Neurology & Psych (from MCQBank) Flashcards
which population do we not find friedereich ataxia?
east asia (china and japan)
american indians
predisposing factor for bulimia
females
low self-esteem
personal/FHx of depression
personal/FHx of obesity
high personal expectations
FHx eating disorders
parents older than average
disturbed family interactions
early menarche
social pressures to be slim
Time to hold someone under section
- 2
- 3
- 4
- 5(2)
- 5(4)
- 135
- 136
2 = 28days, assessment
3 = 6 months, treatment
4 = 72 hours, assessment
5(2) = in hopital, by doctor, 72 hrs
5(4) = in hospital, by nurse, 6 hours
135 = break into house by police
136 = public place, detained by police, 24hr
Simulated disease divided into:
1. Unconsciously produced (somatoform disorders):
- mainly neurological symptoms - ?diagnosis
- multiple organ systems - ?diagnosis
- Intentionally produced (deception syndromes:
- without external incentives - ?diagnosis
- with external incentives - ?diagnosis
- conversion disorder
- somatisation disorder
- factitious disorder (includes Munchausen sydnrome, by proxy is when someone afflict/create the problem on someone else - usually carer on patient)
- malingering
Treatment of Bell’s palsy (within 72 hours)
oral prednisolone 50mg OD for 10 days
Increased risk factors for those who commit suicide
Male
Repeated self-harm
Has physical health conditions
Express suicidal intent
Schneider’s first rank symptoms of schizophrenia
auditory hallucinations
thought withdrawal, insertion or interruption
thought broadcasting
somatic hallucinations
delusional perception
feelings or actions experienced as made or influenced by external agents
New screening tool for eating disorders
SCOFF
Sick, control, one, fat, food
- have you ever eaten so uncomfortably full that you feel sick?
- do you ever worry that you lost control of what you eat?
- have you recently lost weight or gained more than 1 stone in 3 months?
do you believe yourself as fat when others say you are thin? - would you say that food dominates your life?
> =2 is high risk of eating disorder
Multi-system atrophy - signs and symptoms
Autonomic features (Postural hypotension, urinary dysfunction)
Cerebellar ataxia (poor balance, broad-based gait)
Parkinsonism symptoms (resting tremor, rigidity etc)
Normal pressure hydrocephalus - signs and symptoms
Gait disturbance
Urinary incontinence
Dementia
Arteries or Veins affects:
- subarachnoid
- subdural
- extradural
Subarachnoid: vein?
Subdural: cortical bridging veins
Extradural: artery?
Treatment of trigeminal neuralgia
Carbamezepine (also oxcarbamezepine)
?TCA
?Lamotrigine/Baclofen
Cataract, muscle weakness, balding - ?diagnosis
myotonic dystrophy
inheritance pattern for myotonic dystrophy
autosomal dominant
also, has anticipation - ie earlier for successive generations
Inheritance pattern of Freiderich’s ataxia
autosomal recessive
Clinical features of borderline personality disorder
4 main clinical features/areas:
- Emotional instability (affective dysregulation)
- Disturbed patterns of thinking or perception (cognitive distortions or perceptual distortions)
- Impulsive behaviour
- Intense but unstable relationships
Difference between baby blues, postnatal depression and puerperal psychosis
Baby blues - high OR low mood, within 10 days post-delivery. no specific tx as care of baby is not impaired.
Post-natal depression - occurs within 12 months of delivery. low mood, anhedonia, weight changes, sleep disturbance etc. need to be treated as can cause substantive impairment for mum and impaired behavioural/emotional/cognitive changes for baby
Puerperal pyschosis - aka post-partum psychosis. has hallucinations, severe thought disturbance and abnormal behaviour soon after birth. high risk for those who have history of bipolar disorder or previous puerperal psychosis. seek urgent specialist advice
Serotonin syndrome - what is it?
- neuromuscular excitation
- autonomic effects (blurred vision, tremor, myoclonic jerking, tachycardic, hyper-reflexia, ankle clonus)
- altered mental status
Neuroleptic malignant syndrome - what is it?
due to dopamine antagonist (eg anti-psychotic, metoclopramide)
hyperthermia, muscle rigidity, altered mental status, sympathetic nervous system lability, hypermetabolism, elevated creatine kinase
Tx: stop dopamine antagonist (OR start dopamine agonist), rehydration, cooling, tx of rhabdomyolysis (if applicable)
malignant hyperthermia - what is it?
due to inhaled anaesthetics or succinylcholine (suxamethonium)
thought to be autosomal dominant in RYR1
muscle rigidity, tachycardia, hyperthermia, mixed metabolic and respiratory acidosis
tx: dantrolene, cooling, IVI
patient recently started with SSRI for depression. 3 months later she is completely cured. what is the next step?
