPATOMEGALLY (5) Liver palpable at x cm below right costal margin (? icterus. methyl alcohol. hydatid cysts (eosinophylia. aryl robertson pupils. hydatid cyst (?welsh connection – Nb .malar flush). question mark). sitting forward. rupture -> anaphylaxis). collapsing in character. swellin muscles after exertion and myotonia). Indication surgery: aim to replace valve before serious LV dysfunction occurs. slate grey). Quinkes signs (visible cap pulsation). adenoma). nutritional ambylopia (famine. tobacco-alcohol ambylopia.Causes: 1. lymph nodes). if none then Rheumatic/IE likely. Weils dx). Austin flint murmur=severe aortic incompetence (regurgitant jet interefes with mitral valve). scanning speech. arachnodactyly. toxic ambylopia (lead. asc aortic anerysm). 44. fasting sugar. retinal artery occlusion. arthropathy/ank spond. accident prone. congestive cardiac failure (?raised JVP. hypertension. ache. syphilitic gummas (late benign syphilis usually hepatosplenomeggaly and anemia. pychosis (myxoedema madness). Rheumatoid arthritis. 4. 2. Infective endocarditis. 42. B12 deficiency. Marfans syndrome (tall extermities. high arched pakate). SLE (?rash). calcium antagonists decrease rate of deterioration. 250-300/30-50). chest signs). thrombosis or embolus of post ciliary art. compression of optic nerve by a) tumour (pituitry ? bitemporal heminaopsia)) b) aneurysm. ankle oedema. signs of cirrhosis esp gynaecomastia. arsenic. Hurlers syndrome. syphilitic aortitis (argyll robertson pupils. secondary carcinoma (?hard nobly. deafness rare recessive inheritence). AORTIC REGURGITATION (5) Regular pulse. Wide pulse pressure e. fixed kyphosis. pupil reacts consensually to light but not directly. 6 ICS. Other causes: ischemic optic atrophy (abrupt visual loss in elderly +/. vigourous arterial pulsations in neck (Corrigan's sign). Assoc autoimmune dx: pernicious anemia (?spleen. 5. polycstic kidneydx (?kidneys?). Rheumatoid arthritis (?hands. V early optic neruritis direct pupil reflex sluggish not absent – check Marcus Gunn phenomenon (diret reflex. Grave's dx. temporal arteritis). Lebers optic atrophy (6M:1F). diastolic murmur = retrograde flow). Duroziez's sign (fem art auscultated when compressed distally. coarctation of aorta (inn assoc with biscupid aortic valve). hypoparathyroidism. ascites. haemolytic anemia. SACDC). rapid response to penicillin). DM. premature ovarian failure. lupus pernio. Addisons dx (?buccal + scar pigmentation). Freidrichs ataxia. quinine). tabes dorsalis. pigmentation. Hoffman's syndrome (pain. hypothermia. mutiple sclerosis (temporal pallor only ?nystagmus. aneurysm). idiopathoc (presumed autoimmune ?CAH with icterus etc). JVP not raised.). xanthelasma). scratch marks. primary tumours (hepatoma. consecutive optic atrophy (2ry to ganglion cell destruction) 43. nodules). glandular fever. 3. hypothyroid coma. Ank spond (male. high pitched early diastolic murmur audible down LSE and aortic area. Sjorgens (?dry eyes and mouth). nobbly hepatomegally Malignancy – 1ry or 2ry. cerebellar ataxia. insecticides. etc. tender pulsatille liver wiith giant v waves in tricuspid incompetence) Causes of hard. associated with mermemranous VSD. Field testing with head of hat pin reveals central scotoma. mild/moderate dx: ACEinhibitors. Replace valve urgently for infective endocarditis. haemochromatosis (male. clearly delineated. Optic atrophy in DM assoc with DID-MOAD (Diabetes insipidus. gynaecomastia. Common causes: cirrhosis – usually alcohol (?spide naevi. OPTIC ATROPHY (6) Disc pale. cachexia. vitiligo.

briuts. sarcoid.suggesting lesion in optic chiasm. plantars no response. Sjorgens syndrome. There is upper motor neurone spastic weakness with exagerated reflexes in the legs. 5. pyramidal tracts slightly effected. DD of MND: cervical cord compression (Cx MRI). budd chiari syndrome (?icterus. Jun 13. Lyme dx). leprosy. fasciculation of hand. after exercise in fit adults.patients name). also dorsal roots/columns. dec. steppage gait due to bilateral foot drop. shoulder. Rheumatoid. may have indistinct nasal speech. VISUAL FIELD DEFECT (5) homonymous hemianopia homonymous hemianopia. 47. occupational with leaning on elbow (clerks. Charcot Marie Tooth (champagne bottles. mononeuritis multiplex (DM. (amyptrophic lateral sclerosis). spinal muscular atrophy juvenile onset type 3 (Kugelberg Welander dx) survival motor neurone gene defect. Commentry: Wasting of small muscles pf hands due to other causes does not preserve thenar eminence. syringomyelia (dissoc sensory loss). thyrotoxic myopathy. 3. Ankle clonus. 2. May be wasting of small muscles of hand. benign giant fasciculations. hypertension). SLE. loss hypothenar eminence). chronic symetrical spinal muscular atrophy. 7. toe retraction. Following viral infection). Ankle jerks are absent. Other causes of fasciculations: cervical spondylosis. absent). 48. Causes: 1. Commentry:Variable inheritance. clawing of toes. roofer) predisposed by shallow ulnar groove. carpenter. FH: formes fruste (minor changes e. (syringomyelia. occasionally old polio. flexion interphalyngeal joints in 4[SUP]th[/SUP] and 5[SUP]th[/SUP] fingers – ulnar claw hand). weakness of extensors of toes and feet. now look at elbow for cause. Wegeners. arms. 4. papillloedema). Macular sparing therefore normal acuity. deformity>>disability. adjacent half of 4[SUP]th[/SUP] finger. 