neuro shelf Flashcards
surgical evacuation of subdural hematoma if there is evidence of moderate to severe cognitive impairment, if the subdural hematoma is ≥ ?? mm, or if there is midline shift ≥ ?? mm on brain scan.
there is evidence of moderate to severe cognitive impairment, if the subdural hematoma is ≥ 10 mm, or if there is midline shift ≥ 5 mm on brain scan.
Focal deficits involving the contralateral lower limbs indicate involvement of the superior segment of the motor cortex
which herniation?
Subfalcine herniation is the most common cerebral herniation syndrome and is usually due to cingulate gyrus herniation under the falx cerebri, causing compression of the foramen of Monro (leading to hydrocephalus and consequent headache) and branches of the anterior cerebral artery (causing infarction in the ACA territory and consequent contralateral lower limb weakness).
Degeneration of the ???? is the most common cause of subacute or chronic ataxia in patients with alcohol use disorder (seen in 1% of cases). Cerebellar degeneration in this patient group occurs due to the direct toxic effects of alcohol or as a result of thiamine deficiency.
superior cerebellar vermis
This patient presents with periorbital edema, chemosis, high fever, and dysfunction of CN III (bilateral ptosis) and CN VI (impaired lateral gaze) 2 days after the onset of sinusitis.
septic cavernous sinus thrombosis
Intravenous vancomycin, ceftriaxone, and metronidazole
Antibiotic therapy is the mainstay of treatment
This patient has regained normal mental status after her first simple febrile seizure, what to do next?
discharge
Simple febrile seizure
The most common type of febrile seizure. Typically occurs among children 6 months to 5 years of age and is generalized, lasts less than 15 minutes, and does not recur within 24 hours. Usually followed by a quick return to a normal state without focal neurologic deficits, but confusion may be present for a short period of time.
is the most common cause of death in patients with Friedreich ataxia (FA).
heart failure
girl presents with progressive bilateral limb ataxia and weakness, loss of deep tendon reflexes, pallhypesthesia, dysarthria, and skeletal deformities
Inverted feet, hammer toes, and kyphoscoliosis are all typical skeletal deformities
Friedreich ataxia (FA)
The development of focal weakness after a seizure, which typically resolves within 48 hours. Thought to result from exhaustion of the primary motor cortex.`
Todd’s paralysis
darkening of the red reflex, obscuration of the ocular fundus indicate ???
cataracts
form of sensorineural hearing loss, which is identified by a bilateral positive Rinne test and no lateralization on Weber test. It is a multifactorial process caused by the degeneration of the organ of Corti that gradually develops over the course of years, often identified first by difficulty hearing in crowded spaces
Presbycusis
Alcoholic cerebellar degeneration is caused by the degeneration of Purkinje cells in the cortex of the ????
patients present with signs and symptoms of a midline cerebellar lesion, such as gait ataxia (especially on tandem gait), truncal ataxia, dysmetria predominantly affecting the lower extremities (elicited by the heel-knee-shin test), and gaze-evoked nystagmus
cerebellar vermis
Repeated exposure to sounds above a threshold of 85 dB (e.g., motorcycle) or a single exposure to sounds above 120–155 dB (e.g., gunshots, jet takeoffs) can lead to noise-induced hearing loss
Such hearing loss is slowly progressive and affects ?? frequencies (3–4 kHz) first
high
??? test should be performed in all patients with ALS to screen for >>
bedside swallowing test for dysphagia
ALS is characterized by concomitant upper motor neuron and lower motor neuron dysfunction and can manifest with pseudobulbar palsy and bulbar palsy, both of which result in dysphagia.
movement disorder that is associated with rheumatic fever and manifests with speech disorders, neuropsychiatric symptoms (e.g., agitation, anxiety), and involuntary choreiform movements
Sydenham chorea
symptoms of Sydenham chorea typically occur within 6 months after an infection with ??
S. pyogenes (most commonly pharyngitis)
Sudden, painless, transient monocular loss of vision with discoloration along the retinal arterial supply on fundoscopy is highly suggestive of ???
retinal artery occlusion
The best next step in management for a patient with retinal artery occlusion secondary to atherosclerotic emboli is ??
carotid duplex ultrasonography
?? disturbances are common in the later stages of Alzheimer disease and can result in anxiety and further disruption of patients’ cognitive status
Sleep disturbances
Behavioral and environmental regulation, such as adhering to a regular sleep schedule, maintaining a familiar environment, and removing ambient noise, should always be attempted for patients who are agitated or anxious before resorting to pharmacological treatment
?? tremors worsens under direct observation and diminishes with distraction (e.g., while working on the computer). The condition is often associated with psychiatric disorders (e.g., conversion disorder, anxiety disorder, depression).
quick progression to severe symptoms, significant functional disability, and changing of amplitude, frequency, and/or distribution of movement over time.
functional tremors
a postural tremor that typically affects the hands and head, worsens with voluntary movement and/or an anxious state, and is associated with an otherwise normal neurological examination.
Postural tremor = Tremor that appears when the body part is held in a fixed position against gravity
essential tremor
a coarse hand tremor that is aggravated by goal-directed movements (i.e., increases in frequency during a finger-to-nose tes
intention tremor
which pathogen?? cause nonpurulent conjunctivitis, which manifests with photophobia, pruritus on the periocular area, crusts over the eyelashes, conjunctival injection, redness, and watery discharge from the eye
usually unilateral and often manifests with a vesicular rash and corneal involvement (dendritic keratitis). Additionally, patients with a history of atopic dermatitis are particularly susceptible
Herpes simplex virus (HSV)
?? toxicity manifests with neurological symptoms (altered mental status, dysarthria, decreased muscle strength, coarse tremor).
and gastrointestinal symptoms (nausea, vomiting, diarrhea)
lithium toxicity
can be caused by dehydration (due to severe vomiting and diarrhea for the past 2 days), which predisposes him to acute lithium toxicity.
tx for lithium toxicity
lithium toxicity in patients with an altered mental status, seizures, and/or life-threatening arrhythmias
Hemodialysis
Painless and intermittent otorrhea, hearing loss, and a visible defect of the tympanic membrane in a patient who did not complete antibiotic treatment for acute otitis media (AOM) suggest chronic suppurative otitis media (CSOM)
which TX?
Topical fluoroquinolones, such as ofloxacin, in combination with aural toileting, are the preferred treatment for CSOM
The patient presents with a 5-day history fever and headache followed by the acute onset of altered mental status and focal neurological deficits. In combination with the MRI findings of a temporal hyperintense area (cMRT in T2), these signs and symptoms are highly suggestive of ????
herpes simplex encephalitis (HSE)
an acute or subacute inflammatory myelopathy that results in motor, sensory, and autonomic symptoms below the level of the affected segment
Transverse myelitis
Intermetatarsal neuroma (also called Morton neuroma) is caused by entrapment or enlargement of one of the plantar digital nerves
typically manifests with neuropathic pain in the plantar aspect of the foot that is exacerbated by palpation
which manuever?
Mulder sign
Pain is elicited when pressure is applied to the sole of the foot between the metatarsal heads
first-line abortive treatment for children with migraine.
NSAIDs or acetaminophen
A headache calendar should also be recommended to elucidate environmental triggers of headache (e.g., strenuous exercise, stress, certain food).
While there is no definitive treatment for patients with ALS, ??? can be used to slow down the deterioration of motor function and increase life expectancy by 3–4 months
riluzole
spontaneous, nonbullous subconjunctival hemorrhage (SCH) without other symptoms (e.g., changes in visual acuity, photophobia, eye pain, foreign body sensation) work-up???
reassurance and follow-up
Irritability, poor feeding, vomiting, delayed gross motor milestones, upper motor neuron signs (increased muscle tone and hyperreflexia), macrocephaly, a bulging anterior fontanelle, and an MRI showing symmetrical enlargement of all 4 ventricles indicate a symptomatic ?????
communicating hydrocephalus
tx for symptomatic communicating hydrocephalus in children
A ventriculoperitoneal shunt, which diverts excess CSF from the ventricles to the peritoneal cavity, is the standard of care to decrease intracranial pressure in children with a communicating hydrocephalus
?? is indicated for patients with neurologic deficits from spinal cord compression
neurologic symptoms (decreased leg strength and sensation, hyperreflexia, positive Babinski sign) are concerning for cord compression
IV glucocorticoids (dexamethasone)
Glucocorticoids reduce pain, inflammation, and edema, preventing further neurologic damage until definitive treatment is available (e.g., urgent decompression surgery).
If any alarm symptoms or features (immunocompromise, focal neurological deficits, abnormal level of consciousness, seizure at initial presentation, history of CNS disease) are present for meningitis
what to do?
dminister empiric antibiotic therapy until LP can be performed
**also do CT head first to make sure there is no herniation
a crescent-shaped, concave hematoma that crosses suture lines would be seen on CT scan.
subdural hematoma
which hematoma
epidural hematoma
apidly progressive dementia and myoclonus with associated aphasia and agnosia are suggestive of ??
Creutzfeldt-Jakob disease
???? are usually the first-line drugs for long-term prophylaxis of migraine headaches
Beta-blockers (e.g., propranolol)
Other drugs that may be used for migraine prophylaxis include antiepileptic drugs such as topiramate, sodium valproate, and sodium divalproate, tricyclic antidepressants (e.g., amitriptyline), and calcium channel blockers.
?? is recommended for all patients with a TIA as secondary stroke prevention.
Antiplatelet therapy with aspirin or clopidogrel
A noncontrast CT should be performed beforehand to rule out intracranial hemorrhage. Additional strategies for preventing recurrent TIA or stroke in this patient include lifestyle modifications (e.g., exercise, dietary interventions, and weight loss), optimizing blood pressure control, and initiation of statin therapy.
Symptoms include a cape-like distribution of decreased sensitivity to pain and temperature and flaccid atrophic paralysis in the upper extremities.
syringomyelia
(central cord syndrome, can be secondary to whiplash)
risk of expansion of syringomelia
expansion of the syrinx can damage descending hypothalamic fibers in the T1 to T4 segments, which carry sympathetic fibers from the hypothalamus to the intermediate horn, resulting in central Horner syndrome.
??? autoantibodies are seen in 10–25% of patients with CIDP
Progressive ascending motor and sensory deficits for greater than 2 months are characteristic of chronic inflammatory demyelinating polyneuropathy (CIDP).
Anti-GM1
??? indicated for severe or refractory post lumbar puncture headaches from cerebrospinal fluid (CSF) leak syndrome
epidural blood patch: autologous blood injected at the site of the lumbar puncture seals the hole in the dura and resolves the CSF leak that causes the postural headache.
The risk of hemorrhagic transformation is significantly increased in patients who have received thrombolytic medications (e.g., alteplase), antiplatelet therapy (e.g., aspirin, clopidogrel), and/or thrombosis prophylaxis (e.g., heparin, enoxaparin). Other risk factors for HT include hyperglycemia, hypertension, advanced age, delayed initiation of reperfusion therapy, and ??? infarct size.
large
Hemorrhagic transformation (HT) is a common complication of ischemic stroke and typically manifests with neurologic deterioration (e.g., new confusion, worsening neurological deficits) within ?? hours of the inciting ischemic event.
24–48
typically present with symptoms of hydrocephalus/increased ICP and involvement of the cerebellar vermis such as vomiting, morning headaches, ataxia, and cranial nerve dysfunction.
tumor in children
medulloblastoma is most common malignant in children
Ependymomas are often located in the posterior fossa and may also manifest with signs of hydrocephalus, as well as ataxia and cranial nerve dysfunction. However, these tumors are less common than medulloblastomas, accounting for ∼ 10% of pediatric brain tumors.
asymptomatic patients with relatively small (< 3 mm) linear, nondepressed skull fractures workup?
sent home
which patients require further observation for small linear, non-compressed skull fracture? (4)
- signs of potentially elevated ICP require further inpatient observation
- evidence of traumatic brain injury on imaging (e.g., intracranial hemorrhage)
- signs of physical abuse
- caregivers who are unreliable or unable to return if neurological deficits develop within 24 hours after release.
2 most important risk factors for cerebral palsy
Preterm birth and low birth weight
child has signs of UMN injury (positive ankle clonus, extensor plantar response), persistent Moro reflex, feeding difficulties, and developmental delays (all milestones are delayed except for rolling over, a sign of spasticity), as well as an MRI of the head showing periventricular leukomalacia. These features are all consistent with ???
cerebral palsy
Moro reflex?
Recurrent headaches and visual changes in a young woman with obesity and a history of vitamin A use raise concern for ????
Papilledema and an empty sella on MRI support the diagnosis.
idiopathic intracranial hypertension (IIH)
?? can be caused by axonal disorders (e.g., diabetes, alcohol use disorder, HIV, Charcot-Marie-Tooth disease) or demyelinating diseases (e.g., Guillain-Barré syndrome).
Polyneuropathy
??? is required in patients with myasthenic crisis and signs of impending respiratory failure (e.g., pallor, anxiety, tachycardia, tachypnea, cyanosis)
Early endotracheal intubation
The exacerbation of myasthenic symptoms is commonly triggered by infections (evidenced in this patient by the history of a sore throat, runny nose, and fever), surgery, anesthesia, pregnancy, or certain medications.
