Clerkships-NEUROLOGY Flashcards
What is the characteristic sign of an uncal herniation?
“blown pupil” 2/2 compressed 3rd nerve
ppx for post-traumatic seizures
phenytoin
Foster-Kennedy syndrome is caused by? Expound
Optic groove meningioma, ipsilateral optic atrophy and contralateral papilledema, anosmia
[frontal lobe!]
What else can produce ALS-type symptoms? What must be done to rule this condition out before dx with ALS?
cervical myelopathy 2/2 cervical spondylosis/midline disc protrusion
MRI C-spine
Comment on CN hearing pathology for the following CN lesions
V
VII
VIII
V - hypOacusis???? asymptomatic
VII - hyeracuity 2/2 stapedius muscle paralysis, leading to undampened sound
VIII - auditory acuity loss
Progressive Multifocal Leukoencephalopathy
Path? Features? Tx?
JC virus, seeing in immunocompromised, affects subcortical white matter/ occipital and parietal regions, can see visual complaints and “alien hand syndrome” ; treat with HAART
Arnold Chiari Type 2 assoc?
Spina Bifida w/ meningomyelocele
Reccurrent meningitis occurs in patients with what?
CSF leaks, which px as otorrhea/rhinorrhea
Sensorineural vs conductive hearing loss. PE test?
Sensorineural - damage to receptor cells or cochlear division of the auditory nerve
Conductive - damage to ossicles and membranes designed to focus the sound on the cochlea
Webber Test. Place fork on midline:
if equal BL, then it’s normal
if sound is louder in one ear, then it’s EITHER sensorineural in OPPOSITE ear or conductive in THAT ear
For Rinne, AC>BC
Densely enhancing Brain tumor near surface of the brain, near the falx cerebri
Meningioma, most common CNS tumor
Tx - monitor with serial CT scans…. surgery???
Which ocular muscle is usually damaged in facial/orbital trauma? Why? Which CN? Compensation?
Superior Oblique, it is the most anterior in the orbit, CN4 (trochlear)
Patient will head tilt to compensate for impaired intorsion of the eye
What 2 types of tumors are HIV patients at risk for? Are either of these a CNS risk? Lesions?
Kaposi Sarcoma vs Lymphomas
Kaposi can metastasize to CNS vs lymphomas will be primary CNS lymphomas
CNS lymphoma can produce blindness through invasion of the optic nerve
CSF FINDINGS FOR THE FOLLOWING
1) Guillan-Barre
2) Pseudotumor cerebri (idiopathic intracranial htn)
3) MS?
4) HSV-1 encephalitis
1) elevated protein
2) normal except for increased opening pressure (no risk for herniation bc there is no mass effect)
3) !multiple oligoclonal bands!, increased protein, increased leukocyte, increased myelin basic protein
4) elevated protein, leukocytosis, erythrocytosis (RBC), elevated opening pressure, increased % gamma globlulin,, may be cloudy
What is a discouraging/annoying LONG TERM CN deficit that can arise after a head-striking accident? Path? Px?
Ageusia (loss of taste) and anosmia 2/2 acceleration-deceleration injury to the olfactory nerve rootlets at the cribriform plate
volar aspect definition
xerostomia definition
referring to palm or sole (carpal tunnel: tension on volar aspect of wrist)
dry mouth
tx for painful spasticity that interferes with sleep?
spasticity that doesn’t interfere with sleep?
MOA of both interventions? What can you see this spasticity in?
Baclofen, GABA-B agonist, considerable sedation so good for nighttime symptoms
Tizanidine, central alpha-2 agonist, reduces spasticity without compromising strength
Multiple Sclerosis
Offer features of abetalipoproteinemia and explain the pathophys of each. 3 major bullets. Start with genetics.
- AR mut. in microsomal triglyceride transfer protein (MTTP) which impairs VLDL and chylomicron formation/secretion, leading to decreased vit E delivery to nervous system, leading to peripheral neuropathy, ataxia, night blindness, etc.
- lipid profiles are abnormal and fat absorption is affected, leading to fat accumulation in enterocytes. The abnormal lipid profile can deform RBC membranes into star-shaped morphology (acanthocytosis)
- fatty liver and lactose intolerance can also develop
What is a major post-op risk factor following AAA repair? define
arteria radicularis magna (artery of adamkiewicz), which enters T10-L1, may get occluded
1) Steppage gait
2) Antalgic gait
3) Spastic Hemiparetic Gait
4) Spastic Diplegia Gait (scissor gait)
1) Peroneal nerve injury which results in foot drop, patient raises this leg higher during walking to avoid dragging the foot. Foot is brought down with a slap.
