Clin Med: Neuro I Flashcards
3 “headache” populations
- Outpt office- usually migraine or tension
- ER–> must immediately exclude life threatening headaches
- Headaches during pregnancy
To differentiate a HA from brain bleed use…
RED FLAG SYMPTOMS
SSNOOP criteria to ID red flag symptoms
- Systemic symptoms
- 2ndary risk factors/underlying dz (HIV, cancer)
- Neurologic signs/symptoms (confusion, focal neuro findings)
- Onset (sudden, abrupt)
- Older age (new onset/progressive)
- Pattern change (change from previous is frequency or severity)
Primary HA examples
- Migraine
- Tension
- Cluster
- Other (cough, exercise, post coital)
2ndary HA examples
- Trauma
- Vascular (TIA, CVA)
- Substance or substance withdrawal
- Infx (meningitis, influenzas)
- Disorder of homeostasis (HTN, altitude, sleep apnea/hypoxia)
- Attributed to disorder of eyes, ears, sinuses, teeth
- Psychiatric Disorder
Painful Cranial Neuropathies/Facial Pain Examples
- Trigeminal neuralgia
- Optic neuritis
What is considered an episodic tension HA?
14 or less per month
Cluster HA Dx
abortive therapy for cluster HA
- First line–> 100% O2 high-flow mask w/ pt in sitting position
–> 10-20 minutes - triptans
Prophylactic therapy for cluster HA
- Verapamil
- Lithium
“Other” Tx for Cluster HA
- Suboccipital corticosteroid injections in the greater occipital nerve
- Prednisone for 5 days post-attack
- Galcanezumab (Emgality)
Describe a cough induced HA
usually only lasts a few mins after coughing. Last just a few secs or mins
Describe an exercise - induced HA
can last up to a few hrs after strenuous exercise
Describe a post-coital HA
A sudden, severe, throbbing HA that occurs just before or at the moment of orgasm
Define Multiple Sclerosis
Demyelinating disease of the CNS
What age group has relapsing & remitting MS?
25-29yo
What age group has primary progressive MS?
39-41yo
MS is more common in which gender?
women
MS risk factors
- Low UV light exposure (living in northern latitudes, ?Vit D)
- Smoking
- Obesity
MS pathophys
demyelination occurs when the immune system inappropriately causes B & T cells to attack & destroys myelin, causing inflammation which leads to more immune response & more inflammation
MS S/S:Hx
- Optic neuritis
- limb weakness
- numbness, feelings of pins & needles
- urination or BM problems
- vision problems - impaired vision, pain w/ eye movements, double vision, or jerking sensation in visual field
- gait impairment
MS PE: focal spinal cord inflammation
- any form of paresis
- flaccid muscle tone
- reduced/abnl sensation
MS PE: oculomotor exam
- disconjugate eye movements
- nystagmus
MS PE: brainstem, cerebellum, or cerebral dysfunction
- dysmetria on finger-to-nose testing
- intentional or postural tremor
- facial paresis or hypoesthesia
- dysarthria
- dysphagia
- cognitive impairment
What features are suggestive of MS?
- relapses & remissions
- onset b/t 15-50yo
- optic neuritis
- Lhermitte sign
- Internuclear ophthalmoplegia
- fatigue
- heat sensitivity (Uhthoff phenom)
MS diagnosis requires
involvement of ≥ 2 areas of CNS (dissemination in space) at different time points (dissemination in time)
MS Dx Labs
- CBC
- ESR/CRP
- LFT
- BUN/Cr
- Ca++
- glucose
- thyroid function
- vit B12 deficiency,
- HIV
What will MRI show for MS?
lesions
What will CSF analysis show for MS?
oligoclonal bands (IgG)
MS acute episode, including relapse Tx
- dexamethasone
- methylprednisolone
MS 1st line tx for relapse prevention
- Glatiramer acetate (Copaxone)
- Interferon B-1b (Betaseron)
Define Myasthenia Gravis
An autoimmune disorder affecting the NMJ
How will a patient present w/ Myasthenia Gravis?
painless, fluctuating weakness of muscle groups & often begins w/ ocular s/s (ptosis & diplopia).
