Brain Problems
Code 50 - 5 East
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100
What are 2 most common morbidities associated with Tourrettes syndrome?
What is ADHD and OCD TX: RISPERDAL CBT: HABIT REVERSAL
100
74yo African american male brought to the ED with 7 hour history of difficulty speaking,. His pmh include HTN, hyperlipidemia, obesity, carotid stenosis, T2DM. Physical examination shows normal 1st and 2nd heart sounds and no carotid bruits. Neurological exam shows dense Right sided hemiplegia. CT head wo contrast showed no bleed, minimal brain swelling involving the right middle cerebral artery.BP is 185/111, HR 97 and regular. Her fingerstick accucheck is 187. In the setting of acute ischemic stroke, what is his most important modifiable risk factor?
What is obesity
100
A 23-year-old woman comes to the office with her husband for evaluation of recent onset of unusual behavior. While providing the clinical history, the patient begins to cry. Shortly after that the patients’ arms start shaking. Gradually, the shaking becomes more pronounced and involves her legs and head. The patients breathing becomes deep and fast. This continues on and off for several minutes. The shaking stops gradually. The patient opens her eyes and states that she has a headache and is very tired and dizzy. Family history is positive for seizures in the patients’ cousin. There has been a significant amount of family stress recently. Which of the following is the most likely diagnosis? A) Syncope B) Nonepileptic event (pseudoseizure) C) Partial seizure with secondary generalization D) Generalized tonic-clonic seizure E) Basilar migraine
What is C
100
A 65 yo F is brought in by her family because of memory loss. They have noted a worsening of her symptoms over several months. They also report she has had multiple falls hitting her head on one occasion, and has had frequent urinary incontinence. On exam, a gait apraxia is noted. Which of the following is the most likely diagnosis?A) Alzheimer disease B) Normal pressure hydrocephalus C)Dementia with Lewy bodies D)Delirium
What is B Normal pressure hydrocephalus classically causes dementia, incontinence, and gait disturbance
100
A 14-year-old female bumped heads with another player in a soccer game. She was knocked down, appeared briefly dazed, and now has a headache and mild dizziness while seated on the sidelines. Which one of the following would be most appropriate at this point? A) Return to play after symptoms have resolved for at least 30 minutes B) Immediate neuroimaging to rule out intracranial injury C) Complete cognitive and physical rest for 24 hours before returning to normal activities D) Initial complete cognitive and physical rest followed by an individualized graded return to activity E) No sports participation until symptoms have been absent for 1 week
What is D This patient has symptoms typical of a mild concussion without loss of consciousness. In such cases standard neuroimaging can be expected to be normal. The evaluation should include a standard concussion assessment tool, and if concussion is suspected the athlete should be removed from play. Complete physical and cognitive rest are required for the first 1–2 days, but return to normal activity must be individualized depending on the course of symptoms and response to gradually increasing activity. Athletes should be completely free of symptoms before returning to sports activities.
200
19yo male comes to the outpatient clinic for daytime sleepiness lasting several months, patient recently started medical school and has had difficulty staying awake during classes and often falls asleep suddenly even though he gets a good nights sleep. He denies snoring or waking up gasping. The patient feel like someone is in the room with him when he is just falling asleep and reports sometimes hears name being called. His PMH is insigificant, bp 120/70 BMI 23. What is next best step in diagnosing pts symptoms?
What is Sleep study, dx narcolepsy, exclude OSA TX: MODAFINIL Cataplexy> mm weakness assoc with emotional episode SNRI
200
What combo antiplatelet therapy is slightly better than ASA alone after a stroke?
