Clinical Neuroscience Exam 2

Normal Audiogram Range

-10 to 20 Db

Two classes of drugs used to dilate pupils

1. Anticholinergics: paralyze the iris sphincter and provide cycloplegia (paralysis of ciliary body) 2. Adrenergics: directly stimulate pupillary dilator muscles; do not cause cycloplegia-- used if a patient wants to read once they leave the office

Understand Ct phases of stroke.

1. Hyperacute Phase (1-3 hours): loss of grey-white interface; will note the lentiform nucleus sign and insular ribbon sign 2. Sub-Acute Phase (24 hours- 5 days): vasogenic edema that results in mass effect and hypo-attenuation with well defined margins; risk of brain herniation is greater at this stage 3. Chronic (weeks to months): death of atrocytes and supporting cells in which the brain will undergo liqufactive necrosis; well defined CSF density

Explain the production and flow of aqueous humor

1. Made by the ciliary body 2. Circulates to the anterior chamber of the eye 3. 75% of the aqeous humor will be drained through the tabecular outflow (angle → trabecular meshwork → Schlemm's canal → aqueous veins), while the additional 10-25% is drained through the uveoscleral outflow (anterior ciliary body → ciliary muscle → sclera → exit eye)

Benign Paroxysmal Positional Vertigo (BPPV)

A common cause of vertigo that occurs when there is a shift in the location of small crystals (otoconia) in the semicircular canals Patient will complain of vertigo and nystagmus (rotatory); aggravated by head or body movement

Tay-Sachs Disease Define, Clinical Presentation

A deificency of Hexosaminidase A Clinical Presentation: ◦ Myoclonic Jerks ◦ Cherry red spots (cherry red macula in retina) ◦ Floppy baby ◦ Hyperreflexia ◦ Clonus ◦ Babinski sign ◦ Seizure ◦ Enlarged head Death from infection

Autism

A developmental disorder marked by disabilities in language, social interaction, and the ability to understand another person's state of mind. Patients may exhibit head banging, hand clapping, whirling, teeth grinding, rocking, decreased responsiveness to pain, and self mutilation Treatment: Behavioral modification, speech and language therapy, Neuroleptics, Opiate Antagonists

Vascular Malformation

A direct connection between the arterial and venous systems seen in patients under 30. Results in headache, seizures, bruit, and hemorrhage

Acinic Cell Carcinoma Define, pathology, treatment

A parotid malignancy, commonly found in children, which is typically low grade with good prognosis Pathology: Tumor cells are dark staining, with a granular/ honeycomb cytoplasm and potential lymphoid infiltrate Treatment: Excision

List the early interventions for severe TBI

A. Airway protection: usually by intubation B. If suspected Elevated ICP: elevate the patient's head to 30° and keep it midline, ideally with a rigid neck collar C. IV mannitol D. Hyperventilation: goal of pCO2 34-36 mmHg E. Head CT: without contrast as soon as possible to identify lesions that require surgery and determine the extent of injury

Define: A. Ischemic stroke B. Stroke due to ICH

A. An episode of neurologic dysfunction caused by focal cerebral, spinal, or retinal infarction B. Rapidly developing clinical signs of neurologic dysfunction due to a focal collection of blood within the brain parenchyma or ventricular system which is not due to trauma

Phenytoin is a(n): A. Anticonvulsant B. COX-1 Inhibitor C. COX-2 Inhibitor D. Dopamine agonist E. Immunosuppressant

A. Anticonvulsant

The identification of a significant number of neutrophils in a CSF sample would be most consistent with which of the following? A. Bacterial Meningitis B. Pick Disease C. Guillain-Barre Syndrome D. Multiple Sclerosis E. Parasitic Meningitis

A. Bacterial Meningitis

What does Adduction of the true vocal cords do? A. Close the cord B. Open the cord C. Neither opens or closes D. Only works by using the posterior cricoarytenoid muscle E. Is not a function of the normal vocal cords

A. Close the cord

Which of the following is the most serious complication of phenytoin toxicity? A. Death B. Diarrhea C. Diplopia D. Heart Palpitations E. Nausea F. Nystagmus

A. Death

After what age will an inidivual's visual acuity be locked?

Age 7

List the ABCDs for moderate to severe TBI

Airway Breathing Circulation Disability

Describe the mechanism of action of alcohol

Alcohol modulates GABA activity at GABAa and inhibits specific subtypes of NMDA receptors GABA effect mediates anxiolytic and sedative effects, while NMDA effects play a role in tolerance and dependence Rewarding effects are mediated by indirect activation of cannabinoid receptors (act as a feedback mechanism to enhance dopaminergic activity in the reward pathway

Anisometropia

Amblyopia that results from a difference in the refractive errors between the eyes The eye with the lesser refractive error provides the brain with the clearer image, nd the other eye is susceptible to the development for amblyopia

Mycotic Aneurysm

An "infected aneurysm"; they are caused by septic emboli which lodge in a blood vessel, weakening the wall Typically associated with bacterial endocarditis, and are extremely fatal if they rupture This is why a stroke patient with bacterial endocarditis should not be anticoagulated

Lesch-Nyhan Syndrome Define, Clinical Presentation

An X-linked disorder resulting in a HPRT deficiency Clinical Presentation: ◦ Hyperuricemia ◦ Mental Retardation ◦ Spasticity ◦ Choreoathetosis (dance-like movements) ◦ Self-mutilation ◦ Death by chronic renal failure

Know the main causes of conjunctivitis and keratoconjunctivitis

Conjunctivitis - Bacterial ◦ S. Aureus ◦ S. Pneumoniae ◦ H. Influenzae ◦ Neonates: Chlamydia trachomatis, Neisseria gonorrhoeae - Viral ◦ Adenovirus serotype 3, 4, 7 ("swimming pool conjunctivitis") ◦ HSV-1 ◦ CMV (AIDS patients) ◦ VZV (Herpes Zoster Ophthalmicus) ◦ Measles Keratoconjunctivitis (classic pink eye) - Viral ◦ Adenovirus serotype 8, 19, 37 (NO pharyngitis) ◦ HSV-1 (corneal infection)

Opthalmia Neonatorum

Conjunctivitis occurring within the first month of life Considered a Ophthalamic emergency Chlamydial Conjunctivitis is the most common infectious type (onset 5-14 days) Transmitted when mom has active chlamydia infection during birth Can also be caused by Neisseria Gonorrhoeae (onset <1 week after birth)

Argyll Robertson Pupil

Constricts with accommodation but have no reaction to light AKA "Prostitute's Pupil" Differential Dx: Neurosyphilis

Optic Neuritis

Associated with multiple sclerosis, it is inflammation of the optic nerve as it enters the orbit due to demyelination of the CNS and is typically found in younger (18-45), caucasian, females Results in: ◦ Reduced visual acuity and color vision ◦ Dull, aching pain with eye movement ◦ Relative Afferent Pupillary Defect ◦ Normal-appearing nerve or disc swelling Patients should be given IV steroids; never begin with oral steroids d/t increased incidence of recurrence

Myasthenia Gravis

Autoimmune disease in which antibodies attack ACh receptors at the Neuromuscular junction Patients will have fatigable muscle weakness which improves with rest as ACh stores replenish Symptoms: ◦ Ocular: ptosis, diplopia ◦ Blubar: dysphagia, hoarseness ◦ Systemic: neck and limb weakness, respiratory failure

Neurofibromatosis Define, clinical presentation, diagnosis, treatment

Autosomal dominant disorder, with the NF1 gene on chromosome 17 (encoding neurofibromin protein) or NF2 gene on chromosome 22q (bilateral acoustic neuromas encoding neurofibromin 2, schwannomin, or merlin) Clinical Presentation: ◦ Café-au-lait spots ◦ Axillary freckling ◦ Neurofibromas: hard, painful, benign lesions ◦ Lisch Nodules (NF1) ◦ Mental retardation ◦ Seizures Diagnosis: ◦ Dermatologic features ◦ Neurfibromas ◦ Iris Nodules ◦ Family history Treatment: ◦ Symptomatic ◦ Surgery

Congenital Myasthenia

Autosomal recessive disease in which children are born with weakness due to an abnormal manufacturing of the proteins involved at the neuromuscular junction receptors There are no antibodies and mother is not effected

Bacterial vs. Virual vs. Allergic Conjunctivitis signs/ symptoms

Bacterial ◦ Stringy Discharge that may cause lid to stick together ◦ Purulent ◦ Usually effects one eye Viral ◦ Watery discharge ◦ Begins with one eye then spreads to the other ◦ Adenovirus (serotype 3, 4, 7) will also cause fever/ sore throat Allergic ◦ Watery discharge ◦ Fast ◦ Usually affects both eyes simultaneously

Hirshberg Reflex

Corneal light reflex in which you are looking for alignment of the eyes by gauging where the light reflects off the cornea

Traumatic Optic Neuropathy

Edema and vision loss resulting from a noninflammatory abnormality of the optic nerve caused by trauma (typically rapid decerleration MOI) Profound vision loss, with a +rAPD on the affected side with a normal appearing optic nerve

Meniere's Disease

Fluid build up in the scala media which causes it to rupture, creating a "short circuit" that causes hearing loss and vertigo Symptoms include vertigo (severe and recurrent, lasting 5-30 min) accompanied by nausea and vomiting, hearing loss, and tinnitus Can be familial. Patients should be placed on a low salt diet

Torticollis

Focal Dystonia that involves the sternocleidomastoid, trapezius, and scalenus (common to have hypertrophy of the SCM); produces slow twisting movements Can be caused by: hyperthyroidism, antipsychotics, ocular imblance, cervical spine disease, fragment of idiopathic torsion dystonia Treatment: treat underlying cause, botulinum toxin, surgery

Lentiform nucleus sign

Found in the hyperacute phase of stroke (1-3 hours), it is the loss of visualization of either part of or all of the Lentiform nucleus (caudate, putamen, globus pallidus) Will note loss of grey-white interface

Insular ribbon sign

Found in the hyperacute phase of stroke (1-3 hours), it is the loss of visualization of the insular cortex (ribbon)

Conductive hearing loss (CHL)

Hearing loss caused by damage to the mechanical system that conducts sound waves through the external or middle ear to the cochlea Bone conduction levels in normal range, indicating normal inner ear function, but air conduction levels are elevated indicating abnormality in conduction of sound i.e.: Perforation of the tympanic membrane, damage to the ossicles, impaction of ear wax

Lesion of the occipital cortex results in what pattern of vision loss?

Homonymous Hemianopia

Lesion of the optic tract results in what pattern of vision loss?

Homonymous Hemianopia

Most common etiology of hemorrhagic stroke

Hypertension

Explain the importance of context-sensitive halftime of intravenous anesthetics with relations to clinical uses of induction or maintenance

IV Anesthetics are more commonly used for the induction of anesthesia in adults than are inhalation anesthetics → high lipophylicity results in a rapid onset and short duration (redistributed to muscle and lean tissues) Context sensitive half-time: the longer the drug is infused, the longer its half-life becomes

What is the most common reason for true vocal cord paralysis?

Iatrogenic Intubation trauma-- inflation of ET cuff too high Carotid Artery surgery, spinal surgery (cervical fusion), or thyroid surgery injuring the recurrent laryngeal nerve

1/3 rule

If stroke is <33%, early tPA will have a greater therapeutic effect than if the stroke >33% due to increased risk of hemorrhage

Identify and apply the use of dopamine agonists in the treatment of Parkinson's disease

Includes: Ropinirole & Pramipexole Alternative therapy to L-DOPA in patients who experience the "wearing off" effect which causes them to "freeze" or when a patient has early onset Parkinson's Both are D2/D3 agonists, and can cause the same adverse effects as L-DOPA Can cause impulse control disorders, including: ◦ Gambling addiction ◦ Compulsive shopping ◦ Hypersexuality

Midazolam Indication, Mechanism of action, side effect

Indication: Barbiturate IV anesthetic (preoperative; amnesic, anxiolytic, sedative) Mechanism of Action: Potentiation of GABAa receptors, with no analgesic effects; only benzodiazepine suitable for continuous infusion due to shortest context-sensitive half-time Side Effects: ◦ Decreased BP ◦ Respiratory depression

Ketamine Indication, Mechanism of action, side effect

Indication: Dissociative IV anesthetic Mechanism of Action: Noncompetitive inhibition of NMDA receptors, producing significant analgesia Will cause a cataleptic state (nystagmus with pupillary dilation, spontaneous limb movement, analgesia, amnesia) Side Effects: ◦ Emergence Delirium: hallucinations, vivid dreams, delusions, "out of body experience" → useful in pediatric patients; lower incidence and less severe side effects ◦ Indirect sympathomimetic activity → increased BP, HR, and cardiac output ◦ Bronchodilation

L-DOPA Indication, Mechanism of Action, and adverse effects

Indication: First line therapy in the treatment of Parkinson's Disease in those >60 Mechanism of Action: Biosynthetic precursor of dopamine; stimulates the presynaptic D2 receptors (Gi) that are on glutamatergic, GABAergic, and cholinergic nerve terminals and have an inhibitory effect Administered in conjunction with carbidopa (a DOPA decarboxylase inhibitor) that reduces metabolism of L-DOPA in the GI tract, decreasing peripheral toxicity and increasing the amount that gets to the CNS Adverse Effects: Present most in high doses I. CNS ◦ Dyskinesia (chorea like movements) ◦ Visual and auditory hallucinations ◦ Depression ◦ Anxiety ◦ Agitation II. Peripheral ◦ Anorexia ◦ Nausea ◦ Vomiting ◦ Tachycardia ◦ Orthostatic Hypotension ◦ Dystonia: muscle cramping associated with long term use which causes "freezing" (Apomorphine is a rescue medication for this)

Describe the indications and mechanism of action of buspirone and explain why it is not indicated for acute anxiety attacks

Indication: General Anxiety, Smoking cessation (off label) Mechanism of Action: Partial agonist of 5HT1A and 5HT2 receptor with moderate affinity for D2 Dopamine receptor (relief of anxiety without sedative-hypnotic effects) Acute Anxiety: Buspirone takes 2-4 weeks for onset of action (limiting patient compliance and not indicated for acute anxiety)

Propofol, Fospropofol Indication, Mechanism of action, side effect

Indication: IV anesthetic Mechanism of Action: Potentiation of GABAa receptors preduction sedative hypnotic effects with no analgesic properties Side Effects: ◦ Potential drug of abuse → can cause euphoria on recovery ◦ Painful injection ◦ Pronounced decrease in systolic BP (use caution in patients with low BP) ◦ Respirtory depression ◦ Propofol infusion syndrome: metabolic acidosis, hyperlipidemia, rhabdomyolysis, enlarged liver; occurs in prolonged infusion with high doses in young or head-injured patients

Etomidate Indication, Mechanism of action, side effect

Indication: IV anesthetic Mechanism of Action: Potentiation of GABAa receptors, with no analgesic effects Side Effects: ◦ Nausea & Vomiting ◦ Increased EEG activity → seizures ◦ Cardiovascular stability ◦ Safe for induction but not long term infusion

Describe the indications, mechanism of action, and side effects of ramelteon

Indication: Insomnia Mechanism of Action: MT1 and MT2 agonists (located in the suprachiasmatic nucleus they activate Gi-coupled receptors; MT1 activation causes sleepiness and MT2 is involved in the dark-light synchronization of circadian rhythm) Side Effects: ◦ Dizziness ◦ Fatigue ◦ Endocrine Abnormalities (increased testosterone, decreased prolactin) ◦ Use caution is patients on a concomitant CYP1A2 inhibitor

Morphine, Fentanyl Indication, Mechanism of action, side effect

Indication: Opioid IV anesthetic (epidural, post-operative analgesia) Mechanism of Action: μ opioid receptor agonist; does not produce amnesia or loss of consciousess Typically combined with droperinol (antidopaminergic agent) to produce neuroleptanesthsia ("twilight sleep" → adequate analgesia and sedation while maintaining consciousness to permit patient to respond to questions) Side Effects: ◦ Respiratory depression ◦ Overdose can be reversed with naloxone

Riluzole Indications, Mechanism of action, and Adverse effects

Indications: Amyotrophic Lateral Sclerosis (ALS) Mechanism of Action: Inhibits glutamate release, blocks NMDA and Kainate-type glutamate receptors, and inhibits voltage gated sodium channels Adverse Effects: ◦ Nausea ◦ Diarrhea ◦ Hepatic Injury

Memantine Indications, mechanism of action, and adverse effects

Indications: Moderate to severe Alzheimer's Disease (used in conjuction with cholinesterase inhibitors) Mechanism of Action: Low potency, noncompetitive NMDA antagonist, attenuating the excitotoxic effects of glutamate (thought that glutamate firing is toxic to the neurons) Adverse Effects: ◦ Dizziness ◦ Headache ◦ Confusion

Irregular Peaked Pupil is indicative of what?

