Transcript Block 11 Board Review Part 1 of 4

Block 11 Board Review
Part 1 of 4
Neurology/Heme-Onc
11April2014
Chauncey D. Tarrant, M.D.
Chief of Residents 13-14
3% of Initial Certifying Exam!!!
Pediatrics In Review Articles
• Headaches
• Encephalitis
PIR Quiz
1. A 4-year-old boy comes in with a complaint of
headache. His father asks whether a “brain scan” should
be performed. Which of the following characteristics
would be the strongest indication for a magnetic
resonance imaging study of this child’s brain?
A. Age under 5 years.
B. Detection of a slight limp on examination.
C. Headache that awakens him from sleep.
D. Male gender.
E. Unilateral headache.
1. A 4-year-old boy comes in with a complaint of
headache. His father asks whether a “brain scan” should
be performed. Which of the following characteristics
would be the strongest indication for a magnetic
resonance imaging study of this child’s brain?
A. Age under 5 years.
B. Detection of a slight limp on examination.
C. Headache that awakens him from sleep.
D. Male gender.
E. Unilateral headache.
2. A 12-year-old girl presents to your office with a history
of frequent headaches that sometimes make her miss
school. You are trying to differentiate between migraine
and tension headache. Which of the following
statements is true and will help you to differentiate?
A. Migraine headaches are more likely to affect boys.
B. Migraine headaches are relieved by exercise.
C. Migraine headaches cause a “band-like pressure” on
the head.
D. Migraine headaches typically last for several hours.
E. Migraine pain is throbbing and severe.
2. A 12-year-old girl presents to your office with a history
of frequent headaches that sometimes make her miss
school. You are trying to differentiate between migraine
and tension headache. Which of the following
statements is true and will help you to differentiate?
A. Migraine headaches are more likely to affect boys.
B. Migraine headaches are relieved by exercise.
C. Migraine headaches cause a “band-like pressure” on
the head.
D. Migraine headaches typically last for several hours.
E. Migraine pain is throbbing and severe.
3. A 15-year-old girl who has just started to take acne
medication presents to your office with poorly localizing
daily headaches, blurry vision, and tinnitus. Of the
following, which diagnosis is most likely to explain the
findings above?
A. Idiopathic intracranial hypertension.
B. Medulloblastoma.
C. Migraine headache.
D. Tension headache.
E. Trigeminal autonomic cephalalagia (cluster headache).
3. A 15-year-old girl who has just started to take acne
medication presents to your office with poorly localizing
daily headaches, blurry vision, and tinnitus. Of the
following, which diagnosis is most likely to explain the
findings above?
A. Idiopathic intracranial hypertension.
B. Medulloblastoma.
C. Migraine headache.
D. Tension headache.
E. Trigeminal autonomic cephalalagia (cluster headache).
4. You are counseling a parent of a 17-year-old boy who
has frequent tension headaches. The family and young
man would prefer to try lifestyle interventions before
proceeding to medications. Which of the following
lifestyle interventions might be helpful in promoting
headache reduction?
A. Coffee or tea with breakfast daily.
B. Limiting fluid intake to 40 ounces daily.
C. Regular aerobic exercise.
D. Skipping breakfast during weekends to allow for extra
sleep.
E. Television watching before sleep.
4. You are counseling a parent of a 17-year-old boy who
has frequent tension headaches. The family and young
man would prefer to try lifestyle interventions before
proceeding to medications. Which of the following
lifestyle interventions might be helpful in promoting
headache reduction?
A. Coffee or tea with breakfast daily.
B. Limiting fluid intake to 40 ounces daily.
C. Regular aerobic exercise.
D. Skipping breakfast during weekends to allow for extra
sleep.
E. Television watching before sleep.
5. A 14-year-old girl has been diagnosed as having migraine.
The headaches occur twice weekly and have caused her
to miss school at least once per month. The family is
interested in a prophylactic medication to prevent her attacks,
and you plan to start amitriptyline. Of the following studies,
which is indicated as part of amitriptyline therapy?
