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184 Cards in this Set
- Front
- Back
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What is the most common hereditary ataxia in Europe and North America?
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Friedrich's Ataxia
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What is the incidence of Friedrich's Ataxia?
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1 in 40000
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What is the molecular abnormality in Friedrich's ataxia?
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deficiency of frataxin chromosome 9
GAA triplet repeat disorder (normal up to 22, abnormal >120) autosomal RECESSIVE |
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What is the proposed molecular mechanism of pathology in Friedrich's ataxia?
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Frataxin, iron-chaperone system, absence leads to oxidative damage and mitochondrial dysfunction
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What is the only treatment studied by randomized controlled trial for Friedrich's ataxia?
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idebenone
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What is the gene involved in ataxia telangiectasia, chromosome and protein?
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Chromosome 11 q 22-23
ATM gene ATM protein |
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What are the clinical manifestations of AT?
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ataxia at time of walking, wheelchair bound by age 10, death in 20s to 30s; immunodeficiency, malignancy, respiratory failure, endocrinopathy, increased AFP levels, radiation hypersensitivity; restrictive respiratory disease
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What is the differential diagnosis for chorea, dementia, neuropsychiatric symptoms?
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1) Huntington's Disease
2) Neuroacanthocytosis 3) Dentato Rubro Pallidoluysian Atrophy |
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What is the triad for Huntington's disease?
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1) Chorea
2) Dementia 3) Neuropsychiatric symptoms |
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What are some distinguishing features of neuroacanthocytosis vs. huntington's disease?
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neuroacanthocytosis has hypopreflexia, huntington's has hyperreflexia or "hung-up reflexes"
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What is dentato-rubro pallidoluysian atrophy?
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polyglutamine disorder, multiple CAG repeats, more common in North Carolina and Japan
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What is the only movement disorder not characteristic of Wilson's disease?
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chorea
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What medication challenge can be done to diagnose Wilson's disease?
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penicillamine challenge if high urinary copper excretion > 250 mmol
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What is augmentation in restless legs syndrome?
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After treatment with dopa/dopa agonists symptoms start earlier or spread to arms
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What is rebound in RLS?
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symptoms occur upon awakening
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What is recurrence
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symptoms start later in evening after meds
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What is the characteristic reflexes found in Huntington's disease?
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hypotonia with hyperreflexia
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What are the 4 criteria for RLS?
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urge to move the legs
at least partial relief with movmeent worse with recumbency worse with night-time |
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What are the clinical symptoms of spinocerbellar ataxia type 6?
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downbeat nystagmus, older adults
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What are the genetcis of SCA 6?
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calcium channel abnormality, Chromosome 19
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what is riley day syndrome?
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familial dysautonomia with hyperpyrexia, mr, dysphagia, postural hypotension, neuropathy
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What are the genetics, chromosome and protein associated with Panthenate Kinase associated neurodegneration or Hallervorden Spatz?
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AR, pantothenate kinase gene, chromosome 20
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What is the usual age of onset of PKAN or NBIA?
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early 1st decade, late 2nd decade or adulthood
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What are the usual symptoms of NBIA 1?
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dystonia, spasticity, dysarthria, personality change, cognitive decline, retinitis pigmentosa, optic atrophy, seizures, toe walking, rhisus sardonicus, eventually can't walk or talk
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What is the usual imaging finding in NBIA 1?
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Fe deposition in GPi or eye of tiger sign
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What is the missing enzyme in Fabry's disease?
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alpha galactosidase a
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What is accumulates in Fabry's disease?
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ceramide trihexoside
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What are the clinical characteristics of fabry's
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angiokeratoma corpora diffusum, young stroke secondary to smooth muscle proliferation endothelium, small fiber neuropathy; provoked by hot weather, exercise
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What is the differential for distal onset weakness
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neuropathy
dysferlinopathy myotonic dystrophy |
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what is the differential for proximal weakness (neuropathy)
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diabetic amyotrophy
cidp acute intermittent porphyria |
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What would the neuro exam show with episodic ataxia 2?
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downbeat nystagmus, older patient, ataxia , dystonia
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What is the inheritance of episodic ataxia 2?
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AD Chromosome 19 calcium channel
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What is the treatment for EA 2?
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diamox
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What is the difference between EA 2 and hypkalemic periodic paralysis?
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both calcium channel but hypokalemic periodic paralysis on chromosome 1
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What is Oppenheim dystonia?
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DYT1 caused by deletion GAG in chromosome 9 Torsin A
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What is the inheritance of DYT1?
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deletion GAG chromosome 9
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What is the penetrance of DYT1?
