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Neurology Clerkship

By Elsie Riley,2014-04-26 19:40
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Neurology Clerkship

    Neurology Clerkship 2002

    Condensed Cans!

1. Trauma X-Rays Cervical spine, chest, and pelvis

    2. Essential Tremor Tremor x 6 years, better with alcohol, treat with propranolol 3. Alzheimer Disease senile plaques, neurofibrillary tangles, no Lewy Bodies 4. Wernicke-Korsakoff not a direct consequence of alcohol

    5. Parkinson’s Disease resting tremor, shuffling gait, cogwheel rigidity, Babinski is absent 6. Multiple Sclerosis periventricular demyelination, bowl and bladder problems, get an MRI of

    the brain and spine

    7. Cluster Headaches one-sided headache, occurs 1 to 3 times per day, causes tearing in one eye 8. Migraine Headaches strongest genetic component

    9. Subarachnoid Hemorrhage 50 year old man comes to the ER with global headache,

    meningeal signs, photophobia, worst headache of his life, a normal head CT (false negative), LP

    shows blood (could also be an aneurysm get MRA and/or angiography)

    10. Occipital Headaches decreased pinprick over occipital scalp, “occipital neuralgia”

    11. Absence Seizure kid with convulsions, staring spells, unresponsive, treat with VPA 12. Complex-Partial Seizure aura, fearful, unresponsive, post-ictal confusion

    13. Juvenile Myoclonic epilepsy generalized multi-spike waves

    14. 30% of epileptics have a normal EEG

    15. Horner’s Syndrome ipsilateral ptosis, contralateral miosis, ipsilateral anhydrosis, associated

    with Pancoast’s tumor

    16. 50 year old man with bedwetting, thrashing, and a new onset seizure tumor, until proven

    otherwise

    17. Brown-Sequard ipsilateral motor loss, ipsilateral vibratory and position sense loss,

    contralateral loss of pain and temperature.

    18. Bell’s Palsy peripheral VII lesion (ipsilateral facial ptosis), central VII lesion (ipsilateral

    lower facial ptosis)

    19. Myotonic Dystrophy genetic, difficulty with grip release, alopecia, ptosis, can’t hold puffed

    cheeks, hypogonadism, Chr. 19

    20. Huntington’s Chorea male, autosomal dominant, CAG repeats

    21. Myasthenia Gravis young female with focal facial ptosis, fatigue, blurred vision (esp. after

    use), cannot open eyes at the end of the day do the Tenselon Test (Give edrophonium 2ml, then

    3ml, then 5ml… positive if strength increases with each dose)

    22. Guillain-Barre Syndrome parasthesia beginning in feet, SOB, decreased vital capacity, mild

    distal weakness, “heavy legs”, areflexia, decreased position sense, otherwise healthy, follows GI

    infection (campylobacter jejunii) or viral URI ---INCREASED CSF PROTEIN--- 23. Left MCA Stroke global aphasia, right hemiparesis, if A. fib is present, wait five days to

    heparinize.

    24. Subarachnoid Hemorrhage worst headache in your life, trauma is the most likely cause 25. Cervical X-ray must clear C1 to C7

    26. Most common missed fracture on x-ray C2 involving the odontoid process

    27. Back Pain History ask about bowel and bladder function, sex, did it keep them from work?,

    mechanism of injury, rectal exam, treat uncomplicated pain with bedrest x 3 days and NSAIDS 28. Glaucoma visual acuity is not reduced, visual fields are reduced

    29. Macular Degeneration wet vs. dry

    30. Corneal Abrasion fluoroscein dye and slit lamp exam, pressure patch x 1 day 31. Intraocular pressure should be less than 21

32. Esotropia is “eyes inward” , Exotropia is “eyes outward”

    33. Temporal Arteritis a.k.a. Giant Cell Arteritis, feel external carotid for lumpiness, diagnosis

    requires external carotid biopsy, ESR is usually increased treat with steroids 34. Afferent Pupillary Defect lies behind the chiasm

    35. Opthalmia Neonatorum don’t treat

    36. Diabetic Retinopathy look for neovascularization, does not affect cup/disk ratio 37. Pink Eye treat with sulfacetamide

    38. Headache/Pain that awakens one from sleep cancer until proven otherwise

    39. Abnormal CT Bone 35% to 75% bone loss

    40. Herniated Disc recurrent leg pain with cough or straining, ask about bowel/bladder function 41. Prostate cancer doesn’t go to the brain???

