cases for finals and beyond: nervous system 1 st october 2012 alastair brown st1 neurosurgery
TRANSCRIPT
Cases for Finals and Beyond: Nervous System
1st October 2012
Alastair Brown ST1 Neurosurgery
Objectives
Describe 3 common clinical scenarios Understand the relevant signs and symptoms of
common neurological conditions. Understand how to decribe gait patterns in
common neurological conditions Understand the investigations and management Be aware of common sequelae of certain
neurological conditions and their management.
Case 1
FY1 covering the COTE Ward on Night Asked to see Mr Williams
84 year old manHas had a fall on the ward Is confusedNot sure if he has injured himself
On the Phone
What things are you going to ask the nurse to do while you are on your way?Get patient back to bed safelyGet a set of observations (inc neuro
observations)Find notes and drug chartConsider asking for and ECG
On the Ward
What are your three priorities with this patient?
1) Identify any injuries2) Identify cause of the fall3) Try to prevent/limit impact of further falls
What are you going to do next? Take a history Examine patient (General, MSK and Neuro)
On the Ward
Drug chart is in pharmacy Nurse looking after the patient is a bank
nurse and does not know much about him. Thinks he is normally confused Fall was unwitnessed Patient just says don’t know to all
questions.
Examination
General and MSK examination unremarkable with no evidence of external injury.
CNS Cranial nerves unremarkable. PEARL Following commands appropriately
PNS - Inspection:
PNS: Inspection
Describe the face of the patient you saw.ExpressionlessMasked
Describe the movement of the hand you saw.Resting tremor of the left hand Improves following purposeful movement
PNS Tone
PNS: Tone
Describe what you saw Intermittent resistance to passive flexion of the upper limbs.
What is this pattern of rigidity called? Cog wheel rigidity
What condition is this pattern of rigidity associated with? Parkinson’s disease
Can you name another pattern of rigidity seen in the same condition? Lead-pipe rigidity
PNS: Gait
PNS: Gait
Describe the person’s gait No aids Slow Stooped Slow turning Small steps Shuffling Tremor in hands Festinating Would also like to see them stand and sit
What condition is the gait pattern typical of? Parkinson’s disease
Parkinson’s Disease: Features
What are the main pathological features in Parkinson’s disease? Loss of Dopaminergic neurons in the substantia nigra Formation of Lewy bodies.
What are the three cardinal features of Parkinsons disease? Tremor Rigidity Bradykinesia
Parkinson’s Disease: Diagnosis
What investigations are used to diagnose PD? Generally a clinical diagnosis MRI and SPECT can be used but this is rare Trial of treatment often helps to make diagnosis.
Can you name three differential diagnoses for PD Lewy Body dementia Drug – induced parkinsonism Vascular dementia Wilson’s disease in young patients
Parkinson’s disease: Treatment
What is the main treatment of Parkinson’s disease? Levodopa treatment Coupled with Carbidopa to reduce peripheral release
and achieve higher CNS concentration with fewer systemic side effects.
Are you aware of any emerging treatments? Deep brain stimulation (normally of Subthalamic
nucleus)
Parkinson’s: Prognosis and Complications What is the course of Parkinson’s disease?
Progressive condition
What later complications are commonly seen? Postural imbalance Dementia Swallowing difficulties Autonomic dysfunction
Case 2
You are an FY2 in A+E Asked to go to resus to see a patient who
has been brought in with seizures.Name: Ethel O’DonohueFive minute seizure terminated after some PR
Diazepam72 year old femalePMH: Unknown
How are you going to approach this patient? A – Patent and protected B – Sats 100% on 15L Chest clear C – HR 110 reg CRT < 2 secs BP155/60 D – E3V2M4 BM 14.1 Pupils equal and
reactive. Not moving left side. E – Ulcers on left leg, Median sternotomy
scar, no evidence of any external injury.
What investigations are you going to arrange? Bloods
FBC, U+E, , LFTs, CRP, Mg, Clotting ABG
Bedside Tests ECG Urine Dip
Radiology ? CXR ? CT head
Results
Bloods CRP – 54 Otherwise unremarkable ABG:
pH – 7.29 pO2: 54.3, pCO2: 4.9 BE: -12.4 Lactate: 6.4 What does this show?
Metabolic acidosis What is the likely cause?
Seizure
While you are waiting…
Patient starts to have another seizure. First you notice shaking of the left arm and leg Patient then stops responding Then starts to have full tonic-clonic seizure.
What are three steps in the seizure described. Partial seizure Initially simple then becomes complex Secondary generalisation.
Cont…
What is the definition of status epilepticus? One seizure > 30 minutes or multiple seizures without
regaining consciousness for over 30 minutes. What is the emergency management of status?
