Signs and Symptoms to conditions II

Question 1

What investigations are done for Guillain-Barre syndrome?

Answer 1

Nerve conduction studies: Nerve conduction speed will be slow as there is demyelination of peripheral nerves.
Lumbar puncture: CSF in Guillain-Barre syndrome will show <5x10^6 WBC, with an elevated protein and normal glucose levels.
Blood tests: Urea and Electrolytes to exclude hypokalaemia (another cause of acute flaccid tetraplegia)

Question 2

A lady came in with acute onset flaccid tetraparesis. She had a previous history of diarrhoea 2 weeks ago before she started feeling tingling and numbness in her feet. This numbness spreads up from her feet, to her knees and soon started in her arms, in a glove and stocking pattern.
The reflexes are absent and the plantars were mute.
What is the possible differential diagnosis for her and how would you diagnose her from this history?
What are the bacteria and viruses that could have been the cause of her infection?

Answer 2

Acute flaccid tetraplegia is present in hypokalaemia and Guillain-Barre syndrome. However, It is most likely Guillain-Barre syndrome because patients with this condition usually have a preceding infection - Campylobacter Jejuni, Cytomegalovirus, Epstein-Barr Virus, and Mycoplasma Pneumoniae.

Question 3

What is the treatment of Guillain-Barre syndrome?

Answer 3

1. Regular management of vital capacity and cardiac monitoring to ensure there is no abnormal arrhythmia.
2. 1st line treatment is IVIG but must first conduct a blood test for immunogloulin level to ensure there is no IgA deficiency as it can result in anaphylaxis in response to IVIG.
3. Give prophylaxis for Deep Vein Thrombosis (LMWH) and treatment for constipation as these are complications due to immobility caused by Guillain-Barre syndrome.
4. Alternative to IVIG is plasma exchange.

Question 4

What is the condition where patient shows signs of continuous seizure for 30mins or more, or when there are multiple seizures without recovery of consciousness in between?

Answer 4

Status epilepticus

Question 5

What test should be done to patients with status epilepticus, are febrile and/or have a headache?

Answer 5

Lumbar puncture to rule out encephalitis.

Question 6

If patients (presenting with status epilepticus) without known epilepsy, and where there is no obvious metabolic cause for the status epilepticus, what should be done?

Answer 6

An urgent brain imaging with CT or MRI is mandatory to exclude a structural lesion

Question 7

For patients with non-convulsive status epilepticus, how may they present and which test is most definitive in diagnosing it?

Answer 7

Patients with non-convulsive status epilepticus may present as drowsy, confused and irritable.
EEG is the only most definitive test to diagnose non-convulsive status epilepticus.

Question 8

Which test is conducted for patients who are suspected of MND?

Answer 8

Blood tests for elevated Creatine Kinase in MND

Question 9

Which tests are not ideal in patients with MND?

Answer 9

Respiratory rate and Oxygen saturation

Question 10

Horizontal Diplopia on Lateral gaze. What does it indicate?

Answer 10

6th nerve palsy

Question 11

What are pyramidal signs?

Answer 11

Increased extension of legs and flexion of arms.
Shuffling feet
Resting tremor

Question 12

Nystagmus is an indicator of a problem to which parts of the brain? What are the 2 types of nystagmus?

Answer 12

Cerebellum.

It can be rotational or horizontal nystagmus.

Question 13

What is Acetazolamide?

Answer 13

Acetazolamide is a diuretic

Question 14

Which investigation should be done immediately after the onset of headache for Subarachnoid Haemorrhage? Give reasons why.

Answer 14

Unenhanced CT scan.
This is because any delay in CT scanning will allow subarachnoid blood to degrade and increase the possibility of a normal brain scan. ~7% of SAH cannot be seen on the CT after 24 hours, and subarachnoid blood is almost completely reabsorbed within 10 days.

Question 15

What other test should be done for any patient suspected of SAH and a normal brain CT scan?
Describe the results obtained from this test if it is positive for subarachnoid haemorrhage.

Answer 15

Lumbar puncture.
Most patients with SAH will have red blood cells found in the subarachnoid space, which will be detected in the CSF.
CSF is uniformly bloody early on, and becomes xanthochromic (yellow) after several hours due to breakdown products of Hb (bilirubin).

Question 16

At Lumbar Puncture, what is recorded?

Answer 16

1. CSF Opening pressure
2. Protein
3. Red and White cell count
4. Glucose (compare with serum sample taken at the same time)

Question 17

What is Nuchal Rigidity?

Answer 17

Nuchal rigidity is neck stiffness

Question 18

What are the signs that indicates a contraindication of lumbar puncture?

Answer 18

Papilloedema
Focal Neurological Signs
Deteriorating level of consciousness

Question 19

What is to be done if patient shows signs of meningism but has papilloedema?

Answer 19

A CT scan is needed to rule out a mass lesion in the posterior fossa which could also present with meningism.

Question 20

What is the drug of choice for bacterial meningitis?

Answer 20

For adults or children >40KG: Ceftriaxone 2G BD IV

For infants or children <40KG: Ceftriaxone 80MG/KG OD by IV infusion.

Question 21

If patient is above 50yo, what antibiotics will be given if suspected with bacterial meningitis?

Answer 21

Ceftriaxone 2G BD IV + Amoxicillin 2G six times daily IV + Gentamicin 80MG TDS IV for Listeria coverage.

Question 22

Who are the patients at risk of meningitis caused by Listeria infection?

Answer 22

Elderly of >50yo
Newborn infants
Those with alcohol dependency
Immunocompromised