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CMS200 > CMS final key notes > Flashcards

CMS final key notes Flashcards

1
Q

whats predominant in first half of sleep vs second half

A

1st- N3
2nd- REM

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2
Q

who’s more likely to get insomnia

A

women

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3
Q

insomnia definition

A

A repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate time and opportunity for sleep and results in some form of daytime impairment

distress and impair daytime functioning

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4
Q

chronic vs short term vs other insomnia disrosder

A

chronic- 3x/week for 3 months

short term- 1 to 3 months

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5
Q

what distinguished short term from chronic insomnia

A

identifiable cause (i.e. stressful life event, medications, withdrawal from drugs)

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6
Q

genes and molecules in chronic insomnia

A

ApoE4, orexin, histamine, gaba, serotonin, melatonin

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7
Q

Zeitgebers examples

A

social activities, meals, light-dark cycle

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8
Q

biological clock in

A

SCN of hypothalamus

ganglion cells of retina send information to SCN

SCN stimulate pineal gland to release melatonin

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9
Q

when does melatonin peak

A

3 hours before waking

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10
Q

normal circadian intrinsic rhythm

A

> 24 hours- get to 24 hours by zeitgebers

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11
Q

intrinsic vs extrinsic circadian rhythm sleep disorder

A

extrinsic: shift work, jet lag

intrinsic: advance sleep phase disorder, delayed sleep phase disorder etc

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12
Q

Delayed Sleep-Wake Phase Disorder

A

Delayed sleep and wake times relative to what is desired or expected à inadequate sleep and resultant daytime functional impairment

lose at least 2 hours of sleep

sleep inertia (confused when wake up)

depression, excess caffeine and light

treat: sleep hygiene

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13
Q

Advanced Sleep-Wake Phase Disorder

A

Excessive evening sleepiness and early morning awakening

i.e. if out late with friends will still wake up early

hypothesis: internal circadian clock <24 hours

treat: evening bright light therapy

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14
Q

Irregular Sleep-Wake Rhythm Disorder

A

Failure of the circadian rhythm system to consolidate sleepàmultiple short periods of sleep and wakefulness

> 3 periods of wakefulness for at least 1 hour during 24 hrs

esp in dementia

from lack of external cues (zeitgebers)

treat: behavioural and melatonin

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15
Q

jet lag disorder

A

> 2 time zones (can only adjust to 1-1.5 time zones per day)

eastward travel worse

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16
Q

shift work disorder

A

insomnia occurs despite sleep debt

rotating schedules bad (better if swings progress later in day instead of earlier)

try to get 3-4 hours of “anchor” sleep at same time every day

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17
Q

non-24 sleep-wake rhythm disorders

A

Results from a circadian rhythm system not entrained or running without
apparent regulation

i.e. blindness

treat: Rx Tasimelteon (melatonin-receptor agonist)

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18
Q

narcolepsy

A

excessive daytime sleepy with 15 minute sleep attacks

cataplexy (muscle weak)

sleep paralysis (muscle flacid + conscious)

hypnogogic or hypnopompic hallucinations

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19
Q

narcolepsy and REM

A

abrupt transition into REM

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20
Q

narcolepsy after nap

A

feel refresh

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21
Q

narcolepsy type 1 and type 2

A

type 1- low levels of orexin or episode of cataplexy

type 2- normal orexin and no episodes of cataplexy

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22
Q

idiopathic hypersomnia

A

-daytime sleep
-no cataplexy
etccc

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23
Q

klein levin syndrome

A

mostly young men

3-4 times a year for 2 days of hypersonic attack (i.e. 15 hour sleep)

hyrerphagia (hungry), hypersexial

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24
Q

hypersomnia from

A

medical condition (i.e. parkinsons, POTS)

medication/substance

infufficient sleep

psychiatric disorder

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25
Q

paraomnia is

A

abnormal behaviour during sleep

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26
Q

types of parasomnias

A

non-rem: sleep walking, sleep terrors

REM: nightmare, sleep paralysis

other: exploding head, eating disorder, enuresis

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27
Q

sleep terrors

A

N3

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28
Q

sleep walking

A

amnesia of the walking event

N3 or in REM

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29
Q

nightmares

A

during REM

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30
Q

enuresis

A

most in kids

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31
Q

period limb movement disorder

A

during sleep

usually has hypoapnea

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32
Q

Restless legs syndrome

A

can be while awake

-worse with rest, relieved by movements, occurs in evenings

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33
Q

conditions tha mimic sleep loss DDX

A

30-40% = mental health disorder

anxiety, depression, GERD, COPD, brain tumor, medications, shift works, OSA

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34
Q

alcohol use disorder effect sleep

A

acute: decrease latency and reduce REM and increase N3

Chronic: increase N1, decrease REM

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35
Q

caffeine cocaine and stimulates effect

A

NREM and sleep latency

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36
Q

OSA morbidity

A

HTN, heart fail, diabetes

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37
Q

OSA

A

collapse of upper airway –> hypoapnea or apnea

mild: events 5-15 per hour
moderate: 15-30
severe: >30

OSA: >5 with daytime sleepiness

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38
Q

apnea vs hypoapnea

A

cant breath 10 secs

30% reduction

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39
Q

highest LR for sleep apnea

A

nocturnal chocking/ gasping

morning headache

combination of symptoms is better…. alone not very heppful

esp snorning is not helpful to diagnose, good LR- though

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40
Q

good questionnaire for sleep apnea

A

STOP bang score of 3

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41
Q

neck circumference

A

good for OSA increased risk

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42
Q
  • Insomnia: complaints of difficulty initiating sleep or staying asleep
  • Hypersomnia: difficulty staying awake during the day
  • Parasomnia: abnormal movements or behavior during sleep
  • Circadian rhythm disorders: timing of the sleep–wake cycle at undesired or inappropriate times over a 24-hour day
A

