3 Neurology Flashcards
0
Q
Red flags for HAs
A
SUdden onset HA First and worst Focal neuro sxs. Mass AVM Fever infxn Change in personality or mental status
Majority of pts hv nl Hx
1
Q
Number one neuro issue
A
Headaches
primary HA. Most. Tension traction pressure
Secondary HA underlying cause most pts >50 yrs
2
Q
HA exam.
Don’t forget to check
A
BP pulse Fundoscopic exam. Papilledema From inc ICP. Brain tumor glaucoma Papate head neck shoulders Bruits (continuous noise ) AVM arteriovenous malformation a tangle of blood vessels in vein that bypass normal tissue and divert blood from the arteries to the vein
3
Q
Red flags for neuro exam
A
Age > 40 or 50
Neck stiffness
Neuro deficits
Papilledema- sxs represent swelling of optic disk almost always 2ndary to inc ICP
4
Q
Increased ICP almost always gives
A
Papilledema bc sxs represent swelling of. Optic disk
5
Q
Papilledema is
And almost always is
A
Swelling of optic disk r/t Inc ICP
Bilateral
Papilledema presents with swelling of optic disk
6
Q
When to image for HA
A
“Red flag HAs”
Change in pattern
Neuro deficits
Papilledema
Get CT or MRI
Of brain and spine
7
Q
95% of HA
A
Are migraines
8
Q
Papilledema check. What does it look like
A
Blurred margins of optic disc indicate venous engorgement and Papilledema
Inc ICP
9
Q
HA clues from location
Uni
Bilateral
A
Unilateral migraine
Bilateral tension
Always unilateral begins around eye or temple- cluster
10
Q
HA characteristics.
How pain is described
A
Crescendo: migraine
Pressure tightness band like waxes and wains: tension
Pain peaks w in minutes excruciating explosive Cluster
11
Q
HA duration
4-72 hrs
Varies
30-90 min usually up to 180 min
A
4-72 hrs migraine
Varies tension
30-90 min usually up to 180 min cluster
12
Q
HAassociated sxs
Migraine
Tension
Cluster
A
Migraine. N V Aura ?
Tension. None
Cluster. Eyes become red tears rhinorhea ETOH can trigger
13
Q
HA c nasal stuffiness.
A
Sinusitis
14
Q
HA w jaw claudication (pain)with chewing , fever, visual loss, pain in temple
A
Temporal arthritis - giant cell arteritis
Inflammatory disease of arteries of head
15
Q
HA w Visual field defect
A
Optic pathway lesion pituitary tumor
16
Q
HA w blurred vision on bending of head
A
Intracranial lesion
17
Q
HA w N/V
A
Tumor
18
Q
Unilateral vision loss
A
Tumor
19
Q
HA w sweating and tachycardia
A
Pheochromocytoma. Tumor in adrenal medulla
20
Q
HA w Transient visual changes and intracranial noise - me!!
A
Pseudotumor cerebri (idiopathic intercranial hypertension
Also HA N/V pulsitile tinnitis (sounds in ears w same rhythm as pulse)
Without tx- inc swelling of optic disk and vision loss
21
Q
Migraine HA. What changes in cerebral arteries occur?
A
Dilate! That is why tx is w triptan bc theyconstrict. So does caffeine
22
Q
Diagnosis migraine without aura. Meet this criteria for Dx
A
Last 4-72 hrs
Has 2: unilateral, pulsing, mod to severe, aggravated by routine activity
Must have one: N/V, photophobia, phonophobia
5 or more attacks like above
23
Q
Dx migraine w Aura
A
2 attacks w aura
Visual sensual or speech changes transient
Develops over 5-20 min. HA develops over 60 min
24
Migraine triggers
Stress
Menses
Skip meals
Weather sleep odors light ETOH smoking. Foods
25
Migraine pharm mngt
Mod severe:
If > 2 HA month use:
Mod severe 2x/m: use prophy! EXAM*****
- Topiramate(Topamax). Divalproex (Depacote)- for migraines and seizure disorders
- Beta blockers (Propanolol, timolol)
26
What is a med that is a good abortive for acute pain?
| And good to keep in office bc drug seekers don't want
Ketorolac (Toradol) IM.
| Good for. Migraines, m/s, kidney stones
27
Exam. If >2 migraines a month use these meds
> 2x/m: use prophy! EXAM*****
- Topiramate(Topamax). Divalproex (Depacote)- for migraines and seizure disorders
- Beta blockers (Propanolol, timolol)
Limit use of Triptans bc cause rebound HAy
28
What disease causes cupping
And what is it
Exam***
Glaucoma
Cupping is when the optic nerve takes on a hollowed appearance with funds optic exam- bc of loss of ganglion cell axons
The donut whole of the optic nerve gets bigger bc of inc IOP
29
What is one of most common causes of facial pain?