2) Limp caused by patient avoiding weight bearing on the affected side
3) may be seen in patients after strokes—the leg is stiff with a foot drop and the arm is held flexed and adducted. The lower limb is dragged or moved forward by abduction and circumduction with the arm not swinging from its abnormal position
4) occurs with extrapyramidal disorders. The patient uses short steps and drags the foot; the legs are extended and stiff and cross on each other
Sclerotic hippocampus causing intractable complex partial seizures. Dx and tx?
Mesial Temporal Sclerosis (MTS)
Neurosurgery
Other than copper, what can produces parkinsonism similar to the picture seen in Wilson’s disease?
Anemia and white lines transversely across fingernails. What is the toxin?
Personality changes, irritability, tremor, ataxia, often seen in felt, pulp, or paper processing factories. What is the toxin?
Painless motor neuropathy, wrist drop. What is the toxin?
Hair loss, stupor, GI distress, seizures, painful symmetric sensory neuropathy, headaches
Manganese (miners)
Arsenic
Mercury
Lead
Thallium
Rye fungus Claviceps Purpuria can lead to what?
Ergotism: vasoconstriction, degeneration of the posterior columns and dorsal roots
CSF finding in herpes encephalitis (most common cause of acute encephalitis?)
Increased lymphocytes
Mnemonic for migraines
POUND
Pulsatile Once a day Unilateral Nausea Daily activities, interferes with
Reversible posterior leukoencephalopathy
Caused by cyclosporine and tacrolimus (and ecclampsia)
edema
Polymyalgia rheumatica
Arteritis of the elderly characterized by an elevated ESR and normal CPK, also affording anemia, weight loss, and malaise.
Name the def. and expound
Sandoff and Tay Sach’s
arylsulfatase A def. (define path)
Krabbe disease (define path)
Adrenoleukodystrophy
hexosaminidase
metachromatic leukodystrophy (arylsulfatase needed to break down myelin for turnover; def. of this leads to build up in lysosomes)
galactocerebroside beta-galactosidase (galactocerebroside accumulates in macrophages)
impaired addition of coenzyme A to long-chain fatty acids (fatty acids accumulate, damaging adrenal glad and white matter)
Cerebellar signs, ataxia, nystagmus in a patient with breast cancer. Pathophys?
Which primary cancer met to the brain has worst prog.?
Paraneoplastic Cerebellar Degeneration
anti-purkinje cell (anti-Yo)
Malig melanoma
What causes lumbar fracture in automobile accidents?
extreme flexion of spine
Meige syndrome
a form of focal dystonia characterized by blepharospasm, forceful jaw opening, lip retraction, neck contractions, and tongue thrusting. Sometimes these features are produced by phenothiazine or butyrophenone use, but they may also occur idiopathically, more often in women than men, with onset in the sixth decade. Botulinum toxin injection has been more effective in treatment than any oral medication.
Person goes swimming and then develops pruritic skin, followed by parasthesias and loss of bladder control. Dx? NBS? Path?
Schistosomiasis
(S. Mansoni can release eggs into veins that drain into the spinal cord area; granulomas form around these Ova which compress the spinal cord)
MRI to rule out emergent shit
Normal Pressure Hydrocephalus
wet, wacky, wobbly
(gait disturbance, don’t think Parkinson’s or Alzheimer’s in this case)
CT/MRI shows enlargement of the temporal and frontal horns of the lateral ventricles out of proportion to cortical atrophy
Lennox-Gastaut
mental dysfunction, multiple seizure types, and 1- to 2-Hz generalized spike-wave discharges on EEG
UMN disease vs myelopathy
UMN: spasticity, hyperreflexia, +Babinski
Myelopathy: UMN+ loss of position and vibration (posterior column)
Background posterior-dominant rhythm on EEG?
alzhemiers?
spongiform encephalopathy (crueztfield-jacob)?
8-12 Hz,
generalized background slowing
periodic changes in the form of sharp waves or spikes
Subacute Sclerosis Pan-Encephalitis (SSPE)
demyelinating condition s/p measles infection
What happens to handwriting and speech volume as parkinson’s disease progresses?
Smaller and quieter
Innervation of interosseus and lumbricals?
