Transcript Slide 1

GP Clinical Update
Neurology – April 2013
Dr Fiona Chadd GPST1
Dr Sneha Lupini GPST2
Case Presentation
L.F, 28 year old female
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PC: Left sided weakness, dysarthria
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HPC:
 32/40
pregnant, recently treated for acute
pyelonephritis
 Presented 2/7 later with left facial droop, left arm
weakness and slurred speech
 Blurring around the edges of visual fields
 Nausea and vomiting
 Developed left leg weakness whilst in A+E
Further history
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Obstetric Hx:
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PMHx:
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G4 P2, Ante-natal scans normal, active baby
Depression
Migraine - LOV in both eyes, dizziness and photophobia
SHx:
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Lived with partner and 2 children
Worked as a cleaner
Smoker since 14yrs old, 5 cigarettes/day
Examination findings
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Obs: BP 124/92, HR 118, T 37.3, RR 18, Sats 97%
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CVS, respiratory and abdominal examinations unremarkable
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Calves soft non tender
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No neck stiffness / photophobia / rash
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Cranial nerves:
 Visual fields grossly normal, no visual inattention / palsy
 Facial sensation normal
 Left UMN facial weakness improving
 No tongue/ soft palate deviation
Peripheral nervous examination:
RUL
LUL
RLL
LLL
Tone
Normal
Normal
Normal
Normal
Power
5/5 all muscle
gps
3/5 elbow
flexion, 2/5 in
all other
muscle
groups
5/5 all muscle
groups
4/5 all muscle
groups
Co-ordination
Normal
Unable to
perform
Normal
Normal
Sensation
Normal
Normal
Normal
Normal
Reflexes
Biceps +
Ticeps +
Supinator +
Biceps(cannula) Knee +
Ticeps +
Ankle +
Supinator +
Plantars
downgoing
Knee +
Ankle +
Plantars
downgoing
CT head
Initial impression and plan
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Impression:
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Right anterior circulation infarction
Plan:
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Aspirin 300mg OD
 Anti-emetics
 O+G r/v
 MRI mane
 Stroke team r/v
Further review
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Stroke team r/v:
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Subtle left facial weakness
Reduced sensation left side of the face
Mild left arm drift and power 4/5, sensation normal
Impression:
 1.?Sagittal
vein thrombosis
 2. Exclude Stroke
Plan:
1. MRI + MRV
2. Echo
3. O+G r/v
MRI
scan
Further investigations
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Lumbar puncture: Glucose 3.0
Total Prot 0.19
Serology:
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Anti cardiolipin Ab, Ig G, A, M and protein electrophoresis normal
Neuro r/v:
?Acute disseminated encephalomyelitis
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3/7 Methylprednisolone
OP VEPs and repeat MRI in 3/12
Follow up
GP post natal r/v May
 Discussed contraception - patient felt unable to think about it,
wanted to find out what the neurologists opinion was.
Neuro clinic r/v June
 Left arm power improved but slower than right arm
 Left leg tires when walking/shopping for half hour
 Repeat brain and cervical spine MRI - new lesion seen
(Indicates a further non clinical event confirming diagnosis of MS)
GP r/v August
 Presents with PV bleeding and positive pregnancy test.
 Scared and upset, feels unable to deal with this on top of
diagnosis of MS.
 Referred to EPAC.
Key Revision on Multiple Sclerosis
Types of MS
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Benign MS
(10% at onset) – only a few relapses
in a lifetime and none remain
permanent.
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Relapsing/remitting MS
(80% at onset) – symptoms come
and go lasting 2-6 weeks on
average, with 1-2 relapses per year
being typical.
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Secondary progressive MS
(50% of R/R → progressive in 10yrs)
– gradually more or worsening
symptoms with fewer remissions.
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Primary progressive MS
(10% at onset) – from the beginning,
symptoms gradually develop and
worsen over time.
Risk factors, incidence and prevalence
Risk factors
 Not strictly hereditary but increased chance of developing if close relatives have
MS. (General population = 1/1000, primary relative with MS 1/100)
 3:1 female to male ratio
 More common in Caucasians
 Commonly presents at age 30
Incidence
 3-7 people per 100,000 population
are diagnosed with MS each year
 In England and Wales this equates to
about 1800-3400 people
Prevalence
 100-120 people per 100,000
population have MS
 This is approximately 52,000-62,000
people in England and Wales
Presentation of MS
Primary symptoms
Secondary symptoms
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Contractures
Urine infections
Osteoporosis
Muscle wasting
Reduced mobility
Specific MS presentations
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Transverse myelitis
Acute demyelinating optic neuritis
(ADON)
Bilateral internuclear
ophthalmoplegia
Prognosis
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Variable and unpredictable outcome.
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On average the degree of disability a person experiences five years after
the onset on their MS is, approximately three-quarters of the expected
disability at 10-15 years.
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Life expectancy is normal or nearly normal (35 years after diagnosis).
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Factors predicting a better outcome include:
 being female
 <30 at age of onset
 infrequent attacks
 relapsing-remitting type
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50% of deaths are due to the disease process, 15% are due to suicide.
NICE Guidance
CG8 - Multiple sclerosis:
Management of multiple sclerosis
in primary and secondary care
November 2003
Due to be updated in 2014!
NICE Guidance
- Diagnosing MS
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First presentation with neurological symptoms / demyelination
signs and no reasonable alternative diagnosis - a diagnosis of MS
should be considered.
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Second presentation requires referral to a specialist neurology
service for an appointment within 6 weeks and all investigations
completed and a follow up appointment within a further 6 weeks.
