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UWorld Flashcards

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1
Q

Complications of subarachnoid hemorrhage

(a) First 24 hrs
(b) 5-14 days
(c) BMP abnormality

A

SAH complications

(a) Rebleeding in the first 24 hrs
(b) 5-14 days: vasospasm
(c) Hyponatremia 2/2 SIADH (syndrome of inappropriate antidiuretic hormone secretion)

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2
Q

Mechanism by which metoclopromide causes neck pain and stiff/tender neck muscles

A

Metoclopromide-induced dystonia 2/2 activity as a dopamine receptor antagonist

Extrapyramidal symptoms (tardive dyskinesia, dystonic rxns, and Parkinsonisms) are unfrequent but possible side effects of regional

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3
Q

Clinical manifestation of cerebellopontine angle tumors

A

Cerebellopontine angle tumors = acoustic neuromas/meningiomas

P/w HA, hearing loss, vertigo, tinnitus, balance problems

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4
Q

55 yo F w/ sudden onset severe l. periorbital pain and HA

  • blurry vision, sees halos of light
  • pupil dilated and poorly reactive to light

Dx

A

Dx = closed angle glaucoma

  • acute, accompanied by pain
  • buzzword = halos around lights
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5
Q

Most common manifestation of lacunar strokes

A

Most often affect the internal capsule => result in pure motor hemiparesis

ex: pt w/ sudden onset right sided (arm and leg) weakness and normal NCHCT

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6
Q

Cavernous sinus thrombosis

(a) Bugs
(b) Clinical presentaiton

A

(a) Staph/strep from disseinated localized infection

(b) Headache, CN (3,4,V1,V2,6) paralysis, decreased vision, exopthalmous (bulging eyes), chemosis (conjunctival swelling)
- symptoms b/l b/c cavernous sinus has anastomoses crossing midline

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7
Q

3 day old ex-30 weaker born at 1.36 kg (3 lb) w/ hypotonia, seizures, and rapidly increasing head circumference

  • lethargic neonate, tense fontanels, generalized hypotonia
  • Head ultrasound shows hydrocephalus

Dx

A

Dx = intraventricular hemorrhage
-common complication in ex-30 or before seekers

Rapidly increasing head circumference and bulging fontanelles consistent w/ severe hemorrhage

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8
Q

12 yo M w/ symmetric paralysis, absent DTRs, decreased superficial touch and vibratory sense of LE b/l 10 days s/p febrile diarrheal illness

(a) Dx
(b) Mechanism
(c) Etiology

A

(a) Guillan-Barre
(b) Demyelinating polyneuropathy, demyelination of peripheral nerves: mostly motor but also can be sensory and autonomic
(c) In this case most likely 2/2 campylobacter jejuni infxn

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9
Q

58 yo F p/w severe HA (right sided, retro-orbital) and agitation

  • blurry vision, constipation, vom
  • PMH: Parkinson’s, hypothyroid, HTN, chronic Hep C

Which medication most likely responsible?

A

Trihyexyphenidyl (anticholinergic)

Recognize anticholinergic toxicity: dry skin, dry mouth, constipation, urinary retention, flushing, vision changes, confusion

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10
Q

58 yo M w/ sudden onset speaking difficulty (difficulty w/ word finding and can’t follow simple commands) and weakness (marked in RUE, mild RLE)

  • forced conjugate gaze preference to the left
  • neglect of right visual field
  • severe right lower facial droop

PMH: uncontrolled

  • HTN, HLD
  • severe LA enlargement
  • carotid US w/ 25% stenosis

BP 156/96, HR 124 irregulargly irregular

(a) Dx- be specific as to location
(b) Explain all findings

A

(a) Cardiogenic emboli to MCA (probably distal segment of M1)

  • Global aphasia (both expressive and comprehensive) localizes to the left hemisphere
  • forced gaze preference to the left = damage to frontal eye fields
  • right homnomymous hemianopsia (neglecting right visual field) = damage to upper and lower optic radiations in the lateral temporal and parietal lobes

Suggestive of large-occlusion- distal M1 segment of the left MCA
-right-sided weakness (face/arm over leg) consistent w/ left frontal lesion

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11
Q

Most common cause of intraparenchymal hemorrhage in adults vs. children

A

Adults = hypertensive vasculopathy

Children = AVM

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12
Q

Differentiate migraines and tension HA

A

Migraines: 4-72 hrs

  • unilateral
  • pulsatile
  • inhibits daily activity
  • aggravated by physical activity