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only 30 to 40%
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DYT1 is the etiology of chilhood onset dystonia in what percentage of Ashkenazi Jews?
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90%
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DYT1 is the etiology of childhood onset dystonia in what percentage of non-Jewish?
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up to 60%
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What is the usual mode of inheritance of Segawa Syndrome or DYT5?
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AD GTP cyclohydrolase
AR tyrosine hydroxylase |
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What are the clinical characteristics of Segawa syndrome?
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onset: 1-12 yrs.
diurnal variation, worse night starts as focal foot dystonia or gait abnormality; with time develop parkinsonism (can be isolated as adult) |
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How would you treat Segawa syndrome?
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very responsive to 1 week trial of dopa
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What is Myoclonus Dystonia or DYT 11?
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dystonia and proximal myoclonic jerks caused by abnormality in epsilon-sarcoglycan gene on chromosome 7; poor response to any treatment but ETOH (comorbid psych illness)
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What is the penetrance of DYT 11 or myoclonus dystonia?
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100% if inherited from father, 10% if inherited by mother
autosomal dominant |
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What is a palilalia?
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repetition of one's own words, may sound like stuttering; complex tic
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What is tachylalia?
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extremely rapid speech
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What are the clinical characteristics associated with PKAN?
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adult onset- older than 18; parkinsonism, dystonia, dysarthria, rigidity, corticospinal tract involvement, sz, global dev. delay, palilalia and tachylalia
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What are the side effects of intrathecal baclofen pump?
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decreased head & neck control, catheter infection, CSF leaks, baclofen withdrawal or overdose; 10% may lose response to baclofen with time
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What are the clinical characteristics of Wilson's diseae?
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Wilson's is characterized by dystonia (bulbar), dysphagia, dysarthria, scanning speech, hypophonia, focal dystonia, neuropsych symptoms
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What are the lab abnormalities in Wilson's disease?
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low ceruloplasmin
high urinary copper excretion |
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What is the treatment of Wilson's disease?
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copper chelating agents, penicillamine; zinc salts
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Who are good candidates for DBS in children?
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primary dystonia rather than secondary, children before they have fixed orthopedic deformities
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What are the complications of DBS in children?
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lead infection, hemorrhage, stroke
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What hyperkplexia?
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a pathologic startle response characterized by abduction of the arms and flexion of neck, trunk, elbows; also may have hyperreflexia
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What is the etiology of hereditary hyperkplexia?
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cause by mutation in alpha glycine receptor, abnormal chloride ion channel conductance
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What is the definition of chorea?
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brief irregular nonrhythmic nonpurposeful & flows from one body part to another
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What is Huntington's disease like 4 or SCA 17?
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CAG triplet repeat Chr. 17 TATA binding protein; ataxia and chorea
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What is the most common chorea of childhood?
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sydenhaam's chorea
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What is the natural history of sydenham's chorea?
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it resolves on its own within 6 months
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What are some treatment options for severe cases of sydenham's chorea?
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1) vpa
2) TBZ 3) IVIG 4) Prednisone 2 mg/kg/day |
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What type of chorea usually occurs in sydenham's chorea?
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generalized, sometimes hemichorea
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What is paroxysmal nonkinesiogenic dyskinesias?
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random episodes of dyskinesias, can last 15 minutes to 1 hour; triggered by EToh, coffee, stress, tea, chocolate
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What are some of the treatments tried for paroxysmal nonkinesiogenic dyskinesias?
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acetazolamide
antiepileptics clonazepam |
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What is the gene linked with paroxysmal nonkinesiogenic dyskinesias?
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myofibrillogenesis gene on chromosome 2
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What are paroxysmal kinesogenic dyskinesias?
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Characterized by multiple brief episodes of dyskinesias lasting seconds to minutes ; triggered by menstruation, humidity; responds well to Na blocker AEDs
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What are paroxysmal exercise-induced dyskinesias?
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dyskinesias lasting minutes to hours triggered by long periods of walking or exercise; associated with glc transporter and some epilepsies, responds to ketogenic diet
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What dose of propranolol can be used for essential tremor?
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up to 320 mg/ day
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What dose of primidone can be used for essential tremor treatment?
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up to 720 mg/day
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What are some differences in childhood ET?
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the frequency can sometimes be higher in 10 HZ in children and have to use a lower dose of propranolol and primidone
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Why should levodopa not be used in patients with juvenile parkinsonism?
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100% of these patients will develop DID within 1 year
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Why is it important to distinguish DRD from Juvenile parkinsonism?
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DRD responds well to dopa but also parkinsonism may be nearly isolated compared to the dystonia
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What is neuroleptic malignant syndrome?
