question

Tension HA S/S

answer

-Bilateral, non-throbbing, Band like "dull," "pressure," "head fullness", "head feels large," or, more descriptively, "like a tight cap", "band-like," or a "heavy weight on my head or shoulders." -Without photophobia, phonophobia, nausea, or vomiting.

question

What is the common HA:

answer

Tension HA

question

Tension HA Tx

answer

1st NSAIDS 2nd Relaxation exercises

question

Triggers for Tension HA

answer

Stress, fatigue

question

Migraine S/S

answer

Unilateral, throbbing, photophobia, N/V Migraine patients often retreat to quiet, dark rooms and prefer to lie quietly.

question

Migraine triggers:

answer

including chocolate, red wine, hard cheeses, monosodium glutamate, hormonal changes, exertion, fatigue, and stress.

question

Migraine often precede by

answer

aura (involving visual changes, field cuts, or flashing lights affecting one's visual hemifield.)

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Migraine often is associated with other diseases, such as

answer

seizure disorders, essential tremor, Tourette's syndrome, depression, anxiety, and stroke.

question

The triad of headache, nausea, and vomiting in the morning are concerning for a brain tumor in the

answer

posterior fossa

question

Migraine Tx

answer

Mild to moderate migraine headache (1) Abortive therapy may include aspirin, acetaminophen, NSAIDs, or isometheptene. A variety of products may be combined with caffeine, which has an adjunctive effect. (2) Subsequent measures for migraine might include serotonin-receptor agonists, such as the triptans (e.g., sumatriptan, zolmitriptan, rizatriptan, naratriptan, almotriptan, frovatriptan, eletriptan). Various forms of the ergotamines also are useful. Triptans, Reglan (Metocloppramide: SE --> Tardive Dyskinea), *Verapamil for Basilar migraine*

question

Migraine HA prophylaxis

answer

BB, Tricyclic, Progestin if menses related.

question

Cluster HA S/S

answer

-Severe, unilateral, periorbital headaches, Lacrimation, eye injection, rhinorrhea, -unilateral pain of cluster headache often is accompanied by ipsilateral lacrimation, conjunctival injection, nasal congestion, and myosis and ptosis

question

Headaches Diagnosis Test

answer

CT scan or MRI

question

Prophylactic therapy for cluster headaches includes:

answer

valproate, cyproheptadine, lithium, *calcium channel blockers*, and oral corticosteroids.

question

Cluster HA Tx

answer

-Administration of *100% oxygen, injectable forms of ergotamines or sumatriptan*, and analgesics (e.g., intranasal butorphanol).

question

Cluster HA assoc.

answer

Horner's Syndrome (ptosis, miosis, anhydrosis) and Alcohol

question

Complex regional pain syndrome (CRPS) is a disorder of a body region, usually of the extremities, that is characterized by

answer

pain, swelling, limited range of motion, vasomotor instability, skin changes, and patchy bone demineralization. It frequently begins following an injury, surgery, or vascular event such as a stroke.

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Three stages may occur during the course of CRPS

answer

It is a systemic disease affecting both the central and peripheral nervous system

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Complex Regional Pain Syndrome S/S

answer

Severe Pain, burning inupper or the lower extremities; involvement of both upper and lower limbs in the same patient is unusual. "Pain out of proportion"

question

Complex Regional Pain Syndrome risk factor:

answer

immobilization, trauma, female

question

Complex Regional Pain Syndrome Dx

answer

Radionuclide uptake on Bone scintigraphy

question

Complex Regional Pain Syndrome Treatment

answer

Stage 1: 1st Neurotin Stage 2: Add steroid Stage 3: Pain management -Temporary sympathetic nerve block -Smoking cessation ?Anticonvulsants ?Bisphosphonates ?Oral glucocorticoids ?Nasal calcitonin

question

Peripheral Neuropathy S/S

answer

Slow onset for DM (sensory), but fast onset for Guillain (Motor): Sensory Loss, Burning, Weakness

question

Peripheral Neuropathy Dx

answer

Electromyography/ Nerve conduction study

question

Peripheral Neuropathy for DM Tx

answer

Tight blood sugar control Med: Gabapentin, if obese give Topiramate

question

Diabetic Neuropathy

answer

is primarily a symmetrical sensory polyneuropathy, initially affecting the distal lower extremities.

