Neuro

Question 1

ALS

Answer 1

Hx: Progressive onset ~55yo. No urinary sx, no change in mental status. Clumsy? Pain? FHx?
Sx: Weakness & wasting starting with extremities, difficulty swallowing/speaking/breathing, cramps at night.
PE: Positive Babinski*, Sharp/dull is normal, Hyper reflexes (2/4), Normal muscle strength, weak/clumsy w walking on heels & toes, Ocular H & X in space normal
Imx: EMG, MRI of brain to ro lesion
Labs: CBC & CSF normal, Muscle bx, Elevated Creatine kinase
DDX: Thyroid/adrenal dz, Myasthenia gravis
Tx: GF diet, IV glutathione, Fat rich diet, Riluzole 50mg BID

Question 2

Alzheimer’s

Answer 2

Sx: Impaired smell early on, difficulty w familiar tasks, language issues, poor judgement, misplacing things, change in mood/personality
PE: Altered mental status exam, speech, mb sensation, muscle tone
Imx: MRI
Labs: CBC to ro, Homocysteine, Blood Glucose, Heavy metal
Ddx: Dementia, Parkinsons, Hypothyroid, Meds (histamine blockers)
Tx: Exercise, reading, GF low fat low glycemic index diet, cholinesterase inhibitors

Question 3

Brain Tumor

Answer 3

Sx: HA unlike ever before, non-throbbing, worse w exertion/AM/laying, wo relief. Depression, vertigo, N/V, *first seizure after 35yo
PE: Papilledema, reflexes?, visual acuity?
Imx: MRI, CT, Angiography
Labs: CBC, CMP, Thyroid
Ddx: ALS, Migraine, Glaucoma, MS, Stroke, Azlheimers
Tx: Surgical removal, Vit C IV therapy

Question 4

Carpal Tunnel Syndrome

Answer 4

Hx: Pregnant? DM? Hypothyroid?
Sx: Tingling, pain of first 3-4 digits, not worsened w neck movement, may cause pain at night.
PE: +Phalens, +Tinels, Compare hands, -Adsons to ro Thoracic Outlet
Imx: Electromyography
Labs: None
Ddx: TOS, Disk protrusion, Subluxation
Tx: Surgery, B6, Manipulation, Hydrotx, Decrease meat in diet

Question 5

Migraines

Answer 5

Sx: N/V, pulsating unilateral, photophobia, limis ADLs
PE: Normal neuro exam, Fundoscopic, Palpate cranium
Imx: CT or MRI to ro
Labs: None
Ddx: Mass, tension HA, subarachnoid hemorrhage, Temporal arteritis, Meningitis
Tx: AI diet, No tyramine foods (aged, canned, cured, beans, onions, olives, pickles) Magnesium, Meals TID

Question 6

Migraine Hx Red Flags

Answer 6

• Onset after 50 (temporal arteritis, mass lesion)
• Increasing frequency/severity (subdural hematoma, mass lesion, med overuse)
• Sudden onset of HA (subarachnoid hemorrhage, mass lesion, vascular malformation)
• Hx of head trauma (hemorrhage, hematoma)
• Hx of HIV or CA (meningitis, brain abscess, metastasis, opportunistic info)

Question 7

Multiple Sclerosis

Answer 7

Sx: Optic neuritis, Relapse & remission pattern, sx worse w stress and heat, diplopia, Prickly burning pains
PE: Full neuro
Imx: MRI-need 2 lesions to confirm bx
Labs: Normal CBC, CMP, Thyroid. Viral panel w EBV* (Ab in 100% of MS pts)
Ddx: ALS, Guillan Barre, Lyme, Lupus
Tx: IfnB tx, Corticosteroids, Vit D megadoses, EFAs, GF dairy free

Question 8

Parkinson’s

Answer 8

Sx: Tremor worse w stress, emotion, resting, alcohol. Better w sleep. Trunk bent forward, shuffling steps, expressionless face, insomnia, depression
PE: Orthostatic HTN, Tremor should reduce w finger to nose test, Micrographic, Pt cannot perform rapid alternating movement, Normal reflexes, Neg babinksi
Imx: MRI
Labs: Give L-dopa; if sx improve then dx confirmed
Ddx: Huntingtons, Essential Tremor, Cerebellar dz, Corticospinal tract lesion
Tx: Dopamine agonists, L-dopa (but give in end stage), IV glutathione, GF diet, EFA