All interossei innervated by ulnar,
two of the lumbricals by ulnar, two by median
What are some drugs that can cause parkinsonism?
Butyrophenones (haloperidol, etc.) and metoclopramide (which also can cause tardive dyskinesia)
Postconcussion syndrome triad
Personality changes, dizziness, headache
CT negative, but then xanthochromia of CSF, NBS?
It’s SAH, do 4 vessel cerebral angiogram to confirm
Pregnant woman with pseudotumor cerebri, NBS?
Don’t use diuretics unless not pregnant; serial lumbar punctures is best.
Reduced ROM in neck and cervical tenderness. Which type of headache
Tension headache
ESR, and lateral headache?
Temporal Arteritis
What class of medication to avoid in the dementia with lewy body crowd?
Antipsychotics, can lead to neural damange
Best test to confirm Guillain Barre Syndrome
LPC
Cystic lesions in the cerebellum in a patient with AD VHL syndrome. Dx and NBS?
What else can you see in AD VHL? (4)
Hemangioblastomas
Surgical resection asap bc of the risk of bleeding
HSM, retinal angioma/telangiectasia, cerebellar tumors, polycystic kidney/liver disease,
What CNS cell type is the source of most primary tumors?
Glial Cells
What causes “down and out” pupil? What comorbidity?
3rd nerve palsy 2/2 DM
What is a gumma?
Avascular granuloma that forms in the brain that resembles a tumor on imaging and typically occurs in the setting of syphillis
Gradenigo syndrome
petrous pyramidal osteomyelitis; abducens and facial nerve travel close to the tip of the petrous bone so you may see these sequelae.
Pathophys of paraneoplastic cerebellar degeneration
Tumor such as SSLcancer causes anti-neuronal antibodies that lead to ataxia
What kind of visual loss (lateralization) would you see in
middle and posterior cerebral artery ischemia
central retinal artery ischemia
middle/post - some sort of bilateral
central retinal - unilateral
Lead poisoning neuropathy, which nerve is most likely to be affected
radial
Progression of herpes encephalitis in an immunocompetent person
Which virus affects adults and which virus affects kids?
First psychiatric, then seizures can follow
Adults - HSV-1
Kids - HSV-2
Where is the seizure if the patient has olfactory hallucinations during the prodrome
Mesial temporal lobe (typically hippocampus)
Time for DTs vs alcohol withdrawls
1-2 DT
2-4 AQ
Patients who use analgesia 2 or more times a week are at risk for what?
Medication overuse headache. Even triptans can cause this.
Explain the sequence by which you follow to avoid herniation in the setting of LP
IF YOU SEE signs of elevated ICP, THEN you need imaging to r/o mass effect before doing LP.
If, say, it’s pseudotumor cerebri (idiopathic intracranial hypertension), then don’t worry about herniation. it’s just ICP^, no risk for herniation.
If baby presents with neck stiffness and fever, and infectious signs, just do LP.
Describe 4 clinical findings in the setting of elevated ICP and describe whether they’re acute or chronic. Comment on pathophys for each.
Irregular respirations (hypoperfusion of brainstem) Bradycardia (increased stimulation of baroreceptors from the hypertension) Hypertension (decreased cerebral perfusion induces peripheral vasoconstriction)
above are acute (cushing’s triad), PAPILLEDEMA IS CHRONIC
MC cause of lobar hemorrhage in elderly without HTN?
Cerebral amyloid angiopathy (CAA)
beta-amyloid (same as alzheimer’s) deposits in vasculature, predisposing to hemorrhage
Intention or kinetic tremor is brain neuroanatomically due to?
Resting tremor is brain neuroanatomically due to?
Weakness is brain neuroanatomically due to?
Sensory disturbance?
Cerebellar insult
Sustantia Nigra
Internal Capsule
Thalamus
atrophy of putamen and globus pallidus with memory impairment may be?
Hepatolenticular degeneration (wilson’s)
Clacified lesions in brain ddx?
