Neurology Flashcards
What is Ménier’s disease characterized by?
The classic triad of hearing loss, tinnitus, and vertigo.
What symptoms are most consistent with the diagnosis of myasthenia gravis?
Dyspnea, dysphagia, ptosis, and ophthalmoplegia.
What is the appropriate management for Ramsay Hunt syndrome?
Oral aciclovir and valaciclovir.
What is the anchoring heuristic?
A cognitive bias where providers rely too heavily on the initial information they receive and decide on a diagnosis prematurely.
Which nerve is most likely to be compressed in a patient with wrist pain that worsens with repetitive activity?
The median nerve.
What is the treatment for parenchymal neurocysticercosis with more than 2 viable lesions?
Albendazole, praziquantel, and a glucocorticoid.
What is the most effective treatment option for chronic primary insomnia in older patients?
Cognitive behavioral therapy.
What daily preventative medications should be used for frequent migraines?
Beta-blocker, amitriptyline, sodium valproate, and topiramate.
How do Alzheimer’s disease and vascular dementia differ in terms of cognitive impairment?
People with Alzheimer’s disease typically have more impairment with memory, while those with vascular dementia have more impairment with executive functioning.
What is the likely diagnosis for a symmetric, high-frequency, low amplitude tremor that worsens with activity?
Essential tremor.
What tests are commonly used to evaluate for carpal tunnel syndrome?
Phalen’s test and the Tinel sign.
What distinguishes simple partial seizures from complex partial seizures?
Consciousness is preserved in simple partial seizures.
What characterizes pronator syndrome?
Forearm pain with repetitive movements, especially with the elbow extended.
What is consistent with acute delirium with tachycardia and a negative urine drug test?
Intoxication by synthetic cannabinoids.
What is the most appropriate treatment option for an older patient with Parkinson disease experiencing worsening motor function and hallucinations while taking daily ropinirole?
Replace ropinirole with carbidopa-levodopa.
What is the likely diagnosis for sudden, intense pain lasting less than 1 second to 2 minutes along cranial nerve V?
Trigeminal neuralgia.
What occurs when the internal carotid artery becomes distended in a dissection?
Interruption of the ascending sympathetics to the eye may occur, causing a partial Horner syndrome.
What is the initial treatment of a spinal epidural abscess?
Consultation with a neurosurgeon and provision of empiric antibiotic therapy with intravenous vancomycin and a third- or fourth-generation cephalosporin.
What is the treatment for a moderate to severe exacerbation of myasthenia gravis?
IVIG or plasmapheresis.
What are the order steps for a patient suspected of bacterial meningitis?
Blood cultures, lumbar puncture, administration of antibiotics, and dexamethasone.
How are tension headaches typically characterized?
Bilateral and band-like.
Who is at increased risk for meningeal encephalitis and neuro invasive disease from West Nile virus?
Patients older than 50 and those who are immune suppressed.
What symptoms are migraines accompanied by?
At least one of the following: nausea, vomiting, photophobia, or phonophobia.
What does CSF analysis for HSV encephalitis most commonly show?
Elevated lymphocyte count, mildly elevated protein levels, and normal or mildly decreased glucose levels.
Do most patients with West Nile virus remain asymptomatic?
True.
What are typical symptoms of neurocysticercosis?
Seizures, headaches, and hydrocephalus.
What is the best course of action for a patient whose symptoms initially improved with donepezil but have recently worsened?
It is best to continue the donepezil.
What type of hemorrhage is typically described as the worst headache of the patient’s life?
Subarachnoid hemorrhage.
What are the typical characteristics of Ménierè’s disease?
People with Ménierè’s disease are typically older than 50 with slowly progressing tinnitus and deafness in one ear.
How is migraine without aura defined?
History of 5 or more episodes with at least 2 of the following features: unilateral location, pulsating quality, moderate to severe pain, exacerbation with physical activity, lasting 4 to 72 hours each, and accompanied by at least one of the following: nausea, vomiting, photophobia, phonophobia.
What is the likely diagnosis for new onset encephalitis in a patient with primary lung malignancy and negative testing for viral encephalitis?
Paraneoplastic encephalitis.
What diagnostic tests have the highest yield in the workup of patients with distal symmetric polyneuropathy?
Glycated hemoglobin, blood glucose, vitamin B12, methylmalonic acid, and serum protein electrophoresis.
What increases the risk for statin-induced myopathy?
Factors that affect hepatic clearance.
In which population is thoracic outlet syndrome more common?
People who engage in repetitive overhead activities.
What are the findings in lumbar puncture and electromyography/nerve-conduction study within the first week of illness?
They are normal in as many as 50% of cases.
What type of pleocytosis can listerial meningitis result in?
Either a mononuclear or polymorphonuclear-predominant pleocytosis.
What does the cerebrospinal fluid (CSF) show in typical bacterial meningitis?
A polymorphonuclear-predominant pleocytosis; however, listerial meningitis can result in either a mononuclear or polymorphonuclear-predominant pleocytosis.
What are the typical CSF protein and glucose levels in listerial meningitis?
The CSF protein level is often moderately elevated, and the glucose level is either normal or decreased.
What cognitive bias occurs when the evaluation of a current patient is affected by recall of recent cases?
The availability heuristic.
What class of drug typically responds well to mild exacerbation of myasthenia gravis?
Anti-cholinergics.
What is the first-line treatment for BPPV?
The Epley maneuver.
What is the pneumonic for anticholinergic side effects?
Red as a beet, dry as a bone, blind as a bat, mad as a hatter, hot as a hare, full as a flask.
What characterizes Lewy body dementia?
Dementia is either present at onset or develops within a year after onset of Parkinson symptoms.
What causes Leber hereditary optic neuropathy?
A mitochondrial DNA mutation.
What is the typical duration of migraines?
Migraines typically last 4 to 72 hours each.
