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SPECIALTIES ZOOM – LECTURES NEUROLOGY – INTRO & HEADACHES: Primary headaches – migraine, tension, trigeminal autonomic cephalgia’s (TACs), cluster headache (vv bad & Px can be very distressed) Tension: Acute Tension type: simple pain killers – NSAID / paracetamol / aspirin. Chronic Tension type: biofeedback - can reduce the m. tension and allow reduction in pain Migraine:  At least 5 attacks; lasting 4-72hr. (sometimes lasting 15 days / month from prodromal to postdromal)  Unilateral location, pulsating, Mod-severe pain intensity  Symptoms: Nausea, vom, photophobia, phonophobia  Shouldn’t be attributable to another disorder.  More female Px than male. (15-50 yr): oestrogen level fluctuation linked to it. o Take mini pill, IUD – hope they don’t take combined pill. Triggers:  Stress; post exam  Hunger / dehydration / sleep disturbance / diet  Env stimuli / exercise amount (should do more) PREDROMAL = Mood changes, fatigue, food craving, m. pain AURA: neurological symptoms before headache kicks in i.e. visual disturbances from cortical spreading depression. This can go across the cortex; can effect the motor cortex = m. cramping – there is vasoC in the brain; this is bad as some migraine medication causes vasoC; which can be v bad for Px & makes aura worse HEADACHE – dull & nasal congestion. ADVANCED HEADACHE = unilateral , throbbing, nausea, photophobia, phonophobia, osmophobia POST-DROMAL = fatigue, cognitive changes, m. pain Aura Vs Stroke:  Spread of symptoms  age / PMHx  Type of deficit  symptoms evolve in migraine patients & gradual. Stroke = all symptoms come on at once  Positive symptoms with aura  stroke Px LOSE visuals & numbness, Migraine = tingling, pins & needles sensations, flashing lights in visuals Chronic Migraine = when there is >15 days/ month with it. Give Antimigraine tablets  Amitriptyline 100-150mg  Propranolol 80-240mg  Topiramate 25mg-100mg Start on lowest dose & increase the dose up slowly to max dose for 2 months & keep on for 6-12months & then wean off meds  if Px doesn’t respond after 2 months switch to the others on the list. – keep a headache diary too. Greater occipital N Block: for migraine; local anaesthetic – keeps Px pain free between 6w-3m and can do x4/yr Botox for chronic migraine: inhibit the release of peripheral nociceptive NT, reduces no. headaches/month. Have to have failed on 3 preventers Nerve Stimulation: electric shocks, can reduce the aura (cortical spreading depression), can work for migraine without aura too. Pain free with no recurrence of migraine Gamma core – vagal N stimulator – more for cluster headache (however v. expensive) Supra-orbital stimulator: cheaper, Px with at least 2 attacks/month  used as a preventer AND acute setting 1

SPECIALTIES ZOOM – LECTURES Erenumab: (CGRP hormone increased in the blood when migraine would take place) – drug is CGRP pathway monoclonal Ab – can help reduce the no. of headache days. Trigeminal autonomic Cephalgia’s (TACs) Features: unilateral, autonomic features – ptosis, conjunctival injection, lacrimation, nasal congestion rhinorrhoea, restlessness, severe pain. Depending on the headache, will depend on treatment. Cluster headaches: most people have.  ACUTE TREATMENT: sumatriptan, high flow Oxy (100% in oxy mask), N. blocks. o few times a year; comes & goes but is bad  PREVENTION: verapamil, Topiramate, Li o Preventors have big SE, need to monitor freq. & do ECGs Secondary Headache Disorders: Secondary – head & neck trauma, Cranial / cervical disorder / infection / psychiatric disorder High temp, feeling unwell; may be infection meningitis / inflammation. Do a scan of Px Reduced Glasgow coma scale – sometime scan Px If headache comes on within 5 mins = thunderclap; NEED TO SCAN TO FIND THE BLEED. – do lumbar puncture Tumor look at - will need to give steroids because at risk of sight loss. Need to treat aggressively to prevent eyesight loss. Thunderclap headache:  NEED TO EXCLUDE A BLEED: subarachnoid haemorrhage  Worst headache & need scan & lumbar puncture  Likelihood of SAH: female, seizures, vomiting, LOC, focal neurology Not all are brain bleeds:  Intracerebral / subarachnoid haemorrhage  Cerebral venous sinus thrombosis / acute HTN / Reversible Cerebral vasoconstrictive syndrome. Meningitis:  Bacterial – meningococcal meningitis  Viral - (don’t need to treat, just lumbar puncture)  Fungal  Rickettsia Always treat like it’s a bacterial meningitis unless proven otherwise.  Rach on eye / skin  Kernig sign +ve sign when pain limits passive extension of knee  Brudzinski sign - +ve sign when flexion of neck = involuntary flex of knee & hip  Lumbar puncture – see if WCC elevated  ECG, CT, MRI 2

