Med Comp III: Key Phrases Quick Quiz
Neurology
-
Increased ICP with 1. HTN, 2. Bradycardia, 3. Irregular respiration
o ANSWER: Cushing triad for TBI- indicates that ICP has reached a life threatening level
o Poor Prognosis
-
Blunt trauma, brief LOC, possible seizure on impact, memory loss, no structural changes on CT
o ANSWER: Concussion
o Tx: most sx self resolve in 1 week, may develop post-concussive syndrome
-
CT of brain shows posttraumatic lesions, irregular regions with high and low density changes
o ANSWER: Contusion
o Remember that high density areas are blood and low density areas are usually edema
-
CSF otorrhea, rhinorrhea, hemotympanum, raccoon eyes, battle sign
o ANSWER: Basilar skull Fx
-
Little boy gets hit in the head with a baseball and LOC, comes to and appears normal and then
experiences rapid neurological dynsfunction
o ANSWER: Epidural Hematoma - MCC is laceration of the middle meningeal artery
o Lesion appears biconvex in shape
-
Sentinel headaches followed by sudden onset of severe headache with sx of meningeal irritation
o ANSWER: Subachnoid Hematoma
o Remember that it can be caused by TBI laceration of superficial microvessls in
subarachnoid space which would be picked up on CT w/o contrast. However the mc c is
rupture of a “barry aneurysm” and in this case would not be seen. To confirm a negative
Ct scan a lumbar puncture may be performed to look for xanthochromia or blood in the
CSF
-
Elderly, rupture of bridging vessels, lesions are crescent shaped
o ANSWER: Subdural Hematoma
o Venous in origin
o Tx: surgical burr hole for pending herniation, emergent craniotomy
-
Severely depressed consciousness, neurological dysfunction or coma, normal CT or with
punctate hemorrhages, ICP normal
o ANSWER: Diffuse axonal injury
o Due to shearing trauma ;
o majority never come out of nonvegitative state
1
-
Posttraumatic CT shows lesions with high density changes and low density changes within it
o ANSWER: Typical finding for blood and edema of a head CT
o High-density = blood
o Low-density = edema
-
Comminuted fracture displaced inwardly
o ANSWER: Depressed Skull fx
o Tx surgically only if segment is greater than 5mm; usually surgery not needed because
closed  decreased infection
-
Laceration over a fx
o ANSWER: Open skull fx
o Remember that sinus or middle era fx are also considered open fx
-
Clear salty otorrhea, rhinorrhea, hemotympanum, bruising around eyes bilaterally
o ANSWER: Basal skull fx
o Battle sign = bruising of mastoid area
o Racoon eyes = bilateral bruising of eyes
-
Head trauma follow by lucid period  rapid deterioration
o ANSWER: Epidural hematoma
o Key characteristics = appears bi-convex lesion on CT, ARTERIOLE in nature
o MCC: laceration of middle meningeal artery due to fx of temporal bone
o Tx: Surgical burr bole (trephination); if fails then craniotomy
-
Elderly, crescent shaped laceration on CT
o ANSWER: Subdural hematoma
o Characteristics : VENOUS in nature; due to atrophy of brain and bridging vessels
o Tx: Surgical burr bole (trephination); if fails then craniotomy
-
Sudden severe head ache, sentinel headaches, N/V, meningismus,
o ANSWER: subarachnoid hematoma
o Cause: usually secondary to a barry aneurysm ; may be a direct result from TBI
o Dx: ct scan without contrast; if negative but still suspect  lumbar puncture to look for
xanthrochromia
o Tx: sedation, anti-hypertensive medication
-
Discuss tx for↑ ICP
o If GCS <9, prolonged sedation, or extended general anesthesia  ICP probe
o Reverse Trendelenburg position (unless spinal injury or hypotensive)
o Hyperventilation
o Mannitol
2
o
o
o
o
Short acting sedative and analegesics
Low body temp/ice packs
Anticonvulsants maybe
Decompressive caeniectomy
-
Unilateral, Throbbing Headache, n/v, photophobia, phonophobia
o ANSWER: Migraine
o There are many types of migraines
-
Occipital Headache; aphasia, decreased hearing , vertigo, tinnitus, ataxia, visual changes,
dizziness, N/V, bilateral paresthesia, LOC
o ANSWER: Basilar migraine
-
Transient deficit of unilateral hemipesia, hemiparesis, lastis mins to hours, resolves at time of
H/A
o ANSWER: Hemiplegic migraine
-
Palsy of ipsilateral CN III, ptosis, mydraisis, type of migraine
o ANSWER: Opthalmoplegic Migraine
-
Persistent migraine that does not resolve spontaneously
o ANSWER: Status Migranosus
-
Migraine-like headaches greater than 15 days a month for greater than 6 months
o ANSWER: Chronic Migraine
-
Discuss Tx for Mild, Moderate, and Severe Migraines
o For all: dark room, quiet, sleep, compression to ipsilateal temporal artery, icepack
o MILD: Analgesics/NSAIDS
o Moderate/Severe:
 Triptans – best
 Ergot Medications
 Nacrcotics- Demerol
First and Second line tx for prophylaxis of Migraines
o First line: Tricyclic anti-depressants (amitriptyline); beta blockers
o Second Line: calcium blocker, relaxation training, acupuncture
-
-
Bilateral head ache, bifrontal, band-like tension around head, muscular tightness in neck,
furrowed brow, tense masseter muscles, poor posture
o ANSWER: Tension Headache
o Characteristics: may also be described as dull or pulsatile, NORMAL NEURO EXAM
o Tx: analgesics for mild/moderate; if severe can use same as migraine
3
-
Male, excruciating pain, penetrating, piercing, stabbing, exploding, rocking,
o ANSWER: Cluster Headache
o Can be Episodic (MC) or chronic
 Episodic = occurs in clusters lasting 1w to 1 yr, separated by pain-free intervals
of at least 2 weeks
 Chronic – Longer than 1 year without remission, or with remission lasting <2w
o Other key characteristics:
 Ipsilateral lacrimation, miosis, rhinorrhea, ptosis
 Horner’s Syndrome
o TX: DRUG OF CHOICE = SUMATRIPTAN!!
