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Syncope
- Key Differentiation: Short duration, no neurological deficit
- Causes: Vasovagal (triggered by pain/stress), Orthostatic (BP drop with standing), Cardiac (exertion-induced)
- Workup: ECG (arrhythmias), Orthostatic BP (hypovolemia), Tilt Table Test (vasovagal)
- Treatment: Address underlying cause → Fluids for orthostasis, avoid triggers for vasovagal
Hydrocephalus
- Key Differentiation: Increased ICP → Headache, gait instability, urinary incontinence
- Infants: Enlarged head, sunsetting eyes, bulging fontanelles
- Diagnosis: CT/MRI → Enlarged ventricles
- Treatment: VP Shunt (long-term), EVD for acute cases
Coma
- Key Differentiation: Glasgow Coma Scale (GCS)
- ≤8 → Intubate
- Eye (4), Verbal (5), Motor (6)
- Pupil Clues:
- Fixed, dilated → Brainstem herniation
- Pinpoint → Opioids or pontine lesion
- Treatment: Stabilize ABCs, treat underlying cause (glucose for hypoglycemia, naloxone for overdose, mannitol for ICP)
Final Step type Questions
What key symptom differentiates syncope from seizure?
What triad is seen in normal pressure hydrocephalus?
At what Glasgow Coma Scale (GCS) score is intubation typically required?
What is the first-line treatment for increased intracranial pressure in hydrocephalus?
What pupil finding suggests opioid toxicity?
What test is used to diagnose vasovagal syncope?
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Question built from The Final Step type questions
Question 1
An 82-year-old man is brought to the clinic by his daughter due to progressive difficulty walking, forgetfulness, and recent episodes of urinary incontinence. His gait is described as slow and shuffling. A non-contrast CT scan shows enlarged ventricles with no evidence of obstruction. Which of the following is the next best step in confirming the diagnosis?
A. MRI of the brain
B. Lumbar puncture with CSF removal
C. Electroencephalogram (EEG)
D. Serum vitamin B12 level
Question 2
A 35-year-old woman is found unresponsive with shallow breathing. On exam, she is difficult to arouse and has bilateral pinpoint pupils. Her respiratory rate is 6 breaths per minute. Which of the following is the most appropriate initial management?
A. Flumazenil administration
B. Naloxone administration
C. Lumbar puncture
D. CT of the head
Question 3
A 26-year-old woman presents with recurrent episodes of dizziness and lightheadedness. She reports that the episodes typically occur after prolonged standing or emotional stress and are preceded by nausea and diaphoresis. She has no loss of bladder control, tongue biting, or confusion after these events. A tilt table test is performed and reproduces her symptoms with a drop in blood pressure. Which of the following is the most likely diagnosis?
A. Orthostatic hypotension
B. Vasovagal syncope
C. Cardiac arrhythmia
D. Seizure
PANCE questions that dig a little deeper
A 76-year-old man presents with worsening gait instability, urinary incontinence, and memory impairment over the past few months. A CT scan shows enlarged ventricles without obstruction. What is the definitive treatment for this condition?
A. Acetylcholinesterase inhibitors
B. Ventriculoperitoneal (VP) shunt
C. Corticosteroids
D. Levodopa
A 27-year-old woman presents with episodic lightheadedness and syncope. She reports that these episodes often occur after prolonged standing or when she is emotionally distressed. She describes a prodrome of nausea, warmth, and diaphoresis before losing consciousness. The patient denies palpitations or chest pain. After a tilt table test, her symptoms are reproduced with a drop in blood pressure and bradycardia.
Which of the following is the most appropriate initial recommendation?
A. Beta-blocker therapy
B. Increased salt and fluid intake
C. Pacemaker placement
D. Anticonvulsant therapy
A 55-year-old man collapses while exercising. Bystanders report that he had no preceding symptoms and lost consciousness suddenly. He regains consciousness within a minute but feels slightly disoriented. His ECG shows a prolonged QT interval.
Which of the following best differentiates this condition from vasovagal syncope?
A. Presence of a prodrome before loss of consciousness
B. Loss of postural tone before collapse
C. Positive tilt table test
D. Symptom resolution with fluids and rest
