Mehl. bullets dementia + headache Flashcards
M. 59F + temporal headache + muscle pain and stiffness + high ESR; Dx?
temporal arteritis + polymyalgia rheumatica
M. 59F + temporal headache + muscle pain and stiffness + high ESR; best next step?
IV methylprednisolone first, followed by temporal artery biopsy.
M. Brain bleed in patient with Alzheimer; Dx?
Amyloid angiopathy (intracerebral hemorrhage).
M. 87F + Alzheimer + low-grade fever + delirium; next best step?
do urinalysis to look for UTI
as cause of delirium.
M. How to differentiate cluster headache from trigeminal neuralgia?
Cluster will be a male 20s-40s with 11/10 lancinating pain behind the eye waking him up at night (he may pace around the room until it goes away); details such as lacrimation and rhinorrhea are too easy and will likely not show up on the shelf.
In contrast, trigeminal neuralgia will be 11/10 lancinating pain behind the eye (or along the cheek / jaw if V2 or V3 branches affected; it’s when V1 is affected that this diagnoses are more readily confused) -> TN is brought on by a minor stimulus such as brushing one’s hair or teeth, or a gust of wind.
M. Tx and prophylaxis for cluster headache?
Tx = 100% oxygen; prophylaxis = verapamil.
M. Tx and prophylaxis for trigeminal neuralgia?
Tx = goes away on its own because it lasts only seconds;
prophylaxis = carbamazepine.
M. Tx and prophylaxis for migraine?
Tx = NSAID, followed by triptan (triptans are NOT prophylaxis; they are for abortive therapy only after NSAIDs);
prophylaxis = propranolol.
M. 32M + diffuse headache relieved by acetaminophen + sleep; Dx?
answer = tension-type headache;
Tx = rest + taper caffeine (if taking it).
M. Other HY uses for propranolol?
Migraine prophylaxis (FM form gives patient with HTN + migraine; answer = propranolol)
Akathisia (with antipsychotic use)
Thyroid storm (decreases peripheral conversion of T4 to T3)
Essential tremor (bilateral resting tremor in young adult; autosomal dominant; patient will self-medicate with EtOH, which decreases tremor). also the answer on Psych shelf for
lithium-induced tremor.
Hypertension + idiopathic tremor (i.e., tremor need not be essential if patient has HTN ->
answer on FM form is “beta-adrenergic blockade” for the HTN Tx).
Esophageal varices prophylaxis (patients at risk of bleeds)
Hypertrophic obstructive cardiomyopathy (increases preload -> decreases murmur)
Social phobia
M. 50F + jaw pain + headaches + normal ESR; Dx?
Temporal mandibular joint syndrome; if ESR is high, answer is jaw claudication caused by temporal arteritis.
M. 49M + Down syndrome + forgetfulness; which part of brain is affected?
answer = nucleus basalis of Maynert -> high-density of cholinergic neurons (basal forebrain) -> affected in Alzheimer (early-onset
in Down).
M. Pharm Tx for Alzheimer?
acetylcholinesterase inhibitors first (donepezil, galantamine,
rivastigmine);
sometimes Q will ask for mechanism, and answer = “cholinergic”; for more advanced disease try NMDA (glutamate) receptor antagonist (memantine).
M. 74M + MMSE 22/30 + avoids eye contact + weight loss + low mood; DX and Tx?
pseudodementia
Tx = sertraline (SSRI), not donepezil.
M. Main way to differentiate pseudodementia from dementia?
Pseudodementia is depression that presents as cognitive decline; vignette may describe weight loss or gain, avoidance of eye contact, low mood, and/or tearing up during interview; vignette may also mention poor performance on the reverse serial 7s of the MMSE, or the patient is slow drawing a clockface but can rapidly complete it once prompted (apathy); pseudodementia presents as APATHY on MMSE; in contrast, patients with true dementia TRY on the MMSE.
M. How to differentiate normal aging from Alzheimer on Psych shelf?
biggest point is that patients who complain or are concerned about their own cognitive decline do not have Alzheimer;
M. classic example is 68F who frequently says she walks into rooms and can’t remember why she went in there + says she accidentally left the burner on in the kitchen last week and had an argument with her adult daughter about. Dx?
normal aging, not dementia -> patient herself is concerned / complaining, so answer is not dementia on USMLE.
M. Other notable causes of reversible cognitive decline? 4?
hypothyroidism,
B12 deficiency,
neurosyphilis,
neuro Lyme.
M. 53M + BMI 25 + mostly quiet during interview + total cholesterol 300 mg/dL + hepatic AST slightly elevated + HR 60; Dx + next best step in Mx + Tx?
hypothyroidism -> check serum TSH -> give levothyroxine (T4); hypothyroidism can cause dysthymia, high cholesterol, and elevated hepatic transaminases.
M. 81F + cooks own meals since husband passed away + seems depressed + various non-acute neurologic findings + MMSE is 25/30 + no suicidal ideation; next best step?
check serum B12 -. subacute combined degeneration (SCD) = pattern of neurologic dysfunction seen in B12 deficiency.
M. 81F + memory decline; next best step after assessing suicide risk?
Mini-Mental State Exam (MMSE).
81F + cooks own meals since husband passed away + seems depressed + various non-acute neurologic findings; next best step
assess suicide risk (this answer is basically always correct if it’s listed).
48F + BMI 26 + cholesterol elevated + HR 55 + creatine kinase (CK) elevated; Dx?
hypothyroidism -> check serum TSH; hypothyroid myopathy can cause proximal muscle weakness + elevated serum CK.
