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224 Cards in this Set

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Onset of delerium
acute and dramatic
Onset of dementia
chronic and insidious
Common causes of delerium
illness, toxic, withdrawl
Common causes of dementia
Alzheimer disease, multi-infarct dementia, HIV/AIDS
Is delerium reversible?
usually
Is dementia reversible
usually not
Describe attention in delerium
poor
Describe attention in dementia
usually unaffected
Describe arousal level in delerium
fluctuates
Describe arousal level in dementia
normal
Memory impairment in dementia
in early dementia remote memory is usually spared
Memory impairment in delerium
globally impaired
What is pseudodementia
depression, usually in elderly, usually treatable
Which is associated with hallucinations, illusions, delusion, orientation difficulties and sundowning...delerium or dementia?
both
More common treatable causes of dementia
- Vit B12 deficiency
- endocrine disorders (esp. thyroid and parathyroid)
- uremia
- syphilis
- brain tumors
- normal pressure hydrocephalus
- Parkinson's (tx may improve)
Wernicke's encephalopathy is from what deficiency?
thiamine
Ataxia, ophthalmoplegia, nystagmus and confusion =
Wernicke's encephalopathy
An alcoholic with confabulation and anterograde amnesia likely has
Korsakoff syndrome
2 key features of Korsakoff syndrome
- anterograde amnesia
- confabulation
How do you avoid ppt Wernicke's encephalopathy in an alcoholic when they show up in your ER?
give glucose before thiamine
Most common cause of headaches
tension
Recurrent frontal/occipital bilateral headache with stiffness is likely what type?
tension
General treatment of stress headaches
- stress relief
- NSAIDs/acetaminophen
Headache that is unilateral, severe, tender, with watery eyes
cluster
Treatment of cluster headaches
oxygen
True or false: migraines often have a family history?
true
Headaches with aura, photophobia, nausea and vomiting are likely
migrain
Typical age of onset for migraine
10-30 years
Morning headaches with projectile vomiting are concerning for
tumor
What do you order for headache with papilledema?
CT or MRI with contrast
Likely diagnosis of morning headache in obese young woman with nausea and negative CT scan
pseudotumor cerebri
LP in pseudotumor cerebri
elevated opening pressure, otherwise normal
Possible causes of pseudotumor cerebri
- megadoses of vitamin A
- tetracyclines
- withdrawl from corticosteroids
Pseudotumor cerebri without treatment may lead to
permanent vision loss
Treatment of pseudotumor cerebri
- supportive
- weight loss
- shunt/repeated LPs
Worst headache of your life -
subarachnoid hemorrhage
Diagnostic test for subarachnoid hemorrhage
- noncontrast CT
- LP
2 major causes of subarachnoid hemorrhage
- ruptures berry aneurysm
- trauma
Give 4 eye causes of headache
- optic neuritis
- eyestrain from refractive error
- iritis
- glaucoma
Give 2 ear causes of headache
- otitis media
- mastoiditis
List 8 general causes/types of headache
- tension
- cluster
- tumor
- migraine
- pseudotumor cerebri
- meningitis
- subarachnoid hemorrhage
- extracranial causes
What is Kallman syndrome?
- anosmia with hypogonadisms due to gonadotropin-releasing hormone
anosmnia + hypogonadism =
Kallman syndrome
tic douloureux =
trigenimal neuralgia
CNI =
olfactory
CNII=
optic
CNIII =
oculomotor
CN IV =
trochlear
CN V =
trigeminal
CN VI =
abducens
CN 5 innervates
- muscles of mastication
- facial sensation
- afferent corneal relex
unilateral shooting facial pain in older adults =
trigeminal neuralgia
Treatment of trigeminal neuralgia
antiseizure meds like gabapentin and carbamezepine are most effective
CN VII =
Facial
CN VII innervates
- muscle of facial expression
- taste of ant 2/3 tongue
- dkin external ear
- lacrimal gland
- salivary (not parotid) gland
- stapedius muscle
Flat forehead means CNVII is injured where?