?? can cause nonpurulent conjunctivitis, which manifests with photophobia, pruritus on the periocular area, crusts over the eyelashes, conjunctival injection, redness, and watery discharge from the eye
usually unilateral and often manifests with a vesicular rash and corneal involvement (e.g., dendritic keratitis). Additionally, patients with a history of atopic dermatitis are particularly susceptible
Herpes simplex virus (HSV)
??? in combination with aural toileting, are the preferred treatment for chronic suppurative otitis media (CSOM
Painless and intermittent otorrhea, hearing loss, and a visible defect of the tympanic membrane in a patient who did not complete antibiotic treatment for acute otitis media (AOM)
Topical fluoroquinolones, such as ofloxacin,
5-day history fever and headache followed by the acute onset of altered mental status and focal neurological deficits. In combination with the MRI findings of a temporal hyperintense area (cMRT in T2), these signs and symptoms are highly suggestive of ???
herpes simplex encephalitis (HSE).
spontaneous, nonbullous subconjunctival hemorrhage (SCH) without other symptoms (e.g., changes in visual acuity, photophobia, eye pain, foreign body sensation), require what diagnostic workup or treatment??
Spontaneous SCH typically occurs as a result of maneuvers that increase venous pressure in the eyeball (e.g., coughing, straining, heavy lifting, vomiting, Valsalva maneuver).
NONE
Irritability, poor feeding, vomiting, delayed gross motor milestones, upper motor neuron signs (increased muscle tone and hyperreflexia), macrocephaly, a bulging anterior fontanelle, and an MRI showing symmetrical enlargement of all 4 ventricles indicate a symptomatic
communicating hydrocephalus
tx for communicating hydrocephalus
A ventriculoperitoneal shunt, which diverts excess CSF from the ventricles to the peritoneal cavity
Emergent administration of ??? is indicated for patients with neurologic deficits from spinal cord compression
glucocorticoids
?? are usually the first-line drugs for long-term prophylaxis of migraine headaches.
Beta-blockers (e.g., propranolol)
?? is recommended for all patients with a TIA as secondary stroke prevention.
Antiplatelet therapy with aspirin or clopidogrel, lifestyle modifications (e.g., exercise, dietary interventions, and weight loss), optimizing blood pressure control, and initiation of statin therapy.
?? is indicated for severe or refractory post lumbar puncture headaches from cerebrospinal fluid (CSF) leak syndrome
An epidural blood patch
Autologous blood injected at the site of the lumbar puncture seals the hole in the dura and resolves the CSF leak that causes the postural headache. Additional management includes sufficient fluid intake, oral analgesics, and bed rest.
patient’s dilated pupils, labored breathing, speech and swallowing difficulties, and flaccidity suggest a descending paralysis, likely due to ??
botulism
irreversibly inhibiting ACh release from motor endplates in the neuromuscular junction
Botulinum toxins are most often found in home-canned foods and packed meats
Medulloblastoma is the most common malignant brain tumor in children, with a peak incidence between 3–5 years of age. The mass is characteristically located in the ??
cerebellum
The metastasis of a primary central nervous system (CNS) neoplasm inferiorly, typically via cerebrospinal fluid (CSF). Typically presents as nodules along the spine and cauda equina that can cause back pain with neurologic symptoms (e.g., limb weakness). Can be detected by lumbar puncture
spinal drop metastases
A 3-week history of headaches, difficulty sleeping, difficulty concentrating, irritability, and fatigue after a mild traumatic brain injury (mTBI) is consistent with ??
postconcussion syndrome (PCS)
Reassurance and symptomatic therapy are the most appropriate management for patients with PCS
Contact lens use is an important risk factor for bacterial keratitis and is most commonly associated with what pathogen ??
Pseudomonas aeruginosa
A ??? should be performed on all patients following a syncopal episode to rule out cardiac syncope
electrocardiogram (ECG)
Lower extremity radiculopathy that worsens with standing or walking downhill is consistent with ??
lumbar spinal stenosis
In spinal stenosis, different postural changes can widen or narrow the spinal canal and thereby alleviate or worsen symptoms. By leaning forward, the spinal canal is widened and compression of the spinal cord is reduced
Status epilepticus can cause potentially irreversible tissue damage of the CNS, resulting in ??
cortical laminar necrosis (CLN)
seems to be associated with repeated seizures, hypoxia, and hypoglycemia
Following a grand mal seizure, a patient has what acid-base disorder??
postictal lactic acidosis, an anion gap metabolic acidosis that leads to a consequential decrease in serum bicarbonate.
A grand mal seizure is a highly exertional event, during which muscles utilize anaerobic respiration due to inadequate oxygen delivery
chronic ?? deficiency typically present with sensory peripheral neuropathy and hypochromic, microcytic anemia (sideroblastic anemia)
can be result of isoniazid toxicity
pyridoxine (vitamin B6)
?? are the most common cause of acquired hypopituitarism among children.
Craniopharyngiomas
Orbital cellulitis can be distinguished from preseptal cellulitis by the presence of
pain with ocular movements and vision changes
tricyclic antidepressants are generally considered a first-line treatment for postherpetic neuralgia
they are contraindicated in which patients? (give gabapentin instead)
caution in a patient with pre-existing heart disease because they may prolong the QRS and/or QT interval, and thus may lead to arrhythmias.
?? is characterized by sudden, painless loss of vision and an afferent pupillary defect, which manifests with no perception of light in the affected eye and an abnormal swinging flashlight test
Central retinal artery occlusion
The most common organism causing bacterial conjunctivitis in adults is
Staphylococcus aureus, followed by Streptococcal pneumoniae and Haemophilus influenzae. Erythromycin is effective against gram-positive and some gram-negative organisms, making it the empirical antibiotic of choice in patients with bacterial conjunctivitis.
Chronic inflammation and scaling at the eyelid margins associated with eye irritation and visual abnormalities is consistent with a diagnosis of
blepharitis
Warm compresses, lid massage, and gentle lid cleansing are the cornerstones of therapy
Typical symptoms caused by ?? tumors include gait ataxia, truncal ataxia, dysarthria, nystagmus, dysmetria, dysdiadochokinesia, and pronator drift
cerebellar
a rare inherited disorder characterized by the combination of primary brain tumors and colorectal cancer or polyposis.
Turcot syndrome
Mismatch repair cancer syndrome, Turcot syndrome
A rare inherited disorder characterized by the combination of primary brain tumors and colorectal cancer or polyposis. Associated with familial adenomatous polyposis (mostly medulloblastomas) and Lynch syndrome (mostly gliomas).
Once-monthly episodes of nonpulsating, pressing, band-like headache accompanied by a singular autonomic symptom (e.g., phonophobia) and pericranial muscle tenderness lasting 30 minutes to 7 days in conjunction with a normal neurologic examination are characteristic of episodic ????
tension-type headaches (TTHs)
typically starts with a prodrome (fever, headache, malaise) followed by unilateral painful impaired vision with reduced corneal sensation and vesicular skin lesions in the area innervated by the ophthalmic nerve (forehead, bridge, and tip of the nose)
Herpes zoster keratitis
Treatment with ??? is indicated for extracranial carotid artery dissection once a thrombus has been identified and intracranial hemorrhage has been ruled out by CT scan
antithrombotic agents (either anticoagulants such as heparin or antiplatelet drugs)
The presence of severe ipsilateral head and neck pain and partial Horner syndrome (ptosis and miosis) in combination with duplex ultrasonography of the neck showing absent flow in the left internal carotid artery, indicates a ???
carotid artery dissection
type of parasomnia characterized by short (< 60 seconds) dream enactments (e.g., yelling, moving limbs, walking, punching) due to loss of REM sleep atonia, which may lead to injury to self or others
Affected individuals are typically alert and orientated after awakening and remember their dreams.
REM sleep behavior disorder (RBD)
The gradual development of asymmetric lower limb weakness, reduced reflexes in both the knees and ankles, saddle anesthesia, bladder dysfunction, decreased anal tone, and severe back pain with radiation to the lower limb is the classic clinical picture of ??
cauda equina syndrome
what is characteristic of symptoms of Conus medullaris??
Symptoms occur symmetrically
??? in the thoracic spinal cord segments would produce symmetrical lower limb weakness, as well as loss of pain and temperature sensation
Sensation around the buttocks, inner thighs, and genitalia, as well as anal sphincter tone, are classically spared
Central cord syndrome
manifests with symmetrical lower limb weakness and loss of pain and temperature sensations in all areas below the level of the lesion
Anterior spinal cord syndrome
Stroke in this area most commonly manifests with contralateral homonymous hemianopia with macular sparing
The posterior cerebral artery
If the PCA of the nondominant (usually the right) hemisphere is affected, patients may present with
prosopagnosia
because the ??? also supplies the lateral parts of the thalamus, patients with lesions may also report contralateral hemisensory abnormalities such as numbness or paresthesia in the limbs, trunk, and/or chest. Further manifestations include memory deficits, vertigo, and nausea.
posterior cerebral artery (PCA)
If the PCA of the dominant (usually the left) hemisphere is affected, patients may also present with ???
alexia without agraphia, anomic aphasia, and/or visual agnosia due to ischemic damage to the splenium of the corpus callosum, which carries visual information from the visual cortex to the Broca area and Wernicke area
vision loss in the right halves of the visual field (nasal field on the left and temporal field on the right), which is consistent with right-sided ???
This finding suggests the involvement of the visual pathways behind the optical chiasma.
homonymous hemianopia
Bilateral periorbital ecchymosis (“raccoon eyes”) is a classic sign of which fracture?
basilar skull fracture involving the anterior cranial fossa
This man has blood-tinged fluid draining from his nose after trauma that shows a halo sign (rapidly expanding clear ring of fluid surrounding blood), indicating ??
the most likely explanation is a basilar skull fracture of the anterior cranial fossa.
CSF rhinorrhea
The presence of soft drusen near the macula is consistent with
age-related macular degeneration (AMD)
Wet vs nonexudative age-related macular degeneration
Exudative AMD (wet AMD) makes up 10% of cases and is associated with retinal neovascularization, retinal hemorrhage, and/or loss of vision that progresses more rapidly
Nonexudative AMD (dry AMD) is the most common type of AMD and leads to a slowly progressive central or pericentral loss of vision.
Timely drainage of a larger (≥ 2 cm) auricular hematomas < 7 days prevents the formation of a ???
cauliflower ear
which medication for essential tremors can cause acute intermittent porphyria:
elevated urinary levels of aminolevulinic acid and porphobilinogen and 5 P’s of AIP: Painful abdomen, Polyneuropathy, Psychologic disturbances, Purple pee, Precipitated by triggers (like drugs).
Barbiturates (like primidone) trigger acute intermittent porphyria by inducing synthesis of cytochrome P-450 enzymes that contain heme components, thereby reducing heme levels and leading to stimulation of δ-aminolevulinate synthase, which leads to increased levels and accumulation of δ-aminolevulinate and porphobilinogen
folate vs. Vit B12
folate: increased homocysteine levels, and normal methylmalonic acid levels
nystagmus is not typically seen in vitamin B12 deficiency, and levels of both homocysteine and methylmalonic acid would be increased
Headache that worsens when leaning forward, engorged veins over the anterior chest, and swelling limited to the head, neck, and upper extremities are consistent with
superior vena cava (SVC) syndrome
SVC syndrome is most commonly caused by
lung cancer (usually small cell lung cancer or squamous cell carcinoma) or non-Hodgkin lymphoma (particularly in younger patients)
which antipsych meds cause metabolic syndrome?
olanzapine and clozapine
donepezil and galantamine considered first line for?
Alzheimer disease
Also rivastigmine
Acetylcholinesterase inhibitors promote an increase of acetylcholine concentration on the synaptic gap and have been shown to improve cognition and the ability to perform everyday activities.
?? is appropriate additional therapy for patients with moderate to severe AD, which is defined as an MMSE score ≤ 18/30.
Memantine
An NMDA receptor antagonist used to treat moderate to severe dementia. Although the mechanism of action is unclear, memantine is thought to be neuroprotective. Glutamate agonizes NMDA receptors in certain neurons linked to memory in the hippocampus; excessive stimulation of these neurons may lead to damage (i.e., excitotoxicity). By blocking NMDA receptors, memantine may prevent excitotoxicity.
