Cases 1-4 Flashcards
Define Acute, subacute , chronic and recurrent sinusitis
- Acute rhinosinusitis: symptoms < 4 weeks
- Subacute rhinosinusitis: symptoms for 4-12 weeks
- Chronic rhinosinusitis: symptoms > 12 weeks
- Recurrent acute rhinosinusitis: ≥4 episodes per year, with interim symptom resolution
What would make you suspect bacterial sinusitis
Symptoms > 10 days (without improvement) •Unilateral maxillary sinus/facial pain •Maxillary tooth pain •Unilateral purulent nasal discharge •Second sickening •Fever
What pathogens cause acute bacterial sinusitis
-Strep pneumo
•H influenza
•M cattarhalis
•Staph aureus
What medications would you use to treat bacterial sinusitis and how long for both adults and children
1st line therapy: Amoxicillin/clavulanate (Augmentin) •Adults or kids •Penicillin allergic: Doxycycline •Adults: 5-7 days •Kids: 10-14 days
How would you treat viral Rhinosinusitis
Analgesics/antipyretics •NSAIDs & Tylenol •Saline irrigation/nasal spray •Intranasal glucocorticoids •Flonase •Oral or nasal decongestants •Sudafed, Afrin •Vicks
What are some complications of sinusitis?
- Preseptal cellulitis- swelling and erythema but no proptosis or limitation of eye movement
- Orbital cellulitis- Proptosis, limitation of eye movements, diplopia, vision loss
- Septic cavernous sinus thrombosis- bilat ptosis, proptosis, HA, mental status change
- Meningitis- HA, Fever, Nuchal rigidity
- Osteomyelitis of frontal bone
- Epidural, brain, and subdural abscess
Who is more likely to get a migraine men or woman
Woman
What are some migraine triggers?
- Change in weather
- Sleep: to much or to little
- Skipping meals
- Medications
- Menses
- Aged cheese, cured meats, red wine, dried fruits
- Nuts
- SEX
- Altitude
- Sun/heat
What is the pathophysiology of migraine
People who experience migraines are thought to have an increase in Calcitonin gene related signaling. CGRP is a neuropeptide that signals pain in the trigeminal nerve. The release or overproduction of CGRP, which is usually a genetic inheritance, causes the pain associated with a migraine
What are the 4 stages of a migraine
- Prodrome
- Aura
- Headache
- Postdrome
Define Prodrome
beginning phase of a migraine, can last hours to days.
S/Sx: irritability depression sensitivity to light Nausea difficulty sleeping
Define Aura
Can last 5-60mins
S/Sx:
visual disturbances, temporary loss of sight, numbness and tingling on part of the body.
The migraine/HA itself
Can last 4-72hrs
S/Sx:
Throbbing unilaterally Drilling Ice Pick Burning Nausea Vomiting Insomnia
Define Postdrome
Last stage of Migraine, can last 24-48 hours
S/Sx: Inabillity to concentrate Fatigue Depressed Mood Weird but Euphoric Mood Lack of comprehension
What is the abortive therapy for an acute migraine
1st line
- APAP/ASA/Caffeine(Excedrin)
- NSAIDs
- Acetaminophen
2nd line
- Triptans
- Ergotamine nasal spray
3rd line
- Ketorolac injection
- Ergotamine IV
- Dexamethasone
- Opioids- DO NOT USE!!!!!!
What are some prophylaxis Txs for migraines
- Beta Blockers
- Calcium channel blockers
- Anti-depressants
1. SSRIs/SSNRIs: fluoxetine, venlafaxine
2. Tricyclic antidepressants (amitriptyline, nortriptyline)
-Anti-Convulsants: Valproic acid, topiramate
- Calcitonin Gene-Related Peptide Therapy
- Botox
- Magnesium
- Biofeedback/acupuncture/cognitive behavior therapy
What are the differences btw migraine and tension HA
Tension: is generalized or bilateral, affects neck, traps and back of head. Is a steady pain, usually occur in the afternoon, N/V not common
Migraine: Unilateral, Temporal, Throbbing Pain, can happen anytime, N/V more common
Pt education for migraine
- Avoidance of triggers
- Be aware of symptoms and catch them early
- Beware of rebound headaches/medication overuse
- If there is a headache that is different than your typical ones, come in
- Worst headache of your life, go to the ER
- Migraine symptoms can include….
- Side effects of new treatments
- Headache diary
- Menstruation
- Genetic
What are the main things to watch out for when prescribing a abortive therapy
-People with a history of MI, or Stroke or Hemorrhage should not take because these are vasoconstrictors
What are the three Types of CVA
- Ischemic
- Hemorrhagic
- Small Vessel (lacunar)
If an ischemic stroke last less than 24hrs what is it called?
