Elderly Care Flashcards
what type of lesion in occurs in MS
typically, a plaque of demyelination in the CNS or optic nerve
why does MS lead to loss of conduction through a nerve
loss of myelin sheath means inefficient/loss of saltatory conduction therefore neurotransmission is duly impaired to the size of the lesion
how does the MS lesion present itself clinically
evolves over a few days, and last for a few weeks or days, and gradually settles. vision in one eye may deteriorate if the optic nerve is affected, or there is weakness in limb
what does the nature of the neurological deficit in MS depend on
site of the plaque of demyelination
what are the two classifications for dissemination of MS
dissemination in time and place
what is the clinical presentation of MS if it affects the optic nerve
optic neuritis. reduced acuity, blurring most commonly central vision colour vision and density faded the optic disk may be red and swollen, with exudates and haemorrhages
how many weeks doe sit usually take for vision to recover in MS episode
4-8weeks
what are the clinical presentations of MS if it affects the midbrain, pons, medulla
- cranial nerve dysfunction
- cerebellar dysfunction e.g. nystagmua, ataxia
- motor deficits for UMN in any of the four limbs
- sensory deficits, spinothalamic or post column in type in any of four limbs
what are the clinical presentations of MS if it affects the spine
symptoms of tracts, UMN, autonomic in spine - below the level of the lesion.
- heaviness/dragging weakness
- loss of pain and temp sensation
- tingling/numbness/in arms/legs
- clumsiness of hand
- bladder/bowel/sexual dysfunction
what are the accumulated ongoing neurological deficits in a patient who has had MS for a long time?
- asymmetric optic pallor, w/o major deficit in visual acuity
- cerebellar deficit causing nystagmus, dysarthria and arm ataxia
- UMN deficit mild in arms, mod in trunk, sev in legs
- impaired sexual/bladder/bowel dysfunction
- sensory loss most evident in trunk and lower limbs
where does MS have more evident effects - arms or legs
legs (more distal?)
how is MS diagnosed
- MR brain reveals multiple lesions
- neurophysiology - measure CNS nerve conduction
- inflammatory nature of demyelinating lesion may lead to increased lymphocyte and globulin content in CSF
what is the management for mild/early MS?
- inform family and patient of diagnosis and education
- encourage normal attitudes to life, activities
- counselling
what is the management of more serious cases of MS
- continued education and support
- attention to vision, cerebellar deficit, pain (gabapentin/anitryptylline), paraplegia, fatigue
- MDT
- respite care arrangements if required
what is the management ( inc pharmacological ) in all cases of MS
1) immunomodulatory drugs
2) high dose IV cotricosteroids (usually methylprednisolone) over 3 days reducing individual episodes
3) avoid obesity and sedentary lifestyle
list some of the immunomodulatory drugs used in the treatment of MS
azathioprine B-interferon copaxone mitoxantrone natalizumab
what are the DIS and DIT MS criteria
at least 2 episodes of symtpoms
- occur at different points in time
- result from involvement of different areas of the CNS
what are the typical scan feature of MS lesions in the CNS
oval, well defined, enhancement
3-6mm
ring or semi-ring
what are the two main types of stroke
ischaemic and haemorrhagic
what is the usual cause of a cerebellar infarct
emblous from carotid artery atheromatous plaque, but can come from anywehre between aorta and cerebral artery itself.
beware can come from dissecting carotid/vertebral a
patients with which conditions usually get stroke from small vessels disease
those with HTN or diabetes
list some of the cardiac diseases associated with tia/stroke
- af
- mural thrombosis after mi
- aortic or mitral valve disease
- bacterial endocarditis
what is the likely pattern of symptoms in MCA ischaemia?
- loss of contralat face/arm use
- loss of contralat face/arm sensation
- dysphasia
- dyslexia, dysgraphia, dyscalculia
what is the likely pattern of symptoms in ACA ischaemia?
- loss of use or feeling/use in contralat leg
what is the likely pattern of symptoms in PCA ischaemia?
- contralateral homonymous hemionopia
what is the likely pattern of symptoms in opthalmic artery occlusion (from MCA)
monocular loss of vision
what is the likely pattern of symptoms in vertebrobasilar artery occlusion
- double vision
- facial numbness
- facial weakness
- vertigo
- dysphagia
(CN lesions) - dysarthria
- ataxia
- loss of feeling in both of arms/legs
what type of vessels usually occlude to cause a lacunar stroke?
small vessels
what is the likely pattern of symptoms in lacunar stroke?
- pure loss of use of contralat arm and leg
- pure loss of sensation of contralat arm and leg
what must be excluded before you give thrombolysis to a patient with stroke?
haemorrhagic stroke
how are patients assessed and looked after when they come into a&e with suspected stroke?
- rap on call team assess
- determined if they are having a stroke therefore if they need a ct
- stroke unit
what is the importance of the SALT team in patients with stroke
- assess patient’s swallowing to determine need for NBM/NGT if they are at risk from aspiration pneumonia
which other mdt professionals are involved in looking after patients with stroke, apart from doctors and nurses
early involvement of - pt/ot/salt
what meds should be given to a patient with stroke/tia to prevent furhter strokes and manage cardiovascular risk?
aspirin
statin
what is needed to be arranged for the patient after they leave hospital with a stroke?
further care and rehabilitation
community liaison e.g nurses
physical and psychological support
what investigations should be done in the patient’s bloods when they present with stroke
fbc/u&e/esr
lipids and blood glucose
what investigations apart from bloods should be done on patients presenting with stroke
- ecg
- cxr
- echo
- Carotid USS
why is it important to do a CUSS in a patient who presents with stroke
-investigate the patient as they may still benefit from carotid endarterectomy
what is usually the origin of SAH?
berry aneurysm, usually from circle of willis
sometimes rarely av malformations
what is the usual presentation of a SAH
sudden onset thundercalp, very severe, headache
sudden rise in icp can cause haedache, vomiting, reduced consciousness and eventually papilloedema
often brief loc with initial bleed
what may be the presentation of a patient who has an intracranial bleed into the region of the internal capsule
severe motor/sensory/visual problems in contralat side of the body
what is the management of SAH
- CT scan confirmation
- CCB
- manage HTN (not over-vigorously)
- neurosurgery (clips/embolism/packing)
what is the most reliable way to prevent SAH’s
keep BP under control
what should be avoided in a patient with haemorrhagic stroke?
thrombolysis should be AVOIDED!
how do people with olfactory nerve dysfunction present?
loss of sense of smell
inability to taste different foods
list some of the cause of monocular blindness
- prodrome of migraine
- thromboembolism of opthalmic artery (from ICA) - curtain like
- infarction of optic nerve or retina
- GCA
- optic neuritis as part of MS
what is the usual cause of bitemporal hemionopia
optic chiasm compression by pituitary adenoma growing upwards from sella tursica/pituitary fossa
what are some of the causes of homonymous hemionopia
- POCS
- infarct/haematoma in internal capsule
- lesions
- abscesses
- tumurs affecting optic radiations
which condition is often the cause of visual inattention/neglect
stroke
which muscles does myasthenia gravis often affect in the upper body
ocular
bulbar
what is the effect of grave’s disease on ocular muscles
inflammatory swelling o the external ocular muscles within the orbit eventually leads to fibrosis - proptosis, lid retraction, lid lag
what is bulbar palsy and how does it present?
bilateral impairment of CN IX, X and XII causing:
- dysarthria
- dysphagia
- dysphonia and poor cough (vocal cords)
- susceptibility to aspiration pneumonia
list some of the ways in which the recurrent laryngeal nerve can become damaged
- aortic aneurysm
- tumours (esp in mediastinum)
- malignant nodes
- surgery
what is the difference between dysphasia and dysarthria
dysarthria is purely mechanical, whereas dysphasia is an impairment in language
what is the characteristic speech in patients with cerebellar dysfunction?
scanning/staccato dysarthria
where do the spinal nerves exit the spinal column
intervertebral foramina
which anatomical structures herniate to cause prolapse disc
nucleus pulposus protrudes through annulus fibrosus of the intervertebral disc to cause disc prolapse
how does herpes zoster of nerve roots present
painful vesicular eruption of shingles in demraome distrbution.
what is post herpetic neuralgia
pain that follows herpes zoster of nerve roots, even after the rash has disappeared
what may be given to immunocompromised patients who have herpes zoster of nerve roots
systemic aciclovir
what is MND
selective loss of lower motor neurones from the pons, medulla and spinal cord, together with loss of UMNs from the motor cortex of the brain
which functions are left intact in MND
special senses, cerebellar, sensory and autonomic functions are left intact
how may MND first present
as problem in the bulbar muscles or limbs, tends to be either UMN or LMN in nature
list the key features of MND
- muscle weakness
- muscle wasting
- muscle fasciculation
- exaggerated reflexes
- no loss of sensation
what does a limb look like on examination of a patient with MND
- weak, wasted, fasciculating
- deep tendon reflexes very brisk
is there sensory loss in MND?
no
what are most deaths in MND caused by?
Inanition (exhaustion by lack of nourishment) and chest infections due to involvement of bulbar and respiratory muscles account for most deaths
what is Amyotrophic Lateral Sclerosis (ALS)
specific disease that causes death of neurones which control voluntary muscles
a.k.a MND
how does bulbar palsy present in patients with MND
- weakness/wasting
- fasciculation of lower facial muscles and muscles moving in the palate, pharynx, larynx and tongue
how does MND affect muscles of the limb (s+s)
- progressive muscle atrophy
- weakness, wasting and fasciculation of any of the limbs or trunk muscles
- muscle cramps
- small muscles of hand involved
- ALS
- spasticity, clonus
- increased deep tendon reflexes
what is riluzole used to treat and how does it work?