What is recommended for any patient presenting with seizures of focal onset?
Neuroimaging of the brain.
What are the symptoms of spinal stenosis?
They are usually bilateral and tend to resolve when the patient sits or flexes forward while walking.
What is considered a positive straight leg test?
Radicular pain extending to below the knee is reproduced when the affected hip is flexed to 30 to 70 degrees with the knee extended.
What should frequent migraines be treated with?
Daily preventative medications such as beta-blockers, amitriptyline, sodium valproate, or topiramate.
How is ALS clinically defined?
Progressive weakness and physical exam findings of upper and lower motor neuron symptoms with no abnormal sensory findings.
What are the symptoms of Huntington disease?
A triad of uncontrollable movements, progressive cognitive decline, and psychiatric symptoms.
What can improve mild myasthenic symptoms?
Low-dose steroids.
What results from compression of the ulnar nerve?
Cubital tunnel syndrome.
What type of headaches are typically associated with sleep apnea?
Bifrontal and dull in nature, resolving shortly after awakening.
What is the nature of headaches typically experienced after awakening?
They are typically bifrontal and dull in nature and should resolve shortly after awakening, although they can last as long as 4 hours.
What is acute transverse myelitis thought to be most commonly caused by?
An autoimmune reaction to a recent infection.
What are indications for head imaging in a patient with suspected concussion?
Focal neurologic deficits on examination, evidence of skull fracture, Glasgow coma scale less than 15, and amnesia for events that occurred more than 30 minutes before the impact.
What are the symptoms of injury to the ulnar nerve?
Numbness to the small finger and weakness in finger abduction.
What is labyrinthitis associated with?
It is a peripheral vertigo associated with hearing loss that typically develops after systemic viral illness.
What tests should be conducted for a patient with features of dementia?
Evaluation of thyroid-stimulating hormone, serum B12, complete blood count, complete metabolic panel, and structural brain imaging with MRI or CT.
What should patients with restless legs syndrome be evaluated for?
Iron deficiency.
How is migraine without aura defined?
History of 5 or more episodes with at least 2 of the following features: unilateral location, pulsating quality, moderate to severe pain, exacerbation with physical activity, lasting 4 to 72 hours, and accompanied by at least one of the following: nausea, vomiting, photophobia, or phonophobia.
What are the signs of corticobasal syndrome?
Parkinsonian signs, coexisting aphasia, apraxia, dystonia, or alien limb syndrome.
What does the autonomic nervous system regulate?
Heart rate, blood pressure, respiration, digestion, and sexual arousal.
What typically causes Ramsay Hunt syndrome?
Reactivation of latent varicella-zoster virus.
What are periventricular white matter hyperintensities associated with?
Vascular causes of dementia.
What is cauda equina syndrome?
A clinical syndrome caused by compression of nerves involving ≥ 2 of the L2–S5 nerve roots, causing bowel or bladder dysfunction, perianal or saddle anesthesia, variable lower extremity neurological deficits, and back pain.
What is the most likely diagnosis in an afebrile patient with headache and gradually progressive focal neurologic symptoms?
Brain abscess.
What should early evaluation of a delirious patient include?
Investigation for occult infection and metabolic abnormalities.
When are plasma exchange and IVIG typically used in Guillain-Barré Syndrome?
In the acute phase.
What does Creutzfeldt Jacob disease typically cause?
Rapidly progressive dementia, global cognitive impairment, gait abnormalities, and stimulus-induced myoclonus.
What are the most sensitive markers of poor outcome after cardiac arrest?
Lack of pupillary or corneal response, absence of motor response to pain, and a burst suppression pattern on electroencephalogram, all in the absence of sedation.
What is vestibular neuritis?
A peripheral vertigo without hearing loss secondary to inflammation of the 8th cranial nerve.
When is neuroimaging of the brain recommended?
For any patient presenting with seizures of focal onset or with persistent postictal focal deficits even after the first episode.
What is acute delirium with tachycardia and a negative urine drug test consistent with?
Intoxication by synthetic cannabinoids.
What is the likelihood of persistent disability with Guillain-Barré syndrome?
Up to 20% of patients will have persistent disability.
What is partial Horner syndrome associated with?
Ptosis and miosis but not anhidrosis, associated with cluster headaches.
What does Huntington disease manifest with?
A triad of uncontrollable movements, progressive cognitive decline, and psychiatric symptoms.
What shape is bleeding for subdural hematoma typically described as?
Crescent shaped.
What is the most appropriate first diagnostic test in a patient with suspected ALS?
EMG/nerve conduction study.
What is the most effective abortive treatment for cluster headache?
100% oxygen or triptans.
What are the diagnostic tests with the highest yield in the workup of patients with distal symmetric polyneuropathy?
Glycated hemoglobin, blood glucose, vitamin B12, methylmalonic acid, and serum protein electrophoresis.
What should new onset of myalgia, proximal weakness, and creatine kinase elevation prompt detailed questioning about?
Statin use.
Are both very high and very low vitamin A levels associated with IIH?
Yes, both very high and very low vitamin A levels are associated with IIH.
What commonly causes cerebral atrophy?
Alcohol abuse and is found in older age patients.
What is an effective option for patients who have difficulty falling asleep?
Going to bed only when sleepy and spending no more than 20 minutes in bed lying awake.
What does cubital tunnel syndrome result from?
Compression of the ulnar nerve.
What is the likely diagnosis for recurrence of 5 or more attacks of severe unilateral orbital headache with associated prominent autonomic symptoms?
Cluster headache.
What is a subacute decline in neurocognitive performance in a patient with Alzheimer’s disease most frequently attributable to?
An infection or a new medication.
What nerve is most likely to be compressed in a patient with wrist pain that worsens with repetitive activity?
The median nerve.
What is most frequently attributable to an infection or a new medication?
It is most frequently attributable to an infection or a new medication.
What is a common example of vertigo from peripheral causes?
