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R2 - Family Medicine > Neurology > Flashcards

Neurology Flashcards

1
Q

Dizziness

A
  • includes vertigo, light-headedness, faintness, imbalance
  • vasc dz cause presyncopal dizziness dt cardiac dysrhythmia, ortho HyTN, medication
  • vestibular causes dt peripheral lesions affecting labyrinths or vestribular nerves
  • Ask the D’s: diplopia, dysarthria, dysphagia, dysphonia, dysmetria, dysesthesia, drop attacks
  • deafness (transient and bilateral hearing loss is bad; abrupt onset unilateral loss may be bad or benign)
  • dyspnea (SOB)
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2
Q

vertigo

A
  • when dizziness describes a sense of spinning or other motion (specifically the illusion of self or enviromental motion)
  • can be physiologic (after sustained head rotation), pathologic (vestib dysfn)
  • central etiology: multiple sclerosis, brain tumor, head injury, meds
  • sxs:
    • periph: sudden, intermittent, N/V, tinnitus, hearing loss, horizontal/rotary nystagmus
    • central: gradual, continuous, N/V, vertical nystagmus, no auditory component, motor, sensory, or cerebellar deficits
  • dx: dix-hallpike maneuver (nonfatigable nystagmus = central)
  • tx: Periph = vestib suppressants for acute sxs (diazepam, meclizine), Epley maneuver; Central = tx source (deep head-hanging maneuver)
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3
Q

length of dizziness ddx

A
  • seconds: BPPV, ortho HoTN
  • minutes: TIA, migraine
  • hours: vestibular migraine, Meniere dz
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4
Q

peripheral vs central vertigo

A
  • peripheral: unilateral hearing loss and aural sxs
    • unidirectional horizontal nystagmus (use Frenzel eyeglasses to aid detection)
  • central: bilateral hearing loss, unless lesion lies near root entry zone of auditory nerve, double vision, numbness, limb ataxia (brainstem or cerebellar lesion)
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5
Q

head impulse test, diz-hallpicke maneuver, ancillary testing

A
  • HIT: vestribuloocular reflex with 20 deg rapid head rotations - pt fixates on target, head rotated to right or left. If deficient, rotation followed by catch-up saccade in opposite direction
  • Dix-Hallpike: sitting position, head turned 45 deg, hold pack of head and lower pt into supine w/ head extened backward 20 deg while watching eyes (post. canal BPPV = upbeating torsional nystagmus). If no nystagmus after 15-20 secs raist pt to sitting, repeat other side
  • Ancillary testing (audiometry if vestib dz suspected)
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6
Q

Vestibular neuritis

A
  • sudden asymetry of inputs from 2 labrynths or in central connections, stimulating continuous rotation of head
  • Central (cerebellar, brainstem infarct, hemorrhage); Peripheral (affects vestribular nerve or labrynth)
  • sxs: sudden, unilateral vertigo (persists even when head remains still), N/V, oscillopsia (motion of visual scene), imbalance, central sxs (diplopia, weakness, numbness, dysarthria)
  • dx: head impulse test
  • tx: spontaneously resolves (steroids w/in 3 d onset, antivirals NOT beneficial unless herpes zoster (Ramsay Hunt) suspected, vestribular suppresant meds for sxs, resume normal activity ASAP, vestricular rehab
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7
Q

Benign paroxysmal positional vertigo

A
  • Common cause of recurrent vert, caused by dislodged otoconia (calcium carbonate crystals) from utricular macula and moved to semicirc canal
  • sxs: brief (<1 min), provoked by change in head position
    • Post canal BPPV: upward, torsional nystagmus
    • Horizontal canal: horizontal nystag when lying ear down
    • Sup canal: rare
  • dx: + Dix hallpike (produces delayed fatigable nystagmus), Epley maneuver (for posterior canal BPPV)
  • tx: dix-hallpike maneuver (quickly turn pts head 90 deg while supine), avoid using meclizine or similar meds
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8
Q

psychosomatic dizziness or vertigo

A
  • phobic postural vert, psychophysiologic, or chonic subjective dizziness
  • sxs: somatic manifestation of psychiatric condition (major depression, anxiety, panic), chronic dizziness and disequilibrium, increased sensitivity to self-motion and visual motion, worse with complex visual environments
  • dx: neruo exam and vestibular testing: normal
  • tx: SSRIs and cognitive behavioral tx, vestribular rehab tx
  • comorbidity: anxiety, autonomic sxs
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9
Q

