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Pt wakes up with eyes stuck looking up or head stuck turned to the side.
Acute Dystonia (if meds <12hr ago)
Tx: Benztropine or diphenhydramine
After 10 years on fluphenazine, tongue movements and grimacing
Tardive Dyskinesia (>years)
Tx: Benztropine or diphenhydramineNOT L-dopa!!
Also can use amantidine or bromocriptine
Pt reports feeling like they always have to move.
Akathisia (30-90 days).
Tx: Propranolol (1st-line) or benzo
Coarse resting tremor, masked facies, unsteady gait, bradykinesia
Parkinsonism (>6mo)
Tx: Stop antipsychotic!
Switch to atypical or clozapine
W/in hours of a haloperidol injection, pt has CPK, temp of 103F, rigidity, autonomic instability, and
delirium.
Neuroleptic Malignant Syndrome.
1st: D/c the offending med.
2nd: Cooling blankets and dantrolene (or bromocriptine = 2nd-line)
Also caused by metoclopramide, compazine and droperidol
SLEEP EEGs
Awake
SUBSTANCE USE
A 50 y/o known alcoholic presents to the ER with tonic-clonic seizures. BP 180/110, HR 118, T
100.1.
EtOH Withdrawal
Tx: Diazepam or chlordiazepoxide
o 80 & 120hr -lives respectively
o If hes a class C cirrhotic: Oxazepam, Temazepam, Lorazepam (Over The Liver)
Glucuronidated prior to elim
Ophthalmoplegia
Wernicke Encephalopathy. (caused by thiamine defy)
Tx: Give thiamine 1st, then glucose-containing fluids.
Can progress to Korsakoffs syndrome (irreversible damage to mammillary bodies, etc.)
o Apathy, antero/retrograde amnesia, confabulation
o Midbrain atrophy on MRI
A patient is brought into the ER in a non-responsive state. His BP is 100/60, HR is 50, RR is 6. He
has multiple track marks on his arms.
Heroin Overdose
First step: Intubate the patient
Tx: IV or IM naloxone (full mu-opiate antagonist)
Dilated pupils dont change the dx 2/2 respiratory depression can cause hypoxic dilation
Withdrawal sxs:
o Joint and muscle pain
o Dilated pupils, photophobia
o Goosebumps, diarrhea, tachycardia, HTN, GI cramps
o Anxiety/depression
Tx: Clonidine for autonomic sxs
o Ibuprofen for muscle cramps, loperimide for diarrhea.
Methadone, buprenorphrine or naltrexone can be used for long-term dependence.
Horizontal nystagmus, dilated pupils, ataxia, acute psychosis?
Hallucinogen (PCP) intoxication
Can use haloperidol for acute psychosis.
S/p MVC with injected conjunctiva, sedation, asking for Doritos?
Cannabis intoxication.
SI, hypersomnia, depression and anergia?
Cocaine/Amphetamine withdrawal.
Dilated pupils, seizure, tachycardia and HTN?
Cocaine/Amphetamine intoxication
First: EKG, then urine tox
Tx: Lorazepam (for seizures)
o Tx HTN and tachycardia w/CCB
Beta-blockers are CONTRAINDICATED!
Meningitis.
MCC: S. pneumo, H. influenzae, N. meningitidis
o Tx w/ceftriaxone and vanc
In old/young pts: Add Listeria
o Tx w/ampicillin
W/brain surg: Add S. aureus
o Tx w/vanc
Other: TB (abx + steroids), Lyme (IV ceftriazone)
Best 1st step: Empiric abx (+steroids if bacterial)
o Dx: Exam for elevated ICP/CT w/LP+Gram stain
>1000WBC is diagnostic
High protein and low glucose support bacterial
Tx roommates/contacts of pts w/bacterial meningitis and petechial rash: Rifampin!
CLOTTING & BLEEDING
In old people?
Edema, HTN, & foamy pee?
In young person w/ +FH
Whats special about ATIII def?
Young woman w/ mult. SABs?
Post op, plts, clots
What do you treat w/?
Bleeding
Think cancer
Isolated decr in plts?
