Exam 4 Flashcards
What is paresthesia?
The sensation of numbness, prickling, or tinglng experienced in central and peripheral nerve lesions
What are the potential causes of paresthesias?
anatomical or mechanical peripheral nerve injuries; more common to occur at sites that undergo increased pressure or mechanical forces (wrist)
What is the difference between paresthesia and paresis?
Paresthesia- change in sensation
Paresis- change in movement
Where is the associated location of paresthesia for a patient with cervical injury?
arms and hands
Where is the associated location of paresthesia for a patient with a lumbar injury?
buttocks, legs, and feet
Spurling’s sign
radicular pain reproduced when the examiner exerts downward pressure on the vertex while tilting the head toward the symptomatic side
Differentiate between acute and chronic back pain- how will presentations differ?
Acute- presents with localized discomfort that occurs after mechanical stress; may have trouble standing erect; pain may radiate to buttox and thigh
Chronic- hallmark symptom is radiation to one or both buttocks, pain aggravated by activity
What is the straight leg test?
With the patient supine and relaxed, elevate the leg until it begins to bend or the patient reports severe pain in buttock or back; considered positive when the pain is elicited below the level of the knee when the leg is raised less than 60 degrees; would be positive if herniated disc
S&S of epicondylitis
S: stiffness at the elbow, especially at night; difficulty extending the arm in the morning; pain that is worse with gripping or shaking hands
O: inability to fully extend arm at elbow
Describe the Phalen’s test
Test for carpal tunnel: Patient engages in full flexion of wrists by placing back of hands touching in front of them; positive if tingling sensation of the median nerve
Describe Tinel’s sign
Test for carpal tunnel: Examiner taps anterior wrist briskly; positive if this illicits pins and needles sensation of the median nerve over the hand
Describe Finkelstein’s test
Test for De Quervain’s tenosynovitis: patient should flex thumb toward the palm and make a fist (holding thumb under fingers) and deviate wrist towards the ulna; positive if pain on the wrist on the thumb side
Describe McMurray’s test
Test for medial meniscus injury: positive if there is a click sound upon manipulation of the knee
What is the standard diagnostic test for osteoporosis?
Dual energy x-ray absorptiometry (DXA)
Treatment/Management for osteoporosis
Non-pharm: gait training, activity, eliminate hazards in home, prevent fractures
Pharm: Calcium & Vitamin D, estrogen, biphosphonates, testosterone supplements, fluoride
Hormone replacement with estrogen for osteoporosis causes increased risk for what?
breast CA, CAD, stroke, DVT
What is the most common entrapment neuropathy?
carpal tunnel syndrome
What is the clinical presentation for carpal tunnel syndrome?
S: aching sensation that radiates to thenar area; pain at night and in the morning with numbness/paresthesia at thumb & 4th metatarsal, frequently drops objects and can’t open jars
O: Possible swelling, redness, nodules, deformity, muscle atrophy; tests are Allen’s sign, PHalen’s maneuver, Tinel’s sign
Management for carpal tunnel syndrome
Non-Pharm: prevent flection/extension by using a splint
Pharm: NSAIDs, corticosteroid injections, Vitamin B6
What are the red flags when assessing a patient with low back pain?
Hx of trauma, fever, incontinence, unexplained weight loss, a cancer history, long term steroids, parenteral drug use, intense localized pain and an inability to get into a comfortable position
What are the special tests for assessing lower back pain?
-Straight-leg raise: places the L5 & S1 nerve roots and the sciatic nerve under tension
-Reverse straight-leg raise: Places the L1-L4 nerve roots under tension
-Prone rectus femoris test: places the L1-L4 nerve roots under tension
Treatment for low back pain (non-radiating)
Non-pharm: exercise, CBT, electromyography, Tai chi/yoga, relaxation, heat, massage, acupuncture, spinal manipulations
Pharm: NSAIDs, tylenol, muscle relaxers
Clinical presentation of Cauda Equina Syndrome
S: acute or insidious onset, pain in both legs that may be more severe in one, numbness in lower extremities, difficulty voiding, loss of bowel/bladder control
O: Stumbling gait, quadricep or hip extensor weakness, difficulty rising from chair, unable to walk on heels or toes, bilateral footdrop
Why is it so important to recognize cauda Equina?
