MedEd Flashcards
1. Andromeda, a 32 year old female presents with recurrent headaches. They are severe, on the right side of her head and often continue for the rest of the day. Before the headaches start she gets tingling in her arms, and when the headaches start she goes to bed. She is worried they might affect her relationship with her new boyfriend. a Cluster headache b Intracranial space-occupying lesion c Medication overuse d Migraine e Tension headache
migraine
2. Homer, a 45 year old male has had excruciating headaches for the last month. He gets them about 5 times a week and notices his eyes watering. He had a similar episode 6 months ago. They are very disruptive to his poetry. a Cluster headache b Intracranial space-occupying lesion c Migraine d Subarachnoid haemorrhage e Meningitis
cluster headache
3. Atalanta, a 27 year old female athlete presents to the GP with early morning nausea and headaches which has been happening for at least a week. Both are worst when she wakes up and improve throughout the day. She notes that she has been getting tired over the last few weeks, she is late on her period, and is definitely more irritable with her boyfriend, who despite being an Olympian, keeps leaving apple cores scattered around the house. a Excessive excercise. b Migraine c Pituitary tumour d Pregnancy associated tension headache e Trigeminal neuralgia
pituitary tumour (causing raised ICP)
4. Aphrodite, a19 year old female sex-worker presents to A&E with a sudden onset headache that is the worst pain she has ever experienced. She occasionally gets mild headaches after sex, and has been given some medication by her GP for his. She has some neck stiffness and refuses to open her eyes wide or allow them to be examined. a Acute glaucoma b Meningitis c Migraine d Subarachnoid haemorrhage e Trigeminal neuralgia
SAH
5. Leonidas, a 24 year old male, was fencing and suffered and injury to the head when his rival, Xerxes hit him on the head with his shield. Leonidas recovered quickly and was able to continue to fight for the next 20 minutes. However he quickly developed an excruciating headache, started to lose consciousness and had to stop the fight to go to the nearest A&E. He has had a blocked nose for the last week. Epidural haemorrhage Intraventricular haemorrhage Meningitis Subarachnoid haemorrhage Subdural haemorrhage
Epidural haemorrhage
6. Euclid is a 19 year old male currently studying Maths at university. He has been very unwell for the last few days with fever and headache and admits to becoming a little confused lately. He is very anxious about his upcoming exams. He has been taking caffeine pills to help him with revision, however this has affected his sleep and for the last couple of nights he has developed a stiff neck. Medication overuse headache Meningitis Migraine Tension headache Sinusitis
Meningitis
7. Plutarch is a 77 year old male who has come in with a right sided headache. This started yesterday morning and have been getting progressively worse. His memory is a little off because of his dementia, but he says there is a possibility of trauma. His shoulders and neck also feel a little stiff. On examination, there is pain on palpation of the right forehead. Intracranial space-occupying lesions Meningitis Subarachnoid haemorrhage Subdural haemorrhage Temporal arteritis
Temporal arteritis
8. Helen is a 40 year old woman with a history of multiple sclerosis. She has developed a headache over the last couple of days. She has travelled the world and rarely had headaches in the past. She has stopped eating, as chewing simply makes her feel worse. Meningitis Migraine Temporal arteritis Tension headache Trigeminal neuralgia
Trigeminal neuralgia
what is the mneumonic for sinister causes of headache
VIVID
what does VIVID stand for
Vascular (SAH/haematoma) Infection (meningitis/encephalitis) Vision threatening (temporal arteritis/acute glaucoma) Intracranial pressure (hydrocephalus) Dissection (carotid dissection)
what are features of a tension headache
acute or gradual onset generalised headache which lasts for a couple of hours
associated with times of stress or lack of sleep
what is the managment for tension headache
simple analgesics
what are features of a migraine
unilateral pulsating or throbbing headache whichc can last hours to days
associated with an aura (visual or sensory changes)
