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A 74-year-old woman is admitted to the hospital after sustaining a severe left hemispheric ischemic stroke while alone at home. Her son found her collapsed in the living room when he went to visit her. The patient has hypertension for which she takes enalapril but no history of ischemic heart disease or heart failure. On physical examination, blood pressure is 190/105 mm Hg, pulse rate is 80/min, and respiration rate is 16/min. The patient has right hemiparesis, right facial droop, aphasia, and dysarthria. The remainder of the physical examination, including the cardiovascular examination, is normal. Results of laboratory studies, including serum creatinine level, are normal.A CT scan shows frank ischemic changes that occupy most of the left middle cerebral artery territory. An electrocardiogram and chest radiograph show normal findings. Which of the following is the most appropriate treatment of her hypertension at this time? • IV Labetalol • IV Nicardipine • Oral Nifedipine • Withholding of all antihypertensive medications
*If this is the only contraindication, try to reduce BP and then give tpa
Hemorrhagic Stroke • 17% strokes, with 50% intracerebral hemorrhage and 50% subarachnoid hemorrhage • Diagnosis: non-contrast CT; if negative and high suspicion for SAH LP (erythrocytes and xanthrocromia) ICH SAH “Worst headache ever” Complications: Rebleeding Vasospams Hydrocephalus • Complications • Hematoma expansion • Elevated ICP • Lower BP with IV labetalol or nicardipine if sBP >200 or MAP > 150 • Target BP 160/90 or MAP 110 • Hyperventilation, mannitol and Surgical evacuation for elevated ICP
An 82-year-old man is evaluated in the office for an episode of hesitancy in speech, word-finding difficulty, right facial droop, and weakness and awkwardness of the right hand and arm. The episode occurred early yesterday, lasted 20 minutes, and was witnessed by his wife. The patient has a history of coronary artery disease, hypertension, and hyperlipidemia. Current medications are metoprolol, aspirin, hydrochlorothiazide, and lovastatin. On physical examination, temperature is normal, blood pressure is 148/88 mm Hg, pulse rate is 70/min, and respiration rate is 12/min. Neurologic examination reveals no abnormalities. Which of the following is the most appropriate next step in management? • Add clopidogrel • Admit to the hospital • Order outpatient diagnostic studies • Schedule a follow-up visit in 1 week
TIA • Transient neurologic deficit without acute infarction • Risk of stroke at 90 days is 10% • Most stroke risk within first 48 hours, 5.3% patients at risk • Identify patients at highest risk of stroke with ABCD2 score. Hospitalize patients seen within 72hours of initial symptoms and whose score is at least 3.
A 38-year-old woman is evaluated in the office for a 10-month history of increasingly frequent headache. The headache is often worse in the morning on awakening. She has recently started keeping a headache diary, which reveals episodes on approximately 25 days of each month. The headache varies from a near-daily bilateral frontal dull throbbing to a severe left hemicranial throbbing associated with nausea, photophobia, and phonophobia. The patient has a 20-year history of migraine without aura and a history of depression. Her mother also has a history of migraine and depression, and her sister has a history of migraine. The patient has been taking propranolol for 3 months; a mixed analgesic containing butalbital, caffeine, and acetaminophen for mild or moderate headache at least 3 days per week for 9 months; rizatriptan for severe headache at least 2 days per week for 4 months; and citalopram for 1 year. Rizatriptan has become increasingly ineffective over the past month. Physical examination findings, including neurologic examination findings, are normal.Which of the following is the most likely diagnosis for her current symptoms? • Chronic migraine • Chronic tension-type headache • Idiopathic intracranial hypertension • Medication overuse headache
Headache Only image pt with headache if patient has a “red flag” for secondary headache: first or worst headache abrupt onset or thunderclap progression or fundamental change in headache pattern abnormal physical exam neurologic symtoms lasting longer than an hour new headache in pt <5 >50 years old new heache in pt with cancer/pregnant/immunosuppressed headache with LOC headache triggered by exertion, sexual activity or valsalva MRI is study of choice unless there is a skull fracture, acute SAH or ICH and paranasal sinus disease!
