Ageing & Complex health Flashcards
(107 cards)
1
Q
A patient presents with symptoms suggestive of a stroke, how would you assess them?
A
[Introduction]
- Introduce self + Wash hands
- Patient name & DOB
- I am going to be assessing you as you have had some symptoms that suggest that something is going on in your brain. Do you have any pain at the moment?
- I will need you to undress so that I have access to your neck & UL + LL
[Initial assesment]
ABCDE
A-Airway
- Is the patient maintaining their airway?
- If NO -> Use airway opening maneouvre (Head tilt chin lift)
- Get anaesthetic input for airway
B-Breathing
- Brief respiratory exam
- RR
- Tracheal deviation
- Chest expansion
- Chest auscultation
- O2 saturations
C-Circulation
- Brief cardiovascular exam
- HR + Rhythm + Volume
- BP
- Carotid bruits + Irregular pulse (Ischaemic stroke RF)
D - Disability
- GCS Score
- Check pupils
- Measure Blood glucose
- Measure temp
E - Everything else
- Basic neurological exam + CN exam
- Gait
- Speech & Swallowing
- Identify vascular territory based on exam findings - Bamford classification:
- Total anterior circulation stroke (TACS)
- Partial anterior circulation stroke (PACS)
- Posterior circulation stroke (POCS)
- Lacunar syndrome
- Determine stroke severity using NIHSS score
2
Q
What do the following Bamford classifications of stroke suggest?
TACS
A
[Total Anterior circulation stroke]
Large cortical stroke affecting ACA + MCA
Must have ALL:
- Unilateral weakness ± Sensory deficit of face/arm/leg
- Homonymous Hemaniopia
- Higher cerebral dysfunction (Dysphasia/Visuospatial disorder)
3
Q
What do the following Bamford classification of stroke suggest?
PACS
A
Partial Anterior Circulation Stroke
Less severe than TACS, Only part of the Anterior circulation is affected
They have at least 2 of:
- Unilateral weakness ± sensory deficit of face/arm/legs
- Homonymous hemaniopia
- Higher cerebral dysfunction (Dysphasia/Visuospatial disorder)
4
Q
What do the following Bamford classification of stroke suggest?
PCS
A
Posterior circulation stroke
Damage to the posterior circulation (Cerebellum & Brainstem)
They have 1 of the following:
- CN Palsy + Contralateral motor/sensory deficit
- Bilateral motor/sensory deficit
- Conjugate eye movement disorder (Horizontal gaze palsy)
- Cerebellar dysfunction (Vertigo/Nystagmus/Ataxia)
- Isolated homonymous hemaniopia
5
Q
What do the following Bamford classification of stroke suggest?
Lacunar stroke
A
Subcortical stroke secondary to small vessel disease - No loss of higher cerebral function
Must have 1 of the following:
- Pure sensory stroke
- Pure motor stroke
- Sensory/Motor stroke combined
- Ataxic hemiparesis (Weakness/clumsiness on 1 side)
6
Q
If you suspect a patient has had a stroke, what investigations should you carry out?
A
Identify the onset of the stroke, to determine the thrombolysis window
- Contact on-call stroke team
- CT Brain - Identify if ischaemic/haemorrhagic stroke
- ECG - Identify if AF/IHD
- Blood glucose -> Exclude hypoglycaemia
- FBC + CRP -> Exclude infection
- LFTs + Clotting profile -> Exclude clotting disorders
- May require urgent transfer to hyperacute stroke unit for thrombolysis
- If <4.5hrs
7
Q
What is a TIA?
A
Transient ischaemic attack
- Temporary inadequacy of the circulation in part of the brain - Cerebral/retinal/spinal cord deficit
- Transient & reversible lasting <24hrs
8
Q
What are the typical symptoms of a TIA?
A
- Neurological deficit lasting <24hrs
- Witness reports change in behaviour
- Unilateral symptoms
- Weakness affecting arm/leg/side of face
- Dysarthria - Slurred speech
- Sensory symptoms
- Amaurosis fugax
- Visual changes
9
Q
What is a Crescendo TIA?
A
>2 episodes of TIA within a week
Treat as High risk for early stroke
10
Q
If you suspect a patient has had a TIA, how would you investigate it?
A
- Urine dipstick - Negative
- FBC - Normal. Rule out infection
- U&E - Normal. May have abnormal electrolytes
- TSH
- ECG - Normal, May have AF
- PT/INR/APTT - Normal
- Blood glucose - Normal. Rule out hypoglycaemia
- Brain MRI w/diffusion - May show infarcts
- Carotid imaging - Duplex USS + CT Angiography
11
Q
A patient presents with the following Hx, what is the most likely diagnosis. What are the differentials?
A 67-year-old man with a prior history of hypertension, diabetes, hyperlipidaemia, and a 50 pack-year smoking history noted rapid onset of right-sided weakness and subjective feeling of decreased sensation on his right side. His family reported that he seemed to have difficulty forming sentences. Symptoms were maximal within a minute and began to spontaneously abate 5 minutes later. By arrival in the emergency department 30 minutes after onset, his clinical deficits had largely resolved with the exception of a subtle weakness of his right hand. Forty minutes after presentation, all of his symptoms were completely resolved.
A
- TIA
- Stroke
- Hypoglycaemia
- Hyponatraemia
- Intracranial lesion - Tumour/Subdural haematoma
- Migraine
12
Q
How are TIA’s managed?
A
Acute:
- 300mg Aspirin then 75mg daily
- After 2 weeks change to Clopidogrel 75mg
- Confirm diagnosis of TIA
- High intensity statin - Atorvastatin
Secondary Management:
- Inform patient of driving restions - No driving for 1 month, no need to inform DVLA.
- If multiple TIA’s - No driving for 3 months + Inform DVLA
- Lifestyle modification - Stop smoking + Exercise + Reduce alcohol
- BP lowering therapy if Hypertensive
- If AF -> Anticoagulation
13
Q
What is used to determine the risk of stroke after a TIA?
A
ABCD2 score
A- Age
- >60 yrs = 1 pt
B - BP
- SBP >140mmHg ± DBP >90mmHg = 1 pt
C - Clinical features
- Unilateral weakness = 2 pts
- Speech disturbance w/o weakness = 1 pt
D - Duration of symptoms
- >1hr = 2 pts
- <1hr = 1 pt
D - Diabetes
- Yes = 1 pt
Scores:
- >4 - High risk of stroke (See within 24hrs)
- <4 - Low risk of stroke (See within 1 week)
14
Q
What is Carotid stenosis?
