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Flashcards in Neuro and Psych Deck (49):
1

Dermatomes

Upper arm

umbilicus
perineum
perianal

Upper arm: C-5 through T1

umbilicus: T10
perineum: S2 
perianal: S5

•C4: clavicle  “C” is for “clavicle”

•C6: thumb & index    Left hand “OK” sign   makes a “6” with   thumb and index

•C7: middle finger

•C8: little finger

•T4: nipple line  “T” is for “thorax”

•T10: umbilicus  BellybutTEN

•L1: inguinal ligament  IL-L1

•L4: knee  “Down on all fours” –      Down on L4

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2

Cranial nerve three palsy

pupil sparing (2)

pupil involved (2)

pupil sparing (2): diabetes/hypertension, infarction

pupil involved (2): compression, aneurysm

nasal gaze on affected side

3

GCS

•Eye Opening (1-4)

–4:  Spontaneous

–3:  Verbal

–2:  To Pain

–1:  None

•Verbal (1-5)

–5: Full sentences / oriented

–4: Full sentences / confused

–3: Understandable words

–2: Garbled, moans

–1: No vocalization

•Motor Response (1-6)

–6: Follows commands

–5: Localizes pain

–4: Withdraws to pain

–3: Decorticate (Flexes)

–2: Decerebrate (Extends)

–1: Flaccid

4

Doll’s eyes (oculocephalic reflex)

–If brainstem is intact: Eyes move in opposite direction of head movement

–If brainstem is injured: Eyes stay fixed in orbits

5

Cold calorics (oculovestibular reflex)

–If brainstem and cortex are intact: Nystagmus with fast component directed to opposite ear.  “Cold Opposite, Warm Same” = COWS

–Cortex injured but brainstem intact: Eyes deviate toward cold ear

–Brainstem injured: No eye deviation

6

Corneal reflex

–Test CN V and CN VII (touching the cornea elicits bilateral blink)

–Decreased blink in opposite eye suggests brainstem or cortical injury

7

Right Internuclear Ophthalmoplegia

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8

Migraine

prevention (3)

treatment classes (3), contraindications

prevention (3): TCA, BB. CCBs

treatment classes (3)

Ergpts. Triptans, Dopamine antagonists

–Ergotamine, DHE: contraindicated in CAD, PVD, HTN, RF, pregnancy

–Sumatriptan: Contraindicated in heart disease,  HTN, ergotamine, migraine with focal findings

–Dopamine antagonists: Prochlorperazine, promethazine, metoclopramide

9

Cluster headaches
treatment (3)

toxic metabolic headache-what?

Oxygen, intranasal lidocaine 4%, migraine treatments

toxic metabolic headache

•Usually bilateral

•Vasodilation of pain-sensitive arteries

•Fever is the most common cause

•Others: CO, hypoxia, alcohol, tyramine foods

10

Idiopathic intracranial hypertension (pseudo-tumor)

etiology
treatment (4)

etiology: impaired CSF absorption
treatment (4): serial lumbar puncture, acetazolamide, weight loss, shunt

11

Subarachnoid hemorrhage
medical treatment (2)

Aggressive blood pressure control (nicardipine), Nimodipine

 

12

Hydrocephalus
ex vacuo -what

normal pressure classic triad
treatment

VP shunt, unable to depress valve, consider: 

ex vacuo: pseudo-hydrocephalus from cerebral atrophy

normal pressure classic triad: progressive dementia, ataxia, incontinence
treatment: shunt

consider: obstruction

13

CNS mass lesion
most common cause in AIDS and description

headache characteristics: peak intensity time of day, positional change, valsalva

Toxoplasmosis: ring enhancing lesion

headache characteristics: worst in the morning, worse lying down and with Valsalva

14

Meningitis

Brudzinski and Kernig signs

most common bacterial causes (2)

Kernig’s sign: Pain in hamstrings causes inability to straighten leg when hip is flexed to 90

Brudzinski’s sign: Flexion of the hips caused by passive flexion of the neck

both have low sensitivity but high specificity

causes: strep pneumoniae, Neisseria meningitiis

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15

Meningitis

treatment order (2)

CT before LP (5)

Steroids then (or same time as) antibiotics and seriously ill (or CSF WBC > 1000)

CT before LP

–Age at least 60

–Immunocompromised (HIV, immunosuppressive treatment and transplant pts.)

