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Yr 4 General Practice > GP Student Handbook Neuro Common Presentations > Flashcards

GP Student Handbook Neuro Common Presentations Flashcards

1
Q

TATT?

A

Tired all the time

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2
Q

3 interpretations of tiredness

A

Lacking energy
Lack of motivation
Sleepiness

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3
Q

Tiredness examination

A 
History
BMI
Thyroid status
Pallor
Depression assessment
FBC for anaemia, ESR, glucose, ferritin
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4
Q

What is chronic fatigue syndrome?

A

Aka Myalgic encephalitis (ME)

Population prevalence: 0.2%

Main feature: Onset of debilitating fatigue after minimal exercise.

Other features: Malaise, sleep disturbance, difficulty concentrating, muscle pain and headaches

Diagnoses following 4 months of symptoms

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5
Q

Define “faintness”

A

Faintness’ refers to a patient feeling that they might ‘pass out’ (lose consciousness). In simple terms, it results from a transient reduction of oxygen supply to the brain which can be caused by a benign physiological response or by serious or non-serious pathology. All causes of faintness can lead to a transient loss of consciousness (LOC).

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6
Q

LOC?

A

Loss of Consciousness

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7
Q

Cause of feeling faint?

A

Vaso-vagal syncope (sudden drop in HR and BP due to hunger or distress)
Hyperventilation (panic attack)
Postural hypotension
Cardiac syncope (arrhythmia, aortic stenosis, carotid sinus syncope)

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8
Q

Define vertigo

A

Vertigo is an illusory sensation of movement (usually spinning) of either the patient or their environment. Patients often say that it felt ‘as though the world was spinning’; that they had ‘been on a roundabout’ or that it felt ‘like being drunk’.

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9
Q

Peripheral causes of vertigo

A

Affecting the balance organ of the inner ear

  1. Vestibular neuronitis / labyrinthitis (following a viral infection)
  2. Benign paroxysmal positional vertigo (BPPV)
  3. Meniere’s disease
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10
Q

Central causes fo vertigo

A

Affects the brain

  1. Migraine
  2. TIA/ stroke
  3. Cerebellar tumour, acoustic neuroma
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11
Q

Vertigo and faintness examination

A

In most cases, the HISTORY will have distinguished between feeling faint/syncope and vertigo.

In ALL CASES

  • check pulse-rate and rhythm and blood pressure (lying and standing)
  • inspect the sclerae for signs of anaemia.

If CARDIAC SYNCOPE or cerebrovascular disease is suspected
- a cardiological examination - auscultating for carotid bruits.

In VERTIGO

  • otoscopy should be used to inspect for abnormal tympanic membranes and impacted wax
  • neurological examination, including cerebellar abnormalities.
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12
Q

Investigations for vertigo and faintness

A

FBC for anaemia
ECG for arrhythmias and ischaemic heart disease
Echo to check for aortic stenosis

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13
Q

Risk factors for falls in the elderly

A
  • Previous falls. This is the single biggest risk factor2 and it is good practice to enquire about previous falls, and if a fall has occurred, to think about preventative measures.
  • Gait and balance abnormalities.
  • Impaired mobility - muscle weakness and foot problems
  • Visual impairment
  • Cognitive impairment
  • Medication. Risk of falls increases significantly if patients take more than 4 medications. Particularly risky are sedating drugs (including analgesics) and antihypertensives.
  • Household hazards such as loose rugs, cluttered rooms, unstable hand rails.
  • Alcohol
  • Medical conditions which lead to ‘light-headedness’ or vertigo as well as any of the causes of unconsciousness.
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14
Q

What is TUGT and how is it used to assess falls?

A

Timed Up and Go Test

Gait and mobility can be tested using the ‘Timed Up and Go’ (TUGT) test, in which patients are asked to rise from a chair, walk 3m, return and sit down. More than 30 seconds suggests a high risk of falls.

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15
Q

Lower back pain with associated pain in the leg suggests…

A

Sciatica

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16
Q

Causes of back pain

A

Primary:

  • Nerve root irritation
  • Movements, lifting

Secondary:

  • IV disc prolapse –> Nerve root compression
  • Central disc prolapse –> Cauda equina syndrome
  • Ankylosing spondylitis
  • Osteoporosis
  • Bone mets
  • GI or GU pathology
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17
Q

In back pain for IV disc prolapse –> Nerve root compression, what is the common history?

A

Sciatic leg pain

Reduced straight leg raising

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18
Q

In back pain for central disc prolapse (and then cauda equina syndrome), what is the common history and poa?

A

History:
Saddle anaestesia
Bladder/bowel dysfunction

POA:
Urgent orthopaedic referral

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19
Q

In back pain for ankylosing spondylitis, what is the common history and poa?

A 
History:
•	young men
•	night pain
•	morning stiffness
•	symptoms >3/12

POA:
• ESR
• joint examination
• referral to rheumatology

20
Q

In back pain for osteoporosis, what is the common history and poa?

A

History:
• older women
• smoking, steroids
• tenderness (fracture)

POA:
• x-ray if fracture suspected
• dexa-scan

21
Q

What is ankylosing spondylitis?

A

Ankylosing spondylitis (pronounced ank-kih-low-sing spon-dill-eye-tiss), or AS, is a form of arthritis that primarily affects the spine, although other joints can become involved. It causes inflammation of the spinal joints (vertebrae) that can lead to severe, chronic pain and discomfort.

22
Q

In back pain for bones mets, what is the common history and poa?

A

History
• older patients
• primary malignancy
• worsening pain

POA
• PSA
• calcium
• prostate examination

23
Q

In back pain for GI and GI pathology, what is the common history and poa?

