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245 Cards in this Set

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What complication may arise from performing an LP in a pt with ↑ ICP?
Uncal herniation
A child presents to the ER with mental status changes, hypoglycemia, and lesions suggestive of chickenpox. What is the most likely diagnosis?
reye's syndrome
What is the most effective way to prevent bacterial meningitis in newborns?
Prevent Group B Strep (GBS) exposure – give Penicillin or ampicillin to mom during labor
How do the symptoms of encephalitis differ from that of meningitis?
Encephalitis = altered mental status & focal neurologic defects
Meningitis = neither of these
What is the initial radiologic study in a pt with TIA/stroke symptoms? What radiologic studies need to be performed later to evaluate the underlying cause of the TIA/stroke?
Initial study: CT head without contrast
Then: Carotid duplex, echocardiogram, MRA, CTA
What are the symptoms of a basilar artery stroke?
Cranial nerve defects
AMS/ coma
Contralateral full body weakness and ↓ sensation
Vertigo, loss of coordination
Difficulty speaking, visual changes
What is the treatment for nephrogenic diabetes insipidus caused by lithium toxicity?
Hydrochlorothizide + amiloride
How do the features of acute dystonia differ from tardive dyskinesia?
Acute dystonia: neck spasm (torticollis)
Tardive dyskinesia: repetitive facial movements
How does the treatment of acute dystonia differ from that of tardive dyskinesia?
Acute dystonia: diphenhydramine, benztropine
Tardive dyskinesia: d/c neuroleptic or change to one with lower potency
What EEG pattern is seen in cases of absence seizures?
3 cycles/sec spike & wave pattern
What medications are used in the management of Parkinson’s symptoms?
Levodopa + carbidopa
Selegiline (MAO-B inhibitor) used in early disease and has neuroprotective effects
Dopamine agonists:
Bromocriptine (ergot compound)
Non-ergot D3 stimulators – Pramipexole, Ropinirole, Rotigotine (transdermal)
Apomorphine (subQ) – rescue therapy for sudden akinetic episodes
COMT inhibitors: to potentiate levodopa – Entacapone, Tolcapone
Anticholinergics: for tremor – Trihexyphenidyl, Benztropine
Amantidine: to ↑ dopamine release, used as short-term monotherapy in mild disease
What are the characteristic features of amyotrophic lateral sclerosis (ALS, Lou Gehrig’s disease)?
Weakness, but NORMAL sensation
Initial presenting symptoms:
Asymmetric limb weakness (80%) in hands/fingers, shoulder girdle, foot drop, or pelvic girdle
Dysarthria, dysphagia
Upper motor neuron s/s: movement stiffness, slowness, and incoordination; spasticity and hyperreflexia (spastic paralysis); slowed rapid alternating movements; gait disorder
Bulbar UMN s/s: dysarthria, dysphagia, pseudobulbar affect (PBA) with inappropriate laughing, crying, or yawning
Lower motor neuron s/s: weakness, gait disorder, reduced reflexes (flaccid paralysis), muscle atrophy and fasciculations
Cognitive defects: frontotemporal executive dysfunction
Neuromuscular respiratory failure after months-yrs (avg survival from time of diagnosis is 3-5 yrs)
What are the “C’s” of Huntington’s Chorea?
CAG repeat disorder on chromosome Cuatro (4)
Caudate and putamen atrophy on MRI
↓ ACh
↓ GABA
Crazy (dementia)
Choreoform movements
Cuarenta (40) = age of onset
What are the classic symptoms of Parkinson’s?
Resting tremor
Cogwheel rigidity
Shuffling gait
Mask-like facies
Postural instability
What medication is mot commonly used to treat Parkinson’s?
Levodopa + carbidopa (↑ dosage with progression of disease)
Overall, what are the key symptoms in the initial presentation of Amyotrophic Lateral Sclerosis (ALS)?
Asymmetric limb weakness (hands, shoulder girdle, foot drop)
Dysarthria, dysphagia
What will an electromyogram reveal in ALS?
Widespread muscular degeneration & motor block
What medication is used to treat ALS?
Riluzole (may slow progression)
What is the life expectancy once a pt is diagnosed with ALS?
3-5 yrs from diagnosis
What are the major symptoms of Huntington’s disease?
Chorea & cognitive dysfunction/ decline beginning in midlife
What drugs may be used to treat Huntington’s disease?
Neuroleptics, Dopamine antagonists
Tetrabenazine
What are the unique features of dementia caused by Pick’s disease (aka Fronto-temporal dementia)
Dementia +
behavior changes
personality changes
progressive aphasia
What are the unique features of Lewy Body dementia?
Dementia +
Parkinsonian features
visual hallucinations
repeated unexpected falls
What are the usual components of a “dementia work-up”?
- Note: Alzheimer’s = diagnosis of exclusion
- mini mental status exam (MMSE)
- CBC
- UA
- CMP
- Ca2+
- RPR
- HIV
- TSH
- B12
- CT/MRI of head
What drugs are helpful in treating Alzheimer’s Disease?
Cholinesterase inhibitors – Donepezil, Rivastigmine, Galantamine
Vit E may help
Memantine – may improve symptoms
How does one differentiate btw vascular dementia and Alzheimer’s disease?
brain MRI
What are the differing presentations of Alzheimer’s dementia, Pick’s disease, and Lewy body dementia?
see above
What are 2 symptoms that should clue you in to the diagnosis of multiple sclerosis (MS)?
(1) Unilateral optic neuritis presents as diminished visual acuity in the central field of vision. These symptoms can be mild or may progress to severe visual loss. Periorbital pain (aggravated by eye movement) often precedes or accompanies the visual loss.
(2) Internuclear opthalmoplegia (affected eye cannot adduct due to lesion in ipsilateral medial longitudinal fasciculus) pt presents with diplopia
- Prominent nystagmus is often observed in the abducting eye = Marcus Gunn Pupil
What LP finding is diagnostic of MS?
