An 84-year-old female is admitted for a urinary tract infection. On the second night of admission she is found wandering outside the ward in an agitated state. Despite appropriate antibiotic therapy, nursing care and modification of her environment she remains agitated and aggressive and it is judged a potential danger to herself.
What is the most appropriate management?
Correct Answer C: Whilst many doctors may use oral lorazepam in this situation the Royal College of Physicians recommend haloperidol as the first-line sedative. NICE also advocate the use of olanzapine.
Acute confusional state: Acute confusional state is also known as delirium or acute organic brain syndrome. It affects up to 30% of elderly patients admitted to hospital.
Features - wide variety of presentations:
Management:
Which one of the following causes of Horner's syndrome is due to a lesion in the post-ganglionic part of the nerve supply?
Correct Answer A:
Horner's syndrome - anhydrosis determines site of lesion:
Horner's syndrome:
Features:
Distinguishing between causes:
Heterochromia (difference in iris colour) is seen in congenital Horner's
Anhydrosis: see below:
*In reality the appearance is due to a narrow palpebral aperture rather than true enophthalmos.
A 31-year-old man presents around four weeks after a non-specific viral illness characterized by fever, lethargy and sore throat. For the past week he has noticed increasing weakness in his legs which has now started to extend to his arms. On examination he has reduced power, reflexes and slightly reduced sensation in his lower limbs. A few days after admission he becomes short-of breath. His forced vital capacity (FVC) starts to fall and he is transferred to ITU. Given the likely diagnosis,
what is the treatment of choice?
Correct Answer D: This patient has developed Guillain-Barre syndrome (GBS) secondary to a viral illness, possibly the Epstein-Barr virus. The ascending weakness and areflexia point to a diagnosis of GBS.
Guillain-Barre syndrome: management:
Guillain-Barre syndrome describes an immune mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni).
IVIG may be easier to administer and tends to have fewer side-effects:
Prognosis:
A 72-year-old woman with a past history of treated hypertension presents to the Emergency Department.
Yesterday she had a 2 hour episode where she couldn't find the right word when speaking. This has never happened before and there were no associated features. Neurological examination is unremarkable and blood pressure was 150/100 mmHg. Her only current medication is amlodipine.
Correct Answer C: This patients age, blood pressure and duration of symptoms would put her in a higher risk category. Current guidelines advocate specialist review within 24 hours.
Transient ischaemic attack:
NICE issued updated guidelines relating to stroke and transient ischaemic attack (TIA) in 2008. They advocated the use of the ABCD2 prognostic score for risk stratifying patients who've had a suspected TIA:
This gives a total score ranging from 0 to 7. People who have had a suspected TIA who are at a higher risk of stroke (that is, with an ABCD2 score of 4 or above) should have:
If the ABCD2 risk score is 3 or below:
NICE also published a technology appraisal in 2010 on the use of clopidogrel and dipyridamole.
Recommendations from NICE include:
With regards to carotid artery endarterectomy:
*European Carotid Surgery Trialists' Collaborative Group
**North American Symptomatic Carotid Endarterectomy Trial
The following drugs commonly exacerbate myasthenia gravis, except:
Myasthenia gravis: exacerbating factors:
The most common exacerbating factor is exertion resulting in fatigability, which is the hallmark feature of myasthenia gravis . Symptoms become more marked during the day.
The following drugs may exacerbate myasthenia:
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