Injury to the globe which has then re-sealed

Acute Angle Closure Glaucoma

Intense pain, fixed pupil, very red eye, corneal edema, very high IOP (40-70 mmHg), halo around lights, headache, nausea, vomiting True emergency-- can cause blindness in hours due to damage of the optic nerve It is the acute closure of the anterior chamber angle, causing a sudden increase in intraocular pressure when iris gets pushed forward against trabecular meshwork, blocking outflow of aqueous humor

Conduction Aphasia

Lesion in the arcuate Fasciculus → Patient has difficulty with repetition

Describe premalignant lesions of the upper aerodigestive tract

Leukoplakia: A white plaque which cannot be easily scraped off without bleeding. Have a 5-10% chance of becoming cancerous Erythroplakia: Raised, red area that if scraped may bleed. Generally more severe than leukoplakia with a higher chance of becoming cancerous over time (25-70%)

Myopia

Nearsighted (cannot see things that are far) Eye is too long, image is focused in front of the retina

Hyperdense MCA sign

One of the earliest CT signs of a stroke, it is direct visulization of the thrombus/ embolus

Neisserial Conjunctivitis

Onset: 2-6 days after birth Rapidly progressing infection, with copious purulent drainage, chemosis (swelling of conjunctiva), and lid edema

What glaucoma agent should be used to rapidly lower intraocular pressure in acute angle glaucoma?

Oral Carbonic Anhydrase Inhibitors Inhibit aqueous production i.e.- Acetazolamide, Mathazolamide, Dochlorphenamide

Drug Induced Parkinsonism

Parkinson-like symptoms (rigidity, bardykinesia, resting tremor) due to antipsychotic medications, α-methyl dopa (used for HTN), or metoclopramide (used in diabetics with impaired gut motility)

Retinal Detachment

Patient will c/o flashing lights followed by a shower of floaters and then a curtain or cloud in vision Painless

Acute Subdural Hematoma

Patients are most often comatose from the start, but may experience a lucid interval. This is a result of tearing of the bridging veins, patient will suffer from: blown pupil, hemiplegia, Cushing's reflex, and altered respirations (typically Cheynne Stokes)

Compare and contrast the following: pharmacokinetic tolerance, pharmacodynamic tolerance, behavioral tolerance, conditioned tolerance

Pharmacokinetic Tolerance: Repeated exposure to a drug results in upregulation of CYP enzymes and transporters responsible for drug clearance; typically the result of CYP induction which leads to increased drug metabolism Pharmacodynamic Tolerance: Neuronal adaptation resulting in decreased cellular response to the same concentration of drug at the site of action; changes in neurontransmitter release and clearance, decrease in the number of neurotransmitter recepors, altered conduction of ion channels, modified signal transduction and eventually changes to gene expression related to the action of the drug Behavioral Tolerance: Compensatory behavior to mask the effects of intoxication Conditioned Tolerance: Environmental cues associated with drug use, induces a preemptive, reflexive compensatory change; unconscious phenomenon which is often the basis for relapse (i.e.- seeing drug paraphenlia for an upper results in bradycardia in the user)

Orbital Cellulitis

Pre-septal Cellulitis: infection or inflammation confined to eyelids and periorbital structures anterior to the orbital septum Orbital Cellulitis: active infection or inflammation of the orbital soft tissues posterior to the orbital septum ◦ Proptosis (bulging eye) ◦ Decreased vision ◦ Pupil abnormality (APD)

Glaucoma

Progressive optic neuropathy; progressive damage to the optic nerve over time which causes irreversible, slowly progressive loss of peripheral vision; can result in total blindness Signs/Symptoms: ◦ Excavation of optic nerve ◦ Enlarged cup:disc ratio Risk factors: ◦ High intraocular pressure ◦ African American ◦ Family History

What glaucoma agents have ocular side effects of changing iris color and growth of eyelashes?

Prostaglandin Analogs i.e.- Lantanaprost, Bimatoprost, and Travoprost

Ocular side effects of Tetracyclines (esp. Minocycline)

Pseudotumor Cerebri: increased ICP Tetracyclines common used for acne treatment

Anisocoria

Pupil asymmetry greater than 1.5mm

Cardinal Ocular sign of shaken baby

Retinal Hemorrhage, possibly accompanied by periorbital or anterior segment trauma (ecchymosis, orbital fractures, hyphema, etc.)

RIND

Reversible Ischemic Neurological deficit A stroke that improves after lasting for up to a week; exam will reveal neurologic deificts

Describe the mechanism of action, clinical indications, and adverse effects of Tetrabenazine in the treatment of Huntington's disease

Reversible inhibitor of VMAT-2, it will decrease monoamine uptake into synaptic vesicles, thereby depleting monoamine stores (Huntington's disease is thought to cause excessive dopamine levels) Used for the treatment of chorea Adverse Effects: ◦ Sedation ◦ Akathisia ◦ Parkinsonism ◦ Hypotension ◦ Black box warning: severe depression & suicidal thoughts

Most common causes of Acute Otitis Media (AOM)

S. Pneumoniae H. Influenzae M. Catarrhalis

How can you decipher a sharp force trauma wound from a blunt force trauma wound?

Sharp Force: ◦ Margins are "clean"; well-delineated ◦ Minimal associated changes Blunt Force: ◦ Margins are irregular, ragged ◦ Edges may be abraded, undermined margin, contused/ abraded edges

Vestibular Neuronitis (Viral Labyrinthitis)

Sudden severe vertigo typically caused by a virus Typically lasts daya and may recur for months

Cramps

Sudden, forceful, and often painful muscle contractions Multiple causes, including: vigorous exercise, pregnancy, myotonic disorders, sweating, diarrhea, etc. Treatment: Stretching, Quinine, Phenytoin, Diazepam, Procainamide, Caramazepine

Chorea

Sudden, rapid, jerky, purposeless movements involving limbs, trunk, or face

Central Retinal Artery Occlusion

Suddent, painless and often complete vision loss "Like a curtain was drawn down over my eye"

Thrombectomy

Surgical removal of a blood clot that can be done up to 24 hours after the onset of stroke symptoms 1/2 patient will improve

Corneal Edema

Swelling of the cornea which results in dulling of the red reflex, a ground glass appearance, and can be caused by increased IOP, damage to corneal tissue, trauma, surgery, etc.

Identify the incidence, mortality and causes of traumatic brain injury (TBI)

TBI is one of the leading causes of traumatic death an disability; over 8 millions patients will suffer from a TBI each year The vast majority are due to: falls, motor vehicle accidents, sports-related occurrences, and assaults. Among the survivors, most will require prolonged rehabilitation

Arteritic Ischemic Optic Neuropathy

Temporal Arteritis or Giant Cell Arteritis Results from inflammation of medium sized blood vessels leadint to occlusion of the vessels and ischemia; if not treated, patient will go completely blind in both eyes within 2 weeks Patients present with: ◦ Headache ◦ Diplopia ◦ Temporal tenderness ◦ Severe vision loss ◦ Afferent pupillary Defect ◦ Pale disc edema Patient should be placed on immediate steroids

Describe the detoxification process

The first step in the treatment of dependence Goals: ◦ Withdraw the offending agent: Taper (gradually decrease the dose of the drug to ease the symptoms of withdrawal) ◦ Allow the body to adapt to the absence of the offending agent (homeostasis) ◦ Diagnose/ treat comorbid conditions ◦ Prepare patient for long-term rehabilitation

A stroke that appears in both hemispheres of the brain, most likely evolved from where?

The heart

Squamous Cell Carcinoma Define, Clinical presentation, Pathology

The most common type of cancer which starts in the squamous cells (line the mouth and pharynx) Clinical Presentation: Patients often have a significant history of tobacco and alcohol abuse. They present with hoarseness and unexplained dysphagia for more than 3 weeks in duration, fullness in neck, and unexplained cranial nerve deficits. May present with Leukoplakia or erythroplakia Pathology: "Keratinizing pearl"

Thrombotic vs. Embolic Infarct

Thrombotic (clot develops in an artery) ◦ Slowly progressive ◦ Preceeded by a TIA Embolic (clot travels from periphery to brain) ◦ Sudden onet, commonly with a seizure ◦ Specific focal deficits (i.e.- Wernicke's aphasia) ◦ Hemorrhagic transformation (blood travels to injured area)

Subarachnoid Hemorrhage

Typically found in the young, it is blood in the CSF due to aneurysm or trauma due to a defect in the internal elastic lamina media and anterior circulation Females, smokers, and those with hypertension are more at risk Clinically patients will complain of a "sudden" headache which they describe as "the worst of their life," accompanied by nuchal rigidity, alert to coma, and focal deficits

Adie's Tonic Pupil

Typically of viral etiology, it results in denervation of the parasympathetic fibers, leading to sympathetic override Signs/ Symptoms: ◦ Dilated pupil, minimal response to light ◦ Difference in pupil size greatest in light environment

Vasogenic Cerebral Edema

Typically seen with tumors, it is due to leaky capillaries, resulting in increased extracellular fluid in the white matter (outlines gray-white junction) Treatment: steroids

Identify the use of benzodiazepines in alcohol withdrawal

Typically use Lorazepam Controls psychomotor agitation and prevents the progression of severe withdrawal symptoms

What does VDRL stand for?

Venereal Disease Research Laboratory

Describe the mechanism of action of opioid abuse

Ventral Tegmental Area (VTA): GABAergic neurons inhibit the dompaminergic neurons that project to award centers of the brain; endogenous opioids inhibit the GABAergic terminals, this results in an increased dopaminergic signaling This is positive reinforcement that lends to the addictive potential of opioids (euphoria, light to moderate CNS depression, decreased gag reflex, pinpoint pupils)

Version vs. Duction

Version: testing of both eyes moving together in the same direction Duction: testing eye movement of each eye inidividually (covering up one eye)

Hemiballism

Violent form of chorea in which there will be suddent, violent flinging of the limbs due to a lesion of the contralateral subthalamic nucleus Can be caused by vasculature, hemorrhage, tumor, or be iatrogenic

Emmetropia

Vision is normal Eye is correct length, image is focused on the retina

VA

Visual Acuity; the smallest object a person can identify at a given distance from the eye Should always be checked first

Hypopion

WBCs forming pus in the anterior chamber, usually from infection

A 71 year old white male with a history of alcohol abuse and a 20 pack/year tobacco abuse presents with bilateral swellings of the face for several years. He has no pain or tenderness, and has some facial asymmetry. With a fine needle aspiration, straw colored fluid is drawn. Diagnose

Warthin's Tumor (Papillary cystadenoma Lymphomatosum)

How can you confirm diagnosis of Adie's Tonic Pupil?

Weak concentration of Pilocarpine, a parasympathomimetic, normally will not cause a change in pupil size, but will cause miosis of a tonic pupil

Paresis

Weakness

Treatment of cerebral edema

◦ Hyperventilation (fastest): decrease CO2, causes vasoconstriction and less blood flow to the brain and therefore decreased swelling ◦ Osmotherapy- mannitol or glycerol (sucks fluid out of the brain) ◦ Steroids (only works for vasogenic edema) ◦ Diuretics

What will retard rigor mortis?

◦ Hypothermia ◦ Decreased environmental temperature ◦ CO Poisoning ◦ Young ◦ Elderly ◦ Debilitation

What is the most common type of hearing loss in children?

Conductive hearing loss (CHL)

According to the Multicellular theory of tumorigenisis, the Striated ducts cells give rise to (I), the acinar cells give rise to (II), the excretory duct cells give rise to (III), and the Intercalated duct cells give rise to (IV)

(I) Oncocytic tumors (II) Acinic cell carcinoma (III) squamous cell carcinoma & mucopeidermoid carcinoma (IV) Pleomorphic tumors

According to the bicellular theory of tumorigenisis, the excretory duct gives rise to (I) Carcinoma, and the intercalated duct gives rise to (II) Carcinoma.

(I) Squamous cell carcinoma & Mucopeidermoid carcinoma (II) Pleomorphic adenoma, Warthin's Tumor, Oncocytoma, Acinic cel carcinoma, & Adenoid cystic carcinoma

List the four objectives of stroke prevention and treatment.

1. Primary Prevention: reduce HTN, blood thinners, antiplatelet agents 2. Limit Damage from stroke: Ischemic stroke evaluated within 3 hours and no evidence of hemorrhage-- recombinant tissue plasminogen activator (rt-PA). Note: does increase the incidence of hemorrhagic conversion. Lumbar puncture contraindicated with ICH strokes due to the possibility of tonsillar herniation and midbrain compression 3. Optimize functional recovery following stroke 4. Secondary prevention/ Avoid Recurrence

Identify Antipsychotics used in the treatment of Huntington's disease Include Mechanism of action and adverse effects

1. Reserpine: irreversibly inhibits ATP/Mg2+ pump which is responsible for sequestering neurotransmitters into storage vesicles in the presynaptic neuron Adverse Effects: hypotension, depression, suicidal thoughts 2. Diazepam: potentiates GABA, thereby reducing excessive movements & useful anxiolytic effects 3. Neuroleptics: block dopamine transmission 4. Typical Antipsychotics (Haloperidol, Chlorpromazine, Fluphenazine): potent D2 antagonists used for severe chorea Adverse Effects: High potency (Fluphenazine & Haloperidol) most likely to have neurologic side effects including delirium and Extrapyramidal effects (Akathisia- uncontrollable restlessness- sleepiness, autonomic effects)→ treated with Bentropine or diphenhydramine, Neuroleptic Malignant Syndrome (fever, encephalopathy, unstable vials, increased enzymes, muscle rigidity)→ treated with dantrolene or D2 agonists i.e.- bromocriptine, Tardive Dyskinesia (abnormal repetitive, involuntary, stereotyped movements of the face, arms, and trunk); Low potency (Chlorpromazine) most likely to have non-neurologic side effects including anticholinergic (dry mouth, constipation, difficulty urination, loss of accommodation), antihistamine (sedation, weight gain), and α1-blockade effects (hypotension, sedation, failure to ejaculate)

What makes up the middle ear and what is its function?

