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Hey #Medtwitter & #Neurotwitter With 2 simple rules you can learn the #basalganglia direct and indirect pathways for the LAST TIME and actually remember them! 🤯Here’s how! 🧵 :
#MedEd #medicalstudent #Neurology #Neurologyresident #Movementdisorders #Neuroscience #Neuroanatomy
#MedEd #medicalstudent #Neurology #Neurologyresident #Movementdisorders #Neuroscience #Neuroanatomy
Rule 1: The “OG” basal ganglia (striatum and globus pallidi) use GABA ➖as their neurotransmitter. Everything else uses glutamate ➕.
Rule 2: Once you know Rule 1, all you have to do is memorize the order of the structures:
Direct pathway: CS___GiT
Indirect pathway: CS GeS GiT
Rule 2: Once you know Rule 1, all you have to do is memorize the order of the structures:
Direct pathway: CS___GiT
Indirect pathway: CS GeS GiT
Both pathways start with
cortex (C)>striatum (S)
and end with globus pallidus internus (Gi)>Thalamus (T).
For the indirect, just add GeS (Globus pallidus externus>STN) in the middle!
cortex (C)>striatum (S)
and end with globus pallidus internus (Gi)>Thalamus (T).
For the indirect, just add GeS (Globus pallidus externus>STN) in the middle!
1) Migraine Premonitory(Prodromal) Phase::
Presences of non-painful Symptoms, which can start hours to days before the onset of migraine pain and can be predictive of an impending headache.
Presences of non-painful Symptoms, which can start hours to days before the onset of migraine pain and can be predictive of an impending headache.
2) Three Separate Groups of Symptoms::
1::Fatigue & Cognitive changes...
Concentration difficulty, Irritability, depression, fatigue, memory impairment.
2::Homeostatic Changes...
Food craving, Thirst, Yawning, Increased Urination, Sleep disturbance.
1::Fatigue & Cognitive changes...
Concentration difficulty, Irritability, depression, fatigue, memory impairment.
2::Homeostatic Changes...
Food craving, Thirst, Yawning, Increased Urination, Sleep disturbance.
3) 3::Sensory Changes...
Photo, phono, osmo, Phobia, nause, neckstiffness.
Photo, phono, osmo, Phobia, nause, neckstiffness.
1) Migraine with AURA::
Recurrent attacks of unilateral fully reversible visual, sensory, or other CNS symptoms that develops gradually over minutes and usually followed by Headache and associated Migraine Symptoms.
Recurrent attacks of unilateral fully reversible visual, sensory, or other CNS symptoms that develops gradually over minutes and usually followed by Headache and associated Migraine Symptoms.
2) Total 20-40% prevalent,Increased risk in 1st degree Relative + twins + Heritibility. Onset::
Gradual and progressive, unlike abrupt in Stroke.
AURA consists of Positive symptoms like flashing lights, and paresthesia while stroke dominates Negative symptoms like weakness.
Gradual and progressive, unlike abrupt in Stroke.
AURA consists of Positive symptoms like flashing lights, and paresthesia while stroke dominates Negative symptoms like weakness.
3) Duration::
Typically 30 minutes but may be Prolong upto 4 hours. Symptoms::
Visual(90%,most common) > Sensory, language, motor.
Visual::
Scintillating scotoma, Flashing lights, Blurry Visions.
Typically 30 minutes but may be Prolong upto 4 hours. Symptoms::
Visual(90%,most common) > Sensory, language, motor.
Visual::
Scintillating scotoma, Flashing lights, Blurry Visions.
1) Absence Seizures::
Age 5 years to 10 years, history of febrile seizures in only significant.
Simple TAS:
Sudden onset of impaired Consciousness with blank facial stare without other motor, behavioral phenomenon.
Complex TAS:
Accompanied by motor, behavioral or Autonomic
Age 5 years to 10 years, history of febrile seizures in only significant.
Simple TAS:
Sudden onset of impaired Consciousness with blank facial stare without other motor, behavioral phenomenon.
Complex TAS:
Accompanied by motor, behavioral or Autonomic
2) phenomenon.
Clonic... May be subtle, like eye-blinking, Nystagmus, jerk of arms.
Tone... Extension or flexion of trunk in case of contractions(increase tone) , head nodding or dropping objects in case decrease Tone.
