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1. Tell me the positive clinical finings- You should take no more than 30-40 sec for this
2. What are the differential diagnosis- It may take some time as you may be interrupted if going in wrong
direction. But never > 1min.
3. Which investigations would you do for this patient?- 40 sec
4. How do you manage the case? Again 40-60 sec.
If you have answered all of the above in correct manner, you may have further questions which will fetch you towards
full marks. So, time management is very important.
I have made this note for my third attempt of PACES, which I passed. During exam felt quite confident as I have
rehearsed it many times with my friends, juniors and even before mirror. It might seem inadequate, but believe me,
you have small time to answer each question.
This is a template only made for me and not all inclusive. I request all future examinees to prepare their own such
notes which might be more effective if made according to ones own ability, memory and concept.
At the end I have tried to simplify some Neurology scenarios in a schematic pattern, which helps in pattern
recognition during examination.
Obviously this note carries contribution from all of my teachers, mentors, books and notes targeting PACES.
1. COPD
General measures
o Stop smoking
o Pulmonary rehabilitation ( Pt education, Nutrition, Psychological support, Physiotherapy)
o Vaccination
Specific medical
o Bronchodilator- inhaled B agonist/ ICS/ LABA/LAMA
o Antibiotic and systemic steroid for acute exacerbations
o Mucolytics
o LTOT
o Diuretics and Phosphodiesterase inhibitors for Cor pulmonale
Surgery-
o Bulectomy/ Lung volume reduction
o Lung transplant
2. Bronchiectasis
Investigation
o Blood-Differential count, ESR, CRP- to look for signs of infection, Immunoglobin levels
o Chest x ray /HRCT to look for Tram line appearance/Signet ring
o Sputum microscopy and C/S to isolate any organism, particularly Pseudomonas
o Pulmonary function test to look for Obstructive pattern
o ECG and Echocardiography to rule out Cor pulmonale
o 6min walking test for functional assessment
o Sweat test if suspect cystic fibrosis
Management
General measures
o Stop smoking
o Pulmonary rehabilitation ( Pt education, Nutrition, Psychological support, Physiotherapy, POSTURAL
DRAINAGE)
o Vaccination
Specific medical
o Mucolytics
o Bronchodilator- inhaled B agonist/ ICS/ LABA/LAMA
o Antibiotic- systemic / inhalational +/- Steroids
o LTOT
o Diuretics and Phosphodiesterase inhibitors for Cor pulmonale
Surgery-
o Lobectomy
o Bronchial artery embolisation for hemoptysis
o Lung transplant for cystic fibrosis
Investigation
a. Chest x ray to look for bilateral interstitial reticulo nodular pattern. Loss of lung volume
b. HRCT to look for subpleural reticulation and traction broncheitasis, basal honeycombing , ground glass
patterns
c. Pulmonary function test to look for Restrictive pattern with reduced DLCO
d. Blood-Differential count for eosinophilia, ESR, CRP- to look for signs of infection
e. Markers for Autoimmune profile, ACE level, Ca,
f. Brocnchoscopy and BAL /Sputum microscopy and C/S to rule out any organism
g. ECG and Echocardiography to rule out Pulmonary HTN
h. 6min walking test for functional assessment
i. ABG to decide about LTOT
Management
General measures
o Stop smoking and toxic or allergic substances
o Pulmonary rehabilitation ( Pt education, Nutrition, Psychological support, Physiotherapy)
o Vaccination
o LTOT
Specific medical
o Immunosupressive Steroid for ground glass, Thalidomide, Cyclophosphamide,
o Antifibrotic Pirfenidone for IPF ( UIP Pattern on HRCT)
o Diuretics and Phosphodiesterase inhibitors for Cor pulmonale
Surgery-
o Single or Double lung transplantation
4. Pleural effusion
Investigation
a. Chest x ray to look for blunt costophrenic and cardiophrenic angles
b. CT thorax to look for any MASS
c. USG to rule out multisepted/ loculated effusion
d. Pleural fluid assessment for cellularity, protein, sugar, cultures, malignant cell, special tests.
