Nuerology Shelf Exam Flashcards

Question

Preventative migraine therapy for pregnant women

Answer 1

- 1st line: beta blocker (propranolol or metoprolol) | - calcium channel blocker ( verapamil)

Answer 2

Signs: 1. Recurrent severe unilateral headache at peri-orbital, mitosis, ptosis, lacrimation, tearing, rhinorrhea , Conjunctival injection Management: Abortive: - 100% oxygen by face-mask - or subcutaneous sumatriptan ( prevent in: ischemic cardiac disease, pregnancy) Preventative: - verapamil - lithium Timing: - occurs at sleep - progress rapidly for 90 min - up to 8 times daily for 6-8 weeks - period of remission

Answer 3

- treat trigeminal neuralgia Signs: - recurrent & sudden onset, severe, stabbing pain along the V2 (maxillary) & V3 ( mandibular) branches of trigeminal nerve - No miosis

Answer 4

- for temporal arteritis Sign: - age > 50 - headache with localized temporal tenderness - elevated erythrocyte sedimentation rate (ESR)

Answer 5

- used for treatment of deep venous thrombosis (blood clot in vessels of leg)

Answer 6

- autoimmune disease leading to demeylenation of axons in the PNS Signs: - ascending, symmetrical weakness (starts in legs, than spread to arms) - facial nerve palsy - respiratory paralysis - pain can occur - occurs after GI illness Diagnosis: - nerve conduction - cerebrospinal fluid (CSF) via lumbar puncture —> elevated protein + WCC (< 10 million/L) * * albuminocytologic dissociation = elevated CSF protein with normal CSF leukocyte count Risk factors: - viral infection ( CMV, HZV, EBV, HIV) - surgery - upper respiratory tract infection - pneumonia - flu vaccine Treatment: - IV IG

Answer 7

Signs: 1. Mild memory loss 2. Prominent executive dysfunction 3. Focal neurologic deficits

Answer 8

Common cause of stroke in young patients after trauma (fall) or illness Sign: 1. Trauma ( fall) 2. Unilateral headache 3. Neck pain 4. Partial horner syndrome ( ptosis, miosis) 5. Transient ischemic attack ( transient leg weakness) 6. NO tinnitus & NO carotid bruits Risk factors: 1. Trauma or infection 2. HTN, smoking, connective tissue disease (Ehlers Danlos), OCP Diagnosis: 1. CT or MRI angiography Treatment: 1. Within first 4 hours: Thrombolysis 2. After 4 hours: anti-platelet therapy (aspirin)+ anticoagulation 3. For large vessels (MCA): mechanical Thrombectomy

Answer 9

Pathology: 1. Sporadic mutation 2. Combination of UMN lesion + LMN lesion + sensation intact Signs: 1. LMN lesion: - arryflexia - weakness - fasciculation 2. UMN lesion: - hyperreflexia - Spasticity 3. Different limbs will do different things (babiniski is different) 4. Intact sensation Diagnosis: 1. EMG Treatment: 1. Supportive (patient die because all their muscle fail & they can’t breathe) —> use non invasive positive pressure ventilation to improve atalactasis 2. Riluzole (treatment that give patient 3 months to live)

Answer 10

Pathology: 1. Autoimmune disease against Acetyl-choline receptor antibody 2. Someone over 50 Signs: 1. Fatigue ( in the muscle of eyes, throat, and fine movement of distal extremities) - blurry vision - difficulty swallowing - lack of hand coordination 2. Worse in the evening Diagnosis: 1. Antibodies ( Ach-receptor antibodies) 2. EMG ( great amplitude —> fatigue off —> no contraction) 3. CT (look for Thymoma) Treatment: 1. Cholinesterase inhibitors ( to increase Ach) 2. Steroid ( decrease autoimmune or resistance) 3. Crisis (can’t swallow, can’t breathe): IvIg (Plasmapharesis) 4. Thymectomy (remove thymoma)

Answer 11

Pathology: 1. Paraneoplastic syndrome 2. Antibodies against synaptic calcium channel 3. Patient > 50 Signs: 1. Fatigue in proximal muscle (Muscle used the least are the worse) 2. Improvement with use 3. Ex: inability to rise from chair + inability to comb hair + getting things down out of a shelf Diagnosis: 1. Antibodies 2. EMG ( not much contraction —> more attempts —> gets more amplitude) 3. CT (shows small cell lung cancer) Treatment: 1. Treat cancer ( chemoradiation + immunosuppressant) 2. Symptomatic therapy: Guanidine or 3,4-diaminopyridine ( both increase Ach level) 3. Refractory therapy: IvIg or immunosuppressant (Corticosteroid, Azathioprine, 6-Mercaptopurine)

Answer 12

Pathology: 1. Autoimmune disease 2. Demyelination disease Sign: 1. Initial presentation —> Watery diarrhea or flu-shot pain 2. Ascending paralysis (symmetrical) 3. Reach diaphragm = respiratory paralysis 4. Hypo-reflexia 5. Sensory intact Diagnosis: 1. Nerve conduction 2. Lumbar puncture = elevated protein + decreased WCC (<10 million/L) 3. MRI 4. EMG Treatment: 1. Incubation (before LP) 2. IvIG (similar to plasmapharesis) 3. Never give steroid (worsen outcome)

Answer 13

Pathology: 1. Autoimmune disease 2. Demyelinating disorder 3. Young women 20-40 Signs: 1. Any neuro symptoms separated by time & space (relapse then remission) 2. Optic neuritis ( blurred vision + painful eye with movement) Diagnosis: 1st line test: 1. MRI : plaques (opacities) at periventricular white matter (Dawson’s fingers) If MRI was not conclusive —> Less sensitive tests: 2. Lumbar puncture: oligoclonal IgG 3. Evoked potential Treatment: 1. Flare: steroid (high dose IV-steroid for 3-5 days) (IV methyl-prednisolone) - note: plasmapheresis can be performed in patients with MS flare who are refractory to corticosteroid therapy 2. Chronic: - interferon: delay progression - glatiraner - fingolonod 3. Disease modifying therapies: - interferon beta - fumarate - biologics ( natalizumab) 3. Complication: - urinary retention: bethanecol - urinary incontinence: amitriptyline - spasm: baclofen - neuropathic pain: gabapentin (lyrica)

Answer 14

Un-ruptured: 1. Headache, facial pain, third nerve palsy (pupillary dilation, ptosis, down/out eye movement) Ruptured: 1. Thunderclap headache + nuchal rigidity 2. Lead to subarachnoid hemorrhage (SAH) - acute & severe headache + 3rd nerve palsy - vomiting - photophobia - neck stiffness - lethargy

Answer 15

Onset: 1. Neuronal discharge begin in 1 cerebral hemisphere 2. Symptoms: motor (twitching), sensory (paresthesia) , or autonomic (sweating) 3. Structural abnormality (tumor) more likely Categories: 1. No impairment of awareness: - when seizure remains localized to 1 hemisphere 2. Impairment of awareness: - when seizure spreads to the other hemisphere - associated with repetitive automatisms (chewing, picking) - staring + no response to verbal or tactile stimuli Signs: - child - head tilt + repetitive picking - staring + no response to verbal or tactile stimuli - after seizure, postictal confusion, lethargy, postictal paresis/paralysis (TODD paralysis; brief period of temporary paralysis ) Diagnosis: 1. EEG (abnormal electrical activity) vs. interictal EEG (normal) 2. MRI

Answer 16

- generalized (originated from both hemisphere) Signs: - staring spell with/without automatisms (repetitive chewing, picking) - lasts for 10-20 seconds - provoked by hyperventilation - not associated with postictal period

Answer 17

- present in adolescents with myoclonic jerks immediately on wakening - absence & generalized tonic-clonic seizures may be seen

Answer 18

- present by age of 5 - intellectual disability + varying severe seizure (atypical, absence, or tonic) - diagnosis: interictal EEG shows slow spike-&-wave pattern

Answer 19

- sudden, brief movement (grimacing) or vocalization | - intact awareness

Answer 20

- pupil constriction: miosis | - pupil dilation: mydiarisis

Answer 21

- compression of cranial nerve 2 - by aneurysm of internal carotid artery (ICA) or anterior communicating artery (ACA) - signs: unilateral vision loss or bi-temporal hemianopsia

Answer 22

- compression of cranial nerve 3 - by rupture aneurysm of posterior communicating artery (PCA) - signs: ptosis, mydiarisis, dow/out eye

Answer 23

- compression of cranial nerve 4 | - by aneurysm affecting superior cerebellar (SC)

Answer 24

- compression of cranial nerve 6 | - by aneurysm affecting anterior inferior cerebellar artery (AICA)

Answer 25

Signs: 1. Fever 2. Headache 3. Peri-orbital swelling 4. Palsy of CN 3, 4, 6 (opthalmoplegia = weakness of eye muscles)

Answer 26

Caused by: - stroke affecting vertebral artery (VA) or anterior inferior cerebellar artery (AICA) Sign: - contralateral sensory deficit of the extremity - ipsilateral sensory deficit of the face - ipsilateral Horner syndrome

Answer 27

- vascular nerve root compression of V2 & V3 of CN 5 (Trigeminal) as it enters the pons —> leading to demyelination & atrophy of the nerve. - compression is caused by: vascular loop, neoplastic growth or Multiple sclerosis plaque. - demyelinating plaque (EX: Multiple sclerosis) in the pons causes TN Signs: - unilateral - intermittent sharp pain (shock-like stabbing) of cheek & lip - lasts for seconds - 2 min - triggered by minor stimuli (brush teeth, drink cold water, talking, chewing, light touch) - atrophy & demyelination of CN5

