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Flashcards in Neurology Deck (280):
1

Migraine

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

2

Cluster h/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

3

Tension h/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

4

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....

Sumatriptan

5

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

Dx: Migraine

6

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

Migraines
DO NOT USE TRIPTANS with CAD or vasculitides

7

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?

NSAID with prochloroperazine

8

Acute migrain with nausea and vomiting fastest relief?

SQ Sumitriptan

9

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

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

10

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

parental dihydroergotamine

11

Pregnancy with migraine h/ once a week

tylenol or NSAID

12

Pregnancy with migraine h/a no response to NSAIDs

Metoclopramide or Chloroproazine or ondeansetron

13

Migraine ppx for h/a's how often?

2 times per week

14

PPX for migraine <15x/month

BB, amitriptyline, topiramate, sodium valproate

15

PPx for migrai >15/month

Topriamate-> botox

16

PPX migrains with asthma

amitriptyline, topiramate (no BB)

17

Prevention of menstrual h/a

mefenamic acid 2 days prior and upto end of menstruation

18

Migraine with Aura

OCP contraindicated!!

19

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

Analgesic induced h/a
d/c all analgesics

20

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

Tension h/a

21

35yo F c/o excruciating Ice pick like retroorbital h/a - h/o rhinorrhea, lacrimation ipsilateral horner's

Cluster h/a

22

Pt with recurrent h/a >5-6/day unilateral and retrooribtal

Chornic paroxysmal hemicrania
Tx: Indomethacin

23

32yo obese woman BMI>30 with daily h/a - horizontal diplopia - blurring of optic disc margins - spinal tap with inc'd pressure

Pseudotumor cerebri
Tx: Acetazolamide, lumboperitoneal shunt
Etio: obesity, Vit A toxicity, tetracycline, steroids, contraceptives, nitrofurantoin, isotretinoin, minocycline, danazol, tamoxifen, levothyroxine

24

Comoplications of pseduotumor cerebri

Peripheral visual field loss-> central visual field loss

25

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

surgery - brainstem compression

26

65yo h/a ESR 75

Temporal arteritis

27

H/a with rhinorrhea

Cluster h/a

28

100% O2

Cluster h/a

29

H/a with zigzag wavy lines photophobia and aura

Migraine

30

Sumatriptan

Migraine, Cluster h/a

31

Thunderslap h/a, CT head neg, CSF xanthochromia

Subarachnoid hemorrhage

32

Chronic h/a inc'd with lying down

brain tumor

33

Young obese pt with headache and horizontal nysstagmus

Pseudotumor cerebri

34

Acetazolamide

Pseudotumor cerebri

35

50yo F seizure or focal weakness, h/a worse on coughing/lying down CT 4cm large edema/mass effect NO CA+

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

36

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

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

37

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

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

38

Following tumors metastasize to brain

Breast, lung melanoma, lymphoma, renal
(NOT prostate)

39

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

Carbamazepine

40

Facial Palsy

Supranuclear (CVA) - Upper face spared

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

41

Motor Neuron Disease

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

42

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

Infranuclear lesion

43

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

Supra-nuclear lesion

44

65yo M with slurred speech and lower face paralysis

Suprnuclear lesion

45

55yo pw R sided facial paralysis of unknown etio

infranuclear lesion

46

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

Artificial tears, patch R eye at night, start PREDNISONE

47

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

Monocular psychogenic diplopia

48

CN III palsy

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

49

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

CT angio neck
dx: Carotid artery dissection

50

Pt with acute onset diplopia h/o DM, Ptosis

Acute cranial mononeuropathy

51

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

Thyroid opthalmopathy
Tx: steroids

52

R optic neuritis

MS with blindness in right eye

53

Tumor pressing on optic chiasma (acromegaly)

Bitemporal hemianopia

54

Left Optic tract

Right dense homonymous hemianopia

55

Left optic radiation (occipital lobe)

Right homonymous quadrantanopia

56

Stroke

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

57

Pt with TIA higher risk of stroke if...

Duration >10min
Speech disturbance
Age>60
DM

58

Most important risk factor for stroke?

HTN

59

Pt with TIA

Hopsital w/u - carotid dopper, EKG, CT brain, Coags, TEE r/o PFO

60

If carotid shows >70% wtd?

