Neuro and Psych

Question 1

65 yo female presents with forgetfulness and confusion. 1. What questions to ask? 2. What examinations maneuvers to perform? 3. DDx? 4. Test?

Answer 1

1. Onset, Progression, Things that are difficult to remember, Daily activities (Bathing, feeding, toitleting, dressing, transferring from chair, Shopping, Cooking, Money,) Difficultly, Sleeping, SIGE CAPS, HA, Lightheadedness, Falls, Head Trauma, Shaking, Sieizures, Speech, Heart problems. 2. Orthostatics, Nero: Mini-Mental, Cranial Nerves, Motor, DTR, Gait, Romberg, Senory. 3. Alzheimers, Pseudo dementia, Subdural Hematoma, B12, Hypothyroidism, Neurosphylis. 4. CBC, Electrolytes, Calcium, Glucose, BUN/Cr, Serum B12, TSH, T4, CT Head, MRI, EEG or SPECT.

Question 2

53 yo female complains of dizziness. 1. What questions to ask? 2. Important physical exam manuevers? 3. DDx? 4. Test?

Answer 2

1. Positions that elicit dizziness, Tinnitus, Hearing loss, URI, Fever, Chills, N/V/D, HA, head truama, NWT, Current Meds (Diuretics) 2. Check for Neuro, nystagmus, Rhinne, Webers, Orthostatics. 3. Menieres Disease, Orthostatic due to dehydration, BPPV, Labyrinthitis, Perilymphatic Fistula, Acoustic Neuroma. 4. Dix-Haplike, VDRL/RPR (Meniere’s), Audiometry, MRI, Brain Stem Auditory Evoked Potentials, Electronystagmography.

Question 3

35 yo female presents with right sided HA. 1. What questions to ask? 2. Important physical exam maneuvers? 3. DDx? 4. Test?

Answer 3

1. OLDCARTS: how many and how long do they last, location and describe pain and radiation, Does it occur in the morning, Auras, stress/light/noise, relationship to period, relationship to food (caffeine/chocolate) head trauma, Changes in vision, loss of vision, Eye reddness, tearing, congestion, running noise 2. Physical Exam: HEENT, Neck, Heart, Lung, Neuro: (Cranial Nerves, strength, DTRs.) 3. Migraine, Tension HA, Depression, Sinusitis, Pseudotumor Cerebri, Chronic Paroxysmal Hemicrania, Cluster HA, Intracranial Brain Mass 4. CBC, BMP, CT head w/o contrast, MRI Brain, LP

Question 4

66 yo male presents with Tremor? 1. What questions to ask? 2. DDx? 3. Test?

Answer 4

1. OLDCARTS, Context (When does it Shake) Head/Trauma, Falls, HA, TIA, drooling, changes in voice or handwriting, difficulty with ADLs/IADLs, Hx of similar symptoms, caffeine intake, alcohol 2. Parkinsons, Essential Tremor, Physiologic Tremor, Midbrain lesion, Drug-induced tremor, Psychogenic tremor, Wilson’s Disease, Hyperthyroidism 3. TSH, Heavy Metal Screen (Arsenic and Mecury), MRI, Ceruloplasm, Slit Lamp Exam, 24 Hr urinary copper, AST/ALT

Question 5

49 yo male complains of passing out a few hours earlier. 1. What questions to ask 2. DDx? 3. Test?

Answer 5

1. Describe what happen, Tripped, How long were you out for, how long were standing before you fell, LOC before, palpitations before fall, Sounds, Ligths, Smells, Shaking, Tongue biting, loss of bowel and bladder control, weakness, numbness, speech, Confusion after regaining consciousness, HP, CP, SOB, Pulmonary effects. 2. Convulsive Syncope, Vasovagal, Cardiac Arrhythmia, Drug-induced orthostatic hypotension, Seizure, Aortic Stenosis 3. CBC, BMP, CT head, MRI Brain, 24 hr Holter Monitor, Echo, EEG.

Question 6

75 yo male complaining of hearing loss. 1. What questions to ask? 2. Physical exam maneuvers 3. DDx? 4. Test?

Answer 6

1. OLDCARTS, Trauma/Insertion of foreign body/Loud Noise, Specific sounds, distorted speech, location of sound, Ear pain, Ear discharge, Sensation of rooming, spinning, dizziness, feelings of imbalance, ringing in ears, HA, NWT, recent infections. 2. HEENT:Rhine, Weber, Whisper Test, Neuro, Hear/Lung 3. Prebcyusis, Cochlear nerve damage 2/2 loud noise, Otosclerosis, Meniere Dz, Ototoxicity, Acoustic Neuroma. 4. Audiometry, Tympanography, Brain Stem auditory evoked potentials, CT-Head, VDRL/RPR.

Question 7

20 yo female presents with sleeping problems. 1. What questions to ask? 2. Physical Exam maneuvers 3. DDx? 4. Test?

Answer 7

1. Duration, Total hours of sleep per night, time you fall asleep, activities before sleep, sleep interruptions, early spontaneous awakenings, snoring, daytime sleepiness, daytime naps, recent stressful events/illness, Relationships, Sadness/Depression/Anxiety, Exercise, Tremors, Palpitation, Weight, Sweating, Heat/Cold Intolerance, Skin, Hair nail Changes, Change in Stools, Neck and joint pain, Menstrual hx. 2. Thyroid, Tremors and edema of fingers, DTS 3. Anxiety, Caffeine induce insomnia, Hyperthyroidism, Insomnia related to depression, Adjustment insomnia, illicit drug abuse, OSA. 4. TSH, free T4, CBC with diff, Urine Tox, Polysomnography, ECG.

Question 8

27 yo male complaining of seeing strange writing on the wall. 1. What questions to ask? 2. Physical Exam maneuvers 3. DDx? 4. Test?

Answer 8

1. Onset, Content, Duration, Constant/intermittent, Frequency, Do you see writing with your eyes closed? Alleviating and Exacerbating factors, Major life changes on stressors, HA, Vision, Hearing, Content of the voices, feeling of being controlled, Do the voices/writing order you harm yourself or others, Do you think about harming yourself or others, Enjoyment in daily activities, Mental illness in family, sleeping problems, fall asleep suddenly. 2. Check pupils for reactivity, Mental status, Cranial Nerves, Motor Exam, DTRs and gait, Sensation. 3. Substance induced psychosis, Brief psychotic disorder, psychosis secondary to a medical condition, narcolepsy, siezure. 4. Urine tox, Mental status examination, BMP/Electrolyes, LFT, TSH, T4, EEG and Polysomnogram.