OSCE emergencies (Neuro and special senses) Flashcards
meningitis presentation
Typical
- Fever
- Neck stiffness
- Vomiting
- Headache
- Photophobia
- Altered consciousness/ seizure
Meningococcal septicaemia – non-blanching rash
Neonates and babies
- Non specific: hypotonia, poor feeding, lethargy, hypothermia and bulging fontanelle
Special tests
- Kernig’s test
- Brudzinski’s
investigations for meningitis
Bedside
- Basic observation
- Blood glucose
Laboratory
- Blood: meningococal PCR
- Lumbar puncture
lumbar puncture
Bacterial: cloudy, low glucose, neutrophils
TB:
- Turbid
- Low glucose
- Need to do acid fast bacillus
- Lymphocytic (not polymorphic like bacterial)
Viral: normal glucose, high protein
Complications of meningitis
- Hearing loss is a key complication
- Seizures and epilepsy
- Cognitive impairment and learning disability
- Memory loss
- Cerebral palsy, with focal neurological deficits such as limb weakness or spasticity
management of bacterial meningitis
Antibiotics
- Under 3 months – cefotaxime plus amoxicillin (the amoxicillin is to cover listeria contracted during pregnancy)
- Above 3 months – ceftriaxone
- +- vancomycin if risk of penicillin resistant pneumococcal infection e.g. foreign travel or prolonged antibiotic exposure
Steroids if bacterial -> reduce severity of hearing loss and neurological damage
- Dexamethasone 4x daily for 4 days
Notifiable disease
Post exposure prophylaxis (meningococcal infection)
- Highest risk for people that have had close prolonged contact within 7 days to the onset of the illness
- Risk decreases 7 days after exposure (if no symptoms have developed 7 days after exposure they are unlikely to develop illness)
- Management: single dose of ciprofloxacin – give stat
presentation of encephalitis
- Altered consciousness
- Altered cognition
- Unusual behaviour
- Acute onset of focal neurological symptoms
- Acute onset of focal seizures
- Fever
investigations for encephalitis
- Lumbar puncture – viral PCR testing
- CT scan if lumbar puncture contraindicated
o GCS below 9
o Haemodynamically unstable
o Active seizures
o Post-ictal - MRI scan after LP to visualise brain
- Throat and vesicle swabs
- HIV testing
- Swabs
Management of viral encephalitis
- IV acyclovir - HSV and VZV
- IV ganciclovir- CMV
- Repeat LP prior to stopping antivirals
- Supportive and rehab
myasthenic crisis presentation
Myasthenic crisis is a severe complication of myasthenia gravis. It can be life threatening. It causes an acute worsening of symptoms, often triggered by another illness such as a respiratory tract infection. This can lead to respiratory failure as a result of weakness in the muscle of respiration.
myasthenic crisis management
Patients may require non-invasive ventilation with BiPAP or full intubation and ventilation.
Medical treatment of myasthenic crisis is with immunomodulatory therapies such as IV immunoglobulins and plasma exchange.
Example medications
- Reversible acetylcholinesterase inhibitors (usually pyridostigmine or neostigmine) increases the amount of acetylcholine in the neuromuscular junction and improve symptoms
- Immunosuppression (e.g. prednisolone or azathioprine) suppresses the production of antibodies
anaphylaxis presentation
There will be rapid onset of allergic symptoms:
* Urticaria
* Itching
* Angio-oedema, with swelling around lips and eyes
* Abdominal pain
Additional symptoms that indicate anaphylaxis are:
* Shortness of breath
* Wheeze
* Swelling of the larynx, causing stridor
* Tachycardia
* Lightheadedness
* Collapse
anaphylaxis management
- Rapid assessment: A-E
- Give high flow oxygen (15l through a non rebreathe mask)
- Lay patient flat and raise legs
- Adrenaline IM in anterolateral aspect of the middle third of thigh
o Adult 500mg IM
o Should be repeated after 5 mins if no clinical improvement - IV fluid challenge- warmed crystalloid (500ml normal saline over 15 mins) solution e.g. Hartmanns or saline-> to raise BP
- Chlorphenamine (anthistamine)
- Hydrocortisone (steroid)
- Continuing resp deterioration -> bronchodilators e.g. salbutamol
presentation of eczema herpeticum
management of eczema herpeticum
Investigations
- Viral swabs of the vesicles can be used to confirm the diagnosis, although treatment is usually started based on the clinical appearance.
