UWorld Flashcards
Complications of subarachnoid hemorrhage
(a) First 24 hrs
(b) 5-14 days
(c) BMP abnormality
SAH complications
(a) Rebleeding in the first 24 hrs
(b) 5-14 days: vasospasm
(c) Hyponatremia 2/2 SIADH (syndrome of inappropriate antidiuretic hormone secretion)
Mechanism by which metoclopromide causes neck pain and stiff/tender neck muscles
Metoclopromide-induced dystonia 2/2 activity as a dopamine receptor antagonist
Extrapyramidal symptoms (tardive dyskinesia, dystonic rxns, and Parkinsonisms) are unfrequent but possible side effects of regional
Clinical manifestation of cerebellopontine angle tumors
Cerebellopontine angle tumors = acoustic neuromas/meningiomas
P/w HA, hearing loss, vertigo, tinnitus, balance problems
55 yo F w/ sudden onset severe l. periorbital pain and HA
- blurry vision, sees halos of light
- pupil dilated and poorly reactive to light
Dx
Dx = closed angle glaucoma
- acute, accompanied by pain
- buzzword = halos around lights
Most common manifestation of lacunar strokes
Most often affect the internal capsule => result in pure motor hemiparesis
ex: pt w/ sudden onset right sided (arm and leg) weakness and normal NCHCT
Cavernous sinus thrombosis
(a) Bugs
(b) Clinical presentaiton
(a) Staph/strep from disseinated localized infection
(b) Headache, CN (3,4,V1,V2,6) paralysis, decreased vision, exopthalmous (bulging eyes), chemosis (conjunctival swelling)
- symptoms b/l b/c cavernous sinus has anastomoses crossing midline
3 day old ex-30 weaker born at 1.36 kg (3 lb) w/ hypotonia, seizures, and rapidly increasing head circumference
- lethargic neonate, tense fontanels, generalized hypotonia
- Head ultrasound shows hydrocephalus
Dx
Dx = intraventricular hemorrhage
-common complication in ex-30 or before seekers
Rapidly increasing head circumference and bulging fontanelles consistent w/ severe hemorrhage
12 yo M w/ symmetric paralysis, absent DTRs, decreased superficial touch and vibratory sense of LE b/l 10 days s/p febrile diarrheal illness
(a) Dx
(b) Mechanism
(c) Etiology
(a) Guillan-Barre
(b) Demyelinating polyneuropathy, demyelination of peripheral nerves: mostly motor but also can be sensory and autonomic
(c) In this case most likely 2/2 campylobacter jejuni infxn
58 yo F p/w severe HA (right sided, retro-orbital) and agitation
- blurry vision, constipation, vom
- PMH: Parkinson’s, hypothyroid, HTN, chronic Hep C
Which medication most likely responsible?
Trihyexyphenidyl (anticholinergic)
Recognize anticholinergic toxicity: dry skin, dry mouth, constipation, urinary retention, flushing, vision changes, confusion
58 yo M w/ sudden onset speaking difficulty (difficulty w/ word finding and can’t follow simple commands) and weakness (marked in RUE, mild RLE)
- forced conjugate gaze preference to the left
- neglect of right visual field
- severe right lower facial droop
PMH: uncontrolled
- HTN, HLD
- severe LA enlargement
- carotid US w/ 25% stenosis
BP 156/96, HR 124 irregulargly irregular
(a) Dx- be specific as to location
(b) Explain all findings
(a) Cardiogenic emboli to MCA (probably distal segment of M1)
- Global aphasia (both expressive and comprehensive) localizes to the left hemisphere
- forced gaze preference to the left = damage to frontal eye fields
- right homnomymous hemianopsia (neglecting right visual field) = damage to upper and lower optic radiations in the lateral temporal and parietal lobes
Suggestive of large-occlusion- distal M1 segment of the left MCA
-right-sided weakness (face/arm over leg) consistent w/ left frontal lesion
Most common cause of intraparenchymal hemorrhage in adults vs. children
Adults = hypertensive vasculopathy
Children = AVM
Differentiate migraines and tension HA
Migraines: 4-72 hrs
- unilateral
- pulsatile