    42. Melanoma has the highest incidence of metastasis to the brain 43. Pituitary Adenoma young woman, blurry vision, irregular periods, galactorrhea, most

    commonly a prolactinoma

    44. Epidural Hematoma most likely laceration of middle meningeal artery per trauma 45. Skull base fracture with otorrhea or nasal CSF leak pack nose or ear with gauze, give

    antibiotics, 99% seal on their own

    46. CSF electrolytes Na = 150, Cl = 120, K = 3, ATP is active

    47. Causes of intracranial hemorrhage trauma, ruptured aneurysm, AVM, HTN, tumor,

    anticoagulation, iatrogenic, infection

    Neuro Test Facts

    1. Subarachnoid Hemorrhage most common cause is trauma, most common spontaneous cause

    is rupture of an aneurysm

    2. Best study to localize an aneurysm angiogram

    3. Subarachnoid Hemorrhage Diagnosis Try CT first, if negative, then do LP and look for

    blood

    4. Metastases that bleed melanoma, renal cell carcinoma, choriocarcinoma 5. Trauma CT usually done without contrast

    6. Occipital Neuralgia treat with amitriptyline (elavil)

    7. Epidural Hematoma most common cause is trauma (to the middle meningeal artery, which

    passes through the foramen spinosum), usually trauma followed by a lucid period, then problems,

    lens shaped, can cause a midline shift

    8. Subdural Hematoma rupture of bridging veins, often chronic, progressive, if acute then blood

    is hyperintense (more so than chronic)

    9. Fracture of C2 Jefferson Fracture

    10. Fracture of C1 Hangman’s Fracture (through the pars portion of C2)

    11. Overall incidence of Seizure Disorder 1%

    12. Herpes Encephalitis loves the temporal lobe

    13. Alkaline Burn of Eye immediately irrigate, then irrigate some more

    14. Raccoon Eyes suggest orbital floor fracture

    15. Strabismus ocular misalignment (esotropia vs. exotropia)

    16. Forbe Albright prolactinoma

    17. Most common site of HTN hemorrhage deep nuclei, internal capsule

    18. Last suture in the head to close coronal at 30 years

    Cases

; 42 y/o female s/p CABG, oral contraceptive use, 30 pack year history of cigarettes, increased

    LDL…….. Which of these does not effect the risk of CVA? Female

    ; Which systemic tumor doesn’t metastasize to the brain? Prostate (loves the bone, lytic)

    ; 77 y/o female with history of bump on the head, with subsequent progressive aphasia and

    decreased ambulation….. Chronic Subdural Hematoma

    ; Blow to the head on a cold day, with resultant rhinorrhea….. This is a basilar skull fracture

    (petrosal ridge) don’t treat (no ABX), just monitor and wait for spontaneous seal to develop

    ; What infection causes bleeding in the head? Herpes

    Trauma

    ; Glascow Coma Scale is graded from 3 to 15

    ; Trauma: Airway, Breathing, Circulation (ABCs)

    ; Trauma

    o CT Scans: usually non-contrast; white = bone; black = air

    o X-Rays:

    1. Cervical Spine: AP and Lateral (make sure to include C1 through C7/T1

    2. Chest

    3. Pelvis

    ; Most commonly missed fracture on C-Spine: C2 (AKA “axis”)

    ; Most commonly fractured part of C2: odontoid

    Specific Neurological Conditions

    ; Multiple Sclerosis

    o Best test is MRI of brain and spine

    o Periventricular calcifications and plaques

    o Ask about bowel and bladder problems

    ; Amyotrophic Lateral Sclerosis (ALS; “Lou Gehrig’s Dz”): dz of motor neurons

    o UMN and LMN signs: Atrophy and fasciculations in UEs initially (LMN dz). Mild

    spasticity of LEs, increased DTRs (UMN dz)

    o Degeneration of neurons in C-spine and medulla

    ; UMN signs: spasticity, increased DTRs, upward going toes (Babinski sign). Everything goes up in

    Upper MN dz.

