Neurology Flashcards
(197 cards)
0
Q
Difficulty ambulating, leaving the feet stuck to the floor despite intact motor and sensory function characterizes ______ lesion.
An example of a common neurological condition that can result in this presentation is ….
A
Apraxia; frontal lobe
Hydrocephalus
1
Q
Decreased arm swinging when walking suggests…
A
Extra pyramidal symptoms
2
Q
A positive Romberg sign is not necessarily a sign of cerebellar dysfunction but it is a sign of _______
A
Deficit of joint position sense
3
Q
What are normal CSF values?
A
Glucose - 60
Protein - 40 to 50
WBCs - 5 or less per cubic mm (lymphocytes)
Opening pressure - 60-150 mmH2O, 10-20cmH2O
4
Q
What is one of the major hallmarks of an intrathecal hemorrhage or subarachnoid hemorrhage on LP?
A
The CSF is xanthochromic when spun down meaning the supernatant has a yellow tinge.
For a traumatic tap, the supernatant remains clear because the RBCs have not lysed.
5
Q
Oligoclonal bands in CSF suggest…
A
An immune mediated process like: MS, ADEM (Acute Disseminated encephalomyelitis), SLE
6
Q
What form of imaging should be performed before an LP?
What scenarios are the exceptions
A
CT scan should be performed before an LP.
Exceptions: Bacterial meningitis (MRI preferred) and inability to perform CT scan
7
Q
The best way to treat a low pressure headache from LP is…
A
Have patient lie flat.
Increase intake of fluids (including caffeine)
Rarely, epidural blood patch is needed
8
Q
What should be my approach to a patient with altered mental status?
A
ABCs
Look for obvious etiology: Brief history, exam, meningeal signs
Reversible causes: Naloxone, Thiamine, Dextrose. Thiamine is given before dextrose to mitigate risk of Wernicke’s encephalopathy manifestation with administering dextrose alone.
Neuro exam - if focal signs present, do urgent neuro imaging.
9
Q
What brainstem physical exam tests should be performed in a comatose patient?
A
Cranial nerve reflexes
- Pupillary
- Oculocephalic - doll’s eyes
- Caloric testing
- Corneal
- Gag
10
Q
What is the appropriate work-up for a patient with non-focal neurologic findings who is in a coma?
A
DDx: Toxic, metabolic, hypoxic-ischemic, infectious
Work-Up: CBC, electrolytes, glucose, LFTs, Tox screen
Infectious work-up: CXR, UCx, BCx, and/or LP
11
Q
If pinholing improves visual acuity, the problem is a _______ issue.
A
Refractive.
12
Q
Relative afferent pupillary defect is characterized by a pupil that
A
Constricts when light is shone in the other eye but not when light is shone directly in it.
13
Q
A 40 year old man has unilateral hearing loss over the course of 4 months and has also noticed high-pitched ringing in his ears. There is a contrast enhancing mass in the CEREBELLOPONTINE ANGLE.
A
Acoustic schwannoma
14
Q
Parkinson’s like symptoms + autonomic insufficiency (orthostatics) should make me think….
A
Multi-system atrophy (Shy-Drager syndrome)
15
Q
Expansion of the ventricles of the brain as a result of brain atrophy is …
A
Hydrocephalus ex vacuo
16
Q
A patient with a gait abnormality, urinary Incontience, and/or dementia is concerning for…
Work-up:
Treatment:
A
NPH normal pressure hydrocephalus
Work-up: CT/MRI (rule out mass lesions), then LP (therapeutic)
Treatment: (Long-term) V-P shunt
17
Q
A parasaggital meningioma can present with progressive difficulty walking, exclusively lower limb upper motor neuron symptoms.
A
Repeat
18
Q
A young man gets an MRI scan and sees enlarged ventricles and a normal sized fourth ventricle. His symptoms are concerning for:
Work-up:
Treatment:
A
Aqueductal stenosis
Work-up: MRI
Treatment: 3rd Ventriculostomy or V-P shunt
19
Q
Most pediatric tumors (under age 20) are infratentorial (at and below the cerebellum). Most adult tumors are supratentorial.
A
Repeat
20
Q
In _______ disorder, the patient’s symptoms reflect the trauma to which he/she was exposed.
A
Conversion disorder
21
Q
Argyll-Robertson pupil is a pupil that __________ but does not _____. It is highly specific for ________ (disease).
A
Neurosyphilis. Pupil accommodates but does not react.
22
Q
Transient global amnesia – there is full recovery. It can be provoked by IV contrast or hyper viscous states. Can recur but it does so infrequently.
A
Repeat.
23
Q
There are paraneoplastic syndromes directed at the limbic system. They are ______ onset. They are associated with _____ and _____ malignancies.
