Documentos de Académico
Documentos de Profesional
Documentos de Cultura
27 May 2016
10 EXAMINATION TOPICS
MEDICAL EXAMINATIONS
Knowledge is needed but not small print
Clinical problems the basis of study
Common conditions are common!
Patients cannot be manufactured!
Read on bedside clinical problems
Do not learn answers to MCQQ but read around
the stem of the question
Indirectly provide Questions and answers
MEDICAL EXAMINATIONS
Focused on clinical diagnosis mainly by
determining site of lesion on history and
examination
Non neurologists used to quip that you make a
brilliant diagnosis and you are stuck because there
is no treatment
Concentration on diagnosis confirmed by CT and
MRI kindled new interest
Now diagnosis is not a challenge but
MANAGEMENT is.
CONTROVERSIES OF NEUROLOGY ARE MAINLY
CENTRED AROUND MANAGEMENT
POST GRAD EXAMINATIONS
In the past, clinical diagnosis orientated
With modern advances and technology,
diagnosis is more investigation oriented
Hence both clinical and written exams are
more management oriented
Management = appropriate investigation and
correct treatment
ACP- AMERICAN COLLEGE OF
PHYSICIANS
MKSAP 17 2015
MEDICAL KNOWLEDGE SELF
ASSESSMENT PROGRAM
American College of Physicians (ACP)
Medical Knowledge Self Assessment
Program MKSAP 17
American College of Physicians (ACP)
Medical Knowledge Self Assessment
Program MKSAP 17 10 topics
Headache and facial Movement disorders
pain Multiple sclerosis
Head injury Disorders of spinal cord
Seizures and epilepsy Neuromuscular
Stroke disorders
Cognitive impairment Neuro-oncology
#1
stroke
55 year male 1
PRESENTATION
ED - Emergency Department
20 minute episode of painless visual
loss in left eye.
Followed by 5 mt of slurred speech
No residual symptoms
Hypertension on amlopdipine, no
other medication
55 year male 1
SIGNS
Evaluate a T I A
ABCD SCORING SYSTEM
Critique /discussion 1
He has most probably had a TIA without
cerebral infarction in CT, with an ABCD score of 2
ABCD2 score
age
Blood pressure -01
Presentation - speech- - 01
Duration of symptoms
Diabetes mellitus
Critique /discussion 1
A) Carotid ultrasonography
TIA most likely involving both speech area and
uni-ocular vision incriminates the proximal carotid
artery, commonest been in the neck.
Given the high risk of recurrence, Duplex carotids is
most appropriate and is non interventional and
relatively cheap.
Evaluate a T I A
KEY POINT
take home message
In a patient with suspected TIA,
Non invasive Ultrasonic sonography is the
is the most appropriate test to exclude
significant atherosclerotic disease
#2
Epilepsy
22 year female 2
PRESENTATION
10 year history of
Recurrent episodes of fear and anxiety,
associated with dry mouth and roller coaster
sensation in stomach lasting 15-60 seconds.
22 year female 2
PRESENTATION
4 times a year but 1-2/month in last 3 months
Momentarily confused and boy friend says she
becomes fidgety.
Well between episodes.
Medical history otherwise negative and she is
not on drugs or medication
22 year female 2
SIGNS
oVital signs normal
oGeneral and CNS examination
normal
oMRI and EEG normal
22 year female 2
PRESENTATION SIGNS
Educational objective
To diagnose TLE/CPS
#3
Gait disorder
72 year male 3
PRESENTATION
3year history of
Progressive difficulty in walking with imbalance
Slow walk, not agile and recent falls
Occasional problem recalling details, recalling
conversations and events.
Household tasks difficult and also money matters
though he was an accountant before.
Urinary urgency and frequency
Hypertensive on HCT
No history of head trauma, meningitis or ICH
72 year male 3
SIGNS
Vital signs and general examination normal
Slow gait with poor foot clearance, shuffling,
multi step turn, intermittent hesitation
Tandem gait impaired
MMSE 23/30 with points off for serial 7s and
delayed recall.
MRI shows dilated ventricles with no cortical
atrophy
84 year male 3
MRI T 1 MRI T 2
72 year male 3
PRESENTATION SIGNS
3year history of Vital signs and general
Progressive difficulty in examination normal
walking with imbalance Slow gait with poor foot
Slow walk, not agile and clearance, shuffling, multi
recent falls
step turn, intermittent
Occasional problem recalling hesitation
details, recalling conversations
and events. Tandem gait impaired
Household tasks difficult and MMSE 23/30 with points
also money matters though he off for serial 7s and delayed
was an accountant before.
Urinary urgency and frequency
recall.
