PACS Either: or: or: LACS POCS Any of: 2 Bamford, J. et al. Lancet 1991 337:1521 (subscription required). 3 Loss of vision on the same side in both eyes (b p133). 4 Includes dysphasia, visuospatial problems, dGCS. Prognosis LACS, PACS, and POCS have a similar prognosis with 15% mortality by 1yr while 60% live independently; TACS carries a 1yr mortality of 60% with only 5% living independently. Investigations blds FBC, U+E, LFT, glucose, lipids, clotting; ECG; CXR; CT head: urgent if within thrombolysis window, GCS persistently low, on oral anticoagulants/known bleeding di sorder, severe headache at onset of stroke or evidence of iICP; otherwise within 24h. Anter ior circulation strokes also require echo, carotid Doppler and 24h ECG. Treatment see emerg ency treatment b p350; if the patient is a candidate for thrombolysis,5 move fast to ensure timely treatment. Otherwise, aspirin 300mg/24h PO/PR for 14d (provided no hemorrhage on CT ). Assess safety of swallow (b p352); if concerns, keep NBM+IV fl uids and request SALT ass essment. Monitor BP, but do not try to lower BP without discussing with a senior (b p264). Do not use LMWH in acute setting with haemor- rhagic or ischaemic strokes (risk of haemorrh agic transformation). Do not prescribe TEDS (high risk of pressure ulcers). Admit to stroke ward for early mobilization and rehabilitation with multidisciplinary team. Complications aspiration pneumonia, dependent lifestyle, further CVA. 1 NICE guidelines available at (cid :27)guidance.nice.org.uk/CG68 5 See Consider thrombolysis box and resources from the inte rnational stroke trial collabora- tors, available free at (cid:27)www.dcn.ed.ac.uk/ist3 _OHFP.indb 351 _OHFP.indb 351 30/05/2014 16:18 30/05/2014 16:18 352 CHAPTER 11 Neurology and psychiatry Transient ischaemic attack (TIA) A transient episode of neurological dysfunction caused by focal brain ischaemia without infarction. Symptoms typically last less than an hour, but pr olonged episodes can occur. Symptoms/signs as for stroke but resolve completely (though cla ssical defi nitions of TIA describe resolution within 24h, there is no precise time cutoff to distinguish ischaemia from infarction); note that a transient loss of consciousness, or \200\230dizzy turns \200\231 are unlikely to represent a TIA. Management if <3h since symp toms began see b p350; use ABCD2 score to estimate risk of stroke (see Table 11.6) start as pirin 300mg/24h PO. Table 11.6 ABCD2 score to calculate 7d stroke risk1 Age BP Clinical features Unilateral wea kness 1 point \211 60yr Systolic >140mmHg and/or diastolic \211 90mmHg 1 point 2 points 1 point 0 points 2 points 1 point 0 points 1 point Speech disturbance without weakness Other signs \211 60min 10 \200\22359min <10min Yes 7d risk 1.2% 5.9% 11.7% Duration Diabetes Total Score 0 \200\2233 4 \200\2235 6 \200\2237 Management Urgent out-patient \200\230TIA clinic \200\231 follow-up (1wk) Discuss with str oke physician \200\223 likely to need admission for urgent investigation 1 Johnston, S.C. et al. Lancet 2007 369:283 (subscription required). CVA prevention the risk of further events after TIA or stroke can be reduced with close att ention to risk factors. Medical management includes control of BP, cholesterol, and glycaem ia. Antiplatelet therapy options include clopidogrel 75mg/24h PO, aspirin 75mg/24h and dipy ridamole MR 200mg/12h PO: Current health-economic modeling favors the use of clopidogrel fo r those who have had a stroke, and aspirin/dipyridamole combination therapy after a TIA.2 E ncourage smoking cessation, healthy diet and moderate exercise. Carotid endarterectomy shou ld be considered within 2wk if symptomatic carotid stenosis >70%. Safe to swallow? For any patient with dGCS or a suspected neurological disability, perform a simple test of a patient \200\231s safety to swallow by watching the patient attempt to d rink 30ml of water while seated in an upright position. Monitor for: \200 Delayed swallow ing (>2s to initiate swallow) \200 Drooling \200 Cough during or within 1min of swallow ing \200 Dysphonia/ \200\230wet voice \200\231 after swallowing. If any of these features are present, keep NBM+IV fl uids and request a SALT assessment. 