A
Anti-Ma (testicular cancer)
Ovarian teratomas
Rapid onset
24
Cardiac surgery is a big risk factor for ________
Hypoxic-ischemic encephalopathy
25
A personality change over 3 months in a pt even around 50 yrs of age is concerning for ....
Creutzfeld-Jakob disease
Imaging: Posterior hemispheres on DWI
Protein: 14-3-3 in CSF
26
Paranoia, hoarding behavior, and visuospatial deficits are concerning for...
Treatment:
Early Alzheimer's Disease.
Treatment: (Older impaired age group) Quetiapine. Other options: Galantamine (Razadyne), Donepezil (Aricept), Rivastigmine (Exelon)
27
A GCS (Glasgow coma scale) score of ___ is the definition for brain death.
GCS - 3
28
Cranial nerves 5,6,7,8 originate in the _____ part of the brainstem
Pons
29
Neuroimaging - CT vs MRI
CT - bone/calcification is white, acute hemorrhage is white, chronic bleed is grey.
Indications for CT: TRAUMA, Hemorrhage, Hydrocephalus, Neoplasm
MRI
T1 - white matter is white, grey matter is grey, fat is white, CSF is black, blood is white
T2 - CSF is white, fluid is white.
Gadolinium is a contrast agent. Enhancement with Gad indicates break down of blood-brain barrier. In setting of ESRD, Gad is contraindicated due to increased risk of nephrogenic systemic sclerosis.
30
MRI image distinction:
Is resolution good? If it is, the options are T1,T2, and FLAIR.
If resolution is not good. ADC or DWI sequence
If resolution is good and CSF is bright, it is a T2. Pay attn to bright images in posterior fossa - concerning for MS.
If resolution is good, CSF is dark and whit matter is white and grey matter is grey, it is a T1.
31
Lateral medullary syndrome
Clinical manifestations: ______
Vessels affected: ________
Treatment: ________
Clinical manifestations: ipsilateral CN5 (facial pain/temp) and contralateral body pain/temp loss)
Vessels: PICA, Vertebral artery
Treatment: Temporarily with heparin
32
To address delirium (DELIRIUM), provide patients with...
Access to hearing aids, glasses, canes.
| Remove unnecessary restraints and urinary catheters
33
The drug of choice for delirium in the ICU is...
Antipsychotic (Haloperidol)
34
What 2 drugs can make delirium worse in the elderly?
Benadryl and Benzos
35
Nystagmus, opthlamoplegia, unsteady gait and mental status changes are concerning for...
Wernicke's encephalopathy.
Pathophysiology: B1 deficiency
Treatment: Thiamine
36
Cognitive impairment accompanied by fluctuating lethargy and Inattention, hallucinations, and asterixis most likely results from....
Toxic encephalopathy
37
Unlike migraines, patients with ___________ headache can carry out activities of daily living in normal, expedient way. This headache does not worsen with movement or activity.
Tension headache
38
If concerned about a thunderclap headache (reaches max intensity in 60 seconds), evaluate with
CT of the head, then LP.
39
Consider prophylactic treatment in patients with migraine who experience at least ____ episodes/wk.
2 episodes. Treatment: propanolol, metoprolol, valproic acid, topiramate, amitryptyline, timolol)
40
What anti-epileptic drug can reduce the effectiveness of OCPs (oral contraceptives)?
Phenytoin (Dilantin) because it is a potent enzyme-inducer
41
What chemotherapeutic agent can result in an irreversible ataxia?
Cytosine arabinoside. 5-FU can also cause it.
42
Hypertension, confusion, seizures, and visual changes esp in the transplant or cancer patient population is concerning for...
What would be the DDx for the above presentation in a pregnant patient?
PRES - adverse effect associated with several chemo therapeutic agents and tacrolimus and cyclosporine.
Pregnant patient DDx for HTN, confusion, seizures, visual changes: PRES, eclampsia, and cerebral venous thrombosis (thro,bi in the dural venous sinuses)
43
A schizophrenic pt is treated with a common anti-psychotic medication and complains of bouncy legs/the need to move legs/fidgeting movements (akathisia). What drug is likely?
Were the above pt treated with a different anti-psychotic in an emergent setting and developed posturing of limbs and forced upward deviation of the eyes, what would this reaction be called? ______ what therapy would be most appropriate to revert it?
Haloperidol
Reaction: Dystonia. Reversal: IV Benadryl (diphenhydramine)
44
A brain tumor patient presents with agitation, sleep disturbance, and paranoia after initiation of 2 drugs -- one for swelling and one for seizures. What is going on?
What intervention is appropriate?
Pt has developed steroid psychosis. adverse reaction that occurs at any dose.
Treatment: If needed, neuroleptic drugs
45
Stevens-Johnson syndrome is a potential adverse effect of what common class of drugs?
