Exam 3 (week 2) Flashcards
hemiparetic gait - where is lesion
cortex (M1) down to reticulospinal or corticospinal tract
hemiparetic gait - what does it look like
flexion of arm
projection of leg is circumducted during walking
spastic diplegia - where is lesion
interhemispheric fissure of frontal cortex - bilateral leg homunculi in cortex caused by meningioma
what is spacticity
velocity dependent increase in tone
can slowly extend, but if you ramp up speed, they get stuck
what is spastic diplegia usually caused by
cerebral palsy
what does spastic gait look like
narrow, SCISSORING, stiff, spastic gait, toe gait in children
describe parkinsonian gait
narrow based shuffing stooped flexed posture slow decreased 1 arm swing multi-step turn retropulson (fall back) festination (quick steps)
ataxic gait - what does it look like
wide based
unstead - falls towards affected side
can’t do tandem gait
where is lesion/problem in ataxic gait
cerebellum
what causes ataxic gait (2)
alcohol
cerebellar lesion
frontal gait - what do you see
“magnetic gait” -feet stuck to the ground
slow, shuffling
normal arm swing
frontal gait - cause
normal pressure hydrocephalus
normal pressure hydrocephalus “Triad”
wacky (cognitive)
wet (urinary incontinence)
wobbly
functional gait - what do you see
inconsistant, lurching gait
appears dramatic and bizarre
suggestible
no falls or injuries
functional gait - what causes it
psych
what percent of cortex is association cortex
80%
3 “questions” asked by brain regarding cognitive information
attention (is it interesting?)
identification (if it is, what is it?)
planning (what do I do about it?)
what lobe determines if something is interesting
parietal lobe
what lobe determines what something is
temporal lobe
what lobe determines what to do about something
frontal lobe
how are brodmann’s areas distinguished
have different “packing” arrangements - cytoarchitectonic areas - turn out to have different functions
what is in cortical layer 4
recipient layer for thalamic neurons
stroke/lesion in association area of R parietal lobe causes what behavioral changes
contralateral neglect
INATTENTION problem
L visual field only seen by R hemisphere
R visual field seen by both R and L hemisphere
stroke/lesion in association area of R inferior temporal lobe causes what behavioral changes
problems with facial recognition - fusiform face area
prosopagnosia (sometimes congenital)
stroke/lesion in association area in frontal lobe causes what behavioral changes
working memory
executive function
couldn’t match behavior to environment around him
how to test prefrontal disfunction
wisconsin card sorting test - tests working memory and planning
3 areas of brain associated with “thinking” even during rest - “default mode”
- inferior temporal
- posterior cingulate
- medial prefrontal
what do the brains of schizophrenic patients look like compared to control in “Default mode”
more activity, particuarly in frontal and parietal
what do the brains of dementia patients look like compared to control in “Default mode”
hypoactivity in posterior
hyperactivity in frontal (like in schizophrenia)
two main features of language
- symbolic representation - matching of symbols to objects/actions (lexical)
- sterotypic performance - reliable order and contex for language production (syntantic and semantic)
lexical aspect of language controlled by what lobe
identification
L parietal: WERNICKES
syntactical/semantic aspects of language controlled by what lobe
planning/production
L frontal: BROCAS
rolling happens when in babies
4-6 mo
sitting happens when
6-7mo
crawling happens where
9-10 mo
walking happens when
14-15mo
transfering object happens when
6mo
baby bats an object
2-4mo
hands together when
3mo
grabs object hwen
4mo
bring to mouth when
4-5 mo
cooing happens when
2mo
babbling when
6mo
fin pincer grasp when
9-10 mo
word/word approximation when
12mo
vertical line drawing when
2 years
circle drawing when
3 years
proto-imperative pointing -what is it and when does it occur
point with finger to object they want at 12mo
proto-declarative pointing - what is it and when doe sit occur
parent says, where is dog, baby points to dog
14mo
what much of a difference beyond expected connotes delay
2 standard devations
for walking, what month is delayed
18 months
for speaking, what month is delayed
15months
motor apraxia
can’t get words out
at what age can you say someone has an intellectual disability
5 years
difference between mild and moderate delay/intellectual disability in terms of epidemiology
mild delays occur less often in developed countries
moderate-severe happen everywhere at same rate
seizures in children often associated with what
encephalopathy
how long do you correct for gestational age (in preterm birth)
until 1st year of age
formula for expected head circumference
length/2 + 9cm
std dev +/-2.5cm
low tone caused by what (2)
congenital
metabolic
low tone will cause what
delayed motor milestones
which developmental features are most often delayed in autism
social and language
is autism defined by genotype or phenotype
phenotype - we don’t have genetic testing, so autism is an umbrella term covering phenotypes
criteria for autism (5)
- persistent deficits in social interaction and communication
- restricted, repetitive behavior/interest (need more/less stimulation)
- early symptoms (~18mo)
- symptoms cause impairment in functioning (predominately social)
- symptoms not explained by intellectual disability or global developmental delay
when is MCHAT done
16 and 30 mo, or 18mo
if MCHAT is positive, then what do you do
ADOS - intensive. done by psychologist, on individuals 12mo through adulthood.
