Med Comp III: Key Phrases Quick Quiz
Neurology
- Increased ICP with 1. HTN, 2. Bradycardia, 3. Irregular respiration
o ANSWER: Cushing triad for TBI- indicates that ICP has reached a life threatening level
o Poor Prognosis
- Blunt trauma, brief LOC, possible seizure on impact, memory loss, no structural changes on CT
o ANSWER: Concussion
o Tx: most sx self resolve in 1 week, may develop post-concussive syndrome
- CT of brain shows posttraumatic lesions, irregular regions with high and low density changes
o ANSWER: Contusion
o Remember that high density areas are blood and low density areas are usually edema
- CSF otorrhea, rhinorrhea, hemotympanum, raccoon eyes, battle sign
o ANSWER: Basilar skull Fx
- Little boy gets hit in the head with a baseball and LOC, comes to and appears normal and then experiences rapid neurological dynsfunction
o ANSWER: Epidural Hematoma - MCC is laceration of the middle meningeal artery
o Lesion appears biconvex in shape
- Sentinel headaches followed by sudden onset of severe headache with sx of meningeal irritation
o ANSWER: Subachnoid Hematoma
o Remember that it can be caused by TBI laceration of superficial microvessls in subarachnoid space which would be picked up on CT w/o contrast. However the mc c is rupture of a “barry aneurysm” and in this case would not be seen. To confirm a negative Ct scan a lumbar puncture may be performed to look for xanthochromia or blood in the CSF
- Elderly, rupture of bridging vessels, lesions are crescent shaped
o ANSWER: Subdural Hematoma
o Venous in origin
o Tx: surgical burr hole for pending herniation, emergent craniotomy
- Severely depressed consciousness, neurological dysfunction or coma, normal CT or with punctate hemorrhages, ICP normal
o ANSWER: Diffuse axonal injury
o Due to shearing trauma ;
o majority never come out of nonvegitative state
- Posttraumatic CT shows lesions with high density changes and low density changes within it
o ANSWER: Typical finding for blood and edema of a head CT
o High-density = blood
o Low-density = edema
- Comminuted fracture displaced inwardly
o ANSWER: Depressed Skull fx
o Tx surgically only if segment is greater than 5mm; usually surgery not needed because closed à decreased infection
- Laceration over a fx
o ANSWER: Open skull fx
o Remember that sinus or middle era fx are also considered open fx
- Clear salty otorrhea, rhinorrhea, hemotympanum, bruising around eyes bilaterally
o ANSWER: Basal skull fx
o Battle sign = bruising of mastoid area
o Racoon eyes = bilateral bruising of eyes
- Head trauma follow by lucid period à rapid deterioration
o ANSWER: Epidural hematoma
o Key characteristics = appears bi-convex lesion on CT, ARTERIOLE in nature
o MCC: laceration of middle meningeal artery due to fx of temporal bone
o Tx: Surgical burr bole (trephination); if fails then craniotomy
- Elderly, crescent shaped laceration on CT
o ANSWER: Subdural hematoma
o Characteristics : VENOUS in nature; due to atrophy of brain and bridging vessels
o Tx: Surgical burr bole (trephination); if fails then craniotomy
- Sudden severe head ache, sentinel headaches, N/V, meningismus,
o ANSWER: subarachnoid hematoma
o Cause: usually secondary to a barry aneurysm ; may be a direct result from TBI
o Dx: ct scan without contrast; if negative but still suspect à lumbar puncture to look for xanthrochromia
o Tx: sedation, anti-hypertensive medication
- Discuss tx for↑ ICP
o If GCS <9, prolonged sedation, or extended general anesthesia à ICP probe
o Reverse Trendelenburg position (unless spinal injury or hypotensive)
o Hyperventilation
o Mannitol
o Short acting sedative and analegesics
o Low body temp/ice packs
o Anticonvulsants maybe
o Decompressive caeniectomy
- Unilateral, Throbbing Headache, n/v, photophobia, phonophobia
o ANSWER: Migraine
o There are many types of migraines
- Occipital Headache; aphasia, decreased hearing , vertigo, tinnitus, ataxia, visual changes, dizziness, N/V, bilateral paresthesia, LOC
o ANSWER: Basilar migraine
- Transient deficit of unilateral hemipesia, hemiparesis, lastis mins to hours, resolves at time of H/A
