By C. Akrabor. Arkansas Tech University. 2019.
Céphalées de l’adulte : Prise en charge initial au service des urgences order cephalexin 250 mg without prescription, @Serveur –online order cephalexin 750 mg online, jeudi 16 Juin 2011 2. Le choix d’un traitement se fait en fonction de la tolérance du patient (ex : certains patients tolèrent mieux le Dextropropoxyphène que le Tramadol). Le traitement de référence et basé sur les antidépresseurs tricycliques et les antiépileptiques. Doses Indications, effets secondaires Amitriptyline Adultes : 15-100mg/24 heures Antidépresseur. S’il n’est pas suffisant pour traiter les accès paroxystiques éventuels, on ajoutera des antiépiletiques (à prendre le soir): Diazépam 0. Les migraines sont des céphalées souvent d’intensité sévère, intenses, matinales, souvent unilatérales imposant le repos sans bruit dans le noir, empêchant de travailler et sont parfois associées avec des nausées et des vomissements (fréquents chez l’enfant). La céphalée de tension, plus banale, arrive en fin de journée quand on est particulièrement fatigué et stressé. Bien sûre, il faut être sûre de son diagnostic, les migraines sont souvent familiales, elles commencent vers l’adolescence. Si, à l’examen neurologique, on a un doute sur une tumeur cérébrale, un scanner cérébral serait utile pour éliminer le diagnostic. Le traitement des céphalées de tension • Repose sur le paracétamol 1g 4 fois/jour et de la détente physique comme de la relaxation. Attention dose maximale : 4g/jour et risque de cytolyse hépatique massive quand la dose est supérieure à 150mg/kg en une prise. Mais attention à l’action anti-agrégante plaquettaire importante, ce qui réalise une anti-coagulation importante dans les 7 jours qui suivent la prise d’un comprimé d’aspirine. Palier 2 : • Dextropropoxyphène : (30mg + paracétamol 400mg par comprimé) 1 comprimé 3 fois par jour à partir de 15 ans (Si un problème cardiaque doit être évité) • Tramadol : (comprimé à 50mg) 1 comprimé 3 fois par jour à partir de 15 ans. Si la douleur persiste, et si l’enfant ne peut pas avaler, on peut utiliser la morphine S/C, 0. Douleur neuropathiques Contre la douleur continue (lancinante) faite de brûlures et des sensations désagréable permanentes : • Amitryptiline 1 goutte par kg (1 goutte = 1mg) le soir au coucher, à augmenter progressivement (0. Ce conflit discoradiculaire peut se situer dans le canal rachidien, le récessus latéral ou le foramen. Une lombosciatique est une 4ème cause hospitalisée dans le service de neurologie, chez l’hôpital de l’Amitié Khméro-Soviétique. La douleur du membre inférieur est, en règle générale, unilatérale, impulsive à la toux, parfois associée ou remplacée par des paresthésies distales. Hospitalisation de toute urgence, si possible en unité chirurgicale spécialisée dans le rachis. Les injections intrathécales ou facettaires postérieures ne sont en revanche pas indiquées La kinésithérapie et les manipulations rachidiennes ne sont pas indiquées. Une fois que la radiculalgie se sera amendée, de possibles facteurs favorisants doivent être identifiés pour prévenir une récidive. Les opioïdes faibles entraînent souvent des effets indésirables tels que nausées, somnolence, vertiges et constipation. Traitements physiques Ils incluent les tractions vertébrales, les manipulations, la kinésithérapie et les orthèses lombaires. Cependant, le taux de guérison à 1 an des sciatiques non compliquées est toutefois comparable après chirurgie ou traitement conservateur (95 %). Il faut en revanche interdire le port de charges, les mouvements en flexion du tronc et les longs trajets en voiture. La chirurgie agit sur la composante radiculaire de la douleur et non sur la lombalgie. Exemples : • Débuter avec amitriptyline (clomipramine, imipramine) 10 gouttes au coucher (1 goutte = 1mg) • Prendre le soir en raison de leur effet sédatif (amitryptiline). S’il n’est pas suffisant pour traiter les accès paroxystiques éventuels, on ajoutera des antiépiletiques (à prendre le soir) : Diazépam 0. Epidémiologie La prévalence globale de la migraine est estimée à 12 % de la population âgée de 18 à 65 ans avec une prédominance féminine en France (sex-ratio de 3/1). Elle est sous- diagnostiquée (30 à 45 % des sujets traitent leurs symptômes en ignorant leur statut de migraineux). Diagnostic Le diagnostic de migraine repose sur un trépied clinique : évolution par crises séparées par des intervalles libres de toute douleur, caractéristiques sémiologiques propres, examen clinique normal entre les crises. Objectifs de la prise en charge Traitement de la crise : disparition de la céphalée et des symptômes associés. Le traitement doit commencer par une monothérapie, à faible dose, progressivement croissante. Migraine résistante Le méthysergide, réservé aux migraineux résistants aux autres traitements, doit être prescrit avec des fenêtres thérapeutiques de 1 mois tous les 6 mois. La flunarizine peut être utilisée après échec des autres traitements, pour une durée inférieure à 6 mois. En cas de douleur parsiste avec un traitement adequoite donc la recoure du diagnostique et le scanner est nescessaire quand suspectant processus tumeural.