neuropsycho eval - will give you IQ and cognitive strengths/weaknesses
prevelance of autism
1:59
gender preference of autism
4:1
M>F
what percentage of patients with autism do NOT have intellectual disability (AKA only social issues)
15%
what percentage of patients with autism have seizures
25%
genetics associated with autism (3)
fragile X
Tuberous sclerosis
Dup15q syndrome (15q11.2-q13.1)
what early intervention has been proven to be helpful for autism
applied behavioral analysis (ABA)
what does karytope pick up in intellectual delay
chromosomal duplications/delesions, inversions, translocations (trisomy 21, turner)
what does CMA test pick up in intellectual delay
will pick up developmental delay/autism
what does WES test pick up in intellectual delay
mutations in central exons - still misses other things (repeats, mitochondria etc.)
gene panels - what do they pick up in intellectual delay
specific genes (epilepsy panel, autism panel, intellectual disability)
brain MRI - what will it pick up in intellectual delay
won’t tell you function - can see asymmetry or tone problems
long narrow face, large ears, prominent jaw, flexible fingers, flat feet, large testes after puberty
fragile X
diagnostic tests for fragile X (2)
PCR to “size” the number of repeats and
Southern blot to assess methylation
genetics of fragile X
CGG triple repeat
FMR1 gene Xq27.3
steryotyped wringing hand movement, microcephaly, regression of developmental milestones and loss of communication skills after 7-18mo
Rett syndrome
epidemiology of Rett
girls - lethal in boys
sporadic, denovo
death in Rett - what causes it
seizures.
prolonged QT - causes sudden death
genetics of Rett
X linked dominant
MECP2gene Xq28
how to test for Rett genetically
tiered targeted sequencing
child with neonatal hypotonia and failure to thrive hyperphagia leading to obesity
hypogonadism
almond shaped eyes
Prader willi
girl with excessive laughing and smiling absence of intelligible speech protruding tongue hyperactivity seizures
Angelman
prader willi genetics
deletion of paternal 15q11-q13
inheritance of 2 copies of maternal chromosome 15 (which is disordered?)
angelman syndrome
deletion of maternal 15q11-q13
inheritance of 2 copies of paternal chromosome 15 (which is disordered?)
tic disorder presentation age
before 18yr
provisional tic definition
fewer than 12 months,
stop before puberty
persistant tic disorder definition
more than a year
one or more vocal or motor tic (NOT BOTH)
persists beyond puberty
tourette syndrome definition
2+ motor and AT LEAST 1 vocal tic
lasts more than a year
often associated with psych - OCD, anxiety etc.
