Neurology Flashcards
(31 cards)
What is Hoover’s sign as it pertains to Somatisation disorder?
Hoover’s sign is the test used to help differentiate organic v non-organic / functional leg paresis
You place a hand under the affected leg while asking them to lift the unaffected leg against resistance - you will feel counter pressure in the ‘affected’ leg due to involuntary hip extension
When should phenytoin levels be checked?
Phenytoin levels do not need to be checked routinely but should be checked if suspect toxicity or if change of dose.
Need to check TROUGH levels so just before dose is due.
What is the classical presentation for normal pressure hydrocephalus?
Normal pressure hydrocephalus is an important differential to consider in patient’s presenting with confusion / memory loss as it is a REVERSIBLE cause of dementia.
It is caused by reduced resorption of CSF through the arachnoid villi.
Presents with WACKY, WET, WOBBLY
1. Cognitive disturbance / memory loss
2. Urinary incontinence
3. Wide, unstable gait (may present quite similar to parkinsons gait)
Management is ventricloperitoneal shunting
Which medications may cause peripheral neuropathy?
Nitrofurantoin
Metronidazole
Amiodarone
Isoniazid
Vincristine
In what ways does the classical presentation of migraines differ in children versus adults?
In children migraines are more likely to be *Bilateral *Last for shorter periods and have *Gastrointestinal disturbance / abdo pain associated
What DMARDs are available for those with MS?
Natalizumab - can reduce freq and severity of relapses by ~ 68%
Beta interferon (reduces relapses by ~ 30%)
The efficacy of cannabinoids is still debated
IF THE PATIENT HAS BEEN UNABLE TO WALK FOR 6 MONTHS THEN DMARDS ARE UNLIKELY TO BE EFFECTIVE
If there is disease progression despite treatment then normally that treatment should be stopped
Which patients with epilepsy would NOT be suitable to management under primary care and would require secondary care?
Any child / adolescent
Any adult with special needs
Any adult with ongoing seizures or with specific care needs e.g planning a pregnancy/
** Only adults with stable, well-controlled epilepsy should be managed in primary care **
What are the typical signs of lower and upper motor neurone lesions respectively?
UMN - hyperreflexia, spasticity, weakness, upgoing / extensor plantar response
LMN - reduced reflexes, flaccid paralysis, atrophy, fasciculations
What is the typical presentation of amyotrophic lateral sclerosis?
Mixed upper and lower motor neurone signs, involving initially one segment of the neuroaxis (i.e., cranial, cervical, thoracic, or lumbosacral), and then progressively spreading, typically to contiguous areas
What is the most common form of motor neurone disease?
Amyotrophic lateral sclerosis (ALS)
Which medication is shown to prolong survival in ALS and should be offered to all at diagnosis?
Riluzole
What is the first line drug for trigeminal neuralgia?
Carbamazapine
Carbamazepine is the only licensed anticonvulsant medication with proven efficacy to treat trigeminal neuralgia.
Initiate therapy at 100 mg up to twice daily, and titrate in steps of 100–200 mg every 2 weeks, until pain has been relieved.
In the majority of people a dosage of 200 mg three or four times a day is sufficient to prevent paroxysms of pain (maximum dosage 1600 mg daily).
Modified release preparations may be useful, particularly if the person experiences breakthrough pain at night. Once the pain is in remission, the dosage should be gradually reduced to the lowest possible maintenance level, or the drug can be discontinued until a further attack occurs
IF CARBAMAZEPINE DOES NOT WORK THEN REFER TO A SPECIALIST
According to NICE, within what window of time should people who sustain a head injury on anticoagulants (warfarin or NOAC) get a CT Head?
Within 8 hours
What is the typical presentation of diabetic amyotrophy?
PAINFUL mononeuropathy
Often affects the femoral nerve (normally unilateral) leading to wasting of the quadriceps, and LMN signs including loss of knee jerk as well as pain and numbness in the affected dermatome
What is the typical presentation of essential tremor?
Symmetrical, bilateral tremor - normally occurs during active movements and not present at present.
