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Neurology Flashcards

1
Q

Migraine

A

F>M
Q few weeks
1/2 hr onset
Lasts hours to days
Frontal/temporal one or both sides
Throbbing
n/v/aura/photophobia, AM menarch, menses, weahter, stress, worse with movement
Tx: Tylenol/NSAID/ASA -> Sumatriptan->chloropromazine/metochlopramide
Prevention: BB, TCA, Vit B2 (riboflavin), CoQ 10, Topiramate, Botox

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2
Q

Cluster h/a

A

M>F
1-2/day
onset 2-15min
lasts 1/2 hr-2hrs
Orbital/one side
Excruciating
Rhinorrhea, ipsilateral Horner’s, Unilateral lacrimation
Tx: 100 OXYGEN, intranasal lidocaine, sumatriptan
Prevention: Verapamil, valproate, gabapentin

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3
Q

Tension h/a

A 
F>M
How often? Variable
Onset Variable
how long 1/2hr to 7 days
Where: diffuse
Non-throbbing
Band like
Tx: analgesics
Prevention: BB, TCA
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4
Q

25yo F p/w chronic h/a x years noticed from puberty, mainly with waking up, several hours every few weeks, throbbing aw nausea and vom no auras - several tylenol and motrin didn’t help - acute pain would respond to….

A

Sumatriptan

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5
Q

25yo F with FLASHES of light moving across eyes for a few minutes wiht loss of visio nin one eye - left homonymous defect -normal after 45 min

A

Dx: Migraine

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6
Q

Young woman co wk in R arm and leg - PMHx migraines - feels better after couple hours - carotid US, MRI brain and TEE normal dx?

A

Migraines

DO NOT USE TRIPTANS with CAD or vasculitides

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7
Q

52yo M p/w moderately severe befrontal throbbing ha - aw nausea - had h/a for past few years - normal temp - BP 150/90, fundoscopy normla neck supple, pupils reactive no focal neur effects histor significant for CAD wtd?

A

NSAID with prochloroperazine

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8
Q

Acute migrain with nausea and vomiting fastest relief?

A

SQ Sumitriptan

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9
Q

Severe acute migraine not responding to sumatriptan or lasting >72hrs

A

IV dopamin antagonist (prochlorperazine.metoclopramide) + IV diphenyhydramine (prevent acute dystonic rxn)

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10
Q

Severe acute migrain x more than 72hrs - last sumatriptan >24hrs ago with little response - >

A

parental dihydroergotamine

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11
Q

Pregnancy with migraine h/ once a week

A

tylenol or NSAID

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12
Q

Pregnancy with migraine h/a no response to NSAIDs

A

Metoclopramide or Chloroproazine or ondeansetron

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13
Q

Migraine ppx for h/a’s how often?

A

2 times per week

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14
Q

PPX for migraine <15x/month

A

BB, amitriptyline, topiramate, sodium valproate

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15
Q

PPx for migrai >15/month

A

Topriamate-> botox

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16
Q

PPX migrains with asthma

A

amitriptyline, topiramate (no BB)

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17
Q

Prevention of menstrual h/a

A

mefenamic acid 2 days prior and upto end of menstruation

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18
Q

Migraine with Aura

A

OCP contraindicated!!

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19
Q

Pt with migrain h/a takes NSAIDs now not working wth h/a daily from morning to evening

A

Analgesic induced h/a

d/c all analgesics

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20
Q

42yo F chronic non-throbbing h/a worse at end of day - band like around neck

A

Tension h/a

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21
Q

35yo F c/o excruciating Ice pick like retroorbital h/a - h/o rhinorrhea, lacrimation ipsilateral horner’s

A

Cluster h/a

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22
Q

Pt with recurrent h/a >5-6/day unilateral and retrooribtal

A

Chornic paroxysmal hemicrania

Tx: Indomethacin

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23
Q

32yo obese woman BMI>30 with daily h/a - horizontal diplopia - blurring of optic disc margins - spinal tap with inc’d pressure

A

Pseudotumor cerebri
Tx: Acetazolamide, lumboperitoneal shunt
Etio: obesity, Vit A toxicity, tetracycline, steroids, contraceptives, nitrofurantoin, isotretinoin, minocycline, danazol, tamoxifen, levothyroxine

