Neuro Flashcards
ddx for adolescent syncope metabolic disturbance (3) neuro (4) cvd (1) tox (1)
metabolic disturbance
- hypoglycaemia
- hypotension secondary to dehydration
- hyponatraemia
neuro
- epilepsy
- head trauma
- subarachnoid haemorrhage
- meningitis
cardiac arrhythmia
recreational drug use
key features of history for adolescent syncope personal (3) neuro (6) CVD (3) vitals (1)
personal
- fhx epilepsy
- food intake that day, water intake that day
- recreational drug use
fever
neuro sx.
- tongue biting during syncope
- post ictal confusion following period of unconsciousness
- urinary incontinence during syncope
- neurological weaknesses or sensation changes
- recent head trauma
- headache
CVD
- chest pain immediately prior
- sob immediately prior
- palpitations
peripheral neuropathy - ddx
‘DAMIT BITCH’
diabetic neuropathy
alcohol abuse
medication SE - amiodarone, nitrofurantoin, phenytoin, CTX, levodopa
Inflammatory - Guilliane barre syndrome
Tumours - paraneoplastic syndrome
B12 deficiency - alcoholics, pernicious anaemia, coeliacs, sleeve gastrectomy
Infection - HIV, Hep C, leprosy
Trauma
Connective tissue disorders - SLE, polyarteritis nodosa
Hereditary - Charcot marie tooth
diabetic autonomic neuropathy - key features
CVD (2)
GI (2)
urology(2)
CVD
- orthostatic hypotension
- cardiac autonomic neuropathy - resting tachycardia, bradycardia
GI
- gastroparesis
- diarrhoea
urology
- erectile dysfunction
- urinary retention
Rx for painful diabetic peripheral neuropathy
amitriptyline 25mg nocte increase to 150mg
duloxetine 60mg mane, increase to 60mg bd
gabapentin 300mg up to 1200mg per day
pregabalin 75mg bd, increase to 300mg bd
fits, faints, funny turns - key features on hx
any preceding symptoms - sob, headache, recent illness, heart palps, recent head trauma, auras
onset - sudden, slow
does patient remember event
did they lose consciousness
events after episode - urine incontinence, tongue biting, post ictal drowsiness or confusion
PMHx - epilepsy fainting, cvd, dmt, CVD, previous TIA/CVA
Fhx epilepsy
ddx for epilepsy
psych (2)
gen med (2)
neuro (3)
psych
- vasovagal
- pseudoseizure
cardiac arrhythmia
metabolic disturbance
neuro
- TIA
- migraine
- narcolepsy
causes of provoked seizures brain (3) systemic (3) tox (2) wildcard (1)
brain - CVA - trauma - meningitis (infection) systemic - hyponatramia - hypoglycaemia - hypercalcaemia tox - ETOH withdrawal - synthetic cannabinoids (and probably other drugs)
pregnancy - eclampsia
things to look for in examination post fit faint funny turn
- general (3)
- neuro (3)
- CVD (4)
general - fever - cervical spine tenderness on examination neuro - neck stiffness - papillodema - CN exam abnormalities CVD - carotid bruit - orthostatic hypotension (BP, sitting/standing) - irregular pulse - murmurs (heart sounds)
Initial ix for fit faint funny turns
BSL FBC UEC \+/- ECG CT head MRI brain EEG
nonmedication management advice following seizure (7)
no driving until 6/12 episode free no driving 12/12 if dx epilepsy no bathe or swimming alone no working at heights no abseiling, water sports, operating heavy machinery seizure 1st aid education mx of status epilepticus
Multiple sclerosis - key features examination optic (3) general neuro (2) motor neuron (4) brainstem (2)
optic - reduced monoocular blurred vision VA - central scotomata - loss of red color vision general - unilateral neuro SOS - unilateral numbness parasthesia
UMN
- unilateral spastic paresis - weakness, no muscle atrophy
- increased tone no fasiculations or fibrillations
- hyperreflexia - deep tendon reflexes
- positive babinski/upgoing plantar reflex
brainstem
- ataxic gait
- internuclear opthalmoplegia
multiple sclerosis - key investigations
MRI brain + spine with contrast - MS lesions
CSF electrophoresis - oligoclonal bands raised IgG
Evoked vision potential studies
Multiple sclerosis - McDonald dx criteria (4)
objective evidence of 2 or more lesions
disseminated in time and space
with no better explanation for cause
2 x separate episodes, 2 separate CNS regions
Multiple sclerosis - ddx for clinically isolated syndrome (acute demyelination)
neuro (3)
nutritional (1)
infection (2)
other (2)
neuro
- migraine
- cerebral tumour
- spinal cord compression
nutritional - b12 deficiency infection - HIV - syphilis
other
- paraneoplastic syndromes
- psychiatric distress/somatisation
myasthenia gravis - key investigations (3)
anti-acetylcholine receptor antibodies +ve
CT scan chest/thorax - detect thyoma or thyroid tumour
Electromyography - EMG
myasthenia gravis - key features Hx
painless fatigue with exercise
weakness precipitated by stress - cyesis, infection, surgery, emotional
fluctuating symptoms
variable severity of muscle weakness
variable distribution of muscle weakness:
ocular - diplopia,
dysphagia, difficulty chewing, dysphonia/speech, difficulty whistling
limbs proximal to distal, generalised weakness
resp - sob, breathlessness
a/w other autoimmune diseases - SLE, RA, thyroid, pernicious anaemia
FHx
PMHx
myasthenia gravis - nonmedical management
referral to consultant neurologist
detect thyoma with ct chest
exclude associated autoimmune disease
myasthenia gravis - treatment
anticholinesterase inhibitors - pyridostigmine 30mg tds, titrate weekly up to 120mg 4hrly
