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COMMON IS COMMON: THE NEUROLOGY STATION Disclaimer need to know. We have covered the main pointsyou further information required. official guidelines for STARTER PACK: THE HISTORY What to NOT to Forget: General neurological Headache Red flag symptoms Raised ICP symptoms review - Meningitis:fever,stiffness, - Trauma photophobia,rash - Headache worse in morning - Fits/ falls - Sudden occipital headache - Positional- worse flat, straining - dizziness - New neurological deficit - Vomiting - Temporal arteritis :visual - LOC - Reduced GCS - Weakness problems,jaw claudication,scalp - Neurological deficit - Altered sensation tenderness - Glaucoma:visual problems,red Seizures/ Falls Back pain eyes,halos - Incontinence - Disturbs sleep - Check the cardiorespiratory - Saddle anesthesia - Trauma system: chest pain,palpitations, - Neurological deficit - Pregnancy SOB, cough - Raised ICP - Weight loss,fever,night sweats, cancer history, - trauma STARTER PACK: DIFFERENTIALS Vascular Infection Trauma+Toxins Haemorrhage Meningitis,Encephalitis,Lyme Alcohol Infarction disease,HIV,syphilis Drugs Autoimmune Metabolic Iatrogenic Diabetes Steroid myopathy Multiple sclerosis Encephalopathy Hyper/hypothyroidism Inherited conditions Radiotherapy Sarcoidosis, every vasculitis Drugs Neoplastic + Degenerative Nutritional Congenital B12 defficiency Wilsons syndrome Parkinson’s Thiamine defficiency MND STARTER PACK: INVESTIGATIONS Bedside Full neurological exam including cranial nerves,vital signs,urine dip,BM FBC,U+Es,LFTs,CRP,Ca2+,B12,Folate, TFTs,HIV, Lyme disease, Bloods auto-antibody screen,coag,group + save/ cross match Orifices PR exam,swab X-Ray Imaging:Chest X-ray,CT,MRI ECG Routine,check for arrythmias Special tests Lumbar puncture,EMG,visual evoked potentials Can always say MDT approach’ation + 1.CONSERV ATIVE STARTER PACK: ‘full medication review’ APPRAOCH TO 2.MEDICAL MANAAGMENT 3.SURGICALSTARTER PACK: HOW TO AVOID RED FLAGS DVLA→ almost everything in neuro Say when something is a medical or surgical emergency Say“I would also ask for senior review and input” C A S E 1 S a r a a 3 3 - y e a r - o l d w o m e n p r e s e n t t o t h e e m e r g e n c y d e p a r t m e n t w i t h l e f t l e g h e a v i n e s s a n d p a r e s t h e s i a .DIFFERNTIALS? TOP:MS MUST EXCLUDE:Stroke SOL DIFFERENTIALS B12 defficiency Myelopathy GBSHOW WOULD YOU INVESTIGATE THIS PATIENT? Bedside Full neurological exam including cranial nerves,BM FBC,U+Es,LFTs,CRP,ESR,TFT’s,Ca2+,HIV,Lyme,syphilis Bloods Orifices NA X-Ray Imaging:MRI scan,chest X-ray (routine) ECG RoutineA-E approach - exclude cardiac arrythmia (AF in particular) CSF analysis:oligoclonal bands not in serum,increased Ig G Special tests Visual evoked potentialYOUR MRI COMES BACK: Image from:https://dizziness-and-balance.com/disorders/central/pvm.htmYOUR MRI COMES BACK: FIRST:check for correct patient details, date, time ‘This is aT1 weighted axial MRI scan of the head showing periventricular lesions indicative of MS’ Image from:https://dizziness-and-balance.com/disorders/central/pvm.htmH o w w o u l d y o u m a n a g e t h i s p a t i e n t ?MS MANAGEMENT Refer to neurology Specialist MDT approach 1.CONSERVA TIVE Patient education Psychosocial + Lifestyle:support groups, excersie,smoking cessation Inform DVLA Symptomatic treatment: 2.MEDICAL Spasticity- baclofen Neuropathic pain- amitriptyline/ gabapentin Depression- SSRI Urge incontinence- oxybutynin or self-catheterisation Fatigue:amantadine,physiotherapy or psychotherapy Relapse management: Acute