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24
Q

Comoplications of pseduotumor cerebri

A

Peripheral visual field loss-> central visual field loss

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25
Pt with known HTN with h/a and ataxia - CT scan large cerebellar bleed wtd?
surgery - brainstem compression
26
65yo h/a ESR 75
Temporal arteritis
27
H/a with rhinorrhea
Cluster h/a
28
100% O2
Cluster h/a
29
H/a with zigzag wavy lines photophobia and aura
Migraine
30
Sumatriptan
Migraine, Cluster h/a
31
Thunderslap h/a, CT head neg, CSF xanthochromia
Subarachnoid hemorrhage
32
Chronic h/a inc'd with lying down
brain tumor
33
Young obese pt with headache and horizontal nysstagmus
Pseudotumor cerebri
34
Acetazolamide
Pseudotumor cerebri
35
50yo F seizure or focal weakness, h/a worse on coughing/lying down CT 4cm large edema/mass effect NO CA+
Glioblastoma/astrocytoma most common and aggressive primary brain tumor Surgery primary therapy with chemo/radiation dexamethasone
36
50yo h/a worse on coughing, lying down, CT INTRAVENTRICULAR tumor
Choroid plexius papilloma slow growing benign tumor of ventricular system in choroid plexus - inc'd CSF production - inc'd OCP -> hydrocephalus Tx: Surgery
37
50yo F h/o seizure d/o for 4 years - CTH 3cm tumor in sylvian fissure - diffuse enhancement with contrast
``` Meningioma Usually benign Arise from meninges Seizures or weakness Syvian fissure Inc'd ICP ```
38
Following tumors metastasize to brain
Breast, lung melanoma, lymphoma, renal | NOT prostate
39
45yo F lighting pain jabs in gums, cheek, chin, several times per day and last few seconds at a time - no focal neurolgical signs, oral exam normal
Carbamazepine
40
Facial Palsy
Supranuclear (CVA) - Upper face spared ``` Infranuclear - both UPPER AND LOWER face Bell's palsy Accoustic Neuroma Ramsay Hunt syndrome Guillain-barre Lyme Dz Sarcoidosis ```
41
Motor Neuron Disease
Lower motor neuron (Infra-nuclear) - dec'd reflexes, dec'd muscle tone, +Fasciculations Upper motor neurons (Supra-nuclear) - inc'd reflexes, inc'd muscle tone, NO fasciculations
42
30yo with erythema chronicum migrans 4 weeks ago now with left sided upper and lower face paralysis preceded by ha
Infranuclear lesion
43
55yo vesicular lesions on R side face with pain involving ear
Supra-nuclear lesion
44
65yo M with slurred speech and lower face paralysis
Suprnuclear lesion
45
55yo pw R sided facial paralysis of unknown etio
infranuclear lesion
46
60yo M sudden onlset R facial weakness, drooling of saliva inability to close R eye - mouth deviating to left side, unable to raise eyebrows - rest of neuro exam normal
Artificial tears, patch R eye at night, start PREDNISONE
47
Young woman co diplpia - closing one eye - diplpia persists dx?
Monocular psychogenic diplopia
48
CN III palsy
can't look up, down or inward Where is lesion? posterior commuicating artery Dx: MRA brain
49
Pt in MVA brought to ER with h/a - PE shows R pupil 2mm, left pupil 4mm - ptosis of R eye - wtd?
CT angio neck | dx: Carotid artery dissection
50
Pt with acute onset diplopia h/o DM, Ptosis
Acute cranial mononeuropathy
51
Pt with hyperthyroid and exopthalmos - unable to completely abduct and has double vision - cause?
Thyroid opthalmopathy | Tx: steroids
52
R optic neuritis
MS with blindness in right eye
53
Tumor pressing on optic chiasma (acromegaly)
Bitemporal hemianopia
54
Left Optic tract
Right dense homonymous hemianopia
55
Left optic radiation (occipital lobe)
Right homonymous quadrantanopia
56
Stroke
Days Throbotic - 50% preceeded by TIA Embolic - more rapid onset Hemorrhagic - HTN, amyloi angiopathy Minutes TIA - Carotid artery syndrome - Ipsillateral visual loss (amaurosis fugax) Shadow in front of eye - contralateral motor or sensory changes ``` Vertebrobasilar syndrome DDD Dizziness, Diplopia, Dysarthria Sudden wk of legs -> dorp attacks B/l Wk Tx: ASA ```
57
Pt with TIA higher risk of stroke if...
Duration >10min Speech disturbance Age>60 DM
58
Most important risk factor for stroke?
HTN
59
Pt with TIA
Hopsital w/u - carotid dopper, EKG, CT brain, Coags, TEE r/o PFO
60
If carotid shows >70% wtd?
Carotid endarectomy + ASA
61
If TIA and carotid 90% inoperable wtd?
Stent
62
Pt with TIA and cardid US with <50% wtd?
ASA + dipyrimadamole OR plavix
63
Pt h/o TIA no PAD - best management
ASA - can add ACE+- indapamide to decrease recurrence
64
Pt has TIA on ACEi, ASA and statin
d/c ASA and start Plavix | don't use both unless has CAD with stent also
65
Endartectomy vs stent
Endartectomy better mortality, less stroke, | Stent better with high carotid bifurcation
66
Pt with TIA found to have afib
start warfarin
67
Pt with CA going for CABG - what other w/u needed?
Carotid US | If significant stenosis - carotid endarectomy FIRST
68
Pt with diplopia, dyarthria, dizziness - dx with verebrobasilar ischemia wtd?
ASA | Establish dx of vertebrobasilar ischemia with MRA posterior cranial vessels
