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1: Migraine

2: Vitamin B 12 Deficiency
3: Visual Disturbance (Amaurosis Fugax)
4: Transient Ischemic Attack (TIA)
5: Weakness in right arm and leg (Subdural Hematoma)
6: Subarachnoid Hemorrhage
7: Acute Vertigo (PICA)
8: Acute Stroke Counseling
9: Seizure And Subdural Hematoma
10: Acute Brain Syndrome/Acute Confusion/Delirium
11: Hyponatremia Delirium HIDEMAP
12: Hyponatremia (Delirium)
13: Acute confusion in a Postoperative Patient (Delirium Tremens)?Post
surgery Delirium
14: Delirium After Burn Injury(Book 134):
15: Delirium (Digoxin Toxicity)
16: Multiple Sclerosis (Optic Retrobulbar Neuritis) Do it later
17: Multiple sclerosis
18: Cervical Spondylosis with C6 or C7 disc Prolapse
19: Encephalitis
21: Assessment of a comatose patient
22: Recurrent Falls/Assessment of Mechanical Falls


You are a GP and a 35-year-old female came in due to headaches.






(on and off x 6 months; attack started

yesterday, on the back of head, pulsating)

Physical examination
Do you need some painkillers? Since when are you having this
pain? How bad is it?
What type of pain is it? Is it pulsating, throbbing or a dull ache?
Is it one sided of all over your head?
When the pain starts, where does it start first?
How does it progress? is it aggravated by movement, noise or
Do you get any symptoms before the headache starts for
example visual problems, changes in your sense of smell,
nausea or vomiting? Is this the first time?
How many episodes have you had previously? How long does it
What relieves your pain? Is it worse in the morning? did you
have fever recently?
Any infection recently? Do you feel numbness or weakness in
any part of your body? Did you hurt yourself in your head?
Do you think your headache is related to food especially red
wine, cheese, chocolate, bananas, Chinese food, coffee?
How's your general health?
Any history of HPN or DM? What is your occupation?
Any stress at work or home? Any financial problems recently?
How are your periods?
When was your LMP? OCP?
Do you think your headaches are related to your periods?
Any family history of migraines? SADMA?



General appearance: pallor, jaundice, dehydration

ENT: signs of runny nose or watery eyes; check for PEARL;
signs of meningism;
auscultate chest and heart; LN; palpate tummy
CNS: motor weakness, paresthesias or sensory disturbances
cluster headache
subdural hematoma
temporal arteritis
You have a common condition called migraine. 10% of world's
population suffers from migraine. It is more common in females.
Usual age of onset is at a young age. The frequency of
headaches reduces after the age of 50. The exact cause is not
known but there trigger factors including: fatigue, hunger, strong
odors, excessive noise, hormonal changes, and certain kinds of
The mechanism is dilatation of the blood vessels outside the
brain. There are three types: a. Classic (presents with an aura),
b. Common, c. Atypical (abdominal migraine - commonly seen
in kids).

Treatment focuses on two aspects:

1. Treating the acute attack (rest in a quiet dark room, avoid
reading/tv, cold packs to head, and medications)
mild migraine: soluble aspirin 600-900mg q4 or PCM 500mg
q4 + an antiemetic
moderate: ergotamine + antiemetic (metoclopramide)
severe: sumatriptan + antiemetic (metoclopramide or
These medications are also available in the form of
combinations (mersyndol - paracetamol + codeine +

If on OCP, review because it might aggravate migraine

For prevention: lifestyle modification, avoid trigger factors, and
>3 attacks/mo may give preventive medications such as betablockers, cyproheptadine, TCAs, calcium channel blockers x 612 months then taper and review


A 65-year-old man is in your GP clinic with complaints of weakness and numbness

of his legs and unsteady gait. He also complains of tiredness.
o History


(pale, normal BMI, decreased power on both

sides, loss of sensation on both sides,
normal vibration and proprioception,
unsteady gait)


Physical examination

(started since the last 3 months, weakness

in both legs, numbness, unable to keep
balance, tired, headache, pale, no fever,
night sweats, weight loss, weather
preference; had operation 10 years ago for
removal of some part of stomach, alcohol
2drinks/day for last 20 years)

(decreased Hgb, normal iron studies,

decreased vitamin b12, folic acid normal,

Diagnosis and management

Peripheral Neuropathy (Diabetes)
Brain tumor
Vitamin B 12 deficiency
Diet (vegetarian)
Decreased absorption: gastrectomy
Pernicious anemia:
Atrophic gastritis
Hypothyroidism, Diabetes
Less likely: MS, neurosyphilis, GBS, spinal cord


Anemia, weight loss and neurological symptoms

Manifests subacute combine degeneration of spinal cord
B12 >220mol pmol/L = deficiency unlikely
B12 <148 pmol/L = deficiency
Intrinsic factor antibody level is diagnostic
Vitamin B IM injection (1000mcg) body stores are
replenished after 10-14 injection given every 2-3 days
Maintenance with 1000 mcg IM injections every 3rd month
Can use crystalline oral B12
Co-therapy with oral folate 5mg/day

Since when? Is it in one or both legs? Any weakness in any

other part of the body? Does the problem of the gait came
with weakness of the legs? Any problem with your speech
or vision? Since when have you been feeling tired or
weak? Do you feel light-headedness, chest pain or SOB?
Can you tell me about your diet? How is your appetite? Any
episode of heartburn or tummy pain? Any previous gastric
surgery? Any problem with your stools or waterworks?
Have you ever been diagnosed with diabetes? Do you
drink alcohol? How much do you drink? Any headache or
vomiting? Any lack of concentration or irritability? Do you
have any weather preference? In the past, have you ever
been diagnosed with pernicious anemia or malabsorption
syndromes such as celiac disease? Any gastrointestinal
o FHx of autoimmune disease? Are you on any medications
such as PPI or H2 blockers?
Physical examination
o General appearance: pallor
o Vital signs
o ENT: Swollen red tongue (glossitis)
o Neurological exam: gait, tone, power, reflexes, sensation,
vibration or proprioception, Romberg test may be +
depending if the proprioception is lost
o Abdomen: scars, organomegaly
o Urine dipstick and BSL

o FBE: Hgb low and MCV high
o Vitamin B 12 low and folate level normal
o Iron studies
o Intrinsic factor antibody level + diagnostic
o LFTs, TFTs, RFTs
Dx and Mx:
o From the history and PE, you have anemia caused by
vitamin B 12 deficiency which caused the neurological
symptoms. I will refer you to the hematologist and
neurologist for further evaluation and management.
o The treatment is replacement of vitamin B12 1000mcg
injected intramuscularly every 2-3 days. The body stores
can be recovered after 10-15 injections and maintenance is
1000mcg every third month. If there is poor intake, oral
vitamin B12 may also be given. I will also give you oral
folate 5mg as co-therapy.
o The prognosis depends on how long the person had
symptoms and if it is in the first few weeks of the
symptoms, complete recovery usually occurs and if it is
delayed (>1-2months), it might not recover completely. If
left untreated, it can result in progressive and irreversible
damage to the nervous system

You are an HMO and a 50-year-old woman is in the ED with complaint of loss of
vision. She has past history of bypass surgery 2 years ago. She is hypertensive and
is on ACE inhibitors.
o History

Physical examination


(CAROTID BRUIT on CVS examination,

neurologic and eye examination normal)

Diagnosis and management

Painless loss of vision
Anterior circulation
Usually lasts <60 minutes
Can you describe it for me? When did it happen? For how
long did it last? Was it sudden or gradual? Is it the first
episode? Any injury to your eye, swelling or redness? Is it
associated with pain?


(Blurring of Vision, curtain dropping or falling


The loss of vision in your eye is a condition called

amaurosis fugax is due to temporary lack of blood flow to
the retina of your eye and it is called TIA. It usually does
not result in permanent damage but can lead to future
stroke. It is most likely due to hard substance called
atherosclerotic plaque that is formed from fats and other
substances in the wall of your neck vessels. A piece of this
plaque can break off and travel to the retinal vessels
causing a temporary block to the blood flow.
I am going to admit you at the stroke clinic where you will
be seen by a neurologist and cardiologist.


