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R5 - Internal Medicine > Neurology > Flashcards

Neurology Flashcards

1
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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2
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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3
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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4
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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5
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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6
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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7
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
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8
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)
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9
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/kgIV, monitor HR and BP
    • Intubation, IV phenobar
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10
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
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11
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
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12
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)
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13
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
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14
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)
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15
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
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16
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
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17
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
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18
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)
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19
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
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20
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
21
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
22
Q
  • circle of willis and strokes
A
23
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
24
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
25
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
26
Q

chronic migraine

A
  • HA occuring 15 or more days/mo, features of migraine on at least 8 d/mo
27
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
28
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
29
Q

bacterial meningitis etiology, RF, and sxs

A
  • acute = hours to days, chronic = within weeks to months, commonly caused by mycobacteria, fungi, Lyme dizease, or parasites
  • inflamm of meningeal membs, infxs agents colonize nasopharynx and resp tract, neonatal = listeria monocytogenes
  • MCC: strep pneumo, H flu, N meningitidis
  • sxs: TRIAD = fever, nuchal rigidity, change in mental status
    • HA (more severe lying down), N/V, stiff painful neck, malaise, photophob, AMS (confusion, lethargy, coma)
  • signs: ​Rash (maculopap rash with petechiae for N mening) or vesicular lesions (varicella/HSV), inc ICP and its manifestations (papilledema, szs)
    • cranial nerve palsies, +Kernig, +Brudzinski
30
Q

bacterial meningitis dx and tx

A
  • dx: lumbar puncture - unless evidence of space-occupying lesion (neut predom, cell count >1000, low gluc, elevated prot)
    • CT scan of head - recommended before performing LP if focal neuro signs or evidence of space-occupying lesion with high ICP
    • blood cx - prior to abx
  • tx: empiric tx after LP, IV abx immediately if CSF cloudy or bact suspected, steroids if cerebral edema present
    • early onset (<7d) = amp
    • late onset (7d-3mo) = amp + cefotaxime
    • late late (>3mo) = cefotaxime (3rd gen) + vanco
  • health maint: vaccinate asplenic pts and immunocomp for meningococcus
  • prophylax: rifampin or ceftriaxone for close contacts of meningococcal
31
Q

aseptic (viral) meningitis

A
  • caused by a variety of non-bact pathogens, frequently viruses (enterovirus 70 or 71, coxsackievirus A7 or A9 and HSV), MC in summer and fall temps
  • sxs: acute onset of subacute fever, chills, HA, photophob, pain on eye mvmt, N/V/D, myalgias, rash, pleurodynia, myocarditis, herpangina
  • signs: meningismus without local neuro signs, drowsiness or irritability
  • dx: LP (pleocytosis - lymphocyte predom, cell count <1000, normal gluc, elevated prot)
  • tx: supportive, analgesics and fever reduction, better prog than acute bacterial meningitis
32
Q

age or RF: associated etiology of bacterial meningitis and tx

A
  • infants <3mo: GBS, E. coli, Klebsiella, Listeria
    • tx: cefotaxime + vanc + amp
  • 3mo-50y: N mening, strep pneumo, H flu
    • tx: ceftriaxone or cefotaxime + vanc
  • >50y: strep pneumo, N mening, listeria
    • tx: ceftriaxone or cefotaxime + vanc + amp
  • impaired cellular immunity (i.e. HIV): strep pneumo, N mening, listeria, aerobic G- (pseudo)
    • tx: ceftazidime + vanc + amp
33
Q

multiple sclerosis

A
  • women 2x > M
  • etiology: unkown
  • most present in 20-30yo with localizing deficit such as optic neuritis, one-sided weakness, or numbness
  • sxs: transient sensory deficits (MC), dec sensation in upper or lower limbs
    • fatigue MC complaint, weakness, spasticity (pyramidal tract involvement), optic neuritis, internuclear ophthalmoplegia (adduction defect, horizontal nystagmus of abducting eye)
    • ataxia, intention tremor, dysarthria, loss of bladder control, impotence or constipation, memory loss, personality change, anxiety, depression, trigeminal neuralgia
  • dx: clinical - 2 eps of sxs, evidence of 2 white matter lesions
    • lab supported (2 eps of sxs, evidence of 1 white matter lesion on MRI, abnl CSF (oligoclonal bands)),
  • tx: acute attack: high dose IV steroids (doesnt alter outcome or course, just shortens attack)
    • disease modifying: recombinant interferon B-1 alpha/1 beta
    • sxatic tx: baclofen or dantrolene for spasticity, carbamazepine or gabapentin for neuropathic pain, tx depression
34
Q

