Geriatrics and Neurology Flashcards

Question

What is a haemorrhagic stroke?

Answer 1

Haemorrhagic stroke resulting from a vascular rupture in the brain, causing bleeding into the brain parenchyma > injury to the brain tissue ~ 15% stokes

Answer 2

Because the treatment for ischaemic stroke can make the haemorrhage in a haemorrhagic stroke worse.

Answer 3

- Total anterior circulation stroke (TACS) - Partial anterior circulation stroke (PACS) - Lacunar stroke - Posterior circulation stroke

Answer 4

- Unilateral weakness or paralysis in the face, arm or leg - Dysphasia - Ataxia - Visual disturbance - Risk factors

Answer 5

Cerebellar syndrome: - Ataxia in absence of limb weakness - Problems with fine motor movements - Diplopia

Answer 6

- Hemiplegia (unilateral paralysis) - Homonymous hemianopia (visual loss in same side of visual fields in both eyes) - Higher cortical dysfunction, such as dysphasia or neglect (ignores one side of the body)

Answer 7

Two out of three of: - Hemiplegia - Homonymous hemianopia - Higher cortical dysfunction e.g. dysphasia or neglect

Answer 8

A stroke that affects small deep perforating arteries supplying internal capsule or thalamus. Presents as a pure motor stroke, pure sensory stroke, sensorimotor stroke or ataxic hemiparesis (weakness on one side of body)

Answer 9

Ipsilateral oculomotor nerve palsy and contralateral hemiparesis

Answer 10

- CT head ≤ 1 hr of arriving in hospital to rule out haemorrhagic stroke - Blood glucose as hypoglycemia mimics stroke - U+E as hyponatremia mimics stroke + renal failure is contraindicated in some treatments - FBC - ECG (exclude AF) - Prothrombin time to exclude coagulopathy

Answer 11

Stabilise blood glucose levels Maintain hydration status and temperature O2 sats Maintain BP and do not lower unless complications e.g. hypertensive encephalopathy.

Answer 12

ONCE and only when haemorrhagic stroke excluded: - Aspirin 300 mg immediately or 24hrs after thrombolysis (take for 2 weeks) - Thrombolysis with alteplase once haemorrhagic stroke excluded and ≤4.5 hr within onset - Mechanical thrombectomy within ≤ 6.5 hrs of onset

Answer 13

- 1st line: daily clopidogrel (antiplatelet) 75mg for life, after 2 weeks of aspirin 300mg - High-dose statin : such as atorvastatin 20-80mg 48 hours after - Manage hypertension , diabetes , smoking and other cardiovascular risk factors

Answer 14

- Intracranial haemorrhage - TIA - Hypoglycemia

Answer 15

- Unilateral weakness or paralysis in the face, arm, or leg - Sensory loss (numbness) - Dysphasia - Dysarthria - Visual disturbance (e.g. homonymous hemianopia or diplopia) - Photophobia - Headache - Ataxia

Answer 16

MOST COMMON: uncontrolled hypertension Older age Drug use such as amphetamines and cocaine FHx of ICH

Answer 17

- Intracerebral : bleeding within the brain parenchyma - Subarachnoid : bleeding into the subarachnoid space - Intraventricular : bleeding within the ventricles

Answer 18

Same as ischaemic stroke - Non-contrast CT head within 1 hour of arrival - Serum glucose - Serum electrolytes - Serum urea and creatinine - FBC Plus - LFTs - to exclude liver dysfunction as cause - Clotting screen to exclude coagulopathy as cause

Answer 19

- Admission to neurocritical care and neurosurgery - Raised intracranial pressure : consider intubation with hyperventilation, head elevation (30°) and IV hypertonic saline - BP control <140/80 mm Hg - Surgical intervention: decompression hemicraniectomy may be needed

Answer 20

Rehabilitation: Physical, occupational, and speech therapy Secondary prevention: Blood pressure control, discontinuation of harmful substances (e.g., illicit drugs, alcohol), and management of coagulation disorders

Answer 21

- Ischemic stroke: headache less common in IS than HS but rule out with NC-CT - Subarachnoid haemorrhage: sudden "worst headache of my life" - Brain tumor - Meningitis

Answer 22

- Deep vein thrombosis : due to immobility - Aspiration pneumonia : due to dysphagia - Neurological sequelae : such as weakness, impaired mobility, middle cerebral artery syndrome and seizures - Requirement for nutritional support : such as nasojejunal feeding Depression

Answer 23

A neurodegenerative disorder characterised by loss of dopaminergic neurones within the substantia nigra pars compacta (SN PC ) of the basal ganglia (nigrostriatal pathway). This leads to loss of communication between the basal ganglia, thalamus, and motor cortex, resulting in impaired control of voluntary movements .

Answer 24

Inclusion bodies consisting of misfolded α-synuclein in the dopaminergic neurones of the SN PC called Lewy bodies

Answer 25

According to NICE, a diagnosis should be suspected in a patient who has **bradykinesia** and at least one of the following: - Tremor (Resting ‘pill-rolling’ (4-6Hz) tremor) - Rigidity - Postural instability

Answer 26

- Anosmia - Sleep disturbance (REM) - Depression, anxiety, dementia

Answer 27

- Clinical diagnosis Consider - MRI brain: exclude other neurological diseases - SPECT (DaT scan): show reduced dopamine uptake in the basal ganglia

Answer 28

NICE recommends referral to movement disorders specialist (e.g. care of elderly physician) for diagnosis and review every 6-12m Motor symptoms affecting QoL: - Levodopa + decarboxylase inhibitor e.g. co-beneldopa (stops Levodopa from being metabolised in the body before it reaches the brain) Motor symptoms not affecting QoL: - Dopamine agonist e.g. ropinirole or as above

Answer 29

Motor fluctuations: symptoms are initially well-controlled (on period) but then re-emerge prior to the next dose (off period). Freezing: sudden stoppage of movement Dyskinesia: (excessive involuntary movements) levodopa use Non-motor complications: - Impulse control disorders

Answer 30

- Lewy Body Dementia - Meds e.g. antipsychotics, lithium - Wilson's disease - Encephalitis

Answer 31

A transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction

Answer 32

- Sudden onset and brief duration of symptoms (mins) - patient/witness report of focal neurological deficit e.g. unilateral weakness or paralysis, dysphasia, sudden transient loss of vision in one eye (amaurosis fugax)

Answer 33

- Increasing age - Hypertension - Smoking - Diabetes - Hypercholesterolaemia - Atrial fibrillation - Carotid stenosis

Answer 34

- Blood glucose - hypo can cause sudden-onset neuro symptoms - FBC and platelet count - ECG (AF) - Lipid profile

Answer 35

- Antiplatelet therapy - aspirin 300mg - Statin e.g. atorvastatin - Anticoagulant (warfarin/DOAC) if AF - Referral to TIA clinic within 24hrs

Answer 36

Osteoporosis is the reduction in trabecular bone mass/density and disruption of bone architecture , resulting in porous bone with increased fragility and fracture risk.

Answer 37

It is caused by prolonged imbalance of bone remodeling where resorption ( osteoclastic activity) exceeds formation ( osteoblastic activity).

Answer 38

Fight Me! - Female - Post-Menopausal SHATTERED - Steroids - Hyper/hypothyroidism - Alcohol + smoking - Thin (low BMI) - Testrosterone (low) - Early menopause (decreased oestrogen) - Renal/liver failure - Erosive/inflammatory disease (IBD) - DMT1 or malabsorption

Answer 39

1st line + gold standard: Dual X-ray absorptiometry (DEXA) - T- and Z-score Diagnosis = T-score ≤-2.5

Answer 40

Asymptomatic until fragility fractures occur: pain and inability to bare weight. Common sites include NOF, wrist and vertebrae Back pain and kyphosis indicate vertebral fracture.

Answer 41

Risk score tool for estimating 10-year risk of osteoporotic fractures in untreated patients **Personal information: ABFS (Asian baby femaleS)** - Age - BMI - Femoral bone density - Sex - female increased risk **PMH (P.S.R - pumpkin spice Rosa)** - Previous fractures - Secondary osteoporosis - CKD, diabetes type 1, IBD, hyperthyroidism, hyperparathyroidism - Rheumatoid arthritis **Drug history** - Glucocorticoids **Social history** - Smoking - Alcohol 3 units or more per day **Family history** - Parental previous fractures

Answer 42

- Weight-bearing exercise - Increase dietary vitamin D and calcium - Smoking cessation - Reduce alcohol consumption

Answer 43

- Bisphosphonates e.g. alendronic acid - VitD and calcium supplement e.g. adcal D3 - Denosumab for post-menopausal women at high risk of fractures

Answer 44

- Osteopenia if -2.5 < T-score < -1 - Multiple myeloma (bone pain with anaemia & renal failure - Osteomalacia

Answer 45

- Stress - Urge - Mixed - Overflow - Functional

Answer 46

Involuntary urine leakage during increased abdominal pressure, such as coughing, sneezing, or exercise. Caused by weakened pelvic floor muscles or an impaired urethral sphincter

Answer 47

Involuntary leakage with strong, sudden need to urinate, usually due to overactive bladder muscle contractions.

