PANCE/PANRE Breakdown NCCPA Blueprint y Neurologic system –6% of exam content y Diseases of Peripheral Nerves The Neurologic System y PANCE y Headaches y 360 questions x 0.06 = 21.6 y Infectious Disorders y PANRE y Movement Disorders Ryan D. White, PA‐C, MPH y 300 questions x 0.06 = 18 y Vascular Disorders UMDNJ PANCE/PANRE Review Course y NCCPA Blueprint available at y Other Neurologic Disorders (becoming Rutgers University July 1, 2013) http://www.nccpa.net/ExamsContentBlueprint.aspx y Content of this presentation follows NCCPA Blueprint

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) CRPS Diseases of Peripheral Nerves Complex Regional Pain Syndrome y Usually follows trauma to affected limb (may be y Complex Regional Pain Syndrome y Formerly called Reflex Sympathetic Dystrophy minor) y Peripheral Neuropathies y Autonomic and vasomotor dysfunction in the y Most commonly affects hand and ipsilateral shoulder extremities y Early mobilization can help prevent CRPS y One extremity affected y Vitamin C 500mg/day reduces risk in wrist fractures y Pain, swelling, color/temperature changes y Increased uptake on bone scan y Pain is burning, exacerbated by light touch y In late CRPS, osteopenia seen on x‐ray y Skin and nail dystrophy y Treatment –early intervention is best y Muscle atrophy y NSAID, corticosteroids, PT/OT, pain management y Limited ROM y Antidepressants and anticonvulsants (gabapentin) used y Does not follow one peripheral nerve distribution y Regional nerve block and spinal stimulation y No systemic symptoms UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Peripheral neuropathies –signs and Peripheral Neuropathies symptoms Peripheral neuropathies –exam y y Many possible etiologies May be motor, sensory, autonomic or combination y Atrophy/muscle wasting (hands, feet, anterior tibialis) y y May be primarily sensory… Presentation depends on etiology y Fasciculations y Inflammatory/immune (vasculitis, paraneoplastic) y Acute vs. chronic, symmetric vs. asymmetric y Muscle weakness y Metabolic (diabetes) y Motor (weakness) y Stocking‐glove sensory loss y Infectious (HIV, HSV, leprosy) y In legs – tripping on carpeting, curbs y Cold, erythematous or bluish hands and feet y Toxic (chemotherapy, vitamin B6) y In hands – difficulty with fine movements (buttons, y Deficiency (vitamin B12, vitamin B1, vitamin E) zippers, keys) y May have impairment of vibration sense, position y Alcohol‐related y Sensory loss, loss of proprioception sense, light touch, pain sense, temperature sense, y Primarily motor… y In feet – “walking on pebbles”, “ice cold” heel/toe walk, tandem gait y Inflammatory/immune (Guillian‐Barre) y Dysesthesias – “on fire”, “stuck with pins”, numbness, y Diminished deep tendon reflexes (distal first) y Toxic –lead tingling

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Diabetic neuropathy Peripheral neuropathies ‐ diagnosis y Most common cause of neuropathy in the Western Bell’s Palsy world y EMG/NCV y Lower motor neuron facial nerve paresis y If the patient has albuminuria or retinopathy –2x y Nerve/skin biopsy more likely to develop neuropathy y Infection, pregnancy, diabetes y Typically for vasculitis‐related neuropathy y Typically a distal symmetric polyneuropathy y Abrupt onset of facial paresis y Labs –glucose, BUN/Cr, CBC, vitamins B6 and B12, y Autonomic neuropathy also common (erectile y Ipsilateral ear pain, restriction of eye closure, difficulty RPR dysfunction) eating y Genetic tests if indicated y Elevated glucose = increased risk and progression of y 60% recover completely without treatment neuropathy y 10% have long term or permanent sequelae y No treatment to halt progression y Steroids must be initiated within 5 days to see benefit y Tight sugar control! y Acyclovir has not been shown to provide benefit y Gabapentin, nortriptyline, pregabalin (Lyrica), duloxetine, opioids y Lubricating drops and/or eye patch

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Peripheral neuropathies ‐ others Bell’s Palsy Peripheral neuropathies ‐ more y Charcot‐Marie‐Tooth disease (inherited) y Sensory loss and weakness of hands/fingers and legs y Compression/entrapment neuropathies (anterior tibialis weakness = “drop foot”) y Carpal‐tunnel syndrome, radiculopathies y No treatment y y Use ankle‐foot orthoses, genetic counseling Trigeminal neuralgia y Vasculitic (nerve ischemia) y Post‐herpetic neuralgia y Painful, acute onset or motor and sensory symptoms y Pain persisting >6 weeks after herpes zoster infection y Depends on underlying vasculitis y Treat with acyclovir (steroids reduce pain but do not y Etiologies –rheumatoid arthritis, Churg‐Strauss, prevent onset or severity of neuralgia) Wegener’s granulomatosis, polyarteritis nodosa, Sjogren’s, SLE y Diagnosed with nerve/vessel biopsy, EMG y Treat with steroids, methotrexate, azathioprine

UMDNJ PANCE/PANRE Review Course (becoming http://en.wikipedia.org/wiki/Bell's_palsy UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Headaches Cluster Headaches Cluster Headaches y Cluster Headaches y Primarily affects middle‐aged men y Timing y Migraine Headaches y Mechanism not fully understood y Episodes often at night y Tension Headaches y No family history y Daily for several weeks y Last 15 minutes to 3 hours y Symptoms y Occur in “clusters” y Severe unilateral periorbital pain y Lasts 4‐8 weeks, with weeks to months of remission y Ipsilateral nasal congestion and rhinorrhea y May be seasonal y Redness of the eye y Triggers –similar to migraines y Horner syndrome