CSF shows ↑ protein, mildly ↑ WBCs, oligoclonal bands, ↑IgG
WTQ that you missed:

36yo F is brought to the ED due to paraplegia and bladder incontinence. She immediately tells you that she has "multiple sclerosis in remission". She has a h/o optic neuritis and internuclear ophthalmoplegia, and both resolved with treatment. At that time, MRI showed plaques in the periventricular region. She is currently not taking any medications. What is the most appropriate treatment at this time?
Corticosteroids (NOT interferon!)

Notes: Acute exacerbations of MS are treated with corticosteroids. Beta-interferon or glatiramer acetate are used to decrease the frequency of exacerbations in pts with relapsing-remitting or secondary progressive form of MS
What will the brain MRI in an MS pt show?
Multiple asymmetric white matter lesions
What important neuronal tract is the first to be compressed and compromised in the case of syringomyelia?
Spinothalamic tract (pain & temp)
What is the cause of and treatment for Lambert-Eaton syndrome?
Cause: antibodies to presynaptic Ca2+ channels secondary to paraneoplastic syndrome
Tx: immunosuppressive agents & plasmapheresis
What is required to make the diagnosis of Bell’s palsy?
It’s a clinical diagnosis
Diffuse involvement of the entire facial nerve → facial muscle paralysis (upper and lower)
R/O Lyme disease by history: tick bite, heart block, arthritis, vertigo, hearing loss
R/O otitis media by inspecting the TM
R/O stroke by neurological defects
Acute onset (1-2 dys) → progressively worsening weakness for 3 weeks → recovery w/in 6 months
Anything other than the above presentation requires imaging (CT and/or MRI) and screening blood tests to r/o other pathology
What is the treatment for Bell’s palsy?
Eye care to prevent corneal trauma
Artifical tears hourly while awake
Lubricating ointment qHS
Patch covering the eye at night
Glucocorticoids (ie Prednisone 60mg daily x 1 week)
+/- Valacyclovir 100mg tid x 1 week (acyclovir provides no additional benefit over glucocorticoids)
What is the classic presentation of Guillain-Barré Syndrome?
Symmetric muscle weakness that progresses over days to 4 weeks (usually 2 weeks)
Usually beginning in the distal legs but may begin in the arms or facial muscles in 10% of cases
Respiratory muscle paralysis requiring mechanical ventilation in 30% of cases
Facial muscle paralysis and/or oropharyngeal weakness in 50% which may include bilateral facial muscle paralysis
Autonomic dysfunction in 70% - usually tachycardia
Absent or depressed deep tendon reflexes
Little if any change in sensation
No fever at onset of symptoms
GBS may be preceded by Campylobacter jejuni diarrheal illness (about 20% of cases), HIV infection, CMV or EBV infection, Mycoplasma infection, orther viral illness, or immunization (extremely rare)
What’s the prognosis of a pt with Guillain-Barré Syndrome (GBS)?
Spontaneous regression & complete recovery by 1 yr in 80-90%
Relapse in 10%
Prolonged disease (delayed/incomplete recovery) in 5-10%
Death despite ICU care in 5%
What is the treatment of Guillain-Barré Syndrome (GBS)?
Hospitalization for respiratory monitoring including vital capacity, BP monitoring, cardiac monitoring (telemetry), and daily abdominal auscultation for ileus
Mechanical ventilation required in 30% of pts
ICU monitoring for auronomic dysfunction required in 20% of pts
Plasmapheresis or IVIG
Equally effective at shortening time to independent walking by 50%
Combining the two offers no additional benefit
(Steroids are NOT recommended in the treatment of GBS. Previously the mainstay of therapy – but new studies show absolutely no benefit)
if neuropathic pain (40-50% → gabapentin or carbamazepine
if ileus → erythromycin or neostigmine
if hypotensive episodes → fluids +/- phenylephrine (avoid drugs with hypotensive SE)
physical therapy for rehabilitation
HYQ: What causes slowing of nerve conduction velocity?
Demyelination
HYQ: What causes fasciculations and fibrillations at rest on EMG?
LMN lesion
HYQ: What causes a silent EMG at rest (no muscle activity) and a decrease in the amplitude of muscle contraction on stimulation?
Intrinsic muscle disease
What are the different etiologies of Bell's Palsy?
Bell’s Palsy: “my Lovely BELL Had An STD”


- Lyme disease
- Herpes Zoster
- AIDs
- Sarcoidosis
- Tumors
- Diabetes
How does Lambert-Eaton syndrome (LES) differ from Myasthenia Gravis (MG) on history & physical exam?
Lambert-Eaton: weakness ↓ with use
Myasthenia Gravis: weakness worse with use
What are common symptoms of Myastenia Gravis (MG)?
Ptosis
Diplopia
Dysphagia
(worse at end of day)
What test can help diagnose Myasthenia Gravis (MG)?
Tensilon Test (Edrophonium administered)
How does Edrophonium, neostigmine, pyridostigmine work in the treatment of Myasthenia Gravis (MG)?
Edrophonium: short acting, used in diagnosis
Neostigmine: used in treatment
PrRIDostigmine: used to treat (longer acting)
Gets “RID” of MG
How can Bell’s palsy be easily differentiated from a motor cortex stroke?
Bell’s: complete unilateral facial paralysis
Stroke: unilateral lower facial paralysis
What is a classic presentation of GBS?
Ascending paralysis presenting after a recent viral illness
How do you treat GBS?
Supportive care
Plasmapheresis
IVIG
Compare changes in sleep patterns of the elderly to changes in sleep patterns seen in depressed pts:
Depressed: ↓ slow wave sleep (↓ stage 3& 4), ↑ REM sleep, less time to get into REM sleep
Elderly: ↓ REM sleep, ↑ time to get to REM, ↓ slow wave sleep (↓ stage 3&4)
What are the differences btw nightmares vs night terrors?