relapse:methylprednisolone (+/- plasma exchange) Disease modifying drugs- glatiramer acetate,interferon beta Biological therapy- natalizumab C A S E 2 A l i , a 5 4 - y e a r - o l d m a n p r e s e n t s t o t h e e m e r g e n c y d e p a r t m e n t w i t h r i g h t s i d e d w e a k n e s s . P l e a s e t a k e a f o c u s e d h i s t o r y .Before starting the station take 1 minute to think through all the possible differentials and how you are going to address them in the history… TOP:Stroke SOL DIFFERENTIALS Seizure - espodd's palsy Sepsis,encephalitis MigraineHISTORY PC PMH Right sided weakness High cholesterol HPC T2 Diabetes O/E: Onset- 1.5 hours DH Both upper and No pain Simvastatin lower L-sided Reduced sensation on R side Metformin No headaches FH weakness. Power 3/5 on left, No speech disturbance High blood pressure No trauma to head SH 5/5 on right. No neck stiffness Smoker Sensation intact. Didn’t lose consciousnes1 glass of wine a day Been feeling well ICE No changes to vision Am I going to die?HOW WOULD YOU INVESTIGATE THIS PATIENT? Bedside Full neurological exam including cranial nerves,BM,NIHSS,ROSIER FBC,U+Es,LFTs,CRP,ESR,Ca2+,Cholesterol,coag,group+ save/ cross Bloods match Orifices Imaging:Urgent CT scan, diffusion weighted MRI scan (GOLD X-Ray standard), chest X-ray (routine) ECG RoutineA-E approach - exclude cardiac arrythmia (AF in particular) Special testsCT SCAN Patient Name:Ali Hassan Patient DOB: 07/01/1968 Hospital Number: 123456789 Date: 21/04/2022 Time: 17:05 Image from:https://emedicine.medscape.com/article/338385-overviewCT SCAN Patient Name:Ali Hassan Patient DOB: 07/01/1968 Hospital Number: 123456789 Date: 21/04/2022 Time: 17:05 ‘This is an axial non-contrast CT scan of the Head showing hypodensity in the left frontal, parietal and temporal lobe. There is rightwad midline shift and sulcal effacement. This is indicative of left MCA infarct.' Image from:https://emedicine.medscape.com/article/338385-overviewH o w w o u l d y o u m a n a g e t h i s p a t i e n t ?STROKE MANAGEMENT ABCDE + senior review 1.CONSERVA TIVE Imaging within 1 hour Supportive care- regular monitoring of vital signs VTE prophylaxis- stockings 2.MEDICAL Aspirin 300mg (continued for 2 two weeks) If present within <4.5 hours → thrombolysis e.g.Alteplase If present >24 hours only STAT aspirin 300mg Consider thrombectomy within 6 hours of symptom onset or 3.SURGICAL up to 24 hours from onset if salvageable brain tissue Conservative:lifestyle advice,inform DVLA, smoking Long term cessation,MDT approach:stroke nurse,SALT,nutrition, physio,OT Medical: - Clopidogrel orAspirin + dipyridamole - Simvastatin Surgical:Carotid endarterectomy or stentingWHAT IF THE SYMPTOMS HAD RESOLVED?TIA MANAGEMENT A→ E exam, ABCD2 score + senior review 1.CONSERVA TIVE TIA >7 days → specialist assessment within 7 days TIA <7 days → urgent assessment within 24 hours Supportive care- regular monitoring of vital signs 2.MEDICAL Aspirin 300mg (unless contraindicated) Start statin 80mg Anticoagulate ifAF 3.SURGICAL Carotid endarterectomy or stenting if >70% stenosis* Long term Conservative:lifestyle advice,smoking cessation,MDT approach,inform DVLA Medical: nd - Clopidogrel 75 mg lifline:Aspirin 75mg) - Simvastatin 80mg C A S E 3 F a t i m a a 4 2 - y e a r - o l d p r e s e n t s t o t h e e m e r g e n c y d e p a r t m e n t w i t h t h e ‘ w o r s t h e a d a c h e e v e r ’. HEADACHE DIFFERENTIALS? MUST EXCLUDE:subarachnoid haemorrhage MUST EXCLUDE:SOL MUST EXCLUDE:meningitis MUST EXCLUDE:temporal arteritis DIFFERENTIALS Migraine Cluster headache