Neurology Flashcards
State which nerves and vessels run through the cavernous sinus
Nerves:
- CN3 (oculomotor)
- CN4 (trochlear)
- CN5 (V1 + V2, trigeminal ophthalmic and maxillary sinus)
- CN6 (abducens)
Vessels:
- Internal carotid artery
List the sensory modalities that run along the spinothalamic system
3 modalities:
- Pressure / crude touch
- Pain
- Temperature
List the sensory modalities that run along the dorsal column system
4 modalities:
- Fine touch
- Vibration
- Proprioception
- 2 point discrimination
What investigations are needed if you suspect a peripheral nerve entrapment vs a central (spinal) cause
Peripheral nerve entrapment = nerve conduction studies
Central (spinal) cause = MRI
If you’re not sure, can refer for both nerve conduction studies and MRI +/- blood tests
Cranial nerve 1 - state the following:
- Name
- Aetiology of damage (causes)
- Role of nerve
- Sensory / motor / both
- How to assess
- Presenting features of damaged cranial nerve
Name:
- Olfactory
Aetiology of damage (causes):
- URTI
- Trauma / facial damage
- Anterior cranial fossa tumours
Role of nerve:
- Sense of smell
Sensory / motor / both:
- Sensory
How to assess:
- Cover one nostril and ask about sense of smell
Presenting features of damaged cranial nerve:
- Hyponosmia / anosmia
Cranial nerve 2 - state the following:
- Name
- Aetiology of damage (causes)
- Role of nerve
- Sensory / motor / both
- How to assess
- Presenting features of damaged cranial nerve
Name:
- Optic
Aetiology of damage (causes):
- Any disease affecting optic nerve e.g. optic neuritis, anterior optic neuropathy
Role of nerve:
- Vision
Sensory / motor / both:
- Sensory
How to assess:
1. Snellen chart
2. Ophthalmoscopy
3. Pupil size and response to light
Presenting features of damaged cranial nerve:
1. Blurred or absent vision
2. Evidence of pathology on ophthalmoscope
3. Abnormalities in pupil size or response to light
Cranial nerve 3 - state the following:
- Name
- Aetiology of damage (causes)
- Role of nerve
- Sensory / motor / both
- How to assess
- Presenting features of damaged cranial nerve
Name:
- Oculomotor
Aetiology of damage (causes - ischaemia or compressive):
Microvascular causes
- Microvascular ischaemia (pupil spared)
Compressive causes
- Head injury
- Raised ICP = tentorial herniation
- Aneurysm of posterior communicating artery
Role of nerve:
- Move 4/6 eye muscles
- Pupil size and reflex
- Eyelid position
Sensory / motor / both:
- Motor
- Parasympathetic
How to assess:
- Assess position of eye at rest / eye movements
- Assess position of eyelid at rest
- Pupil size and response to light
Presenting features of damaged cranial nerve:
DOWN and OUT
- Down and out appearance to eye
- Ptosis
- Pupil may / may not be affected (affected if compressive cause)
Cranial nerve 4 - state the following:
- Name
- Aetiology of damage (causes)
- Role of nerve
- Sensory / motor / both
- How to assess
- Presenting features of damaged cranial nerve
Name:
- Trochlear
Aetiology of damage (causes - congenital or acquired):
Congenital
Acquired
- Microvascular ischaemia
- Trauma (thin nerve)
- Tumour
Role of nerve:
- Innervate superior oblique extraocular muscle
Sensory / motor / both:
- Motor
How to assess:
- Assess position of eye at rest / eye movements
- Assess position of head at rest (head tilt)
Presenting features of damaged cranial nerve:
UP and IN
- Up and inward appearance to eye
- May be a head tilt
- Diplopia
Cranial nerve 5 - state the following:
- Name and 3 main branches
- Aetiology of damage (causes)
- Role of nerve
- Sensory / motor / both
- How to assess
- Presenting features of damaged cranial nerve
Name and 3 main branches:
Trigeminal
1. Ophthalmic
2. Maxillary
3. Mandibular
Aetiology of damage (causes):
- Orbital / mandibular fracture
- Tumour in posterior cranial fossa (close to pons)
- Trigeminal neuralgia
