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done spring and fall 2017 > 70 neuro > Flashcards

70 neuro Flashcards

1
Q

red flags for HA? 3

A

sudden onset - thunderclap
Escalating in severity/frequency
Associated with systemic symptoms : weight loss, fever, and/or meningeal signs (meningitis); consider cerebellar hemorrhage if nausea and vomiting accompany these signs

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2
Q

thunderclap

A

headache-severe onset, reaches max intensity in seconds accompanied by vomiting

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3
Q

Escalating in severity/frequency eg?

A

intracranial lesion; headache that is worse in am with drowsiness or vomiting may reflect raised ICP

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4
Q

Associated with systemic symptoms? 3

consider what ddx?

A

weight loss, fever, and/or meningeal signs (meningitis); consider cerebellar hemorrhage if nausea and vomiting accompany these signs

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5
Q

tension headaches
triggers? 4

intensity?

how long?

neuro deficits?

s/s

mx

A

triggers- anxiety, depression, situational stress, secondary to muscle strain

Mild to moderate intensity, bilateral, generalized
“Band like “sensation around head

Lasts 30 min- days

No neuro deficits, poor concentration

mx - Mild analgesics
Acetaminophen, aspirin, *NSAIDS
Relaxation techniques. Explore causes of anxiety
Patients with chronic tension headaches need underlying distress to be addressed
Stress reduction
Amitriptyline 10-12.5mg at hs and increase the dose in 10-12.5 mg steps every 2-3 wks as tolerated and as needed for sleep, until there is improvement in headache.
Max dose 100 -125 mg hs
Takes 4-6 weeks before improvement seen and may be accrued up to 3 months
Maintain for at least 3-6 months then taper

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6
Q

Cluster headache
affects who?
SS mostly affecting
how often and how long?

A

middle-aged men.

s/s - Very painful H/A syndrome
Severe unilateral, periorbital pain and behind eye.
bilateral nasal congestion, eye redness, rhinorrhea and lacrimation

how often - clusters can last weeks to months, Lasts <2hrs but several may occur in 24hrs

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7
Q

which HA wakes people from sleep?

Which HA precipitated by alcohol ingestion?

Usually occurs at the same time of year?

which HA has focal neuro deficits?

A

Cluster

Cluster

Cluster

Migraine

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8
Q

Tx for clusters? 4

Prophylaxis? 4

A

O2
limit triggers
Sumatriptan 6mg SQ/intranasal
Ergotamine tartrate inhalation

pro: Prophylaxis
Verapamil 240mg daily
Tapering prednisone from 40mg/d
Ergotamine tartrate po/SQ/pr

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9
Q

POUND for what HA?

A

Migraine

P:pulsating
O: lasts one day
U: unilateral
N: N &amp; V
D: disturbance of daily activity
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10
Q

which is more common of Migraine? aura or without?

s/s - 7

how long?

A

without aura

Unilateral,
Dull or throbbing
Visual disturbances, field deficits, hallucinations
Aphasia, numbness, tingling, clumsiness, weakness
N & V
Photophobia, phonophobia
Appears acutely ill

Build up gradually and lasts several hours

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11
Q

Triggers for Migraines

A

Lack of sleep, no food, alcohol, nitrate foods, menstruation, oral contraception, weather changes, motion sickness

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12
Q

Diagnostics for Migraines ? 4

A

CBC, syphilis screen, ESR, CT head

Temporal arteritis - inflam of temporal arteries

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13
Q

mx of Migraines?

prophylactic therapy?

acute attacks?

what drugs have contraindications, and what are they?

A 
Avoidance of triggers:
Relation/stress management
Eliminate MSG/nitrates in diet
Stabilize/wean caffeine intake
Avoid alcohol

If 2-3x/month prophylactic therapy:
ASA, NSAIDS, propranolol (Inderal) 80-240mg/day
Can use amitriptyline 10-150mg/day but try propranolol first
Various ergotamines, MAO inhibitors

If acute attack:
Rest in dark
Analgesic (ASA)
Serotonin agonists, triptans: containdicated in coronary artery disease, Uncontrolled HTN, pregnancy, Prinzmetal’s angina
Sumatriptan 6mg SQ repeat in 1hr x3
Cafergot 1-2 tabs
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14
Q

common manifestation of Lyme meningitis?