Neurocystercercosis (taenia solium/pork tapeworm larva)
Spatial organization of the 3rd nerve. Which pathology is likely affected by what?
central - motor
peripheral/superficial - pupillary constriction
peripheral will be affected by aneurysm/compression
Classic vs common migraine
common doesn’t have aura
Which cells of the brain are affected by liver failure
astrocytes (and increase in alzhemier type II astrocytes)
Pleocytic CSF with protein and postive VDRL
dementia delusions dysarthria tremor myoclonus Argyll Robertson Pupil
General Paresis (of the insane)
happens after spirochetal infection in elderly but takes a while to manifest
Penicillin can help prognosis
contrast: tabes dorsalis/neurosyphilis where there are no psychiatric manifestations
Findings in Neuroleptic Malignant Syndrome that distinguish it from serotonin syndrome (mnemonic)
FALTER
Fever Autonomic Leukocytosis Tremor Elevated CK Rigidity
Histology of Pick Disease
Silver stain positive intracellular ovoid inclusions of tau protein
Which drug can worsen tinnitus.
Which drugs cause vertigo and which cure it?
aspirin
Aspirin, aminoglycosides, alcohol, quinine cause toxic labyrithitis/vertigo; promethazine, dimenydrimate, and meclizine cure it.
What can hypertensive encephalopathy do to the CSF?
Increase protein
What is status epilepticus?
30+ minutes of seizure
-or-
a series of seizures lasting 30 minutes in which the patient does not regain consciousness
trihexylphenidyl
anti-cholinergic that reduces parkinsonism caused by neuroleptic (pychiatric) drugs
Timing of symptoms in restless leg syndrome vs akathisia
RLS night akathisia day
Posterior fossa neoplasm in adult close to bone?
Tx?
Meningioma. tx surgery
astrocytoma wouldn’t be in posterior fossa
Tropheryma whippeli CNS manifestations
(PAS-positive jejunal histology)
ataxia, seizures, myoclonus, supranuclear gaze disturbance, hypothalamic disturbance, dementia.
Pathognomonic: oculomasticatory myorhythmia - pendular movements of the eyes in concurrence with contraction of the masticatory muscles
inattentiveness, poor concentration, and lethargy. paranoid delusions. mild proximal weakness and ataxia. edema, coarse and pale skin, and macroglossia. delayed relaxation of the ankle reflexes. Dx?
hypothyroidism
Explain why subdural hematoma can occur s/p VP shunt placement?
Sudden reduction in ICP 2/2 CSF volume reduction causes brain barenchyma to pull away from meninges, stretching the bridging veins
NBS in strabismus?
ophthalmology referral
Posterior fossa ependymoma, most feared complication?
tranforaminal (magnum, downwards) or transtentorial (cerebelli, upwards) herniation
What movement issues arise in Cruetzfield-Jacob vs Huntingtons. Compare and contrast.
CJD - myoclonus, a jerking/twitching of a muscle group
Huntingonts - chorea, SMOOTH, FLUID movements
postural effects on headaches and ICP
lying down will increase ICP, while standing up will decrease ICP
therefore, pseudotumor cerebri (benign intracranial HTN) will get BETTER when standing and WORSE when lying
and intracranial hypOtension will get WORSE when standing and BETTER when lying
sudden onset of headache with progressive hemiparesis and the development of obtundation caused by brainstem compression. dx?
MC etiology? If not this etiology, then what else? Distinguish the location of these two.
Intracerebral hemorrhage
Uncontrolled HTN. If not, then amyloid.
HTN usually involves central structures (thalamus, basal ganglia, cerebellum) whereas amyloid usually involves lobar
Most common location for a brain abscess
Gray-white-junction
MC neurologic sequelae from renal failure
BL, distal, peripheral sensorimotor neuropathy 2/2 axonal degeneration
Small red dots in the paracentral region of the retina. Etiology?
DM (cotton wool)
vs htn which would be what? AV nicking (thickened arteriolar wall compresses the venules), copper wiring, narrowing of the arterioles
woman presents with the acute onset of double vision. The second image disappears if she covers either eye. Which nerve is most likely to be impaired in this patient?
Abducens 6th nerve
more common than 3rd nerve, and way more common than 4th nerve
Urinary symptoms of MS?
premature bladder emptying: spastic (UMN) bladder
Where do meningiomas usually originate?
ARACHNOID
syringomyelia symptoms
If syrinx expands, what can happen
vs ALS?
BL sensory loss of pain and temperature (protopathic) in upper limb and
BL SPARING OF FINE TOUCH/PROPRIOCEPTION (epicritic)
C8-T1
Ventral horn gets knocked out (LMN signs)
or lateral horn gets knocked out (Horner’s)
ALS doesn’t have any pain/temp loss
Poliomyelitis vs AR Werndig Hoffman
Poliomyelitis is degeneration of ventral horns 2/2 poliovirus infection
Werndig Hoffman is an inherited degeneration of the ventral horns (floppy baby)
Friedreich Ataxia path and px?? 2 Classic assoc?
