Internal medicine random fact

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Internal medicine random fact
2013-06-16 23:41:38

random key points for IM
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  1. Andiodysplasia is associated with aortic stenosis
    The low glucose concentration of exudative effusions is caused by high metabolic activity of leukocytes within the pleural fluid
  2. HIV is risk factor to develop TTP-suspect this if pt has altered mental status, renal failure, thrombocytopenia, and hemolytic anemia (indirect hyperbilirubinemia)
    • Lights criteria for transudate:
    • 1) pleural fluid protein/serum protein ratio <.5
    • 2) pleural fluid LDH/serum LDH ratio <.6
    • 3) Pleural fluid LDH < 2/3 upper limit of normal
  3. Sarcoidosis typically affects the skin (most commonly erythema nodosum) and the eyes (uveitis)
    Medications that should be withheld before exercise EKG testing include anti-ischemic meds, digoxin, and meds that slow HR (ex. beta blockers)
  4. Thyroid abnormalities can present with proximal muscle weakness (picture very similar to myasthenia gravis but there is lack of eye and bulbar involvement and pt has sx of hyper- or hypothyroid)
    • Tx non-ketotic hyperglycemia coma:
    • 1. Fluid replacement with normal saline and insulin therapy
    • 2. Replace with half saline and insulin therapy
    • 3. Swap to 5% dextrose once blood glucose is 250 mg/dL
    • 4. Potassium once potassium level reaches normal level
  5. Livedo reticularis is seen in cholesterol embolization syndrome
  6. Severe aortic stenosis -> large LV mass -> increased myocardial O2 demand -> anginal chest pain (may see in young pt with congenital AS)
    Best screening for acute hep B: HBsAg and anti-HBc
  7. Presbycusis is sensorineural hearing loss that occurs with aging; occurs in sixth decade of life; presents with high-freq bilateral hearing loss (trouble hearing in noisy, crowded environments)
    Otosclerosis: chronic conductive hearing loss associated with bony overgrowth of stapes that begins with low freq hearing loss in middle aged individuals
  8. Pentamidine is alternative drug to tx PCP when pt cannot tolerate bactrim
    Add prednisolone to PCP tx regimen if PaO2<70 (give bactrim + predisone)
  9. Complications of ventilation with high PEEP: alveolar damage, hypotension, and tension pneumothorax (sudden onset SOB, hypotension, tachycardia, tracheal deviation, and unilateral absence of breath sounds)
    If pt stops hyperventilating during acute asthma exacerbation it could be sign that pt is decompensating (due to fatigue) and intubation may be required
  10. Bochdalek's hernia: congenital diaphragmatic hernia that occurs usu on posterior left side in infants
    Morgagni hernia: congenital diaphragmantic hernia that occurs most often anteriorly
  11. Pleural fluid pearls:
    1. Incr fluid amylase = esophageal rupture, pancreatitis, malignancy
    2. Milk, opalescent fluid = chylothorax
    3. Frankly prurulent: empyema
    4. Bloody = malignancy
    5. Primarily lymphocytis = TB
    6. pH < 7.2 = paraneumonic effusion, or empyema
    Empyema is complicated parapneumonic effusion (means the pleural effusion is infected)
  12. Supplemental O2 is first tx for spontaneous pneumothorax if pt is sx or pneumothorax is large
    Mediastinum shifts away from side of tension pneumothorax (because positive pressure in pleural space collapses lung)
  13. Do NOT get CXR if suspect tension pneumothorax -> immediately decompress with large bore needle or chest tube
    It pt has clubbing, get CXR (lung disease may be present)
  14. Interstitial lung diseases associated with granulomas: Sarcoidosis, histiocytosis x, wegener's granulomatosis, churg-strauss syndrome
    Sarcoidosis: Noncaseating granulomas, African Americans, erythema nodosum, anterior uveitis, cardiac disease is most common cause of death, may have elevated ACE; tx with systemic corticosteroids
  15. Wegener's granulomatosis: c-ANCA ILD
    Churg-Strauss syndrome: p-ANCA ILD seen in pt with asthma
  16. Silicosis: localized and nodular peribrhochial ifbrosis
    Berylliosis: diffuse pneumonitis with granulomas, skin lesions, and *hypercalcemia* (like sarcoidosis)
  17. ILD associated with hypersensitivity: Extrinsic allergic alveolitis (Hypersensitivity pneumonitis) and eosinophilic PNA
    Hypersensitivity pneumonitis: farmer's lung, bird breeders lung, air conditioner lung, bagassosis, mushroom worker's lung
  18. Pulmonary alveolar proteinosis: CR has ground glass appearance with bilateral alveolar infiltrates that resemble a bat shape
    Hypoxia due to shunt is not responsive to supplemental O2
  19. Clinical criteria to dx ARDS:
    1) hypoxemia refractory to O2 therapy with ratio of PaO2/FiO2 <200
    2) Bilateral diffuse pulm infiltrates on CXR
    3) No evidence of CHF (PCWP < 18)
    If PCWP is high (>18), cardiogenic pulmonary edema is more likely
