Clinical Medicine Flashcards by Danny Neuman

What does EDX medicine stand for?

Electrodiagnostic medicine

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What is included in an EDX medicine consultation other than a neuromuscular and MSK history and physical? (4)

differential dx
EDX exam of nerves via nerve conduction studies (NCSs)
EDX exam of mm via needle electromyography (EMG)
final diagnosis

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What are some indication for EDX medicine consultation? (6)

suspected NM or MSK disease involving the:

motor neuron disease (ALS)
nerve root (radiculopathy)
plexus
peripheral n.
NMJ
muscle

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Are central lesions such as a stroke an indication for an EDX medicine consultation?

NO no central lesions

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What are some frequent complains of NM or MSK pathology? (7)

numbness or tingling
decreased sensation
pain
cramping or spasms
weakness
gait difficulty
fatigue

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What can we use to…

clarify etiology of symptoms such as radiculopathy vs. plexopathy vs. neuropathy, type of neuropathy, and source of pain
localize a PNS lesion
predict neurological prognosis

EDX medicine consultation

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What are the three components of an EMG?

nerve conduction studies (NCS)
Electromyography (EMG)
Special tests such as repetitive nerve stimulation

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What can we use to assess the function and integrity of the peripheral nervous system?

EDX testing

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What are the two basic elements of nerve conduction studies?

motor nerve conduction

sensory nerve conduction

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For a NCS, peripheral nerves (motor and sensory) are stimulated with a controlled electrical stimulus. Responses such as _____ _____ _____ ______ and _____ _____ ______ ______ are then recorded.

compound motor action potential (CMAP)

sensory nerve action potential (SNAP)

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When recording NCS for the median nerve, one looks at the ________ , _________, and _____ at various points along the arm and digits.

latency
amplitude
speed

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TQ: What is it called in a NCS when we measure the conduction time from stimulation across a nerve through the NMJ to initial activation of the m. fibers

motor latency

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TQ: What is it called in a NCS when we measure the number of activated muscle fibers

motor amplitude

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TQ: What is it called in a NCS when we measure the conduction time of AP from stimulation across a nerve segment

sensory latency

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TQ: What is it called in a NCS when we measure the number of activated sensory axons

sensory amplitude

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TQ: What is it called in a NCS when we measure the velocity of the fastest conducting axons (motor and sensory)

conduction velocity

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What test is being performed?

needle electrode is inserted into the muscle
multiple muscles are tested
measured at rest and different levels of sustained voluntary contraction
during activity, the electrical shape and pattern of the response can distinguish between nerve and muscle disease

EMG

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What are the evaluated parameters in an EMG? (5)

insertional activity
spontaneous activity
motor unit configuration
motor unit recruitment
interference pattern

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T/F: During an EMG, the muscle shows spontaneous activity at rest without a nerve or muscle abnormality.

FALSE

At rest, the muscle should be silent

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What is being described and is pertinent to what test?

Bursts of electrical activity as the needle is inserted into muscle
due to disruption of muscle fiber membranes
prolonged with denervation, some muscle diseases

Insertional activity on an EMG

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What is being described and is pertinent to what test?

fibrillations, positive sharp waves, fasciculations
hallmark of denervation, muscle membrane irritation

Spontaneous activity on an EMG

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TQ: Repetitive stimulation is part of the ___________ exam

electrodiagnostic

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How do we grade spontaneous activity on an EMG?

0-4
0=no fibs/PSWs
1=persistent in 2 areas
2=persistent in 3+ areas
3=persistent but not obscuring baseline
4=baseline obliterated

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What are the three components of motor unit configuration on an EMG?

amplitude
duration
morphology

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What is a single motor unit?

a motor axon and all its muscle fibers

How do we test for motor unit configuration on an EMG?

muscle is volitionally activated at different force levels

What is being described and is pertinent to what test? | -pattern of motor unit activation with increasing volitional activation

motor unit recruitment on an EMG

What is being described and is pertinent to what test? | -motor unit pattern with full voluntary activation

interference patterns on an EMG (contracting mm.)

What are some general EDX diagnoses? (6)

- normal - radiculopathy - plexopathy - neuropathy - myopathy - widespread denervation (MND)

What are some specific EDX options?(4)

- acute vs. chronic vs. acute & chronic - mild vs. moderate vs. severe - anatomic location (root, plexus, nerve, NMJ, muscle) - distribution (polyradiculopathy, trunk, cord, mono vs. multiplex vs. distal symmetric)

What are some disorders diagnosed or evaluated by EDX testing?