Answer 28

Sign: - inflammation & edema of facial nerve (CN7) - unilateral facial paralysis - not pain

Answer 29

Sign: - reactivation of herpes zoster virus - preceded by dermatomal pain - followed by vesicular rash (after several days)

Answer 30

Signs: 1. Preceded by Group A strep. Infection 2. jerky movement (only while awake, not seen in sleeping) (descending & symmetrical limbs) 3. hypotonia 4. Behavioral changes (emotional liability) 5. +/- rheumatic fever 6. Seen in girls Diagnosis: - via GAS testing with throat culture: Antistreptolysin O (ASO) + antideoxyribonueclease B (Anti-DNAse B) titers - investigate Rheumatic fever via: EEG, ECG, inflammatory markers. Treatment: 1. Penicillin G 2. Haloperidol Prognosis: - spontaneous resolution + recurrence

Answer 31

Signs: 1. Symmetrical tremor (vs. asymmetrical in PD) 2. Heat intolerance 3. Palpitation 4. Weight loss

Answer 32

Pathology: - autosomal recessive - accumulation of Copper Signs: - dysarthria, dystonia, drooling, ataxia - parkinsonism (TRAP) - hepatic dysfunction (HEPATOMEGALY) - Kayser-fleischer rings in eye - abdominal pain + neuropsychiatric symptoms related to hepatitis - Before age of 35 Diagnosis: 1. Slit-lamp light: evaluate kayser-fleischer rings 2. Low serum ceruloplasmin 3. Elevated LFT Treatment: - copper chelation therapy

Answer 33

Signs: 1. Facial Port-wine stain (in forehead, eyelids, cheek) 2. Leptomeningeal capillary-venous malformation (angioma of brain & eye) 3. Glaucoma Diagnosis: 1. Glaucoma: via tonometry (shows elevated intraocular pressure)

Answer 34

Pathology: 1. Optic neuropathy: increase IOP 2. Impaired drainage of intraocular fluid Signs: 1. Tearing, Photophobia, Blepharospasm (Excessive blinking due to increase eyelid muscle contraction). 2. Enlarged globe & cornea 3. Optic nerve cupping Diagnosis: 1. tonometry: shows elevated intraocular pressure (IOP) Treatment: 1. Surgery (pediatric = to preserve vision) 2. +/- pressure-reducing eye drops

Answer 35

Signs: 1. Eyelid swelling 2. Erythema 3. Warmth 4. Tenderness Treatment: 1. Oral antibiotics

Answer 36

Signs: 1. Eyelid swelling, erythema, warmth, tenderness 2. Proptosis (eye bulging) 3. Pain with eye movement Treatment: 1. IV antibiotics

Answer 37

Signs: 1. Combination of vocal (throat clearing) & motor ( shoulder shrugging) tics 2. Peaks at age of 10-12 3. Tics exacerbated by anxiety, stress, fatigue Treatment: 1. VMAT 2 inhibitor (tetrabenzine) 2. Antipsychotics (receptor blocker) 3. Alpha 2 adrenergic receptor agonist (guanfacine, clonidine) —> if ADHD presents 4. (+) behavioral supportive therapy

Answer 38

Pathology: - autosomal recessive (CAG repeats) - early onset & later symptoms - loss of GABA-ergic neurons - atrophy of caudate nucleus + putamen Sign: 1. Motor - chorea + delayed saccade 2. Psychiatry: - depression + irritability + psychosis + Obsessive-compulsive symptoms 3. Cognitive: - executive dysfunction Symptoms: -progressive + abnormal movement (chorea)+ dementia+ dystonia + bradykinesia + rigidity+ behavioral change/agitation Diagnosis: - MRI shows atrophy of caudate nucleus + putamen Treatment: - antisense oligonucleotide therapy + supportive + survival 10-20 years

Answer 39

- drug used in treatment of generalized tonic-clonic seizure - slowly taper & discontinue in patient planning pregnancy or with low risk of recurrence - side effect: (fetal hydantoin syndrome; cardiac defect/abnormal facial feature of newborn)

Answer 40

- treatment of seizure - associated with congenital anomalies ( neural tube defect/ spina bifida & dysmorphic facial feature) -

Answer 41

Sign: 1. Headache + vision changes (optic disc edema) 2. Obesity + women + childbearing age Assessment: 1. Suspected increase ICP: - visual acuity/field + funduscopy 2. Papilledema: - evaluate for mass lesion: - CT/MRI - venography: cerebral venous sinus thrombosis 2. Negative imaging: - lumbar puncture: opening pressure > 250 mm H2O+no sign of infection

Answer 42

SIGNS: 1. Positional Headache: (worse when laying flat = increase ICP; Improve with sitting = decrease ICP) 2. Pulsatile tinnitus: (increase vascular pulsation) 3. Blurry vision: increase pressure on optic nerve (due to increase ICP= papilloedema) 4. Increase BMI + Women + pregnancy Diagnosis: 1. MRI/CT or Venography 3. Lumbar puncture Treatment: 1. Weight loss 2. Acetazolamide ( to decrease CSF production)

Answer 43

Pathology: 1. Systolic > 140 or diastolic < 90 2. In pregnant women ``` Signs: 1. Systolic > 140 or diastolic < 90 2. AND proteinuria or end organ damage Symptoms: 1. Headache + Blurry vision in pregnant women ``` Diagnosis: 1. 24 hr urine collection for total protein Complication: 1. Seizure or stroke Treatment: 1. Magnesium sulfate 2. Blood control ( labetalol or nifedipine) ( same as migraine in pregnant women)

Answer 44

Signs: - morning headache - excessive daytime sleepiness - pregnancy + weight gain + obesity - no tinnitus + No papilledema Diagnosis: 1. Polysomnography

Answer 45

Signs: 1. Vertigo/nystagmus (vestibular nucleus) 2. Ipsilateral face loss of pain/temp. (Trigeminal nucleus)+ contralateral body loss of pain/temp (spinothalamic tract) 3. Bulbar weakness (lower cranial nerves) 4. Ipsilateral Horner syndrome (descending sympathetic)

Answer 46

Pathway : 1. Mesolimbic: efficacy 2. Nigrostriatal: extrapyramidal symptoms (acute dystonia, akathisia, parkinsonism) 3. Tuberoinfundibular: hyperprolactinemia (sexual dysfunction & gynecomastia in men; Note: - dopamine inhibits prolactin release from anterior pituitary gland. - antipsychotic (risperidone) causes hyperprolactenimia by blocking dopamine activity in the tuberoinfundibular pathway. Clinical effects of hyperprolactinemia include, amenorrhea, glactorrhea, gynecomastia, & sexual dysfunction.

Answer 47

Seizure Divided into: 1. Epilepsy = have repeated seizure 1. General (entire body) vs. partial (single part) 2. Complex (LOC) vs. simple (no LOC) 3. Atonic 4. Myotonic 5. Absence 2. First time seizure (VITAMINS= RISK FACTORS) 1. Vascular (stroke) 2. Infection (meningitis, encephalitis) 3. Trauma (TBI, Brain bleed) 4. Autoimmune (Lupus) 5. Metabolic (blood glucose, perfusion, shock, O2, Ca, Na) 6. Ingestion/ withdrawal (alcohol, benzodiazepine) 7. Neoplasm 8. Psych

Answer 48

Seizure: 1. LOC + Limb jerking + bowl/bladder incontinence + tongue biting + postictal state (pass out/confused) Syncope: 1. LOC + Limb jerking + bowl/bladder incontinence + tongue biting + NO postictal state

Answer 49

1. Normal MRI | 2. Normal EEG

Answer 50

- Status: 1st time seizure that last > 5 min + failure to go to baseline for > 20 min Steps to stop Status Epileptic: 1. give benzodiazepine (BDZ) (raluzipam) if it does not work, 2. IV- fos-phenytoin if it does not work, 3. Incubated + midozalan + propofol if it does not work, 4. Phenobarbital (drug-induced coma) - EEG (useful during seizure) - vitamins - give anti-epileptic drugs - valproate - lamotrigine - Levetiracetam (COPRA)

Answer 51

1. Atonic - No LOC + loss of tone (fall)/ football helmet - valproate 2. Myoclonic - No LOC + Unnecessary tone (jerking) - valproate 3. Absence - LOC in child + no loss of tone + ADHD + Boy - ethosuccimide 4. Trigeminal neuralgia - carbamazepine

Answer 52

- full on generalized seizure | - can’t find a reason why they have seizure & they are not getting better !!