o Prophylaxis: DOC = VERAPAMIL
-
First or worst sudden headache, vomiting, menigismus, AMS
o ANSWER: Subarachnoid hemorrhage
o Dx: CT w/o Contrast, if neg  lumbar
-
Fever, Non-focal headache, meningismus
o ANSWER: Meningitis or Encephalitis
o Note: AMS is more common with Encephalitis
o Dx: lumbar puncture with CSF analysis
-
Pain on awakening, progressively worsens, worse with valsalva, ataxia, papilledema, and onset
seizure; triad : headache, vomiting, papilledema
o ANSWER: Brain Tumor
o Dx: CT first  MRI T2
-
Fever, n/v, seizures, H/a
o ANSWER: Brain abscess
o DX: MRI IS BEST
-
Transient, shock-like facial pain
o ANSWER: Trigeminal neuralgia
o Tx: Carbamezapine
-
Elderly, sereve sclap and temporal pain, associated with PMR, palpable tender temporal artery
o ANSWER: Temporal Arteritis
o Dx finding on bx = giants cells, increased ESR
o Tx: Steroids
o Comps: Blindness
-
Groups of Distal muscle weakness of extremities, hyperrflexia, spasticity, Babinski positive
o ANSWER: UMN lesion
4
-
Spondylosis, posterior-occipital pain, increased with activity, hx trauma, spinal/muscle
tenderness
o Answer: Cervical H/A
o Dx: X-ray of C-spine, if -  home for 1 w ; still bad  MRI for herniated disc
-
Temporal H/A, eachache, crepitus
o ANSWER: TMJ syndrome
-
Individual distal muscle weakness, decreased tone, flaccidity, fasciculations, hyporeflexia, absent
babinski, EMG abnormalities
o ANSWER: LMN lesion
-
Abnormal range, rate and force of movement
o ANSWER: Cerebellum Disorder
-
Involuntary movement, changes in tone and posture, no weakness, no changes in reflexes
o ANSWER: Extrapyramidal Disorder
-
Rhythmic, alternating involuntary movements o that are maximal when body part is maintained
against gravity; lessened by rest
o ANSWER: Postural tremor
-
Rhythmic, alternating involuntary movement that is maximal at rest and bones less prominent
with activity;
o ANSWER: Resting Tremor
-
Unilateral, pill rolling tremor
o ANSWER: Type of resting tremor commonly associated with Parkinsons disease
-
Brief, rapid, jerky, purposeless, irregular involuntary movement of distal extremities that may
merge into purposeful acts to mask movement
o ANSWER: Chorea
o Common with Huntington’s Disease, and Wilsons Disease (basal ganglia dz)
-
Writhing movement, with alternating postures of proximal limbs that blend continuously into a
flowing stream or movement; slow
o ANSWER: Athetosis
o Common with Huntington’s Disease, and Wilsons Disease (basal Ganglia dz)
o Choreoathetosis – two occur together!
-
Chorea or athetosis in the setting of Rheumatic fever
o ANSWER: Sydenham’s Chorea
5
-
Twisted into grotesque fixed postures
o ANSWER: Dystonia
o Tx: Anticholinergics, botulinum toxin injection
-
Dystonia of Neck
o ANSWER: Spazmodic torticolis
-
Lead-pipe Rigidity, cogwheel resistance throughout ROM, Flexors and extensors of all 4 limbs,
involuntary movements
o ANSWER: RIGIDITY due to Extrapyramidal lesions or abnormalties
o Example of this type of disorder is Parkinsons
-
Flexors in arms, extensors in legs, hyperactive, positive babinski, no involuntary movements
o ANSWER: SPACTICITY due to UMN lesions/disorder
o Example of this is a stroke
Rapid, brief irregular contraction of muscle or group of muscles
o ANSWER: Myoclonus
o Can be normal (hiccups, sleeping twitch)
o Abnormal causes: metabolic derangements (uremia, degenerative dz (alzheimer’s dz),
close head truma, hypoxic ischemia brain injury
o Tx: underlying cause, benzos, anticonvulsants
-
-
Blinking, nose twich, eye roll, shoulder shrug, jaw or head jerks that are uncontrolled and
repetitive
o ANSWER: Simple Tic
o Tx: neuroletpics (Haloperidol) Benzos
-
Uncontrolled, repetitive, clapping, drumming of fingers, picking scabs, kissing, touching, hitting
self
o ANSWER: Complex Tic
o Tx: neuroletpics (Haloperidol) Benzos
-
Mulitple complex motor and vocal tics, coprolalia
o ANSWER: Tourrett’s syndrome
o Associated with ADD and OCD
-
Violent, continuous proximal limb flinging movements confined to one side of the body
o ANSWER: Hemiballismus
o Caused by lesion (MC infarct) in contralateral subthalamic nucleus
o Tx: Usually self limited 6-8 w; dopamine depleting agents are useful
6
-
-
-
-
-
-
Sustained muscle spasms of facial, neck or trunk muscle groups
o ANSWER: Acute dystonia (Drug induced)
o Tx: DC drug, anticholinergics and antihistamines
Subjective sensation of motor restlessness, occurs days to weeks after neuroleptic drug
o ANSWER: Akathisia
Resting tremor, bradykinesia, rigidity, and postural instability that occurs weeks to months after
neuroleptic tx
o ANSWER: Parkinsonian-like Symptoms
o Tx: DC or reduce drug; Anticholinergics (amantadine, diphenhydramine)
Involuntary facial and tongue movements, rhythmic trunk movements and choreoathetoid
movements of extremities, follows > 6 m of neurolepic therapy
o ANSWER: Tardive dyskinesia
o Tx: gradual reduction of drug; some pt better off with sx and still on drug
Muscular rigidity, fever, tremor, AMS, autonomic instability within 2 w of initiation of
neuroleptic
o ANSWER: Neuroleptic Malignant syndrome
o Tx: DC drug, resolves on own, ICU, maintenance of hydration and cardiopulmonary
function, Dantrolene = muscle relaxant
Adult onset, dementia, involuntary movements, behavioral changes,
o ANSWER: Huntingtons Disease
o Triad = dementia, involuntary movements, behavioral changes
o Atrophy of neurons in basal ganglia and cortex
o Other Key characteristics:
 Chorea = MC associated movement disorder
 Eventually chorea is replaced with dystonia and parkinsonian features and the
end with an akinetic-rgid syndrome, spacticity and clonus
 Dx – family history (autosomal dominant) or measure bicaudate diameter
 Tx: Symptomatic Tx
 Benzos – clanzepam, reserpine
 Depression w/ SSRI’s
 Bradykinesia and rigidiy = levopoda or dopamine agonists
Adult on-set, resting tremor, rigidity, bradykinesia, postural instability, Male, Lewy Bodies
o ANSWER: Parkinson’s Disease- progressive neurodegenerative disorder of
extrapyramidal system
o Dx: none, most tests are done to R/O other etiologies, use hx and clinical evidence
o Tx: this is the only neurodegenerative dz treated long-term – good symptomatic control
for 4-6 yrs
 L-Dopa and Cabidopa = GOLD STANDARD
 Dopaminergic Agonists: bromocriptine, pergolide, pramipexole
7
-
Antibodes to myelin basic protein (MBP) in blood and CSF, Urinary, eyes and lower limb
incontinence
o ANSWER: MS
o Other Key characteristics: Sensory mans are most common, bowel and bladder
problems, fatigue, weight loss babinski sign, lhermitte sign
o MC in women but when men get it’s the more severe form
o Remember that there are different kinds
o DX: MRI of head with gadolinium – gadolinium will enhance plaques
 Also CSF analysis = mononuclear pleocytosis, normal glucose, selective
increased in IgG (oligoclonal bands), increased MBP
o Tx : for general sx of MS = Methylprednisolone IV
 Relapsing remitting = long term use beta-interferon and glatiramer acetate
 Natalizumab = for MS refractory to other tx
 Self Catherter if post-void residual volume >100 ml
-
Acute exacerbations of MS lasting weeks t o months with gradual full or partial remissions
o ANWER: Relapsing-remitting MS (most common)
-
