Meningococcemia:
Patient will be a military recruit or student
Complaining of fever, HA, arthralgias, rash
PE will show petechiae, skin lesions with gray necrotic centers
Diagnosis is made clinically and can be confirmed by blood cultures and gram stain, as well as lumbar
puncture
Most commonly caused by Neisseria meningitidis, an aerobic, gram-negative diplococcus
Treatment is ceftriaxone and vancomycin
Comments: Waterhouse-Friderichsen syndrome: bilateral adrenal hemorrhage + meningococcemia
Subarachnoid Hemorrhage
Patient will be complaining of
abrupt onset of "worst headache
of their life," or "thunder-clap"
headache
Diagnosis is made by non-
contrast CT scan. If CT negative,
and suspicion high, lumbar
puncture
Most commonly caused
by ruptured aneurysm
Treatment is supportive
and nimodipine (decreases
vasospasm)
Bacterial Meningitis (Adult)
Patient will be complaining of a headache, neck stiffness, photophobia, phonophobia, fever
PE will show meningismus, jolt accentuation, Brudzinski’s sign (flex neck), Kernig’s sign (extend knees)
Mnemonic: Brudzinski’s - Bend the brain, Kernig’s - extend knees
Most commonly caused by Streptococcus pneumoniae
Treatment is empiric antibiotic by age:
18 - 50 years: ceftriaxone + vancomycin
> 50 years: ceftriaxone + vancomycin + ampicillin (to cover Listeria)
Comments:
Empiric ABX if CT/LP delayed
HIV patients - Cryptococcus
Parkinson’s Disease
Lewy bodies, substantia nigra dopaminergic neuron loss
TRAP: Tremor (resting, “pill rolling”), Rigidity, Akinesia, Postural instability
Carbidopa/levodopa, anticholinergic drugs
Avoid antipsychotics
Huntington’s Disease
Patient will be a 30 – 50 years old
With a history of a family member
with similar symptoms
Complaining of gradual
chorea and dementia
Diagnosis is made by genetic
testing
Most commonly caused by
autosomal
dominant CAG trinucleotide
repeats
TMT = benzo, dopamine-
depleting, or dopamine-
antagonists.
Tension Headache
Patient will be complaining of bilateral, non-pulsating, bandlike pain
PE will show neck muscle tenderness
Most commonly caused by stress
Treatment is NSAIDs
Comments: most common type of headache
Essential Tremor
Patient with a history of a family member with
similar symptoms
Complaining of hand tremor that is exacerbated by
action and improved after alcohol consumption
Most commonly caused by autosomal dominant
Treatment is propanolol
Migraine Headache
Patient will be a woman
Complaining of the gradual onset of a unilateral > bilateral, throbbing, pulsating headache
Without aura: most common, N/V, photophobia, phonophobia
Aura: scotoma, flashing lights, sounds
Diagnosis is made clinically
Treatment is
Abortive rx: triptans, DHE, antiemetics, NSAIDs
Prophylaxis: ßBs. CCBs, TCAs
Comments: Triptans, DHE: contraindicated in HTN or CV disease
Cluster Headache
Patient will be a man
Complaining of sudden onset, unilateral, and repetitive brief
HAs
PE will show ipsilateral conjunctival injection, lacrimation,
and rhinorrhea
Treatment is Acute: High flow O2; Prophylaxis: CCB's
Guillain-Barré Syndrome
Antecedent pulmonary or GI illness (Campylobacter jejuni)
Rapid ascending symmetrical weakness
Lower extremity weakness > upper extremity weakness
Deep tendon reflex loss → respiratory failure
Normal rectal tone
CSF: markedly ↑ protein with up to 100 lymphocytes/μL
Obtain pulmonary function tests
Rx: IVIG or plasmapharesis, possible prophylactic intubation
Dystonic Reaction
Antipsychotics, antidopaminergic drugs
Hours - days
Muscle spasms (ie torticollis)
Stiffness
Rx: diphenhydramine, benztropine
Concussion
Brief LOC, amnesia
No focal neurologic deficits
Negative CT scan
Herpes Simplex Virus (HSV) Encephalitis
HA, fever, behavioral changes
Temporal lobe
CSF: ↑ RBCs
MRI: temporal lobe edema
Acyclovir
Parkinson’s Disease