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Acute abrupt (usually within 24 hours of exposure) dysautonomia, hyperthermia, elevated CPK, mental status change and rigidity
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What are the risk factors for neuroleptic malignant syndrome?
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young age
refusing food weight loss psychomotor activation high doses of neuroletics |
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What percentage of patients with NMS are fatal?
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20 to 30 %
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How long is recovery for NMS patients ?
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several weeks and rigidity cna last several months
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When during treatment can neuroleptic malignant syndrome manifest?
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It can manifest at any time during treatment
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What is the treatment for neuroleptic malignant syndrome?
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supportive care, removal of neuroleptic; dantrolene and bromocriptine can be supportive
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What are tardive dyskinesias?
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orobuccolingualmasticatory more common in adults, a symptom of chronic neuroleptic use
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When does tardive dyskinesia generally occur?
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anytime during treatment or change to another medication
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What is the treatment for acute dystonic reaction ?
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anticholinergic shot such as benztropine or benadryl with a few days of oral treatment
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What is the Westphal variant of Huntington's disease?
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juvenile onset characterterized by bradykinesia, rigidity, dystonia, seizures
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Why is it that paternal inheritance leads to longer triplet repeats?
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spermatogenesis makes unstable the number of triplet repeats leading to more anticipation
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Why must neuroleptics be slowly withdrawn in patients?
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they can often exhibit the withdrawal emergent syndrome characterized by choreic movements
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What timeframe is required in order to diagnose tardive dyskinesia?
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Must have had a neuroleptic within 6 to 12 months
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What is the natural history of an acute dystonic reaction?
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generally self-limited
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What other medication besides neuroleptics can lead to acute dystonic reactions?
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metoclopramide
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What is the definition of juvenile parkinsonism?
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Parkinson's prior to age 20
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What is benign hereditary chorea?
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nonprogressive chorea of childhood, chromosome 14, inherited autosomal dominant TITF1 gene
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What types of food are rich in copper?
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chocolate, nuts, shellfish and liver
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What is the most common misdiagnosis in children with DYT5 or Segawa syndrome?
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cerebral palsy because of their early gait abnormality
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What is DYT8?
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paroxysmal nonkinesogenic dyskinesia
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What is DYT 10?
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paroxysmal kinesogenic dyskinesia
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What is the most common single gene associated with autism?
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Fragile X
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What is the most common etiology for intellectual disability?
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Fragile X
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What is the difference between a premutation and a full mutation in fragile x?
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premutation is less than 200, full mutation is more than 200
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What is the prevalence of Fragile X premutation ?
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1 in 130 to 250
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What is the gene, mechanism of inheritance Fragile X syndrome?
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Xq23, recessive, CGG triplet repeats; more than 200 lead to disease
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What is the clinical phenotype of classic Fragile X?
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prominent ears, high arched palate, macroorchidism; pes planus (flat foot); developmental delay/autism, psychiatric/behavioral problems, neuropathy, htn, elastin abnl-hyperextensible joints, mvp
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What is the usual phenotype from FXTAS?
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older patient with premutation that may develop an action tremor, ataxia, gait abnormality and family history of fragile x
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What are some other clinical manifestations of patients with premutations for fragile x?
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primary ovarian failure, developmental delay, autism, ocd/ psych, FXTAS (most common)
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What is the usual age of onset for FXTAS?
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50s to 80s more common in >60s
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What is GM2 gangliosidoses commonly misdiagnosed as ?
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Friedrich's ataxia but can distinguish with the asence of scoliosis, cardiomyopathy and hyperreflexia
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What are the clinical features of GM2 gangliosidoses?
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spinocerbellar degeneration, ataxia, dysarthria, incoordination, hyperreflexia (some don't), absence of scoliosis/cardiomyopathy, pes cavus
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What is the usual presenting symptom of Niemann Pick Disease?
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progressive generalized dystonia
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What are the clinical features of Nieman Pick Disease?
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progressive generalized dystonia, progressive dementia, vertical gaze palsy (saccades only first); bone marrow shows foamy sea blue histiocytes
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How can you distinguish the dystonia in LSDs from other primary dystronia?
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the combination of dystonia and other systemic symptoms such as vertical gaze palsy, hyperreflexia or neuropathy, ataxia, etc.
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What is a distinguishing feature of spinal myoclonus?
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persists during sleep
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What is a distinguishing feature of Niemann Pick disease?
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gelastic cataplexy
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What is a distinguishing feature of metachromatic leukodystorphy?
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euphoria
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What is found on bone marrow aspirate for Niemann Pick disease ?