Which area of the vascular network is most commonly affected in carotid stenosis?
A
Narrowing of the carotid arteries, leading to TIA/Stroke
Caused by:
- Atherosclerosis (Most common)
- Aneurysm
- Arteritis
- Carotid dissection
- Vasospasm
Bifurcation of the Common Carotid Artery
15
Q
What are the typical symptoms of carotid stenosis?
A
- Asymptomatic
OR
- TIA/Stroke symptoms
- Contralateral weakness/sensory disturbance
- Ipsilateral loss of vision
- Dysphasia
- Aphasia
- Carotid bruit
16
Q
If you suspect that a patient may have carotid stenosis, what investigations should be carried out?
A
- FBC - Normal
- U&E - Normal
- Duplex USS - Stenosis
- CT Angiogram - Stenosis
17
Q
How is carotid stenosis managed?
A
Asymptomatic:
- Dual antiplatelet - Aspirin 75mg + Clopidogral 75mg
- Risk factor management - Stop smoking/Exercise/Diet modficiations
Symptomatic >70% stenosis
- Carotid endarterectomy
- Dual antiplatelet - Aspirin 75mg + Clopidogral 75mg
18
Q
A patient presents with confusion suggestive of delirium, what differential diagnoses should be considered?
A
- Infection – UTI/Pneumonia/Meningitis/Encephalitis/Sepsis
- Stroke/Subdural haematoma/Epilepsy
- Dehydration
- Hyponatramia/Hypercalcaemia/Thryoid dysfunction
- Thiamine deficiency
- MI/Heart failure
- Drugs – Sedatives/Opiates/Steroids/Alcohol
- Malignancy/Constipation/Urinary retention
19
Q
A patient presents with dizziness/vertigo. What are the differentials to consider?
A
- Peripheral – BPPV/Vestibular neuritis
- Viral labyrinthitis/Menieres disease
- Central – Vertebrobasilar insufficiency
- ENT – Acoustic neuroma/Chronic otitis media
- Stroke – Vertebrobasilar stroke/Cerebellar stroke
- MS/Epilepsy/Migraine
- Diuretics/Alcohol/Trimethoprim
20
Q
A patient presents with a fit/fall/or LoC, what are the differentials that should be considered?
A
Cardiovascular:
- Postural Hypotension
- Arrythmia
- Aortic stenosis
- HOCM
- Carotid sinus hypersensitivity
Neurological:
- Seizure
- Parkinsons disease/Parkinsonism
- TIA/Stroke
- Vasovagal syncope
- MS
- Intracranial haemorrhage
Mechanical:
- Mechanical fall/Postural instability
- Drugs – Alcohol/Polypharmacy
21
Q
What are the key principles for assessing mental capacity?
A
- Able to understand the information
- Retain the information
- Weigh up the information
- Communicate the decision
Confirm capacity – By asking patient to repeat back to you the information they have just gained in their own words. (Understanding)
22
Q
What should be done if a patient is found to lack capacity?
A
Make decisions in their best interests, take into consideration:
- Previous expressed opinions
- Family/Friends views on what patient has expressed
Choose the least restrictive method of treatment
23
Q
When doing a comprehensive geriatric assesment, what should be assessed?
A
- Physical health
- Mental health
- Social circumstances
- Functional ability
- Environment
Physical health
- PMHx + Co-morbidities
- Medication review + list
- Nutritional status
- Skin integrity/Pressure sores
- Falls screening
- Urinary/Faecal incontinence
Mental health conditions:
- Cognitive assesment
- Delirium assesment
- Mood + Anxiety
- Fears
Social circumstances
- Informal support/Support networks
- Formal support - e.g. care packages
- Statutory care + Eligibility
- Finances
Functional abilities
- Mobility + Transfers
- Personal/Domestic/Community/ADLs
Environment
- Housing
- Equipment/Adaptations
- Transport
- Accessibility
24
Q
You are asked to complete a nutritional assesment of an elderly patient, How would you go about doing this?
Complete a MUST Score
A
To identify risk factors for malnutrition
Screening Qs:
- Are you able to feel yourself or do you have any problems? Who assists you?
- Can you prepare your own meals? Who assists you with this?
- Are you able to do your own shopping? Who assists you?
- Have you had any change in your weight? How much?
- Have you had any problems with your teeth/swallowing?
- What is your usual dietary intake?
MUST Score:
- Calculate BMI (Height + Weight)
* >20 kg/m2 – Obese/Normal = 0 points
* 18.5 - 20 kg/m2 = 1 point
* <18.5 BMI = 2 points
- Calculate BMI (Height + Weight)
- Note % of unexplained weight loss in past 3-6mo
* <5% = 0 points
* 5-10% = 1 point
* >10% = 2 points
- Note % of unexplained weight loss in past 3-6mo
- Is the patient acutely unwell + Has there or is there likely to be no nutritional intake for >5 days
* No = 0 points
* Yes = 2 points
- Is the patient acutely unwell + Has there or is there likely to be no nutritional intake for >5 days
25
What do the following MUST Scores mean? How would they be managed?
0 points
1 point
2 points
**0 points -- Low risk**
* Routine clinical care
* Repeat screening
* Treat underlying condition
**1 point -- Medium risk**
* Observe patient + Document dietary intake for 3 days
* If adequate intake:
* Little concern, repeat screening
* Treat underlying condition
* If Not adequate intake:
* Clinical concern
* Improve + Increase dietary intake
* Monitor + Review care plan regularly
* Treat underlying condition
**2 points -- High risk**
* Treat (Unless imminent death)
* Refer to dietician/Nutrition support
* Increase overall dietary intake
* Monitor + Review care plan
* Treat underlying condition
26
What is Malnutrition?
* State of nutrition where there is deficiency or excess of energy/protein/other nutrient
* Causes measurable adverse effects on tissue/body form/function/clinical outcome
27
What are the common causes of malnutrition?
* Drugs -- Decreased apetite/causing constipation
* Ageing -- Gastric motility slowed/Decreased apetite
* Medical conditions -- COPD/Heart failure/CKD/Liver disease
* Malignancy/Depression/Dementia
* Environment -- Frailty/Social isolation
* Surgery/Illness
* D&V/Burns/Wounds/Fever
28
What is meant by the following terms?
