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74 Cards in this Set

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a 45 y woman with a left sided facial palst and Vertigo .

Has impaired hearing on her left side and a vesicular Rash is noted around her External auditory Meatus

J. 'Ramsay Hunt ' Syndrome a.k.a Herpes Zoster infection of the Geniculate gangelion

External auditory meatuys recieves some sensory inner action from the facial (VII) nerve , hence the Vesicular rash over this area

MX: Aciclovir

55 y man presents with a history of recurrent spontaneious attacks of vertigo, hearing loss and tinnitus

These attacks last up to 2 h and are sometimes assx with vomiting

F. Menière's Disease

Assx with Triad : Vertigo + Tinnutius + Deafness

Aetiology Unclear , some say may arise form a dilatation of the endolympahtic system.

Vertigo may be disabling and assx with vomiting

Deafness: sensioneural nature

Mx : Rest for acute attacks

Long term Prophylaxis: Vestibular Sedatives ( e.g. Cinnarizine ( Antihistamine + CaCh B) / Betahistine (anti-vertigo ) but result are disappointing

Surgical : Emdolymph shunt ( from duct) , Clipping

65 y woman presents with

Vertigo , Vomiting, Dysphagia.

OE: Left sided Horner's Syndrome, and loss of pain and temperature on right side of the face

D. Lateral Medullary Syndrome

Horner's Syndrome:

Miosis + Ptosis + Anhidrosis + Enophthalmos (sinking of eye into eyeball)

Posterior Inferior Cerebullar artery ( PICA) supplies Dorsal lateral medullary Plate and parts of the posterior

PICA thrombosis => lesions affecting cranial nerves, descending tracts and the cerebellum , collectively known as " Lat Medullary Syndrome"

Lateral Medullary Syndrome

Ipsilateral Signs :

Decreased pain & temperature sensation of the face ( descending tract and nucleus nerve V )

Palatial , vocal fold paralysis (nerve IX, X involvement )

Horner Syndrome ( sympathetic Tract)

Cerebellum Signs. E.g. Ataxia , nystagmus

Contralateral signs:

Decreased pain and temperature of the body ( spinothalamic tract)

Latera medullary Syndrome, eponymously known as Waalenberg's Syndrome

50 y man presents with Vertigo when rolling over quickly in bed , getting out of bed and bending over

Hearing is normal

B. Benign paroxysmal positional Vertigo

Characterized by short episodes of vertigo triggered by head movements. Caused by free-floating particles in the endolymph of the semicircular Canal which in turn cause continuing stimulation of the auditory canal for several seconds after movements of the head has ceased.

Dx examination by : Hallpik's manoevre

Possible cerebellar mass lesion may be responsible

Mx: Epley manoeuvre ( Orient the head in various position to displace the particles from the posterior canal

Hallpike's Manoeuvre

used to confirm the diagnosis of benign parox- ysmal positional vertigo. The patient is asked to sit upright with the head facing the examiner. The examiner grasps the patient’s head between his hands and rapidly moves the patient from a sitting to lying position with the head tipped below the horizontal plane, 45 ̊ to the side, and with the side of the affected ear (and semicircular canal) downwards.A positive test provokes vertigo and rotatory nystagmus that typically has a latency of a few seconds before onset and fatigues after about 30 s. If the nystagmus appears immediately on performing the manoeuvre and does not fatigue, a cerebellar mass lesion may be responsible and com- puted tomography (CT) should be performed.

20 y man presents with Vertigo having suffered with symptoms of flu for several days

Vestibular neuronitis

Assx with a preceding infection / illness.

The vertigo is severe and presents abruptly with vomiting

Usually the vertigo deminshes after a few days and in many cases there is complete recovery within a couple of weeks.

Some however develop Benignn paroxysmal positional vertigo afterwards

a 40 y man complains of severe headache of sudden onset of 4 h ago , likened to being kicked in the back of the head

has vomited twice and is now feeling stiff in his neck

F. Subarachnoid Hemorrhage

usually caused by rupture of a berry aneurysm found on the circle of Willis.

