Yellow Pages 2.xlsx - Yellow Pages 1(1).csv Flashcards
(183 cards)
1
Q
A 40 yo M has noticed he cannot use the telephone with his left ear because he cannot understand the speaker. He has noticed over these same 4 months a high pitched ringing in his left ear. MRI - contrast enhancing mass in the left cerebellopontine angle
A
Acoustic Schwannoma
2
Q
68 yo F, treated for ET with propanolol, notes improvement. In the month of June she has had episodes of feeling lifhtheaded and nearly fainted when standing in church
A
postural hypotension
3
Q
35 yo F c/o episodes of the “world closing in” with racing of her pulse, diaphoresis, SOB, and tingling of hands and feet
A
hyperventilation/panic attack
4
Q
59 yo F, whenever she turns over in bed to lie facing the wall she has severe spinning, dizziness, nausa. Epply maneuver cures her
A
Benign paroxysmal positional vertigo. The Dix-hallpike maneuver is the provocative maneuver, the Epply maneuver helps get the debris out of the canal. Pathology of BPPV is otoliths stimulating hair cells and making the patient profoundly vertiginous and unidirectional nystagmus
5
Q
24 yo F has tinnitus, vertigo, low frequency hearing loss 3x per year for 2 years
A
Meniere’s disease. Requires more than one episode of vertigo. Eventually low frequency hearing loss develops. Tx - labyrinthe ablation with gentamycin
6
Q
45 yo F, no PMH, p/w dizziness, dysarthia, ataxia over 10 days. Unable to sit or stand w/o assistance, has bilateral dysmetria of upper and lower extrmities
A
Paraneoplastic syndrome (Anti-yo). Associated with small cell lung, gyn, and Non-hodgkins
7
Q
72 yo M p/w sudden severe occipital headaches. Feels he is spinning + falling to the right. Symptoms worsened by coughing, has vomited several times. Exam shows he is unable to stand and has bilateral horizontal nystagmus. BP 170/100
A
Cerebellar hemorrhage. Patient likely needs emergency surgical evacuation
8
Q
80 yo F p/w sudden momentary vertigo, diploplia, and numbness around her mouth. Transiently unable to walk but symptoms then resolve
A
TIA - when in the vertebro-basilar circulation, gives multiple symptoms. Isolated vertigo is rarely a sign of TIA and is more consistent with BPPV
9
Q
55 yo M c/o unsteadiness and lightheadedness on standing. Mild resting tremor and cogwheeling in the upper limbs. BP falls from 140/90 to 110/60 when he stands. Also c/o profound constipation
A
Multiple system atrophy (Shy-drager). Parkinsonian syndrome + autonomic insufficiency. These syndromes are less responsive than idiopathic PD to dopamine repletion
10
Q
50 yo M with h/o ETOH abuse develops slow shuffling steps, difficulty with turns, and urinary incontinence. Recovered from pneumococcal meningitis 5 years ago
A
Communicating hydrocephalus (NPH). Symmetric enlargement of ventricles, presumably 2/2 scarring after meningitis, cal also be seen after SOH or head trauma. next step - high volume tap to see if gait improves
11
Q
83 yo F has become progressiely forgetful, gets lost in neighborhood, fearful someone will break into her house, fails to recognize family, withdrawn. Remembers 0/3 objects at 3 minutes. MRI - cortical atrophy and diffuse enlargement of the ventricls
A
Hydrocephalus ex vacuo. This patient has AD, she has brain atrophty and the ventricles have dilated to fill up the space
12
Q
57 yo M c/o 5 months of progressive difficulty walking and tripping on his own feet. + frontal headache for couple of weeks. Exam - spasticity in the legs and hyperactive reflexis, bilateral babinskis. normal sensory exam
A
Parasagital meningioma. Not coming from spinal cord, because you would also expect a sensory change. The other area of the brain that can selectively target leg fibers is the frontal parasagital region - meningiomas in this area can become quite large before causing gait and exective symptoms
13
Q
35 yo M c/o headaches, gets an MRI/ Learns that “my ventricls are big and I’ve had this all my life” The physician notes that the man’s 4th ventricle is of normal size
A
Aqueductal stenosis, the 4th ventricle will be normal. Sometimes, the hydrocephalus will decompensate in adult life and requires shunting
14
Q
60 yo M c/o tingling in his arms and legs, sensation that the limbs are swollen. Feels unsteady on his legs, especially in the dark. Over 4 days has developed weakness and SOB. Exam - no DTR and nearly absent proprioception and vibration of the limbs. + bilateral facial weakness
A
GBS. Absent vibration and proprioception suggests large myelinated fiber involvement
15
Q
39 yo F with h/o cervical CA develops HA and unsteadiness. HA worsens when lies flat or bends forward. Associated with diploplia and nausea
A
obstructive hydrocephalus. patients with raised ICP may develop 6th nerve dysfunction from the pressure. likely 2/2 met , may require shunting before radiation therapy
16
Q
17 yo F develops morning headaches and nausea, becomes increasingly unsteady on her feet. Has mild left facial weakness and left limb dysmetria as well as papilledema
A
Medulloblastoma. Most adult tumors are supratentorial. Many peds tumors are infratentorial such as this medulloblastoma. Brainstem astrocytomas are also more common in childhood
17
Q
45 yo F brought to hospital after sudden onset R sided weakness. Symptoms appeared following a visit to the ICU to see her father who just had a stroke. Patient is mute, calm, and cooperative. She follows all commands, no abnormalities save for subjective r sided numbness
A
conversion disorder. the nature of the patient’s symptoms may reflect the traumatic event to which he or she has just been exposed
18
Q
78 yo F brought in by her daughter who notes she has been abusive to some of her appartment neighbors. On exam, pupils are small and react only when asked to look at her nose but not to light. Sensation markedly diminished to vibration over the distal legs. absent ankle reflexes. mmse 20/30
A
Neurosyphillis. patient has argyll robertson pupills
19
Q
67 yo M with no PMH, brought in by his wife. During breakfast that AM, he stopped eating and kept asking her the same questions. Couldn’t remember the date, but continued to eat breakfast. After 4 hours, he suddenly began behaving normally, though he recalled nothing of that morning. His PE was wnl
A
Transiet global ischemia. This can be provoked or idiopathic, thought to be related to venous congestion in memory areas. It can recurr, but does no infrequently and recovery is complete
20
Q
30 yo M with no PMH becomes disoriented over two days. He is unable to remember new info and is agitated. MRI shows flair abnormality in both hippocampi
A
Paraneoplastic disorder (limbic picture), likel;y irreversible. Can also happen with HSV encephalitis
21
Q
58 yo M has a CABG c/b afib and a wound infection. He is hospitalized for 3 weeks and returns to work 1 month later. He was previously an active exective, but complains of difficulty multitasking.
A
hypoxic-ischemic encephalopathy. more common than stroke as a complication of cardiac surgery. thought to be due to multiple micro-emboli. symptoms are likely to improve
22
Q
60 yo M falls asleep at the wheel of the car. He hits the steering wheel with brief LOC. Over the next several days he seems lightheaded and complains of nausa and inability to complete his income tax returns
A
Concussion - p/w sleep isturbance, mood change, poor concentration and memory, light headedness, nausa. Can persist for days to months. During immediate period s/p concussion, patient shouldn’t be in a situatin where he can incur another blow to the head
23
Q
50 yo M undergoes personality change over a period of about 3 months. Is disinterested and apathetic. Exam - mild dysarthria, exhibits an exaggerated startle response to the phone ringing and seems to have difficulty navigating the office hallways when he returns from the bathroom
A
CJD. Mad cow is a slower syndrome, seen in younger patients mostly in the UK. Diagnosis made by looking for characteristic abnormalities in posterior hemisphere on diffusion weighted MRI, and presence of 14-3-3 protein in the CSF.
