Headache

Question 1

Stroke:
BP <185/110
BP high
BP 150-220 
\_\_\_\_\_\_\_\_\_

-Thrombectomy < #hrs
-Thrombolysis < #hrs
@#

-@AIS + #Circ @ #imaging
+ CT#/MR# = # ->
do what
@when?

<24hrs/wake up stroke:
@AIS + Prox?Circ -?vessel -?vessel
@?imaging
\+
? /? = ?
\_\_\_\_\_\_\_

Thrombolysis < ?hrs:

• ?/? exclude = CThead @BIGHAM
• BP < ?/110 –>

?drug ?mg -?w->
-? 
-? 
-? @AF
\_\_\_\_\_\_\_\_

Exclude ? 
? outside
? inside
Homeostasis:
-BM ?-? 
-BP high + AIS + PANIC* = ? Tx (?PANIC) 
-->

CT-head exclude bleed=BIGHAM
->
SCAN types

Answer 1

Stroke

Thrombectomy <6hrs
Thrombolysis <4.5hrs
@pre-stroke \
func status <3\NIHSS>5

@AIS + ProxAntCirc
@CT/MR angio 
\+ CTperf/MRd-w = ?save brain tissue ->
Thrombectomy
@6-24hrs/wake up stroke

<24hrs/wake up stroke:
@AIS + ProxPostCirc -basilar -PCA
@CT/MR Angio 
\+
CTperf/MR d-w = ?save brain tissue
\_\_\_\_\_\_\_

Thrombolysis < 4.5hrs

• Hypo/Bleed exclude = CThead @BIGHAM
• BP <185/110 –>

Asp 300mg -2w->
-Clopidog
-Dyp+Asp
-AC @AF
\_\_\_\_\_\_\_\_

Exclude hypo/bleed
FAST outside
Rosier inside
Homeostasis:
-BM 4-11
-BP high + AIS + PANIC* = BP tx
-->

CT-head exclude bleed @:
Bleed tendency 
ICP high 
GCS <13 
HA
AC
Meningism 
-> 
CT/MR angio 
CT Angio / MR d-w = ?save brain tissue 

*Pre-Eclampsia
ADiss
Nephro/Encephalopathy
ICH <6hr/BP150-220 -> 
-BP lowering tx* = Aim 130-140 <1hr 7d 
CCF/MI

*Fucked struct
GCS <6
Hematoma
-major = poor prog
-neurosurg evac

Question 2

ICH (types?)
-?refer to who

-?dx process warrants surg->

SURG:
MCA infarct - ? 
-MCA >50%
-NIHSS >15
-GCS dropping
\_\_\_\_\_\_\_\_\_

PTC @?

ICH
?* = Aim BP range <1hr 7d

iF HAVE ICH + VTE?

Answer 2

ICH (subdural/extradural)
-neurosurg/stroke docs

-HYDROCEPHALUS->

SURG:
MCA infarct - Decomp HemiCraniotomy
-MCA >50% territory 
-NIHSS >15
-GCS dropping
\_\_\_\_\_\_\_

PTC
@emergency
Warfarin reveal
<1hr =
Stop Warf
PTC + Vit K
FFP @unavail
\_\_\_\_\_\_\_

ICH <6hrs/BP 150-220 ->
BP Tx* = Aim BP 130-140 <1hr 7d

*Fucked struct
GCS <6
Hematoma
-major = poor prog
-neurosurg evac
\_\_\_\_\_\_\_\_\_

IF HAVE ICH + VTE?
-AC / IVC filter

Question 3

1. If suspect TIA, initial mx?
2. What do they do at the latter of above answer?
3. What to do is MR d-w confirms?
4. What does the latter answer of q2 entail?

Indication for Carotid Endarterectomy?…
_____________

Venous Sinus Thrombosis = ???
-MR Venogram gold standard Ix

Art Diss = ???

Prosthetic valve –>
stroke AND ICH risk –> ???

HR bleed (surg) + 
HR stroke (AF/prev stroke) --> ???

Stable CVD + AF –> ???

Isch stroke –> AF = ???

For stroke prev:

• AC = ?
• no AC = ?

iF HAVE ICH + VTE?

Answer 3

1. If suspect TIA, initial mx?
   - 300mg + REFER <24hr TIA clinic
2. What do they do at the latter of above answer?
   - MR diff-weighted + carotid imaging/doppler
3. What to do is MR d-w confirms?
   - Statin @48hr
   - Clopi > MR Dyp + Asp
4. What does the latter answer of q2 entail?
   @Carotid Doppler Imaging
   -Stable Neuro + Stenosis >50% NASCET =
   Carotid Endarterectomy
   - Stenosis <50% / <70% ESCT = 2ndary Prev
   _______________

Venous Sinus Thrombosis =
LMWH -5d-> Warf 2-3

Art Diss = AP/AC

Prosthetic valve –>
stroke AND ICH risk –>
Stop AC, Start AP

HR bleed (surg) + 
HR stroke (AF/prev stroke) -->
Stop AC, Start LMWH

Stable CVD + AF –> Stop AP, Start AC

Isch stroke –> AF =
Asp 300 mg 2w –> AC

For stroke prev:
-AC: DOAC/DabigaTHROMBINi/Warf
-no AC = LA Appendage Occlusion
____

iF HAVE ICH + VTE?
-AC / IVC filter

Question 4

Codeine to PO morphine

PO morphine = to…

SC moprhine /?
OXYCOD PO /?

SC diamorphine /?
IV moprhine /?

OXYCOD SC /?

• SP—SI–S
• MO-DM-O
• 22—33–4

Alcohol units?
-AST > ALT (ratio usually> 2:1)
-toAST
________

Monoplegia -?
Hemiplegia -?
Quadriplegic -?
-Paraplegia -?

ACA–MCA–PCA*

*PCA - midbrain Weber
________________

Amaurosis fugax - which vessel?
Locked in syndrome - which vessel?
__________

• Absent < – > horizontal eye-move
• Miosis
• Paralysis=Quadriplegia
• Same FACE: PD/PT (paralysis/deaf // pain/temp)
• Opp limb
• Nystagmus
• Ataxia
• Same FACE: PD/PT (pain/temp)
• Opp limb
• Nystagmus
• Ataxia

__________

• Unilat sensory/motor FAL
• Cog dx - VisuoSpatial/Dysphasia
• HomoHNopia

1 of:
-Sensory
-AtaxicHemiParesis
-Motor
PURELY + HTN

CN dx + CONTRALAR motor/sensory dx
Conjugate EYE dx
CEREbellar dx - ataxia/nystag/vertigo
HomoHNopia

4-6-4 H:
CN4 present?
CN3 present?
CN6 present?

________

Nystagmus: central v peripheral?
______

Brainstem death

_________

Delirium > Dementia
_______

woman 
short-lasting UNILAT side of 
face = behind eye. 
UNILAT-sided tearing + nasal congestion
-no photophobia
-Several times/day 
Tx: indomethacin -> attacks stopped
Dx? Tx?
\_\_\_\_\_\_\_\_\_

?vessel lesions (dominant side - i.e. most ppl are ?-handed so ?-sided MCA fucked):

Lesion -> SPEECH = FLUENT  
sentences that make Sense
-Repetition = FUCKED
-AWARE of Errors making 
Comprehension is NORM 

Lesion -> SPEECH = FLUENT 
sentences that make NO Sense
-word substitution / neologisms  #word-salad
Comprehension FUCKED
Repetition NORM 

Lesion -> SPEECH = NON-FLUENT
sentences that make Sense
-Laboured + Halting 
-Repetition = FUCKED
Comprehension NORM 
\_\_\_\_\_\_\_\_

? @Oed from tumour
? @Raised ICP
? @SAH to reduce vasospasm
__________

Gait ataxia = ?