33-year-old female patient presents with acute, unilateral color blindness, a decrease in visual acuity, and pain with eye movements, all of which are consistent with ???
optic neuritis, which is often the first manifestation of multiple sclerosis (MS)
bilateral buttock pain with walking that is relieved by sitting and leaning forward suggests ??
spinal stenosis
tx for phantom limb pain?
gabapentin
multimodal approach is typically recommended, including mirror therapy, transcutaneous electrical nerve stimulation, NMDA receptor antagonists
combination of acute nausea, imbalance, and vertigo is concerning for acute vestibular syndrome (AVS)
The Head Impulse, Nystagmus, and Test of Skew (HINTS) exam is used to differentiate between central and peripheral causes of AVS. This patient’s negative head impulse test and vertical nystagmus are consistent with a ?? cause of AVS.
central
can be caused by cerebrovascular accident, a stroke affecting the cerebellum or brainstem
or demyelinating diseases of the CNS
common peroneal neuropathy presents with a foot drop (high stepping gait, weakness of foot dorsiflexion) and numbness in the distribution of both the superficial and deep peroneal nerves (dorsum of the foot and first web space, respectively)
foot eversion or inversion?
normal foot inversion because the primary muscle responsible for foot inversion (tibialis posterior) is not innervated by the peroneal nerve
superficial branch of the peroneal nerve controls foot eversion
A tremor that worsens as the hand reaches for an object (intention tremor) and overshooting of the target (hypermetria) indicate a lesion where?
cerebellar dysfunction
most likely cause of cerebellar dysfunction in a woman in her 40s is multiple sclerosis
sudden onset of flaccid paralysis and respiratory failure in a logger from Washington is highly suggestive of
tick paralysis
a neurotoxin produced in the tick’s salivary gland prevents acetylcholine release at the neuromuscular junction. Symptoms typically occur within 2–7 days. Patients present with very rapid ascending paralysis (over 24–48 hours) and ataxia, though mental status remains intact. The treatment simply consists of removing the tick and administering supportive measures (e.g., assisted breathing).
palpitations, dizziness, chest pain, dyspnea, syncopes, and urinary urgency together with the ECG findings (narrow QRS complex with no discernible P waves) suggest ?
paroxysmal supraventricular tachycardia (PSVT)
most commonly caused by atrioventricular nodal reentrant tachycardia (AVNRT) - AV node with slow and fast pathway
management of cervical fracture that is complicated by altered mental status with respiratory insufficiency (respiratory rate of 8/min) ??
Rapid sequence intubation
Cervical fractures may lead to immediate or delayed cervical spinal cord compression and/or phrenic nerve paralysis and subsequent respiratory failure
High doses of dexamethasone in pituitary vs. ectopic source of increased ACTH
dexamethasone sends a negative feedback response to the brain to decrease ACTH production. Since the pituitary is receptive to negative feedback loops but ectopic foci are resistant to negative feedback, cortisol levels will decrease to < 50% of baseline following high doses of dexamethasone if the patient has Cushing disease, but will be relatively unchanged in ectopic ACTH production.
Approx. 25% of patients on lithium develop which neuro sx?
symmetric, nonprogressive, fine (approx. 10 Hz) postural tremor in the distal ends of the upper extremities
Patient with Down syndrome presents with ataxia, quadriparesis, hyperreflexia, and vertebrobasilar symptoms (vertigo, diplopia). These symptoms suggest ??
atlantoaxial instability
tx: Surgical fusion of C1 (atlas) and C2 (axis) stabilizes the upper vertebrae
which drugs increase lithium toxicity?
ACE inhibitors, such as enalapril, cause vasodilation of the efferent arterioles and a subsequent decrease in GFR, which can lead to renal impairment. Lithium has a narrow therapeutic window, and any cause of renal impairment (e.g., chronic kidney disease, NSAID use) or volume depletion (e.g., due to diuretic therapy, cardiovascular disease) can precipitate lithium toxicity.
what are features of lithium toxicity? (4)
myoclonic seizures, altered mental status, coarse tremors, and neuromuscular excitability.
In older patients with MDD, cognitive deficits may resemble ??
dementia (i.e., pseudodementia)
teratogenic effects of valproic acid?
Inhibition of folate absorption in the mother due to valproic acid intake leads to an increased risk of neural tube defects such as spina bifida in the embryo, which may require lower spinal surgery after birth
Critically ill patients with an intact gastrointestinal tract can receive what kind of nutrition??
short-term enteral feeding via nasogastric tube (e.g., less than 3 weeks) if there are no contraindications. Enteral feeding is preferred over parenteral nutrition because it stimulates intestinal motility and prevents atrophy of the GI tract
first-line treatments for all prolactinomas
Dopamine receptor agonists such as cabergoline or bromocriptine
Dopamine agonists usually also induce regression of tumor size, thereby improving symptoms due to mass effect such as headaches or bitemporal hemianopsia.
how does hyperglycemia effevt vision?
. Hyperglycemia with subsequent osmotic diuresis affects visual acuity, most probably due to swelling of the lens.
Diarrhea, Urination, Miosis/Muscle weakness, Bronchospasm, Bradycardia, Emesis, Lacrimation, Lethargy, Salivation, and Sweating should raise concern for ??
cholinergic crisis (DUMBBELLSS)
organophosphate poisoning
tx: atropine; anticholinergic agent that competitively blocks muscarinic acetylcholine receptors
preferred imaging modality for TIA bc it shows even small ischemic changes within 30 minutes after onset (while a CT scan shows changes only after 6–24 hours) and can differentiate acute from chronic lesions
Diffusion-weighted MRI of the brain
neurologic abnormalities (likely TIA or stroke, confusion), fever, impaired renal function (increased BUN and creatinine), microangiopathic hemolytic anemia (decreased hemoglobin, elevated LDH and indirect bilirubin, schistocytes), and thrombocytopenia (platelets < 150,000/mm3)
thrombotic thrombocytopenic purpura (TTP)
A CD4 count < 200 cells/mm3 indicates AIDS. The MRI shows a confluent, hyperintense area of asymmetrical shape that mainly involves the right frontoparietal white matter without any mass effect. In conjunction with the progressive onset of focal neurological deficits, these findings suggest ???
Progressive multifocal leukoencephalopathy
PML is a demyelinating disease of the CNS caused by the reactivation of JC virus and is mainly seen in patients with severe immunosuppression (e.g., AIDS)
Rupture of small penetrating artery vs. saccular aneurysm
A noncontrast CT scan of the head characteristically shows a solitary hyperdense lesion surrounded by hypodense edema (most commonly within the basal ganglia or internal capsule) for small artery
saccular: a noncontrast CT scan of the head would characteristically show focal or diffuse hyperdensity within the subarachnoid space.
Cushing’s triad (hypertension, bradycardia, and irregular respiration) as a result of ??? due to traumatic brain injury (TBI).
increased intracranial pressure (ICP)
response to Cushing’s triad and increased intracranial pressure (ICP)
Elevated ICP leads to a decrease in cerebral perfusion pressure (CPP). The sympathetic nervous system is activated in this situation to increase mean arterial pressure to maintain CPP
spinal shock includes flaccid, areflexic paralysis, bradycardia, and absent ??reflex.
bulbocavernosus
Management of spinal cord injuries in an emergency setting involves obtaining vital signs, airway stabilization, immobilization of the neck and body, a thorough neurological examination, and ???
insertion of a urinary catheter
To prevent bladder distension, acute urinary retention (AUR), and eventual bladder rupture
Although ALS is primarily diagnosed clinically, patients with progressively worsening features of UMN and LMN degeneration should undergo ??? to confirm the diagnosis.
electromyography (EMG)
EMG findings in ALS include spontaneous fasciculation potentials, which reflect the random firing of denervated motor units, and fibrillations and positive sharp wave potentials, which reflect the activity of denervated muscle fibers at rest.
Livedo reticularis and peripheral edema occur as adverse effects in up to 5% of patients who take this medication for Parkinson’s
levido retic = reddish-blue discoloration of the skin in a reticular (net-like) pattern
amantadine
which test first when suspecting acute meningitis??
CT scan of the head before lumbar puncture (LP) is indicated in patients presenting with typical signs of acute meningitis accompanied by signs of increased intracranial pressure or a mass lesion (e.g., altered mental status). The primary goal of obtaining neuroimaging before LP is to mitigate the risk of brain herniation, which can be precipitated by the transient decrease in intracranial pressure caused by LP.
indications for performing a head CT prior to LP in patients with suspected meningitis are summarized in the mnemonic ???
“FAILS:” Focal neurological deficit, Altered mental status, Immunocompromised/ICP elevated, Lesion in the brain or skin near LP site, new-onset Seizures.
Ear pain, otorrhea, hearing loss, and granulation tissue in the external auditory canal are consistent with ??
malignant otitis externa
?? patients are at the greatest risk for developing malignant otitis externa.
Elderly diabetic
??? is a complication of TBI that is thought to be caused by the loss of inhibition of the sympathetic nervous system due to cortical injury.
It usually manifests about one week after the inciting event with recurrent episodes of hypertension, tachycardia, tachypnea, fever, diaphoresis, muscle spasms, and possibly dystonia with posturing.
Paroxysmal sympathetic hyperactivity (PSH)
Nieman Picks vs. Tay-Sachs main sx difference
NP has hePATomegaly
next step for suspected brain abscess (Headache, vomiting, and a focal neurologic deficit (abducens nerve palsy), increased intracranial pressure (ICP)
MRI brain
intraparenchymal lesion with a central hypointense (T1-weighted) or hyperintense (T2-weighted), purulent center and a peripheral ring will be visible
This patient’s presentation with apparent inattentiveness and difficulty following directions when directly spoken to, delayed language development (at 4 years, he should be able to speak in at least 4-word sentences), mispronunciation of words (due to poor speech discrimination), and symptoms of frustration (apparently unprovoked episodes of crying and screaming) warrants a thorough evaluation for ???
hearing impairment: in children can cause delays in speech, language, and cognitive development
Episodes of proximal muscle weakness and hyporeflexia with concomitant ECG findings of hypokalemia are consistent with ??
hypokalemic periodic paralysis (hypoKPP)
ECG: T wave flattening and inversion, prominent U waves, a prolonged PR interval, and ST segment depress
excessive daytime sleepiness, cataplexy (tilting of the head and jaw dropping), hypnagogic hallucinations, and sleep paralysis which condition?
tx?
narcolepsy
modafinil
? is used to differentiate neuropathic (e.g., carpal tunnel syndrome, Guillain-Barré syndrome) from myopathic muscle weakness (e.g., polyomyositis (PM), muscular dystrophy); results are abnormal in approx. 90% of patients with PM. If
Electromyography (EMG)
repeated episodes of painful neck stiffness after administration of haloperidol are suggestive of ??
acute dystonia
tx: benzotropine
focal seizure with impaired awareness is the main presenting feature of which epilepsy?
temporal lobe epilepsy
Focal seizures are caused by structural changes or damage to the brain (e.g., encephalitis, developmental disorders) and originate in the temporal lobe of one brain hemisphere
?? is the strongest predisposing factor for both ischemic and hemorrhagic stroke.
Hypertension
first-line disease-modifying drugs for ??? include glatiramer acetate, dimethyl fumarate, teriflunomide, and fingolimod.
relapsing-remitting MS
*also interferon-beta is one of the drugs
??? has been shown to improve both survival and quality of life in patients with a single brain metastasis.
Surgical resection
delayed development, autistic behavior, long and narrow face with a prominent chin, protruding ears, and above average head circumference indicate
fragile X syndrome
*commonly have mitral valve prolapse
Chest pain, diaphoresis, agitation, elevated temperature, tachycardia, hypertension, and mydriasis suggest the use of stimulants (e.g., amphetamine, cocaine)
tx ??
benzodiazepines such as lorazepam
Neuroleptic malignant syndrome (NMS) is a condition most commonly associated with which drug use??
It presents with altered mental status, fever (often > 39°C/102.2°F), diaphoresis, muscle rigidity, and tachycardia
antipsychotics like haloperidol
first line therapy for restless leg syndrome
gabapentin: alpha-2-delta calcium channel ligands (e.g., gabapentin) are considered first-line pharmacotherapy for RLS
Pharmacotherapy is reserved for severe cases of primary RLS (i.e., symptoms result in functional impairment and sleep disturbance) and patients who do not respond to behavioral interventions (e.g., sleep hygiene, leg massage) or the attempted correction of any iron deficiency (in the case of secondary RLS)
??? and ??? are used as a first-line treatment for painful diabetic neuropathy. The SNRIs duloxetine and venlafaxine can also be used as first-line treatment but are relatively contraindicated for patients already taking a serotonergic agent, such as tramadol, because of the associated risk of serotonin syndrome.
gabapentin and pregabalin
?? is the first-line treatment for the acute management of severe migraine in pregnant patients
Acetaminophen
triptans have vasoconstrictive effect on uteroplacental vessels and increased uterotonic activity, both of which can contribute to fetal growth retardation and intrauterine fetal demise.
Lateral cerebral ventricle enlargement (in addition to decreased cortical volume) is one of the most consistent MRI findings in which patients???
schizophrenic patients
The specific reason for ventricular enlargement is not known, but it seems to stem from diffusely decreased cortical volume and shrinkage of the thalamus and putamen. Frequent use of cannabis is a risk factor for psychosis.
The combination of vertical gaze palsy, nystagmus, eyelid retraction on looking upwards, and pupils that do not react to light, but do accommodate, suggests Parinaud syndrome which raises concern for???
Pinealoma, a tumor of the pineal gland
most common type of pinealoma in children is a germinoma = precocious puberty
Brain dead = cause + demonstrate via examination that the patient is comatose, does not have brain-mediated motor responses (e.g., decorticate or decerebrate posturing, facial grimacing) to noxious stimuli applied above and below the neck, has brainstem areflexia, and has a positive ?? test.
apnea test
After preoxygenation with 100% oxygen, the patient is disconnected from the ventilator and observed for evidence of respiratory drive (such as gasps or chest movement). After 8–10 minutes, an arterial blood gas reading is obtained. If the PCO2 is elevated above normal levels, this signifies an absence of respiratory drive, and the apnea test is considered positive.
A history of palpable purpura, increased fatigue, progressive sensorimotor neuropathy, mildly decreased C3 levels, and nearly undetectable C4 levels in a patient with hepatitis C (hepatitis C antibody and HCV RNA positive) is suggestive of ???
mixed cryoglobulinemia
??? should be the initial step in the treatment of patients with severe HCV-associated mixed cryoglobulinemia to reduce inflammation and prevent organ damage.
