Neuro Flashcards
Where in bones does Ewing Sarcoma arise and which bones are most often affected?
- Arise in the diaphysis of long tubular bones; in the medullary cavity and then invades cortex
- Especially the femur and flat bones of the pelvis
What is the etiology of LGI1 encephalitis?
Failure to identify and treat these patients early may result in permanent brain injury with longterm cognitive deficits, especially short-term memory problems.
Up to 1/3 of patients may relapse after treatment
What are the characteristic of normal pressure hydrocephalus and who is it seen in?
- Symmetric type usually occuring in adults >60 - Develops slowly over time; drainage of CSF is blocked gradually - Enlarged ventricles still exert pressure on brain and can become symptomatic w/ pt’s exhibiting dementia-like manifestatons - Dementia may be similar to Alzheimers and gait abnormalities may suggest Parkinson disease - NPH is often misdiagnoses as one of these diseases
What effects due the AchE have?
bradycardia, bronchoconstriction, salivation, nausea, vomiting
What is the MOA of the gout drug, Pegloticase?
How is it administered?
- Recombinant mammalian uricase, covalently attached to methoxy polyethylene glycol –> prolongs ciruclating half-life and diminished immunogenic response
- Converts uric acid to the far more soluble allantoin
- IV every two weeks
general characteristics of myasthenia gravis:
fluctuating weakness (excessive fatiguability)
distribution of weakness (ocular muscles affected first usually; ptosis and diplopia usually)
clinical response to cholinergic drugs
Primary OA classification in particular affects what?
- Primary OA most common, no identifiable cause is recognized
- Joints affected DIP (distal interphalangeal), PIP (proximal interphalangeal) of fingers
- 1st carpometacarpal joint (base of thumb)
- Hip and knee joints, cervical and lumbar spine
What are the typical diagnostic features seen with an MRI of the head and CT of the spine in a patient with MS?
- Ovoid lesions of high signal on T2WI in periventricular white matter and spinal cord
- Acute lesions may enhance
myotome vs. dermatome vs. sclerotome
myotome: muscle group supplied by single spinal root
dermatome: skin area supplied by single spinal root
sclerotome: area of bone supplied by single spinal root
Which second gen. antipsychotic is more often assoc. with EPS/Tardive Dyskinesia, elevated prolactin, and weight gain/DM?
Risperidone
What is the criteria for Bipolar II Disorder?
- Pt has at least one major depressive episode and one HYPOmanic episode in absence of any manic or mixed episodes
- Hypomanic is the key!
What is commonly seen on radiographs in pt with Erosive OA and how can it be differentiated from RA?
Central erosions (vs. marginal erosions in RA) w/ “seagull” appearance in finger joints
What is the characteristic morphology seen with with subchondral infarcts of osteonecrosis?
Triangular or wedge-shaped segment of tissue that has the subchondral bone plate as its base undergoes necrosis
During a general medical exam of the skin of a patient with impaired consciousness what should be considered with acne?
Long-term antiepileptic use
DTR loss in biceps seen in which nerve roots?
C5-C6
What are the main characteristics of sensory causes of Disequilibrium?
- Proprioceptic deficit
- Visual impairment
- Compensated vestibular disorders
- Worse in dark
- Romberg sign
In sarcoma botryoides (rhabdomysarcomas), where the tumor cells abut the mucosa of an organ, they form a submucosal zone of hypercellularity called what?
Cambium layer
What is the progression and survival rate like for Primary Lateral Sclerosis?
- Slow progression, but can evolve into ALS
- Survival rate better than ALS
what forms do the anti-hypertensives come in
tablets
If the CT findings are normal in a patient believe to have suffered a stroke, what are some other causes you should consider?
Seizure, migraine, hypoglycemia
What does the prefrontal cortex do, in which nicotine alters?
It’s in charge of executive function which include impulse control
differentiating between good and bad
Motivation to work toward a goal
Before beginning antipsychotics the guidelines recommend determining in all patients which baseline items?
- Serum glucose + Lipids + Weight (BMI)
- Blood pressure
- Waist circumference and Personal/Family hx of metabolic and CV dz
what form does ProCentra (dextroamphetamine sulfate) come in
liquid
IR Amphetamine
What is the characteristic sign of Hepatic dysfunction causing stupor and coma?
- Asterixis!
- Pt extends arms and wrists, the wrists will twitch!
Which drugs can be used for methanol/ethylene glycol intoxication by blocking alcohol dehydrogenase and the conversion to formaldehyde?
Fomepizole and ethanol (give them a shot)
What is the criteria for Generalized Anxiety Disorder?
- Excessive anxiety and worry about different aspects of life for most days of ≥6 months assoc. w/ ≥3 of the following:
- Restlessness
- Irratibility
- Sleep disturbance
- Fatigue
- Muscle tension
- Difficulty concentrating
What’s the Kernohan’s notch phenomenon?
Is a result of the compression of the cerebellar peduncle against the tentorium cerebelli due to transtentorial herniation. This produces ipsilateral hemiparesis or hemiplegia (on the side of the herniation) his produces a visible “notch” in the cerebellar peduncle. Because a Kernohan’s notch is caused by an injury creating pressure on the opposite hemisphere of the brain, it is characterized as a false localizing sign..
A right hemisphere trans-tentorial herniation, causes a Kernohan’s notch in the _____ cerebellar peduncle, which results in ________ motor impairment.
A right hemisphere trans-tentorial herniation, causes a Kernohan’s notch in the left cerebellar peduncle, which results in right-sided motor impairment.
What is gliosis?
Proliferation of astrocytes in response to brain injury
Histo of osteopet
What are the requirements of diagnosis for a Vestibular Migraine (central)?
- At least 5 episodes of moderate/severe vestibular sx’s lasting 5 minutes to 72 hours
- Current or previous hx of migraine w/ or w/o aura
- One of more migraine features w/ at least 50% of episodes: headache, photophobia, phonophobia, nausea, aura…
What are the characteristic of a complex partial seizure (i.e., signs/symptoms, time-line, consciousness post-ictal)?
- Nonresponsive staring, possible preceding aura
- Automatisms (action performed unconsciously or involuntarily)
- Loss of consciousness
- Last 1-3 mins
- Post-ictal state
What is the MOA of the second-gen antipsychotic agents?
- Block D2 post-synaptic receptors AND the 5HT2A receptors
- Stronger 5HT2A receptor blockers than D2 receptor blockers
lab findings of Guillan barre
increased protein in CSF; normal cell count and glucose
slow conduction velocity, focal conduction block, prolonged F-waves
compare adverse effects of memantine to the cholinergic medications
memantine has fewer AEs
What are the respiratory patterns of someone with a subtentorial mass lesion?
Bizarre respiratory patterns common
What are 7 common symptoms of patients with MS?
1) Paresthesias
2) Gait disturbances (i.e., transverse myelitis)
3) Weakness
4) Visual loss (i.e., optic neuritis)
5) Urinary difficulty
6) Dysarthria
7) Hemiparesis
Who does NMDA encephalitis most commonly affect?
Most commonly affects young or middle-aged women
Which translocation and fusion gene product is characteristic of Ewing Sarcoma?
t(11;22) –> EWS-FL11 gene
define radiculopathy
nerve root dysfxn may be caused by structural (discs, osteophytes, tumors, etc.) or non-structural (DM, infections, etc) conditions
Which type of anxiety disorder has a strong genetic component?
Panic disorder: 50% of all pt’s have at least one affected relative
Bisphosphonates are the drugs of first choice for what 5 conditions?
- Postmenopausal osteoporosis
- Osteoporosis in men
- Glucocorticoid-induced osteoporosis
- Paget disease of bone
- Hypercalcemia of malignancy
motor signs of PND?
atrophy, muscular weaknesss, decreased or absent deep tendon (muscle stretch) reflexes, fasciculations, cramps
Sudden onset of severe headache (“worst headache of my life”), often with rapid neurologic deterioration is consistent with a _________ hemorrhage
Subarachnoid
What is the most common parasitic nervous system disease in the world and can lead to hydrocephalus?
- Cysticercosis - Taenia Solium (pork tapeworm) CALCIFIED CYSTS
lower limb entrapment neuropathies common nerves involved
peroneal (mc by fibular head by lateral aspect of knee);note: inversion preserved unlike L5 issues
lateral femoral cutaneous n. (commonly from weight gain and tight clothing)
A patient presents after a direct blow to the head which initially knocked him unconscious, after a couple hour lucid interval he begins to exhibit neurological deterioration, what do you suspect?
Epidural hematoma
What are Cheynes-Stokes respirations?
Seen with what disorders?
- Hyperpnia regularly alternating w/ apnea (bilateral hemispheres or diencephalon)
- Many disorders ranging from metabolic to structural
Which 3 organisms are commonly cultured in osteomyelitis seen in pt’s with UTI’s are who are IV drug users?
E. coli + Pseudomonas + Klebsiella
What is the most common childhood form of muscular dystrophy?
Duchenne’s muscular dystrophy (DMD)
Central: Vascular (ischemic) causes of equilibrium disoders are most commonly seen in?
The elderly
Uric acid indicator and what constitutes hyperuricemia?
uric acid > 6.8 mg/dl
With labyrinthine dysfunction (peripheral) leading to dysequilibrium what is the vertigo like, duration of nystagmus, direction of nystagmus, and neuro symptoms?
- Intense vertigo
- Brief nystagmus
- Horizontal/diagonal nystagmus that is fixed
- Never any neuro symptoms
CNS signs
UMN: spastic tone, normal bulk, no fasciculaitons, hyperactive DTRs, +babinski sign
Infarcts may occur in the supratentorial white matter of premature infants and are known as?
Characteristic finding?
- Periventricular leukomalacia
- Chalky yellow plaques = white matter necrosis and calcification
What are the most common forms of Spinocerebellar Ataxias?
Characteristic findings in these diseases?
- SCA 1 (olivopontocerebellar)
- SCA 3 (Machado-Joseph)
*Slowly progressive cerebellar ataxia of limbs combined w/ brainstem signs (dysarthria, oculomotor disturbance, spasticity) and peripheral neuropathy
Which nerve is compressed in Kernohan’s notch?
CN6
What is a synovial cyst and what is a common example of one?
- Herniation of the synovium thru a joint capsule or massive enlargement of a bursa
- Baker cyst seen in popliteal space (behind the knee) in setting of RA
what form does focalin come in
tablet
Diabetic Peripheral Neuropathy, Fibromyalgia, and Chronic musculoskeletal pain
duloxetine
What are Duret hemorrhages and are a result of what?
- Progression of transtentorial herniation producing secondary hemorrhagic lesions in the midbrain and pon - “Flame-shaped” lesions
Psoriatic arthritis can look like OA by presenting how?
Psoriatic arthritis can involve DIP; causes morning stiffness, joint swelling dactylitis and history of psoriasis
Diagnosis of osteomyelitis is strongly suggested by what characteristic radiographic findings?
Lytic focus of bone destruction surrounded by zone of sclerosis
Which bisphosphonate has been most commonly associated with osteonecrosis of the jaw and also dose-dependent kidney damage and rarely atrial fibrillation?
Zolendronic acid
Tell me about hyperuriciemia and gout
Causes gouty arthritis
Monosodium urate crystals in joint fluid or tophi
- Crystals are needle-shaped, negative birefringent by polarized light miscroscopy
- Joints are hot, swollen, tender, dusky, red; fever
- Tophi – nodular deposits of monosodium urate crystals in skin
- Alcohol promotes increased urate production and decreased excretion
What other symptoms can you see with LGI1 Encephalitis?
1) Sleep disturbance is seen in about 50% of patients.
2) May see temporal lobe (esp. hippocampal) abnormality in some patients acutely
what form does Mydayis come in
capsule
ESR is a good marker for monitoring disease activity, especially in what 2 conditions?
Polymyalgia rheumatica and Giant Cell arteritis
What are some of the complications which may arise in the setting of tuberculous spondylitis (Pott disease)?
- Permanent compression fractures –> scoliosis or kyphosis & neurological deficits 2’ to spinal cord and nerve compression
- Other: tuberculous arthritis, sinus tract formation, psoas abscess & amyloidosis
What is the criteria for persistent depressive disorder (dysthymia)?
- Often milder, ≥2 depressive sx’s for most of the day ≥ 2 years for adults and 1 year in children
- During 2 years, cannot be w/o sx for >2 months at a time (is continuous)
What is the duration of disturbance and sx’s for diagnosis of PTSD?
Lasts >1 month with significant distress or impaired functioning
What does the term sequestrum refer to in terms of osteomyelitis; what is seen with rupture of the periosteum?
- Dead bone following subperiosteal abscess
- Rupture of periosteum —> soft tissue abscess which can channel to become a draining sinus
What is Cerebral Palsy and what are the clinical manifestations of this disease?
Occurs due to insults during which period?
- Non-progressive neurologic motor deficits characterized by combination of spasticity, dystonia, ataxia/athetosis, and paresis
- Pre-natal and perinatal periods (are present from birth)
What is the response of microglia to neuronal injury?
Proliferate and accumulate during CNS injury
Pathway of ethylene glycol metabolism?