lower motor neuron lesion
CN VIII =
vestibulocochlear
CN VIII lesions usually manifest as
- deafness
- tinnitus
- vertigo
CN IX =
glossopharyngeal
CNIX innervates
- pharyngeal muscles
- mucous membranes
- afferent gag
- parotid gland
- taster post 1/3 tongue
- skin external ear
- carotid body/sinus
CN X =
vaugs
CN X innervates
- muscles of palate
- muscles of pharynx
- muscles of larynx
- efferent gag
- taste at base of tonge
- abdominal viscera
- skin external ear
Major things to think of in CNX lesions
- aortic aneurysms
- tumors (such as pancoast)
Common things with CNX lesions
- hoarseness
- dysphagia
- loss of gag
- loss of cough
CN XI =
spinal accessory
CN XI innervates
- sternocleidomastoid
- trapezius
Muscle findings in CN XI lesions
- trouble with contralateral head turn
- ipsilateral shoulder drop
CN XII =
Hypoglossal
CN XII innervates
muscle of the tongue
Lesion of CN XII causes
deviation of tongue to affected side
6 Main types of seizures
- simple partial
- complex partial
- absence
- tonic clonic
- febrile
- secondary
key feature of simple partial seziures
conciousness is not impaired
Seizure where consciousness not impaired =
simple partial
Treatment of simple partial seizures
- phenytoin
- valproate
- carbamazepine
3 examples of simple partial seizures
- motor (Jacksonia march)
- hallucinations
- cognitive/affective
Simple partial seizure followed by altered consciousness =
complex partial seizure
Seizure where people perform purposeless movements and may become aggressive if restrained
complex partial seizure
First line agents for treatment of complex partial seziures
- phenytoin
- volproate
- carbamazepine
Typical age of onset of absense seizures
before age 20
absence seizures are a type of _________ seizure
generalized
Duration of absence seizures
10-30 seconds
Seizure with a loss of consciousnes with eye flutterings =
absence seizure
Is there a post-ictal state in absence seizures?
No. This is why people will stare and then pick up a sentence where they left off
First line agents for treatment of absence seizures
- ethosuximide
- valproate
Type of seizure that classically has an aura
tonic clonic
Typical duration of tonic clonic seizures
2-5 minutes
4 common features of the post-ictal state of tonic clonic seizures
- drowsiness
- confusion
- headache
- muscle soreness
First line agents for treatment of tonic-clonic seizures
- phenytoin
- valproate
- carbamazepine
Age for febrile seizure
6 months - 5 years
Type of seizure that usually happens with febrile seizure
tonic-clonic
Treatment of febrile seizure
nonspecific
- treat underlying cause if possible
- acetaminophen
Mass causes of seizure
- tumor
- bleed
Classic metabolic causes of seizure
- hypoglycemia
- hypoxia
- phenylketonuria
Classic toxic causes of seizure
- lead
- cocaine
- carbon monoxide
Classic drug withdrawl causes of seizure
- alcohol
- barbituates
- benzos
- too rapid off anticonvulsants
Classic cerebral edema causes of seizure
- severe hypertension
- eclampsia
Classic CNS infections causing seizure
- meningitis
- encephalitis
- toxoplasmosis
2 important "positioning" things to remember for seizures
- secure the airway
- roll onto side to prevent aspiration
Most common cause of seizures in South America
cysticercosis
Cysticercosis is caused by
Taenia solium (larval form of pork tape worm)
Cysticercosis is most commonly seen in
- people with AIDS
- immigrants (S America)
Treatment of cysticercosis
- niclosamide
- praziquantel
What test should you do before starting any anticonvulsant?
Pregnancy
Most common cause of neurologic disability in US
CVA
Third leading cause of death in US
CVA
3 classic causes of CVA
- ischemia from atherosclerosis
- a fib with emboli
- endocarditis with septic emboli
First imaging performed in suspected CVA is _____
noncontrast CT (rule out bleed)
CT in CVA is often negative for the first _____ hours
24-36
Focal neuro deficit lasting seconds to hours =
TIA
Define transient ischemic attack (TIA)
focal neuro deficit lasting seconds to hours that resolves spontaneously
TIAs typically last
2-3 minutes
This % of right-handed people are left hemisphere dominant
99%
This % of left-handed people are left hemisphere dominat
60-70%
Apathy is concerning for lesion in what part of the brain?
frontal lobe
Inattention is concerning for lesion in what part of the brain?
frontal lobe
Uninhibited behavior is concerning for lesion in what part of the brain?
frontal lobe
Labile affect is concerning for lesion in what part of the brain?
frontal lobe
Broca (motor) aphasia is concerning for lesion in what part of the brain?
dominant frontal lobe
Dominant frontal lobe damage causes which type of aphasia?
Broca
Wernicke (sensory) aphasia is concerning for lesion in what part of the brain?
Dominant temporal lobe
Dominant temporal lobe damage causes which type of aphasia?
Wernicke
memory impairment is concerning for lesion in what lobe of the brain?
temporal
aggression is concerning for lesion in what part of the brain?
temporal lobe
hypersexuality is concerning for lesion in what part of the brain?
temporal lobe
Inability to read, write or name is concerning for lesion in what part of the brain?
Dominant parietal lobe
Unilateral neglect is concerning for lesion in what part of the brain?
