OSCE emergencies (Neuro and special senses) Flashcards
(37 cards)
meningitis presentation
Typical
- Fever
- Neck stiffness
- Vomiting
- Headache
- Photophobia
- Altered consciousness/ seizure
Meningococcal septicaemia – non-blanching rash
Neonates and babies
- Non specific: hypotonia, poor feeding, lethargy, hypothermia and bulging fontanelle
Special tests
- Kernig’s test
- Brudzinski’s
investigations for meningitis
Bedside
- Basic observation
- Blood glucose
Laboratory
- Blood: meningococal PCR
- Lumbar puncture
lumbar puncture
Bacterial: cloudy, low glucose, neutrophils
TB:
- Turbid
- Low glucose
- Need to do acid fast bacillus
- Lymphocytic (not polymorphic like bacterial)
Viral: normal glucose, high protein
Complications of meningitis
- Hearing loss is a key complication
- Seizures and epilepsy
- Cognitive impairment and learning disability
- Memory loss
- Cerebral palsy, with focal neurological deficits such as limb weakness or spasticity
management of bacterial meningitis
Antibiotics
- Under 3 months – cefotaxime plus amoxicillin (the amoxicillin is to cover listeria contracted during pregnancy)
- Above 3 months – ceftriaxone
- +- vancomycin if risk of penicillin resistant pneumococcal infection e.g. foreign travel or prolonged antibiotic exposure
Steroids if bacterial -> reduce severity of hearing loss and neurological damage
- Dexamethasone 4x daily for 4 days
Notifiable disease
Post exposure prophylaxis (meningococcal infection)
- Highest risk for people that have had close prolonged contact within 7 days to the onset of the illness
- Risk decreases 7 days after exposure (if no symptoms have developed 7 days after exposure they are unlikely to develop illness)
- Management: single dose of ciprofloxacin – give stat
presentation of encephalitis
- Altered consciousness
- Altered cognition
- Unusual behaviour
- Acute onset of focal neurological symptoms
- Acute onset of focal seizures
- Fever
investigations for encephalitis
- Lumbar puncture – viral PCR testing
- CT scan if lumbar puncture contraindicated
o GCS below 9
o Haemodynamically unstable
o Active seizures
o Post-ictal - MRI scan after LP to visualise brain
- Throat and vesicle swabs
- HIV testing
- Swabs
Management of viral encephalitis
- IV acyclovir - HSV and VZV
- IV ganciclovir- CMV
- Repeat LP prior to stopping antivirals
- Supportive and rehab
myasthenic crisis presentation
Myasthenic crisis is a severe complication of myasthenia gravis. It can be life threatening. It causes an acute worsening of symptoms, often triggered by another illness such as a respiratory tract infection. This can lead to respiratory failure as a result of weakness in the muscle of respiration.
myasthenic crisis management
Patients may require non-invasive ventilation with BiPAP or full intubation and ventilation.
Medical treatment of myasthenic crisis is with immunomodulatory therapies such as IV immunoglobulins and plasma exchange.
Example medications
- Reversible acetylcholinesterase inhibitors (usually pyridostigmine or neostigmine) increases the amount of acetylcholine in the neuromuscular junction and improve symptoms
- Immunosuppression (e.g. prednisolone or azathioprine) suppresses the production of antibodies
anaphylaxis presentation
There will be rapid onset of allergic symptoms:
* Urticaria
* Itching
* Angio-oedema, with swelling around lips and eyes
* Abdominal pain
Additional symptoms that indicate anaphylaxis are:
* Shortness of breath
* Wheeze
* Swelling of the larynx, causing stridor
* Tachycardia
* Lightheadedness
* Collapse
anaphylaxis management
- Rapid assessment: A-E
- Give high flow oxygen (15l through a non rebreathe mask)
- Lay patient flat and raise legs
- Adrenaline IM in anterolateral aspect of the middle third of thigh
o Adult 500mg IM
o Should be repeated after 5 mins if no clinical improvement - IV fluid challenge- warmed crystalloid (500ml normal saline over 15 mins) solution e.g. Hartmanns or saline-> to raise BP
- Chlorphenamine (anthistamine)
- Hydrocortisone (steroid)
- Continuing resp deterioration -> bronchodilators e.g. salbutamol
presentation of eczema herpeticum
management of eczema herpeticum
Investigations
- Viral swabs of the vesicles can be used to confirm the diagnosis, although treatment is usually started based on the clinical appearance.
