Patient taking Advil develops n/v/d, coarse tremor, ataxia, confusion, slurred speech.

Lithium Toxicity (in this case, precip. by NSAIDs)

Use aspirin or sulindac for pain
Possible EKG findings:
o T-wave flattening
o T-wave inversion + U-waves
Tx: Fluid resuscitation
Emergent dialysis if lithium levels >4 or kidney dz
Major SEs: Weight gain, acne, GI irritation, cramps
MOA: Suppresses inosital triphosphate
Therapeutic levels: 0.6-1.2
o For valproate: 6-12
o For carbamazepine: 60-120
Monitor:
o Li level q4-8wks, TFTs q6mo
o Cr, UA, CBC, EKG
Contraindications: Severe renal dz, MI, diuretics, digoxin, pregnancy or breastfeeding.
o Problems in pregnancy: Ebsteins anomaly = malformed tricusp; atrializes part of RV (if taken
during 1st tri)
o Treatment for bipolar in pregnancy: Clonazepam (esp. 1st trimester)
Bipolar + elevated LFTs and hepatitis Valproate
Also can cause n/v/d, skin rash

Bipolar + Stevens-Johnson Syndrome

Lamotrigine
Less likely = carbamazepine

Bipolar + agranulocytosis Carbamazepine

MC complication: Rash.
Regular CBCs:
o If ANC <2000: Weekly CBC
o If ANC <1000: D/C the med
Bipolar + AFP in a 20wk pregnancy NTD
Could be valproate or carbamazepine Repro-age F should take 4g folate daily
5HT syndrome Myoclonic jerks, tachycardia, htn, hyperreflexia, n/v/d.
SSRI + MAOI
Pounding head, flushing, nausea, myoclonus after eating cheese, drinking red wine, taking decongestant
or meperidine
Hypertensive crisis w/MAOI
Tx: 5mg IV phentolamine

DOC for acute agitation or psychosis: IM haloperidol.

MOA: D2 receptor antagonist @ mesolimbic tract
Helps + sxs.
SEs: Hyperprolactinemia and EPS.
Low-potency acute antipsychotics: Chlorpromazine and thioridazine
Less EPS, more antichol.
SE chlorpromazine: Purple-grey metallic rash over sun-exposed areas, jaundice
SE thioridazine: Prolonged QTc and pigmentary retinopathy
High-potency acute antipsychotics: Haloperidol and fluphenazine
More EPS.
If patient has a history of medication non-adherence: Decanoate forms, every 2-4wks.

Pt wakes up with eyes stuck looking up or head stuck turned to the side.
Acute Dystonia (if meds <12hr ago)
Tx: Benztropine or diphenhydramine
After 10 years on fluphenazine, tongue movements and grimacing
Tardive Dyskinesia (>years)
Tx: Benztropine or diphenhydramineNOT L-dopa!!
Also can use amantidine or bromocriptine
Pt reports feeling like they always have to move.
Akathisia (30-90 days).
Tx: Propranolol (1st-line) or benzo
Coarse resting tremor, masked facies, unsteady gait, bradykinesia
Parkinsonism (>6mo)
Tx: Stop antipsychotic!
Switch to atypical or clozapine

W/in hours of a haloperidol injection, pt has CPK, temp of 103F, rigidity, autonomic instability, and
delirium.
Neuroleptic Malignant Syndrome.
1st: D/c the offending med.
2nd: Cooling blankets and dantrolene (or bromocriptine = 2nd-line)
Also caused by metoclopramide, compazine and droperidol
SLEEP EEGs

Awake

Stage 1Theta waves

Stage 2 K-complexes, Sleep spindles

Slow-wave sleep Delta waves

Sleep-walking/-talking, night terrors
Stage 4 >50% delta
Stage 3 <50% delta

REM Sawtooth waves

Skeletal-muscle paralysis

SUBSTANCE USE
A 50 y/o known alcoholic presents to the ER with tonic-clonic seizures. BP 180/110, HR 118, T
100.1.
EtOH Withdrawal
Tx: Diazepam or chlordiazepoxide
o 80 & 120hr -lives respectively
o If hes a class C cirrhotic: Oxazepam, Temazepam, Lorazepam (Over The Liver)
Glucuronidated prior to elim