- motor neuron disease (ALS) - Radiculopathy - plexopathy - muscle disease (inflam, metabolic, congenital) - NMJ dz - neuropathy (generalized: axonal, demyelinating or mixed: diabetic) - mononeuropathy multiplex - focal (mono): median, ulnar, peroneal, sciatic

What are the 3 EMG "pearls"?

- EDX studies are supplemental (always do history and physical) - EDX results are often time-dependent - EDX studies are not "standardized"

Describe the sequence of events for the NMJ

AP-->depolarization-->calcium influx-->fusion of Ach vesicles with presynaptic membrane and release of Ach-->bind to post-synaptic receptors on the muscle membrane-->contraction-->Ach degraded by AchE

Is Lambert-Eaton myasthenic syndrome (LEMS) a presynaptic or postsynaptic disorder of the NMJ? What about myasthenia gravis?

Lambert-Eaten myasthenic syndrome=pre-synaptic Myasthenia gravis=post-synaptic

Myasthenia gravis (MG) is caused by a defect of NM transmission due to....

an antibody mediated attack on AchR on muscle membrane

MG - unknown how Ab arise - HLA gene? - usually w/ autoimmune disorders (SLE, thyroid) - prevalence 3 in 100,000 - more common in _______ women and ______ men.

younger women | older men

Pt presents with...dx? - Fluctuating weakness: "excessive fatiguability" - ptosis and diploplia - dysarthria, dysphagia, - limb and neck weakness - respond to cholinergic drugs - labs: AchR antibodies - EMG: decremental response on repetitive stimulation - + tensilon test

Myasthenia gravis

What are some treatment options for MG?

- AchE inhibitors - prednisone - plasma exchange/IVIg (especially before surgery)

NM blockers, excessive AchE, corticosteriods, thyroid supps, BOTOX, Mg salts, antiarrhythmics (B-blockers, lidocaine, etc), and antibiotics all may ________or ______ MG

exacerbate or unmask

______-_______ ______ ______ is due to an autoimmune attack against VGCC on the presynaptic nerve terminal - This leads to a presynaptic abnormality of Ach release at the NMJ leading to weakness - often this is associated with lung carcinoma (SCCL)

Lambert-Eaton Myasthenic Syndrome (LEMS)

Pt presents with...dx? - proximal weakness, loss of DTR - myalgias, dry mouth, impotence - oropharyngeal and ocular mm. MILDLY affected - strength improves with exercise - slight response to tensilon test - Hyporeflexia - EMG: low amplitude motor responses that increase after exercise, incremental response on fast repetitive stimulation

Lambert-Eaton Myasthenic Syndrome (LEMS)

What are the two main ways we treat LEMS?

Immunosuppresion and IVIg

What are some key differences in MG and LEMS?

- MG normal reflexes and no dry mouth or impotence - MG strength is weaker post-exercise vs. LEMS which is stronger - MG has a decremental response to fast repetitive stimulation whereas LEMS has incremental response

Pt presents with...Dx? - dry, sore mouth and throat, blurred vision, diploplia, n/v - hypohydrosis, total external opthalmoplegia, facial, oropharyngeal, limb, and respiratory paralysis

Botulism toxin (blocks presynaptic mechanisms for release of Ach)

Anatomy of a peripheral n.: | _________ (individual fibers)-->perineurium (fasicles)-->epineurium (covers whole n.)

endoneurium

Myelinated vs unmyelinated: - myelinated: _______ conduction - unmyelinated: slower

saltatory conduction (fast and skips)

There are ____ types of A fibers that function in a variety of senses. They are all myelinated.

A alpha, beta, gamma, delta

Put in order from fast to slow for the following A fibers: - touch and pressure - proprioception and somatic motor - pain/cold/touch - motor to muscle spindles

proprioception and somatic motor->touch and pressure->motor to muscle spindles->pain/cold/touch

What are some points of injury along a peripheral n.?

``` axon (axonal degeneration) myelin sheath (demyelination) ```

What are some general points of injury for a nerve? (4)

- cell body - nerve root - peripheral n. - wallerian degeneration (severed nerve)

``` TQ: Pt presents with...dx? -pain in scapula/shoulder pain -numbness in fingers -weakness in deltoid/biceps ```

C6 nerve root lesion in neck know the dermatomes!

Nerve root dysfunction that may be caused by structural (discs, tumros, etc) or non-structural conditions (DM, infections)

radiculopathy

What are the most common levels involved in radiculopathy?

