Medical Diagnosis & Treatment Flashcards by Chris Weber

One of the most common medical complaints

Effects 12-16% if the North American population

Headache

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How many work days are lost each year from headaches?

150 million

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Headaches are rarely caused from what kind of strain?

Rarely caused by refractive error (eyestrain) alone

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“Thunderclap” Headache indicates what?

Subarachnoid hemorrhage (SAH)

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Absence of headaches similar to the present headache indicates:

CNS Infection

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Headache with a fever could indicate:

Meningitis

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Headache with rapid onset with exercise

Intracranial hemorrhage associated with a brain aneurysm

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Headache with nasal congestion

Could be Sinusitis

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Headache with papilledema

Increased intracranial pressure

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What are the reasons for imaging a headache

Recent change in pattern, frequency, or severity of headaches
Progressive worsening despite therapy
Focal neurological deficits or scalp tenderness
Onset of headache with exertion, cough, or sexual activity
Visual changes, auras, or orbital bruits
Onset of headache after age 40
History of trauma, hypertension, fever

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Most prevalent headache

“Vice-Like”

Often exacerbated by emotional stress, fatigue, noise, glare

May be associated with neck muscles

Tension headache

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Treatment for tension headaches

Ibuprofen 400-800mg PO q 4-6 hrs - Max 2400mg daily
Naproxen 250-500mg PO q 12 hrs

Tylenol 325-1000mg PO q 4-6 hrs, max 4g/24 hours

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Intense unilateral pain that starts around the temple or eye

Duration: 15 minutes to 3 hours

Usually occurs “seasonly”

Cluster Headaches

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Patient presents with ipsilateral congestion or rhinorrhea, lacrimation, redness of the eye, Horner Syndrome

Associated symptoms of a Cluster Headache

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Initial treatment of choice for a Cluster Headache

Inhaled 100% O2 for 15 minutes

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Treatment medications for Cluster Headaches

Sumatriptan: 6mg SubQ, repeat 6mg >1 after initial dose

Zolmitriptan: 2.5mg Oral, 2.5 mg >2 hour after dose

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Gradual build-up of a throbbing headache

Duration: Several hours

Possible Aura

Family history is often positive

May have associated nausea and vomiting

Migraine

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Treatment for acute migraine attacks

Rest in a quiet, darkened room until symptoms subside

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Migraine abortive treatment

SubQ Sumatriptan: 6mg
Oral Sumatriptan 25, 50, or 100mg
*50mg has been shown to be the most effective

Oral Zolmitriptan: 2.5mg

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When would you prescribe beta blockers, antidepressants, anticonvulsants to treat migraines?

When migraines occur more than 2-3 times a month or associated significant disability

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Treatment for concurring migraine symptoms

Promethazine (antiemetic/antihistamine)

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Symptoms occur 1-2 days of injury, subside within 7-10 days

Often accompanied by impaired memory, poor concentration, emotional instability, and increased irritability

Post-traumatic Headache

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Treatment for Post-traumatic headache

No special treatment required

Simple analgesics are appropriate first line therapy

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Present in 50% of patients with chronic daily headaches

Chronic pain or complaints of headache unresponsive to medication

History reveals heavy use of analgesics

Medication Overuse headache

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Treatment for Medication overuse headache

Withdraw medication (improvement in MONTHS, not days)

Percentage of the population will have at least one seizure

5-10%

What age is the highest occurrence for seizures?

Early childhood and late adulthood

Recurrent UNPROVOKED seizures

Epilepsy

An abnormal, excessive, hypersynchronous discharge from an aggregate of CNS neurons

Seizure

Seizures happen in young adults (18-35) from:

1) Trauma 2) Metabolic disorders 3) CNS infection

Seizures are commonly found in older adults (>35) from:

1) Cerebrovascular disease 2) Brain tumor 3) Metabolic disorders 4) Degenerative disorders 5) CNS Infection

Preictal phase can have an aura Focal seizures with retained awareness One side of the brain is affected

Partial seizures

One part of the brain is affected Appears to be awake but not in contact with environment, does not respond normally Patients will have no memory of what occurred during seizure

Focal Seizure with impaired awareness

Involves the entire brain May or may not lead to alteration of consciousness Most common type is Tonic-Clonic seizure (grand mal)

Generalized seizure

Seizure phase characterized by sudden muscle stiffening

Tonic

Seizure phase characterized by rhythmic jerking

Clonic

What phase of a seizure will tongue biting occur

Clonic

"Todd paralysis"

Weakness of the limbs

What phase of the seizure will patients have somnolence, confusion or headache that may occur for several hours May present with "Todd Paralysis"

Postictal phase

What is used to diagnose a seizure?