- Shingles (in trigeminal distribution)
Role of nerve:
- Sensory to face and scalp
- Motor muscles of mastication
Sensory / motor / both:
- Sensory
- Motor
How to assess:
- Sensory tests on face in 3 areas (sharp and soft)
- Test strength of muscles of mastication
Presenting features of damaged cranial nerve:
- Sensory deficits on face in 3 areas
- Weakness of muscles of mastication
Name the 3 major branches of the trigeminal nerve and which foramen they travel through
- Ophthalmic - superior orbital fissure (via cavernous sinus)
- Maxillary - foramen rotundum (via cavernous sinus)
- Mandibular - foramen ovale (via cavernous sinus)
Cranial nerve 6 - state the following:
- Name
- Aetiology of damage (causes)
- Role of nerve
- Sensory / motor / both
- How to assess
- Presenting features of damaged cranial nerve
Name:
- Abducens
Aetiology of damage (causes):
- Microvascular ischaemia
- Trauma (thin nerve)
- Raised ICP (most commonly affected, steep upward route)
Role of nerve:
- Innervate lateral rectus muscle
Sensory / motor / both:
- Motor
How to assess:
- Assess position of eye at rest / eye movements
Presenting features of damaged cranial nerve:
- Inability to abduct eye laterally to affected side
Cranial nerve 7 - state the following:
- Name
- Aetiology of damage (causes)
- Role of nerve
- Sensory / motor / both
- How to assess
- Presenting features of damaged cranial nerve
Name:
- Facial
Aetiology of damage (causes):
- Parotid disease e.g. parotitis / parotid gland tumour
- Inflammation in facial canal e.g. Bell’s palsy, Ramsey Hunt syndrome
- Damage to petrous bone / lesions around internal acoustic meatus
Role of nerve:
- Innervate muscles of facial expression
- Taste from anterior 2/3 of tongue
- Innervate glands (lacrimal, salivary and nasal)
Sensory / motor / both:
- Motor
- Sensory
- Parasympathetic
How to assess:
- Test muscles of facial expression (raise eyebrows, screw up eyes, blow out cheeks, smile)
Presenting features of damaged cranial nerve:
- Unilateral facial droop
- Inability to carry out facial movements
Outline the difference between Bell’s palsy / facial nerve injury and a stroke, in terms of presentation
Bell’s palsy / facial nerve injury:
- Forehead not spared (CAN’T raise eyebrows)
Stroke:
- Forehead spared (CAN raise eyebrows)
Cranial nerve 8 - state the following:
- Name
- Aetiology of damage (causes)
- Role of nerve
- Sensory / motor / both
- How to assess
- Presenting features of damaged cranial nerve
Name:
- Vestibulocochlear
Aetiology of damage (causes):
- Basal skull petrous bone fracture
- Vestibular schwannoma
- Damage to labyrinthine artery (in a stroke)
Role of nerve:
- Hearing
- Balance
Sensory / motor / both:
- Sensory
How to assess:
- Gross whisper
- Tuning fork testing
Presenting features of damaged cranial nerve:
- Hearing loss
- Vertigo (dizziness)
- Tinnitus
Cranial nerve 9 - state the following:
- Name
- Aetiology of damage (causes)
- Role of nerve
- Sensory / motor / both
- How to assess
- Presenting features of damaged cranial nerve
Name:
- Glossopharyngeal
Aetiology of damage (causes):
- Carotid endarterectomy
- Posterior cranial fossa tumours
- Brainstem lesions
Role of nerve:
- Sensation to oral cavity
- Sensory to posterior 1/3 tongue
- Innervate parotid gland
Sensory / motor / both:
- Sensory
- Parasympathetic
How to assess:
- Gag reflex
Presenting features of damaged cranial nerve:
- Dysphagia
Cranial nerve 10 - state the following:
- Name
- Aetiology of damage (causes)
- Role of nerve
- Sensory / motor / both
- How to assess
- Presenting features of damaged cranial nerve
Name:
- Vagus
Aetiology of damage (causes):
- Recurrent laryngeal nerve (thyroid disease/surgery, superior thorax disease/surgery)
- Posterior cranial fossa tumours
- Brainstem lesions
Role of nerve:
- Innervate larynx / pharynx
- Sensation to larynx / pharynx
- Parasympathetic to many tissues!