who does migraine commonly affect
women
what is the conservative management for migraine
headache diary
to work out and avoid precipitating factors
what is the medical management of migraine
sumitriptan
+analgesia (NSAID)
+antiemetic (metoclopramide)
what is the prophylactic management of migraine
1st line: propanolol
2nd line: amitriptyline
what could patients with migraine get
medication overuse headache with chronic analgesic use
what are features of cluster headache
sudden onset (at the same time each day) of unilateral orbital excruciating pain which lasts for minutes associated with a swollen eye and forehead, nasal congestion
what condition is associated with cluster headache
horners
who does cluster headaches commonly affect
males
what is the medical treatment for cluster headaches
100% O2 through a non-rebreathable mask
sumitriptan (subcut)
what is the prophylactic treatment for cluster headaches
verapamil
what are features of raised ICP
gradual onset of bilateral headache which is worse when lying down or bending over or coughing
associated with seizures, papilloedema, focal neurology
what are the red flag symptoms in raised ICP
seizures
papilloedema
focal neurology
what are causes of raised ICP
space occupying lesions
hydrocephalus
trauma
what is the first line investigation for raised ICP
urgent CT/MRI to exclude underlying lesion
when are headaches caused by raised ICP worse
in the morning
what are features of SAH
sudden onset “thunderclap” headache which is commonly at the back of the skull (like being kicked in the back of the head)
associated with syncope, N+V
why does SAH present with signs of meningism
meningeal irritation
what causes SAH
berry aneurysms at the circle of Willis (associated with Hx or FHx of polycystic kidney disease)
what are risk factors for SAH
alcohol
smoking
HTN
what investigations should be performed with suspected SAH
1 urgent CT scan (within 12hrs)
2 LP
what risk of mortality is associated with SAH
50%
what is the medical management
ABC
AB: maintain airway + breathing
C maintain cerebral perfusion
-hydration
-maintain BP
what is the supportive management
reduce high ICP
-osmotic diuretic (mannitol)
prevent cerebral artery vasospasm
-nimodipine
what is the definitive surgical treatment for SAH
surgical clipping
endovascular coil embolisation
what are features of SDH
gradual onset of sleepiness and personality change (diminished verbal and motor response)
what are risk factors for SDH
age
accidents (trauma)
anticoagulation
what is the definition of SDH
collection of blood between the dural and arachnoid coverings of the brain
is the blood in SDH arterial or venous
venous
what is the 1st line investigation for SDH
urgent non-contrast CT scan
what is the management for SDH
neurosurgery referral
what are features of epidural haemorrhage
acute onset headache after a lucid interval
associated with deterioration of GCS and a history of recent direct trauma
what is commonly seen on examination in epidural haemorrhage
scalp trauma
definition of epidural haemorrhage
collection of blood between the dura and periosteum
is the blood in epidural haemorrage commonly arterial or venous
arterial
what is the first line investigation for epidural haemorrhage
urgent non-contrast CT scan
why is a non-contrast CT rather than a contrast CT scan ordered in suspected haemorrhages
blood is not contained by vessels so contrast can leak into surrounding vessels
what is the most common cause of extradural
high impact trauma
what artery is most commonly affected in extradural
middle meningeal artery
what is the most common cause of SAH
ruptured aneurysms
what is the most common cause of SDH
rupture of vein by minor head trauma
what is the onset of extradural
sudden onset
what is the onset of SAH
sudden onstt
what is the onset of SDH
gradual onset
what symptoms are associated with extradural
blackout followed by a lucid interval followed by a rapidly declining GCS
what are symptoms associated with SAH
worse headache ever
thunderclap
what are symptoms associated with SDH
no/mild symptoms
- worsening confusion
- fluctating consciousness
what are features of meningitis
sudden onset headache
associated with meningism (headache, stiff neck, photophobia)
confusion and seizures are associated
what investigations are completed for meningitis
LP
-CSF protein/glucose
blood culture
CT head
what is giant cell arteritis