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Cluster Headaches Migraine Headaches Migraine Headache y Exam normal except rhinorrhea, lacrimation, maybe y Headache of neurovascular dysfunction y Classic symptoms: Horner syndrome y Dilatation of blood vessels innervating the trigeminal nerve y Unilateral throbbing headache (severe) causes headache (mechanism not entirely understood) y Treatment y Nausea, vomiting, photophobia, phonophobia y Regional cortical blood flow reduced, resulting in y Abortive y May also include: clinical symptoms y Triptans y Cognitive impairment, blurred vision y Symptoms correspond to affected area of cortex y 100% oxygen y Focal neurologic dysfunction y Intranasal lidocaine y Classic and variant forms y Aphasia, numbness/paresthesias, focal weakness, dysarthria, y Corticosteroids y Onset typically in teens –early thirties disequilibrium y Prophylactic y More common in women y Visual field defects (aura) y Verapamil, topiramate, lithium, ergotamine y “Zigzags” or “flashes” of light, visual hallucinations, scintillating y Often a family history of migraine‐like headaches scotomas

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Migraine Headache Migraine Headache Migraine Headaches y “Migraine equivalent” y Common triggers y Clinical diagnosis y Somatic symptoms without headache y y Imaging generally not warranted y Variants y Foods (chocolate, alcohol) y Treatment y Ophthalmoplegic (ophthalmic) migraine y Smells (perfume) y Avoid triggers! y 3rd and/or 6th nerve palsy y Bright lights, loud noises y Stay in dark, quiet room y Basilar artery migraine y Menstruation y Abortive medication y Preventive therapy

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Migraine Headaches Migraine Headaches Tension Headaches y Abortive medications y Preventive Therapy y Most common primary headache y Analgesics (ASA, APAP, NSAIDs) y Antiepileptics y Generalized, constant/daily headache y Ergotamine + = Cafergot y Topiramate, valproic acid y Vise‐like, gripping, tightness, squeezing y Antihypertensives y Triptans (sumatriptan) –mainstay of treatment y NOT typically pulsatile y Contraindicated in CVD, PVD y Propranolol, verapamil, candesartan y Non‐specific, non‐focal y Avoid in pregnancy y Amitriptyline y Poor concentration y May cause nausea/vomiting y Botox y Combine with naproxen for greater benefit y Head and neck tenderness y Droperidol, metoclopramide, prochlorperazine y Exacerbated by stress, fatigue, glare, loud noise y Opioids

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Tension Headache Infectious Disorders Encephalitis y Treatment y Encephalitis y Inflammation/infection of brain parenchyma y Stress reduction y Meningitis y Viral, amebic, tick‐borne y Improve sleep hygiene y Hashimoto’s encephalopathy y ASA, APAP, NSAIDs y Often occurs with concomitant meningitis = y Caution: rebound headaches meningoencephalitis y Caffeine, butalbital used (not recommended in practice)

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Encephalitis ‐ etiologies Encephalitis – signs/symptoms Encephalitis – diagnosis/treatment y Seasonal y Prodrome… y Diagnosis y West Nile, equine encephalitis virus, enteroviruses y Fever, malaise, myalgia, nausea, vomiting, diarrhea, rash y Lumbar puncture –elevated opening pressure, elevated protein and lymphocytes, normal glucose (Coxsackie) y As disease progresses… y CT head prior to LP if risk factors for cerebral herniation y HSV‐1 is most common non‐epidemic cause in US y headache, photophobia, altered sensorium, seizures present… y West Nile is most common epidemic cause in US y May exhibit… y CSF serology or PCR y If immunosuppressed: y meningeal signs, hemiparesis, aphasia, behavioral y Treatment y HIV, Varicella/Zoster, CMV, EBV changes (depending on area(s) of brain affected) y Treat causative agent y Others y If HSV –acyclovir (often empirically) y Supportive –ICU, treat seizures y HSV‐2, measles, mumps, rubella, Dengue fever, rabies y Prognosis is variable (HSV‐1 mortality is 20%)

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Meningitis Bacterial Meningitis ‐ etiologies Bacterial Meningitis ‐ presentation y Inflammation/infection of arachnoid membrane, pia y Haemophilus influenzae y Acute onset of fever, headache, vomiting, stiff neck, mater and intervening CSF y Primarily affects children myalgia, backache, generalized weakness y Bacterial, viral and other y Streptococcus pneumoniae y Can rapidly progress to , obtundation, loss of consciousness, focal neurologic deficit y Decreased incidence due to vaccines for Haemophilus y Predominantly adults (>50 years old) with comorbidities influenzae, Streptococcus pneumoniae and Neisseria y Neisseria meningitidis y Kernig and Brudzinski signs meningitidis y Outbreaks (dorms, barracks, jails) y Petechiae or ecchymotic rash = meningococcal y Predisposing factors y Meningococcal vaccine 85% effective y Rapidly progressive y Otitis media, pneumonia, sinusitis, head injury, y Listeria monocytogenes y Seizures, hydrocephalus, CN abnormalities, hearing cirrhosis/alcoholism, immunodeficiency y Emerging in developed countries as most common cause loss, visual field defects, coma of bacterial meningitis

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Bacterial Meningitis –treatment

