Causes of collapse (groups)
- Low glucose (hypoglycaemia)
- Heart:
- Vasovagal
- Arrythmia
- Outflow obstruction
- Postural hypotension - CNS: seizure
Cardiac causes of collapse
Vasovagal
Arryhtmia (fast/slow)
Outflow obstruction (left: aortic stenosis; right: PE)
Postural hypotension
59 yr old man
Long-standing HTN
Exertional chest pain
Normal ECG
What is the most likely diagnosis?
A. Coronary artery stenosis B. Musculoskeletal C. Pericarditis D. Relapsing polychondritis E. Vasculitis
A. Coronary artery stenosis
HTN
Exertional chest pain
Normal ECG
Crease on ear lobe
Frank’s sign: diagonal crease along the tragus
Thought to be associated with coronary artery disease
Neurology problem: Anatomy
Brain Spinal cord Nerve roots Peripheral nerve(s) Neuromuscular junction
Neurological problem: Pathology
VIITT Vascular Infection Inflammation/Autoimmune Toxic/Metabolic Tumours/Malignancy
Hereditary/congenital
Degenerative
Neurology problem: Where? Anatomy
(level of the lesion/problem) Brain Spinal cord Nerve roots Peripheral nerve(s) Neuromuscular junction
Neurological problem: What? Pathology
VIITT
Vascular (bleed/infarction)
Infection (meningitis/ encephalitis/ abscess)
Inflammation/Autoimmune (demyelination central: MS, peripheral: Guillain Barre. Also vasculitides (CTDS: SLE)
Toxic/Metabolic (DM, B12 deficiency)
Tumours/Malignancy (tumour directly causing symptoms or paraneoplastic manifestation- Pancoast’s)
Hereditary/congenital
Degenerative
Signs of UMN lesion
Tone: increased (spasticity)
Power: decreased
Reflexes: increased (upgoing plantars)
Signs of LMN lesion
Tone: reduced (flaccid)
Power: reduced
Reflexes: reduced
Cerebellar symtpoms
DANISH
Dysdiadokineses/Dysmetria (past pointing)
Ataxia (coordiantion/balance)
Nystagmus
Intention tremor (finger-nose test)
Slurred speech/ scanning (staccato speech)
Hypereflexia/hypotonia
Causes of cerebellar disease:
PASTRIES
Do a CT scan
Posterior fossa tumour Alcohol Stroke Trauma Rare Inherited (Friedrich's ataxia) Epilepsy drugs (carbamazepine, phenytoin) Sclerosis (MS)
OR
Vascular (bleed/clot- Stroke)
Infection (varicella (chicken pox), toxoplasmosis)
Inflammation (demyelination- MS)
Malignancy/Tumour (primary (posterior fossa tumour) or metastasis)
Metabolic/Toxic (B12 deficiency, Alcohol)
Spastic paraparesis
Increased tone in legs, but weakness
Peripheral neuropathy
Subacute combined degeneration
Vitamin B12 deficiency (but can also present in other ways)
Hemisensory loss
Cerebral cortex (contralateral)
Sensory loss below a level (eg- umbilicus)- eg- with pin prick test
Spinal cord
Sensory loss in a dermatome(s)
Nerve roots (eg- radiculopathy)
Sensory loss in a specific area
Mononeuropathy
Glove and stocking distribution of sensory loss
Polyneuropathy (diabetic peripheral neuropathy)
Glove and stocking distribution of sensory loss
Polyneuropathy (diabetic peripheral neuropathy)
Reduced pin prick sensation in there left arm and left leg
Right cerebral cortex
Glove and stocking distribution of sensory loss. Causes:
Polyneuropathy:
The most common is diabetes
Infection: HIV
Inflammation: chronic inflammatory demyelinating polyneuropathy (CIDP)
Malignancy: Paraneoplastic; Paraproteinaemia
Metabolic: Diabetes, Alcohol, B12 deficiency
Glove and stocking distribution of sensory loss. Causes:
Polyneuropathy:
The most common is diabetes
Infection: HIV
Inflammation: chronic inflammatory polyneuropathy disorder (CIPD)
Malignancy: Paraneoplastic; Paraproteinaemia
Metabolic: Diabetes, Alcohol, B12 deficiency
Wasted, shortened lower limb