69
Pt has occasional epistaxis esp when sneezing dx?
vWF dz
70
TPA criteria
Ischemic stroke with clearly defined sx onset No IC bleed on HCT <270 minutes sx onset to TPA
71
Exclusion crtieria for TPA
``` Rapidl improving sx Stroke or head trauna/major 3 months Major surgery w/in 14 days Suspected SAH despite normal CT head SBP>185/>110 on A/C PT>15, plt400 ```
72
65yo M woke up in AM and THEN had stroke CT neg for bleed - presents within 3 to 4.5 hrs
TPA
73
70yo M h/o afib pw sudden onset wk one side CT neg wtd?
TPA | ASA 24-48 hrs later
74
65yo M found in AM in bed with stroke
NO TPA since duration unknown
75
Pt with ischemic stroke, time onset 60 min CT no bleed, BP 200/120 wtd?
Labetoll iV when BP <185.110 then TPA
76
Pt not taking HTN meds x 1 week - BP in office 240/130, h/a visual distrubances with hemianopsia, aura, cortical blindness MRI shows white matter edema in parieto-occiptal regions
Posterior Reversible Encephalopathy syndrome (PRES) Started on nitroprusside - BP 140/90 -> taper nitroprusside
77
Pt with hemorrhagic stroke when should anti-HTN be started
BP>190/100
78
Pt with uncomplicated ischemic stroke not eligible for TPA when to start antiHTN
BP>220/120
79
Pt with ischemic stroke post tPA when to start anti-HTN
BP>170/100
80
ACA stroke
wk leg/foot WITH sensory loss urinary incontinence Primitive reflexes
81
MCA stroke
``` Parietal lboe (dominant) acalculia, agraphia, Lt/Rt disorientation, finger agnosia, tactile agnosia, paresthesia Temporal Lobe - aphasia Pariet laobe Right (non-dominant) -spatial neglect Unable to dress ```
82
PCA stroke
U/L homonymous hemianopia I/L 3rd N palsy - webers' syndrome contralateral sensory abn
83
Lateral Medullary Syndrome (wallengberg)
``` I/L loss pain/temp from face I/L palsy upper and lower face I/L loss of lacrimationa nd salivation I/L loss of taste anti 2/3 tongue Vertigo, nystagmus, nausea, vomiting Tending to fall to same side, wavy images Hoarseness, dysphagia ```
84
Medial Medullary syndrome
Contralateral hemoparesis adn parastesia affected eye looks down and toward nose I/L tongue palsy
85
Basilar artery stroke
Hemiparesis, involutary shaking movement Bulbar muscles invovlement with loss of fxn in throat - unable to move tongue - only eye movements present and called LCOKED IN SYDROME Quadriplegia
86
Pt with right sided hemiplegia and sensory defeits - r hemianopsia and aphasia
L MCA
87
Pt with L foot and leg wk, urinary incontinence
R ACA
88
Pt with R side sensory abn, ptosis L eye, pupillary dilation
L PCA
89
Pt with diplopia, dysartria one sided wk with priorbital numbness and shakign/shivery moveemnts of affected limbs
Basilar artery
90
Pt with quadriplegia, cnat speak can't put tongue out, eye movements ok
Basilar artery
91
Pt with dizziness, n/v, loss of pain/tmep sensation L half of face adn R side body, wavy lines, tends to fall to left while trying to sit up, hoarsemneess, dysphagia
Left Lateral Meduallary syndrome
92
32yo F no Pmhx p/w stroke - exam pain and tenderness over calk - etio?
PFO
93
45yo F lupus and Antiphospholipid syndrome with h/o DVT in past on warfarin PT 3.4 with TIA with R eye blury vision whic resolves in 10 min wtd?
Echo with bubble study
94
82yo M brought in with h/a and R wkness - CT hyperdense lesion in pareital area suggestive of subarachnoid hematoma BP 135/76 - no h/o trauma cause?
Amyloid angiopathy
95
Hepatopul syndrome
see bubbles q4 beats
96
Broca's aphasia
non-fluent speech CAN comprehend Frontal lobe MCA
97
Wernicke's aphasia
fluent speech but non-sensical Can't comprehend Temporal lobe MCA
98
Conductive Aphasia
Can't repeat | CAN comprehend and read
99
Global Aphasia
Sensory and motor aphasia | Branch of middle cerebral or internal carotid artery
100
Pure word blindness
can't read - occipital lobe - PCA
101
Subarachnoid hemorrhage
Thunderclap headache, hit by hammer headache, worst h/a of life nausea, vomiting, alter conciousness, neck stiffness, seizure, CNIII palsy wtd? CTH - If neg -> LP check for xanthochormia LP neg? - MRA r/o reversible cerebral vasocontriction syndrome (tx'd with CCB) Tx: Amlodipine Best test to confirm prior to surgery: Cerebral angiogram
102
Complications of SAH
Rebleed 24hrs - 1 month Vsaospasm 4 to 10 days Hydrocephalus - late
103
Best drug to tx vasospam
Nifedipine
104
Best time to do surgery
ASAP - clipping or coiling for causative aneursym
105
1 week after aneurysm surgery stroke develops - cuase?
vasospasm induced infarct
106
Vertigo - Central
Cause - brainstem/cerebellar dz, MS, cerebellar atrophy, basilar infarct, arnold chiari malformation Nystagmus - Horizontal OR vertical Visual fixation - NO inhibition of nystagmus Hearing loss/tinnitis +- N/V - Pos Severity - severe
107
Vertigo - peripheral
Cause - vestibular neuritis, labrythnthitis, Menier's dz, benign positional vertigo Nystagmus - ONLY horizontal Visual fixation - inhibition of nystagmus Hearing loss/tinnitus - labyrinthitis (vestibular nerutis - ), Menier's dz + N/V - very bad Severity - very bad
