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Let’s break this down

Let’s break this down. Neuroscience: 20/180 Geriatrics + Ethics + immunology: 60/180 Faster to learn Straightforward What is 1 MEQ then? 20/180 =0.11 0.11/2*100 = 5.56 (assuming MEQ is 50%) 5.56*60/100 = 3.33 MARKS for THEORY MD2140. So….

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Let’s break this down

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  1. Let’s break this down • Neuroscience: 20/180 • Geriatrics + Ethics + immunology: 60/180 • Faster to learn • Straightforward • What is 1 MEQ then? • 20/180 =0.11 • 0.11/2*100 = 5.56 (assuming MEQ is 50%) • 5.56*60/100 = 3.33 MARKS for THEORY MD2140

  2. So…. • If you haven’t finish stuff like systemic patho or pharmaco, and have no time to do neuroscience • Ditch it • Or just study stroke and hope you luck out • Go learn why old people are prone to falls

  3. However… • If you got spare time and are already ethical • Neuroscience is FUN • It’s more understanding and less memorizing • If you are memorizing more than you understand, you are doing it wrong • I’m NOT talking about the ‘HOW DO YOU _____’ lectures • It forms the corner-stone of every neuro-exam you gonna have in clinical years. • It’s gonna be super important in future. But maybe not for M2 pros.

  4. Drugs Used in CNS

  5. PharmaQns • Mode of Action • Indications • Side Effects

  6. Drug Types • Anxiolytic + hypnotic • Anti-depressant • Anti-psychotic • Examples?

  7. Anxiolytic + Hypnotic • Benzodiazepine (BZD) • Short acting: Midazolam • Intermediate acting: Lorazepam, Alprazolam • Long Acting: Diazepam

  8. Benzodiazepine (BZD) • Mode of Action?

  9. Benzodiazepine (BZD) • Mode of Action • Binds to specific BZD sites in the CNS and potentiates GABA (an inhibitory neurotransmitter) action by increasing frequency of chloride channel opening • Increase Cl- Influx • Increase neuron hyperpolarization • Sedation • Drug action dependent on GABA • OD doesn’t kill

  10. Benzodiazepine (BZD) • Indications? • Think of 3

  11. Benzodiazepine (BZD) • Indications • Convulsion, seizure (IV) • Anxiety disorder • Insomnia • ‘Date-rape’

  12. Benzodiazepine (BZD) • Side Effect? • Think of 3 classes and some examples

  13. Benzodiazepine (BZD) • Side Effect • CNS: • increase sedation • decrease motor skills • slower reaction time • Anterograde Amnesia (esp with IV) • CVS • Decrease BP, decrease respiration rate • Paradoxical symptoms • Hallucination, irritability, violent tendency, excitement • Floppy Child syndrome (contra-indicated in pregnancy) • TOLERANCE, DEPENDENCE, WITHDRAWAL

  14. Non-BZD hypnotics • Zolpidem, Zopiclone

  15. Depression • Theory for Depression: • Deficiency in monoamines in the synaptic cleft • Deficiency of neurotransmitters to effect it’s action on the post synaptic membrane

  16. Anti-depressants • 2 types?

  17. SSRI • MOA? • Related to the name

  18. SSRI • MOA: • Binds to serotonin reuptake transporter in the presynaptic cell membrane • Increase concentration of serotonin in the synaptic cleft • Name: Fluoxetine, escitalopram • OD WILL NOT DIE!!!

  19. SSRI • Adverse Effect? • Think of 3

  20. SSRI • Adverse Effect: • Anxiety • Weight loss/gain • Headache • Sexual dysfunction

  21. TCA –amitriptyline, imipramine • TCA blocks both serotonin reuptake transporter and norepinephrine reuptake transporter • Gold standard treatment • BUT OD can lead to death • Depressed people tend to want to die more • Easy way to commit suicide

  22. TCA • Side Effect: • Cardiac rhythm: Tachycardia, arrhythmia • Postural hypotension • Anticholinergic effects • CNS: sedation, fatigue

  23. Antipsychotics • Broad classes? • Mode of action?

  24. Antipsychotic - Haloperidol • Typical antipsychotic • Blocks: • Dopaminergic receptors • Serotonic receptors • Histaminic receptors • Cholinergic receptors • Alpha adrenergic

  25. Haloperidol • Side effects?

  26. Haloperidol • Side effect: • Extrapyramidal side effects: • Acute dystonia • Parkinsonism • Akathisia • Malignant syndrome • Tardive dyskinesia

  27. CNS Pathology

  28. Quick Start • What’s the mean ICP? • 7 to 15 mmHg • How much blood does the brain need? • 150ml/100g/min • What can cause acute rise in ICP? (think of 2) • Hemorrhagic stroke, Intracranial Hemorrhage

  29. Quick Start • What can cause gradual focal deficits and also increase in ICP? (Think of 2) • Tumor, infection • What are the 2 different types of hydrocephalus? Name 2 etiology of each. • Non-communicating vs communicating • NC: SOL(medulloblastoma), meningitis (TB meningitis, scarring), congenital (Arnold Chiari malformation) • C: Subarachnoid hemorrhage, NPH, meningitis • What are the presentations and complications of raised ICP? • Papilloedema, headache, nausea, HERNIATION (most dangerous form of herniation is?)

