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Case24-Transient Nadine Soliman Lossof Year 3 Teaching Consciousness 3rdyearclinicalteaching@gmail.comWhatwe’recoveringtoda y +History LOC (what to ask) +Differentials +Syncope +Seizures +Progress Questions +OSCE Tips + Forum PC/HPC Before During After • Situation • Video? • Do they remember falling • Post-ictal (LOC before/after) • Head injury? • Drowsy, • Pre-syncopal symptoms • How long were you out • Tired, • aura, for? • Chest pain/Palpitations, • Did your complexion • Forgetful, • exercise, change? • Groggy, • ringing ears, • Did you seize? • light head, • Was your whole body • Confused • flashing lights/static, shaking? • Aching through • emotional • Tongue bitten? your whole body • Pre-seizure symptoms after • Crying out, • Come back incontient? • Weird smells, • Weird memories, • Lip smacking Systems Review Cardiovascular Gastrointestinal (CVS): Neurological (NS): and Genitourinary Red flags: (GIT/GUM): • Chest pain, • Focal weakness, • Abdominal pain, • Recent infections, • SOB, • Loss of • Bowel or urinary • Palpitations, sensation, changes • Weight loss, • Cough • Balance • Night sweats, changes, • Fevers, • Visual or • Bleeding, Auditory • Dark stools. changesPMHx: has this ever happened before? Previous diagnosis of epilepsy? MHx: anti-hypertensives, levothyroxine? Etc. FHx: Epilepsy, sudden deaths, arrhythmias SHx: smoke, drink alcohol, illicit drugs, What’s life like at home? How’s work? Stress?Differentials +Syncope = LOC due to lack of cerebral blood supply Characteristics Premonitory During Afterwards Previous Ix Treatment symptoms hx Vasovagal • Provoking event • Flaccid fall • Lightheaded • No LOC ECG to rule None • Flashing • Loss of tone • Vomiting before out Syncope lights • ± moaning or • Brief • FHx of cardiogenic • Dehydration growling with hips confusion vasovagal • Emotional and knees • Well oriented Stress extended immediately • Dizzy • ± tonic clonic • Blurring of Vision movements but • Ringing in the not rhythmic ears • ± Tongue biting and incontinence • Lasts seconds Cardiogenic Collapse while Twitching of limbs Might not ± recent LOC ECG Treat exercising Lasts 1-2 mins recognize underlying Syncope people around cause e.g antiarrymthics /pacemakers Provoked: Prodrome: Vasovagal Pain, Dizzy, has clear pre- Position: syncopal Upright Dehydration, Blurring symptoms – Emotional vision, PPP shock Ringing ears Seizures Seizure = abnormal/excessive discharge of electricity to the brain causes a break in activity + takes time to recover Epilepsy Provoked seizures Non-epileptic attack disorder (NEAD) • Alcohol excess Tendency for repeated, • A lcohol withdrawal, Subconscious, involuntary unprovoked seizures jerking Cocaine/amphetamine • Other drugs (i.e tramadol) • Trauma ortumour Characteristics Premonitory During Afterwards Previous Ix Treatment symptoms hx Epileptic • Crying out • Altered awareness • Confusion At least 1 Bedside: Anti- Seizure before • Abnormal lasts 20- 30 other ECG epileptics falling sensations mins episode • May begin • Focal involuntary • Post-Ictal >24hrs Bloods: FBC, DVLA - not movements or with focal convulsions phase: Can prior U&Es, LFTs, allowed to features (widespread) last Glucose, drive (until (right/left • Signs: cyanosis, days/weeks Calcium 1yr seizure- arm tongue biting, ± free) movement) incontinence Imaging: • Lasts 2-3mins MRI/brain imaging NEAD Warning : • Twitching of limbs • Feeling LOC EEG for Psychiatry feeling of • May start jerking horrible before electrophysiolog 'bleeding while still • Strong y to rule out conscious physical cause inside their emotions head' afterHowto Generalized-onset seizures • Origin = both hemispheres classify • Awareness usually impaired, LOC Nonmotor onset seizures Motor onset ▪ Absence • Bilateral from ▪ ± minor motor activity the onset ▪ Defined by earliest prominent feature • Tonic-clonic/grand-mal – stiffening and rhythmic jerking • Clonic – sustained rhythmic jerking • Typical absence • Tonic– stiffening only • Atypical absence (less abrupt • Atonic- loss of tone onset/termination) • Myoclonic – rhythmic jerking not preceded by • Myoclonic stiffening • Eyelid myoclonia • Myloclonic-tonic-clonic – myoclonic jerking + tonic- clonic movement • Myoclonic-atonic – myoclonic jerking + atoniaFocalOnset Focal-onset seizures • Origin = one hemisphere, sometimes one subcortical structure Seizure • Discretely localized or widely distributed Level of awareness • Autonomic dysfunction – GI sensation, heat/cold, flushing, • Focal aware: simple Focal- sexual arousal, palpitations partial onset • Behavioral arrest – main feature nonmotor is cessation of movement and • Focal impaired- Focal-onset motor unresponsiveness awareness: complex • Cognitive dysfunction = partial if awareness is impaired in any part of impaired language or other the seizure cognitive domains, positive signs(déjà vu, hallucinations, illusions, perceptual distortions) • Automatisms – coordinated, purposeless, repetitive motor activity • Emotional dysfunction – emotional changes (anxiety, fear, • Atonic joy), affective signs w/out subject • Clonic –focal rhythmic jerking emotions • Epileptic spasm – focal flexion or extension of arms + flexion of trunk • Sensory dysfunction – • Hyperkinetic – pedaling or thrashing somatosensory, olfactory, visual, • Myoclonic – irregular, brief focal jerking auditory, gustatory, or vestibular sensations • Tonic – sustained focal stiffeningEpilepsyDiagnosis First steps Epilepsy • Call for help Management: • Note and keep track of time • Check for epilepsy ID/jewelry Steps • Protect from injury • Cushion head • Remove harmful objects • DO NOT restrain/put anything in their mouth <5 mins Next steps • Observe them until recovered (from • post-ictal phase) • Neuro referral if first/ Refer to First Fit Examine for and manage injuries Clinic WITHOUT prescribing medications • Advise witness to record further episodes >5 min • Advise to stop driving • Status epilepticus • Advise to contact GP EpilepsyManagement:Mx Generalised and clonic (muscle jerking) episodes. Typically the tonic phaseum valproate comes before the clonic phase. There may be associated tongue TonicClonic biting, incontinence, groaning and irregular brSecond line: lamotrigine or carbamazepine Seizures is confused, drowsy and feels irritable or depressed.the person Focal seizures start in lobes. They affect hearFirst line: carbamazepine or lamotrigine Focal memory and emotions. Seizures Second line: sodium valproate or levetiracetam Absence becomes blank, stares into space and then abruptly returns todium valproate or ethosuximide normal. During the episode they are unaware of their Seizures surroundings and won’t respond. These typically only lasts 10-20 they get older.atients (> 90%) stop having absence seizures as Atonic seizures are also known as “drop attacksFirst line: sodium valproate Atonic characterized by brief lapses in muscle tone. These don’t usually Seizures may be indicative of Lennox-Gastaut syndrome.n in childhood. They Second line: lamotrigine Myoclonic like a sudden “jump”. The patient usually remains awake duringium valproate the episode. They occur in various forms of epilepsy but typically Seizures happen in children as part of juvenile myocloniOtherlepsy. options: lamotrigine, levetiracetam or topiramate MxSideEffects: Sodium Carbamazepine Phenytoin Ethosuximide Lamotrigine Valproate •patients needo • Agranulocytosis • vitamin Dd • Night terrors •Johnsons- • Aplastic • Rashes careful advice anaemia deficiency syndrome or contraception • Induces the • Megaloblastic syndrome. P450 system so anaemia (folate • Liver damage there are many deficiency) threatening skin and hepatitis drug interactions • Osteomalacia rashes. • Hair loss (vitamin D • Tremor deficiency) • Leukopenia There are a lot of warnings about the teratogenic effects of sodium valproate and NICE updated their guidelines in 2018 to reflect this. It must be avoided in girls or women unless there are no suitable alternatives and strict criteria are met to ensure they do not get pregnant.EpilepsyManagement:Lifestyle +The overall goal for managing a patient with epilepsy should be for no seizures and no side-effects from medications +The key aspects of management are +Education and safety, +Treating acute seizures, +Role of the first fit clinic +Long-term treatment with AEDs.SeizureManagement-DVLAComplicationsofEpilepsy +Status Epilepticus +Sudden unexpected death in epilepsy (SUDEP ) +most common cause of death in adults with