Tension HA: 30 min-7 days

  • b/l
  • pressing/tightening, dull (non-pulsatile)
  • mild to moderate, may inhibit but doesn’t prohibit daily activity
  • not aggravated by physical activity
  • no N/V
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13
Q

45 yo M p/w wasting of extremity muscles more apparent on extensor side

  • weakness began distal and asymmetrically
  • recent difficulty w/ swallowing, chewing, and speaking
  • muscles stiffness
  • bowel, bladder, sensory, cognitive fxns intact
  • fasciculations and hyperreflexia of all extremities
  • decreased bulbar reflexes

Dx

A

Dx = ALS (amyotrophic lateral sclerosis

Presence of both UMN and LMN findings

UMN

  • spasticity
  • bulbar symptoms
  • hyperreflexia

LMN
-fasciculations

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14
Q

36 yo F p/w daily bandlike HA, dizziness, and fatigue x1mo after a fall at work w/ LOC

Dx

A

Dx = postconcussive syndrome (following mild TBI)
Symptoms: HA, confusion, amnesia, difficulty concentrating or multitasking, vertigo, mood alteration, sleep disturbance
-resolve w/in week to months, but sometimes can last over 6 mo

While a delayed subdural hemorrhage would result in focal neurologic finding

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15
Q

10 hour old newborn w/ swelling on scalp that wasn’t present at birth

  • swelling limited to surface of one cardinal bone
  • no visible pulsations, indentations of the skull, or discoloration of overlying scalp

Dx

A

Dx = cephalohematoma = subperiosteal hemorrhage

  • always limited to surface of one cranial bone (b/c it’s sub-periosteal)
  • swelling not visible at birth b/c subperiosteal bleeding is slow/gradual
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16
Q

6 mo old F w/ milestone regression

  • hypotonic, hepatosplenomegaly and protuberant abdomen
  • bright red macula, cervical lymphadenopathy

(a) Deficiency
(b) Dx

A

(a) Spingomyelinase deficiency
(b) Neimann-Pick disease

  • autorecessive, loss of motor milestones/hypotonia, cherry red macula
  • different from Tay-Sachs: HSM and areflexia (while hyperreflexic Tay-Sachs)
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17
Q

Pt w/ r. facial droop- what sign would localize facial nerve palsy to below the pons

A

Below the pons if pt is unable to close eye on affected b/c means forehead control is not intact

Lesion in CNS above the facial nucleus would cause lower facial weakness sparing the forehead b/c collaterals (peripherally) are intact

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18
Q

53 yo M w/ occasional shaking of r. hand x3 mo

  • present at rest, stops when reaches for remote
  • no other neurologic symptoms or PMH

Mechanism of disease?

A

Basal ganglia dysfunction

-resting tremor = early sign of Parkinson’s

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19
Q

Focal vs. absence seizures

A

Focal: longer (2-3 mins), can have post-ictal state
-often automatisms

Absence: shorter (10-20 sec), no post-ictal state
-easily provoked by hyperventilation

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20
Q

8 yo M w/ multiple staring episodes that last 2-3 minutesduring which he tilts head and seems like he’s chewing, he is unresponsive during

  • he remains confused for 20 minutes after
  • EEG is unchanged w/ hyperventilation

Dx

A

Dx = focal seizures = originate in single hemisphere, can have lOC
-often have automatisms = repetitive semi-purposeful mov’ts (chewing, swallowing)

Different from absence seizures b/c this kid has post-ictal state, seizures not provoked by hyperventilation, and lasts longer than 10-20 seconds

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21
Q

What type of tremor is a cerebellar tremor?

A

Intention tremor- tremor increases steadily as hand reaches the target

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22
Q

Features of anterior cord syndrome

A

Anterior cord syndrome (often 2/2 burst fracture of the vertebra)

  • loss of motor fxn below the lesion
  • loss of pain and temp on both sides below the lesion
  • intact proprioception
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23
Q

Describe physiologic tremor

A

Not visible under normal conditions, comes out during sympathetic tress (drugs, anxiety)
-usually worse w/ movement

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24
Q

56 yo M w/ b/l HA 3-4 per week

  • mild photophobia, no phonophobia
  • doesn’t interfere w/ work
  • unremarkable neuro exam

Most likely dx?