Answer 48

Involuntary, constant leakage of urine caused by an inability to completely empty the bladder leading to excess urine retention often due to an obstruction or poor bladder muscle function. Caused by neurological damage or outlet obstruction.

Answer 49

A combination of two or more types of incontinence, stress and urge incontinence most common.

Answer 50

Inability to reach the toilet in time due to physical or cognitive impairments, despite normal bladder function.

Answer 51

- Age - Female gender - Previous pregnancies and deliveries: stress incontinence due to weakness of the pelvic floor - Obesity - Menopause - Urinary tract infections - Certain medications: e.g. diuretics

Answer 52

DIAPPERS D - Delirium I - Infection A - Atrophic vaginitis or urethritis P - Pharmaceutical (medications) P - Psychiatric disorders E - Endocrine disorders (e.g. diabetes) R - Restricted mobility S - Stool impaction

Answer 53

Physical exam: pelvic and neurological Questionnaire: assess symptoms and severity Bladder diary: record fluid intake, frequency, incontinence over 3-7 days Urinalysis: exclude infection Post-void residual urine (PVR): uses US or catheterisation to assesses bladder emptying

Answer 54

≥ 45 with unexplained visible haematuria without UTI or persistent/recurrent visible haematuria after UTI treated ≥ 60 with unexplained non-visible haematuria and dysuria or raised WCC on a blood test

Answer 55

- Weight loss, smoking cessation, fluid management and avoiding caffeine - 1st line: pelvic floor muscle training - Duloxetine (SNRI) if not effective - Surgery: gold standard is mid-urethral sling which helps closure of urethra during increased abdo pressure

Answer 56

Bladder training: Scheduled voiding with gradually increasing intervals to distend and improve bladder control Antimuscarinic drugs such as oxybutynin to improve detrusor muscle activity

Answer 57

Treatment focused on the most bothersome component of symptoms.

Answer 58

Localised damage to the skin and underlying soft tissue usually over a bony prominence as a result of pressure or related to a medical or other device.

Answer 59

- Immobility - Age >70 years - Recent surgery or ITU stay - Malnutrition.

Answer 60

Intact skin with a localised area of non-blanchable erythema, or a darker area on dark skin Non-blanchable erythma

Answer 61

**Partial-thickness skin loss** with exposed dermis. The wound bed is viable, pink/red, moist, and may present as an intact or ruptured serum-filled blister

Answer 62

**Full-thickness skin loss**, and adipose (fat) visible in ulcer. Granulation tissue and epibole (rolled wound edges) often present. Slough and/or eschar may be visible.

Answer 63

**Full-thickness skin and tissue loss** with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible.

Answer 64

- Pressure relief through repositioning (ideally every 2 hours) and support surfaces e.g. seat cushions, wheelchairs, mattress - Cleansing + dressing - Pain relief (e.g. paracetamol, ibuprofen, codeine) - Dietitian to optimise nutrition intake

Answer 65

- Venous ulcers: usually lower legs near ankles; accompanied by skin staining. - Arterial ulcers - usually feets, toes, heels

Answer 66

- Visual impairment - Peripheral neuropathy - Vestibular dysfunction, particularly benign paroxysmal positional vertigo (BPPV) - Fear of falling can increase risk of fall

Answer 67

- Syncope - Orthostatic hypotension

Answer 68

- Joint buckling/instability/poor mechanical mobility: may be due to prior injury or arthritis - Deconditioning: insufficient exercise and prolonged periods of immobility leading to reduced muscle tone and function. - Sarcopenia/ osteosarcopaenia: muscle weakness, muscle and/or bone mass loss

Answer 69

- Benzodiazepines, antidepressants, and anxiolytics - Insulin - NSAIDS, opioids - Polypharmacy: ≥ 5 meds

Answer 70

Loose rugs or tiles, poor lighting, clutter etc.

Answer 71

An assessment that identifies the causes of a fall and implements strategies to prevent future falls. Areas that are assessed (NICE): - Falls history - Cognitive impairment and neurological examination - fear relating to falling - visual impairment - Cardiovascular examination - Motor: gait, balance and mobility, and muscle weakness - osteoporosis risk - urinary incontinence - home hazards - Medications review

Answer 72

- Strength and balance training - Home hazard assessment and intervention - Vision assessment and referral - Medication review with modification/withdrawal

Answer 73

- Stroke - Transient ischaemic attack - Joint buckling/instability/mechanical gait disorders

Answer 74

Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. Results in increased vulnerability to stressors. Even "minor" changes like new med, infections or surgery can cause a drastic deterioration in health state, taking the person from independent to dependent.

Answer 75

Age, although frailty is not an inevitable consequence of ageing. Also, co-morbidities increase the risk of developing frailty: - Cognitive impairment - Depressive symptoms - Diabetes

Answer 76

Taking multiple medicines or drugs (usually 4/5+) the risk of problems such as side effects increases as the number of drugs increases.

Answer 77

Warfarin + NSAIDs = increased bleeding risk Warfarin + macrolide Omeprazole + clopidogrel SSRI + NSAID = increased bleeding risk ACEi + Spironolactone = AKI risk and hyperkalaemia Statin + Macrolide = increased statin effect Statin + grapefruit = increased statin effect

Answer 78

- Clinical frailty scale ( 1 is very active to 9 (terminally ill)) - Gait speed test > 5 seconds to walk 4 metres indicates frailty - PRISMA-7 questionnaire ≥3 = frailty

Answer 79

- Optimise diet and nutrition - Exercise: ≥ 150 min moderate intensity or ≥ 75 min vigorous + 2 days of strength - Eye + hearing care - Psychological wellbing - screnning and treat depression - Prevent cognitive decline - active, healthy diet, reduce alcohol and smoking, socialising + groups

Answer 80

They are 4 syndromes that present as Parkinsonism (triad of resting tremor, hypertonia, and bradykinesia) with additional clinical features.

Answer 81

Parkinsonism and vertical gaze palsy

Answer 82

Parkinsonism and early autonomic clinical features such as: postural hypotension, incontinence, and impotence.

Answer 83

Parkinsonism and involves spontaneous activity by an affected limb, or akinetic rigidity of that limb.

Answer 84

Parkinsonism and fluctuations in cognitive impairment and visual hallucinations, often before Parkinsonian features occur.

Answer 85

Syncope is the transient loss of consciousness due to disruption of blood flow to the brain that often leads to a fall, sometimes called a vasavagal episode or fainting.

Answer 86

Primary syncope (simple fainting): - Dehydration - Missed meals - Extended standing in a warm environment - Vasovagal response to a stimuli, such as sudden surprise

Answer 87

- Hypoglycaemia - Dehydration - Anaemia - Infection - Anaphylaxis - Arrhythmias - Valvular heart disease

Answer 88

Vasovagal syncope: clear trigger, blurring/clouding of vision, sweating and dizziness, no postictal period Seizures: lateral tongue biting, urinary incontinence, long postictal period, residual focal neurological deficit, and seizure activity (tonic-clonic or focal seizures).

Answer 89

- ECG - arrhythmia, long QT syndrome - 24hr ECG - ?paroxysmal arrhythmia - Echocardiogram - ?structural heart disease - Bloods: FBC (anaemia), electrolytes (arrhythmias and seizures) and blood glucose (diabetes)

Answer 90

- Avoid dehydration - Avoid missing meals - Avoid standing still for long periods - If prodromal symptoms such as sweating and dizziness, sit or lie down, eat something until feel better

Answer 91

Otipmise management of underlying cause. If waiting for confirmation of underlying cause: - Unexplained syncope: 6 months off driving and inform DVLA. - Advise showers over baths.

Answer 92

An application made by a hospital or care home for patients who has been assessed as lacking capacity to allow them to provide care and treatment. Whilst in hospital, or a care home, the patient is under control and is not able to leave. This means they are “deprived of their liberty” and require a legal framework to protect them.

Answer 93

A simple legal document that allows an adult to consent for another adult to conduct financial affairs on their behalf. It is only valid as long as the donor has capacity.

Answer 94

A document whereby a person legally nominates a person of their choice to make decisions on their behalf if they lack mental capacity. LPA only comes into effect if the patient lacks the capacity to decide for themselves. It does not give the person with LPA control over a decision if they can still make that decision themselves. Can be put in place when the donor has capacity.

