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Flashcards in Neurology Deck (185):
1

non-dominant parietal lobe lesions (right brain for most)

hemispatial neglect (usually left)

2

dominant parietal lobe (left brain for most)

agraphia, acalculia

3

frontal lobe

personality changes

4

subthalamic nucleus

c/l hemiballismus

5

Broca aphasia

nonfluent aphasia
affects written language as well as speech, can't produce words despite good comprehension

6

Wernicke aphasia

poor comprehention, word substitutions, meaningless words

7

Conduction aphasia

poor repetition of what's heard

8

global aphasia

nonfluent speech, poor comprehension, poor repetition

9

Brown Sequard hemisection of spinal cord

All tracts on one side of the cord are affected
Dorsal column- ipsilateral loss of vibration and discrimination below the lesion
Corticospinal tract- ipsilateral spastic paresis (UMN) below the lesion
Anterior motor horn- ipsilateral flaccid paralysis (LMN) at level of lesion
Spinothalamic tract- contralateral loss of pain and temperature below the lesion

10

most common sites (n=2) for berry saccular aneurysms

Anterior communicating artery and posterior communicating artery

11

fasciculations and spastic paralysis

ALS (UMN and LMN)

12

impaired proprioception+ pupils do not react to light

tertiary syphilis (tabes doralis and argyle robertson)

13

bilateral loss of pain and temp below the lesion + hand weakness

syringomyelia

14

bilateral loss of vibration sense + spastic paralysis of legs then arms

B12 deficiency

15

bilateral loss of pain/temp below lesion + bilateral spastic paralysis below lesion+ bilateral flaccid paralysis at the level of the lesion

anterior spinal artery syndrome

(everything but the dorsal column)

16

contralateral hemiballismus

subthalamic nucleus lesion

17

hemispatial neglect syndrome

nondominant parietal lobe

18

poor comprehension

Wernicke's area (MCA), this is receptive aphasia

19

poor vocal expression

Broca's area (MCA). this is expressive aphasia

20

personality changes

frontal lobe lesions

21

agraphia and acalculia

dominant parietal lobe (usually left)

22

Where do the dorsal columns cross over?

medulla after ascending as medial lemniscus

23

where does the lateral corticospnial tract cross over

medullary pyramids

24

where does the spinothalamic tract cross over?

anterior white commisure

25

What are the four main longterm complications of bacterial meningitis in pediatric patients?

hearing loss
seizure disorder
intellectual disability
spastic paralysis

26

gram positive dipococci leading to meningitis

s. pneumoniae

27

gram negative diplococci leading to meningitis

=/- purpura

n. meningitidis

28

small pleomorphic gram negative coccobacilli leading to meningitis

h. influenzae type B
now rarer due to vaccine

29

gram positive rods and coccobacilli leading to meningitis

listeria

30

What medication should be given to close contacts of patients who have neisseria or h. influenzae meningitis?

rifampin or ciprofloxacin

31

Signs of increased ICP indicating CT before LP

focal neurologic deficits
pupil asymmetry
papilledema
seizure
suspicion of mass effect

32

AIDS patient with fungal meningitis

cryptococcal meningitis
treat with intrathecal amphoteriicin B

33

Reye syndrome
organs affected
labs
symptoms/signs
treatment

affects brain and liver
results in significant hypoglycemia

A reaction in children with viral infection who are given ASA

rash
vomiting
increased LFT
headache
lethargy

tx: supportive care

34

encephalitis

meningitis plus AMS

35

HSV

temporal lobe encephalitis

36

WNV

birds are reservoir, mosquitos are vector

37

Reye sydrome

virus + ASA
(brain and liver HEPATOENCEPHALITIS)
potential hypoglycemia

38

Brain abscess

MRI shows ring- enhancing lesion

39

poliomyelitis

detroys motor neurons

40

rabies

negri bodies

41

Toxoplasma gondii

contracted by eating meat or infected soil, litter boxes

affecting heart/liver/eye
Diagnosis: CD4

42

contra-indications for triptans

prinzmetal angina, CHF, pregnancy

43

Treat tension HA

NSAIDs
ergots
sumitriptan
relaxation

44

Treat cluster HA

100% O2 (6L/min on rebreather mask for 20+ min) and sumatriptan or dihydroergotamine (DHE 45)