Bacterial Meningitis ‐ diagnosis y Bacterial meningitis is a medical emergency! Bacterial Meningitis –more treatment y Lumbar puncture – opening pressures and CSF y Rapid initiation of IV antibiotics y Re‐examine CSF 24‐48 hours later if poor response rd analysis y Empiric – vancomycin and 3 generation cephalosporin or y Dexamethasone to reduce sequelae ampicillin y Elevated opening pressure y Trimethoprim‐sulfa if PCN‐allergic y No effect on mortality y CSF ‐ elevated protein, decreased glucose, elevated cell y Pneumococcal –PCN and vancomycin or chloramphenicol y Mannitol if elevated intracranial pressure count (PMN cells) rd y 3 generation cephalosporin if resistant y Chemoprophylaxis of close contacts y CSF – gram stain, culture and PCR y Meningococcal – Penicillin G and ampicillin y Blood cultures y 3rd generation cephalosporin if resistant y H. flu –3rd generation cephalosporin or chloramphenicol and y CT/MRI brain and spine ampicillin y X‐ray chest, sinus, mastoid y 3rd generation cephalosporin = ceftriaxone or cefotaxime

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Meningitis –viral and other Movement Disorders Essential Tremor y “Aseptic meningitis” y Essential Tremor y Postural (sustention) tremor of hands, head and/or y Viral, fungal, chemical, neoplastic, arthropod‐borne y Huntington Disease voice y 60% are enteroviruses (echovirus, Coxsackie) y Etiology unclear y Fecal‐oral transmission > respiratory (seasonal) y Parkinson Disease y Mumps y Often a family history (familial tremor) y Abrupt onset of fever, headache, stiff neck, nausea, y Autosomal dominant vomiting, myalgia, photophobia, +/‐ rash y May begin at any age y Benign clinical course, recovery in 1 –3 weeks y Exacerbated by stress y CSF – lymphocytic pleocytosis, normal glucose, elevated y Alcohol tends to relieve symptoms protein (run PCR and culture) y Prevention is key (MMR vaccine) y No other associated neurologic abnormalities y Acyclovir if HSV, otherwise supportive treatment

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Essential Tremor ‐ treatment Huntington Disease Huntington Disease ‐ differential y Usually not disabling y Autosomal dominant inheritance (chromosome 4) y Other causes of chorea y If treatment necessary: y Worldwide, all ethnic groups y Stroke y Start with propranolol if possible y Gradual onset of chorea, and behavioral y SLE y 60 – 240 mg/day changes y Paraneoplastic syndromes y Primidone next –patients tend to be sensitive to this y Progressive disease y HIV drug y Onset between 30‐50 years old y Group A strep infection (children) y Other options include alprazolam, topiramate, y Typically fatal within 15‐20 years gabapentin y CT or MRI reveals cerebral atrophy y Genetic test available for definitive diagnosis

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Huntington Disease ‐ treatment Parkinson Disease Parkinson ‐ presentation y Treatment is symptomatic y Dopaminergic nigrostriatal system degenerates y Classic findings: y No halting progression or reversal of disease y Imbalance of and acetylcholine in corpus y Resting tremor y Tetrabenazine for dyskinesias striatum y Rigidity y Also consider reserpine for dyskinesias, haloperidol for y Typically not inherited y Bradykinesia behavioral changes. y Onset usually between 45‐65 years old y Postural instability y Genetic counseling for children y Diagnosis based on clinical findings y Masked faces y Lies on a spectrum of disorders called Parkinsonism y Typically no muscle weakness or reflex changes

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Parkinson Disease ‐ treatment Parkinson Disease ‐ treatment Vascular Disorders y Levodopa y Other medications: y Cerebral aneurysm y Converted in body to dopamine y Amantadine may be effective early y Intracranial hemorrhage y Side effects: nausea, vomiting, hypotension, dyskinesias, y Anticholinergics y Stroke restlessness, confusion y Benztropinemesylate(Cogentin), Trihexyphenidyl (Artane), y Transient Ischemic Attack y Avoid in patients with , narrow angle glaucoma orphenadrine (Norflex) y Dopamine agonists y Carbidopa y Pramipexole (Mirapex) and ropinirole (Requip) y Inhibits enzyme that breaks down dopamine y Selective MAOI – rasagiline and selegiline y Does not cross blood‐brain barrier y Deep brain stimulation y Combine with levodopa = lower effective dose of levodopa to diminish side effects (Sinemet)

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Cerebral aneurysm Stroke Stroke Risk Factors y Saccular (“berry”) aneurysms y Ischemic – 85% y Black/Hispanic:White = 2:1 y Arterial bifurcations, often multiple y Thrombotic y Men 40% more likely than women y Typically asymptomatic until rupture y Embolic y Hypertension = 4X risk y Most found in anterior Circle of Willis y Small vessel disease y Risk factors y Diabetes = 2‐6X risk y Hemorrhagic – 15% y Smoking, hypertension, hyperlipidemia y Smoking = 2X risk y Intracerebral y Major complication is subarachnoid hemorrhage y Carotid stenosis y Subarachnoid y Angiography is gold standard for diagnosis y Atrial fibrillation y 2nd leading cause of death worldwide y CT or MRA often used but less sensitive y y 3rd in developed countries Others: obesity, hyperlipidemia, elevated y Monitor if <10mm homocysteine, EtOH, OCP y Surgical or endovascular intervention

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Ischemic stroke vs. TIA Ischemic Stroke Ischemic stroke ‐ presentation y TIA y Thrombotic y Symptoms <24 hours y Time at onset of symptoms y Atherosclerotic plaque y No infarction = no permanent damage y If <3 hours, thrombolysis may be possible y Embolic y Stroke y Usually painless y Piece of mural thrombus breaks off and lodges in y Symptoms >24 hours y Exam to localize lesion cerebral vasculature (afib) y Brain infarction = permanent damage y Focal neurologic deficit y Lacunar infarct y Mental status, speech, cranial nerves, strength, sensation, y But… y Smaller arterioles occluded reflexes y If sxs >1‐2 hours, possibly infarction/stroke and y Findings depend on the occluded vessel generally worse outcome y 1/3 of patients who experience a TIA eventually have a stroke