vasculitis affecting arteries in the head
what could giant cell arteritis of the opthalmic artery cause
blindness
what are features of temporal giant cell arteritis
onset of headache over a couple of days which is usually unilateral and localised to the scalp
associated with pain when eating or brushing hair and a visual disturbance
what would be found on examination of giant cell arteritis
scalp tenderness
what condition is giant cell arteritis associated with
polymyalgia rheumatic (pain and stffness of the shoulders and upper arms)
what is the management for giant cell arteritis
urgent prednisolone (delay can cause blindness)
what are features of trigeminal neuralgia
shooting facial pain in the distibution of the Vth nerve, commonly unilateral
this is provoked by washing, shaving or chewing
what are risk factors for trigeminal neuralgia
elderly
MS
(female + HTN)
what is the management for trigeminal neuralgia
anticonvulsants (cabamazepine)
what is a classic history of sinusitis
7-10 day history of fever and headache with nasal congestion or discharge
how does acute glaucoma present
headache, painful eye, visual changes, vomiting
what is the management for acute glaucoma
acetazolamide (carbonic anhydrase inhibitor)
timolol (BB)
- 70 year old Herodotus is brought in by his daughter to the GP. Over the last week he has developed a headache which lasts most of the day and rarely goes. He lives with his daughter and son-in-law as he is prone to falls due to his recent left hip replacement. The daughter also mentions that his father’s behavior has changed lately and tends to exaggerate some of his stories.
What do you think is the most important step in your management plan?
MRI scan
Routine CT scan
Sumitriptan + NSAIDs
Urgent CT scan
Watchful waiting
Urgent CT scan
10. Alexander, known to his mates as Alex the G, is a 32 year old soldier who has just returned from a tour in Iran. He tells you that he has been getting throbbing bilateral head pain, and puts this down to lack of sleep. As a general, he has multiple reports to write and is finding this difficult with his four friends constantly bickering about one thing or the other. He hasn’t tried any medication and asks that you prescribe some sleeping pills. What is the most appropriate management? Diazepam Codeine NSAIDs Topiramate Refer to A&E
NSAIDs
11. Pythagoras is a 40 year old man who suffers from headaches. 3 weeks ago he was prescribed ibuprofen and has taken it religiously. Initially these worked really well, however now the headaches have returned and are worse than ever. He is very angry and does not think you are taking the right angle towards managing his issue. What is the next course of management? Antibiotics Add a β-blocker Refer to A&E Switch medication to carbamazepine Ask to stop ibuprofen and see in 2 weeks
Ask to stop ibuprofen and see in 2 weeks
- Hippocrates is a 71 year old homeopath who presents with a left sided headache which came on yesterday morning. He tried to tread it with a clever paste made of garlic, vinegar and honey. When he applied the paste he was in great pain, and so believed that his remedy was working. However, his skeptical son told him to see “another doctor” for treatment. What is the most important next step?
Prescribe prednisolone and refer patient to A&E
Prescribe sumitriptan and NSAIDs
Refer to A&E for urgent CT scan
Refer to A&E for urgent non-contrast CT scan
Refer to A&E for MRI
Prescribe prednisolone and refer patient to A&E
A 25-year-old man was hit on the side of the head with the ball, whilst playing cricket. He recovered enough to finish off the game. He then presented to A&E 8 hours later with a severe headache and vomiting. On Examination he pupil are looking down and out, and soon after this he rapidly loses consciousness
Subarachnoid Haemorrhage Extradural Haemorrhage Stokes-Adam’s Attack Postural Hypotension Hypoglycaemia
extradural
A 52 year old fund manager with a history of previous heart attacks, feels some palpitations and collapses. A witness said that he went very pale as he collapsed but then became flushed and regained consciousness after 30 seconds.
Subarachnoid Haemorrhage Extradural Haemorrhage Stokes-Adam’s Attack Postural Hypotension Hypoglycaemia
Stokes-Adam’s Attack
A previously well 14 year old girl collapses after being in a crowd for 2 hours at a pop concert.