continue the SSRI for a further 6 months (following remission of symptoms)
started clozapine for schizophrenia. then developed sore throat - what is happening?
neutropenia side effect
check FBC weekly for the first 18 weeks then fortnightly for next 34 weeks then monthly
reduced visual acuity and colour perception (esp red)
orbital pain worse with exercise
pupillary light defect present
swollen optic disc
?diagnosis
optic neuritis
what is Urthoff phenomenom?
visual loss/neurological symptoms worsenign due to heat or exercise
due to optic neuritis
what is Pulfrich phenomenom?
objects moving in the straight line appear to have a curved trajectory
what is Lhermitte’s sign
shock like sensation radiation down spine due to neck flexion
seen in MS
what anti-depressants to give to breastfeeding ladies?
sertraline or paroxetine
how to create Wernicke’s encephalopathy?
when we give glucose infusion to a patient with chronic thiamine deficiency - therefore, causing thiamine deficiency even further
First line treatment for:
- generalised tonic clonic seizure
- absence seizure
- sodium valproate. if not, lamotrigine
- ethiosuximide
Treatment for tonic clonic seizure for >5min or >3 in an hour
Buccal midazolam
Rectal diazepam if above is not available.
IV lorazepam if there is IV access.
Dementia with myoclonus - ?diagnosis
Creutzfeldt-Jakob disease
For unprovoked seizure- what are the risks for another seizure to occur?
30-50%
after a 2nd unprovoked seizure, this would become 70-80%
recurrent attacks of eye pain for 30min over last few weeks - then followed by lacrimation. often circadian rhythm.
?diagnosis
cluster headache
treatment of cluster headache
acute attack: nasal sumatriptan, oxygen
prophylaxis: short course of prednisolone or verapamil
risk factors of schizophrenia
migration from developing countries (3-fold increase in risk)
children of migrants (second-generation)
urban living (2-fold)
south asian and black population
male (1.4:1)
younger for males (25y/o) and older for female (35y/o)
exposure to Toxoplasma gondii
how does AVPU correspond to GCS?
A - 15
V - 13
P - 8
U - 3
MRC grades of power
0 - none
1 - flicker
2 - with gravity
3 - against gravity
4 - against resistance
5 - normal
what is Pick’s disease?
frontotemporal dementia with inappropriate behaviour
Gait disturbance, urinary incontinence, dementia
Normal pressure hydrocephalus
the 2 main symptoms/criteria for depression are.. ?
low mood
loss of interest or pleasure
Toxicity level for TCA?
> 10mg/kg
Signs and symptoms for TCA toxicity
dilated pupils
dry mouth
drowsiness
tachycardia (sinus)
urinary retention
increased tendon reflexes
extensor plantar responses
Tx of mania
2nd generation or atypical antipsychotics (olanzapine, quetiapine, risperidone) - reduced extra-pyramidal side effect
Lorazepam to aid sleep/reduce agitation
Mood stabiliser eg lithium
Carbamezepine can be used as first line
Rapid tranquilisation
tx of schizophrenia
newer atypical antipsychotics (risperidone, olanzapine) - but the problem with this is weight gain and increase incidence of T2DM and rarely bone marrow depression
depot formulations should be considered
problems associated with sleep for Parkinson’s disease
movement disorder during sleep - nocturnal akinesia (difficulty turning or rising from bed, early morning dystonia, painful cramps and tremor)
circadian rhythm disorders
REM sleep disorder
how does periorbital ecchymosis looks like? and what is the underlying pathology?
panda eyes
basal skull fracture
examples of rating scales for ADHD
Strengths & Difficulties questionnaires
Conner’s rating scale
Tx of generalised anxiety disorder (from longest duration of effective to least)
CBT
SSRI
Self-help (bibliotherapy)
Benzodiazepine should not be used beyond 2-4weeks.
dont give sedating antihistamines.
what is:
1. agoraphobia
2. trichotillomania
3. dermatillomania
4. trichophagia
5. pica
- fear of open spaces & in situations where escape can be difficult or that help wouldn’t be available if things go wrong
- strong habit that causes people to pull out their own hair.
- urge to pick own skin
- repeated ingestion of hair most commonly associated with compulsive hair pulling
- eating disorder in which a person eats things not usually considered food
ataxic gait, slurred speech, scoliosis, pes cavus, muscle weakness of arms and legs
Freiderich’s ataxia
degenerative disease that affects nervous system and heart
how to categorise depression?
- how to treat it?