Automatism... Rubbing face or hand, licking lip, chewing,
Clonic... May be subtle, like eye-blinking, Nystagmus, jerk of arms.
Tone... Extension or flexion of trunk in case of contractions(increase tone) , head nodding or dropping objects in case decrease Tone.
Automatism... Rubbing face or hand, licking lip, chewing,
3) grimacing, scratching.
Autonomic...Pallor, Flushing, salivation, sweating.
Atypical Absences::
Less abrupt onset or cessation, more changes in tone, long duration than TAS, associated with other seizures types & mental Retardation, usually begin before age 5 years,
Autonomic...Pallor, Flushing, salivation, sweating.
Atypical Absences::
Less abrupt onset or cessation, more changes in tone, long duration than TAS, associated with other seizures types & mental Retardation, usually begin before age 5 years,
1) GEFS plus (Genetic Epilepsy with Febrile Seizures plus)
Mildest Benign Form: Normal EEG + IMAGING
1:Simple Febrile Seizures
2:Febrile Seizures Plus
Severe Form: Abnormal EEG + IMAGING
3:Dravet Syndrome
4:Doose Syndrome
Mildest Benign Form: Normal EEG + IMAGING
1:Simple Febrile Seizures
2:Febrile Seizures Plus
Severe Form: Abnormal EEG + IMAGING
3:Dravet Syndrome
4:Doose Syndrome
2) GEFS plus is a genetic syndrome, Defect in 4 Genes, SCN1A, SCN1B, GABRG2, GABRD. Other seizures with FS Or FS-plus are Absence, atonic, myoclonic, and partial.
FS:
Typical convulsive seizures, 6month-6years, with fever 38c' or greater.
FS:
Typical convulsive seizures, 6month-6years, with fever 38c' or greater.
3) FS-plus:
Mild form of generalized epilepsy, different presentations.
1:Febrile Seizures continues past 6 years which is upper limit of FS, than decrease gradually.
2:Febrile Seizures and Afebrile seizures upto typical age for Febrile Seizures.(6 months to 6 years).
Mild form of generalized epilepsy, different presentations.
1:Febrile Seizures continues past 6 years which is upper limit of FS, than decrease gradually.
2:Febrile Seizures and Afebrile seizures upto typical age for Febrile Seizures.(6 months to 6 years).
#NeurologyMorningReport #NMR Case 65 #MedTwitter #NeuroTwitter Updates & Answers posted later today. Asking your help #MedEd #neurology #neurologyresident #neurologist #medstudent #NeurologyProud #MedStudentTwitter Join me in educating. Share your questions and knowledge.
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Page - 25yo man, hx B cell ALL, ?seizure, now w/ AMS Please come to bedside
Admitted w/diarrhea & GI graft vs host disease
h/o ALL, multiple relapses including leptomeninges now in remission
What further information do you need? What are your 1st thoughts about what's going on?
Admitted w/diarrhea & GI graft vs host disease
h/o ALL, multiple relapses including leptomeninges now in remission
What further information do you need? What are your 1st thoughts about what's going on?
See image for details of event and vital signs
Medications: tacrolimus, infliximab, remicade
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Medications: tacrolimus, infliximab, remicade
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Time again for #NeuromuscularQandA? RT. #neurology #medtwitter #MedEd #medstudent #neurologyresident Join me in discussing/learning/educating with #passion n #humor @WNGtweets @MonicaDhakar @MadSattinJ @NinaRiggins @AaronLBerkowitz @RachelSalasMD @StaceyLClardy
@Tracey1milligan
@Tracey1milligan
Q: Doc, doc there’s a patient with sudden onset shoulder pain which worsened precipitously over a couple of hours after recovering from the flu. What should we do?
A: Sounds like a typical history for Parsonage Turner Syndrome. You suspect this when there’s acute onset really severe shoulder pain after an infection, operation, pregnancy or vaccination.
Time again for #NeuromuscularQandA? RT. Let’s talk rhabdo. #neurology #medtwitter #MedEd #medstudent #neurologyresident Join me in discussing/learning/educating w #passion n #humor @WNGtweets @MonicaDhakar @MadSattinJ @NinaRiggins @AaronLBerkowitz @RachelSalasMD
@Tracey1milligan
@Tracey1milligan
Q: Doc, doc, got a 35 year old chap in for terrible muscle aches after running a race. He says his urine is black. What could it be?