Anti-epileptic drugs
46
Which anti-epileptic drug is most closely associated with teratogenicity (especially neural tube defects). It can also cause Parkinsonian-like symptoms in adults and may be associated with weight gain and hair loss.
Depakote (Valproate).
47
A young girl is brought to the ED for ataxia and diplopia. She suffers from seizures managed with carbamazepine (Tegretol). She recently developed a sore throat and is being treated with a common antibiotic ________.
What has it done to her carbamazepine level?
What other AEDs would be affected in a similar way?
Erythromycin.
It has increased her carbamazepine level. Other AEDs that are similar increased in the presence of erythromycin: phenytoin, oxcarbazepine.
Symptoms: Ataxia, diplopia, nystagmus.
48
```
A 50 yr old man with high cholesterol, depression, and angina is having difficulty getting off chairs and climbing stairs. What common drug class cause myopathy (particularly proximal muscles)?
What common lab abnormality may or may not be seen in the context of this adverse effect?
```
Statin-associated myopathy. CK May or may not be elevated.
49
What commonly used anti-epileptic drug is associated with profound hyponatremia? Within what time frame of starting this drug should labs be checked?
Oxcarbazepine. Check labs within 10 days of starting the drug. The profound hyponatremia adverse effect can be exacerbated by the use of Thiazide diurectics or Levetiracetam (Keppra).
50
What does bupropion do to the seizure threshold?
Bupropion lowers the seizure threshold. It should not be given as a psychiatric medicine for someone with history of seizures.
51
What drug, used to counteract Parkinsonian symptoms of neuroleptic medicines is associated with an anti-cholinergic adverse effect clinical presentation?
Benztropine
52
A patient receiving therapy for cancer who appears confused, agitated, has visual problems, and has mild HTN is concerning for _______ likely caused by ______ (drugs).
Appropriate next step is ______
PRES
Drugs: Tacrolimus, cyclosporine.
Withdraw drug?
53
A woman who has just delivered a baby has a severe headache and her blood pressure drops. One of our major concerns is _________ especially if there is an associated bitemporal visual field defect.
Pituitary apoplexy
54
An isolated 6th nerve palsy is usually caused by...
The patient tends to have horizontal diplopia that is worse at a distance.
Diabetes, HTN, ischemia
55
If a patient cannot see out of their eye and I cannot see into their eye on fundus exam and they have been chronically maintained on steroids, they probably have a ________
Cataract (posterior subcapsular)
56
Severe headache, red eyes, and mild ptosis and miosis (I.e. Horner's syndrome) esp in a man are concerning for _________.
One of the considerations if Horner's is present should be ________ because the sympathethics run along with the ___________.
Cluster headache.
First time consideration of cluster headache and Horner's should be carotid dissection.
Sympathethics run with the internal carotid artery.
57
Eye pain, dimming of vision in the affected eye, reduced visual acuity in the affected eye and an APD in a 50 y.o. F is concerning for....
Optic or retrobulbar neuritis
58
An 13yr old boy presents with acute onset dizziness, slurred speech, and blurry vision. His symptoms resolve in 15min. They are concerning for...
Basilar migraine
59
The most common cause of an oculomotor nerve palsy is a ______. What is the sequence of testing that should be done: ________
If the patient is successfully treated and deteriorates 3 days later consider ______. Treat with: ________.
PCOM aneurysm
Tests in following order: 1. CT 2. LP 3. Angiography (MRA or arteriography)
If successfully clipped or coiled PCOM aneurysm and pt deteriorates 3 days later, consider VASOSPASM! Treat with NIMODIPINE.
60
An INO in an older patient is usually due to ______, In a younger pt ___________
INO in older pt: Paramedian pontine perforating vessel stroke
INO in younger pt: Demyelinating lesion
61
GCA is associated with increased risk of what ocular condition?
Central retinal artery occlusion.
Lab abnormality in GCA: Elevated ESR
62
Acute angle closure glaucoma can be treated with what neurological drug?
Topamax (topiramate)
63
Meyer's loop is located in the _____ lobe and serves the _____ field of vision.
```
Temporal lobe (inferiority located)
Superior field of vision
```
64
Tunnel vision (I.e. Sparing of just the central vision) should be concerning for...
Neurosyphilis, malingering, conversion disorder
65
Transient visual obscurations and pulsatilla tinnitus are associated with Papilledema. What visual field change would be expected?
Enlargement of the optic nerve and nasal step of the visual field loss occur in the setting of Papilledema. Visual acuity loss is a late finding.
66
Poor color vision in the form of an abnormal red desaturation or abnormal Ishihara color plates response points toward a ____________ (type of lesion)
Optic nerve. In a middle aged female with an APD, this leads us to consider optic neuritis which would not develop into optic atrophy for 4-6 weeks. Other DDx non-specific to her age: Ischemic optic neuropathy due to temporal arteritis.
67
What is one of the ocular concerns with spinal surgery?