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Cerebral vasculature Ischemic Stroke ‐ presentation Ischemic stroke ‐ diagnosis

Occluded artery Common symptoms y CT‐brain!!! y Investigate etiology of the stroke Internal carotid artery ipsilateral blindness, other symptoms similar to MCA stroke y CBC Middle cerebral artery contralateral hemiparesis, arm/face > leg sensory loss, expressive aphasia y Polycythemia vera, anemia, thrombocytosis, infection y ESR Anterior cerebral artery contralateral hemiparesis, leg > arm/face sensory loss y Hypercoaguable states Posterior cerebral artery contralateral homonymous hemianopia, memory impairment y Giant cell arteritis contralateral hemiparesis and sensory loss, ipsilateral bulbar or cerebellar y Glucose, electrolytes, LFTs Basilar artery signs y PT/PTT/INR ipsilateral sensory loss in face, ataxia, contralateral hemiparesis and sensory Vertebral artery loss y Cardiac investigation gait ataxia, nausea/dizziness, dysarthria, gaze paresis, contralateral y EKG, cardiac enzymes superior cerebellar artery hemiparesis

http://www.cixip.com/index.php/page/content/i UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) d/1007 Rutgers University July 1, 2013) Rutgers University July 1, 2013) CT scan –ischemic stroke CT scan –ischemic stroke Differential Diagnoses y Subdural hematoma/hemorrhagic stroke vs. ischemic stroke y TIA y Seizure y Hyper/hypoglycemia y Bell’s palsy y Tumor y Radiculopathy y Guillain‐Barre

http://radiographics.rsna.org/content/23/3/565/ UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming http://education.vrad.com/interesting- UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) F10.expansion.html Rutgers University July 1, 2013) cases/cerebral-ischemiastroke-case-4/ Rutgers University July 1, 2013) Bell’s Palsy vs. Stroke Bell’s Palsy vs. Stroke Acute Ischemic Stroke Treatment y Thrombolytic therapy y Tissue plasminogen activator (t‐PA) y Must be given within 3 hours of onset y CT first!!! y Monitor CBC

UMDNJ PANCE/PANRE Review Course (becoming http://en.wikipedia.org/wiki/Bell's_palsy UMDNJ PANCE/PANRE Review Course (becoming http://www.ihnigmuh.co UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) m Rutgers University July 1, 2013) t‐PA contraindications Prevention Hemorrhagic Stroke y BP >185/110 y Anti‐platelet therapy y 2/3 subarachnoid hemorrhage (SAH) y Major surgery (especially intracranial) or trauma in y ASA y Ruptured vessel on surface of brain previous 2 weeks y Plavix y 1/3 intracerebral hemorrhage (ICH) y GI bleeding y Control lipids y Ruptured vessel within brain substance y Evidence or history of ICH y statins y Etiology y Recent anticoagulation/bleeding diathesis y Control BP – antihypertensives y Trauma, aneurysm (usually Berry aneurysm in Circle of y ACE‐I in diabetics Willis), arteriovenous malformation (AVM) y No anticoagulants or platelet‐inhibitors for at least 24 hours after administration of t‐PA y Smoking cessation y 25% die within 24 hours y Anticoagulation for afib patients y 50% die within 6 months y Carotid endarterectomy or stenting

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) SAH Symptoms Diagnosis SAH CT scan y Rapid onset, severe headache y CT y “Thunderclap” y Lumbar puncture y “Worst headache of my life” y Cerebral angiography y Prodromal less severe headaches y Definitive study to define source of bleeding y Nausea/vomiting y CBC, PT/PTT/INR, electrolytes y Altered mental status y Neck stiffness

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) SAH Treatment Intracerebral Hemorrhage ICH y BP control y Usually due to hypertension y Beta‐blockers y Other risk factors y Clipping or coiling y EtOH y Nimodipine y Bleeding disorder y CCB to reduce vascular spasm y Cancer (leukemia) y Reduce ICP –prevent hydrocephalus y Anticoagulation y Mannitol y Diuretics y Supportive y Ventilation, seizure prophylaxis, nutritional support

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) ICH Subdural Hematoma SDH ‐ etiology y Symptoms y Trauma y Consciousness is lost or impaired, variable headache, y Anticoagulation vomiting, focal neurologic symptoms y EtOH y Diagnosis y CT y Frequent falls y Management y More common in very young and very old y Supportive y Ventilation, BP control, seizure prophylaxis y Osmotic agents, nutritional support y Monitor ICP y Surgical decompression

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming http://en.wikipedia.org/wiki/Subdural_hematoma UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) SDH SDH Other Neurologic Disorders y Symptoms are variable y Treatment varies with severity y Altered level of consciousness y Confused speech y Watch and wait y Concussion y Difficulty with balance or walking y Craniotomy y Headache y Post‐concussion Syndrome y Diuretics and steroids to reduce brain swelling/ICP y Lethargy or confusion y Cerebral Palsy y Loss of consciousness y Seizure prophylaxis y y Nausea and vomiting y Numbness y y Seizures y Guillain‐Barre Syndrome y Slurred speech y Multiple Sclerosis y Visual disturbances y Weakness y Myasthenia Gravis

