Chapter 10 of 157% of exam

Neurologic System

Neurology items cover cerebrovascular disease, head injury, headaches, infections, movement and neuromuscular disorders, seizures and spinal cord syndromes. The emphasis is on recognizing emergencies and choosing the first test.

Stroke and hemorrhage

Imaging comes first in acute focal deficits and in thunderclap headache. Hemorrhage must be excluded before any thrombolytic is given. In suspected bacterial meningitis, antibiotics should not wait for imaging.

Acute stroke

Noncontrast CT or MRI excludes hemorrhage before thrombolysis.

Merck Manual Professional Edition, Ischemic Stroke

Subarachnoid hemorrhage

Worst headache peaking in seconds; noncontrast CT and, if negative, lumbar puncture for xanthochromia.

Merck Manual Professional Edition, Subarachnoid Hemorrhage

Meningitis

Give antibiotics and glucocorticoids after blood cultures but before imaging if lumbar puncture will be delayed.

Merck Manual Professional Edition, Acute Bacterial Meningitis

Neuromuscular disease

Weakness patterns point to the site of disease. Fatigable weakness suggests the neuromuscular junction, and ascending areflexic weakness suggests peripheral nerves. Spinal cord and cauda equina compression are surgical emergencies.

Myasthenia gravis

Fatigable ptosis and diplopia; acetylcholine receptor antibodies confirm.

Merck Manual Professional Edition, Myasthenia Gravis

Guillain-Barre syndrome

Ascending weakness with areflexia after infection; monitor forced vital capacity; IVIG or plasma exchange.

Merck Manual Professional Edition, Guillain-Barre Syndrome

Cauda equina syndrome

Saddle anesthesia, bladder dysfunction and leg weakness; immediate MRI.

Merck Manual Professional Edition, Cauda Equina Syndrome

Movement disorders and headache

Tremor timing and headache pattern separate common diagnoses. A resting tremor suggests parkinsonism, while a postural or intention tremor suggests essential tremor. Headache type determines both acute and preventive treatment.

Parkinson disease

Resting tremor, rigidity and bradykinesia; carbidopa-levodopa.

Merck Manual Professional Edition, Parkinson Disease

Essential tremor

A postural and intention (action) tremor, usually bilateral; propranolol or primidone are standard treatments.

Merck Manual Professional Edition, Tremor

Cluster headache

Unilateral orbital pain with autonomic features; oxygen or parenteral triptan acutely, verapamil to prevent.

Merck Manual Professional Edition, Cluster Headache

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