Nightmares: during REM sleep, pts that appear to wake-up are actually awake
Night Terrors: during non-REM sleep, pts that appear awake (and are frightened/ screaming, tachycardic, and diaphoretic) are actually not fully awake, difficult to arose, and usually fall right back to sleep after the episode
What is Pickwickian syndrome?
obesity hypoventilation syndrome (OHS) – characterized by
Hypersomnolence
dyspnea
hypoxemia → resulting in cyanosis, polycythemia, and plethora
pulmonary hypertension → leading to right-sided heart failure → peripheral edema
What is required to make the diagnosis of narcolepsy?
Cataplexy (sudden loss of muscle tone) only occurs in narcolepsy and is virtually diagnostic when present
other causes of excessive daytime sleepiness are ruled-out
overnight polysomnogram (to r/o OSA and periodic limb movement disorder)
R/O sedating medications as a cause
Multiple sleep latency test – when given 4-5 opportunities to nap every 2 hrs, narcolepsy pts fall asleep in less than 8min
What is the treatment for narcolepsy?
Avoidance of drugs that cause sleepiness
Scheduled naps (once or twice a day for 10-20min)
Stimulants – Modafinil is 1st line
Support group attendance
If cataplexy → venlafaxine, fluoxetine, atomoxetine
What medications are common in the treatment of insomnia? What makes each one unique?
see above
Explain restless leg syndrome
what's the treatment?
The sensation of unpleasant paresthesias that compels the pt to have voluntary, spontaneous, continuous leg movements that temporarily relieves the sensations. The discomfort worsens at rest, in the evening, and/or during sleep. Sensation of “spiders or ants” on/in feet/calf muscles
Usually a primary, idiopathic disorder
Secondary RLS can result from iron deficiency, end-stage renal disease, diabetic neuropathy, Parkinson’s disease, pregnancy, rheumatic diseases (RA), varicose veins, caffeine intake …
Treatment: Pramipexole or Ropinirole qHS (or levodopa/carbidopa), iron replacement, avoid caffeine, clonazepam qHS, gabapentin, opioids
What kind of tumor is the most common brain tumor?
Metastatic cancer (#1 Lung – #2 Breast- #3 Melanoma)
Are Adult brain tumors most often supra- or infra- tentorial?
Adults = supratentorial, kids = infratentorial
What are the 2 most common primary brain tumors in adults?
“MGM Studios”
Meningioma
Glioblastoma multiforme (most common)
What are the 3 most common primary brain tumors in kids?
(1) Astrocytoma – mc tumor, curable if completely reseted
(2) Medulloblastoma – mc malignant tumor in kids
(3) Ependymomas
What are imp characteristics of Neurofibromatosis type 1?
Café-au-lait spots
Freckling of axilla & inguinal areas
Lisch nodules
Neurofibromas
Benzodiazepines increase which stage of sleep at the expense of what other stages of sleep?
↑ stage 2
↓ stage 3 & 4
What is the symptom that, when present, cinches the diagnosis of narcolepsy?
Cataplexy
A pt comes to your office c/o feeling like “bugs are crawling on or in her legs”. This sensation is relieved by movement of her legs but doing so interferes with her sleep. What are some treatment options for this pt?
Dx: Restless leg syndrome
Treatment options:
Dopamine agonists: Pramipexole, Ropinirole
Levodopa/ carbidopa
Iron replacement
Caffiene avoidance
Clonazepam
Gabapentin
Opioids
What are the different causes of syncope?
Causes (↓ cerebral perfusion)
Reflex syncope
Vasovagal: a/w emotional stress, trauma, pain, sight of blood, prolonged standing
Situational: a/w micturition, defecation, coughing, GI Stimulation
Carotid-sinus hypersensitivity: a/w head-turning, shaving, tight collar
Cardiogenic: a/w exertion, palpitations, CP, SOB
Orthostatic
Cerebrovascular: a/w prolonged LOC, seizures, neuro deficits
No cause will be found in at least 20% of pts. If hospitalized previously for syncope and no cause was found, then less than 15% chance of identifying cause on subsequent hospitalizations
What is the basic work-up for syncope?
Work-up basics:
r/o orthostatic hypotension via Tilt test on multiple occasions (ie 30 min after meals, 0200, before and after BP meds given)
r/o seizure by H&P
more likely seizure: h/o seizure, prodrome of déjà vu, postictal confusion, tongue lacerations
more likely syncope: prodrome of lightheadedness or sweating, h/o prolonged standing
nonspecific: brief limb jerking (15% of syncope pts), urine incontinence
CBC, electrolytes, BUN/Cr. Glucose, assess volume status, pulse ox, EKG, evaluation of medications
In pts over 40 (without h/o carotid disease or carotid bruits) r/o carotid sinus hypersensitivity with carotid sinus massage while on tele monitor. Massage one carotid at the angle of the jaw with circular motion for about 5 seconds. Perform supine then with head of bed elevated. Positive test is symptoms reproduced, SBP falls >49mmHg, or asystole > 3 seconds
Also consider:
Serial CEs and EKGs x3 (esp if >45 yrs old, DM, smoker, prior MI, or >2-3 risk factors)
Echo (esp if murmur, exertional syncope, or h/o heart dz)
Cardiac stress test
Bilateral carotid duplex (esp if >65 yrs old, CAD, PVD, bruit)
24 hour Holter monitor (esp if abnormal EKG, palpitations, heart disease, or FHx of sudden death)
CT head without contrast, EEG (esp if neurologic symptoms, new seizure, HA)
What is the differential diagnosis for a pt presenting to the ER for loss of consciousness?
