N3 Flashcards
Clinical findings of Alzheimer’s disease?
Early
Late
Early?
Anterograde amnesia(immediate recall affected, distant memories preserved) Visuospatial deficit (lost in neighbor) language difficulty(difficulty finding word) Cognitive impairment with progressive decline
Late?
Neuropsychiatric(hallucination and wandering)
Dyspraxia(difficulty in performing learned motor skill)
Lack of insight regarding deficit
Noncognitive neurologic deficit(pyramidal and extrapyramidal motor, myoclonus, and seizure)
urinary incontinence
Cause and symptom of cochlear hair damage?
Metabolic load
Loud voice(High-frequency voice loss and base of cochlear hair cell damage)
a patient will have Sensorineural hearing loss
using earplug is preventive
cerebra hemorrhage fetcher?
2nd common site for IPH
Occipital headache radiate to the neck and shoulder
Nech stiffness(extension to 4th ventricle)
Nystagmus
Ipsilateral Hemi-ataxia(Corticopontocerebral fibers decussate twice)–vermis injury
ipsilateral Extremity ataxia–hemisphere injury
If expand–cranial palsy or stupor and comma
Decompress if size > 3cm
Hemineglect syndrome?
Damage of the non-dominant(usually left)hemisphere
Perform commands on the ipsilateral side
Not see contralateral space(detect by asking to write clock)
Agnosia(not know their defect)
Clinical presentation of Mystenia gravis?
Fluctuating and fatigable proximal muscle weakness
Occular(diplopia and ptosis)
Bulbar(dysphagia and dysarteria)
Respiratory(in crisis)
Cause of exacerbation?
medication(aminoglycoside,flouroquinolol)
NM blocking agent
Beta-blocker
MgSo4
Penicillamine
Physiologic stress(Inf.,Surgery,Px,childbirth)
Diagnosis?
Ice pack test(bedside)
Ach-R binding Ab(specific, diagnostic)
Chest CT(for all patient)
Managment?
ACE inhibitor(physostigmine)
Immunosuppressant for acute exacerbation
Tymectomy(Good clinical progresion enen patient w/o mass)
Corticosteroid indication in multiple sclerosis?
Acute exacerbation
disabling symptoms
plasmapheresis in refractory case
Meralgia paresthetica?
Pain, paraesthesia, and numbness in LFCN distribusion
Compression of LFCN by inguinal ligament
Due to tight belt, clothing and surgery
Obesity,surgery(arthroplasty),lumbar lordosis(Px) and DM increase the risk
Wt loss,behavior change and anticonvulsant(gabapentin in sever case)
Internuclear ophthalmoplegia?
affected side fails to adduct but contralateral eye abducts with horizontal nistagmus
Due to the heavy myelinated medial longitudinal fiber( paired neural tract that communicates CN III with Vl)injury
Cause?
Unilateral–Lacunar stroke with pontine artery
Bilateral–Multiple sclerosis
Treatment of Parkinson’s disease?
Anticholinergic (Triphenixidil)-especially for tremor Levodopa MAO inhibitor(selegiline) can be used for mild symptoms
What is pronator drift(involentary hand pronation on patient supinate on closed eye) indicates?
Upper motor lesion/pyramidal tract b/c affect more supinator muscle
Ischemic stroke present within 3-4.5 Hr?
Alteplase
IS without previous antiplatelet treatment?
Asprin
Start within 24 hours of symptoms
IS occur on a patient with Asprin?
Asprine +Clopidogril/dipyridamol
Stroke with evidence of atrial fibrillation?
Prolonged anticoagulant therapy
Stroke with large anterior circulation artery occlusion with presentation 24 hr of symptoms?
Mechanical thrombectomy(whether alteplase used or not) then Asprin
Patient with intracranial large artery atherosclerosis?
Asprin with clopidogril for 90 days then Asprin.
Unfractionated heparin/LMWH and acute stroke?
Not should be used increase the risk of bleeding
cause of subdural hematoma?
Rapture of bringing vien
Risk factor?
Alcohol and elderly(cerebral atrophy and fall risk)
Infants(thin-walled vessels)
Anticoagulant use
clinical manifestation?
Acute
Impaired consciousness, comma, and confusion
Headache, nausea, and vomiting
Chronic
Headache, somnolence and confusion, lightheadedness
Foccal nurologic deficite
Diagnosis?
