Heroin can be smoked “chasing the dragon” or sniffed/snorted, so no needle marks can still be heroin.

MDMA is sympathomimetic so dilated pupils, hypertension, hyperthermia, tachycardia

Characteristic of PCP is multidirectional nystagmus.

GSF as treatment for Hyper IgM

Topical erythromycin prophylaxis, but treatment if IV/IM Ceftriaxone for infantile Neisseria.
Topical antibiotic prophylaxis does not prevent chlamydial conjunctivitis. Maternal screening
and treatment of chlamydia infection is the most effective way to prevent chlamydial
conjunctivitis. Treatment with amoxicillin! and not doxycycline (teeth yellowing)

primary symptoms of optic neuritis are acute to subacute color blindness, a decrease in visual
acuity, and pain that is aggravated by ocular movements.
Most patients with optic neuritis would have a normal fundus on opthalmoscopy. It is not
uncommon for a cranial CT to show no abnormalities, especially in early MS.

Myopic macular degeneration may occur in younger patients and would also present with an
insidious, painless loss of vision but is seen in patients with pathological myopia.

Secondary acute angle closure glaucoma ?! timeline…?

Bilateral uveitis as extranodal manifestation of non-Hodgkin’s lymphoma

Patients who don’t FULLY return to baseline after a seizure should be considered as being a
complicated case and CT to rule hemorrhage (acute or from a mass) should be done urgently.

VIPoma does not cause flushing according to amboss?!?!?

Human antitoxin for infants versus equine for adults since risk of anaphylaxis is high in infants.

Miller-Fischer variant of Guillain-Barre syndrome has eye symptoms. GBS sometimes (15%) does
and is a late finding.

Aripiprazole does not cause hyperprolactinemia as it is a mixed agonist/antagonist!

Reflexes in B12 deficiency are brisk? Versus absent in tabes dorsalis?

CN palsies in trauma usually occur with edema (1-3 days after head trauma), can be damaged
acutely rarely, also basilar fractures are divided into anterior and posterior.
Cranial bone fracture can be basilar, zygomatic/mandibular, orbital (to note that raccoon eyes
is associated with anterior basilar fractures! …)

Ototoxicity is sensorineural hearing loss and usually tinnitus/nystagmus/dizziness…

Otosclerosis hear better in noisy environments! And usually have tinnitus!

CT scan cannot reliably identify ischemia early on! So who decides on tpa?

Intermittent strabismus normal up to 3 years of age.

First donepezil then memantine.

MG can have an acute exacerbation called Myasthenic crisis (dyspnea/mydriasis/…)

If typical migraine, no MRI.

Always consider Pseudomonas, if applicable, cover it.

Synesthesia may be seen with PCP. Marijuana causes Mydriasis.

Latanoprost first line in POAG. Also, look for contraindications to other drugs, e.i. COPD, AV
block, asthma for timolol.
Laser irodotomy can be used but not for POAG but in angle-closure glaucoma. Surgical
trabeculectomy can be used though!
Negative gonioscopy confirms open-angle glaucoma.

First-line for lead is succimer and EDTA. IM dimercaprol if lead > 70 or has encephalopathy.

End goal is not always to decrease blood flow. For example, craniotomy can increase blood
flow, as well as hypertonic saline, but they will all decrease ICP.
Use hypertonic saline before mannitol , unless very dangerous ICP?!?

sodium nitroprusside should be avoided because of their potential to raise intracranial

pressure. Labetalol better. Hydralazine?

surgical clipping of aneurysms in SAH? does not require post-procedural antiplatelet therapy.

Seizure prophylaxis is not typically indicated for subarachnoid hemorrhage because it may be
associated with worse neurologic outcome. It may be used for select cases with
associated intracerebral bleeding, unsecured aneurysm, or concurrent intracranial pathology.

Acutely manic: Lithium later, haloperidol now (amboss)

MCA stroke would show as temporal and basal ganglia changes vs HSV encephalitis only
temporal. Not seen on CT?

if a brain abscess was suspected, empirical antibiotic treatment would consist of a third-
generation cephalosporin, metronidazole, and possibly vancomycin. Additionally, surgical
drainage and biopsy should be conducted in any abscesses greater than 2.5 cm. Why metro?