Other causes of facial paralysis? 4

A

Facial nerve palsy

Injury to facial nerve from bacterial infection, Herpes Zoster, DM, sarcoidosis, Guillan-Barre syndrome

Stroke
MS
Bell’s palsy

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15
Q

def of bells palsy

common in what pts? 4

when occurs?

ss? 6

A

Abrupt paralysis of the facial muscles innervated by CN 7, due to inflammation - nerves compressed from inflam?

Increasing incidence with age, associated with pregnancy (especially in 3rd trimester and 1 week postpartum), DM, hypothyroidism

Abrupt onset (hours-48hrs)

unilateral facial paralysis
Eyebrow sagging, inability to close the eye, disappearance of nasolabial fold, mouth drawn to the non affected side
Difficulty wrinkling forehead of affected side
2/3 of cases are accompanied by pain in or behind the ear
Drooling, alterations in taste or hearing

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16
Q

if have skin lesions especially external auditory meatus-consider?

A

HSV

17
Q

consider Imaging in facial paralysis if:

A

slow progression beyond 3 wks, or if there is no improvement at 6 mo
Hx of a facial twitch or spasm that precedes facial weakness suggests nerve irritation from tumor and should also prompt imaging

18
Q

tx for bells palsy? 2 drugs

do anything with eyes?

other tx? 1

A

Prednisone: 60-80 mg/d x1 wk (begin w/i 3 d of sx onset)
If believed to be caused by Herpes Simplex Virus then consider use Combo therapy with valacyclovir (1000 mg TID) X 1 week for patient with severe facial palsy at presentation

Prevent corneal injury
Artificial tears, methycellulose drops BID, and HS
Lid may need to be taped shut, especially at night to prevent keratitis

Physical Therapy: various options out there

19
Q

diff btwn bells and trigeminity neuralgia?

A

bells - nerve 7

trigem - nerve 5 - Sudden, usually unilateral, severe, brief stabbing or lancinating recurrent episodes of pain in the distribution of one or more branches of the 5th cranial (trigeminal) nerve.

continuous dull pain

20
Q

ss of neuralgia trigem

A

Headache, sudden, usually unilateral, severe, brief, stabbing or lancinating. Recurrent episodes of pain in the distribution of CN 5, may have continuous dull pain
Pain tends to occur in paroxysms and is maximal at or near onset
Facial muscle spasms can be seen
Pain described as electric, shock like or stabbing
Usually lasts from 1-several seconds but may occur repeatedly
Pain is out of proportion from the stimulus

21
Q

triggers of nerualgia trigem

what to do for this pt? drugs? 3

A 
Chewing
Light touch
Talking
Brushing teeth
Cold air
Smiling/grimacing

refer to neurologist

Carbamazepine 100-200mg po BID. Can increase dose gradually in 200 mg increments as tolerated to total maintenance dose 600-800mg daily plus give prn pain managment
Baclofen: start at 15 mg daily given in 3 divided doses with gradual titration to maintenance dose of 50-60mg/day
Lamotrigine: start at 25mg daily x 2 weeks then increase to 50mg daily for weeks 3 and 4. Dose titrate to effect by increasing by 50mg daily every 1-2 weeks. Suggested total dose is 400mg daily given in 2 divided doses.

22
Q

Headache with gradual onset stiff neck photophobia and fever may be due to?

A generalized headache that is worse in the morning and is associated with drowsiness or vomiting may reflect? eg?

A

meningitis

ICP (aneurysm, subarachnoid hemorrhange, tumor, encephalitis, meningitis, trauma, hydrocephalus, stroke)

23
Q

mx of tension headache? what drug? max dose, taper when?,

how long it takes to work? think original therapeutic purpose

A

find underlying cause addressed Stress reduction

Amitriptyline 10-12.5mg at hs and increase the dose in 10-12.5 mg steps every 2-3 wks as tolerated and as needed for sleep, until there is improvement in headache.
Max dose 100 -125 mg hs
Takes 4-6 weeks before improvement seen and ay be accrued up to 3 months
Maintain for at least 3-6 months then taper

24
Q

how long migraines last?

4 phases?