A. Chest radiograph.
B. Complete blood count.
C. Electrocardiogram.
D. Serum alanine aminotransferase.
E. Serum creatinine.
5. A 14-year-old girl has been diagnosed as having migraine.
The headaches occur twice weekly and have caused her
to miss school at least once per month. The family is
interested in a prophylactic medication to prevent her attacks,
and you plan to start amitriptyline. Of the following studies,
which is indicated as part of amitriptyline therapy?
A. Chest radiograph.
B. Complete blood count.
C. Electrocardiogram.
D. Serum alanine aminotransferase.
E. Serum creatinine.
1. Mosquito control will most likely reduce the
frequency of encephalitis caused by
A. Adenoviruses.
B. Flaviviruses.
C. Herpesviruses.
D. Myxoviruses.
E. Picornaviruses.
1. Mosquito control will most likely reduce the
frequency of encephalitis caused by
A. Adenoviruses.
B. Flaviviruses.
C. Herpesviruses.
D. Myxoviruses.
E. Picornaviruses.
2. A 10-year-old child presents with the signs of acute
encephalitis. While no pattern of brain involvement is
exclusively produced by a single microbiologic agent, the
possibility of herpes simplex being the causative
agent is enhanced substantially by an MRI finding of
lesions concentrated in the
A. Basal ganglia.
B. Frontal lobes.
C. Midbrain.
D. Temporal lobes.
E. Thalamus.
2. A 10-year-old child presents with the signs of acute
encephalitis. While no pattern of brain involvement is
exclusively produced by a single microbiologic agent, the
possibility of herpes simplex being the causative agent is
enhanced substantially by an MRI finding of lesions
concentrated in the
A. Basal ganglia.
B. Frontal lobes.
C. Midbrain.
D. Temporal lobes.
E. Thalamus.
3. A 17-year-old boy has acute encephalitis associated with
weakness in the right arm. He is clinically stable. He had
experienced a febrile illness 3 weeks before presenting with
signs of encephalitis, but had apparently recovered fully. An
MRI demonstrated scattered multifocal abnormalities in both
gray and white matter within the brain. Evaluation of serum
and CSF has been unrevealing. His most likely diagnosis is
A. Acute disseminated encephalomyelitis.
B. Enteroviral encephalitis.
C. Herpes simplex encephalitis.
D. Mycoplasma encephalitis.
E. Multiple sclerosis.
3. A 17-year-old boy has acute encephalitis associated with
weakness in the right arm. He is clinically stable. He had
experienced a febrile illness 3 weeks before presenting with
signs of encephalitis, but had apparently recovered fully. An
MRI demonstrated scattered multifocal abnormalities in both
gray and white matter within the brain. Evaluation of serum
and CSF has been unrevealing. His most likely diagnosis is
A. Acute disseminated encephalomyelitis.
B. Enteroviral encephalitis.
C. Herpes simplex encephalitis.
D. Mycoplasma encephalitis.
E. Multiple sclerosis.
4. The form of encephalitis shown to benefit
most from the use of high-dose
glucocorticosteroids is
A. Acute disseminated encephalomyelitis.
B. Enteroviral encephalitis.
C. Herpes simplex encephalitis.
D. Saint Louis encephalitis.
E. West Nile virus encephalitis.
4. The form of encephalitis shown to benefit
most from the use of high-dose
glucocorticosteroids is
A. Acute disseminated encephalomyelitis.
B. Enteroviral encephalitis.
C. Herpes simplex encephalitis.
D. Saint Louis encephalitis.
E. West Nile virus encephalitis.
5. The likelihood of full recovery from
encephalitis most depends upon
A. Availability of specific treatment.
B. Causative agent.
C. Duration of fever.
D. Initial CSF findings.
E. Timeliness of specific diagnosis.
5. The likelihood of full recovery from
encephalitis most depends upon
A. Availability of specific treatment.
B. Causative agent.
C. Duration of fever.
D. Initial CSF findings.
E. Timeliness of specific diagnosis.
Headaches
What are the physical characteristics
of a headache due to increased ICP?
