#6 Nervous System (UWorld Step 3)

patient's meeting the clinical criteria for brain death should undergo neurologic examination to document ___ . ___ is used to confirm the diagnosis of brain death in patients meeting the above criteria.

Absent cortical and brainstem function Apnea testing

___ Is a universal complication of lumbosacral myelomeningocele (excluding neurological defects close (, followed by lower GI tract dysfunction, and fractures of the lower extremities.

Bladder dysfunction

pregnant patients with MS have a modest increase in ___ (2) compared to those without MS

C-section and assisted delivery

although the frequency is not clear, neutropenia and bone marrow suppression due to ___ use are significant adverse reactions. Elderly patients are also at risk of SIADH. Because of some mild anticholinergic affects, there is a risk of glaucoma, urinary retention or constipation.

Carbamazepine

the constellation of unilateral headache, ipsilateral myosis (small tubal) and ptosis (eyelid drooping) indicates ___ until proven otherwise. imaging of the head and neck vasculature must be obtained and ___ is a reasonable first step. Management consists primarily of ___ . ___ is an important complication of carotid artery dissection

Carotid artery dissection CT angiography (if results are negative but carotid artery dissection is still suspected either MR angiography or catheter angiography (gold standard) may be performed) Antithrombotic therapy (such as antiplatelet agents or anticoagulation) Stroke (Anhydrous is maybe absent and internal carotid artery dissection-AKA partial Horner syndrome-because sweat nerve fibers travel along the external carotid artery)

the symptoms of ___ included severe low back pain, urinary or owl incontinence, motor weakness or sensory loss in the legs bilaterally, and saddle anesthesia.

Cauda equina syndrome

caloric stimulation of the vestibular apparatus as performed by irrigation of the external auditory canal with ___ water. A normal response is characterized by a transient, conjugate, slow deviation of gaze to the ___ side of the stimulus (brainstem mediated), followed by a saccadiic correction to the midline (cortical correction).

Cold same (A caloric response cannot be voluntarily suppressed; therefore, a normal oculovestibular reaction in a comatose patient strongly suggests psychogenic coma)

late neurosyphilis can present with tabes dorsalis (sensory ataxia and lancinating pains) and Argyll Robertson pupils which is defined as ___ .

Constriction with accommodation but not with white

___ are common causes of morbidity and mortality in patients with acute stroke, particularly those with dense hemiparesis. ___ Should be used for prophylaxis in most patients with acute ischemic stroke.

DVT and subsequent PE Low-dose heparin or LMWH (Full dose heparin is used for the treatment of DVT, not its prophylaxis. Full dose anticoagulation is not generally used to treat acute stroke due to the risk of hemorrhagic transformation of the infarct.)

___ is a progressive illness characterized by functional decline and impairment across several cognitive domains.

Dementia (Medications can slow progression, but there is no cure)

the presence of distal symmetric polyneuropathy (in the classic "stocking-glove" pattern) and history of erectile dysfunction are suggestive of significant ___ .

Diabetic neuropathy (Other possible presentations of neurogenic Lee induced erectile dysfunction in the diabetic male included diminished testicular sensation, bladder dysfunction, and inability to masturbate)

patient's with ___ typically present with shortness of breath that is worse in the supine position, and as a result, it is easy to see how the symptoms can erroneously lead to a cardiac workup. One helpful clue on physical examination suggestive of the diagnosis is paradoxical abdominal wall retraction during inspiration when the patient is lying supine.

Diaphragmatic paralysis (Paradoxical abdominal wall retraction during inspiration when the patient is lying supine occurs because the diaphragm was not contracting; a sniff test using fluoroscopy can be helped will in confirming the diagnosis; the most common causes of bilateral diaphragmatic paralysis or neurologic diseases such as ALS)

___ lobe lesions, in addition to having homonymous upper quadrantanopia, almost always involve the language functions, and lead to a aphasia. Wernicke's aphasia is usually seen and is characterized by impairment in the comprehension of spoken or written language. Patient's have difficulty in expressing her thoughts in a meaningful manner.

Dominant temporal

___ are the first line treatment for prolactinomas, including large prolactinomas.

Dopaminergic receptor agonists (Treatment with dopaminergic receptor agonists generally leads to a decrease in tumor size within a few days. Visual symptoms usually improve for the tumors decrease in size as seen on MRI. transsphenoidal and transcranial surgery is rarely required for patients with colectomy home is. Even patients with visual defects or other compressive symptoms may respond to treatment with dopaminergic receptor agonists.)

recent history of non-Hodgkin's lymphoma with classic thoracic radicular pain (wraps around the abdomen) accompanied by weakness and sensory changes in the lower extremities is consistent with ___ . Emergent treatment is with ___ .

Epidural spinal cord compression (bowel/bladder dysfunction usually develop late in the disease but may present early in those with compression at the level of the conus medullaris) High-dose corticosteroids followed by MRI

a number of nerve injuries can occur during carotid endarterectomy. Inadvertent retraction or transection of the ___ nerve causes tongue deviation to the site of injury. The ___ nerve can be damaged after it exits from the stylomastoid foramen and courses along the inferior portion of the ear. The marginal mandibular branch (which supplies the orbicularis oris muscle) is most commonly injured, with a resultant asymmetrical smile.

