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2020 ABIM Awesome Review > 2018 Neurology 4% > Flashcards

2018 Neurology 4% Flashcards

1
Q

Migraine

A

F>M
Q few weeks
1/2 hr onset
Lasts hours to days
Frontal/temporal one or both sides
Throbbing
n/v/aura/photophobia, AM menarch, menses, weahter, stress, worse with movement
Tx: Tylenol/NSAID/ASA -> Sumatriptan->chloropromazine/metochlopramide
Prevention: BB, TCA, Vit B2 (riboflavin), CoQ 10, Topiramate, Botox

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2
Q

Cluster h/a

A

M>F
1-2/day
onset 2-15min
lasts 1/2 hr-2hrs
Orbital/one side
Excruciating
Rhinorrhea, ipsilateral Horner’s, Unilateral lacrimation
Tx: 100 OXYGEN, intranasal lidocaine, sumatriptan
Prevention: Verapamil, valproate, gabapentin

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3
Q

Tension h/a

A 
F>M
How often? Variable
Onset Variable
how long 1/2hr to 7 days
Where: diffuse
Non-throbbing
Band like
Tx: analgesics
Prevention: BB, TCA
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4
Q

25yo F p/w chronic h/a x years noticed from puberty, mainly with waking up, several hours every few weeks, throbbing aw nausea and vom no auras - several tylenol and motrin didn’t help - acute pain would respond to….

A

Sumatriptan

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5
Q

25yo F with FLASHES of light moving across eyes for a few minutes wiht loss of visio nin one eye - left homonymous defect -normal after 45 min

A

Dx: Migraine

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6
Q

Young woman co wk in R arm and leg - PMHx migraines - feels better after couple hours - carotid US, MRI brain and TEE normal dx?

A

Migraines

DO NOT USE TRIPTANS with CAD or vasculitides

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7
Q

52yo M p/w moderately severe befrontal throbbing ha - aw nausea - had h/a for past few years - normal temp - BP 150/90, fundoscopy normla neck supple, pupils reactive no focal neur effects histor significant for CAD wtd?

A

NSAID with prochloroperazine

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8
Q

Acute migrain with nausea and vomiting fastest relief?

A

SQ Sumitriptan

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9
Q

Severe acute migraine not responding to sumatriptan or lasting >72hrs

A

IV dopamin antagonist (prochlorperazine.metoclopramide) + IV diphenyhydramine (prevent acute dystonic rxn)

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10
Q

Severe acute migrain x more than 72hrs - last sumatriptan >24hrs ago with little response - >

A

parental dihydroergotamine

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11
Q

Pregnancy with migraine h/ once a week

A

tylenol

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12
Q

Pregnancy with migraine h/a no response to Tylenol

A

Metoclopramide or Chloroproazine or ondeansetron

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13
Q

Migraine ppx for h/a’s how often?

A

2 times per week

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14
Q

PPX for migraine <15x/month

A

BB, amitriptyline, topiramate, sodium valproate

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15
Q

PPx for migraine >15/month

A

Topriamate-> botox

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16
Q

PPX migraines with asthma

A

Divalproex sodium, topiramate (no BB CI)

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17
Q

Prevention of menstrual h/a

A

mefenamic acid (Ponstel) … 2 days prior and up to end of menstruation

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18
Q

Migraine with Aura

A

OCP contraindicated!! Can cause DVT in brain. Progesterone only IUD.

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19
Q

Pt with migrain h/a takes NSAIDs and tylenol daily. now not working wth h/a daily from morning to evening

A

Analgesic induced h/a

d/c all analgesics

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20
Q

42yo F chronic non-throbbing h/a worse at end of day - band like around neck

A

Tension h/a

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21
Q

35yo F c/o excruciating Ice pick like retro-orbital h/a - h/o rhinorrhea, lacrimation, ipsilateral horner’s

A

Cluster h/a

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22
Q

Pt with recurrent h/a >5-6/day, lasting 15-20minutes, unilateral and retrooribtal

A

Chronic paroxysmal hemicrania

Tx: Indomethacin

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23
Q

32yo obese woman BMI>30 with daily h/a - horizontal diplopia - blurring of optic disc margins - wtd next?

A 
CT scan (r/o) DVT in brain. IF neg --> MRV, if neg --> spinal tap (with incr pressure)
Idiopathic Itracranial HTn (Pseudotumor cerebri)

Tx: Acetazolamide, lumboperitoneal shunt

Etio: obesity, Vit A toxicity, tetracycline, steroids, contraceptives, nitrofurantoin, isotretinoin, minocycline, danazol, tamoxifen, levothyroxine

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24
Q

Comoplications of pseduotumor cerebri

A

Peripheral visual field loss-> central visual field loss

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25
Q

Pt with known HTN with h/a and ataxia - CT scan large cerebellar bleed wtd?

A

surgery -or it may cause brainstem compression

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26
Q

65yo h/a ESR 75

A

Temporal arteritis

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27
Q

H/a with rhinorrhea

A

Cluster h/a

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28
Q

100% O2

A

Cluster h/a

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29
Q

H/a with zigzag wavy lines photophobia and aura

A

Migraine

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30
Q

Sumatriptan

A

Migraine, Cluster h/a

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31
Q

Thunderslap h/a, CT head neg, CSF xanthochromia

A

Subarachnoid hemorrhage

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32
Q

Chronic h/a inc’d with lying down

A

brain tumor

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33
Q

Young obese pt with headache and horizontal nysstagmus

A

Pseudotumor cerebri

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34
Q

Acetazolamide

A

Pseudotumor cerebri

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35
Q

50yo F seizure or focal weakness, h/a worse on coughing/lying down CT 4cm lesion, large edema, mass effect. No calcification..

