03 neurology (22)

1: Migraine

2: Vitamin B 12 Deficiency

3: Visual Disturbance (Amaurosis Fugax)

4: Transient Ischemic Attack (TIA)

5: Weakness in right arm and leg (Subdural Hematoma)

6: Subarachnoid Hemorrhage

7: Acute Vertigo (PICA)

8: Acute Stroke Counseling

9: Seizure And Subdural Hematoma

10: Acute Brain Syndrome/Acute Confusion/Delirium

11: Hyponatremia Delirium HIDEMAP

12: Hyponatremia (Delirium)

13: Acute confusion in a Postoperative Patient (Delirium Tremens)?Post

surgery Delirium

14: Delirium After Burn Injury(Book 134):

15: Delirium (Digoxin Toxicity)

16: Multiple Sclerosis (Optic Retrobulbar Neuritis) Do it later

17: Multiple sclerosis

18: Cervical Spondylosis with C6 or C7 disc Prolapse

19: Encephalitis

21: Assessment of a comatose patient

22: Recurrent Falls/Assessment of Mechanical Falls

1:

You are a GP and a 35-year-old female came in due to headaches.

o Task

History

(on and off x 6 months; attack started

yesterday, on the back of head, pulsating)

Physical examination

Diagnosis

Management

o History

Do you need some painkillers? Since when are you having this

pain? How bad is it?

What type of pain is it? Is it pulsating, throbbing or a dull ache?

Is it one sided of all over your head?

When the pain starts, where does it start first?

How does it progress? is it aggravated by movement, noise or

light?

Do you get any symptoms before the headache starts for

example visual problems, changes in your sense of smell,

nausea or vomiting? Is this the first time?

How many episodes have you had previously? How long does it

last?

What relieves your pain? Is it worse in the morning? did you

have fever recently?

Any infection recently? Do you feel numbness or weakness in

any part of your body? Did you hurt yourself in your head?

Do you think your headache is related to food especially red

wine, cheese, chocolate, bananas, Chinese food, coffee?

How's your general health?

Any history of HPN or DM? What is your occupation?

Any stress at work or home? Any financial problems recently?

How are your periods?

When was your LMP? OCP?

Do you think your headaches are related to your periods?

Any family history of migraines? SADMA?

o PEx:

General appearance: pallor, jaundice, dehydration

Vitals

ENT: signs of runny nose or watery eyes; check for PEARL;

signs of meningism;

auscultate chest and heart; LN; palpate tummy

CNS: motor weakness, paresthesias or sensory disturbances

o DDx:

Migraine

cluster headache

SAH

Meningitis

subdural hematoma

temporal arteritis

o Mx:

You have a common condition called migraine. 10% of world's

population suffers from migraine. It is more common in females.

Usual age of onset is at a young age. The frequency of

headaches reduces after the age of 50. The exact cause is not

known but there trigger factors including: fatigue, hunger, strong

odors, excessive noise, hormonal changes, and certain kinds of

food.

The mechanism is dilatation of the blood vessels outside the

brain. There are three types: a. Classic (presents with an aura),

b. Common, c. Atypical (abdominal migraine - commonly seen

in kids).

o Treatment focuses on two aspects:

1. Treating the acute attack (rest in a quiet dark room, avoid

reading/tv, cold packs to head, and medications)

mild migraine: soluble aspirin 600-900mg q4 or PCM 500mg

q4 + an antiemetic

moderate: ergotamine + antiemetic (metoclopramide)

severe: sumatriptan + antiemetic (metoclopramide or

chlorpromazine)

These medications are also available in the form of

combinations (mersyndol - paracetamol + codeine +

doxylaminesuccinate)

If on OCP, review because it might aggravate migraine

For prevention: lifestyle modification, avoid trigger factors, and

>3 attacks/mo may give preventive medications such as beta-

blockers, cyproheptadine, TCAs, calcium channel blockers x 6-

12 months then taper and review

2:

A 65-year-old man is in your GP clinic with complaints of weakness and numbness

of his legs and unsteady gait. He also complains of tiredness.

Task

o History

(started since the last 3 months, weakness

in both legs, numbness, unable to keep

balance, tired, headache, pale, no fever,

night sweats, weight loss, weather

preference; had operation 10 years ago for

removal of some part of stomach, alcohol

2drinks/day for last 20 years)

o Physical examination

(pale, normal BMI, decreased power on both

sides, loss of sensation on both sides,

normal vibration and proprioception,

unsteady gait)

o Investigation

(decreased Hgb, normal iron studies,

decreased vitamin b12, folic acid normal,

o Diagnosis and management

DDx:

o Stroke

o Peripheral Neuropathy (Diabetes)

o Alcohol

o Brain tumor

o Vitamin B 12 deficiency

o Diet (vegetarian)

o Decreased absorption: gastrectomy

o Autoimmune:

o Pernicious anemia:

o Atrophic gastritis

o Hypothyroidism, Diabetes

o Less likely: MS, neurosyphilis, GBS, spinal cord

compression

Features

o Anemia, weight loss and neurological symptoms

o Manifests subacute combine degeneration of spinal cord

o B12 >220mol pmol/L = deficiency unlikely

o B12

Investigations:

o FBE: Hgb low and MCV high

o Vitamin B 12 low and folate level normal

o Iron studies

o Intrinsic factor antibody level + diagnostic

o LFTs, TFTs, RFTs

Dx and Mx:

o From the history and PE, you have anemia caused by

vitamin B 12 deficiency which caused the neurological

symptoms. I will refer you to the hematologist and

neurologist for further evaluation and management.

o The treatment is replacement of vitamin B12 1000mcg

injected intramuscularly every 2-3 days. The body stores

can be recovered after 10-15 injections and maintenance is

1000mcg every third month. If there is poor intake, oral

vitamin B12 may also be given. I will also give you oral

folate 5mg as co-therapy.

o The prognosis depends on how long the person had

symptoms and if it is in the first few weeks of the

symptoms, complete recovery usually occurs and if it is

delayed (>1-2months), it might not recover completely. If

left untreated, it can result in progressive and irreversible

damage to the nervous system

3:

You are an HMO and a 50-year-old woman is in the ED with complaint of loss of

vision. She has past history of bypass surgery 2 years ago. She is hypertensive and

is on ACE inhibitors.

Task

o History

(Blurring of Vision, curtain dropping or falling

down)


(CAROTID BRUIT on CVS examination,

neurologic and eye examination normal)


Features

o Painless loss of vision

o 20%

o Anterior circulation

o Usually lasts

4:

Variant 1:

Trevor, aged 65 years presents to your GP clinic with his wife Margaret. He tells you

he had funny turn this morning. He has completely recovered and made the

appointment at his wifes insistence. He says he first noticed something was wrong

when he answered the telephone call from his sister and found it difficult to speak.

His wife reports that his words were muddled and he had difficulty making him

understand. She thought he seemed confused at that time.

Task

o Further focused history

(hard to understand what he said, words not

coming out x 5 minutes to become normal;

HTN on coversyl)

o Examination findings from examiner

(BMI 27, BP 150/90)

o Probable diagnosis and treatment advice

Variant 2:

You are in ED and a 60-years-old woman comes to you complaining of left arm

weakness.

Task

o History


o Management

Variant 3:

A 60-year-old female came to the GP clinic with weakness of the right leg. She has

diabetes type I which is well controlled.

Task

o Relevant history


(130/90, normal funduscopy, cranial nerves

intact, no bruit, tone slightly increased, 4/5

left)


DDx (Stroke Mimics)

o Syncope

o Seizure

o Migraine

o Cerebral tumour and other SOLs

o Hypoglycemia

o Hyponatremia

o Delirium

o Head injury

o Medically unexplained (somatisation)

Features

o Definition: transient neurologic dysfunction in the brain,

midbrain, brainstem and optic nerve due to ischemia

lasting 4 = high risk and should REFER

o

History

o What happened? When? Arms, legs, face? Numbness or

tingling?

o Is it for the first time? How long did it last? Is it getting

better or worse?

o Was it sudden in onset?

o Problem with vision (diplopia, blurring), speech, asymmetry

of face? Headache? Loss of consciousness/confusion?