It is a surgical procedure where the plaque is removed from

the vessel and the normal blood flow to the brain is
restored. Second option is (PTA) percutaneous

transluminal angioplasty that is to put a stent to prevent

further stroke.

<60% ASA
60-70% may or may not undergo carotid
>70% carotid endarterectomy


<30% ASA
>30% carotid end-arterectomy

Variant 1:
Trevor, aged 65 years presents to your GP clinic with his wife Margaret. He tells you
he had funny turn this morning. He has completely recovered and made the
appointment at his wifes insistence. He says he first noticed something was wrong
when he answered the telephone call from his sister and found it difficult to speak.
His wife reports that his words were muddled and he had difficulty making him
understand. She thought he seemed confused at that time.



Further focused history

(hard to understand what he said, words not
coming out x 5 minutes to become normal;
HTN on coversyl)
Examination findings from examiner
(BMI 27, BP 150/90)
Probable diagnosis and treatment advice

Variant 2:
You are in ED and a 60-years-old woman comes to you complaining of left arm
o History
o Physical examination
o Management
Variant 3:
A 60-year-old female came to the GP clinic with weakness of the right leg. She has
diabetes type I which is well controlled.
o Relevant history
o Physical examination

(130/90, normal funduscopy, cranial nerves

intact, no bruit, tone slightly increased, 4/5

Diagnosis and management

DDx (Stroke Mimics)

o Syncope
o Seizure
o Migraine
o Cerebral tumour and other SOLs
o Hypoglycemia
o Hyponatremia
o Delirium
o Head injury
o Medically unexplained (somatisation)
o Definition: transient neurologic dysfunction in the brain,
midbrain, brainstem and optic nerve due to ischemia
lasting <1 hour and which resolves completely
o Sudden onset
o Complete recovery in less than 24 hours
o Average duration is 5 mins.
o Consciousness usually preserved
o 90% anterior circulation
o Carotid TIAs unilateral features
o Vertebrobasilar TIAs often have bilateral or crossed
ABCD Stroke Risk Tool
o Age: 60 years (1)
o BP: 140/90 (1)
o Clinical features
o Unilateral limb weakness (2)
o Speech impairment without weakness (1)
o Duration
o 60 minutes (2)
o 10-59 (1)
o Diabetes: 1
o Maximum: 7 points
o >4 = high risk and should REFER
o <4 = low risk
Is it STROKE? Think Fast
o Face (ask person to smile)
o Arms (raise both arms)
o Speech (speak a simple sentence)
o Time (within 3 hours)


What happened? When? Arms, legs, face? Numbness or

o Is it for the first time? How long did it last? Is it getting
better or worse?
o Was it sudden in onset?
o Problem with vision (diplopia, blurring), speech, asymmetry
of face? Headache? Loss of consciousness/confusion?
Change in gait? Head injury? Chest pain? SOB?
Palpitations? Vomiting? Spinning around? Waterworks?
Bowel motions?
o General health? Previous history of stroke, cadiac
problems such as heart attack, valve disease,
hypertension? Diabetes? Lipid levels? SADMA?
Medication (warfarin, anti-hypertensives)
o FHx and social history (lifestyle and stress)
Physical examination
o General appearance and BMI
o Vital signs: especially BP (postural drop) and PR (rate and
o Eyes and neck: PEARL, ophthalmoplegia, carotid bruits,
JVP, funduscopy
o CVS and peripheries
o Neurologic exam: cranial nerves, motor, power, reflex
especially plantar, tone, sensory, coordination
o BSL and Urine dipstick, ECG
o One of the vessels supplying a part of the brain is blocked
by a clot for a brief period of time which causes a decrease
in oxygen supply to that particular area of the brain
temporarily. This is what we call a mini-stroke or TIA. Most
symptoms disappear within an hour although they may last
for 24 hours. It might have come from the heart or it is a
clot that is formed from the vessel of the brain. It is due to
fat deposits within the vessels called plaques. It is
considered as a medical emergency and taken as a
warning sign for future brain attacks.
o Refer to ED or ADMIT to stroke unit ASAP so that you will
be seen by a neurologist. The specialist will assess you
and do some investigations.

I will arrange for urgent CT scan and carotid Doppler

Need to do FBS, lipid profiles, FBE, UEC, LFTs, ECG, 2decho, TFTs, clotting profile, HbA1c
o 20% will get stroke in the next 6 months and 50% of these
people are at risk of getting full-blown stroke within the next
24-48 hours.
o The specialist might consider starting you on clopidogrel or
ASA + dipyridamol to decrease the risk of stroke in the
future (30% decrease in the risk of future stroke after TIA).
o We also need to address your risk factors. Lifestyle
o Diabetic foot
If treating as OP:
o In low risk: arrange CT brain and carotid Doppler (for
possible endarterectomy) within the next 24-48 hours.
o Arrange all basic bloods: FBS, creatinine, cholesterol,
o Refer patient to TIA clinic or neurologist within 7 days
o Management:

Cessation of smoking and lifestyle

modification (weight reduction, exercise,
Start antiplatelet therapy (asprin 100-300mg
OD, clopidogrel 75mg OD or dipyridamol +
ASA 200/25 mg BD;
Anti-hypertensives: ACE inhibitors
Monitor blood sugar
End-arterectomy >70%
Indications for carotid duplex ultrasound
Bruit in the neck
Crescendo TIAs (2 or more in 1 week and
longer lasting)
Internal carotid artery symptoms
Hemispheric stroke
Prior to major vascular surgery

o major stroke risk factors in people who have atrial
o CHF (1)
o Hypertension (1)
o Age >75 (1)
o DM (1)
o Stroke/TIA (2)
0 low aspirin (81-325mg)
1 Intermediate aspirin or warfarin
>2 high risk - warfarin

A 60-year-old man is in the ED where youre working as an HMO where he is
complaining of weakness of his right arms and legs.
o History

(had history of fall 2 weeks ago, noted

headache x 3 days after that and sometimes
headache when bending forward, coughing
or changing head direction; on warfarin;
noted sudden onset of right-sided weakness)

o Physical Examination
o Diagnosis and management
Risk factors
o Elderly patient brain shrinks (cerebral atrophy)
o Dementia
o Alcoholic
o Warfarin
o Head injury (recurrent falls)
o Weakness or numbness
o Headache bending forward or when coughing or when
changing head direction
o Confusion
o Drowsiness
o Personality changes
o Amnesia
o Seizures
o Can you tell me more about what happened? Is it getting
worse or improving? Any change in your vision? Any
problem with speech? Did you have any recent head
injury? How did it happen? Any headache after that? Any
N/V/changes in personality? Drowsiness or confusion?
Episodes of fits? Difficulty in walking or ataxia? Any past
history of heart disease, stroke, DM, increased lipids?
Medications? Do you have enough support?

Physical examination
o General appearance
o Vital signs
o Eyes
o CNS examination
o BSL and dipstick
o Subdural hematoma because of the head injury and you
are also taking warfarin.
o Admit. Referral to neurologist and CT scan.
o Baseline laboratory examination including clotting profile
and INR.
o Small: careful observation until it heals by itself or
temporary insertion of a small catheter and suctioning the
o Large: craniotomy

Variant 1:
A 36-year-old male patient is in the ED with sudden pain on the back of the head
while working in the fields. It is not relieved by Paracetamol.


Physical examination

(headache going to the neck)

(ptosis, dilatation of pupil, neck stiffness)

o Management
Variant 2:
Rosemarie aged 27 years presents to your surgery with history of headache for last
couple of month. She describes headache as feeling funny around her mouth then
flashing bright lights, then a pounding headache always on right side of her head.
The headache could last for several hours sometimes relieved by vomiting. For a
few days afterwards, she feels tired and just a bit off. She had tried pain killers like
panadol and ibuprofen with minimal relief. She is otherwise fit and healthy and has
no previous medical problems and is not on any medications.
o Focused history
o Physical examination
o Diagnosis and management advise
o Migraine
o Subarachnoid Hemorrhage:


occipital headache + vomiting + neck

stiffness; worst headache of my life




Subdural hemorrhage
Tension headache
Can you tell me a bit more about it? When did it occur?
How severe? Where? Does it go anywhere (neck)?
Character? N/V? Is it progressive? Is it the first time? Does
anything make it worse? Photophobia?