epilepsy, mostly poorly controlled epilepsy and nocturnal variants +Trauma +Drowning +Road Traffic Collision (RTC) StatusEpilepticus Status epilepticus is an important condition you need to be aware of and how to treat. It is a medical emergency. It is defined as seizures lasting more than 5 minutes or more than 2 seizures in one hour and patient does not fully recover in between. Management of status epileptics in the hospital: • Take an ABCDE approach: • Secure the airway • Give high-concentration oxygen • Assess cardiac and respiratory function • Check blood glucose levels • Gain intravenous access (insert a cannula) • IV lorazepam 4mg, repeated after 10 minutes if the seizure continues • If seizures persist: IV phenobarbital or phenytoin Medical options in the community: • Buccal midazolam • Rectal diazepamProgressStyle QuestionsQ1Q2Q3Q4Q5Q6OSCETipsGeneralinspection + “Appears fit and well” + Posturing. + Decerebrate + Decorticate + Involuntary movements + Fasciculations + Tremors (more on this later) + Convulsions + Choreoathetoid + Muscle wasting + Meds/assistive devices: walking stick, wheelchair, hearing aids, glasses!, medications + Scars from previous surgeryGeneralobservation Fasiculations Twitching like muscle activity characteristic of LMN damage. Likely due to degeneration of neurons and release of Ach Pill rolling tremor – Parkinson’s disease Symptoms of Parkinsons: Tremor Rigidity (Cog w Akinesia Postural instabilityGeneralobservation Facial nerve palsy Drooping of the lips, eye brow and sagging of the face on the affected side. Facial nerve Ramsey Progress palsy + = Hunt SyndromePosturing Decorticate posturing (mummy- like) – Damage above the level of the midbrain Decerebrate posturing (extension) – Damage at or below midbrain. More worrying. Scored lower on the GCS.UMNvsLMNlesionsVisualfields +Make sure you are at the same level as the patient +Ask them to close their eyes and keep their head still, and says “yes” when they see your finger wiggle +Ask them to cover their eyes and you should cover the contralateral eye. +If they keep moving, politely offer to help “Would it be okay if I place my hand on your head to help keep it steady?” +Test all 4 quadrants, in an X shape, moving in slowly while wiggling your finger.Co-ordinatedgaze +With both eyes open , ask the patient to follow your finger while keeping their head still. +“Let me know if you experience any double vision or discomfort” +Observe the patient’s eyes for nystagmusCranialnervepalsies Oculomotor nerve Abducens nerve Trochlear nerve palsy palsy palsy Eyes down and out Failure of abduction on Tilting of the eyes -> head tilt away from lesion affected sidePupillaryreflexes +Ask if the patient experiences discomfort with bright lights and then briefly explain the procedure. +Using a pen torch, shine light into one of their eyes, checking for the direct reflex (pupillary constriction in that eye) and consensual reflex (constriction in the contralateral eye). +Pathology: +Loss of direct reflex in the left eye and consensual reflex in the right eye? +Loss of direct and consensual reflexes in the right eye?Face, pharynx and tongue +Test the power of facial muscles, showing the patient as you go along +Raise eyebrows, tighten eyelids (+against resistance), puff cheeks (+against resistance), smile +Ask the patient to open their mouth, and using a pen torch, observe the uvula +If it’s deviated to the patient’s right, where would the lesion be? Left +Ask the patient to say “aaah” and observe +Look for symmetrical palate and uvula elevation +Observe tongue for fasciculations, wasting, and deviation. Ask the patient to move it from side to sideNerve supply of facial muscles The facial nerve fibres supplying the upper face receive UMN innervation from both sides of the brain. UMN damage is unlikely to be biilateral. Therefore UMN damage = loss of power in the lower face only. Facial nerve damage = loss of power in all facial muscles on the affected side.Tone: Upper limb +Inspection (as before: fasciculations, tremors, deformity) +Pronator drift +Ask the patient to extend their arms, palms up, with their eyes closed +Pronator drift = pronation with downward movement = contralateral UMN lesion +Cerebellar drift = drifting upwards = damage to