Neuro Flashcards
Define CHRONIC FATIGUE SYNDROME.
CFS is when persistent or intermittent fatigue exists for > 6 months in duration, with no identifiable cause.
Differential Diagnoses for FATIGUE?
PROBABILITY DIAGNOSIS
✔️ stress / burnout
✔️ inappropriate lifestyle factors (e.g. excessive caffeine, physical inactivity)
✔️ sleep problem, such as obstructive sleep aponea
✔️ iron deficiency anaemia
✔️ thyroid problems
✔️ viral infection / post-viral fatigue
RED FLAGS / IMPORTANT CONDITIONS ✔️ congestive cardiac failure ✔️ cardiac arrhythmia ✔️ cardiomyopathies ✔️ EBV, CMV, dengue virus infection ✔️ HIV ✔️ Hepatitis B or C ✔️ syphilis
OFTEN MISSED ✔️ depression / psychiatric illnesses ✔️ food intolerances ✔️ allergies ✔️ malabsorptive conditions (e.g. Coaeliac disease) ✔️ menopause ✔️ pregnancy ✔️ drugs / medications
MASQUERADES ✔️ depression ✔️ diabetes ✔️ drugs ✔️ anaemia ✔️ thyroid ✔️ UTI ✔️ spinal dysfunction
What drugs can commonly cause FATIGUE?
✔️ antidepressants ✔️ anti-epileptics ✔️ sedatives (e.g. benzodiazepines) ✔️ opioids / analgesics ✔️ cardiac drugs (e.g. beta-blockers, CCB, digoxin) ✔️ anti-histamines ✔️ hormones (e.g. OCP, HRT) ✔️ alcohol ✔️ marijuana
Red flag symptoms for FATIGUE?
✔️ unexplained weight loss ✔️ persistent fever ✔️ symptoms of depression ✔️ drug and alcohol use ✔️ sleep disturbances
What are some appropriate INVESTIGATIONS for fatigue?
BEDISDE Ix
✔️ ECG
✔️ blood glucose levels
✔️ urine dipstick +/- MCS
LABORATORY Ix ✔️ FBC + WCC ✔️ Inflammatory markers ✔️ UECs + eLFTS ✔️ CMP ✔️ TFTs ✔️ Iron studies ✔️ Folate + B12 ✔️ Viral serology (dengue, RRV, EBV, CMV)
IMAGING Ix
✔️ CXR
✔️ echocardiogram (if CCF is suspected)
Differential Diagnoses for HEADACHE?
Primary Headache ✔️ tension headache ✔️ migraine headache ✔️ cluster headache ✔️ caffeine withdrawal headache
Secondary Headache
✔️ subarachnoid haemorrhage (rupture of berry aneurysm)
✔️ subdural hematoma / epidural hematoma (traumatic brain injury)
✔️ space occupying lesion
✔️ meningitis / encephalitis (infection)
✔️ systemic disease (e.g. phaeochromocytoma, HTN, hyperthyroidism)
✔️ temporal arteritis
✔️ TMJ or C-Spine pathology
Red flags for HEADACHE?
✔️ patient > 55 years of age ✔️ persistent and worsening ✔️ morning-time / crescendo headache ✔️ worse when bending over, leaning forward, coughing ✔️ associated with fever, night sweats, weight loss ✔️ unexplained weight loss ✔️ focal neurology ✔️ seizure ✔️ vomiting ✔️ neck stiffness + photophobia
MIGRAINE HEADACHE - Key Features & Management
KEY FEATURES
- pulsatile in nature
- unilateral distribution
- proceeded by an aura (e.g. visual, auditory, olfactory)
- associated with photophobia and phonophobia
- duration up to 72 hours
- recurrent episodes; up to two per month
- patient is often able to identify a precipitant (e.g. stress, hunger)
MANAGEMENT
- avoid known triggers
- rest in cool, quiet and dark room
- treat with paracetamol and ibuprofen (mild cases)
- treat with serotonin receptor antagonist, such as ergotamine or sumatriptan (severe cases)
TENSION HEADACHE - Key Features & Management
KEY FEATURES
- bilateral, “band” distribution over the front of the head
- duration can be up to 2 - 3 days
- associated with stress, anxiety and burnout
- worsens throughout the day
MANAGEMENT
- avoid triggers / stresses
- treat with paracetamol and ibuprofen
- maintain adequate hydration
CLUSTER HEADACHE - Key Features & Management
KEY FEATURES
- recurrent, paroxysmal headache that characteristically occurs in the early hours of the morning, waking the patient from their sleep (“alarm clock” headache)
- unilateral, retro-oribital location
- occurs more in males than females (6:1 ratio)
- nil visual disturbances
- nil nausea or vomiting
MANAGEMENT
- paracetamol and ibuprofen
- consider migraine medications (ergotamine or sumatriptan)
- consider a local anaesthetic nerve block in severe cases
TEMPORAL ARTERITIS - Key Features & Management
KEY FEATURES
- unilateral headache located over the temporal region
- thickening + hardening of the temporal artery
- 20% of cases associated with polymyaglia rheumatic (bilateral shoulder pain / stiffness)
- non-specific onset
- most commonly seen in males > 50 years of age
- may be associated with low grade fever, muscle aches and pain, jaw claudication and HTN
MANAGEMENT
- panadol and ibuprofen
- prednisolone 40 to 60 mg PO, two daily doses for 4 to 6 weeks
SUBARACHNOID HAEMORRHAGE - Key Features & Management
KEY FEATURES
- acute onset, “thunderclap” headache
- may be associated with syncope, nausea and vomiting
- neck stiffness and photophobia may also be present
- common in middle-aged females; family history of SAH or berry aneurysm is common
- occurs with physical exertion
- neurological deficits may develop (e.g. hemiplegia, CNIII palsy)
MANAGEMENT
- immediate referral to emergency / neurology
- non-contrast CT head within 6 hours of presentation
- lumbar puncture after 24 hours if CT negative but clinical suspicion remains high
SPACE OCCUPYING LESION - Key Features & Management
KEY FEATURES
- gradual, insidious onset
- headache occurs every day; worsening intensity
- morning-time headache; “crescendo”
- worsens with leaning forward, coughing, sneezing
- may have neurological deficits
- may have seizure
- may have weight loss, fever, night sweats etc.