Type of MS; On set after age 40, gradual decline, accumulated disability without remission, MC
IN MEN
o ANSWER: Primary progressive MS
-
Type of MS, continuous deterioration after about 10 years of relapsing-remitting
o ANSWER: Secondary progressive MS
-
Type of MS that is progressive and episodic
o ANSWER: Progressive Relapsing MS
o This is the worst form; most rapid deterioration
-
Neck flexion that results in an electric shock like felling in torso or extremities
o ANSWER: Lhermitte Sign
-
Acute onset of unilateral visual blurring, flashes of light, central scotoma, decreased acuity,
decreased color perception, and discomfort moving the eyes
o ANSWER: Optic Neuritis
o This is the initial presenstion in 15-20% of pt with MS
o 50% are retrobulbar  cannot see it
o If it is involved anteriorly  papillitis and atrophy (ddx = papilledema)
o Tx: IV methyprednisolone
-
Adduction deficit and abduction nystagmus
8
o
Answer: Bilateral internuclear opthalmoplegia – due to lesion in median longitudinal
fasciculus
-
Acute partial loss of motor, sensory, autonomic, reflex, and sphincter function below level of
lesion, unchanging level
o ANSWER: Acute disseminated encephalitis
-
Acute onset of motor, sensory, cerebellar, and CN defects with encephalopathy, AMS,
progressing to coma and eventual death ; similar to MS
o ANSWER: Acute disseminated encephalitis
o Tx: steroids; IV seizure prophylaxis, plasma phoreisis, IV dexamethsone
-
Asymmetric muscle weakness, increased tone, hyperreflexia, fasciculation and muscle atrophy
o ANSWER: ALS = hallmark is that is affects both UMN and LMN!!!! This is unusual
o Spared areas = extraocular muscles, spincters, autonomic function, bowel and bladder
cardiac and smooth muscle, cognition, hearing vision, and SENSATION
o Cause is unknown; however there is a familial link and also a link to elevated levels of
glutamate in serum and CSF
o Other key signs include : unexplained weight loss (still lose weight even though be
confines and gastrotube); pathologic laughing or crying
o Dx: clinical findings; r/o other ddx, Bx – grouped atrophy
o Tx: none Riluzole (blocks glutamate transmission in CNS)
o Death occurs within 3-5 years of diagnosis; due to respiratory compromise
-
Pathological laughing or crying where pt is aware of lack of control
o ANSWER: Pseudobulbar affect associated with ALS
-
MS sx including disarthria, dysphagia, drooling, and bulbar mosels
o ANSWER: Bulbar ALS – when paired with psychiatric problem have much worse
prognosis
-
Early hypotonia for the first 6 months to 1 year of life followed by spasticity; non progressive
brain lesions
o ANSWER: Cerebral Palsy
o Cause is unknown but is believed to be due to a number of prenatal and maternal RF’s
(remember there is an association with thyroid dysfunction)
o There are 4 general types of CP; Spastic Heiplegic is the most common
9
-
Type of CP, spacticity, hyperreflexia, clonus and babinski , delayed walking time, walk on tip toes
o ANSWER: Spastic CP
o This is the most common form of CP
o NORMAL IQ!!!!
o Can take on 3 general forms
 Spastic Hemiplegia = Can affect one side with spasticity UE < LE ( hemiplegia)
 Spastic Diplegia= Bilateral LE>UE
 Spastic Quadriplegia = all for extremities; floppy neck, wheel chair
 THIS IS THE WROST FORM
 ASSOCIATED WITH EPILEPSY
 ONLY ONE WITH ABNORMAL IQ
-
Type of MS with abnormal movements, hypertonicity, athetoid, choreothetoid, basal ganglia
involvent
o ANSWER: Dyskinetic
o DTRs are normal
o Risk of deafness with kernicterus
-
Type of CP with no specific tonal quality predominating
o ANSWER: Mixed CP
-
Trunkal and extremity hypotonia with hyerreflexia, persistence of primitive reflexes
o ANSWER: Hypotonic CP – rarest form
-
Scissor gate
o ANSWER: Spastic Diplegic form of CP
-
Slowed uncontrolled writhing movements, grimace, drool, tongue outside of mouth, normal IQ
o ANSWER: Dyskinetic form of CP
-
Brief sensory, motor, autonomic or psychic manifestation that lasts a few second sto a few
minutes; with no alteration of consciousness
o ANSWER: Simple Seizure
-
One limb or one part of the body is affected and then proximal where sensory is affected first
followed by motor
o ANSWER: Jacksonian Seizure or “march” (type of simple seizure)
10
-
Purposeless repetitive automatisms with AMS
o ANSWER: Complex seizure
o 80% = temporal lobe (psychic phenomena)
o 20% = frontal lobes (motor cortex located here  crazy motor behaviors like “ride a
bike”
o Preceded by an aura (simple seizure)
o Partial seizures = affect on side of brain
o Generalized seizures = affect both sides )crosses corpus collosum
-
Progression of Partial complex seizure to a state of rigidity, falls to floor, and then convulses
o ANSWER SECONDARY generalized seizure
o “Tonic –clonic”
-
Blank staring with altered consciousness for <30 seconds,
o ANSWER: Absence seizure – type of primary Generalized seizure
o Dx: classic 3.5 Hz generalized spike and slow wave complexes (hallmark)
o Pt will resume normal activity after episode normally with no clue time as elapsed
o Classic vignette is a child who suddenly starts to due poorly (as number of absence
seizures continues
-
Sudden, brief jerk of body part that lasts < 1 second
o ANSWER: Myoclonic seizure
o Not always pathogenic
o Pt often trips/falls/ drop ojects
-
EEG finding fast polyspike and slow wave complexes
o ANSWER: Myoclonus classic finding
Type of seizure where patient suddenly buckles at the knees and appears to faint
o ANSWER: Atonic seizure – due to sudden loss of postural tone (type of generalized
seizure)
-
-
Sudden bilateral, symmetric contraction for several seconds, pt falls with jaws and fists
clenched; tremble and vibrate for 10-30 seconds; postical confusion
o ANSWER: Tonic-Clonic Seizure (type of generalized seizure)
-
After seizing, PT comes in complained of right arm numbness and paralysis
o ANSWER: Todd’s paralysis
o Common affect the occurs after a Tonic-clonic seizure
o May be confused with Stroke – good pt hx key
11
-
Posterior Shoulder dislocation
o ANSWER: usually due to epilepsy or electrocution
o Anterior shoulder dislocations are MC
-
Seizure that lasts 30 mins or longer OR repetitive generalized seizures without return to
consciousness
o ANSWER: Status Epilepticus
o Associated with various physiologic changes
 Lactic acidosis
 CO2 narcosis
 Hyperkalemia
 Hyperglycemia that progresses to hypoglycemia
 Hypertension
 Arryhythmias
 Pulmonary edema
 Aspiration
 Acute tubular necrosis due to rhabdomyolysis
 Loss of autoregulation
 Tachycardia
 Fever
 Positive Babinski sign
 Tongue/cheek/lip laceration
-
Discuss Tx for status epilepticus
o ANSWER: DOC = Lorazepam
o Adequate ventilation/02
o Thiamine and glucose
o Phenytoin if Lorazepam fails
o Phenobarbital 3rd line
-
35 year old pt with a past history of travel to Africa presents with profound acidosis, seizures
that have lead to coma
o ANSWER: INH toxicity
o INH decreases GABA synthesis and increases cerebral excitability
o Ingestion of 6-10g  may be fatal
o Antidote = Vitamin B6
-
Fever without any other evidence for cause of seizure; child 3mo to 5 years
o ANSWER: Febrile Seizure
o Usually lasts < 15 minutes
o Febrile seizure increases risk for development of Epilepsy later in life
o Dx: First febrile seizure needs a full work up!
