neurology dis.
little sensory abnormality
CSF immune profile: usually normal MBP high unlike MS
nasal and rectal viral culture. CSF culture is usually neg.
lesions are one age. Later scans can show new small lesions but actually they were old but not visible then. no black holes. involvement of deep gray matter nucleus. less likely to involve the corpus collusum
SZ or slowing. lesions of the gray matter.
mimic: Bickerstaff encephalitis; or glioma
lesions extending longer; more in the thoracic . "transverse myelitis". lesions on axial view involves over half diameter of spine unlike MS mimic NMO; check NMO antibodies. NMO is relapsing remitting on MRI infectious etiologies mimics ADEM: lylme, HTLV 1-2
pt can present first with viral (HSV) encephalitis, recover then relapse when ADEM occur. this must be distinguished from recurrence of the infection. in encephalitis: fever lasts longer; in ADEM it's only for 1 d.
tumor. lymphoma can respond to steroid then relapse with withdrawl. rheumatologic. abscess. can be ring enhancing: mimic abscess or cystecircusis, l. Leukoodystrophy. Large WM lesions mimic leukodystrophies..
age < 2 yrs. not immunized. edema, bleeding, residual deficits and recurrence
steroid taper. no risk for MS. non taper. risk for MS 25% prepubertal; 85% post puberty. steroid dependent. boys, sz, ON, plaques responds to immunosupprsent.
remarkable sensory abnormality; specially vibration.
CSF. abnormal CSF immune profile.
small multipile lesions on spine, involving less than cross diameter of spine on axial and less longitude extension on sagital.
fatigue. stimulants: Provigil, Ritalin or Amantadine exercise: produce paradoxical effect. tonic spasms. resembles tetanus or dystonis. responds to low carbamazepine, acetazolamide.
dx. types. clinical. in encephalitis: fever lasts longer compared to ADEM where it lasts only 1 day.. lab. CSF: elevated WBC and immune profile neg viral c/s in 70%. Encephalomyeloradiculneuropathy. Encephalitis with peripheral involvement. low reflexes. Enterovirus 71, Coxacie.
dx. tx. immunosuppresant might work better than AED for sz or behavioural.. clinical. systemic ds, arthritis, rash, dis of the heart, kidney, and liver, retinopathy peripheral nerve dis..
B12 deficiency: mimics MS or ADEM on MRI Sarcoidosis:causes basilar menegitic enhancement, WM lesions and vasculitis. also orbital pseudotumor
not shivering for cold not sweating for hot socks are not wet when removed excessive sweating
orthostatic hypotesnion: can presents as fatigue after prolonged standing or bathing.. resting tachycardia, sinus pauses; abnormal RR variation- fixed HR- , QT prolongation, slow recovery after exercise. sustained hypertension; paroxysmal hypo- hypertension.
Bloating, fullness, Nausea severe constipation, less common diarrhea post prandial sym: fatigue, light headedness, sleepiness ; hypotension. acalculeus cholecystitis.
Bladder: frequency, urgency, incontinence. impotence
eye. pupilomotor dysfunction; blurry vision. dry moth/eyes. horner's.
CNS. closely related to parkinson and LBD.. PNS. often combined with pain's small fibers involvement as well.. DM. Amyloid. autoimmune. any of those illustrated sub types can have the Ach receptors antibodies of the ganglio neuronic cells.. glucose intolerance. glucose intolerance can present just as combination of both pain and autonomic neuropathy . clinical types. etiology. pure autonomic. mixed. autoimmune diseases. post viral. +/- AIDP. para neoplstic. autonomic panel includes : anti P/Q type Ca; Ach receptors; Neuronal nicotine receptors abs; anti CV 2; anti purkinje cellPCA2; Anti Hu positive. sympathetic. parasympathetic. both. Sjogren. Sjogren antibodies anti SSA and SSB are only sensitive in 20% the dry mucosa can be part of the Sjogren or part of the associated autonomic neuropathy.. Lambert Eaton. Autonomic neorapathy presents in 60%. anti ganglionic Ach receptors abs.
