Dr David Eagle

Based on 3 cases from A&E and Ward 21 (Neurology):

Acute presentation, history and examination findings

Initial Management Guidance Key learning points

Cover Sheet Text: 62 year old man. Back pain for 5 months after heavy lifting, more

severe last 2 weeks, now unbearable. Not seen GP, taken Paracetamol to some effect.

YAS History: Severe back pain, unable to weight-bear. Required Entonox and Morphine 10mg to

transport.

Formal Clerking Pc:

5 month history of low back pain, 2 weeks of increasing severity, 3 days of being unable to stand.

HxPc: Well until December 2012. Sudden onset of low back pain while lifting shopping

onto bus just before Xmas. Variable pain over next 4 months, taken Paracetamol,

avoided too much rest, not seen GP. Last 2 weeks pain much more severe and difficulty

mobilizing. Last 3 days been unable to stand, just lying on living

room floor...

HxPc continued: Currently severe (10/10) low back/left buttock pain...

▪ Dull ache with sharp twinges on movement,▪ Radiates down left leg to knee,▪ Exacerbated by movement, no comfortable position,▪ Relieved slightly by simple analgesia,▪ Associated with weakness in both legs Left > Right, altered sensation

both feet Left > Right.

No recent bladder or bowel change, no recent diarrhoea or LRTI, eating and drinking, systemically well.

PMHx: HTN, otherwise well.

Meds & Allergies: Nil regular, no known drug allergies.

Soc Hx: Retired builder. Lives with wife in a house with stairs, supportive family close

by. Ex-smoker of 20 pack years, stopped 5 years ago. Occasional drinker.

Fam Hx: Nil relevant.

On Examination: Obs: all stable A, B, C, D: all NAD Abdo: soft and non-tender, no organomegally, BS present,

no AAA palpable, no renal angle tenderness, increased BMI CNS: II XII all NAD

Examination continued: PNS:

PR: Peri-anal sensation intact, normal tone

Right Left

Upper Limb: All NAD All NAD

Lower Limb:Inspection - -

Tone Increased Increased

Power 3-4/5 1/5 throughout

Reflexes ++, downward plantar

++, upward plantar

Sensation Inconsistent reporting ?reduced up to knees

Co-ordination Unable due to reduced power

Anything missing? Impression? Clonus +++ Impression: UMN spinal lesion Discussion with Neurology & Neurosurgery Urgent MRI Spine:

Cord compression at T11 Partial destruction of T11 with vertebral tumour – mets or myeloma L3 disc herniation

To neurosurgery that night for debulking and fixation

At 5 days: Pain free, no return of function PSA 600+ CT Thorax, Abdo, Pelvis: prostate ca with widespread mets Referral to Urology & palliation

Learning points:

Focussed neuro exam

UMN vs LMN – locating the lesion

Suspected cord compression guidelines

Cover Sheet Text: 71 year old man. ?previous TIA, increasing memory loss. 1 day history of confusion/odd behaviour.

Seen by BAT: ROSIER: 0 No focal neurology. Wife states “not his usual self”. Appears confused, delirious, fluctuating, agitated. ?delirium, ED to see...

Formal Clerking Pc:

1 day history of sudden onset odd/inappropriate behaviour on background of mild memory loss.

HxPc: Well recently – no infections, no cough, fever, diarrhoea, SOB. Banged his head on kitchen cupboard 2 days ago but only

mild. Sudden onset behaviour change yesterday afternoon while

wife was at shops, “not himself”, including:▪ Stood to watch TV for 2 hours.▪ Went for meal out, made very unusual meal choices, didn’t

fasten trousers after bathroom visit, episode of urinary incontinence.

▪ Sat up all night watching ‘inappropriate’ TV.

HxPc continued: Himself denies headache, nausea, vomiting or change in

behaviour. PMHx:

GORD, high cholesterol, migraines with aura (used to be 1 every 2 years, 2 in last month).

Meds & Allergies: Simvastatin, Omeprazole, Aspirin; no known drug allergies.

Social Hx: Lives with wife who is well. Retired electrical engineer. 12 units alcohol per week, ex-smoker of 20 pack years.