Myasthenia Gravis: gender prevalence
< 50yo, 3x more common in females
> 50yo, initial dx slightly more males
Myasthenia Gravis is assoc. w/ what other autoimmune disorders?
- Thyroiditis
- SLE
- RA
What can occur in 15% of pts with Myasthenia Gravis?
Thymoma
Myasthenia Gravis pathophys
Autoimmune so, body thinks something is wrong w/ the ACh receptors–> body creates autoantibodies that block the ACh receptors–> ACh can’t bind–> causes muscle weakness
Myasthenia Gravis: S/S&Hx
- ocular weakness asymmetric ptosis & diplopia
- Dysarthria (difficulty speaking)
- change in voice
- trouble chewing
- dysphagia
- weakness & fatigue progress throughout day & worsen w/ activity
Myasthenia Gravis: PE
- check for muscle weakness & fatigability
- impaired eye muscles (extraocular muscles) [painless asymmetries]
- Orbicularis oculi weakness, ectropion, or “peek” sign
- cranial nerve examination
Myasthenia Gravis: neuro exam findings
- asymmetry pattern of weakness of extraocular muscles not involving the same nerve
- normal pupil function
- try to elicit ptosis
Myasthenia Gravis: Dx
- Acetylcholine receptor (AChR), muscle-specific tyrosine kinase (MuSK), or lipoprotein receptor-related protein 4 (LRP4) antibodies
- EMG–> nerve will eventually fatigue & not respond to stimuli
- edrophonium chloride (Tensilon) test resulting in unequivocal resolution of weakness
- CT chest–> thymus tumor?
Acetylcholinesterase inhibitors
- Pyridostigmine
- Neostigmine
Acetylcholinesterase inhibitors
- Pyridostigmine
- Neostigmine
How do Acetylcholinesterase inhibitors work?
Prevent the breakdown of Ach in the NMJ–> incr chance of ACh getting on receptors that aren’t blocked
In Myasthenia Gravis ___ can be given w/ exacerbations & severe dz?
Immunoglobulins
What tx meds can lessen autoimmune rxn in Myasthenia Gravis?
- Corticosteroids
- IVIG
- plasma exchange
Myasthenia Gravis requires what tx?
intubation & ICU admit
In Myasthenia Gravis, __% of people will have ____ w/n ____ of ill
- 25%
- resp failure
- first year
Define Delirium
- caused by acute illness or drug toxicity (sometimes life threatening) - often reversible
I WATCH DEATH mnemonic
I - Infx (UTI, pneumonia, encephalitis)
W - Withdrawal (ETOL, benzos, sedative-hypnotics
A - Acute metabolic (ETOL
T - Toxins (opioids, steriods, anticholinergics, psychotropics)
C -
H
D - Deficiencies (thiamine w/ ETOL, B12)
E - Endocrine (thyroid, hypo/hyperglycemia, adrenal insuff)
A - Acute vascular (shot, HTN enceph)
T - Trauma
H - Heavy Metals
What is the most common form of dementia?
Alzheimer’s Dz
Define Dementia
acquired deterioration in cognitive abilities resulting in decrease in ADLs
Dementia (all forms) Non-pharm approaches
- structure and routine
- no nonessential drugs
- Exclude unrecognized delirium, pain, urinary obstruction, or fecal impaction
- Caregivers speak simply to the patient, break down activities into simple component tasks
- Aerobic exercise (45 mins most days/week) & frequent mental stimulation
Alz (Dementia) Pharmacologic Tx
- Cholinesterase inhibitors for functional impairment
- NMDA receptor antagonist for cognitive ability
Alz Vascular (Dementia) Tx
- Control RFs for stroke
- Cholinesterase inhibitors for functional impairment
- NMDA receptor antagonist for cognitive ability
Dementia w/ Lewy Bodies Pharmacologic Tx
- Cholinesterase inhibitors
- Antipsychotics for behavior changes
- Benzos for sleep disorders
Frontotemporal Dementia Tx
Antipsychotics for behavior changes
