Neurology Flashcards by Clyde Silverio

[Diagnose]

68M chestpain with exertion, receotly passing out, history of DM with metformin

Midsystolic, cresendo-decresendo murmur at right 2nd ICS MCL

Dx: Cardiac syncope, due to aortic stenosis

Initial test: Echocardiography

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If the syncope is unexplained and the patient has no heart disease, what is the most important test?

tilt-table testing

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What is the most common cause of syncope?

neurally mediated (vasovagal)

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What is the SBP cutoff that will result in syncope?

SBP 5mmHg or lower

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What are the cutoffs to say that the patient has orthostatic hypotension?

Reduction in SBP of at least 20 mmHg

2. DBP of at least 10 mmHg within 3 minute of standing or head-up tilt on a tilt table

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What are the possible causes of sudden, no prodromal symptoms, cardiac syncope?

Arrythmia
Blood flow obstruction
Massive MI

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[Syncope vs seizures]

short duration myoclonic jerks <30s

syncope

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[Syncope vs seizures]

preceded by aura/premonitory features; drowsiness/diorientation after attack

seizure

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What is the hallmark of generalized seizures?

Tonic-clonic movements

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What is the most common type of seizure?

generalized tonic-clonic

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What is the most important diagnostic step in seizure?

EEG

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[diagnose]

68M right sided weakness and language disturbance, known hypertensive for 10 years.

PE: 180/100, aphasic, gaze deviated to the left, motor strength RUE and LUE 0/5

Dx: Acute stroke, ischemic vs hemorrhagic

Next step: stabilize patient, rule out stroke mimickers

initial test: non-contrast CT of the head

Artery involved: left MCA

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Cite examples of stroke mimickers

Seizure
Intracranial tumor
Migraine
metabolic ecephalopathy

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TIA is diagnosed if ___

Presents as stroke symptoms but lasts <24 hours and resolve completely

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[Non-contrast CT finding]

Dark areas on CT

Ischemic stroke

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[Non-contrast CT finding]

white areas in the brain

hemorrhagic stroke

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[Type of stroke]

deficit maximal at onset, very rapid

CT: dark areas

Ischemic

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[Type of stoke]

Evolution of deficit over minutes ti hours

headache, vomiting, SBP >220

CT: white areas

hemorrhagic stoke

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The most common site of hypertensive bleed

Basal ganglia (putamen, internal capsule)

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Imaging study for stroke that is very sensitive but not preferred

MRI

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[Types of intracranial bleeds]

Worst headache of my life

SAH

due to rupture of aneurysm

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[Types of intracranial bleeds]

crescent shaped lesion

subdural

due to tearing of superior cerebral veins

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[Types of intracranial bleeds]

biconcave disk-shpaed

Epidural

“lucid” interval, anterior division of middle meningeal artery

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[Stroke localization]

weakness Left > Upper extremity

Anterior cerebral

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[Stroke localization] profound weakness of the upper extremity Aphasia

middle cerebral

[Stroke localization] vertigo, nausea, vomoting, dysarthria, ataxia, gait imbalance

vertebrobasilar artery

[Stroke localization] amorausois fugaX

ophthalmic artery

[Stroke localization] ipsilateral face, contralateral body, vertigo, horner syndrome

Posterior cerebellar

What is the most commonly affected artery in stroke?

MCA

How will you manage ischemic stroke?

1. Thrombolytic therapy (rTPA) 2. Aspirin, clopidogrel, cilostazol 3. Anticoagulation for cardioembolic stroke 4. Neuroprotection 5. citicoline 6. statin

How will you manage hemorrhagic stroke?

1. BP reduction | 2. Mannitor/HTS, elevate head 30-45 degreees, hyperventilate

What is the target pCO2 for patients suffering from hemorrhagic stroke?

pCO2 30-35

cut off time of administering thrombolytics

___ within 3 hours of the onset of symptoms

What are the 5H for neuroprotection

avoid: 1. hypotension 2. Hypoxemia 3. Hypoglycemia 4. Hyperglycemia 5. Hyperthermia

[diagnose] 60M, headache 10/10 worst headache of his life, nausea, vomiting for 2 hours PE: sluggishly responsive pupil, right

Dx: SAH initial test: Non-contrast CT of the head Definitive test: Cerebral angiogram Gold standard: lumbar puncture

Third nerve palsy in subarachnoid hemorrhage is due to an expanding aneurysm at the ___

junction of the PCA and ICA

What drug is used to control spasm in patients with SAH?

