Module 8 Flashcards
1
Q
Trigeminal Neuralgia
A
- Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. If you have trigeminal neuralgia, even mild stimulation of your face — such as from brushing your teeth or putting on makeup — may trigger a jolt of excruciating pain.
- “Tic douloureux”
- V2, V3
- S/S:
- Hemifacial spasm
- Extreme burning or shock-like face pain
- One sided
- Episodic (days, weeks, or months)
- Causes:
- Not definite
- Once believed that the nerve was compressed in the opening from the inside to the outside of the skull
- More likely enlarged or lengthened blood vessel – most commonly the superior cerebellar artery – compressing or throbbing against the microvasculature of the trigeminal nerve near its connection with the pons
- Compression can injure the nerve’s protective myelin sheath and cause erratic and hyperactive functioning of the nerve
- Tx:
- Drugs (not opioids, crabemazapine)
- Surgery
2
Q
Headaches:
Sinus, cluster, tension, migraine
A
Sinus: Pain is usually behind the forehead and/or cheekbones
Cluster: Pain is in and around one eye
Tension: Pain is like a band squeezing the head
Migraine: Pain, nausea, and visual changes are typical of classic form
3
Q
Headaches and Migraines
A
- Causes - DDx
- Underlying pathology: meningitis, tumor, trauma, TIA, temporal arteritis, HTN, dehydration, referred pain
- Testing
- Clinical
- Laboratory tests/hormones
- CT
4
Q
Cluster headaches
A
- Cluster HA : Severe pain around or behind the eye
- Unilateral
- More common in men
- Cluster headaches occur in cyclical patterns or clusters — which gives the condition its name. Cluster headache is one of the most painful types of headache. Cluster headache is sometimes called the “alarm clock headache” because it commonly awakens you in the middle of the night with intense pain in or around the eye on one side of your head.
5
Q
Cluster Headaches
A
Bouts of frequent attacks — known as cluster periods — may last from weeks to months, usually followed by remission periods when the headache attacks stop completely. During remission, no headaches occur for months and sometimes even years.
6
Q
Tension Headaches
A
- Bilateral
- Usually can trace headache to back of skull & top of neck
NSAIDS can help
Can last a couple of hours – couple of days
Some people can suffer from tension headaches daily.
Cause: search for timing to find the cause
7
Q
Tension HA - Precipitating Factors
A
- Emotional - anxiety, depression, anger
- Poor posture, close work under poor lighting conditions, or muscle cramps
- Arthritis, particularly cervical arthritis
- Abnormalities in neck muscles, bones or discs
- Eye strain caused when one eye is compensating for another eye’s weakness
- Misalignment of teeth or jaws
- Noise or lighting
8
Q
Migraine Headaches
A
- Migraine HA : Vasodilation/vasospasm and stretch of nerves: inflammation
- Unilateral (70%), women
- N/V, photophobia, pain, visual changes (aura), hours to months
- Scintillations
- Can be more cyclic – could get 2 or 3 migraines in a week, then nothing for several weeks
- Most migraine medicine includes caffeine – why?
9
Q
Caffeine
A
- Vasoconstrictor
- According to the National Institutes of Health, caffeine is considered a vasoconstrictor. Caffeine constricts blood vessels, which may help migraine sufferers. Blood vessels increase in size during a migraine. Caffeine may help blood vessels return to a normal size, improving the headache. Caffeine is often a vital ingredient in headache medication.
10
Q
Migraine Triggers
A
- Lack of or too much sleep
- Skipped meals
- Bright lights, loud noises, or strong odors
- Hormone changes during the menstrual cycle (estrogen-withdrawal HA)
- Stress and anxiety, or relaxation after stress
- Weather changes
- Alcohol (often red wine)
- Caffeine (too much or withdrawal) – study: constricts blood flow
- Foods that contain nitrates (processed meats)
- Foods that contain MSG
- Foods that contain tyramine, such as aged cheeses, soy products, fava beans, hard sausages, smoked fish, and chianti wine
- Aspartame (nutrasweet and equal)
11
Q
Sinusitis
A
- S/S:
- Nasal congestion and discharge
- Loss of smell
- Fever
- Headache – pressure
- Sore throat and postnasal drip
- Pain over sinuses
- Causes:
- Common cold
- Allergies
- Deviated septum blocking the sinus opening
- Tx:
- Apply warm moist washcloth over face
- Drink plenty of fluids to thin the mucus
- Nasal spray
- Surgery for septum
- Antibiotics
12
Q
Meningitis
A
- Meningitis: most cases: bacterial or viral
- Risk factors: crowded living quarters (dorms, barracks), basilar skull fractures, otitis media, sinusitis or mastoiditis and systemic sepsis
- S/S: fever, HA, photophobia, irritability, clouding of consciousness, and neck stiffness (nuchal rigidity).