What are the physical characteristics
of a headache due to increased ICP?
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progressive
may cause nighttime wakening
are worse with the Valsalva maneuver or exertion.
persistent vomiting
neurologic deficits
Lethargy
personality change
Papilledema
Palsies of the third, fourth, or sixth cranial nerves,
resulting in eye movement or pupillary abnormalities
What elements of the history
characterize a migraine?
What elements of the history
characterize a migraine?
Migraine without aura
A. At least five attacks fulfilling criteria B–D
B. Headache attacks lasting 1–72 hours (untreated or unsuccessfully
treated)
C. Headache has at least two of the following characteristics:
1. Unilateral location, although may be bilateral or frontal (not
exclusively occipital) in children
2. Pulsing quality
3. Moderate or severe pain intensity
4. Aggravation by or causing avoidance of routine physical activity
(eg, walking or climbing stairs)
D. During headache at least one of the following:
1. Nausea and/or vomiting
2. Photophobia and phonophobia (which may be inferred from
behavior)
E. Not attributed to another disorder
What neurologic defects can be
associated with a migraine?
What neurologic defects can be
associated with a migraine?
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Acute confusional state
Benign paroxysmal vertigo
Benign paroxysmal torticollis
Cyclic vomiting
Hemiplegic migraine
Basilar
Ophthalmoplegic
Retinal
Alice-In-Wonderland
What elements of the history
characterize a headache due to
stress/tension/emotion?
What elements of the history
characterize a headache due to
stress/tension/emotion?
• may last for 1 hour or for several days
• described as “band-like,” pressure, or
tightening
• Triggers include stress, fatigue, illness, muscle
pain, tension, particularly in the neck and
shoulders
• may be episodic (<15 days per month) or
chronic (>15 days per month)
Can depression cause headaches?
T or F
Can depression cause headaches?
T or F
What elements of the history
characterize a headache due to
increased ICP?
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What elements of the history
characterize a headache due to
increased ICP?
Progressive
causes nighttime wakening
worse with the Valsalva maneuver or exertion.
persistent vomiting
neurologic deficits
Lethargy
personality change
Papilledema
Palsies of the third, fourth, or sixth cranial nerves,
resulting in eye movement or pupillary abnormalities
What signs and symptoms of a
headache indicate follow-up with MRI
or CT scan?
What signs and symptoms of a
headache indicate follow-up with MRI
or CT scan?
What are the values and limitations of
ancillary neurodiagnostic tests when
evaluating headaches?
What are the values and limitations of
ancillary neurodiagnostic tests when
evaluating headaches?
• Values
– Brain MRI can help investigate potential structural
abnormalities, infection, inflammation, and
ischemia
– CT is good if there is a concern for hemorrhage or
fracture
• Limitations
– No good guidelines to use
What are some abortive treatments
for acute migraines?
What are some abortive treatments
for acute migraines?
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Tylenol
Ibuprofen
Naproxen
Triptans
How do you treat a
stress/tension/emotion headache?
How do you treat a
stress/tension/emotion headache?
• Modification of lifestyle (sleep, hydration,
stressors, etc)
• Acute treatments
What are complications of using
narcotics, sedatives, and NSAIDS when
treating chronic or recurrent
headaches?
What are complications of using
narcotics, sedatives, and NSAIDS when
treating chronic or recurrent
headaches?
• Rebound headaches
What are prophylactic treatments for
recurrent migraines?
What are prophylactic treatments for
recurrent migraines?
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Periactin
TCAs
AEDs
Antihypertensives
Supplements
– Riboflavin
– Melatonin
– Coenzyme Q
Encephalitis
What are the common causes of
encephalitis?
What are the common causes of
encephalitis?
• Infectious (viral, bacterial, fungal, parasitic)
• Parainfectious/Immune Mediated (ADEM,
acute cerebellar ataxia)
• Systemic Infalmmatory (Lupus)
• Malignancy (paraneoplastic)
What are the signs and symptoms of
herpes encephalitis?