12
-
Treatment For single, unprovoked seizure
o ANSWER: Depends how many of the RF’s the pt has
o RFs= Abnormal MRI and Abnormal EEG
o Both RF risk = 80%  prophylax
o One RF risk = 30 – 50%  make pt’s choices
o No RFs = No tx
-
Treatment for actively seizing PTs
o ANSWER: Benzo
-
Treatment for absence seizures
o ANSWER: DOC Ethosuximide
o Valproic Acid (Depakene)
-
Tx for Partial Seizures
o ASNWER: Carbamezapine
-
Common SE of phenytoin
o ANSWER: aplastic anemia, hepatotoxic, gingival hyperplasia
-
Common SE of Valproic Acid
o ANSWER: Hair loss, spinabifida, weight gain
-
Temporary loss of speech, paralysis or paresthesia of contralateral extremity, diplopia, numbess
of face that lasts less than 24 hrs and completely resolves without permanent damage
o ANSWER: Transient Ischemic Attack (brain agina)
o Like a warning sign for future seizure to come
o Tx: Antiplatelet therapy (plavix, aspirin, ticlopidine
 Anticoag if due to cardiac embolus
 Endarterectomy
-
Temporary loss of vision in ipsilateral eye due to clot form carotid to retinal artery
o ANSWER: Amaurosis Fugax
o Part of a TIA
-
Paralysis, contralateral hemiplegia to face and arm , contralateral hemiparesis, homonymous
hemianopsia
o ANSWER: Large vessel Thrombotic Stroke
o MC type of ischemic stroke
o Remember there are 2 types of stroke (ischemic and hemorrhagic)
o Ischemic strokes are MC
o Location Determines location and type of sx
13



-
ACA = contralateral Leg and foot, urinary incontinence,
PCA = Los of central vision, alexia, pupil spared,
Vertibral and Basilar Arteries = ipsilateral face; contralateral trunk/limbs, n/v,
ipsilateral horner’s syndrome
Pure motor or pure sensory involvement
o ANSWER: Small Vessel stroke lacunar infarct
o Often never picked up (1-2cm in size) Cannot see on CT
o RFs = HTN and DM
o Clinical Mans = DO NOT CUASE CORTICAL DEFICITS  no aphasia or apraxia
o Pure motor= (internal capsule) hemiparesis, face, arm, leg
o Pure Sensory = (thalamus) Transient numbness, sensory loss to face, arm, leg.
o Ataxic Hemipareisis may occur as stroke area starts to get bigger
o Tx: PT, OT, SP, prevent secondary comps (DVT)
-
Halo seen on CT due to a stroke
o ANSWER: Ischemic Penumbra
o Area of decreased circulation to brain that can be completely reversible with rapid tx
-
Rapid and sudden presentation of stroke sx, past hx of recent MI, ventricular aneurysm, atrial
fibrillation, bacterial endocarditits or rheumatic heart disease
o ANSWER: Cardiogenic Emblolic Stroke
o Thrombus to heart travels to MCA
o Tx- Anticoag w/heparin; antiplatelet therapy, thrombolytics, anticoagulation if cardiac
embolus, TPAs,
-
Discuss criteria for which PT are candidates for thrombolytic therapy
o ANSWER:
 CT with no evidence of Bleed (no hemorrhagic CVA)
 3 hour window from onset of sx
 BP < 185/110 and controlled
 An Anticoagulants within 48 hrs of administration
 Platelet count > 100,000
 No CVA or head trauma in previous 3 mo
 No major surgery in past 14 days
 No hx of intracranial bleeds
 No rapid improvement
 No GI or GU hemorrhage in last 21 days
 No seizure with onset of stroke
 Glucose with finger stick >50, <200
14
-
-
Hx of HTN, occurred while PT was doing something active, vomiting, headache (“worst headache
of my life”), facidity then spasticity
o ANSWER: Hemorrhagic Stroke
o Due to rupture of bv
o RFs = HTN, age, brain tumor, AV malformation
o Two Types
 Intracerebral hemorrhage
 Subarachnoid Hemorrhage
Congenital malformation; can cause hemorrhagic stroke;
o ANSWER: Ateriovenous malformation
-
Group of neurons in core of brainstem, that receives input from sensory pathways and sends
impulses to the cortex; Maintains attention and alertness
o ANSWER: RAS
o One of 2 components for consciousness
o Other is the Cerebral Cortex = Sensing and Cognition
-
TIPPS AEIOU
o ANSWER: Acronym to remember the causes of acute confused states
o TIPPS = Traums, infection , psych, points, shock
o AEIOU= Alcohol, epilepsy, insulin, opiates, urea
-
Difficult to wake up even with painful stimuli
o ANSWER: Stupor
-
Decreased alertness with sluggish responses
o ANSWER: Obtundation
-
Deep sleep-like state. Cannot be aroused. No sleep wake cycles
o ANSWER: Coma
-
Eyes open, unresponsive, laugh/cry for no reason, yawn, grimace, grunt to nothing specific, limb
and head movements, respiratory and autonomic function retained, no brain activity for
cognition
o ANSWER: Vegitative State
o If persists greater than 6m; chances of reversal is usually 0
o Usually occurs post coma
15
-
Cannot move; paralyzed except for ocular movements, cognition intact
o ANSWER: Locked-in syndrome
o Can still feel sensation of pain and touch
o Due to TBI, medication overdose, or damage to myelin sheath that causes damage to
brain stem stroke, ventral part of pons (lower brain); with no damage to upper brain
-
Trauma, lateral mass, ipsilateral pupil enlargement, sluggish pupils or no reaction at all,
Contralateral hemiparesis, bradycardia, hyptertension
o ANSWER: Uncal transtentorial herniation- herniation of uncus into tentorlal opening
o Uncus = innermost part of temporal lobe
o Key = contralateral paralysis, ipsilateral pupil, Central neurogenic hyperventilation
HTN, Bradicardia, and irregular respiration
o ANSWER: Cushing’s triad for increased intracranial pressure
Midpoint, non-reactive pupils, Cheyne-stokes respirations, positive babinski, decorticate then
decerebrate
o ANSWER: Central transtentorial herniation
o Downward displacement of thalamic region through the tentorial opening
-
-
Worst type of Herniation; cardiac arrest, rapid death
o ANSWER: Tonsillar Herniation
-
Hernation that results in Hydrocephalus/coma
o ANSWER: Infratentorial Lesion that compresses upwards through tentorial notch
-
Herniation that results in cardiac arrest
o ANSWER: Infratentorial Lesion that compresses downwards through foramen magnum
o (Tonsillar herniations also present this way)
-
HTN, bradycardia, widening pulse pressure, irregular respirations, bilateral fixed pupils
o ANSWER: these are all CMs of increased ICP
Method for assessing level of consciousness
o ANSWER: Glasgow Coma scale
o Uses evaluation of eye opening, best motor response, best verbal response
o Lowest score = 3
o Best score = 15
o Less than 8; intubate
o Opens Eyes =
 Spontaneously = 4
 To verbal Comments = 3
 To pain = 2
 No response = 1
o Best Motor Response (Verbal/Painful stimuli
-
16
o
 Obeys=6
 Localizes pain=5
 Flexion withdrawal=4
 Decorticate (flexion) = 3
 Decerebrate (extension) = 2
 No response = 1
Best Verbal response
 Oriented and converses = 5
 Disoriented and converses = 4
 Inappropriate words = 3
 Incomprehensible sounds = 2
 No Response = 1
-
Bilateral dilation
o ANSWER: brainstem involvement
-
Unilateral dilation
o ANSWER: Optic or oculomotor pathway
-
Oculocephalic reflex or Doll’s head eye movement