Cresent shaped hyperdensity(acute) or hypodensity crossing the suture line
managment?
reverse/stope anticoagulant
surgical evaluation for symptomatic one
Primary CNS lymphoma?
One of AIDS-defining illness
Caused by EBV
patient present with, confusion, lethargy. seizure and focal neurologic deficit.
Irregular, solitary, heterogeneous, and ring-enhancing lesion
CSF finding of EBV is confirmatory
Complication of infection of orbit,face and sinous?
Cavernous sinus inflammation which results in thrombosis
Due to ven of the face are valvless
Symptom and sign of CVT?
Headache and vomiting
Papilledema
Binocular palsy
Periorbital edema
Hyperesthesia or hypoesthesia in V1 and V2 distribution
usually bilateral due to cavernous veins are bilateral
Which cranial nerve affected?
CN pass through CS III IV VI(6 CN first affected) V1 V2
Managment?
Aggressive antibiotic treatment
Reduce ICP to decrease the risk of herniation
Diagnosis?
MRI with magnetic resonance venography
papilledema pathophysiology?
ICP—Impaired axoplasmic flow—optic nerve head(blind spot) enlargement
Subclavian steal syndrome pathophysiology?
subclavian artery (usually the left by atherosclerosis b/c left SCA have Sharpe curving and high turbulent flow) blockage before giving vertebral artery–left arm ischemia—vertbrovasilar anastomosis–blood retrogradely move from ipsilateral vertebral artery to Ispsilateral SCA–vertebrobasilar insufficiency(VBA insufficiency symptoms).
Symptoms?
—————Affected arm ischemia
Pain, fatigue, and paraesthesia of affected arm
Systolic B/P discrepancy b/n two arm(>15 mmHg)
Bruit in supraclavicular noch in the affected side
—————-Vertebrobasilar insufficiency symptom
Loss of vision in part or all of both eyes.
Double vision.
Vertigo (spinning sensation)
Numbness or tingling.
Nausea and vomiting.
Slurred speech.
Loss of coordination, dizziness, or confusion.
Trouble swallowing.
Symptoms exacerbated during affected UE exercise B/C exercise-induced vasodilation exacerbate steal–VBI symptoms will be exacerbated
Diagnosis and managment?
Doupler U/S and MRI angiography
managment will be lifestyle modification and stent placement
Most likely cause of both ischemic and hemorrhagic stroke?
Hypertension
Common cancer metastasized to the brain in order?
1-lung 2-breast 3-unknown etiology 4--melanoma 5--Colon
Cracterstich?
Multiple
Found in white and gray matter junction
Vasogenic edema
Steroid decrease edema and symptoms
cerebral toxoplasmosis?
Multiple ring-enhancing lesion CD4 <100 Fever Headache Altered mental status seizure
Neurocysticercosis?
New-onset seizure
On imaging
Cyst on multiple stages (non-ring enhancing, hypodense and have granuloma)
Effect of CO on the brain?
——-Brain(like other tissue) hypoxia by 3 mechanisms?
Bind to Hb(decrease o2 binding)
Shift Hb/O2 dissociation curve to left(affect unloading)
Affect oxidative phosphorylation(complex IV inhibition)
——Symptoms
Mild–headache, confusion, and dizziness
Sever—MI, seizure, comma, and lactic acidosis
In permanent effect—Bilateral globus pallidus hyperintensity b/c of susceptibility to hypoxia
Vasovagal(nurocardiogenic syncope) caracter?
caused by stress, severe pain, and prolonged standing
Due to vagus nerve activation–Bradycardia and hypotension
Have prodrome (feeling warmness, dizziness, nausea,pallor, diaphoresis and abdominal pain
Usually resolves with second up to few minutes
Good prognosis
orthostasis with syncope?
Autonomic dysfunction(will have Hx of Dm or PD) Hypovolemia (Hx of volume loss)
Other causes of syncope and their evidence?
LV outflow obstruction (syncope with exertion and systolic murmur) Ventricular arrhythmia (no prodrome with Hx of IHD/CMP Conduction impairment(previous Hx of fatigue and lightheadedness with ECG abnormality) Carotid hypersensitivity(carotid stimulation while standing precipitate syncope)
How to d/t from seizure?
absence of aura, postictal phase, body movt, unusual body posturing, and tongue laceration.
Tick-borne paralysis?