1. Tympanic Membrane 2. Ossicles 3. Eustachian Tubes 4. Facial Nerve Function: Enhance transmission of sound to the inner ear

Legal Blindness

20/200 or less with correction

Lip Cancer

25-30% of all oral cavity cancers, most are squamous cell in nature They are associated with chronic sun exposure, pipe smoking, cigarette smoking, and alcohol use Basal cell cancer is more octen seen in the upper lip.

Noise-Induced Sensorineural Hearing Loss has a maximal hearing loss peak at what?

4000 Hz

Pleomorphic Adenoma Define, pathology, treatment

A "benign mixed tumor," which is a solitary lesion and the most common salivary gland neoplasm. Typically found in the parotid gland, but also found in minor salivary glands Typically found in females (3-4:1) in the 4th-6th decade of life Pathology: smooth or lobulated, well-encapsulated tumor that is clearly demarcated from the surrounding normal salivary gland; may exhibit pseudopods that extend into the nearby tissue Treatment: Superficial parotidectomy with facial nerve preservation (dissect out facial nerve)

Orbital Fracture Include the most common type, symptoms, and what is found on physical exam

A "blow-out" fracture, with the inferior orbital wall being the most common Caused when there is a backward displacement of the globe, causing an increase in intraorbital pressure and a fracture of the orbit Symptoms: Diplopia, pain with eye movement, blurred vision Physical Exam: Periorbital ecchymosis & edema, subconjunctival hemorrhage, decreased motility

Progressive Supranuclear Palsy (PSP)

A Parkinson's- look alike disease which is more common in males than females Clinical Presentation: difficulty with vertical eye movements (particularly looking down), rigidity, babinksi sign (not seen in parkinson's), unusual to have tremor; patients present with early dysphagia, speech difficulties (progressing to non-fluent aphasia), and dementia There is no treatment, and typically patients will die within 10 years

Sydenham Chorea (St. Vitus Dance)

A disease of childhood (5-15 years) which is more common in females (2:1) and is self-limiting (complete recovery is the rule) but can persist A manifestation of rheumatic fever (following streptococcal infection), antibodies (anti DNA-ase B) will react the the subthalamic and caudate nuclei Results in chorea (rapid, irregular, aimless, involuntary movements), darting tongue (tongue moves in and out when asked to stick out), and behavior symptoms; can be influenced by emotion and external stimuli as well as psychological manifestations Treatment: ◦ Sedatives ◦ Phenothiazines, Haloperidol ◦ Valproid Acid ◦ IV IgG

Tuberous Sclerosis Define, Clinical presentation, Treatment

A disorder of chromosome 9 which has multisystem involvement (skin, brain, lung, renal, etc.) Clinical Presentation: ◦ Hamartia ◦ Adenoma Sabaceum ◦ Seizures ◦ Mental retardation ◦ Ash leaf macules ◦ Subungual Fibroma ◦ Shagreen patches ◦ Café-au-lait spots ◦ Subependymal nodules (candle drippings/ guttering on brain imaging) Treatment: Symptomatic

Hypertensive Encephalopathy

A disorder seen in patients with malignant hypertension (BP >130) which causes generalized arteriolar dilation and loss of cerebral autoregulation Patients present with headache, confusion, seizure, and focal deficits Treatment: control BP

Blepharospasm

A focal dystonia seen more commonly in females than males that causes the eye muscles to twitch Patients will present with increased blinking, grimacing, and extension of the jaw and tongue Treatment: Botulinum Toxin

Constraint Induced Movement Therapy (CIMT)

A form of therapy that helps patients with stroke or other neurological disorders regain use of the affected limb. The patient's good limb is secured such that they cannot use it, such that they are forced to engage in repetitive exercises with the affected limb, allowing the brain to grow new neural pathways

Relative Afferent Pupillary Defect (rAPD)

A medical sign observed during the swinging-flashlight test whereupon the patient's pupils constrict less when a bright light is swung from the unaffected eye to the affected eye. AKA: Marcus Gunn Pupil

Parkinson's Disease Define, Clinical symptoms, Diagnosis, and Treatment

A movement disorder effecting females and males equally, which results from atrophy/ death of the substantia nigra, leading to fewer inputs into the globus pallidus/ putamen Has both genetic and environmental influences Histologically, lewy bodies will be present with neuronal loss noted and asymmetric depigmentation of the substantia nigra, locus ceruleus, and dorsal vagal nucleus Clinical Presentation: ◦ Resting Tremor: "pill rolling"; worse with stress ◦ "Cogwheel" Rigidity: ratchet like movements with a flexed posture ◦ Bradykinesia: slow movements with decreased arm swing, decreased blink rate ◦ Festinating Gait: shuffling ◦ Masked Face: expressionless ◦ Myerson's Sign: patient keeps blinking each time you tap between their eyes Diagnosis: ◦ Lab Test: rule out look-alikes ◦ MRI: rule out other causes (i.e.- other strokes) ◦ PET Scan Treatment: ◦ No cure ◦ Goal is to reduce severity and incidence of symptoms ◦ Educate patient ◦ Support groups ◦ Surgery: destroy brain tissue ◦ Neuroprotective Agents: Selegiline (blocks MAOB to stop formation of toxic metabolites), Rasagiline (newer MAOB Inhibitor) ◦ Anticholinergic Agents: may help with tremor or rigidity (benzotropine, biperiden, trihexyphenidyl) ◦ Amantadine: weak dopaminergic effect that is better tolerated in the elderly than anticholinergics ◦ Dopamine Agonists: (ropinirole, pramipexole) can be used early in the disease sparing use of levodopama; directly stimulated the dopamine receptors without the substantia nigra (can cause nausea, hallucinations, confusion, compulsivity, sleep attacks) ◦ COMT Inhibitor: (tolcapone, entacapone) stops the breakdown of catecholamines; enhances levodopa effectiveness ◦ Levodopa-Carbidopa: the best treatment for Parkinson's; Levodopa will cross the BBB and then be converted to doamine in the blood; carbidopa (need at least 70 mg) will inhibit the peripheral breakdown of levodopa by dopa decarboxylase

Gilles de la Tourette's Syndrome Define, Clinical symptoms, Diagnosis, and Treatment

A neurological movement disorder that also has prominent behavioral manifestations including motor and vocal tics persisting for more than one year; etiology is not known but thought to involve dopamine or dynorphin absence Clinical Presentation: Can include vocalizations (coprolalia-swearing- echolalia- repeat everything that is said to them- palilalia- repeat themselves) or sexual impulses which are can be precipitated by stimulants Can have a family history or have anti-DNAase B antibodies present 50% of individuals will also have features of obsessive compulsive disorder and/or attention deficit disorder Diagnosis: ◦ History and Physical (Multiple tics, lasting longer than 6 months with the presence of a vocalization) Treatment: ◦ May remit on its own ◦ Remove precipitants ◦ Clonidine ◦ Haloperidol ◦ Pimozide ◦ Naltrexone ◦ Marinol ◦ Psychotherapy ◦ Deep Brain Stimulation

Cerebral Palsy

A non-progressive motor disorder due to insult before birth, perinatal, or within the first two years of like Can be Spastic, Dyskinetic (abnormal movements), Ataxic, or mixed and is associated with seizures, mental retardation, an ADD

Explain the pathophysiology behind Alzheimer's disease

A range of conditions that are characterized by the degeneration of the structure and function of the central nervous system or peripheral nervous system Loss of hippocampal and cortical cholinergic neurons leads to impairment of memory and cognitive ability

Red Reflex

A reflection of light off of the retina where all the blood vessels are

Corneal Abrasion Mechanism of Injury, Physical Exam findings, and treatment

A scraping away of the outer layer of the cornea which can result from fingernails, tree branches, or foreign bodies Physical Exam: Irregular light reflex, decreased/ blurred vision, conjunctival injection, fluorescein dye uptake (make sure to look under eyelid) Treatment: Fluoroquinolone drops, Antibiotic ointment, Bandage contact lenses, no patching

Niemann-Pick Disease Define, clinical presentation, Diagnosis

A sphingomyelinase deficiency Clinical Presentation: ◦ Hepatosplenomegaly ◦ Developmental regression ◦ Dementia ◦ Hypotonia ◦ Cherry red spot ◦ Seizures Diagnosis: bone marrow biopsy

Nitrous Oxide (laughing gas)

A strong inhalation anesthetic which is used primarily as an adjunct to other anesthetics to increase their rate of induction The least potent of the inhaled anesthetics, with the fastest induction and recovery Can lead to diffusional hypoxia due to rapid diffusion out of the blood (100% oxygen should be given to avoid hypoxia)

Idiopathic Dystonia Define, Clinical symptoms, Diagnosis, and Treatment

A sustained muscle contraction whose cause is unknown (probable biochemical or genetics) Clinical Presentation: typically begins between ages 5-15, and often focally (foot inversion), patients may present with facial grimacing and spasms will cause marked distortion of the body; patients are mentally normal, and the dystonia will disappear with sleep Diagnosis: based on history and physical Treatment: ◦ Diazepam, anticholinergic meds, baclofen, carbamazepine ◦ Biofeedback ◦ Surgery (thalamotomy)

Tissue Plasminogen Activator (TPA)

A thrombolytic agent that converts plasminogen to plsmin, resulting in fibrinolysis Will break up clots that are < 7mm Can be used in the first 4.5 hours of an ischemic stroke; CT scan has to be negative for blood or stroke In order to use, BP must be <185/110 (use labetolol to decrease) Contraindications: ◦ Presence of suspicion of hemorrhage ◦ Recent trauma, stroke, or surgery ◦ Uncontrolled HTN ◦ Active bleeding ◦ Intracranial tumor, AVM, or aneurysm ◦ Use of other blood thinners (i.e.- warfarin)

Amaurosis Fugax

A transient partial or complete loss of vision in one eye, typically lasting less than 5 minutes "Like a shade covered my eye" TIA of the eye

List the incidence of: A. Cardioembolism B. Large vessel atherosclerotic infarction C. Small vessel lacunar infarction D. Strokes of undetermined cause

A. 15-30% of cases B. 14-40% of cases C. 15-30% of cases D. 30-40% of cases

Describe the incidence of stroke among: A. Adults age 35-44 B. Adults age 65-74 C. African Americans compared to Caucasians

A. 30-120/100,000 B. 670-970/100,000 C. 2x as high for African Americans as for whites

Describe the etiology and clinical features of the following ataxic conditions: A. Fragile X-associated tremor/ataxia syndrome B. Friedreich's ataxia C. Paraneoplastic syndrome

A. A syndrome associated with a pre-mutation with repeats of 55-200 in the Fragile X Mental retardation (FMR1) gene; clinically, males will present with a progressive cerebellar tremor and ataxia B. Autosomal recessive ataxia that results from an unstable GAA expansion on chromosome 9. Clinically, it is characterized by childhood onset gait ataxia and clumsiness, which reflects a combination of spinocerebellar degeneration and peripheral sensory loss. Non-neurological manifestations include cariomyopathy, DM, and skeletal deformities C. Typically associated with gynecological, breast, lung cancer, or lymphoma; anti-Hu/Yo/Ri antibodies are often present; it is the acute onset of ataxia which often predates the identification of the cancer; treatment of the underlying cancer and plasma exchange can be beneficial

List: A. Non-modifiable risk factors for stroke B. Well established Modifiable risk factors for stroke C. Other potential risk factors

A. Age, Sex, Race/Ethnicity, Family History, Genetic Disorders B. HTN*, DM, Cardiac disorders (a-fib, MI, Heart failure), Hyperlipidemia, Cigarette smoking, Carotid Stenosis, TIA, Physical Inactivity, Hypercoagulable states, Alcohol abuse, Substance abuse C. Migraine, Sleep apnea, Cardiac Disorders (SVT, patent foramen ovale), Infections (VZV, Influenza), Inflammation

Distinguish the following spinal cord syndromes: A. Anterior cord syndrome B. Brown-Sequard syndrome C. Central cord syndrome

A. Deficits referable to bilateral anterior and lateral spinal cord columns. Loss of touch, pain, temperature, and motor function below te level of the lesion. Posterior column functions of proprioception and vibratory sensation remain intact B. Deficits are due to a lateral half of the cord. There is functional loss of ipsilateral motor, touch, proprioception, and vibratory sensation as well as contralateral loss of pain and temperature. C. Results in "man in a barrel" syndrome: motor paralysis of both upper extremities with sparing of the lower extremities; weakness is greater proximally than distally. Pain and temperature sensations are generally reduced, but proprioception and vibratory sense spared.

The identification of myelin basic protein in the CSF would be most suggestive of which of the following? A. Demyelinating disease B. Metastatic Tumor C. Osteophytes D. Primary Tumor E. Traumatic tap

A. Demyelinating disease

Define the criteria for the Glascow Coma Scale What is a severe TBI defined as?

A. Eye Response 4: Eyes open spontaneously 3: Eyes open to verbal command 2: Eyes open to pain 1: No eye opening B. Verbal Response 5: Oriented 4: Confused 3: Inappropriate words 2: Incomprehensible sounds 1: No verbal response C. Motor Response 6: Obeys commands 5: Localizing pain 4: Withdrawal from pain 3: Flexion to pain 2: Extension to pain 1: No Motor Response Severe TBI: 8 or less

Be able to distinguish stroke syndromes from: A. Infection B. Seizure C. Brain tumor

A. In patrients with hx of cerebral infarct or hemorrhage, infection may precipitate original strok syndrome B. Unlike strokes, seizures often result in obtunded/ amnestic state with clonic activity, incontinence, or tongue biting; Todd's Paralysis is a postictal deficit resembling weakness/ language defiicts but usually resolves within hours of the seizure C. Seizures often precede focal signs and a CT scan demonstrates enhancing mass even when symptoms are mild

Explain the following Drug-Drug interactions: A. L-DOPA + Vitamin B6 B. L-DOPA + Non-selective MAOI C. L-DOPA + High protein diet

A. L-DOPA + Vitamin B6: Vitamin B6 increases the peripheral breakdown of L-DOPA, decreasing its efficacy B. L-DOPA + Non-selective MAOI: Hypertensive crisis C. L-DOPA + High protein diet: L-DOPA competes with amino acids for transport across the gut wall or BBB, decreasing its efficacy

A. The larger the salivary gland, the more or less likely a tumor is to be malignant. B. The smaller the gland, the more or less likely a tumor is to be malignant.

