Neurology Flashcards
typical features of cerebellar degeneration
- progressive gait dysfunction
- truncal ataxia
- nystagmus
- intention tremor or dysmetria
- impaired rapid alternating movements
what is dysdiadochokinesia?
impaired rapid alternating movements
what is dysmetria
limb-kinetic tremor when attempting to touch a target
what is Babinski sign and what does it indicate
upward deviation of great toe when stroke foot
suggests UMN lesion
what is the clasp knife phenomenon?
velocity dependent resistance to passive limb movement
seen in pts with hypertonia due to pyramidal tract disease
what cancers have primarily multiple brain mets?
lung
melanoma
what cancers usually have solitary brain mets?
breast
colon
renal cell
list cancers that met to brain in order of highest frequency
- lung
- breast
- unknown primary
- melanoma
- colon
cerebral toxoplasmosis most common in CD4 ___
<100
ring enhancing lesions
head imaging with nonenhancing/hypodense lesions, calcified granulomas indicates ____
neurocysticercosis
these are cysts at various stages of development
CSF findings of GBS
high protein
few cells
(albuminocytologic dissoc)
difference in time course for symptoms of GBS vs tick borne paralysis
tick- ascending paralysis over hours (ticks must feed 4-7 days first tho for release of neurotoxin)
GBS- days to weeks
examples of autonomic dysfunction that is often seen in GBS
tachycardia
urinary retention
arrhythmias
how and when does chemotherapy induced neuropathy present
weeks after treament
symmetrical paresthesias in fingers and toes spreading proximally in a stocking glove pattern
symptoms of anterior cord syndrome
BL motor function loss at and below level of injury
decr pain and temp sensation BL that begins 1-2 levels below cord injury
vibration, proprio ok
(basically lose everything except vibration, proprio)
lesions in ___ (3) generally cause UMN symptoms
brain
spinal cord
lesions in ____ cause LMN signs
level of spinal root
what symptoms should you suspect cauda equina syndrome
severe radicular lower back pain
plus:
- impaired motor/patchy sensory/reflex activity in LE
- bowel/bladder dysfunction
- or saddle anesthesia
management if cauda equina syndrome symptoms
urgent MRI
surgical decompression within 24-48 hours to prevent irreversible neurologic sequelae
what nerve roots does cauda equina carry
L2-L5
S1-S5
coccygeal nerve
memantine
- usage
- mechanism
severe Alzheimer disease
blocks action of glutamate on NMDA receptor
what labs should you always get in someone with dementia
thyroid function
vitamin B12
these are potentially reversible causes
potential etiologies of intracranial hypertension
- trauma
- space occupying lesions
- hydrocephalus
- impaired CNS venous outflow
- pseudotumor cerebri
presentation of intrancranial hypertension
- headache - worse at night
- n/v
- mental status changes, cog dysfunction
- focal neuro sxs (vision change, unsteady gait)
- seizure
- symptom worsening with maneuvers that further incr ICP
- papilledema
what maneuvers can worsen symptoms of intracranial hypertension
leaning forward
valsalva
cough
what is cushing reflex and what does it suggest
HTN, bradycardia, respiratory depression
brainstem compression
exam findings of acute angle closure glaucoma
conjunctival erythema
mid-dilated pupil poorly reactive to light
why can heavy ETOH cause alcoholic neuropathy?
alcohol is neurotoxic and results in axonal neuropathy characterized by reduction in small myelinated and unmyelinated fibers
can occur with or without thiamine deficiency
symptoms of alcoholic neuropathy?