24
Q
79 yo F is afraid to be left in the house alone. Goes to the frocery store 3x per day and keeps large amounts of toilet tissue and bottled water in her room. 2x in the past month she has gotten lost on the way home from the grcery store. Unable to balance her checkbook
A
early AD - paranoia, hoarding behavior, visuospatial defects. A good sdative in this older impaired age group is quietiapine
25
Following the death of her husband, a 79 yo F loses appetitie and fails to call her friends or meet with them for their usual activities. She sleeps a lot during the day, but awakens at 4am an dpaces the house.
Major depression. this patient has a clearcut precipitating event, sleep disturbance, and anhedonia
26
8 yo M has a respiratory arrest during an asthma attack. He is untabted and resucitated after a 30 minute effort. 48 hours later he is unresponsive and requires artificial ventilation. GCS 3. No corneal responses, pupils are 6mm and fixed. Cold caloric testing shows no response in either ear, apnea test shows no spontaneous repirations. Patient is Eurthermic and EEG is isoelectric
Brain death. GCS = 3 for brain death. Spouse is first decision maker, followed by parents, followed by oldest child, if relevant
27
75 yo M develops congitive impairement involving more than memory and severe enough to interfere with occupational or social functioning. His condition is properly called
dementia, you are given insufficient info to make a specific diagnosis.
28
24 yo F has been taking AED's for 15 years. She has decided to begin OCP's, but obgyn counsels her that her contraception could fail become of the effects of her epilepsy drug
Phenytoin is a potent enzyme inducer. It can change the efficacy of OCPs as well as other steroids
29
52 yo F has been treated with several cycles of high dose chemotherapy for leukemia. After one of these she begins to have slurred speech and taxic gait as well as incoordination of the limbs
Cytosine arabinsode - after several cycles of this drug, some patients can develop a possibly irreversible cerebellar ataxia. 5 FU also causes this SE
30
30 yo M with schizophrenia c/o bouncy legs for several weeks (akathisia). He is involved in an MVC and comes into the ED highly combative, appears to be hallucinating. He is given a medicine to help sedate him and develops dysotonic posturing of the limbs and forced upward deviation of his eyes
This patient was probably taking something like Haldol but then was given a different antipsychotic and had a dystonic reaction to it. Treatment - IV benadryl. Reglan, depakote, and amphotericin B can also cause dystonic reactions
31
47 yo M recently finished radiation therapy for a right frontal GBM. He is taking two other medications, one is for "swelling" and one is for "seizures". He presents to the ED with diffuse erythematous rash and bullae on the lips. Family notes he has been hallucinating for several days and has been unable to sleep. What medicine is likely to be responsible for the hallucinations?
corticosteroids - patient probably taking them for the edema. See agitation, sleep disturbance, and paranoia and may end with the need for neuroleptics
32
8 yo F brought to the ED due to ataxia and diploplia for 1 day. H/o seizures treated with carbamazepine. Was treated last week with a medicine for sore throat. Her carbamezepine level is found to be 14. What medicine caused this level alteration?
Erythromycin - known association between these two drugs. Elevated leels of carbamazepine (tegretol), phenytoin, oxycarbazepine are assoicated with ataxia, nystagmus, and diploplia
33
30 yo F with epilepsy wishes to conceive and has been seizure free for 3 years. She has gained considerable weight on the medicine, has had hair loss, but is afraid to stop. OBGYN strongly counsels her against this med due to possible NTD
Valproate/depakote
34
50 yo M with HLD, depression, and angina has had difficulty climbing stairs for the last three months, finds he can't get out of a chair without using his arms. Normal sensory exam, normal reflexes. CK is 500. What drug causes this?
Statins have been assoicated with a range of MSK symptoms including myopathy that may have a normal or elevated CK
35
45 yo F with low grade astrocytoma has been taking a seizure med for 1 week. Becomes confused and lethargic
oxcarbazepine - this AED is most associated with hyponatremia - electrolytes should be checked within 10 days of starting the drug. Polypharmacy with diaretics may aggrevate the situation
36
25 yo F with h/o major depression, hypothyroidism, and migraine headache. She takes abortive therapy for migrains with eletriptan, and doesn't remember her psych medicine that she has just started. She comes to the ED with HA and nausea for several hours and has a GTC seizure
bupropion - this antidepressent is associated with lowering the seizure threshold, should not be given to patients with epilepsy
37
5 yo F brought to the ED with c/o blurred vision and seeing strange bugs on the walls. Mom fears she took one of her medications. The child is mildly febrile, pulse is 124, and she is agitated. Which drug did she likely take?
benzotropine - these are symptoms of anticholinergic excess. Mom probably takes these meds to counteract the effects of her neuroleptics.TCA's can also cause anticholinergic effects.
38
48 yo renal transplant recipient becomes confused and agitated 4 days s/p transplant. While his pupils react, he appears unable to see. He has been mildly hypertensive post-op
Tacrolimus - can cause cascular injury with loss of autoregulation, hypertension, vasospasm, seizures, confusion, and an MRI/CT picture of often posterior leukoencephalopathy
39
Seratonin syndrom
SSRI + triptans - tremor, agitation, tachycardia, …
40
Benzo withdrawal
agitation, tachycardia, …
41
70 yo F awakened with mild left eye pain and now c/o horizontal diplopia worse at a distance. She has a 25 y h/o T2DM. PE reveals left eye fails to abduct on attempted gaze to the left. The remainder of the neuro exam is normal
Ischemic abducens palsy 2/2 diabetes. The diploplia is worse at a distance because the patient needs to abduct her eyes slightly from accomodation with near gaze. The cause is an infarct, with good prognosis
42
27 yo F with h/o MS delivers her first child. Shortly after the delivery she develops HA and her HP drops. She has bitemporal visual field abnormalities
pituitary apoplexy/ Sheehan's syndrome. Hemorrhage infaction of the enlarged pituitary peripartum. The patient will develop adrenal insufficiency
43
46 yo F has been on chronic steroid therapy for asthma for several years. She has avascular necrosis of the hips and complains of slow development of vision in oth eyes. The medical student examining her can't visualize her fundus
Cateracts - if the patient can't see out and you can't see in, the cause is likely a lens opacity - this is a common complication of chronic steroid use
44
55 yo M has severe headaches that awaken him at the same time each night. During the HA his eye is red and he has mild ptosis and miosis on the side of the HA
cluster HA - the only primary HA syndrome more common among men vs women. May be associated with a horner's syndrome. If this is a first time HA occurance with horner's one would have to worry about a carotid dissection, as the sympathetics run along the internal carotid
45
10 yo M has poor stereoscopic vision for several years. He has relative afferent papillary defect in his left eye where visual acuity is 20/60 best corrected. Vision in the R eye is 20/20
amblyopia ex anopia/lazy eye/poor vision 2/2 disuse of the eye - this child has always had poor vision in one eye, hence the failure to develop steroscopic vision
46
24 yo F describes sudden double vision. Diploplia is worse on left lateral gaze. PE shows eyes move conjugaely to the right, but when she looks left the right eye does not fully adduct and there is nystagmus in the abducting L eye
internuclear opthalmoplegia - the medial longitudinal fasiculus is involved. In an older person with would be a paramedian pontine perforating vessel stroke, while in a younger person demyelination is usually the problem
47
50 yo F describes pain on movement of her right eye. Over next several hours she notes "dimming of her vision in that eye. On exam her fundi are normal bilaterally but she has a right APD. Visual acuity is 20/200 OD, 20/20 O
optic (retrobulbar) neuritis - pain on eye movement with central scotoma is c/w optic neuritis. Retrobulbar or optic neuritis has a normal fundus with poor vision
48
Papilledema exam
highly anmormal fundus with an enlarged blindspot that later may increae to a ccentrocecal scotoma
49
75 yo F complains of shoulder, neck and hip pain for several weeks. L sided HA for three days, c/o blurred vision in her left eye
giant cell arteritis - this elderly patient has polymyalgia rheumatica. She is at risk for central retinal artery occlusion from the giant cell arteritis. ESR will be elevated, but the definitive diagnositic procedure is a temporal artery biopsy.