A. Less B. More

What are the complications of spinal cord injury?

A. Loss of Sympathetic tone, Hypotension, Bradycardia → Associated with Lesions T3 or above; classic neurogenic shock triad: bradycardia, hypotension, and peripheral vasodilation B. Ventilatory compromise → Injuries at C5 or higher typically require mechanical ventilation; injuries C6 or below do not require ventilatory support, but may have decreased effort due to intercostal muscle innervation being disrupted which can lead to pneumonia C. Thromboembolic disease → leading cause of morbidity and mortality in spinal cord injuries due to development of DVTs without prophylaxis; patients should receive anticoagulation D. Feeding/Nutrition; ileus → Nasogastric tube should be placed to decompress the stomach and parental nutrition should be started; enteral feeding should be delayed until GI motility returns (usually between 2-3 weeks) E. Bladder tone → Can be lost due to spinal shock; Foley catheter should be placed and maintained for a minimum of 5-7 days to drain balder and evaluate circulatory volume & renal status; once spinal shock resolves, autonomic dysreflexia may occur due to bladder distention (skin flushing, hypertension); physical will reveal a distended bladder which can be treated with intermittent catheterization or bladder training; Phenoxybenzamine may also be helful

Describe the etiologies, clinical features of the following movement disorders: A. Parkinsonism (i) Idiopathic Parkinson's disease (ii) Atypical Parkinsonism (Parkinson plus): (a)Multiple system atrophy (b) Dementia with Lewy bodies (c) Corticobasal degeneration (iii) Secondary Parkinsonism B. Chorea (i) Wilson disease

A. Most common extrapyramidal disorder characterized by akinesia, rigidity, tremor, and posterual instability (i) The second most common adult onset neurodegenerative disease (after Alzheimer's); motor symptoms result from the selective loss of dopaminergic neurons in the substantia nigra pars compacta that project into the striatum; pathological hallmark is the presence of eosinophilic cytoplasmic neuronal inclusions (Lewy Bodies) which contain α-synuclein; clinically, it is characterized by asymmetric rigidity, bradykinesia, resting tremor, and postural instability (ii) A group of heterogeneous inherited and sporadic neurodegenerative disorders characterized by Pakinsonism and a reduced or absent response to dopaminergic therapy. (a) sporadic neurodegenerative disorder characterized clinically by the variable combination of Parkinsonism, autonomic dysfunction, cerebellar dysfunction, and extrapyramidal motor signs; classified as either MSA-parkinsoniam type or MSA-cerebellar Type depending on the predominant clinical symptoms (b) Difficult to distinguish from Parkinson's disease; patients will have a high risk for psychosis associated with dopaminergic therapy and antipsychotics may worsen parkinsonism and even lead to death (c) Presents with market asymmetric Parkinsonism, focal limb dystonia, cortical sensory findings, alien limb phenomenon, and myoclonus (iii) Can be caused by medications, toxins, and cerevrovascular disease; drug-induced Parkinsonism can be indistinguishable from Parkinson's Disease, and is frequently asymmetric B. Brief, irregular, random, non-rhythmic movements that flow from one body part to another (i) Autosomal recessive disorder of impaired copper metabolism, causing copper accumulation and neurologic as well as hepatic dysfunction. Will cause chorea, dystonia, Parkinsonism, and tremor with dystonia and tremor predominating.

Review the major blood vessels supplying the brain. A. Review the fetal origin PCA. Why is this significant? B. Review the territory of the anterior choroidal artery C. Review the territory of the MCA. Review the impact of blockages of the main stem, superior and inferior divisions. D. Review the territory of the ACA and impact of strokes affecting this territory. E. Review the distribution of the posterior circulation (vertebral arteries, basilar) and the impact of occlusion of these vessels.

A. PCA that arises directly from the internal carotid artery, thereby making it such that the entire hemisphere (including occipital lobe) is supplied by the internal carotid artery B. Choroid plexus, inferior portion of the posterior limb of the internal capsule, hippocampus, portions of the globys pallidus, posterior putamen, lateral geniculate, amygdala, and ventrolateral thalamus C. Largest branch of Internal Carotid Artery; gives rise to the lateral lenticulostriates (supplies extreme capsule, claustrum, putamen, and most of globus pallidus), superior and inferior divisions supply almost entire lateral cortical surface of the brain (insula, operculum, frontal, parietal, temporal, and occipital cortices) D. Supplies the head of the caudate nucleus and several cortical branches which supply the medial and orbital surfaces of the frontal lobe E. Two vertebral arteries joing to form the basilar artery; occlusion of the distal vertebral artery can cause infarction of the lateral medulla (Wallenberg Syndrome) characterized by vertigo, imbalance, horner syndrome, dysphagia, and sensory loss

Regarding spinal cord injury, recognize: A. The severity of high cervical lesions B. Signs and symptoms suggesting of spinal cord injury C. The features of the neurological exam that determine the level of the injury

A. Spontaneous ventilation will be lost. Lesions below C5 may also impair ventilatory capability. Emergency intubation is required B. Complaint of burning hands or of pain over the spine, numbness, tingling, or weakness C. The level of injury is the lowest spinal cord segment with intact motor and sensory function

Identify the primary function and innervation of the following: A. Superior Rectus B. Medial Rectus C. Inferior Rectus D. Inferior Oblique E. Superior Oblique F. Lateral Rectus

A. Superior Rectus: Elevation (CN III) B. Medial Rectus: Adduction (CN III) C. Inferior Rectus: Depression (CN III) D. Inferior Oblique: Excyclotrosion- External rotation (CN III) E. Superior Oblique: Incyclotorsion- Internal Rotation (CN IV) F. Lateral Rectus: Abduction (CN VI) "LR6SO4"

Explain the mechanism of action and adverse effects of MDMA use

AKA Ecstasy or Molly Primarily effects serotonergic transmision causing serotonin relapse into the extracellular space, inhibition of serotonin synthesis, and blocks serotonin reuptake Adverse effects: nausea, muscle cramping, fever, sweating and chills, shaking and tremors, hallucinations, blurred vision, increased HR and blood pressure, feeling faint Loss of consciousness, extreme body temperatre can occur and lead to organ damage

Broca Aphasia

AKA Expressive/ Nonfluent/ anterior aphasia Chracterized by difficulty producing speech, but understanding is fairly intact → Patient unable to talk, but will follow directions (if patient will squeeze, then let go when directed)

Small Vessel Disease Explain, Risk Factors, and Treatment

AKA Lacunar infarcts These are infarcts that occur in small blood vessels which can present differently based on where they occur; they are diagnosed by clinical syndrome Can be: ◦ Pure motor ◦ Pure sensory ◦ Pseudobulbar palsy (patient looks like something is wrong with the brainstem, but it is due to multiple infarcts above the brainstem) ◦ Clumsy Hand- dysarthria ◦ Hemiataxic- hemiplegic Risk Factors: ◦ Hypertension ◦ Diabetes Mellitus Treatment: ◦ Control blood pressure ◦ Antiplatelet agents (ASA, clopidogrel) ◦ Carotid Endarterectomy: remove build up from carotid (>60-70% stenosis)

Attention Deficit Disorder

AKA Minimal brain dysfunction, it may resemble patients with head trauma and encephalitis It results in: short attention span, hyperactivity, impulsiveness, distractibility, restlessness, lack of coordination, delay in speech development, and emotional lability Treatment: counseling, school placement, medication (stimulants, caffeine)

Describe the mechanism of action and adverse effects of phencyclidine use

AKA PCP Blocks NMDA glutamate receptors which are responsible for mediating excitatory synaptic transmission; involved in synaptic plasticity and memory Adverse Effects: Hallucinations, intense paranoia, Agitation, Amnesia, Vertical and horizontal nystagmus

Warthin's Tumor Define, pathology, treatment

AKA Papillary cystadenoma Lymphomatosum; the second most common benign parotid neoplasm, it is associated with tobacco and alcohol use. In 10% of patients. they will have them bilaterally. Most common in males (5:1) in the 4th to 7th decade of life Pathology: Can aspirate a straw colored fluid, and they contain a double cell layer Treatment: Superficial parotidectomy with facial nerve preservation (disect out facial nerve)

Wernicke Aphasia

AKA Receptive/ Fluent/ Posterior Aphasia Characterized by impaired comprehension, paraphasia, neologisms, and gibberish → Patients will make up words, change words

Mental Retardation

AKA intellectual disability, static encephalopathy Incomplete or insufficient general development of mental capacities which is more noticeable in school years IQ ◦ 50-75% mildly retarded ◦ 30-50% moderately retarded, trainable ◦ <30% severely retarded, not trainable Treatment: medical, education and training, placement of patient (home, institution)

Iris Synechia

Abnormal attachment of iris surface and another structure (lens or corneal endothelium or trabecular meshwork, TM)

What will accelerate and retard decomposition?

Accelerated by: ◦ Fever ◦ Sepsis ◦ Obesity ◦ Increased environmental temperature ◦ Trauma Retarded by: ◦ Infants ◦ Thin Patients ◦ Decreased environmental temperature

Describe the mechanism of action of and adverse effects marijuana

Act on cannabinoid receptor 1 & 2 as an agonist Adverse Effects: difficulty thinking and problem solving, problems with memory and learning, impaired coordination, difficulty maintaining attention

Describe the mechanism of action of nicotine

Activates nicotinic acetylcholine receptors centrally, peripherally, and at the neuromuscular junction Activation of presynaptic nicotinic receptors on dopaminergic neurons facilitates the release of dopamine (positive feedback loop- heteroreceptors)

Define the following terms: addiction, tolerance, sensitization, and dependence

Addiction: A condition in which a person engages in use of a substance or in behavior for which the rewarding effects provide a compelling incentine to repeatedly pursue the behavior despite detrimental consequences; can lead to changed in brain structure and function; biological, psychological, and sociological components5 Tolerance: Repeated or continuous drug use that can result in decreased effect over time when the dose remains constant Sensitization: Inverse tolerance, after the first dose, the drug becomes more potent with subsequent use Dependence: condition where an individual feels compelled to repeatedly administer a psychoactive druge

Becker Muscular Dystrophy Define, Clinical symptoms, Diagnosis, and Treatment

An X-linked recessive disease, which is similar to Duchenne Muscular Dystrophy, with a slower progression These patients have a mutation in the dystrophin gene, but one that results in a smaller dystrophin protein instead of a complete lack of the protein Clinical Presentation: Gradual onset of walking difficulties with loss of the ability to walk by age 25-30 years, progressive muscle wasting with lordosis Diagnosis: ◦ Labs: Extremely elevated CPK (10,000 - 15,000) ◦ Muscle biopsy ◦ EMG ◦ Genetic Testing Treatment: ◦ Symptomatic: mobility, avoid bed sores, manage weight ◦ Immature muscle cell injections (not usually successful) ◦ Steroids (decrease scoliosis) ◦ Death usually by 50

Myasthenic Crisis

An acute exacerbation of myasthenia gravis which requires the use of ventilator support Most often occurs after a major surgery, infection, high dose of steroids, or use of (-mycin) antibiotics which will compete at the neuromuscular junction Can mimic a cholinergic crisis ◦ If medications are stopped, these patients will get better while a MG patient will have no change ◦ Cholinergic crisis patients will also drool

Huntington Chorea Define, Clinical symptoms, Diagnosis, and Treatment

An autosomal dominant disorder (CAG trinucleotid repeat on IT-15 p4 coding for huntingtin protein) which results in atrophy of the caudate nucleus and putamen and therefore the loss of GABA and cholinergic neurons Clinical Presentation: Typically develops between 35-40 years old and will present with: ◦ Triad: extrapyramidal movement disorder, progressive cognitive decline, array of behavioral disturbances ◦ Chorea (rapid, irregular, aimless, involuntary movements) ◦ Personality disorder ◦ Dementia ◦ Milkmaid grips ◦ Extraocular movement difficulties ◦ Dancing gait ◦ Dystonia and rigidity in advanced cases Diagnosis: ◦ Genetic Testing ◦ Neuroimaging: note atrophy of caudate ◦ Microscopically: preferential loss of medium-sized spiny neurons projecting from striatum to external pallidum Treatment: ◦ Symptomatic ◦ Haloperidol, Phenothiazine, Tetrabenazine ◦ Reserpine ◦ Genetic counseling ◦ Genetic therapy

Phenylketonuria (PKU) Define, clinical presentation, treatment

An autosomal recessive disease which results in the impaired conversion of phenylalanine to tyrosine, leading to the accumulation of phenylalanine which is converted to organic acids and interferes with normal metabolism resulting in defective myelination and decreased pigmentation Clinical Presentation: ◦ Vomiting and Irritability during the first two months of life ◦ Delayed intellectual development leading to mental retardation ◦ Seizures, infantile spasms ◦ Blonde hair, Blue eyes, Eczema ◦ Tremors, Babinski Sign Treatment: Dietary

Homocystinuria Define, Clinical presentation

An autosomal recessive disorder resulting in a defect of cystathionine synthase Clinical Presentation: ◦ Seizures ◦ Developmental slowing leading to mental retardation ◦ Multiple thromboembolic events ◦ Ectopia Lentis: displacement or malposition of the eye's crystalline lens (downward and inward)

Acute Akathisia

An inner feeling of restlessness in which a patient is unable to sit still Presents more often in females than males

Myopathy

Any disease of a muscle; typical features include: ◦ Proximal weakness of upper and lower extremities ◦ Difficulty rising out of a chair ◦ Difficulty climbing stairs ◦ Difficulty lifting arms over head

In a CT perfusion curve, what does the area under the curve represent? If the are is decreased, what does this indicate?