o ANSWER: Hemiplegic migraine
- Palsy of ipsilateral CN III, ptosis, mydraisis, type of migraine
o ANSWER: Opthalmoplegic Migraine
- Persistent migraine that does not resolve spontaneously
o ANSWER: Status Migranosus
- Migraine-like headaches greater than 15 days a month for greater than 6 months
o ANSWER: Chronic Migraine
- Discuss Tx for Mild, Moderate, and Severe Migraines
o For all: dark room, quiet, sleep, compression to ipsilateal temporal artery, icepack
o MILD: Analgesics/NSAIDS
o Moderate/Severe:
§ Triptans – best
§ Ergot Medications
§ Nacrcotics- Demerol
- First and Second line tx for prophylaxis of Migraines
o First line: Tricyclic anti-depressants (amitriptyline); beta blockers
o Second Line: calcium blocker, relaxation training, acupuncture
- Bilateral head ache, bifrontal, band-like tension around head, muscular tightness in neck, furrowed brow, tense masseter muscles, poor posture
o ANSWER: Tension Headache
o Characteristics: may also be described as dull or pulsatile, NORMAL NEURO EXAM
o Tx: analgesics for mild/moderate; if severe can use same as migraine
- Male, excruciating pain, penetrating, piercing, stabbing, exploding, rocking,
o ANSWER: Cluster Headache
o Can be Episodic (MC) or chronic
§ Episodic = occurs in clusters lasting 1w to 1 yr, separated by pain-free intervals of at least 2 weeks
§ Chronic – Longer than 1 year without remission, or with remission lasting <2w
o Other key characteristics:
§ Ipsilateral lacrimation, miosis, rhinorrhea, ptosis
§ Horner’s Syndrome
o TX: DRUG OF CHOICE = SUMATRIPTAN!!
o Prophylaxis: DOC = VERAPAMIL
- First or worst sudden headache, vomiting, menigismus, AMS
o ANSWER: Subarachnoid hemorrhage
o Dx: CT w/o Contrast, if neg à lumbar
- Fever, Non-focal headache, meningismus
o ANSWER: Meningitis or Encephalitis
o Note: AMS is more common with Encephalitis
o Dx: lumbar puncture with CSF analysis
- Pain on awakening, progressively worsens, worse with valsalva, ataxia, papilledema, and onset seizure; triad : headache, vomiting, papilledema
o ANSWER: Brain Tumor
o Dx: CT first à MRI T2
- Fever, n/v, seizures, H/a
o ANSWER: Brain abscess
o DX: MRI IS BEST
- Transient, shock-like facial pain
o ANSWER: Trigeminal neuralgia
o Tx: Carbamezapine
- Elderly, sereve sclap and temporal pain, associated with PMR, palpable tender temporal artery
o ANSWER: Temporal Arteritis
o Dx finding on bx = giants cells, increased ESR
o Tx: Steroids
o Comps: Blindness
- Groups of Distal muscle weakness of extremities, hyperrflexia, spasticity, Babinski positive
o ANSWER: UMN lesion
- Spondylosis, posterior-occipital pain, increased with activity, hx trauma, spinal/muscle tenderness
o Answer: Cervical H/A
o Dx: X-ray of C-spine, if - à home for 1 w ; still bad à MRI for herniated disc
- Temporal H/A, eachache, crepitus
o ANSWER: TMJ syndrome
- Individual distal muscle weakness, decreased tone, flaccidity, fasciculations, hyporeflexia, absent babinski, EMG abnormalities
o ANSWER: LMN lesion
- Abnormal range, rate and force of movement
o ANSWER: Cerebellum Disorder
- Involuntary movement, changes in tone and posture, no weakness, no changes in reflexes
o ANSWER: Extrapyramidal Disorder
- Rhythmic, alternating involuntary movements o that are maximal when body part is maintained against gravity; lessened by rest
o ANSWER: Postural tremor
- Rhythmic, alternating involuntary movement that is maximal at rest and bones less prominent with activity;
o ANSWER: Resting Tremor
- Unilateral, pill rolling tremor
o ANSWER: Type of resting tremor commonly associated with Parkinsons disease
- Brief, rapid, jerky, purposeless, irregular involuntary movement of distal extremities that may merge into purposeful acts to mask movement
o ANSWER: Chorea
o Common with Huntington’s Disease, and Wilsons Disease (basal ganglia dz)
- Writhing movement, with alternating postures of proximal limbs that blend continuously into a flowing stream or movement; slow
o ANSWER: Athetosis
o Common with Huntington’s Disease, and Wilsons Disease (basal Ganglia dz)
o Choreoathetosis – two occur together!
