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NEUROLOGY (path) > Intoxication/Substances/Inflammation > Flashcards

Intoxication/Substances/Inflammation Flashcards

1
Q

Ethanol Intoxication

A

Pathophysiology:
- nonalcoholics: blood etoh corresponds w clinical picture
- alcoholics: high etoh w/out apparent intoxication
serum mOsm actual > calculated by 22 osm per 100 mg/dL EtOH in the blood

Clinical:

  • nystagmus
  • dysarthria
  • limb/gait ataxia
  • hypoglycemia

Dx/Rx: thiamine (prevents Wernicke’s encephalopathy)
–> add thiamine before glucose?

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2
Q

Ethanol Withdrawal Big symptoms

A
  • tremulousness and hallucinations
  • seizures
  • delirium tremens
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3
Q

Ethanol Withdrawal : tremulousness and hallucinations

A 
Pathophysiology:
Clinical: 
- agitation
- anorexia
- nausea
- tachycardia

Dx/Rx:

  • diazepam
  • chlordiazepoxide
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4
Q

Ethanol Withdrawal : seizures

A

Pathophysiology: occurs within 48h of cessation of etoh
- 40% single seizure; 90% multiple seizures
Clinical:
- usually not focal
- lasts <6h

Dx/Rx:

  • most resolve spontaneously
  • ppx: diazepam, chlordiazepoxide
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5
Q

Ethanol Withdrawal : delirium tremens

A

Pathophysiology: 3-5 days s/p etoh cessation
lasts <72h

Clinical:

  • confusion
  • agitation
  • fever
  • sweating
  • tachycardia
  • hypertension
  • hallucination

Dx/Rx:

  • IV diazepam
  • beta blockers
  • death may result from cardiovascular collapse, infection, pancreatitis
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6
Q

Sedative intoxication

A

Pathophysiology: complications: aspiration pneumonia, CV collapse

Clinical:

  • confusion/coma
  • respiratory depression
  • hypotension
  • hypothermia
  • reactive pupils
  • nystagmus
  • ataxia
  • dysarthria
  • hyporeflexia

Dx/Rx: supportive care

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7
Q

Sedative withdrawal

A

Pathophysiology: usually occursin patients taking large doses for several weeks
- symtpoms develop 1-3 d s/p cessation
Clinical:
- similar to etoh withdrawal (agitation, anorexia, nausea, tacycardia, seizures, confusion…hallucination? fever? sweating? htn?)
- myoclonus, seizures
Dx/Rx: confirm dx with pentobarbital admin (no rxn confirms dx)
treat: phenobarbital taper

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8
Q

Opioid intoxication

A 
Pathophysiology: confirm dx with naloxone admin
Clinical: 
- respiratory depression
- pinpoint pupils (constricts in bright light)
- coma
- pulmonary edema
- urinary retention
- decreased GI motility
Dx/Rx: IV naloxone, ventilatory support
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9
Q

Anticholinergic intoxication

A 
Pathophysiology: 
- "blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone, bowel and bladder lose their tone, heart runs alone"
Clinical: 
- dilated pupils, blurry vision
- agitation, hallucinations
- flushing
- fever
- dry skin, mucous membranes
- urinary retention, constipation
- tachycardia

Dx/Rx: physostigmine (cholinesterase inhibitor)

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10
Q

Phenylcyclidine

A 
Pathophysiology: Symptoms resolve within 24h
Clinical: 
-drowsiness
-agitation
-disorientation
-amnesia?
- hallucinations
- paranoia
- nystagmus
- ataxia
- hypertonicity
- hyperreflexia
- myoclonus
Dx/Rx:  
- benzodiazepenes for muscle spasm
- antihypertensives
-anticonvulsants
-dantrolene
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11
Q

Hypothyroidism (Myxedema)

A 
Pathophysiology: decreased T3, T4; increased TSH
Clinical:
- delayed relaxation of DTRs
-flat affect, psychomotor retardation
-agitation, psychosis
-dysarthria, ataxia
-hypoglycemia
-hyponatremia
-LP: increased CSF protein
Dx/Rx: Levothyroxine +/- hydrocortisone
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12
Q

Hyperthyroidism (Thyrotoxicosis)

A 
Pathophysiology: increased T3, T4
Clinical: 
Younger patients: agitation, hallucinations, psychosis
Older patients (>50): apathy, depression
all:
- hyperreflexia
-physiologic tremor
Dx/Rx: 
- propylthiouracil or methimazole
- iodine
- propanolol
-hydrocortisone
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13
Q

