Exam 1 Flashcards
cauda equina triad
urinary retention, stool incontinence, saddle anesthesia
Parkinsonism definition
at least 2 of the following: resting tremor, bradykinesia, rigidity, loss of postural reflexes, flexed posture, freezing phenomenon
Parkinsonism definition
at least 2 of the following: resting tremor, bradykinesia, rigidity, loss of postural reflexes, flexed posture, freezing phenomenon
4 categories of parkinsonism
primary, secondary, parkinsonism-plus, heredodegenerative
what is primary parkinsonism
parkinsons disease (sporadic or genetic)
examples of parkinsonism-plus disorders
progressive supranuclear palsy, diffuse lewy body
examples of secondary parkinsonism
parkinsonism caused by drugs, toxins, tumors, normal pressure hydrocephalus
examples of heredodegenerative parkinsonism
alzheimers, huntingtons, wilson’s
3 clinical clues suggestive of primary PD
asymmetric onset, responds to levodopa, resting tremor
how to tell primary PD vs parkinons-plus
Parkinsons plus will have other neuro findings and will not respond to therapy
Parkinons onset
insidious, progressive, worse when under stress. May be intermittent at onset
Parkinsons etiology
degeneration of dopamine producing cells in substantia nigra causing decrease in presynaptic domapine
PD diagnosis
no lab tests. Try l-dopa trial. MRI/CT to rule out other disease
PD peak age of onset
60
PD lifetime risk with and without family history
with: 4% without: 2 %
life expectancy after PD diagnosis
20 years
cause of death with PD
concurrent illness such as aspiration
life expectancy with PD plus disorders
9 years
what % of patients with PD develop dementia
78%
definition of PD dementia
PD for at least 1 year before dementia starts
Diffuse lewy body dementia definition
PD for less than 1 year before dementia
common cause of dementia in PD
depression
type of tremor in PD
resting, pill-rolling
type of handwriting with PD
micrographia
posture in PD
flexed, stooped, loss of posture reflex
emotional ssx in PD
apathy, anxiety, depression
sensory ssx in PD
numbness/tingling, pain in affected extremity
sleep ssx in PD
disturbed REM sleep with thrashing/kicking, may precede onset of PD
what primitive reflex is present in PD and what is this called
Glabellar (persistent blinking while tapping forehead). Myerson’s sign
gait in PD
narrow-based, shuffling, decreased arm swing
when does the wearing off effect occur for levodopa
after 5-10 years
2nd line treatment for PD
dopamine agonists
dopamine agonist examples
pergolide, bromocriptine, cabergoline
dopamine agonist side effects
fibrosis, hallucinations, confusion, sleep attacks, impulse control problems
Myasthenia gravis etiology
IgG antibodies against nicotinic Ach receptor in post-synaptic neuromuscular junction
age of onset for MG in women
20-40
age of onset for MG in men
age 40-60
MG presentation at onset
ptosis without pupillary involvement
MG ssx
muscle fatigability that improves with rest that begins centrally (usually with eye/face ssx)
MG is associated with____ how are these diagnosed
thymoma, thymic hyperplasia. CT
test for MG
Ach receptor antibody
what to do if seronegative MG suspected
test for muscle-specific receptor tyrosine kinase, or tensilon test
EMG findings in MG
normal or increased jitter; repetitive nerve stimulation shows >10% decrement
what is tensilon
IV short-acting Ach esterase inhibitor
MG treatment
low-dose immunosuppression (5 mg prednisone daily then titrate to effect), azathioprine, Ach esterase inhibitors, plasmapheresis, IVIG, thymectomy
how much CSF is produced per hour
20 ml
how does CSF leave brain
drains via arachnoid granulations into venous system
etiology of normal pressure hydrocephalus
unclear, could be decreased draining 2/2 fibrosis from injury/bleed/infection
normal pressure hydrocephalus triad
Adam’s triad: gait instability, urinary incontinence/urgency, dementia