Because it is a medical emergency and the patient would need an immediate surgical nerve decompression to prevent further injury
What are the complementary therapies for osteoarthritis and musculoskeletal problems?
acupuncture, massage, yoga/tai chi, supplements, aromatherapy
Clinical presentation of plantar fasciitis
subcalcaneal pain that sometimes radiates to the arch of the foot while the person is running or walking; pain is worse in the morning
What is the treatment for plantar fasciitis?
-Heel lifts, padded heel cups, orthotic devices
-For acute phase: rest, ice, NSAIDs, local corticosteroid injections
-Heel-cord stretching exercises and a nighttime splint
-Surgery decompression of the plantar fascia are a last resort
Which musculoskeletal diagnosis are more common in the elderly?
Osteoporosis, osteoarthritis, fractures, falls
What diagnosis would X-ray confirm?
-OA
-Erosions
-Calcifications/cysts
-Osteopenia
-Narrowing of joint spaces
-deformity of bones (fractures, dislocation)
When is a CT ordered for a musculoskeletal complaint?
for axial skeletion evalution because of the ability of the CT to visualize the axial plane; examples are for herniated disc, spinal trauma; also bone fractures that may not show on Xray, blood clots, and organ damage
When is an MRI indicated for a musculoskeletal complaint?
When suspecting soft-tissue disorders such as muscle and tendon tears and intra-articular disorders such as labrum tears and meniscus tears, as well as spine disorders; also nerve compression, rotator cuff tears, achilles tendon rupture
What is an EMG and when is it indicated?
A nerve conduction study, is indicated when neurologic abnormalities or paresthesia are present in disorders such as carpal tunnel
How do you define an acute musculoskeletal injury?
acute pain less than 6 weeks’ duration; damage to muscle, tendons, ligaments, nerves & bursae
Strain vs. Sprain
Strain- muscle injury caused by excessive tensile stress placed on a muscle resulting in stiffness & decreased function; affect muscles or tendons that connect muscle-bone
Sprain- stretching or tearing of ligaments that occurs when a joint is forced beyond its normal anatomical range
Describe the degree of sprains
1st degree: stretching of ligamentous fibers
2nd degree: tear or part of the ligament with pain & swelling
3rd degree: complete ligamentous separation
Management for acute musculoskeletal injury
-PRICE: Protect, Rest, Ice, compression, elevation
-Pharm: NSAIDS
-Referral to orthopedic if no relief with conventional methods after 6 weeks
Differential diagnosis for knee pain
Acute: Fracture, meniscal injury, ligamentous injury, musculotendinous strain, extensor mechanism injury, contusions
Chronic: arthritis, tumors, sepsis, overuse
S&S of cervical muscle sprain/strain
S- pain, mid to lower posterior neck; dull/aching exacerbated by movement; occipital headache
O- Decreased ROM w/ poor quality of movement; negative Spurling’s sign; reproducible tenderness
Management of cervical muscle sprain/strain
-Reassurance and time
-NSAIDs & Non-narcotics
-Short-term muscle relaxants
-Physiotherapy: Ice, heat, therapies, cervical traction
What should patients be aware of when taking muscle relaxants?
Cause drowsiness; don’t drink alcohol, don’t drive or operate heavy machinery
S&S of cervical spondylosis
S: Recurring neck stiffness with mild aching, limited ROM with lateral rotation/flexion toward affected side
O: Shoulder abduction weakness, Biceps/Triceps weakness
How does treatment of cervical sprains differ from cervical spondylosis?
-For cervical spondylosis, all of the interventions for a sprain in addition to these:
-Steroids might be indicated if there is radicular pain (pain that radiates down back and into legs or arms)
-Surgery may be indicated if myelopathy/intractable pain/severe disabilities
Is cervical spondylosis acute or chronic?