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A diagnosis of MS should be made clinically:
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by a doctor with specialist neurological experience
primarily on the basis of the history and examination
on the basis of evidence of CNS lesions scattered in space and time
(MRI and/or visual evoked potentials)
NICE Guidance
- Treatments
(the same regardless of first presentation or relapse)
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Acute treatment – any episode causing distressing symptoms or
increased limitation of activities can be treated with high dose
corticosteroids started ASAP.
 IV methylprednisolone 500mg –1g daily, for 3 - 5 days
or
 Oral methylprednisolone 500mg – 2g daily, for 3 - 5 days
Frequent (> 3x/year) or prolonged (> 3/52) use of corticosteroids should be avoided)
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Treatment to reduce disease progression –
 All patients - Linoleic acid 17–23 g/day may reduce progression
of disability (sunflower, corn and soya).
 Relapsing remitting MS – Beta interferon (Avonex, Rebif and
Betaferon) and Glatiramer acetate (Copaxone) – if they can walk
unaided for 100m, had 2 significant relapses in 2 years, aged 18+
 Secondary progressive MS – Beta interferon – if they can walk
unaided for 10m, had 2 disabling relapses in 2 years, had minimal increase in
disability over the last 2 years, aged 18+
NICE Guidance
– Management of MS
related conditions
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Depression/emotionalism
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Anxiety
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Antidepressants or benzodiazapines
Fatigue
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Tricyclic antidepressants or SSRIs
CBT
No treatment, but small clinical benefit from Amantadine 200 mg OD
Treat underlying causes (chronic pain, medication side effects, problems
sleeping)
Cognitive losses
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Formal cognitive assessment
Depression assessment
Medication review
Advice about financial vulnerabilities
NICE Guidance
– Management of MS
related conditions
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Visual problems – more due to loss of control of eye movement than optic neuritis
 Refer to optometrist for glasses
 If no improvement refer to ophthalmologist
 For nystagmus a specialist can try oral Gabapentin
 Adaptive technology
 Register as partially sighted
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Neuropathic pain
 Carbamazepine, Gabapentin, or Amitriptyline
 Pain referral
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Swallowing difficulties
 SALT assessment
 Advice about food consistencies and dietary intake
 Weight and nutritional monitoring
 Chest physiotherapy
 Short term NG feeding
 Long term PEG (recurrent chest infections, inadequate intake, prolonged or
distressing feeding, NG in situ for > 1/12)
NICE Guidance
– Management of MS
related conditions
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Urinary symptoms
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Oxybutynin or Tolterodine for bladder dysfunction
Desmopressin 100–400μg orally or 10–40μg intranasally nocte for nocturia or
daily control of urinary frequency when travelling
Specialist referral if incontinent > 1x/week
Referral to continence service if > 3 UTIs/year
Intermittent catheterisation if high residual volume
Long term catheter as a last resort
Bowel symptoms
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Constipation - dietary advice
- oral laxatives
- suppositories or enemas
 Incontinence - likely overflow, consider constipation treatment
– Management of MS
related conditions
NICE Guidance
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MSS problems – neuro-physiotherapy referral
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Muscular weakness – strengthening exercises
- specialist equipment and orthoses
Spasticity and spasms – stretching exercises
- Baclofen or Gabapentin
Joint contractures – stretching exercises
- local Botox injections
- plaster casts
- surgery
Ataxia and tremor – exercises
- specialist equipment
- surgery
MSS pain – TENS
- antidepressants
- CBT
– Additional
considerations
NICE Guidance
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Vaccinations – patients should have influenza immunisations
and all other vaccinations as normal, as relapses can be
precipitated by infections.
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Pregnancy - the risk of relapse decreases during pregnancy,
but increases transiently postpartum.
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Surgery – all types of stress can worsen MS, but stress due to
operations is not proven to trigger relapses so surgical
procedures should not be postponed.
AKT Questions
1. Which TWO statements regarding
multiple sclerosis are correct?
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a. Annual incidence in UK is 1 in 1,000,000
b. Common in temperate climates
c. Efferent papillary defect noted
d. Bilateral internuclear ophthalmoplegia is a
typical feature of MS
e. Steroids reduce frequency of attacks
f. Oligoclonal bands are pathognomic of MS
2. Choose the most appropriate cause of double
vision in each patient from the list below;
a. Berry aneurysm
e. Multiple sclerosis
b. Cerebral glioma
f. Myasthenia gravis
c. Drug induced
g. Stroke
d. Graves’ disease
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A 35-year-old man who is a non-smoker, suddenly develops a
severe headache and double vision. His right pupil is fixed
and dilated.
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A 27-year-old woman who is a non-smoker, suddenly
develops double vision. She had an episode of reduced visual
acuity in her left eye whilst on holiday 18 months previously,
for which no cause was identified. She has no other
significant past medical history.
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A 48-year-old woman has transitory double vision towards the
end of most days. She smokes 10 cigarettes/day. She has
vitiligo and hypothyroidism.
3. Your Practice Manager, has been off work for the
last six months, with a diagnosis of MS. She
wishes to return to work and realises that getting
to her upstairs office could be problematical and a
whole day’s work could be overtiring. As her
employer, which two decisions would be most
appropriate?
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a. Take her back as Practice Manager on a flexible,
part-time basis
b. Enforce her to take early ill-health retirement
c. Revamp her working place environment
d. Take her back as a Telephonist on a flexible, part-time basis
e. Take her back as Practice Manager only on a full time basis
f. Tell her to keep getting sickness certificates from her Doctor
g. Terminate her employment