Life Raft for Neuroscience 2 Final Exam - Strategief

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Feb 22, 2014 (3 years and 5 months ago)

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Dr. Robbins


26 Questions


Predicted cases are below

Case 5


A 31
-
year
-
old woman with no family history of neurologic disease
and no history of trauma or drug abuse had the spontaneous onset
of a horizontal (“no
-
no”) head tremor. Initially, it was mild and
asymptomatic, but as it increased in severity, the patient noted that
turning her head to the right seemed to increase the tremor,
whereas turning her head to the left decreased the tremor. Her
neurologic examination results were otherwise normal, as well as
her MRI. Beta
-
blockers,
primidone
, and alcohol had little effect on
the tremor. Eighteen months later, the patient returned, reporting
that driving had become difficult because of a tendency for her head
to turn involuntarily to the left, and her attempts to hold her head in
the neutral position markedly increased the tremor and caused
discomfort in her neck. Stress also caused similar problems. Over
time, the involuntary movements were present almost continuously.
Mild finger pressure on her left chin dampened the tremor and the
involuntary movements of her head.

Case 1


A 60 year old male comes to see you for
numbness and a slight weakness in his left
lower face. He states it was present on
awakening yesterday morning. On further
questioning he admits that he has noticed
numbness and clumsiness in his left hand
when buttoning his shirt.

Case 2


A 23 year old male presents with numbness
and tingling of his right hand. The patient’s
hand numbness wakes him up at night and
he has to shake it for normal feeling to
return. There is a positive Tinel's sign over
the median nerve of the wrist. The patient
has no other complaints.

Case 3


A 23
-
year
-
old graduate student was studying late at
night for an examination. As he looked at his
textbook, he realized he was having difficulty
reading through his left eye. When he covered his
left eye, his vision in the right eye seemed normal.
However, when he covered his right eye, his vision
in the left eye was blurred. Other than left ocular
pain when he moved his eyes, he had no other
symptoms.

Case 4


A 65
-
year
-
old man with a history of hypertension,
coronary artery disease presents with a complaint
of sudden onset of double vision. Further
questioning reveals the diplopia occurs only on
horizontal gaze and not vertical gaze. Other than
weakness of the right lateral rectus muscle, there
are no other neurological complaints or findings.

Case 5


A 2
-
year
-
old child was seen by you at 1p.m. due to
stumbling and lethargy associated with nausea and
vomiting. The mother relates the child was in good
health this a.m. but was difficult to arouse from his
nap for lunch. You find the patient to be somnolent,
arouses to light pressure but falls back to sleep and
his pupils are constricted but reactive to light. The
temp is normal and no other neurological signs are
present.

Case 6


A 60
-
year
-
old man presents with a 3 month gradual
decline of strength in his right face and right upper
and lower extremities. He first noticed a weakness
in his face then his hand that progressed for 2
months. This was followed by a progressive
weakness in his right leg to a point where he is now
falling.

Case 7


A 58
-
year
-
old female with a history of a light stroke 9 years
ago that left her with short term memory problems. She
smoked ½ pack/day for 25 years and had intermittent low
back pain for 20 years. She presents to you with a history of
waking up 3 weeks ago with weakness in her right lower
extremity associated with a foot drop. It has not progressed
or improved. She has dorsiflexion weakness and a numbness
from the lateral mid
-
calf to the dorsum of the affected foot.
She has no reflex in her right patella.

Case 3


A 28
-
year
-
old accountant and part
-
time boxer has been
brought to the urgent care clinic by his wife because he has
become irritable and abusive. She reports that he has had
intermittent headaches for 3 months, and the headaches
have become more severe and constant in the past month.
He has been unable to work for about a week because of
excessive drowsiness, and he sleeps for up to 24 hours if not
awakened. The patient is poorly cooperative and says only
that he has a headache.



On neurologic examination, he is drowsy and irritable but
able to follow commands. He has mild to moderate
weakness in his left arm and leg, and a left pronator drift.
Tendon reflexes are hyperactive on the left. There is a left
Babinski’s response. The lower part of his face droops
slightly on the left side.

