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Y2 - OSCE - History > Neuro History > Flashcards

Neuro History Flashcards

1
Q

When taking a neurological history, what key symptoms are we aiming to cover?

A

i. Headaches
ii. Dizziness (faintness/vertigo)
iii. Collapse - Fits and seizures
iv. Weakness
v. Numbness and tingling
vi. Visual Problems
vii. Hearing problems
viii. Speech and swallowing
ix. Psychological symptoms

Symptoms are bold are going to be the presenting complaint in the OSCE cases.

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2
Q

General - What questions should be asking for the PMH, MH, FH and SH for a neurological history?

A
  • Past Medical History
    i. Any pre-existing medical (neurological) conditions?
    ii. Have you previously undergone any operations or procedures?
  • Medication History
    i. Are you currently taking any medications? Prescribed or over the counter?
    ii. Ask about any allergies?
  • Family History – “Do any of your family members have nerve/neurological problems?”
  • Occupational and social history
    i. Living situation – support network - who they live with?
    ii. Able to live independently or require help? Carers?
    iii. Occupation – are you currently working?
    iv. Alcohol and recreational drugs – frequency and volume
    v. Smoking history – quantity and length
    vi. Lifestyle – diet and exercise?
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3
Q

What is a stroke?

A

What is it?
* Stroke is a sudden onset of brain dysfunction, caused by an alteration in blood supply to the brain, resulting in focal symptoms.
* The aetiology of a stroke is either ischaemic or haemorrhagic, with ischaemic stroke being the more common (being responsible for 71% of stroke globally) – build-up of atherosclerotic plaque, which has become unstable, creating a blood clot, blocking blood flow.

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4
Q

How does someone with a stroke normally present?

A
  • Rapid, acute onset – within a few minutes – symptoms don’t resolve in 24 hours
  • Focal neurological defect – almost always some sort of hemiplegia (weakness on one side of the body), with/without other focal neurological signs (impairments of nerves, spinal cord or brain function affecting a specific region of the body)
  • Difference with TIA – stroke leads to longer/more permanent neurological deficits.
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5
Q

What symptoms can people suffering a stroke present with?

A

Symptoms
* Weakness – ask about distribution and severity
* Sensory disturbance - sensation
* Visual disturbance - vision
* Speech disturbance - speech
* Ataxia – balance or coordination - balance
* Dysphagia – swallowing
* Reduced level of consciousness – any associated symptoms?
* Pain – SOCRATES

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6
Q

What are the risk factors for a stroke?

A
  • Ageing
  • Vascular risk factors - hypertension, diabetes, hypercholesterolaemia and previous stroke or TIA
  • Cardiac pathology - (emboli travel from heart) - atrial fibrillation, valvular disease, ischaemic heart disease.
  • Lifestyle – BMI, Diet, (high sodium and red meat + low fibre), smoking, alcohol and environment
  • Drugs – combined oral contraceptive and oral hormone replacement

In past medical history - ask about vascular and cardiac risk factors

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7
Q

What systemic symptoms should you ask for in a stroke history?

A

Systemic
1. Fevers (e.g. septic emboli)
2. Weight change (e.g. dysphagia)

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8
Q

What cardiovascular symptoms could you ask about in the systems enquiry for a stroke history?

A

Cardiovascular
1. Palpitations (e.g. arrhythmia)
2. Chest pain (acute coronary syndrome)
3. Shortness of breath (e.g. heart failure)

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9
Q

What conditions should you be asking about in the PMH for a stroke patient?

A

Past medical History – ask about any conditions listed in the risk factors – vascular and cardiac risk factors: AF, hypertension, IHD, diabetes, high cholesterol and previous Stroke/TIA

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10
Q

What medications are commonly perscribed for a stroke?

A

Medications commonly prescribed…
1. Antiplatelets (e.g. aspirin, clopidogrel),
2. Anticoagulants (e.g. warfarin, apixaban, rivaroxaban, dabigatran)
3. Antihypertensives (e.g. lisinopril, amlodipine)
4. Statins (e.g. atorvastatin)

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11
Q

What are some medications that can increase your risk of a stroke?

A

Medications which increase the risk of ischaemic stroke: combined oral contraceptive pill and oral hormone replacement therapy

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12
Q

Is someone presents with stroke/TIA like symptoms should they be driving?

A

If the patient drives and has presented with TIAs or stroke it is important to advise them not to drive until they have been fully investigated and to inform the relevant driving authority (e.g. DVLA) of their current medical issues.

TIA or stroke may result in temporary or permanent restrictions on the patient’s ability to continue driving (this will depend on the clinical features of the episode and residual neurological deficits).

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13
Q

What is a transient ischaemic attack (TIA)?

A

TIA is a sudden onset of brain dysfunction, caused by an alteration in blood supply to the brain, resulting in focal symptoms.