Disease states assx with high BP e.g. COA , polycystic disease, Ehlers Danlos ( defective Collagen synthesis )

INV: CT , LP : Xanthochromia (denatured RBC) presence ( takes up to 12h , thus LP after 12 h)

a 40 y Businesswoman complains of a headache tat feels like a Tight band around her head

A. Tension Headache

Dx : absence of sx and signs of other types of headache

MX: rarely effective , Avoidance of the precipitants ( stress ) best Remedy .

PS: Chronic use of analgesics can result to Rebound Headache on Withdrawl .

Antidepressants are sometime prescribed although benefit is uncertain.

A 55 y woman presents with a headache that has lasted a few weeks. She gets pain in her jaw during meals and her scalp is tender on palpation.

Giant Cell Arteritis

a medium sized vessel vasculitis.

HINT: scalp tenderness , jaw claudication.

there is a risk BLINDNESS thus treatment should be started ASAP with Oral Corticosteroids

DX: confirmed with temporal artery biopsy and the condition is usually assx with high ESR/ CRP

30 y man complains of rapid onset pain around his left eye every night for the last 2 weeks, assx with lid swelling , watery eye and flushing

He suffers from these bouts every 3 months

J.Cluster Headache

recurrent brief attacks headache around the eye with autonomic sx ( nasal stuffiness, conjunctival hyperemia , Horner's Syndrome)

It last a few weeks and few months

24 y woman complains of a unilateral throbbing headache lasting 6 hr assx with vomiting and photophobia.

She has had several episodes in the past

B. Migraine

classic description includes: a preceding aura before the onset of the headache, but this feature does not occur in most pt.

56 y woman complains of unilateral stabbing pain on the surface of her scalp and around her eyes. The Pain is precipitated by washing or touching the specific area

L. Trigimenal neuralgia

Classic Hx or trigimenal neuralgia affecting the opthalmic division of the trigimenal nerve

The condition more commonly presents with mandibular and maxillary branches.

A 28 y woman complains of headache and double vision which is worse when lying down

OE reveals papilloedema but no facial signs

No abnormal finding on CT

G. Benign Intracranial HTN

A condition of unknown aetiology which usually affects obese women.

causes: Steroids and Tetracycline

Dx: Raised CSF pressure

Sx usually resolves after LP

MX: repeated LP and dieuritics

A 30 y man complains of a dull headache that is worse when lying down or when coughing

He has recently suffered a seizure

J.Space occupying lesion

Classical hx of raised ICP

Seizure in hx is a sinister development and warrants immediate imaging

65 y woman complains of a constant aching pain around the right eye radiating to the forehead

Reduced vision in the eye , which is red and congested with dilated pupil

D. Acute glaucoma

Acute closed angle glaucoma

Most affect long-sighted elderly

Pathology :

Blockage of drainage of aqueous humor from the anterior chamber via the canal of Schlemm.

Stimuli that cause pupillary dilatiation increases the tightness of the contact b/n the iris and lens and can presipitate an attack

70 y woman complains of headache , drowsiness and unsteadiness over other last couple of days.

OE she is found to have papiulloedema.

She remember falling over 3 weeks ago

E. Subdural hematoma

Alcohol abuse/ trauma are risk factors of Chronic subdural haematoma .

Neurosurgical opinion should be sought early.

Can be treated conservatively b/c bleeds clot spontaneously

60 y woman complains of bilateral proximal muscle weakness in the legs and dysphagia

OE: she has purple rash on her cheeks

J. Multiple Sclerosis

Many Non-neurological causes of weakness in the legs : Polymyositis (an autoimmune characterized by non-suppurative inflammation of skeletal muscle )

In Severe disease there can be respiratory muscle weakness and also cardiac involvement

Creating kinase usually elevated .

EMG (electromyography ) characteristically shows fibrillation

40 y man presents with a recent hx of progressive weakness in the arms and legs after an episode of diarrhea

OE revealed flaccid weakness of limbs with no reflexes

E. Guillane Barre SYndrome

ascending polyneuropathy of unknown eitiology , may be assx with a preceding infection.

Symmetrical affection , proximal sooner than distal (sometimes) Cranial nerves & ANS may be involved . Resp muscle invlovment will be fatal, needs to be monitored.