Management
- Aciclovir
- A mild or moderate case may be treated with oral aciclovir, whereas more severe cases may require IV aciclovir.
Complications
- Bacterial superinfection can occur, leading to a more severe illness. This needs treatment with antibiotics.
temporal arteritis
Giant cell arteritis is a systemic vasculitis of the medium and large arteries. It typically presents with symptoms affecting the temporal arteries and is also known as temporal arteritis.
There is a strong link with polymyalgia rheumatica. The patients at higher risk are white females over 50.
temporal arteritis presentation
The main presenting feature is a headache:
- Severe unilateral headache typically around temple and forehead
- Scalp tenderness my be noticed when brushing hair
- Jaw claudication
- Blurred or double vision
- Irreversible painless complete sight loss can occur rapidly
There may be associated systemic symptoms such as:
- Fever
- Muscle aches
- Fatigue
- Weight loss
- Loss of appetite
- Peripheral oedema
temporal arteritis investigations
Bloods
- ESR
- Full blood count may show a normocytic anaemia and thrombocytosis (raised platelets)
- Liver function tests can show a raised alkaline phosphatase
- C reactive protein is usually raised
Imaging
- Duplex ultrasound of the temporal artery shows the hypoechoic halo sign
Procedures
- Temporal artery biopsy (multinucleated giant cells)
management of TA
give stat dose of 60mg prednisolone (usually a rapid response to treatment)
Other medications:
- Aspirin 75mg daily decreases visual loss and strokes
- Proton pump inhibitor (e.g. omeprazole) for gastric prevention while on steroids
acute angle closure glaucoma presentation
The patient will generally appear unwell in themselves. They have a short history of:
- Severely painful red eye
- Blurred vision
- Halos around lights
- Associated headache, nausea and vomiting
Examination
- Red-eye
- Teary
- Hazy cornea
- Decreased visual acuity
- Dilatation of the affected pupil
- Fixed pupil size
- Firm eyeball on palpation
investigations for acute angle closure glaucoma
- Tonometry to assess for elevated IOP
- Gonioscopy (literally looking, oscopy, at the angle, gonio): a special lens for the slit lamp that allows visualisation of the angle
management of AACG
Ophthalmic emergency- need to decrease intraocular pressure ASAP
An example regime would be:
1) Lie patient flat
2) Combination of eye drops, for example:
- a direct parasympathomimetic (e.g. pilocarpine, causes contraction of the ciliary muscle → opening the trabecular meshwork → increased outflow of the aqueous humour)
- a beta-blocker (e.g. timolol, decreases aqueous humour production)
- an alpha-2 agonist (e.g. apraclonidine, dual mechanism, decreasing aqueous humour production and increasing uveoscleral outflow)
3) intravenous acetazolamide
- reduces aqueous secretions
4) Definitive management
- laser peripheral iridotomy
creates a tiny hole in the peripheral iris → aqueous humour flowing to the angle
ophthalmic shingles (Herpes zoster ophthalmicus) background
- Viral disease characterised by unilateral painful skin rash in one or more dermatone distributions of the trigeminal nerve (5th cranial nerve)
o Shared by the eye and ocular adnexa
Pathophysiology
- Due to reactivation of latent varicella-zoster virus present within the sensory spinal or cerebral ganglia
- VZV = dsDNA of the herpes simplex group
presentation of ophthalmic shingles
- Erythematous skin lesions with macules, papules, vesicles, pustules, crusting lesions in the distribution of the trigeminal nerve
- Hutchison’s sign – skin lesions at the tip, side or root of nose
o Strong predictor of ocular inflammation and corneal denervation in HZO - Symptoms: fever, malaise, headache, eye pain prior to eruption of skin
managemen tof ophthalmic shingles
- Oral acyclovir 800mg PO five times daily for 7 to 10 days
- Topical steroids should be used for interstitial keratitis and uveitis
- If increased intraocular pressure found in herpes trabeculitis -> topical steroids should be administered as well as aqueous suppressants (e.g. timolol, brimonidine, dorzolamide, acetazolamide)
- Neuropathic pain -> amitriptyline or pregabalin
- Antibiotic cream if rash infected
- Surgery : if cornea thinning and loss of structural integrity of eye -> cornea transplantation
orbital cellulitis
Type depend on the orbital septum (thin, fibrous, multilaminate structure that attaches peripherally to the periosteum of the orbital margin to form the arcus marginalis).
