Case questions- Neuro

A 50 year-old female with a history of coronary artery disease presents to the office requesting medication for an exacerbation of her migraine headaches. She complains of migraines approximately once a month. What medication is contraindicated in this patient? A. Sumatriptan (Imitrex) B. Propranolol (Inderal) C. Droperidol(Inapsine) D. Naproxensodium(Anaprox)

A. Sumatriptan (Imitrex)

Which is NOT included in diagnostic criteria for PCT: A. papilledema B. MRI showing no structural abnormalities C. elevated OP on LP D. normal CSF composition E. weakness on neuro exam

E. weakness on neuro exam

A patient presents actively seizing with a generalized tonic-clonic seizure that has lasted for over 10 minutes. The patient has a long history of epilepsy and non-compliance with his medication. After protecting the airway, obtaining IV access, and administering glucose, which of the following is the most acceptable treatment? A. diazepam with carbamazepine B. ethosuximide with phenobarbital C. gabapentin with prednisone D. lorazepam with phenytoin

D. lorazepam with phenytoin

23 year old man, history of two traumatic brain injuries and subsequent epilepsy which present as an unresponsive staring spell with automatism of his left hand opening and clenching lasting two to five minutes, brought in by family after they noticed an episode at dinner. Family concerned that even though his automatism has not been constant, he remains unresponsive... What do you think could be happening?

status epilepticus

A 17 year-old college student w/ hx of a seizure episode 4 days ago is brought to the emergency department with a 10 hour history of fever, headache and increasing listlessness. Examination is significant for a temperature of 103 F, nuchal rigidity and a petechial rash on the trunk and extremities. 1. What are some risk factors for this condition? 2. What is the etiology of this condition? 3. What are the most common pathogens associated w/ this condition? 4. What dx studies will you do on this pt? 5. You should hold the abx on this pt until you get a head CT and the LP? 6. What are some findings on the head CT of this pt that would C/I the LP? 7. If you notice posturing in this pt, what would you suspect is happening? 8. What would be your tx for this pt?

1. > 50 yo (really old and really young.) and immunocompromised (HIV, ETOH, DM, Malignancy, immunosupressive drug therapy (MTX, TNF-alpha, steroids, ) lack of immunization, sinusitis, otitis media, or mastoiditis. 2. you usu get it from the encapsulated normal flora in your naso-oropharynx that penetrates the intravascular space. - you can also get it secondary to septicemia from endocarditis or pneumonia. - neurosurgery 3. CHILDREN = S. pneumo and Neisseria men... ADULTS= Hib, Grp B. Strept, Listeria (immunocomprimised and older pts) 4. LP- Definitive dx tool, CBC (WBC may be elevated/decreased), head CT (bcs of the seizure hx), blood cx, lactate (surrogate marker for acidosis and mortality), chem-7 (if vomiting) 5. NO--- you should'nt delay abx tx if there is a high suspicion for ABM. but you should be getting your labs and Blood cx beforehand... you have 2-4 hrs to get your LP before the abx sterilizes your CSF. 6. any sort of shifting of brain tissue or loss of ventricles. 7. Either they are having another seizure or they are herniating their brain. 8. Since they have the severe sx- it is most likely ABM and would be tx w/ abx Vanco + ceftriaxone (or other 3rd gen CPN) as well as steroids PRIOR to or WITH the abx to suppress the inflammatory response that occurs w/ bacterial cell lysis. Dexamethasone 10mg IV q 6 hrs x 4 days.

A 42 year-old with a history of hypertension and diabetes presents with acute onset of right facial weakness and numbness. She says she recently recovered from a URI. On examination her speech and extremity strength are normal, but she has significant weakness on the right side of the face, including the orbicularis oculi. In addition, she complains of roaring in the right ear, and her taste sensation is absent on the right side of the anterior tongue. Sensation is normal to pinprick. 1. What is the most likely dx and at least 1 other ddx? 2. What is the difference between this condition and sxs of a stroke? 3. What are the most common causes? 4. How will they most likely present? 5. When would you expect to see the maximal weakness? 6. Do these pts recover, or is it permanent damage? 7. Why is it important on PE to palpate for a parotid gland mass? 8. What are the txs? 9. What would you do, if after 2-3 weeks the pt is not improving at all? 10. Is it likely for this pt to get this condition again?

1. Bells palsy (CN VII), lyme dz, stroke 2. stroke doesn't usu effect the frontalis muscle- so it spares the forehead! 3. Lyme disease and HSV 1/2. You can also get it w/ pregnancy or herpes zoster. 4. rapid onset (hrs-days), progressive (often present in the am), unilateral facial paralysis (eyebrow sagging, inability to close the eye, disappearence of hte nasolabial fold, mouth drawn to non-affected side) It is possible to loose taste sensation on anterior 2/3 of tongue. *** 60% complain of ear pain or posterior/preauricular pain. 5. about 3 weeks into condition 6. 80-90% recover w/in 6 weeks-3 months- if they start to get better w/in 3 weeks than they have a better chance of fully recovering completely. The larger lesions = least recovery. RF for poor prognosis = > 60, complete paralysis, decreased taste or salivary flow on affected side. 7. If there is a mass in the parotid, it could be compressing against the facial n. and that is what could be contributing to the sxs. 8. EYE care - artificial tears (2/2 inability of eyes to close= drying out), patches or tape eyes shut at night. MEDS - ***steroids (prednisone x 5 day w/ a 5 day taper)** and antivirals (Valacyclovir 1 g TID x 7d or Acyclovir 400 mg x 5x/day x 10 day) beginning w/in 3days of sxs. 9. F/U w/ neurology and get an MRI to look for something else that is causing the CNVII palsy. 10. 7-15% of pts have a recurrence w/in 10 years. If there is recurrence, consider testing for MG.