    ; LMN sings: flaccid paralysis, loss of DTRs, fasciculations, downward going toes ; Myasthenia Gravis (MG): an antibody is made to the neuromuscular junction and commonly

    occurs in females.

    o Signs: fatigue with repetitive use, ptosis, diploplia, dysarthria, NO atrophy or decreases in

    DTRs.

    o Dx: Tensilon test (injections of increasing doses of edrophonium. + test is increased

    strength with increasing dosage).

    ; Gullian Barre: polyneuropathy of unknown cause vs. immune mediated. This is the acute onset of

    a neuropathy with progressive proximal weakness that starts distally and moves proximally. It is

    often secondary to a viral URI, immunizations, or surgery. Onset is 3 days to 5 weeks later.

    o Signs: healthy individual, SOB, decreased VC, “funny” sensation in hands and feet,

    trouble walking, heavy legs, areflexic, decreased proprioception.

    o Pathophysiology: segmental demyelination, increased CSF protein without pleocytosis. ; Alzheimer’s Dz: #1 cause of dementia (multiple infarcts is the second).

    o Pathophysiology: neurofibrially tangles, senile plaques, granulovacular degeneration,

    decreased acetylcholine in the amygdala (estrogens and NSAIDS may help). ; Parkinson’s Disease: decreased dopamine in substantia nigra to striatum, basal ganglia. Lewy

    bodies are present.

    o Signs: early on, a decrease in arm swing with gait, increased tone in flexors and extensors,

    resting tremor, “pill rolling” hand movements, shuffling gait, cogwheel rigidity,

    bradykinesia, no babinski and no UMN signs.

    ; Essential tremor: a tremor for at least 6 years that improves with wine or alcohol. Treatment of

    fine tremors is propranolol, EtOH, or primdone. Course tremors are best treated with valium. ; Huntington’s Chorea: chromosome #4, males, AD

    ; Forbes-Albright Syndrome: prolactinoma (pituitary adenoma).

    o Sxs: HA, blurry vision, irregular periods, breast discharge

    ; Myotonic Dystrophy: chromosome 19

    o Signs: atrophy of facial and neck muscles, weak soft voice, puffy cheeks, balding,

    hypogonadism, ptosis, can’t release hands upon shaking.

    ; Bell’s Palsy: CN VII (facial)

    o Peripheral Lesion: loss of unilateral face and forehead-weakness, can’t wrinkle forehead;

    may present with pain behind the ear. Tx: 80% benign and will recovery within weeks to

    months. Recommend covering the affected eye at night since you can’t close your eye.

    Steroids have a questionable role.

    o Central Lesion: forehead sparing.

    ; Wernicke-Korsakoff: effects of severe sustained thiamine depletion in the face of continued

    caloric intake, it is not a direct result of EtOH consumption.

    o Pathophysiology: axonal demyelination with neural loss, glial loss, endothelial thickening,

    pretectal pericapillary hemorrhages; at higher levels the mamillary bodies, mediodorsal

    thalamic nuclei, and scattered cortical regions suffer, especially the hippocampus.

    o Signs: ocular palsies, ataxia, drowsy, dysarthric, loss of recent memory, confabulations. ; Horner’s Syndrome: sympathetic: ptosis, myosis, anhydrosis. Usually secondary to a pancoast

    tumor of the lung.

    ; Carpal Tunnel: entrapment neuropathy of the median nerve

    o Signs: pain and paresthesias of the hands/digits; Tinel’s sign; Phalen’s sign; pain is worse

    at night and is relieved by shaking the hand.

    o Tx: surgical section of the transverse carpal ligament.

    ; Stupor: a state of psychological unresponsiveness that can be interrupted only by vigorous and

    sustained external stimulation (sternal rub)

    ; Coma: an eyes closed state of unarousable, sleeplike behavior in which patients lack any

    recognizable evidence of awareness of inner thoughts or outer events.

    o Metabolic Causes:

    ; Exogenous psychoactive drugs or poisons

    ; Anoxia or ischemia

    ; Mixed enceophalopathies, pathologic aging, systemic infections, etc…

    ; Hepatic, renal, pulmonary, or pancreatic insufficiency

    ; Hypoglycemia

    ; Meningitis, encephalitis

    ; Multifocal, small structural lesions, ie. Mets, emboli or thrombi

    ; Concussion and postictal states

    ; Ionic and electrolyte imbalances

    ; Nutritional def: thiamine

    ; Hx and Exam of Comatose Pt:

    o Eval of motor and neuroophthalmogic signs plus an appraisal of the initial breathing

    pattern.

    o Brain imaging

    o Systemic studies of blood, urine, CSF, and others when indicated.

