Neuro + gerries Flashcards

Question

What is amyotrophic lateral sclerosis and what is the presentation?

Answer 1

--> most common motor neurone disase --> progressive spasticity --> weakness and wasting with added lower motor neurone signs --> fasciculations --> UMN+ LMN

Answer 2

--> second most common motor neurone disease --> Bulbar describes LMN signs from the 9th, 10th and 12th cranial nerve lesions --> wasted fibrillating tongue/ flaccid tongue --> commonly affects the muscles involved in swallowing and talking --> dysarthria --> dysphagia --> regurgitation and choking on fluids --> eye movements are unaffected --> UMN+LMN

Answer 3

--> type of motor neurone disease --> LMN only --> wasting begins in the small muscles of the hand --> fasciculations is common --> cramps occur --> anterior horn cells affected --> distal muscles are affected first then proximal

Answer 4

--> rare type of motor neurone disease --> Progressive tetraparesis (muscular weakness affecting all four extremities) --> UMN affected only

Answer 5

--> 5-10% of inherited cases --> increased risk with smoking, exposure to heavy metals and certain pesticides

Answer 6

--> muscle wasting --> reduced tone --> fasciculations --> reduced reflexes

Answer 7

--> increased tone or spasticity --> brisk reflexes --> upgoing plantar responses --> clonus - involuntary muscle contractions

Answer 8

--> clinical presentation and excluding other conditions

Answer 9

--> no definitive treatment --> Riluzole can slow the progression of the disease --> MDT --> end of life care --> non-invasive ventilation can be used to support breathing at night

Answer 10

--> Chronic and progressive condition --> demyelination in the CNS (Oligodendrocytes) --> inflammatory process involving the activation of immune cells (T cells) against the myelin --> lesions of demyelination vary in their location over time --> disseminated in time and space

Answer 11

--> cause is unclear, could be caused by: --> Multiple genes -->Epstein–Barr virus (EBV) --> Low vitamin D --> Smoking --> Obesity

Answer 12

Women under 50

Answer 13

--> optic neuritis - most common presentation - demyelination and loss of vision in one eye - decreased visual acuity, pain on eye movement, dyschromatopsia , central scotoma - enlarged blind spot --> sensory - trigeminal neuralgia/numbness/paresthesia/ Lhermitte's sign --> motor - transverse myelitis, UMN weakness, uhtoff's phenomenon - worsening of symptoms when the body is overheated/ limb paralysis/ bells palsy/ horners syndrome --> other - Ataxia is problems with coordinated movements that can be sensory (loss of proprioception) or cerebellar/ erectile dysfunction/ urinary incontinence

Answer 14

--> Clinically isolated syndrome - first episode of demyelination and signs, cannot be diagnosed as the lesions are not disseminated in time and space --> Relapsing-remitting - most common - episodes of disease followed by recovery, In MS the symptoms occur in different areas with different episodes --> Secondary progressive - Secondary progressive MS is where there was relapsing-remitting disease at first, but now there is a progressive worsening of symptoms with incomplete remissions. Symptoms become more and more permanent --> Primary progressive - Primary progressive MS is where there is a worsening of the disease and neurological symptoms from the point of diagnosis without initial relapses and remissions

Answer 15

--> Diagnosis is made by a neurologist based on the clinical picture and symptoms suggesting lesions that change location over time. Symptoms have to be progressive over a period of 1 year to diagnose primary progressive MS. Other causes for the symptoms need to be excluded. --> MRI scans to look for lesions --> Lumbar puncture to look for oligoclonal bands in CSF

Answer 16

Sarcoidosis Systemic lupus erythematosus Diabetes Syphilis Measles Mumps Lyme disease

Answer 17

Acute relapses: Methylprednisolone oral/IV chronic: disease-modifying drugs and biologics - Interferon/Glatiramer, Natalizumab

Answer 18

an umbrella term for genetic conditions that cause gradual weakening and wasting of muscles

Answer 19

Duchenne muscular dystrophy

Answer 20

Duchennes muscular dystrophy Beckers muscular dystrophy Myotonic dystrophy

Answer 21

Gower's sign - child uses their hands on their legs to help them stand up due to proximal muscle weakness

Answer 22

X-linked recessive - males more common

Answer 23

An X-linked (males more common) recessive disorder characterised by progressive muscle wasting and weakness

Answer 24

--> Damage to the dystrophin gene --> no dystrophin produced --> dystrophin is used to strengthen and protect muscle fibres from injury

Answer 25

--> wheelchair by 12 and death by 30

Answer 26

Present in early childhood, before 3 ● Progressive proximal muscular dystrophy with characteristic pseudohypertrophy of the calves ● Major milestones delayed ● Inability to run, hop or jump ● Recurrent falls ● Speech delay ● Fatigue - really common

Answer 27

Initial investigation - serum creatinine kinase Very high ● Genetic analysis ● Muscle biopsy with an assay for dystrophin protein ● Muscle strength test ● Gait assessment

Answer 28

Joint contractures ● Respiratory failure - most common cause of death ● Cardiomyopathies and heart failure ● Gastric dilation ● Learning difficulties ● Constipation, osteoporosis, hypertension

Answer 29

MDT care ● Specialist referral ● Immunisations - influenza and pneumococcal ● Physiotherapy ● Vitamin D and bisphosphonates for bone health ● Corticosteroids ● Mobility help - wheelchair once cannot walk ● Nutritional care ● End-of-life directive and palliative set-up

Answer 30

--> Similar to Duchenne's --> dystrophin gene less affected/maintains some of its function --> symptoms appear later around 8, some can walk assisted in adulthood --> similar management to Duchenne's

Answer 31

Progressive muscle weakness Prolonged muscle contractions - e.g not being able to let go of someones hand after shaking Cataracts Cardiac arrhythmias

Answer 32

autosomal dominant progressive neurodegenerative disease 100% penetrance - all who carry the gene express the trait trinucleotide repeat disorder

Answer 33

Associated with cell loss within the basal ganglia and cortex ● Essentially too much dopamine ● See an increase in CAG repeats on the Huntington gene, on chromosome 4p16.3

Answer 34

Male aged 30-50

Answer 35

Where successive generations have more trinucleotide repeats in the gene which results in --> earlier age of onset --> increased severity of the disease

Answer 36

It typically begins with cognitive, psychiatric or mood problems, followed by the development of movement disorders: Chorea (involuntary, random, irregular and abnormal body movements) Dystonia (abnormal muscle tone, leading to abnormal postures) Rigidity (increased resistance to the passive movement of a joint) Eye movement disorders Dysarthria (speech difficulties) Dysphagia (swallowing difficulties)

Answer 37

● MRI/CT - loss of striatal volume ● Genetic testing ● Tests for SLE, thyroid disease, Wilson’s disease and dementia

Answer 38

Management only, drugs do not affect on progression of condition ● Benzodiazepines (Diazapam) /valproic acid - chorea ● SSRIs if depression present ● Haloperidol for psychosis ● Prognosis is poor ○ Most common death is from concurrent illness, e.g. pneumonia ○ Suicide is the 2nd most common cause

Answer 39

--> inflammation of the meninges --> inflammation usually due to bacterial or viral infection

Answer 40

Neonates: GBS - Group B strep, E-coli Children: Haemophilus influenza, Neisseria meningitides, strep pneumoniae (pneumococcus) Adults: Neisseria meningitides (meningococcus), Strep pneumonia Elderly: Strep pneumoniae

Answer 41

gram-negative diplococcus also known as meningococcus

Answer 42

--> meningococcus (Neisseria meningitides) bacterial infection in the bloodstream. --> Meningococcal refers to the bacteria and septicaemia refers to an infection in the bloodstream. --> cause of the classic “non-blanching rash”. This rash indicates the infection has caused disseminated intravascular coagulopathy (DIC) and subcutaneous haemorrhages.

Answer 43

bacteria is infecting the meninges and the cerebrospinal fluid around the brain and spinal cord.

Answer 44

--> Triad: Headache, neck stiffness, fever --> Acute bacterial infection: - Sudden onset - Papilloedema - usually bilateral - Systemic symptoms - Intense malaise, rigours, photophobia, - - vomiting - Reduced GCS, focal CNS signs, seizures Viral: Self-limiting lasting 4-10 days May have headaches for months afterwards Chronic: TB A long history of vague symptoms of headache, anorexia, and vomiting. Triad is absent or late sign --> if meningococcal septicaemia children can present with a non-blanching rash --> Neonates and babies can present with non-specific signs and symptoms, such as hypotonia, poor feeding, lethargy, hypothermia and a bulging fontanelle.

Answer 45

Kernig’s test Brudzinski’s test

Answer 46

involves lying the patient on their back, flexing one hip and knee to 90 degrees and then slowly straightening the knee whilst keeping the hip flexed at 90 degrees. This creates a slight stretch in the meninges. Where there is meningitis it will produce spinal pain or resistance to movement.

Answer 47

involves lying the patient flat on their back and gently using your hands to lift their head and neck off the bed and flex their chin to their chest. A positive test is when this causes the patient to involuntarily flex their hips and knees.

Answer 48

LP: Bacterial: high protein, low glucose, high neutrophils Viral: normal protein, normal glucose, high lymphocytes TB: high protein, low glucose, high lymphocytes --> blood culture --> throat swabs - bacterial and viral

Answer 49

Under 1 month presenting with fever 1 – 3 months with fever and are unwell Under 1 year with unexplained fever and other features of serious illness

Answer 50

Community: Immediate IM or IV Benzylpenicillin Withhold treatment if true penicillin anaphylaxis, priority is transfer. Hospital: Ideally blood cultures and LP should be done, but do not delay treatment if acutely unwell. IV Cefotaxime or IV Ceftriaxone. Add IV Vancomycin in recent travellers Add amoxicillin in neonates and elderly ○ With rash - Benzylpenicillin IV (meningococcal septicaemia) ○ Without rash - Cefotaxime IV Prophylaxis: Contact in the last 7 days. A single dose of Oral Ciprofloxacin or Rifampicin (except in pregnancy). Corticosteroids - Oral dexamethasone to reduce cerebral oedema and complications (hearing loss, neurological damage). 4 times daily for 4 days to children over 3 months. Viral meningitis - LP can be done, usually self-limiting. Acyclovir may be used in HSV meningitis.

Answer 51

Bacterial - cloudy Viral - clear

Answer 52

Hearing loss, Seizures/epilepsy Cognitive impairment/disability Memory loss, Focal neurological deficit.

Answer 53

--> Guillain-Barré syndrome is an “acute paralytic polyneuropathy” that affects the peripheral nervous system - demyelination. --> It causes acute, symmetrical, ascending weakness and can also cause sensory symptoms. --> It is usually triggered by an infection and is particularly associated with campylobacter jejuni, cytomegalovirus and Epstein-Barr virus.

Answer 54

--> It is usually triggered by an infection and is particularly associated with campylobacter jejuni, cytomegalovirus and Epstein-Barr virus --> Commonly present post-GI infection (~6 weeks after)

Answer 55

Guillain-Barré is thought to occur due to a process called molecular mimicry. The B cells of the immune system create antibodies against the antigens on the pathogen that causes the preceding infection. These antibodies also match proteins on the nerve cells. They may target proteins on the myelin sheath of the motor nerve cell or the nerve axon.

Answer 56

--> Symmetrical ascending weakness (starting at the feet and moving up the body) - TOE TO NOSE WEAKNESS --> hyporeflexia (LMN sign) --> There may be peripheral loss of sensation or neuropathic pain or paraesthesia --> It may progress to the cranial nerves and cause facial nerve weakness --> Involvement of the autonomic nervous system ○ Reduced sweating ○ Reduced heat tolerance ○ Paralytic ileus - intestinal obstruction w/o blockage ○ Urinary hesitancy

Answer 57

Symptoms usually start within 4 weeks of the preceding infection. The symptoms typically start in the feet and progress upward. Symptoms peak within 2-4 weeks, then there is a recovery period that can last months to years.