A 25-year-old male presents to a neurologist with headaches. He notes that the headaches usually occur at night, and that they are usually left-sided and centered behind his eye. The headaches last two hours at a time, and he has experienced several headaches per day for the past four days. He notes a similar experience several months ago, which resolved after a week. His neurologist prescribes a medication for headache prophylaxis. What is the most likely class of medication prescribed? 1. Calcium channel blocker 2. Tricyclic antidepressant 3. Beta blocker 4. Cyclooxygenase inhibitor 5. Opiate

1. Calcium channel blocker

A 30-year-old woman presents with a two year history of anxiety, gait instability, and progressively worsening tics. She has no family history of neurologic disease, but her father committed suicide at age 32. MRI scan of the brain shows atrophy of the cerebral cortex and caudate nucleus. 1. What is the most likely dx, as well as 1 other ddx? 2. What is the definition of this condition? 3. Is this condition reversible? 4. What is the pathophys behind this condition? 5. What will this pt look like when they're walking, sticking their tongue out, and facial expressions?

1. HD, Tourette's d/o, tardive dyskinesia 2. hereditary disorder of the basal ganglua, where the pt will have progressive motor incoordination, abnormal movements, and intellectual decline. 3. NO- it is invariable fatal. 4. Huntingtin proteins interact w/ proteins found onyl in the brain. The altered formed of hunington protein disrupts this interaction leading to nerve death. - Nerve cells of the striatum are the first to die as HD progress. 5. when they're walking, you will see involuntary movement of the arms and hands w/ wider ROM in the tremors. - when asked to stick the tongue out, it will automatically retract back into their mouth. - they have more expressive facial features than PD.

A 26-year-old female presents with chronic headache. The headache commonly begins in the morning, and persists for most of the day. The headache occurs almost daily and averaging around 20 headaches per month. She reports that abortive therapy with zolmitriptan and acetaminophen are no longer effective. She has taken these medications approximately 15-20 times per month for the last 4 months. Her medical history is significant for migraine with aura. Physical examination is completely normal. 1. What is the most likely dx and two other ddx? 2. What are the top 3 medications which have the highest risk to cause MOH? 3. What are some risk factors for MOH? 4. Will these HA go away after you stop giving the medication causing it? 5. What medications is she on that could be causing these HAs?

1. Medication overuse headache 2. the highest risk = Butalbital - then acetaminophen, and opiods are next... 3. obesity, caffine consumption, medication overuse 4. perhaps not--- you may have to take them off and tx the HA. 5. zolmitriptan and acetaminophen

A 31-year-old female presents with a headache that is throbbing and affecting the right-side of her head. She also reports nausea and had one episode of vomiting. Her symptoms began approximately 8 hours ago, where she began to see a bright light that progressively expanded, making it difficult for her to see. Sitting in a quiet dark room improves her symptoms. Medical history is insignificant. She denies alcohol, smoking, or illicit drug use. 1. What is the most likely dx and 3 other ddx? 2. What are the medications available to tx acute migraine? 3. In this pt, what will your first line treatment be? 4. If this pt is refractory to your first line tx, what would you try next? 5. After trying your second line medication, which provides no relief, what can you do?

1. Migraines, meningitis, subarachnoid hemorrhage. 2. 1. NSAIDs/Acetaminphen = 1st line in mild to moderate pain WITHOUT N/V. can be used in combo w/ caffeine. 2. Anti-emetic = metoclopramide, chlorpromazine, prochlorperazone. - can give monotherapy or combo w/ analgesics. - if vomiting, it can make the HA worse, so it is important to get that under control. - works via dopamine antagonism= ADRs... - Dystonia (in adolescents =give benadryl) - QTc prolongation and Torsades 3. DONT USE OPIATES/BUTALBITAL 4. Ergot derivatives= Ergotamine tartate & DHE. - not used so much anymore- it is a vasospastic so you DONT want to use in pts w/ CVD. 5. Triptans - 5HT agonists (B&D receptors) - causes cranial vasoconstriction - there are 7, all are same efficay except Frovatriptan. 3. In this pt I would first try a combo of an anti-emetic and analgesia. 4. I would try a triptan, except Frovatriptan (bcs this not ppx or a chronic HA) 5. If the 1st Triptan doesn't work, then you can switch to a different triptan after the initial triptan was ineffective for 2 episodes.

A 69-year-old gentleman presents to his physician with a chief complaint of blurry vision. Though he currently says he feels fine, he notices that his vision at the end of the day is blurry and sometimes he experiences "double vision." The patient states that he feels weak and fatigued at the end of the day and has noticed with harder foods, weakness in his ability to chew. 1. What is the most likely dx? 2. Which of the following is the best tx option for this pt? A. Plasma exchange B. Prednisone C. Pyridostigmine D. Repeat Cipro therapy

1. Myasthenia Gravis 2. C. Pyridostigmine - you could've also used neostigmine.

A 16-year-old female is brought into the emergency department following a collision on the soccer field. At the scene of the accident, the patient was opening her eyes spontaneously, making random and exclamatory remarks that seemed out of context to witnesses, and she was localizing to painful stimuli. 1. Should she be returned to play after assessment? 2. You tell her that she needs to go on brain rest, what does that mean? 3. According to observational studies, when should this pt most likely be asymptomatic? 4. If this pt had nausea or a HA, what meds could you give her? 5. If her sxs (HA, dizziness, cognitive impairment) persisted beyond the time which was expected and longer than 4-6 weeks, what could she have? What could you give her?

1. NO- an athlete w/ a suspected concussion should NEVER return to play the same day! 2. cognitive and physical rest- usu 24-48 hrs after injury where you remove anything that can stimulate the brain (TV, phones, computers). You need to avoid anything that raises your HR. 3. between 7-10 days. 4. nausea = zofran HA = Tylenol or NSAIDs 5. post concussion syndrome (PCS) - donezapil, antidepressents, anxiolytics, methylphenedine.