symmetric distal polyneuropathy (stocking glove)
characterized by paresthesia, burning pain, ataxia
also commonly lose distal DTRs (eg ankle), light touch, vibration sense
list common causes of peripheral neuropathy
- DM
- hypothyroid
- vit B12 deficiency
- medications (eg phenytoin, cisplatin, platinum chemo, disulfiram)
name the cranial nerves
2: optic
3: oculomotor
4: trochlear
5: trigeminal
6: abducens
7: facial
8: vestibulocochlear
9: glossopharyngeal
10: vagus
11: spinal accessory
12: hypoglossal
most common cause of CN3 (oculomotor nerve) palsy
ischemic neuropathy due to poorly controlled DM
UMN signs
hyperreflexia, spasticity
LMN signs
muscle atrophy
fasciculations
how does ALS usually present
asymmetric limb weakness
bulbar dysfunction
upper and motor neuron symptoms
risk factors multiple sclerosis
vit D deficiency smoking white female HLA-DRB1 USA, europe, cold climate
multiple sclerosis diagnosis
episodic/progressive sxs disseminated over time and space
hyperintense lesions on T2 MRI
oligoclonla IgG on CSF analysis
what are bulbar symptoms
dysphagia, dysarthria
seen in multiple sclerosis
epidemiology of myasthenia gravis
women 20s-30s
men 60s-80s
what are ocular symptoms of myasthenia gravis
diplopia
ptosis
broad flat T waves
hypokalemia
also- U waves, ST depression, premature ventricular beats
primary CNS lymphoma is associated with what virus
EBV
Brown-Sequard presentation
ipsilateral hemiparesis, decr proprio, vibration, light touch AT The level of injury
contralateral diminished pain and temperature 1-2 levels BELOW level of injury (bc lateral spinothalamic tract decussates 1-2 levels above entry point for the corresponding sensory neuron)
genetics of Huntington disease
Autosomal dominant CAG repeat expansion
neuropathology of Huntington
loss of GABA-ergic neurons
imaging features of Huntington
caudate nucleus and putamen atrophy
what is the greatest risk factor for stroke
HTN
high pressure increases shearing force on intracerebral vascular endothelium, promoting formation of thrombi
treatment mild/intermittent restless leg
supplement iron when ferritin <= 75
supportive (massage, heating pads, exercise)
avoid aggravating factors (eg slep depriv, meds)
treatment persistent/moderate to severe restless leg
dopamine agonists (pramipexole) alternate- alpha 2 delta calcium channel ligands (gabapentin enacarbil)
list secondary causes of restless legs
- iron deficiency anemia
- uremia
- DM
- multiple sclerosis, parkinson disease
- pregnancy
- drugs (eg antidepressants, metoclopramide)
how does ETOH cause alcoholic neuropathy
ETOH is neurotoxic, resulting in axonal neuropathy characterized by reduction in number of small myelinated and unmyelinated fibers
symptoms of alcoholic neuropathy
symmetric distal polyneuropathy (stocking glove) - sxs include paresthesia, burning pain, numbness, loss of DTRs
exam usu has loss of light touch and vibration
gait ataxia is common
metabolic causes of peripheral neuropathy
DM
hypothyroid
B12 deficiency
other: MM, MGUS, plasma cell disorders
toxic causes of peripheral neuropathy
ETOH
meds- phenytoin, disulfiram, platinum chemo
heavy metals
infectious causes of periph neuropath
HIV
Lyme
hereditary causes of periph neuropathy
CMT
porphyria
symptoms of intracranial hypertension
HA worse at night, N/V, metal status changes
focal neuro symptoms (eg vision change, unsteady gait)
seizures
symptoms worsen with maneuvers that increase ICP such as leaning forward, valsalva, cough
what is cushing reflex and what does it suggest
HTN
bradycardia
respiratory depression
worrisome finding suggestive of brainsteem compression
exam findings of acute angle closure glaucoma
conjunctival erythema
mid-dilated pupil that is poorly reacive to light
temporal arteritis is associated with what condition
polymyalgia rheumatica (prox muscle stiffness/tenderness)
for what condition should you get CT chest to check for thymoma
myasthenia gravis
treatment for myasthenia gravis
acetylcholinesterase inhibitors (eg pyridostigmine) thymectomy
+/- immunotherapy (steroids, azathioprine)
medications that can cause myasthenia gravis exacerbation
- abx: fluoroquinolones, aminoglycosides
- anesthetics-neuromuscular blocking agents
- cardiac meds - BB, procainamide
- other: magnesium sulfate, penicillamine
- tapering of immunosuppressive medications
causes of myasthenia gravis exacerbations
meds
pregnancy/childbirth
infection
surgery
what is thalamic pain syndrome
severe paroxysmal burning pain over area affected by a talamic stroke, exacerbated by light touch (allodynia)
lateral medullary infarct occurs due to occlusion of what arteries?