Ethylene glycol -> Alcohol dehydrogenase -> glycoaldehyde -> Aldehyde dehydrogenase -> Glycolic acid
Pain in elbow/forearm is seen in which nerve root
C7
Where does embryonal rhabdomyosarcoma most often arise, characteristic morphology, and age group?
- Arise in genitourinary tract
- Patients 1-5 y/o
- Primitive spindle cells, “strap cells” or Tadpole cell
Which pharmacologic agent can cause a 50% reduction in suicidal thoughts in 24-hours and is great for tx of major depressive disorder?
Ketamine
What are the 6 second-gen. aka atypical/novel antipsychotics?
- Aripiprazole
- Clozapine
- Olanzapine
- Quetiapine
- Risperidone
- Ziprasidone
Pathophysioliogy of Myasthenia Gravis:
caused by a defect of neuromuscular transmission due to an antibody-mediated attack upon nicotinic acetylcholine receptors (AChR) on muscle membrane
Enuresis (bed wetting)/urinary incontinence anti depressant
imipramine
Anti CCP in OA is usually?
Negative
What is Rheumatoid factor and what is produced by?
It is an IgM (the most common autoantibody that does this) autoantibody that targets the Fc portion of IgG immunoglobulin
RF is produced by B cells in synovial joints of the RA joints
What are the hallmarks of subacute and chronic neuronal injury (i.e., degeneration)?
Cell loss —> Apoptosis - Reactive gliosis
What is the criteria for Bipolar I Disorder?
- ≥1 manic episode +/- a hypomanic or depressive episode
- Major depressive episode not required, but is often the episode that presents first!
Which 4 benzodiazepines have the longest half-lives all >100 hr and all have active metabolites?
- Chlordiazepoxide
- Clorazepate
- Diazepam
- Flurazepam
How are lab studies usually for OA?
The ESR is generally normal in OA
Where is a common location for ganglion cysts to arise, how to they appear, and arise as a result of what?
- Around joints of wrist
- Firm, fluctuant, pea-sized translucent (you can shine a light through it) nodule
- Arise as result of cystic or myxoid degeneration of CT; hence the cyst wall lacks a cell lining
What other random things do you see go up on labs for RA?
Thrombocytosis (acute phase reactant)
- ANA+ (30% of RA patients)
- Hyperglobulinemia
- Leukopenia / Granulocytopenia
- Low glucose in body fluids
- Synovial fluid – 2/3 PMN’s; WBC’s 5000 – 100,000/mm3
what form does adderall (dextroamphetamine/AMP) come in?
tablet
IR amphetamine
What are the sx’s of withdrawl from barbiturates, benzo’s and ethanol?
Anxiety + insomnia + delirium + tremors + seizures + death
What is the clinical presentation in DMD in kids?
- Proximal muscle weakness (symmetric)
- Rarely have anti-gravity neck flexor strength
- Delayed walking, difficulty running, can’t “keep up” with peers
- Develop a broad based, waddling, gait with exaggerated lordosis
- Gower’s sign present
- Usually first noted around 1 ½ to 2 years old, as developmental milestones in the gross motor domains fail to be met
- Progresses rapidly, severe disease
- Scoliosis develops
- Calf and thigh muscle hypertrophy followed by pseudo-hypertrophy 10. Cognitive dysfunction
- Toe walking and limited hip flexion (by 4-6 years-of-age)
`12. Life expectancy: late teens to mid-twenties
Other than D2-receptors, which other receptors may be blocked by first gen. antipsychotics and how does this correlate with AE’s?
- Muscarinic receptors: dry mouth, constipation, blurred vision…
- Histamine (H1) receptors: sedation
- α1-adrenergic receptors: orthostatic hypotension, dizziness/syncope
Which rare type of brain tumor leads to increased CSF production, thus causing increased ICP and hydrocephalus?
Choroid Plexus Papilloma/Carcinoma
A CRP >____ mg/L is inflammatory
What other factors go up with inflammation?
>8 mg/L
Leukocytosis, thrombocystosis, ferritin, fibrinogen and complement increase
Clinical px of botulism:
dry, sore mouth and throat, blurry vision, diplopia, n/v, hypohydrosis, etc
define classical conditioning
learning is the association of things that take place together in time
the repeated pairing of a neutral (unconditioned stimulus) with one (conditioned stimulus) that evokes a response (unconditioned response) so that the neutral stimulus eventually come to evoke the same response (conditioned response)
What is the morphology of a brain contusion?
What is seen early on and within 24 hours?
- Wedge shaped w/ a broad base lying along the surface at the point of impact
- Early stages: pericapillary edema and hemorrhage
- 24 hours: pyknosis of the nucleus, eosinophilia of cytoplasm and disintegration of the cell
What is seen with the trabeculae that remains in subchondral infarcts (osteonecrosis)?
- Acts as scaffolding for the deposition of new bone in process known as “creeping substitution”
- Pace is too slow to be effective, so there is collapse of the necrotic bone and distortion, fracture and even sloughing of the articular cartilage
When CIS patients do not have multiple demyelinating lesions on MRI, they have a ______% chance of developing MS within several years
20%
*Low risk
What will an EMG of pt with ALS show?
Widespread denervation and reinnervation
What does tuberculous spondylitis (pott’s dz) come from?
From spine involvment in mycobacteria infection cases
Do you get pain with subcondral infarcts? And can lead to what?
Yes and initially only associated with activity and then becomes constant
Often collapse and may lead to secondary osteoarthritis
What is the pathophysiology behind RA?
Multigene Disease
- 1/3 of patients susceptibility from genetic factors HLA-DRB 4 alleles/DRB1 0401 or 0404
- Pathologic changes in joints precedes synovitis in RA patients 5-10 years
- Infiltration of leukocytes, cytokines and macrophages act as antigen presenting cells to activate T cells
- “B” lymphocytes produce autoantibodies, cytokines (TNF alpha, IL-1, IL6), proinflammatory cytokines synovial proliferation, increase synovial fluid, leads to “pannus” that invades cartilage and bone
What are some conditions that can present w/ focal neuro deficits that may be confused with stroke?
1) Migrane w/ aura (primary headache disorder)
2) Hyperglycemia
3) Hepatic abnormalities
Explain four (4) functions that a Behavioral Health Consultant can provide to assist a physician in his or her day-to-day practice.
- Assessment, Education, Brief Intervention, Referral
- Warm hand-offs
- Chronic illness, Mental health disorders
- Prevention
- Quality improvement and quality assurance
DTR loss in finger flexors seen in
C8
Hypomanic episodes are more associated with which type of bipolar disorder?
Bipolar type II
What does dead bone look like microscopically?
Empty lacunae surrounded by necrotic adipocytes which frequently rupture
What are some clinical manifestations for RA? So you can recognize them on the test?
- PIP, MCP/DIP almost never involved • Swan neck (hyperextension of PIP joints) • Boutonniere (button hole deformity) (hyperflexion of PIP joints)
- Pain, swelling, warmth in multiple small joints ( one (1) year • < 10% have abrupt onset of disease
Tenderness, swelling, warmth, erythema, fever, weight loss, anorexia, symmetrical joint involvement
• Skin – subcutaneous nodules; extensor surface of forearm
What are the symptoms of a stroke occuring in the right hemisphere?
- Left hemineglect
- Left sided sensory and motor symptoms
- Left visual field cut
Most of the mutations underlying osteopetrosis interfere with what process?
Acidification of the osteoclast resorption pit, required for the dissoluation of the Ca2+ hydroxyapatite within the matrix
What are some systemic features of RA?
- Fatigue, fever, anemia (NC-NC)
- Elevated acute phase reactants (ESR, CRP)
- Constitutional symptoms – malaise, myalgia, depression
How is diagnosis of Nitrous Oxide Toxicity made and what is the treatment?
- Diagnosis: depletion of Vit B12 w/ similar symptoms
- Tx: B12 replacement
what form does dyanavel XR come in
*liquid*
- Dysarthria (speech difficulty) + dysphagia (difficulty swallowing)+ dysphonia (poor voice quality) + chewing difficulty + drooling
- Almost always progresses to generalized disease i.e., ALS
Due to deficient osteoclast activity what is seen morphologically in the bones of osteopetrosis?
- Bones involved lack a medullary canal; instead contain primary spongiosa (which is normally removed during growth)
- Ends of long bones are bulbous (Erlenmeyer flask deformity)
- Neural foramina are small and compress exiting nerves
Which class and 2 agents are used for tx of Tardive Dyskinesia (TD) assoc. with first gen. antipsychotics?
Selective VMAT2 inhibitor’s: Valbenazine and Deutetrabenazine
Bobbing nystagmus (rapid down, slow up) indicates a lesion where?
Pons
define operant conditioning
learning is the association of things that take place sequentially
Which 2 benzodiazepines have the shortest half-lifes?
Triazolam and Midazolam
indications ketorolacwho cannot take it
short term (<5 days) management of moderately severe acute pain that requires analgesia at the opioid level- usually post-operative stateNOT indicated in peds patients, or for minor or chronic conditions
A diagnosis of panic disorder requires what?
- Panic attack followed by ≥1 month of ≥1 of the following:
- Persistent concern of additional attack
- Worrying about consequencs of attack (i.e., losing control, MI, etc.)
- Behavioral change related to attack
Describe the defect caused by the mutations in CA2 and CLCN7 associated with osteopetrosis?
- CA2: required to generate protons from CO2 and H2O –> absence prevents osteoclasts from acidifying the resporption pit and solubilizing hydroxyapatide, and also blocks the acidification of urine by renal tubular cells
- CLCN7, encodes a proton pump located on the surface of osteoclasts
What are the two genetic mutations asssociated with osteopetrosis?
CA2 and CLCN7
Age of onset for Ataxia-Telangiectasia?
Common findings?
- Disease of infancy (<4 yr. of age)
- Progressive pancerebellar degeneration involving nystagmus, dysarthria, and gait, limb and trunk ataxia
- Choreoathetosis, loss of vibration and position sense in legs, areflexia, and disorders of voluntary eye movements
Sensory for L4, L5, S1
L4: medial calf
L5: lat calf, dorsum foot
S1: postlat calf, lat foot
Pt’s with C5, 6, 7, 8, and 9 deficiency have increased susceptibility to which organism causing osteomyelitis?
Neisseria
What are the two genetic abnormalities associated with BMD?
- In-frame mutation in the dystrophin gene
- Production of abnormal or semi-functional dystrophin
Subdural hematoma etiology and features?
Crescent shaped collection on CT, presents with progressive neurologic sign, due to tearing of bridging veins underneath the dura and above arachnoid, occurs in old people due to cerebral atrophy, herniation is a lethal complication
SLOW
The initial signs of a supratentorial mass lesion are usually (global or focal)?
How do the signs progress?
Motor signs are often?
- Initial signs usually focal
- Progression of signs is rostral to caudal (i.e., herniation pushing down)
- Motor signs are often asymmetric
Which benzodiazepine has a short half-life (5-14 hr), no active metabolite, and the slowest rate of onset?
Oxazepam
what antibodies other than anti-AChR antibodies can be seen with myasthenia gravis?
MUSK and LRP-4 Antibodies
Repeated episodes of isolated vertigo without other neurological symptoms should always suggest?
A non-neurologic cause
What are some of the drug induced causes of peripheral disequilibrium?
- Alcohol!
- Antibiotics - aminoglycosides, tetracycline, vancomycin
- Diuretics
- Chemotherapeutics: cisplatin, methotrexate, vincristine
Anatomy of the NMJ:
nerve AP–> calcium entry–> ACh release–> muscle AP–> muscle contraction
What tumor is NMDA encephalitis commonly associated with?
Commonly associated with presence of teratoma
What is central transtentorial herniation and the signs/symptoms?
- Herniation into foramen magnum
- Leads to early coma, small pupils, normal EOM’s, posturing and later bilateral fixed pupils
- Respiratory arrest and death
Describe the morphological variants of osteomyelitis known as Brodie abscess and Sclerosis osteomyelitis of Garre?
- Brodie abscess: small interosseous abscess frequently involves cortex & is walled off by reactive bone
- Sclerosing osteomyelitis of Garre: in jaw and assoc. w/ extensive new bone formation that obscures much of the underlying osseous structure
Which syndromes is associated with fibrous dysplasia and what is seen in with it?
- McCune-Albright disease: unilateral bone lesions w/ café-au-lait skin pigmentations + endocrine abnormalities; esp. precocious puberty
What are the symptoms of NMDA encephalitis and over what period does it develop?
Typically presents with rapid onset (less than 3 months) of at least four of the six following major groups of symptoms:
– Abnormal (psychiatric) behavior or cognitive dysfunction
– Speech dysfunction (pressured speech, verbal reduction, mutism)
– Seizures – Movement disorder, dyskinesias, or rigidity/abnormal postures
– Decreased level of consciousness
– Autonomic dysfunction or central hypoventilation
Most important histopathologic indicator of CNS injury regardless of etiology? Characterized by what 2 things; what cell?
- Gliosis - BOTH hypertrophy and hyperplasia of astrocytes
giving magnesium salts in myasthenia gravis
should be avoided!; can replace calcium thus interfering with the NMJ
no DTR loss is seen in
L5
Transtentorial (uncinate, mesial temporal) herniation occurs when? Which specific part and of which lobe?
