PassMed Flashcards
1
Q
IIH RF (5 + list 5 drugs)
A
Young Overweight F Pregnant Drugs - COCP, Steroids, Tetracyclines, Vit A, Lithium
2
Q
IIH Features
A
H, Blurred V, Papilloedema, Enlarged blind spot, 6th nerve palsy
3
Q
IIH Mx
A
C- Weight loss
M- Diuretics (acetazolamide), Topiramate
S - Repeat LP, ON sheath decompression + fenestration to prevent damage, LP or VP shunt to reduce ICP
4
Q
GBS define
A
immune mediated demyelination of PNS
- asc weakness - progressive - symmetrical
- reflex RED or ABSENT - sensory sx MILD
5
Q
TIA new definition
A
transient ep of neurological dysftn caused by focal brain, SC, or retinal ischaemia without acute infection
i.e TISSUE - based NOT TIME - based
6
Q
6 drugs worsening MG
A
6X drugs that may exacerbate myasthenia:
- penicillamine
- quinidine, procainamide
- beta-blockers
- lithium
- phenytoin
- ABx: gentamicin, macrolides, quinolones, tetracyclines
7
Q
Raised ICP features (5)
A
- headache
- vomiting
- reduced levels of consciousness
- papilloedema
- Cushing’s triad = WIDE pulse pressure, BRADYCARDIA, irregular breathing, HTN
8
Q
Raised ICP patho + normal range
A
- the normal ICP is 7-15 mmHg in adults in the supine position
- cerebral perfusion pressure (CPP) is the net pressure gradient causing cerebral blood flow to the brain
- CPP = mean arterial pressure - ICP
9
Q
Raised ICP Mx
A
-investigate and treat the underlying cause
-HEAD ELEVATION to 30º
-IV MANNITOL may be used as an osmotic diuretic
-controlled HYPERVENTILATION: aim is to reduce pCO2 → VC of the cerebral arteries → reduced ICP
(Caution needed as may reduce blood flow to already ischaemic parts of the brain)
-REMOVAL of CSF, different techniques include:
—drain from intraventricular monitor
—repeated LP (e.g. IIH)
—VP shunt (for hydrocephalus)
10
Q
MG Mx
A
Management
1-long-acting acetylcholinesterase inhibitors
pyridostigmine is first-line
2-immunosuppression:
prednisolone initially
azathioprine, cyclosporine, mycophenolate mofetil may also be used
3-thymectomy
11
Q
Causes of LMN facial palsy
A
Lower motor neuron: Bell's palsy Ramsay-Hunt syndrome (due to reactivation of herpes zoster) acoustic neuroma parotid tumours HIV multiple sclerosis* diabetes mellitus
12
Q
Facial Nerve supplies what
A
Supply - ‘FACE, EAR, TASTE, TEAR’
face: muscles of facial expression
ear: nerve to stapedius
taste: supplies anterior two-thirds of tongue
tear: parasympathetic fibres to lacrimal glands, also salivary glands
13
Q
Differences between pseudoseizures/psychogenic nonepileptic seizures and true seizures
A
Factors favouring pseudoseizures: pelvic thrusting family member with epilepsy much more common in F crying after seizure don't occur when alone GRADUAL onset
Factors favouring true epileptic seizures:
SUDDEN onset
tongue biting
raised serum PROLACTION
14
Q
WE
A
Confusion, ataxia, nystagmus + ophthalmoplegia
15
Q
Ataxic gait causes
A
Ataxic gaits typically occur following cerebellar injury, the causes of which can be remembered by the mnemonic ‘pastries’
P - Posterior fossa tumour A - Alcohol S - Multiple sclerosis T - Trauma R - Rare causes I - Inherited (e.g. Friedreich's ataxia) E - Epilepsy treatments S - Stroke
16
Q
Ataxic gait feat
A
A wide-based gait with loss of heel to toe walking is called an ataxic gait
17
Q
Temporal lobe seizure features
A
Lip smacking + post-ictal dysphasia are localising features of a temporal lobe seizure
18
Q
spinal cord compression features
A