MANAGEMENT
- immediate referral to specialist neurology is necessary
MENINGITIS - Key Features & Management
KEY FEATURES
- follows viral URTI
- severe headache, “all over”
- associated with neck stiffness + photophobia
- neurological signs + seizure is suggestive of encephalitis
- high fever is usually present
MANAGEMENT
- lumbar puncture is diagnostic
- non contrast CT to exclude space occupying lesion or traumatic brain injury
- IV antibiotics should be started empirically
SINUSITIS - Key Features & Management
KEY FEATURES
- fullness or pressure within the head, particularly the frontal regions
- purulent nasal discharge
- nasal congestion
- symptoms are proceeded by viral URTI
- low grade fever may be present
- loss of smell / reduced smell
MANAGEMENT
- advise of need to clean out sinuses (e.g. nasal saline spray, humidifier)
- paracetamol and ibuprofen for pain and fever management
- amoxicillin + clavulanic acid if symptoms do not subside within 5 - 7 days
Outline key investigations for HEADACHE.
BEDSIDE Ix
✔️ ECG
✔️ Blood glucose level
LABORATORY Ix ✔️ FBC + WCC ✔️ Inflammatory markers ✔️ UECs + eLFTs ✔️ Iron studies ✔️ Vitamin B12 + Folate ✔️ Coagulation ✔️ Viral screen
IMAGING Ix
✔️ Non contrast CT Head
✔️ Lumbar puncture (meningitis / encephalitis + SAH)
Differential diagnoses for CONFUSION in an elderly patient?
PROBABILITY DIAGNOSIS ✔️ delirium ✔️ drugs ✔️ dementia ✔️ depression ✔️ dural hematoma (sub or epi)
RED FLAGS / SERIOUS CONDITIONS
✔️ stroke / TIA
✔️ EDH / SDH
✔️ cardiac failure
✔️ arrhythmia
✔️ renal failure (uraemia)
✔️ hepatic encephalopathy (liver failure)
✔️ intracranial space occupying lesion
✔️ lung cancer (paraneoplastic syndrome such as SIADH)
✔️ infection (meningitis or encephalitis)
✔️ sepsis
✔️ metabolic conditions (e.g. hyponatremia, hypoglycaemia)
OFTEN MISSED ✔️ drug withdrawal / intoxication ✔️ metabolic / electrolyte disturbances ✔️ fecal impaction ✔️ urinary retention ✔️ hypoxia
MASQUERADES ✔️ depression ✔️ drugs ✔️ diabetes ✔️ UTI ✔️ anaemia ✔️ thyroid conditions ✔️ spinal dysfunction
What are some drugs commonly associated with CONFUSION?
✔️anti-cholinergic agents (Parkinson medications, TCAs) ✔️anti-epileptic medications ✔️ anti-depressants (e.g. TCAs) ✔️anti-hypertensive medications ✔️cardiogenic drugs (e.g. beta-blockers, digoxin, CCB) ✔️ corticosteroids ✔️opioids ✔️ sedatives (e.g. benzodiazepines)
Differential diagnosis for VERTIGO?
VERTIGO = episodic, spontaneous / paroxysmal sensation of “spinning”
The causes for vertigo are extensive, and can be classified as:
- peripheral causes
- central causes
PERIPHERAL CAUSES ✔️ BPPV ✔️ Meniere's Disease ✔️ vestibular neuritis ✔️ labyrinthitis ✔️ vestibular neuroma
CENTRAL CAUSES ✔️ cerebellar tumour ✔️ infarct involving the cerebellum ✔️ migraine ✔️ Multiple Sclerosis
Differential diagnosis for PSEUDO-VERTIGO / DIZZINESS?
- Syncope (vasovagal, orthostatic, cardiogenic)
- Disequilibrium
- Giddiness / lightheadedness
Red flags for VERTIGO?
✔️ bi-directional nystagmus (horizontal or central)
✔️ ataxic signs out of proportion to the severity of dizziness
✔️ neurological findings
BPPV - Key Features
KEY FEATURES
- due to displacement of otolith crystals within the semi-circular canal of the middle ear
- paroxysmal vertigo; episodes last 10 to 60 seconds
- induced by rapid head movements (e.g. turning over in bed)
- episodes resolve spontaneously
- horizontal, unilateral nystagmus TOWARDS the affected side
- nil nausea or vomiting
MENNIERE’S DISEASE - Key Features
KEY FEATURES
- due to auto-immune driven inflammation, resulting in increased endolymph within the middle ear
- most common in women aged 30 to 50 years; other auto-immune conditions may be present
- spontaneous attacks of vertigo, not necessarily associated with movements
- associated with tinnitus and reduced hearing unilaterally
- unilateral, horizonal nystagmus AWAY from the affected ear
VESTIBULAR NEURITIS - Key Features
KEY FEATURES
- auto-immune driven inflammation of the vestibular nerve (CNVIII), often after viral infection
- characterised by severe and prolonged vertigo; ongoing for 1 - 2 days
- gait ataxia may also be present
- nystagmus is spontaneous, unilateral and horizontal
