Neurology

Question 1

What is the ddx for spinal cord compression?

Answer 1

metastatic cancer

primary tumors

transverse myelitis

epidermal abscess

epidural hematoma

herniated disc

spondylosis

Question 2

How to work up spinal cord compression with symptoms?

Answer 2

start steroids (dexamethosone)

MRI

neurologic emergency! may need surgery

Question 3

What are the red flags in back pain (cord compression)?

Answer 3

unremitting back pain

constant pain at night

pain worse with laying down

neuro symptoms

sexual function deficits

age >50

prior cancer hx

unexplained weight loss

pain lasting > 1 month

no improvement following conservative tx

Question 4

What is the next step when you find cancer in the spine?

Answer 4

CT to look for other cancer (breast, lung, liver)

Question 5

What is the treatment plan for spinal cord compression with focal neuro findings?

Answer 5

steroids: high dose dexamethasone!!!

if cancer - radiation/chemo depending on cancer

may need sugery if need tissue dx, spinal instability

Question 6

What is the dx in a pt with evolving paralysis and areflexia and no other systemic manifestations?

Answer 6

Guillain Barre

(demylinating disease)

Question 7

How do you dx Guillain barre?

Answer 7

LP

Elevated protein, no WBC

dx test is EMG/Nerve conduction velocity

hx of infection (campylobacter), ascending symmetric weakness

Question 8

How does transverse myelitis present?

Answer 8

clear motor and sensory level loss

hyperreflexia below level

loss of anal sphincter tone

Question 9

How does Botulism present?

Answer 9

early loss of pupillary reflexes and CN abnormalities

paralysis is descending

Question 10

How does Charcot-Marie-Tooth disease present?

Answer 10

very slow onset, rarely gets severe

foot drop/weakness or sensory loss stocking distribution

Question 11

How to manage Guillain Barre?

Answer 11

best to get tx w/in 2 wks onset

tx: plasmapheresis or high dose IVIg (both good)

monitor and provide respiratory support, cardiac arrhythmias, autonomic instability

Question 12

What is the prognosis in Guillain Barre?

Answer 12

good - most people full recovery with/in weeks to months

need PT

Question 13

Ddx for dementia?

Answer 13

normal pressure hydrocephalus

chronic subdural hematoma

vit B12 def

hypothyroidism

terytiary syphilis

alzheimer’s dz

psuedodemential of depression

Pick’s dz (frontotemporal dementia)

Lewy body dementia

Question 14

What is the dx for an elderly pt with dementia, gait ataxia, and urinary incontinence?

Answer 14

normal pressure hydrocephalus

Question 15

How to work up and dx dementia?

Answer 15

reversible causes w/u: Thyroid function tests, HIV/AIDS (30-50 yo), Vit B12, CBC, VDRL, Drug screen, depression signs

MRI - shows atrophy and degeneration

Question 16

How to tx alzheimers?

Answer 16

social support (don’t get lost, prevent injury…etc)

Donepezil, rivastigmine, or galantamine (improve memory and slow loss of memory)

Memantine added to cholinesterase inhibitors (above)

Question 17

How to treat normal pressure hydrocephalus?

Answer 17

LP and remove 30-50ml of CSF and symptoms improve!

Place CSF shunt if caught early

Question 18

What bleeds in subdural hematomas?

Answer 18

bridging veins, can be chronic and slow

Question 19

What bleeds in an epidural hematoma?

Answer 19

middle meningeal artery

deteriorate fast after a lucid interval

Question 20

How to manage subdural hematoma that is symptomatic?

Answer 20

neuro/neurosurg consult

surgical drainage to relieve pressure on the brain

Question 21

What is the ddx for worst headache of life?

Answer 21

subarachnoid hemorrhage

pituitary apoplexy (during difficulty delivery of baby)

migraine

Question 22

What is the w/u for worst headache of life?

Answer 22

1. noncontrast CT!
2. if negative - LP bc CT is negative ~10% of time

*RBCs will not change (stay high) between CSF tube 1 and 4

3. could consider CT angiography or MRA (if other 2 are neg and still think it is an SAH, this is the gold standard and will need to be done either way)

Question 23

How do you figure out the cause of a subarachnoid hemorrhage?

Answer 23

CT angio

or MR angio

*if first image is negative, do a repeat study a little later

Question 24

What is a significant risk factor for subarachnoid hemorrhage?