108
Pt with vertigo and horizontal nystagmus - on visual fixation nystagmus dissappears - dx?
peripheral vertigo
109
Pt with vertigo/horizontal nytagmus - visual fixation negates nystagmus - - inovlvmenet of vestbular portion of 8th nerve with diziness lasting hours to days - no deafness - URI 1 week ago dx?
``` Vestibular neuritis (Labyrinthitis) Tx: Meclizine ```
110
35yo recurrent dizzziness and tinnitius and sensation fullness in ear for months aw n/v - exam horizontal nystagmus disappears with visual fixation - audiogram with hearing loss dx?
Meniere's dz (tinnitus, hearing loss, vertigo) | Tx: Salt restriction, diuretics, surgical ablation
111
70yo M with new onset dizziness x 2 hours, BP high wtd?
MRA posterior vessels r/o brainstem stroke
112
Dx of benign positiional vertigo?
Dix halpike maneurver
113
Pt with vertigo, unilateral tinnitus, progressive hearing loss dx?
Accoustic Neuroma Etio - Schwann cells Dx test - MRI
114
Pt with vertigo while turing in bed, getting in and out of bed, bending over and straightening up, extending neck to look up, epsisoes >30s NO hearing loss dx?
Benign positional vertigo - Dx with Dix halpike maneuver | Tx: Epley otiolith manuever -> Vestibular rehab
115
Pt with vertigo, dysarthria, diplopia, ataxia dx?
Vertebral bulabar insufficiency
116
Duration of vertigo
Seconds: BPPV, TIA Minutes: Migraine, orthostatic hyptension, TIA Hours: Migraine, Meniere's Days: Migraine, Labryrinthitis, Meneire's Weeks: Labryrinthitis
117
Hearing testing
Normal: Webber - tuning fork on forehead - both ears hear same, Rhinne test AC>BC b/l ears Unilateral air conduction deafness - Webber - hear better in affected ear (from forehead) - BC>AC Rhinne test b/l conductive deafness/otosclerosis - webber - both ears hear equally, BC>AC both ears (rhinne) Unilateral sensory deafness - no bone or air conduction from rhine test - webber test on forehead - only normal ear hears b/l sensory deafness - both rhine and webber no hearing either ear...
118
Vertigo with fluctuating hearing loss, tinnitis lasting hours to days
Meniere's dz
119
Vertigo with progressie hearing loss and tinnitus, whisper test decreased - tuning for non left mastoid without response - tuning for on forehead with better hearin gon right
Acoustic neuroma (unilateral sensory hearing loss) - lateralize to good ear
120
Vertigo lasting 30 s and wakes up pt no hearing loss
Benign positional vertigo
121
Vertigo with sudden onset dizziness, dysarthria, diploppia and weakness
Vertebrobasilar ischemia
122
Vertigo post URI, horizontal nystagmus dissappears on visual fixation
Vestibular neuritis - labryrinthitis)
123
MCC vertigo
Benign positional vertigo
124
Tinnitis with gradual onset hearing loss, whisper test decreased - tuning for on mastoid doesn't elicit resposne - tuning for on forehea dwith no loaclization - audiology with high freq hearing loss
Presbycusis
125
MCC dementia
Alzheimer's dz 60yo cognitive impairment, poor short term membory, can't name names paranoit delusions CT/MRI - brain atrophy - dilated ventricles inc'd B amyloid precursuor protein - inc'd presenilin activity, APo protein E4 Neurofibrillary tangles - protein Tau (microtubule)
126
Treatment dementia
MMSE 21-25 - cholinergic augmentation (anticholinesterase), donepezil, galantamine, rivastigmine MMSE 11-20 - cholinergic augmentation plus NMDA antagonist (memantine) MMSE <11 - severe dementia - consider palliative care - d/c meds
127
Effect of cholinesterase inhibitor
Improvement of neuropsychiatric score
128
Pt with alzheimers - family asks about memantine - advice?
SLOWS progression of dementia
129
Pt with alzheimer's on donepezil - has hip surgery - post surgery agitated and confused - dx?
Post op delirium
130
82yo M with alzheimers for several years - has been getting donepezil and memantine, chlorthalidone for HTN, metformin for DM and nortriptylinefor depression getting more agitated - wtd?
d/c anti-cholinergics
131
Donepezil, galantamine and rivastigmine are choinesteras inhibitos used to treat dementia - aw?
Syncope
132
Who is more likely to experience sever disability in performance of daily living - cancer or dementia pt
Advanced dementia
133
62yo sales exective pw forgetfullness - MMSE 27/30 father with alzheimers dx?
Mild cognitive impairment wtd? Neuropsych eval Reasess in 1yr - rate of progression to alheimers 15%/yr Tx: improve cognitive fxn with 6 month program physical activity and cognitive training
134
S/E Ginkgo
inc'd bleeding time
135
75yo Pt brought in by son - father behaving irrationally - father thinks son is imposter and beign kept in prison - looks like home - gets lost in mall freqently now doesn't go - mild tremor soem rigidity - urinary and fecal inctinecne in recetn months - CTH brain atrophy and dilation of ventricles dx?