Change in gait? Head injury? Chest pain? SOB?

Palpitations? Vomiting? Spinning around? Waterworks?

Bowel motions?

o General health? Previous history of stroke, cadiac

problems such as heart attack, valve disease,

hypertension? Diabetes? Lipid levels? SADMA?

Medication (warfarin, anti-hypertensives)

o FHx and social history (lifestyle and stress)


o General appearance and BMI

o Vital signs: especially BP (postural drop) and PR (rate and

rhythm)

o Eyes and neck: PEARL, ophthalmoplegia, carotid bruits,

JVP, funduscopy

o CVS and peripheries

o Neurologic exam: cranial nerves, motor, power, reflex

especially plantar, tone, sensory, coordination

o BSL and Urine dipstick, ECG

Management

o One of the vessels supplying a part of the brain is blocked

by a clot for a brief period of time which causes a decrease

in oxygen supply to that particular area of the brain

temporarily. This is what we call a mini-stroke or TIA. Most

symptoms disappear within an hour although they may last

for 24 hours. It might have come from the heart or it is a

clot that is formed from the vessel of the brain. It is due to

fat deposits within the vessels called plaques. It is

considered as a medical emergency and taken as a

warning sign for future brain attacks.

o Refer to ED or ADMIT to stroke unit ASAP so that you will

be seen by a neurologist. The specialist will assess you

and do some investigations.

o I will arrange for urgent CT scan and carotid Doppler

o Need to do FBS, lipid profiles, FBE, UEC, LFTs, ECG, 2d-

echo, TFTs, clotting profile, HbA1c

o 20% will get stroke in the next 6 months and 50% of these

people are at risk of getting full-blown stroke within the next

24-48 hours.

o The specialist might consider starting you on clopidogrel or

ASA + dipyridamol to decrease the risk of stroke in the

future (30% decrease in the risk of future stroke after TIA).

o We also need to address your risk factors. Lifestyle

modification.

o Diabetic foot

If treating as OP:

o In low risk: arrange CT brain and carotid Doppler (for

possible endarterectomy) within the next 24-48 hours.

o Arrange all basic bloods: FBS, creatinine, cholesterol,

TFTs, RFTs, ECG (TEE)

o Refer patient to TIA clinic or neurologist within 7 days

o Management:

Cessation of smoking and lifestyle

modification (weight reduction, exercise,

alcohol)

Start antiplatelet therapy (asprin 100-300mg

OD, clopidogrel 75mg OD or dipyridamol +

ASA 200/25 mg BD;

Statins

Anti-hypertensives: ACE inhibitors

Monitor blood sugar

End-arterectomy >70%

Indications for carotid duplex ultrasound

Bruit in the neck

TIAs

Crescendo TIAs (2 or more in 1 week and

longer lasting)

Internal carotid artery symptoms

Hemispheric stroke

Prior to major vascular surgery

CHADS SCORE

o major stroke risk factors in people who have atrial

fibrillation

o CHF (1)

o Hypertension (1)

o Age >75 (1)

o DM (1)

o Stroke/TIA (2)

0 low aspirin (81-325mg)

1 Intermediate aspirin or warfarin

>2 high risk - warfarin

5:

A 60-year-old man is in the ED where youre working as an HMO where he is

complaining of weakness of his right arms and legs.

Task

o History

(had history of fall 2 weeks ago, noted

headache x 3 days after that and sometimes

headache when bending forward, coughing

or changing head direction; on warfarin;

noted sudden onset of right-sided weakness)

o Physical Examination


Risk factors

o Elderly patient brain shrinks (cerebral atrophy)

o Dementia

o Alcoholic

o Warfarin

o Head injury (recurrent falls)

Symptoms

o Weakness or numbness

o Headache bending forward or when coughing or when

changing head direction

o Confusion

o Drowsiness

o Personality changes

o Amnesia

o Seizures

History

o Can you tell me more about what happened? Is it getting

worse or improving? Any change in your vision? Any

problem with speech? Did you have any recent head

injury? How did it happen? Any headache after that? Any

N/V/changes in personality? Drowsiness or confusion?

Episodes of fits? Difficulty in walking or ataxia? Any past

history of heart disease, stroke, DM, increased lipids?

Medications? Do you have enough support?


o General appearance

o Vital signs

o Eyes

o CVS

o CNS examination

o BSL and dipstick

Management

o Subdural hematoma because of the head injury and you

are also taking warfarin.

o Admit. Referral to neurologist and CT scan.

o Baseline laboratory examination including clotting profile

and INR.

Treatment

o Small: careful observation until it heals by itself or

temporary insertion of a small catheter and suctioning the

hematoma

o Large: craniotomy

6:

Variant 1:

A 36-year-old male patient is in the ED with sudden pain on the back of the head

while working in the fields. It is not relieved by Paracetamol.

Task

o History

(headache going to the neck) o Physical examination

(ptosis, dilatation of pupil, neck stiffness) o Management

Variant 2:

Rosemarie aged 27 years presents to your surgery with history of headache for last

couple of month. She describes headache as feeling funny around her mouth then

flashing bright lights, then a pounding headache always on right side of her head.

The headache could last for several hours sometimes relieved by vomiting. For a

few days afterwards, she feels tired and just a bit off. She had tried pain killers like

panadol and ibuprofen with minimal relief. She is otherwise fit and healthy and has

no previous medical problems and is not on any medications.

Task:

o Focused history


o Diagnosis and management advise

DDx:

o Migraine

o Subarachnoid Hemorrhage:

occipital headache + vomiting + neck

stiffness; worst headache of my life

o Trauma

(Epidural) o Subdural hemorrhage

o Tension headache

o Tumors

History

o Can you tell me a bit more about it? When did it occur?

How severe? Where? Does it go anywhere (neck)?

Character? N/V? Is it progressive? Is it the first time? Does

anything make it worse? Photophobia?

o Risk factors: Berry aneurysm (85%) - PCKD, bleeding

disorder, AV malformations, head injury, hypertension

o SADMA? General health?



o Vital signs and BMI (BP increased, pulse decreased)

o Eyes: 3rd nerve compression from PCA rupture; ptosis,

absent light reflex, accommodation, diplopia (down and out

eye, pupillary dilation) and papilledema

o Neck stiffness

o Cardiac examination

o Abdomen: (PCKD)

o Neurologic examination

Dx and Mx:

o SAH is a condition where blood leaks out of the blood

vessel in the subarachnoid space that is one of the linings

covering the brain. It is a medical emergency and requires

immediate management. You will be seen by the

neurosurgical team and investigations will be done

especially non-contrast CT scan. If negative (10-20%), a

lumbar puncture will be done (xanthochromia).

o To confirm where the bleed is, a cerebroangiography will

be done. This is a procedure in which a special dye is

injected in the vessels through catheter and xray is taken to

detect/check movement of the dye and site of hemorrhage

is detected. We will also perform all baseline investigation.

o Management involves stabilization of patients condition.

oxygen and IV line, painkillers, medicine for vomiting/anti-

emetic. Nimodipine to prevent spasm of vessels.

o Surgery will be done the neurosurgeon will go for

neurosurgical clipping to prevent bleed of aneurysm. A

metal clip is used to close aneurysm around its neck.

o Endovascular coiling: tiny coils are placed to block flow of

blood into aneurysm to prevent hemorrhage.

7:

You are working in a primary care facility attached to a teaching hospital and a 50-

year-old man is consulting you about intense dizziness. He is a previous patient who

is overweight, and he is on medications for control of hypertension and

hyperlipidemia. He appears unwell and distressed with slight drooping of left eyelid.

His wife drove him to the hospital.