  20. For every change in PaCO2 by 10, pg should chanbe by .08
    if pH change is same direction as PaCo2, primary d/o usu metabolic; if opposite, primar d/o respiratory
  21. Hypercalcemia can cause severe constipation and is common in pt with multiple myeloma (presents as back pain, anemia, renal dysfunction, and incr ESR), as well as metastatic bone cancers from lung, breast, renal, or thyroid
    Signs of hypercalcemia include constipation, anorexia, weakness, renal tubular dysfunction, and neurologic sx
  22. Enthesitis is common finding in ankylosing spondylitis and typical sites of pain include heels (pain with walking), tibial tuberosities, and iliac crests
    Common PE findings of ankylosing spondylitis include decr lumbar spinal mobility and tenderness over sacroiliac joints
  23. Suspect ankylosing spondylitis in any young person with progressive low back pain and spinal stiffness >3 months
    BPH starts in center of prostate
  24. Primary open angle glaucoma: Common in African Americans; presents as gradual loss of peripheral vision leading to tunnel vision with cupping of optic disc because of high intraocular pressure
    Closed angle glaucoma: Char by sudden onset of blurred vision, severe eye pain, nausea, vomiting, and a red eye with hazy cornea and fixed, dilated pupil
  25. Aspirin sensitivity syndrome is a pseudo-allergic rxn that results from aspirin-induced prostaglandin/leukotriene misbalance; tx with luekotriene receptor antagonists
    Chloroquine-resistant Plasmodium falciparum is common in Sub-Saharan Africa and India, Pakistan, and Bangladesh; use mefloquine for prophylaxis
  26. Hypertrophic cardiomyopathy is characterized by abnormal mitral leaflet motion (systolic antioer motion) in addition to hypertrophied IV septum
    Thrombocytopenia is the initial presentation in 10% of HIV cases; suspect HIV in asx pt with normal PE and no abnormalities in other hematopoietic cell lines
  27. Give pneumococcoal and flu vaccination to all HIV pt with CD4>200
    Tx of dehydration is IV crystalloid solutions (ex normal saline)
  28. Colloid soln are used in burns or conditions involving hypoproteinemia
    Gold standard to dx acromegaly is measurement of GH following oral glucose load
  29. Pt with hx of RA, enlarged kidneys, and hepatomegaly in setting of nephrotic syndrome likely have amyloidosis (RA predisposes to amyloidosis) -> get amyloid deposits on renal bx with apple-green birefringence
    Buproprion is FDA approved for smoking cessation
  30. Waldenstrom's macroglobulinemia is char by blood hyperviscosity due to excess IgM production; dx clues = IgM spike on electrophoresis and hyperviscosity
    • Major signs and sx of Waldenstrom's macroglobulinemia:
    • 1. Increased size of liver, spleen, and LN
    • 2. Tiredness from anemia
    • 3. Tendency to bruise/bleed
    • 4. Night sweats
    • 5. Headache and dizziness
    • 6. Various visual problems
    • 7. Pain and numbness in extremities because of demyelinating sensorimotor neuropathy
  31. Multiple myeloma can be distinguished from Waldenstrom's because MM has IgG or IgA and rarely involves hyperviscosity syndomes like retinal vein engorgement
    MGUS is mostly asx or mild sx
  32. Familial hypocalciuric hypercalcemia and primary hyperparathyroidism present with incr serum Ca and increased/inappropriately normal PTH
    • Distinguish the two:
    • FHH has decreased renal calcium excretion
    • PH has normal or elevated renal Ca excretion
  33. Dermatitis herpetiformis: pruritic papules and vesicles over elbows, knees, posterior aspect neck and scalp, with anti-endomysial antibodies in serum
    Avoid mydriatic agents (i.e. atropine) in acute glaucoma
  34. Tx glaucoma with mannitol, acetazolamide, pilocarpine, or timolol
    Anti-toposisomerase-I antibodies are seen in systemic sclerosis
  35. Antimitochondrial antibodies are seen in primary biliary cirrhosis
    anti smooth muscle antibodies are seen in autoimmune hepatitis
  36. CK-MB returns to normal levels 1-2 days later and is best to assess for coronary re-occlusion after MI
    Asx pt with Paget's do not require tx; sx pt can be tx with oral or IV bisphosphonates
  37. CMV colitis in HIV pt with CD4 <50 presents as bloody diarrhea with abd pain, multiple ulcers and mucosal erosions on colonoscopy, and eosinophilic intranuclear and basophilic intracytoplasmic inclusions
    Severe pain in pt with BPH may cause urinary retention due to inability to Valsalva
  38. Nonketotic hyperosmolar syndrome leads to severe dehydration because the hyperglycemia causes glycosuria, leading to water loss
    CT scan of invasive aspergillosis shows pulmonary nodules with halo sign or lesions with an air crescent
  39. Hyperparathyroidism predisposes to development of pseudogout
    Sound travels faster in solids (consolidation), so PNA has increased tactile fremitus