There are nonetheless signs that the patient is responsive purchase cephalexin 500mg overnight delivery, although Coma Caused by Cerebral Mass it may take some ingenuity on the part of the examiner Lesions and Herniations to demonstrate them buy cheap cephalexin 500mg on-line. For example, eyelid elevation is The cranial cavity is separated into compartments by actively resisted, blinking occurs in response to a visual infoldings of the dura. The two cerebral hemispheres are threat, and the eyes move concomitantly with head rota- separated by the falx and the anterior and posterior fos- tion, all of which are inconsistent with the presence of a sae by the tentorium. It is characteristic but not invariable in cata- brain tissue into a compartment that it normally does tonia for the limbs to retain the postures in which they not occupy. Many of the signs associated with coma, and have been placed by the examiner (“waxy ﬂexibility,” or indeed coma itself, can be attributed to these tissue shifts, catalepsy). Upon recovery, such patients have some mem- and certain clinical conﬁgurations are characteristic of ory of events that occurred during their catatonic stupor. They are in essence The appearance is superﬁcially similar to akinetic mutism, “false localizing” signs because they derive from com- but clinical evidence of cerebral damage such as Babinski pression of brain structures at a distance from the mass. The singu- The most common herniations are from the supra- lar problem of brain death is discussed later. Uncal transtentorial pseudocoma in which an awake patient has no means of herniation refers to impaction of the anterior medial producing speech or volitional movement but retains temporal gyrus (the uncus) into the tentorial opening voluntary vertical eye movements and eyelid elevation, thus allowing the patient to signal with a clear mind. The usual cause is an infarction or hemorrhage of the ventral pons, which transects all descending corticospinal and corti- cobulbar pathways. A similar awake but de-efferented state occurs as a result of total paralysis of the muscula- C ture in severe cases of Guillain-Barré syndrome, critical illness neuropathy (Chap. The D proper functioning of this system, its ascending projections to the cortex, and the cortex itself are required to maintain alertness and coherence of thought. Drowsiness and stupor typically occur with mod- displacement of the midbrain causes compression of the erate horizontal shifts at the level of the diencephalon opposite cerebral peduncle, producing a Babinski sign (thalami) well before transtentorial or other herniations and hemiparesis contralateral to the original hemiparesis are evident. In cases of ing the upper brainstem, tissue shifts, including hernia- acutely appearing masses, horizontal displacement of the tions, may compress major blood vessels, particularly the pineal calciﬁcation of 3–5 mm is generally associated anterior and posterior cerebral arteries as they pass over with drowsiness, 6–8 mm with stupor, and >9 mm with the tentorial reﬂections, thus producing brain infarc- coma. Both temporal and central Many systemic metabolic abnormalities cause coma by herniations have classically been considered to cause a interrupting the delivery of energy substrates (hypoxia, progressive compression of the brainstem from above in ischemia, hypoglycemia) or by altering neuronal excitabil- an orderly manner: ﬁrst the midbrain, then the pons, and ity (drug and alcohol intoxication, anesthesia, and ﬁnally the medulla. The same