Case 4


A 69
-
year
-
old right handed retired executive is seeing her
internist for a routine checkup. Her husband mentions that
she has undergone a marked personality change over the
past several months. He also notes that she has been
forgetful for about a year and keeps asking the same things
over and over. She no longer seems interested in her
personal appearance. The mental status examination
confirms these observations. Her speech is fluent, but she
frequently pauses because she can’t think of a word. She has
difficulty following complicated commands. She can only
remember one of three items after a 5 minute delay, and she
recalls no current events. She is unable to subtract two
-
digit
numbers in her head. The remainder of her examination is
normal.

Case 2


A 50 year
-
old male is seen in your office with the
complaint of multiple episodes of visual blindness
in his left eye. The episodes are brief lasting
seconds. The patient has no eye pain during the
events and feels fine otherwise. He has a past
history of angina. Based on history alone you
suspect;

Case 5


A 63 year
-
old patient presented with a stroke that caused
weakness in his left face and upper arm which, for the
most part has resolved after 3 days. Currently you find
that he is still demonstrating some dysprosody and has
some difficulty recognizing familiar objects. You show him
a pen, a key, and a paper clip and the patient holds them
in his hands and is still unable to name them. You suspect
a visual and tactile agnosia. The requirements for making
this diagnosis are all of the following except:

Case 2

Case 6

Case 2


Hemiballismus

is an unusual condition characterized by an
abrupt onset of violent fleeting movements affecting the
limbs, neck and trunk on one side of the body. The most
common etiologic diagnosis causing this disorder is:



A.

Neoplasm


B.

Trauma


C.

Vascular


D.

Degenerative


E.

Inflammatory


A 38
-
year
-
old man who has progressive difficulty
concentrating on his job comes to medical attention
because of irregular, jerky movements of his extremities.
A sister and an uncle died in mental institutions. A
younger brother currently has similar symptoms. His
mother became demented in her middle age.

Case 1


A 64
-
year
-
old male presents with frequent falls. He has
Parkinson symptoms (resting tremor,
bradykinesia
,
cogwheel rigidity). You notice the patient has reduced
voluntary eye (upward) movements and keeps his neck
rather rigid and extended. More importantly the patient
is falling with out warning and has trouble keeping his
balance. When placed on L
-
dopa (
Sinemet
) he had only a
slight improvement.


Case 2


A 72
-
year
-
old retired engineer became acutely confused and disoriented.
Symptoms resolved as mysteriously as they started. Over the next 3 years, he
gradually became depressed and socially withdrawn and had progressive short
-
term memory impairment and repetitiveness. During this time, he would
occasionally have visual hallucinations associated with periodic
confusional

states.
His gait deteriorated, and he developed postural instability with
retropulsion

and
stooping. There was no response to a trial of
carbidopa
/levodopa (
Sinemet
).


Examination was notable for symmetric
parkinsonian

features, masked facial
expression, and postural tremor in his hands. Mental status examination revealed
profound impairment in delayed recall, with no benefit from cues or practice
trials.


Brain MRI demonstrated atrophy; EEG showed diffuse slowing. Trials of various
SSRI agents, H2 blockers for reflux and neuroleptics caused delirium. The patient
continued this downward, fluctuating course until his death in a nursing home 7
years later.


Case 3


A 60
-
year
-
old woman with a history of hypertension has been brought to
the family doctor because her husband “thought she needed to be
checked.” The patient reported that nothing was wrong with her and that
her husband had always been overly protective. Her husband reminded
her that she had had trouble driving recently, getting lost on several
familiar streets, and that at a recent reunion; she had been unable to recall
friends. She was unable to handle normal household budget, leaving bills
unpaid. Recently she is not taking usual care in dressing. The patient
responded that he “was making mountains out of anthills.” The patient
also thought that the house had been recently burglarized and that people
were watching the house. Except for a long history for gout and an ulcer
many years ago, the patient has no history of medical problems. The
patient takes no medication. Physical examination and Neurological
examination were normal except that the patient was making frequent
paraphasic errors. She could not recall any of 3 simple objects. She is aware
of the clinic name but not the town and says it is “fallish” in 1982.


Case 4

Case 5


A 55
-
year
-
old man, premorbidly described by his family as “thoughtful, accomplished, and
intelligent,” began neglecting his home and work responsibilities over a 2
-
year period. He
became increasingly inflexible and uncaring. At work he missed several deadlines, and clients
complained that he “forgot” about them. Consequently, he stopped working. He became more
impulsive, driving late at night without reason. He obsessively checked his furnace numerous
times each day and night, unconcerned about this safety risk.