o ANSWER: EOM intact/brain stem intact
-
Cold water in ear and see nystagmus
o ANSWER: brain stem intact; Caloric test
-
Arms flex at the wrist and elbow with adduction at the shoulder legs extends
o ANSWER: Decorticate posturing
o Indicates extensive cortical hemispheric injury involving diencephalic structures
-
Extensor posturing of the arm at the elbow with the arm internally rotated, leg in extrension
o ANSWER: Decerebrate Posturing
-
Quadriparesis/flaccidity
o ANSWER: indicate pontine or medullary compromise
o Cervical Spine injury
-
Periods of rapid, deep breathing with apneic pauses
o ANSWER: Cheyne-stokes respiration
o Central Herniation
17
-
Breath, hold, let out, pause, (repeat)
o ANSWER: Apeneuistic breathing
o Associated with lower pontine lesions
-
Occasional gasping with periods of apnea
o ANSWER: Ataxic-Chaotic breathing
o Medullary Involvement
-
Pupillary response absent, corneal and gag relex absent, no facial or tongue movement, limbs
are flaccid, an irreversible cessation of all brain function
o ANSWER: Brain Death
o Dx cannot be given if drug intoxication, hypothermia or severe hypotension
-
Ispilateral pupil enlargement, contralateral hemiparesis, Coma, Central Neurogenic breathing
o ANSWER: Uncal Trastentorial herniation
o Due to lateral trauma, Herniation of uncus into tentorial opening
o Remember that CN III (ocular motor) runs near this uncus
o Also associated with cushing’s reflex
-
Midpoint, non-reactive pupils bilaterally, Cheyne-stokes respiration, Cushing’s Triad
o ANSWER: Central Transtentorial Herniation
o Downward displacement of thalamic region through the tentorial opening
o Displacement goes straight down and therefore does not affect the uncus or CN III
o Cause: supratentorial lesions (in cerebrum area)
o Also has a positive Babinski sign
o Usually initially present with decorticate then decerebrate posturing
-
Herniation that presents with cardiac arrest and rapid death
o ANSWER: Tonsillar herniation
o Medial portion of cerebral hemispheres compresses medulla through foramen magnum
o Causes compression of cardiovascular and respiratory centers  death
-
Ataxia, loss of corneal or gag relex, unilateral or bilateral limb weakness or sensory loss prior to
nonreactive pupils, abnormal respiratory patterns, Death
o ANSWER: Infratentorial Herniation
o Herniations in this area can protrude either upward or downward
o Upward : Hydrocephalus/Coma
o Downward: Cardiac arrest
18
-
Bilateral Dilation
o ANSWER: Brainstem involvement
-
Unilateral dilation
o ANSWER: Optic or oculomotor pathway involved
-
Doll’s eye movement
o ANSWER: Indicates oculocepharlic reflex is intact; EOM = Brain stem intact
-
Dilated pupils
o ANSWER: SNS  hypothalamus
-
Constricted Pupils
o ANSWER: PNS
-
Cold water in ear canal with nystagmus
o ANSWER: Caloric testing
o Nystagmus indicates brain stem is still intact
-
After painful stimuli; arms flex at the wrist and elbow with adduction at the shoulder, legs
extend
o ANSWER: Decorticate Posturing
o Extensive cortical hemispheric injury involving diencephalic structures
-
After painful stimuli, extensor posturing of the arm at the elbow with the arm internally rotated,
leg in extension
o ANSWER: Decerebrate posturing
o Midbrain and lower brainstem involvement
-
Quadriparesis/Flaccidity after painful stimuli
o ANSWER: Pontine or medullary compromise; Cervical spine injury
-
Preiod of rapid, deep breathing with apneic pauses
o ANSWER: Cheyne-stokes respiration
o Associated with CNS supratentorial lesion or metabolic causes
o Central Herniation
-
Abnormal pattern of breathing characterized by deep and rapid breaths;
o ANSWER: Central Neurogenic Hyperventilation
o Structural involvement of lower midbrain and upper pons
o Uncal Herniation
19
-
Breath, hold, exhale, stop, breath, hold, exhale, stop
o ANSWER: Apneustic breathing
o Lower pontine lesion or tonsillar herniation
o Massive hernations may also present this way
-
Chaotic breathing, no rhythm, occational gasping with periods of apnea
o ANSWER: Chaotic breathing
o Medullary involvement
-
Describe the management for pt with herniations
o ANSWER: Intubate if GCS<8
o Tx rapidly progressive metabolic disorders
o Monitor signs of increasing ICP (cushings triad)
o If pt with AMS with unknown etiology
 IV Naloxone (narcotic antagonist)
 Give sugar (Dextrose) brain can only go 2 mins without glucose
 Thiamine for alcoholic pt to avoid wenicke disease
o Transtensorial herniation and midbrain compression likely
 Intubation and hyperventilation (reduces partial pressure of CO2 and ICP
 Mannitol and high dose corticosteroids
-
Unresponsive to external visual, auditory, and tactile stimuli, papillary response absent, conreal
and gag relex absent, no facial or tounge movement, limbs are flaccid
o ANSWER: Brain death
o Cannot dx brain death if drug intoxication, hypothermia or severe hypotension
o 2 evaluations and 6 and 12 hours
o Anorexia brain damage requires 24 hours of observation
-
Stage of sleep where you are alert and relaxed, transition period between wake and sleep; easily
aroused by sensory stimuli. Sudden muscle contractions; may hallucinate
o ANSWER: Stage I of sleep
o Loss of muscle tone; head bobbing
-
Period of sleep where brain waves slow, lasts 10-25 minutes, sleep spindles and K complexes,
not aware of external environment but easily aroused
o ANSWER: Stage II of Sleep
o Follows stage I
20
-
Period of sleep with slow waves, deepest and most restorative; bedwetting, night terros, sleep
walking, coma-like
o ANSWER: Stage III and IV
o III = transition phase to stage IV
o Completed in first two 90 minute sleep cycles
o Delta brain waves
-
Stage of sleep with REM sleep, dreams, limbs paralyzed
o ANSWER: Stage 5
o Without this stage pt is irritable and anxious
o Remember that a complete cycle is 90 minutes
-
Name one 90 minute cycle of sleep
o ANSWER: I, II, III, IV, III, II, V
-
Difficulty with starting and maintaining sleep
o ANSWER: Dyssomnias
o Primary insomnia
o Sleep apnea
o Circadian rhythm disorders
o Narcolepsy
-
Abnormal behaviors while sleeping, MC in young children
o ANSWER: Paracomnias
o Primary sleep disorder
o Sleep walking
o Nightmares
-
Micturation 3-4 hours into sleep
o ANSWER: Enuresis
o Type of parsomnia
-
Inability to fall into deep sleep, wakefulness during night, early morning awakening
o ANSWER: Insomnia
o Type of Dyssomnia
o Loss of restorative sleep
o Difficulty falling asleep, staying asleep, waking up too early = common in elderly
o 2 types of insomnia
 Acute
 Chronic
o Dx – sleep diary 1-2 weeks, polysomnography, rule out other disorders
o Tx:
21



Benzo receptor agonists, nonbenzo hypnotic (Zolipidem/Zaleplon) these are
short acting; don’t use longer than 10 days (rebound insomnia and addictive)
Antihistamine = longer acting, drowsiness
Sleep hygeine
-