Answer 95

A patient-led medical decision, made when patient is competent and designed for when the patient becomes incompetent. Advance refusals of treatment are legally binding if: - The person is an adult - Was competent and fully informed when making the decision - The decision is clearly applicable to current circumstances - There is no reason to believe that they have since changed their mind

Answer 96

A state in which a deficiency of energy, protein, and/or other nutrients causes measurable adverse effects on the body’s form, composition, function and clinical outcome.

Answer 97

- Decreased nutrient intake (starvation) - Increased nutrient requirements (sepsis or injury) - Inability to utilise ingested nutrients (malabsorption)

Answer 98

Malnutrition universal screening test (MUST) 1. BMI 2. Unintentional weight loss past 3 - 6m 3. Establish acute disease effect and score 4. Add score from 1,2 & 3 to obtain overall malnutrition risk 5. Management plan according to local guidelines

Answer 99

Score: - 1= low risk - 2 = med risk - 3 = high risk - BMI <18.5kg/m2 - Unintentional weight loss >10% last 3-6mths - BMI <20kg/m2 AND unintentional weight loss >5% within last 3-6mths

Answer 100

Metabolic disturbances as a result of reintroduction of nutrition to patients who are starved/severely malnourished.

Answer 101

- Hypophosphatemia -Hypocalcemia - Thiamine deficiency - Abnormal glucose metabolism

Answer 102

Cardiac arrhythmias, Coma, Convulsions, Cardiac failure

Answer 103

- Monitor blood biochemistry (phosphate, K+, Mg) - Monitor glucose and Na levels - Carefully commence re-feeding with guidelines - Supportive care, and refer to nutritional support team/dietician

Answer 104

Advanced age, inactivity, low calorie intake, low fibre diet, medications, female sex

Answer 105

A chart used to document stool frequency and consistency over a period of time.

Answer 106

Rome IV critieria - constipation may involve some or all: - <3 bowel movements per week - Hard stool > 25% of bowel movements (BMs) - Tenesmus (sense of incomplete evacuation) in > 25% BMs - Excessive straining in more than 25% BMs - Manual evacuation of bowel movements

Answer 107

Primary constipation: - No organic cause Secondary constipation: - Can be due to diet, medications, metabolic, endocrine or neurological disorders or obstruction

Answer 108

Dietary factors, such as inadequate fibre or fluid intake. Behavioural factors, like inactivity (common in inpatients) or avoidance of defecation.

Answer 109

Hypercalcaemia

Answer 110

- Opiates, calcium channel blockers and some antipsychotics

Answer 111

Spinal cord lesions, Parkinson's disease, and diabetic neuropathy

Answer 112

Colon diseases, like strictures or malignancies. Bowel obstruction can cause complete constipation (obstipation)

Answer 113

- PR exam - Stool culture - FIT testing (if accompanied with new rectal bleeding and signs suggestive of colorectal cancer) - Faecal calprotectin (IBD)

Answer 114

- Bloods: FBC (may show an anaemia), U+Es (including calcium), TFTs - Abdominal x-ray if ?secondary cause of constipation such as obstruction - Barium enema if suspicious of impaction or rectal mass - Colonoscopy if suspicious of lower GI malignancy

Answer 115

1. Exclude underlying causes including colorectal cancer 2. Conservative: improve diet, exercise 3. Enema if faecal impaction 4. Medical: laxatives (many different types) - Bulk laxatives e.g. ispaghula husk - Stool softeners e.g. sodium docusate, macrogol Osmotic laxative e.g. lactulose, Stimulant laxatives e.g. senna

Answer 116

The inability of the heart to deliver blood and thus oxygen at a rate that matches the requirements of the body.

Answer 117

Suspect acute HF in patients with: - Breathlessness - Ankle swelling - Reduced exercise tolerance - Fatigue - Nocturnal cough On lung auscultation: coarse bi-basal crackles

Answer 118

- Previous cardiovascular disease - CHD most common cause of HF - Older age - Prior episode of heart failure - Diabetes mellitus

Answer 119

- MI - High-output state e.g. sepsis - Infective endocarditis

Answer 120

- FBC : anaemia can cause HF U&Es : renal failure can cause HF Troponin BNP >100 pg/ml or NT‑proBNP >300 pg/ml ECG : arrhythmias and MI (ST elevation) CXR Transthoracic echocardiogram : systolic and diastolic function, and ejection fraction

Answer 121

A - Alveolar oedema (batwing opacities) B - Kerley B lines C - Cardiomegaly D - Dilated upper lobe vessels E - Pleural Effusion

Answer 122

- Treat underlying cause (e.g. MI) - Stabilise the patient : O2 for SpO 2 ≥94% Fluid restriction : usually <1.5L/day - IV diuretic : furosemide - Inotropes or vasopressors to increase BP if haemodynamically unstable e.g. dobutamine - Non-invasive ventilation (NIV)

Answer 123

- If HF caused by aortic stenosis - aortic valve replacement

Answer 124

1st line : ACE-inhibitor and cardioselective β-blocker e.g. Ramipril + bisoprolol Fluid restriction : usually <1.5L/day Loop diuretic e.g. furosemide

Answer 125

- Heart failure with preserved ejection fraction (HFpEF) = LVEF ≥ 50% - Heart failure with reduced ejection fraction (HFrEF) = LVEF ≤ 50% - Left-sided HF - Right-sided HF

Answer 126

- Myocardial infarction (MI) - Hypertension - Diabetes mellitus - Dyslipidaemia

Answer 127

Symptoms: - SOB - Fatigue and weakness - Cough (frothy white/pink sputum) Signs: - Bilateral basal crackles (sounding “wet”) - Hypotension if severe (cardiogenic shock)

Answer 128

- Ankle swelling (peripheral pitting oedema) - Distended abdo (ascites) - Fatigue and weakness - Hepatosplenomegaly

Answer 129

- NT-proBNP or BNP - ECG: broad QRS complexes + LVH - CXR - Transthoracic echocardiogram: LVEF, diastolic function, valve abnormalities

Answer 130

- Weight loss if BMI >30 - Smoking cessation - Salt and fluid restriction - improves mortality - Supervised exercise-based group rehabilitation programs

Answer 131

1st line = ACE-I and beta-blocker (e.g. ramipril + bisoprolol) Mortality improvement in HFrEF but not HFpEF SGLT2 inhibitors (e.g., dapagliflozin, empagliflozin) for HFpEF

Answer 132

- COPD - ARDS - Renal failure - Liver failure

Answer 133

A chronic, episodic neurological disorder characterised by recurrent, unilateral, throbbing headaches. Typical migraine aura (reversible visual, sensory or speech symptoms) that precede the headache only occurs in 15 - 30% patients.

Answer 134

- Family history of migraine - Female sex - Menstruation - Stressful life events - Obesity - Sleep disorders - Medication overuse.

Answer 135

CHOCOLATE - CHocolate - Oral Contraceptive - Alcohol + Anxiety - Travel - Exercise Others: tiredness, lack of food, dehydration, menstruation, red wine and bright lights

Answer 136

- Prolonged headache ( 4 - 72 hrs if untreated) - Nausea (most commonly associated) - Reduced ability to function - Headache worse on activity (unlike tension headaches) - Photophobia

Answer 137

Clinical diagnosis - fulfils ICHD-3 criteria for migraine Criteria A - At least five attacks fulfilling criteria B-D B - Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) c C - Headache has at least two of the following four characteristics: 1. Unilateral location 2. Pulsating quality 3. Moderate to severe pain intensity 4. Aggravation by or causing avoidance of routine physical activity D - During headache, at least one of the following: 1. Nausea and/or vomiting 2. Photophobia and phonophobia E - Not better accounted for by another ICHD-3 diagnosis

Answer 138

- Triptans (e.g. sumatriptan) - NSAIDS and/or paracetamol - Anti-emetics if needed (e.g. metoclopramide) - High-flow O2

Answer 139

- Avoid triggers - Propranolol - Amitriptyline - Topiramate

Answer 140

Significantly increases risk of ischaemic stroke

Answer 141

5HT1 (serotonin) receptor agonists Routes: oral, nasal, subcutaneous Side effects: flushing, tingling, chest and throat tightness (may mimic angina) Contraindicated in IHD or cerebrovascular disease

Answer 142

- Tension headache (usually bilateral and non-throbbing) - Cluster headaches (most common in men, severe pain around one eye, ≤3 hrs)

Answer 143

Sudden onset severe headache affecting the periorbital area unilaterally.