BPPV (Benign Paroxysmal Positional Vertigo).
What is the straight-leg-raise maneuver used for?
It is a sensitive physical examination maneuver for lumbar disk herniation.
In Lewy body dementia, when does dementia develop?
Dementia is either present at onset or develops within a year after onset of Parkinson symptoms.
What tests are appropriate for a patient with features of dementia?
Evaluation of thyroid-stimulating hormone, serum B12, complete blood count, complete metabolic panel, and structural brain imaging with MRI or CT.
What does ALS mainly affect?
ALS mainly affects the motor neurons, presenting with muscle weakness and atrophy or bulbar symptoms with fasciculations.
What are the steps for a patient suspected of bacterial meningitis?
Blood cultures, lumbar puncture, administration of antibiotics, and dexamethasone.
What is the most effective abortive treatment for cluster headaches?
100% oxygen or triptans.
What symptoms are migraines accompanied by?
Nausea, vomiting, photophobia, or phonophobia.
What does thoracic outlet syndrome typically cause?
Paresthesia, atrophy, and weakness of the hand.
What are common signs of subarachnoid hemorrhages?
Meningeal signs such as neck stiffness.
What does sensory loss in the medial hand and forearm suggest?
A diagnosis of C8 radiculopathy; ulnar neuropathy will not affect the forearm.
What is the likely diagnosis for an obese patient with headaches and papilledema?
Idiopathic intracranial hypertension.
What does synthetic cannabinoid treatment include?
IVF, benzodiazepines, or neuroleptics as appropriate.
What are risk factors for the development of idiopathic intracranial hypertension?
Several acne treatments including systemic tetracyclines and retinoids.
How does pregnancy affect the clearance of lamotrigine and other anticonvulsant agents?
Clearance increases significantly.
Who is at increased risk for meningeal encephalitis and neuroinvasive disease from West Nile virus?
Patients older than 50 and those who are immune suppressed.
What is required to diagnose Parkinson’s disease?
Bradykinesia plus at least one of the following: muscular rigidity, resting tremor, and postural instability.
What is the diagnostic test of choice for evaluating a possible spinal epidural abscess?
MRI of the spine with and without gadolinium.
What characterizes Ménierè’s disease?
The classic triad of hearing loss, tinnitus, and vertigo.
What is the likely diagnosis for a symmetric high-frequency low amplitude tremor that worsens with activity?
Essential tremor.
What is the initial type of exam for cognitive impairment and features of Alzheimer dementia?
MRI brain or CT head.
What is labyrinthitis typically associated with?
Hearing loss and occurs after a viral syndrome.
What is the likely diagnosis for acute facial palsy with a painful vesicular eruption on the auricle?
Ramsay Hunt syndrome.
What are focal seizures with impaired awareness characterized by?
Staring spells, automatisms, and altered mental status.
What would an occipital lobe stroke manifest with?
Hemifield vision loss in both eyes.
What is necessary for a diagnosis of multiple sclerosis?
One clinical event suspicious of focal or multifocal inflammatory demyelination and CSF demonstrating oligoclonal bands unique to the CNS.
What distinguishes migraines from cluster headaches?
Migraines typically include a prodrome and photophobia.
What are the most sensitive markers of poor outcome in the first period after cardiac arrest?
Lack of pupillary or corneal response, absence of motor response to pain, and a burst suppression pattern on electroencephalogram, all in the absence of sedation.
What does cubital tunnel syndrome result from?
Compression of the ulnar nerve, causing wrist pain along the fourth and fifth digits.
How is migraine without aura defined?
History of 5 or more episodes with at least 2 of the following features: unilateral location, pulsating quality, moderate to severe pain, exacerbation with physical activity, lasting 4 to 72 hours, and accompanied by nausea, vomiting, photophobia, or phonophobia.
Is a CT scan necessary in an athlete who sustained a head injury and has a normal neurological exam?
A CT scan is not necessary.
What symptoms suggest West Nile virus after spending time in a wooded area?
Fever, altered mental status, flaccid paralysis, and areflexia in the absence of sensory findings.
What is a variant of Horner syndrome that manifests with ptosis and miosis but not anhidrosis?
Partial Horner syndrome
Associated with cluster headaches.
What are the order steps for a patient suspected of bacterial meningitis?
Blood cultures, lumbar puncture, administration of antibiotics and dexamethasone.
What are the features required to diagnose migraines?
At least two of the following: unilateral location, pulsating quality, moderate to severe pain, and exacerbation with routine physical activities.
What is consistent with acute delirium with tachycardia and a negative urine drug test?
Intoxication by synthetic cannabinoids.
What is the median onset for statin induced myopathy?
4 weeks after statin initiation
Symptoms may develop at any time.
What causes neurocysticercosis?
Taenia solium infection.
What is required for a diagnosis of multiple sclerosis?
1 clinical event suspicious of focal or multifocal inflammatory demyelination and CSF demonstrating oligoclonal bands unique to the CNS.
What is needed to diagnose Parkinson’s disease?
Bradykinesia plus at least one of the following: muscular rigidity, resting tremor, and postural instability.
What is suggestive of increased intracranial pressure?
Headache, transient vision loss, and papilledema.
What should be assumed in a patient with new partial Horner syndrome and ipsilateral headache?
Carotid dissection until proven otherwise.
What is the likely cause of pain in the distal lower extremities with symmetric loss of sensation in a type 2 diabetes patient?
Diabetic peripheral neuropathy.
What is the most common nerve entrapment in carpal tunnel syndrome?
Median nerve.
What does vascular dementia typically manifest with?
Stepwise cognitive decline and mild cognitive impairment.
What should early evaluation of a delirious patient include?
Investigation for occult infection and metabolic abnormalities.
What tests are commonly used to evaluate for carpal tunnel syndrome?
Phalen’s test and Tinel sign.
