PANCE Review > Neurologic System > Flashcards

Neurologic System Flashcards

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1
Q

complex regional pain syndrome (CRPS)

A

autonomic and vasomotor dysfunction in extremities
usually follows trauma to affected limb
- pain or tenderness out of proportion to exam
- swelling, muscle atrophy
- does NOT follow peripheral nerve distribution
- no systemic sxs

Tx:

  • NSAIDS, PT/OT
  • steroids, anti-depressents, gabapentin, etc.
  • early mobilization is key
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2
Q

peripheral neuropathies - sxs, dx

A

may be motor (guillian-barre), sensory (DM), autonomic (DM), or combo

Dx:

  • EMG/NCV (nerve conduction velocity) - primary test
  • labs: glucose, BUN/Cr, vit B6 and B12, RPR
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3
Q

diabetic neuropathy - clinical, tx

A

distal, symmetrical polyneuropathy
- most common peripheral neuropathy in western world

tx: no tx to halt progression
- goal: control sxs and prevent osteomyelitis
- tight glucose control
- foot care

meds:

  • gabapentin
  • pregabalin (lyrica)
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4
Q

charcot-marie tooth disease (CMT)

A

child or adult with progressive motor weakness
- foot drop (anterior tibialis weakness), high arches, hammer toes

Dx: genetic testing

Tx: focus on function

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5
Q

bell’s palsy

A

lower motor neuron facial nerve paresis

  • causes: infection, pregnancy, DM
  • abrupt onset of facial paralysis (complete 1/2 side)
  • 60% recover w/out tx (steroids w/in 5 days benefit)

Note: CVA would be able to move eyebrow

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6
Q

cluster headache - clinical, timing, tx

A

severe, unilateral periorbital pain

  • stabbing
  • middle-aged man
  • often with nasal congestion, tearing on same side

timing:

  • occur in clusters: daily for several wks
  • 15 min- 3 hrs

tx:

  • abortive: 100% oxygen
  • prophylactic: Verapamil
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7
Q

migraine headache - clinical, timing, triggers, tx

A

HA of neurovascular dysfunction

  • often a FH
  • onset teens - 30s
  • women>men

Sxs:

  • throbbing, unilateral, pulsing
  • N/V, photophopbia
  • WORSE with activity
  • last hours to date
  • can have “aura” and prodrome

Triggers:
-stress, foods, ETOH, smells, bright lights, menstrual

Tx:
- avoid triggers, dark/quiet room

Abortive:

  • NSAIDS (mild),
  • triptans (mod/severe): avoid in CVD, PVD, pregnency; combine w/ naproxen for inc. benefit

Preventative (if >3 times/month or interferes w/ life activities):

  • antiepileptics: Topiramate, valproic acid
  • antihypertensives: propranolol

NOTE: if pt over 60, get ESR to R/O giant cell arteritis

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8
Q

tension headaches - clinical, triggers, tx

A

generalized, constant, squeezing

  • most common primary HA
  • DO NOT worse with activity
  • no N/V

Tx:

  • stress reduction, sleep hygiene
  • NSAIDS, acetaminophen

Prophylaxis: TCAs

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9
Q

encephalitis - definition, sxs, dx, tx

A

inflammation/infection of brain parenchyma
- usually viral
Epidemic: west nile virus
Non-epidemic: HSV-1

s/sx:

  • viral prodrome (fever, malaise, myalgia, N/V/D, rash)
  • HA, photophobia, altered sensorium, seizures

Dx:
- lumbar puncture (CSF PCR): showing elevated opening pressure, elevated protein and WBC, glucose (normal if viral)

Tx: do not wait for LP results
- Acyclovir (since most common is HSV-1)

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10
Q

viral vs. bacterial etiology of CSF

A

lumbar puncture (CSF PCR):

  • viral will have normal glucose
  • bacterial will have low glucose (bacteria eat glucose)
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11
Q

meningitis

A

inflammation/infection of arachnoid membrane, pia mater, and CFS in between

  • bacterial, viral, other
  • dec. incidence due to vaccines
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12
Q

bacteria meningitis - clinical, signs

A

acute onset of fever, HA, vomiting, stiff neck, myalgia, backache, weakness

  • rapid progression to confusions, loss of consciousness, sz
  • MEDICAL EMERGENCY

