Module 5 EB #1 Flashcards
Red flag sx of acute HA
*what do these red flag sx exclude?
> 40yo
rapid onset
severe intensity
**thunderclap
-onset after trauma or during exertion
-brain tumor, meningitis, stroke, encephalitis, intercranial hemorrhage, temporal arteritis, acute angle glaucoma, raised ICP, CO poisoning, preeclampsia, aneurysm
When to transfer to the ED for acute HA (accompanying signs)?
-fever, vision change, neck stiffness
-neuro findings: mental status change, motor/sensory deficits, LOC
-past medical hx of HTN or HIV
SNOOOPPPPP
-sx of acute HA
-Systemic S or S (fever, wt loss)
-Neurologic S or S (confusion or impaired alertness)
-Onset (sudden)
-Older (>50yo)
-Occipital (back of head; occipital HA in children)
-Previous HA (new, worse, or different?)
-Progressive, persistent HA
-Precipitated by pressure (bearing down, coughing, sneezing)
-Postural HA (worse when supine, worse waking at night, worse in AM)
-Pregnancy
what is the most important component (what info is most important) in regards to acute HA?
onset of HA
-sudden, persistence = subarachnoid hemorrhage
–> especially when preceded by exertional activities
Elements to the neuro exam regarding acute HA
-VS
-Mental Status
-Motor and Sensory
-Reflexes
-Gait (rapid finger-nose testing)
Ottawa SAH clinical decision scale
100% sensitivity in predicting subarachnoid hemorrhage
-40 years or older
-neck pain/stiffness
-witnessed LOC
-onset during exertion
-thunderclap HA (pain peaks w/i 1 sec)
-Limited neck flexion (on exam)
Diagnostic imaging for acute HA
No contrast = visualize bone and surrounding soft tissue (blood vessels)
Migraine
-what type of dysfunction?
-neuronal dysfunction: a wave of activity by groups of excitable brain cells that trigger chemicals that cause dilation of blood cells –> creates HA
*pain felt by pt triggers more chemicals which leads to further dilation of blood vessels and more painT
Tension HA
-cause?
cause unclear
-derivative pain of tension HA has muscular origin
Cluster HA
-mechanism
vascular dilation trigeminal nerve stimulation, have circadian effects
-histamine release, inc mast cells, genetic factors, and autonomic NS activation may also contribute
Which HA does this describe?
Unilateral pain, throbbing, pulsitile
Migraine
Which HA does this describe?
worse with routine activity
Migraine
Which HA does this describe?
onset and duration of HA = 4-72hrs
Migraine
Which HA does this describe?
Accompanying sx: N/V, photophobia, phonophobia
Migraine
Which HA does this describe?
some have aura preceding AH (commonly visual aura)
Migraine
Which HA does this describe?
Family hx of this type of HA present
Migraine
Which HA does this describe?
Patient reports recent lack of sleep, missed meal, menstruation
Migraine
Which HA does this describe?
precranial tenderness with generalized apin described as vice-like, tight
tension
Which HA does this describe?
not pulsitile
tension
Which HA does this describe?
pain worse at base of neck or occipital area of head
tension
Which HA does this describe?
timing: constant daily HA
tension
Which HA does this describe?
no accompanying focal/neuro deficits = NO AURA
tension
Which HA does this describe?
episodes exacerbated by stress, fatigue, noise
tension
Which HA does this describe?
unilateral, temporal or periorbital pain with one or the following:
-ipsilateral sx: nasal congestion, rhinorrhea, lacrimation, redness of eye
cluster
Which HA does this describe?
pain often occurs at night (awakens patient), then have spontaneous remission
cluster
Which HA does this describe?
timing: episodic and last 15 min to 3 hours; then have spontaneous remission
cluster
Which HA does this describe?
commonly seen in middle aged men ages 20-40
cluster
Which HA does this describe?
no family hx of this HA or migraine present
cluster
Migraine:
patho
brain cells trigger release of chemicals that lead to blood vessel dilation and pain
Migraine:
-drug class most effective for symptomatic or abortive tx
- ergotamine (narrow blood vessels)
- triptans (acts like serotonin; quiets nerves) - constricts blood vessels in brain, slowing inflammation and blocks pain pathways
Migraine
-what should you do for a patient presenting with migraine before prescribing he/she ergotamine or triptans?
place pt in cool, dark room; give simple analgesic (tyl, ibup, naproxen) and reassess pain in 30 min
Tension HA
patho
muscular tension primarily in shoulders, neck leads to pain
Tension HA
-drug class most effective for symptomatic tx
No triptans; address comorbid issues, CBT, etc.
Similar to migraine tx –> prescribe simple analgesics
Cluster HA
-patho
myriad of reasons but similar to migraine HA etiology (brain cells trigger release of chemicals that lead to blood vessel dilation and pain)
Cluster HA
-Drug class most effective for symptomatic or abortive tx
TRIPTANS (sumatriptan SQ or intranasal)
O2 inhaled 100% in nonrebreather mask
Tension HA
-what medications can you consider?
muscle relaxers
-flexeril
-zanoflex
-robaxin
Can abortive drugs be given during pregnancy for HA?
