Lou Gehrig

You will know Lou Gehrig if you are a baseball fan or a Neurologist. Lou Gehrig whose name has been given to Amyotrophic lateral sclerosis was an "ironman" in baseball unfortunately died of ALS.
Amyotrophic lateral sclerosis is a type of motor neuron disease.
What you need to know in MRCP is that if you get a patient with mixed upper and lower motor neuron with no sensory involvement, you may be dealing with MND. Also if you see fasciculations - MND is high on the list. Of course, don't forget cervical myelopathy and multifocal motor neuropathy with conduction block as differential diagnosis.

The other possibility in exam is that you are given a patient with bulbar(as in the picture showing fasciculations and wasting of the tongue) or pseudobulbar palsy and one of the underlying aetiology would be MND.

Remember - The lesion is at the anterior horn cell
(first principle of neurology - Where is the lesion ?)

ECG for medical students

40 years old man with palpitation

What does the ECG show ?

What are the further investigations ?

Outline the treatment plan.

Proximal myopathy 2

Common exam question.
Attached is a video of my patient with proximal myopathy. Without the bed, he would show a classical Gower sign.
What is important is to determine the cause for the proximal myopathy.
In the exam, think of the major groups !

1) Muscular Dystrophy - normally Beckers cause Duchenne would be dead by then unless you are sitting for a paeds exam.
2) Polymyositis/Dermatomyositis
3) Endocrinopathies - Acromegaly, Cushing's, Thyrotoxicosis... look for features of those
4) Metabolic causes- Hypokalaemic periodic paralysis...
5) Myasthenia gravis

Those are the common ones.

Remember also to look for the muscle biopsy scar which is normally at the biceps or quadriceps.
There is no sensory involvement as the pathology is the muscle or neuromuscular junction.

Remember the investigations -
CK
Muscle biopsy
EMG

Treatment would depend on the underlying cause.

Refer to previous post on proximal myopathy

3rd nerve palsy

Neuro-opthalmology always amazes me.

In this patient, there is L 3rd nerve palsy with sparing of the pupil - medical 3rd nerve palsy

Commonest cause are diabetes mellitus and hypertension.

When you get medical 3rd nerve palsy, check for diplopia then other cranial nerves. If only the 3rd nerve involve, test BP and blood glucose.

Other causes include - MS, trauma, collagen vascular disorder, syphilis,etc

It is wise to check for long tract signs and cerebellar signs.

Remember the fancy names ?

Weber syndrome - ipsilateral 3rd nerve palsy with contralateral hemiplegia (lesion in midbrain)

Benedikt's syndrome - ipsilateral 3rd nerve palsy with contralateral involuntary movements such as tremor, chorea and athetosis (lesion in red nucleus of midbrain)

Claude's syndrome - ipsilateral oculomotor paresis with contralateral ataxia and tremor( lesion in 3rd nerve and red ncleus)

Nothnagel's syndrome - unilateral oculomotor paralysis with ipsilateral cerebellar ataxia

To differentiate between central or peripheral - suspect central if unilateral 3rd nerve palsy with superior rectus palsy and bilateral partial ptosis/bilateral 3rd nerve palsy

Medical students : remember this !

SO4 LR6 - superior oblique by 4th CN, lateral rectus by 6th CN, the rest 3rd CN

Splenomegaly

Never rush to examine the patient. Always remember the first few steps. Firstly, always introduce yourself to the patient then shake hand (except in Rheumatology) then ask the patient permission for examination.
The next step is to position the patient. Then it will be to start with inspection.
For the abdomen station, inspect at the end of the bed. This is a very crucial step. If you notice in the above patient which was taken during a medical student exam last year, you could actually get the diagnosis. There is an obvious swelling at the L hypochondriac region and if you are sitting for a medical exam, it must be the spleen or the L kidney.

The favourite questions for medical students :
What are the causes of massive splenomegaly ?

• Malaria
• Chronic myeloid leukaemia
• Myelofibrosis
• Kala azar (mention this last if you are in Malaysia or places where it is not endemic)
• Gaucher's disease
  
• Thalassaemia (though some would classify as mild to moderate)

How do you differentiate a kidney from a spleen ?

Kidney - ballotable, moves inferiorly, resonant on percussion, able to get above it, traube space resonant
Spleen - not ballotable, moves inferomedially, dull on percussion, unable to get above it, splenic notch, traube space dull

The above patient has CML with massive splenomegaly !!

MRCP Book

This is quite a good book that I used in the MRCP PACES during my 3rd attempt. It is point form and gives very good examples especially in the history and communication section.
If you are interested to get it from me for a low rate, email me at thienthienlim@gmail.com.

You may still need to read in PACES although the key word is PRACTISE !!!

Normal Pressure Hydrocephalus

This 70 years old gentleman presented with difficulty in walking for the past 3 years and recently has urinary incontinence. He also has poor memory for the past 1 year.

Favourite question in MRCP Part 1 and 2a(normally may show you a CT brain with hydrocephalus)

Clearly the triad of NPH are DIA(dementia, incontinence and ataxia)

The gait shown is an apraxic gait which sometimes mimic a gait in Parkinsonism.

The CT brain shows hydrocephalus and an LP done would normally be on the high normal about 15 to 20 cmH2O. The gait improved after CSF drainage.

Treatment would be by inserting a ventriculoperitoneal shunt (VP shunt)

Communication skills - Break Bad News

In the MRCP PACES exam, the commonest case that one would get is Breaking bad news !
I must pay tribute for this section to Dr. Kok Lai Sun, Dr. Yoon CK and Dr. Ong Eng Eng who actually trained me in this till I got a 4/4 in my PACES which then made me pass, if not I used to be something like the cartoon above (Malaysian style).

Example :

Candidate information
You are a medical SHO on call for the coronary care unit(CCU).
Please read the scenario below. You may make notes on the paper provided. When the bell sounds enter the examination room to begin the consultation.

Mrs Tan PS
Age 55 years old
Re : Husband, Mr Tan PS, 60 years old

You are asked to talk to Mrs Tan PS regarding her husband, Mr Tan PS who was a 60 years old man who was admitted to the CCU on the previous evening, after experiencing an acute myocardial infarction. Prior to this he had been fit and well. He was a smoker and had hypertension for the past 10 years. Mr Tan had been thrombolysed and treated appropriately. However, during the night he had developed further chest pains and had a cardiac arrest from which he could not be resuscitated, despite a prolonged resuscitation, and died. Mrs Tan was informed regarding the deterioration through the phone but does not know that Mr Tan has passed away. You are to break the bad news to Mrs Tan.

You have 14 minuted to communicate with the patient followed by 1 minute reflection before discussion with the examiners.

How would you approach this type of scenario ?

• Greet Mrs Tan and introduce yourself
• Enquire if anyone else would like to be around during the conversation (such as other family members)
• Enquire what she knows about Mr Tan and her expectations
• Explain briefly on what prompted the admission and she feels he is progressing
• 'Fire a warning shot' (this is very important) - eg. During the night, Mr Tan had another chest pain and possibly another heart attack. Pause after that
  
• Break the bad news. Go on to explain that Mr Tan's heart stopped beating(after another episode of heart attack). Explain that despite efforts of the medical team, he passed away
• Pause and let the news sink in - let Mrs Tan express the shock and sadness, offer tissue if she cries
• Be EMPATHETIC
• Don't speak to much but be empathetic - such as 'Are you ok to go on' or ' I know this must be hard for you...'
• Answer her questions
• Close the interview