Neurology Flashcards
Signs of Parkinsons
- Resting tremor
- Micrographia
- Mask life facies
- Limb bradykinesia
- Asymmetrical reduced arm swing
- Reduced step height
Classes of drugs for parkinsons
1st line
Levodopa (and dopa-decarboxylase inhibitors
= Levodopa/carvidopa
2nd line
Dopamine agonists
= Pramipexole
= Rotigotine (patch)
Other
MAO-B inhibitors
= Rasgiline
Consider in mild symptoms
Anticholinergics
=Benztropine
Good for resting tremor
Dose of Levodopa/carbidopa
or Levodopa/benserazide
50+12.5mg TDS
Increasing to 100mg+25mg TDS
Dose of Pramipexole (modified release)
Once day dosing!!
0.375mg
(Max 4.5mg)
Benefit of dopamine agonists in parkinsons
Cautions
Once day dosing!
Careful for impulse control issues: gambling, etOH, hypersexual
Side effects of parkinson’s medications
- Nausea
- Orthostatic dizziness
- Somlonence
Dopamine agonists: impulse control, hallucinations
Anticholinergics: confusion, dry mouth, urine retention, dry eye, constipation
Dementia pharmacology:
1st line:
Donepezil 5mg nocte (max 10mg)
Galatamine 8mg mane
Rivastigmine patch 4.6mg
OR for SEVERE /not tolerating Acetylcholinesterase inhibitors
Memantine 5mg daily (max 20mg)
Trigeminal neuralgia pharmacology
Carbamazepine MR 100mg BD
Up to 400mg BD
TIA investigations
CT angiography
Carotid artery doppler US
or MR angiography
Painful peripheral neuropathy pharmacology
1st line:
Amitriptyline 25mg nocte (up to 150mg)
Complex partial seizure features
Temporal lobe epilepsy
- Slight perceptual disturbance ( could still do simple task or drive a car)
- Hallucination: smell, sound, visual
Simple partial seizure features
NO loss of consciousness
Jerking movements at angle of mouth or in the thumb and finger- then become bigger to involve the rest of the body.
Narcolepsy treatment
Modafinil 200mg mane
Or mane 100mg, midday 100mg
Distinguishing between labyrinthitis and vestibular neuronitis
Labyrinthitis affects whole inner ear & would have tinitis and hearing loss also
Not just vertigo (and n/v)
Parietal lobe tumour features
Seizures
Impaired: handwriting, numbers, maths
Certain movements
Smell and touch issues
Frontal lobe tumour features
Personality change
Intellectual impairment
urinary incontinence
Hemiparesis
Occipital lobe tumour
Visual field defect
Visuospatial defect
Bell’s Palsy treatment
Prednisolone 75mg 5 days
add Valaciclovir if vesicles present
Definition/features of Mononeuritis Multiplex
- Painful, asymmetrical, asynchronous sensory and motor peripheral neuropathy involving 2 separate nerve areas
Idiopathic intercranial hypertension investgiations
MRI (to exclude SOL)
Lumbar puncture (opening pressure raised >25cmH20)
Idiopathic intercranial hypertension treatment
- Acetazolamide 250mg BD
Increase to 500mg QID as tolerated - Weight loss
Idiopathic intercranial hypertension DDx to rule out
- Space occupying lesion
- Venous sinus thrombosis/obstruction
- Medication induced: Isotretinoin and tetracyclines
Cerebellar signs
- Wide based gait
- Intention tremor
- Dysdiadochokinesis
- Imbalance
- Coordination of complex tasks
Dementia work up (routine (8) and recommended (7))
Routine
- FBC
- ESR
- LFTs
- EUC (ca)
- TSH
- B12,
- Folate
- CTB
Recommended
- CXR
- Fasting BSL
- Fasting lipids
- Fasting homocystine level
- ECG
- MSU
- Serology; HIV & syphilis
Pre-hospital management of suspected meningitis
Obtain blood cultures if possible
ABX:
1) Ceftriaxone 2g (50mg/kg) IV or IM
1) Benzylpenicillin 2.4g (60mg/kg) IV or IM
Features suggestive of Multiple Sclerosis
- Optic neuritis
- Lhermitte sign (shooting pain with neck flexion)
- Internuclear ophthalmoplegia (diplopia)
- Fatigue
- Heat sensitivity (Uhthoff phenomenon)
- Unilateral facial or limb sensory loss
- Subacute motor weakness
Triad for Wernicke’s Encephalopathy
Encephalopahthy
Occulomotor dysfunction
Gait ataxia
Essential tremor management
Propanolol 10mg BD
up to 160mg in 2 divided doses
Damage /tumour in Temporal lobe
- Receptive aphasia
- Difficulty recognising faces
- Emotional disturbance (aggressive behaviour)
- Difficulty identifying objects
Acute migraine treatment (first line agents)
NSAID:
- Aspirin 900mg
- Ibuprofen 400mg
TRIPTAN
- Sumatriptan 50 to 100 mg. Wait 2 hours before repeating dose
Non- pharmacological migraine management
- Cool packs to forehead or back of head
- Heat pack to neck
- Quite dark room
- Regular sleep schedule
- Avoid triggers (chocolate, citrus, MSG)
- Hydration (1.5-2L)
- Limit caffeine
