3, 4, 5 Star topics Flashcards
Anterior cerebral artery stroke (3.5)
Leg/foot/trunk motor and sensory
Middle cerebral artery stroke (3.5)
Hand/arm motor and sensory
Broca and Wernicke areas (speech)
Posterior cerebral artery stroke (3.5)
Vision
CSF findings bacterial meningitis (4)
++ WBC (NEUTROPHILS)
++ CSF pressure
- Glucose
+ Protein
CSF findings fungal/TB meningitis (4)
+ WBC (LYMPHOCYTES)
++ CSF pressure
- Glucose
+ Protein
CSF findings viral meningitis (4)
May be normal
+ WBC (lymphocytes)
+ CSF pressure
Usu glucose/protein normal
MC HA in adults (5)
Tension HA
Sudden, very severe HA w/ FND - next step? (5)
CT w/o contrast / MRI to r/o hemorrhage
Migraine HA presentation, causes (5)
Young adult women.
Unilateral throbbing, N/V, photo/phonophobia, visual auras (scintillating scotomas)
Stress, OCP, menstruation, exertion, foods w/ tyramine/nitrates (aged/rotting, chocolate, meat, alcohol, caffeine, etc).
Cluster HA presentation (5)
Young men.
Clustered in time (same time every day for weeks, then disappear for months)
Severe unilateral, around one eye, with conjunctival injection, eye redness, lacrimation, nasal congestion, nasal discharge, Horner’s
Exacerbated by alcohol
Tension HA presentation (5)
MC HA in adults
B/L band-like tightness in occiput and/or neck
Exacerbated by stress, fatigue
Tension HA treatment (5)
NSAIDs (first line), can try triptans, dihydroergotamine
Cluster HA treatment (5)
100% O2 (6+ L/min on non-rebreather for 20+ minutes), can try triptans, dihydroergotamine
Migraine HA treatment (5)
Sumatriptan (triptans), dihydroergotamine (DHE 45); NSAIDs; antiemetics (chlorpromazine, prochlorperazine, metoclopramide); some combination of drugs (don’t mix vasoconstrictors)
Migraine prophylaxis (5)
CCB (verapamil often first-line), BB (comorbid HTN), TCA anti-depressants (comorbid depression, insomnia, pain syndromes), NSAIDs (comorbid pain, menstrual), anticonvulsants (comorbid bipolar - valproate)
SAH cause, presentation and Dx (4)
Aneurysm rupture (usu berry aneurysm, associated w/ ADPKD, Ehlers-Danlos) Worse headache of my life, sentinal headaches CT scan shows blood in CSF, if negative LP to r/o (blood or xanthochromia; r/o traumatic tap by counting RBC in first and last tube); then do MRA/CTA to localize
Any hemorrhage - diagnosis study of choice
CT w/o contrast
LP C/I if any suspected mass effect
Epidural hematoma cause, presentation, Dx, Rx (4)
Middle meningeal artery rupture
Lucid interval, pupil abnormalities, HA, FND, nausea, seizure
Biconvex (lens shaped), can cross midline
Surgical drainage/burr hole
Subdural hematoma cause, presentation, Dx, Rx
Bridging veins rupture after trauma (elderly w/ falls)
Slowly progressive HA, AMS, contralateral hemiparesis, increased DTR
Crescent shaped, doesn’t cross midline
Surgical drainage, supportive monitoring
Aphasia types (3)
Broca - good comprehension, poor speech
Wernicke - good speech, poor comprehension
Conduction - good speech/comprehension, poor repetition
Global - poor speech, comprehension and repetition
Normal pressure hydrocephalus presentation, Dx, Rx (4)
Wacky (cognitive impairment/dementia), Wet (urinary incontinence), Wobbly (gain abnormality w/ poor foot height and stride length)
CT/MRI shows dilation/enlarged ventricles w/ normal ICP
Ventricoperitoneal shunt
Cs of Huntington disease (3)
CAG repeat disorder on chromosome cuatro Caudate and putamen atrophy on MRI Cognitive decline Chorea Cuarenta (40) age of onset
ALS pathophysiology (4)