Cardiac Arrhythmia Aortic Stenosis Vasovagal Syncope Postural Hypotension Situational Syncope
Vasovagal Syncope
A 75-year-old man is found on his bedroom floor by his wife and is now conscious. He got out of bed in the middle of the night to go to the toilet and felt dizzy and fell to the ground. He is on treatment for hypertension and has no other medical problems.
Cardiac Arrhythmia Aortic Stenosis Vasovagal Syncope Postural Hypotension Situational Syncope
Postural Hypotension
A 56 year old lady collapses whilst running for the bus. O/E there is a thrusting apex beat and an ejection systolic murmur. This is best heard on expiration and radiates to the carotids.
Cardiac Arrhythmia Aortic Stenosis Vasovagal Syncope Postural Hypotension Situational Syncope
Aortic Stenosis
A 20 year old man, who was picked up by the police, is behaving irrationally & is confused & irritable. He is pale & sweaty & smells of alcohol. He keeps asking for biscuits.
Subarachnoid Haemorrhage Extradural Haemorrhage Stokes-Adam’s Attack Postural Hypotension Hypoglycaemia
Hypoglycaemia
44 y/o gentleman. On examination he appears drowsy, only opening his eyes in response to speech, he seems confused and disorientated, and when assessing his movements he is able to obey commands. Calculate his GCS
6 8 9 10 13
13
A 65 year old man with a history of an MI 2 years ago. He lost consciousness and presents to you 36 hours later with reduced power in his left arm and leg.
Stroke Subdural Haematoma Encephalitis SOL Epilepsy
Stroke
A 21-year-old man is walking down the street to visit his friends while suddenly he falls to the ground unconscious. His body goes stiff and then he begins to jerk his arms. He becomes incontinent of urine.
Stroke Subdural Haematoma Encephalitis SOL Epilepsy
Epilepsy
what is a mneumonic for blackouts?
COLLAPSED
Carotid sinus syncope Orthostatic (postural) hypotension refLex - vasovagal syncope Low glucose Arrythmias/stoke-adams attack Panic - anxiety - hyperventilation Situational syncope Epilepsy Drop attacks
what is a classic feature of a extradural haemorrhage
lucid interval following LOC
what is the blood in an extradural haemorrhage
arterial
what are classic features of a SDH history
Hx of falls and progressive confusion
what is the blood in SDH
venous
what are causes of raised ICP
SHIT
abSceSS
Haemorrhage
Infarction
Tumours
plus cerebeal oedema and trauma
what are signs of raised ICP
headache N+V altererd GCS papilloedema pupil changes
what pupil changes can occur in raised ICP
dilated
down and out
what are signs of herniation in raised ICP
opthalmoplegia
ataxia
apnoea
what is the definition of postural hypotension
drop in systolic BP >20mmHg or diastolic BP >10mmHg after standing for 3minutes vs lying
what test is used to confirm postural hypotension
tilt test
who is postural hypotension common in
elderly
what conditions related to peripheral neuropathy cause postural hypotension
inadequate vasomotor reflex
DM
parkinsons
MSA
how low do glucose levels have to be before symptoms of hypoglycaemia show
<3mmol/L
what is the treatment for hypoglycaemia
IV dextrose or IM glucagon
what does a GCS below 8 suggest
coma or severe injury
A 65-year-old hypertensive man has complained of losing vision twice in one eye, which lasted for a few hours and then went back to normal. He says it’s like ‘a black sheet falling over the front of my eye’.
Right-sided Stroke Transient Ischaemic Attack Meningitis Encephalitis Left-side Stroke
Transient Ischaemic Attack
An 80-year-old woman who is a smoker was brought into A&E from a residential home where her carers noticed that she had difficulty swallowing and that she also had difficulty moving her left arm and leg for the past few days.
Right-sided Stroke Transient Ischaemic Attack Meningitis Encephalitis Left-side Stroke
Right-sided Stroke
A 30-year-old woman experienced a strange feeling in her stomach, followed by stiffness & jerking in the left arm. Afterwards, she felt drowsy but remembers everything.