MND - glutamate antagonist which blocks a specific channel associated with damaged neurones to slow the progression and prolong survival from MND
give the ways in which MND can be managed
- physio and drugs for cramps (e.g. quining)
- drooling - hyoscine hydrobromide, glycopyrolate
- depression management
- stiffness - baclofen
- speech therapy, dietetic review
- PEG feeding
- portable NIV
- aids around house e.g. lift, wheelchair, ramp etc
- nursing help and respite care
- discussion re end of life care
what are the common causes of peripheral neuropathy
commonest - alcohol and diabetes mellitus
vitamin deficiency
leprosy is rare cause
how does diabetic neuropathy present
predominantly sensory neuropathy
painful weakness and wasting
autonomic ns involvement causes postural hypotension, impaired bladder/bowel/sexual dysfunction, loss of normal sweating
what is charcot marie tooth
hereditary condition where there are LMN signs in feet, legs and small muscles of the hand - distal weakness and wasting
due to demyelination and remyelination of peripheral nerves
what is the presentation of Guillain Barre syndrome
peripheral neuropathy (affects nerve roots and peripheries) which evolves rapidly over days and produce severe weakness, paralysis and sensory loss. this worsens day by day until 1-2 weeks, then stops advancing. commonly occurs 1-2 weeks after infection e.g. campylobacter enteritis
why does a patient with GBS need to be hospitalised until the disease has run its course
chest and bulbar involvement may require ventilation and NGT to prevent death
are steroids of any benefit in GBS
no - if needed, may manage with IV Immunoglobulin transfusion or plasma exchange to prevent deterioration
what is the pathology behind GBS
thought to be inflammatory/autoimmune - there is demyelination of peripheral nerves (including nerve roots too). Is a peripheral neuropathy
what would be found in LP investigations of a patient with GBS
increased protein in CSF
what are the common causes of death in a patient with GBS
- aspiration pneumonia
- DVT/PE
- cardiac arrhythmia (autonomic involvement of neurones)
what is Myasthenia Gravis
disease that results from impaired neurotransmission neuromuscular synapse - caused by autoantibody whcih attacks ACh receptors on post synaptic membrane
is myasthenia gravis more common in men or women
women
list the s + s of myasthenia gravis
muscle weakness and fatiguability which improves after rest, and is usually worse at the end of the day/ after repetitive use of muscle.
- extraocular involvement causes double vision and ptosis
- bulbar involvement causes dysphagia and dysarthria
- proximal limb weakness - difficulty in lifting arms, standing up etc
- trunk - breathing problems and difficulty sitting from lying position
- distal limb weakness - weak hand grip, ankle and foot weakness
list the tests you would do to confirm diagnosis of myasthenia gravis
- tensilon test - anticholinesterase should produce sudden elevation of weakness
- detection of serum ACh-R antibodies
- EMG studies
- chest radiography/CT for enlargement of thymus identified (uncertain cause why this is assoicated with myasthenia)
list the management options for myasthenia gravis
- oral anticholinesterase drugs e.g. prostigmine and pyridostigmine
- immunosuppression by prednisolone or azathioprine for those not sufficiently managed on anticholinesterases alone
- thymectomy
- plasma exchange to remove circulating antibodies
- hospital admission for myasthenic/cholinergic crisis
what is the inheritance pattern of DMD
X linked recessive
how do patients with DMD present
usually <5 yo, gower’s sign, muscle weakness, pseudohypertrophy of calf muscles
what do patients with DMD die of
profound muscle weakness - predisposes to chest infections, associated cardiomyopathy,
what is found of serology tests of patients with DMD
elevated CK
genetic testing for dystrophin gene
what is myotonic dystrophy
inherited condition where there are dystrophic changes in muscle, associated with myotonic contraction
how does myotonic dystrophy present
difficulty in rapidly relaxing tightly contracted muscle
muscle contracts when hit by tendon hammer/ percussion
(associated cardiomyopathy)
what are polymyositis and dermatomyositis
autoimmune conditions where there is inflammatory cell infiltration into muscle and muscle fibre necrosis.
however, in dermatomyositis, there is additional involvement of skin - especially face and hands
(managed by immunosuppression)
list some of the ways in which the data from death certificates is used in public health
- monitor health of population
- public health interventions
- health services
- medical research
- international comparisons of health and healthcare services
- monitor quality of clinical care in clinical governance programmes
describe death certification in terms of foetal age
<24 wks - non viable foetus, no certification
>24 wks - still birth certificate
does the doctor have to be present at the time of death or see the body after death in order to be able to fill out a death certificate?
no to both (has to have seen patient within 14days of death however)
what are the different sections on the “cause of death” section on the death certificate of a patient
1 a) disease leading directly to death
1 b) other disease or condition (if any) leading to 1a)
1 c) other disease or condition (if any) leading to 1c)
2) other significant conditions, contributing to the death but NOT relating to the disease/condition leading to death
can old age be used as a cause of death on death certificates?
only if no other cause is found
list some unacceptable terms to avoid in death certificates
asphyxia arrhytmia cachexia cardiac arrest coma debility exhaustion HF Liver/renal failure respiratory arrest shock syncope uraemia
what are the rules for describing cancers when filling out death certificates
histopathology of tumour benign or malignant anatomical site primary or secondary date of previous removal if any
list some of the cases you must report to a coroner when dealing with death and death certificates
1) no doctor has treated the deceased within the last 24hours
2) when doctor attending patient didn’t see him or her within the last 14 days before death or after death
3) when death occurred during operation
4) death sudden/unexplained/suspicious
5) due to industrial injury or disease
6) due to accident/violence/neglect/abortion/any kind of poisoning
7) occurred in prison or in police custody or under section of MHA
what drug is given to treat focal epilepsy
carbamazepine
which drug is very teratogenic
child bearing
what is epilepsy
the tendency to suffer from seizures
what are the two main types of epilepsy
generalised and focal
what is the difference between generalised and focal seizures
generalised = electrical discharges start in deep midline structures of the brain and spread rapidly and simultaneously to all parts of the brain - affecting the whole brain focal = electrical discharges start in one part of the cerebral cortex and dont spread to both hemispheres
what is a complex partial seizures
seizure starts off as focal but spread to all of the cerebral cortex, resulting in generalised seizure
list the types of generalised seizure
- primary generalised tonic-clonic
- absence
- myoclonic
list the different phases in a primary tonic-clonic seizure with a brief description
1) tonic phase - LOC and sudden muscle stiffening, limb and neck extension, cyanosis
2) clonic phase - sustained muscle contraction and a series of disorganised jerks and jitters. jaw closes, causing tongue biting, breathing disorganised
3) coma phase - after convulsive movements - breathing becomes regular and regular, colour returns to normal
4) postictal phase - state of confusion, headache, restlessness, drowsiness before final recovery. limb pain, sore tongue
how do absence seizures present
sudden onset and offset, does not usually last more than 10 seconds
few moments pass when patient notices they’ve been unaware of what has happened - suddenly stop what they’re doing, with eyes open and staring blankly. may be rhythmic movements of eyelids
remains standing or sitting
no response to any stimuli
is there usually an aura assoc with generalised otnic clonic seizure
no -aura is usually for partial
what is a myoclonic seizure
take form abrupt muscle jerks, typically causing upper limbs to flex
patient drops anything they are holding
jerks may occur singly or in brief run
consciousness not usually affected
(often coexists with tonic clonic or absence seizures)
how does focal epilepsy present
depends on the part of the brain where the electrical discharge is coming from - can be focal motor, sensory, frontal lobe, temporal etc.
how does frontal lobe partial seizure present
strong convulsive turning of eyes, head and neck towards contralat side; or complex posturing with one arm flexed and the other extended
list some of the subjective symptoms in temporal lobe seizures
- de ja vu
- memories rushing through brain
- loss of memory during attack
- hallucination of smell/taste
- sensation rising in body
list some of the objective symptoms in temporal lobe seizures
- diminished contact with environment
- slow, confused
- lip smacking and sniffing movements
- repetitive utterances/movements
what are febrile convulsions
tonic clonic transient attacks occurring at time of febrile illness in children - especially common in <5years
what is the prognosis for children who have a febrile convulsion
usually very good - a very small percentage of children with febrile convulsions then go on to suffer from epileptic attacks later in life - and these children ususlly have other factors such as FHx, abnormal neuro signs etc.
what is juvenile myoclonic epilepsy
tonic clonic seizures starting in teenagers - primarily generalised, and may not continue into adult yeats
what is status epilepticus
occurence of tonic clonic seizures without recovery in between episodes, or one that lasts >30 mins
what are the steps in managing status epilepticus
1) diazepam PR/buccal midazolam –> repeat in 15 mins
2) lorazepam IV bolus
3) phenytoin infusion
4) refractory status - anaesthetic - propofol/midazolam/thiopental etc.
think of some secondary causes for epilepsy
- brith trauma to brain
- trauma to skull and brain
- meningitis, encephalitis, brain abscess
- infarct/haemorrhage/sah
- trauma/neurosurgery
- alcohol/drug withdrawal
- hepatic/uraemic
- hypo
- tranquilisers/antidepressants
list some of the restrictions that must be advised in the daily life of a patient with epilepsy
- awareness of bathing/driving/riding/bicycle/heights/water sports
- refrain from driving for 1 year
- avoid flashing lights if photosensitive epilepsy
- occupations e.g. HGV or police that are impossible career paths
- other jobs such as working with machinery, nursing, children that may be more difficult if epilepsy is uncontrolled
- pregnancy and teratogenecity counselling in women of child bearing age
- psych factors and support groups
when is surgical treatment used in epilepsy
last line in intractable cases
define delirium
global impairment fo cognitive function, with disturbances of attention and conscious level. abnormal psychomotor, behaviour and affect, disturbed sleep-wake cycle
what is the pattern of symptoms in delirium
fluctuating symptoms, typically worse at night
list some of the risk factors for delirium
- age extremes
- pre-existing dementia
- fracture (esp hip)
- certain prescribed drugs
- recreational drug intoxication and wtihdrawal
- sensory impairment
- surgery
- sleep deprivation
list some of the drugs that are high risks for delirium
- psychogenic drugs e.g. antidepressants, antipsychotics, bzd’s
- antiparkinsonian drugs
- opiates
- diuretics
- anticholinergic drugs
list the different sections of the AMT
1) age
2) time to nearest hr
3) address for recall e.g. 43 west st
4) year
5) name of hospital
6) recognise two persons e.g. nurse, doc
7) DOB
8) year of WW1/WW2
9) name of monarch/prime minister
10) count backwards from 20 to 1
list some of the ways in which you can manage a patient with delirirum
- underlying condition management
- drug review
- maintain hydration and nutrition
- physical and human envt - clock, near window, photos of family
- hearing/visual aids
- avoid unnecessary procedures and changes
- promote regular sleep patterns and routines
- if patient is unsafe to themselves or others - haloperidol for sedation (sometimes olanzapine 2nd line?)