2 NICE interpretation of study data; see (cid:27)guidance.nice.org.uk/TA210 OHFP.indb 352 OHFP.indb 352 30/05/2014 16:18 30/05/2014 16:18 353 FOCAL NEUROLOGY Focal neurology Worrying features dHR, i/dBP, dGCS, severe headache, pyrexia, neck stiff ness, photophobia, vomiting, papilloedema. Think about try to establish an anatomical pattern to abnormalities that will narrow the di ff erential diagnosis (see Table 11.7 b p354). Ask about motor problems (weakness, gait disturbance); sensory disturbance (tingling, pain, numbness); features of cerebellar disease (clumsiness, dysphasia, gait disturbance); sympt oms of cranial nerve and cerebrum involvement (double vision, blurred vision, vertigo, hear ing loss, dysphasia, facial droop); establish speed of onset and signs of underlying diseas e (weight loss, fever, cough, photophobia, neck stiff ness, rashes, behavioral change) or i ICP (headache, nausea, morning vomiting); PMH previous neurology, migraines, epilepsy, eye problems, recent infections, iBP, irregular heart, DM, psychiatric disorder DH focus to sym ptom pattern (eg if peripheral neuropathy, ask about isoniazid, metronidazole) SH alcohol, recreational drugs; FH nerve or muscle problems. Obs BP, HR, GCS (see b p338 if d), glucose . Look for perform a complete neuro exam (b p132) including cerebellar signs; CVS exam for AF and carotid bruit. Investigations these should be determined by the location of the lesion determined by clini cal examination. blds FBC, U+E, Ca2+, glucose, ESR, CRP, autoantibodies; EMG and nerve cond uction studies can help peripheral neuropathy or myopathy; CT/MRI imaging and LP. Urgent CT brainstem or cerebral (lateralising) signs, persistent dGCS, sus- pected subarach noid hemorrhage (b p360), head injury (b p438). Lesion location your aim is to determine which region of the nervous system is aff ected to help target further investigation and aid diagnosis. With motor symptoms there are three m ain areas: \200 Lower motor neuron (LMN) peripheral nervous system; wasting, fasciculatio ns, reduced refl exes and tone, forehead involved if CN VII \200 Upper motor neuron (UMN) central nervous system; increased tone and refl exes with upgoing plantars, if facial weak ness forehead spared \200 Mixed consider motor neuron disease, multiple sclerosis, spinal cord compression (LMN signs at level of compression, UMN signs below), Friedreich \200\231 s ataxia (UMN weakness with absent ankle and knee jerks), syphilis (taboparesis), subacute combined degeneration of the cord. Sensory loss may map to a particular nerve, a nerve root (dermatome), or aff ect one side o f the body up to the level of a signifi cant lesion within the brain or spinal cord (sensor y level). Alternatively, loss may be bilateral and distal ( \200\230glove and stocking \200 \231) suggesting peripheral neuropathy (eg DM). The combination of the anatomical pattern, timecourse and associated features should enable you to make a clinical diagnosis for most lesions. _OHFP.indb 353 _OHFP.indb 353 30/05/2014 16:18 30/05/2014 16:18 O O H H F F P P i i n n d d b b 3 3 5 5 4 4 3 5 4 Table 11.7 Guide to localizing neurological lesions C H A P T E R Motor power Sensory Re \202 exes and tone i1 Features Common causes Stroke (b p351), SOL (b p355), migraine Cerebrum Hemiparesis Hemisensory loss Unilateral higher cortical dysfunction (eg dysphasia) hemianopia Ataxia, nystagmus, slu rred speech, intention tremor, past-pointing Cranial nerve defi cit on opposite side to mot or/sensory signs UMN signs below level of cord damage; may see LMN signs at level Shooting, stabbing pain, often worse on postural change or cough May be mononeuropathy (specifi c ne rve) or polyneuropathy (multiple nerves \200\224distal defi cit > proximal) Bilateral; fati gue with repetitive eff ort Acquired form may be painful with iCK 1 1 N e u r o o g y POCS (b p351), SOL (b p355), MS (b p355), alcohol, phenytoin POCS (b p355), SOL (b p355), M S (b p355) Cord compression/central disc herniation (b p357), spinal stenosis (b p448), MS (b p355) Spinal stenosis (b p448); Disc prolapse, cauda equina syndrome (both b p357) Mono: trauma, compression, infl ammation (eg Bell \200\231s palsy b p355); Poly: several (b p355 ) Cerebellum Normal Normal Normal l i Brainstem Hemiparesis Hemisensory loss a n d i below level may be d at level Normal/d Myelopathy (spinal cord damage) Radiculopathy (nerve root damage) Neuropathy Weakness Bilateral weakness (fi tting spinal level) Bilateral paraesthesia (sensory level) p s y c h i a t r y Unilateral weakness (fi tting nerve root) Unilateral paraesthesia or pain (fi ts nerve root) Paraesthesia Normal/d Normal/d Myasthenia gravis (b p355) Lambert- Eaton (paraneoplastic) Hereditary (eg muscular dystroph y); alcohol, infl ammatory (eg polymyositis), statins, dT4 Neuromuscular junction Myopathy Fatigable weakness Normal Normal/d Bilateral weakness (proximal > distal) Normal 1 Acute intracranial pathology may present with d tone and refl exes before the characteris tic UMN signs develop. 