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Altered level of consciousness Altered level of consciousness Other Neurologic Disorder (cont’d) y Stupor, coma, vegetative state, brain death y History y Seizure disorders y Stupor = unresponsive except to repeated vigorous y Abrupt onset –SAH or brainstem stroke y Prior intoxication or delirium – toxic/metabolic y Status epilepticus stimuli y Comatose = unarousable, no response to external y Exam y Syncope y Response to painful stimuli, pupil reaction to light, eye events y Tourette disorder position and response to passive movement of head, y Reflex movements and posturing may be intact respiration (GCS) y Vegetative state = wakefulness is retained but y Ice water caloric stimulation, “doll’s head response” awareness of self and environment is absent y Serum glucose, electrolytes, calcium, LFTs, BUN/Cr, toxicology studies y Results from serious CNS disorder y EEG, brain imaging (CT, MRI) y Seizure, structural lesion, hypothermia, metabolic y Supportive treatment disorder, toxic/drug‐induced y Dextrose, naloxone, thiamine IV, flumazenil

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Concussion Concussion ‐ presentation Concussion ‐ treatment y Transient trauma‐induced change in mental status y Headache, nausea/vomiting, disorientation, impaired y Grade I (mild) – transient confusion, symptoms last y May or may not involve loss of consciousness concentration, irritability, , clumsiness, visual <15 minutes, no loss of consciousness y Remove from work/duty/play y Primary (coup‐contracoup injury) and secondary disturbance, focal neurologic deficits y Return in 15 minutes (inflammation, diffuse axonal injury) phases y Glasgow Coma Scale and thorough neurologic exam y Grade increases with each subsequent concussion y y Vigilance necessary to detect hematoma or edema CT brain y Grade II (moderate) moderate transient confusion <15 y Symptoms may appear several days later y Treatment depends on severity of injury minutes, no loss of consciousness y Remove for 1 day, y Return after one asymptomatic week y Grade III (severe) –loss of consciousness y ER evaluation, consider admission

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Post‐concussion syndrome Cerebral Palsy Cerebral Palsy y May last several weeks to > 1 year y Chronic, static impairment of muscle tone, strength, y Spasticity is common (75%) y Headache is primary symptom coordination and/or movement y Variable number of limbs affected y Difficulty concentrating, changes in appetite, sleep y Non‐progressive y Ataxia, chorea/dystonia and hypotonia less common abnormalities, irritability y Likely results from cerebral injury prior to, during or y Associated disorders y Neuropsychology evaluation and treatment soon after birth y Seizures (50%) y NSAIDs or triptans for headache y Genetic etiologies less common y Mental retardation (may be mild or severe) y Greater risk for Alzheimer, Parkinsonism, ALS, CTE y Higher incidence with extreme prematurity and small y Language, speech, vision, hearing, sensation disorders for gestational age y Exam: y Intrauterine hypoxia is frequent cause y Spasticity (hyperreflexia), ataxia, microcephaly y Bleeding, infection, birth hypoxia and many more…

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Cerebral Palsy y MRI brain, genetic studies may help determine Dementia Dementia etiology y Progressive decline in intellectual/cognitive function y Collateral history necessary y Treatment to maintain maximal physical function that compromises social or occupational function and y y PT/OT, speech therapy Symptoms depend on region(s) of brain affected leads to loss of independence. y Counseling and education for child and parents y Short term memory loss y Not due to delirium or psychiatric illness y Word finding difficulty y Medications for spasticity as needed y Typically >60 years old y Visuospatial dysfunction y Baclofen, botox injections y Risk factors y Executive dysfunction y Prognosis depends on severity of physical/cognitive y Stroke/vascular disease y Apathy/indifference deficits y Family history y Apraxia y Aspiration, pneumonia and other concurrent infections y Impaired language, loss of insight most common causes of death y Diabetes y Head injury y In mild cases motor deficits may resolve by age 7

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Dementia ‐ treatment Dementia y Aerobic exercise, “mental stimulation” Dementia y Alzheimer Disease y Cholinesterase inhibitors y y Exam to rule out other medical or psychiatric illness y Donepezil (Aricept), rivastigmine (Exelon), galantamine y Cognitive disorder must begin within 3 months of stroke y May identify reversible conditions y Side effects – nausea/vomiting, syncope, dysrhythmia or, y Memantine (Namenda) y B12, folate, free T4, TSH, RPR, CBC, electrolytes, glucose, y Multiple bilateral infarcts in cerebral hemispheres lipids y Mood/behavior: SSRIs (except paroxetine – (lacunar) y Consider cancer screening anticholinergic) y Lewy body Dementia y MRI brain (CT if MRI contraindicated) y : Trazodone (avoid antihistamines and y Parkinsonism, visual hallucinations, fluctuating alertness, y Mini Mental State Exam, Montreal Cognitive benzos) antipsychotic drugs worsen condition Assessment y Agitation: behavioral exercise, address y Frontotemporal Lobar Degeneration y Neuropsychology evaluation y Rule out delirium y Disorder of behavior and personal relationships y Last resort –low does quetiapine (atypical antipsychotic) y Rude, irresponsible, sexually explicit, impulsive, poor y Screen for ! y Black box warning judgment, poor hygiene/grooming, binging, loss of empathy UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Delirium Alzheimer Disease Alzheimer Disease y Acute state of confusion y Transient global disorder of attention y Anterograde amnesia first and most intense symptom y Typically sporatic, not genetic y Clouding of consciousness y 60‐80% of dementias y Mild dementia to death: 2‐3 years to >10 years y Usually result of systemic problem with identifiable y Accumulation of β‐amyloid = neuritic plaques and y If rapid onset, fluctuating course or systemic trigger neurofibrillary tangles symptoms consider alternate diagnosis y y Rapid onset, fluctuating course (may improve in AM) Early – difficulty managing finances, independent y Death from infections (pneumonia), nutrition/eating y Sundowning – PM onset of delirium in demented patient travel, meal preparation problems, PE, cardiovascular disease y y Many possible etiologies Late – difficulty with ADLs y At greater risk for delirium y Bathing, dressing, toileting, feeding y Risk factors – dementia, sleep deprivation, y Need assistance, possibly 24/7 care y Typically no motor deficits immobilization, psychiatric meds, impaired y Cease driving vision/hearing, dehydration y Financial planning

