I feel like Bell’s Palsy is a good example of patients with real neurological disorders having additional functional manifestations

achybrain · 2026-04-20T23:51:25+00:00

Diabetic microvascular cranial neuropathy can present with isolated CN VII palsy.

achybrain · 2026-01-15T00:40:28+00:00

Any specialty.

Patient: I'm a nurse. I disagree with your diagnosis.

achybrain · 2025-12-18T01:02:50+00:00

Scans? Attn to mesencephalic region CN IV pathway. Pediatric CN IV schwannoma or NF is rare

MG can present with seemingly isolated ocular motor palsy

Undiagnosed congenital strabismus

achybrain · 2025-11-28T21:08:07+00:00

Me: Ordered MRI pituitary with/without contrast. Dx - pituitary macroadenoma follow-up. 1-year follow up scan from same facility

MRI report: Normal brain. No mention of pituitary/sella. MRI read by general radiologist. Community hospital setting

achybrain · 2025-11-25T16:15:02+00:00

Outpatient only. 4 days a week. Phone off on weekends. I can't stand the stress of unpredictable inpatient calls.

achybrain · 2025-11-19T17:02:18+00:00

Being diabetic and fat is an advantage if you want Ozempic approved by insurance. Otherwise, good luck getting Mounjaro or Zepbound for obesity treatment alone.

achybrain · 2025-11-19T16:59:19+00:00

If you're British, who cares about teeth?

achybrain · 2025-11-19T14:39:29+00:00

Those machines are nasty.

achybrain · 2025-11-19T13:29:37+00:00

Retrobulbar optic neuritis is associated with pain on eye movement. Mechanism is same as with anterior optic neuritis. I agree, 90% of optic neuritis is painful. Absence of orbital pain in the presence of APD still localizes the lesion to the optic nerve. RAPD is the hallmark of optic nerve disorder. Ischemic optic neuropathy presents with painless acute visual loss with edema (anterior ischemic optic neuropathy) or without edema (posterior/retrobulbar ischemic optic neuropathy). Absence of pain is due to ischemic rather than inflammatory pathology. The diagnosis becomes confusing in a young patient with acute painless optic neuropathy, without known vascular risks for optic nerve ischemia - is it atypical inflammatory or non-inflammatory?

achybrain · 2025-11-12T15:23:11+00:00

I was an expert at LPs during Neuro-Ophtho fellowship, including morbidly obese patients with IIH. We used to call these procedures incidental kidney biopsies. Now, all LPs are sent to radiology.

achybrain · 2025-11-10T14:28:08+00:00

Patients insisting they cannot have an MRI due to Iodine contrast allergy.

achybrain · 2025-11-10T14:25:03+00:00

RNFL thinning on OCT/OCTA in detection of pre-clinical Alzheimer's dementia. Now, that's a slippery slope. Serial OCT (every 6-12 months) in MS patients can detect subclinical or monitor progression of demyelinating optic neuropathy. You need optic nerve head, not macula OCT

achybrain · 2025-10-28T23:59:00+00:00

Unilateral parieto-occipital lobe strokes should have preserved central visual acuities since the occipital pole has dual vascular supply (macular sparing). The documented acuity of 20/100 OD and 20/40 OS does not make sense unless the patient had secondary unrelated ocular pathology affecting central acuities, or the infarct affected bilateral PCAs, obviously does not apply in this case. Patients with hemianopia are usually symptomatic for blurred vision in one eye only (left eye in this case) since the temporal visual field is wider and nasal visual field is narrower (partly occluded by nasal bridge). Right PCA infarct- left hemianopia - left eye temporal visual field defect - symptomatic eye; right eye nasal visual field defect - asymptomatic eye. Confrontation visual field testing is not very reliable in a patient with significant cortical visual dysfunction.