Immunosuppressive therapy (e.g., rituximab and high-dose prednisone)
Pneumocystis pneumonia prophylaxis (trimethoprim-sulfamethoxazole) is also recommended in all patients with mixed cryoglobulinemia who receive immunosuppression
n a child with a recent history of a sore throat, rapid onset of involuntary purposeless movements, emotional lability, hypotonia, inability to sustain contraction (“milkmaid grip”), and flexion of the wrist and extension of the digits when the arms are extended most likely indicate
Sydenham chorea
****feature of rheumatic fever
inflammation within the basal ganglia and cortical structures leads to Sydenham chorea
Treatment with penicillin V is indicated to completely eradicate S. pyogenes and address the underlying cause of this cross-reaction.
??? is the most common brain tumor in children and is usually located within the posterior fossa.
Imaging typically shows a well-circumscribed, enhancing cystic mass within one of the cerebellar hemispheres, but it can also occur in the cerebral hemispheres.
Pilocytic astrocytoma
typical (fluphenazine) vs atypical antipsychotics (risperidone)
atypical antipsychotics have weaker interactions with D2 dopamine receptors, resulting in less dopamine antagonism and lower rates of extrapyramidal symptoms than typical antipsychotics.
infant c. botulinum vs c. tetani
tetani: muscle spasms, myoclonus, irritability, and poor feeding
botulism: hypotony, weakness, poor feeding, and irritability
what is hypercalcemia of malignancy?
metastatic lytic bone lesions cause hypercalcemia
Patients with mild to moderate hypercalcemia are typically asymptomatic or develop symptoms such as constipation, fatigue, and polyuria. Severe hypercalcemia (hypercalcemic crisis), which is seen here, is a life-threatening condition that manifests with oliguria/anuria, dehydration, gastrointestinal symptoms, and an altered level of consciousness
?? antibodies are specific to both dermatomyositis and polymyositis.
Anti-Jo-1
The presence of anti-Jo-1 antibodies is associated with a more aggressive disease course and an increased risk for interstitial lung disease.
?? antibodies may be present with dermatomyositis or polymyositis and are typically associated with a more favorable prognosis
Anti-Mi-2
patients with meningiomas at the ?? present with sensory and motor deficits typically start in one extremity and spread to the others. Late presentation is characterized by spastic quadriparesis (hyperreflexia, positive Babinski’s sign), gait disturbances, and lower cranial nerve palsies (CN IX–XII)
foramen magnum
Hypotonia (floppy infant syndrome), bulbar palsy symptoms (e.g., tongue fasciculations, difficulty feeding), and hyporeflexia are characteristic of ????
Children can also present with recurrent hip dislocation (differences in leg length with external rotation of the affected leg)
Spinal muscular atrophy (SMA) is an autosomal recessive condition caused by apoptosis of lower motor neurons
Leg pain associated with sensory, motor, and vasomotor symptoms following a femur fracture is consistent with
usually develop within 4–6 weeks of the event
complex regional pain syndrome (CRPS)
Physical and occupational therapy is the recommended first-line therapy for CRPS
An acute neurological syndrome caused by thiamine deficiency that is characterized by a triad of confusion, ophthalmoplegia, and ataxia. Requires emergency treatment with thiamine repletion. Typically occurs in alcoholics.
Wernicke encephalopathy
Chronic neurologic condition characterized by selective anterograde and retrograde amnesia with relative preservation of long-term memory. Occurs as a consequence of long-term thiamine deficiency
Korsakoff syndrome
A combination of ???? and ???? are used for empiric treatment of community-acquired meningitis to cover the most likely pathogens in patients between 1 month and 50 years of age, including S. pneumoniae, N. meningitidis, and H. influenza.
Meningococcal meningitis has a high case fatality rate (up to 13%). Rifampin is indicated for post-exposure prophylaxis in all close contacts
vancomycin and a third-generation cephalosporin (ceftriaxone, cefotaxime)
In a high-pressure environment (e.g., during scuba diving), a large amount of gas (primarily nitrogen) is dissolved in blood and tissue fluid. With a sudden subsequent decrease in pressure (e.g., during rapid ascent), air bubbles form because the gas is no longer dissolved (Henry’s law) and they begin to expand (Boyle’s law). These bubbles cause local tissue damage and are primarily responsible for the multisystem manifestations of decompression sickness, which can also include chest pain, dyspnea, myalgia, arthralgia, pruritus, painful lymphadenopathy, and lymphedema.
what is the treatment?
hyperbaric oxygen therapy
vitamin B12 deficiency can manifest with symmetrical peripheral sensorimotor neuropathy, it causes ? type of paresis
**spastic
not flaccid
Progressive symmetric loss of sensation, dysesthesia, decreased muscle strength, and hyporeflexia in the distal lower extremities are consistent with
polyneuropathy
?? is the first step of care in patients with conversion disorder
Patient education
symptoms may resolve after an explanation of the diagnosis and its causes. Strategies for presenting the diagnosis to patients include asking about their perspective of the problem, taking their symptoms seriously, explaining clinical features that are inconsistent with neurologic disease, and emphasizing that symptoms are potentially reversible.
PCP vs stimulants (cocaine/meth)
physical sx
PCP leads to miosis
cocaine or methamphetamine commonly present with dilated pupils
initial step in diagnosis of Duchenne muscular dystrophy (DMD)
serum CK concentration should be obtained as the first step in diagnosis and genetic analysis for DMD gene mutations should then be performed to confirm the diagnosis
how does hypothyroidism cause nipple discharge?
in primary hypothyroidism secretion of thyrotropin-releasing hormone (TRH) by the hypothalamus stimulates the lactotroph cells of the anterior pituitary to release prolactin = nipple discharge + vaginal atrophy in women
As a general rule, patients with a GCS score of ??? or below as a result of traumatic brain injury require intubation and mechanical ventilation to protect the airway and ensure adequate ventilation.
8
High-dose ??? is the treatment of choice in patients with confirmed primary CNS lymphoma.
methotrexate
??? nerve damage, therefore, causes hypertropia (one eye is deviated upward) and vertical diplopia
Trochlear nerve
superior oblique muscle (SOM) is a depressor and intortor of the eyeball.
Abduction of the thumb followed by slow relaxation upon percussion indicates
myotonia:
a very slow relaxation of the muscle after cessation of contraction. Occurs as a result of prolonged depolarization of muscle fibers due to instability of the sarcolemmal membrane.
diabetic mononeuropathy causes ptosis or dilated pupils and why?
Ptosis occurs in patients with oculomotor nerve palsy because the levator palpebrae superioris muscle is innervated by the oculomotor nerve CN3
Whereas patients with oculomotor nerve palsy due to compression usually show dilated pupils, those with diabetic mononeuropathy normally do not have pupillary involvement because the microangiopathy typically involves the vasa nervorum within the oculomotor nerve, while the pial blood vessels (which supply the superficial parasympathetic fibers) are usually spared.
Ring-enhancing lesions seen on MRI, neurologic symptoms (e.g., headache, seizures), and eosinophils in cerebrospinal fluid should raise concern for ??
neurocysticercosis
Cerebral Taenia soleum infection
What test confirms suspected carpal tunnel syndrome (CTS)?
Nerve conduction studies
prolonged altered mental status, headache, Todd paralysis, and aphasia for minutes-to-hours after onset of sx
what happened?
postictal seizure state
remember chronic alcoholics are at increased rx of seizures from alcohol withdrawal
sharp, burning, and radiating pain that worsens with prosthesis use (i.e., when pressure is applied to the stump)
Traumatic neuromas
arise from the disorganized proliferation of nerve fibers or their myelin sheath and usually develop within the first year following amputation.
an indolent type of non-Hodgkin lymphoma that is caused by abnormal production of IgM antibodies by monoclonal plasma cells. This condition usually manifests in older patients with impaired platelet function (nosebleeds), anemia, and mild thrombocytopenia, progressive neuropathy (history of pain and numbness in the feet, muscle weakness), and hyperviscosity syndrome (vision and hearing loss)
Waldenstrom macroglobulinemia
Rapidly deteriorating vision, hearing, motor abilities, and cognition alongside spastic tetraplegia, sensory loss, and adrenal insufficiency (suggested by hyperpigmented skin, fatigue, nausea) in a young boy are characteristic of ???
adrenoleukodystrophy
rare X-linked recessive neurological disease caused by a dysfunctional peroxisomal ATP-binding cassette transporter protein due to a mutation in the ABCD1 gene
main distinguishing factor is the presence of adrenal insufficiency (usually manifesting with hyperpigmented skin but also fatigue, nausea, vomiting, hypotension, etc.
what is the use of trihexyphenidyl and biperiden
Initial monotherapy with an anticholinergic (e.g., trihexyphenidyl, benztropine, biperiden) can be considered in patients with PD who are ≤ 65 years of age if the main symptom is resting tremor and there is no evidence of cognitive impairment, significant bradykinesia, or gait disturbance.
Treatment with natalizumab increases the risk of developing
About 80% of the general population has this latent infection
progressive multifocal leukoencephalopathy (PML), a demyelinating disease of the CNS caused by the reactivation of the JC virus (JCV).
??? is the most appropriate next step in management in patients with an unprovoked first seizure if an intracranial process (e.g., hemorrhage) is suspected = altered mental status, continued disorientation, headache
neuroimaging
most likley CT noncon of head
3 sx of HIV encephalopathy (CD4 count < 200/mm3).
subacute onset of memory impairment, depressive symptoms, and movement disorders (ataxia, dysdiadochokinesia)
is the most common cause of viral encephalitis.
Herpes simplex virus (HSV)
1st, 2nd, 3rd steps for spinal epidural abscess
- MRI of spine
- blood cultures
- empiric antibiotics
- surgical drainage & decompression
which condition?
Hamartomas may manifest in the skin as shagreen patches, angiofibromas, and ash-leaf spots; in the CNS, with secondary seizures, hydrocephalus, and/or intellectual disability; in the kidney, as angiomyolipomas (which may cause pain and impairment of renal function), benign cysts, or renal cell carcinoma
Tuberous sclerosis
initial management of delirium with or without agitation is nonpharmacological and includes measures such as verbal redirection, reorientation, and physical restraints.
If patient continues to be violent and destructive, and verbal redirection has been unsuccessful, first-line pharmacotherapy is???
Haloperidol is the drug of choice for refractory agitation in patients with delirium
corneal haziness with neovascularization is called pannus and is a classic presentation of active ???
initially manifests as follicular conjunctivitis and then progresses to a mixed papillary and follicular conjunctivitis
Trachoma is caused by Chlamydia trachomatis serotypes A–C.
which brachial plexus injuries can be seen from shoulder dystocia from birth trauma?
neonatal Horner syndrome (damages cervical sympathetic nerve fibers) and Klumpke palsy can also result from brachial plexus injury (due to damage of C8 and T1 nerve fibers that supply the ipsilateral intrinsic hand muscles), causing an absent grasp reflex
appearance of gram-negative coccobacilli in cerebrospinal fluid (CSF) in an unvaccinated child w/meng sx indicates
Haemophilus influenzae
rx of transient or permanent sensorineural hearing loss as a result of the spread of infection from the meninges to the cochlea via the cochlear aqueduct
weight gain, bradycardia, and cognitive symptoms that can mimic Alzehimer’s disease/dementia indicate?
elderly patients with hypothyroidism
in a patient history of polysubstance use disorder, after administration of antagonists, which drug can cause seizure?
Benzodiazepine withdrawal due to administration of its antagonist, flumazenil, may precipitate withdrawal seizure, especially in patients with high tolerance to benzodiazepines from chronic use.
If benzodiazepine dependence is suspected, an anticonvulsant (e.g., carbamazepine) is indicated as seizure prophylaxis
where is inflammation in polyomyositis?
Intrafascicular infiltration on muscle biopsy
Inflammatory cellular infiltrates of cytotoxic T cells within muscle fascicle
lab findings for polymyositis?
mildly elevated levels of inflammatory markers: CRP, ESR; and muscle enzymes: creatine kinase, lactate dehydrogenase, AST, and ALT
child has multiple pigmented iris nodules (Lisch nodules), ≥ 6 hyperpigmented macules (café au lait spots), and numerous soft, pedunculated skin nodules (neurofibromas). These findings fulfill the diagnostic criteria for ??
neurofibromatosis type 1 (NF1)
tests for neurofibromatosis type 1 (NF1)
All patients with NF1 and visual symptoms should undergo MRI of the brain with contrast for further evaluation. In addition, all children with NF1 should undergo an annual ophthalmologic examination to screen for optic glioma.
most common CNS tumor associated with NF1
optic glioma
4 brainstem reflexes that must be checked prior to declaring brain death
If all these reflexes are negative, an apnea test is performed, which can confirm the diagnosis
corneal reflex, the gag reflex, cough reflex, and pupillary light reflex
patient presents with symptomatic thrombocytopenia (platelet count < 150,000/mm3, epistaxis, petechiae), microangiopathic hemolytic anemia (schistocytes, elevated LDH, elevated indirect bilirubin, decreased hemoglobin), neurologic abnormalities (seizure, confusion), and renal insufficiency (elevated creatinine). These findings are consistent with ???
thrombotic thrombocytopenic purpura (TTP)
tx for thrombotic thrombocytopenic purpura (TTP).