most comm from extradural compression from spinal mets
- feat: 1st = back pain (worse on lying down and coughing)
- lower limb weakness
- sensory changes: sensory loss and numbness
- neurological signs depend on the level of the lesion
19
Q
how does level of spinal cord compression affect neurological sign presentations
A
- Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level
- Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness
- Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion
20
Q
bone mets
A
Most common tumour causing bone metastases (in descending order)
prostate
breast
lung
Most common site (in descending order) spine pelvis ribs skull long bones
21
Q
Encephalitis features + immed Mx
A
- F, H, psychiatric Sx, seiz, vom
- focal features e.g. aphasia
- peripheral lesions (e.g. cold sores) have no relation to presence of HSV encephalitis
- compl by temporal L seizures: motionless staring, confusion and disorientation, altered ability to respond to others) accompanied by an aura (jamais vu - a feeling of unfamiliarity
MX: intravenous aciclovir should be started in all cases of suspected encephalitis
22
Q
Pituitary apoplexy define + precipitating factors
A
Sudden enlargement of a pituitary tumour (usually non-functioning macroadenoma) secondary to haemorrhage or infarction.
Precipitating factors:
- HTN
- pregnancy
- trauma
- anticoagulation
23
Q
Pituitary apoplexy features + Ix
A
- sudden onset H similar to that seen in SAH
- vom
- neck stiffness
- VF defects: classically bitemporal superior quadrantic defect
- extraocular nerve palsies
- feat of pituitary insufficiency
e. g. hypotension/hyponatraemia secondary to hypoadrenalism
Ix: MRI is dx
24
Q
Pituitary apoplexy Mx
A
urgent steroid replacement due to loss of ACTH
careful fluid balance
surgery
25
Restless Legs Syndrome causes + assoc
```
Causes and associations:
+FHx in 50% of pts with idiopathic RLS
IDA
uraemia
DM
pregnancy
```
26
Restless Legs Syndrome mx
Mx:
- simple measures: walking, stretching, massaging affected limbs
- treat any iron defic
- dopamine AGONISTS are first-line treatment (e.g. PRAMIPEXOLE, ROPINIROLE)
- benzos
- gabapentin
27
what scale to measure disability or dependence in ADLs
Barthel Index
28
Wernicke's vs Brocas
Wernicke's sounds like 'What?' as the patient doesn't understand a command.
Broca sounds like 'broken' as the patient's word-flow is broken.
29
Thoracic outlet syndrome define
-disorder involving compression of brachial plexus, subclavian artery or vein at the site of the thoracic outlet. -TOS can be neurogenic or vascular; the former accounts for 90% of the cases.
30
NEUROGENIC Thoracic outlet syndrome clinic pres
painless muscle wasting of hand muscles, with patients complaining of hand weakness e.g. grasping
sensory symptoms such as numbness and tingling may be present
if autonomic nerves are involved, the patient may experience cold hands, blanching or swelling
31
VASCULAR Thoracic Outlet Syndrome clin pres
subclavian vein compression leads to painful diffuse arm swelling with distended veins
subclavian artery compression leads to painful arm claudication and in severe cases, ulceration and gangrene
32
Thoracic Outlet Syndrome causes
TOS occurs when you get neck trauma to pts with anatomical predispositions eg SOFT TISSUE (70%) eg scalene muscle hypertrophy or OSSEOUS structures (30%) eg cervical rib
33
CN6 palsy manifesting as diplopia could be the first sign of what?