A: Black urine suggests myoglobin. What’s his CK? Is it elevated together with other muscle enzymes (AST, ALT, Aldolase)? If so, think rhabdo. Now the question is whether he’s got a provoked attack or has underlying genetic susceptibility.
(1/7) Lipid Myopathy
1:Carnitine Palmitoyltransferase 2 deficiency
2:VLC acyl-CoA-Dehydrogenase deficiency
3:Trifunctional Deficiency
1:Carnitine Palmitoyltransferase 2 deficiency
2:VLC acyl-CoA-Dehydrogenase deficiency
3:Trifunctional Deficiency
(2/7) Metabolism of fats,Beta-Oxidation, Carnitine.
Excessive accumulation of fatty acids,fatty liver, cardiomyopathy.
Exercise induced weakness, static myopathy, Fasting non-ketotic hypoglycemia, Rhabdomyolysis.
Excessive accumulation of fatty acids,fatty liver, cardiomyopathy.
Exercise induced weakness, static myopathy, Fasting non-ketotic hypoglycemia, Rhabdomyolysis.
(3/7) Labs:
EMG-Myopathic patterns,
BLOOD: lncreased CK, low free carnitine, increased Acylcarnitine, lactate, urinary organic acids,
During Crises ⬆️ CK, Acylcarnitine, myoglobunuria, hypoglycemia, absent ketone formations.
EMG-Myopathic patterns,
BLOOD: lncreased CK, low free carnitine, increased Acylcarnitine, lactate, urinary organic acids,
During Crises ⬆️ CK, Acylcarnitine, myoglobunuria, hypoglycemia, absent ketone formations.
1/10 Mitochondrial Myopathy
A=Muscles:
Symmetric,proximal, ⬆️ CK + Growth Differentiating Factor-15, EMG-Myopathic finding
Biopsy - Cox negative Fibre, Red + Blue ragged Fibres.
A=Muscles:
Symmetric,proximal, ⬆️ CK + Growth Differentiating Factor-15, EMG-Myopathic finding
Biopsy - Cox negative Fibre, Red + Blue ragged Fibres.
2/10 B=Brain:
Ataxia,Dementia,Strokes,Migraine, Dystonia, Mood issues, seizures, Epilepsia partialis (1)
Ataxia,Dementia,Strokes,Migraine, Dystonia, Mood issues, seizures, Epilepsia partialis (1)
3/10 continue(MELAS+POLG) .
MRI Brain,CSF lactat,EEG.
Leigh-Central gray matter,Putamen, caudate, thalamus, cerebellum, midbrain, pons, Medulla, longtracts.
MELAS- Parital +Occipital lobes.(2)
MRI Brain,CSF lactat,EEG.
Leigh-Central gray matter,Putamen, caudate, thalamus, cerebellum, midbrain, pons, Medulla, longtracts.
MELAS- Parital +Occipital lobes.(2)
Time again for #NeuromuscularQandA? RT. #neurology #medtwitter #MedEd #medstudent #neurologyresident Join me in discussing/learning/educating with #passion and #humor @WNGtweets @MonicaDhakar @MadSattinJ @NinaRiggins @AaronLBerkowitz @RachelSalasMD
@Tracey1milligan @StavrosKara
@Tracey1milligan @StavrosKara
Q: Doc, doc, got a middle-aged patient with subacute onset of proximal muscle weakness and CK of 10K. What could it be?
A: Any cutaneous or joint or respiratory issues? If it’s just muscle, it might be necrotizing autoimmune or toxic myopathy with that level of CK.
Time again for #NeuromuscularQandA? RT. #neurology #medtwitter #MedEd #medstudent #neurologyresident Join me in discussing/learning/educating with #passion and #humor @WNGtweets @MedTweetorials @MadSattinJ @NinaRiggins @AaronLBerkowitz @Tracey1milligan
Q: Doc, doc, have a patient with subacute weakness and suspected myositis. Why in the world are we considering these humongous panels of autoantibodies? Can’t we just do a muscle biopsy?
A: Just 2 reasons - diagnosis and prognosis. We send myositis specific antibodies (MSA) and myositis associated antibodies (MAA). MSA are antibodies specifically associated with inflammatory myopathies.
