2 ⼀NEUROLOGY II Flashcards
(289 cards)
1
Q
53
In regards to Carpal Tunnel, the ⬜ n. courses between the ⬜ and ⬜ muscles before crossing under the ⬜ inside the carpal tunnel
A
In regards to Carpal Tunnel, the Median n. courses between the [Flexor Digitorum superficialis] and [Flexor Digitorum Profundus] before crossing under the [Flexor Retinaculum transverse carpal ligament] inside the carpal tunnel
2
Q
Although [minor head trauma] does NOT usually indicate [nHCT]
these 3 “special” groups do…
[HIGH RISK: subjects | symptoms | signs]
_________________
Name the [HIGH RISK subjects]? (6)
A
subjects AKA “patients”
1. age ≥65
2. Coagulopathic
3. IntoxicationDrug/EtOH
4. [PHM([ped vs auto])]
5. [PHM( [vehicular ejection])]
6. [PHM([Fall from height])]
| PHM = Patients with High-Risk Mechanism
3
Q
[minor head trauma] does NOT usually indicate [noncontrast Head CT].
Although [minor head trauma] does NOT usually indicate [noncontrast Head CT], there are 3 “special” groups that do…
[HIGH RISK: subjects | symptoms | signs]
_________________
Name the [HIGH RISK symptoms]? (7)
A
- Retrograde amnesia ≥30min before injury
- [Vomiting ≥ 2]
- Seizure
- Severe HA
- AMSincluding LOC
- Neuro deficit
- GCS ≤14
4
Q
Minor head trauma does NOT usually indicate [noncontrast Head CT].
There are 3 groups that require [noncontrast Head CT] after Minor head trauma..
[HIGH RISK: subjects | symptoms | signs]
_________________
Name the [HIGH RISK signs]? (2)
A
- depressed skull fx
- Basilar skull fx (CSF drainage, hemotympanum, [battle’s postauricular ecchymosis], periorbital hematoma)
5
Q
Injury to the ⬜ causes ⬇︎ ability to Dorsiflex
A
[PF(common or deep) nerve]
________________
foot dropPED
✏️PF = [Peroneal⼀Fibular] - L4 (S1-S2)
6
Q
Lennox Gastaut Dx?
A
Slow Spike-Wave EEG
________________
Lennox Gastaut
7
Q
Lennox Gastaut CP-2
A
Lennox Gastaut
- Lala Land Retarded before 5 yo
- Generalized Tonic Clonic Seizures SEVERE
8
Q
Levodopa is used to treat Parkinson’s Disease
Early SE?-3
_________________
Late SE?
A
Early SE (HAD) = Hallucinations/Agitation/Dizziness
_________________
Late SE (5-10 yrs post tx) = Involuntary mvmnts
9
Q
[Dementia with Lewy Bodies (DLB)] Tx- 2
A
footnote
1. Rivastigmine AChinesterase inhibitor
- [2nd Gen Antipsychotic] for visual hallucination
* REMEMBER THAT DLB PTS ARE SENSITIVE TO ANTIPSYCHOTICS*
“DLB at the DMV “
10
Q
List the difference between Primary and Secondary Generalized Tonic Clonic Seizures
________________
Seizure ATTaCK
A
Primary GTC occur when electrical discharge simultaneously comes from diffuse bilateral cortical areas (i.e. Absence)
vs
Secondary GTC comes from the spread of a [simple partial seizure]
11
Q
List the sequence of events for a [GTC Seizure] - 5
A
Seizure ATTaCK
1st: Aura (nausea/dizziness) vs Simple Partial
2nd: Tonic: Sudden Stiffness–>Falling and cry out
3rd: [Time Out: aPNEA] –> Cyanotic, dusky face
4th: Clonic convulsions + oral involvement
5th: [Krazed: Postictal Amnesia (pt only recalls aura) + Lethargy + incontinence]
12
Q
Pt just fell and started GTC seizing right in front of you!
How should you manage them? - 4
A
Seizure ATTaCK
1st: Roll pt onto side
2nd: Stabilize Head BUT NOT THEIR MVMNTS
3rd: KEEP THINGS OUT OF MOUTH OR AROUND PT
4th: ER if > 5 min
13
Q
Main Features of TIA - 3
A
TIA(Transient Ischemic Attack) is
1. {Transient = [usually < 20m but ≤60m REQD]}
- {Ischemia (without infarction) is FOCAL(→ FOCAL neuro sx)}
- {Attack is [REVERSIBLE⼀NO residual sx⼀NO residual radio]}
🔎radio = radiomanifestations (⊝MRI)
14
Q
Management for Epidural Spinal Cord Compression? -3
A
- [High Dose Dexamethasone IV]
- MRI
- Neurosurg consult
15
Q
[Medial Midbrain Syndrome of Weber] etx
________________
CP-2
A
PCA infarct ➜ damage to –>
- [Oculomotor CN3] → [iPL DOPe]
- [Crus CerebriCST & CorticoBulbar)] → [CTL Hemiparesis→ Face, UE, LE]
_________________
DOPe = [(Down & Out eye) + Ptosis + (eye dilated)]
16
Q
Memantine
MOA
_________________
Indication
A
Blocks Glutamate from binding to NMDA Receptor
_________________
Moderate to Severe Alzheimer’s
17
Q
Memory depends on a BL 4-way circuit
What is this circuit?-4
A
“Having Fun Memories Around”
[Hippocampus temporal lobe] –> Fornix –> [Mamillary Bodies] —> [ANT Thalamus]
18
Q
Meniere’s Disease etx
A
⬆︎endolymphatic fluid in inner ear–> Membranous labyrinth swelling and rupture –> [KRE- K+ Rich Endolymph] leak into [Na+ rich perilymph] –> abnormal hair cell function –> VTNH sx
**Very Terrible Nystagmus & Hearing **
_________________
same sx as Acute Labyrinthitis
19
Q
Acute Labyrinthitis CP - 4?
A
**Very Terrible Nystagmus & Hearing **
- Vertigo
- Tinnitus
- Nystagmus
- Hearing loss which –> Permanent eventually
same sx as Meniere’s Disease
20
Q
MeningoVascular syphilis infects ⬜ , which can present as stroke (2/2 to ⬜) , and is confirmed via ⬜
What is the tx?
A
[subarachnoid space vessels] ; intracranial arteritis ; [CSF VDRL]
_________________
PCN
21
Q
Meniere’s Disease tx - 5
A
1st: Diet(restrict Na+, caffeine, Nicotine, EtOH)
2nd: [antihistamines ⼀Benzo ⼀antiemetics]
3rd: DiureticsLong Term
_________________
Sx = VTNH (Vertigo, Tinnitus, Nystagmus, Hearing loss)
22
Q
Mgmt of Epidural hematoma -3
A
- [Reduce ICP“Stop My Head Swelling!”]
a) SBP > 100
b) Mannitol IV
c) [Hyperventilate to pCO2 25-30]
d) Stress px(H2🟥, PPI)
_________________
2. Remove hematoma
_________________
3. Cauterize Dura (Electrocoagulate & Ligate middle meningeal a. of the dura arteries)
23
Q
Name the 5 components of reducing Intracranial Pressure?
A
“Stop My Head Swelling (Cancer) !”
a) SBP > 100
b) Mannitol IV
c) [Hyperventilate to pCO2 25-30]
d) Stress px(H2🟥, PPI)
➜ e)+/- {CTS (for [CA|Trauma|Sickness_infxn] etx}
24
Q
Most common side effects of INH isoniazid (2)
A
Injuries to
Nerves= Neuropathy (Pyridoxine B6 = tx/px)
and
Hepatocytes= Hepatitis - THIS IS SELF LIMITED AND RESOLVE WITHOUT INTERVENTION
25
4 most common symptoms of Heat Stroke
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**HEAT**
1. **H**yperthermia
2. [**E**xternally *FLUSHED with Dry Skin*]
3. **A**MS(Confusion/HA/LOC/Dizziness)
4. **T**achycardia
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*[⬇︎ core temp by 0.2C/minute] using [Augmentation of EVAPORATIVE COOLING]*
26
Most common [1° CNS Tumors] in Adults (3)
**GMS**
[**G**lioblastoma astrocytoma] (GRADE 4 - MALIGNANT - 2nd MOST COMMON to Metastasis)
**M**eninGioma benign
**S**ChWannoma
*Brain Metastasis=MOST COMMON ADULT BRAIN CA*
27
Most common [1° CNS Tumors] in Pediatrics-3
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
what's the only one that's supratentorial?
**PED**s
**P**ilocytic Astrocytoma = MOST COMMON and can be Supratentorial OR infratentorial
**E**pendymoma (found in 4th Vt)
me**D**ulloblastoma PNET = 2nd most common
***E**pendymoma and me**D**ulloblastoma are infratentorial POST fossa(image)*
28
Most Cryptogenic Stroke are ⬜ in origin. What is Cryptogenic Stroke ⬜ ?
Describe thew workup? -2
embolic;
ischemic stroke w/o obvious source on initial eval
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
advanced cardiac imaging + ambulatory cardiac monitoring
*to detect paroxysmal arrhythmia (afib)*
29
*Most seizures in young children with fever are benign (febrile seizure)*
When is Lumbar Puncture indicated? (4)
1. Nuchal rigidity
2. HA
3. bulging fontanelle
4. prolonged AMS
30
Brachial Plexus damage of
[*proximal* median {C5⼀T1} n]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
clinical presentation? (2)
[**PB** **F**]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[+ thumb paralysis w thenar atrophy]*(if recurrent branch affected)*
| [**PBF**] = [**P**ope's **B**lessing***F**ISTING*]
## Footnote
💡[**P**ope's **B**lessing***F**ISTING*] = the official "*Pope's Blessing*" antecdote.
31
Brachial Plexus damage of
[*proximal* median {C5⼀T1} n]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
cause
[antero*Medial*⼀**pFSF**]
## Footnote
👓{[anteroMedial⼀**pFSF**] = {[anteroMedial⼀**p**roximal humerus displacement] iTSo [**F**OOSA **S**upracondylar **F**x]
32
Brachial Plexus damage of
[*distal* median {C5⼀T1} n]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
cause (2)
1. carpal tunnel
2. wrist laceration
## Footnote
[**UCR** *"median claw"*]
33
Brachial Plexus damage of
[*distal* median {C5⼀T1} n]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
clinical presentation? (2)
[**UCR** *"median claw"*]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[+ thumb paralysis w thenar atrophy]*(if recurrent branch affected)*
## Footnote
=[**U**lnar **C**law***R**esting*] = *the “median claw”*
34
Brachial Plexus damage of
[*proximal* Ulnar {C8, T1} n]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
clinical presentation?
[**UCF**]
## Footnote
=[**U**lnar **C**law***F**isting*]
35
Brachial Plexus damage of
[ULNAR (C8, T1) n]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
cause -3
1. [FALL ONTO FLEXED ELBOW ➜ **POSTERIOR** PROXIMAL HUMERUS DISPLACEMENT]*{→ PROXIMAL ULNA❌ = [**UCF**]} *
2. [MEDIAL EPICONDYLE]*{→ PROXIMAL ULNA❌ = [**UCF**]}*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
3. [BICYCLIST HOOK OF HAMATE INJURY = GUYAN CANAL SYNDROME]*{→ DISTAL ULNA❌ = [**PBR** "ulnar claw"]} *
## Footnote
=[**U**lnar **C**law***F**isting*]
=[**P**ope's **B**lessing***R**esting*] = [the "*ulnar claw*"]
36
Brachial Plexus damage of
[*distal* ULNAR C8-T1 n]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**clinical presentation?**
[**PBR** *"ulnar claw"*]
| *from [BICYCLIST HOOK OF HAMATE INJURY = GUYAN CANAL SYNDROME]*
## Footnote
* * *
* ([hyperextension of 4th MCP and 5th MCP] + [flexion of 4th PIP and 5th PIP])*
=[**P**ope's **B**lessing***R**esting*] = [the "*ulnar claw*"]
37
*Myasthenia Gravis, LEMS and [Myopathies (polymyositis/dermatomyositis)] can be similar*
How can you differentiate these based on reflexes?
**Myopathies[polymyositis/dermatomyositis]** and **LEMS** have ⬇︎ Reflexes.
## Footnote
Myasthenia is normal
38
Myotonia Dystrophy Clinical Manifestation - 6
**My T**onia, **My T**oupee, **My T**V Viewers, **My T**hroat, **My T**icker, **My T**esticles,
**T**onia = Myo**T**onia = [⬇︎ relaxation after volitional muscle contraction accmp/by Weakness & Atrophy] (*cant let go of doorknob*)
**T**oupee = Frontal Balding / daytime sleepiness
**T**V viewer = Cataracts / Ptosis
**T**hroat = SEVERE DYSPHAGIA --\> Aspiration PNA
**T**icker = Arrhythmia
**T**esticle = Testicular Atrophy
*[AUTO DOM C****T****G Repeat]*
39
How does [*Congenital* Myotonia Dystrophy] present? (6)
**My T**onia, **My T**oupee, **My T**V Viewers, **My T**hroat, **My T**icker, **My T**esticles,
* presents at birth with*
* \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*
hypoTonia profoundly
cataracts
inverted V-shaped upper lip
feeding intolerance
respiratory distress
contractures
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*[AUTO DOM C**T**G Repeat]*
40
how is Myotonia Dystrophy initially diagnosed?