His wife became increasingly tearful and anxious, whereas he seemed unaware of her turmoil
and his change in personality. The patient’s personal hygiene declined; he stopped shaving and
dressed sloppily. At social functions, he interrupted conversations, touched people
inappropriately, and spoke in a tasteless and loud fashion, often embarrassing his wife. Despite
these changes, he continued to garden and perform other favored activities, albeit with less
attention to detail.


Examination results revealed a malodorous and unshaven man with disheveled clothes. He
spoke out of turn and was repetitive, stating, ‘I have to go.” At times he attempted to leave the
examination room but returned with gentle coaxing. His affect was otherwise flat. He gave
concrete, terse responses to questions, mostly affirmative, negative, or stating, “I don’t know.”
Naming was impaired. He followed some simple commands, but more complex sequences
were incomplete or disorganized. His memory was relatively intact, although retrieval of
relatives’ names was impaired. He listed only 5 animals in 1 minute, a significant impairment
given his postgraduate education level. Other than motor impersistence and mild rooting reflex
bilaterally, the results of the neurologic examination were relatively unremarkable. Over the
next 2 years, the patient became increasing withdrawn, spoke less, and required prompting for
virtually every activity.

Case 6


A 70
-
year
-
old man presented with a 3
-
year history of
progressive memory loss, which mainly affected his short
term memory. He needed his daughter to remind him of his
appointments and some day
-
to
-
day activities. He had
problems with driving alone as he became confused with the
routes, though he had used them for a long time. He could
not manage his bills as usual. The physical examination was
unremarkable. The Mini Mental State Examination (MMSE)
was 20 out of 30.


Case 7


A 65
-
year
-
old man with hypertension, diabetes mellitus, and
coronary artery disease developed sudden left hemiparesis
and dysarthria 6 months ago. Three months later, his wife
noticed that he could not name the only two grandchildren
he had and could not remember to take his medications. He
could neither operate a remote control nor cook meals as
usual. On examination, there was only slight pronator drift
on his left arm and hyperreflexia of the left extremities.


Clinical features

VaD

AD

History of atherosclerotic
disease

Transient ischemic attack,
strokes, atherosclerotic risk
factors eg., DM, HBP

Less common

Onset

Sudden or gradual

Gradual

Progression

Slow or stepwise progression

Slow, progressive decline

Neurological examination

Neurological deficits

Normal

Gait

Often disturbed early

Usually normal

Memory

Mild impairment in early phase

Prominent in early phase

Executive function

Marked impairment and early

Impaired later

Type of dementia

Subcortical

Cortical

Neuroimaging

Infarction or white matter
lesions

Normal or hippocampal atrophy

Muangpaisan W, Seven steps for internists in evaluating cognitive impairment before performing laboratory investigations.
Intern Med J Thai 2005;21:151
-
61.

Clinical Differences Between Vascular Dementia and Alzheimer's
Disease

Case 8


A 72
-
year
-
old man with a 6
-
month history of
cognitive impairment and visual hallucination
presented to an emergency room after repeated
falls a few days ago. His wife felt that he had been
slow in thinking, speaking, and performing his
routine activities for a few months. On
examination, he had bilateral rigidity, parkinsonian
gait, and masked face. No history of medication
could be elicited.


Clinical features

DLB

AD

Isolated memory impairment

93.8%

31.3%

Parkinsonism

More common

Less common and usually
develops later in the course

Psychiatric symptoms

More likely to occur with dementia
symptoms early in the course

Less likely

Fluctuation of cognitive function

50
-
75%

When delirious

Verbal memory

Better

Worse

Type of memory impairment

Semantic memory

Episodic memory

Executive function

Poor early in the course

Less severe in the early phase

Attention, visuospatial function,
construction abilities

More impairment

Less impairment

Visual hallucinations

Common since early phase

Less prominent in early course

Autonomic involvement

Common

Less common

Neuroleptics response

Extrapyramidal side effect; may
cause death

Behavioral response

Clinical Differences Between Dementia With
Lewy

Bodies and Alzheimer's
Disease

Muangpaisan W, Seven steps for internists in evaluating cognitive impairment before performing laboratory investigations. Int
ern

Med J
Thai 2005;21:151
-
61
.

