Neuro USMLE
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| CN I innervates? Syndrome to look for and its cause? | smell; Kallman's syndrome=anosmia and hypogonadism due to gonadotropin rel hormone defic
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| CN8 innerv? Defic causes? | (vestibulocochlear nerve) for hearing and balance; defic: deafness, tinnitus, vertigo
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| CN9 innerv? Defic causes? | (glossopharyngeal) pharyngeal mscles, afferent gag reflex, parotid, taste in P 1/3 tongue, skin external ear; defic: loss of gag and loss of taste P 1/3 tongue
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| CN10 innerv? Defic? | (vagus) palate, pharynx, larynx, abd viscera, skin of ext ear; defic: hoarseness, dysphagia, loss of gag or cough
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| CN 11 innerv? Defic? | (spinal access nerve) sternocleidomastoid, trapezius; defic: can't turn head to side opp to lesion, shoulder droop
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| CN 12 innerv? Defic? | (hypoglossal) innervates tongue; defic: tongue on protrusion deviates ipsi
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| name 3 spinal tracts and their fxns | corticospinal=mvmt contra limbs, dorsal column=tactile, vibration, sensation; spinothalamic=pain, temp
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| CNV innervates | (aka trigeminal nerve) mastication and facial sensation, afferent limb corneal reflex
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| characteristics trigeminal neuralgia, treatment, rule out other diagnoses | (CN V) unilateral shooting pains in face, incl w brushing teeth, tx: carbamazepine [could be MS, or if bilateral could be stroke]
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| CN3 fxn | eye mvmt, pupil constriction, accomodation, eyelid open
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| CN4 fxn | eye mvmt
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| pneumonic for which CN are sensory, motor | Some say marry money but my brother says big brains matter most
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| pneumonic for eye mvmt mscls innerv | LR6SO4R3-lateral rectus=VI, superior oblique=IV, rest=III
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| how differentiate CNIII, IV, V, VI, and VII problems wrt to eye exam | III: eye is down and out and can only move laterally, IV: can't look down when medial, V/VII: blink reflex, VI: can't look lateral
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| nerves involved in pupillary reflex; 2 types of reflexes | CN II to sense light, III to constrict pupil; direct reflex if light was in that eye, consensual reflex if light was in other eye
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| nerves involved in blink reflex | ophthalmic branch (V1) of CN V to feel stimulus, CNVII to close eyelid
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| if L optic n damaged, what see on pupillary reflex | stimulating L eye causes no response in either eye, stimulating R causes both to respond
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| if L occulomotor n damaged, what see on pupillary reflex | stimulating L eye causes R to respond, stimulating R eye causes R to respond
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| characteristics CN7 UMN? LMN? MC cause for each? | UMN=contralateral lower facial paralysis **forehead is spared, usu cause is stroke; LMN=ipsi upper and lower facial paralysis, **forehead is involved on affected side, usu due to Bell's palsy or tumor
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| Bell's palsy-- how can be difft from CNVII LMN? Causes? | can also have hyperacusis (noises loud) bc stapedius muscle is paralyzed; MC causes: AIDs, Lyme, sarcoid, tumor, DM
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| how difft UMN from LMN | UMN have incrsd tone, spastic, and DTR (although initially may be decrsd for ea) + Babinski's; LMN has decrsd tone, flaccid and DTR, atrophy, fasciculations
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| nerve for ea DTR | achilles=S1,2; knee=L3,4; biceps=C5,6; triceps=C7,8 [just count up]
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| what number cause of death is stroke? % isch v hemorrh | number3, 85% isch
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| how define TIA; usu cause/type | neuro deficit for <24hrs, (usu <30min). Usu embolic and high risk of stroke in next mos.