If no clear sign of delirium, check electrolytes which can be disturbed in elderly if: they don’t
eat, they take laxatives, they have diarrhea/vomit, ANYTHING almost. 30% of cases of delirium
are due to electrolyte disturbances.
Aphasia in strokes in MCA dominant (broca/Wernicke)
Homonymous hemianopia without macular sparing in MCA stroke. Gaze deviation too!
PCA Stroke can have sensory symptoms since supplies thalamus. Also with macular sparing.

Patients with right-sided PCA strokes also present with prosopagnosia due to damage to the
fusiform face area, a symptom not experienced by this patient.
Patients with left-sided PCA strokes present with alexia without agraphia or anomic
aphasia (due to ischemic damage to the splenium of the corpus callosum, which carries visual
information from the visual cortex to Broca's and Wernicke's areas).

Urinary incontinence in ACA stroke? Dysarthria?

Von Gierke doll due to fat deposition due to hyperlipidemia.

Hypocalcemia can trigger a variety of symptoms, ranging from muscle cramps

to seizures and heart failure. Manifestations of chronic hypoparathyroidism include movement
disorders (due to basal ganglia calcifications), cataracts, and skeletal or dental abnormalities

Loss of dtr normal elderly distal axon degeneration/

Craniotomy vs burr hole

However, glucocorticoids (including dexamethasone) should not be used in patients with severe
traumatic head injuries because they are associated with a significant increase in
acute mortality.

Is methadone effective in pain?

Hemodialysis is indicated in the treatment of lithium toxicity if the patient has an altered mental
status. Other indications for hemodialysis include serum lithium concentration > 4.0 mEq/L,
evidence of renal dysfunction, seizures, and/or life-threatening arrhythmias.

Meningitis vs encephalitis complications

Dexamethasone in meningitis

Focal neurological deficits pathophysiology in meningitis

Why not fungal? Acyclovir in viral?

CMV periventricular calcification and usually microcephaly! Vs toxo diffuse and hydrocephalus
Spinal Shock: Babinski after 24 hours, Hyperreflexia in a week! In ASA syndrome, normal DC.

Occlusion of the left internal carotid artery would classically result in a watershed
infarct between the territory of the left anterior cerebral artery (ACA) and left middle cerebral
artery (MCA). A left ACA-MCA watershed infarct can result in sensory deficits of the face, arm,
and/or leg on the right (contralateral) side.

MCA and ACA cause hemineglect?

Friedrich’s ataxia can have optic atrophy!

Although it can increase serum potassium, spironolactone also predisposes the patient
to digoxin toxicity because it decreases renal clearance of digoxin.
. Although acute digoxin toxicity causes hyperkalemia, it paradoxically causes inverted or
flattened T waves. The combination of peaked T waves from hyperkalemia and inverted or
flattened T waves from digoxin results in a biphasic T wave with an initial negative deflection
followed by a positive (or peaked) terminal deflection.

SSRIs (e.g., citalopram) are a first-line drug for REM-related symptoms of narcolepsy , what
about REM without narcolepsy>?

Spinal epidural abscess is different from osteomyelitis. Psoas abscess can present similarly. All
distinguished radiographically.

This patient presents with delayed left-sided peripheral facial nerve palsy, which is most likely
secondary to edema within the facial nerve canal, an epineural hematoma, or a
longitudinal fracture of the temporal bone. First-line treatment involves prescribing a short
course of high-dose prednisone followed by a tapering regimen to control swelling within
the facial nerve canal.
Signs of peripheral in this case where eye stays open but there was NO forehead problems.
Immediate trauma and facial nerve damage may need decompression or if transected repair.

So the patient in Atweh’s clinic might have had brachial neuritis/Amyotrophic neuralgia due to
repeated strain/trauma from volleyball!

While optic neuritis may cause papillitis, which occasionally presents with papilledema, it does
not result in optic atrophy.

Irregular respiration can be a sign of brainstem compression.