question

Diabetic polyneuropathy is generally considered *predominantly axonal-sensory*

answer

Is extremely complex and likely relates to inflammatory, metabolic, and ischemic effects

question

The earliest signs of diabetic polyneuropathy probably reflect the gradual loss of integrity of both large myelinated and small myelinated and unmyelinated nerve fibers:

answer

?Loss of vibratory sensation and altered proprioception reflect large-fiber loss ?Impairment of pain, light touch and temperature is secondary to loss of small fibers

question

Treatment of diabetic peripheral neuropathy ?Glycemic control ?Foot care ?Treatment of pain

answer

-Pregabalin has been found to significantly decrease mean pain score -On a daily basis, patients need to inspect their feet for the presence of dry or cracking skin, fissures, plantar callus formation, and signs of early infection between the toes and around the toe nails. Regular foot examinations by the physician to detect early neuropathy are also an essential component of the treatment of diabetic patients.

question

Treatments that are beneficial for painful diabetic neuropathy include:

answer

a number of antidepressants (eg, amitriptyline, duloxetine, venlafaxine), anticonvulsants (eg, pregabalin, sodium valproate), and capsaicin cream

question

Complications — Diabetic polyneuropathy is

answer

frequently insidious in onset and can lead to formation of foot ulcers and muscle and joint disease.

question

The most common forms of hereditary neuropathy

answer

*Charcot-Marie-Tooth* types 1A, 1B, and X-linked, are all predominantly demyelinating in nature, although substantial coexistent axonal loss is usually also identified.

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Charcot-Marie-Tooth is

answer

also known as hereditary* motor and sensory neuropathy* (HMSN), encompasses the majority of hereditary peripheral neuropathies

question

The most common features of Charcot-Marie-Tooth are weakness and atrophy of the lower leg and foot. High-arched feet and hammertoes (pes cavus) are common but not pathogneumonic.

answer

Most patients present with difficulties walking, twisting of the ankles, and slapping of the feet. Features are normally symmetric, although asymmetries may occasionally occur. The majority of patients remain ambulatory, although they may need braces and other assistive devices. Severe cases also exist. Children with delayed motor milestones, who never ran or ambulated, have a severe early-onset phenotype of CMT1, CMT2, and CMT4 called Dejerine-Sottas syndrome.

question

Diagnostic Factors for Charcot-Marie-Tooth

answer

-family history of neuropathy, pes cavus, or abnormal gait -walking difficulties -pes cavus (hammertoe) -*steppage gait* -diffuse deep tendon hyporeflexia or areflexia -reduced muscle strength -reduced sensation -transient sensory symptoms -transient motor symptoms

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Charcot-Marie-Tooth treatment

answer

Low-impact exercises, such as cycling and swimming, as well as *physical therapy* sessions, increase energy, as well as reducing fatigue and pain

question

*Initial diagnostic procedure for patients with suspected polyneuropathy *

answer

Electrodiagnostic testing with electromyography and/or nerve conduction studies (EMG/NCS)

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Restless Leg Syndrome is

answer

is a disorder characterized by voluntary leg movements prompted by an urge to move which is often associated with unpleasant paresthesias.

question

Restless Leg Syndrome

answer

The urge to move is worse at rest and at night and relieved by movement. Accompanied by *dysesthesias described as creeping, crawling, tingling, cramping, or aching of the extremities.*

question

Restless Leg Syndrome Risk factors:

answer

-Family history consistent with autosomal dominant inheritance -Conditions associated with iron deficiency -End-stage renal disease (hemodialysis patients); associated factors that have been posited to play a role include anemia, iron deficiency, elevated serum calcium, and alterations in central nervous system dopamine. -DM, Multiple sclerosis, Parkinson's Disease pt

question

Restless Leg Syndrome Treatment:

answer

-Iron replacement -Dopamine Agonist: pramipexole or ropinirole

question

Bell's Palsy S/S

answer

Unilateral facial paralysis: -Inability close eye -unable to Wrinkle the forehead -Mouth drawn the non affected side -Loss of taste 2/3 anterior of the tongue -hyperacusis (hearing sensitivity)

question

Bell Palsy's with left affected

answer

On physical exam, the left eye is more open than the right, the left *nasolabial fold is absent, and the left corner of her mouth droops.* On the left side, she cannot voluntarily raise her eyebrow, close her eyelid, elevate her mouth into a smile, snarl, or pucker her lips.

question

Bell's Palsy+ Zoster

answer

Ramsay Hunt Syndrome

question

Bell's Palsy Tx

answer

Predinose, Acyclovir (if +herpes)

question

Bell's Palsy others causes

answer

Lyme disease

question

Transient ischemic attack (TIA) is a

answer

Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.

question

Majority of TIAs resolve within the

answer

first hour, and diagnostic imaging allows recognition that some events with rapid clinical resolution are associated with permanent cerebral infarction

question

Etiology of TIA

answer

-atherosclerosis, lipohyalinosis, inflammation, amyloid deposition, arterial dissection, developmental malformation, aneurysmal dilation, or venous thrombosis. -embolism of thrombus -Inadequate cerebral blood flow due to decreased perfusion pressure or increased blood viscosity. -rupture of a vessel in the subarachnoid space or intracerebral tissue.