Task

o History

(feel so dizzy I can hardly stand up,

everything is spinning around since 1 hour

while having breakfast when I felt pain on left

side of the face; vertigo then numbness on

left side of face, dizzy that I couldnt even sit

up, no LOC, found it hard to get in and out of

the car and falling on the left side and cannot

keep balance; right leg numb, no problem

swallowing, smoker x 10sticks/day; mother

died of stroke)

o PEx:

(BP 145/85, PR: 80 regular, PEARL,

funduscopy normal, nystagmus on Left, left

horner syndrome, absent pain sensation to

pinprick, and corneal reflex is absent,

reduced pain and temperature on right side,

vibration and position sense and light touch

normal, hearing normal, tone, power and

reflexes normal, incoordination and falls to

left side)

o Diagnosis and management with examiner

DDx:

o Stroke (PICA)

o Acute labyrinthitis

o BPPV

o Meniere syndrome

o Migraine

o Cerebral tumor

o Multiple sclerosis

History

o Is my patient hemodynamically stable? Can you describe it

for me please? Since when did this happen to you? Did it

get better or worse? Did you try to stand or walk after this?

Is it for the first time? Any association with headache? Any

associated weakness of your arms, face or legs? Any

problem with speech? Problem with vision? Neck stiffness?

Episode of vomiting? Problem with swallowing? What

about taste sensation? Did you have hoarseness of voice?

Any recent head injury? Problem with hearing? Ringing

sensation in your ear? Fever?

o Chest pain, SOB or palpitation? Previous heart disease?

What about your BP? What about your lipid levels? What

about your blood sugar level? Do you have DM or PVD?

Past history of similar condition? SADMA? Stress?

o FHx of diabetes, hypertension or stroke



o Vital signs and BMI (increased)

o Neurological examination:

o Inspection: head injury, facial asymmetry, muscle wasting,

gait, Romberg test negative, incoordination of movements

of left arm, and hand

o Tone, power, reflex normal

o Cerebellar signs positive

o Sensation, pain and temperature decreased in contralateral

side

o Vibration, joint position and light touch normal

o Cranial nerves: horner syndrome

o Eye movement: normal

o Funduscopy normal

o PEARL

o Nystagmus positive on ipsilateral

o Pain, sensory loss of ipsilateral

o Direct, corneal reflex negative

Dx and Mx:

o Most likely the patient has PICA syndrome because of the

obstruction of the blood supply to the brainstem and

cerebellum. Vertigo is of central brainstem or cerebellar

origin. Significance of crossed signs (numbness on

ipsilateral face and contralateral body) plus cardiovascular

risk factors present in the patient.

o It is a medical emergency. Immediate hospital admission

and assessment by the specialist is necessary.

o Investigations that are needed to be done are MRI/CT

angiography (acceptable) to confirm the diagnosis. Other

investigations are FBE, BSL, RFTs, Lipid Profile, LFTs,

ECG, Echo.

o Management is to advise about CV risk factors and the

patient can be put on ASA and supportive treatment with

active rehabilitation.

8:

A 60-years-old man is brought by his wife to the ED complaining of acute onset of

weakness and numbness of the left side of the body and aphasia/dysphasia 1 hour

ago. The symptoms are still present. He has a history of hypertension and a

pacemaker was inserted a few years ago for heart block. His wife wants to discuss

his condition with you.

Task

Explain the situation to the wife

Explain about management plan and possible outcome

Answer her questions

Counseling

Is my patient hemodynamically stable?

Does the wife have a SPA or consent to discuss her husbands

condition?

I understand that you are quite worried about your husband, but let

me assure that he is in safe hands and we will do our best to help

and treat his condition. Before anything else, do you have any

particular concern that I can address? I will explain the condition,

cause, risks and followup.

Most likely he has a condition called stroke. It is a condition in which

part of our brain stops functioning due to disturbance in the blood

supply to that area of the brain (Draw diagram). The lack of blood

flow can be due to blockage of the vessels by a clot which is a

thrombus or embolus or leakage of blood which is called

hemorrhage. This in turn leads to the symptoms that your husband is

having now.

There are certain risk factors for this to happen: hypertension,

diabetes, smoking, aspirin/warfarin, head injury, peripheral vascular

disease, lifestyle, dyslipidemia

Ask about contraindication to thrombolysis: bleeding disorder or

recent surgery, warfarin/ASA

It is a serious condition and is a medical emergency so he needs to

be admitted to the stroke unit ASAP to stabilize his condition. He will

be assessed by a neurologist who will order some investigations. The

most important is non-contrast CT scan or MRI to see the type of the

stroke and other investigations like FBE, lipid profile, ECG, U&E,

LFTs, RFTs, echocardiography.

If it turns out to be ischemic stroke, he might be put on ASA and if

within 3 hours of onset, a substance called rTPA can be used to

dissolve the clot, but it will be decide by the specialist. However,

there is a risk of intracranial hemorrhage in 5-7% of cases. If it is a

hemorrhage, drugs can be given and/or surgery can be done.

His condition will be stabilized and supportive treatment will be given.

Good nursing care will be provided and this is the cornerstone of

management. It is to maintain skin care (bed sores), feeding,

hydration, proper positioning and monitoring of vital signs, giving

painkillers, and anti-emetics.

Is he going to improve? The outcome cannot be predicted at this time

because it depends on the area involved and the amount of tissue

damage. It can improve or the condition can progress further but we

will try to give him the best quality of life by all possible means.

Long term management: Following initial management, he will be

under the care of a MDT for stroke rehabilitation to recover any lost

function and return to independent living. This team will include

neurologist, specially trained nurses, speech pathologist,

physiotherapist, occupational therapist, social worker and GP for

regular reviews and follow-ups.

It is very important to control the risk factors to prevent further attacks

and this is where your role is vital. Lifestyle modification: exercise,

diet, control BP, sugar, and lipids, smoking cessation

I can also arrange for cardiologist review to assess his pacemaker

and other factors which can increase his risk

Reading material. Support groups.

You are not alone. All support is available for you

Red Flag: FAST Facial asymmetry, Arms difficult to raise, Speech

problems, and Time Call 000

9:

You are a GP in a small rural town and are asked to see a 22-year-old man who

collapsed about an hour ago. He has now fully recovered.

Task:

o Relevant history to try to determine the cause of the

collapse

o Ask examiner for relevant physical findings

o Explain to the patients what you this has likely happened

and what it your immediate plan of action

Differential Diagnosis

o HOCM - rare?

o Vasovagal syncope

o Infection?

o DM (hypoglycemia)

o Trauma?

o Neuro problems?

o Cardiac?

Focused History

o When? Feeling of chest pain? Palpitations? Fever?

Headache? History of trauma? Blurring of vision? Previous

loss of consciousness? Changes in personality? LOC?

Vomiting?

o Ask for patients wife to describe scenario and take

relevant history

o PMHx/SADMA

Physical Findings: all normal: ask for fundoscopic findings

Dx:

o Most likely this is a case of subdural hematoma which may

have resulted from the accident you had. Veins from the

brain bleed out which form a clot which if big enough may

have caused you to have a fit and lose consciousness.

Management:

o Skull x-ray and CT scan

o FBE, UEC,

o Urgent referral to a neurosurgeon/neurologist

Syncopal disorders:

o Common causes: cardiogenic disorders and postural

o hypotension, which are usually drug-induced; vasovagal

o Red flags: onset in older person, neurological S/sx,

headache, tachycardia, irregular pulse, fever, drugs

(social/prescribed), confusion (gradual onset), cognitive

impairment

o Sudden onset: epilepsy, cardiac causes (SVT), TIAs,

vasovagal

o Drugs: alcohol, antiepileptics, antihypertensives,

barbiturates, benzodiazepines, OTC anticholinergics,

peripheral vasodilators (ACE, ARBs, GTN, hydralazine,

prazosin), SSRI, TCAs

10:

Variant 1:

Your next patient in GP practice is an 85-year-old woman who was brought by her

daughter because her mother was acutely confused over the past few days. (one

case with DM and one with UTI)

Task

History

o (3 days and patient unable to recognize anyone,

wondering around the house and at times became

incontinent, + dark, cloud and smelly urine, on

medications for BP and cholesterol)

Explain plan of management

Vatiant 2:

Your next patient Mrs. Gladys George brought to your surgery by the staff from a

Low level nursing facility. Mrs. George moved to the Nursing home one month ago,

after being discharged from an old aged care psychiatry unit. Before her admission,

she had been living independently at home. The precipitant for her admission was a

fire in her flat. When the fire departments arrived Mrs. George was running around

the premises of the building claiming she was Messiah and the blaze was started by

demons. She was to taken to the hospital and was treated at an old age psychiatry

unit. She had normal blood tests and MRI brain showed generalized atrophy

consistent with age. The nursing staff thinks she had lost some weight. She had

been wandering the halls at night on few occasions. She is agitated and seems

confused. On one occasion she asked the staff are the Russians here yet -. One

of the nurses think Mrs. George has been seeing some things.

o Task

o How will you manage Mrs. George

Variant 3:

(Feb 4, 2012): An elderly whos confused and has SOB is admitted in the rural

hospital where youre working which is 300km away from the city. ECG and CXR

showed right-sided heart failure. In the blood test, no abnormalities were detected.

