Clinical- 4 Flashcards
What is a coma?
A state of deep unarousable unresponsiveness that lasts for a prolonged or indefinite period.
What is delirium?
A confusional state in which the level of conscience is depressed but to s lesser extent than a coma
What is dementia?
A chronic confusional state that develops months to years (med school)
What are some pre-existing conditions that may predispose you to confusional states?
Alcoholism, drugs, diabetes, heart disease, epilepsy, head trauma, and various therapeutic drugs
What is the main difference between delirium vs dementia?
Delirium is several hours-days, dementia develops over months-YEARS
What are the clinical signs of hypoglycemia?
Tachycardia, sweating, and dilated pupils progressing to mimic herniation with or without lateralized Sx.
Hypoglycemia-Dx
Low plasma glucose
Hypoglycemia-Tx
IV GLUCOSE YEEEEE
Think diabetic shock!
Bacterial meningitis-Sx
Headache, fever, brudzkinski/Kernig sign
Bacterial meningitis- Dx
+ CSF ram stain, low CSF glucose, increased CSF protein
Bacterial meningitis- Tx
IV antibiotics
What are the 2 types of trauma injuries to cause delirium or dementia?
Subarachnoid hemorrhage anew traumatic intracranial hemorrhage
Wernickes encephalopathy- Sx
Opthalmoplegia, ataxia
Wernickes encephalopathy- Dxq
Macrocyclic anemia possible.
Wernickes encephalopathy- Tx
IV thiamine
What could fever a sign of?
Infection, anti cholinergic or sympathy mimetic intoxication, ethanol or sedative drug withdraw, sepsis
What could hypothermia be a sign of?
Ethanol or sedative drug intoxification, hepatic encephalopathy, hypoglycemia, hypothyroidism, sepsis
What could HTN be a sign of?
Anti cholinergic or sympathomimetric intox, ethanol or sedative drug withdrawal, HTN encephalopathy, subarachnoid hemorrhage
What could bradycardia be a sign of?
Hypothyroidism
What could hyperventilation be a sign of?
Hepatic encepalopathy, hyperglycemia, sepsis
Neck stiffness could be a sign of what?
Meningitis or subarachnoid hemorrhage
Battle sign, raccoon eyes, hemotympanum, or CSF oto/rhinorrhea could be a sign of what?
Head trauma
What could jaundice be a sign of?
Hepatic encephalopathy
Petechial rash could be a sign of what?
Meningococcal meningitis
Heart murmurs could be a sign of what 2 things?
Infection or stroke
Abdominal mass could be a sign of what 4 things?
Aliens, infections, tumors, hepatic encephalopathy
Rectal bleeding could be a sign of what?
Hepatic encephalopathy
Papillae demos could be a sign of what 2 things?
HTN encephalopathy, intracranial mass
Dilated pupils could be a sign of what 4 things?
Head trauma, sedative drugs, withdrawal from ethanol or sedative drugs, sympathomimetric intoxication
Constricted pupils is a sign of what?
Opioid intoxication
Nystagmus or opthamoplegia is a sign of what?
Intox with ethanol, sedative drugs or phencyclidine, vertebrobasilsr ischemia or wernickes encepathalopahy
Tremors could be a sign of what 3 things?
Withdrawl from ethanol or sedative drugs, sympathomimetric intox, thyrotoxicosis
Asterixis could be a sign of what?
Metabolic encephalopathy
Hemiparesis could be a sign of 4 things?
Cerebral infarction, head trauma, hyperglycemia, hypoglycemia
Ataxia could be a sign of what 2 things?
Ethanol or sedative drug intox, or wernickes ecephalopathy
Seizures could be a sign of what?
LOL F ALL THIS
What is meningismus?
A meningeal irritation that is seen in 80% of meningitis cases?
Who typically does NOT have meningismus?
Very young or old, or those with impaired consciousness
What are the 2 signs of meningismus?
brudzkinski (thigh flexion with flexion of the neck)
Kernig (resistance to passive extension of the knee with the hip flexed)
What ages have frontal release signs?
Infants, but disappear when the brain matures.
What is the grasp sign?
Fingers curl in response to stimulation o the palmar surface of the hand
What is the suck sign? ;-)
Stroking the lips causes the pt to begin sucking motions
What is the snout sign?
Tapping the nose causes the protrusion of the lips.
What is the glabellar sign?