Area under the curve represents blood volume. If this area is decreased, this is indicative of ischemia

Subconjunctival Hemorrhage

Bleeding between the conjunctiva and the sclera which is typically benign in nature but cause for concern following trauma Recurrent hemorrhage should prompt evaluation for bleeding disorder and checking INR

What are ways to salvage the ischemic penumbra

Avoid: ◦ Relative hypotension (<185/90) ◦ Hypoxia ◦ Hyperglycemia (>200 leads to death of cells) ◦ Hyponatremia Use of Neuroprotective Agents: ◦ NMDA ◦ NO ◦ GABA ◦ Calcium ◦ Free Radicals

Which of the following would be a contraindication for lumbar puncture? A. Antibiotic therapy B. Anticoagulation therapy C. Bariatric Surgery

B. Anticoagulation therapy

What does the rima glottidis represent? A. True Cords B. Space between true vocal cords C. Space below the vocal cords D. Anterior Commissure

B. Space between true vocal cords

An elevated serum methylmalonic acid level would be consistent with a deficiency in which of the following: A. Vitamin A B. Vitamin B12 C. Vitamin D D. Vitamin E E. Vitamin K

B. Vitamin B12

Identify the use of Baclofen, Gabapentin, Tizanidine in the treatment of ALS

Baclofen (GABAb receptor agonist) can be used to treat the spasticity associated with ALS Gabapentin & Tizanidine can be used to slow the decline in muscle strength

Explain the mechanism of action of Baclofen, Gabapentin, and Tizanidine

Baclofen: GABAb agonist, it helps to control spasticity associated with ALS ◦ Adverse effects: sedation, potential life-threatening CNS depression ◦ Abrupt withdrawal can lead to rebound spasticity, rhabdomyolitis, multi-organ failure, and death. Gabapentin: inhibition of high voltage gates calcium channels, it helps to reduce muscle spasticity associated with ALS by increasing presynaptic inhibition of motor neruons ◦ Adverse effects: ataxia, fatigue, viral infection, nystagmus, tremor, dizziness, suicidal thoughts Tizanidine: α2 receptor agonist, it helps to reduce muscle spasticity associated with ALS by increasing presynaptic inhibition of motor neurons ◦ Adverse effects: drowsiness, asthenia, dizziness

Identify treatment strategies for benzodiazepine or barbiturate overdose

Benzodiazepine Overdose: Flumazenil Barbiturate Overdose: no antidote; since barbiturates are weak acids, sodium bicarbonate can be used to alkalinize the urine to aid in excretion

Describe why ZZZ agents are better than benzodiazepines for insomnia and identify treatment option in an event of overdose

Benzodiazepines will alter sleep architecture (suppressing Stage 3 and REM sleep); while a patient will sleep, it is not restorative sleep and they wake up feeling unrested. ZZZ agents (Zolpidem, Zaleplon, Eszopiclone) have little effect on sleep architecture and therefore can be used for restorative sleep. Only indicated for insomnia; they are selective for the α1 subunit of GABAa, meaning they have less anxiolytic activity and less potential for tolerance and dependence Overdose Treatment: Flumazenil

Papilledema

Bilateral optic disc swelling which is caused by an increased ICP Differential Dx: Papillitis, antibiotics, inflammation

Dacryostenosis

Blockage of nasolacrimal system Mucopurulent drainage, epiphora (excessive tearing) Most patients will have spontaneous resolution by 6 months of age, but the duct can be open surgerically

Describe the injuries that occur to brain tissue as a result of stroke.

Blood Supply completely Interrupted: ◦ 30 Seconds: brain metabolism altered ◦ 1 minute: neuronal function ceases (influx of calcium at the root of injury) ◦ 5 Minutes: anoxia results in cerebral infarction (can be reversed if oxygenated blood flow is restored quickly enough)

Hyphema

Blood in the anterior chamber of the eye, most commonly caused by blunt trauma, but can also be due to penetrating traume, intraocular surgery, proliferative diabetic retinopathy, bleeding disorders, anticoagulant use Will note severely elevated IOP, and patients are typically nauseous or vomiting Patients have high risk of re-bleeding and therefore head should be elevated with activity restriction

Compare and contrast tolcapone and entacapone

Both are COMT inhibitors (prevent the break-down of L-DOPA in the periphery, in order to make it more available to pass through the BBB), and are alternative treatments for Parkinson's Disease Entacapone: selectively and reversibly inhibits COMT in the periphery; it is given in conjunction with L-DOPA in order to get L-DOPA through the BBB ◦ Half life 20-35 min Tolcapone: selectively and reversibly inhibits COMT in the periphery and CNS (penetrates BBB) ◦ Half Life 2-3 hours ◦ Can result in fatal hepatitis Both will result in the same adverse effects as L-DOPA

Compare and contrast selegiline and rasagiline

Both are MAO-B Inhibitors (MAO-B is found mostly in the brain and is responsible for breaking down dopamine); by inhibiting MAO-B, dopamine will be present for longer to have its effects, making these useful alternative treatments for Parkinson's Disease in conjunction with L-DOPA Selegiline: Given in conjunction with L-DOPA, it enhances its actions, and reduces the required dose needed ◦ Metabolized to methamphetamine and amphetamine (can cause disrupted sleep) ◦ Half-life 10 hours Rasagiline: 5x more potent than selegiline ◦ NOT metabolized to methamphetamine or amphetamine ◦ Half Life 3 hours MAO-B Inhibitors will both have potent drug-drug interactions and similar adverse effects as L-DOPA ◦ In conjunction with meperidine (demerol) → stupor, rigidity, agitation, hyperthermia ◦ In conjunction with TCAs and SSRIs→ serotonin syndrome

Spasticity vs Rigidity

Both are increased muscle tone which lead to resistance of movement Spasticity is found in stroke patients, and is rate dependent; if the joint is moved slowly, you can get it to open up Rigidity is usually found in Parkinson's patients and is rate independent, meaning there is always an increase in resistance throughout the movement

Onchocerca Volvulus vs. Loa Loa

Both are worm infections Onchocerca Volculus ◦ Transmitted by the black fly ◦ African River blindness ◦ Itching, redness, photophobia, blurred vision Loa Loa ◦ Transmitted by Chrysops fly ◦ Does not cause blindness

Review the basic plan of the motor systems and identify the signs and symptoms of injury to them (Table 114-1)

Broadly divided into two systems: 1. Pyramidal System: single neuron that originates in the primary motor cortex of the frontal lobes, forms the internal capsule, traverses the brainstem, and ultimately synapses on the lower motor neuons in the anterior horn of the spinal cord → Injury: ◦ Cortex: weakness, cortical symptoms (i.e.- aphasia), spasticity ◦ Internal Capsule (subcortical): Isolated weakness/ clumsiness, absence of cortical symptoms, spasticity ◦ Brainstem: weakness, bulbar symptoms (CN findings), somnolence (drowsiness), spasticity ◦ Spinal Cord: weakness, back pain, sensory loss, bowel and bladder dysfunction 2. Extrapyramidal System: consists primarily of the basal ganglia and the cerebellum, it provides coordinating and integrating information that influence and modulate voluntary motor activity of the motor cortex → Injury: ◦ Basal Ganglia: Rigidity, dystonia, chorea, akinesia/hypokinesia (absent or reduced muscle movements), behavior changes ◦ Cerebellum: gait imbalance, slurred speech, intention tremor, incoordination, hypotonia, oculomotor abnormalities

Ocular side effects of Cloroquine and Hydroxychloroquine?

Bulls-eye maculopathy which is sight threatening

What's the most important treatment to consider in Bell's Palsy (idiopathic facial paralysis)? A. Antibiotics B. Airway Protection for aspiration C. Eye Care D. None of the Above

C. Eye Care

The identification of oligoclonal gamma globulin bands in the CSF would be most suggestive of which of the following conditions? A. Alcoholic cerebellar degeneration B. Korsakoff syndrome C. Multiple Sclerosis D. Shizencephaly E. Subacute combined degeneration

C. Multiple Sclerosis

Another name for Herpes Zoster Oticus is? A. Bell's Palsy B. Necrotizing Otitis Externa C. Ramsay Hunt Syndrome D. Diabetic Neuropathy E. Idiopathic Facial Paralysis

C. Ramsay Hunt Syndrome

Potassium Associated Paralysis

Can either be caused by Hypokalemia or Hyperkalemia and is often precipitated by hunger, food, or cold and often has a familial history Clinical Presentation: acute onset of weakness

Traumatic Cataract

Can occur immediately following the trauma or present several years after

What are the systemic side effect of adrenocorticosteroid eye drops?

Cataracts and Glaucoma

Botulism Define, Clinical symptoms, Diagnosis, and Treatment

Caused by the botulinum toxin (clostridium botulinum) that cleaves the binding protein, such that the vesicle containing ACh cannot bind, and therefore ACh is not released. Affects all acetylcholine releasing neurons Clinical Presentation: Progression over 2-4 days of weakness, opthalmoplegia (eye weakness), respiratory paralysis, facial diplegia, pupillary paralysis, and dry mouth Diagnosis: EMG Treatment: ◦ Antitoxin ◦ Supportive until nerves can manufacture new protein ◦ Guanidine

Ocular side effects of erectile dysfunction agents (i.e.- sildenafil, tadalafil, Vardenafil)

Changes in color and light perception

Pupil sparing CN III palsy

Complete ptosis and loss of ocular motor fuction, but with normal pupillary function Most commonly caused by ischemia which affects the central fibers and spares the superficial parasympathetic fibers Seen commonly in diabetics, and typically resolves in 3 months

Where is CSF made?

Choroid Plexus

Complete CN III Palsy vs. Partial CN III Palsy

Complete: complete ptosis with no eye movement (eye is "frozen") and dilated pupil that responds poorly to light Partial: eye will still have some movement; varying degrees of the above symptoms

In terms of rehabilitation, what is a "barrier"?

Complications that would prevent an individual from improving; can be premorbid and postmorbid

Dystonia

Class of movement disorders characterized by sustained contraction of a muscle or group of muscles leading to twisting movements, abnormal postures, and repetitive movements Can be: rapid and repetitive, focal or generalized, idiopathic or symptomatic Cervical Dystonia is the most common, followed by focal dystonias involving the face and jaw muscles; laryngeal and limb dystonias are rare A mutation in the TOR1A gene is the most common cause of early onset generalized dystonia

Prostaglandin Anaglogs Include: Class, MOA, Clinical use, AE, and Examples

Class: PGF-2α anaglog MOA: Increase outflow of aqueous humor by decreasing resistance of uveoscleral outflow Clinical Use: Open angle glaucoma, ocular hypertension AE: Lengthen and darken eyelashes, iris and periocular skin pigmentatin, headaches; Contraindicated in patients with active intraocular inflammation; caution in patient's with uveitis or Herpes simplex keratitis Examples: Latanoprost, Travoprost, Bimatoprost

Explain the mechanism of action of and side effects of cocaine and amphetamine

Cocaine: Blocks neurotransmitter transporters for dopamine, norepinephrine, and serotonic; potentiates dopaminergic, adrenergic, and serotonergic neurotransmission leading to euphoria Amphetamine: Mixed acting; tyramine-like effects which increases dopamine and other neurotransmitters released by reversing DAT, inhibiting reuptake, and inhibiting MAO Side effects: cocaine can inhibit voltage-gated Na+ channels which can cause fatal cardiac arrythmias

Describe the mechanism of action of flumazenil

Competitive benzodiazepine blocker

Cholesteatoma

Cyst-like mass caused either by the collection of debris in a retraction pocket, congenital epithelial cysts in the middle ear, or retraction/ perforation of the pars flaccida Patients will have drainage, hearing loss, and dizziness with minimal pain

Vitamin B12 plays an essential role in the synthesis of: A. GABAa receptors B. GABAb receptors C. Glutamate D. Myelin E. Neurofilaments

D. Myelin

Low vitamin B12 levels in a patient with diminished vibratory in his lower extremities and bilateral Babinski signs would be most consistent with which of the following? A. Amyotrophic Lateral Sclerosis B. Diffuse Lewy Body Disease C. Multiple Sclerosis D. Subacute combined degeneration E. Supranuclear palsy

D. Subacute combined degeneration

Bloody CSF in all 3 tubes of a lumbar puncture would most likely indicate which of the following? A. Amyotrophic lateral Sclerosis B. Embolic Infarct C. Hydrocephalus D. Subarachnoid Hemorrhage E. Traumatic tap

D. Subarachnoid Hemorrhage

Horner's Syndrome

Denervation of sympathetic fibers, leading to unopposed parasympathetic activity, caused by a lesion anywhere along length of the sympathetic chain Signs/ Symptoms: ◦ Miosis ◦ Difference in pupil size greatest in dark environment ◦ Anhydrosis ◦ Partial Ptosis

Identify dependence syndrome and withdrawal syndrome

Dependence Syndrome: Results from the need for the drug in the brain to maintain "near-normal" functioning; drug needs to be on board for normal functioning Withdrawal Syndrome: when the drug is eliminated from the body, the adaptations that produce dependence becomes apparent (Don't feel yourself)

Hess and Hunt Grading Scale

Describes the severity of a subarachnoid hemorrhage ◦ I: asymptomatic or a slight headache ◦ II: moderate to severe headache with nuchal rigidity ◦ III: Drowsiness, mild focal deificits ◦ IV: semicomatose, posturing ◦ V: deep coma, decerebrate rigidity

Identify the use of desipramine or fluoxetine in a clinical scenario

Desipramine: Tricyclic Antidepressent blocks monoamine uptake (especially norepinephrine) Fluoxetine: Selective Seratonin reuptake inhibitor Used to reduce cravings of cocaine and amphetamine, but do not stop furture use; there is no approved treatment for cocaine/ amphetamine addiction

Chemical Injury of eye Physical Findings and Treatment

Determine pH of the chemical (acid vs base) Physical Exam: whitening, hyperemia, smokiness of cornea, corneal opacification, elevated intraocular pressure Treatment: Immediate copious irrigation until normal pH is restrored

Branch Retinal Artery Occlusion ◦ Area of darkness on the retina = possible edema ◦ Dot = emboli

Diagnose

Extropion ◦ Eyelid margin rolled outwards

Diagnose

Glaucoma ◦ Asymmetric cup:disc ratio ◦ >0.3

Diagnose

Herpes Zoster Ophthalmicus

Diagnose

Hyperthyroidism ◦ Proptosis (bulging eyes)

Diagnose

Persistent Myelination ◦ Possible enlarged blind spot

Diagnose

Retinoblastoma

Diagnose

Scleral Lacertaion

Diagnose

A 45 year old African American male presents with a right sided facial weakness for two months. He is a non-smoker. On physical examination there is a right sided facial tumor. A fine needle aspirate is performed, and pathology shows a swiss cheese pattern. Diagnosis and treatment?

Diagnosis: Adenoid Cystic Carcinoma Treatment: Superficial Parotidectomy with facial nerve disection

A 54-year-old female is brought to the emergency room. She cannot talk or follow commands. Her friend states they were playing bridge 30 minutes ago when she slumped over into the table. She has no previous medical or surgical history. She smokes 2 packs of cigarettes a day. You find a right homonomous hemianopia, right lower facial weakness, right arm paralysis and numbness. Her blood pressure is 210/90 mmHg. Diagnosis? Workup? Treatment?

Diagnosis: Left MCA infarct Workup: CT scan, Labs (platelet count, cholesterol), ECG Treatment: Labetolol to decrease BP, TPA, control atrial fibrillation, anticoagulation therapy

A 65-year-old obese white male comes into the office with a complaint of left sided numbness. He states it occurred 3 days ago and lasted for 10 minutes. He denies all other symtpoms. The patient denies health problems, and states that he only takes vitamins. On examination, you find a right carotid bruit, a heart rate and rhythm which is regular, and a nonfocal examination. His blood pressure is 188/90 mmHg. Diagnosis? Workup? Treatment?

Diagnosis: TIA provided there is a negative MRI Workup: Imaging, Labs (lipids, CBC, A1C), Vessel imagine, Cardiac workup (stress test, echo, EKG) Treatment: Treat hypertension, statin, weight loss program, education, antiplatelet, refer to cardiologist

Amblyopia What is the treatment?