 Beta-blockers mask the signs of autonomic hyperactivity

o Can follow hyperreflexia to dose the benzos during withdrawal
Presentation = ~12-24hrs. since last drink
o Bimodal peak at 8 and 48hrs
Confusion, fluctuations in consciousness and the feeling of ants crawling on him (formication)
o 48-72hrs since last drink
W/BAC of 225mg/mL, ~9h till its out of his system
o EtOH has zero-order kinetics = 25mg/hr
Most specific test for ETOH consumption in past 10 days: Carbohydrate-deficient transferrin
Less specific: Elevated GGT, AST more than twice ALT.
Pt w/confusion, ataxia, and you find this on physical exam:

Ophthalmoplegia
Wernicke Encephalopathy. (caused by thiamine defy)
Tx: Give thiamine 1st, then glucose-containing fluids.
Can progress to Korsakoffs syndrome (irreversible damage to mammillary bodies, etc.)
o Apathy, antero/retrograde amnesia, confabulation
o Midbrain atrophy on MRI
A patient is brought into the ER in a non-responsive state. His BP is 100/60, HR is 50, RR is 6. He
has multiple track marks on his arms.
Heroin Overdose
First step: Intubate the patient
Tx: IV or IM naloxone (full mu-opiate antagonist)
Dilated pupils dont change the dx 2/2 respiratory depression can cause hypoxic dilation
Withdrawal sxs:
o Joint and muscle pain
o Dilated pupils, photophobia
o Goosebumps, diarrhea, tachycardia, HTN, GI cramps
o Anxiety/depression
Tx: Clonidine for autonomic sxs
o Ibuprofen for muscle cramps, loperimide for diarrhea.
Methadone, buprenorphrine or naltrexone can be used for long-term dependence.
Horizontal nystagmus, dilated pupils, ataxia, acute psychosis?
Hallucinogen (PCP) intoxication
Can use haloperidol for acute psychosis.
S/p MVC with injected conjunctiva, sedation, asking for Doritos?
Cannabis intoxication.
SI, hypersomnia, depression and anergia?
Cocaine/Amphetamine withdrawal.
Dilated pupils, seizure, tachycardia and HTN?
Cocaine/Amphetamine intoxication
First: EKG, then urine tox
Tx: Lorazepam (for seizures)
o Tx HTN and tachycardia w/CCB
Beta-blockers are CONTRAINDICATED!

Meningitis.
MCC: S. pneumo, H. influenzae, N. meningitidis
o Tx w/ceftriaxone and vanc
In old/young pts: Add Listeria
o Tx w/ampicillin
W/brain surg: Add S. aureus
o Tx w/vanc
Other: TB (abx + steroids), Lyme (IV ceftriazone)
Best 1st step: Empiric abx (+steroids if bacterial)
o Dx: Exam for elevated ICP/CT w/LP+Gram stain
>1000WBC is diagnostic
High protein and low glucose support bacterial
Tx roommates/contacts of pts w/bacterial meningitis and petechial rash: Rifampin!
CLOTTING & BLEEDING
In old people?
Edema, HTN, & foamy pee?
In young person w/ +FH
Whats special about ATIII def?
Young woman w/ mult. SABs?
Post op, plts, clots
What do you treat w/?
Bleeding
Think cancer
Isolated decr in plts?
Nephrotic syndrome
Factor V Leiden
Heparin wont work
Lupus Anticoagulant
HIT! (If heparin w/in 5-14 days
Leparudin or agatroban
ITP
Normal plts but incr bleeding time & PTT?
Low plts, Incr PT, PTT, BT, low fibrinogen, high Ddimer
and schistocytes?
vWD
DIC!! Caused by gram sepsis,
carcinomatosis, OB stuff

Ischemic strokes DON'T present with N/V and very rarely have LOC or other ICP sx.
ICHemorrhage initially has focal sx followed by incr. ICP sx (N/V, HA, bradycardia, stupor), but v. rarely
LOC.

