neurology case based discussion by clare di bona ed registrar dec 2015
DESCRIPTION
Case 1 Continued….. On Examination Afebrile, obs within normal limits Decreased visual field temporal aspect of R eye Tongue deviates to the rightTRANSCRIPT
Neurology Case Based
Discussion
By Clare Di Bona
ED Registrar Dec 2015
Case 1
Presenting Complaint:
59 yo female
Awoke 10/10 frontal headache, constant
Vomiting+++, photophobia++
Headache and vomiting worse on sitting forward
History of Presenting Complaint: recently well, no history of trauma
PMH: MVA chronic back pain. No history of headaches
Regular Medications: panadeine forte, diazepam. NKDA
Case 1 Continued…..
On Examination
Afebrile, obs within normal limits
Decreased visual field temporal aspect of R eye
Tongue deviates to the right
Case 1 Continued….
Based on the history and examination develop a DDx for this patient’s headache.
Describe the differential diagnosis based on the R sided hemianopia.
Describe the differential diagnosis based on the R sided tongue deviation
Framework for DDx of Headache in the ED– Primary Versus Secondary Approach based on the American College of
Emergency Physicians (see Tintinalli textbook ED reg office)
– A Vitamin CDE approach
– Murtagh approach
– No right or wrong choice as long as you keep in mind the most likely, the potentially critical and know the distinguishing features!!
Primary Headaches
– Migraine neuronal dysfunction rather than a vascular aetiology
– Tension headache pericranial muscle tenderness and heightened sensitivity of pain pathways
– Cluster. Pathophysiology unknown. Unilateral orbital, supraorbital, or temporal pain, accompanied by autonomic phenomena. Unilateral autonomic symptoms may include ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion
A Vitamin CDE Approach– Acquired traumatic brain injury
MVA (young) or falls (elderly) is cause.
Primary insult could include intra and extra parenchymal hemorrhages and diffuse axonal injury.
Secondary insult exac by hypotention, hypoxia, fever, seizures.
– Vascular
SAH
Epidural hematoma
Subdural hematoma
CVA
Cavernous sinus thrombosis
AV malformation
Temporal arteritis
Carotid or vertebral artery dissection
A Vitamin CDE Approach
– Inflammatory
Neuralgia, optic neuritis, iritis, sinusitis, otitis media, mastoiditis, temporal arteritis, meningitis
– Trauma/Toxin
Fractures: facial, base of skull
Subdural haemorrhage, epidural haemorrhage
CO poisoning, nitrates, withdrawal
– Autoimmune:
Cerebral vasculitis: giant cell, takayasu, polyarteritis nodosa, Wegner’s
– Metabolic
Hypoxia, hypoglycaemia, hypercapnia, high altitude cerebral oedema
A VITAMIN AB&C Approach
– Infection
Meningitis, encephalitis, abscess, sinusitis, dental, otitis media
– Neoplastic
Primary or secondary
– Congenital
– Degenerative:
Optic Neuritis
– & (and) Other/Idiopathic:
– Glaucoma
Post lumbar puncture
– Endocrine/Electrical
phaeochromocytoma
What is the significance of a temporal hemianopia?– See Ganong’s Review of Medical Physiology page 185 Figure 12-4
– GO BACK TO THE PATIENT AND RE-EXAMINE!! A single sided temporal loss of visual field doesn’t really fit!
What is the significance of the tongue deviation?
Hypoglossal muscle provides motor supply to the muscles of the tongue
If the tongue deviates to a side it suggests weakening of the muscle on that side
Patient update
– After presenting this case to the ED consultant the signs could indicate the pathology was located in the middle cranial fossa ?venous sinus thrombosis ?CVA or SOL
– Head CT with contrast was normal and she was admitted for consideration of MRI
– Gen Med reg presented their patient to the consultant as having no neurology DDx viral meningitis or SDH (meant SAH). LP was NAD and the patient was discharged.