Diminished vision due to the visual cortex not being stimulated any time from birth through 6-8 years of age; typically unilateral AKA Lazy Eye Treatment: Occlusion Therapy- occlude (patch) the better seeing eye; Pharmacological Penalization- blur vision in the good eye with cycloplegic eye drop (i.e.- Atropine)

Maple Syrup Urine Disease Define, Clinical Presentation

Disorder of branched chain amino acid metabolism (Valine, Leucine, Isoleucine) Clinical Presentation: similar to phenylketonuria but more severe ◦ Vomiting and Irritability during the first two months of life ◦ Delayed intellectual development leading to mental retardation ◦ Seizures, infantile spasms ◦ Blonde hair, Blue eyes, Eczema ◦ Tremors, Babinski Sign

Myasthenia Gravis Define, Clinical symptoms, Diagnosis, and Treatment

Disorder of neuromuscular transmission, that is more common in females (3:1 for <40 year; 1:1 for elderly) Antibodies are formed against the acetylcholine receptors (AChR) which block and accelerate degradation of receptors leading to complement mediated lysis of muscle membranes Patients will usually have a thymus abnormality (hyperplasia or thymoma) and can often present with thyroid disease, lupus, pernicious anemia, and rheumatoid arthritis Clinical Presentation: fluctuating weakness (worsening as the day progresses); ocular form → ocular symptoms which progress to ptosis and diplopia (if restricte here for 2-3 years generally does not progress) ; facial and pharyngeal muscle form → respiratory failure, aspiration, muscle wasting Diagnosis: ◦ EMG: repetitive nerve stimulation (shock the nerve, and see decline in strength of response); single fiber test → most sensitive test ◦ Tensilon (edrophonium) Test: blocks enzyme that breaks down Ach, allowing for more ACh to be available and see improvement of symptoms; "cooling" the muscle with ice can also improve symptoms ◦ CT Scan of thorax: look for thymoma ◦ Antibody testing: anti-AChR, anti-MUSK & anti-striated muscle antibodies (indicates thymoma) Treatment: ◦ Medication: Pyridostigmine, Neostigmine (acetylcholinesterase blockers) allows more ACh to be present ◦ Plasmapheresis: wash antibodies out of system ◦ IV IgG: floods system with antibodies, and the body will slow down its production ◦ Immunosuppresive Medication: steroids, azathiprine, cyclophosphamide, cyclosporin, mycophenolate mofetil ◦ Surgery: remove thymoma or islands of thymus tissue

Identify the use of disulfiram, acamprosate, and topiramate in the treatment of alcohol addiction

Disulfiram: Inhibits aldehyde dehydrogenase, a critical enzyme in alcohol metabolism pathway, resulting in the accumulation of acetaldehyde (toxic metabolite) which causes facial flushing, headache, nausea, vomiting, weakness, orthostatic hypotensin, and respiratory difficulty (used as relapse deterrant) Acamprosate: Antagonist of NMDA glutamate receptors used to maintain abstinence Topiramate: Inhibits AMPA/Kainate glutamate receptors used to maintain abstinence (less so than acamprosate)

Epidural Hematoma

Due to a fracture of the parietal or temporal bone resulting in lacertion of the middle meningeal artery Patients may have a lucid interval prior to coma-- the treatment is surgical

Cytotoxic Cerebral Edema

Due to injury of the white matter and gray matter cells, it is associated with hypoxia and infarction, and results in cellular swelling

Interstitial Cerebral Edema

Due to the obstruction of CSF flow, and seen in hydrocephalus The increased pressure results in increased periventricular extracellular fluid

Duration of action of Atropine Sulfate eye drop and when to use

Duration of Action: 7-14 days Use: will cause dilation of the eye; used for uveitis in order to paralyze the muscles which are spasming

Angioedema of ENT area is commonly caused by? A. Burn Injury B. Acid Reflux C. Antibiotic Reaction D. Seasonal Allergy E. ACE Inhibitors

E. ACE Inhibitors

Acute Epiglottitis causes? A. Acute Respiratory Distress B. May require a tracheostomy C. Is generally caused by a bacterial infection if in children D. Presents typically as patient leaning forward and drooling E. All of the above

E. All of the above

The identification of a significant number of eosinophils in a CSF sample would be most consistent with which of the following? A. Bacterial Meningitis B. Cerebral Abscess C. Guillain-Barre Syndrome D. Multiple Sclerosis E. Parasitic Meningitis

E. Parasitic Meningitis

The best treatment for vocal cord nodules (screamer nodules)? A. Laser B. Cryotherapy C. Microdebriders D. Transoral Robotic Surgery E. Speech Therapy

E. Speech Therapy

The VDRL test can be used for the screening of: A. Herpes B. Lyme Disease C. Pick Disease D. Rabies E. Syphilis

E. Syphilis

Describe the vascular pathogenesis leading to stroke. Describe paradoxical embolism.

Embolism occurs when a thrombus originating from a more proximal source travels through the arteries, and occludes a cerebral artery Paradoxical Embolism occurs when a thrombus crosses from the venous circulation to the left side of the heart through a patent foramen ovale, or less commonly an intrapulmonary arteriovenous shunt

Mechanism of action of inhaled anesthetics

Enhance GABAa and glycine receptors which increases cl- influx and activated K+ channels which leads to hyperpolarization of the neuron They also will diminish excitatory synaptic activity by inhibiting nACh and NMDA receptors, thereby decreaseing Ca2+ and Na+ influx

How do you decipher an entrance vs. exit gunshot wound?

Entrance ◦ Shape: Round, Oval ◦ Tissue missing ◦ Rim of Abrasion ◦ Grime present ◦ Smaller than exit wound Exit ◦ Shape: Slit-like, geometric, irregular ◦ Tissue is not missing; margins can be re-approximated ◦ Larger than entrance wound

Carotid Sinus Syncope

Fainting due to inappropriate stimulation of the carotid sinus baroreceptors i.e.- tight collars, neck ties, neck tumors, neck surgery scars

Hyperopia

Farsighted (cannot see things that are close) Eye is too short, image is focused behind the retina

Muscular Dystrophy

Group of inherited disorders of the muscle; involves some component of the proteins that bind to allow movement of the muscle

Know the role of HPV in the development of head and neck cancer

HPV has been found to play a role in squamous cell carcinomas in young, non-smokers and non-drinkers (particularly in the tonsil and base of tongue) Testing: p16 test (indicates HPV positive) NOTE: HPV+ patients who do not smoke or drink tend to do better than HPV- patients who do not smoke or drink in survival rates or HPV+ smokers and drinkers

Isoflurane

Halogenated Inhaled Anesthetic A volatile liquid at room temperature with a pungent odor, it has a relatively slow onset and recovery Typically used for maintenance

Sevoflurane

Halogenated Inhaled Anesthetic It is a volatile liquid at room temperature which produced an exothermic reaction with desiccated CO2, making it possble to produce airway burns and CO (improved machinery overcomes this) Close to ideal anesthetic having almost all effects wanted of anesthetic, it has a rapid onset and recovery

Desflurane

Halogenated Inhaled Anesthetics A volatile liquid at room temperature with a pungent odor, it has a rapid onset and recovery Typically used for maintenance; it is widely used for outpatient surgery

Enflurane

Halogenated inhaled Anesthetic Produces Fluoride ions as by-products of metabolism which can cause fluoride-induced nephrotoxicity Increases incidence of seizures and therefore should not be used in patients with a seizure history

A:V Nicking

Hardened artery crossing over a softer vein, impeding blood flow

Sensorineural Hearing Loss (SNHL)

Hearing loss caused by abnormalities involving the cochlea or auditory nerve

Thiopental Indication, Mechanism of action, side effect

Indication: Barbiturate IV anesthetic Mechanism of Action: Potentiation of GABAa receptors, with no analgesic effects Side Effects: ◦ Nausea & Vomiting ◦ Suppresses EEG activity ◦ Dose dependent decrease in BP ◦ Respiratory depression

Management of open globe injury

Immediately shield the eye, to prevent further manipulation in order to limit extravasation of ocular contents Surgical repair within 24 hours

Presbyopia

Impaired vision as a result of aging. The lens loses its ability to accomodate (becomes more convex) Patient is usually in their 40's, distance vision is unchanged. but near vision is diminished

Evaluation of a Neck Mass

In an adult, a neck mass >3 week duration is cancer until proven otherwise. The patient should get: 1. Full head and neck examination 2. Fine needle aspirate 3. CT Scan of the neck

Paralysis

Inability to move

Cholinesterase inhibitors Indication, Mechanism of Action, and Adverse Effects

Includes: Donepezil, Rivastigmine, and Galantamine Indication: mild to moderate Alzheimer's Disease Mechanism of Action: prevents the degradation of Acetylcholine, thereby improving cholinergic neurotransmission in affected areas of the brain Adverse Effects: ◦ Cholinergic Adverse Effects: diarrhea, nausea, vomiting ◦ Bradycardia ◦ Syncope ◦ GI Bleeding

Entrapment

Indication for immediate surgical repair Occurs when there is a break in the orbital wall, followed by a pop back into place, trapping musculature Causes a vagal response with attempted eye movement resulting in: bradycardia, nausea, or pre-syncope

Distinguish between long-acting, short-acting, and out-the-liver benzodiazepines and identify important indications, side effects, and treatment option in an event of overdose

Indications: Sedative (anxiolytic), hypnotic (insomnia), induction of anesthesia (midazolam), preoperative anesthesia (amesia, muscle relaxation), status epilepticus (lorazepam, diazepam), alcohol detoxification, night terrors Side Effects: ◦ CNS depression (less than barbiturates) ◦ Tolerance and dependence ◦ Paradoxical reaction (patient can become agressive or sexually disinhibited) Overdose Treatment: Flumazenil Long-Acting: Chlordiazepoxide, Diazepam, Flurazepam Short-Acting: Midazolam, Alprazolam, Triazolam Liver: Oxazepam, Temazepam, Lorazepam (Out The Liver) ◦ Can be used in the elderly and those with hepatic insufficiency

Polymyositis Define, Clinical symptoms, Diagnosis, and Treatment

Inflammation of multiple muscles fasicles that can occur alone or with other disease processes Clinical Presentation: occuring after the age of 35, there will be progressive myopathic findings (proximal muscle weakness, trouble walking up stairs, trouble reaching over head, etc.), typically sparing extraocular muscles Diagnosis: ◦ Biopsy ◦ Labs: Elevated CPK, elevated sedimentation rate ◦ EMG Treatment: ◦ Steroids ◦ Supportive

Traumatic Iritis

Inflammation of the iris most commonly caused by blunt trauma Symptoms: Unilateral decreased vision, photophobia, perilimbal conjunctival injection, anterior chamber reaction Physical Exam: traumatic mydriasis (dilated, poorly reactive pupil), Elevated IOP

Dermatomyositis Define, Clinical symptoms, Diagnosis, and Treatment

Inflammation of the skin and muscle (around the blood vessels) with unknown etiology (over the age of 40, associated with breast and GI cancer) Clinical Presentation: rash of the face, eyelids, extensor surfaces of the knuckles, elbows, and knees; patient will have muscle aches and proximal muscle weakness Diagnosis: ◦ Biopsy ◦ Elevated CPK ◦ EMG ◦ Look for Tumor Treatment: ◦ Steroids ◦ Treat Underlying cause

Mitochondrial Cytopathies

Inherited through the mother, they muscle problems due to dysfunction of the mitochondria Results in lactic acidosis, ragged red fibers, and lipid droplets Includes: Kearns-Sayre syndrome, MELAS, MERRF

How do beta blockers work as glaucoma agents?

Inhibit aqueous production i.e.- Timolol, Levobunolol, Metipranolol, Carteolol

Vertebrobasilar Insufficiency (VBI)

Ischemia to the reticular activating system which is most common in the elderly (usually caused by atherosclerosis of the vertebrobasilar system) Can lead to syncope

Non-Arteritic Ischemic Optic Neuropathy

Ischemic Event/ "stroke" localized at the blood vessels supplying the optic nerve head which results in sudden painless vision loss Patients will have a clear line of where vision is lost (i.e.- superior or inferior arc of visual field loss), and often have cardiovascular risk factors (i.e.- HTN, Hyperlipidemia, DM)

Understand ischemic penumbra and how it relates to perfusion CT.

Ischemic Penumbra: the area of the ischemia stroke which is potentially salvageable, but is at risk to progress to infarction; typically surrounds infarcted cord CT Perfusion: the penumbra will have a normal cerebral blood volume (CBV), increased transit time, and decreased cerebral blood flow (CBF)

Vitreous Hemorrhage

Leakage of blood into areas around vitreous resulting in reduction of vision Can be caused by trauma, conditions causing neovascularization, and SAH

Sturge- Weber Syndrome Define, Clinical Presentation, Treatment

Known as encephalotrigemina angiomatosis, it is a sporadic autosomal recessive disease on chromosome 3 resulting in atrophy and calcification ("trolley track," curvilinear) in the occipital lobe Clinical Presentation: ◦ Port Wine nevus Flammeus ◦ Seizures ◦ Mental retardation ◦ Glaucoma ◦ Contralateral Hemiparesis Treatment: Symptomatic, Surgical

What clinical signs/ symptoms separate Lambert-Eaton syndrome from Myasthenia gravis?

Lambert-Eaton will present with: ◦ Dry Mouth ◦ Autonomic Signs ◦ Pupillary Findings When Myasthenia Gravis will not

Infantile Cataract

Leading cause of childhood blindness; early diagnosis and treatment are extremely important

Where are the parasympathetic fibers of CNIII located and what can cause compression of them? What tests should be ordered?

Location: Periperhy of the nerve, making them vulnerable to compressive lesions Causes: Posterior Communicating Artery Aneurysm; Herniation of the uncal portion of Temporal Lobe Sign/ Symptom: Blown Pupil (no reaction to light) Test: Emergent Vessels Study of Brain (MRA or CTA); Gold Standard is Cerebral angiogram (but this is dangerous)

Pathologically, how do low grade mucoepidermoid carcinomas differ from high grade ones?

Low Grade: more mucus cells with fewer epidermoid cells High Grade: Less mucin with more epithelila tissue; positive immunohistochemical staining for mucin will differentiate a high-grade mucoepidermoid carcinoma from a squamous cell carcinoma

Review the signs and symptoms that result in ischemic stroke.