MEDIAL aspect of the TEMPORAL lobe is compressed against the free margin of the tentorium
in hemispheric lesions, where does the eyes deviate towards with destructive and irritative lesions
destructive: toward lesion
irritative: away from lesion
How does Diazepam differ from Alprazolam in terms of half-life, active metabolites and rate of onset?
Diazepam: long half-life (>100 hr); has active metabolite; very fast onset
- Alprazolam: short half-life (12-15); no active metabolite; fast onset
Morphology of red neurons
- Shrinkage of cell body - Pyknosis of nucleus - Dissapearance of nucleolus - Loss of nissl substance - Intense eosinophilia of the cytoplasm
What is the most comon location for debris causing Benign Positional Vertigo?
How is this diagnosed?
Direction of Nystagmus?
- Posterior semicircular canal
- Use Dix Hallpike manuever, nystagmus provoked w/ affected ear down
- Nystagmus = torsional
Between ESR and CRP, which rises and falls quicker?
CRP
Medullary infarcts are usually small and clinically silent except when they occur in the which 3 settings?
- Gaucher disease
- Dysbarism (i.e., the “bends”)
- Sickle cell anemia
Frontal gaze centers deviate eyes where?
Pontine gaze centers deviate eyes where?
- Frontal gaze centers deviate eyes to opposite side (i.e., if right area is dysfunctional, there is no drive to the left, so eyes will be looking right)
- Pontine gaze centers deviate eyes to same side
what is the dosing and patient age for the anti-hypertensives (guanfacine and clonidine)
what titration is necessary with these medications
every day dosing
pts 6+
downward dose titration over 1+ weeks do reduce risk of rebound hypertension
what form does desoxyn come in
tablet
What are the symptoms of a stroke occuring in the brainstem?
- CN findings w/ contralateral hemisensory or hemimotor sx’s
- Vertigo
what is the one *liquid* extended release amphetamine based stimulant
dyanavel XR
List 5 benzodiazepines that are short to intermediate acting?
- Alprazolam
- Temazepam
- Triazolam
- Oxazepam
- Midazolam
What is seen with a tonic-clonic seizure, how long does it last, and how does the patient feel afterwards?
- Bilateral extension followed by symmetrical jerking of extremities
- Loss of consciousness
- Lasts 1-3 mins
- Post-ictal state
What is the effect of barbituates on CYP450 enzymes?
Can induce CYP450 enzymes
What is Decorticate vs. Decerebrate posturing and where is the lesion for each?
- Decorticate = arms flexed, legs extended (hemispheric)
- DEcrebrate = all extremities Extended (brainstem)
What are the two anticholinergic agents that are coadministered with AChE inhibitors to minimize adverse cholinergic effects (bradycardia, bronchoconstriction, salivation, nausea, vomiting) at muscarinic AChRs?
Atropine
glycopyrrolate
galantamine should not be used in what patients
those with end-stage kidney dz or severe haptic impairment
what extended release methylphenidate-based stimulants used to treat ADHD come in liquid form
*quillivant XR*
How do fluctuation of sx’s differ between generalized anxiety and those of panic anxiety disorder?
Sx’s of generalized anxiety fluctuate more than those of panic anxiety
how to test proprioception in peripheral neuropathy?
romberg maneuver
What is the prototype short-acting barbituate that is used for insomnia?
Secobarbital
Which AE’s are associated with Pegloticase and how can they be managed?
- Infusion rxns i.e., fever, chills, rash, angioedema, bronchospasm, hypo- or HTN
- Need to premedicate w/ glucocorticoids and anti-histamines
When is the typical onset of Friedrich’s Ataxia and what are the common findings?
- Onset before age 20 (young persons disease)
- Gait ataxia w/ absent tendon relfexes in legs and muscle weakness
- Extensor plantar responses
- Pes cavus
- Kyphoscoliosis
sensory C7
3rd digit
What are the 3 intial steps of managing a comatose patient?
1) A: insure patent airways
2) B: insure breathing and adequate oxygenation
3) C: insure adequate circulation and control any active bleeding
*Stabilize neck, get C-spine films if trauma suspected
The effects of nondepolarizing neuromuscular blocking agents are reversed how?
Addition of an acetylcholine esterase (AChE) inhibitors
Which cell type is evident 12-24 hrs after acute CNS hypoxic/ischemic insult?
Red neurons (“red dead guys”)
Which AChE inhibitor is commonly used to reverse neuromuscular blocking drug-induced paralysis?
Neostigmine
CSF analysis via lumbar puncture will have what diagnostic findings in a patient with MS?
Presence of oligoclonal bands and/or increased IgG index/synthesis rate
Where is Spondylosis most commonly seen?
Can lead to?
Early signs?
- Cervical region
- Can lead to myelopathy (spondylotic)
- Unexplained gait impairment or imbalance often an early symptom
benefits of vaping compared to cigarettes
- less expensive
- tastes better
- less smell/stains on fingers
- less teeth staining
- sense of smell and taste improve
- social interactions increase
- less lung damage
Where does the seizure activity begin with Partial Seizures?
Activity begins on one side of the brain
DTR loss in patella vs achilles
patella = L4
achilles= S1
What does conjugate vs. dysconjugate gaze imply about the brainstem?
- Conjugate implies brainstem intact
- Dysconjugate implies brainstem lesion
Which state of altered consciousness is represented by arousal only to noxious stimuli and not enviornmental, only rudimentary awareness (i.e., purposeful motor response)?
Stupor
Which 4 structures are considered peripheral/labyrinthine for the maintenance of equilibrium?
- Utricle
- Saccule
- Semicircular canals
- Vestibular nerve
Rule of thumb for lesion location when pupils are enlarged on one side?
Parasympathetic division (usually CN III)
Which endocrine abnormality can manifest as secondary OA; which joints most often affected?
- Hyperparathyroidism
- Wrist, MCP
What are the symptoms of a stroke occuring in the cerebellum?
- Ipsilater ataxia
- Vertigo
- Nystagmus
list the extended release amphetamine based stimulants used to treat ADHD
- adderall XR
- dexedrine
- dyanavel XR
- Vyvanse
- mydayis
Which agents are co-administered with AChE inhibitors during reversal of the effects of neuromuscular blocking agents to minimize adverse cholinergic effects?
Anticholinergic agents (e.g., atropine, glycopyrrolate) are coadministered with AChE inhibitors to minimize adverse cholinergic effects (bradycardia, bronchoconstriction, salivation, nausea, vomiting) at muscarinic AChRs
What is the response of astrocytes to neuronal injury?
- Hypertrophy of the cytoplasm, accumulation of GFAP, and hyperplasia
What is the criteria for restricting type vs. binge-eating/purging ty of anorexia nervosa?
- Restricting type: 3 months of no binging or purging, but excessive exercising, fasting, dieting
- Binge/purge type: 3 months of binging and purging behaviors: self-induced vomiting, misuse of laxatives, diuretics, enemas
What is the criteria for diagnosing a major depressive episode?
- At least 5 of the following for a 2-week period with at least one either (1) depressed mood or (2) loss of interest or pleasure
- SIG E CAPS
Treatment for MuSK syndrome of myasthenia gravis
poor response to anticholinesterase meds, thymectomy
In mycobacterial osteomyelitis the organisms usually originate from where?
Blood borne, originating from a focus of active visceral disease during initial stages of primary infection; can be direct extension
weakness in shoulder abduction seen in which nerve roots
C5-C6
What are the dopamine-associated AE’s of the first gen. antipsychotics?
- Hyperprolactinemia (tuberoinfundibular pathway): amenorrhea, galactorrhea, gynecomasta, and ↓ libido
- Extrapyramidal sx’s and Tardive Dyskinesia
What is the morphology of alveolar rhabdomyosarcomas?
- Networks of fibrous septae dividing cells into clusters and aggregates; centers are dischohesive
- Resemblance to pulmonary alveoli
- Cross striations are NOT a common feature
What are the risk factors for OA?
Age >55
Female
Obesity
physical labor
genetic mutation
trauma/ joint loading
What is seen in the brains of individuals with CTE (dementia pugilistica) during a post-mortem autopsy?
- Atrophic w/ enlarged ventricles
- Accumulation of tau-containing neurofibrillary tangles
- Characteristic pattern involving superficial frontal and temporal lobe cortex
- Depigmentation of the substantia niagra
pain in prox arm is seen in what nerve root
C6
What is the most common cause of bacterial meningitis in adult, infants, and young children?
Streptococcus pneumoniae
gabapentin is a pregnancy category C
remember that
which dementia drug comes as a twice-daily capsule, a twice-daily solution, and a 24 hour transdermal patch
rivastigmine
What is seen with an Absence (petit mal) seizure, how long does it last, how does the patient feel after?
- Nonresponsive staring, rapid blinking, chewing, clonic hand motions
- Loss of consciousness
- Lasts 10-30 sec
- No post-ictal state
*Abrupt onset and abrupt end
compare mononeuropathy, mononeuropathy multiplex, and polyneuropathy
mononeuropathy: one nerve affectedmononeuropathy multiplex: several nerves affected in different areaspolyneuropathy: sx are diffuse and bilateral
why should aspirin not be used in children with chicken pox or influenza?
due to reye syndrome
In children the periosteum is loosely attached to the cortex, so what is often seen in the acute phase of osteomyelitis?
Sizable subperiosteal abscesses may form, which dissect for long distances along the bony surface
What is the treatment and 5-year survival with Ewing Sarcomas?
- Tx w/ neoadjuvant chemotherapy followed by surgical excision with or without radiation
- 5-year survival of 75% and long-term cure in 50%
pain in scapula and shoulder is seen in what nerve roots
C5-C8
list the other biphosphonates (other than alendronate) and how they are administered
- risedronate (PO)
- ibandronate (PO, IV)
- tiludronate (PO)
- zolendronic acid (IV)
How do you treat DMD?
Steroids
What will examination of someone with Spondylotic Myelopathy show?
- Spastic tone in legs
- Increase knee/ankle jerks
- Babinski signs
- Variable sensory deficits
What must be known when making the call of brain death?
Cause of the coma should be known, it MUST be adequate to explain the clinical picture, and it MUST be irreversible
Age of onset for Ataxia-Telangiectasia?
Common findings?
- Disease of infancy (<4 yr. of age)
- Progressive pancerebellar degeneration involving nystagmus, dysarthria, and gait, limb and trunk ataxia
- Choreoathetosis, loss of vibration and position sense in legs, areflexia, and disorders of voluntary eye movements
the ring finger dermatome map is divided in:
C7 and C8 (ulnar side)
What is the MOA of Disulfiram?
- Irreversibly inhibits aldehyde dehydrogenase leading to buildup of aldehyde
- Causing extreme discomfort in pt’s who drink alcoholic beverages: flushing, throbing HA, N/V, sweating, hypotension, and confusion
RA labs (RF, Anti ccp, Acute phase reactants)? Which is each indicative of?
RF – 70% with RA. (specificity is limited because other diseases are associated with RF)
Anti CCP – antibodies in 70% with RA but has a specificity of 95% - more predictive for erosive disease
Acute phase reactants – ESR, CRP 75% elevated in RA. Use to monitor treatment response
indications for rivastigmine
1) mild to moderate dementia of Alzheimer’s type
2) mild to moderate dementia associated w/ Parkinson’s dz
Treatment for Meniere’s Disease?
- Sodium restriction
- Diuretics: thiazdies, furosemide
- Sugery: endolymphatic sac decompression
MOA clonidine
alpha 2 adrenergic agonistblocks transmission of pain signals from periphery to brain
Where do entecapone and tolcapone act in the nervous system?
- Tolcapone is central and peripheral acting; entacapone is peripheral acting only
cholinesterase inhibitors should be prescribed with caution when the patient is already taking what other drugs
drugs that induce bradycardia or alter AV nodal conduction
- beta blockers
- calcium channel blockers
- lacosamide
What is the characteristic signs of someone with diffuse/metabolic injury of the nervous system (i.e., motor signs, consciousness, breathing, and presentation)?
- Confusion and stupor commonly precede motor signs
- Motor signs usually symmetrical
- Pupillary rxns usually preserved
- Asterixis, myoclonus, tremor, seizures common
- Acid-base imbalance with hyper or hypoventilation
- Fluctuating level of consciousness
What is the ASO titer?
Evidence of a preceding group A streptococcal infection
Acute rheumatic factor (ARF) resulting from autoimmune reaction to infection of strep A
May cause post-streptococcal reactive arthritis; affects small joints (symmetric)
pain seen in medial forearm is seen in which nerve root
C8
Myasthenia Gravis: presyn, synaptic, or postsyn?
Postsynaptic
Simple partial seizure is characterized by what?
focal motor or sensory activity
no LOC
lasting only seconds and no post-ictal state
What are some of the cardiac complications associated with Anorexia Nervosa?
Bradycardia, HYPOtension, QT dispersion, Cardiac atrophy, and Mitral Valve Prolapse
how does Sarin and VX (nerve gases) work? outcomes?
inhibit AChE at NMJ to cause end organ overstimulation (cholinergic crisis)
onset within mins - hrs (vapor or liquid)
death by resp failure):
What is the most important aspect of the evaluation for a patient being seen regularly for bulimia and anorexia nervosa?