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foamy cells and sea blue histiocytes
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What is the usual clinical presentation of the neuronal ceroid lipofuscinosis?
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type a: progressive myoclonic epilepsy
type b: ataxia, extrapyramidal signs, facial dyskinesias, dementia |
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What is the mode of inheritance of NCL?
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heterogenous can be AD or AR
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What is the pathology found on NCL?
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osmiophilic inclusions in lysosomes and fingerprint bodies in liver, skin
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What is characteristic of sialidoses type 1?
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cherry red spot on macula plus progressive myoclonus
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How can you confirm a diagnosis of sialidosis type 1?
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alpha neuraminidase in cultured skin fibroblasts
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What is a method to confirm Pompe's disease in patients?
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test for alpha glucosidase in leukocytes and cultured skin fibroblasts
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What is the deficiency in Fabry's disease?
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alpha galactosidase
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What is the accumulation in Fabry's?
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ceramide trihexoside
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What are the clinical features?
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acroparesthesias, GI disturbance, cardiomyopathy, early stroke, angiokeratoma corporis diffusum
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What is the usual distribution of angiokeratoma corporis diffusum?
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between umbilicus and knee, also called "bathing trunk" area
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What is the deficiency in metachromatic leukodystrophy?
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arylsulfatase A in skin fibroblasts or leukocytes
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What are the 3 exceptions to mode of inheritance in lysosomal storage disorders?
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3 xlinked include: Hunter's, Fabry's, Danon
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What is Vitamin E deficiency, inheritance?
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AR alpha tocopherol transferase protein; low vitamin E; similar to Friedrich's ataxia, progressive ataxia, dystonia, proprioception/dorsal column abnormality
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What is MNGIE?
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mitochondrial neuro-GI encephalomyopathy; deficient thymidine phosphorylase
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What is the clinical presentation of MNGIE?
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in early 20s with borborygmi, abdominal pain, sensory > motor neuropathy
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What is abetalipoproteinemia?
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Similar to Refsum's + GI symptoms steatorhea, chronic diarrhea
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What is the defect in abetalipoproteinemia?
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mutation in MTP leading to abnormal triglyceride transfer protein
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What is the classic neuropathologic finding in FXTAS?
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eosinophilic intranuclear inclusions
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What are the clinical characteristics associated with FXTAS?
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neuropathy, autonomic dysfxn, tremor, memory loss/exec. dysfunction
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What is the rate of CSF obstruction following pediatric CSF diversion procedures?
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>50% and can occur at any time/ 80% lifetime risk
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What is the rate of shunt infection?
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less than 10% usually in first 6 months; after that is rare
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What is the rate of low-drainage complication from shunt?
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15% and can occur at any time
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What are the criteria for definite MSA?
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pathologic glial argyrophilic cellular inclusions in oligodendroglia
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What are the criteria for probable MSA?
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1) autonomic failure
2) poorly dopa responive parkinsonism 3) cerebellar features exclusions: early dementia, abnl vertical gaze, alien limb |
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What are the clinical symptoms of PSP?
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falls, postural instability, retrocolis/axial dystonia, vertical gaze palsy, pseudobulbar palsy, bradykinesia
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What are the pathologic findings in PSP?
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tufted astrocytes in the striatum, thalamus, subthalamic nu, precentral gyrus
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What are the clinical characteristics of CBGD?
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progressive asymmetric apraxia, rigidity, aphasia
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What is the pathology in CBGD?
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neuronal loss/atrophy peri-sylvian ballooned neurons & astrocytic plaques
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What are the 3 criteria for diagnosis of CBGD?
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1) alien limb
2) focal dystonia 3) dementia |
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What are the diganostic criteria for Lewy Body Disease?
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1) fluctuating course
2) parkinsonism 3) visual hallucinations supportive -poorly responsive to dopa -rem sleep disorders -neuroleptic sensitivity |
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What are 3 major and 4 supportive criteria for Dementia with Lewy Bodies?
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1) Parkinsonism
2) Dementia with fluctuations 3) Visual Hallucinations supp: -early falls -neuroleptic sensitivity - rem sleep behavioral d/o - decreased dopa in striatum |
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What disease is associated with Hirano bodies?
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Alzheimer's disease
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What is the deficient enzyme in Nieman Pick disease?
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sphingomyelinase AR
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What are the clinical sx assoc. with Nieman pick?
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first decade, prog generalized dystonia, gelastic cataplexy, dementia;seizures, hepatosplenomegaly, ataxia, vertical gaze palsy bone marrow with foaamy sea blue histiocytes
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What are clinical symptoms of Fabry's disease?