A

Glioblastoma/astrocytoma
most common and aggressive primary brain tumor
Surgery primary therapy with chemo/radiation
dexamethasone

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36
Q

50yo h/a worse on coughing, lying down, CT INTRAVENTRICULAR tumor

A

Choroid plexius papilloma
slow growing benign tumor of ventricular system in choroid plexus - inc’d CSF production - inc’d OCP -> hydrocephalus
Tx: Surgery

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37
Q

50yo F h/o seizure d/o for 4 years - CTH 3cm tumor in sylvian fissure - diffuse enhancement with contrast

A 
Meningioma
Usually benign
Arise from meninges
Seizures or weakness
Syvian fissure
Inc'd ICP
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38
Q

Following tumors metastasize to brain

A

Breast, lung melanoma, lymphoma, renal

NOT prostate

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39
Q

45yo F lighting pain jabs in gums, cheek, chin, several times per day and last few seconds at a time - no focal neurolgical signs, oral exam normal. wtd?

A

Carbamazepine (Tegretol*) trigeminal neuralgia

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40
Q

Facial Palsy

A

Supranuclear (CVA) - Upper face spared

Infranuclear - both UPPER AND LOWER face
Bell's palsy
Accoustic Neuroma
Ramsay Hunt syndrome
Guillain-barre
Lyme Dz
Sarcoidosis
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41
Q

Motor Neuron Disease

A

Lower motor neuron (Infra-nuclear) - dec’d reflexes, dec’d muscle tone, +Fasciculations

Upper motor neurons (Supra-nuclear) - inc’d reflexes, inc’d muscle tone, NO fasciculations

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42
Q

30yo with erythema chronicum migrans 4 weeks ago now with left sided upper and lower face paralysis preceded by ha

A

Infranuclear lesion

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43
Q

55yo vesicular lesions on R side face with pain involving ear

A

Supra-nuclear lesion

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44
Q

65yo M with slurred speech and lower face paralysis

A

Suprnuclear lesion

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45
Q

55yo pw R sided facial paralysis of unknown etio

A

infranuclear lesion

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46
Q

60yo M sudden onlset R facial weakness, drooling of saliva inability to close R eye - mouth deviating to left side, unable to raise eyebrows - rest of neuro exam normal

A

Artificial tears, patch R eye at night, start PREDNISONE

fyi.. bilateral bells palsy can occur with lyme dz

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47
Q

Young woman co diplpia - closing one eye - diplopia persists dx?

A

Monocular psychogenic diplopia

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48
Q

CN III palsy

A

can’t look up, down or inward
Where is lesion?
posterior commuicating artery
Dx: MRA brain

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49
Q

Pt in MVA brought to ER with h/a - PE shows R pupil 2mm, left pupil 4mm - ptosis of R eye - wtd?

A

CT angio neck
dx: Carotid artery dissection
heparin –> surgery

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50
Q

Pt with acute onset diplopia h/o DM, Ptosis

A

Acute cranial mononeuropathy

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51
Q

Pt with hyperthyroid and exopthalmos - unable to completely abduct and has double vision - cause?

A

Thyroid opthalmopathy

Tx: steroids

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52
Q

R optic neuritis

A

MS with blindness in right eye

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53
Q

Tumor pressing on optic chiasma (acromegaly)

A

Bitemporal hemianopia

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54
Q

Left Optic tract

A

Right dense homonymous hemianopia

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55
Q

Left optic radiation (occipital lobe)

A

Right homonymous quadrantanopia

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56
Q

Stroke

A

Days
Throbotic - 50% preceeded by TIA
Embolic - more rapid onset
Hemorrhagic - HTN, amyloi angiopathy

Minutes

TIA -
Carotid artery syndrome -
Ipsillateral visual loss (amaurosis fugax)
Shadow in front of eye - contralateral motor or sensory changes

Vertebrobasilar syndrome DDD
Dizziness, Diplopia, Dysarthria
Sudden wk of legs -> dorp attacks
B/l Wk
Tx: ASA
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57
Q

Pt with TIA higher risk of stroke if…

A 
Duration >10min  (2pts)
Speech disturbance (2pts)
Age>60  (1 pt)
DM (1pt)
HTN (1pt)

……………… >3 score = admit. Score 0-3 (1% stroke risk), 4-5 (4.1%), 6-7 (8.1%)

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58
Q

Most important risk factor for stroke?

A

uncontrolled HTN

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59
Q

Pt with TIA , wtd next

A

Hopsital w/u - carotid dopper (r/o CAS), EKG/extended holter (r/o afib), CT brain, Coags/PTT (r/o LAS), TEE (r/o PFO)

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60
Q

If carotid shows >70% wtd?

A

Carotid endarectomy + ASA

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61
Q

If TIA and carotid 90% inoperable wtd?

A

Stent

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62
Q

Pt with TIA and cardid US with <50% wtd?

A

ASA + dipyrimadamole (Persantine*) OR plavix

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63
Q

Pt h/o TIA no PAD - best management

A

ASA - can also add ACE+/- indapamide to decrease recurrence

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64
Q

Pt has TIA on ACEi, ASA and statin

A

d/c ASA and start Plavix

don’t use both unless has CAD with stent also

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65
Q

Endartectomy vs stent

A

Endartectomy better mortality, less stroke, but worse with high carotid bifurcation…..
Stent better with high carotid bifurcation, but higher mortality/stroke

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66
Q

Pt with diplopia, dyarthria, dizziness - dx with verebrobasilar ischemia wtd?

A

ASA

Establish dx of vertebrobasilar ischemia dx with MRA posterior cranial vessels

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67
Q

Pt w/ treated vertebrobasilar ischemia has occasional epistaxis esp when sneezing dx?

A

vWF dz

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68
Q

TPA criteria

A
  1. Ischemic stroke with clearly defined sx onset
  2. No intracranial bleed on Head CT
  3. time from sx onset to delivery of tPA <270 minutes (4.5hrs), except if diabetic or age >80 then < 3 hrs.
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69
Q

Exclusion crtieria for TPA

A
  1. Rapidl improving sx….
  2. Stroke or head trauna/major 3 months/ Major surgery w/in 14 days….
  3. Suspected SAH despite normal CT head…
  4. SBP>185 or DBP >110…………
  5. on A/C……..
  6. PT>15 sec, plt<100,000, gluc <50 or >400
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70
Q

65yo M woke up in AM and THEN had stroke CT neg for bleed - presents within 3 to 4.5 hrs

A

TPA –> CTA for endovascular procedure

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71
Q

70yo M h/o afib pw sudden onset wk one side CT neg wtd?