symptomatic in only 10% likely to present along retinopathy and nephropathy UE involvement is likely due to CTS and mono neuritis
Presentations. Malignancy w/u. CT chest/pelvic, Mamogram, colono-scope.. steroid tx. Rehab. Hypotension & fever. progressive weakness. abnormal pupillary exam. acute descending weakness. intermittent numbness or foot drop. Dissection can presents like migraine. with unilateral headache, intermittent numbness or weakness. fever, rigidity. NMS, Serotonin syn, PD like NMS Tetanus also think of Anticholinergics or toxins for fever witout rigidity. pre tx. DEXA bone scan for osteoporosis CXR for tuberculosis. supportive tx. Alendronate 70 mg qweek vit D 800 qd Bactrim DS 3x per week Protonix or TUMS tid.. sparing tx. Methotrexate, Cellcept. Azathioprine, IVIG. chronic resp. care. FVC q 3 ms vibrator assisted cough machine BiPaP Non invasive ventilator. saliva. anti cholinergics.; scopolamin patch for sever cases try botox. muscle cramps. quinine is the best, baclofen, Neurontin, Magnisum. septic shock. DIC. autonomic neuropathy. etiologies. specially if bulbar or mutlifocal. check: MG, Myopathies (LGMD, myositis..), ALS. symptoms. excessive saliva, inability to whistle. SOB. optic nerve. 3th nerve. autonomic disease. MG. Miller fisher GBS. Botulism. CIDP. MTX. faster than AZA start 7.5 mg/wk , inc. by 5 mg qwk until 20 mg/kw if no reponse, start IV MTX up to 60 mg/qwk. AZA. slow, takes 6 ms. start 50 mg qd; inc to 2-3 mg/kg within 2 ms can cause sever flu-like symptoms. Cellcept. no hepatic or renal toxicity 1 gm bid. IVIG/ plasmapherisis. third line. MG. Myopathies. ALS. the pathognomic finding sometimes is hyper reflexia including jaw jerk. Cyclosporine. start at 3-4 mg/kg/d and gradually inc. to 6 mg/kg/d goal is trough 50-200. cyclophosphamide. PO 1 mg/kg/d or IV 1 gm/m2/ q month. others. Tacrolimus: similar to Cyclosporine Chlorambucil: similar to cyclophosphamide. Remicade: TNF blocker; also Rituximab.
Neuromuscular & respiratory emergencies. EEG monitoring. Monitoring. ICU quadriplegia. MRI cervical and brainstrem: r/o neck injury and brainstem stroke EMG: critical illness myopathy / neuropathy Spinal cord damage: ischemia or trauma. ind.. tech. signs. in respirtatory compromise from neuromuscular origin, the weakness can progress to failure with no signs of respiratory stress.. Respiratory failure. respiratory function. vital capacity: done with max exhalation. normal 40-70 ml/kg Maximal inspiratory pressure: done with max suctioning in, Normal > 100, F > 70 Maximal expiratory pressure: done with max blowing out normal > 200 , F> 140. ABG. critical illness neuropathy. h/o sepsis use differentiated from myopathy by abnormal phrenic nerve conduction axonal type of neuropathy; differntiated from GBS by normal CSF. critical illness myopathy. h/o steroid ; muscle blockage use elevated CK normal phrneic nerve study; abnormal diaphragm EMG prognosis is worse. sz. coma. vascular. artifact. Increased breathing rate. decreased O2. sweatning. weak cough. no signs of dyspnea in neuromuscular weakness. bedside. expiratory peak flow. Vital capacity. ICU criteria: bulbar dysfunction or automonic instability > 30% reduction in VC or sat <90% VC < 20ml/kg or PI max < 30 cm h2O or PE max < 40 cm. (20/30/40 rule). Increase CO2. post status. 20% remain in electrographic sz after the clinical one stopped.. encephalopathies/ietis. NMJ blockage. blockage with vecuronium can be reversed with neostigmine succinylcholine is not preferred b/o hyperkalemia. but it's very short acting, few min, compared to 20 min for non depolarizing agents.. severe NMJ and GBS. stroke. can predict the post tpa hemorrhage.. ISH. predicting vasospams before they are detected on Doppler by decrease in the A rythem variability.. succinylcholine. can cause hyperkalemia should be avoided in NM disorders.. count to 30 in one breath. neck flexor muscles predict the respiratory muscles..