Answer 53

Dizziness ? 1. sensation of blacking out + pass out + LOC - presyncope vs. syncope 2. Sensation of room spinning + unsteady on feet + no LOC - vertigo

Answer 54

Peripheral vertigo - starts from hearing & balance - tinnitus + hearing loss + No brain stem lesion + No focal neurologic deficit - no imaging is needed Central vertigo - No tinnitus + No hearing loss + brain stem lesion + FND (cerebellar signs) - common + require imaging (MRI) - POSTERIOR FOSSA lesion ( MS, Stroke, tumor, abscess, complex migraine, weird seizure)

Answer 55

BPPV: - PATH: otolith touch hair + brain think you moving - Sign: recurrent/reproducible vertigo + last for < 1 min+ get dizzy with sudden movement - DX: dix-hallpike - TRX epily maneuver (get stone out) Vestibular neuritis = (no hearing loss) (similar to labyrenthitis = have hearing loss) - path: post viral - sign: 4 weeks after URI + vertigo for 1-10 min & +/- hearing loss & +/- N/V - DX: clinical - trx: steroid + meclizine Menier’s disease - path: ? - triad: hearing loss+ tinnitus + vertigo between 30min-1hr. - dx: clinical - trx: salt restriction + thiazide diuretic + meclizine (anti-vertigo drug)

Answer 56

Caused by: - vitamin K deficiency bleeding (VKDB) Sign: 1. first few weeks after birth: - easy bruising + mucosal/GI bleeding 2. 2 weeks-6 months: - intracranial hemorrhage - obstructive hydrocephalus (bleeding block CSF flow= enlarged ventricle= bulging fontanelle & upward gaze movement) - increase ICP ( irritability, vomiting, bradycardia, HTN) Note: - vitamin K activates coagulation factor 2,7,9,10 - vitamin K deficiency increase risk of spontaneous bleeding - intramuscular vitamin K is administered at birth to prevent bleeding

Answer 57

Signs: 1. Lateral ventricular dilation (enlarged ventricle) (obstructive hydrocephalus) 2. Obstruction of CSF flow through 4th ventricle 3. Herniation of cerebellum through foramen magnum 4. Myelo-meningocele

Answer 58

- associated with berry aneurysm | - a rupture that leads to subarachnoid hemorrhage

Answer 59

- cardioembolism (due to atrial fibrillation) lead to embolic stroke. - deficits are maximal at onset (due to rapid occlusion of vasculature) & localized to multiple vascular territories

Answer 60

Bladder dysfunction in children 1. Urinalysis - positive: treat underlying cause (UTI, diabetes) - negative: - night-time symptoms: manage nocturnal enuresis - daytime symptoms: red-flag for spinal cord anomaly ? (1. Neurologic deficits: low extremity weakness + hypotonia + hyporeflexia; 2. Cutaneous lumbosacral abnormality) - yes: do spinal MRI for spinal dysraphism (spina bifida occulta) - no: consider vesicoureteral reflux, constipation, behavioral etiologies

Answer 61

Signs: 1. Lumbosacral dermatologic finding (tuft of hair, dimple, hemangioma, lipoma) 2. LMN signs: lower extremity weakness, hyporeflexia, sensory loss, hypotonia 3. Urinary incontinence, recurrent UTI, constipation Diagnosis: 1. urinalysis 2. MRI of the spine (shows spinal cord tethering) Treatment: 1. Surgical detethering

Answer 62

+ pain + sensory loss L2-L4: - reflux affected: patellar - sensory loss: anteromedial thigh + medial shin - weakness: hip flexion + hip adduction + knee extension (quadriceps) L5 reflux affected: none - sensory loss: lateral shin + dorsum of the foot - weakness: foot dorsiflexion & inversion (tibialis anterior) + foot eversion (peroneus) + toes extension (extensor hallucis & digitorum) S1 reflux affected: achilles - sensory loss: posterior calf + sole + lateral foot - weakness: hip extension (gluteus maximus) + knee flexion (hamstring) + foot planterflexion (gastrocnemius) S2-S4 reflux affected: anocutanous - sensory loss: perineum - weakness: urinary or fecal incontinence + sexual dysfunction Pathology: - nerve compression = due to disc herniation (disruption of annulus fibrosis leads to displacement of the nucleus pulposus & compress nerve root) - signs: acute onset + exacerbated by cough/sneezing - diagnosis of disc herniation: the crossed straight leg raise test (exacerbating of pain with passive lifting of the unaffected leg) (When flexion the extended leg on the unaffected side to around 60° the patient will report the same sharp shooting pain (radicular pain) that they usually experience on the other side. )

Answer 63

1. Eye Opening Response Spontaneously, 4 To speech, 3 To pain, 1 ``` 2. Best Verbal Response Oriented, 5 Disoriented, 5 Inappropriate words, 4 Incomprehensible sounds, 3 No response, 1 ``` ``` 3. Best Motor Response Obeys commands, 6 Localizes pain, 5 Withdrawal from pain, 4 Decorticate flexion, 3 Decerebrate extension, 2 No movement, 1 ```

Answer 64

1. Postural management programme preventing deformities, contractures and pressure sores including muscle tone management through positioning, splinting, mobilising, sitting in alternative seating systems 2. Bladder and bowel management 3. Respiratory care including secretion management, eg suctioning, tracheostomy management 4. Percutaneous endoscopic gastrostomy (PEG) Feeding 5. Management of infections like urinary tract infection, chest infection 6. Management or prevention of medical and neurological complications like seizures.

Answer 65

1. An insult occurred that lead to person LOC FINDING: - depressed cerebral function - brainstem reflexes present = breathing - heart in beating - if they are awake they can move & feel Management: - naloxone to reverse opiate induced coma - thiamine & D50 for hypoglycemia - fluid to support BP - oxygen 1. In order to determine the activity of cerebrum = get EEG

Answer 66

- have sleep-wake cycle—> open eye, can’t communicate, they move, FINDINGS: - no cerebral function (metabolic or anoxic) = no activity - brainstem reflux are intact = person going to breath - heart is beating - motor function intact

Answer 67

1. Pontine stroke 2. Patient is aware & have consciousness Finding: 1. Cerebral function present 2. Brainstem reflex present 3. Heart is beating 4. They can feel, but they can’t move

Answer 68

Findings: - no cerebral function = no brain activity - no brainstem reflux - heart is beating - no motor function Diagnosis: - cerebral function = EEG - brainstem reflux = reflexes - heart = ECG - motor = physical exam Note: - brain death = is absence of brainstem reflexes 1. Corneal reflex 2. Cold water calorics “ Cold=opposite, warm= same” —> quick beating movement of nystagmus —> shoot cold water, eye moves to water, nystagmus beats to other side. —> if no brainstem, shoot cold water, eye does not move vs. persistence vegetative state, shoot cold water, eye move, no beating nystagmus 3. Doll’s eye: move head, eyes are fixed

Answer 69

- vertebral body displacement - occurs gradually within weeks to months - elderly (degeneration) or athletes (overuse injury) - associated with 1. Back pain, followed by 2. Neurologic symptoms

Answer 70

- causes: spinal stenosis + cord compression - signs: neurologic deficits 1. Bilateral 2. Develops over months to years 3. Walking exacerbate symptoms of neurogenic claudication

Answer 71

- autoimmune disease of demyelinating of the CNS SYMPTOMS: 1. Sensory disturbance, motor weakness, bowl/bladder dysfunction 2. Optic neuritis (painful eye movement), internuclear opthalmoplegia (impaired adduction on lateral gaze) 3. Lhermitte sign: electrical sensation on limb or back 4. Uhthoff phenomenon: symptoms worsen with increased body temperature Risk factors: 1. Female 2. HLA DRB1 3. Low vitamin D 4. Epstein Barr infection 5. Geographic location Diagnosis: 1. Episodic/progressive symptoms disseminated over time & space (relapse & remission) 2. Hyperintense lesion on periventricular area on T2 MRI 3. Oligoclonal IgG bands on CSF analysis (lumbar puncture) Note: - non contrast MRI= evaluates disseminated in space (2 brain area involved) - contrast MRI= evaluate disseminated in time (active & chronic lesions) Treatment: 1. Flare: high dose IV steroid (methylprednisolone) 2. Chronic

Answer 72

1. Associated with encephalitis + bell’s palsy

Answer 73

Acute stoke symptoms (hemiplegia + facial droop..) 1. Assessment of ABCs 2. Non-contrast CT of the head + laboratory studies 3. Hemorrhagic stroke: “ prevent further bleeding” - BP control (goal systolic 140-160 mmHg) 1. Nicardipine (iv) 2. Labetalol (iv) - reverse anticoagulation 1. Warfarin = vitamin K, 4 factor PCC 2. Heparin/ LMWH = protamine sulfate 3. Dabigatran = idarucizumab 4. Apixaban, betrixaban, edoxaban, rivaroxaban = andexanet alfa, 4 factor PCC - maintain normal ICP (7-15 mmHg) “reduce risk of brain herniation” 1. Elevate head of bed to 30 degree 2. Keeping neck in neutral position 3. Maintain a normal body temperature 4. Prevent volume overload 5. Sedation 6.Osmotic: Hypertonic saline bolus /mannitol 7. Hyperventilation 6. Decompressive craniectomy 4. Ischemic stroke: 1. Permissive HTN 2. Possible systemic thrombolytics + endovascular thrombectomy

Answer 74

- is given to replete clotting factors in patient with: 1. massive hemorrhage or 2. Reverse the anti-coagulation effect of warfarin (in combination with vitamin K)

Answer 75

- improve oxygen delivery to tissue - occurs in: 1. Massive hemorrhage 2. Hemoglobin < 7 g/dL

Answer 76

Common (peroneal) fibular neuropathy: Risk factors: - immobilization (casts, bedrest) - prolonged leg crossing - protracted squating Signs - foot drop = impaired ankle dorsiflexion & toes extension - impaired sensation (numbness/tingling) over lateral shin & dorsal foot - preserved planterflexion & reflexes Diagnosis: - electromyography (EMG) - nerve conduction studies Treatment: - reduce pressure on the nerve - ankle-foot orthosis splint - physical therapy

Answer 77

Genetics: - autosomal dominant - NF2 gene on chr. 22 - merlin gene ( tumor suppressor) - variable expressivity (at age 20-30) Symptoms: - bilateral vestibular schwannomas - meningioma - spinal tumor (shwannomas, ependymomas) - cataract - cutaneous tumors or skin plaques Tumor surveillance: - audiogram —> initial to screening test to diagnose acoustic neuromas - opthalamologic evaluation - MRI of brain/spine Signs: (of vestibular schwannomas) - bilateral (sensorineural) hearing loss = cochlear nerve -imbalance = vestibular nerve - no vertigo = due to slow tumor growth = compensation -