? = finger-nose ataxia

? - Hypokinetic (e.g. Parkinsonism) or hyperkinetic (e.g. Huntington’s)

? - sensory symptoms, dyLEXia, dysGRAPHia

? - motor symptoms, expressive aphasia, disinhibition

Answer 4

Codeine to PO morphine /10

PO morphine = to…

SC moprhine /2
OXYCOD PO /2

SC diamorphine/3
IV moprhine /3

OXYCOD SC /4

Alcohol units = %.mls / 1000
-make a toAST with alcohol > ALT. 2>1

_________

Monoplegia - 1 limb
Hemiplegia - Unilat 2 limbs
Quadriplegic - 4 limbs
-Paraplegia - Bilat LOWER limbs

ACA MCA PCA*
L>UL ; UL>L

< – HemiParesis
……..Aphasia – > Agnosia
……..Sensory
….HomoHAnopia – > Mac-Sparing

*PCA - Weber Midbrain
-Same CN3, opp HemiParesis
-Agnosia
-Macular sparing HomoHNopia
________________

Amaurosis fugax - Retinal/Ophthalmic Artery
Locked in syndrome - Basilar Artery
____________

Pontine bleed: PAMP

• Absent < – > horizontal eye-move
• Miosis
• Paralysis=Quadriplegia

AICA: Lat Pont

• Same FACE: PD/PT
• ——(paralysis/deaf // pain/temp)
• Opp limb
• Nystagmus
• Ataxia

PICA: Lat Med Wallenburg

• Same FACE: PD/PT (pain/temp)
• Opp limb
• Nystagmus
• Ataxia

______________

Anterior Circulation Stroke:

3=TotalACS
2=PartialACS
-UCH

• Unilat sensory/motor FAL
• Cog dx - VisuoSpatial/Dysphasia
• HomoHNopia

LacACS = L-SAMP 
1 of:
-Sensory
-AtaxicHemiParesis
-Motor
PURELY + HTN

POstCS
_________

4-6-4 H:
CN4 vertical nystagmus
CN3 Ptosis, Dilated, Vertical nystagmus
CN6 horizontal nystagmus

Nystagmus: Central v Periph:
central is:

• B/L
• Assoc sens/motor dx
• Direction = multi / purely uni or rotatory

Brainstem Death:
Coma unknown Ax
Reversible ax excluded
Sedation X
Electrolytes fine

Bronchial stim -> no cough
Response to sound/Supra-Orb Pressure
Occ-Vestib Reflex absent
Corneal Reflex absent
Disconnect ventilator 5-mins -> no resp support
\_\_\_\_\_\_\_

-Emotions = fear, agitation
-Fluct Syx = worse @night, normal periods
-GCS impaired
-Hallucinations/Illusions/Delusions #perception
_________

Paroxysmal HemiCrania
-Indomethacin
__________

MCA lesions (dominant side - i.e. most ppl are right-handed so left-sided MCA fucked):

Conduction aphasia

• Arcuate Fasciculus
• Fluent + Sense + Comp NORM
• Repetition fucked

Wernicke Receptive

• SUP Temp gyrus
• Fluent + NO Sense + Comp FUCKED
• Repetition NORM

Broca Expressive
-INF Frontal gyrus
-NON-Fluent + Sense + Comp NORM
-Repetition fucked 
\_\_\_\_\_\_

Dexa @Oed from tumour
Mannitol @Raised ICP
Nimodipine @SAH to reduce vasospasm
______

Gait ataxia = cerebellar vermis lesions

Cerebellar hemisphere = finger-nose ataxia

Basal ganglia - Hypokinetic (e.g. Parkinsonism) or hyperkinetic (e.g. Huntington’s)

Parietal lobe - sensory symptoms, dyslexia, dysgraphia

Frontal lobe - motor symptoms, expressive aphasia, disinhibition

Question 5

Headache
men > women
severe, throbbing/EXPLOSIVE
@moment of orgasm LOL

Dx? Tx?
____________

Headache: 30 min - 7 days

Bilat, tight pressing

Noooooooo N+V ; NON-Pulsating
?????PHONO/PHOTO-phobia
Physical ADL NOT worsen HA –> not avoid ADL

i.e. OPP TO MIG w/out AURA

Tx??
____________

Headache -
15days / month +++ pre-existing HA dx

overuse of ergotamines, triptans, simple analgesics or opioids.

MORE THAN ? months

Tx??

Answer 5

Coital cephalagia

• post-coital HA
• NSAID

____________

Tension

Paracetamol, 
Asp, 
Acupunt, 
NSAID
\_\_\_\_\_\_\_\_\_\_\_

MOH
-MORE THAN 3 months

Month 1: stop meds
Month 2: HA return –> restart meds

Question 6

Headache: 15 mins – 3hrs !!

5 attacks of severe
UNILAT
Orbital/Supraorbital/Temporal pain

ALCO WORSEN!!!!!!!!

Ipsilateral:
Eye: 
-conjunctival injection/lacrimation; 
-swollen EYELIDS
-mioooooosis 

Nose: congestion/rhinorrhoea;

Face: Sweating/flushing

Ear: Aural fullness

RESTLESS / agitation.

??? is a contraindication to triptan use

Tx??
________________

woman 
short-lasting UNILAT side of 
face = behind eye. 
UNILAT-sided tearing + nasal congestion
-no photophobia
-Several times/day 
Tx: indomethacin -> attacks stopped
Dx? Tx?

A 22-year-old man consults you as he and his housemate have been feeling generally unwell for the past few weeks. Has HEADACHE.

Questions may hint at badly maintained housing e.g. STUDENT HOUSES

Tx?
__________

Uinilat: Tn.M.C
Bilat: Th.Mo

Answer 6

Cluster headache

RATS Vera

Refer
Acute = Triptan, SBOT
Prev: Verapamil

Cardiovascular disease is a contraindication to triptan use
_____________

Paroxysmal hemicrania
-Indomethacin
____________

CO poisoning

oxygen saturation of haemoglobin decreases leading to an early plateau in the oxygen dissociation curve

O2 HF
Hyperbaric chamber
_________

Unilat: TNeur, Migr, Cluster
B/L: TensionHA, MOH

Question 7

Vasc compromise or Trigem Nerve –? demyelination

Wash, Eat, Brush Shave –> Unilat elec shock

Tx?? Ix?

_____________

Headache = 4hr - 3 days!!!!!!!!

PHONO/PHOTO-phobia
Unilat, PULSATING
Mod/Severe Pain
Physical ADL –> worsen –> AVOID ADL

N+V

??? is a contraindication to triptan use

Tx??
___________________

Headache = 4hr - 3 days!!!!!!!!!!!

Zigzag lines and/or SCOTOMA/scintillations !!!!!!!!!!!!!!
Vertigooooooooooo
Aura –> headache within 60 mins!!!

Sensory: pins and needles.
Speech: Aphasia
Motor: weakness

Aura spreads gradually over AT LEAST 5 mins
2 or more symptoms occur in succession.
Each aura = 5-60 minutes.
At least one aura symptom is UNILAT.

??? is a contraindication to triptan use

Tx??

Answer 7

Trigem Neuralgia

Carbemazapine

MRI Head
_________

Migraine w/out aura

PANT TARA

ACUTE 1 +2a/b
Paracetamol 2b
AEmetics
NSAID 2a
Triptan 1

PREV
Topirimate < Propranolol
Acupunc
RiB2flavin
Amitriptyline

Cardiovascular disease is a contraindication to triptan use
__________________

Migraine with aura

PANT TARA

ACUTE 1 +2a/b
Paracetamol 2b
AEmetics
NSAID 2a
Triptan 1

Topirimate < Propranolol
Acupunc
RiB2flavin
Amitriptyline

Cardiovascular disease is a contraindication to triptan use

Question 8

HA + BLURRY vision

CN6 palsy

• eye move in MEDIALLY
• ?horizontal nystagmus

Papilloedema, Large BLIND SPOT

Young
-FAT, Female, Fucked (preg)

Happens to have used TETRACYCLINES

Tx: WALTS

Tx??

Answer 8

BIIC-HTN - Benign Idiopathic IntraCranial HTN

WL, 
Acetazolamide, 
LP
Topirimate (helpWL)
Shunt/Optic nerve sheath decomp/fenest

Question 9

RIGHT EYE–LEFT EYE
? ?
?—–?
?-? ?-?

4- ?CN
3- ?CN
6- ?CN
____________

Diplopia Double Vision 
Direction #H
^                ^
|  < - - - - > |
v                v

?* ?* ?*

CranioPharyngioma = ?
Pituitary tumour = ?

____________

CN formula..?

NTR:

1. RON ?
   - chiasm-> (right chiasm = ?)
2. ROT ?
   - LGN->
3. SIñOR Pi-Ts:
   - RsOR @which lobe -> ?
   - RiOR @which lobe -> ?
   - Rs+iOR = PiTs = ?