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| characteristics of carotid stroke/TIA | loss speech, paralysis/paresthesia/clumsy contra extremity; can have amaurosis fugax (chol emboli to retinal/ophthalmic artery causes ipsi vision loss)
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| define amaurosis fugax | chol emboli to retinal/ophthalmic artery causes ipsi vision loss
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| characteristics of vertebrobasilar stroke/TIA | dizziness, dbl vision, vertigo, numb ipsi face & contra limb, dysarthria, hoarseness, dysphagia, HA, projectile vomitting, drop attacks
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| what paradoxial stroke | venous clot goes through ASD/VSD/PFO and into head
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| 4 causes/types stroke/TIA | embolic (MC, usu from heart), thrombotic (usu atheroscl), lacunar (small vessels), non vascular (anoxic injury, low CO)
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| describe subclavian steal and sympt | stenosis of subclavian before vertebral, so retrograde down vertebral artery to back fill subclavian; BP less in that arm and claudication when exercise that arm
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| causes of stroke in younger pts | OCP, preg, hypercoag (prot C, S), cocaine, amphet, polycythemia, SC
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| risk factors for stroke, which most impt | Age, HTN most impt; smoking, DM, hyperlipid, A Fib, CAD, prev stroke, Fm Hx, carotid bruits
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| MC embolic stroke site | MCA
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| sympt MCA stroke | aphasia (if L (dominant)), neglect/apraxia/confusion (if R), contra paresis face and arm, gaze twd lesion, homo hemianopia
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| stroke a cerebral artery causes | contra paresis and sensory loss in leg (incl foot drop, gait dysfunction), amnesia, personality changes, cognitive changes [this artery also supplies frontal lobes]
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| stroke posterior cerebral artery causes | homo hemianopia, memory deficits, dyslexia/alexia
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| stroke basilar artery | coma, locked in syndrome, CN palsies, apnea, visual symptoms, dysphagia, dysarthia, drop attacks, **crossed weakness/sensory affecting ipsi face and contra body
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| MC site circle of willis aneur | anterior communicating
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| anterior communicating artery aneur sympt | bitemp hemianopsia + frontal lobe
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| posterior communicating artery aneur sympt | CNIII (often see first impaired pupillary light reflex, unlike isch CNIII where that is spared until late]
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| cerebral v subcortical strokes | cerebral: contra motor or sensory face, arms, trunk not usu legs (interhemisph), aphasia if L, visual/spatial more if R; subcortical: hemiparesis is complete (tracks all run together thru internal capsule)
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| key plegias from brainstem | crossed, ipsi face, contra body
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| how to differentiate peripheral neuropathy from myopathy | peripheral neuro: usu asymm, weakness more distal, can have sensory; myopathy: symm w weakness prox>distal, nml sensation
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| how difft NMJ v peripheral neuro or myopathy | NMJ: fatigability, nml sensation
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| general features of spinal cord injury, that are unique to these lesions | decrsd sensation below a sharp band
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| general features of radiculopathy | pain! Affects muscles supplied by that root (myotome), and sensory area supplied by that root (dermatome) Weakness, atrophy, sensory deficit in a dermatomal pattern
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| general features Cb lesion | incoord, intention tremor, ataxia
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| general features of brainstem lesion | cranial nerve and spinal cord findings; ipsi face and contra body hemiplegia
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| fxn radial nerve lesion | no supination, no extension (radial is SUPER), w wrist drop, sensation back hand finger 1-3
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| fxn ulnar nerve lesion | can't cross fingers or V sign, sensation 1/2 of ring finger and pinkie
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| fxn median nerve lesion | can't flex fingers of wrist, thenar eminence atrophied (ie carpal tunnel), sensation 2,3,1/2 of ring from underside to nails, loss pronation. Thumb's up, all's ok when you flex yr nail polish w carpal tunnel
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| axillary n lesion | innerv deltoid, can't abduct to horiz
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| long thoracic n injury (metastetcomy) | serratus anterior, winged scapula, can't abduct past horiz
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| common peroneal n lesion | foot drop, anterolateral sensation leg
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| femoral n lesion | paralysis of quad, can't extend leg and loss of knee jerk, sensation anterior thigh
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| upper brachial plexus lesion | Erbs palsy, arm by side, rotated inward, waiter's tip. Can't abduct arm, felx elbow or supinate
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| lower brachial plexus lesion | Klumpke, median/ulnar n; clawed hand and Horners
