Patient taking Advil develops n/v/d, coarse tremor, ataxia, confusion, slurred speech. Lithium Toxicity (in this case, precip. by NSAIDs) Use aspirin or sulindac for pain Possible EKG findings: o T-wave flattening o T-wave inversion + U-waves Tx: Fluid resuscitation Emergent dialysis if lithium levels >4 or kidney dz Major SEs: Weight gain, acne, GI irritation, cramps MOA: Suppresses inosital triphosphate Therapeutic levels: 0.6-1.2 o For valproate: 6-12 o For carbamazepine: 60-120 Monitor: o Li level q4-8wks, TFTs q6mo o Cr, UA, CBC, EKG Contraindications: Severe renal dz, MI, diuretics, digoxin, pregnancy or breastfeeding. o Problems in pregnancy: Ebstein’s anomaly = malformed tricusp; atrializes part of RV (if taken during 1st tri) o Treatment for bipolar in pregnancy: Clonazepam (esp. 1st trimester) Bipolar + elevated LFTs and hepatitis Valproate Also can cause n/v/d, skin rash Bipolar + Stevens-Johnson Syndrome Lamotrigine Less likely = carbamazepine drinking red wine.Bipolar + agranulocytosis Carbamazepine MC complication: Rash. more antichol. hyperreflexia. SE chlorpromazine: Purple-grey metallic rash over sun-exposed areas. Acute Dystonia (if meds <12hr ago) Tx: Benztropine or diphenhydramine After 10 years on fluphenazine. n/v/d. Pt wakes up with eyes “stuck” looking up or head “stuck” turned to the side. bradykinesia Parkinsonism (>6mo) Tx: Stop antipsychotic! Switch to atypical or clozapine . tachycardia. flushing.” Akathisia (30-90 days). myoclonus after eating cheese. Tx: Propranolol (1st-line) or benzo Coarse resting tremor. 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. every 2-4wks. Low-potency acute antipsychotics: Chlorpromazine and thioridazine Less EPS. jaundice SE thioridazine: Prolonged QTc and pigmentary retinopathy High-potency acute antipsychotics: Haloperidol and fluphenazine More EPS. SEs: Hyperprolactinemia and EPS. masked facies. Regular CBCs: o If ANC <2000: Weekly CBC o If ANC <1000: D/C the med Bipolar + ↑AFP in a 20wk pregnancy NTD Could be valproate or carbamazepine Repro-age F should take 4g folate daily 5HT syndrome Myoclonic jerks. SSRI + MAOI Pounding head. unsteady gait. htn. If patient has a history of medication non-adherence: Decanoate forms. MOA: D2 receptor antagonist @ mesolimbic tract Helps + sxs. taking decongestant or meperidine Hypertensive crisis w/MAOI Tx: 5mg IV phentolamine DOC for acute agitation or psychosis: IM haloperidol. nausea. Sleep spindles Slow-wave sleep Delta waves Sleep-walking/-talking. rigidity. Temazepam. EtOH Withdrawal Tx: Diazepam or chlordiazepoxide o 80 & 120hr ½-lives respectively o If he’s a class C cirrhotic: Oxazepam. temp of 103F.1. pt has ↑CPK.W/in hours of a haloperidol injection. night terrors Stage 4 >50% delta Stage 3 <50% delta REM Sawtooth waves Skeletal-muscle paralysis SUBSTANCE USE A 50 y/o known alcoholic presents to the ER with tonic-clonic seizures. T 100. autonomic instability. 1st: D/c the offending med. Lorazepam (Over The Liver) Glucuronidated prior to elim . compazine and droperidol SLEEP EEGs Awake Stage 1Theta waves Stage 2 K-complexes. HR 118. Neuroleptic Malignant Syndrome. BP 180/110. and delirium. 2nd: Cooling blankets and dantrolene (or bromocriptine = 2nd-line) Also caused by metoclopramide. photophobia o Goosebumps. GI cramps o Anxiety/depression Tx: Clonidine for autonomic sxs o Ibuprofen for muscle cramps. buprenorphrine or naltrexone can be used for long-term dependence. hypersomnia. Horizontal nystagmus. acute psychosis? Hallucinogen (PCP) intoxication Can use haloperidol for acute psychosis. antero/retrograde amnesia. ataxia. Pt w/confusion. tachycardia. Heroin Overdose First step: Intubate the patient Tx: IV or IM naloxone (full mu-opiate antagonist) Dilated pupils don’t change the dx 2/2 respiratory depression can cause hypoxic dilation Withdrawal sxs: o Joint and muscle pain o Dilated pupils.) o Apathy. RR is 6. confabulation o Midbrain atrophy on MRI A patient is brought into the