SIñOR Pi-Ts:
S OR @?-qa 
I  OR  @?-qa 
Post Cerebal Art Occluded = ?
\_\_\_\_\_\_\_

Med #?dx
INO - InterNuclear Ophthalmoplegia
Long
Fasciculus:

So.. normally when you trying to look left for example…
what muscle ABDucts @left eye
+
what muscle ADDucts @right eye

but in INO..
what muscle ABDucts @left eye
\+
what muscle ADDucts=? @right eye
--> 

contra LR6 works ? to stim ? –>
? nystagmus

Answer 9

RIGHT EYE\_\_LEFT EYE
4                                  4
                6-------6
3-dilated                     3-dilated
    ptosis                         ptosis

4-Trochlear
3-Occulumotor
6-Abducens
____________

Diplopia Double Vision 
DIRECTION: #H
^                ^
|  < - - - - > |
v                v

4 6 4

• 4 vertical
• 6 horizontal
• 4 vertical

CranioPharyngioma =
-Inf Bitemp HAnopia

Pituitary tumour =
-Sup Bitemp HAnopia
____________

LR6 SO4 R3 =
-Lr - SO - 3R
6 4

Nerve Tract Radiation:

1. RON - right MonoOccularVisionLoss
   - chiasm-> (right chiasm = right NasalHAnopia)
2. ROT #LeftHomoHAnopia
   - LGN->
3. SIñOR Pi-Ts:
   - RsOR @Pi = LiQA
   - RiOR @Ts #Meyer = LsQA
   - Rs+iOR = PiTs = #LeftHomoHAnopia

SIñOR Pi-Ts:
S OR @PI-qa - Parietal-InfQA
I  OR  @TS-qa - Temp-SupQA
Post Cerebal Art Occluded = Macular SPARING
\_\_\_\_\_\_\_

Med #MS #Stroke
INO - InterNuclear Ophthalmoplegia
Long
Fasciculus:

So.. normally when you trying to look LEFT for example…
contralat LR6 ABDucts @left eye
+
ipsilat MR ADDucts @right eye

but in INO..
contralat LR6 ABDucts @left eye
\+
ipsilat MR3 ADDucts=FAILS @right eye
--> 

contra LR6 works overtime to stim ipsi MR3 –>
contra LR6 nystagmus

Question 10

Diff between: Parkinson’s+Dementia VS Lewy-body?
-Parkinson’s + Dementia = ?
-Lewy-body = ?
__________

Parkinson symptoms

Tremor = WORSE as pt gets closer to target eg. Nose
- indicative of ?dx

Undershooting / Overshooting

Essential tremor VS Parkinson’s disease -
NICE recommend what to differentiate?

Parkinson Tx?

Parkinon’s TRAPS =
-Asymmetric/Symmetric?, pill-rolling @?,
-? with voluntary movement
(Rememer Back 2 the Future guy ice skating?!)

Tremor = WORSENS as reaches out to examiner’s finger
-? tremor = ? dx

?-pointing - pointing BEYOND the finger
@finger-nose test = ? dx
# ?

Tremor = worsens @OUTstetched arms = ? Dx
-bi/unilateral? + worsens/improve? with action
__________

Classical histories of :

1.
Recent 'diagnosis' of Parkinson's...
-POOR response to levodopa
-------impaired BALANCE #Falls
-------O/E vertical-GAZE Palsy #Symm onset

2.
Recent 'diagnosis' of Parkinson's...
-POOR response to levodopa
--IMPOTENT --urinary RETENTION --OLD
\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_

Global deficit 
Relentlessly PROGRESSIVE decline 
-? - fine AND gross motor
-? - impulsive
-? - speech fucked

Apo-Lipo-Protein
Beta-amyloid plaques
Neurofibrillary tangles

Down’s Trisomy 21 therefore HRisk
—-Dx? Tx?

When to avoid galantamine?
When to avoid donepezil?
____________

2 causes of fluctuating GCS?

Fluuuuuuuuuuctuating GCS
Hallucinations
REM sleep dx

Parkinsonism

@Parkinson = Avoid which meds?

Similar to ?? hematoma - fluctuating GCS!!
__________

YOUNG < 65
RAPID AF ONSET!!!!!!
Personality/Speech dx:

3 types:

1. PERSONALITY change and social-conduct dx - PERSONALITY ??’s dx
2. APHASIA SPEEEEECH ChrProgAphasia
3. Semantic

Memory + VisuoSpatial skills FINE

Neurofibrillary tangles
_________
_________
________

Acoustic neuroma = ? SVT
Menieres = ? of SVT + aural fullness

Answer 10

Diff between Parkinson’s + Dementia V Lewy-body?
-Parkinson’s + Dementia =
TRAPS –1/+yr–> Cog dx

-Lewy-body =
TRAPS + Cog dx
<1yr of each other
__________

Tremor - Pill-rolling RESTING
Rigidity - cogwheel LEADpipie
Akinesia brady
Post Instability

Tremor = WORSE as pt gets closer to target
–Intention tremor @ cerebellar dx #DANISH
dysdiadocho, ataxia, nystagmus, INTENTION TREMOR, staCCCato slurring , hypoTonia

Dysmetria - Under/Overshooting - ALS/MS

ET v Parkinsons =
NICE recommend 123I‑FP‑CIT SPECT

Levo/carbi

• Motor improve/cx increase
• ADLs improve
• Adverse rxns decrease (hallucinations/impulse/sleep)
• Time inc = effectiveness decrease

AMANTADINE/DBS
Selegeline MAOi - Tyramine foods, Off-time
Entacapone - COMTi - off-time reduce
Ropinirole/CabergolineCardiacFibrosis - hallucinations/impulse/sleep
DBS

Parkinon’s TRAPS =
-Asymmetric, pill-rolling @rest,
-IMPROVE with voluntary MOVEMENT
(Rememer Back 2 the Future guy ice skating?!)

Tremor = WORSENS as reaches out to examiner’s finger
-Intention tremor = cerebellar dx #DANISH

past-pointing - pointing BEYOND the finger
@finger-nose test = cerebellar dx
#Dysmetria

Tremor = worsens @OUTstetched arms = essential tremor
-BIlateral + WORSEN with action
-Propranolol -> Primidone
__________

Progressive Supranuclear Palsy #PSP

Multi-system atrophy
________
__________

• dysPRAXIA - fine AND gross motor
• dysINHIBITION - impulsive
• dysPHASIA - speech fucked

Alzheimer’s = ALAN GaRD MAdcl

AAAAlzheimer/LLLewy (not antipsychs/galantamine) = AAAChi –> NNNMDAblocker

AChi:

• GGGalantamaine(avoid @Parkinson w/ APsychotics)
• RRRivastigmine/
• DDDonepezil(avoid @AVBlock, BRADYcard NTSEuthyroid)

NmdaBlocker:

• Memantine @:
• -aDDDd-on @mild/mod,
• -aCCChi CI,
• -aLLLone @ severe

Avoid Galantamine + APsych @Parkinson’s
Avoid Donepezil @Brady/ AVN block/ NTSEuthyroid
____________

2 causes of fluctuating GCS?

• subdural hematoma
• LewyBodyDementia

Lewy body dementia
haLewycinations

Parkinsonism:
Tremor pill-rolling/resting
Rigidity - cogwheel/lead-pipe
Akinesia/Bradykinesia
Post Instability
Shuffling gait

@Parkinson = Avoid @

• Antipsychotics - parkinonism TRAP
• Galantamine

@Donepezil = Avoid @
-AVNblock, BRADYcard, NTSEuthryoid

Similar to Subdural hematoma - fluctuating GCS!!
_____________

Fronto Temporal-Serial killer type

Personality PICK’S disease
_________
_________
________

Acoustic neuroma = PROGressive SVT
Menieres = Intermittent attacks of SVT + aural fullness

Question 11

2 causes of fluctuating GCS?

Fluuuuuuuuuuctuating GCS
Hallucinations
REM sleep dx

Parkinsonism?

Avoid which meds???

Similar to ?? hematoma - fluctuating GCS!!

YOUNG < 65
RAPID AF ONSET!!!!!!
Personality/Speech dx:

Diff between Parkinson’s + Dementia V Lewy-body?

• Parkinson’s + Dementia = ?
• Lewy-body = ?

Answer 11

2 causes of fluctuating GCS?

• subdural hematoma
• LewyBodyDementia

Lewy body dementia
-haLewycinations

Tremor - Pill-rolling RESTING  
Rigidity - cogwheel LEADpipie
Akinesia brady
Post Instability
Shuffling gait

Avoid:

• Antipsychotics - parkinonism TRAP
• Galantamine

Similar to Subdural hematoma - fluctuating GCS!!

Young=Fronto-Temporal
- Similar to serial killers!!!
-Personality PICK’S dx
__________

Diff between Parkinson’s + Dementia V Lewy-body?

• Parkinson’s + Dementia = TRAPS –1/+yr–> Cog dx
• Lewy-body = TRAPS + Cog dx <1yr of each other

Question 12

YOUNG < 65
RAPID AF ONSET!!!!!!
Personality/Speech dx:

3 types:

1. PERSONALITY change and social-conduct dx (Pick’s) PERSONALITY ??’s dx
2. ? APHASIA
   - ChrProg?
3. ?

• Memory fine
• VisuoSpatial skills FINE
• Neurofibrillary tangles

Answer 12

Fronto-Temporal
- Similar to serial killers!!!

Personality PICK’S dx

PERSONALITY change and social-conduct dx (Pick’s) PERSONALITY ??’s dx

2. SPEEEEECH APHASIA
   - ChrProgAphasia
3. Semantic

Question 13

Dancing eyes, dancing feet

Ovarian teratoma –>
Psych dx, memory dx, encephalitis, seizures, dyskinesias, autonomic dx, language dx = Anti-??

Sudden onset of multiple seborrheic keratoses
___________________

Small cell lung cancer (anti-??),
Gynae/breast cancers (anti-??), and
Hodgkin lymphoma (anti-??)

Migratory superficial thrombophlebitis
___________________

SmLCC –> weakness ? with movement
-WADDLING gait

Thymoma -
Low Ig=?
Anemia + low retic=?
Weakness ? with movement

Myelodysplasia - tender purple plaques

Answer 13

Opso-myo clonus - Ataxia Syndrome
@ Neuroblastoma/SmLCC

Ovarian teratoma -
Anti-NMDA encephalitis

Sign of Leser-Trelat @ GI / Visceral cancer
___________________

SmLCC lung cancer (anti-Hu),
Gynae/breast cancers (anti-Yo)
Hodgkin lymphoma (anti-Tr)

Pancreatis cancer - Trousseau
___________________

Lambert-Eaton Syndrome

• Antibodies against presynaptic Ca2+ channels at NMJ
• Weakness IMPROVE with movement

Thymoma -
Good Syndrome low Ig, 
Red cell aplasia, 
MyGravis - PostSynap Ach ABs
-Weakness get WORSE with movement 

Sweet Syndrome

Question 14

Motor:Asc weakness (prox muscles before distal ones)
Reflexes: Reduced / absent
Sensory: ?distal paraesthesia
Autonomic involvement: e.g. urinary retention, diarrhoea

Hx of gastroenteritis - Campy
Resp muscle weakness

Dx? Tx?
___________

Thymoma - CT thorax

• Ptosis, Peak Sign/Snarl
• WEAK Reflexes+Power - WORSEN w/ use
• Diplopia
• Resp muscle involvement –> SOB
• bulbar muscle dx –>
  difficulty chewing+swallowing
  #dysphagia #mastication

Dx? Ix? Tx?
_____________

SmLCC
Prox muscle weakness, 
IMPROOOOOOVE with muscle use
Autonomic (dry mouth, impotence)
--WADDLING gait = girdle weakness

Dx? Pathphys?

Answer 14

Guillain Bare

PlasmaPharesis/Exchange
IVIG
Neuropathy - DAG
DVT proph

PI-ND
________________
PI-PPT

Myaesthenia Gravis

• ElectroMyoGraphy
• Post-synaptic AChR AB

PlasmaPharesis/Exchange
IVIG
PyridoStigmine = LA Ach-i
Pred
Thymectomy

________________

Lambert Eaton
Pre-Synaptic Ca channel AB —> reduce Ach –>
So if move more –>
more presynap Ca release –> more ACh release

Question 15

*PRAD: Pyrexia, Rigidity, Autonomic syx, Delirium

SSRI/MAOi/Ecstasy –>
RAPID onset PRAD*
HYPOOOreflexia NOOORMAL pupils
-ALL low - onset time, reflexes, pupils

1. Dx? Tx?

APsych/ Parkinson-meds STOP –>
SLOW onset PRAD*
HYPERreflexia, DILATED pupils
-ALL HIGH - onset time, reflexes, pupils

2. Dx? Tx?
   __________________

Paraesthesia
UNSTEADiness
Restless + SLEEP dx, 
SWEATing
-Mood change

? = HIGHER incidence of
DISCONTINUATION syx
than other SSRI
___________

? = indicated for patients with schizophrenia
who have not responded adequately
to at least 2 TWOOOOOOOOO antipsychotics.

AntiPsychotic HORQ - in old ppl issue?

APsych; SEs and receptors of typicals

Parkinson syx??

Treat EPSE w/ ?

• Intention tremor Ax?
• Dysmetria @ ??

Alpha HE MEN??

Answer 15

1. SeRAPIDtotonin Serotonin Syndrome
   - CyproPhetadine/Chlorpromazine

2. NMS: Anti-pSLOOOOOOOOWcotic
Stop APsych/ Start Parkinson-meds, 
IVF, 
-Dantrolene/?DopAgonists - bromocriptine
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

SSRI Discontinuation Syx

Paroxetine = HIGHER incidence of
DISCONTINUATION syx
than other SSRI

______________________
CLOZAPINE = indicated for patients with schizophrenia
who have not responded adequately
to at least 2 TWOOOOOOOOO antipsychotics.

AntiPsychotic HORQ - in old ppl = VTE/stroke

TRAP+Alpha.HE.MEN
Tard dyskinesia
-choreoathetoid chewing/pouting RETARDEDLY
Restless akathisia
Acute dystonia - torticollis, oculogyric
Parkinsonism EPSE - TRAP
-Tx EPSE w/ procyclidine/benzotropine

Tremor - Pill-rolling RESTING  
Rigidity - cogwheel LEADpipie
Akinesia brady
Post Instability
Shuffling gait 

Intention tremor @ CEREBELLAR dx
Dysmetria - over/undershooting - ALSSS/MSSS
-id-cam
\_\_\_\_\_\_\_\_\_\_\_\_
Alpha receptors - post hypotn
Histamine - sleep/?Weight
EPSE
Muscarinic blocker - opposite of SLUDS
Endo - prolactin
NMaligS 
-slow onset PRAD
-high: onset time, reflexes-Hyper, pupils-dilate

Question 16

Cremaster L??, Anal Wink S??

Reflex: Ankle S??, Knee L??
Bicep C??
BRadialis C??
Tricep C?? 
\_\_\_\_\_\_\_\_\_\_\_

Thumb C?
Middle Finger C?
Little finger C?
________________

Nipple ?

BellyButton - ?

Coeliac ?
_______________________

Inguinal?

SMA ?

MID-Thigh?

IMA ?
________________________

Kneecap ?

Big Toe ?

Lat foot small toe ?
_______________________

Answer 16

Cremaster L1/2, Anal Wink S3/4

Reflex: Ankle S1/2, Knee L3/4
Bicep C5/6
BRadialis C5/6
Tricep C7/8
\_\_\_\_\_\_\_\_\_\_

Thumb C6, Middle Finger C7, Little finger C8
_______________________

Nipple T4

BellyButton - T10

Coeliac T12
_______________________

1nguinal L1

SupMA L1

MidThigh L3

InfMA L3
_______________________

Kneecap L4 all 4’s…

Big Toe L5 ;

Lat foot small toe S1
________________________

Question 17

For headaches:

Acute @migraine/cluster

Prev @migraine/BIIC-HTN/cluster

Answer 17

For headaches:

Acute:
Triptan @migraine/cluster
Subcut/INasal

Prev:
Topirimate @migraine + BIIC-HTN
Verap @cluster

Question 18

Pain
Loss of motor/sensory/autonomic function
Hoffman

Ix?
Tx?

Answer 18

DCM

MRI c-spine 
Spinal surg (neuro/ortho) ASAP

Question 19

1. Laughter → fall/collapse
2. postural tremor:
   worse @ ? –>
   improved @ ?
   Titubation ?

Inheritance?

Tx: ?? –> ??

Answer 19

1 ?cataplexy - ppl can have narcolepsy too

2. ADET: Auto Dom Essential Tremor
   - worse @OUTSTRETCHED arms
   - improved @ ALCO / Rest
   - Titubation = head tremor

Tx: Propranolol –> Primidone

Question 20

Delusion that a friend or partner has been replaced by an IDENTICAL-looking IMPOSTER

Delusional idea that a person whom they consider to be of higher SOCIAL/PROFESSIONAL standing is in LOVE with her

Delusional idea that the various people that the patient meets are in fact the SAME person
________________

Belief that infected with PARASITES / ‘BUGS’ under their skin

Irrational belief that one’s partner is having an AFFAIR with no objective evidence

Delusional idea that one is DEAD/rotting

Answer 20

Capgras - IMPOSTER

De Clerambault - SOCIAL/PROF higher STATUS in LOVE

Fregoli - SAME
________________

EkBom PARASITosis syndrome

Othello - AFFAIR

Cotard - DEAD (nihilistic is rotting etc)

Question 21

MR: (Valsalva -> Syst @mitral-area)
SAM AsH #LVH=deep Q @V1-3ish

OFTEN ASYMPTOMATIC
-SOBOE, angina
Ex -> Syncope #sudden-death

O/E: Jerky/Bisfriens pusle
ECG: deep Q @V1-3ish + ST depr + T-invert
-HOCM assoc w/ which arrythmic dx?

\_\_\_\_\_\_\_\_\_
B12 def -> tracts:
-? dx - ataxia
-? dx - fine movement of ipsilateral limbs
-? dx - prop/vib + fine touch 

Subacute Degen SC

• HIGH-STEP-GAIT
• Eye dx
• Reflex: kneeLMN ankleLMN plantarUMN

Neuro syx YES = ?

Neuro syx NO =
? ->
-DietRelated= ? 
-DietUnRelated= ?
\_\_\_\_\_\_

Brown Sequard:

_________________

If damaged above T1, may present with?

______________

Classic ** pt accidentally BURN their hands WITHOUT Realising **.

• WASTE of SMALL muscles @HAND
• ‘cape-like’ (neck arms trunk)
• SENSORY loss of pain + temperature

-Preservation of what sensory modality #?Tract

crossing ? TRACTS
@ ? ? of Spinal Cord
#FIRST tracts to be affected

Ix? Assoc w/ ?Malformation

___________

P Painless retention
E Eversion of foot weak
N No ankle/knee jerk
I Impotence
S Saddle anaesthesia
-Anatomy of compression?

Ix? Tx? Anatomy?
________

__________

• prob/vibr dx
  |—–> Ataxia + Romberg POS + DTRs absent
• fine touch dx -> Charcot
• Accom Reflex Present - Pupil Reflex Absent
  _______

BOTH UMN+LMN dx:
1)-UMN: Pseudobulbar palsy #BSC
\+
2)-LMN: ?cell involvement #WATFR
\+
3)-NO SENSORY/BOWEL-BLADDER dx... this shit is NORMAL

Dx? Tx = survival?
_________

EXCRUCIATING pain @leg-muscles
---bum/ hip/ thigh
ABSENT REFLEXES
----HbA1c 120 
\_\_\_\_\_\_\_\_\_\_\_\_

Fever + WATFR = ?cell involvement

• -CSF = high WCC + normal CSF BM + norm/high Prot #LYMPHocytes
• -Replicate in GI tract -> kill ?cell

Floppy HYPOtonic baby
Flaccid paralysis
Fasciculations @tongue
#WATFR LMN: Symm Weakness.
\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_

-BSC syx!!!
STIFF spastic tongue
DONALD Duck Speech
BRISK Jaw Jerk i.e. HYPERREFLEXIA 
\_\_\_\_\_\_\_\_

WATFR Palsy of the 
-?CN = swallow/ taste post 1/3
-?CN swallow/ speech 
-?CN = ?Traps
-?CN = Hypoglssal = Tongue WATFR movement
Brainstem Motor Nuclei ?CNs #LoF
-Prognosis?
\_\_\_\_\_\_\_\_\_\_

Towards VS Away

Hypoglossal - Tongue ?
Accessory - ? + cant turn to? 
V3 jaw ? 
Vagus - uvula ?
\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_

Classical histories of :

1.
Recent 'diagnosis' of Parkinson's...
-POOR response to levodopa
-------impaired BALANCE #Falls
-------O/E vertical-GAZE Palsy #Symm onset

2.
Recent 'diagnosis' of Parkinson's...
-POOR response to levodopa
--IMPOTENT --urinary RETENTION --OLD
\_\_\_\_\_\_\_\_

• Motor: Foot-DROP = WEAK LOWER-Extremity
• Sensory dx –> Foot DEFORMITY
• —-pes Cavus=HIGH Arch
• —-Hammer-toe

Answer 21

Mitral Regurg #systolic
Syst Ant Motion of Ant Mitral leaflet
Asym Hypertrophy #LVH=deep Q @V1-3ish
-HOCM assoc w/ Wolff-Parkinson White

\_\_\_\_\_\_\_\_\_
SCD: Subacute Combo Degen of SC
B12 def -> tracts:
-Spinocerebellar dx - ataxia
-CorticoSpinal dx - fine movement of ipsilateral limbs
-DC-ML dx - prop/vib + fine touch 

B12 def tx:
Neuro syx YES =
Admit + ?IM-HCB

Neuro syx NO =
IM-HCB x3/w/2w -->
-DietRelated=OralCyanoCobalamin
-DietUnRelated=IM-HCB/3m
\_\_\_\_\_\_\_\_\_

Same:

@level =

• ALL SENSATION
• LMN

@below level:

• Prop/Vib + FINE-touch #DC-ML
• UMN #CSTract

Opp:
-Pain/Temp + CRUDE-touch: below level - #SPTract
__________________

T1 dx ->
OculoSymp Dx
#IPSILAT Horners
____________

Syringomyelia

-Preservation of Prop/Vibr + FINE-touch 
#DC-ML

Dx = ST-AC
crossing SSSPINOTHALAMIC TTTRACTS
@AAANTERIOR CCCOMMISSURE of Spinal Cord
#FIRST tracts to be affected

Ix: MRI
Assoc w/ Arnold Chiari Malformation
_______

Cauda Equina
-MRI -> Neurosurg+Steds
-spinal roots L2 and below
\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_

Tabes Doraslis-DORSAL-COLUMN-ML
-Accommodation Reflex Present (ARP)
-Pupillary Reflex Absent (PRA)
#House-Case
\_\_\_\_\_\_\_\_

ALS-Lou Gehrig

• ALS dismutase dx
• Riluzole confers survival

1)-UMN: Pseudobulbar palsy #BSC
2)-LMN: ANT HORN cell involvement #WATFR
3)-NO SENSORY/BOWEL-BLADDER dx… this shit is NORMAL
_______

DM Amyotrophy = ABSENT REFLEXES
__________

Fever + LMN signs (WAFER = ?cell involvement)
-CSF = high WCC + normal CSF BM + norm/high Prot
-Replicate in GI tract -> kill ANTERIOR HORN cell
——PolioMyelitis
____________
____________

UMN PSEUDOBulbar Palsy BSC
Stiff Spastic Tongue, Donald Duck, HyperReflexic Jaw-Jerk
_______

LMN PROGRESSIVE Bulbar palsy WATFR
-9CN = swallow/ taste post 1/3
-10CN swallow/ speech 
-11CN = ?Traps
-12CN = Hypoglssal = Tongue WATFR movement
Brainstem Motor Nuclei ?CNs #LoF
-WORST Prognosis
\_\_\_\_\_\_\_\_\_\_

Hypoglossal - Tongue TOWARDS
Accessory - ipsi shoulder droop + cant turn to opp side
V3 jaw TOWARDS
Vagus - uvula AWAY!!!!!

Floppy Flaccid Fascic baby = Spinal Musc Atrophy
-Werdnig Hoffman
_________
_________

1. Progressive supranuclear palsy #PSP
2. Multi-system atrophy
   _________

Charcot Marie Tooth aka HSMN
Hereditary 
Motor  
Sensory 
Neuropathy

Question 22

Common peroneal (fib) nerve = Deep + Superficial

? peroneal nerve-failed:

• dorsiflexion + toe extension
• fooooot EEEEEEVersion
• sensory loss in ??

? peroneal nerve-failed:

• Ankle EEEEEVersion
• sensory loss of ? + ? (except ?)

L5 nerve root –> sciatic –> CPeron = S/D

• hip abduction (gluteal muscles - superior gluteal nerve) - pain and sensory loss @lat side of the thigh, lower leg, foot-dorsum and toes 1-3
• Common peroneal fucked too (as above)

Answer 22

https://www.bmj.com/content/350/bmj.h1736.full

Common peroneal (fib) nerve = Deep + Superficial

Deep peroneal nerve-failed:

• dorsiflexion (tibialis anterior),
• toe extension (extensor digitorum/hallucis longus)
• fooooot EEEEEEVersion (peroneus longus/brevis), and
• sensory loss in first web space

Superficial peroneal nerve-failed:
-Ankle EEEEEVersion (peroneus longus/brevis) and 
- sensory loss of the 
ANT-LAT lower leg + foot-DORSUM 
(except the first web space).

L5 nerve root –> sciatic –> CPeron = S/D

• hip abduction (gluteal muscles - superior gluteal nerve) - pain and sensory loss @lat side of the thigh, lower leg, foot-dorsum and toes 1-3
• Common peroneal fucked too (as above)

Question 23

Hamartomas @?

A?

M?
____________________

A? HYPOPIG spots - fluoresce UV

R?

T?
____________________

O?

M?

A?
____________________

S?
S? over LUMBAR spine

Answer 23

Tuberous Sclerosis - ADom
_________

Hamartomas @CNS/SKIN/white RETINA

AngioFIBromas sebacum adenoma - RED rash

MRegurg
____________________

Ash-leaf HYPOPIG spots - fluoresce UV

Rhabdomyoma heart/LUNG
-LymphAngio-LeioMyoMatosis cysts

Tuberous sclerosis - Cafe au lait
____________________

Other: Butterfly nose, Nail Subung fibromata

Mental retard cog dx

AngioMyoLipoma - renal/PKD
____________________

Seizure
Shagreen rough patches over LUMBAR spine

Question 24

Factors favouring pseudoseizures

Factors favouring true epileptic seizures
__________

Delirium > Dementia
__________

ALS and polio are UMN or LMN conditions??

Stiff spastic tongue
Donald Duck Speech
Brisk Jaw Jerk
________

Palsy of the 
-Tongue
-Chewing muscles 
-Swallowing and 
-Facial muscles 
due to loss of function of Brainstem Motor Nuclei

Answer 24

Pseudoseizures FACTOrs:
- FHx epilepsy/Females

• ALONE = don’t occur
• CRYING after seizure
• Thrusting pelvic
• Onset = GRADUAL

Favour true epilep seizures:
- Tongue biting
- PROLACTIN
__________

-Emotions = fear, agitation
-Fluct Syx = worse @night, normal periods
-GCS impaired
-Hallucinations/Illusions/Delusions #perception
__________

ALS = BOTH  
polio = LLLLLLLMN conditions

PseudoBulbar Palsy
_______

Progressive bulbar palsy
-WORST Prognosis

Question 25

Parkinson symptoms

Intention tremor Ax?
Dysmetria ?

Essential tremor VS Parkinson’s disease -
NICE recommend what to differentiate?

Parkinson Tx?
__________

Starts with

• patients having impaired balance #falls
• O/E vertical-gaze Palsy
• Symmetrical onset + POOR response to levodopa
• Recent ‘diagnosis’ of Parkinson’s…

Classical history of

• poor response to levodopa,
• impotence,
• urinary retention
• OLD age group

Answer 25

Tremor - Pill-rolling RESTING
Rigidity - cogwheel LEADpipie
Akinesia brady
Post Instability

Intention tremor @ cerebellar dx
Dysmetria - over/undershooting - MS/ALS

ET v Parkinsons =
NICE recommend123I‑FP‑CIT SPECT

Levo/carbi

• Motor improve/cx increase
• ADLs improve
• Adverse rxns decrease (hallucinations/impulse/sleep)
• Time inc = effectiveness decrease

AMANTADINE/DBS
Selegeline MAOi - Tyramine foods, Off-time
Entacapone - COMTi - off-time reduce
Ropinirole/CabergolineCardiacFibrosis - hallucinations/impulse/sleep
DBS
__________

Progressive supranuclear palsy #PSP

Multi-system atrophy

Question 26

High-impact trauma e.g. FALL
OR old alcoholic brain atrophy –> ??

Old person
Generalised HA
Sleepiness intermittent = FLUCTUATING GCS

CT = HYPERDENSE i.e. Bright sickle shape = ??
HYPOdense sickle shape = ??

Dx? Which vessels?
____________

low-impact trauma
LOC –> LUCID interval –> rapid GCS drop

Mass effect - - >
uncal herniation + CN3 comp - - >
fixed, dilated pupil
__________

sudden-onset
SEVERE Occipital HA
-MENINGISM: neck stiff+photophob

CT = hyperdensity @ cisterns/sulci.

PKDx - Berry aneurysm

Dx? 
Vessels?
LP done when? Show?
Initial Tx - what does this do? Then??
\_\_\_\_\_\_\_\_\_\_

COCP use + FHx of VTE + Severe HEADACHE = more insidiously than a ‘thunderclap headache’, with ?subtle neurology
-?Ix is the gold standard test for diagnosing ?Dx

Cavernous sinus syndrome 2 Ax = 
-Cavernous Sinus Tumours, OR
-NPC = invades Cavernous Sinus -> 
Corneal Reflex Absent ?Anatomy
Horner ?Anatomy
Opthalmoplegia ?Anatomy
Pain, Proptosis #mass-effect
-max sens low ?Anatomy
-CN 3 ?
-CN 4 ?
-CN 5- (V1=?Reflex, V2=?sensation)
-CN 6 ? + ICA (?) + Symp trunk (?)

-Motor:(down+out, ptosis),
-PSymp(dilated),
-?vertical nystagmus
Ax ?

PAINFUL third nerve palsy = r/o ?

Rectal diazepam ? mg

Answer 26

Subdural

old alcoholic brain atrophy –> fragile bridging veins

damaged BRIDGING veins between
cortex and venous sinuses

HYPERDENSE bright - acute
Hypodense dark - chronic slow

Similar so LEWYBODY dementia - fluctuating GCS!!
_____________

Extra/Epidural haemorrhage
-middle meningeal artery
_______________

Subarachnoid 
-Circle of Willis vessels = basilar and ACA
-LP > 12 hours = Xanthocrhomia
Tx:
-NIMODIPINE = reduce vasospam
-Coiling by IR!
\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_

COCP use + FHx of VTE + Severe HEADACHE = more insidiously than a ‘thunderclap headache’, with ?subtle neurology
-MR Venogram is the gold standard test for diagnosing venous sinus thrombosis

Cavernous sinus syndrome Ax =
Cavernous sinus tumours, OR
NPC = locally invades cavernous sinus. ->
Corneal Reflex Absent,
Horner,
Opthalmoplegia
Pain, Proptosis #mass-effect
-CN 3 Opthalmoplegia (ptosis/diplopia)
-CN 4 Opthalmoplegia
-CN 5- (V1=Corneal Reflex Absent, V2=low max sens)
-CN 6 Opthalmoplegia + ICA (thrombosis) + Symp trunk (Horner’s)

CN3 palsy:
Motor(down+out, ptosis), PSymp(dilated), ?vertical nystagmus
-isch, CavSinThrom, UncalHerniate/trans-tentorial, MidbrainWeber, PComAneurysm

PAINFUL third nerve palsy = posterior communicating artery aneurysm

Rectal diazepam 10 mg

Question 27

Premature neonate
emergency c-section

Floppy and unresponsive

CT = hyperdense bright @ dark CSF spaces @ ventricles

Risk of? What kind..? (cos of clots n shit)

Answer 27

IntraVentrivular haemorrhage

Risk of risk of obstructive hydrocephalus

Question 28

infants

Inc head circumferences
Bulging fontanelles
IMPAIRED upward gaze - sunsetting (why???)
dilated scalp veins

bradycardias, seizures and coma.

Types and causes?

Answer 28

Hydrocephalus
- Communicating non-obstructive -
meningitis -> low CSF reabsorption @arachnoid granulations

• Non-communicating = obstructive - tumours/hemorrhage
  _________

inc head circumferences (splaying of the skull plates allowed by unfused sutures),

Pressure on the
TECTAL PLATE/SUP COLLICUS –>
Sunsetting

Question 29

reduced CSF absorption at the arachnoid villi
–> Reversible dementia

Wet, wobbly, wacky
enlarged fourth ventricle

Dx? NO SIGN OF ??

Answer 29

Normal pressure hence NO SIGN OF RAISED ICP (eg Papilloedema)

Question 30

1.
Cafe au lait
Intellectual dx

Cutaneous NEUROFIBROMAS
? iris hamartomas

Optic GLIOMAS
-meningiomas - > focal neuro

Phaeo!!!!
Seizure/Cataracts

2.
B/L vestib schwanomas AKA
-acoustic neuromas

Answer 30

Neurofibromatosis type 1
-LISCH nodules iris hamartomas

Neurofibromatosis type 2

Question 31

Bells palsy

UMN LMN sx
__________

Criteria for brain stem death testing?

Answer 31

Taste ant 2/3
Hyperacusis
Eye - lacrimation -> ulcer/dry
Ipsi upper AND lower facial muscles

LMN: LOW Weak, atrophy, tone, fascic, reflexes
UMN: Babinski (FAN OUT #UPgoing), Spastic, Clasp knife
_____________

Criteria for brain stem death testing = CuRSE

Coma = Unknown ax

Reversible ax excluded

Sedation = none

Electrolytes = Norm

Test:
Bronchial stimulation -> no cough reflex
response to sound/supraorbital pressure NO
oculo-vestibular reflexes NO
corneal reflex NO
Ventilator disconnect -> no resp effort >5mins

Question 32

What @absence seizure EEG? 
\_\_\_\_\_\_\_\_\_\_\_\_\_
?
-Head/leg movements
-ictal weakness
-Posturing
-Jacksonian-march

?

• Hallucinations,
• Epigastric-rising,
• Automatisms-LIPSMACKING/PUCKING,
• Deja-vu/Dysphasia

-? = Paraesthesia
-? = Floaters/flashes
_____________

Focal epilepsy -? /? #partial
-CL VLOG Tx?