50
central retinal vein occlusion
congested veins, swollen disk, associated with polycythemic states
51
13 yo M c/o dizziness, slurred speech, and double vision. Symptoms resolve after 15 min, then c/o severe HA and begins vomiting
Basilar migraine. In an older person, these symptoms would raise concern for vertebrobasilar TIA's. Basilar migraine is a diagnosis of childhood
52
38 yo F collapses, and begins vomiting. Her neck is held rigidly and she has a dilated left puil. L lid is drooping and the L eye is slightly abducted into primary gaze
posterior communicating aneurysm- painful, pupil involving 3rd nerve palsy. Sequence of diagnostic testing: CT, LP, angiography. If this patient successfully has an aneurysm clipped/coiled and then deteriorates 3 days later, consider vasospasm and treat with nimidopine
53
49 yo F seen emergently become of R eye pain and HA for several hours. She has vomitied twice. Visual acuity is 20/50 on the R and 20/20 on the left. R eye is red and there is cloudiness of her cornea on that side, R pupil is 2mm larger than the L and reacts poorly to light
Angle closure glaucoma - as a rule of thumb, neuro events don't present as red eyes nd the cause is likely optho. Angle closure glaucoma is precipitated by variety of medicines, including tipiramate
54
45 yo M was struck in the eye with a brick during a brawl the night before. He took some aspirin and went to work in the morning, but noted diploplia when he looked up only. On exam his R eye fails to elevate when he is asked to look up and to the left. visual acuity is 20/20 bilaterally
muscle entrapment - when a pateint has a trauma, and diplopia in only one plane of gaze, then the problem is likely local in the eye/orbit. Here, full adduction of the right eye limitation is mediated by inferior oblique
55
37 yo F has 6 months of R sided HA. On exam she has L sided increased muscle stretch reflexes and a homonymous L superior quadrant defect
This patient likely has a neoplasm of the R temporal lobe, affecting meyer's loop. The optic radiations subserving superior visual fields that swing forward into the temporal lobe
56
25 yo F c/o visual problems. She has cirumferential visual loss bilaterally sparing central vision. The visualfield remains the same no matter how far from the testing screen the exam is performed
tunnel vision represents functional visual loss. As the test screen is moved further away the area perceived should enlarge (this is seen with the very organic disease of optic atrophy due to neurosyphillis). Tunnel vision should suggest either malingering or conversion disorder
57
70 yo F c/o severe intermittent right sided cheek pain lasting for 3-5 min. these are precipitated by brushing her teeth. She has had numerous episodes on a daily basis. PE was normal
Trigeminal neuralgia- treatment of choice is carbamazeine. In a younger person, the advent of this syndrome would raise concern for MS
58
74 yo F lost 15 pounds, c/o severe HA and jaw pain when he chews on meat. Exam is normal. Hb is 11
temporal arteritis - a systemic disease with anemia and with jaw claudication. The patient needs a temporal artery biopsy
59
52 yo F has had HA for several years. She just has been involved in a car accident in which she briefly lost consciousness and hit the car in front of her. A CT in the ED w/o contrast shows a hyperdense left frontal parasagittal mass that enhances uniformly with contrast.
meningioma - a lesion in the parasagittal lesion that is hyperdense (full of calcium) on unenhanced CT and that enhances uniformly is probably extra-axial (ie meningioma). Perhaps she had a seizure but perhaps the finding is incidental. A glioblastoma would enhance heterogeneously and would be intra-axial
60
35 yo M is awakened nightly by severe steady retro-orbital left sided HA that lasts for about one hour. He paces around and his wife comments that his left eyelid seems to drop during the pain
Cluster HA, beware the initial horner's without prior h/o HA
61
38 yo F has daily HA's for 3 months. The pain is dull and worsens as the day goes on. Exacerbating features are loud noises or stress at work. PE is normal
Tension HA - more frequent but individually less severe than migrains, they have no well established therapy. Ergonomic adjustments can be made in the work-related HA situations
62
27 yo F has twice monthly HA's that begin with steady increase in pain over the right side of her head. After about 1 hour, she has n/v and photophobia, and severe throbbing HA that can go on for hours. Sleep relieves the HA. What med should be given?
Sumatriptan - migraine w/o aura. Patients with uncontrolled hypertension or CAD should not receive triptans
63
16 yo F had a wisdom tooth extraction and drainage of an abscess. Returns the next day with HA and fever. She has proptosis and erythema of the eyelid on the affected side. She is able to abduct her eye slightly but has no other eye movements
cavernous sinus thrombosis - the eye movement abnormalities are key to the localization. Erythema/proptosis tell you something inflammatory/neoplastic is going on. If the patient had been in an accident, she could have had a carotid cavernous fistula with actual pulsation of the eye
64
47 yo F with no PMH comes to the ED having a GTC seizure. She has felt generally achey for two days. She is obtunded with temp 101, she is diffusely hyperreflexic with bilateral babinskis. She has an emergency CT that shows hypodense areas in both temporal lobes Infection and CSF findings?
encephalitis (CT suggests HSV, which is necrotizing). OP 21, WBC 121, 91%L, RBC 400, GLU 69, protein 97. treatment is acyclovir
65
32 yo HIV+ man with CD4 ct of 120 comes to the ER with 2 days of HA and now intermittent disploplia and intermittent blurred vision. He has bilateral papilledema. CT showed mildly enlarged ventricles Infection and CSF findings?
Cryptococcus - elevated opening pressure is key. Ventricles are enlarged because he has raised ICP and incipient communicating hydrocephalus. Treatment is amphoteracin B and flucytosine. OP 37 WBC 43, 80% L, RBC 0, GLU 78, protein 157
66
2 yo F is treated with abx and recovers from a severe CNS infection. She is left with profound bilateral sensorineural hearing loss. Infection and CSF findings?
bacterial meningitis is associated with hearing loss and visual loss (hellen keller probably had H flu meningitis as a young child). Low sugar and elevated polys are key. OP 27, WBC 2,300 90% PMN, RBC 0, GLU 29, Protein 347
67
40 yo M born in mumbai emigrated to the US 4 years ago. Has felt unwell for about a month and has double vision on looking to the left for 2 days. He has a mildly stiff neck and a left sixth nerve palsy. He is somewhat inattentive and lethargic. A CT scan shows mildly enlarged ventricles Infection and CSF findings?
TB meningitis - country of origin, associated with basilar meningitis with multiple cranial neuropathies, raised ICP, and hydrocephalus. OP 25 WBC 120 100% L, RBC 0, GLU 32, Protein 220
68
27 yo M who works as a nurse completed a series of hepatitis B vaccinations one month previously. He complains of tingling in all limbs and is diffusely weak with absent DTRs, Infection and CSF findings?