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Delirium ‐ etiologies Delirium Delirium ‐ treatment y Intoxication//long‐term alcohol use y Anterograde AND retrograde amnesia y Identify and treat underlying disorder(s) y Infection y impaired short‐term memory and recall y Comprehensive exam, MRI/CT brain, EEG y Endocrine disorder y Disorientation, altered perception, visual y Electrolytes, glucose, BUN/Cr, LFTs, TFTs, CBC, calcium, y Respiratory disorder hallucinations, insomnia phosphate, magnesium, B12/folate, ABGs, blood cultures, UA y Metabolic disorder/nutritional deficiency y Autonomic changes y CSF analysis y Trauma y Tachycardia, dilated pupils, sweating y Consider d/c anticholinergics, analgesics, steroids, CNS y Cardiovascular disorder y Typically lasts <1 week with full recovery depressants y Neoplasm y DSM‐IV and CAM diagnostic criteria y If alcohol withdrawal –meds only if necessary y Seizures y Benzos, β‐blockers, haloperidol y Medications y PREVENTION!

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Guillain‐Barre Syndrome Guillain‐Barre Syndrome Multiple Sclerosis y Acute or subacute progressive polyradiculoneuropathy y Treatment y Diagnosis most common in young adults, especially y Follows infection, vaccine, surgery y Plasmapheresis early women y Campylobacter jejuni has been implicated y IVIG 400mg/kg/day x 5days y Western European lineage y Weakness > sensory disturbance y ICU/ventilatory support if necessary y Temperate climate y Typically begins in legs and spreads proximally y Volume replacement and pressors may be required y Likely autoimmune y Autonomic disturbances may be severe y STEROIDS ARE INEFFECTIVE y Focal areas of demyelination y Cardiopulmonary dysfunction y Recovery takes months y Reactive gliosis – scattered white matter changes in y CSF = ↑protein and normal cell count y 20% left with persisting disability central nervous system y Rule out other neuropathies y Periventricular y Spinal cord

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Multiple Sclerosis ‐ presentation Multiple Sclerosis Multiple Sclerosis ‐ diagnosis y Symptoms y Relapsing‐remitting (most common) y MRI brain and spinal cord y Weakness, numbness, tingling, spasticity, diplopia, y Period of remission after initial episode y Multi‐focal white matter disease disequilibrium, urinary urgency/hesitancy y Over time periods of remission are shorter and y “Black holes” – areas of axonal damage y Fatigue incomplete y y Symptoms can migrate from limb to limb Lumbar puncture y Progressively deteriorating y May be triggered by stress (i.e. infection) y Oligoclonal bands (IgG) y Secondary progressive y Signs y Myelin basic protein y Nystagmus, optic atrophy, UMN findings (i.e. y Initially relapsing‐remitting, then course changes to a y Mildly elevated protein and lymphocytosis steady deterioration hyperreflexia), sensory and/or cerebellar deficits y Electrodiagnostic studies (EMG + NCV) y y Pregnancy reduces relapses, but they are more likely Primary progressive (least common) y Diagnosis is clinical – criteria always changing 2‐3 months postpartum y Steady deterioration from the onset y Dissemination in time and space is important

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Multiple Sclerosis ‐ treatment Myasthenia Gravis Myasthenia gravis ‐ presentation y Acute relapse treated with corticosteroids y Fluctuating weakness of voluntary muscles y Methylprednisolone IV 1g/day x 3 days y Symptoms y y Then oral prednisone 60‐80mg/day x 1 week followed by Autoantibodies to acetylcholine receptors y Ptosis, diplopia, difficulty chewing/swallowing, limb taper y Women>men (HLA‐DR3) weakness y Ocular muscles more commonly affected y Steroids improve symptoms but do not prevent y All ages progression y Often associated with thymus dysfunction (thymoma) y Activity increases the weakness and other autoimmune disorders (SLE, rheumatoid y Diagnosis y Progressive disease ‐ indefinite treatment with B‐ arthritis) interferon or glatiramer y Weakness on exam y Insidious onset y Peek sign, tensilon test y Natalizumab – progressive multifocal leukoencephalopathy y Exacerbated by illness, pregnancy, menstruation y Repetitive nerve stimulation, single fiber EMG (jitter) y Serum acetylcholine receptor antibodies y Immune modulators y Slow, progressive course y Aspiration pneumonia may prove fatal y CXR or CT to investigate for thymoma y Treat fatigue, depression, spacticity also