Occur when the thick stay in the skin for 4-7 day
Due to the release of the neurotoxin
ascending motor paralysis pronounced on one side and develop within hr to days
Absent sensory and autonomic dysfunction
Absent fever and prodromal symptoms
Management Search and remove thick(improve by itself within an hour to days)
How to D/t from GBS?
Paralysis develop within hr to days(days to weeks in GBS) Normal CSF( Albuminocytologic dissociation in GBS) absence of autonomic symptoms (autonomic symptoms present in 70% of GBS patients.
Amitriptyline (TCA) mechanism of action and S/E?
The therapeutic effect is by inhibiting NE and serotonin
S/E
M1 blockage–Anticholinergic symptoms like constipation
H1 blockage–lethargy
Alpha-adrenergic blockage–orthostatic hypotension
Orthostasis?
is a normal physiological response of the sympathetic system to counteract a fall in blood pressure when a person is laying down and assumes the upright position
Orthostasis or orthostatic hypotension (OH)?
is a decrease in blood pressure that happens soon after standing or sitting up.
Systolic gap >=20
Diastolic gap >10
Dix-Alpike test?
Used to diagnose benign paroxysmal positional vertigo which characterized by vertigo with or without nausea/vomiting with head movement.
Sensory Ataxia?
It occurs when the part of your nervous system outside of the brain and spinal cord injured.
You have less sensation in your feet and legs from the nerve damage, so you have less feedback from your brain telling you where your body is in relation to the ground.
Causes. Sensory ataxia can be a manifestation of sensory large fiber peripheral neuropathies and conditions causing dysfunction of the dorsal columns of the spinal cord due to a variety of disorders: infectious, auto-immune, metabolic, toxic, vascular, and hereditary diseases.
The patient will have a positive Romberg test
And unable to perform heal to shell test
Romberg test?
The patient is asked to remove his shoes and stand with his two feet together. …
The clinician asks the patient to first stand quietly with eyes open, and subsequently with eyes closed. …
The Romberg test is scored by counting the seconds the patient is able to stand with eyes closed.
Tandem test?
asses cerebellar ataxia
Ice pack test?
Used for MG
Weakness improve by putting Ice on
The cold environment inhibit ACE activity–improve symptoms
But for diagnosis require a confirmatory test (Ab test)
Myoclonus?
Involuntary muscle relaxation or contraction that results in a limb or joint movement
Caused by genetics, seizure, medication, and prolonged hypoxia.
Posthypoxic myoclonus(PHM)?
Usually occur after cardiac arrest
Have two forms (acute and chronic)
treat both by antiepileptic and supportive care
Acute?
also called myoclonus status epileptics(MSE)
occur while patient on LOC and within 24 hr of insult
Is generalized(symmetric) form
If persist indicate poor prognosis
Chronic?
also called Lance Adam syndrome
occur after days and weeks and the patient regains consciousness
Have focal nature
Critically illness polyneuropathy?
Occur in a patient after prolonged ICU stay
Pheripherial weakness and decreased reflex
Trigeminal neuralgia?
Unilateral severe burning pain
lasts for many seconds and rarely to weeks and months
Exacerbated with minimal activity
V2 and V3 affected mostly and rarely V1(when involved autonomic symptoms like rhinorrhea and lacrimation will be there).
Due to CN V demyelination at the entry to pons(usually due to compression)
Treat with anticonvulsant like carbamazepin
if not responded surgery(decompression and radiosurgery can be considerd)
How to d/t from herpes zoster reactivation?
HZR
Dermatomal distribution
vesicle and rash will be there
Blindness if involve V1(herpes ophthalmitis)
Clinica menifestation of Idiopatic intracranial HTN?
Global Headache Visual loss Pulsatile tinnitus Papilledema(enlarged blind spot) Diplopia(horizontal gaze palsy)--CN VI palsy
Tinnitus?
Is when you experience ringing or other noises in one or both of your ears
Diagnosis?
Normal Neuroimaging
LP: Elevated opening pressure(>250 mmHg) and normal CSF fluid analysis value
Risk factor?
Women in reproductive age
Drug(tetracycline,retinoid,GH and dantrolene)
managment?
wt loss
Acetazolamide
Dream enactment?
REM sleep behavioral disorder
Occur when muscle atonia in REM is absent
The patient will have repeated episodes of violent and autonomic complex motor behavior.