What does injury to the suprascapular nerve result in?
Weakness with external rotation or abduction, especially in the 90 to 180 degree planes.
What is a contraindication for thrombolytic therapy?
Blood pressure greater than 185/110.
What should frequent migraines be treated with?
Daily preventative medications such as beta-blocker, amitriptyline, sodium valproate, and topiramate.
What causes Leber hereditary optic neuropathy?
A mitochondrial DNA mutation.
In which gender does approximately 90% of Leber hereditary optic neuropathy cases occur?
Males.
Which antiepileptic drugs have the lowest observed rates of major congenital malformations when used during pregnancy?
Lamotrigine and Keppra.
What is the most likely diagnosis for a young adult with episodic lightheadedness, pallor, and sweating triggered by stress?
Vasovagal syncope.
What is required for a diagnosis of multiple sclerosis?
One CNS event and either MRI findings demonstrating dissemination in space or CSF demonstrating presence of oligoclonal bands unique to the CNS.
What is the goal blood pressure reduction for a patient with acute stroke who is not a candidate for thrombolysis?
15% in the first 24 hours.
What is an effective option for patients who have difficulty falling asleep?
Going to bed only when sleepy and spending no more than 20 minutes in bed lying awake.
What characterizes a seizure with a sense of déjà vu, epigastric butterflies, and convulsing?
Partial (focal) seizure with generalized tonic-clonic seizure.
What triad manifests in Huntington disease?
Uncontrollable movements, progressive cognitive decline, and psychiatric symptoms.
What suggested diagnosis includes facial weakness, myotonia, cardiac arrhythmia, type 2 diabetes, and hypogonadism?
Myotonic dystrophy.
What does acute onset of pain, weakness, and numbness with a marked sensory level typically localize to?
The spinal cord.
How do Alzheimer’s disease and vascular dementia differ in terms of cognitive impairment?
Alzheimer’s disease typically has more impairment with memory, while vascular dementia has more impairment with executive functioning.
What is the most effective monotherapeutic strategy for delayed sleep-wake phase disorder?
The use of melatonin 4 hours before one’s desired bedtime.
In thoracic outlet syndrome, is pain always present?
True.
What should a patient with ipsilateral partial Horner syndrome, aphasia, and contralateral weakness following neck trauma be evaluated for?
Carotid dissection.
What occurs when the artery becomes distended?
Interruption of the ascending sympathetics to the eye may occur, causing a partial Horner syndrome.
Does anhidrosis occur in partial Horner syndrome?
No, anhidrosis does not occur because the sympathetic innervation of the sweat glands follows the external carotid artery.
What can local distention of the internal carotid artery cause?
Isolated cranial nerve palsies.
What are the symptoms needed to diagnose Parkinson’s disease?
Bradykinesia plus at least one of the following: muscular rigidity, resting tremor, and postural instability.
What are the symptoms of C6 radiculopathy?
Weakness upon elbow flexion, numbness of the lateral hand and sometimes lateral arm, and reduction or absence of the biceps reflex.
What is required for a diagnosis of multiple sclerosis (MS)?
A patient needs only one CNS event and either MRI findings demonstrating dissemination in space or CSF demonstrating presence of oligoclonal bands unique to the CNS.
What is the first-line treatment for trigeminal neuralgia?
Carbamazepine or oxcarbazepine.
What is the most appropriate preventive medication for chronic tension-type headache?
Amitriptyline.
How is migraine without aura defined?
History of 5 or more episodes with at least 2 of the following features: unilateral location, pulsating quality, moderate to severe pain, exacerbation with physical activity, lasting 4 to 72 hours each, and accompanied by at least one of the following: nausea, vomiting, photophobia, phonophobia.
What are the medication recommendations for improving strength and pulmonary function in DMD?
Low-dose prednisone or deflazacort.
What characterizes Ménierè’s disease?
The classic triad of hearing loss, tinnitus, and vertigo.
How does botulism typically present?
As a descending weakness.
What may cerebrospinal fluid studies in transverse myelitis show?
A mild pleocytosis with a leukocyte count >10 cells/L, elevated oligoclonal bands, and an elevated immunoglobulin G index.
What is a key feature of Lewy body dementia?
Dementia is either present at onset or develops within a year after onset of Parkinson symptoms.
What type of brain bleed does a subdural hematoma depict?
Subdural hematoma.
What does ALS mainly affect?
The motor neurons, presenting with muscle weakness and atrophy or bulbar symptoms with fasciculations.
What is vestibular neuritis?
A peripheral vertigo without hearing loss secondary to inflammation of the 8th cranial nerve.
What are the toxicities associated with allopurinol?
Hypersensitivity skin reaction, bone marrow suppression, or hepatotoxicity.
What is the most appropriate first step in managing behavioral issues in a patient with dementia?
A nonpharmacologic (behavioral) intervention.
What increases the risk for meningeal encephalitis and neuroinvasive disease in West Nile virus?
Patients older than 50 and those who are immune suppressed.
What does cubital tunnel syndrome result from?
Compression of the ulnar nerve, causing wrist pain along the fourth and fifth digits.
What is the most appropriate treatment for a patient with severe episodic low-frequency migraine characterized by vomiting?
Subcutaneous sumatriptan due to vomiting.
What cerebrospinal fluid finding is characteristic of multiple sclerosis?
Oligoclonal bands.
What are oligoclonal bands?
Multiple bands on protein electrophoresis that are present in the cerebrospinal fluid but not in the blood.
What is suggestive of a diagnosis of sleep apnea?
The combination of chronic morning headaches, poor sleep quality, and daytime sleepiness and fatigue.
What should be done in cases of an epidural hematoma?
Neurosurgery should be consulted for urgent surgical evacuation.
What is the pneumonic for anticholinergic side effects?
Red as a beet, dry as a bone, blind as a bat, mad as a hatter, hot as a hare, full as a flask.