A brief refresher about #Antibiotic-associated #Encephalopathy #Twittorial #Tweetorial #AMS
Inspired from today's #NoonConference topic
#MedTwitter #MedStudentTwitter #NeuroTwitter #NeurotwitterNetwork #MedEd @MedTweetorials #NeurologyResident #Neurology #RITEReview
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Inspired from today's #NoonConference topic
#MedTwitter #MedStudentTwitter #NeuroTwitter #NeurotwitterNetwork #MedEd @MedTweetorials #NeurologyResident #Neurology #RITEReview
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Antibiotics are commonly prescribed medications in the inpatient and outpatient setting and it's important to recognize #AdverseEvents, including idiosyncratic reactions, such as #encephalopathy.
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Antibitiotics associated with #Encephalopathy:
- Beta lactams
- #Cephalosporins (#Cefepime is the most common,
Ceftazidime)
- Imipenem
- #Penicillin procaine
- Fluoroquinolones
- Macrolides (clarithromycin)
- TMP-SMX
- #Metronidazole
- Isoniazid
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- Beta lactams
- #Cephalosporins (#Cefepime is the most common,
Ceftazidime)
- Imipenem
- #Penicillin procaine
- Fluoroquinolones
- Macrolides (clarithromycin)
- TMP-SMX
- #Metronidazole
- Isoniazid
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Time again for #NeuromuscularQandA? RT. #neurology #medtwitter #MedEd #medstudent #neurologyresident Join me in discussing/learning/educating with #passion and #humor @WNGtweets @MonicaDhakar @MadSattinJ @NinaRiggins @AaronLBerkowitz @dcweisman
Q: Doc, doc, got a patient with acute progression of proximal and distal weakness after the flu 3 weeks ago. Should we get NCS/EMG to confirm GBS?
A: To confirm? What are you looking for? When was the onset of weakness? If within first 2 weeks, you might get the typical demyelinating features in only 50 percent.
Time again for #NeuromuscularQandA? RT. #neurology #medtwitter #MedEd #medstudent #neurologyresident Join me in discussing/learning/educating with #passion and #humor @WNGtweets @MonicaDhakar @MadSattinJ @NinaRiggins @AaronLBerkowitz @RachelSalasMD
Let’s do one on scapular winging. It’s a common neuromuscular condition. Consider it by the company it keeps - a good history and exam will save you time.
Q: Doc doc, my patient got scapular winging after cervical LN biopsy. What’s going on?
Time again for #NeuromuscularQandA? RT. #neurology #medtwitter #MedEd #medstudent #neurologyresident Join me in discussing/learning/educating with #passion and #humor @WNGtweets @MonicaDhakar @MadSattinJ @NinaRiggins @AaronLBerkowitz @RachelSalasMD @melfel6 @StavrosKara
Q: Doc doc, a conundrum. Gotta patient with old mets which resolved after RT to the lumbosacral area ages ago. There’s enhancement of the cauda equina on MRI. Is this cancer or RT damage?
A: Aye, an important question which changes management. Now enhancement could mean either or both, that it could. Does it hurt? RT damage is painless whereas cancer invasion is painful.
Time again for #NeuromuscularQandA? RT. #neurology #medtwitter #MedEd #medstudent #neurologyresident Join me in discussing/learning/educating with #passion and #humor @WNGtweets @MonicaDhakar @MadSattinJ @NinaRiggins @AaronLBerkowitz @RachelSalasMD
Let’s have a philosophical discussion today. Q: Doc doc there are fibs and sharps everywhere on the EMG! Arms, legs, thoracic and lumbar paraspinals. NCS normal. What could it be?
A: Ah, widespread muscle membrane instability. Could be neurogenic, could be myopathic. What’s the recruitment like? Remember reduced recruitment in neurogenic and normal or rapid in myopathic.
Time again for #NeuromuscularQandA? RT. #neurology #medtwitter #MedEd #medstudent #neurologyresident Join me in discussing/learning/educating with #passion and #humor @WNGtweets @neurobickel @MadSattinJ @NinaRiggins @AaronLBerkowitz @RachelSalasMD
Q: Doc, doc, got a patient with CIDP. He wants to know when he can be off IVIG. He’s a gambling man, that he is. Wants to take his chances. #MedStudentTwitter #MedEd #AcademicTwitter
A: Game theory time! Naw, let’s see if we can answer it by closely looking at studies. Or just one. Check out the ICE study in 2008 and see if you can spot Wally. #meded
Time again for #NeuromuscularQandA? RT. #neurology #medtwitter #MedEd #medstudent #neurologyresident Join me in discussing/learning/educating with #passion and #humor @WNGtweets @MedTweetorials @MadSattinJ @NinaRiggins @AaronLBerkowitz @RachelSalasMD
Q: What up doc. This patient’s eyes don’t move right - tell me how to assess and tell me short and sweet.
