Week 22 - Case 1-4

Question 1

what is papilloedema and what is it a sign of

Answer 1

this is a sign of raised intracranial pressure.

Papilledema is a disease entity that refers to the swelling of the optic disc due to elevated intracranial pressure (ICP). This term should be distinguished from disc edema which specifies a broader category of optic disc swelling secondary to other etiologies.

Question 2

what may happen to visual fields in raised intracranial pressure

Answer 2

restricted visual fields

Question 3

what nerve pasly is indicative of raised ICP

Answer 3

sixth nerve palsy

Question 4

increased tone and brisk reflexes are what kind of motor neurone sign

Answer 4

UMN sign

Question 5

what should one reduce with migraines

Answer 5

one should reduce caffeine consumption

Question 6

what is first line acute treatment for migraines

Answer 6

simple analgesia such as paracetamol or NSAIDs

the addition of an anti-emetic may be beneficial for those prone to sickness

Question 7

what are first line options for migraine prevention

Answer 7

propranolol, topiramate or amitriptyline

Question 8

what can be used as a prevent cluster headaches

Answer 8

verapamil

Question 9

is prednisolone used in migraines or cluster headache spells

Answer 9

prednisolone is not used in migraine, although can be used to abort spells of cluster headache

Question 10

what is metoclopramide

Answer 10

an anti emetic

Question 11

does topiramate cause weight loss

Answer 11

yes

Question 12

what is recommend in tension type headaches. medication wise

Answer 12

amitryptiline 10mg at night to try and reduce the headache

Question 13

what can meningitis be caused by

Answer 13

bacteria, viruses or fungi

Question 14

in the UK, community acquired bacterial meningitis in adults and older children is usually caused by what strains

Answer 14

Streptococcus pneumoniae and Neisseria meningitides

Question 15

what strain causes meningitis but mainly in patients over 50 yrs of age and in the immunocompromised

Answer 15

listeria monocytogenes

Question 16

how are TB and meningitis related

Answer 16

TB can disseminate and cause meningitis

Question 17

what are the most common causes of meningitis in neonates

Answer 17

In neonates, the most common causes are group B streptococcus, E. coli, and occasionally Listeria monocytogenes.

Question 18

when is healthcare associated bacterial meningitis mainly seen after

Answer 18

neurosurgery or cranial trauma and in the presence of internal or external ventricular veins

Question 19

what are the most common strains associated with healthcare associated bacterial meningitis

Answer 19

Staphylococci or aerobic gram-negative bacilli are the most common causes of these.

Question 20

what are the 3 viral causes of meningitis

Answer 20

enteroviruses
mumps virus (and other paramyxoviruses)
herpes simplex virus (primary HSV infection or disseminated HSV)

Question 21

what is the most common fungal cause of meningitis

Answer 21

Cryptococcus neoformans

Question 22

in who is cryptococcus meningitis most commonly seen

Answer 22

in patients with severe deficiencies in cell-mediated immunity, such as patients with HIV

Question 23

how to patients with bacterial meningitis present

Answer 23

typically present with a fever over 38 degrees, severe headache, nausea, neck stiffness and a change in mental status usually of sudden onset and are acutely unwell

Question 24

what are the less common manifestations of bacterial meningitis

Answer 24

seizures, aphasia, or hemi- or monoparaesis, coma, cranial nerve palsy, rash and papilledema

Question 25

in what cases is the classic meningococcal rash seen

Answer 25

seen in patients with Neisseria meningitides meningitis (meningococcal disease).