GBS after a vaccination. There is albuminocytologic dissociation; OP 13, WBC 3 100% L, RBC 0, GLU 78, Protein 450
69
8 yo M receiving chemotherapy for ALL complains of ear pain. He has inability to close his left eye, flattening of the Lnasolabial fold, and is unable to wrinkle his forehead on the left. The tympanic membrane is reddish, and some raised red lesions are seein in the external auditory canal
varicella zoster - in the setting of zoster, the third devisionof the trigeminal nerve and left facial palsy (Ramsay hunt syndrome), tx = acyclovir IV
70
38 yo HIV+ man develops HA and L sided weakness. MRI with contrast shows multiple enhancing periventricular masses that continue to grow despite toxoplasmosis therapy
EBV, in the situation of multiple mass lesions in a patient with HIV, the asumption of toxo was correct. However, if they continue to grow, primary cns lymphoma must be considered. This is associated with HIV + EBV
71
13 yo child develops bilateral facial weakness after a family camping trip to the poconos
burgdorferi - lyme disease
72
45 yo F who has taken corticosteroids very frequently for SLE develops HA and stiff neck. Her OP is elevated and she has 200 lymphocytes in her CSF and a negative gram stain
C neoformans. Imminocompromized, elevated opening pressure. Cryptococcal antigen would be the diagnostic procedure
73
62 yo M has a temp of 103, 5 days s/p colectomy for diverticulitis. He had a lumbar epidural catheter for pain control that was removed on POD 4. there is tenderness at the catheter site and hyperreflexia in the legs with bilateral extensor plantar responses
Treatment = ceftriaxone/vancomycin; this patient has an epidural abscess (UMN signs). Etiology likely 2/2 catheter and skin-derived organisms like S aureus
74
20 yo F who emigrated from the dominical republic 4 months ago has a GTC seziure. CT showed multiple calcified lesions throughout the brain
Neurocysticerosis is the most common cause of acquired epielpsy in this part of the world (T solium). Tx = albendazole
75
19 yo college student develops HA, fever, and obtundation. + diffuse purplish rash on her abdomen. She is admitted and her roommates are told to take a preventative medicine
Neisseria meningitidies, her contacts are treated with Rifampin. This reducesnasopharyngeal colonization. Cipro is an acceptable alternative
76
37 yo businessman takes a january trip to chicago and strolls along lake michigan. The next day he notices a gritty sensation in his right eye and drooling from the r side of his mouth.
Bells palsy/7th nerve palsy. Use prednisone if the patient is seen in the first 48 hoursTx - valcyclovir/prednisone
77
pearls about pediatric infections of the cns
lyme - bilateral peripheral 7th nerve palsy; congenital CMV - hearing loss, spasticity, hyperintensities along the ventricular margins on MRI; Raw honey fed to a newborn - tetanus!
78
6 yo M is evaluated for a gait disorder. He walks on his toes, having begun walking at age 18 months. He has generalized hyperreflexia, bilateral babinskis, heel cord contractures, and occasional writhing movements of the upper limbs. Most likely diagnosis?
cerebral palsy, IQ may be normal
79
28 yo M construction worker is evaluated because of clumsiness. He has never been athletic but has noticed an increased tendency to trip. 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 JP at toes
Charcot marie tooth disease. The most common form of peripheral neuropathy. The myelinated fibers are preferentially affected and severity varies.
80
16 yo M evaluated for weakness that involves lifting heavy objects and climbing stairs. His 50 yo uncle is wheelchair dependent with severe weakness. The patient has atrophy of the shoulder and pelvic muscles. His CK is 2340
BMD- this is compatible with the patient already being 16 and his uncle being 50.
81
25 yo F has had several operations to remove skin lesions. She complains of pain in her neck that radiates into the left thumb and index finger. She has an absent biceps and brachioradialis with 2+ reflexes elsewhere. An MRI of the cervical spine shows a dumbell-shaped enhancing lesion at the C6 neural foramen
NF1 - 10x more common as NF2, the latter is associated with acoustic neuromas
82
9 yo M with autism has seizures that are investigated with an MRI. The scan shows numerous subependymal nodules, clostering around the foramen of Monro
tuberous sclerossis. There are two different types, type 1 is less severe and possibly associated with normal intellect
83
12 yo M has torticollis and several facial tics. He also makes gutteral, sometimes obscene utterances. These are greatly diminished when haloperidol is added to his medicines
tourettes - tx is haloperidol or risperidone, the latter preferred recently
84
22 yo F has been weak for 3 days. She reports numerous ER visits for abdominal pain, one occuring right after treatment for a UTI with sulfa abx. On exam, she is diffusely weak and arreflexic without babinskis. There is diminished to pp in stocking glove pattern
acute intermitted porphyria - treatment is IV hematin. The drugs that stress the rate limiting step in Hb metabolism by inducing enzyme function and thus precipitate an attack are sulfa, hormones, and barbiterates
85
25 yo M c/o muscle cramping after exercising or playing basketball. He has dark urine during these episodes. All symptoms resolve within a day.
McArdle's disease - exercise -->glycolyti pathway problem in this instance myophosphrylase: muscle cramping, weakness, dark urine
86
12 yo F is found to have an idiopathic condition of the spine. Her mother has a h/o of the same. She has curvature of the thoracic spine concave to the right. Neuro exam is normal.
scoliosis- has no clearcut known cause
87
5 month old child has a generalized seizure that began with tonic clonic movements of his left arm. He had an uncomplicated delivery at 37 weeks, but head circumference is at the 5th percentile. He responds poorly to sounds and has increased muscle tone with clonus at the ankles. CT shows small hyperdensities along the margins of the lateral ventricles
congenital CMV infection. The nodules are characteristically subpial and subependymal. Congenital CMV syndrome: retardation, microencephaly, seizures, and hearing defects.
88
12 yo reports balance problems. He is areflexic with skyphoskoliosis and pes cavus.
friedreich's ataxia. Typically an autosomal recessive disease,with onset before age 25. the kyphoscoliosis and pes cavus become apparent in childhood along with the gait difficulty. Retinitis pigmentosa-ataxia and dysarthria and absent reflexes are due to sensory axonal neuropathy as well as systemic signs of DM and cardiac conduction and symmetric setpal hypertrophy problems. major pathologic areas are posterior columns, dorsal and ventrial spinocerebellar tracts, and lateral corticospinal tracts. treatment - idebenone, a coenzyme Q10 short-chain analogue that acts as a free radical scavenger.
89
47 yo M p/w progressive weakness of hands and feet and ptosis. He has DM and hypothyroidism. On examhe is balding with wasted temporalis muscles. He shakes his hand with the examiner and can't let go
myotonic dystrophy - an autosomal dominant disorder, associated with failure of muscles to relax, ptosis, and T2DM, hypothyroidism, frontal balding, and a slow course compactible with presentation in mid adult life!
90
45 yo M has been taking isoniazid for TB prophylaxis since a positive PPD on employment screening 6 months ago. He develops numbness andtinlging in his legs and has diminished proprioception and vibration to the mid calf with absent DTR's
pyridoxine (B6)
91
35 yo farm worker is brought to the ED with n/v that developed when he was in the field. He is diaphoretic anddiffusely weak with pinpoint pupils
organophosphate intoxication. Treated with atropine (muscarinic effects) and pralidoxime (nicotinic effects). ED personnel should avoid contact with the patient'sclothing.