Signs:

  • Kernig and Brudzinski - flexion of knees in pain
  • petechiae or ecchymosis rash: meningococcal
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13
Q

bacteria meningitis - dx, tx

A

lumbar puncture:

  • elevated opening pressure
  • CFS: elevated protein, dec. glucose, elevated cell count (PMN)
  • positive gram stain

Blood cultures

CT/MRI of brain and spine

CXR, sinus, mastoid

tx:

  • IV ABX and dexamethasone
  • empiric tx by demographic (1st)
  • pathogen specific tx
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14
Q

viral meningitis - clinical, dx, tx

A

acute onset of fever, HA, vomiting, stiff neck, myalgia, backache, weakness, rash
- 60% are enteroviruses (fecal-oral transmission)

lumbar puncture:

  • slightly elevated opening pressure
  • CFS: elevated WBC, normal or slightly elevated protein, normal glucose
  • negative gram stain

Tx: supportive

  • NSAIDS, analgesics, antiemetics
  • acyclovir if HSV
  • out-patient recovery 1-3 wks

NOTE: prevention key (mumps was #1 cause prior to vaccine)

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15
Q

essential tremor

A

postural tremor of hands, head, of voice

  • genetic
  • may begin at any age
  • worse with stress; less with ETOH

Tx:

  • nothing if not disabling
  • propranolol if disabling
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16
Q

huntington disease

A

progressive disease resulting in death of nerve cells (including brain cells)

  • genetic
  • onset b/t 30-50 (fatal 15-20 yrs)

s/sx: gradual onset chorea (jerky, involuntary mov’t), dementia, behavioral changes

dx:

  • CT or MRI: cerebral atrophy
  • genetic tests for definitive dx

tx: symptomatic
- genetic counseling

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17
Q

Parkinson Disease

A

disease of imbalance of dopamine and acetylcholine in corpus striatum

  • PROGRESSIVE dz
  • usually sporadic (NOT inherited)
  • onset 45-65 y/o
  • lies on spectrum - parkinsonism

s/sx:

  • pill rolling tremor at rest, cogwheel rigidity
  • bradykinesia (trouble initiating mov’t), gait impairment/shuffle

Dx: clinical

tx:

  • early (prevents progression): amantadine, anticholinergics, dopamine agonists, brains stimulation
  • Levodopa (converted in body to dopamine) / carbidopa (inhibits enzyme that breaks down levodopa) is MAINSTAY of treatment
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18
Q

cerebral aneurysm: definition, risks, complication, dx, tx

A

“berry aneurysm” that occur at arterial bifurcations

  • asymptomatic until rupture
  • most in Circle of Willis

Risks: smoking, HTN, hyperlipidemia

complication: subarachnoid hemorrhage
dx: angiography (gold standard)

tx:

  • surgery, endovascular intervention
  • monitor if <10mm
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19
Q

stroke - two types

A

brain infarction
very common - 2nd leading cause of death world-wide

ischemic (85%)
- thrombotic (arthrosclerosis), embolic (a-fib), small vessel dz

hemorrhagic (15%)

  • intracerebral
  • subarachnoid
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20
Q

stroke - risk factors

A

HTN
DM
Smoking

also:

  • atrial fibrillation
  • carotid stenosis
  • black/hispanic
  • men
  • obesity
  • ETOH
  • OCP
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21
Q

transient ischemic attack - definition, cause, W/U

A

acute onset of focal neurologic deficit lasting

  • sxs < 24 hrs
  • no infarction

Cause: emboli from heart or extra cranial artery

W/U: CT or MRI w/in 24 hrs
- also carotid U/S, MRA, CTA

Note: if sxs >1-2 hrs, possibly infarction and generally worse outcome

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22
Q

transient ischemic attack - treatment

A

assess ABCD2 score

  • age (>60)
  • BP>140/90
  • focal weakness on exam
  • duration of sxs > 60 min
  • DM

Tx: Statin, ASA, anti-platelet meds (clopidogrel), carotid surgery of severe stenosis

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23
Q

ischemic stroke -s/sx, dx

A

s/sx:

  • focal neurological deficit (mental status, speech, CNs, strength, reflexes)
  • painless, abrupt onset
  • NIH stroke scale

NOTE: presentation depends on artery occluded
- Middle cerebral artery is MOST COMMON and presents w/ contralateral hemiparesis, arm/face sensory loss, expressive aphasia (Broca’s - partial loss of ability to produce language)

dx:
- non-contrast
CT brain (r/o hemorragic)!!!