Risk factors: Berry aneurysm (85%) - PCKD, bleeding

disorder, AV malformations, head injury, hypertension
o SADMA? General health?
Physical examination
o General appearance
o Vital signs and BMI (BP increased, pulse decreased)
o Eyes: 3rd nerve compression from PCA rupture; ptosis,
absent light reflex, accommodation, diplopia (down and out
eye, pupillary dilation) and papilledema
o Neck stiffness
o Cardiac examination
o Abdomen: (PCKD)
o Neurologic examination
Dx and Mx:
o SAH is a condition where blood leaks out of the blood
vessel in the subarachnoid space that is one of the linings
covering the brain. It is a medical emergency and requires
immediate management. You will be seen by the
neurosurgical team and investigations will be done
especially non-contrast CT scan. If negative (10-20%), a
lumbar puncture will be done (xanthochromia).
o To confirm where the bleed is, a cerebroangiography will
be done. This is a procedure in which a special dye is
injected in the vessels through catheter and xray is taken to
detect/check movement of the dye and site of hemorrhage
is detected. We will also perform all baseline investigation.
o Management involves stabilization of patients condition.
oxygen and IV line, painkillers, medicine for vomiting/antiemetic. Nimodipine to prevent spasm of vessels.
o Surgery will be done the neurosurgeon will go for
neurosurgical clipping to prevent bleed of aneurysm. A
metal clip is used to close aneurysm around its neck.
o Endovascular coiling: tiny coils are placed to block flow of
blood into aneurysm to prevent hemorrhage.

You are working in a primary care facility attached to a teaching hospital and a 50year-old man is consulting you about intense dizziness. He is a previous patient who
is overweight, and he is on medications for control of hypertension and
hyperlipidemia. He appears unwell and distressed with slight drooping of left eyelid.
His wife drove him to the hospital.
o History



(feel so dizzy I can hardly stand up,

everything is spinning around since 1 hour
while having breakfast when I felt pain on left
side of the face; vertigo then numbness on
left side of face, dizzy that I couldnt even sit
up, no LOC, found it hard to get in and out of
the car and falling on the left side and cannot
keep balance; right leg numb, no problem
swallowing, smoker x 10sticks/day; mother
died of stroke)

(BP 145/85, PR: 80 regular, PEARL,

funduscopy normal, nystagmus on Left, left
horner syndrome, absent pain sensation to
pinprick, and corneal reflex is absent,
reduced pain and temperature on right side,
vibration and position sense and light touch
normal, hearing normal, tone, power and
reflexes normal, incoordination and falls to
left side)

Diagnosis and management with examiner

Stroke (PICA)
Acute labyrinthitis
Meniere syndrome
Cerebral tumor
Multiple sclerosis


Is my patient hemodynamically stable? Can you describe it

for me please? Since when did this happen to you? Did it
get better or worse? Did you try to stand or walk after this?
Is it for the first time? Any association with headache? Any
associated weakness of your arms, face or legs? Any
problem with speech? Problem with vision? Neck stiffness?
Episode of vomiting? Problem with swallowing? What
about taste sensation? Did you have hoarseness of voice?
Any recent head injury? Problem with hearing? Ringing
sensation in your ear? Fever?
o Chest pain, SOB or palpitation? Previous heart disease?
What about your BP? What about your lipid levels? What
about your blood sugar level? Do you have DM or PVD?
Past history of similar condition? SADMA? Stress?
o FHx of diabetes, hypertension or stroke
Physical examination
o General appearance
o Vital signs and BMI (increased)
o Neurological examination:
o Inspection: head injury, facial asymmetry, muscle wasting,
gait, Romberg test negative, incoordination of movements
of left arm, and hand
o Tone, power, reflex normal
o Cerebellar signs positive
o Sensation, pain and temperature decreased in contralateral
o Vibration, joint position and light touch normal
o Cranial nerves: horner syndrome
o Eye movement: normal
o Funduscopy normal
o Nystagmus positive on ipsilateral
o Pain, sensory loss of ipsilateral
o Direct, corneal reflex negative
Dx and Mx:
o Most likely the patient has PICA syndrome because of the
obstruction of the blood supply to the brainstem and
cerebellum. Vertigo is of central brainstem or cerebellar
origin. Significance of crossed signs (numbness on


ipsilateral face and contralateral body) plus cardiovascular

risk factors present in the patient.
It is a medical emergency. Immediate hospital admission
and assessment by the specialist is necessary.
Investigations that are needed to be done are MRI/CT
angiography (acceptable) to confirm the diagnosis. Other
investigations are FBE, BSL, RFTs, Lipid Profile, LFTs,
ECG, Echo.
Management is to advise about CV risk factors and the
patient can be put on ASA and supportive treatment with
active rehabilitation.

A 60-years-old man is brought by his wife to the ED complaining of acute onset of
weakness and numbness of the left side of the body and aphasia/dysphasia 1 hour
ago. The symptoms are still present. He has a history of hypertension and a
pacemaker was inserted a few years ago for heart block. His wife wants to discuss
his condition with you.
Explain the situation to the wife
Explain about management plan and possible outcome
Answer her questions
Is my patient hemodynamically stable?
Does the wife have a SPA or consent to discuss her husbands
I understand that you are quite worried about your husband, but let
me assure that he is in safe hands and we will do our best to help
and treat his condition. Before anything else, do you have any
particular concern that I can address? I will explain the condition,
cause, risks and followup.
Most likely he has a condition called stroke. It is a condition in which
part of our brain stops functioning due to disturbance in the blood
supply to that area of the brain (Draw diagram). The lack of blood
flow can be due to blockage of the vessels by a clot which is a
thrombus or embolus or leakage of blood which is called
hemorrhage. This in turn leads to the symptoms that your husband is
having now.
There are certain risk factors for this to happen: hypertension,
diabetes, smoking, aspirin/warfarin, head injury, peripheral vascular
disease, lifestyle, dyslipidemia
Ask about contraindication to thrombolysis: bleeding disorder or
recent surgery, warfarin/ASA
It is a serious condition and is a medical emergency so he needs to
be admitted to the stroke unit ASAP to stabilize his condition. He will
be assessed by a neurologist who will order some investigations. The
most important is non-contrast CT scan or MRI to see the type of the
stroke and other investigations like FBE, lipid profile, ECG, U&E,
LFTs, RFTs, echocardiography.
If it turns out to be ischemic stroke, he might be put on ASA and if
within 3 hours of onset, a substance called rTPA can be used to

dissolve the clot, but it will be decide by the specialist. However,

there is a risk of intracranial hemorrhage in 5-7% of cases. If it is a
hemorrhage, drugs can be given and/or surgery can be done.

His condition will be stabilized and supportive treatment will be given.

Good nursing care will be provided and this is the cornerstone of
management. It is to maintain skin care (bed sores), feeding,
hydration, proper positioning and monitoring of vital signs, giving
painkillers, and anti-emetics.
Is he going to improve? The outcome cannot be predicted at this time
because it depends on the area involved and the amount of tissue
damage. It can improve or the condition can progress further but we
will try to give him the best quality of life by all possible means.
Long term management: Following initial management, he will be
under the care of a MDT for stroke rehabilitation to recover any lost
function and return to independent living. This team will include
neurologist, specially trained nurses, speech pathologist,
physiotherapist, occupational therapist, social worker and GP for
regular reviews and follow-ups.
It is very important to control the risk factors to prevent further attacks
and this is where your role is vital. Lifestyle modification: exercise,
diet, control BP, sugar, and lipids, smoking cessation
I can also arrange for cardiologist review to assess his pacemaker
and other factors which can increase his risk
Reading material. Support groups.
You are not alone. All support is available for you
Red Flag: FAST Facial asymmetry, Arms difficult to raise, Speech
problems, and Time Call 000