Chronic: caused by cumulative stress over time but is exacerbated by trauma, poor body mechanics, postural changes, or a disc injury
F/U for cervical spondylosis
6 weeks; if no improvement can refer to an orthopedic surgeon
How long would acute low back pain persist?
less than 6 weeks
Chronic low back pain duration
Lasts longer than 3 months
Causes of low back pain
-Lumbar strain/sprain
-Spinal stenosis
-Osteoarthritis
-scoliosis
-spondylosis
-Lesion or fracture
S&S of low back pain
S: Pain radiates to buttocks, muscle spasms, history of lifting/twisting with heavy object, prolonged sitting, trauma
O: Diffuse tenderness to lower back; ROM elicits pain, Negative straight-leg to rule out disc herniation
Differential diagnosis for chronic low back pain
Depression
Arthritis
Infection
Mets/tumors
Osteoporosis
What is the most common cause of radicular pain to the lower extremities?
A herniated lumbar disc
S&S of herniated lumbar disc
S: Onset most likely insidious; exaggerated by sitting, walking, standing, coughing, sneezing; radiates from buttock to posterior leg, ankle, foot, paresthesias, weakness
O: Positive straight leg raise; pain & spinal extension when sitting with leg raised (flip sign), possible loss of DTRs
Non-pharmacological management for herniated disc
-Pain relief/improve mobility
-Limit sitting, prolonged standing, or walking; take frequent rest breaks when resuming activity
-Surgery if symptoms persist for > 3 months or significant neurological compromise
Pharmacological management for herniated disc
-NSAIDS
-Short course of muscle relaxants/opioids
-Short course of steroids or epidural steroid injection
Follow up and referral for herniated disc
F/U 7-10 days and every 2 weeks to monitor progress
-Referral for neuro deficits: ankle jerk, bladder/rectal sphincter weakness (incontinence), foot drop
Pharmacological management for lumbar spinal stenosis
-NSAIDS
-Folic acid and Vitamin B12 supplements
S&S of lumbar spinal stenosis
S: Sx progress from proximal to distal; sitting/walking causes pain and weakness in legs
O: Impaired proprioception, possible + romberg, diminished reflexes, lumbar scoliosis
Which part of the spine is the most common injured?
C-spine
S&S of vertebral fracture
S: C/O pain after injury; pain is at a specific pinpoint and described as aching or stabbing
O: possible ecchymosis or swelling
Patient education for vertebral fracture
-Avoid bending, stooping, twisting, or lifting anything over 10 pounds; exercise, fall-prevention
S&S of bursitis
S: pain or swelling of bursal sacs; warmth, possible fever, chills, arthalgias if due to RA or gout
O: Pain may be referred to other structures, induration, erythema, and effusion
When to make a referral for bursitis
Refer to ortho if no improvement w/ conservative therapy after 6 weeks
What is the most common cause of tendinitis or tenosynovitis?
Overuse
S&S of De quervain’s tenosynovitis
S: Pain at radial side of wrist especially with lifting
O: Possible creptis over radial styloid; Allen’s, Phalen’s, Tinel’s are negative; Finkelstein’s test is +
What is Dupuytren’s contracture?
palmar fibromatosis most often in the 4th and 5th fingers
S&S: thumb-index finger web space, difficulty grasping objects, normal sensation
Management: injections/surgery
S&S of rotator cuff syndrome
S: gradual onset, A/L shoulder pain exacerbated by overhead activity, pain radiates to elbow
O: Pain/crepitus with shoulder motion/palpation; Positive Neer & Hawkins signs
When to refer to an orthopedic surgeon for ankle sprain
-If no improvement in 6-8 weeks; would need MRI
Diagnostics for ankle sprain
Anterior drawer test
X-ray ankle & foot
What is the most common articular disease in adults greater than 45 years of age?
Osteoarthritis
Principle sites for osteoarthritis
-Distal interphalangeal joint (DIP)- Herberden’s nodes
-Proximal interphalangeal joint (PIP)- Bouchard’s nodes
-Carpometacarpal joint (CMC)
-Great toe, hips, knees, C/L spines
S&S of osteoarthritis
S: slowly developing localized pain in affected joint, subtle onset, weight-bearing joints with early morning stiffness or stiffness after inactivity that subsides after 30 minutes
O: minimal or no swelling in affected joints; tenderness on direct palpation, crepitus, reduces passive and active ROM
Pharmacological treatments for osteoarthritis
-NSAIDS (topical/PO), tylenol, tramadol, steroid injections (knee or hip joints)
What will an X-ray of a patient with osteoarthritis show?
