Neurology 51% 59% 67% Flashcards by Ade Ighodaro

pt with formication, agitations, and tremor has a past history of alcohol and not schizophrenia because

pt has delirium tremors due to alcohol withdrawl. schizophrenia is a associated with auditory hallucinations (not formication-feeling of insects crawling on skin)

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LSD can lead to what type of hallcucinations

flashback visual

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rod-shaped, crystal-like, and eosinophilic intracellular aggregates of actin

seen in alzheimer’s. Hirano’s bodies

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loss of histological stain seen in cell bodies of neurons after damage to axon

central chromatolysis

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two nerves that make up sciatic nerve

tibial nerve (anterior divisions of L4-S3) and common peroneal (fibular) (posterior divisions of L4-S2)

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symptoms of sciatica

weakened extension of thigh, loss of knee flexion, and loss of function below the knee, pain or sensory loss on posterior thigh, lateral leg and entire foot

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motor and sensory loss of femoral nerve

motor-weak hip flexion and knee extension, sensory-anterior thigh and medial leg and the foot

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motor and sensory loss of obturator nerve

motor-weakness of thigh adduction and medical rotation of thigh, sensory-medial thigh

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motor loss of inferior gluteal nerve

(innervates gluteus maximus) loss of hip extension and difficulty rising from seated position

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motor loss of superior gluteal nerve

(supplies gluteus medius, minimus and tensor fasciae latae) loss of abduction of limb, impaired gait (Trendelenburg gait)

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pt with alzheimer’s and dies from a large intraparechymal hemorrhage is associated with amyloid angiopathy and not rupture Charccot-Bouchaurd aneurysm

C-B is associated with HTN, not lobar hypertension. amyloid hemorrhages can lead to weakening of vessel wall making them prone to rupture and cause large lobar hemorrhage (usually parietal)

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anosognosia

unaware of one’s disease

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hemiansomatognosia

unaware of their own limbs

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selective frontal and temporal lobe atrophy

Pick’s disease

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signs of intraventricular blood

sudden severe headache and neck stiffness (meningeal irritation by blood), later pts have focal deficts from vasospam. can occur as a result of subarachnoid hemorrhage

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chromosome location of pt with retinoblastoma.

chromosome 13. (13q14). mutation of tumor suppressor gene Rb.
a second somatic mutation in retinal cells leads to loss of nuclear protein and cell is stuck in G1 causing tumor growth

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young child pt with bilateral foot drop gait, decreased sensation to light touch and impaired proprioception has impaired deep peroneal nerve and not obturator because

pt has Carcot-Marie-Tooth disease mc nerve affected is deep peroneal (fibular) nerve. loss of dorsiflexion (foot drop gait). obturator nerve supplies medial compartments of thigh (loss of adduction and medial rotation)

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triad of Charot-Marie-Tooth dz

foot drop, pes cavus (high arched feet), stork-like appearance of legs, sensory loss of light and tough proprioception. disease damages myleininated fibers in peripheral nervous system

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which nerve is a branch of peroneal nerve and has no motor function in leg

sural nerve. provides cutaneous innervation to skin on lateral leg

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nerve damaged in mid-humeral fracture

radial nerve

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muscle and action of musculocutaneous nerve (C5-C6)

all muscles of anterior compartment of arm; flex elbow and supination (biceps brachii)

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muscle and action of medial nerve (C5-T1)

forearm- anterior compartment (except flexor carpi ulnaris and ulnar half of digitorum profundus); flex wrist and all digits, pronation
hand- thenar compartment; opposition of thumb. central compartment lumbricles of digits 2/3; flex MP and extend PIP and DIP of 2/3

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muscle and action of ulmar nerve (C8-T1)

forearm- anterior compartment (flexor carpi ulnaris and ulnar half of flexor digitorum profundus)-flex wrist (weak) and digits 4/5
hand-hypothenar compartment, central compartment (interossei muscles palmar and dorsal)- dorsal-abduct digits 2-5; palmar adduct digits 2-5. (lumbricals digits 4/5)-flex MP and extend PIP/DIP of digits 4/5
(adductor pollicus)- adduct the thumb

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muscle and action of axillary nerve (C5-C6)

deltoid-abduct shoulder

teres minor-lateral rotation of shoulder

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muscle and action of radial nerve (C5-T1)

posterior compartment- muscles of arm and forearm-extend MP, wrist and elbow. supination