Acoustic neuroma

A
  • intracranial benign tumor affecting CN VIII, bilateral acoustic neruomas associated with neurofibromatosis type II, progressive vertigo
  • sxs: unilateral, progressive hearing loss, unsteadiness, vertigo, tinnitus, impaired speech discrim, HA
  • signs: decreased corneal reflex, diplopia, facial weakness or numbness
  • dx: head impulse test: deficient respone, MRI (dense enhancing lesions, enlarged internal auditory canal), LP (elevated protein)
  • tx: asymptomatic = serial MRIs; larger lesions = surgery or SRS
  • complicaiton: loss of corneal reflex from trigem involvement
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10
Q

syncope

A
  • loss of consciousness/postural tone 2ary to acute dec in cerebral blood flow; 20% pts have 1ary dx of anxiety, mood, or substance abuse
  • Ddx:
    • seizure
    • cardiat et: arrhythmias (sick sinus, v-tach, AV block, rapid SVT), obstruction of blood flow (aortic sten, HCM, mitral valve prolapse), massive MI
    • vasovagal: ↑parasymp, ↓symp stim, MCC, emotional stress, fear, etc.; premonitory sxs = pallor, sweat, light-headed, N, dec vision, roaring in ears; Tilt table study to reproduce sxs; tx = supine, elevate legs, BB
    • orthostatic HoTN: caused by ganglionic blocking agents, DM, old, defect in vasomotor reflexes; posture is main cause, + tilt table, tx with inc sodium and fluids, fludrocortisone
    • TIA, hypoglyc, hypervent, hypersensitivity, mech reduction of venous return (valsalva, postmicturition), meds
  • EKG FOR ALL PTS
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11
Q

Seizure

A
  • synchronoous dc of electrical activity or chonic disorder or recurrent, idiopathic seizures not reporduced by 2ary cause
  • causes: 4Ms and 4Is
    • Metabolic (hyponatremia, H2O tox, hypoglycemia, hyperglyc, hypocalc, uremia, thyroid storm, hypertherm
    • Mass lesions (brain met, 1ary brain tumor, hemorrhage)
    • Missing drugs (noncompliance w/ anticonvusants, withdrawal from ETOH, benzos, barbituates)
    • Miscellaneous: pseudosiezures (psych), eclampsia, HTN enceph, febrile
    • Intox (cocaine, lithium)
    • Infxn (septic shock, bact, viral meningitis, brain abscess)
    • Ischemia (embolic stroke, TIA, syncope)
    • Increased ICP (dt trauma)
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12
Q

epilepsy

A
  • chronic, reccurent seizures not produced by 2ary cause
  • Triggers: sleep dep, emotional stress, meds, infxn, alc
  • Causes: childhood and age
  • sxs: dz requires 2+ separate seizures (unprovoked)
  • dx: if known epileptic → check anticonculsant levels, if 1st seizure → CBC, CMP, gluc, renal fn, urinalysis
    • ​EEG (abnormal pattern is NOT dx on its own), CT, MRI, LP, preg, PRL (serum levels rise abruptly in postictal state only in true epilepsy)
  • tx: ABCs, check for noncompliance, check drug levels, increase dose of first anticonvulsant if persistent, add second drug if szs still uncontrolled. if controlled on 2 drugs, continue for 2y and then taper
    • first seizure: EEG with neuro consult, if normal then recurrence is low.
    • dont tx most pts with only one seizure
    • start antiepileptics only if EEG abnl, MRI abnl or status epilepticus
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13
Q

simple partial seizure (focal), or aura

A
  • sxs: consciousness INTACT (not impaired)
    • seizure is localized but may evolve - can be described as a sensation (N, epigastric sensation), abnl thought (fear, deja vu), or involuntary mvmt
    • pt can interact normally w/ enviro except for limitations imposed by seizure itself on local brain fns
    • may involve transient unilateral clonic-tonic mvmt
    • 60% of pts with partial epilepsy
  • dx: EEG
  • tx: phenytoin and carbamazepine (alternatives = phenobarb, depakote, primidone)
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14
Q