A 65-year-old man present with a tremor in his right hand. The tremor is maximal at rest, diminishes during movement, and is absent during sleep. Family members report changes in facial expression. 1. What is the most likely dx and two other ddx? 2. What are some sxs that are classic to this condition? 3. What is the cause of this condition?

1. PD, severe depression, neurodegenerative dz. 2. tremor at rest... usu starts as "pill-rolling tremor". their movements become slow and difficult to initiate. They will have a shuffling gate, and have a mask-like face. Some also suffer from dementia. Speech becomes hypophonic. 3. you loose dopaminergic neurons in the substantia nigra, locus cerulerus and other parts of the brain stem.

An obese 31-year-old female presents to the neurologists office complaining of severe headaches, visual obscurations, ringing in the ears and what her primary care doctor called "papilledema". She has been taking large amounts of vitamin A because a friend told her that it would give her more energy. Examination of the patient shows limited abduction of both eyes. 1. What is the most likely dx and two other ddx? 2. How would you define this condition? 3. What are some clinical features of this condition? 4. What are few etilogies for this condition? 5. If you did an LP on this pt, what opening pressure would you expect to see? 6. What would your pharmacologic tx be for this pt? 7. What would your non-pharmacologic tx be for this pt?

1. Pseudotumor Cerebri, acute closed glaucoma, cerebral edema. 2. syndrome of intracranial HTN w/ normal brain parenchyma! 3. HA, transient visual obstructions, pulsatile tinnitus, flashing lights, retroorbital pain, diplopia, perminant vision loss. 4. primary - obese, recent wt gain secondary - cerebral venous abnormalities, meds, medical conditions. 5. > 250 mmHg in adults > 280 mmHg in children 6. Acetazolamide = TOC to lower CSF production. Topiramate may be an option May give loop diuretics as adjunct. 7. wt loss serial LP surgical tx - those who fail primary therapy. - optic n. fenestration - shunts

A 53 year-old female with sudden onset "of the worst headache she has ever had" presents to the emergency department. She has a history of migraines but states that the current headache is not like her usual headaches. Results of her physical examination are unremarkable. 1. What is the most likely dx? what are 2 ddx? 2. How are most of these conditions caused? 3. What are the main risk factors? 4. What is the mortality rate? 5. What is the most common presentation? 6. What diagnostics should you do for this pt? 7. How should you manage this pt?

1. SAH - ddx = intracranial bleed, meningitis, venous thrombosis. 2. ruptured saccular aneurysms. 3. tobaccos use and HTN 4. 50% 5. severe HA- "worst of their life" sudden onset, N/V, LOC. - 30-50% will have a warning leak... 6. non-contrast head CT. (high for the 1st 6-12 hrs) if CT is (-) do LP to look for blood or xanthochromia. if the pt is stable, you can do a CTA to find source. 7. - admit to ICU - if GCS <8 = intubate - control HTN goal = < 160 - bed rest + laxatives= no straining bcs it can cause a rebleed. - Numodipine - to prevent vasospasm. - surgery= craniotomy (if increased ICP) or clip/coil 24-72 hrs after SAH.

An 8-year-old girl is brought in by her parents after they noted her to have repeated episodes of uncontrolled arm "twitching." that lasts 30 or so secs each time. She does not lose consciousness during these episodes. 1. What is the most likely dx? 2. Is she experiencing the motor, sensory, or autonomic symptoms manfiested w/this condition? 3. Is there a tx of choice? 4. Is surgery an option for this condition?

1. Simple partial seizure 2. She has the motor type- where she is twitching. - if it was sensory: tingling, pain, heat, cold, phantom sensations, ect. - if it was autonomic: abdominal, cardiac, resp, urogenital signs. 3. There is no one drug of choice. 4. yes- if they're refractory to medical tx and if they have a well-localized sz w/ documented video EEG and corresponding lesion on neuroimage.

A 72 year-old patient with a history of hypertension and atrial fibrillation presents with episodes of weakness, numbness, and paresthesias in the right arm. At the same time, she notes speech difficulty and loss of vision in her left eye. These symptoms come on abruptly and clear within minutes. Physical examination is normal except for the previously known arrhythmia. 1. What is the most likely dx, as well as 3 other likelihoods? 2. What is the old and new definition for this condition? 3. Is this condition as emergency? 4. How many risk factors does this pt have for this condition and what are some other common risk factors? 5. What would be the likely artery involved in this pt based off of their sx? 6. What timeframe is he at the highest risk for a stroke? 7. What is the score system that you can use to identify pts w/ TIA who at the greatest risk of subsequent stroke? 8. Is it recommended that this pt be admitted to the hospital? 9. What are some things that you are going to do for this pt to prevent him from having a stroke? ___________________________________________________________________________________ the following is based on if sx persisted: 10. If his BP was 220/110 and he was given ASA as tx- would you treat his HTN right away?? 11. If he is going to be given rtPA, what is his BP goal?

1. TIA, intracrainial bleed, stroke, partial seizure 2. old = neurological sx < 24 hrs. new= neurological deficit w/o acute infarction. 3. YES- bcs it is the precursor to a stroke. Like unstable angina for the heart. 4. This pt has 3 risk factors. non-modifiable: increased age, male, low birth weight, FHx, modifiable: HTN, cigarette smoking, A fib, DM, estrogen, obesity/dislipidemia, cocaine/amphetamine use. 5. MCA = aphasia, motor and sensory deficit, hemianopia. 6. If the pt had a TIA, then the greatest risk for a stroke is w/in the 1st 48 hrs. 7. ABCD score 8. YES- for at least 72 hours because he loss his vision. monocular blindness or an ABCD score > 3 = admitted for 72 hrs. 9. - HTN goal = 140/90 (may resume HTN meds in 24 hrs) - DM A1c < 7% - smoking cessation - carotid endarectomy is stenosis > 60%. - Atorvastatin 80mg QD. - thrombotic = start ASA or antiplatelet - embolic= warfarin or other anticoag ________________________________________________________________________ 10. Not necessarily in this case, it depends on if it is symptomatic (im guessing) if it is not required, you hold they HTN meds. if required, you only lower it 10-15% w/in the 1st 24 hrs. 11. in order to give rTPA thier BP needs to be < 185/110.