Plasma exchange therapy + glucocorticoid (e.g., prednisone)
1st vs 2nd gen antipsychotics
second-generation antipsychotics (e.g., quetiapine, ziprasidone) exhibit antagonistic activity at 5-HT2A receptors, and, to a lesser degree, D3, α-adrenergic, and H1 receptors and weaker D2 receptor antagonists than first-generation antipsychotics
Impaired adduction of the ipsilateral eye and abduction nystagmus of the contralateral eye (i.e., dissociated nystagmus) on lateral horizontal gaze should raise concern for
internuclear ophthalmoplegia (INO)
often caused by MS, demyelination of the medial longitudinal fasciculus (MLF)
??? is used to treat symptomatic exacerbations in acute intermittent porphyria (AIP).
Five P’s” of acute intermittent porphyria (AIP): Painful abdomen, Polyneuropathy, Psychologic disturbances, Precipitated by drugs/alcohol, and Purple pee
Hemin
It functions as an inhibitor of δ-aminolevulinate synthase which in return leads to decreased heme synthesis and decreased production of intermediates that are thought to cause symptoms in AIP.
exposure to what??
distal sensorimotor polyneuropathy, white bands across the nails (Mees lines), and hyperkeratosis. Workers in battery factories have an increased risk of being exposed
arsenic
cause of death in acromegaly
**cardiomyopathy
Cardiovascular complications such as hypertension, concentric ventricular hypertrophy, and arrhythmias are the most common complications and the cause of death in ∼ 60% of patients with acromegaly.
initial treatment of choice for cryptococcal meningitis
India ink stain showings a prominent capsule = infection with Cryptococcus neoformans.
intravenous amphotericin B and oral flucytosine for at least 2 weeks
Oral fluconazole is then administered for at least 8 weeks (consolidation therapy)
followed by maintenance therapy with lower dose fluconazole for at least 12 months.
what work-up is needed for clinically suspected Bell’s palsy?
tx?
NONE for routine, idiopathic Bell’s palsy
Imaging studies and blood tests are appropriate for atypical presentations, such as a slowly progressive palsy (which may be caused by mass effect from a tumor) or bilateral involvement (which may be caused by Lyme disease)
Tx: oral glucocorticoids
?? are the first-line treatment for primary open-angle glaucoma (POAG)
Topical prostaglandins such as latanoprost
Children with a history of seizure disorder are at increased risk of having a seizure with the administration of the ?? vaccine.
vaccine is contraindicated for children with uncontrolled seizures
pertussis
Watery diarrhea, crampy abdominal pain, episodic cutaneous flushing triggered by eating or emotional events, asthma-like attacks, and a murmur indicative of tricuspid regurgitation are highly suggestive of ??
carcinoid syndrome
serotonin secretion from extraintestinal neuroendocrine tumors
deficiency caused by carcinoid tumors
Pellagra, or niacin deficiency =
Dementia, dermatitis, diarrhea, and glossitis
Slowed and reduced amplitude of repetitive movements (e.g., foot tapping, opening and closing the hand, or tapping thumb and index fingers) is a sign of ????? , which is a hallmark feature of PD
bradykinesia
New-onset seizure and CT scan results showing ring-enhancing lesions in a patient with HIV infection are highly suggestive of a diagnosis of ???
cerebral toxoplasmosis
Treatment of cerebral toxoplasmosis consists of (3)
pyrimethamine, sulfadiazine, and leucovorin (folinic acid)
Pyrimethamine and sulfadiazine inhibit folic acid metabolism in T. gondii, while folinic acid is administered to alleviate myelotoxic side effects
caused by narrowing of the central spinal canal due to degenerative changes of the spine. This condition most commonly affects older adults (> 50 years of age) and usually manifests with neck pain (which can radiate to the arms due to concomitant nerve root compression), paresthesias, findings of lower motor neuron injury at the level of the lesion (e.g., hyporeflexia), and findings of upper motor neuron injury below the level of the lesion (e.g., hyperreflexia, Babinski sign)
cervical spondylotic myelopathy (CSM)
Parkinson-plus syndromes should be considered if parkinsonism does not ??
respond to levodopa treatment
??? is a neurodegenerative disease that belongs to the Parkinson-plus syndromes. It is characterized by motor abnormalities (tremor and rigidity), autonomic dysfunction (orthostatic hypotension and urinary incontinence), and cerebellar symptoms (dysdiadochokinesia, gait disturbances, dysarthria).
Multiple system atrophy
??? is the screening test of choice for Lyme disease
Patient presents w/ peripheral facial nerve paralysis
Enzyme-linked immunosorbent assay (ELISA)
If ELISA is positive, Western blot should be performed to confirm the diagnosis
Patients with neurosarcoidosis most commonly present with ??? ; some may have meningitis, peripheral neuropathy, myopathy, and neuroendocrine dysfunction, such as hypopituitarism or central diabetes insipidus
Chest x-ray is the most appropriate initial test
facial nerve palsy
???? radiculopathy typically manifests with ipsilateral pain or paresthesia extending from the dorsal medial forearm up to the fingers II–IV and in palmar fingers II–IV (ulnar half of II, III entirely, radial half of IV). Damage to the root leads to impaired function of the triceps, wrist flexor, and finger extensor muscles as well as a reduction in triceps reflex.
C7
???? radiculopathy typically manifests with ipsilateral pain and paresthesia extending from the radial aspect of the forearm to the thumb and radial side of the index finger
damage to the nerve root leads to impaired function of the biceps and wrist extensor muscles as well as a reduction in biceps and brachioradialis reflexes, none of which is seen here.
C6
??? radiculopathy typically manifests with ipsilateral pain and paresthesia over the anterior shoulder
damage to the nerve root leads to impaired function of the biceps and deltoid muscles as well as a reduction in biceps reflex
C5
cupped optic discs (a cup-to-disc ratio > 0.6), optic disc pallor, and decreased visual acuity == ??
Open-angle glaucoma
Chronically increased intraocular pressure in patients with open-angle glaucoma causes slowly progressive optic nerve atrophy
unvaccinated patient has a 3-day history of coryza, cough, conjunctivitis (the “3 Cs”), fever, and multiple bluish-gray lesions on an erythematous background, all of which suggest an active ???? infection
measles
*blue-grayish spots are koplik spots
??? is a rare NEURO complication of measles infection
usually develops at least 7 years after the initial infection and is characterized by dementia, myoclonus, and epilepsy, leading to coma and death
Subacute sclerosing panencephalitis (SSPE)
Broca aphasia is caused by damage where?
inferior frontal gyrus of the dominant (typically left) hemisphere
MCA
first-line treatment for trigeminal neuralgia ??
Carbamazepine
??? cancer is also the single most common source of brain metastases
Lung
several round lesions at the border of the gray and white matter of the brain suggest ??
brain metastases
Intravenous or intramuscular antiemetics such as prochlorperazine or chlorpromazine can be used as monotherapy for ???? , especially if sx are associated with vomiting
acute migraine attacks
Forceps-assisted delivery increases the risk of developing which neuropathy?
peripheral facial nerve palsy as the forceps compress the facial nerve against the mandible or parts of the skull
In neonates (age < 1 month), empiric treatment for bacterial meningitis consists of ??
ampicillin plus an aminoglycoside (e.g., gentamicin) and/or a third-generation cephalosporin (e.g., cefotaxime).
pathogens responsible for neonatal meningitis
Typically caused by group B Streptococcus, E. coli, or L. monocytogenes.
female patient is > 50 years old and presents with amaurosis fugax, jaw claudication, headaches, constitutional symptoms (night sweats, weight loss, fatigue), and a markedly elevated ESR
what diagnosis??
giant cell arteritis (GCA)
??? typically manifests with both upper and lower motor neuron signs. Bladder and bowel dysfunction within hours of the injury, hyperreflexia of the ankles, symmetric lower extremity weakness, and back pain are all consistent with this diagnosis.
Conus medullaris syndrome
??? are the most common cause of viral meningitis
Enteroviruses (e.g., coxsackieviruses)
first-line treatment for patients with suspected giant cell arteritis (GCA)
Medium doses of oral glucocorticoids, such as prednisone, are indicated in patients without signs of acute ischemic organ damage (e.g., impaired vision and/or neurologic deficits)
**also temporal artery biopsy
2 signs of neurosyphilis
positive Romberg test suggesting tabes dorsalis and
Argyll Robertson pupil: Bilateral miosis and light-near dissociation as a result of a dorsal midbrain lesion, which selectively damages the fibers that control the pupillary reflex but spares the more ventral fibres that control the accommodation reflex
A patient with a tibial fracture, pale, cool skin, weak peripheral pulses, as well as increased capillary refill time and a positive stretch test (pain in the calf muscle on passively dorsiflexing the foot) all suggest ???
compartment syndrome and impending critical limb ischemia
tx: Fasciotomy
??? is the prophylactic treatment of choice for chronic tension headache, which is defined as episodes occurring at least 15 days per month for more than 3 months
Amitriptyline
chronic tension headache is defined as ??? episodes occurring at least per month for more than 3 months
>15 days
Mastoiditis is a severe complication of acute otitis media that usually manifests with persistent or recurrent symptoms of otitis media after initial improvement, profuse ear discharge, a tender and edematous mastoid, and anterolateral protrusion of the auricle.
Mastoiditis should usually be confirmed via what imaging??
CT scan of the temporal bone
gold standard test for diagnosis of angle-closure glaucoma
Gonioscopy allows for direct visualization of the anterior chamber angle of the eye
recommendation for mild TBI
Observe for 6 hours in the ED and refrain from contact sports for one week
progressive worsening headache, chemosis, cranial nerve VI palsy (impaired right-sided lateral gaze), increased intracranial pressure (evident by headache and bilateral papilledema), and the occlusive lesion in a cerebral sinus on imaging indicates ????
cerebral venous thrombosis (CVT)
tx for cerebral venous thrombosis (CVT)
low molecular weight heparin (LMWH), such as dalteparin
what is a favorable prognistic factor for schizophrenia??
acute onset of symptoms
adverse effect of cyclophosphamide (often given to patients with polyarteritis nodosa)
SIADH
shaken baby syndrome is associated with what type of hematoma??
subdural hematoma
**shearing of briding veins
also diffuse axonal injury is seen
Reye syndrome presents with features of ????? such as profuse vomiting, lethargy, altered mental status, headache, and papilledema (due to increased intracranial pressure).
hepatic encephalopathy
compression of adjacent white matter and/or a rim of cerebrospinal fluid (CSF) around the tumor (hyperintense appearance of CSF on T2-weighted imaging) indicate which tumor
meningioma
occupations that involve hammering and lifting heavy objects, such as carpentry, the ulnar nerve can be compressed proximally within the ???? as a result of repetitive elbow flexion, which decreases the volume of the cubital tunnel. Decreased pinch strength occurs as a result of weakness of the adductor pollicis muscle, which appears as the Froment sign.
cubital tunnel (cubital tunnel syndrome)
headaches, vision abnormalities (e.g., blurry vision, diplopia, photopsia), and bilateral papilledema
most commonly seen in women with obesity aged 15–44 years
Idiopathic intracranial hypertension
Mixed lytic and sclerotic lesions are typical radiological findings in
Paget disease of bone (PDB)
Carbamazepine can cause what systemic syndrome as a side effect?
drug-induced hypersensitivity syndrome (HSS): fever, lymphadenopathy and a diffuse morbilliform rash that progresses to confluent erythema with accentuation of the hair follicles, as well as facial edema.
HSS usually develops 2–8 weeks after initiating treatment and is also referred to as drug reaction with eosinophilia and systemic symptoms (DRESS) as further symptoms include hematologic abnormalities (e.g., leukocytosis with eosinophilia), and internal organ involvement (e.g., hepatitis, pneumonitis, nephritis)
hemiparesis, hemisensory deficits, miotic and nonreactive pupils, and gaze deviation downward and toward the affected side of the body (i.e., away from the side of the brain lesion) is a phenomenon known as “wrong way eyes” and characteristically occurs in hemorrhage where??
thalamus
ataxia, ophthalmoplegia, and areflexia a few weeks after an infection
Miller-Fisher syndrome (MFS)
Detection on serological testing of anti-GQ1b antibodies, which are specific to MFS, confirms the diagnosis
MRI classically appear as ring-enhancing masses with perifocal edema. These tumors are typically located in the supratentorial white matter of the cerebral hemispheres (e.g., left temporal lobe), and may cross the midline (i.e., butterfly ??)
astrocytomas (gliobastoma)
One of the first signs of magnesium sulfate toxicity is ????
If left untreated, the toxicity can progress to respiratory depression and even cardiac arrest.
depressed or absent deep tendon reflexes.
simple febrile seizure (a generalized seizure lasting < 15 minutes) due to herpangina
what is the treatment?