You are a GP in a small rural town and are asked to see a 22-year-old man who
collapsed about an hour ago. He has now fully recovered.
o Relevant history to try to determine the cause of the
o Ask examiner for relevant physical findings
o Explain to the patients what you this has likely happened
and what it your immediate plan of action
Differential Diagnosis
o HOCM - rare?
o Vasovagal syncope
o Infection?
o DM (hypoglycemia)
o Trauma?
o Neuro problems?
o Cardiac?
Focused History
o When? Feeling of chest pain? Palpitations? Fever?
Headache? History of trauma? Blurring of vision? Previous
loss of consciousness? Changes in personality? LOC?
o Ask for patients wife to describe scenario and take
relevant history
Physical Findings: all normal: ask for fundoscopic findings
o Most likely this is a case of subdural hematoma which may
have resulted from the accident you had. Veins from the
brain bleed out which form a clot which if big enough may
have caused you to have a fit and lose consciousness.
o Skull x-ray and CT scan
o Urgent referral to a neurosurgeon/neurologist
Syncopal disorders:
o Common causes: cardiogenic disorders and postural
o hypotension, which are usually drug-induced; vasovagal


Red flags: onset in older person, neurological S/sx,

headache, tachycardia, irregular pulse, fever, drugs
(social/prescribed), confusion (gradual onset), cognitive
Sudden onset: epilepsy, cardiac causes (SVT), TIAs,
Drugs: alcohol, antiepileptics, antihypertensives,
barbiturates, benzodiazepines, OTC anticholinergics,
peripheral vasodilators (ACE, ARBs, GTN, hydralazine,
prazosin), SSRI, TCAs

Variant 1:
Your next patient in GP practice is an 85-year-old woman who was brought by her
daughter because her mother was acutely confused over the past few days. (one
case with DM and one with UTI)


o (3 days and patient unable to recognize anyone,
wondering around the house and at times became
incontinent, + dark, cloud and smelly urine, on
medications for BP and cholesterol)
Explain plan of management

Vatiant 2:
Your next patient Mrs. Gladys George brought to your surgery by the staff from a
Low level nursing facility. Mrs. George moved to the Nursing home one month ago,
after being discharged from an old aged care psychiatry unit. Before her admission,
she had been living independently at home. The precipitant for her admission was a
fire in her flat. When the fire departments arrived Mrs. George was running around
the premises of the building claiming she was Messiah and the blaze was started by
demons. She was to taken to the hospital and was treated at an old age psychiatry
unit. She had normal blood tests and MRI brain showed generalized atrophy
consistent with age. The nursing staff thinks she had lost some weight. She had
been wandering the halls at night on few occasions. She is agitated and seems
confused. On one occasion she asked the staff are the Russians here yet -. One
of the nurses think Mrs. George has been seeing some things.
o Task
o How will you manage Mrs. George

Variant 3:
(Feb 4, 2012): An elderly whos confused and has SOB is admitted in the rural
hospital where youre working which is 300km away from the city. ECG and CXR
showed right-sided heart failure. In the blood test, no abnormalities were detected.
The daughter wants to talk to you.
o Talk to the daughter
o Counsel accordingly
o (LHF SOB sec. backflow of blood into lungs and patient
cannot breathe properly)
o Sit upright, start furosemide to remove fluids CPAP if
not working
o Start high flow oxygen, explain about heart failure
o Arrange cardiology consultation;
o Investigation: Transthoracic Echocardiography to measure
ventricular function
Advice: Low-salt low fat diet, ideal weight, stop smoking/alcohol,
control HTN, DM and lipids; ACEI, diuretic, beta-blockers when
no indications to transfer to hospital


Hours to weeks

Slow insidious
Months to years

Course over 24

Fluctuates worse at
common (esp. visual)
Common (visual)
usually or auditory

Minimal variation

Acute Psychosis
Depends on response to
Minimal variation

Misperception rare

May be misperception


Common, mainly auditory

Normal to impaired

Variable, may be
One or both present

Difficulty finding
correct words
Often absent

Variable may be
Variable: normal, rapid or
Usually absent

Organic Illness
or drug toxicity

o Depression/Drugs/alcohol
o Ears/Eyes
o Metabolic (hyponatreamia, diabetes, hypothyroidism)
o Emotion/encephalopathy (loneliness)
o Nutrition (Vitamin B12/diet)
o Trauma/tumor
o Infections
o Arteriovascular disease (CVA, MI)
o LFTs, BSL, TSH, FBE, Blood culture, U&E, CXR, CT scan,
urine MCS, ECG
o What do you mean confused?
o Did she have any fever?
o Lumps or bumps?
o Any headaches or early morning vomiting?
o Did she lose consciousness at any time? Any weakness in
any part of the body or any problem with speech? Any
chest pain or shortness of breath?
o How about her appetite and weight?
o Has she lost any weight? Any weather preference? Any
swelling all over the body? Any medical illnesses like
diabetes or hypertension? SADMA? Any recent change in

medications? Problems with waterworks? Any change in

color? Any concerns with the bowel?
o Whom does she live with at home? How is her mood?
What does she do? Recent hospitalization
o I would like to admit your mother to the hospital. I will
arrange an ambulance for that. There are a lot of reasons
for acute confusion or delirium.
o From the history, I believe she has a UTI, but because she
is also hypertensive, she might also be suffering from a
stroke which is why we need to admit her to do some
investigation for hypoxia (pulse oxymetry, saturation, ABG
and CXR), sepsis or infection (FBE, blood culture, urine
MCS, ESR/CRP), metabolic (BSL, U&E, arterial pH),
cardiac (ECG, cardiac enzymes), CVA (CT scan). They will
also review the medications.

An 83-year-old man developed strange behavior, confusion and disorientation for
the last couple of days. He lives in the nursing home. He is on some drugs:
Indapamide (hyponatremia, hypokalemia, hyperglycemia), statin, imipramine. His
physical examination is unremarkable. BSL is also normal. Blood test has done:
Sodium 120mmol/L, Potassium 4.5mmol, Urea is normal, Creatinine is normal.
o Explain the test results to the daughter, and the possible
causes of his confusion.
Low sodium level (135-145mEq/L)

Pseudo hyponatremia:
o Cause: DM If the sugar is high: Hyperglycemia.
The fluid is high the sodium seems to be low but its
Osmolality Formula:
o 2 X Na + GGlu/18 + BUN/2.8
If the glucose/sodium is high the osmolality is high. High
osmolality hyponatremia
If the osmolality is normal: True hyponatremia sodium goes
low because of low osmolality.
Causes: look for the extracellular FLUID volume.
If ECF volume: HIGH
o Cardiac failure, nephrotic syndrome, kidney/liver
o Low: external causes: vomiting, diarrhea, blood loss,
burns, sweating.
Renal causes:
Nephropathy, losing water along
with sodium. Anti-diuretic hormone
causes the losing of the sodium.
Indapamide: Its not losing salt but it
is losing the water.

If ECF volume is NORMAL:

o SIADH. The water retained in the body. It comes with
anything in the brain, in the chest, small cell lung
cancer, pneumonia, drugs (tricyclic anti-depressant
o Hypothyroidism.
o Psychogenic polydipsia.
Need to ask the patient about the: BSL, Kidney problem, Liver
problem, Diarrhea, Taking any drugs, Any problem with
brain/chest, Any weather preferences, increase or decrease of
the fluid

Patient is having hyponatremic encephalopathy. When people
have hyponatremia, it is going to give symptoms in the CNS.
Symptoms come with sudden drop of the sodium.
Isotonic/hypertonic. If the sodium drops slowly the fluid
becomes hypertonic. Fluid always goes to the higher
concentration thus losing the water which then goes to the
cells especially the brain cells. It causes herniation of the brain.
If we give the sodium too quickly, the cells will shrink quickly
and the brain is going to die which is called central pontine
myelinolysis. Dont replace it too quickly 0.5-1 mEq/hr.

Sodium level, Urine osmolality, serum osmolality, RFTs,


Advice the patient we are going to replace it slowly.

Treatment is to reverse the cause.
Give normal saline. (Vomiting, diarrhea)



Restrict the fluid. Patient can be given some normal

saline and furosemide. (Give the sodium slowly
pushes the water out)

Severe hyponatremia: Hypertonic Saline

Symptoms: N/V headaches/ restless/ irritable/

drowsy/ seizure/confusions/coma/death.

If you get dehydrated, serum osmolality goes up. When secreting

ADH the urine becomes concentrated, urine osmolality is high. If
serum osmolality is low, it means increase of the fluid, theres diluted
urine the urine osmolality is low. If there is a lot of ADH/ SIADH,
theres a lot of fluid in the body. But the water is not coming out.
Urine osmolality is high. The body is trying to keep the water.