SPECIALTIES ZOOM – LECTURES Treatment - AB Cervical artery dissection:  Symptoms – thunderclap headache.  From hyperextension of the neck. – vertebral artery  Normally ataxic gait  Horner’s syndrome signs; constriction of pupil, ptosis drooping of upper eyelid) – due to damage to the sympathetic N of faces. Brain tumour:  2 unprovoked seizure 24hr apart  unprovoked seizure with >60% chance of having another one within 10 years (having LD or EEG shows increase risk) Pathophysiology:  Normally : inhibitory & excitatory systems in brain = balanced  When normal balance = disrupted, neurons become HYPEREXCITABLE  loss of inhibition & increased excitation  increasing risk of seizure activity  Childhood = genetic disorders develop / show & trauma increase risk  Later in life = structural changes – falls / strokes Classification:  Primary - genetic / idiopathic o Onset in childhood, good response to AEDs o ‘normal brain’, favourable prognosis  Secondary – symptomatic / metabolic / structural conditions o Onset in any age, variable response to AEDs o Brian pathology & variable prognosis  Focal-onset seizure: o Originate within networks of ONE HEMISPHERE of brain o Localised OR widely distributed o Preserved Awareness - observable motor or autonomic components involving subjective sensory / psychic phenomena. Focal tonic movements of limb / grimacing / contraversive movements / visual impairment / twitching of face – all depends where the focal point is. o Impaired awareness. Dyscognitive. –  Impairment of consciousness / awareness  Not the whole brain having epileptic focus; but 2 parts of hemispheres can be effected. o Evolve to bilateral , convulsive seizures  Generalised onset: o Originate at some point within & rapidly engage bilaterally distributed networks o Include cortical & subcortical structures but do not necessarily include entire cortex o GENERALISED Tonic-CLONIC seizures:  Starts with sudden LOC & generalised stiffening of body (tonic phase) followed by m. contraction (clonic phase)  Burst of generalised polyspike wave discharge  then rhymical generalised alpha freq  repetitive polyspike wave complexes o Absence - typical absence, atypical absence. 3

SPECIALTIES ZOOM – LECTURES  Usually present during childhood / adolescence  LOC 3-15s, including brief staring spells and / or eyelid flutter  Undetected  Normal 3-Hz spike wave discharge o Myoclonic:  Adolescence, persisting throughout adulthood  Sudden, brief arrhythmic jerks of arms & extremities  Single or multiple jerks  Associated with fall & no LOC  Often early in morning / after awakening.  Seizures may be triggered by photic / sensory stimulation / sleep deprivation.  sleep deprive patients or light effect  ECG trace shows diffuse bursts of polymorphic spike / poly spike-and wave discharges followed by voltage attenuation o Atonic  Unknown: Common behaviours during / after seizure: Aphasia, memory impairment, anxiety, fear, crying, auditory change, dystonic, aggression, eye-blinking, dysphasia Anti-epileptic drugs:  Complete seizure freedom  Well tolerated  SE (acute dose related toxicity) idiosyncratic (rash), chronic(bone health / osteoporosis)  Minimal interactions & easy use AED – generalised tonic-clonic seizures: 1. Lamotrigine / Levetiracetam / Sodium Valproate 2. Lacosamide AED Focal Seizures: 1. Lamotrigine / Levetiracetam / Carbamazepine 2. Lacosamide AED Absence Seizure: 1. Sodium Valproate / Ethosuximide 2. Lamotrogine Refractory epilepsy: when a first drug has not provided control  add additional AED / substitute; this may increase tolerability & reduce SE. Breakthrough seizures to prevent (add another before taking another away) – add-ons atm are quite good. Acute management: Symptoms prior to seizure:  AURA: altered sensations, involuntary movements, visual / auditory hallucinations  Sleep deprivation / alcohol / drug intake / flashing lights  Headache, nausea, vom, limb weakness  Differentials ; chest-pain, palpitation, syncope, dizziness During the seizure:  Unless a focal seizure, patient unable to collateral history  Collapse, LOC  Lack of movement / muscle tone / motor activity starting 1 side  M. stiffening, rhythmic jerking of limbs  Head / eyes deviating  Automatism – lip smacking, blinking  Tongue biting; middle of tongue = classic sign 4

SPECIALTIES ZOOM – LECTURES  Incontinence  Duration of event – anything...