What does nystagmus resulting from a central etiology look like?
Nystagmus may be horizontal, vertical, or torsional.
What is the Dix Hallpike maneuver used for?
It is used to diagnose benign paroxysmal positional vertigo (BPPV).
What does acoustic schwannoma manifest as?
Hearing loss and constant vertigo.
Which antiepileptic drugs have the lowest rates of major congenital malformations during pregnancy?
Lamotrigine and Keppra.
How should suspected neurocysticercosis be evaluated?
With both CT and MRI of the head.
What is a common cause of a subacute decline in neurocognitive performance in a patient with Alzheimer’s disease?
It is most frequently attributable to an infection or a new medication.
What is the most appropriate acute treatment for a disabling MS relapse?
A high-dose IV glucocorticoid.
What characterizes ulnar neuropathies?
Sensory loss limited to the hand, 4th and 5th fingers, and a positive Tinel sign at the elbow.
What is the average annual decline on the Mini-Mental Status Examination in patients with Alzheimer’s disease?
3 to 4 points.
What is the treatment for a moderate to severe exacerbation of myasthenia gravis?
IVIG or plasmapheresis.
What is the Ultra-Brief Confusion Assessment Method (UB-CAM) used for?
To assess for delirium.
What should patients with a suspected brain abscess be treated with?
Broad-spectrum antibiotics and stereotactic aspiration.
What medication class has been proven effective for secondary prevention of stroke?
Statins.
How does injury to the radial nerve manifest?
With decreased sensation to the dorsum of the hand and weakness with elbow, wrist, and thumb extension.
What are typical characteristics of Menière’s disease?
Patients are typically older than 50 with slowly progressing tinnitus and deafness in one ear.
What are subdural hematomas typically associated with?
Trauma to the bridging veins.
What is labyrinthitis typically associated with?
Hearing loss and occurs after a viral syndrome.
What are risk factors for the development of idiopathic intracranial hypertension (IIH)?
Several acne treatments including systemic tetracyclines and retinoids.
What is a potential diagnosis for new onset temporal frontal headaches, fatigue, weight loss, and inflammatory markers in a patient over 50?
Giant cell arteritis.
What is the treatment for giant cell arteritis?
High-dose oral steroids.
What is the first step in managing behavioral issues in a patient with dementia?
A nonpharmacologic (behavioral) intervention.
When does dementia surface in Idiopathic Parkinson’s disease?
Years to decades after the onset of motor symptoms.
What are the symptoms of Huntington’s disease?
A triad of uncontrollable movements, progressive cognitive decline, and psychiatric symptoms.
What characterizes a circadian rhythm sleep-wake disorder?
An antegrade shift of the sleep-wake cycle by > 2 hours.
What does the autonomic nervous system regulate?
Heart rate, blood pressure, respiration, digestion, and sexual arousal.
What is the treatment for acute tension-type headache?
Aspirin or nonsteroidal anti-inflammatory drugs.
What should be considered for patients with frequent headaches or chronic headache?
Preventive treatment.
What defines episodic headache?
1 to 14 headache days per month.
What defines chronic headache?
15 or more headache days per month.
When should blood pressure medications be considered in patients with ischemic stroke?
If BP is greater than 220/120.
What is the next step for an athlete suspected of having a concussion with a normal neurological exam?
Recommend rest from sports for at least the remainder of the day.
What type of headaches are typically associated with sleep apnea?
Bifrontal and dull in nature, resolving shortly after awakening.
What is the diagnostic test for BPPV?
The Dix-Hallpike maneuver.
What is the diagnosis for a clinical syndrome caused by compression of nerves involving ≥ 2 of the L2–S5 nerve roots?
Cauda equina syndrome.
What is the drug of choice for prevention of cluster headaches?
Verapamil.
What are the steps for a patient suspected of bacterial meningitis?
Blood cultures, lumbar puncture, administration of antibiotics and dexamethasone.
How does statin induced myopathy typically present?
Typically presents with myalgias.
What characterizes Menière disease?
The classic triad of hearing loss, tinnitus, and vertigo.
What are indications for head imaging in a patient with suspected concussion?
Focal neurologic deficits, evidence of skull fracture, Glasgow coma scale less than 15, amnesia for events that occurred more than 30 minutes before the impact.
What might cerebrospinal fluid studies in transverse myelitis show?
Mild pleocytosis with a leukocyte count >10 cells/L, elevated oligoclonal bands, and an elevated immunoglobulin G index.
What is the most appropriate treatment for severe episodic low-frequency migraine characterized by vomiting at onset?
Subcutaneous sumatriptan due to the vomiting.
What is the likely diagnosis for recurrence of 5 or more attacks of severe unilateral orbital headache with prominent autonomic symptoms?
Cluster headache.
What is the best medication class for managing the neurobehavioral element of Lewy body dementia?
Cholinesterase inhibitor.
What is the more appropriate treatment for a patient with psoriatic arthritis and alcoholism?
A TNF alpha inhibitor because methotrexate can be hepatotoxic.
What tests are appropriate for a patient with features of dementia?
Evaluation of thyroid-stimulating hormone, serum B12, complete blood count, complete metabolic panel, structural brain imaging with MRI or CT.
What is internuclear ophthalmoplegia?
The inability to adduct one eye, common in MS patients.
What is the treatment for parenchymal neurocysticercosis with more than 2 viable lesions?
Albendazole, praziquantel, and a glucocorticoid.
What signs are present in corticobasal syndrome?
Parkinsonian signs, coexisting aphasia, apraxia, dystonia, or alien limb syndrome.
What is the diagnosis for head trauma with nausea and periodic spinning sensation lasting less than a minute?
BPPV.
What is the most appropriate first-line treatment for trigeminal neuralgia?
Carbamazepine or oxcarbazepine.
What is the goal for blood pressure reduction in acute stroke patients who are not candidates for thrombolysis?