Progressive loss of UMN (corticospinal tract) and LMN (anterior horn cells)
ALS S/Sx (4)
Weakness but normal sensation
80% initial symptom: asymmetric limb weakness
20% dysarthria and dysphagia (bulbar dysfxn)
UMN, Bulbar UMN, LMN signs and symptoms, cognitive defects
Respiratory failure 3-5 years on average after dx
ALS labs, radiology, tests, treatment (4)
Labs/radiology to r/o other pathology (B12, HIV, syphilis, CT/MRI)
Electromyogram demonstrates widespread muscular denervation and motor block
Riluzole = only FDA approved treatment
MS path, presentation (3)
AI progressive demyelinating disease of brain and spinal cord
Variable initial presentation w/ multiple neurologic complaints, may have remissions, worse w/ stress
MS labs, radiology, treatment (3)
CSF w/ increased protein, mildly increased WBC, oligoclonal bands (IgG)
MRI brain, spine shows multiple asymmetric white matter lesions
Corticosteroids for acute attacks, IFN-B for maintenance; also methotrexate, glatiramer
Syringomyelia path, presentation, treatment (3)
Post-traumatic cystic degeneration of spinal cord from unknown mechanism
Channel compresses anterior white commissure (loss of pain and temperature 1-3 levels below lesion), anterior horns if big enough (LMN signs)
Surgical decompression, may need shunting if recurrent
Coma work-up (3.5)
History
Pupils
Ocular motility
Motor function
Febrile seizures - presentation (4)
6 months - 6 years w/ no CNS infx, lesion, abnl, hx of afebrile seizures.
Fever >102 (39) w/ rapid rise in temperature
Tonic-clonic seizures <15 min (atypical seizures can occur at lower temps and last longer)
Febrile seizures - labs/imaging (4)
LP if meningitis suspected or age <12 months
EEG, CMP usu normal
Febrile seizures - treatment (4)
Respiratory stability Acetaminophen/ibuprofen as antipyretic Atypical seizures need more in-depth workup Reassure parents No anti-epileptics unless cause
Febrile seizures - complications (4)
35% recurrence
Very little increase in lifetime risk of epilepsy
Atypical - more likely to recur, occur over longer periods of time, increased risk of epilepsy
Neural tube disorders - types (3.5)
Spina bifida occulta (defect in closure of dorsal vertebral arches, usu at lumbosacral junction)
Meningocele (herniation of meninges)
Myelomeningtocele (herniation of spinal cord and meninges)
Anencephaly (failure to close of cranial NT; absence of forebrain, meninges, portions of skull; death w/i days)
Neural tube disorders - risk factor, prevention (3.5)
Poor folate intake
Child-bearing age women = 0.4 mg (400 ug) folate/day
Women w/ prior child w/ NTD or taking anticonvulsants = 4 mg folate/day
Neural tube disorders - prenatal labs/imaging (3.5)
Increased AFP on quad screen
Increased ACHase during gestation
May see on US
Neural tube disorders - complications (3.5)
Increased risk of UTI and CNS infx
Severe: bowel and bladder incontinence, flaccid paralysis, poor sensation, LMN signs, hydrocephalus
Anencephaly: death within a few days
Cerebral palsy - risk factors (3)
Usu from perinatal complications, or during development
Prematurity**, IUGR, birth trauma, neonatal seizures or cerebral hemorrhage, perinatal asphyxia, multiple births, intrauterine infx (esp chorioamnionitis)
Cerebral palsy - types, S/Sx (3)
Spastic (damage of pyramidal tracts) - spastic paresis, frequent MR, gait abnl
Dyskinetic (extrapyramidal pathology) - choreoathetoid, dystonic, ataxic movements, dysarthria
Both - hyperactivity, seizures, limb disorders
Cerebral palsy - treatment (3)