NO
Which type(s) of HA can recur?
Migraine and cluster
-HA that occurs 2-3x/MO or significant disability associated with attack
Migraine HA
-prescribe prophylactic/preventative med (how many options total?)
Topiramate
Valproic acid
Propanolol
Verapamil
Amitriptyline
Botox
Riboflavin
(7)
Cluster HA
-prescribe prophylactic/preventative med
Lithium
Topiramate
Verapamil
foods that trigger migraine or cluster AH
chocolate and ETOH
Considerations in HA management
avoid opioid meds d/t SE (including rebound HA)
keep HA diary to identify triggers and avoid any precipitating factors if known
Other HA disorders
-posttraumatic HA
-analgesic rebound HA
-primary cough HA
-HA d/t intracranial mass
Posttraumatic HA
-def
-how quickly does HA appear? does it worsen?
-sx
-tx
-HA following closed head injury regardless of LOC
-pain appears w/i 24 hours; worsens over weeks but gradually subsides
-constant dull ache; can be localized, lateralized or generalized; associated with N/V, seeing black spots - scintillating scotoma
-simple analgesics (tyl, ibup)
Analgesic rebound HA
-def
-how long do these meds need to be used to become a risk factor?
-simple analgesic effects (timeline)
-tx
-using ergotamines, triptans, opioids, and meds containing butalbital (fioricet)
-for more than 10 days per MO
-simple analgesics (tyl, acetylsalicylic acid, NSAIDs) taken more than 15 days per MO
-“fix the why” - prescribe preventative tx for migraines so they will stop using these meds as frequently (topiramate, valproic acid, verapamil, amitriptyline, botox, riboflavin, propanolol)
Primary cough HA
-def
-what should you be thinking? what should you order?
-tx
-pain with coughing, straining, sneezing, laughing (only lasts a few minutes)
-THINK BRAIN TUMOR. Order CT or MRI
-once brain tumor is r/o, NSAID (indomethacin)
HA d/t intracranial mass
-when does this tend to occur (age)? what should you order?
-aggravating factors
-how does body counteract inc ICP in this state?
-associated systemic signs that may be associated w/ this?
-new or worsening HA in middle or later life; order MRI or CT
-worse when lying down; awakens the patient at night (same as cluster HA :) ); peaks in the AM after overnight recumbency
*lying down increases CIP but our SCF and spine can adjust for this; with a tumor, prevents feedback system from operating as normal and leads to inc ICP
-body’s natural response to counteract inc ICP is to keep you upright
-fever, night sweats, weight loss
facial pain: trigeminal neuralgia
-where is the pain felt? descriptor of pain?
-what makes this pain worse?
-is neuro exam abnormal or normal?
-can remission occur?
-effect women or men more? at what point of life does this tend to occur?
-unilateral stabbing pain localized to the second and third division of the trigeminal nerve = pain arising at one side of the mouth and shoots toward the eye, ear, or nostril ON THAT SIDE
-with touch (even air hitting face)
-normal
-yes
-women; middle and later life
Facial pain: trigeminal neuralgia
-why does this occur?
-tx
-impinging of trigeminal nerve leads to misfiring and nerve pain
-carbamazepine - decreases nerve impulses that cause seizures and pain (anticonvulsant)
Facial pain: trigeminal neuralgia
-when to expect MS with these sx?
-drug of choice for MS and trigeminal neuralgia
-<40yrs
-gabapentin
Facial pain: posttherpetic neuralgia
-what should we be thinking?
-who is this common in (what population)?
-sx
-what aids in dx?
-tx
-prevention
*what NOT TO DO
-herpes zoster (singles)
-elderly/immunocompromised; when first division of trigeminal nerve is affected
-severe visible rash (when first division of trigeminal nerve is affected - rash on forehead, bridge of nose)
-hx of shingles and presence of cutaneous scaring
-acyclovir or valacyclovir when given >3hrs after rash onset
-shindrix vaccine
*DO NOT ADMINISTER SYSTEMIC CORTICOSTEROIDS: weakens immune system, makes virus/rash worse
Facial Pain: TMJ
-def
-sx
-tx
-due to injury to jaw, joint, or muscles of head and neck; grinding/clenching of teeth, or stress causing one to tighten facial/jaw muscles
-pain, tenderness in face, jaw joint area, around ear w/ chewing, speaking, opening mouth wide; jaw can get struck; clicking, popping, grinding sounds of jaw with opening/losing/chewing = can be painful
-simple analgesics; sometimes muscle relaxants (refer to dentist - mouthguard?
Facial pain: SAH
-most common cause?
-other causes?
-risk factors?
-what do patients present with?
-role of NP
-med
-trauma
-rupture of arterial saccular “berry” aneurysm or an AVM (from high BP?)
-older age, female, nonwhite ethnicity, HTN, smokier, consuming large amounts of alc
-present with sudden severe HA (WORST HA they have ever experienced); proceed to vomit
*signs of meningeal irritation (stiff neck, dec neck flexion are common): transient LOC, appear confused/irritable, progresses to coma; focal neuro deficits are ABSENT
-stat transfer to ER for CT; neuro surgery consult; ICU admission
-nimodipine = reduces iscehmic deficits from arterial vasospasm
Facial pain: pseudotumor cerebri - “Idiopathic Intracranial HTN”
-def
-RF
-etiology (most common)
-S/S
-NP role
-meds
“False Brain Tumor”
-pressure around brain inc; causes HA and vision problems (double vision)
-overweight women 20s-40s
-(many) - thrombosis of transverse sinus (complication of otitis media) is the most common; abrupt cessation of PO steroids; long-term use tetracycline or PO contraceptives
-worsened by straining; fondoscopic exam reveals edema and abducens palsy (causes eyes to turn out); chronic IH will cause pulse incronis tinnitis
-REFER to ER for CT; r/o emergent HA causes including space occupying lesions of the brain
-initiated and managed by neuro
Adjustment disorders
-def (when did stressor occur?)
-common rxns to stress
*does this resolve?
-tx
-signs of anxiety/depression d/t identifiable stressor that has occurred in past 3MO; sx are out of proportion to the severity of the stressor but not as severe as major depression or GAD
-manifests as developing somatic complaints: running away, drinking ETOH excessively, over eating, starting an affair
-this condition is completely situational; usually resolves when stressor resolves or when individual effectively adapts to situation
-behavioral techniques: CBT with emphasis on strengthening existing coping methods); lorazepam (for limited time)
trauma and stressor-related disorders: PTSD
-key to dx
-sx
-more common in which sex?
-tx
-establish if pt experienced a traumatic or life threatening event
-flashbacks, obtrusive images/intrusive thoughts, nightmares; pt feels like they experience moment repeatedly; causes pt to avoid stimuli that could be associated with the event
-more common in women and when event is associated with physical injury
-centered around interventions that will help pt integrate the event in an adaptive way
*psychotherapy: initiate ASAP; brief 8-12 sessions
*drug of choice: SSRIs: sertraline and paroxetine + others
Anxiety
-sympathomimetic sx of anxiety
-impact of trigger avoidance
-what is a contributing factor to anxiety?
-response to a CNS state that perpetuates further anxiety (fight or flight) –> anxiety can be self-perpetuating
-reinforcement of the anxiety (person continues to associate trigger w/ anxiety and never relearns through experience that the trigger need not always result in fear, or that anxiety will naturally improve with prolonged exposure to an objectively neutral stressor)
-lack of structure is frequently a contributing factor; no thoughts to occupy their time leads to over-thinking
Generalized Anxiety Disorder
-short term or chronic? which sex is this more common?
-sx + how long do sx need to be present for dx
-triggers
-physical manifestations
-tx
-chronic, women
-apprehension, worry, irritability, difficulty concentrating, insomnia; must be present (more days than not) for at least 6MO
-everyday activities
-tachycardia, HTN, nausea, epigastric pain, HA, near-syncope
-SSRI (venlafaxine, duloxetine) or SNRI (escitalopram, paroxetine)
Phobia disorder
-short term or chronic?
-def
-debilitating fears
-tx
-chronic, specific object or situation
-fear out of proportion to the danger posed
-debilitating fears: social phobia - patient remains isolated at home
-desensitization; SSRI (venlafaxine, duloxetine) or SNRI (escitalopram, paroxetine)
Panic disorder: panic attack
-def
-sx
-key to dx
-recurrent, unpredictable episodes of intense surges of anxiety and marked physiologic manifestations = impending doom
*pt appears dyspneic, tachycardic, report palpitations, HA, dizziness, numbness of extremities, feeling smothered or nauseous, bloating
-psychic pain and suffering the individual expresses
Panic disorder: panic disorder
-def
-RF
-what can this presentation mimic?
-tx
-dx when panic attacks are accompanied by a chronic fear of the recurrence of an attack or a maladaptive change in behavior = try to avoid potential triggers of the panic attack
-family hx, female, premenstrual period, mitral valve prolapse
-MIMIC a cardiac event = MI must be ruled out w/ EKG and cardiac enzymes
-SSRI (venlafaxine, duloxetine) and SNRI (escitalopram, paroxetine)
Panic disorder
-2 categories
-complications
-must R/O what?
-first line tx:
-first line drug class
-panic attack, panic disorder
-inc risk of major depression or suicide attempts; ETOH abuse and dependence on sedatives
-cardiovascular, endocrine, respiratory, neurologic, substance related syndromes
-psychotherapy (CBT)
-SSRIs (venlafaxine, duloxetine) or SNRIs (escitalopram, paroxetine)
**antidepressants take approx 2-4 weeks before effective
**abrupt withdrawal can lead to suicidal thoughts
abrupt withdrawal of antidepressants (SSRI and SNRI) can lead to what?
suicidal thoughts
OCD
-def
-2 components
-what does it often coexist with?
-prevalence
-tx
-irrational idea or impulse repeatedly and unwantedly intrudes into awareness; anxiety so overwhelming that only alleviated by ritualistic performance of the compulsion; chronic disorder that waxes and wanes
-obsessions (recurring distressing thoughts); compulsions (repetitive actions); unwanted by patient
-major depression
-equal among sexes; highest rates in young, divorced/separated, unemployed individuals
-SSRIs, tricyclic antidepressant clomipramine + CBT
*thought-stopping
somatic sx disorders (abnormal illness behaviors): somatic sx disorder
-chronic or temporary?
-complaint of pt?
-onset; more common in men or women?
-chronic
-complains of one or more somatic sx exhibited as disproportionate and persistent thoughts about the seriousness of the sx
-usually before 30 yrs of age; 10x more common in women
somatic sx disorders (abnormal illness behaviors): conversion disorder
-def
-tends to occur simultaneously with what?
-somatic manifestation:
-“conversion” of psychic conflict into physical neurologic sx in parts of body innervated by the sensorimotor system (ie paralysis)
-panic disorder or depression
-takes the place of anxiety; is often paralysis
somatic sx disorders (abnormal illness behaviors): factitious disorders
-def
-munchausen syndrome
-munchausen by proxy
-sx production is intentional; pt consciously produces sx; characterized by self-induced or described dx or false physical and laboratory findings for the purpose of deceiving clinicians or other healthcare personnel (common deceptions: self-mutilation, fever, hemorrhage, hypoglycemia or seizures)
-self-inflicted
-factitious disorder imposed on another
somatic sx disorders (abnormal illness behaviors):
-tx (for somatic sx disorder, conversion disorder, factitious disorder)
*what is a mainstay of tx?
-multifaceted
*behavior: biofeedback
*social: family member involvement
*psychological: PCP establishes relationship with patient
**medical support with careful attention to building a therapeutic clinician-patient relationship is a mainstay of tx
Chronic Pain Disorders
-essentials of dx
-what is counterproductive?
-chronic complains of pain
-sx frequently exceed signs
-minimal relief with standard tx
-hx of “doctor shopping”
-frequent use or several nonspecific meds
**it is counterproductive to speculate about whether pain is real
Chronic pain disorders
-medical tx
*what is the highest priority?
-medically treating the pt with a single clinician in charge of the comprehensive treatment approach
Chronic pain disorders
-behavioral tx
*what should be identified?
*what type of therapy is helpful?
*first line tx of choice for neuropathic pain?
-other meds used?
-identify and eliminate pain reinforcers to decrease med use
-group therapy with family is helpful
-SNRIs: venlafaxine, duloxetine
-anticonvulsants (gabapentin, pregabalin) and TCA (nortriptyline)
what meds can help treat fibromyalgia?
-anticonvulsants, duloxetine + milnacipran
Depression
-def
-what is a common presentation of depression?
-mild sadness to intense despondency and feelings of guild, worthlessness, hopelessness; inability to concentrate, ruminations, lack of decisiveness; loss of interest + decrease work/recreation involvement; excessive sleep, loss of sleep, change in appetite, dec libido, suicidal ideations
-somatic complaints with negative medical work-up
Mania
-def
-euphoria to irritability
-insomnia, hyperactivity, racing thoughts, pressured speech; grandiosity with extreme overconfidence; variable psychotic sx
Adjustment disorder presenting with depressed mood
-def
-when does this type of depression subside?
-depression in reaction to an identifiable stressor or adverse life situation; subside when stressor removed
Major depressive disorder
-def
-sx
-do sx improve?
-syndrome of mood, physical and cognitive sx that occurs at any time of life
-loss of interest and pleasure, withdrawal from activities, feelings of guild; inability to concentrate, some cognitive dysfunction, anxiety, chronic fatigue, feelings of worthlessness, somatic complaints (unexplained somatic complaints frequently indicate depression), loss of sexual drive, thoughts of death; insomnia anorexia w/ wt loss, constipation
-improvement as the day progresses
dysthymia
-def
-sx
-how long must pt suffer until dx?
-sx in relation to MDD
-chronic depressive disturbance expressed in those with MDD
-sadness, loss of interest and withdrawal from activities
-sx are over a period of >2years or more, with a relatively persistent course
-sx are milder, but last longer than MDD
Premenstrual dysphoric disorder
-def
depressive sx during the late luteal phase (last 2 weeks) of menstrual cycle
Bipolar disorder
-def
-two types
-episodic mood shifts into mania, major depression, hypomania, mixed mood states; bipolar mimics several other major mental disorders
-bipolar I and bipolar II
Bipolar disorder: bipolar I
-def
has manic episodes only
Bipolar disorder: bipolar II
-def
individuals who experience hypomanic episodes without frank mania
Bipolar disorder: mania
-def
-are onset of episodes abrupt or drawn out?
-how long to episodes last?
-sx
*definition of Rapid cycling (what is there a higher incidence of?)
-mood state characterized by elation with hyperactivity, overinvolvement in life activities, increased irritability, flight of ideas, easy distractibility, and little need for sleep; initially attractive to others but then become irritable with swings into depression, aggression, grandiosity
-abrupt (sometimes caused by life stress)
-may last several days to months (manic modes are of shorter duration than depressive episodes
-pts excessively spend money, resign from job, hasty marriage, sexual acting out, alienation of friends and family
*4 or more discrete episodes of mood disturbance in 1 yr (higher incidence of hypothyroidism)
Cyclothymic disorder
-def
-similar to what?
-dx
-chronic mood disturbances + episodes of subsyndromal depression and hypomania; alternates between hypomanic sx and mild/moderate depressive moods
-similar to bipolar II
-sx must be present for at least 2 years and are milder than those that occur in depressive or manic episodes
Drug-induced depression
-common meds
-corticosteroids
-PO contraceptives
-digitalis
-clonidine
-levodopa
-interferon
-stimulants (when they have depressive syndrome during withdrawal)
-use of depressants (ETOH, sedatives, opioids)
complications associated with depression
-most important complication
-R/F
-suicide
-bipolar I disorder, men >50yo, women, comorbidities ie CA, COPD, AIDS, those on hemodialysis, those who drink ETOH
what is a MAJOR RED FLAG for IMPENDING SUICIDE?
a depressed pt who makes dramatic improvement
Depression
-tx
CBT +
SSRIs or SNRI
TCAs and MAOI
Atypical (Wellbutrin)
electroconvulsant therapy ECT
what is the most effective tx for depression?
CBT + med
Depression (tx)
-SSRI or SNRI
*fluoxetine - SE
*pt with cardiac hx, what to prescribe?
*what are patients at risk for when taking SSRIs?
-Prozac: long time used, old drug; very trusted. SSRI. Drug of choice for those who have never been prescribed meds before; sexual SE most common complaint
-sertraline (zoloft)
*serotonin syndrome: occurs w/ ingestion of high doses of SSRIs and present w/ sx of rigidity, hyperthermia, autonomic instability, myoclonus, confusion, delirium, coma
Depression
-what is the tx drug class of choice?
SSRI or SNRI
Depression (tx)
-TCAs
*how often are these used
rarely d/t drug interactions
Depression (tx)
-atypical med (what’s it called)
-SE
Wellbutrin
-used widely now d/t weight loss and sexual arousal SE; great choice for someone never on meds who is interested in losing wt
what occurs with abrupt cessation of SSRIs or SNRIs?
how should med be discontinued?
-can precipitate sx of withdrawal and/or suicidal thoughts
-must reduce gradually over period of weeks or months
Depression (tx)
-teratogenic meds
SSRIs
-fluoxetine (prozac)
-sertraline
-venlafaxine
-citalopram
SSRI
-what risk is increased?
-what SSRI is drug of choice if pt taking warfarin?
-bleeding (affects platelet serotonin levels and creates abnormal bleeding)
-sertraline and citalopram
How to switch from one depression drug class to another
-if switching one drug class to another, wait 2-3 weeks between
-if switching between meds w/i same drug class, no wash out time needed
what is the most effective form of tx for severe depression
(when should it be used?)
-who can this therapy NOT be performed on?
-electroconvulsant therapy ECT
-used when medical conditions preclude the use of antidepressants or there is a nonresponsiveness to these meds and extreme suicidality
-those with cardiac disorders, bronchopulmonary disease (COPD, asthma), venous thrombosis hx, or hx of aortic aneurysm
Bipolar (tx)
-used combination of what?
-med types for each
-combination of antipsychotics and mood stabilizers
-antipsychotics: faster acting drugs that begin easing sx w/i hrs
-mood stabilizers: slow and steady mechanism; takes few wks to kick in; even out swings in mood
-antipsychotics: olanzapine (zyprexa), quetiapine (seroquel), risperidone, aripiprazole (ability), clozapine (clozaril)
-mood stabilizers: lithium, tegretol, depakote, lamictal, valproic acid, depakene
what is lithium toxicity?
-causes
> 2mEq/L
-any Na+ loss
drug interactions with lithium?
diuretics (need to inc lithium)
ACE-inhibitors (need to dec lithium)
Bipolar (tx)
-meds (quick notes about each)
-lithium (>2mEq/L; caused by loss of Na+, drug interactions)
-antipsychotics (for acute mania)
-valproic acid (first line tx for mania; treats mania, panic disorder, migraine HA; drug interactions)
-carbamazepine (used when lithium not an option; significant teratogenic effects; many drug interactions (less than lithium)
-lamotrigine (maintenance tx of bipolar - not effective in acute mania; CANNOT be given w/ valproic acid - toxicity; STOP med if rash, fever, lymphadenopathy, oral mucosa ulcerations)
what can valproic acid be used to treat?
mania, panic disorder, migraine HA
Insomnia
-def
-assess for:
-psych disorders related to persistent insomnia
-tx
-difficulty initiating or staying asleep w/ intermittent wakefulness during night; early morning awakening, or any combo of these
-excessive alc use; heavy smokers; withdrawal from sedatives; use of stimulants; other causes - stress, physical discomfort, chronic conditions (sleep apnea, RLS), daytime napping, early bedtimes, screen use before bed
-depression; manic disorders (decreased total sleep time + decreased need for sleep are cardinal features and important early sign of impending mania)
-good sleep hygiene; meds: sedative hypnotics (benzo’s) are last resort; drug class of choice = short acting benzodiazepines (lorazepam, Ambien)
*in elderly, trazadone
types of hyperinsomnia
-obstructive sleep apnea
-Narcolepsy
-periodic limb movement
what is the most common sleep disorder?
sleep apnea
narcolepsy
-def
-when does it begin? which sex is more common?
-trigger?
-cataplexy
-tx
-abrupt transition into REM sleep
-begins in early adult life; males and females equally; severity levels off by 30’s
-strong emotional trigger will cause a cataplexy (sudden loss of muscle tone)
-stimulants (modafinil and armodafinil; destroamphetamine)
Periodic limb movement disorder (RLS)
-def
-tx
-occurs only w/ sleep with subsequent daytime sleepiness, anxiety, depression, cognitive impairment (RLS occurs while awake as well)
-requip, neuropro, mirapex
Parainsomnias
-def
-most common in what population/age group?
-abnormal behaviors in sleep (sleep terrors, nightmares, sleep walking, enuresis)
-more common in children
Common disorders with acts of aggression
depression, schizophrenia, personality disorders, mania, paranoia, temporal lobe dysfunction
Meds and illicit drugs that produce aggression
anabolic steroids, amphetamines, crack cocaine, phencyclodine
disorders of aggression
-tx
-psychological (often refused)
-pharmacological: antipsychotics (drug class of choice)
Buspirone: anxiolytic that treats sx of fear, tension, and irritability (taken daily, unlike Xanax which is PRN)
Alcoholism use disorder
-a drink
-at risk drinking
-12oz beer, 8oz malt liquor, 5oz wine, 1.3oz shot
-repetitive use of ETOH often to alleviate anxiety or solve other emotional problems (inc risk for developing ETHO disorder). >4 drinks/day, 14 drinks/wk men; >3 drinks/day, 7 drinks/wk women
Alcoholism use disorder
-acute intoxication
-intoxication
-lethal range
-legal limit for driving under the influence (legal limit for driving is 80mg/dL)
-ataxia, dysarthria, N/V, drowsiness, errors of commission, psychomotor dysfunction, disinhibition, nystagmus (>150mg/dL)
-respiratory depression, stupor, seizures, shock syndrome, coma, death. Serious overdoses d/t combo alc with other sedatives (350-900mg/dL)
Most definitive biologic marker for chronic alcoholism?
carbohydrate deficient transferrin
-GGT and MCV if elevated indicate serious alcohol problem as well.
Alcohol withdrawal
-when does it occur? sx?
-severe major withdrawal: when does it occur? sx?
-withdrawal seizures
-delirium tremons (DT)
-w/i 6hrs; tremors, anxiety, tachycardia, N/V, insomnia
-w/i 48-96hrs; disoriented, agitated, diaphoretic, whole body tremor; vomit, high BP, reports visual, tactile, or auditory hallucinations
-can occur 8hrs after last drink, but usually won’t manifest until >48hrs after alcohol has stopped
-48-72 hours after last drink; may occur 7-10 days later; most severe form of alc withdrawal
**detoxing from alc can kill patient
wernick-korsakoff syndrome
-what kind of deficiency?
-d/t what?
d/t thiamine deficiency; caused by chronic alcoholism
wernicke-encephalopathy
-causes what?
causes brain damage –> in lower parts of brain (thalamus, hypothalamus)
korsakoff psychosis
-d/t what?
-how to treat?
-results from permanent damage to areas of the brain involved with memory
-exhibit confusion, ataxia, anterograde or retrograde amnesia
-early recognition and tx w/ IV thiamine is necessary to dec damage
Alcoholism
-tx
-antabuse (disulfiram): creates toxic rxn when alc consumed, ie violent vomiting
-naltrexone: opioid antagonist; lowers relapse rates over 3-6M after cessation of drinking
-acamprosate: reduces cravings, maintains abstinence
Alcoholism
-tx of acute withdrawal sx
-in ER with IV benzo’s; outpatient with short course diazepam with taper dose
CIWA-Ar score
tool used to determine sx severity of withdrawal
-max score 67
-0-9 absent
-10-15 mild
-16-20 moderate
-21-67 severe
Other drug and substance dependencies: opioids
-sx of intoxication
-sx of overdose
-tx
-mood, feelings of euphoria; drowsiness; N; needle tracks; miosis
-resp depression, peripheral vasodilation, pinpoint pupils, pulmonary edema, coma, death
-Methadone (use when off opioids for 7-10 days already)
-Suboxone (partial agonist)
grades of withdrawal (from drug and substances)
0 craving and anxiety
1 yawning, lacrimation, rhinorrhea, perspiration
2 previous sx + mydriasis, piloerection, anorexia, tremors, hot/cold flases w/ generalized acting
3 and 4 inc intensity of previous sx w/ inc temp, BP, pulse, and resp rate and depth
Other drug and substance dependencies: Psychedelics (LSD, etc.)
-initial sx
-later sx
-tx
*bad trip
*flashback
-tension to emotional release
-hallucinations, erratic behavior
*protect pt from erratic behavior; severe cases = antipsychotic (haloperidol)
*short course of an antipsychotic drug (olanzapine, risperidone)
Other drug and substance dependencies: phencyclidine (psychedelic drug mimic)
-presents with what sx?
presents w/ disorientation and detachment from surroundings
Other drug and substance dependencies: marijuana
-causes what?
-dx with what test?
-less inhibited emotions, impaired immediate memory, conjunctival injection (redness)
-urine test
Other drug and substance dependencies: stimulants (amphetamines and cocaine)
-cocaine
*sx
-amphetamines
*when does tolerance develop?
*sensitization
-dilated pupil, euphoria; unexplained nasal bleeding
-tolerance develops quickly; sensitized to future use of stimulants (even small amounts of mild stimulants (caffeine) can cause sx of paranoia and auditory hallucinations
Other drugs and substance dependencies: caffeine (along with nicotine and alcohol)
-what does caffeine improve?
-what do chronically depressed patients use to self-medicate?
-sx of withdrawal
-performance (with 30-200mg/day)
-use caffeine drinks as self-medication; diagnostic clue may help distinguish some major affective disorders
-HA, irritability, lethargy, occasional N
Childhood psych disorders: anxiety
-different or same as adults? explain.
-can benzo’s be prescribed?
same as adults except first line tx
-CBT with exposure is first line tx; if unsuccessful, fluoxetine or prozac is prescribed as first line drug (kids 8yrs and older)
**NO BENZOS!
Childhood psych disorders: separation anxiety
-how is this diagnosed?
-tx
-4 weeks + significant distress
-CBT (if unsuccessful, SSRI)
Childhood psych disorders: selective mutism disorder
-stipulations with dx
-tx
-pt cannot have autism, cannot be d/t communication or psychotic disorder
-CBT (if unsuccessful, SSRI)
Childhood psych disorders: phobias
-same or different from adults?
-tx?
same as adults
-CBT
Childhood psych disorders: panic disorder
-same or different from adults?
-when is it likely to present?
-R/F
-Tx
-same
-after puberty; likely to have stressor preceding onset
-separation anxiety
-CBT (if unsuccessful, SSRI **NO BENZOS)
Agoraphobia
-def
fear of open spaces
-an excessive fear of being in a situation where panic-like sx might occur (avoidance of situations that can cause panic to occur)
Childhood psych disorders: generalized anxiety disorder
-same or different from adults? explain?
-what kind of complaints to these pts have?
-tx
-same
*young kids worry about competence or performance
*older kids worry about issues like family finances
-somatic complaints: GI upset, HA are common
-psychotherapy is first line (SSRI can be added if insufficient)
Childhood psych disorders: social anxiety disorder
-same or different from adults?
-tx?
-same
-CBT (SSRI is ineffective)
Childhood psych disorders: OCD
-when does onset occur (which sex has earlier onset)?
-what does sudden onset of sx warrant?
-tx
-if patient exhibits WHAT = increased risk of comorbidities?
-childhood w/ males having earlier onset (before age 10y)
-group A strep screening
-first line: psychoeducation but combo of CBT and meds is the best therapy (SSRIs –> fluvoxamine and sertraline are FDA approved specifically for OCD)
Childhood psych disorders: depression
-how to identify depression
-how often should children be screened? at what age?
-scales to assess pediatric depression?
-tx
-ask pt about sx
-annual screening for depression in 12yrs old or older
-beck depression scale or PHQ-9 Modified for Teens
-CBT + fluoxetine
what are SNRI’s contraindicated with?
HTN
do not take SSRI with what drug?
tryptophan = causes serotonin syndrome
Childhood psych disorders: disruptive mood dysregulation disorder (DMDD)
-def
-onset of illness
-which sex is more at risk
-tx
-persistent irritability and severe behavioral outbursts at least 3x weekly for 1 year or more; mood in between these sx is persistently negative, irritable, angry and sad; must occur in 2 settings
-prior to 10yrs old
-males
-therapy for kid and family
Childhood psych disorders: suicide in children and adolescents
-who is at highest risk?
-when do you routinely assess for suicide risk in pediatric population?
-what warrants immediate referral for psych crisis assessment (ER)?
-white adolescent boys
-assess suicide risk routinely in kids 12yrs and older
-suicidal ideation accompanied by any plan warrants immediate referral for psych crisis assessment in nearest ER
Disruptive, impulse-control, and conduct disorders: oppositional defiant disorder
-essentials of dx and typical features
-more common in what environment?
-at what age is the evident at?
-tx
-pattern of hostile, negativistic, defiant behavior lasting at least 6MO (does not meet criteria for conduct disorder)
-families w/ caregiver dysfunction, substance abuse, parental psychology psychosocial stress (more common among kids w/ hx of multiple changes in caregivers, inconsistent, harsh, neglectful parenting; or serious marital discord)
-evident by age 8
-recommend support for parenting skills; assess for comorbid conditions (ADHD, depression, learning disabilities)
Disruptive, impulse-control, and conduct disorders: conduct disorder
-characteristics
-tx
-family dysfunction, poverty, abuse, violence, ADHD, learning disabilities, mood disorders; persistent pattern of behavior that includes:
*defiance of authority
*violating rights of others or society’s norms
*aggressive behavior toward persons, animals, property
-stabilize environment, improve home functioning; ID learning disabilities. NO MEDS ARE EFFECTIVE
Somatic symptom and related disorders: conversion disorder
-tx
reassure child and family that sx are a rxn to stress; encourage to continue normal daily activity; use noninvasive techniques (PT); if sx don’t resolve, refer to mental health specialist
what are conversion disorders associated with?
sexual over stimulation or abuse
Microhematuria
-def
-dx
-painful hematuria in children; should be investigated for UTI; associated with back pain/fever = suggests pyelonephritis
-urine dipstick eval but verify by microscopic RBC count
Glomerulonephritis
-features
-hematuria, edema, HTN, RBC cast in urine
Acute glomerulonephritis
-S/S
-affected children require eval of WHAT?
-when is renal biopsy needed?
-hematuria, urinary RBC casts, HTN, edema (periorbital facial, extremities, ascites d/t salt and H2O retention w/ impaired glomerular fx –> manage with diuretics)
-eval of BP, renal fx, serum albumin, urine/protein excretion
-when etiology of glomerulonephritis is unclear
Acute postinfectious glomerulonephritis
-dx
-manifestations
-tx
-dx of acute poststreptococcal GN; supported by recent hx (7-14days) of group A strep infection (usually pharyngitis or less common impetigo)
-asymptomatic microhematuria to gross hematuria
-no tx required, full recovery occurs
Acute interstitial nephritis
-commonly caused by WHAT?
-sx
-dx
-tx
-drug related w/ B-lactam-containing antibiotics or NSAIDS; also infectious etiologies (ie Epstein-Barr virus)
-fever, rash, eosinophilia may occur w/ drug associated cases (urinalysis usually reveals leukocyturia and mild hematuria + proteinuria)
-renal biopsy –> demonstrates characteristic tubular and interstitial inflammation
-immediate identification and removal of causative agent whenever possible; tx with corticosteroids can be helpful in pts w/ renal insufficiency or associated nephrotic syndrome (dialysis support occasionally needed)
Idiopathic nephrotic syndrome of childhood
-classic features
-what is required for tx?
-when is onset? (age)
-proteinuria, hypoalbuminemia, edema, hyperlipidemia, clinical findings
-require corticosteroid tx
-<6yo at onset
UTI
-at what age to girls have more UTIs than boys?
-most common organisms?
-NB sx
-preschool children sx
-school-aged children sx
-dx
-tx
-6MO
-E coli, klebsiella, proteus, gram-negative bacteria
-nonspecific: fever, hypothermia, jaundice, poor feeding, irritability, vomiting, failure to thrive, sepsis
-abd/flank pain, vomiting, fever, urinary frequency, dysuria, urgency, enuresis
-classic signs of cystitis (frequency, dysuria, urgency)
-gold standard is urine culture
-uncomplicated: tx for 7-10d, amoxicillin, bactrim, first gen cephalosporin
HA in children
-most common types in children
-migraine and tension
Migraines in children
-same or different sx than adults?
-tx
-same
-use of simple analgesics (acetaminophen, ibup) is the first line therapy; FDA approved med almotriptan (approved for ages 12-17) and vizatriptan (approved for ages 6-17)
prevention of migraines in children
-what is the centerpoint of tx?
-tx
-biobehavioral management (sleep hygiene, adequate duration of sleep, good sleep quality, improve fluid intake, eliminate caffeine, regular nutritional meals, exercise, stress management
-topiramate (ages 12-17); CBT; coenzymeQ10 and magnesium oxide