Migraine prophylaxis
- Amitriptyline 10mg
- Candesartan 4mg
- propanolol 20mg (avoid in asthma)
- Topiramate 25mg
Medication overuse headache management
- Gradually wean opioids and triptans
- Bridge with Naproxen MR 750mg daily for 5 days in first week then wean
Trigeminal neuralgia pharmacological management
Carbamazepine 100mg BD
Trigeminal neuralgia clinical features
- Trigeminal distribution: V2 V3 more common
- Paroxysmal electric shock /stabbing nature of pain
- Unilateral
- Tigger zones
- Brought on by innocuous stimuli (wind, light touch)
- Autonomic symptoms: unilateral lacrimation, conjunctival injection, rhinorrhoea
Agitation in aged care pharmacology
Risperidone 0.25mg BD PRN
Acute dystonia management
HINT: Single agent
Benztropine 1mg IM or IV
Childhood Absence Epilepsy features
1. Onset age
2. How long seizures for
3, EEG findings
- 4-10yrs
- 2-20 secs (tens per day)
- Generalised rhythmic spikes or double spike wave discharges ~3Hz
Cluster headache features
(gender predominance, frequency & duration of attack, etOH trigger)
Also other features
- M> F
- up to 8 daily
- 15-180 minutes
- SEVERE (called suicide headache)
- yes etOH Trigger
Tearing, conjunctival injection, Fullness of the ear, tinnitus
Agitation, restless
First line agent for PREVENTION of cluster headache management and caution for this
Verapamil IR 80mg TDS
for 2 weeks titrate up to 160mg TDS
HEART BLOCK
must do ECG before every dose increase
- PR interval & severe bradycardia
**increase dose every 2 weeks
First line agent for ACUTE treatment of cluster headache (2 agents)
Sumatriptan 6mg subcut
High flow oxygen 100% 15L tight fitting non-rebreather 15-20mins then stop
3 questions for assessing falls risk
- More than 2 falls in last 12 months
- Presenting following a fall?
- Difficulty with walking or balance?
Causes for muscle weakness (and fatigue) in upper limbs
- MND
- Cervical myelopathy
- MS
- Inclusion body myositis (distal weakness)
- Thyrotoxicosis
- B12 deficiency
- Myasthenia gravis (more proximal weakness)
Exam findings in MND/ALS
- Brisk reflexes in a wasted limb
- Split hand sign
- Fasciculation
- Dysarthria/dysphagia
Peripheral neuropathy differentials
- Diabetic neuropathy
- B12 Deficiency
- Paraproteinuria
- Peripheral vascular disease
- Idiopathic
- Restless leg syndrome
- Hypothyroidism
- Alcohol related peripheral neuropathy
- Medication: Amiodarone, metronidazole
Post TIA/CVA carotid artery stenosis cut off for end arterectomy?
> 70% (ipsilateral)
Marginal for 50-69%
Post stroke: antiplatelet therapy
Aspirin 100mg daily
OR
Clopidogrel 75mg daily
OR
Dipyriamole MR + Aspirin 200 + 25mg BD
**
DAPT could be good 3 weeks -3 months post but not strictly in guidelines
Status Migrainosus
Sumatriptan 6mg subcut
Tension headache prophylaxis
Amitriptyline 10mg nocte increasing up to 75mg
Bell’s Palsy exam findings
- Decreased tearing from eye
- Vesicles
- Loss of taste anterior 2/3 tongue
- Hyperacusis
- Drooling
Bell’s Palsy treatment
- Pred 75mg (1mg/kg)
- artifical tears
- review 3-4 weeks
- MRI if not improved in 4 months
- Valaciclovir 1g 8hourly 7d
TIA driving exclusion period (private and commercial)
- 2 weeks
- 4 weeks
Peripheral neuropathy ‘Burning foot” differentials
- Peripheral vascular disease
- B12 deficiency
- Tarsal tunnel syndrome
- Reynauds
- Diabetic nephropathy
- Chilblains
- hypothyroidism
- etoH
- Complex regional pain syndrome
- Chemotherapy
3Hz wave and spike EEG - type of seizure
Absence seizure
What medications can you NOT use in parkinsons (cautions)
Metoclopramide
Prochlorperazine
Migraine in children pharmacology
1st line: ibuprofen 10mg/kg up to 400mg
TRIPTAN
1st line: Sumatriptan 10-20mg IN (repeat 2 hrs)
if nausea:
Ondansetron: 0.1mg/kg up to 8mg orally
Cluster headache prevention (pharmacology)
Verapamil IR 80mg TDS increasing to 160mg TDS
Dementia NON-pharmacological considerations
- My aged care assessment
- Enduring guardian
- Advanced care directive
- Legally needs to inform RMS of diagnosis
- Home medication review
- Dementia australia website
- Maintain social activities
- Exercise for 30 mins most days
Differentials for limb weakness
- MND
- MS
- Chronic inflammaotry demyelinating neuropathy (CIDP)
- Radiculopathy (myeloradiculopathy)
- Myositis
- B12 deficiency
- Thyrotoxicosis
- Lead poisoning
- Myesthenia gravis
- Space occupying lesion
- Bulbar palsy
Post stroke use of DAPT? Time frame
- Endorsed by stroke foundation for 3 weeks of DAPT