“AEIOU TIPS”
Alcohol
Epilepsy/ Environment
Insulin
Overdose/ Opioids
Uremia (electrolyte disturbances)
Trauma
Infection
Psychogenic Stroke
What should you think about for initial empiric therapy in a pt coming into the ER with loss of consciousness?
Glucose, Thiamine, Naloxone
Why is thiamine given in a glucose infusion to alcoholics with hypoglycemia?
Glucose administration in the absence of thiamine can theoretically exacerbate damage to the mammillary bodies and worsen Wernicke’s encephalopathy
What measurements make for a (+) Tilt test?
Measurements made while standing:
↑ HR >20 bpm
↓ SBP > 20 mmHg
↓ DBP > 10 mmHg
What is the most common cause of syncope?
Vasovagal response
In an intact brainstem, the pt’s eye should move in which direction with ice water infusion into an ear canal?
Toward the ear receiving the ice water
What are the elbows doing in decorticate posturing?
Flexing
A pt is brought into the ER with loss of consciousness. What do you give before starting empiring glucose administration?
Thiamine
Whats the likely cause of syncope if it occurred while shaving?
carotid sinus hypersensitivity
Whats the likely cause of syncope if it occurred while singing in a choir concert?
vasovagal (prolonged standing)
Whats the likely cause of syncope if pt has a (+) tilt test after taking BP meds?
orthostatic hypotension
Whats the likely cause of syncope if pt has a prolonged loss of consciousness?
cerebrovascular
Whats the likely cause of syncope if it was preceded by palpitations?
cardiogenic
Whats the likely cause of syncope in a Type I diabetic pt
hypoglycemic
HYQ: Lung cancer accompanied by muscle weakness is indicative of what?
Lambert-Eaton Syndrome (most common 2° small cell cancer of lung)
HYQ: A 66yo F with forgetfulness and decreased bilateral parietal lobe activity on PET scan has what form of dementia?
Alzheimer’s Dementia
HYQ: What is the most sensitive test for multiple sclerosis?
MRI of head & orbits
HYQ: What medication decreases the frequency of relapses in pts with multiple sclerosis (MS)?
Interferon-β
Glatiramer
HYQ: A 35yo F presents with ptosis and diplopia that worsens throughout the day. What is the underlying problem?
Dx: Myasthenia Gravis (MG)
Pathophysiology: antibodies to ACh receptor at the neuromuscular junction
HYQ: What is the MOA of the preferred medication in the treatment of restless leg syndrome?
Dopamine agonists
What EEG waveforms correspond to the different stages of sleep?
Stage 1: theta
Stage 2: sleep spindles & K+ complexes
Stage 3 & 4: Delta
REM: beta
What is the next step once a brain tumor has been identified on CT or MRI of the head?
Full body CT scan
Bone Scan
What are the treatment options for benign essential tremor?
β-blockers
Benzos
Primidone
Thalamotomy
Deep brain stimulation
WTQ that you missed:

54yo M presents to the office with several months h/o hand tremors that are unresponsive to OTC medication. The tremors always become worse when he is in public places. Sometimes, the hand tremors are so bad that he is unable to grasp. He denies trauma, fever, loss of muscle function or any prior stroke. His PMHx is significant for vague abdominal pains, the cause of which was never found. He is given some medication. A month later, he comes back and says, "the tremor is gone, but now I have colicky abdominal pain, confusion, headaches, hallucinations, and dizziness". What is the medication that the pt was given that caused this pt's new symptoms?
Primidone

Propanolol & Primidone are used to treat essential tremors. Primidone is an anticonvulsant that converts into phenylethylmalonamide & phenobarbital. The administration of primidone can precipitate acute intermittent porphyria, which manifests as abd pain, neurologic & psychiatric abnormalities (as seen in this pt). It can be diagnosed by checking for urine porphobilinogen
What medications are used in the treatment of Alzheimer’s Disease?
Cholinesterase inhibitors: Donepezil, Rivastigmine, Galantamine
NMDA receptor blocker: Memantine
What test is used to confirm the most common cause of syncope?
Tilt table test
Describe what light reflexes will be seen in both eyes if the right optic nerve is damaged prior to the pretectal nucleus (aka afferent defect)
No constriction of either the left or right eye when light is shone in the right eye
Both pupils constrict if the light is shone in the left eye
Describe what light reflexes will be seen in both eyes if the right oculomotor nerve is damaged (aka efferent defect)
Right eye will not respond to light shone in either eye
Left eye will constrict when a light is shone in either eye
What is amblyopia and what are the signs/symptoms?
↓ vision due to a disruption in the normal development of vision usually from strabismus, cataracts, or refractive error prior to age 10
possible presentations: esotropia (inward deviation), exotropia (outward deviation), diplopia and/or refractive error not correctable with lenses
What is the most common cause of blindness in the following populations of adults in the US?
Over age 55 → macular degeneration
Under age 55 → diabetes mellitus
Blacks of any age → glaucoma
What are the distinguishing features of bacterial, viral, and allergic conjunctivitis?
What cause of red eye most closely matches the statement:
May indicate a collagen-vascular disorder
Uveitis
What cause of red eye most closely matches the statement:
Potential serious complication of corneal ulceration
Herpes simplex keratitis
What cause of red eye most closely matches the statement:
Colored halos
Acute angle closure glaucoma
What cause of red eye most closely matches the statement:
Itching eye
Allergic conjunctivitis
What cause of red eye most closely matches the statement:
Preauricular lymph node enlargement
Viral
What cause of red eye most closely matches the statement:
“dry eyes”
Sjogren’s Syndrome
What cause of red eye most closely matches the statement:
Shallow anterior chamber
Acute angle closure glaucoma
What is the most likely cause of conjunctivitis appearing in the first 24 hrs of life?
Chemical conjunctivitis
What are the classic features that distinguish orbital cellulitis from periorbital cellulitis?