Hypertensive on HCT MRI shows dilated
No history of head trauma, ventricles with no cortical
meningitis or ICH atrophy
72 year male 3
Which of the following is the
most appropriate next step in
management
(A) MR angiography
(B)Large volume lumbar puncture
(C) trial of donepezil
(D) trial of levodopa
Critique /discussion 3
(A) MRI angiography
Periventricular white matter changes seen in MRI
are similar to non specific changes of small vessel
disease. Periventricular white matter changes in
MRI of NPH may be due to trans-ependymal
absorption of CSF.
However extensive neuro-vascular investigations
are not indicated unless clinically or radiologically
indicated
Critique /discussion 3
(B) Large volume lumbar puncture
Indicated in this patient with the triad of gait
abnormality, cognitive impairment, urinary
disturbance and MRI showing ventriculomegaly
without proportionate cortical atrophy.
LP with removal of 30-50ml of CSF with
measurement of ICP is needed. Before and after LP
cognitive, balance and gait examination is needed.
How soon after LP should repeat examination be
carried out is ?.
Critique /discussion 3
42
Comparison of gaits
3
MULTI INFARCT
DEMENTIA
MRI SMALL VESSEL DISEASE 3
Triad of gait abnormality, dementia 3
and incontinence
E) LEWY BODY DEMENTIA
Overlap with Parkisons disease and
dementia
Fluctuations in cognition
visual hallucinations
No response or worsened by L Dopa
48
Lewy body 3
Found in
1. Parkinsons
2. Lewy body
dementia
NPH 3
3
KEY POINT
Large volume LP should be done
before VP shunt for NPH
tremor
#4
52 year female 4
SYMPTOMS
tremor of upper limbs
for 20 years
recently more
prominent, with
difficulty in writing and
using fork and knife
No other Parkinson
features of (T)RAP
52 year female 4
Signs
normal vital signs
outstretched arms show a
Show a large amplitude tremor
and on finger nose testing
B/L and absent at rest
mildly abnormal tandem
gait
52 year female 4
SYMPTOMS Signs
normal vital signs
tremor of upper outstretched arms
limbs for 20 years show a
tremor
recently of upper
more
Show a large amplitude
tremor
limbs forwith
prominent, 20 and on finger nose
years in writing
difficulty testing
B/L and absent at
using
and fork
recently and
more rest
knife
prominent, with mildly abnormal
No Parki features tandem gait
of (x)RAP
52 year female 4
Which of the following is the most
appropriate next step in treating this patient?
A) Botulinum toxin
B) DBS
C) Levodopa
D) Primidone
E) Topiramate
critique 4
A) Botulinum toxin
Can be effective for essential tremor of voice
and head, but for limbs benefit is limited
because of weakness and side effects.
B) DBS
Useful only for those refractory to medication
and severe disabling tremor. Too early for
patient who has not had the full range of
effective drugs
critique 4
C) Levodopa
Does not have features of Parki like tremor at rest
and unlikely to show a response
D) Primidone
Features are of a familial benign tremor which is
usually non progressive. Primidone and
propranolol are the FDA approved first line
treatment. Primidone was removed from BNF as
an AED but was reintroduced for BET on
recommendation by UK neurologists.
critique 4
E) Topiramate
Topiramate is a second line drug for BET but
is contraindicated in a patient with kidney
stones and glaucoma
Stroke due to atrial
fibrillation
#5
57 year woman in ED
o Symptoms
A) Aspirin
B) Dabigatran
C) I V heparin
D) Warfarin
CRITIQUE 5
She has A Fib and an acute L hemisphere infarct.
She is beyond window period for rtPA therapy
Anticoagulation with warfarin or newer
anticoagulants like dagibataran is required for long
term Mx to prevent thrombo-embolism.
If infarct was small and patient stable, warfarin may
have been considered
Withholding anticoagulants for 4 days to 2 weeks is
recommended for moderate or large strokes
Until that time patients are managed with aspirin
Critique 5
She has had an acute ischaemic stroke and has
atrial fibrillation
No other obvious cause is present and she is
beyond window period for rtPA
Aspirin no later than end of 2nd day is standard
practice in stroke units and reduces risk of
recurrence in next two weeks without risk of a
bleed.
aspirin should be added to patients medical
regimen
#6
MYASTHENIA
Treat myasthenic crisis 6
60 year male in ED
Symptoms
Progressive SOB for 10 days,
3 month h/o difficulty in swallowing
5 month h/o blurry vision and fatigue
UTI treated with ciprofloxacin after which
fatigue and other symptoms worsened
markedly
Treat myasthenic crisis 6
Signs
Temp, BP, pulse rate normal
RR 21/mt
B/L ptosis, diplopia with sustained horizontal
gaze, nasal speech snarling smile,
Weakness of neck flexion and all limb muscles
with demonstrable fatigability
No atrophy or fasciculation
Normal reflexes and sensation
Treat myasthenic crisis 6
Investigations
FBC and metabolic screen normal
CXR normal
Serum Mg 1.2 mg/dl ( 0.62Mmol/L)
Admitted to ICU
Diminishing VC
Treat myasthenic crisis 6
Question
Which of the following is the most
appropriate emergency treatment
A) High dose i.v steroids
B) I V Magnesium
C) I V Pyridostigmine
D) plasmapharesis
Critique 6
Patient is in myasthenic crisis plasmapharesis
should be started without delay
Diagnosis conclusive on history
Immediate Rx with PE or IVIG
Mg deficiency presents as muscular hyper excitability
not weakness. Mg can worsen MG by NM blockade.
