First Fit

Question 1

Identify the red flags for headache the following case study

• 55 year old woman woke from sleep with worst headache ever and slurred speech, heavy vomiting. Symptoms resolved but husband concerned. PMHx hypertension on Losartan.
• During assessment dropped GCS and arrested. PEA. ROSC without return of GCS.
• HR 45, BP 240/60, RR 8, SpO2 100%, Temp 36OC
• GCS 7 (E4, V1, M2) Both pupils fixed and dilated. Right eye fixed gaze deviation to right. Seizures. Flexure posturing. Globally increased tone. Plantars upgoing.

Answer 1

Onset, Headache, characteristics, Neurology, Associated features,

IN this case
Awoke from sleep, Rapidity of onset
• Worst headache ever • Loss of consciousness • Persistent vomiting
• Hard neurology

Question 2

Diagnosis of SAH

Answer 2

How do you diagnoses SAH?
• You have to think about it to diagnose it
• Non-contrast CT scan • Lumbar puncture •ContrastCT/MRI

Pitfalls:
• The headache has gone!
• Chronic headache
• Vague symptoms

Question 3

What is cushings reflex?

Answer 3

• Hypertension
• Bradycardia
• Irregularbreathing
• RelatedtoelevatedICP

Question 4

Do we still need to do LPs in SAH

Answer 4

Sensitivity,specificity, NPV and PPV approach 100% IF:
within 6hrs of onset
5mm slices
Neuroradiologist / experienced radiologis

Question 5

Risks of LP

Answer 5

• Failure
• Pain
• Bleeding
• Infection
• Nerve damage
• Worsening headache

Question 6

Treatment of SAH

Answer 6

• Probably a bit advanced! • Supportivecare(Airway
protection, SpO2 94-98%)
• Additionalconsiderations:
• Normothermia
• Normocarbia
• Situp45O
• Aggressivetreatmentofseizures
• Blood pressure control (complex and
controversial)
• Reversal of coagulopathy

• Ultimately…
• Neurosurgeons • Decompression • ICPmonitoring • Mannitol
• Hypertonic saline • CTangio+/-clips

Question 7

Identify the red flags in the following case study:

• 54 year old woman. Increasing frequency and severity headaches last 3 months. Unilateral from right eye to occiput. Nauseous. Worse lying down. Has noticed some weakness in left hand and arm. Difficulty lifting cup to mouth. Previous migraines – this is different. Persistent cough.
• Left hand flexors 4/5 power. Reflexes slightly brisker left v Right.
• Obs NAD
• Bloods NAD
• Investigations?

Answer 7

Intracerebral malignancy
Red flags
• In this case
• Change in severity/nature of
headaches
• Positionalsymptoms
• Signs/symptoms of or high clinical suspicion of malignancy
• Hard neurology

Question 8

Management of Intracerebral malignancy

Answer 8

Management
• Find the primary • ?steroids
• ?RTX
• ?surgery

Question 9

Treatment of migraine

Answer 9

• Preheadache
• Triptans e.g. sumatripatan
• Treatment of headache
• Paracetamol
• NSAIDs (400mg ibuprofen, 900mg ASA)
• Antiemetics–metoclopramide, domperidone
• NOTopiates
• Above applies to most headaches!

Question 10

Prevention of migrane

Answer 10

• Prevention

* Triggers (caffeine, alcohol, cheese) • Topiramate, propranolol, verapamil

Question 11

58yr old man. Mild left sided headache. Wife noticed the right side of his face looks odd and his speech was different. Then noticed he couldn’t walk properly and his right hand was felt unusual. Started 2hrs ago. PMHx diet controlled diabetes
• Right facial droop. Right side inattention/extinction. Drift in right upper and lower limbs. Increased reflexes right side. Right side homonymous hemianopia. AF. BP 150/80.

What is the diagnosis?

Answer 11

Stroke

Question 12

Stroke treatment

Answer 12

Hyperacute 
• Rule out bleed
• Thrombolysis/Clot retrieval
• Telemetry/ECG monitoring
• BP control
• Early admission to stroke unit
• Swallow Ax
• Aspirin 300mg

Acute
• 300mg aspirin OD 2/52 • If AF = anticoag
• If no AF = clopidogrel
• PT/OT early
• Cholesterol
• 24 hour tape
• Cardiac valve abnormalities • Diabetes
• Hypertension
• ?CarotidEndarterectomy

Question 13

Identify the red flags in the following case study
• 67 year old man “off legs”. Known metastatic prostate cancer on bicalutamide. Low and mid back pain, worse when lying down.
• MRC 3 power in lower limbs rigid tone, brisk reflexes, upgoing plantars, absent anal tone. Sensation absent below waist.

Answer 13

Red flags present
• Hard neurology (notice a
pattern?)
• Worse lying down/not improved with rest
• Malignancy
• Breast, Prostate, Kidney,
Lung, Thyroid • Age over 55

Question 14

MSCC/back pain Management

Answer 14

• Treatment
• High dose steroids
(dexamethasone) • PPI protection
• Limit mobilisation
• D/w oncology/haematology ?RTX
• Surgery

Question 15

What is the diagnosis?
• 22 year old gymnast competing next week at an international level. Sudden onset collapsing episode unable to move from the waist down.
• Poor engagement, vacant and odd manner, emotionally flat. • 0/5 power in all limbs. Sensation absent. Reflexes normal,
plantars down going.
• When asked to remove her socks, power variable in both lower limbs.

Answer 15

Somatisation/functional illness

Question 16

Somatisation/functional illness Yellow flags

Answer 16

• Features of mental health issue
(anxiety, depression, PD)
• Catastrophising
• Unbearablepain
• Variable/inconsistentsymptoms
• Difficultpatient-clinician relationship
• Focus on loss of function
• Non-localisingsigns/symptoms

Question 17

Somatisation/functional illness Management

Answer 17

• Treatment of non-organic disease
• Reassure on the absence of worrying signs/presence of good signs!
• Don’t dismiss their concerns
• Signposttosupportservices
• Talk - explore their social and psychological factors
• Don’toverinvestigate(false positives, reinforcement)
• How would you deal with uncertainty?