A: If patient can’t move eyes to command but can reflex when you snap your fingers right and left - that’s supranuclear - think PSP.
Time again for #NeuromuscularQandA? RT. #neurology #medtwitter #MedEd #medstudent #neurologyresident Join me in discussing/learning/educating with #passion and #humor @WNGtweets @MedTweetorials @MadSattinJ @NinaRiggins @AaronLBerkowitz @Tracey1milligan
Q. What up doc. My #IBM patient doesn’t have #NT51a antibodies and my #SLE patient has #NT51a antibodies. I’m confused.
A: If only life wasn’t messy. 30 percent of #IBM patients don’t have #NT51a and false positives happen with #SLE and #Sjogrens which can cause #overlapmyositis.
Alright shall we talk about a common condition Bell’s Palsy? RT. #neurology #medtwitter #MedEd #medstudent #neurologyresident Join me in discussing/learning/educating with #passion and #humor @WNGtweets @MedTweetorials @MadSattinJ @NinaRiggins @AaronLBerkowitz @Tracey1milligan
Q: Doc doc. This patient got a droopy left face. What next? #neurology #medtwitter #MedEd #medstudent #neurologyresident
A: Localize, splice, dice. 3 little nerve shoots in the facial canal to remember - nerve to stapezius, chorda tympani, posterior auricular. There you go: check hearing, taste, pain behind the ear.
#NeuromuscularQandA! Questions you always wanted to ask your friendly #neuromuscular doc. RT. #neurology #medtwitter #MedEd #medstudent #neurologyresident Short answers only. Join me in discussing/learning/educating with #passion and #humor @WNGtweets @somedocs @MedTweetorials
Q: Cor blimey doc. You can tell what sort of vitamin deficiency neuropathy the patient has by looking at the blood? #twilight #bella #MedTwitter #MedStudentTwitter #MedEd @AaronLBerkowitz @MadSattinJ @Tracey1milligan @WNGtweets @NinaRiggins @RachelSalasMD @AlexMuccilli
A: Elementary, my dear Watson. #megaloblastic anemia - think B12 and Folate deficiency. #leukopenia - think copper deficiency. Throw in normocytic anemia - think #dysautonomia and small fiber neuropathy. Treat these and we treat #2birdswithonestone. Sherlock, out. @dysclinic
Is it time for #NeuromuscularQandA? Questions you always wanted to ask your friendly #neuromuscular doc. RT. #neurology #medtwitter #MedEd #medstudent #neurologyresident Short answers only. Join me in discussing/learning/educating with #passion and #humor @WNGtweets @somedocs
Q. What’s going on doc. Patient with a shivery tongue. Is it #fasciculations? Is it #ALS? Is it #MG? Is it #tremor? #meded #MedStudentTwitter #MedTwitter @AaronLBerkowitz @Tracey1milligan @RachelSalasMD @DxRxEdu @MadSattinJ @EricLawson90 @NinaRiggins @neurochecklists @WNGtweets
A: Judge the tongue by the company it keeps. If it’s weak and wasted it ain’t tremor. #Musk myasthenia gravis and #ALS tongues may be weak and wasted with fasciculations. So try #steriods - If it responds to steroids it ain’t ALS - gotta be #MG. #clinicaldiagnosis
A #practical topic for today. #Pregnancy changes things - but more so for our #neurology patients - or not? #pearls from the #EAN2020 #MedEd #MedTwitter #MedStudentTwitter #neurologyresident @EANeurology @WNGtweets
Let’s first address #multiplesclerosis. Patients get better in third trimester and 30% relapse #postpartum. Immune responses shifts to anti-inflammatory in 3rd trimester to accommodate fetus - #etcomehome - but rebounds after birth. #MedEd #doubledoc #AcademicTwitter
Continue #firstlineinjectables #glatiramer and #interferon - these don’t cause #teratogenicity. In flares, consider IVIG and PLEX. How about #steroids? Usually fine except in 1st trimester when they can cause birth defects #MedEd #MedStudentTwitter #MedTwitter
