Clin Med 3 Flashcards
failure to thrive def vs causes vs PE vs dx criteria vs tx
inadeq growth or fail to maintain growth vs child can’t use calories, malabsorption, inc metab demands vs dysmorph, subq fat stores, adenopathy vs wt/ht <5th percentile; wt dec 2 percentile, wt for ht = <5th percentile; inadeq wt for ht/age/BMI vs involve parents, support, inpt eval
Fail to thrive from insufficient calories: inadeq food vs emesis vs child not taking enough food
Poor knowledge, Food insecurity, Formula dil, BF difficulties vs pyloric stenosis, esophagitis vs oromotor dysfxn, behavior feeding problem, anorexia from systemic illness
fail to thrive from malabsorption d/t:
CF, celiac dz, hepatobiliary dz, short gut syndrome
fail to thrive from inc metab demand d/t:
endo/metab d/o, congen infxn like TORCHES/HIV, genetics, immunodef/autoimmune
developmental delay def vs causes vs screening examples
child not meeting milestones in >1 area of development vs genetic, environ, metab, vision/hearing, autism vs newborn screen, hgb, Pb, vision/hearing, MCHAT-R, lipid, depression
why is hgb impt to screen? when is it screened?
anemia = cause of DD d/t lack of Fe, hgbnopathy, chronic dz, too much cow’s milk. birth, 12mo, 24mo
why is Pb impt to screen? when to do it?
sig cause of DD. 12 & 24mo by blood, 6mo by risk assessment
what’s MCHAT-R? when to do it?
modifed checklist for autism in toddlers-revised. risk assessment for autism spectrum d/o at 18 & 24mo
when/why do lipid screen
9-11yo, 17-21yo; see if high risk for CVD
OMAS = assoc w/ neuroblastoma which are found in where? what do they express?
adrenal glands, chest, neck of children <5yo. neurofilament protein Hu –> plasma cells make antiHu igG to attack neuroblastoma but also brain –> autoimmune
how to dx vs tx OMAS?
those 3 sxs, CSF w/ high protein w/o inc in cells => albuminocytologic dissociation, blood test w/ EBV & VZV vs dexamethasone, azathioprine, ACTH; IV igG; benzodiazepines, antiepi, rehab
MS pathology vs sxs vs dx vs tx
inc Th17 inflamm, myelin lost & oligodendocytes destroyed –> astrocytes activated, lymphocytes invade brain parenchyma b/c BBB broken vs paresthesias, muscle cramps, optic neuritis vs space/time, CSF oligoclonal bands, EEG vs immunomodulary therapy, dimethyl/diroximel fumerate, PT/OT; INFB, IVIG, antiCD20
Guillain Barre syndrome. dx vs tx
molec mimicry b/w C. jejuni/CMV/EBV ab w/ GM1/2, GD1b along a dermatome –> ascending symmetrical weakness/dec reflexes/flaccid paralysis, tachy/bradycardia, hypo/pertension. LP w/ albumonicyto dissoc, CT/MRI show cauda equina nerve root enhancement, nerve condux show nerve root demyelin vs resp therapy, cardiac monitor, analgesia, IVIG/plasma exchange
MG genetics. comorbidities?
HLA-B, HLA-DRB1, thymic abnlity –> postsynaptic Ach receptor autoab –> affects skel muscles, transplacental transfer –> neonatal MG lasting 2-3mo. autoimmune DM, RA, Hashimoto’s
how to dx vs tx MG?
immunofluorescence, EMG, edrophonium, chest rads vs AchEI, IVIG/plasma, immunosuppressants, thymectomy
Lambert-Eaton syndrome. risk factors? dx vs tx
autoimmune against voltage gated Ca2+ channels –> presynaptic d/o –> can’t release Ach –> muscle weakness, dec reflexes. SCLC, smoking. sxs, inc reflex after ctx muscle, ab, repetitive nerve stim studies vs corticosteroids, IVIG, plasmaphoresis, chemo if ca
stage 1 vs 2 vs 3 sleep characteristics
together make 75-80% of sleep time. slower alpha waves w/ sharp waves at the end of stage, dec EMG, slow eye movements vs delta waves, sleep spindles, K complexes vs more delta waves
REM sleep
20-25% of sleep time, aroused EEG, sexual arousal, saccadic eyes, dream, assoc w/ pons
tonic vs phasic phase of REM sleep
desynch EEG, a/hypotonia, monosynpatic depression, polysynaptic reflexes vs rapid eye movements, inc HR/bp, irreg resp, mid ear activity, tongue movements
which parts of brain generate wake vs NREM vs REM sleep?