Management
- Aciclovir
- A mild or moderate case may be treated with oral aciclovir, whereas more severe cases may require IV aciclovir.
Complications
- Bacterial superinfection can occur, leading to a more severe illness. This needs treatment with antibiotics.
temporal arteritis
Giant cell arteritis is a systemic vasculitis of the medium and large arteries. It typically presents with symptoms affecting the temporal arteries and is also known as temporal arteritis.
There is a strong link with polymyalgia rheumatica. The patients at higher risk are white females over 50.
temporal arteritis presentation
The main presenting feature is a headache:
- Severe unilateral headache typically around temple and forehead
- Scalp tenderness my be noticed when brushing hair
- Jaw claudication
- Blurred or double vision
- Irreversible painless complete sight loss can occur rapidly
There may be associated systemic symptoms such as:
- Fever
- Muscle aches
- Fatigue
- Weight loss
- Loss of appetite
- Peripheral oedema
temporal arteritis investigations
Bloods
- ESR
- Full blood count may show a normocytic anaemia and thrombocytosis (raised platelets)
- Liver function tests can show a raised alkaline phosphatase
- C reactive protein is usually raised
Imaging
- Duplex ultrasound of the temporal artery shows the hypoechoic halo sign
Procedures
- Temporal artery biopsy (multinucleated giant cells)
management of TA
give stat dose of 60mg prednisolone (usually a rapid response to treatment)
Other medications:
- Aspirin 75mg daily decreases visual loss and strokes
- Proton pump inhibitor (e.g. omeprazole) for gastric prevention while on steroids
acute angle closure glaucoma presentation
The patient will generally appear unwell in themselves. They have a short history of:
- Severely painful red eye
- Blurred vision
- Halos around lights
- Associated headache, nausea and vomiting
Examination
- Red-eye
- Teary
- Hazy cornea
- Decreased visual acuity
- Dilatation of the affected pupil
- Fixed pupil size
- Firm eyeball on palpation
investigations for acute angle closure glaucoma
- Tonometry to assess for elevated IOP
- Gonioscopy (literally looking, oscopy, at the angle, gonio): a special lens for the slit lamp that allows visualisation of the angle
management of AACG
Ophthalmic emergency- need to decrease intraocular pressure ASAP
An example regime would be:
1) Lie patient flat
2) Combination of eye drops, for example:
- a direct parasympathomimetic (e.g. pilocarpine, causes contraction of the ciliary muscle → opening the trabecular meshwork → increased outflow of the aqueous humour)
- a beta-blocker (e.g. timolol, decreases aqueous humour production)
- an alpha-2 agonist (e.g. apraclonidine, dual mechanism, decreasing aqueous humour production and increasing uveoscleral outflow)
3) intravenous acetazolamide
- reduces aqueous secretions
4) Definitive management
- laser peripheral iridotomy
creates a tiny hole in the peripheral iris → aqueous humour flowing to the angle
ophthalmic shingles (Herpes zoster ophthalmicus) background
- Viral disease characterised by unilateral painful skin rash in one or more dermatone distributions of the trigeminal nerve (5th cranial nerve)
o Shared by the eye and ocular adnexa
Pathophysiology
- Due to reactivation of latent varicella-zoster virus present within the sensory spinal or cerebral ganglia
- VZV = dsDNA of the herpes simplex group
presentation of ophthalmic shingles
- Erythematous skin lesions with macules, papules, vesicles, pustules, crusting lesions in the distribution of the trigeminal nerve
- Hutchison’s sign – skin lesions at the tip, side or root of nose
o Strong predictor of ocular inflammation and corneal denervation in HZO - Symptoms: fever, malaise, headache, eye pain prior to eruption of skin