Asymmetrical joint space narrowing, bony cysts & osteophytes, subchondral sclerosis (for worsening disease)
Risk factors for osteoporosis
low body weight, smoking, excessive alcohol, low calcium intake, vitamin D deficiency, chronic use of glucocorticoids, thyroxine, long-term phenytoin
S&S of osteoporosis
S: often no symptoms until fracture occurs; gradual onset of back pain
O: Compression fracture with acute point tenderness, kyphosis
When should a patient with osteoporosis be referred to endocrinology?
If you suspect secondary causes are present such as hormone imbalances
Follow up for patients with osteoporosis
Repeat bone density scans every 2 years
DDX for osteoporosis
Neoplasm, osteomalacia, skeletal hyperparathyroidism, hyperthyroidism
Causes of confusion in the elderly
-Depression, delirium, dementia, Alzheimer’s, metabolic disturbances, infections, tissue hypoxia & ischemia
Difference between dizziness and vertigo
Dizziness- feeling unsteady or off balance, faint, light-headed, often is brief with abrupt or gradual onset
Vertigo- false sensation of rotation or movement of patient or their surroundings
S&S of tension headache
Bilateral, bandlike pain that is non-pulsating; possible N/V but usually no photophobia
S&S of migraine headache
Unilateral, Pulsating; N/V often present; photophobia, phonophonia, may or may not have an aura
S&S of cluster headache
Night-time, unilateral, non-pulsating; causes tearing, sweating, congestion, rhinorrhea, red eyes, ptosis
Non-pharm treatments for different types of headaches
Tension: stress management, massage
Migraine: Avoid triggers
Cluster: 100% O2 mask
Pharm treatments for different types of headaches
Tension: ASA, tylenol, NSAIDs, muscle relaxers
Migraine: Triptans, NSAIDs, antiemetics, propanolol, nortriptyline, topiramate
Cluster: Sumatriptan, indomethacin
What is temporal arteritis and what labs should be tested if suspecting?
local swelling, tenderness/pulselessness over temporal artery; causes fever, anorexia, weight loss, chills
-CHECK ESR & CRP
What is a thunderclap headache?
Abrupt, severe, sudden onset reaching maximum intensity in 1 minute- this is an EMERGENCY because it is likely a subarachnoid hemorrhage aneurysm rupture
When to refer someone with headaches to neurology?
Neurological deficits, increased frequency and severity of unilateral headaches, atypical auras, changes in personality, excessive sleepiness and new onset of progressive deficits
Women with migraines have a higher risk of what emergent diagnosis if they are taking estrogen-containing contraceptives?