- Milder S/S in viral, usually self-limiting
- Meningococcal meningitis (caused by Neisseria meningitidis) usually causes a petechial rash
- Other bacteria - Streptococcus pneumoniae, and Listeria monocytogenes – usually no rash
- Testing:
- Culture of CSF
- CSF:
Bacterial>cloudy, ↑neutrophil and protein levels, ↓ glucose levels
Viral> ↑ Lymphocyte count, mild to mod. protein elevation, normal glucose levels
13
Q
Kernig’s Sign & Petechial Rash
A
Positive: Pt cannot extend leg due to pain
Irritates inflammation
Meningococcal meningitis: Petechial rash
14
Q
Encephalitis
A
- Encephalitis: acute inflammation of the brain, most commonly viral
- S/S: mild to severe, fever, HA, increased ICP, stiff neck, photophobia, progress to seizure
- EBV
Rabies
Herpesviridae (2 is genital sores, 1 is genital sores), VZV is varicella zoster causes shingles in older adults and chicken pox in kids
WNV West Nile Virus from misicotes
15
Q
Temporal Arteritis (AKA Giant Cell Arteritis)
A
- Inflammation of temporal arteries
- Causes
- Mostly unknown > immune response effecting arteries
- Signs and Symptoms
- > 50 y/o
- Throbbing pain, visual changes, weakness, loss of appetite, jaw pain/fatigue while chewing
- Often mistaken for tension HA
- Can lead to irreversible vision loss
- Testing
- Inflammation >
- ↑ CRP
- Biopsy for definitive Dx video
- Inflammation >
- Tx:
- Corticosteroids (1-2 years)
*Inflammation of temporal arteries NOT vein
Usually guys
Tough diagnosis to make
Look for CRP it is a non specific chronic marker
Longer term corticosteroids suppresses the immune system and they might look like poufy and get cushin’s syndrome, their skin will be thin, GI bleeding from thinning of GI tract, do blood work it will show microcytic hypochromic RBCs, at risk for osteoporosis (bone thinning/reapsorption)
16
Q
Intracranial Hematomas
A
- Epidural/Extradural- bleeding in epidural space fast
- Subdural- bleeding in subdural space fast/slow
- Causes
- Head trauma
- Anticoagulants /anti-platelet - increased risk
- Age – increased risk
- Congenital malformations – increased risk
- Skull fracture
- Aneurysm
- Head trauma
- Signs and Symptoms
- HA, N/V, visual changes, seizures, ALOC, hemiparesis, speech disorders
- Testing
- CT/MRI
*Classified where the bleeding is taking place in the place
Epi means on top
With an epidural hematoma the blood is sitting on top
Sub is beneath the blood is pooling below the duramoder and collecting on the brain
Anticoagulants like heparin, warfarin, plauix
Congenital malformation is?
Ruptured aneurysm can be a cause
N/V because pons medulla region could be compressed
Visual changes because the optic 2 could be compressed
Go over cranial nerves
Hemiparesis is?
17
Q
Epidural Hematoma
A
- Accumulation of blood between dura and skull
- Almost always results from skull fracture (temporal bone) & middle meningeal artery laceration & bleeding
- Underlying brain usually minimally damaged; neurological deficits & HA begin within hours
- Usually bleed fast
Almost always from a skull fracture
s/s will come on fast within hours
18
Q
Middle meningeal artery
A
Epidural Hematoma
19
Q
Subdural Hematoma
A
- Accumulation of blood beneath dura, covering surface of brain
- Usually due to laceration of veins that penetrate dura
3 types: Acute, sub-acute, chronic - Causes inc ICP, herniation may result Look in the eyes, what might you see?