x

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43
Q

gold standard of sleep questionaires

A

Pittsburg sleep quality inventory PSQI

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44
Q

godl standard test for OSA

A

polysomnography

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45
Q

sleep diary

A

Identifying behaviours or patterns that may be targeted for intervention

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46
Q

1 cause of death

A

ischemia heart disease

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47
Q

75% of myocardial infarction from

A

plaque rupture (atherosclerosis)

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48
Q

risk factors for atheroscleorsis

A

male (decrease estrogen), hypertesnion, smoking , DM, chylamida, lp(a)

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49
Q

atherosclerosis symptoms depend on artery effected

A

I.e. coronary heart disease: angina/ chest pain

PAD: leg cramp

vertebral artery disease. weak body on one side

mesenteric: weight loss, diarhea

general: stroke, fatigue, dizzy, low back and chest pain, ED, cold and pain hand and feet

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50
Q

skin in atheroscleorsi

A

xqnthoma

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51
Q

atherosclerosis labs

A

LDL, glucose, hsCRP

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52
Q

look for atherosclerotic lesion

A

angiography

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53
Q

complications of atherosclerosis

A
  1. occlude vessel
  2. disrupt plaque (hemorrhage or rupture)
  3. emboli
  4. aneyrsym
  5. peripheral vascular disease (claudication)
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54
Q

peripheral vascular disease

A

outside heart and brain

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55
Q

peripheral artery disease

A

in major arteries distal to the aortic arch

upper and lower extremities

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56
Q

classic/ intermittent claudication

A

fatigue, muscle discomfit, cramp, pain in lower limbs

induced by exercise and relive by rest in 10 mins

in 10-30% of patients with PAD

LR+ 3.30

Edinburgh claudication questionnaire LR+11

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57
Q

skin in PAD

A

ulcers, gangrene, pallor them rubor, cold skin, dystrophic nails, distal hair loss, diminished pulses, bruits

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58
Q

best LR+ for PAD

A

8.1
abnormal posterior tibial pulse

44.6 LR+ if DP and PT pulses absent

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59
Q

ankle brachial index (ABI) for PVD/PAD

A

for lower extremity hemodynamics

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60
Q

screening fo PAD

A

USPSTF- insufficient evidence for routine screening if asymptomatic

AHA/ACC says people with increased risk should be assessed

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61
Q

ABI screening for PAD

A

ABI if have history or exam findings of PAD

if have increased risk of PAD but no findings then can also do

ABI screen if diabetic > 50 yrs old

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62
Q

critical limb ischemia

A

in 1-2% of PAD/PVD cases

ischemia of collateral vessel that maintain limb perfusion

sx: >2 week (chronic) ischemic rest pain, ischemic wounds, tissue loss, gangreene

nocturnal symptoms, worse at night

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63
Q

acute limb ischemia

A

abrupt interruption of arterial blood flow to an extremity

i.e. cold, pain, pale, diminished pulses, sensory or motor

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64
Q

labs for PVD

A

CBC, electrolytes, fasting glucose, lipids, kidney function (creatinine, urinalysis)

althrought CRP, lp(A), and homocysteine are all risks for PVD–> dont help with clinical benefit

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65
Q

duplex ultrasonography/ doppler

A

determine PAD location

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66
Q

MRA or CTA (angiography)

A

for vascular imaging

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67
Q

gold standard for PAD diagnosis

A

catheter-based angiography

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68
Q

DVT

A

unilateral

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69
Q

neurogenic claudication (spinal stenosis)

A

narrowing of foramen, esp lumbar

degenerative osteoarthritis or spondylosis

low back and leg pain, worse with standing or walking (i.e. exercise) and better when lying or sitting

better with flexion, worse with extension

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70
Q

venous thromboembolism (VTE)

A

blood clotting conditions

includes deep vein thrombosis DVT and pulmonary embolism PE

PE more fatal

DVT: in legs (swell, warm, red, pain)

PE: clot travels to and blocks lungs (SOB, chest pain, rapid HR)

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71
Q

virchow triad VTE

A

hypercoagulability
vascular damage
circulatory stasis

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72
Q

PE develops in 50% of patients with proximal lower DVT

A

low oxygen (hypoexmai)

dyspnea**, tachypnea, chest pain

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73
Q

Pulmonary embolism; wells score clinical prediction rule

A

signs of DVT, alternative diagnosis less likely, HR>100,…

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74
Q

DVT; wells score

A

cancer, bedridden, swollen leg, edema…

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75
Q

most common DVT

A

lower extremity 10x more common than upper extrimitiy

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76
Q

tests for DVT and PE

A

d -dimer (fibrin degradation product) if low likelihood and imaging if high likelihood

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77
Q

abdominal aortic aneurysm AAA

A

increase vessel diameter by> 50%

infalmmed and degeneration of arterial wall lead to dilation and rupture

seen in PAD

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78
Q

risk factors for PAD

A

renal dysfunction +12
heart failure +7
>65 yrs old +5
….