NG tube
Gastrostomy
Parenteral v Enteral
TPN
PPN
* **NG tube** -- Tube from nose to stomach (Nasogastric tube)
* **Gastrostomy** -- Tube inserted from skin into the stomach (Invasive)
* **Parenteral** -- Feeding not via the GI tract into a vein
* **Enteral** -- Feeding via the GI tract
* **TPN** -- Feeds into the SVC (Total Parenteral Nutrition)
* **PPN** -- Feed into the peripheral veins (Partial Parenteral Nutrition)
29
What is a stroke?
* Neurological symptoms caused by disruption of the blood supply to the brain
* Focal/Global disturbance of cerebral functions
* Lasts \>24hrs
30
What are the 2 types of stroke?
* Ischaemic stroke -- Vascular occlusion/Stenosis
* Most common cause
* Intracerebral haemorrhage -- Intraparenchymal ± SAH
31
What is an Ischaemic stroke?
What are the different causes of it?
Transient or permanent reduction in cerebral blood flow due to:
* Arterial occlusion/Stenosis
Causes:
* Large arteries -- Extracranial carotid arteries/Vertebral arteries/intracranial arteries
* Small vessel -- Lacunar infarcts
* Cardioembolism - Thrombus from heart
* Vessel disease -- Dissection/Vasculitis/VTE
* Sickle cell disease/APS
32
What is a haemorrhagic stroke?
Bleed in the brain caused by chronic HTN
Due to:
* Primary spontaneous --
* Idiopathic/Anticoagulation induced
* Secondary -- Vascular malformation/Cerebral tumour/Recreational drug use (Cocaine/Amphetamines)
* Haematological malignancy
* Vascular rupture -- Shearing of brain tissue + adjacent vessels
33
Which conditions classically lead to strokes in the following patients?
Young
Old
Young patient:
* Vasculitis
* SAH
* Thrombophilia
* Venous sinus thrombosis
* Strangulation/Fibromuscular dysplasia (Leads to carotid artery dissection)
Older patient \>65 yrs:
* Thrombosis in situ
* Cardiac origin emboli e.g. AF
* Atheroembolism
* CNS bleed - HTN/Injury/Aneurysm
* Vasculitis
34
Who classically gets strokes?
Patients with:
* HTN
* DM
* PAD
* Use of the COCP
* Post TIA
* Hyperlipidemia
* Smokers
* Heart disease -- Valvular/IHD/AF
35
When examining a patient suspected of suffering from a stroke, what signs should you look for?
Meningism signs:
* Neck stiffness/Headache/Photophobia
* Visual changes
Raised ICP signs (Haemorrhagic stroke):
* Headache
* Coma
* Papilloedema
Ischaemic stroke:
* Carotid bruit
* AF
* HTN
36
A patient presents with the following history, what is the most likely diagnosis? What are the differentials?
A 70-year-old right-handed man is discovered by a family member to have difficulty speaking and comprehending spoken language, and an inability to raise his right arm. He was last known to be fully functional 1 hour ago when the family member spoke to him by phone. There is a history of treated hypertension and diabetes.
* **Ischaemic stroke**
* Haemorrhagic stroke
* Hypoglycaemia
* CNS tumour
* TIA
* Subdural bleed
* Hemiplegic Migraine
37
A patient presents with the following history, what is the most likely diagnosis? What are the differentials?
A 70-year-old man with a history of chronic hypertension and atrial fibrillation is witnessed by a family member to have nausea, vomiting, and right-sided weakness as well as difficulty speaking and comprehending language. The symptoms started with only mild slurred speech before progressing over several minutes to severe aphasia and right arm paralysis. The patient is taking warfarin.
* **Haemorrhagic stroke**
* Ischaemic stroke
* Hypoglycaemia
* Encephalopathy
* Hemiplegic migraine
* Seizure
38
A patient presents with the following Hx suggestive of stroke, what investigations should be carried out?
A 70-year-old man with a history of chronic hypertension and atrial fibrillation is witnessed by a family member to have nausea, vomiting, and right-sided weakness as well as difficulty speaking and comprehending language. The symptoms started with only mild slurred speech before progressing over several minutes to severe aphasia and right arm paralysis. The patient is taking warfarin.
* **CT Head** -- Rule out/in Intracerebral haemorrhage
* If CT Head is clear, but Hx suggestive of Haemorrhagic stroke -- MRI Brain
* **ECG + Troponin** -- Assess for MI/AF
* **Blood glucose** -- Normal. Rule out hypoglycaemia
* FBC -- Thrombocytopenia/Polycythemia/Anaemia
* ESR -- Normal. Rule out GCA
* U&E -- Normal. Rule out electrolyte imbalance LFTs + Clotting screen -- Rule out coagulopathy
39
A patient presents with a Suspected/confirmed stroke, how would you manage this?
* O2 therapy if SATS \<95%
* Blood sugar control if DM
* Manage BP
* Swallowing assesment
Ischaemic stroke:
* Within 4.5hrs + No C/I to thrombolysis
* Alteplase (Thrombolysis)
* 24hrs later - 300mg Aspirin
* \>4.5hrs since onset or C/I to thrombolysis
* Aspirin 300mg acute + for 2 weeks
* Change to Clopidogrel
* If AF -- Warfarin
Haemorrhagic stroke:
* Neurosurgical review -- May require decompressive craniotomy
* ICU
* BP Management
40
What are the contraindications for thrombolysis?
* Seizure at onset of stroke
* Stroke or serious head injury 3 mo prior
* LP in last week
* Symptoms suggesting SAH
* Major surgery 2 weeks prior
* INR \>1.4
41
What are the complications that can arise after a stroke?
* Residual neurological problems
* Neuropathic pain
* Depression/Anxiety
* Swallowing difficulty
* Cognitive impairment
* Speech/Visual impairment
* Sexual dysfunction
42
What are the components of the NIHSS score, used to determine stroke severity etc?
* Level of consciousness
* Orientation -- Knows month + own age
* Open + Close eyes on command
* Best gaze
* Visual fields
* Facial pareisis
* Motor function R + L arm & Leg
* Limb ataxia
* Sensory
* Language
* Dysarthria
* Extinction & Inattention
43
What is Dysarthria?