Symptoms and signs of ischaemic stroke, but resolving (hence transient) - most resolve within minutes; all within 24 hours by definition

The aetiology of a TIA is either ischaemic or haemorrhagic, with ischaemic stroke being the more common (being responsible for 71% of stroke globally) – build-up of atherosclerotic plaque, which has become unstable, creating a blood clot, blocking blood flow.

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14
Q

What are the clinical features of a TIA?

A
  • Rapid, acute onset – within a few minutes – Most symptoms resolve within minutes and all symptoms resolve within 24 hours!
  • Focal neurological defect – almost always some sort of hemiplegia, with/without other focal neurological signs (impairments of nerves, spinal cord or brain function affecting a specific region of the body)
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15
Q

What are the symptoms associated with a TIA?

A

Symptoms
* Weakness – ask about distribution and severity
* Sensory disturbance
* Visual disturbance
* Speech disturbance
* Ataxia – balance or coordination
* Dysphagia – swallowing
* Reduced level of consciousness – any associated symptoms?
* Pain – SOCRATES

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16
Q

What are the risk factors for a TIA?

A
  • Ageing
  • Vascular risk factors - hypertension, diabetes, hypercholesterolaemia and previous stroke or TIA
  • Cardiac pathology - (emboli travel from heart) - atrial fibrillation, valvular disease, ischaemic heart disease.
  • Lifestyle – BMI, Diet, (high sodium and red meat + low fibre), smoking, alcohol and environment
  • Drugs – combined oral contraceptive and oral hormone replacement
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17
Q

What systemic symptoms should you ask for in a TIA history?

A

Systemic: fevers (e.g. septic emboli) and weight change (e.g. dysphagia)

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18
Q

What cardiovascular symptoms could you ask about in the systems enquiry for a TIA history?

A

Cardiovascular - palpitations (e.g. arrhythmia), chest pain (acute coronary syndrome), shortness of breath (e.g. heart failure)

19
Q

What conditions should you be asking about in the PMH for a TIA patient?

A

Past medical History – ask about any conditions listed in the risk factors – Cardiovascular risk factors

AF, hypertension, IHD, diabetes, high cholesterol and previous Stroke/TIA

20
Q

What medications are commonly perscribed for a TIA?

A

Medications commonly prescribed
1. Antiplatelets (e.g. aspirin, clopidogrel)
2. Anticoagulants (e.g. warfarin, apixaban, rivaroxaban, dabigatran)
3. Antihypertensives (e.g. lisinopril, amlodipine)
4. Statins (e.g. atorvastatin)

21
Q

What medications can increase the risk of a TIA?

A

Medications which increase the risk of ischaemic stroke: combined oral contraceptive pill and oral hormone replacement therapy

22
Q

What is epilepsy?

A

Epilepsy is a brain disorder characterized by enduring predisposition to epileptic seizures - defined as either
a) Two or more (≥2) unprovoked seizures
b) One unprovoked seizure…… and high probability of more (risk factors)

Seizures - Abnormal excessive or synchronous discharge of cortical neurones (cortical disease) - referred to as an electrical brainstorm – Sudden, uncontrolled, burst of electrical signals in your brain.

23
Q

How to approach a epilepsy PC/HPC?

A
  • Important to ask about a collateral history – was anyone around when you lost consciousness.
  • Important to establish what happened before, during and after the seizure.
24
Q

What questions should you be asking about before the seizure occured?

A
  • Rule out any evidence for a syncopal episode
    i. Cardiogenic syncope - feel sweaty, hot, lightheaded, breathless, or have chest pain or palpitations?
    ii. Orthostatic - “Were you sitting or standing for a long time?” “Were you in a hot or stuffy environment?
    iii. Postural - “Did you move from sitting to standing, or lying to standing immediately before this happened?”
  • Establish whether there was any abnormal brain activity
    i. Abnormal sensations before the seizure? – e.g. aura, déjà vu, etc.
    ii. Arm or leg weakness before the episode?
    iii. Did you feel that any of your movements before the episode were not voluntary?
    iv. Did you or anyone else notice behavioural changes?
25
Q

What should you ask about when gathering information on events during a seizure?

A

During – ask for a description about what was happening during the event?
* Patient alert or unresponsive?
* Muscle stiffening (tonic) or stiffening & jerking movements during the episode (tonic-clonic)?
* Tongue biting?
* Incontinence?
* Length of seizure?

26
Q

What should you ask about when gathering information on events after a seizure?

A

After

  • Length of time - How long did it take for the seizure to stop?
  • Post-ictal features
    a) When the episode stopped how long was the patient unconscious for?
    b) Did you feel disoriented after the event?
    c) Any muscle/tongue pain after the event?
    d) “Can you/they recall what has happened since the seizure in full?” – Anterograde amnesia may occur after seizures
  • Tongue biting and prolonged unresponsiveness with the absence of typical syncopal symptoms at onset is strongly suggestive of a seizure.
27
Q

What are the risk factors for a seizure?