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knife touching nerve on upper border of the greater sciatic foramen injures the superior gluteal and not the pudenal because

the superior gluteal nerve artery and vein exit the greater sciatic foramen above the piriformis (muscle in greater sciatic foramen), pudendal nerve exits foramen below piriformis, as does the inferior gluteal nerve and sciatic nerve

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obturator nerve exits where

obturator canal

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pt who smells of wine, presents with confusion, disorentiation, bruises unsteady gait and horizontal nystagmus on lateral gaze and bilateral rectus palsies (CN VI palsy) has thamine deficiency and not vit B12 def because

pt has Wernicke-Korsakoff syndrome- likely to occur in setting of alcohol abuse.

vit B12 def causes anemia and subacute combined degeneration syndrome- loss of DCML spinocerebellar, and corticospinal tracts- not CN defects.

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Wernicke’s vs Korsakoff’s

Wernicke encephalopathy (WE)- early, encephalopathy, ataxia, and oculomotor dysfunction
Korsakoff- late, confabulation, anterograde and retrograde memory loss (thalamus and mamillary bodies damage)

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thiamine B1 deficiency can cause Wernicke-Korsakoff’s and polyneuritis (dry beriberu) and not megaloblastic anemia b/c because

megaloblastic anemia is due to vitB12/ folate def. thiamine can also cause wet beriberi-dilated cardiomyopathy

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pellagra triad and vit def

vit b3 niacin def-diarrhea, dermatitis, nd dementia

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vit def in night blindness

vit A

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nerve associated with injury:

elbow
anterior dislocation of shoulder or fracture at surgical neck of humerus
wrist (carpal tunnel)
“Saturday night palsy”, compression of spiral groove or mid-humeral shaft fracture

ulnar, axillary, median, and radial

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inability to recognize faces

prosopagnosia-bilateral lesion of visual association cortex

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anogosia

normal perception devoid of meaning

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deficit in cognition about one’s illness

anosognosia-lesion in non-dominant parietal lobe

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fabrication of stories and event that never happened to fill in memory gaps

confabaulation-seen in dementias

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“dissociative orders not otherwise specified”

Gasner syndrome-giving approximate answers instead of exact ones, seen in prison inmates

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mc location of arachnoid cysts

sylvian fissue

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pt with ptosis, and mydriasis has lesion in oculomotor nerve and not superior cervical ganglion b/c

s.c.g. lesion would cause miosis, ptosis, and anhidrosis-horner’s syndrome

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muscle that closes eyelid/CN

orbicularis oculi and facial nerve

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CN that controls afferent limb of corneal blink reflex

trigeminal

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afferent and efferent pathway in pupilary light reflex, present in blind person?

afferent- CN II (optic) to pretenctal area. to efferent-CNIII to cilliary ganglion to pupillay sphincter muscle- miosis. yes doesn’t involve visual cortex

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edinger-westphal nucleus

CN III nucleus

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CNIII mediates what 3 actions in eye

levator palpebrae- eyelid opening
pupillar constriction-parasympathetic fibers
cilliary muscle-accommodation

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embryonic connection between 3rd and 4th vent is mesencephalon and not metencephalon b/c

mes-midbrain-sylvian aqueduct, vs met- pons and cerebellum (upper part of 4th vent)

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pregnant women with mumps infection can give birth to a child with

non communicating hydrocephalus-aqueductal stenosis

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mitochondrial enzyme that uses thiamins B1

pyruvate dehydrogenase

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immigrant pt with meningitis and CSF with lymphs, plasma cells, macs, fibroblasts, and increased protein, and depressed glucose has mycobacterium tuberculosis and not neisseria meningitis b/c

pt has chronic meningitis- caused by fungus, mycobacterium, syphilus
neisseria causes acute pyogenic meningitis- increased neutrophils, and viruses cause acute lymphocytic meningitis-increase lymphocytes alone.