Lewy bodies, substantia nigra dopaminergic neuron
loss
TRAP: Tremor (resting, “pill
rolling”), Rigidity, Akinesia, Postural instability
Carbidopa/levodopa, anticholinergic drugs
Avoid antipsychotics
Spinal Cord Compression
Back pain
Urine retention/inability to void
Decreased rectal tone
Saddle anesthesia
Lower extremity weakness
Temporal Arteritis (Giant Cell Arteritis)
Patient will be a woman > 50 y/o
Complaining of monocular visual loss,
unilateral headache, jaw claudication
PE will show tender temporal Artery
Labs will show ESR > 50
Diagnosis is made by temporal artery biopsy
Treatment is high dose steroids ASAP
Comments: Associated polymyalgia rheumatica
Myasthenia Gravis
Patient will be complaining of proximal muscle
weakness, ptosis, and diplopia that is worse at
the end of the day
PE will show ice test improves sx
Diagnosis is made
by edrophonium (tensilon) test, EMG
Most commonly caused by autoimmune
destruction of acetylcholine receptors
Treatment is acetylcholinesterase inhibitors,
such as pyridostigmine
Comments: associated with thymoma
Idiopathic Intracranial Hypertension (Pseudotumor
Cerebri)
Young obese females
Vitamin A toxicity, steroids, tetracycline
↓ CSF absorption
HA + visual sx
Papilledema, CN VI palsy
↑ opening pressure on LP
Acetazolamide, serial LPs
Cryptococcus neoformans
Patient will be HIV (+)
Complaining of headache, fever, stiff neck, photophobia,
vomiting
Labs will show CD4 < 100
Diagnosis is made by India ink stain of CSF (round
encapsulated yeast), Cryptococcal antigen (CrAg) - CSF or
serum
Treatment is amphotericin B (fungicidal), flucytosine (fungicidal),
fluconazole (fungistatic)
Intracranial Abscess
Contiguous infection of middle ear, sinus, or teeth, surgery,
trauma, hematogenous spread
HA, fever, focal neurological deficit
CT/MRI with contrast
Ring enhancing lesions
ABX (3rd gen cephalosporin + metronidazole if no source
known), neurosurgery consultation
Transverse Myelitis
Causes: viral, autoimmune, idiopathic
Paraplegia, sensory impairment, sphincter disturbance
Dx: MRI
Multiple Sclerosis
Patient will be a caucasian female
Complaining of pain with eye movement, monocular
vision loss, sensory abnormalities
PE will show spinal electric shock sensation with neck
flexion (Lhermitte phenomenon)
CSF will show ↑ IgG protein, WBC pleocytosis
Diagnosis is made by T2-weighted MRI
Most commonly caused by a demyelinating disorder
Treatment is symptomatic, methylprednisolone
Comments: Bilateral internuclear ophthalmoplegia (eyes can't look at nose) is pathognomonic
Febrile Seizure - Simple
Patient will be a child 6 mos – 5 yrs
Complaining of a single generalized seizure lasting < 15 mins
Most commonly caused by rapid rise in temperature
Treatment is supportive care
Temporal Arteritis (Giant Cell Arteritis)
Patient will be a woman > 50-years-old
Complaining of monocular visual loss, unilateral headache, jaw claudication
PE will show a tender temporal artery
Labs will show ESR > 50
Diagnosis is made by temporal artery biopsy
Treatment is high dose steroids ASAP
Comments: Associated with polymyalgia rheumatica
Central Vertigo
Lesion of brainstem or cerebellum
Constant dizziness with variable response to movement
Gradual onset
Rare hearing loss and Tinnitus
Spontaneous nystagmus increased by visual fixation
Positional nystagmus- Multidirectional no latency or fatigue
N/V more severe in cerebellar hemorrhage
Cerebellum=ataxia, lateralizing dysmetria
Brainstem=Dysarthria, dysphasia, diplopia, Horner's syndrome, blindness
Treat symptoms
Patients require admission
Peripheral Vertigo
CN VIII, vestibular apparatus
Onset: sudden
Hearing loss, tinnitus
Positional
Nystagmus: uni-directional, never vertical,
fatigable, can be inhibited
No neurologic sx
Complex Regional Pain Syndrome
