Neuro (8%) and Uro/Renal (8%) Flashcards
Pt presents with unilateral facial drooping and inability to wrinkle forehead on one side. What is the treatment?
Prednisone UNLESS in an area where Lyme is endemic; can add acyclovir
Eye patch at night to prevent corneal abrasion
If paralysis persists >10 days, consider EMG; if progresses, consider surgical decompression
What is the nerve affected in Bells Palsy?
CN VII
What is the transmission pattern of Huntington Dz and what is the causative mutation?
Autosomal dominant
Expanded tri-nucleotide (GAG) repeats in the HTT gene
How can penetrance of Huntington Dz be predicted?
# of GAG repeats in HTT gene: <28 = WNL 28-35 = asymptomatic carrier 36-39 = incomplete penetrance 40+ = completely penetrant; will develop HD
What part of the brain is affected in Huntington Dz?
GAG repeats in the HTT gene cause atrophy of the caudate nucleus and putamen
CVA vessel identification: aphasia, gaze preference, and half-sided vision
MCA
CVA vessel identification: Leg paresis, hemiplegia, incontinence
ACA
CVA vessel identification: half-sided vision with lots of dizziness
PCA
CVA vessel identification: coma, cranial nerve palsies, apnea, vertigo
Basilar artery
CVA vessel identification: “Clumsy hand syndrome”, ataxis hemiparesis, pure motor OR pure sensory stroke
Lacunar infarcts
25 YO female with refractory HTN presents to ED with “worst HA of my life”. What is the likely underlying etiology?
Polycystic kidney disease is RF for subarachnoid hemorrhage, 2/2 rupture of berry aneurysms
What area is affected in pt who cannot process language but can still form and speak words?
Wenicke’s area
What area is affected in patient who cannot physically speak but can process language?
Broca’s area
What is the time frame in which tPA should be administered?
W/in 3 hours from last known normal
What is the treatment for a patient who presents with unilateral HA with lacrimation, recurrent at night?
Likely cluster HA
Treat acute with 100% O2 6-12 L/min via NRB (preferred); +/- triptan subQ
Prophylaxis with verapamil
What are 4 characteristics that help describe delirium?
- Reversibility
- Fluctuating levels of disorientation
- Hallucinations likely
- Secondary to underlying medical condition
What is the MC cause of AMS in the inpatient setting?
Delirium
- EtOH is MC cause
- Heightened risk after surgery, esp in patients with CVD or DM
What are two key features that help distinguish delirium from dementia?
Delirium is more likely to present with hallucinations; dementia rarely does
Delirium is reversible
How is the treatment of vascular dementia different from that of AZD?
AZD is treated with cholinesterase inhibitors (donepezil)
Vascular dementia treated with BP control
Patient with rapid onset of fever, HA, seizures, focal neuro deficits, and impaired consciousness is sus for what condition?
Encephilitis – more likely to present with AMS than meningitis
What’s the difference between a Parkinsonian tremor and a hereditary tremor?
Parkinsonian: Tremor at rest
Essential tremor: Intention tremor
Describe LP findings in Guillain Barre
Normal glucose
Normal WBC
Elevated protein
Pt presents with fever, HA, stiff neck and LP shows elevated lymphocytes with normal glucose and protein <200. What is the likely dx?
Viral meningitis
Describe/differentiate Kernig vs Brudzinksi signs
Kernig - can’t extend Knee w/o hip flexion
Brudzinski - neck flexion results in hip and knee flexion
Describe the LP findings in bacterial meningitis
Decreased glucose
Increased neutrophils
Increased protein
Increased pressure
Pt presents with fever, HA, and stiff neck. What is the next diagnostic step?
LP for CSF examination UNLESS: - papilledema - seizures - confusion - focal neuro effcs are present, in which case get a CT first to r/o mass effect
What are some acute treatment options for migraine HA?
Toradol, reglen, benadryl combo
vs
Sumatriptan
What is the treatment for status migrainosus?