Trauma SinusitisHOW WOULD YOU INVESTIGATE THIS PATIENT? Bedside Full neurological exam including cranial nerves,BM FBC,U+Es,LFTs,CRP,coag,group+ save/ cross match Bloods Orifices X-Ray Imaging:Urgent CT scan,chest X-ray (routine) ECG ST elevation may be seen LP:12 hours post headache if CT negative Special tests Digital subtractional catheter angiography (gold standard)YOUR CT SCAN COMES BACK.. Image from:https://radiopaedia.org/cases/subarachnoid-haemorrhage-4YOUR CT SCAN COMES BACK.. ‘This is a non-contrast axial CT scan of the head showing hyper density all basal cisterns, the bilateral sylvian fissures and inter-hemispheric fissure.This is consistent with a subarachnoid haemorrhage.’ Image from:https://radiopaedia.org/cases/subarachnoid-haemorrhage-4YOUR LUMBAR PUNCTURE COMES BACK.. Opening pressure:Increased Appearance: Yellow RBC’s: Present Xanthochromia: PresentH o w w o u l d y o u m a n a g e t h i s p a t i e n t ?SUBARACHNOID HAEMORRHAGE MANAGEMENT ABCDE + senior review + urgent referral to neurosurgery 1.CONSERVA TIVE Bedrest + BP control Supportive care- regular monitoring of vital signs VTE thromboprophylaxis (TED stockings) 2.MEDICAL Nimodipine (21 day course to stop vasospasm) 3.SURGICAL Coil or craniotomy and clipping Hydrocephalus- external ventricular drain Long term approach:stroke nurse,physio,OT, inform DVLAion,MDT Medical:address comorbidities C A S E 4 H a r r y a 6 1 - y e a r - o l d p r e s e n t s t o t h e G P w i t h l o s s o f s e n s a t i o n i n h i s h a n d s a n d f e e t . SENSORY NEUROPATHY DIFFERENTIALS? Diabetic neuropathy Alcoholism DIFFERENTIALS Drugs amiodarone,isoniazid, nitrofurantoin) B12/ thiamine defficiency VasculitisHOW WOULD YOU INVESTIGATE THIS PATIENT? Bedside Full peripheral vascular examination, ABPI,BM FBC,U+Es,LFTs,CRP, ESR,B12,folate,TFT’s,autoantibody screen, Bloods cholesterol Orifices NA X-Ray NA ECG NA Special tests Consider nerve conduction studiesA f o c u s s e d h i s t o r y r e v e a l s t h a t t h a t t h i s p a t i e n t i s a t y p e 2 d i a b e t i c . H i s H B A 1 c i s 5 2 m m o l / m o l . H o w w o u l d y o u m a n a g e t h i s p a t i e n t ?DIABETIC NEUROPATHY MANAGEMENT Patient education→ better diabetic control Lifestyle advice,inform DVLA MDT approach- diabetes nurse,dietician,pain management CONSERVA TIVE team 1) Review medications for diabetes as per guidelines 2) Symptom control: MEDICAL - Pain:amitriptyline,gabapentin,duloxetine - Gastroparesis:metoclopramide - GORD:PPIs - Depression:SSRI C A S E 5 K a t y a 1 5 - y e a r - o l d g i r l i s b r o u g h t i n t o t h e e m e r g e n c y d e p a r t m e n t b y h e r m o t h e r a f t e r h a v i n g a n ‘ o d d ’ f a l l .DIFFERENTIALS OF A FALL? Seizure Arrythmia DIFFERENTIALS Drugs (overdose or toxicity) Vasovagal syncope Mechanical fall FITS/ FALLS: THE HISTORY History of presenting complaint section BEFORE DURING AFTER -When? - LOC? - Memory? -Where? - Incontinence?Tongue biting? - Confusion? -What? - any injuries? - Tiredness after? -Warning signs?Vision? - What part of the body had firs- Any muscle weakness/ altered -Dizziness,chest pain, contact with the floor? sensation/ speech difficulty palpitations? - Length? - Who took you to the hospital? Do a full med review in DHBACK TO THE PATIENT.. The history reveals - Loss of consciousness,no memory - 2 minutes of jerking movements - Still tired for 3 hours after - No drug/ alcohol use - First time to experience an event like this - DH:oral contraceptive pill Causes of seizures Epilepsy (unidentified cause) Epilepsy post