The daughter wants to talk to you.

Task

o Talk to the daughter

o Counsel accordingly

o (LHF SOB sec. backflow of blood into lungs and patient

cannot breathe properly)

o Sit upright, start furosemide to remove fluids CPAP if

not working

o Start high flow oxygen, explain about heart failure

o Arrange cardiology consultation;

o Investigation: Transthoracic Echocardiography to measure

ventricular function

Advice: Low-salt low fat diet, ideal weight, stop smoking/alcohol,

control HTN, DM and lipids; ACEI, diuretic, beta-blockers when

stabilized

no indications to transfer to hospital

Features Delirium Dementia Acute Psychosis

Onset Rapid Slow insidious Rapid Duration Hours to weeks Months to years Depends on response to

treatment

Course over 24 hours

Fluctuates worse at night

Minimal variation Minimal variation

Consciousness Reduced Alert Alert

Perception Misperceptions common (esp. visual)

Misperception rare May be misperception

Hallucinations Common (visual) usually or auditory

Uncommon Common, mainly auditory

Attention Distractable Normal to impaired Variable may be impaired

Speech Variable, may be incoherent

Difficulty finding correct words

Variable: normal, rapid or slow

Organic Illness or drug toxicity

One or both present Often absent Usually absent

Causes:

o Depression/Drugs/alcohol

o Ears/Eyes

o Metabolic (hyponatreamia, diabetes, hypothyroidism)

o Emotion/encephalopathy (loneliness)

o Nutrition (Vitamin B12/diet)

o Trauma/tumor

o Infections

o Arteriovascular disease (CVA, MI)

Investigations:

o LFTs, BSL, TSH, FBE, Blood culture, U&E, CXR, CT scan,

urine MCS, ECG

Hx:

o What do you mean confused?

o Did she have any fever?

o Lumps or bumps?

o Any headaches or early morning vomiting?

o Did she lose consciousness at any time? Any weakness in

any part of the body or any problem with speech? Any

chest pain or shortness of breath?

o How about her appetite and weight?

o Has she lost any weight? Any weather preference? Any

swelling all over the body? Any medical illnesses like

diabetes or hypertension? SADMA? Any recent change in

medications? Problems with waterworks? Any change in

color? Any concerns with the bowel?

o Whom does she live with at home? How is her mood?

What does she do? Recent hospitalization

Management

o I would like to admit your mother to the hospital. I will

arrange an ambulance for that. There are a lot of reasons

for acute confusion or delirium.

o From the history, I believe she has a UTI, but because she

is also hypertensive, she might also be suffering from a

stroke which is why we need to admit her to do some

investigation for hypoxia (pulse oxymetry, saturation, ABG

and CXR), sepsis or infection (FBE, blood culture, urine

MCS, ESR/CRP), metabolic (BSL, U&E, arterial pH),

cardiac (ECG, cardiac enzymes), CVA (CT scan). They will

also review the medications.

11)

An 83-year-old man developed strange behavior, confusion and disorientation for

the last couple of days. He lives in the nursing home. He is on some drugs:

Indapamide (hyponatremia, hypokalemia, hyperglycemia), statin, imipramine. His

physical examination is unremarkable. BSL is also normal. Blood test has done:

Sodium 120mmol/L, Potassium 4.5mmol, Urea is normal, Creatinine is normal.

Task

o Explain the test results to the daughter, and the possible

causes of his confusion.

Low sodium level (135-145mEq/L)

Pseudo hyponatremia:

o Cause: DM If the sugar is high: Hyperglycemia.

The fluid is high the sodium seems to be low but its

normal.

Osmolality Formula:

o 2 X Na + GGlu/18 + BUN/2.8

If the glucose/sodium is high the osmolality is high. High

osmolality hyponatremia

If the osmolality is normal: True hyponatremia sodium goes

low because of low osmolality.

Causes: look for the extracellular FLUID volume.

If ECF volume: HIGH

o Cardiac failure, nephrotic syndrome, kidney/liver

failure

o Low: external causes: vomiting, diarrhea, blood loss,

burns, sweating.

Renal causes:

Nephropathy, losing water along

with sodium. Anti-diuretic hormone

causes the losing of the sodium.

Drug:

Indapamide: Its not losing salt but it

is losing the water.

If ECF volume is NORMAL:

o SIADH. The water retained in the body. It comes with

anything in the brain, in the chest, small cell lung

cancer, pneumonia, drugs (tricyclic anti-depressant

imipramine)

o Hypothyroidism.

o Psychogenic polydipsia.

Need to ask the patient about the: BSL, Kidney problem, Liver

problem, Diarrhea, Taking any drugs, Any problem with

brain/chest, Any weather preferences, increase or decrease of

the fluid

Counseling

Patient is having hyponatremic encephalopathy. When people

have hyponatremia, it is going to give symptoms in the CNS.

Symptoms come with sudden drop of the sodium.

Isotonic/hypertonic. If the sodium drops slowly the fluid

becomes hypertonic. Fluid always goes to the higher

concentration thus losing the water which then goes to the

cells especially the brain cells. It causes herniation of the brain.

If we give the sodium too quickly, the cells will shrink quickly

and the brain is going to die which is called central pontine

myelinolysis. Dont replace it too quickly 0.5-1 mEq/hr.

Inx:

o Sodium level, Urine osmolality, serum osmolality, RFTs,

LFTs, BSL, UEC.

Mx:

o Advice the patient we are going to replace it slowly.

Treatment is to reverse the cause.

o Give normal saline. (Vomiting, diarrhea)

CCF:

o Restrict the fluid. Patient can be given some normal

saline and furosemide. (Give the sodium slowly

pushes the water out)

Severe hyponatremia: Hypertonic Saline

o Symptoms: N/V headaches/ restless/ irritable/

drowsy/ seizure/confusions/coma/death.

If you get dehydrated, serum osmolality goes up. When secreting

ADH the urine becomes concentrated, urine osmolality is high. If

serum osmolality is low, it means increase of the fluid, theres diluted

urine the urine osmolality is low. If there is a lot of ADH/ SIADH,

theres a lot of fluid in the body. But the water is not coming out.

Urine osmolality is high. The body is trying to keep the water.

Patient comes with confusion: If the patient has fever, problem with

urine, Any sepsis, Any edema

Address the drug it can be because of high/low fluid volume. We

need to find out the cause. Ill be calling the registrar we will manage

the condition accordingly.

12:

Your next patient in GP practice is an elderly man with a long history of

hypertension and diabetes. He has developed tiredness, confusion, and hes

behaving strangely for the last 2 days. Investigations show sodium is 120,

potassium, chloride, bicarbonate, Urea and creatinine are all normal.

Task

Explain results to daughter

o (indapamide, atenolol, imipramine, and meds for DM;

good control)

Explain possible causes and management

Basic Investigations: According to HIDEMAP

Hypoxia: pulse oximetry, oxygen saturation, ABG, CXR

Infection: Sepsis: Blood culture, urine MCS, FBE, ESR/CRP, CXR

Drugs: diuretics, benzodiazepines, morphine,

Endocrine: e.g Diabetes

Metabolic: ABG, BSL, urea and electrolytes

Alcohol: LFTs

Psychosis: MSE

ECG: cardiac enzymes and ECG

Counseling

Does the daughter have authority to talk in behalf of the father?

From the blood reports, your father has a condition called

hyponatremia. There are some minerals in our body and one of it

sodium and there is a low level of this in your fathers body. Low

sodium means low osmolarity causing leakage of water into the brain

cells leading to edema of the brain and this causes confusion, but

there can be other reasons for confusion.