question

A transient ischemic attack (TIA) should be considered a syndrome. These syndromes are conveniently divided into three pathophysiologic mechanisms:

answer

?Large artery low-flow TIA (true TIA) ?Embolic TIA, which may be artery-to-artery, or due to a cardioaortic or unknown source ?Lacunar or small penetrating vessel TIA

question

Large artery low-flow TIA (true TIA) Low-flow TIAs usually are short-lived (minutes) and often recurrent.

answer

Due to hemodynamically significant stenotic lesions at the origin of the internal carotid artery, at the siphon portion of the internal carotid artery where collateral flow to the circle of Willis is inadequate, or in the middle cerebral artery stem. Symptoms due to ischemia from these lesions often include hand, arm, leg, face, tongue, or cheek numbness or weakness together

question

Embolic TIAs in the anterior circulation: Embolic TIAs typically last hours rather than minutes as in low-flow TIAs.

answer

may be large enough to occlude the middle cerebral artery stem, producing a contralateral hemiplegia

question

TIA Clinical features

answer

a. If the TIA is related to a disturbance in carotid circulation, patients may demonstrate contralateral hand-arm weakness with sensory loss, ipsilateral visual symptoms or aphasia, or amaurosis fugax. Carotid bruit may be present, but with a high-grade stenosis (95%), it may be absent. b. Those experiencing vertebrovascular TIA may demonstrate diplopia, ataxia, vertigo, dysarthria, cranial nerve palsies, lower extremity weakness, dimness or blurring of vision, perioral numbness, or drop attacks.

question

TIA S/S

answer

Has weakness , visual loss, numbness but resolves

question

TIA Dx

answer

-Brain imaging with CT or MRI -Noninvasive options for evaluation of large vessel occlusive disease include magnetic resonance angiography (MRA), computed tomography angiography (CTA), carotid duplex ultrasonography (CDUS), and transcranial Doppler ultrasonography (TCD)

question

TIA tx

answer

-ASA, clopidogrel (Plavix) -*Cardiogenic TIA* requires anticoagulation, initially with *intravenous (IV) heparin for those who are admitted to the hospital and with warfarin for long-term therapy.*

question

TIA with BP ;185/100 treat with:

answer

Labetalol

question

Ischemia — There are three main subtypes of brain ischemia:

answer

?Thrombosis ?Embolism ?Systemic hypoperfusion

question

What is a major risk factor for ischemic stroke?

answer

Chronic hypertension Others: hypercholesterolemia, diabetes, oral contraceptives, cigarette smoking, heavy alcohol use, AIDS, and elevated blood homocysteine levels.

question

Stroke Clinical features a. Signs and symptoms of stroke begin abruptly and, by definition, last longer than 24 hours. They correlate with the area of the brain that is supplied by the affected vessel, especially with ischemic events.

answer

b. In most cases, hemiparesis or hemisensory deficit is revealed on history and physical examination. One can localize the lesion to one side, contralateral to these deficits.

question

Anterior Circulation Stroke:

answer

associated with hemispheric signs and symptoms (aphasia, apraxia, hemiparesis, hemisensory losses, visual field defects: Homonymous Hemianopia).

question

Posterior Circulation Stroke:

answer

which supplies the brain stem, cerebellum, thalamus, and portions of the temporal and occipital lobes, commonly are associated with evidence of brain stem dysfunction (coma, drop attacks, vertigo, nausea, vomiting, ataxia).

question

Ischemic Stroke Anterior involves

answer

Frontal and middle cerebral arteries

question

Ischemic Stroke S/S

answer

Hemiparesis

question

tPA contraindition

answer

1. BP ; 185/100 2. Recent MI the last 3 months 3. Major surgery 14 days ago 4. Increase PTT 5. Platelet 1.7 7. Glucose ;50 8. Active bleed 9. Head trauma the last 3 months 10. Hx of intracranial Hemorrhage

question

Ischemic Stroke Posterior Cerebellar Function "VANISH'D

answer

Vertigo Ataxia Nystagmus Intention tremor Slurred speech Heel-shin test Dysdiadochokinesia

question

Lacunar Stroke Syndrome

answer

?Pure motor hemiparesis ?Pure sensory stroke ?Ataxic hemiparesis

question

Lacunar Stroke often occur with pt with

answer

HTN and Diabetes

question

Pure motor hemiparesis

answer

It is characterized by weakness involving the face, arm, and leg on one side of the body in the absence of "cortical" signs (aphasia, agnosia, neglect, apraxia, or hemianopsia) or sensory deficit.

question

Pure sensory stroke

answer

defined as numbness of the face, arm, and leg on one side of the body in the absence of motor deficit or "cortical" signs.

