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Step 3 > Neurology > Flashcards

Neurology Flashcards

1
Q

TIAs

A

always due to emboli or thrombosis

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2
Q

best initial diagnostic test for either stroke or TIA

A

head CT w/o contrast

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3
Q

Lesions: anterior cerebral artery

A

LE weakness
UE weakness
personality changes
urinary incontinence

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4
Q

Lesion: middle cerebral artery

A 
UE weakness
aphasia
apraxia/neglect
Eyes deviated TOWARD side of lesion
C/L homonymous hemianopsia
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5
Q

Lesions: Posterior cerebral artery

A

prosopagnosia - inability to recognize faces

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6
Q

Lesion: Vertebrobasilar artery

A 
vertigo
NV
"drop attacks"
labile BP
sensory changes in face and scalp
dysarthria, dystonia
vertical nystagmus
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7
Q

Lesion: posterior inferior cerebellar artery (lateral medullary)

A

ispilateral face
contralateral body
Vertigo
Horner’s syndrome

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8
Q

what test is needed to evaluate posterior circulation infarcts?

A

MRI

MRA - for brainstem

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9
Q

C/I: thrombolytics

A 
hx of hemorrhagic stroke
presence of intracranial neoplasm/mass
active bleeding/surgery within 6 weeks
presence of bleeding disorder
CPR within 3 weeks
suspicion of aortic dissection
stroke in last year
cerebral trauma/surgery within 6 months
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10
Q

best initial therapy for person with stroke > 3 hours

A

aspirin

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11
Q

what do you give if a person has developed a stroke while on aspirin?

A

switch to clopidogrel OR add dipyridamole

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12
Q

when do you use ticlopidine in a stroke patient?

A

only pts who are intolerant of both ASA and clopidogrel

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13
Q

s/e ticlopidine

A

TTP

neutropenia

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14
Q

important management post-TPA

A

neuro checks every hour

keep BP < 180/100

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15
Q

F/U studies to do in all stroke patients

A

Echo
Carotid dopplers
EKG and Holter monitor if EKG is normal

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16
Q

additional tests to run in a young patient (<50) with a stroke

A

ESR
VDRL/RPR
ANA, dsDNA
Protein C/S, factor V leiden, antiphospholipid

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17
Q

Management of status epilepticus

A
  1. Benzos - Ativan; repeat if still seizing after 1 min
  2. If seizure persists after 10-20 minutes –> Fosphenytoin
  3. Continues for 10-20 minutes –> Phenobarbital (Intubation/ventilation considered)
  4. General anesthesia –> pentobarbital, thiopental, midazolam or propofol
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18
Q

Tests to order in seizure patient:

A
  1. Na, Ca, glucose, creatinine and Mg levels
  2. Head CT
  3. urine tox screen
    if these are negative then:
  4. EEG
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19
Q

when should you get a neuro consult in a seizure patient?

A

all seizure patients, once the initial workup is done

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20
Q

what should you order if you suspect a pseudoseizure?

A

psych consult

PRL level - normally rises after a real seizure

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21
Q

which conditions mandate that you treat chronically after first seizure?

A
  1. strong family hx
  2. abnormal EEG
  3. status epilepticus
  4. noncorrectable precipitating cause - brain tumor
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22
Q

first line therapies for seizures:

A

valproic acid
carbamazepine
phenytoin
levitiracetam

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23
Q

lamotrigine - s/e

A

steven johnson/severe skin reactions

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24
Q

second line therapies for seizures

A

gabapentin

phenobarbital

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25
Q

which anti-epileptic drug is most dangerous in pregnancy

A

valproic acid

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26
Q

which side are most anti-eplipetic drugs assoc with

A

bone loss and osteoporosis

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27
Q

DX. Parkinsons

A

clinical

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28
Q

Tx. mild parkinsons symptoms

A

60: amantadine

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29
Q

s/e anticholinergics in PD

A

worsen memory

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30
Q

first line treatment for severe PD (interferes with daily living)

A

Dopamine agonists - pramipexole, ropinirole, cabergoline

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31
Q

what do you start if you have really severe disease or disease progression in PD

A

levodopa/carbidopa –> most effective treatment

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32
Q

Pt with PD being treated with levodopa develops psychosis - what do you give?