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transynaptic degeneration

nucleus in CNS dies b/c of dengeneration of afferent pathway from DRG (i.e loss of gracilus and cuneatus nuclei in Friedreich’s ataxia (FA))

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dentate nucleus receives input and projects to

input-Purkenje fibers and output-cerebellar neocortex through middle cerebellar peduncles

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gag reflex afferent and efferent arc

afferent-IX and efferent X

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loss of ability to shrug shoulders and raise arms above horizontal level is cause by damage to spinal accessory and no axillary nerve b/c

s. a- innervates trapezius muscle

a. -branch of brachial plexus and innervates deltoid and teres minor muscles

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surgery to reach pituitary adenoma travels through which sinus? not ethmoid b/c

sphenoid. ethmoid is related to medial wall of orbit

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which is reversible delirium or dementia

delirium

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pediatric tumor with evidence of both neuronal and glial differentiation

medulloblastoma

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can pineal gland cause bitemporal hemianopia? why or why not? what else is found here?

no b/c it’s in the posterior aspect of brain along with superior colliculus

trigeminal nerve branches are and exit the skull where?

V1 (opthalmic)-superior orbital fissure
V2 (rmaxillary)-foramen rotundum
V3(mandibular)-foramen ovale

nerves that exit skull via hypoglossal canal, jugular foramen, internal auditory meatus, stylomastoid foramen, superior orbital fissure, optic canal, cribiform plate, foramen spinosum

12
9,10,11
7,8
chorda tympani (branch of facial nerve)
opthalmic branch of trigeminal (V1), 3,4,6
CN 2 and opthalamic artery
CN 1
middle meningeal artery

strabismus

eyes aren’t in same direction. i.e. CN III palsy- down and out

artery defect and ophthalmologic deficit

anterior communicating
internal carotid
ophthalmic artery
posterior cerebral
posterior communicating

aneurysm can cause bitemporal communicating
cacification can cause binasal hemianopia
monocular blindness
homonymous hemianopia with macular sparing
CN III palsy

brain lesions

crescentic microrganisms and necrosis
central necrosis surrounded by granulation tissue and gilosis
encapsulated oval microorganisms
intranuclear and and intracytoplamic inclusions
poorly differentiating cells with pseudopalisading necrosis

toxoplasmosis (crecent shaped tachizoites)-ring enhancing and central necrosis
bacterial abcess-ring enhancing and central necrosis
-cryptococcus-clustered hyperdensities in larged virchow-robin spaces
-subacute sclerosing panencephalitis
-grade VI asrocytoma (GBM)

round brain lesion at junction of cortical gray and white matter? not astrocytoma b/c

metastatic- from breast, kidney, lung ,colorectal and melanoma. astrocytoma has a irregular shape

pt with closed angle glaucoma is caused by? not cimetidine because

amitriptyline is a tricyclic antidepressant with anticholingergic affects cimetidine is a H2 antagonist that reduces gastric acid release

Goldmann’s visual test that reveals bitemporal hemianopia. pt has HA and what type of tumor and symptom? breast discharge and not tinnitus because

pt has pituitary adenoma- goldmann’s test has image with dots showing where pt can see. mc type is prolactinoma=milky breast discharge. tinnitus is associated with schwannomas

pt with right homonymous hemianopsia but 20/20 vision has occlusion where? and not Acomm because

Acomm would cause bitemporal hemianopsia. PCA- leads to homonymous hemianopia and spares the macula and visual acuity is preserved.

Chiari I vs Chiari II ( age, meningomyelocele, hydrocephalus, synringomyelia, symptoms)

I- adults, no, rare, and rare, HA, neck pain, cerebellar symptoms, lower brainstem symp (dysarthia, dysphagia, nystagmus), can be asymptomatic
II-infants, always present, common, common, brainstem dsyfunction (swallowing and feeding difficulties, stridor, nystagmus) weakness of extremities, and central cord symptoms

holoprosencephaly

incomplete separation of cerebral hemispheres across midline=cyclopia, associated with trisomy 13 (Patau syndrome) and 18 (Edwards)

lissencephaly vs polymicrogyria

=smooth brain, lack of brain gyri and sulci vs excessive number of small gyri on brain surface (associated with Chari II malformation)

use what to treat GAD in man worried about sex dsyfunction and not fluoxetine because

buspirone (nonbenzodiazepine anxiolytic with no sexual dysfunction problems).
fluoxetine is and SSRI (can cause sexual dsyfunction) is not used to treat GAD.