Video EEG monitoring

What labs are needed after a seizure has occurred?

Electrolytes, LFT, CBC, Finger stick glucose

Treatment for active seizure

Diazepam 5mg IV/IM Q5-10 minutes (do no exceed 30mg) MEDEVAC Immediately

Seizure lasting more than or equal to 5 minutes or 2+ seizures without recovery in-between is classified as?

Status Epilepticus (EMERGENCY)

Status Epilepticus treatment

- Diazepam 5mg IV/IM - Valproic Acid 30mg/kg - Intubation

Not associated with abnormally excessive neuronal activity Usually there is no postictal phase Eyes are closed, usually episodes last longer than 2 minutes

Psychogenic nonepileptic seizure (PNES)

Treatment for Psychogenic nonepileptic seizure

Psychotherapy with cognitive behavioral therapy or interpersonal therapy

What are the two major branches from the carotid artery?

Anterior cerebral artery (ACA) Middle cerebral artery (MCA)

Two vertebral arteries fuse to become what artery?

Basilar Artery

What are the branches of the Basilar artery?

Right and Left Posterior Cerebral Arteries (PCA)

What supplies the Cerebellum and Brainstem with blood?

Basilar Artery

What interconnects the internal carotid and vertebral basilar arteries?

Circle of Willis

An acute neurologic injury that occurs as the result of the interrupted blood flow to the brain

Stroke

Rupture of a blood vessel causing bleeding into the brain and lack of cerebral blood flow leading to ischemia

Hemorrhagic stroke

Blockage of a blood vessel causing lack of cerebral blood flow leading to ischemia

Ischemic stroke

TIA and CVA are subtypes for what kind of stroke?

Ischemic stroke subtypes

What percentage of strokes are ischemic?

80%

The 3rd leading medical cause of death & 2nd most frequent cause of neurological morbidity

Stroke

Risk factors of stroke

HTN, atherosclerosis and age

Obstruction of an artery due to a blockage that forms in the vessel; often due to atherosclerosis

Thrombotic

Obstruction of an artery due to a blockage from DEBRIS that has broken off from a distal area

Embolic

Lack of brain blood flow from decreased systemic blood flow

Systemic Hypoperfusion

What lobe is affected when a patient is having a seizure with VISUAL phenomenons (colors, flashes, scotoma)?

Occipital lobe

What lobe is affected when a patient is having a seizure with PARESTHESIA (tingling, pain, temperature)?

Parietal lobe

What lobe is affected when a patient is having a seizure with hallucinations, epigastric rising, emotions, automatisms, Deja vu?

Temporal lobe

What lobe is affected when a patient is having a seizure with head and neck movements, Jacksonian march, posturing?

Frontal lobe

Episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, WITHOUT acute infarction?

Transient Ischemia Attack (TIA)

Episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, WITH acute infarction of central nervous system tissue?

Cerebral Vascular Accident (CVA)

What is the only way to determine the difference between a TIA and a CVA?

MRI

What clinical mnemonic is used for clinical manifestations of stroke?

FASTER FACE drooping or numbness on one side of the face ARMS - one limb being weaker or more numb than the other side STABILITY - steadiness on feet TALKING - slurring, garbled, nonsensical words, inability to respond normally EYES - Visual changes REACT - MEDEVAC immediately and note time of symptom onset

What intracranial hemorrhage generally has a gradual onset?

Intracerebral hemorrhage

What intracranial hemorrhage has a rapid response to pain, usually "the worst headache of my life"?

Subarachnoid hemorrhage

What number of patients with ICH have headache, vomiting, decreased level of consciousness?

