Neurology Flashcards
Management suspected TIA
300mg aspirin OD until diagnosis established (or 14 days) or DOAC if AF
Refer TIA clinic urgently for CT head, carotid doppler
If bleeding disorder urgent CT head
Clopidogrel 75mg OD lifelong
Atorvastatin 80mg
Bloods- FBC, U+E, lipids, LFT, CRP, HbA1c, and random glucose.
INR if on warfarin, or clotting screen if considering DOAC.
ECG, looking for AF or recent MI
Driving advice stroke and TIA
1xTIA must not drive for 1 month but need not notify DVLA.
Multiple TIAs must not drive for 3 months and must notify DVLA. Stroke must not drive for 1 month but may not need to notify DVLA. Driving may resume after 1 month if there has been satisfactory clinical recovery. DVLA does not need to be notified unless there is residual neurological deficit 1 month after the episode and, in particular: visual field defects, cognitive defects, impaired limb function.
Management acute stroke
Admit, 999 if<4.5hrs
Thrombolysis if <4.5hrs
Thrombectomy if <6hrs or wake up stroke
Differentials of TIA
Hypoglycaemia
Migraine aura
Hypotension with or without syncope
Confusion
Isolated vertigo
Partial epileptic seizure
Anxiety
Transient global amnesia
Drop attacks
CFS symptoms
overwhelming physical and mental fatigue and loss of stamina>3 months
Post exertional fatigue
Pain is migratory/widespread
Un-refreshing sleep
Orthostatic intolerance
Ix for CFS
FBC, ferritin, TFT, CRP, U+E, LFT, bone, HBA1c, anti-TTG
If associated with a viral illness: EBV, CMV, HIV
If bacterial infections, inflammatory joint pain, muscle pain, or lupus or vasculitis: immunoglobulins,
ANA, RF, anti-CCP,
CK, cortisol
Treatment CFS
Education, support groups
CFS MDT
Energy management
Graded exercise
If fibromyalgia consider amitriptyline/duloxetine
Increased salt intake, compression socks for POTS
Differentials in CFS
Anaemia
Malignancy (weight loss/night sweats)
OSA (snoring/stopping breathing)
Cardiac (syncope, during exercise SOB)
Autoimmune condition (RF/SLE)
Addison’s
Diabetes
HIV/CMV/EBV
Hypothyroidism
Neuro symptoms to screen for in dementia assessment
Gait, balance, vision, speech and language, Parkinsonism, upper motor neuron symptoms.
Definition of dementia
Progressive impairment 2+ cognitive domains (memory, language, behaviour, or visuospatial or executive function) leading to significant functional decline (enough to affect ADLs) that cannot be explained by another disorder or adverse effects of medication
Behavioural symptoms to ask about in dementia testing
Apathy, sleeping problems, restlessness, agitation, calling out, repetitive behaviour, wandering, socially inappropriate behaviour, aggression, disinhibition, changes in eating and drinking behaviour.
Cognitive symptoms to ask about in dementia testing
Memory, language, insight, judgement, problem-solving, processing speed, concentration and attention, ability to use objects.
ADL impairments to ask about in dementia testing
Continence and toilet hygiene, bathing, eating and drinking, cooking, shopping, dressing, shaving and hair care, socialising, housework, gardening, transport, managing money, employment.
Risks of dementia
Safety in the home, financial mismanagement, wandering, elder abuse, aggression towards others, inappropriate or unwanted sexual behaviour, alcohol and drug misuse, medication adherence issues, dangerous driving, self neglect
Ix for ?dementia
Bloods (FBC U+E LFT, bone, TFTs, B12, folate)
CT head
?syphilis/HIV
Screen of polypharmacy, alcohol/drugs
Referral criteria adult memory impairment
Routine memory team ref unless:
Age<65 with prominent:
psychiatric symptoms or uncertain diagnosis, CMHT
Age>65 prominent psychiatric symptoms or complex challenging behaviour- older adults mental health
Atypical neurological features or uncertain diagnosis, neurology ref
Causes of facial nerve palsy
Bell’s palsy
TIA/stroke (forehead sparing)
Guillain-Barré syndrome
MS
Necrotising otitis externa
Cholesteatoma
Schwannoma (acoustic neuroma)
Ramsay Hunt syndrome (herpes zoster oticus)
Mumps/ Rubella/ EBV/ Lyme disease
Cerebral/parotid/Nasopharyngeal carcinoma
Temporal bone #
Sarcoidosis
TB
Referral criteria Bell’s palsy
Admit if:
bilateral facial nerve palsy.
diplopia, dysphagia, or dizziness.