What is aggrenox Plavix also is better than asa alone
200
A 26-year-old woman comes to the office because of recurrent episodes of unusual behavior. She usually has a warning—a “weird” feeling in her stomach —prior to the episodes. Her husband has witnessed most of the events, and states that the patient suddenly freezes, looks around, smacks her lips, and moves her fingers repetitively. The episodes usually last between 30 seconds and 2 minutes. She has no recollection of the events after the warning. Afterward, the patient is confused and disoriented for as long as 10 minutes. The patient has had at least 10 episodes over the last 2 years. Which of the following is the most likely diagnosis? A) Complex partial seizures B) Absence seizures C) Nonepileptic events (pseudoseizures) D) Migraine E) Transient global amnesia
What is A
200
A 75yo M with a PMH of poorly controlled HTN is brought in by his daughter for evaluation. He has become increasingly forgetful over the past year, missing engagement with his children and grandchildren. He is also unable to remember directions, resulting in his becoming lost when driving alone. He has no psychiatric history, although his wife died 1yr ago. Which of the following features is necessary in order to accurately diagnose dementia? A) Agitation B) Fluctuation in consciousness C) Radiographic findingsD) Hallucinations E) Another cognitive deficit
What is E For a diagnosis of dementia one or more additional cognitive deficits must be present in addition to memory impairment: aphasia, apraxia, agnosia, or a disturbance in executive functioning
200
A case of meningococcal meningitis has just been confirmed at a day-care center. The susceptibility of the microorganism is not yet known. At this point, you should do which one of the following for the day-care center contacts? (check one) A. Culture their nasopharyngeal secretions B. Administer meningococcal vaccine C. Prescribe sulfadiazine D. Prescribe chloramphenicol (Chloromycetin) E. Prescribe rifampin (Rifadin)
What is E, Rifampin Rifampin, in the absence of major contraindications, is the drug of choice for preventing the spread of meningococcal disease when the susceptibility of the organism is not known. In this situation, meningococcal vaccines are of no value because their protective effects take a few days to develop, and because they do not protect against group B meningococci, the most prevalent strain for meningococcal disease. Sulfadiazine is the drug of choice if the meningococcus is known to be susceptible to it. Chloramphenicol and penicillin, which are effective in treating the disease, are ineffective in eliminating nasopharyngeal carriers of meningococci, possibly because they do not appear in high concentrations in saliva. Culturing contacts for meningococcal carriage in the nasopharynx has no value for identifying those at risk for meningococcal disease.
300
Juvenile myoclonic epilepsy is characterized by early morning myoclonic jerks with subsequent generalized tonic clonic seizures. Treatment usually is with valproic acid. What is the characteristic EEG finding?
What is Bilateral poly spike and slow discharges
300
Above which blood pressure range is a contraindication to receiving tpa within 3-4.5h window within onset of symptoms?
What is BP>185/110 1ST 24h, s/p tpa, no antiplt, no atc, no invasive testing for 24h, strict control with IV HTN med
300
A 33yo man is brought to the ED by ambulance after having 3 generalized tonic-clonic seizures over 30min w/o recovering consciousness between seizures. His friend states that he has a hx of epilepsy but is not compliant w/ his meds. During exam, the patient has another generalized seizure. He becomes cyanotic despite O2 suppementation. HR 110/min, BP 150/90. He continues to have seizures despite receiving 8mg of IV lorazepam en route to the hospital. The pt weighs approximately 80kg (176 lb). Which of the following IV meds should be administered next?A) Fosphenytoin 1600mg (Phenytoin equivalent) B) Phenobarbital 1600mg C) Phenytoin 1000mg D) Valproic acid 1600mg
What is A
300
A man brings his 45yo wife to the ED. He states she has been ill for 3 days and has been running a temperature of 99.8-100.5 F. Today she is having difficulty staying awake, is talking to persons who are not there, and at times appears to be frightened of something. She is restless and somewhat combative when restrained. What is the most likely diagnosis? A) Acute stress disorder B) Bipolar I disorder, manic type C)Brief psychotic disorder D) Delirium E) Dementia
What is D This is a psychotic level disorder (pt is hallucinating); pt has a fluctuating level of consciousness and is disoriented. Also, there is a clear history of a febrile condition that developed rather rapidly, all of which suggest delirium
300