- Chorea or athetosis in the setting of Rheumatic fever
o ANSWER: Sydenham’s Chorea
- Twisted into grotesque fixed postures
o ANSWER: Dystonia
o Tx: Anticholinergics, botulinum toxin injection
- Dystonia of Neck
o ANSWER: Spazmodic torticolis
- Lead-pipe Rigidity, cogwheel resistance throughout ROM, Flexors and extensors of all 4 limbs, involuntary movements
o ANSWER: RIGIDITY due to Extrapyramidal lesions or abnormalties
o Example of this type of disorder is Parkinsons
- Flexors in arms, extensors in legs, hyperactive, positive babinski, no involuntary movements
o ANSWER: SPACTICITY due to UMN lesions/disorder
o Example of this is a stroke
- Rapid, brief irregular contraction of muscle or group of muscles
o ANSWER: Myoclonus
o Can be normal (hiccups, sleeping twitch)
o Abnormal causes: metabolic derangements (uremia, degenerative dz (alzheimer’s dz), close head truma, hypoxic ischemia brain injury
o Tx: underlying cause, benzos, anticonvulsants
- Blinking, nose twich, eye roll, shoulder shrug, jaw or head jerks that are uncontrolled and repetitive
o ANSWER: Simple Tic
o Tx: neuroletpics (Haloperidol) Benzos
- Uncontrolled, repetitive, clapping, drumming of fingers, picking scabs, kissing, touching, hitting self
o ANSWER: Complex Tic
o Tx: neuroletpics (Haloperidol) Benzos
- Mulitple complex motor and vocal tics, coprolalia
o ANSWER: Tourrett’s syndrome
o Associated with ADD and OCD
- Violent, continuous proximal limb flinging movements confined to one side of the body
o ANSWER: Hemiballismus
o Caused by lesion (MC infarct) in contralateral subthalamic nucleus
o Tx: Usually self limited 6-8 w; dopamine depleting agents are useful
- Sustained muscle spasms of facial, neck or trunk muscle groups
o ANSWER: Acute dystonia (Drug induced)
o Tx: DC drug, anticholinergics and antihistamines
- Subjective sensation of motor restlessness, occurs days to weeks after neuroleptic drug
o ANSWER: Akathisia
- Resting tremor, bradykinesia, rigidity, and postural instability that occurs weeks to months after neuroleptic tx
o ANSWER: Parkinsonian-like Symptoms
o Tx: DC or reduce drug; Anticholinergics (amantadine, diphenhydramine)
- Involuntary facial and tongue movements, rhythmic trunk movements and choreoathetoid movements of extremities, follows > 6 m of neurolepic therapy
o ANSWER: Tardive dyskinesia
o Tx: gradual reduction of drug; some pt better off with sx and still on drug
- Muscular rigidity, fever, tremor, AMS, autonomic instability within 2 w of initiation of neuroleptic
o ANSWER: Neuroleptic Malignant syndrome
o Tx: DC drug, resolves on own, ICU, maintenance of hydration and cardiopulmonary function, Dantrolene = muscle relaxant
- Adult onset, dementia, involuntary movements, behavioral changes,
o ANSWER: Huntingtons Disease
o Triad = dementia, involuntary movements, behavioral changes
o Atrophy of neurons in basal ganglia and cortex
o Other Key characteristics:
§ Chorea = MC associated movement disorder
§ Eventually chorea is replaced with dystonia and parkinsonian features and the end with an akinetic-rgid syndrome, spacticity and clonus
§ Dx – family history (autosomal dominant) or measure bicaudate diameter