Answer 58

--> clinical diangosis --> Brighton criteria --> nerve conduction studies - reduced signal through nerves --> Lumbar puncture - Raised protein with a normal cell count and glucose

Answer 59

--> IV immunoglobulins --> Plasma exchange (alternative to IV IG) --> Supportive care --> VTE prophylaxis (pulmonary embolism is a leading cause of death) e.g LMWH --> avoid corticosteroids as can make symptoms worse --> good prognosis, most recover

Answer 60

Infection and inflammation of the brain parenchyma. Broad term with various causative agents. Most commonly caused by viruses.

Answer 61

Viral - most common HSV VZV, EBV, CMV, HIV, measles, mumps, arboviruses (West Nile) Non-viral - Bacteria, fungal, parasitic TB, Mycoplasma, Rickettsia, Bacterial meningitis (Listeria, Neisseria) Cryptococcus, Histoplasmosis Malaria, Toxoplasmosis, Schistosomiasis Non-infectious - Paraneoplastic Post-infectious Autoimmune

Answer 62

An intracranial infection provokes an inflammatory response causing inflammation of the cortex, white matter, basal ganglia and brain stem depending on the causative organism. This results in neurological signs and systemic signs of infection. The frontal and temporal lobes are mostly affected. `

Answer 63

Classic triad - Fever, headache, altered mental status/focal neurological signs: Insidious onset, can also be abrupt - Features of a viral infection to begin with - fever, malaise, nausea, headaches - Behavioural change - a common early sign - Decreased consciousness, confusion - Focal neuro signs - cranial nerve palsies, hemiparesis, cerebellar ataxia, dysphagia, dysarthria - Seizures - Signs of raised ICP may lead to coma

Answer 64

Anything that causes behavioural change DKA Hypoglycaemia Hepatic encephalopathy B1 (thiamine) deficiency also called Beri-beri Meningitis Stroke Drug overdose Brain tumour

Answer 65

--> Lumbar puncture, sending cerebrospinal fluid for viral PCR testing --> CT scan if a lumbar puncture is contraindicated --> MRI scan after the lumbar puncture to visualise the brain in detail --> EEG recording can be helpful in mild or ambiguous symptoms but is not always routinely required --> Swabs of other areas can help establish the causative organism, such as throat and vesicle swabs --> HIV testing is recommended in all patients with encephalitis --> Contraindications to a lumbar puncture include a GCS below 9, haemodynamically unstable, active seizures or post-ictal.

Answer 66

--> Intravenous antiviral medications are used to treat the suspected or confirmed underlying cause: --> Empirical Aciclovir in suspected encephalitis treats herpes simplex virus (HSV) and varicella-zoster virus (VZV) --> Ganciclovir treats cytomegalovirus (CMV) --> Repeat lumbar puncture is usually performed to ensure successful treatment prior to stopping antivirals --> Other viral causes have no effective treatment and management is supportive. --> Followup, support and rehabilitation is required after encephalitis, with help in managing the complications.

Answer 67

Lasting fatigue and prolonged recovery Change in personality or mood Changes to memory and cognition Learning disability Headaches Chronic pain Movement disorders Sensory disturbance Seizures Hormonal imbalance

Answer 68

Shingles ● Painful rash caused by reactivation of a nerve infection caused by the varicella-zoster virus

Answer 69

First presents as chickenpox in childhood ● Varicella-Zoster remains dormant in the dorsal root ganglia ● Travels through peripheral sensory nerves to the skin ● Less contagious than primary infection

Answer 70

--> immunocompromised --> HIV --> malignancy

Answer 71

Red, painful rash - dermatomal distribution ○ Most commonly cervical, trigeminal, thoracic and lumbar dermatomes ● Fluid-filled blisters ● Stabbing or burning pain ● Fever, headache, fatigue ● Itching

Answer 72

● PCR test ● CSF analysis ● Bloods & cultures ● Often a clinical diagnosis

Answer 73

Antiviral therapy ○ Acyclovir ○ Valacyclovir ○ Famciclovir ● Immunocompromised patients should be treated with IV acyclovir ● Analgesia ● Antipyretics

Answer 74

Malaria is an infectious disease caused by members of the Plasmodium family of protozoan parasites. Protozoa are single-celled organisms.

Answer 75

Plasmodium falciparum

Answer 76

Through the bites of female anopheles mosquitoes

Answer 77

Plasmodium falciparum is the most severe and dangerous form Plasmodium vivax Plasmodium ovale Plasmodium malariae

Answer 78

Malaria is spread by female Anopheles mosquitoes, most commonly at night time. Infected blood is sucked up by feeding mosquitoes. Malaria in the blood reproduces in the gut of the mosquito producing thousands of sporozoites (malaria spores). When that mosquito bites another human or animal the sporozoites are injected by the mosquito. These sporozoites travel to the liver of the newly infected person. They can lie dormant as hypnozoites for several years in P. vivax and P. ovale. They mature in the liver into merozoites which enter the blood and infect red blood cells. In red blood cells, the merozoites reproduce over 48 hours, after which the red blood cells rupture releasing loads more merozoites into the blood and causing haemolytic anaemia. This is why people infected with malaria have high fever spikes every 48 hours.

Answer 79

Symptoms occur from 6 months post-infection P. vivax and P. ovale commonly present 6 months post-infection Non-specific Symptoms -->Fever, sweats and rigors --> Malaise --> Myalgia --> Headache --> Vomiting Signs --> Pallor due to the anaemia --> Hepatosplenomegaly --> Jaundice as bilirubin is released during the rupture of red blood cells Severe disease in P. falciparum --> Shortness of breath --> Fits and hypovolaemia --> AKI and nephrotic syndrome

Answer 80

--> Travel history --> Thick and thin blood smears A negative film can be seen If negative, 2 more films should be sent over the next 48 hours --> Rapid diagnostic tests Detect parasitic antigens --> PCR --> FBC, LFTs, U&Es, blood gases, blood culture --> CXR, lumbar puncture

Answer 81

Treatment: - Uncomplicated falciparum: artemisinin-based combination (Artemether with lumefantrine) therapy - Uncomplicated non-falciparum: artemisinin-combination therapy or chloroquine (many strains of malaria are now resistant to chloroquine) - Severe falciparum: IV artesunate or IV quinine dihydrochloride Do not treat those with G6PD deficiency Need specialist help

Answer 82

Cerebral malaria Seizures Reduced consciousness Acute kidney injury Pulmonary oedema Disseminated intravascular coagulopathy (DIC) Severe haemolytic anaemia Multi-organ failure and death

Answer 83

Meningioma - benign Glioblastoma - highly malignant

Answer 84

--> focal neurological symptoms as they develop, depends where the tumour is --> often present with signs and symptoms of raised ICP - headaches - Altered mental state - Visual field defects - Seizures (particularly focal) - Unilateral ptosis - Third and sixth nerve palsies - Papilloedema (on fundoscopy)

Answer 85

The frontal lobe as this lobe is responsible for personality and high-level decision making

Answer 86

Brain tumours Intracranial haemorrhage Idiopathic intracranial hypertension Abscesses or infection

Answer 87

Constant Nocturnal Worse on waking Worse on coughing, straining or bending forward Vomiting

Answer 88

--> Papilloedema is a swelling of the optic disc secondary to raised intracranial pressure --> The sheath around the optic nerve is connected with the subarachnoid space. --> CSF under high pressure can flow into the optic nerve sheath. --> increases the pressure around the optic nerve where it connects with the back of the eye at the optic disc, --> causing optic disc swelling. --> This can be seen on fundoscopy examination. - retinal vessels are able to flow straight across a flat surface, whereas they will curve over a raised disc.

Answer 89

- Lung - Breast - Renal cell carcinoma - Melanoma

Answer 90

Gliomas are tumours of the glial cells in the brain or spinal cord. There are three types to remember (listed from most to least malignant): Astrocytoma (glioblastoma multiforme is the most common) Oligodendroglioma Ependymoma

Answer 91

Meningiomas are tumours growing from the cells of the meninges in the brain and spinal cord. They are usually benign, however, they take up space and this mass effect can lead to raised intracranial pressure and neurological symptoms.

Answer 92

--> Benign

Answer 93

They can press on the optic chiasm and cause bilateral hemianopia

Answer 94

--> Compression of optic chiasm - bilateral hemianopia --> They have the potential to cause hormone deficiencies or to release excessive hormones which can lead to: - Acromegaly - Hyperprolactinaemia - Cushing’s disease - Thyrotoxicosis

Answer 95

Management options include: Palliative care Chemotherapy Radiotherapy Surgery - dependent on the grade and behaviour of the brain tumour

Answer 96

Trans-sphenoidal surgery Radiotherapy Bromocriptine to block prolactin-secreting tumours Somatostatin analogues (e.g. octreotide) to block growth hormone-secreting tumours

Answer 97

Acoustic neuromas are benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear.

Answer 98

cerebellopontine angle

Answer 99

Unilateral

Answer 100

Neurofibromatosis type 2 - a genetic condition that causes tumours to grow along your nerves

Answer 101

The typical patient is aged 40-60 years presenting with a gradual onset of: Unilateral sensorineural hearing loss (often the first symptom) Unilateral tinnitus Dizziness or imbalance A sensation of fullness in the ear Can be a presentation of facial nerve palsy

Answer 102

--> Audiometry is used to assess hearing loss. There will be a sensorineural pattern of hearing loss. --> CT/MRI - establish the diagnosis and features of the tumour. MRI provides more detail than CT.

Answer 103

ENT specialist management options include: --> Conservative management with monitoring may be used if there are no symptoms or treatment is inappropriate --> Surgery to remove the tumour (partial or total removal) --> Radiotherapy to reduce the growth

Answer 104

--> Vestibulocochlear nerve injury, with permanent hearing loss or dizziness --> Facial nerve injury, with facial weakness

Answer 105

Bulbar palsy refers to a set of signs and symptoms linked to the impaired function of the lower cranial nerves, typically caused by damage to their lower motor neurons or to the lower cranial nerve itself. The impacted cranial nerves are a set of nerves that arise straight from the brainstem and include cranial nerves IX (9), X (10), XI (11), and XII (12). Lower motor neurons are the neurons that connect the central nervous system, such as the brain and spinal cord, to the muscles they innervate

Answer 106

--> Progressive bulbar palsy is more common and refers to the escalation of symptoms over time. It can occur in both children and adults. --> Non-progressive bulbar palsy, on the other hand, refers to bulbar palsy that does not worsen; it is considered very uncommon

Answer 107

--> share many of the same symptoms, --> Pseudobulbar palsy (damage to the upper motor neurons) is often characterized by the atypical expression of emotion displayed by unusual outbursts of laughing or crying, called emotional lability. --> Bulbar palsy, an individual’s emotions usually remain unaffected. --> Pseudobulbar palsy includes the absence of facial emotions, a spastic and pointed tongue, and an exaggerated jaw jerk.

Answer 108

9, 10, 11 and 12

Answer 109

--> Cranial nerve IX (the glossopharyngeal nerve) is involved in salivation, swallowing, and the gag reflex. --> If cranial nerve IX is injured, it can lead to difficulty swallowing (dysphagia) and a reduced gag reflex. --> Common signs and symptoms of damage to the other cranial nerves include difficulty chewing, nasal regurgitation, slurred speech, difficulty in handling secretions, aspiration of secretions, altered vocal ability (dysphonia) and difficulty articulating words (dysarthria), reduced gag reflex, drooling, difficulty chewing, difficulty with consonants, atrophic tongue, weak jaw/facial muscles, normal or absent jaw jerk reflex

Answer 110

Most common: - Brainstem stroke (especially lateral medullary syndrome) - Brainstem tumour Other causes: - Motor neuron disease - GBS

Answer 111

--> Clinical diagnosis based on history --> CSF analysis to rule out MS --> MRI to diagnose a brainstem stroke or tumour

Answer 112

--> No known treatment --> Supportive treatment - medications to stop drooling, feeding tube to help with dysphagia, speech and language therapy to help with speech, chewing and swallowing --> Other specific treatments based on the cause

Answer 113

The cerebellum is the region of the brain responsible for controlling stance, gait, and balance, as well as the coordination of complex and goal-directed movements

Answer 114

Acute --> Infarction, TIA --> Head trauma, oedema, haemorrhage --> Infections (acute postviral cerebellitis), including: Adults: VZV, EBV, Lyme disease, tertiary syphilis, malaria, prion diseases (e.g., Creutzfeldt-Jakob disease) Children: VZV, coxsackievirus, parvovirus B19, HHV-6, hepatitis A, enteroviruses, measles, mumps, Lyme disease, etc. --> Medication, toxins, and poisons: barbiturates, benzodiazepines, heavy metals, and chemotherapy Subacute and chronic --> Alcoholism --> Intracranial tumours (e.g., medulloblastoma) --> Vitamin deficiencies: vitamin B12 deficiency, vitamin B1 deficiency (Wernicke encephalopathy) --> Paraneoplastic cerebellar degeneration --> Genetic: Friedreich ataxia, ataxia telangiectasia, spinocerebellar ataxia, --> Multiple sclerosis --> Wilson disease (rare)

Answer 115

DANISH - Dysdiadochokinesis - Inability to perform rapidly alternating agonistic-antagonistic movements - Ataxia - coordination balance and speech - gait - Nystagmus - Intention tremor - finger-to-nose test with shaky hands - Scanning speech, dysarthria - words are broken down into separate syllables and spoken with varying force - Hypotonia, hyporeflexia cerebellar drift - pronator drift

Answer 116

Neuroimaging (CT/MRI): indicated to rule out infarction, haemorrhage, tumours, oedema Laboratory testing: complete blood cell count; electrolytes, vitamin B12 levels, vitamin B1 levels Genetic testing: if other diagnostic tests are negative or inconclusive

Answer 117

treat the underlying cause

Answer 118

Lower motor neuron weakness of cranial nerve VII (facial nerve) → acute peripheral facial palsy

Answer 119

--> exits the brainstem at cerebellopontine angle --> passes through the temporal bone and parotid gland --> then divides into five branches Temporal Zygomatic Buccal Marginal mandibular Cervical

Answer 120

motor - It supplies the muscles of facial expression, the stapedius in the inner ear and the posterior digastric, stylohyoid and platysma muscles in the neck Sensory - It carries taste from the anterior 2/3 of the tongue. parasympathetic - It provides the parasympathetic supply to the: Submandibular and sublingual salivary glands Lacrimal gland (stimulating tear production)

Answer 121

--> Each side of the forehead has upper motor neurone innervation by both sides of the brain. However, each side of the forehead only has lower motor neurone innervation from one side of the brain --> In an upper motor neurone lesion, the forehead will be spared, and the patient can move their forehead on the affected side. - should be referring for suspected stroke. --> In a lower motor neurone lesion, the forehead will NOT be spared, and the patient cannot move their forehead on the affected side.

Answer 122

Cerebrovascular accidents (strokes) Tumours

Answer 123

Pseudobulbar palsies Motor neurone disease

Answer 124

idiopathic Thought to be related to inflammation and oedema of the facial nerve secondary to viral infection or autoimmunity

Answer 125

symptoms Presents with rapid onset (<72 Hours) of unilateral facial weakness post-auricular/ear pain Difficulty chewing incomplete eye closure drooling tingling in cheek/mouth hyperacusis - decrease in everyday sound tolerance Non-forehead sparing symptoms ocular dryness decreased taste Asymmetrical smile Drooping of the corner of the mouth Drooping of the eyebrow

Answer 126

Clinical diagnosis - based on unilateral facial weakness, of rapid onset, without forehead sparing (with forehead sparing suspected UMN lesion) → may include routine blood tests, neuroimaging, specialist tests e.g lumbar puncture → consider HIV test

Answer 127

Treatment → Management largely supportive, but prednisolone may be used in those presenting within 72 hours of onset. antiviral treatment e.g acyclovir can be considered → eye care - lubricating drops, taping eye when sleeping, sunglasses outdoors, referral to ophthalmology considered

Answer 128

Epilepsy is an umbrella term for a condition where there is a recurrent tendency to have seizures - chronic

Answer 129

Seizures are transient episodes of abnormal electrical activity in the brain. There are many different types of seizures. spontaneous and intermittent

Answer 130

The epileptic attack itself

Answer 131

Nonspecific symptoms that precede an epileptic attack

Answer 132

Sensory disturbances that precede an attack, usually by minutes. More specific.

Answer 133

Family history – Idiopathic Premature birth Developmental abnormalities Trauma Drugs – cocaine Space occupying lesion – tumour, infection, haematoma

Answer 134

--> Primary generalised - 30/40% --> partial/focal - 60-70%

Answer 135

- Originates in the midbrain or brainstem - Electrical discharge in both hemispheres - Associated with LOC or awareness

Answer 136

--> Focal onset, an electrical discharge is restricted to one area of the brain --> It may develop into a generalised (secondary)

Answer 137

--> Generalised tonic-clonic seizures --> tonic seizures --> clonic seizures --> Absence seizures --> atonic seizures --> myoclonic seizures

Answer 138

--> Often no aura --> tonic phase - rigid, tongue biting, incontinence, no breathing during the phase --> Clonic phase - convulsions, limb jerking, eye-rolling, uncoordinated breathing --> self - limiting --> Physical injuries are common --> prolonged post-ictal phase - confused, drowsy, irritable

Answer 139

--> high tone --> Rigid stiff limbs --> no limb jerking

Answer 140

--> seizures with muscle jerking

Answer 141

--> patient becomes blank, stares into space and then abruptly returns to normal

Answer 142

--> sudden loss of muscle tone and movement and they fall --> also known as drop attacks

Answer 143

--> Sudden brief muscle contractions

Answer 144

--> Simple partial seizure --> Complex partial seizure --> partial seizures with secondary generalisation

Answer 145

--> No loss of consciousness --> No post-ictal signs --> isolated limb jerking --> Head turning away from the side of the seizure --> isolated paraesthesia --> Todd's paralysis - temporary paralysis/weakness

Answer 146

--> most commonly in the temporal lobe --> can affect awareness/memory before during or after --> Visual/auditory hallucinations --> lip-smacking - automatism --> Post-ictal confusion/drowsiness is common

Answer 147

--> partial seizures that spread to the lower brain areas which initiate a generalised seizure --> usually tonic-clonic --> 2/3rds with partial seizures develop generalised seizures

Answer 148

Speech comprehension, memory and emotion are affected Anxiety Automatisms = lip-smacking

Answer 149

Motor disturbances Jacksonian march = up and down the motor homunculus Postictal Todd’s palsy

Answer 150

sensation Occipital = vision ( visual phenomena = spots, lines, flashes)

Answer 151

EEG = supports the diagnosis MRI/ CT head = exclusion of space-occupying lesions Blood to rule out metabolic disturbances

Answer 152

- Generalised Tonic-Clonic = 1st line: Sodium Valproate (males) & Lamotrigine or Levetiracetam (females) - Tonic/atonic = Sodium Valproate (males) & Lamotrigine (females) - Myoclonic = Sodium Valproate (males) & Levetiracetam (women) - Absence = 1st line: Ethosuximide 2nd line: Sodium Valproate (male) & Lamotrigine or levetiracetam (female) NB - Carbamazepine may exacerbate absence seizure - Partial (focal) = 1st line: Lamotrigine or Levetiracetam 2nd line: Carbamazepine

Answer 153

a continuous seizure lasting over 5 minutes or repeated seizures with no recovery in between. IV Lorazepam ( first line), if ineffective Phenytoin

Answer 154

Metabolic disturbances ( low sodium, hypoxia) Longer Don't occur in sleep No incontinence + tongue biting Pre ictal anxiety signs No muscle pain

Answer 155

type of seizure that occurs in children with a high fever

Answer 156

between 6 months and 5 years

Answer 157

generalised tonic-clonic seizures last less than 15 minuets only occur once in a single febrile illness

Answer 158

when they consist of partial or focal seizures, lasting more than 15 minutes or occur multiple times during the same febrile illness

Answer 159

Rule out differentials complex febrile convulsions may need extra investigations treat the underlying cause e.g infection

Answer 160

Epilepsy Meningitis, encephalitis or another neurological infection such as cerebral malaria Intracranial space occupying lesions, for example, brain tumours or intracranial haemorrhage Syncopal episode Electrolyte abnormalities Trauma (always think about non-accidental injury)

Answer 161

--> Permanent neurological problems resulting from damage to the brain around the time of birth --> not a progressive condition

Answer 162

Antenatal --> maternal infections --> Trauma during pregnancy perinatal --> Birth asphyxia --> pre-term birth postnatal --> meningitis --> Severe neonatal jaundice --> head injury

Answer 163

Spastic --> hypertonia and reduced function due to damage to the upper motor neurones dyskinetic --> problems controlling muscle tone, with hypertonia and hypotonia, from damage to the basal ganglia ataxic --> problems with coordinated movement resulting from damage to the cerebellum mixed --> a mix

Answer 164

Monoplegia: one limb affected Hemiplegia: one side of the body affected Diplegia: four limbs are affected, but mostly the legs Quadriplegia: four limbs are affected more severely, often with seizures, speech disturbance and other impairments

Answer 165

--> become evident during development --> Failure to meet milestones --> Increased or decreased tone, generally or in specific limbs --> Hand preference below 18 months is a key sign to remember for exams --> Problems with coordination, speech or walking --> Feeding or swallowing problems --> Learning difficulties --> Upper motor/lower motor, inspection, tone, power and reflex signs --~> gait abnormalities

Answer 166

--> no cure, management of symptoms --> Management involves a multi-disciplinary team approach --> physio --> occupational therapy --> Speech and language therapy --> dieticians --> orthopaedic surgeons --> Muscle relaxants for spasticity, epileptic drugs and drugs for excessive drooling can be given --> social workers

Answer 167

occurs in neonates as a result of hypoxia during birth hypoxia- lack of oxygen ischaemia - restriction of blood to the brain encephalopathy - malfunctioning of the brain --> can lead to permanent damage and cerebral palsy

Answer 168

anything that leads to asphyxia - Maternal shock - Intrapartum haemorrhage - Prolapsed cord, causing compression of the cord during birth - Nuchal cord, where the cord is wrapped around the neck of the baby

Answer 169

--> Sarnat staging Mild: -->Poor feeding, general irritability and hyper-alert --> Resolves within 24 hours --> Normal prognosis Moderate: --> Poor feeding, lethargy, hypotonic and seizures --> Can take weeks to resolve --> Up to 40% develop cerebral palsy Severe: --> Reduced consciousness, apnoeas, flaccid and reduced or absent reflexes --> Up to 50% mortality --> Up to 90% develop cerebral palsy

Answer 170

--> Supportive care - neonatal resuscitation/ ventilation/ seizure treatment --> Therapeutic hypothermia - to help protect the brain from hypoxic injury - reduces inflammation --> MDT involvement for any lasting disability

Answer 171

Collection of blood between the dura mater and the bone is usually caused by head injury

Answer 172

After a traumatic head injury with low consciousness levels or slow to improve or lucid interval