status Epil.. tx. medical. versed. Dilantin. actually may not work at all. so if benzo failed go to propofol. Arivan. should not exceed the max amount b/o metabolic acidosis induced by the solvent, propyl glucocol.. propoful. causes hypotension less mortality than barbiturate so if benzo failed, propofol should be tried next. pentobarbital. caused hypotension and decrease cardiac mortality. Ketamine. can be used for conscious sedation with versed for minor surgery in older kids can cause agitation cause no change in BP or increase.. others. HTN post status. usually does not need management as the AED meds and the positive pressure ventilation will lower it.. loading. 0.2 mg/kg/. drip. 0.1-2 mg/kg/hr. loading. 0.1 mg/kg. drip. 9 mg/hr. loading. 3-5 mg/kg. drip. 1 mg/kg/hr. loading. 12 mg/kg. drip. 0.25-0.4 mg/kg/hr as per EEG. loading. 1-4.5 mg/kg given with benzo. maint.. 0.5-2.5 mg/kg. VPA. Topamax. through GT loading dose. Keppra. 1-3 gm. theopental. is long acting and fat soluble form of pentobarb. paraldehyde.
surgery. can not anticogaulate after the surgery mostly used in younger pt who b/o lack of atrophy tend to have worse ICP. CVS. Rt stroke: bradycardia Lt stroke: tachycarida. tx. prevention. ASA: decrease risk by 14% with no dose difference. entero coated ASA is less efficient than regular ASA. Ticlopidine; is an old analogue to ASA with same stroke prevention but more side effects (neutropenia) Plavix is slightly better than ASA Aggrenox: the best prevention. can cause headache, so it can be started qd for few days with ASA then bid. it lacks the cardiac prevention profile unlike ASA or plavix in Afib if pt is unable to take warferin, ASA is given instead at 325 mg all pt should be placed on statins regardless of LDL levels; however the high doses of statins (lipitor 80) can increase risk of hemorrhage. statins should not be stopped suddenly. ACEi are not unique among HTN meds for stroke prevention anti coagulation in the following cases: Afib, Mitral stenosis, severe CHF. Imaging. rehab. tPA. interventional. better only for: large vessels occlusion in ICA, MCA no response to Iv tPA beyond 3 hrs. surgery. indication for symptomatics 70-99% and may be indicated for symptomatics 50-69%. may be not indicated for women. For asymptomatics 60-99% had to be decided on individual bases ASA is recommended peri operative and to 3 ms after surgery is best done within 2 weeks of CVA. surgical. endarectomy for all stenosis over 70% for some of stenosis 50-69% Angioplasty and stenting only if endarectomy is not possible for co moribidities. CTA. source images can estimate the infarcted core as accurate as CBV in Perfusion. CT perfusion. best triage for new CVA along with CTA CBF and MTT showes penumbra but CBV showes the ischemic cores CBV can be visualized from the source imaging of CTA as oligoemic area. MRI. contrast is contradicated in severe renal failure or HD. it can cause Nephrogenic systemic fibrosis. Micro bleeds on GRE scan are not contradiction for giving tPA. depression. SSRI are best so it does not interfere with Warferin Lexapro 10 mg, celexa 20, zoloft 25. HTN. treat if > 185/10 ; if no tPA treat only if > 220 Nitropaste labetolol 10mg q 5 min Nicardipine: 5 mg/hr drip can be increased every 5-10 min. post 3 hrs. IV tPA can be given 3-5 hrs only if there is big mismatch on perfusion scan.. IA tPA. for distal clots beyond M2 up to 6 hrs. device retreiver. for MCA/ICA +/- IA tPA up to 8 hrs. stent / angioplasty. for athersclersis. is inferior to endarectomy except for high risk pts.
