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YEAR 4 - ACC > Headache + ENT > Flashcards

Headache + ENT Flashcards

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1
Q

What is meningococcal disease?

A

Meningococcal septicaemia
OR
Meningococcal meningitis

Or a combination of both

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2
Q

What are the main causes of bacterial meningitis?

A

Neonates

  • Group B strep
  • Listeria monocytogenes
  • E. coli

Infants

  • H. influenzae
  • N. meningitides
  • S. pneumoniae

Adults
- same as infants

Elderly

  • S. pneumoniae
  • L. monocytogenes
  • TB
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3
Q

What are some non-infective causes of meningitis?

A 
Malignant cells
Drugs - NSAIDs, trimethoprim
Sarcoidosis
SLE
Behcet's disease
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4
Q

What are some early features of meningitis?

A 
Headache
Fever
Leg pains
Cold hands and feet
Abnormal skin colour
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5
Q

What features make up ‘meningism’?

A
  • Neck stiffness
  • Photophobia
  • Kernig’s sign = pain and resistance on passive knee extension with hip fully flexed
  • Bruzinkski’s sign = involuntary lifting of leg when lying supine and head is raised
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6
Q

How would meningitis present in an infant?

A

High-pitched cry
Bulging fontanelle
Vomiting
Drowsiness

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7
Q

What indicates invasive meningococcal disease?

A
  • Petechial rash that is non-blanching (use glass test to check)
  • Signs of shock: prolonged cap refill, hypotension, tachycardia
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8
Q

What investigation should you do first in suspected meningitis?

A

Blood cultures

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9
Q

After taking blood cultures, how is meningitis managed?

A
  • IV antibiotics - start immediately on any clinical suspicion
  • IV dexamethasone 10mg - to reduce meningism
  • Airway support
  • Fluid resuscitation
  • LP (only do this before IV antibiotics if they are stable; CI in raised ICP and coagulopathies)
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10
Q

What is the blind/empirical therapy for meningitis?

A

IV ceftriaxone (3rd generation cephalosporin)

If atypical pathogens, add IV amoxicillin
If Listeria, add gentamicin

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11
Q

What antibiotic should GPs give to treat meningitis in the community?

A

IM benzylpenicillin

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12
Q

What should be given as prophylaxis to those in close-contact with meningitis?

A

Rifampicin

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13
Q

What complications can arise from meningitis?

A

Immediate complications:

  • DIC
  • Raised ICP
  • Pericardial effusion

Delayed complications:

  • Encephalopathy
  • Hearing loss
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14
Q

Describe the CSF analysis in bacterial, viral + TB meningitis

A

Bacterial

  • Cloudy, turbid appearance
  • > 1.5g/L protein (normal 0.2-0.4)
  • Low glucose
  • Neutrophils ++++

Viral

  • Clear appearance
  • Normal protein
  • Normal glucose
  • Lymphocytes ++++

TB

  • Cob-web like appearance
  • > 1.5g/L protein
  • Low glucose
  • Lymphocytes ++++
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15
Q

What is the most common focal neuropathy with a space occupying lesion?

A

CN VI palsy - most common as it has long intracranial path

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16
Q

What causes temporal arteritis?

A

Autoimmune vasculitis affecting the posterior ciliary arteries

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17
Q

Who should you always consider temporal arteritis in?

A

All patients over 50 years with a recent sudden onset headache

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18
Q

What condition is temporal arteritis associated with?

A

Polymyalgia rheumatica

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19
Q

How does temporal arteritis present?

A 
Headache
Scalp tenderness e.g. when combing hair
Tongue/jaw claudication - pain on chewing
Amaurosis fugax - transient visual loss 
Sudden unilateral blindness
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20
Q

What is the risk with temporal arteritis?

A

Irreversible bilateral visual loss - can occur suddenly if not treated so emergency refer to ophthalmologist

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21
Q

What are some extracranial symptoms of temporal arteritis?

A 
Malaise
Dyspnoea
Weight loss
Morning stiffness
Unequal or weak pulses
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22
Q

How does the retina appear in temporal arteritis?

A

Pale papilloedema
Pale, waxy, elevated disc = ischaemia
Splinter haemorrhages

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23
Q

What bloods must be done in temporal arteritis?

A

ESR - raised >47

CRP - raised

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24
Q

What provides a definitive diagnosis of temporal arteritis?