Hypoglycemia

A 
Pathophysiology: most commonly seen 2/2 insulin administration in diabetic patients
- also seen in etoh, malnutrition, hepatic failure, insulinoma
Clinical: 
- tachycardia
-sweating
-pupillary dilation
-  +/- seizures, loss of consciousness
Dx/Rx: D5W
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14
Q

Hyperglycemia

A 
Pathophysiology: 
DKA vs. Hyperosmolar hyperglycemic 
DKA: young, DM1, glucose 300-600, osm350, no ketosis, no metabolic acidosis, +coma, +seizure
Clinical: 
- blurred vision
- dry skin
- anorexia
- polyuria, polydipsia
DKA: kussmaul respiration
hyperosmolar hyperglycemic: hypotension, dehydration, focal neuro signs, seizures
Dx/Rx: 
- insulin
- fluids
- correct K+, phos
- allow glucose to remain at 200-300 for 24h to prevent cerebral edema
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15
Q

Hypoadrenalism

A 
Pathophysiology: decreased cortisol
Clinical: 
- fatigue
-weight loss
-anorexia
-hyperpigmentation (increased acth)
-hypotension
-n/v/d
-confusion vs. seizure vs. coma
Dx/Rx: 
- hydrocortisone
-correct hypoglycemia, hyponatremia
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16
Q

Hyperadrenalism

A 
Pathophysiology:
- usually results from administration of exogenous corticosteroids
-confirm dx w 24h urine cortisol or dexamethasone suppression test
Clinical:
-truncal obesity
-flushing
-hirsutism
-menstrual irregularities
-cutaneous striae
-acne
-depression vs. euphoria
- +/- psychosis, memory impairment

Dx/Rx:

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17
Q

Hyponatremia

A

Pathophysiology: acute brain swelling can result from hypoosmolarity of extracellular fluid
- neurologic complications a/w serum Na<120
Clinical:
- headache, n/v
- lethargy
-weakness
-confusion
-muscle cramps
-papilledema, tremor, asterixis, seizures

Dx/Rx: correct hyponatremia slowly (to avoid central pontine myelinolysis)

18
Q

Hypercalcemia

A 
Pathophysiology: neurologic sx present when Ca2+ >17 mg/dL
Clinical:
- thirst
- polyuria
- constipation
-n/v, abd pain
-nephrolithiasis
- h/a, lethargy, weakness
Dx/Rx: IV hydration, occult cancer evaluation
19
Q

Hypocalcemia

A

Pathophysiology: symptoms at serum Ca levels s sign: carpopedal spasm s/p tourniquette
Dx/Rx: calcium gluconate, IV phenytoin if seizures

20
Q

Wernicke’s encephalopathy

A

Pathophysiology:
-usually a complication of etoh 2/2 thiamine deficiency
-neuronal loss, demyelination, gliosis
- macrocytic anemia
Clinical:
- ophthalmoplegia
-ataxia
-confusional state: prominent d/o of immediate recall and memory
- long term complications: Korsakoff syndrome: anterograde + retrograde amnesia, confabulation, lack of insight, apathy

Dx/Rx: thiamine!

21
Q

Vitamin B12 deficiency

A

Pathophysiology:

  • usually 2/2 pernicious anemia (autoimmune response to intrinsic factor)
  • neuro symptoms may precede macrocytic anemia
  • hypersegmented neutrophils

Clinical:

  • peripheral neuropathy
  • nutritional vision loss (centrocecal scotoma)
  • gait ataxia
  • Lhermitte sign: electric shock-like sensation down spine with neck flexion
  • low grade fever
  • glossitis
  • confusion +/- psychosis

Dx/Rx:

  • methylmalonic/homovanillic acid in urine
  • IV b12
  • abnormalities present >1 year unlikely to resolve
22
Q

Hepatic encephalopathy

A 
Pathophysiology: 
-occurs as complication of cirrhosis, hepatitis, etc. (etoh most common)
-liver dz produces symptoms by impairing metabolism of toxins (increased ammonia, toxin; increased GABA activity)
- increased bilirubin, ast/alt, ammonia, pt, ptt
Clinical: 
-asterixis
-increased glutamate in csf
-somnolence
-agitation
-nausea, anorexia, weight loss
- nystagmus, dysconjugate gaze
-Type II Alzheimer's astrocytes
-fetor hepaticus (breath)