A,B,C Call for Help IV Lorazepam Phenytoin infusion Sedation Barbituate coma
CXRCan you describe this radigraph?
Adequate technical film
Normal lung appearances.
CT HeadCan you describe the CT scan?
-Hypo-intense area in the right hemisphere seen on multiple slices of CT no evidence of midline shift
What is the most likely cause for these findings?
-Stroke
What vascular territory has been affected?
Right MCA
PNS: Inspection
What comments can you make about this gentleman’s posture? Flexed elbows Flexed wrist Flexed digits Inversion of left foot
What is the posture typical of? Spastic paralysis
Would this be typical of an acute stroke? No, spasticity develop over weeks
to months. What would you expect to find
examining his reflexes? Hyperreflexic
PNS: Tone
PNS: Tone
What is the pattern of rigidity seen?Clasp knife rigidity.
What conditions is this pattern of rigidity seen in?Upper motor neurone lesions
PNS: Gait
PNS: Gait
Can you describe this person’s gait?No aidsReasonable speechSpastic postureHip hitching of right legCircumduction of right leg
What is this pattern of Gait called?Hemiplegic gait.
CNS and Remaining PNS
Sensation – normal Power 1/5 on left and 5/5 on right CNS unremarkable. How do you grade power?
0 – No movement1 – Flicker of movement2 – Can move a joint with gravity eliminated3 – Can move a joint against gravity4 – Reduced from normal power5 – Normal power
Stroke
How would you define stroke? Sudden loss of circulation to an area of brain resulting
in a corresponding neurological deficit that persists for more than 24 hours.
What would your differentials include? Todd’s paresis Intracranial haemorrhage SOL Previous neurosurgery
Stroke: Investigation and Diagnosis
What risk factors are you aware of for stroke? Vascular risk factors (smoking, diabetes, hypertension, age) Previous stroke AF Thrombophilias
How would you investigate someone you believed may have had a stroke? History and examination CT/MRI ECHO ECG Carotid dopplers
Stroke: Management
What treatments can be given in acute stroke? Aspirin Thrombolysis (currently within 3 hours of onset)
What other treatments can be given in the longer term to reduce the risk Modification of vascular risk factors (Statin, smoking cessation, etc) Warfarin if patient has AF Carotid endarterectomy.
What are the other components of stroke patient management? PT/OT- rehabilitation SALT to assess swallowing
Case 3
You are an FY1 in acute medicine 27 year old female Presents with vision problems for last 3 days Complaining of blurry and double vision and pain
on looking around Mother has noticed has been quite clumsy Normally fit and well.
CN II
Visual acuity L Eye 6/4.5 R Eye 6/12
Which eye has better vision? L eye
Which fundus is normal? b)
What is the abnormality seen in a) Swollen optic disc
What is the likely diagnosis? Optic neuritis
a)
b)
CNS: III,IV,VI
What eye disorder is shown here? Internuclear
opthalmoplegia Which eye is
affected? Right eye
Which neurological structure is involved? Medial longitudinal
fasciculus
Right
Left
Convergence
PNS: Coordination
PNS: Coordination
What sign is being demonstrated in this patients left arm? Intention tremor
Which hemisphere of which part of the brain is not working L cerebellar hemisphere
What other signs would you test for in this patient? Dysdiadochokineses Past pointing Romberg’s test.
PNS: Gait
PNS: Gait
Describe this patient’s gait. No aids Normal walking speed Poor balance Broad based gait Unsteady
What is the name for this gait pattern? Ataxic gait
What dysfunction is this gait pattern normally due to? Cerebellar dysfunction
Case 3 Cont …
What is the likely diagnosis?Multiple sclerosis
What would be your differential diagnosis?Space occupying lesionOther inflammatory CNS conditions
(vasculitis, sarcoidosis etc.)Clinically isolated syndrome
Multiple sclerosis: Background
What is your understanding of Multiple sclerosis? Immuno-mediated demyelinating disease of the
central nervous system.
What patterns of disease are you aware of? Relapsing-remitting Primary progressive Secondary progressive
MS: Diagnosis and Investigation
How would you investigate this patient? Bloods
Routine Auto-antibodies Infectious serology (Lyme, VDRL) Vitamin B12
MRI CSF – Oligoclonal bands and IgG Visual and Somatosensory evoked potentials
MRI – Of Patient with MS
MS: Treatment
What treatments are used in the acute treatment of MS?MethylprednisolonePlasma exchange
What treatments are used in the long-term management of MS: InterferonOther immunomodulatory drugs
Objectives
Describe 3 common clinical scenarios Understand the relevant signs and symptoms of
common neurological conditions. Understand how to decribe gait patterns in
common neurological conditions Understand the investigations and management Be aware of common sequelae of certain
neurological conditions and their management.
