Part 2 Flashcards
20y Marine, headache, confusion, purpuric rash, 103 degree fever? Dx?
= Bacterial Meningitis: PMN predominance, increased protein, low glucose
42y Secretary with headache. Now stiff and unresponsive? Dx?
= Subarachnoid Hemorrhage: Stiff and Unresponsive
31y M from haiti. Feels tired, dull headache. Taking Isoniazid? Dx?
= Tuberculosis: Lymphocyte predominance, increased protein, low glucose
50y M hospitalized with 3 days of progressive painless weakness in the lower limbs with areflexia? Dx
= Guillain Barre: Increased Protein, Lymphocyte predominance, Normal glucose
27y Female. Overweight. 1 wk diffuse headache. Bilaterally blurred optic discs and flame hemorrhage. MRI normal? Dx
= Pseudotumor Cerebri: MASSIVELY INCREASED Opening pressure, normal protein and glucose
70y policeman. Blindness for 20 minutes in the right eye last night that lasted for 20 minutes. History of DM, HTN. On presentation, neuro exam and visual exam normal? Dx?
= TIA of R internal carotid artery
Elderly man. Unresponsive. Taken to ER. BP 200/110. Normal vitals otherwise. Shallow breaths. Pupils 2mm reactive. Moans, no response to noxious stimuli. CT “Shown”. ? Dx?
= Hypertensive Cerebral Hemorrhage
65y M with 1 wk lower back pain that radiates to foot. Painful vesicles over R shin, dorsal foot, great toe. Pain prevented sensory exam. ⅘ dorsiflexion of the right foot. ? Location?
= Lesion in L5 root
24y M in a head on collision and pulled out of car. Unable to move hands/lower limbs. Smoker. BP 100/65. Upper limbs 5/5 strength. 0/5 strength in lower limbs. Reflexes 2+ in upper limbs, Reflexes absent in lower limbs. Pain and temp not present below neck? Location?
= Spinal cord trauma C8/T1
28y F aimlessly turning knob on dishwasher. She is awake-appearing. Does not answer/follow commands. After 5 minutes, leaves to nap in her room. Upon waking, she is alert but cannot remember the event? Dx?
= Complex partial seizure
22y F with brief, severe mandible pain provoked by talking? Dx?
= Trigeminal neuralgia
75y F in the ER with slurred speech and clumsy left arm. MI 5 years ago. No cardiac symptoms. On aspirin, digoxin, potassium, and furosemide. BP 180/85, Pulse 88. Temp 37.2. L palate does not elevate. Voice hoarse. L dysmetria. L face pain/temp decreased. Proprioception/vibration intact. R body pain/temp decreased. ? Location?
= Left lateral medulla lesion (Wallenberg)
52y M. Trouble opening jars w/ right hand for 3 weeks. History of rheumatoid arthritis and on 10mg Prednisone. BP 135/78. R dorsal interossei are weak. 5/5 strength everywhere else? Location?
= R C8 root lesion
55y Businessman. 3 months progressive trouble finding words/reading. MRI shows L perisylvian mass. Pathology report is poorly differentiated carcinoma?
= Metastasis from lung most likely
18y F. Generalized tonic-clonic seizures since 6 months old. On 300mg phenytoin. Good seizure control but experiences clumsiness/slurred speech for past 2 days. Falls when walking straight line. Dysarthric. Mild nystagmus in all directions. Strength/sensation intact. What test do you order?
= Order serum phenytoin levels
52y F waitress. Worsening frontal headache over the past few weeks. Transitions from silly to depressed often. Taking Ibuprofen PRN. Vitals normal. Intermittently giggles. MRI is “shown”. What kind of lesion is this?
= Astrocytoma (not meningioma because of acute onset)
16 y student presents with weak legs after a diving accident. Has trouble walking. Lower limb strength ⅘. Difficult to move lower legs. Stiff/spasm of legs. Clonus at the knee and ankle. Bilateral babinski signs. Upper limbs are normal. How do we treat this?