Clinical features

DLB

PDD

Tremor

Less common

Common

Motor symptoms

Bilateral

Unilateral predominant

Axial Predominant ie., postural instability,
gait difficulty and masked face

Common

Less common

Parkinsonism at diagnosis

25 to 50%

100%

Response to Levodopa

Poor

Good

Cognitive impairment

Before or within one year of
motor symptoms

Usually developed after motor
symptoms 4
-
5 years (at least 1 year)

McKeith

I, et al. Dementia with
Lewy

bodies. Lancet Neurol. 2004;3:19
-
28.

Clinical Differences Between Dementia With
Lewy

Bodies and Parkinson’s
Disease

Case 9


A 50
-
year
-
old woman presented with behavioral change
over the course of two years. She had less concentration to
accomplish her assigned tasks and was less responsible to
her job. She had begun eating more and had gained 20
pounds in 5 months. She told lies and dirty jokes, stole office
stationary, and picked up objects within reach and sight. She
had poor personal hygiene and refused to take a bath. Apart
from grasp, and palmomental reflexes, the physical
examination did not reveal any other abnormality. Her
MMSE was 29/30, but her performance on the clock drawing
test was poor.


Clinical Features

FTD

AD

Age at onset

Rarely > 75 years

Increased markedly with age

Early behavioral problems

Common

Unusual

Socially inappropriate behaviors

Common early in the course

Usually in severe case

Memory impairment

Less prominent in early course

Early and profound impairment

Language problems

May have isolated language problems
without memory impairment

Usually associated with memory
impairment

Visuospatial defect

Rare in mild to moderately impaired
case

Common

Motor signs

More common (in FTD with motor
neuron disease

Less common

Mood


Marked irritability, anhedonia,
withdrawal, alexithymia (difficulties in
understanding, processing, or
describing emotions), euphoria, lack
of guilt, apathy or suicidal ideations

Sadness, tears, anhedonia, apathy, guilt

Psychotic features

Rare persecutory delusions, usually
jealous, somatic, religious, and
bizarre behaviors

Usually have delusion of misidentification
or persecutory type and usually occur in
middle or late stage

Appetite, dietary change

Increased appetite, carbohydrate
craving 80%, weight gain

Less common: anorexia and weight loss

Clinical Differences Between
Frontotemporal

Dementia and Alzheimer's
Disease

Muangpaisan W, Seven steps for internists in evaluating cognitive impairment before performing laboratory investigations. Int
ern

Med J Thai
2005;21:151
-
61.

Case 3


A 54
-
year
-
old man presents with a several
-
month history of progressive dementia,
apathy, dysarthria, tremor, and myoclonus.

Case 3


This 45
-
year
-
old male who is undergoing
immunosuppression for Hodgkin disease presents in your
office with a 3 week history of personality change and
intellectual impairment. He noticed over the past 24 hours
he has problems with his vision, stumbling and occasionally
is confused. His vital signs are normal and a left homomous
hemianopia and ataxia is noted. He has dysmetria bilaterally
upper and lower extremities.

You suspect a
subacute/chronic viral infection complicating his
immunosuppression therapy.

Case 2



A 78
-
year
-
old man was brought to the sleep specialist by
his wife for episodes of disturbed sleep. His wife had
recently noted him yelling or kicking in his sleep. On
several occasions, he seemed to try to get out of bed.
Once she had to wake him because he was punching her,
completely contrary to his character and past behavior.
When she woke him after this episode, he told her that he
had dreamed that someone was trying to attack him. His
wife reported that recently her husband had also been
having difficulty with memory loss. An all
-
night sleep test
demonstrated abundant tonic muscle activity during REM
sleep.


A 58
-
year
-
old man who is a former boxer develops
symptoms of dementia associated with
psychomotor slowing. The symptoms did not
develop until more than 10 years after cessation of
the boxing.

Case 3

Case 5


An 80 year
-
old
-
male was seen by you in the ER.
The patient and family states the patient has
been unsteady and falling but is able to get up
with help and return to his previous state of
function. Your exam revealed a history of
incontinence and a progressive decline in
mentation associated with a wide based
apraxic

gait. Your exam reveals hyperactive bilateral
DTRs, a dementia like state, an
apraxic

gait,
incontinence and bilateral papilledema.

