2 - Neurological Common Presentations and Investigations Flashcards
How do you take a history for a blackout/LOC/fall?
Patient and Collateral History
Before:
- Any warning e.g epileptic aura, palpitations, chest pain, SOB, sweating
- Circumstance e.g watching TV, hit head
During (Collateral)
- Duration
- LOC
- Movements (floppy/stiff/jerking)
- Incontinence/bite side of tongue
- Complexion (cyanosis seizure, pale syncope)
After
- What can patient remember about attack (amnesia)
- Any muscle ache
- Any drowsiness/confusion (post-ictal)
- Injuries from fall
Background: When did attacks start, how frequent, getting more frequent
PMHx: Cardiac
Dx and Allergies: Postural hypotension
FHx
SHx
What are some systems review questions you should ask in a ‘blackout’ history?
What are some causes of ‘blackouts’?
Syncopal:
- Cardiac: arrhythmias, aortic stenosis
- Postural Hypotension: drugs, dehydration, autonomic dysfunction
- Neurogenic: vasovagal
Seizures
- Epilepsy
- Infections
- Electrolyte disturbances
- Drugs
Drop Attacks
Hypoglycaemia
Stokes-Adams Attacks
Instability: e.g Parkinson’s, Arthritis can predispose to falls
What is vasovagal syncope?
Reflex bradycardia and peripheral vasodilation provoked by emotion, pain or standing too long
Pre-Syncopal Symptoms: nausea, pallor, sweating, narrowing of visual fields
May have brief clonic jerking of limbs due to cerebral hypoperfusion but rapid recovery
How can you tell the difference between a seizure and syncope from a history?
What are some precipitants of breakthrough seizures in epilepsy?
- Sleep deprivation
- Poor medication compliance
- Alcohol
What is a Stokes-Adams attack?
Transient arrhythmias that cause drop in cardiac output so LOC
Patient falls to ground with no warning apart from palpitations. They go pale with a slow or absent pulse and then recover in seconds and flush. Respiration continues the whole time. May jerk
Associated with tacky/brachyarrhythmias and complete heart block
How can anxiety lead to a black out?
Hyperventilatin causes hypocapnia so vasoconstriction
What is a drop attack?
Sudden fall to the ground without LOC
Causes: hydrocephalus, cataplexy, narcolepsy
What investigations should you consider after a blackout?
- Bloods: CRP, Glucose, FBC, U+Es, CK, PRL
- ABG
- Lying/Standing BP
- ECG and 24h Tape
- EEG
- ECHO
- CT/MRI head
Advise against driving whilst trying to find cause
What examinations/systems review should you do when a patient comes in with a blackout?
Cardiac
Neurological
What are some important questions to ask in the history for vertigo/dizziness?
Timing
•When started
•Acute/ gradual onset
- Duration
- Progression
- Intermittent or continuous
- *Background to attacks**
- E.g had before, frequency, impact on life
Associated Symptoms
- Difficulty walking or standing
- Relief on lying or standing still
- N+V
- Sweating
- Hearing loss
- Tinnitus
What are some causes of vertigo?
Peripheral
- BPPV
- Meniere’s
- Labrinthitis
Central
- Stroke
- MS
- Vestibular migraines
- Ototoxicity e.g amino glycoside abx, loop diuretics (furosemide)
- Acoustic neuroma
How can you tell the difference between central and peripheral vertigo?
- Dix Hallpike and Epley manoeuvre
- HINTS examination
Which patients with vertigo should you perform a HINTS examination on?
HINTS exam looks for the presence of central vertigo
What is the HINTS examination?
Head Impulse Test
- Exclude H+N trauma and neck OA before doing
- If corrective saccade suggests issue with ipsilateral vestibulocochlear nerve so peripheral
- If no corrective saccade central
- Uses VOR reflex
Nystagmus
- Unidirectional means peripheral vertigo
- Bidirectional or Vertical means central vertigo
Test of Skew
- Cover one eye then rapidly move to the other, observe for any vertical or diagonal corrective movement
- If movement then central cause
What are some tests you can do when a patient complains of hearing loss?