what 2 things to think about in terms of psych in infants
homeostasis
attachment
how does reactive attachment disorder happen
when the environment goes wrong (neglect, abandonment, abuse etc.) - problem with Care
emotionally withdrawn 9 month infant, rarely seeks comfort, rarely responds to comfort, limited positive affect, persistently emotionally disturbed, not babbling, playing etc. has been removed from caregiver for some times
reactive attachment disorder
7 year old adopted kid, climbed onto stranger’s lap, walked into someone else’s house, tells strangers intimate details of her life, doesn’t check in with caretaker, no stranger danger
disinhibited social engagement disorder
what is one of the most commonly reported socially aberrant behaviors in post-institutionalized children
disinhibited social engagement disorder
how common are sleep disorders in kids 1-5
25-43%
BEARS acronym regarding sleep
Bedtime routine Excess daytime sleeping or dysfunction Awake after sleep Routines Snoring
What are nightmares
parasomnia that happens during REM - so you remember
what chidlhood sleep disroder can be inherited
non-REM sleep parasomnia - night terror or sleep walking
what childhood sleep disorder could be linked to fear or anxiety
nightmares
what age is separation anxiety most often
7-8 yo
what is most common anxiety disorder of childhood
separation anxiety
learning disorder familial prevalance
4-8x higher risk in first degree relatives
when are learning disorders generally picked up
high school
IQ for mild intellectual disability
50-70
types of ADHD
inattentive
hyperactive-impulsive
combination
what ADHD type is the most common
combined
what percentage of ADHD is genetic
80%
do meds alone work better than meds plus therapy?
work the same
what percentage of kids respond well to treatment to ADHD- complete school as normal
50%
ADHD and risk for depression and substance abuse
untreated ADHD has 2-3x higher risk for dpression and substance abuse
angry, irritaible kid who is defiant, vindictive interaction with someone (not sibling) where they lose tempber, argues, blames other for mistakes
oppositional defiance disorder
really bad kid who’s agressive, destructive, deceitful, harmful to animals, commits serious violation of rules, theft
conduct disorder
2 dimensions of disruptive behavior
overt (aggressive, bullies, stubborn)
covert (steals, sets fires, harms animals)
what percentage of child mental helath referrals are due to ODD or CD
1/3 - 2/3
genetic influences on conduct disorder
lead
peinatatl problems (smoking)
frontal lobe decreased glucose metabolism
myer-overton corelation
relationship between lipid bilayer/water partition coefficient and potency
what receptor/neurotransmitter to many anesthetics work through
GABA
activation of post synatpic GABA receptors does what to post synatpic action potential generation potential
makes post synaptic more leaky, less excitable less voltage change
receptor worked on by isoflurane
GABA
receptor worked on by sevoflurane
GABA
receptor worked on by etomidate
GABA
receptor worked on by propofol
GABA
receptor worked on by ketamine
NMDA
receptor worked on by nitrous oxide
kainate and NMDA
one dose of volatile anestetic agent is also called
minimum alveolar concnetration (MAC)
at what MAC does mild anesthesia occur
0.3 MAC
at what MAC does amnesia occur
0.5 MAC
what is target MAC for surgery - 99% of subjects are immobile
1.3 MAC
what MAC dose is potentially lethal
2.0 MAC
what is induction MAC
2.0 MAC - could be lethal if maintained
what works quicker - low solubility anestetics or high solubility anesthetics
low solubility
halothane adverse effects (1)
immune response causing HEPATIC NECROSIS, fever, nausea vomiting and rash
enflurane adverse effects (3)
CARDIOvascular DEPRESSION due to decreased contractility
SEIZURES
uterine muscle relaxant
isoflurane advantages
cardiac is good
isoflurane adverse effects (1)
progressive respiratory depression
sevoflurane advantages
can be used for outpatient - rapid recovery
desflurane advantages (2)
used for outpatient surgery
not soluble in fat
desflurane adverse effects/disadvantages (3)
irritating to airways
needs specially heated vaporizer
can evoke tachycardia
metohxyflurane blood:gas (high or low)
high
methoxyflurane metabolism (high or low)
high
methoxyflurane advantage
very potent
methoxyflurane adverse (2)
extensively metabolized
renal failure/tox
nitrous oxide use
analgesic
advantages of nitrous oxide
analgesic