An 81-year-old man is evaluated for the gradual onset and progression of memory loss over the past year. He says he has difficulty recalling the names of familiar people, has misplaced his wallet on numerous occasions, and is slower to find his car in large, crowded parking lots. He continues to manage his finances, travel with his wife, and perform the activities of daily living without difficulty. He has borderline hyperlipidemia that is managed by diet alone. A paternal uncle developed Alzheimer dementia at age 74 years. His only medications are aspirin and a daily multivitamin. On physical examination, temperature is 36.7 °C (98.1 °F), blood pressure is 126/82 mm Hg, pulse rate is 68/min, respiration rate is 14/min, and BMI is 26. His level of alertness, speech, and gait are normal. He scores 26/30 on the Folstein Mini–Mental State Examination, losing all three points on the recall portion and one point on the orientation section for incorrectly stating today’s date. Results of a complete blood count, serum vitamin B12 measurement, thyroid function tests, and a basic metabolic panel are normal. An MRI of the brain without contrast shows no abnormalities.Which of the following is the most likely diagnosis at this time? • Alzheimer dementia • Dementia with Lewy bodies • Frontotemporal dementia • Mild Cognitive impairment • Vascular dementia
Dementia • MMSE < 22 indicates demetia • Alzheimer Disease: Insidious, progressive dz with significant impairment of normal daily functioning. Persistent forgetfulness is hallmark. • Cholinesterase inhibitors: donepezil, rivastigmine, galantamine • N-methyl-d asparte R antagonist: memantine
A 62-year-old woman is evaluated for a 1-year history of tremor that affects both upper extremities. She says that her handwriting has become sloppier since she first noticed the tremor and that she occasionally spills her morning coffee because of it. Although she feels otherwise healthy, she is concerned that she may have Parkinson disease. The patient has a history of hyperlipidemia controlled by diet and exercise but is otherwise healthy. Her mother, who died at age 79 years, had a similar tremor. Her only medication is a daily multivitamin. On examination, she has a mild tremor in the upper extremities that is present with the arms extended and during finger-to-nose testing. No resting tremor is apparent. Muscle tone and gait and limb coordination are normal. Administration of which of the following drugs is the most appropriate treatment of this patient? • Carbidopa-Levodopa • Clonazepam • Propranolol • Ropinirole
A 53-year-old woman is evaluated in the office for a 4-month history of tremor. The tremor affects both upper extremities and is present “most of the time.” She has a 15-year history of type 2 diabetes mellitus; she also has a history of hypertension, gastroparesis, and chronic kidney disease. Medications are insulin glargine, insulin lispro, lisinopril, hydrochlorothiazide, and metoclopramide. On examination, she has diminished pedal pulses. Speech, language, and mental status are normal. Cranial nerve function is normal, although a paucity of facial expression is noted. Movements are slow, and there is mild bilateral upper and lower extremity rigidity. Deep tendon reflexes are normal, as are results of manual muscle strength testing. Sensory examination reveals distal sensory loss. She had a mildly stooped posture but no postural instability. A 4-Hz resting tremor in both upper extremities is noted, as is a prominent postural tremor. Which of the following is the most likely diagnosis? • Dementia with Lewy bodies • Drug-induced parkinsonism • Multiple system atrophy • Parkinson disease
Parkinson’s Disease • Symptoms: (the 4 R’s) initially unilateral disease • Resting tremor and cogwheeling • Rigidity and flexed posture • Retarded movement (brady and hypokinesia) • Loss of postural Reflexes **Acutely discontinuing dopa therapy may cause NMS. Treat with a dopamine agonist: bromocriptine, amantadine or dantrolene
A 33-year-old man is evaluated for a 3-day history of worsening weakness and numbness of the right arm and leg. He has a 5-year history of multiple sclerosis. His only current medication is glatiramer acetate. On physical examination, temperature is 36.5 °C (97.7 °F), blood pressure is 105/75 mm Hg, pulse rate is 68/min, and respiration rate is 14/min. Moderate right arm and leg weakness, hyperreflexia, an extensor plantar response, and vibratory sense impairment are noted. Which of the following should this patient receive to treat his acute relapse? • Empiric antibiotic therapy • Immune globulin, intravenously • Methylprenisolone, intravenously • Plasmapheresis • Prednisone only