Answer 78

- thoracic aortic aneurysm repair can cause spinal cord ischemia, especially in the anterior cord Sign: - loss of spinothalamic tract ( pain, temperature, crude touch) - loss of lateral corticospinal tract (UMN) - Loss of anterior horn ( LMN) - level of injury (just above umbilicus = T12) - related to surgery involving aortic aneurysm repair (thoracic aortic aneurysm repair) Symptoms: - distal, bilateral loss of motor control (flaccid paralysis/LMN signs initially, followed by spasticity/hyperreflexia/UMN signs ) - loss of pain, temperature & crude touch sensation in the lower extremities - urinary retention (damage to descending autonomic tract) - intact vibration, proprioception, & light touch ( dorsal column tract) (preserved posterior spinal artery —> vertebral/PICA—> normal perfusion to posterior spinal cord—> intact dorsal column tract)

Answer 79

- develops due to hyper-flexion of neck (during incubation) + cervical spindylosis (degenerative changes in the spine) - greater motor impairment in the upper extremities compared to lower extremities Signs: - loss of pain + temperature sensation of upper extremities - weakness in upper extremities > lower extremities

Answer 80

Sigs: - lower extremities motor + sensory deficits Caused by: - epidural hematoma = puncture of the spinal dura

Answer 81

Pathology: - decrease CSF absorption by arachnoid granulation - NPH is associated with meningitis + subarachnoid hemorrhage - NPH result in periventricular ischemia + increased venous resistance - Extra CSF in the ventricle = ventricles expand to prevent increase ICP = characteristics, ventriculomegaly out of proportion to sulcal enlargement Signs: - gait change ( wide-based + frequent falls) - memory changes (forget familiar places/ can’t recall after 5 min) - urinary urgency - depressed affect (frontal lobe compression) - UMN signs (hyperreflexia/spasticity/ + Babniski/ increase tone) in the lower extremities Diagnosis: - Miller Fisher (lumbar tap) test = improved gait with spinal fluid removal - MRI = enlarged ventricle out of proportion to underlying brain atrophy Treatment: - ventriculoperitoneal shunting

Answer 82

Parkinsons: - bradykinesia + either tremor (pill-rolling) or rigidity (cogwheel) - later: postural instability (falls) + memory impairment - accumulation of alpha-synuclein within dopaminergic neurons NPH: - gait change + memory change + urinary urgency - accumulation of CSF within ventricles + No ICP increase Alzehimer’s: - early memory impairment Later: gait + urinary urgency - accumulation of amyloid plaques

Answer 83

Causes: - dementia - subacute combined degenerative (SCD) with ataxia & inconsistence Signs: - bilateral lower extremity paresthesia - glossitis - macrocytic anemia

Answer 84

Pathology: - when seizure persists for more than 5 min or does not respond to 1st & 2nd line anti-convulsant —> patient is in status epilepticus - untreated SE is fetal or leave patient with severe neurologic problem Management: (goal = get the seizure under control within 30 min) 1. Assessment of ABCs (mask oxygen, pulse oximetry) (incubation is not necessary if oxygenation is good) (if not incubated put patient in the lateral position to prevent aspiration) 2. Obtain finger-stick glucose, CBC, metabolic panel ( Mg, Ca, Na), LFT, ABG, level of anti-convulsant, toxicology screen 3. Two large -bore IV + run maintenance normal saline 4. If patient have no know seizure disorder or definitive etiology —> give: 100mg IV thiamine + 50mL 50% dextrose - note: don’t give dextrose, if finger-stick glucose is in normal range or is elevated 5. Start first line anti-convulsant (Benzodiazepine) - 4 mg IV Lorazepam - OR 10 mg IM Midazolam (or diazepam) - repeat if no response within 30 sec or so 6. If there is no response within 1 min to the 2nd dose of 1st line anti-convulsant —> go to 2nd line anti convulsant - 15-20 mg of Phenytoin equivalent (fosphenytoin) IV at a rate of 150 PE/min - OR 15-20 mg/kg phenytoin IV at rate of 50 mg/ min - NOTE: Exceeding the dose lead to cardiac complication - A further dose of phenytoin (10 mg/kg IV rate 50 mg/min) can be given if continued seizing despite administration of 1st dose 7. Alternative 2nd-line anticonvulsant include: - Levetirazetam - valproate - phenobarbital 8. If patient is not responsive to 1st & 2nd line medication or seizure is not seizing for more than 30 min, incubate patient, and administer general anesthesia - 0.2 mg IV load of Midazolam, then 0.2-0.6 mg/kg/ hr. Infusion - 2 mg IV load of Propofol, then 2-5 mg/kg/hr infusion 9. Patient responded to 1st or 2nd line should get = EEG 10. Non contrast CT scan = after stopping seizure 11. Pre- & post -contrast MRI 12. If patient is still unresponsive & definitive etiology cant be determined = consider-non-convulsant status epileptics (NCSE) - Order 24 Hr EEG ``` Note: Types of atypical status epilipticus: 1. Focal motor status 2. Absence status 3. Partial complex status ```

Answer 85

Early management: 1. Assessment of ABCs 2. Order laboratory tests (CBC, toxic, metabolic panel) - electrolyte disturbance, sepsis, vitamin deficiencies (wernickes encephalopathy), poisoning… 1. Activated charcoal where appropriate 2. 100mg IV thiamine + 50 mL Iv D50W 3. BDZ overdose: 0.2 mg/min IV Flumazenil, 1mg max 4. Opioid overdose: 0.4-2 mg IV naloxone (0.8 mg/ KG/hr infusion) 3. Neurological exam:

Answer 86

1. Medial frontal lobe —> subfalcine 2. Diencephalus —> central herniation into midbrain - shows: cheyne stokes: periods of hyperventilation + apnea alternating - small pupil + reactive = diencephalic pupil - brain stem reflex normal - paratonic = resist exam - symmetric 3. Uncal herniation: - assymetric - dilation of ipsilateral pupil - ipsilateral eye down/out - contralateral motor effect

Answer 87

- loss of frontotemporal neurons - degeneration of frontal/temporal lobes Signs: 1. Progressive dementia 2. Changes in personality/behavior 3. Aphasia

Answer 88

Signs: 1. obese/female 2. headache (worse with recumbent position, at night, after waking up, during straining for bowl motion, heavy lifting) 3.bilateral transient visual changes/loss 4.enlarged physiologic blind spot (Papilledema) - due to bulging optic disc = due to CSF + Increased ICP Treatment: - acetazolamide = reduce CSF production

Answer 89

- painless, rapid, & transient monocular vision loss - caused by retinal ischemia from atherosclerosis emboli - patient have vascular risk factors: smoking, hyperlipidemia

Answer 90

Signs: 1. Corneal edema/cloudiness 2. Fixed/middilated pupil 3. Conjunctival redness 4. Eye pain

Answer 91

Anterior uveitis: 1. Eye pain + redness +photophobia 2. Signs: ciliary flush (perilimal injection) + hypopyon (liquid) Posterior uveitis: 1. Painless + floaters + reduced visual acuity

Answer 92

Type A: - signs: neck pain + headache + ischemic stroke - vertebral artery dissection - affect posterior spinal artery - lead to: loss of vibration/propioception/light touch below lesion + minimal weakness Type B: - signs: bilateral paralysis+loss of pain/temp/crude touch/ urinary retention/ intact vibration - thoracic artery aneurysm - affect anterior spinal artery - anterior spinal cord ischemia

Answer 93

- exposed to hot environment while performing activities Signs: 1. Temperature > 40 2. Altered mental status (confused) 3. Tachycardia, tachypnea, flushing 4. Complication: - rhabdomyolysis - DIC : epistaxis (nose bleed) - End organ dysfunction Management: - patient stabilization (ABCs) - rapid cooling techniques (ice water immersion) - fluid resuscitation - treatment of End organ dysfunction

Answer 94

Signs: - fever - altered mental status - DIC - Neck rigidity

Answer 95

Signs: - fever - altered mental status - N/V

Answer 96

Signs: - anesthesia use (halothane, succinylcholine) - diffused rigidity

Answer 97

Peripheral vertigo: etiology: 1. BPPV (vertigo with head position changes, less than 1 min vertigo + diagnose with Dix-hall-pike maneuver + treated with epely maneuver) 2. Meniere disease (fluctuating hearing loss + episodic vertigo + tinnitus) 3. vestibular neuritis (continuous vertigo w/horizontal nystagmus after URI) 4. Labyrinthitis: continuous vertigo w/horizontal nystagmus after URI + hearing loss + treated with meclizine/motion sickness) nystagmus: 1. Never purely vertical (horizontal or transverse) 2. Inhibition by fixation of gaze 3. Fatigable (<1min duration) 4. Latency period (2-40 sec) Neurologic signs: 1. Hearing loss + tinnitus 2. Preserved walking 3. No CNS Central vertigo: etiology: stroke (cerebral), multiple sclerosis, migraine Nystagmus: - any trajectory (vertical mostly) - not inhibited by gaze fixation - not fatigubale (> 1 min duration) - no latency period Neurologic symptoms: - no hearing loss or tinnitus - severe postural instability (recurrent falls) - CNS signs: headache, diplopia, weakness/numbness of face or limbs, dysarthria Diagnosis: Noncontrast CT of head (evaluation of cerebellar stroke, hemorrhage)