Case 7

A retired NFL football player developed
memory difficulties, mood fluctuations varying
from depression to rage. At times he has
inappropriate behavior associated with
hypersexuality. During his career he
experienced 20 documented concussions.

Case 3

A 52
-
year
-
old “street person” who has been living out

of a cardboard box in a city park for the past 5 years

after loosing everything in the stock market. He

presents with a global confusion, ataxic gait,

horizontal nystagmus, and conjugate gaze palsies. He

looks emaciated and is known to consume alcohol

when he has the money. His BP is 100/60, normal

respirations, somewhat agitated and unable to follow

commands.

Case 9

This 80
-
year
-
old edentulous female presents with a

sensory ataxia,
paresthesias
, impaired memory, fecal

incontinence, and evidence of neuropathy and spinal

cord dysfunction. She has noted that at night she has

to keep a light on to prevent falling when going to the

bathroom. She is being treated for a hiatal hernia and

chronic gastritis for the past 10 years. She has been

unable to eat food that she has to chew because she

cannot afford dentures. Her exam revealed a mild

dementia, decreased proprioception and vibration in

the lower extremities, absent ankle reflexes and

positive bilateral Babinski's and a positive Romberg

test.

Case 11

A 24 year
-
old
-
female is found in here garage

with the car running. You see her in the ER

initially unresponsive after administering

oxygen she becomes lethargic then confused,

complaining of
headache, nausea, dyspnea.

Assuming she survives and your diagnosis

was correct.

A 50
-
year
-
old man experienced the sudden onset of vertigo. Examination
revealed dysarthria, difficulty in swallowing, a left Horner’s syndrome, left
palatal weakness, and loss of pain sensibility over the left face and the right
limbs and trunk. He had coarse ataxia and in
-
coordination of his left arm.

Case 3

Case 10


A 72
-
year
-
old woman with history of hypertension noticed
tingling in her right arm. Within 30 minutes, her right leg buckled
and she fell. Her husband helped her up. She was able to walk
without support. She rested, but within an hour, she noted
speech difficulties and more definite right
-
sided weakness.


She was brought to the ED and was noted to have mild right arm
weakness and some word
-
finding difficulties. Her blood pressure
was 140/80 mm Hg. She got up to go to the bathroom, walked
approximately 10 ft, and collapsed on the floor. She was then
globally aphasic, with left gaze deviation (i.e., paralysis of gaze to
the right) and right hemiplegia. Within 10 minutes, she became
unresponsive.

Case 11


A 58
-
year
-
old woman with substantial history of arterial
hypertension presented to the ED with a 1
-
hour
duration of acute
-
onset headache, gait unsteadiness,
and left arm incoordination.


On examination, the patient was alert and oriented but
had left
-
sided
dysmetria
, gait ataxia, and left
-
sided CN
-
VI and CNVII palsies. Her BP was 200/110 mm Hg.



A 64
-
year
-
old male presents with frequent falls. He has
Parkinson symptoms (resting tremor,
bradykinesia
,
cogwheel rigidity). You notice the patient has reduced
voluntary eye (upward) movements and keeps his neck
rather rigid and extended. More importantly the patient
is falling with out warning and has trouble keeping his
balance. When placed on L
-
dopa (
Sinemet
) he had only a
slight improvement.


Case 2


A 60
-
year
-
old woman develops paroxysms of sharp stabbing pain in
her right malar area and upper lip, gums, and teeth. Each attack lasts
a few minutes and is comparable in abruptness and severity to pain
produced by a tooth being drilled. It is precipitated by brushing the
teeth and by eating, so that over several weeks she has lost nearly
10 pounds. The pain never spreads beyond the region described,
and between attacks she is symptom free except for fear of
recurrence, which occurs many times throughout the day. Low
potency analgesics do not prevent the attacks.


During examination, brief convulsive movements of her face and jaw
accompany an attack of pain, and the physician is able to trigger the
pain by lightly rubbing her face with a tongue blade. The
neurological examination is otherwise normal.


Case 1


A 30
-
year
-
old woman is seen with new
-
onset
bilateral asynchronous trigeminal neuralgia. It
began without warning 5 days ago and over
-
the
-
counter medications is not relieving the pain. She
has no other complaint and her history and
examination confirms trigeminal neuralgia.


