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A PACES > Neurology > Flashcards

Neurology Flashcards

1
Q

Seizure history

A

Before
-Prodromal
- Infective causes eg Headache Fever
- D&V -> electrolytes
- Drug use / alcohol
- Sleep deprivation (especially new presentation in students)
- Stress
- Blood sugars
- Any headaches with vomiting
- Head trauma

During
- Collateral
- Stiff and rigid (vs floppy and flaccid) followed by rhymic movements
- tongue biting - LATERAL
- faecal incontinence

After
- Any immediate first aid
- Post ictal at least several minutes
- Weakness (tods paresis)

PMH
- Known seizures
- Malignancy - breast renal melanoma
- Immunosuppression (infection)

Meds
Meidcation compliance
recent abx - cipro
Clozapine
Anticoagulants

Social
Profession building / HGV
Driving
Alcohol

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2
Q

Difference in prodrome of vagal vs seizure

A

Vagal
- Nausea, tunnel/darkening vision, tinnitus

Seizure
- Flashing lights, blurring of vision (rather than dimming)
-Smell or taste
- Numbness tingling

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3
Q

What is tods pareisis how long does it last

A

Unilateral weakness post seizure - often 48hrs

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4
Q

2 most common cancers mets to brain

A

Breast
RCC clear cell
melanoma

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5
Q

no driving with epilepsy / seizure?

A

1 year seizure free
6 months post 1st seizure

Ultimately case by case up to DVLA

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6
Q

What should you advice people who may have had a seizure and work eg on building site

A

Need to contact their occupational health department

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7
Q

seizure exam

A

Look
- Moth and tongue
- Head, neck, shoulder injuries

Focal signs eg SOL
- Visual fields
- Eye movements
- Pronator drift
- Gait
- Tone and power

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8
Q

What are the causes of seizures you should present and explain to examiner why / why not in this case?

A

Genetic

Structural
- SOL
- Trauma Bleeding
- CVA in elderly

Infective
- TB Malaria HIV
- Meningitis

Metabolic
-Uraemia
- Heaptic encephalopathy
- Low sodium

Autoimmune

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9
Q

Investigations first seizure

A

Baseline obs
- Temp
- LS BP
- Finger prick glucose

Bloods
FBC / CRP
Renal function
Electrolytes
LFTs - alcohol excess

CT head - any SOL

EEG

1st seizure clinic

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10
Q

Advice for new epilepsy

A

Work
- Any changes
- Occy health

Driving
- No driving until 1 year seizure free

Activities
- Shouldn’t stop doing things they enjoy but may need to modify
- No swimming alone
- High level climbing eg roofer

Shower rather than bath

Mothers
- Breast feeding -ideally sat on floor
- Changing baby.- floor mat

Pregnancy and contraception
- Contraception effects on meds (COCP)
- Barrier methods
- May need to change siezure meds
- Folic acid for at least 3 months before ( neural tube defects)
- If only option is valproate - should be on pregnancy prevent program

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11
Q

Anti epileptics in pregancy

A

Aim for single medication at lowest dose
Lamotrigine / Leveteracitam for labias

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12
Q

Difference between optic neuopathy and atrophy

A

Neuropathy - Optic nerve not working

Atrophy - Permanent damage to optic nerve

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13
Q

Optic neuritis history

A

Describe whats happening

Time period

Both eyes or one?

Look like looking through frosted glass - Blurred vision
Or seeing 2 of everything - double vision
Loss of visual field

Any issues with acuity?
Colour vision - RED - difference between eyes?
Pain?

intermittent vs constant

Issues when cough or bend over = IIH
Pulsatile tinnitus

Any issues post hot shower / bath

Been to opticians?