Trigeminal neuralgia
Sudden severe unilateral facial pain
Cranial nerve 5 has three locations: top middle face and line going from top to jaw
Cotton wisp stroke on face causes pain
30
Facial pain sharp intense piercing - they see dentist a lot first bc think dental pain
Paroxysmal (comes and goes) pain
No neural deficit
trigeminal neuralgia
Common neuralgia in elderly
Exam***. Treatment: Carbamazepine (Tegretal)
31
What med is used with Trigeminal Neuralgia and also used for seizures and bipolar?
Pt education? EXAM
Carbamazepine( Tegretol).
Makes pt sleepy/drunk- don't take till get home!
32
Acute peripheral facial nerve palsy
| CN?
Bell's palsy
CN VII
Caused by virus herpes
33
Bell's palsy
Always r/o
Diagnosis and progression
R/o stroke
Onset over 1-2 days progressive
Max sxs in 3 wks
85% recovery in 3 weeks
Function returns 3-4 m
Edu: eye care
*** psych support ***. Give them hope! Tell them we will drive to full recovery. Hyperlacrimation.
Give Botox for facial spasm.
34
EXAM.
Bell's palsy
New guideline
How much? When start?
"High dose" steroids will drive recovery from 30% to 10%!!!! Exa
Start w in 3 d of sx onset!!!!
60 mg Prednisone QD x3 d Whoa!
Then move to 50, 40, 30, 20,10
Also oral antiviral
Later Botox for facial spasm
35
Assessment for Bell's palsy
CN VII
```
Close eyes
Elevate brow. Frown
Show teeth
Pucker lips
Tense soft tissue of neck
```
***. If can't close eyes when blink. Ocular lubricant QH while awake
Sleep lacrolube on eye then paper tape eye at HS
36
These two meds used together are for:
-High dose oral steroids w in 3 d of sx onset!.
60mgx3 day then. 50. 40 30 20 10
Also
- Antiviral. Acyclovir....
Bell's palsy
37
Sxs of Bell's palsy
Unilateral
Drooping eye
Starts w a "twitch"
38
50 yo w Bell's palsy Dx.
| What will increase likelihood of complete recovery
high dose steroid stared w in 3 d of onset of sxs onset
39
Symptom of vestibular fxn
Causes spinning and swaying
N and V. Postural instability
Single episode or recurrent
VERTIGO
40
2 types of vertigo
Flip pt algorithm
Peripheral: Vestibular. I can manage in clinic. Prob BPV.
99% of vertigo this
Central: REFER. Brainstem or cerebellum.
***nystagmus lasts >1-2 min prolonged! -Exam!!!!!
Impaired gait and mobility
41
peripheral vertigo sxs
Examples of
Central vertigo sxs
Peripheral vertigo: Severe vertigo. Severe N and V.
Recurrent vertigo Nystagmus lasts 1-2 min. Impaired gait and mobility. Single episode of vertigo lasting min to hrs
42
Pt with hearing loss and vertigo probably has
Ménière's disease. ENT refer
Ménière's is auditory and vestibular disease
Vertigo. Hearing loss. Tinnitus.
Overproduction or impaired absorption of endolymph in inner ear
Low salt diet and diuretics
43
Dix Hallpike maneuver provoked sxs for what?
Benign positional vertigo
BPV is brief and reproducible
Change in position provokes sxs
Dix Hallpike maneuver. Lay down and turn head to left or right - watch for vomit!
44
Tx of vertigo
OTC antihistamines: meclazine. Dimenhydrate (Dramamine)
For severe vertigo:
Benzos. Alprazolam. Lorazepam(atavan)
Time
Get to ENT
45
Vertigo
| What to do
Refer most cases except BPV
46
Rest vs action tremors
Rest. Occurs when tremulous body part is supported by gravity and not engaged in purposeful activity
Action. Occurs when the body part is not being used
47
Chronic progressive neuro degenerative disorder characterized by rest tremor rigidity bradykinesia (slow movement) and gait disturbance
Parkinson's disease
Diagnosis made by response to dopaminergic therapy. If movement smooth
48
Cardinal features of Parkinson's disease
Tremor at rest- pill-rolling (present in 70%)
Bradykinesia major cause of disability
Rigidity. Inc resistance to passive movement
Gait disturbance- FALLS primary concern
49
What neurotransmitter is part of pathology in Parkinson's?
Exam**
Dopamine!!!