Carotid endarectomy + ASA

61

If TIA and carotid 90% inoperable wtd?

Stent

62

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

ASA + dipyrimadamole OR plavix

63

Pt h/o TIA no PAD - best management

ASA - can add ACE+- indapamide to decrease recurrence

64

Pt has TIA on ACEi, ASA and statin

d/c ASA and start Plavix
don't use both unless has CAD with stent also

65

Endartectomy vs stent

Endartectomy better mortality, less stroke,
Stent better with high carotid bifurcation

66

Pt with TIA found to have afib

start warfarin

67

Pt with CA going for CABG - what other w/u needed?

Carotid US
If significant stenosis - carotid endarectomy FIRST

68

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

ASA
Establish dx of vertebrobasilar ischemia with MRA posterior cranial vessels

69

Pt has occasional epistaxis esp when sneezing dx?

vWF dz

70

TPA criteria

Ischemic stroke with clearly defined sx onset
No IC bleed on HCT
<270 minutes sx onset to TPA

71

Exclusion crtieria for TPA

Rapidl improving sx
Stroke or head trauna/major 3 months
Major surgery w/in 14 days
Suspected SAH despite normal CT head
SBP>185/>110
on A/C
PT>15, plt400

72

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

TPA

73

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

TPA
ASA 24-48 hrs later

74

65yo M found in AM in bed with stroke

NO TPA since duration unknown

75

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

Labetoll iV when BP <185.110 then TPA

76

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

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

77

Pt with hemorrhagic stroke when should anti-HTN be started

BP>190/100

78

Pt with uncomplicated ischemic stroke not eligible for TPA when to start antiHTN

BP>220/120

79

Pt with ischemic stroke post tPA when to start anti-HTN

BP>170/100

80

ACA stroke

wk leg/foot WITH sensory loss
urinary incontinence
Primitive reflexes

81

MCA stroke

Parietal lboe (dominant)
acalculia, agraphia, Lt/Rt disorientation, finger agnosia, tactile agnosia, paresthesia
Temporal Lobe - aphasia
Pariet laobe Right (non-dominant)
-spatial neglect
Unable to dress

82

PCA stroke

U/L homonymous hemianopia
I/L 3rd N palsy - webers' syndrome
contralateral sensory abn

83

Lateral Medullary Syndrome (wallengberg)

I/L loss pain/temp from face
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

84

Medial Medullary syndrome

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

85

Basilar artery stroke

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

86

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

L MCA

87

Pt with L foot and leg wk, urinary incontinence

R ACA

88

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

L PCA

89

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

Basilar artery

90

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

Basilar artery

91

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

Left Lateral Meduallary syndrome

92

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

PFO

93

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?

Echo with bubble study

94

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?

Amyloid angiopathy

95

Hepatopul syndrome

see bubbles q4 beats

96

Broca's aphasia

non-fluent speech
CAN comprehend
Frontal lobe
MCA

97

Wernicke's aphasia

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

98

Conductive Aphasia

Can't repeat
CAN comprehend and read

99

Global Aphasia

Sensory and motor aphasia
Branch of middle cerebral or internal carotid artery

100

Pure word blindness

can't read - occipital lobe - PCA

101

Subarachnoid hemorrhage

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

102

Complications of SAH

Rebleed 24hrs - 1 month
Vsaospasm 4 to 10 days
Hydrocephalus - late

103

Best drug to tx vasospam

Nifedipine

104

Best time to do surgery

ASAP - clipping or coiling for causative aneursym

105

1 week after aneurysm surgery stroke develops - cuase?

vasospasm induced infarct

106

Vertigo - Central

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

107

Vertigo - peripheral

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

108

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

peripheral vertigo

109

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?

Vestibular neuritis (Labyrinthitis)
Tx: Meclizine

110

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?

Meniere's dz (tinnitus, hearing loss, vertigo)
Tx: Salt restriction, diuretics, surgical ablation

111

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

MRA posterior vessels r/o brainstem stroke

112

Dx of benign positiional vertigo?

Dix halpike maneurver

113

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

Accoustic Neuroma
Etio - Schwann cells
Dx test - MRI

114

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?

Benign positional vertigo - Dx with Dix halpike maneuver
Tx: Epley otiolith manuever -> Vestibular rehab

115

Pt with vertigo, dysarthria, diplopia, ataxia dx?