SAHemorrhage doesnt present w/focal deficits, but does present w/ICP sx.
DM pts susceptible to CN3 nerve ischemia/neuropathy (parasympathetics intact, so only paralysis); if CN3
compression, will have ptosis, fixed, dilated pupil, and no accomodation.
Ataxia w/ dizziness, occipital HA, vomiting = cerebellar hemorrhage, no matter heat stroke risk
HA + focal neuro sx _ ring-enhancing lesin on CT- fluid collection in ethmoid sinus = brain abscess 2ary to
ethmoid sinusitis (only 50% of abscesses have fever)--anaerobes, esp S. vioridans, are common--Tx w/ 4-8 wks
min abx and drain

cerebellar sx--gait dyfxn, truncal ataxia, nystagmus, intention tremor, dysmetria, impaired RAM
1st-line tx for intention tremor: PRopranolol; may also tx w/topiramate, primidone (benzos if severe)
Complication of heat stroke: Rhabdo, coagulapathic bleeding, renal failure, ARDS; infx rarely cause temps over
105F; hypothalamic stroke can result in neurogenic fever

PICA occlusion: Accessory nerve/CN11 compromiseParalysis of ipsilateral sternocleidomastoid & traps

Lesions BETWEEN pons and medulla will cause contralateral lower facial droop
Glossopharyngeal/CN IX injury: Jugular foramen syndrome (posterior fossa tumor/bleed) = loss of gag reflex
+ dysfxn of carotid sinus Increased risk of syncope
Brain mets from breast, colon and renal cell ca are usually single mets
SAH rarely presents w/focal deficits/herniation sx
Fasciculations are an LMN sign
Diabetic neuropathy signs are LMN only
DM pts more likely to have spinal epidural abscess
CJD: PRNP protein testing (genetic)
Sharp wave complexes on EEG and elevated 14-3-3 proteins in CSF
Imaging for ALz: Diffuse cortical and subcortical atrophy which is pronounced in temporal and parietal lobes
IIH/psudotumor cerebri can be caused by: Isotrentinoin, tetracyclines, GH; cessation of meds leads to resolution
Anterior cord syndrome: Burst fx of vertebra; total motor loss below lesion, P&T loss below lesion bilat
Central cord syndrome: Burning pain and paralysis in UEs w/sparing of LEs, seen in neck hyperextension
Brown-Sequard: Hemisection w/ipsilateral motor and proprioception loss, contralateral P&T loss below lesion

Suspected MS imaging: MRI with and w/out gadolinium

3513
Medicine
Nervous System
Essential tremor tx w/ beta-blockers or primidone (converts to phenbarb and PEmalonamide)--may precip acut
eintermittent porphyria (abd pain, neurologic & psych abnormalities)--check urine porphobilinogen
3630
Medicine
Nervous System
GBS also precip by Herpesvirus, Mycoplasma, and H. flu; more common in lymphoma, SLe and sarcoidosis
3643
Medicine
Nervous System
Acute exaacerbatons of MS are tx w/IV steroids
3690
Medicine
Nervous System
With hypovolemia in setting of heat and heavy extertion, heat exhaustion; add temp >104F and CNS dysfxn
(seizure/delirium) = failure of thermoregulation/heat stroke; body temp over 105F may cause rhabdo
3723
Medicine
Nervous System
Note that ischemic strokes DON'T present with N/V and very rarely have LOC or other ICP sx. ICH prsents
w/focal deficits; SAH doesn't. Both present w/ICP sx.
3725
Medicine
Nervous System
GBM: Cross midline, 'butterfly', central necrosis, heterogenous/serpiginous contrast Also HA that worsen
w/position, andN/V low grade astrocytoma presents w/seizure and have longer duration of sx infarction resolves
in 6-8 weeks
3726
Medicine
Nervous System
!!THIS question details midbrain/brainstem hemorrhagic strokes
3727
Medicine
Nervous System
Intubate pts in myasthenic crisis, then do plasmapheresis and corticosteroids
3728
Medicine
Nervous System
Bas gang hemorr: hemiplegia, hemises loss, gze palsy stupor coma; cerebellar hem = facial weakness neck
stiffness, gaze palsy, nystagmus, gait ataxia, NO hemiparesis, stupor/coma if herniation; thalamus hem:
hemiparesis, hemisens loss, upgaze palsy, nonreactive miosis, eyes Toward hemiparesis; lobar: poss seizures,
contralat homo hemianop, contralat, plegia/paresis contralat hemiparesis eyes AWAY from hemiparesis; pos
homorrage = deep coma, total paralysis w/in minutes, react
3771
Medicine
Nervous System
Riluzole--glutamate inhibitory used for ALS may prolong survival; elevates liver enzymes and may cause
nausea and wt loss
3817