Answer 173

--> most commonly due to head trauma resulting in a fracture of the temporal or parietal bone causing a rupture in the middle meningeal artery

Answer 174

Young adults

Answer 175

--> head injury --> Brief LOC or drowsiness --> Lucid interval - period of improved neurological symptoms and consciousness followed by a rapid decline over hours as the haematoma gets large enough to compress the intracranial contents --> followed by a rapid decline, sever headache, vomiting, confusion, seizures, raised ICP - cushings reflex - triad of hypertension, bradycardia, irregular breathing, physiological response to raised ICP to attempt to improve perfusion

Answer 176

--> Subarachnoid haemorrhage --> subdural haemorrhage --> meningitis

Answer 177

CT head --> shows a hyperdense biconcave region, limited by the cranial sutures, lemon shape

Answer 178

--> ABCDE assessment --> IV mannitol - reduce ICP --> Neurosurgery - Clot evacuation - burr hole craniotomy, ligation of the middle meningeal artery --> may need incubation or ventilation

Answer 179

Spontaneous bleeding between the arachnoid and pia mater, usually due to a rupture of a cerebral aneurysm, mainly in the communicating arteries in the circle of willis

Answer 180

High mortality (50% die straight away), 10-20% more from rebleeding, 50% left with significant disability

Answer 181

--> Hypertension --> Known aneurysm --> Previous SAH --> Smoking --> Alcohol --> FHx --> cocaine --> sickle cell anaemia Bleeding disorders --> PKD --> Coarctation of the aorta --> Connective tissue disorders - ED --> associated with berry aneurysms

Answer 182

- Traumatic injury - Aneurysmal rupture - berry (70-80%) at communicating branches - AV malformations - an abnormal artery and venous connections (15% of cases) - Idiopathic

Answer 183

Tissue ischaemia - due to bleeding loss, causing cell death Raised ICP - Blood into cranial space, space-occupying lesion Blood-causing meningism - could obstruct CSF outflow (hydrocephalus) Vasospasm - bleeding irritates other vessels causing ischaemic injury

Answer 184

Thunderclap headache - typically occipital, excruciating Sentinel headache - Before the main rupture, early sign - 6% cases - Nausea, vomiting, seizures, visual disturbance, LoC, photophobia

Answer 185

- Meningeal irritation - Neck stiffness, Kernig's (leg raise - pain), Brudzinski (neck raise - hip\knee flexion) - Retinal, vitreous and subhyaloid bleeds w/ or without papilloedema - Focal neurological signs - e.g. 3rd nerve palsy - Increased BP

Answer 186

Immediate CT head - detects >95%, star-shaped sign Lumbar puncture - if normal ICP, after 12 hours (xanthochromia - confirms SAH, raised red cells) MR/CT angiography - establish source, in all patients fit for surgery

Answer 187

coning risk

Answer 188

--> ABCDE assessment --> IV fluids - maintains cerebral perfusion --> Nimodipine - Ca2+ antagonist, reduces the risk of vasospasm --> neurosurgery - endovascular coiling or surgical clipping, ventricular draining - hydrocephalus

Answer 189

Cushing's reflex - triad of hypertension, bradycardia, irregular breathing, physiological response to raised ICP to attempt to improve perfusion

Answer 190

Accumulation of blood between the arachnoid and dura mater, usually due to the rupture of a vein (bridging veins) . Can be acute or chronic.

Answer 191

--> more common in elderly and alcoholics (brain atrophy and falls risk) --> Co-morbidities that make the patient more vulnerable to falls - dementia and delirium --> most due to trauma --> anticoagulation --> history of coagulopathy --> history of LOC

Answer 192

--> More common in the elderly and alcoholics (brain atrophy and increased falls) --> Most due to trauma --> Anticoagulation --> Co-morbidities that make a patient more vulnerable to falls - dementia and delirium --> history of coagulopathy --> history of LOC

Answer 193

--> More common in the elderly and alcoholics (brain atrophy and increased falls) --> Most due to trauma --> Anticoagulation --> Co-morbidities that make a patient more vulnerable to falls - dementia and delirium --> history of coagulopathy --> history of LOC

Answer 194

--> Bleeding from bridging veins into subdural space --> forms a haematoma which stops the bleeding --> weeks/months later the clot autolyses - clot draws water in and expands --> Radual increase in ICP - midline shift - herniation and coming - coma and death

Answer 195

Fluctuating consciousness Drowsiness Headache Confusion Behavioural change Signs of ICP – vomiting, nausea, seizure, raised BP, Cushing's triad (bradycardia, hypertension and irregular breathing) Coma – many present with this GRADUAL DETERIORATION

Answer 196

--> CT head - acute: hyperdense crescent-shaped area/ chronic: hypodense crescent shape, not limited to cranial sutures

Answer 197

Starts with basics – ABCDE, Start oxygen, Maintain systolic BP >90 mmHg Neurosurgery: Burr hole – irrigation + evacuation Craniotomy – to reduce ICP acutely Address cause for fall – arrhythmias, cataracts IV mannitol – reduce ICP

Answer 198

Ischaemic stroke (87%) Haemorrhagic stroke (13%)

Answer 199

Thrombus formation or embolus, for example in patients with atrial fibrillation Atherosclerosis Shock Vasculitis systemic hypoperfusion - cardiac arrest

Answer 200

Caused by occlusion of blood vessels by a clot. Infarcted area dies causing permanent deficit, penumbra surrounding may regain function with recovery.

Answer 201

Aetiology: Anything that increases the risk of an embolus forming Atherothromboembolism - e.g. from the carotid artery Cardioembolism - AF, post MI, valve disease, IE Hyperviscosity syndrome - e.g. Waldenstrom’s macroglobulinemia, polycythaemia vera Hypoperfusion - systemic blood loss Vasculitis Fat emboli - long bone fracture Venous sinus thrombosis - infection, injury, pregnancy, inflammatory conditions (very rare only 1%)

Answer 202

--> Increasing age >65 --> Hypertension --> Smoking Male Diabetes Recent/past TIA Hyperlipidaemia Heart disease - IHD, AF, valve disease Peripheral vascular disease Clotting disorder Vasculitis Alcohol Infective endocarditis Carotid bruit - stenosis Black, Asian

Answer 203

Immediate CT scan - Distinguish ischaemic from haemorrhagic, shows site of infarct, may be negative in first few hours Diffusion-weighted MRI - gold More sensitive, for a confirmed diagnosis Blood tests - Glucose (rule out hypoglycaemia), FBC (polycythaemia), ESR (vasculitis), U&Es, cholesterol, INR (if on warfarin) ECG - In AF or MI Carotid ultrasound - carotid stenosis - endarterectomy to remove plaques

Answer 204

Bamford stroke classification

Answer 205

This system categorises stroke based on the initial presenting symptoms and clinical signs. This system does not require imaging to classify the stroke, instead, it is based on clinical findings alone.

Answer 206

A total anterior circulation stroke (TACS) is a large cortical stroke affecting the areas of the brain supplied by both the middle and anterior cerebral arteries. All three of the following need to be present for a diagnosis of a TACS: Unilateral weakness (and/or sensory deficit) of the face, arm and leg Homonymous hemianopia Higher cerebral dysfunction (dysphasia, visuospatial disorder)

Answer 207

A partial anterior circulation stroke (PACS) is a less severe form of TACS, in which only part of the anterior circulation has been compromised. Two of the following need to be present for a diagnosis of a PACS: Unilateral weakness (and/or sensory deficit) of the face, arm and leg Homonymous hemianopia Higher cerebral dysfunction (dysphasia, visuospatial disorder)* *Higher cerebral dysfunction alone is also classified as PACS.

Answer 208

A posterior circulation syndrome (POCS) involves damage to the area of the brain supplied by the posterior circulation (e.g. cerebellum and brainstem). One of the following need to be present for a diagnosis of a POCS: Cranial nerve palsy and a contralateral motor/sensory deficit Bilateral motor/sensory deficit Conjugate eye movement disorder (e.g. horizontal gaze palsy) Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia) Isolated homonymous hemianopia

Answer 209

A lacunar stroke (LACS) is a subcortical stroke that occurs secondary to small vessel disease. There is no loss of higher cerebral functions (e.g. dysphasia) One of the following needs to be present for a diagnosis of a LACS: Pure sensory stroke Pure motor stroke Sensorimotor stroke Ataxic hemiparesis

Answer 210

anteromedial area of the cerebrum

Answer 211

majority of the lateral cerebrum

Answer 212

a mixture of the medial and lateral areas of the posterior cerebrum

Answer 213

allows healthcare professionals to consistently evaluate the level of consciousness of a patient. It is commonly used in the context of head trauma, but it is also useful in a wide variety of other non-trauma related settings. Regular assessment of a patient’s GCS can identify early signs of deterioration.

Answer 214

motor responsiveness, verbal performance and eye-opening. The highest response from each category elicited by the healthcare professional is scored on the chart.

Answer 215

15 highest 3 lowest - coma or dead

Answer 216

Eye-opening spontaneously 4 points Eye-opening to sound 3 points Eye-opening to pain 2 points No response 1 point Not testable NT

Answer 217

Orientated 5 points Confused conversation 4 points Inappropriate words 3 points Incomprehensible sounds 2 points No response 1 point Not testable NT common questions - “Can you tell me your name?” “Do you know where you are at the moment?” “Do you know what the date is today?”

Answer 218

Obeys command 6 points Localises to pain 5 points Withdraws to pain 4 points Flexion decorticate posture (abnormal flexion response to pain) 3 points Abnormal extension decerebrate posture 2 points No response 1 point Not testable NT

Answer 219

Acute loss of cerebral/ ocular function with sudden symptoms lasting less than 24 hours mainly due to an atherothromboembolism from an artery Temporary focal cerebral ischaemia due to lack of oxygen, no infarction

Answer 220

Same as IHD --> Age --> smoking --> HTN --> cardiovascular disease --> AF --> Diabetes

Answer 221

--> main cause atherothromboembolism - mainly from the carotid arteries --> Cardioembolism - valvular disease/prosthetic valve, after an MI or AF

Answer 222

Carotid territory symptoms - 90% --> Amaurosis fugax --> aphasia --> hemiparesis --> hemisensory loss --> Hemianopic visual changes Vertebrobasilar territory symptoms - 10% --> diplopia, vertigo, vomiting --> chocking and dysarthria --> ataxia --> Hemisensory loss --> Hemianopic or bilateral visual loss --> tetraparesis --> Loss of consciousness (rare)

Answer 223

→ Diffusion-weighted CT/MRI → first line → Carotid imaging with doppler ultrasound → Then MR/CT angiography if the stenosis is found → Bloods → Glucose → FBC - polycythaemia → ESR - raised in vasculitis → INR - if pt is on warfarin → U&E → Cholesterol → ECG - AF? → Echocardiogram

Answer 224

→ immediate management → loading dose of Aspirin 300mg + refer to specialist to be seen within 24hrs of onset of sx → Antiplatelet therapy → Standard treatment is aspirin 75mg daily with MR Dipyridamole or clopidogrel daily → patients with AF → anticoagulation e.g DOAC/warfarin → carotid endarterectomy - if >70% carotid stenosis, reduces stroke and TIA risk by 75% → Control CV risk factors → BP control, Smoking cessation, Statins, no driving for 1 month

Answer 225

Giant cell arteritis is a systemic vasculitis of the medium and large arteries. It typically presents with symptoms affecting the temporal arteries and is also known as temporal arteritis. --> medical emergency as a complication is vision loss which is irreversible, high dose steroids are given immediately if a diagnosis is suspected

Answer 226

--> women --> over 50 --> Strong link with polymyalgia rheumatica 50% of patients with temporal arteritis have PMR

Answer 227

Chronic vasculitis, characterised by granulomatous inflammation of the walls of medium and large vessels

Answer 228

The main presenting feature is a headache: Severe unilateral headache typically around temple and forehead Scalp tenderness may be noticed when brushing hair Jaw claudication Blurred or double vision Irreversible painless complete sight loss can occur rapidly There may be associated systemic symptoms such as: Fever Muscle aches Fatigue Weight loss Loss of appetite Peripheral oedema

Answer 229

--> clinical presentation --> Raised ESR --> Temporal artery biopsy - multinucleated giant cells found --> Temporal artery ultrasound may show thickening of the wall - halo sign --> FBC may show normocytic anaemia and thrombocytosis --> LFT's - raised Alkaline phosphatase --> CRP usually raised

Answer 230

--> medical emergency --> Urgent referral to rheumatologist/ophthalmologist if vision loss --> WITH visual symptoms - 60-100mg of prednisolone one off in primary care --> WITH visual loss - secondary care - methylprednisolone 500mg-1g of IV methylprednisolone for 3 days --> Without visual loss- 40-60mg of prednisolone per day --> aspirin - reduces risk of strokes and visual loss --> PPI for steroids

Answer 231

DON’T – Don’t stop taking steroids abruptly. There is a risk of adrenal crisis. S – Sick Day Rules. T – Treatment Card. O – Osteoporosis prevention with bisphosphonates and supplemental calcium and vitamin D. P – Proton pump inhibitor for gastric protection.