- Whisper test
- Tuning fork tests: Webers and Rinne’s with 512 or 256 Hz
- Audiometry/Tympanometry
What are some causes of conductive hearing loss?
- Wax impaction
- Otitis media with effusion (glue ear)
- Eustachian tube dysfunction
- Ear infections
- Perforations of the tympanic membrane
- Chronic supppurative otitis media
What are some causes of chronic sensorineural deafness?
- Presbycusis (high frequency)
- Noise-induced hearing loss
- Congenital infections (e.g. rubella, CMV)
- Neonatal complications (e.g. kernicterus)
What are some causes of sudden sensorineural hearing loss?
Needs urgent same day referral to ENT
- Gentamicin
- MS
- Stroke
- Acoustic neuroma
- Noise exposure
What investigations should you do if there is sudden sensorineural hearing loss?
- ESR
- FBC
- LFT
- PANCA
- Viral titres
- MRI
- Lymph node and nasopharyngeal biopsy
What are some causes of tinnitus?
ANY UNILATERAL TINNITUS NEEDS INVESTIGATING TO EXCLUDE ACOUSTIC NEUROMA
ANY PULSATILE COULD BE CAROTID ARTERY DISSECTION OR STENOSIS OR AV MALFORMATION
- Inner ear damage and hearing loss
- Wax
- Head injury
- Post stapedectomy
- Meniere’s
- Loop diuretics or Aminoglycosides
How is tinnitus managed?
- Exclude serious causes
- Cognitive therapy
- Masking e.g white noise, hearing aid
- Cochlear nerve section (if disabling, last resort as causes deafness)
What questions do you need to ask when a patient presents with bilateral leg weakness?
Where is the lesion?
- Are the legs flaccid (LMN) or spastic (UMN)
- Is there sensory loss? If there’s a sensory level think spinal cord
- Is there loss of bowel/bladder control. If yes then likely to be in conus medullar is or caudal equine
What is the lesion?
- Was the onset sudden or rapidly progressive, if yes this is emergency as may mean cord compression
- Any signs of infection e.g tender spine, fever, raised WCC, raised ESR, CRP
What are some differentials for bilateral leg weakness?
- Cord compression
- Cauda equina
- MND (ALS)
- MS
What are some differentials for bilateral leg weakness?
- Cord compression
- Cauda equina
- MND (ALS)
- MS
What are some differentials for the following patterns of leg weakness?
- Unilateral foot drop
- Weak legs with no sensory loss
- Chronic spastic paraparesis
Unilateral foot drop
- DM
- Common perineal nerve palsy
- Stroke
- Prolapsed disc
- MS
Weak legs with no sensory loss
- MND
Chronic spastic paraparesis
- MS
- Cord malignancy/Metastasis
- MND
- Syringomyelia
What are some differentials for the following patterns of leg weakness?
Chronic Flaccid Paraparesis
- Peripheral neuropathy
- Myopathy
Absent Knee Jerks and Extensor Plantars (combine LMN/UMN)
- MND
- Conus Medullaris
- Myeloradiculitis
- Subacute combined degeneration of the cord
What are some examples of pathologies causing the following gaits?
- Spastic
- Apraxic
- Ataxic
- Myopathic
- Psychogenic
What are some basic care principals you should consider for paralysed patients?
- Avoid pressure sores: turn, pressure relieving matresses
- Prevent thrombosis: passive movement of paralysed limbs, pressure stockings, LMWH
- Bowel evacuation
- Catheterisation
- Exercise unaffected limbs to avoid loss of function
What might an ABG show in a seizure?
Metabolic (lactic) acidosis
How do you describe a cranial mass on MRI/CT?
What are some examples of SOLs?
How may a SOL present?
LESS THAN 8
INTUBATE