Septum is the only barrier between infection spreading from eyelid to the orbit
1) Pre-septal – pre/periorbital
- Anterior to septum
2) Post-septal- orbital
- Posterior to septum
Mode of infection
- Contiguous spread from surrounding periorbital structures such as paranasal sinuses (ethmoidal most common)
presentation or preorbital/orbital cellulitis
Presentation
Key differentiation: pain on eye movement, reduced eye moved, changes to vision, abnormal pupil reactions and forward movement of eyeball (proptosis)
- Worsening oedema
- Orbital signs
o Proptosis
o Ophthalmoplegia
o Decreased visual acquity
o Loss of red colour vision – first sign of optic neuropathy
o Chemosis
o Painful diplopia
management of otitis externa
Mild
- Acetic acid – antifungal and antibacterial effects
Moderate
- Topical antibiotic and steroid e.g. neomycin, dexamethasone and acetic acid -> Otomize ear spray
- Beware of aminoglycosides (gentamicin)-> ototoxic, esp if undiagnosed perforation
Severe
- Oral antibiotics e.g. fluclox or clarithromycin
- Ear wick
Fungal -> clotrimazole ear drops
malingnant otitis externa
- Severe and life-threatening form of otitis externa
- Infection spreads to bones surrounding ear canal and skull
o Osteomyelitis of temporal bone
presentation of malignant otitis externa
- Symptoms more severe than normal otitis external
- Persistent headache
- Severe pain and fever
- Examination: granulation tissue a the junction between the bone and cartilage in the ear canal (halfway along) – key finding
management of malignant otitis externa
Management
- Admission
- IV antibiotics
- Imaging (CT or MRI)
management of acute otitis media
- Most resolve without Abx in 3 days
- Simple analgesia
- Consider delayed antibiotics prescription
- When immediate antibiotics: co-morbidities systemically unwell, immunocompromised
o Amoxicillin for 5- 7 days
o Clarithromycin if penicillin allergic
management of otitis media with effusion
- Watch and wait
- Hearing tests
- Auto inflation -> nasal balloon -> ventilating middle ear two to three times a day
- Hearing aids
- Grommets
mastoiditis
- Infection of the mastoid bone of the skull
- Middle ear cavity communicates via mastoid antrum with mastoid air cells
- Provides a potential route for middle ear infections to spread into the mastoid bone (mastoid air cells)
- Osteomyelitis
presentation of mastoiditis
- Fever, irrationality
- Swelling of the ear lobe
- Redness and tenderness behind the ear
- Drainage of the ear
- Bulging and drooping of the ear.
presentation of quinsy (peritonsillar abscess)
Presentation
- Sore throat
- Painful swallowing
- Fever
- Neck pain
- Referred ear pain
- Swollen tender lymph nodes
- If its unilateral (quinsy) will deviate the uvula towards the swelling
Additional symptoms that can indicate a peritonsillar abscess include:
* Trismus, which refers to when the patient is unable to open their mouth
* Change in voice due to the pharyngeal swelling, described in textbooks as a “hot potato voice”
* Swelling and erythema in the area beside the tonsils
which organisms cause quinsys
- Streptococcus pyogenus
- Or Staph aureus, H.influenzae
