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PANCE Review > Neurologic System > Flashcards

Neurologic System Flashcards

1
Q

complex regional pain syndrome (CRPS)

A

autonomic and vasomotor dysfunction in extremities
usually follows trauma to affected limb
- pain or tenderness out of proportion to exam
- swelling, muscle atrophy
- does NOT follow peripheral nerve distribution
- no systemic sxs

Tx:

  • NSAIDS, PT/OT
  • steroids, anti-depressents, gabapentin, etc.
  • early mobilization is key
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2
Q

peripheral neuropathies - sxs, dx

A

may be motor (guillian-barre), sensory (DM), autonomic (DM), or combo

Dx:

  • EMG/NCV (nerve conduction velocity) - primary test
  • labs: glucose, BUN/Cr, vit B6 and B12, RPR
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3
Q

diabetic neuropathy - clinical, tx

A

distal, symmetrical polyneuropathy
- most common peripheral neuropathy in western world

tx: no tx to halt progression
- goal: control sxs and prevent osteomyelitis
- tight glucose control
- foot care

meds:

  • gabapentin
  • pregabalin (lyrica)
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4
Q

charcot-marie tooth disease (CMT)

A

child or adult with progressive motor weakness
- foot drop (anterior tibialis weakness), high arches, hammer toes

Dx: genetic testing

Tx: focus on function

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5
Q

bell’s palsy

A

lower motor neuron facial nerve paresis

  • causes: infection, pregnancy, DM
  • abrupt onset of facial paralysis (complete 1/2 side)
  • 60% recover w/out tx (steroids w/in 5 days benefit)

Note: CVA would be able to move eyebrow

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6
Q

cluster headache - clinical, timing, tx

A

severe, unilateral periorbital pain

  • stabbing
  • middle-aged man
  • often with nasal congestion, tearing on same side

timing:

  • occur in clusters: daily for several wks
  • 15 min- 3 hrs

tx:

  • abortive: 100% oxygen
  • prophylactic: Verapamil
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7
Q

migraine headache - clinical, timing, triggers, tx

A

HA of neurovascular dysfunction

  • often a FH
  • onset teens - 30s
  • women>men

Sxs:

  • throbbing, unilateral, pulsing
  • N/V, photophopbia
  • WORSE with activity
  • last hours to date
  • can have “aura” and prodrome

Triggers:
-stress, foods, ETOH, smells, bright lights, menstrual

Tx:
- avoid triggers, dark/quiet room

Abortive:

  • NSAIDS (mild),
  • triptans (mod/severe): avoid in CVD, PVD, pregnency; combine w/ naproxen for inc. benefit

Preventative (if >3 times/month or interferes w/ life activities):

  • antiepileptics: Topiramate, valproic acid
  • antihypertensives: propranolol

NOTE: if pt over 60, get ESR to R/O giant cell arteritis

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8
Q

tension headaches - clinical, triggers, tx

A

generalized, constant, squeezing

  • most common primary HA
  • DO NOT worse with activity
  • no N/V

Tx:

  • stress reduction, sleep hygiene
  • NSAIDS, acetaminophen

Prophylaxis: TCAs

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9
Q

encephalitis - definition, sxs, dx, tx

A

inflammation/infection of brain parenchyma
- usually viral
Epidemic: west nile virus
Non-epidemic: HSV-1

s/sx:

  • viral prodrome (fever, malaise, myalgia, N/V/D, rash)
  • HA, photophobia, altered sensorium, seizures

Dx:
- lumbar puncture (CSF PCR): showing elevated opening pressure, elevated protein and WBC, glucose (normal if viral)

Tx: do not wait for LP results
- Acyclovir (since most common is HSV-1)

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10
Q

viral vs. bacterial etiology of CSF

A

lumbar puncture (CSF PCR):

  • viral will have normal glucose
  • bacterial will have low glucose (bacteria eat glucose)
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11
Q

meningitis

A

inflammation/infection of arachnoid membrane, pia mater, and CFS in between

  • bacterial, viral, other
  • dec. incidence due to vaccines
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12
Q

bacteria meningitis - clinical, signs

A

acute onset of fever, HA, vomiting, stiff neck, myalgia, backache, weakness

  • rapid progression to confusions, loss of consciousness, sz
  • MEDICAL EMERGENCY

Signs:

  • Kernig and Brudzinski - flexion of knees in pain
  • petechiae or ecchymosis rash: meningococcal
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13
Q

bacteria meningitis - dx, tx

A

lumbar puncture:

  • elevated opening pressure
  • CFS: elevated protein, dec. glucose, elevated cell count (PMN)
  • positive gram stain

Blood cultures

CT/MRI of brain and spine

CXR, sinus, mastoid

tx:

  • IV ABX and dexamethasone
  • empiric tx by demographic (1st)
  • pathogen specific tx
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14
Q

viral meningitis - clinical, dx, tx

A

acute onset of fever, HA, vomiting, stiff neck, myalgia, backache, weakness, rash
- 60% are enteroviruses (fecal-oral transmission)

lumbar puncture:

  • slightly elevated opening pressure
  • CFS: elevated WBC, normal or slightly elevated protein, normal glucose
  • negative gram stain

Tx: supportive

  • NSAIDS, analgesics, antiemetics
  • acyclovir if HSV
  • out-patient recovery 1-3 wks

NOTE: prevention key (mumps was #1 cause prior to vaccine)

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15
Q

essential tremor

A

postural tremor of hands, head, of voice

  • genetic
  • may begin at any age
  • worse with stress; less with ETOH

Tx:

  • nothing if not disabling
  • propranolol if disabling
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16
Q

huntington disease

A

progressive disease resulting in death of nerve cells (including brain cells)

  • genetic
  • onset b/t 30-50 (fatal 15-20 yrs)

s/sx: gradual onset chorea (jerky, involuntary mov’t), dementia, behavioral changes

dx:

  • CT or MRI: cerebral atrophy
  • genetic tests for definitive dx

tx: symptomatic
- genetic counseling

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17
Q

Parkinson Disease

A

disease of imbalance of dopamine and acetylcholine in corpus striatum

  • PROGRESSIVE dz
  • usually sporadic (NOT inherited)
  • onset 45-65 y/o
  • lies on spectrum - parkinsonism

s/sx:

  • pill rolling tremor at rest, cogwheel rigidity
  • bradykinesia (trouble initiating mov’t), gait impairment/shuffle

Dx: clinical

tx:

  • early (prevents progression): amantadine, anticholinergics, dopamine agonists, brains stimulation
  • Levodopa (converted in body to dopamine) / carbidopa (inhibits enzyme that breaks down levodopa) is MAINSTAY of treatment
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18
Q

cerebral aneurysm: definition, risks, complication, dx, tx

A

“berry aneurysm” that occur at arterial bifurcations

  • asymptomatic until rupture
  • most in Circle of Willis

Risks: smoking, HTN, hyperlipidemia

complication: subarachnoid hemorrhage
dx: angiography (gold standard)

tx:

  • surgery, endovascular intervention
  • monitor if <10mm
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19
Q

stroke - two types

A

brain infarction
very common - 2nd leading cause of death world-wide

ischemic (85%)
- thrombotic (arthrosclerosis), embolic (a-fib), small vessel dz

hemorrhagic (15%)

  • intracerebral
  • subarachnoid
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20
Q

stroke - risk factors

A

HTN
DM
Smoking

also:

  • atrial fibrillation
  • carotid stenosis
  • black/hispanic
  • men
  • obesity
  • ETOH
  • OCP
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21
Q

transient ischemic attack - definition, cause, W/U

A

acute onset of focal neurologic deficit lasting

  • sxs < 24 hrs
  • no infarction

Cause: emboli from heart or extra cranial artery

W/U: CT or MRI w/in 24 hrs
- also carotid U/S, MRA, CTA

Note: if sxs >1-2 hrs, possibly infarction and generally worse outcome

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22
Q

transient ischemic attack - treatment

A

assess ABCD2 score

  • age (>60)
  • BP>140/90
  • focal weakness on exam
  • duration of sxs > 60 min
  • DM

Tx: Statin, ASA, anti-platelet meds (clopidogrel), carotid surgery of severe stenosis

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23
Q

ischemic stroke -s/sx, dx

A

s/sx:

  • focal neurological deficit (mental status, speech, CNs, strength, reflexes)
  • painless, abrupt onset
  • NIH stroke scale

NOTE: presentation depends on artery occluded
- Middle cerebral artery is MOST COMMON and presents w/ contralateral hemiparesis, arm/face sensory loss, expressive aphasia (Broca’s - partial loss of ability to produce language)

dx:
- non-contrast
CT brain (r/o hemorragic)!!!