A

TPA….. minimal improvement?? –> intra-arterial tPA

ASA 24-48 hrs later

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72
Q

65yo M found in AM in bed with stroke

A

NO TPA since duration unknown

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73
Q

Pt with ischemic stroke, time onset 60 min CT no bleed, BP 200/120 wtd?

A

Labetolol iv when BP <185/110, then TPA

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74
Q

Pt not taking HTN meds x 1 week - BP in office 240/130, h/a visual distrubances with hemianopsia, aura, cortical blindness MRI shows white matter edema in parieto-occiptal regions

A

Posterior Reversible Encephalopathy syndrome (PRES)
Started on nitroprusside - BP 140/90
-> taper nitroprusside

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75
Q

Pt with hemorrhagic stroke ….. when should anti-HTN be started

A

BP>180/100

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76
Q

Pt with uncomplicated ischemic stroke not eligible for TPA ….. when should anti-HTN be started

A

BP>220/120

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77
Q

Pt with ischemic stroke post tPA ….. when should anti-HTN be started

A

BP>170/100

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78
Q

ACA stroke

A

CL weakness leg/foot WITH sensory loss
urinary incontinence
Primitive reflexes, incr. DTR

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79
Q

MCA stroke

A 
PARIETAL lobe (dominant) ... 
 - acalculia, agraphia, Lt/Rt disorientation, finger agnosia, tactile agnosia, paresthesia
TEMPORAL Lobe - aphasia
PARIETAL Lobe Right (non-dominant)
- spatial neglect, Unable to dress
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80
Q

PCA stroke

A

U/L homonymous hemianopia
I/L 3rd N palsy - WEBERS’ syndrome
contralateral sensory abn

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81
Q

Lateral Medullary Syndrome (wallengberg synd) PICA

A

I/L loss pain/temp from face/ CL pain/temp loss. body.
I/L palsy upper and lower face
I/L loss of lacrimationa nd salivation
I/L loss of taste anti 2/3 tongue
Vertigo, nystagmus, nausea, vomiting
Tending to fall to same side, wavy images
Hoarseness, dysphagia

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82
Q

Medial Medullary syndrome

A

Contralateral hemoparesis adn parastesia
affected eye looks down and toward nose
I/L tongue palsy

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83
Q

Basilar artery stroke

A

Hemiparesis, involutary shaking movement
Bulbar muscles involvement with loss of fxn in throat - unable to move tongue - only eye movements present and called LOCKED IN SYNDROME
Quadriplegia

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84
Q

Pt with right sided hemiplegia and sensory defeits - r hemianopsia and aphasia

A

L MCA

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85
Q

Pt with L foot and leg wk, urinary incontinence

A

R ACA

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86
Q

Pt with R side sensory abn, ptosis L eye, pupillary dilation

A

L PCA

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87
Q

Pt with diplopia, dysartria one sided wk with priorbital numbness and shakign/shivery moveemnts of affected limbs

A

Basilar artery

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88
Q

Pt with quadriplegia, cnat speak can’t put tongue out, eye movements ok

A

Basilar artery

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89
Q

Pt with dizziness, n/v, loss of pain/tmep sensation L half of face adn R side body, wavy lines, tends to fall to left while trying to sit up, hoarsemneess, dysphagia

A

Left Lateral Meduallary syndrome

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90
Q

32yo F no Pmhx p/w stroke - exam pain and tenderness over calk - etio?

A

PFO

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91
Q

45yo F lupus and Antiphospholipid syndrome with h/o DVT in past on warfarin PT 3.4 with TIA with R eye blury vision whic resolves in 10 min wtd?

A

Echo with bubble study

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92
Q

82yo M brought in with h/a and R wkness - CT hyperdense lesion in pareital area suggestive of subarachnoid hematoma BP 135/76 - no h/o trauma cause?

A

Amyloid angiopathy

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93
Q

Hepatopul syndrome

A

see bubbles q4 beats on TTE

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94
Q

Broca’s aphasia

A

non-fluent speech
CAN comprehend
Frontal lobe
MCA

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95
Q

Wernicke’s aphasia

A

fluent speech but non-sensical
Can’t comprehend
Temporal lobe
MCA

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96
Q

Conductive Aphasia

A

Can’t repeat

CAN comprehend and read

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97
Q

Global Aphasia

A

Sensory and motor aphasia

Branch of middle cerebral or internal carotid artery

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98
Q

Pure word blindness

A

can’t read - occipital lobe - PCA optic radiations

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99
Q

Thunderclap headache, hit by hammer headache, worst h/a of life nausea, vomiting, alter conciousness, neck stiffness, seizure, CNIII palsy wtd?

A

Subarachnoid hemorrhage —
CT head ->
If neg -> LP check for xanthochormia
LP neg? - MRA r/o reversible cerebral vasocontriction syndrome (tx’d with CCB)
Tx: Amlodipine
Best test to confirm prior to surgery for SAH: Cerebral angiogram

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100
Q

Complications of SAH

A

Rebleed 24hrs - 1 month
Vsaospasm 4 to 10 days
Hydrocephalus - late
CSW syndrome: decr. Na and BP

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101
Q

Best drug to tx vasospam

A

Nifedipine

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102
Q

Best time to do surgery

A

ASAP - clipping or coiling for causative aneursym

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103
Q

1 week after aneurysm surgery stroke develops - cuase?

A

vasospasm induced infarct

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104
Q

Vertigo - Central

A

Cause - brainstem/cerebellar dz, MS, cerebellar atrophy, basilar infarct, arnold chiari malformation
Nystagmus - Horizontal OR vertical
Visual fixation - NO inhibition of nystagmus
Hearing loss/tinnitis +-
N/V - Pos
Severity - severe

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105
Q

Vertigo - peripheral

A

Cause - vestibular neuritis, labrythnthitis, Menier’s dz, benign positional vertigo
Nystagmus - ONLY horizontal
Visual fixation - inhibition of nystagmus
Hearing loss/tinnitus - labyrinthitis (vestibular nerutis - ), Menier’s dz +
N/V - very bad
Severity - very bad

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106
Q

Pt with vertigo and horizontal nystagmus - on visual fixation nystagmus dissappears - dx?