A

Risk Factors
* May occur at any age, most common at extremes (very old or young)
* Family History
* Previous CNS infection
* Head trauma
* CNS lesion
* Stroke
* Antenatal or perinatal brain insult
* Prior seizure

28
Q

What systemic symptoms should you be asking about when someone presents with epilepsy?

A

Systemic - Fevers (e.g. cerebral abscess, meningitis), weight change (e.g. malignancy), confusion (e.g. CNS infection)

29
Q

What cardiovascular symptoms should you be asking about in the systems enquiry for epilepsy?

A

Cardiovascular: palpitations (e.g. arrhythmia), chest pain (acute coronary syndrome), shortness of breath (e.g. heart failure)

30
Q

When taking a PMH from a epilsepsy patient, what should you be asking for?

A

Past medical History
a) Establish whether there is a history of epilepsy? When was your last episode? What does it normally look like?
b) If epilepsy if present, explore potential triggers – stress, sleep disruptions, alcohol or recreational drugs and remembering medication.
c) Any other medical conditions or surgeries?

31
Q

What drugs are relevant to think about in the context of epilepsy?

A
32
Q

What are some extra things to consider when taking a history for epilepsy?

A

Driving - If the patient drives and has presented with a seizure it is important to advise them not to drive until they have been fully investigated and to inform the relevant driving authority.

Occupation - working with heavy machinery or at heights?

Bathing and swimming – advise not to take any baths alone

Children or dependents – implications for carrying children and breastfeeding.

Sleep – disrupted sleep = increased risk

33
Q

What is a migraine?

A
  • Migraine is a common type of primary headache.
  • Described as a severe, unilateral and throbbing headache.
  • Migraine is a neurovascular disorder – changes in blood flow and sensitivity of some nerves, making them for sensitive to pain.
34
Q

What are the clinical features of migraines?

A

Approach – Socrates
* Site - Unilateral, retro-orbital (behind eye) but can be whole head
* Character - Severe, pulsating/throbbing
* Timing - Duration - 4-72 hours
* Associated features
a) Photophobia - light
b) Phonophobia – sound
c) Nausea and vomiting
d) Desire to lie still / Exacerbated by movement
e) Aura may precede - less than 60 minutes before, spreads over time, 90% visual, can effect sensation (face and hand) and speech (dysphasia) - different to TIA (associated with loss + quicker)
f) Prodromal and postdromal features: tiredness, irritability, yawning, poor concentration

35
Q

What are the risk factors for a migraine?

A
  • Post-puberty – 3x more likely in Females
  • Age – starts during puberty, peaks at 35-45
  • Genetics – family history
  • Hormonal factors – periods, pregnancy, menopause, COCP
  • Environmental triggers – Tiredness, emotional stress, change in sleep pattern, alcohol, dehydration, certain foods (cheese, chocolate, red wine and citrus fruits) and menstruation.
  • Obesity
36
Q

What is a tension type headache?

A
  • Tension-type headache is form of episodic primary headache.
  • Lay description - pain on both sides of your head, face or neck
  • Typically associated with stress or mental tension
37
Q

What are the clinical features of tension headaches?

A

Approach – Socrates
- Site - Whole head (e.g. frontal/temporal) and bilateral
- Character - Dull, pressing character – ‘tight’
- Associated features - Usually no associated features and rather non-specific
- Timing – 30min - 4 hours
- Exacerbating/releiving factors - stress / pain killers
- Severity – mild/moderate

  • Only considered a disease (rather than normal) if arise spontaneously and frequently.
38
Q

What are the risk factors for a tension headache?

A

Risk Factors
* Stress/mental tension
* Missing meals
* Tiredness
* Lack of sleep

39
Q

What systemic symptoms should you ask about in a headache history?

A

Systemic
1. Fevers
2. Weight loss
3. Waking you up at night
4. Neck Stiffness

40
Q

What MH questions should you be asking for a headache history?

A

Medication history
- Currently taking any prescribed medications or over-the-counter remedies?
- Are you currently taking anything to help with your headaches?
- If yes, how much are they taking (medication overuse headaches – opiates, triptans, NSAIDs and paracetamol)

41
Q

What FH questions should you be asking for someone with headaches?

A

Family History
Any family history of headaches?
Any bleeding or clotting disorders?
Cancers?
Bleeds of the brain?

42
Q

Social history questions for a headache history?

A

Social History
a) General - how is it impacting their life, occupation, accommodation, support network, independence and smoking
b) Smoking
c) Alcohol
d) Recreational drugs

43
Q

What are the headache red flags that you should keep in the back of your mind?

A

Red Flags
i. New onset, changing headache over 50
ii. Headache under 5 years old
iii. Thunderclap headache – peak intensity – very quickly – within 5 minutes
iv. Headache waking people
v. Decreased consciousness
vi. Worsening headache with fever
vii. Headache precipitated by the Valsalva manoeuvre – coughing, straining or laughing
viii. First/worst headache of their life
ix. Headache that changes posture

Y2 - OSCE - History (5 decks)

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