3 3 0 0 / / 0 0 5 5 / / 2 2 0 0 1 1 4 4 1 1 6 6 : : 1 1 8 8 355 FOCAL NEUROLOGY Space-occupying lesion (OHCM9 b p502). Causes tumor, aneurysm, abscess, subdural or extradu ral haematoma. Symptoms focal neurology, seizures, behavioral change, early morning headach e, vomiting, visual disturbance. Signs focal neurology, papilloedema. Investigations CT, MR I (brainstem/cerebellum); LP only if no iICP. Treatment for iICP see b p360, surgical remov al of lesion. Spinal stenosis spinal canal narrowing 2 eg osteoarthritis (spondylosis) ca uses radiculopathy or myelopathy; consider decompressive laminectomy. Myasthenia gravis (OH CM9 b p516). Symptoms weakness, diplopia, dysarthria; worse in evening than morning. Signs muscle fatigability, especially on upward gaze, normal refl exes. Investigations blds antib odies to ACh receptor; EMG; Tensilon test (improvement with edrophonium); CT chest (15% w ill have thymoma). Treatment anticholinesterase (eg pyridostigmine), immunosuppression; thy mectomy (even if no thymoma); plasmapheresis in refractory cases. Myasthenic crisis trigger ed by illness, surgery or drugs; severe fatigue may involve the diaphragm causing respirato ry failure requiring ventilation; assess with spirometry (FVC). Requires immunosuppression plasmaphe resis. Bell \200\231s palsy rapid onset mononeuropathy of facial nerve (VII); pr edni- solone (40mg/24h PO) started within 72h reduces symptoms; aciclovir may also help; pr otect aff ected eye (tape closed at night, artifi cial tears and sunglasses). Polyneuropath ies (OHCM9 b p508). Causes acute Guillain \200\223Barr (post-infectious; can rapidly prog ress to respiratory failure; regular spirometry (FVC) to assess; treat with IV immunoglobul ins ventilation if worsening); subacute drugs (eg isoniazid, metronidazole), toxins (eg le ad), nutritional defi ciency (eg vitamin B); chronic malignancy, paraproteinaemia (b p396), connective tissue disease, meta- bolic disorders (eg uraemia, DM, b p328), hypothyroidism (b p334); hereditary eg Charcot \200\223Marie \200\223Tooth. Symptoms/signs may be motor (d istal weakness) and/or sensory (par- aesthesia). Investigations blds FBC, B12, folate, U+E, LFT, glucose, TFT, ESR, serum elec- trophoresis, ANCA, ANA; urine dipstick; CXR; nerve con duction studies. Treatment treat or remove the cause if possible. Complications wounds, ulc ers, joint abnormalities eg Charcot joint. Multiple sclerosis1 (OHCM9 b p500) Infl ammatory , demyelinating disease of the CNS, leading to multiple neurological defi cits separated in time and location. Symptoms patients will present variably with motor (weakness, clumsines s), sensory (visual disturbance, numbness) or autonomic defi cits (incontinence). Signs any focal neurology, including LMN and UMN signs; typically bilat- eral spastic limbs, visual disturbance, internuclear ophthalmoplegia. Investigations areas of infl ammation and demyel ination on MRI; slowed nerve conduction; LP CSF electrophoresis may show oligoclonal bands. Treatment MDT approach to preserve and support function; consider steroids in acute fl are s (avoid >3 courses/year); B-interferon or glati- ramer acetate can reduce relapse frequenc y; antispasmodics (eg baclofen). Complications contractures, pressure ulcers, recurrent UTI s, unsafe swallow. 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG8 _OHFP.indb 355 _OHFP.indb 355 30/05/2014 16:18 30/05/2014 16:18 356 CHAPTER 11 Neurology and psychiatry Back pain (OHGP3 b p484) Worrying features bladder/bowel changes, fever, weight loss, age <20yr or >55yr, steroids, thoracic pain, previous cancer, progressive neurological defi cit, perianal anesthesia, pul satile abdominal mass. Think about serious cord compression, cauda equina syndrome, metastases, myeloma, infection , fracture, aortic aneurysm; common mechanical back pain (see Table 11.8), renal colic. Ask about trauma/lifting (mechanism), location of pain, duration, aggra- vating/relieving fact ors, radiation, pain in joints, pain or tingling in legs, leg weakness, bladder (retention or incontinence), fecal incontinence, altered sensation on passing stool, weight loss; PMH previous back/joint pain, neu- rological problems, osteoporosis, anemia; DH steroids, analg esia; FH joint or back problems; SH occupation (lifting, prolonged sitting). Look for scoli osis, kyphosis, bony or paraspinal tenderness; reduced range of movement (especially fl exi on), pain on straight leg raise (b p149); lower limb neurological defi cit (motor, sensory, refl exes); expansile abdominal mass; PR dtone or sensation (sacral/saddle anesthesia). In vestigations if you suspect mechanical back pain and worrying features are not present, no further investigation required; otherwise consider: blds FBC, ESR, CRP, Ca2+, ALP, PSA; CXR spinal X-ray if post-trauma or risk of pathological fracture; MRI spine: as emergency if cord compression or cauda equina suspected, urgent if suspect malignancy, infection or fra cture, routine if suspect infl ammatory disorder; DEXA.1 Table 11.8 Common causes of back pain History Weakness, numbness ( pain) below lesion, incontinence Leg weakness and pain (often bilateral), urinary and/or fecal incontinence Pain, worse on movement, brought on by lifti ng/trauma \200\230Infl ammatory type \200\231 pain,2 joint pain, no trauma, family history Sudden onset pain in an elderly patient Examination Dermatomal distribution; UMN below lesion, LMN at lesion dperianal sensation, d anal tone, dleg power, sensation and refl exes Investigations Emergency/Urgent