BRAIN METS
- CN6 (ABDUCENS) is thinnest CN + longest intracranial course
- v susceptible to compression when SOL develoop
34
ACUTE mx of stroke
- BL GL, hydration, O2 sats + T should be maint within normal limits
- BP should not be lowered in the acute phase unless there are compl e.g. Hypertensive encephalopathy*
- aspirin 300mg orally or rectally should be given asap if a haemorrhagic stroke has been EXCL
- w/rto AF, anticoagulants should not be started until brain imaging has EXCLUDED HAEMORRHAGE, and usu not until 14 days have passed from the onset of an ischaemic stroke'
- if the cholesterol is > 3.5 mmol/l pts should be commenced on a STATIN. Many physicians will delay tx until after at least 48 hours due to the risk of HAEMORRHAGIC TRANSFORMATION
35
autonomic dysreflexia is what
- clinical syndr occurs in pts who have had a SCI at, or ABOVE T6 spinal level.
- Briefly, afferent signals, most comm triggered by FAECAL IMPACTION or URINARY RETENTION (but many other triggers have been reported) cause a SYMP spinal reflex via thoracolumbar outflow.
- The usual, centrally mediated, parasymp response however is prevented by the cord lesion.
- The result is an UNBALANCED physiological response, characterised by extreme HTN, FLUSHING + SWEATING above the level of the cord lesion, agitation, and in untreated cases severe consequences of extreme HTN have been reported, e.g. haemorrhagic stroke
36
Mx of autonomic dysreflexia
Mx involves removal/control of the stimulus + tx of any life-threatening HTN +/or BRADY.
37
Mx of neuropathic pain
- 1st-line tx*: amitriptyline, duloxetine, gabapentin or pregabalin
- if the 1st-line drug tx does not work try DIFF ONE
- in contrast to standard analgesics, drugs for neuropathic pain are typically used as monotherapy, i.e. if not working then drugs should be switched, not added
- tramadol may be used as 'RESCUE tx' for exacerbations of neuropathic pain
- topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia)
- pain mx clinics may be useful in pts with resistant problems
38
syringomyelia define
collection of CSF (fluid filled cyst) within the SC
39
syringomyelia causes
- Chiara malformation - strong association
- trauma
- tumours
- idiopathic
40
syringomyelia features
-a ‘CAPE-LIKE’ (neck, shoulders and arms)
LOSS of SENSATION to PAIN + TEMPERATURE but the preservation of light touch, proprioception and vibration
-classic examples are of patients who accidentally burn their hands without realising
-this is due to the crossing SPINOTHALAMIC TRACTS in the anterior commissure of the spinal cord being the 1st tracts to be affected
-SPASTIC WEAKNESS (predominantly of the lower limbs)
-NEUROPATHIC PAIN
-UPGOING PLANTARS
-autonomic features: HS due to compression of the sympathetic chain, but this is rare
----bowel and bladder dysfunction
-scoliosis will occur over a matter of years if the syrinx is not treated
NB. associated with Arnold-Chiari malformation
41
stroke thrombolysis for acute ischaemic stroke when to give
-Thrombolysis with alteplase should only be given if:
it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial)
-haemorrhage has been definitively excluded (i.e. Imaging has been performed)
42
ABSOLUTE CI to thrombolysis
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- LP in preceding 7 days
- GI haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
43
RELATIVE CI to thrombolysis
- Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks
44
Thrombectomy for acute ischaemic stroke must take into account pts overall clinical status HOW
NICE recommend that all decisions about thrombectomy take into account a patient's overall clinical status:
-NICE recommend a pre-stroke functional status of less than 3 on the modified Rankin scale and a score of more than 5 on the National Institutes of Health Stroke Scale (NIHSS)
45
for PROXIMAL ANTERIOR CIRC strokes on CTA or MRA when to offer thrombectomy
ASAP + < 6 hours of SX onset, + IV thrombolysis (if within 4.5 hours)
46
in what cases can you give thrombectomy between 6 and 24h previously (incl wake up strokes)
-confirmed occlusion of proximal anterior circulation on CTA or MRA AND if potential to salvage brain tissue as shown by CT perfusion or diffusion weighted mRI showing LIMITED INFARCT CORE VOLUME
47
for wake up strokes what time do you assume stroke occurred
time they went to sleep
48
when to CONSIDER thrombectomy together with intravenous thrombolysis (if within 4.5 hours) ASAP for people last known to be well up to 24 hours previously (including wake-up strokes)?
