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Year 3 OSCE > Case 4- Headache > Flashcards

Case 4- Headache Flashcards

1
Q

Migraine headache

A

Unilateral pulsating headache
Last between hours-days
May be visual aura (scotoma)
Photophobia, nausea, phonophobia
Sufferers don’t want to move
Children- GI disturbance

NB- can get slight paralysis

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2
Q

Management of migraines

A

Limit stimuli, supportive management (diet, exercise etc.)
Acute- oral triptan (not in pregnancy) and NSAID (or paracetamol)
Prophylaxis (2 or more attacks per month)- topiramate or propranolol (use the latter in pregnancy and women of child-bearing age)

NB- antiemetic in migraine: metoclopramide (no more than 5 days- risk of extra-pyramidal side effects)

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3
Q

Cluster headache

A

Short painful attacks around one eye
Last between 30mins-3 hours
Occur once/twice a day for 1-3 months
May be lacrimation/ flushing
Can see partial Horner syndrome
Tend to be pacing around in agony (unlike migraine sufferers)

NB- can also get aura, photophobia, hyperacusis, swollen red eye

Management- 100% oxygen, s/c triptan

verapamil (or lithium/Prednisolone) for prophylaxis

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4
Q

Tension headaches

A

Bilateral tight band sensation
Recurrent
Occurs late in the day
Associations with stress
Tightness in muscles of the neck

Use paracetamol or NSAID
Supportive- lifestyle modifications (esp. stress)
Acupuncture as prophylaxis

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5
Q

Investigations for GCA

A

Bloods- ESR, CRP, LFTS (raises ALP)
Temporal artery biopsy- gold standard (if biopsy negative and still clinically suspicious- treat anyway)

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6
Q

Management of GCA

A

Steroids (PPI and bone protection)
Aspirin
Referral to vascular surgeons, ophthalmology (same day if vision loss), and rheumatology

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7
Q

Trigeminal neuralgia

A

2 second paroxysms of stabbing pain in unilateral trigeminal nerve distribution (electric shock)
Face screws up with pain (tic doloroux)

Carbamazepine is first line
If doesn’t respond or atypical features/red flags- refer to neurology

NB- could be a tumour pressing on the trigeminal ganglion. MRI head may be me necessary

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8
Q

Investigations for meningitis

A

Bedside- pneumococcal urinary antigen, lumbar puncture with viral PCR, throat swabs for n. Meningitidis and s. Pneumoniae
Bloods- FBC (WCC, anaemia), UE, cultures at different sites, clotting profile (DIC), LFT (derangement), serology for common meningitis viruses
CT head- when neurological symptoms predominate
Involve microbiology early

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9
Q

Management of meningitis

A

Supportive- IV fluids, notify PHE
Medical- IV cefotaxime (add IV amoxicillin if younger than 3 months or older than 50 years), IV steroids if older than 3 months, one dose PEP for any contacts within 7 days of onset (oral rifampicin or ciprofloxacin)

NB- in community IM benzylpenicillin should be used

Contraindications to steroids;
-Septic shock
-Meningococcal septicaemia
-Meningitis post-surgery
-Immunocompromised
-<3months

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10
Q

Kernigs test

A

Lie patient on back- flex one hip and knee to 90 degrees and slowly straighten the knee whilst keeping the knee flexed
Positive test- spinal pain/ resistance to movement

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11
Q

Brudzinskis test

A

Lie patient flat on back and use hands to lift their head and neck off the bed to touch their chest with their chin
Positive- patient involuntarily flexes hips and knees

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12
Q

Subarachnoid Haemorrhage

A

Usually the result of a cerebral aneurysm
Very sudden onset severe headache
Meningismus
Deviation of central sulcus on a CT and blood present in the sulci

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13
Q

Meningitis Features

A

Triad- fever, headache, nuchal rigidity

Altered mental state, photophobia, nausea and vomiting, malaise, seizures, purpuric rash, Kernigs and Brudzinskis