MRI to look for lesion Emergency/Urgent MRI to look for les ion 3Cord compression 3Cauda equina syndrome Mechanical back pain Pain reproduced by straight leg raise, unilateral neurology dlumbar fl exion, pain on squee zing pelvis; painful red eye (b p426) Central pain over a discrete vertebrae; reduced ROM Rarely needed; MRI only if considering referral for fusion RhF \200\223ve, iESR, sacroilii tis on X-ray Spondylitis Fracture on X-ray Vertebral (wedge-shaped collapse fracture vertebral body) 2 Pointers to a n infl ammatory etiology include: morning stiff ness, pain that improves with exercise but not rest, alternating buttock pain, nocturnal pain during 2nd half of night on ly. Finding \211 2/4 of these should prompt a search for a spondyloarthropathy (eg ankylos ing spondylitis, reactive arthritis, psoriatic or IBD associated arthritis). 1 See (cid:27)www.sheffi eld.ac.uk/FRAX/ \200\223 a WHO validated tool to assess fracture risk (and need for DEXA or osteoporosis treatment) in those without worrying features (b p437). OHFP.indb 356 OHFP.indb 356 30/05/2014 16:18 30/05/2014 16:18 357 BACK PAIN Mechanical back pain including disc prolapse1,2 Symptoms low back pain, worse on coughing/m oving, may radiate to leg. Signs pain on straight leg raise (b p149), tenderness next to th e verte- brae; radiculopathic pain/numbness; normal sensation and tone on PR. Investigation s MRI spine only if progressive abnormal neurology or fea- tures of cord compression/cauda equina syndrome. See Table 11.9. Treatment early mobilization, avoid lifting, maintain good posture; analgesia (b p86, consider tricyclic or strong opioids if paracetamol, NSAIDs and weak opioid ineff ective); diazepam 2mg/8h PO for muscular spasm; reassess urgently if bil ateral symptoms or urinary/fecal incontinence. Table 11.9 Types of mechanical back pain \200\230Sprain \200\231 Disc prolapse Muscular pain and spasm without neurology \200\230Slipped disc \200\231, may compress the nerve root causing a unilateral radiculopathy (eg sciatica) Degenerative changes of the spi ne eg osteoarthritis Spondylosis Spondylolysis Recurrent stress fracture leading to a defec t (typically in L5) Spondylolisthesis Anterior displacement of a vertebra; may present in y ounger patients; conservative management; spinal fusion if severe Narrowing of the spinal canal eg due to osteoarthritis, causes leg aching and heaviness on walking (spinal claudication) Lumbar spinal stenosis (b p448) 3Cord compression Causes tumor, abscess/TB, trauma, haematoma, central disc prolapse. Sympt oms weakness and/or numbness of legs, continuous/shooting pains, urinary retention or incon tinence, fecal incontinence. Signs LMN signs at the level of the lesion, UMN signs below, n ormal above, sharp boundary of reduced sensation, spinal shock (b p481). Investigations urg ent MRI spine, look for cause. Treatment catheterise; refer immediately to orthopedics/neur osurgeons. Complications weakness, reduced sensation, incontinence, impotence. 3Cauda equin a syndrome Causes central disc prolapse, tumor, abscess/TB, haematoma, trauma. Symptoms uri nary incontinence or retention (may be painless), fecal incontinence, bilateral leg weaknes s and pain. Signs bilateral reduced power (LMN) and sensation, reduced perianal (saddle) se nsation, reduced anal tone, bilateral absent ankle refl exes. Investigations urgent MRI spi ne. Treatment catheterise; refer immediately to orthopedics/neurosurgeons. Complications we akness, reduced sensation, incontinence, impotence. Vertebral collapse fracture Causes trau ma, osteoporosis, tumor. Symptoms sudden onset back pain; may be mild trauma if pathologica l. Signs central vertebral tenderness, reduced mobility. Investigations spinal X-ray. Treat ment analgesia, assess ability to cope, treat osteoporosis (b p437). 1 See (cid:27)www.bmj. com/content/326/7388/535.full for a brief, free and readable overview. 2 NICE guidelines fo r persistent pain available at (cid:27)guidance.nice.org.uk/CG88 _OHFP.indb 357 _OHFP.indb 357 30/05/2014 16:18 30/05/2014 16:18 358 CHAPTER 11 Neurology and psychiatry Headache 1 Worrying features dGCS, sudden onset, severe, recurrent vomiting, photophobia, r ash, neck stiff ness, focal neurology, seizures, papil- loedema, diHR, diBP. Think about emergencies intracranial hemorrhage (subarachnoid, subdural, extradural), menin gitis, encephalitis, iintracranial pressure (ICP), temporal arteritis, acute glaucoma, hype rtensive crisis; common dehydration, tension, infection, migraine, extracranial (sinuses, e yes, ears, teeth), trauma, post-LP, post-nitrates; other cluster, postcoital, hypoglycaemia , hyponatraemia. See Table 11.10. Ask about severity, location, bilateral vs. unilateral, speed of onset, character, change w ith coughing, nausea and vomiting, visual changes (before or currently), trauma, seizures, rashes, neck pain, sweating; PMH previous headaches, migraines (and usual symptoms); DH nit rates, analgesics, antihypertensives; SH recent stressors. Obs temp, GCS, glucose, HR, BP, fl uid balance: \200 Cushing \200\231s re \202 ex is a l ate sign of iICP: dHR and iBP. Look for volume status (b p380); evidence of meningism: neck stiff ness, photophobia, Kernig \200\231s sign (fully fl ex hip and passively extend knee, +ve if painful in head or neck); non-blanching rash (check whole body); red eye (b p426), visual disturbance or papilloedema; focal neurology; temporal artery tenderness and pulsati lity; tenderness over sinuses; evidence of recent head trauma; dental hygiene, ear discharg e. Investigations in the absence of worrying features it is appropriate to give pain relief wi thout investigations; otherwise secure IV access and send blds FBC, ESR, U+E, LFT, glucose, CRP, clotting and bld cultures; ABG especially if dGCS. Discuss with a senior whether a CT head LP are required (see b p552); EEG may help diagnose encephalitis. Treatment exclude emergencies and treat other causes with simple analgesia (b p86) and fl uids if dehydrated (b p380); ask to be con- tacted if symptoms fail to improve or worsen: \200 New onset GC S <15 (see b p338) \200 New onset focal neurology reevaluate for meningitis, encephalitis or iICP (b p360): 15l/min O2, consider ABx \200\223 call a senior urgently \200 Sudden (onset <2min), severe and constant consider a subarachnoid (b p360): 15l/min O2, lie fl at \200\223 call a senior urgently Unwell, deranged obs always consider meningitis/sepsis (b p360), classic symptoms in <30%: 15l/min O2, IV fl uids, discuss ABx with senior Red, painful eye, dacuity acute glaucoma (b p427), urgent ophthalmology referral Temporal tenderness consider temporal arteritis (b p361) \200 Hypertensive (BP >200/120mm Hg) (b p262). 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG150 OHFP.indb 358 OHFP.indb 358 30/05/2014 16:18 30/05/2014 16:18 359 HEADACHE Table 11.10 Common causes of headache History Examination Investigations Rapid onset, severe pain, vomiting, dGCS if severe May be normal, neck stiff ness, photophobia, focal neurology d/fl uctuating GCS; may be sig ns of iICP Bleed seen on CT; xanthochromia in CSF Subarachnoid or warning bleed Subdural or extradural haematoma Trauma, confusion, vomiting Blood seen on CT iWCC, iCRP; CSF: neutrophilia dglucose Abnormal CT: enlarged ventricles focal lesion Meningitis septicaemia Unwell, irritable, drowsy, feels ill rash Febrile septic, neck stiff ness, photophobia non-blanching rash Pupillary abnormalities, focal neurology; late signs: papilloedema, Cushing \200\231s refl ex Pyrexia, dGCS, confusion, focal neurology, neck stiff ness, photophobia Raised ICP Vomiting, blurred vision, dizzy, drowsy, worse on coughing/ bending, seizures CT/MRI: oedema, temporal lobe changes; CSF: iL \230 protein iCRP, iiiESR with anemia, ip lts and iALP Encephalitis Drowsy, confused, vomiting, seizures, preceding fl u-like illness, non-specifi c symptoms Tender, palpable, non-pulsatile temporal artery, tender scalp Temporal arteritis Age >55yr, visual disturbances, weight loss, polymyalgia, jaw pain Photophobia, visual fi eld defects, may have focal neurology None Migraine Previous migraines, visual aura; unilateral, throbbing, nausea, vomiting Cluster Recurrent daily headaches, unilateral, \200\230stabbing \200\231 Agitated, rhinorrhoea, lacrimation, sweating None Tension Bilateral, band-like pressure, worse when stressed Normal; occasional scalp tenderness None May have iL \230, N \230 or E \230 Sinusitis Frontal pain, blocked/ runny nose Tender above or below eyes Normal; may identify \200\230trigger point \200\231 None Trigeminal neuralgia Frequent, brief \200\230stabbing \200\231 pains; unilateral in distribution of CN V; previ ous facial herpes zoster May mimic migraine or SAH, but meningism absent dvisual acuity, dilated, oval pupil, red around cornea, tender Consider CT/LP to rule out SAH Exertional Sudden, explosive bilateral pain typically on exercise or orgasm iintraocular pressure Acute glaucoma Age >50yr, blurred vision, pain in one eye, often occurs at night Drug induced Many medications can induce headaches, particularly nitrates, Ca2+ channel ant agonists and metronidazole with alcohol b p438 b p427 b p438 b p480 Subdural haematoma Extradural haematoma Acute glaucoma Sepsis _OHFP.indb 359 _OHFP.indb 359 30/05/2014 16:18 30/05/2014 16:18 360 CHAPTER 11 Neurology and psychiatry 3Subarachnoid hemorrhage (OHAM3 b p384) Potentially devastating bleed (typically aneurysmal ) into subarachnoid space. Symptoms rapid onset (<2min), severe, continuous (>2h) headache; often occipital ( \200\230hit around back of head \200\231), vomiting, dizziness; may have seizures. Signs neck stiff ness, drowsy, photophobia, focal neurology, dGCS. Investigation s urgent CT head; since this may miss small bleeds (20%), if CT normal, then LP (>12h after onset) for xanthochromia. Treatment 15l/min O2, analgesia (codeine 30mg PO or 5mg morphine IV) and anti-emetic, eg metoclopramide 10mg IV/IM. Refer urgently to neu- rosurgeon for en dovascular coiling or neurosurgical clipping and consider transfer to ICU if dGCS. Lie the patient fl at and advise not to get up or eat. Reassess often and request neuro obs. Nimodi pine (60mg/4h PO) pre- vents vasospasm and improves outcome.1 Keep systolic <130mmHg, using IV B-blockers, unless lethargic (suggests vasospasm; may require permissive hypertension). Focal neurology or dGCS carry a worse prognosis. Complications cerebral ischaemia, rebleed ing, hydrocephalus, death. 