Neurology

Question 1

person goes camping, has diarrheal illness, OR RECENT FLU SHOT
few weeks later develops weakness/numbness, hyporeflexia

what’s going on?

Answer 1

campylobacter infection -> postinfectious GBS

Question 2

step 2 has what variant of MS.

how to dx MS?

Answer 2

relapsing-remittent.

so has episodes, fine in between.

dx with MRI = periventricular white matter/ Dawson’s fingers

Question 3

this is not how to dx MS for initial diagnostic test, but what will lumbar puncture show?

Answer 3

oligoclonal IgG bands

Question 4

how to treat MS flare?

how to maintenance treat MS?

Answer 4

flare - high dose IV steroids. 3-5 days

maintenance - interferon, Glatiraner, Fingolimod

Question 5

what are the complications associated with MS and how to treat?

Answer 5

bladder spasms - baclofen, Cyclobenzaprine, oxybutinin?
urinary retention - bethanechol
urinary incontinence - amitryptiline
neuropathic pain - gabapentin, amitryptiline

Question 6

how to dx GBS

Answer 6

lumbar puncture
“albuminocytologic dissociation”
lots of protein but few cells

Question 7

GBS treatment/management

Answer 7

supportive. don’t hesitate to intubate if needed.
IVIg

DONT GIVE STEROIDS. will worsen. and higher chance of relapse.

Question 8

what is 1st and 2nd line treatment for MG.

tx for MG crisis

Answer 8

1st line: pyridostigmine (anticholinesterase)

2nd line if nonresponsive to 1st line: steroids

crisis: IVIg

btw don’t forget to look for the thymoma. but i’m sure you knew that

Question 9

what are the antibodies against in MG vs Lambert eaton

Answer 9

MG: post synaptic ACh receptor

LES: Ca channels in presynaptic membrane -> prevent ACh release

Question 10

since LES is weakness in less used muscles as opposed to in MG, which muscles/presentation have weakness?

Answer 10

proximal muscle weakness.

hard getting out of a chair. reaching up to cabinet/shelf.

Question 11

how to dx LES?

Answer 11

EMG. initial muscle contraction is small waves. get bigger and bigger the more they contract. opposite pattern of MG

Question 12

treatment of LES

Answer 12

look for and treat the small cell lung cancer

if not related to cancer, use immunosuppressants (Azathioprine, 6-MP)

Question 13

patient presents with combined UMN (hyperreflexia, weakness) and LMN (hyporeflexia, fasciculations, weakness) findings (Babinski can be different on each side), with sparing of sensation.

dx? what test to dx?

Answer 13

ALS

Dx by EMG

Question 14

dopamine agonist treatment med names (older and newer)

when would you use these in Parkinsons?

Answer 14

older - bromocriptine
newer - Ropinirole and Pramipexole

for young (<60-70 years old) and functional people

Question 15

when do you use ACh R-antagonists like Benztropine in Parkinsons?

Answer 15

young people with tremor only.

side effect profile not worth for elderly.

Question 16

what are Selegiline and Capones and how are they used in Parkinson’s

Answer 16

Selegiline - MAO-B antagonists
Capones - COMT antagonist

used when Levodopa-carbidopa starts wearing off. they inhibit the enzymes that break down dopamine.

Question 17

no cure for essential/familial tremor but what can you give for symptomatic control?

Answer 17

BB

Question 18

what is intention tremor caused by?

Answer 18

cerebellar dysfunction. from stroke or atrophy of cerebellum

Question 19

elderly male has sciatica like pain and positive straight leg test, no history of heavy lifting. dx/next step?

Answer 19

xray and possibly MRI to rule out compression fracture. if negative, -> osteophyte.
neurosurgery > conservative management

Question 20

warning sx of lower back pain indicating emergency (6)

what do u give immediately (besides surgical intervention)

Answer 20

1. history of cancer
2. urine or bowel incontinence or retention
3. erectile dysfunction or priapism
4. bilateral LE weakness
5. sensory deficits in dermatome pattern (saddle anesthesia)
6. fever

give dexamethasone!

Question 21

guy was lifting heavy stuff, now has back pain. positive straight leg test, exacerbated by hip flexion, movement, cough, activity.

dx? tx?

Answer 21

disc herniation

neurosurg better than conservative management at 6 months. same after 1 yr or more

Question 22

woman with back pain. on physical exam, “point tenderness or vertebral step off”

Answer 22

compression fracture. she has osteoporosis

Question 23

elderly person with leg and butt pain, pseudoclaudication (positional and sx don’t reach all the way down to feet).
dx?