Question 26

what percentage of patients with meningococcal infection present with sepsis with or without meningism

Answer 26

10-20%

Question 27

what is kernig's sign

Answer 27

position the patient on their back with their hips flexed to 90 degrees this test is positive if there is pain on passive leg extension at the knee joint

Question 28

what is Brudzinkski's sign

Answer 28

position the patient on their back and passively flex their neck. this is positive if the patient involuntarily bends their knees

Question 29

what are the main differential diagnoses for meningism beside bacterial meningitis

Answer 29

viral meningitis fungal meningitis tuberculous meningitis drug-induced meningitis encephalitis malignancy CNS abscess HIV infection subarachnoid haemorrhafge

Question 30

when should a lumbar puncture be done in suspected meningitis

Answer 30

should be performed within 1 hour of arrival at the hospital if it is safe and the patient is haemodynamically stable

Question 31

what should be commenced immediately after a LP

Answer 31

antibiotics

Question 32

what should happen if a LP cannot be performed in one hour of arrival to hospital

Answer 32

blood cultures should be taken, antibiotics started and an LP when sadde

Question 33

what laboratory investigations are you going to request for suspected meninigitis

Answer 33

Bloods: - Blood cultures - FBC, U+E, LFTs, and clotting screen – to rule out coagulation abnormalities, inflammatory markers may be raised, and platelets may be low. - Meningococcal and pneumococcal PCR - Glucose – to compare with the CSF - HIV test Throat swab: - Microscopy, culture, and sensitivity CSF: - Microscopy, culture, and sensitivity - Viral PCR - Protein - Glucose - Lactate

Question 34

which intervertebral space will you aim to insert your needle into for a LP

Answer 34

between L3 and L4 or L4 and L5 because this is below the level at which the spinal cord terminates

Question 35

what should you make sure the patient doesnt have before an LP

Answer 35

make sure the patient is not taking anticoagulants or have a clotting disorder

Question 36

when should a head CT be performed before an LP

Answer 36

Immunocompromised state History of central nervous system (CNS)infection, masses, or stroke New-onset seizure Papilledema Altered consciousness Focal neurologic deficit

Question 37

what do patients with bacterial meningitis urgently require for treatment

Answer 37

IV antibiotic treatment with agents that penetrate the CSF well and cover the likely pathogens according to history

Question 38

what is the first line antibiotic treatment for community acquired meningitis

Answer 38

ceftriaxone IV with additional amoxicillin IV if listeria is likely

Question 39

what is the alternative treatment for community acquired meningitis if there is severe penicillin allergy

Answer 39

Chloramphenicol IV.

Question 40

what is treatment for strongly suspected bacterial meningitis

Answer 40

Dexamethasone IV 10mg four times daily for four days can be started within 12 hours of antibiotics commencement.

Question 41

what is given for confirmed meningococcal meningitis

Answer 41

oropharyngeal eradication is required either ceftriaxone or a single dose of ciprofloxacin alongside treatment.

Question 42

what are the treatment options for viral meningitis

Answer 42

there currently are no proven beneficial treatments for viral menigitis Once the diagnosis of viral meningitis is made, antibiotics should be stopped. Some clinicians treat herpes meningitis with acyclovir or valaciclovir, but to date, there is limited evidence for this to be effective. Treatment should be supportive with analgesia and fluids if necessary.

Question 43

what is characterisically seen in patients with raised ICP headaches

Answer 43

her headaches are made worse by straining or bending over

Question 44

what are the typical examination findings of raised ICP

Answer 44

Papilloedema, restricted visual fields and enlarged blind spots are all typical of raised intracranial pressure.

Question 45

if there is right sided pronator drift what does this indicate

Answer 45

a left hemisphere space occupying lesion

Question 46

what may be given if there is a significant amount of oedema and swelling seen on a head CT

Answer 46

dexamethasone

Question 47

what are extradural haemorrhages usually a result of

Answer 47

an arterial bleed which is vulnerable to trauma on the temporal region of the head

Question 48

what is the pattern of consciousness with extra dural haemorrhages

Answer 48

patients may regain consciousness following a brief period of impaired consciousness at the time of injury this initial loss of consciousness is usually the result of cerebral concussion

Question 49

when does the level of consciousness begin to deveop

Answer 49

when the haemotoma develops

Question 50

what does the lucid interval in extra dural haemorrhages risk

Answer 50

frequently results in delayed or missed diagnosis with catastropic consequences.