describe the types of delirium
1) hyperactive/agitated: psychomotor agitation, increased arousal, inappropriate behaviour
2) hypoactive delirium: psychoactive retardation, lethargy, excessive somnolence
3) mixed
list the non-reversible types of dementia
- alzeihmers
- vascular
- lewy body
- frontotemporal
- others e.g. CJD, HIV
list the reversible types of dementia
- chronic alcohol abuse
- vitamin deficiencies e.g. thiamine, B12, T4
- normal pressure hydrocephalus
- infection e.g. syphilis
- metabolic.endocrine
- neoplastic frontal lobe tumours
what are the risk factors for dementia
- genetic: Apo E4 allele
- vascular risk factors
- nutritional, social, educational
what are the protective factors for dementia
- diet - vitamins etc
- physical activity
- mentally challenging/complex work
- mental activity - reading, cultural involvement etc
list some fo the symptoms associated with frontal lobe alzeihmers
irritable, disinhibited, personality changes, behaviour changes
list some of the symptoms associated with temporal lobe alzeihmers
apraxia, agnosia, apathy
what are the features of mild alzeihmers
- forgetfulness
- recent memory deficit
- normal ADLs
what are the features of moderate alzeihmers
- significant memory loss
- personality and behaviour changes
- language problems
- impaired ADLs
what are the features of severe alzeihmers
- dysphasia
- aggression
- restlessness, wandering
- delusions
- hallucinations
what does lewy body dementia tend to affect the most
memory, praxis, language, reasoning
visual hallucinations, parkinsonism
what is the clinical course in alzeihmers dementia
gradual onset, slow progression
what is the clinical course in vascular dementia
stepwise deterioration - first deficit plateus before worsening
what is the clinical course of frontotemporal dementia
insidious - slow symptom progression
what are the features of alzeihmers dementia
- memory loss
- personality changes
- behaviour changes
- ADL impairment
what are the features of vascular dementia
- memory and congition impairment
- uneven deficit distribution
- UMN signs
what are the features of lewy body dementia
- visual hallucinations
- repeated falls
- parkinsonism
what are the features of frontotemporal dementia
- slowly progressive frontal lobe symptoms
- language and speech problems
- RARE to have memory problems
- behaviour changes
what are the pathological features of alzeihmers dementia
- shrunken brain, wide sulci, ventricular atrophy, temporal lobe atrophy,
- B amyloid plaques
- neurofibrillary Tau tangles
- neurone loss and neuronal tract decay
what are the pathological features of vascular dementia
- arteriosclerosis
- thrombus/embolus
- neuronal death
- vasculitis
- haemorrhage
what are the pathological features of lewy body dementia
- lewy bodies
- a synuclein
- ubiquitin
- cerebral and substantia nigra
list some of the differences between delirium and dementia
- delirium is acute onset, dementia chronic
- attention decreased more in delirium
- hallucinations more common in delirium
- tremor/myoclonus more common in delirium
- physical illness signs more common in delirium
- fluctuating signs and symptoms in delirium, whereas dementia is more consistent
describe how someone with a tension headache would present
pain feels like a tight band around head
what is thought to be the cause of tension headaches
excess contraction of head and neck muscles
how is tension headache managed
reassurance - and also explain why a scan would not be beneficial if they are asking for one
midification of lifestyle, relaxing therapies
small night time doses of amitryptilline
treat underlying depression
how would someone with migraine present
<40y/o for first presentation, usually FHx
episodes of headache lasting few hours-days and feeling normal between attacks
prodrome
aura - e.g. blurred vision, tingling, unilat weakness rarely etc
headache is throbbing, severe, at front of head, worse on one side
nausea, vomiting, pallor, photophobia may be associated
list some of the possible triggers for migraine
- stress/fatigue/relaxation after stress
- skipping meals/binge eating
- menstruation/ovulation/menopause/cocp/early post partum
- head injury
- htn
what are some of the ways in which patients with migraine can be managed
- encourage avoiding triggers e.g. stress
- individual attacks may respond to simple analgesia +/- dopamine antagonist e.g. aspirin and metoclopramide
- failing that, serotonin angonists e.g. ergotamine and triptans
- sublingual meds if ptt is vomiting
- preventative - regular b blockers, amitryptilline, sodium valproate
how may a patient with cluster headache present
occur repetitively once/twice a day for several weeks, with long intervals in between (hence clusters)
attacks last between 1/2 hour to 2 hours
severe, around eye, ipsilateral signs of autonomic dysfunction - redness, swelling, nasal congestion, horner’s syndrome
what can be given to help a cluster headache
o2
injection of sumitriptan
steroids and verapamil as preventative
anticonvulsants may be tried later on
what is analgesic-depedant headache
overuse of analgesia can lead to headaches daily, often throbbing in nature
which drugs are more likely to give you analgesic-dependant headache
weak opioids such as codeine
ergotamine, triptans
how is analgesic dependant headache treated
discontinuing causative drug
gradual amitryptilline introduction for prophyalxis
describe the headaches found in those with increased ICP
worse when lying flat, in morning, may be woken from sleep
other neuro signs e.g. vomiting, papilloedema
describe the headaches found in those with decreased ICP
relieved by lying flat, rapidly resume when ptt upright
describe how a patient with GCA headache would present
headache and tenderness of scalp
superficial temporal artery may appear red, swollen, non pulsatile and feel tender
who is most prone to subdural haematomas
elderly people, alcoholics, people on anticoags who bang their heads
how may people with subdural haematomas present
cognitive decline, subacute headache and increased ICP signs
how does sah and meningitis headache present
neck stiffness
felt throughout head, and especially occcipitally
how does trigeminal neuralgia present
sudden, momentary pains, like electric shocks (lacinating pain) in the distribution of the trigeminal nerve waxes and wanes unilat - usually maxillary or mandibular severe stabs of pain triggered by contact with skin
list some of the triggers for trigeminal neuralgia
cold on face washing shaving cleaning teeth talking eating drinking
what drugs are given to patients to treat trigeminal neuralgia
anticovulsants like carbamazepine, lamotrigine and gabapetin
describe how someone with post herpetic neuralgia presents
after a painful vesicular phase, the pain persists in affected patients.
causes constant burning pain in the area affected by shingles
how is post herpetic neuralgia managed
TCA’s
gabapentin
topical capsaicin cream
how may someone with post concussion syndrome present
symptoms of headache, poor conc, dizziness, irritability, for months-years after head trauma/concussion episode
define malnutrition
deficiency or excess of energy, protein or other nutrients that cause adverse effects on tissue body form, body function and clinical outcome
what are some of the causes of malnutrition
- unbalanced or insufficient diet
- increased nutritional demand e.g. surgery, infection
- impaired absorption of foods e.g. N&V, diarrhoea
list some of the consequences of malnutrition
- impaired immune system
- increased risk of pressure sores
- decreased wound healing
- muscle wasting/weakness, including resp and cardiac muscle
- impaired mental function
- increased length of hospital stay
list the steps of achieving adequate nutrition
- oral nutrition first
- enriched oral nutrition
- oral nutritional supplements
- alternative route of feeding e.g. NGT/PEG
list some of the factors taken into account when assessing nutritional status
- medical - vomiting/diarrhoea/pressure sores
- physical - appearance, loose clothes, feeding difficulties
- dietary
- nutritional screening tool, score
explain what an NG tube is used for
short term feeding directly into stomach, for <14days
explain what Gastrostomy is for
long term feeding, directly into stomach from abdominal surface
list the different regimens for enteral feeding
- continuous pump feeding
- intermittent pump feeding
- bolus feeding
what are some of the indications for use of oral nutritional supplements
poor appetite, regardless of BMI
low BMI
difficulties in meeting nutritional requirements
what should be monitored in patients in terms of feeding
- nutritional intake
- tolerance
- weight
- oral intake
- fluid balance
- biochem (electrolytes, refeeding bloods)
which electrolytes should be monitored in patients who are receiving enteral feeding
serum K+, PO4 3-, Mg2+ every 12-24 hours when feeding started
which patients are at risk of refeeding
those ho have had very little/ no food intake for >5 days, especially if already undernourished or weight loss
define refeeding syndrome
severe fluid and electrolyte shifts, and related metabolic complications in malnourished patients undergoing refeeding
list some of the physiological mechanisms involved in refeeding sydnrome
- increased carbohydrate metabolism, using thiamine
- increased uptake of glucose, PO3 4-, and K+ into cells
- Mg2+, Na+ and K+ used for cellular pumps
- increased protein synthesis
list the consequences of refeeding syndrome
- decreased phosphate
- decreased potassium
- decreased magnesium
how is refeeding managed
- lower rate of feeding
- during first few days of feeding: oral thiamine supplements, vitamin B, multivitamins, trace element supplements
- monitor fluid balance
- monitor biochem
what are the steps in the MUST score
1- measure BMI
2- not percentage of unplanned weight loss and score
3- establish acute disease effect/no nutritional intake>5 days and score
4- add scores from steps 1-3 and obtain overall risk of malnutrition
5- use management guidelines/stepwise policy
list some of the risk factors for pressure sores
- immobility
- reduced sensation/awareness
- poor circulation
- moisture
- poor nutrition
- previous pressure ulcers
which score is used to predict risk of developing pressure sore in a patient
waterlow score
what is the management of pressure sores
look for infection signs exacerbating factors debride and dress issue viability input, plastics, photographs, documentation, datix
describe Myasthenia Gravis
autoimmune disease of the NMJ characterised by fluctuating weakness in certain skeletal muscle groups
list the muscle groups commonly affected by MG
- extraocular
- bulbar
- limbs (proximally)
- resp muscles
what are the ages commonly affected by MG
20-30 F
60-80 M
what is the pathophysiology of MG
Autoimmune destruction of Ach-R sites at the NMJ by antibodies, means that there are less Ach receptors for muscle contraction
what is the difference between MG and Lambert Eaton syndrome
failure presynapse to release acetylcholine in L-E, whereas MG is the destruction of Ach-R in the postsynapse
what are the features of MG
- easy fatiguability of certain muscle groups
- fluctuating, painless
- weaker in the evening or with repetitive use/activity