Multiple Sclerosis Acute Relapse: distinguish between pseudo (infection) or true • Observe if minimal symptoms • IV methylprednisolone or plasmapheresis Disease Modifying Therapies (relapsing remitting disease): • Interferon beta 1a/b • Glatiramer • Natalizumab (assoc with PML) • Mitoxantrone No therapies for primary progressive
A 34-year-old woman is evaluated in the office for right-sided facial paralysis that she noticed on awakening 1 hour ago. She has a 10-pack-year smoking history. Personal and family medical history is noncontributory. Her only medication is a daily oral contraceptive. On physical examination, temperature is 36.5 °C (97.7 °F), blood pressure is 110/70 mm Hg, pulse rate is 82/min, respiration rate is 14/min, and BMI is 26. Limb strength, reflexes, and tone are normal bilaterally. Findings from a sensory examination, which included her face, are also normal. When asked to raise her eyebrows, the patient does not elevate the right side. When asked to shut her eyes, she cannot close the right one, but the globe rotates upward, partially covering the iris. When asked to smile, the patient does not move the right side of her face. Which of the following is the most likely diagnosis? • Graves opthalmopathy • Left cerebral infarction • Right facial nerve (Bell) palsy • Right trigeminal neuralgia
Bell’s Palsy: ipsilateral facial paralysis • Treat with prednisone if within 7 days of symptom onset to shorten course and improve function.. • Cortical lesions spare forehead and eyelid **L5 radiculopathy also causes foot drop, but cannot invert OR evertfoot. Also weak thigh muscles.
A 56-year-old man is evaluated in the office for a 1-month history of intermittent weakness of the left foot, a 6-month history of progressive right arm weakness, and 1-year history of muscle cramps. He says he feels lately as if he is “catching” his foot on things when ambulating. He has noticed no shortness of breath, dysphagia, or other bulbar symptoms and reports no other pain, sensory loss, or bowel or bladder impairment. The patient is otherwise healthy, has no history of disease, and is unaware of any family history of neurologic disorders. He takes no medications. Results of a general medical examination are normal. Neurologic examination reveals normal speech, language, and mental status. His tongue appears atrophic with fasciculations. He has diffuse weakness and atrophy of the proximal muscles in the right arm; fasciculations are noted. Left arm strength and muscle bulk are normal. Moderate weakness of the distal muscles in the left leg is noted, with fasciculations present in both lower extremities. Deep tendon reflexes are brisk in the upper and lower limbs, and the plantar response is extensor bilaterally. Sensory examination reveals no abnormalities, and there is no appendicular ataxia. Laboratory studies show a serum creatine kinase level of 602 U/L. Results of a complete blood count; measurement of serum creatinine, electrolyte, and vitamin B12 levels; and liver chemistry studies are normal. A radiograph of the chest shows no abnormalities.Which of the following is the most likely diagnosis? • Amyotrophic Lateral Sclerosis • Cervical Myelopathy • Chronic Inflammatory DemyelitingPolyradiculoneuropathy • Primary Lateral Sclerosis
Diseases of the Spinal Cord • Viral infection, Autoimmune dz or MS • Leg weakness, numbness, sensory level at trunk. • Diagnosis: MRI, CSF with inc protein and lymphocytosis • B12 deficiency (even without anemia), copper deficiency, nitrous oxide exposure • Gradual weakness, paresthesias, loss of proprioception and ataxia. • Diagnosis: MRI, check MMA and HC (both inc with B12 def) Subacute Combined degeneration of the spinal cord • Back Pain, fever, local tenderness, radicular pain +neuro deficits • Diagnosis: MRI, blood cultures • Treat: laminectomy, drainage and antibiotics Epidural Abscess
Spinal Stenosis Claudication
A 32-year-old woman is seen for a follow-up evaluation. She had a witnessed generalized tonic-clonic seizure 1 week ago and was evaluated in the emergency department, where results of physical examination, complete blood count, measurement of serum electrolyte levels, and urine toxicology screen were all normal. She is otherwise healthy, has no significant personal or family medical history, and takes no medications. Results of a repeat physical examination are also normal.In addition to electroencephalography, which of the following diagnostic tests should be performed next? • Ct of the head • Lumbar puncture • MRI of the brain • Positron emission tomography