Family Hx: Nil relevant.

On examination: Obs: sO2: 95%, HR: 100, apyrexial Patient dismissive and mildly uncooperative throughout

but maintained attention and consistent conscious level A, B, C: slight crackles right base CBG: 8.1 AMTS: 8/10 (incorrect address and WWII dates – would

have known) CNS: II XII all NAD (unable to perform fundoscopy) PNS: all NAD Gait: NAD

Differential? Possible causes:

Cerebrovascular: frontal stroke (?bleed secondary to lesion).

Infective: encephalitis, meningitis (neuro TB, syphilis). Toxic: CO, acute withdrawal, opiods. Metabolic/Endo: hypoglycaemic (metabolic

encephalopathy, thyrotoxicosis, Addision’s) Paraneoplastic Any cause of delirium Acute psych disorder

Investigations: Urine dip: -ve FBC, U&Es, LFTs, B12, ferritin: all NAD. Folate: 4.5 (slightly low) CXR: nil acute

CT head:▪ Intracerebral haematoma medial frontal lobe on right, ▪ Previous small infarction left frontal lobe.

Admitted to stroke Discharged after 4 weeks rehab Out-patient MRI/MRA

Learning points:

Diagnosis easily missed – subtle symptoms, diagnosis reliant on collateral history.

BAT assessment ROSIER score (ie weakness, visual field and speech disturbance) driven – will therefore miss frontal lobe and cerebellar strokes.

CT head justified on detail of history and clear acute onset.

Formal Clerking Pc:

22 year old man, normally fit and well. 5 day history of generally unwell, fever, headache and seizures

today. HxPc:

Well recently – no foreign travel, symptoms of infection or bites. 5 days ago began with general flu-like symptoms – generalised

headache, myalgia, runny nose, feverish, anorexia, nauseated. Had taken some Paracetamol to little effect. Today, increasingly drowsy, headache more severe. @ 15:00 partial seizure, starting with left hand shaking,

progressed up arm to involve all left side, lasting <2 mins, resolved spontaeuously.

2x futher seizures – one in Ambulance, one in A&E.

HxPc continued: Not noticed a rash, no neck stiffness, mild photophobia.

MedHx: Usually fit & well, no history of cold sores.

Meds & Allergies: Nil regular; no known drug allergies.

Social Hx: Lives with girlfriend who has been well. Works in a call centre. Occasional light drinker, non-smoker, denies any

recreational drug use. Family Hx:

Nil relevant.

On examination: Obs: temp: 38.7, else NAD A, B, C: NAD D: drowsy but easily rousable, GCS 14 – slightly confused

speech CBG: 4.3 Abdo soft & non-tender

Marked dysarthria CNS: left-sided facial droop with forehead sparing,

drooling & watering left eye, else NAD

Examination continued: PNS: Right Left

Upper Limb: All NAD All NAD

Tone Normal Reduced

Power 5/5 2/5 throughout

Reflexes + +

Sensation Normal Reduced fine touch

Lower Limb:

Tone Normal Reduced

Power 5/5 4/5 throughout

Reflexes +, downward plantar +, downward plantar

Sensation Normal Normal

Impression? Likely viral encephalitis Investigations:

Urine dip: -ve FBC, U&Es, LFTs: all NAD. Blood cultures sent CT Head: NAD

Immediate Management: Rectal Diazepam followed by Phenytoin infusion IV Aciclovir (10mg per kg) TCI Neurology

At 5 days: CSF: raised lymphocytes only, negative viral PCR MRI: right-sided temporal, parietal and frontal hyperintensities

consistent with encephalitis On 14 day course of IV Aciclovir, initial improvement, relapse at 3 days

(as aciclovir incorrectly switched to oral), improved on return to IV.

Complete recovery by discharge

Learning points:

Mortality if untreated roughly 70%.

Prognosis dependent on early recognition at treatment.

Target starting Aciclovir within 30mins of attendance – don’t wait for imaging/LP.

Suspect in anyone with altered behaviour/new seizures/focal neurology with infective prodrome.