45

migrrane HA

sumatriptan (or other triptan), dihydroergotamine (DHE 45), NSAIDs, and/or antiemetics (chlorpromazine, perchlorperazine, metaclopramide) in varying combinations based on severity, nature of symptoms and patient history

46

What agents can be used for migraine prophylaxis

CCB (verapamil)
Beta-blockers: propanolol, metoprolol
TCAs:amitriptyline, nortriptyline (good choice if comorbid depression, insomnia, pain syndrome)
NSAIDs: naproxen (good choice if menstrual migraine, comorbid osteoarthritis or other pain that could benefit from NSAIDs)
Anticonvulsants:valproic acid (good if history of bipolar disorder), topiramate, gabapentin

47

characteristic features of idiopathic intracranial hypertension

young obese woman
-HA- daily, pulsatile, possible n/v, possible retroocular pain -worse with eye movement
-papilledema
-most worrisome sequela is vision loss due to CNII compression
-CT scan is normal
-CSF pressure is elevated >200 mmH2o in non-obese patient, >250 mm H2O in obese patient

48

Treat IIH

confirm absence of other pathology with CT and MRI of head to r/o central venous thrombosis

discontinue any inciting agents (eg excess vitamin A, accutane, tetracyclines)

weightloss if obese

acetazolamide is first line

invasive treatment options:
-serial lumbar punctures
-optic nerve sheath decompression
-lumboperitoneal shunting (CSF shunt)

49

HA made worse by foods containing tyramine

migraine

50

HA in obese woman with papilledema

IIH

51

HA with jaw muscle pain when chewing

temporal arteritis aka giant cell arteritis

52

HA with periorbital pain, ptosis, miosis

cluster

53

HA with photophobia and/or phonophobia

migraine

54

HA with B/L frontal/occipital pressure

tension HA

55

HA with lacrimation and/or rhinorrhea

cluster

56

elevated ESR

giant cell arteritis

57

"worse HA of my life"

SAH

58

headache and extraocular muscle palsies

cavernous sinus thrombosis

59

scintillating scotomas prior to HA

migraine with aura

60

HA before or after orgasm

postcoital cephalalgia

61

HA Responsive to 100% O2 supplementation

cluster HA

62

frontal HA made worse by bending over

sinus HA

63

trauma to head- headache begins days after the event, persists for over a week and does not go away

subdural hematoma

64

treat neonatal meningitis empirically with which antibiotics?

ampicillin and gentamicin

65

part of the brain implicated in coma

reticular activating system

66

TIA definition

transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction

67

Pure motor hemiparesis lacunar syndrome

-weakness of face, arm, leg on one side of body
-absent sensory or cortical signs (aphasia, neglect, apraxia, hemianopsia)
MC (50% of lacunar strokes)

68

pure sensory lacunar stroke syndrome

-sensory defect (numbness) of the face, arm, leg on one side of the body
-absent motor or cortical signs

69

Ataxic hemiparesis lacunar syndrome

-ipsilateral weakness and limb ataxia out of proportion to the motor defect, possible gait deviation to the affected side
-absent cortical signs

70

Sensorimotor stroke lacunar syndrome

-weakness and numbness of the face, arm, leg on one side of the body
-absent cortical signs

71

dysarthria clumsy hand syndrome lacunar stroke syndrome

facial weakness, dysarthria, ---

-dysphagia, and slight weakness and clumsiness of one hand
-absent sensory or cortical signs
-least common

72

bacterial meningitis plus purpura (what organism?)

neisseria meningitidis

73

reye syndrome

virus+aspirin (brain + liver)