- inhibits daily activity
- aggravated by physical activity
Tension HA: 30 min-7 days
- b/l
- pressing/tightening, dull (non-pulsatile)
- mild to moderate, may inhibit but doesn’t prohibit daily activity
- not aggravated by physical activity
- no N/V
45 yo M p/w wasting of extremity muscles more apparent on extensor side
- weakness began distal and asymmetrically
- recent difficulty w/ swallowing, chewing, and speaking
- muscles stiffness
- bowel, bladder, sensory, cognitive fxns intact
- fasciculations and hyperreflexia of all extremities
- decreased bulbar reflexes
Dx
Dx = ALS (amyotrophic lateral sclerosis
Presence of both UMN and LMN findings
UMN
- spasticity
- bulbar symptoms
- hyperreflexia
LMN
-fasciculations
36 yo F p/w daily bandlike HA, dizziness, and fatigue x1mo after a fall at work w/ LOC
Dx
Dx = postconcussive syndrome (following mild TBI)
Symptoms: HA, confusion, amnesia, difficulty concentrating or multitasking, vertigo, mood alteration, sleep disturbance
-resolve w/in week to months, but sometimes can last over 6 mo
While a delayed subdural hemorrhage would result in focal neurologic finding
10 hour old newborn w/ swelling on scalp that wasn’t present at birth
- swelling limited to surface of one cardinal bone
- no visible pulsations, indentations of the skull, or discoloration of overlying scalp
Dx
Dx = cephalohematoma = subperiosteal hemorrhage
- always limited to surface of one cranial bone (b/c it’s sub-periosteal)
- swelling not visible at birth b/c subperiosteal bleeding is slow/gradual
6 mo old F w/ milestone regression
- hypotonic, hepatosplenomegaly and protuberant abdomen
- bright red macula, cervical lymphadenopathy
(a) Deficiency
(b) Dx
(a) Spingomyelinase deficiency
(b) Neimann-Pick disease
- autorecessive, loss of motor milestones/hypotonia, cherry red macula
- different from Tay-Sachs: HSM and areflexia (while hyperreflexic Tay-Sachs)
Pt w/ r. facial droop- what sign would localize facial nerve palsy to below the pons
Below the pons if pt is unable to close eye on affected b/c means forehead control is not intact
Lesion in CNS above the facial nucleus would cause lower facial weakness sparing the forehead b/c collaterals (peripherally) are intact
53 yo M w/ occasional shaking of r. hand x3 mo
- present at rest, stops when reaches for remote
- no other neurologic symptoms or PMH
Mechanism of disease?
Basal ganglia dysfunction
-resting tremor = early sign of Parkinson’s
Focal vs. absence seizures
Focal: longer (2-3 mins), can have post-ictal state
-often automatisms
Absence: shorter (10-20 sec), no post-ictal state
-easily provoked by hyperventilation
8 yo M w/ multiple staring episodes that last 2-3 minutesduring which he tilts head and seems like he’s chewing, he is unresponsive during
- he remains confused for 20 minutes after
- EEG is unchanged w/ hyperventilation
Dx
Dx = focal seizures = originate in single hemisphere, can have lOC
-often have automatisms = repetitive semi-purposeful mov’ts (chewing, swallowing)
Different from absence seizures b/c this kid has post-ictal state, seizures not provoked by hyperventilation, and lasts longer than 10-20 seconds
What type of tremor is a cerebellar tremor?
Intention tremor- tremor increases steadily as hand reaches the target
Features of anterior cord syndrome
Anterior cord syndrome (often 2/2 burst fracture of the vertebra)
- loss of motor fxn below the lesion
- loss of pain and temp on both sides below the lesion
- intact proprioception
Describe physiologic tremor
Not visible under normal conditions, comes out during sympathetic tress (drugs, anxiety)
-usually worse w/ movement
56 yo M w/ b/l HA 3-4 per week
- mild photophobia, no phonophobia
- doesn’t interfere w/ work
- unremarkable neuro exam
Most likely dx?