3Meningitis (OHAM3 b p355, OHCM9 b p832) Symptoms headache, neck pain, photophobia, seizures, unwell. Signs iHR, dBP, itemp, dGCS or abnormal mood, neck stiff ness, rash, focal neurology. Investigations treat fi rst; blds iWCC, iCRP; CT then LP (b p552). Treatment contact a senior; ceftriaxone 4g IV STAT if you have a clinical susp icion of bacterial meningitis. Resuscitate as needed (b p472). Contact public health regard ing contact tracing (see also sepsis, b p480). Complications iICP, hydrocephalus, focal neu rology, seizures, death. 3Encephalitis (OHAM3 b p362) Brain infl ammation, usually viral. R are and easily missed in early stages. Symptoms abnormal behavior, seizures, drowsy, headac he, neck pain. Signs altered personality, dGCS, focal neurology, neck stiff ness, itemp. In vestigations CT followed by LP (b p552), send CSF for viral PCR; CT/ MRI/EEG may all show t emporal lobe changes. Treatment be guided by microbiology; eg aciclovir 10mg/kg/8h IV (10 \200\22314d). Complications iICP, seizures, death. 3Raised intracranial pressure \200\223 ICP (OHAM3 b p372) Causes CVA, tumors, trauma, infection (including abscess), cerebral oede ma (eg post-hypoxia), electrolyte imbalance, idiopathic. Symptoms headache and vomiting (wo rse in morning and coughing/ bending over), tiredness, visual problems, seizures. Signs dGC S, focal neurology; late signs include Cushing \200\231s refl ex (dHR, iBP) papilloedema. Investigations urgent CT head to assess cause and severity. Treatment elevate the head end of the bed to 30 and correct hypotension with 0.9% saline. Discuss with a senior before giving mannitol or dexa- methasone (tumors only) to reduce the ICP. Involve a neurosurgeon/ neurologist early. Complications herniation of the brain ( \200\230coning \200\231). 3Acut e glaucoma (b p427), needs urgent ophthalmology review. 1 Pickard, J.D. et al. BMJ 1989 298 :636 available free at (cid:27)www.ncbi.nlm.nih.gov/pmc/articles/ PMC1835889/ OHFP.indb 360 OHFP.indb 360 30/05/2014 16:18 30/05/2014 16:18 361 HEADACHE Temporal arteritis (OHAM3 b p644) Symptoms headache, jaw pain on eating, visual problems, a ching muscles. Signs temporal artery and scalp tenderness, pulseless or nodular temporal ar tery. Investigations blds iiESR (>50mm/h), iCRP, iplts, dHb all suggestive; defi n- itive d iagnosis requires biopsies (multiple sites) in \211 1wk of starting therapy. Treatment sta rt 60mg/24h prednisolone PO and strong analgesia. Discuss with on-call surgeon/ENT to arran ge urgent out-patient biopsy and liaise with ophthalmology to exclude visual complications; Doppler USS of the artery can be helpful. Out-patient rheumatology follow-up. Complication s blindness (10 \200\22350%), TIA/stroke. Migraine (OHCM9 b p462) Recurrent, pulsatile head aches with strong familial tendency. Suspect an alternative pathology if sudden onset, or > 55yr with no previous migraines. Symptoms throbbing headache, initially unilateral often wi th nausea vomiting, photophobia; 20% may experience a preceding aura (fl ashing lights, z igzag, visual loss). Signs may mimic TIA (visual defects, focal neurology) but slower onset . Investigations normal; perform blds, CT, LP as required to rule out alternative/coexisten t pathology. Treatment abortive: simple analgesia (see b p86), anti-emetic, 5HT1 agonis ts (eg sumatriptan); preventative: B-blocker (eg propranolol), or anti epileptics (eg topir amate). Sinusitis Infl ammation of the mucosa of the paranasal sinuses due to bacteria, viruses or fungi; may become chronic. Symptoms blocked nose, nasal discharge, facial pain, unable to s mell. Signs tender over sinuses (above medial eyebrows, bridge of nose, below eyes), purule nt nasal discharge, temp usually normal. Treatment try a mixture of beclometasone nasal spr ay 2 sprays to each nostril/12h ephedrine nasal drops 1 \200\2232 drops in each nostril/6 h (7d max) saline nebs 5ml/2 \200\2234h. If severe (eg purulent mucus, systemically unwe ll) prescribe amoxicillin 500mg/8h PO. Complications local spread of infection, chronic sin usitis. Cluster headaches Recurrent, short-lived, severe, unilateral \200\230stabbing \200\231 hea daches occurring up to several times/day (often in early morning). Patients become agitated during attacks, and may experience rhinorrhoea, lacrimation or facial sweating. Treatment abortive: 5HT1 agonists (eg sumatriptan nasal spray), 15l/ min O2; preventative: Ca2+ chann el blockers (eg verapamil), lithium. Post-dural puncture usually present within 4 \200\2235 d of LP, epidural or spinal anesthetic, (rarely up to 7d); lie patient fl at, treat with an algesia and ifl uid intake (especially caff einated drinks). Contact anesthetist if severe/ persistent to consider epidural blood patch. 