2007 #1 . secretaries on telephone). syphilitic myopathy. osteoarthrosis elbow with osteophytic encroachment of ulnar nerve in cubital tunnel -> limited elbow movement. There are no sensory signs. carcinoma. weakness sparing the thenar eminence. Only slight distal sensory sensoty loss. Sensory loss over 5[SUP]th[/SUP] finger. Sometimes scotoma 2ry to compression of optic nerve causing optic atrophy. 2. polyarteritis nodosa. fasciculation. bilateral extensor plantars. amoebic abscess (?tropical connection ?name ?appeaance). 46. MOTOR NEURONE DISEASE (5) Weakness. hx injury). AF. amyliod. emphysema (apparent hepatomegally). Condition becomes arrested in midlife. 45. Inverted champagne botle legs is more neuromythology. C8 lesion (Pancoasts tumor ?Horners). ascites. 6. Mainly motor nerves. absent ankle jerks only). constant flexion/extension elbow (bricklayer. Rarely: Talipes eqionovarus. optic tract lesion behind chiasma. Patient has ulnare nerve lesion. fasciculating tongue and palatal paralysis (progressive bulbar palsy). Causes CVA (?ipsilateral hemiplegia. palpable nerves). pes cavus. pes cavus. injuries at wrist/elbow. acute stages of poliomyelitis rarely in old polio. tumour (?ipsilateral pyramidal signs. lateral popliteal ?and ulnar nerves palpable (in some families only). Churg Strauss. syphilitic amyotrophy. darsal and palmer aspects of medial hand. but upper limb reflexes are exagerated (Progressive muscular atrophy – minimal pyramidal signs can be inc. causes 1. Reidels lobe.g. wasting. pituitry tumour (?acromeg sujitvasanth10. painter/decorater. (hyperextension at MCP joints. cervical rib (sensory disturbance v light). CHARCOT MARIE TOOTH DISEASE (5) Distal wasting of lower limbs.There is slow progression up the limbs. ULNAR PALSY (5) Generalised muscle wasting of hands (dorsal guttering. relatively preserved thighs. tenser hepatomegally). Pes cavus. neuralgic amyotrophy (eg. Bitemperal hemianopia bitemporal field defect worse on R/L. excessive carrying angle (malunion). fracture dislocation of elbow (?scar deformity. heart murmur.

2. hypopituitrism. 2. papillloedema). 1ry tumor). haemorhage/haematomomyeloma trauma. etc). heart murmur. cerebellar signs. intradural spinal neoplasm. Joinf position and vibration in tact. disc prolapse. ankle jerk absent on effected side. SPINAL CORD COMPRESSION (5) Brown sequard syndrome:difficulty walking. Soft touch. blood . Immedate dexamethasone. Pt unable to stand on toes. Nat hx: midline pain. . granuloma. lossof joint position/vibration senses on side of monoparesis. osteoperotic vertebral collapses. sarcoma. sickle cell. Lebers optic atrophy (6M:1F). carniopharygioma (calcification on skull xray). gnaecomastia. optic tract lesion behind chiasma. papilloedema causes enlarged blind spot and peripheral constriction). VISUAL FIELD DEFECT (5) homonymous hemianopia homonymous hemianopia. pinprick diminished both legs up to level of e. nutritional (famine. RECENT ONSET back pain suggests spinal cord compression requires urgent investigation. tumours: epidural (mets. 4. etc but MS frequently causes retrobulbar neuritis without other signs).suggesting lesion in optic chiasm. more on R/L with hypertonia. 3. X ray. Bitemperal hemianopia bitemporal field defect worse on R/L. menstrual irreg). Pagets. galactorrhoea. sensory loss. or normal (retrobulbar neuritis) causes: consider demyelinating dx (?nystagmus. No neuological abnormality in upper limbs. Suggests lesion in contralateral temporal cortex. T8/9 segments. radiular pain. tunnel vision. Scotoma: central scotoma. ischaemia. Macular sparing therefore normal acuity. And plantar flexion at ankle. astrocytoma. Causes CVA (?ipsilateral hemiplegia. aneurysm (glioma. hyperreflrxia (?clonus). lymphoma. coarctation aorta. briuts. mets).g. outer half of sole. 2rys). supraseller meningioma. hypertonia. Field defects occasionally due to retinal damage. 2. pituitry tumour (?acromegally. weakness. monoparesis R/L leg. spondylosis. meningioma. spinal vasc malformation. Funnel/tunnel vision: visual fields constricted with central vision presevered. homonymous upper quadrantanopia. disc is pale (atrophy). tobaccoalcohol ambylopia. tumour. RA). Sensation impaired on outer border of foot.g. loss of pain and temp on opposite side below the level of e. CT. mescular dx. Spinal disc problem due to herniation of L5 disc compressing S1 root. muscular weakness without wasting. Spinal cord compression: muscular weakness both legs. swollen and pink (papillitis). ank spond. intradural extramedullary (neurofibroma. T8 segment. Walks with trendelenburg lilmp as pelvis shifts to normal side due to weak abductors on affected side.sujitvasanth10Guest SUMMARIES CONTINUED 1. Examine fundi for retinitis pigmentisa. B12 def. extensor plantars. tumour (?ipsilateral pyramidal signs. sphincter disturbance. cirresponding calf muscles flabby with weakness of extension and abduction at hip. bilateral extensor plantars. late myelopathy from radiation. causes 1. MRI (preferred over myelograpphy) Disc herniation: R/L buttock is loose and droopy due to wasting of unerlying glutei. hyperreflexia. (occasionally seen in hysteria. AF. toxins (methyl alcohol). widespread choroidoretinitis. intramedullary (ependymoma. Theses features suugest Brown Sequard syndrome (hemisection of spinal cord from injury. ruptures spinal cord anerysm. Causes: vertebrae/discs: fracture/dislocation. Sometimes scotoma 2ry to compression of optic nerve causing optic atrophy. hypertension). atlanto axial dislocation )trauma. multiple sclerosis). glaucoma (pathological cupping). compression. DM).