Pharmacology: reduce spasms (botulinum toxin, dantrolene, baclofen, benzos)
PT, bracing, surgery
Speech therapy, special education, social and psychological support
Metformin (4)
Mech: decreases hepatic gluconeogenesis, increases insulin activity peripherally
Use: usu first line in DM II
AE: GI (esp diarrhea), rare lactic acidosis, decreased B12, C/I in hepatic and renal insufficiency (stop if transient increase in Cr; metabolized in kidneys)
Other: decreases LDL, TG, raises HDL; no weight gain, no hypoglycemia
Sulfonureas (4)
Glyburide, Glimepiride, Glipizide
Mech: stimulate insulin release from B-cells
Use: frequently second line after metformin
AE: hypoglycemia, weight gain, C/I in hepatic or esp renal insufficiency (greater risk of hypoglycemia)
Other: inexpensive, requires fxn pancreas
Thiazolidinediones (TZDs) (4)
Pioglitazone, Rosiglitazone
Mech: Increases tissue uptake of glucose, somewhat decreases hepatic gluconeogenesis
AE: weight gain and fluid retention (C/I in CHF, stop if peripheral edema develops)
Other: no hypoglycemia
Glyburide (4)
Sulfonurea
Mech: stimulate insulin release from B-cells
Use: frequently second line after metformin
AE: hypoglycemia, weight gain, C/I in hepatic or esp renal insufficiency (greater risk of hypoglycemia)
Other: inexpensive, requires fxn pancreas
Glimepiride (4)
Sulfonurea
Mech: stimulate insulin release from B-cells
Use: frequently second line after metformin
AE: hypoglycemia, weight gain, C/I in hepatic or esp renal insufficiency (greater risk of hypoglycemia)
Other: inexpensive, requires fxn pancreas
Glipizide (4)
Sulfonurea
Mech: stimulate insulin release from B-cells
Use: frequently second line after metformin
AE: hypoglycemia, weight gain, C/I in hepatic or esp renal insufficiency (greater risk of hypoglycemia)
Other: inexpensive, requires fxn pancreas
Pioglitazone (4)
Thiazolidinedione (TZD)
Mech: Increases tissue uptake of glucose, somewhat decreases hepatic gluconeogenesis
AE: weight gain and fluid retention (C/I in CHF, stop if peripheral edema develops)
Other: no hypoglycemia
Rosiglitazone (4)
Thiazolidinedione (TZD)
Mech: Increases tissue uptake of glucose, somewhat decreases hepatic gluconeogenesis
AE: weight gain and fluid retention (C/I in CHF, stop if peripheral edema develops)
Other: no hypoglycemia; recent study showed no association w/ ischemic MI
CAD risk factors (5)
Tobacco use
HTN (BP >140/90 or treatment)
HDL 45, F >55)
HDL >60 cancels 1 risk factor
CAD equivalents (5)
DM
AAA
PVD
Symptomatic carotid artery disease
When to treat cholesterol w/ medication (5)
LDL >160 (0-1 risk factors)
LDL >130 (2+ risk factors)
LDL >100 (CAD or equivalent)
Systolic ejection murmurs (crescendo-decrescendo) (5)
Aortic stenosis (2nd right interspace to neck, may radiate more widely, much MC) Pulmonic stenosis (2-3rd left interspace)
Holosystolic murmurs (5)
Mitral regurgitation (apex -> axilla) Tricuspid regurgitation (LLSB -> RLSB) VSD
Late systolic murmurs (5)
Mitral valve prolapse (apex -> axilla)
Early diastolic murmurs (5)
Aortic regurgitation (L side of sternum) Pulmonic regurgitation (upper L side of sternum)
Mid/late diastolic murmurs (5)
Mitral stenosis (apex)
Benign murmurs, need no workup (5)
Asymptomatic Split S1 Split S2 on inspiration S3 < 40 yo Early, quiet systolic murmur
Murmurs heard best in left lateral decubitus (5)
Mitral
L sided S3, S4
Murmurs louder with inspiration (5)
Tricuspid regurgitation
Tricuspid stenosis
Maybe VSD?`
Murmurs louder with Valsalva (5)
Hypertrophic cardiomyopathy????