Sensory may be numb and tingling in the limbs.

Mx: IV immunoglobulin is often used to shorten the duration of Disease . Prognosis is good with 85% making complete or near complete recovery

55 y man presents with bilateral progressive worsening muscle weakness

Marked wasting of lower limb muscle and very brisk lower limb reflexes

Sensation is normal

D.Motor neuron Disease

A progressive degenerative disease that affects the upper and lower motor neurons . characteristically there is NO sensory involvements

Most common pattern of involving of Motor Neuron disease

(Extra info)

(i) Progressive muscular atrophy:

anterior horn wasting lesion with wasting often beginning in the distal muscles of the hand and then spreading. Fasciculation is a common finding.

(ii) Amyotrophic lateral sclerosis:

involvement of the lateral corti- cospinal tract gives a progressive spastic teraparesis/paraparesis. The presence of LMN signs, e.g. wasting, fasciculation, differenti- ates this diagnosis from other causes of spastic weakness.

(iii) Progressive bulbar palsy:

the lower cranial nerve nuclei and their connections are primarily affected. Dysarthria and dysphagia are common symptoms. This pattern of disease is more common in women than in men.

A 13 y old presents with bilateral peps caves tin clawing of the toes. There is atrophy of peroneal muscle and reduced reflexes and sensation distally

B. Charcot Marie Tooth disease

A progressive peroneal muscle atrophy. An Atuotsomal Dominant and Recissive inheritances observed in diffrent families. clinical variants have been identified assx with diffrent gene defects : HSMN type I and II are most common

Charcot- Marie - Tooth

HSMN type I

HSMN type II

A demyelination neuropathy of insidious onset presenting typically in the first decade of life with foot deformities (pes caves) , muscle weakness ( distal weakness that affects legs earlier and ore severely than arms) and loss of balance.

the presents of food drop results in frequent trips and falls


Presents altere in the second decade of life, weakness in distal lower limb muscles is often accompanied by distal sensory loss. Foot deformities are less marked than in type I disease and patients may even be completely asymtomatics.

A 30 old secretary presents with bilateral leg weakness and blurred vision. Fundoscopy reveals pale optic discs bilaterally

K. Bilateral stroke

Pale bilateral optic discs indicate previous subclinical episodes of optic neuritis.

Dx: Clincially , but MRI is the imaging of choice to detect demyelinating plaques.

CSF: oligoclonal bands of IgG on electrophoresis.

Electrophysiological test reveal delays in the propagation of potentials.

Mx: Methylprednisolone can reduce the severity of relapses but does not improve long term prognosis. Interferon B has been shown to reduce the relapse rate in pt suffering from the relapsing remitting form of the illness but its use is limited b/c of its high cost

Inability to dorsifles foot after blow to the side of knee

Nerve lesion in :

B. Peroneal nerve

Blow to leg compresses the common peroneal nerve against the head of the fibula. There is a weakness in eversion and the presence of foot drop. There may be some numbness on the anterolateral aspect of the shin

Sensory loss over medial one and a half fingers

J.Ulnar N Leison

Median supplies sensation to the palmar surface of the first three and half fingers.

In ulnar nerve palsy there may be features of a ' CLAW HAND ' i.e. Hyeprextension of the metacarpophalngeal joint sand flexion at the intraphalangeal Joints of the fourth and fifth fingers

a 25 y man presents with a WINGED SCAPULA and the inability to raise his arm above the horizontal

D.Long Thoracic Nerve

Supplies Serratus anterior which allows lateral and forward movements of the scapula

Sensory loss bilaterally below the level of the umbilicus


is the level of umbilicus

Right sided ptosis, miosis, wasting of small muscles of the right hand

I:Klumpke's Paralysis ( C8-T1 lesion)

With paralysis of the small muscles of the hand, arm held in addiction and lack of sensation over the ulnar side of the arm.

Presence of Horner's syndrome results from ablution of of T1 ( preganglionic sympathatic fibres eave the spinal nerve soon after it emerges from the Intravertebral foramen)

A 55-year-old man presents with unilateral weakness, wasting andfasciculation of the tongue. On examination the tongue deviates to theleft on protrusion.