rapid induction
little tox
disadvantages/adverse effects of nitrous oxide (2)
can’t use in patient with any enclosed air space (air embolus, loop of bowel) because it will expand
can cause hypoxia
what is malignant hyperthermia and what is it caused by
inherited inability of sarcoplasmic reticulum to sequester Ca2+, volatile anesthetics and succinylcholine cause increased body temp and massive muscle contraction
advantages of sodium thiopental
no vomitting or excitement after anesthetic
water sol
disadvantages of sodium thiopental (4)
no analgesia
slow recovery
no antagonist
resp and CV depression
what kind of drug is sodium thiopental
barbiturate
propofol advantages
forgetful rest
little accumulation
rapid metabolism
propofol disadvantages
no analgesia
CV depression
injection pain
not water sol
ketamine advantages
no resp depression
analgesic
ketamine disadvantages
hallucinations(less likely in children)
increased muscle tone and involuntary movements (less likely in children)
etomidate advantages
there is an antagonist
etomidate disadvantages
accumulates
no analgesia
injection pain
what percentage of american shave alcohol or drug abuse/addiction
20%
cost of drug and alcohol abuse to US society
~200 billion/year
what genes are thought to be polymorphic for substance use disorder (4)
D4 dopamine receptor
mu opioid
delta opioid
dopa transporter
diference between physioloigical dependence and substace use disorder
substance usde disorder includes behavioral syndrome - drug seeking behavior
what 3 neuronal populations are targetted in the reward pathway
- GABA interneurons
- dopa neurons in VTA
- medium spiny GABA neurons in NAc
what pathway do ALL drugs of abuse activate
mesolimbic dopa reward pathway (1 or more of the neuronal populations between VTA and NAc)
alcohol reward pathway mech of action (3)
enhance GABA binding at GABAa
inhibit glutamate activation of excitatory NMDA
facilitate release of endogenous opioids in VTA
TX for mild alcohol withdrawal (2)
sympathetic driven
clonidine or propranolol to suppress symp activity
TX for severe alcohol withdrawal (1)
seizures
diazepam (long acting benzo)
TX for preventing alcohol relapse (5)
(aversion therapy)
1. disulfram (nausea vomitting)
(anti-craving)
- naltrexone
- acamprosate
- topiromate
- SSRI
barbiturates reward pathway mech of action (2)
increase GABA binding to GABAa
at high doses can directly open GABAa
bartiburate detox tx (1)
to suppress seizures
reversal of dependence
stabilize patient on long acting phenobarbital, taper (4-8wk)
benzos reward pathway mech of action
increase GABA binding to GABAa
benzo withdrawal following moderate usage symptoms
anxiety, light sensitivity, paresthesia, cramps, dizziness, sleep disturbances
benzo withdrawal following high dose usage symptoms
delirum
seizures
benzo detox treatment
tapering doses of phenobarbital OR diazepam (long acting benzo)
opioid reward pathway mech of action
activation of mu-opioid receptor on GABA interneurons in VTA
opioid withdrawal tx (3)
- methodone
- LAAM (longer acting than methodone - 2-3/week instead of daily)
- buprenorphine (more favorable - partial agonist, less resp failure, antagonist to heroin, better compliance) as sublocade, suboxone
nicotine reward pathway mech of action
stimulates nicotinic Ach receptors on dopa neurons in VTA
tx for nicotine use disorder (3)
- nicotine replacement (gum/patch) - slower pharmacokinetics than smoking
- buproprion - antidepressant, antagonist of nicotinic Ach receptors, inhibits dopa and NE reuptake (reduces craving and withdrawal)
- varenicline - partial agonist on nicotinic Ach - superior (40% quit rate)
amphetamine mech of action in reward pathway
enhance release of dopa and NE
also weakly blocks MAO and acts as direct agonist
cocaine mech of action in reward pathway
blocks reuptake of dopa (and less so for NE and 5-HT)
overdose of cocaine symptoms/cause
seizures (because of blocking GABAa, increasing CNS excitability)
cocaine/amphetamines tolernace symptoms
reverse tolerance - sensitization (with chronic use can get increase susceptiility to cardiac arrhytmias and stroke)
tx to reduce relapse for cocaine/amphetamine use disorder
topiramate
5-HT related psychedelics (2)
LSD
psilocybin
dopa and amphetamine related psychedelics (1)
MDMA
dissociative drugs (2)
PCP, Ketamine
mech of action for LSD (1)
agonists at 5-HT, dopa, and adrenergic reeptors
mech of action for MDMA (3)
induce 5-HT and dopa release
5-HT reuptake inhibition