prog. type. dx. surgery. medical. volume. volume: = largest diameters X number of slices X slices thickness / 2 Critical voulme= 30 ml. IVH. critical volume is 20 ml. deterioration. dec. glasco scale or incr. NIHS by 2. coagulopathy. fluid-fluid level. Trauma. brain contusion mostly frontals. angio. required for: dural-arterial venous fistula vasculitis cortical vein thrombosis small AVM. ICP monitor. all pt with GCS < 8 should have ICP monitor goal to ICP < 20 and CPP > 60. evacuation. BP. lower ICP. in case of increased ICP: elevating the HOB improve cerebral perfusion will not work if pt had systemic hypotension; in this case head should be placed down.. SZ prophylaxis. for 1 week Dilantin, Keppra. NCSE. reverse coagulation. hematoma can expand for 7 ds. normal INR does not necessary remove risk of bleeding b/o factor 9 is not measured. you need to correct the factors to 30-50% of their normal values. DVT prophylaxis. strokes induce low grade of DIC; slightly high FDP start with pneumatic compression from day 2: can use heparin 5000 sq TID or lovenox 40 subq if DVT developed: need IVC filer.. intubation. for change in mental status. like for GCS < 8 in stroke: it's usually required after few days, during the edema phase.. daily labs. Anemia: keep Hg > 7 Na: avoid hypo; but hyper is ok if euvolumic. Glucose control ABG: avoid hypoxemia. Re-anticoags. should be held for 1-2 weeks. FEN. NPO for several days including NG. maint. IV are NS with 20 kcl 50-100 cc/hr. CVA. ischemia; hematoma expansion; edema. hydrocephalus. NCSE. medical. IVH. no HTN. lobar. ventriculostomy. drains IVH monitors hydrocephalus no need for daily csf cultures unless if there's fever. can be left for up to 14 ds.. Parenchymal probe. others. cerebellar. IVH. lower BP. MAP=130 ; SPB= 180 severe lowering casue ischemia. Nivadipine, Labetolol, esmolol. for renal pts: used Fenoldopam. inc. BP. to avoid ischemia start with norepinephrine or phenylephrin; aslo vasopressin dopamine is poor in NICU. manitol. mannitol 20% ; 0.25 - 1.4 g/kg boluses over 20 min ; can repeat q 3 hrs. check osmolarity frequently, stop if > 320 stop if osmo gap > 15; osmo gap= measured osmolarity - (2Na+ bun/2.8 + gluc/18) risk of ARF, dehydration or rebound ICP. Hypertonic saline. can be given as : bolus : HTS 23.4% ; 1 ml/kg ; then infusion 2-3 % at 0.1 - 1 ml/kg/hr or : 23.4% as 30-60 cc iv bolus q 6 hrs. or 3% bolus 150 cc q 4-6 hrs or 3% infusion 0.5-1 cc/kg/hr side effects: CHF, bleeding. other. clinical. worsening the consciousness level and spasticity. tx. versed drip. coumadin. reverse with either: vit K + PCC vit K + FFP + f VII. heparin. 1 mg protamine reverse 100 u heparin in the last 4 hrs. 1000 units/hr heparin is reversed by 25 mg protamine. Lovenox. only partially neutralized with protamine; use max dose of 50 mg protamine.. argatroban. can not be reversed.. ITP. symptomatic hematoma (not in the brain ) can be reversed : 2 FFP + 20 cryprecipitate + 6 Platelets. tech. TV: 6 ml/kg ; pCO2=35- 40; O sat > 92 in MICU : slight hypercapnia is usually allowed to prevet mechanical lung injury; however this can increase ICP in NICU pats. high PEEP can increase ICP; this can counterpart by elevating HOB. weaning. good strength: FVC > 15 ml/kg; NIF < -30. trachestomy. after 7 ds. however can wait for 2-3 weeks to see if pt is improving neurologically. weaning. can wean regardless of the neurological status if was not neurologically deterioration and if able to cough and suction less than 1 q 2 hrs. can breath and FiO2< 50%.. late labs. adrenal insufficiency after 1 week. cortisol < 5 once or < 15 twice. presents as low BP,. deep ICH. anti-caogulation should be resumed in 1-2 weeks. Lobar ICH. anti coagulation risk is high.. central vein oxymetry. CT. > 3 cm or ischemia of third of cerebellulm hemisphere. effacement of quadrigeminal cistern need daily CT to r/o acute hydrocephalus.. Clinical. depressed consciousness brainstem compression signs; ispsilateral babenski. tx. Intra-ventricular tPA. drianage. incr. risk of bleeding along the drain.cc. hyperventilation. goal is Pco2 26-30. barbiturate. hypothermia. 34 c. side effects: rebound hyperthermia causes mortal ICP pneumonia bradycarida thrombocytopenia. Lasix. given in combination with the other agents.. FFP. FFP 15 mg/kg or 6 packs can cause volume overload; also pulmonary edema from allergic reaction normalizes INR in 30 hrs. Vit K. vit K IV 10 mg X 3d. f VII. normalized INR in 8 hrs but INR should not be used for monitoring half life is 2.5 hrs; thus it should be used in conjuction with FFP dose : 1.2 - 4.8 mg. PCC. Prothrombin complex concentrate concentrate of 2, 7, 9 and 10 normalize INR in 1- 2 hrs. dose: 15 u/kg for INR < 5 ; or 30 u/kg for INR > 5.