C.XII left ( Hypoglossus)

Tongue deviates to the side of the leison

A 44-year-old man presents with progressive perceptive deafness,vertigo, unilateral facial weakness and loss of sensation on that side ofthe face. Imaging reveals the presence of a cerebellopontine tumour.

I.V, VII, VIII (Trigeminal, Facial, Vesitbulococlear )

Cerebellopontine tumours often present clinically as a result of impinge-ment on cranial nerves in the cerebellopontine angle

A patient complains of a hoarse voice, difficulty in swallowing andchoking when drinking fluids. Examination reveals visible weakness ofelevation of the palate, depression of palatal sensation and loss of thegag reflex.

J. IX, X (Glossopharngus , vagus )

rarely occur in isolation and can alsoaccompany nerve XI and XII lesions after infarction in the brain stem oras a result of pathology around the jugular foramen.

A 28-year-old man presents after surgery with an inability to rotatethe head to the right and to shrug the left shoulder.

H. Left XI ( Accessory )

motor supply to trapezius and sternocleido-mastoid. The latter muscle allows rotation of the head to the opposite side.

A 35-year-old woman with multiple sclerosis complains of diplopia.Examination reveals inability to abduct pupil on one side.

CN lesion?

K. VI Abducent

Diplopia in multiple sclerosis can result from demyelination of cranialnerves associated with eye movements, i.e. III, IV and VI. ( Optic, trochlear, Abducent )

A jerky tremor of outstretched hands in an alcoholic with decompen-sated liver disease.

L. Asterixis

( Flapping tremor, liver flap)

This is elicited by asking the patient to ‘stretch out your arms and cockyour wrists back

Non-rhythmic jerky purposeless movements in the hands of a55-year-old man.

D. Chorea

Huntington's disease : autosomal dominant condition resultingfrom a trinucleotide repeat mutation on the short arm of chromosome 4.

There isloss of neurons in the caudate nucleus and putamen.

Sx: pt usually presents in middle age with development ofchorea. The condition is progressive and dementia may occur in thelatter stages.

MX: Tetrabenazine

PS: Sydenham chorea is a rare complication of Rheumatic fever.

A 75-year-old man with poorly controlled diabetes is distressed bywild flinging of his right arm and right leg.


(A type of chorea ( due to decreased subthalamic nucleas of the basal ganglia). Results in flailing undesired movements of limbs )

Usually the underlying pathology is infarction/haemorrhage in the con-tralateral subthalamic nucleus.

Grimacing and involuntary chewing in a 75-year-old woman onlong-term treatment with neuroleptics

A. Tardive dyskinesia

( involuntary movement of the face and jaw ) that usually appears onlyafter long-term treatment with typical antipsychotic medications andother drugs with dopamine antagonist activity, e.g. metoclopramide.

Withdrawal of the responsible drug can lead to improvement but thecondition is irreversible in some patients.

Atypical antipsychoticmedications such as clozapine and risperidone are less likely to causeextrapyramidal side effects and tardive dyskinesia

Past-pointing in a 60-year-old woman being investigated forunsteady gait.


Dysdiadochokinesis (incoordination of rapidly alternating movement),nystagmus and intention tremor are signs of cerebellar disease that canbe easily elicited/observed at the bedside.

A 45 y woman complains of pain behind the right ear and that her mouth his sagging on the right hand side

J. Bell's Palsy

( LMN leison affecting VII facial) , may also loose ant 2/3 taste.

Prognosis of complete recovery is common

In UMN lesion ( CVA ) there will be sparing of the forehead - thus be able to raise eyebrows.

62 y woman presents with a stiff spastic tongue and 'Donal Duck'- like speech .