A 70 yo male presents with headache and neck stiffness. On physical exam, the patient is febrile, Kernig's sign is present, and no rash is noted. A spinal tap reveals a white count of 250/cm3 with 100% neutrophils, total protein 250 mg/dL (15-60), and glucose 35 mg/dL (50-80). 1. How would this pt most likely describe his HA? 2. What is the sensitive classic sign of this condition? 3. Why might you see AMS in this pt? 4. What are the signs that you can preform if they complain of neck pain/stiffness are highly specific, but NOT sensitive to this condition? 5. 1/3 of ABM pts present w/a palsly/dysfunction of what CNs? Why? 6. If this pt presented w/ a seizure as well, what would that be pathopnemonic for? 7. What type of rash is classic with this condition, esp if it is caused by what organism? 8. Does this pt's WBC warrant suspicion for bacterial or aseptic? 9. Based on the other aspects of the CSF results, what is the most likely etiology of his condition?

1. This is a HA that is unlike any other HA and is typically generalized and severe. ("diffuse, dull") 2. fever and if they are hypothermic - it could indicate potential sepsis. 3. It can be caused when the meningitis has caused increased ICP or if there is cerebral edema. 4. Kernigs - unable to straighten leg greater than 135 degrees w/o pain. Brudzinski - severe neck stiffness causes hips and knees to flex when neck is flexed. 5. CN III (pupils and extraocular movements), VI (unimpeded medial rectus), VII (facial movements) , VIII (hearing deficits/dizziness). whenever there is an infectious process, it can make you thrombogenic aka "sticky". 6. Meningitis that has crossed over into the parenchyma and is now causing encephalitis. 7. petechial or purpuric rashses classically seen w/ meningicoccemia. 8. The WBC themselves don't warrant suspicion bcs they are under 100, but the fact that they are 100% neutrophils is very indicative of an early bacterial meningitis and you should tx it like such. 9. BACTERIAL = increased WBC(100-5000) w/ PMN glucose decreased protein elevated

A 12-year-old boy had an episode during basketball practice where he fell to the floor and became stiff-looking, then had 2 minutes of symmetric clonic movements. 1. What is the most likely dx? 2. Name the cry that is common before this type of sz... 3. how long does the tonic phase last in this sz? 4. Are they breathing during the tonic phase? 5. are the convulsions during the clonic phase arrhythmic or rhythmic? 6. Describe the post-ictal phase... 7. What are some txs?

1. Tonic-Clonic seizure 2. prodromal ictal cry 3. the tonic phase usu lasts 10-20 secs. 4. no- bcs everything is just contracted! 5. they are rhythmic- and may bite their tongue or cheek. At the end of this phase, there is body relaxation, which is where they may experience urinary incontinence. 6. this is the phase after the clonic portion that can last 30 mins to hours, where the pt experiences amnesia, difficulty talking, HA, and variable periods of unconsciousness (initially stupurous, but as they gradually awaken they can get confused, agitated, and combative) 7. valproic acid lamotrigenen topiramate Zonisamide Phenytoin Carbamazepine

A 10-year-old male presents with his parents who have concerns about his constant outbursts. They state he calls out at odd times but does not seem to be aware he is doing it. He also seems to shrug his shoulders every few minutes even when he has not been asked a question. His parents are worried because he does not seem to have any close friends at school and his teachers are starting to label him as a troublemaker. 1. What is the most likely diagnosis? 2. What are the most common presentations for this condition? 3. Describe what a tic is... 4. T or F: most TS pts have premonitory sensations (burning, tingling, itching, or pain) preceding tics that are relieved by the execution of the tics. 5. Is TS a condition for life? 6. How do you dx TS? 7. How do you tx this condition?

1. Tourette Syndrome 2. Tourette syndrome initially presents with motor tics (80%) or phonic tics (20%) although ultimately it becomes a combination of the two. Symptoms are usually first noticed in childhood before the age of 15 years. 3. Tics are sudden, brief, uncontrollable, repetitive movements or vocalizations. - it can be as simple as blinking, clearing the throat, or shoulder shrugging. - more complex tics could include jumping, kicking, echolaia (repeating other's words), or coproalia (speaking obscenities) 4. True 5. Not usu... the sxs usually are gone by the early 20's. But there are cases of adult TS. 6. two or more motor tics and one or more vocal tics. - the tics should happen nearly every day > 1 yr w/o a tic-free period of > 3 consecutive months. 7. Pharm: Clonidine or Botulism. Non-pharm: CBT, DBS.

A 6-year-old boy is brought to the pediatrician by his parent's due to episodes of "staring into space." This occurs several times a day and lasts only a few seconds. During these episodes, the boy is unresponsive to the parents and does not fall down or shake. After the episode, the boy returns to his normal activity and is not confused. The parent's deny any history of head trauma, medications, or infection. Neurological exam is normal. An EEG is performed, which shows 3-Hz spike and wave form. 1. What is the most likely dx? 2. How long should these episodes last? 3. Would you expect a post-ictal period after these episodes? 4. What is the age that is most associated w/this condition? 5. What are some triggers for this condition? 6. What is the tx for this?

1. absence seizure 2. < 20 secs. 3. you shouldn't have one... 4. childhood or adolescents... but may cont. into adulthood but kids can grow out of them. 5. bright, flashing lights and hyperventilation 6. Ethosuximide= if the pt ONLY has absence sz valproic acid, topamax, lamotrigine= combo sz

A 65 year-old patient with steroid-dependent chronic obstructive lung disease presents with a headache that has been increasing in severity over the past 24 hrs, accompanied by nausea and vomiting. He denies fever, but has had photophobia and a stiff neck. 1. What is the most likely dx, and two other top ddx? 2. What are the typical hrs of onset for this condition? 3. What are the cardinal sx for this condition? 4. Of these sx- how many sx on average do the confirmed cases usu have? 5. What populations can you expect may NOT have fever? 6. What treatments can you give him to rule our influenza? 7. What risk factors does this pt have for his condition? 8. If he started to show signs of AMS or elevated ICP (aka papilledema) what would your tx plan become?