3Hypertensive crises hypertension usually repr esents a response to the pain of headache and responds to treatment of the headache. Howeve r, BP>200/120mmHg may represent the cause of a headache (b p265). _OHFP.indb 361 _OHFP.indb 361 30/05/2014 16:18 30/05/2014 16:18 362 CHAPTER 11 Neurology and psychiatry Dizziness Worrying features hypoxia, iHR, irregular HR, dBP, dglucose, chest pain, sudden o nset, unable to stand. Think about vertigo labyrinthitis, vestibular neuronitis, benign positional vertigo, trauma , ototoxic drugs, M ni re \200\231s, CVA, multiple sclerosis, acoustic neuroma; imbalance hypoglycaemia, alcohol intoxi- cation, Wernicke \200\231s encephalopathy, CVA, cerebellar space-occupying lesion, intracranial infection, B12 defi ciency, normal pressure hydroceph- alus, syncope/presyncope (b p442). Ask about see box; PMH previous dizziness, iBP, DM, MS, IHD; DH antihypertensives, diuretics, aminoglycosides, insulin, oral hypoglycaemics; SH al cohol. Obs temp, HR, lying and standing BP, glucose, GCS. Look for ability to stand, gait; Romberg \200\231s test (see box), change with posi- tion, cerebellar signs (DANISH \200 \223 dysdiadochokinesia, ataxia, nystagmus, intention tremor and past pointing, slurred spe ech, hypotonia), focal neu- rology, examine ear using otoscope (eff usion, perforation); ir regular pulse. Investigations the type of dizziness (vertigo, ataxia, postural, syncope) sh ould be determined from history alone; if syncope is suspected, inves- tigate for cardiogen ic causes (b p260); for vertigo and ataxia, acute investigation is rarely required; conside r a CT head if a CVA or tumor is g ; suspected or there are cerebellar signs; audiometry if vestibular features. p y Key questions in \200\230dizziness \200\231 The sensation of dizziness is diffi cult to de scribe ( \200\230giddy \200\231, \200\230funny do \200\231, \200\230muzzy headed \200\231 ) and refl ects some critically diff erent underlying pathologies; try to map your patient \200\231s symptoms onto a medical equivalent by asking about: \200 Loss of consciousness suggests seizures (b p346) or syncope (b p260). The impending sense of loss of consciousnes s, often with a \200\230graying out \200\231 of vision, is described as presyncope; causes and management are similar to syncope Postural symptoms are worse on standing after a sedentary period; this suggests postural hy potension and should prompt a review of medications Vertigo is the sensation of the world moving or spinning about the patient and is worse on sudden head movements; this suggests a problem with the labyrinth, vestibular nerve or brai nstem (b p363) \200 Ataxia is shown by the inability to stand or walk straight; patients may have problems with fi ne limb movements; this suggests problems with proprioception or cerebellar function (b p363). Always ask about onset, deterioration, hearing loss, tinnitus, nausea, vomiting. Romberg \200\231s test1 The cerebellum normally receives information needed to keep us upri ght from 2 sensory systems: vision and proprioception (via the spinal dorsal columns). Norm ally, one system can compensate for loss of the other. With the eyes closed and the feet pl aced together, a patient who sways exces- sively or falls is \200\230Romberg +ve \200\231, having lost proprioception. With a cerebellar lesion, the patient will struggle to maintai n posture even with the eyes open. 1 Described by the pioneering C19th German neurologist M oritz Romberg, working amongst the destitute of Berlin with tabes dorsalis (tertiary neurosyphilis). OHFP.indb 362 OHFP.indb 362 30/05/2014 16:18 30/05/2014 16:18 363 DIZZINESS Vertigo (OHCS8 b p554) ) g ( p Worrying features focal neurology, multidirectional or non-fatiguing nystagmus. Treat the sensation of vertigo whilst determining the underlying cause. Centrally acting an tihistamines (eg cyclizine 50mg/8h PO) and pheno- thiazines (eg prochlorperazine 5mg/8h PO) are particularly eff ective; betahistine 16mg/8h PO may also be used. Benign positional ve rtigo Sudden onset vertigo lasting seconds following specifi c head movements. Treated with Epley maneuver (a series of movements to dislodge the vestibular debris causing the sympto ms OHCS8 b p555) and referral to physiotherapy for vestibular exercises. Inner ear in \202 ammation causes sudden onset vertigo, nystagmus and severe nausea without focal neurology. Reassure and treat as above. \200 Vestibular neuronitis viral infection