Type of insomnia that lasts 1 night to 1 week
o ANSWER: Acute
o Due to emotional stress, caffeine, pain, change in sleep schedule, nonconductive sleep
environments
o Causes sleepiness, negative mood, impaired performance
-
Type of insomnia that occurs 3 days per week for at least 1 month
o ANSWER: Chronic insomnia
o Due to depression, stress, pain, medical conditions, chronic fatigue syndrome, sleep
apnea, restless leg syndrome
-
Male 30-60 with hx of snoring and excessive daytime sleepiness, nocturnal gasping, moderate
obesity, large neck circumference, mild to moderate HTN
o ANSWER: Sleep apnea- periods of breathing cessation during sleep
o Can go up to 120 seconds without breathing; can have up to 500 episodes per night
o RF: obesity, increased neck girth, males, increasing age
o 2 types
 Obstructive sleep apnea – due to obstruction; No 1 RF = Obesity
 Central sleep Apnea- due to disorder affecting the respiratory center in the
brain
o Tx
 Mild –moderate = Weight loss, avoid aggravating factors such as alcohol,
sedatives, sleep lateral postion
 Severe- Nsal CPAP
 Uvulopalatopharyngoplasty
-
Muscle weakness without LOC
o ANSWER: Cataplexy
o Commonly associated with narcolepsy
22
-
Daytime sleep attacks in boring, sedentary situations
o ANSWER: Narcolepsy
o Abrupt transition into REM sleep
o Dx – history, sleep studies show rapid entrance into REM sleep
o Tx Stimulants like Methyphenidate
 Wake promoting therapeutics
 REM Sleep depression with antidrepressants
 Adequate nocturnal sleep with planned day time naps
-
Repetitive movement of large toe with flexion of ankle, knee, hip during sleep
o ANSWER: Periodic Movement disorder
o Occurs during state I or II
-
Irresistible urge to move legs, creepy-crawly sensation
o ANSWER: Restless leg syndrome (RLS)
-
Fear, sweating, tachycardia, confusion with amnesia of event, screaming during sleep
o ANSWER: sleep terror
o Movement and behaviors not expected in sleep
o Stages 3-4
-
Ambulation during sleep with amnesia during event
o ANSWER: Sleepwalking
o Occurs during Stages 3-4
o MC in ages 6-12
-
Sudden onset of headache, fever, nausea, vomiting, neck stiffness, nuchal rigidity, kernig’s sign,
brudzinski’s sign
o ANSWER: Meningitis
o Sudden usually indicates acute or bacteria etiology
o Bacterial has a worse prognosis than viral
o Neonates = Group B Streptocci
 Itx= cefotaxime + ampicilline + vancomycin (aminocycoside if <4w)
o Children over 3 mo = Neisseria Meningitidis
 Itx= Ceftriaxone or cefotaxime + vanco
o Adults 18-50 = Stretococcal pneumonia
 ITx= Ceftriaxone or cefotaxime + vanco
o Elderly (Over 50) = streptococcal pneumonia
 ITx= Ceftriaxone or cefotaxime + vanco + ampicillin
o Immunocompromised= Lysteria monocytogenes
o Diagnosis:
23
o



If with Maculopapular rash with petechiiae = N. meningitides
If with Vesicular lesions = varicella or HSV
Lumbar puncture for CSF analysis PERFORM CT FIRST IF THERE ARE FOCAL NEUROLOIGC SIGNS OF IF
THERE IS EVIDENCE OF A SPACE OCCUPYING LESION WITH ELEVATIONS
IN ICP
 Cloud y= pyogenic  start empiric tx STAT
 Bacterial = WBC >1000, WBC diff = PMNs, low glucose, high protein
 Aseptic Meningitis = WBC < 1,000, WBC diff = lymphocytes and
monocytes, glucose = normal, protein = moderate elevation
 Blood cultures before ignition of tx




See imperical tx above
Start IV abx stat after LP unless CT required or delay in LP
Steroids if cerebral edema
Vaccinate
 All pt >65 for s. pneumonia
 Asplentic pt for S.pneumonia, N. meningitides, H. influenza
 Immunocompromised pt for meningococcus
Prophylax
 Rifampin or ceftriaxone (1 dose IM ceftriaxone) for all direct contacts
Tx

-
Prodrome HA, malaise, myalgias, within hours to days  acute illness; nuchal rigidity, fever,
headache, with increased AMS
o ANSWER: Encephalitis
o MCC = Viral (arboviruses and HSV)
o CSF PCR = most specific and sensitive test for diagnosing many various viral
encephalitides (HSV-1, CMV, EBV, VZV)
o MRI of Brain = STUDY OF CHOICE
 Increased areas of T2 signals in frontotemporal localization = HSV encephalitis
o EEG= useful in dx of HSV-1 etiology
 Unilateral or bilateral temporal lobe discharges
o Tx: supportive, venterilator if needed
 HSV = acyclovir (2-3w)
 CMV = encephalitis = ganciclovir or fascarnet
-
Flexion of neck causes involuntary flexion of hips and legs
o ANSWER: Brudzinski Neck Sign
o Due to extensions of meninges
o Meningitis
24
-
Flex hip and knee causes pain, pain abates with leg extension
o ANSWER: Kernigs’s sign
o Meningitis
-
Japanese, over 70, comes into ED concerned they are suffering from a stroke or seizure due to
unilateral facial paralysis and drooping, mastoid tenderness
o ANSWER: Bells Palsy
o Cause unsure; viral, infectious, and familial links
o Tx: Steroids, antivirals, eye hygiene
-
Dystocia, paralyisis of brachial area of arm
o ANSWER: Erbs palsy
o Tx: some self resolve
 Neurosugery – avulsion fracture repair
 Nerve transplants
 Subscapularis reslease
 Latissimus Dorsi tendon Transfers
o Arthritis later in life = common
Mother comes in with her 2 year old son concerned. He has become more clumsy, and his gate
is still abnormal.
o ANSWER: Muscular dystrophy ( Duchenne’s)
o You may be able to determine it is the more severe form just from the fact that he is
presenting with sx so young
o Due to defect in dystrophin gene- characterized by proximal muscle weakness
o MC associated with Pulmonary Disorders
o Other classic findings
 Never can fully run
 Problems climbing stairs
 By 18 mo will have drooping of legs with prone position
 Pseudohypertrophy in calves
 Gower’s Maneuver
 Increased Lumbar Lordosis
o Dx
 CK levels will be 7,000 to 15,000 (normal is 12-25)
 DNA analysis of dystrophin
 If CK levels high, and DNA analysis negative  muscle biopsy
Mother comes in concerned about her 8 year old son; increased clumsiness, and her son has
been complaining of “cramps”
o ANSWER: Muscular Dystrophy (Becker’s)
o Less severe form; usually present clinically around age of 8
o Due to deletion in Dystrophin gene
o Dx is important because it is associated with Cardiomyopathies
-
-
25
o
Dx= Serum CK is moderately eleveated (5-100 x) normal
26
Cardiology
-
Palpitation, tunnel vision, nausea, dizziness, palor, diaphoresis
o ANSWER: prodromal sx of autonomic reflex mediated syncope
o There are 4 categories of autonomic reflex mediated syncope
 Vasovagal
 Orothostatic
 Carotid sinus hypersensitivity
 Situational syncope
-
Pt is on the phone standing when they receive bad new about a family member, start to have
tunnel vision, dizzy and LOC.
o ANSWER: Vasovagal Syncope
o Classically this is initiated by some type of nxious stimulus or characteristic setting
(trauma, pain, emotional stress, fear), and if standing vertical at time of the event,
attacks can be aborted or resolved by reclining
o Dx of this should not be made without classic prodromal sx!