Vertebral bulabar insufficiency

116

Duration of vertigo

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

117

Hearing testing

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...

118

Vertigo with fluctuating hearing loss, tinnitis lasting hours to days

Meniere's dz

119

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

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

120

Vertigo lasting 30 s and wakes up pt no hearing loss

Benign positional vertigo

121

Vertigo with sudden onset dizziness, dysarthria, diploppia and weakness

Vertebrobasilar ischemia

122

Vertigo post URI, horizontal nystagmus dissappears on visual fixation

Vestibular neuritis - labryrinthitis)

123

MCC vertigo

Benign positional vertigo

124

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

Presbycusis

125

MCC dementia

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)

126

Treatment dementia

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

127

Effect of cholinesterase inhibitor

Improvement of neuropsychiatric score

128

Pt with alzheimers - family asks about memantine - advice?

SLOWS progression of dementia

129

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

Post op delirium

130

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?

d/c anti-cholinergics

131

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

Syncope

132

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

Advanced dementia

133

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

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

134

S/E Ginkgo

inc'd bleeding time

135

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?

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

136

Pt with dementia, parkinsonian sx of brady kinesia and postual instability, VISUAL HALLUCINATIONS, no resting tremor, extremem regigity, cytoplasmic inclusion bodies in subcortical tissue

Dementia with lewy bodies (lions in backyard...)

137

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

Huntington's dz

138

Memantine

Alzheimer's dz

139

Loss of interest, disinhibition, urinates in neighors lan, hyperseuxal

Fronto-temporal dementia

140

Contacminated corneal transplants and growth hormone

Creutzfeldt-jakob dz

141

EEG intermittent sharp waves with slow background

Creutzfeldt-jakob dz

142

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

Multi-infarct dementia
tx: optimize CVA prevention (smoking cess, statins, ASA etc)

143

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

Alzheimer's dz

144

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

Normal pressure hydrocephalus
tx: VP shunt

145

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

Creutzfeldt-jakob dz

146

Pt sees roaring lions/bears, stiffness, tremor

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

147

Multiple Sclerosis

Demyelination of white matter in brain and spinal cord
Demyelination - plaques in the white matter on MRIwGAD
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

148

Optic Neuritis

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

149

Other presentations of MS

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

150

Dx of MS

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: Cell 2 IgG olgoclonal bands suggestive of MS

151

Tx of MS

Acute Relapses -
InterNucOph, Optic Neuritis, fxn impairment -> IV methylprednisolone 1g qd x 3-5 days and taper
Active dz or to prevent relapse
IFN B1a-c
Fatigue - amantadine

152

What causes acute relapse in MS

Infections
before high dose steroids always r/o infection
Young women shoudl be on contraception to avoid teratogencity on IFN tx

153

MC presentation of MS

parathesias, tingling sensation, loss of vibration sense (dorsal column)

154

Blurry vision, diplopia

MS

155

Methylprednisolone x 5 days then taper

Acute MS relapse

156

Alpha interferon

NOT Tx for MS

157

B interferon

PPx for relapse

158

Amantadine

Tx for MS fatigue

159

Optic Neuritis

Better prognosis

160

Sensory sx

Better prognosis

161

Relapsing remitting

Better prognosis

162

Progressive relapsing MS

Worse prognosis - d/c B infn

163

Age>40 at dx of MS

worse prognosis

164

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

internuclear ophthalmoplegia
etio - Medial longitudinal fasciulus - MS

165

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

Optic neuritis

166

Pt with MS not responding to B interferon

start mitoxantrone

167

Parkinson's dz

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

168

When to treat Parkinson's

Only start when sx have negative impact on functioning status
1. Replete dopamin in brain -
Levodopa (peripheral effects not needed) so add carbidopa (prevents periopheral effect of levodopa)
2. Dopamine agonist (pt <70yo): pramipexole, ropinirole bromocriptine
3. Inhibitors of dopamin breakdown - selegiline, tolcapone - allows higher doses of L dopa to cross BBB
4. Anti-cholinergics - dec s/e levodopa (trihexyphenidyl, Benztropine)

169

Complications of Treatment

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

170

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

Levodopa and carbidopa

171

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

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

172

Pt with long standing parkinson's dz on L&Carbidopa now c/o wk and bradykinesia dx?