A

peripheral vertigo

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107
Q

Pt with vertigo/horizontal nytagmus - visual fixation negates nystagmus - - inovlvmenet of vestbular portion of 8th nerve with diziness lasting hours to days - no deafness - URI 1 week ago dx?

A 
Vestibular neuritis (Labyrinthitis)
Tx: Meclizine
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108
Q

35yo recurrent dizzziness and tinnitius and sensation fullness in ear for months aw n/v - exam horizontal nystagmus disappears with visual fixation - audiogram with hearing loss dx?

A

Meniere’s dz (tinnitus, hearing loss, vertigo)

Tx: Salt restriction, diuretics, surgical ablation

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109
Q

70yo M with new onset dizziness x 2 hours, BP high wtd?

A

MRA posterior vessels r/o brainstem stroke

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110
Q

Dx of benign positiional vertigo?

A

Dix halpike maneurver

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111
Q

Pt with vertigo, unilateral tinnitus, progressive hearing loss dx?

A

Accoustic Neuroma
Etio - Schwann cells
Dx test - MRI

112
Q

Pt with vertigo while turing in bed, getting in and out of bed, bending over and straightening up, extending neck to look up, epsisoes >30s NO hearing loss dx?

A

Benign positional vertigo - Dx with Dix halpike maneuver

Tx: Epley otiolith manuever -> Vestibular rehab

113
Q

Pt with vertigo, dysarthria, diplopia, ataxia dx?

A

Vertebral bulabar insufficiency

114
Q

Duration of vertigo

A

Seconds: BPPV, TIA
Minutes: Migraine, orthostatic hyptension, TIA
Minutes to Hours: Migraine, Meniere’s
Hours to Days: Migraine, Labryrinthitis, Meneire’s
Days to Weeks: Labryrinthitis

115
Q

Hearing testing

A

Normal: Webber - tuning fork on forehead - both ears hear same, Rhinne test AC>BC b/l ears
Unilateral air conduction deafness - Webber - hear better in affected ear (from forehead) - BC>AC Rhinne test
b/l conductive deafness/otosclerosis - webber - both ears hear equally, BC>AC both ears (rhinne)
Unilateral sensory deafness - no bone or air conduction from rhine test - webber test on forehead - only normal ear hears
b/l sensory deafness - both rhine and webber no hearing either ear…

116
Q

Vertigo with fluctuating hearing loss, tinnitis lasting hours to days

A

Meniere’s dz

117
Q

Vertigo with progressie hearing loss and tinnitus, whisper test decreased - tuning for non left mastoid without response - tuning for on forehead with better hearin gon right

A

Acoustic neuroma (unilateral sensory hearing loss) - lateralize to good ear

118
Q

Vertigo lasting 30 s and wakes up pt no hearing loss

A

Benign positional vertigo

119
Q

Vertigo with sudden onset dizziness, dysarthria, diploppia and weakness

A

Vertebrobasilar ischemia

120
Q

Vertigo post URI, horizontal nystagmus dissappears on visual fixation

A

Vestibular neuritis - labryrinthitis)

121
Q

MCC vertigo

A

Benign positional vertigo

122
Q

Tinnitis with gradual onset hearing loss, whisper test decreased - tuning for on mastoid doesn’t elicit resposne - tuning for on forehea dwith no loaclization - audiology with high freq hearing loss

A

Presbycusis

123
Q

MCC dementia

A

Alzheimer’s dz
60yo cognitive impairment, poor short term membory, can’t name names
paranoit delusions
CT/MRI - brain atrophy - dilated ventricles
inc’d B amyloid precursuor protein - inc’d presenilin activity, APo protein E4
Neurofibrillary tangles - protein Tau (microtubule)

124
Q

Treatment dementia

A

MMSE 21-25 - cholinergic augmentation (anticholinesterase), donepezil, galantamine, rivastigmine
MMSE 11-20 - cholinergic augmentation plus NMDA antagonist (memantine)
MMSE <11 - severe dementia - consider palliative care - d/c meds

125
Q

Effect of cholinesterase inhibitor

A

Improvement of neuropsychiatric score

126
Q

Pt with alzheimers - family asks about memantine - advice?

A

SLOWS progression of dementia

127
Q

Pt with alzheimer’s on donepezil - has hip surgery - post surgery agitated and confused - dx?

A

Post op delirium

128
Q

82yo M with alzheimers for several years - has been getting donepezil and memantine, chlorthalidone for HTN, metformin for DM and nortriptylinefor depression getting more agitated - wtd?

A

d/c anti-cholinergics

what is going to delay nursing home placement? –> enroll the wife in support group (decreased care giver burden)

129
Q

Donepezil, galantamine and rivastigmine are choinesteras inhibitos used to treat dementia - aw?

A

Syncope, bradycardia w/ increased pacemaker placement, hip fracture

130
Q

Who is more likely to experience sever disability in performance of daily living - cancer or dementia pt

A

Advanced dementia

131
Q

62yo sales exective pw forgetfullness - MMSE 27/30 father with alzheimers dx?

A

Mild cognitive impairment
wtd? Neuropsych eval
Reasess in 1yr - rate of progression to alheimers 15%/yr
Tx: improve cognitive fxn with 6 month program physical activity and cognitive training

132
Q

S/E Ginkgo

A

inc’d bleeding time. ginkgo does not work

133
Q

75yo Pt brought in by son - father behaving irrationally - father thinks son is imposter and beign kept in prison - looks like home - gets lost in mall freqently now doesn’t go - mild tremor soem rigidity - urinary and fecal inctinecne in recetn months - CTH brain atrophy and dilation of ventricles dx?

A

Alzheimer’s dz
tx: not very effective
Acetylcholinesterase inhibitor, NMDA rct antagonist

134
Q

Pt with dementia, parkinsonian sx of brady kinesia and postual instability, VISUAL HALLUCINATIONS, no resting tremor, extreme regidity, cytoplasmic inclusion bodies alpha-synuclein protein in subcortical tissue

A

Dementia with lewy bodies (seeing and doing inapprop things)

135
Q

35yo pt with dementia father with dementia at age 40 dx?

