1. Director, Neurology Clerkship Associate Professor of Neurology
I hope you find this file helpful for student preparation for the Neurology Shelf Exam.  The audio for the last 9 slides will be completed shortly, however for your information, the slides present topics I discuss with students during the shelf review session.
Sincerely,
Heather Anderson, MD
Director, Neurology Clerkship
Associate Professor of Neurology
Bulbar weakness
DDx: ALS, MG or other neuromuscular junction abnormalities
Facial pain
Trigeminal neuralgia – “shock-like”, 1 trigeminal distribution, precip: eating, talking, chewing, touching
Tx: carbamazepine
Facial palsy
Bell's Palsy
Ramsey Hunt (Herpes Zoster – Acyclovir)
Lyme disease (rash, may have meningitis, other CN palsies, later may have encephalopathy)
Low sensitivity of serology in 1st few wks. ELISA 1st → confirmatory western blot.
Tx doxy, rocephin

2. Neuro-ophthalmology Optic neuritis Amarosis fugax Amblyopia Diplopia
Afferent pupillary defect
Amarosis fugax
Amblyopia
Diplopia
Ptosis
Optic neuritis
Sudden, reduced vision in the affected eye
Loss of color vision
Pain with eye movement
APD – optic nerve or severe retinal disease
Amarosis fugax – Temporal arteritis, carotid stenosis
Case: Pt with hx of episodes of left sided weakness and veil over right eye – which carotid? (right)
Amblyopia – partial or complete loss of vision in 1 eye (congenital abnl development).
Causes = strabismus (crossed eyes)
Case: History of poor vision in 1 eye since birth in a pt with strabismus
Diplopia
Determine direction which provokes the symptoms
CN 3 palsy – on forward gaze, eye is down and out
Is the pupil involved (dilated) or spared
Involved could be PCOM aneurysm, compressing parasympathetic fibers
Case: Sudden onset of double vision, pain over right temple in a patient with a history of HTN, DM. On exam – mild ptosis on R, failure of R to adduct and impaired upgaze on R, pupils 3mm sluggish
CN 4 – depression of eye primarily on adduction
palsy – diplopia better on tilt opposite, worse on tilt same
Ptosis – MG, CN III, Horner’s
Case: Ptosis on the left, left pupil smaller than the right but reactive – exam otherwise normal
Horner syndrome – sympathetic chain (brainstem stroke, tumor in lung apex, carotid dissection)

3. Other Cranial Nerve Disorders
Bulbar weakness
Facial pain
Facial palsy
Bulbar weakness
DDx: ALS, MG or other neuromuscular junction abnormalities
Facial pain
Trigeminal neuralgia – “shock-like”, 1 trigeminal distribution, precip: eating, talking, chewing, touching
Tx: carbamazepine
Facial palsy
Bell's Palsy
Ramsey Hunt (Herpes Zoster – Acyclovir)
Lyme disease (rash, may have meningitis, other CN palsies, later may have encephalopathy)
Low sensitivity of serology in 1st few wks. ELISA 1st → confirmatory western blot.
Tx doxy, rocephin

4. Vertigo Meniere’s Benign positional vertigo Labyrinthitis
Aminoglycoside-induced neurotoxicity
Cerebellar hemorrhage
Vertebrobasilar TIA
Meniere’s disease
Episodes of vertigo, nausea, vomiting w/ diminished hearing and tinnitus
Tx: Restrict salt/caffeine/tobacco, use of diuretics, meclizine, benzos
Acoustic neuroma – unsteadiness, less commonly true vertigo (slow growing so gradual asymmetries in vestib fxn)
Benign positional vertigo - Dix-Hallpike (Epley or Barany maneuvers)
Recurrent episodes of vertigo lasting ≤ 1 minute, may be associated with nausea and vomiting
Typically recur periodically for weeks to months without therapy
Provoked by looking up while standing or sitting, lying down or getting up from bed, and rolling over in bed
Sxs may wax and wane over time; often sudden remissions, only to have the episodes recur at a later date
May have evidence of prior inner ear damage
Labyrinthitis - prolonged, severe episodes of vertigo accompanied by nausea, vomiting, and disequilibrium
Aminoglycoside-induced neurotoxicity, cisplatin-based chemotherapeutics.
Case: Ill pt who develops deafness, tinnitus, balance, vertigo
Cerebellar hemorrhage
abrupt onset bioccipital HA, n/v, vertigo, loss of balance, worse with coughing/straining
Vertebrobasilar TIA
Case: 8-10 min episode of vertigo/swaying, diplopia, facial numbness, hemisensory loss, Wallenburg