*[AUTO DOM C**T**G Repeat]*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**My T**onia, **My T**oupee, **My T**V Viewers, **My T**hroat, **My T**icker, **My T**esticles
41
Name 2 indications for a [***Contrast*** Head CT]
intracranial abscess
intracranial mass
42
Name 4 Factors that differentiate [Lambert Eaton Myasthenic Syndrome] from Myasthenia Gravis
1. [LEMS] improves with exercise/exertion during the day!
2. [LEMS] will show **no imprvmnt** with [Tensilon Edrophonium] injection OR ice pack
3. {[LEMS] nerve testing shows [**DEC** DTR] but [**INC** Interactive Muscle responses✏️]}
4. {[LEMS] has autonomic dysfunction*(orthostasis, dry mouth, impotence)*}
## Footnote
✏️[Interactive Muscle Response] = voluntary muscle initiated by host
43
# "*{HA with [**FRATwIPS**] are Red Flags!}"* and need [⬜2 to r/o ⬜2]
List DDx for this [Headache Red Flag]:
*{HA with* *[**🅆orst after physical activity**]} *(2)
▶{*STAT* [©️Brain MRI]}
▶{*STAT* [🅽HCT if c/f SAH)]} ;
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
▶▶mass intracranial;
▶▶[*cere*bral venous sinus thrombosis (DEC CSF outflow)]
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
1. Mass
2. SAH
## Footnote
"*{HA with [**FRATwIPS**] are Red Flags!}"*
44
# "*{HA with [**FRATwIPS**] are Red Flags!}"* and need [⬜2 to r/o ⬜2]
List DDx for this one:
*{HA with* *[**🄸NC Frequency** **or** **INC Severity**]} *(3)
▶{*STAT* [©️Brain MRI]}
▶{*STAT* [🅽HCT if c/f SAH)]} ;
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
▶▶mass intracranial;
▶▶[*cere*bral venous sinus thrombosis (DEC CSF outflow)]
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
1. M ass
2. S ub🄳ural hematoma
3. M ed overuse
| "MSM *always [INC frequency] or [INC SEVERITY]😈*"
## Footnote
"*{HA with [**FRATwIPS**] are Red Flags!}"*
45
# "*{HA with [**FRATwIPS**] are Red Flags!}"* and need [⬜2 to r/o ⬜2]
List DDx for this [Headache Red Flag]:
*{HA with* *[**🅃hunderclap**⼀**Sudden**⼀**"worst HA of life"**]}*
▶{*STAT* [©️Brain MRI]}
▶{*STAT* [🅽HCT if c/f SAH)]} ;
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
▶▶mass intracranial;
▶▶[*cere*bral venous sinus thrombosis (DEC CSF outflow)]
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
SAH
## Footnote
"*{HA with [**FRATwIPS**] are Red Flags!}"*
46
"*{HA with [**FRATwIPS**] are Red Flags!}"* and need [⬜2 to r/o ⬜2]
▶{*STAT* [©️Brain MRI]}
▶{*STAT* [🅽HCT if c/f SAH)]} ;
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
▶▶mass intracranial;
▶▶[*cere*bral venous sinus thrombosis (DEC CSF outflow)]
## Footnote
"*{HA with [**FRATwIPS**] are Red Flags!}"*
47
# "*{HA with [**FRATwIPS**] are Red Flags!}"* and need [⬜2 to r/o ⬜2]
List DDx for this [Headache Red Flag]:
*{HA with* *[**🅁adical personality😵changes**]} *(4)
▶{*STAT* [©️Brain MRI]}
▶{*STAT* [🅽HCT if c/f SAH)]} ;
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
▶▶mass intracranial;
▶▶[*cere*bral venous sinus thrombosis (DEC CSF outflow)]
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
1. i ntracerebral hemorrhage
2. m ass
3. m eningitis
4. e ncephalitis
| "i m me *("I am me!😭": Radical Personality ∆)*"
## Footnote
"*{HA with [**FRATwIPS**] are Red Flags!}"*
*_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
intracerebral_hemorrhage:mass:meningitis:encephalitis*
48
# "*{HA with [**FRATwIPS**] are Red Flags!}"* and need [⬜2 to r/o ⬜2]
List DDx for this "{HA with [**FRATwIPS**]"} :
*{HA with* *[**🄰ge ≥50 yo**]} *(2)
▶{*STAT* [©️Brain MRI]}
▶{*STAT* [🅽HCT if c/f SAH)]} ;
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
▶▶mass intracranial;
▶▶[*cere*bral venous sinus thrombosis (DEC CSF outflow)]
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
1. Mass
2. Giant Cell Temporal Arteritis
## Footnote
"*{HA with [**FRATwIPS**] are Red Flags!}"*
49
# "*{HA with [**FRATwIPS**] are Red Flags!}"*
List DDx for this [Headache Red Flag]:
*{HA with* *[**🄿apilledema**]} *(4)
⭐**PAID**⭐
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
▶*"[HA with 🄿apilledema] and [HA with 🄵ocal neuro ∆ ] both come from getting...
**PAID**...which INC pressure...which hurt my **HEAD**"*
▶▶(***PAID*** causes → {[ICP] which → **H.E.A.D.**sx]}) 📄
## Footnote
📄[***PAID***etx → {[ICP] → **H.E.A.D.**sx]})
***P***CIIH
***A***V Malformation
[***I***NC CSF inproduced]
{[***D***EC CSF out([**Mass** vs [Cerebral Venous Sinus Thrombosis])_©️Brain MRI stat)]}
\_\_\_\_\_\_\_\_\_➜ \_\_\_\_\_\_\_\_
[ICP]
\_\_\_\_\_\_\_\_\_➜ \_\_\_\_\_\_\_\_
[**H**A (with focal neuro ∆ 🚩 | with *Papilledema* 🚩)]
[**E**ye vision ∆ + *Papilledema*]
[**A**MS]
[**D**oesn't eat 2/2 NV]
50
# "*{HA with [**FRATwIPS**] are Red Flags!}"*
List DDx for this [Headache Red Flag]:
*{HA with* *[**🄵ocal neuro changes**]} *(4)
⭐**PAID**⭐
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
▶*"[HA with 🄿apilledema] and [HA with 🄵ocal neuro ∆ ] both come from getting...
**PAID**...which INC pressure...which hurt my **HEAD**"*
▶▶(***PAID*** causes → {[ICP] which → **H.E.A.D.**sx]}) 📄
## Footnote
📄[***PAID***etx → {[ICP] → **H.E.A.D.**sx]})
***P***CIIH
***A***V Malformation
[***I***NC CSF inproduced]
{[***D***EC CSF out([**Mass** vs [Cerebral Venous Sinus Thrombosis])_©️Brain MRI stat)]}
\_\_\_\_\_\_\_\_\_➜ \_\_\_\_\_\_\_\_
[ICP]
\_\_\_\_\_\_\_\_\_➜ \_\_\_\_\_\_\_\_
[**H**A (with focal neuro ∆ 🚩 | with *Papilledema* 🚩)]
[**E**ye vision ∆ + *Papilledema*]
[**A**MS]
[**D**oesn't eat 2/2 NV]
51
# "*{HA with [**FRATwIPS**] are Red Flags!}"* and need [⬜2 to r/o ⬜2]
List DDx for this [Headache Red Flag]:
*{HA with* *[**🅂ystemic Sx(fever, rash)**]} *(2)
▶{*STAT* [©️Brain MRI]}
▶{*STAT* [🅽HCT if c/f SAH)]} ;
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
▶▶mass intracranial;
▶▶[*cere*bral venous sinus thrombosis (DEC CSF outflow)]
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
1. Encephalitis
2. Meningitis
## Footnote
"*{HA with [**FRATwIPS**] are Red Flags!}"*
52
[Name the 4 **EPS**-**E**xtra**P**yramidal**S**ymptoms]
| *(typically caused by [D2🟥] Rx)*
EPS = **TADD**
{**T**ardive dyskinesia⬅︎ < [Valbenazine|DeuTetrabenazine] > }
{[**A**kathisia (restlessness)]⬅︎ < 1st⼀lower D2🟥 Rx dosage --(if persist)--> ⼀give BBB\* 2nd >}
{**D**ystonia (sudden twisted posture worst with activity [*Torticollis = dystonia of the "neck"*])⬅︎ < bdIV >}
{[**D**rug-induced P|RKinsonism]⬅︎ < bAIV >}
| *(EPS is typically caused by [D2🟥] Rx)*
## Footnote
🔎bdIV = [Benztropine IV] vs [Diphenhydramine IV]
🔎[D2🟥] = [D2 R Blocker]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
🔎🔲 ⬅︎ < Treatment >
53
Tx for each **EPS**-**E**xtra**P**yramidal**S**ymptom -4
EPS = **TADD**
{**T**ardive dyskinesia⬅︎ < [Valbenazine|DeuTetrabenazine] > }
{[**A**kathisia (restlessness)]⬅︎ < 1st⼀lower D2🟥 Rx dosage --(if persist)--> ⼀give BBB\* 2nd >}
{**D**ystonia (sudden twisted posture worst with activity [*Torticollis = dystonia of the "neck"*])⬅︎ < bdIV >}
{[**D**rug-induced P|RKinsonism]⬅︎ < bAIV >}
## Footnote
🔎bdIV = [Benztropine IV], [Diphenhydramine IV]
🔎bAIV = [Benztropine IV], [Amantadine IV]
🔎D2B = [D2 R Blocker]
🔎{BBB\* = Betablocker_propranolol, Benzo_lorazepam, [Benztropine IV]}
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
🔎X ⬅︎ < Treatment >
54
Name the 4 classic sx of [INC IntraCranial Pressure]- 4
**HEAD**
1.**H**A, Positional, **worst at night/morning**
2.[**E**ye papilledema & vision ∆ ]
4.**A**MS
5.[**D**oesn't eat (NV)]
55
Name the Major UMN signs (5)
UMN signs = **W**eak **MESH**
## Footnote
**W**eakness
[**S**pastic Gait & Paralysis (*partially from disproportionate Extensor weakness*)]
[**E**xaggerated Reflexes (_Babinski_)]
**M**ental Status change
**H**emipLegia
56
Parinaud Syndrome etx
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How does it clinically present?-5
[dorsal Midbrain SUP colliculi Pretectum]❌➜
"Parinaud *LOSS* his **PUPAw**"
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[**P**upillary light reflex\_*LOSS*]
[**U**pward Conjugate Vertical Gaze\_*LOSS* (paralysis)]
**P**tosis
**A**taxia
*[+/- **w**ater hydrocephalus 2/2 obstructive Pineal GlandGerminoma]*
| [(*PUPAw*) Parinaud Dorsal Midbrain syndrome]
## Footnote
📖*etx =[Dorsal Midbrain SUP colliculi Pretectum] controls [conjugate vertical gaze]. if lesioned/ compressed (i.e. byPineal GlandGerminoma) → PUPAw/[Upward conjugate vertical gaze] paralysis*
57
Name the most common pineal gland tumor
* * *
and how it clinically manifest (2)?
Germinoma
* * *
* [Parinaud Dorsal Midbrain syndrome (*PUPAw*)]
* [Pituitary hypothalamic dysfunction (if in suprasellar region)]
58
Name the red flags that indicate a HA may be **malignant** (8)
[**FRATwIPS**] *cause malignant HA*
- **F**ocal neuro ∆
- **R**adical personality ∆
- **A**ge ≥50
- [**T**hunderclap⼀Sudden⼀"worst HA of life"]
- **w**orst after physical activity
- [**I**NC Freq or INC Severity]
- **P**apilledema
- [**S**ystemic sx (fever/rash)]
*HA diary should contain OPQRSSTAP*
## Footnote
"*{HA with [**FRATwIPS**] are Red Flags!}"*
59
Name the Serotonergic Drugs -7
1. SSRI
2. SNRI
3. TCA
4. Tramadol
5. MDMA
## Footnote
*6. Linezolidabx*
*7. MAOIantidepressant*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*#6-7 = Serotonergic Honorable mentions(= C❌D with #1-5 due to ⇪ Serotonin Syndrome risk)*
60
**Neonatal Abstinence Syndrome**
Classic Signs - 5
**TYT D**oes **H**eroin
1. **T**remors
2. **Y**awning
3. **T**achypnea
4. **D**iarrhea
5. **H**igh Pitched Cry
*Caused by maternal opioid (**H**eroin) use during pregnancy*
61
*Neonate comes in with Hydrocephalus, delineated by bulging fontanelles*
1st Diagnostic test you should obtain?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx?