OE she had a brisk jaw jerk and was prone to laughing inappropriately

I. Pseudobulbar palsy

(UMNL) - upper motor neuron leison

Bilateral leison of the lower brainiac nuclei and can be assx with emotional liability

Known to occur in Multiple scelerosis , MND motor neuron disease, after bilateral strokes affecting Corticobulbar pathways

27 y woman presents with wasting and weakness of the small muscles of the hand

EX reveals loss of pain and temp sensation over the trunk and arms with intact vibration sense

H. Syringomyelia

Is fluid filled cavity ( Syrinx) within the spinal cord. Assx with Arnold Chiari malformation ( a malformation of skull causing CSF flow obstruction )

The Syrinx expansion will destroy the middle part of the spine ( where the PAin and Tempresture Decussate at the middle ) but will spare the Vibration and tactile ( because they are in the posterior column unaffected by the Syrinx

It has a 'Cape' like distribution loss of pain and temp, due to it happeningin the cervical spine ( c5,6,7)

Mx: Surgical Decompression

34 y woman complains of generalized weakness in her muscles diplopia and weakening of her voice if talking for longer than 30 s

Ex : Bilateral ptosis

E. Mysthenia gravis

Aquired Autoimmune , sx due to anti acetylcholine receptors Antibodies. ( Dx test)

Mx: anticholinesterases ) i.e. Oral pyridostigmine), + Oral corticosteroids ( for immuno suppression

PSS: aware of Easton- Lambert syndrome ( bronchial small cell carcinoma ) due to defective acetylcholine at NMJ giving rise to Mysthenic Syndrome

Difference b/n MS and MG:

MS: muscle strength increases and reflexes return with repeated contraction

MG: more weaknesss and reduction of reflexes on repeated contraction

15 y boy found to have several coffee-colored patches on his body

SLit-lamp examination reveals presnce of Lish Nodules

D. Neurofibromatosis

Type I. (A.k.a. Recklinghausesn's disease)

Autosomal dominant

Dx: requires 2/7 of diagnosis criteria :

(i) six or more café-au-lait spots 5 mm (in children 10) or 15 mm in adults

(ii) axillary/inguinal freckling

(iii) two or more neurofibromas or even one plexiform neurofibroma

(iv) optic glioma

(v) two or more Lisch nodules (iris hamartoma detected with slit-lampexamination)

(vi) osseous lesion such as sphenoid dysplasia/pseudoarthrosis

(vii) family history in first-degree relative.

a 65 y man with a festinate , ,shuffling gait

F. Parkinson's Disease

as a result of impairment o frighting reflexes, sufferers are sometimes observed to fall stiffly 'like a tree' without putting their arms out to break the fall.

60 woman walks with a. drop foot and high stepping gait shortly after a hip replacement

D. Sciatic Nerve injury

It is derived from the Anterior primary Rami 'L4,5,S1,2,3' and divers into the common peroneal and tibial nerve about 2/3rd of the way down the thigh.

its Injury is imp post-op complication of ip replacement. and can result from direct trauma or traction on the nerve

Sx: There is lack of sensation over the lateral leg below the knee and entire sole of the foot and inability to dorsiflex or ever foot

65 man presents after a stroke with a stiff right leg that drags forward in an arc

L. Spastic Gait

Strokes give rise to UMNL with weakness in a 'Pyramidal distribution. the Combo of spasticity in the leg extensors and weakness worse in the flexors of the lower limb gives rise to this spastic gait characterized by a stiff circumducted leg.

A broad based high stepping gait in a known alcoholic

G. Sensory Ataxia

results form a loss of proproveption caused by peripheral neuropathy ( in this pt 2ry to alcohol abuse) .

Romberg's test is used to identify proprioceptive sensory loss by demonstrating loss of postural control in darkness

A broad based unstable gait with veering to the right side

B. Cerebellar Ataxia

Cerebellar disease affecting one hemisphere tends to cause the pt to veer towards to the side of the lesion.

If cerebellar disease affects the cerbllear midline vermis there is truncal ataxia giving rise to difficulty in standing and even sitting on a stool unsupported

A 70 man complains of several black out s and falls every day

The blackout lasts for several sec and is preceded by palpitations

E.Stokes - Adams Attack

caused by transient arrhythmias that decrease cardiac output sufficient to cause syncope. ( either tachycardias or bradycardia)

Recover is typically quick. The pt is characteristically pate with syncope and becomes flushed upon recovery

A 65 y woman presented with attacks of sudden weakness of the legs causing her to fall to the ground . there in no loss of consciousness or confusion afterwards.

She has not had any attacks for several months now.

G. Drop attack

there should be no loss of consciousness.