Tapping between the pts eyebrows causes the pt to blink every time he is tapped rather than stop blinking after the first few.
What’s the purpose of the mini-mental status exam?
Test the level of consciousness in a pt with some sort of cognitive decline.
What does the mini-mental status exam show?
Wakefulness, arousability, orientation, attention and memory
What is recent memory?
Te ongoing ability to learn new info.
Wat is remote memory?
The ability to recall material that some1 of comparable cultural and educational backgrounds can be assumed to know.
What is immediate memory?
Being able to repeat a random series of number. Shows the material has been registered.
What are the Sx of ethanol use? Lol
Confusional state with nystagmus, dysarthria, and limb/gait ataxia.
What are intoxicated pts at a high risk for?
Head trauma, life threatening hypoglycemia, and chronic alcoholism increases the risk for bacterial meningitis.
What is the treatment for alcohol use?
Not required unless a withdrawal syndrome ensues
What occurs during the first 2 days after stopping drinking?
Tremulousness and hallucinations, agitation, anorexia, nausea, insomnia, tachycardia, HTN.
What drug can u give during the first stage of alcohol withdrawal to help the Sx?
IV lorazepam
When can seizures occur during alcohol withdrawal?
Within 24 hrs but can happen multiple times though a short interval
How can u treat szrs during alcohol withdrawal?
IV lorazepam
What is the most serious alcohol withdrawal Sx?
Delirium tremens
When does delirium tremens happen?
3-5 days
What are the Sx to delirium tremens?
Agitation, fever, sweating, tachycardia, HTN, hallucinations and death from external factors.
What can u give to treat delirium tremens?
Lorazepam and electrolyte correction
What are the lab values for normal CSF?
Clear, < 5 cells/uL, pressure 70-200mmH2O, glucose > 45mg/dL, protein < 45 mg/dL,
What are the CSF characteristics of bacterial meningitis?
Cloudy, inc pressure, WBC increased (pmn), dec glucose, inc protein
What are the CSF characteristics of TB?
Normal or cloudy, inc pressure, inc WBC (mn), dec glucose, inc proteins
What are the CSF characteristics of fungal meningitis?
Normal or cloudy, normal or inc pressure, inc WBC, dec glucose, inc proteins
What are the CSF characteristics of viral encephalitis?
Normal color, normal or inc pressure, increased WBC (mn), normal glucose, normal or inc pressure
What are the CSF characteristics of leptomeningal carcinomatosis?
Normal r cloudy, normal or increased pressure, WBC normal or inc, big dec in glucose, normal or inc proteins
What are the CSF characteristics of subarachnoid hemorrhage?
Pink-red, inc pressure, RBC’s, normal or inc PMN, normal or dec glucose, inc proteins
What is myxedema a sign of?
Hypothyroidism
What are the Sx to myxedema?
Flat affect, psychomotor retardation, agitation and psychosis
What do u find on clinical exam for myxedema?
Dysarthria, deafness, ataxia, DELAYED TENDON REFLEXES
Thyrotoxic crisis is a condition related to what chronic disease?
Hyperthyroidism
What are the main Sx associated with hyperthyroidism?
Action tremor, Hyperreflexia, and EXOPTHALMOS
What are the Sx of activated thyrotoxic crisis?
In younger pts, agitation, hallucinations and psychosis
What is apathetic thyrocytosis?
Happens in older people, apathetic and depressed
What does hyponatremia cause?
Brain swelling cuz of the hyperosmolarity of the extracellular fluid.
What causes hyponatremia?
Hypothyroidism, adrenal insufficiency, thiazide diuretics, NSAIDs, ecstasy, and SIADH.
What are Sx of hyponatremia?
Confusion, coma, papillae demos, tremor, rigidity, szrs and some focal neurological deficits.
What is the Tx for hyponatremia?
water restriction or IV hypertonic saline with furosemide
What is the very veyr very bad condition related to rapid correction of hyponatremia?
central pontine myelinolysis
WHat are the Sx to central pontine myelinolysis?
confused state, paraparesis, dysarthria, dysphagia, reflex changes and possibly even locked-in syndrome
What is the Tx for central pontine myelinolysis?
Nothing. Best way to prevent it is by treating hyponatremia with restriction of water and if needed, small infusions of hypertonic saline.
What are the 3 findings for hypocalcemia?