metabolic abnormalities that produce logic signs that corresponds to each affected level. Other coma may in milder form induce widespread cortical dysfunction and an acute confusional state. Thus, in meta- bolic encephalopathies, clouded consciousness and coma are in a continuum. Brain stores of glucose provide energy for ∼2 min after blood ﬂow is interrupted, and oxygen stores last 8–10 s after the cessa- tion of blood ﬂow. The upper Conditions such as hypoglycemia, hyponatremia, midbrain and lower thalamic regions are compressed and hyperosmolarity, hypercapnia, hypercalcemia, and hepatic displaced horizontally away from the mass, and there is and renal failure are associated with a variety of alterations transtentorial herniation of the medial temporal lobe struc- in neurons and astrocytes. The lateral ventricle which causes neuronal destruction, metabolic disorders opposite to the hematoma has become enlarged as a result generally cause only minor neuropathologic changes. Some changes in ion ﬂuxes across neuronal membranes, and produce coma by affecting both the brainstem nuclei, neurotransmitter abnormalities. Overdose of medications alters nerve cell function, and causes increased concentra- that have atropinic actions produces physical signs such tions of potentially toxic products of ammonia metabo- as dilated pupils, tachycardia, and dry skin. Apart from hyperammonemia, which of to the Cerebral Hemispheres these mechanisms is of critical importance is not clear. The mechanism of the encephalopathy of renal failure is This special category, comprising a number of unrelated also not known. A multi- damage, thereby simulating a metabolic disorder of the factorial causation has been proposed, including increased cortex. Similar bihemispheral damage is produced by any large shifts in sodium and water balance in the brain. The pres- hyperosmolar state, and hyponatremia from any cause ence of seizures and the bihemispheral damage is some- (e. Sodium levels <125 mmol/L induce confusion, and <115 mmol/L are associated with coma and convulsions. Acute respiratory and cardiovascular problems should In all of these metabolic encephalopathies, the degree of neurologic be attended to before neurologic assessment. In most change depends to a large extent on the rapidity with which the instances, a complete medical evaluation, except for serum changes occur. The pathophysiology of other meta- vital signs, funduscopy, and examination for nuchal bolic encephalopathies, such as hypercalcemia, hypothy- rigidity, may be deferred until the neurologic evalua- roidism, vitamin B12 deﬁciency, and hypothermia, are tion has established the severity and nature of coma. In the remainder, certain Epileptic Coma points are especially useful: (1) the circumstances and Continuous, generalized electrical discharges of the cor- rapidity with which neurologic symptoms developed; tex (seizures) are associated with coma even in the absence (2) the antecedent symptoms (confusion, weakness, of epileptic motor activity (convulsions). The self-limited headache, fever, seizures, dizziness, double vision, or coma that follows seizures, termed the postictal state,may vomiting); (3) the use of medications, illicit drugs, or alco- be caused by exhaustion of energy reserves or effects of hol; and (4) chronic liver, kidney, lung, heart, or other locally toxic molecules that are the byproduct of seizures. Fever sure reversible and leaves no residual damage providing suggests a systemic infection, bacterial meningitis, hypoxia does not supervene.