impotence. high dose DST 8 mg/day 2 days supresses in Cushings Dx (pit) but not extopic ACTH or adrenal tumour. mass. petallar clonus. anticoagulants. Look for underlying steroid resoinsive inflam/autoimmune disorder. abrupt xy descent. adrenocortical adenoma (MEA1 = 1ry parathyroidism. islet cell tumor e. Cushing's dx (pituitry adenoma (basophilic or chromophobe) or hypothalamic lesion leading to XS ACTH. visual field defect). no signs above level. Diagnosis: 1. Causes: 1. acne. proximal muscle weakness. proximal muscke weakness. amyloid. treat with pre-adrenalectomy radiation. paradoxical pulse. medical Rx (metyrapone) with radiotherapy. she is hersuite. 24hr urinary cortisol. Little's dx). extensor plantars (? abdominal reflexes. everted umbilicus. severe dehydration). disuse atrophy). Freidrichs ataxia (?pes cavus.5 mg/day prednisolone for >3 months or immediately if >15mg/day. kyphosis. 2. acute disseminated encephalomyelitis. clear lungs. oedema). bisphosphonates. ovarian and gastrointestinal – hard nobbly liver. .g. Rare causes 4. thin skin (skin fold on back of hand). truncal obesity. ectopic ACTH secreting non endocrine tumour (oat cell ca of bronchus (wt los. Meigs syndrome (ovarian fibroma – surgically treatable). diabetes (fundi). 5. with deep voice. Devic's dx. chest signs. trauma (?scar. ASCITES (4) Generalised swelling abdomen. OCP. Other: syringpmyelia (kyphoscoliosis. transverse myelitis. 3. stretch marks pregnancy). cardiomegally. ca pancreas. back/neck pain. Birth injury (cerebral palsy. Budd Chiarri (rapid ascites. cachexia. leuconychia – Rx diuretics spirinolactone. underlying tumor. ankle clonus. MRI. cirrhotics). Last resort bilateral adrenalectomy risks Nelson's syndrome (unsupressed pit tumour mass effect. peripheral oedema (salt retention). Treatment: transpheniodal hypophysectomy (usually microadenoma) 80% cured. establish cause. CRH test – cushings dx 50% inc cortisol. 3. intoduce blood / foreign sustances intrathecally. e. spinal arachnoiditis. vertebral collapse. carcinoid tumour (usually bronchial). 65+. loss of height). TB peritonitis (?ethnic origin. CXR calcified pericardium). buffalo hump. Malabsorption). dysdiadokinesia). Dex supression test. pituity tumour). stocatto speech. progressive necrotising myelopathy (young adults with acute illness/malignancy). Zollinger Ellison. gait). slender build. diabetes mellitus. cx spondylosis). MS. fluid thrill. non teratomatous ovarian tumour. back pain (osteoperosis. deformity of back). Causes: 1. ankle/sacral oedema. purple striae on abdomen (cf pale pink in obesity. 6. myxoedema (?facies. cerebellar signs. central resonance. therapeuric ACTH. wasted hands. CUSHING'S SYNDROME (5) Moon face. . UC. hepatomegally – pulsatile if TR. For all patients >7. 4. Best signs: easy bruising. polycythemia rubra vera. Congestive cardiac failure (??raised JVP.smooth hepatomegally no chronic signs. murmur) Other: neprotic syndrome (?young. fasciculations). RF: longterm steroids. bronchial adenoma. flanks stony dull on precussion . S3. endocrine disorders (Cushings. premature menopause <45. prophylaxis for osteoperosis: HRT women. aioride. tachycardia. 2. pigmentation. Motor neurone dx (?no sensory signs.dyscrasia. thyrotoxicosis) 4. dissociated sensory loss. icterus. difficult rising normally from squatting. pigmentation (esp ectopic/exogenous ACTH). 2. 5. 2. 3. 3. intrabdominal malignancy (esp. therapeutic corticosteroids. overnight/low dose dexamethasone suppression test. cord compression (?sensory level. nodes. . ant spinal art thrombosis (sudden onset. cirrhosis and portal hypertension (?hypatomegally icterus. dissociated sensory loss yp to level). testosterone men. other features: hypertension. often pigmented due to ACTH. immobility. chylous dx (lymphatic obstrction) 5. pancreatic dx. constructive pericarditis ((JVP. MS (nystagmus. Normal response is supression with low dose 2mg/day 2days or overnight DST 1mg night before. hypoalbuminemia (e. 20% of FalsePos. SPASTIC PARAPARESIS (4) Increased tone legs. Causes of Cushings: 1. loud early S3 (pericardial knock). Trosier's sign). cmmalcitriol. ataxia. ankle jereks – v rare). Horners syndrome).f. inflamatoryspinal osteomyelitis. amenorrohea. collagen dx). parascentesis. adrenocortical carcinoma. low trauma fracture. low K alkalosis. pychiatric disorder (commonly depression). chronic dx. excessive bruising.g. shifting dullness. loss of circadian rhythm. weak (if chronic contractures. irregullar menses. spider naevi. TB/Potts dx spine.