MG. labs. AChr -. if AChR was neg, always check MusK especialy in bulbar weakness and spared ocular. EMG, Endorphin test, thymus scan are likely normal. tx: is less effective.
consider genetic tests in many muscles dis. could avoid doing biopsy. such as : duchene's and Baker's MD 95%; Myotonic dystrophies 100%, FSH 98%; Limb- Girdle dis. I is dominant, II is recessive. both only 50% go to genetests.org
Myotonic dystrophy. Statins myopathy. Muscle dystrophies. Duchene's or Baker's are tested by DNA mutation for the dystrophin.. Limb Girdle muscle dis.. presents as proximal weakness. type I is dominant, type II is recessive. Lamin deficiency can only be confirmed with DNA testing. Muscle biopsy is neg.. Myositis. Myalgia. biopsy only required if there's weakness, elev CK, exercise confined, isolated maylgia could have abnormal biopsy but it's not specific or diagnostic the finding of non tender points in pt with myalgia supports dx of Fibromyalgia.. tx. presentaion. clinical. pain, weakness, ++ CK noticed by lying down aggravated with fasting can happen anytime after the treatment. symptoms donot always resolves with stopping the meds. biopsy and EMG may be normal. in severe cases, changing the stating to another one will not work; try alternatively: niacin, bile resins.. tx. same like neuropathy: Neurontin, PT, NSAID. short course of steroids. Baker's. dx. anti Jo-1 see malignancy w/u. tx. see steroid tx start prednisone ( 1 mg/kg) or 100 qd for 1-2 w then qod if no response by 4-6 ms then stop when response plateau then taper off by 5 mg q 2 weeks Cellcept 1 gm bid can be started along steroids or if there is relapses. types. supportive. steroids. cardiac. cardiac involvement could be the only presentation can have either CHF or conduction block or arrythemia (Afib, V tach,...). contracutres. limited ROM: joints contractures, spine rigidity and limited ROM are remarkable in Emery -Dreifuss AD. in the X linked form, contractures precede weakness. Myotonic dystrophy can have limited ROM.. bulpar. can be only nasal speech. polymyositis. inclusion body myositis. asymmetric, and more in flexors muscles. muscle biopsy is neg in 1/3 usually refractory to tx.. cardiac. Cardiac: Echo, EKG, Holter; tx with ACEi and B blockers can slow progress; later consider early pacemaker. resp.. Resp: FVC lying and sitting, overnight pulse ox, Pulmonary function test.
types. tx. Alzheimer. insight is usually saved until late.. vascular dementia. usually presents shortly after CVA. urinary incontinence is early. LBD. fronto-temoral. unlike Alzheimer, starts with personality problems; insight is impaired early , speech problem is early memory loss is late, had two types: frontal dominant, with personality changes ; and temporal dominant with progressive aphasia that's either fluent or non fluent. the fluent subtype has semantic dementia or visual agnosia with loss of words meanings. Primary progressive aphasia is a type of the temporal dominant,. cognitive. ACEi like Aricept. indicated for mild to moderate dementia Namenda for mod. to severe dementia. can be added to Aricept.; it can worsen sz.. behavioural. for anxiety: Trazodone, Buspirone can help neurolyptics: likely to have no benefits can try : SSRI, AED, for Abulia: try sinemet, stimulants, SSRI. parkinsonism. mostly with no tremor wide fluctuation from day to day associated with REM behavior disorder.. dementia. visual hallucination and good insight that's not real.
