neuro Flashcards
history of weakness in hands, asymmetrical, gets tired after walking 100m, twitches in biceps. 74 years old, HTN, drinks a little. Top Differentials
MND, other differentials are Parkinson’s, syringomyelia, cervical radiculopathy, MG
examination findings in MND
muscle weakness in pyramidal distribution (upper and lower limbs), muscle wasting, thenar eminence wasting, hypo/hypertonia, resp distress, dysarthria, fasciculations, foot drop, absent or spastic reflexes, poor swallow
which form is most likely of MND
Amyotrophic lateral sclerosis (ALS), most common, no speech/swallow/breathing difficulty, mixed UMN and LMN, other forms more commonly seen in women
other forms of MND
progressive muscular atrophy (LMN), progressive bulbar palsy, primary lateral sclerosis (UMN)
right sided body weakness, history of HTN and T2DM, Fh of stroke. Investigations?
FBC, Us and Es, coagulation profile, glucose - to identify any underlying conditions such as polycythaemia
ECG to look for cardiac abnormalities such as A fib to see for cause of embolic stroke, and if needs anticoags
Ct scan of head to rule out hemorrhagic stroke and assess for ischaemic stroke to allow treatment approach
treatment for confirmed stroke
Ischaemic - intravenous thrombolysis, antiplatelet therapy, bp and glucose control
Haemorrhagic- bp control, neurosurgical intervention
stroke driving restrictions
pts with confirmed stroke must refrain from driving for a period of time until cleared by treating doctor, emphasise importance of safety, and to discuss concerns they have and info on alternative transportation
systems review for seizure
Asks about relevant symptoms in other body systems (such as numbness, weakness, tingling, vertigo, problems with balance, and problems with memory)
ask about chest pain or palpitations
ask about preceding aura, visual or sensory disturbance
seizure DVLA
no drive for 6 months if brain imaging and EEG normal, forever if abnormal
initial investigations after seizure if stable
Oxygen saturations - to identify
Blood glucose - to identify hypoglycaemia
Full blood count - to screen for anaemia and leukocytosis suggesting infection
Urea and electrolytes - to identify deranged electrolytes (such as hyponatraemia and hypernatraemia) and uraemia
Toxicology screening - if illicit substance use is suspected
Antiepileptic drugs are generally prescribed following a
second seizure.
status epileptics management
Perform an ABCDE approach, more specifically assessing the airway and considering air adjuncts (such as an oropharyngeal airway), checking oxygen saturations, and checking blood glucose.
The first-line drug in the hospital setting is IV lorazepam, which can be repeated once after 10-20 minutes.
classic vasovagal syncope or cardiac blackout history
dizziness, nausea or lighteheadness presyncopal/prodromal. With trigger
other Dx are epilepsy, psychogenic seizure, hypoglycaemia, TIA, migraine
neurology clinic investigations after fit
FBC/LFT/UsandEs: useful for baseline for drugs, anaemia could cause syncope, sodium and uraemia could contribute to blackout, blood glucose and calcium important as they could cause blackout, prolactin/CK raised in non epileptic seizures,
ECG for arrhythmia
EEG for brain wave activity
LP to rule out underlying infection
CT/MRI to evaluate structural integrity of brain
pregnant patient with epilepsy management
discussions of risks to unborn child if taking anti seizure meds such as sodium valproate (neural tube defects, cardiovascular, developmental delay).
refer to specialist team for review- lamotrigine and levetiracetam are reasonable safe
advice they must continue meds, 2/3 will not have a deterioration in seizures during pregnancy
breastfeeding- most women are encouraged to breastfeed and child will be monitored for things like failure to thrive or feeding difficulties/drowsiness
what do to when patient says funny turn
say what do you mean by that
specific symptom to enquire in funny turn
bladder incontinence
using neuro tip in sensory exam
always say does this feel sharp, then go from the bottom of the foot upwards and say when does this start to feel blunt, or feel less strong
Peripheral vascular disease first symptom
claudication
peripheral neuropathy can be described as
neuropathy of small fibres
don’t forget in peripheral lower limb exam
Babinski
ptosis and headache, third nerve palsy. Ix and Mx of diagnosis
Ct brain, exclude DM or GCA,
Diagnosis: PCA (single well defined structure)
Mx: endovascular coiling, surgical clipping and embolisation.
CT angiogram for aneurysm, same density as adjacent artery
headache and confusion, cancer history
CT scan with contrast (IV iodinated contrast)
multiple enhancing lesions. no midline shift or herniation, normal ventricles
Intracranial mets from known melanoma
how to see contrast
MCA or internal cerebral veins - light up white
where is basilar artery on scan
above midbrain
how can you make a CT show more bone
windowing - when only need to see skull. No contrast needed as skull naturally more dense than brain
old person with focal neurology management
Ct non contrast (incase of allergy/kidney issue, not needed as purpose is to tell if hemorrhagic or ischaemic which does not need contrast as fresh blood will be white due to acute nature)
Ischaemic stroke Mx
alteplase, mechanical thrombectomy
guided by CT angiogram to see if full blockage that needs removing
how to present a CT basic starting points example
Ct head, axial frame, non contrast
Hypo or hyper dense lesions
USS description of density
hypo hyper echoic
MRI description of density
intensity
Blurring of vision and pain, Hx of carpal tunnel, young female
optic neuritis, MRI brain and orbit
should be defined circle with white middle and black edge, if blurred, optic neuritis
Demyelination due to MS
History of sore throat radiating to ear, throat lump
USS neck, FNA, query oropharyngeal cancer
MRI neck with contrast
Ct neck abdo fir stage
oropharynx on CT should have gas, no gas = cancer
normal vs abnormal lymph node
normal looks like a kidney with vessels going into it, abnormal is more rounded and large with more blood vessels
what lies either side of pituitary fossa
cavernous sinus
neurofibromatosis 2, gradual onset hearing loss in Right ear and difficulty with balance, dull headache.
Cause, imaging and findings
bilateral vestibular schwannomas, MRI brain with contrast
glioblastoma symptoms features
describe
axial image from MRI brain with contrast at level of cerebellopontine angle. Bilateraly enhancing lesions, larger on right, vestibular schwannomas or meningiomas.
Describe
Coronal image from MRI brain with contrast demonstrating enhancing lesions at the left vertex extending along the convexity, but also a further lesion in the right ventricle
Loss of sense of smell and taste, blocked nose, wakes at night. Diagnosis and imaging
chronic rhino sinusitis, needs non contrast CT of sinus
Describe
Coronal non contrast CT of sinuses, there is opacification of left maxillary sinus, anterior ethmoid air cells, both middle and left inferior meats
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