question

Ataxic hemiparesis

answer

Develop ipsilateral weakness and limb ataxia that is out of proportion to the motor deficit. Some patients may exhibit dysarthria, nystagmus, and gait deviation towards the affected side.

question

What is the Cerebral Aneurysm?

answer

is an acquired focal abnormal dilation of the wall of an artery in the brain. Intracranial aneurysms are most commonly located at branching points of the major arteries at the base of the brain, which course through the subarachnoid space.

question

Types of cerebral aneurysm

answer

*Saccular* -Often termed a *berry aneurysm*, as it resembles a berry hanging from a vine -Rounded outpouching attached by a neck or stem to a brain artery. *Fusiform* -Also called atherosclerotic aneurysm -Forms as media damage leads to arterial stretching and elongation -Intraluminal clots may form.

question

Cerebral Aneurysm most common

answer

Berry Aneurysm

question

Ruptured saccular (berry) aneurysm accounts for approximately 75% of nontraumatic cases of:

answer

subarachnoid hemorrhage (SAH) and has a mortality rate of 50%

question

Cerebral Aneurysm Presentation

answer

HA, nuchal rigidity (New neck stiffness that includes pain on stretching the neck meninges with maneuvers.)

question

Cerebral Aneurysm assoc with

answer

Polycystic kidney Disease, Coarctation of the aorta, Endocarditis, Ehlers-Danlos

question

Cerebral Aneurysm Dx

answer

CT(referred initial diagnostic study)/MRI

question

Cerebral Aneurysm Tx

answer

Coiling. Clipping

question

Cerebral Aneurysm if rupture can lead to:

answer

Subarachoid Hemorrhage

question

Subarachnoid hemorrhage S/S:

answer

Acute onset Tunderclap HA, "Worst HA of my life" PE: Nuchal rigidity, impaired mental state Other signs of meningeal irritation, including *photophobia, nausea/vomiting*, and meningeal stretch signs, may also be seen.

question

HA, nuchal rigidity (Cerebral Aneurysm) + photophobia, nausea/vomiting (bleeding) =

answer

Subarachnoid hemorrhage

question

Subarachnoid hemorrhage Dx on CT

answer

-Look for Hyperdense area on CT. -Hyperdense areas in the basal cisterns, major fissures, and sulci

question

Subarachnoid hemorrhage Tx

answer

Clip or coil aneurysms

question

How you reverse Heparin treatment?

answer

Protamine Sulfate "He Pro me"

question

Subarachnoid hemorrhage: What should be performed if CT is unrevealing?

answer

Lumbar Puncture

question

How you reverse Warfarin treatment?

answer

Vitamin K & fresh frozen plasma (FFP) "War with Kings"

question

Brain Tumor Met

answer

1st Breast 2nd Lung 3rd GI 4th Kidney "Be loved or Get Knocked up"

question

Brain Tumor Dx

answer

MRI

question

Primary Brain Tumor Frontal lobe

answer

personality or intellectual change

question

Primary Brain Tumor Temporal Lobe

answer

lip smacking, olfactory or gustatory

question

Primary Brain Tumor Parietal Lobe

answer

sensory seizure or sensory loss

question

Primary Brain Tumor Brain stem

answer

cranial nerve palsy

question

Primary Brain Tumor Pituitary Tumor

answer

Endocrine symptoms

question

Primary Brain Tumor Occipital Lobe

answer

Visual defect or hallucination

question

Primary Brain Tumor Tx

answer

Surgery or radiotherapy

question

Epidural hematoma caused by

answer

Someone getting hit in the head

question

Epidural hematoma

answer

Transient loss of consciousness so-called "lucid interval"

question

Epidural hematoma other signs to look for:

answer

hematoma expansion leads to elevated intracranial pressure and clinical signs, such as an ipsilateral dilated pupil, hemiparesis.

question

Epidural hematoma artery involved

answer

Middle meningeal artery "MMA fighter"

question

Epidural hematoma CT brain

answer

Convex, biconvex, lens shape

question

Epidural hematoma Tx

answer

Urgent surgery

question

Elderly pt with multiple fall over the past 6 months or year..think!

answer

Subdural Hematoma

question

Subdural hematoma is

answer

a collection of blood between the dural and arachnoid coverings of the brain. As the volume of the hematoma increases, the intracranial pressure may rise and cause herniation.

question

___________ is the most common cause of Subdural hematoma, with the majority of cases related to motor vehicle accidents, falls, and assaults.

answer

Head trauma

question

Subdural hematoma risk factors:

answer

-Patients with significant cerebral atrophy are at high risk for SDH. -Recent trauma, elderly, those with a history of chronic alcohol abuse, and those with previous traumatic brain injury, coagulopathy, anticoagulant use.