74

brain abscess

MRI with ring-enhancing lesion

75

poliomyelitis

destroys motor neurons

76

rabies

negri bodies

77

HSV

temporal lobe encephalitis

78

normal CSF pressure

50-180

79

normal CSF WBC

80

normal CSF glucose

40-70

81

normal CSF protein

20-45

82

treatment for trigeminal neuralgia

carbamazepine
phenytoin
gabapentin
valproic acid
surgical decompression

83

treatment for someone with htn and recurrent migraine

propanolol or CCB (like nifedipine)

84

sudden onset of severe HA, vomiting, meningismus

subarachnoid hemorrhage

85

patient taking warfarin falls and bumps his head

subdural hematoma

86

brief loss of consciousness following head trauma; rapid clinical deterioration hours later

epidural hematoma

87

elderly patient with mild headache for 2 weeks, now becoming lethargic

SDH

88

patient with unilateral hemiparesis and BP 220/130 mm Hg

stroke- parenchymal hemorrhage

89

ruptured intracranial aneurysm

SAH

90

ruptured AVM

parenchymal hemorrhage or SAH

91

biconvex- shaped hematoma

epidural hematoma

92

crescent-shaped hematoma

subdural hematoma

93

Imaging appropriate for suspected intracranial hemorrhage

CT of head without contrast

faster and cheaper than MRI

94

First line med for absence seizures

ethosuximide

95

what drugs are used to treat status epilepticus

ABC
IV/IM benzodiazepine (diazepam, lorazepam)
If that doesn't work, use phenobarbital (intubate first, as respiratory depression may occur)

phenytoin or fosphenytoin to help prevent immediate recurrence

96

treat eclampsia with...

magnesium sulfate
+/- benzodiazepine (eg diazepam, lorazepam)
c-section after the seizure

97

Adverse effects of phenytoin:
Phenytoin Has Given MDs Frustation

Peripheral neuropathy
Hirsutism
Gingival hyperplasia
Megaloblastic anemia due to decreased folate absorption
Drug- induced lupus
SJS
Fetal hydantoin syndome

98

anti-epileptics that are teratogens

phenytoin
carbamazepine
valproic acid (spina bifida- ppx with 4mg folic acid)

99

what drugs cause SJS



seizure drugs: ethosuximide, lamotrigine, carbamazepine, phenytoin, phenobarbital

antibiotics: sulfonamides, PCNs

Allopurinol

100

Agranulocytosis

carbamazepine
clozapine
colchicine
PTU, methimazole

101

Hepatotoxic anti-epileptics

valproid acid
carbamazepine

102

Which drugs induce CYP450

Coronas, Guiness, and PBRs incude chronic alcoholism

Carbamazepine
Griseofulvin
Phenytoin
Barbiturates
Rifampin
St. Johns wort
Chronic alcoholism

103

Focal sensory or motor deficit with NO loss of consciosness

simple partial seizure

104

Focal sensory or motor deficit with impaired consciousness (commonly localized to temporal lobe on EEG)

complex partial seizure (temporal lobe a common site)

105

Involves both hemispheres of brain with a pattern of neuromuscular activation: tonic, clonic, tonic- clonic, myoclonic, atonic. Loss of consciousness present with postictal period

generalized convulsive seizure

106

characterized by a brief (few seconds) impairment of consciousness. spike and wave on eeg, no post-ictal stage

absence seizure

107

characteristic features of amyotrophic lateral sclerosis

weakness but with normal sensation
initial presenting symptoms are
-asymmetric limb weakness (80%), in hands, fingers, shoulder girdle, lower extremity (foot drop), or pelvic girdle

dysarthria or dysphagie (bulbar dysfunction) (20%)

UMN si/sx: movement stiffness, slowness and incoordination; spasticity and hyperreflexia (spastic paralysis); slowed rapid alternating movements; gait disorder

Bulbar UMN si/sx: dysarthria, dysphagia, pseudobulbar affect (inappropriate laughing, crying, yawning)

Lower MN si/sx: weakness, gait disorder, reduced reflexes (flaccid paralysis), muscle atrophy, fasciculations

cognitive deficits: frontotemporal executive dysfunction

neuromuscular respiratory failure after months to years (average survival from time of diagnosis is 3-5 years)

108

How do you diagnose ALS?