*Discuss suicidality
MC identifiable cause of neuropathy in US is? nerves affected?
Diabetes Mellitus
CN 3 and 6 mostly
also has Bells palsy commonly
list the non-stimulant
atomoxetine/strattera ER
LGI1 Encephalitis most commonly affects who?
Occurs more commonly in men (2:1)
What kind of seizures is LGI1 Encephalitis associated with? Do they respond to antiepileptic drugs?
Typically involves faciobrachial dystonic seizures
– These are brief seizures involving one side of the face and the arm on the same side, often occurring frequently, sometimes hundreds of times per day.
– These seizures often do not respond to antiepileptic drugs alone and may require immunotherapy to abate.
Which anti-psychotic is indicated for tx of recurrent suicidal behavior?
Clozapine
define negative reinforcement and give an example
removing something to increase a behavior
ex: kid doing the dishes to stop his mom’s nagging
ex: taking away plastic sheets to increase nights w/o bed-wetting
What do overdose effects of ethanol look like?
Slurred speech, drunken behavior, dilated pupils, weak and rapid pulse, clammy skin, shallow respiration, coma, death
which dementia drugs comes as a twice-daily tablet or solution and an extended-release once-daily capsule
galantamine
what extended release methylphenidate-based stimulants used to treat ADHD come in tablet form
concerta
- contempla XR-ODT
Plain radiographs of Ewing Sarcoma will show what; what is characteristic of the periosteal rxn of these tumors?
- Destructive lytic tumor w/ permeative margins that extends into surrounding soft tissues
- Produces layers of reactive bone deposited in an ONION SKIN like fashion
What are the most common soft tissue sarcomas of childhood and adolescence?
Embryonal and alveolar type of rhabdomyosarcoma
Tx for sarin and vx (nerve gases)
decontamination (remove clothes, clean skin w/ water and sodium hypochlorite)
resp support
atropine
benzos for seizures
How is rasburicase different from pegloticase?
nonpegylated recombinant uricase for prevention of acute uric acid nephropathy due to tumor lysis syndrome in patient with high-risk lymphoma or leukemia
What is the inheritance pattern of the mild form of osteopetrosis and what are the clinical features?
- Autosomal dominant
- Dx in adolescence or adulthood –> repeated fractures
- Mild CN defecits and anemia
Rule of thumb for lesion location when pupils are enlarged bilaterally?
Bilateral CN III lesion, post-ictal, or intoxications
Why do absent or unequal pupillary responses imply a brainstem lesion?
Nuclei/tracts controlling pupils are anatomically adjacent to ARAS
Guillan-Barre:
ascending motor paralysis; symmetric
no/minimal sensory symptoms/signs
What is the criteria for Cyclothymic disorder?
- Characterized as dysthymic disorder (milder depression) w/ intermittent hypomanic episodes
- ≥2 years (adults) and 1 year (children) experiencing repeated episodes of hypomania and depression (not severe enough to meet criteria for major depressive episode)
LEMS is often associated with
Small cell lung cancer
HIV neuropathy is in what patients with what CD4 counts?
30-50% AIDS pts (CD4<200)
What is the MOA of the first gen. anti-psychotics?
Block dopamine (D2) post-synaptic receptors
Which opioid receptor antagonist can be used in the acute setting of an OD?
Naloxone
CRP monitors what?
Assesment of disease activity and proinfammatory cytokine release
bupropion
What do imaging studies of OA show?
- Asymmetric joint – space narrowing
- Subchondral sclerosis – thickening
- Osteophytes and marginal lipping
- Bone cysts
- Joint mice (loose particles)
EMG findings of LEMS:
low amplitude motor responses that facilitate (increase) after brief period of exercise; incremental response on fast repetitive stimulation
What parts of the brain involved with generalized seiures?
Both sides of the brain
what part of the brain is affected if the patient has central neurogenic hyperventilation
midbrain
Peroneal mononeuropathy at fibular head, results of nerve conduction studies:
@ankle and below knee = normal but ABOVE knee get significantly abnormal nerve conduction (decreased amplitude and conduct velocity
What are the two forms of autoimmune encephalitis?
NMDA Encephalitis
LGI1 Encephalitis
In acquired syphillis (T. Pallidum and T. pertenue) when do the bone lesions typically present and how?
- May begin in early tertiary stage, 2-5 years after initial diagnosis
- Saddle nose, palate and extremities (esp. long tubular bones like tibia)
Treatment of botulism
ICU monitoring w/ resp support and general medical care
(ventilation, feeding tube; wait till toxin leaves!)
define negative punishment and give an example
removing something to decrease a behavior
ex: taking away someone’s freedom and putting them in jail to decrease criminal behavior
Simple partial seizure
pt is aware (conscious)
Progressive Bulbar Palsy is due to selective involvement of what?
Motor nuclei of the lower CN’s
Which test can be done to clinically document someone as being brain dead?
- Apnea test
- Disconnect ventilator –> Catheter w/ 100% O2 and observe chest wall and abdomen for movement
- No respiratory movements for 8 mins (PCO2 >60mmHg
Earlier the onset of bulbar symptoms in ALS, the (Longer or shorter) the course of the disease?
Shorter
Why is it important to ask about family hx of mood disorders?
50% of pt’s with bipolar disorder have a 1st-degree relative with a mood disorder
what extra measures does the rivastigmine patch require once prescribed
dose adjustments for hepatic impairment and low body weight
What symptoms would result from Subfalcine herniation with compression of the ACA?
Contralateral lower extremity weakness
Which level of the pons is assessed with the Oculocephalic manuever (Doll’s Eyes) vs. Caloric (oculovestibular) reflex test?
- Oculocephalic = mid pons; assess CN III, IV, and VI
- Caloric = lower pons
what form does adderall XR come in
capsule
sensory C5 location
lateral arm
How do you tx depression that is tx resistant?
Electroconvulsive Therapy (ECT)
What 2 congenital conditions cause ventricular system obstruction?
1) Acqueductal stenosis 2) Dandy-Walker malformation
Dysthymic disorder can be more difficult to tx what are some options?
CBT + Pharm: SSRIs, SNRIs, MAOIs
Apomorphine uses
Injected subcutaneously for quick, temporary relief of off-periods of akinesia in patients on dopaminergic therapy (clinical benefits within 10 minutes)
What are some of the common AE’s associated with the second gen. antipsychotics?
Weight gain and Metabolic Sydrome: hyperglycemia/insulin resistance, hyperlipidemia
MOA memantine
- *antagonist of NMDA type glutamate receptor**
- binds to the intra-pore magnesium site, blocking the NMDA receptor from being activated
(glutamate may contribute to pathogenesis of Alzheimer’s dz)
What is pseduogout? And where does it deposit? And what does Xray show?
Calcium pyrophosphate deposition (Pseudogout)
– Hands/knees
– X-rays show cartilage calcification (chondrocalcinosis)
sensory C8
4th + 5th digit
weakness in elbow flexion seen in:
C6
sensory symptoms of peripheral nerve dz have pain/burning sensations..these are secondary to what?
small unmyelinated fiber dz (w/ dysesthesia, hyperalgesia, hyperpathia)
Why is the cortex not typically affected in medullary infarcts (osteonecrosis)?
Due to its collateral blood flow
if a pt has myasthenic crisis, what should you do?
stop anticholinesterase meds and use PLEX, IVIg
In practice, will oftens see elements of which type of edema(s)? What morphological characteristics of the brain will be seen and this can lead to?
- Both vasogenic and cytotoxic edema - Gyri flattened, sulci narrowed, and ventricles compressed —> Herniation!
define positive reinforcement and give an example
adding something to increase a behavior
ex: giving candy to a kid so they keep cleaning their room
What is the MOA of Naltrexone?
- µ-opioid receptor antagonist (long-acting)
- ↓ craving for alcohol and the rate of relapse to either drinking alcohol dependence for the short-term (12 weeks)
elbow, wrist, and finger EXTENSION weakness in:
C7
How can non-adherence to antipsychotic meds be managed; which 6 agents can be used? *test Q*
- Manage w/ Long-Acting Injectable Agents (LAIA’s)
- Haloperidol decanoate
- Fluphenazine decanoate
- Risperidone + Olanzapine + Aripiprazole + Paliperidone (ROAP)
What type of signs/sx’s seen with ALS?
- Mixed upper (spasticity, hyperreflexia, Babinski sign)
and
- LMN (atrophy, fasciculations) signs
list the immediate release amphetamine based stimulants used to treat ADHD
Criteria for SLE as an FYI
- Malar rash – Erythema, malar eminence spare nasolabial folds (butterfly rash)
- Discoid rash – Erythematous patches • Photosensitivity – Rash due to sunlight
- Oral ulcers – May include nasopharyngeal ulcers; usually painless • Arthritis – 2 or more peripheral joints, tender, swelling/effusion; non erosive arthritis • Serositis – Pleuritis, rub or plerual effusion or pericarditis, ECG changes, rub or pericardia effusion
What is Cytotoxic edema and when is it seen?
- Increase in INTRAcellular fluid secondary to neuronal, glial, or endothelial cell membrane injury - Generalized hypoxic/ischemic insult or w/ metabolic derangment
Secondarily generalized seizure
symptoms that are initially associated with a preservation of consciousness that then evolves into a loss of consciousness and convulsions
common sites of radial mononeuropathy
axilla-crutch palsy
humerus/spiral groove- saturday night palsy (MC)
supinator (posterior interosseous branch)
wrist (superficial radial sensory branch)
How is the Phase II desensitizing block by Succinylcholine reversed?
Acetylcholinesterase inhibitors
Diagnosis of major depressive disorder requires what?
Presence of one or more major depressive episodes and the absence of any manic, hypomanic, or mixed episodes
Which imaging modalty is the best for bony abnormalities (trabecular, cortical bone), erosions, fractures, degenerative or inflammatory arthritis?
CT
What is the classic triad of clinical findings exhibited by patients with normal pressure hydrocephalus?
- “Wet, wacky, and wobbly” - Often exhibit a magnetic gait - Dementia-like sx’s; impaired recognition (often not severe) - Urinary incontinence; appears late in illness and is generally of the spastic hyperreflexic, increased-urgency type
How does Ewing Sarcoma typically present?
- Painful enlargin mass; frequently tender, warm, and swollen
- Some have systemic findings that mimic infection –> including fever, ↑ ESR, anemia, and leukocytosis!
what impairment seen with large myelinated sensory fibers in peripheral nerve disease?
light touch (cotton swab) two point discrimination vibration (128 hz tuning fork) joint position sense
which dementia drug comes as a once-daily tablet and a once-daily disintegrating sublingual tablet
donezapil
Extensive ischemic damage of both white and gray matter leading to large cystic lesions during the perinatal period is known as?
Risk factor for developing?
- Multicystic encephalopathy
- Cerebral Palsy
list the sustained release methylphenidate-based stimulants used to treat ADHD
- ritalin SR
- desoxyn
what part of the brain is affected if the patient has ataxic respirations
medullary respiratory centers
Osteopetrosis is also known as what?
Marble bone disease and Albers-Schonberg disease
Typical presenting sx’s of (progressive) spinal muscular atrophy?
- Often begins with symmetric upper extremity involvement
- Weakness + atrophy + respiratory difficulty
In terms of clinically isolated syndrome (CIS) what is a monofocal episode as a differential diagnosis for MS?
Person experiences a single neurologic sign or symptom that’s causes by a single lesion (i.e., optic neuritis in one eye)
The homogenous pattern of ANA is indicative of what antibody?
Histone antibody >95% drug induced lupus
Consciousness depends on arousal of the cerebral cortex by the ____________
Brainstem Ascending Reticular Activating System (ARAS)
pain in ant lat thigh, knee, and medial calf seen in:
L4
What does the presence of Homer-Wright rosettes in Ewing Sarcomas indicate?
A greater degree of neuroectodermal differentiation
(PTEN)
Anti-DS DNA antibody is seen in 50% of what? How is ANA?
SLE
ANA sucks and even normal patients can have it elevated
what form does dexedrine come in
capsule
XR amphetemine
incidence of Myasthenia gravis happens in who?
younger women and older men; most sporadic
When is Mycobacterial osteomyelitis detected?
What are the clinical symptoms of it?
Could go years undetected
Sx: Low grade fever, localized pain, chills, and weight loss
Which markers, if positive, have a 99.5% specificity for RA?
Anti-CCP + RF (+)
Charcot-Marie-Tooth neuropathy type 1A main info:
MC- demyelinating
AD
chromsoome 17
pes cavus
distal symmetric atrophy (Legs>arms)
onset 1st and 2nd decade
EMG: slowing of motor nerve conduction velocities (demyelination)
How many signs/sx’s must be present for diagnosis of a panic attack and how long do they last?
- Discrete period of intense fear or discomfort, in which ≥4 of the following developed abruptly: Palpitations, sweating, trembling, sensation of SOB, chest pain, dizziness, fear of losing control/dying, parasthesias, chills or hot flashes
- Reach peak within 10 mins and usually last <25 mins
Unexplained fever vs. localized pain are more common findings of osteomyelitis in which age group (adults or children)?