A

quetiapine

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33
Q

Pt with PD on levodopa develops on off phenomena

A

COMT inhibitors

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34
Q

Alternatives to Levodopa/carbidopa if not effective for PD

A

add COMT inhibitors
MAOI: selegeline, rasagiline
deep brain stimulation

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35
Q

Features of essential tremor (4)

A
  1. both at rest and intention
  2. Normal life expectancy, no other neuro sx
  3. AD inheritance
  4. Tx. Propranolol
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36
Q

good prognostic factors for MS

A
  1. optic neuritis
  2. female
  3. early age onset
  4. relapsing form of disease
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37
Q

best initial and most accurate diagnostic test for MS

A

MRI

- repeat 3 months after initiating therapy

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38
Q

when would you do a LP in a pt with MS

A

only if MRI is non-diagnostic

youll see: oligoclonal bands, T lymphocytes, elevated IgG index

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39
Q

best initial therapy for acute MS exacerbation

A

steroids

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40
Q

disease modifying therapy in MS

A

beta interferon and glatiramer
- both are teratogenic
mitoxantrone
natalizumab - may cause PML

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41
Q

additional meds in MS for fatigue (1) and spasticity (2)

A
  1. amantadine

2. baclofen or tizanidine

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42
Q

for all patients with memory loss - what do you order?

A
  1. head CT
  2. B12 level
  3. RPR/VDRL
  4. Thyroid function testing
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43
Q

Tx. alzheimers disease

A

donepezil, rivastigmine, galantamine

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44
Q

CF: Frontotemporal dementia (Picks disease)

A 
Personality changes (disinhibition, impaired executive function, irritability), Hyperoral behavior --> memory loss is the last part to go
Head CT: focal atrophy of frontal/temporal lobes
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45
Q

CF: Creutzfeld Jakob disease

A

young patient with rapidly progressive dementia and myoclonus

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46
Q

Dx. tests for CJD

A

EEG
MRI
CSF –> 14-3-3 protein
Brain biopsy = most accurate

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47
Q

Lewy body dementia

A

PD symptoms + dementia (visual hallucinations)

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48
Q

Dx. testing for normal pressure hydrocephalus

A
  1. Head CT
  2. LP
  3. Miller Fisher test - assess gait before and after removal of CSF
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49
Q

phenytoin toxicity

A

nystagmus on far lateral gaze
blurred vision, diplopia
ataxia, slurred speech
dizziness, drowsiness, lethargy

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50
Q

what do you do if pt presents with phenytoin toxicity?

A

decrease dose or treatment schedule to minimize drug peak levels

51
Q

once a stroke pt is admitted to the hospital and treated with ASA etc. - what should be evaluated next?

A

bedside swallow evaluation with speech therapy before giving any meds or food PO

52
Q

is heparin used in treatment of acute stroke patients?

A

yes! low dose subcu heparin is used for DVT prophylaxis, esp. in patients with dense hemiparesis
- full dose heparin is not used

53
Q

BP management in stroke patients

A
  1. no tpa? permissive HTN up to 220/120. If greater, IV BB
  2. tpa? want to keep BP < 180/100
  3. hemorrhagic stroke? CCB, nicardipine
54
Q

what should you do if PD patient presents with symptoms that make you consider depression?

A

difficult to ascertain bc many symptoms overlap, but may do trial of SSRIs before altering PD meds

55
Q

senile gait (due to aging)

A

“walking on ice” - feed wide apart with knees/hips flexed, legs straight and arms flexed/extending as if expecting to fall

56
Q

spastic paraparesis gait

A

pt drags legs forward with every step (circular leg movements)

57
Q

cerebellar ataxic gait

A

drunken sailor gait - jerky pt, walks in zigzag pattern

58
Q

First step in Wernicker’s encephalopathy

A

THIAMINE 200 mg IV/24 hours

glucose after

59
Q

Parinaud’s syndrome

A 
loss of pupillary reaction
vertical gaze paralysis
loss of optokinetic nystagmus
ataxia
headache --> obstructive hydrocephalus
60
Q

CF: craniopharyngioma

A

headache
diabetes insipidus
deficiency of one or more pit. hormones

61
Q

Foster Kennedy syndrome

A

frontal lobe tumor - optic atrophy on side of tumor and papilledema on contralateral side

62
Q

antihypertensives used in controlling BP in acute stroke

A

IV labetalol, nicardipine or sodium nitroprusside

63
Q

what tests must be done to rule out reversible causes of dementia?