Answer 232

Early neuro-ophthalmic complications: --> Vision loss --> Cerebrovascular accident (stroke) Late: --> Relapses of the condition are common --> Steroid-related side effects and complications --> Cerebrovascular accident (stroke) --> Aortitis leading to aortic aneurysm and aortic dissection

Answer 233

--> recurrent throbbing headache often preceded by an aura & associated with nausea, vomiting and visual changes --> most common cause of episodic headache - recurrent --> more common in females and common onset before 40 years.

Answer 234

--> genetics > FHx --> female --> age - majority of first migraines are in adolescence

Answer 235

Mnemonic – CHOCOLATE Chocolate Hangovers Orgasms Cheese Oral contraceptives Lie-ins Alcohol Tumult ie. Loud noises Exercise no known cause - but we know the triggers

Answer 236

Prodrome - yawning, cravings, mood/sleep changes Aura - precedes attack and can be a variety of symptoms, visual disturbances e.g lines, dots, zig-zags and somatosensory signs e.g paresthesia, pins and needles can be with or without aura At least 2 of: Unilateral pain (usually 4-72hrs) Throbbing-type pain Moderate>severe intensity Motion sensitivity Plus, at least 1 of: Nausea/vomiting Photophobia/phonophobia There also must be a normal examination and no attributable cause

Answer 237

At least 2 of: Unilateral pain (usually 4-72hrs) Throbbing-type pain Moderate>severe intensity Motion sensitivity Plus, at least 1 of: Nausea/vomiting Photophobia/phonophobia There also must be a normal examination and no attributable cause

Answer 238

--> Usually, diagnosis is made clinically with few/no investigations required; however, in certain cases, other causes for headaches must be ruled out: --> lab tests - CRP, ESR --> CT/MRI red flags ie. Indications Worst/severe headache ie. Thunderclap Change in pattern of migraine Abnormal neurological exam Onset >50yrs Epilepsy Posteriorly located headache --> Lumbar puncture indications Thunderclap headache Severe, rapid onset headache/ progressive headache/ unresponsive headache

Answer 239

--> Triptans eg. Sumatriptan C/I in IHD, uncontrolled HTN S/Es = arrhythmias, angina > MI --> NSAIDs eg. naproxen --> Anti-emetic eg. prochlorperazine --> AVOID opioids & ergotamine Prevention Required if >2 attacks per month OR require acute meds >2x per week Beta-blockers eg. propranolol TCAs eg. amitriptyline Anti-convulsant eg. Topiramate

Answer 240

Tension headaches Migraines Cluster headaches Secondary headaches Sinusitis Giant cell arteritis Glaucoma Intracranial haemorrhage Subarachnoid haemorrhage Analgesic headache Hormonal headache Cervical spondylosis Trigeminal neuralgia Raised intracranial pressure (brain tumours) Meningitis Encephalitis

Answer 241

Fever, photophobia or neck stiffness (meningitis or encephalitis) New neurological symptoms (haemorrhage, malignancy or stroke) Dizziness (stroke) Visual disturbance (temporal arteritis or glaucoma) Sudden onset occipital headache (subarachnoid haemorrhage) Worse on coughing or straining (raised intracranial pressure) Postural, worse on standing, lying or bending over (raised intracranial pressure) Severe enough to wake the patient from sleep Vomiting (raised intracranial pressure or carbon monoxide poisoning) History of trauma (intracranial haemorrhage) Pregnancy (pre-eclampsia)

Answer 242

- tension headaches - migraines - cluster headaches

Answer 243

--> common type of primary headaches --> mild ache across the forehead - band like pain --> could be due to muscle aches in the frontalis, temporalis, occipitalis --> No visual changes --> Can be episodic <15 days/month or chronic >15 days/month (for at least 3 months)

Answer 244

Stress Sleep deprivation Bad posture Hunger Eyestrain Anxiety Noise - no known cause

Answer 245

Usually at least one of the following: Bilateral Pressing/tight & non-pulsatile (like an elastic band) Mild/moderate intensity +/- scalp tenderness No aura, vomiting or sensitivity to head movement Can be some “pressure” behind eyes, but pain isn’t localised to be around the eye

Answer 246

Avoidance of triggers & stress relief Symptomatic relief Aspirin Paracetamol Ibuprofen AVOID OPIOIDS Limit analgesics to no more than 6 days per month to reduce the risk of medication-overuse headaches

Answer 247

Episodic headaches lasting from 7 days up to 1 year, usually a couple of weeks with pain free periods between that last around 4 weeks --> considered the most disabling primary headache --> rarer than migraines and more common in males --> typically affects adults with onset usually 20-40 years

Answer 248

Smoker Alcohol male genetics - autosomal dominant gene has a link.

Answer 249

Rapid onset of excruciating pain, classically around the eye however other common areas are the temples or forehead Pain is strictly unilateral and localised to one area It rises to a crescendo over a few minutes and last for 15-160 minutes, once or twice a day usually around the same time of day Ipsilateral autonomic features: Watery & bloodshot eye Facial flushing Rhinorrhoea (blocked nose) Miosis (pupillary constriction) +/- ptosis (seen in 20%)

Answer 250

Acute attacks Analgesics are unhelpful 15L 100% O2 for 15 mins via non-rebreather mask Triptans eg. Sumatriptan Prevention Verapamil (CCB) = 1st line prophylaxis Prednisolone Reduce alcohol consumption & stop smoking

Answer 251

Those caused by organic pathology

Answer 252

Giant cell/temporal arteritis Sentinel headache Thunderclap headache Headache of a morning Trauma Medication overuse Trigeminal neuralgia Systemic infection Meningitis/encephalitis

Answer 253

Episodes of acute severe facial nerve pain within the distribution of the trigeminal nerve, rare condition most common in women

Answer 254

→ vascular compression, the most common cause of trigeminal neuralgia → compressions caused by other lesions e.g meningioma → Multiple sclerosis can lead to Trigeminal neuralgia due to demyelination of the trigeminal nerve → can be idiopathic

Answer 255

→ female sex → advancing age → multiple sclerosis → FHx

Answer 256

→ Short-lived episodes (seconds to minutes) of electric shock pain in the distribution of the trigeminal nerve → attacks may be recurrent and triggered by things such as cold air or eating

Answer 257

CT/MRI - identify lesion/vascular compression clinical diagnosis - pain lasts form a fraction of a second to 2 minutes and is severe and electric shock-like/stabbing or sharp in quality which precipitates by innocuous stimuli within the affected trigeminal distribution → rule out other conditions - jaw or dental problems, cluster headaches, post-herpetic neuralgia – a type of nerve pain linked to shingles

Answer 258

→ Carbamazepine - mainstay of management → second line → gabapentin/lamotrigine → Surgical → Microvascular decompression

Answer 259

--> Ophthalmic - provides sensation to the forehead, anterior scalp, nose and eyes - the conjunctiva --> Maxillary - Provides sensation to the mid-face, lower eyelid, nasal cavity, palate, upper lip and maxillary teeth --> mandibular - Provides sensation to part of the scalp, part of the ear, lower face, tongue, the floor of the mouth and mandibular teeth. Provides motor input to the muscles of mastication (temporalis, masseter, medial and lateral pterygoids) and the tensor tympany

Answer 260

Bilateral pain is considered a red flag Onset before 40 years Hearing difficulties or other ear problems Sensory changes Previous skin/oral lesions that could exhibit perineurally Isolated involvement of ophthalmic division Bilateral symptoms Optic neuritis Family history of multiple sclerosis

Answer 261

Lesion on the sympathetic chain supplying the eye

Answer 262

Dilator pupillae: involved in mydriasis or dilation of the pupil Superior tarsal (or Muller’s) muscle: aids in elevating the upper eyelid with the levator palpebrae superioris Sweat glands THINK HORNERS

Answer 263

Horner’s syndrome is characterised by the triad of ptosis (drooping eyelid), anhidrosis (lack of sweating) and miosis (constricted pupil) on the ipsilateral side

Answer 264

Isolated injury systemic disease process

Answer 265

The presence of systemic features with Horner’s can help guide the identification of lesion location and inform further investigations. For example, patients with cough and weight loss should undergo a chest X-ray to screen for a Pancoast tumour. For unclear cases, Horner’s can be diagnosed pharmacologically using eye drops. - apraclonidine - reverses pupillary constriction due to antagonistic effects on alpha 2 receptors

Answer 266

Like investigations, the management of Horner’s depends on the underlying cause. Accurate and timely investigation of sudden-onset Horner aids in reducing morbidity and mortality of patients.

Answer 267

Central disc protrusion (mostly lumbar) – often due to disc degeneration Tumour/haematoma/abscess Trauma

Answer 268

Myelopathic - affects the entire spinal cord Motor deficit below the level of compression – generally UMN pattern if gradually progressive Sensory deficit up to the level of compression Disruption of bladder/bowel control Lower back aching pain radiating distally

Answer 269

--> MRI spine - T1+T2 weighted

Answer 270

Surgical laminectomy to relieve the pressure, removal of any mass lesions if possible

Answer 271

--> surgical emergency where the nerve roots of the cauda equina at the bottom of the spine as compressed --> The cauda equina is a collection of nerve roots that travel through the spinal canal after the spinal cord terminates around L2/L3

Answer 272

→ Herniated disc - most common → tumours - mets → spondylolisthesis - anterior displacement of vertebra out of line with one below → Abscess infection → trauma

Answer 273

→Saddle anaesthesia (loss of sensation in the perineum – around the genitals and anus) → Loss of sensation in the bladder and rectum (not knowing when they are full) → Urinary retention or incontinence → Faecal incontinence → Bilateral sciatica → Bilateral or severe motor weakness in the legs → Reduced anal tone on PR examination

Answer 274

→ medical emergency - immediate neurosurgery referral for lumbar decompression surgery → Emergency MRI scan to confirm

Answer 275

Treatment → Surgical decompression as soon as possible → Immobilise spine → Anti-inflammatory agents → chemotherapy if Mets → antibiotics if an infection is present

Answer 276

lateral lumbar/cervical disc protrusion – secondary to spondylosis (osteoarthritic change in the spine) and/or disc generation Tumours Trauma / mechanical strain

Answer 277

--> Radiculopathy - compression of individual nerve root CERVICAL --> pain - Sharp, stabbing pain in affected root distribution, radiating distally from shoulders --> sensory (numbness/paraesthesia) - in dermatomes supplied by the affected nerve roots --> Motor (LMN weakness) - in myotomes supplied by the affected nerve roots - C5 - elbow flexion, C6 - wrist extension, C7 - elbow extension LUMBAR --> Pain - Sharp, stabbing pain in affected root distribution, radiating distally from the lower back (sciatica) --> sensory (numbness/paraesthesia) - in dermatomes supplied by the affected area --> motor - in myotomes supplied by the affected nerve roots - L4 - ankle dorsiflexion, L5 - hallux dorsiflexion, S1 - plantarflexion --> special tests - straight leg raise - painful hip flexion, worsened by ankle dorsiflexion

Answer 278

--> MRI spine T1+T2 weighted

Answer 279

Rest +/- analgesics. If pain and more importantly neurological deficit persists: Cervical – anterior cervical discectomy and fusion (ACDF) Lumbar – microdiscectomy

Answer 280

Commonly referred to as a pinched nerve, radiculopathy is injury or damage to nerve roots in the area where they leave the spine. This condition can affect anyone and result from disc degeneration, disc herniation or other trauma.