50
Pharm for Parkinson's disease
Levadopa (Sinemet). Most effective usually first choice
With dopamine agonists to stim dopamine receptors
Anticholinergic meds
51
Physiologic tremors
Not present under nl circumstances
Meds- amphetamines. SSRIs TCAs nicotine. ETOH withdrawal
Anxiety. Excitement fear
52
What meds can help with physiological tremors
Propanolol
NP
Exams. Flights.....
53
What is most common tremor?
```
Essential tremor. 5% of population. ET
Sometimes familial
More common w aging
Bilateral action tremor of hands forearms head voice chin lip - voice quivers in old ladies
Tremor on legs is unusual
```
54
Clinical features of Essential tremor (ET)
Med used.
.
Apparent as arms are outstretched in front of body
More apparent at the end of a goal directed activity- hand shakes as glass gets closer to lips
No other neuro deficits
Propanolol mayhelp
55
Always ask: does tremor go away when u drink ETOH?
If yes- usually Essential tremor Helps w diagnosis
56
Cerebellar tumors
Refer now!!!
Etiology. Stroke, MS. Trauma
Can be postural. Kinetic or action
57
What drug probably worsens sxs of Essential tremor ET?
Caffeine!!!
Makes better: Propanolol, alcohol, diltiazem (muscle relax)
58
The most common inflammatory demyelinating disease of the CNS
Exam!!!
Multiple sclerosis. MS
59
Multiple sclerosis sxs
Fatigue. Pain. balance problems. Visual loss. Unusual presentation
Sensory sxs. Numbness, tingling. Pins, tightness. Coldness. Swelling of limbs and trunk. Vision loss- field cut
2 clinically distinct episodes with at least partial resolution
60
Exam. Most common disorder of neuromuscular transmission
***Autoimmune disorder****
Myasthenia gravis. Remember videos of teens w this
61
Most common upper and lower motor neuron disease.
Exam!
Exam!!
"A- my-o- trophic lateral sclerosis
Amyotrophic lateral sclerosis. ALS. Lou Gerhig's disease - American baseball player. Harper Bates!
Destroys motor neurons the brain cells that control muscle movement
3-5 yrs usually...
*Asymmetric* limb weakness, hand weakness, foot drop
Increased risk in head injuries. Lou Gerrig was a football player before baseball
62
Most common:
Inflammatory, demyelinating CNS disease
Disorder of neuromuscular, transmission
Upper and lower motor neuron disease
Inflammatory, demyelinating CNS disease: multiple sclerosis
Disorder of neuromuscular transmission: myasthenia gravis
Upper and lower motor neuron disease: amyotrophic lateral sclerosis. "A- my-o- trophic lateral sclerosis"
63
Dementia
Impairment in----- Plus 1 or more cognitive domain ----
Dementia
Impairment in memory. Plus 1 or more cognitive domain ----
- Apraxia: difficulty w motor planning to perform tasks or movement or speech when asked
- Agnosia: Inability to process sensory info- can't recognize objects, persons, sounds, shapes or smells, when the specific sense is not affected and there is no memory loss
- Executive function. Aka cognitive control/ mngt of memory, reasoning, task flexibility, problem solving, planning and execution...
64
Dementia mild cognitive impairment (MCI).
Memory impairment and difficulties.
65
Mental status exam
MMSE. Good and quick
Exam determines:
No labs or imaging can detect. Must. Talk w Pt.
Exam determines:
Normal vs abnormal cognition
Dementia vs delirium
Primary psychiatric disease
66
Cognitive testing that is most widely used and validated for sensitivity and specicifity
Mini mental status exam
Score less <24 suggests dementia or delirium
Assesses memory language and attention
Sample questions
1. Orientation to time. What is date
2. Registration. Repeat back words
3. naming- what is this
4. Reading. Read this and do what it says
67
Physical exam for dementia
Look for something that is masquerading as dementia
Look for: Neuro deficits or tremors
Signs consistent with stroke
Gait difficulties
68
Dementia look alikes
Medications:
Amelie's brown bag test: bring in all meds u r taking- ones that can impair cognitive fxn- analgesics, anticholinergics( block neurotransmitter acetylcholine involved with parasympathetic nerve impulses that are responsible for involuntary smooth muscle responses). Bronchodilators!
Depression. Prior stroke. Tumor. Parkinson's disease
1/5 of pts that present with sxs of Dementia have reversible! Go for that 20 %!!!!
69
Labs for Dementia
AAN recs what imagining?