list some of the precipitants of MG becoming worse
stress, activity, menses, illness, thyroid dysfunction, trauma, temperature extremes, drugs
list some of the drugs affecting neuromuscular transmission, therefore could have an effect on MG
- aminoglycosides e.g. streptomycin
- B blockers
- CCBs
- procainamide
- succinylcholine
- chloroquinine, penicillamine
- magnesium
- ACEi
list some of the complications of MG
- resp failure
- aspiration
- resp infection
- acute exacerbation
describe a myasthenic crisis
severe exacerbation of MG, where facial muscles slack, unable to support head, jaw slack, voice has nasal quality, body limp, gag reflex absent (can lead to aspiration)
what is the most important thing to do in a patient with myasthenic crisis
secure airway and monitor breathing with regular FVC measurements - may require intubation if deteriorating
describe a cholinergic crisis
excess use of cholinesterase inhibitors can lead to excessive Ach stimulation. produces flaccid muscle paralysis, weakness (similar to myasthenic crisis), urinary retention, bradycardia, small pupils, SSLUDGE syndrome
list the components of SSLUDGE in cholinergic crisis
- Salivation
- Sweating
- Lacrimation
- Urinary incontinence
- Diarrhoea
- GI upset
- Emesis/hypermotility
list some of the diagnostic studies for MG
- ACh-R antibodies
- Tensilon test
- EMG
- CT thorax (thymus)
- ice test
describe the Tensilon test
performed in patients with MG - IV anticholinesterase (edrophonium chloride) causes markedly improved symptoms
why is a ct thorax sometimes performed in patients with MG
may show enlarged thymus - association, unknown reason. abnormal thymus often present, and thymectomy can help improve symptoms
what is the ice test in MG
placing ice over fatigues (esp extraocular) muscles helps rest them and restore their function after fatiguing
what are the cautions in in patients undertaking tensilon test
those with heart problems - may case bradycardia (therefore have atropine drawn up ready)
should only be performed by a neurologist, with cardiac monitoring
what is the therapeutic management for MG
- anticholinesterase inihibitors e.g. neostigmine, pyridostigmine
- corticosteroids to reduce immune response start LOW dose; azathioprine is steroid-sparing option
- IV Ig
- plasmaphoresis - removes Ach-R antibodies and can cause a short term improvement
what is the most common subtype of GBSin the western world
AIDP - acute inflammatory demyelinating polyradiculopathy
what other condition overlaps with GBS
miller-fischer syndrome
describe Guillain Barre Syndrome
acute rapidly-progressing polyneuritis/polyenuropathy, usually post infectious, affecting the peripheral nervous system
what is the pathophysiology of GBS
unknown aetiology, frequently preceded by infeciton/trauma/immune system stimulation etc. with cross reaction between schwann cells causing loss of myelin. this disrupts nerve impulses
list the main infectious organisms causing GBS
Campylobacter jejuni is main CMV EBV HIV VZV shigella M. pneumoniae
what are the clinical manifestations of GBS
usually develops 1-3 weeks post infection, often complaining of backache, pain, muscle cramps, weakness, hyperaesthesia, tingling in feet extending up
this becomes worse and then plateus at around 4 weeks, after which recovery occurs
what are the required features for diagnosing GBS
1) progressive weakness in both arms and legs
2) areflexia/hyporeflexia
list some features supportive of diagnosis of GBS
- progression over weeks
- relatively symmetric
- mild sensory s+s
- CN involvement
- recovery begining at 2-4wks
- autonomic dysfunction
- typical CSF/EMG/NCS features
what are the CSF changes in GBS
initialyl may be none, however, increased protein with normal cells in CSF is typical
list some of the complications of GBS
- autonomic NS dysfunction causing arrhythmias, postural hypotension, HTN, urinary retention, ileus etc.
- respiratory - monitor FVC
- dvt/pe, siadh, pain, renal failure, hyperCa2+
what is the therapeutic management for GBS
close observation, bedside spirometry, ventilatory support, ecg and cardiac montioring nutritional support dvt prophylaxis urinary cath may be needed laxatives and bowel care pain control with opiates
specifically:
- IV immunoglobin
- plasmaphoresis within first 2 weeks of onset for severe cases
- STEROIDS NOT EFFECTIVE
list some differentials for acute flaccid paralysis
- mass in brainstem/sc
- trauma
- GBS, miller fischer, lyme, diptheria
- MG, lambert eaton
- neurotoxins e.g. botulinum
- myopathies, steroids, thyrotoxicosis, muscular dystrophies
list some stroke mimics
- migraine aura
- epilepsy
- transient global amnesia
- intracranial lesion/SOL
- MS
- Labyrinthine disorders
- metabolic disorders e.g.. hypercalceamia, hypoglycaemia, , hyponatreamia
- peripheral nerve lesions
- MG
- psychological
list some of the drugs/substances that can cause intracerebral haemorrhage
cocaine
amphetamines
alcohol
list some of the questions to ask about the onset of symptoms in patients with ?stroke
- day and time
- what they were doing
- sudden?
list some of the associated symptoms to ask about in patients presenting with ?stroke
- headache
- focal or global symptoms
- vomiting
- altered conscious level
- cardiac symptoms
list some of the major modifiable risk factors in stroke
hypertension, heart disease, af(?), diabetes mellitus, smoking, hypercholesterolaemia
what is 5 and 4 on the MRC scale of power
5 = normal power against resistance and gravity 4 = reduced power, but still some against gravity/resistance
what is 3 and 2 on the MRC scale of power
3 = reduced power, can overcome gravity but not resistance 2 = muscle can move with gravity/resistance removed
what is 1 and 0 on the MRC scale of power
1 = flicker of movement 0 = no movement
list some of the causes of weakness at the anterior horn cell level
MND/ALS
poliomyelitis
syringomyelia, tumours (mass)
list some of the features of myopathic weakness
proximal, symmetrical
no sensory loss or fasciculation
no reflex change or wasting
list some of the conditions causing neuromuscular weakness
myasthenia gravis
myasthenic syndrome (LEMS)
neurotoxins
what is lambert eaton syndrome associated with
paraneoplastic
define adverse drug reaction
any response to a drug which is noxious or unintended
list some of the factors that can affect compliance in the elderly population
- complexity of regimes
- manual dexterity - cannot open containers etc
- poor vision, tremor etc
what is the probem of NSAIDs in the elderly population
reduce prostaglandins (gastroprotective - therefore GI bleeds can occur renally-cleared therefore can be nephrotoxic and cause renal failure therefore aim to keep doses for under 1 week
list some of the common se of BZDs
sedation, confusion, ataxia
list some of the common se of antipsychotics
sedation, epse, neuroleptic malignant syndrome, postural hypotension
list some of the common se of opioids
sedation, confusion, constipation, resp depression
list some of the common se of antihypertensives
postural hypotension, syncope, falls, u and e disturbance in thiazides and acei, arf
list some of the drugs with anticholinergic activity (associated with increased confusion in elderly)
- tca’s
- drugs for overactive bladder e.g. oxybutinin
list the stimulant laxatives
senna
bisacodyl
picosulphate
glycerol suppository
list the bulk laxatives
fybogel
movicol
list the osmotic laxatives
lactulose
enemas
list a lubricant laxative
arachis oil
what are 1 and 2 on the bristol stool chart
1 - separate hard lumps
2 - lumpy, sausage-shaped
what are 3 and 4 on the bristol stool chart
3 - like sausage but with cracks on surface
4 - smooth, soft, sausage shaped
what are 5 and 6 and 7 on bristol stool chart
5 - soft blobs, clear cut edges
6 - fluffy pices, ragged edges, mushy
7 - watery, no solid pieces
how do you manage risk in a patient post-TIA
as there is high risk of another stroke in next 24-48hrs, refer to TIA clinic in 24hours, tell them not to drive, aspirin cover
what are the components of the ABCD2 score, and what does the score tell us
A - age >60 B - BP >140/90 C - clinical ipsilat weakness/speech D - diabetes D - duration (different intervals) score of 4 or more means they need to be seen in TIA clinic within 24hrs; <4 - within 7 days
what should be commenced in patients who present with a TIA
- aspirin 300mg
- simvastatin 40mg
(thrombolysis within 4.5 hours if not getting any better, refer to neurosurgeons for thrombectomy etc)
what are the two main categories of headache
primary e.g. tension, cluster, migraine
secondary e.g. infection, trauma, metabolic, neoplasia
list the red flag symptoms of headache
- thunderclap
- neck stiffness
- rash
- photophobia
- focal neurology
- nausea/vomiting
- present on waking/worse when lying down
- valsalva/bending down exacerbates
- papilloedema
- fever
- recent onset of change in character
list some acute headache types
- meningitis
- encephalitis
- other infections
- sah
- post ictal
- migraine
- cluster
list some chronic headache types
- temporal arteritis
- migraine
- analgesic abuse
- tension
- paget’s
- increased icp/bih
list the symptoms in subarachnoid haemorrhage
thunderclap headache neck stiffness, photophobia focal neurology N and V altered conscious level subhyaloid heaemorrhage
what is the underlying pathology in sah
berry aneurysms, av malformations, htn, idiopathic
what are the ways to diagnose a sah
CT - most sensitive in first 24 hours
LP 12 hours after onset showing xanthochromia; measure opening pressure (protect sample from light)
cerebral angiography if fit for neurosurgery (neurosurgeon involvement)
list some of the complications of sah
rebleed, vasospasm, poor cerebral perfusion, hydrocephalus,
how is sah treated
neurosurgeons - clipping of aneurysm, embolisation of aneurysm w/ coils
what is positive kernigs sign
in meningitis - when thigh is flexed at hip and knee flexed at 90 deg, the subsequent extension of the knee is painful - leading to resistance
how is meningitis treated immediately
1.2g benzylpenicillin, +/- steroids
iv fluids, O2, cultures (meningococcal PCR)
isolate for 24hours
then give 2g ceftriaxone iv
should you do LP in meningitis
no if increased icp signs or drowsiness
what is the white cell count like in LP of bacterial meningitis
increased polymorphs
what is the white cell count like in LP of viral meningitis
increased lymphocytes
what is the white cell count like in LP of TB
elevated mixed
what is the protein content like in LP of bacterial meningitis
increased
what is the protein content like in LP of viral meningitis
increased
what is the protein content like in LP of TB meningitis
usually increased
what is the glucose content like in LP of bacterial meningitis
reduced to less than 50% of serum level
what is the glucose content like in LP of viral meningitis
normal
what is the glucose content like in LP of TB meningitis
reduced to 50% of serum level
what is the appearance like in LP of bacterial, viral and TB meningitis
bacterial - cloudy
viral - can be clear or cloudy
TB - slightly cloudy, fibrin webs
list some of the causes of bacterial meningitis
- N meningitides in adolescents
- S pneumoniae in older populations
- listeria monocytogenes in >50y/o
- H influenzae
- S aureus
- E.coli, klebsiella, proteus, pseudomonas