Patient comes with confusion: If the patient has fever, problem with
urine, Any sepsis, Any edema

Address the drug it can be because of high/low fluid volume. We

need to find out the cause. Ill be calling the registrar we will manage
the condition accordingly.

Your next patient in GP practice is an elderly man with a long history of
hypertension and diabetes. He has developed tiredness, confusion, and hes
behaving strangely for the last 2 days. Investigations show sodium is 120,
potassium, chloride, bicarbonate, Urea and creatinine are all normal.

Most likely, the hyponatremia was caused by the indapamide. This is

a medication which affects the kidneys diluting capacity and
increases sodium excretion. (Once the depletion occurs, there is
non-osmotic release of ADH and causes water retention worsening


At this stage, I will call the ambulance because your father needs
urgent treatment. In the hospital he will be reviewed by a medical
registrar. IV lines will be secured and blood taken for further
investigations. They will start him on IV fluids (PNSS or hypertonic
saline 3% for rapid correction). A cranial CT scan will also be

Explain results to daughter

(indapamide, atenolol, imipramine, and meds for DM;

good control)

Explain possible causes and management

Basic Investigations: According to HIDEMAP

Hypoxia: pulse oximetry, oxygen saturation, ABG, CXR
Infection: Sepsis: Blood culture, urine MCS, FBE, ESR/CRP, CXR
Drugs: diuretics, benzodiazepines, morphine,
Endocrine: e.g Diabetes
Metabolic: ABG, BSL, urea and electrolytes
Alcohol: LFTs
Psychosis: MSE
ECG: cardiac enzymes and ECG

Does the daughter have authority to talk in behalf of the father?

From the blood reports, your father has a condition called
hyponatremia. There are some minerals in our body and one of it
sodium and there is a low level of this in your fathers body. Low
sodium means low osmolarity causing leakage of water into the brain
cells leading to edema of the brain and this causes confusion, but
there can be other reasons for confusion.
Is your father on any medications? Does he take any alcohol? Any
problem with his vision or hearing? How is his diabetes? Is it well
controlled? Is he on any medications? Have you seen him gasping or
having SOB or any sweet smell from the mouth? Any chance he
could be lonely or depressed? Any headaches or early morning
vomiting? Any chance he had a fall? How are his waterworks? Did he
have any fever? Any problems with the heart or weakness or
numbness of his body? Has he vomited or had diarrhea?

You are an orthopedic resident called by the ward NOD to see a 65-year-old man
who had a left knee replacement 2 days ago. He had been quite okay until today
where he seemed to be confused, restless and agitated. He had become verbally
aggressive and wants to pull out his drip and go home. His vital signs are BP
130/90, PR 102 regular, T 38.3, RR: 30. Cardiorespiratory examination is difficult
because patient is not cooperative. Per abdomen examination reveals some lower
abdomen tenderness. CNS examination is normal as far as you can assess. You
found the patient to be slightly confused and disoriented to time, place and person.
You could not do the whole MMSE because of lack of cooperation. ECG is normal
and you have asked the nurse to send the blood for troponin. Reviewing the medical
record, you note that the patient is drinking 6 cans of beer per day. His preoperative
biochemistry was normal except for elevated GGT, Hgb 120, MCV 110 with normal
b12 and folate.


Present and liaise with registrar who wants to know what is

happening and what is the most likely diagnosis
How you suggest to manage the patient
o On reviewing the chart, patient drinks 6 cans of beers
per day with mild anemia.
o The most likely diagnosis is delirium tremens due to
alcohol withdrawal following surgery over the last 2-3
o What else could cause delirium?
Hypoxia, infection, electrolyte disturbance,
metabolic causes, or narcotic overdose due
to pain relief.
o What further tests would you like to organize?
FBE, Blood culture, CXR, ABG, ESR/CRP,
Urine MSU, BSL, U&E, LFTs. Review the
drug chart and re-adjust pain relief and
narcotics dosages. CT scan.
o How do you manage the patient?
If the patient is getting violent, I would like to
call security (to make environment safe).
Start high-flow OXYGEN!!!! Move patient to
a quiet room with appropriate lighting and

with one nurse looking after the patient.

Consider involving relatives and friends.
Physical restrains as per hospital protocol.
Be prepared to sedate the patient
(Diazepam PO or IM midazolam 2.5mg SD
or olanzapine PO).
Monitor the vital signs and IV access, fluid balance,
oxygen and pulse oximetry. Consider IV thiamine.

(Condition 149): You are an intern called to the ward to see a patient who became
acutely confused after a left total knee replacement. A few hours earlier, he started
to behave in an irrational manner, became agitated and difficult to manage. Until this
stage he had been making an uneventful postoperative recovery. His confusion has
now culminated in the patient being disoriented, noisy, and difficult to restrain. The
patients wife is with the patient and she has been unable to help.

Assess the situation

Formulate management plan
Counsel patients wife as to the cause of the current problem

A 60-years-old man became restless and shouting in the postop ward. He had knee
replacement this morning and was uneventful. Morphine was given to relieve his
pain. Investigations were done are results are pending. Patient has hallucinations
and delusions and MMSE shows that hes disoriented. He has history of drinking 4-6
cans of beer every night.


Report to registrar about patients condition

Answer his questions

Assess situation
Is my patient hemodynamically stable? I would like to start with
DRABC and call for help and restrain patient as per hospital
Ensure and assess DANGER (physical restraints); DRABC
Institute pulse oximetry and put in high-flow oxygen.

Intravenous access: Insert IV cannula, collect blood samples

for routine hematological and biochemical screens, BSL, blood
culture if febrile
PMHx (DM or CVD), drug use (alcohol),
Case notes and nursing observation: any recent change in VS,
fluid balance, recent drug administration, details of recent
surgical procedure (complication, Blood loss), sleep pattern
and behavior
Comments in medical and nursing record and any abnormal
laboratory investigations
Physical examination
Establish orientation
Check vital signs and examine cardiorespiratory systems
Look for evidence of sepsis (abdomen and wound)
Look for evidence of VTE (legs, chest)
Look for any neurological deficits
Dipstick and BSL
Causes of Confusion
Hypoxia (very common cause particularly in elderly) ABG,
Metabolic (electrolytes, blood sugar estimation, arterial pH)
Cardiac disease (ECG)
CVA (neurologic examination)
Opiate overdose or effect of other drugs
Drug withdrawal (alcohol, benzodiazepines, narcotics)
Exacerbation of pre-existing medical conditions (dementia,
Reassure: The situation is under control
The investigations may yield a cause for confusion

Alcohol withdrawal is a common cause of postoperative

confusion and should be easily controlled and problem selflimiting
Regular reviews with monitoring of VS, I&O and any changes
in behavior

You are a night intern in a general hospital and your next patient is a 25-year-old
male student with 20% partial thickness burn sustained when throwing fuel over fire.
The burns involving all the limbs are being managed conservatively and have been
dressed under IV ketamine. You have been called because the patient is unable to
sleep, restless and distressed and has pulled out the IV line delivering patientcontrolled analgesia which is morphine 1mg/hr.


Determine the cause of sleeping problem

o (was out camping with friends, threw petrol over fire
and caught burn; cannot remember how it happened;
doesnt know how he got to hospital? feels being
chased and saw angel of death; doesnt want to close
eyes because something bad might happen; sees
strange looking people and suddenly disappear;
believes nurses are dangerous and think they are
here to harm; believes that nurses are giving the
wrong drugs; feels pain but cannot be bothered by the
drips thats why I pulled them out; not under the
influence of alcohol; no illicit drug use; no headaches)
Perform MMSE
Explain to the patient the nature of the problem and what can
be done to help


May I know a bit more about what happened? When did it

happen? How were you brought to the hospital? Do you know
which hospital you are admitted and for how long?
I understand youre unable to sleep. May I know the reason for
it? For how long is this happening to you? Do you hear voices
when nobody else is around? Do you see things when nobody
else is around you? Do you feel things or have any strange
experience? Do you think somebody is trying to hurt you? By
any chance, do you think of harming yourself or others?
Do you feel pain at the moment? How is your general health?
Do you feel feverish? Any headaches, SOB, racing of heart, or
tummy pain? Hows your appetite? Do you have N/V? What

about your waterworks or bowel motions? Any pain or burning

sensation? Are you comfortable in this hospital environment?
PMHx: Any condition like diabetes, thyroid, liver, kidney, or
heart disease, anemia? CVA? Mental/psychiatric illness or
neurologic disorder? Previous hospitalization? Previous similar
episodes? SADMA?
FHx of psychiatric illnesses? Hows your home situation?
ORARL: problems with orientation, registration/recall, attention and
Most likely you have a condition called delirium or acute brain
syndrome. This is a common complication of major injuries and
their treatment such as your burns. It will get better along with
your recovery. Your visual problems and fears are part of it
and do not mean that you have a mental illness like
schizophrenia. We need to find out the cause. In your case,
pain relief medication (ketamine/morphine) may be the cause,
but we need to look for infection/sepsis, change in your vital
signs, fluid balance, and do relevant investigations.
I will let the nursing staff know about your concern so that they will take extra
care for you and explain what they are doing (assign same staff each shift to
care for the patient).