Cervical: - C5-6=C6 nerve root compression - C6-7=C7 nerve root compression Lumbar: - L4-L5=L5 nerve root compression - L5-S1=S1 nerve root compression

Pt presents with...Dx? - pain in scapula/shoulder region - sensory loss in lateral arm - weakness upon shoulder abduction - Biceps DTR loss

C5 nerve root radiculopathy

Pt presents with...Dx? - pain in scapula/shoulder/proximal arm (biceps) - sensory loss in the 1st and 2nd digit, lateral arm - weakness upon shoulder abduction and elbow flexion - Biceps DTR loss

C6 nerve root radiculopathy

Pt presents with...dx? - pain in the scapula/shoulder/arm/elbow/forearm - sensory loss in the 3rd digit - weakness upon elbow ext, wrist ext - Triceps DTR loss

C7 nerve root radiculopathy

Pt presents with....dx? - pain in the scapula/shoulder/arm/medial forearm - sensory loss of the 4th and 5th digit - weakness upon finger abduction and finger flexion - cant flex fingers (intrinsic mm. of hand)

C8 nerve root radiculopathy

Pt presents with...dx? - pain in the antlat thigh, knee, medial calf - sensory loss of the medial calf - weakness upon hip flexion, knee extension - Patella DTR loss

L4 nerve root radiculopathy

Pt presents with...dx? - pain in the dorsolateral thigh and lateral calf - sensory loss in the lat calf and dorsum of foot - weakness upon foot dorsiflexion, inversion, eversion - NO DTR LOSS

L5 nerve root radiculopathy

Pt presents with...dx? - pain in the post thigh and post calf - sensory loss in the postlat calf and lat foot - weakness in hamstrings and foot plantarflexion - Achilles DTR loss

Lumbosacral radiculopathy

What are the 3 categories we classify peripheral neuropathy as?

mononeuropathy polyneuropathy mononeuropathy multiplex

Pt presents with..dx? - single nerve root affected - specific pattern of sensory loss - weakness only in specific mm.

mononeuropathy

Pt presents with...dx? - diffuse, symmetrical disease-motor sensory or both - stocking/glove sensory loss - distal weakness, possible atrophy (legs first) - hypo or arreflexia - usually progressive - acquired or inherited

polyneuropathy

A positive sensory symptom for peripheral neuropathy resulting in pins and needles sensation is a paresthesia secondary to ______ ______ fiber disease

large myelinated

A positive sensory symptom for peripheral neuropathy resulting in a burning sensation is pain secondary to _____ _________ fiber disease

small unmyelinated

What is a negative sensory symptom for peripheral neuropathy?

loss of sensation (vibration, pain, temp, etc.)

What are some motor symptoms for peripheral neuropathy?

- distal weakness - cramps - muscle fasciculations - atrophy - decreased deep tendon reflexes - reduced tone

Large myelinated sensory fibers: impairment of...

- light touch (cotton swab) - 2 pt - vibration (128 Hz tuning fork) - joint position sense

Small unmyelinated sensory fibers: impairment of...

- temperature perception | - pain perception (pin prick)

TQ: Nerve roots dont split fingers, so if 2 fingers are affected + pain in the neck then it is...

C6 radiculopathy

TQ: If all 3 fingers are affected then it is a peripheral nerve disease such as...

median n. peripheral neuropathy

TQ: If the entire 4th and 5th fingers are affected then the diagnosis could be...

C8 radiculopathy

TQ: What nerve is affected? - wrist compression - anterior interosseus compression

median n. entrapment neuropathy

TQ:What nerve is affected? - elbow compression with recent elbow leaning - froment sign

Ulnar n. entrapment neuropathy

TQ: What nerve is affected? - spiral groove compression - wrist drop (saturday night palsy)

Radial n. entrapment neuropathy

TQ: What nerve is affected? - fibular neck compression - foot drop, weak evertors - sensory loss in dorsum of food - crossing the legs, or elderly

peroneal n. entrapment neuropathy

TQ: What nerve is affected? - inguinal ligament compressoin - tight clothing/weight gain - sensory loss in the lateral thigh

lateral femoral cutaenous n. entrapment neuropathy

TQ: Pt presents with CC of the outside of their calf being numb...how can we tell if it is a peroneal n. neuropathy or a radiculopathy?

the peroneal nerve allows for dorsiflexion, eversion L5 nerve root allows for dosiflexion, everion AND INVERSION.. if inversion weak then L5 radiculopathy if inversion strong then peroneal n.