Nondominant parietal lobe
Nuclei of CN III and IV are in the
Midbrain
Nuclei of CN V, VI, VII and VIII are in the
Pons
Nuclei of CN IX, X, XI and XII are in the
Medulla
Cerebellar CVAs/lesions classically cause these 6 problems
- ataxia
- dysarthria
- nystagmus
- intention tremor
- dysmetria
- scanning speech
resting tremor is usually from a lesion in the
basal ganglia
chorea is usually from a lesion in the
basal ganglia
2 classic findings in basal ganglia lesions
- resting tremor
- chorea
Classic finding in lesion to subthalamic nuclei
hemiballismus
Hemiballismus may be caused by a lesion here:
subthalamic nuclei
Heritability of Huntington disease
autosomal dominant
Age of onset of Huntington disease
35-50
Irregular, spasmodic, involuntary movements of limb/face are called _____ and are found in _____
- choreiform movements
- Huntington disease
Cognitive deficits in Huntington disease
- progressive intellectual deterioration
- dementia
- psychiatric disturbances
CT/MRI finding in Huntington disease
atrophy of caudate nucleus
Treatment of Huntington disease
- supportive
- antipsychotics may help
Bradykinesia, rigidity, resting tremor and postural instability =
Parkinson's disease
Classic tetrad in Parkinson's disease
- bradykinesia
- rigidity
- resting tremor
- postural instability
Characteristics of the "pill rolling tremor"
- goes away with movement
- goes away when asleep
Mean age of onset of Parkinson's
60`
Drug treatments of Parkinson's
- levodopa/carbidopa
- bromocriptine
- pergoline
- MAOB inhibitors (selegiline)
- amantadine
- anticholinergics (trihexyphenidyl, benztropine)
- antihistamines
Treatment of Parkinsonian side effects from antipsychotics...
- anticholinergics (benztropine, trihexyphenidyl)
- antihistamines (diphendydramine)
Heredity of benign tremor?
autosomal dominant
Treatment of benign essential tremor?
b-blockers
4 "other" important causes of resting tremor
(other than Parkinsons)
- hyperthyroidism
- anxiety
- drug withdrawl/intoxication
- benign essential tremor
What is hepatolenticular degeneration?
Wilson disease (this is why there's a tremor)
Childhood causes of intention tremor
- cerebelar astrocytoma
- medulloblastoma
- hydrocephalus (prior menigitis, Arnold-Chiari, Dandy-Walker)
- Friedreich ataxia
- ataxia-telangiectasia
Heritability of Friedreich ataxia
autosomal recessive
Age of onset of Friedreich ataxia
5-15 years
Adult causes of intention tremor
* cerebellar disorders
- alcoholism
- tumor
- ischemia/hemorrhage
- MS
Cause of amyotrophic lateral sclerosis
idiopathic
ALS =
Amyoptrophic lateral sclerosis
Lesions of ALS are located here
Both upper and lower motor neurons
Is ALS more common in men or women?
men
Mean age of onset of ALS?
55 years
List 3 UMN lesion signs
- spasticity
- hyperreflexia
- Babinski
List 3 LMN lesion signs
- fasciculations
- atrophy
- flaccidity
(Very) general prognosis of ALS
50% of patients die within 3 years of onset
Do not perform an LP acutely in these situations
- acute head trauma
- signs of high ICP
(risk of uncal herniation)
Give normal profile of CSF for cells, glucose, protein and pressure
- cells: <3
- glucose: 50-100
- protein:20-45
- pressure (mmHg):100-200
Give typical profile of CSF in bacterial meningitis for cells, glucose, protein and pressure
- cells: >1000 (PMNs)
- glucose: <50
- protein:100
- pressure: >200
Give typical profile of CSF in viral/aspeptic meningitis for cells, glucose, protein and pressure
- cells: >100 lymphs
- glucose:40-100
- protein: 20-45+
- pressure: 100-200+
Give typical profile of CSF in pseudotumor cerebri for cells, glucose, protein, pressure
- cells: 3
- glucose: 50-100
- protein: 20-45
- pressure: >200
Give typical profile of CSF in Guillain-Barre syndrome for cells, glucose, protein, pressure
- cells: 0-100 lymphs
- glucose: 50-100
- protein: >100
- pressure: 100-200
Give typical profile of CSF in subarachnoid hemorrhage for cells, glucose, protein, pressure
- cells: RBCs
- glucose: 50-100
- protein: >45
- pressure: >200
Give typical profile of CSF in multiple sclerosis for cells, glucose, protein, pressure
- cells: 0-3+
- glucose: 50-100
- protein: 20-45+
- pressure: 100-200
Normal opening pressure in LP
100-200 mmHg
These LP results indicate:
- cells: 3
- glucose: 75
- protein: 30
- pressure: 150
normal LP
These LP results indicate:
- cells: 1,000 PMNs
- glucose: 40
- protein: 100
- pressure: 250
Bacterial meningitis
These LP results indicate:
- cells: 100 lymphs
- glucose: 75
- protein: 50
- pressure:210
Viral meningitis
The LP results indicate:
- cells: 3
- glucose: 75
- protein: 40
- pressure: 300
Pseudotumor cerebri
These LP results indicate:
- cells: 100 lymphs
- glucose: 75
- protein: 150
- pressure: 150
Guillain-Barre
These LP results indicate:
- cells: RBCs
- glucose: 75
- protein: 60
- pressure: 250
subarachnoid hemorrhage
These LP results indicate:
- cells: 5
- glucose: 75
- protein: 50
- pressure: 150
MS (generally normal but sometimes slightly elevated cells and protein)
Abnormal lab results in CSF with MS
- oligoclonal bands
- myeline basic protein (during active demyelination)
Classic stain for crypotcoccal meningitis
India Ink
LP in AIDS with high lymphocytes, worry about...