Risk of posterior ischemic optic neuropathy esp in setting of prolonged anesthesia, hypotension, or pressure on the eye.
68
A headache particularly in an obese female in the setting of a normal MRI or slit-like ventricles on imaging is concerning for...
Diagnosis made by ____
Pseudotumor cerebri
Diagnosis made by LP.
69
Intermittent right sided cheek pain lasting 3-5 min precipitated by brushing teeth is concerning for...
Treatment is _______
Tic douloureux (trigeminal neuralgia) - unilateral stabbing facial pain.
Treatment: carbamazepine
70
Jaw claudication (jaw pain) and anemia in an elderly male should still point in the direction of ....
GCA/Temporal arteritis. The disease is particularly common in those over the age of 50.
Next step: temporal biopsy
71
A uniformly enhancing, extra-axial mass in the parasaggital region is likely a _________
A heterogenously enhancing, intra-axial mass is probably ________
Uniformly enhancing, extra axial mass: meningioma
Heterogenously enhancing, intra-axial mass: glioblastoma
72
Patients with what conditions SHOULD NOT receive sumatriptan?
Patients with uncontrolled HTN or coronary artery disease.
73
Pulsation of the eye after an accident is concerning for ...
Carotid-cavernous fistula
74
CSF analysis
RBCs present in CSF in setting of encephalitis particularly confined to the temporal lobes suggest...
Treatment:
Herpes simplex encephalitis
Treatment: acyclovir
75
CSF analysis
In an HIV+ patient with diplopia, intermittent blurry vision, Papilledema and a CD4 count under 200, consider...
Treatment:
Cryptococcus. WBC is elevated in CSF.
Treatment: Amphotericin B and flucytosine
76
Bacterial meningitis can be associated with hearing loss and vision loss.
Repeat
77
CSF analysis
A high lymphocyte count, high opening pressure, and low glucose in the setting of a clinical history of travel or exposure to high-risk populations should suggest .... (The course of this disease is subacute)
Multiple cranial nerves can be involved
TB meningitis
78
Ramsay Hunt syndrome characterized by left peripheral facial nerve palsy is due to ________ with vesicles on the skin of the ear canal.
Treatment:
Varicella zoster or Herpes zoster
Treatment: acyclovir
79
In a HIV+ patient, multiple gadolinium enhancing periventricular masses should first be suspicious for _______ (disease/agent). If this infection is ruled out, the next suspicion should be _________ (disease) which is caused by ______(agent).
Toxoplasmosis - first suspicion.
If not responsive to treatment then suspect CNS lymphoma which is due to EBV.
80
Bilateral facial nerve palsy or bilateral facial weakness especially in the northeast = _______ until proven otherwise.
Lyme disease!
81
In an immunocompromised patient (including chronic steroids) with elevated opening pressure and overwhelming lymphocytes in CSF, the most likely agent is ________. Diagnosis made by: ______.
Cryptococcus neoformans.
| Diagnosis: Cryptococcal antigen
82
Treat an epidural abscess which is likely due to skin organisms with...
vanc/ceftriaxone
83
Neurocysticercosis which appears as _____________ on imaging and can present with _________ can be treated with ______
Imaging: multiple calcified lesions
Presentation: Seizure (incl generalized tonic clonic seizure)
Treatment: Albendazole
84
Acceptable prophylaxis for N. Meningitidis is ________ or _______ because they reduce nasopharyngeal colonization.
Rifampin or ciprofloxacin can be used as prophylaxis in close contacts of someone with meningitis.
85
Hearing loss, spasticity, and hyperintensity along the ventricular margins on MRI of a newborn are concerning for...
Congenital CMV
86
A peripheral 7th nerve palsy should be treated with _______ in the first 48 hours and then add on _______. Likely agent: _________.
Treat Bell's palsy f unknown etiology with prednisone in first 48 hours.
Add on: antivirals (valacyclovir, acyclovir, famcyclovir).
Agent: Herpesvirus.
87
Triplet repeats, caudate atrophy, and choreiform movements are concerning for...
Huntington's Disease
88
6 year old who walks on his toes began walking at 18 months, and has generalized Hyperreflexia, bilateral Babinski signs, heel cord contracture and occasion writhing movements of upper limbs likely has...
Cerebral palsy. IQ may be normal.
89
A 28 year old construction worker is evaluated for clumsiness. He has noted an increased tendency to trip (he has never been athletic). He has high-arched feet and moderate weakness of foot and ankle muscles. Reflexes are 1+ except absent at the ankles. There is diminished vibration and propioception at toes. Diagnosis:
Charcot Marie Tooth Disease. Abnormal myelin is unstable and peripherally breaks down especially in feet.
90
In Becker's muscular dystrophy, one might expect to see ________ of the shoulder and pelvic muscles. A common lab abnormality might be an elevated _____.
atrophy of shoulder and pelvic muscles.
| CK can be elevated.