A

Huntington’s dz

136
Q

Memantine

A

Alzheimer’s dz

137
Q

Loss of interest, disinhibition, urinates in neighors lawn, hypersexual. abnormal agressive behavior

A

Fronto-temporal dementia

138
Q

Contacminated corneal transplants and growth hormone

A

Creutzfeldt-jakob dz

139
Q

EEG intermittent sharp waves with slow background

A

Creutzfeldt-jakob dz

140
Q

65yo M chronic HTN, hx CVA 3 ya with rapid onset dementia no problem naming names ataxia nd diplopia, extensor reflex, no sensory loss - CT scan multiple no-enhancing hypodense lesions

A

Multi-infarct dementia

tx: optimize CVA prevention (smoking cess, statins, ASA etc)

141
Q

65yo M onset of memory loss noticed by family, difficulty naming names, no motor sx - paranoid delusions

A

Alzheimer’s dz

142
Q

80yo F pw dementia, urinary incotinence wid based gait, CT scan enlarged ventricles and sulci NOT enlarged

A

Normal pressure hydrocephalus

tx: VP shunt

143
Q

55yo M onset of dementia with RAPID deterioration, myoclonic jerks, NO incontinence

A

Creutzfeldt-jakob dz

144
Q

Pt sees roaring lions/bears, stiffness, tremor

A

Dementia with Lewy bodies
motor features of parkinson’s
bizarre visual hallucinations
Tx: sx tx of parkinsonian sx, anti-psycotics

145
Q

Multiple Sclerosis

A

Demyelination of white matter in brain and spinal cord…..
Demyelination - plaques in the white matter on MRI w/GAD
Brain- Optic nerve - optic neuritis
Medial longitudinal fasciculus - Internuclear ophthalmoplegia - one eye can’t pass midline (both eyes can’t look same way)

Spinal cord - > Dorsal columns: Sensory changes, vibration and position sense loss
-> corticospinal tracts - MOTOR sx - wk, spacsiticy, hyperreflexia

146
Q

Optic Neuritis

A

Inflammation of Optic Nerve
Subacute decrease in vision +- periocular pain
Visuion blurry post excerc or heat/smoking or stress
Relative afferent pullilary defect
Tx: IV methylprednisone

147
Q

Other presentations of MS

A 
Bladder dysfxn
Bowel dysfxn
Sexual dysfxn
Trigeminal neuraligia
Cognitive dysfxn (thinning of corpus callosum
Spasticity - carbamazepime helps
Fatigue - tx with Amantadine
NO seizures
No aphasia
No h/a
148
Q

Dx of MS

A

Clinical presentation
Best imaging - Flare - MRI inc’d T2 signal dec’d T1 signal
Enhancement with Gad in active lesions
If MRI inconclusive - evoked potential studies - conduction velocities
CSF: Cells<10. > 2 IgG oligoclonal bands suggestive of MS

149
Q

Tx of MS

A

Acute Relapses -
InterNucOph, Optic Neuritis, fxn impairment -> IV methylprednisolone 1g qd x 3-5 days and taper
Active dz or to prevent relapse:
IFN Beta 1a (avonex), IFN Beta 1b (betasone), IFN Beta 1c (copaxone*)
Fatigue - amantadine

150
Q

What causes acute relapse in MS

A

Infections
before high dose steroids always r/o infection
Young women shoudl be on contraception to avoid teratogencity on IFN tx. if inadvertentently becomes pregnant on interferon therapy, NO need for therapeutic abortion.

151
Q

MC presentation of MS

A

spasticity

152
Q

Blurry vision, diplopia

A

MS

153
Q

Methylprednisolone IV 1g/day for x 5 days then taper

A

Acute MS relapse

154
Q

Alpha interferon

A

NOT Tx for MS

155
Q

B interferon

A

MS PPx for relapse

156
Q

Amantadine

A

Tx for MS fatigue

157
Q

Optic Neuritis in MS

A

Better prognosis

158
Q

Sensory sx in MS

A

Better prognosis

159
Q

Relapsing remitting in MS

A

Better prognosis

160
Q

Progressive relapsing MS

A

Worse prognosis - d/c B infn

161
Q

Age>40 at dx of MS

A

worse prognosis

162
Q

32yo with intermittent diplopia - numbness/paraesthesia - attempted adduction affected eye -> horizontal nystagmus - Visual acuity - 20/20

A

internuclear ophthalmoplegia

etio - Medial longitudinal fasciulus - MS

163
Q

Young woman develops “thick tongue” blurry vision after hot showser - after exc or after hot weather - dx?

A

Optic neuritis

164
Q

Pt with MS not responding to B interferon

A

start mitoxantrone

165
Q

Parkinson’s dz

A

Movement d/o 2/2 decrease DOPAMINE from SUBSTANTIA NIGRA
Clinical Dx
Cl Fts RRRR
R esting tremor 4-7 Hz - pill rolling - pronation/supination
R igidity - cog wheel regidity - dec’d arm swing
R etarded movement - bradykinesia and dyskinesia
R eflex lost - postural reflex lost-> frequent falls

166
Q

When to treat Parkinson’s

A

Only start when sx have negative impact on functioning status
1. REPLETE DOPAMINE IN BRAIN - - -
Levodopa (peripheral effects not needed) so add carbidopa (prevents periopheral effect of levodopa)
2. DOPAMINE AGONISTS (start in pt <70 yo): pramipexole, ropinirole bromocriptine
3. INHIBITORS OF DOPAMINE BREAKDOWN - selegiline, tolcapone - allows higher doses of L dopa to cross BBB
4. ANTI-CHOLINERGICS TO decr. s/e of levodopa (trihexyphenidyl, Benztropine)

167
Q

Complications of Treatment

A

L-Dopa side effects
Involuntary movements - fascial lingual dystonia, chorea, athetosis
Psychiatri symptoms - confusion, depression hallucinations psychosis
on-off phenomenon - alternative hyperkinesia-hypokinesia

168
Q

55yo M p.w slow shuffling gait - resting tremor and brdykinesia - ADL with difficulty - cogwheel rigidity and spacticity of muscles - now would start…

A

Levodopa and carbidopa

169
Q

Pt started on levodopa-carbidopa c/o nausea wtd?