Orbital: proptosis, opthalmoplegia, ↓ vision, double vision, pain with movement
(orbital involves the eye & more serious than periorbital)
What is the treatment for orbital cellulitis?
Immediate IV Vancomycin + IV cefotaxime (or ceftriaxone) until afebrile and clinically improved (3-5days) then oral antibiotics (based on sensitivity) for 2-3 weeks
Consult ophthalmology and ENT for recommendations and consideration for need of surgical debridement
What are the diff btw a chalazion, hordeolum & anterior blepharitis? What is the treatment for each?
Chalazion: Inflammation of internal Meibomian sebaceous glands (eyelid swelling)
Tx: Usually self-limiting but can be tx with surgical excision and/or intralesional steroid injection
Hordeolum: Infection of external sebaceous glands of Zeiss or Mol (tender, red swelling at the lid margin)
Tx: how compress 3-4x/day for 10-15 min
If unresolved in 48hrs, then I&D
+/- antibiotic ointment q3hrs
Anterior Blepharitis: infection of eyelids & lashes secondary to seborrhea (red, swollen lid margins + dandruff on lashes)
Tx: wash lid margins daily with shampoo
Removal scales daily with cotton ball
Antibiotic ointment qd to lid margins
How does damage to the right optic nerve (CN 2) present differently than damage to the right oculomotor nerve (CN 3)?
Damage to Right CN 3 (Oculomotor n)
Shine light into right pupil → constriction only of L pupil
Shine light into left pupil → left pupil will constrict
Damage to Right CN 2 (Optic n)
Shine light into right pupil → no constriction of right or left pupil
Shine light into left pupil → BOTH pupils will constrict
Does strabismus cause amblyopia or does amblyopia cause strabismus?
Strabismus causes amblyopia
Does viral conjunctivitis form pus?
Yes, but not as much as bacteria
Compression or lesion of the sympathetic trunk will give a cluster of symptoms collectively known as Horner’s syndrome. What are those symptoms? What is the classic cause?
S/S: miosis, anhidrosis, ptosis of the eyelid
Cause: tumor in the apex of the lung (Pancoast’s tumor)
A pt c/o watery, red, itchy eyes. On exam you notice evidence of mild pharyngitis. What might be the cause of her condition?
Adenovirus or allergies
What important diseases are assoc with uveitis?
Inflammatory Bowel Diseases (IBD): Chrohn’s Disease & Ulcerative Colitis
Juvenile Rheumatoid Arthritis (JRA)
Ankylosing spondylitis
On morning OB/GYN rounds, a very concerned new mother asks you about her 12 hr newborn’s red eyes. What is the likely reason for the baby’s red eyes?
Chemical irritation from antibiotic drops
What is the classic presentation of a pt that has a cataract?
Painless, progressive ↓ in vision manifested with difficulty driving at night, reading road signs, or reading fine-print
Usually bilateral, but often unilateral
Near-sightedness is often an early manifestation
Possible disabling glare in bright sunlight or from oncoming headlights (more likely with steroid induced cataracts)
What is the treatment for acute angle-closure glaucoma?
What is the treatment for a corneal abrasion?
What disease would you suspect in a 35yr old F with new-onset rapid loss of vision and pain when moving the eye? Tx?
Dx: optic neuritis of multiple sclerosis
Tx: IV steroids
What eye abnormalities might be seen in pt with Vit A def?
Night blindness or complete blindness
Xerothalmia
Bitot’s spots (areas of abnormal squamous cell proliferation and keratinization of the conjunctiva)
During a yearly physical, a middle aged man jokes that he needs to buy some reading glasses b/c he is having difficulty reading fine print. He also notes that he has trouble driving at night and reading road signs. Though the pt may have some presbyopia, for what else should you examine him?
Cataracts
What is the pattern of vision loss in open angle glaucoma?
From peripheral → central (tunnel vision)
What is the major exam finding in open angle glaucoma?
Cup to optic disc ratio > 50%
What are some major exam findings in open angle glaucoma?
Severe eye pain, Red, inflamed eye
Hard orbit, Dilated pupil
Central to peripheral vision loss is characteristic of which type of eye pathology?
Macular degeneration
Retinal detachment occurs acutely and is painless, what does the patient experience?
Window shade being pulled over eye
Might see numerous floaters
What are some things that would be seen on funduscopic exam of a pt suspected of having retinal vessel occlusion?
Retinal artery occlusion → cherry red spot
Retinal vein occlusion → cotton wool spot, retinal hemorrhages
What are the causes of a cherry red spot seen on funduscopic exam?
Retinal artery occlusion
Niemann-Pick Disease, Tay-Sachs disease
What medication can be given for both glaucoma & altitude sickness?
acetozolamide
When is observation without antibiotics appropriate for a child with acute otitis media?
According to the 2004 AAP/AAFP guidelines you may refrain from antibiotics & simply observe if:
Age 6mos – 2yrs + dx is questionable + illness is not severe + appropriate f/u available + ABX can be started promptly if symptoms worsen
Age > 2 + illness is not severe + appropriate f/u available + ABX can be started promptly if symptoms worsen
Antibiotics should be started if improvement is not noted in 48-72hrs
What are the classic s/s of bullous myringitis?
What it is: a bullous/vesicular inflammation of the tympanic membrane that may occur in a/w acute otitis media
s/s: more painful than usual acute otitis media
otoscopy: large, reddish vesicle on the TM
What is the tx for bullous myringitis?
Mycoplasma pneumonia is a common organism → tx with oral macrolides
Topical analgesics
What are the diagnostic features of mastoiditis?