Cause is unclear and they resolve spontaneoulsy

21 y student presents with hyperventilation tachycardia and light headedness and is Brought to the A&E after 'blacking out'

I. Anxiety Attack

Hyperventilation leads to a reduction in the PaCo2 and Resp alkalosis . Hypocapnic induced cerbral vessel VC gives rise to the light headedness & 'Blackout"

PS: always make sure you find out if black out is 'loss of vision' or'loss of consciousness'

34 y woman falls woman falls to the ground after hearing some bad news

C. vasovagal syncope

results from reflex bradycardia and peripheral VD in response to pain, emotion , or prolonged standing.

The pt may later report sx of nausea and closing in of the other visual fields before collapse. the pt is unconscious for about 2 min and recovery is rapid in the supine

a 60 woman who has recently started anti hypertensive medication has a fall after getting out of bed

B. Postural hypotension

antiHTN meds isa common cause of post hypotension particularly in elderly

may occur as a result of hypovolemia and /or autonomic dysfunction, e.g. diuretics may cause hypovolaemia and B blockers affect the ANS.

Other drugs ANS dysfunction: L-dopa & tricyclic antideppressants

a 75 y old , right handed woman is noted to ignore stimuli on the left side of her body

L. Right Parietal lobe lesion

pt has sensory neglect -> non-dominant hemisphere . she's right handed -> dominant left hemisphere. Lesion on the Right Parietal lobe

non-dominant lobe is responsible for visuospatial skills that is reflected in the signs encountered.e.g. visual agnosia, dressing apraxia, constructional apraxia

65 y woman with suspected dementia is noted to be aggressive and sexually disinhibited.

H. Frontal lobe lesion

HINT: Social and Sexual disinhibited

Other sx: apathy , emotional lability , incontinence

65 y man has been unable to understand the ward staff over the last few days and speaks fluently in jargon that cannot be understood. His speech and language were previously normal

J. Dominant temporal lobe lesion

Wernicke's dysphagia

His comprehension is impaired and his speech is fluent but full of jargon - that he is obivious to -

Look out for neologisms ( in absence of psychosis) . A Lesion in the Broca's area ( locate din the dominant frontal lobe ) gives rise to an expressive dysphasia i.e. non-fluent speech wth intact comprehension

a 34 y woman with Multiple sclerosis is found to have bilateral internuclear opthalmoplegia

C. Medial longitudinal fasiculus Lesion

Bilateral internuclear ophthalmoplegia is almost exclusively found inmultiple sclerosis and is caused by bilateral involvement of the MLF.

When pt is asked to look towards the right, the left eye fails toadduct and the right eye develops coarse nystagmus in abduction. This iscaused by the left MLF lesion. and vise versa

41 y man presents with dementia , irregular jerky movementsof the trunk and limbs. His father suffered from similar problems

E . Caudate Nucleas Lesion

Huntington's disease

Autosomal Dominant condition present in middle age.

Pathologically, there isprogressive degeneration of the striatum (caudate nucleus and putamen)and cerebral cortex

a 45 y woman on anti epileptic therapy complains of acne and increased facial hair growth . She is on no other medicaiton

G. Phenytoin

Phenytoin toxicity is associated with a ‘cerebellar syndrome’ (ataxia,nystagmus, intention tremor). Skin and collagen changes, includingacne, hirsuitism and gum hypertrophy, have led to phenytoin becomingan unpopular drug, especially among younger patients.

It mayalso cause a folate-deficiency macrocytic anaemia.

25 y man presents with visual field defects 2 months after starting a new anticonvulsant therapy

L. Vigabatrin

Itis reserved for the treatment of epilepsy that is not satisfactor-ily controlled by other drugs.

It has also been used as monotherapy inthe treatment of West’s syndrome (infantile spasms).