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79
Q

dysuria

A

pain or burn after urine

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80
Q

UTI

A

bacterial infection from uretha to renal pelvis

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81
Q

UTI upper vs lower

A

upper: kidney and ureter

lower: bladder, urethra, prostate (male)

upper less common but more severe

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82
Q

lower UTI

A

cystitis
urethritis
prostatiits

upper; pyelnoneprhitis

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83
Q

uncomplicated vs complicated UTI

A

uncomplicated: normal urinary tract

complicated: male, pregnanct, abnormal urinary tract, diabeters…

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84
Q

UTI most common in

A

young women sexually active

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85
Q

most common UTI

A

acute cytistis

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86
Q

acute cystitis

A

bladder infection

diagnose with pyuria (WBC in urine) and bacteriuria

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87
Q

bacteria causing acute cystitis

A

KEEPS
75-95% e. coli

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88
Q

symptoms in acute cysitis

A

dysuria, suprapubic pain

hematuria (blood, urinary frequency and urgency

absence of discharge, CVA tender, N/V, fever

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89
Q

atypical presentation of acute cystitis in older

A

delirium, lethargy, functional decline

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90
Q

high LR for UTI

A

self diagnosis in patients with recurrent UTI LR+4

1 symptom isn’t that helpful

combine: dysuria and frequency without vaginal discharge = LR+ of 24.6

90% likelihood of cystitis so can treat without testing

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91
Q

A woman with dysuria and frequency but without vaginal discharge or irritation has a 90% likelihood of having cystitis,

A

treat without testing

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92
Q

urine dipstick urinalysis

A

leukocyte esterase, nitrites (from bacteria), WBC, hematuria, ph, ketones, bilirubin, glucsoe

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93
Q

high LR+ for urinalysis for cystitis

A

leukocyte esterase 12-48
nitrite 3-30

false negative common for nitrites bc not all bacteria make them

  • Do not rule out cystitis by a urinalysis that is negative for both leukocyte esterase and nitrites in the presence of a convincing clinical presentation
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94
Q

urine culture (find exact organism) only whne

A

antimicrobial resistance suspected

or in cystitis suspected in men

NOT uncomplicated cystitis

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95
Q

treat acute cysitits

A

1-5 days antibiotics if uncomplicated

7-14 days if complicated

symptom relief in 36 hours

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96
Q

asymptomatic bacteriruai

A

bacteria in urine without symtpoms

esp in old women

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97
Q

only screen or treat for asymptomatic bacteria if

A

pregnant (12-16 wk) (bc pre term birth) or getting a urologic procedure

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98
Q

recurrent cystitis

A
  • 2 episodes of acute cystitis within the last 6 months, or
  • 3 episodes of acute cystitis within the last year

do urine culture to see if recurrent or relpasign infection

pelvic exam for women nd rectal exam for men

**hygiene, increase fluid intake

atrophic vaginitis if estrogen decrease in menopause

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99
Q

acute pyeloneprhtitis

A

parenchyma of kidney

ascend for UTI

same KEEPS- esp e. coli

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100
Q

symptoms in pyelonephritis

A

rapid, dysuria, frequency, urgency, hematuria, fever, chills, N/V, flank or back pain, CVA

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101
Q

pyelonephritis on urinalysis

A

white blood cell casts

CBC

antibitotics for 7-14 days

send to hospital if pregnancy, unstable vitals, immunocompromsed

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102
Q

infectious urethritis

A

infection induce inflammation of uretha

usually from STI (esp homosexual male)

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103
Q

cause of infectious urethritis

A

80% gonococcal
2nd: chalmydia

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104
Q

STIs of the genitourinary tract manifest as urethritis in men and cervicitis in women

symptoms

A

dysuria, discharge , dyspareunia..

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105
Q

urethritis/ cervicitis from STI test

A

urine, PCR for gonorrhoea or chlamydia

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106
Q

urethritis from renters syndrome AKA reactive arthritis

A

autoimmune inflamamtory arthritis

from infection getting into genitals or bowel

swollen joints, urination burns

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107
Q

acute bacterial prostatis (men)

A

ascending urethral infection or intraprostatic reflux

from e coli (KEEPS) or gonorrhea

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108
Q

symptoms of acute abacterial prostatitis

A

fever, chills, vomit, low back pain, dysuria, painful ejaculation and defecation

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109
Q

test acute bacterial prostatitis

A

rectal exam
4 part urine culture VB1,2,EPS, VB3

support with antipyretics and stool softeners and antibiotics (4-6 weeks)

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110
Q

chronic bacterial prostates

A

irritative or obsrtuctuvie lower urinary tract symptoms etccccc

3-4 months of antibiotics

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111
Q

DDX of dysuria (pain when urine)

A

dermatologic, infectious, non infectious….

non inflam: endocrine, neoplastic, pscyhogenic///

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112
Q

CVA LR- is 0.9

A

useless - if not CVA then still might have kidney problem

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113
Q

dysuria further testing

A
  • May not be required (e.g., in a woman presenting with uncomplicated UTI) – can treat empirically

or urinalysis…

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114
Q

Given the frequency with which peripheral vascular disease is asymptomatic, what percentage of patients is the Edinburgh Claudication Questionnaire targeted towards (pick the closest match)?
Question 1 Answer

a.
90%

b.
10%

c.
70%

d.
30%

A

maybe 10% idk

115
Q

pseudodementiaa

A

depression or psych disorder alone or with dementia

116
Q

dementia

A

major neurocogntiive disorder- cognitive decline, affect ADL, not delirium or depression