91
A muscular dystrophy that is associated with Type II DM, frontal balding, ptosis, slow relaxation of grip is concerning for
Myotonic dystrophy.
92
A 25 yr old with several operations to remove skin lesions, pain in her neck that radiates to her left thumb and index finger and absent brachioradialis and biceps reflexes. She has a dumbbell lesion at C6 on MRI.
Neurofibromatosis Type I.
NF 2 is associated with acoustic neuromas.
93
A 9 year old boy with autism has seizures which are investigated with MRI. Scan shows numerous subependymal nodules, clustering around the foramen of Munro. Diagnosis:
Tuberous sclerosis. Type I is less severe and possibly associated with normal intellect.
Genetic disorder affects cellular differentiation, proliferation, and migration early in development, resulting in a variety of hamartomatous lesions that may affect virtually every organ.
94
How do you treat Tourette's?
Haloperidol or risperidone
95
A 22 year old is experiencing abdominal pain occurring right after treatment for a UTI with sulfonamide antibiotics.she diffusely weak and arreflexic without Babinski's. There is diminution to pinpoint in a stocking-glove pattern. Diagnosis: . Treatment:
Acute intermittent porphyria. AIP is like GBS with autonomic symptoms (esp abdominal pain). A buildup of the precursors for the enzyme (whose activity is diminished by the sulfa drugs in susceptible individuals) causes peripheral and autonomic neuropathies.
Treatment: IV hematin.
96
A 30 year old man complains of pain and weakness after exercise. He has dark urine during these episodes. Diagnosis:
McArdle Disease (Glycogen storage disease V) - deficiency of myophosphorylase results in muscle cramping, weakness, dark urine.
97
A 5 month old child has generalized tonic clinic seizure. His head was in the 5th percentile, he responds poorly to sounds, has increased muscle tone with clonus at the ankles. CT shows small hyperdensities along the margins of the lateral ventricles.
Congenital CMV - associated with mental retardation, microcephaly, seizures, hearing defects.
98
A 12 yr old reports balance problems. He is arreflexic with kyphoscoliosis and pew cavus. Diagnosis:
Friedrich's ataxia - frataxin protein - 9q13 - mitochondrial protein. Usually autosomal recessive - onset before 25. Kyphoscoliosis, pes cavus, gait abnormality. Spinocerebellar signs: limb ataxia, dysarthria. Dorsal columns, spinocerebellar tracts, and corticospinal tracts are affected.
99
A 45 year old taking isoniazid therapy for TB prophylaxis after a positive PPD develops numbness and tingling in his legs, diminished propioception, absent DTRs concerning for...
Pyridoxine (B6) deficiency
100
A 35 year old farm worker is brought to the emergency room with n/v that developed when he was in the field. He is diaphoretic and has pinpoint pupils. Diagnosis:
Organophosphate deficiency. Phosphorus binds tightly to acterlcholinesterase.
If Sarin gas, symptoms include: muscle weakness, dyspnea, miosis, headache, blurred vision.
Treatment of OP poisoning: atropine AND pralidoxime
101
A common cause of pseudotumor cerebri is...
Vit A excess
102
A patient with history of alcoholism comes to ED unsteady nod confused. He presents with nystagmus and bilateral abductees weakness. Diagnosis:
Thiamine deficiency
103
A 69 year old man who has had total colectomy for UC presents with broad-based ataxic gait, and is unable to stand together with his eyes open. He has absent ankle reflexes and diminished proprioception at the toes and ankles. No Babinski's.
These are spinal and cerebellar signs suggestive of Vit E deficiency.
104
A 49yo woman who works as a ceramic designer complains of abdominal pain and constipation for several months. She has weakness of her limbs, particularly the extensor muscles. Sensory exam is normal. Diagnosis:
Lead poisoning - the extensor muscles and autonomic signs are a giveaway!
105
A patient with history of seizures shows up in the ED with unsteadiness, slurred speech, horizontal nystagmus, and bilateral limb dysmetria. Diagnosis:
Phenytoin or carbamazepine excess (cerebellar signs)
106
A 67 yo man has paresthesias in his hands and feet. He is know to have Atrophic gastritis. He has both UMN and LMN signs in upper and lower limbs. Vibration and position sense are diminished in hands and feet. Diagnosis:
B12 deficiency - subacute combined degeneration
107
In a pt who has received TPN, tremulousness with cog wheeling should make me consider...
manganese intoxication. Manganese in the basal ganglia manifests as increased signal on T1.
108
A total body rash with nausea, vomiting, tinnitus, several oval patches on the neck and increased pigmentation in the axilla for 12 days, decreased pinprick on feet, grayish line on nails are concerning for...
Arsenic poisoning.
109
Rhabdomyolysis can occur in Delirium Tremens which is seen _____ (time) after cessation of alcohol.