Electromyogram shows widespread denervation and motor block

109

What is the one FDA- approved drug for ALS?

Riluzole, which decreases glutamate- induced excitotoxicity in the CNS (excess can be toxic to the brain)

110

Multiple sclerosis

progressive demyelination of brain and spinal cord

women ages 20-40

sx: vision abnormalities
paresthesias
sensory deficits
weakness in the face, limbs, eyes, diplioia, ptosis, urinary urgency, incontinence, retention

over time, progresses
worse with stress and overheating

Eye findings:
Unilateral optic neuritis (inflammation of the optic nerve), causing acute onset eye pain worse with movement and central vision loss. Afferent pupillary defect (Marcus Gunn pupil)

Internuclear ophthalmoplegia (damage to medial longitudinal fasciculus)- ipsilateral eye cannot adduct on lateral gaze (away from the MLF lesion- the injured side cannot adduct on lateral gaze)
The eye contralateral to the lesion experiences nystagmus
normal convergence (medial rectus muscle functional)

CSF:
increased protein
increased WBC count
oligoclonal bands

MRI of brain and orbits
MRI of spinal cord
look for asymmetric demyelinating lesions
Still, MS is a clinical diagnosis

111

Neuromyelitis optica (NMO)

bilateral optic neuropathy
lesions in cervical spinal cord

usually spares the brain
positive NMO-IgG

112

How do we treat MS?

acute- corticosteroids in high doses for a few days

Maintenance- avoid stress
treat with interferon- beta
glatiramer
natalizumab is 3rd line

113

Alzheimer Disease characteristics

progressive memory loss
loss of executive function
disinhibition
personality changes
delusions

a diagnosis of exclusion

114

Alzheimer- cholinesterase inhibitors

donepezil
galantamine
rivastigmine

may slow progression of disease

memantine (NMDA inhibitor)

115

Dementia with Lewy bodies

similar to parkinsonism

Dementia
Parkinsonian features (bradykinesia, tremor, cogwheel rigidity, festinating gait)
visual hallucinations
episodes of syncope (repeated falls)

116

Frontotemporal dementia (aka Pick disease)

dementia plus inappropriate social behavior

dementia plus progressive aphasia (difficulty understanding what is said, difficulty speaking)

117

Normal pressure hydrocephalus

arachnoid granulations fibrose and can't absorb CSF

Wacky (cognitive impairment or dementia)
Wet (urinary incontinence)
Wobbly (gait disturbance- magnetic gait, short steps, low to the ground)

Dx: MRI, dilation of ventricles
Tx: ventricular shunting so that extra CSF goes to the peritoneum

118

Myasthenia gravis

antibodies bind acetylcholine receptors at neuromuscular junction

may be associated with
thymoma
thymus neoplasm
thyrotoxicosis

more common in young adult women

weakness that worsens throughout the day, ptosis, diplopia, dysarthria, dyspnea, dysphagia

symptoms improve with Tensilon test (edrophonium, which stimulates the AChR, and is very short-acting)

nerve stim, EMG

119

Treatment for MG

anticholinesterase- neostigmine, pyridostigmine

thymectomy
immunosuppression: prednisone, azathioprine

plasmapheresis
IVIG

120

Lambert- Eaton syndrome

antibodies against presynaptic voltage- gated calcium channels

associated with small cell lung cancer

paraneoplastic syndrome

121

Treat LES

treat underlying cancer
cholinesterase inhibitors- pyridostigmine
immunosuppressants
plasmapheresis