Symptoms occur days- weeks after developing AOM
Erythema, edema, tenderness behind the ear
External ear displaced
Diagnosis made from CT scan of the mastoid process
Cholesteatoma
Def: overgrowth of desquamated keratin debris w/in the middle ear space that may eventually erode the ossicular chain and external auditory canal
Causes: negative middle ear pressure (chronic retraction pocket) from Eustachian tube dysfunction or direct growth of epithelium thru a TM perforation
Commonly a/w chronic middle ear infection
PE: grayish-white “pearly” lesion behind or involving the TM, conductive hearing loss, vertigo
Tx: surgical removal usually tympanomastoidectomy & reconstruction of the ossicular chain
What are the distinguishing characteristics of acute labyrinthisitis?
Acute onset of vertigo, N/V, and nystagmus, auditory function preserved = vestibular neuritis
Hearing loss + above symptoms = labyrinthitis
Single episode that last days-weeks (usually not >2wks)
Preceded by a viral URI
Nystagmus: horizontal, suppressed with visual fixation, and has a fast phase away from the affected side
Abnormal head thrust test: when examiner rapidly turns the pt’s head to the affected side, the pt is unable to maintain visual fixation
Gait instability but preserved ambulation
Absence of focal neurologic defects
What is the tx for acute labrinthitis (vestibular neuritis)?
Typically subsides spontaneously w/in weeks
Corticosteroid taper shown to improve recovery (ie methylprednisolone 22 day taper, start with 80mg and taper by 20mg q3days then by 50% q3 days after 20mg reached)
Symptomatic treatment only in for the first 48hrs of illness
Ie scopolamine patch, meclizine, metoclopramide, or promethazine
Long-term recovery is theoretically delayed if used long-term
Vestibular rehabilitation exercises
MRI if >60yrs, headache, focal neuro signs, vascular risk factors, or sustained vertigo inconsistent with acute labyrinthitis (vestibular neuritis)
What is the most common cause of conductive hearing loss in adults? What is the most common cause of sensorineural?
Conductive → otosclerosis (otic bones become fixed)
Sensorineural → presbycusis
What is the treatment for Ramsay Hunt syndrome?
Ramsey hunt syndrome is herpes zoster oticus
Narcotic analgesia for pain reflied
Oral steroids to ↓ inflammation
Antiviral therapy with valacyclovir (highest efficacy) famciclovir, or acyclovir (lowest cost)
What are the important characteristics seen on otoscopic exam of a pt with otitis media?
Red tympanic membrane
Bulging TM with decreases mobility
What is the next step in the evaluation of a pt with hearing loss, vertigo, and tinnitus after a physical exam in the clinic?
MRI of temporal region to r/o acoustic neuroma
What are the potential complications of acute otitis media?
Ruptured TM
Meningitis
Hearing loss
Bullous myringitis
Mastoiditis
Brain abscess
Sigmoid sinus thrombosis
Benign paroxysmal positional vertigo (BPPV) is caused by?
Dislodged otolith in semicircular canal
How do you fix BPPV?
(self-limiting) Epley’s maneuver
In acute labyrinthitis, a pt will have symptoms of vertigo, nystagmus, and nausea & vomiting. What other imp symptom will they have?
Hearing loss (but NOT tinnitus)
What are the symptoms in Meniere’s Disesae?
Vertigo, ↓ hearing, tinnitus, N/V, feeling of ear fullness
What cranial nerve is associated in the deficit of an acoustic neruoma (schwannoma)?
CN 8
What would you see in a pt on exam of pt with cholesteatoma?
Grayish-white pearly lesion
HYQ: A 10yo boy develops worsening arm & leg weakness over a period of 3 days that has now worsened to include symmetric facial muscle weakness. Deep tendon reflexes are absent, and sensation is intact. What is the dx?
Guillain Barre Syndrome
What would be the visual field defect for a lesion of the optic tract?
Homonymous hemianopia
What is the pattern of vision less in glaucoma vs macular degeneration?
Glaucoma: peripherally → centrally
Macular Deg: central loss, peripheral vision maintained
What is the easiest way to distinguish a hordoleum form a chalazion?
Hordeolum: swelling is at eyelid margin (acute infxn)
Chalazion: swelling is within eyelid (chronic)
What is the differential diagnosis for dislocation of the lens?
Marfan syndrome, Homocystinuria, Alport Syndrome
What is the treatment for macular degeneration (MD) vs retinal detachment (RD)?
MD: supplementation with Vit C & E, copper, zinc
Intravitreal Ranibizumab
Laser photocoagulation of lesions
RD: Laser photocoagulation, cryotherapy
Explain how the Weber test can help distinguish conductive hearing loss from sensorineural hearing loss:
Normally: sound heard midline
Conductive loss: sound will lateralize to affected side
Sensorineural loss: sound will lateralize to unaffected side
Which disorders are a/w cherry red spot on macula?
Tay-sachs, Niemann Pick, Retinal artery occlusion
What is the next step in the management of a pt that has sustained a chemical burn injury to the eye?
Wash out the eye with water!
What is the treatment for closed-angle glaucoma?
Eye drop combination of β-blockers, α-agonists, cholinergic agonists, prostaglandin analogs
Acetazolamide orally
IV mannitol
Laser irridotomy
What personality disorder fits the following statement:

Excessive need to be taken care of, submissive & clinging behavior, low self-confidence, fears of separation & losing support
dependent
What personality disorder fits the following statement:
Grandiosity, feels he is entitled to things, lack of empathy
narcissistic
What personality disorder fits the following statement:
Suicide attempts (→ 15% mortality), unstable mood & behavior, sense of emptiness and loneliness, impulsiveness
borderline
What personality disorder fits the following statement:
Distrustful, suspicious, litigious
paranoid
What personality disorder fits the following statement:
Lifelong voluntary social withdrawal, no pscyhosis, emotional expression is limited (restricted range of affect)
schizoid
What personality disorder fits the following statement:
Feeling of inadequacy, hypersensitive to rejection or criticism, socially inhibited, shy
avoidant
What personality disorder fits the following statement:
Constant mood of unhappiness & pessimism
depressive
What personality disorder fits the following statement:
Odd appearance, thoughts & behavior; no psychosis; social awkwardness
schizotypal
What personality disorder fits the following statement:
Controlling, perfectionistic, orderly, stubborn, indecisive
obsessive-compulsive
What personality disorder fits the following statement:
Criminality, unable to conform to social norms, disregard for others’ rights
antisocial
What personality disorder fits the following statement:

Excessively dramatic, emotional, and extroverted; sexually provocative behavior, unable to maintain intimate relationships
histrionic
Paranoid PD - what defense mechanism is commonly used?
projection
Borderline PD - what defense mechanism is commonly used?