reticular activating system but diffusely localized vs basal forebrain, medulla vs basal forebrain, pons
polysomnography
diag test to record brain electrical activity/EEG, eye/jaw/leg muscle movement/EMG, airflow/resp, EKG, O2 sat
mult sleep latency test
5 20min naps 2 hrs apart –> document obj excessive sleepiness & lseep onset. mean sleep latency <5min –> pathologic sleepiness
Epworth sleepiness scale: 0 vs 1 vs 2 vs 3
never doze off vs slight chance dozing vs mod chance dosing vs high chance dozing. score >10 –> abnl
Mallampati classification of OSA: 1 vs 2 vs 3 vs 4
soft palate, uvula, fauces, ant/post pillars vs soft palate, uvula, fauces vs soft palate, base of uvula vs no soft palate
sx (day & nocturnal) vs PE vs dx vs tx vs prevent OSA?
excess somnolence, forgetfulness, personality change, dry mouth when wakening, morning HA, impotence; snoring/choking in sleep, fighting for breath, acid reflux, insomnia vs obesity, large uvula/low hanging soft palate, retro/micrognathia, HTN, cardiac arrhythmia vs PSG, apnea hypoapnea index/resp disturbance index (<5 = nml, 15-30 = mod, >30 = severe OSA) vs C/BPAP, tongue retaining devices, uvulopalatopharyngoplasty, tonsillectomy/adenoidectomy, tracheostomy vs avoid alc, sed, hypnotics, lose wt/exer
narcolepsy sx vs genetics
tetrad of excess daytime sleepiness, cataplex (loss of skel muscle tone), sleep paralysis, hypnagogic halluc vs HLA-DQB1-0602, dec CSF hypocretin in post and lat hypothal, fhx
dx vs tx narcolepsy
excess daytime sleepiness & cataplex; MSLT vs behavior therapy; ritalin, pemoline, ar/modafinil
insomnia. assoc vs dx vs tx
a sx not a dx; difficulty falling/maintaining sleep, waking too early, nonrefreshing sleep. assoc w/ EDS, fatigue, difficult conc, irritability vs when other conditions = ruled out, PSG/MSLT not required vs sleep hygiene, short acting hypnotics
parasomnia
violent or subtle motor activity, autonomic or behavioral phenomena in sleep or sleep-wake transition
parasomnia classifications: sleep wake transition vs arousal d/o vs REM vs others
rhythmic movements, nocturnal leg cramps, sleep talking vs confusional arousals, sleep terrors, sleep walking vs behavior d/o, nightmares, sleep paralysis vs sleep bruxism, sleep enuresis
sleep terrors/Pavor nocturns
terrified screaming w/ autonomic component (tachycardia/apnea, diaphoresis, mydriasis), disorient/confusion when waking; occurs in 1st half of sleeping period N3
nightmares. when do they occur in sleep?
vivid dreams in REM causing person to wake up b/c emotions in dream threaten sense of security while resting; occurs in 2nd half of sleep during REM
REM sleep behavior d/o. assoc w/? PSG shows? tx?
skel muscle atonia in REM –> complex motor activity in REM –> talk/laugh, punch/kick. assoc w/ Parkinsons, mult system atrophy, lewy body dementia. high EMG activity during REM. clonzepam 0.5-2mg
what part of the brain = master of circadian clock? how do circadian rhythm sleep d/o occur?
suprachiasmatic nuclei. physcial environ = altered relative to internal circadian time
delayed sleep phase syndrome. tx?
sleep = delayed in relation to desired sleep time –> insomnia, difficulty waking at desired time. chronotherapy: intentionally delay sleep onset by 2-3h on successive days until desired bedtime achieved; phototherapy: exposing bright light to stay awake
advanced sleep phase syndrome. dx vs tx?
sleep early to wake up early; more common in elderly. clincally vs chronotherapy: shift sleeping schedule 2-3h backwards; phototherapy: bright light in evening
what are neurocut/Phakamatoses d/o?