Nephrotic syndrome
Factor V Leiden
Heparin wont work
Lupus Anticoagulant
HIT! (If heparin w/in 5-14 days
Leparudin or agatroban
ITP
Normal plts but incr bleeding time & PTT?
Low plts, Incr PT, PTT, BT, low fibrinogen, high Ddimer
and schistocytes?
vWD
DIC!! Caused by gram sepsis,
carcinomatosis, OB stuff
Ischemic strokes DON'T present with N/V and very rarely have LOC or other ICP sx.
ICHemorrhage initially has focal sx followed by incr. ICP sx (N/V, HA, bradycardia, stupor), but v. rarely
LOC.
SAHemorrhage doesnt present w/focal deficits, but does present w/ICP sx.
DM pts susceptible to CN3 nerve ischemia/neuropathy (parasympathetics intact, so only paralysis); if CN3
compression, will have ptosis, fixed, dilated pupil, and no accomodation.
Ataxia w/ dizziness, occipital HA, vomiting = cerebellar hemorrhage, no matter heat stroke risk
HA + focal neuro sx _ ring-enhancing lesin on CT- fluid collection in ethmoid sinus = brain abscess 2ary to
ethmoid sinusitis (only 50% of abscesses have fever)--anaerobes, esp S. vioridans, are common--Tx w/ 4-8 wks
min abx and drain
cerebellar sx--gait dyfxn, truncal ataxia, nystagmus, intention tremor, dysmetria, impaired RAM
1st-line tx for intention tremor: PRopranolol; may also tx w/topiramate, primidone (benzos if severe)
Complication of heat stroke: Rhabdo, coagulapathic bleeding, renal failure, ARDS; infx rarely cause temps over
105F; hypothalamic stroke can result in neurogenic fever
Pediatrics
Nervous System
Lesch-Nyhan--self-mutilation w/dystonia and elev. uric acid = def'y in hypoxanthie guanine phosphoribosyl
transferase, def'y in purine metabolism
3837
Medicine
Nervous System
SCC in lung can present w/mediastinal lymphadenopaathy as well as LE syndrome
3923
Medicine
Nervous System
Memory impairment in NPH is slow and progressive
3959
Medicine
Nervous System
!!!!*****
4022
Medicine
Nervous System
ACA stroke: Contralat motor/sensory deficits, more in LEs than UEs; urinary incontinence; gait dysparxia,
primitive reflexes, abulia, emotional disturbance Note that incontinence is a cortical sx (never seen in midbrain
infarcts)
4089
Medicine
Nervous System
cortical laminar necrosis results from excitatory cytotox-->status seizures; defined as seizures for more than 5
min without recovery in between
4130
Medicine
Nervous System
MSA= parkonsonism, autonomic dysfxn, widespread neuro signs
4255
Medicine
Nervous System
craniopharyngioma rare in adults, but bimodal age dist: child, 55-65y/o. Optic neuritis is us. assoc w/loss if
central vision and afferent pupillary defect
4268
Medicine
Nervous System
Posterior limb internal capsule (lacusnar infarct) unilateral motor deficit; no sensory cortical or vis field deficits;
MCA = contralateral motor and sensory (face arm leg), "gaze at stroke" homonomous hemianopsia; aphasia,
hemineglect; ACA = contralat somatosens + motor dficiet, LEs with ABULIA, dyspraxia, emotional
disturbances, incontinence; Vertebrobasilar = alt syndromes w/contralat hemiplegia and ipsilateral cranial nerve
deficits + possible ATAXIA
4269
Medicine
Nervous System
R-side lateral medullary infarct = Wallenberg: falling to side of lesion, ipsilat limb ataxia, diplopia, nystagmus,
vertigo; loss of P&T in ipsilat face and CONTRA lat trunk/limbs; ipsilat vocal cord paralysis; ipsilat Horner's
syndrome-->lat cerebellar lesions do not cause Horner's & have minimal dizziness
4274
Medicine
Nervous System
Brown-Sequard = contralaterla pain and temp loss 2 levels below lesion (spinothalamic tracts decussate almost
immediately)
4366
Medicine
Nervous System
Metoclopramide = DA antagonist; can produce dystonia (tenderness/stiffness) as well as parkinsonism and TD;
risk of NMS; tx SEs w/benztropine or dphenhydramine
4367
Medicine
Nervous System
ANGLE-CLOSURE GLAUCOMA, acute: haloed lights, periorbital pain, unilat lacrimation, severe HA, poss.