Another surgeon generic 500mg cephalexin with mastercard, through frequent blood-lettings and many medicines order 500mg cephalexin overnight delivery, effected that he remained free from epilepsy for four weeks, but soon afterwards the epilepsy returned while he was taking his noonday nap, and the patient had two or three fits in the nights; at the same time he was attacked with a very severe cough and suffocating catarrh, especially during the nights, when he expectorated a very fetid fluid. At last, after much medicine, the disease increased so much that he had ten fits at night and eight during the day. Nevertheless he never in these fits either clenched his thumbs or had foam at his mouth. During his nightly attacks he remains in the deepest sleep without awaking, but in the morning he feels as if bruised all over. The only warning of a fit consists in his rubbing his nose and drawing up his left foot, but then he suddenly falls down. In the same place the author mentions also a woman whose fingers contracted from an itch driven out by external means; she suffered of them a long time. He became insane, sang or laughed where it was unbecoming, and ran until he sank to the ground from exhaustion. From day to day he became more sick in soul and in body, until at last hemiplegy came on and he died. The intestines were found grown together into a firm mass, studded with little ulcers full of protuberances, some of the size of walnuts, which were filled ,with a substance resembling gypsum. Artificial irritants applied to the skin and a strong emetic brought back the itch again; when the eruption extended over the whole body all the former accidents disappeared. Who, after reading even the few cases described, would hesitate to acknowledge that the Psora, as already stated, is the most destructive of all chronic miasmas? Who would be so stolid as to declare, with, the later allopathic physicians, that the itch-eruption, tinea and tetters are only situated superficially upon the skin and may, therefore, without fear, be driven out through external means since the internal of the body has no part in it and retains its health? If the examples here adduced by me from both the older and from modern non-Homoeopathic writings have not yet enough convincing proof, I should like to know what other examples (even my own not excepted) could be conceived of as more striking proofs? How often (and I might say almost always) have opponents of the old school refused all credence to the observations of honorable Homoeopathic physicians, because they were not made before their own eyes and because the names of the patients were only indicated with a letter; as if private patients would allow their names to be used! And do I not prove my point in a manner most indubitable and most free from partisanship through the experience of so many other honest practitioners? The man who, from the examples given and from innumerable others of a like nature, is not willing to see the exact opposite of that assertion blinds himself on purpose and works intentionally for the destruction of mankind. Or are they so little instructed as to the nature of all the miasmatic maladies connected with diseases of the skin that they do not know that they all take a similar course in their origin? And that all such miasmas become first internal maladies of the whole system before their external assuaging symptom appears on the skin? We shall more closely elucidate this process, and in consequence we shall see that all miasmatic maladies which show peculiar local ailments on the skin are always present as internal maladies in the system before they show their local symptom externally upon the skin; but that only in acute diseases, after taking their course through a certain number of days, the local symptom, together with the internal disease, is wont to disappear, which then leaves the body free from both. In chronic miasmas, however, the outer local symptom may either be driven from the skin or may disappear of itself, while the internal disease, if uncured, neither wholly nor in part ever leaves the system; on the contrary, it continually increases with the years, unless healed by art. I must here dwell the more circumstantially on this process of nature, because the common physicians, especially of modem days, are so deficient in vision; or, more correctly stated, so blind that although they could, as it were, handle and feel this process in the origin and development of acute miasmatic eruptional diseases, they nevertheless neither surmised nor observed the like process in chronic diseases, and therefore declared their local symptoms as secondary growths and impurities existing merely externally on the skin, without any internal fundamental disease, and this as well with the chancre and the fig-wart as with the eruption of itch, and fore - since they overlooked the chief disease or perhaps even boldly denied it - by a mere external treatment and destruction of these local ailments they have brought unspeakable misfortunes on suffering humanity. With respect to the origin of these three chronic maladies, as in the acute, miasmatic eruptional diseases, three different important moments are to be more attentively considered than has hitherto been done: First, the time of infection; secondly, the period of time during which the whole organism is being penetrated by the disease infused, until it has developed within; and thirdly, the breaking out of the external ailment, whereby nature externally demonstrates the completion of the internal, development of the miasmatic malady throughout the whole organism. When the smallpox or the cowpox catches, this happens in the moment when in vaccination the morbid fluid in the bloody scratch of the skin comes in contact with the exposed nerve, which then, irrevocably, dynamically communicates the disease to the vital force (to the whole nervous system) in the same moment. After this moment of infection no ablution, cauterizing or burning, not even the cutting off of the part which has caught and received the infection, can again destroy or undo the development of the disease within. The same is the case, not to mention several other acute miasmas, also when the skin of man is contaminated with the blood of cattle affected with anthrax. If, as is frequently the case, the anthrax has infected and caught on, all ablutions of the skin are in vain; the black or gangrenous blister, nearly always fatal, nevertheless, always comes out after four or five days (usually in the affected spot); i. Does it not take three, four or five days after vaccination is effected, before the vaccinated spot becomes inflamed? Does not the sort of fever developed - the sign of the completion of the disease-appear even later, when the protecting pock has been fully formed; i. Does it not take ten to twelve days after infection with smallpox, before the inflammatory fever and the outbreak of the smallpox on the skin take place? What has nature been doing with the infection received in these ten or twelve days? Was it not necessary to first embody the disease in the whole organism before nature was enabled to kindle the fever, and to bring out the emption on the skin? Measles also require ten or twelve days after infection or inoculation before this eruption with its fever appears. After infection with scarlet fever seven days usually pass before the scarlet fever, with the redness of the skin, breaks out. What else but to incorporate the whole disease of measles or scarlet fever in the entire living organism before she had completed the work, so as to be enabled to produce the measles and the scarlet fever with their eruption. Among many persons bitten by mad dogs - thanks to the benign ruler of the world only few are infected, rarely the twelfth; often, as I myself have observed, only one out of twenty or thirty persons bitten. The others, even if ever so badly mangled by the mad dog, usually all recover, even if they are not treated by a physician or surgeon.