Alzheimer's dz tx: not very effective Acetylcholinesterase inhibitor, NMDA rct antagonist
136
Pt with dementia, parkinsonian sx of brady kinesia and postual instability, VISUAL HALLUCINATIONS, no resting tremor, extremem regigity, cytoplasmic inclusion bodies in subcortical tissue
Dementia with lewy bodies (lions in backyard...)
137
35yo pt with dementia father with dementia at age 40 dx?
Huntington's dz
138
Memantine
Alzheimer's dz
139
Loss of interest, disinhibition, urinates in neighors lan, hyperseuxal
Fronto-temporal dementia
140
Contacminated corneal transplants and growth hormone
Creutzfeldt-jakob dz
141
EEG intermittent sharp waves with slow background
Creutzfeldt-jakob dz
142
65yo M chronic HTN, hx CVA 3 ya with rapid onset dementia no problem naming names ataxia nd diplopia, extensor reflex, no sensory loss - CT scan multiple no-enhancing hypodense lesions
Multi-infarct dementia | tx: optimize CVA prevention (smoking cess, statins, ASA etc)
143
65yo M onset of memory loss noticed by family, difficulty naming names, no motor sx - paranoid delusions
Alzheimer's dz
144
80yo F pw dementia, urinary incotinence wid based gait, CT scan enlarged ventricles and sulci NOT enlarged
Normal pressure hydrocephalus | tx: VP shunt
145
55yo M onset of dementia with RAPID deterioration, myoclonic jerks, NO incontinence
Creutzfeldt-jakob dz
146
Pt sees roaring lions/bears, stiffness, tremor
Dementia with Lewy bodies motor features of parkinson's bizarre visual hallucinations Tx: sx tx of parkinsonian sx, anti-psycotics
147
Multiple Sclerosis
Demyelination of white matter in brain and spinal cord Demyelination - plaques in the white matter on MRIwGAD Brain- Optic nerve - optic neuritis Medial longitudinal fasciculus - Internuclear ophthalmoplegia - one eye can't pass midline (both eyes can't look same way) Spinal cord - > Dorsal columns: Sensory changes, vibration and position sense loss -> corticospinal tracts - MOTOR sx - wk, spacsiticy, hyperreflexia
148
Optic Neuritis
Inflammation of Optic Nerve Subacute decrease in vision +- periocular pain Visuion blurry post excerc or heat/smoking or stress Relative afferent pullilary defect Tx: IV methylprednisone
149
Other presentations of MS
``` Bladder dysfxn Bowel dysfxn Sexual dysfxn Trigeminal neuraligia Cognitive dysfxn (thinning of corpus callosum Spasticity - carbamazepime helps Fatigue - tx with Amantadine NO seizures No aphasia No h/a ```
150
Dx of MS
Clinical presentation Best imaging - Flare - MRI inc'd T2 signal dec'd T1 signal Enhancement with Gad in active lesions If MRI inconclusive - evoked potential studies - conduction velocities CSF: Cell 2 IgG olgoclonal bands suggestive of MS
151
Tx of MS
``` Acute Relapses - InterNucOph, Optic Neuritis, fxn impairment -> IV methylprednisolone 1g qd x 3-5 days and taper Active dz or to prevent relapse IFN B1a-c Fatigue - amantadine ```
152
What causes acute relapse in MS
Infections before high dose steroids always r/o infection Young women shoudl be on contraception to avoid teratogencity on IFN tx
153
MC presentation of MS
parathesias, tingling sensation, loss of vibration sense (dorsal column)
154
Blurry vision, diplopia
MS
155
Methylprednisolone x 5 days then taper
Acute MS relapse
156
Alpha interferon
NOT Tx for MS
157
B interferon
PPx for relapse
158
Amantadine
Tx for MS fatigue
159
Optic Neuritis
Better prognosis
160
Sensory sx
Better prognosis
161
Relapsing remitting
Better prognosis
162
Progressive relapsing MS
Worse prognosis - d/c B infn
163
Age>40 at dx of MS
worse prognosis
164
32yo with intermittent diplopia - numbness/paraesthesia - attempted adduction affected eye -> horizontal nystagmus - Visual acuity - 20/20
internuclear ophthalmoplegia | etio - Medial longitudinal fasciulus - MS
165
Young woman develops "thick tongue" blurry vision after hot showser - after exc or after hot weather - dx?
Optic neuritis
166
Pt with MS not responding to B interferon
start mitoxantrone
167
Parkinson's dz
Movement d/o 2/2 decrease DOPAMINE from SUBSTANTIA NIGRA Clinical Dx Cl Fts RRRR R esting tremor 4-7 Hz - pill rolling - pronation/supination R igidity - cog wheel regidity - dec'd arm swing R etarded movement - bradykinesia and dyskinesia R eflex lost - postural reflex lost-> frequent falls
168
When to treat Parkinson's
Only start when sx have negative impact on functioning status 1. Replete dopamin in brain - Levodopa (peripheral effects not needed) so add carbidopa (prevents periopheral effect of levodopa) 2. Dopamine agonist (pt <70yo): pramipexole, ropinirole bromocriptine 3. Inhibitors of dopamin breakdown - selegiline, tolcapone - allows higher doses of L dopa to cross BBB 4. Anti-cholinergics - dec s/e levodopa (trihexyphenidyl, Benztropine)
169
Complications of Treatment
L-Dopa side effects Involuntary movements - fascial lingual dystonia, chorea, athetosis Psychiatri symptoms - confusion, depression hallucinations psychosis on-off phenomenon - alternative hyperkinesia-hypokinesia
170
55yo M p.w slow shuffling gait - resting tremor and brdykinesia - ADL with difficulty - cogwheel rigidity and spacticity of muscles - now would start...
Levodopa and carbidopa
171
Pt started on levodopa-carbidopa c/o nausea wtd?
Take with low protein meal or carbidopa 30 min prior to levodopa
172
Pt with long standing parkinson's dz on L&Carbidopa now c/o wk and bradykinesia dx?
On-off phenomenon - inc dose/frreq +- selegiline (inhibits levodopa breakdown)
173
70yo F parkinson's dz on levodopa and carbidopa did well for several years now with inc'ing sx - > dosage of levo/carbidopa inc'd-> psychsis wtd?
start atypical antipsychotic - quetiapine or clozapine
174
Pt with refractory schizophrenia started on clazapine - 3 weks later develops agranulocytosis WBC 500 wtd?
d/c clozapine and never use again
175
Pt with Parkinson's dz hospitalized with PNA confused, agitated at night -
start lorazepam
176
Parkinson's related dementia
Quetiapine or clazapine
177
Parkinson's related DELIRIUM
Lorazepam or Quetiapine
178
Pt pw bradkinesia, abn gait, inc'd muscle tone and mild dementia - exam reveal erect posture with hyperextension of neck no tremor, vertical ophthalmoplegia; trouble walking downstairs, eating or reading
Progressive Supranuclear palsy Slow movements, problem with voluntary eye movement, diplopia while reading (hard to get eyes close together Tx: TCA (amitripline)
179
Essential or Familial/Kinetic Tremor
Autosomal dominant, mainly hands/head Intention tremor at 7-10hz (physiogic >9) Aggrevated by anxiety, anteropost flapping hands Gets better at rest dec'd with etoh Tx with propranolol -> primadone
180
Pt with creepy-crawly sensations, itchiness, pain, parestesias, jerky movement every 20-40 s while sleeping - fatigue during day Sx transiently relieved with movement or walking - can occur with or wihtout Parkinson's A/W Iron def anemia
Dx: Restless leg syndrome -established by H&P If IDA - iron therapy - if not better in 12 wks start dopamin agonist No iron def - dopamin agonist (perfolide, pramipexole, ropinrole or gabpentin
181
periodic limb movementd/o with jerky movements during sleep dx by?
Polysomnography
182
Pt while writing, hand goes into spasm - phalen/tinel's neg, serum Ca 9mg
Acute dystonic rxn
183
Pt get phenothiazine for n/v - coupel hours later - pt eyes are tuck in particular gaze (left or right) wtd?
Diphenhydramine
184
Acute Dystonia
Torticollis - fixed flexion of neck Blepharospams Writers cramp
185
18yo M with twitching of face, grimacing and movements of neck
Tourette's syndrome | Tx: neuroleptics
186
Tremor best seen at rest
Parkinson's
187
Tremor aggrevated by anxiety
Essential/kinetic
188
Tremor dec'd by rest
Essential/Kinetic or Cerebellar
189
Tremor relieved by etoh
Essential/Kinetic
190
Tremor activated by action
Essentiail/kinetic, parkinson, cerebellar
191
Tremor in head/voice tremors
Essential/kinetic
192
Chin tremors
Essential/Kinetic or parkinsons
193
Familial tremors
essential/kinetic
194
Tremor on fexion-extension
Essential/kinetic
195
Tremor on pronation/supination
Parkinson's
196
Tremor at rest and on movment
Parkinsons
197
Neuromuscular dz
Myasthenia gravis Autoimmune Ab to POST-synaptic Ach rct's Low level of Ach rct Cl ft: WEAKNESS as day PROGRESSES (repetive acts) reflexes normal Extraoc/oc muscles-> Ptosis, diplopia Facial muscles-> diff chewing, dysartria BUlabar muscles - diff swallowing Prox limb muscles - wk brushing hair Intercostal an diaphragmatic wk -> resp failure (Myasthenic crisis) Edrophonium challenge test (Tensilon test) -> Ptosis should get better Ach rct ab + in 90% gen MG, 50% ocular MG
198
Dipolpia
+Ptosis+wkness -> MG +INO-> MS +dysarthria+ataxia+dizziness-> Verterobasil TIA +cauda equina -> Leptomeningial metastaisis
199
Pt with diplopia, fatigue at end of day difficulty brushing hair, recently while eating regurg thru nose, diplpia, ptosis both eye way to do dx?
Ach rct Ab test
200
35yo prox muscle wk, ptosis, diplopia, EOMI intact, vision intact, replex intact
Repetive nerve stim studies MS - gets weaker with repeated stim Eaton lamburt - stronger with repeated stim
201
Pt dx with MG wtd next
CT chest r/o thymoma - if present resect
202
40yo F works on farm lately gets tired - diplopia on exam - pupils ok refelxes ok vision ok - dx?
MG - reponsd to physostigmine | not organophosphate - pupils would be constricted
203
30yo smoker with diplopia - tired at end of day - difficulty swallowing, chewing, nasal regurg - develops progressive wk and goes into resp facilure - dx?
MG
204
What makes MG wkness worse?
``` aminoglycoside abx Antiarrythmics BB Infxn Electrolytes d/o ```
205
Pt with myasthenic crisis wtd?
ICU Plasma exhange Immunglob/steroids Elective intub for VC<20ml/kg
206
Pt with MG on pyridostigmine now with acute exacerbation wtd?
immunoglobulin/steroids
207