A

Tension HA

  • b/l
  • doesn’t prohibit activity, mod-mild intensity
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25
46 yo M develops severe HA only in certain postures, sometimes LOC C/f
C/f intraventricular tumor b/c positionally blockage of CSF flow that causes sudden increase in ICP => acute HA w/ possible LOC
26
72 yo F w/ HTN, DM2, CAD suddenly drops fork while eating -speech becomes slurred, develops r sided weakness Dx
Dx = Lacunar stroke in basal ganglia -intracranial bleed -progressive symptoms w/ early focal neurologic symptoms and h/o HTN
27
Triad of Wernicke's encephalopathy
1. Encephalopathy (confusion) 2. Ocular dysfunction - often opthalmoplegia = paralysis of one or more EOM 3. Cerebellar/gait ataxia
28
58 yo F p/w difficulty walking - b/l foot numbness and tinging - currently on bleomycin, doxorubicin, and vicristine for Hodgkin lymphoma Dx
Dx = chemotherapy-induced peripheral neuropathy -stocking-glove distribution Most likely from vincristine -also from cisplatin and paclitaxel
29
Pt p/w Hemi-Neglect of the left side Locate the lesion
Lesion = right parietal cortex -responsible for spatial orientation -ignoring side of space = non-dominant parietal lobe
30
Immediate reversal agent for (a) Wafarin (b) Heparin
(a) Warfarin can be reversed with prothrombin complex concentrate (KCentra) which contains vitamin-K dependent clotting factors for rapid reversal - also give IV vitK: takes about 12 hrs to kick in (b/c need to remake factors) (b) Protamine sulfate binds to heparin to inactivate it
31
55 yo M w/ impaired vision x6 mo - intermittent morning headaches and decreased libido - decreased vision in temporal fields b/l Dx
Dx = craniopharyngioma = benign sellar mass - compression of the optic chiasm => bitemporal blindness - symptoms of pituitary hormone deficiency (ex: hypogonadism)
32
(a) How to make a diagnosis of NPH | (b) How to tx NPH
(a) Dx NPH w/ enlarged ventricles on neuroimaging and LP not showing elevations in ICP (b) Serial CSF removal w/ large volume LP, eventually VP shunt
33
Type of tremor often relieved w/ alcohol
Essential tremor | -usually b/l action tremor of the hands
34
64 yo F BIB son for cognitive impairment - started 3 mo ago - unsteady gait, mild muscle weakness on left, prominent pronator drift of left arm, positive Romberg's sign - PMH: HTN, stable CAD, diet-controlled DM - normal affect Dx
Dx = Vascular dementia -b/c of the focal neurologic finding Not Alzheimer's which would be more specific memory loss and language deficit w/o focal neurologic finding
35
Path report shows grade IV astrocytoma Best tx?
Cranial radiotherapy (???)
36
Guillain-Barre (a) CSF finding (b) Tx
GB (a) Albuminocytologic dissociation: elevated protein w/ normal cell count (b) IVIG or plasmaphoresis
37
Mechanism of disease in Parkinson's
Alpha-synuclein accumulation in the neurons of the substantia nigra
38
23 yo M w/ worsening HA x1wk - insect on right cheek 2 wks ago - b/l eye swelling - T 101F, TTP b/l on forehead and mid face Dx
Dx = cavernous sinus thrombosis | = blood clot in cavernous sinus, usually 2/2 spreading infection from sinus, ears, teeth etc
39
S/p generalized seizure 6 yo boy is alert and awake but unable to move r. arm and leg - normal speech and behavior - normal imaging Mgmt?
Mgmt = supportive b/c this will self-resolve w/in 36 hours Todd's paralysis = postictal partial or complete hemiplegia involving ipsilateral upper and lower extremity -mechanism thought to involve neuronal exhaustion or inhibition
40
32 yo F p/w LE paresthesias and balancing difficulties - tingling in feet - PMH: severe Crohns - reduced vibration and proprioception in LE - hyperreflexia of UE - H/H 8/24 w/ MCT 108 Dx
Dx = Vitamin B12 deficiency - most likely 2/2 chronic malabsorption from Crohn's - hint = macrocytic anemia Neurologic sign = subacute combined degeneration - progressive symmetric polyneuropathy, usually LE - early degeneration of dorsal columns - late degeneration of corticospinal
41
25 HIV+ M p/w AMS - disoriented, lethargic - last CD4 40, on Bactrim ppx - MRI shows solitary, irregular, weakly ring-enhancing mass in periventricular area - seriology +Toxo - PCR of CSF shows EBV DNA Most likely dx?