Urgent ENT if:
LMN palsy + hearing loss, parotid lump or otorrhoea.
If no improvement 3w or not resolved by 3m
Management Bell’s palsy
Prednisolone 60 mg a day for 5 days, then reduce by 10 mg a day for 5 days and stop.
Aciclovir 800 mg orally, five times a day for 7 days.
Lubricant eye drops
Eye taping at night
When can epilepsy be diagnosed?
2+ unprovoked epileptic seizures, >24 hrs apart or
one unprovoked (or reflex) seizure with>60% probability of further seizures, or
identified epilepsy syndrome.
Management seizure
Seizure>5 minutes or recurrent seizures without regaining consciousness (status epilepticus), call 999 and:
buccal midazolam
recovery position
Call 999 if:
concerns about breathing.
serious provoked cause suspected, (stroke, meningitis, trauma
Severe headache persisting more than 1 hour postictally)
Features suggesting seizure verus faint
Seizure:
Cyanosis
Biting of tongue
Postictal myalgia
Prolonged (>10 minutes) confusion
Syncope:
Dizziness
Bilateral spots, darkening
Very rapid (within minutes) recovery
Risk factors for cardiac syncope
Associated palpitations, shortness of breath, or chest pain.
History of cardiovascular disease
Family history of sudden death
Older age
Cardiovascular risk factors
4 most common primary headaches
tension-type headache.
migraine.
medication overuse headache.
trigeminal autonomic cephalgias (including cluster headache).
What should you consider with sudden onset thunderclap headache
Like a blow to the head
Peak pain intensity within 5 minutes
Often occipital
Subarrachnoid haemorrhage
Reversible cerebral vasoconstriction syndrome
Venous sinus thrombosis
Arterial dissection
Raised ICP symptoms
Headache made worse by coughing, sneezing, bending, exertion, lying down, worse in mornings
Vomiting
Features migraine
Nausea, photophobia, phonophobia, or osmophobia with recurrent attacks lasting 4 to 72 hours of headache with:
Unilateral
Moderate to severe
Pulsating
Exacerbated by usual physical activity
20% will have aura: Visual scintillations, scotoma.
Sensory aura-migrating unilateral paraesthesiae spreads over minutes
Features medication overuse headache
10 days/month when taking triptans, opioids, ergots
15 days/month when taking paracetamol, NSAID
Worse on waking
Aggravated by physical exercise
Nausea
Restlessness, anxiety, irritability, and poor concentration
Features cluster headache
Severe unilateral orbital, supraorbital, or temporal pain lasting 15 minutes to 3 hours if untreated.
Occur 1 to 8 times a day.
Ipsilateral conjunctival injection/lacrimation
Nasal congestion or rhinorrhoea
Localised forehead and facial sweating
Constricted pupil or ptosis, eyelid oedema
Restlessness
Headache features requiring 999
First‑ever sudden onset (thunderclap) severe headache, or significant change in character or severity of usual headache.
First‑ever headache with focal neurological signs, confusion, or drowsiness (esp if head injury in last month)
Headache with systemic symptoms of illness, e.g. meningism, rash, or fever.
Speech, limb, or facial weakness.
Management migraine
Ibuprofen 600mg + 1g paracetamol + metoclopramide 10mg (or prochlorperazine)
Sumatriptan, can rpt after 2hrs if effective but wears off
Consider prophylaxis if>2 disabling episodes/month, propranolol/amitriptyline/topiramate
Riboflavin 400 mg
Management menstrual migraine
If predictable, frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg three times a day) from 2 days before until 3 days after bleeding starts.
COCP
Apply a 100 microgram oestrogen patch 3 days before the anticipated onset of bleeding, and leave in place for 7 days.
Cluster headache management
Sumatriptan, 20 mg intranasally at onset or Rizatriptan 10 mg as melt
Oxygen 100% for 10 to 20 minutes helps some patients
Prednisolone 60 mg for 5 days, 40 5 days, 20 5 days, 10 r 5 days then stop to terminate cluster
Prophylaxis: greater occipital nerve block or Verapamil
Features MND
MND progressive neurological disorders causing death within 5 years from respiratory failure and dysphagia
progressive weakness and wasting of the muscles controlling limb movement, speech, swallowing, or breathing.