Answer 98

Malignancy: 1. Nocturnal pain 2. Systemic symptoms (weight loss..) 3. Neurologic symptoms (weakness/ hyporeflexia) 4. New onset scoliosis Tethered spinal cord (closed spinal dysraphism) 1. Back/buttlock/leg pain worse with activity & improves with rest 2. Neurologic symptoms: LMN signs (weakness/ hyporeflexia) 3. New onset scoliosis 4. Lumbosacral cutaneous abnormality (lipoma) 5. Muscle atrophy + foot drop + bladder/bowel dysfunction 6. MRI of spine is diagnostic Chronic multifocal osteomyelitis: 1. Nocturnal pain 2. Systemic symptoms Spondylosis & spondylolisthesis: 1. After repetitive trauma (gymnastics) 2. Pain with extension Ankylosis spondolytis 1. Morning stiffness 2. Pain worse at rest 3. Sacroiliac joint tenderness Disc herniation: 1. Due to trauma 2. Lower back pain, worse with flexion, radiated to leg

Answer 99

Acute herpetic neuralgia: 1. Persist < 30 days after skin rash onset 2. Treat: analgesia, NSAIDS Subacute herpetic neuralgia: 1. Persist > 30 days, but resolves within 4 months of rash onset 2. Treat: Analgesia, NSAIDS Post-herpetic neuralgia: 1. Persist > 4 months from rash onset 2. Treat: Gabapentin, tricyclic antidepressant, pregabalin

Answer 100

1) positive confusion assessment method (CAM) - acute onset + fluctuation + inattention + disorganized thinking + altered consciousness 2) History ( pain, trauma, substance use, dehydration, urinary retention) + physical examination ( Vital signs, cardiopulmonary, neurologic, skin) + medication ( opioids, anticholinergic + BDZ) + data ( Complete metabolic panel, LFT, CBC, ECG, Urinalysis) 3) infectious: - culture (urine, blood) + urinalysis - chest xray: hypoxia, crackles - lumbar puncture: meningismus 4) metabolic: - ABC: hypoxia, acidosis - Ammonia: liver failure - TSH: suggestive symptoms (Hyper/Hypo) 5) neurologic: - CT scan/MRI: focal deficits/ anticoagulation - EEG: seizure history - Toxicology screen: suggestive history

Answer 101

1) depression: - SSRI - SNRI 2) fatigue: - modafinil - methylphenidata - amantadine 3) neuropathic pain: - gabapentin —> used for restless leg syndrome (urge to move leg, relief with movement) - duloxetine —> depression/peripheral neuropathy 4) urinary urgency: - oxybutynin - tolterodine 5) spasticity: - beclofen - tizanidine

Answer 102

- long term (> 5 years) use of metformin can lead to vitamin B12 deficiency due to alternating in calcium hemostasis. —> lead to impaired absorption of Vitamin B12 at terminal ileum - signs: 1) megaloblastic anemia (low MCV) 2) lower extremity Paresthesias (myelinated peripheral nerves) 3) impaired vibration/proprioception/light touch & sensory ataxia (dorsal column tract) ( gait impairment that worsen with eye closed —> positive romberg sign) 4) neuropsychiatric changes (Irritability, crying spells) 5) positive babniski sign (lateral cortical tracts)

Answer 103

Parkinson disease: 1. Rest tremor: (occurs at rest, improves with activity) 2. Pill-rolling 3. Affects hands or legs 4. Often asymmetric 5. Associated with rigidity + bradykinesia 6. Drugs: - levadopa - dopamine agonist (pramipexole) - anticholinergic (trihexyphenidyl) Essential tremor: 1. Action tremor (occurs with activity) 2. Hands, head, voice 3. Usually bilateral 4. Associated with: family history, improves with alcohol 5) drugs: - propranolol - primidone

Answer 104

Pathology: 1. Autosomal dominant 2. Disorder of heme pathway 3. Reduced activity of porphobilinogen deaminase Triggers: - alcohol, tobacco - progesterone containing drugs - surgery, fasting Signs: 1. Abdominal pain 2. Weakness of proximal upper extremity + areflexia 3. Autonomic dysfunction (hypertension, tachycardia, diaphoresis, tremor) 4. Neuropsychiatric symptoms ( hallucination, anxiety, psychosis, restlessness) 5. Red-tinged urine that oxidize with light/air exposure Diagnosis: 1. Elevated serum & urine: PBG, ALA, porphyrins 2. +/- hyponatremia, elevated transaminases 3. Positive urobilinogen Management: 1. Glucose & hemin (heme analogue)

Answer 105

Signs: 1. Abdominal pain 2. Neuropsychatric symptoms 3. Anemia 4. Joint pain 5. Fatigue

Answer 106

Pathology: - autosomal recessive - GAA repeat - abnormal frataxin protein (expressed in brain/heart/pancreas) Lead to: - neurologic dysfunction (brain) (dysarthria, nystagmus, loss of DTR, Progressive gait & limb ataxia in adolescent) - cardiomyopathy (heat) (age of death 30-40) - diabetes (pancreas) Signs: 1. Kypho-scoliosis 2. Hypertrophic cardiomyopathy 3. High arch (pes cavus + hammer toes) Symptoms: 1. Dorsal column: loss of vibratory/proprioception/light touch 2. Dorsal root ganglion: decrease DTR 3. Lateral corticospinal: spastic weakness 4. Spinocerebellar: ataxia Diagnosis: 1) genetic testing Management: 1) physical therapy 2) support

Answer 107

Pathology: - autosomal dominant - Signs: 1) rash: - cafe au lait macules (chest/ arm) - freckles at axillary & groin - neurofibromas (thigh) 2) scoliosis (spinal cord vertebrae) 3) pseudoarthrosis (long bones, tibia) 4) optic glioma (eyes) 5) Lisch nodules (eyes) (iris hemartoma) Symptoms: 1) headache (worse in the morning, due to increase ICP while laying supine at night) 2) decrease visual acuity 3) seizure + intellectual disability Increase risk for: - intracranial mass —> assess with MRI of brain/eye - astrocytoma - brainstem glioma

Answer 108

1. Rule out: meningitis or encephalitis 2. Carry risk for brain herniation 3. Should be considered only if brain imaging excludes space-occupying mass, which should be suspected in patient with morning headache

Answer 109

Signs: 1. Burning pain 2. Paresthesia 3. Ataxia 4. Stock-glove pattern 5. Loss of DTR + light touch + vibration senses

Answer 110

Motor deficits: 1. anticholinergic drugs (trihexyphenydil) 2. Amantadine 3. Dopamine agonist (pramipexole) 4. MAO-inhibitor 5. COMT inhibitor 6. Levadopa Mood/anxiety: - SSRI - SNRI Psychosis: - anti-psychotic agents ( pimavanserin, quetiapin) - cholinsterase inhibitor (donepezil) Sleeping disturbance: - melatonin - trazodone - quetiapin - mirtazapine Cognitive impairement: - acetylcholinesterase inhibitor (donepezil) - NMD receptor antagonist ()

Answer 111

1. Tension-like headache: - worsen by stress - bilateral & band-like pain - no visual changes 2. Cluster headache: - unilateral & orbital or temporal pain - associated with ptosis, miosis, & lacrimation - no blurry vision - resolution of symptoms (<3 hrs)

Answer 112

1. Frontotemporal dementia: - Early personality/ behavior changes - late memory deficit - manifest around age 60 (earlier than AD) 2. Dementia with lewy body: - dementia + Parkinsonism ( together) - visual hallucination & REM-sleep behavior disorder 3. Normal pressure hydrocephalus (NPH): - early gait change (broad base/shuffling) + memory change + urinary urgency 4. Vascular dementia: - stepwise decline is classic - early deficits in executive function > memory deficit - cerebral vascular disease ( atherosclerosis, arteriosclerosis, cerebral amyloid angiopathy) - Ex: rapid development of memory loss, executive dysfunction, & behavioral changes (apathy, paranoia, social withdrawn) 4 months after a stroke - treatment: control HTN/diabetes + anti platelet + cholinesterase inhibitors 5. Alzheimer disease: - early anterograde memory loss (immediate recall affected, distant memory preserved), late behavioral/personality changes - visuospatial deficit (lost in own neighborhood) - language difficulties (difficulty finding words) - cognitive impairment with progressive decline - Late findings: 1. Hallucination, wandering 2. Difficulty performing learned motor task 3. Urinary urgency 4. Personality/ behavioral change

Answer 113

Duchenne muscular dystrophy (DMD): 1. X-linked recessive 2. Deletion of Dystrophin gene 3. Age 2-3 4. Signs: proximal muscle weakness (Gowers sign) + calf pseudohypertrophy 5. Associated with: cardiomyopathy + arrhythmia + scoliosis 6. Adolescent in wheelchair + death by age 20-30 from respiratory or heart failure Becker muscular dystrophy (BMD): 1. X-linked recessive 2. Deletion of Dystrophin gene 3. Age 5-15 4. Signs: milder proximal muscle weakness compared to DMD 5. Associated symptoms: cardiomyopathy + arrhythmias 6. Death by age of 40-50 due to heart failure Classic myotonic: (muscle pain, wasting, delayed relaxation) 1. Autosomal dominant 2. Trinucleotide in DMPK gene (CTG repeat) 3. Age 12-30 4. Signs: Facial & distal muscle atrophy + Grip (hand) myotonia 6. Associated with: cardiomyopathy, arrhythmia, dysphagia, cataract, testicular atrophy 7. Death from 45-55 due to respiratory or heart failure

Answer 114

1. Shuffling gait as seen in Parkinson disease

Answer 115

Type of cerebellar ataxia: 1. Lesion of the vermis = truncal ataxia 2. Lesion of the cerebral hemisphere =limb ataxia Type of ataxia: 1. Staggering & swaying from side to side

Answer 116

- spastic ataxia - the gait appears stiff or rigid with circumduction ( the spastic leg leg is abducted & advanced while in extension & internal rotation) & planter flexion of the affected limb.