= Baclofen
47y M poorly controlled diabetic. Wakens with L limb paralysis. BP 165/85, Pulse 76, Temp 37. Left upper and lower limbs ⅘ strength, increased Left reflexes, Left babinski. Cannot raise R eyebrow. R facial droop. Eye maneuvers are normal. Where is the lesion?
= Right Pons
56y M with sensation of burning feet when trying to sleep at night. Feet are sensitive to light touch. Pain and temp decreased in lower extremities. Position and strength are intact. Reflexes 2+ in upper limbs and 1+ in lower limbs. CBC and blood labs are normal. How do we treat this?
= Carbamazepine
4y M constantly falls when running. He must hang on to furniture to rise. Enlarged calves? Dx?
= Duchenne Muscular Dystrophy
59y carpenter. Ache behind L ear. Can’t taste breakfast well. Drools when drinking coffee. Vitals normal. Facial/forehead paralysis? Dx?
= Bell’s palsy
63y F with episodes for minutes of R hand clumsiness. No pain/tingling. 60 pack year smoking history. Diabetic. Soft systolic murmur. Normal neuro exam. Normal brain MRI, carotid duplex, echo, CBC. Abnormal EKG. What medicine should we prescribe for this patient to prevent these episodes?
= Warfarin with target INR of 2.5
60yM with HTN. Has L hemiplegia, L visual field deficit. MRI shows R fronto parietal temporal infarct. Suddenly he becomes difficult to arouse but is breathing normally. What medication do we start immediately??
= Mannitol
73y M is unresponsive. Temperature is 33 degrees celsius. No vestibulo ocular reflex. No pupillary reflex. On mechanical ventilation. Failed apnea test. What do we do??
= Warm the body before pronouncing dead. (MUST BE WARM AND DEAD)
62y/o smoker, 10lb weight loss, cant walk farther than 50ft; reflexes elicitable only after 5s of strong isometric contraction? Dx? Path?
= Lambert eaton syndrome- impaired release of Ach
30y/o female with a droopy left eyelid, double vision after reading for 30min? Dx, Rx?
= myasthenia gravis- loss of Ach receptors
16 y/o nausea/vomiting, speech slurred, trouble swallowing, post family picnic? dx Rx?
= Botulism- Impaired release of Ach
Patient had a stroke of 12 hours duration? TPA?
= Can’t give TPA, but still within the timeframe for a thrombectomy (24hrs), so you need to do emergent angiography or stenting
Right inferior quadrantanopia? Location?
= Left parietal lobe lesion
In the OR s/p CABG, woman gets stiff, clenches teeth, has vigorous flexion-extension movements of all limbs- movements continue for 30 minutes; therapy?
= lorazepam 2-4mgIV push over 5 minutes
Pt right handed, confused and wandering through the woods, cannot follow written commands? Lesion, location?
= Language deficits with poor comprehension= lesion in the left superior temporal lobe
40 y/o woman, continuous involuntary scratching, grasping, and turning movements for the last year- Huntington’s disease. The most specific diagnostic test?
= Inc trinucleotide repeats on a specific chromosome
42 y/o woman with involuntary turning of her head to the right throughout the day, which can be suppressed temporarily by resting her chin on her hand? Dx rx?
= cervical dystonia; treat with Botox
Woman with history of breast cancer post chemo, now in remission for 3 years, and presenting with generalized tonic-clonic seizures; MRI shows 3 ring enhancing lesions= Complication of Chemotherapy?
= immunosuppression
8 y/o boy kept after school for not paying attention in class- teacher always observes him staring into space? Dx rx?
= Absence seizures- Treat with Ethosuximide, Valproate
30 yr old man, 3 yr history of numbness and weakness in the right or left lower limb every 4-6 months. Symptoms resolve without treatment in 7-10 days. Electrical sensation down his back whenever he flexes his necn. On exam, limbs are strong with normal sensation except decreased vibration at both ankles. He has ankle clonus and babinski sign bilaterally; nystagmus only on left gaze? Dx, Rx?
= Probable MS- Treat with parenteral beta interferon
8 y/o becomes unresponsive after MVA. Right pupil is blown and unreactive to light? Dx?