Sensory / motor / both:
- Sensory
- Motor
- Parasympathetic
How to assess:
- ‘Ahhh’
- Gag reflex
Presenting features of damaged cranial nerve:
- Dysphagia
- Weak cough
- Hoarse voice
Cranial nerve 11 - state the following:
- Name
- Aetiology of damage (causes)
- Role of nerve
- Sensory / motor / both
- How to assess
- Presenting features of damaged cranial nerve
Name:
- Accessory
Aetiology of damage (causes):
- Posterior triangle lesions/surgery
- Posterior cranial fossa tumours
- Brainstem lesions
Role of nerve:
- Innervate trapezius muscle
- Innervate sternocleidomastoid muscle
Sensory / motor / both:
- Motor
How to assess:
- Shrug shoulders (trapezius)
- Turn head into hands (sternocleidomastoid)
Presenting features of damaged cranial nerve:
- Weakness in shrugging shoulders
- Weakness in turning head into hands
Cranial nerve 12 - state the following:
- Name
- Aetiology of damage (causes)
- Role of nerve
- Sensory / motor / both
- How to assess
- Presenting features of damaged cranial nerve
Name:
- Hypoglossal
Aetiology of damage (causes):
- Posterior cranial fossa tumours
- Carotid endarterectomy
- Brainstem lesions
Role of nerve:
- Tongue movements (speech and eating)
Sensory / motor / both:
- Motor
How to assess:
- Stick tongue out front
- Tongue movements
Presenting features of damaged cranial nerve:
- Tongue deviation out front to affected side (lick your wounds)
- Tongue weakness
Outline which structures the sympathetic and parasympathetic nervous systems innervate in the head and neck
- Eyes
- Glands
- Smooth muscle
Sympathetic nervous system:
Eyes:
- Dilator pupillae
- Superior tarsal muscle
Glands:
- Sweat glands
Smooth muscle:
- Blood vessels
Parasympathetic nervous system:
Eyes:
- Sphincter pupillae
- Cilliary body
Glands:
- Lacrimal
- Salivary
- Mucosal
Smooth muscle:
- Respiratory tract
- GI tract
Outline Horner’s syndrome, including the main 3 features
Horner’s syndrome occurs from pathology in the lung apex or carotid artery (& branches) and disruption to the sympathetic chain
- Leads to autonomic dysfunction and unopposed parasympathetic stimulation
Ipsilateral symptoms:
1. Partial ptosis
2. Miosis (constricted pupil)
3. Anhidrosis
Outline some investigations to do with someone presenting with Horner’s syndrome
- Cocaine eye drops (normally causes pupil dilation)
- CT or MRI head and neck
List some differentials for headaches
Primary:
- Tension headaches
- Migraines
- Cluster headaches
Secondary:
- Intracranial haemorrhage
- Medication overuse
- Raised ICP e.g. tumours
- Giant cell arteritis / TMJ dysfunction / trigeminal neuralgia / acute glaucoma
- Infection e.g. meningitis, encephalitis
- Referred pain from H&N pathology e.g. otitis media, tonsillitis
- Hypoxia e.g. carbon monoxide poisoning
List some differentials for seizures (fits) / convulsions
- Epilepsy
- Non-epileptic attack
- Vasovagal syncope
- Electrolyte disturbances e.g. hypoglycemia, hypocalcemia
- Acute toxic effects e.g. antidepressant overdose
- Acute withdrawal e.g. Ethanol, Benzodiazepines
- Sepsis
- Increased ICP e.g. malignancy, hydrocephalus
- Febrile seizures
List some differentials for an unconscious patient (structural / systemic / psychogenic)
Structural:
- Trauma / traumatic brain injury
- Cerebrovascular disease
- Tumours / malignancy
- Infection / inflammation e.g. meningitis
- Haemorrhages
Systemic:
- Seizures
- Intoxication e.g. alcohol, illicit drug use
- Metabolic causes e.g. hypoglycaemia, electrolyte abnormalities, hepatic encephalopathy
- Adrenal crisis
- Neuroleptic malignant syndrome
Psychogenic:
- Catatonia
- Severe depression
- Non-epileptic attacks
List some differentials for a sudden loss of consciousness
Vascular:
- Stroke (ischaemic or haemorrhagic) / TIA
- Cardiac arrest / arrhythmias
- Volume depletion e.g. blood loss, anaphylaxis
Infection:
- Meningitis / encephalitis
- Sepsis
Neoplasm / neurological:
- Vasovagal response
- Migraines (associated with syncope in some people)
- Epilepsy
- Non-epileptic attacks
Drugs:
- Intoxication
Trauma
Endocrine:
- Hypoglycaemia
Briefly describe a coma and signs of impaired consciousness
A coma is a profound and occasionally extended state of unconsciousness
Signs of impaired consciousness:
- Reduced alertness
- Diminished wakefulness
- Decreased awareness of oneself and environment
List some differentials incoordination, gait disturbance and impaired balance
Neurological:
- MS
- Cerebral palsy
- GBS
- Stroke (posterior circulation)
- Cerebellopontine angle lesions
- Space-occupying lesions
- Neurodegenerative e.g. Parkinson’s disease, dementia, amyotrophic lateral sclerosis
Other:
- Alcohol / drugs / medications e.g. alcohol, Lithium
- Infectious e.g. neurosyphilis
- Metabolic e.g. B12 deficiency, Wilson disease, secondary to peripheral neuropathy
List some differentials for generalised hypokinesia (reduced movements)
Parkinsonism
Catatonia
Psychomotor depression
Arthritis
Hypocalcaemia (dystonia)
(not 100% sure)
List some differentials for hyperkinesia (increased movements)
Epilepsy
Tics, such as Tourette syndrome
Essential tremor
Huntington’s disease (chorea)
Functional movement disorder
(not 100% sure)
List some differentials for focal neurological weakness
Local:
- Nerve / tissue injury
- Disorders of a single nerve or nerve group e.g. carpal tunnel syndrome
- Spinal root entrapment
- Spinal cord compression
Neurological / systemic:
- Degenerative nerve illness e.g. MS
- Infections e.g. meningitis or encephalitis
- Stroke / TIA
- Brain tumor
- Cerebral palsy
List some differentials for generalised neurological weakness
Diseases:
- Myasthenia gravis or Lambert-Eaton syndrome
- Hereditary muscle disorders e.g. muscular dystrophy
- Polymyositis or dermatomyositis
- Deconditioning due to inactivity (disuse atrophy)
- Sepsis / severe illness
- Critical illness myopathy / paralytic agents in critical care
- Electrolyte abnormalities e.g. hypocalcemia
- Common myopathies e.g. alcohol myopathy, corticosteroid myopathy
List some differentials for speech, swallow or language problems
- Trauma e.g. brain injury e.g. hypoxic brain injury
- Infection e.g. epiglottitis, tonsillitis, GORD
- Neoplasia e.g. tumors / malignancy
- or neurological e.g. degenerative neurological diseases e.g. ALS, MS, MND and Huntington disease, bulbar palsy, neuromuscular disorders e.g. muscular dystrophy
- Drugs e.g. intoxication, anti-muscarinics
- Endocrine?
- Vascular e.g. stroke / TIA
- Reduced conscious level
- Autism spectrum disorder
List some differentials for urinary incontinence
Urological:
- Urge / stress incontinence
- UTI
- Prostatitis
Neurological:
- Spinal cord damage e.g. cauda equina / spinal cord compression
- Spina bifida
- MS / Parkinson’s disease
- Stroke / TIA
- Hydrocephalus
- Diabetes
List some differentials for faecal incontinence
Gastro:
- Trauma / surgery to anal sphincter
- Overflow constipation
- IBD / IBS / chronic diarrhoea or constipation
- Severe haemorrhoids / rectal prolapse
- Congenital problems e.g. Hirschprung’s disease or anal atresia
Neurological:
- Spinal cord damage e.g. cauda equina / spinal cord compression
- Spina bifida
- MS / Parkinson’s disease
- Stroke / TIA
- Hydrocephalus
- Diabetes
List some differentials for reduced cognition
Neurological:
- Alzheimer disease
- Stroke
- Parkinson disease / Huntington disease
- MS
- Lewy body dementia
- Tumour / malignancy
Other:
- Developmental disorders e.g. Down syndrome
- Severe depression / anxiety / catatonia
- Delirium
- Head injury
- Meningitis
- Sepsis
- Intoxication e.g. alcohol, drugs, toxins
- Wernicke Korsakoff syndrome
List some differentials for behaviour or personality change
Organic:
- Stroke
- Tumour / malignancy
- Dementia
- Postictal (after seizure)
- Meningitis / encephalitis
- Sepsis (hallucinations)
- MS / Parkinson’s / Huntington’s
Non-organic:
- Pain / tiredness
- Delirium
- Metabolic causes e.g. hypoglycaemia
- Severe depression / anxiety / catatonia / bipolar
- Intoxication e.g. alcohol, illicit drugs or withdrawal
List some differentials for neuropathic pain syndromes (central, peripheral, mixed)
Central:
- After spinal cord injury
- After stroke
- MS
Peripheral:
- Painful neuropathy e.g. diabetic neuropathy, post-chemotherapy neuropathy
- Radiculopathy
- Injury to nerve itself (trauma)
- Nerve compression e.g. carpal tunnel syndrome
- Post-surgical e.g. post-mastectomy, post-thoracotomy
Mixed:
- Complex regional pain syndromes
- Chronic back pain
- Cancer-related pain
Describe neuropathic pain and list some positive features and negative features of neuropathic pain
Neuropathic pain = painful condition caused by neurological lesions or diseases
Positive features = extra sensation perceived by the patient
- Pain
- Paresthesia
- Numbness
- Tingling
Negative features = loss of functions
- Sensory deficits
- Motor deficits
- Cognitive deficits
List some differentials for sensory disturbances
Metabolic:
- Diabetes mellitus
- Vitamin B12 / folate deficiency
- Nutritional deficiencies
Immune-mediated:
- SLE
- Sarcoidosis
- Sjögren syndrome
- Coeliac disease
Toxic:
- Chemotherapy
- Drug-induced
- Alcohol
Hereditary:
- Ehlers-Danlos syndrome
- Haemochromatosis
Infectious:
- Syphilis
- Leprosy
- HIV
Other
- Idiopathic
- Fibromyalgia
- Vasculitis
List some differentials for transient motor and sensory disturbances
- TIA
- Seizure
- Raised ICP
- Migraine (with aura)
- MS
- Electrolyte abnormalities
- Psychiatric disorders e.g. panic disorder, schizophrenia
List some potential causes of ICP
Vascular:
- Aneurysm
- Intracranial haemorrhage / stroke
- Hydrocephalus
Infection:
- Meningitis / encephalitis
- Intracranial abscess
Neoplasm / neurological:
- Tumours
Trauma:
- Head trauma
Outline how raised ICP can present
- Headache
- Diplopia / blurred vision
- N&V
- Behavioural changes
- Reduced conscious level
- Seizures
Cushing’s triad: bradycardia, hypertension, irregular breathing
Outline some initial investigations and first line management steps for raised ICP
Investigations:
- Fundoscopy (optic disc swelling)
- CT / MRI head
Management:
- Elevate head to 30 degrees
- IV Mannitol or hypertonic saline
- Neurological observations every 15 mins
- Involve seniors and contact ICU
Outline how a subarachnoid haemorrhage can present
- Thunderclap headache during episode of strenuous activity
- Neck stiffness
- Photophobia
- N&V
- Neurological symptoms e.g. visual changes, dysphasia, focal weakness, seizures, reduced consciousness
Outline some initial investigations and first line management steps for subarachnoid haemorrhage
Investigations:
- CT head within 6 hours of headache onset (hyper-attenuation in the subarachnoid space), after 24 hrs the sensitivity significantly reduces
- Consider lumbar puncture after 12 hours (raised RBC count and yellow colour from bilirubin)
- CT angiography later to confirm site of bleeding
Management:
- Oral Nimodipine 60mg 4 hourly (prevent vasospasm)
- Elevate head
- Hourly neuro observations
- Reverse any anticoagulants
- Analgesia / antiemetics
- Refer for neuro bed and discuss with neurosurgeons
List some causes of subarachnoid haemorrhage
70% = berry aneurysms
10% = HTN
10% = AV malformation
5% = idiopathic
+ trauma
Outline how meningitis / encephalitis can present
- Fever
- Non-blanching purpuric rash if bacterial meningitis
- Headache, stiff neck, photophobia
- N&V
- Reduced conscious level
- Seizures
Outline some initial investigations and first line management steps for meningitis / encephalitis
Investigations:
- FBC, U&E, glucose, LFT, CRP, clotting, lactate
- Blood cultures, throat swab and skin swab
- Meningococcal and pneumococcal PCR
- Lumbar puncture (CT head first if signs of brain shift)
Management:
- Isolate patient
- IV Ceftriaxone 2g immediately and continued every 12-hours initially
- If bacterial suspected, also give IV Dexamethasone 10mg every 6 hours
- Intravenous fluids and oxygen if required
- Inform public health
Outline the recognised definition of status epilepticus
- Over 5 minutes of single continuous seizure
- OR 2 or more discrete seizures between which there is incomplete recovery of consciousness
Outline some initial investigations and first line management steps for status epilepticus
Investigations:
- Take bloods when gaining access (FBC, U&Es, LFTs, bone profile, magnesium, CRP, VBG, coagulation)
- CBG
- Bloods for levels of any anti seizure medications
Management:
- Early involvement senior staff
- Secure airway and high flow 15L O2
- Immediate IV access
- After first 5 mins, IV Lorazepam (or buccal Midazolam)
- If continuing after next 5 mins, IV Lorazepam 2nd dose
- If continuing after next 5 mins, IV Phenytoin
- Call 2222
List some aftercare management steps post-status epilepticus (and investigations)
- Place in recovery position
- Monitor for respiratory depression, wean off O2
- Give anti-epileptic to prevent seizure recurrence (Levetiracetam, Sodium valproate or Phenytoin)
Investigations:
- Investigate any injuries e.g. shoulder dislocations
- Consider CT head
Request specialist neurology assessment - same/next day
Outline 2 diagnostic indicator assessment that can be used for suspected stroke
FAST test (community idenitifiation)
Face
Arm
Speech
Time (act fast and call 999)
The ROSIER scale = Recognition Of Stroke In the Emergency Room
- Score based on the clinical features and duration
- Stroke is possible in patients scoring 1 or more
Outline some initial investigations an acute stroke
Investigations:
- CT head
- Bloods (FBC, clotting profile, INR, U&Es, LFTs, CRP, bone profile, creatine kinase, lipids, TFTs, magnesium, HbA1c and HIV serology)
- CBG
- ECG (atrial fibrillation)
Outline first line management steps for an acute stroke of the following categories
- TIA
- Minor ischaemic / TIA
- Major ischaemic
- Haemorrhagic
General:
- A-E assessment (ensure patent airway, O2 sats and haemodynamically stable)
- Transfer to stroke unit
- Urgent non-contrast CT head
- Give Aspirin 300mg (if not haemorrhagic)
TIA:
- Aspirin 300 mg oral loading dose
- Clopidogrel 600mg oral loading dose
- Diffusion-weighted MRI scan
= can be managed in community with TIA clinic
Minor ischaemic:
- Aspirin 300 mg oral loading dose
- Clopidogrel 600mg oral loading dose
+ subsequently lifestyle advice
= can be managed in community with minor stroke clinic
Major ischaemic:
- IV thrombolysis with Alteplase if within 4.5 hours (Aspirin 300mg loading dose if thrombolysis contraindicated)
- Consider surgical thrombectomy (proximal anterior circulation or proximal posterior circulation)
Haemorrhagic:
- Reversal of any anticoagulation (anticoagulants, antiplatelets, NSAIDs)
- Lower BP to 140mmHg if high
- Consider surgical management
Outline some initial investigations and first line management steps for cauda equina / spinal cord compression
Investigations:
- Bloods (FBC, U&Es, LFTs, CRP, Group & Save, clotting screen)
- Urgent whole spine MRI
Management:
- IV access
- Analgesia
- Urgent surgical decompression (chemotherapy/radiotherapy or steroids in malignant cord compression)
Outline some initial investigations and first line management steps for head trauma
Approach depends on GCS score = blue light to Nottingham if GCS < 9
Investigations:
- CT head (based on risk factor list)
Management:
- Stabilise neck if indicated
- Regular neuro obs
- Analgesia / antiemetics
- Consider reversing anticoagulation / consider tranexamic acid
- Consider referral to neurosurgeons
Outline how acute respiratory distress can present
Acute onset (within 1 week)
- Dyspnoea
- Tachypnoea
- Tachycardia
- Reduced O2 sats
Outline some initial investigations and first line management steps for acute respiratory distress
Investigations:
- O2 sats
- ABG
- Chest x-ray (bilateral opacities)
- Sputum culture / blood culture
Management:
Supportive control e.g. preventing DVT
- High flow O2 15L
- Consider prone positioning
- Mechanism ventilation with low tidal volume
- Antibiotics if suspect bacterial cause
Giant cell arteritis (GCA) - state the following:
- Pathophysiology
- Typical patient
- Presentation
- Investigation
- Management
Pathophysiology:
- Systemic vasculitis affecting medium and large arteries
- Key complication is vision loss, is often irreversible
Typical patient:
- Over 50
- Caucasian female
- Strong association with polymyalgia rheumatica
Presentation:
- Severe unilateral temporal headache
- Scalp tenderness
- Jaw claudication
- Vision changes (blurred or double vision)
- Systemic symptoms e.g. fever, muscle aches, fatigue, loss of appetite
- Temporal artery can be tender or thickened +/- reduced pulsation
Investigation:
- Bloods including ESR
- Temporal artery biopsy (multinucleated giant cells)
- Duplex ultrasound (“halo” sign and stenosis of the temporal artery)
Management:
- High dose steroids!!