T/F: In 25% of pts with peripheral neuropathy it is idiopathic

TRUE

Peripheral neuropathy etiology: - hereditary - metabolic (DM) - endocrine (thyroid) - infectious (mono, hep, lyme, HIV, leprosy, syphilis, herpes) - immune mediated - deficiency (B vitamans, E, Cu) - toxins (alcohol, metals) - idiopathic (__%) - drug induced (phenytoin, isoniazid, alkaloids, etc) - vasculitic (RA, SLE) - Paraneoplastic (cancer)

What are the two types of chacot-marie-tooth neuropathies (hereditary motor sensory neuropathies)?

CMT I: most common & demyelinating CMT II: axonal

Pt presents with..dx? - autosomal dominant - onset in adulthood - distal symmetric atrophy (legs>arms) - areflexia - mild sensory loss - EMG: normal motor nerve conduction loss (axonal loss)

CMT II

What are the 2 main acquired demyelinating polyneuropathies?

AIDP and Guillain-Barre Syndrome

Guillain-Barre syndrome is acute _________ motor paralysis often caused by illness, surgery, immunization, HIV, or Hodgkin's dz -effects 1-2 in 100,000/yr

ascending

Pt presents with...Dx? - low back/leg pain at onset - ascending usually symmetric weakness - hypo or absent DTRs - no/minimal sensory symptoms or signs - **respiratory failure possible, autonomic involvement - CSF: high protein, normal glucose - NCVs: slowed CV

Guillain-Barre syndrome

What is the prognosis for Guillain-Barre syndrome?

- 90% recover in wks to months - 25% require ventilator - :( if NCV/EMG low amplitude motor responses b/c then implies axonal involvement

What variant of Guillain-Barre syndrome involves opthalmoplegia, ataxia, arreflexia, facial weakness, dysarthria, dysphagia, and GQ1b and GT1a antibodies

Miller-Fisher syndrome

This polyneuropathy is similar to GBS but is persistent (i.e.> 2mo) - progressive or relapsing course - may have monoclonal Ab - Tx: IVIg, steroids, plasma exchange, immunosuppresive agents

Chronic inflammatory demyelinating polyneuropathy (CIDP)

What is the most common identifiable cause of neuropathy in the US?

Diabetes Mellitus (feel it in the feet)

T/F: EMG/NCV usually leads to specific diagnosis

FALSE! EMG/NCV rarely leads to specific diagnosis except for axonal vs. demyelinating aka GBS, CMT1

Which nerve is biopsied for neuropathy?

sural n.

GAF score showing that pt is a candidate for inpatient care

GAF score 1–30

GAF score showing that pt is a candidate for outpatient care

GAF score 31–69

GAF score showing that medical necessity is not indicated bc pt is functioning too well to be candidate for therapy

70+

TQ: - Pt has a reduced level of consciousness and difficulty focusing, shifting or sustaining attention - Cognitive change that a dementia cannot better explain - Symptoms develop rapidly (hours to days) and tend to vary during the day (i.e., acute onset ***) - General medical condition has directly caused condition

Delirium due to a general medical condition

TQ: - Pt has a reduced level of consciousness and difficulty focusing, shifting or sustaining attention - Cognitive change that a dementia cannot better explain - Symptoms develop rapidly (hours to days) and tend to vary during the day (i.e., acute onset ***) - Symptoms developed during substance intoxication or they are caused by the use of a medication

Substance Intoxication Delirium

Substances assoc w delirium: (8)

- Alcohol - Opiates - Antipsychotic drugs - Antihistamines ***(diphenhydramine or benadryl) - PCP - Benzodiazepines - Steroids - Anti-Parkinson's drugs

TQ: | What substance for sleep should never be given to older people bc it notoriously causes delirium?

Antihistamines - Diphenhydramine ("BAD BAD BAD") - Benadryl

In someone coming in with mental status changes, and if they're a COPD pt or oncology pt, what would you look for in the meds list?

