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Line 219: − − =Missed Concepts= − *SNRI (venlafaxine), SSRIs, or TCAs can be used for narcolepsy associated cataplexy (loss of muscle tone associated with strong emotions) − *Lower limb hypertonia (spasticity), hyperreflexia, clonus, associated with developmental delay in an infant with history of prematurity or intrauterine infection, think cerebral palsy. Clinical diagnosis, but MRI will show periventricular leukomalacia and basal ganglion lesions. − *Suspicion for abusive head trauma in an infant should be evaluated with a '''head CT''' − *Pituitary Adenoma, including large ones, are first treated with oral dopamine antagonists. − *'''Epilepsy followed by renal failure''' are the leading causes of death in tuberous sclerosis.
→Myasthenia Gravis
=Missed Concepts=
*SNRI (venlafaxine), SSRIs, or TCAs can be used for narcolepsy associated cataplexy (loss of muscle tone associated with strong emotions)
*Lower limb hypertonia (spasticity), hyperreflexia, clonus, associated with developmental delay in an infant with history of prematurity or intrauterine infection, think cerebral palsy. Clinical diagnosis, but MRI will show periventricular leukomalacia and basal ganglion lesions.
*Suspicion for abusive head trauma in an infant should be evaluated with a '''head CT'''
*'''Epilepsy followed by renal failure''' are the leading causes of death in tuberous sclerosis.
*Treatment for DA antagonist (metoclopramide, prochlorperazine, antipsychotics) induced acute dystonia (such as torticollis) is IV diphenhydramine or benztropine.
*Cerebral palsy is a common complication of premature and presents by 1-2 with '''UMN signs, periventricular leukomalacia (get brain MRI), delayed motor milestones'''.
=Brain=
=Brain=
==Stroke==
==Stroke==
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*Dx: Ischemic vs. Hemorrhagic. Can localize stroke based on symptoms. NCCT head to rule out hemorrhage; CTA, MRI to look for filling defects and ischemic injury; TTE, telemetry to evaluate for afib. Differential includes TIA, seizure.
*Dx: Ischemic vs. Hemorrhagic. Can localize stroke based on symptoms. NCCT head to rule out hemorrhage; CTA, MRI to look for filling defects and ischemic injury; TTE, telemetry to evaluate for afib. Differential includes TIA, seizure. Stroke in a young IV drug user with a murmur, think '''mycotic aneurysm'''.
*Tx: For ischemic stroke, give tPA within 4.5 hrs of symptom onset, otherwise hep gtt. If large occluding clot in major vessel, can do endovascular thrombectomy within 24 hrs. Contraindications to tPA include recent major surgery, history of hemorrhagic stroke, BP >180/105 mmHg, Plt < 100k, INR > 1.7, age < 18, intrabdominal bleed. Use caution in the 3-4.5 hr window in patients over 80, with DM, with a recent stroke, or on DOACs. '''Keep BP below 180/105 mmHg to avoid hemorrhagic transformation''' and avoid starting anticoagulation or anti platelet agents in the first 24 hrs after tPA. Prevention includes aspirin ('''even if patient has history of recurrent falls'''), statin, clopidogrel, blood pressure control, rate/rhythm control or ablation/Watchman for Afib, weight loss, diabetes control, and smoking cessation. Treatment for hemorrhagic stroke includes blood pressure control, surgical decompression (ventricular shunt or craniotomy).
*Tx: For ischemic stroke, give tPA within 4.5 hrs of symptom onset if no contraindications. If large vessel occlusion, can do endovascular thrombectomy within 24 hrs. Contraindications to tPA include recent major surgery, history of hemorrhagic stroke, BP >180/105 mmHg, Plt < 100k, INR > 1.7, age < 18, intrabdominal bleed. Use caution in the 3-4.5 hr window in patients over 80, with DM, with a recent stroke, or on DOACs. '''Keep BP below 180/105 mmHg to avoid hemorrhagic transformation''' and avoid starting anticoagulation or anti platelet agents in the first 24 hrs after tPA. Prevention includes aspirin ('''even if patient has history of recurrent falls'''), statin, clopidogrel, blood pressure control ('''most important'''), rate/rhythm control or ablation/Watchman for Afib, weight loss, diabetes control, '''start ppx dose heparin between 24-48 hrs (if not already on thrombolytics, therapeutic anticoagulation, or DAPT)''', and smoking cessation. Treatment for hemorrhagic stroke includes blood pressure control, surgical decompression (ventricular shunt or craniotomy).
==Hematoma==
==Hematoma==
=Neuromuscular Junction=
=Neuromuscular Junction=
==Myasthenia Gravis==
==Myasthenia Gravis==
*H&P: Autoantibodies against AChR, presents with muscle weakness that worsens as the day progresses and with exercise and improves after sleep. Constantly used muscles (think postural muscles, diaphragm, and eyelids) are affected first. May have positive family history. May have thymoma.
*H&P: Autoantibodies against nAChR, presents with muscle weakness that worsens as the day progresses and with exercise and improves after sleep. Constantly used muscles (think postural muscles, diaphragm, and eyelids) are affected first. May have positive family history. May have thymoma.