characteristics of gait in NPH
slow, short steps, shuffling, wide stance
which ssx comes first and second in NPH
first: gait instability, second: urinary ssx
characteristics of dementia in NPH
inattention, slow recall, decreased spontaneity
imaging findings for NPH
ventriculomegaly with preserved volume of brain parenchyma
NPH tx
VP shunt
Guillain-Barre etiology
autoimmune demyelination of peripheral nerves following minor infection or associated with SLE, Hodgkins
GB demographic
equally in both sexes, age 30-50
GB presentation
rapidly progressive (in hours to days) tingling, muscle weakness, paralysis affecting both sides of body that starts in legs and spreads to arms with absent reflexes and autonomic instability
GB tests
lumbar puncture, EMG
GB tx
plasmapheresis, IVIG, blood thinners, respiratory support, supportive care
GB prognosis
most people recover completely but may take anywhere from weeks to years
what % of ALS cases are genetic
10%
what is ALS
upper and lower motor neuron disease in which the neurons die
ALS ssx
muscle twitching, weakening, paralysis that is progressive
what is not affected by ALS
senses, bowel/bladder function, cognition
ALS physical exam findings
weakness, tremors, spasms, atrophy, stiffness, clumsiness, emotional incontinence, abnormal reflexes
ALS tx
first line: riluzole to slow progression. Symptomatic meds: Baclofen/diazepam for spasticity, amitriptyline to decrease saliva
ALS prognosis
death often occurs within 3-5 years
ALS variants
progressive muscular atrophy, primary lateral sclerosis
how to test L4/L5 innervated muscles
resist patient’s abducted leg at lateral upper thigh to test gluteus medius, resist pt’s ability to dorsiflex foot (tibialis anterior), resist great toe extension (extensor hallucis longus)
how to test L5/S1 innervated muscles
Overcome hip extension (gluteus maximus), resist patient’s ability to evert foot (peroneus muscles)
abnormalities in muscle strength of L4-S1 innervated muscles indicates
lumbar disc disease or lumbar spinal stenosis, sciatica
vertebral compression fractures ssx
upper thoracic may be asymptomatic, lower thoracic/lumbar: point tenderness and pain but no neurologic abnormalities
red flags for back pain due to systemic disease
age >70, recent trauma, unexplained weight loss/fever, immunosuppression, history of cancer, osteoporosis, prolonged use of glucocorticoids, disabling/progressive focal deficits, ssx > 6 weeks, IV drug use
vertebral compression fracture tx
activity modification, pain control (opioids, NDSAIDs, calcitonin), PT, fall prevention, treat underlying osteoporosis
triad of cauda equina
urinary retention, stool incontinence, saddle anesthesia
L2 dermatome
groin
L3 dermatome
anterior thigh
L4 dermatome
anterior/lateral thigh, medial leg
L5 dermatome
lateral/posterior thigh, lateral leg, dorsal foot
S1 dermatome
posterior thigh, posterior leg, plantar foot
C2 dermatome
temporal/parietal scalp
C3 dermatome
nec
C4 dermatome
neck and medial shoulder
C5 dermatome
top of shoulder, lateral upper arm
C6 dermatome
radial forearm, thumb, index, long fingers
C7 dermatome
long and ring fingers, upper back around scapula
C8 dermatome
ulnar forearm, ring and small fingers
when to refer for spinal surgery
loss of bowel control, inability to urinate, saddle anesthesia, profound weakness, ataxic/myelopathic gait
when to refer to nonsurgical treatment for back pain
mild weakness, back pain without radiculopathy, radicular numbness/pain
imaging to evaluate compression fracture
AP/lateral plain films
positive straight leg test indicates what
herniated disc as cause of pain
what is a positive straight leg raise test
patient experiences sciatic pain when straight leg is at angle between 30 and 70 degrees when Pt is supine and knee is straight
what does a positive Hoffmans sign indicate
hyperreflexia
what constitutes a positive Hoffman’s sign