Steroids

- Longer than 6 months - Delusions - Hallucinations - Incoherent, disorganized speech - Severely disorganized or catatonic behavior - "Waxy flexibility"

Schizophrenia

TQ: - Possible genetic factors * - 1% prevalence ** - The later the onset, the better the prognosis * - High rate of suicide * - Equally prevalent in M/F, seen earlier in men** - Possible viral infection influence

Schizophrenia

Tx of choice for psychotic depression:

Electroconvulsive therapy (ECT)

TQ: - A distinct period of elevated, expansive, or irritable mood lasting at least 1 week - Grandiosity - Decreased need for sleep * - More talkative than usual - Flight of ideas/thoughts are racing - Distractibility

Manic episode within bipolar disorder

TQ: - Preoccupation with imagined defect in the body, usually the face - Frequent visits to dermatologist/plastic surgeon - Depression and OCD are common

Body dysmorphic disorder | type of somatoform disorder

TQ: - Paresthesias / anesthesias - Weakness - Paralysis - Pseudoseizures - Involuntary movements (e.g., tremors, tics) - Sensory disturbances (blindness, mutism)

Conversion disorder

- Voluntary control of symptoms - Self-injected feces or saliva - Bizarre or unusual symptoms

Factitious disorder

Production or intentional symptoms in another individual (usually a child) for the purpose of having the other person assume the sick role

Munchausen by proxy | a type of factitious disorder, NOS

- Inability to recall important personal info | - Usually info regarding traumatic experience

Dissociative amnesia

- Sudden, unexpected travel away from home | - Inability to recall one's past / personal identity

Dissociative fugue

- Formerly known as "multiple personality disorder" | - Often survivors of sexual abuse

Dissociative identity disorder

Ambien causes ___________, including nightmare, sleep terror, and/or sleepwalking.

parasomnias

Frontal lobe injury typical of what disorder?

Impulse control disorder

What impulse control disorder involves pulling hair out?

Trichotillomania

One event within a 3 month period constitutes an __________ disorder.

Adjustment

- Inflexible**, maladaptive, and rigidly pervasive pattern of behavior - Cause subjective distress and/or impaired functioning - Person is usually unaware of problem - Presents by early adulthood

Personality disorder | Axis II

Personality diagnosis cannot be made until the person is at least __ years of age.

Diagnoses of personality disorders are notoriously unreliable in the _______ population.

elderly

TQ: - Disorder characterized by irrational suspicions and mistrust of others - Cluster A ("weird" disorder)

Paranoid personality disorder | Axis II

TQ: - Lack of interest in social relationships, seeing no point in sharing time with others (e.g., don't care if they have friends or not) - Appear indifferent to the praise or criticism of others and often seem cold or aloof - E.g., the unibomber - Cluster A ("weird" disorder)

Schizoid personality disorder | Axis II

TQ: - Characterized by odd behavior or thinking - Ideas of reference (i.e., believing that public messages are directed personally at them) - Odd beliefs or magical thinking - Vague, circumstantial, or stereotyped speech - Excessive social anxiety that does not diminish with familiarity - Idiosyncratic perceptual experiences or bodily illusion - Cluster A ("weird" disorder)

Schizotypal personality disorder | Axis II

- Repeated violations of the law** - Pervasive lying and deception - Physical aggressiveness - Reckless disregard for safety of self or others - Consistent irresponsibility in work and family environments - Lack of remorse - 3x more in men - At risk for substance abuse** - Cluster B (dramatic, emotional, or erratic disorder)

Antisocial personality disorder ("sociopath") (Axis II)

TQ: - Frantic efforts to avoid expected abandonment - Unstable and intense personal relationships and self-image - Impulsivity* in 2+ area that are self-damaging (e.g., sex, substance abuse, reckless driving) - Suicidal behaviors - cutting*** - Feelings of emptiness, anger - Immature personality traits ("teddy bear sign," "tweety bird sign") - Will often "split" staff members/providers against each other** - Often victims of sexual or emotional abuse - High rate of comorbid major depression - 3x more in women - Cluster B (dramatic, emotional, or erratic disorder)

Borderline personality disorder | Axis II

- Excessive emotionality and attention-seeking behavior - Dramatic, sexually provocative/seductive - "La belle indifference" - don't care if they make a scene

Histrionic personality disorder | Axis II

- Exaggeration of their own talents or accomplishments - Sense of entitlement - Lack of empathy - Envy of others - Arrogant, haughty attitude - 50-75% male

Narcissistic personality disorder | Axis II

- Actually desire relationships with others (differs from schizoid in this way) - Paralyzed by their fear and sensitivity to negative evaluation - Feelings of inadequacy - Avoidance of social interaction - Cluster C (anxious or fearful disorders)

Avoidant personality disorder | Axis II

- Pervasive psychological dependence on other people - Difficulty making decisions w/o guidance and reassurance - Discomfort or helplessness when alone - Urgent seeking for another relationship when one has ended - Cluster C (anxious or fearful disorders)

Dependent personality disorder | Axis II

TQ: - Characterized by rigid conformity to rules, moral codes and excessive orderliness - Preoccupied with perfectionism and control - Lack flexibility and openness - Often stingy/stubborn - 2x more in men - Cluster C (anxious or fearful disorders)