SUbthreshold depressive symptoms
(active monitoring)
Mild - few symtoms (in excess of 5) and minor functional impairment
(active monitoring to persistent subthreshold depressive symptoms - see below)
Moderate
- psychological intervention. avoid use antidepressants.
TO
- offer antidepressant and HIGH-intensity psych intervention
(SSRI first line - citalopram, fluoxetine, paroxetine, sertraline)
Severe
if tension headache >2days per week - ?tx
prophylactic medication - amitryptiline
Classification of seizure:
- Focal onset
- Generalised onset
Give examples of diagnosis under each
FOCAL ONSET - impaired awareness
- Focal motor seizure
- Focal sensory seizure
- complex partial seizures
GENERALISED ONSET - onset in 2 brain hemispheres
- Tonic-clonic
- Absence
- Myoclonic
- Atonic
what is conduct disorder?
repetitive and persistent patterns of anti-social, aggressive or defiant behaviour that amounts to significant and persistent violations of age-appropriate social expectations
Tx: cognitive behavioural therapy
what is oppositional defiant disorder?
pattern of angry/irritable mood, argumentative/defiant behaviour or vindictiveness at least 6 months. they are NOT aggressive to people/animal/property/theft/deceit
who are more likely to get absence seizure
female
children
how to provoke absence seizures? hence used to diagnose the patient
asking them to hyperventilate for 3-5 minutes can provoke the seizure
risk factors for self-harm
age (16-24 for female and 25-34 for males)
socio-economic disadvantage
social isolation
stressful life events
bereavement by suicide
mental health problems
chronic physical health diseases
alcohol +/- drug misuse
involvement with the criminal law system
increased risk of suicide for these patients who self-harm
male
repeated self-harm
physical health problems
expressed suicidal intent
treatment of tuberculous meningitis, lupus vulgaris
RIPE for 2 months and then RI for a further 10 months
2nd line drugs: streptokinase, cycloserine, ethionamide, levofloxacin
Lupus vulgaris: RIPE for 8 weeks then RI for 16 weeks
what is the difference between prodrome and aura for migraine?
prodrome: a sensation that the migraine is coming - irritability, lack of concentration, food cravings, tiredness
aura: distinct neurological symptoms (transient visual, sensory, language, motor disturbances) signalling the migraine will soon occur. most common type is eye problems: scotomas, photophobia or visual scintillations (eg zigzag lines)
tx of migraine
Simple analgesia +/- anti-emetic(eg aspirin 600-900mg, ibuprofen 400-600mg)
Rectal analgeia/Rectal anti-emetic
Triptans
Prophylaxis: beta-blocker and amitryptiline - 1st line.
Sodium valproate and topiramate - 2nd line.
Headache relieved on standing - ? diagnosis
Idiopathic intracranial HTN
AKA pseudotumour cerebri, benign intracranial HTN
which cranial nerve is most likely to be affected for idiopathic intracranial HTN?
6
difficulty in sucking/drinking through a straw & winging of scapula- ?type of dystrophy
fascioscapulohumeral muscular dystrophy
inheritance pattern for Duchenne muscular dystrophy?
X-linked recessive
proximal muscular dystrophy and pseudohypertrophy of calves
what counts as epilepsy?
> =2 unprovoked seizure occuring >24hr apart
1 unprovoked seizure and probability of further seizure is >=60% over next 10 years (similar to general recurrence risk after 2 unprovoked seizure)
diagnosis of epilepsy syndrome
Learn the side effects of:
- aripiprazole
- lithium
- clozapine
- valproate
- fluoxetine
- lethargy, increase BP, somnolence, increase HR, n&v, diarrhoea
- diarrhoea, vomit, drowsiness, muscle weakness, lack of coordination, ataxia, blurred vision, tinnitus, large output of dilute urine. need to check TFT, U&E, calcium when on lithium
- delirium, sedation, coma, increase HR, resp depression/failure, increase salivation, aspiration pneumonia, arrhythmias, seizure
- CNS depression, increase HR, reduced BP, n&v, abdo pain, low Na, lactic acidosis, low Ca, low glucose.
- increase HR, drowsiness, tremor, n&v, seizure, cardiac conduction abnormalities
what is Rich’s foci?
Myobacterium tuberculosis seed in the meninges -> forms small foci -> can increase in size and rupture into subarchnoid space
Lupus vulgaris VS scrofuloderma
Scrofuloderma: breakdown of skin overlying a tuberculous focus usually at lymph node but can also occur over in skin over infected bones and joints.
