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Line 22: − + − + − + − + − + + + + + + + + + + + + + + + + + + + + + − + − **Must have SBP > 100, temp > 36°C, PaCO2 35-45, euvolemia, off all sedatives − **If above conditions are met, test for brainstem reflexes: pupillary reflex (II, III), corneal reflex (V, VII), doll's eye reflex (III, IV, VI, VIII), and gag reflex (IX, X) − **If no brainstem reflexes, do apnea test: positive if no breathing when PaCO2 is 60 mmHg or 20 mmHg higher than patient's baseline − **If apnea test is equivocal, can do four vessel angiography, EEG, or duplex US − **Rule out secondary causes of coma (e.g. test for severe hypoglycemia) − + − + − + − + − + Line 58:
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no edit summary
=Brain=
=Brain=
==Stroke==
==Stroke==
*H&P: Ischemic stroke has same risk factors same as ASCVD, with addition of afib, endocarditis, mechanical valve, cardiac shunt. BE FAST. NIHSS. Permanent neurological deficits. Hemorrhagic stroke risk factors include hypertension, blood thinner, trauma, smoking, cancer.
*H&P: Ischemic stroke risk factors parallel ASCVD, with addition of afib, endocarditis, mechanical valve, cardiac shunt. BE FAST. NIHSS. Permanent focal neurological deficits. Hemorrhagic stroke risk factors include hypertension, blood thinner, trauma, smoking, cancer. Different brain areas cause different stroke syndromes, such as thalamic strokes (pure sensory), insular strokes (pure motor), left MCA (dysphasia), right MCA (left arm and face), cerebellar (ataxia, poor coordination), posterior cerebral artery (homonymous hemianopsia), ACA (personality changes, leg weakness)
*Dx: Ischemic vs. Hemorrhagic. Can localize stroke based on symptoms. NCCT head to rule out hemorrhage; CTA, MRI to look for filling defects and ischemic injury; TTE, telemetry to evaluate for afib. Differential includes TIA, seizure.
*Dx: Ischemic vs. Hemorrhagic. Can localize stroke based on symptoms. NCCT head to rule out hemorrhage; CTA, MRI to look for filling defects and ischemic injury; TTE, telemetry to evaluate for afib. Differential includes TIA, seizure.
*Tx: For ischemic stroke, give tPA within 4.5 hrs of symptom onset, otherwise hep gtt. If large occluding clot in major vessel, can do endovascular thrombectomy within 24 hrs. Contraindications to tPA include recent major surgery, history of hemorrhagic stroke, Plt < 100k, INR > 1.7, age < 18, intrabdominal bleed.
*Tx: For ischemic stroke, give tPA within 4.5 hrs of symptom onset, otherwise hep gtt. If large occluding clot in major vessel, can do endovascular thrombectomy within 24 hrs. Contraindications to tPA include recent major surgery, history of hemorrhagic stroke, Plt < 100k, INR > 1.7, age < 18, intrabdominal bleed. Use caution in the 3-4.5 hr window in patients over 80, with DM, with a recent stroke, or on DOACs. Prevention includes aspirin, statin, clopidogrel, blood pressure control, rate/rhythm control or ablation/Watchman for Afib, weight loss, diabetes control, and smoking cessation. Treatment for hemorrhagic stroke includes blood pressure control, surgical decompression (ventricular shunt or craniotomy).