A goal blood pressure reduction of 15% in the first 24 hours.
What mechanical event do benzos, SSRIs, and anticonvulsants increase the risk of in the elderly?
Falls; benzos should be avoided in the elderly if possible.
What is the diagnostic test of choice to evaluate a possible spinal epidural abscess?
MRI of the spine with and without gadolinium.
What is the first step in diagnosing bacterial meningitis?
Obtain blood cultures followed by a lumbar puncture.
What symptoms suggest a potential diagnosis of Giant cell arteritis?
New onset temporal frontal headaches, fatigue, weight loss, and inflammatory markers (ESR > 100) in patients over 50.
What is the treatment for Giant cell arteritis?
High-dose oral steroids.
What does the autonomic nervous system regulate?
Heart rate, blood pressure, respiration, digestion, and sexual arousal.
What symptoms are associated with seizures?
Aphasia, fever, and lymphocytic pleocytosis in the cerebrospinal fluid.
What should prompt consideration of herpes simplex virus encephalitis?
Aphasia, fever, and lymphocytic pleocytosis in the cerebrospinal fluid.
What does symptom onset over seconds or minutes suggest?
A vascular event.
What does symptom onset over several hours or days suggest?
An abscess.
What does progression of symptoms over weeks to months suggest?
A neoplasm.
What is the diagnosis for acute onset of progressive dyspnea and paresthesia with diminished reflexes?
Guillain-Barre Syndrome.
What is the first step in diagnosing Guillain-Barre Syndrome?
Measurement of respiratory function such as vital capacity and MIP.
What is cytoalbuminologic dissociation?
Elevated protein but normal leukocytes in cerebrospinal fluid.
What triggers recrudescence in patients with prior stroke?
Symptoms are usually similar to their initial presentation but not as severe, commonly triggered by infection, hypotension, hyponatremia, hypoglycemia, insomnia, stress, and benzodiazepine use.
Do menstrual migraines occur consistently at the same time of the menstrual cycle?
True.
What indicates a likely C6 radiculopathy?
Bilateral upper-extremity paresthesia and biceps weakness.
What combination of symptoms is consistent with a diagnosis of Parkinson disease?
Resting tremor, rigidity, and bradykinesia.
What features typically characterize migraines?
Unilateral location, moderate to severe quality of pain, and exacerbation with physical activity.
What does CSF analysis for HSV encephalitis commonly show?
Elevated lymphocyte count, mildly elevated protein levels, and normal or mildly decreased glucose levels.
What happens when the axillary nerve is damaged?
It results in paresthesias and diminished sensation to light touch over the lateral aspect of the shoulder.
What is a common cause of subacute decline in neurocognitive performance in a patient with Alzheimer disease?
Most frequently attributable to an infection or a new medication.
What type of headaches are associated with sleep apnea?
Headaches.
What are common causes of headaches?
Most frequently attributable to an infection or a new medication.
What is sleep apnea?
A disorder characterized by repeated interruptions in breathing during sleep.
What type of headaches are typically experienced after awakening?
Headaches are typically bifrontal and dull in nature and should resolve shortly after awakening, although they can last as long as 4 hours.
What are indications for head imaging in a patient with suspected concussion?
Focal neurologic deficits on examination, evidence of skull fracture, Glasgow coma scale less than 15, amnesia for events that occurred more than 30 minutes before the impact.
What commonly causes cerebral atrophy?
Alcohol abuse and found in older age patients.
What are the signs of corticobasal syndrome?
Patients will have parkinsonian signs as well as coexisting aphasia, apraxia, dystonia, or alien limb syndrome.
How is ALS clinically defined?
Progressive weakness and physical exam findings of upper and lower motor neuron symptoms with no abnormal sensory findings.
What treatment options improve outcomes for symptomatic carotid stenosis?
Better outcomes when treated with stenting or endarterectomy than when treated with medical management alone.
What characterizes Ménierè’s disease?
Fluctuating hearing loss, tinnitus, aural fullness, and recurrent severe vertigo.
What does direction changing nystagmus suggest?
Suggests a diagnosis of central vertigo.
How can motor fluctuations be reduced in Parkinson’s disease?
Aim for a more even distribution of carbidopa-levodopa dosing.
What are the primary symptoms of Parkinson’s disease?
Result from reduced activity of dopamine-secreting cells.
What are sensitive markers of poor outcome after cardiac arrest?
Lack of pupillary or corneal response, absence of motor response to pain, and a burst suppression pattern on electroencephalogram, all in the absence of sedation.
What is the best medication class for managing cognitive symptoms of Lewy body dementia?
A cholinesterase inhibitor, such as donepezil.
What is the likely diagnosis for a symmetric high-frequency low amplitude tremor that worsens with activity?
Likely diagnosis: Essential tremor.
What are typical anticholinergic symptoms?
Dry eyes, dry mouth, and constipation.
What defines migraine without aura?
A history of five or more episodes that last 4 to 72 hours each, have at least two of the following features: unilateral location, pulsating quality, moderate to severe pain, and exacerbation with routine physical activities, and are accompanied by at least one of the following symptoms: nausea, vomiting, photophobia, or phonophobia.
How long do Ménierè’s disease episodes typically last?
Typically lasts 30 minutes to many hours.
What type of nystagmus is seen with peripheral vertigo?
Usually spontaneous unidirectional horizontal nystagmus.
What is the typical age of people with Ménierè’s disease?
Typically older than 50 with slowly progressing tinnitus and deafness in one ear.
What do glucocorticoids increase the likelihood of in Bell’s palsy?
Complete recovery of facial function.
What results from injury to the ulnar nerve?
Numbness to the small finger and weakness in finger abduction.
What is the appropriate management for Ramsay Hunt syndrome?
Oral Aciclovir and valaciclovir.
What is the purpose of the Dix-Hallpike maneuver?
Used to diagnose BPPV.