MCA ◦ Superior Division: patient unable to speak or produces sparse, agrammatic speech despite ability to fully comprehend spoken and written material ◦ Inferior Division: patient produces fluent, prosodic, nonsensical speech; unable to follow directions ◦ Large Infarct: total loss of language function; patient mute and does not comprehend ACA ◦ Weakness limited to the legs ◦ Incontinence PCA ◦ Visual loss without motor deficits ◦ Behavioral disturbances (delirium, amnesia) Brainstem ◦ Midbrain: vertical gaze deficits, impaired consciousness (reticular activating system)

Diuretics for Glaucoma Include: MOA, Clinical use, AE, and Examples

MOA: Carbonic anhydrase inhibitor (decrease aqueous humor production) Clinical Use: chronic open-angle glaucoma, acute-angle closure glaucoma prior to surgery AE: (Acetazolamide) malaise, kidney stone, contraindicated in sulfonamide allergy (Dorzolamide) altered taste, contraindicated in sulfonamide allergy Examples: Acetazolamide (oral), Dorzolamide (topical)

β-Adrenergic Blockers for Glaucoma Include: MOA, Clinical use, AE, and Examples

MOA: Decrease aqueous humor production by the ciliary body Clinical Use: Open angle glaucoma, Ocular HTN, acute angle-closure glaucoma AE: Ocular irritation, dry eyes, bradycardia, hypotension, bronchospasm; contraindicated in COPD/ Asthma/ Heart failure/ Bradycardia/ Systemic Hypotension Examples: Timolol, Levobunolol, Carteolol, Metipranolol, Betaxolol

α-Adrenergic agonists for Glaucoma Include: MOA, Clinical use, AE, and Examples

MOA: Reduce aqueous humor production by the ciliary body & increase uveoscleral outflow Clinical Use: (Brimonidine) Open angle glaucoma, ocular hypertension; (Apraclonidine) prevention and treatment of postsurgical IOP elevation, acute angle closure glucom AE: Ocular irritation, dry eyes, allergic reaction, fatigue, bradycardia, hypotension, headache Examples: Brimonidine, Apraclonidine

Cholinergic agonists for Glaucoma Include: MOA, Clinical use, AE, and Examples

MOA: contracts iris spincter and ciliary muscle, thereby opening trabecular meshwork and increasing aquous humor outflow Clinical Use: open-angle glaucoma, ocular HTN, acute angle-closur glaucoma AE: Ocular irritation, myopia, miosis, lacrimation, salivation, perspiration, N/V/D Examples: Pilocarpine, Carbachol

Uvea/ Uveal Tract

Made up of the iris, ciliar body, and choroid

Lesion of the optic radiation results in what pattern of vision loss?

Meyer's Loop: Inferior radiations in the temporal lobe, resulting in "pie in the sky" Baum's Loop: superior radiations in the parietal lobe, resulting in "pie on the floor"

Compare potency and rate of induction/elimination of inhalation anesthetics based on partition coefficient and minimal alveolar concentration

Minimal Alveolar Concentration (MAC): the alveolar partial pressure that abolishes movement response to a surgical incision in 50% of patients; inversely proportional to potency (the higher the MAC, the less potent the drug) For agents with low solubility in the blood, equilibrium is achieved more quickly and therefore induction and elimination rate is faster

Strabismus Include Treatment

Misalignment of the eyes Treatment: treat amblyopia if present; surgery is indicated if misalignment persists, especially if patient is in spectacles

How is spasticity measured?

Modified Ashworth Scale 0: No increase in tone 1: Slight increase in muscle tone, manifested by a catch and release or minimal resistance at the end of the ROM movement difficult when the affected part(s) is moved in flexion or extension 1+: Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM 2: More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved 3: Considerable increase in muscle tone, passive 4: Affected part(s) rigid in flexion or extension

Monocular vs. Binocular Diplopia

Monocular: double vision that is present only when one eye is closed → Never a neurological Issue → Can be due to tear film, corneal abnormalities, cataracts, or lens displacement Binocular: double vision present with both eyes open, that resolves with occlusion of either eye → Caused by ocular misalignment (eyes are not working together)

Acute Dystonic Reaction

More common in young patients, it may present with their tongue sticking out and neck bent to the side (acute torticollis); a common side effect of antipsychotics Treatments: Diphenhydramine, benztropine, diazepam

Tardive Dyskinesia

Most common drug induced (dopamine receptor blocking agents- typically neuroleptic antipsychotics), idiopathic movement disorder Patients can present with persistent, often permanent, repetitive involuntary movements most commonly involing the lower face and orolingual-buccal muscles (chewing, tongue darting, piano playing fingers, marching in place) Treatment: ◦ Avoid complication ◦ Eliminate cause ◦ Tetrabenzine ◦ Reserpine

Neuroleptic Malignant Syndrome

Most common in young adults, it is a reaction to antipsychotics that occurs within the first 30 days of treatment and evolves over 1-2 days. Patients will present with autonomic dysfunction, fever, severe rigidity, akinesia, altered mental status, acidosis, and myoglobinuria (due to muscle contraction) which can lead to kidney failure 5-20% of patients will die Treatment: Supportive (bromocriptine, dantrolene)

Retinoblastoma

Most common intra-ocular malignancy in childhood Patients most commnly present with leukocoria, but can also present with strabismus, glaucoma, and poor vision

Mucoepidermoid Carcinoma Define, pathology, treatment

Most common salivary gland malignancy which is most commonly found in the parotid gland. Pathology: Typically a high grade tumor (less mucus cells and more epithelial cells/ tissue) Treatment: Superficial parotidectomy with facial nerve preservation (dissect out facial nerve) for early stage tumors; for later staged, may require more radical excision with additional dissection or post-operative radiation

Intraparenchymal Hemorrhage

Most commonly caused by hypertension, it is due to the rupture of small penetrating arteries located in the putamen, thalamus, pons, cerebellum, or lobes Typically followed in older individuals, treatment depends on location

Transient Global Amnesia

Most likely caused by vascular causes, it is the sudden loss of memory that occurs in the middle age to elderly

Tetany

Muscle spasms due to spontaneous firing of peripheral nerves resulting in prolonged spasms of limb muscles, seizures, circumoral paresthesias, and laryngospasm Typically associated with hypocalcemia, hypomagnesemia, and alkalosis; may present with Trousseau & Chvostek Signs (inducing spasm through tapping on facial nerve or inflating BP cuff)

Wilson Disease Define, clinical presentation, diagnosis, and treatment

Mutation of the ATP7B gene on chromosome 13 resulting in toxic accumulation of copper, leading to hepatic dysfunction and cirrhosis Clinical Presentation: ◦ Onset between 11-25 years ◦ Jaundice ◦ Tremor (resting, intention, or wing-beating) ◦ Rigidity, Dystonia ◦ Kayser-Fleischer rings: dark rings that appear to encircle the iris of the eye ◦ Psychiatric symptoms Diagnosis: ◦ Laboratory: liver function tests, urine for copper and amino acids, serum ceruloplasmin level ◦ Liver Biopsy ◦ CT Scan Treatment: ◦ Penicillamine or Trientine ◦ Diet: low copper, Zinc salts

Drug Induced Myasthenia

Myasthenia Gravis exacerabation caused by certain medications Drugs ending in -mycin put patients at increased risk

Explain the use of naltrexone, naloxone, or methadone

Naltrexone: Used in the treatment of opioid and alcohol dependence; it is an opioid antagonist that competitively blocks the binding of opioids to the opioid receptor; used for the maintenance of abstinence Naloxone: Used for opioid overdose, it is an opioid antagonist, that competitively blocks the binding of opioids to the opioid receptor; it rapidly reverses opioid activity Methadone: Used in opioid detoxification and severe pain management; it is a long-acting opioid agonist that produces cross tolerance to other opioids; has a significant abuse potential (it is a strong opioid) and potential for overdose; has a long half life compared to heroin or morphine (once daily administration)

Identify the nomenclature, indications, and side effects of barbiturates

Nomenclature: End in -barbital (phenobarbital, pentobarbital, secobarbital) or -pental (thiopental) Indications: Sedative (anxiolytic), hypnotic, seizure, induction of anesthesia (thipental) Side Effects: long half life and low therapeutic index (mostly replaced by use of barbiturates) ◦ Severe CNS depression ◦ Tolerand and dependence ◦ Contraindicated in patient's with prophyria (induce α-aminolevulinate synthase) leading to abdominal pain, sun-exposed blistering lesions, and red-wine colored urine

Cup-to-disc ratio (C/D)

Normal: 0.3 Larger than 0.3 can be indicative of glaucoma

Which eye is OD? Which eye is OS?

OD: Right eye OS: Left eye

Wallenberg's Syndrome

Occlusion of the vertebral or PICA arteries which results in: ◦ Ipsilateral facial numbness ◦ Ipsilateral Ataxia ◦ Ipsilateral Horner's Syndrome ◦ Dysphagia ◦ Hoarseness ◦ Loss of taste ◦ Ipsilateral Numbness of arm and leg ◦ Contralateral loss of pain and temperature

Myelinogenesis

Occurs at the end of the first trimester, but is primarily a postnatal event Can be affected by metabolic disease, infection, genetics, hormonal disturbance, nutrition, placenta, trauma, medications, and drugs As a structure myelinates, it becomes functional

What are the clinical features of spinal shock?

Occurs following an acute injury, resulting in the temporary loss of spinal reflexes below the level of injury. ◦ Loss of muscle stretch reflexes ◦ Loss of bulbocavernosus reflex ◦ Loss of anal wink In high cervical injuries, lower reflexes (bulbocavernosus and anal wink) may still be present ◦ "Schiff-Sherrington" phenomenon: reflexes affected above the level of injury

Global Aphasia

Occurs with a middle cerebral artery occlusion → All aspects of speech are affected

Periventricular Hemorrhage Define, Clinical presentation, Treatment

Occurs within the first 48 hours of infants who typically are underweight; associated with hyaline membrane disease and pneumothorax They are caused by increased or decreased blood pressure, or increased venous pressure Clinical Presentation: ◦ Type I: confined to the matrix; asymptomatic ◦ Type II: extends into the lateral ventricle; Irritable, lethargic ◦ Type III: Enlarges ventricle; Apnea, decreased heart rate, opisthotonus, extensor posturing, brainstem findings ◦ Type IV: Extends into the brain substance; Apnea, decreased heart rate, opisthotonus, extensor posturing, brainstem findings Treatment: ◦ Type I: No treatment ◦ Type II: No treatment ◦ Type III: Serial lumbar punctures, ventriculostomy, ventriculoperitoneal shunt ◦ Type IV: Serial lumbar punctures, ventriculostomy, ventriculoperitoneal shunt

OD

Oculus Dexter; right eye

OS

Oculus Sinister; left eye

OU

Oculus Uterque; both eyes

Compare and contrast older and newer generations of sedative-hypnotics in terms of: Safety profile, Pharmacokinetics, Pharmacodynamics, Effects on GABAa activation

Older: Barbituates and Alcohol ◦ Follow linear dosing curve: increase the dose, increase the effects ◦ Therapeutic Index is more narrow than newer drugs: more dangerous ◦ Directly activate GABAa channel at high concentrations; increase duration of channel opening ◦ Induce CYP Enzymes Newer: Benzodiazepines and ZZZ drugs ◦ Deviate from linear dosing curve: will exhibit a plateau effect ◦ Enhance actions of endogenous GABA on GABAa receptor (ZZZ drugs are selective for the α1 selective); increase frequency of channel opening ◦ Inhibit CYP Enzymes Both: ◦ Cross the placental Barrier ◦ Detected in breast milk

Macular Disease

Painless reduction in visual acuity which is most commonly caused by age releated macular degeneration Patients will complain of central metamorphopsia (wavy vision)

Retinal Vein Occlusion

Painless subacute loss of vision, often severe Can be cleared. "Blood and thunder" fundus

Papillitis vs. Papilledema

Papillitis: optic nerve inflammation Papilledema: swelling of the optic disc from increased ICP; bilateral optic nerve swelling

Plegia

Paralysis; inability to move

Myasthenic Syndrome (Lambert-Eaton Syndrome) Define, Clinical symptoms, Diagnosis, and Treatment

Paraneoplastic syndrome associated with small cell lung cancers (as well as breast cancer and lymphomas) Antibodies are formed against the pre-synaptic calcium channels, resulting in an inability of ACh vesicles to bind and release into the synaptic cleft; will affect all presynaptic nerve terminals Clincal Presentation: Areflexia (will improve with exercise), weakness, dry mouth, metallic taste, autonomic signs, and pupillary findings Diagnosis: EMG Treatment: ◦ IV IgG → minimize antibody effect ◦ 3,4 diaminopyridine ◦ Guanidine ◦ Treat tumor

Ishihara Plates

Plates used to test for color vision - First plate is control (everyone should be able to see)

Compare and contrast positive and negative reinforcement

Positive Reinforcement: Perceived rewards (euphoria, anxiolytic) Negative Reinforcement: Relief factor (acute withdrawal, reduced stress, reduced dysphoria)

Recognize the signs and symptoms of post-concussive syndrome

Post-concussive syndrome (PCS): a complicationof TBI with the most common symptoms being headache, difficulty concentrating, appetite changes, sleep abnormalities, and irritability Generally, lasts for a few week post-injury, but, uncommonly, it can persist beyond a year or more Treatment is symptomatic

What artery is directly adjacent to CNIII?

Posterior Communicating Artery (PCOM)

Craniosynostosis

Premature fusion of a single of multiple sutures ◦ Primary or secondary (ex: microcephaly) ◦ Scaphocephaly (60%) - sagittal suture fused ◦ Brachycephaly (20%) - coronal sutures fused

Parotid Tumor Presentation

Presentation: (Benign) presents as a painless mass (Malignant) presents as a painful mass with the potential for facial nerve paralysis or numbness, and trismus (inability to open mouth)

Describe the pathophysiology behind Parkinson's disease

Progressive neurological disorder of muscle movement due to the loss dopamerinergic neurons in the substantia nigra that are normally present to inhibit the output of GABAergic cells in the striatum. This results in inappropriate activation of neurons. Characterized by: ◦ Tremor ◦ Rigidity ◦ Bradykinesia ◦ Postural instability ◦ Loss of sense of smell is one of the earliest symptoms Pathological hallmark is lewy body (aggregation of α-synuclein)

Astigmatism

Refracting power of the cornea is different in one meridian than another

Convulsive Syncope

Seizure triggered by a rapid decline in blood pressure causing hypoperfusion of the brain

Pervasive Developmental Disorder

Similar to autism, but not as severe, it may be diagnosed as Asperger syndrome or schizoid personality disorder

Tics

Simple, highly personalized, idiosyncratic mannerisms (sniffing, clearing throat, protruding chin, blinking) which are seen between ages 5-10 Rapid, stereotypical, non-rhythmic irresistible, controllable (can be voluntarily suppressed but this results in increased urge and rebound exacerbation) movements or vocalizations which are seldom persistent Treatment: ◦ Remove exacerbating causes ◦ Ignore it ◦ Adults: sedatives, psychotherapy

Treatment for frostbite of external ear

Slowly warm

During a lumbar puncture, where is CSF removed from?