e. Blood-Differential count , ESR, CRP- to look for signs of infection,
Albumin, Urea/ electrolytes to rule out any renal disease, LFT to rule out any liver disease
f. ECG and Echocardiography to rule out Pulmonary HTN/ cardiac decompensation
g. Markers for Autoimmune profile
h. Pleural biopsy in refractory cases
i. Other Special tests as required
Diagnosis of plerual effusion Clinically 500ml, x ray PA 300ml, x ray lat decubitus-180ml , USG 30ml
Management:
1. Therapeutic Pleural drainage if Symptomatic, infective ( empyema)
2. Treatment of the cause
3. Decortication/intrapleuarl thrombolytics for multiloculated effusion
4. Pleurodesis for refractory malignant effusion
5. Lobectomy / Pneumonectomy
Investigation
o Chest x ray to look for confirmation
o CT thorax to look for underlying cause
o Pulmonary function test to look for Obstructive
o Blood-Differential count , ESR, CRP- to look for signs of infection,
o ECG and Echocardiography to rule out Pulmonary HTN
o Other Special tests as required
Management:
o Supportive
o Management of the original disease
Indication of Lobectomy
o Localized broncheictasis with massive hemoptysis
o Lung abscess
o Solitary pulmonary nodule
o Trauma
o Aspergiloma
o NSCLC T3AN0M0
o TB not done now a days
Indication for Pneumonectomy
o Massive Broncheictasis
o Multiple lung abscess
o Fungal infection Malignancy
o Trauma
o Bronchial obstruction with destroyed lung
o Congenital lung disease
o Malignant mesothelioma/ disseminated thymoma
Investigation
o Chest x ray to look for confirmation
o CT thorax to look for underlying cause and look for other lung pathologies
o Pulmonary function test to look for volume loss
o Blood-Differential count , ESR, CRP- to look for signs of infection,
o ECG and Echocardiography to rule out Pulmonary HTN
o Sputum gram stain and culture to look for infection, AFB and NAAT to rule out TB
Management:
1. General
Smoking cessation/ Pulmonary rehabilitation
Specific
Bronchodilator
Early antibiotic therapy for suspected infection
7. Lung Consolidation ( d/d- Pneumonia/ Infarction/ mass)
Investigation
o Chest x ray to look for confirmation
o CT thorax to rule out any mass lesion
o Blood- Septic screening -Differential count , ESR, CRP, PCT - to look for signs of infection, Urea/ electrolytes-
CURB 65,
o ABG to look for hypoxemia/ hypercapnoea
o Sputum gram stain and culture to look for infection, cytology for malignant cells
o ECG and ECHO to rule out pulmonary embolism
o Bronchoscopy with BAL for microbiology, cytology
o If septic screen and embolism negative- send autoimmune profile
Management
General measures
o Stop smoking and toxic or allergic substances
o Pulmonary rehabilitation ( Pt education, Nutrition, Psychological support, Physiotherapy)
o Vaccination
Specific medical
o Pneumonia Antibiotics/ Bronchodilator/ Mucolytics
o Infarction LMWH/ warfarin/ modification of risk factor
o Mass Chemo/ radiotherapy/ surgery
8. Lung collapse ( d/d Malignancy/ TB/Hilar L/N / Mucus plug)
o Chest x ray for confirmation
o CT thorax to rule out any mass lesion, Enlarged L/N
o Blood- Septic screening -Differential count , ESR, CRP-
Urea/ electrolytes/ LFT / ACE level
o ABG to look for hypoxemia
o Sputum gram stain and culture to look for infection, cytology for malignant cells
o Bronchoscopy to rule out any endobronchial growth, BAL for microbiology, cytology , Biposy , NAAT
Management
General measures
o Physiotherapy
o Positive pressure ventilation
Specific medical
o Mucus plug Bronchodilator/ Mucolytics/ Bronchoscopy and lavage
o Malignancy Chemo/ radiotherapy/ Bronchoscopy may need stenting
o Others Bronchoscopy and treatment of the cause , may need stenting
Investigation
Investigations
USG abdomen for confirmation of diagnosis
Ascetic fluid for SAAG, Cell count, type, , Sugar, Protein, Malignant cell, Culture
To look for etiology
o Alcohol and drug history
o Metabolic profile ( NASH)
o Viral markers
o Cerulopasmin and urinary copper study( WILSONS)
o Ferritin (HH)
o Liver biopsy( NASH, PBC, PSC)
o Auto antibodies: AMA ( PBC) , ASMA, , IgG, Anti LKM ( AIH) ANCA (PSC)
o Alpha 1 antitrypsin
o AFP for HCC
o Renal parameters and urinary protein for Nephrotic syndrome
o ECHO for CCF/ CP/ RCM
o Thrombophilia workup and CECT abdomen for Veno-occusive disease
Management:
General Patient education / salt and fluid restriction
Medical- Diuretics- Spironolactone, Furosemide
Treatment of SBP
Therapeutic paracentesis
Investigation