Head CT
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Ventricular Shunt
62
Nerve roots for Ankle Jerk Reflex
*"1, 2 buckle my shoe - 3, 4 kick the door - 5, 6 pick up sticks - 7, 8 lay down straight"*
S**1** - S**2**
63
Nerve roots for Patellar Reflex
*"1, 2 buckle my shoe - 3, 4 kick the door - 5, 6 pick up sticks - 7, 8 lay down straight"*
L**3** - L**4**
64
Nerve roots for Biceps Reflex
*"1, 2 buckle my shoe - 3, 4 kick the door - 5, 6 pick up sticks - 7, 8 lay down straight"*
C**5** - C**6**
65
Nerve roots for Triceps Reflex
*"1, 2 buckle my shoe - 3, 4 kick the door - 5, 6 pick up sticks - 7, 8 lay down straight"*
C**7** - C**8**
66
Genetic etx of Neurofibromatosis Type 1
[17q1**1** mutation] ➜ suppression of [**NTS**-**GAP**] ➜ [(*CLAP ON*) tumor sx]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[**NTS**-**GAP**] = [NeuroFibroMin Tumor Suppressor-GTPase Activating Protein]
67
Characteristics of Neurofibromatosis **Type 1** (6)
"**CLAP** **ON** type 1!"
1. [**C**afe Au Lait *HYPERpigmented s*pots ≥ 6]
2. **L**isch nodules
3. [**A**coustic Schwannoma *uL* ➜ HA/Tinnitus/Vertigo]
4. **P**heochromocytoma
5. **O**ptic N glioma
6. **N**eurofibroma PLEXIFORM
## Footnote
*Note: NF1 in Newborns will present w/Macrocephaly, ⬇︎Feeding ,learning disabilities*
68
Identify disease
**L**isch nodules seen in Neurofibromatosis TYPE 1
**CLAP** **ON** type 1!
69
Neurofibromatosis **Type 2**
Clinical Presentation - 4
**[B** 2]4
- [**Bilateral** Acoustic Schwannomas➜ Bilateral DEAF]
- BL Cataracts
- [Belowpigment (*hypOpigmented*) Cafe Au Lait spots]
- Benign Multiple Meningiomas
70
Ocular Tonometry indication
Measures intraocular pressure*(≥30 = ⊕Acute CAG!)*
## Footnote
*(≥30 mmHg = ⊕Acute Closed Angle Glaucoma! → OpHtho consult + Timolol/CTS/Acetazolamide STAT)*
71
# Normal Retina consist of ____, _____ and \_\_\_\_\_\_
Papilledema occurs when ⬜ , and this is commonly caused by what 3 conditions?
normal [Retina**DSL**] = **DSL**: [**D**isc margin sharp /**S**mall veins linear /**L**arge vessels sharp]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
{***PCM*** causes [INC ICP**(H.E.A.D.) sx**]→ transmitted to (Optic CN2) → (papilledema[RetinaDSL]} ;
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
| "
## Footnote
"***PCM*** causes Papilledema"
1. ***P***CIIH
2. [***C***SF❌[(⬇︎CSF out⼀*CVST*✏️) vs (⇪CSF in/made) ]
3. ***M***ass intracranial
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
✏️CVST = [CErEbral Venous Sinus Thrombosis *( → ⬇︎CSF outflow)*]
72
Parkinsonism is often caused by ____ or \_\_\_\_\_
Name 2 *rare* causes of Parkinsonism
Common =
✔︎ {*DIRECT* Striatum[Substantia nigra pars compacta degeneration *(2/2 idiopathic "LABS" accumulation)*}
vs
✔︎ [D2🟥]Rx
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
rare =
-CO2 toxicity
-ManGanese toxicity
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*🔎LABS = [Lewy α-synuclein BodieS]*
73
Parkinsonism Clinical signs (8)
**PARK** & **hamp**
[**P**ill Rolling Resting 4-6 Hz **unilateral** Tremor] worst with Rest & Mental Task
[**A**Reflexia posturally (should have late onset)] --\>Shuffling Gait/Fall when turning or stopping
[**R**igidity Cogwheel]
Brady**K**inesia
+
- **h**ypOphonic speech
- **a**utonomic ⬇︎ (constipation / bladder problems / orthostatic hypOtension)
- **m**icrographia
- **p**oker masked face
*P|RK([P or R ]+ K)= primary signs*
74
Parkinson's Disease Tx = SA**L**ADS
**L**
MOA (2)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Complications (3)
"Eat **SALADS** after you Park"
{🔧[**L** + C ]
🔧with [ (E vs T) ]}
-----\-\-
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
⊗ *arrhythmia*: (**L**evodopa can → peripheral catecholamine formation → arrhythmia)
⊗*dyskinesia involuntary mvmts]*: chronic **L**evodopa can → [dyskinesia involuntary mvmts] after admin = "on/off phenomenon"
⊗*akinesia*: between doses
## Footnote
🔎 = [**L**evodopa(Dopamine Precursor) + (Carbidopa)] with [(Entacapone or Tolcapone)] *
75
Parkinson's Dz Tx - 6
"Eat **SALADS** after you Park"
## Footnote
1. {[**L**evodopa(Dopamine Precursor)+ Carbidopa] with [Entacapone|Tolcapone]}
2. **A**mantadine
3. {[**A**nticholinergics (Benztropine)]*➜ treats [Parkinsons "P|R toxic cholinergism"]*} ✏️
4. [**D**opamine PostSynaptic R Agonist](NonErgot: Ropinirole vs. Pramipexole) & (ergot:bromocriptine)
5. **S**elegiline
6. **S**urgery
- Pallidotomy: Destructive of [Globus Pallidus:internal]
- SubThalamic nuc. inhibition with electrode
- ANT Choroidal a ligation
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*📝Parkinson dz = {[loss of dopamine] + ["P|R toxic cholinergism"]}. Anticholinergics"Benztropine" treat toxic cholinergism (**P**ill rolling tremor + **R**igidity cogwheel only)*
76
*Patient with c/f meningitis has received antibiotics prior to having lumbar puncture*
How may this affect CSF analysis? (4)
Abx pretreatment can cause CSF:
- **G**lucose *HIGHER than expected*
- **P**rotein *lower than expected*
- [Gram Stain] yield *lower than expected*
- [Gram Culture] yield *lower than expected*
77
*Patient presents with lower extremity paralysis with paresthesia*
workup?
78
Patients s/p recent [*ischemic* CVA/TIA] have ⇪ risk for what 3 complications following [*ischemic* CVA/TIA]?
Because of this, CVA/TIA pts should undergo ⬜ within 24 hours
*pts s/p [**ISCHEMIC**CVA/TIA]... have ⇪ risk for developing:*
1. [*(within 3d)*hemorrhagic conversion]
2. [*(within 3d)*cerebral edema]
3.[*(WITHIN 30d)*REPEAT STROKE]
## Footnote
[**BALTIC***(post ischemic stroke mgmt)*] STAT
79
patients with undetermined [altered mental status] should RECEIVE which 3 drugs on arrival? -3
***N**ot **T**hinking **G**reat*
1. **N**aloxone
2. [**T**hiamine B1 ➜
3. [**G**lucose /Dextrose IV)]
80
Patients with [late-life major depression onset \> 65 yo] are at INC risk for developing what 2 conditions?
Alzheimer's
Vascular dementia
81
*PE is common cause of early death in recovering Stroke patients, so DVT px is needed*
How is DVT px determined for Acute Ischemic Stroke patients? (2)
if patient received
[thrombolytics | dual antiplatelet | therapeutic anticaogulation] ➜ IPC
\_\_\_\_\_\_\_\_versus\_\_\_\_\_\_\_\_\_
[ASA only] ➜ [IPC + SQ Prophylactic Heparin]
*IPC = Intermittent Pneumatic Compression*
82
[Pineal gland tumors] p/w ⬜ syndrome, and some [Pineal gland tumors] are ⬜ that secrete ⬜
Describe cp for this syndrome -5
[*PUPAw*Parinaud's dorsal midbrain syndrome] ;
Germinomas ; HCG
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[(*PUPAw*)]
[**P**upillary light reflex\_*LOSS*]
[**U**pward Vertical Gaze\_*LOSS* (paralysis)]
**P**tosis
**A**taxia
*[+/- **w**ater hydrocephalus 2/2 obstructive Germinoma]*
| “Parinaud *LOSS* his **PUPAw**”
## Footnote
✏️PPDMS can also occur with any [Dorsal Midbrain SUP Colliculi Pretectal]❌
83
PKU-Phenylketonuria S/S (4)
*PKU smells a* ***MESS****!*
**M**usty Odor
**E**czema
**S**eizures
**S**low mentally (retard)
84
Postconcussive syndrome can persist anytime from ⬜ to ⬜ post TBI, and involves what 8 major sx?
hours to ≥6 months after TBI
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
*postconcussive from* **ADAM'S VHS**
**A**mnesia
**D**ifficulty concentrating/multitasking
**A**nxiety
**M**ood alteration
**S**leep ∆
**V**ertigo dizziness
**H**A
**S**o CONFUSED
85
Prolactin level of ⬜ = Prolactinoma
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx? -2
\> 200
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Dopamine R agonist (bromocriptine ergot vs cabergoline)] \<
1cm \< [Surgery for MACROademona]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*tx ⬇︎tumor size (even visual sx) within few days. Surgery rarely indicated*
86
Pronator Drift is a good indicator of what type of disease?
[UMN Pyramidal Tract Dz (think stroke)]
* * *
* Pyramidal Tract = CorticoBulbar and CorticoSpinal
* Clasp Knife phenomenon also indicates Pyramidal Tract Dz*
87
*Pt has advancing foot crossing over opposite foot similar to closing scissor blades*
What causes Scissors Gait?
*"spastic"* UMN(Corticospinal *Pyramidal* Tract) lesions
## Footnote
**S**pasticity causes **S**cissors Gait
88
*Pts are recommended to employ ⬜ during the prodromal phase of VANS to abort the syncopal episode*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Name two examples (2)
[physical counterpressure maneuvers]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[crossing legs while tensing body muscles] or [clenching fist while tensing arm muscles]
*these improve venous return and cardiac output*
89
Pts with Cerebellum lesions have _____ (*ContraLateral vs Ipsilateral*) Hemiataxia. Why is this? ; Why are Cerebellar hemorrhages so dangerous?
**IPSILATERAL** ; CorticoPontoCerebellar fibers decussate TWICE ; May extend down into brainstem --\> Coma & Death
## Footnote
*Image: L Cerebellar hemorrhage --\> L hemiataxia*
90
Recall the Oculosympathetic Horner's pathway - 9
[H**P****I** - U**LS** - f**c**m]
1. **H**ypothalamus
2. **P**asses as hypothalamospinal tract in **lateral medulla**
3. [**I**ML C8-T1 Cilospinal Center of Budge] *= SNX1* ⼀→ exits @ T1 and travels
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
4. **U**nder Subclavian Artery as *[sympathetic chain trunk]*
5. **L**ung Apex
6. **S**UP cervical ganglion near carotid bifurcation *(= *SNX2)*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
7. **f**acial Sweat Glands
8. **c**arried with CN5B1 **thru cavernous sinus** & then **SUP orbital fissure** to Pupil Dilator
9. [**m**uller's superior tarsal muscle] innervation
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
✏️*2 / 3 / 5 / 6 / 8 are most common sites of Horner's syndrome*
*🔎SNX = Synapse*
91
What are the most common causes of Horner's Syndrome? - 5
* Lateral Medullary syndrome of Wallenberg
* [spinal cord lesion *above T1* (Brown Sequard hemisection/syringomyelia)]
* Lung Apex tumor
* Neck Carotid Trauma
* Cavernous Sinus Thrombosis
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[H**P****I** - U**LS** - f**c**m] *2 / 3 / 5 / 6 / 8 are most common sites of Horner's syndrome*
92
Sciatica
etx
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Clinical Presentation - 3
"Having Sciatica makes you break **LAWS**"
* [**L**ower Back pain w/radiation down POSTERIOR thigh --\> lateral foot]
* **A**nkle jerk reflex ABSENT (this can occur naturally with age!)
* **W**eak Hip Extension
* [**S**1 n PosteroLateral compression at L4-5 or L5-S1] --\> UMN signs
93
Sciatica tx -3
*"Having Sciatica makes you break **LAWS**"*
1. NSAIDs
2. APAP
3. Self-Limited
## Footnote
*NSAIDs + APAP = 1st line tx as Sciatica sx are Self limited*
94
Sciatica
dx? -2
"Having Sciatica makes you break **LAWS**"
Dx = **CLINICAL**
(Only use MRI for confirmation of disc herniation if sensory/motor deficit, cauda equina syndrome sx or epidural abscess r/o)
95
*Seizures and Syncope are difficult to differentiate*
Name features that help differentiate Seizures from Syncope - 4
**Seizures** has...
1. Postictal confusion
2. Postictal lethargy
3. Triggered by flashing lights
4. Tongue laceration
*beware: Clonic jerks can occur during syncope associated w/cerebral hypoxia!!*
96
**Serotonin Syndrome** Clinical Presentation (8)
"Serotonin gave me the **🆂HI🆅🅴RS**!"