A

Temporal artery biopsy - within a week of starting steroids

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25
What is the treatment for temporal arteritis?
Start prednisolone 60mg OD immediately to avoid visual loss If there is visual loss/history of amaurosis fugax - IV methyprednisolone
26
What presents similarly to subarachnoid haemorrhage?
Venous Sinus Thrombosis
27
What is venous sinus thrombosis?
Acute thrombosis (blood clot) in the dural venous sinuses (which normally drain blood from the brain) causing cerebral infarction
28
Which sinus is most commonly affected by venous sinus thrombosis?
1. Sagittal sinus thrombosis | 2. Transverse sinus thrombosis
29
What are the risk factors for venous sinus thrombosis?
Prothrombotic haematological conditions (thrombophilia) Hormonal factors (pregnancy, COCP, peri-partum period) Local factors (sinus infection, trauma, skull abnormalities) Systemic disease (malignancy, dehydration, sepsis)
30
What is the onset of symptoms like in venous sinus thrombosis?
Gradually come on over days or weeks
31
How does venous sinus thrombosis present depending on the sinus affected?
Sagittal sinus (most common) - headache, vomiting, seizures, decreased vision, papilloedema Transverse sinus - headache, mastoid pain, focal CNS signs, seizures, papilloedema Sigmoid sinus - cerebellar signs, lower cranial nerve palsies Inferior petrosal sinus - CN V & VI palsies, temporal and retro-orbital pain Cavernous sinus - headache, chemosis, swollen eyelids, proptosis, painful ophthalmoplegia, fever
32
What often causes cavernous sinus thrombosis?
Spread from facial pustules or folliculitis
33
What imaging is done for venous sinus thrombosis?What would you see on the imaging?
Non-contrast CT - hyperdensity in the affected sinus (i.e. absent sinus) CT venogram - might be initially normal but show filling defect at 1 week (delta sign) MRI T2-weighted images - visualise thrombus directly
34
How do you treat venous sinus thrombosis?
LMWH to anticoagulate Then start warfarin to reach INR 2-3 If unresolved, give thrombolysis or mechanical thrombectomy
35
When is a mechanical thrombectomy futile?
Large infarcts | Impending herniation
36
Name some triggers of migraines
CHOCOLATE ``` Chocolate Hangovers Orgasms Cheese/caffeine Oral contraceptives Lie-ins Alcohol Travel Exercise ```
37
What precedes the headache in a migraine?
Prodromal symptoms - Hours/days - Yawning - Cravings - Sleep or mood changes
38
What types of aura may occur during a migraine?
Aura - Visual - Somatosensory - paraesthesiae - Motor - dysarthria, ataxia, hemiparesis - Speech - dysphasia
39
Describe the headache in a migraine. What associated symptoms present with the headache?
Headache - Unilateral, pulsating headache - Can wake patient in the night Associated symptoms - Nausea + vomiting (only once or twice) - Photophobia, phonophobia
40
What is the prophylactic treatment of migraines?
- Propanolol - Amitryptiline - 12 weekly botulinum toxin injections in chronic migraines
41
How do you treat a migraine during an attack?
1. Simple analgesic with anti-emetic e.g. paramax = combination preparation of ibuprofen + prochlorperazine 2. Triptans = 5-HT1 (serotonin) receptor agonist
42
What usually causes otitis media?
Viral URTI - adenoid pads enlarge and block off eustachian tube
43
Who commonly presents with otitis media?
Children aged 3-6 years, following URTI
44
How does otitis media present?
Earache and deafness Fever Discharge is a later sign associated with a decrease in pain due to perforated tympanic membrane
45
What test identifies the side of the hearing loss?
Weber's test - Conductive hearing loss = loudest in affected ear - Sensorineural hearing loss = quieter in affected ear
46
How can you distinguish between whether it is a conductive or sensorineural hearing loss?
Rinne's test - if the tuning fork is perceived louder on the mastoid process, there is a conductive hearing loss
47
When should you treat otitis media with antibiotics?
Perforation Bilateral otitis media Infants below age of 2
48
What is the first line antibiotic for otitis media?
Amoxicillin
49
What is a complication of otitis media?
Mastoiditis - boggy swelling behind the ear, pushes the ear forward
50
What most commonly causes bacterial tonsillitis?
Group A beta-haemolytic streptococcus
51
What else can cause purulent exudate in the throat?
Epstein Barr Virus
52
What criteria is used to predict whether tonsillitis has a bacterial cause?
Centor criteria - Tonsillar exudate - Anterior cervical lymphadenopathy - Temperature > 38 - Absence of cough If >2 consider treating with antibiotics
53
What investigation can be done if EBV is suspected?
Monospot test
54
What antibiotics are used to treat bacterial tonsillitis?
1st line - PO phenoxymethylpenicillin 500mg QDS for 10 days (unless allergic) 2nd line - clarithromycin
55
What should you never prescribe for tonsillitis?
Amoxicillin | If it were EBV, it would cause all over body rash
56
What is a complication of tonsillitis?
Quinsy = peritonsillar abscess
57
What is the cardinal feature of encephalitis?
Altered mental status - this is less prominent in meningitis
58
What is the most common cause of encephalitis?
Herpes simplex virus type 1
59
Aside from altered mental status, how might encephalitis present?
Flu-like prodromal symptoms Fever New seizures
60
What is the gold standard investigation for suspected encephalitis?
LP with CSF sent for viral PCR
61
What is the best imaging modality for suspected encephalitis?
MRI (because CT head often appears normal acutely)
62
What is the typical distribution of herpes simplex encephalitis?
Temporal distribution
63
What is the management of suspected encephalitits?
Treatment should be initiated while awaiting definitive diagnosis of the condition as the progression of HSE is very rapid 1. Immediate IV acyclovir 10mg/kg TDS for 2 weeks 2. Broad spectrum antimicrobial cover with 2g IV ceftriaxone BD 3. Supportive management of complications e.g. anticonvulsants for seizures
64
What is a side effect of acyclovir that must be monitored for? How do you minimise the risk of the side effect
Nephrotoxicity - acyclovir can crystallise in the glomeruli Manage with adequate hydration and dose tapering
65
What is the criteria for head CT after head injury (as recommended by NICE)?
Clinical evidence of skull fracture More than 30 minutes retrograde amnesia. Focal neurological deficit or seizure. GCS <13 at any time (or <15 2 hours after injury). More than 1 episodes of vomiting. Loss of consciousness and any amnesia in patients who: - Are >65 years - Suffered a dangerous mechanism of injury (great height, road traffic accident) - Have evidence of coagulopathy (including anticoagulation with warfarin).

YEAR 4 - ACC (11 decks)

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