Reduced T,R,P unilaterally
Scars on leg
Sensation normal
Polio myelitis (favourite for OSCE)
Pure motor neuropathy (LMN- reduced TRP)
Wasted shortened limb (chronic)
Normal sensation
Lots of scars- corrective surgery as person grows
Toxic/metabolic causes of peripheral neuopathy:
Drugs: (amiodarone; psychotoxic drugs- phenytoin) Alcohol (high MCV, high GGT) B12 deficiency (high MCV) Diabetes: (HbA1C) Hypothyroidism Uraemia (high urea/creatinine)
Amyloidosis (chronic infection/inflammation or Myeloma)
Toxic/metabolic causes of peripheral neuopathy:
Drugs: (amiodarone; psychotoxic drugs- phenytoin) Alcohol (high MCV, high GGT) B12 deficiency (high MCV) Diabetes: (HbA1C) Hypothyroidism Uraemia (high urea/creatinine)
Amyloidosis (chronic infection/inflammation or Myeloma)
Toxic/metabolic causes of peripheral neuopathy:
Drugs: (amiodarone; psychotoxic drugs- phenytoin) Alcohol (high MCV, high GGT) B12 deficiency (high MCV) Diabetes: (HbA1C) Hypothyroidism Uraemia (high urea/creatinine)
Amyloidosis (chronic infection/inflammation or Myeloma)
55 year old man Numbness and tingling in hands and feet PMH: T1DM On basal/bolus insulin HbA1C: 50mmol/L B12: 500pg/ml (200-900) eGFR: 90
Reduced sensation to PP (glove and stocking distribution)
- Codeine
- Duloxetine
- Hydroxocobalamin
- Paracetemol
- Pregabalin
- Duloxetine (first linbe- NICE)
(also used for premature ejaculation)
Codeine/Paracetemol won’t work
Hydroxocobalamin- used in B12 deficiency
Pregabalin- used but not first line (considered if duloxetine is not effective)
55 year old man Numbness and tingling in hands and feet PMH: T1DM On basal/bolus insulin HbA1C: 50mmol/L B12: 500pg/ml (200-900) eGFR: 90
Reduced sensation to PP (glove and stocking distribution)
- Codeine
- Duloxetine
- Hydroxocobalamin
- Paracetemol
- Pregabalin
- Duloxetine (first linbe- NICE)
(also used for premature ejaculation)
Codeine/Paracetemol won’t work
Hydroxocobalamin- used in B12 deficiency
Pregabalin- used but not first line (considered if duloxetine is not effective)
55 year old man Numbness and tingling in hands and feet PMH: T1DM On basal/bolus insulin HbA1C: 50mmol/L B12: 500pg/ml (200-900) eGFR: 90
Reduced sensation to PP (glove and stocking distribution)
Diabetic peripheral neuropathy
Toxic/metabolic causes of peripheral neuopathy:
Drugs: (amiodarone; psychotoxic drugs- phenytoin) Alcohol (high MCV, high GGT) B12 deficiency (high MCV, anaemia) Diabetes: (HbA1C) Hypothyroidism (TFTs) Uraemia (high urea/creatinine)
Amyloidosis (chronic infection/inflammation or Myeloma)
55 year old man Numbness and tingling in hands and feet PMH: T1DM On basal/bolus insulin HbA1C: 50mmol/L B12: 500pg/ml (200-900) eGFR: 90
Reduced sensation to PP (glove and stocking distribution)
Diabetic peripheral neuropathy
55 year old man Numbness and tingling in hands and feet PMH: T1DM On basal/bolus insulin HbA1C: 50mmol/L B12: 500pg/ml (200-900) eGFR: 90
Reduced sensation to PP (glove and stocking distribution)
Diabetic peripheral neuropathy
Non metabolic causes of peripheral neuropathy:
Infection: HIV
Inflammation/Autoimmune: vasculitis, CTD (SLE), inflammatory demyelinating neuropathy (GBS acute, CIDP)
Non metabolic causes of peripheral neuropathy:
Infection: HIV
Inflammation/Autoimmune: vasculitis, CTD (SLE), inflammatory demyelinating neuropathy (GBS acute, CIDP)
Tumour/malignancy: paraneoplastic, paraproteinaemia
Hereditary: hereditary sensory, motor neuropathy (eg- if have pers cavus- arch in foot- so peripheral neuropathy has been there a long time)