–A history of CNS disease (mass lesion, stroke or focal infection)

–Seizure within the last week

–Abnormal neuro exam / altered mental status

16

Aseptic Meningitis

causes categories (4)

Viral: Varicella, herpes (HSV), enterovirus, West Nile

Atypical bacterial: TB, Lyme disease (weeks after rash), Syphilis

Fungal: AIDS, transplant, chemo, chronic steroids

Noninfectious: Neurosarcoidosis, connective tissue disease, vasculitis, drugs (NSAIDs)

17

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18

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19

GBS

associated antecedents (3)

Hallmark finding

CSF finding
treatment meds(2)

Campylobacter gastroenteritis, Mycoplasma, flu vaccine
loss of DTRs
elevated protein
plasmapheresis, IV IG

20

multiple sclerosis

most common initial presentation

pathognomonic finding

Optic neuritis: Unilateral, Central vision loss, pain with eye movement and papillitis (papilledema of one eye)

 

Pathognomonic: Bilateral internuclear ophthalmoplegia
(eyes can't look at nose)

 

21

multiple sclerosis

diagnosis: rad, LP (2), nerve

Tx for exacerbation (3)

diagnosis: MRI, LP with increased protein and increased IgG oligoclonal bands

Tx: steroids, ACTH, interferon

22

Pure muscle weakness
causes review (9)

•Hypokalemic periodic paralysis

•Myasthenia gravis

•Lambert-Eaton syndrome

•Tick paralysis

•Botulism

•Certain toxins

•Amyotrophic lateral sclerosis (ALS)

•Polio

•West Nile Virus

23

Acute periodic paralysis

common trigger

associated conditions (2)

inheritance of hereditary form and tx

Exercise

associated conditions (2): hypokalemia, thyrotoxicosis

inheritance of hereditary form and tx: autosomal dominant, avoid high carbohydrate high salt diet

24

Myasthenia gravis

etiology
associated comorbid condition and frequency
weakness pattern and hallmarks (2)

Autoantibody to acetylcholine receptor
thy,moma, 25%
proximal greater than distal weakness, worsens with activity, ptosis, diplopia

25

Myasthenia gravis

diagnosis (2) and caveat with first medicine

exacerbation trigger (2)

 

 

dx, caveat: 

–Tensilon (edrophonium) test: Increases ACh, by blocking breakdown of ACh by cholinesterase = increases muscle strength / EMG = rapid fatigue; can cause AV block, cardiac arrest - give atropine first

–Blood: Anti-acetylcholine receptor antibodies

exacerbation trigger (2)

–Exacerbation vs. inadequate treatment (myasthenic crisis)

–Over-medication (cholinergic crisis)

 

26

Myasthenia gravis

treatment (4)

Physostigmine or neostigmine (ACH inhibitors), thymectomy, prednisone, plasmapheresis

27

Lambert-Eaton syndrome
what

associated comorbid finding

differences from more common condition (2)

what: similar to myasthenia gravis

associated comorbid finding: cancer, 50% (especially SC lung)

differences from more common condition (2): decreased DTR. Weakness improves with use

28

Botulism
3 forms
etiology
Hallmark

3 forms: infant, wound, foodborne
etiology: neurotoxin blocks ACh release
Hallmark: impaired motor and autonomic function

–Foodborne: inadequately processed canned foods

–Wound: contaminated wound or street drugs

–Infant: ingest spores from honey; most common in breastfed (also less severe in this subset)

29

Botulism

Clinical characteristic categories (3)

–Bulbar symptoms – diplopia (the most common early finding), ptosis, dysphagia, dysphonia, dysarthria

–Descending flaccid paralysis

–Anticholinergic symptoms (dry mouth, urinary retention, dilated pupils, ileus, decreased tears)

–Sensory exam and mental status are normal

30

Botulism
treatment - all forms
additional for wound variety (2)

treatment - all forms: antitoxin
additional for wound variety (2): penicillin, wound debridement

31

Tick paralysis

Hallmark

differentiator from similar condition
treatment

Hallmark: rapidly ascending paralysis

differentiator from similar condition: no paresthesia, more rapid progression
treatment: remove tech

32

Wernicke's encephalopathy

etiology
classic findings (5)

treatment (2)

Complication (sx -2)

Thiamine (B1) deficiency
•Encephalopathy (altered mental status), nystagmus, ophthalmoplegia (esp. lateral rectus), ataxia, short-term memory problems

treatment: thiamine, magnesium
Korsakoff's psychosis: amnesia, confabulation

33

West Nile virus
percent affected
severe form

tx

percent affected: 20% overall, rate and severity increases with age
severe form: flaccid paralysis with intact sensation

Dx: CSF IgM

tx: supportive

34

Seizure

Duration of Todd's paralysis

Initial ED W/U new adult seizure (5)

Peds non-febrile common causes (2)

Duration: up to 24 hours

Initial ED W/U: Glucose, lytes, CT, LP, toxicology screen

Peds non-febrile: hyponatremia, AGE

35

Partial Seizures

Simple vs complex

Drug doses (?)