Answer 144

- Watery and bloodshot eye - Lacrimation - Rhinorrhoea - Ptosis - Lid swelling

Answer 145

15 minutes to 3 hours

Answer 146

Brain and pituitary MRI with and without contrast. - Normal in cluster headache - Abnormal indicates secondary cause e.g. tumour

Answer 147

- Avoid triggers, - Prophylaxis = Verapamil (calcium channel blocker for vasodilation) - Acute attacks = 100% oxygen via non-rebreather mask and subcutaneous Dtriptan

Answer 148

- Bilateral, non-pulsatile headaches - Tightness sensation, like a band around the head - Scalp muscle tenderness

Answer 149

Analgesia according to the WHO pain ladder (paracetamol or NSAID) - Address stress as a common precipitating factor

Answer 150

Vasculitis affecting extracranial branches of the carotid artery. Common in > 50

Answer 151

- Headache - Scalp pain or tenderness (particularly when brushing hair) - Temporary blindness that can progress to irreversible blindness

Answer 152

Oral prednisolone

Answer 153

Increase in the pressure within the skull, with normal levels <20mmHg

Answer 154

Late-stage symptoms of raised intracranial pressure: - Bradycardia - Hypertension - Irregular respirations

Answer 155

- Headache - Nausea - Vomiting - Confusion

Answer 156

- Papilloedema (optic disc swelling) on fundoscopy - Altered consciousness

Answer 157

1st line: - CT head to identify tumours or haemorrhage - Fundoscopy: to identify papilloedema

Answer 158

- ABCDE - Elevate head 15 - 20 degree - Hypertonic saline/mannitol to osmotically reduce cerebral oedema - Dexamethasone if brain abscess or tumour

Answer 159

- Antibiotics: if meningoencephalitis or brain abscess (ceftriaxone) - Ventriculo-peritoneal (VP) shunts for hydrocephalus - Surgical excision of tumours

Answer 160

Epilepsy is a neurological condition characterised by recurrent seizures. Seizures are paroxysmal alteration of neurological function as a result of excessive, hypersynchronous firing of neurons within the brain

Answer 161

- Focal - Generalised - Focal to bilateral - Unknown Important to know origin as it determines treatment

Answer 162

1. Where the seizures began 2. Level of awareness during the seizure 3. Other features of the seizure e.g. motor

Answer 163

- Automatism: lip smacking, picking - Automatic behaviour: running, walking - Auras: déjà vu, unpleasant smells

Answer 164

Predominantly motor symptoms: pelvic thrusting, bicycling, tonic posturing

Answer 165

- Parasthesias - Visual hallucinations - Visual illusions - More subjective and difficult to diagnose than other areas

Answer 166

- Visual hallucinations - Amaurosis fugax - Rapid and forced blinking - Movement of head or eyes to the opposite side

Answer 167

- Focal aware - Focal impaired awareness

Answer 168

- Bedside: FBC, blood glucose, electrolyte screen, tox screen if drugs suspected, LP and CSF analysis if infection suspected - CT head (1st line) - MRI brain (gold standard) - Electroencephalography (EEG) All adults must be referred to specialist via "first fit" clinic. Diagnosis usually after 2 unprovoked seizures or 1 if abnormal EEG

Answer 169

Lamotrigine or Levetiracetam

Answer 170

Generalised seizures affect both hemispheres and always impair awareness. They can be classified as motor or non-motor.

Answer 171

- Tonic-clonic - Tonic - Clonic - Myoclonic - Atonic

Answer 172

Stiffening of limbs (tonic) with rhythmic jerking (clonic) simultaneously

Answer 173

Sudden stiffness or tension in muscles of arm, legs or trunk

Answer 174

Repeated jerking movements of arms or legs on one or both sides of the body

Answer 175

Some or all of the body suddenly twitches. Usually lasts less than a second. Can be generalised or focal

Answer 176

Sudden loss of muscle strength. Might cause a person to drop to the ground Can be generalised or focal

Answer 177

Education - avoiding triggers, safety measures Stop driving and inform the DVLA: - First unprovoked seizure with normal EEG: 6-month suspension - First unprovoked seizure with a structural abnormality or epileptiform activity on EEG: 12-month suspension - Established epilepsy: can apply for a license if seizure-free for 12-months or 5 years if an HGV driver

Answer 178

They are generalised non-motor seizures which involve brief changes in awareness, staring or repeated movements like lip-smacking.

Answer 179

- Sodium valproate - highly teratogenic so avoid in women of childbearing age - Lamotrigine/Levetiracetam in women of childbearing age - Absence seizure: Ethosuximide

Answer 180

Before, during and after seizure, eye-witness account is important. **Pre-ictal** - Risk factors for epilepsy - Seizure triggers: e.g. alcohol - Aura: subjective feeling of warning pre-seizure **Ictal** - Length of the seizure - Appearance: jerking suggests tonic-clonic, behavioural arrest suggests absence - Progression: e.g. jacksonian march - seizure spreads from the distal part of the limb toward the face - Consciousness - Injury: tongue biting, head injury - Urinary incontinence **Post-ictal** - Drowsiness, headaches, amnesia, confusion around 30 minutes - Neurology: e.g. Todd’s paresis (weakness/paralysis in body after seizure)

Answer 181

Status epilepticus (SE) is a single, continuous seizure lasting >5 minutes or two or more seizures within five minutes without regaining consciousness in between. It is a medical emergency.

Answer 182

ABCDE approach: - Securing the airway - Giving high-concentration oxygen - Checking blood glucose levels - Gaining IV access (inserting a cannula)

Answer 183

1st line: benzodiazepine (e.g. IV lorazepam 4mg or diazepam 10mg or buccal midazolam 10mg) Repeat after 5-10 minutes if the seizure continues If ineffective then IV levetiracetam, phenytoin or sodium valproate Call on-call anaesthetist if still ineffective

Answer 184

- Glucose, - ECG: cardiac arrhythmias can precipitate seizures - ABG - FBC, U&Es and LFTs - Sodium, calcium, magnesium - Inflammatory markers: identify possible infection

Answer 185

Multiple sclerosis (MS) is a demyelinating central nervous system condition clinically defined by two episodes of neurological dysfunction (brain, spinal cord, or optic nerves) that are separated in space and time.

Answer 186

- Family history - Previous CNS trauma or infection - Previous history of seizures

Answer 187

- Female - 20 - 40 - Family history (HLA-DR2) - Northern latitude

Answer 188

**Relapsing-remitting (85%)** - Episodic flare-ups lasting days - months with periods of remission - 60% progress to secondary progressive **Secondary progressive** - Begins with a relapsing-remitting course but progressively worsens with no periods of remission **Primary progressive (10%)** - Symptoms get progressively worse from disease onset with no periods of remission

Answer 189

- Blurred vision and red desaturation (optic neuritis) - most common presentation - Weakness/tingling/numbness - Symptoms worsen after hot bath/shower (Uhtoff’s phenomenon)

Answer 190

Diagnosis made by a neurologist based on the clinical picture and symptoms suggesting lesions that change location over time. Other causes for the symptoms need to be excluded. **McDonald criteria** 2 or more relapses with either: - Objective clinical evidence of 2 or more lesions OR - Objective clinical evidence of one lesion WITH a reasonable history of a previous relapse Consider MRI - periventricular white matter lesions CSF analysis = oligoclonal bands

Answer 191

Methylprednisolone IV or oral

Answer 192

Disease-modifying therapy e.g. Interferon beta, glatiramer acetate

Answer 193

SAH is a type of intracranial haemorrhage characterised by blood within the subarachnoid space. It is most commonly caused by trauma (traumatic SAH).

Answer 194

- Trauma (e.g. head injury) - Berry aneurysm (80% of spontaneous SAH)

Answer 195

- Increasing age: >50 - Hypertension - Smoking - Family history - Autosomal Dominant Polycystic kidney disease (PKD) - Alcohol excess

Answer 196

- Severe sudden-onset headache (peaks within 1-5 mins and lasts > 1 hour) - Vomiting - Depressed consciousness/loss of consciousness - Neck stiffness and muscle aches (meningismus)

Answer 197

- Urgent non-contrast CT head - Diagnostic if hyperdense appearance of blood in the subarachnoid space/basal cistern - Lumbar punture if normal CT, NICE recommend LP > 12 hours after symptom onset, because bilirubin takes time to accumlate in CSF SAH on CSF will show: - Raised red cell count - Xanthochromia (a yellow colour to the CSF caused by bilirubin) CT angiography to confirm source of SAH

Answer 198

- Urgent referral to neurosurgery - Call the anaesthetist (UK) - Medical: 1st line is nimodipine (calcium-channel blocker) to prevent vasospasm - Surgerical: 1st line is endovascular coiling of aneurysm

Answer 199

- Migraine (can be severe headache but often previous hx) - Intracerebral haemorrhage (ICH) - Meningitis (fever present)

Answer 200

Inflammation of the meninges, the membranes covering the brain and spinal cord Most commonly caused by bacteria or viruses

Answer 201

- Herpes simplex virus (HSV, HSV-1 in Western world) - Enterovirus e.g. coxsackie virus - Varicella zoster virus (VZV).