Obsessive-compulsive personality disorder | Axis II

- Presence of two or more distinct identities or personality states - MC in women - Assoc w/ hx of sexual abuse

Dissociative identity disorder | Axis II

Tx that examines the way pts perceive events. - Assumes that perceptions are shaped by early life - Identify perceptual distortions and their historical sources - Frequency = several times/week to once a month - Makes use of transference

Psychodynamic psychotherapy

- Tx that deals with how people think about the world and their perception of it - Typically limited to episodes of 6-20 weeks, once weekly

Cognitive Behavior Therapy (CBT)

- Tx that allows interpersonal psychopathology to display itself among peer pts - Usually once weekly over a course that may range from several months to years

Group psychotherapy

TQ: - Tx of choice for Borderline personality disorder*** - Both individual and group formats - Manual-based therapy is on the development of coping skills to improve affective stability and impulse control and on reducing self-harmful behavior

Dialectical Behavior Therapy (DBT)

T/F: Medications are curative for any personality disorder.

FALSE | Medications are NOT curative for any personality disorder.

What classes of medications are safe and reasonably effective? (2)

- Selective serotonin reuptake inhibitors (SSRIs) | - Newer antidepressants

Which cluster of personality disorders has the worst prognosis?

Cluster B - Susceptible to problems of substance abuse - Impulse control, suicidal behavior

Culture with highest rate of alcoholism:

Native Americans

TQ: | Important to supplement alcohol dependent and alcohol withdrawal patients with:

Thiamine

Clinical presentation: - Daily or frequent drinking to function - Violence assoc w/ drinking, and defensive when confronted - Neglect of food intake, physical appearance and hygiene - Nausea/vomiting, shaking in the morning, confusion

Alcoholism

TQ: | What is the detox order set for alcohol withdrawal? (5)

- Benzodiazepines** - Antipsychotics - Fluids - Vitamins (Thiamine***) - Restraints

What is the term to describe alcohol withdrawal (30% mortality rate is not treated)?

"Delirium Tremens"

- Drug used to maintain abstinence in alcoholics following withdrawal - Inhibits GABA in CNS and antagonizes the receptor in a similar way as alcohol - Does NOT treat withdrawal, prevent intox, interact with, or lessen harmful effects of alcohol - Generally well tolerated

Acamprosate

- Drug used to control EtOH intake | - Produces unpleasant adverse effects if the patient drinks during the course of treatment

Disulfram

TQ: | What are some signs for intoxication of stimulants (amphetamines and cocaine)? (9)

- Incr energy and alertness - Anxiety / irritability - Insomnia, exhaustion - Hyperthermia - Loss of appetite and weight - Hallucinations - Dilated pupils*** (mydriasis) - Incr BP and pulse - Seizures

Treatment for stimulant abuse: - For HTN and hyperthermia: - For psychotic symptoms:

- For HTN and hyperthermia: Phentolamine | - For psychotic symptoms: Haloperidol

TQ: | Things to remember for PCP intoxication: (5)

- Violence*** - Hyperactivity - Nystagmus - Muscular rigidity - Seizures

TQ: - Euphoria - Constricted (pinpoint) pupils (miosis) - Constipation Think:

Opioids

Drug for treatment for abuse of opioids:

Naloxone

Drugs / drug combos to treat withdrawal for opioids: (3)

- Buprenorphine or methadone - Buprenorphine and naloxone *** - Clonidine

TQ: Gold standard study used to make diagnosis of MS: What would you see? Will acute lesions enhance?

MRI - Ovoid lesions of high signal on T2 weighted imaging in the periventricular*** white matter and in spinal cord - Yes, acute lesions enhance

What MS imaging study will give you an idea of what's happening in the optic pathway?

VEP (Visual Evoked Potential test) -optic neuritis

TQ: | In MS, what would you see in lumbar puncture for CSF analysis?

Presence of oligoclonal bands and/or increased IgG

TQ: | How is MS diagnosed?

By multiple lesions over space and time. - "Remissions and exacerbations"

Only medication approved for chronic progressive MS:

Betaseron (interferon beta-1B) Also used: Copaxone

Dz-modifying (maintenance) meds for MS: (3)

- Avonex, Rebif - Betaseron - Copaxone

Other meds to be considered for pts with progressive dz (chronic progressive MS): (4)

- Azothiaprine - Methotrexate - Novantrone - Cyclophosphamide

Medication used to treat an acute exacerbation in MS:

High dose corticosteroids | Solumedrol

It's nearly impossible to differentiate a first time MS attack from a post-infectious or post-immunication encephalomyelopathy (Acute Disseminated Encephalomyelitis - ADEM). How can you make a diagnosis in the future?