92
23 yo comes to the ED agitated and confused. Friends say he got drunk last night, but they don't know what else went on. He is garrulous and places around the room. Pupils are widely dilated
PCP ingestion (story also consistent with cocaine)
93
22 yo F has been taking self prescribed meds to avoid the acne that plagued her in her teenage years. She complains of daily frontal headache and has bilateral papilledema
Vitamin A excess
94
A 74 yo F comes to the physician with her husband because she has been been forgetful since the beginning of the winter season four months earlier. She takes no medications did not receive the flu vaccine, and comments that everyone in the house seems to have a headache and nausea this season
carbon monoxide exposue - the season and the fact that others in the family are unwell are keys. People may develop globus pallidus necrosis some weeks after the exposure
95
40 yo M with h/o ETOH abuse comes to the ED confused and unsteady. He has nystagus in all directions of gaze with bilateral abducens weakness
thiamine deficiency - give thiamine before glucose. Suspect with any combination of confusion eye movement abnormalities
96
69 yo M who has had a total colectomy for UC and who has lost 20 pounds recently has a broad-based ataxic gait and is unable to stand with his feet together eyes open. He has absent ankle reflexes and diminished proprioception at the toes and ankles. there are no babinskis
vitamin E deficiency - spinocerebellar ataxia, myopathies, dysarthria, loss of DTR's, loss of vibratory sensation and proprioceptionn, anemia, retinopathy, impairment of immune response
97
49 yo F who works as a ceramics designer c/o abdominal pain and constipation for several months. She has weakness of her limbs, particularly involving the extensor uscles. Sensory exam is normal
lead poisoning - autonomic symptoms and the predominence of extensor muscle weakness
98
28 yo M with a seizure disorder comes into the ED because of unsteadiness and slurred speech. He has prominent horizontal nystagmus and biateral limb dysmetria. Ataxic gait
phenytoin excess - signs of phenytoin or carbamazepine excess are cerebellar
99
67 yo M c/o parasthesias in his hands and feet. He is known to have atrophic gastritis. Exam shows bilateral babinskis and hyporeflexia in upper and lower limbs. Vibration and position sense are diminished in the hands and feet
B12 deficiency
100
70 yo F has been in the hospital for 3 months after a severe bout of pancreatitis. She is receiving TPN and is now tremulous with cogwheeling of the limbs and stiffness
manganese intoxication - in the basal ganglia manifests as increased signal on T1. this can be seen in cirrhosis of many etiologies as well as excess manganese ingestion
101
55 yo M has been injured in a MVC. On arrival in the ED he is unresponsive. A subdural hematoma is drained and yet he fails to awaken. He has a generalized seizure on POD #2. what is the most likely electrolyte abnorality?
hyponatremia - the most common electrolyte abnorality in essentially any CNS process
102
33 yo M has a total body rash for 12 days and has experienced n/v and tinnitus. He has several oval patches on the neck and increased pigmentation around the axillae. Neuro exam shows decreased sensation to pinprick over the feet. He has some grayish lines on his nails
arsenic poisoning. Wells have resulted in epidemics of arsening poisoning in bangladesh
103
45 yo M with h/o alcoholism is brought to the ED with fever and flu-like symptoms. 48 hours after admission, he is agitated, disoriented, and has a total body tremor
delerium tremons. Withdawal seizures occur within 24 hours of cessation of ETOH. Rhabdomyolysis can be seen in the setting of delerium tremens. Confusion and sezures can also be seen after benzo or chlordiazepine (librium) withdrawal, usually with a fairly long delay of up to a week
104
51 yo auto mechanic has developed hand weakness and difficulty walking. On exam he has bilateral wristdrop and footdrop. Heis mildly anemic with mcv of 76
lead poisoning - key is the microcytic anemia
105
40 yo M with h/o ETOH abuse comes to the ED disoriented. A plastic container with a sweet smelling substance was found under his bed and his girlfriend is nowhere to be found. Strength and sensation are normal at initial exam. Bicarbonate is 9, with an increased anion gap. serum ketones are negative, Ua shows crystals. what did he ingest?
ethylene glycol smells sweet - it has been used as a drug of abuse of assault. Patients may develop profound peripheral nerve and cranial nerve dysfunction (almost locked in). Recent deaths of ore than 80 children in nigeria traced to diethylene glycol.
106
17 yo student who plays varsity tennis and double bass complains of pain in her left fourth and fifth singers. She has mild interosseous weakness. Reflexes are normal
ulnar neuropathy - it is traumatized as the arm is stretched. Treatmetn is transportation, or moving the nerve
107
69 yo M complains of back and leg pain. When he stands or walks the pain is worse. It is relieved a bit by bending forward. Straight leg raising is + at 45 degrees, weakness of hip flexor muscles bilaterally. Reflexes are absent in the lower extremities but normal in the upper extrmities. no babinskis
lumbar spinal stenosis - relief by bending forward is 2/2 eliminating lumbar lordosis and inceasing the diameter of the compromised spinal canal a bit. Patients say they are better going uphill/upstairs vs downstairs. An older diabetic could develop a painful leg with absent ankle reflex and decreaed quadriceps strength.
108
48 yo neurosurgeon c/o pain in his right heel and difficulty standing on his toes. He has mild low back pain. There is plantar flexion weakness of his right foot. The right ankle reflex is absent
S1 radiculopathy - akle reflex is S1. if this were a sciatic nerve lesion there would be damage to both the common and peroneal and tibial nerves with paralysis of all the muscles of the foot. Flexion of the knee would be impaired as well and the patient could not stand on either his heel or his toes
109
29 yo M complains of numbness in his hands. He has burned himself at the stove a couple of times. Exam reveals atrophy of the intrinsic muscles of the hands and diminished pp and lt in the hands and across the shoulder with preserved vibration and proprioception. upper limb reflexes are absent. reflexes in the legs are brisk and there are bilateral babinskis
syringomyelia (tube in the spinal cord) is a developmental anomaly associated also with arnold-chiary malformation. The key to cervical spine localization here is LMN signs at the arms and UMN signs at the legs. Syrinx tends to enlarge laterally with time (spares posterior columns). there is slow evolution of pain and kyphoscoliosis. at times, the syrinx is marsupialized or drained to the SAH
110
40 yo professional drummer complains of progressive numbness in his hands. There is worsened pain after a musical performance, and the pain also awakens him at night. On exam there is normal strength but tapping at the wrist produces pain in the first four digits
carpel tunnel . Tx - wrist splint at night, then division of the carpel ligament, usually highly successful.
111
axillary nerve entrapment
shoulder abduction, injured with clavicular and shoulder injury
112
anterior interosseous nerve entrapment
inability to make a pinch with thumb and index finger + normal sensation
113
27 yo F whose sister and first cousin have lupus complains of weakness that worsens as the day goes on. At times she has diplopia when she is fatigued. Exam shows orbicularis oculi weakness after repetitive lid closure and diplopia after sustained lateral gaze. reflexes and sensation are normal
NMJ dysfunction -this is a family with autoimmune diseases. This patient has MG. treatment is with pyridostigmine. Thyroid disease and a thymoma need to be considered
114
eaton lambert syndrome
paraneoplastic, weakness improves with exertion
115
botulism
presynaptic, failure of acetylcholine release, home-canned vegetables
116
59 yo M has been hospitalized for an allogenic stem cell transplant for one month. He has been largely bed bound with multiple infections. He now complains of R leg weakness. Exam shows weakness of right ankle dorsiflexion, eversion and great toe extension. there is decreased sensation on the dorsum of the foot and anterolateral shin. reflexes are normal
peroneal neuropathy - the common peroneal nerve is very vulnerable to injury where it winds around the neck of the fibula, here affected by pressure by pressure from lying in bed. Foot cannot be everted or dorsiflexed. Innervates tibilais anterior and extensor hallucis longus among others.