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

173

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?

start atypical antipsychotic - quetiapine or clozapine

174

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

d/c clozapine and never use again

175

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

start lorazepam

176

Parkinson's related dementia

Quetiapine or clazapine

177

Parkinson's related DELIRIUM

Lorazepam or Quetiapine

178

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

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

179

Essential or Familial/Kinetic Tremor

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

180

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

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

181

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

Polysomnography

182

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

Acute dystonic rxn

183

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

Diphenhydramine

184

Acute Dystonia

Torticollis - fixed flexion of neck
Blepharospams
Writers cramp

185

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

Tourette's syndrome
Tx: neuroleptics

186

Tremor best seen at rest

Parkinson's

187

Tremor aggrevated by anxiety

Essential/kinetic

188

Tremor dec'd by rest

Essential/Kinetic or Cerebellar

189

Tremor relieved by etoh

Essential/Kinetic

190

Tremor activated by action

Essentiail/kinetic, parkinson, cerebellar

191

Tremor in head/voice tremors

Essential/kinetic

192

Chin tremors

Essential/Kinetic or parkinsons

193

Familial tremors

essential/kinetic

194

Tremor on fexion-extension

Essential/kinetic

195

Tremor on pronation/supination

Parkinson's

196

Tremor at rest and on movment

Parkinsons

197

Neuromuscular dz

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

198

Dipolpia

+Ptosis+wkness -> MG
+INO-> MS
+dysarthria+ataxia+dizziness-> Verterobasil TIA
+cauda equina -> Leptomeningial metastaisis

199

Pt with diplopia, fatigue at end of day difficulty brushing hair, recently while eating regurg thru nose, diplpia, ptosis both eye way to do dx?

Ach rct Ab test

200

35yo prox muscle wk, ptosis, diplopia, EOMI intact, vision intact, replex intact

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

201

Pt dx with MG wtd next

CT chest r/o thymoma - if present resect

202

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

MG - reponsd to physostigmine
(not organophosphate - pupils would be constricted)

203

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

MG

204

What makes MG wkness worse?

aminoglycoside abx
Antiarrythmics
BB
Infxn
Electrolytes d/o

205

Pt with myasthenic crisis wtd?

ICU
Plasma exhange
Immunglob/steroids
Elective intub for VC<20ml/kg

206

Pt with MG on pyridostigmine now with acute exacerbation wtd?

immunoglobulin/steroids

207

Eaton Lambert syndrome

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

208

Pt with wk, inabilit to get up form chair, BETTER with excercise - h/o chronic smoking - DECREASED reflexes, repetive nerve stim with incremental INCREASE with continuing potentials dx?

Eaton Lambert 2/2 small cell lung CA

209

Better with repetition

Eaton labert

210

Worse with repetition

MG

211

Hyporeflexia

Eaton lambert

212

Normal relfex

MG

213

Abx infxn worse

MG

214

Small cell CA

Eaton labert

215

Thymoma

MG

216

Pre-synaptic Ab

Eaton lambert

217

Post-synaptic anti-acetychoie rct ab

MC

218

Ptosis/diplopia

MG

219

Muscle wkness

MG & eaton lambert

220

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?

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

221

Spinal cord

Myelopathy - Upper motor neuron
Radiculopathy - Lower motor neuron

222

Cervical spondylitis

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/yelogram
Tx: Steroids

223

Syringomyelia

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

224

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

Syringomyelia

225

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

Spinal stenosis

226

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

Transverse myelitis

227

Pt with stock and glove districtuion of tingling senssation, pt confused has ataxia, spasticity and clonus

Subacute combined degenration of spinal cord

228

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

Cervical Spondylitis

229

Radiculopathy

L 5 +foot drop, can't evert OR invert foot
Peroneal +foot drop can't evert but CAN invert foot

230

Reflexes

L5 - dec'd dorsiflexion, NO ankle jerk
S1 dec'd plantar flexion - dec'd ankle jerk

231

Elderly pt with c/o back pain inc'd wiht walking - expecially down hill and standing - numbness in legs - decreased while sitting - MRI would show?