question

Subdural Hematoma Dx:

answer

CT brain -Concave, crescent shaped

question

The categories of acute, subacute, and chronic SDH are arbitrarily defined by time from onset:

answer

?Acute SDH presents one to two days after onset ?Subacute SDH presents 3 to 14 days after onset ?Chronic SDH presents 15 or more days after onset

question

Acute subdural hematoma PE

answer

symptoms of elevated intracranial pressure including headache, vomiting, anisocoria, dysphagia, cranial nerve palsies, nuchal rigidity, and ataxia.

question

Chronic subdural hematoma PE

answer

The insidious onset of headaches, light-headedness, cognitive impairment, apathy, somnolence, and occasionally seizures, may occur as a consequence of chronic SDH, and symptoms may not become evident until weeks after the initial injury. Global deficits such as disturbances of consciousness are more common than focal deficits after SDH.

question

Subdural Hematoma S/S

answer

HA, N/V, nuchal rigidity, anisocoria, dysphagia

question

Subdural Hematoma Tx

answer

*Burr holes* or craniotomy -Once the diagnosis has been established, *burr holes* over the hematoma are indicated to evacuate the clot.

question

Subdural Hematoma increase intracranial pressure. What is treatment?

answer

Hyperventilation, *Mannitol*

question

Seizure Partial Seizure: Simple and complex

answer

Simple: Consciousness is not impaired Complex: Consciousness is impaired (Over 30 sec)

question

Seizure Generalized: Absence, Tonic-Clonic

answer

Absence: Staring <15 sec Tonic: Body very stiff and rigid Clonic: Convulsions and limb jerking

question

Seizure eval:

answer

Glucose Level, Electrolytes, ABG, CBC, Urine toxic, Drug

question

Partial Seizure two type: -Complex partial seizure -Simple partial seizure

answer

-A complex partial seizure (CPS) implies that consciousness is impaired -Simple partial seizures (SPS) are not associated with altered consciousness.

question

Complex partial seizure

answer

they often seem to stare into space and either remain motionless or engage in repetitive behaviors, called automatisms, such as facial grimacing, gesturing, chewing, lip smacking, snapping fingers, repeating words or phrases, walking, running, or undressing. Patients may become hostile or aggressive if physically restrained during complex partial seizures.

question

-Simple partial seizures

answer

-Beginning of the seizure are referred to as the warning or aura. -The symptoms of simple partial seizures vary from one patient to another and depend entirely on where the seizure originates in the brain, that is, the part of the cortex that is disrupted at the onset of the seizure. A seizure that begins in the occipital cortex may result in flashing lights, while a seizure that affects the motor cortex will result in rhythmic jerking movements of the face, arm, or leg on the side of the body opposite to the involved cortex (Jacksonian seizure).

question

Partial Seizure focal location in the brain affected often

answer

temporal lobe

question

Generalized Seizure: start midbrain or brainstem, spread to both cortices

answer

Subtypes of generalized seizures are: -tonic-clonic seizures (grand mal) -absence seizures (petit mal) -myoclonic seizures.

question

What is the frequent complication of alcohol withdrawal?

answer

Generalized Seizure

question

Tonic-Clonic Seizure Presentation

answer

-It begins with an abrupt loss of consciousness, often in association with a scream or shriek. -*All of the muscles of the arms and legs as well as the chest and back then become stiff*. The patient may begin to appear cyanotic during this *tonic phase* -After approximately one minute, the *muscles begin to jerk and twitch for an additional one to two minutes. During this clonic phase* the tongue can be bitten, and frothy and bloody sputum may be seen coming out of the mouth.

question

Absence seizures (petit mal)

answer

Absence seizures (also called petit mal) usually occur during childhood and typically last between 5 and 10 seconds. They frequently occur in clusters and may take place dozens or even hundreds of times a day. *Absence seizures cause sudden staring with impaired consciousness*

question

Absence Sz tx

answer

Ethosuximide, Valproic Acid

question

Partial Sz Tx

answer

Carbamazepine, 2nd line Valproic Acid

question

Generalized Sz Tx

answer

Valproic Acid

question

Phenytoin can be used for

answer

Partial and Generalized, but not Absence Sz

question

The most common medical neurologic emergency in childhood, ____________ is a serious and often life-threatening medical emergency

answer

status epilepticus (SE) Lasts for a sufficient length of time (30 minutes or longer in most studies) or is repeated frequently enough that the individual does not regain consciousness between seizures

question

Status epilepticus emergency due to

answer

permanent brain damage secondary to hyperthermia, circulatory collapse, or excitotoxic neuronal damage

question

Status Epilepticus

answer

Sz longer than 5-10 min.