117
Q

who’s likely to get demnetia

A

women old

118
Q

most common dementia 70-80%

A

alzheimers

followed by FLTD 25%

119
Q

strongest risk factor for demtnai

A

age

120
Q

most common symptoms of dementia

A

memory impairmenta

121
Q

agnosia

A

cant remember familiar things

122
Q

aphasia

A

motor or sandy language disturbance

123
Q

apraxia

A

cant do motor task

124
Q

if :dementia” develops quick

A

be wary that its from infection or neoplasm etc

should be slow

125
Q

1st step for dementia

A

history and phsycial exam

then mini cog then MMSE or MOCA then screen for depression, do labs and neuroimag

126
Q

medications that impair cognition (dementia)

A

anticholinergics, sleep aids and anxiolytics, analgesics such as codeine containing agents

127
Q

screening for dementia

A

USPSFT current evidence is insufficient to assess the benefits vs. harms of screening for cognitive impairment in older adults.

If dementia is suspected, physicians can use brief screening tests such as Mini-Cog then if abnormal do MOCA or MMSE

128
Q

pseduodementia

A
  • Psychiatric disease can lead to impaired cognition (pseudodementia).
  • Clinical presentation: poor focus and concentration may primary complaint
129
Q

labs for dementia

A

CBC, TSH, b12, metabolic panel

neuroimaging to rule out intracranial (MRI)

130
Q

APOe4 gene testing

A

Genetic testing for apolipoprotein E4 allele is NOT recommended as part of the routine evaluation for cognitive impairment.

only if have family history

131
Q

delirium

A

Acute confusional state that often occurs in response to an identifiable trigger

predisposing factors: depression, old, dementia, strokes, alcohol use

precipitation factrors: drugs, surgery, alcohol, metabolic coma

132
Q

symptoms in delirium

A

inattention, reduced orientation to environmnet, hyper or hypo active

ACUTE
fluctuating course wax and wane in a day

133
Q

delirium and dementia can coexist

A

need to resolve delirium then to diagnose dementia

134
Q

Labs for delirium

A

CBC, chemistries, glucose, renal and liver function tests, urinalysis, test for occult infectio

135
Q

MCI

A

A decline from a previous state of mental functioning that causes no or minimal interference with daily activities.

15% progress to dementia

136
Q
  • KEY feature differentiating MCI from dementia
A

Maintains level of function and capacity for independence in everyday activities

137
Q

MCI reassess

A

annually to evaluate for progression to dementia.

138
Q

non amnestic and amnestic MCI

A

amnestic= memory loss

139
Q

MCI

A

evidence of lower performance in one or more cognitive domain

maintains preserved independence in functional abilities

change in cognition in comparison to the patient’s previous level.

140
Q

alzheimers

A

amyloid plaques and neurofibrillary tangles

141
Q

which allele of APOE is bad for AD

A

E4 (not E2 or E3)

142
Q

vascular risk for dementia

A

Hypercholesterolemia, hypertension, diabetes mellitus, metabolic syndrome, obesity, and physical inactivity,

143
Q

Around one-third of AD cases globally could be prevented by addressing modifiable vascular risk factors

A

!

144
Q

AD presentation

A

most amnestic (memory)

nonamnestic: language, execute dysfunction, language impari

personality

depression

gait

145
Q

imaging for AD

A

PET
CSF (amyloid an tau)

146
Q

genetic testing

A
  • Recommended for young patients with a history of first-degree relatives with young- onset dementia.12
    *
  • APOE genotype is not recommended for routine evaluation of AD: most do not have the associated alleles, and current medical management would not change by the test results.
147
Q

Diagnosing Alzheimer’s disease (AD) is challenging due to emotional responses from patients and families.

A
  • Factors like coping mechanisms, culture, family dynamics, and existing knowledge impact reactions. Clinicians should be empathetic, honest, and provide resources for education and support.
  • Goals include protecting memory, delaying progression, and ensuring safety.
  • Use “Alzheimer disease” for diagnosis communication.
  • Encourage local support groups and resources for effective patient management.
148
Q

AD medications

A

cholinesterase inhibitors, NMDA receptor antagonists, and potentially aducanumab and other monoclonal antibodies targeting amyloid.

149
Q

vascular dementia

A

Stepwise or progressive accumulation of cognitive deficits in association with repeated strokes.

