Neuro and Psych Flashcards
Dermatomes
Upper arm
umbilicus
perineum
perianal
Upper arm: C-5 through T1
umbilicus: T10
perineum: S2
perianal: S5
- C4: clavicle “C” is for “clavicle”
- C6: thumb & index Left hand “OK” sign makes a “6” with thumb and index
- C7: middle finger
- C8: little finger
- T4: nipple line “T” is for “thorax”
- T10: umbilicus BellybutTEN
- L1: inguinal ligament IL-L1
- L4: knee “Down on all fours” – Down on L4
Cranial nerve three palsy
pupil sparing (2)
pupil involved (2)
pupil sparing (2): diabetes/hypertension, infarction
pupil involved (2): compression, aneurysm
nasal gaze on affected side
GCS
•Eye Opening (1-4)
–4: Spontaneous
–3: Verbal
–2: To Pain
–1: None
•Verbal (1-5)
–5: Full sentences / oriented
–4: Full sentences / confused
–3: Understandable words
–2: Garbled, moans
–1: No vocalization
•Motor Response (1-6)
–6: Follows commands
–5: Localizes pain
–4: Withdraws to pain
–3: Decorticate (Flexes)
–2: Decerebrate (Extends)
–1: Flaccid
Doll’s eyes (oculocephalic reflex)
–If brainstem is intact: Eyes move in opposite direction of head movement
–If brainstem is injured: Eyes stay fixed in orbits
Cold calorics (oculovestibular reflex)
–If brainstem and cortex are intact: Nystagmus with fast component directed to opposite ear. “Cold Opposite, Warm Same” = COWS
–Cortex injured but brainstem intact: Eyes deviate toward cold ear
–Brainstem injured: No eye deviation
Corneal reflex
–Test CN V and CN VII (touching the cornea elicits bilateral blink)
–Decreased blink in opposite eye suggests brainstem or cortical injury
Right Internuclear Ophthalmoplegia
Migraine
prevention (3)
treatment classes (3), contraindications
prevention (3): TCA, BB. CCBs
treatment classes (3)
Ergpts. Triptans, Dopamine antagonists
–Ergotamine, DHE: contraindicated in CAD, PVD, HTN, RF, pregnancy
–Sumatriptan: Contraindicated in heart disease, HTN, ergotamine, migraine with focal findings
–Dopamine antagonists: Prochlorperazine, promethazine, metoclopramide
Cluster headaches
treatment (3)
toxic metabolic headache-what?
Oxygen, intranasal lidocaine 4%, migraine treatments
toxic metabolic headache
- Usually bilateral
- Vasodilation of pain-sensitive arteries
- Fever is the most common cause
- Others: CO, hypoxia, alcohol, tyramine foods
Idiopathic intracranial hypertension (pseudo-tumor)
etiology
treatment (4)
etiology: impaired CSF absorption
treatment (4): serial lumbar puncture, acetazolamide, weight loss, shunt
Subarachnoid hemorrhage medical treatment (2)
Aggressive blood pressure control (nicardipine), Nimodipine
Hydrocephalus
ex vacuo -what
normal pressure classic triad
treatment
VP shunt, unable to depress valve, consider:
ex vacuo: pseudo-hydrocephalus from cerebral atrophy
normal pressure classic triad: progressive dementia, ataxia, incontinence
treatment: shunt
consider: obstruction
CNS mass lesion
most common cause in AIDS and description
headache characteristics: peak intensity time of day, positional change, valsalva
Toxoplasmosis: ring enhancing lesion
headache characteristics: worst in the morning, worse lying down and with Valsalva
Meningitis
Brudzinski and Kernig signs
most common bacterial causes (2)
Kernig’s sign: Pain in hamstrings causes inability to straighten leg when hip is flexed to 90
Brudzinski’s sign: Flexion of the hips caused by passive flexion of the neck
both have low sensitivity but high specificity
causes: strep pneumoniae, Neisseria meningitiis
Meningitis
treatment order (2)
CT before LP (5)
Steroids then (or same time as) antibiotics and seriously ill (or CSF WBC > 1000)
CT before LP
–Age at least 60
–Immunocompromised (HIV, immunosuppressive treatment and transplant pts.)