* Disorder of speech -- Motor
* Articulation + Pronounciation
* Signifies Broca's or Bulbar dysfunction
44
What is Dysphasia?
Disorder of language - thoughts + ideas that are spoken
**Receptive**:
* Difficulty in comprehension
**Expressive**:
* Difficulty putting words together to form meaning
45
What can be seen on a CT scan in a patient with a stroke?
* Hyperdense artery -- Suggests clot
* Hypodense cortex -- Ischaemic damage
* May have cytotoxic oedema surrounding area
* Hyperdense lesion in cortex -- Haemorrhagic stroke
46
A patient has presented with a tremor, you are asked to assess them. How would you go about this?
**[Introduction]**
* Introduce self + Wash hands
* Ask patient name + DOB + Age
* I am going to be doing an exam to look at how your brain is working, looking at your arms and legs, as well as your walking
* Is that ok?
* Any pain at the moment?
* I will need to be able to see your arms ± legs so I will need you to undress accordingly
**[General inspection]**
* I will start the examination by looking at you from the end of the bed, looking for:
* Walking aids
* Looking at the patient:
* Any obvious tremor -- Fine or Coarse
**[Tremor]**
* Assess for resting tremor:
* Can you rest your hands on your lap and close your eyes
* Count down from 20
* Assess if tremor
* Ask to lift opposite hand up and down on lap (Synkinesis)
* Assess for postural tremor:
* Can you hold your arms out in front of you
* If tremor worsens -- Postural tremor
* Hold palms out facing me -- Flapping tremor
* Assess for action tremor:
* Can you pick up a pen lid from out of my hand or pick up a glass of water
* Ask patient to move finger from my hand to their nose
* Test other side
* Assess for bradykinesia:
* Can you spread your index finger + thumb as wide as you can
* Can you tap them together rapidly and repetitively (Opposition)
* Watch for reduction in speed of movement + rhythm + amplitude
**[Gait]**
* Can you get up and walk up and down the room for me, ill watch from here. Do you need any mobility aids?
* Assess gait for:
* Shuffling gait
* Hesitant gait (Difficulty starting + turning)
* Festinant gait (Walks faster + faster so they dont fall over)
* Lack of arm swing (Increased tone)
* Unsteadiness - tend to fall
* Freezing - Stop whilst moving
**[Face]**
* Can you take a seat on the exam couch now for me
* Observe face:
* Hypomima
* Any drooling
* Glabellar tap:
* Repeatedly tap on forehead - should blink in response to 1st tap then stop
* Note if blinking continues within continued tapping
* Eye movements:
* Test eye movements with H test
* Note for:
* Vertical gaze palsy
* Nystagmus
* Assess speech:
* Can you count down from 100 please
* Listen for softening of speech + faint (Hypophonia)
* Slowing down of thought
* Can you say baby hippopotamus + British Constitution
* Assess for dysarthria/Staccato speech
**[Rigidity/Limb exams]**
* Assess UL/LL tone, looking for:
* Increased tone (Spasticity/Rigidity)
* Test with synkinesis (if no Increased tone)
* Test bradykinesia:
* In UL -- Can you touch your thumb to your index finger repeatedly
* In LL -- Can you tap the bed with your heel repeatedly
* Look for -- Slowing of movement
**[Power/Reflexes/Sensation]**
* Assess to see if there is any dysfunction in these
**[Other tests]**
* Check for postural hypotension -- Lying + Standing BP
* Check writing for micrographia
* Cognitive testing -- MMSE
* Drug Hx
**[Complete exam]**
* Thank patient + Wash hands
* I would take a full Hx + full neurological examination
* Differentials
* Investigations
* Management
47
What signs would you expect on examination in a patient with Idiopathic parkinsons disease?
* Unilateral coarse pill rolling tremor
* Resting tremor
* Bradykinesia
* Gait problems -- Shuffling/Hesitant/Festinant/Lack of arm swing/Unsteadiness/Freezing
* Hypomima/Drooling
* Continued blinking on Glabellar tap
* Hypophonia/Dysarthria/Stacatto speech
* Cogwheel rigidity
* Normal Power/Reflexes/Sensations
* Micrographia
48
What are the following signs of?
* Postural tremor
* Flapping tremor
* Action tremor
* Vertical gaze palsy
* Nystagmus
* Dysarthria/Staccato speech
* Orthostatic hypotension
* Decreased cognition
* DHx
* **Postural tremor** -- MS
* **Flapping tremor** -- Hepatic/Respiratory/Renal failure
* **Action tremor** -- Physiological tremor
* **Vertical gaze palsy** -- PSP
* **Nystagmus** -- MSA/Cerebellar pathology
* **Dysarthria/Staccato speech** -- Cerebellar pathology
* **Orthostatic hypotension** -- Degenerative PD/MSA
* **Decreased cognition** -- Lewy body dementia
* **DHx of parkinsonism drug** -- Drug induced parkinsonism
49
What is Idiopathic Parkinsons disease?
Movement disorder due to the degeneration of dopaminergic pathways in the basal ganglia leads to overall decreased dopamine available
Characterised by TRAP:
* Tremor at rest
* Rigidity
* Akinesia/Bradykinesia
* Postural instability
50
What causes Idiopathic parkinsons?
Selective loss of Nigrostriatal dopaminergic neurons in Substantia nigra of basal ganglia
* Deposits of protein synuclein
* Decreased activity of direct pathway
* Increased activity of indirect pathway
Lead to increased inhibition of movement to the thalamus
51
Who classically gets IPD?
What is the classic presentation (Symptoms/Signs) of PD?
\>55yrs
Men \> Women
Symptoms/signs:
* Slow progressing neurodegeneration
* Bradykinesia
* Resting tremor
* Gait + Balance disturbance
* Hypomima (Fixed facial expression)
* UMN signs - Rigidity
* Asymmetry
* Normal muscle strength
* Normal reflexes
* Down going/Absent Plantar reflex
52
A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?
A 69-year-old man presents with a 1-year history of mild slowness and loss of dexterity. His handwriting has become smaller, and his wife feels his face is less expressive and his voice softer. Over the last few months he has developed a subtle tremor in the right hand, noted while watching television. His symptoms developed insidiously but have mildly progressed. He has no other medical history, but he has noted some mild depression and constipation over the last 2 years. His examination demonstrates hypophonia, masked facies, decreased blink rate, micrographia, and mild right-sided bradykinesia and rigidity. An intermittent right upper extremity resting tremor is noted while he is walking. The rest of his examination and a brain MRI are normal.