Generalised epilepsy - LOC = ATAM Tx?
-which antiepeileptic is MOST teratogenic

Answer 32

Absence = 3Hz @EEG
_____________

Motor FRONTAL lobe

• Head/leg movements
• ictal weakness
• Posturing
• Jacksonian-march

Non-motor:
-Temporal 
Hallucinations,
Epigastric-rising, 
Automatisms-LIPSMACKING/PUCKING, 
Deja-vu/Dysphasia

-Parietal lobe (sensory) = Paraesthesia
-Occipital lobe (visual) = Floaters/flashes
_____________

Focal: Carbamaz Lamotrigine VLOG
Valproate, Levetiracetam, Oxycarbamaz, Gabapentin

Focal epilepsy #partial

• aware = simple
• impaired-aware = complex

Absence = 3Hz @EEG: Valproate Ethosux Lamotrigine
T-C GEN: Valproate Carbamaz Lamotrigine
Atonic: Valproate Lamotrigine
Myoclonic: Valproate Lamotrigine

Valproate MOST teratogenic

Question 33

MS types? Tx?

MOPED
L GAMMA BINS

Answer 33

Relapse-Remit
2° prog
1° prog

Mcdonald criteria
Oligoclonal Antibodies CSF - IgG
PeriVent Plaques high T2 signals @MRI
Evoked Potentials - delayed but preserved
Dawson FLAIR fingers = 90° to CCallosum 

Lifestyle : diet/ex/Smoke

Glatiramer
Azo
MethylPred
MITOX
AMANTADINE

Baclofen botox
IFN B
Natalizumab/Alemtizumab/FingoLiMod
SSRI

Question 34

HA worse morning / Valsalva bend forward
low GCS
CUshing high BP / low HR
Papilloedema
Pupil - same CN3 Dilate, opp HParesis uncal CONING
Seizure/personality
\_\_\_\_\_\_\_\_\_\_\_

Towards VS Away

Hypoglossal - Tongue ?
Accessory - ? + cant turn to? 
V3 jaw ? 
Vagus - uvula ?
\_\_\_\_\_\_\_\_\_\_\_

Common cause of headaches in kids

Get ABDO PAIN TOO!!!!

Treat??? what over ? years is legit??
_______

Pupillary REFLEX #constriction #Psymp

Retina
-CN2-> PTN or Hypothal

PTN -> EdW
-CN3->
Ciliary Ganglion
-ShortC.nerves->
Sphincter pupillae

Pupillary DILATION:
Retina 
-CN2->
Hypothal -> 
CilioSpinal Budge (C8-T2) ->
Sup cerv.gang 
-ICAplexus, CavSinus, orbit = long Cil Nerve->
Pup Dilator

Answer 34

Raised ICP
___________

Hypoglossal - Tongue TOWARDS
Accessory - shoulder droop + cant turn to opp side
V3 jaw TOWARDS
Vagus - uvula AWAY!!!!!
\_\_\_\_\_\_\_

Migraine!!!!

Ibuprofen first line!!!

Triptan >12yrs
_______

Pupillary Reflex #symp:

Retina
-CN2-> PTN or Hypothal

PTN -> EdW
-CN3->
Ciliary Ganglion
-ShortC.nerves->
Sphincter pupillae

Retina 
-CN2->
Hypothal -> 
CilioSpinal Budge (C8-T2) ->
Sup cerv.gang 
-ICAplexus, CavSinus, orbit = long Cil Nerve->
Pup Dilator

Question 35

? scans = detect diffuse axonal injury + cancer

? useful to see if the contusions are INC in size.

? = useful @SAH patient when looking for Ax.

? = useful for tumours or possible abscesses

Answer 35

MRI scans = detect diffuse axonal injury + cancer

Repeat CT = useful to see if the contusions INC in size.

CT angio = useful @SAH patient when looking for Ax.

CT w/ contrast = useful for tumours or possible abscesses

Question 36

PolyNeuropathy, CCF
Wernicke-Korsakoff syndrome

1. Confusion, Lillepution, Tremor

2. NOAC
NySTAGmus, 
OPHthalmoplegia, 
ATAXia, 
Confuuuusion
- PolyNeuropathy 

3. Konfabulaton, Amnesia, Memory
4. DT syx + autonomic ?activity
   - high GGT, high MCV-NON-megalo, CDT
   - TICS MATCH RALPH FBD-apo
   - —(RAlcoLPH=NON-meg), (FBD-apo=Megalo)

Ix:
Low red cell tranSKETOLase
MRI = petechial haemorrhages @mamillary bodies and ventricle-walls.

Answer 36

Thaimine

Vit B1111111111 Ber1 Ber1

1. Delirium Tremens CoLT
2. Wernicke NOAC
3. Korsakoff KAM
4. Alco withdrawal - autonomic HYPERactivity

Question 37

Meningitis

KerniG - ?
Brudinzki - ?

Present @age:
<3m = ?
>3m = ?
-@triax=not give at ?
-@triax=not give at ?

Dexa @CSF..?

Organisms under:
<3m ?
>3m ?
Any Age ?
\_\_\_\_\_\_\_\_\_\_\_\_

CSF - look @ ?
-WCC = ?

-BM ?

-Prot ? what kind of ‘..morphonuclocytes’?
____________

@GP tx?
?
\+ 
Notify ? / NBR?
-Y = ?
-N = ?

Proph = ?

What is shit against TB meningitis?

Answer 37

Meningitis

KerniG - the leG one
BrudinNECKzki - the NECK one

Present @age:
<3m = cefoTAX + Amoxi
>3m = cefTRIAX + Dexa
-@triax=not give at ca2+ infusion 
-@triax=not give at LF/Acidosis/Prem 

Dexa @CSF

• gram stains
• WCC >1 / Prot >1g/L
• purulent

Organisms under:
<3m:
-GBS Agalactaie - 14d
-E.coli, 
-Listeria w/ Amoxi 21 d / Gent 7d
-Strep pneu 14d

> 3m

• S.pneu 14d
• H.flu 10d
• N.men 10d

Any Age:
Crytococc/CMV
Arbo
Mumps
Entero
\_\_\_\_\_\_\_\_\_\_\_\_

CSF - look @ WCC/BM/Prot
1. WCC = high

2. BM low:
   >plasma/2
   Rifampicin

@GP tx?
999
\+ 
Notify PHE / NBR? 
-Y = ADMIT + IM/IV BenPenG
-N = ADMIT

What is shit against TB meningitis?
-Ethambutol

Question 38

RIGHT EYE__LEFT EYE
4 4
6——-6
3-? 3-?

4- ?CN
3- ?CN
6- ?CN
____________

Diplopia Double Vision DIRECTION:
^ ^
I I
v v

4* 6* 4*

CranioPharyngioma = ?
Pituitary tumour = ?

____________

CN formula..?

NTR:

1. RON ?
   - chiasm-> (right chiasm = ?)
2. ROT ?
   - LGN->
3. SIñOR Pi-Ts:
   - RsOR @which lobe -> ?
   - RiOR @which lobe -> ?
   - Rs+iOR = PiTs = ?

SIñOR Pi-Ts:
S OR @?-qa 
I  OR  @?-qa 
Post Cerebal Art Occluded = ?
\_\_\_\_\_\_\_

Med #?dx
INO - InterNuclear Ophthalmoplegia
Long
Fasciculus:

So.. normally when you trying to look left for example…
what muscle ABDucts @left eye
+
what muscle ADDucts @right eye

but in INO..
what muscle ABDucts @left eye
\+
what muscle ADDucts=? @right eye
--> 

contra LR6 works ? to stim ? –>
? nystagmus

Answer 38

RIGHT EYE\_\_LEFT EYE
4                                  4
                6-------6
3-dilated                     3-dilated
    ptosis                         ptosis

4-Trochlear
3-Occulumotor
6-Abducens
____________

Diplopia Double Vision DIRECTION: #H
^ ^
I I
v v

4 6 4

• 4 vertical
• 6 horizontal
• 4 vertical

CranioPharyngioma = Inf Bitemp HAnopia
Pituitary tumour = Sup Bitemp HAnopia
____________

LR6 SO4 R3 =
-Lr - SO - 3R
6 4

Nerve Tract Radiation:

1. RON - right MonoOccularVisionLoss
   - chiasm-> (right chiasm = right NasalHAnopia)
2. ROT #LeftHomoHAnopia
   - LGN->
3. SIñOR Pi-Ts:
   - RsOR @Pi = LiQA
   - RiOR @Ts #Meyer = LsQA
   - Rs+iOR = PiTs = #LeftHomoHAnopia

SIñOR Pi-Ts:
S OR @PI-qa - Parietal-InfQA
I  OR  @TS-qa - Temp-SupQA
Post Cerebal Art Occluded = Macular SPARING
\_\_\_\_\_\_\_

Med #MS #Stroke
INO - InterNuclear Ophthalmoplegia
Long
Fasciculus:

So.. normally when you trying to look LEFT for example…
contralat LR6 ABDucts @left eye
+
ipsilat MR ADDucts @right eye

but in INO..
contralat LR6 ABDucts @left eye
\+
ipsilat MR3 ADDucts=FAILS @right eye
--> 

contra LR6 works overtime to stim ipsi MR3 –>
contra LR6 nystagmus

Question 39

Fred is your SPACKER*
FRAT? bro, always: 
-staggering ?Tract
-falling ?Tract
*(?Tract) 

but has a

• sweet - ?
• big heart - ?
• funny eyes+toes - ?