fixed kyphosis compensatory extension cervical spine to keep visual axis horizontal. 2. Discussion: 8M:F. lacunar state. 3. tends to fall to R/L. no argyl robertson pupils). normal pressure hydrocephalus. R/L arm flexed. Look at eyes for iritis. aortic incompetence. Old polio (?effected leg short due to polio as child). 4. extensor plantars). Rombers test negative. with each step tilts pelvis to other side to keep toe off ground. shuffling and lost its spring. This suggests weakness of proximal lower limbs and pelvic girdle. lifts right foot to avoid scraping toe because he has R/L foot drop. suggests cerellar dx predom R/L (finger nose. toe scraping floor. SACDC (?pyramidal signs. when asked to turn to side whole body turns as a block (rigid spine). pelvis dropping on each side as foot leaves ground. 3. 2. sensation to confirm) Causes of spastic paraplegia: demyelinating disease. absent ankle jerks. Ataxic. hip. 4. Freidrichs ataxia (pes cavus. other cerebellar degenerations (?Freidrichs ataxia – pres cavus.e. Causes: demylinating dx. esp during heel to toe test which he fails. neither turning or straight walking is fluent. He has Parkinsons dx. Distance normally increases >5cm on flexion. cervical myelopathy (?mid cervical reflex pattern in arms. 87% HLA B27 positive (50% 1[SUP]st[/SUP] deg relatives . alcoholic cerebellar deterioration. Lead. placing feet flat on the ground like walking on ice (sticky feet. chest for apical fibrosis.Spastic gait stiff. tendecny to retropulsion (therefore inc risk falls). SACDC (?post column loss. dysdiadokinesia. chest expansion reduced. held tightly to side. Difficulty walking heel to toe. 6. plantars. This is gait apraxia. ataxia worse on closing eyes. vacant expression. polymyositis. scoliosis. (examine tone. both heels and toes slap on the ground). Steppage gait: steppage gait. Arms held flexed and do not swing. occiput test (against wall). absent ankle jerks and peripheral neuropathy. gait festinant (i. rickets/osteomalacia. taboparesis (?Argyll Robertson pupils. spleen. trunk moves side to side. Commest causes Duchenne muscular dystrophy. 2. cord compression. 2 marks 5 cm above and below. Waddling gait: lumbar lordosis. Heavy metal poisoning e. loss lumbar lordosis. stooping gait. Charcot Marrie Tooth dx (?pes cavus. cannot hop on 1 foot. tremor often unilateral. elbows lead piping. 4. pyramidal signs if taboparesis present). hereditary spastic paraplegia. Schobers test – sacral dimples . Gait apraxia (magnetic gait) elderly person with briad based gait. arms held wide (upper and lower limbs tend to shake). ABNORMAL GAIT (4) Cerebellar ataxia wide based gait. About to fall forward. distal leg atrophy. Hands show pill rolling tremor. unblinking and stiff. forefoot flops to ground before heel. Hemiplegic gait: R/L leg stiff. non metastatic sydrome of malignancy (esp bronchus). Hereditary spastic paraplegia (rare). general paralysis of the insane (?dementia. cerebllar signs). stocatto dysarthria). Causes: 1.g. pupils. reflexes.kyphoscoliosis). Walks on a wide base. trombone tremor of tongue). (look for frontal lobe signs dementia. peripheral neuropathy. fist clenched. Tests:Fails Heel. anemia). Tabes dorsalis (?facies. kyphoscoliosis. Parkinsonian gait: face depressed. anemia. Suggests sensory ataxia (look for argyl robertson pupils. anemia). AIDS myelopathy (late phase – direct HIV CNS involvement). cerebral diplegia (rare). This is hemiplegic gait. HTLV1 (afrocarribean pops – tropical spastic paraperesis). Unable to walk on his R/L heel. Sensory ataxia taxic and stamping (feet tend to throw. Rombergs positive. initially hesitent. awkward sissors or wading through mud gait suggesting spastic paraplegia. increased diaphragmatic excursion causing prominent abdomen. Causes of foot drop lateral popliteal n palsy (?injury below and lateral to knee). suck and grasp reflexes). nystag. takes short steps. subdural hematoma. ANKYLOSING SPONDYLITIS (4) Male. (wrists cog-wheel rigidity. 3. Toes reach ground before heel. 5. R leg describes semicircle. absent ankle jerks. parasagital cranial meningioma. 6. demylinating dx (ataxia in MS is usually mainly cerebellar). magnetic gait). tumour. tumour. palpable lat pop +/ulnar neerve). post column loss) . watching his feet and the ground. glabellar tap sign) in milder cases lessor swing of arm. 7. expressionless. wide based waddling gait. (rare). Causes/l degen dx similar to Alzheimers. pyramidal signs in legs). hand muscles wasted. Diabetic pseudotabes (?fundi). stooped question mark posture.