150
Q

risk factors for vascular dememtia

A

hyperlipidemia, hypertension, diabetes mellitus, and smoking (tobacco)

151
Q

physical signs in vascular dementai

A

hemiparesis (one sided muscle weakness), pseudobulbar palsy and visual field defects

152
Q

course of vascular dementia

A

Acute onset (following cerebrovascular event) of cognitive impairment with some stabilization (if only one vascular event) and/or stepwise deterioration (if multiple infarcts)

153
Q

Lewy body dementia

A

alpha syncliun (lewy boes) in the cortex

154
Q

Lewy body symptoms

A

attention and executive function,

hallucination, parkinson gait

NOT MEMMORY AS MUCH

other possible: REM sleep disorder, poor dopamine uptake

155
Q

frontotemporal lobe dementia

A
  • Behavior variant (bvFTD)
  • Language variant:
  • Non-fluent variant primary progressive aphasia (nfvPPA)
  • Semantic variant primary progressive aphasia (svPPA)
156
Q

risk for frontal temporal dementia

A

head trauma, thyroid disease, genes

157
Q

FTLD presntiatia

A

decline in social cognition and/or executive abilities, but with relative sparing of learning and memory, and perceptual–motor function

BAD BEHAVIOUR- disinhibition**

loss of emotional reactivity, apathy

MEMORY INTACT UNTIL LATE IN DISEAE

158
Q

FTLD biomarker in blood and CSF

A

neurofilmaent light chain

159
Q

BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA (BPSD)

A

agitation, depression, apathy

  • cognitive/perceptual (delusions, hallucinations)
  • motor (e.g., pacing, wandering, repetitive movements, physical aggression)
  • verbal (e.g., yelling, calling out, repetitive speech, verbal aggression)
  • emotional (e.g., euphoria, depression, apathy, anxiety, irritability)
  • vegetative (disturbances in sleep and appetite)

Sundowning affects 2/3 of patients with dementia: behavioral disturbances often occur in the evening

160
Q

whats suggestive of delirium

A

fever, hypoxia, abdominal tenderness, fluid overload, inflammation, or new localizing neurologic deficit

161
Q

anemias

A

lower than normal level of healthy red blood cells or hemoglobin

  • Characterized by low hemoglobin, low hematocrit, low RBC count on the complete blood count (CBC)
162
Q

symptoms of anemai from decreased oxygen delivery to tisuse

A

fatigue, tachycardia, palpitations, dyspnea on exertion

163
Q

best LR+ for anemai pallor

A

conjunctival rim

  • Conjunctival rim pallor (LR+ 16.7) * Palmar crease pallor (LR+ 7.9)
  • Palmar pallor (LR+ 5.6)
164
Q

causes of anemia

A

reticulocytopenia- decreased RBC production
i..e DNA synthesis lesion (megaloblastic anemia), hemoglobin synthesis lesion (IDA)

reticulocytosis- increased RBC destruction (hemolysis) or accelerate RBC loss
i.e. spherocytosis, blood loss, cold or warm antibody, hypersplenism

165
Q

acute blood loss

A

hypotension, tachycardia, ecchymose (bruising)

melena, hematemesis, hematuria, menorrhagia

166
Q

low reticulocyte vs high reticulocyte

reticulocyte= immature RBC

A

low: RBC underpdorcution anemia

high: hemolysis or bone marrow response to blood loss

167
Q

reticulocyte production index x

A

normal= 1

<2= hypoprofliferative anemia (underproduction)

> 2 = hyper proliferative anemia (hemolysis or blood loss)

168
Q

MCV= average size of RBC

A

normocytic

macrocytic- subcategory of megaloblastic (impaired DNA synthesis) or non megaloblastic

microcytic

169
Q

microcytic anemia in

A

iron deficency
thalassemia
anemia of chronic inflam (also normocytic)

170
Q

normocytic

A

anemia of chronic inflam (could also be microyctic)
anemia of renal/kdiney disease

171
Q

macrocytic anemia

A

megaloblastic: b12 or folate deficient

non-megaloblastic: myelodysplastic syndrome

172
Q

non-megaloblastic macrocytic could be caused by

A

liver disease or hypothyroid

173
Q

MCV

A

not specific

174
Q

IDA

A

most common anemia

microcytic , hypochromic

causes: chronic blood loss, diet, impair absorb, increase demand..

175
Q

IDA symptoms

A

restless leg, pica, glossitis, chelitis (tongue), koilonchia nails

176
Q

best marker for IDA

A

decreased serum ferritin

also decrease transferrin, serum iron

increase TIBC

177
Q

B12 deficiency anemia

A

megaloblastic macryoctic anemia (high MCV)

impairs DNA synthesis

lack intrinsic factor

metformin, PPI impair absorption

178
Q

b12 deficiency anemia: pernicious anemia

A

autoimmune-mediatedgastricatrophy→lossofparietal cells→decreased secretion of intrinsic factor→decreased dietary vitamin B12 absorption

179
Q

diagnose pernicious anemi

A

anti-intrinsic factor antibodies

180
Q

tests in b12 deifciney anemia

A

low serum b12

high homocysteine

high methylmalonic acid MMA

181
Q

folate deficiency anemia

A

qegalobasltic macryopcytic anemia (high MCV)

impair DNA synthesis

182
Q

ddx of folate from b12 defiance anemia

A

in folate increased homocysteine but normal MMA in folate deficiency

both are high in b12

183
Q

anemia of renal disease

A

kidney disease decreases EPO which decrease RBC

normcytic normochromic

low hemoglobin, low serum iron

184
Q

2nd most common anemia

A

anemia of chronic disease (i.e. infection, inflame, malignancy, tumor)