Nimodipine

[Headache type] unilateral/bilateral with aura

Dx: migraine Abortive Tx: Sumatriptan Prophylactic: Propranolol

[Headache type] unilateral, tearing and redness of eye, rhinorrhea, no aura

Dx: cluster Abortive Tx: sumatriptan Prophylactic Tx: verapamil

[type of meningitis] WBC >1000, mostly PMNs Low glucose High protein

bacterial

[Diagnosis] headache, fever, stiff and painful neck

Dx: bacterial meningitis Etiology: S. pneumoniae, N. meningitides, H. influenza Initial test: CT scan of the head then CSF analysis Accurate test: CSF culture

[type of meningitis] WBC < 300 Normal glucose High protein

TB meningitis

[type of meningitis] WBC <300 Normal glucose normal protein

Viral meningitis

What is the most common cause of meningitis in neonates?

1. GBS 2. E. coli 3. L. monocytogenes

What is the most common cause of meningitis in children >3 months?

1. N. meningitidis 2. S. pneumoniae 3. H. influenzae

What is the most common cause of meningitis in adults?

1. S. pneumoniae 2. N. meningitidis 3. H. influenzae

What is the most common cause of meningitis in elderly?

1. S. pneumoniae 2. N. meningitidis 3. L. monocytogenes

What is the most common cause of meningitis in immunocompromised?

1. L. monocytogenes 2. Gram neg bacilli 3. S. pneumoniae

What is the best initial test for cryptococcal meningitis?

India ink

What is the most accurate test for cryptococcal meningitis?

crytococcal antigen

What is the best initial therapy for cryptococcal meningitis?

1. Amphotericin B | 2. 5 flucytosine

[Dementia] chronic progressive decline in multiple areas of cognitive functioning, no focal deficit, >65 years old

Alzheimers

[Dementia] Parkinsonian symptoms + dementia

lewy body

[Dementia] wet, weird, wobbly

normal pressure hydrocephalus

What are the initial workup test will you request for patients with memory loss?

1. head CT/MRI 2. VDRL 3. B12 4. T4

What is the CT scan finding in patients with alzheimer's?

diffuse, symmpetric atrophy

[diagnose] resting tremors, festinating gait, hypominmia, intact cognition and memory

Parkinsons disease

What is the drug of choice for a patient with parkinsons age 60 and above?

amantadine

What is the first line drug for patients with severe parkinsons disease?

1. Levidopa | 2. Carbidopa

What is the strongest risk factor for dementia?

increasing age

[pharma] Drug that inhibits DOPA carboxylase?

carbidopa

[pharma] peripheral COMT inhibitors

Entacapone | Tolcapone

[pharma] central COMT inhibitors

Tolcapone

[pharma] MAO-B inhibitor

Resagiline | Selegiline

[pharma] Increases dopamine availability in the postsynaptic space

Amantadine

[pharma] dopamine agonist

Bromocriptine Ropinirole Pramipexole

What is the most effective drug for parkinsons?

levodopa/carbidopa

[parkinsons] adjunct to levodopa and carbidopa

MAOI

[diagnosis] demyelinating, previous diarrhea, symmetric ascending muscle paralysis that begins in the lower extremity; rubbery legs

GBS Tx: IVIg or plasmapharesis

What are the commonly associated infections in GBS

1. campylobacter jejuni | 2. Herpesvirus

What is the most specific diagnostic test for GBS>

nerve conduction study, electromyography

What is the CSF finding in GBS?

markedly elevated protein concentration with normal cell count

[diagnose] diplopia, drooping eyelids, weakness of the muscles of mastication and dysarthria associated with thymoma snarling facial expression

Dx: Myasthenia Gravis Pathophysio: antibodies against acetylcholine receptors

What is the best initial test for MG?

Anti-acetypcholine receptor antibodies immunoassay

What is the most accurate test for MG?

Clinical presentation and ACHR are more sensitive and specific than an edrophonium stimulation test

What is the drug of choice for MG?

1. Pyridostigmine | 2. Neostigmine

What is the clinical criteria for Schizophrenia according to DSM V?

At least 2 of the following at least 6 months 1. Delusion 2. Hallucination 3. Disorganized speech 4. Disorganized behaviour 5. Negative symtoms

What antipsychotic medications that diminish positive symtoms?

1. First generation - chlorpromazine, Haloperidol | 2. Second generation - clozapine, quetiapine

[Diagnosis] 1 months of Delusion, Hallucination

BRP

[Type of bipolar disorder] Manic episodes + delusion, hallucinations

Bipolar I

[Type of bipolar disorder] hypomanic + psychotic symptoms during depression

Bipolar II

What are examples of manic episodes?

1. Distractability 2. Irresponsibility 3. Grandiosity 4. Flight of ideas 5. Agitation 6. Sleep, decreased need 7. Talkativeness

What are the criteria for MDD?

at least 5 of 9 for 2 weeks 1. Sleep disturbance 2. interest diminished 3. Guilt 4. Energy loss 5. concentration decreased 6. appetite change 7. psychomotor retardation 8. suicidal ideation