Flashcards in Neurology Deck (280):
Q few weeks
1/2 hr onset
Lasts hours to days
Frontal/temporal one or both sides
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
lasts 1/2 hr-2hrs
Rhinorrhea, ipsilateral Horner's, Unilateral lacrimation
Tx: 100 OXYGEN, intranasal lidocaine, sumatriptan
Prevention: Verapamil, valproate, gabapentin
How often? Variable
how long 1/2hr to 7 days
Prevention: BB, TCA
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....
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
Young woman co wk in R arm and leg - PMHx migraines - feels better after couple hours - carotid US, MRI brain and TEE normal dx?
DO NOT USE TRIPTANS with CAD or vasculitides
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
Acute migrain with nausea and vomiting fastest relief?
Severe acute migraine not responding to sumatriptan or lasting >72hrs
IV dopamin antagonist (prochlorperazine.metoclopramide) + IV diphenyhydramine (prevent acute dystonic rxn)
Severe acute migrain x more than 72hrs - last sumatriptan >24hrs ago with little response - >
Pregnancy with migraine h/ once a week
tylenol or NSAID
Pregnancy with migraine h/a no response to NSAIDs
Metoclopramide or Chloroproazine or ondeansetron
Migraine ppx for h/a's how often?
2 times per week
PPX for migraine <15x/month
BB, amitriptyline, topiramate, sodium valproate
PPx for migrai >15/month
PPX migrains with asthma
amitriptyline, topiramate (no BB)
Prevention of menstrual h/a
mefenamic acid 2 days prior and upto end of menstruation
Migraine with Aura
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
42yo F chronic non-throbbing h/a worse at end of day - band like around neck
35yo F c/o excruciating Ice pick like retroorbital h/a - h/o rhinorrhea, lacrimation ipsilateral horner's
Pt with recurrent h/a >5-6/day unilateral and retrooribtal
Chornic paroxysmal hemicrania
32yo obese woman BMI>30 with daily h/a - horizontal diplopia - blurring of optic disc margins - spinal tap with inc'd pressure
Tx: Acetazolamide, lumboperitoneal shunt
Etio: obesity, Vit A toxicity, tetracycline, steroids, contraceptives, nitrofurantoin, isotretinoin, minocycline, danazol, tamoxifen, levothyroxine
Comoplications of pseduotumor cerebri
Peripheral visual field loss-> central visual field loss
Pt with known HTN with h/a and ataxia - CT scan large cerebellar bleed wtd?
surgery - brainstem compression
65yo h/a ESR 75
H/a with rhinorrhea
H/a with zigzag wavy lines photophobia and aura
Migraine, Cluster h/a
Thunderslap h/a, CT head neg, CSF xanthochromia
Chronic h/a inc'd with lying down
Young obese pt with headache and horizontal nysstagmus
50yo F seizure or focal weakness, h/a worse on coughing/lying down CT 4cm large edema/mass effect NO CA+
most common and aggressive primary brain tumor
Surgery primary therapy with chemo/radiation
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
50yo F h/o seizure d/o for 4 years - CTH 3cm tumor in sylvian fissure - diffuse enhancement with contrast
Arise from meninges
Seizures or weakness
Following tumors metastasize to brain
Breast, lung melanoma, lymphoma, renal
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
Supranuclear (CVA) - Upper face spared
Infranuclear - both UPPER AND LOWER face
Ramsay Hunt syndrome
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
30yo with erythema chronicum migrans 4 weeks ago now with left sided upper and lower face paralysis preceded by ha
55yo vesicular lesions on R side face with pain involving ear
65yo M with slurred speech and lower face paralysis
55yo pw R sided facial paralysis of unknown etio
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
Young woman co diplpia - closing one eye - diplpia persists dx?
Monocular psychogenic diplopia
CN III palsy
can't look up, down or inward
Where is lesion?
posterior commuicating artery
Dx: MRA brain
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
Pt with acute onset diplopia h/o DM, Ptosis
Acute cranial mononeuropathy
Pt with hyperthyroid and exopthalmos - unable to completely abduct and has double vision - cause?
R optic neuritis
MS with blindness in right eye
Tumor pressing on optic chiasma (acromegaly)
Left Optic tract
Right dense homonymous hemianopia
Left optic radiation (occipital lobe)
Right homonymous quadrantanopia
Throbotic - 50% preceeded by TIA
Embolic - more rapid onset
Hemorrhagic - HTN, amyloi angiopathy
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
Pt with TIA higher risk of stroke if...
Most important risk factor for stroke?