Environmental disturbances like lighting and noise will be addressed

for your benefit. If you want your family/friends to be here, I can help
with that.
You will also be seen by a physician registrar to give some
medication to help with your sleep and arrange other painkillers if
For sleep: short-acting benzodiapines (alprazolam, oxazepam,
lorazepam); low-dose haloperidol or olanzapine IM for agitation
Investigations: FBE, U&E, LFTs, ESR/CRP, blood culture if indicated,
RFTs, BSL, CXR, ABG, ECG, urine MCS, TFTs, urine drug screen

Your next patient in ED is a 70-year-old male brought in by ambulance because his
son found him with worsening confusion and complaining of worsening nausea
during his weekly visit. He is slightly demented but managed to live alone at his
home with some help from meals on wheels and district nurse coming 2x per




o (confusion, unable to recognize him, did not skip
meals, no fever, headache, problem with heart rhythm
and HTN on medications with digoxin, and fluid
tablets/water pill; problem with vision)
Physical examination
o (VS normal except pulse is irregular, CNS
unremarkable, chest, lungs and abdomen normal,
urine dipstick negative, BSL normal)
o (FBE normal, urine microscopy and normal, U&E
(potassium increased, sodium normal, ABG), CT scan
normal, RFTs normal, CXR negative, ECG showing
AF), Digoxin level increased!!! HyperkalemiaArrythmia
Diagnosis and management
narrow therapeutic range
indications: CHF & AF
optimum dose with ACEI, loop diuretics and beta-blocker
Contraindications: HOCM, WPW
Cause hyperkalemia cardiac arrhythmias deaths
Elderly patient
Previous MI
Increased calcium, decreased magnesium

Decreased potassium potentiates digoxin toxicity

pushes extracellular potassium shift
Renal insufficiency
Causes: deteriorating renal function, dehydration, electrolyte imbalances,
drug interactions precipitates chronic toxicity
Acute overdose or accidental exposure to plants containing cardiac
glycosides may cause acute toxicity
Hyperkalemia, hypernatramia, hypomagnesemia increase the toxic
cardiovascular effects of digoxin because of their depressive effects on the
Na+/K+ ATPase pump
Yellow vision (xanthopsia)
Irregular pulse
Stop digoxin
Check potassium
Treat arrhythmia
Digibind IV
Do no combine with verapamil!
Supportive correct fluid loss
Correct hyperkalemia (insulin, HCO3, correct acidosis,
resonium with laxatives)
Management of Arrhythmias: atropine to counteract digoxin
Digoxin FAB fragments: LMW antibodies which combine with
digoxin and are then excreted in the urine (40mg vials, each
binds about 0.6mg of digoxin)

Mandy aged 35 years presents to your GP clinic. She tells you that she had
intermittent blurring of vision for the last few weeks. She attributed this to stress at
work and had not asked for help but yesterday evening she had similar episodes.
She is otherwise fit and healthy. Mandy works as secretary in an office and has to
work every day form 8-5.


Focused history
o (2 episodes, 30 pack years, lasting few minutes, no
Physical examination
o (looks well, 130/80, vitals normal, 80 minutes, regular,
BMI 27; VA: R eye 6/12, L 6/6, visual fields normal;
EOM normal; funduscopy blurring of disc margin in
right side, no carotid bruit)
Differential diagnosis and management advise
Differential Diagnosis
Atypical Migraine (without headache)
Multiple sclerosis
Retrobulbar Neuritis
Usually woman with 20-40 years
Loss of vision in one eye over a few days
Retro-ocular discomfort with eye movements
Variable visual acuity
Usual central field loss (central scotoma)
Afferent pupil defect on affected side
Optic disc swollen if inflammation anterior in nerve
Optic atrophy appears later
Disc pallor is invariable sequel

Lumbar puncture (oligloconal IgG in 80%)
Visual evoked potentials: 80%
Test visual field of other eye; consider MRI; most recover
spontaneously but with diminished vision

You are an HMO in ED and a 35-year-old woman presented with 2 weeks history of
visual disturbances and pins and needles in the left hand and difficulty walking.



Physical Examination findings


(Its a blur vision I cannot see properly. All over. I find

difficulty identifying the colors as well. Started
yesterday. Weakness of the left hand. The similar
thing happened 10 years ago. Bowel is ok. But hard
to control the bladder sometime. Right leg is also
(Patient looks distressed. No dysmorphic feature.
Ophthalmolplegia, diplopia. Pupils are normal. Visual
acuity is decreased. Hearing is ok. Impaired co
ordination. Spastic Para paresis in lower limbs with
impaired reflexes. Upper limb: Impaired sensation)

Investigations if you think are necessary (MRI)

Diagnosis and Management
Demyelinating and inflammatory disease of the CNS
No peripheral nerve involvement and only UMN signs and symptoms
Most progressive neuro disability (20-50yo)
Involves Optic nerve, brainstem, periventricular areas, and spinal
Cause is unknown
Evidence that the disease is an autoimmune response to virus
(EBV), bacteria or chemicals in genetically predisposed adults
Plaques in white mater
Onset: 17-35 years old but peaks at 40 years
Early onset (<30yo) usually benign and late onset is usually
malignant. The patient has classical relapse and remissions. Average
duration is about 30year from diagnosis to death. The average time
to needing a walking aid is 15 years. Most common presentation is
optic neuritis in 60% of cases.

2 Most common types:

o Relapsing-remitting 80%; no progression between relapse; better
o Progressive from onset
Clinical features:
o Optic features: Optic neuritis (most common presentation), Monoocular periorbital pain, Decreased visual acuity, decreased color
o If with brainstem lesions: (+) diplopia, nystagmus, ataxia, vertigo,
ophthalmoplegia (very common cause is MS), facial nerve palsy,
trigeminal neuralgia
o Muscle weakness
o Hyperreflexia and spasticity (UMN lesion) of trunk and lower limb

o Paresthesia and sensory loss

o Bladder dysfunction
2 specific symptoms:
o Lhermittes sign: electric pain on neck flexion
o Uhthoffs phenomenon: worsening of symptoms with heat
Diagnostic criteria:
o Lesions are invariably UMN
o >1 part of CNS involved
o Episodes separated in time and space
o Practically diagnosed after a second relapse or when MRI shows
new lesions
o Early diagnosis requires evidence of contrast-enhancing lesions or
new T2 lesions on the MRI indicating dissemination in time
o MRI initial, best and most reliable
o CSF analysis increased protein and mononuclear cells; oligoclonal
o Visual evoked potential