ADEM should never recur. If a pt develops future symptoms or new lesions on MRI, MS is more likely diagnosis. (Time is the answer!)

What drug is most commonly used to treat spasticity assoc w/ MS?

Baclofen

What drugs are most commonly used to treat intention tremor assoc w/ MS? (3)

- Propranolol - Primidone - Clonazepam

What drugs are most commonly used to treat urinary urgency (spastic bladder) assoc w/ MS? (2)

- Oxybutinin | - Detrol LA

What drug is most commonly used to treat urinary retention/hesitancy assoc w/ MS? (1)

Bethanechol

What drugs are most commonly used to treat painful dysesthesias assoc w/ MS? (5)

- CBZ - OXCBZ - Gabapentin - Phenytoin - Baclofen

MC bradykinetic disorder (aka Akinetic Rigid syndrome)

Parkinsonism - Idiopathic Parkinson's dz** - Postencephalitic - Toxin-induced - MPTP (meperidine analog)

TQ: | Cardinal features of Idiopathic Parkinson's dz: (3)

* *Tremor: resting*, starts unilateral, "pill-rolling," mouth or chin tremor * *Rigidity: increased resistance to passive movement, "cogwheel" quality * *Akinesia / Bradykinesia: slowness, often difficulty initiating movement - Shuffling - Masked facies, "reptilian stare" - Myerson sign - sustained blinking, pt can't stop after tapping on forehead

Other Akinetic Rigid syndromes: (3)

- Progressive Supranuclear Palsy (PSP) - Shy-Drager Syndrome (Multiple Systems Atrophy - MSA) - Cortical Basal Ganglionic Degeneration (CBGD)

- Bradykinesia and rigidity | - Loss of voluntary control of eye movements (esp vertical gaze**)

Progressive Supranuclear Palsy (PSP)

- Bradykinesia and rigidity - Pronounced autonomic dysfunction (dysautonomia)** - NO tremor

Shy-Drager Syndrome (Multiple Systems Atrophy - MSA)

- Bradykinesia and rigidity - May also see cortical sensory loss, apraxia, myoclonus or aphasia ** - "Alien limb"

Cortical Basal Ganglionic Degeneration (CBGD)

- Gradual onset and progression of chorea and dementia - Caused by inherited trinucleotide repeat gene defect on Chr. 4 - Autosomal dominant, lifespan 15yr after onset of symptoms - Caution for suicide

Huntington's dz

- Occurs mainly in children and adolescents as a complication of a previous infection with Group A hemolytic strep - May be form of arteritis - Unilateral choreiform movements - Tx: bedrest and antibiotics

Sydenham's Chorea

- Characterized by dystonic movements and postures without other signs - Onset may be in childhood or later life, but remains throughout life - May see torticollis, blepharospasm, oromandibular spasm, arm/leg dystonia

Idiopathic Torsion Dystonia

- Dystonia confined to focal area - Blepharospasm - Oromandibular dystonia - Spasmodic torticollis - Writer's cramp

Focal Torsion Dystonia

Tx of choice for Focal Torsion Dystonia:

BOTOX

TQ: - Autosomal recessive disorder of copper metabolism that produces neurologic and hepatic dysfunction - Chr. 13 - Decreased binding of copper to ceruloplasmin >> free copper deposits into tissues - Presents in childhood or young adult life - Both bradykinetic and hyperkinetic features present - Dx: incr copper excretion in 24hr urine collection, labs: decr serum ceruloplasmin, Kayser-Fleischer Ring** on eye exam - Tx: Penicillamine (chelating agent)

Wilson's dz

- Chronic multiple motor and vocal tics - Onset before age 21 - Most cases sporadic - MC in males - Tics vary in presentation - Tx: Clonidine, haldol, phenothiazines

Gilles De La Tourette's syndrome

- Postural or kinetic tremor of both hands and may involve the head or voice - Can begin in early adulthood, but often not until later in life - Progresses slowly over years to decades - EtOH often decreases the tremor temporarily - Tx: Beta-blockers (propranolol), primidine, benzodiazepines

Essential Tremor | aka Benign Familial Tremor

What are the 2 basic components of an electrophysiologic exam?