Non metabolic causes of peripheral neuropathy:
Infection: HIV
Inflammation/Autoimmune: vasculitis, CTD (SLE), inflammatory demyelinating neuropathy (GBS acute, CIDP)
Tumour/malignancy: paraneoplastic, paraproteinaemia
Hereditary: hereditary sensory, motor neuropathy (eg- if have pers cavus- arch in foot- so peripheral neuropathy has been there a long time)
34 year old man Weakness in legs Blurred vision Legs: T: Increased; P: decreased; R: brisk, decreased pin prick sensation Fundoscopy: shows blurred optic disc
Most likely causes of blurred vision? A. Amaurosis fugax B. Anterior uveitis C. Papillodoema D. Pailiitis E. Vitreous haemorrhage
Weakness in both legs, increased tone- spastic paraparesis (not LMN)
There is a level of sensory loss (legs)
Lesion is in the spinal cord- inflammation in CNS so MS
D. Pappilitis- inflammation at the head of the optic nerve
DDx of blurred optic disc is papilloedema or papillitis
Blurred optic disk of fundoscopy:
- Papilloedema
- Papillitis
Both may have blurred vision (more likely in papillitis) and optic disc won’t be clear. However- papillitis will have pain when moving the eye (inflammation)
34 year old man Weakness in legs Blurred vision Legs: T: Increased; P: decreased; R: brisk, decreased pin prick sensation Fundoscopy: shows blurred optic disc
Most likely causes of blurred vision? A. Amaurosis fugax B. Anterior uveitis C. Papillodoema D. Pailiitis E. Vitreous haemorrhage
Weakness in both legs, increased tone- spastic paraparesis (not LMN)
There is a level of sensory loss (legs)
Lesion is in the spinal cord- inflammation in CNS so MS
D. Pappilitis- inflammation at the head of the optic nerve
DDx of blurred optic disc is papilloedema or papillitis
Blurred optic disk of fundoscopy:
- Papilloedema
- Papillitis
Both may have blurred vision (more likely in papillitis) and optic disc won’t be clear. However- papillitis will have pain when moving the eye (inflammation)
34 year old man Weakness in legs Blurred vision Legs: T: Increased; P: decreased; R: brisk, decreased pin prick sensation Fundoscopy: shows blurred optic disc
Multiple sclerosis
In CNS (spastic pareisis) In spinal cord (sensory loss in both legs- a level- otherwise would be one side and in arm as well).
Blurred vision
Therefore inflammation in spinal cord and in optic nerve: 2 lesions separated in space/time- MS
Blurred optic disc margins (fundoscopy)
Blurred vision
Pain on eye movement
Where and what?
Optic nerve Optic neuritis (papillitis)
Inflammation of optic nerve (eg- in MS)
Blurred optic disc margins (fundoscopy)
Blurred vision
Pain on eye movement
Where and what?
Optic nerve Optic neuritis (papillitis)
Inflammation of optic nerve (eg- in MS)
Weak legs
Upgoing planatars, hypereflexia
Fevers, night sweats
Pott’s Disease: TB of the spine- abscess compressing spinal cord
MRI: diagnosis
Neurosurgeons and and TB treatment
Causes of spastic paraparesis:
weak legs, hypertonia, upgoing plantars
Vascular: infarction in anterior spinal artery
Infection: Abscess (Pott’s disease TB)
Inflammation: MS, transverse myelitis (associated with Mycoplasma pneumoniae)
Toxic/metabolic: B12 deficiency
Tumour/Malignancy: Tumour of spinal cord
Multiple Sclerosis:
Two lesions
Separated in time/space
Multiple Sclerosis:
Two lesions
Separated in time/space
60 year old pain and paraesthesia in right anterolateral thigh PMH: T2 diabetes Metformin HbA1C: 60 mmo
BMI: 30
Reduced pin prick sensation in anteriolateral thigh
Next step? A.Lose weight B. Insulin C.Statin D.Aspirin E.MRI brain
A. Lose weight
Where? What?
