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DEN303 - IHD > Neurology Symposium - neurology in dentists chair > Flashcards

Neurology Symposium - neurology in dentists chair Flashcards

1
Q

Epilepsy questions

What is epilepsy

A

Perinatal trauma, febrile convulsions, head injury, family history, CNS infections e.g meningitis or encephalitis

Tendency to have recurrent seizures
Umbrella term e.g juvenile myoclonic epilepsy

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2
Q

Syncope questions

A

Transient loss of consciousness, due to loss of cerebral perfusion
Preceding symptoms - dizziness, nausea, hot
Postural
Negative signs - absence of function e.g not clenching tongue
Cardiovascular RF

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3
Q

Non-epileptic attack disorder (NEAD)

A

Psychosocial substrate e.g childhood trauma, domestic or sexual abuse, response to
Contextual
Awareness - will appear unconscious but not
Fluctuant

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4
Q

Non-epileptic attack disorder (NEAD) questions

A 
Psychosocial substrate
Contextual 
Awareness
Fluctuant 
Eyes tight and closed
May be unresponsive
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5
Q

Is Case 1 typical of an NEA

A

No - it is epileptic

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6
Q

Checklist for NEAD vs Epilepsy

in NEA context

A

Shaking - amplitude can vary throughout frequency and evolution
Eyes - shut
Incontinence
O2 Zats and other observations - stay the same in NEA
Unpleasant bites - sides in epilepsy
Responsiveness - can sometimes respond
Estimated duration - longer than epilepsy
Speed of recovery - come round quickly

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7
Q

Less reliable signs of differentiation (NEAD)

A

Injuries
Pelvic thrusting
Incontinence
Twitching

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8
Q

True or False : If he is still shaking after 30 seconds, he requires intravenous lorazepam 4 mg

A

FALSE

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9
Q

Emergency management of GTC seizures

Which medications

A

Self limiting
2-4mg lorazepam if prolonged (repeat if needed) - min of 5 mins
IV phenytoin 1g over 20 mins with cardiac monitor if not settling
30mg/kg levitoracitan or valproate 30mg/kg
if in dentists chairs call 999

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10
Q

T or F: An MRI scan of case I is likely to show a brain tumour

A

False

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11
Q

Syndrome classification

2 types and triggers

A

Idiopathy generalised epilepsy juvenile myoclonic epilepsy - photosensitivity, sleep deprivation, alcohol

Localisation related epilepsy - aura, focal neurology, age, PMH

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12
Q

Indications for further treatment after single seizure

A

Previous myoclonic seizures or absences
Congenital neurological deficit
Unequivocal epileptiform changes on EEG
Risk of recurrence is unacceptable to pt

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13
Q

Choice of anticonvulsant
Men
Women
Localisation related epilepsy

A

Valproate - teratogenic in women
Lamotrigine
Lamotrigine, carbamazepine, levetiracetam

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14
Q

Summary

What to take into account with treatment

A 
Watch carefully
Protect from injury, O2 and recovery position 
ECG and listen to heart
Treatment - syndrome and sex of pt
Driving advice
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15
Q

Case 2
A 23yo lady comes in with right-sided toothache. It is worse when touching the right side of her face and when she brushes her teeth. There is no other PMH of note.
The teeth appear normal, but she insists you remove the right lower molars because the pain is excruciating. Neurological examination is normal.

What is the diagnosis?
Will teeth be removed as requested?

A 
Site: Right lower face
Onset: Sudden, 
Character: Electric/ Sharp
Radiation: Around face/mouth
Association: Nil
Time: Paroxysmal
Exacerbating: Touch, cold, wind, E+D
Severity: Excruciating

Right trigeminal neuralgia
No

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16
Q

Likeliest cause

A 
Cerebellopontine angle tumour
Demyelination
Nasopharyngeal carcinoma
Vascular loop - pressure of a vessel onto nerve 
Viral infection
Pontine tumour
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17
Q

Case 1
An 18yo man comes in for a tooth extraction. Half way through, he goes stiff, turns blue, his limbs starts shaking and he bites his tongue. His partner in the waiting room says he has had episodes of daydreaming since his teens. He sometimes becomes anxious in the car. He is always clumsy and dropping things in the mornings. He occasionally gets headaches. He has had a cough recently. Worse when tired.

