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Year 3 > Week 22 - Case 1-4 > Flashcards

Week 22 - Case 1-4 Flashcards

1
Q

what is papilloedema and what is it a sign of

A

this is a sign of raised intracranial pressure.

Papilledema is a disease entity that refers to the swelling of the optic disc due to elevated intracranial pressure (ICP). This term should be distinguished from disc edema which specifies a broader category of optic disc swelling secondary to other etiologies.

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2
Q

what may happen to visual fields in raised intracranial pressure

A

restricted visual fields

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3
Q

what nerve pasly is indicative of raised ICP

A

sixth nerve palsy

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4
Q

increased tone and brisk reflexes are what kind of motor neurone sign

A

UMN sign

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5
Q

what should one reduce with migraines

A

one should reduce caffeine consumption

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6
Q

what is first line acute treatment for migraines

A

simple analgesia such as paracetamol or NSAIDs

the addition of an anti-emetic may be beneficial for those prone to sickness

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7
Q

what are first line options for migraine prevention

A

propranolol, topiramate or amitriptyline

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8
Q

what can be used as a prevent cluster headaches

A

verapamil

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9
Q

is prednisolone used in migraines or cluster headache spells

A

prednisolone is not used in migraine, although can be used to abort spells of cluster headache

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10
Q

what is metoclopramide

A

an anti emetic

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11
Q

does topiramate cause weight loss

A

yes

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12
Q

what is recommend in tension type headaches. medication wise

A

amitryptiline 10mg at night to try and reduce the headache

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13
Q

what can meningitis be caused by

A

bacteria, viruses or fungi

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14
Q

in the UK, community acquired bacterial meningitis in adults and older children is usually caused by what strains

A

Streptococcus pneumoniae and Neisseria meningitides

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15
Q

what strain causes meningitis but mainly in patients over 50 yrs of age and in the immunocompromised

A

listeria monocytogenes

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16
Q

how are TB and meningitis related

A

TB can disseminate and cause meningitis

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17
Q

what are the most common causes of meningitis in neonates

A

In neonates, the most common causes are group B streptococcus, E. coli, and occasionally Listeria monocytogenes.

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18
Q

when is healthcare associated bacterial meningitis mainly seen after

A

neurosurgery or cranial trauma and in the presence of internal or external ventricular veins

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19
Q

what are the most common strains associated with healthcare associated bacterial meningitis

A

Staphylococci or aerobic gram-negative bacilli are the most common causes of these.

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20
Q

what are the 3 viral causes of meningitis

A

enteroviruses
mumps virus (and other paramyxoviruses)
herpes simplex virus (primary HSV infection or disseminated HSV)

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21
Q

what is the most common fungal cause of meningitis

A

Cryptococcus neoformans

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22
Q

in who is cryptococcus meningitis most commonly seen

A

in patients with severe deficiencies in cell-mediated immunity, such as patients with HIV

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23
Q

how to patients with bacterial meningitis present

A

typically present with a fever over 38 degrees, severe headache, nausea, neck stiffness and a change in mental status usually of sudden onset and are acutely unwell

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24
Q

what are the less common manifestations of bacterial meningitis

A

seizures, aphasia, or hemi- or monoparaesis, coma, cranial nerve palsy, rash and papilledema

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25
Q

in what cases is the classic meningococcal rash seen

A

seen in patients with Neisseria meningitides meningitis (meningococcal disease).

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26
Q

what percentage of patients with meningococcal infection present with sepsis with or without meningism

A

10-20%

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27
Q

what is kernig’s sign

A

position the patient on their back with their hips flexed to 90 degrees

this test is positive if there is pain on passive leg extension at the knee joint

28
Q

what is Brudzinkski’s sign

A

position the patient on their back and passively flex their neck.

this is positive if the patient involuntarily bends their knees

29
Q

what are the main differential diagnoses for meningism beside bacterial meningitis

A

viral meningitis
fungal meningitis
tuberculous meningitis
drug-induced meningitis
encephalitis
malignancy
CNS abscess
HIV infection
subarachnoid haemorrhafge

30
Q

when should a lumbar puncture be done in suspected meningitis

A

should be performed within 1 hour of arrival at the hospital if it is safe and the patient is haemodynamically stable

31
Q

what should be commenced immediately after a LP

A

antibiotics

32
Q

what should happen if a LP cannot be performed in one hour of arrival to hospital

A

blood cultures should be taken, antibiotics started and an LP when sadde

33
Q

what laboratory investigations are you going to request for suspected meninigitis

A

Bloods:
- Blood cultures
- FBC, U+E, LFTs, and clotting screen – to rule out coagulation abnormalities, inflammatory markers may be raised, and platelets may be low.
- Meningococcal and pneumococcal PCR
- Glucose – to compare with the CSF
- HIV test

Throat swab:
- Microscopy, culture, and sensitivity

CSF:
- Microscopy, culture, and sensitivity
- Viral PCR
- Protein
- Glucose
- Lactate

34
Q

which intervertebral space will you aim to insert your needle into for a LP

A

between L3 and L4 or L4 and L5 because this is below the level at which the spinal cord terminates

35
Q

what should you make sure the patient doesnt have before an LP

A

make sure the patient is not taking anticoagulants or have a clotting disorder

36
Q

when should a head CT be performed before an LP

A

Immunocompromised state
History of central nervous system (CNS)infection, masses, or stroke
New-onset seizure
Papilledema
Altered consciousness
Focal neurologic deficit

37
Q

what do patients with bacterial meningitis urgently require for treatment

A

IV antibiotic treatment with agents that penetrate the CSF well and cover the likely pathogens according to history

38
Q

what is the first line antibiotic treatment for community acquired meningitis

A

ceftriaxone IV with additional amoxicillin IV if listeria is likely

39
Q

what is the alternative treatment for community acquired meningitis if there is severe penicillin allergy

A

Chloramphenicol IV.