Anterolateral thigh, pain and paraesthesia (prickling)- one area- so mononeuropathy
He has meralgia parasthetica: compression of the lateral femoral cutaneous nerve (as it passes inguinal ligament)
Reassure, avoid tight garments, LOSE WEIGHT
If persistent: carbamazepine, gabapentin
Sensory innervation of hand: lateral 3 1/2 digits (index and middle finger)
Median nerve
Sensory innervation of the hand: Medial 1 1/2 digits (little finger)
Ulnar nerve
Sensory innervation of the hand: Medial 1 1/2 digits (little finger)
Ulnar nerve
Sensory innervation of the hand: base of thumb (dorsal)
Radial nerve
Sensory innervation of the hand: base of thumb (dorsal)
Radial nerve
check to see if sensation at base of the thumb- anatomical snuffbox
Radial nerve palsy:
wrist drop, sensation lost at base of hand and back and proximal of first 3 fingers
Pain in buttock, radiating down the leg below the knee
Sciatica- compression of lumbosacral nerve roots (radiculopathy)
Compression by disc herniation, spinal canal setnosis
Radiculopathy (disease of nerve roots)
wrist drop, loss of sensation at base of thumb
Radial nerve palsy
wrist drop, loss of sensation at base of thumb
Radial nerve palsy
60 year old man Recurrent falls Tremor at rest Rigidity More forgetful Dysphagia Microphagia (small handwriting) Limited upgaze
Most likely diagnosis?
A. Progressive supranuclear palsy B. Lewy body dementia C. Stroke D. Epilepsy E. Alzheimer's disease
Parkinsonian features
PLUS limited upgaze
A. Progressive supranuclear palsy
Parkinson’s (tremor, rigidity, bradykinesia)
PSP (Steele-Richardson syndrome): parkisnonian features, upgaze abnormality
Triad of tremor, rigidity, bradykinesia
Parkinson’s disease
Alzheimer’s and Parkinsonian features
PLUS hallucinations
Lewy Body dementia
55 yr-old man confusion and chest pain no headache or neck stiffness recently moved to new house Temp: 37 PR: 100, BP: 120/60 Normal CVS/Resp/GI/Neuro exam ECG: sinus tachycardia, widespread ST depression Blood glucos: 7 mmol/L WCC/CRP normal CT head normal
New house: CO poisoning
Rule out other things (normal)
55 yr-old man confusion and chest pain no headache or neck stiffness recently moved to new house Temp: 37 PR: 100, BP: 120/60 Normal CVS/Resp/GI/Neuro exam ECG: sinus tachycardia, widespread ST depression Blood glucos: 7 mmol/L WCC/CRP normal CT head normal
New house: CO poisoning
Rule out other things (normal)
Causes of confusion (reduced AMTS):
VIITT/VIMM and others
Hypoglycaemia!!!
Vascular: bleed Infection: meningitis, encephalitis Inflammation: cerebral vasculitis Metabolic/Toxic: CO poisoning Malignancy/Tumour
Other causes:
post-ictal (history of seizure)
Dysphagia (receptive/expressive)- not confused but can’t communicate- stroke/TIA
Dementia: Alzheimer’s, Vacular (multi-infarct- history of IHD/PVD), alcoholic (signs of excess alcohol), Inherited eg- Huntington’s (other features- chorea)
Depressive pseudodementia (depression): elderly, withdrawn, poor eye contact. Often a precipitating factor
Causes of confusion (reduced AMTS)
VIITT/VIMM and others
Hypoglycaemia!!!
