[Intro: 100 B.P.M. Four bars Rhodes in a descending minor-seventh figure. Cello enters under bar three. Voice already singing, never speaking.] [Verse 1] [Lead Vocalist — sung, even, first-line law as a rising phrase.] M.R. and C.T. without contrast for any patient with a new, progressive cognitive complaint to exclude occult cerebrovascular disease, structural abnormality "tum". [Chorus] [Lead Vocalist — hook. Gait-line lifts; “the least” held and fallen. Harmonies enter on “shunt.”] Normal pressure hydrocephalus enlarged ventricles, brain atrophy. If C.S.F. drainage improvement of gait then place lumboperitoneal or ventriculoperitoneal shunt , gait apraxia improves; the cognitive impairment least likely. [Verse 2] [Lead Vocalist — drug names given full notes, not rattled.] Lecanemab or donanemab for early Alzheimer, monitor with M.R. due to cerebral edema and hemorrhage. Cholinesterase inhibitors “donepezil, rivastigmine, galantamine”, first-line therapy for Alzheimer and dementia with Lewy bodies. Memantinefor moderate to severe Alzheimer. [Verse 3] [Lead Vocalist — colder water on “ice water”; nystagmus line leans with the slow component.] Oculovestibular reflex; with ice water. Nystagmus slow component toward the irrigated ear. [Verse 4] [Lead Vocalist — breathing patterns as four sung stanzas, same melody, dynamics following the breath-type.] Cheyne-Stokes with bihemispheric or diencephalic disease or metabolic disorders. Central neurogenic hyperventilation; tegmentum. Apneustic breathing pontine level. Ataxic breathing ; lower pontine tegmentum and medulla [Verse 5] [Lead Vocalist — warmer on the highly-effective list, then thinner on C.I.S.] Multiple sclerosis; acute relapse, I.V. followed by oral steroid. To reduce attacks, highly effective “rituximab, natalizumab, or fingolimod” and moderately effective “teriflunomide, glatiramer, or interferon”. for many treatment deplete B-cells, so avoid live vaccines Symptomatic therapy for spasticity, neurogenic bladder, or fatigue ‘modafinil’. Dalfampridine to improve timed gait. Risk for developing M.S. may be offered beta-interferon or glatiramer [Verse 6] [Lead Vocalist — Friedreich shadow sung as one long falling line.] Vitamin E deficiency, disorder similar to Friedreich ataxia so spinocerebellar degeneration; limb ataxia, sensory loss, absent D.T.R., slurring of speech, pigmentary retinal degeneration. [Verse 7] [Lead Vocalist — immobilization held; steroid window counted.] Spinal trauma; immobilization; if compression early decompressive laminectomy, I.V. high doses of corticosteroids [Verse 8] [Lead Vocalist — upper-motor line almost kind, then the face.] Pseudobulbar palsy, due to an upper motor “bilateral corticobulbar” lesion. Dysarthria, dysphagia, facial and tongue weakness, emotional lability [Verse 9] [Lead Vocalist — two drug mechanisms given their own bars.] Riluzole and edaravone for A.L.S. [Verse 10] [Lead Vocalist — list kept singing; no bark.] Mononeuropathy multiplex in vasculopathy (diabetes, arteritis), leprosy, sarcoidosis, radiation Charcot-Marie-Tooth, H.M.S.N. type 1 and 2. Dejerine-Sottas Disease, type 3. Refsum Disease "phytanic acid metabolism", Type 4, pigmentary retinal degeneration. [Verse 11] [Lead Vocalist — distal and lower-limb fall.] Uremia may cause symmetric sensorimotor polyneuropathy, affect the lower limbs more and more distal. Plasma cell myeloma "formerly multiple myeloma", symmetric sensorimotor axonal polyneuropathy Neuropathy Associated with Critical Illness, difficulty in weaning from a ventilator, wasting and weakness of the extremities and loss of D.T.R. [Verse 12] [Lead Vocalist — triad as three rising notes; antibody named clean.] Miller Fisher, triad of ophthalmoplegia, ataxia, and areflexia; anti-G.Q.1.b. A.b. [Verse 13] [Lead Vocalist — “prednisone ineffective” is the cut; recovery line quieter.] Guillain-Barré, prednisone ineffective. Use plasmapheresis or I.V.I.G. Admit to I.C.U. if F.V.C. declines. Good recovery, may take many months 20 percent left with disability. [Outro verse] [Lead Vocalist — last protocol still fully sung, last word fallen.] Chronic Inflammatory Polyneuropathy, use prednisone. Then I.V.I.G. then plasmapheresis. [Chorus] [Lead Vocalist — hook once more, stacked altos, quieter.] Multiple sclerosis; acute relapse, I.V. followed by oral steroid Cholinesterase inhibitors worsen behavioral symptoms of Frontotemporal demantia [Ending: Rhodes figure unfinished. Cello holds one extra bar. One rim click. Silence.] [End]