sometimes diazepam. rigidity. 10. 3. cerebellar. 7. hands and feet (lips. dystonic spasms/posturing. fundi dilated retinal veins.auscultation normal breath sounds. abnormal O2 release (2. slurred low volume monotonous speech. Discussion: 3M:1F. 9. deep aching pain. idiopathic – triad: urinary incontinence. tracheal narrowing (extrathoracic): acute (infective epiglottitis. dementia – CT/MRI diagnosis consider ventriculosystemic shunt). 1ry polycythemia: raised red cell mass. pernicous anemia). PD often misdiagnosed as benign essential tremor (aut dom. rbc. RtoLshunt. plt. mild extrapyramidal). dysphagia). tongue. improves with alcohol. splenomegally (70%). 5. Features: tremor. with permission pull down lower lid – conjunctival vessels engorged. once startedshows quick shuffling steps trying to keep up with centre of gravity.tendency to fall backwards. Positive glabellar tap. apical fibrosis. b and HCTall elevated. intralluminal mass/neoplasm. no added sounds. meningitis. no other focal abnormality. signs generally asymetric (decreased by intention. chest expansion normal. Low MCV (iron stores depleted). neoplasia. vitiligo. Difficulty starting walking (freezing). bronchial stenosis.3 DPG deficiency. trauma (FB. dysarthria. tracheomalacia). treulous untidy. Manganeses poisoning). cateracts). Echymosis (spontaneous bruising). Causes of Parkinsonism: drug induced. cerebral tumours affecting basal ganglia. interfence tissue O2 metab (cobalt poisoning). drroling (hypersalivation. sacroiliitis. Steele-RichardsonOlszewski syndrome(supranuclear gaze palsy. Alzheimers dx (severe dementia. neurosyphilis. arterioscclerotic Parkinsons. Stiff-Man syndrome: rare disease severe progressive muscle stiffness. carbon monoxide. resonance normal. axonal brain damage (cardiac arrest. SAH. propranolol). cardiac conduction defects. achiles tendinitis). sluggish pupils. PARKINSONS DISEASE (3) Expressionless. dementia if untreated). unblinking face. bradykinesia (touch thumb with each finger – slow initiation. stratonigral degeneration: part of mutisystem atrophy (autonomic failure. cannot perform 2 motor tasks simultaneously. 2ry polycythemia: Phyiologically apropriate: arterial hypoxemia (COPD. lead pipe rigidity at elbow. blood pressure raised. thyroid. smoke inhilation). musous membranes). ovarian. Phys inappropriate neoplasm (renal. 60% anti GAD ab positive. cirrhosis.) handwriting small. phaeochromocytoma). secondary amyloidosis. hepatocellular. chronic (neoplastic. Tracheal stenosis causes: congenital (webs.HLAB27. STRIDOR (4) Comfortable at rest. hydronephrosis). photophobia. scatch marks (pruritis). 6.g. 9% sacroilitis). initially asymetrical peripheral arthritis large joints. croup). traumatic fracture/atlantoaxial subluxation. iritis (acute. titubation. POLYCYTHEMIA RUBRA VERA (4) Facial plethora. 3. tends to fall. postencephalopathic. Likely tracheal stenosis following prologed ventilatory support. axial rigidity. smokers COHb). post trauma. fatiguability). wcc. better on exercise. 4. redness. Resp rate 12. low back pain worse on waking. dusky cyanosis face. circumcorneal conjuctival injection causing synechiae. Expiratory stridor (lower intrathoracic obstruction: FB. normal pressure hydrocephalus (head injury. 6. does not swing arms. gait apraxia. chorea. Inspiratpry stridor: upper airway obstruction. stooped. spine lower extremities superimposed muscle spasms trigerred by ext stimulus/emotion – falls like tin soldier. hemangioblastoma. continous pill rolling tremor. aortiitis. extrarticular manifestaations: 1. aquired (tracheostomy or intubation). exlude 2ry causes including psuedopolycythemia dehydration). 4. Management: refer for rigid bronchoscopy to thoracic surgeon for dilatation and/or stent insertion or primary reconstruction. enthesitis (plantar fascitis. Diseases with Extrapyramidalfeatures: 1. healed tracheostomy scar. lower tracheal stenosis. olivopontocerebellar atrophy). intention tremor worsened by stress. from bedside noisy high pitched sound with each inspiration. TB). cogwheeling at wrist. 8. post infection (e. 5. psychotic behaviour. Jakob-Creutzfeldt dx (prion . 2. subtle dementia/frontal lobe syndrome). EMG characyeristic. Starts <45yrs. 2. non neoplastic dx cysts. Age 30-50 respons to bdz. pyramidal signs. tracheal stenosis). Also seen in aotuimmune condition DM. pickwickian syndrome). poor balance. Wilsons dx (Kyser-Fleisher rings. blephroclonus (eyeslid tremor when gently closed). hepatomegally (40%).

possible thrill. amyloidosis (hypoaadenalism preceded by nephrotic syndrome). Abdominal reflexes absent. Left parasternal heave. bilateral adrebalectomy. mitral middiastolic flow murmur in large shunt. AIDS related hypoadrenalism: adrenal haemorrhage (newborns esp breech. Most likely diagnosis is demyelinating dx (useful euphamism) Spastic paraparesis: ? middle aged. slight upper limb dysdiadokinesia. onest with optic/sensorimotor (i. Conxlude with heamodynamic significance. in nipples and pressure points (also periorbital). Apex displaced half way bttween mid clavicular and ant ax line. Raynaud's. Muscular septum defects close spotaneously duting childhood. azathioprine. CPU). Benign course: if pure sensory presentation. pernicious ane. lupus. 13. fatigue. cortical blindness. worsens with temp. Palmer). Other features like polymyosistis. rheumatoid arthritis. Loud p2 if pulm hypertension. myopathy. buccal mucosa. increased tone. granulomatous dx (rarley sarcoidosis).Investigations: Check VEP's (delayed). downs. extensor plantars. urine creatine.lymphocytosis up to 50 cells/mm3. subacute. encephalopathy. possible pulmonary regurgitation. high dose iv immunoglobculins if refractory. Pansystolic murmur LSE. ionternuclear opthalmoplegia. CSF oligoclonal bands in CSF but not in serrum. stroke. skin/muscle calcification. polyphasic action potentials. spasticity). MRI scan best imaging modality. MULTIPLE SCLEROSIS (3) Cerebellar syndrome: ?young adult. acute SBE. 5% assoc AR. Eisenmengers complex. adrenal vein thrombosis after trauma/venography). extensor sirfaces elbows/knees. Treatment: steroids (initially high dose). 8. meningococcal and pseudomonal sepsis. Juvenile form occurs 1st decade. VENTRICULAR SEPTAL DEFECT (3) Often young patient. 