1 Launch Neurology Toronto WWW.LAUNCHNEUROLOGYTORONTO.COM 1. Behavioral neurology a) How do you test for calculation? b) Name two prefrontal lobe tests? c) How do you test for apraxia? How is apraxia of left frontal lobe lesions different from that of left parietal lobe lesions? 2. Epilepsy a) Define Drug resistance and Epilepsy remission and Seizure freedom? b) What advise will you give a patient to prepare for a sleep deprived EEG? c) What is hemolytic disease of the newborn? How do you prevent it? d) 20 female with a seizure. 1) What questions will you ask to identify the type of seizure disorder? 2) Patient has symptoms of both myoclonic and absence seizures. What investigation will you do? 3) Patient insists for the best medication. What will you give? 4) When you described the issues with VPA with pregnancy, she is asking for an alternative. What will you give? How will you prescribe it? 5) You started her on LTG. If the patient wants to become pregnant and if patient agrees with a prescription of LTG, what all things you would like to discuss? 6) What is the mechanism behind the need for increased dose of LTG? 7) “If we keep the concentration appropriate, will LTG cause any seizures doctor?” 8) You prescribed LTG. Patient cannot sleep well at night. How do you manage? 9) After delivery she stated to take is on OCP. How does that affect LTG? 3. Headache a) How will you treat severe headache in pregnancy? b) What are the FDA drug categories? c) What are the features of aura in Migraine with aura? d) How do you treat acute SUNCT in ER? What prophylaxis can you prescribe? 4. Internal Medicine a) Patient with history of chronic alcoholism. Now has double vision for the last 1 week. What is the most common diagnosis? How do you manage? 1) What typical questionnaire you will administer? 2) Where will you refer this patient? 3) How do you manage if this patient become delirious in the hospital after 2 days? 4) What is the typical doze of diazepam for alcohol withdrawal delirium? 5) How do you manage post-operative delirium?
15
Embed
Launch Neurology Toronto …launchneurologytoronto.com/images/Launch Neurology Toronto.pdfApraxia of speech – pa, ta, ka, pataka, pataka, Repeat pencil 3 times, Hopeful-hopefully,
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
Launch Neurology Toronto WWW.LAUNCHNEUROLOGYTORONTO.COM
1. Behavioral neurology
a) How do you test for calculation?
b) Name two prefrontal lobe tests?
c) How do you test for apraxia? How is apraxia of left frontal lobe lesions different from that of
left parietal lobe lesions?
2. Epilepsy
a) Define Drug resistance and Epilepsy remission and Seizure freedom?
b) What advise will you give a patient to prepare for a sleep deprived EEG?
c) What is hemolytic disease of the newborn? How do you prevent it?
d) 20 female with a seizure.
1) What questions will you ask to identify the type of seizure disorder?
2) Patient has symptoms of both myoclonic and absence seizures. What investigation will you
do?
3) Patient insists for the best medication. What will you give?
4) When you described the issues with VPA with pregnancy, she is asking for an alternative.
What will you give? How will you prescribe it?
5) You started her on LTG. If the patient wants to become pregnant and if patient agrees with a
prescription of LTG, what all things you would like to discuss?
6) What is the mechanism behind the need for increased dose of LTG?
7) “If we keep the concentration appropriate, will LTG cause any seizures doctor?”
8) You prescribed LTG. Patient cannot sleep well at night. How do you manage?
9) After delivery she stated to take is on OCP. How does that affect LTG?
3. Headache
a) How will you treat severe headache in pregnancy?
b) What are the FDA drug categories?
c) What are the features of aura in Migraine with aura?
d) How do you treat acute SUNCT in ER? What prophylaxis can you prescribe?
4. Internal Medicine
a) Patient with history of chronic alcoholism. Now has double vision for the last 1 week. What is
the most common diagnosis? How do you manage?
1) What typical questionnaire you will administer?
2) Where will you refer this patient?