= Right optic nerve lesion
35 y/o man post trauma–>generalized tonic-clonic seizures controlled with phenytoin (300mg/day) for 1 month. Serum phenytoin is 15mg/dL (normal is 10-20)? Rx?
Tx= Inc phenytoin to 350mg/day
Trigeminal neuralgia Rx?
= Carbamazepine
2 y/o man, receiving CPR and on ventilator= sudden jerks of the limb or whole body what is this?
= Myoclonus (poor prognostic indicator)
Retired teacher, tremor of the right hand and chin that only occur when quietly seated and watching TV? Lesion, location?
= Parkinson’s- substantia nigra problem
Cook with postural Bilateral hand tremor? Lesion, location?
= Essential tremor- unknown anatomic site lesion
Woman in cardiac rehab with involuntary flinging movements of right upper limb? Lesion, location?
= hemiballismus- contralateral subthalamic nucleus lesion
Receptionist, undershooting target when she picks up the phone in her right hand? Lesion, location?
= Dysmetria= Ipsilateral cerebellar hemisphere lesion
Professional pianist with involuntary spasms of his right fingers which curl into a fist? Lesion, location?
= Focal dystonia= substantia nigra lesion
“Sense of motion” w/ activity such as bending over. Takes B12. when head is lowered on exam table gets nystagmus when head is turned to the right. But no nystagmus when head is turned to the left?
benign vestibular dysfx
3 YO with 3 months of periodic diplopia. Weak chewing/arms/ SOB that required mechanical ventilation in ER. bilateral ptosis. IV tensilon test improves symptoms. How to regain strength quickly?
plasmapheresis
73YO with gait ataxia, h/o stroke. Takes diltiazem, glyburide and HTN meds. In hospital develops diplopia, dysarthria. MRI shows increased signal on FLAIR. Where is the infarction?
pons
Patient kicks spouse at night. (very obvious RLS patient. How to you relieve symptoms?
levodopa
TBI, generalized tonic clonic seizures that have been repetitive for the past hour. Glucose and electrolytes are normal. IV meds in ER do not help. What other meds can you give?
20 meq of fosphenytoin
60YOM confusion over the past month. Multiple car wrecks recently and over drawn his bank account. 50 pack year smoking history. Ataxia for 1 week. Distal weakness in lower extremity, no ankle reflexes, 2+ reflexes everywhere else with decreased pin and temp in feet. Patien is positive for anti-HU antibodies. What caused these symptoms?
SCcarcinoma
Know the indications for carotid endarterectomy or stenting?
cervical internal carotid at 80%…. 100% stenosis is inoperable,
Patient with frontal HA, aphasia, generalized tonic clonic seizures. Unresponsive, 40 degree celsius fever. Given anti convulsive. What else should you do for patient?
give acyclovir.. (implied that this is herpes encephalitis)
20 YO found down. Sleepy agitated. In ER he is fully awake with no recollection and is fully cooperative. What likely happened?
generalized seizure
22 year old wakes up blind in R eye.. Was partially blind in L eye last year which resolved w/o treatment. How to treat??
methylprednisone 25mg IV Q6
Occipital HA, clumsy Rarm and Rleg, chronic abd pain. 10 lb weight low. CT shows cerebellar mass. In hospital patient had slurred speech and unarousable w/ O2 92%. What therapy do you give?
Lactulose, naloxone, thiamine, dexamethasone or methylphenidate… i think the answer is dexa not sure
Cant climb stairs, progresses to the point where cant get out of bed or wiggle toes, weak lower extremities and weak finger flexion. Upper arms have no deficits. Decreased vibration/positions in feet.? Dx?
GBS
65 with memory impairment for 6 months, gets lost alot, making poor decisions. No neuro PMH. what would you find? Rx?
amyloid plaques in hippocampus
- donepezil
30 yo with wrist drop, tricep weakness, 2+ reflexes everywhere except tricep is +1. What part of arm is injured?
Radial neuropathy from mid humerus.. (cant remember if this is correct)
50 M 2 weeks weakness in deltoids, biceps, and brachioradialis. Also neck pain radiating to right shoulder. Tingling numbness in right thumb. Which nerve involved?