Patient will have a history of previous
extremity injury or fracture
Complaining of light touch causing
extreme pain and allodynia (pain felt from
a nonpainful stimulus, such as clothes or
bed sheets on the skin)
Treatment is NSAIDs, gabapentin,
sympathectomy
Ciguatera Poisoning:
Second most common fish-borne toxin
Cause by dinoflagellate toxin
Barracuda, grouper, red snapper
Hot-cold reversal
Supportive care, atropine, mannitol
Subdural Hematoma
Patient will be elderly or alcoholic
With a history of a fall or traumatic head
injury
Complaining of headache, mental status
changes, seizures, or focal deficits
Diagnosis is made by non-contrast CT, crescent-shaped hematoma
Most commonly caused by rupture of the bridging veins
Treatment is neurosurgical consultation
Myasthenia Gravis
Patient will be complaining of proximal muscle weakness, ptosis, and diplopia that is worse at the end of the
day
PE will show ice test improves sx
Diagnosis is made by edrophonium (tensilon) test, EMG
Most commonly caused by autoimmune destruction of acetylcholine receptors
Treatment is acetylcholinesterase inhibitors, such
as pyridostigmine
Comments: associated with thymoma
Bell’s Palsy
Patient with a history of viral prodrome
Complaining of waking up with unilateral facial nerve paralysis, hyperacusis and taste disturbance
PE will show CN VII nerve palsy that does not spare the forehead
Most commonly caused by HSV
Treatment is prednisone, artificial tears, tape eyelid shut
Comments: Bilateral: Lyme disease, infectious mononucleosis
Ischemic Stroke
Anterior cerebral artery: frontal lobe dysfunction, apraxia, contralateral paralysis (lower > upper)
Middle cerebral artery: contralateral paralysis (upper > lower), contralateral hemianopsia, aphasia
Posterior cerebral artery and VBI: LOC, nausea/vomiting, CN dysfunction, ataxia, visual agnosia
Rule out hypoglycemia
CT reveals loss of grey-white interface, acute hypodensity
Thrombolytics
Trigeminal Neuralgia (Tic douloureux)
Patient will be complaining of sudden unilateral electric shock-like pains in gums, cheek, chin, temporal
forehead
PE will show pain in V2 and V3 distributions, not V1
Treatment is carbamazepine
Status Epilepticus
PE will show > or equal to 5 minutes of continuous seizure activity or more than one seizure without
recovery from the postictal state in between episodes
Most commonly caused by a change in the medication regimen of someone with a seizure disorder
Treatment is
1st: Benzodiazepines (lorazepam etc.)
2nd: Phenytoin or fosphenytoin
3rd: Pentobarbital
Absence Seizures (petit mal)
Patient will be 5 - 10 y/o
Complaining of sudden mental status
alteration without motor activity, blank stare
EEG would show symmetric 3-Hz spike and
wave activity
Treatment is ethosuxamide
Comments: no aura or postictal state
Meralgia Paresthetica
Lateral femoral cutaneous neuropathy
Inguinal ligament injury
Dysesthesia/numbness of
proximal anterolateral thigh
Rx: loose clothing, weight loss
Putamen Hemorrhage
Contralateral hemiparesis/hemiplegia
Contralateral sensory loss
Homonymous hemianopia
Syringomyelia
CSF cavity in spinal cord
Most common location: cervical spine
Arnold-Chiari malformation
Loss of pain and temperature sensation with
preservation of proprioception and light touch in
"cape-like" distribution
MRI
Gullain-Barre Syndrome
Patient with a history of recent minor respiratory or
GI illness
Complaining of symmetric,
progressive ascending muscle weakness
PE will show lack of deep tendon reflexes
Lumbar puncture results will demonstrate increased
CSF protein but a normal cell count
Most commonly caused by Campylobacter jejuni
Treatment is supportive, plasmapheresis or IVIG
Common Peroneal Neuropathy
Proximal fibula injury
Footdrop
Numbness in web space between 1st and 2nd toes
Rx: ankle splint