Is your father on any medications? Does he take any alcohol? Any

problem with his vision or hearing? How is his diabetes? Is it well

controlled? Is he on any medications? Have you seen him gasping or

having SOB or any sweet smell from the mouth? Any chance he

could be lonely or depressed? Any headaches or early morning

vomiting? Any chance he had a fall? How are his waterworks? Did he

have any fever? Any problems with the heart or weakness or

numbness of his body? Has he vomited or had diarrhea?

Most likely, the hyponatremia was caused by the indapamide. This is

a medication which affects the kidneys diluting capacity and

increases sodium excretion. (Once the depletion occurs, there is

non-osmotic release of ADH and causes water retention worsening

hyponatremia).

At this stage, I will call the ambulance because your father needs

urgent treatment. In the hospital he will be reviewed by a medical

registrar. IV lines will be secured and blood taken for further

investigations. They will start him on IV fluids (PNSS or hypertonic

saline 3% for rapid correction). A cranial CT scan will also be

organized.

13:

You are an orthopedic resident called by the ward NOD to see a 65-year-old man

who had a left knee replacement 2 days ago. He had been quite okay until today

where he seemed to be confused, restless and agitated. He had become verbally

aggressive and wants to pull out his drip and go home. His vital signs are BP

130/90, PR 102 regular, T 38.3, RR: 30. Cardiorespiratory examination is difficult

because patient is not cooperative. Per abdomen examination reveals some lower

abdomen tenderness. CNS examination is normal as far as you can assess. You

found the patient to be slightly confused and disoriented to time, place and person.

You could not do the whole MMSE because of lack of cooperation. ECG is normal

and you have asked the nurse to send the blood for troponin. Reviewing the medical

record, you note that the patient is drinking 6 cans of beer per day. His preoperative

biochemistry was normal except for elevated GGT, Hgb 120, MCV 110 with normal

b12 and folate.

Task

Present and liaise with registrar who wants to know what is

happening and what is the most likely diagnosis

How you suggest to manage the patient

o On reviewing the chart, patient drinks 6 cans of beers

per day with mild anemia.

o The most likely diagnosis is delirium tremens due to

alcohol withdrawal following surgery over the last 2-3

days.

o What else could cause delirium?

Hypoxia, infection, electrolyte disturbance,

metabolic causes, or narcotic overdose due

to pain relief.

o What further tests would you like to organize?

FBE, Blood culture, CXR, ABG, ESR/CRP,

Urine MSU, BSL, U&E, LFTs. Review the

drug chart and re-adjust pain relief and

narcotics dosages. CT scan.

o How do you manage the patient?

If the patient is getting violent, I would like to

call security (to make environment safe).

Start high-flow OXYGEN!!!! Move patient to

a quiet room with appropriate lighting and

with one nurse looking after the patient.

Consider involving relatives and friends.

Physical restrains as per hospital protocol.

Be prepared to sedate the patient

(Diazepam PO or IM midazolam 2.5mg SD

or olanzapine PO).

o Monitor the vital signs and IV access, fluid balance,

oxygen and pulse oximetry. Consider IV thiamine.

(Condition 149): You are an intern called to the ward to see a patient who became

acutely confused after a left total knee replacement. A few hours earlier, he started

to behave in an irrational manner, became agitated and difficult to manage. Until this

stage he had been making an uneventful postoperative recovery. His confusion has

now culminated in the patient being disoriented, noisy, and difficult to restrain. The

patients wife is with the patient and she has been unable to help.

Task

Assess the situation

Formulate management plan

Counsel patients wife as to the cause of the current problem

A 60-years-old man became restless and shouting in the postop ward. He had knee

replacement this morning and was uneventful. Morphine was given to relieve his

pain. Investigations were done are results are pending. Patient has hallucinations

and delusions and MMSE shows that hes disoriented. He has history of drinking 4-6

cans of beer every night.

Task

Report to registrar about patients condition

Answer his questions

Assess situation

Is my patient hemodynamically stable? I would like to start with

DRABC and call for help and restrain patient as per hospital

protocol.

Ensure and assess DANGER (physical restraints); DRABC

Institute pulse oximetry and put in high-flow oxygen.

Intravenous access: Insert IV cannula, collect blood samples

for routine hematological and biochemical screens, BSL, blood

culture if febrile

PMHx (DM or CVD), drug use (alcohol),

Case notes and nursing observation: any recent change in VS,

fluid balance, recent drug administration, details of recent

surgical procedure (complication, Blood loss), sleep pattern

and behavior

Comments in medical and nursing record and any abnormal

laboratory investigations


Establish orientation

Check vital signs and examine cardiorespiratory systems

Look for evidence of sepsis (abdomen and wound)

Look for evidence of VTE (legs, chest)

Look for any neurological deficits

Dipstick and BSL

Causes of Confusion

Hypoxia (very common cause particularly in elderly) ABG,

CXR, ECG

Hypotension

Sepsis

Metabolic (electrolytes, blood sugar estimation, arterial pH)

Cardiac disease (ECG)

CVA (neurologic examination)

Pain

Opiate overdose or effect of other drugs

Drug withdrawal (alcohol, benzodiazepines, narcotics)

Exacerbation of pre-existing medical conditions (dementia,

hypothyroidism)

Counsel

Reassure: The situation is under control

The investigations may yield a cause for confusion

Alcohol withdrawal is a common cause of postoperative

confusion and should be easily controlled and problem self-

limiting

Regular reviews with monitoring of VS, I&O and any changes

in behavior

14:

You are a night intern in a general hospital and your next patient is a 25-year-old

male student with 20% partial thickness burn sustained when throwing fuel over fire.

The burns involving all the limbs are being managed conservatively and have been

dressed under IV ketamine. You have been called because the patient is unable to

sleep, restless and distressed and has pulled out the IV line delivering patient-

controlled analgesia which is morphine 1mg/hr.

Task

Determine the cause of sleeping problem

o (was out camping with friends, threw petrol over fire

and caught burn; cannot remember how it happened;

doesnt know how he got to hospital? feels being

chased and saw angel of death; doesnt want to close

eyes because something bad might happen; sees

strange looking people and suddenly disappear;

believes nurses are dangerous and think they are

here to harm; believes that nurses are giving the

wrong drugs; feels pain but cannot be bothered by the

drips thats why I pulled them out; not under the

influence of alcohol; no illicit drug use; no headaches)

Perform MMSE

Explain to the patient the nature of the problem and what can

be done to help

History

May I know a bit more about what happened? When did it

happen? How were you brought to the hospital? Do you know

which hospital you are admitted and for how long?

I understand youre unable to sleep. May I know the reason for

it? For how long is this happening to you? Do you hear voices

when nobody else is around? Do you see things when nobody

else is around you? Do you feel things or have any strange

experience? Do you think somebody is trying to hurt you? By

any chance, do you think of harming yourself or others?

Do you feel pain at the moment? How is your general health?

Do you feel feverish? Any headaches, SOB, racing of heart, or

tummy pain? Hows your appetite? Do you have N/V? What

about your waterworks or bowel motions? Any pain or burning

sensation? Are you comfortable in this hospital environment?

PMHx: Any condition like diabetes, thyroid, liver, kidney, or

heart disease, anemia? CVA? Mental/psychiatric illness or

neurologic disorder? Previous hospitalization? Previous similar

episodes? SADMA?

FHx of psychiatric illnesses? Hows your home situation?

MMSE: - DO MMSE from JM LATER IN REVISION

ORARL: problems with orientation, registration/recall, attention and

concentration

Most likely you have a condition called delirium or acute brain

syndrome. This is a common complication of major injuries and

their treatment such as your burns. It will get better along with

your recovery. Your visual problems and fears are part of it

and do not mean that you have a mental illness like

schizophrenia. We need to find out the cause. In your case,

pain relief medication (ketamine/morphine) may be the cause,

but we need to look for infection/sepsis, change in your vital

signs, fluid balance, and do relevant investigations.

I will let the nursing staff know about your concern so that they will take extra

care for you and explain what they are doing (assign same staff each shift to

care for the patient).