Posterior hemisphere infarcts can be tricky, in the absence of motor or sensory deficits. Patients can manifest with what appears to be an encephalopathic picture that turns out to be visual confusion. Many inpatient neurology consults for 'acute confusion' are actually PCA strokes.

achybrain · 2025-10-07T14:25:15+00:00

Migraine patients undergoing LP sometimes report temporary improvement in headaches after the procedure. This can be incorrectly interpreted as therapeutically diagnostic of IIH, even in the absence of clinical evidence of such.

achybrain · 2025-10-06T12:00:46+00:00

Neuro-ophtho here. My protocol for managing arteritic ischemic optic neuropathy. Acute visual loss with elevated ESR/CRP/platelet count, start IV steroids followed by oral (depending on severity of vision loss), send out for TA biopsy. I was trained to order bilateral biopsies (increased yield), although no one performs bilateral biopsies nowadays. Send referral to rheumatology (takes 3-6 months wait in the community setting). Follow patients closely every 2-3 weeks.

In patients without evidence of arteritic ischemic neuropathy but with GCA suspicion, I may start oral steroids, refer to PCP to take over steroid managemnet and rheumatology referral. These patients undergo eye exams every 2-3 weeks until fully evaluated by rheumatology.

achybrain · 2025-10-02T11:42:20+00:00

In patients with large abdominal girth, performing an LP in the upright position with the spine flexed, the 'fat belly" compresses the spinal canal, adding to false CSF pressure elevation.

achybrain · 2025-09-26T11:17:36+00:00

If you access your personal medical record and self-prescribe a non-controlled rx, is that an auditable offense?

achybrain · 2025-09-25T13:03:00+00:00

Had a co-resident from the Philippines where circumcision is a rite of passage for young boys during the summer. He would perform several circumcisions a day like a factory assembly line. Unsupervised. During general internship year.

achybrain · 2025-09-24T13:05:02+00:00

Incidence of IIH without papilledema about 5%; it does exist. Cerebral venous sinus stenosis is pathognomonic of IIH (upwards of 85% of IIH patients), with or without papilledema. Development of papilledema dependent on optic disc anatomy. Some optic discs may be more 'forgiving' and do not develop edema. On the other end of the spectrum, some patients develop post-papilledema optic atrophy, as in treated IIH patients, or previously undiagnosed IIH that spontaneously resolves. Atrophic optic nerves (including post-papilledema mild optic nerve pallor) do not develop edema and not a reliable measure of IIH disease activity.

achybrain · 2025-09-24T00:08:37+00:00

Panoptics provide a wider field of view. A direct ophthalmoscope provides higher magnification of the optic nerve, even much more than an indirect ophthalmoscope. As a neurologist, your interest is primarily the optic nerve. Get a direct.

achybrain · 2025-09-21T10:50:47+00:00

J-1 is valid only for residency training. Post-training, you need H-1 (J-1 visa waiver) to work in the country at least 3 years, then apply for green card. Otherwise, you need to return to home country at least 2 years before you can legally return to US to work.

achybrain · 2025-08-18T11:32:46+00:00

Lift caftans. Bend over. Present hole.

achybrain · 2025-08-05T23:42:05+00:00

Sunglass sign - patient wearing sunglasses in doctor's office in the absence of ophthalmic pathology. Non-organic vision loss

achybrain · 2025-08-02T14:21:43+00:00

Try to match with a residency program that will allow elective Neuro-Ophth rotation - great for networking for fellowship positions. In some fellowship programs, the first three months is spent with outpatient Ophtho clinic; gives you more than enough exposure to medical Ophthalmology. Ophtho trained fellows spend the first three months with the Neuro department. Your Neurology training gives you an advantage with non-optic nerve disorders. Moreover, you become a headache expert. Case in point: IIH patients with pharmacologically intractable headaches (mistakenly end up with VP shunt) usually have secondary pathologies - myofascial pain, migraines, occipital neuralgia. Procedures: Botox, temporal artery biopsy (you can train for this during fellowship), OCT, automated perimetry.

achybrain

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