general w/u for unclear movements dis: Imaging: PET, PET with fludro dopa labs: heavy metals, para- neuplstic panel, rheumatology panel, thyroid, HD genetic, blood smear, wilson panel, HIV para neuoplastic w/u and body scans. blind tx: reserpine, Klonopin +/- anticholinergics. also consider clozapine, or verapamil after all think of psychogenic
symptoms. diseases. consider other eitologies: Para neuplastic syn. infections: HIV, virals,... heavy metal poisonings. dystonia. for cervical dystonia: check the MRI cervical for cord compression. essential tremor. in severe cases there is rest tremor and must be recognized from parkinson's tremor a cluse is response to ETOH; (myoclonic dystonia also responds to ETOH). chorea. difficulty maintain protruded tongue is pts with Huntington dis.. violent activity. Parkinson. Huntington dis. acanthocytosis can mimic HD on MRI and chorea findings. there is associated neuropathy and high CK also HD like disease , in blacks, is identical to HD but neg genetic test ,. tics. RLS. can be in arms or trunks only 5% have iron deficiency, can be associated with neuropathy or radiculopathy. the best tx then is Neurontin. acute. from neuroleptics. chronic. can be tremor-like and repetitive or myoclonic pure neck tremor without associated hand tremor is likely dystonia, it's the most common presentation of Wilson dis. especially proximal tremor.. tx. Propranolol, Mysolin and Klonopin Topamax works but needs dose >200 and cause side effects. labs. anti-phospholipids abs, Lupus, Thyroid panel, ASLO, ESR, non ketotic hyperglycemia. tx. Tetrabenzine, Reserpine, Neuroleptics, Klonopine, valproic acids. Ballismus. can be b/l in HIV, non ketotic hyperglycemia,. paroxysmal dyskinesia. congenital. responds to klonopin, carbamazepine,. tx. symptoms. exam. postural instability test : evaluates risk for fall. need to pull the pt one step backward. also: feet should be in normal position unlike Romberg where feet should be closed together needs to document the time of last dose. tests. floudri dopa PET scan showes decreased asymmetric uptake. help to recognize psychogenic cases. tx. Riserpine and Tetrabenzine are preferred over neuroleptics as they deplete dopamine and donot cause tardive dyskenisia. however only Riserpine is available in US. tx. tx; anticholinergics (diphenhydramin 50 IV ). presentation. ddx. can mimics focal sz pharyngeal and vocal cords dystonia must be recognized from titanus, cervical dystonia must have MRI cervical to r/o fxs or arthritis neck rigidity from menengial irritation can mimic dytonia too also neck and pharyngeal infections or cellulitis hypocalcemia can presents with titanus like or paroxysmal dystonia MS can have acute tonic spsams: tonic spasms. tx. Sinemet. Sinemet CR: does not improve the motor fluctuating and has unpredictable absorption and might increase nausea sudden withdraw can causes NMS like syn. however it can stopped in cases of severe dyskinesia. agonist. MAO b. Rasagiline is MAOi b that can be used with SSRI. it's also available as patch. COMT. Entacapone and Tolcapone. anti colintergics. DBS. performed in the sub-thalamic neuclus. specially for dyskinesia and prolonged off time must be young and cognitively intact. fluctuation. can be non motor: like emotional, depression or activity level or even back pain.. off time. tx: instant release sinemet or apomorphine prolonged off time can cause NMS like syn,. dyskinesia. Pain. from axial rigidity. involves back, shoulder, neck.. can fluctuate with on- off motor response. Also can be from Dystonia can be discomfort from sensory symptoms or RLS usually correlates with off time try apomorphine. but also dyskinesia.. behavioral. for fatigue see: fatigue in MS. dysautonomia. includes: orthostatic hypotension, dysphagia, urinary retention. NMS of parkinson. hyperpyrexia syn of PD. presents like NMS: fever, rigidity, rhabdomyolysis, DVT/PE results from abrupt withdraw of sinemet. tx with sinemet; also can giveh bromocriptine or Dantroline 10 mg/kg IV ; same like NMS. oculogyric crisis. can mimics partial sz. with forced eyes deviation, hyperventilation can be from dpaminergic withdrawal or from neuroleptics. tx; anticholinergics (diphenhydramin 50 IV or bemztropin 1 mg). dystonia storm. severe generalized dystonia: need ICU admission and might need genearlized anathesia ( propofol) and muscle blockers can be triggered from infection or drug chagne tx: try tthe combination of