What are the indications for head imaging in a patient with suspected concussion?
Focal neurologic deficits on examination, evidence of skull fracture, Glasgow coma scale less than 15, amnesia for events that occurred more than 30 minutes before the impact.
What does acoustic schwannoma manifest as?
Hearing loss and constant vertigo.
What are the characteristics of migraines?
Accompanied by at least one of the following symptoms: nausea, vomiting, photophobia, or phonophobia.
What may paraneoplastic encephalitis exhibit on MRI?
Enhancement involving one or both temporal lobes.
What is considered a positive straight leg test?
Radicular pain.
What indicates a positive straight leg test?
Radicular pain extending to below the knee when the affected hip is flexed to 30 to 70 degrees with the knee extended.
When is neuroimaging indicated for recurrent headaches?
Typically reserved for patients who present with focal neurologic symptoms.
What symptoms are associated with thoracic outlet syndrome?
Paresthesia, atrophy, and weakness of the hand.
What triad is most consistent with normal-pressure hydrocephalus?
Gait impairment, cognitive impairment, and urinary dysfunction.
What diagnostic tests have the highest yield in distal symmetric polyneuropathy workup?
Glycated hemoglobin, blood glucose, vitamin B12, methylmalonic acid, and serum protein electrophoresis.
What is the treatment for acute tension-type headache?
Aspirin or nonsteroidal anti-inflammatory drugs. Preventive treatment can be considered for patients who do not respond to acute treatment.
What tests are commonly used to evaluate carpal tunnel syndrome?
Phalen’s test and Tinel sign.
What does delayed relaxation of skeletal muscles following contraction describe?
Myotonia.
What imaging is preferred for evaluating the first seizure in a healthy patient?
MRI is preferred over CT.
What is the recovery time for Guillain-Barré syndrome?
Recovery can potentially take months to years.
What is the likely diagnosis for recurrent severe unilateral orbital headache with autonomic symptoms?
Cluster headache.
What is the initial treatment for a spinal epidural abscess?
Consultation with a neurosurgeon and provision of empiric antibiotic therapy with intravenous vancomycin and a third- or fourth-generation cephalosporin.
What is the treatment for parenchymal neurocysticercosis with more than 2 viable lesions?
Albendazole, praziquantel, and a glucocorticoid.
What does injury to the musculocutaneous nerve affect?
Elbow flexion and forearm sensation.
What is the most appropriate treatment for neurocysticercosis with more than one lesion?
Albendazole, praziquantel, and dexamethasone.
What symptoms are consistent with myasthenia gravis?
Dyspnea, dysphasia, ptosis, and ophthalmoplegia.
When is an MRI of the brain not helpful in assessing neurological damage?
In the absence of focal neurologic findings on exam.
What are the symptoms needed to diagnose Parkinson’s disease?
Bradykinesia plus at least one of the following: muscular rigidity, resting tremor, and postural instability.
Is the Minnesota Multiphasic Personality Inventory relevant in the initial evaluation of cognitive problems?
No, it is generally not relevant.
What is the likely diagnosis for slowly progressive weakness of proximal leg and finger flexor muscles?
Inclusion body myositis.
What should patients with a suspected brain abscess be treated with?
Broad-spectrum antibiotics and stereotactic aspiration.
What features do migraines typically have?
Unilateral location, pulsating in nature, moderate to severe, and exacerbates with physical activity.
What daily preventative medications are used for frequent migraines?
Beta-blocker, amitriptyline, sodium valproate, and topiramate.
What can dopamine agonists cause in older patients with Parkinson’s?
Hallucinations and confusion. The next best step is to switch to carbidopa/levodopa.
How does vascular dementia typically manifest?
With a stepwise cognitive decline and mild cognitive impairment.
What does fasciculations mean?
Muscle twitches.
What is the treatment for neurocysticercosis with more than one lesion?
Albendazole, praziquantel, and dexamethasone.
What symptoms are associated with GBS?
Acute onset of progressive dyspnea and paresthesias along with diminished reflexes on physical examination.
What should be evaluated immediately in patients with respiratory issues?
The patient’s respiratory function should be evaluated immediately.
What is the typical presentation of recrudescence in patients with prior stroke?
The symptoms are usually similar to their initial presentation but not as severe.
What are common triggers for symptoms in patients with prior stroke?
The most common triggers include infection, hypotension, hyponatremia, hypoglycemia, insomnia, stress, and benzodiazepine use.
What side effects can dopamine agonists cause in older patients with Parkinson’s?
Dopamine agonists can potentially cause hallucinations and confusion as abnormal side effects.
What does cerebrospinal fluid (CSF) studies in transverse myelitis show?
CSF studies may show a mild pleocytosis with a leukocyte count >10 cells/L and elevated oligoclonal bands.
What does symptom onset over seconds or minutes suggest?
It suggests a vascular event.
What does symptom onset over several hours or days suggest?
It suggests an abscess.
What does progression of symptoms over weeks to months suggest?
It suggests a neoplasm.
What is required for a diagnosis of MS?
A patient needs only one CNS event and either MRI findings demonstrating dissemination in space or CSF demonstrating presence of oligoclonal bands unique to the CNS.
What sugar levels are typical in tuberculous meningitis?
Tuberculous meningitis typically has low sugar levels in the CSF.
What is the most common predisposition to subdural hematoma?
The most common predisposition to subdural hematoma is cerebral atrophy.
What is the most useful investigation in an adult with an initial unprovoked focal seizure?
The most useful investigation is MRI.
What are alarm symptoms associated with acute onset back pain?
Acute onset back pain, lower extremity weakness, urinary incontinence, and loss of rectal tone.
What is the initial diagnostic test for acute onset back pain with alarm symptoms?
The initial diagnostic test is MRI.
What is the likely diagnosis for a symmetric, high-frequency, low amplitude tremor that worsens with activity?