- TB meningitis
- Fungal meningitis
Is MS more common in men or women?
women
Typical age of onset of MS
20-40
List 6 common presenting features of MS
- paresthesias
- weakness/clumsiness
- visual disturbances
- gait disturbances
- incontinence/urgency
- vertigo
2 classic symptoms of MS
- internuclear ophthalmoplegia
- scanning speech
Reflex related finding in MS
often + babinski
Most sensitive tool to show demylinating plaques in MS
MRI with and without contrast
Symmetrical LE weakness distally, lost reflexes and viral illness =
Guillain-Barre'
Sensory changes in Guillain-Barre'
Mild or absent
You may make a Guillain-Barre' patient worse if you give them...
steroids
Treatment of Guillain-Barre'
- plasmapharesis
- time
Watch Gauillain-Barre' patients carefully for
ascending weakness that involves respiratory muscles
Lower motor neuron disease is associated with this finding on EMG
fasciculations/fibrillations at rest
Most common cause of syncope
vasovagal
If a person passes out when they have a stroke, where is the likely lesion (vessel)
posterior circulation; syncope is generally uncommon in stroke
Important common causes of altered mental status in the ER
- hypoglycemia
- opiod overdose
- thiamine defeciency
- alcohol
- drugs
- DKA
- CVA
- seizure
Treatment of opiod overdose
naloxone
6 important general causes of peripheral neuropathy
- metabolic
- nutritional
- toxic/meds
- immune related
- trauma
- infection
3 metabolic causes of peripheral neuropathy
- diabetes
- uremia
- hypothyroidism
4 vitamin defeciencies that cause peripheral neuropathy
- B12
- B6
-Thiamine (dry beriberi)
- Vitamin E
Patient with B6 defeciency presents with neuropathy. What med were they likely on?
Isoniazid
Peripheral neuropathy with wrist drop and foot drop is classically caused by
lead poisoning
4 drugs that classically cause peripheral neuropathy
- lead/heavy metals
- isoniazid
- vincristine
- ethambutol (optic)
6 autoimmune disorders that are associated with peripheral neuropathy
- Guillain-Barre'
- Lupus
- Polyarteritis nodosa
- Scleroderma
- Sarcoidosis
- Amyloidosis
3 common causes of peripheral neuropathy associated with trauma
- carpal tunnel
- pressure paralysis (radial nerve in alcoholics)
- fractures
5 infections that cause peripheral neuropathy
- lyme disease
- diphtheria
- HIV
- tick bite
- leprosy
Pathology of myasthenia gravis
autoimmune disease attacks acetylcholine receptors
Typical age and gender for myasthenia gravis
women age 20-40
3 classic features of presenation of myasthenia gravis
- ptosis
- diplopia
- generalized muscle fatiguability
What is Tensilon?
edrophonium (a short acting anticholinesterase)
Edrophonius is also known as
Tensilon
What is Tensilon used for
diagnosis of myasthenia gravis
Describe the Tensilon test for myasthenia gravis
- symptoms improve with injection Tensilon (short active anticholinesterase)
Most patients with myasthenia gravis also have this removed
the thymus
Treatment of myasthenia gravis
- plasmapheresis in acute attack
- Long acting anticholinesterase (pyridostigmine, neostigmine)
How can you differentiate myasthenia gravis from Eaton Lambert syndrome?
Eaton Lambert spares the extraoccular muscles
Eaton Lambert syndrome is associated with what?
small cell lung cancer (paraneoplastic syndrome)
Mechanism of disease of Eaton Lambert syndrome
impaires release of acetylcholine from the nerves
What effect does repetitive activity have on Eaton Lamber?
Weakness improves
Poisoning with miosis, excessive bronchial secretions, urinary urgency, diarrhea
Organophosphate poisoning (parasympathetic effects)
Treatment of orhanophosphate poisoning
- atropine
- pralidoxime
Describe the myasthenic type effects of aminoglycosides
- in high doses causes weakness similar to myasthnia gravis
- prolong the effects of musculr blackage in anesthsia
Findings in Sturge-Weber syndrome
- Port wine stain over divisions of V2 and V3
- glaucoma
- seizures