- Ophthalmoplegia – Nystagmus, CN VI palsy, gaze center palsy
- Ataxia – Primarily ataxia of gait
- Confusional State – Global confusion based on MME, with immediate disorder of immediate recall and recent memory. May progress to coma.
Wernicke Encephalopathy (WE)- etiology
Usually due to alcoholism
Due to a lack of B1 (thiamine)
WE- clinical findings
Neuronal loss, demyelination, and gliosis is periventricular gray matter. Proliferation of small blood vessels and petechial hemorrhages may be seen. Most commonly affected areas are thalamus, mammillary bodies, PAG, cerebellar vermis, and CN VI and VIII
WE- Tx
IV Thiamine with dextrose to begin.
Parenteral thiamine is continued for days after.
WE- prognosis
Ocular symptoms improve after 1 day of treatment
Ataxia and confusion improve within 1 week of treatment
Long term complication of WE is Korsakoff syndrome
Korsakoff Amnestic Syndrome (KAS)- etiology
lack of B1 (thiamine)
KAS- clinical Sx
Antegrade amnesia
Retrograde Amnesia
Confabualtion (making up memories)
Apathy
KAS- Tx
IV Thiamine
KAS- prognosis
Amnesia and brain damage do not always respond to thiamine replacement therapy. Only 20% reversible.
What is the most common cause of B12 deficiency?
pernicious anemia, which is a defect in the production of intrinsic factor associated with atrophic gastritis, anti-parietal cell antibodies, and achlorhydria
What are the clinical findings to pernicious anemia?
anemia or orthostatic hypotension, but could also be gait ataxia or a bandlike tightness around the trunk or limbs, and electric shock like sensation around the spine caused by neck flexion (Lhermitte sign)
What are the lab findings in B12 deficiency?
macrocytic anemia, leukopenia, hypersegmented neutrophils and thrombocytopenia with giant platelets. Diagnosis confirmation is serum B12 <100 pg/mL. A Schilling test determines whether defective GI absorption is the cause
What is the Tx for B12 deficiency?
IM injection of cyanocobalamin for 1 week.
What is the prognosis for B12 deficiency?
Neurologic complications are reversible if abnormalities present less than a year, but there’s no guarantee.
What does hepatic encephalopathy occur in?
Occurs as a complication of cirrhosis, portosystemic shunting, chronic active hepatitis or hepatic necrosis
What is the most common underlying disorder of hepatic encephalopathy?
Alcoholism
What are the Sx for hepatic encephalopathy?
agitation, somnolence, coma, nystagmus, asterixis.
What are the Tx’s for hepatic encephalopathy?
restricting dietary protein, balancing electrolytes, discontinuing causitive drugs, and providing antibiotics and fresh frozen plasma.
What are the characteritics of Reye syndrome?
encephalopathy or coma with lab evidence of hepatic dysfxn
What patient population does Reye syndrome occur in?
Kids
Kids can get Reye several days after what infections?
viral illness, esp varicella or HiB
What is the most common dermatological sign of Lyme disease?
an expanding annular skin lesion that usually appears over the thigh, groin, or axilla.
What are the less distinctive generalized signs of Lyme disease?
fatigue, headache, fever, neck stiffness, joint or muscle pain, anorexia, sore throat, and nausea
Neurological involvement may present up to 10 weeks later and is characterized by what signs?
meningitis or meningoencephalitis and disorders of the cranial or peripheral nerves or nerve roots. Bilateral facial weakness from involvement of cranial nerve VII is very common
What are the brain manifestations of Lyme disease?
Lyme meningitis usually produces a headache that may be accompanied by photophobia, pain when moving the eyes, nausea and vomiting
What happens if you leave Lyme disease untreated?
to recurrent oligoarthritis and chronic neurologic disorders including memory, language and other cognitive disturbances
What is the Tx for Lyme disease?
doxycycline or amoxicillin given orally for 2-3 weeks. For CNS involvement, treatment is IV ceftriaxone for 2-4 weeks
What is the most common cause of sporadic fatal encephalitis in the US?
HSV1 infections
What are the CSF characteristics in HSV1 encephalitis?
increased pressure, lymphocytic or mixed lymphocytic and PMN pleocytosis, mild protein elevation, and normal glucose
How does a newborn get HSV2 encephalitis?
during passage through the birth canal of a mother with active genital lesions
What does HSV2 cause in adults?
usually causes meningitis instead of encephalitis
What are the Sx of herpes encephalitis?
headache, stiff neck, vomiting, behavioral disorders, memory loss, anosmia, aphasia, hemiparesis and focal or generalized seizures
HSV encephalitis is often confused with what?