* **Idiopathic Parkinsons disease**
* Benign essential tremor
* Drug or toxin induced parkinsons
* Huntingdons disease
* Lewy body dementia
* Wilsons disease
* MSA/PSP/Vascular parkinsons
53
What are the diagnostic criteria for PD?
* Muscular rigidity
* Resting tremor
* Postural instability
* Unilateral onset
* Progression
* Good response to L-Dopa
* Asymmetry
54
A patients presents with the following symptoms, suggestive of PD. What investigations should be ordered?
* Clinical diagnosis
* Hx + Examination
* L-Dopa test for 12 weeks, symptoms should resolve
* CT/MRI brain
* Exclude secondary cause + vascular pathology
* DAT testing -- Confirm diagnosis, but not usually used.
55
How is a patient with confirmed PD, managed?
* Patient education
* Inform the DVLA
Supportive management:
* MDT
* Physiotherapy + OT
* Nurse specialist
Medical management:
* Regular review 6-12 mo
* Assess disability + cognition
* QoL affected -- Co-Careldopa/Co-Beneldopa (Dopamine + COMT)
* QoL Not affected -- Pramipexole/Rasagiline (MAO B inhibitor)
56
What are the side effects caused by long term PD management?
* Motor fluctuations:
* On off phenomena
* Wearing off -- Fluctuations in response + duration of medications
* Dyskinesia
* Depression + Anxiety
* Compulsive disorders
* REM sleep behaviour disorder
* Nocturnal akinesia
Consider drugs such as Pramipexole/Ropinirole/Selegeline/Rasagiline
57
What are the complications that can develop in PD in the long term?
* Infections
* Aspiration pneumonia
* Bed sores
* Poor nutrition
* Falls
* Bowel/Bladder disorders
58
You are asked to explain the dopaminergic drugs used for parkinsons disease (Levadopa - Co-Careldopa/Co-Beneldopa) + Ropinorole + Pramipexol). How would you do this?
Layout:
* Check what the patient knows
* Brief history
* Do they know what the drug is?
* Indication & Action of the drug
* Side effects
* How to take it
* Monitoring requirements
[Indication & Action]
Indications
* In early parkinson’s disease - when dopamine agonists are preferred over levodopa
* Late parkinson’s disease - Levadopa, with dopamine agonists as an add on option
* Secondary Parkinsonism
Action
* Deficiency of dopamine in Nigrostriatal pathway - links substantial nigra in the midbrain -\> Corpus striatum in Basal Ganglia
* Via direct and indirect pathways
* Leads the Basal ganglia to exert greater inhibition on the thalamus = reduces excitation to the motor cortex (Results in bradykinesia + Rigidity)
Treatment with agonists -- Increase dopaminergic stimulation to the striatum
* Dopamine itself cannot be given because it cant cross the BBB
* Levadopa - precursor of dopamine can enter the brain via a membrane transporter
* Ropinirole & Pramipexol -\> Selective agonists for the D2 receptor - predominates in the corpus striatum
[How to take it]
* Always given with peripheral dopa-decarboxylase inhibitor (Carbidopa) to reduce conversion to dopamine outside the brain
* Ensure it is taken at specific times to produce the best symptom control for patient
Can be taken as:
* Tablet/Transdermal patch
* Best taken with food
Length - As long as it works
Effect - Fast acting
1st line dopamine agonists - ROPINIROLE + PRAMIPEXOL
Late presentation - LEVADOPA (AS CO-CARELDOPA/CO-BENELDOPA)
* Co-beneldopa (Benserazide)
* Co-careldopa (Carbidopa)
[Important SE]
* Nausea
* Drowsiness
* Confusion
* Hallucinations
* Hypotension
* Excess can lead to excessive and involuntary movements -\> Dyskinesias
Levadopa specifically
* Wearing off effect - patients symptoms worsen towards the end of the dosage interval
* Gets worse as duration of therapy increases
* Can be overcome by increasing dose/frequency Can lead to excessive and involuntary movements -\> Dyskinesias
* This is the on-off effect
Complications/Contraindications
Use cautiously in:
* Elderly
* Existing cognitive/psychiatric disease -\> Risk of causing confusion & hallucinations
* CVD -\> Risk of hypotension
* Avoid combination with Typical antipsychotics & Metoclopramide
Patient will have access to specialist nurse
[Monitoring requirements]
* Monitoring of SE
* BP monitoring - assess for hypotension
59
What are the symptoms/signs in vascular parkinsonism?
How is it managed?
* Predominant lower body signs
* No stooped posture - stand straight
* Tremor less common
* Rigidity of LL + lack of facial expression
Management:
* May respond to levadopa
* Management of CVD risk factors
60
What are the symptoms/signs of drug induced parkinsonisms?
How is it managed?
* Hx of dopamine blocking drug use such as anti-psychotics/metoclopramide
* Symmetrical rigidity
* Lack of facial expression
Management:
* Reduce or stop drug if possible
61
What is Multiple system atrophy?
* Neurodegenerative disorder due to cell loss in the brain + spinal cord
* Leads to symptoms affecting autonomic + motor systems
* Parkinsonian features + cerebellar ataxia + autonomic dysfunction
62
Who classically gets multiple system atrophy?
What are the symptom/signs?
* Male \> Females
* Develop disease when \>40yrs old
Symptoms/signs:
* Urinary dysfunction
* Postural hypotension -- lightheaded/dizzy on standing + fainting
* Cerebellar ataxia -- uncoordinated movement, lack of control of voluntary movement
* Poor/temporary response to levadopa
* May have constipation
* Neuropsychiatric symptoms -- depression/insomnia/dementia
63
How would you investigate a patient with suspected MSA and manage them?
Investigations:
* Clinical diagnosis, presence of:
* Autonomic features ± Urogenital features ± extrapyramidal features ± cerebellar features
* MIBG Scintigraphy -- Increased uptake in MSA
* FDG PET scan -- caudate putamen index decreased in MSA less than PD
Management:
* No cure or therapy to stop progression
* Manage postural hypotension
* Manage constipation/incontinence/falls
* Prevent deconditioning with physical activities
* SALT -- assist with swallowing
* Levadopa for movement disorder
* Patient education -- poor prognosis
64
What is Progressive supranuclear palsy?