12. ADDISONS DISEASE (3) Generalised pigmentation due to ACTH increasing melanin. Suggests spastic paraplegia due to demyelinating dx. not assoc malignancy. insidious). Investigations: muscle enzymes (aldolase. Percutaneous transcatheter closure. unpredictable course (acute.ia. 21OH def -> neonatal salt wasting. cerebellat ataxia. brain tumour. GI tract). in scars (esp recent ones).g. contractures. Other features of VSD Maladie de Roger. Diagnosis Addisons or Nelsons (?temporal field defect. subcutaneous/ intramuscular calcification. scleroderma. NOT cerebellar/brainstem). Discussion: 2M:3F. EMG (fibrillation. also aidible at apex. Lhermitte's phenomenon (Tingling down spine on bending neck). rapidly progressive dementia. infrequent relapses. muscle biopsy. hypoparathyroidism). associated malinancy (current recommendation 40+ yrs investigate for breast. Discussion: 2M:F May present with pseudohematuria (myoglobinemia).11. hypoparathroidism (basal ganglia calcification).g. weakness. raynauds rare. normal JVP. bilateral clonus. DERMATOMYSOSITIS (3) Heliotrope rash. Associations acute MI with septal rupture. Pyramidal and dorsal column signs. benign condition after 5 years. remitting (66%). low bp. multifocal neuro signs – aphasia. over eyelids and periorbital areas. comgenital adrenal hyperplasia (inherited defects e. and fingernails (prominent nail-fold telangectasias). <1g/l protein. Subcutaneous oedema (mainly eyes) proximal muscle weakness +/tenderness. temporal pallor of discs. Causes of 1ry hypoadrenalism: autoimmune adrenalitis.). ESR often normal. ambiguous genitalia in females). anticoagulants). myoclonus. paroxysmal symptoms may respond to carbemazepine. ataxic nystagmus. arthralgia. Causes of Skin pigmentation: racial including skin .e.dysphagia due to upper oesophagus involvement. other conn tissue dx – steroid responsiveness more likely). secondary deposits. Oligoclonal bands also in infection. back of hands especially knuckles (Gottron's papules=flat topped violaceous papules). slurred speech with ataxia and widespread cerebellar signs. more marked in skin creases (e. turners.(heliotropum=fragrent purple flowers). usually euphoria despite disability. DM. long remissions. ovary. high freq bizare discharges). ?abdominal scar for bilateral adrenalectomy). regular pulse. overlap with Rheumatic fever. rare in tropics. may have associated premature ovarian failure and vitiligo (also associated with thyroiditis. petellar clonus. heel-shin test suggests some ataxia in legs. lung. Fundi may show involvement. TB (?lung signs). haemochromatosis. bilateral spasticity. 14. fungal dx (histoplasmosis).

palatal lesions) Facial weakness includes frontalis (raise eyebrows). Discussion: Life expectency 40 years. appendix abscess (investigate with US). thyrotoxicosis. flat feet. colonoscopy). LMN FACIAL PALSY (2) On the R/L side there is paralysis of upper and lower face. malabsorption. somewhat pale adult. long narrow face. moves with respiration?. colonoscopy). non tender hard mass. This is Crohn's disease. bimanually ballotable?. splenomegally. 4) Mass RIF: young. recurrent dislocations). ovarian tumour (US.(lips and tongue drawn opposite side). amiodarone (grey). needs CT).e no dissection). Tremor of the iris (iridodenesis) often only visible on slit lamp suggesting lens dislocation. Causes: illiocecal TB (?asian ?chest signs). amoebic abscess (?travel). disscetion can occur) Other signs: heterochromia of iris. shape. Pulsatile mass: vulsatile abdominal mass (anterior and transverse) 6x4 cm palpable 2 cm above umbilicus reaching to epigastrium. lymphoma (generalised lymphadenopathy. apical fibrosis. hypotonia (+/. freely mobile 5x4 cm (measure) firm non-tender mass RIF. Femoral pulses palpable just before radials (i. myopia. OGD). no organomegally. the ee turns up on attempted closure (Bell's phenomenon) and unable to to raise R/L eyebrow. volunatary and involunatey movements of mouth paralysed on R/L. so the eye cannot be closed (or can be easily opened by examiner. 2. Mass in upper abdomen: define size. MARFAN'S SYNDROME (2) Tall with disproprtionatley long extremities (pubis-sole > pubis-vertex). chronic infection esp TB. hepatomegally. chronic arsenic poisoning). no fitulae. drugs (phenothiazines (blue-grey). aspergilloma. lymph nodes eksewhere.g. occipital). Likely AAA commonest cause atherosclerosis. genu recurvatum. May have collapsing pulse. Must differentiate from renal mass. minocycline (purple-blue bone and blue oral discoloration). Asthma). lymph nodes. faecal mass. ovarian tumour (US/CT). cervical. Aut dominant. decreased subcutaneous fat. osteoperosis. Causes: 1. Bells palsy. No abdominal organs enlarged. diverticular abscess (?tender). This is probably a diverticular abscess – usually tender. tender?. Corner of mouth droops. look for PVD in feet. retroperitoneal sarcoma. lymphoma (generalised lymphadenopathy. Look for heerpes in ear/on neck (trigeminal. ABDOMINAL MASS (2. Causes: carcinoma colon (non tender. no hepatosplenomegally. 15. ileal carcinoid (rare) Mass LIF: ekderly patient with freely mobile 6x5 mass in LIF. aortic coarctation. (Troisier's sign. Homocystinuria can appear similar (other abnormalities mental retardation. investigate CT). carcinoma pancreas (?icterus. lymphoma (?hepatosplenomegally. endocrine (ACTH therapy (e. Investe with: US/CT. no bruits over mass or femorals.. antimalarials (blue grey). fibrillin defect Chr 15q. Meischer's elastoma (smooth nodules/papules in neck skin). Does not move with respiration. spleen or liver. mitral valve prolapse. stapedius paralysis causes . retinal detachment. arhyria. carcinoma caecum (?older person. Taste preserved in mild Bell's palsy (swelling nerve in facial canal). hepatosplenomegally. 16. extopic ACTH).pigment. sun tanning. 17. malar flusj. bronchiectasis). Ramsay Hunt syndrome (herpes zoster on ext aud meatus and geniculate ganglion – taste ant 2/3 tongue lost +/. get above?. bullae. hypertextendable joints. elongated fingers and toes (arachnodactyly). inguinal/femoral hernia. spleen). beta blockade decreases development of aortic complications in some patients. Check for cervical lymph nodes ?Troisiers sign. needs CT). Epigastric mass: round hard non tender mass 8x6 cm with ill defined edges in epigastrium. uremia). chronic debilitation (malignancy. Urine cyanide-nitrprusside test positive). cystic lung disease (pnemothorax. auscultate for AR (cystic necrosis of aortic media. more severe taste lost. cytotoxics. span greater then height. orbicularis oculi (close your eyes tight). consistency. Cushings dx. corrugator superficialis (frown). Causes: carcinoma colon. bacterial endocarditis. pectus excavatum. ? courvoisier's sign – palpable gall bladder unlikely stones. Underdeveloped musculature.funnel/pigeon chest. Causes: carcinoma stomach. cirrhosis. CT). DOWNWARD lens dislocation (Marfans upgoing). kyphoscoliosis. cannot bury eyelashes). high arched palate. pigments (haemochromatosis – slate grey. amoebic abscess. nasolabial fold smoothed out.