1. acute bacterial meningitis, influenza, epidural abscess, acute glaucoma, brain abscess, temporal arteritis. 2. Acute bacterial meningitis is typically associated w/a rapid onset, developing over 24 hrs. 3. HA, fever, neck stiffness, AMS 4. in confirmed cases- they usu have at least 2/4 5. elderly and immunocompromised don't have to present w/a fever in ABM. These may also not have elevated WBCs. 6. If you are unsure whether it is meningitis or influenza and you don't want to tap them, you can give them IVF, antipyruetics, and analgesics. If they feel better- than it's not likely meningitis. If they don't get better than you will need to tap them. 7. age= > 50 yo immunosuppressant drug = chronic steroids 8. His brain is becoming swollen, so you need to get a neurosurgical consult, mannitol, and mild hyperventilation. - you could consider hypertonic saline.

A 28-year-old woman with a history of mixed connective tissue disease on low-dose prednisone and ibuprofen presented with a history of high-grade fever, frontal headache, nausea and generalized bodyaches for 1 day. Physical examination revealed an alert lady in no acute distress. She had a temperature of 103°F and she was hypotensive on presentation. Neck flexion was slightly limited because of pain. Kernig's and Brudzinzki's signs were absent and no focal neurological deficits were elicited on exam. her CSF profile showed negative bacterial and fungal cultures, but positive for enterovirus. 1. What is your dx? 2. What is the most common viral organism involved in this condition? 3. How does these pts typically present? 4. What are some other viral organisms that can cause this? 5. If you decide to do a LP, what would you expect the opening pressure to be? 6. What values would you expect to see in her CSF? 7. What would be her tx? ____________________________________________________________________________________ If her condition was caused by a fungus: 8. What fungus would most likely be causing her sx? 9. what would her CSF values look like?

1. aseptic meningitis. 2. enterovirus 3. Pts w/aseptic meningitis have similar abrupt onset of sx as ABM (HA, N/V, nucal rigidity, photophobia, fever) BUT they are less severe. 4. HSV 1/2, VZV, LCM (mouse feces) 5. between 20-50 mmHg. 6. VIRAL = increased WBC(10-500) w/ lymphocytes glucose normal (50-80) protein elevated (15-60) 7. You would've admitted her and given her IV abx while you awaited the culture. then you can d/c them after 24-48 hrs. any tx is symptomatic. You could've given valacyclovir if there was a change in MS- but since there wasn't in this pt- I wouldn't have. ________________________________________________________________________ 8. Cryptococcus 9. FUNGAL = WBC (0-500) w/ lymphocytes glucose normal to decreased (50-80) protein elevated (15-60)

A pt present w/ a fever, HA, and is "not acting right," according to the patient's daughter. On physical exam the patient has unsteady gait, and weakness of his left arm. The patient is started on antibiotics and a CT of the head is obtained. The CT demonstrates a ring enhancing lesion. 1. What is the most likely dx and at least 1 ddx? 2. What are they caused by? 3. Why do they have an effect? 4. How could the infection gotten in the brain? 5. Would you ever do an LP on this pt? 6. What is the gold standard dx? 7. What is the tx for this pt? 8. What is the duration of the pharamcological tx?

1. brain abscess and before getting the CT- it could've been meningitis, encephalitis... 2. infections, trauma, or surgery. 3. destroys the brain/spinal tissue. compresses the parenchyma. elevates ICP. interferes w/ CSF or blood flow. 4. direct invasion (bone, lymph, veins)- these are typically a single abscess from otitis media, sinusitis, dental infection. usu involving the temporal and frontal areas. Hematogenous spread- bacteremia (from emphyema, lung abscess, endocarditis,) typically multiple abscesses, often MCA distribution. 5. NO NO NO... always C/I in LP attributed to the risk of herniation. 6. MRI - most sensitive for early cerebritis, satellite lesions, ring edema, and esp posterior fossa and brain stem. 7. combined medical and surgical: - aspiration or excision -empric abx (3-4th CPN + Vanco+ metronidazole until C&S results. -dexamethasone for edema. 8. They should be on abx for 6-8 weeks via PICC.

36-year-old male presents with recurrent bouts of left-sided severe lancinating periorbital pain. His symptoms began 20 minutes prior, and appears to occur daily for the past several weeks. During his headache episodes, he constantly tears, and has a "runny nose." Miosis, ptosis, and conjunctival injection is appreciated on exam. 1. What is the most likely dx and two other ddx? 2. What is clinical presentations are known to be seen in this condition? 3. T or F - - - severity of this condition has been associated w/ suicide. 4. Does this pt have the chronic or episodic form? 5. Would you expect his autonomic sxs (tears, rhinorrhea, miosis, ptosis, conjuctival injection) occur all the time or only during the HA? 6. T or F - - - aggitation may also be associated w/this type of HA. 7. What are the acute tx's for this condition? 8. What are some preventative txs? 9. What are the chronic txs?

1. cluster HA, Migraine headache, Trigeminal neuralgia 2. severe episodic unilateral HA and autonomic dysfunction. 3. True 4. He has the episodic form, which is the most common and can occur up to 8-10 episodes/day and can last from 7 days to 12 months. - the chronic form has nor remission and is identified as a year of HA. 5. The autonomic sxs should only happen during the HA episode 6. True! 7. 100% oxygen non-rebreather mask 12-15 L x 15-20mins. Sumatriptan - 6 mg SQ- may repeat 1 hr later. or you can give it intranasal (given on the contralateral side of the HA. last line= Intranasal Lidocaine, PO ergotamine, DHE, octreotide. 8. Verapamil or steroids. 9. Verapamil and Lithium = meds. you can also do deep brain stimulation.