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1) Pediatric/early stroke
2) small fiber neuropathy 3) Renal disease 4) Angiokeratoma corpora diffusum in bathing trunk distribution 5) SX provoked by hot weather & exercise |
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What is the mode of inheritance of Fabry's?
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X linked recessive
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What is the deficient enzyme in Fabry's?
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alpha galactosidase A
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What accumulates in Fabry's?
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ceramide trihexoside in smooth muscle, perithelial and endothelial cells
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What is the mode of inheritance of episodic ataxia type 2, protein, chromosome?
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autosomal dominant
calcium channel chromosome 19 |
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What are the clinical characteristics of episodic ataxia 2?
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intermittent downbeat nystagmus; ataxia
+/- dystonia |
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What are some neuro-optho manifestations of PD?
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hypometric saccads, limit upgaze palsy, blepharospasm, saccadic pursuit, ocular apraxia, abnormal vergence
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What is the one sensory symptom assoc with PD?
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anosmia
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What some symptoms of rigidity?
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shoulder pain
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What is the characteristic hand posture of basal ganglia disease called
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striatal hand deformity
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What is the MOA of amantadine?
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anti-NMDa, anticholinergic, increase dopamine release (postulated)
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What is guillan mollaret triangle?
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red nuceus ipsi central tegmental tract to inferior olive contralateral icp to dentate nucleus to contralateral scp to red nucleus
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What does a lesion in the central tegmental tract of guillan mollaret triangle usually cause?
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palatal myoclonus
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What paraneoplastic antibody is associated with opsoclonus myoclonus?
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anti-anna 2 or anti-ri assoc. with neuroblastoma in children or breast and lung in adult
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What type of vascular event can treat ET?
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dentate nucleus stroke
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What is the target of DBS for ET?
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Vim thalamus
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What supplies the head of the caudate nucleus?
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recurrent antery of huebner
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What peduncle does the dentatothalamic tract and dentatorubral tract travel in?
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scp
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What does the pontocerebellar tract travel in?
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mcp
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What are the clinical features associated with DRPLA?
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CAG triplet repeat disorder, myoclonic epilepsy, dementia, ataxia and choreoathetosis
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What is the triplet repeat disorder associated with friedrich's attaxia?
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GAA
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What imaging abnormality may be noted in Machado Joseph disease or SCA-3 with limitation of eye movements?
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pontine atrophy
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What basal ganglia part does methanol affect?
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putamen
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What basal ganglia part does carbon monoxide affect?
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globus pallidus hemorrhage
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What eye abnormality would occur first in a patient with HD who is beginning to develop symptoms?
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slowing of saccades
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What is the most efficacious responsbe to DBS?
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equivalent to her current best on-state
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What is the penetrance of DYT1 or Torsin A?
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Low penetrance, 70% of carriers show no signs of dystonia
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What two muscles are involved in torticollis with head to left?
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right sternoclediomastoid and left splenius capitis
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What movement disorder do patients with gaucher disease develop?
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spontaneous parkinson's disease, glucocerebrosidase deficiency
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sphingomyelinase
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niemann pick c
gelastic cataplexy, dystonia, abnormal downward movements |
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hexosamindase b
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GM 2 gangliosidos
Friedrich's ataxia like (without cardiomyopathy and scoliosis) |
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glucocerebrosidase deficiency
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gaucher
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acetylcholinesterase deficiency
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synaptic congenital myasthenic syndrome
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What type of paroxysmal dyskinesia is responsive to treatment?
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paroxysmal kinesiogenic dyskinesias
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In PARK1 caused by alpha synuclein mutations, what is the clinical characteristics
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more cortical features, more frequent cognitive decline, less reponsibe to dopa, younger age of onset
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What are the clinical manifestations of DRPLA?
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young, juvenile or adult onset:
general ataxia, choreoathetosis & dementia (prog myoclonic epilepsy in younger patients) |
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Where are the tufted astrocytes located in PSP?
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striatum, thalamus, subthalamic nucleus, precentral gyrus
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What is the abnormal protein in benign hereditary chorea?
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TITF 1 thyroid transcription factor gene
also assoc with lung & thyroid cancer ??sellar cancer |
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What are the clinical manifestations of benign hereditary chorea?
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chorea, ataxia, mr, developmental delay; should be autosomal dominant disorder
**only chorea responds to levodopa |
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What are the clinical symptoms of neuroacanthocyosis?
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chorea
orofacial dyskinesias (tongue thrusting) difficulty feeding sensory neuropathy & myopathy acanthocytes on blood smear (EDTA, glass to stress blood & EM ) elevated CK |