agonist at 5-HT, dopa and adrenergic receptors
abuse disorder liklihood for psychedelics
low
mech of action of dissociatives
inhibit glutamatergic NMDA in reward pathway
peripheral effects of dissociatives
sympathomimetic - increased HR, BP, sweating
classical conditioning
scared of thunder, which is associated with lighning. over time, lightning alone will cause fear response
operant conditioning
reinforcement - press lever to get reward (positive), press lever to stop adverse stimulus (negative)
punishment - add adverse stimulus to decrease behavior (positive), remove pleasant stimulus to decrease behavior (negative)
what type of “schedule” is the most reinforcing?
intermittent variable ratio
what is the percentage range for heritability of alcohol and drug dependence
40-60%
CAGE tool
C - had to Cut back
A - others Annoyed
G - Guilty
E - need Eye opener
how many DSM symptoms for mild, moderate and severe use disorder
mild = 2-3 moderate = 4-5 severe = >6
alcohol withdrawal symptoms within 6-12hr
insomnia, anxiety, tremors, sweating, GI upset, palpitations
alcohol withdrawal symptoms within 12-24hr
visual, auditor or tactile hallucinations
alcohol withdrawal symptoms within 24-48hr
generalized tonic clonic seizures
alcohol withdrawal symptoms within 48-72hr
delirium tremens - visual hallucinations, disorientation, tachycardia, HTN, fever, agitation, sweating
triad with wernicke’s
- confusion
- ataxia
- abnormal eye movements
triad with korsakoff’s
- amnesia
- confabulation
- hallucinations
what is bruxism
grinding teeth - meth mouth
PCP intoxication symptoms (Acronym)
RED DANES
Rage
Erythema
Dilated pupils
Delusions Amnesia Nystagmus Excitation Skin dryness
tx for PCP
acidification of urine…?
when does glial washing occur
slow wave sleep
what is poor glial washing associated iwth
amyloid plaques in alzheimers
how often does REM happen
90 - 120 min intervals - doesn’t start til 1.5 hours
after exposure, how much time is best for learning
up to 2 days of sleep, and then plateaus
how much sleep does an adult need
7-9 hours
how much sleep does a teenager need
9.25h
how much sleep does an 5-12 year old need
10-11hr
processes of circadian rhythim
Process S (homeostatic sleep drive)
Process C (clock dependent alertness)
what is the retino-hypothalamic pathway
there are photopic receptors (retinal gangioln cells) that process light, at dusk, secretes melatonin due to input from suprachiasmatic nucleus
delayed sleep phase usually between what times
3am - 11am
who gets delayed sleep phase
teenagers and some people geneticaly
how does sleep changewith age
decreased slow wave, increased fragmentation
what percentage of individual has chronic insomnia
15%
what kind of insomnia responds to CBT
sleep onset
symptoms for narcolepsy
- excessive sleepiness
- sleep paralysis
- hypnogogic hallucination
- cataplexy
- fragmentation of sleep
does orexin make you awake or sleepy
sustains wakefulness
degrees of hypothermia
mild: 90-95
moderate: 82-90
severe: <82
degrees of frostbite
1st: superficial, limited to skin and superficial tissue, swelling and redness
2nd: superficial, with blisters over first 24hr that will slough off
3rd: deeper, involves bloody blisters that blacken and slough off about 2 weeks after injury
4th: muscles and bones, causes necrosis and loss of tissue
difference between heat exhaustion and heat stroke
heat exhaustion: weakness and loss of water
heat stroke: results in hyperthermia (>104)
how to determine age of lice
distance from scalp -> 1cm = 1month
treatment for lice
permethrin 1% cream 2x (once a week later)
why is scabies more contagious than lice
scabies can live on surface for 24 hours. also you can’t see them
symptoms of scabies
very very itchy
treatment for scabies
promethrin 5% cover whole body for a whole day and then wash off
also have to wash and dry clothing in heat
how much more likely are patients with mental illness to suffer violence
10x
what percentage of homeless individuals suffer from severe mental illness versus the general population
25% vs 6%
what substances are abused most often in homeless population, and what percent
tobacco - 70-80%
alcohol - 38%
what is leading cause of death in homeless population between 40s and 60s
cardiovascular disease
parts of “quadruple aim” model
- patient experience of care
- per capita cost
- population health/outcomes
- clinician experience
what level of government regulates most health policy
state
is healthcare in the constitution?