122

Guillain- Barre syndrome (acute inflammatory demyelinating polyradiculopathy), classic presentation

symmetric muscle weakness that progresses over days to 4 weeks (2 avg)

usually beginning in distal legs, but may begin in arms or facial muscles in 10% of cases
-respiratory paralysis requiring mechanical ventilation in 30% of cases.
-facial muscle weakness and/or oropharyngeal weakness in 50% which may include bilateral facial muscle paralysis
-autonomic dysfunction in 70% of patients (tachycardia)
-absent or depressed deep tendon reflexes
-little if any change in sensation
-no fever at the onset of symptoms
-GBS may be preceded by campylobacter jejuni diarrheal illness (about 20% of cases), HIV, CMV, EBV, mycoplasma, other viral infection, immunization (rare)

123

How is diagnosis of GBS made in a patient with ascending muscle paralysis and preserved sensation?

characteristic clinical presentation
CSF shows albuminocytologic dissociation (elevated protein and normal WBCs)
Electrodiagnostic studies such as nerve conduction studies and EMG, which show evidence of demyelination

124

Prognosis of GBS

death despite ICU care in 5%
prolonged disease with delayed or incomplete recovery in 5-10%
relapse in 10%
spontaneous regression and complete recovery by 1 year in 80-90%

125

Treatment of GBS

hospitalization for respiratory monitoring including vital capacity, BP monitoring, cardiac monitoring (telemetry), and daily abdominal auscultation for ileus
30% of patients require mechanical ventilation
20% of patients require ICU monitoring for autonomic dysfunction

Plasmapheresis or IVIG are equally effective at shortening time to independent walking by 50%, while combining the 2 offers no additional benefit

Steroids are NOT recommended in treating GBS.

126

How do we diagnose Bell's palsy?

First, make sure it is LMN facial muscle paralysis (the whole face is involved, and this actually looks worse than stroke)

rule out Lyme disease by history: tick bite, heart block, arthritis, vertigo, hearing loss

rule out otitis media by inspecting the TM

rule out stroke by looking for other defects

acute onset (1-2 days), with progressively weakening weakness for 3 weeks, leading to recovery within 6 months

Anything other than this particular presentation warrants CT and/or MRI, and screening blood tests to rule out other pathology (Lyme, zoster, AIDS, sarcoid, tumors, diabetes).

127

Treat Bell's Palsy

eye care
-artificial tears hourly while awake, lubricating ointment qHS, patch over eye at night

glucocorticoids in medium doses

+/- valacyclovir

128

benign essential tremor

idiopathic, but can be familial
fixed oscillation of hands or head

treat (alcohol makes it better)
beta blockers
benzodiazepines
primidone
thalamotomy
deep brain stimulation

129

Chorea

rapid flinching distal limb and facial movements

associated with hyperthyroidism, huntington, lupus, levodopa use, rheumatic fever

130

Athetosis

writhing, snakelike movements
associated with cerebral palsy, encephalopathy, huntington disease, wilson disease

131

Dystonia

sustained contractions of proximal limb or trunk

associated with neuroleptic drug use, wilson disease, parkinson, huntington, encephalitis

treatment: levodopa/carbidopa, botulinum toxin

132

Hemiballismus

flinging movements of extremities

associated with stroke (subthalamic nucleus lesion)

treatment: haloperidol

133

Tics

brief, repetative, involuntary movement or sound

associated with tourette, OCD, ADHD
Treatment:DA antagonists

pimozide
tetrabenazine
fluphenazine

134

Lots of Bad Stuff Kills Glia

common mets to the brain

Lung cancer
Breast cancer
Skin cancer- melanoma
Kidney- RCC
GI tract tumors- colon cancer

135

MGM Studios: most common brain tumors in adults

Metastasis
Glioblastoma
Meningioma
Schwannoma

136

Animal Kingdom, Magic Kingdom, Epcot

common brain tumors in children

Astrocytoma
Medulloblastoma
Ependymoma

137

How to treat a brain tumor

resection
radiation
chemotherapy
corticosteroids
anticonvulsants

138

How to treat mets to the brain

full body imaging
surgical resection
palliative radiation

Prognosis:
depends on tumor- glioblastoma is aggressive and offers 6 month survival