misc (postpartum. taste not affected. -ve angiogram. osteoarthrosis (?related to old fracture). Lofflers endocarditis.8 palsy. |Cushings. surgical decompression. vascular lesion). myasthenia gravis (?ptosis. Differetial Diagnosis: mutiple extrasystoles (only 1 pause at a time. Intensity enhamced by minimal exercise. numbness or paresthesia in palm and fingers. heamochromatosis. 3.hyperacusis).Non invlovement of forearm flexors i. ischaemic heart disease (esp MI). acromegally (?facies. role of cardioversion. middle ear dx (deafness). gaucher's. mucopolysaccharideosis. carcinoma. rickettsial. Causes of AF: 1. peripheral radiculopathy. acromegally. Investigation: nerve conduction studies Treatment: intrcarpal steroid injections. thrill at left sternal border. look at neck (goitre). sarcoid. There may be mitral regurgitation. parotid tunour (?palpable. pallegra. muscular dystrophies) .). DM). some muscular dystrophies. pAN. hemiplegia).e. uremia. local neoplastic infiltration (paricularly lymphoma). heart. Rheumatoid arthritis (?spindling of fingers. thyrotoxicosis. Weakness of abduction. Tennels sign to confirm (percussion paraesthesia). sinoatrial (sick sinus syndrome) disease with primay involvement of conduction tissue. rheumatic heart disease. corticosteroids. heart block). obesity. large spade-like hands. Treatment: anticoagulation (see latest guidelines). normal volume (jerky if very severe(. lithium. just lateral to MCL. dilative often 2ry to IHD). Casues: Guillain Barre. ruptured Baker's cyst. multiple atrial ectopics with shifting pacemaker. pregnancy. MND (rarely). proximal muscle weakness). hypertensive heart disease. Colleagen dx (SLE. Causes: idiopathic (females. 18.. cardiomyopathy (idiopathic i. etc). Whipples dx). 4[SUP]th[/SUP] heart sound. hoarse voice. Amyloid. viral.e. cerebellar signs. middle aged obese. joint. mononeuritis multiplex (DM. glycogen storage dx. 7. eyes (exopthalmos). pulse. ejection systolic murmur (may be harsh) over left 3[SUP]rd[/SUP] interspace. . fibroplastic (endomyocardial fibrosis. endocrine (thyrotoxicosis.7. phenothiazines). JVP not elevate (may show a wave). tophacous gout. SLE.meningoencephalitis. sarcoidosis. hypothyroidism. myxoedema) and rheumatoid arthritis. myxoedema. pontine lesion (MS. 5. 6. forcefull apex 5ICS. treatment aim (rate control vs cardioversion). sob. tast loss ant 2/3/ tingue). tuberculous tenosynovitis. hemianopia). constrictive pericarditis. Phallens sign (flex wrists 1 minute). tumour. leprosy). radiates WIDELY to base and axilla. knee effusion. Causes of cardiomyopathy: 1. genetic (HOCM. may be double apical impulse caused by a strong presysolic impulse of atrial systole). paroxysmal atrial tachycaria with block. complaining of pain. mycobacterial). trauma. peripheral radiculopathy. males with unaccustomed hand use). Lyme dx (classic bilateral CN7+/. ATRIAL FIBRILLATION (2) Pulse is . bilateral LMN CN7 palsy easily missed as no asymettry. variable strabismus. cingenital facial diplegia. Differential diagnosis:cerebellopntine angle compression (acoustic neuroma or meningioma 5. A flutter with variable block. Myxoedema (?facies. OCP. adriamycin. infiltrative (myloidosis. Rheumatoid. younger women excessive hand use. autonomic neuropathy. gut (rectal bx). Sensory loss over palmer three and a half fingers and wasting of thenar eminence. neoplastic./min and irregularly irregular in rate and volume suggesting atrial fibrillation with a controlled ventricular response (uncontrolled if >90). icessent atrial tachycardia). metabolic (thiamine deficiency. 4. cyclophosohamide. primary amyliodosis (?peripheral neuropathy. thick nerves.6. face (mitral faces. bilateral Bell's. chest (thoracotomy scar).PAN. carcinoid). Discussion: chorda typani:leavesfacial nerve in middle to supply ant 2/3 tongue. 19. 9. HYPERTROPHIC CARDIOMYOPATHY (2) Regular or irregular pulse. electrolyte imbalance).. kwashiokor. ulnar deviation. infective (viral. CARPAL TUNNEL (2) Stout middle aged lady. torniquet test (2 minutes above systolic -> parethesia). Discussion: symptoms: asymptomatic. nodules). sarcoidosis. particularly bad at night. Churg Strauss. Toxic (alcohol. Sup petrosal branch leaves before this to supply lacrymal gland and stepdius. prophyria. emetine. 2. may be abolished with exercise cf AF which is worsened).. acute infection esp lung. Wegeners. 20. Check for facies (acromegally. flexion and opposition of thumb. Can flex DIP thumb) suggests carpal tunnel syndrome. ankle jerks).