Subarachnoid Space

Duchenne Muscular Dystrophy (DMD) Define, Clinical symptoms, Diagnosis, and Treatment

The most common form of muscular dystrophy (and most common form of myopathy in children) which is an X-linked recessive disease resulting in a lack of dystrophin protein Clinical Presentation: usually presents prior to the age of 3, with a gradual onset of walking difficulties (toe walking, waddling gait, most unable to walk by age of 11), progressive muscle wasting with lordosis, Gower's sign (in order to get up off the ground, need to climb their body), areflexia, mental retardation Diagnosis: ◦ Labs: Extremely elevated CPK (10,000 - 15,000) ◦ Muscle biopsy ◦ EMG ◦ Genetic Testing Treatment: ◦ Symptomatic: mobility, avoid bed sores, manage weight ◦ Immature muscle cell injections (not usually successful) ◦ Steroids (decrease scoliosis) ◦ Genetic Therapy: change genotype to phenotype (trying to change from DMD to Becker's) ◦ Most dead by 25

Myotonic Dystrophy (Steinert Disease) Define, Clinical symptoms, Diagnosis, and Treatment

The most common inherited muscle disease in adults, it is autosomal dominant and results in a defect in the muscle membrane function Clinical Presentation: ◦ Slowly progressive ◦ Myotonia - action (contraction of the muscle with a hard time relaxing) or percussion (muscle contraction with reflex testing) ◦ Weakness and wasting of distal limb muscles; facial weakness and swallowing difficulty ◦ Stiffness in the cold ◦ Hypersomnolence; personality; mental retardation ◦ Cataracts (early onset) ◦ Cardiac arrhythmia ◦ Gonadal atrophy ◦ Frontal balding Diagnosis: EMG (will hear "revving" Treatment: ◦ Symptomatic ◦ Pacemaker ◦ Eye Surgery ◦ Myotonia Medication: Phenytoin, Quinidine, Procainamide

Essential tremor

The most common movement disorder that is often referred to as "senile tremor" or "familial tremor" It is a tremor with action (movements) that is an autosomal dominant disease which is more common in females, caucasions, and the elderly; it is most apparent with stress and outstretched arms and can involved the head and voice Treatment: ◦ Alcohol ◦ β- Blocker ◦ Primidone: seizure medication with sedating effect ◦ Diazepam, Clonazepam, Lorazepam ◦ Topiramate: can cause kidney stones ◦ Surgery (Deep brain stimulation, Ablation)

Adenoid Cystic Carcinoma Define, pathology, treatment

The second most common salivary gland malignancy, it commonly exhibits perineural invasion (facial nerve) and metastasizes to the lungs Pathology: Swiss Cheese pattern Treatment: Parotidectomy

Strabismic Amblyopia

The tendency of a child's brain to suppress the images from the deviating eye

Describe the reason for using multiple general anesthetics in combination

There are (5) desired effects of general anesthetics: 1. Analgesia 2. Amnesia 3. Immobility 4. Inhibition of autonomic reflexes 5. Unconsciousness None of the current general anesthetics available are capable of achieving all desired effects, and therefore a combination of inhalation and intravenous general anesthetics are used ("balanced anesthesia")

Sclera

Thick, outer coating of the globe; usually white/ opaque Extremely difficult to penetrate

Conjunctiva

Thin, vascular tissue covering the sclera and inner aspect of the eyelids

Weber Syndrome

Third nerve palsy with contralateral hemiplesia due to a midbrain stroke

Cortical Blindness

Total or partial loss of vision in a normal-appearing eye caused by damage to the brain's occipital cortex Normal pupillary light response and normal fundus exam

TIA

Transient ischemic Attack A sudden, focal, neurologic deficit lasting less than 24 hours (majority resolve within 1 hour); presumed vascular origin, it is confined to an area of the brain or eye perfused by a specific artery. It is a warning that a larger stroke is going to occur There is no evidence on the MRI

Define amaruosis fugax and describe why this is an ominous sign.

Transient monocular blindness The ophthalmic artery is the first major branch of the internal carotid artery, supplying blood flow to the optic nerve and retina; internal carotid artery disease will therefore commonly cause a TIA of the optic nerve/retina and is a warning sign of impending cerebral stroke

Neonatal Myasthenia

Transient myasthenia gravis which affects infants born to myasthenic mothers due to transplacental transfer of maternal antibodies to the fetus Clinical Presentation: weak cry, weak suck, respiratory insufficiency

Explain the use of amantadine in the treatment of Parkinson's disease

Typically used for the treatment of the flu, it is an alternative treatment for Parkinson's Disease It is an indirect dopamine agonist, blocks the NMDA receptors, and inhibits cholinergic receptors While it will have little effect on tremors, it is effects against rigidity and bradykinesia Adverse Effects: ◦ Livedo reticularis → spider webbing look on the extremities ◦ Dizziness ◦ Lethargy ◦ Sleep disturbances ◦ Hallucinations ◦ Confusion ◦ Hypotension ◦ Urinary retention ◦ Dry mouth

Recognize the signs and symptoms of central motor system dysfunction.

Upper motor neuron lesions ◦ Prior to medullary decussation: contralateral weakness ◦ Post medullary decussation: ipsilateral weakness ◦ Weakness more distally than proximally ◦ Increased muscle tone with spasticity ◦ Increased muscle stretch refelxes ◦ Pathologic reflexes (i.e.- Babinski) ◦ Little to no muscle atrophy Basal Ganglia Lesions ◦ Movement disorders: characterized by heterogenous and mixed impairments in voluntary movement ◦ Not associated with muscle weakness ◦ Involuntary movements Cerebellum ◦ Eye movement abnormalities ◦ Scanning dysarthria: abnormal modulation of speech volume and velocity ◦ Irregular, uncoordinated voluntary movements with irregular amplitude, velocity, and rhythm ◦ Tremor with sustained posture ◦ Irregular placement of the limb with voluntary movements (i.e.- finger to nose or heel to shin) ◦ Intention tremor (increasing amplitude of tremor as one approached the target)

Describe the use of varenicline in a clinical scenario

Used in the treatment of nicotine addiction Partial agonist at a specific subtype of nicotinic acetylcholine receptors; acts as a pharmacologic antagonist at nicotinic receptors in the presence of the full agonist nicotine Prevents withdrawal symptoms and the euphoria of a full agonist

Seidel Test

Used to assess for perforated globe by looking for the leaking of aqueous humor following an eye injury or surgical procedure A positive test is one in which there is diluted dye adjacent to the site of injury or wound

Fluorescein Dye Exam

Used to detect any epithelial defects of the eye whe a light with cobalt blue filter is directed onto the surface of the eye

How is visual acuity measured?

Using a Snellen Chart 20/20 vision indicates that a patient can see at 20 feet what is normally seen at that distance Vision of 20/200 would indicate that a person must be 20 feet away to see what a person with normal vision can see at 200 feet

Pusher Syndrome (Lateropulsion)

Usually a result of a right hemisphere stroke, the patient will push themselves towards the contralateral side of the stroke The patient's concept of verticle is skewed to the same angle as the "push" and they push in that direction because the brain thinks that angle is upright Treatment involves getting the brain to realize that if they keep pushing, they will fall over (mirror therapy)

Chronic Subdural Hematoma

Usually found in elderly patients with cerebral atrophy with a less evident traumatic event Patients will have mild focal deficits, confusion, and headache. Hematoma is encysted by a pseudomembrane

Pituitary Macroadenoma will cause what pattern of vision loss?

Will compress the optic chiasm, resulting in bitemporal hemianopia

Intraocular Pressure (IOP)

a measurement of the fluid pressure inside the eye Normal: 8-22 mmHg (average 16 mmHg)

cc

with correction (glasses or lenses)

sc

without correction (glasses or lenses)

Cranial Nerve III Palsy

◦ "Down & Out" eye position: the only muscles still innervated are Lateral rectus (abduction) & Superior Oblique (depression) ◦ Ptosis: complete eyelid closure due to CNIII innervating levator Palpebrae ◦ "Blown Pupil": loss of parasympathetic input; sympathetic tone overrides parasympathetic tone

What Antiplatelets can be used for stroke prevention? What are indications?

◦ Aspirin: <326 mg/day ◦ Ticlopidine: reduces risk of stroke better than ASA & clopidogrel, but required CBC monitoring due to neutropenia and thrombocytopenia ◦ Clopidogrel ◦ Dipyridamole: can cause headaches in patients ◦ Dipyridamole + ASA is best combination treatment Indications: ◦ Progressive TIA ("stroke in evolution") ◦ Known source of emboli (atrial fibrillation) ◦ Hypercoagulable states (factor V mutation)

Signs and Symptoms of: Internal Carotid Occlusion

◦ Asymptomatic → if the circle of willis is well developed ◦ Middle Cerebral artery territory (MCA) → Unilateral weakness and numbness in the face, arm, speech ◦ Anterior Cerebral artery territory (ACA) → Unilateral weakness and numbness in the leg ◦ Posterior cerebral artery territory (PCA) → Unilateral vision changes

Describe the common sites of plaque formation in the cerebral vasculature

◦ Bifurcation of the common carotid artery ◦ Origins of the MCA and ACA ◦ Origin of the vertebral artery from the subclavian artery

Comon symptoms of TIA in the vertebrobasilar distribution

◦ Bilateral: weakness, numbness, & vision loss ◦ Combination of: diplopia, vertigo, ataxia, dysphagia

Pharmacologic Localization of Horner's Syndrome

◦ Cocaine Test: cocaine eyedrops placed in the eye, which inhibits the reuptake of norepinephrine at the NM junction, causing pupil dilation → In Horner's Syndrome, pupil dilation will not occur ◦ Hydroxyamphetamine Test: eye drop which is an indirect agonist that causes release of norepinephrine from presynaptic terminal; a normal pupil will dilate → In Horner's Syndrome, pupil dilation will not occur

What is the general stigmata of asphyxiation?

◦ Cyanosis ◦ Petechial Hemorrhages ◦ Right sided cardiac dilatation ◦ Visceral Congestion

Signs and Symptoms of: Middle Cerebral Artery Occlusion

◦ Hemiplegia & Hemianesthesia → face and arm more affected than the leg ◦ Homonomous Hemianopia ◦ Aphasia if dominant hemisphere is affected

Signs and Symptoms of: Anterior Cerebral Artery Occlusion

◦ Hemiplegia & Hemianesthesia → leg more affected than face an arm ◦ Urinary Symptoms ◦ Apathy

Signs and Symptoms of: Posterior Cerebral Artery Occlusion

◦ Hemiplegia or hemiparesis ◦ Homonomous Hemianopia

Possible causes of Anisocoria

◦ Horner's Syndrome ◦ Adie's Tonic Pupil

What are risk factors for stroke?

◦ Hypertension (#1) ◦ Heart Disease ◦ Previous stroke/ TIA ◦ Carotid Bruit (narrowing in artery of neck) ◦ Diabetes Mellitus ◦ Smoking ◦ Age ◦ Apolipoprotein E4 ◦ Elevated homocysteine levels ◦ Factor V Mutation

Adverse effects of inhaled anesthetics

◦ Increased ICP: dilation of cerebral vasculature, increased cerebral blood flow ◦ Seizures: enflurane causes excitation of the CNS ◦ Depressed cardiac contractility: decreased cardiac output, decreasing MAP and triggering baroreceptor reflex causing increased HR (Enflurane and Sevoflurane attenuate this response and there is no increased HR ◦ Halothane will sensitize the heart to catecholamines, increasing risk of cardiac dysrhythmia ◦ Respiratory depression ◦ Bronchodilation: note, Isoflurance and desflurane are pungent and can provoke airway irritation and coughing (should be used with caution in asthmatics) ◦ Halothane Hepatitis: Hepatic necrosis; CYP mediated biotransformation produced a reactive metabolite that causes hypersensitivity reaction and acetylation of liver proteins

Cushing's Effect

◦ Increased systolic BP ◦ Decreased pulse (<60) ◦ Cheynne Stokes Resirations Symbolic of increased ICP

What are the main levels of rehab?

◦ Inpatient Rehab: either inpatient rehab facility or inpatient rehab unit; Aggressive; typically require 3 hours of PT per day for 6 days a week ◦ Skilled Nursing Facility: do not need to keep progressing to stay in the facility as you do for inpatient rehab ◦ Outpatient Therapy: 2-3 days/ week for 30 minute sessions; reserved for patients with less severe strokes or those who have graduated from other levels of rehab ◦ Home Therapy: Usually for patients with less severe strokes without transportation; 2-3 times per week

Cranial Nerve VI Palsy Include common causes

◦ Inward turned eye (unopposed medial rectus) ◦ Diplopia when turned to the ipsilateral side; resolves when turned to the contralateral side Causes: ◦ Children & Adults (18-45 years): increased ICP, MS, Tumor/ Cancer ◦ Adults 50+: Ischemia (typically resolves within 3 months)

Workup for Stroke

◦ Labs: CBC, platelet count, PT, PTT, lipid profile, HgA1C, homocysteine level ◦ CT or MRI ◦ Carotid Ultrasound ◦ Echocardiogram ◦ Cardiac Monitor ◦ Angiogram

Identify opioids that are commonly abused

◦ Morphine ◦ Heroin ◦ Codeine ◦ Oxycodone ◦ Fentanyl

What pathologies can cause color vision loss?

◦ Optic Neuritis (seen in patients with MS) ◦ Macular Degeneration

Management of Spasticity

◦ Oral Medication: Baclofen, Tizanadine, Benzodiazepines, Dantrolene (also used for neuroleptic malignant syndrome) ◦ Botulinum: numb the nerve ◦ Surgery: cut the ligamen ◦ Serial Casting: cast the contracture into a functional or less painful position; works well with botox, oral baclofen, etc.

What electrolyte imbalances can cause muscle weakness?

◦ Potassium <2.5 or >7.0 ◦ Calcium <7.0 or >12.0 ◦ Magnesium (particularlly high)

What will accelerate rigor mortis?

◦ Prior Exercise ◦ Increased environmental temperature ◦ Fever ◦ Acidosis ◦ Uremia ◦ Seizure

Recognize the signs and symptoms of mild TBI or concussion

◦ Transient alteration of consciousness (only a minority will completely lose consciousness) ◦ Memory impairment Colleagues, coaches, athletic trainers, parents, and other observers must have a heightened suspicion when a potential head injury event occurs

Common symptoms of TIA in the carotid distribution

◦ Unilateral: weakness & numbness → ACA territory: leg → MCA territory: face, arm, speech → PCA territory: vision changes ◦ Aphasia ◦ Monocular vision loss → Amaurosis Fugax

Cranial Nerve IV Palsy Include common causes

◦ Upward eye deviation with extorsion: extorsion is alleviated by head tilt to the opposite side, bringing the affected eye into intorted position Causes: ◦ Congenital ◦ Closed head trauma ◦ Microvascular ischemic disease (typically improves within 3 months)

Recognize the signs and symptoms of peripheral motor system dysfunction.

◦ Weakness ◦ Muscle atrophy ◦ Hypotonia ◦ Hyporeflexia ◦ Fasciculations ◦ Fibrillations

Evolution of Extrapyramidal (EPS) side effects and treatment

◦ Within 4 hours: acute dystonia (muscle spasm, stiffness, ocylogyric crisis) ◦ Within 4 days: akathisia (restlessness) ◦ Within 4 weeks: bradykinesia ◦ Withing 4 months: tardive dyskinesia Treatment: Bentropine or Diphenhydramine

Identify the use of buprenorphine in a clinical scenario

𝜇-opioid partial agonist It alleviates withdrawal symptoms associated with decreased plasma levels of opioids, with a low risk of overdose since it is a patial agonist