Spinal stenosis
Ligamentum flagum

232

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

Sciatica with herniated disc

233

If anal sphincter tone lost or bldder fxn wtdd?

MRI - r/o cauda equina syndrome

234

Sensory loss on Lateral aspect of thigh what spinal segment?

L2

235

One of most common causes of mononeuritis multiplex

PAN

236

Polyneuropathy - Guillan barre

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

237

Botulism -

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

238

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

Ulnar neuropathy

239

Nocturnal awakening with pain and paraesthesias

Median nerve

240

Alcoholic with diplopia and weakness of the right hand

Radial neuropathy

241

Difficulty standing on toes, reflexes dec'd

Sciatica

242

Wrist drop -

Radial neuropathy

243

Foot drop

Peroneal nerve comopression

244

Antibody induced acute polyneuropathy - occurs in

Guillain-barre syndrome

245

Yound pt with ankle sprain - takes NSAIDs - extreemm tenderness when bed sheet touchs - exam bluish discoloration - dx?

Complex regional pain syndrome - reflex sympathetic dystrophy
If pt with patchy deminralization - bisphosphonates are effective - treatment even in absense of osteoporosis

246

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

Can go back and play (no LOC)

247

20yo playing football - concussive injury - no LOC - in daze on immediate exam - 20 min later alert and oriente but with some amnesia which resooles 15 min later

Monitor closely, if no sx for week then can play again

248

24yo had a concussioni playing ice hockey - lost conciousness x 30 sec - upon waking alert, oreient, figner to nose normal - vision fnorma - WTD (less than 1 min LOC with normal physical exam)

Send hoem with family observation withold from competition - if remains asx can back to play in 1 week

249

24yo had concussion playing contact sports, lost consiounes x 20 sec and waking up was in daze which cleared up on wya to ER (less than one min LOC, abn physical exam upon awakening

ER eval with CT/MRI - withdraw from competition - if asx can go back to play in 2 weeks

250

Concussion with LOC > 1 min with nromal phsyical

ER eval with CT/MRI - withold from competition - if still asyxmt back to play in 2 weeks

251

Seizures

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

252

Medications that cause seizures

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

253

Best Anti-sz med for elderly

Lamotrigene

254

Best anti-Sz med for with liver dz

Keppra (Levetrcetam)

255

Best anti Sz medication in pregnancy

Carbamapezine

256

What antiseizure medication causes kidney stones

Topiramate

257

After the first seizure - best dx imaging is...

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

258

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?

Syncopal convulsions

259

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

neurocardiogenic syncope

260

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

partial seizure/psychomotor epilepsy

261

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

Iv Mg SO4

262

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

Partial seizure

263

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?

Temporal lobe

264

Young woman with epigastric rising sensation - most likely dz?

simple partial seizure
temporal lobe (deja vu)

265

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?

Pseudoseizure
dec'd Ca+

266

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?

Sleep deprived EEG
dx: Complex partial

267

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

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

268

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

1. IV glucose + thiamine
2. Lorazepam
3. Loading dose Phenytoin or Fosphenytoin
4. Maximize Phenytoin
5. Phenobarb/Midazolam
6. General anaestheia/neruomuscular blockade

269

Pt with new monset seizure - post ictal state recommendation?

No driveing
No swimming

270

Pupils

Mid dilated - glaucoma
Mid constricted - uveitis (iridocylitis)
b/l dilated - anti-cholinergics, botulism, cocaine
unilateral dilated - CN III compression
b/l constriction - Opiates, pontine infarct, organophosphate poisoning

271

MRI/CT infarct

hypodense area - no enhancement

272

MRI/CT bleed

hyperdense area, no need for contrast CT

273

MRI/CT Multi-infarct dementia

Mulitple hypodense areas, no enhancement

274

MRI/CT Tumor

Enhancing lesion

275

MRI/CT Brain abscess

Ring enhancing lesion

276

MRI/CT Toxoplasmosis

Multople ring enhancing lesions

277

MRI/CT Cerebral atrophy

Dilated ventricles AND dilated sulci

278

MRI/CT Normal pressure hydrocephalus

Dilated ventricles, sulci NOT dilated**

279

MRI/CT Multiple Sclerosis

White matter plaques, enhance with active dz

280

MRI/CT Alzheimer's

Brain atrophy +- Periventricular white matter lesions