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Yr4 Neuro > 1. Disorders affecting consciousness - CASES > Flashcards

1. Disorders affecting consciousness - CASES Flashcards

1
Q 
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

A

vasovagal syncope - fainted

prodrome present typical of syncope

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2
Q

Case 1b:

why not a seizure?

A

orientated
short period of time
evident triggers - previous illness, hot temperature, standing

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3
Q

Case 1c:

what are the 4 P’s of vasovagal syncope - give examples in this case

A

Predisposition - flu-like symptoms
Provocation - hot temperature, standing
Prodrome - tunnel vision, rising in ears, draining sensation
Posture - collapses to floor

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4
Q

Case 1d:

why is this prodrome common

A

cochlea and retina are very sensitive to low O2 - vision/hearing changes can be the first indication someone might pass out

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5
Q

case 1e:

might jerks suggest something other than vasovagal syncope?

A

only if continuous/high number

2-3 jerks is normal

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6
Q

Case 1f:

what investigations might be carried out for this woman

A

ECG for arrhythmias

bloods - anaemia, glucose levels

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7
Q

Case 1g:

what is the best thing to and worst thing to do for a person about to faint

A

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

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8
Q

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

A

Generalised tonic clonic seizure

tonic - stiffness
clonic - jerking

jerking - should be symetrical movements, synchronised

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9
Q

Case2b:

what might have caused the seizure

A

provocation/triggers present - alcohol, lack of sleep, physical exertion

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10
Q

Case2c:

is the time of unconscious normal for this kind of seizure

A

yes - should be <5 mins

> 5 mins = ?stasis ?non-epileptic causes

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11
Q

Case2d:

what investigations should be done

A

MRI - gold standard
CT
EEG - only provides a snapshot of activity at the time

ECG - arrhythmias
FBC
electrolytes
Blood glucose
infection screen
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12
Q

Case2e:

what advice would you give this man

A

6 months no driving after a first seizure
work - ladders, heavy machinery
reduce alcohol intake

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13
Q

Case3f:

what treatment would be given

A

none initially after first seizure - treat on subsequent attacks (epilepsy needs multiple attacks for diagnosis)

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14
Q

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

A

Non-epileptic attack - dissociative/panic attack

stress can be a trigger

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15
Q

Case3b:

what tests might you do

A

ECG
MRI scan
EEG

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16
Q

Case3c:

how might you explain the diagnosis to the patient

A

protective mechanism from trigger - dissociation

even though not a seizure still a valid diagnosis

17
Q

Case3d:

what are the typical presentations of a dissociative attack

A

lying very still
OR
thrashing around

18
Q

Case3e:

how can these attacks be managed

A

prevention
avoid triggers
breathing exercises

19
Q

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)

A

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
20
Q

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

A

pupil dilation = pressure on the brainstem
= RAISED ICP

pupil unreactive = 3rd nerve palsy - root in the brainstem

21
Q

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

A

LEFT

hemiparesis = localising sign
(seen on the contralateral side to damage)

3rd nerve palsy = false localising sign (seen on ipsilateral side to damage)

22
Q

Case4d:

what other signs might suggest increased pressure on the brainstem

A

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
23
Q

Case4e:

when assessing a patient for a response to pain, where should you assess it

A

above the neck

- enables you to distinguish from localising (GCS-M5) and flexing (GCS- M3) to pain

24
Q

Case4f:

what else might be seen in a third nerve palsy along side a dilated pupil

A

ptosis

pupil “down and out”

25
Q

Case4g:

what is the best course of management for this patient

A 
stabilise C spine
ABCDE
GCS <8 = intubate+ventilate
treat raised ICP
cranial imagine - may need decompressive surgery/removal of haematoma
repeated neuro obs (GCS)
26
Q

Case4h:

what is the management for raised ICP

A
  1. surgery to relieve pressure (+/-shunt)
  2. osmotic agents eg mannitol
  3. Nurse with head at 30-45% (venous return)
  4. reduce pain
  5. maintain good PO2, reduce PCO2
  6. reduce metabolism (reduce temp, barbiturates)
27
Q 
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

A

focal seizure - complex partial seizure (due to loss of awareness)

NOT absence seizure - usually in kids/teens and lasts ~15secs

28
Q

Case5b:

what is the memory of a familiar situation called

A

deja vu

29
Q

Case 5c:

which brain region might be affected

A

temporal lobe

  • complex situational area
  • olfactory perception

diagnosis from scan - mesial temporal sclerosis

30
Q

Case5d:

what investigations are required

A 
MRI
CT
EEG
ECG
routine bloods
31
Q

Case5e:

what is required for this patient to be diagnosed with epilepsy

A

more than one seizure

32
Q

Case5f:

what are some risk factors for epilepsy

A

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

33
Q

Case5g:

what is the treatment for epilepsy

A

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
34
Q

Case5h:

what are the common drugs used in treating epilepsy

A

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

35
Q

Case5i:

with regards to the pharmacological treatment of epilepsy, what might you need to consider if our patient was female

A

pregnancy - sodium valproate is teratogenic and can cause developmental delays during pregnancy

Yr4 Neuro (17 decks)

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