Antipyretic therapy (NSAIDs such as ibuprofen, or acetaminophen)
Symptomatic management of neuropathic pain from diabetic peripheral neuropathy can be achieved with SNRIs such as ????
duloxetine
One of the major complications of long-standing undertreated diabetes mellitus is ????, which typically arises 5–10 years after disease onset and may manifest as diabetic nephropathy, retinopathy, or neuropathy
microvascular damage
??? is commonly seen in patients with multiple sclerosis or spinal cord injury. involuntary contractions of the detrusor muscle press small amounts of urine against the contracted sphincter muscle = irregular, small volume loss of urine and the lack of an urge to urinate
Detrusor sphincter dyssynergia (DSD)
sudden, monocular loss of vision; does not resolve spontaneously
manifests with massive retinal hemorrhages, dilated tortuous retinal veins, macular edema, and papilledema on fundoscopic examination
Thrombotic occlusion of the retinal vein
***flame shaped hemorrhages
fundoscopic examination shows microaneurysms, increased tortuosity of the retinal arterioles, and “Hollenhorst plaques” (bright, yellow, refractile bodies at the bifurcations of the retinal arterioles), which are indicative of cholesterol crystal embolizations
hypertensive retinopathy
?? is a clinical syndrome that manifests with seizures, headache, visual disturbances, and altered mental status and is characterized by radiographic findings consistent with bilateral vasogenic edema in the subcortical white matter of the posterior cerebral hemispheres, particularly in the parieto-occipital regions. Diagnosis is based on neuroimaging
Posterior reversible encephalopathy syndrome (PRES)
**often caused by immunosuppressive medications
can occur following injury to the CNS and should be high on the differential diagnosis for any neurosurgery patient presenting with hyponatremia.
euvolemic, hypotonic hyponatremia
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
most common side effects of ECT include ???, tension headaches, nausea, and transient muscle pain
reversible amnesia (retrograde more often than anterograde amnesia)
Relative contraindications for ECT include increased intracranial pressure, ?????, severe arterial hypertension, and ???
(2)
recent myocardial infarction (within the last 3 months) and acute glaucoma
is it safe for elderly and pregnant women to use ECT
yes
Pronator drift is a sensitive test for ??? lesions and can reveal subtle weakness that may be undetectable on traditional confrontation strength testing.
upper motor neuron (UMN) deficits
Sudden onset of paraparesis and autonomic dysfunction immediately after an ??? surgery, especially in the setting of intraoperative hypotension, is highly suggestive of anterior spinal artery (ASA) syndrome
aortic srugery
artery that contributes to spinal cord perfusion (artery of Adamkiewicz) can be injured during aortic surgery.
?? often present with position-dependent symptoms of obstructed blood flow through the atrioventricular valves
Additionally, patients may present with constitutional findings (e.g., weight loss, fever, or anemia)
typical auscultatory finding (also present in this patient) is an early diastolic “plop” followed by a mid-diastolic rumbling murmur best heard at the apex that results from the obstructed blood flow through the mitral valve, and mimics the murmur of mitral stenosis
cardiac myxoma
Early-morning neck pain in a patient with rheumatoid arthritis should raise suspicion for ???
atlantoaxial subluxation
loss of ligamentous stability between the atlas (C1) and axis (C2), which can result in compression of the spinal cord, medulla, and/or vertebral arteries by the odontoid process, especially upon neck flexion
?? is the initial diagnostic test of choice to evaluate patients for atlantoaxial instability.
Extension and flexion x-ray of the cervical spine
Diagnosis is established if the distance between the anterior arch of the atlas and the dens axis (i.e., the atlantodental interval) is increased to > 3 mm in a fully flexed position.
??? are contraindicated in stroke patients with likely septic cardioembolism from IE because the rate of postthrombolytic intracerebral hemorrhage is significantly higher in these patients than in those with other etiologies of ischemic stroke
thrombolytics
management of ischemic stroke in patients with IE includes intravenous antibiotics and ???
evaluation for cardiac surgery
Where does blood pool on CT for a subarachnoid hemorrhage?
brainstem and basal cisterns
which syndrome?
Classic examination findings include limitation of upward gaze (ie, downward gaze preference), light-near dissociation (ie, pupils reactive to accommodation but not to light), and bilateral eyelid retraction (ie, Collier sign), resulting in visible sclera above the superior corneal limbus
Parinaud syndrome (or dorsal midbrain syndrome) results from pressure on the pretectal region of the midbrain near the superior colliculus and the oculomotor nerve (CN III)
**typically caused by pinealoma**
choroid plexus papilloma (CPP) is a highly vascular, neuroepithelial tissue found within the ventricles. Most common in infants, CPP is a rare, slow-growing, benign overgrowth of the choroid plexus that produces?
increased CSF
features of locked-in syndrome include: preserved consciousness because the midbrain reticular formation is spared, Preserved sensation because sensory pathways are not affected and preserved brainstem and preserved spinal reflexes because they do not require cortical input.
which gaze is preserved?
absent horizontal eye movements because coordinated conjugate gaze is controlled in the pons; however, vertical eye movements and eyelid elevation are preserved because they are controlled in the rostral midbrain.
The ??? nerve innervates the muscles of the anterior compartment of the thigh (ie, quadriceps femoris, sartorius, pectineus) and is responsible for knee extension and hip flexion. It also provides sensation to the anterior thigh and medial leg (via the saphenous branch). Patients with this nerve injury also have decreased patellar reflex, as the reflex involves the quadriceps muscle
femoral
20% of patients using SSRIs develop a ??? tremor, possibly due to serotonergic stimulation of the cortical and thalamic nuclei. The following characteristics support a diagnosis of a medication-enhanced tremor:
Temporal relationship to initiation of the medication
Dose-response relationship
Lack of tremor progression
Symmetry of the affected limbs
enhanced physiologic tremor,
diabetic neuropathy typically presents how??
symmetric sensory polyneuropathy in a glove and stocking pattern
**not typically weakness
alternative therapy for essential tremor (not propanolol)
primidone - anticonvulsant
*used for pt’s with reactive airway disease, nonselective beta blockers are contraindicated
T2 hyperintensity of the spinal cord and no compressive lesion is most consistent with ???
hyperintensity on spinal MRI is characteristic because the inflammatory infiltrate leads to an increase in water content in the spinal cord
transverse myelitis (TM)
?? first-line management for Idiopathic transverse myelitis
high-dose intravenous glucocorticoids
patient’s seizure behavior associated with forceful eye closure and absence of self-injury, incontinence, or postictal confusion is suggestive of ??
psychogenic nonepileptic seizure (PNES)
Patients with dementia with Lewy bodies (DLB) are extremely sensitive to ???, and use of this class of medication may be associated with worsening confusion, parkinsonism, and autonomic dysfunction
antipsychotics
a degenerative condition associated with spinal canal narrowing due to the formation of osteophytes in the lateral vertebral bodies and ossification of the posterior longitudinal ligament/ligamentum flavum
cervical spondylosis
insidious, progressive neurologic deficits in older patient
lower motor neuron findings in upper extremeties and upper motor neuron findings in lower extremeties
cervical spondylotic myelopathy from cervical spondylosis
Damage to the cervical spine nerve roots (peripheral nervous system), which leads to neck pain that radiates to the shoulders/arms and lower motor neuron findings (eg, weakness, atrophy, reduced reflexes) in a myotome/dermatome distribution in the upper extremities
Damage to the spinal cord descending tracts (central nervous system), which leads to unsteady gait (spastic, scissoring walk), a sensation of leg weakness/stiffness, and upper motor neuron signs (eg, increased reflexes, increased tone, upgoing Babinski sign) in the lower extremities
tingling, numbness, and burning of the bilateral hands that worsen during hemodialysis suggests?
carpal tunnel syndrome (CTS)
Bell palsy presents with acute, progressive, unilateral facial weakness. what work-up is needed?
none for classic presentation
what kind of tremor is associated with alcoholic cerebellar degeneration
postural tremor
imaging modality and hallmark for diffuse axonal injury
MRI shows numerous minute punctate hemorrhages in the white matter (ie, axons) and blurring of the gray-white interface (due to edema).
Guillain-Barré syndrome is caused by demyelination of which nerves?
peripheral nerve fibers
psychiatric symptoms (eg, anxiety, psychosis, insomnia), autonomic instability (eg, hyperthermia, hypertension, tachycardia), cognitive impairment, rigidity, hyperreflexia, dystonia, and focal seizure after a flu-like prodrome in the setting of known ovarian teratoma strongly suggest ??
anti-NMDA receptor (anti-NMDAR) encephalitis
tx = immunosuppresive + removal of tumors
diagnosis = GluN1 antibodies in CSF
Treatment of stroke in sickle cell disease patients is ??
exchange transfusion (ie, slowly removing the patient’s blood and replacing it with allogeneic blood), which lowers the relative percentage of sickled cells compared to healthy red blood cells. By decreasing RBC sickling, exchange transfusion increases the oxygen-carrying capacity of the blood and improves hyperviscosity, limiting further occlusion.
Unilateral foot drop, Numbness/tingling over the dorsal foot and lateral shin. Impaired ankle dorsiflexion (walking on heels) and great toe extension, Preserved plantar flexion (walking on toes) and reflexes
which neuroapathy?
common fibular/peroneal nerve compression
common fibular neuropathy has which impairment of flexion?
Impaired ankle dorsiflexion (walking on heels) and great toe extension
first-line therapy for ALS patients with respiratory insufficiency
Noninvasive positive-pressure ventilation (NIPPV) improves respiratory function by opening the upper airway and providing positive end-expiratory pressure to improve atelectasis
3 step management of hemorrhagic stroke
Blood pressure control: Reversible and titratable antihypertensive medications such as intravenous nicardipine or labetalol are used, with a systolic blood pressure goal of 140-160 mm Hg.
Reversal of anticoagulation: Targeted reversal of any anticoagulation; vitamin K is typically given to patients on warfarin, and protamine sulfate to patients on heparin.
Regulation of ICP: Increased ICP is treated with interventions such as head-of-the-bed elevation, sedation, and osmotic therapy (eg, mannitol).
warning signs for headaches that should lead to MRI:
Neurologic findings: Seizure, changes in consciousness, specific deficits
Other: New at age >40, sudden onset, trauma, present on awakening
one more???
Differences compared to prior headaches: Change in frequency, intensity, characteristics
at what point is therapy advised for tourrette’s syndrome?
Behavioral therapy consists of habit reversal training in which the patient learns to substitute a voluntary movement that is incompatible with the tic.
Pharmacological options include vesicular monoamine transporter 2 (VMAT2) inhibitors (eg, tetrabenazine), which are increasingly preferred as initial treatment; antipsychotic medications (eg, risperidone), which are associated with a risk of parkinsonism, tardive dyskinesia, and metabolic effects; and alpha-adrenergic agonists (eg, guanfacine, clonidine), which are helpful when comorbid attention deficit hyperactivity disorder or behavioral issues are present
when tics are severe, disabling, or distressing
3 types of pharm for tourette’s syndrome
vesicular monoamine transporter 2 (VMAT2) inhibitors (eg, tetrabenazine); antipsychotic medications (eg, risperidone), which are associated with a risk of parkinsonism, tardive dyskinesia, and metabolic effects; and alpha-adrenergic agonists (eg, guanfacine, clonidine), which are helpful when comorbid attention deficit hyperactivity disorder or behavioral issues are present
mainstay of therapy for Bell’s palsy
high-dose oral glucocorticoids (eg, prednisone) within 72 hours of symptom onset
anterior cord syndrome and other severe spinal cord injuries can disrupt the ??? tracts involved in bladder control, leading to acute urinary retention. Therefore, ???? should be performed to prevent bladder distension and possible injury.
autonomic tracts
catherization
abnormal huntingtin protein is particularly toxic to the caudate nucleus and putamen (ie, neostriatum). The neostriatum is rich in ???-producing neurons that are preferentially destroyed due to HD
GABA
which brain infection??
CT scan of the brain with intravenous contrast reveals several asymmetric, hypodense, nonenhancing white matter lesions with no edema
progressive, multifocal leukoencephalopathy (PML), a life-threatening neurologic disease caused by the reactivation of JC virus
Cerebellar & retinal hemangioblastomas
Pheochromocytoma
Renal cell carcinoma (clear cell subtype)
which syndrome??
Von Hippel Landau
The most common cause of spontaneous intraparenchymal hemorrhage impacting the basal ganglia is ??
hypertensive vasculopathy involving the small penetrating branches of the major cerebral arteries
common areas for hypertensive vasculopathy leading to intraparenchymal hemorrhage
(4)
basal ganglia, cerebellum, thalamus, pons
rapid eye movement (REM) sleep behavior disorder has a very strong association with the future development of
alpha-synuclein neurodegenerative disorders; ie Parkinsons
3 physical exam findings of brain herniation
Unconsciousness due to dysfunction of the ascending reticular activating system responsible for arousal
Midsized, fixed pupils due to impairment of both parasympathetic and sympathetic nerve fibers innervating the pupil
Abnormal limb posturing due to disruption of descending tracts (eg, rubrospinal, vestibulospinal) typically involved in reflexive and postural movements. This commonly begins with decorticate (flexor) posturing with damage above the level of the midbrain (ie, red nucleus) but often changes to decerebrate (extensor) posturing as brainstem injury progresses caudally.
decorticate vs. decerebrate posturing
Abnormal limb posturing due to disruption of descending tracts (eg, rubrospinal, vestibulospinal) typically involved in reflexive and postural movements. This commonly begins with decorticate (flexor) posturing with damage above the level of the midbrain (ie, red nucleus) but often changes to decerebrate (extensor) posturing as brainstem injury progresses caudally.
pregnant patient with an uncomfortable feeling in her legs temporarily alleviated by movement most likely has
restless legs syndrome (RLS)
typically worse during gestation, improves after delivery
**typically caused by iron deficiency in all types of patients
A positive CSF real-time quaking-induced conversion test (RT-QuIC) confirms a diagnosis of ???