-
70 year old Patient was laying down all night got up to go the bathroom; LOC
o ANSWER: Orthostatic syncope
o Due to insufficient response of the ANS to increase sympathetic output and decrease in
PNS
o When pt stands, blood is shifted to lower body and Q drops.
o Increased risk in pts with diabetic neuropathy, medications, volume depletion (n/v
diarrhea, trauma)
o Also increased prevalence in the elderly
-
Elderly, male patient, with history of HTN and angina comes in complaining of LOC while
shaving
o ANSWER: Carotid sinus hypersensitivity
o Due to the stimulation of an abnormally sensitive carotid body by external pressure 
abnormal vagal response with bradycardia asystole of great than 3s or drop of BP >50
mmHg
o Most common in elderly males with ischemic heart disease, HTN, and head/Neck
malignancies
o Associated with an inciting event such as a tie, shaving (electric razor), or even just
turning of neck in severe situations
-
Patient comes in complaining of repeated episodes of LOC after micturation
o ANSWER: Situational syncope
o Abnormal autonomic reflex response to specific stimulus
27
o
May be associated with an underlying sidease process such as esophageal stricture in
swallow syncope, prostatic hypertrophy, or bladder neck obstruction with micturation
syncope and constipation with defecation syncope
-
50 year old male, LOC with no warning
o ANSWER: Cardiac Syncope
o Causes include:
 Obstructive Cardiac Lesions- commonly occurs in the setting of physical
exetation or as a response to vasodilation from medication of heart
 Cardiac dysrhythmia- usually occurs suddenly, with prodromal syndromes if
any, lasting less than 3 seconds and is (Hall Mark)
 Aortic Stenosis- If elderly pt, make sure to r/o aortic stenosis
 Hypertrophic Cardiomyopathy
 Pulmonary outflow obstruction
 13% of pts with acute pulmonary embolism
-
2 MC sx of Pulmonary Emobolism
o ANSWER: Tachypnea and Dyspnea
o Get D-miner, VQ scan or spiral CT (initial) and pulmonary angiogram (DxTOC)
-
Chest pain that radiated to the neck, DOE, and Syncope
o ANSWER: Aortic Stenosis
-
18 year old, senior in high school, playing basketball, goes up for a lay up and suddenly has lOC
o ANSWER: Classic presentation of Hypertrophic cardiomyopathy
o Type of Cardiogenic Shock
-
Sudden brief episodes, with diplopia, vertigo, dysarthria, dysphageia, ataxia
o ANSWER: Brainstem Ischemia Syncope
o Type of neurological caused syncope
-
PT comes in complaining of syncope while working out. He was doing curls on his left arm. He
also noticed he can do way more reps in his left
o ANSWER: Subclavian steal syndrome
o Rare cause of brain stem ischemia
o Characterized by abnormal narrowing narrowing of the subclab artery proximala to
origin of the vertebral artery
o Exercise in ipsilateral arm causes blood to e shunted “stolen” form vertebrobasilar
system to subclavian artery supplying the arm muscles
o More common on the left
o PE findings =
 Coldness
28





Parestheias
Numbness
BP lower in the effected arm
Pluses are weaker in affected arm
Tx: stent
-
PT with hx of panic attacks, and major depressive disorder, young female, repeated episodes of
syncope
o ANSWER: Munchowsins Syndrome
-
Explain Carotid sinus massage test
o Used to rule out carotid hypersensitivy
o Pt on cardiac monitor with atropine available
o Massage for 5 seconds at the point of greatest carotid pulse intensity at the level of the
thyroid cartilage unilaterally
o Maximal response occurs after about 18 seconds
o Positive test = production of 3 seconds of asystole or fall in systolic pressure of
50>mmHg or syncope
o If result is negative, process is repeated on teh other carotid sinus
o Contraindicated: buits, CVA hx, MI hx, carotid stenosis
-
Head-up- tilt-table Test
o Used to confirm autonomic dysfunction
o Collect baseline Bp and EKG at start with pt lying supping
o Lilt head to 30 degrees checking bp and EKG for 5 minutes
o Then tilt head up to 60 degrees for 45 minutes
o Then lower table until patient is flat and evaluate how body response to stress
o Thentilt talbe to 60 degrees for 15 minutes
o Positive = drop in Bp associated with sx
-
Pt just went through prosthetic valve surgery, 20 days later develops rapid onset of high fever,
tachycardia and fatigue
o ANSWER: Prosthetic Valve Endocarditis
o This would be early Prosthetic valve endocarditis
o Can also be late valve Endocarditis if got after 60 days of procedure
 Early Prosthetic Valve Infective Endocarditis = less than 60 days, MCC= Staph
 Late Prosthetic Valve Infective Endocarditis= 60 days after procedure; MCC =
Strep
29
-
Explain the key differences between acute and subacute infective endocarditis
o ANSWER: Acute is caused by more virulent pathogens and Most commonly staph
aureus. Acute is characterized by a rapid onset with high spiked fever, tachycardia, and
extensive valve damage. Subacute endocarditis is caused by less virulent pathogens,
fever is usually more mild, onset is slower, and signs chronic complications can also be
seen such as low RBC count and weight loss
-
Patient comes in with a new murmur; After echo it is determined that the tricuspid valve is
involved and blood cultures are positive for staph and candida antigens. What would you expect
this patients history to be positive for?
o ANSWER: IV drug use
o New onset murmur should always raise suspicion for Infective Endocarditis
o IV drug use associated Infective endocarditis is most commonly cause by staph, however
polimicrobial and fungal causes are also common
 MC fungal causes are aspergillus or candida
o Also keep in mind that usually the MC valve/murmur is mitral prolapsed, however in
infective endocarditis the MC affected valve is the tricuspid
-
MC valve affected in Rheumatic fever
o ANSWER: Mitral
o Also aortic (left side)
-
70 year old patient with hx of DM has been admitted to the medical floor for 2 weeks, with an
intravenous catheter. Develops rapid onset of fever, tachycardia, fatigue and echo show signs of
extensive valve damage
o ANSWER: Health-Care Associated Infective Endocarditis
o MC due to invasive therapies like intravenous catherter, hyperalimentation lines,
pacemakers, and dialysis
o These pts are usually older and have some type of Co-morbid illness
o MCC = Staph Aureus
o Keep in mind that this type of infective endocarditis is commonly MRSA and resisitant to
normal empiric tx with PNC, naficillin and gentamicin ; use vanco and gent instead
-
Explain Diagnosis of Infective Endocarditis
o ANSWER:
 Always suspect in pt with new heart murmer and unexplained fever, or with
staphylococcal septicemia
 Gold standard = culture of a pathologic organism from a valve or other
endocardial surface
 Elevated ESR
 Echocardiograph
 Tee
30

Dukes = 2 Major, One major and 3 minor, 5 minor
 Major = Blood Culture Positive, Evidence of Endocardial Involvement,
serology
 Minor= predisposing condition, fever >38C, Vascular phenomena,
vascular phenomena, immunologic phenomena, echocardiogram,
microbiologic evidence
-
Pt presents with chest pain that radiates to backand neck and is alleviated with leaning forward,
pericardial friction rub, and PR depression on ECG
o ANSWER: Acute Pericarditis
o MCC are idiopathic and infectious
 Idiopathic= usually 1-2 weeks, preceded by flu-like sx, resp or gi
 Infectious
 Viral = MC in 18-30 year olds echovirus, coxsackie, HIV, hepatitis A or B,
 Bacterial = TB
 Fungal = Taxoplasmosis
o Classic ECG findins = ST elevation with PR depression
 Progression of ECG findings include
 St elevation with PR depression
 ST returns to normal
 T wave inverts
 T wave returns to normal
o Blood tests may show: increased ESR, C-reactive protein, and leukocyte count
o Tx = self limited, tx underlying cause, NSAIDS
-
On physical exam you notice JVD, kussmaul’s sign, pericardial known, and ascites. What would
you expect to with cardiac catheterization?