Hypoglossal Facial

___ usually affects healthy adolescence and often begins with myoclonic jerks in the upper extremities within the first hours of waking. Generalized tonic clonic seizures occur later in the disease course and almost all patients. Electroencephalogram classically demonstrates ___ during the interictal period. ___ Is the first line recommended treatment as it successfully suppress his seizures and up to 80% of patients. It should be used cautiously in women of childbearing age due to potential teratogen AcipHex.

Juvenile myoclonic epilepsy (JME) Bilateral polyspike and slow discharge Valproic acid (up to 50% of patients can have a concomitant psychiatric diagnosis such as anxiety disorder. ssleep deprivation can be a common precipitant of seizures, but most patients with that disease require lifelong treatment with anticonvulsants.)

the cremasteric reflex corresponds to the ___ level of the spinal cord, a region also responsible for hip flexion and adduction.

L1-L2 (This reflex can be diminished or lost secondary to diabetic autonomic neuropathy)

dorsiflexion and plantar flexion is regulated by the ___ region of the spinal cord.

L5 S2

___ occurs due to occlusion of the posterior inferior cerebellar or vertebral artery. Patient's develop loss of pain and temperature over the ipsilateral face and contralateral body, ipsilateral bulbar muscle weakness, vestibular cerebellar (e.g. vertigo, nystagmus, ipsilateral limb ataxia), and Horner's syndrome. Motor function of the face and body is typically spared.

Lateral medullary infarct (Wallenberg syndrome)

patients with suspected cerebral palsy should undergo ___ imaging of the brain to look for abnormalities.

MRI

___ (alternating hypoglossal hemiplegia) is typically due to branch occlusion of the vertebral or anterior spinal artery. Patient's developed contralateral paralysis of the arm and leg and tongue deviation toward the lesion. Contralateral loss of tactile and position sense can also occur with infarcts that extends dorsally.

Medial medullary syndrome

___ presents with contralateral ataxia and hemiparesis of the face, trunk, and limbs (i.e. ataxic hemiparesis). there is also variable loss of contralateral tactile and position sense.

Medial mid pontine infarction

___ is the leading cause of death in patients with tuberous sclerosis complex.

Neurologic impairment (Uncontrollable seizures, aspiration pneumonia, and obstructive hydrocephalus can result from progressive CNS involvement. Renal involvement such as obstructive renal angiomyolipoma and renal failure is the second most common cause of death after neurologic involvement.)

lesions of the ___ lobe can cause visual disorders (homonymous upper quadrantanopia) and impaired perception of complex sounds (auditory agnosia)..

Nondominant temporal

oopioid withdrawal can be managed with ___ (2).

Opioid agonists (methadone, buprenorphine), non-opioid agents (clonidine) (Due to their high level of required supervision, opioid agonists should only be used for detox and supervised inpatient or outpatient settings. Vital signs abnormalities can occur with opioid withdrawal and should be treated with opioid withdrawal medications, followed by traditional blood pressure medications if the pressure remains dangerously elevated.)

the earliest sign of ___ toxicity is the presence of nystagmus on far lateral gaze. Some other effects include blurred vision, diplopia, ataxia, slurred speech, dizziness, drowsiness, lethargy, and decreased mentation, which progresses to coma. The first step in management of side effects due to higher drug levels is to ___ .

Phenytoin Reduced the dose or alter the treatment schedule to minimize the peak drug levels (Abrupt cessation of an antiepileptic drug is not recommended. Any epileptic drug but needs to be withdrawn due to intolerable side effects should be tapered gradually (over days to weeks) to prevent seizure relapse)

what are the 2 causes of hypocalcemia following parathyroidectomy?

RELATIVE HYPOPARATHYROIDISM (results from suppression of normal parathyroid glands by high calcium levels which failed to respond to low calcium levels following surgery) and HUNGRY BONE SYNDROME (caused by the sudden withdrawal of parathyroid hormone in patients with severe hyperparathyroidism, causing an increased importance of calcium from the circulation to bone-serum calcium typically falls to its nadir between 2 and 4 days following surgery) (Signs of hypocalcemia are typically bilateral; unilateral signs may suggest an alternative diagnosis)

sphincter tone is regulated by the ___ region of the spinal cord.

S2-S4

acoustic neuromas result from the proliferation of ___ cells

Schwann (schwannomas

___ typically presents with the sudden onset of severe headache and possible nausea, vomiting, reflux of consciousness, focal neurological deficits, or meningismus. Patients usually developing suddenly worsening headache different from that typical headache pattern, or any intensive new headache typically described as ___ . noncontrast head CT is the initial preferred test for diagnosis, followed by ___ if the head CT is negative.

Subarachnoid hemorrhage "The worst headache of my life" Lumbar puncture documented xanthochromia

___ is a genetic syndrome that leads to benign tumors throughout the body. Clinical manifestations most commonly include cutaneous and central nervous system involvement. The initial evaluation should include a thorough skin examination, CNS and abdominal imaging, and ___ if seizures are suspected.