A 56-year-old female with a history of poorly controlled type 2 diabetes mellitus presents with a complaint of progressive loss of sensation and weakness in both legs over the past 2 days and low back pain that is nonradiating. She also reports that she is unable to feel bowel movements or urination. She says she has not had any fever or chills. On examination she has a low-grade fever with a blood pressure of 142/84 mm Hg. She has no sensation to pinprick or vibration from the T9 level down, bilaterally. She is unable to move her legs voluntarily or resist gravity, and no reflexes are elicited in the lower extremities. Her WBC count is 12,700/mm3 (N 4000–10,000) and her erythrocyte sedimentation rate is 127 mm/hr (N 1–25). Which one of the following would be most appropriate at this point? A) Antiplatelet therapy B) Intravenous corticosteroids C) Thoracic spine films D) MRI of the thoracic spine
What is D, MRI This patient has symptoms and signs consistent with a spinal cord lesion. With rapidly progressing symptoms of paraparesis and sensory abnormalities in a diabetic patient, an epidural abscess is likely. This is considered a neurologic emergency, because a permanent deficit can result if the problem is not addressed promptly. MRI of the thoracic spine, which is the level of her deficits, is the best next step in the evaluation of this patient. Intravenous antibiotics are a necessary treatment, along with surgical debridement, if the MRI demonstrates the underlying problem. Thoracic spinal films are not helpful in this situation. Neither antiplatelet therapy nor corticosteroids are indicated for a spinal epidural abscess
400
15 month old male brought to the ER by ambulance after episode of jerking movements at home. The patient was sitting in the living room playing with his toys when he developed uncontrollable rhythmic jerking of his extremities that lasted approx 2 minutes. Physical exam showed hypopigmented lesions on the patients back, what test should be performed in evaluation of the patient?
What is TSC NEURO INVOLVEMENT LEADING CAUSE OF DEATH BRAIN MRI> HAMARATOMAS EEG> SEIZURES, WORSEN OVER TIME, CAN LEAD TO SA, aspiration, obstructive hydrocephalus Derm, brain, heart >RHABDOMYOMAS kidneys >ANGIOMYOLIPOMAS
400
69yo Colombian male brought to the ED with right sided weakness that started 45 mins ago, according to his daughter, he dropped his glass of kool-aid and was subsequently unable to walk. His pmh include HTN, hyperlipidemia, T2DM. Physical examination shows normal 1st and 2nd heart sounds and no carotid bruits. Neurological exam shows dense Right sided hemiplegia. CT head wo contrast was negative for ICH, tpa is administered. 4 hours later, the patients right sided weakness is improved. He has no headache, blurred vision or nausea. BP is 198/110, HR 87 and regular. Her fingerstick accucheck is 145. IV labetalol is started, in this patient, the IV labetalol should be titrated to achieve a BP range of?
What is <185/105 but >140/90 1ST 24h, s/p tpa, no antiplt, no atc, no invasive testing for 24h, strict control with IV HTN med to keep bp <185/105 but >140/90 Ischemic stroke, no tpa, BP <220/120
400
A 1yr old child presents for a well-child checkup, but the parents are concerned about giving the child his immunizations. Which of the following is a true contraindication to the administration of the fourth DTaP vaccine? A) Child is currently on amoxicillin for an otitis media B) Positive family history of adverse reactions to DTaP vaccine C) A past history of infantile spasms D) Child is currently febrile to 39 C (102.2 F) E) Prolonged seizures for 6 days after the last DTaP vaccine
What is E There are few contraindications to vaccines, but many misconceptions about contraindications. The one contraindication for ALL vaccines is a prior history of a severe allergic reaction to a component of the vaccine. For the DTaP, another contraindication is the occurrence of encephalopathy (such as coma, altered level of consciousness, or prolonged seizures) within 7 days of administration of the previous dose.
400
A 66yo man is brought in by his family because of difficulty with memory and disorientation that has worsened over the past 5 months. A careful history and physical examination is performed. Which of the following tests is most appropriate in this patient?A) Head CT or MRI B) Lumbar puncture C) Rapid plasma reagin (RPR) D) EEG
What is A
400
A 50-year-old male presents to your office with a 1-hour history of an intense retro-orbital headache. This started while he was jogging and eased somewhat when he stopped, but has persisted along with some pain in his neck. Other than a blood pressure of 165/100 mm Hg, his examination is unremarkable. Noncontrast CT of the head is also unremarkable. His pain has persisted after 2 hours in the emergency department. What is the most appropriate next step?