Guillain-barre syndrome

A
  • autoimmune rxn against periph nerves, inflamm demyelination, Abs against postsynaptic nicotinic acetylcholine receptors at NMJ of skeletal mm cells
  • hx: previous viral infxn, surg, HIV, CMV, etc.
  • sxs: rapidly progressive bilat and flaccid weakness, usually symmetric, distal to central, sphincter control and micturition SPARED, absence of fever or other systemic sxs
  • signs: dec or absent DTRs in weak limbs
  • dx: BRIGHTON CRITERIA (LP - inc prot, nl glucose and pressure, WBC <50 cells; electrodx - dec motor nerve conduction velocity)
  • tx: admit and monitor for resp failure, HIGH DOSE IVIG, plasmapheresis for severe resp comp or weakness, DO NOT GIVE STEROIDS!!!
35
Q

giant cell arteritis

A
  • age >50yo, F2x >M, inc risk of aortic aneurysm and dissection
  • sxs: malaise, fatigue, weight loss, low grade fever, new HA (severe), visual impairment (optic neuritis - blindness), jaw pain with chewing (intermittent claudication), tenderness over temporal artery, absent pulse, palpable nodules, polymyalgia rheumatica
  • dx: very elevated ESR, bx temporal artery (90% sensitive)
  • tx: high dose steroids to prevent blindness, start immediately, do not wait for bx results (treat 4wk, then taper and maintain 2-3y), follow ESR levels, if untreated, most self-limiting
36
Q

intracranial tumors

A
  • 50% are malignant and associated with high mortality
  • General: HA (worse in morning, often holocephalic but can be ipsilateral to side of tumor, can present as migraine with unilateral throbbing pain with visual scotoma), +/- N/V, cognitive difficulties, personality changes (apathy, withdrawal from social circumstances, mimicking depression, gait disorder)
  • Focal: subacute, progressive, hemiparesis, aphasia, visual field defect (noticed by pt and revealed after it leads to injury), language difficulties (mistaken for confusion), szs (common)
37
Q

Intrinsic “malignant” tumors

A
  • astrocytoma (grade 1-3): occurs in children and young adults, MC in childhood, occurs in cerebellum
    • sxs: grade II+ present with szs
    • dx: MRI - nonenhancing lesions w/ inc T2 signal
    • tx: surgical resection, radiation tx, chemo
    • median survival = 5y
  • glioblastoma (grade 4): MC malig primary brain tumor, age 60-70
    • sxs: HA, szs, focal neuro def
    • dx: MRI - ring enhancing masses w/ central necrosis and surrounding edema
    • tx: resection + partial field external beam RT + chemo, 6-12mos adjuvant chemo
    • median survival = 14.6mo, high recurrence
  • medulloblastoma: MC malig brain tumor of childhood
    • sxs: HA, ataxia, brainstem involvement
    • dx: MRI - dense enhancing tumors in post fossa + hydrocephalus
    • tx: max surg resection + craniospinal irradiation + chemo
38
Q

extrinsic “benign” tumors

A
  • meningiomas: MC primary brain tumor, incidence inc with age, MC in women or NF type II
    • sxs: HA, sz, focal neuro def
    • dx: MRI - partially calcified, dense enhancing
    • tx: if asxatic no intervention, complete resection = cure, external beam RT or stereotactic radiosurg
  • acoustic neuroma: intracranial benign tumor affecting 8th nerve, bl associated with NF II
    • sxs: unilat, progressive sensorineural hearing loss, unsteadiness, vertigo, tinnitus, impaired speech, discrimation, HA, dec corneal reflex, diplopia, facial weakness
    • dx: head impulse test - deficient response toward affected side; MRI densely enhancing lesions enlarging in internal auditory canal; LP elevated protein
    • tx: if asxatic serial MRIs; surgery or SRS for larger llesions
  • craniopharyngiomas: rare, suprasellar, partially calcified, solid, or mixed, arises from remnants of rathke’s pouch, bimodal distribution
    • sxs: HA, visual impairment, impaired growth (children), hypopituitarism (adults)
  • pituitary tumors = 9% brain tumors
39
Q