Creutzfeldt-Jakob disease
patients with ? deficiency are at increased risk of MS development
other risk factors (eg, geographic location, colder climates, reduced sunlight exposure) are likely related to this. Epstein-Barr virus infection and smoking are also associated
vitamin D
young woman with hand stiffness and muscle atrophy associated with a flat affect, ptosis, and dysarthria has findings suggestive of ???
myotonic dystrophy (MD)
myotonic dystrophy (MD) is a multisystem autosomal dominant disorder most commonly caused by which mutation?
expansion of cytosine-thymine-guanine (CTG) trinucleotides in the dystrophia myotonica protein kinase (DMPK) genemyotonic dystrophy (MD)
??? is characterized by delayed muscle relaxation after contraction with progressive muscle atrophy and weakness.
Involvement of the muscles of the face can lead to ptosis, flat affect (likely due to prolonged weakness), and lid lag after closing the eyes tightly. Oropharyngeal muscle weakness (eg, dysarthria) may also occur.
Involvement of the distal musculature (eg, intrinsic muscles of the hands, ankle dorsiflexors) explains the classic grip myotonia (inability to quickly release the hand grip).
Other common associated features, reflecting involvement of systems other than muscular system, include cataracts, testicular atrophy, and sleep disturbances (eg, hypersomnia, excessive daytime sleepiness). Genetic testing confirms the diagnosis
myotonic dystrophy (MD)
Non–pupil-sparing CN III palsies are frequently caused by ??
mass effect and should be considered due to an intracranial aneurysm until proved otherwise. Patients should undergo immediate MR or CT angiography of the head for evaluation.
Pupil-sparing CN III palsies are typically caused by ??
microvascular ischemia and are associated with diabetes, hypertension, hyperlipidemia, and advanced age. Observation and supportive care may be appropriate in patients with vasculopathic risk factors (eg, diabetes, hypertension).
Severe carbon monoxide poisoning can cause myocardial ischemia, ????, coma, and death
seizure (evidenced by urinary incontinence and lateral tongue biting)
??? are the most common presenting feature of tuberous sclerosis complex (TSC), with typical onset in infancy or early childhood.
Seizures (eg, infantile spasms, tonic-clonic)
Intellectual disability and developmental delay are particularly prominent in patients with refractory epilepsy.
cause/pathophysiology of trigeminal neuralgia is??
compression of the trigeminal nerve root as it enters the pons, leading to demyelination and atrophy of the nerve
serotonin and norepinephrine inhibitor (SNRI), ???? , has demonstrated efficacy in treating painful diabetic neuropathy. It can also be used as a first line treatment for depression
duloxetine
partial Horner syndrome characterized by ptosis and miosis and NO anhidrosis is a feature of??
internal carotid artery dissection
sympathetic fibers responsible for facial diaphoresis travel along the external carotid artery)
history of severe bipolar disorder and acute immobility and mutism are suggestive of ??
catatonia
catatonia is a syndrome (not a specific disorder) of marked psychomotor disturbance that occurs in severely ill patients with mood disorders with psychotic features, psychotic disorders, autism spectrum disorder, and medical conditions (infectious, metabolic, neurologic, rheumatologic). Common features include decreased motor activity, lack of responsiveness during interview, posturing, and waxy flexibility (initial resistance to repositioning by the examiner, followed by maintenance of new repositioned posture)
Treatment of catatonia includes ??? and/or electroconvulsive therapy (ECT).
benzodiazepines (most commonly lorazepam)
hemorrhage where?
contralateral hemiparesis and hemianesthesia and conjugate gaze deviation toward the side of the lesion
hemianesthesia due to disruption of the corticospinal and somatosensory fibers in the posterior limb and conjugate gaze deviation toward the side of the lesion due to damage of frontal eye field efferents in the anterior limb
for organophosphate poisoning, what should be given after atropine?
pralidoxime, a cholinesterase-reactivating agent that has both nicotinic and muscarinic activity, should be given to treat neurotoxicity
**atropine is only a muscaranic antagonist
Pralidoxime should be given only after atropine, because pralidoxime can cause transient acetylcholinesterase inhibition, which can momentarily worsen symptoms
**in a young patient (children)
jerky, irregular, involuntary contractions of the limbs and face that cannot be suppressed
Poor execution of motor tasks due to hypotonia and intrusion of choreic movements, which can result in intermittently weakened hand grip (ie, milkmaid grip)
Tics (eg, repetitive throat clearing)
Behavioral changes: emotional lability, anxiety, irritability, obsessive-compulsive behaviors
Sydenham chorea 2/2 to GAS infection
Always consider ??? when a patient with Parkinsonism experiences orthostatic hypotension, impotence, incontinence, or other autonomic symptoms
Shy-Drager syndrome
multiple system atrophy (Shy-Drager syndrome) = Parkinsonism + Autonomic dysfunction (postural hypotension, abnormal sweating, disturbance of bowel or bladder control, abnormal salivation or lacrimation, impotence, gastroparesis, etc) + Widespread neurological signs (cerebellar, pyramidal or lower motor neuron)
patient with untreated HIV (inconsistent antiretroviral use) has headaches, nausea/vomiting, confusion, abducens nerve palsy, and scattered, umbilicated skin papules, raising strong suspicion for infection with ???
Cryptococcus neoformans
?? infection usually presents with subacute (eg, 2 weeks in this patient) meningeal manifestations (eg, headache, nausea/vomiting, neck stiffness, dizziness) followed by signs of ischemic stroke (eg, sudden-onset unilateral weakness, hyperreflexia).
**prececed by constitutional symptoms and a rash that is typically symmetric, maculopapular, and involving the extremities (including palms and soles) and the trunk
Meningovascular syphilis
typical features of cerebellar hemorrhage include ??? headache (may radiate to neck/shoulders), neck stiffness (due to extension of blood into the 4th ventricle), nausea/vomiting, and nystagmus.
occipital headache
acute monocular vision loss following 2 months of headache and associated lateral scalp tenderness to palpation in a patient age ≥50 suggests??
giant cell arteritis
??? is the most dreaded complication of GCA
Vision loss
most patients experience transient monocular vision loss (ie, amaurosis fugax) prior to developing permanent vision loss. Anterior ischemic optic neuropathy (AION), the most common ocular manifestation, occurs due to partial or complete occlusion of the posterior ciliary artery and is characterized by a pale, edematous disc with blurred margins
Threatened (eg, vision change) or confirmed vision loss in GCA requires what treatment??
high-dose intravenous glucocorticoids (eg, methylprednisolone 500-1,000 mg daily
When tremor is the dominant symptom of PD (ie, without significant bradykinesia/rigidity), ??? therapy is often effective. Treatment is typically limited to younger patients (ie, ≤65), such as in this case, due to the risk of adverse effects in older patients.
anticholinergic therapy (eg, trihexyphenidyl)
full or partial CN ?? palsy suggests an enlarging or ruptured aneurysm of the adjacent posterior communicating artery.
CN 3, oculomotor defecits
?? is a common adverse effect of lithium, possibly due to increased iron accumulation in the substantia nigra.
Tremor
Lithium-induced enhanced physiologic tremor is typically symmetric, limited to the hands and upper limbs, and occurs when the medication is started or the dose is increased (eg, after a manic episode). It is nonprogressive and often decreases over time, even with no dosage reduction.
For patients with recurrent vasovagal syncope, management consists of advice to avoid triggers and ??
Physical counterpressure maneuvers
assume a supine position with leg raising at the onset of symptoms. Also leg crossing with tensing of muscles, handgrip and tensing of arm muscles with clenched fists during the prodromal phase can improve venous return and cardiac output, sometimes aborting syncopal episodes.
tramadol is an analgesic medication with ??? activity.
serotonergic
can cause Serotonin Syndrome when combined with SSRIs
thunderclap headache (TCH), bilateral visual field defects (suggesting involvement of the optic chiasm) and ophthalmoplegia (eg, impaired right eye adduction consistent with oculomotor nerve [CN III] compromise) localize the lesion to the region of the ???
pituitary and sella turcica
often secondary to pituitary adenoma (prolactinoma)
what type of gain in PD?
narrow-based and shuffling
bulbar symptoms of PD (3)
Hypophonia (a soft voice)
Aspiration of liquids (coughing when drinking)
Loss of olfactory function (often perceived by patients as change in taste)
??? % stenosis: Revascularization with carotid endarterectomy (CEA) is generally recommended.
70%-99%
??? is the most common inherited form of intellectual disability
Affected boys classically have a long face, prominent chin and forehead, protruding ears, and macroorchidism; infants and young children are more likely to have hypotonia and macrocephaly, and joint hypermobility can also occur
Fragile X syndrome (FXS)
Patients classically have a brief loss of consciousness, followed by a lucid interval of minutes to hours.
epidural hematoma
Sensorineural hearing loss, most commonly seen following ??? meningitis, is due to inflammation of the cochlea and/or labyrinth and may not be immediately apparent
Streptococcus pneumoniae
all patients with bacterial meningitis should undergo ??? testing as soon as possible (ideally, before hospital discharge).
audiologic
Acute toxicity of this drug???? initially manifests with signs of cerebellar dysfunction: horizontal nystagmus (ie, nystagmus on lateral gaze), ataxia (eg, wide-based gait), dysmetria (eg, on finger-nose testing), slurred speech, and nausea/vomiting are common, and hyperreflexia may occur.
phenytoin
??? meningitis is typically marked by subacute symptoms of meningeal irritation (eg, vomiting, headache, nuchal rigidity) and imaging findings of basilar meningeal enhancement, hydrocephalus, and stroke due to vasculitis.
Tuberculous
motor sx of cauda equina vs. conus medullaris
Lesions in the brain, spinal cord, and conus medullaris (tapered end of the spinal cord) generally cause upper motor neuron findings such as hypertonia, spasticity, hyperreflexia, and positive Babinski sign. In contrast, lesions at the level of the spinal roots (conus medullaris) usually cause lower motor neuron findings such as decreased/absent reflexes and decreased muscle tone.
initial lab work-up for dementia (4)
Evaluation als involves neuropsychological testing (eg, Montreal Cognitive) and neuroimaging.
complete blood count, vitamin B12, TSH, complete metabolic panel
patient’s cranial nerve (CN) palsy (ptosis, dilated pupil), acute hypoxemic respiratory failure, muscle weakness (eg, inability to hold the head up), and cutaneous abscesses raise strong suspicion for ??
wound botulism
his patient’s increasing forgetfulness, low energy and motivation, sleep disturbance, and psychomotor retardation (eg, slowed speech, thinking, movements) are consistent with ?
major depressive disorder (MDD).
the pathophysiology of tardive dyskinesia is thought to involve what change in dopamine D2 receptor?
upregulation and supersensitivity resulting from chronic blockade of dopamine receptors
young patient has Horner syndrome in the setting of a cervical paravertebral mass, findings suspicious for ??
neuroblastoma.
Neuroblastoma is the most common extracranial solid tumor of childhood, with a median age <2. The tumor arises from neural crest cells, which are precursors to the sympathetic ganglia and adrenal medulla.
Tumor involvement of the cervical paravertebral sympathetic chain can lead to ipsilateral Horner syndrome (ie, ptosis, miosis, anhidrosis).
lab tests for neuroblastoma
Urine and serum catecholamines (vanillylmandelic acid and homovanillic acid) are elevated in the majority of patients; tissue biopsy is required for definitive diagnosis.
High-risk features of head trauma in children age ≥2 include:
Altered mental status
????
Severe mechanism of injury (eg, fall >1.5 m [5 ft], high-impact hit, serious motor vehicle collision)
Vomiting or severe headache
Signs of basilar skull fracture
Loss of consciousness (LOC)
Shoulder abduction reduces tension on the impinged nerve root, and improvement of symptoms when the hand is placed on the top of the head (ie, shoulder abduction relief test) is both diagnostic and therapeutic for ???
cervical radiculopathy
if CT scan results are negative, ?? should be performed in all patients with a high level of concern for SAH
lumbar puncture (LP)
Profound hemineglect is usually due to a lesion impacting the ???, which is responsible for spatial organization
nondominant parietal lobe
usually right side
Cyanotic ???: Triggered by vigorous crying, leading to cyanosis, and loss of consciousness (LOC) with rapid return to baseline.