of the vestibula r nerve; improves within 1 \200\2232wk but can take 2 \200\2233mth to fully resolve Labyrinthitis as for vestibular neuronitis with hearing loss or tinnitus. M ni re \200 \231s attacks of severe vertigo lasting several hours, with tinnitus and progressive low fr equency hearing loss. Treat as above, and refer to ENT. Motion sickness rarely encountered in hospital, however cinnarizine j 30mg PO 2h before journey is eff ective. g y Nystagmus is found with many peripheral and central causes of vertigo. Causes include: stro ke, MS, space occupying lesions, labyrinthitis, ves- tibular neuronitis, benign positional vertigo, trauma, drugs of abuse (alcohol, LSD, PCP, ketamine), medications (lithium, SSRIs, phenytoin), M ni re \200\231s, Wernicke \200\231s encephalopathy; congenital (rare). Imbalance/ataxia Ataxia can be diff erentiated from vertigo on history; there are two types : \200 Cerebellar \200\230DANISH \200\231 signs (see earlier in this topic); unstable ev en with eyes open Sensory Romberg \200\231s +ve (see box), loss of proprioception, preservation of fi ne coordination; \200\230stamping \200\231 gait, spinal/neuropathy signs. Cerebellar ataxia Causes CVA, multiple sclerosis, alcohol toxicity, Wernicke \200\231s ence ph- alopathy, phenytoin, B12 defi ciency, normal pressure hydrocephalus, infection, space-o ccupying lesions, trauma, paraneoplastic. Management MRI is the most useful diagnostic test (consider CT if acute onset), neurology referral, some underlying causes are treatable: \200 Wernicke \200\231s encephalopathy thiamine (B1) defi ciency often as a result of chro nic alcohol excess results in confusion, ataxia, ophthalmoplegia, and nystagmus; treated wi th thiamine (PO/IV, b p218), as for Korsakoff \200\231s syndrome, to which it may progress if left untreated. Sensory ataxia Causes cervical spondylosis, MS, peripheral neuropathy, syringomyelia, spina l tumor, spinal infection, B12 defi ciency, Friedreich \200\231s ataxia, syphilis. Manageme nt urgent MRI if acute onset, otherwise consider tests for peripheral neuropathy (b p355), spinal X-rays, routine MRI, nerve con- duction studies, neurology referral; often treated w ith B12. _OHFP.indb 363 _OHFP.indb 363 30/05/2014 16:18 30/05/2014 16:18 364 CHAPTER 11 Neurology and psychiatry Aggressive behavior emergency Stay between the aggressor and the exit \200 Get extra help from other staff and/or secur ity \200 Consider phoning the police. Safety 3Call for senior help/security early if the situation is deteriorating. \200 Assess the s afety is anyone at acute risk? \200 Emergency sedation if they are a risk to themselves o r others1 \200 lorazepam 1 \200\2232mg (1mg elderly/renal failure) PO/IM/IV STAT \200 h aloperidol 5 \200\22310mg (2mg elderly) PO/IM/IV STAT \200 Can be used together or separa tely Try to establish the precipitant from staff /relatives \200 Ask a member of staff who kno ws the patient to accompany you \200 Invite the patient to sit down with you and discuss the problem \200 Listen until they feel they have explained the problem \200 Assess the patient for signs of psychosis or acute confusion \200\223 are they physiologically unwell, psychologically disturbed or merely angry Apologize and/or off er sympathy as appropriate \200 Address any concerns raised by the p atient \200 Ask specifi cally about pain or worry \200 Consider off ering oral sedation or analgesia \200 Attempt to defuse the situation \200 If unsuccessful contact a senio r for help.p Common causes Acute confusion (delirium) b p341 \200 Intoxication (drugs/alcohol) \200 Psychosis due to an underlying psychiatric disorder b p365 \200 Anger/frustration/poor communication b p21 \200 Pain b p86 \200 Hypoxia b p270 \200 Hypoglycaemia b p323. Sectioning and the Mental Health Act 2007 In England and Wales, this Act allows the hospitalization of individuals who are believed t o be aff ected by a mental illness that: \200 Requires assessment or treatment and \200 Is suffi ciently serious to pose a threat to self or others and \200 Requires hospitaliz ation to which they are unable/unwilling to consent. If you feel this applies to your patie nt, speak to your seniors and the psy- chiatrist on call urgently. Critically, these powers only apply to detention for the purposes of assessment or treatment of mental illness and cannot be used to detain for treatment of physical illness. In this case, treatment deci- s ions should be based upon an assessment of mental capacity (b p28). In Scotland and Norther n Ireland, similar powers are granted under the Mental Health Act 2003 and Mental Health Or der 1986 respectively. 1 If a patient poses a risk to themselves or others any doctor can give emergency sedation, without the patient \200\231s consent and with restraint, under the Mental Capacity Act (2 005). OHFP.indb 364 OHFP.indb 364 30/05/2014 16:18 30/05/2014 16:18 365 MOOD DISTURBANCE/PSYCHOSIS