Pt with TIA
Hopsital w/u - carotid dopper, EKG, CT brain, Coags, TEE r/o PFO
If carotid shows >70% wtd?
Carotid endarectomy + ASA
If TIA and carotid 90% inoperable wtd?
Pt with TIA and cardid US with <50% wtd?
ASA + dipyrimadamole OR plavix
Pt h/o TIA no PAD - best management
ASA - can add ACE+- indapamide to decrease recurrence
Pt has TIA on ACEi, ASA and statin
d/c ASA and start Plavix
don't use both unless has CAD with stent also
Endartectomy vs stent
Endartectomy better mortality, less stroke,
Stent better with high carotid bifurcation
Pt with TIA found to have afib
Pt with CA going for CABG - what other w/u needed?
If significant stenosis - carotid endarectomy FIRST
Pt with diplopia, dyarthria, dizziness - dx with verebrobasilar ischemia wtd?
Establish dx of vertebrobasilar ischemia with MRA posterior cranial vessels
Pt has occasional epistaxis esp when sneezing dx?
Ischemic stroke with clearly defined sx onset
No IC bleed on HCT
<270 minutes sx onset to TPA
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
65yo M woke up in AM and THEN had stroke CT neg for bleed - presents within 3 to 4.5 hrs
70yo M h/o afib pw sudden onset wk one side CT neg wtd?
ASA 24-48 hrs later
65yo M found in AM in bed with stroke
NO TPA since duration unknown
Pt with ischemic stroke, time onset 60 min CT no bleed, BP 200/120 wtd?
Labetoll iV when BP <185.110 then TPA
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
Pt with hemorrhagic stroke when should anti-HTN be started
Pt with uncomplicated ischemic stroke not eligible for TPA when to start antiHTN
Pt with ischemic stroke post tPA when to start anti-HTN
wk leg/foot WITH sensory loss
Parietal lboe (dominant)
acalculia, agraphia, Lt/Rt disorientation, finger agnosia, tactile agnosia, paresthesia
Temporal Lobe - aphasia
Pariet laobe Right (non-dominant)
Unable to dress
U/L homonymous hemianopia
I/L 3rd N palsy - webers' syndrome
contralateral sensory abn
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
Medial Medullary syndrome
Contralateral hemoparesis adn parastesia
affected eye looks down and toward nose
I/L tongue palsy
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
Pt with right sided hemiplegia and sensory defeits - r hemianopsia and aphasia
Pt with L foot and leg wk, urinary incontinence
Pt with R side sensory abn, ptosis L eye, pupillary dilation
Pt with diplopia, dysartria one sided wk with priorbital numbness and shakign/shivery moveemnts of affected limbs
Pt with quadriplegia, cnat speak can't put tongue out, eye movements ok
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
32yo F no Pmhx p/w stroke - exam pain and tenderness over calk - etio?
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
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?
see bubbles q4 beats
fluent speech but non-sensical
CAN comprehend and read
Sensory and motor aphasia
Branch of middle cerebral or internal carotid artery
Pure word blindness
can't read - occipital lobe - PCA
Thunderclap headache, hit by hammer headache, worst h/a of life
nausea, vomiting, alter conciousness, neck stiffness, seizure, CNIII palsy wtd?
If neg -> LP check for xanthochormia
LP neg? - MRA r/o reversible cerebral vasocontriction syndrome (tx'd with CCB)
Best test to confirm prior to surgery: Cerebral angiogram
Complications of SAH
Rebleed 24hrs - 1 month
Vsaospasm 4 to 10 days
Hydrocephalus - late
Best drug to tx vasospam
Best time to do surgery
ASAP - clipping or coiling for causative aneursym
1 week after aneurysm surgery stroke develops - cuase?
vasospasm induced infarct
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
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
Pt with vertigo and horizontal nystagmus - on visual fixation nystagmus dissappears - dx?
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)
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
70yo M with new onset dizziness x 2 hours, BP high wtd?
MRA posterior vessels r/o brainstem stroke
Dx of benign positiional vertigo?
Dix halpike maneurver
Pt with vertigo, unilateral tinnitus, progressive hearing loss dx?
Etio - Schwann cells
Dx test - MRI
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
Pt with vertigo, dysarthria, diplopia, ataxia dx?
Vertebral bulabar insufficiency
Duration of vertigo
Seconds: BPPV, TIA
Minutes: Migraine, orthostatic hyptension, TIA
Hours: Migraine, Meniere's
Days: Migraine, Labryrinthitis, Meneire's
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...
Vertigo with fluctuating hearing loss, tinnitis lasting hours to days
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
Vertigo lasting 30 s and wakes up pt no hearing loss
Benign positional vertigo
Vertigo with sudden onset dizziness, dysarthria, diploppia and weakness
Vertigo post URI, horizontal nystagmus dissappears on visual fixation
Vestibular neuritis - labryrinthitis)
Benign positional vertigo
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
60yo cognitive impairment, poor short term membory, can't name names
CT/MRI - brain atrophy - dilated ventricles
inc'd B amyloid precursuor protein - inc'd presenilin activity, APo protein E4
Neurofibrillary tangles - protein Tau (microtubule)
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
Effect of cholinesterase inhibitor
Improvement of neuropsychiatric score
Pt with alzheimers - family asks about memantine - advice?
SLOWS progression of dementia
Pt with alzheimer's on donepezil - has hip surgery - post surgery agitated and confused - dx?
Post op delirium
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?
Donepezil, galantamine and rivastigmine are choinesteras inhibitos used to treat dementia - aw?
Who is more likely to experience sever disability in performance of daily living - cancer or dementia pt
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
inc'd bleeding time
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?
tx: not very effective
Acetylcholinesterase inhibitor, NMDA rct antagonist
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...)
35yo pt with dementia father with dementia at age 40 dx?
Loss of interest, disinhibition, urinates in neighors lan, hyperseuxal
Contacminated corneal transplants and growth hormone
EEG intermittent sharp waves with slow background
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
tx: optimize CVA prevention (smoking cess, statins, ASA etc)
65yo M onset of memory loss noticed by family, difficulty naming names, no motor sx - paranoid delusions
80yo F pw dementia, urinary incotinence wid based gait, CT scan enlarged ventricles and sulci NOT enlarged
Normal pressure hydrocephalus
tx: VP shunt
55yo M onset of dementia with RAPID deterioration, myoclonic jerks, NO incontinence
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
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
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
Other presentations of MS
Cognitive dysfxn (thinning of corpus callosum
Spasticity - carbamazepime helps
Fatigue - tx with Amantadine
Dx of MS
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
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
Fatigue - amantadine
What causes acute relapse in MS
before high dose steroids always r/o infection
Young women shoudl be on contraception to avoid teratogencity on IFN tx
MC presentation of MS
parathesias, tingling sensation, loss of vibration sense (dorsal column)
Blurry vision, diplopia
Methylprednisolone x 5 days then taper
Acute MS relapse
NOT Tx for MS
PPx for relapse
Tx for MS fatigue
Progressive relapsing MS
Worse prognosis - d/c B infn
Age>40 at dx of MS
32yo with intermittent diplopia - numbness/paraesthesia - attempted adduction affected eye -> horizontal nystagmus - Visual acuity - 20/20
etio - Medial longitudinal fasciulus - MS
Young woman develops "thick tongue" blurry vision after hot showser - after exc or after hot weather - dx?
Pt with MS not responding to B interferon
Movement d/o 2/2 decrease DOPAMINE from SUBSTANTIA NIGRA
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
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)
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
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
Pt started on levodopa-carbidopa c/o nausea wtd?
Take with low protein meal or carbidopa 30 min prior to levodopa
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)
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
Pt with refractory schizophrenia started on clazapine - 3 weks later develops agranulocytosis WBC 500 wtd?
d/c clozapine and never use again
Pt with Parkinson's dz hospitalized with PNA confused, agitated at night -
Parkinson's related dementia
Quetiapine or clazapine
Parkinson's related DELIRIUM
Lorazepam or Quetiapine
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)
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
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
periodic limb movementd/o with jerky movements during sleep dx by?
Pt while writing, hand goes into spasm - phalen/tinel's neg, serum Ca 9mg
Acute dystonic rxn
Pt get phenothiazine for n/v - coupel hours later - pt eyes are tuck in particular gaze (left or right) wtd?
Torticollis - fixed flexion of neck
18yo M with twitching of face, grimacing and movements of neck
Tremor best seen at rest
Tremor aggrevated by anxiety
Tremor dec'd by rest
Essential/Kinetic or Cerebellar
Tremor relieved by etoh
Tremor activated by action
Essentiail/kinetic, parkinson, cerebellar
Tremor in head/voice tremors
Essential/Kinetic or parkinsons
Tremor on fexion-extension
Tremor on pronation/supination
Tremor at rest and on movment
Ab to POST-synaptic Ach rct's
Low level of Ach rct
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
+Ptosis+wkness -> MG
+dysarthria+ataxia+dizziness-> Verterobasil TIA
+cauda equina -> Leptomeningial metastaisis
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
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
Pt dx with MG wtd next
CT chest r/o thymoma - if present resect
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)
30yo smoker with diplopia - tired at end of day - difficulty swallowing, chewing, nasal regurg - develops progressive wk and goes into resp facilure - dx?