trauma,stroke,SOL Alcohol,drugs + withdrawal Psychogenic non-epileptic seizures Pre-eclampsia Metabolic disturbancesHOW WOULD YOU INVESTIGATE THIS PATIENT? Bedside testl signs,full neurological examination,lying standing,BP,BM,pregnancy FBC,U+E’s,LFT’s,bone profile,toxicology screen,prolactin+ CK Bloods Orifices NA X-Ray Imaging:chest X-ray, CT head ECG Bradycardia,arrythmia Special tests Electroencephalogram (eleptiform activity) EPILEPSY MANAGEMENT Generalised tonic colonic seizure: Refer to first seizure clinic CONSERVA TIVE Patient education Inform DVLA + do NOT drive Lamotrigine (sodium valproate and carbamazepine MEDICAL contraindicated) SURGICAL Only if structural abnormality Generalised tonic colonic Focal seizure Absence seizure seizure 1 line:sodium valproate 1 line:lamotrigine or carbamazepine 1 line:sodium valproate or 2 line:lamotrigine or 2 line:sodium valproate or ethosuximide carbamazepine levetiracetam NB:Avoid Carbamazepine C A S E 6 H e n r y a 7 2 - y e a r - o l d m a n p r e s e n t s t o t h e G P w i t h a t r e m o r, s t i f f i n e s s a n d d i f f i c u l t y w a l k i n g . Parkinson's disease Parkinson's dementia DIFFERENTIALS Drug-induced parkinsonism Parkinson's plus syndromes HOW WOULD YOU INVESTIGATE THIS PATIENT? Refer to specialist Full neurological exam,lying/ standing blood pressure,urine dip Bedside Bloods FBC,U+E’s,LFT’s,TFTs Orifices NA X-Ray Imaging:if diagnostic uncertainty → single photon emission computed tomography (SPECT). Routine (falls assessment) ECG Special tests NAHISTORY + EXAMINATION.. Characteristically Motor symptoms: asymmetrical! Non-motor symptoms - Pill rolling tremor - Neuropsychiatric problems:depression, - Cogwheel rigidity anxiety,apathy,hallucinations,impulse control - Bradykinesia disorder - Shuffling gait - Autonomic dysfunction:dysphagia, - Mask like face constipation,urgency,incontinence,orthostatic - Micrographic hypotension,sexual dysfunction - Microphonia - Sleep disorders:insomnia - Sensory disorders:hyposmia,pain, paresthesia To my knowledge..Cardiff have not asked for a Parkinson's examination.It is usually an upper/lower motor neuron exam.But you may be asked about Parkinson's features in the questions.PARKINSON’S DISEASE MANAGEMENT Refer to PD specialist CONSERVA TIVE Patient educationialist nurse,physio,OT,SALT,counselling Inform DVLA 1 line:Levodopa + dopa-decarboxylase inhibitor e.g. MEDICAL carbidopa (prevents peripheral conversion) 2 line:Dopamine agonist e.g.bromocriptine or MOA-B irdibitors e.g.selegiline 3 line:COMT inhibitors e.g.entacapone SURGICAL Deep brain stimulation for refractory symptomsIF YOU ELICIT SIGNS IN YOUR NEURO EXAM: BACK TO THE BASICS 1) Break it down into UMN or LMN UMN lesion LMN lesion Increased tone decreased tone Spasticity Wasting and fasciculation Hyperreflexia Hyporeflexia Weakness Weakness 2) Is is bilateral or Unilateral Bilateral UMN Unilateral MS Intracranial:MS,CVA,SOL Myelopathy Brainstem:MS MND Spinal cord: MS,Trauma,SOL,abscessIF YOU ELICIT SIGNS IN YOUR NEURO EXAM: BACK TO THE BASICS 3) for LMN divide it up into Bi/unilateral + whether sensation is intact or not Bilateral LMN + altered sensation Unilateral LMN Diabetes mellitus Radiculopathy (dermatomal sensory loss) Metabolic:B12/ thiamine defficiency Plexopathy (vast dermatomal sensory loss) Infections:herpes zoster,HIV,Lyme,SyNerve palsy Toxins:alcohol,drugs e.g.amiodarone Inherited:CMT Bilateral LMN:intact sensation Guillain Barre syndrome Lambert Eaton syndrome Lead poisingFINALLY: SPOT DIAGNOSISTHANK YOU ☺ A b d e l r a z i k Y T @ c a r d i f f . a c . u k