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24
Q

ischemic stroke - tx

A

ABCs
Correct glucose
Thrombolytic therapy: rtPA (w/in 4.5 hrs of onset)
Lower BP (so can receive rTPA) : Labetalol, nicardipine
Aspirin (if rtPA contraindicated)
Mannitol: lowers ICP
PT/OT

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25
thrombolytic therapy (rtPA) contraindications
``` BP>185/110 head trauma or stroke in previous 3 mo recent CNA surgery GI bled Hx of ICH Recent anti-coag/bleeding diathesis Glucose < 50 ``` Note: no anticoagulants of platelet-inhibitors for 24 hrs after admin of t-PA
26
ischemic stroke - prevention
anti-platelet therapy: ASA, Plavix control lipids: statins control BP: ACE-I in DM smoking cessation anti-coagulation for A-fib patients (Warfarin, DOAC) carotid endarterectomy or stenting
27
intracranial hemorrhage (ICH) - definition, causes, dx
bleeding into brain causes: - HTN (very abrupt), trauma, drugs (anti-coagulants, 1-2 day onset) - Asian and AA dx: - CT brain (differentiate from ischemic stroke so DO NOT give tPA) - investigate for coagulopathy: PT/PTT/INR - CTA to find site of bleed
28
intracranial hemorrhage (ICH) - tx
manage HTN: nicardipine control ICP: mannitol, fluid restrict seizure ppx: fosphenytoin reverse coagulopathy: FFP (fresh frozen plasma), vit K surgical evacuation of hemotoma
29
subarachnoid hemorrhage (SAH) - definition, cause, s/sx, dx
ruptured vessel in subarachnoid space - high mortality cause: trauma follow by ruptured aneurysm s/sx: - rapid onset, severe HA (thunderclap; worst of life) - N/V, AMS, neck stiffness dx: - non-contrast CT - LPL blood in CSF - cerebral angiography: finds source of bleed - CBC, coag studies, electrolytes
30
subarachnoid hemorrhage (SAH) - tx
BP control: beta-blockers Sz ppx: fosphenytoin Nimodipine: CCB to reduce vascular spasm surgery: clipping, coiling reduce ICP: Mannitol, diuretics Support: ventilation, nutrition
31
subdural hematoma (SDH) - definition, causes, common population, s/sx
hemorrhage beneath dura -venous bleed = slower causes: - trauma (may be minor) - anticoagulation - ETOH - frequent falls common: very young and very old s/sx: - unilateral HA and ipsilateral enlarged pupil - subacute many progress over 3-7 days
32
subdural hematoma (SDH) - dx, tx
CT brain: crescent-shaped collection over 1 or both hemispheres - crosses sutures, not midline - concave
33
epidural hematoma (EDH)
blood accumulates below skull but above dura - arterial bleed = faster s/sx: - lucid interval of min to hrs b/f alter mental status dx: CT brain - bi-convex-shaped - does not cross suture lines
34
altered level of consciousness - causes and definitions
result from a serious insult to CNS - seizure, structural lesion, hypothermia, metabolic d/o, toxic/drug induced stupor: transient arousa by vigorous stimuli coma: non-arousable, no response to external events vegetative: wakefulness present but awareness absent
35
altered level of consciousness - dx
Glasgow coma scale - mild head injury: 13-15 - moderate head injury: 9-12 - severe head injury: 8 or less finger-stick glucose STAT EKG: did MI occur Labs: serum glucose, electrolytes, calcium, LFTs, BUN/Cr, tox studies, ABG EG, brain CT/MRI, LP
36
altered level of consciousness - tx
tx depends on etiology - correct underlying d/o supportive tx: - stabilize c-spine, ABCs - control sz - empiric ABX if meningitis - lower ICP: mannitol, surgical decompression - coma cocktail: dextrose, naloxone (in case opioid OD), thiamine IV (correct deficiency in ETOH)
37
concussion - definition, s/sx, W/U, tx