    ; Decorticate Rigidity (abnormal flexor response):

    o This posture implies a destructive lesion of the corticospinal tracts within or very near the

    cerebral hemispheres. When this is unilateral it is the posture of chronic spastic hemipleiga ; Decerebrate Rigidity (abnormal extensor response):

    o This posture may occur spontaneously or only in response to external stimuli such as light,

    noise, or pain. It is caused by a lesion in the diencephalon, midbrain, or pons. Although

    severe metabolic disorders such as hypoxia or hypoglycemia may also produce it. ; Lesion of the medial longitudinal fasciculus (MLF):

    o The MLF connects CN III to CN VI. Lesions cause internuclear ophthalmoplegia. With

    this lesion, the eyes at rest may either be parallel or show a mild skew deviation but move

    disjunctively on lateral gaze. During lateral gaze toward the side of the MLF lesion, the

    ipsilateral eye abducts and shows nystagmus, the contralteral eye partly or completely fails rdto move nasally because of absence of ascending impulses to reach toe opposite 3 nucleus.

    May be caused by infarct from vessel dz or by demyelinating dz.

    ; Pupillary Light Reflex:

    o Afferent Limb: CN II

    o Efferent Limb: CN III

    o Ganglion cells of the retina project bilaterally to the pretectal nuclei; pretectal nuclei of the

    midbrain projects to the EW nucleus of CNIII, which gives rise to the preganglionic

    parasympathetic fibers, which synapse in the ciliary ganglion. The postganglionic

    parasympathetic fibers innervate the sphincter of the muscles of the eye. ; Corneal Reflex:

    o Afferent Limb: CNV

    o Efferent Limb: CN VII

    ; Facial Nerve (CNVII):

    o The lower part of the face normally is controlled by UMN only on one side of the cortex-

    the opposite side

    o The upper face is controlled by pathways form both sides of the cortex (lesion of the right

    cortex can’t move Left lower face, but can move left upper face.

    Spinal Cord Injuries (Bowel, Bladder, Rectal)

    ; Herniated Disc/Nucleus Pulposis: lateral leg pain with cough and sneeze; ask about retention and

    incontinence. Tx: supportive, will get better with time. Donut to sit on. ; Back/Disc Pain: ask about bowel/bladder changes, sexual function. Do a rectal exam, palpate the

    spine and look for paravertebral spasm. The discs start to degenerate around the age of 8.

    o Tests: lumbar spine X-ray

    o Tx: symptomatic with NSAIDS, bedrest for 2-3 days, then mobilize

    ; Brown-Sequard Syndrome (incomplete transection of the spinal cord). Patient was stabbed in the

    left side of the back.

    o Left leg: weakness, hyperreflexic, decreased proprioception, intact pain and temp

    o Right Leg: decreased pain and temp, intact strength, reflexes, and proprioception.

    o Check bulbocavernosus reflex and rectal sphincter tone

    Ophthalmology

    ; Intraocular pressure: normally less than 20 mmHg

    ; Glaucoma: > 20 mmHg; no change in visual acuity

    ; Presbyopia: loose elasticity in the lens; you can’t see things close up

    ; Afferent Pupillary Defect (APD) (Marcus Gunn): damage to unilateral optic nerve ; Ophthalmia Neonatorium: no tx needed and will resolve spontaneously. ; Conjunctivitis: treatment is sulfacetamide

    ; Alkaline Burn: flush eyes with copious amounts of water

    ; Amblyopia: subnormal visual acuity in one or both eyes; won’t grow out of it

    ; Strabismus: abnormal ocular interaction or misalignment

    ; Orbital Fracture: sunken eyes, no roof involvement

    ; Diabetic Retinopathy: no cupped disc

    ; Macular Degeneration, corneal abrasion

    ; Esotropia: deviation to the inside

    ; Exotropia: deviation to the outside

    Brain/Skull Injuries

    ; Epidural Hematoma: rupture of the middle meningeal artery (enters skull Foramen spinosum).

    1. Lateral Skull Fx, medical emergency because of the rapid bleeding

    2. Sxs: progression from transient LOC to lucency then to coma.

    3. Signs: fixed, blown pupil (secondary to uncal herniation and compression of CNIII

    parasympathetics.