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Myasthenia gravis ‐ Treatment Seizure Disorders Seizure classification ‐ focal y Acetylcholinesterase inhibitors y Epilepsy – recurrent, unprovoked seizures y With (simple partial) or without (complex partial) y Pyridostigmine (Mestinon), neostigmine (Prostigmin) y Transient disturbance of cerebral function due to impaired consciousness y Symptomatic benefits but does not change course of neuronal hyperexcitability y Focal part of one cerebral hemisphere activated disease y Etiology may be: y May evolve to generalized seizure y Avoid aminoglycosides y Genetic y Motor (jerking) or somatosensory (paresthesias) y Thymectomy should be considered if <60 years old y Structural/metabolic symptoms may spread along limb or other parts of y Steroids, IVIG, plasmapheresis also considered y Congenital anomaly, trauma, tumors/lesions, vascular body abnormalities (AVM), degenerative disorders (Alzheimer), y Jacksonian March infectious diseases y Visual, olfactory, auditory and gustatory regions of brain y Unknown may be involved y Autonomic symptoms possible (sweating, flushing)

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Seizure classification ‐ generalized Seizure classification ‐ generalized Seizures ‐ prodrome y Absence (petit mal) y Tonic‐clonic (grand mal) y Headache, myoclonic jerks, lethargy, mood changes y Brief impairment of consciousness –patient often y Sudden loss of consciousness with rigidity (tonic) may occur hours before attack unaware y Respiratory arrest lasting <1minute y Aura may arise seconds‐minutes before generalized y May include tonic/clonic movements y Jerking, convulsive movements (clonic) seizure y 2‐3 minutes y Atonic component y Most occur unpredictably y y Urinary/fecal incontinence, tongue biting, aspiration Automatisms possible y Triggers may include lack of sleep, stress, missed meals, y Followed by a flaccid coma and possibly a postictal state y Autonomic component possible () menstruation, alcohol (consumption or withdrawal), of confusion y Occurs almost exclusively in childhood flashing lights, music. y Upgoing toes on plantar reflex testing may indicate postictal state

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Seizures ‐ evaluation Seizures ‐ treatment Seizures ‐ medication y MRI brain (CT if MRI contraindicated) y Medications y Generalized or focal y MRA may be necessary to view vascular anomaly y Alcohol‐withdrawal seizures treated with y Classics y EEG benzodiazepines y Valproic acid, phenytoin, carbamazepine, phenobarbital, topiramate, primidone, lamotrigine y y Avoid triggers Labs y Levetiracetam (Keppra) y y Avoid dangerous situations CBC, glucose, electrolytes, calcium, magnesium, LFTs y Others y Driving, operating machinery, roofing, etc. y Lumbar puncture to r/o infection y Zonisamide, pregabalin, gabapentin y Comply with state laws y Lacosamide y Adjunct therapy for complex partial seizures only y Absence y Ethosuximide, valproic acid, clonazepam

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Seizure medication considerations Syncope y Pregnancy Status epilepticus y Transient loss of consciousness y Valproic acid is significantly teratogenic y Medical emergency! y Usually leads to fall if patient is standing y Topiramate, phenobarbital, topiramate, carbamazepine y Repeated seizures without recovery between y May be cardiogenic (arrhythmias, aortic stenosis), –cat. D y Fixed epileptic condition lasting >30 minutes orthostatic hypotension, or vasodepressor (common y Dosing frequency y Maintain airway faint) y Side effects/interactions y More likely in elderly y 50% dextrose IV for potential hypoglycemia y Monitoring y Autonomic neuropathy/dysautonomia y Benzodiazepines initially y Serum levels for most drugs y Impaired regulation of BP, HR, etc. in response to stress, y Phenytoin, fosphenytoin for maintenance y Not levetiracetam posture, heat, exercise (carotid mechanoreceptors) y Precipitates in glucose‐containing solutions y CBC (anemia, blood dyscrasia) y May be central or peripheral y Phenobarbital, midazolam may be required y Hepatic function y Diabetes mellitus II is a common cause y Respiratory depression and hypotension possible y Discontinuation –wait at least 2 years seizure‐free y Carotid stenosis y May require intubation

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) Syncope Tourette Syndrome y Motor tics (80%) –face, head, shoulder y Evaluate for head injury from fall y Full name: Gilles de la Tourette syndrome y Sniffing, blinking, frowning, shrugging, head thrusting, etc. y Cardiac workup y Frequent motor and/or phonic tics for at least one y Echopraxia (imitating movement of others) y Carotid imaging year y Phonic tics (20%) y y Symptoms begin before age 21 Treatment y Grunt, bark, hiss, throat‐clearing, cough y Midodrine (vasoconstrictor) y Etiology not completely understood y Coprolalia (obscenities) y Fludrocortisone (volume expander) y Likely chromosomal abnormality y Echolalia (repetition of others) y maintain adequate hydration y Chronic course, but may be relapsing/remitting y Palilalia (repeating words or phrases) y Treat cardiac abnormalities y Often associated with obsessive/compulsive y Tics may be self‐mutilating y Caution with driving behaviors y Ultimately a combination of motor and phonic tics develops

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) A 45 year old man presents with episodes of left‐sided retro A 45 year old man presents with episodes of left‐sided retro orbital pain, tearing and rhinorrhea nightly x several weeks. orbital pain, tearing and rhinorrhea nightly x several weeks. Tourette Syndrome What is the most appropriate treatment? What is the most appropriate treatment? y Treatment is symptomatic 1. Sumatriptan and 1. Sumatriptan and 89% y Cognitive behavioral therapy y α‐adrenergic agents (clonidine) 100% O2 100% O2 y Typical antipsychotics are the only FDA‐approved meds 2. Ibuprofen and 2. Ibuprofen and y Haloperidol 100%O2 100%O2 y Unfavorable side‐effect profile 3. Amitriptyline 3. Amitriptyline 4. Verapamil 4. Verapamil