Posterior Inferior Cerebellar or vertebral artery
–> wallenberg syndrome
what is wallenberg syndrome and what are the symptoms
vestibulocerebllar sxs (vertigo, diff sitting upright w/o support, diplopia, nystagmus, ipsilat limb ataxia)
sensory sxs- lose pain and temp in ipsilateral face + contralateral trunk and limbs
ipsilateral bulbar muscle weakness- dysphagia, aspiration, dysarthria, dysphina, hoarseness (ipsilat vocal cord paralysis)
autonomic dysfnx - ipsilat Horner’s syndrome, intractable hiccups, lack of automatic respiration esp during sleep
what is transverse myelitis
immune-mediated infiltration of inflammatory cells into a segment of the spinal cord
–> neuron and oligodendrocyte cell death and demyleination
symptoms of transverse myelitis
rapidly progressive motor weakness that progresses from flaccid to spastic with UMNS
autonomic dysfunction
sensory deficits with a distinct sensory level
what spinal cord level does transverse myelitis often affect?
*inflammation localizes to contiguous spinal cord segments, usually in the thoracic cord
LP and MRI findings in transverse myelitis
MRI: enhancement of affected cord segments
LP: pleocytosis and elevated IgG
management of transverse myelitis
high doese IV glucocorticoids, foten with plasmapheresis
symptoms of anterior spinal artery syndrome?
weakness and loss of pain/temp below lesion
proprioception, vibration spared
cause and symptoms of subactue combined degeneration
B12 deficiency
- sensory ataxia
- progressive spastic parapersis
- incontinence
occurs over years, often a/w neuropsych changes
most common cause oculmotor (CN3) palsy
ischemic neuropathy dt poorly controlled DM
symptoms of CN3 palsy
ptosis, diplopia
down-and-out gaze
normal pupillary response
(damage to inner somatic nerve fibers that innervate leavtor of eyelid and 4 of the EOM / while sparing the peripheral parasympathetic fibers that innervate sphincter or iris and the ciliary muscles)
what extraocular muscles are innervate by CN3 (oculomotor)
Superior rectus
Medial rectus
Inferior rectus
Ingerior oblique
3 cardinal signs of Parkinson disease
rest tremor (freq manifests in one hand first)
bradykinesia
rigidity
meaning of myelopathy
a nervous system disorder that affects the spinal cord
symptoms of cervical myelopathy
progressive ambulation difficulty and extremity weakness
LMN signs at level of lesion (arms) –> weakness, atrophy
UMN signs below level of lesion (legs) - eg hyperreflexia
most common cause of cervical myelopathy in older adults
spondylosis (degenerative spine disease that causes canal narrowing with cord compression)
cause of Bell palsy
reactivation of herpes simplex virus
Treatment of Bell palsy
steroids
some also recommend acyclovir
what is Todd paralysis
self-limited, focal weakness or paralysis that occurs after a focal or generalized seizure
sxs are self-limited and resolve in hours
cause of infant botulism
ingestion of C botulinum spores –> colonize gut and lead to production and release of neurotoxin
how is cause of foodborne botulism diff from infant botulusm
foodborne: ingest preformed C botulinum toxin
infant: ingestion of spores
difference in presentation of foodborne vs infant botulism?
foodborne: descending flaccid paralysis preceded by prodrome of n/v, abdominal pain, diarrhea
infant: bulbar palsies, constipation, drooling, hypotonia- even if infant hasn’t been fed honey!
infant presents w/ bulbar palsies, constipation, hypotonia, has never eaten honey - what’s going on?
suspect infant botulism from inhalation of soil spores
highest incidence of infant botulsm?
California
Pennsylvania
Utah
(have greatest concentration of soil C botulinism spores)
treatment of infant botulism
botulism immune globulin ASAP, even before diagnostic confirmation of stool spores or toxin
treatment of foodborne botulism
botulism antitoxin
symptoms of spinal muscular atrophy (Werdnig Hoffmann disease)
generalized symmetric proximal weakness, hyporeflexia
weakness greater in lower than upper extremities
diagnosis of absence sz
EEG with 3Hz spike wave discharges during episodes
Friedreich ataxia inheritance pattern
autosomal recessive
Friedriech ataxia is due to what mutation
excess trinucleotide repeat, most commonly GAA –> abnormal frataxin protein which is highly expressed in heart, brain, pancreas
neurologic findings of Friedreich ataxia
- loss of position and vibration sense (dorsal spinal column)
- dysarthria
- loss of DTRs
- progressive gait and limb ataxia
non-neurologic findings of Friedreich ataxia
- hypertrophic cardiomyopathy (incr risk arrhythmia, HF, may have fhx sudden cardiac death)
- kyphoscoliosis, pes cavus
additional management after IV abx for native valve bacterial endocarditis with acute cardioemoblic stroke
none, careful observation
consider surgery if significant valve dysfunction, persistent/hard to treat infection, or recurrent embolism
what time frame does foodborne botulism symptoms develop?