Vascular: bleed: headaches, collapse. Subdural haematoma (fall, fluctuating conciousness)
Infection: meningitis, encephalitis (?temp, ?intracranial (meningitis/enceph), ?extra-cranial (chest/UTI in elderly)
Inflammation: cerebral vasculitis, autoimmune encephalitis
Metabolic/Toxic: CO poisoning, drugs, U&Es, LFTs, Vit deficiency, Endocrinopathies
Malignancy/Tumour
Other causes:
post-ictal (history of seizure)
Dysphagia (receptive/expressive)- not confused but can’t communicate- stroke/TIA
Dementia: Alzheimer’s, Vacular (multi-infarct- history of IHD/PVD), alcoholic (signs of excess alcohol), Inherited eg- Huntington’s (other features- chorea)
Depressive pseudodementia (depression): elderly, withdrawn, poor eye contact. Often a precipitating factor
Causes of confusion (reduced AMTS)
VIITT/VIMM and others
Hypoglycaemia!!!
Vascular: bleed: headaches, collapse. Subdural haematoma (fall, fluctuating conciousness)
Infection: meningitis, encephalitis (?temp, ?intracranial (meningitis/enceph), ?extra-cranial (chest/UTI in elderly)
Inflammation: cerebral vasculitis, autoimmune encephalitis
Metabolic/Toxic: CO poisoning, drugs, U&Es, LFTs, Vit deficiency, Endocrinopathies
Malignancy/Tumour
Other causes:
post-ictal (history of seizure)
Dysphagia (receptive/expressive)- not confused but can’t communicate- stroke/TIA
Dementia: Alzheimer’s, Vacular (multi-infarct- history of IHD/PVD), alcoholic (signs of excess alcohol), Inherited eg- Huntington’s (other features- chorea)
Depressive pseudodementia (depression): elderly, withdrawn, poor eye contact. Often a precipitating factor
GCS:
Eyes (4) Verbal response (5) Motor response (6)
GCS Eyes:
1: no response
2: open to pain
3: open to speech
4: spontaneous opening
GCS Motor:
Motor (6)
1: no response to pain
4: withdraws to pain
5: localising response to pain
6: obeying commands
GCS Verbal:
Verbal (5)
1: none
2: sounds
3: words
4: confused conversation
5: orientated
GCS Verbal:
Verbal (5)
1: none
2: sounds
3: words
4: confused conversation
5: orientated
Abbreviated Mental Test:
DOB Age Time Year Place Recall (3 words) Recognise doctor/nurse Prime minister Second WW Count backwards from 20
Abbreviated Mental Test:
DOB Age Time Year Place Recall (3 words) Recognise doctor/nurse Prime minister WWII Count backwards from 20
Abbreviated Mental Test:
DOB Age Time Year Place Recall (3 words) Recognise doctor/nurse Prime minister WWII Count backwards from 20
Abbreviated Mental Test:
DOB Age Time Year Place Recall (3 words) Recognise doctor/nurse Prime minister WWII Count backwards from 20
Headache in the Emergency Department (serious causes):
Meningitis (fever, neck stiffness, meningism, Kernig’s sign)- treat with ceftriaxone
Subarachnoid haemorrhage: (sudden onset, thunderclap. CT, LP (xanthochromia- yellow CSF- breakdown products of RBCs))
Giant cell arteritis: polymyalgia rheumatic, (shoulder girdle pain, stiffness, jaw claudication, malaise, fever).
>50years. Give high dose steroids
Also:
Migraine: throbbing, vomiting, photo/phonophobia, FHx, Aura
Headache in the Emergency Department (serious causes):
Meningitis (fever, neck stiffness, meningism, Kernig’s sign)- treat with ceftriaxone
Subarachnoid haemorrhage: (sudden onset, thunderclap. CT, LP (xanthochromia- yellow CSF- breakdown products of RBCs))
Giant cell arteritis: polymyalgia rheumatica(shoulder girdle pain, stiffness malaise, fever) or alone.