185
Q

anemia of chronic disease

A

impaired iron transport from iron storage sites (e.g., liver, spleen, bone
marrow) to developing RBCs→decreased production of RBCs

normocytic normochromic

increased iron stores, low serum iron,

186
Q

other test for anemia of chronic disease

A
  • Liver enzymes if there is history of liver disease
  • Creatinine if there is history of kidney disease
  • Elevated inflammatory markers: ESR and CRP
187
Q

basic metabolic panel to see if chronic kidney disease

A

Glucose
* Calcium
* Sodium
* Potassium
* Carbon dioxide
* Chloride
* Blood urea nitrogen (BUN)
* Creatinine

then look at GFR

188
Q

most common inherited disoders

A

thalassemias

189
Q

thalasssmeia

A

Congenital abnormality of hemoglobin synthesis → decreased production of RBCs

alpha or beta

190
Q

4 missing Alpha gene

A

hydros fatalis

191
Q

3 missing alpha genes

A

hemoglobin h disease

192
Q

symptoms in moderate to sever thalamsemia

includes β- thalassemia intermedia, β-thalassemia major, and Hemoglobin H disease

A
  • Severe anemia
  • Growth disturbances and delayed puberty
  • Bone abnormalities (e.g., osteoporosis)
  • Splenomegaly
  • Pallor or jaundice
193
Q

mild thalassemia

A

hypo chronic and microcytic anaemia may have splenomegaly

very mild

194
Q

diagnose thalassemia

A

look at family history of anemia

CBC, hemoglobin electrophoresis, genes

195
Q

myelodysplastic syndrome

aka hyperplastic bone marrow with bone marrow failure, refractory anemia, smoldering leukemia, preleukemia

A

Blood cell components fail to mature → deficient production of mature cells into peripheral blood (including RBCs)

196
Q

5 types of myelodysplastic syndrome

A
  1. Refractory anemia
  2. Refractory anemia with excess blasts
  3. Refractory anemia with leukemia in transformation
  4. Refractory anemia with sideroblasts
  5. Chronic myelomonocytic leukemia

can transform into leukemia in certain time frames

197
Q

myelodyspalstic syndrome presentation

A

megaloblastic or microcytic anemia

pancytopenia: anemia with abmnormalieties in 1 or 2 of other marrow cell lines (WBCs, platelets)

198
Q

hemolytic anemia

A

normocytic

caused by RBC destruction

inherited (i..e sickle cell) or acquired (i.e. infection)

199
Q

extravascular vs intravascular hemolytic anmie

A

extravascular- RBC prematuelry removed from circulation by liver and spleen (MAJORITY)

intravascular: RBC lysed in circulation

200
Q

symtoms of hemolytic anemia

A

SOB, fatigue, tachycardia, jaundice, lymphadenopathy, hepatosplenomeagly

diarrhea

hematuria

201
Q
  • Hemolytic anemia with diarrhea → consider hemolytic uremic syndrome
  • Hemolytic anemia with hematuria → consider paroxysmal nocturnal hemoglobinuria
A

x

202
Q

tests for hemolytic anemia

A
  • Elevated reticulocyte count
  • Increased lactate dehydrogenase (LDH)
  • Elevated unconjugated bilirubin
  • Decreased Haptoglobin

Coombs: cold or warm agglutinin (immune)

spherocytes, bite cells

203
Q

untreatmed anemia

A

in pregnancy premature, low birth weight

elderly: cardiac complication

kids: neurolgoical development

204
Q

A naturopathic doctor receives lab results for their patient who has fatigue, the results of which indicate a macrocytic anemia. What is the most appropriate differential diagnosis?
Question 3 Answer

a.
Kidney disease, copper deficiency, zinc deficiency

b.
Vitamin B12 deficiency, hypothyroidism, liver disease

c.
Anemia of chronic inflammation, copper deficiency, myelodysplasia

d.
Aplastic anemia, lead toxicity, thalassemia

A

B

205
Q

What lab result should most increase a naturopathic doctor’s estimate for the probability of anemia?

Question 4 Answer

a.
Low hemoglobin

b.
High RDW (red cell distribution width)

c.
High MCV (mean corpuscular volume)

d.
Low ferritin

A

A

206
Q

how many headaches are life threatening

A

< 1%

207
Q

findings for secondary headaches on physicals

A

focal neurological deficits, papilledema, bitemporal hemianopia, homonymous hemianopia, decreased visual acuity, or increased pain with Valsalva method

208
Q

new headaches

A
  • recent onset or
  • chronic headaches that change character/qualitty
209
Q

headache changes

A
  • Change in severity is less important than change in quality
210
Q

most common primary headaches

A

migraine and tension type

211
Q

most new headaches are

A

benign but almost all serious headaches are new

212
Q

primary vs secondary

A

primary: tension-type headache, migraine headache, cluster headache ( no underlying caused) (no labs or imaging as gold standard)

secondary from other thing (i.e. infection, vascular, temporal arthritis, URTI, TMJ, cervical degeneration, brain tumor )

213
Q

are most headaches primary or secondary

A

primary

214
Q

worrisome headaches

A

new and secondary

215
Q

SNNOOP10 for red flags in headache

A

systemic
neoplasm
neurlogic
onset
old
Pattern, positional, preceiptatied, papilledema, progressive or atypical presentation, pregnancy, painfulful eye, post trauma, painfkiller

216
Q

highest LR for red flags in headaches

A

disequilibrium (49)

headache causing awakening from sleep (1.7-98)

217
Q

neuroimaging in headache

A

if have red flag

(new and sudden onset severe, >50 yrs old, HIV, associated with neurologic deficits)