    PNA also has egophony, bronchophony, and whispered pectoriloquy
  40. Fluid or air outside lung disrupts transmission of sound, so pleural effusion and pneumonthorax have decreased fremitus
    Low serum Fe, low ferritin, and ELEVATED TIBC = iron deficiency anemia

    (have the space for iron but can't find to bind it)
  41. Hypoparathyroidism is char by low calcium and elevated PO4 in the presence of normal renal function
    Osteomalacia shows decr serum Ca and PO4 and presents as bone pain and tenderness
  42. New clubbing in pt with COPD indicates development of lung cancer
    Increased extracellular pH (as from respiratory alkalosis) can increase affinity of serum albumin to calcium -> incr albumin bound Ca
  43. NSAID therapy can lead to SIADH
    Common cutaneous associations of primary billiar cirrhosis include xanthomas and xanthelasmas
  44. Mono and primary HIV infection can present similarly. Distinguish by rash and diarrhea more common in HIV and tonsilar exudates more common in EBV
    D-xylose absorption is abnormal in both bacterial overgrowth and celiac disease

    The D-xylose test becomes normal after Abx tx with bacterial overgrowth
  45. Hypovolemic shock: hypotension, tachycardia, decr pulmonary capillary wedge pressure (aka central venous pressure), decr CO, and inc PVR (peripheral vascular resistance)
    Use oseltamivir or zanamivir (neuraminidase inhibitors) to tx flu

    Rimantadine and amantadine only work for influenza A
  46. Pulsus paradoxus: >10 mmHg fall in systemic BP during inspiration

    Seen in cardiac tamponade, or severe asthma or COPD
    Central retinal artery occlusion is emergently treated wtih ocular massage and high-flow oxygen administration
  47. Hx of hemothorax predisposes to empyema and pt presents with low-grade fever, dyspnea, and chest pain. Surgery is required to remove clotted blood and thick fibrinous peel
    IBD is most likely dx in pt with subacute to chronic presentation of abd pain, tenesmus, and blood diarrhea.