mechanism of methamphetamine. hormone that plays a role in central reinforcement. no NE because

induces dopamine release., NE, and serotnine. doapmine. NE is produces systemic side effects (HTN)

blow to the head followed by lucid (asymptomatic period) is what type of bleed? not subdural because

epidural
subdural-can be chronic but usually seen in elderly also not associated with lucid period but usually a rapid decline in consciousness also a forceful blow to head is associated with epidural

battle sign, raccoon sign, pneumocephalus

basilar skull fracture- delayed ecchymiosis over mastoid process, periorbital ecchymiosis, CSF leaking from nose

5-HT 
1D/1B agonist
1A agonist
2 inhibitor
3 inhibitor

sumatriptan, buspirone, atypical antipsychotics (clozapine), ondansetron (antiemetic)

EPI is good for which type of glaucoma?

open angle, never used for closed b/c is causes mydriasis which would exacerbate the symptoms

Latanoprost

prostaglandin F2 used to treat open angle glaucoma. reduces IOP by increasing outflow of aqueous humor

bezocaine

ester-type local anesthetic (along with cocaine, procaine, tetracaine)

how to you test for these nerves: (reflexes or muscle & dermatomes)
S1, L4, L5 what about L3 and L2 which don’t have reflexes

plantar reflex and exert foot against oppositions, achilles tendon reflex, dermatome is lateral aspect
patellar reflex, dermatome is medial aspect,
tibaialis posterior reflex- hard to illicit, to test have pt plantar flex and evert foot against opposition, dermatome is central aspect of foot
no reflexes so use hip flexion (L2, L3, L4) and hip adductors (L2, L3, L4); dermatones are on anterior thigh

newborn ventilated with FiO2 as a premie and devleops whites puipilary reflex after 3 wks has? the underlying cause is? not pigmentated epithelium because?

severe retinopathy of prematurity (formerly known as retrolental fibroplasia), major risk factors are prematurity and intensive O2 therapy (FiO2 of 100%)
increased levels of O2 leads to vasoconstriction of retinal vessels- increase VEGF production in blood proliferation
pigmented epithelium degeneration is a feature of retinitis pigementosa and senile macular degeneration (both of these are unlikely during prego)

saturday night palsy

drunk individual’s arm is draped over back of chair-damage to radial nerve

does carpal tunnel affect palm sensation

no? branch of median nerve- palmar cutaneous passes above the carpal tunnel

lesion of dorsal gray horn vs column

horn has sensory input lesion leads to loss of pain and temp signals (1st neruon in spinothalamic tract)
column has input for vibration and position sense.

ventral column vs ventral horn

horn contains LMNs- lesion cause ipsilateral flaccid paralysis
column contains anterior corticospinal tract- not as important as lateral corticospinal. contains some ipsilateral UMN

19 yr MVA pt with anisocoria, dilated right eye, hemiplegia and extensor planatr reflex on left side, with epidural hematoma the artery damaged is? not superior orbital fissure because?

middle meningeal artery-enters in middle cranial fossa, leads to epidural bleed, pressure on parasympathetics causes dilated pupil.

Not superior orbital fissure it contains the opthalmic vein, and CN III, IV, VI. pt’s oculomotor movements are intact.

what structures are contained in the

anterior cranial fossa
inferior orbital fissure
posterior cranial fossa
superior orbital fissue

olfactory nerve
vein that communicates with pterygopalatin and infratemporal space
brain stem and cerebellum, vertebral and basilar arteries
ophthalmic vein, CN III, IV,VI

encephalitis in HIV pt (locations of each)

HIV
Aspergillosis
Mycobacterium
PML

diffuse
blood vessels-produces hemorrhagic infarcts
basal surface of brain
myelin

nerves needed to say

VII (move lips)
XII (move tongue)
X (raise palate)

pt on tricyclics passed away from complication due to? not respiratory depression because

lethal arrhythmia is a complication from tricyclic meds. respiratory depression in a common cause of death in sedative-hypnotic and narcotic overdoses.

drug known to cause priapism

trazodone-heterocyclic antidepressant

most likely cause of fungal meningitis in an immunocompromised pt is monomorphic yeast and no septate hyphae b/c

mc is cryptoccocus meningitis and not aspergillus

pt with “locked in syndrome” has lesion where? not midbrain b/c

pon-where basillar artery travels, tegmentum is spared-pt is aware of surroundings
midbrain-lesions here can be medial-ispsilateral oculomotor nerve palsy and contra-lateral hemiplagia or lateral-leading to ipsilateral ocuomorot nerve palsy, c. cerebellar ataxia with intention tremor, and c. loss of tactlie senstation from trunk and extremities. or tectal-leading to failure of upward gaze.

