Block 11 Board Review - PowerPoint Presentation

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Block 11 Board ReviewPart 1 of 4

Neurology/

Heme-Onc

11April2014

Chauncey D. Tarrant, M.D.

Chief of Residents 13-14Slide2

3% of Initial Certifying Exam!!!Slide3

Pediatrics In Review Articles

Headaches

EncephalitisSlide4

PIR QuizSlide5

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.Slide6

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.Slide7

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.Slide8

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.Slide9

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).Slide10

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).Slide11

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.Slide12

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.Slide13

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.Slide14

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.Slide15

1. Mosquito control will most likely reduce the frequency of encephalitis caused by

A. Adenoviruses.

B.

Flaviviruses

.

C.

Herpesviruses

.

D.

Myxoviruses

.

E.

Picornaviruses

.Slide16

1. Mosquito control will most likely reduce the frequency of encephalitis caused by

A. Adenoviruses.

B.

Flaviviruses

.

C.

Herpesviruses

.

D.

Myxoviruses

.

E.

Picornaviruses

.Slide17

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.Slide18

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.Slide19

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.Slide20

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.Slide21

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.Slide22

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.Slide23

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.Slide24

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.Slide25

HeadachesSlide26

What are the physical characteristics of a headache due to increased ICP?Slide27

What are the physical characteristics of a headache due to increased ICP?

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

abnormalitiesSlide28

What elements of the history characterize a migraine?Slide29

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 disorderSlide30

What neurologic defects can be associated with a migraine?Slide31

What neurologic defects can be associated with a migraine?

Acute

confusional

state

Benign paroxysmal vertigo

Benign paroxysmal torticollis

Cyclic vomiting

Hemiplegic migraine

Basilar

Ophthalmoplegic

Retinal

Alice-In-WonderlandSlide32

What elements of the history characterize a headache due to stress/tension/emotion?Slide33

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

)Slide34

Can depression cause headaches? T or FSlide35

Can depression cause headaches?

T

or FSlide36

What elements of the history characterize a headache due to increased ICP?Slide37

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 abnormalitiesSlide38

What signs and symptoms of a headache indicate follow-up with MRI or CT scan?Slide39

What signs and symptoms of a headache indicate follow-up with MRI or CT scan?Slide40

What are the values and limitations of ancillary neurodiagnostic

tests when evaluating headaches?Slide41

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 useSlide42

What are some abortive treatments for acute migraines?Slide43

What are some abortive treatments for acute migraines?

Tylenol

Ibuprofen

Naproxen

TriptansSlide44

How do you treat a stress/tension/emotion headache?Slide45

How do you treat a stress/tension/emotion headache?

Modification of lifestyle (sleep, hydration, stressors,

etc

)

Acute treatmentsSlide46

What are complications of using narcotics, sedatives, and NSAIDS when treating chronic or recurrent headaches?Slide47

What are complications of using narcotics, sedatives, and NSAIDS when treating chronic or recurrent headaches?

Rebound headachesSlide48

What are prophylactic treatments for recurrent migraines?Slide49

What are prophylactic treatments for recurrent migraines?

Periactin

TCAs

AEDs

Antihypertensives

Supplements

Riboflavin

Melatonin

Coenzyme QSlide50

EncephalitisSlide51

What are the common causes of encephalitis?Slide52

What are the common causes of encephalitis?

Infectious (viral, bacterial, fungal, parasitic)

Parainfectious

/Immune Mediated (ADEM, acute cerebellar ataxia)

Systemic

Infalmmatory

(Lupus)

Malignancy (

paraneoplastic

)Slide53

What are the signs and symptoms of herpes encephalitis?Slide54

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

meningoencephalitisSlide55

What are the clinical symptoms of encephalitis?Slide56

What are the clinical symptoms of encephalitis?

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 abnormalitiesSlide57

What is the role of neurodiagnostic testing in the evaluation of a child with encephalitis?Slide58

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 workupSlide59

What diagnostic tests are useful in a child with encephalitis?Slide60

What diagnostic tests are useful in a child with encephalitis?

MRI (with and without contrast)

CBC, CMP, UA

LP

Acute treatment if indicated*

EEG*Slide61

How do you manage encephalitis?Slide62

How do you manage encephalitis?

Supportive care, unless causative agent is identifiedSlide63

What are some common sequelae of encephalitis?Slide64

What are some common sequelae of encephalitis?

Depends on causative agent

Can have

neuro

deficits or none at all Slide65

PREPSlide66

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 isSlide67

A

.

acute

psychosis

B.

carbon

monoxide poisoning

C.

confusional

migraine

D

.

postictal

state

E.

pseudotumor

cerebri

Slide68

A

.

acute

psychosis

B.

carbon

monoxide poisoning

C.

confusional

migraine

D

.

postictal

state

E.

pseudotumor

cerebri

Slide69

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 isSlide70

A

.

acute

cerebellar ataxia

B.

ataxia

telangiectasia

C.

Friedreich

ataxia

D.

Guillain-Barré

syndrome

E

.

opsoclonus

-myoclonus-ataxia

syndromeSlide71

A

.

acute

cerebellar ataxia

B.

ataxia

telangiectasia

C.

Friedreich

ataxia

D.

Guillain-Barré

syndrome

E

.

opsoclonus

-myoclonus-ataxia

syndromeSlide72

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 H

2

0. 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 isSlide73
Slide74

A

.

atomoxetine

B.

isotretinoin

C.

montelukast

D. riboflavin

E

.

vitamin

B12 Slide75

A

.

atomoxetine

B.

isotretinoin

C.

montelukast

D. riboflavin

E

.

vitamin

B12 Slide76

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 isSlide77

A

.

cyproheptadine

B

.

ergotamine

C

.

fluoxetine

D.

propranolol

E.

topiramate

Slide78

A

.

cyproheptadine

B

.

ergotamine

C

.

fluoxetine

D.

propranolol

E.

topiramate

Slide79

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 H

2

0; 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 isSlide80

A

.

Coccidioides

immitis

B

.

Enterovirus

C

.

Neisseria

meningitidis

D

.

Taenia

solium

E

.

West

Nile virus Slide81

A

.

Coccidioides

immitis

B

.

Enterovirus

C

.

Neisseria

meningitidis

D

.

Taenia

solium

E

.

West

Nile virus Slide82

Quick AssociationsSlide83
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