This is known as a TIA and are caused by focal brain, spinal cord, or retinal issues and resolve on their own
What are the two types of ischemic stroke
- Thrombotic: Occlusion forms locally at the site
2. Embolic: Occlusion breaks off from another place moves and gets clogged in a different place
Difference BTW Hemorrhagic Vs Lacunar
Lacunar strokes are either pure motor or pure sensory deficits they do not have both
Risk Factors for a CVA
- Increased age
- Afib
- Hypercoagulable states
- HTN
- Smoking
- DM
- Drug use
- TIAs
S/Sx of ACA stroke
- Contralateral paralysis and sensory loss that mostly (or only) affects the leg
- Abulia (apathy)
- Urinary incontinence
- Gait apraxia
- Grasp reflex or sucking reflex
S/Sx of MCA stroke
Hemiparesis primarily affecting face & arm
Hemisensory deficit primarily affecting the face & arm
Gaze preference toward the affected hemisphere
Aphasia (if dominant hemisphere is affected)
Hemianopsia
May have apraxia and sensory neglect
S/Sxs of PCA stroke
Homonymous hemianopsia affecting the contralateral visual field
May be denser superiorly
Anomic aphasia (difficulty naming objects)
Alexia without agraphia (inability to read, but able to write)
Visual agnosia
Contralateral hemisensory loss and hemiparesis
Unilateral headache
Memory impairment
Oculomotor (III) nerve palsy
What are some S/Sxs of Lacunar strokes
- Pure Motor Hemiparesis
- Pure sensory Stroke
- Ataxic hemiparesis
- Sensorimotor Storke
- Dysarthria- Clumsy hand syndrome
S/Sxs of pure motor lacunar stroke
Weakness involving the face, arm, and leg on one side of the body. No sensory deficit
Pure Sensory lacunar Storke S/Sxs
Numbness of the face, arm, and leg on one side of the body. No motor deficit
Ataxic Hemiparesis lacunar stroke S/Sx
Weakness and numbness of the face, arm, and leg on one side of the body
Dysarthria-clumsy hand syndrome
s/sxs
Facial weakness, dysarthria, dysphagia, and slight weakness and clumsiness of one hand
Evaluation of CVA
- Neuro exam
- CT w/o contrast to eval for hemorrhage
- MRI: More sensitive to detect early ischemia
- MRA: Eval arteries for stenosis, occlusion, or aneurysm
- EKG: Eval for arrhythmia
- Carotid Doppler: Check for carotid stenosis
- Echo: Eval for possible embolic source
What is the TPA inclusion Criteria
- Age ≥ 18 years
- Clinical diagnosis of ischemic CVA with a measurable neurologic deficit
- Time of onset <4.5 hours
What are some exclusion criteria for TPA
- Evidence of intracranial hemorrhage on CT
- Previous intracranial hemorrhage
- Severe uncontrolled HTN (SBP>185 or DBP >110)
- Known AVM, neoplasm, or aneurysm
- Thrombocytopenia <100k
- Current use of an anticoagulant with INR >1.7 or PT >15 seconds
- Heparin use within 48 hours and abnormally elevated aPTT
- Current use of a direct thrombin inhibitor or direct factor Xa inhibitor with lab evidence of anticoagulant effect
- Arterial puncture at a noncompressible site in previous 7 days
- Active internal bleeding
- Significant stroke or head trauma in the previous 3 months
- Recent intracranial or intraspinal surgery
- Serum glucose < 50
What are some relative Exclusion criteria for TPA
- Minor or isolated neurologic signs
- Rapidly improving stroke symptoms
- Major surgery or serious trauma in the previous 2 weeks
- GI or urinary tract bleeding in the previous 3 weeks
- MI in previous 3 months
- Seizure at the onset of stroke with postictal neurologiuc impairments
- Pregnancy
Relative exclusion criteria if onset was from 3-4.5 hrs
- Age >80
- Oral anticoagulant use regardless of INR
- Severe stroke (NIHSS score >25)
- Combination of both previous ischemic stroke and diabetes
BP management for ischemic CVA
- need a blood pressure to maintain perfusion to the brain
- drastic lowering of BP usually makes Pts worse
- Before thrombolysis: lower SBP to <185 and DBP to <110
Afterward, BP needs to be maintained <180/105 for at least 24 hours
If a Pt is not going to get TPA do they suggest you treat the BP? If they do at what BP level would you intervene
If not pushing TPA than no BP intervention needed unless SBP> 220 or DBP>120 or if they have any of the following
-active ischemic CAD
- heart failure
- aortic dissection
-hypertensive
encephalopathy
- ARF
- preeclampsia/eclampsia
Additional Management of CVA Pt
Antithrombotic therapy
Aspirin, clopidogral (Plavix), or aspirin-extended release dipyridamole (Aggrenox) all choices
Warfarin or NOAC for those with afib
VTE prophylaxis
Lipid lowering with statin
Blood pressure reduction after the acute phase of the ischemic stroke has passed
Smoking cessation
Exercise
Weight reduction
What are some clues from H&P that will make you think claudication
- Pt can walk 4 blocks (discrete distance) prior to pain
- Sitting helps
- Pain resumes with activity again
- Pain in legs with reclining in chair
- Dangling them down relieves the pain
- Advil does not help
- PMH clues you in
- Diminished pulses, smooth hairless legs that are cooler to touch, thickened toenails, color changes, +Buerger test
What would be a positive Buerger test
Pallor in the feet/ lower extremities after lowering legs from holding them at an angle of 45 degrees for 1-2 minutes
What is the Main Cause of PAD
PAD is most commonly secondary to atherosclerosis
What are some clinical S/Sxs of PAD
- Asymptomatic
- Intermittent claudication
- Atypical pain
- Pain at rest
- Nonhealing wounds
Usually on feet - Ulcers
- Gangrene
- Dry or wet
- Thin, hairless/shiny skin
- Cool skin
- Blue toe syndrome
Define claudication
- Exertional leg pain that classically occurs after a certain distance of walking
- Resolves with rest
- Symptoms resume again when patient resumes walking and goes the same distance
- Buttocks, hip, thigh, or leg pain
Location can often correlate with the site of the lesion
aortoilliac disease affects what parts of the body?