🆂hivering
[**H**yperreflexia & Myoclonus]
**I**NC Temp
[🆅itals Unstable (tachycardia vs. tachypnea vs. HTN)]
[🅴ncephalopathy (Confusion vs. Agitation)]
**R**estlessness
**S**weating
_________________
🆂🆅🅴 = Serotonin Syndrome *triad*
97
*SIDS is sudden infant death that can't be explained*
What are 4 major ways to ⬇︎ risk of SIDS?
1. **Supine** Sleeping position
2. NO second hand smoke
3. Use Pacifier during sleep
4. ROOM sharing (NOT bed sharing)
98
Negative Cremasteric reflex could be caused by ⬜ (3)
1. Testicular Torsion
2. [L1-L2 spinal cord damage (*will be accompanied by loss of hip Flexion & loss of hip ADDuction*)]
3. Diabetic neuropathy
## Footnote
*"**L**1, **L**2*...his testicles move"* Cremasteric reflex 🅽 roots
99
Testicular Torsion and Acute Epididymitis
what do they share?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do they differ?
Sim = Both have [Acute Testicular Pain]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Differences =
1. TT has [**High Riding** testes] and [NEGATIVE cremasteric reflex]
2. [AE has Fever, Pyuria & **CORD** TTP]
100
Step-Wise Tx to Restless Leg Syndrome - 4
1st: NonPharm (Leg Massage/Heat/Exercise/Iron Supplement)
2nd:[NonErgotPostsynpatic Dopamine🟢] ✏️
3rd: Gabapentin (if pt also has insomina vs chronic pain)
4th: Opioids
## Footnote
✏️examples: Pramipexole|Ropinirole
-Gabapentin MOA= [α2-delta Ca+ channel ligands]
101
[STURGE Weber Syndrome] Clinical Presentation -6
**STURGE**
💊1.[**S**tain_Red(Nevus Flammeus Port Wine Stain) along CN5B1|B2 vs (congenital uL cavernous hemangioma) ]*(tx= Argon Laser)*
2.[**T**ramline gyrification calcifications on CT]
3.**U**nilateral
4.**R**etardation
💊5.[{**G**laucoma IPL] + [CTL Homonymous Hemianopia]}*(tx=⬇︎IOP)*
💊6.{⭐⭐ **E**PILEPSY ⭐⭐*(tx=anti-Epileptics)*}
102
Sturge Weber Syndrome Tx -3
💊{[**S**tain_Red*✏️*]**(tx= Argon Laser)**}
💊{[{**G**laucoma IPL] + [CTL Homonymous Hemianopia]]**(tx= ⬇︎IOP)**}
💊{[⭐⭐ **E**PILEPSY ⭐⭐]**(tx= antiEpileptics)**}
## Footnote
✏️[**S**tain_Red*([Nevus Flammeus Port Wine Stain]|uL cavernous hemangioma)*]
#**STURGE**sx
103
Name the Lower Motor Neuron signs - 4
LMN signs (**FAAW**) - **F**asciculations / **A**trophy & **A**reflexia / **W**eakness
104
Tetanus takes ⬜ days to onset after exposure to endospores
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx? - 5
**2** days;
1. *Tetanus Ig**G** Immune Globulin*
2. *Tetanus **V**accine*
3. Abx
4. Diazepam
5. Mechanical ventilation ICU
*Comes from puncture wound vs burn*
105
The criteria for Status Epilepticus is ⬜ or ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you manage Status Epilepticus (5)
106
CP of VertebroBasilar TIA - 5
Labyrinths: **DIZZINESS**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Brainstem*( → "crossed" signs)*] : **DIPLOPIA**,
**DYSARTHRIA**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Cerebellum: **BL Clumsiness**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Spinal Cord: **BL Weakness**
107
Tourette Syndrome CP -2
Tics - BOTH MOTOR AND VOCAL AT SAME TIME!
(Motor & Vocal -shoulder shrugs/blinking/grimacing/[**coprolalia swearing**])
108
Tourette syndrome tx (7)
haloperidol FGA
pimozide FGA
* * *
Risperidone SGA
Aripiprazole SGA
* * *
[Alpha 2 R agonist]
Tetrabenazine
* * *
[CBT habit reversal therapy]
109
Tuberous Sclerosis Clinical Presentation (12)
**HAMARTO(MAS)ss**
## Footnote
[**H**amartomas benign]
[**A**ngioMyoLipoma in Kidney]
**M**itral Regurgitation
[**A**sh Leaf Macules]
[**R**habdomyoma Cardiac --\> Valvular Obstruction]
**T**uberous Sclerosis
auto d**O**m
**M***ental Retard-triad* ⭐
[**A***ngiofibroma on Face-triad*] - ⭐ *image*
[**S***eizures-triad - ORDER EEG*] ⭐
**S**EGA (SubEpendymal Giantcell Astrocytoma)
[**S**hagreen forehead patches]
110
Patients with Tuberous Sclerosis must receive a ⬜ test; especially since (⬜2) is the leading cause of death in these patients
EEG ; [SEIZURES and associated CNS decline]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
**HAMARTOMAsss**
111
Tx for Catatonia - 2
Lorazepam
## Footnote
and/or
ECT
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*consider Lorazepam challenge = Lorazepam 2 mg IV ➜ observe result (if pt relieved within 5 min = catatonia)*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
"Catatonia is **WIMPEN** around"
112
Sx of Catatonia - 6
"Catatonia is **WIMPEN** around"
**W**AXY FLEXIBILITY
**I**mmobility
**M**utism
**P**osturing
[**E**choLalia/EchoPraxia]
**N**egativism
| " **WIMPEN** sx "
## Footnote
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*consider Lorazepam challenge = Lorazepam 2 mg IV ➜ observe result (if pt relieved within 5 min = catatonia)*
113
How do you diagnose Catatonia?
Lorazepam challenge =
[Lorazepam 2 mg IV] ➜ observe patient ➜
= [posi⊕ive patient rxn(*pt relieved within 5 min)*] = ⊕Catatonia dx
= [negative or no pt rxn] = inconclusive
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*note: a negative response does NOT rule out catatonia*
| "Catatonia is **WIMPEN** around"
114
Tx for Essential Tremor - 6
Propranolol \> [**PAT** - **P**rimodone vs **A**nticonvulsants vs **T**opiramate] \> Benzo \> Surgery
| *socially* relieved by EtOH
## Footnote
*Onsets at 45 yo and 50% cases are AUTO DOM*
115
tx for Guillain Barre syndrome -2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
when is this tx indicated?
plasma **EXCHANGE**
or
IVIG
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**nonambulatory pts** should receive tx if their sx have been present \< 4 wks
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*ambulatory pts recover on their own*
116
Tx for **Single** Brain Metastasis (likely from ⬜ primary) - 3
*[Lung NonSOLC]*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
SURGERY>SRS>[Whole Brain Radio]
## Footnote
✏️ ⭐ [(SRS) Stereotactic RadioSurgery(*Use SRS 1st in non-surgical pts)* ]]
117
Tx for **Multiple** Brain Metastasis (likely from ⬜ primary)
Whole Brain Radio
*Likely from [Lung NonSOLC] primary*
118
Tx of **Pediatric** Migraine - 3
1. Dark Quiet Room +
2. NSAID
3. Triptans (refractory)
## Footnote
*Triggers = stress/lights/odors/foods*
119
Typical sx of dementia are ⬜3 ; and although most cases are caused by ⬜ , 20% dementia patients have reversible causes
*“Dementia is **G**eriatrics **L**osing **C**ognition”*
1. **G**ait
2. **L**anguage
3. [**C**ognition MMSE \< 24]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Alzheimer's
## Footnote
*r/o [**VhS**reversible dementia] prior to [Alzheimer dementia] dx*
120
What are the 3 **reversible** causes of dementia??
▶***VhS***
[**V**itB12 deficiency] | **h**ypOthyroid| [**S**ad(*MDD "Pseudodementia")*]
| *🔎MDD = Major Depression Disorder*
## Footnote
*r/o [(**VhS**)reversible dementia] prior to [Alzheimer dementia] dx*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*“Dementia is **G**eriatrics **L**osing **C**ognition”*
121
[Ulnar Nerve Syndrome] typically occurs at the ⬜ , usually from what scenario?
**ELBOW** (where ulnar n lies at medial epicondylar groove before passing thru cubital tunnel) ; Leaning on Elbows at desk
*May also occur at forearm in DM pts*
122
[Ulnar Nerve Syndrome]
CP-5?
*“Leaning on Elbows at desk(P). hamate fracture(d)”*
1.[numb IPL 4th and 5th digits]**[distal | PROXIMAL] ❌**
2.[weak "clumsy" IPL hand]**[distal | PROXIMAL] ❌**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
3.[numb IPL hypOthenar**PROXIMAL❌ only**]
4.[DEC IPL **wrist flexion****PROXIMAL❌ only**]
5.[DEC IPL **hand grip****PROXIMAL❌ only**]
*PROXIMAL Ulnar n is especially vulnerable to❌at as it runs posterior to medial epicondyle_elbow. ⬇︎IPL hypOthenar sensation, ⬇︎IPL wrist flexion and ⬇︎IPL hand grip = cp*
*May also occur at forearm in DM pts*
123
# What are the *UpToDate* clinical recommendations for
[Vitamins & Dietary Supplements] in [pts with new dx Dementia]?
**NOT RECOMMENDED**
| (no clinical evidence they help)
124
Valproic Acid
side effects -3
*Val hated **B**aby **L**iver **P**lates!*
1. **B**aby = Teratogenic Neural Tube Defects
2. **L**iver = hepatotoxic
3. **P**latelet drop = thrombocytopenia
* pts should be monitored for these side effects*
125
VertebroBasilar insufficiency affects the (⬜4) of the CNS and occurs because of (⬜3)
## Footnote
Labyrinths: **DIZZINESS**
[Brainstem*( → "crossed" signs)*] : **DIPLOPIA**, **DYSARTHRIA**
Cerebellum: **BL Clumsiness**
Spinal Cord: **BL Weakness**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[emboli, thrombus, arterial dissection]
126
What 2 conditions is Tourette syndrome associated with?
ADHD
Obsessive Compulsive Disorder
127
What are Risk factors for PCiiH [Pseudotumor Cerebri Idiopathic Intracranial HTN] - 4
1. [OOOO (Overweight Ogles{Women} On OCP (*will usually have Empty Sella Turcica*))]
2. Tetracyclines
3. Vitamin A OD (Isotretinoin)
4. Growth Hormone
*This HA will make you go Blind!*
128
What are the 2 most important clinical values to monitor for Guillain Barre syndrome?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*cross reacting abs against peripheral nerves*
Negative Inspiratory Force
Tidal Volume vital capacity
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*assess' respiratory status*
129
What are the 7 major complications of Newborn Prematurity
## Footnote
*Less than 32 weeks gestation specfically*
"*Premies stay* **BURPPIN***"*
## Footnote
**B**ronchopulmonary Dysplasia
**U**cantBreathe (Neonatal Respiratory Distress Syndrome)
**R**etinopathy
**P**atent Ductus Arteriosus
**P**alsy CEREBRAL
**I**ntraventricular Hemorrhage
**N**ecrotizing Enterocolitis (⬆︎gastric residual volume with abd distension)
130
[Oculomotor CN3] palsy CP? -4
*eye is* **DOPe**
[**D**own & **O**ut] + **P**tosis + [**e**ye dilated]
131
What are the causes of [Oculomotor CN3] palsy?-5
"**T**hird **P**alsy **C**auses ***D**OPe* **P**resentation"
1. **T**UMTL herniation
2. **P**CA occlusion
3. **C**avernous Sinus Thrombosis
4. [**D**M oculomotor CN3 central ischemia (no *e*ye Dilation)]
5. **P**OST communicating artery aneurysm
## Footnote
***DOPe***
132
What are the functions of [Oculomotor CN3]? -7
E. .SUP Orbital fissure ➜
e1. Upper
▶[SUP rectus (***D***)]
▶[LPS (***P***)]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
e2. Lower-a
▶[inf Oblique]
▶[inf rectus]
▶[Medial rectus (***O***)]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
e2. Lower-(b)
▶ < ciliary branch: {ciliary ganglion}: [CPM (***e***)] + [ciliary m]>
| ***DOPe*** = *Oculomotor CN3 palsy* sx
## Footnote
1. [inf oblique]EWG
2. [inf rectus]EWG
3. [SUP rectus]EWG : ***D***
4. [medial rectus]EWG : ***O***
5. {[*Levator Palpebrae Superioris*]*EWG = elevates eyelid}* : ***P***
6. {[*Constrictor pupillae m (ciliary branch) *]*cg ←EWG = constricts pupil}* : ***e***
7. [*ciliary m* = contracts ciliary m]
133
Recite the pathway of the [Oculomotor CN3], starting with its nucleus (*which houses the ⬜ ganglion)* in the ⬜ ? -8
[EW ganglion]; midbrain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
a.{[Oculomotor CN3 nucleus] of midbrain}
B. SCA
c. PCA
d. Cavernous Sinus
E. .SUP Orbital fissure
e1-Upper. ➜ [SUP rectus (***D***)] / [LPS (***P***)]
e2-lower-a. [inf Oblique (***D***)] / [Medial rectus (***O***)] / [inf rectus]
e2-lower-b. < ciliary branch: {ciliary ganglion}: [CPM (***e***)] >
| ***DOPe*** = *Oculomotor CN3 palsy* sx
## Footnote
▶ LPS = . {[*Levator Palpebrae Superioris*]*EWG = elevates eyelid}* : ***P***
▶cPM= {[*constrictor Pupillae M (ciliary branch) *]*cg ←EWG = constricts pupil}* : ***e***
134
What are the 4 most common causes of excessive daytime sleepiness?