Myoclonic Seizure Complex Partial Seizure Simple Partial Seizure Tonic-Clonic Seizure Absence Seizure
Complex Partial Seizure
A 21-year-old man is walking down the street to visit his friends while suddenly he falls to the ground unconscious. His body goes stiff and then he begins to jerk his arms. He becomes incontinent of urine.
Myoclonic Seizure Complex Partial Seziure Simple Partial Seizure Tonic-Clonic Seizure Absence Seizure
Tonic-Clonic Seizure
what are signs of a stroke
UMN lesion contralateral motor and sensory signs no fasciculations no muscle wasting weakness (esp of arm extensors and leg flexors) hyperreflexia positive babinski sign pronator drift
what are features of a posterior cerebral artery lesion
homonymous hemianopia
visual agnosia
prosopagnosia
what is amaurosis fugax`
transient and painless loss of vision in one eye due to embolus into the central retinal artery
what features indicate a simple partial seizures
no LOC
no post-ictal phase
what features indicate a complex parpostial seizure
most commonly arise from temporal love (deja-vu, depersonalisation, altered emotion)
consciousness impaired
post-ictal confusion
what does tonic mean
limb stiffening
what does clonic mean
limb jerking
what is status epilepticus
continuous seizure lasting >30mins
what is the medical management for status epilepticus
slow IV bolus lorazepam a second dose is administered if no response in 10 minutes
if still no response IV phenytoin or diazepam
what is Brudzinski sign
indication for meningitis
passive flexion of the neck causes flexion of the legs
what is encephalitis
inflammation of brain parenchyma
what are metabolic causes of LOC/seizure
hyponatraemia
hypocalcaemia
what classic history of hyponatraemia
headaches, vomiting, drowsiness + seizures
associated with thiazide diuretics
what is a classic history of hypocalcaemia
complication of thyroid surgery CATS convulsions arrythmias tetany spasms
what signs are associated with hypocalcaemia
chovesteks sign
trousseus sign
A 50-year-old man presents with an instantaneous onset of a severe headache, followed by drowsiness & vomiting. Shortly after presentation he loses consciousness
Subarachnoid Haemorrhage Extradural Haemorrhage Anaemia Postural Hypotension Hypoglycaemia
SAH
An 80 year old man fainted with a 2 week history of abdominal pain and coughing up a black coffee-ground like substance. He has been feeling irritable, tired and sleepy.
Subarachnoid Haemorrhage Extradural Haemorrhage Anaemia Postural Hypotension Hypoglycaemia
Anaemia
A 10-year-old girl is not doing well at school, her teacher says she doesn’t concentrate and shows no interest. Her parents also noticed the girl has moments (around 10secs) when she just stares blankly, blinking and then returns to normal. It happens up to several times an hour.
Myoclonic Seizure Complex Partial Seziure Simple Partial Seizure Tonic-Clonic Seizure Absence Seizure
Absence Seizure
A 71 year old man with long standing hypertension lives on his own. He is found by his son with marked right upper limb weakness and difficulties with speech. He is now incontinent of urine and has some personality changes.
Right-sided Stroke Transient Ischaemic Attack Meningitis Encephalitis Left-side Stroke
Left-side Stroke (with frontal lobe involvement for personality changes)
A 87-year-old lady had a seizure at home. Her husband says she has been drowsy for the last couple of days. She is otherwise in good health but she has recently started antihpertensive drugs. On examination, her skin turgor is reduced.
Hypercalcaemia Hypocalcaemia Hyperglycaemia Hypoglycaemia Hyponatraemia
Hyponatraemia
A 66-year-old was getting increasing confused over the last couple of days. She was admitted after a seizure. She appears distressed and is pyrexial with mild meningism but no rash. A CT head scan shows changes in the left temporal lobe and cerebral oedema.
Right-sided Stroke Transient Ischaemic Attack Meningitis Encephalitis Left-side Stroke
Encephalitis