thumb and fingers flex
imaging for disc herniation at L3/L4
cannot see on x-ray, needs MRI
myelopathy vs myelomalacia
myelopathy is due to extrinsic compression of cord that is symptomatic but may be reversible. Myelomalacia is when the cord becomes atrophic and gliotic as a result of chronic injury and is irreversible
main types of headaches
primary, secondary, other
headache red flags
duration < 6 months, age <5 or >50, acute onset, atypical ssx, rash, neuro deficit, vomiting, recent trauma, infection, HTN, immunosuppression, pregnancy
red flag physical exam findings for headache
elevated BP, decreased neck ROM, signs of head trauma, loss of vision, unequal pupils, focal deficits
characteristics of migraine without aura
duration up to 3 days, unilateral, pulsing, moderate to severe pain, N/V, photo/phonophobia
migraine with aura characteristics
visual disturbances, paresthesias, speech problems
tension headache duration
up to one week
tension headache ssx
bilateral, tight, mild to moderate, not aggravated by activity, no N/V or aura
cluster headache onset and duration
peaks in 10 minutes, lasts up to 3 hours
cluster headaches ssx
excruciating, piercing/stabbing, unilateral, periorbital, restless
labs for dizziness
CBC, CMP, thyroid, B12, BGL
what is tabes dorsalis
demyelination due to untreated syphilis
tabes dorsalis onset
may be decades after initial syphilis infection
tabes dorsalis ssx
weakness, diminished reflexes, neuropathic pain, ataxia, joint degeneration, personality changes, positive Rombers
tabetic gait
high-stepping gait with Pt’s feet slapping the ground due to lack of proprioception
pupillary finding in tabes dorsalis
argyll robertson pupil
what is charcot foot
sudden softening of the bones in the foot that can occur in people who have neuropathy, leading to fractures and arch collapse giving the foot a rocker-bottom appearance
demographic for trigeminal neuralgia
classically women over 50
branches of trigeminal nerve
ophthalmic, maxillary, mandibular
what is trigeminal neuralgia
severe pain to one or more branches of trigeminal nerve due to compression near the pons, often by an enlarged superior cerebellar artery
trigeminal neuralgia tx
carbamazepine, baclofen, lamotrigine, other anticonvulsants, amitriptyline, opiates
Bells palsy treatment
steroids, antivirals if appropriate, protect eye
onset of diabetic peripheral neuropathy
within 15-20 years, or sooner with poor glucose control. Distal to proximal
diabetic peripheral neuropathy ssx
sensory ataxia especially at night
ssx of neuropathy due to nutritional deficiency
distal, symmetric sensory, motor, and autonomic findings especially painful dysthesia
nutritional causes of neuropatyh
deficiencies of thiamine, B6, B12, niacin, folic acid
percentage of dialysis patients suffering from neuropathy
60%
infectious causes of neuropatyh
HIV, herpes zoster, guillain-barre, lyme disease
most common cause of peripheral neuropathy
diabetes
BPPV etiology
likely dislodged otoconia (calcium granules)
BPPV ssx
episodic vertigo, nystagmus, nausea precipitated by changes in head position
eval maneuver for BPPV
Dix-hallpike
menieres disease aka
endolymphatic hydrops
menieres disease ssx
recurrent vertigo, tinnitus, hearing loss, fullness in ear, usually unilateral
menieres disease tx
diuretic, send to ENT
1st line meds for migraine prevention
topiramate, amitriptyline, propranolol
2nd line meds for migraine prevention
gabapentin, verapamil, neuro consult
1st line meds for tension/cluster HA prevention
amitriptyline
2nd line meds for tension or cluster HA prevention
gabapentin, topiramate
chronic causes of demyelinating peripheral neuropathy
DM, hypothyroid, multiple myeloma, liver disease, amiodarone
chronic causes of axonal peripheral neuropathy
DM, uremia, B12 deficiency*, lyme disease, ETOG
what medication to use for PD psychosis
quetiapine