    If there are worsening sx and signs of sepsis, toxic megacolon should be considered -> get abd xray!
  48. Dx criteria of toxic megacolon (lethal complication of IBD):
    Radiographic evidence of colonic distension PLUS
    Three of the following: fever >38, HR >120, neutrophilic leukocytosis >10,500, or anemia
    One of the following: Volume depletion, altered sensorium, electrolyte disturbances, hypotension
    Effect modification is present when the effect of main exposure on outcome is modified by level of another variable (ex. women with FHx breat cancer have incr risk of breast cancer with OCPs, smoking incr risk of VT with use of estrogens, or risk of lung cancer due to smoking is greater with hx of asbestos exposure)

    Effect modification is NOT a bias
  49. Diffuse cortical and subcortial atrophy that is disproportionately greater in the temporal and parietal lobes is seen in Alzheimer's disease
    Marked atrophy of frontal and temporal lobes is seen in frontotemporal dementia
  50. Postictal lactice acidosis commonly occurs following tonic-clonic seizure, leading to transient anion gap metabolic acidosis that resolves without tx 60-90 min following resolution of seizure activity
  51. Untreated hyperthyroid pt are at risk for rapid bone loss from incr osteoclastic activity, and for cardiac tachyarrhythmias (ex a-fib)
    Cholesterol embolization can cause ARF, bluish discoloration (livedo reticularis) of lower extremities, GI sx, incr eosinophils in blood or urine, and decr complement levels
  52. MS is one of few conditions that may present with bilateral trigeminal neuralgia
    Hyperthyroidism in elderly may present as weight loss, weakness, and/or a-fib (consider this before depression or occult malignancy in elderly pt)
  53. T3 is more biologically active than T4 (T4 is converted to T3)
    T4 is bound to TBG

    Pregnancy, liver disease, OCP, and aspirin -> incr TBG -> decr functional T3
  54. Use radioactive T3 uptake to distinguish hyperthyroidism vs incr TBG

    T3 uptake incr in hyperthyroidism

    T3 uptake decr in high TBG (more binding sites for T3, so thyroid can't take it up)
    Years of severe untx hypothyroidism -> myxedema coma following trauma, infection, cold exposure, or narcotics

    Tx with IV thyroxine, hydrocortisone, and maintain BP and respiration
  55. Subclinical hypothyroidism: Normal T4 with elevated TSH; look for nonspecific or mild sx of hypothyroidism and elevated LDL levels
    See antimicrosomal antibodies in Hashimoto's thyroiditis
  56. Hurthle's Cell tumor: variant of follicular cancer that is more agressive and spread by lymphatics; does not take up iodine; tx is total thyroidectomy
    Hot nodules = hyperfunctioning and rarely associated with malignancy
  57. Cold nodules - hypofunctioning; 20% are malignant
    Papillary cacrinoma is most common thyroid cancer

    Hx of radiation exposure is most important risk factor
  58. Medullary carcinoma comes from parafollicular cells (C cells) and produces calcitonin
    • Medullary carcinoma
    • 1/3 sporadic
    • 1/3 familial
    • 1/3 associated with MEN II
  59. Microadenomas (<10 mm) tend to either remain same side or regress with time. Only 10-20% continue to grow
    Cardiovascular disease is most comon cause of death in pt with acromegaly
  60. Lab abnormalities with acromegaly:
    Can use octrotide or somatostatin analog to suppress GH secretion as tx for acromegaly due to GH secreting pituitary tumor
  61. Calcification of suprasellar region on brain imaging is nearly dx of craniopharyngioma
    • DDx for pt with polyuria and polydipsia:
    • Diabetes mellitus
    • Diuretic use
    • Diabetes insipidus
    • Primary polydipsia
  62. Diabetes insipidus: central vs nephrogenic (lithium use)
    Tx central with desmopressin
    Tx nephrogenic with Na restriction and thiazide diuretics
    Primary polydipsia is usu psychiatric disturbance

    Deprive pt of water and urine osm will appropriately incr
  63. Hypovolemic hyponatremia: volume contracted

    Hypervolemic hyponatremia: volume expanded with edema

    Euvolemic hyponatremia: SIADH (volume expanded without edema)
    Hypoparathyroidism can be primary or pseudohypoparathyroidism

    Hypo has low PTH

    Pseudo has high PTH
  64. Hypoparathyroidism: hypocalcemia (tetany, prolonged QT), rickets/osteomalacia, cataracts