Dx/Rx:

  • diatary protein restriction (this has changed)
  • correct coagulopathy
  • lactulose to decrease ammonia absorption
23
Q

Reye syndrome

A 
Pathophysiology: usually occurs in kids s/p viral illness
- risk factor: salicylate administration
Clinical:
- encephalopathy +/- coma
- evidence of hepatic dysfunction
Dx/Rx:
24
Q

Uremia

A 
Pathophysiology: renal failure, esp when acute or rapidly progressive
- increased serum urea nitrogen (BUN), creatinine, potassium
-metabolic acidosis
Clinical: 
-encephalopathy +/- coma
- hyperventilation
-motor manifestations
-peripheral neuropathy
Dx/Rx: 
-hydration
-protein restriction
-dialysis
25
Q

Bacterial meningitis

A

Pathophysiology: bacteria gain access to CNS via colonizing the nasopharynx –> local tissue invasion –> bacteremia –> hematogenous seeding of subarachnoid space
age-stratified etiology
50 y: S.pneumoniae

Clinical:

  • fever
  • confusion
  • vomiting
  • h/a
  • neck stiffness
  • petechial rash seen in 50-60% w/ N.meningitidis
  • Brudinski sign: flexion of knee with passive flexion of neck
  • CT/MRI: contrast enhancement of cerebral convexities
  • LP: increased opening pressure, PMNs, protein

Dx/Rx: antibiotics, dexamethasone

26
Q

TB Meningitis

A

Pathophysiology: reactivation of latent TB that ruptures into the subarachnoid space

Clinical:

  • fever
  • lethargy
  • ha
  • vom
  • stiff neck
  • diplopia
  • LP: leukocytosis w/ monos, glucose <20, + AFB stain

Dx/Rx: rifampin, isoniazid, pyrazinamide, ethambutol

27
Q

Toxoplasmosis

A 
Pathophysiology: toxoplasma gondii from undercooked meat vs. cat excrement
- symptomatic infection a/w Hodgkin's dz, immunosuppression, AIDS
Clinical:
- usually asymptomatic
-skin rash
-lymphadenopathy
-myalgia
-CT: ring enhancing lesions

Dx/Rx: pyrimethamine + sulfadiazine

28
Q

Cystercercosis

A

Pathophysiology: follows ingestion of pork tapeworm taenia solium
- symptoms result from mass effect of intraparenchymal cysts

Clinical:

  • peripheral, CSF eosinophilia
  • h/a
  • hydrocephalus
  • myelopathy

Dx/Rx: albendazole

29
Q

Metastases

A 
Pathophysiology: 
diffuse metastatic seeding may complicate systemic cancer, esp:
- acute lymphocytic leukemia (ALL)
- NHL (non-Hodgkin's lymphoma)
- melanoma
- breast carcinoma
- occurs 3 mos-5 years after dx

Clinical:

  • h/a
  • lethargy
  • confusion +/- memory impairment
  • LP: VERY low glucose, + malignant cells, + HCG, AFP, CEA

Dx/Rx: radiation, chemotherapy

30
Q

HTN Encephalopathy

A

Pathophysiology: sudden increase in bp +/- chronic HTN

  • bp >250/250 to see symptoms
  • increased risk in renal failure
  • due to cerebrovascular spasm, impaired autoregulation, intravascular coagulation, etc.

Clinical:

  • -> retinal arteriolar spasm: papilledema, retinal hemorrhage, exudates
  • vomiting
  • focal neurologic deficits
  • +/- seizures

Dx/Rx: IV sodium nitroprusside

31
Q

Lyme disease

A

Pathophysiology: borrellia burgdorferi

Clinical:

  • erythema migrans upon acute infection
  • meningitis or meningoencephalitis 5-10 wks s/p exposure
  • +/- cardiac conduction abnormalities

Dx/Rx:

  • doxycycline x 4wks
  • ceftriaxone IV x 4 wks if meningitis
32
Q

HSV Encephalitis

A

Pathophysiology:

  • usually >40 yo
  • HSV1 latent reactivation w/ spread along cranial nerves
  • acute, hemorrhagic, necrotizing process in medial temporal lobe

Clinical:

  • h/a, n/v
  • stiff neck
  • behavioral changes
  • anosmia
  • hemiparesis
  • LP: increased RBCs in CSF

Dx/Rx: acyclovir (early!)

