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Phase 2a Kaveesha Rajapaksa Ryad Chebbout

Neurology. Phase 2a Kaveesha Rajapaksa Ryad Chebbout. The Peer Teaching Society is not liable for false or misleading information…. Aims. Headache Weakness/Collapse Neurosurgical Emergencies. The Peer Teaching Society is not liable for false or misleading information…. GCS.

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Phase 2a Kaveesha Rajapaksa Ryad Chebbout

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  1. Neurology Phase 2a KaveeshaRajapaksa RyadChebbout The Peer Teaching Society is not liable for false or misleading information…

  2. Aims • Headache • Weakness/Collapse • Neurosurgical Emergencies The Peer Teaching Society is not liable for false or misleading information…

  3. GCS The Peer Teaching Society is not liable for false or misleading information…

  4. Fred 27 year old gentleman, mechanic, lives with parents, smoker, T1DM. 1 day hx headache, feeling hot and sweaty. What else do we need to know? Differential? The Peer Teaching Society is not liable for false or misleading information…

  5. Meningism Symptom Triad: • Headache • Nuchal Rigidity • Photophobia Differential? The Peer Teaching Society is not liable for false or misleading information…

  6. Meningism Signs Triad: • Kernigs– hip flexion and knee extension = pain • Brudzinski – lift head off couch = involuntary lifting of legs • Nuchal Rigidity – inability to flex neck forward The Peer Teaching Society is not liable for false or misleading information…

  7. Meningitis • Meningococcus, Pneumococcus (Listeria, CMV, H.influenzae) • IV/IM Benzylpenicillin • FBC, U&E, LFT, Coag, Glu • Blood Culture • LP +/- CT • Dexamethasone IV + Cefotaxime IV +/- Ampcillin IV +/- Acyclovir IV • Rifampicin Prophylaxis • Sepsis, DIC, Seizures, Coma The Peer Teaching Society is not liable for false or misleading information…

  8. Meningococcal Septicaemia • Petechial Rash + Sepsis (cold peripheries, Decreased CRT, Hypotensive, Tachycardic • No LP • Cefotaxime IV • ICU The Peer Teaching Society is not liable for false or misleading information…

  9. Fred Further questioning revealed that Fred had been forgetting things recently, wandering off, acting inappropriately and been drowsy. Cause? The Peer Teaching Society is not liable for false or misleading information…

  10. Encephalitis • Infectious Prodrome = Fever +/- Rash +/- Lymphadenopathy +/- Cold Sores +/- Conjunctivitis • Bizarre Behaviour, Decreased GCS, Headache, Seizure • Viral (HSV-1/2, Bacterial Meningitis, TB, Malaria) • Immediate Acyclovir IV • Bloods, Blood Cul., Viral PCR, CT Head, LP (viral PCR) The Peer Teaching Society is not liable for false or misleading information…

  11. Subarachnoid Haemorrhage • Berry Aneurysm, Arterio-Venous Malformations • RF: Smoking, HTN, Bleeding Disorders • Causes of Berry Aneurysm? • Occipital ‘thunderclap’ Headache • Decreased GCS (drowsiness, coma) • Focal Neurology (PCOM = CNIII) • CT - not always seen • LP – xanthochromia > 12hr after onset The Peer Teaching Society is not liable for false or misleading information…

  12. Subarachnoid Haemorrhage • Neurosurgery • Nimodipine • Ct Angio • Coiling/ Clipping/ Stent/ Balloon Remodeling The Peer Teaching Society is not liable for false or misleading information…

  13. Margaret 54 year old lady, 1/52 hx headache, worse in morning and coughing, vomited this morning. Retired, lives alone. On examination find hard, fixed, 5x5cm lump in rt breast, and right axillary lymphadenopathy. What has happened? The Peer Teaching Society is not liable for false or misleading information…

  14. Raised ICP Causes? Other Sym/Sig? The Peer Teaching Society is not liable for false or misleading information…

  15. Raised ICP • Papilloedema • Decreased GCS, Pupillary Changes, Seizures, Focal Neurology, VI Nerve • CT +/- LP • LP = Opening Pressure (normal < 15mmHg) • Neurosurgical • Dexamethasone (tumour) • Mannitol The Peer Teaching Society is not liable for false or misleading information…

  16. Patrick 52 yr old gentleman, banker, non-smoker, lives with wife and child. 1/52 hx headache, severe. No neck stiffness, no photophobia, no fever, worse towards end of day, no vomiting, no focal neurology. What else do you want to know? Differential? The Peer Teaching Society is not liable for false or misleading information…

  17. Migraine • Unilateral, throbbing, 4-72hr • Nausea/Vomiting, Photophobia, Phonophobia • Preceded by aura (visual, somatosensory, motor) • Triggers: Choc, Cheese, Alcohol, Exercise • Acute: NSAID/Triptan • Prev: Propanolol The Peer Teaching Society is not liable for false or misleading information…

  18. Cluster Headache • Rapid onset, severe, around one eye • Miosis, Lacrimation, Injection, Rhinorrhoea, Ptosis • 15-160min, 1/2 x Day, 4-12wks, pain-free months/years • RF: Male, Smoker • Acute: O2, Triptan The Peer Teaching Society is not liable for false or misleading information…

  19. Tension Headache • Severe? • Gradual Onset • Band-Like • Every Day, Chronic • Bilateral The Peer Teaching Society is not liable for false or misleading information…

  20. Trigeminal Neuralgia • Recurrent, Sharp, Stabbing, Unilateral • Mandibular/Maxillary Distribution • Tic Doloureux • Trigg: Eating, Washing, Shaving • Primary or Secondary (Aneurysm, Tumour, MS) • MRI • Carbamazepine/Lamotrigine The Peer Teaching Society is not liable for false or misleading information…