no, except in the preamble that says “to promote the general welfare”
how does federal gov get away with regulating helathcare?
- tax and spend (can create incentives for states to act - highway funds etc.)
- interstate commerce (health insurance, child labor, civil rights, environmental protection)
- necessary and proper elastic clause
Medicare and medicaid and levels of government involvement
medicare - federal is direct purchaser
medicaid - state program, federal sets minimum services for baseline
Romer’s law
when you build more beds, more people will fill them - also applies to technology (CT, MRI etc)
definition of treatment resistant depression
people who do not respond to at least 2 antidepressants
pros and cons of uni vs bilateral seizure induction thearpy
uni = less effective but fewer memory loss side effects
bi = more effective, more cognitive effects
how much of the applied charge actually gets into the brain
20% - skull impedes a lot
ECT effects (3)
- increases GABA transmission and receptor antagonism
- down regulates beta adrenergic receptors
- increaes endogenous opioids
ECT absolutely contraindications
increased intracranial pressure
can you use ECT in pregnancy
yes
side effects of ECT
temporary retrograde amnesia and confusion
transcranial magnetic stimulation (TMS) uses (2)
neuropathic pain
treatment resistant major depressive dirosder and bipolar disorder
TMS adverse effects
some fainting or discomfort - not a lot
bright light therapy uses
seasonal depression
vagus nerve stimulation mechanism
changes blood flow in brain and boosts neurotransmitters
deep brain stimulation uses (3)
MDD
OCD
Parkinsons
what unit is measured for ECT
mili coulombs
sexual response cycle
desire
excitement/arousal
orgasm
relaxation
diagnostic criteria for female sexual interest/arousal disorder
absent/reduced sexual interest with 3 domains, of at least 6 months duration causing distress, w/o any other psych disorder, meds
diagnostic criteria for male hypoactive sexual desire disorder
deficient/absent sexual desire for 6 months duration causing significant distress w/o any other psych disorder, meds
timing for premature ejaculation
under 1min
what percentage of male population suffers from premature ejaculation
30%
40% of men treated for sexual disroder
demographics for premature ejaculation
college educated men
treatment for premature ejaculation
1- squeeze technique
2- stop start
3- psychotherapy sensate focus
4- SSRIs or topical anesthetics
4 types of difficulties you can see with genito-pelvic pain/penetration disorder
one of the following:
- difficulty with vaginal penetration
- difficulty with geneital pain during intercourse
- fear/anxiety about pain during intercourse
- tightening of pelvic floor muscles during penetration
diagnostic criteria for parahpilias
intense, recurrent fantasies towards non consenting individuals or that humiliate oneself or others
EITHER 6 months of fantasies that cause distress or impairment
or having acted on the fantasies, with or without distress or impairment
voyeurism
peeping tom
exhibitionism
exposing to unsuspecting individual
frotteurism
rubbing against people in crowds