A

thyroid function tests
vitamin B12 deficiency
vitamin B1 deficiency in alcoholics

64
Q

Preventative therapy for cluster headaches with a duration of > 2 months

A

Verapamil

alt: prednisone, lithium but both are much less studied

65
Q

acute (abortive) management of cluster headaches

A

100% O2 inhalation

- can also give triptans (easier for at home)

66
Q

Binswanger’s disease

A

vascular dementia with white matter infarcts; presents with apathy, agitation and bilateral corticospinal/bulbar signs

67
Q

drug approved for ALS

A

Riluzole - glutamate inhibitor; delays progression

68
Q

Dx. of Cerebral palsy

A

diagnosed based on history and physical examination but MRI should be ordered to look for any abnormalities or possible etiology of symptoms

69
Q

an area of decreased sensation over anterolateral thigh without any muscle weakness or DTR abnormalities

A

meralgia paresthetitica –> entrapment of lateral femoral cutaneous nerve

70
Q

psychogenic coma

A

perform caloric testing - normal reaction to caloric testing of external auditory canal is suggestive (transient, conjugate, slow deviation of gaze to the side of the stimulus followed by saccadic correction to the midline)

71
Q

classic triad of sx for spinal epidural abscess

A

fever
severe focal spinal pain
neurologic deficits –> radiculopathy, motor/sensory deficits, bowel or bladder dysfunction, paralysis

72
Q

initial management of pt presenting with seizures

A
  1. ventilation/circulation
  2. IV lines - obtain blood for glucose, CBC and electrolytes
  3. urine toxicology sent
73
Q

management of patient presenting with unilateral Bell’s palsy

A

no further workup

treat with corticosteroids and supportive eye care

74
Q

MMSE score of < 20

A

dementia

- senility usually has > 25

75
Q

sites that may be biopsied to diagnose sarcoidosis

A
  1. any palpable LN
  2. subcutaneous nodule except erythema nodosum
  3. enlarged parotid gland
  4. lacrimal gland
76
Q

when should a head CT or MRI be done for a headache

A
  1. sudden and/or very severe
  2. onset after age 40
  3. assoc. with focal neurological findings
77
Q

best initial abortive therapy for a migraine

A

sumatriptan or ergotamine

78
Q

prophylactic therapy for a migraine

A

if >4 headaches /month:

  1. BB - propranolol
  2. alternate prophylactic medications: CCBs, TCAs, SSRIs
79
Q

CF: pseudotumor cerebri

A

obese young woman with headache plus:

  • 6th nerve palsy
  • visual field loss
  • transiently obscure vision
  • pulsutile tinnitus
80
Q

most accurate diagnostic test for pseudotumor cerebri

A

LP with opening pressure measurement

81
Q

Tx. pseudotumor cerebri

A

weight loss
acetazolamide
surgery if the above two fail

82
Q

Management: BPV

A
  1. canalith repositioning procedure

2. meclizine (modest response)

83
Q

vertigo and dizziness that is not related to changes in position - dx? tx?

A

dx. vestibular neuritis

tx. meclizine

84
Q

acute hearing loss, tinnitus and vertigo

A

labrynthitis - cochlear portion of inner ear

- self limited, may be treated with meclizine

85
Q

vertigo, hearing loss and tinnitus that is chronic with remitting and relapsing episodes

A

Meniere’s disease

86
Q

Tx. Meniere’s disease

A

salt restriction
diuretics i.e. furosemide
H1 antagonists - decrease amt of endolymph production

87
Q

ataxia in addition to hearing loss, tinnitus and vertigo

A

acoustic neuroma

88
Q

anyone with vertigo should get which test

A

MRI of internal auditory canal

89
Q

normal CSF protein level can exclude…

A

bacterial meningitis

90
Q

CSF glucose levels < 60% of serum levels are diagnostic of…

A

bacterial meningitis

91
Q

empiric therapy for meningitis

A

ceftriaxone
vancomycin
steroids

92
Q

meningitis in an HIV patient with CDC < 100: dx? tests?

A

dx. cryptococcal meningitis
best initial test: india ink stain
most accurate test: cryptococcal antigen

93
Q

Tx. cryptococcal meningitis

A

IV amphotericin + flucytosine

Oral fluconazole prophylaxis until CDC >100

94
Q

Tx. meningitis due to Lyme disease

A

IV ceftriaxone or penicillin

95
Q

Tx. TB meningitis (Very high CSF protein level)

A

RIPE therapy + Steroids

- longer therapy (12 months)

96
Q

who should receive prophylaxis with Neisseria meningitidis

A

Any close contacts (household members or those who shared cups/kisses etc); school and work contacts do not need prophylaxis

97
Q

Neisseria prophylaxis

A

Rifampin

Ceftriaxone

98
Q

patient presents with acute onset of fever and altered mental status - dx? best initial test? most accurate test?