baclofen, depakote, pimozide. and Atrane but might need urgent DBS. Botox. both type A and B are immunogenics. medical. high dose of anti-cholinergics Haldol. DBS. in the Globus Palidus. best for generalized dystonia with mutation DYT1. new. Requip and Mirapex. old. Amantadin or Bromocriptine. tx. tx: decrease sinemet and add dopamine agonist (in particular Amantadine 100 bid) severe case need admission for rhabomyolysis causing ARF or CHF or for respiratory dyskenisia. etiologies. likely to result from pt self medicating dysregulation, also might be from infections. presentations. Respiratory dyskenisia can presents as SOB and dyspnea. it can alternate very rapidly with off times. (like every 15 min) painful dystonia can present during off times. psychosis. decrease the dopamine doses Seroquel UTI,or infection must be r/o early sign of behavioral problems is paucity of speech and history. Psychosis usually underline a dementia remove anti cholinergics, Amantadine, D agonists,. impulse control. associated with dopamine tx includes: gambling, shopping, OCD, hyperphagia, self feeling of clinical worsening tx: decrease dopamine agonist, seroquel? anti depressents?. dementia. Aricept and rivastigmine. however they might increase tremor. cognitive test best by mocatest.org. anxiety. for insomnia: trazodone, Remeron also seroquel, for panic attacks: if routine tx failed, try ampomorphine or extra LD to abort..
rehab. maximum recovery is usually reached by the third month,. spondolysis. transverse myelitis. imaging. autonomic dysreflexia. acute discharge of sympathetic nerves in spine cord lesions above T6. tx. symptoms. pain can improve by worsening of the diesease unlike neurological symtoms which usually worsen.. exam. Spine ROM, palpating the spine, straight leg and head compression. etiologies. symptoms. 100% bladder dysfunction and parathesia. band like dysthesia in levels of lesions.. prognosis. 1/3 recover, 1/3 moderate and 1/3 severe disability. tests. MRI. CT myelogram if MRI is not availbale MRI gradient for disks and MRI STIR for spine.. symtoms. sudden HTN and bradycardia with sweating.. triggered by bowel or urinary retention or ulcer. tx. medical. NSAID muscle relaxants: Flexeril steroids: Medrol pack 21 of 4 mg. start with 6 tabs and taper by one daily for total of 6 days. Neurontin TCA: for radicular pain patches: lidocaine, NSAID patches, opiates (Percocet, Oxycodone, Lortab=Vicodin, Tylenol with codein ) or Ultram. epidurals. help only the pain for few weeks. effect resolved by 3 ms does not improve outcomes or activities or neurological symptoms.. PT. Chiropracter: good only for back pain with no radiculopathy, mostly for cervical pain.. surgery. to preserve the neuro function but likely would not restore it. two parts: decompression and stabilization. muscoloskeltal. back pain in the absence of any neurological causes.. labs. CSF: pleocytosis, IgG index , protein 14-3-3. imaging. always consider brain MRI and evoked potentials.. noraml variants. on para sagital : foramen look like upside down pear with the root occupying the third, conjoined nerves: tow nerve roots exiting from same foramen; it can be mistaken with disc fragment or tumor, nerve root diverticulum: expansion of the dura around the root make it look like nerve sheet tumor, Tarlov cyst: dura enoculated cysts in the sacrum Schmorl's Node: disk herniation into the vertebral body. can look like tumor infiltration to the vertebra body, synovial cysts: from facets.. degenerative dis.. once myelomalacia develops " increased spine signal on T2" it's unlikely for symptoms to resolve with surgery. the endplates changes from degenerative dis. can mimic tumor infiltration; however the hallmark is the location along the endplates edges only. Signal on T1 or T2 can be anything' facet joint dis. : causes muscle skeletal pain on its own, or contribute to spinal stenosis. Also it can be associated with synovial cyst which causes bones erosions. Para articular defect: shortening of the pedicles causing congenital spodolithisis.. op & trauma. syringes tetheres cord arachnoiditis. acute. like any HTN managments with vasodilators Nitro sublingual or nitro paste 1/2 clonidine 0.1-.02 hydralazine 10-20. prophylaxis. clonidine 0.2 bid prazosin 0.5-1 qd. facet joint. not all agree on its existence steroid injection into facet joints might help mostly in neck possible intervention is radio ablation of the innervating branch.