Pallid ??? (less common): Typically occurs after minor trauma and without crying, as seen in this patient. Pain or fear causes the heart rate to slow and the child become pale, diaphoretic, and limp. Brief LOC follows, and patients are sometimes sleepy or confused for a short period after.
breath-holding spell (BHS)
stroke 4 weeks ago; as numbness improved, patient developed allodynia (burning pain exacerbated by touch) and hyperesthesia in areas impacted by the stroke (right arm and leg). These findings are likely due to the development of
thalamic pain syndrome, a central neuropathic pain syndrome that can develop after a stroke impacting the thalamus (most likely a lacunar stroke); the adjacent basal ganglia can also be impacted, resulting in athetosis (writhing movements) or ballistic movements
The thalamus relays sensory information between various subcortical areas and the somatosensory cortex.
which are alpha-2-delta calcium channel ligands ?
gabapentin, pregabalin
Approximately 30% of patients on metformin develop clinically significant ??? deficiency after ≥5 years of treatment
neuropsychiatric manifestations (eg, irritability, crying spells), sensory ataxia (swaying when standing with eyes closed), and positive Babinski sign
vitamin B12
Left CN III palsy with contralateral weakness of the lower face (corticobulbar tract), arm, and leg (corticospinal tract) is most likely caused by a left ???infarction due to occlusion of mesencephalic branches of the posterior cerebral artery (ie, Weber syndrome)
midbrain
??? often presents within 4-6 weeks following trauma (eg, fracture, sprain) or surgery; characterized by burning or tingling pain out of proportion to the inciting event. The pain does not follow a dermatomal distribution and is typically worsened by movement or light contact (allodynia)
sensory changes (allodynia, hyperesthesia), edema/sudomotor changes (eg, sweating) and vasomotor changes (eg, erythema, altered skin temperature). X-ray often shows patchy demineralization, and bone scintigraphy may show increased uptake in the affected limb.
complex regional pain syndrome (CRPS)
subependymal nodules, periungual fibromas
which disease?
tuberous sclerosis
Rett syndrome is an X-linked genetic disorder that occurs mainly in girls and is characterized by neurodevelopmental regression at age 6-18 months after a period of normal development. In addition to loss of purposeful hand movements (eg, inability to feed herself, stereotypical movements such as hair-pulling) and gait disturbances (eg, lurching gait), other findings can include ????
seizures
ptoms of intracranial hypertension include headache (worse at ???), nausea/vomiting, and mental status changes.
night
downward pronator drift is sensitive and specific for lesion where
UMN lesion in pyramidal/corticospinal tract
Hoffman sign (flexion and adduction of the thumb when flicking the nail of the middle finger) suggests a lesion where??
corticospinal tract
patient developed weakness, paresthesias, and hyperreflexia after intubation; in the setting of her known rheumatoid arthritis (RA), this presentation suggests spinal cord compression due to
atlantoaxial joint instability
sensory loss: Lateral shin, Dorsum of the foot
Weakness: Foot dorsiflexion & inversion (tibialis anterior), Foot eversion (peroneus), Toe extension (extensor hallucis & digitorum)
which injury?
L5
loss of achilles reflex
sensory loss to posterior calf and sole + lateral foot
wekaness of hip extension, knee felxion, and foot plantarflexion
S1 injury
Alzheimer disease initially presents with memory impairment. Neuroimaging generally demonstrates atrophy in which lobe of the brain?
temporal lobe atrophy, which is most prominent in the hippocampi and surrounding medial temporal lobes.
??? commonly presents with an acute, painless, monocular vision disturbance accompanied by flashes of light and/or floaters.
may be a complication (acute or delayed) of intraocular surgery; other common risk factors include advanced age, myopia, and ocular trauma.
Retinal detachment
Antibodies directed at ???, a ganglioside found in peripheral nerves, are thought to contribute to the rapid-onset ophthalmoplegia present in Miller Fisher syndome ; these antibodies are high sensitive for MFS
GQ1b
Clinical features include multiple café-au-lait macules, axillary and inguinal freckling, Lisch nodules (iris hamartomas), and ????.
neurofibromas
neurofibromatosis type 1 (NF1). NF1 is an autosomal dominant neurocutaneous disorder caused by mutations in the NF1 gene
?? poisoning can cause permanent hypoxic brain injury, as evidenced in this patient’s MRI showing bilateral hyperintensity of the globus pallidus, an area highly sensitive to hypoxic conditions.
carbon monoxide
??? is characterized by rapidly progressive ascending paralysis **within hours (which may be asymmetrical), absence of fever and sensory abnormalities, and normal CSF examination.
Tick-borne paralysis
Removal of the tick results in spontaneous improvement in most patients.
Patients with dementia have an increased risk of developing agitated delirium in the hospital. ??? are useful for treating acute agitation in elderly patients with dementia.
Typical and atypical antipsychotics
Benzodiazepines are typically not recommended in this setting.
A single brain abscess usually results from direct extension of an adjacent infection (eg, otitis media, sinusitis, dental infection). ???? are the 2 most commonly isolated organisms. Headache, fever, focal neurologic deficits, and seizure may be present. Brain imaging (CT scan, MRI) typically reveals a single ring-enhancing lesion with central necrosis.
Viridans streptococcus and Staphylococcus aureus
??? is a common electrolyte abnormality that causes weakness, fatigue, and muscle cramps. When severe, it can lead to paralysis and arrhythmia. The ECG may show U waves, flat and broad T waves, and premature ventricular beats
Hypokalemia
reduced renal clearance of uremic toxins leads to high levels of blood urea nitrogen (BUN) and symptoms of lethargy and somnolence. The diagnosis of uremia is based on clinical symptoms/signs and not on an absolute BUN level. Symptoms typically appear at a BUN level of >100 mg/dL but can develop at lower levels. Uremic encephalopathy is an indication for ???
urgent hemodialysis
Patients who develop serious bleeding (eg, intracerebral hemorrhage) due to excess anticoagulation with warfarin should have their anticoagulation immediately reversed with ??? (2) to reduce the risk of death and permanent disability.
intravenous vitamin K and prothrombin complex concentrate
CSF analysis generally shows lymphocytosis with a leukocyte count of 100-500/mm3, mild protein elevation, low glucose, and elevated adenosine deaminase
Tuberculous meningitis is generally marked by subacute symptoms of meningeal irritation with or without cranial nerve palsy and stroke
This patient with fever, muscle stiffness, trismus/lockjaw (inability to open his mouth completely), and painful muscle spasms triggered by physical stimuli likely has ???
tetanus
c. tetani bacterium secretes a toxin that binds to the peripheral nerve terminals and, using retrograde axonal transport, arrives at a central nervous system synapse, where it blocks the release of ???? across the synaptic cleft.
inhibitory neurotransmitters glycine and GABA
patient with confusion and fever has multiloculated, rim-enhancing fluid lesions in the temporal lobe, indicating likely
Brain abscess usually occurs due to direct spread from adjacent infection (eg, sinusitis) or hematogenous spread from distant infection. In this case, the presence of subacute nonspecific symptoms, subconjunctival hemorrhage (petechiae), and signs of mitral valve insufficiency (holosystolic murmur at cardiac apex) raises suspicion for left-sided infective endocarditis (IE) with septic emboli to the eye and brain.
The diagnosis of ?? can be supported with the bedside ice pack test, in which an ice pack is applied over the eyelids for several minutes, leading to an improvement in ptosis
myasthenia gravis
the cold temperature improves muscle strength by inhibiting the breakdown of acetylcholine at the neuromuscular junction, thereby increasing acetylcholine availability to the nicotinic receptor.
Infectious keratitis causes eye pain/redness, photophobia, and blurred vision. Slit-lamp examination revealing branching dendritic corneal ulcerations is diagnostic of ????; patients with HIV are at increased risk.
herpes simplex virus keratitis
One of the earliest findings in ??? is distortion of straight lines such that they appear wavy
it is the most common cause of blindness in industrialized nations. Activities that require fine visual acuity are usually the first affected, and patients with this condition may report that straight grid lines appear curved.
Macular degeneration
??? often presents with sudden-onset hazy vision or vision loss. Proliferative diabetic retinopathy is a common risk factor. Examination frequently shows red blood cells or floating debris and a dark red glow with loss of fundal details on fundoscopy.
Vitreous hemorrhage
anterior uveitis is most often idiopathic or traumatic but can be associated with systemic inflammatory diseases such as certain infections, sarcoidosis, spondyloarthritis, and ???
inflammatory bowel disease
Examination findings include ciliary flush, pupillary constriction, a hazy “flare” in the aqueous humor, and hypopyon.
anterior uveitis
patient with apparent ear pain (eg, clutching her ear while crying), facial nerve weakness, and granulation tissue in the external auditory canal (EAC) likely has ???, an osteomyelitis of the skull base.
necrotizing (malignant) otitis externa (NOE)
Necrotizing (malignant) otitis externa represents osteomyelitis of the skull base and is most commonly caused by ????. The characteristic presentation consists of severe ear pain and ear drainage; granulation tissue may be seen in the ear canal. Progression of the infection may lead to cranial neuropathies
Pseudomonas aeruginosa
Temporomandibular joint disorder can result in referred pain to the ear that is worse with chewing. Patients typically have a history of ??
nocturnal teeth grinding
Otitis media with effusion may be a cause of ear pain and fullness in adults. The pain is typically less than that of otitis externa, the external canal is clear, and fluid is seen where??
behind the tympanic membrane
patient has acute, persistent vertigo consistent with ?? it is a self-limited disorder that sometimes follows a viral upper respiratory infection. can be associated with significant nausea and vomiting as well as impaired gait, with the patient falling toward the affected side.
vestibular neuritis (VN)
Carpal tunnel syndrome is common in patients with ??? and is frequently bilateral. This disease causes soft tissue thickening and mucinous infiltration, which can lead to compression of the median nerve within the carpal tunnel.
hypothyroidism
presence of an extra-axial well-circumscribed or round homogenously enhancing dural-based mass on MRI is strongly suggestive of a ????. These tumors usually undergo calcification and can appear hyperdense on non-contrast head CT scan
meningioma
perioral cyanosis can be a sign of ?
seizure
often seen in the post-ictal state due to lack of breathing during seizure
Examination shows diffuse, fluctuant scalp swelling that extends beyond the suture lines and potentially beyond the skull to the neck. The swelling shifts with movement and expands over 2-3 days. Prompt diagnosis is critical because progressive bleeding can lead to hypovolemic shock, disseminated intravascular coagulation, and death. Treatment is generally supportive (eg, volume resuscitation, correction of coagulopathy).
Subgaleal hemorrhage: caused by the shearing of veins between the dural sinuses and scalp due to scalp traction during delivery.
** Cephalohematoma does not cross suture lines or lead to significant blood loss.
National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria. According to these criteria, cervical spinal imaging is necessary if any of the following is present:
Neurologic deficit
Spinal tenderness
Altered mental status
Intoxication
Distracting injury
what is the preferred screening test to evaluate for CS injury???
A CT scan of the CS without contrast
??? deficiency typically occurs in patients with a history of gastric surgery (eg, bariatric), chronic malabsorption (eg, inflammatory bowel disease), or excessive zinc ingestion. Symptoms include slowly progressive myeloneuropathy similar to that of vitamin B12 deficiency (eg, distal extremity paresthesia, numbness, sensory ataxia), anemia, hair fragility, skin depigmentation, hepatosplenomegaly, edema, and osteoporosis.
Copper
Multiple sclerosis may result in disabling spasticity. Baclofen, an agonist at the GABA-B receptor, and ????, an alpha-2 adrenergic agonist, are the most commonly used medications for reducing muscle tone and painful muscle spasms.
tizanidine
Tizanidine, an alpha-2 adrenergic agonist, improves spasticity, perhaps by decreasing alpha motor neuron excitability
Chronic lead toxicity presents in adults with neuropsychiatric, gastrointestinal, and general symptoms, including peripheral sensorimotor neuropathy, fatigue, abdominal pain, and constipation. It can lead to hypertension, nephropathy, hyperuricemia, and microcytic anemia with basophilic stippling seen on peripheral smear. Treatment for symptomatic patients involves chelation therapy with an agent such as ????
calcium disodium EDTA
this imaging finding and difficulty swallowing means ??
Myasthenia gravis is caused by autoantibody-mediated degradation of acetylcholine receptors at the neuromuscular junction, which often leads to fatigable ocular and bulbar muscle weakness. Most patients with acetylcholine receptor antibodies have thymic abnormalities (eg, thymoma), which appear as an anterior mediastinal mass on chest imaging.
?? should be supplemented to all women at child-bearing age who are prescribed valproic acid
folate
TIA is a transiet neurologic deficit that lasts <24 hours
It is most commonly caused by ?
CT scan can be negative
cerebal emboli
polymyalgia rheumatica vs. fibromyalgia vs. polymyositis
polymyalgia rheumatica: symmetric pain; usually women >50; fever/weight loss/fatigue
fibromyalgia: **point tenderness; women <40
polymyositis: muscle weakness only, no pain
subdural hematoma sx (acute vs. chronic)
Acutely symptomatic SDH typically manifests with altered mental status, focal neurological signs, and signs of increased ICP, and it can progress to brain herniation and death if not treated.
Chronic SDH manifests gradually with cognitive deficits, impaired memory, personality changes, and focal neurological signs. Subacute SDH can manifest with features of acute and/or chronic SDH.
temporal arteritis vs. tempomandibular joint disorder vs. trigeminal neuralgia
for GCA: glucocorticoids should be administered immediately, even prior to diagnostic workup if needed, to reduce the risk of permanent vision loss and cerebral ischemia.
constitutional sx, temporary blindesss, unilateral headache
vs. tempomandibular joint disorder: Constant, dull, and unilateral w/intervals of sharp pain; tx is nsaids
vs. trigeminal neuralgia: shooting pain many times a day; tx is IV lidocaine and start regular anticonvulsant therapy
dry beri-beri vs. wernicke encephalopathy
both due to thiamine def
dry beri-beri: **peripheral neuropathies
wernicke enceph: confusion, nystagmus/diplopia, ataxic gait
(korsakoff when confabulation, personality change, and amnesia occur)