Pupils and ICP?

ntravenous neostigmine therapy is a highly effective treatment option for acute colonic pseudo-
obstruction (Ogilvie syndrome) that is indicated if supportive therapy (i.e., bowel
rest, intravenous fluids with correction of any electrolyte abnormalities, bowel decompression)
does not relieve symptoms within 24–48 hours, provided that the patient does not display signs
of colonic ischemia, perforation, or peritonitis (e.g., fever, abdominal guarding or rebound).

Since Oglivie syndrome can present with only right sided dilatation, how do you distinguish
from other causes of obstruction? Loss of haustra in mechanical obstruction for example.

To have alcohol intoxication, BAC 0.15-0.30 is for moderate intoxication. Tachycardia usually,
while benzos can present like alcohol intoxication. Watch out for co-ingestions.

An important exception are bite wounds to the head or neck (closer to central nervous tissue).
There are reports of such cases in which rabies infection occurred within 4 days. Therefore, PEP
should be initiated immediately in patients with bite wounds to the head or neck.

Cortical laminar necrosis is the complication of status epilepticus.

Infarction of the red nucleus, which is seen in patients with Benedikt's syndrome, can result
in Holmes's tremor as well as in hypertonicity on the contralateral side. However, hypertonicity
associated with infarction of the red nucleus affects extensor muscles more than flexor
muscles, which results in a decerebrate posture (unlike this patient who has a normal range of
motion and increased resistance to both flexion and extension). Moreover, patients
with Benedikt's syndrome would have ataxia contralaterally (unlike this patient who has a
normal finger-nose test) and features of oculomotor nerve palsy (e.g., ptosis, exotropia)
ipsilaterally.

Parkinson plus include Multi-system atrophy, Corticobasilar degeneration, PSP and Lewy body

Cocaine and other drug use (e.g., alcohol, heroin, or amphetamines) can
trigger chorea and hallucinations, which are also seen here.
Chorea first in Huntington, Later dystonia/akinesia!

Observation should also be considered for patients with febrile seizure who have partial or focal
seizure activity, prolonged seizure (> 15 min), delayed recovery to baseline, or postictal focal
neurologic deficits. There are two types of febrile seizures.

Trigeminal neuralgia can be treated with carbamazepine or Heat/radiofrequency ablation,

surgical decompression, botox all of these not 1st line.

Cauda equina vs conus medullaris and treatment if not malignancy

Voiding cystourethrogram is the test of choice to diagnose posterior urethral valves (PUV), if
Potter sequence with bilateral present kidneys. Don’t forget, MCC of Potter is PUV in males.

Thoracic Outlet syndrome can cause paresthesias, edema and even BP difference in one arm.
Chlorprocaine fastest onset and shortest duration. Lidocaine actually intermediate

CBT in Alzheimer’s.

Wilson disease cirrhosis or HPTM?

Topical cipro-cortisone against pseudomonas otitis?!

Essential tremor can affect the voice and could be mistaken for dysarthria

Drooling and dysarthria pretty common in Wilson’s disease.

Trisomy 21 (Down syndrome) is the most common chromosomal disorder seen in live
births. Infants with trisomy 21 are usually diagnosed based on a combination of classic clinical
features including: brachycephaly, dysmorphic facial features (e.g., epicanthus, protuberant
tongue, flattened nasal bridge, hypertelorism), a single transverse palmar crease, and sandal
gapdeformity. This child does exhibit some features of Down syndrome, e.g., flattened nasal
bridge and upward slanting eyes with small palpebral fissures, but the absence of all other
typical features makes this diagnosis highly unlikely.

Syringomyelia flaccid paralysis not spastic? No UMN signs in syringomyelia? Syringobulbia?

Pronator drift is a SIGN OF UMN lesion, in UPDRIFT it is parietal/cerebellar!

Initial therapy was blood patch in amboss for severe post LP headache, not bed rest…

Oral tricyclic antidepressants (TCAs) are the first-line medications for postherpetic neuralgia.
However, they should not be administered in this patient because of his history of myocardial
infarction, as they may prolong the QRS and/or QT interval, which may lead to arrhythmias.