A

Dx. encephalitis
Test initial: head CT
accurate test: PCR of CSF

99
Q

Tx. herpes encephalitis

A

IV acyclovir 10 mg/kg q8

100
Q

HIV positive patient presents with fever, headache and focal neurological deficits. Head CT shows ring enhancing lesion - next step?

A

Tx. with pyrimethamine and sulfadiazine for 2 weeks and then repeat head CT. If toxoplasma will go away - if cancer, will need a brain biopsy

101
Q

Management of PML

A

Tx. HIV and raise the CD4 count; lesions will disappear as HIV improves

102
Q

A patient who recently moved from Mexico comes in with seizures. Head CT shows multiple cystic lesions that are not yet calcified. Management?

A

Neurocysticercosis
COnfirm diagnosis with serology
Tx. Albendazole + Steroids

103
Q

Steps in Management of Large Intracranial Hemorrhage with mass effect

A
  1. Decreased ICP:
    a) Intubation/Hyperventilation (pCO2 25-30)
    b) Mannitol - takes 90 min to work
    c) Barbiturate coma = last effort
  2. Surgical Evacuation
104
Q

Subarachnoid hemorrhage
Best initial test(1)
Most accurate test (2)

A
  1. Head CT w/o contrast
    - may be normal w/in first 24-72 hours of onset
  2. Lumbar Puncture
    - xanthochromia; supernatant will be yellow
105
Q

normal WBC to RBC ratio

A

1:500

infection is present only if > 1:500

106
Q

Treatment SAH

A
  1. Angiography
  2. Embolization of the vessel
  3. Rx. nimodipine PO (CCB that decreases risk of stroke)
107
Q

Pt presents with loss of sensation of pain and temperature in UE bilaterally in capelike distribution over neck, shoulders and down both arms - dx? test? tx/

A

Dx. syringomyelia
Test: MRI
Tx: surgery

108
Q

what can present with tenderness over the spine? in either of these cases - what is the next best step?

A

cord compression
spinal epidural abscess
NEXT step -> MRI

109
Q

most urgent next step in cases of cord compression

A

give steroids - to decrease swelling

110
Q

You suspect a spinal epidural abscess - what should you treat with?

A

Antibiotics against Staph ex. oxacillin, nafcillin

111
Q

anterior spinal artery infarction

A

all sensation is lost except position and vibratory sense (which travel down posterior column)

112
Q

Brown Sequard syndrome

A

traumatic injury to the spine, i.e. knife wound

Pt loses ipsilateral position, vibratory sense and Contralateral pain and temp below the lesion

113
Q

Tx. diabetic peripheral neuropathy

A

Gabapentin or pregabalin

114
Q

Management of carpal tunnel syndrome

A

Initially = wrist splint

on CCS - move the clock forward, and if no improvement may try injecting steroids

115
Q

Tx. Bell’s palsy

A

steroids

116
Q

Tx. reflex sympathetic dystrophy

A
  1. NSAIDs
  2. Gabapentin
  3. Nerve block
  4. Surgical sympathectomy
117
Q

Tx. restless legs syndrome

A

pramipexole, ropinirole

118
Q

Pt comes in with suspected Guillain Barre syndrome - next best step?

A

peak inspiratory pressures (predicts weakness of diaphragm and likelihood of respiratory failure) and determines who gets treatment

119
Q

Tx. Guillain Barre syndrome

A

either IVIG or plasmaphoresis (not combination)

120
Q

Myasthenia Gravis

  • best initial test (1)
  • most accurate test (2)
  • what test do you order after DX? (2)
A
  1. ACH-R antibodies
  2. clinical presentation and ACH-R ab are most SN and SP than Tensilon test
  3. CHEST CT - to r/o thymoma
121
Q

best initial therapy for myasthenia

A

pyridostigmine or neostigmine

122
Q

Tx. of myasthenia in pt unresponsive to neostigmine

A

if pt is < 60, thymectomy

Prednisone if thymectomy does not work

123
Q

Man presents to you after his most recent gym outing c/o NV, dizziness, auditory changes, blurry vision, diplopia and interscapular pain - DX? test?

A

Dx. intracranial hypotension

Test: MRI

124
Q

Tx. intracranial hypotension

A

best rest and IVF for 2 weeks

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