Items 204–206 Select the most likely disease process for the clinical syndromes described order cephalexin 500 mg with mastercard. A nonpregnant woman has bitemporal hemianopsia cephalexin 250mg mastercard, irregular menses, and galactorrhea. A 55-year-old type 2 diabetic patient has lost weight and has had good control of his blood sugar on oral agents. A newly diagnosed type 2 diabetic patient asks for clarification about dietary management. Caloric intake should be very consistent from one day to another Endocrinology and Metabolic Disease 107 209. As part of a review of systems, a 55-year-old male describes an inabil- ity to achieve erection. A skull x-ray shows sharply demarcated lucencies in the frontal, parietal, and occipital bones. A 40-year-old alcoholic male is being treated for tuberculosis, but he has not been compliant with his medications. In the advanced stage of this disease, the most likely electrolyte abnormalities will be a. Because of per- sistent morning glycosuria with some ketonuria, the evening dose is increased to 20 units. This worsens the morning glycosuria, and now mod- erate ketones are noted in urine. A 30-year-old woman is found to have a low serum thyroxine level after being evaluated for fatigue. In the hos- pital, blood pressure is labile and responds poorly to antihypertensive ther- apy. Her past medical history shows that she developed hypotension during an operation for appendicitis. Insulin-dependent diabetes mellitus Items 221–223 Match each symptom or sign with the appropriate disease. On physical examination, he has an elevated jugular venous pressure, S3 gallop, and hepatomegaly. The patient reports that his father died from thyroid cancer and that a brother had a history of recurrent renal stones. Blood calcitonin concentration is 2000 pg/mL (normal is less than 100); serum calcium and phosphate levels are normal. Administer suppressive doses of thyroxine and measure levels of thyroid- stimulating hormone e. A 32-year-old woman has a 3-year history of oligomenorrhea that has progressed to amenorrhea during the past year. She has observed loss of breast fullness, reduced hip measurements, acne, increased body hair, and deepening of her voice. Physical examination reveals frontal balding, clitoral hypertrophy, and a male escutcheon. The physician is considering this patient’s illness to be secondary either to a retained antrum or to a gastrinoma. A 55-year-old woman who has a history of severe depression and who had radical mastectomy for carcinoma of the breast 1 year previously devel- ops polyuria, nocturia, and excessive thirst. A 30-year-old nursing student presents with confusion, sweating, hunger, and fatigue. The patient has no history of diabetes mellitus, although her sister is an insulin-dependent diabetic. The patient has had several similar episodes over the past year, all occurring just prior to reporting for work in the early morning. On this evaluation, the patient is found to have high insulin levels and a low C pep- tide level. When severe hyperglycemia and dehydration increase serum osmolarity above 380 mOsm/L, lethargy or coma occurs. Serum osmolarity is measured by the formula: Plasma glucose + + blood urea nitrogen + 2 (serum Na + K ) + 18 2. As can be seen from the equation, osmolarity depends mostly on the concentration of sodium. Serum osmolarity will rise significantly when dehydration pre- vents the dilution of serum sodium that might otherwise occur with hyper- glycemia. Hyperosmolarity reflects both hyperglycemia and severe dehydration with hypernatremia. Hypotonic saline may be given for severe hypernatremia or congestive heart failure. Hyperglycemia can be corrected 116 Copyright © 2004 by The McGraw-Hill Companies, Inc. The patient’s serum potassium is in the normal range and would not be expected to fall rapidly, but should be monitored. Medical nutrition therapy is a term now used to describe the best possible coordination of calorie intake, weight loss, and exercise.