prednisolone 5mg od, titrate up to 1mg/kg/day max 75mg mane
azathioprine 1.5-2.5mg/kg po od
multiple sclerosis - key features history
onset of symptoms over days to weeks of: blurred vision, diplopia painful eye movement motor weakness sensory weakness/parasthesia unsteady gait bowel or bladder dysfunction FHx MS previous episodes head trauma headache vertigo
Vertigo - central causes (3):
CVA
cerebral tumour
MS
Vertigo - peripheral causes (4):
Meniere’s diease
labyrinthitis
Benign paroxsymal postional vertigo
vestibular neuronitis
Vertigo - key features Hx
any associated tinnitus or hearing loss preceding viral illness provoked from change in position duration of episode any associated neurological symptoms - weakness, ataxia, confusion, paraesthesia any associated N+V medications - ototoxic drugs, antihypertensives stress/panic attacks recent head trauma
Headaches red flags
Age >50yrs
pmhx active or past malignancy
thunderclap headache
1st ever headache with focal neurology
hx recent head trauma
increasing severity or frequency of headache
positional - increases when lying, bending, coughing, straining, valsalva
associated systemic illness - fever, neck stiffness, rash
PMHx - HIV, cancer, immunocompromise
Papilodema
FHX berry aneurysm
headache - history
is this worse than previous headaches? severity of headache? where is the pain? does it radiate anywhere? onset - sudden, slowly? any prodromal symptoms? is it made worse by coughing bending straining any fevers, rashes, neck stiffness any vomiting any vertigo or dizziness any vision changes any photophobia PMhx medications any recent trauma
Headache - examination
vital signs face and scalp - masses, neck stiffness neuro exam - perrla, cn exam, RAPD, fundoscopy for papilloedema CVS exam - HS, carotid bruits
headache Ix
CT/MRI for chronic heaache with ?intracranial pathology
CT head/mri for chronic headache with associated neuro SOS
Headache - indication for neurology referral
dx uncertain inadequate or no response to treatment condition or disability worsens irretractable or daily headaches urgent t/f to ED if ?CVA/TIA, head trauma, meningitis
Ramsay hunt syndrome - key features
Typically presents with a triad of otalgia, cutaneous
vesicles in a dermatomal distribution and
unilateral facial nerve palsy.
cutaneous vesicles in external auditory canal
diffuse otitis externa, crusting
preauricular ln swelling
Pmhx - chicken pox as child
Ramsay hunt syndrome - mx
‘facial nerve recovery’ - aciclovir 800mg 5 times per day for 7-10days
prednisolone - 1mg/kg <75mg po mane for 7-14days
‘management of postherpetic neuralgia’ - pregabalin 75mg - 300mg po bd, gabapentin 100-300mg po tds
‘eye care’ - regular lubricating eye drops throughut day, taping eye shut at night
clinical review at 7 days to check response to treatment
educate on sos of opthalmic complications
facial weakness - ddx
Stroke/TIA multiple sclerosis otitis media, schwannoma Bells palsy(idiopathic) Ramsay Hunt Syndrome Myasthenia gravis head trauma temporal bone fracture cerebral tumour, parotid tumour, lymphoma neurofibromatosis
facial weakness - Peripheral nerve palsy - key features examination
weakness of forehead, eye and mouth weakness in raising and furrowing brow smooth forehead/no wrinkles weakness in blinking/closing eye weakness in grimacing and smiling flattening of nasolabial fold
facial weakness - upper motor neuron/CNS - CVA key features examination
lower face only
nasolabial fold flattening
weakness in smiling and grimacing
sparing forehead, brows and eyes
Bells palsy - mx
Advise patients that facial nerve recovery can take several weeks or months.
eye care - drops and tape shut eyelid at night
cover and protect eye in windy and dusty conditions
prednisolone 1mg/kg <75mg po mane for 5 days
educate on sos corneal abrasion/ulcer
Stroke risk assessment after suspected TIA (ABCD2)
age> 60 (1)
bp >140/90 (1)
Clinical features - unilat weakness (2) speech disturbance only (1)
duration <10min (0), 10-59mins (1), >60mins (2)
diabetes mellitus (1)
Management of chillblains
betamethsone 0.05% topically bd keep warm and dry peripheries exercise indoors avoid cold exposure nifedipine CR 20mg od
Raynaud’s phenomenon management
avoid cold exposure keep warm and dry peripheries quit smoking avoid b-blockers of if severe trial nifedepine 20-30mg
DEMENTIA mnemonic - causes of cognitive decline
Drugs
Eyes and Ears (cant see/hear properly)
Metabolic - hypo/hyper - Na, Ca, Thyroid, UEC
Emotion - depression
Nutrition - vit b12 def
Trauma or Tumour - Intracranial bleed or mass
Infection - uti, pneumonia
Alcohol, Alzheimers, atherosclerosis(CVA)
Indication for geris referral
unclear diagnosis
atypical presentation
psychotic or severe behavioural issues
commencement of anti dementia medications
Dementia - ddx (4 Ds)
depression
delerium
drugs
Dementia/cognitive decline - Ix
FBC ESR LFT Calcium TFT B12 CT brain
HINTS exam
Head impulse test - positive = eyes saccade to refocus = peripheral
nystagmus = unilateral, horizontal - peripheral
test of skew = cover/uncover = eye remains motionless after uncover = peripheral
oligoclonal bands + raised IgG in CSF electrophoresis suggests what disease
multiple sclerosis
myasthenia gravis - pathohysiology
autoimmune disease, destroys nicotiniv acetylcholine receptors