***POND***
1. **P**eriodic Limb Movement
2. **O**SA
3. **N**arcolepsy
4. **D**epression
*dx = Polysomnography*
135
# *Late neurosyphilis can present with Dementia, ARP and TDPCD*
What are the primary manifestations of TDPCD? (2)
## Footnote
*TDPCD = Tabes Dorsalis Posterior Column Disease*
*ARP = Argyll Robertson Pupils*
1. Sensory ataxia (from loss of dorsal root/DCP 2 TVP)
2. lancinating radiculopathy (face, back, extremities)
## Footnote
*🔎Sensory ataxia = inability to "sense" legs*
136
What are the Risk Factors for Alzheimer's Dz - 6
CLAV--\> HANDU
1. \> 60 yo
2. Female
3. Family hx
4. Head Trauma
5. ⊕[Apolipoprotein E**4**]*"ApoE4 is BAD 4U!"*
6. Down's Syndrome (they have ⬆︎ [**chromo 21** transmembrane amyloid precursor glycoprotein])
137
What are the major functions of [Vagus CN10] - 5
**VAGUS**
**V**ocal Cord Phonation
[**A**LG :*motor* and *sensory*]
[**G**ag reflex*E ➜FFerent limb*] *(loss of Gag = [Glossopharyngeal CN9] problem)]*
[**U**'ll COUGH reflex*a←fferent limb*]✏️
[**S**wallowing & Palate Elevation(*VagusCN10❌ → Uvula deviates OPPOSITE lesion*)]
| ✏️*vagus CN10 sends cough sensory information TO nc*
## Footnote
*Image: {**Left** [Vagus CN10] palate dysfunction}*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_x\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*🔎**ALG** = **A**ortic & Heart*(baroreceptor/chemoreceptor)* , **L**ungs_bronchi, **G**I:*
*{EFFerent.afferent.}*
138
# [**VANS**] is categorized into what 3 sub-types?
*With these sub-types in mind:*
Name all the common triggers of [**VANS**]? -8
| [***VANS*** *= (Vasovagal Autonomic Neurocardiogenic_reflex-Syncope)*]
"the **VANS** are ***VCS***"
1.***V***EMOTION
2.***V***PAIN
3.***V***[Prolonged Standing*(via VagusCN10 Aortic Baroreceptors)*]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
4.***C***Carotid Massage
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
5.***S***Coughing
6.***S***Meals
7.***S***Defecation
8.***S***Urination
| *these →parasympathetic SPIKE = [vasoDilation, ⬇︎HR]→ ⬇︎brain perfusion*
## Footnote
*VANS is preceded by nausea, sweating and dizziness*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*🔎*
***V****= [Vasovagal ⼀VANS]*
***C*** *= [Carotid⼀VANS]*
***S*** *= [Situational⼀VANS]*
139
a. What are “crossed signs” ?
* * *
b. What do they indicate? Explain.
a. {[IPL Cranial Nerve deficits] with [CTL Body deficits]} ⼀*example: Lateral Medullary syndrome of Wallenberg*
* * *
b. **Brainstem Stroke**:
because brainstem is where most cranial nerves originate and also where *many motor and sensory fibers CROSS MIDLINE,* brainstem strokes characteristically create “crossed signs”
140
What causes Hemiballismus
▶[*(BTiC)*Lacunar Stroke] damage
▶▶to {[**B**asal Ganglia**Subthalamic nc ( = modulates Basal Ganglia output)**]}
▶▶▶→ [CTLHemi*B*allismus & involuntary writhing]}
| *Note: Basal Ganglia is in Subcortical nuclei*
141
What hallmark sign of encephalitis discerns it from meningitis?
⭐AMS⭐
(*specific to encephalitis*)
## Footnote
*encephalitis* sx = **FAVORS**
142
What is Akathisia?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you treat it? -2
restlessness (typically 2/2 [D2 R Blocker] Rx)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[attempt dosage DEC 1st *(if 2/2 [D2 R Blocker] medication)*] ➜ [propranolol 2ND]
143
Describe Essential Tremor-2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What is it *socially* relieved by?
1. [ (BUE/Voice/Head) Action Tremor **worst w/Action**]
2. **No additional neuro ∆**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
relieved with EtOH
## Footnote
✏️[e❌acerbated by : HYPERthyroid | Lithium | Valproic Acid]
✏️ Onset at 45 yo
✏️50% cases are AUTO DOM
144
What is Pseudodementia?
Severe Depression in Elderly tht **mimics Alzheimers** **dementia**.
*"Elderly c/o SLEEP PROBLEMS, memory loss and attention problem, but really have depression"*
| *Tx = SSRI*
## Footnote
*r/o [(**VhS**)reversible dementia] prior to [Alzheimer dementia] dx*
145
What is [Sensory receptive aprosody]?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How does it occur?
Inability of pt to understand prosody/vocal inflections **by other people**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
Damage to [**NonDominant** Cortex opposite to Wernicke's area]
146
What is the action of the Inferior Oblique m?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What is the action of the Superior Oblique m?
**IOUO SODO**
**I**nferior**O**blique = **U**p and **O**ut
**S**uperior**O**blique (*innervated by Trochlear CN4*) = **D**own and **O**ut
147
# *In Brain Death dx, {⊕ancillary= [(⬜) with (⊝IC Blood Flow>⬜min )]}*
Name 3 diagnostic modalities you can use to determine (*IC Blood Flow*) during Brain Death dx
*[⊕EEG = isoelectric & NO bstem & NO SS]*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1. [**Radioisotope brain scan**]
vs
2. [TransCranial Doppler]
vs
3. [Carotid AngioCTA/MRA]
| *⭐{⊕ancillary= [(⊕EEG3 ) with (⊝IC BFlow >10m)]}*
## Footnote
💡*(⊝IC Blood Flow) is typically 2/2 associated brain edema*
148
What is the femoral nerve responsible for? -5
1. MOTOR:EXTENDS KNEE
2. REFLEX:KNEE
3. SENSORY:Anteromedial thigh
4. SENSORY:medial leg
5. SENSORY:arch of foot
149
What is the tx for [Cryptococcal *Neoformans*] meningoencephalitis? (4)
[(Amphotericin B) + (Flucytosine)]GOE2w (sx abate/CSF sterile)
➜ {[HD Fluconazole]8w *(+ start HAART)*}
➜ [LD Fluconazole]1y
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Cryptococcal n. meningitis = {[Elevated CSF opening \>250] + [lymph WBC \<50]} in pt with CD4\<100*
150
What is the most common cause of Fatal Sporadic Encephalitis in the U.S.?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Should you use CT or MRI for dx?
Herpes Encephalitis
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
MRI **(and then CSF PCR=Gold Standard Dx)**
151
What is the most common cause of Lateral Medullary Syndrome of Wallenberg?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
2nd most common?
**Intracranial Vertebral a occlusion** ;
## Footnote
PICA occlusion
152
What is Therapeutic hypOthermia often used for?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How low of temp can you go?
Prevents hypoxic Brain injury in pts with [**out of hospital** cardiac arrest]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
32C
153
What is the [**ARAS** (**A**scending **R**eticular **A**ctivating **S**ystem)] important for?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Lesions of the ⬜ where ARAS is located leads to what? - 2
**ARAS** “***A**lways **R**etaining **A**wake **S**tate”* = keeps you awake!
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
lesions of **upper brain stem** --\> Somnolence or Coma
154
What is unique about [Trochlear CN4]?
Only cranial nerve to exit **DORSAL** midbrain and then decussate and innervate **CTL** Superior Oblique muscle
## Footnote
IOUO SODO
155
What is [Post Intensive Care Syndrome]?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What are the risk factors? (3)
pt s/p ICU, now c/o [⬇︎QOL 2/2 sustained residual *physical-psych-neuro*deficits primarily developed io\ ***"(MAD)***" *ICU* experience]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
***MAD***
1. **M**echanical ventilation prolongation
2. **A**RDS
3. **D**elirium
## Footnote
*🔎QOL = Quality Of Life*
156
Explain how certain *drug class* cause **EPS**?
Which *drug class* cause **EPS** the most?
*inadvertantly*[Blocking (Nigrostriatal D2 R )];
[**F**GA(Haloperidol/Fluphenazine) ]
## Footnote
*🔎**F**GA = **F**irst generation Antipsychotics*
157
What other condition is [**LEMS** - Lambert Eaton Myasthenic Syndrome] associated with?
"**LEMS** has a good **SOLC**(soul)"
**SOLC**-**S**mall **O**at cell **L**ung **C**arcinoma
158
What other condition is [Myasthenia Gravis] associated with?
Thymoma (thymic hyperplasia)
159
What pCO2 (mmHg) should pts with INC intracranial pressure be hyperventilated to?
25-30
160
what role does Steroids play in Intracranial Bleeding?
NONE
| *"**S**top **M**y **H**ead **S**welling !"*
161
What dx should you suspect in a pt who has doMAP? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
explain
*doMAP = [down & out eye + Miosis⼀Anhidrosis⼀Ptosis]*
Cavernous Sinus Compression!
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Oculomotor **AND sympathetic (*****Horner's*****)**] fibers cross thru Cavernous Sinus and if compressed ➜
**doMAP** [(down & out eye) + Miosis⼀Anhidrosis⼀Ptosis]
162
What would a [**R** **Partial Retinal lesion**] manifest as
R Monocular scotoma
163
Lesion at which letter would result in [**R Nasal Hemianopia**]
D
164
Lesion at which letter would result in [**L Pie on the Floor (Homonymous INF quadrantanopia)**] lesion
G
165
Name the two 1st line Rx groups for treating Dementia? (2)
[AChE inhibitors] \> [NMDA *Glutamate* R Blocker]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*AChE inhibitor = Acetylcholinesterase inhibitor*
166
What's the most common Brain CA in adults?
METASTATIC
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*(from another primary ⼀like Lung NonSOLC)*
167
What's the best way to approach treatment for [Neuroleptic Malignant Syndrome]-2
Treat [Rigiditiy lead pipe] with Dantrolene (inhibits Ca+ release from sk. muscle sarcoplasmic reticulum)
+
supportive care
168
In order from Most to least common, name sites of Berry Saccular Aneurysm? - 4
## Footnote
*SAH occur usually in Suprasellar Cistern*
[ANT communicating] \> [POST communicating (*will result in CN3 palsy*)] \> MCA \> [POST Circulation]
169
What's the most common cause of SubArachnoid Hemorrhage?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What's the 2nd?
*Usually in the Suprasellar Cistern*
**Trauma** \> [Berry Saccular Aneurysm]
170
When should epidural hematoma be evacuated ideally?
before Transtentorial herniation
171
In order from Most common to least common, Name the 5 most common origins of Brain Metastasis?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Which of these present as **MULTIPLE** (not solitary) brain metastasis?-2
Most common= **[LUNG NonSOLC]**
\> Breast \> unknown\>**Melanoma**\>Colon
## Footnote
**[Lung NonSOLC]** & **Melanoma** --\> **multiple**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
rare = Oropharyngeal
172
Where are Brain Metastasis typically found? - 2
Gray White Junction vs Watershed Zones
## Footnote
✏️ Brain metastases are multifocal and spherical
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
✏️Most common= **[LUNG NonSOLC]**\> Breast \> unknown\>**Melanoma**\>Colon
173
Where do most disc herniations occur? - 2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Risk factor for disc herniation?
between
* L4-5 OR
* L5 - S1
* * *
SMOKING = Risk factor
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Positive Crossed Straight Leg = Lumbar Disc herniation*
174
What 4 locations is pain radiated to in L5 Radiculopathy?
1. Lower Back
2. Butt
3. [Lateral Thigh]
4. [LateralAntero Leg]
## Footnote
*L5 Radiculopathy can also cause Foot dropPED*
175
Where do most Medulloblastomas occur?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How does this present clinically?