Normal profiles (adequate control) Preprandial levels < 6 mmol/L and 1 hour postprandial < 7 cheap cephalexin 750mg line. Starting dose may be based on previous insulin requirements discount cephalexin 750mg on-line, if known, or empiric starting dose: • Insulin, intermediate acting, 10 units. Adjust insulin dosage daily according to blood glucose profiles, until control is adequate. Where the above recommended regimen is not feasible Twice-daily regimen with biphasic insulin. Empiric starting dose if previous insulin requirements are not known: • Insulin, biphasic. During the first 48 hours give insulin 4-hourly according to blood glucose levels. Resume prepregnancy insulin or oral hypoglycaemic regimen once eating a full diet. The newborn is at risk of: » hypoglycaemia, » respiratory distress syndrome, » hyperbilirubinaemia, and » congenital abnormalities. The risk is particularly high in women with mechanical valves, Eisenmenger’s syndrome or pulmonary hypertension. Spontaneous delivery is usually preferable to Caesarean section, unless there are obstetric reasons for surgery. Avoid a prolonged second stage of labour by means of assisted delivery with forceps (preferably) or ventouse. Contraception, including the option of tubal ligation should be discussed after delivery in all women with significant heart disease. Women who had serious complications during pregnancy should be advised not to become pregnant again. Practise strict infection control if using multi-dose vials, with one vial per patient and use of needle-free adaptor. Consider the use of warfarin throughout pregnancy for women with older generation mechanical valves, or valves in the mitral position Prophylaxis for venous thromboembolism » More than one previous episode of venous thromboembolism. Procedures for which endocarditis prophylaxis is indicated include: » Vaginal delivery in the presence of suspected infection. Delivery Contraction and retraction of the uterus after delivery increases the total peripheral resistance, and causes a relative increase in circulating volume. The main pathology is widespread endothelial damage from a placental endotheliotoxin. Treatment Antihypertensives Drug treatment will be dictated by blood pressure response. When needed, combine drugs using lower doses of the three agents before increasing the doses to a maximum. Add 2 vials (2 x 100 mg) of labetalol (5 mg/mL) to the remaining 160 mL of sodium chloride 0. Ergot-containing drugs are contraindicated in hypertensive women, including pre-eclampsia, following delivery of the baby. Pre-eclamptic and eclamptic women are hypovolaemic, particularly when the haematocrit exceeds 40%, but are also susceptible to pulmonary oedema. Both epidural and spinal anaesthesia may be used for operative delivery in hypertensive women, including pre-eclampsia. Epidural analgesia is ideal for labour and delivery, but should only be undertaken by experienced practitioners in a unit properly equipped for resuscitation and with facilities available for urgent operative delivery. Management will include preventing further seizures, controlling the blood pressure, referral to a high-care unit and delivery of the baby if not already post-delivery. To prevent eclamptic seizures, magnesium sulphate is recommended for patients with severe pre-eclampsia, including imminent eclampsia. When used for prevention of eclampsia, magnesium sulphate is administered for 24 hours, and then stopped. Stop magnesium sulphate if knee reflexes absent or if urine output < 100 mL/ 4 hours or respiratory rate <16 breaths/minute. Notify the person who will resuscitate the newborn that a benzodiazepine and/or magnesium has been given to the mother. Women should be advised that there’s an increased risk of congenital abnormalities if these drugs were taken during pregnancy. Decisions about postpartum contraceptive use and method of infant feeding must be made in the antenatal period. Note: If mother has received <3 doses, the baby should be treated for congenital syphilis. For penicillin sensitive patients, the penicillin desensitisation regimen is an option. If penicillin is not used, the baby must be regarded as inadequately treated and given penicillin after delivery. Retreat mother with doxycycline once she has stopped breast feeding • Doxycycline, oral, 100 mg 12 hourly for 28 days.