Tension HA
- b/l
- doesn’t prohibit activity, mod-mild intensity
46 yo M develops severe HA only in certain postures, sometimes LOC
C/f
C/f intraventricular tumor b/c positionally blockage of CSF flow that causes sudden increase in ICP => acute HA w/ possible LOC
72 yo F w/ HTN, DM2, CAD suddenly drops fork while eating
-speech becomes slurred, develops r sided weakness
Dx
Dx = Lacunar stroke in basal ganglia
-intracranial bleed
-progressive symptoms w/ early focal neurologic symptoms and h/o HTN
Triad of Wernicke’s encephalopathy
- Encephalopathy (confusion)
- Ocular dysfunction
- often opthalmoplegia = paralysis of one or more EOM - Cerebellar/gait ataxia
58 yo F p/w difficulty walking
- b/l foot numbness and tinging
- currently on bleomycin, doxorubicin, and vicristine for Hodgkin lymphoma
Dx
Dx = chemotherapy-induced peripheral neuropathy
-stocking-glove distribution
Most likely from vincristine
-also from cisplatin and paclitaxel
Pt p/w Hemi-Neglect of the left side
Locate the lesion
Lesion = right parietal cortex
-responsible for spatial orientation
-ignoring side of space = non-dominant parietal lobe
Immediate reversal agent for
(a) Wafarin
(b) Heparin
(a) Warfarin can be reversed with prothrombin complex concentrate (KCentra) which contains vitamin-K dependent clotting factors for rapid reversal
- also give IV vitK: takes about 12 hrs to kick in (b/c need to remake factors)
(b) Protamine sulfate binds to heparin to inactivate it
55 yo M w/ impaired vision x6 mo
- intermittent morning headaches and decreased libido
- decreased vision in temporal fields b/l
Dx
Dx = craniopharyngioma = benign sellar mass
- compression of the optic chiasm => bitemporal blindness
- symptoms of pituitary hormone deficiency (ex: hypogonadism)
(a) How to make a diagnosis of NPH
(b) How to tx NPH
(a) Dx NPH w/ enlarged ventricles on neuroimaging and LP not showing elevations in ICP
(b) Serial CSF removal w/ large volume LP, eventually VP shunt
Type of tremor often relieved w/ alcohol
Essential tremor
-usually b/l action tremor of the hands
64 yo F BIB son for cognitive impairment
- started 3 mo ago
- unsteady gait, mild muscle weakness on left, prominent pronator drift of left arm, positive Romberg’s sign
- PMH: HTN, stable CAD, diet-controlled DM
- normal affect
Dx
Dx = Vascular dementia
-b/c of the focal neurologic finding
Not Alzheimer’s which would be more specific memory loss and language deficit w/o focal neurologic finding
Path report shows grade IV astrocytoma
Best tx?
Cranial radiotherapy (???)
Guillain-Barre
(a) CSF finding
(b) Tx
GB
(a) Albuminocytologic dissociation: elevated protein w/ normal cell count
(b) IVIG or plasmaphoresis
Mechanism of disease in Parkinson’s
Alpha-synuclein accumulation in the neurons of the substantia nigra
23 yo M w/ worsening HA x1wk
- insect on right cheek 2 wks ago
- b/l eye swelling
- T 101F, TTP b/l on forehead and mid face
Dx
Dx = cavernous sinus thrombosis
= blood clot in cavernous sinus, usually 2/2 spreading infection from sinus, ears, teeth etc
S/p generalized seizure 6 yo boy is alert and awake but unable to move r. arm and leg
- normal speech and behavior
- normal imaging
Mgmt?
Mgmt = supportive b/c this will self-resolve w/in 36 hours
Todd’s paralysis = postictal partial or complete hemiplegia involving ipsilateral upper and lower extremity
-mechanism thought to involve neuronal exhaustion or inhibition
32 yo F p/w LE paresthesias and balancing difficulties
- tingling in feet
- PMH: severe Crohns
- reduced vibration and proprioception in LE
- hyperreflexia of UE
- H/H 8/24 w/ MCT 108
Dx
Dx = Vitamin B12 deficiency
- most likely 2/2 chronic malabsorption from Crohn’s
- hint = macrocytic anemia
Neurologic sign = subacute combined degeneration
- progressive symmetric polyneuropathy, usually LE
- early degeneration of dorsal columns
- late degeneration of corticospinal
25 HIV+ M p/w AMS
- disoriented, lethargic
- last CD4 40, on Bactrim ppx
- MRI shows solitary, irregular, weakly ring-enhancing mass in periventricular area
- seriology +Toxo
- PCR of CSF shows EBV DNA
Most likely dx?