[*infratentorial* Cerebellar VERMIS]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Truncal ataxia]
176
Describe Features of **BENA** (**Brocas Expressive NonFluent Aphasia)** -4
1.❌[Non*fluent* speech]
2.❌[Right Hemiparesis]
3.❌Impaired Naming
## Footnote
4.❌Impaired Repetition
177
Describe Features of **Wernickes Aphasia** - 4
1.❌ [Non*comprehensive* speech]
2.❌ [R *"pie in sky"*(R SUP homonymous quadrantonopia) ]
## Footnote
3.❌impaired Repetition
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
4.✔︎ [*fluent* speech]
*Conductive AND Wernicke Area = Dominant SUP Temporal*
178
Describe Features of **CONDUCTION** **Aphasia**
**VERY POOR** Repetition
## Footnote
*This is in addition to Fluent but many phonemic errors*
179
Which 3 conditions is Valproic Acid used to treat?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Why do Women need greater precaution when taking Valproic Acid?
Epilepsy | Juvenile Myoclonic Epilepsy| Bipolar disorder
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Valproic Acid is **teratogenic ➜** Neural Tube Defects
180
[MAOI antidepressant] and [Linezolid abx] are 2 drugs that are contraindicated with the ____ class of drugs
Seroternergic
181
Which 3 Neuro Diseases Cross the Corpus Callosum?
1. Gliomas (*AGE - i.e. Glioblastoma*)
2. Multiple Sclerosis
3. CNS Lymphoma
182
Which areas of the brain are affected by [HSE-Herpes Simplex Encephalitis]? - 2
1. Medial temporal
2. Inferior frontal
183
Which CA metastastize to the spinal cord? -5
1. Breast
2. Lung
3. NonHodgkins lymphoma
4. Renal
5. Prostate
184
Which 3 CNS tumors affect Spinal Cord?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx?-2
1. Meningioma benign
2. Ependymoma (usually 4th Vt)
3. Metastasis (Prostate/Renal/Lung/Breast/Multiple Myeloma)
## Footnote
Tx = Radiation + Dexamethasone
185
# Brainstem strokes cause [IPL Cranial Nerve deficits] and [CTL Body deficits]
Which Cranial Nerve nuclei originate from the midbrain? (3)
186
# Brainstem strokes cause [IPL Cranial Nerve deficits] and [CTL Body deficits]
Which Cranial Nerve nuclei originate from the Pons?
187
# Brainstem strokes cause [IPL Cranial Nerve deficits] and [CTL Body deficits]
Which Cranial Nerve nuclei originate from the Medulla?
188
Which disorder results in a Waddling gait and why?
Muscular dystrophy; Gluteal m weakness
## Footnote
*Waddling Gait = walks like Penguin from Batman*
189
Which grade Astrocytoma is this? How can you tell? CP?
**LOW** grade astrocytoma; it has NO CONTRAST ENHANCEMENT ; Seizures
190
Which imaging should be obtained for CVA/TIA w/u? - 4
1. NHCT
2. [CTA/MRA_head-neck]📸
3. Carotid Cervical US
4. TTE
| **BALT(I)C**
191
which medication is given for Cluster HA px?
Verapamil
192
Which Second Generation Antipsychotics are most associated with *causing*
[Extrapyramidal (TADD)] sx -2
Risperidone \> Lurasidone
| *"Risper, Lura.. and stop being so extra"*
193
Loss of **Gag Reflex** indicates what cranial nerve damage
IPL[Glossopharyngeal CN9]
194
**Dysphagia** indicates what cranial n. damage (2)
[Glossopharyngeal CN9] and [Vagus CN10]
195
**Dysphonia/Hoarseness** indicates what cranial n. damage
[Vagus CN10]
| *fx = **V.A.G.U.S.***
196
Which 3 vessels are affected by [**TUMTL**-**T**ranstentorial **U**ncal **M**edial **T**emporal **l**obe] Herniation?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What manifestations result from this?
[**TUMTL** Hernation--\> Compression of [**POP**- **P**CA / **O**culomotor CN3 / **P**aramedian Pontine vessels] --\>
Compression of:
1. [**P**CA] --\> Occipital lobe infarct --\>CTL[homonymous hemianopia w/Macular sparing]
2. [**O**culomotor CN3]--\> IPL[**DOPe** ⼀"Down & Out" Eye + Ptosis + eye dilated]
3. [**P**aramedian Pontine vessels] --\> Duret Hemorrhage
197
Why are competitive weight lifters at risk for Orthostatic Syncope? (2)
▶[competitive weight lifters] often use [diuretics and fluid restriction] to rapidly lose weight for lighter weight category
▶▶[diuretics and fluid restriction] → hypOvolemia → orthostatic syncope
*GET [DIURETIC URINE ASSAY] + ORTHOSTATIC BP = Dx*
198
Why are Multiple Sclerosis pts at risk for BL Trigeminal Neuralgia
Demyelination may occur at Trigeminal **nucleus** --\> **BILATERAL** neuralgia
## Footnote
*Sx will be disseminated in space and time*
199
Why does Fluoxetine need __ weeks to washout before starting a MAOI?
5
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
SSRI + MAOI ➜ SEROTONIN SYNDRONE *(SHIVERS)*
200
Why is Altered mental status in a pt who had a large **ischemic** stroke 2 days prior alarming? - 3
*pts s/p [**ISCHEMIC**CVA/TIA]... have ⇪ risk for developing:*
⭐1. [*(within 3d)*hemorrhagic conversion]
⭐2. [*(within 3d)*cerebral edema]
3.[*(WITHIN 30d)*REPEAT STROKE]
| because of this **BALTIC** should be started STAT
201
Why is Heparin NOT USED in pts with Acute Stroke?
⬆︎Bleeding Risk if stroke turns out to be Hemorrhagic
202
Why should all patients with Parkinson's disease be screened for Major Depression Disorder?
Many ParkDZ sx overlap with [MDD (a possible comorbidity of ParkDZ)] and **if Sad and/or [Interest loss] is present ➜ Antidepressant tx**
203
*You suspect a pt had an ischemic Stroke*
After FIRST, ruling out Hemorrhagic stroke with ⬜ , what thrombolytic therapy should be given?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
When should you give it?
🅽onContrast Head CT; [*ART*tPA thrombolysis]IV✏️
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**WITHIN 4.5 HOURS OF SX ONSET!**
## Footnote
✏️[*A*lteplase |*R*eteplase |*T*enecteplase]tPA thrombolysis
204
[90% R handed] and [60% L handed] people have [⬜ (R | L)] hemispheric dominance for speech and language
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What part of the brain is likely damaged in [Acalculia or Agraphia] ?
*difficulty with Arithmetic or Writing*
LEFT
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[*Dominant* inferiorParietal]
205
[90% R handed] and [60% L handed] people have [⬜ (R | L)] Hemisphere dominance for speech and language
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What part of the brain is likely damaged in Construction apraxia?
## Footnote
*Can NOT copy simple line drawings*
LEFT = DOMINANT
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[*NonDominant* Parietal]
206
[90% R handed] and [60% L handed] people have [⬜ (R | L)] hemispheric dominance for speech and language
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What part of the brain is likely damaged in Aphasia?
*unable to speak*
LEFT
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[*Dominant* temporal]
207
[90% R handed] and [60% L handed] people have [⬜ (R | L)] hemispheric dominance for speech and language
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What part of the brain is likely damaged in Dressing apraxia? (2)
*difficulty donning clothes*
LEFT
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[*NonDominant* Parietal] or [*BL* Parietal]
208
[90% R handed] and [60% L handed] people have [⬜ (R | L)] hemispheric dominance for speech and language
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What part of the brain is likely damaged if patient unable to discern Right from Left ?
LEFT
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[*Dominant* inferior Parietal]
| *DysLaterality*
209
[Amyotrophic Lateral Sclerosis] (Lou Gehrig's)]
clinical presentation? -3
1. ❌[UMN *Weak MESH*❌ (especially motor nc 5/9/10/12)]*progressive*
2. ❌[LMN *FAAWS* ❌] *progressive*
3. ✔︎ [cognition/ocular/bowel/bladder]*intact*
210
[Amyotrophic Lateral Sclerosis] (Lou Gehrig's) etx - 2
1. Rare = [Superoxide Dismutase gene mutation] --\> copper-zinc dysfunction ---\>[Upper **AND** Lower Motor Neuron Disease!]
2. Common = Idiopathic
## Footnote
*UMN Dz includes loss of neurons in motor nc. 5/9/10/12*
211
# Treatment
P7BP (3)
| [Peripheral facial CN7 Bells palsy]
[CTS **within 3d onset**] + [EYE artificial tears] + [EYE patch]
*recovery within 1-6 mo of sx onset*
212
[Central facial **S**troke palsy] and [Peripheral facial CN7 Bells palsy] both present with ⬜ and ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What are 3 ways to discern them from one another?
| CSP|P7BP
- Nasolabial fold loss
- Lower Lip droop
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
❌[**⊕S**paring*(forehead & eyebrows)* = ⊕**S**troke]
❌{[**⊕S**HUTS EYE CLOSED] = [⊕**S**troke]}
## Footnote
*🔎CSP = [Central_facial Stroke palsy]*
*🔎P7BP = [Peripheral_facial CN7 Bells palsy]*
213
[Central venous sinus thrombosis] occurs in ⬜ states (pregnancy), and p/w which 3 major symptoms?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx?
prothrombotic;
HA / ICP / [focal deficits from venous stroke/hemorrhage]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Heparin (*this is safe even with intracerebral hemorrhage*)
214
[Creutzfeldt Jakob Dz] etx
PrP (prion protein), normally in neurons as [α -helical structure] converts--\> [**INFECTIOUS** **Beta pleated sheets**] --\> Protease resistance --\>
Vacuoles in [**Gray** Matter Neurons & Neutrophils] develop --\> Cyst = [**Spongiform** Gray Matter]
215
[Creutzfeldt Jakob Dz] CP - 3
[**RAPIDLY** Progressive Dementia] + [STARTLE Myoclonus] --\> DEATH
## Footnote
*Can be Acquired vs. Inherited*
216
*[Excessive daytime sleepiness] is mostly 2/2 ⬜ but in young people it may be a sign of Narcolepsy*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
DSM5 Clinical criteria for Narcolepsy?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Confirmatory Dx?
insufficient sleep
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[**sleep ∆ ➕ ≥ 3x/week ➕ ≥3 mo**]
***with***
**([Cataplexy] or [CSF hypOcretin-1 deficiency] or [REM latency ≤ 15 min] )**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* Dx = POLYSOMNOGRAPHY*
* * *
(*sleep* ∆ = sudden or recurrent sleep lapse/napping multiple times a day)
*hypnoGOgic /hypnopompic hallucinations also common sx*
217
*Cataplexy presents as ⬜, and indicates Narcolepsy*
Tx for Narcolepsy?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What's the specific treatment for Cataplexy? -4
(Conscious, Brief, Sudden, BL)Muscle tone loss precipitated by intense laugh/joking
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Modafinil = *Narcolepsy*
* \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*
*Cataplexy tx:*
1. SNRI
2. SSRI
3. TCA
4. Sodium Oxybate (rarely used)
218
[Juvenile Myoclonic Epilepsy] cp? -2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
EEG findings? -2
1. [Teenage UE myoclonus → GTC +/- Absence]
2. frequently within the **1st hour of waking**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
a. [*interictal* BL polyspike]
+
b. [*interictal* slow wave discharge]
219
[Juvenile Myoclonic Epilepsy] tx
Valproic Acid
220
# There are 3 types of Neural Tube Defects [sO/ mO / mOm]
etx for [Neural Tube Defect] -3
-[folate B9 deficiency before&during pregnancy]
-➜ failure of caudal neuropore (at 4WG) to fuse closed ➜ [lower vertebral column defect] ultimately ➜ [1 of 3 *herniation* *= [sO/ mO / mOm]*
-⭐{eventually .. [(fetal αFP) and (fetal AChE)] leak into amniotic fluid and finally maternal serum}
221
# There are 3 types of Neural Tube Defects [sO/ mO / mOm]
etx for [Neural Tube Defect] involves failure of ⬜ fusion/closure due to ⬜ deficiency during pregnancy → 1 of 3 types of NTD herniation:
❓ Describe the 3 types of NTD herniation
[caudal neuropore (precursor to lower vertebrae)] ; [folic B9]
-with 1 of 3 *herniation:*
1▶ {[Meninges ⊝] ⼀ [NeuralTissue ⊝] = [sO ( dura intact/normal αFP/ +/- hair tuft or skin dimple))]}
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
2▶ [Meninges **⊕**] ⼀ [NeuralTissue ⊝] = mO [dura meninges TORN]/⇪ αFP
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
3▶ [Meninges **⊕**] ⼀ [NeuralTissue **⊕**] = mOM →{dura meninges TORN/neural tissue ❌/ ⇪ αFP} = [**NEUROGENIC BOWEL AND BLADDER**
222
how do you screen for Neural Tube Defects i.e. ( [Spina Bifida Occulta/Meningocele/Meningomyelocle]] ? -2
**15-20WG****[maternalAFP]***screen*
-*(if positive)*→
**[FETAL ANATOMY US]***CONFIRMATION*
| *🔎AFP = alpha fetoprotein*
## Footnote
🧠 ⇪15-20WG[mAFP] may indicate fetal NTD|fetal abd wall defect|multigestation
223
[T or F]
Patients with [remote hx opioid use disorder, currently Abstinent x months], will require HIGHER-than-usual doses of opioids for acute pain control
FALSE
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Abstinent patients with hx OUD **LOSE ALL OPIOID TOLERANCE WITHIN MONTHS** of cessation = if hx remote, treat with normal dose opioids*
224
[T or F]
If you give opioids to [abstinent patients with hx of opioid use disorder] it requires a discussion of risk /benefits First (unless it's in the setting of obvious and severe pain)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Why or why not?