Other contraindicated drugs aminoglycosides, beta
blockers and Ca channel blockers
Pyridostigmine can make condition worse by
increasing secretions
6
Key point
Patients in Myasthenic crisis should
be treated emergently with
Plamapheresis or IVIG
Cholinergic side effects 6
Cholinergic symptoms (effects of excess acetyl
choline)
Effect on cholinergic nerve endings and
parasympathetic cranial nerves
NMJ fasciculation
Cholinergic sympathetic sweating
Parasympathetic cranial nerves
III, VII, IX, X
Parasympathetic cranial nerves6
III small pupil
VII, IX salivation
X vomiting
bronchial secretions and bronchospasm
bradycardia, cardiac arrest
abdominal cramps and colics
Similar side effects with cholinergic drugs
neostigmine, pyridostigmine
6
MYASTHENIC vs CHOLINERGIC CRISIS
Symptoms similar
increased weakness of affected muscles
Weakness of additional muscles
Respiratory distress
Pre-crisis features may help differentiate dose of
medication, infections, other drugs.
Test dose of tensilon worsens cholinergic but may
improve myasthenic crisis
MYASTHENIC CRISIS - Mx 6
Key point
O2 therapy and subcutaneous sumatriptan
are the most effective cluster headache
treatments and verapramil is drug of choice
for cluster headache prevention
#8
Facial palsy
Facial palsy 8
53 year man with persistent R sided facial
weakness of 3 months
Difficulty in closing R eye and wrinkling
forehead,
increased sensitivity to loud noises and
occasional slurred speech
Bells palsy was diagnosed and 10 day course
of Prednisolone given
Facial palsy 8
Key point
MRI brain is appropriate in a patient with
poor recovery in 3months after appropriate
therapy.
#9
MS and pregnancy
29 year female 9
Evaluated at a routine follow up of MS
diagnosed 3 years ago
She wishes to discontinue oral contraceptive
and become pregnant.
She has no other personal or family history of
note
Medications are Fingoimod, Vit.D and oral
contraceptive
Female MS 9
Signs
Key point
Discontinue fingolimod. Pregnancy should
give adequate protection against relapse of
MS
#10
Cognitive
impairment
52 year female 10
SYMPTOMS
1 year h/o increasing forgetfulness.
Names, appointments, conversations
lives alone and copes reasonably with ADL
including working as orderly in school and
enjoys life.
52 year female 10
SIGNS
No abnormality in CVS, RS, abdomen.
CNS examination normal except for
MMSE 24/30
Loses points on
Orientation
Delayed recall
52 year female 10
SYMPTOMS SIGNS
1 year h/o increasing No abnormality in
forgetfulness. CVS, RS, abdomen.
Names, appointments, CNS examination
conversations normal except for
lives alone and copes
reasonably with ADL MMSE 24/30
including working as Loses points on
orderly in school and Orientation
enjoys life.
Delayed recall
10
Q10. Which of the following is the most
likely diagnosis
A) Dementia
B) Depression
C) MCI
D) normal aging
Critique 10
A) dementia - patients cognitive deficit must interfere
with daily functioning and result in some dependence.
Pay bills
Shopping
Financial management
Taking medication
Driving
Family events
Recall of holidays
Critique 10
B) Depression
On patient history and exclusion of
others.
Depressed mood and anhedonia
Inability to experience pleasure
Dysthymia
No diagnostic tests
Critique 10
C) MCI minimal cognitive impairment
Between dementia and normal aging
No significant functional disability
Montreal cognitive assessment scale
better with more memory recall and
executive function
10-20% become demented each year it
is 1-2% in normal population
Critique 10
D) Normal aging
No features of depression,
disproportionate dependence for ADL
that cannot be accounted on neural
or physical, cardiac, respiratory or
musculo -skeletal disabilities.
Montreal Cognitive assessment
MOCA vs MMSE
MMSE MOCA
FOLSTEIN 1976 1996
High language component Better for MCI
30 point scale 30 point scale
7-8 minutes 10-12 minutes
orientation to time, date, and orientation to time, date, and
place. place.
tests for recall, but tests for recall, but
remember three items. remember five items.
examining orientation, word little more in depth and
recall, language abilities, includes tasks such as a clock-
attention and calculation, and drawing test and a trail test
visuo-spatial ability. (connecting the dots
Good Day