CNS d/o resulting in lesions on skin, eye, other organs of ectodermal region
tuberous sclerosis. tx?
auto dom TSC1 on 9q34 + TSC2 on 16q13 –> no hamartin + tuberin –> triad of mental retard, epi, skin lesion (benign hamartoma, adenoma sebaceous, hypomelanin, cardiac/renal tumors, subependymal giant cell tumors). correct hydrocephalus, ctrl epi, monitor other organs
NF1
auto dom NF1 –> no neurofibromin –> 6+ cafe au lait, 2+/1plexi neurofibroma, axilla freckles, 2+ Lisch nodules, optic glioma, sphenoid dysplasia, 1st relative w/ NF1
NF2
auto dom NF2 –> no merlin –> vestibular schwannoma, hearing loss, tinnitus, bal probs
sturge-Weber syndrome. tx?
facial capillary venous malformation/port white stain affecting brain & eye, sz, glaucoma, mental retard/learning disability, hemiplegia/atrophy, behav/emotional probs. laser therapy for wine stains, anticonvulsant/surg for sz, eye drops/surg for glaucoma, PT for paralysis
VHL. type 1 vs 2. tx?
auto dom VHL tumor suppressor gene –> no VHL protein –> non/cancerous tumors or fluid-filled cysts. low risk pheochromocytoma vs high risk 2A/B/C –> pheochromocytoma, renal cell ca; hemangioblastoma in brain & spinal cord –> HA, emesis, atax; retinal angioma –> vision loss, pancreas tumors. surg, rads therapy, better to tx when small
2005 def of sz vs epi. 2014 def of epi?
transient abnl/excessive or synchronous neuronal brain activity vs brain d/o w/ predeposition to epi sz & by bio/cog/psych/social conseq of the condition. 2 unprovoked szs >24h apart, 1 sz w/ higher chance of another sz, 2 szs w/ reflex epi
simple vs complex partial sz
pt = aware of event; can progress to dyscognitive or tonic clonic sz vs pt w/ impaired awareness during sz –> confused, amnesia; 30s-3min
absence sz
sudden onset w/o aura, prompt offset, momentarily LOC, eye flutter; 3-15s
tonic vs atonic sz
sudden stiff, max arm extension, extratemporal origin, refractory to therapy, assoc w/ fall/injury; few seconds vs sudden onset, sudden loss in tone, head drop/fall/injury; 1-2s
myclonic sz vs tonic-clonic sz
sudden jerks, max arm extension, photic/sensory triggered; 1s vs focal/generalized onset, tonic extension of limbs, rhythmic clonic jerking, cess breathing/tongue biting/incont, LOC, post ictal sleep
Jacksonian march. area it affectS?
focal sz w/ clonic or tonic movements usually face/hands; primary motor cortex –> precentral gyrus
how does a sz occur?
excitation (gluE, asp NT; Na+/Ca2+ ions), inhibition (GABA; Cl- entering, K+ leaving)
what is stroke?
vasc event –> focal brain injury; in old def: sxs lasting <24h, in new def: +dmg seen in (diffusion) MRI w/in min or CT w/in 6h
what is TIA?
pathologically same as stroke but sxs last for less time & not seen in img; have same eval & risk factors
ABCD2 interpretation stroke risk: 0-3 vs 4-5 vs 6-7pts. NIH stroke interpretation: 0 vs 1-4 vs 5-15 vs 16-20 vs 21-42
low risk vs mod risk vs high risk. no stroke sxs vs minor stroke vs mod stroke vs mod to severe stroke vs severe stroke
atherosclerosis vs thrombus vs embolism
plaque w/ irreg surfaces building up in blood vessels, usually chol –> block vessel –> stroke vs clot/plaque building up & block vessel in situ vs clot/plaque breaks off –> travels thru till it blocks vessel –> stroke
stroke risk factors vs protective factors
prev stroke, >65yo, female, black; HTN (tx if >140/90 <60yo or >150/90 >60), high chol (tx if LDL <100 or <70 if concomitant risk); DM/metab syndrome, tobacco esp smoking; soda, high salt, obese, sleep apnea vs cruciferous & green leafy veggies, citrus fruits, juice, coffee, Mediterranean diet, exer
rapid stroke eval
last seen nml = rtPA clock starts: sudden or gradual onset (grad = stroke mimics like migraines), vasc risk factors, eligibility for rTPA, triage in EMS or ER, labs/head CT
yes vs no for rTPA candidate
stroke onset w/in 4.5h, >18yo, <185/110, INR <1.7, PLT >100000, blood glu >50
vs
severe head trauma, intracranial/spinal surgery, ischemic stroke past 3mo, heparin w/ 48h, prev or current intracranial blee, aneurysm, tumor, AVM
post stroke early vs late complications
allergy to rTPA, reperfusion bleed/edema; malig cerebral edema, recurrent stroke, DVT, dysphagia/aspiration –> PNA, infxn vs fall, sz, sleep d/o breathing, depression
stroke tx goal for 72h vs long term
avoid stroke extension, protect ischemic penumbra: nml saline/no dextrose, >92% satO2, glu >150, temp <99, ASA 325mg 24h post rTPA, don’t lower bp unless >210/100; OT/PT, speech/swallow eval –> bed up 30degrees vs ASA/extended, clopidogrel if allergic to ASA, anticoag
what happens if there is hypovolemia/hypoTN?