139

Neurofibromatotis type 1
von Recklinghousen disease

Autosomal dominant, NF1 gene on chromosome 17

at least 2 of the following:

>5 cafe au lait spots
1 neurofibromas
axillary or inguinal freckling
optic glioma
>1 iris hamartoma (Lisch nodules)
bone lesions
first- degree relative with NF1

140

NF2

AD, chromosome 22
b/l acoustic schwannomas

141

Stages of sleep (N1, N2, N3)
awake- beta
awake, relaxed- alpha
N1-theta
N2- Sleep spindles, K complexes
N3- delta waves
REM- beta waves

N1: fast delta, light sleep
N2: intermediate, sleep spindles and K complexes, decreasing frequency, increasing amplitude
45% of sleep is N2 sleep

N3, deep sleep, slow delta waves
REM every 1-2 hours, beta waves, low voltage, high frequency

142

increases N2 sleep, decreases N3 sleep

Benzodiazepines

helps you go to sleep, but you don't get good rest
can reduce night terrors, and nocturnal enuresis, which occur during N3

143

nightmares versus night terrors

nightmares occur during REM sleep, the patient who appears to awaken is actually awake

night terrors occur during non-REM (Stage 3) sleep, and may appear to awaken but not really awaken, can be difficult to arouse, and is usually able to fall asleep right after the episode

144

Narcolepsy- requirements for diagnosis

cataplexy only in narcolepsy and is virtually diagnostic when present

other causes of excessive daytime sleepiness are ruled out, overnight polysomnogram (to rule out OSA and periodic limb movement disorder)
rule out sedating medications as a cause

multiple sleep latency test- when given 4-5 opportunities to nap every 2 hours, narcolepsy patients fall asleep in less than 8 minutes

145

How do we treat narcolepsy?

avoid drugs that cause sleepiness
schedule naps 1-2 times daily for 10-20 minutes
Modafinil, a stimulant, can be used first-line
support group attendance

if cataplexy, venlafaxine, fluoxetine, or atomoxetine

146

Insomnia meds

melatonin
valerian
antihistamines (diphenhydramine, doxylamine)
trazodone
TCAs (amitriptyline, doxepin)
benzodiazepines
zolpidem/zaleplon
eszopiclone
ramelteon

147

Melatonin for insomnia

non-addictive, OTC, vivid dreams, safe for

148

Valerian for insomnia

OTC herbal, no evidence

149

Antihistamines for insomnia (diphenhydramine, doxylamine)

used by patients first-line, associated with poor sleep quality, not for long-term use, anticholinergic side effects (avoid in the elderly)

150

Trazodone for insomnia

antidepressant, decreases sleep latency, small risk of priapism

151

TCAs (amitriptyline, doxepin) for insomnia

antidepressant, small risk of arrhythmia (obtain EKG prior to use), anticholinergic side effects (avoid in the elderly)

152

Benzodiazepines (temazepam, lorazepam, clonazepam, diazepam, chlordiazepoxide) for insomnia

addictive, short-term only (

153

zolpidem/zaleplon for insomnia

act at the benzo receptor, short- term only (

154

eszopliclone for insomnia

may be used longterm

155

ramelteon for insomnia

non-addictive because it works at melatonin receptors instead of GABA/benzo receptors, avoid if hepatic insufficiency, longterm studies are lacking

156

Resless legs

parasthesias compel patient to have voluntary, spontaneous, continuous leg movements that temporarily relieve the sensations, discomfort is worse at rest/evening/during sleep, spiders or ants on/in feet/calf muscles, usually primary idiopathic disorder

May be secondary to iron deficiency, ESRD, diabetic neuropathy, Parkinson, pregnancy, rheumatic disease, varicose veins, caffeine intake