Eaton Lambert syndrome
``` Autoimmune/Oat cell CA Antibody to PRE-synaptic rct's Weakness BETTER with repetitive action HYPO-reflexia no ptosis no diplopia ```
208
Pt with wk, inabilit to get up form chair, BETTER with excercise - h/o chronic smoking - DECREASED reflexes, repetive nerve stim with incremental INCREASE with continuing potentials dx?
Eaton Lambert 2/2 small cell lung CA
209
Better with repetition
Eaton labert
210
Worse with repetition
MG
211
Hyporeflexia
Eaton lambert
212
Normal relfex
MG
213
Abx infxn worse
MG
214
Small cell CA
Eaton labert
215
Thymoma
MG
216
Pre-synaptic Ab
Eaton lambert
217
Post-synaptic anti-acetychoie rct ab
MC
218
Ptosis/diplopia
MG
219
Muscle wkness
MG & eaton lambert
220
60yo M pw complaints of pain in shoulders, tired at end of day acan't keep head up - recently choked on food, slurring speech - has had diffuctly wearing pants /shirt - exam mild wk neck muscles- twithcing of shoulder - spasticity of muscles, hyper reflexia - sensory exam ok dx?
ALS dx - EMG tx: Anti=glutamic acid - Riluzole
221
Spinal cord
Myelopathy - Upper motor neuron | Radiculopathy - Lower motor neuron
222
Cervical spondylitis
Compression of cervical Cord - UMN with sensory changes UMN changes: Spasticity, hyper-reflexia of deltoid, beceps, triceps, extensor plantars Sensory changes - Loss of position and vibration sense in lateral arm/lateral 3 fingers Dx: MRI/yelogram Tx: Steroids
223
Syringomyelia
Cavitation of central spinal cord -> LMN with sensory changes LMN changes - weakness of upper limbs; start with hands and proceeds proximally to shoulders Sensory chages - Lateral column changes: temperature and pain sensation lost - touch and vbration preserved Dx: MRI Tx: Monitor if progresses - > surgery
224
Pt with wk of hand now progresses to shoulder - pain/temp sensation lost but touch and vibration preserved - MRI cavitary lesion of spinal cord
Syringomyelia
225
Pt with deep ache in buttocks and thighs when standing, disappears on sitting
Spinal stenosis
226
Pt with pain in thoracic area - flu one week ago or SLE - Now with wk of legs and bladder disturbances - getting worse - hyperreflexia (UMN)
Transverse myelitis
227
Pt with stock and glove districtuion of tingling senssation, pt confused has ataxia, spasticity and clonus
Subacute combined degenration of spinal cord
228
Pt with loss of vibration in lateral three fingers, hyper reflexia of deltoid, bicepts and triceps
Cervical Spondylitis
229
Radiculopathy
L 5 +foot drop, can't evert OR invert foot | Peroneal +foot drop can't evert but CAN invert foot
230
Reflexes
L5 - dec'd dorsiflexion, NO ankle jerk | S1 dec'd plantar flexion - dec'd ankle jerk
231
Elderly pt with c/o back pain inc'd wiht walking - expecially down hill and standing - numbness in legs - decreased while sitting - MRI would show?
Spinal stenosis | Ligamentum flagum
232
55yo M after lifting weights - lower back pain - leg raise >45 deg with pain - anal sphincter tone good, dorsiflexion R foot slightly dec'd, ankle jerk dec'd
Sciatica with herniated disc
233
If anal sphincter tone lost or bldder fxn wtdd?
MRI - r/o cauda equina syndrome
234
Sensory loss on Lateral aspect of thigh what spinal segment?
L2
235
One of most common causes of mononeuritis multiplex
PAN
236
Polyneuropathy - Guillan barre
Guillain Barre - inflammation of nerves with segmental demyelination LMN - ascending paralysis CSF - in'c protien, normal WBC Nerve conducion - slow conduction tx: IVIG-> plasma phereisis Elective intubation if reps muscles invovled
237
Botulism -
Descending paralysis blurred vision, diplopia, dysarthri, dysphagia diarrhea/vom in young pt with dilated pupils Labs; toxin in serum or stool Tx: botulism anti-toxin
238
Cyclist with paresthesia in little finger adn inability to adduct little finger and index finger - hypothenar wasting
Ulnar neuropathy
239
Nocturnal awakening with pain and paraesthesias
Median nerve
240
Alcoholic with diplopia and weakness of the right hand
Radial neuropathy
241
Difficulty standing on toes, reflexes dec'd
Sciatica
242
Wrist drop -
Radial neuropathy
243
Foot drop
Peroneal nerve comopression
244
Antibody induced acute polyneuropathy - occurs in
Guillain-barre syndrome
245
Yound pt with ankle sprain - takes NSAIDs - extreemm tenderness when bed sheet touchs - exam bluish discoloration - dx?
Complex regional pain syndrome - reflex sympathetic dystrophy If pt with patchy deminralization - bisphosphonates are effective - treatment even in absense of osteoporosis
246
19yo playing football has a sudden imopact and falls to ground - appears confused upon immediate exam - no LOC, 15 minute later normal cognition and vision and finger -nose test - wtd?
Can go back and play (no LOC)
247
20yo playing football - concussive injury - no LOC - in daze on immediate exam - 20 min later alert and oriente but with some amnesia which resooles 15 min later