(72+ hours)
- IVF
- Parenteral kertoralac
- Dopamine receptor blocker (antiemetics, including metoclopramide, prochlorperazine, chlorpromazine)
Often parenteral dexamethasone is also added to help prevent attack relapse
What are some CIx for commonly used migraine medications?
Don’t use triptans in ischemic heart disease, smokers, or >60 YO.
Don’t use ergotamine in pregnancy
Don’t use propranolol in pregnancy
What is the pathophys involved in a patient who presents with ptosis which varies in severity throughout the day?
Likely myasthenia gravis
Antibody-mediated, T-cell dependent immunologic attack on proteins of the postsynaptic membrane of the ACh receptors in the neuromuscular junction
Antibodies = AChR-Ab
How is myasthenia gravis diagnosed?
Single-fiber electromyography (EMG)
Immunologic assay showing ACh-R-Ab
What is the MOA of the drug of choice for a patient who presents with bradykinesia, resting tremor, and shuffling gait?
Sinemet (carbidopa-levadopa) is the 1st line treatment for Parkinson disease
Levodopa gets converted to dopamine after carbidopa helps it cross BBB and inhibits breakdown in the plasma
What is the pathophys involved in Parkinson Dz?
Loss of dopaminergic neurons in the substantia nigra
What are some important AE’s ass’d with the first line treatment for Parkinson’s?
Carbidopa-levodopa
- Impulse control disorders
- LE edema
- Orthostatic hypotension
- Drowsiness
- N/V
EEG shows interictal spikes in frontotemporal region of brain
Complex focal seizure
EEG shows slow waves in temporal region of brain
Complex focal seizure
EEG shows bilateral, symmetric, 3 Hz spike and waves
Generalized seizure
What is the 1st and 2nd line treatments for status epilepticus?
1st line = benzos
- IV Lorazapam is 1st line
- IM midazolam if IV cannot be established
2nd line = phenytoin/fosphenytoin
What kind of acid/base imbalance and electrolyte abnormality is expected in a patient who has been having excessive vomiting?
Hypochloremic
Hypokalemic
Metabolic alkalosis
What is the best indicator of presence of chronic renal failure?
Proteinurea
- Spot urine albumin:Cr is preferable
What is nephrotic range proteinurea?
> 3gm in 24 hours
What is the MC cause of CKD?
Uncontrolled DM, HTN
What is the MC cause of CKD ass’d with malignancy?
Membranous nephropathy
What are the labs associated with and treatment for renal osteodystrophy?
Low Ca2+
High Phosphate
– Give calcitriol and phosphate binders
Also watch out for signs of osteomalacia: replace vitamin D and Ca2+
Which drugs are most commonly associated with acute interstitial nephritis?
5 P’s:
- Pee (diuretics)
- Pain (NSAIDs)
- PPIs
- PCN
- rifamPin
What are some s/sx of acute interstitial nephritis?
Hematuria
Rash
Possible fever
- Likely recent drug use (diuretics, NSAIDs, PPI, PCN, or rifampin)
What is the #1 RF for bladder cancer?
Smoking
Painless hematuria in a smoker on a test is almost certainly …
Bladder cancer
What are the s/s of glomerulonephritis?
- Hematuria
- HTN
- Azotemia (elevated BUN)
- Proteinurea
May also see fever, peripheral edema, malaise. Will likely have recently recovered from GAS infection, URI or GI infection.
What is the gold standard diagnosis for glomerulonephritis?
Renal biopsy- not generally done or needed
Describe the pathogenesis of glomerulonephritis
Post GAS immunologic inflammation of glomeruli causing protein and RBC leakage into urine
How is a hydrocele diagnosed?
Testicular US to r/o mass
MC cause of acute scrotal pain?
Epididymitis
What is the treatment for a patient who presents with localized testicular pain and tenderness with palpation of the posterior testis?
NSAIDs + antibiotics:
<35 YO/higher risk of STIs:
- cover gonorrhea, chlamydia
- Ceftriaxone
- Doxy (can sub AZ)
> 35 YO & low risk of STIs:
- Cover enteric apathogens
- Levofloxacin 500 mg PO x 10 days
Any patient practicing anal intercourse:
- Cover gonorrhea, chlamydia, and enteric pathogens
- Ceftriaxone
- Levofloxacin
What are two clinical signs that are suggestive of testicular torsion?