dec cardiac output or hypovolemia –> low bp to maintain perfusion. if systemic hypoTN –> focal artery stenosis –> brain distal to stenosis –> prone to ischemia
watershed infarcts. risk factors?
systemic hypoTN w/o focal vessel stenosis in watershed regions (b/w ACA/MCA or PCA/MCA). orthostat hypoTN, perioperative, MI, cardiac dysrhythmia, severe lg vessel stenosis
intracerebral hemorrhage sxs
focal cerebral sxs & deficits, sudden onset severe HA, sz, altered consc, WORSENING in short period of time, ICP
intracerebral hemorrhage causes
trauma, hem stroke, ishcemic stroke turning to hem stroke, aneurysm rupture/Charcot Bouch pseudoaneurysm/Berry, arterial dissection, amyloid angiography, vasc malformations, tumor
hem stroke sxs vs eval vs tx
sudden onset neuro deficit, HA, but hard to tell diff b/w ischemic stroke –> vs neuro eval, noncontrast head CT, LP, bp b/c major risk factor vs no anticoag, keep bp <160/80, neurosurg decompression
intracerebral aneurysm sxs vs eval vs tx
loss of consc w/ focal findings, thunderclap HA, subarach hem, ICP –> irreg breathing, dil pupil, abnl extraocular vs noncontrast head CT, LP if CT neg, cerebral angiography/CTA/MRA vs clip/coil, prevent sz & arterial spasm, supportive
berry vs Charc-Bouch aneurysms
mult, sac, 2-25mm, in circle of Willis; rupture –> subarach hem or ICH w/o SAH vs chronic HTN, BG/thal/brainstem, <1mm; sm arterioles rupture –> hem stroke
arterial dissection features vs eval vs tx
carotid = most common but can affect any vessel; pain, HA, focal neuro deficits for wks; assoc w/ SAH vs angiogram, CTA/MRA, LP vs ASA 325mg; if persistent embol –> anticoag, bypass, vein graft; if vertebrobasilr & intracranial dissections –> clip, balloon/graft, reverse flow
vascular malformation features vs eval vs tx
v/v –> cavernous hemangioma, venous angioma; a/v –> a/v malformations –> more likely to bleed b/ higher pressure –> sz, HA, ICH; smaller = worse than lg vs angio, CTA/MRA, noncontrast CT/MRI vs no tx/monitor for v/v; embolization, radiation, resection for a/v
amyloid angiopathy features vs eval vs tx
recurrent or petchial lobar hem (seen on gradient echo MRI) vs cerebral bx for amyloid vs no tx, avoid anticoag & anti PLT
most common hem brain tumors
glioblastoma, primary CNS lymphoma, melanoma, choriocarcinoma, renal cell ca, bronchogenic ca
brain abscess forms in which order of lobes? by what bacteria and what can they lead to?
front/temp > front-par > par > cerebellar > occ. strep anginosus –> dental plaque, oral abscess
direct vs indirect brain abscess. sxs?
single abscess –> mid ear, mastoid, sinuses, front lobe vs mult abscesses –> MCA, GW jxn, par lobe. ipsi HA, intracranial HTN, papilledema, meningism
eval vs tx of brain abscess
high serum CRP & WBC, CT/MRI: ring enhance vs metronidazole to prevent anaerobe DNA synthesis (disulfram rxn if w/ alc)
nonop vs op tx for closed head injury
hypertonic saline, mannitol/diuresis, hypervent vs EVD w/ CSF drain, surgical decompression
spinal vs neurogenic shock
temporary, in/complete, contused phenomenon vs loss sympathetic/preserved parasympathetic, hemodynamic phenomenon
when to do surg for SDH vs EDH?
> 5mm MLs, >1cm thick vs >30cm cubed, GCS <9