An 8-year-old boy is brought to a neurologist because of episodes of impaired consciousness that lasts about 60 secs associated with repetitive, stereotyped arm movements. He often does not remember the preceding event and is usu confused. 1. What is the most likely dx? 2. If this pt had an aura, what would the most likely location of the condition? 3. If the pt had motor effects like bicyling with their legs or fencing, what location in the brain would you think may be involved? 4. Can these develop into secondary generalized sz (tonic clonic)?

1. complex partial seizures 2. Auras are associated w/ temporal lobes seizures in 80% of cases. 3. frontal lobe seizure - they tend to be more bizarre motor behavior 4. yes!!!

A 23-year-old male is brought to the ED following a football accident in which he was not wearing a helmet. He lost consciousness and after regaining consciousness had an episode of nausea and vomiting. 1. What is the most likely dx? 2. If he were to return to play and get a second head injury before the first one was fully recovered, what syndrome could he get? 3. If he had imPACT testing done at the beginning of the season, could it be used to dx his concussion? 4. When can he return to learning? 5. What are his requirements for returning to play? 6. What happens if he starts to have sxs again during non-contact drills during football practice 4 days later?

1. concussion 2. second injury syndrome- a very serious syndrome that is caused by massive brain swelling that can cause death! 3. NO- the impact testing is NOT for dx purposes- it is for recovery purposes. 4. He may return w/ academic adjustments after he can concentrate on a task longer than 30-45 mins 5. there is a minimum of 5 days before they can fully return. There are 5 stages that increase in physical excretion. stage 1 - no activity stage 2- light aerobic exercise stage 3- sport-specific exercise stage 4- non-contact drills stage 5- full contact practice They also need have had a successful return to school, sx free and off meds, normal neuro exam, and back to baseline and cognitive performance measures. 6. he needs to attempt the protocol again at the previous level (sport-specific exercise)

A six-year-old girl presents in the pediatric emergency room after tripping and falling on the playground and striking her head against the ground. Her anxious parents state that there was no loss of consciousness or behavior changes, but she has felt nauseous, vomited twice, has had a HA since the fall. 1. What is a likely dx and two others? 2. What is the management strategy if you were the admitting PA in the ED? 3. What neurological scale can you use to measure the severity of neurological brain injury in this pt? 4. What are the ranges of this scale? 5. When should the score on this scale be expected to improve back to normal in this pt? 6. By asking her to repeat serial numbers or spelling words backwards/forwards- what are you assessing? 7. By asking her to state her full name, what month, date, year it is, as well as her location. What are you assessing? 8. By testing her extraocular movements, visual acuity, and pupillary reaction, smooth pursuits, saccades testing, convergence, what are you assessing? 9. Would you be able to do the vestibular ocular reflex testing if she had a spinal injury? 10. When would it be indicated for this pt to get a CT? 11. Would you order a contrast or non-contrast CT?

1. concussion, subdural hemorrhage, cerebral hemotoma. 2. get a good hx and a baseline neuro exam w/ retesting q 30 mins. Observe them for about 4 hrs and manage her sxs... give Tylenol for her HA, and anti-emetics for nausea. 3. glascow coma scale (GCS) 4. ranges from 3-15. immediately after injury. 5. the GCS should improve to 15 w/in 2 hrs. 6. Level of alertness 7. Orientation 8. visual function 9. NO- it involves moving the pt's head quickly and looking to see how they correct for it. 10. if she has: - LOC - abnormal neuro findings - deteriorating condition. 11. non-contrast CT bcs you are looking for a bleed.

45 yo female w/a hx of a solid organ transplant whose on immunosuppression presents w/a fever and altered mental status. She isn't arousable and has become very lethargic. It is reported that she had a seizure at home. An MRI showed hemorrhagic changes and increased enhancement in the temporal lobe. 1. What is the most likely dx as well as 2 other ddx? 2. What are the two most common causes of this condition? 3. What are the sx associated w/this condition? 4. What would it be called if this pt also had signs of CSF showing elevated protein and WBC, but decreased glucose? 5. How can you tell the difference of whether it is a primary or secondary manifestation? 6. What is the most common, world-wide cause of secondary encephalitis? 7. What is the most common cause of primary manifestation encephalitis?

1. encephalitis, brain abscess, heat stroke 2. direct viral invasion (primary manifestation) or a hypersensitivity reaction (indirect rxn that occurs weeks later after a viral infection= secondary manifestation) 3. fever, HA, AMS**, often accompanied by seizures or significant focal neurological deficits. 4. meningoencephalitis. 5. you look at the CSF and the secondary manifestation will NOT have viral protein because the virus is no longer there... 6. Measles - this is why we vaccinate against it! 7. HSV 1/2 or Enterovirus

A 62-year-old man reports involuntary shaking of both his hands, arms, and head. The hand shaking appears to worsen with writing, eating, or drinking from a cup. During periods of stress, his shakes worsens. He has noticed that drinking wine improves his symptoms. Family history is significant for his father also having similar symptoms. On physical examination, there is a 4-10 Hz tremor elicited when both of his arms are outstretched forward. There is no tremor at rest. 1. What is the most likely dx and at least one other ddx? 2. In this condition, where does the tremor usu start? 3. When is the tremor in this condition most likely to occur? 4. What will the tremors look like w/ more advanced age? 5. What are the core criteria for dx of this condition? 6. Would you expect that drinking ETOH causes the tremors to disappear? 7. What is the tx? 8. What can you do if the pt doesn't respond to pharmacological measures? 9. What is the prognosis of this condition?