C8
77M, neck pain, decreased pain/tmep clavicles to belly button. Normal strength and sensation in limbs.
syringomyelia
52W, falls d/t weak left leg. Ankle clonus and babinski in L ankle. Decreased proprioception in left toes. Right leg strong, with decreased pain/temp?
Brown Sequard,
70M acute back pain and paraplegia w/ decreased pin/temp with proprioception intact?
Anterior Spinal Artery Syndrome
5W, spastic lower limbs and babinski with +3 reflexes. Upper limbs normal. Low proprioception in feet?
Sub acute combined degeneration,
0W obese, numb tingling feet w/ some trips and falls. Increased urination. Diminished dorsiflexion and toe extension in left foot. Which lab would be abnormal? AIC ESR CK Serum Protein TSH
A1C
59W, 1 month trouble combing hair and achy on climbing stairs. ⅗ weakness in neck, delts, tris, bis, hips, and quads. Diagnosis? Spinal stenosis Cervical myelopathy Myotonic Dystrophy Polymyositis Dermatomyositis
Myotonic Dystrophy
Drowning victim with seizure not responding to benzos? . Drug target??
Na Channels
- 24W with migraines?. Drug target??
Serotonin
- 35M with command auditory hallucinations and delusions?. Drug target??
Dopamine
- 20W with ptosis and slurring of speech after lecturing 6 hours?. Drug target??
Ach
- 75M with alzheimer’s. Drug target??
Ach
32M 1 week progressive painless weakness in lower limbs, hands, face. Mildly numb both feet. 0/5 strength in legs, ⅗ arms. Dyspnea, slurred speech, chokes on food. No reflexes. How to feed? TPN central catheter Liquid Diet NG Tube PEG, liquid diet PO, with aspiration precautions
TPN central catheter
NG?
80M hard time walking and 2 falls x 1 month. No dizziness or LOC. Says loses control of legs. Bent over and stooped walking with small steps to turn. Staggers when lightly pushed. Rigid arms and legs. How to Diagnose? CT MRI EEG LP No Test
NO TEST
72W 2 weeks choking on food 15 lb weights loss. Weak arms with legs spasms. Normal sensory. Vertebral compression fracture year ago. Slurred speech, slow tongue movement. Tongue and limb fasciculation. Babinski. Diagnosis?\ ALS Botulism GBD Epidural cord compression Polymyositis
ALS
35M, shaky hands and trouble writing, father same issue. Shaky hands when arms extended. Rx? L Dopa Propranolol Trihexyphenidyl Haloperidol B. toxin
Propranolol
46M falls asleep while talking. When started, falls limp to floor. Vivid dreams. Diagnosis. REM Disorder OSA Central sleep apnea Narcolepsy Complex partial narcolepsy
Narcolepsy
73W shaking right hand. Slow shuffling gait. Rocks to stand up from chair. Given med now hallucinating. Upper arms twisting and turning. What was given? L dopa Haloperidol Propranolol Diazepam Donezepil
L dopa
1 month URI symptoms. 47M with weakness. Legs ⅗, feet 0, Arms normal, no reflexes. Speech slurred, falling out of bed. Rx? Methylprednisolone Beta interferon Pyridostigmine IVIG Azathioprine
IVIG
32W, diplopia. Left eye cannot adduct to look right Right fully abducts with nystagmus. Normal left up and down movement. Pupils react normal. Lesions? CN III CN VI MLF Tectal midbrain Left frontal eye field
MLF
8W 2 weeks dull HA and nausea on OCPS, febrile. 20/25 vision. Normal disks and lifght reflex. Bitemporal hemianopsia. Problem? Pinealoma Pituitary adenoma Pontine tumor Bilateral occipital lobe tumor MS
Pituitary adenoma
Same patient now has tingling in legs and feet and ataxia a week later. Brain scan with normal findings. Which CSF studies to order? Oligoclonal bands VDRL Cytology Viral culture PcR HSV
Oligoclonal bands
32M entering detox confused and unsteady gait. Nystagmus with limited eye movement. Falls when walking on straight line. Rx? Diazepam Haloperidol Thiamine B12 Steroid
Thiamine