==Hematoma==
==Hematoma==
! !! Vessel affected !! History !! Imaging
! !! Vessel affected !! History !! Imaging
|-
|-
| Epidural || Middle meningeal artery || High energy impact (e.g. MVA), Lucid interval || Lens shaped (high pressure arterial bleed compresses brain); doesn't cross suture lines
| '''Epidural''' || Middle meningeal artery || High energy impact (e.g. MVA), Lucid interval || Lens shaped (high pressure arterial bleed compresses brain); doesn't cross suture lines (due to tethering of the dura to skull)
|-
|-
| Subdural || Bridging veins || Old person or alcoholic with a fall (low energy) || Crescent shaped (low pressure venous bleed doesn't compress); may cross suture lines
| '''Subdural''' || Bridging veins || Old person or alcoholic with a fall (low energy) || Crescent shaped (low pressure venous bleed doesn't compress); may cross suture lines
|}
|}
! !! H&P !! Treatment !! Prophylaxis
! !! H&P !! Treatment !! Prophylaxis
|-
|-
| Migraine || F > M, throbbing, unilateral, aura, nausea, vomiting, photophobia, phonophobia, visual disturbances, family history, hours to days || NSAIDs, SQ triptans, CGRPs || AEDs (topiramate, valproate), Beta blockers (propranolol), Verapamil, low-dose TCAs (amitryptaline), zonisamide, botox, CGRPs
| '''Migraine''' || F > M, throbbing, unilateral, aura, nausea, vomiting, photophobia, phonophobia, visual disturbances, family history, hours to days || NSAIDs, SQ triptans, CGRPs || AEDs (topiramate, valproate), Beta blockers (propranolol), Verapamil, low-dose TCAs (amitryptaline), zonisamide, botox, CGRPs
|-
|-
| Cluster || M > F, sharp/stabbing, unilateral, retro-orbital, occurs at the same time each day, resolves quickly; exam reveals Horner syndrome, ipsilateral nasal congestion, conjunctival injection, lacrimation || 100% O2, SQ triptans || AEDs (topiramate, valproate), Verapamil, lithium, steroids
| '''Cluster''' || M > F, sharp/stabbing, unilateral, retro-orbital, occurs at the same time each day, resolves quickly; exam reveals Horner syndrome, ipsilateral nasal congestion, conjunctival injection, lacrimation || 100% O2, SQ triptans || AEDs (topiramate, valproate), Verapamil, lithium, steroids
|-
|-
| Tension || dull/tight/pressure, bilateral, band-like, can extend into the neck and shoulders, triggered by stress, lasts up to 7 days || NSAIDs/APAP, massage, heat, relaxation || Avoid triggers
| '''Tension''' || dull/tight/pressure, bilateral, band-like, can extend into the neck and shoulders, triggered by stress, lasts up to 7 days || NSAIDs/APAP, massage, heat, relaxation || Avoid triggers
|}
|}
==Seizure==
==Seizure==
*H&P: Aura, symmetrical rhythmic convulsions, eyes deviate towards contralateral side, lateral tongue lacerations, bowel/bladder incontinence, post-ictal state, post-seizure myalgias, can have transient weakness that mimics stroke (Todd paralysis)
*H&P: Aura, can have a guttural cry at onset, symmetrical rhythmic convulsions, eyes remain open and deviate towards contralateral side during focal phase, lateral tongue lacerations, bowel/bladder incontinence, post-ictal state, post-seizure myalgias, can have transient weakness that mimics stroke (Todd paralysis)
*Dx: EEG. Differentiate between focal (simple and complex) and generalized (grand mal, petit mal, myoclonic, atonic). Differential includes metabolic (hepatic encephalopathy, hyponatremia, hypomagnesemia, hypercalcemia, hypoglycemia), infectious (meningitis), intoxication (or drug withdrawal), neoplastic (brain tumor), vascular (aneurysm, stroke, hemorrhage, dissection). Get CBC, BMP, LFTs, urine tox screen, AED levels, consider MRI
*Dx: EEG. Differentiate between focal (simple and complex) and generalized (grand mal, petit mal, myoclonic, atonic). Differential includes metabolic (hepatic encephalopathy, hyponatremia, hypomagnesemia, hypercalcemia, hypoglycemia), infectious (meningitis), intoxication (e.g. INH, Bupropion), EtOH withdrawal, neoplastic (brain tumor), vascular (aneurysm, stroke, hemorrhage, dissection). To evaluate for secondary causes, get CBC, BMP, LFTs, EtOH level, urine tox screen, AED levels, consider MRI in an adult with first-time seizure.
*Tx: [[AEDs]] (no first line agent, decide on a case-by-case basis). For [[status epilepticus]], ABCs, give IV lorazepam, fosphenytoin if seizure persists, consider induced coma if all else fails.