A

History
• unrestricted movement
• no association with movement

POA
• urinalysis
• urology imaging
• referral to specialist

24
Q

Red flags with low back pain?

A
  • Progressive, persistent or severe neurological deficit

* Bladder or bowel dysfunction

25
Q

Name an example of a back screening tool?

A

Keele Start Back screening tool

26
Q

Most common type of chronic headache?

A

Tension-type headache (TTH)

27
Q

Epidemiology of migraine?

A

10-15% of adult population

28
Q

Types of headache presenting to a gp

A
  1. Primary headache: Refers to headache with no identifiable pathology.
  2. Secondary headache: Refers to headache with identifiable pathology (e.g. neurological, sinusitis, dental)
  3. Chronic daily headache (CDH): 15 or more episodes of headache per month for at least 3 months. CDH is most often due to tension-type headache or migraine (table 1).
    Cluster headache is also a primary chronic headache. Chronic headache can be secondary to sinusitis, medication-overuse, and very rarely to intracranial pathology.
  4. Acute headache: Starts suddenly and gets worse quickly. Acute headache is less common than chronic headache. E.g.
    Primary- Thunderclap or primary sexual headache
    Secondary- GCA (older, vision loss), Meningitis/encephalitis (fever, rash), SAH (“hit over the head”) or ICH
29
Q

Headache associated features from the history?

A
  • Is there a fever?
  • Are there focal neurological symptoms?
  • Are there visual symptoms such as flashing lights/wavy lines or visual loss?
  • Is there a prodrome?
  • Is there an aura?
  • Is there nausea and/or vomiting
30
Q

Trigger and associated conditions in headaches?

A 
Diet (the ‘5 Cs’ for migraine – cheese, chocolate, coffee, coke and citrus fruits)
Alcohol
Stress
Insomnia
Resp illness
General health
31
Q

What are the triptan drugs?

A

Triptans are a class of medications that are selective serotonin (5-HT) !B/1D receptor agonists. Triptans are primarily used in the acute treatment of moderate to severe migraine

E.g. almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan

32
Q

Anti-emetic drugs

A

Phenothiazine e.g. Prochlorperazine
Anti-histamine e.g. Cyclizine, cinnarizine
Hyoscine hydrobromide (for motion sickness)
Ondansetron

33
Q

Red flags with new acute headache?

A
  • Worsening headache with fever, ? meningitis
  • Sudden onset headache with maximum intensity in 5 minutes, ? SAH
  • Features suggestive of raised intracranial pressure
  • Features of intracranial pathology
34
Q 
Difference between migraine and TTH:
Pattern?
Duration?
Location?
Description?
Onset?
Exacerbaters?
Associations?
A 
Migraine:
Pattern? Episodic
Duration? 4-72hrs
Location? Unilateral
Description? Pulsating
Onset? With prodrome
Exacerbaters? Light, food, stress and insomnia
Associations? N/V, aura
TTH:
Pattern? Episodic/continuous
Duration? Hrs-days
Location? Bilateral (frontal, occipital, neck/shoulders
Description? Pressure or band like pain
Onset? No prodrome
Exacerbaters? Stress
35
Q

Presentation of depression

A

Common: Sadness and hopelessness

Non-specifically:

  • Tiredness
  • Fatigue
  • Loss of libido
  • Unexplained physical symptoms
36
Q

Depression symptoms

A

Symptoms of depression
• Depressed mood
• Loss of interest or pleasure in almost all activities
• Insomnia or hypersomnia
• Loss of appetite, substantial weight loss or weight gain
• Fatigue or loss of energy
• Psychomotor agitation or retardation
• Diminished ability to think or concentrate
• Feelings of worthlessness or inappropriate guilt
• Recurrent thoughts of death or suicide

37
Q

Two screening questions can be useful in the detection of depression, what are they?

A
  • During the last month, have you often been bothered by feeling down, depressed, or hopeless?
  • During the past month have you often been bothered by little interest or pleasure in doing things?
38
Q

What are the classification of depression in terms of severity?

A
  • Subthreshold depressive symptoms Fewer than 5 symptoms.
  • Mild depression Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment.
  • Moderate depression: Symptoms or functional impairment are between ‘mild’ and ‘severe’
  • Severe depression: Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms.
39
Q

Define subthreshold depression?

A

Fewer than 5 symptoms.

40
Q

Define mild depression

A

Few symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment.

41
Q

Define moderate depression

A

Symptoms or functional impairment are between ‘mild’ and ‘severe’

42
Q

Define severe depression

A

Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms.

43
Q

How to ask patients about suicidal ideation and intent?

A
  • Have you thought of killing yourself?
  • Have you thought how you would do it?
  • Have you thought when you would do it?
  • Have you tried before?
44
Q

What is the stepped care for depression?

A

For patients experiencing mild to moderate depression there is no convincing evidence that antidepressant drugs are more effective than placebo.

Psychological therapies including individual cognitive behavioural therapy, behavioural activation, and interpersonal therapy have greater supportive evidence but less accessibility.

Alternative management approaches such as guided self help based on CBT or behavioural principles including computerized CBT, and structured exercise programmes are more generally available and are effective

45
Q

What is the management plan for moderate to severe depression (when no response to CBT)?

A

Medication + high intensity psychological interventions

Medication:

  • SSRI anti-depressants
  • 1-2 week review after starting treatment –> every 2-4 weeks for 3 months
  • If minimal/no impact after 3-4 weeks then increase dose or switch medication
  • Once reached “usual self” continue for 6 months
  • If discontinuing treatment, gradual withdrawal over 4 weeks

Yr 4 General Practice (9 decks)

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