within 36h of toxin ingestion
mechanism of botulism toxin
inhibits presynaptic release of Ach at the NMJ
presentation of putaminal hemorrhage involving the adjacent inernal capsule
contralateral hemiparesis and hemianesthesia
conjugate gaze deviation TOWARD side of lesion (dt damage of frontal eye field efferents)
medial medullary syndrome occurs due to occlusion of __
vertebral or anterior spinal artery
contralteral paralysis of arm and leg (lat corticospinal tract)
contralateral loss of position sense (dorsal column medial lemniscus)
tongue deviation toward lesion (Hypoglossal nerve)
treatment options for postherpetic neuralgia
gabapentin, pregabalin
TCA (amytriptylline)
topical capsaicin and lidocaine
opioids effective but not preferred due to dependence
explain neurogenic shock cause and symptoms
lesions above T1 interrupt descending sympathetic fibers –> unopposed parasympathetic stimulation of vessels and heart = hypotension and bradycardia, hypothermia bc lack of peripheral vasoconstriction; areflexia, anesthesia, paralysis, distended bladder below level of the lesion
usu have initial period (sev minutes) of massive sympathetic stimulation due to release of NE from adrneals, leading to HTN and tachy
secondary stroke prevention for acute ischemic stroke
sntiplatelet with aspirin
secondary stroke prevention in those with acute cardioembolism
anticoagulation wtih heparin
pt with worse headache in his life. CT negative. next step?
suspected SAH, some CTs still negative
get LP to check for high opening pressure and xanthochromia
etiology of cerebral amyloid angiopathy
abnormal beta-pleated amyloid deposition in cerebral vessels leading to vessel fragility
second most common cause od intracerebral hemorrhage after HTN, typically lobar in location, pts age >75
symptoms of hypertensive encephalopathy
marked BP elevation w/ progressive HA, N/V, nonlocalizing neuro symptoms (eg confusion, restlessness) due to cerebral edema
sxs of vertebral artery dissection
with head/neck trauma
local pain
focal neuro deficits dt cerebral iscehmia cause by thromboembolism or hypoperfusion
concomitant disruption of posterior infecrior cerebellar artery –> lateral medullary syndrome
medical treatment for idiopathic intracranial hypertension?
what if fail medical therapy?
acetazolamide +/- furosemide
optic nerve sheath decompression or lumboperitoneal shunting if refractory to medical therapy
steroids and LP can be used as bridging therapy for pts awaiting definitive surgical tx, but not rec as long term primary tx
symptoms of aminoglycoside toxicity
can be ototoxic to both the cochlea AND vestibular system
= sensorineural hearing loss and imbalance
positive head thrust test assesses vestibuloocular reflex which is affected by _______ vestibulopathies
peripheral, but not central
what is equinovarus deformity
clubfoot - feet point down and inward
progressive multifocal leukoenceophalopathy is associated with reactive of __ virus
JC
manifestations of common fibular neuropathy
usually transient
- foot drop
- sensory changes over dorsal foot, lateral shin
- impaired dorsiflexion
- impaired great toe extension
causes of common fibular neuropathy
leg immobilization
leg crossing
protracted squatting
most frequently affected locations of hypertensive hemorrhages
basal ganglia (putamen)
cerebellar nuclei
thalamus
pons
putaminal hemorrhage almost always involves the adjacent ____ leading to sytmpoms of?
internal capsule
contralateral hemiparesis and hemianesthesia (disruption of the corticospinal and somatosensory fibers) and conjugative gaze deviation twd side of the lesion (damage of frontal eye field efferents)
lobar hemorrhages due to amyloid angiopathy most often involve which lobes?
occipital lobe (causing homonymous hemianopsia) parietal lobe (causing contralat hemisensory loss)
next step in pt with Guillaine-Barre who is hemodynamically stable
serial PFTs to assess respiratory muscle strength
most common mononeuropathy in pts on dialysis? cause?
