4 Flashcards
Ursula presents to the GP with a neck lump. What information from the patient’s history and examination could the GP seek?
History -previous infection -previous neck lumps -family history f any cancers -duration -how the lump has changed over time -any pain -red flags (i.e. weight loss, night sweats, changes in voice which can imply laryngeal or pharyngeal cancer) -age Examination -any other abnormal signs -location of lump -palpation features -is it mobile? -moving on swallowing? -sticking out your tongue?
Other than lymphadenopathy what are other causes of neck lumps?
-large thyroid gland
Dermoid cyst
-lipoma
-abscess
Explain the location and features of some neck lumps
- Lipoma: benign fatty tissue growth, mobile, located around thyroid gland area, can wrap fingers around it
- Thyroglossal duct cyst: over on sticking tongue out
- Goitre: moves on swallowing, can’t get fingers around it
- Salivary gland cancer: pain on eating, just under parotid gland
- Lymphadenopathy: lump is hard
- branchial-cleft cyst: fluid-filled near SCM, usually happens in kids
James is 40 and sustains a head injury after falling from his motorcycle. He was not wearing a helmet. He hit his head on the pavement and was knocked unconscious for up to a minute. On regaining consciousness he was alert and orientated and was able to stand up. He had a few minor grazes on his elbow. He declined the option of going to hospital and instead return home. Several hours later, his parents find him on the chair, confused and drowsy.
An intracranial haemorrhage is suspected. What type intracranial haemorrhage is most likely? What vessel is the most likely source of the bleeding?
Extradural and middle meningeal artery
Rose is 85 and was found wandering the streets disorientated and confused. She was taken to the hospital and her vital signs are BP 140/90, PR 72, RR 16, temp 36.8C, oxygen saturation on air 98%. There are no other signs on physical examination and she appears comfortable though a little agitated. CXR, blood tests and urinalysis are all normal.
What could the differential diagnosis be for a pt. Presenting with confusion? Which diagnosis is most likely in this case? What vessel is the most likely source of bleeding?
- meds
- UTI
- any chest infections
- hypoglycaemia
- hypoxia
- intracranial haemmorhage: subdural (most likely)
- Bridging vein (most likely vessel)
Luther is 50 and presents with a headache. He complains of the light hurting his eyes and finds it painful when the doctor tries to flex his neck. He feels nauseous and vomited several times. He has felt generally unwell the last 3 days, with a sore throat and a fever. Vital signs show: temp. 38C, PR 100, BP 125/60, RR 18, and o2 saturation’s 100% on air.
What is the most likely cause for the patient’s clinical signs and symptoms?
-Meningitis
Arnold is 65 and goes to GP after having monocular blindness affecting the right eye. He described the visual loss like a black curtain falling over the eye, lasting 10 min before he regained normal vision. No other signs were present. GP suspects a type of transient ischaemic attack and has done a test to find a stenosis of an artery in the neck.
In which vessel is the stenosis?
-internal carotid artery
What is the cortical homunculus?
- a distorted representation of how different parts of the brain represents different motor functions of the body
- similar to a person hanging upside down from a monkey bar
Where in the brain will the motor fibres decussate to the opposite side?
-at the medullary pyramids
Is there contralateral cortical control of the cranial nerves? Why or why not?
-cranial nerves branch out before the medullar pyramids so decussation does not occur
What is one similarity and difference between the cranial nerves and spinal nerves?
S: part of the peripheral nervous system
D: relate to brainstem (except 2 which arise from forebrain), spinal nerves are from spine
-cranial nerves arise at irregular intervals from CNS while spinal nerves arise in segments
How many cranial nerves are there?
24 in total
-12 pairs
What structures do the cranial nerves supply? What is the exception?
- supply structures of the head and neck
- except vagus nerve (CN X0 also supplies structures in thorax and abd
What are the different types that the axons of the cranial nerves can be?
- purely special sensory: such as smell, sight, hearing, 3 CN
- purely motor: innervation muscles, 5 CN
- mixed sensory and motor: like spinal nerves
- +/- autonomic (hitch-hike): only 4 CN carry autonomic
What is the brainstem?
- Adjoins the brain to the spinal cord
- Continuous with spinal cord caudally
- vital role in regulation of cardio-respiratory function and maintaining consciousness
- location of majority of cranial nerve nuclei
- ascending sensory and descending motor fibres between brain and rest of body run through the brainstem
How many cranial nerve arise from each part of the brainstem and forebrain?
- forebrain (extension of brain and not brainstem) 2 CNs
- midbrain: 2 CNs
- Pons: 4 CNs
- medulla: 4 CNs
Describe the olfactory nerve (CN 1)
-one nose so CN 1
-arise from fibres of olfactory nerves (in roof of nasal cavity), to cribiform foramina, to olfactory bulb, to olfactory tract to temporal lobe (uncus)
-is a special sensory nerve for olfaction (sense of smell)
-paired anterior extensions of forebrain rather than a “true” cranial nerve
Clinical points
-not often tested: may just ask about difficulties/changes in sense of smell
-if you are testing formally, test one nostril at a time
-loss of sense of smell: anosmia
-commonest cause of anosmia is cold, respiratory tract infection
-head injury can also cause anosmia (secondary to shearing forces and/or basilar skull fracture)
-tumours at base of frontal lobes (within anterior cranial fossa) may involve CN 1
Describe the optic nerve (CN 2)
-2 eyes so cranial nerve 2
-is a special sensory nerve for sight
-paired anterior extension of forebrain rather than a “true” cranial nerve
-part of the visual pathway
-impulses generated by cells within retina in response to light: generates action potentials which propagate along optic nerve
-via other components of the visual pathway they reach primary visual cortex where they are perceived as vision
-arise from retinal ganglion cells (back of eye), to axons from optic nerve (originate from optic disc), then exits back of orbit via optic canal, then the fibres cross and merge at optic chiasm
Clinical points
-visual acuity tests (ex. Snellen chart which is the letters chart)
-visual fields
-pupillary light responses (to see if optic nerve is working)
-seen directly with ophthalmoscope (i.e. optic disc= point at which nerve enters the retina)
-carries extension of meninges: nerve affected when raised ICP
-swollen optic disc (papillodema)
What does the optic nerve do?
Carries sensory fibres from one eye (retina)
What does the optic chiasm do?
- mixing of sensory fires from right and left optic nerves
- continues further into brain to become optic tract
