Neurology Flashcards
Essential Tremor
Postural or kinetic tremor (4-12hz = medium)
FHx important
Temporary benefit post ETOH
Exclude hyperthyroidism first
Commence propranolol 10mg BD
- can increase up to 160mg divided up into 2-3 doses
If not improving -> Refer
Specialists may use botulinum toxin or deep brain stimulation in uncommon cases
NOT AN INTENTION TREMOR. THIS = Cerebellar lesions/stroke/drugs/alcoholism
Trigeminal Neuralgia
Recurrent, unilateral shock-like pain in trigeminal distribution (usually V2-V3)
Can be triggered by simple actions like brushing teeth, eating, speaking, shaving, exposure to wind/cold.
Attacks last seconds to minutes then brief refractory period
Affects people 40-70 F>M
May be associated with neurovascular compression or MS = NEEDS MRI
Mx: Carbamazepine MR 100mg BD. Can increase up to 400mg BD (Oxcarbazepine often better tolerated but less effective)
Parkinson’s Disease
Bradykinesia + ONE OF:
- Muscular rigidity
- 4-6hz RESTING tremor
- Postural instability (not due to another cause like visual/proprioreceptive/cerebellar/vestibular)
Supporting diagnostic features:
- Good response to levodopa (clear response within 2-3 weeks)
- progressive disorder
- persistent asymmetry
- unilateral resting tremor
Rx:
Levodopa/Carbidopa 50+12.5mg orally TDS increasing to 100mg+25mg TDS over 1-2 weeks
ALL antiparkinsons drugs cause nausea. AVOID metoclopramide + prochloperazine in Parkinsons as make sx worse
Mononeuritis Multiplex
Painful, asymmetrical, asynchronous sensory and motor peripheral neuropathy involving isolated damage to at least 2 separate nerve areas
Peroneal and Ulnar nerves typically involved
Complication of diabetes
Antiepileptics and pregnancy/contraception
Avoid sodium valproate in women of child bearing age / ensure adequate contraception - neural tube defects
Carbamazepine/Phenytoin/Topiramate all decrease effectiveness of COCP
If taking contraception and above meds: Increase daily ethinylestradiol to at least 50mcg daily + no hormone free pills
Avoid progesterone only pills + implanon + vaginal ring.
Mirena/Copper IUD/Depo medroxyprogesterone is fine
For emerg contraception -> Copper IUD. If unsuitable/declined, then double levonorgesterol dose
Idiopathic Intracranial Hypertension
Typically in young, overweight women, often after recent weight gain
Can be associated with COCP, Vitamin A analogues, Tetracycline
Can cause permanent vision loss if untreated
Sx: Headache, peripheral vision loss, decreased visual acuity
Typically worse in morning and when lying down. May also have pulsatile tinnitus
Diplopia due to 6th nerve palsy in severe cases
Papilloedema on fundoscopy
Ix:
Confirm diagnosis with lumbar puncture = opening pressure >25cm H20
SOL and venous obstruction must be excluded with MRI
Mx
Weight loss. Consider bariatric surgery
Acetezolamide 250mg BD increasing to 500mg QID as tolerated
Continue to monitor visual acuity + colour vision + visual fields
Dementia
Assessments to make:
Cognitive, behavioural, psychological symptoms (carer/family input useful)
Physical examination (other causes of cognitive impairment = UTI, CCF, Visual/hearing impairment)
Activities of Daily living (including safety issues like driving, falls, nutrition)
Depression (Geriatric depression scale)
Medication review
Cognitive screening (MMSE, GPCOG)
Ix:
FBC, ESR, LFT, Calcium, TSH, B12/Folate, CT Head
Consider: CXR, Fasting BSL, Fasting Lipids, EEG, MSU MCS, HIV/Syphillis serology
Bacterial Meningitis
Headache, fever, nuchal rigidity, change in mental status, nausea
Ex:
Illustrate meningeal irritation
- passive or active flexion of neck (unable to touch chin-to-chest)
Kernig/Brudzinski are late signs
- Brudzinski = spontaneous hip flexion when neck flexed passively
Ix
Lumbar puncture (In hospital)
- lactate >3.5 helps distinguish from aseptic meningitis
Mx
Commence empirical ABx if presentation to hospital going to be >60min.
Take blood cultures + commence Ceftriaxone 2g IV or Benzylpenicillin 2.4g
- Ceftriaxone if in rural communities (ie next dose may be >6 hrs)
Multiple sclerosis
Presenting symptoms:
- Sensory loss in limbs or one side of face
- Unilateral vision loss
- Acute motor weakness
- Diplopia (often with opthalmoplegia)
- Gait or balance disturbance
- Lhermitte sign (electrical shock running down back/limbs on neck flexion)
- Vertigo
- Bladder problems
- Heat sensitivity (Uhthoff Phenomenon)
Typically 10-50yo
Can be associated with optic neuritis and trigeminal neuralgia
Signs:
Can have mixed upper and lower motor neurone signs
Wernicke’s Encephalopathy
Life threatening thiamine deficiency
Characterised by ataxia (broad/staggering gait), confusion, occulomotor dysfunction
Generally chronic alcohol use, but can be due to cancer, bariatric surgery, recurrent vomiting or diarrhoea
To stop progression to Korsakoff syndrome, high dose IV thiamine
= Thiamine 200-500mg TDS for 5-7 days THEN Thiamine 100mg TDS orally for 1-2 weeks THEN Thiamine 100mg daily
Wernicke’s Encephalopathy
Life threatening thiamine deficiency
Characterised by ataxia (broad/staggering gait), confusion, occulomotor dysfunction
Generally chronic alcohol use, but can be due to cancer, bariatric surgery, recurrent vomiting or diarrhoea
To stop progression to Korsakoff syndrome, high dose IV thiamine
= Thiamine 200-500mg TDS for 5-7 days THEN Thiamine 100mg TDS orally for 1-2 weeks THEN Thiamine 100mg daily