Environmental disturbances like lighting and noise will be addressed

for your benefit. If you want your family/friends to be here, I can help

with that.

You will also be seen by a physician registrar to give some

medication to help with your sleep and arrange other painkillers if

required.

For sleep: short-acting benzodiapines (alprazolam, oxazepam,

lorazepam); low-dose haloperidol or olanzapine IM for agitation

Investigations: FBE, U&E, LFTs, ESR/CRP, blood culture if indicated,

RFTs, BSL, CXR, ABG, ECG, urine MCS, TFTs, urine drug screen

15:

Your next patient in ED is a 70-year-old male brought in by ambulance because his

son found him with worsening confusion and complaining of worsening nausea

during his weekly visit. He is slightly demented but managed to live alone at his

home with some help from meals on wheels and district nurse coming 2x per

week.

Task

History

o (confusion, unable to recognize him, did not skip

meals, no fever, headache, problem with heart rhythm

and HTN on medications with digoxin, and fluid

tablets/water pill; problem with vision)


o (VS normal except pulse is irregular, CNS

unremarkable, chest, lungs and abdomen normal,

urine dipstick negative, BSL normal)

Investigation

o (FBE normal, urine microscopy and normal, U&E

(potassium increased, sodium normal, ABG), CT scan

normal, RFTs normal, CXR negative, ECG showing

AF), Digoxin level increased!!! Hyperkalemia-

Arrythmia

Diagnosis and management

Features:

narrow therapeutic range

indications: CHF & AF

optimum dose with ACEI, loop diuretics and beta-blocker

Contraindications: HOCM, WPW

Cause hyperkalemia cardiac arrhythmias deaths

Precautions:

Elderly patient

Ischemia

Previous MI

Hypothyroidism

Increased calcium, decreased magnesium

Decreased potassium potentiates digoxin toxicity

pushes extracellular potassium shift

Renal insufficiency

Causes: deteriorating renal function, dehydration, electrolyte imbalances,

drug interactions precipitates chronic toxicity

Acute overdose or accidental exposure to plants containing cardiac

glycosides may cause acute toxicity

Hyperkalemia, hypernatramia, hypomagnesemia increase the toxic

cardiovascular effects of digoxin because of their depressive effects on the

Na+/K+ ATPase pump

Toxicity:

Yellow vision (xanthopsia)

Irregular pulse

N/V

Anorexia

Confusion

Treatment:

Stop digoxin

Check potassium

Treat arrhythmia

Digibind IV

Do no combine with verapamil!

Management

Admit!

Supportive correct fluid loss

Correct hyperkalemia (insulin, HCO3, correct acidosis,

resonium with laxatives)

Management of Arrhythmias: atropine to counteract digoxin

Digoxin FAB fragments: LMW antibodies which combine with

digoxin and are then excreted in the urine (40mg vials, each

binds about 0.6mg of digoxin)

16:

Mandy aged 35 years presents to your GP clinic. She tells you that she had

intermittent blurring of vision for the last few weeks. She attributed this to stress at

work and had not asked for help but yesterday evening she had similar episodes.

She is otherwise fit and healthy. Mandy works as secretary in an office and has to

work every day form 8-5.

Task

Focused history

o (2 episodes, 30 pack years, lasting few minutes, no

PMHx)


o (looks well, 130/80, vitals normal, 80 minutes, regular,

BMI 27; VA: R eye 6/12, L 6/6, visual fields normal;

EOM normal; funduscopy blurring of disc margin in

right side, no carotid bruit)

Differential diagnosis and management advise

Differential Diagnosis

Atypical Migraine (without headache)

TIA

Multiple sclerosis

Neurosyphilis

Toxins

Retrobulbar Neuritis

Usually woman with 20-40 years

Loss of vision in one eye over a few days

Retro-ocular discomfort with eye movements

Variable visual acuity

Usual central field loss (central scotoma)

Afferent pupil defect on affected side

Ophthalmoscopy:

Optic disc swollen if inflammation anterior in nerve

Optic atrophy appears later

Disc pallor is invariable sequel

Investigation:

MRI

Lumbar puncture (oligloconal IgG in 80%)

Visual evoked potentials: 80%

Management:

Test visual field of other eye; consider MRI; most recover

spontaneously but with diminished vision

17:

You are an HMO in ED and a 35-year-old woman presented with 2 weeks history of

visual disturbances and pins and needles in the left hand and difficulty walking.

Task

o History

o (Its a blur vision I cannot see properly. All over. I find

difficulty identifying the colors as well. Started

yesterday. Weakness of the left hand. The similar

thing happened 10 years ago. Bowel is ok. But hard

to control the bladder sometime. Right leg is also

weak)

o Physical Examination findings

o (Patient looks distressed. No dysmorphic feature.

Ophthalmolplegia, diplopia. Pupils are normal. Visual

acuity is decreased. Hearing is ok. Impaired co

ordination. Spastic Para paresis in lower limbs with

impaired reflexes. Upper limb: Impaired sensation)

o Investigations if you think are necessary (MRI)

o Diagnosis and Management

Features

o Demyelinating and inflammatory disease of the CNS

o No peripheral nerve involvement and only UMN signs and symptoms

o Most progressive neuro disability (20-50yo)

o Involves Optic nerve, brainstem, periventricular areas, and spinal

cord

o Cause is unknown

o Evidence that the disease is an autoimmune response to virus

(EBV), bacteria or chemicals in genetically predisposed adults

o Plaques in white mater

o F>M

o Onset: 17-35 years old but peaks at 40 years

o Early onset (1 part of CNS involved

o Episodes separated in time and space

o Practically diagnosed after a second relapse or when MRI shows

new lesions

o Early diagnosis requires evidence of contrast-enhancing lesions or

new T2 lesions on the MRI indicating dissemination in time

Diagnostics:

o MRI initial, best and most reliable

o CSF analysis increased protein and mononuclear cells; oligoclonal

IgG

o Visual evoked potential

Treatment: Principles:

o All patients should be referred to neurologist for confirmation of

diagnosis.

o Rule out depression and anxiety.

Acute attacks:

o Corticosteroids (methylprednisolone 1gm over 5 days) and plasma

exchange Disease-modifying therapy

o Severe: immunosuppresants (MTX, AZT, Cladribine, fingolimod)

Prevention of relapse:

o Interferon

o Glatiramer (mimic myelin)

o Natalizumab

o Prednisolone 75mg once a day for 4 day or 50mg for 4 days.

o If severe relapses (optic neuritis , brain stem signs): Hospitalized. IV

therapy: methyl prednisolone 1 g in 200mL of saline daily for 3-5

days

o For long term: methotrexate with folic acid or Cyclophosphamide.

o Refer to neurologist

o Refer to psychologist

o Refer to physiotherapist if with spasticity

o Support groups

o * In classical trigeminal neuralgia only severe pain; but if with

sensory multiple sclerosis

History

o I understand from the notes you have visual problems. What do you

mean by visual disturbances? Doctor theres blur vision, I cannot

identify colors. Sometimes I have double vision as well.

o Is it getting worse? Yes.

o I also understand you have pins and needles in your left arm is it

associated with weakness? Yes.

o Do you have weakness anywhere else in your body? Yes weakness

in my right leg as well. Is it difficult to walk? Yes when I walk I fall to

one side, I had a few falls. Any Headache N/V? No. Any pain

anywhere? Especially your eyes? Yes. Any neck stiffness? No. How

about the water works? I cant control my bladder (urinary urgency).

How about the bowel? Good no problem. Any past medical history?

Same happen 10 years ago. Anything runs in the family? Myasthenia

Gravis. Single, smoker, artist. Drinks alcohol occasionally

Physical Examination

o General appearance: She is distress.

o No facial abnormality. Facial palsy drooping of eye lids

o Eye: Ophthalmoplegia, visual acuity is decreased, visual fields are

normal, theres double vision, pupils are normal. Fundoscopy: Optic

neuritis/atrophy.

o Cranial nerves: Id also like to check 5 to 12. No abnormality for all

other cranial nerve.

o Neurological examination of the upper and lower limbs: Spastic

paraparesis in lower limb, increase reflexes, impaired coordination,

(Heel and the shin test). Lower limbs: Theres impaired sensation.