FALSE
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**Even if they're in severe pain**, in _[now-abstinent (hx) opioid users]_ you MUST FIRST DISCUSS risk (such as life threatening relapse)/benefit with patient before giving opioids
225
[T or F]
Patients on maintenance/chronic opioid therapy require HIGHER-than-usual doses of opioids for acute pain control
TRUE
226
[T or F] Incidentally discovered lesions in the sella are fairly uncommon
FALSE
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
small lesions in the sella are incidentally discovered all the time = follow closely with Pituitary gland also
227
[T or F] patients with Parkinson disease often have underlying depression, and this is managed by increasing their Parkinson Meds' dosage
FALSE
**TREAT WITH SSRI**
*psychomotor retardation and sadness are hard to see in Parkinson's so BE ON THE LOOKOUT FOR MDD*
228
[Thiamine B1] deficiency causes ⬜ and **BeriBeri** 2/2 to ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Describe BeriBeri (3)
[Wernicke Korsakoff Syndrome] and [BeriBeri] ; [impaired glucose metabolism → ATP depletion]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[**BeriBeri** falls into 3 subtypes (*WET, DRY, BOTH)*] :
1.[High Output Dilated HF + edema] = ***WET***
2.[Symmetrical Peripheral Neuropathy + muscle wasting] = ***DRY***
3.[***WET*** and ***DRY***]*(BOTH)*
## Footnote
Think **ATP**: [Thiamine B1] is needed to make ATP with:
[α-ketoglutarate dehydrogenase (TCA)],
[Transketolase (HMP shunt)],
[Pyruvate dehydrogenase (TCA)]
229
Amaurosis Fugax CP -4
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
etx
- **monocular vision loss**
- nonpainful,
- [transient ( \< 10 min)]
- "*curtain descended over eye*"
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Central Retinal artery occlusion] from [Carotid Artery atherosclerotic emboli]
230
▶ In Multiple Sclerosis patients, muscle spasms are a common disabling **M**otor sx; usually occurring in the ⬜.
▶Name the1st line tx options for [MS muscle spasms]? (2)
▶ adjunct tx? (2)
▶LE
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
▶[Baclofen PO or Tizanidine PO]
▶*physical therapy, stretching*
231
▶Cryptococcus ⬜ is a yeast that can cause opportunistic meningoencephalitis in patients CD4 ⬜
▶▶In addition to CNS sx, specific skin findings such as ⬜ may also appear.
▶Neoformans ; \<100
▶▶[central umbilicated papules (*resembling molluscum contagiosum*)]
232
Since ⬜ overdose produces ⬜ sx which *mimics* brain death, how do you differentiate it from actual brain death?
Baclofen; [complete atonia, aReflexia +/- fixed Dilated pupils] ;
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Baclofen OD ➜ **Loss of Bicep (Spinal) Reflexes**]
Brain Death has intact Spinal Reflexes
## Footnote
📖*Baclofen MOA = GABA-B agonist*
233
⬜ treats ALS. What the MOA?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Amyotrophic Lateral Sclerosis*
Riluzole ; [DEC neuron Glutamate secretion]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*progressive weakness + **UMN AND LMN deficits** + [cognition/ocular/bowel/bladder preservation]*
234
In ischemic Stroke, ⬜ is the most severe potential complication of [tPA thrombolysis]
hemorrhagic conversion
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*reverse with Antifibrinolytics vs Cryoprecipitate*
235
How do you **reverse** [tPA thrombolysis] when the greatest complication of [tPA thrombolysis] *( __?\_\_ ) …* occurs? -3
hemorrhagic conversion
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1. [aminocaproic acid *Antifibrinolytic* (inhibits Plasminogen activators)]
2. [transexemic acid *Antifibrinolytic*]
3. [Cryoprecipitate (fibrinogen, factor8, vWF): (replaces clotting factors)]
236
237
Syringomyelia
clinical features (4)
🔴cystic cavity formation within (usually C8-T1) spinal cord
🔴(2/2 brain herniation during Chiari 1 vs trauma vs tumor)
🔴damages ANT commissural fibers first → [**UE CAPE-LIKE BL PAIN/TEMP LOSS**]
🔴Eventually Ventral Horns are destroyed also –> [LMN *FAAW**(Fasciculations / Atrophy & Areflexia / Weakness)*]
238
A: List the 6 stages of Sleep
B: List their associated EEG waveform
239
# *The Limbic system contains 5 organs and has 6 functions*
a. Name the 5 organs that make up the Limbic system
b. Name the 6 functions of the Limbic system
a. **CHAMP**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
b. ["famous"6 F's]
240
CSF is returned via ⬜ into the ⬜, which ultimately dumps into the ⬜
arachnoid granulations; [SUP sagittal sinus] ; [Internal Jugular Vein]
## Footnote
💡[SUP sagittal sinus*(found in dura)* ] = main location of CSF return
241
CSF is made by [⬜ of the ⬜] and then reabsorbed by ⬜
ependymal cells; [*Lateral Ventricle*choroid plexus];
[arachnoid villi granulations] *(which dumps CSF into the dura's [SUP sagittal sinus] → Internal Jugular Vein)*
242
Describe CSF path from Lateral Ventricles to Subarachnoid Space (9)
💧{[(CSF made by Ependymal cells) of Choroid Plexus ]OF LAT VT}
🧠LAT VTCSF
💧 *--(InterVt Foramen of Monro)-->*
🧠3rdVT
💧 *--(Cerebral Aqueduct of Sylvius)-->*
🧠4thVT
💧 *{--([Foramen Luschka *(Laterally)*] or [Foramen Magendie *(Medially)*] )-->}*
🧠Subaracnoid space
243
# difference between
[Communicating Hydrocephalus] vs [NONCommunicating Hydrocephalus]
*COMM*: [arachnoid scarring (post meningitis, etc)] → **[⬇︎arachnoid granulation CSF reabsorption]** → [ ⇪CSF accumulation = ICP/papilledema/herniation]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*NComm*: **ventricle structural blockage***(i.e. [CAS stenosis] vs [FOM colloid cyst])* → [ ⇪ CSF accumulation = ⇪ ICP/papilledema/herniation]
## Footnote
*🔎CAS = Cerebral Aqueduct of Sylvius*
*🔎FOM = Foramen of Monro*
244
**Spinal Muscular Atrophy** etx and CP
[ANT Horn Cell degeneration] from [*Chromo 5* SMN1 and 2 gene mutations]--\> LMN signs of FAAW- ***W**eakness/[**a**trophy & **a**reflexia] /**F**asciculations*
## Footnote
⭐2 onsets: [Infantile Werdnig Hoffman*FATAL*] vs [Adult*NONFatal*]
245
**Spinal Muscular Atrophy**
What's the difference between Infant type and Adult type
*Infantile* onset = (**Werdnig Hoffman**) --\> [Auto Recessive FATAL condition --\> *Floppy Baby* from diffuse [Distal muscle atrophy]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*adult/child* onset types = [Non-fatal Chronic Disability]
246
Describe Friedreich Ataxia (8)
Fri**E**dreich is **Fratastic**! He's your fav., **twisted,** **frat** brother, always **studdering** and **falling**, but has a **sweet**, **big heart**
Fri**E**dreich = [Vitamin **E** Deficiency] mimics it
**Fratastic** has 9 letters = [Chromo 9 Auto Recessive GAA repeat]
**twisted** = Kyphoscoliosis @ childhood
**frat** = [**frataxin** (**iron binding protein**) defect]
**studdering** = Dysarthria
**falling** = [Falls & Ataxia + (Pes Cavus High Foot Arch)]
**sweet** = DM
**big heart** = Hypertrophic Cardiomyopathy = COD
*Involves Degeneration of [Dorsal, Lateral CST & SpinoCerebellar]*
247
Loss of **Gag Reflex** indicates what cranial nerve damage
Glossopharyngeal CN9 *Ipsilateral*
248
**Dysphagia** indicates what n. damage (2)
[Glossopharyngeal CN9] and [Vagus CN10]
249
**Dysphonia/Hoarseness** indicates what n. damage
[Vagus CN10]
250
Atomoxetine Indication
**Non**Stimulant ADHD Rx
251
What are the Afferent and Efferent nerves for Corneal Reflex?
252
What are the Afferent and Efferent nerves for Lacrimal Reflex?
253
What are the Afferent and Efferent nerves for Jaw Reflex?
254
What are the Afferent and Efferent nerves for Pupillary Reflex?
[optic CN2] --(*Pupillary Reflex*)--> [oculomotor CN3]
255
cp for [Trigeminal CN5] motor lesion (3)
✔︎ causes [IPL pterygoid m paralysis] ➜
✔︎ unopposed contralateral pterygoid muscle contraction →
✔︎ jaw deviates **TOWARD** lesion
## Footnote
*"I lick my wounds at 5, 11 and 12"*
256
*uvula* cp for [Vagus CN10] lesion (2)
✔︎weak side relaxes and uvula points **away** from lesion
257
cp for [spinal accessory CN11] lesion (2)
✔︎ shoulder droops **toward** lesion*"I lick my wounds at 5, 11 and 12"*
✔︎weakness turning head CTL
## Footnote
💡[hypoglossal CN12] also points **toward** lesion(2/2 weakened IPL tongue muscles)
✏️*"I lick my wounds at 5, 11 and 12"*
258
| 🛑*[postgang sympathetic pupillary fibers] travel with CN5B1*
259
Cavernous Sinus syndrome is caused by ⬜*3*
1. Pituitary mass
2. carotid-cavernous fistula
3. [infectious cavernous sinus thrombosis *(facial|dental infxn uses facial veins and spreads into cavernous sinus)*]
260
# Cavernous Sinus syndrome
clinical presentation (8)
a. [CN3/4/6 → (IPLDO3P/ophthalmoplegia)]
b. [CN5B1 → IPL DEC corneal reflex]
c. +[sympathetic pupillary fibers (travels with CN5B1)]→ [IPLHorner's_MAP] → [IPLCavernous\_**doMAP**]
d. {[CN5B2 → [ IPL DEC Maxillary sensation]}
e. proptosis
f. papilledema
g. Vomiting
h. HA
## Footnote
📖causes:
1. Pituitary mass
2. carotid-cavernous fistula
3. [infectious cavernous sinus thrombosis *(facial|dental infxn uses facial veins and spreads into cavernous sinus)*]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**🔎DO3P**("DOPe" Oculomotor CN3 Palsy) = [down/out + Ptosis + (eyeDilated-myDriasis)] = [SPECIFIC TO IPLOculomotor CN3❌]
**🔎[Horners\_MAP]** = [Miosis+Anhidrosis+Ptosis] = SPECIFIC TO [IPLSYMPATHETIC CHAIN❌]
**🔎[Cavernous\_doMAP]** = [down/out + Miosis + Anhidrosis + Ptosis] =SPECIFIC TO [IPLOculoSYMPATHETIC CHAIN❌*(likely within Cavernous Sinus) = [CAVERNOUS SINUS SYNDROME]*]
261
# *Which mastication muscles*
close the jaw? (3)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
open the jaw?