- group B strep
- mycobacterium
when should you consider an urgent CT with someone who has meningitis
- reduced conscious level
- signs of increased ICP
- suspicion of SAH
what is the clinical presentation of TB meningitis
insidious onset 1-9 months
mild headache + constitutional upset
what is the treatment for Tb meningitis
- RIPE therapy for 2 months + steroids
- double therapy (isoniazid, rifampicin + pyridoxine) for 12 months at least
- may require shunt insertion
what is the characteristic pain of SOL headache
deep, aching, dull pain
who is most affected by temporal arteritis
> 50 y/o
female
how does temporal arteritis present
tender red scalp
visible tortuous artery
constitutional symptoms e.g. weight loss, night sweat, fever, joint aching, jaw claudication
(assoc with PMR)
what tests would you carry out to diagnose temporal arteritis
- raised plasma viscosity/ESR
- temporal artery biopsy >1 cm to account for skip lesions
list some of the causes of raised ICP
sol - tumour, abscess
venous sinus thrombosis
hydrocephalus
benign intracranial HTN
list the symptoms of raised ICP
- headache on waking, worse when lying down
- papilloedema
- nausea and vomiting
- bradycardia if severe
- periodic breathing aponea (cyclical changes in breathing)
- false localising signs
who is especially at risk of venous sinus thrombosis
cancer patients, pregnant
what is the treatment for venous sinus thrombosis
anticoagulation
describe cushings reflex
bradycardia and increased hr, irregular breathing due to effects of raised ICP affecting the brainstem
what are the features of migraine headache
unilateral, throbbing
photo and phonophobia
aura may be associated
how is migraine headache treated
analgesics,
antiemetics,
triptans
can use prophylactic treatment like propanolol, amitryptilline, topiramate
list some of the symptoms of cluster headache
- severe short-lived, unilateral headache
- around the eye
- nasal congestion/rhinorrhoea/conjunctival infection
- episodic - daily for weeks, then nothing in between
what is the treatment for cluster headache
- high dose O2
- triptans
- analgesics
- steroids
- lithium
- verapamil
what is the typical patient who presents with benign intracranial htn
usually young, overweight woman
how is benign intracranial hypertension diagnosed
- ct scan and venous scan of brain
- LP with manometry (once imaging is normal - dont want coning!!)
- papilloedema usually present
what is the normal pressure in the brain, and what is it in BIH
normal - 15-20mmhg
bih - 25 mmhg
what is the management for BIH
weight loss is effective
relieve pressure immediately - send to neurosurgeons
may be able to insert shunt
what is the management of tension headaches
- reassurance
- stress/anxiety relief and relaxation
- mamagement of depression
- small night time doses of amitryptilline
what is the management of migraine
encourage patient to avoid triggers
analgesia and dopamine antagonist e.g. aspirin + metoclopramide
serotonin agonists such as ergotamie and triptan family of drugs failing that
(sublingual if vomiting persistent problem)
what are some of the preventative drugs that can be given in migraine
b blockers, amitryptilline, sodium valproate
how is analgesic-dependant headache treated
stop offending drug - gradual amitryptilline prophylaxis
which patients are most susceptible to subdural haematoma
elderly, alcoholic, on anticoags
how does trigeminal neuralgia present
sudden momentary pains like electric shocks (lancinating pain) in the distribution of the trigeminal nerve
which drugs may be given to control trigeminal neuralgia
gabapentin, amitryptilline
anticonvulsants like carbamazepine, lamotrigine etc
how does post herpetic neuralgia present
following acute painful vesicular stage, pain persists in small percentage of patients, causing constant burning pain in thin area affected by shingles.
may not be able to sleep properly, depressed
what is the management for post herpetic neuralgia
TCA’s
gabapentin
topical capsaicin
what is post concussion syndrome
following concussion, patient may suffer from symptoms for months/years after - headaches, poor conc, memory problems, irritability etc
describe the arteries that make up the circle of willis
- 2 vertebral arteries -> basilar artery
- 2 internal carotids -> circle of willis
- basilar artery -> circle of willis
- circle of willis : ACA, MCA, PCA
when is surgery performed in carotid artery stenosis
> 50% occlusion, symptomatic
define stroke
sudden onset of focal neurological deficit attributable to vascular cause i.e. in a vascular territory
either haemorrhagic or embolic/thrombotic
would you usually expect symptoms such as headache, loc etc in stroke patients
no -these are generalised, not focal neurological deficits. however, there are some exceptions
what other risk factors, apart from vascular ones, should be considered in patients who have had a stroke
- cocp
- trauma
- hiv
- cannabis
- legal highs
- cocaine
- …other elicit drugs
list some of the lobar symptoms of stroke affecting the frontal lobe
- motor problems, especially leg movements
- broca’s - dysphasia
- urinary incontinence
- disinhibition
- heigher mental function impairment
- memory
- personality change
list some of the lobar symptoms of stroke affecting the parietal lobe
- problems with facial/object recognition - agnosia
- sensory disturbance
- quadrantonopias (optic radiations pass here)
- nominal aphasia, dysphasia
- language problems
- inattention
list some of the lobar symptoms of stroke affecting the temporal lobe
- auditory/vestibular
- wernicke’s area - dyphasia
- memory problems
- quadrantonopias (optic radiations)
list some of the lobar symptoms of stroke affecting the occipital lobe
- visual symptoms (homonymous hemianopias)
list some of the lobar symptoms of stroke affecting the cerebellum/brainstem
- cranial nerve disturbance
- ataxia
- past pointing
- vertigo
- unsteady
- nausea and vomiting
why is important to ask if patient woke up with stroke symptoms
gives indication about whether it occurred during sleep
what is the usual pathophysiology of ischaemic stroke?
often carotid artery thrombus being thrown off and an embolus, causing occlusion and ischaemia in brain
can also come from arch of aorta
venous thrombosis more rare - this can happen in the cerebral venous sinuses or dvt going through a patent foramen ovale
how do the acute symptoms in stroke differ from the ones that emerge later
acutely - hypotonic, loss of reflexes
later - more umn signs - hypertonic, upgoing plantars etc
list some post stroke complications
1) infections
2) metabolic upset
3) malnutrition
4) seizures
5) contractures
6) incontinence, disability
7) depression, anxiety, cognitive decline
8) pneumonia
9) shoulder/hip subluxation
list some of the red flag symptoms in someone who presents with a stroke
- falls
- headache preceding neurology
- progressive neurology
- fluctuating/deteriorating consciousness
- systemicatically unwell
- no vascular risk factors
- inconsistent
list the bloods that should be done in a patient with stroke
- platelets, fbc
- u+e
- LFT
- glucose, lipids
- crp/plasma viscosity (vasculitic disease)
what is the NIHSS
scale/score looking at many domains in a stroke patient - dictating use of thrombolysis in a clinical setting
can look at whether people are improving or getting worse
list two disability outcome scores following stroke
barthel index
ranken
which vessels are usually affected in TACS
prox - ICA/MCA
which vessels are usually affected in PACS
MCA (more distal)
which vessels are usually affected in LACS
single perforating - small vessel disease
which vessels are usually affected in POCS
PCA, posterior circulation arteries
which symptoms must be present for a TACS in the oxford classification of stroke
- contralat hemiparesis/hemianaesthesia
- contralat hemianopia
- higher cerebral dysfunction
which symptoms must be present for a PACS in the oxford classification of stroke
2/3 of those of TACS or motor deficits restricted to face/leg/arm only or restricted cortical signs
which symptoms must be present for a LACS in the oxford classification of stroke
- pure motor
- pure sensory
- sensorimotor
- ataxic hemiparesis
which symptoms must be present for a POCS in the oxford classification of stroke
brainstem/cerebellar/occipital involvement/signs
what are the NICE guidelines on the pharmacological management of ischaemic stroke
thrombolysis with alteplase if no CI
aspirin 300mg
may initiate statins
list some of the secondary causes for haemorrhagic stroke
- haemorrhagic transformation of infarct
- tumours
- vascular
- coagulopaty
- cocaine, alcohol
what are some of the predictors of poor outcome in patients with haemorrhagic stroke
- ?30mls
- intraventricular
- deep locations e.g. thalamus
- elderly
- GCS <9
what are the locations for a head bleed
- intraparenchymal
- intraventricular
- subarachnoid
- subdural
- extradural
how is a haemorrhagic stroke diagnosed
CT - acute bleed seen as white
MRI for hyperacute, subacute, chronic bleeds
may want to do angiogram if venous infarct transformed to bleed
what is the management for haemorrhagic stroke
- neurosurgery for clot reduction, decompression, craniotomy
- intraventricular shunt insertion
- medical supportive measures e.g. obs, seizures,
how many months after a heamorrhagic stroke should a follow up scan take place
2 months
go through the stages of appearance of a CT in haemorrhagic stroke, according to progression of time
- hyperacute - high density, white
- acute - perilesional oedema appears as lower density than that of surrounding brain
- subacute - globin molecule breaks down starting from periphery and going inwards (appears darker at edges)
- chronic - dark
list some of the “mass effects” of haemorrhagic stroke
- effacement of ventricles
- displacement of ventricles
- midline shift
- twisted ventricle
- hydrocephalus
- cerebral herniation (subfalcine, uncal, tentorial, coning)
what is the equation for calculating the cerebral perfusion pressure (CPP)
CPP = MAP - ICP
if CPP becomes <70mmhg, brain suffers ischaemic injury
where does blood collect in an extradural haematoma, and how does it look on CT
- collects between naked bone and layer of dura
- appears as biconcave, hyperdense, “lentate’ lesion
where does blood collec tin subdural haematoma and what does it look like on ct
collects between arachnoid and dura
crescent shaped, sulcal markings often present
which veins are usually torn in subdurals
bridging veins
how are MRIs useful in head imaging
good for finding underlying pathology, aged bleeds, subacute and chronic bleeds (bad at acute)
what do late/subacute bleeds look like on MRI as compared to acute bleeds
late ones tend to show up as bright (depends on weighting), whereas earlier bleeds are much harder to detect on MRI and may even appear normal
what pattern of symptoms do you expect to see in an MCA ischaemia
- loss of use/sensation of contralat face, arm
- dysphasia
- dyslexia, dysgraphia, dyscalculia
what pattern of symptoms do you expect to see in an ACA ischaemia
- loss of use/feeling in contralat leg
what pattern of symptoms do you expect to see in an PCA ischaemia
- contralateral homonymous hemionopia
what pattern of symptoms do you expect to see in an ICA ischaemia
arm, face and leg
hemionopia?