o ANSWER: “square root sign”
o This is the classic finding for Constrictive pericarditis
o This is characterized as fibrous scarring and adhesions of both pericardial layers
o Square root sign is because diastolic filling is only impeded late in diastoli. This is a key
different between constrictive pericarditis and temponade (diastolic filling impaired
throughout diastoli)
o Ascites and edema are common because the inability to completely fill the ventricles
causes back up of blood into the atria and in to systemic ciculation
o Diagnosis
 Echocardiogram = test of choice= thickened pericardium
 ECG = low WRS with generalized T waves
 Cardiac Catherization = elevated and equal diastolic pressure in all chambers,
rapid y descent ; square root sign
o Treatment
31
-
-
-
 Pericardial stripping = most definitive
Patient comes and on PE you notice muffled heart sounds, a soft PMI, dullness at the left lung
base and pericardial friction rub; What would you expect to see on CXR of this patient
o ANSWER: “Water bottle appearance” = enlarged heart without pulmonary vascular
congestion; NOTE: enalargement of cardiac silhouette if >250mL of fluid
o This patient has a pericardial effusion
o MC fluid is exudative = pericardial injury or inflammation
o Diagnosis
 Echo = dx test of choice
 ECG = low QRS voltage, Twave flattening, Electrical alterans(in in the presence
of temponade as well)
o Treatment
 Pericardiocentesis not indicated unless cardial tamponade is present
 Supportive, repeat echo in 1-2 weeks
Patient presents with hypotension, JVD, and muffled heart sounds. What would you expect to
find on ECG?
o ANSWER: Electrical Alterans (alternate beat variation in direction of ECG )
o This is classic presentation of Cardiac Tamponade and is a triad known as Beck’s Triad
o Diastolic filling is inhibited throughout diastoli
o CM that distingui tamponade from constrive percarditis include
 JVD
 Sinus tachy
 Hypotension
 Narrow pulse pressure
 PUlus paradoxus (decrease in arterial pressure during inspiration>10mmHg)
 Distant heart sounds
o Diagnosis
 Echo = BEST
 CXR
 ECG-electrical alterans
 Cardiac catheterization = equalization of pressure in all 4 chambers
Tx
o Hemodynamtically Stable
 Monitor with echo, cxr, ECG
 If with hx of renal failure  dialysis is more useful
o Hemo unstable
 PEricardiocentesis
o Hemorrhagic secondary to trauma
 Emergent surgery
32
-
-
Pt comes in complaining of a “sense of fullness”, abdominal pain, hypotension, and palpable
pulsatile abdominal mass. What is the test of choice to confirm your diagnosis?
o ANSWER: Ultrasound- 100% sensitive in detecting AAA
o This is the classic triad for AAA
o Other common manifestionations include
 Pain in back or lwer abdomen that radiated to the groin, buttock or legs
 Grey Tuner’s Sign – ecchymosis on back/flanks
 Cullen’s Sign – ecchymoses around umbilicus
o Treatment
 Depends on size of Aneurysm
 Normal size = 2 cm
 If >5cm or sx  surgical resection with synthetic graft placement
 If asx or <5cm  tx is controversial periodic imaging is recommended
o There is no safe size for an AAA, small ones can rupture
Pt comes in to ED with severe, tearing/ripping/stabbing pain in anterior of chest and
interscauplar region. What test would you order?
o ANSWER: TEE and CTscan are preferred tests for dx of aortic dissection
o There are 2 types
 A = ascending
 B= descending
o MC sites for dissection include
 Aortic arch
 2.2 cm about aortic root
 Distal to left subclavian artery
o MC ddx is MI but it is very important to differentiate between the 2 because
administration of thrombolytics can be fatal in a person with aortic dissection
o Tx = Emergency
 Admit to ICU for
 Arterial blood pressure monitoring with arterial line
 Central venous pressure monitoring with central catherter
 Cardiac performance and filling pressures with swn-ganz catehrization
 Urine output monitoring with a foley cath and bag
 IV Beta-Blocker (Latetalol)
 CI = hypersensitivity to drug/class, severe asthma, heart block,
uncompensated heart failure, bradycardia, severe obstructive
pulmonary disease, hypotension
 CCB when besta blockers are CI = Diltiazem
 CI = hypersensitivity to drug/class
 Seconds or third degree atrioventricular block
 Sick sinus syndrome
 Hypotension
33
o
 Left vent dysfunction
 Pulmonary congestion
IV Sodium nitroprusside
 Lowers BP to 120 mmHg
 CI= hypersensitivity to druge/class
 Poor cerebral perfusion
 Poor coronary perfusion
-
PT comes in complaining of headache and claudicatio with exercise and leg fatigue. On PE you
notice hypotension in lower extremities, well developed upper body with underdeveloped lower
half, cold extremities. What would you expect to see on CXR
o ANSWER: “figure 3 appearance” of Aortic coartction
o Narrowing/constriction of aorta
o MC at origin of left subclavian  increased left vent afterload
o MC in Males
o If present in females may be associated with Turner’s syndrome
o ECG = left ventricular hypertrophy
o Treatment
 Surgical decompression
 Percutaneous balloon aortoplasty
-
Pt with a past history of MI (3 weeks ago) comes in with fever, malaise, and chest pain. On PE
you note a friction rub, and labs show a leukocytosis. What would you suspect?
o ANSWER: Dresseler’s Syndrome
o Also known as postmyocardial infection syndrome
o Immunologically based syndrome consisting of fever, paliase, pericarditis, leukocytosis,
and pleuritis
o Occurs weeks to months after an MI
o Commonly confused as a seond MI
o Tx: Aspirin
-
Name the drugs that are associated with reducing mortality in MI
o ANSWER: ASA, beta-blockers, and Ace inhibitors
-
65 year old, African American male Patient with a hx of CAD, and hypertension, comes in
complaining of DOE, and having to get up in the middle of the night because he cannot breathe
and go open a window for a while. On PE you notice tachycardia, HTN and rales. What would
you suspect?
o ANSWER: Heart failure (left sided)
o This patient had several risk factors associated with HF including: race (African
American, Hispanic, Native American), Age (60>), and a hx of CAD and HTN
34
o
o
o
o
-
Left sided heart failure most commonly presents with DOE, orthostatic hypotension and
paroxysmal nocturia (the feeling SOB in middle of night), and Tachycardia as a
compensatory mechanism for the decreased SV
Left sides heart failure can also cause a back up of fluid into the pulmonary circulation
 Pulmonary edema; acute pulmonary edema is a medical emergency and indicated
decompensated CHF
CXR = Bat wing appearance
Pink frothy sputum
In the above PT, what other sx would suggest Right sides heart failure?
o ANSWER: Bipedal edema, SOB, Hepatomegaly, Caput medusa, S4, hemorrhoids,
splenomegaly
o MCC of right sided heart failure is left sided heart failure (other causes include cor
pulmonale and tricuspid regurg)
o Right sided heart failure causes back up of blood in the venous circulation. This leads to
affects on the spleen and liver.
 Spleen = hepatomegaly, ascites, heatojugular reflux, caput madusea
 Speel = splenomegaly
o Right and left sided Heart failure commonly occur together
35