48 hrs.
Seizures that occur from Withdrawal from benzos or Librium usually take longer to manifest with a delay of up to a week.
110
Microcytic anemia and foot drop and wrist drop point to what form of intoxication?
Lead poisoning.
111
Increased Anion gap, metabolic acidosis, and urine crystals suggests...
Ethylene glycol poisoning. Peripheral nerve and cranial nerves affected.
112
Hemiballismus - repetitive, constantly flailing large amplitude movements of the limbs localizes to...
Subthalamic nucleus
113
Tennis elbow involves the ________ epicondyle and ________ nerve.
Lateral epicondyle. Radial nerve.
114
The ankle reflex localizes to _____.
S1
115
LMN signs in the upper extremities and UMN signs in the lower extremities localizes to pathology affecting the _______ region of the spine.
Cervical
116
How is myasthenia gravis diagnosed?
Tension test or Edrophonium
117
The patella reflex is primarily ____
L4
118
If inversion of the foot is affected in addition to other peripheral nerve signs then it is a ____ radiculopathy.
L5
119
Pure UMN and LMN signs with no sensory involvement especially including speech being affected is likely...
ALS
120
A woman with several weeks of posterior headache, mild dysphagia, unsteadiness, with 4/5 weakness in her limbs and brisk reflexes and bilateral Babinski's is concerning for pathology at her _______
Foramen magnum (UMN, cerebellar, lower cranial nerve)
121
Opponens muscle is innervates by the ________ nerve.
Median
122
What is the acute medical treatment for suspected spinal cord compression?
High dose methylprednisolone
123
If someone has a brain tumor with mass effect like a glioblastoma (already confirmed with imaging) that is symptomatic, one of the first priorities is to reduce ICP with one of the following 2 drugs: ________
IV Mannitol or Dexamethasone
124
To lower bp in hypertensive emergency with intracranial effects, use ________
Nitroprusside
125
What are drug options for neuropathic pain?
Gabapentin, nortriptyline, pregabalin (Lyrica), duloxetine (Cymbalta).
It would NOT be wise to use amitryptyline in an elderly patient because it has stronger anti-cholinergic effects than nortriptyline and would result in urinary retention in an older adult who may have BPH.
126
Analgesic rebound headache can present as a mixed tension type headache and migraine headache. Next step is ______
Repeat.
| Next step: stop meds
127
What are the EMG findings of myopathy vs neuropathy:
Myopathy: No fibrillation potentials on needle insertion, low amplitude motor units, early recruitment of motor units but normal interference pattern
Neuropathy: Fibrillation potentials on needle insertion, large motor units, with reduced interference when patient asked to contract the muscle strongly.
128
Caudate nucleus along with the closely related _______ and ______ place a role in ______ (voluntary or involuntary) movement.
Caudate, putamen, and globus pallidus play a role in voluntary movement.
129
What part of the brain is very affected in Alzheimer's disease? Individuals with what genetic syndrome are at increased of early AD-like changes?
Nucleus Basalis of Meynert - cholinergic nucleus
Down's syndrome
130
If a patient rescued from a mine injury presents with bilateral tremor two weeks later, what area is affected by delayed necrosis in the setting of ____ poisoning?
Globus pallidus. CO poisoning.
131
Huntington's disease affects what part of the brain? It is characterized by what genetic inheritance pattern and what DNA sequence error?
Caudate nucleus
| Autosomal dominant; triplet repeats
132
A man who develops sudden flinging movements of his right arm for example, is concerning for pathology in what region of the brain?
By what mechanism does this pathology occur?
Subthalamic nucleus because he is presenting with hemiballisumus. The mechanism by which this occurs is likely small, lacunar stroke.
133
Thiamine deficiency affects the _______ (part of the brain) and demonstrates as difficulty retaining new information. Common risk factors include:
Mamillary bodies.
| Risk factors: bariatric surgery, alcoholism, poor nutritional states
134
A woman develops head chase and has dilated pupils that do not react and an inability to look up. When she attempts to do so, she develops retractory nystagmus. Where is the pathology?
Pineal gland; also known as dorsal midbrain syndrome or Parinaud's syndrome.
135
In Parkinson's disease what part of the brain can either be ablated or deep brain stimulated in Parkinson's Disease that is refractory to levodopa/carbidopa (Sinemet)?
Subthalamic nucleus
136
Behavioral change in the setting of developing a new eating disorder (particularly eating a lot) is concerning for involvement of ____________ (part of brain).
Hypothalamus (supraoptic nucleus).
137
Lacunar strokes are treated with ________.
Treatment: Aspirin. Also manage risk factors with statins. A lacunar stroke would be visualized in the internal capsule.
138
Endocarditis leading to septic emboli can cause an embolic stroke that then can become hemorrhagic. The appropriate treatment is _______.
Antibiotics. Do NOT anticoagulate.
139
A Saturday night (radial nerve palsy) is treated with ________
Wrist splint. Extensor are weak, flexor are intact.
140
A patient with vertigo, dysphagia, left facial numbness, left palatal paresis, and right arm/facial numbness, left Horner's and right beating nystagmus is concerning for...
Lateral medullary syndrome (Wallenberg). Treatment is warfarin because it is usually due to a vertebral artery occlusion or a PICA occlusion.
141
A patient with stroke-like symptoms who not only has arm involvement but also has leg involvement likely involves what vascular distribution?
Internal carotid artery. If the pt is well beyond the 3 hour TPA window, the aspirin should be given. CT imaging initially might not show the infarct but the stroke would show up bright on MRI DWI sequence.
142
A patient with history of A-fib who refused to take Coumadin and is now presenting with forgetfulness and bumping into walls likely has ... Treatment:
Vascular dementia. Treatment: Return to warfarin.
143
A subdural hematoma must treated with:
Surgically evacuated
144
A pregnant woman with headache, lethargy, who presents with a generalized seizure is concerning for...
Treatment:
Venous sinus thrombosis
Treatment: anticoagulation
145
A patient can still have conjugate roving eye movements but if they are awake without being alert for ____ weeks, they are considered to be in a ________
6 weeks; persistent vegetative state. The patient can have NO apparent interaction with the external environment in order for this to be true. This is NOT the same as locked-in state where a patient still has vertical eye movements.
146
The treatment for cataplexy is....
Modafinil (Provigil)
147
A patient who has received haloperidol who presents with fever, rigid muscles, elevated CK, and elevated WBC is concerning for _______. The treatment is ______
Neuroleptic malignant syndrome.
| Treatment: Dantrolene (muscle relaxant) or benzodiazepines
148
Progressive supranuclear palsy manifests as Parkinsonism ('gait difficulties) and limited ocular movement. It is less responsive than Parkinson's to dopaminergic treatment.
Repeat.
149
In multiple sclerosis, individuals present with a ______ (small or big) capacity bladder as a result of UMN disease. The treatment is:
Small capacity bladder demonstrated by low Post-void residual.
Treatment: Oxybutynin (Ditropan) or tolterodine (Detrol)
150
Lambert Eaton syndrome tends NOT to affect the eye. Fatigability during the day is classic for NMJ disease.
Repeat
151
A patient with severe headache is diagnosed with Subarachnoid hemorrhage and treated with coiling. 5 days later he presents with facial droop and mild R sided muscle weakness. These symptoms are concerning for...
What drug could be used to prevent this re-presentation?
Cerebrovascular infarction or vasospasm
Drug to prevent vasospasm: Nimodipine
152
A urinalysis with significant proteinuria in a neurological setting should raise my suspicion for ...
Immune complex disease or septic emboli as the cause.
153
Cerebral septic emboli are treated with...
Broad-spectrum antibiotics.
154
What is the treatment for Lambert Eaton?
Plasmapheresis or immunosuppressive drug therapy.
155
In myasthenia gravis, deep tendon reflexes are ________ (present or absent) whereas in Lambert-Eaton, deep tendon reflexes are _______.
Myasthenia - preserved DTRs.
| Lambert-Eaton - depressed or absent DTRs.
156
The study of choice to evaluate a patient for Multiple sclerosis is ________
MRI with and without gadolinium - study of the brain
157
Cocaine and methamphetamine cause strokes via what mechanism?
Drug-induced vasospasm.
158
Treat (insert) multiple sclerosis with:
Acutely Flaring:
Relapsing-remitting:
Progressive:
Treat (insert) multiple sclerosis with:
Acutely Flaring: High dose corticosteroids
Relapsing-remitting: Interferon-beta (reduces freq of relapse and disability)
Progressive: Immunosuppresive therapy (Methotrexate, cyclosporine, mitoxantrone)
159
Treat exertional heat stroke [heat exhaustion (T>104F) AND CNS symptoms] with...
Ice water immersion. Ice water immersion, however, is contraindicated if the person is suffering from classic heat stroke in the absence of exertion. In that case, evaporative cooling is associated w/better outcomes.
160
High flow oxygen and sumatriptan are the treatment for which type of headache?
Cluster headache
161
A pontine hemorrhage would present as...
Deep coma, paraplegia, Pinpoint pupils, Decerebrate (extensor posturing),
162
Gaze palsy (looking to one side), ataxia, vomiting, occipital headaches, and facial weakness in a hypertensive patient are concerning for...
Treatment:
Cerebellar hemorrhage
Treatment: emergent decompression
163
Multiple, hypodense, non-enhancing lesions with no mass effect in the white matter of an HIV+ patient with CD4 count of 70 are concerning for... __________. Focal neurologic signs. The brainstem and cerebellum may be involved.
