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