encephalitis etiology and sxs

A
  • diffuse inflamm of brain parenchyma and seen simultaneously with meningitis, usually viral in origin (HSV-1, arbovirus, enterovirus), toxoplasmosis, cerebral aspergillosis
  • RF: AIDS, immunosuppressed, travel to underdeveloped countries, mosquito exposure, exposure to wild animals (bats)
  • sxs: prodromal (HA, malaise, myalgia), within hrs-days, acutely ill, HA, fever, photophobia, nuchal rigidity, confusion, delirium, disorientation, behavior abnlities, focal neuro findings (hemiparesis, aphasia, CN lesions, and seizures)
40
Q

encephalitis dx and tx

A
  • dx: CXR, urine and blood cx, UTox, chem, LP (lymphocytosis, normal glucose - viral), CSF cx neg, CSF PCR most sensitive and specific for HSV, CMV, EBV, and VZV, MRI brain, EEG, brain bx indicated in acutely ill pt with focal enhancing lesion on MRI w/o clear dx
  • tx: supportive, antivirals (acyclovir for HSV, ganciclovir or foscarnet for CMV), manage szs and cerebral edema
  • 10% mortality
41
Q

Myasthenia gravis etiology and sxs

A
  • autoimmune disorder - autoantibodies against nicotinic acetylcholine receptors of NMJ leading to reduced post-synaptic response to Ach = significant muscle fatigue
  • F 20-30yo, M50-70yo
  • sxs: skeletal mm weakness - preserved sensation and reflexes (worse with continued use, fluctuating), ptosis and/or diplopia, blurred vision, bulbar sxs (dysarthria, dysphagia, fatigable chewing, progresses slowly with periodic exacerbations
  • signs: myasthenic “sneer” - mid lip rises, but corners of mouth fail to move, neck extensor and flexor muscles (dropped head syndrome)
42
Q

myasthenia gravis dx and tx

A
  • dx: ice pack test (80% spec), edrophonium (tensilon) test (use in pts with obvious ptosis who will benefit from drug admin), Ach receptor ab test (most specific - FIRST STEP), repetitive nerve stim (RNS), EMG, CT of thorax to r/o thymoma
  • tx: AchE inhib (pyridostigmine), thymectomy (sxatic relief), steroids, azathioprine, cyclosporine, and mycophenolate mofetil
  • myasthenic crisis, bridging, adjuvant, or for refractory causes: plasmapheresis removes abs, IVIG tx for acute exacerbations, monitoring, monitor serial forced vital capacities
43
Q

huntington disease

A
  • involuntary writhing of muscle groups, autosomal dominant disorder
  • sxs: progressive dementia (early age of onset, subtle changes in cognitive fning), choreiform mvmts (restlessness, expansive dance-like mvmts in multiple limbs)
  • Associated with depression
44
Q

Cerebral (intracranial) aneurysm

A
  • develops from normal hemodynamic stress or HTN, develops at jn of communicating branch with main cerebral artery (Ant Comm + Ant Cerebral), AV malformation (ruptured berry aneurysm - MC, 80% - most located in anterior circulation), fusiform, mycotic (bacterial endocarditis)
  • associated: polycystic kidney dz, marfan syndrome
  • sxs: may manifest as compression as crannial nerves (CN III, IV, VI), causes of rupture = strenuous activity (exercise, coitus, physical work)
  • dx: noncon CT head - if normal, do LP; contrast CT or MRI for aneurysms >5mm or AV malformations, LP, cerebral angiography (gold standard)
  • tx: open surgical clipping, endovascular coiling (preferred)
  • complication: subarachnoid hemorrhage; of pts with aneurysms that rupture, 33% die before reaching the hospital, 30% recover without disability
45
Q