- Nerve conduction studies | - Electromyography (EMG)

Common symptoms requiring EMG: (4)

- Paresthesias (tingling) - Muscle spasm - Paresis (weakness) - Pain in the limb

Definitive diagnosis is NOT reached with only an EMG, so what is it useful for?

Really an extension of physical exam

When you test for nerve conduction and EMG, are you testing for CNS or PNS?

Peripheral nervous system | -Starts with anterior horn cell, runs distally

What are some examples of mononeuropathy? (3)

- Carpal tunnel syndrome - Cubital tunnel syndrome - Radial nerve palsy (Saturday night palsy)

What does a radiculopathy involve?

Nerve root! | -E.g., C5, C6, S1, etc

What are some examples of polyneuropathy?

Sensory AND motor affecting multiple nerves - Starts distal, lower extremities (toes) - LMN involvement - hyporeflexia

- Weakness in proximal* lower limbs - Symmetric - Areflexia (LMN) - NO sensory loss - Progress days-weeks - Good prognosis - back to normal, near normal

Guillain-Barre syndrome | Acute Inflammatory Demyelinating Polyneuropathy -AIDP

MC level and cervical nerve root to be involved in cervical radiculopathy?

C6-7 >> Nerve root C7

Irregular, brief, "dancelike" movements; may be incorporated into purposeful movements

Chorea

Writhing, sinuous movements (often occur in combination with chorea)

Athetosis

Sustained muscle contractions that produce twisting and repetitive movements and abnormal postures

Dystonia

Large amplitude, flinging movement, usually from proximal part of an extremity

Ballism

Brief, rapid, repetitive, seemingly purposeless stereotyped action that may involve single or multiple muscle groups

Tic

TQ: | A general medical condition is coded on what Axis?

Axis III

TQ: | Major depressive disorder goes hand in hand with what?

Myocardial infarction (MI)

TQ: | Describe Stress Theory.

Stimulation of the sympathetic nervous system >> Tachycardia, HTN, increased CO >> Stress

TQ: -Medical symptoms: fever, photosensitivity, butterfly rash*, joint pains, headache -Psychiatric symptoms: depression, mood disturbances, psychosis*, delusions, hallucinations

Systemic Lupus Erythematosus (SLE) Musculoskeletal system

- Medical symptoms: sensory distortions, violence*, belligerence* - Psychiatric symptoms: confusion, psychosis, dissociative states, catatonic-like state, bizarre behavior

Seizure disorder Musculoskeletal system

30% of asthmatics meet criteria for _____ disorder or ___________.

30% of asthmatics meet criteria for PANIC disorder or AGORAPHOBIA.

TQ: -Medical symptoms: heat intolerance, excessive sweating, diarrhea, weight loss, tachycardia*, palpitations, vomiting, fine tremor, ADHD-like, impaired recent memory*, bulging eyes* -Psychiatric symptoms: nervousness, excitability, irritability, pressured speech, insomnia, psychosis*, visual hallucinations

Hyperthyroidism Endocrine system

TQ: -Medical symptoms: increased urination/thirst, high glucose levels -Psychiatric symptoms: frustration, loneliness, dejection, depression**

Diabetes mellitus Endocrine system (Diabetes and depression go together like cardiac stuff and depression)

TQ: -Medical symptoms: excessive thirst, polydipsia, stupor, coma, seizures - Psychiatric symptoms: confusion***, lethargy, personality changes - elderly people

Hyponatremia Metabolic system

TQ: -Medical symptoms: neuropathy, cardiomyopathy, Wernicke-Korsakoff syndrome, malaise, common in alcoholics -Psychiatric symptoms: poor concentration, confusion, confabulation

Thiamine deficiency Metabolic system

TQ: -Medical symptoms: pallor, dizziness, peripheral neuropathy, dorsal column signs, ataxia -Psychiatric symptoms: irritability, inattentiveness, psychosis, dementia***

Cobalamin (Vit. B12) deficiency

Abdominal pain + psychosis

Acute Intermittent Porphyria

Which Axis? Primary psych diagnosis: Personality disorder: Medical condition:

Primary psych dx: Axis I Personality disorder: Axis II Medical condition: Axis III

Basic features of the DSM: | -Primarily designed to describe the manifestations of mental illness, does NOT deal with _________.

DSM does NOT deal with CAUSATION.

TQ: | Limitations of the DSM: (5)

- Does NOT deal with causation - Many of the illnesses have overlapping symptoms - Questionable validity of some diagnoses - Some symptoms seen in pts do not fit within specific diagnoses - Classifications and codes for each illness are essential for billing and insurance purposes