Answer 202

Age (infants, young children, young and older adults) and exposure to insect vectors.

Answer 203

- Headache - Photophobia - Neck stiffness - Fever - Nausea and vomiting

Answer 204

- Kernig’s sign: flexed hip and the knee at 90°, extension of knee = pain - Brudzinski sign: severe neck stiffness causes the hips and knees to flex when the neck is flexed

Answer 205

- Blood tests: FBC, U+E, clotting, blood glucose - Arterial Blood Gas - Blood cultures - CT Head - Lumbar puncture for CSF analysis - bacterial culture, viral PCR, cell count, glucose, protein

Answer 206

Suspected meningitis, unknown cause: empirical antibiotics and follow local guidelines Confirmed viral: supportive care - Analgesia/antipyretic (pain ladder) - Anti-emetics (e.g., ondansetron) if vomiting - IV fluids if needed - Stop empirical antibiotics

Answer 207

Appearance = Cloudy Protein = High (>1g/L) Glucose = Low (<50% serum glucose) White Cell Count = High - 10-5000/mm3 (neutrophils) Culture = +ve for bacteria

Answer 208

Appearance = Clear Protein = Mildly raised/normal (<1g/L) Glucose = High (>60% serum glucose) White Cell Count = High 1000/mm3 (lymphocytes) Culture = Negative

Answer 209

Children + adults N. meningitidis aka meningococcus S. pneumoniae aka pneumococcus Neonates Group B streptococcus (GBS)

Answer 210

Bacterial! It is a life-threatening inflammation of the meninges! Needs urgent empirical antibiotics

Answer 211

- Headache - Neck stiffness - Fever - Altered mental status Children with meningococcal meningitis can have a non-blanching rash

Answer 212

- Advanced age (over 60s) - Crowded places (e.g. student halls) - Exposure to causative microorganisms - Immunocomprising conditions e.g. diabetes

Answer 213

Community: - Empirical antibiotics: signle dose IM/IV benzylpenicillin or ceftriaxone - Hospital admission/transfer Hospital: - Follow local guidelines and seek guidance from micrology - Under 3 months – cefotaxime plus amoxicillin (amoxicillin is to cover listeria) - Above 3 months – ceftriaxone

Answer 214

Encephalitis

Answer 215

Encephalitis describes inflammation of the brain parenchyma.

Answer 216

HSV-1 - 95% cases

Answer 217

- Under 1 or over 65 years - Immunodeficiency - Body fluid exposure: HIV, - Organ transplantation - Animal or insect bites (mosquito bites for West Nile virus)

Answer 218

- Altered mental state - Fever - Rash - Focal neurological deficit (e.g. ataxia, aphasia) - Behavioural changes (e.g. withdrawal, personality changes, psychosis

Answer 219

- Blood tests: FBC, CRP, U&Es, LTFs - Viral throat swab - CT or MRI (preferred) head - HSV affects temporal lobes and bilateral multifocal haemorrhage seen CSF analysis: - lymphocytosis + raised protein if viral - PCR for HSV and other common viral causes - Blood cultures

Answer 220

Aciclovir for HSV-1

Answer 221

- Hypoglycaemia - Hepatic encephalopathy - Diabetic Ketoacidosis (DKA)

Answer 222

An abnormal growth occurring in any tissue within the cranium, including the brain, cranial nerves, meninges, skull and pituitary gland. - Benign or malignant - Primary or secondary (metastatic)

Answer 223

A common exam scenario is an unusual change in personality and behaviour, which indicates a frontal lobe tumour. The frontal lobe is responsible for personality and higher-level decision-making.

Answer 224

Usually asymptomatic when small, progressive focal neurological deficits as they grow bigger. Symptoms and signs of raised intracranial pressure (ICP)

Answer 225

- Headache: red flags are constant, worse in morning, nocturnal, vomiting Other clinical features - Altered mental state - Visual field defects - Seizures (particularly partial seizures) - Unilateral ptosis (drooping upper eyelid) - Third and sixth nerve palsies (eye down and out, can't abduct)

Answer 226

Papilloedema - swelling of optic disc secondary to ICP

Answer 227

Tumours of the glial cells in the brain or spinal cord. Glial cells surround and support neurons. Glial cells include astrocytes, oligodendrocytes and ependymal cells.

Answer 228

Grades 1 to 4. Grade 1 = most benign Grade 4 = most malignant (e.g., glioblastoma multiforme).

Answer 229

- Most aggressive: astrocytoma (the most common and aggressive form is glioblastoma) - Oligodendroglioma - Least aggressive: Ependymoma

Answer 230

Tumours originating from cells of the meninges Usually benign but they take up space and the "mass effect" can lead to ICP and neurological symptoms.

Answer 231

- Lung - Breast - Renal cell carcinoma (Kidney) - Melanoma

Answer 232

Usually benign, but can press on optic chiasm if grows large enough Visual field defect = bitemporal hemianopia Causes hypo/hyperpituitarism, causing: - Acromegaly (excessive growth hormone) - Hyperprolactinaemia (excessive prolactin) - Cushing’s disease (excessive ACTH and cortisol) - Thyrotoxicosis (excessive TSH and thyroid hormone)

Answer 233

- Trans-sphenoidal surgery (through the nose and sphenoid bone) - Radiotherapy - Bromocriptine to block excess prolactin - Somatostatin analogues (e.g., octreotide) to block excess growth hormone

Answer 234

Benign tumours of the Schwann cells that surround the auditory nerve (vestibulocochlear nerve). Schwann cells provide myelin sheath of the PNS Usually unilateral, bilateral associated with neurofibromatosis type 2 Management options include: Conservative management with monitoring may be used if there are no symptoms or treatment is inappropriate Surgery to remove the tumour (partial or total removal) Radiotherapy to reduce the growth

Answer 235

40 - 60, gradual onset of: - Unilateral sensorineural hearing loss (often the first symptom) - Unilateral tinnitus - Dizziness or imbalance - Sensation of fullness in the ear - Facial nerve palsy (if the tumour grows large enough to compress the facial nerve)

Answer 236

- Conservative: active monitoring if no symptoms or treatment not suitable - Surgery to remove the tumour (partial or total removal) - Radiotherapy to reduce the growth

Answer 237

1st line: MRI head Biopsy to confirm histological diagnosis, taken during surgical removal

Answer 238

Depends on type and grade and is guided by MDT, main options are: - Surgery - Chemotherapy - Radiotherapy - Palliative care

Answer 239

- Injury to the spinal cord as a result of external pressure - Causes damage to white matter and grey matter resulting in partial or complete loss of sensory modalities and motor function. - Can lead to acute, sub-acute or chronic spinal cord injury

Answer 240

Trauma: e.g. car accident Vertebral compression fractures: e.g. osteoporosis Intervertebral disc disease: disc herniation Tumours: e.g. metastatic disease Infection: discitis, TB (Pott’s disease)

Answer 241

- High-risk sporting activity: e.g. horse-riding - High-risk occupation: construction - Malignancy: particularly breast, prostate, renal, lung, multiple myeloma metastasis - Age - Immunosuppression or IVDU: osteomyelitis, discitis, epidural abscess

Answer 242

- UMN signs: hyperreflexia, spasticity, and a positive Babinski's sign. - Sensory disturbance (temp, fine touch, vibration): typically below lesion level - Deep and localized back pain - Radicular sensory disturbance: stabbing sensation at the level of the lesion. Bladder and bowel incontinence or retention.

Answer 243

- Full neuro exam: tone, power, reflexes, sensation, proprioception - Urgent whole spine MRI, aim to surgically decompress within 48 hours

Answer 244

- Immediate immobilisation - Surgical spinal cord decompression and stabilisation

Answer 245

- Dexamethasone: reduce inflammation Radiotherapy: palliative Surgery: depending on the impact of radiotherapy, age and prognosis

Answer 246

- IV antibiotics - Surgery: spinal cord decompression or CT-guided needle aspiration if abx ineffective

Answer 247

- MS - Peripheral neuropathy

Answer 248

Cauda equina syndrome (CES) is caused by compression of the lumbosacral nerve roots of the cauda equina below the spinal cord Neurological emergency!

