Neurology

Question 1

Whats the difference between bacterial, viral and fungal/TB CSF?

Answer 1

Bacterial - Turbid/cloudy appearance, high protein, low glucose, WCC>500 +VE gram stain.

Viral - Clear appearance, normal protein & glucose, wcc >1000
+ Monocytes

Fungal/TB - Fibrin Web Appearance
+ Monocytes

Question 2

Indications of a lumbar puncture?

Answer 2

Bacterial/viral meningitis
Subarachnoid haemorrhage 
Intracranial hypertension
Diagnosis of MS/GBS/Sarcoid 
Therapeutic removal of CSF

Question 3

Contraindications of lumbar puncture

Answer 3

Raised intracranial pressure 
Mass lesion in brain/spinal cord 
Local infection near site of LP
congenital spinal problems (spina bifida)
Low platelets <40) or on anticoagulants

Question 4

SAH lumbar puncture shows what type of cells?

Answer 4

Elevated RBC to WBC ratio 1:1000
Xanthochromia (Yellowish) LP > 12 hours later
Elevated opening pressure

Question 5

Which dermatomes are commonly affected in shingles

Answer 5

T1-L2

Question 6

Do you get a prodromal period with shingles if so what do you experience?

Answer 6

Burning pain over the dermatomes affected, followed by fever, headache and lethargy.
Macular rash which becomes vesicular. It does not cross the midline.

Question 7

What investigations should be carried out for a suspected TIA?

Answer 7

Offer aspirin 300 mg immediately (loading dose)
Immediate hospital admission if symptoms are currently occurring
Urgent CT scan to rule out haemorrhage
Urgent referral for investigation within 24 hours if symptoms occurred within 7 days
urgent referral within 72 hours if symptoms occurred over 7 days ago.
Do not use ABCD2 scoring system.

blood tests - glucose and ECG to rule out other causes if it doesn’t cause delay

Question 8

Gold standard investigation for Meningitis

Answer 8

Lumber Puncture

Question 9

How is active TB investigated?

Answer 9

acid-fast bacilli

Question 10

Stroke Management

Answer 10

Alteplase is recommended in the treatment of acute ischaemic stroke if it can be administered within 4.5 hours of symptom onset and if intracranial haemorrhage has been excluded by CT

Question 11

How do you investigate Lyme disease, Borrelia burgdoferi?

Answer 11

1. Erythema migrans (bulls eye rash)

2. ELISA antibodies to Borrelia burgdoferi

Question 12

What condition is seen in Obese female patient, with headaches, pappilodema, diplopia and unreactive pupils? and what is the investigation?

Answer 12

idiopathic intracranial Hypertension

Lumber puncture

Question 13

Elderly patient, memory problems, confusion, walking difficulties, inability to focus on tasks? what condition is this and what is the treatment/?

Answer 13

Normal pressure hydrocephalus 
Lumber pressure (will note the high pressure)

Question 14

Symptoms - Hyperacusis, loss of nasiolabial fold, tearing eyes, tingling jaw and pain behind the ears, facial weakness. would you refer for this condition?

Answer 14

Bell’s Palsy
NO - treat with steroids within 72 hours
conservative management - tapes, eye drops

Question 15

How is essential tremor diagnosed?

Answer 15

Clinical - tremor with fine motor actions, can involve the head or voice. Is not present after drinking alcohol or taking benzodiazepams.

Question 16

When would you admit to hospital a patient with shingles?

Answer 16

Shingles - varicella-zoster virus. Refer if they are demonstrating Hutchinson’s sign - vesicles appearing on the tip, root or side of the nose. This indicates it is effecting the nasocillary nerve, which will eventually effect the eye.

If they have a red eye.

visual symptoms.

Question 17

Name some reasons for blackouts and its investigations:

Answer 17

Epilepsy - tongue biting, tonic clonic movements, post confusion, prodromal de ja vu, loss of bowel/urine. Refer 2 weeks to neurology for assessment.
Fainting - 3’ps (vaso-vagal) - Pro dromal - hot, sweating, pale, flushing. posture - prolonged standing, provoking factors - pain, medical procedure. - Tilt test.
Carotid sinus - when moving head to the side. first line investigation - carotid sinus massage.
Arrhythmia - feeling or palpitations, gallop beating, ECG, family history of cardiology - refer within 24 hours.
Orthostatic hypotension - medications, dehydration. Worse when standing, relieved by lying down.
Micturition syncope
straining when constipated
unexplained syncope -ambulatory ECG.

Question 18

Dangerous causes of black outs

Answer 18

Neuro - Strokes, haemorrhages
cardiac - MI, arrythmias, cardiac tamponade
GI - Aortic dissection
Resp - PE
Heam - occult bleeding, ectopics, abdominal bleed, rectoperineal bleeding
Endocrine - Addissions disease, hypoglycemia

Question 19

diagnostic investigation for a female patient, 30-40’s with optic neuritis, muscle weakness, and loss of sensation, shock like sensation radiating down their neck Lhermitte’s symptom and ataxia.

Answer 19

Multiple sclerosis note Only a consultant neurologist should make a diagnosis of MS based on McDonald criteria.

MRI scan and lumbar puncture. If these tests show lesions in the central nervous system and oligoclonal bands in your spinal fluid, a diagnosis of MS could be made immediately.

Question 20

what is the Cavernous sinus ?

Answer 20

Spaces located behind each eye socket, under the brain. It is where the jugular vein drains back from the brain to the rest of the body. You can get a thrombis here - which is one swollen eye with the other swelling within 48 hours.

Question 21

how is cavernous sinus thrombosis investigated?

Answer 21

Clinical and CT scan is considered superior to MRI for the detection of early clot formation in the cavernous sinuses,[47] whereas MRI is superior for the rest of the dural venous sinuses.

Question 22

How do you differentiate between aseptic and septic cavernous sinus thrombosis?

Answer 22

FBC - Leukocytosis.

Question 23

Thunderclap headaches peaks between 1-5 mins lasts an hour and have nausea and vomiting, how is this condition diagnoised?

Answer 23

CT head - Hyperdense bleed.

If there is no findings, wait 12 hours them proceed with a lumber puncture.

Question 24

How do you investigate suspected pulmonary TB ?

Answer 24

Chest x ray and 3 sputum samples
spontaneously-produced, deep cough sputum samples
1. early morning sample for acid-fast bacilli
2. Mycobacteria culture
3. specialist molecular tests/drug sensitivity testing, depending on local laboratory protocols.

Question 25

What are the latent tb tests?

Answer 25

Mantoux - more than 5mm it is positive
interferone gamma release assay IGRA - detects TB antigens in the body

If either is positive, after considering BCG (bacillus-calmette - gurein) then treat for latent TB.
Three months of isoniazid (with pyridoxine) and rifampicin, or
Six months of isoniazid (with pyridoxine).