Module 7 Flashcards
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
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
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
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
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)
Identify conditions that cause facial pain
sinusitis
trigeminal neuralgia
menignitis
post herpetic neuralgia
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
what are the classifications of seizures?
partial seizures and generalized seizures
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
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
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
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%
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
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
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
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