–A history of CNS disease (mass lesion, stroke or focal infection)
–Seizure within the last week
–Abnormal neuro exam / altered mental status
Aseptic Meningitis
causes categories (4)
Viral: Varicella, herpes (HSV), enterovirus, West Nile
Atypical bacterial: TB, Lyme disease (weeks after rash), Syphilis
Fungal: AIDS, transplant, chemo, chronic steroids
Noninfectious: Neurosarcoidosis, connective tissue disease, vasculitis, drugs (NSAIDs)
GBS
associated antecedents (3)
Hallmark finding
CSF finding treatment meds(2)
Campylobacter gastroenteritis, Mycoplasma, flu vaccine
loss of DTRs
elevated protein
plasmapheresis, IV IG
multiple sclerosis
most common initial presentation
pathognomonic finding
Optic neuritis: Unilateral, Central vision loss, pain with eye movement and papillitis (papilledema of one eye)
Pathognomonic: Bilateral internuclear ophthalmoplegia
(eyes can’t look at nose)
multiple sclerosis
diagnosis: rad, LP (2), nerve
Tx for exacerbation (3)
diagnosis: MRI, LP with increased protein and increased IgG oligoclonal bands
Tx: steroids, ACTH, interferon
Pure muscle weakness causes review (9)
- Hypokalemic periodic paralysis
- Myasthenia gravis
- Lambert-Eaton syndrome
- Tick paralysis
- Botulism
- Certain toxins
- Amyotrophic lateral sclerosis (ALS)
- Polio
- West Nile Virus
Acute periodic paralysis
common trigger
associated conditions (2)
inheritance of hereditary form and tx
Exercise
associated conditions (2): hypokalemia, thyrotoxicosis
inheritance of hereditary form and tx: autosomal dominant, avoid high carbohydrate high salt diet
Myasthenia gravis
etiology
associated comorbid condition and frequency
weakness pattern and hallmarks (2)
Autoantibody to acetylcholine receptor
thy,moma, 25%
proximal greater than distal weakness, worsens with activity, ptosis, diplopia
Myasthenia gravis
diagnosis (2) and caveat with first medicine
exacerbation trigger (2)
dx, caveat:
–Tensilon (edrophonium) test: Increases ACh, by blocking breakdown of ACh by cholinesterase = increases muscle strength / EMG = rapid fatigue; can cause AV block, cardiac arrest - give atropine first
–Blood: Anti-acetylcholine receptor antibodies
exacerbation trigger (2)
–Exacerbation vs. inadequate treatment (myasthenic crisis)
–Over-medication (cholinergic crisis)
Myasthenia gravis
treatment (4)
Physostigmine or neostigmine (ACH inhibitors), thymectomy, prednisone, plasmapheresis
Lambert-Eaton syndrome
what
associated comorbid finding
differences from more common condition (2)
what: similar to myasthenia gravis
associated comorbid finding: cancer, 50% (especially SC lung)
differences from more common condition (2): decreased DTR. Weakness improves with use
Botulism
3 forms
etiology
Hallmark
3 forms: infant, wound, foodborne
etiology: neurotoxin blocks ACh release
Hallmark: impaired motor and autonomic function
–Foodborne: inadequately processed canned foods
–Wound: contaminated wound or street drugs
–Infant: ingest spores from honey; most common in breastfed (also less severe in this subset)
Botulism
Clinical characteristic categories (3)
–Bulbar symptoms – diplopia (the most common early finding), ptosis, dysphagia, dysphonia, dysarthria
–Descending flaccid paralysis
–Anticholinergic symptoms (dry mouth, urinary retention, dilated pupils, ileus, decreased tears)
–Sensory exam and mental status are normal
Botulism
treatment - all forms
additional for wound variety (2)
treatment - all forms: antitoxin
additional for wound variety (2): penicillin, wound debridement
Tick paralysis
Hallmark
differentiator from similar condition
treatment
Hallmark: rapidly ascending paralysis
differentiator from similar condition: no paresthesia, more rapid progression
treatment: remove tech
Wernicke’s encephalopathy
etiology classic findings (5)
treatment (2)
Complication (sx -2)
Thiamine (B1) deficiency
•Encephalopathy (altered mental status), nystagmus, ophthalmoplegia (esp. lateral rectus), ataxia, short-term memory problems
treatment: thiamine, magnesium
Korsakoff’s psychosis: amnesia, confabulation
West Nile virus
percent affected
severe form
tx
percent affected: 20% overall, rate and severity increases with age
severe form: flaccid paralysis with intact sensation
Dx: CSF IgM
tx: supportive
Seizure
Duration of Todd’s paralysis
Initial ED W/U new adult seizure (5)
Peds non-febrile common causes (2)
Duration: up to 24 hours
Initial ED W/U: Glucose, lytes, CT, LP, toxicology screen
Peds non-febrile: hyponatremia, AGE
Partial Seizures
Simple vs complex
Drug doses (?)
