Neurology

Question 1

Acute DO (drug overdose)

Answer 1

Admission

• suicidal precaution
• NPO
• neuro-obs q4H
• cardiac monitor
• Bld x CBC LRFT bone clotting INR RG VBG
• Bld x paracetamol, salicylate, ethanol
• Urine x toxicology
• CXR
• ECG
• Consult psychi mane

For morphine/opiod
- IV naloxone 0.1mg stat
- repeat q2min if unresponsive: 0.2mg > 0.4mg > 0.8mg > 1mg (not exceed 1mg each time)
- if drowsy, start at IV naloxone 0.1mg stat
(heroin long t1/2, naloxone short t1/2)

Question 2

Confusion/ seizure

Answer 2

Admission

• NPO
• Neuro-obs q1H/q4H
• Convulsion chart
• O2 supplement aim SaO2 >=90%
• H’stix stat
• Bld x CBC LRFT bone clotting RG +- VBG Mg AED
• CXR
• ECG
• U CTB
• IV valium 5mg stat> IV dilantin (phenytoin) 15-20mg over 30mins, then PO/IV dilantin 300mg
• Correct e disturbance, hypoglc
• Book EEG
• Inform MO for ICU if persistent/ status

Question 3

CVA (ischemia)

Answer 3

Ix
- CTB, CXR, ECG, Hstix

Admission

• NPOEM until ST assessment
• Neuro obs q4H
• ?Hstix TDS + nocte
• ?chart IO
• Bld x CBC LRFT bone clotting INR RG
• Bld x HbA1c, FG, FL mane
• CXR
• ECG
• U CTB
• Resume usual meds
• PO aspirin 80mg daily (RO h’age, not massive e.g. cortical sign)
• w/h anti-HTN (aim BP <220/120)
• w/h DM drugs (as NPO)
• refer physio, occu, speech

Question 4

Dizziness

Answer 4

Admission

• DAT
• Obs q4H
• H’stix x1
• Postural BP x3
• +- cardiac monitor
• Bld x CBC LRFT Bone RG
• CXR
• ECG + long lead II
• +- CTB
• Urine x multistix
• Resume usual meds
• PO stemetil (prochlorperazine maleate) 10mg q8H

Question 5

Decrease GC

Answer 5

Admission

• DAT
• Neuroobs q4H
• H’stix x1
• Postvoid bladder scan, if RU >=350mL, foley to BSB
• Bld x CBC LRFT bone clotting RG
• Bld C/S if fever >38
• Sputum x C/S
• Urine x multistix, C/S
• CXR, AXR
• ECG
• CTB if dull looking
• IVF if dehydration
• Resume usual meds
• Lactulose/ duocloax/ fleet
• +- consult OT x MMSE, ADL assessment

Ward complain

• Exclude h’age, h’agic transformation post stroke, SLE, leukemia)
• Neuroobs q1H
• CTB

Question 6

Headache

Answer 6

Ward complain

• Exclude significant (h’age, h’agic transformation post stroke)
• Check GCS, 4limbs power
• +- CTB
• analgesics

Question 7

LOC

Answer 7

Admission

• Bed rest
• DAT
• Obs q4H
• H’stix
• Postural BP x3
• +- cardiac monitor
• Bld x CBC LRFT bone clotting INR RG
• CXR
• ECG +- long lead II
• U CTB
• MSU x multistix, toxicology
• Resume usual meds
• Book IP Holter, EEG

Question 8

Meningitis

Answer 8

Admission

• NPOEM
• Neuroobs q4H
• Convulsion chart
• Bld x CBC LRFT bone clotting INR RG
• HSV serology
• Bld x C/S if fever >38
• Sputum C/S, AFBx3
• MSU x multistix, C/S
• CXR
• ECG
• U CTB
• Resume usual meds
• IV ceftriaxone 2g q8H + IV acyclovir 10-15mg/kg q8H
• Consider LP

Question 9

Numbness

Answer 9

Ward complain

• Exclude stroke, cord lesion, radiculopathy, plexopathy
• Keep obs
• +- gabapentin 300mg nocte if intractable

Question 10

ICH

Answer 10

Admission
 - NPOEM until ST assessment
 - Neuroobs q4H
 - Bld x CBC LRFT bone clotting INR RG
 - Bld x HbA1c FG FL mane
 - CXR
 - ECG
 - U CTB
 - Resume usual meds
 - w/h anticoagulant
 - BP aim SBP <=220
 >>>> IV labetalol 200mg in 100mL NS, usu 15ml/H (range 0-30mL/H)
 >>>> or IV GTN 30mg in 100mL NS, usu 15mL/H (range 0-20mL/H +- 2mL per time)
 >>>> or IV isoket 50mg in 100mL NS, usu 4mL/H (range 0-10mL/H +- 2mL per time)

• refer physio, occu, speech

Question 11

3rd/6th nerve palsy

Answer 11

Admission

• NPOEM until ST assessment
• Neuroobs q4H
• Bld x CBC LRFT bone clotting INR RG, CRP/ESR
• Bld x ANCA ANA Anti-dsDNA RF C3/C4 B12/folate TSH VDRL
• Bld x HbA1c RG RL mane
• Bld x C/S if fever >38
• CXR
• ECG
• U CTB
• Resume usual meds
• PO aspirin 80mg daily (RO h’age, massive stroke)
• W/H anti-HT (aim SBP <=220)
• refer physio, occu, speech
• consider LP, MRI brainstem brain