CNS lymphoma
Not toxo- pt is on pox, MRI would show multiple, ring enhancing lesions in the basal ganglia, tons of ppl have positive serology
57 yo M p/w right arm/leg weakness x2 hrs, mild constant HA x3 days
- BP 180/100
- NCHCT normal
Dx
Dx = lacunar stroke 2/2 small-vessel lipohyalinosis
Tx for spinal abscess
In addition to abx, need immediate surgical decompression to prevent cauda equina syndrome and complications of spinal cord compression
64 yo M p/w falls
- loses balance when he tried to turn or stop suddenly while walking
- hand tremor that started in left hand, now affects both hands
Most likely dx
Dx = Parkinson’s
Tremor often started unilaterally then generalizes
General effect of Arnold-Chiari and Dandy-Walker malformations
Both Arnold-Chiara and Dandy-Walker are congenital malformations causing noncommunicating hydrocephalus due to blockage of the CSF flow in the posterior fossa
2 features of Kluver-Bucy syndrome
Hyperphagia and hypersexuality
34 yo postpartum F s/p epidural injection c/o severe HA upon standing, relieved whenever lie down
(a) Dx
(b) Tx
(a) Dx = intracranial hypotension
(b) Tx = autologous blood patch
Manifestation of chemotherapy-induced peripheral neuropathy
Symmetric, distal, sensory neuropathy that spreads in a stocking-glove pattern
- so hands and feet, symmetric
- numbness/tinging over weakness
Side effect of trihexyphenidyl
Trihexyphenidyl = anticholinergic
Dry mouth, blurred vision, constipation, nausea, urinary retention
dry as a bone, mad as a hatter…
2 features specific to intraventricular tumors
- positional/postural headaches (develop HA in certain postures/positions)
- LOC due to sudden increase in ICP if there is an acute obstruction
2 most common bugs that cause brain abscess
Brain abscess: most commonly from direct extension (dental work, sinusitis, otitis media) of strep viridans or staph aureus
2 bacteria = strep viridans and staph aureus
9 yo F w/ unsteady gait and LE weakness
- wide based gait
- decreased vibratory/position sense in LE, absent ankle jerks b/l
- deformed feet w/ high plantar arches
- MRI: atrophy of cervical spinal cord
- EKG: T-wave inversions of inferior and lateral chest leads
Dx
Dx = Friedrichs Ataxia = autosomal recessive of trinucleotide repeats
P/w gait incoordination (ataxia) 2/2 degeneration of spinal cord neurons
-also causes degeneration of cardiac muscle fibers => myocarditis
Differentiate early vs. late signs of diabetic neuropathy
Usually starts w/ alterations in sensation
-loss of proprioception
Very late manifestation is motor findings, and def no UMN findings
So if pt p/w motor weakness, hyperreflexia, upgoing plantar reflex- no diabetic neuropathy
34 yo M p/w difficulty walking for several days
- lower back pain x1 wk since lifting injury
- h/o URI 1 mo ago
- smokes and occasional IVDU
- reduced strength in LE, normal UE
- mild hyperreflexia LE, positive Babinski
(a) First test
(b) Dx
(a) MRI of the spine to diagnose
(b) spinal cord compression
-signs of UMN distal to site of compression
Positive pronator drift- locate the lesion
Pronator drift is also called pyramidal drift- indicates UMN lesion where pronation is stronger than supination
=> lesion localizes to the pyramidal tract
Clinical presentation of acute intervertebral disk prolapse
Severe radicular pain w/ positive straight leg raising test
56 yo M w/o h/o HA p/w dull moderate HA x2 mo over right temple
- worse in mornings or after a nap
- unremarkable neuro exam
Most likely dx
CNS neoplasm
Red flag signs
- new onset HA in adult w/o h/o HA
- localized
- morning HA
17 yo F BIB father 30 mins s/p LOC at home
- stressed and sleep deprived
- 3 similar episodes over the last mo
- normal vitals/physical exam, oriented to name but not time/place
- FS 100
Other expected finding?