N/V, elev ESR; can occur d/t anticholinergics (pupil dilation); MC in women, Asian, Inuit, farsightednness
4372
Medicine
Nervous System
spinal epidural abscess--fever, focal spinal tenderness/back pain, neurologic dysfxn; get MRI, ESR, and CTguided aspiration/culture
4392
Medicine
Nervous System
Cuda equina syndrome cause by compression of spinal nerve roots, NOT conus medullaris--causes LMN signs;
conus medullaris compromise causes HYPERreflexia and perianal anesthesia w/sudden-onset severe back pain
(vs. radicular pain)
4393
Medicine
Nervous System
Hypokalemia: weakness, fatigue, hyporeflexia, tetany, rhabdo, arrhyth (severe) ECG shows broad flat T waves
ST depression, U waves and PVCs; HCTZ is K-wasting (hyperaldost can also cause)
4401
Medicine
Nervous System
Anticholinergics used on PD--benztropine, trihexylphenidyl; selegiline is an MAO-Bi used in PD;
bromocriptine is a DA agonist used in PD
4408
Medicine
Nervous System
DM pts susceptible to CN3 nerve ischemia/neuropathy (parasympathetics intact, so only paralysis); if CN3
compression, will have ptosis, fixed, dilated pupil, and no accomodation.
4427
Medicine
Nervous System
!!THIS question details gait disorders--COPY Foot drop usually = L5 radic (common peroneal nerve)
4458
Medicine
Nervous System
Ataxia w/ dizziness, occipital HA, vomiting = cerebellar hemorrhage, no matter heat stroke risk
4482
Medicine
Nervous System
Posterior limb int capsule MC site for lacunar stroke: Sx affect contralat face, leg, arm equally; thromboti
origin; not visible on CT soon after--microatheroma and lipohyalinosis are pathpphys resp.
4513
Medicine
Nervous System
HA + focal neuro sx _ ring-enhancing lesin on CT- fluid collection in ethmoid sinus = brain abscess 2ary to
ethmoid sinusitis (only 50% of abscesses have fever)--anaerobes, esp S. vioridans, are common--Tx w/ 4-8 wks
min abx and drain
4552
Surgery
Nervous System
Herniation syndromes: UOA Uncal-->oculomotor-->then abducens
4618
Medicine
Nervous System
cerebellar sx--gait dyfxn, truncal ataxia, nystagmus, intention tremor, dysmetria, impaired RAM
4619
Medicine
Nervous System
!!THIS question details dementia presentations
4622
Medicine
Nervous System
Tx of choice for agitation in elderly is low dose haloperidol; benzos are contraindicated in older pts (can cause
paradoxic agitation, + have slower metab)
4687
Medicine
Nervous System
RLS is tx w/ ropinirole or pramipexole--DA agonists
4691
Medicine
Nervous System
Epidural spinal cord compression causes: injury (EG, MVA), malignancy (L, B, P ca, myeloma), infx (epidural
abscess); severe local back pain; pain worse in recumbent pos'n/at night; symm LE weakness, paraplegia w/ inc.
DTRs; IV glucorticoids, stat MRI, radiation onc + neurosurg consult
4703
Medicine
Nervous System
Complication of heat stroke: Rhabdo, coagulapathic bleeding, renal failure, ARDS; infx rarely cause temps over
105F; hypothalamic stroke can result in neurogenic fever
4708
Medicine
Nervous System
Elev ICP /ICHtn: >20mmHg. Diffuse HA, worse in morning, N/V early in day, vision changes, CN deficits
somnolence confusion n=unsteadiness Remember Cushing's reflex: HTN + bradycardia
4900
Medicine
Nervous System
papilledema can cause momentary vision loss that changes with head position; amaurosis fugax is us. vascular
(embolus to opth artery); galucoma may cause periph visual field deficits (not actue angle-closure, though);
optic neuritis is unilat eyes pain and vision loss w/afferent pupillary defect.
4913
Medicine
Nervous System