What are the signs and symptoms of
herpes encephalitis?
• Basal frontal and mesial temporal lobes with
prominent lesions on MRI in older children
and adults
• Hemorrhagic meningoencephalitis
• >50% ofcases in individuals >20 y
• causes up to 30% of neonatal
meningoencephalitis
What are the clinical symptoms of
encephalitis?
What are the clinical symptoms of
encephalitis?
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Seizures,
upper-motor-neuron weakness
Sensory disturbances
Lethargy
coma
Weakness, hyperkinetic (dystonia, choreoathetosis) or
parkinsonian movement abnormalities, apathetic or disinhibited
behavior
Salt and water disturbances (eg, syndrome of inappropriate
antidiuretic hormone, diabetes insipidus)
adrenal and thyroid failure
Paroxysmal autonomic dysfunction
Sensory disturbances
postural abnormalities
What is the role of neurodiagnostic
testing in the evaluation of a child with
encephalitis?
What is the role of neurodiagnostic
testing in the evaluation of a child with
encephalitis?
• LOCALIZATION!
• MRI can yield false negative results early in
course
• CT for identifying substantial cerebral edema,
midline shift or hemorrhage
– Generally not sufficient for workup
What diagnostic tests are useful in a
child with encephalitis?
What diagnostic tests are useful in a
child with encephalitis?
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MRI (with and without contrast)
CBC, CMP, UA
LP
Acute treatment if indicated*
EEG*
How do you manage encephalitis?
How do you manage encephalitis?
• Supportive care, unless causative agent is
identified
What are some common sequelae of
encephalitis?
What are some common sequelae of
encephalitis?
• Depends on causative agent
– Can have neuro deficits or none at all
PREP
A 10-year-old boy is at school when his teacher notices that he is staring out
the window. She can’t get him to stop staring or respond to her, so he is
brought to the emergency department. No other children had similar
symptoms. On arrival, his physical examination reveals a temperature of
37.2°C, blood pressure of 100/60 mm Hg, heart rate of 85 beats/min, and a
respiratory rate of 20 breaths/min. The boy is awake and seems restless. He
follows one-step commands (eg, “take off your shoes”), but does not follow
two-step commands. He knows his name, but not where he is. The remainder
of the physical examination findings is unremarkable. Results of computed
tomography of the head without contrast, serum sodium and glucose, and
serum and urine toxicology testing are normal. As you are completing your
examination, the boy’s parents arrive and report no known ingestions at
home, no history of seizures or headaches, and no similar prior events. The
boy is adopted and no family history is known. After 2 hours of observation,
he is alert and responding normally to commands, but complains of a
headache and vomits.
Of the following, the MOST likely diagnosis is
A. acute psychosis
B. carbon monoxide poisoning
C. confusional migraine
D. postictal state
E. pseudotumor cerebri
A. acute psychosis
B. carbon monoxide poisoning
C. confusional migraine
D. postictal state
E. pseudotumor cerebri
A 3-year-old girl suddenly refuses to walk. There is no reported history of
injury or ingestions. She has been well, although several children in her
preschool class have been absent because of illness. Physical examination
shows a temperature of 37.8°C, blood pressure of 88/62 mm Hg, heart rate of
96 beats/min, and respiratory rate of 20 breaths/min. She is crying loudly but
calms down when her mother holds her. The girl’s neck is supple and there
are no skin lesions. Her neurologic examination shows conjugate eye
movements in all directions. She has strong, symmetric facial movements
when crying and strong, symmetric limb movements when she is resisting
examination. After being calmed again, her deep tendon reflexes are found to
be absent. She can sit independently, but, when placed standing, she
wobbles, immediately adopts a wide-based stance, refuses to take steps, and
collapses to the floor while crying. Results of magnetic resonance imaging of
the brain with and without contrast are normal.