Complex partial seizure

A
  • consciousness IMPAIRED (spans from minimal to complete unresponsiveness), preceding aura, ictal manifestations (1-3 mins), eyes usually open during ictus, automatisms (purposeless, involuntary, repetitive mvmts), epigastric sensation or vague cephalic sensation, olfactory or gustatory hallucinations, deja vu, micropsia, macropsia, fear, pleasure, anger, voices, music, speech arrest, absence-like sxs
    • contralateral: eye dev, arm extens, fencing posture, clonic mvmts of face, fingers, hand, foot
    • postictal confusion (fatigue, ipsilateral HA, mins to hours)
  • dx: EEG
  • tx: trileptal, lamictal, phenytoin and carbamazepine
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15
Q

Generalized tonic clonic (grand mal) seizure

A
  • eyes open and “roll to back of head”, begins with sudden LOC, apnea, urinary incontinence, vomiting
  • Tonic phase: extensor posturing for 20-60s (rigid trunk, limb extension, bilaterally symmetrical)
  • clonic phase: progressively longer periods of inhibition → lasting up to 60s
  • postictal phase: transient deep stupor → 15-30min of lethargy, confusion → hours to days of HA, muscle soreness, mental dulling, mood changes
  • signs: cyanosis, foaming at mouth, tongue biting, hypoxemia
  • dx: lactic acidosis, elevated catecholamines, increased CK, PRL, corticotropin, cort
    • EEG: generalized high amp rapid spiking
  • tx: roll pt onto side, levetiracetam, topiramate, zonisamide, phenytoin and carbamazepine, phenobarb, depakote, primidone
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16
Q

absence (petitmal) seizures

A
  • school aged children, resolves with age
  • sxs: disengage from current activity, “stare into space”, minor clonic activity (eye blinks, head nodding), brief (lasts a few seconds), but quite frequent (up to 100x/d), impairment of consciousness, no loss of postural tone and no postictal confusion
  • dx: EEG shows 3/s spike and slow wave activity
  • tx: ethosuximide, depakote, zonisamide
17
Q

myoclonic seizures

A
  • rapid recurrent, brief muscle jerks of face or hands → massive bilat spasms simultaneously affecting head, limbs, trunk
  • occurs bilaterally, synchronously or asynchronously, may occur shortly after waking up, but can occur at any time
  • dx: EEG
  • tx: keppra (levatiracetam), depakote (valproic acid)
18
Q

Status epilepticus

A
  • causes: noncompliance, ETOH widrawal, intracranial infxn, neoplasm, metabolic dz, drug overdose
  • sxs: prolonged, sustained unconsciousness w/ persistent convulsive activity lasting longer than 30 min OR 2 or more sequential seizures without full recovery of consciousness between them
  • dx: EEG, MRI
  • tx: ABCs, IV, O2, monitor, CMP, Ca, Mg, Phos, CBC, UTox, troponin, AED levels, gluc
    • if hypoglyc, give 100mg IV thiamine and 50ml 50% dextrose, 0.1 mg/kg IV lorazepam, repeat if persistent
    • IV fosphenytoin or IV phenytoin 20mg/kg IV, monitor HR and BP
    • Intubation, IV phenobarb
19
Q

Alzheimer’s dz

A
  • 2/3 all . cases of dementia (MC form of dementia)
  • 60-70yo, mostly >85
  • caused by dec Ach synth, impaired cortical cholinergic fn
  • sxs: insidious and progressive memory loss, cog deficits (disorientation, language, inability to perform complex fns, inattention, visual misperception, poor problem solving, inappropriate . social behavior, hallucinations), intellectual decline in . 2+ areas of cognition by MMSE, formal neuropsychological testing to confirm
  • dx: clinical dx, CT or MRI shows cortical atrophy with enlargement of ventricles
    • path: intracellular neurofibrillary tangles and extracellular neuritic plaques
    • CBC, CMP, heavy metal, Ca, gluc, TSH, B12, renal, LFT, drug/ETOH
  • tx: cholinesterase . inhib (donepezil, rivastig, galantamine), memantine (NMDA receptor antag for mod-severe), ginko, lecithin, vitE
  • onset to death = 5-10yrs
20
Q