Absence of Phren sign (no relief with elevation)
Absence of cremesteric reflex
What are some s/sx associated with hydronephrosis?
Often asx, discomfort associated with bladder distention, obstructive stones, or secondary infections.
If chronic, labs may show hyperkalemia
If bilateral or underlying kidney disease, Cr may be elevated
Pt presents with painful hematuria and is restless during exam. What is the diagnostic test of choice for the likely diagnosis?
Helical CT / non-con CT “stone protocol”
What are the size parameters that dictate treatment of a kidney stone?
<5 mm, likely to pass spontaneously
> 8 mm, unlikely to pass, consider lithotripsy
What is the MC site of obstruction in nephrolithiasis?
Ureterovesical junction
What is the MC type of kidney stone?
Ca oxalate
What dietary advice should be given to patients with frequent kidney stones of ANY type?
All types of stones:
- Enough fluid to produce 2 L urine per day
- Limit sodium intake <2300 mg/day (low sodium increased proximal Ca2+ reabsorption = less Ca2+ excretion)
- Increase fruit, vegetable intake (esp K+ rich)
- Weight loss
What are some dietary adjustment that should be suggested to patients with recurrent kidney stones of the MC variety?
Ca+ Oxalate stones are MC
- INCREASE dietary (not supplementary) Ca2+ at meals
- Ca2+ binds to oxalate in intestine, reducing oxalate absorption
- Reduce nondairy animal protein intake
- Don’t take Ca2+ supplements
- Avoid vitamin C supplements
What is the most clinically important inhibitor of Ca2+ oxalate stone formation?
Citrate - chelates Ca2+ in the urine = decreased free Ca2+ available to bind with oxalate or phosphorus
Pt with very high intake of animal protein develops nephrolithiasis and urine pH is excessively low - what is suspected type of stone and what is the treatment?
Uric acid stone
Increase fruit/vegetable intake
Potassium citrate supplementation
What kind of large kidney stones form in the setting of UTI?
Struvite “staghorn calculus”
What kind of stones are ass’d with familial history and huge numbers of stones?
Cystine stones
In what case would a patient with kidney stones be advised to AVOID fruits and greens?
Patients with Ca phosphate stones (rare) ass’d with increased (alkaline) urine pH
Patients with FHx of refractory HTN should be screened for what condition?
Polycystic kidney disease
How is polycystic kidney disease treated?
- ACEi/ARB for BP control
- Dietary sodium restriction
- Increased fluid intake (>3 L per day)
- Pts with GFR 25+: Tolvaptan (vasopressin receptor blocker)
Also screen family via US
What is a lab abnormality on CBC that might be associated with renal cell carcinoma?
High Hg/Hct 2/2 increased epo production
What are parameters for prostate cancer screening?
- 55-69 and life expectancy >10 years
or - Starting at 40 if there is FHx or pt is Black
Pt has PSA of 60 on 2 separate occasions 6 months apart. What is the next step in diagnosis?
CT or MRI pelvis
Consider MRI-US fusion to direct biopsy
What is the MC type and location of prostate cancer?
Adenocarcinoma of the peripheral zone
What are some s/sx of prostatitis?
Fever
Pain in the perineal, sacral, or suprapubic regions
Possible urinary retention
*Exquisitely tender, warm, boggy prostate
How is acute prostatitis diagnosed and treated?
UA with micro, C&S
Blood culture
(NO PSA)
Tx with doxycycline 100mg BID 2-6 weeks
What are alarm signs associated with varicocele, and what is the concern?
- R-sided or bilateral
- Doesn’t disappear when laying supine
Concern for IVC obstruction
What is the inpatient treatment for pyelonephritis?
IV amp + gent
–> transition to PO cipro
What is the outpatient treatment for pyelonephritis?
Cipro BID x7-14 days
What are the tx for uncomplicated UTI?
Nitrofurantoin 1st line
TMP-SMX next
Cipro/levoflox reserved