1. confirmation of diagnosis- USG abdomen
2. Look for etiology
o Alcohol and drug history
o Metabolic profile ( NASH)
o Viral markers
o Cerulopasmin and urinary copper study( WILSONS)
o Ferritin (HH)
o Auto antibodies: AMA ( PBC) , ASMA, , IgG, Anti LKM ( AIH) ANCA (PSC)
o Alpha 1 antitrypsin
o AFP for HCC
o ECHO for CCF/ CP/ RCM
o Liver biopsy ( NASH, PBC, PSC)
3. Look for complications
o LFTs
o PT, INR, Albumin
o FBC with inflammatory markers
o CECT ABDOMEN
Management:
Investigations:
Management
5. Hepatospleenomagally
Investigations:
Investigations:
Management
7. Jaundice +/_ hepato/ Hepatospleenoegally (DCLD, Hepatitis, Hemolytic disease, malignancy, infections)
Investigations:
o Confirmation: LFTs
o For etiology
o USG of Abdomen followed MRCP/ CT depending on USG findings
o Viral markers
o Autoimmune profile (AMA,ANA, ASMA, Anti LKM)
o PBS look abnormal cells, spherocytes,
o Hemoglobin electrophoresis, DCT to look for hemolytic diseases
o HIV serology
o FOR complication
o Coagulation profile
o OGD for esophageal varices
o Renal parameters
o Septic screen
o Ascitic fluid if any
8. Jaundice and Ascites +/_ hepato/ Hepatospleenoegally ( DCLD, , Malignancy ,Disseminated TB, Cardiac
cirrhosis)
o Confirmation: LFTs
o For etiology
o USG of Abdomen followed MRCP/ CT depending on USG findings
o Viral markers
o Autoimmune profile (AMA,ANA, ASMA, Anti LKM)
o Ascitic fluid for Cellularity, SAAG, Malignant cell, Culture
o Laparoscopy and peritoneal biopsy
o Echocardiography
o For complication
o Coagulation profile
o OGD for esophageal varices
o Renal parameters
o Septic screen
Management
9. Polycystic Kidney
Investigation
Management:
General
o Patient education and counseling about course of disease and complication
o Attempt 3lit fluid intake per day to suppress ADH secretion
o Screening of 1st degree relatives from the age f 20yr at least 3 cyst uni/ bilateral
o Avoid contact sports/risk of trauma to abdomen
Specific medical
o ACEI for control of hypertension
o Avoid nephrotoxic drugs
o Antibiotics for UTI/ cyst infection
o Renal replacement therapy
o Indication of Nephrectomy
Recurrent infection
Uncontrolled hemorrhage
Suspected malignancy
Symptomatic mass effect
Extension of polycystic kidney into transplant site.
o Management of Hematuria- bed rest, hydration and analgesia
Investigations
Management
MDT
Patient education and counseling, compliance to immunosuppressant
Monitoring for toxicity of immunosuppressant
o FBC, Renal parameters, LFT
o Septic screen
o Dermatology surveillance for PTLD
Treat acute presentation of sepsis with antibiotic/ Antiviral/ antifungal
Renal replacement therapy if graft function deteriorates despite adequate immunosupression
o Uremic encephalopathy
o Pericarditis
o Refractor fluid overload
o Decompensated metabolic acidosis and hyperkalemia
Lower limb Weakness
Examine neck
Lower cranial Nv
cerebreller
Paraparesis/ paraplegia
No
Syringomyelia
Sensory Deficit
Yes NO Polio
Root Lesion Peripheral nerve Both root and nerve Muscle hypertrophy fasciculation
Ankle Jerk
Lateral thigh and leg compartment Part of leg and No sensory loss
& Dorsum of foot Dorsum of foot Bilateral
Usually unilateral Unilateral
H/O Pain
EHL weakness
Unilateral Bilateral
Polio HSMN
Burn mascular dystrophy
Taruma spinal mascular atrophy
Syringomyelia
Palpable nerve
HSMN
Acromegally
Leprosy
CIDP
Amyloidosis
Neurofibromatosis
Upper limb Weakness
LMN and UMN Bilateral (D/D- bilateral stroke/MND/ PD/ Freidreichs/ cervical 1-4)
MND
Friedreichs No
No
Deficit
Tremor Yes PD
Spinal Level Dissociated sensory loss Peipheral nerve pattern Multiple sclerosis
cervical myelopathy
Upper limb LMN Cerebeller Alcohol, drugs, Syrings,
Sensory Deficit
Yes NO Polio
Root Lesion Peripheral nerve Both root and nerve Muscle hypertrophy fasciculation
Dermatomal loss Gloves pattern both/ variable Proximal Distal/proximal
D/D- MND, Cervical myelopathy, Syrings, combined median and ulnar nerve damage,Peripheral neuropathy(
CMT) , C8T1 lesion ( cervical rib, Pancoast tumor, trauma)
1. Hand-
a. 5 movements of thumb 4 movements of fingers 1 movement of little finger
b. DTR c. Sensory d. Cerebeller e. Lower limb/ cranial
WASTING OF HAND
Unilat stroke
No sensory loss gloves pattern Dermatomal pattern C8-T1 Dissociated cerebeller+ dorsal
Spinal Cord
Cervical Spondylosis Look at back
Syringomyelia Test sensation over cap area, look for Horners
Anterior Horn Cell
Motor Neuron Disease Fasiculation of the tongue or other muscles, ?bulbar speech