question

Status Epilepticus Tx

answer

-Maintain ABCs; consider rapid intubation for airway protection. -Administer thiamine, followed by glucose and naloxone to presumptively treat potential etiologies. -Give an IV benzodiazepine (lorazepam or diazepam) plus a loading dose of fosphenytoin.

question

Status Epilepticus Caused by

answer

Decrease in K+, Na+, hypoglycemia

question

Neurogenic Syncope is due to

answer

reflex response Triggered by stress: Venipuncture, prolonged standing, heat, fear of injury, painful or noxious stimuli

question

Neurogenic Syncope Dx

answer

Check orthostatic , Glucose Tilt table test Holter monitor

question

Neurogenic Syncope Tx

answer

Avoid situation causing the trigger Pt education Proper Hydration

question

Concussion is

answer

is a closed head injury due to a direct blow to the head or deceleration of the head from an impulsive force that results in a change in mental status.

question

Diagnosis of concussion should be considered if 1 or more of the following are reported or observed:

answer

-Confusion or disorientation -Amnesia near the time of the injury (retro- or anterograde) -Loss of consciousness for up to 30 minutes -Neurologic or neuropsychological problems -Score 13 or higher on the Glasgow Coma Scale (GCS).

question

Concussion Symtoms and Sign

answer

-The hallmark symptoms of concussion are confusion and amnesia, sometimes with, but often without, preceding loss of consciousness. - Early symptoms of concussion (within minutes to hours) include headache, dizziness (vertigo or imbalance), lack of awareness of surroundings, and nausea and vomiting

question

How many min after injury can you do the Glasgow Coma Scale?

answer

30min after injury

question

Tremors: Resting

answer

Parkinson's disease Tremor at rest goes away with movement Tx: Dopamine agonist

question

Cantu Guidelines Grade 2

answer

+LOC 30mins but <1 week Anything less than that should be grade 1 Anything greater should be grade 3

question

Tremors: Action 2 kinds

answer

Physiologic: Due to caffeine, catecholamines, nicotine, anxiety. Tx with removal of offending agents Essential: Genetic Tx: Propranolol and primidone

question

Tremors: intention

answer

Tremor increase in severity as the hand moves closer to its target. Tx: no treatment

question

Parkinson's Treatment

answer

age 65: Levodopa, carbidopa Pt <65 taking Levodopa, this can cause dyskinesia

question

Parkinson's Disease S/S:

answer

shuffling stepping gait, cogwheel rigidity, pill-rolling, lack of facial expression.

question

Huntington' s disease

answer

is an inherited, autosomal dominant disorder that occurs throughout the world in all ethnic groups.

question

Huntington' s disease S/S

answer

a. The disease is characterized by progressive *chorea* and dementia; it is usually fatal within 15 to 20 years. b. The earliest mental changes often are behavioral, with irritability, moodiness, and antisocial behavior that generally progress to an obvious dementia. c. The earliest physical signs may be a mere restlessness or fidgetiness, but, eventually, *severe choreiform* movements and dystonic posturing occur.

question

Huntington' s disease Dx

answer

CT demonstrates cerebral atrophy as well as atrophy of the caudate nucleus. MRI and PET scans have shown decreased glucose metabolism in an anatomically normal caudate nucleus.

question

Huntington' s disease Tx:

answer

*Chorea: Tetrabenazine* Chore+psychosis: Olanzapine, risperidone, haloperidol Symptomatic treatment for the disease may include phenothiazines to control dyskinesia, and haloperidol or clozapine to control any behavioral disturbances.

question

Extrapyramidal syndrome is usually due to the intake of

answer

Haldol

question

Extrapyramidal syndrome

answer

movement disorders such as akathisia, dystonia, and parkinsonism, caused by antipsychotic drug therapy

question

What is akathisia?

answer

-The state of restlessness characterized by an urgent need for movement, usually as a side effect of medication.

question

What akathisia can be prevented by giving?

answer

Benzodiazepine medicationf

question

Extrapyramidal syndrome tx

answer

Diphenhydramine (Benadryl)

question

Tardive Dyskinesia

answer

A side effect of long-term use of traditional antipsychotic drugs causing the person to have uncontrollable facial tics, grimaces, and other involuntary movements of the lips, jaw, and tongue.

question

Guillain-Barre is an

answer

autoimmune neuropathies, are *predominantly demyelinating*, and a variety of clinical and experimental data have implicated both humoral factors and cell-mediated immune phenomena, which damage myelin and/or the myelin-producing Schwann cells.

question

Guillain-Barre PE

answer

Acute asymmetric ascending inflammatory neuropathy; Weakness begins in lower and ascends; respiratory failure can occur in sever cases; *reflexes invariably decreased or absents*; 2/3 of patient have respiratory or GI illness 1-3 weeks prior to onset; Albuminocytologic dissociation

question

Guillain-Barre

answer

Weakness of the legs to total paralysis of all four limbs, facial muscles, and eyes.