Answer 281

Ménière’s disease is a long-term inner ear disorder that causes recurrent attacks of vertigo, and symptoms of hearing loss, tinnitus and a feeling of fullness in the ear.

Answer 282

Hearing loss Vertigo Tinnitus

Answer 283

excessive buildup of endolymph in the labyrinth of the inner ear, causing a higher pressure than normal and disrupting the sensory signals. This increased pressure of the endolymph is called endolymphatic hydrops

Answer 284

typical patient 40-50 years old, presenting with unilateral episodes of vertigo, hearing loss and tinnitus --> Vertigo - comes in episodes - last between 20 minutes to several hours, not triggered by movement or posture --> Hearing loss - fluctuates at first, but then becomes more permanent - sensorineural, unilateral and affects low frequencies first --> Tinnitus - initially occurs with episodes of vertigo before eventually becoming more permanent, unilateral --> A sensation of fullness in the ear --> Unexplained falls (“drop attacks”) without loss of consciousness --> Imbalance, which can persist after episodes of vertigo resolve --> Spontaneous nystagmus may be seen during an acute attack - unidirectional

Answer 285

--> Diagnosis of Ménière’s disease is clinical, based on the signs and symptoms. It will be made by an ear, nose and throat (ENT) specialist. --> Patients will need an audiology assessment to evaluate hearing loss.

Answer 286

Management involves: Managing symptoms during an acute attack Prophylactic medication to reduce the frequency of attacks For acute attacks, short-term options for managing symptoms include: Prochlorperazine Antihistamines (e.g., cyclizine, cinnarizine and promethazine) Prophylaxis is with: Betahistine

Answer 287

Myasthenia gravis is an autoimmune condition that causes muscle weakness that gets progressively worse with activity and improves with rest typical women under 40 and men over 60

Answer 288

Binding of autoantibodies to acetylcholine receptors in NMJ - blocks postsynaptic receptor - increased activity leads to more receptors blocked - less muscle stimulation with increased activity → Can be inherited

Answer 289

→ muscle weakness that worsens during physical activity and improves after rest. → Nearly all patients with the condition will experience some form of eye-related symptoms at some point e.g ptosis and diplopia → Proximal muscles are more affected → Weakness may be observed in the small muscles of the hands, as well as the deltoid, triceps, and bulbar muscles, which are responsible for chewing and speaking. → does not typically cause muscle wasting or affect sensation. → Seizures may be a possible complication

Answer 290

→ Antibody testing - AChR, MuSK and LRP4 → TFT’s → CT/MRI of the thymus to look for thymoma → Edrophonium test - IV neostigmine improves Sx

Answer 291

→ Symptomatic treatment with reversible acetylcholinesterase inhibitors - pyridostigmine/neostigmine → immunosuppression - prednisolone/azathioprine suppresses the production of antibodies → Monoclonal antibodies - Rituximab/eculizumab - targets B cells and reduces the production of antibodies → Thymectomy → Myasthenic crisis - IVIg + plasmapheresis + Non invasive ventilation

Answer 292

--> damage or dysfunction of a single peripheral nerve, cranial nerves, spinal nerve etc --> most cause sensory and motor impairment, usually affecting the hands, feet and arms

Answer 293

Cubital tunnel syndrome - ulnar nerve neuropathy Carpal tunnel syndrome - median nerve mononeuropathy peroneal nerve dysfunction

Answer 294

--> Nerve compression against a hard surface - compression can cause segmental demyelination --> Entrapment of nerve in narrow anatomical spaces -->Repetitive actions that cause trauma to neuron --> infections, radiation and cold

Answer 295

--> depends on the affected nerve and underlying cause --> Sensory - numbness, pain and tingling --> Motor - weakness, atrophy, loss of coordination

Answer 296

--> Rest, avoidance or removal of the causative agent --> NSAIDS --> Treat underlying cause! --> immobilising area --> corticosteroids --> decompression

Answer 297

--> genetic condition that causes nerve tumours (neuromas) to develop throughout the nervous system --> benign, but causes neurological and structural problems --> two types - NF type 1 and type 2 --> Type 1 more common

Answer 298

NF1 gene on chromosome 17 codes for a protein called neurofibromin - TS protein autosomal dominant inheritance

Answer 299

2 of the 7 must be present C – Café-au-lait spots (6 or more) measuring ≥ 5mm in children or ≥ 15mm in adults R – Relative with NF1 A – Axillary or inguinal freckles BB – Bony dysplasia such as Bowing of a long bone or sphenoid wing dysplasia I – Iris hamartomas (Lisch nodules) (2 or more) are yellow-brown spots on the iris N – Neurofibromas (2 or more) or 1 plexiform neurofibroma G – Glioma of the optic nerve

Answer 300

--> clinical criteria --> genetic testing --> X-rays - bone pain and bone lesions --> CT/MRI investigate lesions elsewhere in the body

Answer 301

There is no treatment of the underlying disease process or to prevent the development of neurofibromas or complications. Management is to control symptoms, monitor the disease and treat complications.

Answer 302

Migraines Epilepsy Renal artery stenosis causing hypertension Learning and behavioural problems (e.g. ADHD) Scoliosis of the spine Vision loss (secondary to optic nerve gliomas) Malignant peripheral nerve sheath tumours A gastrointestinal stromal tumour (a type of sarcoma) Brain tumours Spinal cord tumours with associated neurology (e.g. paraplegia) Increased risk of cancer (e.g. breast cancer) Leukaemia

Answer 303

The neurofibromatosis type 2 gene is found on chromosome 22. It codes for a protein called merlin, which is a tumour suppressor protein particularly important in Schwann cells. Mutations in this gene lead to the development of schwannomas (benign nerve sheath tumours of the Schwann cells). Inheritance is autosomal dominant.

Answer 304

acoustic neuromas - hearing loss, tinnitus, balance problems

Answer 305

Surgery can be used to resect the tumours, however risk of permanent nerve damage.

Answer 306

--> reversible cause of dementia seen in elderly patients --> thought to be secondary to reduced CSF absorption at the arachnoid villi --> can be secondary to head injury, subarachnoid haemorrhage or meningitis.

Answer 307

Classic triad Urinary incontinence dementia and bradyphrenia gait abnormality - similar to Parkinsons symptoms develop over a few months

Answer 308

MRI/CT --> Ventriculomegaly/ sulcal enlargement

Answer 309

ventriculoperitoneal shunting

Answer 310

Diagnosed after at least 3 months of disabling fatigue affecting mental and physical function more than 50% of the time in the absence of other disease which may explain symptoms

Answer 311

Fatigue is the central feature, other recognised features include --> Sleep problems, such as insomnia, hypersomnia, unrefreshing sleep, a disturbed sleep-wake cycle --> Muscle and/or joint pains --> headaches --> painful lymph nodes without enlargement --> sore throat --> cognitive dysfunction, such as difficulty thinking, inability to concentrate, impairment of short-term memory, and difficulties with word-finding physical or mental exertion makes symptoms worse --> General malaise or 'flu-like' symptoms --> dizziness --> nausea --> palpitations

Answer 312

NICE guidelines suggest carrying out a large number of screening blood tests to exclude other pathology e.g. FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK, ferritin, coeliac screening and also urinalysis

Answer 313

All of these symptoms should be present: Debilitating fatigue that is worsened by activity, is not caused by excessive cognitive, physical, emotional or social exertion, and is not significantly relieved by rest. Post-exertional malaise after activity in which the worsening of symptoms: is often delayed in onset by hours or days is disproportionate to the activity has a prolonged recovery time that may last hours, days, weeks or longer. Unrefreshing sleep or sleep disturbance (or both), which may include: feeling exhausted, feeling flu-like and stiff on waking broken or shallow sleep, altered sleep pattern or hypersomnia. Cognitive difficulties (sometimes described as 'brain fog'), which may include problems finding words or numbers, difficulty in speaking, slowed responsiveness, short-term memory problems, and difficulty concentrating or multitasking.

Answer 314

refer to a specialist CFS service if the diagnostic criteria are met and symptoms have persisted for 3 months energy management a self-management strategy that involves a person with ME/CFS managing their activities to stay within their energy limit, with support from a healthcare professional physical activity and exercise do not advise people with ME/CFS to undertake exercise that is not part of a programme overseen by an ME/CFS specialist team should only be recommended if patients 'feel ready to progress their physical activity beyond their current activities of daily living' graded exercise therapy used to be recommended but is now specifically not recommended by NICE cognitive behavioural therapy NICE stress this is 'supportive' rather than curative for CFS

Answer 315

--> low levels of orexin (hypocretin) a protein which is responsible for controlling appetite and sleep patterns --> early onset REM sleep --> associated with HLA-DR2

Answer 316

typical onset in teenage years hypersomnolence cataplexy (sudden loss of muscle tone often triggered by emotion) sleep paralysis vivid hallucinations on going to sleep or waking up

Answer 317

multiple sleep latency EEG

Answer 318

daytime stimulants - modafinil nighttime sodium oxybate

Answer 319

--> a type of peripheral neuropathy typically leading to sensory loss and not motor loss --> complication of diabetes

Answer 320

--> sensory loss and not motor loss --> sensory loss in glove and stocking distribution --> lower legs affected first

Answer 321

--> managed in the same way to neuropathic pain first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin if the first-line drug treatment does not work try one of the other 3 drugs tramadol may be used as 'rescue therapy' for exacerbations of neuropathic pain topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia) pain management clinics may be useful in patients with resistant problems

Answer 322

L1 - splits into the cauda equina

Answer 323

Dorsal column spinothalamic tract

Answer 324

the posterior section of the spinal cord carries information about fine touch, vibration, proprioception decussates just before it reaches the medulla - remains ipsilateral

Answer 325

the anterior section of the spinal cord information regarding pain and temperature fibres decussate immediately as then enter the cord ascend contralaterally

Answer 326

Corticospinal tract

Answer 327

--> carries motor information from the frontal lobe to skeletal muscles --> immediately decussate when entering the spinal cord --> Fibres travel contralaterally

Answer 328

interruption of all ascending and descending tracts bilaterally, resulting in bilateral loss of motor function, and complete loss of all modes of sensation below the level of the lesion.

