1. Disorders affecting consciousness - CASES Flashcards
Case 1a: 18yr old female standing in a hot shop flu-like symptoms over last 24hrs vision tunnels, ringing in ears, draining sensation
collapses unconscious - 2-3 leg jerks, looks pale, comes round after 30 seconds
feels hot and light headed after coming round
differentail diagnosis
vasovagal syncope - fainted
prodrome present typical of syncope
Case 1b:
why not a seizure?
orientated
short period of time
evident triggers - previous illness, hot temperature, standing
Case 1c:
what are the 4 P’s of vasovagal syncope - give examples in this case
Predisposition - flu-like symptoms
Provocation - hot temperature, standing
Prodrome - tunnel vision, rising in ears, draining sensation
Posture - collapses to floor
Case 1d:
why is this prodrome common
cochlea and retina are very sensitive to low O2 - vision/hearing changes can be the first indication someone might pass out
case 1e:
might jerks suggest something other than vasovagal syncope?
only if continuous/high number
2-3 jerks is normal
Case 1f:
what investigations might be carried out for this woman
ECG for arrhythmias
bloods - anaemia, glucose levels
Case 1g:
what is the best thing to and worst thing to do for a person about to faint
best - help them put their head between their knees or lie down with their legs elevated
worst - keep them propped up - can trigger a seizure
Case2a:
19yr old builder
15 pints night before
only 3 hrs of sleep
11am at work falls to ground - goes stiff with arms flexed/legs extended, starts jerking limbs for 2 minutes, stops breathing for 10 seconds, lips go blue
then laboured breaching, unconscious for 2 mins, incontinent of urine
drowsy and muddles for 5 mins, sleeps for 30 mins
no memory of events and a sore tongue after
differential diagnosis
Generalised tonic clonic seizure
tonic - stiffness
clonic - jerking
jerking - should be symetrical movements, synchronised
Case2b:
what might have caused the seizure
provocation/triggers present - alcohol, lack of sleep, physical exertion
Case2c:
is the time of unconscious normal for this kind of seizure
yes - should be <5 mins
> 5 mins = ?stasis ?non-epileptic causes
Case2d:
what investigations should be done
MRI - gold standard
CT
EEG - only provides a snapshot of activity at the time
ECG - arrhythmias FBC electrolytes Blood glucose infection screen
Case2e:
what advice would you give this man
6 months no driving after a first seizure
work - ladders, heavy machinery
reduce alcohol intake
Case3f:
what treatment would be given
none initially after first seizure - treat on subsequent attacks (epilepsy needs multiple attacks for diagnosis)
Case3a:
26yr old female
lots of stress at work
- develops fast breathing, feels lightheaded, falls to ground, lies motionless with eyes closed for 10 mins
disorientated for a few minutes, frightened
differential diagnosis
Non-epileptic attack - dissociative/panic attack
stress can be a trigger
Case3b:
what tests might you do
ECG
MRI scan
EEG
Case3c:
how might you explain the diagnosis to the patient
protective mechanism from trigger - dissociation
even though not a seizure still a valid diagnosis
Case3d:
what are the typical presentations of a dissociative attack
lying very still
OR
thrashing around
Case3e:
how can these attacks be managed
prevention
avoid triggers
breathing exercises
Case4a:
54 yr off out celebrating, drinking
gets in a fight, falls and hits head off wall
gets up but minutes later weakness in right arm/leg
A&E - pupils equal (4mm) and reactive
laceration to L temple
GCS 14/15 (disorientated)
moderate right face/arm/leg weakness
differential diagnosis (what in particular might you be worried about)
bleeding in the brain
left temple laceration = think extradural haematoma
- middle meningeal artery at risk of bleed
- over the pterion its quite weak - blows here can damage structures beneath
Case4b:
30 minutes later he is drowsier GCS now 7/15
left pupil noticed to be 8mm and unreactive
what do these new developments suggest
pupil dilation = pressure on the brainstem
= RAISED ICP
pupil unreactive = 3rd nerve palsy - root in the brainstem
Case4c:
the man had weakness on the right side of his body, but the left pupil is unreactive to light
what side of the brain is the problem
LEFT
hemiparesis = localising sign
(seen on the contralateral side to damage)
3rd nerve palsy = false localising sign (seen on ipsilateral side to damage)
Case4d:
what other signs might suggest increased pressure on the brainstem
increasing blood pressure and declining heart rate
= tentorial herniation (coning)
check for other brainstem reflexes
- pupillary light reactions (II,III)
- doll’s eye movements (IV, VI, VIII)
- corneal reflex (V, VII)
- if intubated, gentle tugging on endo-tracheal tube may elicit gag reflex
Case4e:
when assessing a patient for a response to pain, where should you assess it
above the neck
- enables you to distinguish from localising (GCS-M5) and flexing (GCS- M3) to pain
Case4f:
what else might be seen in a third nerve palsy along side a dilated pupil
ptosis
pupil “down and out”
Case4g:
what is the best course of management for this patient
stabilise C spine ABCDE GCS <8 = intubate+ventilate treat raised ICP cranial imagine - may need decompressive surgery/removal of haematoma repeated neuro obs (GCS)
Case4h:
what is the management for raised ICP
- surgery to relieve pressure (+/-shunt)
- osmotic agents eg mannitol
- Nurse with head at 30-45% (venous return)
- reduce pain
- maintain good PO2, reduce PCO2
- reduce metabolism (reduce temp, barbiturates)
Case5a: 25yr old male student notices disgusting smell memory of a familiar situation stares into space for 60 seconds picking at buttons making chewing movements not responding to friends recovers after 60 seconds but feels tired and has a headache
differential diagnosis
focal seizure - complex partial seizure (due to loss of awareness)
NOT absence seizure - usually in kids/teens and lasts ~15secs
Case5b:
what is the memory of a familiar situation called
deja vu
Case 5c:
which brain region might be affected
temporal lobe
- complex situational area
- olfactory perception
diagnosis from scan - mesial temporal sclerosis
Case5d:
what investigations are required
MRI CT EEG ECG routine bloods
Case5e:
what is required for this patient to be diagnosed with epilepsy
more than one seizure
Case5f:
what are some risk factors for epilepsy
FH
focal brain damage/pathology - eg stroke, tumour, trauma, learning difficulty, meningitis
toxins, drug withdrawal, infection, metabolic disturbances (eg hypoglycaemia)
sleep deprivation
ALL LOWER SEIZURE THRESHOLD
Case5g:
what is the treatment for epilepsy
treat risk factors if possible eg reduce/stop alcohol
drug therapy if >1 seizure
- 2/3 respond well to treatment
- 1/3 can be drug resistant
Case5h:
what are the common drugs used in treating epilepsy
Sodium valproate (epilim)**
carbamazepine (tegretol)
lamotrigine
phenytoin**
leviteracetam**
topiramate
gabapentin/pregabalin
phenobarbitone - injectable version can be used to treat status epilepticus
**available for IV use
Case5i:
with regards to the pharmacological treatment of epilepsy, what might you need to consider if our patient was female
pregnancy - sodium valproate is teratogenic and can cause developmental delays during pregnancy