Brain abscesses and other CNS ifnections
What is the Tx for HSV encephalitis?
IV Acyclovir for 14-21 days.
What are the 5 neurological complicaitons to HIV infections?
dementia, myelopathy (infection of the spinal cord), neuropathy (infection of the nerves), myopathy (degradation of muscles), and stroke
What are the Sx for HIV-1 meningitis?
headache, fever, signs of meningeal irritation, cranial nerve (especially CN VII) palsies, focal neurologic abnormalities, or seizures. An acute confusional state is occasionally present. There will be a lymphocytic CSF, with elevated protein and normal glucose. Symptoms resolve within 1 month
What is the Sx to cryptococcal meningitis/meningoencephalitis?
headache, confusion, stiff neck, fever, nausea, seizures, and cranial nerve palsies
How do you Dx crytpococcal infections?
+ CSF india ink
use curry to Dx
What are the Sx to cerebral toxoplasmosis?
fever, headache, altered mental status, and seizures
What is the classical findings on MRI for cerebral toxoplasmosis?
Rim enhancements
What cells does CMV encephalitis affect?
neurons, astrocytes, oligodendrocytes, endothelial cells, and ependymal cells.
What are the Sx for CMV encephalitis?
are fever, confusion, coma, seizures, and focal neurologic signs. Myelopathy and radiculopathy may also occur.
What is the most common brain tumor assocatied with HIV?
primary CNS lymphoma
What are the Sx for 1o lymphomas?
confused state, hemiparesis, aphasia, seizures, cranial nerve palsies, and headache
What are the Dx findings for 1o lymphomas?
CSF shows eleveated protein, mild lymphocyte count, and low glucose count. MRI shows enhancing lesions which make it hard to distinguish from toxoplasmosis.
What are the Sx for pneumocystis carinii?
pneumonia that causes hypoxia and a confusional state.
What si the most common parasitic infection of humans?
malaria
What is the protozoan to cause malaria?
plasmodium falciparum
What are the Sx for malaria?
fever, chills, myalgia, nausea, anemia, renal failure, hypoglycemia, and pulmonary edema
How do u get toxoplasmosis?
Cat poo poo
Define: this bug attacks healthy young people exposed to warm, polluted fresh water. Enter through the cribiform plate producing a diffuse meningoencephalitis. Characterized by headache, fever, nausea, meningeal irritation, and disordered mental status.
Naegleria Fowleri
Define: this species cause subacute chronic meningitis and granulomatous encephalitis. The cerebellum, brainstem, basal ganglia and cerebral hemispheres are affected. Causes acute confusional state, fever, headache, and meningeal signs. Lasts from about 1 week to 3 months.
Acanthamoeba/Hartmanella
What causes cysticerosis?
ingestion of Taenia Solium cysts
What are the clinical findings of cysticerosis?
Neurologic manifestations result from mass effect, obstruction of CSF flow or inflammation. Seizures are common, but other symptoms are headache, focal neurologic deficits, hydrocephalus, myelopathy, and subacute meningitis. Ophtalmoscopic examination may show ocular cysts.
Where in the world is angiostronglysus cantoensis meningitis?
southeast asia, hawaii and other pacific islands
How do u get angiostronglysus cantoensis meningitis?
eat raw mollusks
What are the Sx for angiostronglysus cantoensis meningitis?
Meningitis with periopheral blood and CSF eosinophilia, stiff neck, vomiting, fever, parasthesias.
What causes rocky mountain spotten fever?
Rickettsia Rickettsii through tick bites
Sx of RMSF?
Symptoms are fever, headache, and characteristic rash that involves palms and soles and spreads centrally. Can cause a confusional state and less often, coma or focal neurologic abnormalities.
How do fungi reach the CNS?
by hematogenous spread from the lungs, heart, GI, eyes, or skin
What happens in hypertensive encephalopathy?
sudden increase in BP, with/or without pre-existing chronic hypertension, which may result in encephalopathy and headache, which may develop over a period of hours to days
Define concussions
loss of consciousness for seconds to minutes, followed by a confusional state that usually lasts from minutes to hours and is characterized by prominent retrograde and anterograde amnesia