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| fxn of interosseus | palmar adduct, dorsal abduct PAD DAB
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| how long might it take for isch stroke to show by non contrast CT | 24-48hrs
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| what order if present s/s acute stroke | non contrast CT, ECG, CXR, CBC, PT/PTT, Lytes, Glu, caortid U/S, Echo
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| when to tx acute stroke w tPA | <3hrs no contraindications, incl: prior hemorrh stroke, sz w onset stroke, stroke or head trauma w/in 3mos, HTN BP>185/110, BG<50 or >400, age <18, bleeding (GI, urinary <21d), plt <100K, INR>1.7 or elev PTT, surg<14d, recent MI, think TIA (rapid improve)
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| tx of acute stroke other than maybe tPA | 1) ASA (don't give if tPA), 2) tx HTN only if >220/110, 3) treat F, hyperglu
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| once give tPA what must control | BP <185/110
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| longterm tx s/p stroke | ASA if sm vessel dz, manage risk factors (HTN most impt, also DM, hyperlipid, etc), carotid endartectomy if nec
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| epidural bleed: describe clinical present and anatomy (where blood is, how appears on imaging) | lucid interval, often temporal bone fx m. meningeal artery; biconvex blood bw dura and skull
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| subarachnoid hemorr: describe clinical present and anatomy (where blood is, how appears on imaging) | worst headache, ruptured berry aneurysm (MC A. commun artery, blood in CSF, blood bw pia and arachnoid)
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| subdural bleed: describe clinical present and anatomy (where blood is, how appears on imaging) | elderly pts, EtOH, may not remember fall, bridging veins, blood bw dura and arachnoid, crescent moon shaped on imaging
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| order of compartments for cranial bleeds moving from brain surface outwards | pia-[subarachnoid space]-arachnoid-[subdural space]-dura-[epidural space]-skull
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| clinical signs transtentorial (central) herniation | bilateral small and reactive pupils, Cheyne-Stokes respirations, flexor or extensor posturing
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| clinical signs uncal herniation | CNIII gets entrapped, fixed and dilated ipsilateral pupil [from mass in middle fossa]
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| clinical signs cerebellar tonsillar herniation | compression medulla, respiratory arrest, usu rapidly fatal [from mass in posterior fossa]
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| describe Cushing triad | from incrsd ICP: HTN, bradycardia, repir irreg
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| cerebral perfusion is determined by | MAP-ICP (nml ICP 5-15)
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| MC location intracranial hemorrh | BG (66%), then Pons and Cb ea 10%
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| key clinical factors suggesting intracranial hemorrh | focal neuro deficit that WORSENS over next 30-90min, AMS, signs incrsd ICP
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| how pupils help differentiate place of intracranial hemorrh | pin point=pons, poorly reactive=thal, dilated=putamen
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| tx intracranial hemorrh (after CT confirms) | control BP if >16-180/105, but slowly, if elevated ICP give mannitol and diuretics…surgery maybe for Cb hematomas, otherwise no
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| if CT in suspected SAH is negative, what do | LP, diagnostic if xanthochromic (yellow CSF) bc means RBC have been there for a while (v traumatic tap)
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| once SAH diagnosed, what do | cerebral angiography and call neurosurg; quiet rest in dark room w head elevated and stool softeners, nifedipine for vasospasm, control HTN
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| name 5 key adult brain tumors | glioblastoma (type IV astrocytoma), meningioma, schwannoma, oligodendroglioma, pit adenoma
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| name 5 key pediatric brain tumors | pilocytic atrocytoma, medulloblastoma, ependymoma, hemangioblastoma, craniophrangioma
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| name where ea of 5 pediatric tumors occur: pilocytic atrocytoma, medulloblastoma, ependymoma, hemangioblastoma, craniophrangioma | pilocytic atrocytoma=P fossa, medulloblastoma=Cb, ependymoma=4th ventricle, hemangioblastoma=Cb, craniophrangioma=supratentorial
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| what are the 3 MC primary adult brain tumors, in order | 1) glioblastoma, 2) meningioma, 3) schwannoma
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| which primary brain tumor is found in the cerebral hemispheres and can cross the corpus callosum | glioblastoma
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| majority of adult primary brain tumors are supra or infratentorial? Pediatric? | adult are usu supratentorial, pediatric are infratentorial
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| what brain tumors suspect for hydrocephalus in kids | ependymoma (4th ventricle), medulloblastoma (Cb but can compress 4th v)
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| what brain tumor assoc w von Hippel Lindau | hemangioblastoma in Cb
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| what brain tumor can cause bitemporal hemianopia (so confused w pituitary adenoma) | craniopharyngioma (benign childhood tumor, MC childhood supratentorial tumor)
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| supratentorial tumor in kid--think what? Benign or malignant? | craniopharyngioma, benign
