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* CMS Neuro--- I don't get it.. :(
  dream250 - 12/10/17 03:36
  Can anyone please explain?

A 2 year old girl has the sudden onset of unsteady gait following chickenpox. Physical exam shows an irritable but alert child with normal vital signs. She is unable to stand or sit unsupported. There is bilateral horizontal nystagmus. The neck is supple. Analysis of CSF shows 14 leukocytes (N=0-7) and protein concentration of 60. Gram stain shows no organisms. Which of the following is most likely Dx?

A) Acute cerebellar ataxia
b) Ataxia-telangiectasia
C) Benign paroxysmal vertigo
D) Cerebellar astrocytoma
E) Friedreich Ataxia

Why is the answer A? Can anyone please explain?

2----A 52 y/o man comes to the doc b/c of a 1 month history of numbness and tingling of the ring and small fingers of his right hand that radiates to his palm. His symptoms are not constant and exacerbated at night. He has a 2 week history of decreased grip strength and wasting of the small muscles in his right hand. He has not had neck or arm pain. 4 months ago, he was diagnosed with pancreatic cancer, since then, he underwent Whipple procedure and is currently receiving chemo with gemcitabline. Since his diagnosis, he has had significant fatigue and an 18 kg weight loss. He is 173 tall and weighs 54kg. BMI is 18. His temp is 37, pulse is 95, and BP is 120/79. There is wasting of the interosseous muscles on the right. Muscle strength is 3/5 in the right interosseous and hypothenar muscles and flexor digitorum profundus of the ring and small fingers. It is full elsewhere. Deep tendon reflexes are 2+ throughous. Babinski sign is absent. Sensdation to pinprick and temp is temp is decreased over the ulnar aspect of the palm and dorsum of the hand ring and small fingers; proprioception is intact. The remainder of the neurologic exam shows no abnormalities. Which is the cause of his symptoms.

A. C8 nerve root infiltration by tumor

B. Cervical disc herniation

C. Chemotherpay neurotoxicity

D. Ulnar nerve compression

E. Vit B12 def.

Why not A?

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* Re:CMS Neuro--- I don't get it.. :(
  dream250 - 12/10/17 05:05
  Another q, I dont get.

52 yo M with diffuse dull bilateral headache w/ hst of HTN, med non compliant, he is alert but confused. BP 240/150. Fundoscope shows hemorrhage and exudate. Why give him nitroprusside and not nifidipine?
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* Re:CMS Neuro--- I don't get it.. :(
  drphd - 12/12/17 09:48
  For q2- In case of C8 nerve root compression - s/s has to be bilateral ( not just right side).

for question 1: Acute cerebellar ataxia : complication of chicken pox , bilateral horizontal nystagmus , ataxia.
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* Re:CMS Neuro--- I don't get it.. :(
  dream250 - 12/13/17 02:42
  Thank you drphd ... It make sense.  
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* Re:CMS Neuro--- I don't get it.. :(
  dream250 - 12/13/17 02:47
  I didn't know chicken pox was related to acute cerebellar ataxia.. learned something new.

Found more info:

The history given above is a classic presentation of acute post-infectious cerebellar ataxia. 25% of children with this disorder have a history of varicella infection within 1 month prior to the onset of the disorder and 5% of children have a previous history of varicella vaccination. The onset of acute cerebellar ataxia is usually explosive, often with the child awakening from sleep with maximal symptoms of ataxia and nystagmus. In any child with acute ataxia, it is important to obtain a drug screen and a careful history of any possible toxic exposures since poisoning and acute cerebellar ataxia account for most of the cases of acute ataxia in children. Resolution of the symptoms occurs in most children over a period of weeks to months.
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* Re:CMS Neuro--- I don't get it.. :(
  drphd - 12/14/17 09:13
  During my internal medicine rotation, I actually saw a young patient with acute cerebellar ataxia . And it was found on later than she had a recent attack of chicken pox.  
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* Re:CMS Neuro--- I don't get it.. :(
  dream250 - 12/15/17 08:44
  Interesting... I didn't get to see any such cases during my IM rotation or Fam/peds. Where did you do yours, if you don't mind me asking?  
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* Re:CMS Neuro--- I don't get it.. :(
  jussoju - 12/19/17 12:31
  For 1, acute cerebellar ataxia is autoimmune and can happen after infections in children; the rest of the choices didn't make much sense - did you have any particular choice that confused you?

For 2 - Chemo induced. Vit B12 would cause proprioception loss, and C8 infiltration would also present with possible back pain (along with bilaterality as mentioned by someone before)
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* Re:CMS Neuro--- I don't get it.. :(
  dream250 - 12/20/17 07:39
  Thank you jussoju!  
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