Answer 23

spinal stenosis.

confirm with MRI. needs surgery

Question 24

person with back pain, LOSS of pain/temp in cape like disstribution, SPARING of proprioception. can have progressive loss of motor and sensation. BURNS THEMSELVES WHILE COOKING. what is dx?

Answer 24

syringomyelia. (pocket of CSF bulges into anterior cord)

Question 25

person with hx of HTN, CAD, smoking, probably male. back pain, spastic paralysis and loss of proprioception. what is dx?

Answer 25

AAA with affected anterior spinal artery ASA

Question 26

elderly person with back pain, relieved by flatulance or BM. dx?

Answer 26

constipation

Question 27

treatment for MSK back pain (inciting event of heavy lifting but no disc herniation or fracture)?

Answer 27

NSAIDs and stretching. NOT BEDREST

Question 28

if person, esp younger, comes in with back pain, what visceral organ stuff do you need to consider?

Answer 28

kidney stone pyelo gyn stuff - ovarian torsion, cyst, ectopic preg, severe cramping

Question 29

management for disc herniation

Answer 29

NSAIDs, bed rest. as opposed to MSK injury which does NOT require bed rest!

Question 30

2 things to do that can improve or even cure BPPV

Answer 30

1. movement exercises dislodge and break up stones | 2. Epley/Semont/Foster/Brandt-Daroff maneuvers

Question 31

meds for labyrinthitis/vestibular neuritis (2)

Answer 31

often comes few weeks after a URI. if someone comes in with NEW ONSET sx you can give steroids within 72 hours. otherwise Meclizine for symptom control during episodes until condition naturally resolves in months

Question 32

tx for Meniere's dz

Answer 32

diuretics, low salt diet

Question 33

focal neuro deficits AND vertigo. next step for dx?

Answer 33

probs posterior fossa lesion imposing on cerebellum/brainstem. (tumor, stroke, vertebrobasilar insufficiency) get MRI. if neg get MRA. note: if neg, might just be complicated migraine

Question 34

what can you give for symptomatic vasogenic edema from brain tumor? (HA, vertigo, ataxia, psychotic sx, coma)

Answer 34

steroids

Question 35

person has stroke or TIA. on carotid ultrasound they have 60-70% stenosis. WHEN should you do a CEA on them? (now vs later)

Answer 35

within 2 weeks. emergent/acute timing.

Question 36

the 4 Ds of posterior circulation stroke

Answer 36

Dizziness (vertigo) Diplopia - double vision Dysarthria Dysphagia

Question 37

how many hours from onset of sx can you give tPA for acute stroke NOT due to bleeding

Answer 37

3-4.5 hours

Question 38

what are contraindications to give tPA? (in other words, even if pt has acute stroke < 3 hours onset, still can't give tPA)? (

Answer 38

any brain bleed ever | recent bleed in body (like GI bleed)

Question 39

if stroke is hemorrhagic you can't give them tPA obvis, but what can you give them whilst calling neurosurg

Answer 39

drop blood pressure sys <150 with IV drip | FFP to raise platelets and stop bleeding. esp if INR is high.

Question 40

what kind of stroke do u want to lower BP vs raise/permissive HTN? what are the BP goals for these situations?

Answer 40

hemorrhagic - drop BP with IV drip sys <150 | ischemic (embolic, thrombotic) - permissive HTN for first 24-48 hours. 210/120 max w/ tPA. 180/105 max w/o tPA

Question 41

when trying to find etiology of stroke what tests do you do? CT wo contrast is always first. if that's neg and no signs of bleeding where else do u look?

Answer 41

EKG - look for a-fib (CHADS>2 give warfarin w/o bridge) Echo - look for thrombus (warfarin w/ bridge) Carotid US

Question 42

u do carotid US on person who had stroke/TIA. what is treatment for different % stenosis?

Answer 42

60% and symptomatic (stroke, TIA) or >70% = CEA within 2 weeks (stent if can't tolerate open surgery) otherwise just medically treat the artery dz

Question 43

if post stroke and not on tPA, you start ASA within 24 hours for 2ndry stroke prevention. if on aspirin they get another stroke (aspirin failure) what do you put them on next for antiplatelet?

Answer 43

add 2nd agent -> aspirin + dipyridamole. note: if allergic to aspirin, can use clopidogrel.