    Dx: Low serum Ca, high serum PO4, low PTH, low urine cAMP
    Vitamin D and calcium replacement in hypoparathyroidism can lead to kidney stones; keep serum calcium 8.0-8.5
  65. Pseudohypoparathyroidism caused by end organ resistance to PTH
    Lab findings of pseudohypoparathyroidism: low calcium, high phosphorus, high PTH, and low cAMP
  66. Primary hyperparathyroidism: Stones, bones (osteitis fibrosa cystica or brown tumors), groans, pyschiatric overtones
    • Indications for surgery in primary hyperparathyroidism:
    • Age <50 yr
    • Marked decr in bone mass
    • Nephrolithiasis, renal insufficiency
    • Markedly elevated serum calcium
    • Urine calcium >400 mg in 24 hr
  67. Secondary hyperparathyroidism: Chronic renal failure most common cause (see high PTH and low/low-normal serum calcium)
    • Cortisol is generally a catabolic glucocorticoid:
    • -Impairs collagen production
    • -Enhances protein catabolism
    • -Leads to glucose intolerance (anti-insulin effect)
    • -Impairs immunity because it inhibits PMNs and T-cells
    • -Enhances catecholamine activity -> HTN
  68. Signs of high cortisol can be nonspecific (obesity, HTN, osteoporosis, or DM) and some are more helpful (easy bruising, striae, myopathy, and virilizing signs)
    Cushing's syndrome = excessive glucocorticoids due to any cause
  69. Cushing's disease is pituitary Cushing's syndrome caused by pituitary adenoma
    Pt with Cushing's disease may have hyperpigmentatoin because of incr ACTH

    Pt with Cushing's syndrome (diff cause not pituitary) will not have hyperpigmentation
  70. T
  71. Algorithm to dx Cushing's syndrome:
    1. Abnormal dexamethasone suppresion test -> measure ACTH
    2. Low ACTH = adrenal tumor or hyperplasia -> Adrenal imaging
    3. High ACTH -> high dose dexamethasone suppression test
        a. >50% suppressed = Pituitary Cushin's, get pituitary MRI
        b. <50% suppressed = ectopic ACTH tumor, get chest CT, CT abd, and octreotide scan
    4. Can also use CRH stimulation test
        a. + response is pituitary Cushing's
        b. - response is ectopic ACTH producing tumor
    Healthy: Normal cortisol/ACTH, suppression with low and high dose dexa; mild incr with CRH test

    Cushing's: High cortisol ACTH, no suppression low-dose dexa, suppression high-dose dexa, incr with CRH test

    Adrenal tumor or ectopic ACTH producing tumor: High cortisol/ACTH, no suppression low dose dexa, no suppression high dose dexa, no change with CRH
  72. Any 24 hr urine collection should also test amount of Ur creatinine to determine if the pt has provided appropriate sample

    (ex. 24 hr collection for metanephrines and catecholamines for pheocromocytoma)
    If urine epinephrine is elevated the tumor must be adrenal or near the adrenal gland (organ of Zuckerkandl)
  73. Rule of 10s for pheochromocytoma:
    10% familial
    10% bilateral (suspect MEN II)
    10% malignant
    10% multiple
    10% in children
    10% are extra-adrenal (more often malignant), with organ of Zuckerkandl most common site (located at aortic bifurcation)
    If the following are present, pheochromocytoma is dx until proven otherwise: Headache, profuse sweating, palpitations, tachycardia, apprehension or sense of impending doom
  74. MEN syndrome: AD inheritance with incomplete penetrance
    • MEN I: Wermer's syndrome -> 3 Ps
    • Parathyroid hyperplasia
    • Pancreatic islet cell tumor (ZES, insulinoma)
    • Pituitary tumor
  75. MEN IIA: Sipple's syndrome -> MPH
    Medullary thyroid carcinoma (100% have it)
    • Men IIB: MMMP
    • Mucosal neuromas in nasopharynx, oropharynx, larynx, and conjunctiva (nearly 100% have)
    • Medullary thyroid carcinoma (more aggressive than in MEN IIA)
    • Marfanoid body habitus
    • Pheochromocytoma
  76. Suspect hyperaldosteroniam in pt with hypokalemia not on diuretic
    In hyperaldosteronism, distinguish adenoma from hyperplasia