Stroke
DDx for paresthesias/paresis
Arterial occlusion, arteriosclerosis, nerve entrapment syndrome (Carpal tunnel), neuropathy, TIAs, herpes zoster
Difference between resting and intentional tremor
Resting- occurs in relaxed & supported extremity and ends with purposeful movement
Intentional- occurs with attempted voluntary movement
Difference between focal and generalized seizures
Focal- affecting one part of the brain and often due to a focal lesion
Generalized- affecting the entire brain; tonic-clonic, absence, myoclonic, tonic, and atonic; often associated with childhood onset
Describe absence seizures
Nonmotor; sudden interruption of ongoing activities- blank stare; lasts for a few seconds
Describe tonic-clonic (grand mal) seizures
Tonic stiffening of muscles, fall to ground, rigidity, may inhibit respiration, tongue may be bitten; loss of bladder control; clonic convulsive movements; postictal period- depressed LOC followed by deep sleep and possible headache
Describe atonic seizure
Sudden loss of muscle control
Describe psychogenic nonepileptic seizures (PNES)
Paroxysmal seizure-like events arising from psychological disturbances rather than abnormal electrical brain activity
Possible causes of seizures
Epilepsy, drug overdose, drug withdrawal, head trauma, strokes, degenerative brain disease, infections, tumors
Management for patients with seizures
-Prevent recurrence with medications
-Identify type of seizure before treatment
-Baseline CBC, CMP, LFT before starting therapies and monitor throughout
-Serum drug levels to assess therapeutic
-Referral to neurologist early
-Wean meds slowly if wanting to discontinue
S&S of Alzheimer’s disease
S: Initial complaints of memory problems usually from a family member; changes in behavior, decreased ability to complete normal tasks
O: May not show obvious signs of confusion, but clinician should ask questions like “What did you do last Sunday?” and perform separate assessments with family and patient; Pertinent information to gather: Family hx, medications, depression, anxiety, sleep issues; Functional Activities Questionnaire (FAQ) given to family, MoCa completed with patient
Pharmacological treatments for patients with Alzheimer’s disease
-Cholinesterase inhibitors: Donepezil, Galantamine, Rivastigmine, Galantamine
-N-Methyl-D-Aspartate-Receptor-Antagonist: memantine
-Anti-psychotics (use with caution): risperidone, olanzapine, quetiapine
Non-pharmacological interventions for Alzheimer’s disease
-Protect physical health, emotional support, maintain optimal function to prevent/reduce excess disability
-Good nutrition, exercise, preventive care
-Referral to memory disorder center
Difference between Parkinson’s disease and Parkinsonian Syndrome
-Parkinsonian syndrome is a general term that refers to any condition that causes the types of movement problems (rest tremor, rigidity, bradykinesia, postural instability, flexed posture, freezing) observed in Parkinson’s disease; Parkinson’s disease is the most common cause of Parkinson’s syndrome
What are some secondary causes of Parkinsonism?
-CVA
-Infection
-Trauma
-Toxins
-Hereditary (Wilson’s disease- excess copper)
6 major symptoms of Parkinson’s
- Tremor at rest
- Rigidity
- Bradykinesia
- Hypokinesia
- Flexed Posture
- Loss of postural reflexes
What is the freezing phenomenon?
transient episodes, usually lasting seconds, in which the motor activity being attempted by an individual is halted
Diagnostics for Parkinson’s
-Presence of parkinsonism and absence of exclusion criteria (such as cerebellar abnormalities/antidopaminergic medication)
-MRI
-SPECT & PET
-Levodopa trial
Non-pharm management for Parkinson’s
-Referral to movement disorder neurologist or neurosurgeon to discuss deep brain stimulation
-Speech therapy, dysphagia screening
Pharmacological management for Parkinson’s
-Levodopa is the most efficacious
-MAO-B Inhibitors: Selegiline
-Dopaminergic- Carbidopa/Levodopa
-Anticholinergics- Trihenyxphenidyl
Antiviral- Amantadine
TRAP pneumonic for signs of parkinson’s
Tremor: shaking, usually starting on one side
Rigidity: stiffness of the limbs, neck, or trunk
Akinesia: loss or impairment in power or voluntary movement
Posture and Balance
S&S of ALS (Lou Gehrig’s)
-Starts in one limb or region of spinal cord; bulbar onset poorer prognosis as swallowing and breathing are affected sooner
-Weakness will spread to other areas of the body
-Bowel and bladder control are usually not affected
What is the only medication shown to improve survival of ALS?
Riluzole
Hemorrhagic vs. Ischemic Strokes Vs. TIA
Hemorrhagic: bleeding in the brain, often due to weakend vasculature or aneurysm; intracerebral, subarachnoid, epidural, subdural
Ischemic- embolism, thrombosis, hypoperfusion
TIA- temporary episode of focal ischemia which resolves spontaneously
Name some modifiable risk factors of stroke
-HTN
-Cardiac disease
-Diabetes
-HLD
-Smoking
-Illicit drugs
-Lifestyle
What is the most common cause of an intracerebral hemorrhage?
Hypertension
What is the most common cause, signs, and symptoms of a subarachnoid hemorrhage?