question

Initial diagnosis of Guillain-Barré syndrome (GBS) is based upon the clinical presentation.

answer

Cerebrospinal fluid analysis — In patients with GBS, lumbar puncture often reveals an *elevated CSF protein with a normal CSF white blood cell count. This finding, known as albuminocytologic dissociation*

question

Guillain-Barre can be cause by what...

answer

Campylobacter jejuni, CMV, HIV, or by recent immunization

question

Guillain-Barre Dx

answer

1st initial :Lumbar puncture Increase CSF protein, with normal WBC -Electromyography

question

Guillain-Barre Tx

answer

-1st Line IV Immune globulin -Plasma exchange (remove circulating antibodies) *Avoid Steroids*

question

Myasthenia Gravis

answer

autoimmune attack of acetycholine receptors in neuromuscular junction

question

Myasthenia Gravis Word breakdown

answer

My=Muscle A= Without Sthenos= Strength

question

Myasthenia Gravis Symptoms

answer

Proximal to distal weakness Eyes: bilateral Ptosis usually 1st The weakness is limited to the eyelids and extraocular muscles

question

Myasthenia Gravis

answer

DTR are intact, no sensory abnormalities, normal pupillary light relfex

question

Myasthenia Gravis Dx:

answer

Best initial test: Acetylcholine receptor antibody. *More reliable laboratory methods that aid in the confirmation are serologic tests for autoantibodies and electrophysiologic studies* (muscle fiber contraction on repetitive nerve stimulation) Edrophonium/Tensilon Test (Acetylcholinesterase inhibitor)

question

Myasthenia Gravis: Chest radiographs (CT or MRI should be obtained to rule out a coexisting _________.

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Thymoma

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Myasthenia Gravis associated with

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High incidence of thymus abnormalities

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Myasthenia Gravis tx

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Pyridostigmine (cholinesterase inhibitor) Thymectomy if < 60 y.o.

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Myasthenia Gravis Alternative treatment

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-Corticosteroids, immunosuppressive agents. -If steroid fail- Azathioprine usually added. -IV immunoglobulin, and plasmapheresis are effective in patients with refractory disease.

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Myasthenia Gravis can cause by medication:

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Magnesium Sulfate, pencillamine, *aminoglycoside*, interferon-Alpha

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Myasthenia Gravis S/S

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ptosis, weak chewing, fatigue, weakness with everday activities (brushing hair, etc)

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Multiple Sclerosis

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Distal to proximal weakness or or visual changes often over many years due to demyelination and inflammation on CNS not peripheral).

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Patients with MS typically follow either a relapsing-remitting pattern of episodes or a primary progressive course.

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A secondary progressive form also is seen, in which the relapsing-remitting pattern changes to one of progressive degeneration.

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Multiple Sclerosis Dx

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-diagnosis cannot be based exclusively on laboratory findings. *MRI with gadolinium is very effective for visualizing white matter lesions in the CNS.* 2nd: *Oligoclonal bands and elevated CSF IgG and IgG synthesis rates are present in 80% of MS cases*

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Multiple Sclerosis MRI hints

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White matter changes/ T2 hyperintensity

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Multiple Sclerosis Lab

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mild lymphocytosis or slight protein elevation, elevated immunoglobulin G index, oligoclonal bands, and increased myelin basic protein

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Multiple Sclerosis S/S

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Optic neuritis & vision changes often 1st

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Multiple Sclerosis Tx

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Acute: Glucocorticoids Long-term: Interferon Beta

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The cerebral palsy (CP) syndromes are

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characterized by abnormalities of motor activity and posture.

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Cerebral Palsy 3 Types Movement disorder classification

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Spastic Dyskinetic Ataxic

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Cerebral Palsy: Spastic

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Spastic CP is an upper motor neuron syndrome. S/S: spastic hyperreflexia, extensor plantar, response, and clonus May be: Diplegia, asymmetric, Hemiplegia, Quadriplegia

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Cerebral Palsy: Dyskinetic

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Involuntary, recurring, and occasionally stereotyped movements with a varying muscle tone. Subgroups include: Dystonia: characterized by involuntary, sustained contractions resulting in twisting and abnormal postures. Chorea: rapid, involuntary, jerky, and fragmented motions; tone is usually decreased but fluctuating. Athetosis: slower, constantly changing, writhing, or contorting movements.

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Cerebral Palsy: Ataxic

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Loss of muscular coordination with abnormal force and rhythm, and impairment of accuracy. Commonly presents with gait and trunk ataxia, poor balance, past pointing, terminal intention tremor, scanning speech, nystagmus and other abnormal eye movements, and hypotonia.