ER in a non-responsive state. then urine tox Tx: Lorazepam (for seizures) o Tx HTN and tachycardia w/CCB Beta-blockers are CONTRAINDICATED! . HTN. Beta-blockers mask the signs of autonomic hyperactivity o Can follow hyperreflexia to dose the benzos during withdrawal Presentation = ~12-24hrs. Dilated pupils. HR is 50. Methadone. He has multiple track marks on his arms. etc. (caused by thiamine def’y) Tx: Give thiamine 1st. loperimide for diarrhea. ~9h till it’s out of his system o EtOH has zero-order kinetics = 25mg/hr Most specific test for ETOH consumption in past 10 days: Carbohydrate-deficient transferrin Less specific: Elevated GGT. His BP is 100/60. since last drink o Bimodal peak at 8 and 48hrs Confusion. Can progress to Korsakoff’s syndrome (irreversible damage to mammillary bodies. depression and anergia? Cocaine/Amphetamine withdrawal. seizure. tachycardia and HTN? Cocaine/Amphetamine intoxication First: EKG. SI. fluctuations in consciousness and the feeling of ants crawling on him (formication) o 48-72hrs since last drink W/BAC of 225mg/mL. S/p MVC with injected conjunctiva. asking for Doritos? Cannabis intoxication. diarrhea. sedation. then glucose-containing fluids. AST more than twice ALT. ataxia. dilated pupils. and you find this on physical exam: Ophthalmoplegia Wernicke Encephalopathy. SABs? – Post op. . ICHemorrhage initially has focal sx followed by incr. high Ddimer and schistocytes? vWD DIC!! Caused by gram – sepsis. ICP sx (N/V. pneumo. stupor). ↓plts. MCC: S. bradycardia. but v. rarely LOC. PTT. 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. meningitidis o Tx w/ceftriaxone and vanc In old/young pts: Add Listeria o Tx w/ampicillin W/brain surg: Add S. clots • What do you treat w/? • Bleeding Think cancer – Isolated decr in plts? Nephrotic syndrome Factor V Leiden Heparin won’t work Lupus Anticoagulant HIT! (If heparin w/in 5-14 days Leparudin or agatroban ITP – Normal plts but incr bleeding time & PTT? – Low plts. influenzae. Incr PT. HA. H. carcinomatosis.Meningitis. aureus o Tx w/vanc Other: TB (abx + steroids). & foamy pee? – In young person w/ +FH – What’s special about ATIII def? – Young woman w/ mult. HTN. low fibrinogen. BT. N. OB stuff Ischemic strokes DON'T present with N/V and very rarely have LOC or other ICP sx. GH. primidone (benzos if severe) Complication of heat stroke: Rhabdo. no matter heat stroke risk HA + focal neuro sx _ ring-enhancing lesin on CT. dysmetria. ARDS. DM pts susceptible to CN3 nerve ischemia/neuropathy (parasympathetics intact. but does present w/ICP sx. Ataxia w/ dizziness. vioridans. fixed. truncal ataxia. renal failure. colon and renal cell ca are usually single mets SAH rarely presents w/focal deficits/herniation sx Fasciculations are an LMN sign Diabetic neuropathy signs are LMN only DM pts more likely to have spinal epidural abscess CJD: PRNP protein testing (genetic) Sharp wave complexes on EEG and elevated 14-3-3 proteins in CSF Imaging for ALz: Diffuse cortical and subcortical atrophy which is pronounced in temporal and parietal lobes IIH/psudotumor cerebri can be caused by: Isotrentinoin. tetracyclines. esp S. total motor loss below lesion. and no accomodation. nystagmus. are common--Tx w/ 4-8 wks min abx and drain cerebellar sx--gait dyfxn. contralateral P&T loss below lesion . occipital HA. coagulapathic bleeding.SAHemorrhage doesn’t present w/focal deficits. may also tx w/topiramate. vomiting = cerebellar hemorrhage. P&T loss below lesion bilat Central cord syndrome: Burning pain and paralysis in UEs w/sparing of LEs. will have ptosis.fluid collection in ethmoid sinus = brain abscess 2ary to ethmoid sinusitis (only 50% of abscesses have fever)--anaerobes. infx rarely cause temps over 105F. cessation of meds leads to resolution Anterior cord syndrome: Burst fx of vertebra. seen in neck hyperextension Brown-Sequard: Hemisection w/ipsilateral motor and proprioception loss. dilated pupil. intention tremor. impaired RAM 1st-line