Occur in the first 90 minutes of sleep(REM) and increase second half of sleep (REM frequancy increase)
Long-term association?
A patient will have an increased risk of future alpha-Synuclein inclusion disease(PD, LBD, and multiple system atrophy)
Bells palsy?
LM CN VII(involve lower and upper face)
Mainly due to the Nurothropic virus reactivation(mainly HSV)–Inflammation–Demyelination and compression due to edema.
Decrease lacrimation, loss of test in anterior 1/3 of the tongue, and hyperacusis.
Treat with corticosteroid and acyclovir
Unilateral UMN inervated CN?
Vll (innervating the LMN)
Xll (innervating genioglosus(protrude the tongue anteriorly and deviate the tongue to the opposite side)
LAmbert-Eton syndrome?
Due to Ab blocking ca channels in a presynaptic cleft in the motor neuron terminal–defective ACh release
Mainly related to underlying malignancy(MC:SCLCa)
A patient will have proximal muscle weakness improved by activity
Autonomic neuropathy(dry mouth)
Absent DTR
Diagnose with
Treat with guanidine or 3,4 diaminpyridine
Immunoglobulin or corticosteroid in refractory cases
Delirium manifestation?
Reduced/Fluctuation of LOC
Decrease attention
Associated with anxiety, agitation, and/or hallucination
predisposing factor?
Dementia Parkinson Disease Prior stroke Advanced Age Sensory impairment
Precipitating factor?
Drug Infection Electrolyte disturbance Metabolic condition Systemic illness CNS condition
Initial workup for suspected cognitive impairment?
Cognitive testing
Laboratory testing
Imaging
Cognitive testing?
MMSE(<24/30–MCI/Dementia)
Montreal cognitive assessment(<26/30)
Mini-cog(abnormal 3-word recall or clock-drawing test)
Laboratory?
Routine:CBC,TSH,VitB12 and CMP)
Selective:Folate,Syphiliis and Vit D
atypical(early onset) or suspected infection or maligancy:CSF analysis
Imaging?
Brain CT/MRI
atypical(having seizure activity): EEG
The first test to do inpatient with stroke?
Non-contrast head CT
sign of ulnar nerve injury?
above elbow: Sensory defect in medial 5.4th finger and motor paralysis of intrinsic hand muscle and FCU And FDP(decrease gripe strength)
at wrist: all above except decreasing HG
Sign of cerebral amyloid angiopathy?
Parital and occipital lobe heamorage
MCC of lobar hemorrhage in age >60
Mainly inpatient history of Alzheimer
Confusion,lethargy,hemisensory loss and neglect(DHI).
B-amyloid(same AD) protein accumulation in medium and small cerebral vessel–Rapture–ICH mainly during exercise.
Warfarin-induced ICH?
Supratherapeutic warfarin(high INR)
Acetaminophen will exacerbate the toxicity
Give immediately PCC and if not available FFP
Lowering SBP < 140
Cervical spondylotic myelopathy?
Caused by degenerative disease of spinal vertebra–osteophyte in LB and SLL/LF–spinal channel stenosis–SC compression/interruption of SC supplying arthery
Common in the older patient
Neck pain radiating to shoulder and arm
Lehermitte sign(electric shock-like pain radiate to spine)
LMNL sign in UE(atrophy and flaccid paraysis)
UMN signs in LE
Unsteady gait
How to d/t ALS?
ALS: asymmetric paralysis and no Lehermitte sign
How to d/t spinal stenosis?
SS: Back pain and paralysis exacerbate walking and improve withstanding(pseudo claudication)
Not involve UE
How to d/t MS?
No LMNL sign
preventive medication for migraine?
Topiramate
Divalproex sodium
TCA
Beta blocker
when to give?
frequent(>4 month) or persistent(> 12 Hr symptom
Disabling pain(affect work)
Unable to take or unresponsive to abortive Tx
Analgesic abuse-related headache
Huntington’s disease symptoms?
Chorea and delayed saccade
Depression, irritability, psychosis, or OCD
Defect in executive function
finding?
CAG trinucleotide repeat
Autosomal dominant
GABA-ergic neuronal damage
Caudate nucleus and putamen atrophy
managment?
Supportive
Die within 10-20 years
Locus coeruleus?
Produce NE
Found posterior to the pons
can be damaged in PD and Alzimer