Pediatrics
Nervous System
Lesch-Nyhan--self-mutilation w/dystonia and elev. uric acid = def'y in hypoxanthie guanine phosphoribosyl
transferase, def'y in purine metabolism
3837
Medicine
Nervous System
SCC in lung can present w/mediastinal lymphadenopaathy as well as LE syndrome
3923
Medicine
Nervous System
Memory impairment in NPH is slow and progressive
3959
Medicine
Nervous System
!!!!*****
4022
Medicine
Nervous System
ACA stroke: Contralat motor/sensory deficits, more in LEs than UEs; urinary incontinence; gait dysparxia,
primitive reflexes, abulia, emotional disturbance Note that incontinence is a cortical sx (never seen in midbrain
infarcts)
4089
Medicine
Nervous System
cortical laminar necrosis results from excitatory cytotox-->status seizures; defined as seizures for more than 5
min without recovery in between
4130
Medicine
Nervous System
MSA= parkonsonism, autonomic dysfxn, widespread neuro signs
4255
Medicine
Nervous System
craniopharyngioma rare in adults, but bimodal age dist: child, 55-65y/o. Optic neuritis is us. assoc w/loss if
central vision and afferent pupillary defect
4268
Medicine
Nervous System
Posterior limb internal capsule (lacusnar infarct) unilateral motor deficit; no sensory cortical or vis field deficits;
MCA = contralateral motor and sensory (face arm leg), "gaze at stroke" homonomous hemianopsia; aphasia,
hemineglect; ACA = contralat somatosens + motor dficiet, LEs with ABULIA, dyspraxia, emotional
disturbances, incontinence; Vertebrobasilar = alt syndromes w/contralat hemiplegia and ipsilateral cranial nerve
deficits + possible ATAXIA
4269
Medicine
Nervous System
R-side lateral medullary infarct = Wallenberg: falling to side of lesion, ipsilat limb ataxia, diplopia, nystagmus,
vertigo; loss of P&T in ipsilat face and CONTRA lat trunk/limbs; ipsilat vocal cord paralysis; ipsilat Horner's
syndrome-->lat cerebellar lesions do not cause Horner's & have minimal dizziness
4274
Medicine

Nervous System
Brown-Sequard = contralaterla pain and temp loss 2 levels below lesion (spinothalamic tracts decussate almost
immediately)
4366
Medicine
Nervous System
Metoclopramide = DA antagonist; can produce dystonia (tenderness/stiffness) as well as parkinsonism and TD;
risk of NMS; tx SEs w/benztropine or dphenhydramine
4367
Medicine
Nervous System
ANGLE-CLOSURE GLAUCOMA, acute: haloed lights, periorbital pain, unilat lacrimation, severe HA, poss.
N/V, elev ESR; can occur d/t anticholinergics (pupil dilation); MC in women, Asian, Inuit, farsightednness
4372
Medicine
Nervous System
spinal epidural abscess--fever, focal spinal tenderness/back pain, neurologic dysfxn; get MRI, ESR, and CTguided aspiration/culture
4392
Medicine
Nervous System
Cuda equina syndrome cause by compression of spinal nerve roots, NOT conus medullaris--causes LMN signs;
conus medullaris compromise causes HYPERreflexia and perianal anesthesia w/sudden-onset severe back pain
(vs. radicular pain)
4393
Medicine
Nervous System
Hypokalemia: weakness, fatigue, hyporeflexia, tetany, rhabdo, arrhyth (severe) ECG shows broad flat T waves
ST depression, U waves and PVCs; HCTZ is K-wasting (hyperaldost can also cause)
4401
Medicine
Nervous System
Anticholinergics used on PD--benztropine, trihexylphenidyl; selegiline is an MAO-Bi used in PD;
bromocriptine is a DA agonist used in PD
4408
Medicine
Nervous System
DM pts susceptible to CN3 nerve ischemia/neuropathy (parasympathetics intact, so only paralysis); if CN3
compression, will have ptosis, fixed, dilated pupil, and no accomodation.
4427
Medicine
Nervous System
!!THIS question details gait disorders--COPY Foot drop usually = L5 radic (common peroneal nerve)
4458
Medicine
Nervous System
Ataxia w/ dizziness, occipital HA, vomiting = cerebellar hemorrhage, no matter heat stroke risk
4482
Medicine
Nervous System
Posterior limb int capsule MC site for lacunar stroke: Sx affect contralat face, leg, arm equally; thromboti
origin; not visible on CT soon after--microatheroma and lipohyalinosis are pathpphys resp.

