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Important features in the history
- If you would like to have a go at adding some “top tips” to this page for this specialty (and have your name displayed proudly with bradfordvts), please email me – rameshmehay@googlemail.com
Important features in the Examination
Vertigo: The HINTS examination
Let’s talk about the HINTS exam—a nifty tool for distinguishing between peripheral and central causes of vertigo. Think vestibular neuritis versus something more serious like a stroke. It’s especially useful for patients showing symptoms within just hours or days of experiencing vertigo and nystagmus.
- Reassuring signs in a HINTS exam: Unidirectional nystagmus, no vertical skew, and an abnormal head impulse test? You’re likely looking at vestibular neuritis!
- Worrying signs in a HINTS test: If you see bidirectional or vertical nystagmus, vertical skew, or a normal head impulse test, it’s time for imaging to rule out a posterior or cerebellar stroke.
Red Flags
Other Top Tips
- EPILEPSY:
- 1st seizure in young people: medication is often only started after a 2nd seizure. In contrast, new-onset epilepsy in older people (>65y) is often treated after just a single seizure. Why? More likely to be an underlying cause – for example, scarring from a stroke. Risk of harm from seizures may be greater – for example, seizure causes fall >> fracture. Also, more likely to live alone – increased risk of sudden unexpected death in epilepsy (SUDEP).
- All older people with a seizure need to be seen urgently at the hospital for a full workup. Immediately if you think there may have been a stroke that triggered this. 2ww if you are concerned there may be an underlying tumour. Neurology outpatients within 2 weeks for all with new onset of seizures.
- Decision to treat is made by the hospital but GPs asked to up-titrate medication. Bear in mind that as a general rule of thumb: the initial dose and rate of titration of antiepileptic medication in older people should be about half of that in younger patients – helps with tolerability.
- EPILEPSY:
- Young individuals typically start treatment after their second seizure, while older adults (over 65) may begin after the first due to potential underlying issues, like stroke scarring, and higher risks of falls and fractures. They are also more likely to face a higher risk of sudden unexpected death in epilepsy (SUDEP).
- Older adults experiencing seizures should consult a doctor promptly, especially if a stroke is suspected. Concerns about a tumor require urgent evaluations, ideally within two weeks.
- Hospitals dictate treatment, while general practitioners adjust medications, usually starting older adults with half the typical dose of antiepileptic medications for better tolerability.
- EPILEPSY:
- When younger folks experience their first seizure, doctors typically wait for a second one before starting medication. However, for our beloved seniors (those 65 and older), the approach is a bit different—they often begin treatment after just one seizure. You might wonder why this is the case. Well, it’s because they could have some serious issues at play, like complications from a stroke. Additionally, older individuals might be more susceptible to falls, and living alone increases the risk of sudden unexpected death in epilepsy (SUDEP).
- If any older adult has a seizure, it’s important to head to the hospital for a quick check-up—especially if there’s a chance of a stroke involved! If you have concerns about a tumor, it’s best to fasttrack within two weeks. Also, anyone experiencing a new seizure should schedule a visit with a neurologist within a fortnight!
- While the hospital decides when to start medication, it’s the GPs who are often asked to adjust the dosages. As a general guideline, when older patients are prescribed antiepileptic medications, they typically start with about half the dose that younger patients might receive to help minimize any side effects!