3) How do you manage if this patient become delirious in the hospital after 2 days?
4) What is the typical doze of diazepam for alcohol withdrawal delirium?
5) How do you manage post-operative delirium?
2
b) List viruses causing predominantly encephalitis and meningitis
c) 60 Male with acute onset seizures once at home. H/o HTN, smoking. History & exam. Cough,
loss of weight, bone pain, mild unilateral weakness & lesion on CT brain at the gray-white
junction with edema. How do you manage?
5. Movement disorder
a) Palatal tremor
1) Palatal tremor (Watch a video) Where is the lesion?
2) What are the types of palatal tremors?
3) How do you treat palatal tremor?
4) What is common accompanying change in the eyes?
b) Examine a person with parkinsonian features
c) DBS how do you select a candidate for DBS and what locations will you select?
6. MS/Inflammatory
a) What are the relapse rates of MS during pregnancy and post-partum periods compared to the
normal?
b) What are the differential diagnosis for very large white matter lesions?
c) What are the diagnostic criteria for NMO spectrum disorders?
7. Neuromuscular
a) What are the three typical features of ICU myopathy and explain why?
b) How do you differentiate between pseudobulbar palsy from bulbar palsy?
c) What special history and examination will you carry out in a case of myopathy?
d) How to you test myotomes of upper and lower limbs? What muscles will you test for L5
myotome?
8. Neuro-Ophthalmology
a) Name nuclei associated with horizontal and vertical eye movements?
b) 48 F has diplopia. O/E abnormal lid elevation with any ocular movements for more than a few
months. What is the name of the condition? What are the different types? What investigations
will you order?
c) A patient has nystagmus. How do you differentiate between central and peripheral
nystagmus?
9. Pediatric Neurology
a) Name three neurological disorders that has high chances to appear sporadically and mention
the percentage chances? What other mode of transmission do each one of them have?
b) A patient diagnosed with Neurofibromatosis type 2 does not have any vestibular schwanoma.
Can this be correct? Yes or No. Substantiate your answer.
3
c) A child with mild mental impairment show neck extension, nodding, some features of
spasmodic torticollis that last only for a few minutes. What specific history do you want to
ask? Is it occurring while eating?
d) Differentiate between Typical v/s Atypical absence seizures?
e) Write a list of diseases affected by AD, AR, XD and XR pattern of inheritance?
10. Stroke
a) What conditions give number needed to treat (NNT) values 8, 6, 4 and 2?
b) Name four conditions that can cause Moyamoya disease?
c) What investigations will you do for stroke in a young patient?
d) Patient on warfarin. Now INR is high. How do you manage?
11. Telemedicine
a) Name three neurological disorders where NSAIDs are contraindicated?
b) GBS-like ascending paralysis is seen in which electrolyte abnormality?
c) Relapse rates in MS
1. MS patient who don’t want to take any medications
2. MS patient who is taking disease modifying drugs
3. MS during 3rd trimester
4. MS during postpartum period
ANSWERS
1. Behavioral neurology
a) Ask patient to calculate 6+8-7. Note that simple addition or subtraction are not enough.
b) Prefrontal lobe tests
1) Wisconsin Card Sorting Test: Color, form, number - challenges the subject to shift cognitive
sets without warning. Poor cognitive flexibility & perseveration will show up.
2) Stroop test (Read the print of the name of a color printed with a different color)
c) Praxis testing
Check for handedness
“I will make sure that vision, hearing, attention and orientation are normal before testing for
apraxia” Hearing or vision problem – Yes/No questions; 3 step command
“I WILL RULE OUT ABNORMALITIES IN STRENGTH, CO-ORDINATION, BALANCE &
SENSATIONS”
Test 1 proximal & 1 distal group muscles in each limb
Gross coordination – FNF; Fine coordination: pick up a pen
4
Balance – stand up on one leg for a couple of seconds
Sensation: Close your eyes – which hand am I touching now?