tx for intention tremor: PRopranolol. so only paralysis). hypothalamic stroke can result in neurogenic fever PICA occlusion: Accessory nerve/CN11 compromiseParalysis of ipsilateral sternocleidomastoid & traps Lesions BETWEEN pons and medulla will cause contralateral lower facial droop Glossopharyngeal/CN IX injury: Jugular foramen syndrome (posterior fossa tumor/bleed) = loss of gag reflex + dysfxn of carotid sinus Increased risk of syncope Brain mets from breast. if CN3 compression. more common in lymphoma. lobar: poss seizures. cerebellar hem = facial weakness neck stiffness. NO hemiparesis. pos homorrage = deep coma. nonreactive miosis. andN/V low grade astrocytoma presents w/seizure and have longer duration of sx infarction resolves in 6-8 weeks 3726 Medicine Nervous System !!THIS question details midbrain/brainstem hemorrhagic strokes 3727 Medicine Nervous System Intubate pts in myasthenic crisis. stupor/coma if herniation. SLe and sarcoidosis 3643 Medicine Nervous System Acute exaacerbatons of MS are tx w/IV steroids 3690 Medicine Nervous System With hypovolemia in setting of heat and heavy extertion. ICH prsents w/focal deficits. then do plasmapheresis and corticosteroids 3728 Medicine Nervous System Bas gang hemorr: hemiplegia. flu. gze palsy stupor coma. react 3771 Medicine Nervous System Riluzole--glutamate inhibitory used for ALS may prolong survival. Mycoplasma. heat exhaustion. Both present w/ICP sx. gait ataxia. 3725 Medicine Nervous System GBM: Cross midline.Suspected MS imaging: MRI with and w/out gadolinium 3513 Medicine Nervous System Essential tremor tx w/ beta-blockers or primidone (converts to phenbarb and PEmalonamide)--may precip acut eintermittent porphyria (abd pain. heterogenous/serpiginous contrast Also HA that worsen w/position. 'butterfly'. contralat. and H. plegia/paresis contralat hemiparesis eyes AWAY from hemiparesis. elevates liver enzymes and may cause nausea and wt loss 3817 . contralat homo hemianop. upgaze palsy. hemisens loss. nystagmus. add temp >104F and CNS dysfxn (seizure/delirium) = failure of thermoregulation/heat stroke. SAH doesn't. body temp over 105F may cause rhabdo 3723 Medicine Nervous System Note that ischemic strokes DON'T present with N/V and very rarely have LOC or other ICP sx. central necrosis. thalamus hem: hemiparesis. gaze palsy. eyes Toward hemiparesis. hemises loss. neurologic & psych abnormalities)--check urine porphobilinogen 3630 Medicine Nervous System GBS also precip by Herpesvirus. total paralysis w/in minutes. primitive reflexes. defined as seizures for more than 5 min without recovery in between 4130 Medicine Nervous System MSA= parkonsonism. emotional disturbances. more in LEs than UEs. LEs with ABULIA. ACA = contralat somatosens + motor dficiet. hemineglect. aphasia. 55-65y/o. Optic neuritis is us. vertigo. gait dysparxia. nystagmus. assoc w/loss if central vision and afferent pupillary defect 4268 Medicine Nervous System Posterior limb internal capsule (lacusnar infarct) unilateral motor deficit. ipsilat vocal cord paralysis. "gaze at stroke" homonomous hemianopsia. uric acid = def'y in hypoxanthie guanine phosphoribosyl transferase. dyspraxia. autonomic dysfxn. but bimodal age dist: child. 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. no sensory cortical or vis field deficits. incontinence. urinary incontinence. 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. ipsilat limb ataxia. 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. abulia. MCA = contralateral motor and sensory (face arm leg). widespread neuro signs 4255 Medicine Nervous System craniopharyngioma rare in adults.Pediatrics Nervous System Lesch-Nyhan--self-mutilation w/dystonia and elev. diplopia. ipsilat Horner's syndrome-->lat cerebellar lesions do not cause Horner's & have minimal dizziness 4274 Medicine . loss of P&T in ipsilat face and CONTRA lat trunk/limbs. MC in women. acute: haloed lights. can occur d/t anticholinergics (pupil dilation). can produce dystonia (tenderness/stiffness) as well as parkinsonism and TD. get MRI. radicular pain) 4393 Medicine Nervous System Hypokalemia: weakness. severe HA. no matter heat stroke risk 4482 Medicine Nervous System Posterior limb int capsule MC site for lacunar stroke: Sx affect contralat face. 