*Tx: [[AEDs]] (no first line agent, decide on a case-by-case basis). For [[status epilepticus]], ABCs, give IV lorazepam, fosphenytoin if seizure persists, consider induced coma if all else fails.
{| class="wikitable"
|+ Common AEDs
|-
! Drug !! Spectrum/Indications !! Side effects
|-
| Levetiracetam (Keppra) || Broad || Suicidality
|-
| Lamotrigine || Broad (also mood stabilizer) || SJS
|-
| Valproate || Broad || Teratogenic, weight gain, hair loss, tremor, liver failure
|-
| Topiramate || Broad (also migraine ppx) || Cognitive impairment, weight loss, kidney stones
|-
| Carbamazepine || Narrow (focal, also trigeminal neuralgia) || Hyponatremia, pancytopenia
|-
| Phenytoin || Narrow (focal) || Gingival hyperplasia, bone demineralization, drug-induced lupus
|-
| Ethosuximide || Narrow (Abscence) || Sedation
|}
==Brain Death==
==Brain Death==
*Dx:
*Dx: Must have SBP > 100, temp > 36°C, PaCO2 35-45, euvolemia, off all sedatives. If these conditions are met, test for brainstem reflexes: pupillary reflex (II, III), corneal reflex (V, VII), doll's eye reflex (III, IV, VI, VIII), and gag reflex (IX, X). If no brainstem reflexes, do apnea test: positive if no breathing when PaCO2 is 60 mmHg or 20 mmHg higher than patient's baseline. If apnea test is equivocal, can do four vessel angiography, EEG, or duplex US. Rule out secondary causes of coma (e.g. test for severe hypoglycemia)
*Tx: If two physicians agree on diagnosis, withdraw care (even in absence of family agreement)
*Tx: If two physicians agree on diagnosis, withdraw care (even in absence of family agreement)
==Vertigo==
==Vertigo==
*H&P: Differentiate between dizziness and lightheadedness. Peripheral and central vertigo present differently. Peripheral is positional, improves with eye fixation, and
*H&P: Differentiate between dizziness and lightheadedness. Peripheral and central vertigo present differently. Peripheral is positional, improves with eye fixation or closure, and central is more likely to have focal neural deficit.
*Dx: BPPV, MS, Meniere disease
*Dx: Nystagmus is rotary, unilateral, and fatigable in peripheral vertigo. In central vertigo, nystagmus is bilateral, sometimes vertical (highly specific). No headache, no CNS findings, mild ataxia, that lasts seconds (BPPV), minutes to hours ('''Ménière disease'''), more than a day (acute vestibular neuritis or labyrinthitis) or is variable duration ('''MS''', chronic otitis media, acoustic neuroma). No headache, no CNS findings, moderate-severe ataxia with (VBI-vertebrobasilar insufficiency) or without (acute vestibular neuritis or labyrinthitis) falling.
*Tx: Treat underlying cause. For BPPV, the Epley maneuver, PT, antihistamines, and benzos can all help.
*Tx: Treat underlying cause. For BPPV, the Epley maneuver, PT, antihistamines, benzos, and '''scopolamine''' can all help.
=Spinal Cord=
=Spinal Cord=
==Spinal Cord Compression==
==Spinal Cord Compression==
*H&P:
*H&P: Low back or neck pain associated with limb weakness, sensory changes
*Dx: Sensory level, pain, weakness, numbness, or hyperreflexia below the level of compression, bowel/bladder incontinence and saddle anesthesia with caudal equina. Differential includes tumor, disc herniation, osteomyelitis, epidural abscess, aneurysm, epidural/subdural hematoma, fracture
*Dx: Sensory level, pain, weakness, numbness, or hyperreflexia below the level of compression, bowel/bladder incontinence and saddle anesthesia with cauda equina. Stat MRI. Differential includes tumor, disc herniation, osteomyelitis, epidural abscess, aneurysm, epidural/subdural hematoma, fracture
*Tx: Based on etiology. Don't give steroids for infection. May need neurosurgical decompression.