Treatment: Principles:
o All patients should be referred to neurologist for confirmation of
o Rule out depression and anxiety.
Acute attacks:
o Corticosteroids (methylprednisolone 1gm over 5 days) and plasma
exchange Disease-modifying therapy
o Severe: immunosuppresants (MTX, AZT, Cladribine, fingolimod)
Prevention of relapse:
o Interferon
o Glatiramer (mimic myelin)
o Natalizumab
o Prednisolone 75mg once a day for 4 day or 50mg for 4 days.
o If severe relapses (optic neuritis , brain stem signs): Hospitalized. IV
therapy: methyl prednisolone 1 g in 200mL of saline daily for 3-5
o For long term: methotrexate with folic acid or Cyclophosphamide.
o Refer to neurologist
o Refer to psychologist
o Refer to physiotherapist if with spasticity
o Support groups
o * In classical trigeminal neuralgia only severe pain; but if with
sensory multiple sclerosis
o I understand from the notes you have visual problems. What do you
mean by visual disturbances? Doctor theres blur vision, I cannot
identify colors. Sometimes I have double vision as well.
o Is it getting worse? Yes.
o I also understand you have pins and needles in your left arm is it
associated with weakness? Yes.
o Do you have weakness anywhere else in your body? Yes weakness
in my right leg as well. Is it difficult to walk? Yes when I walk I fall to
one side, I had a few falls. Any Headache N/V? No. Any pain
anywhere? Especially your eyes? Yes. Any neck stiffness? No. How
about the water works? I cant control my bladder (urinary urgency).
How about the bowel? Good no problem. Any past medical history?
Same happen 10 years ago. Anything runs in the family? Myasthenia
Gravis. Single, smoker, artist. Drinks alcohol occasionally

Physical Examination
o General appearance: She is distress.
o No facial abnormality. Facial palsy drooping of eye lids
o Eye: Ophthalmoplegia, visual acuity is decreased, visual fields are
normal, theres double vision, pupils are normal. Fundoscopy: Optic
o Cranial nerves: Id also like to check 5 to 12. No abnormality for all
other cranial nerve.
o Neurological examination of the upper and lower limbs: Spastic
paraparesis in lower limb, increase reflexes, impaired coordination,
(Heel and the shin test). Lower limbs: Theres impaired sensation.
Gait: ataxic gait.
Diagnosis and Management
o Jane, from history and examination I suspect you have a condition
called MS but to confirm the diagnosis Id like to order some
investigation and refer you to the neurologist for further assessment
investigation: lumbar puncture, Visual evoke potential, MRI.
o If this is MS, it is an autoimmune disorder. Whats happening is
demyelination (Nerve cells covered by sheath and it got destroyed).
Its uncommon. More common in women, this disease has classical
relapse and remission. Typically presents with pins and needles,
bladder dysfunction etc. Depending on where the demyelination is in
the brain. It is a serious condition but dont worry we will help you. It
is not curable but manageable. Our aim is to slow the progression of
the disease and increase the period btw relapses. Most likely the
neurologist will put you on long term immune suppressants. Acute
phases handled by steroid.
o Refer to neurologist. Review frequently. Reading material
o Red flags: Vision and other symptoms come up.
Critical Errors:
o Not referring to neurologist
o Not doing MRI and Fundoscopy

Variant 1:
A middle-aged woman comes to your GP practice complaining of pain in the right
shoulder associated with neck pain.


Focused History

Perform Physical examination

(No more than 2 minutes) last couple of

months, in the shoulder and neck and
traveling to neck, no trauma, painful in some
(Limited movement to the right side of the
neck---pain on the lower cervical spine;
Elbow flexion & extension of the wrist weak;
numbness of thumb and index finger;
Sensory loss of outer forearm & index finger

After 6 minutes, the examiner will stop you and you need to
explain diagnosis and differential diagnosis and advise
further investigation

Variant 2:
You are a GP and a middle-aged lady came in with shoulder pain for the last few
o History

Physical examination

(started 3 days ago, no trauma, sudden,

shoulder or neck, BOV, headache, first time,
computer analyst)
(tenderness on C6-7, weakness of wrist
extension and elbow extension, loss of
sensation over 3rd finger)

Diagnosis and management


Pain question (SORTSARA): When did it start? Where? On

a scale of 1-10, how bad is the pain? Travelling anywhere
like the neck, back of head, between shoulder blades, arm,
or forearm? Any diurnal variation? Constant or come and
go? Any trauma? Any morning stiffness of the neck? Is the
pain precipitated by activity? Does anything relieve the pain
like painkillers or rest? Pain in the neck on one or both
sides? Any precipitating factor? Any weakness in the hand
or upper limbs? Numbness/tingling? Can you drive back
(reverse) your car? Associated features: swelling, chest
pain, SOB, thyroid disease? Headache? Ear pain? Any
problems with gait or weakness of lower limb? Any
problems with bowel or waterworks? PMHx of joint or neck
problems? SADMA
o Ask patient to release her gown for inspection
o Inspection shoulder - On the same level: Any muscle
wasting in the shoulder, Bulk of muscle, Contour of neck
from the side, Lateral flexion to the neck or torticollis, Any
neurocutaneus stigmata, no muscle wasting or any trauma,
no abnormal contour of the spine, step deformity, squaring
of shoulders, winging of scapula
o Palpations of neck midline from the back---pain on the
left or right side? From central to lateral digital of the




cervical spine and thoracic spine; temperature; Bulk of

muscle of shoulders (trapezius and supraspinal muscle and
lower part of head) if theres any pain; thyroid and LAD;
Any area on the shoulder or forearm; Palpate
temporomandibular joint
o Turning the head up and down, to left and right 45 and 90
degrees (flexion, extension) 6 movements
o Examine shoulder with both hands flexion, extension,
internal rotation, external rotation, circumduction
o Elbow flexion extension
o Wrist supination, pronation, flexion, extension, ulnar
deviation, radial deviation
o Hands all the joints
o Thumb adduction, abduction, opposition
Muscle power please resist my hand; Chicken wings
Power loss
Outer arm
Biceps (C5,6)
Biceps + brachio
radialis (C5,6)
Hand/ middle Triceps and
Triceps (C7-8)
& ring finger
Long flexor
Fingers (C8)
forearm/ little fingers; long
Inner arm

o Disc prolapse due to cervical spondylosis
o Ankylosing spondylitis
o Rheumatoid arthritis
o Traumatic strain or sprain
o Myopathy level C6
Diagnosis and Management
o From my examination finding, its most likely youre
suffering from a degenerative condition with C6
compression due to disc prolapse consistent with cervical
o PRICE/heat/massage/warm hydrotherapy
o Investigation: FBE, ESR, CRP, rheumatoid factor, HLA B27
antigen, CT or MRI cervical spine
o I need to refer you to orthopedic surgeon
o Painkillers (NSAIDs x 2 weeks) and neck collar (especially
at night; limited time)
o Physiotherapy
o Steroids
o Surgery: limited role. Indications are: intractable pain or
with neurologic deficit.

You are working in ED and an 18-year-old male patient is brought in by his friend
because of confusion and agitation since the last 12 hours. He also had an episode
of seizure during this time. On examination, his GCS is 14, temperature is 38.5C,
BP 140/90, PR 90/minute and RR 18. Neck stiffness is negative. Lumbar puncture
has been done and results are as follows: Glucose level normal, protein increased,
Gram stain negative, cell: lymphocytes 90%.

Explain results of LP to friend
Diagnosis and Differential Diagnosis
Encephalitis: meningitis + brain parenchyma
Altered mental status/confusion/irrational
Focal neurological deficits
Predominant in meningitis
Neck stiffness
Electrolyte Imbalance (Hypo/Hyperglycemia)
Brain abscess
Substance abuse
Head injury
Organisms: mostly virus especially Herpes Simplex Virus
CT/MRI: cerebral edema
Lumbar puncture: predominantly lymphocytes (90%)

FBE and BSL, LFTs, Blood culture

IV fluid
IV lorazepam seizures
From history and examination, most likely he has encephalitis.
It is the infection of the brain substance and the covering
(meninges) most likely due to a virus. It is a serious condition
and needs immediate management. Therefore, we will keep
him in the hospital and arrange urgent neurological
consultation. In the meantime, I will be giving him oxygen, IV
fluids, paracetamol for fever, intravenous lorazepam for active
seizures. I would also take blood for baseline investigations
such as FBE, ESR/CRP, BSL, LFTs, U&E, Blood culture.
The treatment is mainly supportive and symptomatic, but the
specialist will do further assessment and can order further
investigations (EEG changes in temporal lobe and CSF PCR
for HSV) before starting treatment.
The specialist may prescribe IV acyclovir if HSV is suspected
which is one of the main causes of this condition.
Will he fully recover?
o It is a serious condition but usually the outcome is
good. Dont worry he is in safe and experienced

A 30-year-old man is referred to your GP clinic as he is diagnosed with idiopathic
epilepsy by his neurologist. He has been put on sodium valproate for treatment. He
is a courier driver and getting married very soon.