Degeneration of cerebellum AND spinal cord track (DRG)
ataxia AND loss of vibratory/proprioception, muscle weakness, loss of DTR
Hypertrophic cardiomyopathy + DM
[frataxin gene AR GAA ch9, leads to free radical damage]
What level do you do an LP and which layers do you pierce through?
L4-L5, you go through everything but not the PIA (skin, ligament, epidural space, dura, arachnoid, subarachnoid space).
[spinal cord ends at L2]
organophosphate poisoning.
explain the pharmacology and how it affects the nervous system
anticholinesterase (anti-acetylcholineesterase), which increases ACh, leading to motor neuron overstimulation
(wheezing, cramps, diaphoresis, twitching, vomiting, headaches)
Bulbar vs pseudobulbar paresis
Bulbar - palsy of LMN CN 9-12
pseduobulbar - palsy of UMN CN 9-12
Drug of choice to treat ecclampsia?
Magnesium (sulfate)
Weakness in right face, right arm, right leg. Vessel?
Penetrating branch of middle cerebral artery (lenticulostriate)?
Pure motor stroke - posterior limb of the internal capsule, (lacunar infarct)
Drug of choice for trigeminal neuralgia
carbamazepine
Pelizaeus-Merzbacher disease
Pelizaeus-Merzbacher disease is a demyelinating disorder that belongs to a group of degenerative diseases known as sudanophilic leukodystrophies. Leukodystrophy refers to the disturbance of white matter, and sudanophilic refers to the Sudan-staining characteristics of the involved white matter. Children with Pelizaeus-Merzbacher disease typically become symptomatic during the first months of life, but survival may extend into the third decade of life. Most affected persons are male.
optic atrophy, choreoathetosis, seizures, ataxia
Initial approach to a seizing patient?
Place them in the lateral decubitus position to avoid aspiration of gastric contents.
Hodgkin’s patient has carotid stenosis. Why may this be?
ionizing radiation accelerates atherosclerosis
Loss of pinprick sensation in the webbing between 1st and 2nd toe?
L5
Papillitis vs papilledema? What could papillitis be an early sign of?
Papilitis has vision loss while papilledema doesn’t.
Papilitis could be a sign of MS
MC cause of brain abscess in AIDS. NBS? Tx?
MC cause of ring enhancement in AIDS. NBS?
MC fungal cause of malig. otitis externa and osteomyelitis of the base of the skull in AIDS?
Toxoplasma Gondii; gram stain/culture, then stereotactic I&D, then SULFADIAZINE/PYREMETHAMINE
Toxoplasma Gondii and Primary CNS Lymphoma; CSF analysis w/ EBV PCR (to r/o PCNSL), then?
Aspergillus
Alzheimer’s meds for regular patients vs institutionalized/advanced disease?
Donepezil for average joe
Memantine for advanced disease
B12 deficiency causes what? Be specific
Ddx
Dorsal column disease, leading to losses of vibration and proprioception, NOT PAIN AND TEMP (spinothalamic)
diabetic neuropathy would better explain pain/temp loss, light touch loss, ankle reflex absent, some weakness, preservation of vibration/proprio, etc. Insidious onset
Concussion.
Grades and guidelines for sports.
ED criteria
- Head trauma w/ no structural damage on imaging
- retrograde amnesia +/- LOC
Grade 1: no LOC, 15 minutes confusion, must sit out 1 week (hospital if Sx>1 hr)
Grade 3: +LOC, must sit out 1 month, (hospital evaluation regardless)
If CT negative, dcg patient, but needs someone at home to monitor for lapse into coma.
Tx for grade IV astrocytoma?
THIS IS THE SAME THING AS GLIOBLASTOMA MULTIFORME!!!!!
surgical resection, then radiation
aminoglycoside toxicity
vestibular (dysequilibrium): gentamicin, streptomycin
chochlear: neomycin, tobramycin, kanamycin
What can improve the outcome of a patient s/p traumatic brain injury?
Hypothermia
Diffuse axonal injury
Result of angular trauma, seen at the gray-white junction but not visible on CT
Which portion of the spinal cord is more likely to infarct?
Which tract will this involve as far as sensation is concerned?