About Half

Outpouchings and ballooning of artery due to weakness in the vascular wall

Aneurysm

Imaging used for a stroke

Non-contrast CT MRI

Labs/interventions needed for a suspected stroke patient

- EKG - O2 Saturation - Fingerstick blood glucose (FBG) - CBC MEDEVAC Immediately

At what Blood pressure levels would you think about lowering a stroke patients BP?

Systolic >220 Diastolic >120 In this case lower the blood pressure by 15% with a Beta Blocker

When can you give Aspirin to a suspected TIA patient?

Thorough Neuro exam reveals no abnormalities and with MO guidance

Where can you find the disposition "Cerebrovascular disease including stroke, transient ischemic attack, and vascular malformation is disqualifying"?

MANMED 15-106

Uncomfortable "creeping, crawling" sensation or "pins and needles feeling" in the limbs, especially the legs Occurs during periods of inactivity (Evening)

Restless Leg Syndrome (RLS)

Patients with RLS will experience what symptom that may or may not awake them?

Periodic Limb Movements of Sleep (PLMS)

Causes of Restless Leg Syndrome

1) CNS and PNS abnormalities 2) Reduced iron stores 3) Alterations in dopaminergic systems 4) Circadian physiology 5) Neurotransmitter imbalances of glutamate and GABA

PNS abnormality in patients with restless leg syndrome

Hyperalgesia (Increased sensitivity of pain)

What level of sensation do patients with RLS experience?

Deep sensation

What can exacerbate RLS?

Antihistamines Dopamine receptor antagonists (antinausea - metoclopramide) Antidepressants like SSRIs and SNRIs

What can be the cause of a patients volitional movements like foot tapping, bouncing, leg rocking?

Lack of circadian rhythm pattern

Definition of Akathisia

Intense desire to move

How can you tell the difference between patients with RLS and nocturnal leg cramps?

Nocturnal leg cramps would have disorganized spasms of muscles associated with PALPABLE muscle contraction

What levels or Serum Ferritin indicate low iron etiology?

<45 to 50mcg/L

Treatment for RLS caused by low iron

Ferrous Sulfate 325mg three times daily for 3-6 months | Turns stool black & Very constipating, use a stool softener/laxative

Patients that respond only to repeated vigorous stimuli

Stuporous patients

Causes of a coma

1. Seizures 2. Hypothermia 3. Metabolic disturbances 4. Bilateral cerebral hemispheric dysfunction 5. Disturbance of the brainstem reticular activating system 6. Mass lesion involving one cerebral hemisphere that compresses the brainstem

ABRUPT onset of coma could suggest

Subarachnoid hemorrhage Brainstem stroke Intracerebral hemorrhage

Slow onset and progression of a comatose patient would suggest?

Structural or mass intracranial lesions

Purposeful limb withdrawal to painful stimuli suggests that:

Sensory and motor pathways are intact

Unilateral absence of responses to painful stimuli despite application of stimuli to both side of the body suggests:

Corticospinal lesion

Bilateral absence of painful stimuli responses suggests:

Brainstem involvement Bilateral pyramidal tract lesions Psychogenic unresponsiveness

Posturing may occur with lesions of the internal capsule and rostral cerebral peduncle

Decorticate (flexor)

Posturing may occur with dysfunction or destruction of the midbrain and rostral pons

Decerebrate (extensor)

Unilateral absence of corneal reflex implies damage to?

Ipsilateral Pons or a trigeminal nerve deficit

Bilateral absence of corneal reflex can be seen with:

Large Pontine lesions or in deep pharmacologic coma

Ipsilateral hemispheric lesion, contralateral pontine lesion, or ongoing seizures from the contralateral hemisphere could cause what kind of eye movements?

Conjugate deviation

Deep breathing with alternate periods of apnea Found in bi-hemispheric, diencephalic disease, or metabolic disease

Cheyne-Strokes Respiration

Central neurogenic hyperventilation occurs with lesions in what part of the CNS?

Brainstem tegmentum

Prominent end-inspiratory pauses Suggest damage at the pontine level

Apneustic breathing

Completely irregular pattern of breathing Associated with lesions of lower pontine tegmentum and medulla

Atactic breathing

Max score of GCS

Lowest score of GCS

What is the GCS verbal response graded for an intubated patient?

What GCS range suggests a minor brain injury?

13-15

What GCS range suggests moderate brain injury?

9-12

What GCS range suggests severe brain injury?

3-8

Naloxone dosage

IV/IM/SubQ: 0.4 to 2mg (repeat doses every 2-3 minutes as needed)

What should be considered when administering Naloxone to an opioid dependent patient?

Avoid acute withdrawal syndrome Use lower doses like 0.1 to 0.2mg

Sudden deceleration or acceleration of the head that leads to impact of the brain against the cranium

Concussion

Mildest subset of traumatic brain injury (TBI) May or may not lose consciousness

Concussion

According to the CDC how many concussion cases were there in 2013?

2.8 million

Leading cause of concussions

Falls (47%)

Most accident prone to concussion

Young (15-34), male, and drunk

How long would you observe and awaken a concussed patient?

Direct observation for 24 hours Awaken every 2 hours

Occurs when patient is symptomatic from the 1st concussion and sustains a 2nd concussion

Second Impact Syndrome (FATAL)

Repeated concussions lead to cumulative neuropsychologic deficits. -Behavior changes, personality changes, depressions, increased suicidality, Parkinsonism, speech and gait abnormalities

Chronic Traumatic Encephalopathy (CTE)

Thin areas of the skull

1) Temporal region | 2) Nasal Sinuses

Battle sign, Raccoon eyes, hemotympanum, CSF rhinorrhea/otorrhea, cranial nerve deficits would indicate what type of skull fracture?

Basilar skull fracture | base of the skull fracture

Bradycardia + Hypertension + Respiratory irregularity

Cushing's Triad

Suspected signs of increased ICP or brain herniation you should:

1) Secure and maintain an open airway 2) Elevate the head of the bed by 25-30 degrees 3) Ventilate for oxygenation and avoid hypercarbia

What types of IV solutions do you NOT want to use when treating a patient with increased ICP?

1) Glucose containing 2) Hypotonic (Avoid overhydration; more hydration = more pressure)

What osmotic therapies can be used to reduce brain volume by drawing free water out of tissue and into circulation where it can then be excreted by the kidneys?

1. Mannitol (osmotic diuretic) 1g/kg IV 15-20% solution | 2. Hypertonic NaCl 7.5% 250 cc open bolus

What should you consider as a last resort in an increased ICP patient?

Hyperventilation

What are the types of Intracranial Hemorrhage (ICH) locations?

1) Epidural 2) Subdural 3) Subarachnoid 4) Intracerebral bleed

ICH Classification: - 1-4% of head trauma cases - Highest among adolescents - Usually caused by traffic accidents, falls, and assaults - 75-95% have a skull fracture

Epidural hematoma

What artery is commonly affected in an epidural hematoma?

Middle Meningeal Artery

Treatment for epidural hematoma

Immediate neurosurgical consultation -Operation likely required: Trephination, Burr hole

ICH Classification: - 20% of severe head injuries - Elderly, ETOH abusers, people on anticoagulants - Can occur WITHOUT impact - 60% mortality rate

Subdural Hematoma

Cranial Hematoma that: - Tears binding veins, drain from the brain to the Dural sinuses - May tamponade, GRADUAL progression - May be CHRONIC

Subdural Hematoma

Acute subdural hematoma usually presents itself how many days after onset?

1 to 2 days

Chronic subdural hematoma usually presents itself how many days after onset?

15 days

ICH Classification: - Usually a rupture of a blood vessel (aneurysm) is involved - Trauma or a congenital anomaly - Bleeding is high pressure, combines with CSF causing severe pain

Subarachnoid Hematoma (SAH)

What are some activities that increase risk for a SAH?

Drug use (cocaine, amphetamines), smoking, hypertension, alcohol use

Checklist by MACE, used as soon as possible on a patient with suspected head injuries

IED Injury ``` Evaluation H: Headaches or vomiting? E: Ear ringing A: Amnesia/loss of consciousness D: Double vision or dizziness S: Something feels wrong? ``` Distance: Service member within 50 meters of blast?

Concussion that impacts the opposite side from rebound motion

Coup-Contrecoup

Red flags for a concussion

Lack of recall or repetitious questioning

Early symptoms of a concussion (minutes to hours)

Headache, dizziness, vertigo, imbalance, nausea, vomiting

Delayed symptoms of a concussion (hours to days)

Mood/cognitive disturbance, light/noise sensitivity, sleep disturbance

If seizures occur within what time frame it's more related to TBI than epilepsy?

One week of head injury

Complete a MACE exam within how many hours?

48 hours

First concussion results in how many hours of rest or limited duty?

24 hours

Second diagnosed concussion within a 12-month period results in how much rest?

7 days

Three concussions in a 12-month period would result in:

Return to duty delayed until a RECURRENT concussion evaluation has been conducted

1) Comprehensive Neurological Evaluation 2) Neuroimaging 3) Neuropsychological Assessment 4) Functional Assessment 5) Duty Status Determination

Recurrent Concussion Evaluation

- 40 million persons affected each year - MVA (47%), Falls (23%), Violence (14%). Sports (9%) - Largely affects young males

Spinal cord injuries

What is the pathophysiology for severe spinal cord injuries?

Injury to vertebral column which leads to mechanical compression of the spinal cord

What part of the spine would indicate poor respiratory function and may require intubation if necessary?

Cervical

What medications could reduce spinal cord swelling?

Steroid use: Methylprednisolone 125mg IM/IV 4-6 hours prn *Consult with MO*

What mnemonic is used for C-spine X-ray?

NSAID ``` N: Neurological Deficit S: Spinal Tenderness A: Altered mental status I: Intoxicated D: Distracting injuries ```

What disks are the most commonly affected in patients with Radiculopathy (pinched nerve)?

L5-S1 disks (90% of the time)

Causes electric shock-like pain radiating down the posterior aspect of the leg often to below the knee

Sciatica

What spinal herniation causes pain, paresthesia and sensory loss in the inguinal region

What spinal herniation location is classified as acute back pain that radiates around the anterior aspect of the thigh knee and may have weakness of hip flexion, knee extension and hip adduction?

L2, L3, L4

What spinal herniation has pain radiating down the lateral aspect of the leg into the foot and decreased strength in foot dorsiflexion, toe extension, foot inversion, foot eversion?

Spinal herniation resulting in pain radiating down posterior aspect of leg into the foot, weakness in plantar flexion due to gastrocnemius

Presence or worsening of radicular pain with straight leg testing

Lasegue's Sign

Bundle of nerves that spread out from the bottom of the spinal cord

Cauda equina

Causes of cauda equina syndrome

1) Herniated Disk 2) Infection or inflammation 3) Cancer 4) Spinal Stenosis

Clinical presentation: - Pain, numbness, or tingling in the lower back and spreading down 1 or both legs - Leg weakness, "Foot drop" - unable to hold your foot up while walking - Problems with bladder or bowel control - Problems with sex

Cauda Equina Syndrome

An entrapment neuropathy caused by compression of the median nerve between the carpal ligament and other structures within the carpal tunnel

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome is commonly seen in what types of patients?

Pregnancy Diabetes mellitus Rheumatoid arthritis

Nerve that innervates thumb, pointer, middle and half of the ring finger

Median Nerve

What is used for Carpal tunnel diagnosis?

Tinel or Phalen's sign exacerbates neuropathic symptoms Diagnosed with ultrasound and nerve conduction studies

Carpal tunnel definitive treatment

Carpal tunnel release surgery

An acute facial paralysis of a specific pattern, lower motor neuron disease affects CN VII Rare (34 out of 100,000 people)

Bell's Palsy

What diseases are associated with Bell's Palsy?

Herpes Simplex Virus Lyme Disease HIV

Upward rolling of the eye on an attempted lid closure

Bell's Phenomenon

How would you differentiate a stroke from Bell's Palsy?

In a stroke there is no forehead paralysis. Intact forehead muscle tone suggests stroke.

Moderate Bell's Palsy treatment

Prednisone (steroid) 60 mg PO daily x 7 days, then 5 day taper

Severe Bell's Palsy treatment

Prednisone (steroid) 60 mg PO daily x 7 days, then 5 day taper AND Valacyclovir (antiviral) 1000mg 3 times daily for 7 days

What percentage of Bell's Palsy recover completely without treatment?

60%

What percentage of Bell's Palsy patients remain disfigured?

10%

In a Bell's Palsy, how would you treat them to avoid corneal ulcerations?

Artificial tears, lubricating ointment, and possibly an eye shield

Inflammation of the coverings of the brain | May be viral or bacterial, spirochete, or fungal etiology

Meningitis

Common bacterial causes of meningitis

1) Streptococcus pneumonia 2) Neisseria meningitides 3) Listeria monocytogenes

Viral etiologies for meningitis

- Enterovirus - Herpes simplex (13-36% of patients with genital herpes) - West Nile Virus

Classic triad of acute meningitis

1) Fever 2) Nuchal Rigidity 3) Change in mental status

Meningitis symptoms with a RASH would come from what etiology?

Neisseria meningitides

How could you tell the difference between meningitis and encephalitis?

Encephalitis brain function is abnormal leading to altered mental status, motor and sensory deficits, altered behavior, speech disorders Meningitis, cerebral function is normal

Spontaneous flexion of hips during flexion of neck

Brudzinski sign

Inability or reluctance to allow full extension of knee when hip is flexed at 90 degrees

Kernig sign

Treatment for bacterial meningitis

Antibiotic that crosses the blood-brain barrier - Ceftriaxone (Rocephin) 2g IV Q12Hr - Vancomycin Dexamethasone 0.15mg/kg IV Q6hr (decreases inflammation)

Meningitis prophylaxis for exposed crew

- Ciprofloxacin (500mg PO x 1) | - Mask patients and medical personnel in close proximity

Three categories of Chronic Pain

1) Nociceptive pain 2) Neuropathic pain 3) Centralized pain

Pain caused by stimuli that threaten or result in bodily tissue damage

Nociceptive pain

Pain resulting from maladaptive response to damage or pathology of the somatosensory nervous system Can occur in absence of active stimuli or as exaggerated response to minor or moderate stimuli

Neuropathic pain

Reduced ability of the CNS to diminish responses to peripheral stimuli

Centralized pain

An acutely painful condition that persists beyond the usually expected 6-12 week time course for healing

Chronic pain

Initial treatment for chronic pain management

Non-pharmacologic therapies - Home exercise programs - Physical therapy

Medications that inhibit descending pain modulation (Neuropathic pain treatment)

Gabapentin TCA's SNRI's

How many stages are there for NREM?

THREE 1) Beginning sleep cycle 2) Become less aware (people spend 50% in this stage) 3) Deepest sleep stage, muscles relax, delta wave sleep

Dreams occur in this stage and brain is more active, eyes move rapidly "Paradoxical sleep"

REM

How many REM periods are there every night and how long in total?

4-5 REM Periods, make up 1.5 to 2 hours

When does the first REM period start?

80-120 minutes after onset of sleep

What is impaired by loss of sleep?

Creativity and rapidity of response to unfamiliar situations

How do you diagnose insomnia?

1. Chronic diagnoses established by history | 2. Sleep history for 1 week

Short term insomnia (less than once a month in duration) usually is caused by?

Psychologic or physiologic stress

How should chronic insomnia be treated?

Psychological sleep referral for cognitive behavior therapy

What are medications that can help with insomnia?

Melatonin Trazodone Vistaril (hydroxyzine) Diphenhydramine

Sensation of motion when there is no motion or an exaggerated sense of motion in response to movement

Vertigo

Etiologies of peripheral vertigo

BPPV Herpes Zoster Otitis Media Aminoglycoside toxicity

Etiologies of central vertigo

Brainstem ischemia Multiple sclerosis Vestibular migraine

Quickly lowering the patient to the supine position with the head extending over the edge and placed 30 degrees lower than the body, turning the head left or right

Dix-Hallpike Testing

Patients with benign paroxysmal positioning vertigo (BPPV) will elicit what response after a Dix-Hallpike test?

Delayed onset (~10 seconds) of fatigable nystagmus

If no nystagmus from a Dix-Hallpike test, indicates what?

CNS Disease

Treatment of vertigo

Anti-vertigo: - Meclizine 25-50mg q 6-12 hours - Diazepam 1mg PO q 12 hours Antiemetic: - Ondansetron 4mg PO/IV q 8 hours - Promethazine 12.5 to 25mg every 4-6 hours

Medical Diagnosis & Treatment Flashcards

(211 cards)