TSH and B12. *****
CBC. CMP electrolytes folate Consider RPR and HIV (low yield)
American academy of neuro (AAN) either for routine initial evaluation of dementia: No contrast head CT or MRI. Looking for anatomical abnormality like tumor or fluid
Findings can say "generalized and focal atrophy"- haha. Nl w aging
Screen for dementia bc it may be a co-
morbid
70
Top 3 dementia in order of occurence
Alzheimer's disease. 60-80%
Vascular dementia 10-20%
Parkinson's dementia 5%
71
Clinical dementia rating (CDR)
Assess severity of AD- memory. Orientation. Judgement. And problem solving community affairs home and hobbies
Used for driving etc.....
72
Watch Triptan use as patients age bc can:
Exam*
Blood pressure can rise bc Triptans constrict blood vessels
So now switch to prophylactic meds like propranolol
Exam: pt w migraines for 20 yrs has newly developed HTN. Which med will now cause safety issue?
Amlodipine -(CCChBlocker for HTN a or CAD)
Sumatriptan
Simvastatin-(statin; dyslipidemia)
Amitriptyline- TCAS-depression, migraine HA, neuralgia
Answer: sumatriptan bc Constricts BV and BP could rise
73
What is number one neurological ailment?
Temporal arteritis
Migraine HA
Bell's palsy
Trigeminal neuralgia
Migraine!!!!
74
A common comment from patients with Essential tremor is
Etoh improves sxs
75
A 26 yo co asymmetric limb weakness. Which is not part of the diff?
Multiple sclerosis
Amyotrophic lateral sclerosis
Myasthenia gravis
Parkinson's disease
Parkinson's doesn't cause weakness it causes a tremor
The rest could be weakness
76
Which med is not used for migraine prophylaxis?
Amitriptyline
Propranolol
Sumatriptan
Feverfew
Sumatriptan is abortive! The rest are prophy
77
What herb can be used for migraine prophylaxis?
Feverfew
78
76 yo has sxs of dementia and poorly mngt HTN, and in no compliant w BP a meds. What kind of dementia might this suggest?
Lewy body dementia
Vascular dementia
Alzheimer's dementia
Nothing in particular
Lewy body dementia - usually w Parkinson's
Vascular dementia- yes!
Alzheimer's dementia no
Nothing in particular
79
A 35 yo has BPV. She has taken 4 doses of Meclazine in past 24hrs. Which statement is true?
1. Meclazine is a once daily med
2. She should be sx free now
3. Her vertigo is probly better
4. One or two more days of meclazine will be needed
1. Meclazine is a once daily med- no, q4-6 h
2. She should be sx free now- better but not
3. Her vertigo is probly better- yes*
4. One or two more days of meclazine will be needed
80
CN mneumonic
O O O To Try And Feel very glossy vagina, Sperm heaven!
OlOpOcTrochTrig AbdFacVestGlossVagSpinacHypogloss
OLd OPen OCeans TROuble TRIbesmen ABout Fish VEnom Giving VArious ACute/SPlitting Headaches
81
CN 1
Olfactory. Smell
82
CN II
Optic. Snellen chart
20/80. Means at 20 feet, the patient can see what a normal person can see at 200 ft
83
CN III
Oculomotor
Eye movements
Pupillary constriction
Accomodation
84
CN IV
Trochlear
A good mnemonic to remember which muscles are innervated by what nerve is to paraphrase it as a molecular equation: LR6SO4R3
Lateral Rectus - Cranial Nerve VI
Superior Oblique - Cranial Nerve IV
the Rest of the muscles - Cranial Nerve III.
85
LR6 SO4 R3
What CNs does it describe
Muscles of the eye and their cranial nerves
Abducens (abducts)Lateral rectus muscle VI 6
Superior oblique Trochlear (Trolley lifts up) IV 4
The rest of muscles III 3
86
CN IV
Trochlear
Superior oblique muscle.
LR6 SO4 R3
87
Mneumonic for CN eye muscles?
LR6 SO4 R3
Lateral rectus CN IV
Superior oblique VI
Rest of muscles III
88
CN V
Cranial nerve V. Trigeminal.
Like trigeminal neuralgia- supplies sensation to the face- nasal buccal mucosa, and teeth. Mastication*
89
CN VI
Abducens.
| LR6 SO4 R3
90
CN VII
Facial muscles and anterior 2/3 of tongue
| CN IX 9 does post 1/3 tongue
91
CN VII
Vestibulocochlear
Hearing, balance, awareness of position
92
CN IX. 9
Glossopharyngeal
Sensation to pharynx
Post 1/3 of tongue
Tympanic membrane
93
CN X
Vagus
Parasympatheticfibers to chest, abdomen, and motor fibers to pharynx, larynx, and
Sensory fibers to ear, meninges, viscera
94
CN XI
Spinal accessory
Sternocleidomastoid and trapezius muscle
95
CN XII
Hypoglossal
Muscles of tongue
Observe fasciculations when pt sticks out