carpal tunnel syndrome
mos commonlyy: dialsis relaed amyloidosis- inflamm stim formation of beta 2 microglobulin, which is inadeq cleared and deposied as myloid within carpal tunnel
other:
- incr venous pressure during HD
- blood racking from fisual into the carpal tunnel
- deposition calcium phosphae in unnel
tetanus MOA
closridium tetani toxin blocks release of inhibitory Glycine and GABA across the synaptic cleft
differences between neonatal conjunctivitis caused by chlamydia vs gonorrhea
gonorrhea_ presents age 2-5 days, purulent
chlamydia: 5-14 days, milder chemosis and lid swelling, watery discharge
formal visual acuity testing is recommended starting at __
age 4 / cooperative 3yo
should be screened at every well child
initial workup of suspected dementia
- neuropsych testing
- CBC, CMP, TSH, B12
- neuroimaging
most common type of headache in pediatric population
migraines
indications for head imaging in a child with HA
- coordination difficulty
- n/t or focal neuro signs
- HA that causes awakening from sleep
- increasing HA frequency
tx acute dystonia
benztropine, diphenhydramine
sxs craniopharyngioma
optic chiasm compression -> bitemporal hemianopsia
pituitary stalk compression -> endocrinopathies- growth failure in children, pubertal delay, sexual dysfnx in adults, DI
classic presentation of Friedrich ataxia?
progressive ataxia in adolescence
what is cephalohematoma?
bleed over he surface of one cranial bone, due to birth rauma
subperioseal bleeding is slow so swelling often no visible until several hours afer birth
nonender, doesn’ cross suure lines
mosl uncomplic and resorb sponaneousl wihin few weeks o monhs. a increased risk for hperbili as blood breaks down, m need phooherap
features of Lennox-Gastaut sndrome
usu presns b age 5 w/ ID and severe seizures of various types
inerictal EEG: slow spike and wave pattern
what type of seizures are triggered by hperventilaion?
absence
absence EEG
3 Hz spike wave
absence tx
ethosuximide
facors disinguishing Marfan from homocsnuria?
homocsinuria is AR
- intellectual disability
- thrombosis (eg stroke), hromboemoblic evens a an age
fair complexion, megaloblasic anemia
most common predisposing factor for orbital cellulitis?
ttttt
sinusitis
not as common but also /maxillary/ tooth abscess
how to reverse warfarin
IV vitamin K (effects in 12-24h)
prothrombin complex concentrate- contains vitamin K activated factors, acts within minutes and lasts hours (FFP if not available)
how to reverse warfarin
IV vitamin K (effects in 12-24h)
prothrombin complex concentrate- contains vitamin K-dependent clotting factors, acts within minutes and lasts hours (FFP if not available)
characteristics febrile seizure, management
no previous afebrile seizure
quick return to baseline
reassurance
ACA occlusion leads to contralateral sensory and motor deficit predominantly in ___ extremity
lower
may also have urinary incontinence
MCA occlusion leads to contralat sensory and motor deficit primarily in __
face, upper limb
Anterior spinal artery stroke
contralateral paralysis upper and lower limb
ipsilateral tongue deviation (hypoglossal)
dysphagia, hoarseness, decr gag reflex = ___ stroke
PICA
loss of pinprick sensation over 1st and 2nd webspaces beween toes can be due o __ or __
injur ot L5 roo or peroneal nerve
type 2 neurofibromatosis involves a gene abnormality on chromosome _
22
neglect is more common with __-sided brain lesions
right
most common brain tumor in children?
low grade astrocytoma
medulloblastomas arise from ______ and presents with __
cerebellar vermis
ataxia (dt involvement of cerebellum)
neuroblastomas arise from __ and usu present with __
sympathetic ganglion cells
abdominal mass
what is Uhthoff phenomenon
MS sxs worsening during exposure to high temps
differences in signs/sxs of HSV vs CMV retinitis?
HSV(and VZV) = painful ketatitis/conjunctivitis –> rapidly progressive visual loss
fundoscopy: widespread, pale peripheral lesions, cenral retinal necrosis
CMV- no pain, no conjunctivitis
fundoscopy: fluffy white lesions, hemorrhages
MRI Alzheimer’s disease shows ____ atrophy
temporal lobe
meds that can precip acute glaucoma
anticholinergics
vision changes expected with open angle glaucoma
tunnel vision (lose peripheral vision)
wernicke encephalopathy triad
ataxia
oculomotor sxs
encephalopathy (confusion, lethargy)
3 black box warnings for valproic acid?