Answer 249

- Lumbar disc herniation: the most common cause of CES - Trauma - Spinal tumour

Answer 250

- Bladder dysfunction (overflow incontinence, less awareness of full bladder) - Lower limb weakness - absent reflexes too - Saddle anaesthesia - red flag - Lower back pain & sciatica

Answer 251

- Gold-standard - non-contrast MRI spine - lesions and compression od neural structures

Answer 252

- Urgent surgical decompression, 48-hour window remains controversial as some studies showed that it can affect prognosis. - VTE prophylaxis - PPI (e.g. omeprazole) to prevent gastric stress ulcer - Bladder/bowel management (catheter, laxatives, manual evacuation)

Answer 253

- Spinal stenosis - Spinal epidural abscess (fever often present) - Sciatica

Answer 254

Myasthenia gravis is a chronic autoimmune disorder of the postsynaptic membrane at the NMJ of skeletal muscle. Autoantibodies against the nicotinic acetylcholine receptor (AChR) and sometimes muscle-specific kinase (MuSK) Fewer available binding sites for acetylcholine (Ach), resulting in weakness.

Answer 255

- Female gender: 2:1 - Family history - Other autoimmune conditions: personal or FHx e.g. SLE, RA - Thymoma or thymic hyperplasia

Answer 256

- Muscle weakness worse at end of the day - Double vision - Droopy eyelids - Dysphagia (chewing/swallowing) - SOB - might indicate myasthenic crisis

Answer 257

- Muscle strength fatigability, might have diurnal pattern (better in morning than evening) - Unilateral/bilateral ptosis - Myasthenia snarl - "snarling" expression when smiling

Answer 258

- Beta-blockers - Lithium - Penicillamine - Gentamicin - Quinolones - Phenytoin

Answer 259

1st line: Acetylcholine receptor (AChR) antibody analysis Muscle-specific tyrosine kinase (MuSK) antibodies if above -ve Serial pulmonary tests Chest CT for thymoma or thymic hyperplasia -Repetitive nerve conduction studies: decremental muscle response

Answer 260

Complication of myasthenia gravis due to weakening of the respiratory muscles and is often provoked by infections or medications. Presents with SOB which can progress to respiratory failure

Answer 261

- IV immunoglobulin or plasmapheresis - Intubation: if severe respiratory compromise - Corticosteroids as an adjunct

Answer 262

First-line: pyridostigmine which is an acetylcholinesterase inhibitor

Answer 263

Lambert-Eaton syndrome, usually as a result of SCLC, improves with exercise unlike MG

Answer 264

Motor neuron disease (MND) is a disorder of both upper and lower motor neurons mostly present ≥ 40. Amyotrophic lateral sclerosis (ALS) most common ~50%

Answer 265

A neurodegenerative disorder characterised by progressive muscle weakness that can start in limb, axial, bulbar, or respiratory muscles and then generalises relentlessly, causing progressive disability and ultimately death, usually from respiratory failure.

Answer 266

Both UMN and LMN symptoms - Upper extremities weakness - difficulties with e.g. brushing teeth, dressing due to mix of UMN and LMN - Difficulties arising from sitting - LMN causing lower limb weakness - Difficulties with swallowing (dysphagia) - Difficulties with speech (dysarthria) - Hyperreflexia - UMN - Fasciculations, especially on the tongue - Muscle wasting: particularly of small hand muscles and tibialis anterior

Answer 267

No sensory abnormalities No extraocular involvement No cerebellar involvement

Answer 268

Clinical diagnosis Consider: - Electromyography: fibrillation potential (action potentials generated by recently denervated muscle fibres) - Nerve conduction studies: reductions in amplitude - MRI spine: exclude spinal pathologies that mimic MND e.g. cervical cord compression - Pulmonary function tests: risk of respiratory failure

Answer 269

- Riluzole: prolongs survival in ALS by 2-4m - Respiratory support: non-invasive ventilation at home, usually BiPAP, prolongs life by 7m Supportive treatment: - Antispasmodics: such as baclofen - Feeding support: often PEG tube - Speech and language therapy - Physiotherapy

Answer 270

- Aspiration pneumonia - Respiratory failure: often in advanced disease when respiratory muscles have been affected - Most patients die within 3- 5 years from onset of symptoms from respiratory complications

Answer 271

Muscular dystrophy is an umbrella term for genetic conditions that cause gradual weakening and wasting of muscles. Main type is Duchenne's muscular dystrophy (DMD-exams)

Answer 272

X-linked recessive muscular dystrophy caused by a defective gene for dystrophin on the X-chromosome. Dystrophin is a protein that provide structural stability to muscles at a cellular level. Women who are carriers don't usually notice the symptoms, her offsprings have: - 50% chance of carriers if female - 50% chance of the condition if male

Answer 273

Children with proximal muscle weakness get on their hands and knees and push into a "downward" dog position and slowly stand up legs first and walk their hands up as the muscles around the pelvis are not strong enough to get their upper body erect without the help of their arms.

Answer 274

- Serum creatinine kinase - elevated CK levels are characteristic of DMD, levels of over 20,000 international units/L not common. - 50-100 times normal level consistent with DMD - Genetic testing

Answer 275

No cure Aims to improve QoL MDT: doctors, nurse, OT, Physio Medical appliances e.g. wheelchairs, braces Medical management of complications e.g. spinal scoliosis and HF

Answer 276

GBS is an acute paralytic polyneuropathy that affects the peripheral nervous system. It causes acute, symmetrical, ascending weakness and can also cause sensory symptoms. Usually triggered by a preceding infection, associated with: - Campylobacter jejuni - Cytomegalovirus (CMV) - Epstein-Barr virus (EBV).

Answer 277

- Autoimmune condition - Due to a process called molecular mimicry. - The B cells of the immune system create antibodies against the antigens on the triggering pathogen. - These antibodies also match proteins on the peripheral neurones. - They may target proteins on the myelin sheath (demyelinating form) or the nerve axon (axonal form).

Answer 278

Required features: - Symmetrical ascending weakness that begins in the feet - Hyporreflexia/arflexia Supprotive of diagnosis: - Peripheral loss of sensation, neuropathic pain or/and autonomic dysfunction (urinary retention, heart arrhythmias). Symptoms start within 4 weeks of the triggering infection. Symptoms peak within 2-4 weeks Recovery period of months to years

Answer 279

Clinical diagnosis with Brighton criteria supported by investigations: Nerve conduction studies - reduced signal through the nerves Lumbar puncture for CSF analysis - raised protein with a normal cell count and glucose

Answer 280

- 1st line: IV immunoglobulin, or plasmapheresis (plasma exchange) - Supportive care - VTE prophylaxis (pulmonary embolism is a leading cause of death) - Severe cases with respiratory failure may require intubation, ventilation and admission to the ITU

Answer 281

- Myasthenia gravis - Lambert-Eaton myasthenic syndrome (LEMS) - Botulism

Answer 282

Diabetic peripheral neuropathy (DPN) refers to a variety of peripheral nerve disorders caused by diabetes. Mainly caused by chronic hyperglycaemia.

Answer 283

- Poorly controlled hyperglycaemia - Older age (e.g., >70 years), - Prolonged duration of diabetes (e.g., >10 years), and tall stature.

Answer 284

- Distal Symmetrical Sensory Neuropathy - Resulting from loss of large sensory fibres. Clinical features - Sensory loss in a 'glove and stocking' distribution, typically affecting touch, vibration and proprioception.

Answer 285

Neurological exam - assess extent of sensory and motor deficits Clinical diagnosis with bloods to exclude differentials: - Fasting blood glucose - HbA1c - Serum TSH - U+E (renal disease) - B12 (exclude deficiency) - LFTs - FBC +ESR (anaemia, inflammatory diseases)

Answer 286

Glycemic control and supportive measures Diet and exercise effective in type 1 and 2 Multiple insulin injections are more effective in type 1 than type 2 Proper foot and wound care

Answer 287

- Vitamin B12 deficiency: peripheral neuropathy, typically in a glove and stocking distribution. May also feature megaloblastic anemia - Alcohol-induced peripheral neuropathy: presents similarly to DPN but may also have accompanying signs of chronic alcohol misuse.

Answer 288

A chronic, progressive condition characterised by painful or painless bone and joint destruction in the limbs that have lost sensory innervation. The condition primarily affects patients with peripheral neuropathy, usually from long-standing diabetes.

Answer 289

6Ds (some are imaging features) - Destruction of bone and joint - Deformity - Degeneration - Dense bones - Debris of bone fragments - Dislocation

Answer 290

Tarsometatarsal joints, but it can involve any joint in a limb that has lost sensation due to neuropathy.

Answer 291

Clinical diagnosis with imaging: 1st line = X-ray - shows bone destruction, debris, sclerosis (dense bones), and dislocation.

Answer 292

Prolonged off-loading, often involving special footwear or plaster casts, to allow healing and prevent further damage. Long-term use of orthotics for prevention of recurrences.