Parkinson’s dz

A
  • loss of dop containing neurons located in substantia . nigra and locus ceruleus, usually >50yo, meds that cause park = chlorpromazine, metoclopramide, reserpine
  • sxs: pill rolling tremor at rest, bradykinesia, cogwheel rigidity . (rachet like jerking, test tone in one limb while pt clenches opposite fist), poor postural reflexes, difficulty initating walking, shuffling steps, masked facies, micrographia, dementia, personality changes early (withdrawn, apathetic, dependent, depression)
    • significant disability within 5-10y
  • dx: clinical dx
  • tx: no cure, carbidopa levodopa (Sinemet) (can . cause dyskinesias after 5-7yrs of tx, N/V/anorex, “on-off” phenomena dt dose response relationship), dopamine receptor agonists (bromocriptine, pramipexole) - INITIATE FIRST! delay need for levodopa, Selegiline (MAOI inhib - adjunct tx, enhances effect of levodopa), amantadine, anticholinerg, amitryp, surg
21
Q

essential tremor

A
  • familial (autosomal dom)
  • sxs: worse with certain postures, head tremor, vocal tremulousness, improved with alc
  • tx: propranolol (1st line), primidone, alprazolam, small amnts alc, gabapentin, topiramate or nimodipine, deep brain stim
22
Q

Bell’s palsy

A
  • hemifacial weakness/paralysis of mm innervated by CN VII dt swelling of cranial nerve
  • uncertain cause, possibly viral
  • sxs: URI preceding event, acute onset unilateral facial weakness/paralysis, both upper and lower parts of face - mastoid pain, decreased tearing, cannot raise eyebrow on affected side, weak orbicularis oculis (unable to close eye), impairment or loss of taste
  • signs: check ext ear canal for rash or vesicles to r/o Ramsay Hunt, hyperacusis (tuning fork)
  • dx: clinical, consider Lyme dz (dont use steroids), EMG testing if paresis fails to resolve in 10d
  • tx: no tx required, short course of prednisone and acyclovir, wear eye patch to prevent abrasion, surg decompress of CN VII, prognosis good (80-90% full recovery in 6wk-3mo)
23
Q

Delirium

A
  • “waxing and waning”, rapid onset, “sundowning” = worse at night
  • sxs: rapid deterioration in mental status (h-d), fluctuating level of awareness, disorientation, abnl vitals, may have visual hallucinations, dont have to be agitated but may have slow blunted responsiveness
  • dx: MMSE, labs (CMP, B12/folate), LP in febrile delirious pt (cerebral edema)
  • tx: almost always reversible - tx underlying cause, haloperidol for agitation/psychosis, supportive care
24
Q

causes of delirium

A
  • Causes: SMASHED and P. DIMM WIT
  • SMASHED =
    • Structural brain abnlity (stroke, hematoma, tumor, etc.)
    • Meningitis/mental illness
    • Alc/acidosis
    • Seizures (postictal)/substrate deficiency (thiamine)
    • Hypercapnia/hyperglycemia
    • Endocrine (addisonian crisi, thyrotox, hypothyroid)/encephalitis/encephalopathy,
    • Drugs
  • P. DIMM WIT =
    • Postop state
    • Dehydration
    • Infxn
    • Meds (TCAs, roids, antichol, hallucinogens, coke)
    • Metals (heavy)
    • Withdrawal (ETOH, benzos)
    • Inflammation (fever)
    • Trauma (burns)
25
Q