  21. Giant Cell Arteritis • >50yrs, Subacute onset (~2wk) • Headache, Scalp Tenderness, Jaw Claudication (pain in jaw whilst eating), AmaurosisFugax • ESR • Prednisolone PO • Temporal Artery Biopsy • Polymyalgia Rheumatica • Aching/Tenderness/Stiffness • Bilateral • Shoulders/Proximal Limb The Peer Teaching Society is not liable for false or misleading information…

  22. Headache Summary • Meningitis • SAH • Encephalitis • SOL/Raised ICP • Migraine • Cluster • Tension • Trigeminal Neuralgia • GCA Others: • Medication Overuse • Glaucoma • Dental Abscess • Sinusitis • Chronic Subdural Haematoma • Trauma The Peer Teaching Society is not liable for false or misleading information…

  23. James 77 year old retired miner, Hx of drooping right face while making breakfast; awake but not responsive to wife, followed by slumping to his right and falling of his chair. PMH: AF, angina, MI 5 years ago, High BP and cholesterol DH: Aspirin, Simvastatin, Ramipril, Bendroflumethiazide, etc etc. Smoker: 20 a day for 61 years. Drinks 3 pints of beer every week The Peer Teaching Society is not liable for false or misleading information…

  24. James Any more you would like to know? Why was he unresponsive? Why did he fall down? What is the DDx (and the difference)? How many risk factors can you identify? Whats missing? The Peer Teaching Society is not liable for false or misleading information…

  25. Pathophysiology of Stroke 2 Mechanisms: ischaemic & haemorrhagic Ischaemic: Thrombus (Atherosclerosis) Artery stenosis Dissection (Major cause in under 40’s): Symptoms? Embolic Hypoperfusion (Anaemia, shock, watershed) The Peer Teaching Society is not liable for false or misleading information…

  26. Anatomy Recap The Peer Teaching Society is not liable for false or misleading information…

  27. Classification of Stroke TACS (Total) – Motor and Sensory +Hemianopia + Higher cortical dysfunction PACS (Partial) – 2/3 of the above or Higher cortical dysfunction alone LACS (Lacunar) – Usually pure motor or pure sensory POCS (Posterior) – Hemianopia, cerebellar, nystagmus, cranial nerve with contralateral motor or sensory problem What is Higher Cortical dysfunction? The Peer Teaching Society is not liable for false or misleading information…

  28. James On examination – Weakness of right arm and leg is 3/5, brisk reflexes, extensor plantars, cranial nerves grossly intact, has receptive dysphasia What stroke syndrome does he have? What is the initial investigation? (Specific) Further investigations? The Peer Teaching Society is not liable for false or misleading information…

  29. Treatment ABCDE Oxygen if Sats below 95% Alteplase if Ischaemic and TPA not contraindicated. If TPA contraindicated, then Aspirin Contraindications – Stroke or MI in the past 3 months Any major bleeds or Surgery recently Low platelets or been on warfarin for long (INR >1.7) Pregnancy The Peer Teaching Society is not liable for false or misleading information…

  30. Post Stroke Management Investigations such as carotid doppler or MR angiography Long term medical therapy – Aspirin and Clopidogrel, Antihypertensive, Heparin/Warfarin if AF Rehab – Physio, OT, SALT The Peer Teaching Society is not liable for false or misleading information…

  31. TIA Difference? Example? Classic DDx to TIA? Stroke Risk prediction tool? Investigations? Management? The Peer Teaching Society is not liable for false or misleading information…

  32. Natasha A 15 year old was hit on the left temple with a baseball and he became unconscious. After about ten minutes, he regained consciousness, but he soon became lethargic, and over the next two hours, he was stuporous. His left pupil was fixed and dilated an was becoming increasingly SOB. DDx? The Peer Teaching Society is not liable for false or misleading information…

  33. Extradural Haematoma Cause? Pathophysiology of the disease? Investigations? The Peer Teaching Society is not liable for false or misleading information…

  34. Treatment Neurosurgery – Decompressive craniotomy The Peer Teaching Society is not liable for false or misleading information…

  35. Derek 72 year old presents with gradually increasing confusion over 3/7, headache which is worse on lying down, and right sided weakness PMH: Fall 2 weeks ago, Previous TIA 7 years ago DH: Aspirin SH: Non-Smoker, Drinks 15 pints over the weekend Diagnosis? The Peer Teaching Society is not liable for false or misleading information…

  36. Subdural Haematoma Pathophysiology? Can you identify the risk factors in the history? Why is the course different to EDH? The Peer Teaching Society is not liable for false or misleading information…

  37. Treatment Watchful waiting Neurosurgery if required The Peer Teaching Society is not liable for false or misleading information…

  38. Daphne 83 yr old lady, known colon cancer, chemotherapy. Complains of sudden onset back pain and inability to walk. Examination reveals: • Weak Legs • Flaccid Legs with reduced reflexes • Sensation Loss below L1 • Loss of Anal Tone What’s going on? Causes? The Peer Teaching Society is not liable for false or misleading information…

  39. Spinal Cord Compression • Malignancy, Infection (abscess), Trauma • Back Pain • Bilateral Radicular Pain, LMN Signs at Level of Compression, UMN Signs and Sensory Loss Below, Sphincter Disturbance • Acute: Tone and Reflexes Reduced The Peer Teaching Society is not liable for false or misleading information…

  40. Cauda Equina Syndrome • Lesions at or below L1 • Lumbosacral Pain (early) • Flaccid, Areflexic, Often Asymmetric Paraparesis • Saddle Anaethesia • Bladder/Bowel Dysfunction (late) Is it UMN or LMN? The Peer Teaching Society is not liable for false or misleading information…

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