Visual field defectsare common and careful monitoring for this adverse effect is required.Unfortunately, in many cases these defects can persist even after treat-ment is discontinued

21 y woman presenting with status epilepticus complains of rectal irritation after being given an antiepliptic medication per rectum

C. Paraldehyde

Other Mx of Status epileptics :

IV benzodiazepine first line mx but assx with high risk of venous thrombophlebitis thus emulsion preparation are available to limit this

IV Lorazepam also popular in major status episode, advantage of longer duration of action , bt slower onset of action

32 y woman on treatment for temporal lobe epilepsy complains of tremor, drowsiness and thinning hair. she is found to have mildly raised liver enzymes levels

E. Sodium Valporate

it inhibits activity of cytochrome P450 enzymes and thus will potentiate the activity of any drugs that are metabolized by these enzymes.

Liver funciton test must be monitored before and during first few months of therapy.

It is C/I in active Liver disease

24 man who has recently stated adjunctive anti epileptic therapy complains of a rash with blisters in the mouth and flu sx

Drugs being used ?

J. Lamotrigine

pt are warned to seek medical advice if rash/flu-like sx develops while on the drug.

Risk of developing STEVEN-JOHNSON SYNDROME and Toxic epidermal necrolysis may be increased if lamotrigine is used with Sodium Valporate

52 y man with ishcameic heart disease requires mx for an acute migraine attack that has not responded to paracetamol

H. High dose Aspirin & Metoclopramide

this should provide releif for the sx of pain and n&v assx with migraine

Serotonin 5HT1 agonists ( Sumatriptan) are indicated if pt fails to respond to conventional analgesics . PS : but are C/I in pt with Coronary Artery disease, previous MI, Uncontrollable HTN

75 y has a headache and painful red congested eye with dilated non-responsive pupil. Mx?

J. Acetazolamide

Dx: Acute Glaucoma - medical Emergency ( risk of blindness)

Sx often precipitated made worse by the dark.

Severe pain can lead to N&V

Acetazolamide acts by decreasing the formation of Aqueous humor.

After intraocular pressure been reduced, surgical intervention ( Peripheral iridectomy ) can prevent recurrence

65 y woman presents with a headache that has lasted a few weeks. she gets pain in her mouth during meals and her scalp is tender on palpation. Mx

E. Prednisolone.

Dx: Giant Cell Arteritis

Dx test: ESR raised.

Patholgy : Skip lesion occur in temporal arteritis and so a negative temporal artery biopsy is not an indication to stop mx in the face of high clinical suspicion of GCA

70 y woman requiring mx for troubling trigeminal neuralgia

K. Carbamazepine

A benzodiazepine and used in anticonvulsion.

29 man with a skull fracture is suffering from a very severe pain overlying the laceration to his head. He has been admitted for overnight observation. Mx

D. Paracetamol

Ps: Morphine causes pupillary constriction and should not be given as analgesia in the case of head injury due to interference with neurological observation

Improvement of tremor in a 70 y pt of Parkinson's disease on mx with Levodopa


G. Benzhexol

a muscarinic Aceetycholine Receptor Antagonist

used in mx of Parkinson's tremor.

Useful in treating tremor and rigidity , and reduction sialorrrhoea ( hyper salivation )

but little effect on bradykinesia

control of vomiting in a pt being treated for Parkinson's disease

J. domperidone.

Antiemetic ,

does not penetrate the bbb ( blood brain barrier)

can be given with centrally acting dopamine agonists to counteract their emetogenic effect

65 y man with Parkinson's disease cannot tolerate levodopa-based therapy despite careful titration . Mx

C. Bromocriptine.

a Dopamine receptor Agonist

Indicated if Levodopa therapy is no longer adequate / intolerable

use limited due to S/E : hypotension , fibrotic reaction e.g. Pulmonary fibrosis

a pt on therapy for Parkinson's disease requires urgent treatment for acute psychosis

A. Clozapine

an atypical aneiphyschotic and is thus preferred to the typical antipsychotic which have more marked extrapyramidal S/E

First thing to do though should be to reduce the dose of responsible anti-parkinsonian drug

75 man with severe Parkinson's disease with sx the remain uncontrolled on maximum oral therapy

H. Apomorphine.

a morphine derivative, white crystalline compound used as an emetic and in treatment of parkinsons'

SC/ infusion indicated with motor sx of Parkinson's remain refractory to max therapy with levodopa and other drugs.

Hospital admission required for initiation of treatment

A/E: N&V common and so pretreatment with domperidone is standard