- Ppl who have acute ischaemic stroke and confirmed occlusion of the PROXIMAL POSTERIOR CIRCULATION (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA AND
- if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
49
vestibular schwannoma (acoustic neuroma) features
TRIAD
1. vertigo
2. hearing loss, tinnitus
3. absent corneal reflex.
-unilateral SNHL that is progressive - raises suspicion
Features can be predicted by the affected cranial nerves:
- cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
- cranial nerve V: absent corneal reflex
- cranial nerve VII: facial palsy
50
generalised T-C seiz mx
sodium valproate
second line: lamotrigine, carbamazepine
F--> 1ST = LAMOTRIGINE
51
ABSENCE seizures mx
=SV or ethosuximide
- SV particularly effective if co-existent tonic-clonic seizures in primary generalised epilepsy
- carbamazepine can WORSEN
52
MYOCLONIC seizures mx
-SV
2nd line: clonazepam, lamotrigine
-carbamazepine can WORSEN
53
FOCAL seizures mx
- carbamazepine or lamotrigine
| - 2nd line: levetiracetam, oxcarbazepine or sodium valproate
54
VF defects: left homonoymous hemianopia
means visual defect to the left, ie lesion of RIGHT optic tract
- congruous = complete or symmetrical VF loss = lesion of OPTIC RADIATION OR OCCIPITAL CORTEX
- incongruous = incomplete or asymmetric = OPTIC TRACT lesion
- macula sparing = lesion of OCCIPITAL CORTEX (glaucoma + retinitis pigmentosa)
55
VF defects - homonoymous QUADRANTANOPIAS
PITS
parietal - inferior
temporal - superior
56
MS gold std imaging
MRI WITH CONTRAST
| -to view plaques showing areas of demyelination
57
brain abscess mx
IV 3rd gen cephalosporin + metronidazole
| + Dex for ICP Mx
58
loss of corneal reflex - controlled by what nerve
trigeminal - CN V
59
hoovers sign is used for what, and what is it
differentiate bet ORGANIC + NON-ORGANIC lower leg weakness
- based on synergistic contraction
- if pt was genuinely trying to lift their weak leg then you would feel the NORMAL limb pushing DOWN against your hand = ORGANIC cause of paresis
60
mx of pt on warfarin/DOAC/bleeding disorder presenting with TIA
ADMIT imemdiately for imaging to exclude a haemorrhage
61
defective downward gaze + vertical diplopia
CN 4 = TROCHLEAR
- problem with SO
- cause can be poorly controlled diabetes
62
neuroleptic malignant syndrome tetrad
1/hyperthermia
2/muscle rigidity
3/autonomic instability
4/altered mental status
63
defective eye abduction + horizontal diplopia
CN 6 = ABDUCENS
64
anterior cerebral artery x1
contralateral hemiparesis + sensory loss, lower extremity>upper
65
middle cerebral artery x 3
1. contralateral hemiparesis + sensory loss, upper extremity>lower
2. contralateral homonoymous hemianopia
3. aphasia
66
posterior cerebral artery
1. contralateral homonymous hemianopia with macular sparing
| 2. visual agnosia
67
Weber's syndrome (branches of posterior cerebral artery that supply the midbrain)
1. Ipsilateral CN III palsy
| 2. Contralateral weakness of upper and lower extremity
68
Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenburg syndrome)
1. Ipsilateral: facial pain and temperature loss
2. Contralateral: limb/torso pain and temperature loss
3. Ataxia, nystagmus
69
Anterior inferior cerebellar artery (lateral pontine syndrome)
SX similar to Wallenburg's
- BUT
- ipsilateral: facial paralysis + deafness
70
retinal/opthalmic artery
amaurosis fugax
71
basilar artery
locked in syndrome
72
Raised ICP Mx
- ix and treat cause
- HEAD ELEVATION to 30 degrees
- IV MANNITOL can be used as an osmotic iduretic
- CONTROLLED HYPERVENTILATION - aim to reduce pCO2-- > VC of cerebral arteries --> reduced ICP
- REMOVAL OF CSF --> drain from IV monitor, repeat LP, VP shunt