Treat: pramipexole, ropinirole (or levodopa/carbidopa), iron replacement, avoid caffeine, clonazepam qHS, gabapentin (if the DA agonists aren't working), opioids

157

What is the next step after a brain tumor has been identified on CT or MRI?

full body CT and bone scan to look for the primary tumor

158

Causes of syncope

reflex syncope (BP and HR drop)
Vasovagal- associated with emotional stress, trauma, pain, sight of blood, prolonged standing
situational- associated with micturition, defecation, coughing, GI stimulation

carotid- sinus hypersensitivity: associated with head turning, shaving, tight collar

cardiogenic- exertion, palpitations, chest pain, SOB

orthostatic

cerebrovascular- associated with prolonged loss of consciousness, seizures, neurologic deficits

no identifiable cause (20% without known cause)

159

syncope versus seizure

seizure: hx of seizure, prodrome of dejavu, postictal confusion, tongue lacerations

more likely syncope: lightheadedness or sweating, prolonged standing

nonspecific: brief limb jerking, urine incontinence

CBC (anemia), electrolytes, BUN/Cr (arrhythmia), glucose (hypoglycemia)

volume status
pulse-ox and ECG (cardiogenic)

evaluate meds
in patients over 40, rule out carotid sinus hypersensitivity

consider
1. serial cardiac enzymes, ECGx3, especially if >45yo, DM, smoker, prior MI or >2-3 risk factors
2. echo (murmur, exertional syncope, hx of heart disease)

3. cardiac stress test
4. bilateral carotid duplex especially if >65yo, CAD, PVD, bruit
5. 24hr Holter monitor especially if abnormal SCG, palpitations, heart disease, FHx of sudden death
6. CT head w/o contrast and EEG is neuro sx, new seizure, HA

160

Persistent vegetative state versus coma

PVS:
normal sleep cycles
inability to perceive and interact with environment
preserved autonomic function for >1 month

Coma:
history, pupils, ocular motility, motor function

161

normal response to cold caloric testing (intact brain stem)

conjugate eye deviation towards ice water, followed by nustagmus in the opposite direction

no eye deviation indicates CN3, or 6 involvement, suggestive of brainstem damage

deviation without nystagmus indicates cerebral hemispheres damaged or suppressed

162

Doll's eye oculocephalic reflex test

normal when the eyes are fixed on a particular point

163

DDx for patient presenting unconscious

AEIOUTIPS

Alcohol
Epilepsy/environment
Insulin
OD/Opioids
Uremia
Trauma
Infection
Psychogenic
Stroke

164

3 things you can give empirically to an unconscious patient

thiamine, glucose, naloxine

165

tilt table test results suggestive of orthostatic hypotension

measurements taken while patient is standing:
increase in HR greater than or equal to 20BPM
decrease in SBP greater than or equal to 20

drop in DBP more than or equal to 10 mmHg

166

What are the elbows doing in decorticate posturing?

flexing

167

what pathogens most commonly cause otitis media

s. pneumo
h. influenzae
m. catarrhalis
s. pyogenes
viruses

168

si/sx of aom

ear pain
decreased hearing
fever
bulging TM with decreased mobility
poor light reflex
+/- bloody discharge

169

when is it reasonable to observe without abx in aom?

age 6 mos-2 yrs + U/L AOM w/o otorrhea + mild illness + appropriate fu available + abx started promptly if symptoms worsen

or

age> or = 2 yrs + UL or BL AOM wo otorrhea + mild illness + appropriate fu available + abx can be started promptly if symptoms worsen

with agreement between caregiver and provider

abx started if improvement not seen between 48-72 hours

consider treating if painful

170

what medications do you use to treat AOM?