1. essential tremor, drug-induced tremor. 2. typically starts from either hands or forearms. 3. can be postural, occuring w/outstretched arms, kinetic, or even at rest. It can happen during such actions as touching their finger-nose, writing, drinking, or drawing the spirals. 4. With advancing age, the tremor will be slower, but greater in amplitude (which can be more disabling) 5. - postural or kinetic tremor of the hands and forearms. - head tremor w/ NO dystonia (quick sudden abrasive movements) - absence of other etiologic factors and neuro sxs. (meds, ETOH, parkinsonism, dystonia, hyperthyroidism) 6. yes, ETOH gets rid of the tremor. 7. propanolol and primidone are 1st line. either alone or in combo. 8. DBS (deep brain stimulation) 9. the tremors get worse for some people and can really have an impact on daily living. It can also lead to complications like: pneumonia, falls, ect.

A 19-year-old woman presents to the ED after multiple episodes of vomiting in the last 6 hours. The vomitus is non-bloody and non-bilious. The vomiting started shortly after she began having a throbbing, unilateral headache and associated photophobia. She has had several similar headaches in the past (4 times this month). Her vital signs are unremarkable. 1. What is the most likely dx and two other ddx? 2. Should this pt consider ppx therapy? 3. What are some non-pharm methods to prevent this condition from happening? 4. What pharm therapy could you offer her?

1. migraine -- tension HA, meningitis 2. Yes, you can consider ppx therapy bcs it is suggested for pts who have 3-4 migraine days/month. 3. keep a migraine diary to identify triggers and observe regular habit- sleep,meals, exercise, stress reduction. 4.anti-epileptics= Divalproex, valproate, topiramate B-blockers= metoprolol, propanolol, timolol triptan= Frovatriptan

A 28-year-old male lawyer presents with headache. He describes the headache as of tightening quality on both sides of his forehead. It is non-throbbing, but feels like a "tight cap." He denies phonophobia or photophobia. On physical exam, there is pericranial muscle tenderness. 1. What is the most likely dx and at least three other ddx? 2. What is the duration of this condition? 3. Is this condition usu associated w/ nausea and vomiting? 4. Is this condition associated w/ phonophobia or photophobia? 5. how many days a month would you expect this pt to have had HAs? 6. What are the three main subtypes of this condition? 7. What is the mainstay tx for this HA? 8. Would Sumatriptan be useful in this pt? 9. Would muscle relaxants be used in this pt?

1. tension HA, migraine, cluster HA, over-use HA. 2. It can be anywhere from 30 mins to several days. 3. NOPE 4. It can be associated w/none or ONE... not both at the same time. 5. no more than 15 HA/month. 6. infrequent episodic = < 1 day/month. frequent episodic= 1-14 days/month chronic = > 15 days/month 7. simple analgesics , but be aware that the more you use them, the less they become effective. 8. Not really- evidence has shown that triptans are no better than placebo in pts with pure TTH. 9. Nope- there is no evidence that they're effective in acute TTH bcs muscle spasms aren't really the cause.

A 67 year-old female with history of HTN, DM, and smoking presents to the emergency department with mild expressive aphasia, right facial weakness and mild right arm weakness. She had awakened 60 minutes ago and was speaking to her husband when her speech suddenly became difficult to understand and weakness was noted. 1. What are some important questions to ask for your HPI for this condition? 2. What is important to look for in her PMH? 3. What needs to be included in the neuro exam of this pt? 4. What is the algorithim for her care? 5. What glucose level do you want this pt to be in and why? 6. What is your initial dx of choice? Then what other modalities can you order?

1. the time of onset, or if unknown, time of last seen normal. Also if they have had similar sx occur before (aka TIAs?) 2. HTN, DM, vascular dz, CHF, smoking hx, ect... 3. - mental status (AAOx4) - language (name objects, colors, repeat simple words, comprehension of speech, check ability to write and read, describe an action in a photo. - CN - motor strength - coordination, gait, and equilibrium - reflexes - sensor 4. She is suspected to have a stroke, first you need to check her glucose and her ABCs. Then obtain the CT to determine if it is caused from a hemorrhage or from a TIA/ischemia. - If it is ischemic, then you will consider thrombolytic therapy or a thrombolectomy. Then establish the cause and tx it appropriately. - if it is hemorrhagic then consider lower BP, and establishing the cause so you can tx it. ruptured aneurysm = coil or clip. HTN ICH = consider surgery to decompress area. - regardless of cause- after tx you should ppx for DVT, suggest PT, OT, Speech therapy, eval for rehab. 5. glucose should be w/in 60-180 bcs it is correlated w/ good stroke outcomes. 6. CT = dx of choice. then you can order different MRIs, CTP (will shown areas that have a potential to be salvaged), MRA or CTA, Echo.

An 23-year-old female presents to the ER complaining of a "terrible" headache. She states that it began 8 hours ago and describes it as a throbbing pain in the front of her head. She also has been nauseous all day and vomited three times (nonbloody, nonbilious). Light hurts her eyes. Her mother gave her acetaminophen when the pain first started, but it didn't help. 1. What is the most likely dx and two other ddx? What is the most appropriate next step in treatment? 1. IV fluids 2. Acetaminophen 3. Ibuprofen 4. Sumatriptan 5. Morphine 3. Which of the following is an appropriate therapy for this patient's vomiting? 1. Propranolol 2. Amitriptyline 3. Ergonovine 4. Chlorpromazine 5. Calcium channel blockers

1.. migraine -- tension HA, meningitis 2. 3. Ibuprofen 3. 4. Chlorpromazine

A 27-year-old is admitted to the neurosurgical trauma ward after a motorcycle crash. He was not wearing a helmet. He opens his eyes in response to painful stimuli, makes no sounds, and extends to painful stimuli (Glasgow Coma Scale 5). The neurosurgery resident observes that his intracranial pressure is severely elevated. He lectures the medical student that all of the following are methods of reducing intracranial pressure with the exception of: 1. Raising the head of the bed 2. Instilling hypotonic fluids 3. Intubation and hyperventilation 4. Administration of Mannitol 5. Administration of hypertonic fluids