no vision loss = Prednisolone
vision loss = Methylprednisolone
- Daily Aspirin (reduce vision loss and stroke risk)
If vision changes - same day referral to ophthalmologist
If no vision changes - discuss with specialist and refer using GCA fast-track pathway
Continue on steroids until symptoms have resolved, can take years
List some complications of giant cell arteritis (including complications related to medications)
- Vision loss (often irreversible)
- Stroke
Steroid-related complications e.g., weight gain, diabetes and osteoporosis
Bulbar palsy - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Impaired function of cranial nerves (CN9, 10, 11 and 12)
- Variety of causes which damage the bulbar aspect of the brainstem
- Progressive or non-progressive
Presentation:
- Dysphagia, absent gag reflex, difficulty chewing, drooling
- Dysphonia, dysarthria, slurred speech
- Atrophy of tongue, jaw muscles, facial muscles
- Aspiration e.g. aspiration pneumonia
Investigations:
- MRI (for stroke / tumour)
- Lumbar puncture and CSF analysis (MS)
Management:
If acute presentation, secure airway (A-E approach)
No known treatment, supportive measures:
- Medications for drooling
- NG tube / feeding tube for swallowing difficulties
- Speech and language therapy
Outline the main causes of bulbar palsy
- Brainstem stroke
- Brainstem tumours
- Guillain Barre syndrome
- Various genetic conditions
State the 3 parameters that doing the ‘Romberg’s test’ will test
- Vision = removed during the test
- Proprioception
- Vestibular function (inner ear)
If abnormal test, do Unterberg’s test where the patient marches (removing proprioception) to decide whether there is an issue with proprioception or vestibular function
If damage to vestibular system, will turn torwards side of the lesion
For the following brain arteries, state what areas of the brain they supply
- Vertebral arteries
- Pontine arteries
- Lenticulostriate arteries
- Posterior cerebral arteries
- Middle cerebral arteries
- Anterior cerebral arteries
Vertebral/basilar arteries
- Anterior 2/3 of spinal cord
- Cerebellum
- Midbrain
Pontine arteries (branch off basilar artery):
- Pons
Lenticulostriate arteries = deep nuclei:
- Basal ganglia
- Internal capsule
Posterior cerebral arteries = posterior areas:
- Occipital lobe
- (inferior) temporal lobe
- Midbrain and thalamus
Middle cerebral arteries = lateral areas:
- (lateral) frontal lobe incl. primary motor cortex
- (lateral) parietal lobe incl. somatosensory cortex
- (superior) temporal lobe
Anterior cerebral arteries = medial areas:
- (medial) frontal lobe
- (medial) parietal lobe
- Corpus callosum
For upper motor neurones lesions, state the results for the following (increase or decrease):
- Muscle mass
- Muscle strength
- Muscle tone
- Reflexes
- Fasciculations (present/not present)
Muscle mass = mildly decreased
Muscle strength = mildly decreased
Muscle tone = increased (spasticity)
Reflexes = increased (hyperreflexia)
Fasciculations (not present)
For lower motor neurones lesions, state the results for the following (increase or decrease):
- Muscle mass
- Muscle strength
- Muscle tone
- Reflexes
- Fasciculations (present/not present)
Muscle mass = significantly decreased
Muscle strength = significantly decreased
Muscle tone = decreased (flaccid)
Reflexes = decreased (hyporeflexia)
Fasciculations (present)