Worsened by caffeine, stress
Improved by alcohol, beta blockers and rest
May involve upper limbs, head and neck
Tx is with propranolol or primidone
What is the treatment window for suspected Bell’s Palsy?
If presents within 72 hours of symptom onset, start steroids:
- 60mg Pred for 5/7 then taper by 10mg per day (total course 10 days)
OR
50mg Pred for 10/7
Advise:
artificial tears / lubricants
taping eye closed with microporous tape during the night if can’t close eye
using sunglasses
REFER IF
- Nil improvement after 3 weeks
- Incomplete resolution by 3 months
- Atypical features
- New neurological symptoms develop
Which patients with a head injury need to be referred to A&E for assessment?
Glasgow coma scale (GCS) less than 15
Any loss of consciousness
Any focal neurological deficit
Any signs of skull fracture
Persistent headaches
Vomiting episodes
Any seizures
History of previous neurosurgery
High-energy head injuries (fall of > 1m, or over 5 stairs or those attained during a significant RTA)
History of bleeding/clotting disorders
Current anticoagulation therapy
Current drug or alcohol intoxication
Safeguarding concerns
Ongoing clinical concerns
How should you manage a suspected TIA in primary care?
If history of bleeding disorder or on anticoagulant then refer in for urgent imaging to exclude haemorrhage and don’t give them Aspirin!
If TIA symptoms within the last 24 hrs, give Aspirin 300mg ASAP and continue this daily until they see the specialist.
(If already on Aspirin 75mg OD do NOT give the high dose Aspirin)
Should see specialist within 24 hours if TIA was in the last 7 days.
If TIA was > 7 days ago, then should see specialist within 7 days.
Specialist normally will start on Clopidogrel 75mg OD (UNLESS high risk for further TIAs or intracranial stenosis in which case might give Dual therapy with clopidogrel and aspirin for 3 months or aspirin and ticagrelor for 1 month)
What is the advice on driving / informing the DVLA after a TIA or stroke?
For a single TIA or stroke, can’t drive for 1 month BUT don’t need to inform the DVLA
Need to inform the DVLA if 1 month after the stroke there are still residual neurological deficits that may affect driving
If multiple TIAs can’t drive for 3 months and DO need to inform the DVLA.
What is the typical presentation of restless legs syndrome?
An urge to move the lower limbs associated with paraesthesia-type sensations such as crawling or tingling worse in the evening or over night and temporarily improved by movement
Often familial. Some cases have an autosomal dominant inheritance
Risk factors: pregnancy (affects 1/3rd of pregnant women) , iron deficiency, advanced CKD, excessive intake of caffeine, alcohol or chocolate, medications like antidepressants and antiepileptics
What are the available management options for patients with restless legs syndrome?
Lifestyle - reducing alcohol, coffee, chocolate, massaging and applying heat to the legs, moderate exercise during the day
DRUG TREATMENT NOT RECOMMENDED FOR RESTLESS LEGS IN PREGNANCY
1st line medical management for severe or daily symptom: Gabapentinoid medications e.g Pregabalin or Gabapentin taken regularly at the lowest dose to produce effect.
Alternative: PRN Codeine or Tramadol for intermittent painful RLS symptoms
Dopamine agonists (rotigotine, ropinirole and pramipexole) used to be 1st line but now discouraged as may lead to augmentation (needing increasingly higher doses to control symptoms)
What is the first line prophylaxis for cluster headaches ?
Verapamil
What is the typical presentation of progressive supranuclear palsy?
Gait disturbance leading to recurrent falls
Anxiety/ personality changes
Vertical gaze palsy - limited eye movements in the upwards and downwards directions
Fatigue
What cognitive screening tools are recommended by NICE to screen for cognitive impairment in primary care
6-item cognitive impairment test (6-CIT)
10 point cognitive screener (10-CS)
Mini-COG
Dementia should not be excluded just because someone scores normally on one of these though!!!
Also need to do bloods to exclude reversible causes of dementia, check anti-cholinergic burden of medications and need to take a collateral from a family member or carer.
Should always be referred to specialist service to make the diagnosis.