  30. Keep going… • What are the 4 most common tumors in children? Where are they found? • Medulloblastoma (posterior fossa/infratentorial) • Pilocytic Astrocytoma (Glioma, anywhere in the brain parenchyma) • Ependymoma (para/intra-ventricular) • Germ Cell tumor (Mid-line) • What are the presentation of a slow-growing Meningioma? • SOL • Focal deficits and raised ICP • What type of CNS tumor (that we’ve learned) cross the midline and forms a butterfly shape lesion? What grade is it? • GlioblastomaMultiforme (Grade IV)

  31. Keep going… • What must you suspect if you find primary lymphoma in the brain? • HIV • Immunosuppression • What can be the possible diagnoses when there are multiple SOL in the brain? • Lymphoma, Abscess, METASTASIS • What are the acute, chronic, and pregnant complications of drinking alcohol? (Name 1 each) • Acute: Respiratory depression -> Death • Chronic: cerebellar atrophy, cortical atrophy, Wernicke’s encephalopathy, Korsakoff syndrome • Pregnant: fetal alcohol syndrome (growth retardation)

  32. Almost there… • What histological changes of the brain can you see in Alzheimer’s disease? • Amyloid plagues / Neurofibrillary tangles (tau protein in neurons) • These cannot be digested. Leads to reactive gliosis and neuronal damage and progressive cognitive decline • Which lobe is most affect in AD – Smaller, atrophied brain? • Temporal Lobe • What are the clinical features of Parkinson’s Disease? • TRAP – asymmetric • Mask-like face • Gait abnormality • Respond to LevoDopa (for 5 to 7 years)

  33. Almost there… • What are the 2 broad groups of meningitis? • Bacterial vs Aseptic • What’s the difference in Cell/Glucose/Protein? • What are the top 3 cause of meningitis in neonates? • E coli, Listeria monocytogenes, Streptococcal agalactiae • What are the other few bacteria that cause meningitis in pediatrics? (young children) • Nisseriameningitidis, Streptococcal pneumonia, Hemophilus influenza type B • THEY ALL HAVE CAPSULE!!!!!!!!!

  34. HYPERTENSION AND IT’S ASSOCIATED HYPERTENSIVE CEREBRAL VASCULAR DISEASE IS IMPORTANT!!!!!!!

  35. Localising Lesions

  36. Revision • DCML • Spino-thalamic • Corticospinal • Spino-cerebellar • General route, Decussation, Function?

  37. UMN VS LMN • What is UMN and LMN? • How does it help in localizing the level of the lesion? • Understand: Inverted supinator jerk and Inverted knee jerk • Where is the level of the lesion?

  38. UMN vs LMN • Inverted Supinator Jerk • Weak biceps jerk (C5, 6) • Weak brachioradialis jerk (C5,6) • Brisk triceps Jerk (C7, 8) • (Brisk flexion of the fingers) • Will this guy be able to breathe? • Inverted Knee Jerk • Weak knee jerk (L3) • Brisk ankle jerk (S1)

  39. What’s wrong with this guy?

  40. Brown Sequard Syndrome • Where is the Lesion? • T2 to L2 • How to narrow down further? • Strength of Hip Flexion • Cremasteric reflex • Superficial Abdominal Reflex • What are the OTHER clinical signs? • UMN signs… WHICH SIDE? • Loss of proprioception and touch… WHICH SIDE?

  41. Brown Sequard Syndrome • Hemisection of the spinal cord • What are some SOL in the spinal cord that can cause hemicord syndrome? • Tumor (meningioma, lymphoma), Abscess • Can syringomyelia/hydromyelia cause brown sequard?

  42. Revision • What is somatotopy? • Of the Brain • Of the Spinal Cord

  43. Ascending weakness • What are the causes of ascending weakness? • Guillain-Barre syndrome • Myelopathy (compression, vascular, inflammation) • What are some microbes that can cause Guillain-Barre syndrome? • Campylobacter jejuni • CMV • Influenza • Varicella • How will a syringomyelia present? (usually grows laterally and anteriorly)

  44. Stroke • What are the 2 different type of infarct? • “An artery can either _____ or ______.” • What are the risk factors for each? (name at least 5) • What are the etiologies? (at least 2 for each)

  45. Stroke • Ischemic infarct vs hemorrhagic infarct • What are the risk factors? • Hypertension, Diabetes, hyperlipidemia, TIA, Hypercoagulable state, Atrial Fibrillation, RHD, Vascular malformations (Berry aneurysm, Charcot-Bouchard Aneurysm, AVM, moya-moya) • What are the etiologies? • Ischemic: Shock, acute plague change, thromboembolism • Hemorrhagic: Rupture of aneurysm, trauma, tumor, malignant hypertension

  46. Revision • What clinically important areas does the superior branch of the middle cerebral artery supply? • How about the inferior branch of the MCA?

  47. MCA • Superior • Frontal Lobe: Broca(left), FEF, Primary Motor Cortex(UL and Face) • Parietal lobe: Somatosensory cortex (UL and Face) • Inferior • Parietal lobe: Wernicke’s Area(left), Somatosensory cortex(UL and Face) • Parietal and Temporal Lobe: Optic Radiation(contralateral homonymous hemianopia) • Internal Capsule (lenticulostriate arteries, LL and lots of other stuff) • What about the PCA and ACA?

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