Lupus vulgaris: painful cutaneous tuberculosis skin lesions with nodular appearance. usually at the face around the nose, lids, lips, cheeks, ears. lesion is solitary, small, sharply marginated, red-brown papules of gelatinous consistency. Tx: RIPE for 8 weeks and then RI for 16 weeks
string sign on angiography - ? diagnosis
carotid artery dissection
involuntary face movement and verbal outburst ?diagnosis
gilles de tourette syndrome
(tics and verbal outburst)
Tx: anti-psychotic such as pimozide, risperidone, sulpride
what happens if right pons is affected?
contralateral hemiparesis, ipsilateral facial palsy, ipsilateral abducens palsy
this ventral pontine syndrome is called millard-gubler syndrome due to occlusion of penetrating branches of basilar artery
what happens if one-sided midbrain is damaged?
unilateral damage of corticospinal tract(contralateral hemiparesis), corticobulbar tract (contralateral hypoglossal nerve palsy), occulomotor nerve (ipsilateral ptosis, diplopia, eye pointing down and out)
3 features of Lewy body dementia
Parkinsonian motor symptoms (accompany/precede dementia)
recurrent well-formed/complex visual hallucinations
fluctuating attention/cognitive impairment
EEG findings of
- absence seizure
- creutzfeldt-Jakob disease
Absence: spike and wave complexes (exacerbated by hyperventilation)
CJD: periodic sharp wave complexes
tx of absence seizure
ethosuximide (for girls of child-bearing age)
for males: same as above or valproate
2nd line for girl/3rd line for boys : lamotrigine
what is riles day syndrome
present from infant
hereditary sensory and autonomic neuropathy type II
affects sensory, sympathetic and some parasympathetic neurones
absence of overflow tears when emotional crying after 7months old
persistent bilateral conjunctival irritation
DVLA rules after stroke
Group 1 drivers: not drive for 1 month
if there are any lingering symptoms post-1 month (visual field loss, cognitive defect, impaired limb function), then need to inform DVLA.
presentation of acute glaucoma
painful red eye
dilated, fixed pupil
anti-depressants now complaining of blurred vision
?cause ?what is happening
TCA has anti-cholinergic effect
cause dilated pupils and blurred vision (due to failure of accommodation)
what is the DaT scan used for?
dopamine active transfer scan
- for parkinson’s disease
what is the difference in timeframe between acute and chronic subdural haemorrhage?
acute: within hours
chronic: in weeks
difference in presentation between progressive supranuclear palsy VS idiopathic parkinson’s disease
supranuclear palsy (vertical) - ie on upward or downward gaze
prominent postural instability with tendency to fall in the first year of disease onset
onset >40yo
gradually progressive
Damage to frontal lobe - ?PC
expressive dysphasia : Broca’s area
motor cortex dysfunction
personality
disinhibition, euphoria, labile mood, apathy
anosmia
incontinence
grasp reflex
Damage to parietal lobe - ?PC
visuospatial, language, sensory
Damage to temporal lobe -?PC
memory
verbal - dominant, non-verbal - non-dominant
personality changes
fugue
receptive dysphasia - Wernicke’s area
Damage to occipital lobe - ?PC
homonymous hemianopia
Damage to cerebellopontine angle - ?PC
ipsilateral deafness
nystagmus
corneal reflex decreased
palsies of CN VII, V
ipsilateral cerebellar changes
Damage to midbrain - ?PC
unequal pupils
inability to move eyes down/up
somnolence
amnesia
hemicrania VS cluster headache
the number of times occuring: hemicrania (multiple times in the day), cluster (usually once a day)
duration of attacks: hemicrania (minutes), cluster (minutes to hours)
treatment: hemicrania (indomethacin), cluster (sumatriptan, oxygen)
Differences between:
- hemiballismus
- chorea
- tic
- Tourette’s syndrome
- akathisia
- athetosis
-
- sudden violent swinging UNILATERAL movement (wild flinging of limbs)
- sudden unintended, uncontrollable, random and flowing jerky movements which fit from one part of the body to another.
- sudden repeated movements/twitches/sounds
- Tourette’s = tic + verbal outburst
- inability to sit still
- slow, writhing, continuous worm-like movement of limbs/trunk
complications of anti-psychotics
(eg haloperidol)
akathisia (cannot sit still, restless legs)
acute dystonia (torticollis, opisthotonus) due to anti-dopaminergic activity-> tx: anticholinergic drugs (procyclidine) or benzodiazepine (diazepam)
parkinsonism (extrapyramidal side effects)
tardive dyskinesia (chewing, grimaces, choreoathetosis)
superior division of MCA of dominant hemisphere affected - what type of dysphasia?
inferior division of MCA of dominant hemisphere affected - what type of dysphasia?