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| diffusely infiltrating brain tumor in P fossa in child, dx? Benign or malignant? | pilocytic astrocytoma, benign
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| MC primary CNS neoplasm, characteristics | astrocytoma (ie glioblastoma), arise IN cerebral hemispheres, infiltrate brain w indistinct boundaries and can cross corpus callosum
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| besides astrocytomas, what cancers appear in parenchyma? | mets (50%)-in order of freq: Lung, breast, melanoma, kidney, GI
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| differential for ring enhancing lesion | met, brain abscess, glioblastoma multiform, lymphoma, toxo
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| name 2 extraparenchymal brain tumors | meningioma, scwhannoma
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| are schwannomas unliateral or bilateral? Assoc? | always unilateral, if bilateral then its NF II
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| describe population that get meningiomas | usu 40-50, females >2x than males
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| how do meningiomas appear on imaging | extracerebral, rounded w well-defined dural bases that compress underlying brain
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| schwannomas--malignant or benign? | benign (no malignant potl)
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| where schwannoma arise? Presenting symptom? | cerebellopontine angle, involved 8th cranial; first present w hearing loss (+/- tinnitus, loss of balance, nystagmus)
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| schwannoma and meningioma--surg excision? | yes, although meningiomas have high recurrence rate
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| calcified lesion external to brain parenchyma in adult--think what? | meningioma
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| 4 types of MS | 1)clinically silent/stable/benign (may progress late), 2) relapsing and remitting (MC), 3) 2ry progressing (relaps/remit gradually worsens), 4) 1ry progressive
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| key clinical features MS | white matter plaques; scanning speech, intention tremor/INO/incontinence, nystagmus. Also optic neuritis w sudden vision loss
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| describe INO, where injury is | injury medial longitudinal fasculus (MLF), If R MLF is affected and pt looks L, the R eye can't adduct and stays midline while the L abducts and start nystagmus (pt also sees dbl looking L)
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| tx acute MS attack | hi dose IV steroids can shorten but won't alter overall progression dz, most attacks resolve <6wks
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| disease modifying MS tx | INF, can cause flu-like sympt. Only use cyclophosphamide and other non specific immunomodulators in rapidly progressive bc many SE
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| Rx for mscl spasticity in MS | baclofen (deriv of GABA)
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| neurpathic pain tx | carbamazepine (Na channel) or gabapentin (neurontin, GABA analog)
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| describe Guillan Barre clinical progression | infxn (often URI) or immun 1 wk before, symmetric distal weakness starts in legs w loss DTR **sensation intact, ascending paralysis, watch for respir paralysis (use spirometry to monitor)
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| treatment Guillan Barre | usu stops spontaneously, plasmaphoresis reduces severity and length **don't give steroids, could make it worse!
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| mech MG | autoantibodies Ach R at NMJ
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| key characteristics MG clinically | mscl fatigue, esp extraocular, often asymm prox mscl wknss at end of day
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| compare Lambert-Eatn Myasthenic syn to MG | Lambert-Eaton is often w SCLC, Ab to Ca++, sympt get better with use
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| test for MG | 1) auto Ab (20% neg), 2) edrophonium (Tensilon, anticholinesterase) improves sympt
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| what extra diagnostic need MG | CT to evaluate thymoma (10-15% on scan), but histol abnl ~75%
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| tx MG longterm | pyridostigmine, steroids if not responding
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| vit B12 and Friedrich ataxia damages which neural tracts, signs on exam? | demyelin of dorsal columns, corticospinal, and spinoCb; ataxic gait, hyperreflexia, impaired position/vibration sense
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| describe Friedrich's ataxia (genes, pathophys, clinical) | AR triple repeat expansion dz of mitochondria; leads to demyelin of dorsal columns, corticospinal, and spinoCb; ataxic gait, hyperreflexia, impaired position/vibration sense
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| describe syringomyelia (pathophys and clinical) | (basically a cyst of CSF) crossing fibers of [spinothal tract I think] are damaged; leads to bilateral loss of pain and temp sensation in shoulders (capelike distrib), +/- muscle atrophy hands
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| what leads to destruction of anterior horns spinal column? Cause? Symptoms? | polio and werdnig-Hoffman; flaccid paralysis (LMN)
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| occlusion ventral spinal artiery causes what? Clinical? | damages everything except dorsal columns, so only have tactile, vibration, sensation
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| 3 syphillis, aka? Damages? | tabes dorsalis damages dorsal roots and columns; impaired propioception and locomotor ataxia