In neonates triad is typically absent, so may show lethargy, hypotonia, irritability, n and v, dyspnoea, fontanelle bulge, high pitched cry, seizures (all latter symptoms)

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14
Q

Encephalitis

A

May be similar to meningitis but more focal neurological deficits eg. Seizures, behavioural changes, altered consciousness

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15
Q

Notifiable diseases PHE

A

Encephalitis
Hepatitis
Meningitis
Food poisoning
Legionnaires
Malaria
TB

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16
Q

Encephalitis investigations

A

Lumbar puncture with PCR for HSV
Throat swab
Bloods- FBC UE cultures at different sites
CT head- oedema frontal lobes
EEG

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17
Q

Migraine risk factors

A

Stress, chocolate, red wine, cheese, hormonal changes in women, analgesia overuse

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18
Q

Cluster headache management

A

Triptans
High flow oxygen

Prednisone as prophylactic treatment

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19
Q

Contraindications to a lumbar puncture

A

Raised ICP- papilloedema, focal neurology
Coagulation defect
Sign of infection at site of needle insertion

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20
Q

Encephalitis risk factors

A

Animal or insect bite
Freshwater swimming

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21
Q

Epidural haematoma

A

Middle meninges artery rupture (or dural venous sinus)
Lucid interval very typical
Fusiform shape on CT- doesn’t cross the suture lines

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22
Q

Subdural haematoma

A

Venous in origin- bridging veins
Elderly (anticoagulation), alcoholics, debilitated people at risk
Fluctuating levels of consciousness- injury can be weeks ago
Crescent shaped haematoma- crosses the suture lines, mass effect (midline shift)
Chronic (old subdurals) are hypodense (dark) on imaging
Surgical decompression with burr holes if symptomatic

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23
Q

Raised ICP Sx

A

Headache, vomiting, blurred vision, reduced GCS, bradycardia, HTN, paiploedema

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24
Q

Medication overuse headache features

A

Present for 15 or more days a month
Developed or worse whilst taking meds
Opioids and Triptans- most at risk

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25
Q

Management of MOH

A

Withdraw analgesia (analgesics and Triptans- abruptly)
Opioids- gradual

NB+0- may get withdrawal symptoms eg. Vomiting, hypotension, tachycardia, restlessness, sleep disturbance, anxiety

26
Q

What is the most common complication post-meningitis

A

Sensory neural hearing loss

27
Q

Common migraine triggers

A

Tiredness, stress
Alcohol
Combined OCP
Lack of food or dehydration
Cheese chocolate red wine
Menstruation
Bright lights

28
Q

Migraines in pregnancy

A

Paracetamol
NSAIDs (1st and 2nd trimester)
Avoid aspirin

Migraine with aura- COC pill contraindicated (stroke)

29
Q

Thoracic outlet syndrome

A

Compression of brachial plexus, subclavian artery or vein at site of thoracic outlet (NB can have neurogenic or vascular presentation, or both)

Painless muscle wasting of hand muscles, hand weakness, altered sensation, cold hands, swollen hands, painful arm claudication, distended veins

30
Q

How do triptans work

A

5 HT1B and D agonists

31
Q

Tuberous sclerosis features

A

Autosomal dominant
Depigmented ash leaf spots that fluoresce under UV light
Roughened patches of skin over the lumbar spine (Shagreen patches)
Angiofibromas
Cafe au lait spots may be seen
Fibromata beneath nails
Developmental delay and intellectual impairment
Epilepsy
Retinal harmatomas

32
Q

Triptans and ergotamine’s

A

Don’t take within 24 hours of one another- coronary artery spasm

33
Q

Features of GCA

A

Constitutional- fever, weight loss, night sweats
Temporal artery inflammation- temporaL headache, tender temporal artery, jaw claudication, scalp tenderness
Vistula defecits- scotoma (curtain), amaurosis fugax (complete vision loss)
Diplopia
Poly myalgia rheumatica Sx (aching, morning stiffness in proximal limb muscles)

