Disability Notes 2

Question 1

When should a patient have imaging for suspected stroke within 1 hour?

Answer 1

• indications for thrombolysis/ early anticoagulation treatment
• on anticoags
• known bleeding tendency
• GCS <13
• unexplained progressive, fluctuating symptoms
• pappiloedema, neck stiffness or fever
• severe headache at onset

Question 2

What patients warrant thrombolysis in stroke?

What score can be used and what does a score >0 mean?

Answer 2

• time of onset <4.5 hours and ROSIER score >0

- ROSIER score, high likelihood of stroke

Question 3

What are the parameters of the Rosier Score?

Answer 3

• Assymetric facial/ elg/ arm weakness (1 each)
• speech disturbance
• visual field defect
• -ve points for syncope and seizures

Question 4

What are the contraindications to thrombolysis?

Answer 4

• Seizure at onset of stroke
• symptoms suggesting SAH
• stroke in last 3 months
• major surgery/ trauma in last 2 weeks
• previous intracranial haemorrhage
• intracranial neoplasm
• aneurysm
• bleeding in last 3 weeks from anywhere
• INR>1.7

Question 5

What bloods/ investigations would you order?

Answer 5

• ECG
• FBC
• U+Es
• Cholesterol
• Glucose (rule out hypo)

Question 6

What risk factors are there for stroke?

Answer 6

• Previous stroke/ TIA
• Hypertension
• Diabetes
• PVD, IHD
• AF
• current/ ex- smoker
• hyperlipidaemia

Question 7

After CT how should these patients be managed?

Answer 7

• Alteplase 0.9mg/kg
• 10% given as bolus, 90% infusion

Aspirin 300mg OD for 2 weeks if NO bleed, then clopidogrel 75mg OD for life

• Statin
• Monitor RFs

Question 8

If the patient has AF how should management change?

What anti-coagulant should they get?

Answer 8

Offer anti-coagulation if:

• Male + CHA2DS2-VASc score of 1 or more
• Female + CHA2DS2-VASc score of 2 or more
• NOACs: Dabigatran, rivaroxaban, apixaban

Question 9

What is the CHA2DS2S VASc score breakdown?

Answer 9

• Congestive heart failure
• Hypertension
• Age >75
• Diabetes
• previous Stroke/ TIA (2)
• Vascular disease
• Age 65-74
• Sc Sex category- (female 2)

Question 10

How would you assess bleeding risk in patients with AF who are anticoagulated? Explain it

Answer 10

• HAS BLED score
• Hypertension
• Abnormal liver/ renal function
• Stroke
• Bleeding
• Labile INR
• Elderly (age> 65)
• Drugs/ Alcohol

Question 11

What are the common organisms causing meningitis?

Answer 11

• N meningitides/ Strep pneumoniae

- listeria in young and old

Question 12

What signs can be elicited?

Answer 12

• headache, neck pain, photophobia, seizures
• tachycardia, hypotensive, pyrexial, reduced GCS,
• non blanching, petechial rash
• Brudzinskis (neck flexing)
• Kernig’s sign (knee extension)

Question 13

What is the treatment for Meningitis?

Answer 13

• Community: IM benzylpenicillin 1.2g

- Hospital: ceftriaxone 2g IV

Question 14

What bloods would you do in meningitis?

Answer 14

• (FBC/ U+Es/ LFTs, CRP, BM, clotting, blood gas)

Question 15

What investigations would you do apart from bloods in meningitis?

Answer 15

• Blood cultures
• throat swab
• PCR
• CT scan
• LP

Question 16

What is the glucose like in bacterial, viral and TB lumbar punctures?

What components of WCC are high in bacterial and then viral meningitis?

Answer 16

• low, normal, low
• neutrophils >1000
• lymphocytes
• LP turbid means bacterial

Question 17

Name causes for seizures.

Answer 17

• Epilepsy,
• hypoglycaemia, hyper/ hyponatraemia, hypoxia, hypercalcaemia
• hypertension/ eclampsia
• stroke, alcohol withdrawal
• meningitis, encephalitis

Question 18

What is defined as status epilepticus?

Answer 18

• Convulsive seizure, continued for >30 mins

- OR continued one after the othern

Question 19

What is the management of elipesy?

Answer 19

• ABCDE, recovery position
• manage CAUSE of seizure
• If seizure >5mins, call for senior help, attach cardiac monitor and one of:
• IV lorazepam (4mg stat) repeat every 10 mins
• PR diazepam 10mg. Can repeat every 10 mins up to 30 mg
• Buccal midazolam 10mg

Question 20

What is the management of epilepsy cont.

Answer 20

• If seizure lasts >20 mins:
• call the anaesthetist
• phenytoin- 20mg/kg IV at <50mg/min
• (phenobarbitol if taking phenytoin)

if seizure lasts >40 mins:
- manage on ICU with thiopentone/ propofol infusion

Question 21

What bloods would you get in epilepsy?

Answer 21

• FBC, U+Es, LFTs, Ca, glucose, blood cultures

Question 22

What are the symptoms of alcohol withdrawal?

Answer 22

• tremor, sweating
• N and V
• anxiety, psychomotor agitation
• headache, insomnia
• malaise, weakness
• hallucinations
• grand mal convulsions
• tachycardia/ hypertension

Question 23

When does delirium tremens set in?

What is it characterised by?

Answer 23

• 1-3 days post alcohol cessation

- symptoms of alcohol withdrawal and hallucinations involving insects/ small animals

Question 24

how is delirium tremens managed?

What is the CIWA-Ar score out of? When does the patient start to get out of control, aggressive and angry?

Answer 24

• Reducing dose of chlordiazepoxide
• IV pabrinex 1+2 (PO thiamine and vitamin B co-strong)
• CIWA-Ar score
• around 20

Question 25

What is Wernicke’s due to?

What are the symptoms?

Answer 25

• thiamine B1 deficiency
• some are sub-clinical but should still be treated with pabrinex
• visual changes- double vision, eye movement abnormalities
• loss of muscle co-ordination
• retrograde or anterograde amnesia
• inability to form new memories
• hallucinations/ confabulation

Question 26

What are the CIWA score components?

Answer 26

• auditory hallucinations
• visual hallucinations
• tactile hallucinations
• nausea and vomiting
• anxiety
• tremor
• paroxysmal sweats
• headache and agitation

Question 27

What kind of peripheral neuropathy will they have?

Answer 27

• abnormal reflexes
• ataxia, broad based gait
• polyneuropathy