* Neurodegenerative Parkinsonism syndrome affecting:
* Cognition - Apathy/Disinhibition/Anxiety
* Eye movements (Vertical gaze palsy, due to CN3 dysfunction)
* Posture -- Extrapyramidal (Postural instability + Akinesia)
* Tremor
* Pseudobulbar palsy
65
How is PSP managed?
* No effective therapy
* May have relief from levadopa
* Physiotherapy
* Poor prognosis
66
What is the most common cause of tremor?
* Essential tremor
67
How does essential tremor classically present?
Symptoms/Signs:
* Worse on movement - postural + intention
* Distal + Symmetrical tremor
* Familial
* Jaw + Head + voice tremor
* Coarse tremor
* Absent at rest
* Better with alcohol
* No neurological signs
Investigations:
* Clinical diagnosis
* TFTs
* U&E
* FBC
Management:
* Mild -- No treatment
* Moderate to severe -- Treatment:
* Propranolol or Primidone
* Deep brain stimulation
68
What is a physiological tremor?
Tremor in exagerated form due to:
* Anxiety
* Hyperthyroidism
* Hypoglycaemia
* Caffeine excess
* Medications
* Fever
Symptoms/Signs:
* Bilateral
* Symmetrical
* Non-progressive over time
* No other motor symptoms
Investigations:
* Clinical diagnosis
* TFTs
* U&E
* FBC
Management:
* Manage causative conditon
69
A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnosis?
A 68-year-old woman presents with a complaint of 'shaking hands'. She reports a 10-year history of bilateral hand tremor that has slowly progressed and is worse in her right hand. It mainly bothers her when she is using her hands for various tasks. She has great difficulty drinking from cups and eating peas and other foods, and uses either a straw or both hands to eat and drink. She also finds writing and signing cheques problematic. She has come to rely increasingly on her spouse for assistance with activities of daily living, and has retired from work as a secretary. She has stopped eating out in restaurants because of the social embarrassment. She denies any slowness of movement, rigidity, or cramping. Her father has a long history of tremor, but otherwise she has no personal or family history of neurological diseases. When the patient has a glass of red wine, she notes that her tremor abates.
* **Essential tremor**
* Idiopathic PD
* Wilsons disease
* Drug induced tremor
* Physiological tremor
70
What is Postural Hypotension?
* BP lower than usual causing symptoms such as dizziness or light-headedness
Defined as:
* SBP \<90mmHg
* DBP \<60mmHg
* Can lead to syncope -- Loss of consciousness due to reduced cerebral perfusion
71
Who classically gets orthostatic hypotension?
What are the symptoms/signs?
* Common in elderly due to changes to BP control (Decreased baroreflex mechanisms)
* HR control + decreased vascular resistance
Symptoms/Signs:
* BP \<20mmHg within 3 mins of standing
* Falls/Syncope
* Normally asymptomatic
* May have Hx of dizziness/light headedness
* Blurred vision
* Weakness
* fatigue
* Nausea
* Palpitations
* Headache
72
What are the causes of orthostatic hypotension?
* Cardiac/Endocrine/Neurological
Cardiac:
* Aortic stenosis/Arrythmia/MI/Pericarditis/Heart failure
Endocrine:
* DM
* Phaechromocytoma
* Primary hyperaldosteronism
Neurological:
* Vasovagal syncope - prolonged standing
* Vasospasm
* Alcoholic neuropathy
Other:
* Pregnancy
* Varicose veins
* Drugs affecting BP -- Antidepressants/Levadopa/Alcohol/Diuretics
73
How would you investigate and manage orthostatic hypotension?
Investigations:
* FBC
* U&E
* Fasting glucose
* Pregnancy test - if young female
* ECG
* Tilt table test -- diagnostic for orthostatic hypotension
* Lying + standing BP
Management:
* Cardiology referral if heart disease/abnormal ECG
* Patient education - triggers to avoid, stand up slowly
* Review medication
* Compression stockings
* Increase fluid intake
74
What are the ways in which patients can handover their consent to others?
* LPA - Legal
* Advanced statement
* Advanced decision/decision to refuse treatment - Legal
* Best interests
75
What is syncope?
What are the causes?
Transient loss of consciousness due to transient global cerebral hypoperfusion (Decreased nutrient delivery) with rapid onset + short duration + complete recovery
Causes:
* Neurally mediated syncope/Reflex syncope - most common
* Orthostatic hypotension - most common
* Cardiac arrythmia
* Structural cardiac or Cardiopulmonary disease
* Substance abuse
* Psychogenic
76
What are the types of neurally mediated syncopes?
* Vasovagal syncope - due to emotional/orthostatic stress
* Situational syncope - micturition/cough syncope
* Carotid sinus hypersensitivity - when turning head
* Glossopharyngeal neuralgia
77
What cardiac arrythmias can cause syncope?
* Sick sinus syndrome/AVN disease
* Paroxysmal SVT/VT
* Brugada's/Long QT syndrome
* Malfunctions of ICD/Drug induced
78
What are the structural cardiac or cardiopulmonary causes of syncope?
* Obstructive valvular disease
* ACS
* HOCM
* Aortic dissection
* Pericardial disease
* PE/Pulmonary HTN
79
What are the differential diagnoses for syncope?
* Syncope
* Falls/Trauma
* Dizziness/Vertigo
* TIA/Stroke
* Epilepsy
* Alcohol/drug abuse
80
In a patient presenting with syncope how would you investigate them?
* ABCDE assesment
* Cardio + Neuro + Resp exams
* Observations
* BP - Lying + standing
* Bloods:
* FBC - Looking for anaemia
* Blood glucose - Rule out hypoglycaemia
* Prenancy test - rule out pregnancy
* U&E -- Rule out dehydration ± metabolic disturbance
* ECG -- Rule out ischaemia/arrythmia
* Tilt table test - diagnose orthostatic hypotension
* Carotid sinus massage -- rule out carotid sinus hypersensitivity
81
What is vertigo?
* Type of dizziness, where there is a false sensation that yourself or surroundings are moving or spinning.
* Due to mismatch b/w vestibular/visual/somatosensory systems
82
What are the causes for vertigo?
Central (Cerebral cortex/cerebellum/brainstem):
* Cerebrovascular disease
* Migraine
* MS
* Acoustic neuroma
* Intoxication
* Diplopia
Peripheral (Vestibular system):
* Viral labrynthitis
* BPPV
* Vestibular neuritis
* Menieres disease
* Motion sickness
83
What is the most common cause of vertigo?