Gait: ataxic gait.

Diagnosis and Management

o Jane, from history and examination I suspect you have a condition

called MS but to confirm the diagnosis Id like to order some

investigation and refer you to the neurologist for further assessment

investigation: lumbar puncture, Visual evoke potential, MRI.

o If this is MS, it is an autoimmune disorder. Whats happening is

demyelination (Nerve cells covered by sheath and it got destroyed).

Its uncommon. More common in women, this disease has classical

relapse and remission. Typically presents with pins and needles,

bladder dysfunction etc. Depending on where the demyelination is in

the brain. It is a serious condition but dont worry we will help you. It

is not curable but manageable. Our aim is to slow the progression of

the disease and increase the period btw relapses. Most likely the

neurologist will put you on long term immune suppressants. Acute

phases handled by steroid.

o Refer to neurologist. Review frequently. Reading material

o Red flags: Vision and other symptoms come up.

Critical Errors:

o Not referring to neurologist

o Not doing MRI and Fundoscopy

18:

Variant 1:

A middle-aged woman comes to your GP practice complaining of pain in the right

shoulder associated with neck pain.

Task

o Focused History

(No more than 2 minutes) last couple of

months, in the shoulder and neck and

traveling to neck, no trauma, painful in some

movement,

o Perform Physical examination

(Limited movement to the right side of the

neck---pain on the lower cervical spine;

Elbow flexion & extension of the wrist weak;

numbness of thumb and index finger;

Sensory loss of outer forearm & index finger

numb)

o After 6 minutes, the examiner will stop you and you need to

explain diagnosis and differential diagnosis and advise

further investigation

Variant 2:

You are a GP and a middle-aged lady came in with shoulder pain for the last few

days.

Task

o History

(started 3 days ago, no trauma, sudden,

shoulder or neck, BOV, headache, first time,

computer analyst)


(tenderness on C6-7, weakness of wrist

extension and elbow extension, loss of

sensation over 3rd finger)


o History

o Pain question (SORTSARA): When did it start? Where? On

a scale of 1-10, how bad is the pain? Travelling anywhere

like the neck, back of head, between shoulder blades, arm,

or forearm? Any diurnal variation? Constant or come and

go? Any trauma? Any morning stiffness of the neck? Is the

pain precipitated by activity? Does anything relieve the pain

like painkillers or rest? Pain in the neck on one or both

sides? Any precipitating factor? Any weakness in the hand

or upper limbs? Numbness/tingling? Can you drive back

(reverse) your car? Associated features: swelling, chest

pain, SOB, thyroid disease? Headache? Ear pain? Any

problems with gait or weakness of lower limb? Any

problems with bowel or waterworks? PMHx of joint or neck

problems? SADMA

Inspection

o Ask patient to release her gown for inspection

o Inspection shoulder - On the same level: Any muscle

wasting in the shoulder, Bulk of muscle, Contour of neck

from the side, Lateral flexion to the neck or torticollis, Any

neurocutaneus stigmata, no muscle wasting or any trauma,

no abnormal contour of the spine, step deformity, squaring

of shoulders, winging of scapula

o Palpations of neck midline from the back---pain on the

left or right side? From central to lateral digital of the

cervical spine and thoracic spine; temperature; Bulk of

muscle of shoulders (trapezius and supraspinal muscle and

lower part of head) if theres any pain; thyroid and LAD;

Any area on the shoulder or forearm; Palpate

temporomandibular joint

Movement

o Turning the head up and down, to left and right 45 and 90

degrees (flexion, extension) 6 movements

o Examine shoulder with both hands flexion, extension,

internal rotation, external rotation, circumduction

o Elbow flexion extension

o Wrist supination, pronation, flexion, extension, ulnar

deviation, radial deviation

o Hands all the joints

o Thumb adduction, abduction, opposition

Muscle power please resist my hand; Chicken wings

Sensation

Reflexes

NR Sensory Muscle Power loss Reflex

C5 Outer arm Deltoid Arm abduction

Biceps (C5,6)

C6 Outer forearm/ thumb/index

Biceps Elbow flexion wrist extension

Biceps + brachio radialis (C5,6)

C7 Hand/ middle & ring finger

Triceps and finger extensors

Elbow extension

Triceps (C7-8)

C8 Inner forearm/ little finger

Long flexor fingers; long extensors; thumb

Grip Fingers (C8)

T1 Inner arm interossei Finger spread

DDx:

o Disc prolapse due to cervical spondylosis

o Ankylosing spondylitis

o Rheumatoid arthritis

o Traumatic strain or sprain

o Myopathy level C6

Diagnosis and Management

o From my examination finding, its most likely youre

suffering from a degenerative condition with C6

compression due to disc prolapse consistent with cervical

spondylosis

o PRICE/heat/massage/warm hydrotherapy

o Investigation: FBE, ESR, CRP, rheumatoid factor, HLA B27

antigen, CT or MRI cervical spine

o I need to refer you to orthopedic surgeon

o Painkillers (NSAIDs x 2 weeks) and neck collar (especially

at night; limited time)

o Physiotherapy

o Steroids

o Surgery: limited role. Indications are: intractable pain or

with neurologic deficit.

19:

You are working in ED and an 18-year-old male patient is brought in by his friend

because of confusion and agitation since the last 12 hours. He also had an episode

of seizure during this time. On examination, his GCS is 14, temperature is 38.5C,

BP 140/90, PR 90/minute and RR 18. Neck stiffness is negative. Lumbar puncture

has been done and results are as follows: Glucose level normal, protein increased,

Gram stain negative, cell: lymphocytes 90%.

Task:

Explain results of LP to friend

Diagnosis and Differential Diagnosis

Management

Encephalitis: meningitis + brain parenchyma

Altered mental status/confusion/irrational

Focal neurological deficits

Seizures

Predominant in meningitis

Photophobia

Neck stiffness

Vomiting

DDx:

Meningitis

Delirium

Electrolyte Imbalance (Hypo/Hyperglycemia)

Brain abscess

SOL

Substance abuse

Head injury

Organisms: mostly virus especially Herpes Simplex Virus

Investigation:

CT/MRI: cerebral edema

Lumbar puncture: predominantly lymphocytes (90%)

PCR of CSF

EEG

FBE and BSL, LFTs, Blood culture

Management

Oxygen

IV fluid

Acyclovir

IV lorazepam seizures

Counselling:

From history and examination, most likely he has encephalitis.

It is the infection of the brain substance and the covering

(meninges) most likely due to a virus. It is a serious condition

and needs immediate management. Therefore, we will keep

him in the hospital and arrange urgent neurological

consultation. In the meantime, I will be giving him oxygen, IV

fluids, paracetamol for fever, intravenous lorazepam for active

seizures. I would also take blood for baseline investigations

such as FBE, ESR/CRP, BSL, LFTs, U&E, Blood culture.

The treatment is mainly supportive and symptomatic, but the

specialist will do further assessment and can order further

investigations (EEG changes in temporal lobe and CSF PCR

for HSV) before starting treatment.

The specialist may prescribe IV acyclovir if HSV is suspected

which is one of the main causes of this condition.

Will he fully recover?

o It is a serious condition but usually the outcome is

good. Dont worry he is in safe and experienced

hands.

20:

A 30-year-old man is referred to your GP clinic as he is diagnosed with idiopathic

epilepsy by his neurologist. He has been put on sodium valproate for treatment. He

is a courier driver and getting married very soon.

Task

Explain the condition to the patient and talk about further

management

Answer his questions

Features

Due to a fault somewhere in the complex electrical circuit of

the brain and the nervous system results in brain being

unable to work properly for a brief period

Causes: unknown (but can be caused by damage from

previous infections, scars from previous head injuries, tumors,

excessive alcohol or drug use or genetic factors)

Common: 1:100; M=F; seems to run in families

Do you have any concerns?

o Disorder in which a person is prone to having

recurrent seizures which result from the release of the

abnormal electrical impulses by the nerve cells of the

brain. In your case, the cause is unknown and hence

it is called idiopathic. It is a common condition and

affects 1:50. Aim of the treatment is to achieve

complete seizure-control by one medication which is

called monotherapy and lifestyle management.

o A single drug is initiated and the dose is adjusted

accordingly until it controls the seizures and/or the

side effects. 70-80% will have no seizures after

treatment with first-line drugs. If the maximum

tolerated dose fails to control the seizures, it needs to

be replaced by another drug. The first drug is stopped

once the therapeutic effect of the 2nd one is achieved.