If patients repeatedly vomit on opioid medications, they could develop

hypochloremic, hypokalemic metabolic alkalosis. This in turn leads to mild hyponatremia with
a urine sodium level greater than 20 mEq/L due to a compensatory increase in the excretion
of NaHCO3 in urine. This patient, however, has normal serum chloride and potassium levels.

Cerebral salt wasting syndrome, which may occur in patients after neurosurgical procedures, is
a poorly understood cause of hypovolemic, hypotonic hyponatremia. Patients with cerebral salt
wasting syndrome have a low serum osmolality, as seen here, but also present with symptoms
of hypovolemia (e.g., hypotension, tachycardia) and paradoxical polyuria.
Severe cases treated with hypertonic saline and fluticasone.
For severe manic episodes, combination therapy with lithium or valproate plus an atypical
antipsychotic is usually preferred over monotherapy.

CMV Lesions are perivascular (meaning around the retinalvessels), while toxoplasma lesions are
nonvascular (meaning their distribution is not related to the vessels).

HIV retinopathy is coton wool spots with no acute presentation.

Other features that may help distinguish cerebral toxoplasmosis from primary CNS lymphoma
include the appearance of a large (> 4 cm), solitary lesion, and involvement of the corpus
callosum or periventricular area.

High-dose methotrexate is the treatment of choice in patients with confirmed primary CNS
lymphoma. PCNSL also responds well to whole brain radiation. In patients with renal
insufficiency (glomerular filtration rate < 30 mL/min/1.73 m2), alternative chemotherapeutic
agents such as cytarabine or temozolomide may be used.

If an audiometry was performed, it would typically show low-frequency hearing loss, which can
be a helpful finding in differentiating Ménière's disease from other conditions that present
with hearing loss in other frequency ranges (e.g., acoustic neuroma).

Absolute contraindications for organ donation include malignancy that is incurable

or metastatic, sepsis, transmissible spongiform encephalopathies (e.g., Creutzfeldt-
Jakob disease), and cardiac arrest that occurred before brain death, none of which apply to this
patient.

HIV and Hep C are absolute CI as they can donate to individuals who are also Hep C or HIV +!!

The absence of abdominal reflex is an early and important sign of MS, seen in about 70% of
patients.
The absence of the abdominal reflex can be a sign of lower motor neuron injury.
However, unlike monosynaptic deep tendon reflexes, the abdominal reflex is a
polysynaptic superficial reflex that is processed centrally, within the brain, thus its
absence often implies damage of the spinal cordor brain.

The pulse pressure would likely increase following fluid resuscitation rather than decrease.

Hyperglycemia with subsequent osmotic diuresis also affects visual acuity, most probably due
to swelling of the lens. This is in HHS.
patients with IBM often present with weakness in the hand or fingers (distal muscles)

GBS may present with symptoms of autonomic dysfunction, it resolves within 2 months,
meaning that GBS can be ruled out based on the fact that this patient's symptoms have
been present for the past 6 months. CIDP may persist for months, but it is not
associated with dysautonomia

A rare genetic disease called thiamine-responsive megaloblastic anemia may present

with macrocytic anemia that is responsive to treatment with thiamine. However, the onset of
this disorder is during childhood or adolescence, and it presents with other clinical
manifestations such as type 1 diabetes mellitus and sensorineural hearing loss.

Stent if atherosclerotic RAS like heart duh only angioplasty typically for FMD except in
exceptions.

Polycythemia vera by names means many cells. (polycythemia)

An oral glucose tolerance test is used to screen for hyperglycemia and diabetes. In patients
with acromegaly, it is part of a test used to determine whether a patient is
experiencing ectopicproduction of growth hormone.

The features of microcephaly, spasticity, sensorineural hearing loss, and pigmentary retinal
mottling in this newborn, whose mother traveled to Brazil during the first trimester of
her pregnancy, indicate congenital Zika syndrome.

Akinetic mutism
A condition characterized by decreased motor responses and paucity of speech. Caused by
injury to the mesial frontal region of the brain (e.g., from traumatic brain injury, hydrocephalus,
Creutzfeldt-Jakob disease).