**M**asseter/te**M**poralis/**M**edial_pterygoid
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**L**ateral pterygoid
| *"**M**unch your jaw closed, then **L**ower it open"*
262
What are some triggers of *Primary* GTC Seizure? - 9
*Seizure **AT(Ta)CK***
1. Flashing lights
2. Sleep Deprivation
3. Hyperventilation
4. EtOH
5. Infection
6. Cocaine
7. Whole Brain Anoxia
8. [Rapid Na+⬇︎]
9. [Rapid Glucose⬇︎]
| **ATTaCK**
## Footnote
👓▶Seizures = sync high freq neuronal firing{(partial focal [simple vs complex]) vs (GZD [MATTA])}
▶Epilepsy = DO of recurrent seizures
263
# 2 categories of seizures, Partial focal vs GZD diffuse.
[GZD diffuse] seizure
| what are the subtypes? (5)
✔︎5 subtypes *MATTA*
1. [**M**yoclonic (quick jerky mvmts)]
2. [**A**tonic (LOSS of "stiff" Tone*"just drops to floor"*)]
3. [**T**onic-Clonic_*grand mal* (stiff ↔mvmt)]
4. [**T**onic (just stiff Tone)]
5. [**A**bsence_*petit mal* (blank stare\3hz\No postictal confusion)]
| Tonic = stiff // Myoclonus: mvmt jerky
## Footnote
👓▶Seizures = {sync⼀high freq⼀neuronal firing{(partial focal [simple vs complex]) vs (GZD [MATTA]}
▶Epilepsy = DO of recurrent seizures
✔︎ *Seizure **ATTaCK***
264
# 2 categories of seizures, Partial focal vs GZD diffuse.
Partial focal seizure
| clinical features (6)
✔︎ affect single area of brain (but can secondarily proceed to GZD diffuse
✔︎ typically originates in medial temporal lobe
✔︎(*maps*) = motor/sensory/autonomic/psychic
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
✔︎ 2 types:
⚡[simplepartial focal = ⊕consciousness]
⚡[complexpartial focal = ⊝ consciousness]
## Footnote
👓▶Seizures = sync high freq neuronal firing{(partial focal [simple vs complex]) vs (GZD [MATTA])}
▶Epilepsy = DO of recurrent seizures
✔︎ *Seizure **ATTaCK***
265
# **Bethanechol**
MOA
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Indication (2)
**activates bowel/bladder**[Muscarinic🟢*Direct* cholinomimetic]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
-ileus
-urinary retention
| *"BethanE makes you pee!"*
## Footnote
*resistant to AChE*
266
# **Carbachol**
MOA
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Indication
[Muscarinic🟢*Direct* cholinomimetic] = **constricts pupil → ⬇︎IOP**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\
[Cglaucoma]
| [*closed angle*glaucoma]
## Footnote
[glaucoma] = [*closed angle*glaucoma]
267
# **Pilocarpine**
MOA (3)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Indication (2)
[Muscarinic🟢*Direct* cholinomimetic] =
1. **stimulates tears/sweat/saliva**
2. [**contracts ciliary muscle**→ open angle glaucoma tx]
3. [**contracts pupillary sphincter** → closed angle glaucoma tx]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
-#2 → open angle glaucoma tx
-#3 → closed angle glaucoma tx
## Footnote
*resistant to AChE*
268
# **Methacholine**
Indication
challenge test for diagnosing asthma
## Footnote
[Muscarinic R agonist*Direct* cholinomimetic] = **induces bronchoconstriction** → ""
269
# **Edrophonium**
MOA
(short acting)[AChE inhibitor*Indirect* cholinomimetic] = ⇪ ACh
## Footnote
*historically* for: diagnosis of myasthenia gravis
270
# **Neostigmine**
MOA
[AChE inhibitor*Indirect* cholinomimetic] = ⇪ ACh
## Footnote
NO CNS BBB Xng
271
# **Physostigmine**
MOA
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Indication
**(BBB Crossing)** [AChE inhibitor*Indirect* cholinomimetic] = ⇪ AChcentrally
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
treats [Muscarinic R Blockade *(atropine/Jimson Weed/anticholinergic)*] TOXICITY
| *"Physo phyxes atropine OD"*
272
# **Pyridostigmine**
MOA
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Indication
(LONG acting)[AChE inhibitor*Indirect* cholinomimetic] = ⇪ ACh
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Myasthenia Gravis
| *"PyRido Rids of Myasthenia Gravis"*
## Footnote
NO CNS BBB Xng
273
# **Hyoscyamine**
MOA
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Indication
Μ🟥*antispasmodic*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
IBS
## Footnote
*(same as Dicyclomine)*
274
# **Tropicamide**
MOA (2)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Indication
[Muscarinic🟥*myDriasis + cyclopLegia* ]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
pupil dilation
## Footnote
*Atropine & Homatropine = similar Eye application*
275
# **Solifenacin**
MOA
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Indication
**(⬇︎Bladder spasms)**Muscarinic🟥
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Urge incontinence
## Footnote
*(same as Oxybutynin & Tolterodine)*
276
# **Scopolamine**
MOA
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Indication
**(CNS)**Μ🟥
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Motion Sickness
## Footnote
Μ = Muscarinic
277
# **Glycopyrrolate**
MOA
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Indications (3)
Μ🟥
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*IV*: ⬇︎ PreOp airway secretions
*PO*: ⬇︎drooling
*PO*: ⬇︎peptic ulcer
## Footnote
Μ = Muscarinic
278
# **Atropine**
MOA
*competitive*Μ🟥
## Footnote
▶[Organophosphate/Parathion/Muscarinic R agonist OD /Cholinomimetic Tox] → **DUMBBELSS**
▶Atropine bl🛑cks **DUMBBELSS**
▶[Atropine tox/anticholinergic tox/Jimson Weed tox] → *Blind\bat, Dry\bone, Hot\hare, Mad\hatter, Red\beet, Bowel + Bladder\loses tone, Heart\alone*
279
# **Homatropine**
MOA (2)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Indication
**(myDriasis + cyclopLegia)**[Muscarinic🟥]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
pupil dilation
## Footnote
*Atropine & Tropicamide = similar Eye application*
280
i.*Toxicity* of [*Drugs A(Cholinomimetic, ⬜, ⬜ or ⬜)*] → ⬜sx
ii.[*Drug B(⬜)*] bl🛑cks these sx
iii.but OD of *Drug B* can → [⬜sx]
iv. which would then require [*Drug C(⬜)*] to correct
i.*Toxicity* of [*Drugs A("**COPS**")*] → [**DUMB BELSS**sx]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
ii.[*Drug B(Atropine Alice)*] bl🛑cks these sx
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
iii.but OD of [*Drug B(Atropine Alice )*] can → [*Blind\bat, Dry\bone, Hot\hare, Mad\hatter, Red\beet, Bowel + Bladder\loses tone, Heart\alone*sx]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
iv. which would then require [*Drug C(Physostigmine)*] to correct
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
▶**COPS**toxicity →
**C**holinomimetic
**O**rganophosphate
**P**arathion Pesticide
[**S**hit/Sex ⼀Feed/Breed ⼀Muscarinic R agonist]→
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
"i.*toxic* **COPS** inevitably → [**DUMB BELSS**], smh.
ii. *Atropine Alice* happily cleans up those **DUMB BELSS**...
iii. but too much of *Atropine Alice* can → [Blind\bat, Dry\bone, Hot\hare, Mad\hatter, Red\beet, etc.]
iv. so *PhysoStigmine* sticks around to Phyxe too much *Atropine Alice*"
281
# **Neostigmine**
Indication (4)
1. postop ileus
2. postop urinary retention
3. myasthenia gravis
4. reversal of NMJ blockade
| [AChE inhibitor*Indirect* cholinomimetic]
## Footnote
NO CNS BBB Xng
282
A: What are the 7 Steps of Visual Pathway starting with light entering eye?
B: Light Entering Eye:
TEMPORAL Retina Fields pass _____ [crossed/uncrossed]
vs.
nasal retina fields pass ____ [crossed/uncrossed]
A: Pathway of Visual Info from Retina [**RN CT L DV**]
*"**RN** **C**an **T**ry **L**earning **D**irect **V**ision"*
1. Light enters ---> hits **R**etina
2. Travels in Optic **N**erve
3. Optic **C**hiasm*[NRts Axons CROSS HERE]*
4. Optic **T**ract
5.[**L**ateral Geniculate Nucleus of Thalamus]
6. [Optic Ra**D**iations*(Meyer's Temporal Loop vs. Parietal direct path)*]
7. [Area 17 -Calcarine Primary **V**isual cortex]
B: Light Entering Eye:
TEMPORAL Retina Fields pass UNcRossed
vs.
nasal retina fields pass crossed @ Optic Chiasm
## Footnote
🔎*NRts = [Nasal Retina field⼀Temporal Sight]*
283
A: Although Visual Perception begins in ______, collateral visual info enters ____ via Pretectal Area= for ___ _____ and _____ _____ for ________
B: Pretectal Area uses ___ nuclei of _____ for ___ _____ and projects both ipsilateral & contralateral via ____ _____
A: Although Perception of vision begins in [Area 17 CPVC] collateral visual info enters Brainstem via Pretectal Area=FOR PUPILLARY REFLEX and [SUP Colliculus]=For head&eye movement
B: Pretectal Area uses [Edinger-Westphal nuclei] of midbrain for PUPILLARY REFLEX and projects both ipsilateral & contralateral via POSTERIOR commissure
284
What would occur if there was a Lesion in ...
1. R Optic N. ---->
3. Optic Chiasm ----->
4. R Optic Tract--->
5. R [meyer's loop-inferior Optic Radiation] -->
6. R [Lateral Geniculate nucleus of thalamus]-->
7. R [Dorsal Parietal-SUPERIOR OPTIC RADIATION]
8. R [Area 17 CPVC]
B: Which 2 lesions present the same Visual sx?
Lesion in ... (using R side damage as example)
1. R Optic N. ----> BLIND RIGHT EYE
- -------------------------------------------------------------------------------------
3. Optic Chiasm -----> [Bitemproal hemianopia] (both temporal fields knocked out)
- -------------------------------------------------------------------------------------
4. R Optic Tract--->[CTL homonymous hemianopia] {Lose L-eye Temp} and {R- eye nasal}
- -------------------------------------------------------------------------------------
5. R [meyer's loop iOR ("pie in sky")] --> "Pie in the Sky Lesion' = [CTL homonymous upper quadrantanopia]
- -------------------------------------------------------------------------------------
6. R [Lateral Geniculate nucleus of thalamus]-->[CTL homonymous hemianopia]
- -------------------------------------------------------------------------------------
7. R [Dorsal Parietal SOR ("pie on floor")]-->[CTL homonymous LOWER quadrantanopia]
- -------------------------------------------------------------------------------------
8. R [Area 17 CPVC]--> [CTL homonymous hemianopia with macular/fovea sparing]
- -------------------------------------------------------------------------------------
**Lesions of Optic Tract and [Lateral Geniculate Nucleus of thalamus] PRESENT SAME VISUAL SX!**
CTL = Contralateral (or L in this case)
285
How does [Pupillary Light Reflex] present when there is..
A. [Optic CN2] damage? why?
B. [Oculomotor CN3] damage? why?
*PUPILLARY LIGHT REFLEX io\\*
A. [Optic CN2] Damage----> BL PUPIL FREEZE = EQUAL PUPILS that do NOT REACT AT ALL becuz signal is NEVER sent to [Edinger-Westphal nucleus]= NO accomodation on either side
vs.
B: [Oculomotor CN3] damage--->
✔︎{[IPL (*side with CN3 damage*) pupil freeze]
with
✔︎{[CTL (*side with NO CN3 damage*) pupil constriction]
## Footnote
✔︎ {[IPL (*side with CN3 damage*) pupil freeze]
= [⊕optic N relay] but [⊝ oculomotor CN3 accomodation] → pupil freezes/never changes}
plus
✔︎{[CTL (*side with NO CN3 damage*) pupil constriction]
= [⊕ optic N relay] and [⊕ oculomotor CN3 accomodation] → pupil constricts appropriately}
286
A: In order to change gaze & focus on very close objects you need the ____ REFLEX which involves what 3 things?
B: Why does this reflex also involve the [Visual association cortex]?
C: How does your body know when this needs to be activated? [2]
In order to change gaze & focus on very close object you need the ACCOMMODATION REFLEX which involves..
1. eye convergence via [medial recti m.]
2. Ciliary m. constriction --->Lens thicken
3. Constriction of both pupils-->DEC light entering due to greater reflectance from close object
B: Involves [visual association cortex] because it is a CONSCIOUS act to change your gaze from far to near
--------------------------------------------------------------------------------------
C: *[Visual Association Cortex] realizes something is "out-of-focus"-->sends signals (via internal capsule) to [supraoculomotor nuclei]--->generates motor control that bilaterally sends signals to Oculomotor complex
**Oculomotor complex uses [Edinger-Westphal nucleus] to control [ciliary ganglion]-->sends short ciliary n. to [ciliary m.] and iris sphincter
Oculomotor neurons control [medial recti m.]
287
Optic Radiation is AKA the _____ ______
Optic Radiation is AKA [Geniculocalcarine tract]
288
A: The [Pupillary Light Reflex] involves a ⬜ reflex and ⬜ reflex. Describe each?
B: After light is shone thru 1 eye, BOTH pupils constrict becuz ⬜
C: What part of the brain facilitates [Pupillary Light Reflex]?
A: DIRECT reflex = light is shone thru R pupil and the R pupil constricts
CONSENSUAL reflex= light is shone thru R pupil BUT L pupil constricts also
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
B:
▶both pupils constrict becuz
▶ IPL [Optic CN2] fibers synapse at **IPL [rostral midbrain's SUP colliculus *pretectal olivary nc*]** which send →
▶**BILATERAL connections to each [Edinger-Westphal nucleus]** *(which houses and communicates with each own's respective [Oculomotor CN3 nc]
)*
▶= activates each respective [Oculomotor CN3] nc
▶which sends respective [Oculomotor CN3] fibers to each's respective Ciliary ganglion--->
▶CG sends [*Parasympathetic* short ciliary nerves] to ---> ▶constrict respective **[sphincter pupillae m.]**
## Footnote
C: [**_Rostral Midbrain_** SUP colliculus]
289
# *pt presents with Ptosis*
Recite DDx algorithm for Ptosis -4
## Footnote
#cavernous sinus, sympathetic, Horners