loss sensation of contralateral body and face

lesion in thalamus (sensory relay center)

Intraventricular hemorrhage (IVH) in preterm infant, leading to obstruction of foramina of monro is caused by bleeding from where?

germinal matrix (vry vascular)- can bleed into lateral ventricles and clot b/f being absorbed

therapy for OCD? not busprione because

give TCAs (clomipramine) or SSRIs (fluoxetine)
Buspirone-nonbenzodiazepine anxiolytic, stimulates 5-HT1a receptors, used for GAD, no sedation, addiction, or tolerance effects

mc brain tumor? located where?

metastases (lung, breast, kidney colon, and melanoma), located at junction of cortical gray and white matter

hyperacusis seen in UMN or LMN?

LMN (close to facial nerve damage hear can lead to increased sensitivity to sound b/c of stapedius muscle paralysis) in LMN lesion in face check for loss of facial nerve function due it’s proximity to the nerve.

subarachnoid hemorrhages due to berry aneursyms are associated with

marfan’s Ehler’s-danlos, adult polycystic kideny disease, HTN, and smoking

treatment for delirium tremens? in pts with liver dz?

benzodiazepines; LOT- lorazepam, oxazepam, temazepam

mechanisms of drugs used with pt suffering from alcohol

withdrawl
discourage alcohol abuse
methanol od ethlylene toxicity
decrease cravings for alcohol and opiods
wernicke-korsakoff

benzodiazepems (LOT-lorazepame, oxazepam, temazepam if pt has liver dz)
disulfiram (inhibit alcohol dehyrdrogenase, cause increased effects of alcohol)
fomepizole (inhibits alcohol dehydrogenase)
naltrexone (opioid receptor antagonist)
thiamine (W-K is assiociated with malnutrition seen in alcoholics)

mechanism of ethylene metabolism and toxicities

eth-glycoaldehyde (via alcohol dehydrogenase); aldehyde dehydrogenase converst glycoaldehyde-glycolic acid which gets converted to oxalic acid. toxic to kidney, brain, and causes metabolic acidosis

mechanism and toxicity of methanol metabolism

-methanol to formaldehyde via alcohol dehydrogenase; aldehyde dehydrogenase converts formaldehyde to formic acid. toxic to eyes, lungs, and severe anion gap metabolic acidosis

mechanism of ethanol metabolism

ethanol to actealdehyde via alcohol dehydrogenase and acetaldehyde to acetic acid via acetaldehyde dehydrogenase (this step is inhibited by disulfiram)

toxicities of acetaldehyde

breakdown product of alcohol N&V, HA, hypotension, combines with folate and inactivates it, combines with thiamine and decreases availability (W-K syndrome)

mechanism of gout and chronic alcoholism

lactate breakdown product from muscle wasting competes with urate for excretion

role of muscle length regulators

spindle fibers
intrafusal fibers
extrafusal fibers
alpha motor neurons
golgi tendon organs

-attach to intrafusal fibers and defect changes in tension. synpases with alpha motor neurons which innervate the muscle. (i.e. patella reflex) extrafusal fibers produce but do not modulate tension
golgi tendon organs do not participate in myotactic reflexes, the regulate muscle tension and are invovled in fine control of movement and posture.

mechanism of tPA

serine protease that bind to fibrin protein threads of a thrombus and converts the enmeshed plasminogen to plasmin allowing for fibrinolysis

naegeria fowleri vs acanthamoeba

affects heathly pts (usually divers or those in contact with freshwater)
affects immunocompromised
both can infect brain and cause meningioencephalitis

strasbismus

aka heterotropia. when eyes do not point in same direction

increases dopamine release

amphetamine-indirect-acting sympathomimetics

inhibits monoamine oxidase (4)

MAO inhbitors (tranylcypromine, phenelzine, iproniazid, and isocarboxazid)

potentiate GABA

benzodiazepines and barbiurates

selectively inhbit reuptake of serotonin

SSRIs- fluoxetine, paroxetine, sertraline

brain stem lesion tips:
whenever lesion involves spinal trigeminal (ispilateral loss of pain on face).
-if it’s bilateral loss of any 1 sense or function
-if vagus nerve is involved (hoarseness and trouble swallowing)
if toungue is deviated CN XII
-if you see olives

it’s a lateral lesion (AICA or PICA)
it’s a place where there’s only 1vessel supply (basilar artery in pons)
it’s PICA (Wallenbery Syndrome)-lateral medullary syndrome
it’s in medial medulla-ASA
you’re in medulla

deficits seen in medial midbrain syndrome? aka?