Question 51

describe the typical clinical presentation of a subdural haematoma

Answer 51

Unlike extra-dural haematomas, sub-dural haematomas are venous in origin and hence they may occur even after a trivial injury in a vulnerable subject. Elderly patients, alcoholics and other debilitated people are at higher risk. The haematoma develops very sowly (a venous ooze) and hence the latent period between the injury and clinical presentation may be weeks or even months. Headache, drowsiness and confusion are common in the late stages. Fluctuating level of consciousness for a variable period is typical of SDHs as the haematoma contracts and expands due to osmotic effects.

Question 52

what are the two classifications of brain tumours

Answer 52

Primary brain tumours: arise from the intracranial structures such as meninges (meningioma) or glial cells (gliomas or astrocytomas). Meningiomas are usually slow growing. Whereas gliomas show a range of growth with multiforme being the worst. Secondary metastases: from primary tumours usually arising from bronchus, breast, stomach, prostate, thyroid or kidneys

Question 53

what does a generalised myoclonic seizure described as

Answer 53

early morning shakines

Question 54

what is standard practice in the UK for people who have developed seizures

Answer 54

MRI brain

Question 55

what is the most common antiepileptic medication

Answer 55

lamotrigine

Question 56

what is the rule with seizures and the DVLA

Answer 56

in the UK this patient would have to refrain from driving until he is seizure free for one year

Question 57

A 24 year old man presents to A+E with severe right sided headaches at night. The brief headaches wake him from sleep several times per night and have been going on for the last 2 weeks. During the headache his eye waters and his nose feels blocked. He describes the headaches as the most severe he’s ever had. Neurological examination is normal. He is otherwise fit and well. He smokes 20 cigarettes per day and does not drink alcohol. He works shifts as a safety operative in a nuclear power plant. What is the likely cause of his headaches?

Answer 57

cluster headaches

Question 58

what type of headaches make people wake from their sleep

Answer 58

cluster headaches

Question 59

what are brief recurrent nocturnal headaches suggestive of

Answer 59

cluster headaches

Question 60

what are daily featureless headaches usually suggestive of

Answer 60

tension headaches

Question 61

what do sharp shooting pains around the face suggest

Answer 61

trigeminal neuralgia

Question 62

what does whoosing tinnitus and pain worse on standing suggest

Answer 62

features of low CSF pressure headaches

Question 63

The following CSF results are obtained in a patient presenting with acute headache, fever and neck stiffness: Opening Pressure: 28cm (nr <20cm) CSF white cell count – 566 (90% neutrophils) (nr <4WBC) CSF protein – 1.1g/L (nr <0.4g/L) CSF glucose – 2.8mmol/L (nr >50% plasma gluc) Plasma glucose 6.1mmol/L What is the most likely diagnosis?

Answer 63

bacterial meningitis The basic clinical syndrome is consistent with meningitis. The CSF pattern of raised pressure, neutrophilic leucocytosis and low glucose is highly suggestive of a bacterial aetiology.

Question 64

A 24 year old woman attends her GP due to episodes noted by her new boyfriend. He describes her as seeming to stare into space and chew her lip for 1-2 minutes. She then seems confused for about 5minutes before returning to normal. The patient sometimes feels that she knows when an attack is going to happen but finds it hard to describe this feeling. What is the most likely diagnosis?

Answer 64

focal impaired awareness seizures

Question 65

what are the typical characteristics of focal impaired awareness seizures

Answer 65

loss of awareness coupled with what sound like orofacial automatisms. a brief postictal period of confusion is common after such events

Question 66

A 52 year old man with known advanced alcoholic liver disease is admitted to A+E with a low GCS following a witnessed generalized tonic clonic seizure at home. What is the most appropriate initial investigation?

Answer 66

Blood glucose In any patient presenting with altered conscious level a blood glucose is a vital initial test. In this patient hypoglycaemia could be the cause of both the seizure and the reduced GCS. Patients with advanced liver disease are at increased risk of hypoglycaemia due to faulty hepatic gluconeogenesis.