what pattern of symptoms do you expect to see in an opthalmic artery ischaemia
monocular loss of vision
what does the chadsvasc score predict
stroke risk for patients with AF
what are the components of the chadsvasc score
- ccf
- htn
- age
- diabetes mellitus
- sex
- stroke
list some of the clinical problems following stroke
- dysphasia, dysarthria
- delirium
- dysphagia
- dyspraxia
- sensory neglect
- visuospatial perception
- executive function difficulties
- weakness of limbs
- sensory loss
- hemianopia
- depression
- thalamic pain
- shoulder pain
list some ddx for cerebellar infarct
- bppv
- meniere’s disease
- migrainous vertigo
- vestibular neuritis
- labyrinthitis
list some symptoms/ signs of cerebellar infarct
- vertigo
- max intensity at onset
- severe ataxia
- difficulty walking
- direction-changing nystagmus
- focal neurology signs
what is the advice re driving in patients who have had a stroke
- do not drive for 1 month
- tell dvla and insurance company
what is the rosier score for
quick assessment as to whether patients presenting in a and e are likely to have had a stroke
includes parameters such as loc, seizures, asymmetrical facial/arm/leg weakness, speech disturbance, visual field defect
what are some of the ways in which complications of stroke can be managed
- early as possible involvement of PT/OT/SALT
- mobile as soon as possible, heparin, turning, comfortable position
- antiepileptics if seizures
- surgery for contractures.neurosurgery
- neuropathic pain management
- antidepressants
- treat any uti/other infections that may develop
list some of the risk factors for delirium
- icreasing age
- comorbidities/ severe illness
- infections
- malnutrition
- particular medications, polypharmacy
- immobility
- decreased ADLs; superimprosed on dementia
- urinary catheter
- u and e imbalance
- constipation
define delirium
acute confusional state, characterised by disturbed consciousness, cognitive function or perception. Has an acute onset and fluctuating course
list the 4 criteria for diagnosing delirium with the DSMIV criteria
- disturbance of consciousness
- change in cognition
- acute
- due to medical condition/intoxication/substance withdrawal/multiple aetiologies
what are the negative effects on recovery, from delirium
- increased mortality
- risk of falls increased
- prolonged hospital admission
- higher complication rates
- institutionalisation
- increased risk of developing dementia
list some of the precipitating factors for delirium
- immobility
- medication
- physical/medical
- iatrogenic
- surgery
- malnutrition
- intercurrent illness
- dehydration
list some of the features of hypoactive delirium
- lethargy and reduced motor activity
- excess somnolence
- depression-like symptoms
list some of the features of hyperactive delirium
- increased motor activity and agitation
- hallucinations
- inappropriate behaviour, aggression
what are the 10 domains in the AMT test
1) age
2) time to nearest hour
3) address to recall at end of test e.g. 42 west street
4) year
5) name of hospital/where they are presently
6) recognise two persons e.g. nurse/doctor
7) dob
8) name of monarch/prime minister
9) start date of ww1/ww2
10) count backwards from 20-1
why is it useful to be mindful when treating elderly patients with drugs which have anticholinergic properties
increased risk of delirium
what investigations should you order in a patient with delirium
- bloods e.g. fbc, renal/liver function etc
- ecg
- cxr/urinalysis to to and find source of infection
- regular obs
- may need cultures, ct, eeg, lp, abg (specific situations)
what are the rules for sedation in delirium
- try and avoid, but if required then use the minimum amount of time/dose, least restrictive
- sedative drugs themselves can often precipitate delirium
- when all else has failed
- patient danger to themselves/others, lacking capacity
- use of haloperidol first line; lorazepam 2nd
list some of the non-pharmacological measures in the management of delirium
- hearing aids and glasses available
- reduce change in staff and ward transfers
- familiar objects, clock, near window, photos of relatives
list some of the pharmo-related management options in delirium
- drug review
- treat underlying condition
- sedatives - try to avoid unless very necessary
what is the management of delirium
- try and find precipitating factor and manage this!
- drug review is essential
- nutrition, hydration, control distressing physical symptoms
- attention to physical and human environment, hearing and visual aids
- avoid unnecessary procedures e.g. catherisation
- promote regular sleep patterns, routines
- sedation as last resort
list the non-reversible types of dementia
1) AD
2) vascular
3) lewy body
4) fronto temporal
5) cjd, aids dementia etc
list the reversible types of dementia
- chronic alcohol abuse
- thiamine/b12/t4 deficiency
- normal pressure hydrocephalus
- infections e.g. syphillis
- metabolic/endocrine
- neoplastic e.g. frontal lobe tumours
list some fo the risk factors for dementia
- apoE4 gene
- vasc factors for vasc dementia
- nutritional, social, engagement, education
list some of the protective factors for dementia
- diet - veg, fruit, antioxidants
- physical activity
- mentally challenging/complex work
- mental activity e.g. reading, cultural
list some of the symptoms of AD affecting mainly the frontal lobe
irritability, disinhibited, change in behaviour
list some of the symptoms of AD affecting mainly the parietal lobe
agnosia, apraxia, apathy
what are the features of mild dementia
- forgetful
- recent memory deficit
- adl’s not impaired
what are the features of moderate dementia
- significant memory loss
- personality and behaviour changes
- difficulties in orientation and language
- impaired adl’s
what are the features of severe dementia
- dysphasia
- aggression
- restlessness, wandering
- delusions, hallucination
what is the clinical course of AD
gradual onset, slow progression
what is the clinical course of vascular dementia
stepwise deterioration (first deficit plateus before next one commences)
what is the clinical course of lewy body dementia
fluctuating memory and cognitive function
what is the clinical course of frontotemporal dementia
insidious - slow symptom progression
what are the features of AD
memory loss
personality changes
behaviour changes
adl impairment
what are the features of vascular dementia
memory and cognition impaired
uneven deficit distribution
umn signs
what are the features of lewy body dementia
visual hallucinations
repeated falls
parkinsonism
what are the features of frontotemporal dementia
slowly progressive frontal lobe symptoms
language and speech problems
memory problems RARE
behaviour changes
list the pathological features of AD
shrunken brain, wide sulci, ventircular atrophy, median temporal lobe atrophy (esp hippocampus)
B amyloid plaques
neurofibrillary tau tangle
neuronal loss, neuronal tract decay
list the pathological features of vascular dementia
arteriosclerosis thrombus/embolus neuronal death vasculitis haemorrhage
list the pathological features of lewy body dementia
lewy bodies
alpha synuclein
ubiquitin
cerebral and substantia nigra
list some of the differences between delirium and dementia
- delirium is acute, dementia is chronic
- attention is decreased more in delirium
- hallucinations more common in delirium
- psychomotor activity more likely to be affected in delirium
- physical illness symptoms more likely in delirium
- signs and symptoms are fluctuating/worse during night in delirium, whereas in dementia they are consistent
how would you assess insight in a patient
1) does patient believe theyre suffering from illness at all?
2) do they believe they have a mental illness
3) do they believe they will benefit from treatment
4) will they accept the treatment
list the bloods that may be undertaken in the confusion screen
- fbc
- b12/folate/haemotinics
- u and e
- lft
- inr
- tft
- calcium
- glucose
list some causes of non-syncopal attacks
- metabolic e.g. hypoglycaemia, hypoxia..