Case 2

Question


Symptomatic trigeminal neuralgia often occurs with
which of the following medical problems?


A 55
-
year
-
old right
-
handed male is seen in the ER due to sudden weakness
in his right hand and face while mowing his yard. He had no pain at the
onset and was alert and had fluent speech. His only noticeable problem was
weakness of his left hand and face. The symptoms cleared after 45 minutes.


Case 5

Case 9



A 75
-
year
-
old man complains of “blurred vision” in his left eye. The
symptoms began several days ago and have progressed slowly. There is
no eye pain. He also complains that he has been unable to chew meat
because of pain in his jaw. With glasses he is barely able to count fingers
with the left eye, but right eye visual acuity is normal. He has a left
afferent pupillary defect and a swollen left optic disk. The remainder of
his examination is normal.








A 76
-
year
-
old man complained of dull, left
-
sided head pain
with some radiation of the discomfort to the right side of the
head. He had no nausea or vomiting with the pain, but had
lost 10 pounds over the previous 2 months. His erythrocyte
sedimentation rate was 102 mm/hr, and he was mildly
amenic. An extensive investigation for malignancy revealed
no signs of lymphoma, carcinoma, or leukemia.


Case 4

Case 4


A 50
-
year
-
old male involved in a fall at home. He
struck the side of his head on the wooden arm of
a chair during his fall. The patient seemed fine
except he complained of a headache. Tylenol did
not relieve it and the patient did not want to go
to the ER. His wife insisted and by the time he
arrived 1 hour later he seemed somnolent and
had nausea which he attributed to a ham and
cheese sandwich he had eaten earlier. Your
examination revealed a mild weakness of his left
arm. No other localizing neurological deficits
were noted.

Case 1

A 72
-
year
-
old man presented with distal paresthesias, more

pronounced in his hands than in his feet, unsteady gait, and

frequent falls. His family noted some memory loss of unclear

duration.

On examination, he was oriented to self and place but not to

month or year. He immediately registered 3 items, but recalled

only 1 item at 5 minutes with clues provided. Visual acuity was

poor. On motor examination, he had 4/5 lower extremity strength.

His gait was broad based, spastic, and ataxic. Romberg sign was

positive. He had loss of vibratory sense in the legs, absent

position sense in toes, and hyperesthesia to pinprick in distal

extremities. Muscle stretch reflexes were normal. Babinski

signs were present. The patient’s hematocrit was 29%, with a

mean corpuscular volume of µm3. Vitamin B12 level was 34

(reference range, > 190pg/mL).


A 26
-
year
-
old graduate student presents to the emergency
room with a severe left
-
sided throbbing headache,
associated with nausea, vomiting, and photophobia. She has
tried taking ibuprofen without relief. On further questioning,
she relates that she has been having similar headaches 3 to 4
times per month for the past year. Her mother had a similar
problem. Her examination is normal.

Read case to get pharm answer for
headache pharm

Case 2

A 12
-
year
-
old girl presented with difficulty running and

standing stationary and frequent stumbling. General

examination demonstrated scoliosis and pes cavus. On

neurologic examination, the patient had truncal and

gait ataxia, a positive Romberg sign, areflexia, and

extensor plantar responses.

Case 6

A 23
-
year
-
old man presents with a 7
-
year history of arm and vocal

tremor. The tremor became more noticeable with action and

posture, it never occurred at rest. His gait changed as well with

mild unsteadiness, and he experiences a slight tremor of his head

when walking. Your examination reveals a
dysarthric

scanning

and slightly slow speech accompanied with a vocal tremor. A mild

hypotonia

without cog
-
wheeling or
bradykinesia

on motor exam.

Rapid alternating movements were mildly uncoordinated, with

dysdiadochokinesis

and
dysmetria

was seen. Sensory and DTR

exam was normal. Routine laboratory findings include low platelet

count 100,000 (N
-
165
-
415). Total bilirubin 2.7mg/dl (N 0.30
-
1.30)

and direct bilirubin 0.8 mg/dl (N 0.04
-
0.38) were mildly elevated.

The remainder of the routine chemistry and hematology studies

were normal. An abdominal ultrasound revealed mild

hepatomegaly and marked splenomegaly.