-Ruptured arterial aneurysms
-Severe headache (thunderclap), vomiting, drowsiness
Risk factors for ischemic stroke
AFib, prosthetic heart valves, valve vegetation, MI, atherosclerosis
Diagnostics for stroke
-First CT to determine if hemorrhage
-MRI
-Glucose (rule out hyper/hypoglycemia)
-NIHSS- stroke scale
Describe Kernig’s test for meningitis
-Patient is supine or in a chair
-Hip and knee are flexed to 90 degrees and attempt is made to extend the knee
-The test is positive if the maneuver causes pain in the neck or back
Describe Brudzinki’s sign for meningitis
-Patient is supine
-Flexion of the neck causes flexion of the hips and knees
S&S of meningitis
S: headache, photophobia, neck pain/stiffness (nuchal rigidity)
O: Fever, tachycardia, tachypnea, pain with eye movement, Kernig’s and Bruzinksi, seizures, altered LOC
Management for meningitis
-Immediate hospitilization- refer to ER if suspected
Causes of encephalitis
-Virus- most common
-Bacteria
-Parasites
-Chemical & autoimmune reactions (syphilis, Rocky Mountain spotted fever, mycoplasma, Lyme disease, tuberculosis)
S&S of encephalitis
S: Confusion, altered LOC, headache, photophobia, personality changes, amnesia
O: Fever, systemic infection, nuchal rigidity, rash, hemiparesis, CN palsy, focal seizures, ataxia, movement disorder
Management of Encephalitis
-If suspicious, referr for hospitilization
-Identify/Treat cause
Diagnosis for encephalitis/Meningitis
-LP
-CBC, CMP, blood cultures, sputum cultures
-CT/MRI
-EEG (encephalitis)
S&S of Herpes Zoster
S: Unexplained pain along a dermatome for 48-72 hours before rash appears; rash- later
O: Unilateral vesicular rash along dermatome
Tx for herpes zoster
-Antivirals- famciclovir, acyclovir, valacyclovir
-Corticosteroids for pain- prednisone
-Calamine lotion, Burrow’s solution dressing
Tx for postherpetic neuralgia (PHN) related to herpes zoster
-Alagesics (tylenol/NSAIDS)
-tricyclic antidepressants
-Gabapentin
-Lidocaine patch
When should a patient with herpes zoster be referred to a specialist?
-Refer to ophthalmologist if ophthalmic lesions
-Refer to neurologist if lesions become infected or PHN is present for >3 months after
Patient education for herpes zoster
-Lesions are contagious until they crust
-Take medications with food, complete entire course
-Shingles vaccine for >60yrs
S&S of trigeminal neuralgia
S: Severe paroxysmal pain on one side of face; onset after trigger point is stimulated; lasts a few seconds & stops with no pain between episodes
O: Cranial nerves have normal motor function; no residual ache/pain
Pharmacological management for trigeminal neuralgia
-Carbamazepine, gabapentin, possible TCAs, topical capsaicin
Non-pharm management for trigeminal neuralgia
Acupuncture, TENS; microvascular decompression if no relief from other treatments, trigger avoidance, nutritional counseling
What is Bell’s Palsy?
Idiopathic CN7 palsy- lower motor neuron facial paralysis; self-limiting and possible for complete recovery in a few weeks; cause is often viral, HSV
S&S of Bell’s palsy
S: Acute onset partial or total paralysis 1 side of face; May worsen over 2-3 days; loss of taste on ipsilateral tongue, postauricular pain, sensitivity to sound
O: Acute onset, no other CNS symptoms, absence of forehead wrinkles on affected side, Bell’s phenomenon, flattened nasolabial fold, unclear pronunciation
What is bell’s phenomenon?
