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