4513
Medicine
Nervous System
HA + focal neuro sx _ ring-enhancing lesin on CT- fluid collection in ethmoid sinus = brain abscess 2ary to
ethmoid sinusitis (only 50% of abscesses have fever)--anaerobes, esp S. vioridans, are common--Tx w/ 4-8 wks
min abx and drain
4552
Surgery
Nervous System
Herniation syndromes: UOA Uncal-->oculomotor-->then abducens
4618
Medicine
Nervous System
cerebellar sx--gait dyfxn, truncal ataxia, nystagmus, intention tremor, dysmetria, impaired RAM
4619
Medicine
Nervous System
!!THIS question details dementia presentations
4622
Medicine
Nervous System
Tx of choice for agitation in elderly is low dose haloperidol; benzos are contraindicated in older pts (can cause
paradoxic agitation, + have slower metab)
4687
Medicine
Nervous System
RLS is tx w/ ropinirole or pramipexole--DA agonists
4691
Medicine
Nervous System
Epidural spinal cord compression causes: injury (EG, MVA), malignancy (L, B, P ca, myeloma), infx (epidural
abscess); severe local back pain; pain worse in recumbent pos'n/at night; symm LE weakness, paraplegia w/ inc.
DTRs; IV glucorticoids, stat MRI, radiation onc + neurosurg consult
4703
Medicine
Nervous System
Complication of heat stroke: Rhabdo, coagulapathic bleeding, renal failure, ARDS; infx rarely cause temps over
105F; hypothalamic stroke can result in neurogenic fever
4708
Medicine
Nervous System
Elev ICP /ICHtn: >20mmHg. Diffuse HA, worse in morning, N/V early in day, vision changes, CN deficits
somnolence confusion n=unsteadiness Remember Cushing's reflex: HTN + bradycardia
4900
Medicine
Nervous System
papilledema can cause momentary vision loss that changes with head position; amaurosis fugax is us. vascular
(embolus to opth artery); galucoma may cause periph visual field deficits (not actue angle-closure, though);
optic neuritis is unilat eyes pain and vision loss w/afferent pupillary defect.
4913
Medicine
Nervous System

!!THIS question details features of tremor

4914
Medicine
Nervous System
1st-line tx for intention tremor: PRopranolol; may also tx w/topiramate, primidone (benzos if severe)
4921
Medicine
Nervous System
Embolic stroke: sx onset abrupt and maximal initially; thrombotic, sx fluctuate w/ periods of
progression/imrpvement; ICH, sx progress over min-hours, followed by incr. ICP sx; SAH, severe HA at sx
onset, meningeal irrit, focal deficit uncommon
10499
Medicine
Nervous System
Subacute combined degeneration --prog symm polyneuropathy grater in legs than arms; advanced dis can cause
UMN signs, memory loss; methylmalonic acis levels will eb elevated
4619 Medicine Nervous System
!!THIS question details dementia presentations
4913 Medicine Nervous System
!!THIS question details features of tremor
3726 Medicine Nervous System
!!THIS question details midbrain/brainstem hemorrhagic strokes