>50years. Give high dose steroids
Also:
Migraine: throbbing, vomiting, photo/phonophobia, FHx, Aura
Headache in the Emergency Department (serious causes):
Meningitis (fever, neck stiffness, meningism, Kernig’s sign)- treat with ceftriaxone
Subarachnoid haemorrhage: (sudden onset, thunderclap. CT, LP (xanthochromia- yellow CSF- breakdown products of RBCs))
Giant cell arteritis: polymyalgia rheumatica(shoulder girdle pain, stiffness malaise, fever) or alone.
>50years. Give high dose steroids
Also:
Migraine: throbbing, vomiting, photo/phonophobia, FHx, Aura
Throbbing headache, vomiting, photo/phonophobia, FHx, Aura
Migraine
High dose aspirin (900mg)/ naproxen (NSAIDs)
Determining what management of stroke:
Time of onset
4.5 hours
Management of stroke
Management of stroke >4.5 hours
> 4.5 hours
- CT head (exclude haemorrhage)
- Aspirin (300mg), assess swallow
- Maintain hydration, oxygenations, monitor blood glucose
(Don’t treat BP acutely unless >220/120- dangerous to bring it down to quickly)
TIA
- Aspirin
- Don’t treat BP actuely (unless >220/120 or other indication)
- ECG, Echocardiogram
- Carotid Doppler
- Risk factor modification
Management of stroke
Management of stroke >4.5 hours
> 4.5 hours
- CT head (exclude haemorrhage)
- Aspirin (300mg), assess swallow
- Maintain hydration, oxygenations, monitor blood glucose
(Don’t treat BP acutely unless >220/120- dangerous to bring it down to quickly)
TIA
- Aspirin
- Don’t treat BP actuely (unless >220/120 or other indication)
Find underlying cause- to see if the patient is a candidate for carotid end arterectomy: - ECG, Carotid Doppler, Echocardiography (thrombus in the heart causing emboli)
- Risk factor modification (stop smoking, DM, HTN)
TIA
- Aspirin
- Don’t treat BP actuely (unless >220/120 or other indication)
Find underlying cause- to see if the patient is a candidate for carotid end arterectomy: - ECG, Carotid Doppler, Echocardiography (thrombus in the heart causing emboli)
- Risk factor modification (stop smoking, DM, HTN)
40 year old
Back ache
LMN weakness (weak legs and depressed reflexes)
Admitted to HDU
Regular FVC
Cardiac monitor
IVIG
Most likely diagnosis?
A. Guillain-Barre B. Stroke C. Cord compression D. Cauda equina syndrome E. Myaesthenia Gravis
A. Guillain-Barre
LMN, young person
Back ache- radiculopathy (nerve roots)
Stroke and Cord compression would cause UMN signs (brisk reflexes)
Cauda equina- LMN legs, but saddle (perianal) anaesthesia, problems with bowel (is still a DDx- MRI to see any compression)
Management of Guillain-Barre
- Admit to HDU
- Regular FVC (forced vital capacity- respiratory depression)
- Cardiac monitor (autoimmune disturbances)
- IVIG (IV immunoglobulins treatment)
If FVC drops below 20ml/kg- send to ITU- intubation
Management of Guillain-Barre
- Admit to HDU
- Regular FVC (forced vital capacity- respiratory depression)
- Cardiac monitor (autoimmune disturbances)
- IVIG (IV immunoglobulins treatment)
If FVC drops below 20ml/kg- send to ITU- intubation
Management of Guillain-Barre
- Admit to HDU
- Regular FVC (forced vital capacity- respiratory depression)
- Cardiac monitor (autoimmune disturbances)
- IVIG (IV immunoglobulins treatment)
If FVC drops below 20ml/kg- send to ITU- intubation
Management of Giant Cell Arteritis:
Giant cell arteritis/Temporal arteritis:
If suspected: Start on high dose prednisolone 60mg/d immediately to prevent visual loss
Blood: ESR (will be increased) and so will CRP
Get a temporal artery biopsy within 7 days of starting treatment (10% will be negative as skip lesions occur)