CNS lymphoma Not toxo- pt is on pox, MRI would show multiple, ring enhancing lesions in the basal ganglia, tons of ppl have positive serology
42
57 yo M p/w right arm/leg weakness x2 hrs, mild constant HA x3 days - BP 180/100 - NCHCT normal Dx
Dx = lacunar stroke 2/2 small-vessel lipohyalinosis
43
Tx for spinal abscess
In addition to abx, need immediate surgical decompression to prevent cauda equina syndrome and complications of spinal cord compression
44
64 yo M p/w falls - loses balance when he tried to turn or stop suddenly while walking - hand tremor that started in left hand, now affects both hands Most likely dx
Dx = Parkinson's Tremor often started unilaterally then generalizes
45
General effect of Arnold-Chiari and Dandy-Walker malformations
Both Arnold-Chiara and Dandy-Walker are congenital malformations causing noncommunicating hydrocephalus due to blockage of the CSF flow in the posterior fossa
46
2 features of Kluver-Bucy syndrome
Hyperphagia and hypersexuality
47
34 yo postpartum F s/p epidural injection c/o severe HA upon standing, relieved whenever lie down (a) Dx (b) Tx
(a) Dx = intracranial hypotension | (b) Tx = autologous blood patch
48
Manifestation of chemotherapy-induced peripheral neuropathy
Symmetric, distal, sensory neuropathy that spreads in a stocking-glove pattern - so hands and feet, symmetric - numbness/tinging over weakness
49
Side effect of trihexyphenidyl
Trihexyphenidyl = anticholinergic | Dry mouth, blurred vision, constipation, nausea, urinary retention dry as a bone, mad as a hatter...
50
2 features specific to intraventricular tumors
- positional/postural headaches (develop HA in certain postures/positions) - LOC due to sudden increase in ICP if there is an acute obstruction
51
2 most common bugs that cause brain abscess
Brain abscess: most commonly from direct extension (dental work, sinusitis, otitis media) of strep viridans or staph aureus 2 bacteria = strep viridans and staph aureus
52
9 yo F w/ unsteady gait and LE weakness - wide based gait - decreased vibratory/position sense in LE, absent ankle jerks b/l - deformed feet w/ high plantar arches - MRI: atrophy of cervical spinal cord - EKG: T-wave inversions of inferior and lateral chest leads Dx
Dx = Friedrichs Ataxia = autosomal recessive of trinucleotide repeats P/w gait incoordination (ataxia) 2/2 degeneration of spinal cord neurons -also causes degeneration of cardiac muscle fibers => myocarditis
53
Differentiate early vs. late signs of diabetic neuropathy
Usually starts w/ alterations in sensation -loss of proprioception Very late manifestation is motor findings, and def no UMN findings So if pt p/w motor weakness, hyperreflexia, upgoing plantar reflex- no diabetic neuropathy
54
34 yo M p/w difficulty walking for several days - lower back pain x1 wk since lifting injury - h/o URI 1 mo ago - smokes and occasional IVDU - reduced strength in LE, normal UE - mild hyperreflexia LE, positive Babinski (a) First test (b) Dx
(a) MRI of the spine to diagnose (b) spinal cord compression -signs of UMN distal to site of compression
55
Positive pronator drift- locate the lesion
Pronator drift is also called pyramidal drift- indicates UMN lesion where pronation is stronger than supination => lesion localizes to the pyramidal tract
56
Clinical presentation of acute intervertebral disk prolapse
Severe radicular pain w/ positive straight leg raising test
57
56 yo M w/o h/o HA p/w dull moderate HA x2 mo over right temple - worse in mornings or after a nap - unremarkable neuro exam Most likely dx
CNS neoplasm Red flag signs - new onset HA in adult w/o h/o HA - localized - morning HA
58
17 yo F BIB father 30 mins s/p LOC at home - stressed and sleep deprived - 3 similar episodes over the last mo - normal vitals/physical exam, oriented to name but not time/place - FS 100 Other expected finding?
Dx = seizure -not syncope b/c there is a post-ictal state (while syncope returns to baseline immediately) Also expect tongue lacerations, Tonic-clonic seizure
59
45 yo M p/w HA x4 mo - HA generalized and constant, worsened by bending/coughing - personality changes, N/V, papilledema - nonfocal neuro exam - CT: butterfly lesion w/ central necrosis Dx