if non-dominant MCA affected -? PC
Broca’s (expressive)
Wenicke’s (receptive)
hemineglect syndrome (not aware of contralateral side - sensation/surroundings etc)
quadriplegic but can communicate only through eye movements - what is damaged?
pons (ie basilar artery stroke)
causes ‘locked in syndrome’
loss of all muscles of face, arm and leg - where is the lacunar stroke?
posterior limb of the internal capsule
(contralateral side)
loss of all sensation to the face, arm and leg - where is the lacunar stroke?
ventral posterolateral (VPL) nucleus of thalamus (contralateral side)
loss of motor and sensory to the face, arm and leg - where is the lacunar stroke?
posterior limb of the internal capsule and thalamus
triggers of transient global amnesia
sex
cold or hot water (in shower)
heavy exercise
may be a correlation with migraine but not CVA
similarities and differences in PC for acoustic neuroma and meniere’s disease
similarities: vertigo, tinnitus, hearing loss, sensorineural deafness
difference: feeling fullness of one ear, facial nerve involvement, loss of corneal reflex
diet-related risk factors for increasing intracranial pressure
vitamin A food-products (including retinoid)
high salt content
high BMI
which migraine treatment cannot be used for patients with IHD?
sumatriptans
anterior part of the spinal cords contain which motor/sensory output sections?
corticospinal (motor)
spinothalamic (pain and temperature
severe headache and vomitting. tx for periorbital cellulitis. tonic clonic seizure. where is the damage?
cevernous sinus thrombosis
what is lateral medullary syndrome?
ipsilateral sensory loss to face
contralateral sensory deficit to trunk
dyaphagia
dysarthria
due to blockage of posterior inferior cerebellar artery
differences in:
schizoid personality disorder
shizoaffective disorder
schizophrenia
schizotypal personality disorder
SPD: prefer to be alone. has isolating behaviour. no weird/magical thinking. not delusional. no psychotic symptoms. has flat affect & no interest in interpersonal relationships.
SD: has psychotic symptoms.
S: triad of: though disturbances, auditory hallucinations and delusions.
SPD: has weird/magical thinking.
Personality disorder - how many types?
3 types:
- odd/eccentric personality (includes schizoid and paranoid PD)
- dramatic, erratic, emotional (includes borderline, histrionic PD)
- anxious (include obsessive-compulsive PD)
what is stellwag sign?
incomplete or reduced blinking
due to Grave’s eye disease/exopthalmos
what are ‘obsessions’?
intrusive thoughts, images or impulses that repetitively and stereotypically enter the person’s mind. patients typically recognise their own thoughts and almost invariably find them distressing (as they perceive them as senseless, obscene, violent or blaspheme) and they unsuccessfully try to resist them. Common themes include aggression, dirt and contamination, fear of causing harm, religion and sex.
unfavourable prognosis for schizophrenia
prolonged premorbid history of social withdrawal
no catatonia
family history in first-degree relatives
insidious onset
MRI changes
stiff spastic tongue and donald-duck speech. brisk jaw action.
?diagnosis
pseudobulbar palsy
Histrionic personality disorder - what is it?
excessive emotionality and attention-seeking behaviour
- quite dramatic and often sexually provocative or seductive
- good social skills but tend to use this to manipulate others and become centre of attention
Antisocial personality disorder -what is it?
Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;
More common in men;
Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
Impulsiveness or failure to plan ahead;
Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
Reckless disregard for the safety of self or others;
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
Special psychiatric diagnosis - what are they??
- De Clerambault’s syndrome
- Fregoli syndrome
- Capgras syndrome
- Othello syndrome
- Cotard’s syndrome
- Ekbom’s syndrome
- Ganser syndrome
- AKA erotomania - delusion of being loved by someone of superior social status. Common in women.
- a familiar person (eg spouse) is falsely identified in strangers.
- a familiar person is supplanted by a stranger who is their exact double.
- delusion og infedility of a spouse or partner. more common in males. recurrent accusations of indefility, searches for evidence, repeated interrogation of the partner, test of partner’s fidelity and sometime stalking.
- nihilistic delusions of their body or self having disappeared. common in women.
- delusion of infestation with insects
- syndrom of approximate answers
40yo healthy presents with recurrent double vision and drooping of eyelids. appeared and resolved without any intervention. occasionally hoarseness and swallowing problems. neuro exam is normal.
?diagnosis
myasthenia gravis
dissociative fugue - what is it?
- purposeful travel beyond the usual everyday range
- maintenance of self-care
- dissociative amnesia
(PS: stupor requires profound diminution of voluntary activities)
Core symptom of depressions?
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