A

Take with low protein meal or carbidopa 30 min prior to levodopa

170
Q

Pt with long standing parkinson’s dz on Levodopa-Carbidopa now c/o wkness and bradykinesia … what happened?

A

On-off phenomenon - inc dose/freq +/- selegiline/rasagiline (inhibits levodopa breakdown)

171
Q

70yo F parkinson’s dz on levodopa and carbidopa did well for several years now with inc’ing sx - > dosage of levo/carbidopa inc’d-> psychsis wtd?

A

start atypical antipsychotic - quetiapine or clozapine

172
Q

Pt with refractory schizophrenia started on clazapine - 3 weks later develops agranulocytosis WBC 500 wtd?

A

d/c clozapine and never use again

173
Q

Pt with Parkinson’s dz hospitalized with PNA confused, agitated at night -

A

start lorazepam

174
Q

Parkinson’s related dementia

A

Quetiapine (seroquel*) or clozapine

175
Q

Parkinson’s related DELIRIUM

A

Lorazepam or Quetiapine

176
Q

Pt pw bradkinesia, abn gait, inc’d muscle tone and mild dementia - exam reveal erect posture with hyperextension of neck no tremor, vertical ophthalmoplegia; trouble walking downstairs, eating or reading

A

Progressive Supranuclear palsy
(Slow movements, problem with voluntary eye movement, diplopia while reading (hard to get eyes close together)
Tx: TCA (amitripline)

177
Q

Essential or Familial/Kinetic Tremor

A

Autosomal dominant, mainly hands/head
Intention tremor at 7-10hz (physiogic >9)
Aggrevated by anxiety, anteropost flapping hands
Gets better at rest
dec’d with etoh
Tx with propranolol -> primadone

178
Q

Pt with creepy-crawly sensations, itchiness, pain, parestesias, jerky movement every 20-40 s while sleeping - fatigue during day
Sx transiently relieved with movement or walking - can occur with or wihtout Parkinson’s
A/W Iron def anemia

A

Dx: Restless leg syndrome
-established by H&P
If IDA - iron therapy - if not better in 12 wks start dopamin agonist
No iron def - dopamin agonist (perfolide, pramipexole, ropinrole or gabpentin

179
Q

periodic limb movementd/o with jerky movements during sleep dx by?

A

Polysomnography

180
Q

Pt while writing, hand goes into spasm - phalen/tinel’s neg, serum Ca 9mg

A

Acute dystonic rxn

181
Q

Pt get phenothiazine for n/v - coupel hours later - pt eyes are stuck in particular gaze (left or right) wtd?

A

Diphenhydramine

182
Q

Other manifestations of Acute Dystonia..

A

Torticollis - fixed flexion of neck
Blepharospams
Writers cramp

183
Q

18yo M with twitching of face, grimacing and movements of neck

A

Tourette’s syndrome

Tx: CBT then neuroleptics

184
Q

Tremor best seen at rest

A

Parkinson’s

185
Q

Tremor aggrevated by anxiety

A

Essential/kinetic

186
Q

Tremor dec’d by rest

A

Essential/Kinetic or Cerebellar

187
Q

Tremor relieved by etoh

A

Essential/Kinetic

188
Q

Tremor activated by action

A

cerebellar > essential/kinetic > parkinson

189
Q

Tremor in head/voice tremors

A

Essential/kinetic

190
Q

Chin tremors

A

Essential/Kinetic or parkinsons

191
Q

Familial tremors

A

essential/kinetic

192
Q

Tremor on fexion-extension

A

Essential/kinetic

193
Q

Tremor on pronation/supination

A

Parkinson’s

194
Q

Tremor at rest and on movment ***

A

Parkinsons

195
Q

Neuromuscular dz

A

Myasthenia gravis
Autoimmune
Ab to POST-synaptic Ach rct’s
Low level of Ach rct
Cl ft:
WEAKNESS as day PROGRESSES (repetive acts) reflexes normal
Extraoc/oc muscles-> Ptosis, diplopia
Facial muscles-> diff chewing, dysartria
BUlabar muscles - diff swallowing
Prox limb muscles - wk brushing hair
Intercostal an diaphragmatic wk -> resp failure (Myasthenic crisis)
Edrophonium challenge test (Tensilon test) -> Ptosis should get better
Ach rct ab + in 90% gen MG, 50% ocular MG

196
Q

neuromuscular diseases … .Dipolpia

A

+Ptosis + wkness –> MG
+INO –> MS
+dysarthria + ataxia + dizziness –> Verterobasilar TIA
+cauda equina –> Leptomeningial metastaisis

197
Q

Pt with diplopia, fatigue at end of day difficulty brushing hair, recently while eating regurg thru nose, diplopia, ptosis in both eyes. wtd to get dx?

A

Ach receptor Ab test

198
Q

35yo prox muscle wk, ptosis, diplopia, EOMI intact, vision intact, DTR intact. wtd next

A

Repetive nerve stim studies
MS - gets weaker with repeated stim
Eaton lamburt - stronger with repeated stim

***Single fiber electromyography (SFEMG) is more sensitive than nerve stimulation studies (100% SFEMG vs 65% NCS) but SFEMG is operator dependent.

199
Q

Pt dx with MG wtd next

A

CT chest r/o thymoma - if present resect

200
Q

40yo F works on farm lately gets tired - diplopia on exam - pupils ok refelxes ok vision ok - dx?

A

MG - reponsd to physostigmine

(not organophosphate - pupils would be constricted) this exam you go with presentation

201
Q

30yo smoker with diplopia - tired at end of day - difficulty swallowing, chewing, nasal regurg - develops progressive wk and goes into resp facilure - dx?

A

MG

202
Q

What makes MG wkness worse?

A 
aminoglycoside abx
Antiarrythmics
BB
Infxn
Electrolytes d/o ***
203
Q

Pt with myasthenic crisis wtd?

A

admit to ICU,
Plasma exhange,
Immunglob/steroids,
Elective intubation for vital capacity <21 ml/kg

204
Q

Pt with MG on pyridostigmine now with acute exacerbation wtd?