A

hours to days

Prodrome (60%)- lassitude, irritability, difficulty concentrating, nausea 24-48 hrs prior to onset of headache
+/-Aura (~25%)-visual (scintillations to scotoma), sensory (tingling on 1 side of the limb/face leading to numbness for up to 1 hr), less common are dysphagic aura (language) http://www.youtube.com/watch?v=ZrrviW0Od-w
http://www.youtube.com/watch?v=qVFIcF9lyk8
Headache-usually unilateral, throbbing/pulsatile quality. Termination-usually w/i 24 hr; sometimes 72 hr often during sleep without tx
Postdrome-fatigue, sleepiness, irritability

25
Q

meds for migraines - 6

A

Sumatriptan 85mg/naproxen 500 mg tab
More effective than either agent as monotherapy
Rizatriptan (Maxalt) 5 or 10mg orally disintegrating tabs (may repeat in 2 hrs prn-max 30mg/day)
Antiemetics
Metoclopramide IV/IM can be used as montherapy for acute tx
Diphenhydramine IV is recommended to be given concurrently to prevent adverse events (utd)
Opioids shouldn’t be used for tx of migraine, except as a last resort d/t to potential for addiction and overdose

26
Q

Prophylactic meds for migraines - 3 types

A

BBs-first line, reduce frequency and severity by 50%
Propranolol start at 40 mg BID; dose range 40-160 mg daily
Metoprolol start at 100 mg BID; dose range 100 -200 mg daily
Timolol start at 20 mg BID; dose range 20 to 30 mg daily
Not to be used in >60 y.o. or smokers (d/t risk of CV events)
Amitriptyline starting 10 mg at hs, dosage range 20 -50 mg at hs
Antiepileptic drugs: valproate, topiramate
NSAIDS (naproxen)

27
Q

abortive mx for cluster HA? 2

A

Abortive
O2 5-8 L/minX10 min (12L/min non-rebreather mask x15 min
And/or SC sumpatripatan 6mg effective within 20 min

28
Q

tx for cluster HA, SE what to do with follow up?

A

verapamil is associated with an increased incidence of ECG abnormalities, including heart block and bradycardia

29
Q

Benign Paroxysmal Positional Vertigo, what is it, what to do?

ss?

A

positional vertigo, try physio

Attributed to calcium debri (otoliths) in the semicircular canal.

Clinical Manifestations
Recurrent vertigo lasting ≤1min with head movement
Wks-months without tx
May be accompanied by n/v
Nystagmus with provocation
30
Q

how to dertermine if true vertigo

A

True vertigo can be reproduced. If it can’t it is unlikely to be vertigo.
If patient tells you they are continuously dizzy, it is not vertigo
Then try to determine if it central or peripheral.
Central will be accompanied by brainstem sx: diplopia, facial numbness, weakness, hemiplegia, dysphagia
Peripheral
Timing and precipitating factors help to elucidate most causes
Consider neuroimaging for vertigo with neurologic s/s risk factors for CV disease, or progressive unilateral hearing loss

31
Q

Meniere’s
patho?

dx?

avoid?

tx?

A

Patho:
Results from idiopathic endolymphatic hydrops
Typically presents in 20-40 y.o.
Clinical Features:
Episodic vertigo (20min-24 hr duration and sensorinueral hearing loss (becomes permanent),tinnitus lasting min-hrs
Pain in the ear, aural fullness, nausea

dx - Clinical-no specific test
Audiometry
Refer early to ENT to do workup. MRI may be ordered to r/o CNS lesions

avoid - Avoid caffeine, nicotine, alcohol, MSG, nicotine
Salt restriction to 1-2 g/day
Stress reduction

tx -
HCTZ 50 mg BID
Surgery

32
Q

MS clinical feautures

A

Clinical Presentation
Attacks typically a few hrs -days; last anywhere from >24 hours to a few months
Sensory Deficits
Visual and Occulomotor Deficits
nystagmus
Coordination issues
vision, numbness, nerve pain, dizziness, balance/ coordination, difficulty walking, muscle weakness, tremors, bowel/bladder, difficulty thinking

Paresthesisa/ sensation in the extremities
“Numbness, pin/needles, tightness, coldness, swelling”
Lhermitte phenomenon – classic, only when having an attack, 10%
Transient sensory sx-electric shock radiating down the spine or into the limbs with flexion of the neck
PEx:
Impairment of vibration and joint position sense
Decreased perception to pain and light

33
Q

Lhermitte phenomenon

A

– classic, only when having an attack, 10%

Transient sensory sx-electric shock radiating down the spine or into the limbs with flexion of the neck

done spring and fall 2017 (8 decks)

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