Neurology II scenarios Flashcards
Would you expect to see a pt with ataxia?
No; uncommon, 150,000 people in US
A pt has disordered speech/fine motor skills; can’t button shirt, pick up pencil, etc. However, their gait is fine. What is likely what’s happening?
Apraxia
A 65 year old pt’s hands are shaking bilaterally, especially when intentional movements, like drinking/eating, writing, tying shoes, etc. However, she notes that when she drinks alcohol, it gets better. She notes that it has started to involve her voice.
1) Dx?
2) Tx?
1) Essential tremor
2) D/c caffeine and any aggravating meds
exclude secondary causes
Propranolol or primidone (B Blockers have central depressive effect; primidone works to increase GABA)
Refer to neurology if not comfortable treating it
A 65 year old pt being treated for new-onset depression has a unilateral pill rolling tremor at rest that resolves with intentional movement and cogwheel rigidity. You also observe bradykinesia/shuffling gait and freezing movements. They say these Sx have started slowly.
1) Dx?
2) Tx options?
1) Parkinson’s Disease
2) Dopamine agonist:
a) Levodopa-Carbidopa (Sinemet)
-Carbidopa is adjunct to reduce peripheral side effects (nausea/vomiting, dreaming, psychosis, dyskinesias) & increase CNS bioavailability of levodopa (dopamine agonist)
or
b) Anticholinergics (indirectly ^dopamine): Benztropine Mesylate
A 35 year old pt has new but slow onset dementia Sx, depression Sx, and involuntary and unpredictable movements of extremities (chorea). Their partner notes behavioral changes in the pt.
Potential Dx?
Tx?
1) Huntington’s
2) Symptomatic, cannot be cured or halted; Tetrabenazine can help treat dyskinesia; dopamine blockers.
-Genetic testing of offspring should be offered with counseling
ALL HD patients should be referred to neurology
A 9 year old male pt has involuntary motor and vocal tics that can be described as sudden, repetitive gestures, sounds, or words. These decrease with concentration.
1) Potential Dx?
2) Tx?
1) Tourette’s
2) Treat underlying conditions (psych) as able, goal is for “normal” life:
-Symptomatic, behavioral therapy (habit reversal training)
-Clonidine
-dopamine antagonists
-choose treatment with best SE profile for specific patient
-Haloperidol
-Tetrabenzine
-Treat any underlying comorbidities (ex/ ADHD, OCD)
-Botox if tics limited to a small area
-Stimulants contraindicated
What are the odds of your 10 year old pt’s Tourette’s going away? Explain
50% of children with Tourette’s syndrome will have tics resolve prior to 18, but tics may return later in life
A pt has restless legs accompanied by unpleasant sensations in the Bilat legs (arms and trunk not affected,) intolerable tingling, crawling, creeping; relieved by moving or walking.
1) Dx?
2) Tx?
1) Restless legs
2) Dopaminergic agonists (ropinirole,) gabapentin, clonazepam, treat underlying cause (IDA,) optimize sleeping habits, stretching, or massage. A lifelong disorder but can typically be controlled.
True or false: your pt with Parkinson’s is more at risk for RLS
True
A pt on antipsychotics presents with chronic, persistent, hyperkinetic movement disorder/restlessness of face and distal extremities.
1) Potential Dx?
2) Tx?
1)
2) Early recognition; immediate gradual removal of offensive agent
Can be permanent provider needs to educate patient on symptoms to watch for.
Low rate of spontaneous remission, often causes permanent disability
Dopamine depleting drugs ex/ tetrabenazine (** depression
61-year-old male withinvoluntary movements of the left hand, which occur only at rest.The symptom has been obvious to his wife for two months. Exam reveals apill-rolling tremor at rest; a significant lack of arm movement, stooped posture and shuffled gait while walking, and cogwheeling of the shoulder jointswith passive ROM.
What is the most likely diagnosis?
What is it caused by?
How do you want to treat it?
(rhetorical questions from ppt)
A pt, female aged 86, has a gradual progression in memory loss and dysfunction in language. She also notes insomnia and depression.
1) Likely Dx?
2) Tx?
1) Alzheimer’s Disease
2) Cholinesterase inhibitors, donepezil (but major GI and psych SE) rivastigmine patch (less GI SE,) Memantine (less SE)
A 3 year old pt has fever, HA, vomiting, convulsions, delirium; neck and back stiffness, petechial rash. Purulent CSF, Gm (–) diplococci. +Kernig and Brudzinski signs on PE.
1) Likely Dx?
2) How do you Dx this?
3) Tx?
1) Meningitis- meningococcal
2) Blood or csf culture = dx (Neisseria meningitidis)
3) IV PCN G q 4hr x 5-7 d
A pt has acute inflammation of the brain, with Sxs of HA, AMS with neurologic dysfunction, personality changes and hallucinations.
1) Dx?
2) Tx?
1) Encephalitis - viral
2) Depends on etiology
HSV – IV acyclovir
West Nile – supportive
Tick-born infections must be reported to local health dept or CDC
A pt presents with new onset headaches,nausea and vomiting, and seizures. They also note irritability. What are these a symptom of?
Increased intracranial pressure (ICP) (which itself is a Sx of a brain tumor)
An HIV+ pt has a persistent severe headache worse in the morning with nausea and vomiting. It’s completely different from their normal migraines.
Cause of these Sx?
Brain Tumor
Seizures will be a common presentation of what type of neoplasm?
Primary intracranial tumors
If someone says they have the most common primary malignant brain tumor, what do you think their prognosis is?
Poor prognosis < 30% survival rate @ 1 year bc they have a glioblastom/ grade 4 (high grade) astrocytoma