11% 0% 0%

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) Rutgers University July 1, 2013) 1234 Which is the most appropriate initial Which is the most appropriate initial A woman presents at 24 weeks gestation for medication for migraine prophylaxis? medication for migraine prophylaxis? treatment of recurrent tonic‐clonic seizures. What is the best treatment option? 1. Sumatriptan 1. Sumatriptan 1. Phenobarbital 75% 2. Metoclopramide 2. Metoclopramide 2. Levetiracetam 3. Propranolol 3. Propranolol 3. Valproic acid 4. Butalbital 4. Butalbital 4. Topiramate

21%

4% 0%

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) 1234 Rutgers University July 1, 2013) A woman presents at 24 weeks gestation for You suspect Alzheimer Disease in an 80 year old You suspect Alzheimer Disease in an 80 year old treatment of recurrent tonic‐clonic seizures. What patient. What is the most appropriate initial patient. What is the most appropriate initial is the best treatment option? medication? medication? 1. Phenobarbital 1. Quetiapine 1. Quetiapine 68% 86% 2. Levetiracetam 2. Paroxetine 2. Paroxetine 3. Valproic acid 3. Donepezil 3. Donepezil 4. Topiramate 4. Alprazolam 4. Alprazolam

19% 13% 10% 5% 0% 0%

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) 1234 Rutgers University July 1, 2013) Rutgers University July 1, 2013) 1234 37 year old woman presents with intermittent weakness, A patient with a history of AD presents with A patient with a history of AD presents with paresthesias and fatigue. MRI brain reveals multifocal white disorientation and visual hallucinations x 3 hours. disorientation and visual hallucinations x 3 hours. matter disease. CSF shows oligoclonal bands. What is the What is the most appropriate treatment? What is the most appropriate treatment? diagnosis? 1. Stat alprazolam 1. Stat alprazolam 1. Guillian‐Barre 2. Stat haloperidol 2. Stat haloperidol 61% 2. Myasthenia Gravis 3. Increase dose of 3. Increase dose of 3. Huntington Disease donepezil donepezil 4. Multiple Sclerosis 4. Discontinue 4. Discontinue diphenhydramine diphenhydramine 22% 17%

0%

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) 1234 Rutgers University July 1, 2013) 37 year old woman presents with intermittent weakness, paresthesias and fatigue. MRI brain reveals multifocal white Patient presents with L‐sided facial droop, Patient presents with L‐sided facial droop, matter disease. CSF shows oligoclonal bands. What is the expressive aphasia and LUE weakness. Where is the expressive aphasia and LUE weakness. Where is the diagnosis? stroke? stroke? 1. Guillian‐Barre 1. Right MCA 1. Right MCA 92% 92% 2. Myasthenia Gravis 2. Basilar artery 2. Basilar artery 3. Huntington Disease 3. Right PCA 3. Right PCA 4. Multiple Sclerosis 4. Left MCA 4. Left MCA

8% 6% 0% 0% 0% 2%

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) 1234 Rutgers University July 1, 2013) Rutgers University July 1, 2013) 1234 Patient presents with L‐sided facial droop, Patient presents with L‐sided facial droop, Which of the following is true regarding expressive aphasia and LUE weakness x 2 hours. expressive aphasia and LUE weakness x 2 hours. cerebral aneurysms? After the H&P, what is the best next step? After the H&P, what is the best next step?

1. Administer t‐PA 1. Administer t‐PA 78% 1. Commonly found in posterior Circle of 2. CT scan of head 2. CT scan of head Willis 3. Emergency coiling 3. Emergency coiling 2. Typically present with procedure procedure headaches, blurred 4. Administer ASA, 4. Administer ASA, vision 3. CT is gold standard of Plavix and Plavix and 22% simvastatin simvastatin diagnosis 4. SAH is a major 0% 0% complication UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) 1234 Rutgers University July 1, 2013) Which of the following is true regarding A 60 y/o man complaining of resting tremor of the hand has A 60 y/o man complaining of resting tremor of the hand has cerebral aneurysms? postural instability and cogwheel rigidity on exam. Which is postural instability and cogwheel rigidity on exam. Which is the most appropriate initial medication? the most appropriate initial medication?

1. Commonly found in 60% 1. Tetrabenazine 1. Tetrabenazine 98% posterior Circle of 2. Propranolol 2. Propranolol Willis 2. Typically present with 3. Alprazolam 3. Alprazolam headaches, blurred 32% 4. Carbidopa‐levodopa 4. Carbidopa‐levodopa vision 3. CT is gold standard of diagnosis 4. SAH is a major 6% 2% 2% complication 0% 0% UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) 1234 Rutgers University July 1, 2013) Rutgers University July 1, 2013) 1234 A 6 year old unvaccinated girl presents with acute A 6 year old unvaccinated girl presents with acute onset high fever, malaise, N/V, confusion and stiff onset high fever, malaise, N/V, confusion and stiff neck. Which is the most appropriate first step? neck. Which is the most appropriate first step?

1. Administer IV 1. Administer IV 88% dexamethasone dexamethasone 2. Lumbar puncture 2. Lumbar puncture 3. CT head 3. CT head Thank you and good luck! 4. X‐ray sinus 4. X‐ray sinus

10% 2% 0%

UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) Rutgers University July 1, 2013) 1234 Rutgers University July 1, 2013) References y Bickley, Lynn S., Bates Guide to Physical Examination and History Taking, 10th Ed., Philadelphia, PA; LWW, 2009 y Goldman, L. Schafer, A., Goldman’s Cecil Medicine, 24th ed. Saunders;Philadelphia:2012. y McPhee, S. Papadakis, M. Rabow, M, Current Medical Diagnosis & Treatment 2013, 52nd Ed., USA; McGraw‐Hill Co., 201

UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013)