- teratogen
- life-threatening pancreatitis
- hepatotoxicity
Babinski reflex is normal up to age __
2 years
inheritance NF1
autosomal dom
inheritance NF2
autosomal dom
characteristics of CIDP
2 months symmetric both proximal and distal weakness
reduced/absent DTRs
what can differentiate Alzheimer’s from frontotemporal dementia?
memory is often spared in FTD
burning, numbness/tingling = ___ lobe seizure
parietal
deja vua, unusual taste/smell, feeling of fear = __ lobe seizure
temporal
pt with diplopia and tilting head to one side
trochlear nerve palsy (CN4)
hemiballismus is due to lesion in __
subthalamic nucleus
sxs commonly seen in Bell’s Palsy
hyperacusis
decr taste anterior 2/3 of ipsilat tongue
expected pupil exam for non-pupil sparing CN 3 palsy vs pupil sparing CN 3 palsy?
causes?
non-pupil sparing: expect one pupil to be more dilated. due to CN3 compression; parasymp fibers respondible for pupil constriction are not spared
pupil sparing: expect pupils to be symmetric. due to nerve ischemia such as from DM. parasymp fibers are spared
management of generalized status
- IV benzos for sz termination
- nonbenzo AED to prevent recurrence (eg fosphenytoin, phenytoin, keppra, valproate)
- MRI, CT to eval for structural abnormality, hemorrhage, ischemia
- continuous EEG if pt does not return to normal state of consciousness after medical therapy
characteristics of frontotemporal dementia
early personality changes
compulsive behaviors
hpyerorality
frontotemporal atrophy on imaging
characteristics of vascular dementia
early executive dysfunction
stepwise
cerebral infarct and/or deep white matter changes on imaging
manifestation of phenytoin toxicity
cerebellar dysfunction (horiz nystagmus, ataxia, dysmetria, slurred speech), hyperreflexia
AMS
inheritance tuberous scelrosis
autosomal dominant
TSC gene mutations -> benign tumors (hamartomas) of brain, skin, other organis
most common presenting feature of tuberous sclerosis
seizures
exam signs of tuberous sclerosis
- hypopigmented macules (ash leaf spots)
- angiofibromas
- thickened skin w/ orange peel like texture
- subependymal nodules on brain imaging (brain hamartomas)
all pts with suspected tuberous sclerosis should be evaluated for __
cardiac rhabdomyoma, with echo
cervical spondylotic myelopathy presents with __ signs in UE and ___ signs in LE
LMN in uppers (cervical spinal root compression)
UMN in lowers (compression of spinal cord descending tracts)
sxs syringomyelia
loss of pain and temp in cape-like distribution (shoulders, back, arms)
inheritance Duchenne’s and Becker’s
XLR
inheritance myotonic dystrophy
autosomal dominant
Bell Palsy management
glucocorticoids!
+/- acyclovir, valacyclovir which may speed time to recovery
protective eyewear if can’t close their eye
what is an early finding of macular degeneration
straight lines appear wavy
neuroimaging Alzheimer’s
temporal lobe atrophy
sxs macular degeneration
central vision loss
sxs glaucoma
peripheral vision loss
early on is asymptomatic
exam shows cupping of optic disc
epidural hematoma most likely to compromise which cranial nerve early on?
3 oculomotor
complications after bacterial meningitis in children
- intellectual/behavioral disabilities
- hearing loss
- cerebral palsy
- epilepsy (usu focal)
features of glucocorticoid-induced myopathy
proximal muscle weakness and atrophy (LE more involved)
NO pain
NORMAL ESR and CRP
two agents that might provoke idiopathic intracranial htn
vitamin A
glucocorticoids
peak time for etoh wihdrawal seizures
1-2 days
peak time for DTs
2-4d
olfactory sz are a/w lesions in _
mesial temporal lobe, esp hippocampus or parahippocampal gyrus
most common visual field defect after L temporal lobectomy
R superior quadrantanopsiaff
differentiating polymyositis from polymyalgia rheumatica?
polymyositis- weakness
polymyalgia rheumatica- also painful