§ Tx: Symptomatic Tx
· Benzos – clanzepam, reserpine
· Depression w/ SSRI’s
· Bradykinesia and rigidiy = levopoda or dopamine agonists
- Adult on-set, resting tremor, rigidity, bradykinesia, postural instability, Male, Lewy Bodies
o ANSWER: Parkinson’s Disease- progressive neurodegenerative disorder of extrapyramidal system
o Dx: none, most tests are done to R/O other etiologies, use hx and clinical evidence
o Tx: this is the only neurodegenerative dz treated long-term – good symptomatic control for 4-6 yrs
§ L-Dopa and Cabidopa = GOLD STANDARD
§ Dopaminergic Agonists: bromocriptine, pergolide, pramipexole
- Antibodes to myelin basic protein (MBP) in blood and CSF, Urinary, eyes and lower limb incontinence
o ANSWER: MS
o Other Key characteristics: Sensory mans are most common, bowel and bladder problems, fatigue, weight loss babinski sign, lhermitte sign
o MC in women but when men get it’s the more severe form
o Remember that there are different kinds
o DX: MRI of head with gadolinium – gadolinium will enhance plaques
§ Also CSF analysis = mononuclear pleocytosis, normal glucose, selective increased in IgG (oligoclonal bands), increased MBP
o Tx : for general sx of MS = Methylprednisolone IV
§ Relapsing remitting = long term use beta-interferon and glatiramer acetate
§ Natalizumab = for MS refractory to other tx
§ Self Catherter if post-void residual volume >100 ml
- Acute exacerbations of MS lasting weeks t o months with gradual full or partial remissions
o ANWER: Relapsing-remitting MS (most common)
- Type of MS; On set after age 40, gradual decline, accumulated disability without remission, MC IN MEN
o ANSWER: Primary progressive MS
- Type of MS, continuous deterioration after about 10 years of relapsing-remitting
o ANSWER: Secondary progressive MS
- Type of MS that is progressive and episodic
o ANSWER: Progressive Relapsing MS
o This is the worst form; most rapid deterioration
- Neck flexion that results in an electric shock like felling in torso or extremities
o ANSWER: Lhermitte Sign
- Acute onset of unilateral visual blurring, flashes of light, central scotoma, decreased acuity, decreased color perception, and discomfort moving the eyes
o ANSWER: Optic Neuritis
o This is the initial presenstion in 15-20% of pt with MS
o 50% are retrobulbar à cannot see it
o If it is involved anteriorly à papillitis and atrophy (ddx = papilledema)
o Tx: IV methyprednisolone
- Adduction deficit and abduction nystagmus
o Answer: Bilateral internuclear opthalmoplegia – due to lesion in median longitudinal fasciculus
- Acute partial loss of motor, sensory, autonomic, reflex, and sphincter function below level of lesion, unchanging level
o ANSWER: Acute disseminated encephalitis
- Acute onset of motor, sensory, cerebellar, and CN defects with encephalopathy, AMS, progressing to coma and eventual death ; similar to MS
o ANSWER: Acute disseminated encephalitis
o Tx: steroids; IV seizure prophylaxis, plasma phoreisis, IV dexamethsone
- Asymmetric muscle weakness, increased tone, hyperreflexia, fasciculation and muscle atrophy
o ANSWER: ALS = hallmark is that is affects both UMN and LMN!!!! This is unusual