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| symptoms of ALS (amyotrophic lateral sclerosis=Lou Gehrigs)? | asymmetric, progressive weakness, UMN and LMN signs (spasticity, hyperreflex, + Babinski AND fascicul, atrophy, flaccidity); treatment is supportive
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| pyramidal tract aka | corticospinal=mvmt contra limbs
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| Pseudotumor cerebri-describe what it is and how it presents | incrsd ICP papilledema, daily headaches worse in am +/- N/V; young obese women
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| Pseudotumor cerebri-describe how diagnose and treat | CT, MRI negative; concern about vision loss; treatment supportive w wgt loss and lumbar puncture or CSF shunt
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| Pseudotumor cerebri-potl causes | large doses vit A, tetracyclines, wdrawal from corticosteroids can cause
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| differentiate resting tremor, intention tremor, and hemiballsimus as to causes | hemiballismus (involuntary, unilateral flailing limbs) from subthalamic nucleus, intention tremor due to Cerebellar dz, resting tremor due to basal ganglia
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| Brown-Sequard syndrome--distrib of lesion and clinical findings | hemisection of spinal cord; contra pain and temp, ipsi hemiparesis and ipsi loss of position/vibration (dorsal columns)
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| what Rx may help extend life ALS | rituzole (glutamine blocking agent)
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| 2 main types of sz, which more common | partial (70%), generalized
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| subtypes of partial sz | 1) partial; simple partial (consciousness intact), complex=LOC, postictal, may have automatisms, olfactory or gustatory halluc
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| subtypes of generalized sz | tonic-clonic, absence (45% of these can have minor clonic, ie eye blinking)
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| what's name of paralysis s/p seizure | Todd's paralysis, can last hrs-days
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| tx generalized tonic clonic or partial sz | phenytoin and carbamzepine
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| tx for absence sz | ethosuximide and valproate
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| describe Rinne test | vibrating tuning fork on mastoid until they can’t hear it, then move to outside ear—they should be able to hear (+ test).
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| describe Weber test | tuning fork on forehead, which side is louder
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| outcomeof Weber/Rinne if conductive loss | abnl (-) Rinne (bone conduction>air); Weber louder in affected (think of cotton in yr ear)
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| outcome Weber, Rinne if sensorineural loss | nml (+) Rinne (air >bone conduction); Weber louder in unaffected (good) side
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| types of Vertigo (4) | 1) Peripheral: benign positional, Meniere's, labyrinthitis; 2) central (tumor, CVA, MS)
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| how test for benign positional vertigo in the office | have pt go rapidly from sitting to laying while turning head->should reproduce
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| describe Meniere's dz and px | thgt 2/2 fluid retention, recurrent severe vertigo, tinnitus, hearing loss lasting for hrs to days; recur mos-yrs later and hearing loss eventually permanent
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| tx Meniere's | low Na diet, diuretics, maybe also anti chol and anti His [meclizine]
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| when pt falls w vertigo, which side do they fall to | same side as lesion
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| dominant lesion in R handed person? L handed? | 95% R handed are L dominant, 50% of L handed are L dominant
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| describe location of lesion and clinical presentation of Wernicke's aphasia | Posterior superior temporal gyrus, wordy receptive/sensory/fluent aphasia, use wrong or nonsensical words; they don't comprehend written or spoken language; can't follow commands or repeat
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| describe location of lesion and clinical presentation of Broca's aphasia | expressive/nonfluent broken, short sentences but meaningful. Comprehension intact. Impaired repetition. Posterior inferior frontal gyrus
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| describe conduction aphasia | can't repeat bc no cxn bw Broca's and Wernicke's
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| defect causing L homo hemianopia w macula sparing | R visual cortex
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| defect causing L homo hemianopsia | R optic tract
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| defect causing L upper quad anopsia | R optic radiations in R temporal lobe
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| defect causing L lower quad anopsia | R optic radiations in R parietal lobe
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| defect causing L homo hemianopsia w macular sparing | R occipital lobe, from P cerebral artery occlusion
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| lesion causing bitemporal hemianopsia | optic chiasm (usu pit tumor)
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| define difft types of glaucoma, general features | open angle (90%): painless, incrsd intraocular P 20-30mmHg, progressive visual field loss, incsrd cup-to-disk on fundo exam; closed-angle: sudden ocular pain, see halos around light, intraocular P >30, N/V, sudden decrsd vision, fixed, mid-dilated pupil