Dementia

A
  • RF: old age
  • sxs: insidious, progressive, preserved consciousness, rarely hallucinations, no tremor unless dt parkinson
  • tx: typically irreversible unless cause = hypothyroid, neurosyph, vitB12/folate/thiamine def, meds, hydroceph, depression, subdural hemotoma
    • pharm tx: vitE, tacrine, donepezil
26
Q

vascular dementia

A
  • multi-infarct, stepwise decline dt series of infarcts
  • M>W
  • sxs: forgetfulness in absence of depression and inattentiveness
    • cortical - speech difficulty, trouble performing routine tasks, sensory interpretation difficulty, confusion, amnesia, executive dysfn
    • subcortical - gait problems, urinary difficulties, motor deficits, personality changes
  • tx: control HTN and metabolic disorders, tx same as Alzheimer dz
27
Q

frontotemporal dementia

A
  • frontal lobe sxs: behavioral sx (euphoria, apathy, disinhibition) and compulsive disorders
  • primitive reflexes (frontal release signs): palmomental, palmar grasp, rooting reflexes
  • dx: MRI (frontal or ant temp lobe atrophy), PET (frontal and/or ant temp hypometabolism)
  • tx: supportive care, SSRIs for depression
28
Q

Lewy body dementia

A
  • Features of alzheimer and Parkinson dz but progression more rapid than in Alzheimer dz
  • sxs: visual hallucinations predominate, extrapyramidal features and fluctuating mental status, sensitive to adverse effects of neuroleptics (make worse)
  • tx: neuroleptics for hallucinations . and psychosis, cholinesterase inhibitors: donepezil, rivastigmine, galantamine, selegiline (slows progression)
29
Q

ischemic stroke

A
  • 85%
  • etiology in young pts: OCP, hypercoagulable states (preg, malig, vWF, antiphospholipid Ab syndrome), vasoconstrictive druge use (cocaine, amphet, polycythemia vera, sickle cell)
  • RF: age and HTN, smoking, DM, HLD, afib, Fhx of stroke, previous stroke/TIA, carotid bruit, drugs
  • dx: CT noncon differentiates hem vs ischem, MRI, EKG, carotid duplex scan, MRA (definitive test for stenosis of vessels of ehad/neck and for aneurysms)
  • tx: acute (IV O2 monitor), GRADUAL BP control (IV labetalol, DONT GIVE ANTIHTN MEDS UNLESS SBP >200, DBP >120, or MAP >130)
  • prevention: control HTN, DM, smoking, HLD, obesity, ASA, carotid endarterectomy
  • Stable stroke: t-PA tx (unless >3 hrs after event, uncontrolled HTN, bleeding dz, hx of surg or trauma), ASA, anticoagulants
    • if w/in 3h give thrombolytics
    • if after 3h give aspirin
  • anticoags, assess pts ability to protect airway, keep NPO, elevate HOB
30
Q

Lacunar stroke

A
  • internal capsule, pons, thalamus, causes 20% of all strokes; usually affects subcortical structures
  • Narrowing of large arterial lumen dt thickening of vessel wall (not by thrombosis)
  • RF: hx of chronic HTN and DM
  • affected arteries: MCA, circle of Willis, basilar and vertebral arteries
  • sxs: hemiparesis - weakness of entire left or right side
    • internal capsule: pure motor hemiparesis
    • pons: dysarthria, clumsy hand
    • thalamus: pure sensory deficit
  • dx: focal features and usually contralateral pure motor or pure sensory deficits
  • tx: prevention of lacunar strokes: control HTN
31
Q

transient ischemic attack

A
  • brief episode of neurologic dysfn caused by focal brain or retinal ischemia, blockage in flow does not last long enough to cause permanent infarction, retinal artery (MCA) → amaurosis fugax
  • sxs: sudden onset neuro deficit, lasts minutes to <1h, reversal of sxs within 24h
  • dx: carotid doppler US, MRA of neck
  • tx: hospital admission for new onset and recurrent TIA, unless confident dx of cause of event can be made, antiplatelet tx (ASA +/- dipyridamole OR clopidogrel), if high risk → warfarin should be used, RF for recurrent stroke, average 5% risk per year
32
Q

circle of willis and strokes

A
33
Q

CHADS2 scoring

A
  • for stroke risk
  • C: cardiac failure
  • H: HTN
  • A: age >75y
  • D: diabetes
  • S: stroke or TIA (2 pnts)
  • each other is 1 pnt each
  • CHADS score 2 or greater is associated with annual risk of sstroke over 4%
  • 0: ASA
  • 1: ASA or warfarin
  • 2: anticoagulated unless specific CI
34
Q