Explain the condition to the patient and talk about further

Answer his questions


Due to a fault somewhere in the complex electrical circuit of

the brain and the nervous system results in brain being
unable to work properly for a brief period
Causes: unknown (but can be caused by damage from
previous infections, scars from previous head injuries, tumors,
excessive alcohol or drug use or genetic factors)
Common: 1:100; M=F; seems to run in families

Do you have any concerns?

o Disorder in which a person is prone to having
recurrent seizures which result from the release of the
abnormal electrical impulses by the nerve cells of the
brain. In your case, the cause is unknown and hence

it is called idiopathic. It is a common condition and

affects 1:50. Aim of the treatment is to achieve
complete seizure-control by one medication which is
called monotherapy and lifestyle management.
o A single drug is initiated and the dose is adjusted
accordingly until it controls the seizures and/or the
side effects. 70-80% will have no seizures after
treatment with first-line drugs. If the maximum
tolerated dose fails to control the seizures, it needs to
be replaced by another drug. The first drug is stopped
once the therapeutic effect of the 2nd one is achieved.
The 2nd part of the management is:
o healthy lifestyle and avoidance of triggering factors
like fatigue, physical exhaustion, stress, lack of sleep
and excess alcohol, and avoidance of flashing/strobe
lights and open fires.
With proper treatment, most patients can achieve complete
control of seizure and lead a normal life.
Side effects: nausea, anorexia, vomiting,
dizziness/drowsiness, tiredness or fatigue, gait disturbance like
ataxia, visual disturbance, and most drugs can cause a rash.

Sodium valproate:
o hair loss, rare but serious liver toxicity (LFTs every 2
months for 6 months after starting), NTD (spina bifida)
o ginigival hyperplasia, hirsutism, fetal malformation (cleft lip
and palate), CHD
o anorexia, nausea, vomiting, dizziness, skin rash, tinnitus,
diplopia, ataxia, tiredness and fatigue; safest in pregnancy

When to stop treatment?

will be reviewed for the need of the drugs annually and they
will be stopped if you are free of seizures for 2-3 years.
Can I continue my work?
I will be checking with vicroads because you have to be careful
with driving. Each case has to be considered individually but
the rule is if you are seizure-free for 1-2 years. The applicant
applying for learners license should be seizure-free for 2 years
then annual review for 5 years.
contact centerlink, social support/worker; should not work close to
heavy machinery, dangerous surroundings, heights, or near deep
water; jobs not allowed: public transport (bus driver), police,
military, aviation
Can I play Sports?
Avoid scuba diving, hand gliding, parachuting, rock climbing, car
racing and swimming alone especially surfing; contact sports:
relative CI
Can I get married?
Yes and you can expect to have normal sexual life and normal
children and your children have a slightly increased chance of
having epilepsy (3%).
Red flags:
Take special care with open fires, do not swim unsupervised
Advice for carers:
Dos: roll person on to his side with head turned to one side
and chin up and call for medical help if convulsion lasts longer
than 10 minutes
Donts: move person unless necessary for safety, force
anything into persons mouth, try to stop the fit
Regular follow-ups: monitor medication levels and side effects
of the drugs
Refer to support groups
Reading materials
In female patients: interaction with OCP so increased doses; if
patient wants to get pregnant (high-risk pregnancy) start

patient on 5mg folic acid; planned pregnancy; NO

contraindication for breastfeeding


A young patient is brought to ED, he is unconscious. His airway is patent and

breathing without difficulty. His blood pressure is stable and temperature is 37.5.



Examination and commentary

Differential diagnosis
Investigation you would like to arrange

CVA (SAH, stroke)
Drug/alcohol overdose (sedative hypnotics, tranquilizer,
alcohol, antipsychotics)
o Diabetic hyper/hypoglycemia, hypothyroidism, uremia,
hepatic coma
o Multiorgan failure (adrenal)
o CO narcosis
o Psychiatric problem
o Inspection for any bruises, lumps/bumps, bleeding, signs of
trauma (raccoon eyes, battle sign, bleeding from ears,
nose), jaundice, facial asymmetry,
o CHECK PEARL (miosis: pontine lesions, opioid overdose;
dilated: raised ICP; signs of multiorgan failure, funduscopy
for raised ICP and diabetic/HTN changes), neck stiffness,
mouth for tongue bite marks
o Face: breathing pattern (metabolic acidosis DKA,
hypoventilation, drug overdose),
o Smell of the breath
DKA: fruity smell,

Alcohol: Fetor Hepaticus

Uremic Coma

Peripheries: Tone, IV drug marks/insulin injection marks,

snake bite, circulation, pulse oximetry, temperature,
Heart: arrhythmia

o Urine dipstick and BSL

o FBE, blood cultures, ESR/CRP, cranial CT scan, LFTs,
blood or urine drug screen, Urea & Electrolytes, RFTs,
lumbar puncture
o Thiamine 100 mg IM
o Oxygen
o Naloxone 0.1 0.2 mg IV
o Glucose (give IV bolus of glucose) 50 mls
Causes of COMA
CO narcosis
CO2 narcosis; respiratory failure
Overdose of
Alcohol, opioids, tranquilizers, antidepressants,
CO, analgesics
Diabetes (hypoglycemia, DKA), hypothyroidism,
hepatic failure, Addison failure (uremia),
ICH (hematoma, head injury, cerebral
Infratentorial (posterior fossa): cerebellar tumor,
brainstem infarct/hemorrhage, wernicke
Meningismus: SAH, meningitis
Other: encephalitis; overwhelming infection


A 70-year-old man comes in your GP clinic because of recurrent falls. He had stroke
7 years ago and had weakness of left lower limb.




Task 2


(had 3 eps. for the last 3 mos, noted lightheadedness;

gardening when he stood up; got up from bed and fell
down; medications for BP, TCAs, and diuretic)

Physical examination
Provisional and Differential diagnoses


Hearing (vestibulococchlear)
CVS (arrhythmia, MI, anemia, BP)
Chest (PE)
GIT(bleeding and diabetes)
PMHx: Medications: Polypharmacy
Can you tell me more about it?
Can you describe these falls for me?
You had a stroke 4 years ago. How is your general health after that?
Did you feel dizzy, lightheadedness or fainting before the fall? Any
LOC in any episode?
Did you injure/hurt yourself? What did you do after you fell down?
Did you notice any weakness or numbness of your body? Any
slurring of speech? Any BOV? Any shaking or jerking of your body?
Did you bite your tongue or wet yourself?
Do you have any problem with your memory?
How is your mood lately? Any problem with hearing or vision?

General appearance: anemia, dehydration, jaundice
Vital signs: POSTURAL DROP (drop of 15mmHg systolic or
10mmHg diastolic)
o Neurologic: gait, tone, power, reflexes, coordination, sensation
o Eyes: Visual acuity, eye movements, visual fields fundoscopy
o CVS: Carotid Bruit, Apex Beat, Murmurs
o Abdomen
o Most common cause of your recurrent falls is postural hypotension
which is sudden change in blood pressure by changing position. In
your case, this is most likely due to polypharmacy. It is important to
change them or reduce the medications.
o I would refer you to the fall clinic where you will be seen by MDT and
assessment team.
o Investigations: FBE, UEC, Ct scan, MSU, LFTs, ECG, etc..
o Your BP will be monitored regularly.
o Refer to ophtha and ENT for vision and hearing tests.
o Occupational therapists
o Physiotherapist (strenghtening exercises)
o Social worker (financial, meals-on-wheels)
o Admit and refer to falls clinic.

Differential diagnosis to Examiner

Do you feel everything is spinning around you or any problem

maintaining your balance?
Do you feel short of breath, chest pain or racing of your heart? What
about your BP? What medications are you on?
Do you take your meals regularly? Hows your appetite? Any change
in the color of the stools? Do you feel thirsty or passing urine more
than normal?
Have you ever been diagnosed with diabetes?
Do you have any joint pain or problem with walking?
Do you live alone or with family? Can you manage your life by
yourself? Financial problems? Do you have proper lighting and
protection in your home?
PMHx: DM, hypertension, epilepsy, etc.; Drug History; SADA;