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| tx closed angle glaucoma | pilocarpine, oral glycerin and/or acetazolamide
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| tx open angle glaucoma | can include b-blockers, a agonist, prostaglandins (latanoprost), acetazolamide
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| types of macular degeneration | exudative wet=neovascular w sudden vision loss; atrophic/non exudative/ dry (90%)=yellow-white dposits drusen
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| findings on fundo exam: cotton wool | HTN
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| findings on fundo exam: dot blot hemorr | DM
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| findings on fundo exam: neo vascul | DM
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| findings on fundo exam: pale fundus, cherry spot | central retinal artery occlusion
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| findings on fundo exam: tortorous retinal veins | retinal vein occlusion
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| findings on fundo exam: focal yellow-white deposits | macula drusen (macula degeneration)
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| findings on fundo exam: incrsd cup to disk ratio | glaucoma
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| findings on fundo exam: blurred optic disk margins | papilledema or papillitis
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| differentiate fundo changes see with DM, HTN | DM: dot-blot hemorrhages, neovasc retina; HTN: ateriolar narrowing and cotton-wool spots and may see papilledema in severe HTN/HTN emergency
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| common causes blindness in US, infxs causes (3) | DM in younger adults, macular degen in >55; river blindness (onch volvulus, a helminth, give ivermectin), chl trachomatis, toxo carnis (if granuloma)
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| what's river blindness? What's the treatment | river blindness (onch volvulus, a helminth, give ivermectin),
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| how recognize central retinal artery occlusion? Tx? Assoc? | sudden, painless, unilateral loss of vision; most common due to emboli (carotid, heart), but also temporal arteritis; no tx exc temporal arteritis give corticosteroids
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| 3 causes of sudden, unilateral vision loss, painless | 1) central artery occlusion (pale fundus, cherry red spot), 2) central vein occlusion (distended retinal veins, retinal hemorrhages), 3) retinal detach (pt reports floaters, flashes of light, curtain coming down)
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| describe Sturge Weber | neurocutaneous dz; SKIN: congenital port wine stain (hemangioma), NEURO: leptomeningeal angio, glaucoma, sz, hemiparesis, MR
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| describe tuberous sclerosis | neurocutaneous dz; hamartomas in skin, CNS, organs; astrocytoma, MR, sz **facial lesions with ash leaf spots, shagreen patches (thickened skin)
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| describe neurofibromatosis | neurocutaneous dz; café au lait, axillary freckling, Lisch nodule (iris), neurofibromas in skin, neural tumors (meningiomas, acoustic neuromas), optic path glioma, Pheorenovascular HTN, scoliosis, sz
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| NF1 v NF2 | NF1:café au lait, Lisch nodule (iris), gliomas, meningiomas, pheo, scoliosis; NF2: bilateral acoustic neuroma, juvenile cataracts (Step 1 pdf)
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| von Hippel Lindau | neurocutaneous dz; **renal cell carcinoma, hemangioblastoma cerebellum, retinal angiomas, cysts in kidney and liver, pheochromocytomas, polycythemia,
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| name 4 neurocutaneous dzs | Sturge Weber, tuberous sclerosis, NF, von Hippel Lindau
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| NF2? Chromosome? Gene? | bilateral acoustic scwhannoma, juvenile cataracts; chrom 22, gene NF2
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| Lisch nodules are charact of? | (found in iris) Neurofibromatosis
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| NF1 aka? Chromosome? | von Recklinghausen's disease=NF type 1; chrom 17
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| café au lait spots with normal IQ? With MR? with anemia? | nml IQ:NF; MR: McCUne Albright or tuberous sclerosis; anemia: Fanconi's anemia
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| which neurocut has hamartomas (incl skin)? skin hemangioma? Skin neurofibromas? | hamartomas: tuberous sclerosis; skin hemangiomas: Sturge Weber and von Hippel-Lindau; skin neurofibroma: NF
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| which neurocut has MR? | tuberous sclerosis, Sturge Weber
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| describe corticospinal tract path and where decussates | Start in motor cortex, cross over in medulla, become LMN in anterior horn of spinal cord at that level.
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| describe dorsal/posterior column tract path and where decussates | Start in mscl spindles, golgi tendon organs, Pacini&Meissner’s disks, signal through dorsal root ganglion up fasciculus gracilus and cuneatus (upper body), cross in medulla
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| describe spinothal tract path and where decussates | Afferent/ascending. Start free nerve endings, pain fibers, cross at level of spinal cord (anterior/ventral white commissure), then go the length of the spinal cord to thalamus.
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