218
Q

pretest probability for severe intracranial pathology

A

thunderclap headache 43%

219
Q

predict neuroimaging abnoramlities

A

cluster type headache LR+ 11
(they’re primary and benign but symptoms overlap with serious headaches)

abnormal neurological 5.3

difficult to classify and not a primary ehadaachees 3.8

220
Q

MRI, CT with or without contrast

A

CT if trauma and hemorrhage

otheer if progressive worse

221
Q

lumbar puncture for headache

A

infection, RBC, xanthochromia (yellow CSF from bilirubin)

do if have: meningeal sign, HIV, altered mental status, neurological deficits

222
Q

labs for headache

A

CBC (infection)
ESR and CRP (temporal arteritis)
metabolic panel
endocrine (pituitary)

223
Q

rhinosinusitis and headache

A

bacterial or viral infection of sinus an dnsal–> facial pain, pressure

high LR+ symptoms after URTI, if Dr thinks it is

better in 7-10 days

do antibiotics

224
Q

meningitis

A

headaches, fever, stiff neck, alter mental status

viral (common) or bacterial (more fatal)

acute, rapid onset

225
Q

meningeal sings

A
  • Kernig sign (resistance to knee extension with hip flexion)
  • Brudzinski sign (involuntary hip flexion with neck flexion)
  • Nuchal rigidity (resistance to neck flexion)
  • Jolt accentuation of headache (worsening of headache by horizontal rotation of the head).
226
Q

bacterial meningitis 95% sensitivity

A

2 of: headache, fever, stiff neck, mental status change

227
Q

diagnose meningitis

A

CSF from lumbar puncture

228
Q

head trauma

A

minor in 90% (glasgow coma scale)

symtoms: loss of consciousness, amnesia, headache

229
Q

CT for minor head truma LR+

A

physical exam findings suggest skull fractures (16)

GCS score of 13 (4.9)

230
Q

skull fracture findings

A

CSF otorrhea, periorbital ecchymosis (racoon eye), hemotympanum (ear drum), postauricalualr echymosis (battle sign)

231
Q

mild TBI

A

headache mint to hour and days to weeks after even

early: fatigue, dizzy nausea
late: anxiety, concentrating, sleep, light sensitive

232
Q

head trauma testing

A

CT

233
Q

subarachnoid hemorrhage

A

blood vessel rupture btw space in brain and skull

WORST HEADACHE OF LIFE

vomit, neck stiff, lose consciousness

234
Q

risks for subarachnoid hemorrhage

A

cigarettes, hypertesnion, old man

235
Q

type of headache in subarachnoid hemorrhage

A

thunderclap headache (abrupt and max intensity usually with vomiting)

warning “sentinel” headache

236
Q

subarachnoid hemorrhage testq

A

non constrast CT then lumbar puncutre if needed (xanthochromia)

237
Q

idiopathic intracranial hypertension

A

severe daily headaches in young obese women (chronic)

may awaken from sleep

associated with visual disturbance

238
Q

symptoms in idiopathic intracranial hypertension

A

chronic headache and progressive visual deterioration

239
Q

90% finding in idiopathic intracranial hypertesnion

A

papilledema

240
Q

12% of times in idiopathic intracranial hypertension

A

CN6 palsy

241
Q

test in idiopathic intracranial hypertesnion

A

increased ICP

normal MRI or CT

242
Q

prognosis of idiopathic intracranial hypertesnion

A

vision loss

243
Q

temporomanidcular disorder headahce

A

TMJ cause headache and facial pain when chew

esp women

jaw sounds, jaw mobilitiy

244
Q

signs for TMJ headahce

A

facial pain 96%
ear discomfit 82%
headache 79%
jaw discomfort or dysfunction 75%

245
Q

brain tumors

primary or metastatic

A

metastatic 7x more common (lung 37%, breast, melanoma)

progressive headache

headache, worse in morning, N/V, alter mental status, weak

246
Q

neurological exam in brain tumor

A

hemiparesis (one sided muscle weak), impaired cognition, sensory loss, gait abnormalities

247
Q

symptoms for brain tumor

A

headache, seizure,

anosmia, apraxia, cognitive delay, drowsiness, dysphagia, hallucinations, memory loss, nausea and vomiting, pain, and stiff neck

248
Q

primary brain tumors have different manifestationn depending on location

A

i.e. thalamus has behavioural dn language change

front lobe has dementia, gait, sensory loss

249
Q

brain tumor test

A

MR then CT

250
Q

medication over use headache

A

from analgesics

highest risk: opioids, triptans, ergotamines, NSAIFs and acetominaphrin

one of the most common secondary headaches

more in women, low SES

associated with chronic migraine or tension type headache

251
Q

time course of medication overuse headahce

A

> 15 headaches/ month for 3 months of medication use

take the drugs for 10-15days/month

252
Q

symptoms in medication overuse headache

A

neck pain, sleep, GI, anxiety/depress, autonomic (rhinorrhea)

253
Q

temporal arteritis

A

> 50 years old with jaw claudication

esp if have poly myalgia rheumatica

254
Q

LR+ for temporal arteritis

A

scalp tenderness and jaw claudication 17

headahce and jaw claufidation 8

255
Q

test for temporal arteritis

A

gold standard- temporal artery biopsy

ESR

256
Q

prognosis of temporal arteritis

A

could go blind

257
Q

primary headaches

tension-type headaches, migraines, and cluster headaches

A

short <4 hours (cluster, stabbing, SUNA, SUNCT)
long> 4 hours (migraine, tension)