Of the following, the MOST likely diagnosis is
A. acute cerebellar ataxia
B. ataxia telangiectasia
C. Friedreich ataxia
D. Guillain-Barré syndrome
E. opsoclonus-myoclonus-ataxia syndrome
A. acute cerebellar ataxia
B. ataxia telangiectasia
C. Friedreich ataxia
D. Guillain-Barré syndrome
E. opsoclonus-myoclonus-ataxia syndrome
A 16-year-old boy has had constant daily headache for 1 month. The headache is all
over his head; it comes and goes but never fully resolves. The pain worsens with
coughing, sneezing, and laughing. He has mild nausea and photophobia and ringing in
his ears. He reports that his vision “grays out” sometimes but he does not have tunnel
vision or visual loss. His past medical history is notable for acne, asthma, and
attention-deficit/hyperactivity disorder (ADHD). He is currently taking oral isotretinoin
for his acne, oral montelukast and inhaled fluticasone for his asthma, and atomoxetine
for his ADHD. He also takes vitamin B12 supplements and riboflavin as natural
remedies for headache. There is no family history of migraine. On physical
examination, his weight is 65 kg, height is 178 cm, and blood pressure is 102/76 mm
Hg. His funduscopic examination is shown in Item Q102 (both eyes exhibit similar
findings). The remainder of his physical examination findings is normal. Results of
magnetic resonance imaging of the brain are normal. Lumbar puncture is performed
in the lateral decubitus position with legs extended, and the opening pressure is 340
mm H20. Cerebrospinal fluid protein is 13 mg/dL and glucose is 64 mg/dL, and there
are 3 white blood cells/µL and 204 red blood cells/ µL.
Of the following, the medication MOST likely to cause the boy’s symptoms and signs is
A. atomoxetine
B. isotretinoin
C. montelukast
D. riboflavin
E. vitamin B12
A. atomoxetine
B. isotretinoin
C. montelukast
D. riboflavin
E. vitamin B12
An 8-year-old girl has had frequent, severe headaches for the past 8
months. They are bifrontal and associated with nausea, photophobia,
and blurry vision. They last 2 to 3 hours and occur 1 to 2 times per
week, mostly at the end of a school day. She also has asthma and
attention-deficit/hyperactivity disorder. Her father and paternal aunt
have migraine headaches. She is typically a good student, but lately
her grades have fallen due to absenteeism caused by the headaches.
On physical examination, she is a thin, slightly nervous-appearing girl.
Her funduscopic examination shows crisp optic disk margins, and
extraocular movements are conjugate and intact in all directions.
There is no nystagmus. The remainder of her physical examination
findings are normal.
Of the following, the BEST prophylactic medication for her headaches
is
A. cyproheptadine
B. ergotamine
C. fluoxetine
D. propranolol
E. topiramate
A. cyproheptadine
B. ergotamine
C. fluoxetine
D. propranolol
E. topiramate
A 15-year-old boy is on a wilderness trip in the desert Southwest, United
States, as part of a drug and alcohol rehabilitation program. He develops a
fever and stiff neck and then has a generalized seizure. He is transported
urgently to the nearest emergency department. On arrival, he has another
generalized seizure and is given lorazepam 4 mg intravenously. Physical
examination after lorazepam administration reveals a temperature of 39.1°C,
blood pressure of 150/76 mm Hg, heart rate of 130 beats/min, and
respiratory rate of 14 breaths/min. He is somnolent, there are no signs of
trauma, and there are no rashes or insect bites. The remainder of his physical
examination findings are normal. Computed tomography of the head without
contrast is normal. Lumbar puncture is performed in the lateral recumbent
position with legs extended. Cerebrospinal fluid (CSF) opening pressure is 380
mm H20; CSF protein is 182 mg/dL, and glucose is 8 mg/dL; and there are 900
white blood cells/µL (81% of which are polymorphonuclear leukocytes) and
190 red blood cells/µL.
Of the following, the MOST likely cause of this boy’s symptoms is
A. Coccidioides immitis
B. Enterovirus
C. Neisseria meningitidis
D. Taenia solium
E. West Nile virus
A. Coccidioides immitis
B. Enterovirus
C. Neisseria meningitidis
D. Taenia solium
E. West Nile virus
Quick Associations