34
Q

Meningitis bacterium 0-3mnths

A

Group B Streptococcus (most common cause in neonates)
E. coli
Listeria monocytogenes

35
Q

Meningitis bacterium 3mnths-6years

A

Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae

36
Q

Meningitis bacterium in 6-60 years

A

Neisseria meningitidis
Streptococcus pneumoniae

37
Q

Meningitis bacterium >60 years

A

Streptococcus pneumoniae
Neisseria meningitidis
Listeria monocytogenes

38
Q

Nausea and migraine

A

metoclopramide

39
Q

Paroxysmal Hemicrania

A

Paroxysmal hemicrania (PH) is defined by attacks of severe, unilateral headache, usually in the orbital, supraorbital or temporal region. These attacks are often associated with autonomic features, usually last less than 30 minutes and can occur multiple times a day.

Shares many features with cluster headaches

Management- indomethacin.

40
Q

Metronidazole and alcohol

A

disulfiram-like reaction with alcohol (find what disulfiram does)

41
Q

Mumps

A

fever
malaise, muscular pain
parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral in 70%

Management;
rest
paracetamol for high fever/discomfort
notifiable disease

Prevention- MMR vaccine (80% effective)

Complications
-orchitis (more common in post-pubertal males)
-hearing loss - usually unilateral and transient
-meningoencephalitis
-pancreatitis

42
Q

Necrotising Fasciitis

A

type 1 is caused by mixed anaerobes and aerobes (often occurs post-surgery in diabetics). This is the most common type

type 2 is caused by Streptococcus pyogenes

Risk factors;
skin factors: recent trauma, burns or soft tissue infections
diabetes mellitus (the most common preexisting medical condition, particularly if the patient is treated with SGLT-2 inhibitors)
intravenous drug use
immunosuppression

43
Q

Features and management of necrotising fasciitis

A

The most commonly affected site is the perineum (Fournier’s gangrene).

Features;

acute onset
pain, swelling, erythema at the affected site
often presents as rapidly worsening cellulitis with pain out of keeping with physical features
extremely tender over infected tissue with hypoaesthesia to light touch
skin necrosis and crepitus/gas gangrene are late signs
fever and tachycardia may be absent or occur late in the presentation

Management;
urgent surgical referral debridement
intravenous antibiotics

44
Q

Norovirus

A

also known as the winter vomiting bug, is one of the most common causes of gastroenteritis in the UK

Features;

Develop within 15 - 50 hours of infection
patients experience nausea, vomiting, and diarrhoea, which may be accompanied by headaches, low-grade fevers, and myalgia.

Transmission- Faecal-oral route, with the virus becoming aerosolized

Investigations- stool culture viral PCR (polymerase chain reaction).

45
Q

Management of norovirus

A

Limit transmission- isolate patients, handwashing (not hand gel)
Ensure adequate hydration (D+V)

46
Q

Pnuemococcal pneumonia

A

Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia

Characteristic features of pneumococcal pneumonia
-rapid onset
-high fever
-pleuritic chest pain
-herpes labialis (cold sores)

47
Q

Pseudomonas aeruginosa

A

an aerobic Gram-negative rod. It causes a number of clinically important infections in humans:

chest infections (especially in cystic fibrosis)
skin: burns, wound infections, ‘hot tub’ folliculitis
otitis externa (especially in diabetics who may develop malignant otitis externa)
urinary tract infections

48
Q

Microcephaly

A

an occipital-frontal circumference < 2nd centile

Causes include
-normal variation e.g. small child with small head
-familial e.g. parents with small head
-congenital infection (Zika)
-perinatal brain injury e.g. hypoxic ischaemic encephalopathy
-fetal alcohol syndrome
-syndromes: Patau
-craniosynostosis