amoxicillin for 10 days
amoxicillin + clavulanic acid
cephalosporin -cefdinir

tympanic tubes if recurrent

171

complications of AOM

mastoiditis
meningitis
hearing loss
sigmoid sinus thrombosis
brain abscess
ruptured TM
labyrinthitis
bullous myringitis (vesicular inflammation of TM, more painful than usual AOM, large, reddish vesicles seen on exam)

172

What is the treatment fo bullous myringitis?

mycoplasma pneumoniae a common organism, treat with oral macrolide

topical analgesics

173

diagnostic features of mastoiditis

-symptoms days to weeks after AOM
-erythema, edema, tenderness behind ear
-external ear displaced
-diagnosis made from CT scan of mastoid process

174

swimmer's ear- otitis externa

s. aureus
pseudomonas
s. epidermidis

associated with water in the ear
painful swollen ear, white discharge, red and swollen ear canal
pinna tenderness, normal TM

175

Treat otitis externa

topical- polymixin, neomycin, fluoroquinolone, hydrocortisone

oral- cephalosporins, fluoroquinolone

176

BPPV

feeling of rotational movement 2/2 otolith

brief episodic vertifo occurs with vertain movements, nystagmus

Dix hallpike exacerbates nystagmus

CT, MRI
TSH

Tx: Epley menauver

177

acute labyrinthitis

acute onset vertigo, n/v, nystagmus
single episode lasing days to weeks
preceded by viral URI
horizontal nystagmus suppressed with visual fixation, with fast phase away from affected side
abnormal head thrust test- patient unable to maintain visual fixation when examiner rapidly turns patient's head to affected side

absence of neurologic defects
preserved ambulation

typically subsides spontaneously within weeks
corticosteroid taper improves recovery

symptomatic tx with scopolamine, metoclopramide, etc in the first 48 hours

vestibular rehabilitation exercises can be helpful

MRI if >60, HA, focal neuro signs, vascular risk factors or sustained vertigo inconsistent with acute labyrinthitis (vestibular neuritis)

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Meniere disease

aka endolyphatic hydrops
caused by distention of endolymphatic compartment of inner ear

acute vertigo lasting hours
n/v
decreased hearing
ear fullness
tinnitus
low frequency hearing loss

assoc with depression

Tx: anticholinergics
antiemetics
antihistamines
salt restriction
thiazide diuretics
surgical decompression (obliteral vestibular apparatus with gentamicin)

179

acoustic schwannoma

3rd MC brain tumor in adults
compression of CN VIII with b/l tumors

hearing loss
dizziness
tinnitus
ul facial palsy
decreased sensation
sensorineural hearing loss

dx with MRI

tx surgical excision

180

hearing loss

conductive (wax, orosclerosis)- air should be better than bone conduction in the Rinne test

sensorineural (presbycusis)
Weber test- equal hearing on both sides versus, sound heard better in the ear where bone conduction is faster = conductive

sound heard better in the ear where conduction was slower= sensorineural hearing loss

181

Cholesteatoma

overgrowth of desquamated keritin debris within the middle ear space that may eventually erode the ossicular chain and external auditory canal, leading to conductive hearing loss

causes: neg middle ear pressure (chronic retraction pocket) from eustachian tube dysfunction or direct growth of epithelium through a TM perforation

commonly associated wtih chronic middle ear infection

Tx: surgical removal, tympanomastoidectomy, reconstruction of ossicular chain

182

Ramsay Hunt syndrome

herpes zoster oticus (reactivation of herpes in the ear)

i/l facial paralysis
ear pain
vesicles in auditory canal/auricle
tinnitus
vertigo
abnormal taste perception

tx: narcotic analgesia for pain relief
oral steroids to decrease inflammation
antiviral therapy with valacyclovir (highest efficacy), famciclovir, acyclovir

183

meniere triad of symptoms

vertigo, tinnitus, hearing loss

184

ACUTE LABYRINTHITIS

HEARING LOSS, VERTIGO, NAUSEA, VOMITING

185

What is Todd's paralysis?

postictal hemiparesis lasting about 15 hours (but not more than 24 hours)