Weber’s syndrome-contralateral spastic hemiparesis (coticospinal tract), contralateral hemipariesis of lower half of face (corticobulbar tract-UMN), dilated pupil, ptosis, and lateral strabismus (CN III)

temporalis muscle in innervated by CN located where? not lower pons because?

CN V located in mid pons (along with 6). lower pons contains CN 7 (muscle of facial expression and stapedius muscle) and 8.

CNs in medulla

9,10,11,12

CNs in midbrain

3, 4

MS autoimmune disease that presents with destruction of (2) but relative preservation of (1). initiated by what WBCs? that react against self antigens and secrete (1). why not IgG or IgGM? hypersensitivity type?

central loss of oligodendrocytes and myelin
preserves axons
CD4+ TH1 lymphoctytes
secrete interferon-gamma to activate macs which cause destruction
type IV
not IgG-b/c that’s type II or III
not IgM b/c that’s type III (i.e. rheumatoid arthritis)

interlukin-10 produced by

product of TH2 lymphocytes

transforming growth factors beta- produced by? action on?

produced by TH2 to encourage B-call type switching

gene mutation in Friedriech’s ataxia? chromosome? repeeat. loss of neurons where? leads to death of nuclei in medulla. this is called?

frataxin gene, 9, (GAA). degeneration of large sensory myelinated neurons in DRG, can cause transsynaptic degeneration

2 causes of bacterial meningitis in elderly pts. most common cause and it’s most important pathogenic mechanism

neisseria meningitidis and strep pneumonia.

strep pneuo- IgA polysaccharide capsule

cytolysins are produced by which (2) bacteria

staphylococcus aureus and clostridum perfringens

rapidly progressive dementia, with startle myoclonus, EEG activity is

Creutzfledt-Jacob disease (CJD)-spongiform change in gray matter

melanocytes, odontoblasts, schwann cells, para and sympa ganglia neurons, and sensory ganglia of CN V, VIII, IX, and X and leptomeninges come from what germ cell layer

neural crest cells

enterochromaffin cells are derived from? and give rise to?

stem cells that give rise to gut epithelium

haploid of G1/G0 vs G2 vs S?

G1/G0-2N (neuronal cells)
G2-4N (non-neuronal cells)
S- halfway b/t 2N and 4N (tumor cells)

hematoma caused by tearing central bridging veins vs hematoma caused by cerebral artery

both subdural-cresent shaped, doesn’t cross midline, extends across sutures and dips into falx cerebi
cerebral artery-more serpetine appearnce b/c they follow exact contour of brain filling in any adjacent suci or cisterns

Cushing reflex-

HTN and bradycardia in response of ICP.

CCP

MAP-ICP

polymyalgia rheumatica is associated with what vascular patholigy

temporal arteritis (can cause HA and jaw claudication) common in elderly

ligation of MCA causes most ischemic damage because

it’s not a part of the circle of Willis (Acomm, ACA, internal carotid, Pcomm, PCA)

widespread neuronal loss gliosis in subcortical site

progressive supranuclear palsy, opthalmoplegiaa, pseudobulbar palsy, axil dystonia, and bradykinesia. intelligence is normal

increased ICP can lead to what CN palsy?

6-false localizing sign (b/c it has a long course)

look away from lesion vs looking towards

stroke vs seizure

two mc causes of bacterial meningitis in neonates. how to tell b/t the two? treatment?

group B strep and e. coli. gram stain. give ampicillin to GBS positive mothers during labor. give enema prior to delivery in E. coli infected women

CNs
corneall reflex
taste from anterior 2/3 of tongue
general sensation of anterior 2/3 of tongue

V, VII, V

bird droppings

rodent dropping

crytococcoisis and histoplasmosis

- hantavirus-fatal respiratory illness-desert in SW part of US

meningioma of the parasagittal regino and falx cerebri is located where? what part of homunculus is affected?

superiorly b/t two hemispheres. motor and sensory to lower extremeties

CAMP test positive

group B strep

treat NPH delerium with?

ventricular shunt

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