Polio
Spinal muscular atrophy Examination of lower limbs
Nerve Lesions
Median Alone will not give wasting of all small muscles of the hand
Ulnar Should have a claw hand
Peripheral Neuropathy e.g. CMT absent reflexes, forearms > hands, thickened nerves
Brachial Plexus C8-T1 ? clubbed from lung ca, cervical ribs, Horners
Myopathy
Myotonic Dystrophy Appearance, weak neck muscles
Distal myopathy e.g. inclusion body myositis
3rd nerve
Inspection- Complete ptosis, Lift the eyelid see eyeball down and out see pupil miosis/ mydriasis
Check
4, 6, V1
Disc- papiloedema, Retinopathy
Ispilat cerebeller
Contra pyramidal- webers
Associated syndromes
Caverous sinus syndrome- III, IV, V1, V2., VI + symatetic fibers horners
Orbital apex- II, III,IV, V1, VI
Superior orbital syndrome- III, IV, V1, VI
4th nerve
INO
6th Nerve
Cause- DM, MS, Basal meningitis, Vasculitis, False localizing sign, CP angle Mass
Approach
Relavant
1. Associated 3rd , 4th search Gaze palsy
2. Associated V1- Cavernous
3. 7th Brain stem
4. 8th CP angle
5. Disc- DN/HTN/OA/papiloedemafalse localizing sign
6. Long tract sign - Brain stem syndrome- Millard gublers syndrome VI+ VII+ contra hemiparesis
7th Nerve
Approch
corneal reflex,
otoscopy,
formal audiometry and
examination of upper and lower limbs.
Pseudobulbar Bulbar
UMN LMN
CN V, VII (IX, X,XII) CN IX, X,XII
Facial expression, mastication Diminished gag
Bilateral degeneration of corticobulbar tracts Tongue fasciculation, wasting
Gag reflex, tongue spasticity Jaw jerk normal
Jaw jerk exagerated Unilateral raspy voice
Spastic dysarthria Bilateral nasal speech
Daffy Duck GBS, Stroke, MND
MS, MND
Myotonic Dystophy:
Unilateral Bilateral
Without Without
With ophthalmoplegia ophthalmoplegia With ophthalmoplegia ophthalmoplegia
Steps:
Hormers
follow scheme
of Horner s Cant close eye tightly Can close tightly but cant open
Central 1st order Demyelination /Syringomyelia No sweating in face, arm and trunk
2nd order Trauma, surgery, pancoast , Lymph node, goiter No sweating in facearm trunk
normal
3rd order cavernous sinus syndrome, carotid dissection Sweating normal
Sequence
Presentation
Fetures Investigation
Fatigable ptosis CBC, ESR
Complex ophthalmoplegia CXR to look for mediastinal mass
Nasal speech CT chest for thymoma
Bulbar weaknessNasal speech, poor swallow Anti AChR antibody 85%
Proximal weakness UL>>LL Anti MuSK antibody 15%
Reflex/ sensory normal Vital capacity
Look for sternotomy scar RNST >10% decrement on 3HZ
Look for features of immunosupession Single Fiber EMG (most specific)
o Cushingoid Thyroid profile, CPK
FBS
Single breath count FVC Treatent
Other autoimmune disease Patient education and counseling
Avoidance of precipitators
LEMS Acute:
limb girdle weakness LL>>UL o IvIG/Plasma Exchange
Rarely Ptosis and diplopia Maintenance
Diminished reflexes become brisk after o Acetylcholine esterase inhibitors
exercise o Immunosuppressant
Associated with malignancy- SCLC o Steroid
Anti voltage gated Ca cannel antibody o Azathioprine
Autonomic dysfunction o MMF
EMG shows second wind phenomenon o Cyclophosphamide
Mx-3,4 Diaminopyridine and treatment of
tumor Thymectomy -For all patients even if there is
no thymoma
Friedreichs ataxia: Pyramidal+ LMN+ Cerebeller+ Dorsal Column
If asked Lower limb= Start from gait Wasting+ pes cavus+ UMN + post column+ + absent jerk +cerebeller
If asked upper limb= See tremor in hand to rule out parkinsons if no look for cerebeller signs
1. Myopathic face Wasting & weakness of facial muscle D/D- (MG/ MD)
2. No Ptosis and eye movements are normal
3. Proximal muscle weakness and wasting
4. Superior margin of scapula are visible from front
5. Winging of scapula with positive Beevor sign
6. Foot drop
7. Hearing aid
Fasciculation cause
MND
Syringomyelia
Cervical myelopathy
Thyrotoxic myopathy
HSMN
Electrolyte disturbance( hypokalemia, hypomagnesemia)
Proximal myopathy
D/D- Cushings, Acromegally, Osteomalacia, Thyroid ds, PMR, PM, DM, MG, electrolytes, Drugs, Muscular dystrophies
Inspection:
Management
General: Patient education, counseling, MDT, Patient autonomy for future choice, early involvement of palliative care
Specific:
Symptom control-
a. Baclofen for spasticity
b. Analgesia for pain
c. Anticholinergic for drooling of saliva
d. Magnesium and Vitamin E for Fasciculation
e. SSRI for depression
NIV
PEG
Riluzol does not improve symptom, does not prevent death. Prolong survival 3 month after 18 month therapy.
