Block 11 Board Review Part 1 of 4

1. Block 11 Board ReviewPart 1 of 4 Neurology/Heme-Onc 11April2014 Chauncey D. Tarrant, M.D. Chief of Residents 13-14

2. 3% of Initial Certifying Exam!!!

3. Pediatrics In Review Articles • Headaches • Encephalitis

4. PIR Quiz

5. 1. A 4-year-old boy comes in with a complaint of headache. His father asks whether a “brain scan” should be performed. Which of the following characteristics would be the strongest indication for a magnetic resonance imaging study of this child’s brain? A. Age under 5 years. B. Detection of a slight limp on examination. C. Headache that awakens him from sleep. D. Male gender. E. Unilateral headache.

6. 1. A 4-year-old boy comes in with a complaint of headache. His father asks whether a “brain scan” should be performed. Which of the following characteristics would be the strongest indication for a magnetic resonance imaging study of this child’s brain? A. Age under 5 years. B. Detection of a slight limp on examination. C. Headache that awakens him from sleep. D. Male gender. E. Unilateral headache.

7. 2. A 12-year-old girl presents to your office with a history of frequent headaches that sometimes make her miss school. You are trying to differentiate between migraine and tension headache. Which of the following statements is true and will help you to differentiate? A. Migraine headaches are more likely to affect boys. B. Migraine headaches are relieved by exercise. C. Migraine headaches cause a “band-like pressure” on the head. D. Migraine headaches typically last for several hours. E. Migraine pain is throbbing and severe.

8. 2. A 12-year-old girl presents to your office with a history of frequent headaches that sometimes make her miss school. You are trying to differentiate between migraine and tension headache. Which of the following statements is true and will help you to differentiate? A. Migraine headaches are more likely to affect boys. B. Migraine headaches are relieved by exercise. C. Migraine headaches cause a “band-like pressure” on the head. D. Migraine headaches typically last for several hours. E. Migraine pain is throbbing and severe.

9. 3. A 15-year-old girl who has just started to take acne medication presents to your office with poorly localizing daily headaches, blurry vision, and tinnitus. Of the following, which diagnosis is most likely to explain the findings above? A. Idiopathic intracranial hypertension. B. Medulloblastoma. C. Migraine headache. D. Tension headache. E. Trigeminal autonomic cephalalagia (cluster headache).

10. 3. A 15-year-old girl who has just started to take acne medication presents to your office with poorly localizing daily headaches, blurry vision, and tinnitus. Of the following, which diagnosis is most likely to explain the findings above? A. Idiopathic intracranial hypertension. B. Medulloblastoma. C. Migraine headache. D. Tension headache. E. Trigeminal autonomic cephalalagia (cluster headache).

11. 4. You are counseling a parent of a 17-year-old boy who has frequent tension headaches. The family and young man would prefer to try lifestyle interventions before proceeding to medications. Which of the following lifestyle interventions might be helpful in promoting headache reduction? A. Coffee or tea with breakfast daily. B. Limiting fluid intake to 40 ounces daily. C. Regular aerobic exercise. D. Skipping breakfast during weekends to allow for extra sleep. E. Television watching before sleep.

12. 4. You are counseling a parent of a 17-year-old boy who has frequent tension headaches. The family and young man would prefer to try lifestyle interventions before proceeding to medications. Which of the following lifestyle interventions might be helpful in promoting headache reduction? A. Coffee or tea with breakfast daily. B. Limiting fluid intake to 40 ounces daily. C. Regular aerobic exercise. D. Skipping breakfast during weekends to allow for extra sleep. E. Television watching before sleep.

13. 5. A 14-year-old girl has been diagnosed as having migraine. The headaches occur twice weekly and have caused her to miss school at least once per month. The family is interested in a prophylactic medication to prevent her attacks, and you plan to start amitriptyline. Of the following studies, which is indicated as part of amitriptyline therapy? A. Chest radiograph. B. Complete blood count. C. Electrocardiogram. D. Serum alanine aminotransferase. E. Serum creatinine.

14. 5. A 14-year-old girl has been diagnosed as having migraine. The headaches occur twice weekly and have caused her to miss school at least once per month. The family is interested in a prophylactic medication to prevent her attacks, and you plan to start amitriptyline. Of the following studies, which is indicated as part of amitriptyline therapy? A. Chest radiograph. B. Complete blood count. C. Electrocardiogram. D. Serum alanine aminotransferase. E. Serum creatinine.

15. 1. Mosquito control will most likely reduce the frequency of encephalitis caused by A. Adenoviruses. B. Flaviviruses. C. Herpesviruses. D. Myxoviruses. E. Picornaviruses.

16. 1. Mosquito control will most likely reduce the frequency of encephalitis caused by A. Adenoviruses. B. Flaviviruses. C. Herpesviruses. D. Myxoviruses. E. Picornaviruses.

17. 2. A 10-year-old child presents with the signs of acute encephalitis. While no pattern of brain involvement is exclusively produced by a single microbiologic agent, the possibility of herpes simplex being the causative agent is enhanced substantially by an MRI finding of lesions concentrated in the A. Basal ganglia. B. Frontal lobes. C. Midbrain. D. Temporal lobes. E. Thalamus.

18. 2. A 10-year-old child presents with the signs of acute encephalitis. While no pattern of brain involvement is exclusively produced by a single microbiologic agent, the possibility of herpes simplex being the causative agent is enhanced substantially by an MRI finding of lesions concentrated in the A. Basal ganglia. B. Frontal lobes. C. Midbrain. D. Temporal lobes. E. Thalamus.

19. 3. A 17-year-old boy has acute encephalitis associated with weakness in the right arm. He is clinically stable. He had experienced a febrile illness 3 weeks before presenting with signs of encephalitis, but had apparently recovered fully. An MRI demonstrated scattered multifocal abnormalities in both gray and white matter within the brain. Evaluation of serum and CSF has been unrevealing. His most likely diagnosis is A. Acute disseminated encephalomyelitis. B. Enteroviral encephalitis. C. Herpes simplex encephalitis. D. Mycoplasma encephalitis. E. Multiple sclerosis.

20. 3. A 17-year-old boy has acute encephalitis associated with weakness in the right arm. He is clinically stable. He had experienced a febrile illness 3 weeks before presenting with signs of encephalitis, but had apparently recovered fully. An MRI demonstrated scattered multifocal abnormalities in both gray and white matter within the brain. Evaluation of serum and CSF has been unrevealing. His most likely diagnosis is A. Acute disseminated encephalomyelitis. B. Enteroviral encephalitis. C. Herpes simplex encephalitis. D. Mycoplasma encephalitis. E. Multiple sclerosis.

21. 4. The form of encephalitis shown to benefit most from the use of high-dose glucocorticosteroidsis A. Acute disseminated encephalomyelitis. B. Enteroviral encephalitis. C. Herpes simplex encephalitis. D. Saint Louis encephalitis. E. West Nile virus encephalitis.

22. 4. The form of encephalitis shown to benefit most from the use of high-dose glucocorticosteroids is A. Acute disseminated encephalomyelitis. B. Enteroviral encephalitis. C. Herpes simplex encephalitis. D. Saint Louis encephalitis. E. West Nile virus encephalitis.

23. 5. The likelihood of full recovery from encephalitis most depends upon A. Availability of specific treatment. B. Causative agent. C. Duration of fever. D. Initial CSF findings. E. Timeliness of specific diagnosis.

24. 5. The likelihood of full recovery from encephalitis most depends upon A. Availability of specific treatment. B. Causative agent. C. Duration of fever. D. Initial CSF findings. E. Timeliness of specific diagnosis.

25. Headaches

26. What are the physical characteristics of a headache due to increased ICP?

27. What are the physical characteristics of a headache due to increased ICP? • progressive • may cause nighttime wakening • are worse with the Valsalva maneuver or exertion. • persistent vomiting • neurologic deficits • Lethargy • personality change • Papilledema • Palsies of the third, fourth, or sixth cranial nerves, resulting in eye movement or pupillary abnormalities

28. What elements of the history characterize a migraine?

29. What elements of the history characterize a migraine? Migraine without aura A. At least five attacks fulfilling criteria B–D B. Headache attacks lasting 1–72 hours (untreated or unsuccessfully treated) C. Headache has at least two of the following characteristics: 1. Unilateral location, although may be bilateral or frontal (not exclusively occipital) in children 2. Pulsing quality 3. Moderate or severe pain intensity 4. Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs) D. During headache at least one of the following: 1. Nausea and/or vomiting 2. Photophobia and phonophobia (which may be inferred from behavior) E. Not attributed to another disorder

30. What neurologic defects can be associated with a migraine?

31. What neurologic defects can be associated with a migraine? • Acute confusional state • Benign paroxysmal vertigo • Benign paroxysmal torticollis • Cyclic vomiting • Hemiplegic migraine • Basilar • Ophthalmoplegic • Retinal • Alice-In-Wonderland

32. What elements of the history characterize a headache due to stress/tension/emotion?

33. What elements of the history characterize a headache due to stress/tension/emotion? • may last for 1 hour or for several days • described as “band-like,” pressure, or tightening • Triggers include stress, fatigue, illness, muscle pain, tension, particularly in the neck and shoulders • may be episodic (<15 days per month) or chronic (>15 days per month)

34. Can depression cause headaches? T or F

35. Can depression cause headaches? T or F

36. What elements of the history characterize a headache due to increased ICP?

37. What elements of the history characterize a headache due to increased ICP? • Progressive • causes nighttime wakening • worse with the Valsalva maneuver or exertion. • persistent vomiting • neurologic deficits • Lethargy • personality change • Papilledema • Palsies of the third, fourth, or sixth cranial nerves, resulting in eye movement or pupillary abnormalities

38. What signs and symptoms of a headache indicate follow-up with MRI or CT scan?

39. What signs and symptoms of a headache indicate follow-up with MRI or CT scan?

40. What are the values and limitations of ancillary neurodiagnostic tests when evaluating headaches?

41. What are the values and limitations of ancillary neurodiagnostic tests when evaluating headaches? • Values • Brain MRI can help investigate potential structural abnormalities, infection, inflammation, and ischemia • CT is good if there is a concern for hemorrhage or fracture • Limitations • No good guidelines to use

42. What are some abortive treatments for acute migraines?

43. What are some abortive treatments for acute migraines? • Tylenol • Ibuprofen • Naproxen • Triptans

44. How do you treat a stress/tension/emotion headache?

45. How do you treat a stress/tension/emotion headache? • Modification of lifestyle (sleep, hydration, stressors, etc) • Acute treatments

46. What are complications of using narcotics, sedatives, and NSAIDS when treating chronic or recurrent headaches?

47. What are complications of using narcotics, sedatives, and NSAIDS when treating chronic or recurrent headaches? • Rebound headaches

48. What are prophylactic treatments for recurrent migraines?

49. What are prophylactic treatments for recurrent migraines? • Periactin • TCAs • AEDs • Antihypertensives • Supplements • Riboflavin • Melatonin • Coenzyme Q

50. Encephalitis