eyeball turns upward when trying to close eyelid
Treatment for Bell’s palsy
-Not always necessary
-Steroids generally recommended
-Eye protection (patient generally can’t fully close eyelid): artificial tears to keep eyes moist, eye patch at night
S&S of Guillain-Barre syndrome
-Ascending paralysis beginning in legs and progressing in ascending fashion
-Extremity tingling, back pain, autonomic dysfunction
Common cause of Guillain-Barre
Most often Postinfectious following gastric campylobacter infection
Management for Guillain-Barre
IV gamma globulin/plasmapheresis
-Emergent referral to emergency department due to risk of rapid respiratory failure
S&S of myasthenia gravis
Muscle fatigue, weakness, eye movement and speech often affected; weakness worse later in the day
Diagnostics for MG
Tensilon test (tensilon is injected IV and provider assesses muscle strength; considered positive if strength increases after tensilon), Electromyography
Describe the pathophysiology of MG
Autoimmune process in which antibodies target receptor for acetylcholine at neuromuscular junction
Management for MG
-Anticholinesterase agents
-Immunosuppressants
-IV immunoglobulins
-Plasmapheresis
S&S of multiple sclerosis
S: weakness of legs, bladder & bowel dysfunction, ataxic gait, paresthesias, optic neuritis, unilateral blurred vision, dulling colors
O: Diplopia, blurred vision, loss of visual acuity, limb weakness, hyperreflexia, spasticity, dysarthria, tremor, ataxia, mood changes
Diagnostics for multiple sclerosis
-Through H&P: 2 or more areas of CNS must be involved at 2 different periods of time
-LP: an evaluation of CSF for the presence of lymphocytes and oligoclonal IgG bands
-MRI: a sensitive, objective measure of plaques and is used to measure the outcomes of treatment
-McDonald criteria
Describe Mcdonalds criteria
A person who has experienced at least two clinical attacks, and has clear-cut evidence of damage in at least two distinct brain areas, can be definitively diagnosed with MS, as that individual fulfills requirements for both dissemination in space and time.
Goals of management for MS
- Delay progression of disease
- Manage chronic symptoms
- Treat acute exacerbations
Pharmaceutical management of MS
Relapsing/Remitting: benefit from disease-modifying agents ( can increase risk for opportunistic infection)
-Acute exacerbation- glucocorticoids (methylprednisolone)
-Antispasmodics- baclofen
-If tremors- clonazepam
-Neuropathic pain- gabapentin, duloxetine
What are the most common causes of confusion in the elderly?
Delirium or dementia
What are the most common causes of delirium?
Pneumonic DELIRIUM:
Drugs
Electrolyte imbalance
Lack of drugs (withdrawal, uncontrolled pain)
Infection
Reduced sensory input
Intracranial (CVA)
Urinary retention or fecal impaction
Myocardial/pulmonary
What are some common triggers of migraine headaches?
-Stress
-Hormonal (low estrogen)
-Environmental (excessive sun, bright lights, weather changes)
-PHenylethylamine (cheese, red wine, chocolate)
-Physical activity at high altitudes
-Fatigue
-Cigarettes
-Dehydration
What are the U.S. Department of Transportation regulations regarding licensing for interstate trucking for a person with a seizure disorder?
Anyone with a history of seizures is unable to be licensed to drive in interstate trucking
Describe the Mini-Mental State Examination (MMSE)
-set of 11 questions that providers use to check for cognitive impairment; checks orientation to time and place, attention/.concentration, short-term memory, language skills, visuospatial abilities, and ability to understand and follow instructions; score <24 is abnormal
Describe the purpose of the Get UP and Go test
Purpose is to assess mobility/risk for falls; Provider has the patient sit and identify a line 10 feet away; when the provider says “go” the patient walks to the end of the line and then back to the chair to sit down; an older adult who takes greater than 12 s is at risk for falling
Define and describe the purpose of the Montreal Cognitive Assessment (MoCa)
-A rapid screening instrument for mild cognitive dysfunction; thought to assess a broader array of cognitive domains compared to the MMSE
-Mild cognitive impairment is 18-25 points
-10-17 is moderate cognitive impairment
What are the prescribing considerations for donepezil (cholinesterase inhibitor)?
-Indicated for mild to moderate AD
-SE include: nausea, diarrhea, anorexia, weight loss
-Use with caution in patients with mild to moderate hepatic impairment
What are the prescribing considerations for memantine?
