MTB 2 Flashcards
Best initial therapy for peripheral neuropathy?
Pregabalin or gabapentin
TCAs
Seizure meds
Peripheral neuropathy in biker with pressure on palms of hands, trauma to medial side of elbow?
Ulnar N.
Wasting of hypothenar eminence
Pain in 4th and 5th fingers
PN w pressure of inner, upper arm; Sat night palsy, use of crutches?
Radial N.
Wrist drop
PN w obesity, pregnancy, sitting w crossed legs?
Lateral Cutaneous N of thigh
pain/numbness of outer aspect of one thigh
PN that worsens w walking?
Tarsal tunnel - Tibial N
Pain/numbness ankle and sole of foot
PN with high boots, pressure on back of knees?
Peroneal N.
Weak foot w/decreased dorsiflexion and eversion
PN seen in typists, carpenters, working w hands
Median N
Thenar wasting
Pain/Numbness in first 3 digits
CN 7 Palsy in stroke
Pt CAN wrinkle forehead on affected side
CN 7/Bells palsy hearing/taste changes?
Hyperacusis - CN7 supplies stapedius = shock absorber on middle ear ossicles
Taste - CN7 supplies sensation of taste anterior 2/3 tongue
Most accurate test for CN7 Palsy?
EMG
Nerve conduction
Complication with CN7 palsy?
Corneal ulceration
Ab MOA in Guillain Barre?
Molecular mimicry
Most specific test for Guillain Barre?
EMG
CSF findings for Guillain Barre?
Albuminocytologic Dissociation
- Increased protein in CSF: 800
- No increase in cell count
What test can differentiate who may die from Guillain Barre?
PFTs
- decreased FVC, peak inspiratory pressure
Death = dysautonomia and resp failure
Monitor resp fnc w serial measurements of bedside VC
TX for Guillain Barre?
IVIG
OR
Plasmapheresis
What test should be done before IVIG?
Check for IgA deficiency
- anaphylactic shock
What vaccine is CI in Guillain Barre?
Trivalent influenza (egg) Use Tamiflu
Tick Paralysis v Guillain Barre?
Tick - Children at nape of neck - Usually descending, but can be ascending CSF: NO albuminocytologic dissociation TX: Remove tick
Myasthenia Gravis presentation
Double vision, difficulty chewing
Weakness of limb muscles - worse at END of day
Ptosis
Normal pupillary responses
Best initial test for MG?
Ach Receptor Ab
Most Accurate test for MG?
EMG
Alternative for erdophonium test?
Ice test: place ice on eyelids, decrease temp inhibits Ach esterase -> enzymatic activity requires increased temps that leads to increased Ach in NM Junction
Where do we see Trident tongue?
MG
What imaging test should be done with MG?
Chest Xray/CT/MRI
Look for thymoma or thymic hyperplasia
Best initial TX for MG?
Pyridostigmine = longer acting
Neostigmine
Pathophys for MG?
Abs against Ach Receptors at NM Junction
Decreased Ach Receptors
When is thymectomy done in MG?
If meds don’t work and pt is under age 60
If pt is over 60 - Prednisone
What is done in an acute myasthenic crisis?
IVIG
Plasmapheresis
Endotracheal intubation
Prior to thymectomy, what do we do?
Plasmapheresis to remove abs by squeezing thymus
Myasthenic crisis can precipitate.
What are DDX for difficulty rising from a chair?
- Lambert Eaton
- Parkinson Dz
- Dermatomyositis
- ALS
- Hypothyroidism induced myopathy
Lambert Eaton Myasthenic syndrome
Ass’d with
Presentation
Increased muscle strength on repetitive Ctx
Small cell Ca
DTRs absent, increased thirst, proximal muscles affected
How do brain abscesses spread?
Contiguous infxn in sinuses, mastoid air cells, otitis media
Presentation of brain abscess
HA - nocturnal or morning N/V Fever Seizures Focal neuro findings
Best initial test for brain abscess
CT or MRI
Ring or contrast enhancing lesion w surrounding edema and mass effect
Most accurate test for brain abscess
Brain Bx
Tx for brain abscess
Empiric: PCN + metronidazole + Ceftriaxone/Cefepime
Vanco if recent neurosurgery (greater risk of resistant staph)
Is brain bx needed for brain abscess?
Yes. necessary to determine precise organism
Most common cancers that mets to brain?
BLT KC Breast Lung Thyroid Kidney Colon
MC artery in stroke?
MCA
What does MCA supply?
Lateral surfaces of brain Temporal lobe Face, arms, hands - motor and sensory Brocas Wernickes
Deficits seen with MCA stroke?
Weakness or sensory on Contralateral side
Homonymous hemianopsia - loss of visual field on opposite side of stroke - look twd side of lesion
Aphasia if on dominant side
MCA stroke in non-dominant lobe?
Preserved speech, comprehension w confusion
Apraxia - unable to perform tasks when asked
ACA stroke deficits?
Contralateral weakness/sensory loss - LE>UE (leg, foot, trunk)
Personality/Cognitive defect - confusion
Urinary incontinence
Leg more than arm weakness
PCA stroke deficit?
Ipsilateral sensory of face, 9th and 10th CNs
Contralateral sensory loss of limbs
Limb ataxia
How does a medial cerebellar infarction present?
Vermis
Vertigo
Nystagmus
How does a lateral cerebellar infarction present?
Dizziness
Ataxia
weakness
What is Wallenberg syndrome?
PICA infarction
- Ipsilateral Facial sensory loss
- Contralateral Body sensory loss
- Vertigo, ataxia, dysarthria, dysphagia
- Ipsilateral orners
What to think of if we see vertigo and nystagmus?
Vestibulocerebellar impairment
Best initial test in stroke?
CT without contrast
Most accurate test in stroke?
MRI
What is CN III Palsy w Contralateral Hemiplegia?
Weber
What is CN III Palsy w Contralateral ataxia, athetosis?
Benedikt
What is the Tx for a non-hemorrhagic stroke of less than 3 hrs?
Thrombolytics
What is the Tx for a non-hemorrhagic stroke of more than 3 hrs?
Aspirin
What is the Tx for a hemorrhagic stroke?
Nothing
What is the Tx for a stroke pt already on aspirin?
Add dipyridamole
OR
Switch to Clopidogrel
When is Heparin the answer in stroke?
Never. It causes hemorrhagic strokes
What are AE’s of Ticlopidine?
Neutropenia
TTP
When is carotid angioplasty and stenting the answer for strokes?
Never.
When do we do endarterectomy?
Symptomatic cerebrovascular disease
More than 70% stenosis
When do we do Holter in stroke pts?
Initial EKG is normal, to detect atrial arrthymias
Do we use steroids in Guillan Barre
No. No proven benefit
When is thymectomy CI?
Age over 60/65
Pre-pubertal