What is A lumbar puncture Early diagnosis of a nontraumatic subarachnoid hemorrhage is paramount for achieving a good outcome when a patient presents with a headache that is unusually severe and feels different than other headaches. Risk factors include smoking, hypertension, heavy alcohol use, and a family history of aneurysm or hemorrhagic stroke. The initial evaluation should consist of noncontrast CT of the head (SOR C). If it is negative or equivocal the next step would be to perform a lumbar puncture to determine whether or not the cerebrospinal fluid is xanthochromic. The absence of xanthochromia rules out subarachnoid hemorrhage (SOR C).
500
Healthy 6yo female brought to office by dad for follow up. Dad has NF-1 and is concerned his son may have the same disease. He is particularly worried that he developed 5 new café-au-lait spots in the last year, he previously had 2. PE shows 7 CALS and two freckles in the axilla. Dad wants to know what further tests need to be done, what immediate referral does this patient need today?
What is Gliomas > lisch modules, when dx, pts need immediate ophtalmalogic referral Kids can have other CNS tumors, developmental problems, bone dysplasia
500
What are the 2 most frequent cause of early death in acute stroke patients, especially those with hemiparesis?
What is cerebral edema and PULMONARY EMBOLISM ASA 325mg to minimize cerebral edema Prevalence of DVT in acute stroke pts. Is 2-10%, highest risk 2-7d following stroke, start sq low dose heparin or lovenox Hemorrhagic stroke: DVT PPX> SCDs
500
An infant presents with a large, flat vascular malformation over the left face and scalp. The mother notes that her other child was born with a capillary hemangioma on his arm and asks if this is the same thing. You explain that this vascular malformation is different and that you will want to monitor him for another condition. Which of the following major abnormality is likely to be associated with this congenital anomaly? A) Deafness B) Seizures C) Wilms tumor D) Congestive heart failure E) Optic glioma
What is B A flat capillary vascular malformation in the distribution of the trigeminal nerve is the primary cutaneous lesion in the Sturge-Weber syndrome. The malformation involves the meninges and results in atrophy to the underlying cerebral cortex. The damage is manifested clinically by seizures, mental deficiency, and hemiparesis or hemianopsia on the contralateral side. Cause is unknown
500
An 80 yo woman is admitted to the hospital for altered mental status. Her family says that she has been confused and falling asleep frequently and that she has been hallucinating---talking to people who are not in the room. They report that prior to this illness, she was independent and “sharp as a tack.” On urine analysis, she is found to have a urinary tract infection (UTI). Which of the following is the most appropriate treatment? A) Start rivastigmine (Exelon) for worsening of Alzheimer dementia B) Start an alerting agent such as modafinil (Provigil) for symptomatic treatment of her hypersomnia? C) Start an antibiotic for treatment of her infection and optimize management of any other medical conditions D) Give her a dose of ziprasidone (Geodon) for her hallucinations?
What is C
500
A 75-year-old male has not seen a physician in 25 years and presents with advanced Parkinson’s disease. The best initial treatment would be: (check one) A. Referral to a neurosurgeon for thalamotomy B. Amantadine (Symmetrel) C. Benztropine (Cogentin) D. Pramipexole (Mirapex) E. Carbidopa/levodopa (Sinemet)
What is E, carbidopa/levodopa While anticholinergics such as benztropine and amantadine may provide some improvement of symptoms, these effects wane within a few months. Such medications are not a good option in this patient with advanced disease. Dopamine agonists provide some improvement in motor complications, but are mainly used to delay the introduction of levodopa in younger patients, to avoid levodopa-related adverse reactions. Carbidopa/levodopa is better for initial therapy in older patients, and those who present with more severe symptoms. Slow-release versions of this combination may decrease motor fluctuations. Stereotactic thalamotomy is used to ameliorate tremors that have become disabling. This procedure has been replaced by other surgical options such as pallidotomy and high-frequency, deep-brain stimulation of specific nuclei
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