The 2nd part of the management is:

o healthy lifestyle and avoidance of triggering factors

like fatigue, physical exhaustion, stress, lack of sleep

and excess alcohol, and avoidance of flashing/strobe

lights and open fires.

With proper treatment, most patients can achieve complete

control of seizure and lead a normal life.

Side effects: nausea, anorexia, vomiting,

dizziness/drowsiness, tiredness or fatigue, gait disturbance like

ataxia, visual disturbance, and most drugs can cause a rash.

Sodium valproate:

o hair loss, rare but serious liver toxicity (LFTs every 2

months for 6 months after starting), NTD (spina bifida)

Phenytoin:

o ginigival hyperplasia, hirsutism, fetal malformation (cleft lip

and palate), CHD

Carbamazepine:

o anorexia, nausea, vomiting, dizziness, skin rash, tinnitus,

diplopia, ataxia, tiredness and fatigue; safest in pregnancy

When to stop treatment?

will be reviewed for the need of the drugs annually and they

will be stopped if you are free of seizures for 2-3 years.

Can I continue my work?

I will be checking with vicroads because you have to be careful

with driving. Each case has to be considered individually but

the rule is if you are seizure-free for 1-2 years. The applicant

applying for learners license should be seizure-free for 2 years

then annual review for 5 years.

Employment:

contact centerlink, social support/worker; should not work close to

heavy machinery, dangerous surroundings, heights, or near deep

water; jobs not allowed: public transport (bus driver), police,

military, aviation

Can I play Sports?

Avoid scuba diving, hand gliding, parachuting, rock climbing, car

racing and swimming alone especially surfing; contact sports:

relative CI

Can I get married?

Yes and you can expect to have normal sexual life and normal

children and your children have a slightly increased chance of

having epilepsy (3%).

Red flags:

Take special care with open fires, do not swim unsupervised

Advice for carers:

Dos: roll person on to his side with head turned to one side

and chin up and call for medical help if convulsion lasts longer

than 10 minutes

Donts: move person unless necessary for safety, force

anything into persons mouth, try to stop the fit

Regular follow-ups: monitor medication levels and side effects

of the drugs

Refer to support groups

Reading materials

In female patients: interaction with OCP so increased doses; if

patient wants to get pregnant (high-risk pregnancy) start

patient on 5mg folic acid; planned pregnancy; NO

contraindication for breastfeeding

21:

A young patient is brought to ED, he is unconscious. His airway is patent and

breathing without difficulty. His blood pressure is stable and temperature is 37.5.

Task

o Examination and commentary

o Differential diagnosis

o Investigation you would like to arrange

DDx:

o Meningitis/encephalitis

o CVA (SAH, stroke)

o Epilepsy

o Trauma

o Drug/alcohol overdose (sedative hypnotics, tranquilizer,

alcohol, antipsychotics)

o Diabetic hyper/hypoglycemia, hypothyroidism, uremia,

hepatic coma

o Multiorgan failure (adrenal)

o CO narcosis

o Psychiatric problem

Examination

o Inspection for any bruises, lumps/bumps, bleeding, signs of

trauma (raccoon eyes, battle sign, bleeding from ears,

nose), jaundice, facial asymmetry,

o CHECK PEARL (miosis: pontine lesions, opioid overdose;

dilated: raised ICP; signs of multiorgan failure, funduscopy

for raised ICP and diabetic/HTN changes), neck stiffness,

mouth for tongue bite marks

o Face: breathing pattern (metabolic acidosis DKA,

hypoventilation, drug overdose),

o Smell of the breath

DKA: fruity smell,

Alcohol: Fetor Hepaticus

Uremic Coma o Peripheries: Tone, IV drug marks/insulin injection marks,

snake bite, circulation, pulse oximetry, temperature,

hydration

o Heart: arrhythmia

o Urine dipstick and BSL

Investigations

o FBE, blood cultures, ESR/CRP, cranial CT scan, LFTs,

blood or urine drug screen, Urea & Electrolytes, RFTs,

lumbar puncture

Management

o Thiamine 100 mg IM

o Oxygen

o Naloxone 0.1 0.2 mg IV

o Glucose (give IV bolus of glucose) 50 mls

Causes of COMA

CO narcosis CO2 narcosis; respiratory failure

Overdose of drugs

Alcohol, opioids, tranquilizers, antidepressants, CO, analgesics

Metabolic Diabetes (hypoglycemia, DKA), hypothyroidism, hepatic failure, Addison failure (uremia),

Apoplexy ICH (hematoma, head injury, cerebral tumor/abscess) Infratentorial (posterior fossa): cerebellar tumor, brainstem infarct/hemorrhage, wernicke encephalopathy Meningismus: SAH, meningitis Other: encephalitis; overwhelming infection Trauma

22:

A 70-year-old man comes in your GP clinic because of recurrent falls. He had stroke

7 years ago and had weakness of left lower limb.

Task

o History

(had 3 eps. for the last 3 mos, noted lightheadedness;

gardening when he stood up; got up from bed and fell

down; medications for BP, TCAs, and diuretic)


o Provisional and Differential diagnoses

o Management

Task 2

o History

o Differential diagnosis to Examiner

DDx:

o Stroke

o Dementia/delirium/Depression

o Epilepsy

o Hearing (vestibulococchlear)

o Vision

o CVS (arrhythmia, MI, anemia, BP)

o Chest (PE)

o GIT(bleeding and diabetes)

o Musculoskeletal

o PMHx: Medications: Polypharmacy

Hx:

o Can you tell me more about it?

o Can you describe these falls for me?

o You had a stroke 4 years ago. How is your general health after that?

o Did you feel dizzy, lightheadedness or fainting before the fall? Any

LOC in any episode?

o Did you injure/hurt yourself? What did you do after you fell down?

o Did you notice any weakness or numbness of your body? Any

slurring of speech? Any BOV? Any shaking or jerking of your body?

Did you bite your tongue or wet yourself?

o Do you have any problem with your memory?

o How is your mood lately? Any problem with hearing or vision?

o Do you feel everything is spinning around you or any problem

maintaining your balance?

o Do you feel short of breath, chest pain or racing of your heart? What

about your BP? What medications are you on?

o Do you take your meals regularly? Hows your appetite? Any change

in the color of the stools? Do you feel thirsty or passing urine more

than normal?

o Have you ever been diagnosed with diabetes?

o Do you have any joint pain or problem with walking?

o Do you live alone or with family? Can you manage your life by

yourself? Financial problems? Do you have proper lighting and

protection in your home?

o PMHx: DM, hypertension, epilepsy, etc.; Drug History; SADA;

PEx:

o General appearance: anemia, dehydration, jaundice

o Vital signs: POSTURAL DROP (drop of 15mmHg systolic or

10mmHg diastolic)

o Neurologic: gait, tone, power, reflexes, coordination, sensation

o Eyes: Visual acuity, eye movements, visual fields fundoscopy

o CVS: Carotid Bruit, Apex Beat, Murmurs

o Abdomen

Management:

o Most common cause of your recurrent falls is postural hypotension

which is sudden change in blood pressure by changing position. In

your case, this is most likely due to polypharmacy. It is important to

change them or reduce the medications.

o I would refer you to the fall clinic where you will be seen by MDT and

assessment team.

o Investigations: FBE, UEC, Ct scan, MSU, LFTs, ECG, etc..

o Your BP will be monitored regularly.

o Refer to ophtha and ENT for vision and hearing tests.

o Occupational therapists

o Physiotherapist (strenghtening exercises)

o Social worker (financial, meals-on-wheels)

o Admit and refer to falls clinic.

03 neurology (22)

Documents

o task history

o treatment

hyponatremia delirium

acute attack rest

post surgery delirium

delirium digoxin toxicity

medications mild migraine

atypical abdominal migraine