Case 9

This 80
-
year
-
old edentulous female presents with a

sensory ataxia,
paresthesias
, impaired memory, fecal

incontinence, and evidence of neuropathy and spinal

cord dysfunction. She has noted that at night she has

to keep a light on to prevent falling when going to the

bathroom. She is being treated for a hiatal hernia and

chronic gastritis for the past 10 years. She has been

unable to eat food that she has to chew because she

cannot afford dentures. Her exam revealed a mild

dementia, decreased proprioception and vibration in

the lower extremities, absent ankle reflexes and

positive bilateral Babinski's and a positive Romberg

test.

Case 5


A 20
-
year
-
old college student is seen by you after
experiencing a focal seizure while hiking alone in
Yellowstone National Park, involving the left leg, lasting 1
minute. Followed by a headache that resolved over
night. When he made it out of the woods he came to the
nearest ER. History is significant for migraine headaches,
one or two a month which he treats with
triptans
, an
unenhanced CT scan 1 year ago after a severe status
migrainosus

was normal. no prior seizures, drug use, or
trauma. He feels fine now and there is no neurological
deficit.

Dr. Carlson


5 questions

1)
Voluntary movement: both gamma and alpha motor neurons are activated
simultaneously by descending commands during voluntary motor movements.

2)
What would happen to stretch reflexes if you lose type
Ia

primary afferents?

I
don’t know, but they respond to the rate of change in muscle length as well as
the raw change in muscle length. In other words, they carry both static and
dynamic info. MY GUESS is that you would be
HYPOreflexive
. NOT SURE
THOUGH.

3)
I have no idea what the other 3 questions will be.


Dr. Towns


12 questions

1)
Where would the lesion be if you can hold something in your hand but can’t
identify it?
Stereognosia
.
Stereognosis

tests determine whether or not the
parietal lobe of the brain is intact. Or somewhere in the dorsal columns
-
medial
lemniscus

pathway.

2)
Differences between dominant and non
-
dominant hemisphere control.

1)
Non
-
dominant hemisphere:
agnosia
, apraxia, others…

2)
Dominant hemisphere: speech


APHASIA (speech problem).

3)
Aphasias: Question about disconnection syndrome. Answer is probably along
these lines: Poor repetition but fluent speech, intact comprehension. The lesion
is in the ARCUATE FASCICULUS that connects
Broca’s

and Wernicke’s areas. (see
page 404 in 2011 First Aid)

4)
What arteries are affected if you have hypertension and then have a stroke?
Didn’t hear all these but I know middle cerebral artery was one of the options.

5)
Know in details what happens in an infarction of the internal capsule.

6)
I don’t know anymore of the questions.



The pharmacology guys


3 from Dr. Theobald on Headaches and
6 from Dr.
Middlemas

(Info from Erin
Majchrzak



Thanks)

Acute
Headache Treatment

Triptans
: constricts dilated cranial vessels outside the CNS by stimulating 5
-
HT receptors;
stimulates 5
-
HT receptors on trigeminal vascular neurons

Ergot Alkaloids (Ergotamine): agonists of alpha
-
1 and 2 adrenergic receptors and 5
-
HT receptors to
reduce amplitude of pulsations of cranial arteries

Isometheptene
: mild
symphathomimetic

vasoconstrictor

NSAIDS: inhibit synthesis of prostaglandins and autacoids; for migraines and tension HA

Prophylaxis Headache Treatment

5
-
HT antagonists (
Methysergide
,
Cyproheptadine
)

Methysergide
: potent serotonin receptor antagonists,
vasoconstricts

cranial vessels

For prophylactic of migraine and vascular headaches

Cyproheptadine
: 5
-
HT2 antagonist, H1
-
antagonist, weak anti
-
cholinergic and depressant

For receptor blocking activity

Beta Blockers (
Propanalol
): unclear
MoA

Tricyclic Antidepressants (
Amitryptyline
):unknown
MoA

For migraines and chronic tension headaches

Calcium channel blockers: inhibit vascular smooth muscle by inhibiting Calcium influx

For migraines and vascular cluster HA

Lithium: unknown
MoA
; may inhibit enzymes involved in signal transduction of 5
-
HT3 receptors

For chronic cluster HA and episodic type HA

Corticosteroids: related to prostaglandin synthesis; suppress inflammation

For ACUTE and PROPHYLAXIS of chronic or episodic cluster HA

The pharmacology guys


3 from Dr. Theobald on Headaches and
6 from Dr.
Middlemas

(Info from Erin
Majchrzak



Thanks)