concussion

A
  • falls (28%), MC (20%), struck by heavy object, assault
  • sxs: minor head injury (GCS >13), asxatic ~2hr, normal mental status, no evidence of skull fx, normal physical exam +/- LOC, sz activity, V, irritability, lethargy, HA, confusion, gait problems
  • dx: scalp hematoma, palpable crepitus, fundoscopic exam, neuro exam, SCAT2 (MMSE + physical), imaging usually normal and NOT required, CT if <48h, MRI if >48h, especially image if: severe HA/worsening, prolonged recovery, focal def, szs, slurred speech, unsteady gait, weakness, persitent vomiting, behavior changes, evidence of skull fx
  • tx: observe in ER x4h, rest until asxatic, light aerobic exercise, sport-specific training, noncontact training drills, full contact after medical clearance, return to play 24h for each stage
46
Q

peripheral neruopathy (polyneuropathy)

A
  • refers to generalized relatively homogenous process affecting many peripheral nerves, with the distal nerves affected most prominently
  • causes: DM, alcohol abuse, HIV
  • sxs: symmetric distal sensory loss, burning or weakness, paresthesias (numbness or tingling), burning or pain in feet, gait abnlity, autonomic disturbances most commonly ikn hands and feet, weakness of lower legs and hand resulting in “stocking glove distribution” of sensory loss
  • signs: decreased DTRs, decreased vibration and two-point discrimination, Semmel-Weinstein (monofilament gauge)
  • dx: EMG and/or nerve conduction study (initial) if no clear etiology or when sxs rapidly progressive; labs = blood gluc, serum B12 with MMA (+/- homocysteine) and serum protein electrophoresis; m or nerve bx, skin bx, autonomic testing, quant sensory testing
  • tx: if DM, need tight control; if painful diabetic polyneruopathy - gabapentin, amitriptyline (TCA), alpha-lipoic acid
47
Q

carpal tunnel syndrome etiology and sxs

A
  • numbness and tingling and/or pain in median nerve distribution, F>M
  • RF: obesity, female, comorbidity (DM, preg 3rd trim, RA, hypothyroid, genetics, aromatase inhib use
  • severe cases: clumsiness “difficulty holding objects, turning keys or doorknobs, buttoning clothing, or opening jar lids”
  • sxs: pain (involvement of first 3 digits, radial half of 4th digit, worse at night and awaken pt from sleep, better by shaking or wringing hands or blacing them under warm water), paresthesias (may radiate proximally into forearm or above elbow to shoulder, provo
48
Q

carpal tunnel dx and tx

A
  • dx: phalen maneuver (flex wrist with elbow in full extension - backs of hands against one another - positive if pain and/or paresthesia in median innervated fingers within one minute of wrist flexion)
    • tinel test (percussion over prox portion of carpal tunnel - positive if pain and/or paresthesia, less sensitive than phalen sign - 50%)
    • nerve conduction study (NCS) with EMG (excludes polyneuropathy, plexopathy, and radiculopathy, delayed distal latencies and slowed conduction velocity
  • tx: mild = nocturnal wrist spint in neutral position x1mo, steroid injxns methylprednisolone, no more than 1/wrist q6mo, oral steroids prednisone daily 10-14d, PT/OT or yoga
    • moderate to severe = electrodiagnostic studies (first), surgical decompression
  • should resolve postpartum in pregnancy
49
Q

complex regional pain syndrome

A
  • reflex sympathetic dystrophy
  • characterized by regional pain in affected limb, restricted mobility, edema, color changes of skin, spotting bone thinning, follows soft tissue injury
  • sxs: severe burning or throbbing pain with associated allodynia in affected region/extremity, cyanosis, abnl sensitivity to temp, abnl skin temp, atrophy
  • dx: clinical, bone scintigraphy, plain XR, MRI, regional nerve block = diagnostic
  • tx: early mobilization following injury, TCAs, gaba, pregabalin, lamotrigin, NSAIDs, calcitonin adjunctive, bisphosphonates, IVIG, regional nerve blocks, dorsal column stim

R5 - Internal Medicine (10 decks)

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