migraine. migraine with aura increase risk of CVD and CVA x 2. Chronic daily. same is analgesics over use 15 days per month; 8 of them are migraines it's uncertain if NSAID causes that as NSAID can be given daily to prevent migraine. Trigeminal ha. in a subtype of cluster headache, symptoms can e very short, lasting only seconds, and can be triggered with certain head movements.. hypnic ha. ha in elderly resembles cluster for being nocturnal but no autonomic features.. intractable ha. consider MRI with MRV/MRA LP with pressure reading ESR for giant cell arteriits Indomethasine. tx. prophylaxis. consider for 2 attacks /weeks. or for fewer if the attacks were disabling. birth control is required for most of those meds when other co morbid conditions co exist with migraine: use the best drugs for each and not necessary the one drug for both placebo effect is 30s%. most drugs are 50s% consider underling depression. sypmtoms. the aura can be dysartheria but not weakness. symptoms should be at least 5 min headache should follow within 60 min Triggers include: chocolate, ETOH, cheese, sweetners. acute. typical acute tx is: vit B2 / Magnesium 400 mg (or feverfew) Inderal LA 60 qam ( or tompamax) Zomig ZMT prn (or Maxalt). for vomiting: nasal spray or injections). surgical. closure of PFO occipital nerve block. tx. start prophylaxis tx on month before tapering off analgesics at the end of the taper to prevent rebound headache can use: dexamethasone 4 mg bid for 3 days; or steroid Medrol pack or sumatripatans 100 mg tid for 2 days (then prn) for milder pain: NSAID or hydroxyzine 50. cluster. differentiate it from migraine: short escalating (10 min) and lasting ( 1.5 hrs) pt is agitated and restless, where in migraine he's calm unilateral with cranial autonomic dysfunction. paroxysmal hemicrania. severe headache with very frequentt attacks up to 40 /d. By definition it must responds to Indomehtasine (up to 300 mg). hemicrania continua. continues headache resemble chronic daily ha but unilateral.. Tigeminal neuralgia. the ha is electrical shocks. ACEi. ACEi and ARI are prophylaxis effective and can be used to decrease CVD and CVA risks in pts with the aura migraine. b blockers. Propranolol 40-400 mg, Metoprolol,100 -200 Atenolo 50-200. Ca channel. verapamil (80 tid), nifedipine, dilitazem all results are ambiguous. they work best for hemiplegic migraine or migraine with prolonged aura. Nifidepine is vasodilator and occasionally can worsen. AED. only toapamax (25-100) , valproate ; possibly neurontin. TCA. anitryptalin, nortryptalin 10-50 mg; but not SSRI. NSAID. can be used, less likely to develop rebound ha. naproxen, Indomethasine,. vitamins. riboflavin B2, 400 mg Mg 400 mg co enzyme Q 150 - 300 mg, Feverfew petasites hybridus 150mg qd melatonin 3 mg qhs. PT. consider chirpopractic or acupunctures.. botux. if the previous tx failed.. migraine status. depaken 500 mg IV Ketorolac plus Prochlorperazine short run of IV steroid or Medrol pack. out pts. tx. start with O2 100% @ 7-15 L/m Triptans and Ergots Lidocaine nasal drop 4-6% Prednisone 60 for days then taper off.. prophylaxis. verapamil 160 tid ( twice the dose for migraine) lithium 150-300 tid Neurontin , Indomethacine, Ergotamin. triptans. Triptans ( or the combo ones with NSAIDS) for refractory cases use large doses: like sumatriptan 100 mg should be given early in the attack. others. Ergots. (cafergot, ?excedrin migrain? Combos (Fiorinal, Fioricet, Esgic,) all are caffein + ASA + Butalbital for sedation. Midrin has vasocnstrictor.. All are less effective to migraine than triptans.. fast metl. probably works same like regular tab Zomig ZMT, Maxalt MLT. Sub q. best for pts with nausea Imitrex. N. spray. works faster than tab. Imitrex, Zomig.