Answer 329

lateral hemisection of the spinal cord

Answer 330

ipsilateral weakness below the lesion- corticospinal tract decussates near the medulla ipsilateral loss of proprioception and vibration sensation, fine touch - dorsal columns do not immediately decussate contralateral loss of pain and temperature sensation - spinothalamic tract decussates immediately

Answer 331

front of the spinal cord is damaged and the posterior aspect is preserved

Answer 332

--> Bilateral loss of pain and temperature sensation - spinothalamic in anterior portion damaged --> Bilateral spastic paralysis and UMN signs - corticospinal tracts can also be damaged --> dorsal column intact so fine touch, proprioception and vibration will be intact

Answer 333

Carpal tunnel syndrome is caused by compression of the median nerve as it travels through the carpal tunnel in the wrist, causing pain and numbness in the median nerve distribution on the hand.

Answer 334

Swelling of the contents (e.g., swelling of the tendon sheaths due to repetitive strain) Narrowing of the tunnel

Answer 335

sensory innervation of the palmar aspects and full fingertips of the thumb, index and middle finger and the lateral half of the ring finger motor function of thenar muscles at the base of the thumb - Abductor pollicis brevis (thumb abduction) Opponens pollicis (thumb opposition – reaching across the palm to touch the tips of the fingers) Flexor pollicis brevis (thumb flexion

Answer 336

idiopathic Repetitive strain Obesity Perimenopause Rheumatoid arthritis Diabetes Acromegaly Hypothyroidism

Answer 337

gradual onset, intermittent, worse at night Numbness Paraesthesia (pins and needles or tingling) Burning sensation Pain motor symptoms - thenar muscles affected Weakness of thumb movements Weakness of grip strength Difficulty with fine movements involving the thumb Wasting of the thenar muscles (muscle atrophy)

Answer 338

Phalens Tinels

Answer 339

Carpal tunnel questionare Nerve conduction studies

Answer 340

Rest and altered activities Wrist splints that maintain a neutral position of the wrist can be worn at night (for a minimum of 4 weeks) Steroid injections Surgery - flexor retinaculum cut to release the pressure on the median nerve

Answer 341

--> Common peroneal nerve compressed against the head of the fibula

Answer 342

Foot drop - ankle dorsiflexion deficit, ankle eversion also affected sensory deficit over dorsal foot

Answer 343

--> entrapment of the ulnar nerve at the cubital tunnel of the elbow

Answer 344

Weakness/wasting of muscles supplied by the ulnar nerve such as adductor pollicis in the thumb

Answer 345

Avoid pressure splinting

Answer 346

Extension of sepsis from the middle ear or sinuses trauma Surgery to scalp penetrating head injuries embolic events from endocarditis

Answer 347

depends on the site --> headache often dull, persistent --> fever may be absent and usually not the swinging pyrexia seen with abscesses at other sites --> focal neurology e.g. oculomotor nerve palsy or abducens nerve palsy secondary to raised intracranial pressure --> Other features consistent with raised intracranial pressure nausea papilloedema seizures

Answer 348

Surgery: Craniotomy is performed and the abscess cavity debrided - the abscess may reform because the head is closed following abscess drainage. IV antibiotics: IV 3rd-generation cephalosporin + metronidazole Intracranial pressure management: e.g. dexamethasone

Answer 349

Causes: HE IS NOT MAAD Hypoxia - resp failure, MI, PE Endocrine - cushing's, thyroid, glucose Infection - pneumonia, UTI Stroke - ^ICP, head trauma Nutrition - thiamine/B12 def Others - pain, lack of sleep Theatre - anaesthetics Metabolic - electrolytes Abdominal - urine retention Alcohol - intox + withdrawal Drugs - BZD, opioids

Answer 350

General --> Mechanical (e.g. poor footwear/visual impairment)/ Polypharmacy Cardiovascular --> Arrhythmias/ Orthostatic hypotension/ Bradycardia/ Valvular heart disease Neurological --> Stroke/ Peripheral neuropathy/ gait abnormalities Genitourinary --> Incontinence/ Urinary tract infection Endocrine --> Hypoglycaemia Musculoskeletal --> Arthritis/ Disuse atrophy ENT --> Benign paroxysmal positional vertigo Ear wax

Answer 351

Bedside --> Vital signs (BP/HR/RR/SpO2/Temperature) - Sepsis/ Bradycardia --> Lying and standing blood pressure - Orthostatic hypotension --> Urine dipstick - Infection/ Rhabdomyolysis (+++ blood) --> ECG -Bradycardia/ Arrhythmias Cognitive screening (e.g. AMT) --> Cognitive impairment Blood glucose --> Hypoglycaemia secondary to poor oral intake Bloods--> Full blood count - Anaemia/ Infection (raised white cells) --> Urea and electrolytes - Dehydration/Electrolyte abnormalities/ Rhabdomyolysis --> Liver function tests - Chronic alcohol use --> Bone profile - Calcium abnormalities in malignancy/ Over-supplementation of calcium --> Imaging Chest X-ray - Pneumonia --> CT head- Chronic or acute subdural Stroke --> Echo - Valvular heart disease (e.g aortic stenosis) --> Specialist - Tilt table test Dix-Hallpike test - Benign paroxysmal positional vertigo --> Cardiac monitoring (e.g. 48hr tape) If no symptoms during the monitoring episode in the hospital

Answer 352

1 Gait --> Physiotherapy 2 Visual problems --> Eye test and ensure wears glasses 3 Hearing Difficulties --> Remove earwax/ Hearing assessment 4 Medications review --> Reduce unnecessary medication 5 Alcohol intake --> Alcohol cessation advice Alcohol service referral 6 Cognitive impairment --> Referral to a psychiatric team 7 Postural hypotension --> Review medication/ Improve hydration 8 Continence --> Treat or rule out infections Continence assessment 9 Footwear --> Ensure good-fitting footwear 10 Environmental hazards --> Turn on lights Take up rugs

Answer 353

Nitrates Diuretics Anticholinergic medications Antidepressants Beta-blockers L-Dopa Angiotensin-converting enzyme inhibitors - (ACE) inhibitors

Answer 354

Benzodiazepines Antipsychotics Opiates Anticonvulsants Codeine Digoxin Other sedative agents

Answer 355

Osteoporosis is a condition where there is a reduction in bone mineral density

Answer 356

refers to a less severe reduction in bone density than osteoporosis. Reduced bone density makes bone less strong and more prone to fractures

Answer 357

Older age Female Reduced mobility and activity Low BMI (<18.5 kg/m2) Rheumatoid arthritis Alcohol and smoking Long term corticosteroids. NICE suggest the risk increases significantly with the equivalent of more than 7.5mg of prednisolone per day for more than 3 months) Other medications such as SSRIs, PPIs, anti-epileptics and anti-oestrogens

Answer 358

Post-menopausal women are a key group where osteoporosis should be considered. Oestrogen is protective against osteoporosis. Unless they are on HRT postmenopausal women have less oestrogen. They also tend to be older and often have other risk factors for osteoporosis.

Answer 359

--> FRAX score - the risk of fracture in 10 years, gives results as a percentage 10-year probability of a major osteoporotic fracture and Hip fracture. Age, BMI, co-morbidities, smoking, alcohol and family history. You can enter a result for bone mineral density (from a DEXA scan) --> Dexa scan - done at hip, measures BMD, Z score corrected to patients age/ T-score - BMD of a healthy young person - >-1 = normal/ -1 - -2.5 = osteopenia/ <-2.5 = osteoporosis/ <-2.5 + # = severe osteoporosis

Answer 360

--> Calcichew D3 - calcium and vitamin D (colecalciferol) supplementation + Bisphosphonates - They work by interfering with osteoclasts and reducing their activity, preventing the reabsorption of bone (Alendronate/Risedronate/ zoledronic acid) --> Alternatives --> Denosumab monoclonal antibody that works by blocking the activity of osteoclasts. --> Strontium ranelate is a similar element to calcium that stimulates osteoblasts and blocks osteoclasts but increases the risk of DVT, PE and myocardial infarction. --> Raloxifene is used as secondary prevention only. It is a selective oestrogen receptor modulator that stimulates oestrogen receptors on bone but blocks them in the breasts and uterus. --> Hormone replacement therapy should be considered in women that go through menopause early.

Answer 361

Reflux and oesophageal erosions. Oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this. Atypical fractures (e.g. atypical femoral fractures) Osteonecrosis of the jaw Osteonecrosis of the external auditory canal

Answer 362

It may be defined as defecation that is unsatisfactory because of infrequent stools (< 3 times weekly), difficult stool passage (with straining or discomfort), or seemingly incomplete defecation

Answer 363

overflow diarrhoea acute urinary retention haemorrhoids

Answer 364

The Rome IV diagnostic criteria for constipation include spontaneous bowel movements occurring fewer than three times a week.

Answer 365

Chronic constipation usually describes symptoms which are present for at least three months.

Answer 366

Functional (primary or idiopathic) constipation is chronic constipation without a known cause. Secondary (organic) constipation is constipation caused by a drug or underlying medical condition.

Answer 367

Identification of red flag symptoms or signs that may suggest a serious underlying cause, such as colorectal cancer. Exploration of the person’s understanding of constipation and their normal pattern of defecation including the frequency and consistency of stools, symptoms of faecal impaction and/or incontinence. Assessment of associated rectal, abdominal, or urinary symptoms. The severity and impact of symptoms on daily life and functioning. Any risk factors or possible secondary causes. Any self-help measures or drug treatments tried. Abdominal and rectal examination.

Answer 368

Benign paroxysmal positional vertigo (BPPV) is a common cause of recurrent episodes of vertigo triggered by head movement. It is a peripheral cause of vertigo, meaning the problem is located in the inner ear rather than the brain. It is more common in older adults.

Answer 369

BPPV is caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals. This occurs most often in the posterior semicircular canal. They may be displaced by a viral infection, head trauma, ageing or without a clear cause. The crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system. Head movement creates the flow of endolymph in the canals, triggering episodes of vertigo.

Answer 370

-->Head injury -->Vestibular neuronitis (post-viral illness) -->Labyrinthitis (due to age-related degeneration of the labyrinth) --> Complications of mastoid/stapes surgery

Answer 371

Older age (onset common between 40 to 60 years old). Female sex (women are twice as likely to have BPPV compared to men) Meniere’s disease (usually diagnosed alongside BPPV in 30% of cases) Patients with migraines and/or anxiety disorders

Answer 372

Typical symptoms of BPPV include: Brief episodes of vertigo usually lasting 30 seconds to 1 minute Symptoms provoked by head movements such as rolling over in bed, gazing upwards (e.g. when placing an object on a shelf), bending forward (e.g. when tying shoe laces, sitting down) Less common symptoms include: Nausea Light-headedness, imbalance (as a result, patients may present with a fall – hence, it is crucial to consider vestibular dysfunction; see the Geeky Medics guide to the assessment of falls) Dix-Hallpike test positive - rotational vertigo and nystagmus

Answer 373

--> Dix-Hallpipe manouvre

Answer 374

Persistent vertigo: indicative of Meniere’s disease Tinnitus, hearing loss or aural fullness: indicative of Meniere’s disease, labyrinthitis Long and gradual onset, viral prodrome: indicative of vestibular neuronitis, labyrinthitis Visual, speech, motor or sensory loss: indicative of a CNS lesion Vertical/down-beating nystagmus: indicative of a CNS lesion

Answer 375

--> BPPV is often a self-limiting condition, and symptoms may subside within 6 months of onset. Patients should be advised to: Avoid positions that may provoke vertigo symptoms and Counsel that symptoms may re-occur. One study identified a 36% symptom recurrence rate within 48 months of onset. --> If sx persists then vestibular rehabilitation- Epley manoeuvre - reposition the displaced otoconial particles back into the utricle/ Brandt-Daroff exercises

Answer 376

Urge incontinence Stress incontinence

Answer 377

Urge incontinence is caused by overactivity of the detrusor muscle of the bladder. Urge incontinence is also known as overactive bladder. The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs

Answer 378

Stress incontinence is due to the weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder. The typical description of stress incontinence is urinary leakage when laughing, coughing or being surprised.