-Indicated for moderate-severe AD
-Can be used in conjunction with Cholinesterase inhibitors (donepezil)
-C/I in patients with renal and hepatic impairment
-Use with caution in patients with cardiac conduction abnormalities and peptic ulcers
The onset of Parkinson’s disease is most common in what age/gender group?
Midde-later life, with a mean age of 57 years; more common in men
What nerve is affected with trigeminal neuralgia? What are the 3 branches of this nerve?
-Trigeminal nerve (cranial nerve V)
-Three main branches: V1 (opthalmic), V2 (maxillary), V3 (mandibular branch)
MS is commonly diagnosed in what age group?
between 20-50 years old
What are the most common early signs of MS?
-Weakness of the legs
-Bladder and bowel dysfunction
-Ataxic gait
-Paresthesias in the extremities
-Optic neuritis
What is the main principle in the management of stroke prevention?
-Modification and reduction in risk factors: control hypertension, ASA for prophylaxis, anticoagulation for patients with Afib
Describe how you would educate the patient on the signs of a CVA
Acronym BE FAST:
Balance loss
Eyesight changes
Facial drooping
Arm weakness
Speech Difficulties
Time- act fast
Compare and contrast different types of meningitis
-Bacterial: rapid onset; Tx: cefotaxime/ceftriaxone plus vancomycin or ampicillin
-Chronic: symptoms develop over weeks to months (less acute); treat cause- PCN G for syphilis, ceftriaxone for Lyme disease
-Viral: More benign; self-limited syndrome; Tx with acyclovir if HSV or VZV
What are the potential causes of syncopal episodes in the elderly?
-Medications/Polypharmacy
-Hypotension
Why are the elderly at risk for falls? What are the potential complications for the elderly patient as a result of a fall?
-Increasing age, medications, and cognitive deficits
-Falls are the most common cause of a traumatic injury in the elderly
-Most common complications include hip or head fracture
Describe the pneumonic RITUAL
A guideline for providers to assess and teach fall prevention:
-Review self-assessment from older adults
-Identify risk factors
-Test gait and balance
-Undertake multifactorial assessment
-Apply interventions (canes, walkers, bathroom bars)
-Later follow-up
Apley scratch test
a rotation test technique used to assess and measure shoulder range and motion in a patient with shoulder pain, shoulder instability, or any other issue in this area
Empty can test
a clinical test used to test the integrity of the supraspinatus tendon. In this test, the patient is tested at 90° elevation in the scapular plane and full internal rotation (empty can). The patient resists downward pressure exerted by the examiner at the patients elbow or wrist.
Allen test
Tests collateral blood flow in hand; examiner tests blood flow by compressing the radial artery if blood flow does not return to hand the test is considered negative
Patellar Apprehension sign (Fairbank test)
Tests for patellar instability; examiner places lateral/medial force on patella while patient bends knee to 90 degrees and then back to straight; positive if patient tries to move their knee away from pressure
Lachman test
Tests for ACL injury;
1. Patient is supine with leg flexed to 30 degrees and rotated out slightly
2. Provider places one hand on the tibia and one on the lower thigh
3. Provider pulls lower leg forward while maintaining position of thigh
4. Graded on system with normal -severe
Valgus/varus stress test
Valgus: provider pushes bent knee medially while abducting ankle; tessts for MCL injury
Varus: provider pushes bent knee laterally while adducting foot; knee bent at 30 degrees; tests for LCL injury
SNOOP pneumonic for red flag migraines
-Systemic symptoms such as fever, vomiting
-Neurologic symptoms- decreased LOC, gait disturbance, slurred speech, seizures
-Onset- abrupt, thunderclap
-Older age at onset >40
-Progression of headache worsening over time: papilledema, position changes, precipitated by valsava maneuver
When would you want to order imaging for a patient with a migraine?
-If red flag symptoms are present; imaging not needed if no red flags signs are present
Treatment for common migraine
-Trial 550 mg naproxen daily to start 2 days before onset of menstruation (for menstrual migraine)
-Sumatriptan 100 mg PO at onset of migraine and one more in 2 hours if needed
Sumatriptan precautions
don’t exceed 300 mg daily; risk of rebound headache if using more than twice weekly
F/U for migraine
2-4 weeks