    Adenoma + HTN tx with bilateral adrenalectomy

    hyperplasia + HTN tx with spironolactone
  77. Most common cause of Addison's disease (primary adrenal insufficiency) worldwide is TB

    Most common cause of adrenal insufficiency overall is abrupt cessation of exogenous glucocorticoids
    Findings of AI: weight loss, weakness, pigmentation, anorexia, nausea, postural hypotension, abd pain, hypoglycemia
  78. Primary adrenal insufficiency: Hyperpigmentation and hyperkalemia

    Secondary: no hyperpigmentation or hyperkalemia
    Most common presentation of secondary AI: pt on long-term steroids who stops them suddenly (ex for surgery) or who has increased need for them (ex infection)
  79. Primary vs secondary AI:

    Primary = high ATCH, high renin, low aldosterone

    Secondary = low ACTH, normal renin and aldosterone
    Females with congenital adrenal hyperplasia develop normally and will be fertile if tx early
  80. 90% of cases of congenital adrenal hyperplasia due to 21 hydoxylase deficiency

    Females are born with ambiguous external genitalia but normal ovaries and uterus

    Hyponatremia and hyperkalemia from lack of aldosterone

    Dx with 17-hydroxyprogesterone in serum
    Type I IDDM has HLA association (DQ/DR)

    Type II NIDDM has no HLA association but 90% concordance rate between identical twins (stronger genetic component)
  81. Hypertriglyceridemia with HDL depletion is the characteristic lipid profile of insulin resistance and poorly controlled DM
    Dawn phenomenon: increase in nocturnal secretion of GH -> hyperglycemia

    Somogyi effect: rebound response to nocturnal hypoglycemia -> hyperglycemia
  82. If glucose is elevated at 3 am, pt has dawn phenomenon; incr evening insulin
    If glucose is low at 3 am, pt has Somogyi effect and evening insulin should be decr
  83. It pt has fasting glucose > 240, insulin is agent of choice
    If pt has fasting glucose 140-240, oral hypoglycemic agents are effectiv
  84. Microalbuminuria: 30-300 mg/day; albumin:cr ratio of .02 to .2
    Pt with diabetes esp susceptible to developing radio-contrast induced ARF (be sure to hold metformin)
  85. Diabetic nephropathy:
    Hyperglycemia -> incr GFR -> microalbuminemia -> proteinuria -> decr GFR -> ESRD
    In progression of diabetic nephropathy, strict glycemic control slows or prevents progression from microabluminuria to proteinuria; once this  stage is past, glycemic control does little to prevent ESRD
  86. Tx of DKA: insulin, fluids, potassium
    Complications of DKA: cerebral edema if glucose levels drop too quickly; hyperchloremic nongap metabolic acidosis from rapid infusion of large amount of saline
  87. Primary organ at risk in hypoglycemia is brain
    • It pt presents with hypoglycemia of unknown cause measure:
    • Plasma insulin level
    • C-peptide
    • Anti-insulin antibodies
    • Plasma and urine sulfonylurea levels
  88. 85% of strokes are ischemic; 15% are hemorrhagic
    • Types of ischemic strokes:
    • TIA
    • Reversible ischemic (sx last > 24 hrs)
    • Evolving stroke
    • Completed stroke
  89. TIA involve either carotid or vertebrobasilar system

    Carotid system see: temporary loss of speech, paralysis/paresthesias of contralateral extremity; amaurosis fugax

    Vetebrobasilar see decr perfusion of posterior fossa, dizziness, double vision, numbness of ipsilateral face and contralateral limbs, dysarthria, hoarseness, dysphagia, projectile vomiting, headaches, and drop attacks
    • Causes of stroke:
    • Ischemia due to atherosclerosis
    • A-fib with clot emboli to brain
    • Septic emboli from endocarditis
  90. Evaluate source of embolic stroke with echo, carotid dopper, and then EKG/holter monitoring
    Most common location is middle cerebral artery-> results in contralateral weakness, sensory loss, and hyperreflexia
  91. Subclavian steal syndrome where stenosis of subclavian artery causes reversal of blood flow from ipsilateral vertebral artery to supply blood to exercising left arm