What makes MG wkness worse?
Pt with myasthenic crisis wtd?
Elective intub for VC<20ml/kg
Pt with MG on pyridostigmine now with acute exacerbation wtd?
Eaton Lambert syndrome
Autoimmune/Oat cell CA
Antibody to PRE-synaptic rct's
Weakness BETTER with repetitive action
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
Better with repetition
Worse with repetition
Abx infxn worse
Small cell CA
Post-synaptic anti-acetychoie rct ab
MG & eaton lambert
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?
dx - EMG
tx: Anti=glutamic acid - Riluzole
Myelopathy - Upper motor neuron
Radiculopathy - Lower motor neuron
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
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
Tx: Monitor if progresses - > surgery
Pt with wk of hand now progresses to shoulder - pain/temp sensation lost but touch and vibration preserved - MRI cavitary lesion of spinal cord
Pt with deep ache in buttocks and thighs when standing, disappears on sitting
Pt with pain in thoracic area - flu one week ago or SLE - Now with wk of legs and bladder disturbances - getting worse - hyperreflexia (UMN)
Pt with stock and glove districtuion of tingling senssation, pt confused has ataxia, spasticity and clonus
Subacute combined degenration of spinal cord
Pt with loss of vibration in lateral three fingers, hyper reflexia of deltoid, bicepts and triceps
L 5 +foot drop, can't evert OR invert foot
Peroneal +foot drop can't evert but CAN invert foot
L5 - dec'd dorsiflexion, NO ankle jerk
S1 dec'd plantar flexion - dec'd ankle jerk
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?
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
If anal sphincter tone lost or bldder fxn wtdd?
MRI - r/o cauda equina syndrome
Sensory loss on Lateral aspect of thigh what spinal segment?
One of most common causes of mononeuritis multiplex
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
blurred vision, diplopia, dysarthri, dysphagia
diarrhea/vom in young pt with dilated pupils
Labs; toxin in serum or stool
Tx: botulism anti-toxin
Cyclist with paresthesia in little finger adn inability to adduct little finger and index finger - hypothenar wasting
Nocturnal awakening with pain and paraesthesias
Alcoholic with diplopia and weakness of the right hand
Difficulty standing on toes, reflexes dec'd
Wrist drop -
Peroneal nerve comopression
Antibody induced acute polyneuropathy - occurs in
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
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)
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
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
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
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
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
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)
Medications that cause seizures
Imipenum, tramadol, bupropion, haldol, meperiridine, PRBC
Partial: Carbamazepine, phenytoin, valproate, levetiracetam, lamotrigine, gabapentin
Best Anti-sz med for elderly
Best anti-Sz med for with liver dz
Best anti Sz medication in pregnancy
What antiseizure medication causes kidney stones
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
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?
Pt in dental chair passes out andhas jerky movement o arms and legs, completely recovers in 30 sec - diaphoretic - similar episode once before
22yo h/a, smells of burnign rubber, feels strange, no convulsions seen dx?
partial seizure/psychomotor epilepsy
Pt has generalized seuzures not better with dilantin - serum Ca low, ca cl injections don't help wtd?
Iv Mg SO4
22yo with weird sensation in stomach followed by sudden freezing, swallowing chewing, lip smacking - minute later she starts talking and doesn't recall eepsode
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?
Young woman with epigastric rising sensation - most likely dz?
simple partial seizure
temporal lobe (deja vu)
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?
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
Pt with onset of seziure of left arm and then spreads to left leg - after episode wk of left arm and leg dx?
starts at arm and marches toward leg in terms of sx (begin with fingers - end with legs) - NO LOC
Treatment of status epilepticus (sz >30min or LOC between 2 mor more seizures
1. IV glucose + thiamine
3. Loading dose Phenytoin or Fosphenytoin
4. Maximize Phenytoin
6. General anaestheia/neruomuscular blockade
Pt with new monset seizure - post ictal state recommendation?
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
hypodense area - no enhancement
hyperdense area, no need for contrast CT
MRI/CT Multi-infarct dementia
Mulitple hypodense areas, no enhancement
MRI/CT Brain abscess
Ring enhancing lesion
Multople ring enhancing lesions
MRI/CT Cerebral atrophy
Dilated ventricles AND dilated sulci
MRI/CT Normal pressure hydrocephalus
Dilated ventricles, sulci NOT dilated**
MRI/CT Multiple Sclerosis
White matter plaques, enhance with active dz