*Dx: Look for ptosis that improves with ice pack test. Edrophonium test is positive. '''Single-fiber''' EMG shows unstable "jittery" baseline between APs. '''CT chest to look for thymoma.'''
*Dx: Look for ptosis that improves with ice pack test. Edrophonium test is positive. '''Single-fiber''' EMG shows unstable "jittery" baseline between APs. '''CT chest to look for thymoma.'''
*Tx: 1st line pyridostigmine. '''2nd line steroids or immunomodulating meds (e.g. cyclosporine, azathioprine). Plasmapheresis or IVIG for myasthenia crisis. Thymectomy may reduce symptoms and exacerbations.'''
*Tx: 1st line pyridostigmine. '''2nd line steroids or immunomodulating meds (e.g. cyclosporine, azathioprine). Plasmapheresis or IVIG for myasthenia crisis. Thymectomy may reduce symptoms and exacerbations.'''
=Autoimmune Disorders=
=Autoimmune Disorders=
==Guillain-Barré syndrome==
==Guillain-Barré syndrome==
*H&P: Ascending paralysis typically following a respiratory or GI (e.g. campylobacter) infection. Also known as Acute Inflammatory Demyelinating Polyneuropathy (AIDP). Lasts 2-4 weeks. If it lasts > 8 weeks, think CIDP, C for Chronic. '''Hyporeflexia and parasthesias'''.
*H&P: Ascending paralysis that has an onset of '''days''', typically following a respiratory or GI (e.g. campylobacter) infection. Also known as Acute Inflammatory Demyelinating Polyneuropathy (AIDP). Lasts 2-4 weeks. If it lasts > 8 weeks, think CIDP, C for Chronic. '''Hyporeflexia and parasthesias'''.
*Dx: Clinical. Can get EMG which shows slow conduction (due to demyelination). LP will show albuminocytologic dissociation (elevated protein, normal WBCs). '''Differential includes transverse myelitis, which is more likely to have a sensory level and bowel/bladder involvement. Get an MRI to rule it out if diagnosis is unclear'''
*Dx: Clinical. Can get EMG which shows slow conduction (due to demyelination). LP will show albuminocytologic dissociation (elevated protein, normal WBCs). '''Differential includes transverse myelitis, which is more likely to have a sensory level and bowel/bladder involvement, and tic paralysis which progresses over hours'''. Get an MRI to rule it out if diagnosis is unclear'''
*Tx: Usually self resolves. '''Frequently monitor vital capacity at bedside.''' '''Plasmapheresis or IVIG''' speed up resolution of symptoms '''and are indicated in patients who are nonambulatory and had symptom onset within last 4 weeks'''.
*Tx: Usually self resolves. '''Frequently monitor vital capacity at bedside.''' '''Plasmapheresis or IVIG''' speed up resolution of symptoms '''and are indicated in patients who are nonambulatory and had symptom onset within last 4 weeks'''.
*H&P: Demyelinating autoimmune disease that can be relapsing remitting, primary or secondary progressive, or progressive/relapsing.
*H&P: Demyelinating autoimmune disease that can be relapsing remitting, primary or secondary progressive, or progressive/relapsing.
*Dx: MRI shows periventricular fingerlike white matter lesions, LP shows oligoclonal bands, '''VEPs show delayed conduction'''
*Dx: MRI shows periventricular fingerlike white matter lesions, LP shows oligoclonal bands, '''VEPs show delayed conduction'''
*Tx: '''1st Copaxone, Glatiramer acetate, or interferon'''. '''2nd Dimethyl fumarate, natalizumab, teriflunomide'''. Acute exacerbations use high-dose steroids. Symptom targeted treatment: SSRIs for depression; PT, stretching, massage, '''baclofen''' for spasticity; amantadine for fatigue; Gabapentin for neuropathic pain; timed voiding, fluid restriction, or oxybutynin for urinary incontinence
*Tx: '''1st Copaxone (i.e. Glatiramer acetate), or interferon'''. '''2nd Dimethyl fumarate, natalizumab, teriflunomide'''. Acute exacerbations use high-dose steroids (IV or PO are equally effective, but PO is preferred in patients with '''optic neuritis'''). Symptom targeted treatment: SSRIs for depression; PT, stretching, massage, '''baclofen''' for spasticity; amantadine for fatigue; Gabapentin for neuropathic pain; timed voiding, fluid restriction, or oxybutynin for urinary incontinence
=Neuropsychiatric Disorders=
=Neuropsychiatric Disorders=
*Dx: MRI shows atrophy of mammary bodies. EtOH level. Presents with ataxia, '''ophthalmoplegia''', confusion, confabulation, retrograde amnesia. Differential includes NPH.
*Dx: MRI shows atrophy of mammary bodies. EtOH level. Presents with ataxia, '''ophthalmoplegia''', confusion, confabulation, retrograde amnesia. Differential includes NPH.
*Tx: High dose thiamine. Electrolyte repletion. Multivitamin. CIWA protocol for EtOH withdrawal.
*Tx: High dose thiamine. Electrolyte repletion. Multivitamin. CIWA protocol for EtOH withdrawal.