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. not visible on CT soon after--microatheroma and lipohyalinosis are pathpphys resp. HCTZ is K-wasting (hyperaldost can also cause) 4401 Medicine Nervous System Anticholinergics used on PD--benztropine. fatigue. U waves and PVCs. will have ptosis. trihexylphenidyl. arrhyth (severe) ECG shows broad flat T waves ST depression. . N/V. selegiline is an MAO-Bi used in PD. and CTguided aspiration/culture 4392 Medicine Nervous System Cuda equina syndrome cause by compression of spinal nerve roots. conus medullaris compromise causes HYPERreflexia and perianal anesthesia w/sudden-onset severe back pain (vs. arm equally. leg. so only paralysis). hyporeflexia. thromboti origin. ESR. NOT conus medullaris--causes LMN signs. occipital HA. neurologic dysfxn. risk of NMS. elev ESR. tetany. if CN3 compression. fixed. poss. vomiting = cerebellar hemorrhage. farsightednness 4372 Medicine Nervous System spinal epidural abscess--fever. bromocriptine is a DA agonist used in PD 4408 Medicine Nervous System DM pts susceptible to CN3 nerve ischemia/neuropathy (parasympathetics intact. dilated pupil. Inuit. periorbital pain. Asian. and no accomodation. rhabdo. tx SEs w/benztropine or dphenhydramine 4367 Medicine Nervous System ANGLE-CLOSURE GLAUCOMA. unilat lacrimation. focal spinal tenderness/back pain.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. 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. infx rarely cause temps over 105F.fluid collection in ethmoid sinus = brain abscess 2ary to ethmoid sinusitis (only 50% of abscesses have fever)--anaerobes. P ca. DTRs. B. 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. vision changes. esp S.4513 Medicine Nervous System HA + focal neuro sx _ ring-enhancing lesin on CT. myeloma). ARDS. vioridans. worse in morning. though). vascular (embolus to opth artery). coagulapathic bleeding. dysmetria. infx (epidural abscess). hypothalamic stroke can result in neurogenic fever 4708 Medicine Nervous System Elev ICP /ICHtn: >20mmHg. pain worse in recumbent pos'n/at night. malignancy (L. severe local back pain. + 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. benzos are contraindicated in older pts (can cause paradoxic agitation. 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. truncal ataxia. IV glucorticoids. amaurosis fugax is us. paraplegia w/ inc. galucoma may cause periph visual field deficits (not actue angle-closure. intention tremor. Diffuse HA. 4913 Medicine Nervous System . N/V early in day. radiation onc + neurosurg consult 4703 Medicine Nervous System Complication of heat stroke: Rhabdo. stat MRI. renal failure. optic neuritis is unilat eyes pain and vision loss w/afferent pupillary defect. MVA). symm LE weakness. nystagmus. advanced dis can cause UMN signs. primidone (benzos if severe) 4921 Medicine Nervous System Embolic stroke: sx onset abrupt and maximal initially. severe HA at sx onset. focal deficit uncommon 10499 Medicine Nervous System Subacute combined degeneration --prog symm polyneuropathy grater in legs than arms.!!THIS question details features of tremor 4914 Medicine Nervous System 1st-line tx for intention tremor: PRopranolol. may also tx w/topiramate. followed by incr. thrombotic. sx fluctuate w/ periods of progression/imrpvement. sx progress over min-hours. methylmalonic acis levels will eb elevated 4619 Medicine Nervous System !!THIS question details dementia presentations 4913 Medicine Nervous System !!THIS question details features of tremor 3726 Medicine Nervous System !!THIS question details midbrain/brainstem hemorrhagic strokes . ICH. SAH. memory loss. meningeal irrit. ICP sx.