*Tx: Based on etiology. Don't give steroids for infection. May need neurosurgical decompression.
*H&P: Neurogenic claudication-low back pain that radiates to the buttock that is worse with spinal extension, walking downhill, and standing, better with walking downhill and leaning forward. Negative SLR.
*H&P: Neurogenic claudication-low back pain that radiates to the buttock that is worse with spinal extension, walking downhill, and standing, better with walking downhill and leaning forward. Negative SLR.
*Dx: Degenerative changes and neuroforaminal narrowing on xray or MRI.
*Dx: Degenerative changes and neuroforaminal narrowing on xray or MRI.
*Tx: NSAIDs, PT, multimodal, MNB, MND, ESI, laminectomy
*Tx: NSAIDs, PT; multimodal, MNB, MND, ESI, laminectomy
==Transverse Myelitis==
==Transverse Myelitis==
*H&P: Inflammatory spinal cord process without compression but with weakness, numbness, and autonomic dysfunction below the level of the lesion.
*H&P: Inflammatory spinal cord process without compression but with weakness, numbness, and autonomic dysfunction below the level of the lesion.
*Dx: Bright area on MRI. Test CSF to rule out HSV, VZV, Lyme, MS.
*Dx: Bright area on MRI. Test CSF to rule out HSV, VZV, Lyme, MS.
*Tx: Glucocorticoids. Plasma exchange.
*Tx: IV glucocorticoids. Plasma exchange.
==Cord Syndromes==
==Cord Syndromes==
=Anterior Horn Cells=
=Anterior Horn Cells=
==Amyotrophic Lateral Sclerosis==
==Amyotrophic Lateral Sclerosis==
*H&P: Idiopathic progressive destruction of upper and lower neurons with pure motor symptoms
*Dx: Combined UMN and LMN symptoms. EMG shows denervation and re-innervation, fasciculations.
*Tx: '''Riluzole, Edavarone'''
=Nerve Roots=
=Nerve Roots=
==Radiculopathy==
==Radiculopathy==
*H&P: Lower back or neck pain that radiates down the arms or legs.
*Dx: Acute onset pain is usually due to herniated disc. Chronic pain is usually due to spondylosis. Straight leg raise is positive in lumbar radiculopathy. Spurling maneuver (extend the neck and rotate to the side of the pain, then apply downward pressure) is positive in cervical radiculopathy.
*Tx: NSAIDs, PT, ESI, discectomy
=Peripheral Nerves=
=Peripheral Nerves=
==Bell Palsy==
==Bell Palsy==
*H&P:
*Dx:
*Tx:
==Carpal Tunnel Syndrome==
==Carpal Tunnel Syndrome==
*H&P:
*Dx:
*Tx:
=Neuromuscular Junction=
=Neuromuscular Junction=
==Myasthenia Gravis==
==Myasthenia Gravis==
*H&P:
*Dx:
*Tx:
==Lambert Eaton Myasthenia==
==Lambert Eaton Myasthenia==
*H&P:
*Dx:
*Tx:
=Muscle=
=Muscle=
==Muscular Dystrophy==
==Muscular Dystrophy==
*H&P:
*Dx:
*Tx:
=Movement Disorders=
=Movement Disorders=
==Parkinson Disease==
==Parkinson Disease==
*H&P:
*Dx:
*Tx:
==Huntington Disease==
==Huntington Disease==
*H&P:
*Dx:
*Tx:
=Autoimmune Disorders=
=Autoimmune Disorders=
==Guillain-Barré syndrome==
==Guillain-Barré syndrome==
*H&P:
*Dx:
*Tx:
==Multiple Sclerosis==
==Multiple Sclerosis==
*H&P:
*Dx:
*Tx:
=Neuropsychiatric Disorders=
=Neuropsychiatric Disorders=
==Dementia==
==Dementia==
*H&P:
*Dx:
*Tx:
==Wernicke-Korsakoff Syndrome==
==Wernicke-Korsakoff Syndrome==
*H&P:
*Dx:
*Tx: