Miscellaneous 2 Flashcards
>What are the trigeminal autonomic cephalalgias (TACs)? >What are the 4 types of TAC’s >What differentiates the Stabbing(Ice Pick) HA from the TAC’s?
>They are a group of primary headache disorders characterized by unilateral trigeminal distribution pain that occurs in association with ipsilateral cranial autonomic features. >●Hemicrania continua is characterized by continuous pain with exacerbations ●Cluster headache has a relatively long attack duration(15 minutes-3 hours) and relatively low attack frequency ●Paroxysmal hemicrania has intermediate duration(2-30 minutes) and intermediate attack frequency ●Short-lasting unilateral neuralgiform headache attacks have the shortest attack duration(1-600 seconds) and the highest attack frequency >The Stabbing HA lasts just a second and can be localized anywhere in the head (as opposed to the TAC’s which are localized in or around the eye or the temple. The Stabbing HA is NOT accompanied by ipsilateral autonomic symptoms
What are the causes of dysphonia and hoarseness?
Common Differential History Exam MUSCLE TENSION DYSPHONIA: adult presenting with THROAT DISCOMFORT, NECK TENDERNESS, VOCAL FATIGUE, POSSIBLE VOICE LOSS, AND DYSPHAGIA; possible associated URI, phonotrauma, GERD, laryngopharyngeal reflux, asthma, known allergies, sinusitis, neuromuscular abnormalities, depression, anxiety, stress, and/or recent psychological trauma. [4] tension and TENDERNESS OF CERVICAL, LARYNGEAL (EXTRINSIC MUSCLES), AND NECK MUSCLES; signs of associated condition ACUTE LARYNGITIS; -acute onset of breathiness, vocal weakness, and fatigue following a respiratory infection (BACTERIAL, VIRAL, FUNGAL), TB, laryngopharyngeal reflux, phonotrauma, or exposure to environmental irritants or noxious agents occurring at any age [7] head and neck exam unremarkable **EVALUATE AIRWAY..CAN BE FATAL ESPECIALLY IN CHILDREN(who have small airway CHRONIC LARYNGITIS: -roughness, altered pitch and volume, and voice breaks following prolonged history of recurrent respiratory infections (bacterial, viral, fungal), TB, episodic sore throats, globus, chronic cough and throat clearing, and painful swallowing; possible associated exposure to environmental irritants, noxious agents or gastric acid (laryngopharyngeal reflux), and/or phonotrauma [19] [14] head and neck exam unremarkable REFLUX LARYNGITIS: -altered vocal pitch, chronic cough and throat clearing with excess throat mucus or postnasal drip; dysphagia to solids, liquids, or pills, and coughing after eating or lying down; breathing difficulty or choking episodes, globus [52] and heartburn (in 60 YEARS OF AGE COMPLAIN OF DIFFICULTY MAKING THEMSELVES HEARD, ALTERED PITCH (INCREASED IN MEN, DECREASED IN WOMEN), ROUGHNESS, BREATHINESS, TREMULOUSNESS, AND changes in their singing voice [22] head and neck exam unremarkable ESSENTIAL TREMOR: SLOWLY WORSENING TREMULOUS VOICE WITH FLUCTUATION OF VOCAL PITCH AND VOLUME OVER MONTHS TO YEARS IN MIDDLE TO LATE ADULTHOOD; [23] SYMPTOMS WORSEN IN DEMANDING SPEAKING SITUATIONS OR WITH INCREASED EMOTION AND STRESS; [61] POSSIBLE family history of tremor 6- to 8-Hz TREMOR OF HANDS, VOICE, and sometimes head [23] not resolved on movement; vocal tremor more evident with connected speech than with singing or sustained phonation [61] UNCOMMON: PARADOXICAL VOCAL FOLD MOTION (PVFM): EPISODIC SELF-LIMITING BREATHING ATTACK WITH THROAT TIGHTNESS, DIFFICULTY INHALING, HOARSENESS, COUGH, AND WHEEZE IN RESPONSE TO A SPECIFIC TRIGGER; POSSIBLE ACUTE AIRWAY OBSTRUCTION with stridor and LOC; possible associated asthma, GERD, laryngopharyngeal reflux, known allergy, URI, occupational/environmental irritant exposure, and/or recent surgery with intubation; commonly occurs in female athletes palpable laryngeal tension, [12] with LARYNGEAL ELEVATION, PAIN, AND/OR TENDERNESS AROUND LARYNX and narrowing of thyroid hyoid space [78] GRANULOMA WITH/WITHOUT CONTACT ULCER: pain, globus, coughing, throat clearing, mild roughness, and voice breaks associated with phonotrauma, acid irritation (laryngopharyngeal reflux), or intubation; occurs during ages 20 to 40 years in nonintubation-related cases [7] [30] [94] head and neck exam unremarkable RECURRENT RESPIRATORY PAPILLOMA: gradually worsening hoarseness over several months; biphasic and inspiratory stridor (progressive if involvement of subglottis) occurring in the first 10 years of life or adulthood; [7] less commonly presents with aphonia, chronic cough, recurrent pneumonia, failure to thrive, dysphagia, acute respiratory distress, and stridor; [39] previous history of treatment for asthma, croup, allergies, vocal fold nodules, or bronchitis is common in children head and neck exam unremarkable HYPOKINETIC DYSARTHRIA poor awareness of voice changes secondary to sensory deficits of PARKINSON DISEASE, BUT may complain of breathiness, hoarseness, vocal fatigue, quiet and monotonous speech, difficulty with pitch variation, slurred speech, altered rate of speech with short rushes of speech, and impaired intelligibility; [54] other symptoms include loss of sense of smell, walking difficulties, and tremor characterized by rigidity (cogwheel), resting tremor (4-6 Hz), and bradykinesia (masked facies, shuffling gait, and decreased arm swing) **UNILATERAL VOCAL FOLD PARALYSIS/PARESIS: DIFFICULTY SWALLOWING, SHORTNESS OF BREATH, BREATHINESS, WEAK AND QUIET VOICE, LOSS OF HIGH NOTES, AND INCREASED VOCAL EFFORT AND FATIGUE RELATED to recent history of surgery (thoracic, cervical, skull base) or intubation; [99] possible neurologic symptoms of stroke, brainstem lesion, or bulbar palsy; [40] unexplained weight loss in malignancy surgical scars; neurologic signs of stroke, brainstem lesion, or bulbar palsy; unilateral oral and facial weakness; possible cachexia, and regional cervical lymphadenopathy BILATERAL VOCAL FOLD PARALYSIS/PARESIS: difficulty swallowing, shortness of breath, breathiness, weak and quiet voice, loss of high notes, and increased vocal effort and fatigue related to recent history of thyroidectomy or intubation; possible neurologic symptoms of stroke or brainstem lesion; unexplained weight loss in malignancy; possible history of sarcoidosis, TB, amyloidosis, or radiation therapy for head and neck cancer [40] surgical scars; neurologic signs of stroke, brainstem lesion, or amyotrophic lateral sclerosis; bilateral oral and facial weakness; possible cachexia and regional cervical lymphadenopathy ADDUCTOR SPASMODIC DYSPHONIA: gradual progression - or, more rarely, sudden onset - after illness or stressful/traumatic experience of strained, strangled voice quality with increased vocal effort, vocal fatigue, and voice breaks in 30- to 40-year-old patient; [61] possible associated tremor [7] task specific movement abnormality; dystonia tremor (6-8 Hz); evidence of other focal dystonias (writer’s cramp, blepharospasm, torticollis) [7] ABDUCTOR SPASMODIC DYSPHONIA: gradual progression - or, more rarely, sudden onset - after illness or stressful/traumatic experience of breathiness, vocal breaks, and voiceless speech sounds in 30- to 40-year-old patient; [61] possible associated tremor [7] dystonia tremor (6-8 Hz); evidence of other focal dystonias (writer’s cramp, blepharospasm, torticollis) [7] LEUKOPLAKIA: mild dysphonia to aphonia, breathiness, raspy voice quality, and possible otalgia in patient WITH a HISTORY OF TOBACCO USE AND EXCESSIVE ALCOHOL CONSUMPTION; POSSIBLE HISTORY OF PREVIOUS RADIATION THERAPY OR LARYNGOPHARYNGEAL REFLUX [31] [34] [36] head and neck exam may be normal; POSSIBLE REGIONAL CERVICAL LYMPHADENOPATHY AND/OR WHITE PATCHES ON THE TONGUE, BUCCAL MUCOSA, AND/OR PALATE VOCAL FOLD CANCER: SYMPTOMS DEPEND ON TUMOR SIZE, LOCATION, AND PROGRESSION AND INCLUDE DYSPHONIA AND APHONIA, DIFFICULTY BREATHING, STRIDOR, DYSPHAGIA, OTALGIA, and unexplained WEIGHT LOSS WITH HISTORY OF TOBACCO USE AND EXCESSIVE ALCOHOL CONSUMPTION IN A 50- TO 70-YEAR-OLD PATIENT [31] [34] head and neck exam may reveal REGIONAL CERVICAL LYMPHADENOPATHY; [36] mirror exam will identify location and macroscopic extent of tumor within larynx [36]
What are the criteria for Anaphylaxis?
Diagnostic criteria for anaphylaxis
Anaphylaxis is highly likely when any ONE of the following three criteria is fulfilled:
- Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula)
AND AT LEAST ONE OF THE FOLLOWING:
A. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, hypoxemia)
B. Reduced BP* or associated symptoms of end-organ dysfunction (eg, hypotonia, collapse, syncope, incontinence)
- TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to a LIKELY allergen for that patient (minutes to several hours):
A. Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula)
B. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, hypoxemia)
C. Reduced BP* or associated symptoms (eg, hypotonia, collapse, syncope, incontinence)
D. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting)
- Reduced BP* after exposure to a KNOWN allergen for that patient (minutes to several hours):
A. Infants and children - Low systolic BP (age specific)* or greater than 30% decrease in systolic BP
B. Adults - Systolic BP of less than 90 mmHg or greater than 30% decrease from that person’s baseline
BP: blood pressure.
* Low systolic blood pressure for children is defined as:
Less than 70 mmHg from 1 month to 1 year
Less than (70 mmHg + [2 x age]) from 1 to 10 years
Less than 90 mmHg from 11 to 17 years
Describe the diagnosis/appearance of Herpes Zooster Opthalmicus
Herpes zoster ophthalmicus (HZO), a serious sight-threatening condition, has been linked to VZV reactivation within the trigeminal ganglion [22,23]. Incidence rates of HZO complicating herpes zoster in various population surveys have ranged from 8 to 56 percent [22,24]. The frontal branch within the first division of the trigeminal nerve is most frequently involved, and 50 to 72 percent of patients experience direct ocular involvement
The acute syndrome typically begins with a prodrome of headache, malaise, and fever; unilateral pain or hypesthesia in the affected eye, forehead, and top of the head may precede or follow the prodrome. With the onset of a vesicular eruption along the trigeminal dermatome, hyperemic conjunctivitis, episcleritis, and lid droop can occur Almost two-thirds of HZO patients develop corneal involvement (keratitis) that results from a necrotic ganglionitis ,epithelial keratitis may feature punctate or dendriform lesions. Iritis occurs in approximately 40 percent of patients with herpes zoster ophthalmicus and can be associated with chronic vasculitis, atrophy, and poorly reactive pupils
Clinicians should also be aware that vesicular lesions on the nose are associated with a high risk of herpes zoster ophthalmicus (Hutchinson’s sign) [25]. Lesions in this area of the face signify involvement of the nasociliary branch of the trigeminal nerve, which also innervates the globe
Early diagnosis is critical to prevent progressive corneal involvement and potential loss of vision [27]. The standard approach to herpes zoster ophthalmicus is to initiate antiviral therapy (acyclovir, valacyclovir, or famciclovir) to limit VZV replication and to use adjunctive topical steroid drops to reduce the inflammatory response and control immune keratitis and iritis. Selected surgical procedures including corneal transplant and lid repair are performed less often.
What is Acute Retinal Necrosis and what is the leading cause?
VZV has been implicated as the leading causative pathogen of acute retinal necrosis (ARN) ; HSV has occasionally also been identified as an etiologic agent and has been described in patients with a history of herpes encephalitis . In a study evaluating samples of aqueous humor, VZV DNA was detected in seven of the nine patients with necrotizing retinopathies of suspected viral origin and in four of six patients with ARNARN in the immunocompetent host — ARN has been reported in immunocompetent hosts. The clinical presentation features acute iridocyclitis, vitritis, necrotizing retinitis, occlusive retinal vasculitis with rapid loss of vision, and eventual retinal detachment. Patients typically complain of blurred vision and pain in the affected eye due to progressive necrotizing retinitis; the disease can subsequently involve the other eye in 33 to 50 percent of patients. The mechanism of bilateral involvement is not clear, but one study found a diminished or absent VZV-specific delayed hypersensitivity reaction in patients with ARN compared to patients with herpes zoster involving only the skinRetinal detachment is a common complication of ARN.
Intravenous acyclovir therapy for ARN usually affords clinical improvement in 48 to 72 hours and can decrease the risk of contralateral eye involvement when administered for more than three months. One pharmacokinetic study evaluated intravitreal drug concentrations in 10 patients with ARN after 24 hours of oral valacyclovir and found substantial penetration, even in the uninflamed eye. Some practitioners use oral antiviral agents for maintenance therapy, although there does not appear to be a consensus on the need for long-term treatment. There are few data on the use of oral agents for the initial treatment of infection .
Systemic corticosteroid use may decrease the severity of ocular inflammation
What are the causes of erectile dysfunction?
√ Erectile dysfunction is most commonly related to endocrine, neurologic, or vascular disease; a medication side effect; or psychogenic factors. A history of sudden failure in a man with previously normal function – in contrast to a gradual loss of tumescence – is suggestive of a psychogenic etiology.
What medications and other agents often contribute to erectile dysfunction?
vA complete list of prescription and nonprescription medications, any recreational drug use, and alternative therapies must be elicited to assess whether any of these might be the cause of the sexual dysfunction. Among the most commonly implicated medications are antihypertensives (including diuretics), antidepressants and other psychotropic agents, nicotine, alcohol, and cimetidine.[2,5] Carefully assessing and switching medications or counseling the patient to eliminate toxic habits may lead to restored function
Whats the most common cause of sudden onset erectile dysfunction?
Most brief, sudden-onset erectile dysfunction is psychogenic. In psychogenic cases, recent psychological events such as transient anger at the spouse, guilt over normal but “unfaithful” sexual interest in another person, or stress and burnout at work may be involved. Most such cases respond to temporary restraint, reassurance, sensate focusing (review of sexual practices), and tincture of time. If these fail, referral for psychological or sexual counseling is advised.
