Module 7 Flashcards by Allyssa Sy

Name the various types of headaches and their clinical features

migraine headache (with or without aura) - without aura - unilateral, throbbing, pulsating pain, photophobia, nausea, vomiting 
with aura- aura occurs before heading (can be visual, somatosensory), prodrome can occur several days before headache, unilateral, throbbing, pulsating pain

tension headache- acute, tight band around head, no nausea or vomiting

cluster headache - occurs at night, waking up with several, unilateral, retroorbital pain, may have partial horner sign (constricted pupil, drooping, sinking of eye)

medication overuse headache - overuse of OTC meds (>10 days of the month), rebound pain, dull headaches worse in the day

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Headache red flags

systemic symptoms
neurological signs (changes in mental status)
onset sudden - thunderclap/worst headache ever
older age >50 years
papilloedema, positional changes makes it worse

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What would you ask in the history of a patient presenting with headache

characterization of headache, duration, quality, location of pain, triggers, age of onset, associated symptoms (nausea, vomiting, photophobia)
what meds tried, family hx

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what is included in a physical exam of a patient presenting with headache?

fundoscopic/pupillary assessment
carotid/veterbral arteries 
mental status
neck stiffness, weakness
gait changes

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Discuss some management techniques in a patient with headache

dependent on type of headache

non pharm: behavioural management (relaxation techniques, biofeedback, acupressure, activity, sleep, meals, headache diary)

pharm: preventative therapy (anticonvulsants, beta blockers, TCAs, CCB)
abortive therapy - meds used to decrease symptoms associated with headache (analgesics, NSAIDS, corticosteroids, triptans)

cluster headaches require rapid therapy given acute onset (verapamil, lithium, triptans)

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Identify conditions that cause facial pain

sinusitis
trigeminal neuralgia
menignitis
post herpetic neuralgia

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Define epilepsy vs seizure. Who is at risk?

epilepsy-recurrent, unprovoked, and habitual seizure activity caused by excessive electrical impulses in the brain
seizure- isolated event caused by excessive electrical impulses

at risk: usually peaks in neonates or pediatrics, then again later in life
head trauma, vascular disorders, brain tumours, genetic disposition (strongest predictor) can cause seizures

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what are the classifications of seizures?

partial seizures and generalized seizures

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what is the difference between a focal/partial seizure vs a generalized seizure?

partial- limited to one cerebral hemisphere, may progress to a generalized seizure
generalized - begins in both cerebral hemispheres

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List seizures classified under partial seizures and their clinical presentations

simple partial seizures - aura of a complex seizure. no loss of consciousness. may be purely subjective. motor (tonic/clonic activity of one limb), sensory (auditory, olfactory, hallucination), psychic (deja vu, fear)

complex partial seizure - seizure activity has spread to brain stem or both hemispheres. altered consciousness. repetitive movements.

partial to generalized - seizure has spread bilaterally and involves the motor cortex. tonic clonic seizure occurs

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List seizures classified under generalized seizures and their clinical presentations.

generalized seizures differ from partial seizures because both cerebral hemispheres are affected. consciousness is almost always altered.

non convulsive - absence/petit mal (daydreamer, looking off)

convulsive - tonic clonic, grand mal, abrupt jerking, increased rigidity and laxity (similar to partial to generalized seizures- need to know the difference in order to prescribe appropriately

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A patient with complex partial seizures presents with an aura of feelings of deja vu, epigastric discomfort, and unilateral, repetitive arm movements. What cerebral lobe is most likely involved?

temporal lobe (motor, emotion, language)
most common 75-85%

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What are some common causes of epilepsy?

pediatrics, genetic disposition
trauma
stroke, vascular disorders
degenerative disorders (dementia, alzheimers)
metabolic changes (electrolyte disorders)
infections (AIDS, toxoplasmosis)
autoimmune diseases (lupus)
unknown causes/idiopathic

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What are some common pharmaceutical choices in treatment of epilepsy?

depends on the type of seizure
levetiracetam (Keppra) s/e: anxiety, agitation, depression
first line in both types of seizures, no sedation, no need to monitor drug levels

lamotrigine - used in both types of seizures, safe in pregnant women, less side effects, major side effect is SJS

valproic acid (generalized seizures only) no pregnant women, monitor bloodwork between 50-100 VA level

dilantin/phenytoin ( usually reserved in status epilepticus) stays in blood for 7 days post consumption, monitor b/w

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Describe the difference between delirum and dementia

delirium- significant health concern in older adults, often first and only indicator of underlying physical illness
often misdiagnosed as dementia
disturbance of cognition, attention, and consciousness, inability to focus or sustain attention
short term memory loss
disorientation
develops over a short amount of time
usually due to underlying cause such as meds, illness, intoxication, withdrawal

dementia - ongoing cognitive impairment, increases in >65 years and progresses at >85 years
several symptoms but progressive memory loss and behavioural changes
alzheimer’s is the most common type of dementia

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Describe the pathophysiology behind alzheimer’s disease

amyloid plaques and neurofibrillary tangles causing atrophy in several lobes of the brain
uncertain causes

Describe the clinical manifestations of alzheimers in stages

stage 1: memory loss, personality changes, word finding, depression/anxiety, progresses slowly and worsens with time

stage 2: worsening memory, loss of language, disorientation, paranoia, hallucinations, delusions, urinary incontinence

stage 3: incontinence, motor rigidity, agnosia (loss of senses), aphraxia (delay in motor neuron to complete task, pt understands the task but can’t physical complete it)

what are some common differential diagnoses of alzheimers?

alcohol/drug induced dementia
parkinson's
depression
infection
vitamin deficiency ie) vitamin b12