PMH
Currently pregnant?
Migraine
Any eye problems / glassess
Vascular risk factors

Meds

Social

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14
Q

How does time scale relate to the aetiology of vision loss

A

Months - inherited

Weeks - possibly malignant

Days - Inflammatory

sudden - Vascular

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15
Q

ADD IN Visual tract symptoms to field defect

A
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16
Q

Curtain coming down over vision =

A

Amaurosis fugax

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17
Q

GCA causes what type of optic neuritis

A

Anterior ischemic

  • vascular
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18
Q

Visual field disturbance time period of 20 mins with headache most likely

A

Migraine

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19
Q

Visual symptoms when getting out of hot bath

A

Uhthoff’s phenomenon

[Due to bodys repair of myelin sheath not being as strong
- Doesn’t cause long term damage

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20
Q

Groups of causes of optic neuropathy

A

Ischemic - More likely in older vascular
- GCA - arteritic
- Micovascular - risk factors

Inflammatory
- More likely in younger

Infiltrative
- Sarcoid

Nutritional
- carb only
- Slow progressive symmetrical
- Thiamine, A, E, Folate

Methanol poisoning

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21
Q

What is added to mri scan in MS

A

Gadolinium

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22
Q

Pregnant patient with rapidly progressive optic neuritis

A

Nerve sheath meningioma
- hormone sensitive

23
Q

Key sign on exam of optic neuritis

A

RAPD

24
Q

What is Leber’s optic atrophy?

How does it present?

A

Visual loss both eyes
Or sequentially (12 months) of both eyes

Central visual loss only
- Cant read chart but good peripheral vision

25
Q

Optic neuritis exam

A

Measure acuity - snellen

Quick test of colour vision - red in each eye
Ishihara plates

Visual field - finger counting in 4 quadrants (1 or 2)

RAPD

**State examination with slit lamp + dilating drops

Complete and full systematic neuro exam

26
Q

How to assess RAPD ?
What is normal?
What is abnormal?

A

In a dimly lit room, have the patient look at a distant point.

Shine a light into one eye for about three seconds.

Quickly move the light to the other eye and observe the pupils.

Repeat the steps a few times to confirm your findings.

A normal response is when both pupils constrict equally when light is shined into each eye individually. When the light is moved between the eyes, the pupils should not dilate or escape.

If the pupil dilates when the light moves from one eye to the other, a RAPD is present. This indicates that there is a difference in the afferent pathway between the two eyes.
[Supported if the good pupil constricts when light goes back to it]

27
Q

Fundoscopy of optic neuropathy vs atrophy q

A

Neuropathy - swollen

Atrophy - Pale

28
Q

Optic neuritis investigations

A

Vitamin D
ESR and CRP - giant cell

Consider aquaporin 4 and MOG antibodies - atypical eg neuromyelitis optica

Imaging
Orbital MRI
- longer section of signal uptate in optic nerve suggestive of atypical

[If compressive MRI brain]

Sampling
Consider LP for oligoclonal bands

If history of sarcoid
-Consider serum ACE
- CT CAP

Referral to neuroophthalmologist

29
Q

Treatment optic neuritis

A

Typical - consider steroids
-> Plasmapheresis

30
Q

What happens in atypical optic neuritis when you stop steroids

A

Gets worse again

31
Q

Risk of MS if typical optic neuritis

A

about 50% in 15 years

32
Q

TIA max length

A

24 hours

33
Q

TIA history

A

What was going on

Motor / sesnsory
- How fast, how long
- Should be sudden onset but may wear off gradually

Speech
- Hard to get words out
- Difficulty understanding words - dysphasia

Vision
- Transient amarousis fugax
- Loss of visual field

Mimics
- Headache - GCA / Migrane / Venous sinus thrombosis / meningitis
- Seizure like activity / tongue biting / post ictal

PMH
-Diabetes - blood sugar around event
- AF / Palps
- Vascular - cardiac / Hypetension / PVD / T2DM / IHD / TIA / stroke

Drug history
AF anticoagulated?
-> Compliance

Social
- Smokling
- Alcohol -> AF
- Function at home / work
- Drive?