- Unexplained fever = children
- Localized pain = adults
what extended release methylphenidate-based stimulants used to treat ADHD come in capsule form
- aptensio XR
- focalin XR
- metadate CD
- ritalin LA
What are the AE’s associated with bisphosphonates?
- Esophagitis: minimized by taking meds with 8oz of water
- Osteonecrosis of the jaw
- Atypical femur fractures
pain in dorsal thigh, lat calf seen in
L5
What is the clinical indication for using Pegloticase?
Tx of chronic gout in those refractory to conventional therapy
What are the essential elements of the neurological examination for a patient with stupor?
- Pupillary responses
- Corneal reflex
- Extaocular movements
- Cough/gag reflex
- Motor responses
- Respiratory pattern
*Start at highest CN and work your way down
What are two frequent pathogens for osteomyeltits?
H influenzae, group B strep (agalactiae)
What is the difference between a tonic and a clonic seizure?
- Tonic = Muscle stiffness, rigidity (think increased tone)
- Clonic = Repetitive, jerking movements
What is the prognosis of patients with NMDA encephalitis?
Although these patients can present with severe deficits, many will improve with aggressive treatment, though improvement may take a long time (e.g. 1 year)
what presents with a stocking/glove sensory loss?
polyneuropathy (diffuse symmetrical usually)
What is the characteristic appearance of old traumatic lesions on the surface of the brain?
Where is the morphology most commonly seen?
- Depressed, retracted, yellowish-brown patches involving the crest of the gyri (plaque jaune)
- Most commonly located at the sites of countercoup injuries
How does Vestibular Neuronitis differ from BPV?
- Spontaneous attack of vertigo, typically lasting up to 2 weeks (findings similar to BPV)
- But is NOT typically positonal
When CIS patients have multiple demyelinating lesions on MRI, they have a __________% chance of developing MS within several years
60-80%
*High risk
Epsidural hematoma etiology and features?
Lens shaped
RAPIDLY DEVELOPING
Middle meningeal artery (arteries)
Pathway of ethanol metabolism?
Ethanol -> Alcohol dehydrogenase -> Acetylaldehyde -> Aldehyde dehydrogenase -> Acetic acid
describe how nicotine can affect the adolescent brain
nicotine interferes with the maturity of the prefrontal cortex –> affects its neuroplasticity –> leads to alterations in:
- gene expression
- cell structure
- intracellular signaling
- synaptic pruning
- axon myelination
*- memory and attention
What type of syndrome can be caused by Vitamine E deficiency?
Spinocerebellar similiar to Friedrich’s
which is
- Gait ataxia w/ absent tendon relfexes in legs and muscle weakness
- Extensor plantar responses
- Pes cavus
- Kyphoscoliosis
A subfalcine herniation may lead to compression of the ________ artery leading to infarction
Anterior Cerebral artery (ACA)
What is the tx for PTSD?
- SSRIs and Venlafaxine
- CBT
Which deficits predominate in (progressive) spinal muscular atrophy; mean age of onset?
- Mean age = 64 y/o
- LMN ( focal weakness, muscle atrophy, decreased muscle stretch reflexes and tone) deficits predominate due to degeneration of anterior horn cell
- NO upper motor neuron involvement
What is the prototype ultra-short acting barbituate used in anesthesia?
Thiopental
Convergence nystagmus or Retractory nystagmus indicates a lesions where?
Mesencephalon
Herniation is displacement of brain tissue due to _____ or ______
Mass effect or Increased intracranial pressure
What age does Oculocutaneous telangiectasia usually appear?
Common findings?
- Usually appears in teen years
- Immunological impairment (decreased IgA and IgE) usually evident later on and manifested by recurrent sinopulmonary infections
- Changes of skin and hair, hypogonadism, and insulin resistance
an autoimmune attack against what occurs in lambert-eaton myasthenic syndrome (LEMS)?
voltage-gated calcium channels
describe classical conditioning to treat phobias
relaxation activity (CS) + object of phobia (UCS) –> relaxation (UCR)
object of phobia (CS) –> relaxation (CR)
What is the location of the lesion if the eyes have a ping-pong nystagmus?
Bihemispheric, midbrain
MOA sumatriptan
5-HT agonist
What lab value will be extremely elevated for DMD?
CK
in the caloric test, what happens with cold and hot bilateral irrigation
cold: the eyes deviate downward
hot: eyes deviate upward
What must be ruled out before making the call that someone is brain dead?
- Sedative intoxication
- Hypothermia (<90F)
- Neuromuscular blockage
- Shock
*All can mimic brain death*
What is the inheritance pattern of the severe infantile form of osteopetrosis and what are the clinical features?
- Autosomal recessive
- Usually evident in utero or soon after birth
- Fracture, anemia, and hydrocephaly –> post-partum mortality
- Those who survive have CN defects: optic atrophy, deafness, and facial paralysis
What is the prognosis of (progressive) spinal muscular atrophy?
Survival rate ≥15 years (better w/ earlier age of onset)
Where do alveolar rhabomyosarcomas arise?
Where do embryonal rhabomyosarcomas arise?
Both arise in kids and usually found growing in siuses, head and neck, and GU tract (especially vaginas)
Grape like appearance*
DTR loss in triceps seen in
C7
What are the (3) Cholinesterase inhibitors antagonize nondepolarizing blockade by increasing amount of ACh at NMJ?
Neostigmine
pyridostigmine
edrophonium
list the anti-hypertensives for attention
- clonidine/kapvay ER
- guanfacine/intuniv ER
how does stupor and coma affect the oculocephalic maneuver
moving head side to side: eyes move with head turn
moving head up and down: eyes move with head movement
What is an important prognostic finding associated with tx of Ewing Sarcoma?
Amount of chemotherapy-induced necrosis
Formulation of amphetemines:
Adzenys XR-ODT
3:1 ratio of d-amphetamine & L amphetamine isomers
what extended release methylphenidate-based stimulants used to treat ADHD come in chewable tablet form
*quillichew*
What is a tonsillar herniation and why is it life threatening?
- Displacement of the cerebellar tonsils through the foramen magnum
- Can can brainstem compression and compromises vital respiratory and cardiac centers in the medulla
How are the OA affected joints characterized? How’s the ROM?
The finding most consistent with the diagnosis of osteoarthritis is a cool joint effusion
The effusion is typically not warm to touch or shows erythema over the site
Diffuse MCP involvement or thoracic spine pain are not typical features of OA.
Normal range of motion is not a likely finding in OA.
What is Rheumatoid arthritis?
Autoimmune, chronic systemic
- Inflammatory disease, symmetrical
- Targets synovial tissues, diarthrodial joints
- Polyarthritis, extra-articular features
- Idiopathic
Complex partial
pt loses consciousness
What are the symptoms of a stroke occuring in the left hemisphere?
- Aphasia (Loss of ability to understand/express speech)
- Right sided sensory and motor symptoms
- Right visual field cut
define the unconditioned stimulus and response and the conditioned stimulus and response in the pavlov’s dog example
UCS: meat powder
UCR: salivation
CS: bell ringing
CR: salivation
*unconditioned response and conditioned response are always the same*
How many episodes and for what duration must they occur for diagnosis of Binge Eating Disorder?
Occur on average 1x/week for ≥3 months
What is the inhertance pattern for DMD?
X linked recessive
In which type of RA will rheumatoid factor (RF) be present 100% of the time? How about early/regular RA?
“Nodular” RA is 100%
70% patients with regular RA
Fibrous dysplasia is due to mutations in what?
Gain of function somatic mutation GNAS1
other tests can perform on myasthenia gravis
tensilon test - ptosis typically disappears after injection (not for long); atropine = antidote to side effects (bradycardia)
ice bag test - apply to ptotic lids for 2 mins and can see 2 mm improvement (+)
Describe the Gower maneuver and discuss its clinical significance
Clinically, it is a sign of severe proximal muscle weakness
First legs have to be pulled up under the body and the weight shifts to hands and feet
The hips are then thrust into the aire as the knees are straightened and the hands are brought close to the legs
They extend their trunk by the hands and get up
What occurs if cholinesterase inhibitors are given during the phase I depolarizing block of Succinylcholine?
Potentiate the block; not reversal
How and when does skeletal syphillis (T. Pallidum and T. Pertenue) present when congenital?
- Appear about 5th month gestation and fully developed at birth
- Saber shin: massive reactive periosteal bone deposition on medial and anterior surfaces of the tibia
Regardless of etiology, medullary infarcts (osteonecrosis) are geographic and involve which parts of bone?
Trabecular bone & marrow
what form does atomoxetine/strattera ER come in
capsule
Bisphsphonates are structural analogs of what; what is their MOA?
- Structural analogs of pyrophosphate, normal component of bone
- Incorporated into bone, then inhibit bone resorption by ↓↓ both the number and activity of osteoclasts
Perinatal ischemic lesions of the cerebral cortex leading to thinned-out, gliotic gyri is known as?
Ulegyria
Sellegeline uses
- slows the breakdown of dopamine and prolongs the antiparkinsonian effects of levodopa; may reduce mild on-off or wearing-off phenomena; adjunctive therapy in patients with declining or fluctuating response to levodopa
A disorder of the brain and spinal cord characterized by a tendency for periods of increasing and decreasing symptoms and signs (exacerbation and remissions), which result from loss of myelin at multiple sites in the CNS, defines what?
MS
What is diffuse vs. focal mass effect that is associated with herniation?
- Diffuse: generalzied brain edema - Focal: tumors, abscesses, or hemorrhages
what is the oculocephalic maneuver?
doll’s eye
- passive horizontal head rotation –> eyes move horizontally opposite
- passive vertical head rotation –> eyes move vertically opposite
What is a big difference about patients perceptions of their actions with OCPD vs. OCD?
- OCPD: pt does NOT perceive they have a problem
- OCD: they know their compulsions and obsessions are not reasonable (most of the time)
Stress incontinence antidepressant
duloxetine
Ewing sarcoma is most often seen in which age group and has a predilection for which ethnicity?
- 80% arise in pt’s <20 y/o with slightly more males affected
- Striking predilection for whites, while blacks/asians rarely affected
What is a secondary generalized (partial onset) seizure (symptoms, consciousness, timeline, post-ictal)?
- Starts on one side of brain and then progresses to bilateral tonic-clonic activity
- Loss of consciousness
- Lasts 1-3 mins
- Post-ictal state
What is the Erosive subtype of OA; seen most often in whom?
- Affects DIP and PIP joints; more painful than typical hand OA
- More common in women
sensory nerve action potentials in plexopathy vs. radiculopathy
plexopathy = abnormal radiculopathy = normal
Which 2 second-gen antipsychotics have the least amount of AE’s with it?
Aripiprazole and Ziprasidone
Which 4 drugs can be used in the tx of acute alcohol withdrawal syndrome?
Diazepam
Lorazepam
Oxazepam
Thiamine
what form does methylin come in
*liquid*
What is the only second-gen anti-psychotic that is assoc. with hyperprolactinemia (like the first-gen’s)?
Risperidone
Guillan barre treatment
plasmapharesis, IVIG
what form does Zenzidi (dextroamphetamine) come in?
Tablet
IR Amphetamine
What is seen commonly with epiphyseal infection (osteomyelitis) in infants?
Spread thru the articular surface or along capsular and tendoligamentous insertions into joints —> septic or suppurative arthritis
MOA aspirin
irreversible Inhibition of COX
Etiologies of Presyncope?
What can make it worse?
- Arrythmia, hypotension, vasovagal excess, pulmonary emboli, drugs
- Aggravated by: increased temperature, prolonged standng, large meals, and deconditioning
What are the two genetic abnormalities that lead to DMD? And what is the pathogenesis behind this?
1) Frameshift mutation in the dystrophin gene
2) Dystrophin is absent or totally non functional
Dystrophin occurs nearly everywhere in the body, without it muscle membrane tears, necrosis occurs, fibrosis develops, etc
XR-ODT %eges
50% IR & 50% XR
Which benzodiazepine has the fastest rate of onset?
Diazepam
What are the OA bone characteristics?
Altered chondrocyte function
Loss/thinning of cartilage
Subchondral bone thickening (sclerosis)
Remodeling of bone
Marginal spurs (osteophytes)
Cystic changes to subchondral bone
Mild reactive synovitis
What joints are affected in OA? And how is the pain characterized?
OA usually affects weight bearing joints and frequently used joints; hips, knees, spine, hands (DIP, PIP, 1st CMC – thumb base)
Pain worse with activity; alleviated with rest
• Morning stiffness (about 30 minutes)
What is the most effective tx for depression and is often used in tx resistant cases?
Electroconvulsive Therapy (ECT)
What is the seen in the acute phase of osteomyelitis?
Bacteria proliferate and induce neutrophilic inflammatory rxn; necrosis of bone cells and marrow ensues within first 48 hours
Prognosis of ALS?
- Relentlessly progressive disease without remissions, relapses, or stable plateaus.
- Death from respiratory failure, pneumonia (aspiration), pulmonary embolus.
- Mean duration of symptoms 4 years (27-43 months).
- Death within 2 to 5 years.
Anticentromere antibody is for what?
Scleroderma CREST
Calcinosis, raynauds, esophageal dysmotility, sclerodactyly, and telangiectasia
what is the rule of thumb for anisocaria?
if it’s the large pupil –> should fail to constrict to light
if it’s the small pupil –> should fail to dilate in the dark
PNS signs
LMN: flaccid one, atrophic, sometimes fasciculations, hypoactive DTRs, no plantar reflex; hands and feet sensory loss
what form does ritalin come in
tablet
in brainstem lesions, were does the eye deviate towards with destructive lesions
away from the lesion
Enlargement of the entire ventricular system (“symmetric dilation”) due to accumulation of CSF not being properly absorbed at the dural sinus level is known as?
Communicating (“non-obstructive”) hydrocephalus
sensory symptoms of peripheral nerve dz have paresthesias…these are secondary to what?
large myelinated fiber dz (pins and needles)
What are the characteristics of Meniere’s Disease and who is most often affected?
Hallmarks?
- Recurrent episodes of spontaneous vertigo, lasting minutes to hours
- Low frequency hearing loss = Hallmark
- Tinnitus and aural fullness
- Woman are 3x more affected
Which predisposing factor incrases the risk for severe RA?
Genetic factors: HLA-DRB4/ DRB 0401/4
if you have a paraneoplastic etiology of peripheral neuropathy it is most likley
pure sensory neuropathy (dorsal ganglionopathy)
What is the prototype long-acting barbituate that is used for seizures?
Phenobarbital
Treatment for Benign Postional Vertigo?
- Often resolves on its own within a few weeks
- Positional exercises helpful: Sermont manuever
- Meds such as: vestibular suppressants, antiemetics, and anxiolytics
what form does Evekeo (amphetamine sulfate) come in?
capsule
(IR Amphetamine)
Most cases of osteonecrosis (avascular necrosis) are due to what 2 etiologies?
- Fractures or corticosteroid tx
- May also be seen w/ bisphosphonate tx (especially jaw!)
Impaired consciousness means involvement of what 3 things?
- Diffuse or bilateral impairment of both cerebral hemispheres, or
- Failure of brainstem ARAS, or
- BOTH
describe how behavioral therapy for phobias work
pairing relaxation with a feared stimulus to induce calming
feared stimulus + relaxation –> decreased anxiety
feared stimulus –> relaxation
Synovial inflammation with hypertrophy and effusion is seen with what?
Osteoarthritis
define positive punishment and give an example
adding something to decrease a behavior
ex: child kneels on rice to decrease lying
Rule of thumb for lesion location when pupils are constricted?
Sympathetic division (hypothalamus, carotid)
What can mimic infectious encephalitis and what is the time line like for that entity?
Autoimmune encephalitis should be considered in patients with rapidly progressive (usually < 6weeks) encephalopathy or psychiatric disturbance, especially if seizures also present. Fever may or may not be present. Some of these entities have overlap with paraneoplastic syndromes and may be associated with tumors.
What labratory studies will be abnormal in NMDA encephalitis?
At least one of the following laboratory study results:
– Abnormal EEG (focal or diffuse slow or disorganized activity, epileptic activity, or extreme delta brush)
– CSF with pleocytosis or oligoclonal bands and/or NMDA receptor antibodies
What is the tx for normal grief (bereavement)?
Grief counseling; do NOT give them antidepressants
onset of activity, what patients, and schedule for non-stimulants
onset: 1-4 weeks
patients: those intolerant of stimulant effects or those resistant to using stimulants
- schedule: non-scheduled, refills and samples allowed up to 1 year
What are the 5 first-gen. aka typical/conventional antipsychotics?
- Chlorpromazine (low-potency)
- Fluphenazine (high-potency)
- Thioridazine (low-potency)
- Haloperidol (high-potency)
- Thiothixene (high-potency)
Which intracranial location is most susceptible to a direct parenchymal injury which results from trauma to the head?
Crests of the gyri = greatest amt. of force
list the immediate release methylphenidate-based stimulants used to treat ADHD
- focalin
- methylin
- ritalin
Subfalcine herniation involves displacement of the _______ under the _______
Cingulate gyrus under the falx cerebri
What are the 3 high-potency first gen. antipsychotic agents and what AE’s are they more associated with?
- Fluphenazine + Haloperidol + Thiothixene
- More movement (EPS) and endocrine effects (prolactin)
what extended release methylphenidate-based stimulants used to treat ADHD come in transdermal patch form
*daytrana*
What is seen in the chronic phase (after first week) of osteomyelitis; what does the term involucrum refer to?
- Chronic inflammatory cells release cytokines that stimulate osteoclastic resorption, ingrowth of fibrous tissue and deposition of reactive bone at the periphery
- Newly deposited bone can form a shell of living tissue, known as involucum, around the segment of devitalized infected bone
Secondary injury associated seen in subarachnoid hemorrhage is often associated with what?
Etiology?
Vasospasm
Arterial venous malformaiton/aneurysms
What are the criteria for a hypomanic episode?
- Similar to a manic episode but is less severe
- Episodes last ≥4 consecutive days and no psychotic features
Which deficits prevail in Primary Lateral Sclerosis; what are the signs/sx’s?
- Upper motor neuron (corticospinal) deficits prevail
- Weakness, spasticity, hyperreflexia, Babinski signs
Babinski: when the big toe bends up and back to the top of the foot and the other toes fan out
What is the histo like for mycobacterial osteomyelitis?
Caseous necrosis and granulomas
Which first gen. antipsychotic is associated with more prolactin elevation, sedation, anticholinergic effects, orthostatic hypotension and a dose-dependent retinitis pigmentosa?
Thioridazine
Which state of altered consciousness is represented by disorientation, stimuli misinterpretation, and hallucinations (visual)?
Delirium
A sense of impending loss of unconsciousness often associated with pallor, sweating, visual dimming or constricted fields, is known as?
Presyncope
What are the 3 P’s associated with pinpoint pupils?
1) Pontine lesion
2) oPiates
3) Pilocarpine
Which underlying GI disease can lead to secondary OA; which joints most often affected?
- Hemochromatosis
- 2nd/3rd MCP joints and wrist
EMG findings of Myasthenia gravis
decremental response on repetitive stimulation; increased “jitter” on single fiber EMG
diagnostic criteria for bulimia nervosa
- recurrent episodes of binge eating
- recurrent inappropriate compensatory behavior to prevent weight gain
- events at least 2x/week for three months
What are the criteria for persistence of brain death?
- 6 hours w/ confirmatory (flat) EEG: performed to tech. standards of AEES
- 12 hours w/o a confirmatory isoelectric EEG
- 24 hours for anoxic brain injury w/o confirmatory isoelectric EEG
tolcapone and entacapone MOA
- COMT metabolizes levodopa to 3-O-methyldopa, which competes with levodopa for transport across the intestinal mucosa and the blood-brain barrier
- COMT inhibitors (tolcapone and entacapone) prolong the activity of levodopa by inhibiting its peripheral metabolism, which decreases clearance and increases bioavailability
What is osteonecrosis?
What part of the bone does it involve?
Infection of the bone and marrow
Medullary cavity or involves the medulla and the cortex
What is seen with an Atonic seizure, duration, and how does patient feel after?
- Sudden loss of muscle tone –> head drops or patient collapses
- Loss of consciousness
- Variable duration
- Post-ictal state
Apomorphine MOA
dopamine agonist at dopamine D2 receptors
The syndrome associated with Copper deficiency can present very similar to what?
B12 deficiency
giving predisnone for myasth. gravis
is a treatment but make sure to give high initial dose ; can exacerbate
What are the 2 low-potency first gen. antipsychotic agents and what AE’s are they more associated with?
- Chlorpromazine and Thioridazine
- More sedation, hypotension, and ↓ seizure-threshold
what nerves are tested in the corneal test
5 and 7
Pathway of methanol metabolism?
Methanol -> Alcohol dehydrogenase -> Formaldehyde -> Aldehyde dehydrogenase -> formic acid
What are some of the rare AE’s associated with the first and second gen. antipsychotics?
- QTc prolongation and negative inotropic effects –> ↑ risk for women, elderly and those on anti-arrhythmics
- Seizures: with first gen.
Ewing Sarcoma is a malignant bone tumor characterized by what?Primitive round cells without obvious differentiation
Primitive blue round cells without obvious differentiation
Treatment of LEMS
first tx/look for malignancy
AChE inhibitors
Amifampridine
immunosuppression
IvIg
Which genetic aberrations and translocations are associated with alveolar rhabdomyosarcomas?
Fusion of FOXO1 with either PAX3 = (2;13) or PAX7 = (1;13)
Characteristic morphology of fibrous dysplasia includes what?
Curvilinear shapes of the trabeculae of woven bone mimic Chinese characters and bone lacks prominent osteoblastic rimming
What lab values are indicative of BMD?
CK at diagnosis is usually elevated…but not as reliably as it is in DMD
Which first generation antipsychotic is more often associated with weight gain, DM, and hypercholesterolemia?
Chlorpromazine
Lambert-Eaton: presyn, synaptic, or postsyn?
Presynaptic
MOA non-stimulants for ADHD treatment
enhance neurotransmitter transmission via:
- inhibit NE pre-synaptic reuptake
- agonist of CNS alpha 2A adrenergic receptors
what form does Vyvanse come in
capsule
XR amphetemine
What can cause B12 deficiency?
- Malabsorption syndromes
- Surgery
- Drugs (H2 receptor antagonists)
- Nitrous oxide use (whip-its!!!)
- Fish tapeworm
What is the criteria for diagnosis of a Manic Episode?
- Abnormally and persistently elevated, expansile, or irritable mood lasting at least 1 week with at least 3 of the following:
- Manics DIG FAST
D- Distractability
I- Impulsive
G- Grandiosity
F- Flight of ideas
A- Agitation
S- Decreased need for sleep
T- Talkative
EMG/NCV tool:
can broadly classify into axonal or demyelinating; rarely leads to specific dx; may provide localization of particular nerves, may provide indication of severity
what form does ritalin SR come in
tablet
indications ergotamine
drug of choice for terminating ongoing migraine attack
what impairment seen with small unmyelinated sensory fibers in PND?
temperature perception pain perception (pin prick)
describe the caloric stimulation test and what nerves it tests
COWS
1) pour cold water in left ear –> eyes should slowly move to right and quick movement to the left (left nystagmus)
2) pour cold water in right ear –> eyes should slowly move to left and quick movement to the right (right nystagmus)
coma pt: eyes will deviate away and then stay there
nerves 8 (stimulation from the water to the brainstem), 6 (abducting the eye), 3
finger abduction and finger FLEXION weakness seen in
C8
What are 3 possible consequences of progression of transtentorial herniations?
1) Compression of CN III —> pupillary dilation; eye is “down and out” (ipsilateral to lesion) 2) Compression of PCA —> ischemia of primary visual cortex 3) Large herniation may compress contralateral cerebral peduncle —> hemiparesis ipsilateral to side of herniation = Kernohan notch = “false localizing sign”
MOA dihydroergotamine
blocks inflammation associated w/ trigeminal vascular system and suppresses release of CGRP
what is apneustic breathing and in what conditions is it seen
Alcohol is metabolized via what type of kinetics?
Zero-order kinetics; rate of metabolism remains constant and is independent of concentration or amount of chemical
Treatment of multifocual motor neuropathy
IVIG
What are specific interventions that can be done to reduce ICP?
- Elevate head of bed
- Intubate and hyperventilate to PCO2 of 20 mmHg
- Use mannitol for ischemic lesions
- Use decardron for tumor, abscess, and perhaps cerebral hemorrhage
The pathophysiology of ALS is due to degeneration of which 4 things?
- Betz cell
- Lower brainstem nuclei
- Descending corticospinal tracts
- Anterior horn cells
Etiology unknown
What is the origin of most osteomyelitis in both healthy children and adults?What is the origin of most osteomyelitis in both healthy children and adults?
- Children: hematogenous spread from trivial mucosal injuries i.e., defecation or vigorous chewing of hard foods or from minor infections of skin
- Adults: more often arise as complication of open fractures, surgical procedures, and diabetic infections of the feet
cholinesterase inhibitors are contraindicated in what patients
those with baseline bradycardia or known cardiac conduction system disease (sick sinus syndrome, incomplete heart block)
–> due to risk of syncope, falls, and fractures
sensory C6
1+2nd digit; lateral arm
A positive Romberg test indicates what?
- A somatosensory dysfunction (proprioception)
*With the eyes open, three sensory systems provide input to the cerebellum to maintain truncal stability. These are vision, proprioception, and vestibular sense. When pt closes eyes during Romberg test you remove that visual sense.
What would an Xray for RA do?
How about CT?
X-rays of hands and feet – detect symmetrical involvement of MCP/MTP joints; erosions
• CT – more sensitive detecting erosions
What is the inheritance pattern for Becker’s Muscle Dystrophy?
X linked recessive
Traumatic Brain Injury (TBI)
associated diminished or altered state of consciousness. Brain function is temporarily or permanently impaired and structural damage may or may not be detectable with current technology from repeated head blows from external mechanical forces
What are 3 types of Parial Seizures?
- Simple partial
- Complex partial
- Secondarily generalized (partial onset)
What is commonly seen preceding brainstem dysfunction (4 D’s) due to a subtentorial mass lesion?
- Dysequilibrium
- Dysarthria
- Dysphagia
- Diplopia
*Vertigo
What defines unresponsivness in someone who is truly brain dead?
Absence of?
- Unresponsive to ALL sensory input, including pain and speech
- Absent brainstem reflexes
How does the the levels of Rheumatoid Factor (RF) correlate with a disease process?
High levels associated with aggressive dz, joint erosions, and worse prognosis
What is typical clnical presentation of ALS?
Age at onset 20-60 years, most common after age of 50. First sign often hand clumsiness or impaired dexterity with mild wasting/weakness of hand intrinsics. Eventually, other hand/arm become involved. Weakness/atrophy spreads proximally in arms. Before long, legs become similarly affected. Later, atrophic weakness spreads to tongue, pharynx, and muscles of respiration. Accompanying symptoms include fasciculations, cramps, drooling, weight loss.
What is Hydrocephalus Ex-Vacuo? Whom is it seen in? What is the CSF pressure?
- Compensatory increase in ventricular volume secondary to loss of brain parenchyma - Atrophy with increasing age, stroke or other injury, chronic neurodegenerative disease - CSF pressure is NORMAL!!!
Botulism is what kind of paralysis?
descending
What is the tx for Cyclothymic Disorder?
- Mood-stabilizing drugs
- Supportive psychotherapy: CBT
MOA ergotamine
blocks inflammation associated w/ trigeminal vascular system and suppresses release of CGRP
What antibiotics are usually given for meningitis?
Vancomycin plus a third generation cephalosporin
Selegiline MOA
Selective irreversible MAO-B inhibitor (inhibits MAO-A at high doses); slows the breakdown of dopamine and prolongs the antiparkinsonian effects of levodopa
how does nicotine use in adolescence affect health later in life
can cause behavioral disturbances later in life such as substance abuse and mental health problems
Most common cause of recurrent vertigo and characteristics?
- Benign Positional Vertigo
- Brief recurrent episodes of vertigo triggered by changes in head positon
Large, pressure producing supratentorial mass lesions can cause coma how?
- Dysfunction in the upper ARAS
- Downward herniation of the brain to compress the ARAS
In terms of clinically isolated syndrome (CIS) what is a multifocal episode as a differential diagnosis for MS?
AKA?
- aka Acute Disseminated Encephalomyelitis (ADEM)
- Person experiences more than one sign or symptom caused by lesions in more than one place (i.e., optic neuritis in one eye plus hemiparesis)
What are the sensory sx’s seen with ALS?
How is the bladder affected in ALS?
How are the eyes in ALS?
NONE
No extraocular involvment
Bowel/bladder normal
What is fibrous dysplasia and what has it been linked to?
- Benign tumor likened to localized developmental arrest
- ALL components of normal bone present, but they do not differentiate into mature structures
How does ESR change with age? And what’s it mainly used for?
Rises with age and used to monitor disease activity/progression especially polymyalgia rheumatica and GCA
Rheumatoid Factor (RF) can positive in which conditions?
- Healthy pt’s and pt’s >60 y/o
- Sjogrens syndrome and SLE
- Sarcoidosis, malignancy, and lung disease
- Cryoglobulinemia
- Primary biliary cirrhosis
- Mixed CT diseases
What is the most common cause of noncommunicating (obstructive) hydrocephalus in the neonate/infant?
Aqueductal stenosis
indications for donazepil
treatment of dementia of the Alzheimer’s type
- mild, moderate, and severe
Monostotic fibrous dysplasia most often occur when and affects which bone; presenting sx’s?
- Early adolescence and equally in boys and girls; typically asymptomatic
- The femur, tibia, ribs, jawbones, calvarium, and humerus = most commonly affected
What is Vasogenic edema and is often seen following what?
- Increased EXTRAcellular fluid due to BBB disruption and increased vascular permeability - Fluid shifts from INTRAvascular compartments to INTERcellular spaces - Can be either localized (i.e., adjacent to neoplasms or inflammation) or generalied often follows ischemic injury
What is the MOA and use of Acamprosate?
- Weak NMDA-receptor antagonist and GABAa receptor agonist
- Reduces short-term and long-term relaspse rates (more than 6 months)
What type of hemorrhage is seen in the germinal matrix of premature infants?
Often found near which junction; may extend where and cause?
- Intraparenchymal hemorrhage
- Junction between thalamus and caudate nucleus
- May extend into ventricles —> subarachnoid space —> hydrocephalus (obstructive)
During a general medical exam of the skin of a patient with impaired consciousness what should be considered with dry skin?
- Hypothyroid
- Drugs (anticholinergics, TCA’s)
Myasthenia crisis vs. cholinergic crisis
Myasthenic crisis: rapid deterioration of dz itself; may occur spontaneously or after infection, certain drugs; aspiration, diffuse weakness, resp failure possible
cholinergic crisis: rare; rapid increase in weakness from excess anticholinesterase meds; N&V, COLIC, DIARRHEAL, brady; MIOSIS and/or FASCICULATIONS (big clues)
Acquired demyelinating polyneuropathies
Acute: Guillan-Barre
Chronic- chronic inflammatory demyelinating polyneuropathy
What are 4 hematologic (CBC) indicators of SLE?
- Hemolytic anemia w/ reitculocytosis
or
- Leukopenia (<4000/mm3 total)
or
- Lymphopenia (<1500/mm3 total) on 2+ occasions
or
- Thrombocytopenia (<100,000/mm3)
What are the 2 classes + agents used to tx the extrapyramidal sx’s (EPS) of first gen. antipsychotics?
- Anticholinergic agents: benztropine + trihexyphenidyl
- Antihistamine agents: diphenhydramine
indications tramadol
moderate to moderately severe painmore effective than codeine, less effective than morphine
Why is the direction of nystagmus provoked by the anterior type of Benign Postional Vertigo significant?
- This is a more rare form
- Dix Hallpike will causes a downbeat (vertical) nystagmus, which is usually only seen in central lesions.
- Must carefully assess to rule out brainstem or cerebellar lesions!
With central dysfunction leading to dysequilibrium what is the vertigo like, duration of nystagmus, direction of nystagmus, and neuro symptoms?
- Mild vertigo
- Persistence of nystagmus, which can be in vertical direction
- Usually some neuro symptoms
pain in post thigh and post calf is seen in
S1
peripheral neuropathy = same as
polyneuropathy
MOA butorphanol
prototype for the agonist-antagonist opioids used to treat mild to moderate pain
After exercise, what happens with strength in LEMS?
strength improves w/ exericse
Which type of anxiety disorder is most often seen in assoc. w/ anorexia nervosa?
Obsessive compulsive disorder
What are the characteristics of Mal de Debarquement (“Sickness of Disembarkment”)?
Duration?
Treatment?
- Illusion of movement as an after effect of travel (sea, car, train)
- Rocking, swaying feeling after getting off a boat
- Duration = usually <24 hours; sometimes longer
- Tx: meclizine, scopolamine, benzodiazepines (dizziness meds)
precautions flurbiprofen
may slow or delay healing
Common cause of death in someone with Friedrich’s Ataxia?
Cardiomyopathy
warnings and precautions for rivastigmine
1) dose should be titrated as prescribed and re-initiated at the lowest dose if interrupted for more than a few days
2) weight should be monitored during patch therapy
What is seen with diffuse idiopathic skeletal hyperostosis (DISH); what are the criteria?
- Calcification and ossification of spinal ligaments i.e., anterior longitudinal ligament and enthesis (tendon/lig. attachement to bone)
- No SI joints involvement*
- Ossifications of at least 4 contiguous vertebral levels, usually on the right side of spine
list the extended release methylphenidate-based stimulants used to treat ADHD
- aptensio XR
- concerta
- comtempla XR-ODT
- daytrana
- focalin XR
- metadate CD
- ritalin LA
- quillichew
- quillivant XR
Hip involvement in OA most commonly manifests as what sx?
Groin pain
Which second-gen. antipsychotic is associated with agranulocytosis and requires monitoring of WBC; REMS program?
Clozapine
What type of injury is associated with localized vs. generalized vasogenic edema?
- Localized: adjacent to inflammation or neoplasms - Generazlied: follow ischemic injury
What is the criteria for diagnosing a major depressive episode?
- At least 5 of the following for a 2-week period with at least one either (1) depressed mood or (2) loss of interest or pleasure (SIG E CAPS)
S- sleep disturbance
I-interest lost
G- Guilt or feelings of worthlessness
E- Energy loss/fatigue
C- concentration problems
A- Appetite/weight changes
P-Psychomotor retardation
S- Suicidal
What is the first sign and the first symptom of a Cerebellopontine Angle Tumor?
- First symptom = hearing loss (CN VIII)
- First sign = absent corneal reflex (loss of CN V and VII)
What is the clinical presentation of BMD kids?
1. Proximal symmetric muscle weakness
2. Neck flexor muscle strength is preserved
3. Presents later in life, usually not earlier than 5yo
- Less severe disease than DMD, slower progression
- Usually ambulatory into their 20’s, sometimes longer
- Cognitive dysfunction usually not present
- Independent walking until late teens or early 20’s
- Life expectancy between fourth and sixth decades
indications for galantamine
treatment of mild to moderate dementia of the Alzheimer’s type
Entecapone and tolcapone can be helpful in what situations?
May be helpful in patients receiving levodopa who have developed response fluctuations
If meningitis is suspected, what should you do immediately?
Blood culture/lumbar puncture STAT
Start on Dexamethasone and empirical antiobiotic therapy
What is seen with a Myoclonic Seizure, duration, and how does patient feel after?
- Brief, rapid symmetrical jerking of extremities and/or torso
- Loss of consciousness
- Lasts < few seconds
- Minimal post-ictal state
What is an important consideration before prescribing pt Naltrexone for tx of alcohol and opiate dependence?
Must be opioid-free before initiating therapy because naltrexone can precipitate an acute withdrawal syndrome
MOA opioids
bind to opioid receptors in the CNS causing inhibition of ascending nerve pathway, altering the perception of and response to pain and producing generalized CNS depression
3 main adverse effects of opioids
- CNS depression
- constipation
- hypotension
what is the black box warning for opioids
serious, life-threatening, or fatal respiratory depression may occur
carbon dioxide retension
list the acute adverse effects of opioid use
- respiratory depression
- N/V
- pruritis
- urticaria
- constipation
- urinary retention
- delirium
- sedation
- myoclonus
- seizures
warnings/precautions naloxone
acute opioid withdrawal: naloxone causes release of catecholamines which may precipitate acute withdrawal or unmask pain
warnings/precautions naltrexone
- accidental opioid OD (pts on naltrexone may respond to lower opioid doses than previously used, so using opioids again could cause OD)
- acute opioid withdrawal
Discuss four (4) benefits of Integrated Healthcare
- Improved patient experience and outcomes
- Decreased healthcare expenditures
- Improved access to care
- Improved provider satisfaction
Describe what an effective integrated care team looks like.
Explain four (4) functions that a Behavioral Health Consultant can provide to assist a physician in his or her day-to-day practice.
- Assessment, Education, Brief Intervention, Referral
- Warm hand-offs
- Chronic illness, Mental health disorders
- Prevention
- Quality improvement and quality assurance
What is mononeuritis multiplex?
describes a disease process that damages several nerves in a haphazard fashion
Mononeuritis multiplex describes a disease process that damages several nerves in a haphazard fashion and is commonly due to what?
Vasculitis i.e., polyarteritis nodosum
What is PAN’s symptoms so you recognize it?
systemic vasculitis of the small and medium-sized vessels, which leads to tissue ischemia; most commonly involving skin, peripheral nerves, muscles, joints, gastrointestinal tract, and kidneys
Nonspecific symptoms: fever, abdominal, muscle, and joint pain
Renal involvement: hypertension, renal impairment
Coronary artery involvement; increased risk of myocardial infarction
Skin involvement: rash, ulcerations, nodules
Neurological involvement: polyneuropathy (mononeuritis multiplex), stroke
GI involvement: abdominal pain, melena, nausea, vomiting
Usually spares the lungs
What is Gullian- Barre characterized as?
Acute inflammatory demyelinating polyneuropathy
Histologic features of Guillain-Barre Syndrome are characterized by what?
Inflammation and demyelination of spinal nerve roots and peripheral nerves = radiculoneuropathy
2/3’s of Guillain-Barre Syndrome cases are preceded by what; which etiologies have been implicated?
- Acute, influenza-like illness
- Campylobacter Jejuni, CMV, EBV, and Mycoplasma penumoniae, or prior vaccination
Morphologically what is the most prominent lesion seen in Guillain-Barre Syndrome? What else do you see?
Segmental demyelination affecting peripheral nerves
Also see perivenular & endoneurial infiltration by lymphs, macrophages and a few plasma cells
What antibodies do you see with Guillain-Barre?
Anti-myelin antibodies
Clinical presentation of Guillain-Barre Syndrome is dominated by what signs/sx’s; what characteristic CSF finding will there be?
- Ascending paralysis and areflexia
- DTR’s lost early in the process
- ↑ CSF protein levels w/ little or no CSF pleocytosis (inflammatory cells remain confined to the roots) (no cells in csf)
How is Guillain-Barre Syndrome managed clinically?
Plasmapheresis and IV Ig
What is the most common acquired inflammatory peripheral neuropathy?