Answer 379

Chronic urinary retention due to obstruction to the outflow of urine. Chronic urinary retention results in an overflow of urine, and incontinence occurs without the urge to pass urine. It can occur with anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries.

Answer 380

Increased age Postmenopausal status Increase BMI Previous pregnancies and vaginal deliveries Pelvic organ prolapse Pelvic floor surgery Neurological conditions, such as multiple sclerosis Cognitive impairment and dementia

Answer 381

A bladder diary should be completed, tracking fluid intake and episodes of urination and incontinence over at least three days. There should be a mix of work and leisure days. Urine dipstick testing should be performed to assess for infection, microscopic haematuria and other pathology. Post-void residual bladder volume should be measured using a bladder scan to assess for incomplete emptying. Urodynamic testing can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination.

Answer 382

Avoiding caffeine, diuretics and overfilling of the bladder Avoid excessive or restricted fluid intake Weight loss (if appropriate) Supervised pelvic floor exercises for at least three months before considering surgery Surgery Duloxetine is an SNRI antidepressant used second line where surgery is less preferred

Answer 383

Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin SE dry mouth, dry eyes, urinary retention, constipation and postural hypotension and worsening dementia Mirabegron is an alternative to anticholinergic medications Invasive procedures where medical treatment fails

Answer 384

a sudden or chronic decrease in the intake of sufficient nutrition to support the body’s requirements for growth, healing, and maintenance of life. Malnutrition can be acute or chronic (longer than 3 months)

Answer 385

Inadequate amounts of nutrients (e.g. poor variety in diet) Difficulty absorbing nutrients (e.g. gastrointestinal dysfunction such as coeliac disease) Increased nutritional demands (e.g. post-surgery for healing or increased metabolic demands due to illness and certain drugs)

Answer 386

--> Those with chronic illnesses --> Living in supported accommodations --> Excessive alcohol intake --> Being hospitalised for extended periods of time --> Problems with dentition, taste or smell --> Polypharmacy --> Social isolation and loneliness --> Mental health issues including grief, anxiety and -------> depression --> Cognitive issues including confusion

Answer 387

High susceptibility or long durations of infections Slow or poor wound healing Altered vital signs including bradycardia, hypotension, and hypothermia Depleted subcutaneous fat stores Low skeletal muscle mass

Answer 388

--> Hx - weight, meals, protein, hydration --> Weight, BMI, muscle mass and subcutaneous fat stores

Answer 389

--> Dieticians lead management --> If a reversible cause is found e.g infection treat it --> Oral nutritional support --> Parenteral nutrition for those unable to swallow or intestinal failure

Answer 390

--> caused by the rapid reintroduction of normal nutrition in patients who are chronically malnourished --> In chronic malnutrition patients their intracellular stores of electrolytes such as potassium and phosphate are depleted --> Sudden normal nutrition leads to a sudden shift of these electrolytes from extracellular to intracellular driven by a large insulin response --> Sudden drop in extracellular electrolytes leading to hypokalemia and hypophosphataemia --> can lead to arrhythmias and seizures

Answer 391

Impaired immunity (increased risk of infections) Poor wound healing Growth restriction in children Unintentional weight loss, specifically the loss of muscle mass Multi-organ failure Death

Answer 392

clinical features of impaired heart function, specifically the function of the left ventricle to pump blood out of the heart and around the body.

Answer 393

--> impaired left ventricular function - chronic backlog of blood to the left ventricle - left atrium/pulmonary veins and lungs experience increased volume and pressure - leads to pulmonary oedema --> Heart failure with reduced ejection fraction - <50% --> Heart failure with preserved ejection fraction - >50% - issue with ventricles filling with blood - diastolic dysfunction

Answer 394

Ischaemic heart disease Valvular heart disease (commonly aortic stenosis) Hypertension Arrhythmias (commonly atrial fibrillation) Cardiomyopathy

Answer 395

Breathlessness, worsened by exertion Cough, which may produce frothy white/pink sputum Orthopnoea, which is breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use) Paroxysmal nocturnal dyspnoea Peripheral oedema Fatigue

Answer 396

Tachycardia (raised heart rate) Tachypnoea (raised respiratory rate) Hypertension Murmurs on auscultation indicating valvular heart disease 3rd heart sound on auscultation Bilateral basal crackles (sounding “wet”) on auscultation of the lungs, indicating pulmonary oedema Raised jugular venous pressure (JVP), caused by a backlog on the right side of the heart, leading to an engorged internal jugular vein in the neck Peripheral oedema of the ankles, legs and sacrum

Answer 397

--> Clinical assessment - Hx and examination --> NT-proBNP bloods --> ECG --> Echocardiogram --> Bloods - to look for anaemia, renal function, thyroid function, liver function, lipids and diabetes --> chest X-ray and lung function tests to exclude lung pathology

Answer 398

R – Refer to cardiology A – Advise them about the condition M – Medical treatment P – Procedural or surgical interventions S – Specialist heart failures MDT input, such as the heart failure specialist nurses, for advice and support

Answer 399

A – ACE inhibitor (e.g., ramipril) titrated as high as tolerated B – Beta blocker (e.g., bisoprolol) titrated as high as tolerated A – Aldosterone antagonist when symptoms are not controlled with A and B (e.g., spironolactone or eplerenone) L – Loop diuretics (e.g., furosemide or bumetanide) additional specialist treatments - SGLT2 inhibitor (e.g., dapagliflozin) Sacubitril with valsartan (brand name Entresto) Ivabradine Hydralazine with a nitrate Digoxin

Answer 400

--> can treat underlying valvular heart disease --> Implantable cardioverter defibrillators - for patients who have had ventricular tachycardia or V fib before --> Cardiac resynchronization therapy CRT - severe heart failure with EF < 35%, involves bi-ventricular pacemakers - leads to the right atrium and both ventricles - aim to synchronise the contractions --> heart transplant in severe disease

Answer 401

AHF involves the acute failure of the heart to pump blood to meet the body’s demand

Answer 402

Congestion in the pulmonary or systemic circulation. Pulmonary oedema develops when the left ventricle is unable to empty, which increases the hydrostatic pressure in pulmonary vasculature leading to pulmonary oedema and hypoxia. These patients are ‘WET’. Hypoperfusion of vital organs as the cardiac output is reduced. These patients are ‘COLD’. 50% of patients will show signs of congestion without signs of hypoperfusion (WET-WARM). 45% of patients will show signs of congestion with signs of hypoperfusion (WET-COLD). 5% of patients will show no signs of congestion (DRY-WARM or DRY-COLD).

Answer 403

Causes of new-onset AHF include: Acute myocardial dysfunction (e.g. ischaemia due to myocardial infarction) Acute valve dysfunction Arrhythmias Causes of acute decompensation of CHF include: Infection Acute myocardial dysfunction (e.g. ischaemia due to myocardial infarction) Uncontrolled hypertension Arrhythmias Worsening chronic valve disease Non-adherence with drugs/diet Change in drug regimen Withdrawal/reduction of heart failure medications inappropriately Initiation/increase of rate-control medications inappropriately Other medications: steroids, non-steroidal anti-inflammatories, pioglitazones

Answer 404

Acute LVF causes a type 1 respiratory failure (low oxygen without an increased carbon dioxide). Symptoms include: Shortness of breath Looking and feeling unwell Cough with frothy white or pink sputum Signs on examination include: Raised respiratory rate Reduced oxygen saturations Tachycardia (fast heart rate) 3rd heart sound Bilateral basal crackles (sounding “wet”) on auscultation of the lungs Hypotension in severe cases (cardiogenic shock) There may also be signs and symptoms related to the underlying cause, for example: Chest pain in acute coronary syndrome Fever in sepsis Palpitations with arrhythmias If they also have right-sided heart failure, you could find: Raised jugular venous pressure (JVP), caused by a backlog on the right side of the heart, leading to an engorged internal jugular vein in the neck Peripheral oedema of the ankles, legs and sacrum

Answer 405

--> Clinical assessment (history and examination, starting with an ABCDE approach in any acutely unwell patient) --> ECG to look for ischaemia and arrhythmias --> Blood for anaemia, infection, kidney function, BNP - sensitive but not specific - shows overload of heart , and consider troponin if suspecting myocardial --> infarction --> Arterial blood gas (ABG) --> Chest x-ray - Alveolar oedema (bat wing shadowing) , Kerley B lines (interstitial oedema) , cardiomegaly, dilated upper lobe vessels, pleural effusions - loss of costophrenic angle --> Echocardiogram - structural abnormalities and ejection fraction

Answer 406

S – Sit-up - fluid sinks to lung bases O – Oxygen - if stats less than 95% D – Diuretics - IV furosemide I – Intravenous fluids should be stopped U – Underlying causes need to be identified and treated (e.g., myocardial infarction) M – Monitor fluid balance Severe cases may require (guided by an experienced specialist): Intravenous opiates, such as morphine, which act as vasodilators Intravenous nitrates act as vasodilators and may be considered in severe hypertension or acute coronary syndrome Inotropes, such as dobutamine, to improve cardiac output Vasopressors, such as noradrenalin, to improve blood pressure Non‑invasive ventilation Invasive ventilation (involving intubation and sedation)

Answer 407

Pressure ulcers develop in patients who are unable to move parts of their body due to illness, paralysis or advancing age. They typically develop over bony prominences such as the sacrum or heel.

Answer 408

malnourishment incontinence lack of mobility pain (leads to a reduction in mobility)

Answer 409

Waterlow score

Answer 410

Grade 1--> Non-blanch-able erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin Grade 2--> Partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister Grade 3 Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Grade 4 Extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with or without full-thickness skin loss

Answer 411

--> A moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound --> Swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. --> The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis) --> consider referral to the tissue viability nurse surgical debridement may be beneficial for selected wounds

Answer 412

Presence of lewy bodies in the susbtantia nigra, paralimbic and neocortical areas

Answer 413

up to 40% of patients with Alzheimer's have Lewy bodies.

Answer 414

-progressive cognitive impairment --> typically occurs before parkinsonism, but usually both features occur within a year of each other. This is in contrast to Parkinson's disease, where the motor symptoms typically present at least one year before cognitive symptoms --> cognition may be fluctuating, in contrast to other forms of dementia --> in contrast to Alzheimer's, early impairments in attention and executive function rather than just memory loss -parkinsonism -visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen

Answer 415

--> usually clinical --> single-photon emission computed tomography (SPECT) is increasingly used. It is currently commercially known as a DaTscan. Dopaminergic iodine-123-radiolabelled 2-carbomethoxy-3-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (123-I FP-CIT) is used as the radioisotope. The sensitivity of SPECT in diagnosing Lewy body dementia is around 90% with a specificity of 100%

Answer 416

--> Both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer's. --> neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. Questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent

Answer 417

neuroleptics - antipsychotics as patients can develop irreversible parkinsonism

Answer 418

--> personality change --> impaired social conduct --> hyperorality --> disinhibtion --> increased appetite --> perseveration behaviours

Answer 419

--> atrophy of the frontal and temporal lobes - macroscopic --> micrscopic --> spherical aggregations of Tau protein

Answer 420

Signs and Symptoms ● Onset tends to be insidious and progressive ● Present with 3 main symptoms: ○ Behavioural issues, e.g. loss of inhibition/empathy, compulsive behaviours, difficulty planning ○ Progressive aphasia, e.g. slow, difficult speech, grammatical errors ○ Semantic dementia, e.g. loss of vocabulary, problems understanding

Answer 421

Bloods - B12, TFTs, U&Es (?other causes) ● FBC and LFTs for suspected encephalopathy ● MMSE ● MRI - frontal/temporal atrophy