ipsilateral cerebellum +Tone +“Relax and let me take the weight of your arm” +Range of movements at different speeds. Why? +Three types of hypertonicity: Lead-pipe, clasp-knife, cogwheel rigidity Hypertonicity Clasp knife spasticity Cogwheel rigidity Lead pipe rigidity UMN lesion Parkinson’s disease Also seen in PDTone: Lower limb +Ask the patient to relax as you will be moving their legs +Raise their knee slowly, observing the position of the heel +Repeat this at a faster speed +Ankle clonus: rapid dorsiflexion -> +ve if the patient’s feet beatMuscle power +MRC muscle power scaleMuscle power: Upper limb +Ask the patient to stick their arms out +Test each movement on one side and then the other to compare. Always test against resistance and isolate +It helps to show them the action you are testing for + Test for +Shoulder abduction (C5, C6) +Wrist flexion (C7) and extension (C8) +Finger flexion (C8), extension (C7) and abduction (T1) + Abduction: ask them to fan their fingers out and “stop me pushing them in” +Thumb abduction (T1)Muscle power: Lower limb +With the patient lying down, ask them to relax and test for +Hip flexion and extension +Knee flexion and extension +Ankle dorsiflexion and extension +Again, make sure you repeat every action on both sides before moving to the next one for comparisonReflexes +As in year 2: biceps, triceps, supinator, ankle, knee, plantar. +Often, the reflex is very subtle, so look at the muscle compartment you are testing for a twitch +Try to get the reflex twice, then try potentiation, by asking the patient to clench their jaw on the count of 3 +When testing reflexes, always feel for the tendon first. +When testing biceps and supinator, tap on your fingers rather than the tendon directly.Reflexes +Plantar reflex: +Use an orange stick (or pen) along the lateral aspect of the foot up to metatarsals and then moving medially. +Normal = down going = negative Babinski sign +Abnormal = up going = positive sign + This is normal in children up to 1 year old + Indicates UMN lesion thereafterCo-ordination +Only finger to nose; you do not need to do the heel to shin test +Communication can be challenging. I use “put your index finger on your nose”.. “Now touch my finger using your index finger, and back to your nose”.. “Keep going back and forth as fast as you can” +Give instructions in a stepwise manner +be careful not to touch your nose! +Move points rapidly, making sure you stetch the patients arm far out +You are looking for intention tremor and past pointingSensation +Use a neurotip, not cotton wool! +Demonstrate to the patient on their sternum, “It is sharp but should not cause significant pain”. +With the patient’s eyes closed lightly touch each dermatomal area. +Know your dermatomes! +On the arms they go in an anticlockwise fashion +Legs + L1 = inguinal ligament + L3 = knee caps + S1 = big toeVibration +Just like year 2 +Using a vibrating fork, demonstrate the feeling on their sternum. +Ask them to close their eyes and test both sides on the thumb and big toe. +Ask them to tell you when they can feel it and when it stops +If sensation is normal distally, there is no need to test further. If abnormal, retest more proximally until they can feel the vibrations.Furthertests +Gait +Ask them to walk in a straight line +If they manage to do that, ask them to walk heel to toe +“I am here to catch you if you feel unstable” +Romberg test +Ask them to stand still and close their eyes +What does this test for? +Finally, wash your hands, ask the patient to dress, and present to the examinerPresentingtotheexaminer +Today I performed a neurological examination of Mr. X, a 30 year old gentleman. He appeared fit and well (always start with a general comment). I did not observe any posturing, tremors, fasciculations, or muscle wasting (comment on general inspection). Pupillary reflexes and visual fields were normal in both eyes, and facial muscle power was normal (cranial nerves). Tone, reflexes, and sensation were normal in upper and lower limbs and muscle power was 5/5 in all groups (limbs). There were no signs of cerebellar disease. To conclude this examination I would like to (any parts that you were asked not to do).ThankY ouforListening! Any Questions? 3rdyearclinicalteaching@gmail.com