33
Q

SLE

A

Pathophysiology:

  • most common autoimmune encephalopathy
  • F>M (9x) w/ o/s 10-40y
  • usually correlates w vasculitis, mucositis

Clinical:

  • seizures
  • altered mental status
  • (+) ANA, dsDNA antibodies

Dx/Rx:

  • corticosteroids
  • +/- anticonvulsants
34
Q

DIC

A

Pathophysiology:

  • pathologic activation of coag + fibrinolytic system in setting of systemic illness
  • small multifocal infarcts w/ petechia hemorrhage in white and gray matter

Clinical:

  • coma
  • focal neuro deficits
  • seizures

Dx/Rx:

  • transfusion
  • fresh frozen plasma (all coagulation factors)
35
Q

TTP

A

Pathophysiology:

  • thought to be IgG mediated reaction against vWF –> large vWF aggregates stimulate platelet aggregation
  • can be precipitated by antiplatelet agents
  • normal PT/PTT

Clinical:

  • thrombocytopenic purpura
  • microangiopathic hemolytic anemia
  • neurologic dysfunction
  • fever
  • renal disease
  • h/a, altered mental status
  • hemolytic anemia
  • schistocytes

Dx/Rx: plasmaphoresis

36
Q

Alzheimer’s disease

A

Pathophysiology:

  • increased risk in trisomy 21, mutations in amyloid precursor protein, increased APOE4 alleles on chromosome 19
  • beta-amyloid is constituent of neuritic plaques
  • decreased cholinergic neurons in cerebral cortex, hippocampus

Clinical:

  • impairment in recent memory
  • disorientation in time, space
  • aphasia, anomia, acalculia
  • psychosis, hallucinations
  • death 5-10 yrs s/p onset

Dx/Rx:

  • memantidine (NMDA=glutamate receptor antagonists)
  • acetylcholinesterase inhibitors
37
Q

Creutzfeldt-Jakob

A

Pathophysiology:

  • invariably fatal, transmissible
  • infectious agent =prion accumulation

Clinical:

  • rapidly progressive dementia
  • myoclonus
  • extrapyramidal symptoms

Dx/Rx:

38
Q

Normal Pressure Hydrocephalus

A

Pathophysiology: communication hydrocephalus 2/2 decreased absorption of CSF

Clinical:

  • dementia
  • gait apraxia (initial manifestation)
  • incontinence

Dx/Rx:

  • LP
  • shunting (VP)
39
Q

Diffuse Lewy Body Disease

A

Pathophysiology:

  • 2nd most common dementia
  • Lewy bodies contain alpha-synuclein, tau

Clinical:

  • cognitive decline without prominent motor symptoms
    1) cognitive fluctuations
    2) auditory or visual hallucinations
    3) Parkinsonism (rigidity, akinesia)

Dx/Rx:

  • anticholinesterase
  • caution with neuroleptics (antipsychotics)
40
Q

Neurosyphilis

A

Pathophysiology:

  • treponemal tests (FTA-ABS) are reactive in active neurosyphilis
  • non-treponemal tests (VDRL, RPR) can be negative

Clinical:
General paresis:
- meningoencephalitis 2/2 active spirochetal infection
- gradual change in memory, personality, behavior

Tabes Dorsalis:

  • Argyll Robertson Pupil (accommodates but does not react to light)
  • lancinating pains
  • areflexia
  • optic atrophy
  • hypertrophic joints
  • hyperextended knees

Dx/Rx:

  • penicillin G (IV or IM)
  • Jared-Herxheimer reaction: fever, leukocytosis occurring shortly after therapy begins (reaction to endotoxins released due to death of harmful organisms)
41
Q

Progressive Multifocal Leukoencephalopathy

A

Pathophysiology:

  • results from JC virus infection
  • common in AIDS, lymphoma, leukemia, carcinoma, TB, sarcoid, immunosuppression

Clinical:

  • dementia
  • focal neurologic deficits

Dx/Rx: watch for IRIS (immune reconstitution inflammatory syndrome)

42
Q

Vascular dementia

A

Pathophysiology:

  • 3rd most common cause of dementia
  • most patients have significant past infarcts

Clinical:

  • abrupt onset of dementia with focal signs and symptoms
  • pseudobulbar palsy: dysarthria, dysphagia, pathologic emotionality

Dx/Rx: treat htn

NEUROLOGY (path) (8 decks)

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