5. Seizures DDx for causes of seizures Metabolic Drug-induced Structural
Developmental
Tumor, abscess, etc.
Trauma, previous stroke, other injury
Quick review of additional material since seizure material has been provided elsewhere
Epilepsy = >1 unprovoked seizure
Electrolytes
Hypoglycemia, hypo Ca, Mg, hypo or hypernatremia
Hyponatremia could be caused by SIADH (head trauma) – low serum osm & Na, high urine osm
Case: Pt has been ill, dehydrated → seizure. What test? Draw sodium level
Auras
olfactory, auditory, or gustatory hallucinations, deja vu, fear = temporal lobe
Herpes favors temporal lobe
Thrombotic thrombocytopenic purpura
Can cause seizure (2º to hemorrhage, uremia, hyponatremia, fever). Anemia, low platelets, elevated creatinine, purpura

6. Multiple Sclerosis Demographics Diagnostic features of MS INO
Transverse myelitis
Urinary incontinence – detrusor hyperreflexia (upper motor neuron lesion)
Multiple episodes of neurologic deficit over space and time
Treatment – A question which has shown up on the shelf exam in the past is the long-term management of MS. If they ask the question (they might not ask it anymore), but the answer they were looking for is interferon beta. This is not a complete answer since other classes are available for long-term management, so hopefully the question is no longer being asked
Demographics - Young woman (20’s-30’s)
INO (internuclear ophthalmoplegia)
failure of ipsi eye to adduct with nystagmus of contra eye
Lesion is in ipsi MLF
Transverse myelitis
Case: 1 week hx of progressive sensory loss to T10 level, for example, w/ accompanied urinary urgency and freq, nocturia, perception of a tight band-like sensation around midabdominal region
Can occur anywhere in spinal cord (T10, aching b/t shoulder blades (lower cervical or upper thoracic)
Consider demyelinating lesion if history of previous neurologic event (optic neuritis, etc)

7. Parkinson’s Plus Syndromes
Progressive supranuclear palsy
Lewy body dementia
Corticobasal degeneration
Multiple system atrophy
PSP
No voluntary vertical eye movements, but preserved Doll’s eyes
Diffuse brainstem disease, neuronal loss, NFTs, gliosis in reticular formation & ocular motor nuclei.
Early pathology is primarily in midbrain, leads to early vertical eye movement abnormalities
Characteristic exam findings in addition to eye findings: Gait instability, rigidity
Lewy Body Dementia
Fluctuations in cognitive function
Hallucinations
Parkinsonism
Falls, syncope
Sensitivity to neuroleptics
Corticobasalganglionic degeneration
Shy-Drager (Multiple system atrophy)

8. Other Movement Disorders
Opisthotonos
Opisthotonos (only the back of the head and the heels would touch the supporting surface) dystonic rxn from Compazine (prochlorperzine) or other phenothiazines or antipsychotics – Tx = Benadryl (anticholinergic)

9. Toxins Organophosphate poisoning Anticholinergic syndrome Toxicity
Carbon monoxide poisoning
Medication side effects
Case: Farm worker develops SOA, n/v, blurred vision, salivation, fasciculations = organophosphate poisoning.
Tx = atropine, remove clothing
Pralidoxime binds organophosphate-inactivated acetylcholinesterase, but no demonstrated benefit, and its use may be harmful
Case: Pt taking a new medication, develops tachycardia, dry mouth, flushed skin = anticholinergic syndrome
Tx = physostigmine
Any subacute change in neurologic fxn within 1 month of Rx change (especially AEDs) – consider Rx AE
Case: 45 yo man with long-standing hx szs → after a recent doctor’s appt, develops bilateral nystagmus and ataxia on f-to-n, wide-based, neuro exam o/w nl
What to ask? Was there a change in medication?
Increased Dilantin dose recently → Dilantin toxicity
Case: 40 yo man restoring an old home, wood-burning stove → disorientation, confusion, severe headache, pulse ox 100%.
Carbon monoxide poisoning
Check carboxyhemoglobin level
Tx = hyperbaric oxygen
Case: 35 yo man with schizophrenia, taking clozapine, Prilosec, simvastatin, and aspirin. He develops fever, malaise, severe sore throat = agranulocytosis from clozapine
Case: 20 yo man suddenly develops chest pain, tachycardia, elevated blood pressure, and pupils are equal and reactive = cocaine

10. Conversion Disorder Discussion of features characteristic of
Pseudoseizures (non-epileptic events)
Pseudocoma
Pseudoweakness
Etc.
Hoover’s sign
Hand over face
Collapsing or giveaway weakness
Tunnel vision
Sensory loss that stops exactly at midline

11. Meningitis Diagnosis Treatment Etiologies
Rifampin – prophylactic therapy against Neisseria meningitides
Ceftriaxone – acute tx for N meningitides
Physical exam findings – headache, neck stiffness, fever, photophobia, n/v
Could be viral or bacterial
Review CSF lab results
If there are seizures in the presentation, think HSV