A 70-year-old man is seen in the office for routine follow-up of partial seizures that began 2 years ago after a stroke. At that time, he was started on phenytoin, 300 mg/d, and has had no subsequent seizures; he tolerates the medication well, with no reported adverse effects. His current medications are phenytoin, an angiotensin-converting enzyme inhibitor, a statin, and aspirin. Results of physical examination, including a neurologic examination, are normal.Laboratory studies show a total serum phenytoin level of 9 mg/L (35.6 µmol/L) (therapeutic range, 10-20 mg /L [39.6-79.2 µmol/L]). Results of a complete blood count and liver chemistry tests are normal. Which of the following is the most appropriate next step in management? • Continue the phenytoin at the current dosage • Increase the phenytoin dosage • Measure the free serum phenytoin level • Substitute gabapentin for the phenytoin
Diagnosis: MRI preferred over CT • Increased seizure recurrence with: • abnormal EEG • history of prior neurologic injury • FHx • partial seizure is first seizure • MRI with abnormality • Treatment Pearls: • After first seizure, start AEDs only in those with high recurrence risk. Start AEDs in everyone after their second seizure. • Monotherapy preferred over polytherapy; uptitrate medication until seizure free or develop adverse side effects. When changing medications, slowly withdraw first med while slowly uptitrating second. • Make dose adjustments based on clinical seizure control and drug side effects moreso than based on therapeutic levels. • Consider slowly tapering AEDs off after being seizure free for 2 years. • Juvenile myoclonic epilepsy requires lifelong treatment. • Continue therapy: abnormal neuro exam or underlying structural abnormality.
Common Rashes Contact Dermatitis: reaction to environmental exposure Allergic: epicutaneous patch testing dx Irritant Treat: mid-high steroids and avoid irritant Atopic Dermatitis: chronic pruritic skin condition; mostly on wrist or antecubital/popliteal fossa Treat: Mid-High steroids (low steroids on face) Psoriasis: chronic, inflammatory disease. Erythematous plaques with silvery scales and dry itchy patches.
Pityriasisrosea: hearld patch (arrow) and christmas tree distribution of rash on back Seborrhic dermatitis: faint pink patches with yellow greasy scale usually at hairline. Treat: dandruff shampoos with zinc or selenium or azole fungal creams. Rosacea: actiniform eruptions and flushing of mid face. It involves the nasolabial folds (lupus spares them) and there are telangiectasias (acne does not have). Treat: topical metronidazole or azelic acid
Fungal Skin Infections Tinea: caused by dermatophytes which infect only top layer of skin Diagnosis: KOH scrapping Treatment: topical azole (miconazole, clotrimazole); oral azoles for recurrent or scalp involvement. • Pedis: infection of feet • Capitis: infection of scalp- can cause hair loss • Corporis: infection of body (ringworm) • Versicolor: Caused by yeast overgrowth (Malassezia furfur) on the skin and hair follicle. Thrives during warm humid weather. • Treatment: selenium sulfide lotion, topical azoles; oral azoles for recurrent infections Candida:treat with topical nystatin or azole antifungal
Parasitic Skin Infections • Scabies: (Sarcoptesscabiei) • Tx: premethrin cream; oral ivermectin for persistant infection. • Tx family members and close contacts as well and wash all clothing, linens • Lice (Pediculus) • Tx: topical pediculicides, premethrin or poivermectin • Bedbugs: • Tx: topical steroids and po antihistamines for sx relief
Ulcers • Venous Stasis Ulcer: occurs in the setting of venous insufficiency. • Limb with chronic edema. • Treatment: Compression stockings, Unna boot check arterial status • Neuropathic Ulcer: develop in insensate limbs, pts with dm and severe neuropathy. • Painless ulcers in pressure areas • Ulcers surrounded by thick, hyperkeratotic skin • Treatment: debridement and off loading of pressure • Arterial Ulcer: from localized ischemia from peripheral vascular disease. • develop over bony prominences • Very painful, worse when ext elevated • Ulcer is “punched out” and surrounding skin is red, tender, taut. Absent distal pulse • ABI <0.6 = arterial compromise • Treatment: revascularization, wound care