117
59 yo M complains of weakness or left leg pain. There is also some pain in the L buttok. Exam shows weakness of the L toe extesnsion and decreased pinprick over a small area of the to of the left foot. Reflexes are normal
L5 radiculopathy. Pain in the lateral thigh and anterolateral leg with sensory loss primarily in the dorsal aspect of the foot. Inversion is affected as well
118
a 49 yo M complains of mild weakness in his hands and his wife comments that his voice has been slightly slurred. Along with these symptoms over the past two months he has noted he occasionally trips. Exam shows brisk reflexes including jaw jerk and bilateral babinskis with atrophy and fasiculations of the anterior thigh muscles and several muscles of the forearm as well as the tongue. sensory exam is normal.
motor neuron disease (ALS) - the patient has no sensory signs but has both UMN and LMN signs. UMN signs are above the level of his LMN signs in part. This does not allow localization in the cervical spine
119
a 4 yo boy with tetrology of fallot has been lethargic for a week. He has had some mild weakness in left arm and eg and at least ons observed L sided seizure
cerebral hemisphere - cerebral lesion involving seizures, the pathology is probably a brain abscess
120
46 yo F complains of several weeks of posterior HA, mild dysphagia and unsteadiness. She has mild 4/5 weakness in her limbs with brisk reflexes throughout and bilateral babinskis. There are fasiculations in the R half of her tongue. Sensory exam is normal
foramen magnum - she has LMN signs in the form of fasiculations in her tongue, cereballar symptoms, and UMN signs. This could come from the foramen magnum region and possibly could be a benign process like a meningioma.
121
68 yo M returns one month after CABG because of weakness of his right hand. He has pain along the medial aspect of his r hand and forearm and began immediately after the operation. He has weakness of the right flexor carpi ulnaris, opponens, abductor pollicis brevi, and interossei
brachial plexus - this patient has been positioned incorrectly with shoulder externally rotated and hyperabducted during anesthesia, stretching the brachial plexus. Prognosis is good but he could develop a complex regional pain syndrome (pain, sympathetic changes in the skin, and atrophy if there is incomplete recovery.) other situations - prolonged swelling, casting for an injury, tumor infiltration from breast/lung, brachial neuritis, bith related injuries
122
78 yo M has undergone AAA repair. Following the surgery he is unable to move his legs. Pinprick is absent below T6 but proprioception is relatively preserved. There are no DTRs in the legs and toes are silent.
spinal artery occlusion - artery of ademkiewicz may be involved here. Anterior part of the cord is more at risk because the posterior cord is well supplied with radicular anastamosing arteriolar branches. There are no DTR at this stage becomes of spinal shocj. eventually the parapalegic patient will develop spasticity and UMN signs. acute treatment for spinal cord compression is high dose methylprednisolone
123
42 yo raiologist has been playing tennis and notes sudden neck and R arm pain radiating into his forearm. His arm is slightly weak in extension at the elbow and wrist. There is no triceps reflex on the right
C7 radiculopathy. Recall that in the cervical region the nerve root exits above the like-numbered vertebral body and that there are eight cervical roots and only 7 cervical vertebrae.
124
47 yo F p/w 5 months or progressive difficulty getting out of her car and climbing stairs. her arms ache after carrying grocery bags. No ptosis, diplopia, or speech or swallowing problems. There is weakness of arm abduction and hip flexion and extension. can't rise from a chair w/o using her arms. sensory examination is normal
muscles - probably polymyositis. Diagnosis is made by proximal distribution of weakness, elevated CK, and ultimately EMG.
125
70 yo M with prostate cancer has had back pain and now complains of weakness in his right leg. He has 3/5 strength in the right leg and mild weakness of the L side. Sensory exam shows diminished proprioception and vibration on the right and diminished pinprick and temp sensation on the left below T10
Brown-Sequard - the epidural spinal cord compression is lateralized to the R compressing ipsalateral corticospinal and posterior colmn functions and contralateral spinothalamic tract
126
10 yo child has asymmetric pupils several days after liver transplantation. Remainder of exam is normal. A left jugular vein catheter had been placed. Ptosis on the left, left pupil = 3mm, right = 5mm; both constrict normally directly and consensually
horner's syndrome - the patient's sympathetic chain has been breached. Remove the catheter!
127
myopathy of hypothyroidism
Hypothyroidism is usually associated with weight gain, cold intolerance, and some cognitive slowing, also produces a myopathy
128
myopathy of steroid exposure
proximal, painless myopathy
129
40 yo M has had progressively severe r sided headaches for three weeks. MRI with gadolinium shows a large heterogenously enhancing mass in the R temporal lobe. What medicine shoud you give?
steroids - the priority here is to reduce ICP. This could also be done more with IV mannitol
130
69 yo F c/o one month of intermittent left facial pain radiating to her upper teeth. The pain is sharp and electrical. Exam is normal. What medication?
carbamazapine - the diagnosis is trigeminal neuralgia, the treatment is a soidium channel blocking AED. In younger patients, this symptom makes one worry about MS
131
70 yo hypertensive man takes coumadin for afib. He had a syncopal episode earlier today and now is drowsy and complaining of head pain. What is the emergency diagnostic procedure of choice?
head CT - gives info about edema, blood, honey problems
132
55 yo M who is noncompliant with his medication comes to the ER with HA and confusion. BP is 220/130. What med?
nitroprusside - needs a parenteral quick acting antihypertensive agent
133
56 yo diabetic man complains of burning pain in the legs that keep him awake at night.his EMG shows a small fiber axonal neuropathy. Which med?
gabapentin (or nortriptyline)
134
67 yo M is not awakening promptly after CABG. He has had an MRI scan that showed an old left frontal infarct. Exam shows that at times hes is quite alert, but that at others he has word finding difficuty and stares straight through without reponding. What diagnostic test?
EEG - patient not waking up, waxing /waning in mental status with an inadequate explanation for an acute process on his MRI. Possibility of seizures 2/2 old infarct area.
135
pseudotumor cerebri
normal MRI or slit like ventricles, diagnosis by LP
136
30 yo F has mixed tension type and migraine HA;s. they used to be more severe, but now are more frequent, occuring up to 5 times daily. On each occasion she takes to ibuprofen, 2 fioricet (caffeine, barbituate, tylenol), and a cup of coffee. This regimen is being used 3-4 times per day. what therapy do you recommend?
stop medications - this patient has rebound headache. Using triptans, ergots, and fioricet more than a couple times of weeks can lead to this
137
35 yo F complains that she has had progressive weakness of her arms and legs. She is unable to comb her hair, get out of her car without assistance or go up stairs without holding on. Exam shows moderate proximal muscle weakness and but UE and LE. reflexes are 1+ and sensory exam is normal. what diagnostic test?
EMG - myopathic vs neuropathic
138
EMG of myopathy
no insertional fibrillations, low amplitude small motor units, early recruitment of motor units but normal interference pattern
139
EMG of neuropathic disease
fibrillation potentials on needle insertion, large motor units, reduced interference pattern when patient asked to contract muscle more strongly
140
48 yo F is about to enter an experimental protocol for metastatic melanoma. A neuro imaging study to required to rule out cns metastases. What is the best test?
brain MRI = better than CT, overal view of numbers of mets and possible meningeal disease
141
19 yo obese F has been taking tetracycline for acne and now complains of a severe HA. Her PCP has obtained an MRI that shows no mass lesions. Exam shows bilateral papilledema. What is the next best step in management?