•Simple: No LOC, mental status is preserved

•Complex: Temporal lobe, altered mental status, bizarre behavior; “psychomotor” seizures

–Lorazepam 0.05-0.1 mg/kg (longer acting;

    drug of choice)

–  Phenytoin 18 mg/kg

–  Phenobarbital 8-20 mg/kg

36

Status epilepticus

classic and newer definitions
classic board exam cause and treatment

Classic: continuous seizure greater than 30 minutes

Newer: Status epilepticus

≥5 minutes of continuous seizures, or

≥2 discrete seizures between which there is incomplete recovery of consciousness

Classic boards: INH overdose/B6 deficiency -> treat with thiamine

37

Lower and upper motor neuron signs

in particular: positive Babinski? Fasciculations? Increased tone? DTRs increased? 

Upper: positive Babinski, Increased tone DTRs increased 

Lower: Fasciculations

Upper: 

•Hyperreflexia

•Clonus

•Normal muscle mass

•Spasticity (increased tone and reflexes)

•Babinski's sign

Lower

•Weakness

•Atrophy

•Fasciculations

•Decreased DTRs

38

ALS, Lou Gehrig's disease

What?

Cauda equina

Upper vs LMN lesion?

Motor or sensory?

Anal tone?

Degeneration of upper and lower motor neurons etiology unknown

Upper vs LMN lesion? Lower

Motor or sensory? Both

Anal tone? Decreased

39

Back pain, IVDA

Back pain, motor > sensory findings

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Vertebral osteo/disitis

Back pain, motor > sensory findings: red flag for spinal cord compression

40

Diagnosis, typical location

etiologies (3)

findings

associated with

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Diagnosis, typical location: Syringomyelia of the cervical cord

etiologies: trauma, infection, idiopathic

findings: inter-osseous muscle wasting and loss of pain and temperature sensation in the hands

associated with: Chiari defects of the cerebellum

41

Hemorrhagic stroke

most common location
goal blood pressure, agents (3)

most common location: basal ganglia, thalamus
goal blood pressure, agents: 160/90, labetalol, nicardipine, nitroprusside

42

Stroke syndrome patterns (CNs, other motor, other sx)

Cerebral

Brainstem

Pontine (4)

Cerebral: cranial nerves, motor and sensory

Brainstem: ipsilateral cranial nerve and facial weakness; contralateral sensory and motor

Pontine: coma, miosis, gaze paresis, altered respiratory pattern

43

Stroke syndromes

MCA (3)

PCA

vertebrobasilar (4)

 

MCA: contralateral motor/sensory of face and arm, aphasia (dominant hemisphere)/hemi neglect (non dominant), contra homonymous hemianopia

PCA: contra homonymous hemianopia, visual agnosia

vertebrobasilar: 

balance, vertigo, nystagmus etc.
dysarthria, dysphagia
quadriplegia
coma

44

Wallenberg’s syndrome: what, sx (3)

Locked-in” syndrome: what, sx (3)

Wallenberg’s syndrome: vertebral artery thrombosis, ataxia/n/v, decreased pain/temperature ipsilateral face, contralateral body, ipsilateral Horner

Locked-in syndrome: basilar artery occlusion at the pons (also seen in other conditions damaging the pons), patient awake and understanding, only motor activity is diaphragmatic breathing and vertical eye movements

45

Lacunar syndromes

diagnostic caveat

Types (5)

diagnostic caveat: often missed by CT (small micro infarct in the midbrain,HTN/DM), 25%  of all ischemic strokes

Types (5)

your motor
pure sensory
ataxia-hemiparesis
dysarthria-heiparesis

mixed sesorimetor 

46

Neurology trivia

blood pressure cut off for tPA

gaze preference during seizure versus intracerebral stroke

Ophthalmoplegic migraine

headaches worse on awakening

185/110

seizure away from focus, stroke-towards affected side
migraine with cranial nerve palsy's of 3,4,6, diplopia

worse on awakening: hypoxia, mass, cluster, pseudo-tumor

47

Neurology trivia 2

myopathy weakness pattern
unexplained syncope consider
neurologic medication contraindicated in second and 3rd° AV block

Proximal greater than distal muscle weakness
vertebrobasilar ischemia
phenytoin

48

Neuroleptic malignant syndrome

etiology and timing
symptoms (3)
treatment (2)

etiology and timing: neuroleptics causing decreased dopamine, usually within two weeks of starting medication
symptoms (3): fever, AMS, unstable vital signs, elevated CPK/leadpipe rigidity
treatment (2): bromocriptine and dantrolene

49

Serotonin syndrome
etiology and cause categories (4)
symptom categories (3)
treatment (2)

etiology: Access central and peripheral serotonin - antidepressants, opioids, CNS stimulants, triptands
symptom categories (3)

cognitive: AMS, agitation, hypomania, hallucinations, coma
autonomic: shiverring, diaphoresis, HTN, tachy, nausea, diarrhea
somatic: myoclonus, tremor, hyperreflexia
treatment (2): benzodiazepines, chlorpromazine, Cyproheptadine