Splitting
Histrionic PD - what defense mechanism is commonly used?
Repression
Obsessive-Compulsive PD (OCPD) - what defense mechanism is commonly used?
isolation
What is the difference btw obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder?
Personality disorders do not recognize their behavior is disruptive
What are the distinguishing characteristics btw antisocial personality disorder & conduct disorder?
Conduct disorder = diagnosed < 18yrs
What is the diff btw alcohol abuse & alcohol dependence?
Alcohol abuse: repeated alcohol use despite recurrent adverse consequences
Alcohol dependence: at least 3 of the following: tolerance, withdrawal, alcohol abuse, inability to quit, cut-back, or regulate use, great amt of time spent obtaining, using or recovering
What treatments are effective in helping prevent relapse in recovering alcoholics?
Alcoholics anonymous: is the best relapse prevention
Naltrexone (Revia, Vivitrol)
Disulfran (Antabuse)
Topiramate (Topamax)
Acamprosate (Campral) tid
What is the tx for an extremely agitated & possible violent pt under the influence of PCP?
What drug is causing the following symptoms:
Post-op constipation and/or respiratory depression
Opioid OD
What drug is causing the following symptoms:
Severe depression, HA, fatigue, insomnia/ hypersomnia, hunger
Cocaine withdrawal or amphetamine withdraw
What drug is causing the following symptoms:
Pinpoint pupils, N/V, seizures
Opioid OD
What drug is causing the following symptoms:
Belligerence, impulsiveness, nystagmus, homicidal ideations, psychosis
PCP OD
What drug is causing the following symptoms:
HA, anxiety/depression, weight gain
Caffeine, nicotine withdrawal
What drug is causing the following symptoms:
Anxiety/depression, delusions, hallucinations, flashbacks
LSD intoxication
What drug is causing the following symptoms:
Euphoria, social withdrawal, impaired judgment, hallucinations
Marijuana intoxication
What drug is causing the following symptoms:
Rebound anxiety, tremors, seizures, life-threatening
Withdraw from alcohol, benzos, barbiturates
What drug is causing the following symptoms:
Anxiety, piloerection, yawning, fever, rhinorrhea, nausea, diarrhea
Opioid withdrawal
A pt comes to your office after becoming dissatisfied with her former doctor. She explains to you why she has changed physicians. According to her, the former doctor is the most evil creature with absolutely no redeeming qualities. She finishes her story and remarks that she “can tell you are so smart and will cure her of all things.” What personality d/o might she have?
Borderline (splitting)
An answer of “yes” to 2 or more questions on the CAGE questionnaire indicates that a pt may have a problem with a substance such as alcohol. What does it stand for?
Cut Down, Annoyance, Guilt, Eye opener
In which vitamins are alcoholics typically deficient?
Thiamine, B2, B6, Folate, B12, Vit A & C
What is the most successful treatment for alcoholism?
12-step programs
List the symptoms a/w the life threatening condition Delirium Tremens (DT):
Tachycardia, HTN, Diaphoresis, Delirium, Seizures, Agitation
HYQ: What is the DOC for alcohol withdrawal?
Long acting benzodiazepines
What drug should be avoided in the treatment of a pt in the ER with amphetamine intoxication?
β-blockers (will ↑BP even more b/c you leave α1 unopposed)
What drugs can be used in the case of HTN in a pt with cocaine or amphetamine intoxication?
Benzos, Phentolamine(Oraverse, Regitine)
What is the antidepressant used for help with nicotine addiction?
Buproprion (Wellbutrin) or Varenicline (Chantix)
Opioids do what to the pupils?
Miosis (pupillary constriction) = pinpoint pupils
What are the treatment options for a pt with PCP intoxication?
Benzos +/- Haldoperidol (or other antipsychotic)
Restraints, supportive care
Which eating disorder can be treated with SSRIs?
Bulimia
Note: SSRIs are not helpful in treating anorexia, but can help depression a/w anorexia
T/F: Anorexia & bulimia both involve vomiting/purging?
True
What serum lab abnormalities may be seen in a pt with prolonged excessive vomiting/ purging?
↑ amylase from salivary gland inflammation
hypochloremic metabolic alkalosis
Refeeding syndrome can result in the following:
***Hypophosphatemia
cardiovascular collapse, rhabdomyolysis, confusion, seizures
What are 2 key differences btw somatization disorder and conversion disorder?
Conversion: sensory or motor deficits linked to a preceding stressor
Somatization: physical symptoms that are hard to “pin down” (pain, nausea, vomiting)
Are pain medications helpful in the tx of pain syndrome?
No (use SSRIs or TCAs)
What is a major difference btw factitious/Munchausen disorder and somatization/conversion disorder?
Factitious: pt performs actions to bring about symptoms
Somatization/conv: symptoms from no act on pt’s part
What are key features of delirium that differ it from dementia?
Delirium: alterating levels of consciousness, develops & changes rapidly over course of day, changes are attributable to meds, disease, drug use/abuse, generally reversible
What is the difference btw “sundowning” and delirium?
Sundowning seen with dementia
What is a common cause of delirium in the elderly?