Answer 117

- gait apraxia ( Bruns ataxia) - seen in normal pressure hydrocephalus (NPH) - Strength, coordination, & sensory function are intact, but difficulty initiation of forward movement of the feet, when they are in contact with the ground (magnetic gait)

Answer 118

- slap gait - gait instability + wide-based gait - patient may stomp their feet against the floor (slap gait) to help them know where their lower limbs are relative to the ground

Answer 119

- high steppage gait due to foot drop | - patient flex hip & knee to raise the foot & avoid dragging the toe with each step

Answer 120

L5 radiculopathy: 1. back pain 2. Weakness in eversion + dorsiflexion Peroneal neuropathy: 1. Compression of nerve at head of fibula 2. Due to crossing/squatting 3. Paresthesia + sensory loss over dorsum of foot 4. Normal foot inversion + planter flexion (tibial nerve) Diagnosis: 1. EMG 2. Nerve conduction studies

Answer 121

- vestibular gait - unsteady, falling to one side - normal sensation, reflexes & motor strength - Nausea - vertigo

Answer 122

High- risk factors: require CT to rule out intracranial hemorrhage 1. Altered mental status 2. LOC 3. Trauma 4. Headache + vomiting 5. Basilar skull fracture ( raccoon+ battle signs/ CSF & blood from nose) Resolved high-risk: require 4-6 hrs observation - no altered mental status + no signs of basilar fracture + resolved high-risk symptom (vomiting) Low-risk: discharge home

Answer 123

- focal dystonia of (sternocleidomastoid) muscle - sustained muscle contraction resulting in twisting, repetitive movement, or abnormal posture - discontinue of causative agent= improvement

Answer 124

- brief, irregular, unintentional muscle contraction | - movement tend to flow from one to another but are not repetitive or rhythmic

Answer 125

- sensation of restlessness that causes the patient to move frequently

Answer 126

- refers to slow, writhing movement that affects the hand & feet - occurs in Huntington disease ( + chorea)

Answer 127

- unilateral, violent arm flinging - caused by damage to the contralateral sub-thalamic nucleus - disruptive & self-limited

Answer 128

- involuntary jerking movement - rhythmic or patterned ( opposite to chorea) - initiated by contraction or relaxation

Answer 129

Caused by: - repetitive shaking of the baby (acceleration-deceleration) forces lead to subdural bleeding (hematoma) due to shearing of the bridge veins & coup-contecoup injury Signs: - seizure (tonic-clonic) - increasing head circumference - bulging/tense anterior frontanelle - papilledema (blurred optic disc margin) - retinal hemorrhage

Answer 130

- shows in premature babies, in the first few days - lead to hydrocephalus ( obstruction of CSF flow) - shows seizure + bulging fontanelle

Answer 131

Etiology: 1. Genetic mutation causing loss of photoreceptors 2. Progressive retinal degeneration 3. Symptoms onset from age 10 through adulthood Feature: 1. Night blindness 2. Progressive visual field loss ( mid-periphery defect/ high density of rod) 3. Decrease visual acuity (late finding) Fundoscopic finding: 1. Retinal vessels attenuation + optic disc pallor + abnormal retinal pigmentation Prognosis: - legally blind by age of 40 Treatment: 1. Measure to slow disease progression = omega-3 fatty acid

Answer 132

Signs: 1. Excessive dryness of cornea + conjunctiva 2. Night blindness

Answer 133

Signs: 1. Acute vision loss 2. Floaters 3. Flashes of light Fonduscopic finding: 1. Retinal tear &/or elevation

Answer 134

Signs: 1. Painless peripheral vision loss ( in late adulthood) 2. Otic disc cupping

Answer 135

Ischemic stroke: 1. Symptoms + non/contrast CT of head (consistence) Time since symptoms onset: 1) <4.5 hr: give thrombolysis (tPA) 2) > 4.5 - 24 hrs: not eligible for Thrombolysis - obtain CT angio of head/neck * ) large vessel occlusion: mechanical thrombectomy * *) absent of large vessel occlusion: antiplatelet therapy: aspirin/clopidogrel + investigate for embolic source 3) > 24 hrs: not eligible for thrombolysis - standard post-ischemic stroke management (anti-platelet therapy: aspirin/clopidogrel + investigate for embolic source) NOTE: - When ischemic stoke causes massive cerebral edema & hemorrhagic transformation = malignant hemispheric infarction (MHI)

Answer 136

initiate: - Anti-platelet therapy To rule out AF: - ECG - telemetry Long-term stroke prevention: - oral anticholinergic: 1) rivaroxaban 2) apixaban 3) warfarin

Answer 137

Signs: - urge to move leg - Discomfort improves with movement (dysesthesia) - Discomfort increase at rest/night Associated with: 1. Pregnancy 2. Iron deficiency 3. Diabetes 4. Uremia 5. PD & MS 6. DRUGS: antidepressant, antipsychotics, antiemetics Treatment: - iron supplement (if ferritin < 75 ng/mL) - mild symptoms/ intermittent: carbidopa-levadopa - frequent symptoms: gebapentin or pregabalin (calcium channel blockers) - avoid (dopamine aginists: pramipexole or ropinirole)

Answer 138

- common in pregnancy Signs: - numbness - motor weakness - not immediately relieved with movement - pain is burning & shock-like

Answer 139

Scenario: - child with refractory epilepsy + development delay + subependymal nodule + hypopigmented macules Pathology: - autosomal dominant - mutation in TSC 1 or TSC2 gene (inherited or de novo) - lead to benign tumors (hemartomas) of brain, skin & other organs Feature: 1. Dermatology: - ash-leaf spots - angiofibromas of malar region (facial) - shagreen patches 2. Neurologic: - CNS lesions ( subependymal tumors/nodules) - epilepsy (infantile spasm, tonic-clonic) - intellectual disability / development delay (in refractory epilepsy) - autisms or behavioral disorder (hyperactivity) 3. Cardiovascular: - rhabdomyomas 4. Renal: - angiomyolipomas (benign tumor of kidney: anemia, fever, pain or HTN) Surveillance: - regular eye & skin examination - serial MRI of brain & kidney - serial ECG & baseline Echo - baseline EEG - neuropsychatric screening

Answer 140

Cuased by: - bilateral temporal lobe lesion - especially in, hippocampus & amygdala Signs: 1. Excessive touching + hyper-sexuality 2. Bulimia 3. Placidity 4. Visual agnosia 5. Amnesia

Answer 141

- lead to “locked-in syndrome” - signs: qaudraplagia + inability to speak + inability to swallow + able to blink & move eyes vertically + conscious preserved

Answer 142

- sings: 1. Decrease sensation & motor of arms + Sparing of legs + bladder dysfunction 2. Neck pain + stiffness 3. Caused by Hyperextension (falling, whiplash) 4. Seen in elderly with cervical spondylotic myopathy

Answer 143

Signs: 1. Loss of pain/temperature (1-2 levels below injury level) 2. Bilateral hemiparesis (at injury level) 3. Intact vibratory/proprioception/light touch

Answer 144

Signs: 1. Increasing forgetfulness 2. Low energy + motivation 3. Sleep disturbance 4. Psychomotor retardation (slow speech, thinking, movement)

Answer 145

MDD vs. AD: - in AD (dementia + apraxia + agnosia + aphasia) 1. aphasia: loss of the ability to understand and express speech. 2. agnosia: inability to recognize people, objects, sounds, shapes, or smells. 3. apraxia: inability to have purposeful body movements. - in AD, patients are less concern about their memory loss + brought by family member for evaluation

Answer 146

Pathology: - disruption of CSF drainage from the central canal - formation of fluid-filled cavity (syrinx) that compress surrounding tissue - seen with: 1. Arnold -chiari type 1 malformation (extension of the cerebellar tonsils into foramen magnum) 2. Meningitis 3. Inflammatory disorder 4. Tumor 5. Tumors Signs: - symptoms can present after months to years after incident - involves the cervical or thoracic spine - upper extremity loss of pain/temperature (cape-like) - upper extremity intact vibratory/proprioception/light touch - if syrinx is enlarged = lead to flaccid paralysis/ weakness + central pain + urgency + lower extremity Diagnosis: - MRI shows intra-medullary cavity filled with CSF Management: 1. Surgical intervention (shunt placement)

Answer 147

Infant botulism - ingestion of C.botulinum spores (from environment/ construction work/ honey) - sign: descending flaccid paralysis - treat: human-derived botulism immune globulin + respiratory support + nasogastric tube feeding - signs: bilateral bulbar palsies ( ptosis, sluggish pupillary response to light, poor suck & gag reflexes) + followed by descending flaccid paralysis (hypotonia) + constipation & drooling (autonomic dysfunction) Food-brone botulism - ingestion of preformed C.botulinum toxin (canned food) - descending flaccid paralysis + N/V + Abdominal pain + diarrhea - treat: equine-derived botulism antitoxin Guillain-Barre syndrome - autoimmune demyelination of PNS - ascending flaccid paralysis + to the rest of the body - treat: pooled human-immune globulin

Answer 148

- seen in MS - caused by conjugate horizontal gaze - the ipsilateral eye (to the damage of MLF) can’t be adducted & the contralateral eye to the MLF damage can be abducted with horizontal nystagmus - preserved convergence & reactivity to light Note: - unilateral MLF = seen with lacunar stroke in the pontine artery distribution - bilateral MLF = seen with multiple sclerosis