Answer 24

1st degree relative with subarachnoid hemorrhage (anuerysm)

Question 25

How to tx subarachnoid hemorrhage?

Answer 25

ICU, telemetry and electrolyte monitoring, DVT prevention (compression devices, no antithrombotic meds) 1. neurosurgical consult 2. surgical clipping and coiling with 48-72 hours 3. Nimodipine (CCB) for 21 days to prevent post-SAH vasospasma and ischmemia

Question 26

What are complications of subarachnoid hemorrhage?

Answer 26

re-bleeding delayed brain ischemia from vasospasm hydrocephalus hyponatremia due to SIADH

Question 27

What is the most common cause of subarachnoid hemorrhages?

Answer 27

**aneurysm** less common: cocaine, arterial dissection, AVM, coagulopathy, trauma

Question 28

What is meniere's disease?

Answer 28

chronic vertigo unilateral hearing loss and tinnitus comes and goes

Question 29

What is vestibular neuritis?

Answer 29

labyrinthitis - inflammation of vestibular neuritis vertigo, acute, severe, unsteadiness GI sx: N/V, may last hours

Question 30

How to tx Meniere's disease?

Answer 30

meclizine salt reduction and diuretics

Question 31

What is a Ddx for seizure with focal symptoms?

Answer 31

sz with todd paralysis stroke w/ sz AVM w/ sz brain tumor w/ sz metabolic cause of sz cocaine overdose or alcohol/benzo withdrawal

Question 32

How to work up first time sz?

Answer 32

electrolytes, glucose, ABG, CBC, UA, tox screen CT with and w/o contrast or MRI w/ contrast if meningitic s/sx - LP

Question 33

What is a Todd paralysis?

Answer 33

hemiparesis that resolves within hours of sz

Question 34

What could a brain enhancing lesion be?

Answer 34

abscess, tumor, lymphoma, toxoplasmosis

Question 35

How to treat seizures that persist/status?

Answer 35

A, B, C IV benzo, benzo IV forsphenytoin/phenytoin IV phenobarbital propofol and intubation

Question 36

How to tx toxoplasmosis?

Answer 36

pyrimethamine and sulfadiazine + folinic acid if ring enhancing lesion in HIV + pt, start tx, then CT in 2 wks, if lesion isn't responding - further eval (biopsy)

Question 37

How to treat a patient for seizures in adults?

Answer 37

phenytoin (load and then daily dose) levetiracetam, lamotrigine, valproic acid

Question 38

What is the sz med lamotrigine's dangerous side effect?

Answer 38

cutaneous hypersensitivity - stevens johnson syndrome

Question 39

What vitamin must be given if a pregnant woman is on seizure meds?

Answer 39

folic acid!!! most sz meds deplete folate

Question 40

What are the major side effects of phenytoin?

Answer 40

cardiac toxciity hemolytic anemia, nephritis, fever, rash hirsutism, gingival hyperplasia

Question 41

How to w/u and tx concern for stroke?

Answer 41

CT non contrast (hemorrhagic or not) \*can take 24 hrs to show up! tPA if presents within 3 hoursof persistent neuro findings and no active bleeding aspirin is \> 3 hrs and no a-fib

Question 42

What studies do we need to get for stroke pts while inpt?

Answer 42

repeat CT 3 days later EKG ECHO Carotid doppler 24-hr telemety

Question 43

Who should be put on heparin if they have a stroke?

Answer 43

only if a-fib present! \*be careful, can make the stroke hemorrhagic

Question 44

Is it more common to have an ischemic stroke or a hemorrhagic stroke?

Answer 44

ischemic (80%) hemorrhagic (20%)

Question 45

What are contraindications for TPA in stroke?

Answer 45

previous stroke/head trauma w/in 3 months BP \>185/110 recent surgery w/in 2 wks abnormal PT/PTT GI/GU bleeding w/in 21 days PLTS \< 10k coma or stupor

Question 46

What aretery is affected in a stroke with symptoms of aphasia/apraxia (can't do a learned skill that you could before)?

Answer 46

middle cerebral artery emboli from heart lodge here 80% of time

Question 47

What is the most common source of emboli for embolic strokes?

Answer 47

HEART! a fib, mitral stenosis, vegetations