40
Q

what is treatment for strongly suspected bacterial meningitis

A

Dexamethasone IV 10mg four times daily for four days can be started within 12 hours of antibiotics commencement.

41
Q

what is given for confirmed meningococcal meningitis

A

oropharyngeal eradication is required either ceftriaxone or a single dose of ciprofloxacin alongside treatment.

42
Q

what are the treatment options for viral meningitis

A

there currently are no proven beneficial treatments for viral menigitis

Once the diagnosis of viral meningitis is made, antibiotics should be stopped. Some clinicians treat herpes meningitis with acyclovir or valaciclovir, but to date, there is limited evidence for this to be effective. Treatment should be supportive with analgesia and fluids if necessary.

43
Q

what is characterisically seen in patients with raised ICP headaches

A

her headaches are made worse by straining or bending over

44
Q

what are the typical examination findings of raised ICP

A

Papilloedema, restricted visual fields and enlarged blind spots are all typical of raised intracranial pressure.

45
Q

if there is right sided pronator drift what does this indicate

A

a left hemisphere space occupying lesion

46
Q

what may be given if there is a significant amount of oedema and swelling seen on a head CT

A

dexamethasone

47
Q

what are extradural haemorrhages usually a result of

A

an arterial bleed which is vulnerable to trauma on the temporal region of the head

48
Q

what is the pattern of consciousness with extra dural haemorrhages

A

patients may regain consciousness following a brief period of impaired consciousness at the time of injury

this initial loss of consciousness is usually the result of cerebral concussion

49
Q

when does the level of consciousness begin to deveop

A

when the haemotoma develops

50
Q

what does the lucid interval in extra dural haemorrhages risk

A

frequently results in delayed or missed diagnosis with catastropic consequences.

51
Q

describe the typical clinical presentation of a subdural haematoma

A

Unlike extra-dural haematomas, sub-dural haematomas are venous in origin and hence they may occur even after a trivial injury in a vulnerable subject. Elderly patients, alcoholics and other debilitated people are at higher risk. The haematoma develops very sowly (a venous ooze) and hence the latent period between the injury and clinical presentation may be weeks or even months. Headache, drowsiness and confusion are common in the late stages. Fluctuating level of consciousness for a variable period is typical of SDHs as the haematoma contracts and expands due to osmotic effects.

52
Q

what are the two classifications of brain tumours

A

Primary brain tumours: arise from the intracranial structures such as meninges (meningioma) or glial cells (gliomas or astrocytomas). Meningiomas are usually slow growing. Whereas gliomas show a range of growth with multiforme being the worst.

Secondary metastases: from primary tumours usually arising from bronchus, breast, stomach, prostate, thyroid or kidneys

53
Q

what does a generalised myoclonic seizure described as

A

early morning shakines

54
Q

what is standard practice in the UK for people who have developed seizures

A

MRI brain

55
Q

what is the most common antiepileptic medication

A

lamotrigine

56
Q

what is the rule with seizures and the DVLA

A

in the UK this patient would have to refrain from driving until he is seizure free for one year

57
Q

A 24 year old man presents to A+E with severe right sided headaches at night. The brief headaches wake him from sleep several times per night and have been going on for the last 2 weeks. During the headache his eye waters and his nose feels blocked. He describes the headaches as the most severe he’s ever had. Neurological examination is normal. He is otherwise fit and well. He smokes 20 cigarettes per day and does not drink alcohol. He works shifts as a safety operative in a nuclear power plant. What is the likely cause of his headaches?

A

cluster headaches

58
Q

what type of headaches make people wake from their sleep

A

cluster headaches

59
Q

what are brief recurrent nocturnal headaches suggestive of

A

cluster headaches

60
Q

what are daily featureless headaches usually suggestive of

A

tension headaches

61
Q

what do sharp shooting pains around the face suggest

A

trigeminal neuralgia

62
Q

what does whoosing tinnitus and pain worse on standing suggest

A

features of low CSF pressure headaches

63
Q

The following CSF results are obtained in a patient presenting with acute headache, fever and neck stiffness:

Opening Pressure: 28cm (nr <20cm)
CSF white cell count – 566 (90% neutrophils) (nr <4WBC)
CSF protein – 1.1g/L (nr <0.4g/L) CSF glucose – 2.8mmol/L (nr >50% plasma gluc)
Plasma glucose 6.1mmol/L

What is the most likely diagnosis?

A

bacterial meningitis

The basic clinical syndrome is consistent with meningitis. The CSF pattern of raised pressure, neutrophilic leucocytosis and low glucose is highly suggestive of a bacterial aetiology.

64
Q

A 24 year old woman attends her GP due to episodes noted by her new boyfriend. He describes her as seeming to stare into space and chew her lip for 1-2 minutes. She then seems confused for about 5minutes before returning to normal. The patient sometimes feels that she knows when an attack is going to happen but finds it hard to describe this feeling.
What is the most likely diagnosis?

A

focal impaired awareness seizures

65
Q

what are the typical characteristics of focal impaired awareness seizures

A

loss of awareness coupled with what sound like orofacial automatisms.

a brief postictal period of confusion is common after such events

66
Q

A 52 year old man with known advanced alcoholic liver disease is admitted to A+E with a low GCS following a witnessed generalized tonic clonic seizure at home.

What is the most appropriate initial investigation?

A

Blood glucose

In any patient presenting with altered conscious level a blood glucose is a vital initial test. In this patient hypoglycaemia could be the cause of both the seizure and the reduced GCS. Patients with advanced liver disease are at increased risk of hypoglycaemia due to faulty hepatic gluconeogenesis.

67
Q
A

Year 3 (63 decks)

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