Monitor closely, if no sx for week then can play again
248
24yo had a concussioni playing ice hockey - lost conciousness x 30 sec - upon waking alert, oreient, figner to nose normal - vision fnorma - WTD (less than 1 min LOC with normal physical exam)
Send hoem with family observation withold from competition - if remains asx can back to play in 1 week
249
24yo had concussion playing contact sports, lost consiounes x 20 sec and waking up was in daze which cleared up on wya to ER (less than one min LOC, abn physical exam upon awakening
ER eval with CT/MRI - withdraw from competition - if asx can go back to play in 2 weeks
250
Concussion with LOC > 1 min with nromal phsyical
ER eval with CT/MRI - withold from competition - if still asyxmt back to play in 2 weeks
251
Seizures
Generalized 1. Tonic Clonic - valproate, lamotrigine, levetiracetam, topriamate 2. Absense/Petit mal: without aura or post ictal sx, 3 sec spike and wave patternon EEG tx: ethosuximide, valproate, lamotrigine Partial 1. Simple - focal seizure affects small volume of cortex, no LOC (psychic sensation, deja vu 2. Complex - involves large enough cortex to cause loss of conciousness tx: Carbamazepine, phenytoin, valproate, levetiracetam, lamotrigine, gabapentin(adjunctive)
252
Medications that cause seizures
Imipenum, tramadol, bupropion, haldol, meperiridine, PRBC | Partial: Carbamazepine, phenytoin, valproate, levetiracetam, lamotrigine, gabapentin
253
Best Anti-sz med for elderly
Lamotrigene
254
Best anti-Sz med for with liver dz
Keppra (Levetrcetam)
255
Best anti Sz medication in pregnancy
Carbamapezine
256
What antiseizure medication causes kidney stones
Topiramate
257
After the first seizure - best dx imaging is...
CT if neg -> MRI Then do EEG (epileptiform spike +- slow waves NORMAL EEG does NOT r/o seizure d/o
258
Pt makign presentation to supervisor slumps over in chair, diaphretic, has jerks of arms nad legs several times - completely recovers in 30 sec and has pallor, BP normal, cardiac/neuro exam normal dx?
Syncopal convulsions
259
Pt in dental chair passes out andhas jerky movement o arms and legs, completely recovers in 30 sec - diaphoretic - similar episode once before
neurocardiogenic syncope
260
22yo h/a, smells of burnign rubber, feels strange, no convulsions seen dx?
partial seizure/psychomotor epilepsy
261
Pt has generalized seuzures not better with dilantin - serum Ca low, ca cl injections don't help wtd?
Iv Mg SO4
262
22yo with weird sensation in stomach followed by sudden freezing, swallowing chewing, lip smacking - minute later she starts talking and doesn't recall eepsode
Partial seizure
263
30yo F brought to office - say having recurrent spells of starting for several seconds the haveing intense familiarity with surrounding sand strangers most likely affected lobe is?
Temporal lobe
264
Young woman with epigastric rising sensation - most likely dz?
``` simple partial seizure temporal lobe (deja vu) ```
265
22yo F with husband and narrating complaint then her leg starts jerking which gets wors and on /off x several minutes - then SOB, then holds head tight afte r3 min jerking stops and feels dizzy and has headache dx?
Pseudoseizure | dec'd Ca+
266
55yo brought in by family - having episodes when staring blankly for several seconds then shakes hand repeately fo rfew minutes then feels tired - no focal neuro deficits, MRI normal wtd?
Sleep deprived EEG | dx: Complex partial
267
Pt with onset of seziure of left arm and then spreads to left leg - after episode wk of left arm and leg dx?
Jacksonian seizure frontal lobe starts at arm and marches toward leg in terms of sx (begin with fingers - end with legs) - NO LOC
268
Treatment of status epilepticus (sz >30min or LOC between 2 mor more seizures
1. IV glucose + thiamine 2. Lorazepam 3. Loading dose Phenytoin or Fosphenytoin 4. Maximize Phenytoin 5. Phenobarb/Midazolam 6. General anaestheia/neruomuscular blockade
269
Pt with new monset seizure - post ictal state recommendation?
No driveing | No swimming
270
Pupils
Mid dilated - glaucoma Mid constricted - uveitis (iridocylitis) b/l dilated - anti-cholinergics, botulism, cocaine unilateral dilated - CN III compression b/l constriction - Opiates, pontine infarct, organophosphate poisoning
271
MRI/CT infarct
hypodense area - no enhancement
272
MRI/CT bleed
hyperdense area, no need for contrast CT
273
MRI/CT Multi-infarct dementia
Mulitple hypodense areas, no enhancement
274
MRI/CT Tumor
Enhancing lesion
275
MRI/CT Brain abscess
Ring enhancing lesion
276
MRI/CT Toxoplasmosis
Multople ring enhancing lesions
277
MRI/CT Cerebral atrophy
Dilated ventricles AND dilated sulci
278
MRI/CT Normal pressure hydrocephalus
Dilated ventricles, sulci NOT dilated**
279
MRI/CT Multiple Sclerosis
White matter plaques, enhance with active dz
280
MRI/CT Alzheimer's
Brain atrophy +- Periventricular white matter lesions

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