Dx = high-grade astrocytoma = glioblastoma multiforme
60
56 yo M w/ acute right sided weakness and numbness - hyperreflexia RUE/RLE, decreased sensation to pinprick and light touch on r - mild dysarthria - NCHCT shows hyperdensity in the left basal ganglia Mechanism of disease and Dx
Mechanism = hypertensive vasculopathy causing lacunar stroke
61
Neimann-Pick disease vs. Tay-Sachs (a) Age of onset (b) Main features (c) Differentiating factors
(a) Both have 2-6 mo age of onset, autosomal recessive (b) Both: loss of motor milestones, hypotonia, cherry-red macula (c) NP: areflexic w/ hepatosplenomegaly TS: hyperreflexic w/o HSM
62
Two main features of Friedreich's ataxia
Ataxia- gait instability/imbalance -LE weakness Cardiac abnormalities -myocarditis, EKG abnormalities Autosomal recessive, trinucleotide repeat d/o
63
Type of stroke that shows normal NCHCT
Lacular stroke
64
4 yo p/w worsening ear pain - s/p 10d abx for otitis media - morning HAs improved after vomitting - bulging, opaque left TM - tender, erythematous left mastoid - WBC 17k (80N) (a) First step in dx (b) Dx
(a) CT w/ contrast (or can do MRI, CT just faster) CT: hypointense center w/ ring enhancement, surrounding edema = brain abscess (b) Brain abscess - otitis and mastoiditis => direct spread of infection into temporal brain abscess
65
Main features of neuroleptic malignant syndrome
- fever (can be super high like 104) - mental status change - generalized rigidity - autonomic instability: tachycardia, labile BP, tachypnea, diaphoresis Rigidity and hyperthermia may induce muscle necrosis => CK elevation
66
29 yo M w/ h/o PSA p/w sudden onset confusion and fever to 102.6F - recently admitted for hallucinations, d/c on meds - BP 150/110, HR 112, RR 24, profuse diaphoresis - diffuse muscle rigidity x4 extremities - tremor Dx
Dx = NMS (neuroleptic malignant syndrome) 2/2 antipsychotic use -or can be 2/2 antiparkinsonian (DA agonist) withdrawal Tetrad of findings - change in mental status - fever - generalized rigidity - autonomic dysregulation (tachy, tachypneic, diaphoretic) Can also see CK elevations due to muscle necrosis from rigidity/fever
67
In addition to triptans, name another drug that can be used as abortive therapy for migraine headaches
IV antiemetics: chlorpormazine, prochlorperazine, or metoclopramide Prochlorperazine = antiemetic
68
84 yo F p/w progressive confusion and increased weakness x2 wks - baseline is normal activity, now very somnolent/difficult to arouse - muscle strength 4/5 r, 3/5 left - upgoing plantar reflex on left Dx
Dx = subdural hematoma -insidious onset of HA, somnolence, confusion, and possibly focal neurologic deficits (hemiparesis) 2/2 compression of underlying cortex Not internal capsule infarct: would be super acute and no findings of somnolence
69
Type of paralysis caused by tick vs. botulism
Mostly all types of paralysis besides botulism are ascending -tick paralysis is ascending (so is Guianne-Barre) While botulism causes descending paralysis
70
Acute tx for botulism
Equine antitoxin therapy = heptavalent botulinum antitoxin | -provides passive immunity
71
First line tx for absence seizures
Ethosuxamide
72
S/p IPH in the right cerebellar hemisphere, pt will present w/ ataxia of which side?
``` Right sided (ipsilateral) ataxia -b/c corticopontocerebellar fibers decussate twice ```
73
What physical exam finding is rather specific for a pyramidal tract lesion
Positive pronator drift: eyes closed and arms outstretched w/ palms upwards, arm involuntarily drifts downward and palm turn towards the floor Pyramidal (corticospinal) tract disease: pronation is stronger than supination
74
Symptoms in addition to Parkinsonian features that indicate diagnosis of MSA
Think MSA (multiple system atrophy) when a pt w/ Parkinsonism experiences orthostatic hypotension, impotence, incontinence, or other autonomic symptoms
75
Mgmt for Multiple system atrophy
- Anti-Parkinsonian drugs are generally ineffective - tx aimed at intravascular volume expansion (counteract the orthostatic hypotension) w/ fludrocortisone (synthetic mineralocorticoid), salt supplementation, alpha agonists, and compression stockings
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