Answer 149

- preganglionic parasympathetic | - damage to EWN= ipsilateral fixed & dilated pupil that is un-reactive to light or accommodation

Answer 150

- ptosis, diplopia, dysphagia

Answer 151

- Located in thalamus - rely information to ipsilateral primary visual cortex - damage= contralateral homonymous hemianopsia

Answer 152

- damage to ML = contralateral loss of vibration, proprioception, and light touch

Answer 153

Oclumotor (3) nerve palsy: - mydriasis (dilated pupil), ptosis, down/out Trochlear (4) nerve palsy: - vertical diplopia + worsen when affected eye looks down/towards the nose (ex: walking downstairs, reading) Abducens (6) nerve palsy: - inability to abduct the eye

Answer 154

- damage of OC= bitemporal hemianopsia - occurs with anterior communicating artery aneurysm or tumor with the sella turcica ( craniopharyngioma or pituitary adenoma)

Answer 155

- a lesion of ON = optic neuritis | - result in monocular vision loss

Answer 156

- well articulated, non-sensical speech & lack of language comprehension - word salad type of speech - seen with wernicke aphasia (located in the caudal superior temporal gyrus of the dominant temporal lobe) - caused by = infarcts at the inferior division of the MCA

Answer 157

- speech is halted & non-fluid - caused by= infarct at the superior division of MCA - located at the superior region of frontal lobe = broca’s area - usually seen with contralateral hemiparesis (due to involvement of primary motor cortex)

Answer 158

- produce cranial nerve dysfunction - lead to dysarthria (motor speech disorder leading to difficulty producing sounds) - does not lead to aphasia (disorder of language processing)

Answer 159

Etiology: 1. AVM ( isolated or associated with hereditary hemorrhagic telangiectasia/HHT) 2. Aneurysm 3. Sickle cell disease or hemophilia Signs: 1. Headache + vomiting 2. Seizure 3. Focal neurologic deficits (contralateral hemiparesis) 4. Altered mental status (somnolence) 5. HTN —> due to increased ICP Imaging: 1. Head CT: intraparenchymal, intraventricular or subarachnoid hyperdense fluid collection with irregular margin Management: 1. Supportive (anti-epileptics) 2. Reduction of ICP (elevated head of bed, surgical decompression)

Answer 160

- cerebellar mass presents with increased ICP | - signs: morning headache + vomiting + ataxia + poor coordination

Answer 161

Pathology: - (CGG) repeats expansion of FMR1 - gene methylation silences FMR gene - X-linked dominant Feature: - developmental delay + intellectual disabilities - ADHD + autism - anxiety - self-harming behavior (hand biting) Findings: - long faces with prominent forehead + chin - large, protruding ears - macroorchidism (age > 8) (large testes) - macrocephaly + hypotonia - joint hypermobility (finger, wrists) Diagnosis: - FMR1 DNA analysis (PCR or southern blot) Management: - normal life expectancy

Answer 162

Signs: - joint hyper-mobility - increase risk of aortic root disease

Answer 163

- progressive brain deterioration - microcephaly - development regression - most common in girls (MECP2 mutation ) - mutation is fetal in boys

Answer 164

Feature: - transient neurologic disturbance ( dizziness, disorientation, amnesia ) following a TBI - no structural intracranial injury - signs: headache + vomiting + dizziness + slurred speech + incoordination + LOC Management: - rest for > 24 hours - gradual return to activity: 1) aerobic exercise —> non-contact sport —> contact sport 2) limited screen time + shortened school day + frequent breaks

Answer 165

Signs: - unsteady gait - electric shock sensation in the spine - upper limb weakness + atrophy (LMN lesion) - lower extremity tone/reflexes increased ( UMN lesion) - bowel/bladder incontinence Note: - myelopathy —> elderly —> cervical spondylosis (spinal canal narrowing due to formation of osteophytes in the lateral vertebral body or ossification of the posterior longitudinal ligament/ ligamentum flavum) - history of fibromyalgia + shoulder/neck pain

Answer 166

Triggers: 1. Diabetes 3. Long standing HIV infection 4. Uremia 2. Medication: flouroquinolones & metronidazole ( 2 months of use) 5. Chemotherapy: cisplatin 6. Toxicity: alcohol, heavy metal 7. Others: digoxin, amiodarone, dapsone Etiology: - damage to distal sensory peripheral nerve axons Features: - symptoms begins in toes/feet: progress proximally over time —> in stock-glove distribution (2-3 wks) - distal numbness/tingling/ pins & needle sensation - decrease in pain, temperature, vibration sensation - decrease ankle & babniski reflexes Treatment: - pain management: 1) gabapentinoid 2) Tricyclic antidepressant 3) duloxetine 4) capsaicin cream

Answer 167

Pathology: - fetal disease caused by abnormally folded protein (prion) Features: 1. Rapidly progressive dementia 2. Myoclonus ( provoked by startle) 3. Cerebellar signs (ex: ataxia) 4. Upper motor neuron signs ( ex: hyperreflexia) 5. Extra-pyramidal signs (ex: hypokinesia) 6. Mood/sleep disturbance Findings: - MRI shows: 1. Widespread atrophy of cerebral or cerebellum 2. Enhancement of putamen or caudate head (hockey stick sign) 3. Enhancement of cortical ( cortical ribboning) - CSF: normal routine analysis (non-inflammatory), positive 14-3-3 protein titers, positive RT-QuIC test - EEG: Tri-phasic, synchronous discharges - Neuropath: spongiform degeneration without inflammation Management: 1. Fetal in < 12 months

Answer 168

Pathology: - autosomal dominant - mutation in VHL gene in chromosome 3 Feature: 1. Cerebellar/ CNS & retinal hemangioblastoma - decrease visual acuity due to edema or distortion of retina - bleeding from tumor leads to retinal detachment + glaucoma + vision loss 2. Renal cell carcinoma ( clear cell type) 3. Pheochromocytoma 4. Light -brown facial patches (cafe au lait) Management: 1. Eye/retinal examination 2. MRI of brain + spine + abdomen 3. Plasma or urine metanephrines 4. Tumor resection Note: - Bilateral retinal hemangioma + family history of adrenal tumor = VHL disease

Answer 169

Signs: - one/side neck & shoulder pain - numbness + decrease pinprick sensation in forearm - worse with neck movement - refractory to pain killer - limited neck rotation + limited lateral bending

Answer 170

1. Strain - neck injury - pain/stiffness with neck movement 2. Facet osteoarthritis - older patient - pain/stiffness worse with movement - relieved with rest 3. Radiculopathy (cervical disc herniation or cervical spondylosis) in elderly - pain radiates to shoulder/arm - dermatomal senory/motor/reflex finding - positive spurling test 4. Spondylitic myelopathy - lower extremity weakness + gait change + bowel/bladder dysfunction - Lhermitte sign 5. Spondyloarthropathy - young men - HLA- B27 - relieved with exercise - prolonged morning stiffness Spinal metastasis: - constant pain - worse at night - not responsive to position changes Vertebral osteomyelitis: - focal tenderness - fever & night sweat - intravenous drug use, recent infection, immune compromised

Answer 171

Risk factors: - obesity, pregnancy, medication ( retinoid/vitamin A, tetracycline, growth hormones) Signs: - headache, n/v, visual changes, neck pain, back pain Findings: - elevated opening pressure (LP) (> 250 mm H2O) - papilledema/enlarged blind spot - MRI to rule out tumor - MRI venography to rule out venous thrombosis Management: - weight loss - carbonic anhydrase inhibitor ( topiramate, acetazolamide) - shunting or optic nerve sheath fenestration

Answer 172

- When ischemic stroke causes cerebral edema & hemorrhagic transformation - signs: 1. Rapid neurologic deterioration (obtundation, eye deviation) 48 hours after ischemic stroke 2. Cerebral edema: lead to brain herniation due to increased ICP 3. Hemorrhagic transformation: blood go from injured blood vessels into brain parenchyma Diagnosis: - repeated non-contrast CT of head Management: - decompression hemicraniectomy

Answer 173

Associated conditions: 1. Chronic alcoholism (most common) 2. Malnutrition (Anorexia nervosa) 3. Hyperemesis gravidarum Pathology: - thiamine deficiency (vitamin B12) Feature: - encephalopathy (confusion) - oculomotor dysfunction/opthalamoplegia (horizontal nystagmus & bilateral abducens palsy) - postural/gait ataxia Treatment: - vitamin B1 (thiamine) followed by Iv glucose

Answer 174

Pathology: - immune mediated destruction of spinal cord - often post-infection Feature: 1. Bilateral weakness: initially flaccid (LMN), followed by spastic (UMN) 2. Bilateral sensory dysfunction 3. Distinct sensory level 4. Bowel/bladder dysfunction Diagnosis: - MRI of spine: no compressive lesion, increased T2 signal (hyper-intensity) in the cervical spinal cord (spinal cord edema !!) - Lumbar puncture: increase WBC, increase IgG index (evident of inflammation) Treatment: - high-dose IV glucocorticoids - plasmapheresis

Answer 175

- second leading cause of intracerebral hemorrhage, after HTN in adults - lobar in location - signs: 1. Patient > 75 2. Abnormal beta-pleated amyloid protein deposition In cerebral blood vessel —> lead to arteriopathy & vessel fragility ``` Findings: - MRI shows 1. Initial: multiple small foci of prior hemorrhage (microbleed) - non-contrast CT shows: 1. Lobar Hemorrhage (hyper-dense) ```

Answer 176

- weakness in wrist extension + numbness in forearm & thumb

Answer 177

- weakness in triceps extension & wrist flexion + numbness in index & middle finger