Murmurs softer with Valsalva (5)
Aortic stenosis
Aortic stenosis - causes (5)
Congenital defect
RHD
Calcification in elderly patients (usu >60)
Tertiary syphilis (tree-barking aortitis) (rare)
MCC: congenital bicuspid valve (usu around age 40)
Aortic stenosis - symptoms (5)
Chest pain
Dyspnea on exertion
Syncope
Aortic stenosis - exam (5)
Weak, prolonged pulse (parvus et tardus)
Crescendo-decrescendo systolic murmur radiating from R upper sternal border to carotids
Valsalva decreases
Aortic stenosis - treatment (5)
Valve replacement if symptomatic
Mitral regurgitation - causes (5)
RHD (MC murmur in RHD) MVP Papillary muscle dysfunction (post MI) Endocarditis LV dilation
Mitral regurgitation - exam (5)
Harsh holosystolic murmur radiating from apex to axilla, louder in LLD
Aortic regurgitation - causes (5)
Endocarditis (classic)
RHD
Tertiary syphilis
Aortic regurgitation - exam (5)
Bounding pulses
Widened pulse pressure
Diastolic decrescendo murmur at R 2nd intercostal space or down L sternum
Capillary pulsations in nail bed, more visible with applied pressure (Quincke sign)
Rhythmic head bobbing (deMusset sign)
Mitral stenosis - causes (5)
RHD
Mitral stenosis - exam (5)
Opening snap after S2
Diastolic rumble at apex
LA enlargement
Acute pericarditis - causes (4)
Viral infection
TB, SLE
Uremia, neoplasm, drug toxicity (isoniazid, hydralazine)
Post-MI, radiation, recent heart surgery
Acute pericarditis - exam (4)
Pleuritic chest pain, dyspnea, cough Pain worse supine, lessens w/ leaning forward Friction rub Pulsus paradoxus Global ST elevation/PR depression on EKG
Acute pericarditis - treatment (4)
Treat underlying cause
NSAIDs for pain, inflammation
Pericardiocentesis for large effusions
Acute pericarditis - complication (4)
Chronic constrictive pericarditis
Cardiac tamponade - causes (4)
Chest trauma
Progressive acute pericarditis, LV rupture following MI, dissecting aortic aneurysm
Cardiac tamponade - exam (4)
Dyspnea, tachycardia, tachypnea, JVD, pulsus paradoxus
Beck triad (hypotension, distant heart sounds, JVD)
Enlarged heart shadow on CXR
Large effusion seen on echo (dx)
Global low voltage on EKG (or electrical alternans)
Cardiac tamponade - treatment (4)
Immediate pericardiocentesis (high mortality)
Cardiogenic shock treatment (5)
Dobutamine (first line), dopamine No IVF (risk of pulm edema) (intra-aortic balloon pump, PCTA for MI)
Septic shock treatment (5)
Treat underlying infection
IVF
Norepinephrine if needed
Hypovolemic shock treatment (5)
IVF
(Transfusions, surgery if needed to stop bleeding)
(Dressings, skin grafts maybe for burns)
Anaphylactic shock treatment (5)
Maintain airway
Epinephrine
(IV diphenhydramine)
(IVF)
Neurogenic shock treatment (5)
IVF
Pressors
Atropine for bradycardia
Cause of cardiogenic shock (5)
Heart muscle failure
Cause of extracardiogenic shock (5)
Compression of heart
Cause of hypovolemic shock (5)
Not enough fluid to pump
Cause of anaphylactic shock (5)
Vasodilation (histamine release)
Cause of neurogenic shock (5)
Vasodilation, bradycardia (autonomic dysfxn)
Cause of septic shock (5)
Vasodilation (inflammatory proteins)
Shock caused by pump failure (5)
Cardiogenic
Shock caused by pump compression (5)
Extracardiogenic (tension pneumo, massive hemothorax, cardiac tamponade)
Shock caused by lack of fluid to pump (5)
Hypovolemic
Shock caused by vasodilation from histamine release (5)
Anaphylactic
Shock caused by vasodilation from autonomic dysfxn (5)
Neurogenic
Shock caused by vasodilation from inflammation (5)
Septic
Kawasaki disease - diagnostic criteria (3.5)
Fever >40/104 for at least 5 days + 4/5 (CRASH):
Conjunctivitis (bilateral, non-exudative, painless)
Rash (on trunk)
Adenopathy (cervical LN)
Strawberry tongue (and diffuse mucositis)
Hands and feet (desquamation, erythema or edema)
Kawasaki disease - biggest complication (3.5)
Coronary vasculitis in 25% can lead to aneurysm, MI, sudden death
Kawasaki disease - treatment (3.5)
Frequently self-limited
IVIG (w/i 10 days of onset if possible)
High dose ASA until 48 hrs post fever
Low dose ASA until inflammatory markers recover (ESR, platelets) (usu about 6 wks)
Echo during acute phase and 6-8 wks later
NO steroids
Tetralogy of Fallot - characteristics (4)
VSD
Overriding aorta
RV outflow obstruction w/ pulmonary stenosis
RVH