49
Q

Mitochondrial diseases

A

Mitochondrial inheritance has the following characteristics:
-inheritance is only via the maternal line as the sperm contributes no cytoplasm to the zygote
-none of the children of an affected male will inherit the disease
-all of the children of an affected female will inherit the disease
-generally, encode rare neurological diseases
poor genotype:phenotype correlation - within a tissue or cell there can be different mitochondrial populations - this is known as heteroplasmy

Histology
-muscle biopsy classically shows ‘red, ragged fibres’ due to increased number of mitochondria

50
Q

Causes and management of nappy (napkin) rashes

A

Irritant dermatitis- the most common cause, due to irritant effect of urinary ammonia and faeces
Creases are characteristically spared

Candida dermatitis- typically an erythematous rash which involve the flexures/creases and has characteristic satellite lesions

Seborrhoeic dermatitis- erythematous rash with flakes. May be coexistent scalp rash

Psoriasis- a less common cause characterised by an erythematous scaly rash also present elsewhere on the skin

Atopic eczema- other areas of the skin will also be affected

General management points;
-disposable nappies are preferable to towel nappies
-expose napkin area to air when possible
-apply barrier cream (e.g. Zinc and castor oil)
-mild steroid cream (e.g. 1% hydrocortisone) in severe cases
-management of suspected candidal nappy rash is with a topical imidazole. Cease the use of a barrier cream until the candida has settled

NB- candida/creases (C for C)

51
Q

Neck masses in children

A

pass medicine

52
Q

Necrotising enterocolitis

A

Necrotising enterocolitis is one of the leading causes of death among premature infants. Initial symptoms can include feeding intolerance, abdominal distension and bloody stools, which can quickly progress to abdominal discolouration, perforation and peritonitis.

Abdominal x-rays are useful when diagnosing necrotising enterocolitis, as they can show:
-dilated bowel loops (often asymmetrical in distribution)
-bowel wall oedema
-pneumatosis intestinalis (intramural gas)
-portal venous gas
-pneumoperitoneum resulting from perforation
-air both inside and outside of the bowel wall (Rigler sign)
-air outlining the falciform ligament (football sign)

Management;
Neonates with suspected NEC need to be nil by mouth with IV fluids, total parenteral nutrition (TPN) and antibiotics to stabilise them. A nasogastric tube can be inserted to drain fluid and gas from the stomach and intestines.

NEC is a surgical emergency and requires immediate referral to the neonatal surgical team. Some neonates will recover with medical treatment. In others, surgery may be required to remove the dead bowel tissue. Babies may be left with a temporary stoma if significant bowel is removed.

53
Q

Neonatal blood spot screening

A

Performed at 5-9 days of life

The following conditions are currently screened for:
-congenital hypothyroidism
-cystic fibrosis
-sickle cell disease
-phenylketonuria
-medium chain acyl-CoA dehydrogenase deficiency (MCADD)
-maple syrup urine disease (MSUD)
-isovaleric acidaemia (IVA)
-glutaric aciduria type 1 (GA1)
-homocystinuria (pyridoxine unresponsive) (HCU)

54
Q

Neonatal hypoglycaemia

A

Transient hypoglycaemia in the first hours after birth is common.

Persistent/severe hypoglycaemia may be caused by:
-preterm birth (< 37 weeks)
-maternal diabetes mellitus
-IUGR
-hypothermia
-neonatal sepsis
-inborn errors of metabolism
-nesidioblastosis
-Beckwith-Wiedemann syndrome

Features
may be asymptomatic
autonomic
-‘jitteriness’
-irritable
-tachypnoea
-pallor
neuroglycopenic
-poor feeding/sucking
-weak cry
-drowsy
-hypotonia
-seizures
other features may include
-apnoea
-hypothermia

Management;

asymptomatic
-encourage normal feeding (breast or bottle)
-monitor blood glucose

symptomatic or very low blood glucose
-admit to the neonatal unit
-intravenous infusion of 10% dextrose

55
Q

Neonatal sepsis

A

Early-onset sepsis in the UK is primarily caused by group B strep infection (75%)