LP - psuedotumor cerebri is treated with repetitive high volume LP's, and ultimately an VP shunt.
142
visual field of papilledema
enlarged blindspot with some peripheral field constriction
143
74 yo F has had memory loss since a small lacunar infarction1 year ago. She has no desire to go out, stays at home without calling her friends, and feels hopeless. She is taking one aspirin once daily as her only medication. MMSE is 29/30. what would be a good choice of medication
SSRI
144
80 yo F has been afraid to move outside her home or to be left alone. She frequently leaves the stove on and gets lost in her own backyard. MMSE 17/30. What medication?
Donepezil (aricept), a cholinesterase inhibitor. It has modest benefits for patients with mild/mod alzheimers dz
145
25 yo F has a 1 month h/o fatigue on running up the stairs. When she is tired her eyelinds feel droopy and twice she has had a 15 min episode of horizontal diploplia just after exercising. On repetitive lid closure her eyelids develop ptosis. Sensory exam and reflexes are normal
next step = EMG with repetitive stimulation for diagnosis; treat with pyrostigmine, a cholinesterase inhibitor
146
25 yo HIV + man with CD4 count of 40 comes into the ER with a generalized seizure. He has right sided hyperreflexia and a right babnski. MRI shows multiple ring enhancing lesions in the left parietal region. What is the apropriate first treatment?
pyrimethamine/sulfadiazine - this patient most likely has toxo. If lesions grow despite apropriate abx, he may have primary CNS lymphoma which would require dx by demonstration of EBV in CSF or brain biopsy
147
80 yo F has widely metastatic breast cancer and is cared for by hospice. She is moaning in severe pain and requests more medication. When she is pain free her respirations are slow and she becomes very somnolent
opiates - this patient should be given enough pain meds, understanding that such sedation my hasten death.
148
45 yo M with down syndrome becomes increasingly forgetful over a period of 12 months. He gets lost on his daily walks and has less ability to care for himself. Exam shows memory decreased from a prior baseline at 40. patient's mood and affect appear normal. Where is the pathology in the brain?
Nucleus basilis of Meynert - down syndrome patients develop early AD like changes. This is a cholinergic nucleus and some of the neurochemical pathilogy of alzheimers disease is cholinergic deficiency
149
26 yo miner is rescued after a mine explosion. He has been underground for 24 hours and is comotose on rescue. After two days he appears to be awakening slowly. Two weeks later he develops significant bilateral tremor. Where is the pathology in the brain?
Globus pallidus - delayed necrosis of the globus pallidus is a feature of CO poisoning
150
35 yo M has a personality change in the past 6 months. He has become irritable and impulsive and has made inappropriate comments at work. His father developed similar symptoms at about the same age. He has sudden course involuntary jerking of the arms. Where is the pathology in the brain?
Caudate nucleus - this is huntington's dz, autosomal dominant, triplent repeats
151
69 yo hypertensive man man develops sudden flinging movements of his right hand, accidentilly knowkcing over a coffee pot and burning his left leg. Where is the pathology in the brain?
subthalamic nucleus - the movement disorder described is hemiballismus. The stroke pathology is lacunar (small vessel) stroke. This is common in patients with DM, HTN< or a h/o smoking
152
50 yo morbidly obese woman undergoes bariatric surgery and has a prlonged period of n/v. she loses 70 pounds in a four month period and her family notices that she seems confused, lethargic, and forgetful. She has difficulty retaining any new information
mammillary bodies - apart from alcoholism and poor nutritional states (psychiatric conditions, chemotherapy) bariatric surgery is emerging as a cause of thiamine deficiency.
153
30 yo woman develops HA's. exam shows dilated pupils that do not react and inability to look up. When she attempts to do so, she develops refractory nystagmus
pineal - the eponym for this is paranaud's or dorsal midbrain syndrome and the pathology is in the pineal region. Could be a pinealoma or pineoblastoma, astrocytoma or other pathology. But the syndrome is region-specific.
154
70 yo M has been taking levodopa/carbidopa for 10 years. He has difficulty with persistent resting tremor of his right hand. Dosage adjustments has become very difficult and he has periods of dyskinesias of his limbs and other extremely bradykinetic "frozen" periods. he might benefit from what type of surgery? and of what area?
subthalamic nucleus - this area is either lesioned (ablative) or stimulated (DBS)
155
30 yo F presents with behavioral alteration. She can't seem to stop eating and has gained 30 pounds in the past two months. She grabs food and beverages and stuffs her mouth with both hands, complaining loudly when she can't eat at will. Where is the pathology in the brain?
Supraoptic nucleus - the eating disorder suggests hypothalamic involvement - this is the nucleus
156
57 yo M with lung cancer becomes weak over four weaks with limb weakness that improves with repeated strength testing. Sensation is normal
presynaptic acetylcholine terminals - eatern lambert syndrome is associated with antibodies to presynaptic calcium channels and decreased releae of acetylcholine. The patient's weakness actually improves with exertion, in distinction to MG/ the usual associated condition is small cell lung cancer.
157
65 yo M p/w painless, swollen, deformed ankle. He remembers falling 2 weeks ago. Where is the pathology?
afferent sensory fibers - this patient has a charcot joint - he is not guarding his injured ankle because he does not appreciate pain.
158
70 yo R handed F with longstanding hypertension and T2DM with sudden face, arm, and leg weakness. There are no sensory, visual, or speech deficits. Mechanism, image, treatment?
small vessel occlusion in internal capsule, aspirin + risk factor management. The patient has pure motor hemiparesis, thus, the pathology is not likely to be a carotid occlusion which would have given her sensory, visual, and language problems
159
24 yo M with h/o IVDU presents with fever and SOB. He has a loud diastolic murmur. Blood cultures show staph aureus. Within 24 hours of admission he c/o sudden severe HA and becomes less alert. His right leg appears to move less than his left leg
hemorrhagic stroke, antibiotic therapy - the patient has a sudden embolic event from endocarditis. It is to the ACA and rapidly becomes hemorrhagic. CT will show a lesion with blood and edema. He should not be anticoagulated.
160
Causes of stroke in younger patients
embolic event from endocarditis, dissection, patent foramen, coagulopathy, cocaine, vasculitis
161
55 yo M with a h/o ETOH abuse awakens to find his right arm is "lame." on exam he has weak elbow extension. Finger and wrist extension are even weaker than elbow extension. No clear cut sensory loss, though he is difficult to test. Remainder of neuro examis normal. mechanism and treatment?
not a stroke, Saturday night palsy, wrist splint. This is a radial n. palsy -only extensor muscles are affected. You can be sure of this by asking him to pronate his forearm and testing all the flexor muscles individually.
162
60 yo M develops sudden vertigo, dysphagia, and left facial numbness. On exam he has right arm and leg numbness, left facial numbness, left palatel paresis, a left horner's syndrome, and a R-beating nystagmus. mechanism and treatment?