Discuss some evaluation techniques in a patient suspected of alzheimer’s

family history, detailed report given ongoing progression of alzheimers
physical and neuro exam
substances review
congnition, moood, behaviour
MMSE
MOCA - used to determine cognitive status
referral to neuro as necessary

How do you manage a patient with alzheimer’s

non pharm:
improve quality of life as much as possible
social engagement, activity of daily living
safety (driving, cooking)

pharm: cholinesterase inhibitors (prevents breakdown of acetylcholine, maintains as much motor activity as possible)
SSRIs for mood

What is Bell Palsy and who is at risk?

acute, idiopathic unilateral weakness/paralysis of the facial nerve
<72 hour onset with no identifiable cause
usually self limiting, but small risk of ongoing paralysis and increased risk of eye injury
affects younger men and women, women in pregnancy
co morbidities such as DM, hypothyroidism, upper resp infection, obesity, HTN

Describe the pathophysiology behind Bell Palsy

affects cranial nerve 7 -facial nerve
usually SPARES the forehead
triggering event causes inflammation and edema of the facial nerve, can cause ischemia if underlying condition is not treated leading to permanent paralysis
URTI, HSV, VZV, lyme disease, autoimmune diseases cana all cause edema of the facial nerve

What is the clinical presentation of Bell Palsy?

acute and then progressive symptoms, max paralysis within 72 hours of onset
pain to ear 1-2 days prior to onset
facial stiffness, pulled to one side
restriction of eye closure, difficulty eating and facial movements
taste disturbances and increased sensitivity to sound
tearing, drooling, mild healing deficit
HSV/VZV related Bell palsy may have vesicles to the TM

What are the diagnostics/evaluation tools used in someone suspected of Bell Palsy?

usually history and physical exam is sufficient to diagnose

may consider serology for lyme disease if required

Discuss the management of someone with Bell Palsy

goal is to reduce swelling and inflammation to the cranial nerve to prevent ischemia and protect the ey initiate steroids (prednisone) start antivirals if indicated (valtrex, acyclovir) protection of the eye: lubricants, eyeglasses/protective covers, tape down eyelids at night refer if no improvement

Describe the difference between vertigo, presyncope, and dysequilibrium

all forms of dizziness vertigo- oneself or environment is spinning, tilting, moving back and forth; can be further classified into peripheral (BPPV, menieres) or central (tumour, MS, brainstem ischemia) presyncope - lightheadedness, wooziness, impending faint, fainting doesn't actually occur. may be underlying cardiac issue (arrythmia, mitral valve stenosis, aortic regurgitation) dysequilibrium - sense of insecurity or imbalance, unsteadiness while walking. can be caused by parkinsons, peripheral neuropathy, MSK, cardiovascular disorders

Describe the evaluation of a patient presenting with dizziness.

review meds, substances, hx neuro exam (CN, romberg with pronator drift, gait, DTR, sensory exam, motor strength) CT/MRI if lesion is suspected cardiac testing ie) ECG if cardiovascular changes are suspected blood work including vitamin b12 to rule out deficiency

]Differentiate between hemorrhagic and ischemic stroke in regard to clinical features

hemorraghic (more deadly) risk factors: smoking, HTN, connective tissue disorders, family hx, drug use abrupt onset of headache, nausea and vomiting, neurological dysfunction, dizziness ``` ischemic stroke (most common) risk factors: HTN, increased age, smoking, cardiovascular comorbidities, hyperlipidemia no headache, stuttering neurological deficits over several hours ```

Differentiate between hemorrhagic and ischemic stroke in regard to evaluation

both require CT scan to differeniate type of stroke and what area is affected hemorragic stroke will have an abnormal CT scan at presentation ischemic stroke- CT scan will start normally and then progress at approx 12 hours

Differentiate between hemorrhagic and ischemic stroke in regard to treatment

stroke related symptoms should be evaluated immediately clot reducing medications stroke related to elevated BP should be lowered but not immediately for risk of hypoperfusion anti thrombolytics within 3 hours increases chance of survival physical rehab within 48 hours improves outcomes

Describe the clinical presentation of a patient with multiple sclerosis

presents with a clinically isolated syndrome such as eye pain, optic neuritis visual disturbances, intermittent eye pain, parasthesias, weakness, facial pain, bowel/bladder dysfunction at later onset heat around the waist (MS hug) different forms of the illness: relapsing remitting MS- most common, consisting of relapses and remissions secondary progressive - natural evolution of RRMS (in 50% of cases), steady state of deterioration , progressive with no relapses primary progressive (PPMS)- disability from initial presentation without relapses or remissions

Describe the appropriate evaluation and referrals for a patient with multiple sclerosis

refer to neurologist rule out other causes MRI is essential events must occur 30 days apart lasting 24 hours at a time and occur in two separate locations of the brain s/s must be consistent with demyelinating illness

Describe clinical manifestations of patients with intracranial tumours

rare type of cancer with unknown cause primary (from nervous system) or metastatic occurs mostly in those who are immunocompromised breast cancer = higher rates of brain tumours expansion and displacement of healthy brain tissue can cause cascade of effects edema- increased permeability of the vessels ischemia- occlusion because of tumour ``` seizures non focal symptoms (headache, confusion, papilloedema, vomiting, dementia. anger, personality changes, gait disorders focal symptoms (motor, sensory, language, vision changes) ```

Describe evaluation of patients with intracranial and spinal tumours

physical and hx exam MRI preferred- more sensitive to lesion CT scans on other systems in case of metasteses

Describe clinical manifestations of patients with spinal tumours

insidious onset pain with coughing or straining, pain to back, radicular pain, motor deficits, parasthesias bowel/bladder dysfunction localized spinal tenderness