Answer 178

Cerebral cortex: (astrocytoma, 1. Headache + seizure + focal neurologic deficits ( hemiparesis /speech problem) 2. Increase ICP signs (morning headache, vomiting, papilledema) Brainstem: (brainstem glioma, craniopharangioma, optic glioma, pinealoma) 1. Cranial nerve deficits 2. Ataxia + poor coordination Posterior fossa: (cerebellar astrocytoma + medulloblastoma, infratentorial ependyndoma) 1. Increase ICP signs (morning headache, vomiting, papilledema) 2. Ataxia + poor coordination

Answer 179

Symptoms: 1. Systemic: fever, weight loss, fatigue, malaise 2. Headache 3. Jaw claudication 4. Polymylagia rheumatica (muscle pain/stiffness of shoulder + hip) 5. Visual disturbance: amaurosis fugax + anterior ischemic optic neuropathy (vision loss) 6. Age > 50 Diagnosis: 1. Normochromic anemia 2. Elevated ESR & CRP 3. Temporal artery biopsy Treatment: 1. Polymyalgia rheumatica only: low-dose oral glucocorticoids ( prednisone 10-20 mg daily) 2. Giant-cell arteritis: intermediate-high dose of oral glucocorticoid (prednisone 40-60 mg daily) 3. Giant cell arteritis with vision loss: Pulse high-dose IV glucocorticoid (methylprednisolone, 1000mg DAILY) for 3 days, followed with intermediate-high dose of oral glucocorticoids. Note: ** to prevent blindness = treatment with systemic glucocorticoid should not be delayed while awaiting for temporal artery biopsy

Answer 180

- if patient have type of a headache (migraine, or cluster headache …) - have a new onset of headache that is different in characteristic + increase ICP signs (morning headache + vomit + papilledema) - immediately evaluate with MRI of brain

Answer 181

Diplopia + ptosis (motor fibers/ paralysis of levator palpebrea superioris)+ mydriasis (parasympathetic fibers/sphincter papillae muscle) + impaired adduction/impaired lateral gaze (opthalamoplegia) Caused by: 1. Aneurysm, tumor ( mass effect) = non-pupil sparing CN 3 2. Microvascular ischemia (diabetes, HTN, hyperlipidemia, advanced age) = pupil-sparing CN3 Diagnosis: 1. MRI or CT angio

Answer 182

Etiology: 1. Small penetrating artery occlusion due to HTN arteriolar sclerosis 2. Combination of microatheroma formation + lipohyalinosis that ultimately leads to thrombotic small-vessel occlusion Affected areas: 1. Basal ganglia 2. Subcortical white matter ( internal capsule, corona radiata) 3. Pons Risk factors: 1. HTN Signs: 1. Absence of: - cortical signs ( aphasia, agnosia, neglect, apraxia, hemianopia) - seizure - mental status changes - CN deficits 2. Common syndromes: - pure motor hemiparesis (common) - pure sensory stroke - ataxic hemiparesis - dysarthria- clumsy hand syndrome Diagnosis: - usually not seen on non-contrast CT scan after incident

Answer 183

- trauma - Lead to ischemic stroke due to thromboembolism or hypo-perfusion Signs: 1. Neck pain 2. Partial Hornor syndrome ( ptosis + miosis)

Answer 184

- occurs in patients with hyper-coagulable state ( pregnancy, malignancy) Signs: - headache - seizure - altered mental status - increased ICP - Focal/diffused neurogenic defects - CT shows: cerebral edema, venous infarction, areas of hemorrhage

Answer 185

-large -artery occlusion causes more severe symptoms than small-artery occlusion (lacunar stroke) Signs: - contralateral homonymous hemianopsia - hemiparesis - hemisensory loss - seizure - altered mental status - cortical signs

Answer 186

Epidemiology: - staph aureus - HIV, Diabetes, alcohol, elderly - distant infection, spinal procedure, injection drugs Signs: - triads: fever + back pain + neurologic sign ( sensory/motor deficits, bowl/bladder dysfunction, paralysis) - increase ESR Diagnosis: - MRI of spine with contrast - blood & aspirate culture Treatment: 1. broad-spectrum antibiotics (vancomycin + ceftriaxone) 2. Urgent aspiration/ surgical decompression

Answer 187

Encephalitis: - inflammation of the brain - signs: 1. Acute onset of focal neurologic findings ( altered mental status, focal CN deficits, ataxia, hyperreflexia, focal seizure) 2. Fever 3. Confusion + strange Behavioral (hypomenia, hyperphagia, hypersexuality, amnesia) 4. CSF: - lymphocytic pleocytosis ( increase erythrocyte, increase protein) 5. Temporal lobe lesion seen with HSV ENCEPHALITIS Meningitis: -inflammation of the meninges that surrounds the brain & spinal cord

Answer 188

Note: estrogen- containing OCP is contraindicated in patients with migraine with aura due to increase risk of ischemic stroke Signs: - unilateral throbbing headache - associated with photophobia, phonophobia, N/V - lasts 4-72 hours - symptoms of aura: 1. Visual ( wavy lines, visual loss) 2. Sensory ( paresthesia, numbness) 3. Auditory ( sounds, hearing loss) 4. Motor dysfunction ( tremor, weakness) Increase risk factor: - migraines are associated with ischemic stroke - the risk increases with the use of Estrogen-containing OCP—> should be discontinued

Answer 189

Parkinsonian: 1. Parkinson disease, dementia with lewy body, vascular dementia, multiple system atrophy 2. Narrow-based + shuffling gait ( reduced stride length Weakness with spasticity 1. Myelopathy 2. UMN lesion (spinal cord injury, cerebral palsy) 2. Narrow-based + scissoring + toes scrape the floor Myopathic 1. Myopathies , myasthenia gravis 2. Waddling, abnormal pelvic tilt (limb gridle weakness) Magnetic 1. Normal pressure hydrocephalus 2. Difficulty initiating steps ( move slowly + wide base + several step to turn around) Vestibular: 1. Benign positional paroxysmal vertigo, meniere disease 2. Stumbling or veering to one side ( usually the affected side) Cerebellar ataxia: 1. Stroke, drug toxicity, alcohol, hereditary 2. Wide-based + stumbling, lurching + maybe one side of bilateral depending on etiology Sensory ataxia: 1. Sensory neuropathy, B12 deficiency 2. Wide-based + high-stepping/ stamping + worse in the dark

Answer 190

Etiology: - unconjugated bilirubin crosses BBB - deposits in basal ganglia & brainstem nuclei (neuronal damage, atrophy, necrosis) Signs; 1. Hyperkinetic movement (chorea, dystonia) 2. Hearing loss (sensorineural) 3. Gaze abnormality

Answer 191

Signs: 1. Early postural instability (falls) 2. Early autonomic dysfunction ( orthostatic, urinary urgency) 3. Ataxic gait

Answer 192

- caused by decrease lithium clearance due to decrease renal perfusion (dehydration) Signs: 1. Neurologic symptoms (lethargy/confusion/ataxia/tremor) 2. Cardiac abnormality ( QT prolongation, bradycardia)

Answer 193

- associated with 1st generation antipsychotics (haloperidol & fluphenazine) Acute dystonia: - sustained contraction of the neck/tongue/mouth/eye muscles - treatment: benztropine, diphenhydramine Akathesia: - subjective restlessness (inability to sit still) - treatment: beta-blocker (propranolol), benzodiazepine (lorazepam), benztropine Parkinsonism: - gradual onset tremor + bradykinesia + rigidity - treatment: benztropine, amantadine Tarda dykinesia: - gradual onset after prolonged therapy (> 6 months)—> dykinesia of mouth/face/trunk/extremity - treatment: valbenazine, deutetrabenazine

Answer 194

- compression of median nerve leads to carpal tunnel syndrome - CTS common in patients on hemodialysis - signs: 1. Pain/tingling/numbness in the lateral hand

Answer 195

- patient with PD - take anticholenergic drug (trihexyphenidyl) for resting tremor - predispose to acute angle-closure glaucoma Signs: - acute headache, nausea, blurry vision, dilated pupil, red eye, see halos, eye pain - can develop vision loss within 2-5 hours Note: Other drugs associated with ACG: antiemetics, decongestant, anticholinergics

Answer 196

Etiology: - CTG repeat expansion in DMPK gene - autosomal dominant Signs:

Answer 197

- sudden onset, persistence vertigo + neurologic signs (headache + dysmetria + ataxia) - thrombolysis + IV alteplase = (administer to patient with ischemic stroke who do not have aphasia, weakness)

Answer 198

Different signs occurs hours to days after TRAUMATIC BRAIN INJURY: - headache, dizziness, fatigue, confusion, amnesia, difficulty concentrating, or multitasking, sleep disturbance, anxiety , mood change, vertigo - resolve by it is own

Answer 199

Signs: - lump in abdomen and chest - bruised eye - back pain - horner syndrome (ptosis, miosis) - cervical paravertebral sympathetic chain

Answer 200

- benign tumor of CN 8 Signs: - sensorineuronal hearing loss + imbalance (CN 8 dys) - facial numbness/ paralysis (CN 5/ 7 dys) - unilateral deficit (bilateral seen with NF type 2)

Answer 201

- lead to stroke - treat with transfusion exchange - diagnose with Hemoglobin electrophoresis

Answer 202

- GCA typically in patient > 50 (headache, jaw pain when chewing) - TMJD: headache, muscle spasm, jaw fatigue, facial pain (+ tenderness of muscle of mastication, pain/crepitus/audible clicks from the joint)