A

Clumsiness may be myoclonic jerk –> random muscle spasm

Biting tongue - forced tonic contractions

18
Q

First aid for fits

A

Clear area
Open airway
Don’t restrict head

19
Q

Does case 1 require treatment after a single tonic-clonic fit

A

No

20
Q

EEG significance

A

only 30% sensitive
Activities seen in 0.5% healthy adults
Do an ECG e.g to identify risk of heart blocks (sino

21
Q

Diagnosis of MS

A

Clinical evidence of 2 attacks
Prev episodes
Demyelination of nerve in time and pace after 1 attack

22
Q

Treatment of MS

A

2 relapses in 2 years

Natalizumab

23
Q

Treatment of trigeminal neuralgia

Which drugs and details

A

Carbamazepine - hepatotoxic and may affect combined pill
Phenytoin
Microvascular decompression
Radio surgery and nerve blocks

24
Q

Case 3 A 70yo man in the waiting room suddenly collapses. He is unable to speak and has dense weakness of the right side of his face, arm and leg

A

Left side paralysed

Speech centres affected

25
Q

What is priority in case 3

A

give aspirin (if not haemorrhage stroke)
Take to hospital if haemorrhage
Thrombotic stroke can be given aspirin

26
Q

Case 3 - On arrival in hospital, he is no better. FBC, ESR, U/Es, LFTs, glucose and clotting are normal. Cholesterol is 3.4mmol/L. An urgent CT brain is organised and performed an hour after onset.

A

CT shows nothing
MRI not necessary
Consider for THROMBOLYSIS - dissolve any clots already present and prevents further clots from forming for next hour

27
Q

Important questions for 3

A

Age/persistent/CT
Is he taking warfarin?
End stage illness/surgery/gi bleed/ trauma 3/52?
Retinopathy/pericarditis/pancreatitis/childbirth/CPR/recent stroke?
Blood pressure >185/100?
Are bloods normal (Plats, LFTs)?

28
Q

Dark shadow indicates clotting

Better treatment than thrombolysis?

A

Thrombectomy - removing clot

29
Q

Case 4 A 70 year old man with a history of Parkinson’s disease attends for a routine check-up. At the end of the consultation, he “freezes” and is unable to get out of the chair. His usual medications are Sinemet 125mg five times a day, Rotigotine patch 8mg/day and Madopar dispersible prn. On examination, there is cogwheeling, resting tremor, bradykinesia and some dyskinesias.

What is parkinson’s
triad

A

Progressive Neurodegenerative disease involving loss of dopamine production

Sinemet and madopar - levopar
Rotigotine (dopamine agonist)

stiffness, rigidity, tremor
gait impairment

30
Q

What to do about case 4

A

Give madopar dispersible 62.5mg

31
Q

Parkinson’s disease - diagnosis

A 
Clinical
Idiopathic
Triad of features- Tremor, Rigidity, Bradykinesia
Other symptoms
Parkinson’s plus
32
Q

Management of PD

A 
L-dopa (dyskinesias, wearing off)
Dopamine agonists (neuropsychiatric side effects)
Amantadine - anticholinergic
MAO-B  inhibitors (Selegiline)
COMT inhibitor (Entacapone) 
Apomorphine pump, Duodopa
Surgery
33
Q

Long term complications

A 
Wearing off
Dyskinesias
Off and on freezing
Falls
Constipation
Neuropsychiatric - hallucinations
34
Q

Case 5 A 45yo man comes for a check-up. He has noticed slurred speech and swallowing problems over the last two months.
Examination of his teeth is unremarkable but his tongue movements are very slow, the jaw jerk is brisk.

A

Dysphagia

Brisk jaw jerk via tendon hammer

35
Q

Likely diagnosis of case 5

A

Motor neurone disease - bulbar onset disease is worse

36
Q

Diagnostic test for MND

A

EMG

37
Q

Criteria for diagnosis of motor neurone disease

UMN

LMN

A

Progressive
Mixed UMN and LMN signs
- spasticity and stiffness

LMN 
- muscle wastage 
Regions involved
Exclude other causes
Definite/probable/possible
38
Q

Diagnosis
Sensory signs
Eyes
Sphincters

A

Shouldn’t be incontinent

39
Q

Prognosis is better in BOD

A

False

40
Q

Medication for BOD

A

Riluzole

41
Q

Are there other treatments for MND

A

Non-invasive ventilation, BPAP

42
Q

Carbamazepine is

Phenytoin long term use

A

an enzyme inducer - antibiotics

Gingival hyperplasia

DEN303 - IHD (58 decks)

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