    4. Tests: CT will show a lens shaped convex hyperdensity

    ; Subdural Hematoma: rupture of the bridging veins after head trauma (hx of fall). It is more

    insidious, if acute the prognosis is dismal. Remember: geriatric patients can get these by simple

    cerebral atrophy.

    5. Signs: HA, change in MS within days to weeks. If chronic, it can present as a dementia

    or aphasia. Contralateral hemiparesis (decreased ambulation).

    6. Tests: CT will show a crescent shaped, concave hyperdensity. If it is chronic the fluid

    will be darker, if acute the fluid is brighter.

    ; Subarachnoid Hemorrhage (SAH): most common cause is trauma. Most common cause of

    spontaneous SAH is aneurysm rupture.

    7. Signs: worst HA of life, HA everywhere, stiff neck, photophobia

    8. Tests: CT, if normal (only 4% false negative), then proceed to LP to look for blood. If

    you suspect an aneurysm then get an MRA (4 vessel angiogram).

    ; Basilar Skull Fx: CSF leak and otorrhea, rhinorrhea. There is no tx, give 4x4, 94% will

    spontaneously seal.

    ; Intracranial Hemorrhage (causes):

    1. Trauma

    2. Ruptured aneurysm

    3. A/V malformation

    4. HTN

    5. Tumor

    6. Anticoagulation therapy

    7. iatrogenic

    8. infection (herpes)

    ; Herpes Virus: invades the temporal lobe and can cause bleeding in the head.

    ; Mets to the CNS that bleed: melanoma, renal cell carcinoma, choriocarcinoma

    ; Highest incidence of mets to CNS: melanoma (systemic tumor that doesn’t go to brain-prostate)

    Case: 42 yo female that is s/p CABG, OCP use, 30 PYH, increased LDL. Which of the following does not affect risk of CVA: female.

    Case: Patient with BP of 270/120 presents with sudden onset hemiplegia. Dx: HTN hemorrhage at the internal capsule. Tx is to reduce the BP to a premorbid state but don’t let it get too low.

    Case: Global aphasia with right hemiparesis, lucency in right middle cerebral artery with ECG showing A. fib. Tx is to wait five days to heparinize.

    Case: Female patient with HTN, dizziness, orthostatics, going for surgery on carotids and on Minipress (prazosin) as an anti-HTN medication.

     Dx: side effect of medication Tx: give different medication

Headaches

    ; Cluster HA: male with unilateral intense HA, occurring 1-3 times per day with watery eyes and

    nose, Horner’s syndrome, eyelid edema and conjunctival injection.

    o Tx: prophylaxis with Ca channel blocker, ergotamine, lithium, or prednisone.

    ; Migraine HA: genetic component

    ; Temporal Arteritis: usually > 55yoa, HA in temporal region, visual loss, increased ESR.

    o Dx: temporal artery biopsy Tx: steroids

    ; Occipital Neuralgia: chronic occipital HA, sharp, decreased pinprick, otherwise nml

    o Tx: amitriptyline

    Case: Pt with HA waking him or her at night is cancer until proven otherwise. The work up includes an X-ray (need 35-75% bone loss to see anything) and CT may be abnml.

Seizures

    ; Overall incidence of seizure disorder is about 1%.

    ; EEG: 30% of epileptics will have a normal EEG

    ; Complex-Partial Seizure: 16 yo with strange sensation, fearful, unresponsive, postictal confusion.

    ; Juvenile Myoclonic Epilepsy: generalized multi-spike waves

    ; Generalized Seizures: 12 yo male with convulsions, postictal staring and unresponsiveness. Tx is

    with VPA

    ; Seizure Treatments

    o Partial: tegretol, dilantin, depakote

    o Generalized: depakote

    o Absence: zerontin (ethosuxamide) and depakote

    Case: shaking arm after studying for test possible seizure ER for CT or MRI

    Case: adult with bedwetting, thrashing, new onset seizure: tumor until proven otherwise. Get an MRI.

Miscellaneous

    ; CSF production is an active (ATP requiring) process with absorption being passive (gradient from

    subarachonid space vs. sagittal sinus. Contents include Na of 150, K of 3.0 and Cl of 120.

    ; Last suture in the skull to close is the coronal

    ; If a victim is behind the steering wheel in an accident and you see them. The correct response for

    the test is to drive on by.

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