* Viral labrynthitis
* BPPV
84
How do you assess a patient presenting with vertigo?
* Identify if symptoms are dizziness or vertigo?
Any associated symptoms:
* Ear symptoms -- Hearing loss/discharge/tinnitus
* Neurological symptoms -- Headache/diplopia/visual disturbance/ataxia/dysarthria or dysphasia
* Autonomic symptoms -- N&V/Sweating/palpitations
* Migraine aura
* Recent URTI or ear infection -- Viral neuronitis/labrynthitis
* Hx of migraine
* Anxiety/Depression
* Head trauma/recent labrynthitis -- BPPV
* CVD -- Stroke
Examination:
* Neurological exam
* CN exam
* Ear exam
* Eye exam
* Rombergs test
* Dix Hallpike
85
What is Benign Paroxysmal Positional Vertigo?
* Most common cause of vertigo, due to inner ear dysfunction
* Otoliths detached from macula in SC canals - most common is Post SC
* Continues to move after head stops -- vertigo (Conflicting sensation with sensory input)
Caused by:
* Idiopathic
* Head injury
* Viral neuronitis - post viral illness
* Chronic middle ear disease
86
Who classically gets BPPV?
What are the symptoms/signs?
* Any age, usually \>50yrs
* Women \> Men
Symptoms/Signs:
* Episodes of vertigo triggered by head movements
* Worse when head tilted to specific side
* Sudden onset + rapid resolution if head remains still
* N&V
* Worse in the mornings
* May have falls
* Vertical nystagmus (Towards forehead)
* Normal ear exam
* Normal CN exam
* Normal Neurological exam
* Dix hallpike - positive
87
You are asked to explain the dix hallpike manouvre to a patient, how would you do this?
* Ask patient if any cervical spine pathology
* Ask pt to keep eyes open + stare at my nose
* Pt sitting with head at 45 degs, to the left (for L Post SC)
* Lay patietn down until head is dependent 30 deg below level of couch
* Observe for nystagmus for 30s
* Return to upright position
* Repeat on other side
* On sitting pt experiences vertigo to confirm diagnosis
88
A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnosis?
A 65-year-old woman presents with a chief complaint of dizziness. She describes it as a sudden and severe spinning sensation precipitated by rolling over in bed onto her right side. Symptoms typically last \<30 seconds. They have occurred nightly over the last month and occasionally during the day when she tilts her head back to look upwards. She describes no precipitating event prior to onset and no associated hearing loss, tinnitus, or other neurological symptoms. Otological and neurological examinations are normal except for the Dix-Hallpike manoeuvre, which is negative on the left but strongly positive on the right side.
* **BPPV**
* Acute vestibular labrynthitis
* Menieres disease
* Acoustic neuroma
* MS
* TIA/Stroke
* Anti-convulsant/Anti-hypertensives
89
A patient presents with the following Hx suggestive of BPPV, how would you investigate and manage them?
A 65-year-old woman presents with a chief complaint of dizziness. She describes it as a sudden and severe spinning sensation precipitated by rolling over in bed onto her right side. Symptoms typically last \<30 seconds. They have occurred nightly over the last month and occasionally during the day when she tilts her head back to look upwards. She describes no precipitating event prior to onset and no associated hearing loss, tinnitus, or other neurological symptoms. Otological and neurological examinations are normal except for the Dix-Hallpike manoeuvre, which is negative on the left but strongly positive on the right side.
Investigations:
* Clinical diagnosis
* Dix Hallpike manouvre - to confirm Post SC involvement (BPPV)
* If uncertain - CT/MRI
Management:
* Advise that symptoms are self limiting but may recur
* Limit symptoms by slowly getting out of bed + decreasing head movements
* Epley manouvre - can be immediate resolution, not always
* Must not drive or operate heavy machinery whilst symptomatic
90
You are asked to explain the Epley manouvre, how would you do this?
* Used to treat BPPV - aim is to reposition the otoliths back into the utricles in the posterior SC canals
* Sit pt upright on couch with head turned to 45deg to affected side
* Place hands on either side of pts head and guide pt to lie down with head dependent + 30 deg over the egde of the couch
* Wait for 30s - 1 min for nystagmus to resolve
* Rotate head to 90deg to opposite side with pt upward but head dependent
* Roll pt on side whilst holding head - rotate head to face downwards to ground
* sit pt up sideways - maintain head rotation
* Rotate head to central position with chin on their chest
* Should be NO nystagmus
* Can take days/weeks to recover or immediately
91
What is Menieres disease?
* Disease of the inner ear due to change in fluid volume in the labrynth
* Menieres syndrome - if cause if known
* Progressive distension of membranous labryinth in inner ear leads to damage to vestibular system -- vertigo + cochlea -- Hearing loss
Characterised by:
* Episodic sudden onset of vertigo
* Low frequency hearing loss
* Low frequency roaring tinnitus
* Sensation of fullness in affected ear
92
What are the causes for menieres disease?
* Overproduction or under absorption of endolymph
linked to:
* Food allergy
* Congenital or acquired syphillis
* Hypothyroidism
* Acoustic/physical trauma
* Internal auditory canal stenosis
93
Who classically gets menieres disease?
What are the symptoms/signs?
* 40-60yrs, can happen at any age
* Rare in children
* Females \> Males
* Increased risk if: Atopy/Autoimmune condition/FHx/Recent viral illness
Symptoms/Signs:
* Episodic sudden onset of vertigo
* Low frequency hearing loss
* Low frequency roaring tinnitus
* Sensation of fullness in affected ear
* Fluctuating + episodic pattern (Months of remission)
* May have drop attacks -- no LoC + Vertigo + Imbalance/spinning sensation
94
A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnosis?
A 40-year-old woman presents with a 1-year history of recurrent episodes of vertigo. The vertigo spells are described as a sensation of the room spinning that lasts from 20 minutes to a few hours and may be associated with nausea and vomiting. The spells are incapacitating and are accompanied by dizziness, vertigo, and disequilibrium, which may last for days. No loss of consciousness is reported. The patient also reports aural fullness, tinnitus, and hearing loss in the right ear that is more pronounced around the time of her vertigo spells. Physical examination of the head and neck is normal. A horizontal nystagmus is noted. She is unable to maintain her position during Romberg's testing or the Fukuda stepping test. She turns towards the right side and she is unable to walk tandem. Her cerebellar function tests are normal.