2. Instilling hypotonic fluids

A 42-year-old gentleman presents to the ED after a week of a worsening sensation of heavy lower extremities. The patient describes a few episodes of intense nausea, vomiting, and diarrhea a few days ago. Physical examination elicits bilateral 2-out-of-5 lower and upper extremity strength and absent ankle and patellar reflexes. He has most recently been complaining of shortness of breath if he attempts to have conversations with others. Routine labs, chest radiograph, and head CT are all unremarkable. His recent gastrointestinal complaints were most likely due to which of the following organisms? 1. Bacillus cereus 2. Staphylococcus aureus 3. Streptococcus pneumoniae 4. Campylobacter jejuni 5. Streptococcus viridans

4. Campylobacter jejuni

A 54-year-old male presents with back pain, leg weakness, and night sweats. He admits to occasional IV drug use. Otherwise, his past medical history is unremarkable. On physical exam, there is tenderness over the lumbar spine. His vital signs are as follows: Temp 39.0, BP 140/89, HR 102, RR 17, O2 sat 98% on room air. On physical exam, he has bilateral up-going great toes on Babinski reflex testing as well as patellar hyperreflexia bilaterally. What is the best next step in the diagnosis of this condition? 1. Electromyography 2. Spinal tap for CSF analysis 3. Lumbar spine xray 4. Lumbar spine MRI 5. Lumbar spine CT

4. Lumbar spine MRI This patient most likely has a lumbar epidural abscess as evidenced by upper motor neuron signs and spinal tenderness in the setting of fever and IV drug use. The best confirmatory test for this condition is an MR scan of the spine.

A 34-year-old female presents to her primary care physician with recurrent headaches. She notes that the headaches began several months ago, and that the most recent headache has been persistent for more than 5 days, without fluctuation. She describes the headache as bilateral and dull, and she denies photophobia, phonophobia, visual changes, facial weakness, and nausea. She notes that she has been feeling stressed for the past month, since her father recently had a hip fracture, and she is responsible for taking care of him. What is the most appropriate next step? 1. Verapamil 2. Sumatriptan 3. Oxygen therapy 4. MRI head 5. Ibuprofen

5. Ibuprofen

A 28 year-old female presents to the clinic complaining of a "prickly sensation" that started bilaterally in her feet two days ago and difficulty walking. She now has the dysesthesia from her mid-thigh down to her toes. On physical examination she has diminished pain and temperature sensation, absent reflexes, loss of proprioception in her legs bilaterally, and muscle strength is 1+/5+ in the lower extremities and 5+/5+ in the upper extremities. What is the most likely diagnosis? A. Guillain-Barré syndrome B. Multiple sclerosis C. Myasthenia gravis D. Spinal cord compression

A. Guillain-Barré syndrome

A 2 month-old infant has had a single, generalized tonic-clonic convulsion lasting 4 to 5 minutes. There is no history of trauma and the infant had been well previously. Physical findings include a temperature of 39.6 degrees C (103.2 degrees F), a bulging tympanic membrane on the right, and an inflamed pharynx. The next most appropriate step is to A. perform a lumbar puncture. B. order x-ray studies of the skull. C. obtain an electroencephalogram. D. send home with antibiotics and an anticonvulsant.

A. perform a lumbar puncture.

A 75 year-old male presents to the ER with the following stroke findings: right-sided hemiparesis (face and hand more affected than leg), homonymous hemianopsia of the right half of both visual fields, and aphasia. Where is the location of his stroke? A. Anterior cerebral artery B. Middle cerebral artery C. Posterior cerebral artery D. Internal carotid artery

B. Middle cerebral artery - Patients with anterior cerebral artery stroke will have findings greater in the legs than hands. - Posterior cerebral artery stroke patients will have midbrain and thalamic or sensory findings. - Internal carotid artery stroke patients will have amaurosis fugax, visual disturbances and crossed symptoms.

Imaging for evaluation of headache is indicated in: A. new onset headache in persons > 40 years B. headache worsened with Valsalva like maneuvers C. headache associated with seeing flashing lights D. headache worse at rest E. headache as severe as previous headaches

B. headache worsened with Valsalva like maneuvers

An 8-year-old boy is admitted for "seizures" that are described as "20-second lapses of awareness" when he blinks his eyes. After these attacks, he resumes his previous activity. Which of the following seizure types is most likely? A. tonic-clonic B. myoclonic C. absence D. focal

C. absence

A 12 month-old in the emergency department is diagnosed with possible viral meningitis. Which of the following cerebral spinal fluid (CSF) laboratory results is most consistent with this diagnosis? A. Decreased CSF glucose level and increased protein B. Decreased CSF total protein level and very few neutrophils C. Increased CSF mononuclear (lymphocytic) cells and normal glucose D. Increased CSF C-reactive protein and normal glucose

C. Increased CSF mononuclear (lymphocytic) cells and normal glucose

A 30 year-old female presents to the office complaining of generalized weakness and reduced exercise tolerance that improves with rest. On physical examination you note the presence of bilateral eyelid ptosis, proximal muscle weakness and normal reflexes. What is the most likely diagnosis? A. Lambert-Eaton syndrome B. Organophosphate intoxication C. Multiple sclerosis D. Myasthenia gravis

D. Myasthenia gravis ***Common symptoms of Lambert-Eaton syndrome are proximal muscle weakness of lower limbs, cranial nerve findings, and depressed or absent reflexes. Patients commonly have a malignancy.

A 75 year-old male presents for a routine physical. Vitals are normal with no orthostatic changes. On physical examination, a fine cortical movement with repetitive rubbing of the tip of the thumb along the tips of the fingers is noted at rest. Which of the following is the most likely diagnosis? A. Seizure disorder B. Peripheral neuropathy C. Shy-Drager syndrome D. Parkinson's disease

D. Parkinson's disease