Features of MS
inflammatory disease of CNS resulting in neurological deficits
2 episodes of demyelination across space and time
MRI demyelinating lesions.
Onset is between age 20 -40
optic neuritits (monocular decrease in visual acuity, colour red fades, pain on eye movement)
Diplopia
Nystagmus
Common MS problems and management
Neuropathic bladder- solifenacin, bladder botox
Spasticity: baclofen, cannabis
Anxiety and depression
Parkinson’s disease features
Bradykinesia
Pill rolling resting tremor, unilateral
Cogwheeling rigidity
Shuffling gait, loss of arm swing
Postural instability
Small handwriting
Mask like face
What should be considered in painful neuropathy?
alcohol dependency
diabetes
porphyria
vitamin B1/ B12 deficiency
Ix for neuropathy
Examination incl tone and bulk, power, reflexes, sensation, proprioception
FBC, CRP, B12, folate, HbA1c, U+E, LFTs, TFTs, protein electrophoresis
Nerve conduction studies
Management painful neuropathy
Amitriptyline 1st line
Gabapentin 2nd line
Capsaicin/lidocaine
Injury prevention and foot care
Name 4 cerebellar signs
nystagmus
dysarthria
ataxia
dysdiadochokinesia (inability to perform rapidly alternating movements)
Name 8 causes of tremor
Essential tremor (FHx)
Parkison’s
Anxiety
Thyrotoxicosis, Cushing’s disease, phaeochromocytoma
Hypoglycaemia.
Salbutamol, caffeine, lithium, Amphetamines, alcohol withdrawal.
Features essential tremor
Bilateral hands, neck, voice
FHx
Worse on movement
Absent at rest
Suppressed by alcohol
Management essential tremor
Avoid caffeine, stress, tiredness
Use wrist weights, heavy cups/cutlery/straw
Propranolol 10-20mg OD-BD
Features trigeminal neuralgia
severe, sharp, lightning, electric, or jolting pain lasting second, episodic facial pain, in the distribution of one or more branches of the trigeminal nerve.
Mostly unilateral.
Infrequent- periods of remission or with a frequency of up to 100x/day Triggered by touching the face, talking, cold wind, vibration, cleaning teeth
Can be symptom of MS
Features of trigeminal neuralgia that hint at underlying condition
Oral/skin lesion that could travel to nerve (eg melanoma)
Autonomic features such as tearing/sweating/injected sclera (cluster headache)
optic neuritis (MS)
Tender temporal area and jaw claudication (GCA)
Management trigeminal neuralgia
Trial carbamazepine 100 mg BD, increase by 100 mg to 200 mg OD every 2 weeks. Continue until pain is relieved. Maximum dose is 1600 mg a day
Use MR if night time symptoms
Seek urgent med advice if fever, sore throat, rash, mouth ulcers, bruising, or bleeding.
If responds after 2-3 weeks, request MRI trigeminal nerves + routine ref neurosurgery
Urgent neurosurgery if disabling/severe/causing malnutrition and not responding
Routine oral surgery if no response carbamazepine
Signs upper motor neurone lesion
Contractures
Increased tone (spasticity/rigidity) +/- ankle clonus
Pyramidal pattern of weakness (extensors weaker than flexors in arms, and vice versa in legs)
Hyperreflexia
Upgoing plantars (Babinski sign)
Signs lower motor neurone lesion
Atrophy
Fasciculations
Reduced tone
Absent reflexes
Downgoing/absent plantars
Symptoms idiopathic intracranial hypertension
Headache worse in the morning, generalized, throbbing
nausea and vomiting
Worse with coughing and sneezing. Pain in neck + shoulders
pulsatile tinnitus
Peripheral visual loss (papilloedema)
Associated with obesity, tetracycline abx long term,
Management IIH
Weight loss, exercise, low salt diet
Acetazolamide
LPs
Surgery/stenting
AMTS-10 Qs?
Age
DOB
Give address (42 West Street)
Time
Year
Address
Monarch
Job roles x2
WW2 started (1939)
20->1
Address from earlier