TARDIVE DYSKINESIA (2) Elderly patient with chronic schizophrenia with stereotyped tic-like orofacial dyskinetic (involuntary movements) including lip smaking. jerky. bilateral clubbing.eads). syncope often after cessation after exercise (decreased CO or VT) cf aortic stenosis DURING exercise. poor survival. substituted benzamides (metoclopromide). lymphagioleiomyomatosis. Neuroleptics that ihibit dopamine: phenothiazines (chlorpromazine). LAD. Spirometry recording book. bronchiolitis obliterans syndrome – progressive obstruction rapid progression. This is chorea. Echo: asymetrical septal hypertrophy. bilateral clubbing. septal thickness >18 mm. rate limiting calcium antags. sarcoidosis. Graft dehiscence). Treatment: beta blockers. family history). 23. right thoracotomy scar. . left base dull to precussion. No effective treatment immuosuppressives commonly tried.min nasal cannulae. few scattered inspiratory squeeks right lung. Risk factors of poor outcome: syncope. dementia. Bronchiolitis obliterans syndrome: middle aged woman with right lung transplant increasingly breathless over last few months. drug induced chorea . tardive = not occuring till 3 months. CXR – normal or left atrial enlargement. offer 1[SUP]st[/SUP] deg relarives screening. accentuated by activity preventing relaxation and distorting movement. chewing. drug side effects – azathioprine. corticosteroids. often de novo. Aspergillus. RR=12. Restrictive lung disease: pulmonary fibrosis (idiopathic. akathasia (restlessness. abnormal posturing of hands (wristr flexed.g. bacterial. Oxygen 2l. Acute rejectiion=non productuve cough. precussion and breath sounds normal. Movements flit to dofferent parts of body randomly. Causes: sydenham chorea (5-15 yrs old. abrupt. midline sternotomy. HSV. alpha1antitrypsin deficuency. ventricular arrythmiad. there may have been recurrent episodes of acute rejection now developed borchiolitis obliterans syndrome requiring large doses of steroids and continuous oxygen therapy. septal hypertrophy (Q inf and lat precordia. secondary to connective tissue disease. other – pneumocystis). butyrophenones (haloperidol). unease).g. tall QRS midprecordial leads. responds to anticholinergics rather than Ldopa) 22. FH sudden death. Parkinson's syndrome (tremor less common. ?heart murmur. other neuoleptic induced extrapyramidal reactions: acute dystonia (soon after starting drug e. CHOREOATHETOSIS (2) Brief. There may be choreoathetoosis of limbs and trunk.palpitations.Complications: perioperative (e. rejection – hyperacute (within hours). age 30-40. pouting and grimacing. may occur during preg or OCP). irreversible airflow obstruction. fingers hyperextended at MCP joints). general air of restlessness. pacing (ICD for high risk individuals). present at rest. may be on active transplantation list – llok for a bleeper. bronchiectasis. outflow tract gradient >40 mmHg. systolic anterior motion of mitral valve leaflet. poor bp response to exercise. malaise. quasi purposeful involuntary movements (do not integrate into a coordinated act). LUNG TRANSPLANT (2) Successful lung transplant: young man (major operative procedure for severe chronic respiratory problem) not breathless at rest. fine inspiratory crackles to mid zones left lung. reserpine. 1/3 Hx Rheumatic fever. It is likely patient on sustained phenothiazine treatment for at least 6 months. features of Cushing's syndrome. Suppurative lung disease includes cystic fibrosis. I suspect cystic fribrosis with successful double lung transplant. Obstructive lung disease (emphysema. unable to protrude tongue (darts in and out). chronic allergic alveolitis). RR=18. Langerhans cell granulomatosis.Inidcations for Lung transplant: pulmonary hypertension:primary. huntingtons chorea (often lower limbs. dyspnoea. reduced TLC and gas transfer. oculogyric crisis). dizziness. angina. 21. myomectomy. septal ablation. Consider retrasplantation. ECG normal in 25%. or secondary to systemic disease and Eisenmengers syndrome. fungal – Candida. variable penetrance. infection: viral (CMV. When the upper limbs are raised there is pronation of the forearm. reduced exapnsion both lungs. Suggest lung transplant for pulmonary fibrosis. tetrabenazine. acute (common 1-2 episodes in first 6 months###BOT_TEXT###. dancing gait. cyclosporin. Discussion: Condition often persists even after drug withdrawn. HCM = aut dom various myosin genes. equal expansion bilaterally.

assoc exanthem. spinocerebellar degeneration. resp. dystonia (sustained deforming spasm e. hepatic).(neuroleptics. myoclonus (shock-like jerks e. senile chorea (idiopathic orofacial dyskinesia no dementia). carbon monoxide. occasionally face. scoliosis).. salbutamol). L-dopa). intracerebral tumour (?pyramidal. torticollis. subacute encephalitis). other(epidemic encephalitis. post-thlamectomy. tremors (PD. digits. metabolic (renal. .g. physiologic (sleep. drugs (alcohol. Wilsons). idiopathic hypocalcemia. tics. caffein. papiloedema). some may result on lordosis. SLE. exrecise. throtoxicosis.Hemichorea/hemibalism: CVA (? hemiplegia. MS. essential familial. essential/familial).g. tongue). hemianopia). CVA. chorea. thhyrotoxicosis. Other dyskinesias: athetosis (slow coarse irregular writhing muscular distortion hands. Epilepsy. feet. anxiety). trauma.