    Will see BP less in left arm vs right and decr pulse in L arm and upper extremity claudication

    tx surgical bypass
  92. Stroke deficit in anterior cerebral artery: contralateral lower extremity and face
    Stroke deficit in middle cerebral artery: aphasia, contralateral hemiparesis
  93. Stroke deficit in vertebral/basilar:
    Ipsilateral ataxia, diplopia, dysphagia, dysarthria, and vertigo
    Contralateral homonymous hemaniopsia with basilar PCA lesions
    • Stroke deficit with lacunar infarcts
    • Internal capsule: Pure motor hemiparesis
    • Pons: Dysarthria, clumsy hand
    • Thalamus: Pure sensory deficit
  94. Screen all pt with carotid duplex if they have carotid bruit, peripheral vascular disease, or coronary artery disease
    If pt <50 yrs presents with stroke, look for vasculitis, hypercoaguable state, or thrombophilia

    Order: Protein C, protein S, antiphospholipid antibodies, factor V leiden mutation, ANA, ESR< RF, VDRL/RPR, lyme serology, TEE
  95. If pt presents within 3 hrs of stroke: thrombolytics
    If after 3 hours: aspirin
    If cannot take aspirin: clopidogrel
    If cannot take aspirin or clopidogrel: ticlopidine

    Warfarin and heparin have no proven efficacy and aren't given in acute setting
    Tx of strokes is prophylactic and aims to prevent ischemic events in future (damage is already done and nothing can be done to salvage dead brain tissue)
  96. If carotid stenosis is >70% and pt is sx, carotid enarterectomy is indicated
    Cocaine is major cause of stroke in young pt
  97. Pupillary findings in intracerebral hemorrhage and corresponding level of involvement
    Pons: Pinpoint pupils
    Thalamus: Poorly reactive pupils
    Putamen: Dilated pupils
    CT scan is best way to distinguish ICH from ischemic stroke
  98. Tx of intraparenchymal hemorrhagic stroke is supportive, but BP reduction must be gradual so as not to induce hypotension
    • Common sites of subarachnoid hemorrhage:
    • 1. Junction of anterior communicating artery with anterior cerebral artery
    • 2. Junction of posterior communicating artery with internal carotid artery
    • 3. Bifurcation of middle cerebral artery
  99. Polycystic kidney disease is associated with berry aneurysms
    Be sure to get ophthalmologic exam to rule out papilledema
  100. Goal of tx of parkinson's is to enhance dopamine's influence or inhibit achetocholine's influence
    Shy-Drager syndrome = parkinsonian sx + autonomic insufficiency
  101. Meds that cause parkinsonian side effects: neuroleptic drugs (chlorpromazine, haloperidol, perphenazine), metoclopramide, reserpine
    Patietns with tremor as major Parkinson sx have better prognosis than those who have bradykinesia
  102. Progressive supranuclear palsy (PSP) may resemble Parkinson's but there is no tremor and PSP have ophthalmoplegia
    Always keep Wilson's disease in mind in young pt with movement disorder!
  103. Donepezil and anticholinesterase meds are only indicated for Alzheimer's dementia and Lewy body dementia (not other types of dementia)
    • Ddx of coma or stupor
    • S: structural brain pathology like stroke, hematoma, tumor, hydrocephalus, herniation, abscess
    • M: meningitis, mental illness
    • A: alcohol, acidosis
    • S: Seizures, substrate deficiency
    • H: Hypercapnia, hyperglycemia, hyperthermia; hyponatremia, hypoglycemia, hypoxia, hypotension/cerebral hypperfusion, hypothermia
    • E: Endocrine causes, encephalitis, encephalopathy
    • D: drugs and dangerous compounds
  104. MRI, CSF, and evoked potentials are abnormal in 90% of MS pt
    IV steroids hasten recovery of acute episodes but do not results in longterm outcome improvement in MS