Family history
- Clotting issues
- heart attack / stroke at young age

34
Q

Good way of grouping signs syptoms of strokes vs stroke mimics

A

Stroke / tia -> Loss of function

If flashing lights / floaters / tingling etc more likely something else

35
Q

ABCD2 score

A

Score 1-3 (low)
2 day risk = 1.0%
7 day risk = 1.2%

Score 4-5 (moderate)
2 day risk = 4.1%
7 day risk = 5.9%

Score 6–7 (high)
2 day risk = 8.1%
7 day risk = 11.7%

36
Q

TIA exam

A

Tar staining

Feel pulse ?AF

BP

Auscultate carotid bruis

Xantholasma - eyes

Pronator drift

CNs - especially if facial / visual fields
Visual acuity

Tone / power / Sensation / reflexes

Dsarthria - say baby hippopotamus

Dysphasia - name this (pen / phone)

Fundoscopy

36
Q

2 TIA most common differentials

A

Migraines
- Usually spreading and gradual onset
- Headaches
- Flashing lights
- Pins and needles

Seizures
- Likely to have amnesia

Consider optic neuritis if visual only

37
Q

What side weakness if there is speach disturbance in TIA

A

Speech disturbance = right sided weakness

\UNLESS left handed

  • All right handed people have speech centre on L side
    ie if there is speech disturbance and L sided weakness ?migrane / L handed
38
Q

TIA investigations

A

Bloods
- FBC, U&Es
-Cholesterol
-HBA1C
-Glucose

ECG +/- 24hr tape depending if not found AF

Imaging
- CTB
- Likely to get an MRI at TIA clinic
- Carotid doppler

39
Q

Ix if young and tia

A

Thrombophilia screen
Vasculitis screen

Echo - valvular pathology
PFO - will need bubble / TOE

40
Q

Carotid doppler scores for endarctetomy

A

Carotid stenosis > 50% and symptoms related to that side refer to vascular surgery

41
Q

TIA + chest pain / neck pain / occipital headache worry

A

Vertebral artery dissection
-> CT angio

42
Q

TIA lifestyle advice

A

Low salt
Exercise
Smoking / alcohol
Healthy diet
Control BP / Diabetes

43
Q

TIA treatment

A

Aspirin 300mg for 2 weeks then 75mg clopidogrel life long

Hypertensive managment

Statins if cholesterol high

AF

44
Q

Driving post TIA

A

1 month
- I would check DVLA before to check

HGV - at least 1 year

45
Q

3 main differentials of Peripheral neuropathy

A

Diabetes
Alcohol
B12 deficiency

Amyloid etc

46
Q

What is myasthenia gravis?

A

Antibodies to post synaptic Acetyl coline receptors
(Not all signals get down)

  • in first stage can increase ACH in receptors to treat

Over time get thickening of receptors and complement deposition - harder to treat which would lead to a fixed weakness

47
Q

End of bed what might you see in myasthenia

A

Head droop
Ptosis
Salivation

In paces most will have stable occular myasthenia

48
Q

Myasthenia vignette? And history? Key things to check!?

A

30 year old presents with droopy eyes at night / double vision / weakness

When is weakness

Fatigability

Ptosis / double vision that’s worse after reading etc
Double vision that is variable
- sometimes next to each other / sometimes on top
struggling to finish chewing meal

Proximal muscle weakness

Coexisting autoimmune
Thyroid
Lambert eaton syndrome Cough / weight loss / haemoptysis / dry mouth / sweating / palps

ANY DYSPNEA
ANY DYSPHAGIA / CHOKING

PMH
Cancer
Autoimmune eg thyroid

Family history
Congenital myasthenia syndrome

DH
Previous immune checkpoint inhibitors for Ca

Social history
Smoking alcohol
Driving - diplopia ptosis
How affecting function

49
Q

Bar ach what is the other antibody that can occur in myasthenia? In who?

A

Black afrocaribbean
Anti muscle specific kinase antibodies

50
Q

What is a myasthenic crisis

A

Exacerbation of underlying myasthenia which leads to respiratory/ Bulbar compromise

51
Q

When would you want to refer to ICU in myasthenia. Name 4

A

FVC <20mls/kg

Progressive decline in FVC

Can’t complete sentences

Struggling with secretions

Can’t lift head from pillow

52
Q

Some myasthenia patients struggle to do mouth movements for FVC? What other bedside test for monitoring

A

Count as far as possible in 1 breath

A PACES (8 decks)

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