Neuro Cases 1

Question 1

What is broad based DDX based on CC?

Answer 1

migraine
dehydration
headache
increased ICP
heat stroke
whiplash
sinus infection

Question 2

basic types of primary headache

Answer 2

tension type
migraine
cluster
other (cold stimulus)

Question 3

secondary headache

Answer 3

something else going on & headache is a response

more likely to be fatal

Question 4

What is the most important for a headache CC?

Answer 4

HPI will give you 95% to make good DDX

Question 5

HA-specific history includes

Answer 5

exacerbation or relief w/ change in position

effect of activity on pain

relationship w/ food or alc

response to previous treatment

review of current meds

any recent change in vision

assoc w/ recent trauma

enviro factors, change in method of BC, change in work, state of general health

Question 6

What is major cause of HA for older individuals?

Answer 6

23% of older individuals had headache due to medication

Question 7

Historical features for most common causes of HA

Answer 7

headaches are very common & history of headache is most important thing to help you decide what is causing it

Question 8

PE for HA CC

Answer 8

obtain BP & pulse

listen for bruit @ neck & eyes & head (clinical signs of arteriovenous malformation)

palpate head/neck/shoulder

check temporal & neck arteries

examine spine & neck (paraspinal) muscles

Question 9

Neuro exam for HA

Answer 9

mental status
CN exam
funduscopy
symmetry on motor reflex
gait
station

Question 10

SNOOP

Answer 10

will most likely have a secondary HA

systemic
neuro
onset is new (50 yo)
other assoc conditions
previous HA history

Question 11

why is snoop important?

Answer 11

could represent space-occupying mass, vascular lesion, infection, metabolic disturbance or systemic problem

Question 12

Need for emergency eval

Answer 12

sudden thunderclap HA

acute or subacute neck pain

HA w/ suspected meningitis

HA w/ global or focal neuro deficit

HA w/ orbital or periorbital symptoms

HA & possible CO exposure

Question 13

Abnormal findings for case #1

Answer 13

BMI (morbidly obese)

tearful, holding hand to left side of head

hypertensive (high pulse)

AROM restricted in all planes

TPP noted @ left occipital condyle

Question 14

abnormal structural exam for case #2

Answer 14

OSE: paraspinal neck muscles tight, ropy,

cranial vault has severely diminished CRI

Question 15

working DDX for pt based on history & exam

Answer 15

most likely a tension headache

atypical migrane

extension SD

Question 16

what is the plan for case #1?

Answer 16

medication

return to clinic

OMM cranial therapy

Question 17

Case #2-dizziness DDX

Answer 17

concussion
stroke
low blood sugar
alcohol

Question 18

for dizziness, what subjective data do you want?

Answer 18

OLDCAARTS

dizzy specific:
history of trauma

frequency, intensity & duration of attack

severity (how is this affecting your life)

assoc symptoms (blurry vision, syncope, N/V, hearing loss)

personal/FH of similar symptoms

review of meds

Question 19

Vertigo

Answer 19

pt describe sensation of self-motion when they are not moving or distorted self-motion during normal head movement

Question 20

causes of vertigo

Answer 20

result of asymmetry w/ in vestibular system

disorder of peripheral labyrinth of central connections

Question 21

TiTrATE (eval of dizziness)

Answer 21

takes symptoms & puts into 3 clinical scenarios:

Timing of symptom
Triggers that provoke
And a Targeted Exam

Question 22

3 clinical scenarios for dizziness

Answer 22

episodic triggered symptoms

spontaneous episodic symptoms

continuous vestibular symptoms

Question 23

Basics of targeted exam for cc Dizziness

Answer 23

HEENT

CV
neurologic, (including Romberg)

Dix-Hallpike maneuver (to diagnose BBPV)

Question 24

Dix-Hallpike maneuver

Answer 24

looking for nystagmus (fast phase)

Question 25

BBPV (peripheral disorder)

Answer 25

loose canaliths get stuck in semicircular canals (body around has no idea where head is in space)

most common btwn 50-70 yo

treatment consists of Epley maneuvers (PT) & home treatment

no lab or imaging or pharm treatment

Question 26

Meniere disease

Answer 26

vertigo assoc w/ hearing loss, +/- tinnitus

most common @ 20-60 yo

any accompanying HA & hearing loss can be worsened during attack

HALLMARK: hearing loss

Question 27

Abnormal findings for case #2

Answer 27

moderate distress

towel stained w/ fluid suspected to be emesis

left nystagmus

failed whisper test on R

Weber Rinee testing cconfirmed R sensorineural hearing loss

Romberg test is +, Dix-Hallpike test +

Question 28

What is our assessment for case #2?

Answer 28

DDX: Dizziness-Minere’s disease, BBPV, toxin exposure

Question 29

What is the plan for case #2?

Answer 29

fluids

anti-emmetic (stop puking)

EKG

referral to ENT or neuro, audiologist

follow-up plan w/ primary care w/ in 48 hours

Question 30

Syncope

Answer 30

loss of consciousness

Question 31

classifications of syncope

Answer 31

cardiac

neurally mediated (reflex)-something that drops BP quickly

orthostatic hypotension (lying to sitting, sitting to standing & BP drops so pass out)

Question 32

diagnostic approach

Answer 32

exam/tests: detailed history & focus exam, EKG, orthostatic vital signs

Question 33

what should history focus on for syncope?

Answer 33

is loss of consciousness attributed to syncope?

is there a history of CV disease?

are there clinical features to suggest a specific cause of syncope?

Question 34

working DDX for case #3

Answer 34

cut himself shaving, saw blood & passed out

orthostatic hypotension (standing while shaving & blood pooled to his feet)

neural mediated (turned head to left & flexed forward which crunched down on carotid artery)

Question 35

What is the plan for #3?

Answer 35

EKG (want to get EKG for any pt w/ dizziness in ER)