Dx = seizure
-not syncope b/c there is a post-ictal state (while syncope returns to baseline immediately)
Also expect tongue lacerations, Tonic-clonic seizure
45 yo M p/w HA x4 mo
- HA generalized and constant, worsened by bending/coughing
- personality changes, N/V, papilledema
- nonfocal neuro exam
- CT: butterfly lesion w/ central necrosis
Dx
Dx = high-grade astrocytoma = glioblastoma multiforme
56 yo M w/ acute right sided weakness and numbness
- hyperreflexia RUE/RLE, decreased sensation to pinprick and light touch on r
- mild dysarthria
- NCHCT shows hyperdensity in the left basal ganglia
Mechanism of disease and Dx
Mechanism = hypertensive vasculopathy causing lacunar stroke
Neimann-Pick disease vs. Tay-Sachs
(a) Age of onset
(b) Main features
(c) Differentiating factors
(a) Both have 2-6 mo age of onset, autosomal recessive
(b) Both: loss of motor milestones, hypotonia, cherry-red macula
(c) NP: areflexic w/ hepatosplenomegaly
TS: hyperreflexic w/o HSM
Two main features of Friedreich’s ataxia
Ataxia- gait instability/imbalance
-LE weakness
Cardiac abnormalities
-myocarditis, EKG abnormalities
Autosomal recessive, trinucleotide repeat d/o
Type of stroke that shows normal NCHCT
Lacular stroke
4 yo p/w worsening ear pain
- s/p 10d abx for otitis media
- morning HAs improved after vomitting
- bulging, opaque left TM
- tender, erythematous left mastoid
- WBC 17k (80N)
(a) First step in dx
(b) Dx
(a) CT w/ contrast (or can do MRI, CT just faster)
CT: hypointense center w/ ring enhancement, surrounding edema = brain abscess
(b) Brain abscess
- otitis and mastoiditis => direct spread of infection into temporal brain abscess
Main features of neuroleptic malignant syndrome
- fever (can be super high like 104)
- mental status change
- generalized rigidity
- autonomic instability: tachycardia, labile BP, tachypnea, diaphoresis
Rigidity and hyperthermia may induce muscle necrosis => CK elevation
29 yo M w/ h/o PSA p/w sudden onset confusion and fever to 102.6F
- recently admitted for hallucinations, d/c on meds
- BP 150/110, HR 112, RR 24, profuse diaphoresis
- diffuse muscle rigidity x4 extremities
- tremor
Dx
Dx = NMS (neuroleptic malignant syndrome) 2/2 antipsychotic use
-or can be 2/2 antiparkinsonian (DA agonist) withdrawal
Tetrad of findings
- change in mental status
- fever
- generalized rigidity
- autonomic dysregulation (tachy, tachypneic, diaphoretic)
Can also see CK elevations due to muscle necrosis from rigidity/fever
In addition to triptans, name another drug that can be used as abortive therapy for migraine headaches
IV antiemetics: chlorpormazine, prochlorperazine, or metoclopramide
Prochlorperazine = antiemetic
84 yo F p/w progressive confusion and increased weakness x2 wks
- baseline is normal activity, now very somnolent/difficult to arouse
- muscle strength 4/5 r, 3/5 left
- upgoing plantar reflex on left
Dx
Dx = subdural hematoma
-insidious onset of HA, somnolence, confusion, and possibly focal neurologic deficits (hemiparesis) 2/2 compression of underlying cortex
Not internal capsule infarct: would be super acute and no findings of somnolence
Type of paralysis caused by tick vs. botulism
Mostly all types of paralysis besides botulism are ascending
-tick paralysis is ascending (so is Guianne-Barre)
While botulism causes descending paralysis
Acute tx for botulism
Equine antitoxin therapy = heptavalent botulinum antitoxin
-provides passive immunity
First line tx for absence seizures
Ethosuxamide
S/p IPH in the right cerebellar hemisphere, pt will present w/ ataxia of which side?
Right sided (ipsilateral) ataxia -b/c corticopontocerebellar fibers decussate twice
What physical exam finding is rather specific for a pyramidal tract lesion
Positive pronator drift: eyes closed and arms outstretched w/ palms upwards, arm involuntarily drifts downward and palm turn towards the floor
Pyramidal (corticospinal) tract disease: pronation is stronger than supination
Symptoms in addition to Parkinsonian features that indicate diagnosis of MSA
Think MSA (multiple system atrophy) when a pt w/ Parkinsonism experiences orthostatic hypotension, impotence, incontinence, or other autonomic symptoms
Mgmt for Multiple system atrophy
- Anti-Parkinsonian drugs are generally ineffective
- tx aimed at intravascular volume expansion (counteract the orthostatic hypotension) w/ fludrocortisone (synthetic mineralocorticoid), salt supplementation, alpha agonists, and compression stockings