Parkinson Drugs

Dopamine Agonists: first line drugs;
Pramipexole
,
Ropinivole
,
Apomorphine

Levodopa: converted to dopamine in striated neurons (presynaptic
terminals)

SE:
dyskinesias
, nausea, vomiting, postural
hypotensions
, psychosis

Carbidopa
: inhibits
decarboxylating

enzymes in intestines and peripheral
tissues

SE: dyskinesia and psychiatric problems sooner

COMT Inhibitors (
tocapone

and
entacapone
): blocks peripheral conversion
of L
-
dopa

Anticholinergic Drugs: second line; better tolerated, for young patients

Trihexyphenidyl

and
benztropine
: block M receptors in striatum to
reduce tremor and rigidity

Amantadine: second line; inhibits
dopa

uptake, stimulates
dopa

release,
blocks cholinergic and glutamate receptors


The pharmacology guys


3 from Dr. Theobald on Headaches and
6 from Dr.
Middlemas

(Info from Erin
Majchrzak



Thanks)

Alzheimer’s Disease

AChE

Inhibitor Agonists (cross BBB, for mild to moderate disease)

Tacrine
: poor oral availability,
Hepatatoxic

SE: nausea, vomiting, salivation, sweating,
bradycardia
,
hypotension, fainting

Donepezil: selective for
AChE
, modest effects; good oral
availiability

Often combined w/
Memantine

SE:
bradycardia
, nausea, diarrhea, anorexia, ab. pain, vivid dreams

Rivastigmine
:
AChE

and
BChE

inhibitor; best for those w/hallucinations

SE: nausea/vomiting


they’re much worse

Galantamine

Hydrobromide
: high death rate, so not often used

NMDA Receptor (glutamate) antagonists: induces receptor activation and
thus Calcium in cell death, also causes a release of extra glutamate

Memantine
: for moderate to severe disease, is uncompetitive w/a
moderate affinity for NMDA

Has a fast on and off when glutamate activates the receptor;
blocking pathological levels w/maintaining physiologically needed
glutamate activity

Often combined w/Donepezil

SE: dizziness, HA, confusion

Drugs for Epilepsy and Seizures

Types
of Seizures

Tonic
-
Clonic

(grand
-
mal): tonic rigidity followed by
clonic

jerking, loss of consciousness

Carbamazepine, Phenobarbital, phenytoin,
primidone
, valproate

Absence (petit
-
mal): sudden onset, abrupt cessation, altered consciousness

Ethosuximide
, valproate

Simple Partial: focal process, alert during seizure

Carbamazepine, valproate, phenytoin

Complex Partial: localized onset, widespread, automatism, amnesia from event

Carbamazepine, valproate, phenytoin

Myoclonic: series of jerky contractions

Valproate

Status
Epileticus

Lorazepam
, Diazepam

Sodium Channel Blockers

Phenytoin: for tonic
clonic
, simple and complex partial and status
epileticus
; not during pregnancy

Locasamide
: adjunct to partial onset seizures; dizziness

Lamotrigine
: single and complex partial, absence, myoclonic, tonic
-
clonic

Fine for pregnancy, dizziness

Zonisamide
: for complex partial, tonic
-
clonic

and in combo w/others; dizziness, kidney stones

Calcium Channel blockers

Ethosuximide
: absence, combined w/others; causes nausea, GI effects, drowsiness, anorexia

GABA + modulators

Phenobarbitol

(also agonist): for partial seizures and tonic
-
clonic
; sedation

Primidone

(also agonist): same as
phenobarbitol
; sedation

Lorazepam
: status
epileticus
; drug of choice for this syndrome; drowsiness, tolerance development

Diazepam: same as
lorazepam

Clonazepam: for absence and myoclonic seizures

Multiple
MoA

Cabamazepine
,
Oxcarbazepine
: tonic
-
clonic
, simple and complex partial; SLE, drowsiness, tolerance can quickly
develop

Valproic

acid: absence, tonic
clonic
, myoclonic, simple and complex partial; hepatic failure

Topiramate

(NA channel blocker/GABA modulator): obesity, tonic
-
clonic
, partial complex