What’s he going to die from?
______________

Cataracts
Muscle weakness
FRONTAL balding
________

toddler w/ delayed motor milestones
-CALF hypertrophy
-prox hip girdle muscle weakness
-high CK (suggest what to do? what would this show?
-Gower's sign 
\_\_\_\_\_\_\_\_\_

Paeds clinic
-prog difficult whistling + sucking through straw

Answer 39

Fred is your SPACKER 
FRATaxin bro, always: 
- staggering (Ataxia #SpinoCerebellar tract)
-falling (DC-ML) cos of prop/vib
-(CST - spastic paralysis) 

but has a

• sweet (DM)
• big heart (Hypertroph CM)
• funny eyes = nystagmus/pes cavus

AR = metabolic except ataxias
AD = structural except Gilbert, HL2

Die from CARDIO MYOPATHY
____________

Myotonic dystrophy
-Autosomal Dom
__________

Duchenne - XLr
-high CK (suggest to do MUSCLE BIOPSY=absent dystrophin)

Facio-Scapulo-Humeral Musc Dystrophy

Question 40

MRC Power scale
-NRGS-fn

Alert ?
Voice ?
Pain ?
Unresponsive ?

Answer 40

5 normal

4 resistance
3 gravity

2 some

1 flicker
0 none

Alert 15
Voice 12
Pain 8
Unresponsive 3

Question 41

? @GCS 3-8 w/
normal/abnormal CT scan.

Gingko leaf @CXR =?
Air under diaphragm =?

raised ICP from:
-subdural/extradural/cerebral oedema
-cerebral oedema from tumour?
Tx?

Give what @SAH to reduce vasospasm?

HypoNat + Head Injury =?

Minimum of cerebral perfusion pressure of:

• ? mmHg in KIDS
• ? mmHg in ADULTS.

Mass/Tumour/Hematoma ->
CN3 compression IPSI-lat - >
Unilat DILATED pupil =
UNresponsive 2 light

Pupil dilated:

• Unilateral ?
• Bilateral ?

Constricted:

• Unilateral = ?
• Bilateral = ?

Answer 41

ICP monitoring @GCS 3-8 w/
normal/abnormal CT scan.

Gingko leaf @CXR = Subcut emphtsema
Air under diaphragm = perf

Dexa @Oed from tumour
Mannitol @Raised ICP
Nimodipine @SAH to reduce vasospasm

SIADH

Minimum of cerebral perfusion pressure of:

• 40-70 mmHg in KIDS
• 70mmHg in ADULTS.

Hutchinson Pupil

Pupil dilated:
-Unilateral = 
CN3 dx #TransTentHerniation #Hutchinson Pupil 
Holmes-Adie Pupil+absent knee reflexes
Marcus Gunn RAPD

-Bilateral = CN3 dx bilat

Constricted:
-Unilateral = Symp dx

-Bilateral =
Argyll-Robertson = DM/Syph #prostitues-pupil
Opiates,
Pontine dx

Question 42

Incoordination of
rapidly alternating
movement
(slap L dorsum and L palm on R-palm in alternating-fashion)

Wild flinging of limbs

Semi-directed
Irreg movements
NOT repetitive/rhythmic
appear = one muscle 2 next - like a dance

Answer 42

Dys-Dia-Dhocho-Kinesis

HemiBallismus

Chorea

Question 43

• CEREbellar haemangiomas: –> SAH
• RETinal haemangiomas –> vitreous haemorrhage
• renal CYSTS (premalig) –> clear-cell RCC
• phaeo
• extra-renal CYSTS: epididymal, panc/liver
• endoLYMPHatic sac tumours

Answer 43

Von Hippel-Lindau

Question 44

Marcus-Gunn RAPD Ax
-M.ARCO

Tunnel vision Ax
-T.ROPIC

Scotoma Ax
-S.CAM
___________

Hypopyon Ax
-PAK

Squint strabismus:
-Up till when is it normal?
-When to start worrying?
-Types?
-Ix?
-Tx?
\_\_\_\_\_\_\_\_

Aciclovir: when Top/PO?

Answer 44

Marco Tropical Scam in Pak:

Marcus-Gunn RAPD

• AION
• RVO/RAO-central
• CRVO/CRAO
• Optic Neuritis: MS/DM/Syph

TTTunnel Vision:

• Ret pigmentosa
• Optic Atrophy @TTTabesDorsalisSyph
• POAG-ACAG
• ICP high i.e. pappilooedema
• ChorioRet-CMV/Toxo

Scotoma:
-CRVO
-ARMD 
-Migraine - scintillating
\_\_\_\_\_\_\_\_\_\_\_\_\_

Hypopyon:
-Post-op endophthalmitis,
-Ant uveitis, 
-Keratitis
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

• Intermittent squint in NEWborn <3 months = NORMAL - underdeveloped eye muscles
• > 3m ?start worrying #refer

Concomitant: Convergent In > Divergent Out
Paralytic: muscle paralysis

Ix:
Corneal light reflection
Cover test

Tx: Refer - eye patch @ >3months
________

Aciclovir:
Top @HSV Keratitis
PO @HZO

Question 45

DM2 - poorly controlled
EXCRUCIATING pain @leg muscles
-thigh/hip/bum

ABSENT REFLEXES

Answer 45

DM Amyotrophy

Question 46

Monoplegia -?
Hemiplegia -?
Quadriplegic -?
-Paraplegia -?

ACA–MCA–PCA*

*PCA - midbrain Weber
________________

Amaurosis fugax - which vessel?
Locked in syndrome - which vessel?
__________

• Absent < – > horizontal eye-move
• Miosis
• Paralysis=Quadriplegia
• Same FACE: PD/PT (paralysis/deaf // pain/temp)
• Opp limb
• Nystagmus
• Ataxia
• Same FACE: PD/PT (pain/temp)
• Opp limb
• Nystagmus
• Ataxia

__________

• Unilat sensory/motor FAL
• Cog dx - VisuoSpatial/Dysphasia
• HomoHNopia

1 of:
-Sensory
-AtaxicHemiParesis
-Motor
PURELY + HTN

4-6-4 H:
CN4 present?
CN3 present?
CN6 present?

________

Nystagmus: central v peripheral?
______

Brainstem death

Answer 46

Monoplegia - 1 limb
Hemiplegia - Unilat 2 limbs
Quadriplegic - 4 limbs
-Paraplegia - Bilat LOWER limbs

ACA MCA PCA*
L>UL ; UL>L

< – HemiParesis
……..Aphasia – > Agnosia
……..Sensory
….HomoHAnopia – > Mac-Sparing

*PCA - Weber Midbrain
-Same CN3, opp HemiParesis
-Agnosia
-Macular sparing HomoHNopia
________________

Amaurosis fugax - Retinal/Ophthalmic Artery
Locked in syndrome - Basilar Artery
____________

Pontine bleed

• Absent < – > horizontal eye-move
• Miosis
• Paralysis=Quadriplegia

AICA: Lat Pont

• Same FACE: PD/PT (paralysis/deaf // pain/temp)
• Opp limb
• Nystagmus
• Ataxia

PICA: Lat Med Wallenburg

• same as above EXCEPT
• paralysis and deafness

______________

Anterior Circulation Stroke:

3=TotalACS
2=PartialACS

• Unilat sensory/motor FAL
• Cog dx - VisuoSpatial/Dysphasia
• HomoHNopia

LacACS Assoc w/ HTN 
1 of:
-Sensory
-AtaxicHemiParesis
-Motor
PURELY
\_\_\_\_\_\_\_\_\_

4-6-4 H:
CN4 vertical nystagmus
CN3 Ptosis, Dilated, Vertical nystagmus
CN6 horizontal nystagmus

Nystagmus: Central v Periph:
central is:

• B/L
• Assoc sens/motor dx
• Direction = multi / purely uni or rotatory

Brainstem Death:
Coma unknown Ax
Reversible ax excluded
Sedation X
Electrolytes fine

Bronchial stim -> no cough
Response to sound/Supra-Orb Pressure
Occ-Vestib Reflex absent
Corneal Reflex absent
Disconnect ventilator 5-mins -> no resp support