A

immunoglobulin/steroids

205
Q

Eaton Lambert syndrome

A 
Autoimmune/Oat cell CA
Antibody to PRE-synaptic rct's
Weakness BETTER with repetitive action
HYPO-reflexia
no ptosis
no diplopia
206
Q

Pt with wk, inabilit to get up form chair, BETTER with excercise - h/o chronic smoking, 30 pack years- DECREASED reflexes, no ptsosis, repetitive nerve stim with incremental INCREASE with continuing potentials dx?

A

Eaton Lambert 2/2 small cell lung CA

207
Q

Better with repetition

A

Eaton labert

208
Q

Worse with repetition

A

MG

209
Q

Hyporeflexia

A

Eaton lambert

210
Q

Normal relfex

A

MG

211
Q

Abx infxn worse

A

MG

212
Q

Small cell CA

A

Eaton labert

213
Q

Thymoma

A

MG

214
Q

Pre-synaptic Ab

A

Eaton lambert

215
Q

Post-synaptic anti-acetychoie rct ab

A

MC

216
Q

Ptosis/diplopia

A

MG

217
Q

Muscle wkness

A

MG and Lambert-Eaton

218
Q

60yo M pw complaints of pain in shoulders, tired at end of day acan’t keep head up - recently choked on food, slurring speech - has had diffuctly wearing pants /shirt - exam mild wk neck muscles- twithcing of shoulder - spasticity of muscles, hyper reflexia - sensory exam ok dx?

A

ALS
dx - EMG
tx: Anti-glutamic acid = Riluzole

219
Q

Spinal cord

A

Myelopathy - Upper motor neuron

Radiculopathy - Lower motor neuron

220
Q

Cervical spondylitis

A

Compression of cervical Cord - UMN with sensory changes
UMN changes: Spasticity, hyper-reflexia of deltoid, beceps, triceps, extensor plantars
Sensory changes - Loss of position and vibration sense in lateral arm/lateral 3 fingers
Dx: MRI/myelogram
Tx: Steroids

221
Q

Syringomyelia

A

Cavitation of central spinal cord -> LMN with sensory changes
LMN changes - weakness of upper limbs; start with hands and proceeds proximally to shoulders
Sensory chages - Lateral column changes: temperature and pain sensation lost - touch and vbration preserved
Dx: MRI
Tx: Monitor if progresses - > surgery

222
Q

Pt with wk of hand now progresses to shoulder - pain/temp sensation lost but touch and vibration preserved - MRI cavitary lesion of spinal cord

A

Syringomyelia

223
Q

Pt with deep ache in buttocks and thighs when standing, disappears on sitting

A

Spinal stenosis

224
Q

Pt with pain in thoracic area - flu one week ago or SLE - Now with wk of legs and bladder disturbances - getting worse - hyperreflexia (UMN)

A

Transverse myelitis

225
Q

Pt with stock and glove distribution of tingling sensation, pt confused has ataxia, spasticity and clonus

A

Subacute combined degenration of spinal cord

226
Q

Pt with loss of vibration in lateral three fingers, hyper reflexia of deltoid, bicepts and triceps

A

Cervical Spondylitis

227
Q

L5 Radiculopathy

A

= +foot drop, can’t evert OR invert foot

…. while Peroneal nerve injury has + foot drop, can’t evert, but CAN invert foot

228
Q

L5 vs S1 radiculopathy / reflex presetnation

A

L5 - dec’d dorsiflexion, NO ankle jerk

S1 - dec’d plantar flexion - dec’d ankle jerk

229
Q

Elderly pt with c/o back pain inc’d with walking - expecially down hill and standing with numbness in legs It decreased while sitting, shaking leg makes it better. MRI would show?

A

Spinal stenosis

… hypertrophy of Ligamentum flagum.. TX = PT

230
Q

55yo M after lifting weights - lower back pain - leg raise >45 deg with pain - anal sphincter tone good, dorsiflexion R foot slightly dec’d, ankle jerk dec’d

A

Sciatica with herniated disc… wtd? analgesics and activity as tolerated

231
Q

If anal sphincter tone lost or bladder dysfxn (wet or soiled), wtdd?

A

MRI - r/o cauda equina syndrome

232
Q

Sensory loss on Lateral aspect of thigh what spinal segment?

A

L2

233
Q

One of most common causes of mononeuritis multiplex

A

PAN

234
Q

Polyneuropathy - Guillan barre

A

Guillain Barre - inflammation of nerves with segmental demyelination
LMN - ascending paralysis
CSF - in’c protien, normal WBC
Nerve conducion - slow conduction
tx: IVIG-> plasma phereisis
Elective intubation if reps muscles invovled

235
Q

Botulism -

A

Descending paralysis
blurred vision, diplopia, dysarthri, dysphagia
diarrhea/vom in young pt with dilated pupils
Labs; toxin in serum or stool
Tx: botulism anti-toxin

236
Q

Cyclist with paresthesia in little finger adn inability to adduct little finger and index finger - hypothenar wasting

A

Ulnar neuropathy

237
Q

Nocturnal awakening with pain and paraesthesias

A

Median nerve

238
Q

Alcoholic with diplopia and weakness of the right hand

A

Radial neuropathy

239
Q

Difficulty standing on toes, reflexes dec’d

A

Sciatica

240
Q

Wrist drop -

A

Radial neuropathy

241
Q

Foot drop

A

Peroneal nerve comopression

242
Q

Antibody induced acute polyneuropathy - occurs in

A

Guillain-barre syndrome…..

occurs over wks to months

243
Q

Young pt with ankle sprain - takes NSAIDs - extreme tenderness when bed sheet touches - exam bluish discoloration - dx?

A

Complex regional pain syndrome (formerly reflex sympathetic dystrophy)

If pt with patchy demineralization, bisphosphonates are effective - treatment even in absense of osteoporosis**

244
Q

19yo playing football has a sudden impact and falls to ground - appears confused upon immediate exam - no LOC, 15 minute later normal cognition and vision and finger -nose test - wtd?

A

Remove from play –> licensed healthcare provier will decide on case by case basis whne to return to play..