Answer 293

- Bisphosphonates - slows down bone destruction - Gabapentin or pregabali for paiin - Topical anesthetics

Answer 294

Resection of bony prominences to prevent ulcers or improve fitting of footwear. Amputation if severe or concurrent uncontrolled infection.

Answer 295

- Most common mononeuropathy - It is a collection of symptoms and signs caused by compression of the median nerve in the carpal tunnel.

Answer 296

In the wrist, there is a fibrous band called the flexor retinaculum that runs across the palmar side of the wrist. The carpal bones lie underneath. The carpel tunnel is a passage, from the forearm to the hand. that runs between the flexor retinaculum and the carpal bone. It contains the median nerve and the forearm flexor tendons.

Answer 297

Compression of the contents of the carpal tunnel (causing carpal tunnel syndrome) is the result of either: Swelling of the contents (e.g., swelling of the tendon sheaths due to repetitive strain) Narrowing of the tunnel

Answer 298

It passes through the carpal tunnel, and is responsible for sensory innervation of the palmar aspects and full fingertips of the: - Thumb - Index and middle finger - The lateral half of ring finger

Answer 299

Thenar muscles motor function - Abductor pollicis brevis (thumb abduction) - Opponens pollicis (thumb opposition) - Flexor pollicis brevis (thumb flexion)

Answer 300

Most commonly idiopathic Key risk factors: - Repetitive strain - Obesity - Perimenopause - Rheumatoid arthritis - Diabetes - Acromegaly - Hypothyroidism

Answer 301

Gradual onset, worse at night Sensory symptoms: numbness, paraesthesia, burning sensation and pain in the distribution of the palmar digital cutaneous branch of the median nerve (see above) Motor symptoms affect thenar muscles - Weakness of thumb movements - Weakness of grip strength - Difficulty with fine movements involving the thumb - Wasting of the thenar muscles (muscle atrophy)

Answer 302

- Phalen's - Tinel's

Answer 303

- Hand exam with special tests Carpal tunnel questionnaire: the Kamath and Stothard carpal tunnel questionnaire (CTQ) It scores based on questions such as: - Do symptoms wake you at night? - Do you have trick movements (e.g., shaking the hand) to improve symptoms? - Is your little finger affected? (Answering yes scores negatively, making carpal tunnel syndrome less likely) High score = more likely to be carpal tunnel syndrome - Electromyography (EMG): to assess the electrical activity of the muscles at rest and during contraction. Gold standard: - Nerve Conduction Studies (NCS): to measure the speed and strength of signals traveling through the median nerve.

Answer 304

- Rest and altered activities - Wrist splints for a minimum of 4 weeks - Steroid injections - Surgery Surgery: - Day case under local anaesthetics - Open or endoscopic - The flexor retinaculum is cut to release the pressure on the median nerve.

Answer 305

- Cubital tunnel syndrome - Ulnar nerve compression at the elbow - Cervical nerve root entrapment

Answer 306

Radiculopathy is a condition where a nerve root in the spinal column becomes inflamed or compressed, causing pain, numbness, or weakness radiating along the nerve root’s pathway.

Answer 307

- Herniated discs - Spinal stenosis - Degenerative disc disease

Answer 308

- Cervical radiculopathy: neck and upper limbs - Thoracic radiculopathy: mid-back and torso Lumbosacral radiculopathy: lower back and lower limbs

Answer 309

Age: most common 30 - 50 Occupational factors: heavy lifting or repetitive movements Osteoarthritis: cervical radiculopathy can arise from osteoarthritic changes in the C-spine

Answer 310

A dermatome is a patch of skin that receives sensory nervous supply from a single spinal nerve root (e.g. T1).

Answer 311

Symptoms: - Radiating pain originating in neck or back - Paraesthesia or numbness - Muscle weakness Signs: - Positive straight leg raise test = places stress on L2 -L4 and sciatic nerve, lumbar radiculopathy - Sensory deficits in a dermatomal distribution - Reduced muscle power

Answer 312

Overlapping clinical features Weakness of foot dorsiflexion Weakness of toe extension Differences L5 radiculopathy: Weakness during foot inversion Common peroneal nerve injury: Weakness during foot eversion L5: Lower limb tendon reflex changes present Common peroneal: no changes to lower limb reflexes L5: L5 dermatomal distribution of sensory loss Common peroneal: sensory loss over the anterior aspects of foot and leg

Answer 313

- MRI: level and cause of nerve root compression if severe - Nerve conduction studies: to assess the speed of nerve signal transmission. - Electromyography (EMG): measures electrical activity in muscles and identifies the affected nerve root.

Answer 314

First-line: NSAIDs: ibuprofen Physiotherapy to relieve pressure on affected nerve root Second-line: Epidural steroid injections: if severe to reduce inflammation Surgery: laminectomy or discectomy if conservative and medical treatment not effective

Answer 315

- Sudden-onset severe headache reaching maximum intensity within 5 minutes: - Subarachnoid haemorrhage New-onset headache in a person aged over 50 years: - Temporal arteritis - Space-occupying lesion Progressive or persistent headache or headache that has changed dramatically: - Space-occupying lesion - Subdural haematoma Headache worse on standing or sitting: raised ICP e.g. space-occupying lesion - Headache worse on waking - raised ICP Recent head trauma <3m: subdrural haematoma

Answer 316

Brain metastases occur when cancer cells spread from their primary location to the brain via haematogenous spread (via blood).

Answer 317

A membrane that extends from the dura mater that invaginates to separate the occipital and temporal lobes (superiorly) from the cerebellum and brain stem (inferiorly). Used to categorise brain metastases as it affects treatment. - Supratentorial - Infratentorial

Answer 318

- Lung cancer - Breast cancer - Melanoma - Colorectal cancer - Renal cell carcinoma

Answer 319

- Headache that is worse on lying flat e.g. at night and first thing in the morning - N+V - Reduced consciousness - Seizure - Blurred vision

Answer 320

- Focal neurological deficits: determined by site of brain metastasis - ICP: e.g. papilloedema (optic disc swelling) on fundoscopy - Cushing triad: hypertension, bradycardia and irregular respirations - Hemiparesis

Answer 321

MRI brain: Gold standard as detailed and can identify even small metastases CT brain: less sensitive than MRI but more available in emergencies

Answer 322

Corticosteroids: dexamethasone to reduce oedema

Answer 323

- Radiotherapy: whole brain radiotherapy (WBRT) for multiple metastases - Stereotactic radiosurgery : delivery of a high dose of radiation focally to the tumour - Surgery: if solitary tumour or as a diagnostic tool if primary unknown - Chemotherapy: drugs with good CNS penetration, such as temozolomide, topotecan, and irinotecan Targeted therapies and immunotherapy: immune checkpoint inhibitor (ICI), ipilimumab effective in recurrent brain metastases

Answer 324

Physical therapy can help regain lost motor skills or muscle strength. Occupational therapy: help patients return to their normal daily activities, including work Speech therapy if difficulties with speech

Answer 325

A rare condition that occurs when the ventricles of the brain become enlarged due to an increase in CSF in the brain space, without a concomitant increase in the CSF opening pressure on a lumbar puncture. Produces a rapidly progressing dementia-like picture with gait disturbances not responsive to levodopa

Answer 326

- Mostly idiopathic Secondary causes: - Subarachnoid haemorrhage - Intracerebral haemorrhage - Severe meningitis - Brain tumour - Head trauma

Answer 327

Classic triad (Hakim's triad) of: - Mental impairment (poor conc, poor memory, increasing confusion), - Urinary incontinence - Gait disturbance (shuffling + "magnetic" like feet stuck to floor)

Answer 328

- CT/MRI head: key diagnostic features include ventriculomegaly; absence of macroscopic obstruction to CSF flow - Levodopa challenge - give levodopa if PD suspected to confirm

Answer 329

1st line Ventriculo-peritoneal shunting (VPS): permanent CSF diversion from the ventricular system to the peritoneum via shunt surgery.

Answer 330

- Parkinson's disease - Parkinson-plus syndromes - Alzheimer's

Answer 331

Hydrocephalus is a neurological disorder characterized by an excessive accumulation of CSF within the brain's ventricular system, leading to ventricular enlargement or ventriculomegaly. This increase in CSF results in raised intracranial pressure.

Answer 332

Symptoms often relate to ICP: - Early morning headaches - Nausea and vomiting - Lethargy - Vision disturbances - Balance problems - Cognitive difficulties Investigations and management are the same as NPH

Answer 333

- Brain tumours - Subdural haematoma - Benign intracranial hypertension

Answer 334

Huntington’s disease is an autosomal dominant genetic condition that causes progressive neurological dysfunction. It is a trinucleotide repeat disorder involving a mutation in the HTT gene on chromosome 4, causing an excessive repetition of the CAG trinucleotide (>38 repeats)which codes for the huntingtin (HTT) protein.