In addition to the two “classic” modes of sensation this tract is responsible for, name two more
Anterior
Spinothalamic Tract (pain/temp)
(two-point discrimination, graphesthesia)
Which type of aphasia is seen in alzhemiers?
Transcortical sensory
Abortive treatment for cluster headaches?
inhaled O2
Explosion in Iraq, severe hearing loss followed by partial recovery. [What is the principle site of damage 2/2 ACOUSTIC TRAUMA] What kind of hearing loss is it?
Sensorineural vs conductive?
High pitch vs low pitch?
cochlea; acoustic insult only has enough energy to shear off receptor cells; this leads to high tone sensorineural loss
[mechanical trauma can cause eardrum perforation which leads to high tone conduction loss]
Vision deficit seen with B12 def.
Centrocecal scotoma
Treatment for increased ICP at what point? Mnemonic for tx?
> 20 is worrisome ; ICP-HEAD
- Intubate
- Calm (sedate)
- Place Drain (ventriculostomy)
- Hyperventilate to PCO2 35ish (short term, LT will vasoconstrict and lead to ischemia)
- Elevate head
- Adequate BP (CPP>70)
- Diurese (mannitol)
Jacksonian March
With a Jacksonian march, or sequential seizure, the patient develops focal seizure activity that is primarily motor and spreads. This type of seizure often secondarily generalizes, at which point the patient loses consciousness and may have a generalized tonic-clonic seizure. The hand is a common site for the start of a Jacksonian march. The face may be involved early because the thumb and the mouth are situated near each other on the motor strip of the cerebral cortex.
Which brain tumor typically has hyperostosis as opposed to the usual thinning of the skull.
Meningioma
Distinguish polymyositis from MG, mononeuropathy multiplex, and the dystrophies
Polymyositis is clinically distinguished from the muscular dystrophies by its less prolonged course and lack of family history. It is distinguished from myasthenia gravis by its lack of ocular muscle involvement, absence of variability in strength over hours or days, lack of response to cholinesterase inhibitor drugs, and the characteristic EMG findings. Cervical myelopathy usually causes hyperreflexia. Mononeuritis multiplex causes asymmetric signs, usually with sensory loss, and does not affect swallowing.
Justify your choice in drug for seizures in the setting of hemorrhage?
Phenytoin (quick acting)
NOT lamotrigine because that takes weeks to get into your system
Most common cause of dementia?
Alzhemiers
Tunnel vision vs concentric constriction
exam findings which help you distinguish?
Tunnel vision is probs conversion disorder/malingering bc it is not a physiologic vision loss pattern.
Tunnel vision, when the test screen is moved away from the patient the patient reports the same size field.
Concentric constriction (2/2 optic atrophy/neurosyphillis), when the test screen is moved away from the patient, the patient reports perceiving the area perceived enlarging, but the overall visual field is always smaller than the normal visual field.
Anat/histo of neuro loss in chronic alc
Superior vermis of cerebellum - loss of purkinje cells and atrophy of molecular layer
Name some anti epileptics that upregulate liver enzymes and One that doesn’t.
Phenytoin, oxcarbazepine, carbamazepine, phenobarbital
Levetiracetam.
PE finding during phenytoin toxicity?
Nystagmus
Comment on the EMG findings in LEMS, MG, and botulism
Botulism is a disorder of the neuromuscular junction (NMJ). The characteristic findings are decremental response of the muscles to repetitive stimulation of the nerve at a low frequency (2-5 Hz) and incremental response to repetitive stimulation at high frequency (20-50 Hz). Other disorders of the NMJ, such as myasthenia gravis and Lambert-Eaton myasthenic syndrome (LEMS), also manifest with decremental response to repetitive stimulation at low frequencies due to depletion of acetylcholine in the synaptic cleft. Higher rates of stimulation lead to increased calcium in the presynaptic terminal, which allows more acetylcholine to be released in presynaptic disorders such as botulism and LEMS, thereby increasing the response of muscle. However, in myasthenia gravis, which is characterized by loss of acetylcholine receptors postsynaptically, there is no increase in response at higher rates of stimulation, because there is already a maximal amount of acetylcholine present in the synaptic cleft.
Male px of myotonic dystrophy ? EMG?
Men with myotonic dystrophy characteristically exhibit problems with relaxing their grip, hypersomnolence, premature baldness, testicular atrophy, and cataracts. The EMG pattern displayed by these patients is often referred to as the dive bomber pattern because of the characteristic sound produced when the evoked action potentials are heard. The cardiac defect that evolves in these persons usually requires pacemaker implantation to avoid sudden death. Psychiatric problems also develop in many patients with myotonic dystrophy, but their basis is unknown.