- Simple: No LOC, mental status is preserved
- Complex: Temporal lobe, altered mental status, bizarre behavior; “psychomotor” seizures
–Lorazepam 0.05-0.1 mg/kg (longer acting;
drug of choice)
– Phenytoin 18 mg/kg
– Phenobarbital 8-20 mg/kg
Status epilepticus
classic and newer definitions
classic board exam cause and treatment
Classic: continuous seizure greater than 30 minutes
Newer: Status epilepticus
≥5 minutes of continuous seizures, or
≥2 discrete seizures between which there is incomplete recovery of consciousness
Classic boards: INH overdose/B6 deficiency -> treat with thiamine
Lower and upper motor neuron signs
in particular: positive Babinski? Fasciculations? Increased tone? DTRs increased?
Upper: positive Babinski, Increased tone DTRs increased
Lower: Fasciculations
Upper:
- Hyperreflexia
- Clonus
- Normal muscle mass
- Spasticity (increased tone and reflexes)
- Babinski’s sign
Lower
- Weakness
- Atrophy
- Fasciculations
- Decreased DTRs
ALS, Lou Gehrig’s disease
What?
Cauda equina
Upper vs LMN lesion?
Motor or sensory?
Anal tone?
Degeneration of upper and lower motor neurons etiology unknown
Upper vs LMN lesion? Lower
Motor or sensory? Both
Anal tone? Decreased
Back pain, IVDA
Back pain, motor > sensory findings
Vertebral osteo/disitis
Back pain, motor > sensory findings: red flag for spinal cord compression
Diagnosis, typical location
etiologies (3)
findings
associated with
Diagnosis, typical location: Syringomyelia of the cervical cord
etiologies: trauma, infection, idiopathic
findings: inter-osseous muscle wasting and loss of pain and temperature sensation in the hands
associated with: Chiari defects of the cerebellum
Hemorrhagic stroke
most common location
goal blood pressure, agents (3)
most common location: basal ganglia, thalamus
goal blood pressure, agents: 160/90, labetalol, nicardipine, nitroprusside
Stroke syndrome patterns (CNs, other motor, other sx)
Cerebral
Brainstem
Pontine (4)
Cerebral: cranial nerves, motor and sensory
Brainstem: ipsilateral cranial nerve and facial weakness; contralateral sensory and motor
Pontine: coma, miosis, gaze paresis, altered respiratory pattern
Stroke syndromes
MCA (3)
PCA
vertebrobasilar (4)
MCA: contralateral motor/sensory of face and arm, aphasia (dominant hemisphere)/hemi neglect (non dominant), contra homonymous hemianopia
PCA: contra homonymous hemianopia, visual agnosia
vertebrobasilar:
balance, vertigo, nystagmus etc.
dysarthria, dysphagia
quadriplegia
coma
Wallenberg’s syndrome: what, sx (3)
Locked-in” syndrome: what, sx (3)
Wallenberg’s syndrome: vertebral artery thrombosis, ataxia/n/v, decreased pain/temperature ipsilateral face, contralateral body, ipsilateral Horner
Locked-in syndrome: basilar artery occlusion at the pons (also seen in other conditions damaging the pons), patient awake and understanding, only motor activity is diaphragmatic breathing and vertical eye movements
Lacunar syndromes
diagnostic caveat
Types (5)
diagnostic caveat: often missed by CT (small micro infarct in the midbrain,HTN/DM), 25% of all ischemic strokes
Types (5)
your motor
pure sensory
ataxia-hemiparesis
dysarthria-heiparesis
mixed sesorimetor
Neurology trivia
blood pressure cut off for tPA
gaze preference during seizure versus intracerebral stroke
Ophthalmoplegic migraine
headaches worse on awakening
185/110
seizure away from focus, stroke-towards affected side
migraine with cranial nerve palsy’s of 3,4,6, diplopia
worse on awakening: hypoxia, mass, cluster, pseudo-tumor
Neurology trivia 2
myopathy weakness pattern
unexplained syncope consider
neurologic medication contraindicated in second and 3rd° AV block
Proximal greater than distal muscle weakness
vertebrobasilar ischemia
phenytoin
Neuroleptic malignant syndrome
etiology and timing
symptoms (3)
treatment (2)
etiology and timing: neuroleptics causing decreased dopamine, usually within two weeks of starting medication
symptoms (3): fever, AMS, unstable vital signs, elevated CPK/leadpipe rigidity
treatment (2): bromocriptine and dantrolene
Serotonin syndrome
etiology and cause categories (4)
symptom categories (3)
treatment (2)
etiology: Access central and peripheral serotonin - antidepressants, opioids, CNS stimulants, triptands symptom categories (3)
cognitive: AMS, agitation, hypomania, hallucinations, coma
autonomic: shiverring, diaphoresis, HTN, tachy, nausea, diarrhea
somatic: myoclonus, tremor, hyperreflexia
treatment (2): benzodiazepines, chlorpromazine, Cyproheptadine