258
Q

if no red flags dont need imaging for primary headaches

A

just history and physical exam

259
Q

cluster headache

A

unilateral and cluster in time (brief 15-180 min, up to 8 episode a day)

90% episodic (remission for 1 month)

young men

autonomic + restless

260
Q

symptoms of cluster headache

A

rapid onset, in retro orbital area or temporal region

unilateral

autonomic: congestion, eyelid edema, sweat forehead, lacrimation

restless and agitated 90%

261
Q

clusteheadache testing

A

yes, neuroimagin bc LR=11

262
Q

comobrid in cluster headache

A

depression, sleep apnea, restless leg, astham

263
Q

Short-lasting Unilateral Neuralgiform Headache (SUNCT or SUNA)

A

trigmeinal nerve stimuli

1 second- 1o mins

unilateral pain
autonomic: eye edema, lacrimation, rhinorrhea, forehead sweat

264
Q

SUNA vs SUNCT

A

SUNA
either lacrimation or conjunctival injection but not both

SUNCT
both lacrimation and conjunctival injection

265
Q

primary stabbing headaches

A

shortest lasting; 3 seconds

42% temporal region; can change location

no autonomic symptoms

266
Q

migraine

A

chronic, unilateral pulsating headache with nausea, photophobia, phonophobiaa

possible aura (60 min)

4-72 hours

267
Q

most common primary headache

A
  1. tension
  2. migraine
268
Q

migraine symptoms

A

pulsating or throbbing pain, bilateral 60% (or uni?)

nausea, photophobia, photophobia

worse with stress, menstrual, nitirite or tyramine in foods, fatigue

269
Q

auras in migraines in 1/3 of patients

A

<30 mins (70%) and stars of flashes (83%) or zig zags (56%)

blind spot then falshing light

270
Q

migraine screening tool if have score of 2 or 3 its LR+ 3.25

A

2 and 3 have good LR-

  1. Nausea: “Did you ever feel nauseous when you had headache pain?” (BEST LR+ OF 3.2 alone)
  2. Photophobia: “Did light trouble you when you had headache pain (much more than when there was no headache)?”
  3. Disabling Intensity: “Did your headache ever limit your ability to work, study or do something you needed to, for at least 1 day?”
271
Q

risk for episodic to chronic migraine

A

if frequent, medication overuse, obese, diabetes, arthritis, head or neck injiury

272
Q

tension type headache

A

most common

worse withs tress and end of day

273
Q

symptoms of tension headache

A

bilateral pressure (pressing/ non pulsing)

274
Q

migraines are

A

PULSITLE (tension type are not)

275
Q

migraines can be worse qith

A

chocolate, cheese, phsycial activity

276
Q

POUND for migraine

A
  • Pulsatile quality
  • Duration of 4 - 72 hOurs
  • Unilateral location
  • Nausea or vomiting
  • Disabling intensity

if 4-5 of these then LR+ 24

277
Q

chronic headaches

A

> 15 headaches / month for 3 months

usually migraine or tension or medication overuse

other risks
* Chronic pain, especially musculoskeletal pain * Cutaneous allodynia
* Sleep disorders
* Obesity
* High caffeine consumption
* Stressful life events, especially in middle age

278
Q

chronic migraine

A
  • May evolve from episodic migraine
  • Patient typically report progressively frequent bilateral frontotemporal TTH-type symptoms with superimposed full- blown migraine attacks
  • Comorbidities: obesity, obstructive sleep apnea, depression, chronic pain disorders, cardiovascular disease, sleep and emotional disturbances
279
Q

chronic tesnsion type

A
  • Long attack duration and nausea are predictive of development of chronic TTH
  • Bilateral, non-pulsatile, absence of associated symptoms * Pericranial tenderness is often found on palpation
280
Q

headache impact test (how you feel)
headache diary
PHQ9, CAGE

A

x

281
Q

A 32-year-old man presents with concerns of a rapid-onset, severe headache with mild neck stiffness which started while performing pushups 2 hours ago. He has no other known illness. On physical examination, there are no neurological abnormalities. The naturopathic doctor considers tension headaches to be a likely diagnosis. What other differentials should they consider?
Question 1 Answer

a.
Primary thunderclap headache and exercise-induced migraine

b.
Subarachnoid hemorrhage and primary exercise headache

c.
Primary stabbing headache and cluster headache

d.
Cervicogenic headache and headache attributed to fasting

A

B

282
Q

A naturopathic doctor has seen the following pediatric patients regarding their headaches.
PA. a 2-year-old girl
QB, a 7-year-old boy
RC, a 9-year-old boy
SD, a 14-year-old girl
Which of them was most likely to be experiencing migraines?
Question 3 Answer

a.
PA

b.
SD

c.
QB

d.
RC

A

B

283
Q

What aspect of patient-centered interviewing is particularly applicable to initiating an interview with a patient experiencing headaches?
Question 5 Answer

a.
Use the patient’s name, in case confusion is a symptom associated with the patient’s headaches

b.
Ensure patient readiness and privacy, since patients are often embarrassed about the cause of their headaches (e.g. headaches associated with sexual activity)

c.
Understand the patient’s agenda, since patients often seek medical care for headaches when they are concerned about serious diagnoses

d.
Attend to non-verbal cues such as autonomic changes which may be present in migraine auras or cluster headaches

A

C

CMS200 (22 decks)

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