Migraines

A
  • W>M, MC + FHx, precipitating factors = emotional stress, hormones, not eating, weather, sleep disturbances, odors, neck pain, lights, ETOH, smoke, sleeping late, heat food, exercise, sex
  • Comorbidities: sleep disturbances
  • sxs: recurrent attacks
    • 4 phases:
      • Prodrome: euphoria, depression, irritability, cravings, C, neck stiffness, etc.
      • Aura (25%)
      • HA: unilateral, pulsatile, V, photophob, better w/ lying down, dark, quiet
      • Postdrome: pain w/ sudden mvmts, drained, exhausted
  • dx: clinical, neuroimaging indicated for first/worst HA, >50yo, head CT, MRI
  • complications: status migrainosus, persistant aura w/out infarction, migrainous infarciton, migraine aura-triggered seizure
35
Q

Migraines with and without aura

A
  • w/aura: autosomal dominant with incomplete penetrance
  • w/out aura: most common type (75%)
  • causes: serotonin depletion
  • aura sxs: aura (doesnt always precede HA, gradual development but can be acute <5min, no longer than 1h, pos and neg features, completely reversible)
    • positive sxs: visual (bright lines, shapes, objects), auditory (tinnitus, etc.), somatosensory (burning, pain, paresthesia), or motor (jerking, repetitiv rhythmic movements)
    • Negative sxs: loss of vision, hearing, feeling, or ability to move a part of the body
  • non-aura sxs: sever unitaleral throbbing HA lasts 4-72hrs, N/V, photophobia, increased sens of smell
  • aura dx: at least 2 attacks, fully reversible aura
    • characteristics, at least 2: 1 aura spreads gradually over >5mins, and 2+ sxs occur in succession, each aura lasts 5-60mins, at least 1 aura is unilateral, aura followed by HA within 60mins
  • non-aura dx: at least 5 attacks, lat 4-72hrs, at least one of N or V or both
  • tx: NSIADs, tylenol, antiemetics (mild-mod), PO triptan or sumatriptan, naproxen, SQ suma, nasal suma and solmitriptan (mod-severe), DHE agonist, sumatriptan, DONT USE BB AS INITIAL TX IF >60 AND IN SMOKERS
    • emergent migraines: sumatriptan, metoclopramide, prochlorperazine, DHE, Ketorolac
36
Q

chronic migraine

A
  • HA occuring 15 or more days/mo, features of migraine on at least 8 d/mo
37
Q

tension HA

A
  • unkown cause, W>M, precipitated by stress, depression, anxiety, most prevelent HA in general population and second most prevalent disorder in the world
  • sxs: bilateral, “vice like”, encircles entire head, nonthrobbing, lasts 30min to 7d
  • signs: increased pericranial m tenderness
  • dx: CT/MRI, blood work, spinal fluid analysis
    • at least 10 eps of HA, lasting 30min to 7d each, at least 2 of (bilateral, pressing or tightening, mild or mod, not aggravated by routine activity)
  • tx: NSIADs, triptans
    • emergent setting: metoclopramide + diphenhydramine, ketorolac, chlorpromazine
    • pregnancy: butalbital with tylenol
38
Q

cluster HA

A
  • rare, middle aed men, chronic cig smokers, episodic (90%), last 2-3mo, chronic cluster last 1-2y, HA do not remit
  • sxs: unilateral, excruciating orbital, supraorbital, or temporal pain (behind the eye), deep, burning, searing or stabbing pain
    • associated: ipsilateral lacrimation, facial flushing, nasal stuffiness/dc, begins few hrs after pt goes to bed, awakens from sleep, occur nightly 2-3mo, then dissapear, worse with alcohol and sleep
  • signs: pallor, diaphoresis, horner syndrome, restlessness, agitation, focal neuro symptoms, sensitivity to alc
  • dx: at least 5 attacks, either or both - conjunctival injection or lacrimation, nasal congestion or rhinorrhea, eyelid edema, forehead or facial sweating or flushing, sensation of . fullness in ear, miosis or ptosis, restlessness or agitationattacks occur between qod and 8/d for more than half the time when disorder is active
  • tx: O2 inhalation via nonrebreather, SQ sumatriptan
  • prophylaxis: verapamil, ergotamine, methylsergide, lithium, steroids, resolution w/in 1 wk

R2 - Family Medicine (14 decks)

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