transient trauma-induced change in mental status - may or may not involve LOC - simple: resolves w/in 3 wks - complex: does not resolve s/sx: - HA, N/V, disorientation, irritability, visual disturbance, neurological deficits W/U: - Head CT: use Canadian CT Head rules to determine risk (GCS<15, possible skull fx, vomit >2x, age<65, mechanism) - ADMIT: age >65, intoxication, soft tissue injury above clavicle - MRI if sxs persist > 14 days or worsen Tx: MUST be cleared by trained provider - cognitive and physical rest key
38
post-concussive syndrome
sxs lasting weeks to > 1 year s/sx: - HA, trouble concentrating, fatigue, dizziness, irritability
39
cerebral palsy - clinical, s/sx
chronic, static impairment of muscle tone, strength, coordination, and movement (does not progress) - results from insult to neonatal nervous system / brain - possibly hypoxia, infection s/sx: spasticity, ataxia - can have associated developmental delay or sz d/o
40
cerebral palsy - dx, tx
dx: clinical tx: maintain maximal physical fx - PT/OT, speech - counseling, education meds: for spasticity (Baclofen, botox) prognosis depends on severity of deficits
41
dementia - definition, risk factors
progressive decline in intellectual and cognitive fx - compromises social and occupational fx - leads to loss of independence - age > 60 typical Loss of ST memory and 1+ cognitive deficit: - aphasia: impaired word-finding - apraxia: impaired motor tasks - agnosia: impaired recognition of objects - impaired executive fx (planning) Risk factors: - age, stroke, FH, DM, head injury
42
alzheimer disease - cause, s/sx
loss of ST memory (anterograde amnesia) - most common type of dementia cause: accumulation of B-amyloid plaques in brain s/sx: - early: difficulty w. finances, independent travel meal prep - late: difficulty with ADLs usually no motor deficits
43
alzheimer disease - tx
aerobic exercise, mental stimulation 1st line: acetylcholinesterase inhibitors - donepezil (Aricept) - rivastigmine (Exelon)
44
Types of dementia (in addition to alzheimer disease) - Vascular - Lewy body - Frontotemporal lobar degeneration
Vascular: due to multiple infarcts to brain (stroke) - motor slowing, gait d/o Lewy body: dementia with parkinsonism, visual hallucinations, - antipsychotics worsen Frontotemporal lobar degeneration: d/o of behavior and personal relationships - rude, sexually explicit, poor judgment, poor hygiene
45
delirium - definition, causes
global impairment in cognitive functioning that is sudden in onset - presents with diminished level of consciousness, inattention, visual hallucinations, autonomic changes (tachycardia, sweating) - usually reversible - lasts <1 wk Causes: - Hypoxia - Hypoglycemia - Acute intoxication or withdrawal - Meningitis/ encephalitis - Intracranial injury - Hypo/hypernatremia - Drug side effects - Medications!!
46
guillain-barre syndrome - definition, causes, s/sx, dx tx, prognosis
acute, inflammatory demyelinating polyneuropathy causes: infection, vaccine surgery - Caplylobacter jejuni (?) s/sx: - weakness>sensory disturbance ("rubbery legs") - begins distal and spreads proximal - motor paralysis - autonomic disturbance: cardiopulmonary (may need intubation) dx: - CSF: inc. protein - R/O other neuropathies tx: - plasmapheresis, IVIG - steroids are INEFFECTIVE Prognosis: - recovery takes months! - 15-20% w/ lasting disability
47
multiple sclerosis - definition, causes, s/sx, dx tx, prognosis
focal areas of demyelination - scattered white matter changes in CNS (periventricular, spinal cord) - likely autoimmune - progressive dz - women>men (white) - can occur postpartum s/sx: - weakness, numbness, optic neuritis, diplopia - nystagmus, UMN findings (hyper-reflexia) types: - relapsing-remitting - secondary progressive - primary progressive Dx: - s/sx must be disseminated in time and space - s/sx last at least 24 hrs at least 1 mo apart - pathology in anatomically noncontiguous white matter tracts of CNS - MRI: brain and spinal cord ("black holes", "dawson's fingers" in brain) - LP: oligoclonal bands (IgG) tx: - acute attacks: corticosteroids (do not prevent progressive) - progressive dz: B-interferon or glatiramer