Progressive multifocal leukoencephalopathy (PML) - JC Virus
164
AIDS dementia complex presents as atrophy on imaging...
Repeat
165
Flat T waves, U waves, and ST depression are characteristic of what?
Hypokalemia
166
NPH will show up in an elderly person as enlarged ventricles on CT/MRI, normal opening pressure on LP, gait instability, urinary incontinence, and dementia. What is the treatment?
Treatment: Large volume LPs and V-P shunt
167
Hypertension has the strongest PMH risk factor association for strokes.
Repeat
168
Cortical and subcortical atrophy especially in the parietal and temporal areas in an elderly patient (over 60) are concerning for..
Alzheimer's disease
169
A patient between the ages of 40-60 who presents with dementia and personality changes with later progression to memory loss is concerning for...
Frontotemporal dementia
170
The most common electrolyte abnormality in the setting of a subarachnoid hemorrhage is...
Hyponatremia (cerebral salt wasting syndrome due to inapproapriate release of ADH/vasopressin and inappropriate release of BNP)
171
In Bell's palsy (peripheral 7th nerve palsy), the ability to raise the brow and wrinkle forehead is ________ (absent or present).
Absent.
Only in a central 7th nerve palsy is brow raising forehead wrinkling spared.
172
It is appropriate to perform a carotid endarterectomy on an Asymptomatic stenosis greater than 60% especially if it so 80% stenosis or more in a man.
Also in general, appropriate medical optimization for a stenosis of 50% or less is: ________
Repeat.
Medical optimization: aspirin or statins
173
Trihexyphenidyl is a ____________ (type of drug) used in Parkinson's and for Parkinsonism that can result in constipation, vomiting.
Anti cholinergic
174
Normal pressure hydrocephalus first presents with gait instability which is the most prominent symptom and then later urinary incontinence and dementia develop.
What is the gait like?
Repeat
Gait of NPH: broad-based shuffling gait.
175
What class of drugs are good for acute migraine management?
Anti-emetics: Prochlorperazine, metclopramide
176
Guillain-Barré syndrome is treated with..
IVIG or plasmapheresis
177
An ulcer over a bony prominence with no associated erythema or wound discoloration etc is liekely a....
Pressure ulcer
178
In opiate poisoning, people have _______ pupils and respiratory _______.
Pinpoint pupils
| Respiratory depression
179
Nystagmus, hypotonia, and gait instability to the ipsilateral side are still consistent with a __________ (type of lesion)
Cerebellar
180
Spinal cord compression can present as focal point tenderness over the spine.
Repeat
181
In acute spinal shock pts may have only ______ signs (LMN vs UMN)
LMN (arreflexic, flaccid paralysis)
182
What is the triad of Ménière's disease?
Dizziness, hearing loss, and tinnitus.
183
The best next step in treating idiopathic intracranial HTN is...
Acetazolamide
184
In brain death, the heart does not generally respond to atropine, there is no spontaneous respiration to PCO2 values over 50.
Repeat
185
Fluctuating cognition with variations in alertness and awareness, recurrent visual hallucinations, and Parkinsonism are usually seen in...
Lewy body dementia.
186
Pick's disease is a fronto temporal dementia. Visuospatial deficits are usually spared.
Repeat
187
Conjugate gaze palsy, nystagmus, gait ataxia and altered mental status suggest _________
Wernicke's encephalopathy (Thiamine deficiency - B1 deficiency). No further tests are needed. Oculomotor symptoms + gait ataxia + encephalopathy = Wernicke's.
188
Fixed, mid-dilated pupil, sudden eye pain, halos around light suggest...
Acute angle closure glaucoma
189
ESR is usually > ____ in temporal arteritis
50mm/hr
190
A rapid acsending paralysis that occurs over the course of hours to days with no albumino-cytologic dissociation in the CSF is concerning for... ______ esp in the setting of no fever and symptoms that are more pronounced in one leg vs another.
Tick-borne paralysis
191
Quetiapine is a ____________ type of drug
Anti-psychotic
192
Anyone presenting with acute onset fever headache, myalgias and rash who was previously healthy should be considered for _______
Meningococcal infection
193
An elderly patient with bacterial meningitis should be treated with which antibiotics?
Vancomycin, ampicillin, ceftriaxone
Vanc and ceftriaxone cover penicillin-resistant Strep Pneumo and ampicillin covers listeria.
194
Early mobilization of stroke patients, even within the first 48 hrs, is recommended to reduce complications.
Repeat . E.g. Reduce decubitus ulcers, deconditioning.
195
Give t-Pa within 3 hours of a stroke.
Repeat
196
For uncomplicated strokes (e.g. No aortic dissection, CAD, heart failure), anti-HTN meds should be held until systolic is over 220 or diastolic is over 120.
Repeat