UTI or Meds (Anticholinergics, Benzos, mind-altering meds)
What are the 2 most common causes of dementia & how do you differentiate btw them when making a diagnosis?
Alzheimer’s Disease (70%)
Vascular Dementia (15%)
CT/MRI can help you diagnose vascular dementia
A nurse pages you, saying that one of your elderly pts has been sleeping most of the 2 days he’s been on the unit, but is very agitated and aggressive with the nurses while awake. She aske you to write for a benzodiazepine to sedate the pt- what do you propose instead & why?
Dx: Delirium, which can be worsened with benzos
Tx: antipsychotics (Haloperidol)
What disease that causes dementia is also a/w visual hallucinations and frequent falls?
Lewy Body Dementia
What disease that causes dementia is also a/w unpleasant behavioral and personality changes?
Pick’s Disease
What lab work should be obtained in a pt with a new dx of dementia to r/o secondary causes?
Chem 7, CBC, TSH, Vit B12, RPR, HIV
What comorbidities are common with ADHD in children?
Up to 50% of kids with ADHD have at least one comorbidity:
Oppositional defiant disorder, conduct disorder, learning disabilities, depression, bipolar disorder, anxiety disorder
What criteria must be met before a child can be started on pharmacotherapy for ADHD?
Completed diagnostic assessment
Age 6 or older
Parents accept the medication as appropriate
School will cooperate with administration & monitoring
No previous sensitivity to the chosen medication
Normal HR & BP (EKG before tx is not necessary)
Seizure free
Absence of Tourette’s syndrome or pervasive develop delay
Household does not contain substance abusers
What other medications can be used in the tx of ADHD in kids who fail to respond to stimulants or atomoxetine?
TCAs, Bupropion (Wellbutrin), α-2 agonists (Clonidine)
What are the common complications of ADHD stimulant medications, and how are these complications managed?
What therapeutic options are available for Tourette’s disorder?
What are some of the characteristic features of autism?
“living in his own world”
symptoms evident prior to age 3
lack of responsiveness to others, poor eye contact, absence of social smile
impairments in communication, language delay, repetitive phrases
peculiar repetitive, ritualistic habits (ie spinning around, hand flapping)
Fascination with specific, seemingly mundane objects (vacuum cleaners, sprinklers)
Usually below-normal intelligence
What are the characteristic features of Asperger’s syndrome?
Social impairment
Repetitive activities
Behavior & interest abnormalities
No language problems
No cognitive delays
What are the characteristic features of childhood disintegrative disorder (CDD)?
Regression of development in multiple areas after a period of at least 2 yrs of normal development
Regression may be seen in the areas of expressive or receptive language, social skills or adaptive behavior, bowel or bladder control, play, or motor skills
CDD is an “autism spectrum disorder” which looks just like autism except for the period of normal development
CDD is often a/w an organic condition such as seizures or metabolic disorder
How is ADHD diagnosed?
6 symptoms of ADHD, in 2 or more settings (ie home AND school); before age of 7, impairs ability to function
What’s the diff btw conduct disorder & oppositional defiant disorder?
Conduct: blatant disregard to the feelings & rights of others (& hurts animals)
ODD: doesn’t like rules, but not harmful to others
When treating a child suspected of having a learning disorder, what first must be investigated?
Hearing or vision problems
How is Asperger’s syndrome different from autism?
Asperger’s doesn’t have cognitive or language problems
How is childhood disintegrative disorder different than autism?
CDD: regression of development, multiple areas, after a period of at least 2 yrs of normal development
Often a/w organic conditions – seizures, metabolic d/o
HYQ: What features are unique to PCP intoxication that allows you to distinguish it from LSD intoxication?
PCP: visual hallucinations, aggression, agitation
LSD: visual hallucintations
HYQ: A 19yo slender F presenting with recent weight loss is found to have erythema of her turbinates and nasal septum. What is the cause of her weight loss?
Cocaine abuse
HYQ: What is the downside of adding bupropion to nicotine replacement in a pt trying to quit smoking?
↑ risk of severe HTN
Name the childhood psychiatric disorder:

Females only. Loss of previously acquired purposeful hand skills btw 6-30mos
Rett Disorder
Name the childhood psychiatric disorder:
Impairments in social interactions, communications, play. Repetitive behaviors
Autism
Name the childhood psychiatric disorder:
Impairment in social interaction, no language delay
Asperger’s
Name the childhood psychiatric disorder:
Stereotyped hand mvmts
Rett Disorder
Name the childhood psychiatric disorder:
Characterized by hostility, annoyance, vindictiveness, disobedience & resentfulness
Oppositional Defiant d/o
Name the childhood psychiatric disorder:
Multiple motor & vocal tics
Tourette’s
Name the childhood psychiatric disorder:
Impulsive and inattentive
ADHD
7yo that avoids going to school to stay home with parent
Separation anxiety
What somatoform disorder:

Unexplained pain
Pain disorder
What somatoform disorder:
Pt with normal anatomy is convinced a part of their anatomy is abnormal
Body dysmorphic disorder
What somatoform disorder:
Unexplained loss of sensory or motor function. Normal exam/tests
Conversion disorder
What somatoform disorder:
Unwavering belief by the pt that she has a specific disease (despite medical assurances)
Hypochondriasis
What somatoform disorder:
Unexplained complaints in multiple organ systems
Somatization disorder
What somatoform disorder:
False belief of being pregnant
Pseudocyesis
What are the characteristics of refeeding syndrome?
Metabolizing fat → carbs
Hypophosphatemia, cardiovascular collapse, rhabdomyolysis, confusion, seizures
What are the components of the CAGE questionnaire?
Cut down
Annoyance
Guilt
Eye opener
A pt is brought to the ER by police and is restrained and exhibiting violent behavior. What OD is likely? Tx?
Dx: PCP OD
Tx: benzos, antipsychotic (haloperidol), dark quiet room