48
myasthenia gravis
autoantibodies to acetylcholine receptors - autoimmune dz - slow, progressive - women>men - may be associated with thymus d/o s/sx: - fluctuating weakness of voluntary muscles - weakness worsens with repetitive activity - insidious onset: illness, pregnancy, menstruation - ptosis, diplopia, difficult chewing/swallowing - limb weakness dx: - weakness on exam - serum acetylcholine receptor antibodies Tx: - acetylcholinsterase inhibitors: pyridostigmine, neostigmine
49
epilepsy
recurrent, unprovoked seizures
50
seizure - definition, causes, types
transient disturbance of cerebral function due to neuronal hyper excitability causes: - genetic - strutural - metabolic - unknown focal: - simple partial: w/out impaired consciousness - complex partial: with impaired consciousness general: - tonic-clonic - absence (petit mal)
51
focal seizure - types, s/sx, tx
simple partial: w/out impaired consciousness complex partial: with impaired consciousness s/sx: - motor jerking or paresthesias along limb or part of body tx: anti-convulsants - lamotrigine, carbamazepine, oxcarbazepine - phenytoin - Levetiracetam (Keppra)
52
absence (petit mal) seizure - s/sx, tx
type of generalized seizures brief impairment of consciousness - pt often no aware - may include tonic/clonic movements - enuresis possible - EXCLUSIVELY in childhood (< 20 y/o) Tx: anti-convulsants - valproic acid - ethosuximide
53
tonic-clonic (grand mal) seizure - s/sx, tx
type of generalized seizures - sudden loss of consciousness with rigidity (tonic) - jerking, convulsive mov't (clonic) - 2-3min - urinary/fecal incontinence, tongue biting, aspiration followed by: - flaccid coma - postictal state of confusion tx: - valproic acid - ethosuximide
54
seizure evaluation/dx
EEG: mainstay of dx - paroxysmal spikes, sharp waves MRI of brain (CT if MRI contraindicated) Labs: CBC, glucose, electrolytes, calcium, Mg, LFTs LP: r/o infection
55
seizure - tx
meds: - Valproic acid, phenytoin, carbamazepine, phenobarbital, topiramate, lamotigine - ETOH w/drawal: benzodiazepine lifestyle: - avoid triggers - avoid dangerous situations (driving, operating machinery) - comply w/ state laws Note: tx until >2 yrs sxs free
56
seizure - medication considerations
many sz meds are teratogens: - avoid in pregnancy: valproic acid - cat D: carbamazepine, phenobarbital, topiramate Many have side effects and interactions Must monitor serum levels for most drugs - except Keppra (levetiracetam) Wait at least 2 yrs sz-free to d/c meds
57
status epilepticus - definition, cause, tx
repeated seizure, without recovery, lasting > 30 minutes - MEDICAL EMERGENCY cause: poor medication adherence tx: - ABC: maintain airway - dextrose IV (potential hypoglycemia) - benzos to break seizure
58
syncope - definition, 3 types
transient loss of consciousness - due to global impairment of cerebral blood flow - often impairment of vasoconstriction 3 types: 1. cardiogenic: arrhythmias, aortic stenosis 2. orthostatic hypotension - autonomic neuropathy (DM) common cause 3. neurally mediated/vasovagal: provoked by fear, pain - preceded by sweating, dizziness
59
syncope - manage / tx
vasovagal: -avoid triggers All: - eval for head injury from fall - cardiac W/U - carotid imaging - tx cardiac abnormalities Meds: - midodrine: vasoconstrictor
60
tourette syndrome
frequent motor and/or phonic tics lasting at least 1 year - sxs must begin b/f age 21 - cause is not known (possibly chromosomal) - chronic course; may be relapsing/remitting - often associated with OCD - motor tics and phonic tics tx: symptomatic - CBT 1st line - FDA-approved: antipsychotics (Haloperidol)
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