Cardiovascular
Aortic Stenosis
Median sternotomy scar
Cause Metallic valve replacement
Tissue valve replacement
Bicuspid aortic valve
CABG
Corrective surgery of congenital heart
Congenital Disease
Rheumatic fever Heart transplant
Supravalvular aortic stenosis Thymectomy
Degenerative in old people
Severity
Investigation
Management
Asymptomatic-
IE prophylaxis for Dental, Genitourinary and Colonic procedure prophylaxis
Moderate/ severe stenosis undergoing other cardiac surgery
Gradient of > 40 mm Hg with any of the following
o LVEF < 50%
o Abnormanl BP response on ETT
o LVH > 15mm
o VT
o Valve area < 0.6 cm2
Aortic regurgitation
Cause
Severity
Investigation
Specific include
Medical: management of
Hypertension
Heart failure
PAH
Associated pathology
Surgical
Bioprosthetic
Complication
IE
Thromboembolism
Hemolysis
Valve dysfunction Heart failure
Over/under anti coagulation
Mitral Stenosis (D/D- left Arial Myxoma, Left Atrial thrombus, Austin flint Murmur)
Cause
Rheumatic fever
Congenital
RA
SLE
Carcinoid
Severity
Echo criteria
Investigation
Management
Specific include
Medical: management of
o Hemoptysis
o Recurrent thromboembolic event despite anticoagulation
o Hoarseness of voice ( Ortners syndrome)
o Pulmonary hypertension
PBMV- wilkins score Low / minimal MR/ No thrombus in LA
MR cause
Acute: IE, Papilary muscle dysfunction MI, Trauma
Chronic- MVP, Reumatic fever, Connective tissue disorder dilated LV ( functional MR),Post MI
Severity
Soft S1
S3, S4, Displaced apex,
Systolic thrill
Diastolic flow murmur
Pulmonary hypertension and congestion
Investigation
FBC to look for anemia
Blood cultures for IE
LFTs to look for coagulation profile
Urine dipstick for hematuria
ECG to look for Atrial Fibrillation, left atrial enlargement, previous infarction
X ray chest to look for Double right heart border, Cardiomegally, pulmonary congestion
Echocardiography (TTE/ TOE)to look for LV size and ejection function, valve area and gradient,
Coronary Angiography
Management
Specific include
Medical:
Complication of valve
Investigations
Infective endocarditis
Dukes criteria
Major Minor
Patients at risk
If patients at risk are undergoing a gastrointestinal or genitourinary procedure at site where infection is
suspected, they should receive appropriate antibacterial therpy that includes cover against that cause
endocarditis.
Patients at risk of IE should be
a. Advised to maintain good oral hygiene
b. Told how to recognize signs of IE and when to seek expert advice
NICE do not advocate prophylaxis even for high risk patients whereas AHA recommends so.
Major Minor
C Carditis Arthalgia
E Erythema marginatum Fever
N nodules Subcutenous High ESR
C Chorea Raised WBC
E eryhtema marginatum Prolong PR
R Previous Rheumatic fever
Treatment General and specific
Rest
High dose aspirin
Penicillin
Prophylaxis-
o Primary Penicilin V or clindamycin for 10 days
o Secondary Pencilin V for 5-10 yrs