***dont give steroids for traumatic brain injury

245
Q

Seizures

A

Generalized
1. Tonic Clonic - valproate, lamotrigine, levetiracetam, topriamate
2. Absense/Petit mal:
without aura or post ictal sx, 3 sec spike and wave patternon EEG
tx: ethosuximide, valproate, lamotrigine

Partial
1. SIMPLE- focal seizure affects small volume of cortex, no LOC (psychic sensation, deja vu

  1. COMPLEX- involves large enough cortex to cause loss of conciousness
    tx: Carbamazepine, phenytoin, valproate, levetiracetam, lamotrigine, gabapentin(adjunctive)

DONT START ANTI-SEIZURE MEDICATION ONSTROKE PATIENT UNLESS THEY HAVE SEIZURES

246
Q

Medications that cause seizures

A

Imipenem, tramadol, bupropion, haldol, meperiridine, PRBC
Partial: Carbamazepine, phenytoin, valproate, levetiracetam, lamotrigine, gabapentin

other causes of seizures: cocaine, alcohol w/d, hypoglycemia, syncopal convulsions, pseudoseizures

SEIZURE –> DECR. HCO3.

247
Q

Best Anti-sz med for elderly

A

Lamotrigene

248
Q

Best anti-Sz med for with liver dz

A

Keppra (Levetrcetam) (ALSO BEST FOR HIV)

249
Q

Best anti Sz medication in pregnancy

A

Carbamapezine

250
Q

What antiseizure medication causes kidney stones

A

Topiramate

251
Q

After the first seizure - best dx imaging is…

A

CT –> if neg –> MRI
Then do EEG (epileptiform spike +/- slow waves
NORMAL EEG does NOT r/o seizure d/o

252
Q

Pt makign presentation to supervisor slumps over in chair, diaphretic, has jerks of arms nad legs several times - completely recovers in 30 sec and has pallor, BP normal, cardiac/neuro exam normal dx?

A

Syncopal convulsions

253
Q

Pt in dental chair passes out andhas jerky movement o arms and legs, completely recovers in 30 sec - diaphoretic - similar episode once before

A

neurocardiogenic syncope (P waves w/o QRS? decr. HR)

254
Q

22yo h/a, smells of burnign rubber, feels strange, no convulsions seen dx?

A

partial seizure/psychomotor epilepsy

255
Q

Pt has generalized seuzures not better with dilantin - serum Ca low, ca cl injections don’t help wtd?

A

Iv Mg SO4

256
Q

22yo with weird sensation in stomach followed by sudden freezing, swallowing chewing, lip smacking - minute later she starts talking and doesn’t recall eepsode

A

Partial seizure (doesnt recall = complex partial)

257
Q

30yo F brought to office - say having recurrent spells of starting for several seconds the haveing intense familiarity with surrounding sand strangers most likely affected lobe is?

A

Temporal lobe

258
Q

Young woman with epigastric rising sensation - most likely dz?

A 
simple partial seizure
temporal lobe (deja vu)
259
Q

22yo F with husband and narrating complaint then her leg starts jerking which gets wors and on /off x several minutes - then SOB, then holds head tight afte r3 min jerking stops and feels dizzy and has headache dx?

A

Pseudoseizure

dec’d Ca+

260
Q

55yo brought in by family - having episodes when staring blankly for several seconds then shakes hand repeately fo rfew minutes then feels tired - no focal neuro deficits, MRI normal wtd?

A

Sleep deprived EEG

dx: Complex partial

261
Q

Pt with onset of seziure of left arm and then spreads to left leg - after episode wk of left arm and leg dx?

A

Jacksonian seizure
frontal lobe
starts at arm and marches toward leg in terms of sx (begin with fingers - end with legs) - NO LOC

262
Q

Treatment of status epilepticus (sz >30min or LOC between 2 mor more seizures

A
  1. IV glucose + 100mcg thiamine ….
  2. Lorazepam ….
  3. Loading dose Phenytoin 10mg/kg or Fosphenytoin (Cerebyx* all of it at once)
  4. Maximize Phenytoin –> 10mg/kg more
  5. Phenobarb (Luminal) or Midazolam (Versed)
  6. General anaestheia and neruomuscular blockade
263
Q

Pt with new monset seizure - post ictal state recommendation?

A

No driving

No swimming

264
Q

Pupils

A
  1. Mid dilated - glaucoma ..
  2. Mid constricted - uveitis (iridocylitis) or compression of sympathetic chain (CXR or CT-A to r/o dissec.) ..
  3. BL dilated - anti-cholinergics, botulism, cocaine/barbituates OD, anoxia. ..
  4. UL dilated - CN III compression (MRA lesion –>PCA)
  5. BL constriction - Opiates, pontine infarct, organophosphate poisoning
265
Q

MRI/CT findings in different diseases.. infarct?

A

hypodense area - no enhancement

266
Q

MRI/CT findings in different diseases.. bleed?

A

hyperdense area, no need for contrast CT

267
Q

MRI/CT findings in different diseases.. Multi-infarct dementia?

A

Mulitple hypodense areas, no enhancement

268
Q

MRI/CT findings in different diseases.. Tumor?

A

Enhancing lesion

269
Q

MRI/CT findings in different diseases.. Brain abscess

A

Ring enhancing lesion

270
Q

MRI/CT findings in different diseases.. Toxoplasmosis

A

Multople ring enhancing lesions

271
Q

MRI/CT findings in different diseases.. Cerebral atrophy

A

Dilated ventricles AND dilated sulci

272
Q

MRI/CT findings in different diseases.. Normal pressure hydrocephalus

A

Dilated ventricles, sulci NOT dilated** MRI

273
Q

MRI/CT findings in different diseases.. Multiple Sclerosis

A

White matter plaques, enhance with active dz

274
Q

MRI/CT findings in different diseases.. Alzheimer’s

A

dilated ventricles**+ Brain atrophy, Periventricular white matter lesions

275
Q

Neuro imaging for headache shouldbe ……

A

MRI, not CT. If stroke, hemorrhage, and head trauma suspected then non contrast CT

276
Q

Pt w/ vertigo while turning in bed/getting in aand out of bed, bending over and straightening up, extending neck to look up, episodes last about 30secs. Denies hearing loss. dx? tx?

A

benign paroxysmal positional vertigo… dx w/ dix-hallpike

tx.. epley-otolith maneuver

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