Certain histological features Sex predict metastasis; for example multiple mitoses and Male only large cell calcifying cell type buy 500 mg cephalexin otc. Symptoms Seizures: Features that suggest a seizure include wit- nessed convulsions (one or both sides of the body) buy cephalexin 500 mg cheap, post- Headache ictal (post-seizure) confusion, drowsiness and headache. Most headaches of the tongue and urinary incontinence (due to re- do not have a serious cause. The history is the most laxation of the bladder sphincters) and other injuries important diagnostic tool. If there As with most types of pain, speciﬁc features that must are warning signs prior to the seizure, e. Auras are un- pain is sometimes generalised, but if focal may be de- usual in other types of ﬁts and faints except for in mi- scribed as frontal, occipital, temporal and either unilat- graine which does not result in loss of consciousness or eral or bilateral. Drugs, including recreational drugs and substances Absence seizures (previously called petit mal) are such as alcohol, nicotine and caffeine, can lead to found only in children – the individual appears brieﬂy headaches, either directly or during withdrawal. Sudden onset r Notall seizures are due to epilepsy – intracranial le- Severe pain r sions such as tumours, stroke and haemorrhage, or ex- Associated neurological abnormalities r tracranial causes such as drugs and alcohol withdrawal Impaired consciousness r are important underlying causes. Seizures r Metabolic causes that must be excluded in any sus- Previous head injury or history of fall or trauma r pected ﬁt or faint include hypoglycaemia and hypocal- Signsofsystemic illness caemia. The headache may subside or persist, but is typically at its worst at the dramatic onset. Meningitis A generalised headache classically associated with fever and neck stiffness. Care is required to exclude temporal arteritis in patients over the age of 50 years if a short history. When due to an underlying tumour, the time course may be short, or over months to years depending on the site and any associated complications such as haemorrhage or hydrocephalus. Migraine Classical migraine has an aura (a prodrome of symptoms such as ﬂashing lights) lasting up to an hour preceding the onset of pain, frequently accompanied by nausea and vomiting. The headache is often localised, becoming generalised and persists for several hours. Cervical spondylosis Pain in the suboccipital region associated with head posture and local tenderness relieved by neck support. Temporal arteritis Severe headache and scalp tenderness over the inﬂamed, palpably thickened superﬁcial temporal arteries with progressive loss of the pulse. In both types sociated with paraesthesia, numbness, cramps and motion, particularly of the head, can exacerbate the sen- tetany. With a chronic lesion such as a tumour, adaptive Hysteria may lead to non-epileptic attacks (pseudo- mechanisms reduce the sensation of dizziness over a pe- seizures) with or without feigned loss of consciousness. The patient will drop to the ground in front of witnesses, withoutsustaininganyinjuryandhaveaﬂuctuatinglevel Labyrinth disorders (peripheral lesions) of consciousness for some time with unusual seizure- Peripherallesionstendtocauseaunidirectionalhorizon- like movements such as pelvic thrusting and forced eye tal nystagmus enhanced by asking the patient to look in closure. This is a diagnosis they tend to veer to one side, but walking is generally of exclusion and should be made with caution. Symptoms last days to weeks and can be is the sensation experienced when getting off a round- reduced with vestibular sedatives (useful only in the about and as part of alcohol intoxication. Positional testing with the Hallpike appears after a few seconds (latency), lasts less than manoeuvre is diagnostic. It tient’seyesarecloselyobservedfornystagmusforupto responds poorly to vestibular sedatives. This test can Central lesions provoke intense nausea, vertigo and even vomiting, Acentral lesion due to disease of the brainstem, cere- particularly in peripheral lesions. For ex- ample, risk factors for cerebrovascular disease, previous history of migraine, demyelination, or the presence of any other neurology. Altered sensation or weakness in the limbs Altered sensation in the limbs is often described as numbness, pins and needles (‘paraesthesiae’), cold or hot sensations. Painful or unpleasant sensations may be felt, such as shooting pains, burning pain, or increased sensitivity to touch (dysaesthesia). There may be a pre- cipitating cause, such as after trauma, or exacerbating features. The distribution of the sensory symptoms, and any associated pain (such as radicular pain, back pain or neck pain) can help to determine the cause. Depending on the level of the lesion the weak- r Can you get up from a chair easily? Signs to use your arms to help you get up from a include: chair or to climb up stairs? Glove and stocking sensory loss in all modalities (pain, temperature, vibration and joint position sense) occurs in peripheral neuropathies. They may have peripheral muscle weakness, which is also bilateral, symmetrical and distal. Bilateral symmetrical loss of all modalities of sensation occurs with a transverse section of the cord.