- epilepsy
- intoxication
- tias - vertebro-basal
- psychogenic syncope
what are the categories of causes for syncopal attacks
1) neurally-mediated reflex syncope
2) orthostatic
3) arrhythmia (cardiac)
4) structural cardiac/cardiopulm disease
5) cerebrovascular (vascular steal syndrome)
list some of the causes for neurally-mediated reflex syncope
- vasovagal
- carotid sinus syncope
- situational faint e.g. post micutrition
- glossopharyngeal/trigeminal neuralgia
list some causes of orthostatic syncope
- volume depletion
- autonomic failure - primary or secondary
- drugs, alcohol
list some causes of cardiac arrhythmia syncope
- sinus node dysfunction
- av conduction disease
- svt/vt
- inherited e.g. long qt
- implanted device malfunction
list some causes of structural/cardiac/cardiopulm syncope
- valvular disease
- acute MI/ischaemia
- obstructive cardiomyopathy
- atrial myxoma
- acute aortic dissection
- pericardial disease/tamponade
- pe/pulm hypotension
define syncope
symptom defined as transient, self limited LOC associated with loss of voluntary muscle tone. Onset relatively rapid and subsequent recovery spontaneous, usually prompt. underlying cause is transient global hypoperfusion
what is a poor prognostic factor in syncope
structural heart disease
list some of the features suggesting a neurally-mediated syncope
- after sudden unexpected stimulus
- standing in warm crowded places
- N and V associated with syncope
- post prandial <1 hour
- after exertion
- syncope with throat/facial pain (glossopharyngeal/trigeminal neuralgia)
list some of the circumstances where you would hospitalise a patient with syncope
- suspected/known significant heart disease
- ecg abnormality suggesting arrhythmia
- syncope during exercise
- syncope when supine
- fhx of sudden death
- sudden onset palpitations in absence of heart disease
- frequent, recurrent episodes
- arrhythmia causing syncope
- cardiac ischemia
- structural heart/cardiopulm disease
- stroke/focal neurology
what should be assessed when a patient presents with syncope
- obs
- gait/balance
- joints
- cns
- cvs, ecg - lying and standing
- vision
- medications
- cognition
- continence history
- referral for tilt-table test in some cases
list the circumstances in which you would refer a patient with syncope to a specialist falls service
- previous fragility fracture - attended a and e/call 999 with fall? - 2 + intrinsic factors in fall - frequent unexplained falls - falls in nursing/residential home - unsafe housing - very afraid of falling
what are the factors that should be considered when trying to work out the aetiology of falls
- intrinsic (to do with patient)
- extrinsic(to do with surroundings/envt)
list some of the multidisciplinary interventions for patients with falls
- strength and balance training
- home hazards assessment and intervention
- vision assessment and referral
- meds review/modification/withdrawal
- also assess future risk, interventions to prevent future falls
what are the suggestions for drivers who have had a syncopal event
if simple e.g. vasovagal, then can continue
others- domestic drivers shouldnt drive for 1 month, depending on cause
professional drivers - longer
in order to rule out other causes of tloc, what questions should be asked to the patient/ in the collateral history
- tongue biting
- limb jerking - duration
- duration of episode
- presence of confusion during recovery period
- weakness down one side during recovery period/before
if, after taking full history, examination and investigations, you are still unsure of the cause of a patient’s syncope, what should be considered next
does the patient have cardiac history/structural heart disease
- if no and normal ecg - no further evaluation usually required
- if yes/abnormal ecg - cardiac evaluation, and manage as per diagnosis
list the three categories of causes for cardiac syncope
- arrhythmia
- structure
- vascular
list some of the structural disease that may cause cardiac syncope
- cardiomyopathy e..g obstructive
- atrial myxoma
- pericardial disease/tamponade
- valvular
how do you test for neuronally-mediated syncope
- tilt table test
- carotid sinus massage
- ?implantable loop recorder/24 ecg
what is the criteria for diagnosing orthostatic hypotension
systolic BP fall >20mmHg or diastolic >10mmHg in first 10 mins of standing
how would you manage orthostatic hypotension
- treat underlying cause e.g. hypovolaemia, drugs, addisson’s etc
- increased salt intake
- fludocortison or midrodine are pharmacological treatments
how do you manage vasovagal syncope
- education and reassurance
- physical counter pressure
- action when recognising prodrome symtpoms
- drug/polypharmacy alteration
- (midodrine)
how do you manage carotid sinus sensitivity syndrome
- dual-chamber pacing for cardioinhibitory-type CSSS
- prevention and abortive measures
- reassurance
- physical counter pressure manoeuvres
- polypharmacy alteration
what investigations should be done in patients who experiences blackouts
- blood glucose
- blood gases
- ecg
- eeg
- cario evaluation
list some personal safety advice that you may give a patient who suffers with blackouts
- do not drive motor vehicles if subject to sudden episodes of LOC
- consider showers instead of baths
- job considerations - machinery, heights
- care with some recreational activities e.g. swimming
list some changes in elderly patients, which would lead to them being at increased risk of falls
- decreased visual acuity
- balance impairment
- sarcopenia
- kyphotic posture
- increased body sway
- irregular gait pattern, small steps
- cerebrovascular changes, contributing to cognitive changes
- sensory impairment
describe how the apley manouvre is performed
1) lie patient on back, neck extended 30deg and turned to one side at 45deg - nystagmus will occur if BPPV is present
2) after 30-60 seconds, turn head 90deg to face the other side
3) after 30-60 seconds, turn them on their side, and turn their head another 90deg so that their face is against the pillow (at 45 deg from horizontal)
4) after 30-60 seconds, the patient should sit up
list the drugs associated with high risk of falls
1) antihypertensives
2) opiates and analgesics
3) long acting hypoglycaemic drugs
4) hypnotics, long lasting BZDs
5) antidepressants esp TCAs
6) antiepileptics
7) anticholinergics (anticholinergic burden)
list some of the extrinsic features for falls
- older housing
- poor lighting
- clutter, pets underfoot, cables
- inappropriate footwear, esp slippers
- incorrect use of walking aids
- lack of grab rails in bath/shower
- unfamiliar envt e.g. care home
- uneven/icy/wet pavements
list some of the sequelae after a long lie on floor following fall
- pressure sores
- rhabdomyolysis
- hypothermia
- hypostatic pneumonia
list some of the steps you can take to reduce the cosnequences of falls
- pt/ot involvement to increase confidence with mobilising
- vit d and calcium prescription
- maintain good environment temp
- carpeting, remove obstacles and dangers
- place emergency bedding where it can be reached from floor
- personally worn alarm system
- education about safety in home - family and patient
list some of the physical complications of immobility
- muscle wasting
- contractures
- osteoporosis
- pressure sores
- hypothermia
- hypostatic pneumonia
- costipation
- incontinence
- dvt
list some of the psychological complication of immoblilty
- depression
- loss of confidence
what is the definition of ataxia
loss of coordination
what is the definition of apraxia
inability to execute voluntary purposeful movement despite demonstrating normal muscle function
what is the definition of agnosia
inability to recognise sensory input even when the specific pathway is not defective
what are some of the gait signs which indicate incoordination on examination
- inability ot stand on narrow base
- broad based gait
- romberg sign
- inability to stand on one leg
- impaired tandem gait
- positive unterberger signs
- impaired hell-shin test
- impaired foot tapping
list some of the upper limb signs which indicate incoordination on examination
- difficulty with rapid alternating movements
- dysdiadokokinesis
- impaired finger-nose test
- past-pointing
- intention tremor
- rebound test
list some of the causes for sensory ataxia
- sensory neuropathy
- ms
- subacute combined degeneration
- tabes dorsalis
- cervical myelopathy
- cord tumours
list some of the forms of agnosia
- alexia (dyslexia)
- auditory, visual
- prosopagnosia (faces)
- amusia (music)
- astereogenesis (shapes)
list some of the signs of parietal lesion
- apraxia
- parietal drift
- sensory inattention
- 2 point discrimination
- astereogenesis
- dysgrafisthesia
- visual field defect - quadrantonopia
what is a seizure
the clinical manifestation of abnormal and excessive excitation of a population of neurones
what is epilepsy
a tendency towards recurrent seizure unprovoked by systemic or neurological insults
what is important to elicit in terms of a patient’s childhood history if they present with seizures
- birth trauma
- meningitis
- childhood illness
list some of the specialist tests in epilepsy
- EEG - sleep deprived/non sleep deprive
- video telemetry
- MEG
list the different types of seizure
generalised: tonic, clonic, tonic-clonic, atonic, myoclonic, absence
focal: simple partial - simple partial can become a secondary generalised seizure
list some of the impacts of epilepsy
- unable to drive/do certain jobs or activities
- social embarassment
- risk of injury
- risk of sudden death
- comorbidities e.g. neuro disability, drug s/e, depression
what is the definition of status epilepticus
seizure activity continuous for >30 minutes or recurrent seizures w/o 5 minute breaks in between attacks
what is the management of status epilepticus
- buccal midazolam or PR diazepam
- ambulance can administer: IV diazepam or lorazepam
- if lorazepam fails: phenytoin, ITU admission (may give midazolam)
what is important to remember about phenytoin
zero-order metabolism
state some of the different mechanisms of action for antiepileptic drugs
- enhance GABA
- suppress Glutamate
- acts on Na+/K+ channels
- Na/Ca dependent action potentials
- direct effect on neuronal firing
which drugs are usually used to treat generalised seizures
sodium valproate
lamotrigine
keppra
which drugs are used to treat complex partial seizures
carbamazepine
lamotrigine
keppra
how do absence seizures present
tend to occur in children, with multiple attacks, where patient may not be aware. speech stops, look blank, stop what theyre doing. eyelids may flutter.
what should not be used to treat absence seizures
carbamazepine
what is neurofibromatosis
several genetically-inherited conditions that carry a high possibility of tumour formation - nf1 and nf2 type
what are the features of nf1
- cutaneous conditions
- 6 or more cafe au lait spots
- 2 of more neurofibromas
- 2 or more growth on iris
- behaviour and learning problems
- scoliosis
- optic gliomas
- growths in sc?