Buttocks & Hips
Aching, may have weakness of thigh or hip with walking. Diminished pulses in 1 or both groins
Leriche syndrome: triad of claudication, absent or diminished femoral pulses, & ED
Where would find a clot in someone experiencing pain in the thigh
Common Femoral Artery
Clot in the upper 2/3 of superficial femoral artery would affect what body part?
This would cause pain in the calf
Clot in the lower 2/3 of femoral artery would affect what body part?
Popliteal area
If a Pt was experiencing pain in the foot where would you expect the clot to be?
Tibial or peroneal
What is the Tx for acute limb ischemia
Start heparin immediately & immediate revascularization
Define an Arterial Ulcer
Arterial ulcers are very painful whereas venous are dull and achy
Arterial Ulcers are also deeper than venous ulcers, have well defined boarders, and are more dry than venous ulcers
What are the 6 Ps for acute limb ischemia
Pain, pallor, pulselessness, paresthesia, paralysis, and perishingly cold
Define Venous Ulcer
These ulcers are usually found on the lower part of the legs, are shallow, have irregular boarders, and have a moderate to heavy amount of exudate and are considered “wet”.
Define Diabetic Ulcer
They are usually seen on the bony prominences of the body where continues pressure occurs. The main difference with these types of ulcers is that there will not be any pain associated with the ulcer. The pt is unable to feel it or even notice it.
Absent Reflexes, foot deformities
What do you use for ABIs
this is performed using a doppler probe
What is an ABI?
This is a ratio of the ankle systolic BP divided by the Brachial systolic BP
Whats a normal range for an ABI
0.9 to 1.3
What ABI is diagnosiable for PAD
A value less than or equal to 0.90
What does an ABI > 1.3 indicate?
This is indicative of calcified vessels
An ABI that is down 20% after exercise is diagnostic of what?
Arterial obstruction
Who might you consider having perform Exercise testing?
Might be considered in patients with atypical pain & a normal ABI
What does an Exercise test show?
Exercise treadmill tests give the most objective evidence of how much someone is functionally limited
Can also show response to treatment
What is the initial imaging study for PAD
-CT angiography: initial study
-Conventional arteriography remains the gold standard for vascular imaging
In cases of acute ischemia, is preferred because simultaneous intervention possible
Whats the reason for ordering vascular imaging?
Main goal: Provide clinicians with the information needed for an intervention
Level & extent of disease
Tx for PAD
Risk factor modification
Smoking cessation, control DM and HTN, lose weight
Antithrombotic therapy long-term
ASA or Clopidogrel (Plavix)
Lipid-lowering therapy with at least a moderate intensity statin
Irrespective of LDL cholesterol level
Tx for claudication
- Initial: supervised exercise program
- Cilostazol (Pletal)
Contraindicated in ANY patients with CHF (↓survival). Patients with CAD have ↑ risk of angina & MI
s/e: headache, diarrhea, infection, rhinitis - Revascularization
- For life threatening ischemia –or-
- Patients with significant/disabling symptoms unresponsive to lifestyle modifications & medication
- Need to first undergo vascular imaging to determine the anatomy & extent of disease
- Stenting or bypass
Prognosis/Complications of PAD
- PAD is a strong predictor of adverse CV outcomes
Regarded as a CHD risk equivalent - Predictors of progression to critical ischemia: Diabetes, ↑pack year smoking hx, lower ABI
- Risk of major amputation in patients with intermittent claudication
7% over 5 years
12% over 10 years
What affects Med dosing?
Age Weight Renal Function Hepatic Function Other current medications
What are the available forms of Amoxicillin
Capsules: 250 mg, 500 mg
Tablets: 500 mg, 875 mg
Chewable: 125 mg, 250 mg
Suspension: 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml
Describe the Schedule I-V drug classes
Schedule I
No currently accepted medical use in the US, lack of accepted safety, and high potential for abuse
Ie: heroin, marijuana (psh lies), cocaine
Schedule II
High potential for abuse, physical, and psychological dependence
Oxycodone, morphine, dilaudid, fentanyl, Ritalin, amphetamine
Schedule III
Lower potential for abuse
Ketamine, depo-testosterone, Tylenol with codeine
Schedule IV
Low potential for abuse (relative to other categories)
Xanax, , valium, Ativan, restoril, klonopin
Schedule V
Low potential for abuse, usually a preparation with limited quantities of narcotics
Robitussin with codeine