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24
Q

ischemic stroke - tx

A

ABCs
Correct glucose
Thrombolytic therapy: rtPA (w/in 4.5 hrs of onset)
Lower BP (so can receive rTPA) : Labetalol, nicardipine
Aspirin (if rtPA contraindicated)
Mannitol: lowers ICP
PT/OT

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25
Q

thrombolytic therapy (rtPA) contraindications

A 
BP>185/110
head trauma or stroke in previous 3 mo
recent CNA surgery
GI bled
Hx of ICH
Recent anti-coag/bleeding diathesis
Glucose < 50

Note: no anticoagulants of platelet-inhibitors for 24 hrs after admin of t-PA

26
Q

ischemic stroke - prevention

A

anti-platelet therapy: ASA, Plavix

control lipids: statins

control BP: ACE-I in DM

smoking cessation

anti-coagulation for A-fib patients (Warfarin, DOAC)

carotid endarterectomy or stenting

27
Q

intracranial hemorrhage (ICH) - definition, causes, dx

A

bleeding into brain

causes:
- HTN (very abrupt), trauma, drugs (anti-coagulants, 1-2 day onset)
- Asian and AA

dx:

  • CT brain (differentiate from ischemic stroke so DO NOT give tPA)
  • investigate for coagulopathy: PT/PTT/INR
  • CTA to find site of bleed
28
Q

intracranial hemorrhage (ICH) - tx

A

manage HTN: nicardipine

control ICP: mannitol, fluid restrict

seizure ppx: fosphenytoin

reverse coagulopathy: FFP (fresh frozen plasma), vit K

surgical evacuation of hemotoma

29
Q

subarachnoid hemorrhage (SAH) - definition, cause, s/sx, dx

A

ruptured vessel in subarachnoid space
- high mortality

cause: trauma follow by ruptured aneurysm

s/sx:

  • rapid onset, severe HA (thunderclap; worst of life)
  • N/V, AMS, neck stiffness

dx:

  • non-contrast CT
  • LPL blood in CSF
  • cerebral angiography: finds source of bleed
  • CBC, coag studies, electrolytes
30
Q

subarachnoid hemorrhage (SAH) - tx

A

BP control: beta-blockers

Sz ppx: fosphenytoin

Nimodipine: CCB to reduce vascular spasm

surgery: clipping, coiling

reduce ICP: Mannitol, diuretics

Support: ventilation, nutrition

31
Q

subdural hematoma (SDH) - definition, causes, common population, s/sx

A

hemorrhage beneath dura
-venous bleed = slower

causes:

  • trauma (may be minor)
  • anticoagulation
  • ETOH
  • frequent falls

common: very young and very old

s/sx:

  • unilateral HA and ipsilateral enlarged pupil
  • subacute many progress over 3-7 days
32
Q

subdural hematoma (SDH) - dx, tx

A

CT brain: crescent-shaped collection over 1 or both hemispheres

  • crosses sutures, not midline
  • concave
33
Q

epidural hematoma (EDH)

A

blood accumulates below skull but above dura
- arterial bleed = faster

s/sx:
- lucid interval of min to hrs b/f alter mental status

dx: CT brain
- bi-convex-shaped
- does not cross suture lines

34
Q

altered level of consciousness - causes and definitions

A

result from a serious insult to CNS
- seizure, structural lesion, hypothermia, metabolic d/o, toxic/drug induced

stupor: transient arousa by vigorous stimuli
coma: non-arousable, no response to external events
vegetative: wakefulness present but awareness absent

35
Q

altered level of consciousness - dx

A

Glasgow coma scale

  • mild head injury: 13-15
  • moderate head injury: 9-12
  • severe head injury: 8 or less

finger-stick glucose STAT

EKG: did MI occur

Labs: serum glucose, electrolytes, calcium, LFTs, BUN/Cr, tox studies, ABG

EG, brain CT/MRI, LP

36
Q

altered level of consciousness - tx

A

tx depends on etiology
- correct underlying d/o

supportive tx:

  • stabilize c-spine, ABCs
  • control sz
  • empiric ABX if meningitis
  • lower ICP: mannitol, surgical decompression
  • coma cocktail: dextrose, naloxone (in case opioid OD), thiamine IV (correct deficiency in ETOH)
37
Q

concussion - definition, s/sx, W/U, tx

A

transient trauma-induced change in mental status

  • may or may not involve LOC
  • simple: resolves w/in 3 wks
  • complex: does not resolve

s/sx:
- HA, N/V, disorientation, irritability, visual disturbance, neurological deficits

W/U:

  • Head CT: use Canadian CT Head rules to determine risk (GCS<15, possible skull fx, vomit >2x, age<65, mechanism)
  • ADMIT: age >65, intoxication, soft tissue injury above clavicle
  • MRI if sxs persist > 14 days or worsen

Tx: MUST be cleared by trained provider
- cognitive and physical rest key

38
Q

post-concussive syndrome

A

sxs lasting weeks to > 1 year

s/sx:
- HA, trouble concentrating, fatigue, dizziness, irritability

39
Q

cerebral palsy - clinical, s/sx

A

chronic, static impairment of muscle tone, strength, coordination, and movement (does not progress)

  • results from insult to neonatal nervous system / brain
  • possibly hypoxia, infection

s/sx: spasticity, ataxia
- can have associated developmental delay or sz d/o

40
Q

cerebral palsy - dx, tx

A

dx: clinical

tx: maintain maximal physical fx
- PT/OT, speech
- counseling, education

meds: for spasticity (Baclofen, botox)

prognosis depends on severity of deficits

41
Q

dementia - definition, risk factors

A

progressive decline in intellectual and cognitive fx

  • compromises social and occupational fx
  • leads to loss of independence
  • age > 60 typical

Loss of ST memory and 1+ cognitive deficit:

  • aphasia: impaired word-finding
  • apraxia: impaired motor tasks
  • agnosia: impaired recognition of objects
  • impaired executive fx (planning)

Risk factors:
- age, stroke, FH, DM, head injury

42
Q

alzheimer disease - cause, s/sx

A

loss of ST memory (anterograde amnesia)
- most common type of dementia

cause: accumulation of B-amyloid plaques in brain

s/sx:

  • early: difficulty w. finances, independent travel meal prep
  • late: difficulty with ADLs

usually no motor deficits

43
Q

alzheimer disease - tx

A

aerobic exercise, mental stimulation

1st line: acetylcholinesterase inhibitors

  • donepezil (Aricept)
  • rivastigmine (Exelon)
44
Q

Types of dementia (in addition to alzheimer disease)

  • Vascular
  • Lewy body
  • Frontotemporal lobar degeneration
A

Vascular: due to multiple infarcts to brain (stroke)
- motor slowing, gait d/o

Lewy body: dementia with parkinsonism, visual hallucinations,
- antipsychotics worsen

Frontotemporal lobar degeneration: d/o of behavior and personal relationships
- rude, sexually explicit, poor judgment, poor hygiene

45
Q

delirium - definition, causes

A

global impairment in cognitive functioning that is sudden in onset

  • presents with diminished level of consciousness, inattention, visual hallucinations, autonomic changes (tachycardia, sweating)
  • usually reversible
  • lasts <1 wk

Causes:

  • Hypoxia
  • Hypoglycemia
  • Acute intoxication or withdrawal
  • Meningitis/ encephalitis
  • Intracranial injury
  • Hypo/hypernatremia
  • Drug side effects
  • Medications!!
46
Q

guillain-barre syndrome - definition, causes, s/sx, dx tx, prognosis

A

acute, inflammatory demyelinating polyneuropathy

causes: infection, vaccine surgery
- Caplylobacter jejuni (?)

s/sx:

  • weakness>sensory disturbance (“rubbery legs”)
  • begins distal and spreads proximal
  • motor paralysis
  • autonomic disturbance: cardiopulmonary (may need intubation)

dx:

  • CSF: inc. protein
  • R/O other neuropathies

tx:

  • plasmapheresis, IVIG
  • steroids are INEFFECTIVE

Prognosis:

  • recovery takes months!
  • 15-20% w/ lasting disability
47
Q

multiple sclerosis - definition, causes, s/sx, dx tx, prognosis

A

focal areas of demyelination

  • scattered white matter changes in CNS (periventricular, spinal cord)
  • likely autoimmune
  • progressive dz
  • women>men (white)
  • can occur postpartum

s/sx:

  • weakness, numbness, optic neuritis, diplopia
  • nystagmus, UMN findings (hyper-reflexia)

types:

  • relapsing-remitting
  • secondary progressive
  • primary progressive

Dx:

  • s/sx must be disseminated in time and space
  • s/sx last at least 24 hrs at least 1 mo apart
  • pathology in anatomically noncontiguous white matter tracts of CNS
  • MRI: brain and spinal cord (“black holes”, “dawson’s fingers” in brain)
  • LP: oligoclonal bands (IgG)

tx:

  • acute attacks: corticosteroids (do not prevent progressive)
  • progressive dz: B-interferon or glatiramer
48
Q

myasthenia gravis

A

autoantibodies to acetylcholine receptors

  • autoimmune dz
  • slow, progressive
  • women>men
  • may be associated with thymus d/o

s/sx:

  • fluctuating weakness of voluntary muscles
  • weakness worsens with repetitive activity
  • insidious onset: illness, pregnancy, menstruation
  • ptosis, diplopia, difficult chewing/swallowing
  • limb weakness

dx:

  • weakness on exam
  • serum acetylcholine receptor antibodies

Tx:
- acetylcholinsterase inhibitors: pyridostigmine, neostigmine

49
Q

epilepsy

A

recurrent, unprovoked seizures

50
Q

seizure - definition, causes, types

A

transient disturbance of cerebral function due to neuronal hyper excitability

causes:

  • genetic
  • strutural
  • metabolic
  • unknown

focal:

  • simple partial: w/out impaired consciousness
  • complex partial: with impaired consciousness

general:

  • tonic-clonic
  • absence (petit mal)
51
Q

focal seizure - types, s/sx, tx

A

simple partial: w/out impaired consciousness

complex partial: with impaired consciousness

s/sx:
- motor jerking or paresthesias along limb or part of body

tx: anti-convulsants
- lamotrigine, carbamazepine, oxcarbazepine
- phenytoin
- Levetiracetam (Keppra)

52
Q

absence (petit mal) seizure - s/sx, tx

A

type of generalized seizures

brief impairment of consciousness

  • pt often no aware
  • may include tonic/clonic movements
  • enuresis possible
  • EXCLUSIVELY in childhood (< 20 y/o)

Tx: anti-convulsants

  • valproic acid
  • ethosuximide
53
Q

tonic-clonic (grand mal) seizure - s/sx, tx

A

type of generalized seizures

  • sudden loss of consciousness with rigidity (tonic)
  • jerking, convulsive mov’t (clonic) - 2-3min
  • urinary/fecal incontinence, tongue biting, aspiration

followed by:

  • flaccid coma
  • postictal state of confusion

tx:

  • valproic acid
  • ethosuximide
54
Q

seizure evaluation/dx

A

EEG: mainstay of dx
- paroxysmal spikes, sharp waves

MRI of brain (CT if MRI contraindicated)

Labs: CBC, glucose, electrolytes, calcium, Mg, LFTs

LP: r/o infection

55
Q

seizure - tx

A

meds:

  • Valproic acid, phenytoin, carbamazepine, phenobarbital, topiramate, lamotigine
  • ETOH w/drawal: benzodiazepine

lifestyle:

  • avoid triggers
  • avoid dangerous situations (driving, operating machinery)
  • comply w/ state laws

Note: tx until >2 yrs sxs free

56
Q

seizure - medication considerations

A

many sz meds are teratogens:

  • avoid in pregnancy: valproic acid
  • cat D: carbamazepine, phenobarbital, topiramate

Many have side effects and interactions

Must monitor serum levels for most drugs
- except Keppra (levetiracetam)

Wait at least 2 yrs sz-free to d/c meds

57
Q

status epilepticus - definition, cause, tx

A

repeated seizure, without recovery, lasting > 30 minutes
- MEDICAL EMERGENCY

cause: poor medication adherence

tx:

  • ABC: maintain airway
  • dextrose IV (potential hypoglycemia)
  • benzos to break seizure
58
Q

syncope - definition, 3 types

A

transient loss of consciousness

  • due to global impairment of cerebral blood flow
  • often impairment of vasoconstriction

3 types:

  1. cardiogenic: arrhythmias, aortic stenosis
  2. orthostatic hypotension
    - autonomic neuropathy (DM) common cause
  3. neurally mediated/vasovagal: provoked by fear, pain
    - preceded by sweating, dizziness
59
Q

syncope - manage / tx

A

vasovagal:
-avoid triggers

All:

  • eval for head injury from fall
  • cardiac W/U
  • carotid imaging
  • tx cardiac abnormalities

Meds:
- midodrine: vasoconstrictor

60
Q

tourette syndrome

A

frequent motor and/or phonic tics lasting at least 1 year

  • sxs must begin b/f age 21
  • cause is not known (possibly chromosomal)
  • chronic course; may be relapsing/remitting
  • often associated with OCD
  • motor tics and phonic tics

tx: symptomatic
- CBT 1st line
- FDA-approved: antipsychotics (Haloperidol)

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