what are the features of nf2
- bilateral acoustic neuromas often leading to hearing loss
- prenatally - may have bilat cestibular schwanommas
- skin neurofibromas
- eye lesions
- spinal lesions
what are some of the investigations that may be done to diagnose neurofibromatosis
radiography ct mri eeg slit lamp examination genetic testing histology
what is the treatment for neurofibromatosis
- surgical removal of tumours e.g. acoustic neuromas
- chemo for optic pathway gliomas
- specialist team
- management of hearing loss
what is multiple sclerosis
an inflammatory demyelinating condition of the cns which eventually leads to axonal loss, neurodegeneration
what is the epidemiology of ms
affects f more than m
f 25-35
more frequent in populations further away from equator
list some of the presentations of ms
- optic nerve inflammation - visual changes
- diplopia
- if affecting brainstem - can cause cranial nerve deficits
- ataxia
- vertigo
- weakness, clumsiness
- bladder, bowel dysfunction
- pain
- sensory loss
what do the lesions of ms look like on imaging
round/oval shaped, well defined, 3-6mm enhancement
how is ms diagnosed
at least 2 episodes of symptoms occuring at two different points in time and involving different areas of the cns (lesions)
MR brain revealing lesions
what are the different patterns of ms presentation/progression
- relapsing-remitting
- relapsing-remitting with persistent deficit
- primary progressive
- progressive relapsing
what is the treatment and management of MS
- education, mdt
- treat exacerbations with corticosteroids, iv Ig, plasma exchange
- pain control, anitspasmodics
- mamaneg impaired bladder/bowel function
- immune-modulating drugs - B interferon, capoxone 1st line; natalizumab/mitoxantron/fingolimod 2nd line
- physio
- psychological support, counselling
- avoid obesity and sedentary state
what is the presenation of cn1 disorder
anosmia, all foods taste the same
what is the presentation for cn2 disorder, depending on anatomical position of lesion
- ipsilateral monocular blindness (migraine, embolism of opthalmic artery, GCA, infarction of optic nerve/retina)
- bitemporal hemionopia (pituitary gland tumour)
- contralateral homonymous hemionopnia (POCS, SOL in post part of brain…)
what are the functions of the cn3
- looking up (superior rectus)
- looking down (inferior rectus)
- adduction (medial rectus)
- looking up in adducted position (inferior oblique)
what is the function of cn4
- looking down in adducted position (superior oblique)
what is the function of cn6
- abduction (lateral rectus) - aka abducens nerve
what is the presentation of cn3 palsy
dilated pupil, down and out, weakness of eye movement
what is the presentation of cn4 palsy
incomplete depression of the eye in the adducted position
what is the presentation of cn6 palsy
unable to abduct eye
what is the presentation of horner’s syndrome
minor ptosis (due to small innervation of LPS), constricted pupil, enophthalmos, loss of sweating on affected side of face
what is the innervation of the LPS
CNIII mostly, with very small proportion supplied by sns
what autonomic supply does the facial nerve supply
lacrimal and salivary gland
what does the facial nerve supply
muscles of face
autonomic supply
afferent taste fibres for ant 2/3 tongue
muscles of inner ear
hows does bells palsy present
usually, after some aching around the ear, facial weakness develops quite quickly, causing facial droop on one side (including the forehead muscles)
usually proximal enough to affect hearing and taste
drainage of tears from eye may be affected
list some of the symptoms of cnviii dysfunction
deafness, tinnitus, vertigo, loss of balance, nystagmus, ataxia
what does the cnxi supply
scm and part of trapezius
what do cnix and x supply
mouth and throat for normal speech and swallowing.
glossopharyngeal - taste perception in post 1/3 tongue
autonomic functions
vagus - reucrrent laryngeal nerve
what is bulbar palsy
where there is bilat impairment of cnix, x, xii, causing syarthria, dysphagia, dysphonia
where is the recurrent laryngeal nerve vulnerable
neck and mediastinum e.g. aortic aneurysm, tumours, malignant nodes, surgery
list some of the common pathologies affecting the nerve root
- prolapsed intervertebral disc
- herpes zoster
- metastatic disease
- primary tumours/neurofibromas causing compression
what are the symptom of a prolapsed disc
- pain
- reduced rom
- reduced slr
- sensory loss in affected dermatome
- weakness, wasting with time
- loss of tendon reflexes in appropriate segmental value
list some of the different intervertebral disc diseases
- acute disc prolapse
- gradual multiple disc hermiation
- cervical myelopathy
- cauda equina
which diseases tend to affect the sacral plexus of nerves
gynaecological - as plexus runs down iliopsoas, and over pelvic brim
what is meralgia paraesthesia
chronic entrapment of lateral cutaneous nerve of thigh as it penetrated the inguinal ligament of deep fascia around asis
paraesthesia and partial numbness over anterolateral aspect of the thigh
what is mnd
disease where there is selective loss of lower motor neurones from brainstem together with upper motor neurones from motor cortex of brain.
special senses, cerebellar and sensory functions are left INTACT
where does mnd first tend to present
bulbar muscles or the limbs
initially either umn or lmn,
what are the key features of mnd
- muscle weakness
- muscle wasting
- fasciculation
- bulbar muscles affected
- exaggerated reflexes
- no loss of sensation
what happens as mnd progresses
becomes more generalised and tends to affect but umn and lmn
inanition (exhaustion by lack of nourishment) or chest infections (due to involvement of bulbar/resp muscles)account for most deaths
what is the main drug treatment for mnd
Riluzole - a glutamate antagonist which blocks a specific channel associated with damaged neurones, slows progression and increases survival
list some of the ways to improve QOL in patients who have mnd
- explanation and education
- self help groups
- drugs for cramps, drooling (hyoscine hydrobromate), depression, stiffness
- salt, dietician, peg?
- communication aids for dysarthria
- non invasive protable ventilators for resp muscle weakness
- ot - alterations to house e.g. rails, ramps
- nursing help and respite care
- timely discussion about terminal care
is it ul or ll that tends to be affected more in peripheral neuropathy
legs and feet
list some of the causes of peripheral neuropathy
- commonly diabetes mellitus and alcohol
- vitamin deficiency B1, B12
- leprosy
list osme of the neural effects of diabetes mellitus
- sensory neuropathy
- if affects autonomic ns - abnormal pupils, postural hypotension, impaired bladder/bowel/sexual function
- dry feet
what is charcot marie tooth
inherited condition where there is demyelination and remyelination of nerves - causing pes cavus, muscles weakness and wasting
what does romberg’s test look for
proprioception
what is duchenne muscular dystrophy/how it presents
inherited x linked condition, which usually presents with muscular weakness, gower’s signs (prox myopathy), pesudohypertrophy of calf muscles, before the age of five
what are some of the complications of dmd
chest infections
cardiomyopathy
profound muscle weakness
what tests can be done to diagnosis dmd
- prenatal detection
- genetic
- elevated level of ck in blood
what are the hallmark features of parkinsons
- bradykinesia
- rigidity
- resting tremor
- postural instability
list some of the non-motor problems associated with parkinsons disease
- salivation
- sweating
- pain
- sphincter problems
- sleep disorders
- smell
- mood
- psychosis
- dementia
list the different classes of agents used to treat parkinsons disease
- levodopa
- dopamine receptor agonists
- MAOB inhibitors
- COMT inhibitors
- anticholinergics
what is the main use of anticholinergics in parkinsons
tremor
list some of the features of psychosis in Parkinsons
complex visual hallucinations
paranoid ideation
list some of the hyperkinetic movements disorders
- huntingtons
- chorea
- dystonia
- hemiballismus
- tremor
- myoclonus
- tic
tardive dyskinesia is a side effect from which drugs
antipsychotics
what are the features of tremor in parkinsons patients
resting tremor, suppressed by purposeful movement
what is the typical tremor in cerebellar disease
mainly on movement or sustained posture
what is the pathophysiology of parkinsons disease
damage of the dopamine-producing neurones in the substantia nigra, affecting the nigrostriatal pathways
list some of the early symptoms of parkinsons disease
- aches and pains
- disturbed sleep
- anxiety and depression
- slower dressing
- slower walking
list some of the later symptoms of parkinsons disease
- tremor
- difficulty turning in bed
- stooping or shuffling
- softer speech
- spidery handwritting, micrographia
list some of the signs that may be observed when seeing a parkinsons patient
reduced arm swing when walking slowing of movements stooping pedestal turning hypomimia increased tone throughout range of movement constant resistance (lead pipe)
why are patients with PD likely to have falls
posture and movement changes
orthostatic hypotension more likely - due both to PD and the drugs PD patients take
describe how dementia in PD presents
patients start to lose thread of conversation, memory loss, confusion, visual hallucinations
may even have sleep and behavioural disturbance
list some levodopa drugs
duodopa, caramet, madopar and sinemet
list the MOAB inhibitor drug
selegiline
list the COMT inhibitor drug
entacapone
list the glutamate antagonist used in pd
amantadine
list the cholinergics used in pd
rivastigmine, donepezil
list some dopamine agonists
aripiprazole, bromocriptine, rotigoxine, mirapexin
what are some of the cautions/advice that should be given to patients who are prescribe Levodopa drugs for PD
may work very well initially, but effects can wear off after a few years.
May give dyskinetic effects when first administered, and wear off by the time of the next dose
give a caution given to patients started on dopamine agonists
may experience compulsive/impulsive behaviour
how are COMT inhibitors, and glutamate agonists used
in conjunction with Levodopa drugs
list some of the non-oral treatments for PD
- deep brain stimulation
- apomorphine
- transdermal patch (if problem with PO use)
- duodopa - intestinal gel (for severe fluctuations)
how is apomorphine used in PD
used as subcut injection in patients who experience a loss of body movements, slow movements of loss of control of body movements
list some of the different types and causes for dementia
- alzeihmer’s
- lewy body
- vascular
- intracranial pathology
- alcohol and drugs
- hiv-aids, syphillis, cjd, vit B deficiency
list some of the memory-related symptoms of dementia
- disorientation, especially to time
- impaired knowledge of recent events
- forgetfulness, repeating self, loses things around house
- increasing dependence on familiar surroundings and daily routine
list some of the symptoms relating to thinking/understanding/reasoning of dementia
- poor organisation
- ordinary jobs poorly executed
- slow, inaccurate, circumstantial conversation
- poor comprehension
- difficulty in making decisions or judgements
- increasing dependence on relatives
list some of the dominant hemisphere functions of dementia
- decreased vocabulary, overuse of simple phrases
- difficulty naming and word finding
- occassional misuse of words
- reading, writing, spelling problems
- difficulties in calculation and inability to handle money
do patients with dementia usually have insight
no
what is the cause of vascular dementia
usually widespread small vessels disease - due to htn, dm etc. diffuse damage
what are the investigations of someone with dementia
accurate history and collateral history
full physical examination
test memory ,language, spatial orientation, reasoning
carefully examine mental state, mmse
explore s and s of anxiety and depression
ct/mri scanning may be needed
how may someone with a chronic subdural present
may not recall causative head injury, but can become drowsy and intellectually impaired over a few days
focal neuro signs appear late
list some of the routine bloods that should be done for dementia
- fbc
- esr
- u and e, glucose, calcium, lfts, tfts
- syphillis serology
- vit b12
- antinuclear ab
list some of the ways in which dementia may be managed
- careful explanation
- assess social situation and family’s ability to provide support
- old age psychiatry and community services
- voluntary care organisations, support groups e.g. alzeihmer’s society
- careful trial of cholinesterase inhibitor e.g. donepezil
- seeking power of attorney and legal advice
- treat coexisting anxiety and depression