* **Menieres disease**
* BPPV/Acute vestibular neuronitis
* Acoustic neuroma/OM
* Vertebrobasilar insufficiency/TIA/Stroke
* SoL/Migraine
* Anaemia/DM
95
A patient presents with the following Hx suggestive of menieres disease. How would you investigate and manage the patient?
A 40-year-old woman presents with a 1-year history of recurrent episodes of vertigo. The vertigo spells are described as a sensation of the room spinning that lasts from 20 minutes to a few hours and may be associated with nausea and vomiting. The spells are incapacitating and are accompanied by dizziness, vertigo, and disequilibrium, which may last for days. No loss of consciousness is reported. The patient also reports aural fullness, tinnitus, and hearing loss in the right ear that is more pronounced around the time of her vertigo spells. Physical examination of the head and neck is normal. A horizontal nystagmus is noted. She is unable to maintain her position during Romberg's testing or the Fukuda stepping test. She turns towards the right side and she is unable to walk tandem. Her cerebellar function tests are normal.
Investigations:
* Clinical diagnosis - Tinnitus/Vertigo/Hearing loss
* Rule out other causes:
* FBC -- Normal
* ESR -- Normal
* TFTs -- Normal
* Syphillis screen
* Fasting glucose -- Normal
* U&E -- Normal
* Audiometry -- Sensorineural hearing loss
* MRI brain -- Rule out acoustic neuroma
Management:
* No cure
* Inform DVLA
* Acute attacks:
* Prochlorperazine/Cyclizine/Promethiazine (Vertigo/Nausea)
* If severe D&V -- Admission for rehydration
* Prednisolone
* Prophylaxis:
* Low salt diet
* Trial betahistadine - reduce frequency/severity of attacks
* Hearing aids for hearing loss
96
What is vestibular neuritis/labrynthitis?
* vestibular neuritis' be confined to cases in which the vestibular nerve only is involved, with the term 'labyrinthitis' being used in cases in which the vestibular nerve and the labyrinth are affected
* Vestibular neuritis is a very common cause of vertigo
* Vestibular neuritis is most likely a vestibular neuropathy caused by reactivation of latent type 1 herpes simplex virus in the vestibular ganglion
* cases of labyrinthitis appear to be viral in origin and an upper respiratory tract infection
97
What are the causes of falls in the elderly?
**DAME**
Drugs:
* Polypharmacy
* Antihypertensives/sedatives/opioids
Ageing related:
* Vision changes
* Cognitive decline
* Gait abnormalities
* OA
Medical causes:
* Cardiac hypotension
* Arrythmia
* Neurological causes -- PD/Stroke/Neuropathy
* Cataracts
Environmental:
* Walking aids
* Footwear
* Home hazards
98
What is Delirium?
* Acute fluctuating change in mental status with inattention and disorganised thinking + altered level of consciousness
* Abnormality of thought/perception/levels of awareness
* Acute onset + intermittent
* Life threatening
99
What are the different types of delirium?
Hyperactive:
* Increased arousal
* Restlessness/agitation/hallucinations/innapropriate behaviour
Hypoactive:
* Lethargy/Decreased motor activity
* Incoherent speech or lack of interest
Mixed:
* Combination of both
100
What are the key features of delirium?
* Disturbance in attention -- decreased clarity of awareness of environment
* Change in cognition (Memory deficit/disoriented/language disturbance)
* Develops over a short period of time (hrs or days)
* acute change from baseline/fluctuates over the course of the day
* Disturbance is caused by medical conditon/drug/substance withdrawal. Not dementia
101
What are the causes of delirium?
* Acute infection -- UTI/Sepsis/Pneumonia
* Prescribed drug -- Benzodiazepine/Morphine/Steroids
* Post op
* Alcohol/Carbon monoxide poisoning/Barbituate withdrawal
* CVA/SDH/IHD
* Hypoxia/Hypoglycaemia/Hepatic or renal impairment
* Vitamin B12 or Thiamine deficiency
* Trauma/Constipation/Urinary retention/SoL
102
How would you investigate a patient with delirium? How would you manage them?
Investigations:
* MMSE - assess cognition
* FBC -- Infection or anaemia
* U&E -- Electrolyte imbalance/dehydration/renal impairment
* Glucose
* Ca+ levels
* LFTs
* TFTs
* ECG + Troponin
* Vitamin B12 + Folate
* Urine dipstic + microscopy + culture
* Blood culture
* Observations - O2, HR, BP
* CT brain
* CXR
Management:
* Treat underlying cause
* Consent may be provided during lucid moments
* Supportive management -- Clear communication + reminders to orientate themselves + familar objects and people + relaxation
* Maintain hydration + nutrition
* Adequate space + sleep - Side room
* Ensure pt remains independent as much as possible
* Acute management if agitated:
* Antipsychotics - Olanzepine/Haloperidol or Lorazepam if PD
* Diazepam if due to alcohol
* May have residual disorientation/inattention
103
How are patients assessed in terms of their cognition?
* 4AT test - Delirium
* AMTS score
* MMSE
104
You are asked to certify a death, how would you do this?
* 1. Wash hands
* 2. Confirm the identity of the patient – check the wrist band
* 3. General inspection – skin colour / any obvious signs of life
* 4. Look for signs of respiratory effort
* 5. Does the patient respond to verbal stimuli? – “Hello Mr Smith, can you hear me?”
* 6. Does the patient respond to pain? – press on fingernail / trapezius squeeze / supraorbital pressure
* 7. Assess pupils using pen torch – after death they become fixed and dilated
* 8. Feel for a central pulse – carotid artery
* 9. Auscultation:
* Listen for heart sounds for at least 2 minute
* Listen for respiratory sounds for at least 3 minutes
* Wash hands and exit the room
105
What does the following CT scan show?
**Ischaemic stroke**
* Hyperdense segment of vessel (Thrombus)
* Loss of grey-white matter differentiation
* Cortical hypodensity ± parenchymal swelling
106
What does the following CT scan show?
**Haemorrhagic stroke**
* Hyperdense collection of blood
107
What does the following CT scan show?
Lacunar infarct
* Ill defined hypodensities
* Hypodense foci (Similar to CSF)