I am looking to see if the person is using correct body parts, making correct movements in
correct spatial orientation & with correct speed & repetition of movement where relevant
Ideomotor – Left parietal
Upper limb- meaningless gesture, pantomime a salute (show it), Show how you brush your teeth
with your right hand, Use it wrongly & ask to command.
How do you use this correctly – act to me? How you really use it?
Lower limb – kick a ball
Whole body – stand like a boxer
Bucco-facial apraxia – stick out your tongue, blow a kiss, blow out a match, drink using a straw
Apraxia of speech – pa, ta, ka, pataka, pataka, Repeat pencil 3 times,
Hopeful-hopefully, Spagatti, Episcopalian
Constructional tasks – copy a cross, triangle with a triangle, draw a flowerpot, design blocks
Gait apraxia – ask to walk
Only left hand affected – Anterior corpus callosum – Geshwind
Ideomotor (Only motor) Left parietal lesion - has anosognosia & left frontal lesion - can
recognize the defect
Ideational – Entire left hemisphere
Fold a letter, put it in an envelope, seal, stamp, address & mail 2) Light a candle
Ideational (Planning): Entire left hemisphere. Can’t do sequence (Can’t make a sandwich)
Imitation problem – Right hemisphere
Limb Kinetic Apraxia – Cannot unbutton the shirt. Cannot pick a coin from the table
2. Epilepsy
Theory
a) Definitions
1) Drug resistance = failure of adequate trials of 2 appropriately chosen, tolerated &
administered anti-seizure drugs (whether as monotherapy/ in combination) to achieve
seizure freedom
2) Epilepsy remission: 10 years seizure free with last 5 years off AEDs + passed the age of
epilepsy syndromes
3) Seizure freedom: "Rule of 3": Seizure free after an intervention period = 3x the largest pre-
intervention inter-seizure interval or 12 months, whichever is longer
b) Reduce sleep by one hour both at the beginning and at the time of getting up
5
c) Hemorrhagic disease of the newborn is due to the side effect of enzyme inducing anti-seizure
medications that the mother is taking during pregnancy. It can be prevented by prescribing
Vitamin K 10mg OD PO during last trimester to the mother and by giving the newborn a one
time injection of 1 mg vitamin K
d) 19 year old female with seizures
1) Ask for symptoms of myoclonic (exaggerated with reduced sleep and alcohol), atypical
absences (see pediatric question 9d), generalized tonic clonic seizure and other types of
seizures
2) EEG routine with photic stimulation & hyperventilation and sleep deprived EEG
3) Valproic acid is the best medication for both myoclonic and absences
4) LTG. Start 25 BID x 1week, slowly increase to 100 BID (over 6 weeks) (Max 150/200
BID). Get a blood level, if seizure not controlled after 100 BID to further increase doze
5) Check blood levels of LTG before becoming pregnant and it will become necessary to
increase the dose of LTG during pregnancy to maintain same blood level. Follow up this
during the postpartum period
6) Mechanism: Increased estrogen especially during third trimester activates uridine glucuronyl
transferase (UGT) & lowers LTG
7) LTG may worsen myoclonus in some patients: tell this to your patient
8) LTG has some stimulating effect. So give the last dose of the day before 4 pm
9) Same as the answer to 6). This time it is due to oestrogen in the pill. Patient may again need
more LTG. Maintain the pre-pregnancy level
3. Headache
a) Severe headache in pregnancy Rx: Metoclopramide, Tylenol, Hydration if needed. [Tryptan in
pregnancy: Not recommended normally. But can be given. No teratogenic effects are reported.
Commonest side effect is atonia of uterus and so it can cause increased uterine bleeding. If
needed during lactation: Bottle feed baby for several hours after taking tryptan]
b) FDA drug categories
A: Human studies failed to show any defect in the 1st trimester
B: Animal studies – no defect – Clopidogrel
C: Animal studies – defect – ASA
D: Human fetal risk: VPA (but has to compare risk & benefit when treated)