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Cerebral Palsy due to

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The multifactorial etiology was illustrated in a series of 213 children diagnosed with CP in Australia. Major CP-associated pathologies other than acute intrapartum *hypoxia were identified in 98 percent of cases*

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Cerebral Palsy Diagnostic test:

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MRI periventricular leukomalacia, congenital malformation, stroke or hemorrhage, cystic lesions

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Cerebral Palsy Treatment:

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Treatment is supportive, with the goal of attaining maximum function and potential in physical, occupational, and speech ability

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Meningitis aseptic meningitis:

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-Viral or other cause -Most common cause is enterovirus (Coxsackie A and B viruses, Echoviruses, and Polioviruses) - Additional etiologies include other infections, (mycobacteria, fungi, spirochetes), parameningeal infections, medications, and malignancy

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Meningitis Bacteria

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S. Pneumonia N. Meningitis (Look for rash)

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Meningitis aseptic Presentation

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headache, nausea and vomiting, photophobia, neck stiffness (nuchal rigidity), fever

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Meningitis Daignostic

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Examination of the cerebrospinal fluid (CSF) is crucial for establishing the diagnosis of bacterial meningitis, identifying the causative organism, and performing in vitro susceptibility testing . Indications for CT scan before LP — Every patient with suspected meningitis should have CSF obtained unless lumbar puncture (LP) is contraindicated.

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What is the rational for dosing dexamethasone prior to or along with the first dose of antibiotics for empiric treatment of bacterial meningitis?

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Dexamethasone when given with or prior to the first dose of antibiotic reduces the risk of *Hearing losss* in children with meningitis, especially in the cases of Influenza B, TB, meningitis.

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Meningitis Bacteria Tx

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Dexamethasone (used to minimize adema within the CNS) Ceftriaxone, Macrolides, Penicillin

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In adults with bacterial meningitis, dexamethasone reduces both morbidity and mortality especially in the case of

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Strept Pneumo

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Meningitis Bacteria look for increase in intracranial pressure

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Do fundascopic exam to r/o papillaedma

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Most common Meningitis Bacteria in the 1st month of life

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Group B strep and E.Coli

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In the adult with rash, which of the following is the most likely organism to cause bacterial meningitis?

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N. Meningitis

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What is the treatment for viral meningitis?

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-Acetaminophen for pain -IV Fluid -Empiric antibiotics Until viral is confirmed -Acyclovir if suspicion of HSV

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In the adult neutropenic (immunocompromised) patient, which of the following is the most likely organism to cause bacterial meningitis?

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Listeria

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What is Encephalitis?

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is a pathologic state of brain parenchymal dysfunction demonstrated by an altered state of consciousness and/or signs of neurologic dysfunction (e.g., seizures, personality changes, cranial nerve palsies, speech problems, and motor and sensory deficits).

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Encephalitis organisms:

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HSV and arboviruses are the most common causes of encephalitis. Rarer etiologies include CMV, toxoplasmosis, West Nile virus, VZV, Borrelia, Rickettsia, Legionella, enterovirus, Mycoplasma, and cerebral malaria. Children and the elderly are the most vulnerable

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Encephalitis presentation

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-markedly altered consciousness, seizures, personality changes, or other focal neurologic signs. -Lethargy, confusion, coma, and focal neurologic deficits (cranial nerve deficits, accentuated DTRs) may also be present.

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Encephalitis Diagnostic Test

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initial diagnostic step in the patient with suspected viral encephalitis is analysis of the CSF; lumbar puncture

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Encephalitis treatment

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-HSV encephalitis: Requires immediate IV acyclovir. -CMV encephalitis: Treat with IV ganciclovir +/? foscarnet. -Give doxycycline for suspected Rocky Mountain spotted fever, Lyme disease, or ehrlichiosis.

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Rabies S/S

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Hydrophobia, aerophobia, pharyngeal spasms, and hyperactivity

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Rabies Tx

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Rabies Immunoglobulin

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Encephalopathy: vomiting, confusion, Sz, coma in child after exposure to

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Saliccylates (ASA), Pept-Bismol Condition called *Reye's Syndrome*

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What is Reye's Syndrome?

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Reye's Syndrome, or fatty liver encephalopathy, has been associated with ASA use in children with viral infections, including influenza.

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Reye's Syndrome treatment

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-Ondansetron may be given to decrease vomiting. -Seizure: phenytoin

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Dementia with Lewy Bodies:

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-Visual hallucinations -Progressive dementia -Spontaneous motor features of Parkinsonism

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Alzheimer's Disease

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-Age >60 -MMSE -Memory loss

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Alzheimer's Disease Treatment

answer

Donepezil, rivastigmine, and galantamine.

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