Answer 335

Insidious, progressive worsening of symptoms. Initially, cognitive, mood, and psychiatric symptoms e.g. concentration impairments, personal hygiene changes, personality changes such as irritability, and temper outbursts. Later onset: - Chorea (involuntary, random, irregular and abnormal body movements) - Dystonia (abnormal muscle tone, leading to abnormal postures) - Rigidity (increased resistance to the passive movement of a joint) - Dysarthria (speech difficulties) - Dysphagia (swallowing difficulties)

Answer 336

Clinical diagnosis supported by: - Genetic testing i.e. CAG repeat testing: - Positive result = ≥ 40 CAG repeats on 1 of the 2 alleles - certain development of HD in lifetime - Intermediate result = 36 to 39 repeats - may/ may not develop HD - CT or MRI - caudate or striatal atrophy in moderate-severe disease

Answer 337

- Behavioural and genetic counselling for patient, carer and family - Tetrabenazine - chorea symptoms - MDT input to improve QoL - Physiotherapy to improve mobility, maintain joint function and prevent contractures - Speech and language therapy - Antidepressants (e.g., SSRIs) - Advanced directives to document their wishes as the disease progresses - End-of-life care

Answer 338

You have to counsel a child of someone with HD, 50% chance of inheritance. Must be 18 before deciding Your job is to provide info for the patient to make an informed decision, not to advise them to have a test or not Usual outcome - patient to think about it further and return if they have further questions.

Answer 339

A progressive condition, life expectancy is around 10 - 20 years from symptom onset. As disease progresses, patients become more frail and susceptible to illness (e.g., infection). Death = aspiration pneumonia or suicide.

Answer 340

- Parkinson's disease - Wilson's disease

Answer 341

Essential tremor (ET), is a progressive tremor affecting predominantly the upper limb. I Absent at rest, occurs in posture and movement (i.e. action tremor). Typically without additional neurological signs or symptoms.

Answer 342

- Advanced age: >50% of cases in patients >70 - Family history - Caucasian ancestry - Exposure to environmental toxins: organochlorine pesticides, lead, mercury

Answer 343

Tremor: - Upper limb (hands, somestimes voice/head tremor) - Worse on movement and posturing - Bilateral Improvement with drugs that affect gamma-aminobutyric acid (GABA)-ergic systems: - Alcohol - Benzodiazepines - Gabapentin

Answer 344

Movement Disorder Society on tremor criteria: - Isolated tremor syndrome of bilateral upper limb action tremor - At least 3 years’ duration - With or without tremor in other locations (e.g., head, voice, or lower limbs) - Absence of other neurological signs, such as dystonia, ataxia, or parkinsonism.

Answer 345

Urine - 24-hour urinary copper: Wilson’s disease Bloods - TFTs: hyperthyroidism - U&Es: electrolyte disturbance - LFTs: hepatic failure - Serum caeruloplasmin: Wilson’s disease Imaging - MRI head: exclude structural cause - SPECT (dAT) scan: Parkinson’s disease

Answer 346

Depends on severity and effects on ADLs - Mild disease: Observation - Moderate disease: first-line (medical) is propranolol - Treatment-resistant disease: surgery: deep brain stimulation or MRI-guided thalamotomy

Answer 347

Bleeding into the potential space between the skull and the dura mater. The blood collection is called extradural haematoma (EDH).

Answer 348

Most common is trauma e.g. blunt force. Causes middle meningeal artery rupture Non-trauma: - Haemorrhagic tumour - Coagulopathy - Infection

Answer 349

Initial brief loss of consciousness followed by a lucid interval (~20% patients) Then subsequent deterioration of neurological status and reduced GCS Often accompanied by physical evidence such as bruising, Battle’s sign (bruising behind mastoid process), periorbital haematoma (racoon eyes), Bleeding from one/both ears

Answer 350

Glasgow coma score (GCS) 3 (completely unresponsive) to 15 (responsive) Mild TBI: GCS 13-15; mortality 0.1% Moderate TBI: GCS 9-12; mortality 10% Severe TBI: GCS <9; mortality 40%.

Answer 351

Non-contrast CT head - EDH appears as a hyperdense biconvex collection often below temporal bone.

Answer 352

Urgent neurosurgery opinion Aim to reduce ICP Bed position so head at 30 degrees Intubation if reduced GCS Oxygen (15L 100% through non-rebreather mask) Hypertonic saline/mannitol to reduce ICP Maintain perfusion (= MAP - ICP) via inotropes (increase cardiac contractility) and vasopressors (increase MAP)

Answer 353

Definitive management - Craniotomy and haematoma evacuation if ≥ 30cm 3 regardless of the GCS score Serial CT and observation ONLY if: - < 30cm 3 - < 15mm thickness - < 5mm midline shift - GCS > 8 without focal deficit

Answer 354

- If TBI then mortality risk increases as GCS decreases. - Neurological deficits such as gait, mobility, muscle weakness dysarthria, dysphasia - Cognitive deficits e.g. memory and concentration - Intracranial lesions such as extradural haematoma - Depression - PTSD

Answer 355

Cerebral palsy (CP) is an umbrella term for a non-progressive disease of the brain originating during the antenatal, perinatal or early postnatal period. Results in motor and postural disorders, 80% have spasticity

Answer 356

**Antenatal (80%):** - Premature birth: 35% of babies born before 26 weeks will develop CP - Maternal infections: chorioamnionitis, and TORCH infections **Perinatal:** - Asphyxia - Birth trauma **Postnatal (10%):** - Neonatal sepsis - Meningitis

Answer 357

**Spastic: (70 - 90%)** - Due to damage to pyramidal pathways - Hypertonia and hyperreflexia - "Scissor" gait due to tight adductor muscles Dyskinetic: - Damage to basal ganglia (involved in inhibition of movement) - Dystonia (random, slow movements in limbs/trunk) - Chorea (random "dance-like" movement) Ataxic - Damage to cerebellum - Uncoordinated movements - Signs of cerebellar lesion

Answer 358

- Muscular dystrophies - progressive weakness and loss of muscle mass - Metabolic disorders: developmental delay, sezures, failure to thrive - Juvenile idiopathic arthritis - joint inflammation, stiffness, pain and swelling

Answer 359

Clinical diagnosis with supporting tests: - Imaging - MRI head - periventricular leuko- (white matter) malacia (softening), congenitial malformations, stroke/haemorrhage, cystic lesions

Answer 360

MDT - physiotherapy (mobility, strength training), OT (adaptive equipment), speech therapy, dietitian Medical: Baclofen or botulinum toxin as muscle relaxant

Answer 361

Delirium (sometimes called 'acute confusional state') is an acute , fluctuating, clinical syndrome characterised by inattention ,an impaired level of consciousness and disturbed cognitive function

Answer 362

- Hyperactive delirium: agitation, hallucinations, restlessness, combativeness - Hypoactive delirium: associated with lethargy , reduced activity and concentration - Mixed delirium with symptoms and signs of both hyper- and hypoactive delirium

Answer 363

- Advancing age - Co-morbidities - Dementia - Current hip fracture - Increased time in hospital

Answer 364

PINCH ME Pain Infection (Ma)lNutrition Constipation (De)Hydration Medication Environment (change)

Answer 365

- Disorganised thinking and cognitive disturbance - Memory impairment , language disturbance - Disorientation + confusion - Loss of awareness of surroundings - Reversal of sleep-wake cycle

Answer 366

4AT Alertness AMT4 (adderviated mental test 4) - age, date of birth, place, current year Attention (months of the year backwards) Acute changes/fluctuating course

Answer 367

Depends on clinical picture - ECG - Urinalysis - Urine or sputum culture: infection - Bloods: FBC, BM, LFT, bone profile, TFT, U+E, folate and B12

Answer 368

- Most patients = hospital admission DOLS if needed 1st line: - treat precipitating factors, - optimise management of co-morbidities - Reorientation methods e.g. accurate, easily readable calendars and clock Sedation: avoid unless patient is a risk to themselves and others, de-escalation technique first. Haloperidol 0.5mg if sedation needed

Answer 369

- Capacity is assumed, it needs to be proven otherwise - Enabling people to make their own decisions - Unwise decisions - Best interests - Least restrictive option

Answer 370

Chronic, neurological condition characterised by recurrent seizures. Seizures are paroxysmal alterations in neurological activity caused by excessive, hypersynchronous firing of neurons.

Answer 371

- Generalised - Focal - Focal to bilateral

Answer 372

- Tonic-clonic - Myoclonic - Tonic - Clonic - Atonic

Geriatrics and Neurology Flashcards

(399 cards)