EMG: repetitive discharges with minor stimulation
Sudden dizziness in older patient noticed when turning the head or shaving? Dx? Gold standard test?
Syncope 2/2 carotid baroreceptor overstimulation.
Dx - carotid massage w/ EKG. remember to doppler first if bruits are heard
What can you histologically see in CMV and HIV CNS infections?
microglial nodules
Tx for listeria meningitis?
Ampicillin Gentamicin?
Donepezil effects.
DOES NOT AFFECT THE RATE OF NEURODEGENERATION. only improves cognitive symptoms
Which CN affected in sarcoid
7
among anti-convulsants, name some of the most potent hepatic enzyme inducers; name one non-inducer
phenytoin, oxcarbazepine, carbamazepine, phenobarbital
levetiracetam
Jarish-herxheimer
syphillitic infxn, tx steriods
EEG findings in Lennox-gastau
Creutzfeldt-Jakob
Infantile Spasms
Absence seizures
Lennox-Gastaut-multifocal slow spike and wave activity.
Creutzfeldt-Jakob disease-Triphasic spike and wave. is characteristic of
infantile spasms (West Syndrome)-Hypsarrhythmia
absence seizures-3 Hz spike and wave phenomenon
NBS in restless leg syndrome?
polysomnogram (sleep study)
Fibrillations, fasciculations
lower motor neuron signs?
Cauda equina vs conus medullaris syndrome
Cauda vs conus
gradual radicular vs sudden back
unilateral vs bilateral
LMN vs BOTH umn/lmn
hypo/areflexia vs hyperreflexia
rare sexual dysfunction vs frequent sexual dysfunction
bladder dysfunction late vs bladder dysfunction early
SADDLE anesthesia vs PERIANAL anesthesia
Progressive supranuclear pasly (PSP) vs Parkinson’s
STAIRS; impaired vertical gaze
pseudobulbar: dysphagia, dysarthria
Wernicke’s Encephalopathy triad
vs
Korsakoff’s psychosis triad
confusion, ataxia, ophthalmoplegia
anterograde + retrograde amnesia, confabulation, and lack of insight
Person in a crash presents with hypovolemic shock. What kind of brain hemorrhage is responsible?
NONE. FUCKING NONE. THERE IS NOT ENOUGH VOLUME TO CAUSE SHOCK. THEY’RE BLEEDING SOMEWHERE ELSE. LOOK FOR IT.
central cord syndrome px
old patient, hyperextension of neck, paralysis and burning pain of UE
Grand mal seizure, what ortho injury? What nerve injury?
Posterior shoulder dislocation (held close to body), radial nerve damage
Person who wears pointy shoes that bunch the toes together faces pain. Dx? Pathophys? Tx?
Morton Neuroma
Inflammation of the common digital nerve
Conservative: change shoes, nsaids, but surgical resection can help too
Subclavian steal syndrome
atherosclerosis before the takeoff of the vertebral artery. Nothing happens at rest, but upon arm exertion, the arm “steals” flow from vertebral artery leading to vertigo/gait abN, as well as coldness and tingling in the arm
dx arteriogram, tx bypass
Facial nerve trauma signs that onset slowly? Dx+NBS?
Facial nerve edema; resolves spontaneously
Sentinal bleed?
“sunset eyes”
“Mild SAH”
parinaud (pineal); upward gaze paralysis
autonomic dysreflexia. px? pathophys? tx short term and long term?
“causalgia” (reflex sympathetic dystrophy)
paraplegic who who has HIGH level paraplegia (T6), px with pounding headaches and malignant HTN and diaphoresis and bradycardia
[held up at a meeting, can’t self cath like usual, full bladder can trigger it or any visceral stimulus]
excessive alpha-adrenergic stimulus.
tx alpha block, long term CCB
vs
s/p crushing injury, constant burning agonizing pain, cold/cyanotic/moist extremity, very easily excitable pain, refractory to analgesics
dx successful sympathetic block relieving symptoms
tx sympathectomy
32 on 1/25/15 full block please go back and review
glucocorticoid induced myopathy
table on ddx of myopathy
Facial paralysis with forehead muscle sparing?
without sparing?
Intracranial/central/above pons (can close eye)
peripheral/below pons/bell’s