Tuberous sclerosis complex Electroencephalography

___ is characterized by the triad of confusion, ataxia, and nystagmus (leading to ophthalmoplegia), though all 3 features may not always be present. The above is considered a medical emergency and requires urgent administration of ___ either intravenously or intramuscularly.

Wernicke's encephalopathy Thiamine (always remember that IV glucose given BEFORE thiamine may precipitate symptoms of Wernicke's encephalopathy or cause rapid deterioration of symptoms)

___ are the first line treatment in patients with Alzheimer's dementia

acetylcholine esterase inhibitors (donepezil offers benefits and wants a day dosing, improvement in behavioral and cognitive domains, and has fewer side effects) (Patients with Alzheimer's disease have decreased levels of acetylcholine due to degeneration of the basal nucleus of Meinert in the forebrain and diffuse deficiency of choline acetyltransferase, which is responsible for synthesis of acetylcholine)

___ is is a loss of muscle tone triggered by strong emotions and is a common symptom of narcolepsy. ___ Medications may mildly improve the symptoms but are often insufficient, especially if there is a significant safety risk. Other medications for cataplexy include ___ (4)

cataplexy Stimulant SSRIs, SSRIs, TCAs, and sodium oxybate ( the salt form of gamma hydroxybutyrate-rarely used in the United States secondary to abuse potential and restrictive regulations)

the hallmark feature of Korsakoff's psychosis is ___ . Patients confabulate to fill in memory gaps that experience; both anterograde and Richard date amnesia occurred, though ___ amnesia is more prominent.

confabulation Anterograde (The area involved of the brain in patients with Wernicke-Korsakoff syndrome is the diencephelon, particularly the mamillary bodies in the thalamus)

acute multiple sclerosis exacerbation is treated with ___ . Patients with optic neuritis should receive ___ as oral agents may be associated with an increased risk of recurrence. ___ Can be used in refractory cases.

corticosteroids IV corticosteroids Plasmapheresis (Oral and IV corticosteroids are considered equally efficacious in hastening recovery from an acute MS exacerbation; however, IV steroids should be used in cases of optic neuritis because oral steroids are associated with an increased risk of recurrence)

___ affects up to 50% of patients with Parkinson's disease. He can easily be overlooked because some features may be attributed to the progression of Parkinson's disease. It has a significant impact on disability, and should be highly suspected in patients who present with any of the classic signs (e.g. early morning awakenings, poor eye contact, etc.)

depression (Uncertain cases are usually managed with a trial administration of SSRIs for changes in the medications for Parkinson's disease are considered)

visual hallucinations are a prominent symptoms in many patients with Louis body dementia and can be exacerbated by therapy with ___ ___ is characterized by leaden paralysis and interpersonal rejection sensitivity, not visual hallucinations

dopamine agonists Atypical depression

___ can help to save levodopa treatment for a later time when a Parkinson's patients symptoms are more severe, and it might be preferred as the initial treatment in patients less than 65 years of age.

dopamine agonists such as pramipexole

___ presents with fever, focal spinal tenderness/back pain, and neurological dysfunction. evaluation includes ___ (5). ___ is the intervention that is recommended for most patients

epidural abscess Urgent MRI, blood cultures, inflammatory markers (ESR and CRP), CT-guided aspiration and culture, and antibiotics Emergency surgical decompression

___ lesions affect the motor and principal sensory nuclei of the ipsilateral trigeminal nerve, causing weakness of the muscles of mastication, diminished jaw jerk reflex, and impaired tactile and position sensation In contrast, dysphagia, hoarseness, and diminished gag reflex are more typical of a ___ infarct due to cranial nerve IX and X involvement

lateral mid-pontine Lateral medullary

___ lobe lesions present with constructional and dressing apraxia.

nondominant parietal

important findings that help differentiate traumatic LP from ___ are xanthochromia and discoloration of symptoms centrifuged CSF due to hemoglobin breakdown.

subarachnoid hemorrhage (Xanthochromia and discoloration of centrifuged CSF appeared to 2 every 4 hours after RBCs enter the subarachnoid space. These are present and more than 90% of patients within 12 hours of SAH.)

the constellation of sudden onset headache, nausea, and nuchal rigidity is characteristic of ___ . Signs of right cranial nerve III palsy (ptosis and anisocoria) is a typical finding with ___ artery aneurysm (about 20% of cerebral aneurysms) due to proximity of the nerve to the artery's path.

subarachnoid hemorrhage Posterior communicating (A preceding history of diplopia may be due to cranial nerve III neuropathy secondary to mass effect from the unruptured aneurysm)

a high CSF RBC count without xanthochromia is characteristic of ___

traumatic lumbar puncture (A RBC count exceeding 6000/mm3 may indicate traumatic LP, but other important causes, mainly SAH, should be ruled out. WBC elevation in traumatic LP is commonly explained by the blood leak if approximately 1 WBC is present per 1000 RBCs. The protein level is elevated in the presence of traumatic LP, and the glucose level is typically high.)