Risk factors
-Mother who has had a previous baby with GBS infection, who has current GBS colonisation from prenatal screening, current bacteruria, intrapartum temperature ≥38ºC, membrane rupture ≥18 hours, or current infection throughout pregnancy
-Premature (<37 weeks): approximately 85% of neonatal sepsis cases are in premature neonates
-Low birth weight (<2.5kg): approximately 80% are low birth weight
-Evidence of maternal chorioamnionitis

Patients typically present with a subacute onset of;
Respiratory distress (85%)
Grunting (grunting neonate, think sepsis)
Nasal flaring
Use of accessory respiratory muscles
Tachypnoea
Tachycardia: common, but non-specific
Apnoea (40%)
Apparent change in mental status/lethargy
Jaundice (35%)
Seizures (35%): if cause of sepsis is meningitis
Poor/reduced feeding (30%)
Abdominal distention (20%)
Vomiting (25%)
Temperature
The clinical presentation can vary from very subtle signs of illness to clear septic shock
Frequently, the symptoms will be related to the source of infection (e.g. pneumonia + respiratory symptoms, meningitis + neurological symptoms)

NB- all the usual tests eg. urine, LP, 2x blood cultures etc.

NB- sepsis 6 (oxygen, fluids and ABX in etc.)

The NICE guidelines recommend use of intravenous benzylpenicillin with gentamicin as a first-line regimen for suspected or confirmed neonatal sepsis

56
Q

Nephrotic syndrome in children

A

In children the peak incidence is between 2 and 5 years of age. Around 80% of cases in children are due to a condition called minimal change glomerulonephritis. The condition generally carries a good prognosis with around 90% of cases responding to high-dose oral steroids.

57
Q

Newborn resuscitation

A
  1. Dry baby and maintain temperature
  2. Assess tone, respiratory rate, heart rate
  3. If gasping or not breathing give 5 inflation breaths*
  4. Reassess (chest movements)
  5. If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1
58
Q

Nocturnal enuresis

A

The majority of children achieve day and night time continence by 3 or 4 years of age. Enuresis may be defined as the ‘involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract’

NB- before 5, reassurance and follow up given

Nocturnal enuresis can be defined as either primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months before)

Management;

look for possible underlying causes/triggers
-constipation
-diabetes mellitus
-UTI if recent onset

general advice
-fluid intake
-toileting patterns: encourage to empty bladder -regularly during the day and before sleep
-lifting and waking

reward systems (e.g. Star charts)
-NICE recommend these ‘should be given for agreed behaviour rather than dry nights’ e.g. Using the toilet to pass urine before sleep

enuresis alarm
-generally first-line for children
-have sensor pads that sense wetness
-high success rate

desmopressin
-particularly if short-term control is needed (e.g. for sleepovers) or an enuresis alarm has been ineffective/is not acceptable to the family

59
Q

Noon Syndrome

A

An autosomal dominant condition associated with a normal karyotype. It is thought to be caused by a defect in a gene on chromosome 12

As well as features similar to Turner’s syndrome (webbed neck, widely-spaced nipples, short stature, pectus carinatum and excavatum), a number of characteristic clinical signs may also be seen:
-cardiac: pulmonary valve stenosis
-ptosis
-triangular-shaped face
-low-set ears
-coagulation problems: factor XI deficiency

60
Q

Normal lower limb variants in children

A

pass medicine

61
Q

Obesity in children

A

Cause of obesity in children
-growth hormone deficiency
-hypothyroidism
-Down’s syndrome
-Cushing’s syndrome
-Prader-Willi syndrome

Consequences of obesity in children
-orthopaedic problems: slipped upper femoral epiphyses, Blount’s disease (a development abnormality of the tibia resulting in bowing of the legs), musculoskeletal pains
-psychological consequences: poor self-esteem, bullying
-sleep apnoea
-benign intracranial hypertension
-long-term consequences: increased incidence of type 2 diabetes mellitus, hypertension and ischaemic heart disease

Year 3 OSCE (61 decks)

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