Likely diagnosis: Essential tremor.
Do all antiepileptic drugs have teratogenic effects?
True, all antiepileptic drugs have some teratogenic effects.
What characterizes pronator syndrome?
Pronator syndrome is characterized by forearm pain with repetitive movements, especially with elbow extended.
What is characteristic of herpes simplex virus encephalitis?
Encephalitis accompanied by personality changes and temporal-lobe enhancement on MRI.
What treatment option provides better outcomes for patients with symptomatic carotid stenosis?
Patients have better outcomes when treated with stenting or endarterectomy than when treated with medical management alone.
What mnemonic is used for anticholinergic side effects?
Red as a beet, dry as a bone, blind as a bat, mad as a hatter, hot as a hare, full as a flask.
What is the first-line abortive therapy for acute menstrual migraines unresponsive to NSAIDs?
The triptan class of drugs.
What is the likely diagnosis for positional vertigo with normal hearing?
Likely diagnosis: BPPV.
What shape does an epidural hematoma display within the skull?
A convex lens shape.
Are confusion, fever, and pleocytosis typically seen in botulism?
No, they are not typically seen in botulism.
What clinical syndrome is caused by compression of nerves involving ≥ 2 of the L2–S5 nerve roots?
Cauda equina syndrome.
What can cauda equina syndrome cause?
Bowel or bladder dysfunction, perianal or saddle anesthesia, variable lower extremity neurological deficits, and back pain.
What are the medication recommendations for improving strength and pulmonary function in DMD?
Low-dose prednisone or deflazacort.
What results from compression of the ulnar nerve?
Cubital tunnel syndrome, causing wrist pain along the fourth and fifth digits.
What is labyrinthitis typically associated with?
Hearing loss and occurs after a viral syndrome.
What type of pleocytosis can listerial meningitis result in?
Either a mononuclear or polymorphonuclear-predominant pleocytosis.
What are the symptoms of spinal stenosis?
Usually bilateral and tend to resolve when the patient sits or flexes forward while walking.
What type of vertigo typically manifests with other neurologic symptoms?
Central vertigo.
What type of medications commonly cause drug-induced parkinsonism?
Antipsychotic medications.
What happens when the axillary nerve is damaged?
It results in paresthesias and diminished sensation to light touch over the lateral aspect of the shoulder.
What is the first step for bacterial meningitis treatment?
Obtain blood cultures followed by broad spectrum antibiotics.
What is labyrinthitis associated with?
Peripheral vertigo and hearing loss, typically developing after a systemic viral illness.
What is included in synthetic cannabinoid treatment?
IVF, benzodiazepines, or neuroleptics as appropriate.
What should be the first step in migraine management if possible?
Nonpharmacologic treatment (lifestyle change).
What is the most effective monotherapeutic strategy for delayed sleep-wake phase disorder?
The use of melatonin 4 hours before one’s desired bedtime.
What is the initial treatment of a spinal epidural abscess?
Consultation with a neurosurgeon and provision of empiric antibiotic therapy with intravenous vancomycin and a third- or fourth-generation cephalosporin.
What does injury to the suprascapular nerve likely result in?
Weakness with external rotation or abduction, especially in the 90 to 180 degree planes.
What will corticobasal syndrome patients have?
Parkinsonian signs as well as coexisting aphasia, apraxia, dystonia, or alien limb syndrome.
How does injury to the radial nerve manifest?
With decreased sensation to the dorsum of the hand and weakness with elbow, wrist, and thumb extension.
What diagnostic tests have the highest yield in the workup of patients with distal symmetric polyneuropathy?
Glycated hemoglobin or blood glucose, vitamin B12, methylmalonic acid, and serum protein electrophoresis.
What is a variant of Horner syndrome that manifests with ptosis and miosis but not anhidrosis?
Partial Horner syndrome, associated with cluster headaches.
What is the likely diagnosis for a patient with parkinsonism, early dementia, fluctuations in cognition, and visual hallucinations?
Lewy body dementia.
What is the initial type of exam for cognitive impairment and features of Alzheimer dementia?
MRI brain or CT head.
What is Ménierè disease characterized by?
The classic triad of hearing loss, tinnitus, and vertigo.
What are migraines accompanied by?
At least one of the following symptoms: nausea, vomiting, photophobia, or phonophobia.
What is the key physical finding in tension headaches?
Pericranial muscle tenderness, which can be assessed by palpating the frontalis and temporalis.
What would an occipital lobe stroke manifest with?
Hemifield vision loss in both eyes.
Is neuroimaging of the brain recommended for any patient presenting with seizures of focal onset?
Yes, it is recommended.
When is imaging of the brain recommended?
Imaging of the brain is recommended for any patient presenting with seizures of focal onset or with persistent postictal focal deficits even after the first episode.
What is the key physical finding in tension headaches?
The key physical finding in tension headaches is pericranial muscle tenderness, which can be assessed by palpating the frontalis, temporalis, masseter, pterygoid, sternocleidomastoid, splenius, and trapezius.
How is migraine without aura defined?
Migraine without aura is defined as a history of 5 or more episodes that have at least 2 of the following features: unilateral location, pulsating quality, moderate to severe pain, and exacerbation with physical activity. They last 4 to 72 hours each.
What symptoms accompany migraine without aura?
Migraine without aura is accompanied by at least one of the following: nausea, vomiting, photophobia, or phonophobia.
What is a variant of Horner syndrome associated with?
A variant of Horner syndrome that manifests with ptosis and miosis but not anhidrosis is associated with cluster headaches.
What is the next management step for a patient with well-controlled epileptic seizures?
The next management step is to continue the current dose of the antiepileptic drug if the patient is well-controlled on a stable dose with no adverse effects and has supratherapeutic levels of the drug.
What characteristic period is associated with an epidural hematoma?
An epidural hematoma will have a characteristic period called the lucid interval.