73
what is Lhermitte syndrome in MS - L for LIMBS
paraesthesia in LIMBS on NECK FLEXION
74
what is Uhthoffs phenomenon in MS - U for EYES
worsening of VISION after RISE IN BODY TEMP
75
what can common peroneal nerve lesion cause weakness of
Loss of foot dorsiflexion + foot eversion
76
how do chronic SDH look on CT head
HYPODENSE (dark)
CRESCENTERIC in shape
NOT restricted by suture lines
77
Oxford stroke classification = Bamford Classification - classifies stroke based on initial Sx - what are the 3 criteria
1. Unilateral hemiparesis +/or hemisensory loss of F, A, Leg
2. Homonymous hemianopia
3. Higher cognitive dysfunction eg dysphasia
78
TOTAL anterior circulation infarcts - 15% strokes
involve middle + anterior cerebral arteries
| -all 3 of Oxford stroke classification present
79
PARTIAL anterior circulation infarcts (PACI) - 25% strokes
- involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
- 2 of the above criteria are present
80
LACUNAR infarcts - 25% strokes
- involves perforating arteries around the internal capsule, thalamus and BG
- presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis
81
POSTERIOR circulation infarcts - 25%
```
-involves vertebrobasilar arteries
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
```
82
other recognised stroke patterns - LATERAL MEDULLARY SYNDROME
Lateral medullary syndrome (posterior inferior cerebellar artery)
aka Wallenberg's syndrome
-ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner's
-contralateral: limb sensory loss
83
other recognised stroke patterns - Weber's syndrome
- ipsilateral III palsy
| - contralateral weakness
84
PHENYTOIN MOA and adverse effects - acute, chronic, idiosyncratic, teratogenic
MOA: induces p450
ACUTE: intially - dizziness, diplopia, nystagmus, slurred speech, ataxia
later: confusion, seizures
CHRONIC: common - gingival hyperplasia (secondary to increased expression of platelet derived growth factor, PDGF), hirsutism, coarsening of facial features, drowsiness
megaloblastic anaemia (secondary to altered folate metabolism)
peripheral neuropathy
enhanced vitamin D metabolism causing osteomalacia
lymphadenopathy
dyskinesia
IDIOSYNCRATIC:
- F
- rashes, including severe reactions such as toxic
- epidermal necrolysis
- hepatitis
- Dupuytren's contracture*
- aplastic anaemia
- drug-induced lupus
TERATOGENIC:
-associated with cleft palate + CHD
85
if pt has aphasia with stroke - most likely site of stroke is where?
- for aphasia to be present it means dominant hemisphere affected--> most commonly LEFT (regardless of handedness)
- MCA on dominant side--> supplies both Wernicke's + Broca's areas of the cortex
- responsible for understanding + production of speech
86
NPH triad mnemonic
WET - urinary incontinence
WACKY - dementia + bradyphrenia (pathological slowing of mental processes)
WOBBLY - gait abnormality (can be like PD)
87
before starting phenytoin what should you ensure is on pt
CARDIAC MONITORING
| -due to pro-arrythmogenic effects
88
Secondary prevention of stroke
1st line = CLOPI - in ischaemic stroke
2nd line = Aspirin + MR dipyridamole if Clop CI or not tolerated - in ischaemic stroke
3rd line = just MR dipyridamole - if aspirin or clop CI or not tolerated
89
what lobes are Wernickes and brocas
WC - wernickes responsible for comprehension/understanding - so it is located near the ear in the TEMPORAL LOBE
- then signal to arcuate fasciculus to Broca's
- BP - Brocas resp for production of speech - so it is located near the mouth in the FRONT LOBE
90
in trauma what quick test determines if fluid is CSF
checking fro glucose - it is NOT present in MUCUS but is present in CSF
-beta 2 transferrin would be gold standard