Wallenberg syndrome - lateral medullary syndrome - lower crianial nerve dysfunction + crossed sensory signs. Mechanism is either vertebral artery occlusion or posterior inferior cerebellar artery occlusion. There is a risk or proximal propagation of thrombosis into the caudal basilar artery with worsening infart. Many doctors would fully anticoagulate such patients with warfarin
163
65 yo M comes to the ED with a two day history of fluctuating facial and arm numbness. For the last twelve hours he has been extremely weak in face arm and leg of the symptomatic side and has significant sensory deficit on that side as well. mechanism and treatment?
internal artery occlusion, treat with aspirin. This patient has had TIA's and now a completed stroke. He is outside the window of tpa and endarterectomy with reperfusion at this stage may actually be dangerous. CT is normal acutely but the diffusion weighted MRI shows stroke in the whole territory
164
58 yo F has a h/o afib but has refused to take coumadin. She has become somewhat forgetful in the past few months and complains that "she can't see right and I'm bumping into walls" mechanism and treatment?
vascular dementia - get her back on coumadin. Patient has had multiple cortical infarcts from a fib. Scans show multiple bilateral and a wedge shaped embolic stroke.
165
81 yo F with a broken hip develops confusion and agitation in the hospital. Eventually a neurologist is called and notes that all limbs are strong, but that she has an inferior quadrantonopsia and sensory neglect. mechanism and treatment?
recent mca embolism, unclear treatment. Nondominant parietotemporal (inferior branch mca) stroke. If this were a dominant hemisphere lesion on the other side the patient would have Wernicke's aphasia with pressure "world salad" speech. Treatment is unclear because we don't know how far away from her hip surgery she is.
166
68 yo lawyer has a seizure disorder since a stroke several years ago. He is in afib, on coumadin, digoxin, and phenytoin. He fell down during a witnessed seizure and has become less alert over the next several hours. mechanism and treatment?
subdural hematoma, surgical evacuation. This patient fell while anticoagulated. Concave appearnce on unenhanced CT. his coagulopathy should be temporarily corrected and the hematoma evacuated.
167
60 yo M had an episode of weakness of his right upper extremity and difficulty with word finding that resolved completely within 30 minutes. He has essential hypertension intermittently well controled. HR is 80 and regular. A soft L carotid bruit is heard and carotid dipplers show a 75% narrowing of the L ICA. echo is normal. mechanism and treatment?
TIA, endarterectomy. Greatest risk for TIA to stroke is less than 48 hours. In general, advice is to admit TIA's.
168
78 yo F is brought to the physician's office by her worried daughter and son in law. She has left the door to the house open on a couple occasions and forgotten an appointment. On exam she is a little anxious and tears at times. MMSE 26/30. she has slightly limited upgaze. pupils are irregular after cateract surgery. she has a mild tremor of the oustretched hand worse when she tries to write (like her dad and grandfather). she has a mild proximal musscle weakness on getting out of a chair. reflexes are 2+ except for the ankle reflexes which are absent. toes are downgoing bilaterally. mechanism and treatment?
not a stroke. Here the patient's one functional problem that deserves treatment might be the essential tremor. Treatment is with tipiramate or sometimes with beta blockers - both are hard to tolerate for older people. In geriatric neurology, important to distinguish what symptom needs a workup.
169
28 yo F who is 38 weeks pregnant develops HA, lethargy, and then has a generalized seizure
venous sinus thrombosis. Although the lesion is frequently hemorrhagic, treatment is anticoagulation.
170
biggest risk factor for stroke
hypertension. If the patient has hypertensive encephalopathy, first get the pressure down.
171
firm indications for warfarin
afib, decreased EF, mural thrombus, atrial clot, mechanical valves, DVT. Not intracranial vascular stenosis. Heparin for dissection
172
75 yo F becomes suddenly comatose. Where is the lesion?
sudden onset of coma associated with brainstem disease, pathology is less likely to be pontine hemorrhage or basilar occlusion - pinpoint pupils, quadraperesis, impaired eye movements
173
30 yo F has been unresponsive for 6 weeks following an electrolyite induced cardiac arrythmia. Her EEG shows normal sleep cycles but is unresponsive to external stimuli. She is deeply comotose but has roving conjugate eye movements. She has no advance directive and her husband and faily are quarreling over her care
persistent vegatative state - it takes 6 weeks to formally meet criteria for PVS. The patient is awake without being alert.
174
minimally conscious state
in which there is more apparent interaction with the environment compared with PVS
175
locked in syndrome
patient is awake but cannot move at all, except, usually, vertical eye movements. Thus the patient is competent to make own treatment decisions
176
30 yo woman has episodes of sudden daytime drowsiness. At times when confronted with a funny or emotionally laden situation, she will fall down abruptly.
cataplexy - treatment is with modafinil (provigil)
177
70 yo M is brought to the psychiatrist by his wife who is upset that he has been assaulting her at night. He remembers a recurrent dream about his house being robbed and he is fighting intruders. He has no prior psychiatric history and exam is normal
REM sleep disorder - innormal REM sleep there is loss of muscle tone. These patients act out their dreams. The syndrome is sometimes a harbinger of parkinsons disease
178
30 yo mother of 4 carries a diagnosis of seronegative lupus, MRI negative MS, chronic fatigue syndrome, IBS, and fibromyalgia. She now is concerned that a tick bite from 2 weeks ago has caused neuroborreliosis. She complains of diffuse joint pains, monocular diplopia, and body and head splitting sensory loss throughout the left side. exam is normal
Somatization disorder
179
69 yo F complains that she is losing her memory. She lives alone and does all her own housework, drives to a shelter at which she volunteers, and plays cards once weekly. She has lost 20 pounds in the past few weeks, and attributes it to not being interested in food. she is considered stopping her volunteer work. she frequently mentions her husband who dies last year and wishes she had a chance to talk to him about some longstanding issues between. general and neurologic exam, including MMSE are normal
major depresion - she appears at first to have dementia, but this is the pseudodementia of depression, which can be an early sign of alzheimers disease
180
71 yo M is transferred to the ICU because of fever to 104 and lethargy. He had undergone CABG five days previously and had nocturnal confusion since day two requiring haloperidol. Exam shows BP 170/90, patient is rigid with masked facies and resting tremor. CBC shows WBC of 13,000 with 80% PMNs. electrolytes and renal and hepatic function are normal. CK is 1200
neuroleptic malignant syndrome - treatmetn is with dantrolene, a direct skeletal muscle relaxant, or with benzos
181
37 yo F who had absance seizures as a young child but who has not been on any medication for years comes to the neurologist complaining of episodes of sudden fearfulness usually occuring when she is in bed. She feels her throat tightening, pulse racing, and vision dimming. she would like to go back on anti-epilectic medicines
not uncommon with patients with epilepsy discontinue their meds. Fear of seizures can lead to a phenotype hard to distinguish from the original events. The patient may need to be monitored in the epilepsy unit.
182
29 yo F comes to the ED with c/o stiffness in her legs and urinary urgency with some incontinence. One year ago she had an episode of optic neuritis. She has sensory level to pinprick at T10 and decreased vibration and proprioception at the ankles. She has bilateral babinskis. UA is normal. PVR is 20cc
detrusor hyperreflexia - this is the small capacity, UMN bladder, in a patient with MS. Fortunately her PVR is small and she likely has not had many UTI's as a result. Her detrusor hyperreflexia could be treated with oxybutynin (ditropan) or telterodine (detrol). beware cognitive problems on anticholinergics in patients with or without pre-existing cogntive dysfunction
183
59 yo M develops drooping of the left eyelid and diploplia. This varies throughout the day, worsening towards the end of the day when he also has difficulty swallowing his dinner. His has nasal speech and poor adduction of his R eye on looking to the left. pupuils are equal and reactive
MG -- worsening later in the day, fluctuation make NMJ problem likely. Eye involvement makes this more likely to be MH than lambert eaton which typically doesn't involve ocular muscles and gets better with repetitive activity