Chronic inflammatory Demyelinating Poly(radiculo)neuropathy
Chronic inflammatory Demyelinating Poly(radiculo)neuropathy is characterized by what type of neuropathy?
Symmetrical mixed sensorimotor polyneuropathy that persists for 2 months or more
Which 2 features of Chronic inflammatory Demyelinating Poly(radiculo)neuropathy distinguish it from Guillain-Barre?
Time course (presence at least 2 months) and actually responds to steroids (unlike GB)
How is Chronic inflammatory Demyelinating Poly(radiculo)neuropathy treated?
Glucocorticoids + IVIg + plasmapheresis
Upon sural nerve biopsy in patient with Chronic inflammatory Demyelinating Poly(radiculo)neuropathy what is a characteristic finding?
Onion-bulbs: excessive proliferation –> multiple layers of Schwann cells wrap around an axon like the layers of an onion
What is the most common pattern of peripheral neuropathy seen with Diabetes?
Ascending distal symmetric sensorimotor polyneuropathy
Prevalence of peripheral neuropathy associated with diabetes is dependent on what?
Duration of the disease
Biopsies of the affected peripheral nerves/arterioles in diabetes will show what finding and with what stain?
Endoneurial arterioles show thickening, hyalinization, and intense PAS-(+) of their walls + extensive reduplication of basement membranes
Diabetic peripheral neuropathy is characterized by a relative loss of which size and type of nerve fibers?
Small myelinated and unmyelinated fibers
What are “positive sx’s” associated with diabetic peripheral neuropathy? What are other clinical symptoms?
Paresthesias and dyesthesias = painful sensations
Other than peripheral neuropathy, what is another manifestation of diabetic nervous system dysfunction that is often seen?
Autonomic dysfunction: postural hypotension, incomplete bladder emptying (↑ infections) and sexual dysfunction
Uremic neuropathy seen in setting of renal failure is a distal, symmetric neuropathy often associated w/ what signs and sx’s?
Muscle cramps + distal dysesthesias + ↓ DTRs
Disorders of NMJs present with what?
Painless muscle weakness
Myastheina Gravis is associated with autoantibodies against what?
- ACh receptors on post-synaptic membrane (85% cases)
- Muscle-specific receptor tyrosine kinase (15%)
There is a strong association with AChR autoantibodies seen in Myathenia Gravis and which abnormalities?
Thymic abnormalities: Thymoma and Thymic hyperplasia
Myasthenia gravis patients with AChR autoantibodies usually present with what signs/sx’s?
- Fluctuating weakness that worsens with exertion and over course of day
- Diplopia and ptosis due to involvement of extra-ocular muscles
What electrophysiologic findings help distinguish Myasthenia Gravis and Lambert-Eaton Myasthenic Syndrome?
- M.G. = Diminished muscle responses after repeated stimulation
- L.E.M.S = Increased muscle response after repeated stimulation
What is 1st line tx for Myasthenia Gravis and what other tx’s can be used to control the sx’s?
- 1st line = Acetylcholinesterase inhibitors
- Plasmapheresis and immunosuppressives (glucocorticoids, cyclosporine, rituximab) –> ↓ autoAb titers
Lambert-Eaton Myasthenic Syndrome is an autoimmune disorder due to what?
Antibodies block ACh release by inhibiting pre-synaptic Ca2+ channel
50% of Lambert-Eaton Myasthenic Syndrome cases are associated with what underlying condition?
Malignancy; most often small-cell carcinoma of lung
Pt’s with Lambert-Eaton Myasthenic Syndrome typically present with what sx’s?
Weakness of the extremities and autonomic dysfunction
Clostridium botulinum, botox has what affect on the NMJ?
Blocks release of ACh
Curare muscle relaxant has what effect on on the NMJ?
blocks AChR → flaccid paralysis
Which drugs are associated with slowly progressive muscle weakness which predominantly affects type I fibers?
Chloroquine and hydroxychloroquine
How do the type of mutations of Dystrophin differ between Duchenne and Becker muscular dystrophy?
- Duchenne: deletions or frame shift mutations –> total absence
- Becker: synthesis of a truncated version, which retains some function
What will immunohistochemical staining for dystrophin show in Duchenne vs. Becker muscular dystrophy?
- Duchenne: absence of normal sarcolemmal staining pattern
- Becker: shows reduced staining
What morphological changes are seen with disease progression in Duchenne and Becker muscular dystrophy?
Muscle tissue is replaced by collagen and fat cells = Fatty replacement or change”
Where does weakness associated with Duchenne muscular dystrophy begin and how does it progress?
- Begins in pelvic girdles —> extends to shoulder girdles
- Pseudohypertrophy of calves often present
- Wheel-chair bound around age 9.5
Which lab value can aid in the diagnosis of Duchenne and Becker muscular dystrophy?
↑↑↑ CK
What is a key feature of Myotonic Dystrophy?
Myotonia: sustained involuntary contraction of a group of muscles; can be elicited by percussion on thenar eminence
Myotonic dystrophy is caused by what?
Expansions of CTG triplet repeats in 3’-noncoding region of DMPK gene
How does Myotonic Dystrophy present signs and sx’s?
Gait, then atrophy of facial muscles = ptosis and “hatchet face,” frontal balding, cataracts, cardiomyopathy
Malignant hyperthermia is associated with what mutations?
RYR1 mutation
What can trigger hyperthermia? And how do those agents do it?
Halogenated inhalational agents
• Anesthetic triggers ↑efflux of Ca⁺² from sarcoplasmic reticulum→ tetany & excessive heat production
Malignant hyperthermia leads to what clinical symptoms?
hypermetabolic state: tachycardia + tachypnea + muscle spasms and later hyperpyrexia
Pt’s with anxiety, type A behavior, hostility, anger, and acute mental stress are at an increased risk for what?
- 2-fold ↑ risk of incident MI and CAD-related mortality
- Strongest evidence shows ↑ incidence of depression
Asthmatics are at an increased risk for which psych disorders?
- Panic disorder or agoraphobia
- Fear of dyspnea can trigger asthma attacks and high levels of anxiety
Diabetes is associated with an increased risk for what psych conditions?
Frustration, loneliness, dejection, and depression
What are some of the psych sx’s associated with hyponatremia?
Confusion, lethargy, personality changes
Which psych sx’s are very common with pancreatic carcinoma?
Depression, lethargy, anhedonia, apathy, and ↓ energy
Acute intermittent porphyria psych symptoms?
Abdominal pain with psychosis, paranoia, acute depression, agitation, visual hallucinations
What are some of the psych sx’s associated with hepatic encephalopathy?
Euphoria, disinhibition, psychosis, and depression
What are some of the psych sx’s associated with frontal lobe tumors?
- Mood changes + irritability + facetiousness
- Impaired judgement + Impaired memory
- Delirium
- Loss of speech
- Loss of smell
What medication should be avoided in elderly hospitalized pt’s especially those with delirium?
AVOID benzodiazepines
Which commonly used drug is associated with mania + psychosis (hallucinations)?
Corticosteroids
Personality disorders consist of an enduring pattern on inner experience and behavior that deviates markedly from the expectations of the individul’s culture. This pattern is manifested in 2 (or more) of which 4 areas?
- Cognition: perception and interpretation of self, others and events
- Affect: the range, intensity, liability, and appropriateness of emotional response
- Interpersonal functioning
- Impulse control
ule of thumb is that personality disorder diagnosis cannot be made until which age?
≥18 y/o
Which personality disorder is characterized by irrational suspicions and mistrust of others?
Paranoid personality disorder (Cluster A)
Which personality disorder is characterized by a lack interest in social relationships, seeing no point in sharing time with others, little pleasure in activities, and appear indifferent to the praise or criticism of others?
Schizoid personality disorder (Cluster A)
What are the characteristics of Schizotypal personality disorder (cluster A)?
- Odd behavior, beliefs and/or magical thinking (in contrast to Schizoid)
- Vague, circumstantial, or stereotyped speech
- Excessive social anxiety that does not diminish with familiarity
Which personality disorder is characterized by repeated violations of the law, pervasive lying and deception, physical aggressiveness, reckless disregard for safety of self or others, irresponsibility, and lack or remorse?
Antisocial personality disorder (Cluster B)
Antisocial personality disorder is 3x more common in which sex?
Males
Pt’s with antisocial personality disorder are at risk for what 4 co-morbid conditions?
- Anxiety disorders
- Substance abuse
- Somatization disorder
- Pathologic gambling
What are the major characteristics of Borderline personality disorder (Cluster B)?
- Unstable mood and interpersonal relationships; intense anger
- Fear of abandonment
- Sense of emotional emptiness
- Impulsivity in ≥2 potentially self-damaging areas i.e., sex, substance abuse, etc..
- Recurrent suicidal behaviors or threats or self-mutilation
3x more common in women
What is important to keep in mind when tx pt with Borderline personality disorder?
- Need to set rigid boundaries!
- These pt’s are very manipulative; will often “split” staff members
Which personality disorder is characterized by attention-seeking, dramatic speech and emotional exprssion, shallow and labile emotions, and sexual provocativity?
Histrionic personality disorder (Cluster B)
Pt’s with Narcissistic personality disorder are at risk for what 3 co-morbidities?
- Anorexia nervosa
- Substance abuse
- Depression
Pt’s with Borderline personality disorder have a high rate of what co-morbid condition?
Major depression
How does Avoidant personality disorder (cluster C) differ from Schizoid (cluster A)?
They desire relationships with others
Which personality disorder is characterized by hypersensitivity to rejection and criticism, socially inhibited, timid, feelings of inadequacy and a desire for relationships with others?
Avoidant personality disorder (Cluster C)
Which personality disorder is characterizd by being preoccupied w/ perfectionism and control, lack of flexibility or openness, often stingy as well as stubborn?
Obsessive-Compulsive personality disorder (Cluster C)
What is the best treatment for Borderline Personality Disorder?
Dialectial Behavior therapy (DBT)
Learn coping skills and impulse control and focus on stabilizing self destructive behavior
Which drug can be used off-label for impulse control in pt’s with personality disorders?
Valproic acid
Treatment of personality disorders
-tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) are usually not prescribed
-selective serotonin reuptake inhibitors (SSRIs) and newer antidepressants are safe and reasonably effective
-less effective than in patients with uncomplicated major depression -anticonvulsants: Valproic acid
What is psychodynamic therapy?
examines the ways that patients perceive events,
assumption that perceptions are shaped by early life
identify perceptual distortions and their historical sources
facilitate the development of more adaptive modes of perception and response
frequency from several times a week to once a month; it makes use of transference
Cognitive Behavior Therapy [CBT]
deals with how people think about their world and their perception of it
typically limited to episodes of 6-20 weeks, once weekly
What is the diagnostic criteria for Schizophrenia?
- ≥2 of the following for most of 1 month; at least 1 of the first 3 sx’s
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative sx’s
What is criteria for Delusional Disorder?
- Presence of 1+ delusions with duration of 1 month
- Functioning is NOT impaired and behavior is not obviously bizarre or odd
What is the diagnostic criteria for Brief Psychotic Disorder?
- Presence of 1+ of the following sx’s. At least one being the first 3.
- Delusions, Hallucinations, Disorganized speech, Grossly disorganized or catatonic behavior
- Duration of an episode is at least 1 day but <1 month
What is the diagnostic criteria for Schizophrenifrom Disorder?
- Two (or more) of the following, each presnt for a significant portion of time during a 1-month period. At least one must be the first 3 sx’s:
- Delusions, Hallucinations, Disorganized Speech, Grossly disorganized or catatonic behavior, Negative sx’s
- Episode must last at least 1 month but <6 months
What is the diagnostic criteria for Schizoaffective Disorder?
- An uninterrupted period of illness during which there is a major mood disorder (major depressive or manic) concurrent with criterion A of schizophrenia
- Delusions or hallucinations for ≥2 weeks in absence of major mood episode (depressive or manic)
There must be the presence of one or both of which 2 sx’s for diagnosis of substance/medication-induced psychotic disorder?
- Delusions
- Hallucinations
What is the timeline for Schizophrenia vs. Schizophreniform vs. Brief Psychotic Disorder?
- Schizophrenia: >6 months
- Schizophreniform: 1-6 months
- Brief psychotic disorder: <1 month
what is the diagnostic criteria for PTSD
Duration of disturbance and symptoms is more than 1 month
1) person exposed to a traumatic event in which both were present:
- person experienced/witness actual or threatened death/injury/integrity of self or others
2) persistent re-experience of event
3) persistent avoidance of stimuli associated with trauma
4) persistent increased arousal (difficulty sleeping, irritability, hypervigilance)
5) negative cognitions
treatment for PTSD
- *- drug of choice: SSRIs**
- cognitive processing thearpy
- eye movement desensitization and reprocessing (EMDR)
**avoid addictive prescriptions like benzos
define acute distress disorder
sx similar to PTSD but lasting 3 days to 1 month after trauma exposure
define adjustment disorder
development of emotional/behavioral sx in response to an identifiable stressor
- occurs within 3 months of stressor
- results in significant distress out of proportion to severity of stressor or impairment of function
does not persist past 6 months
time period for adjustment disorder
occurs within 3 months of stressor, usually does not persist beyond 6 months