- Effects begin 48 hrs post trauma: HA, confusion
- Blood that is pooling beneath the dura
The brain gets smushed
Caused include increased ICP
If it smushed the optic nerve you will see visual changes and if motor nerve you will see motor changes
20
Q
Epidural Hematoma
A
- Also called an extradural hematoma, this type occurs when a blood vessel — usually an artery — ruptures between the outer surface of the dura mater and the skull. Blood then leaks between the dura mater and the skull to form a mass that compresses the brain tissue.
- Some people with this type of injury may remain conscious, but most become drowsy or comatose from the moment of trauma. The risk of dying of an epidural hematoma that affects an artery in your brain is substantial unless you get prompt treatment.
21
Q
Subdural Hematoma:
A
- Acute. This type is the most serious and potentially life-threatening. It’s generally caused by a severe head injury, and signs and symptoms usually appear immediately. Rapidly changing velocities (acceleration/deceleration injuries, i.e. Shaken Baby Syndrome) within the skull may stretch and tear small bridging veins.
- Subacute. In subacute subdural hematoma, signs and symptoms take longer to appear, sometimes days or weeks after your injury.
- Chronic. Less severe head injuries may cause a chronic subdural hematoma. Bleeding from chronic subdural hematoma may be much slower, and symptoms can potentially take weeks to appear. You may not even recall injuring your head.
- All three types require medical attention as soon as signs and symptoms are apparent, or permanent brain damage may result.
- The risk of subdural hematoma is greater for people who use aspirin or anticoagulants daily, who abuse alcohol, or who are very old.
- subacute is longer, it could be days to weeks
- for 3 to 4 weeks a person has symptoms it could be chronic
22
Q
Hematoma Treatment
A
- Medication
- Need to decrease the ICP
- Mannitol
- High dose Corticosteroids to decrease cerebral edema
- Barbiturates to induce coma
- Surgery to preserve the integrity of cerebral tissue
23
Q
Papilledema
A
- Swelling of the optic disc
- S/S:
- Headache
- Nausea
- Vomiting
- Might have vision problems i.e. double vision
- Causes:
- Increased intracranial pressure
- Brain tumor, cerebral trauma, meningitis, encephalitis
- Tx:
- Depends on the cause
- The optic disc normally
Severely blurred optic disc
- The optic disc normally
24
Q
Aneurysm
A
- Categorized by shape/form:
1) Saccular/Berry aneurysm - congenital abnormality- Ruptured berry aneurysm is most common cause of acute subarachnoid hemorrhage
2) Fusiform aneurysm - arteriosclerotic changes
3) Dissecting aneurysm
- Ruptured berry aneurysm is most common cause of acute subarachnoid hemorrhage
- Aneurysms often asymptomatic until rupture resulting in acute subarachnoid and/or intracerebral hemorrhage
- If aneurysm puts pressure on brain can cause S/S depending on location changes in vision, HA, eye pain
- Rupture: “Worst HA of my life” with or without LOC, neurological S/S
25
Q
Pituitary Adenoma
A
- Mostly benign tumors
- 1 in 1000 adults
- Causes
- DNA mutation
- Signs and Symptoms
- Function of the pituitary?
- N/V, HA, visual changes
- Testing
- Hormone levels
- MRI
- Biopsy
- Tx
- Surgery to remove pituitary gland (hypophysectomy)
- Hormone replacements
- Radiation therapy
- Hormone replacements
- Drug therapy
- Adenoma is benign
- Adeno means a gland
- Carcinoma means cancer
- Reason for the visual changes is the optic nerve sits on top of the pituitary gland so that is the reason for visual changes
26
Q
Pituitary Adenoma most common hormones involved
A
1) Prolactin
- What does it do?
- (Galactorrhea)
- 30% of all P.A.
2) ACTH
- What does it do?
- (Cushing’s syndrome)
3) GH
- What does it do?
- (Acromegaly)
- Galactorrhea is flow of breast milk
- target of ACTH is?
- GH is growth hormone it “grows you”
- If the pituitary adenoma is making high ACTH is still cushing’s but its still cushing’s disease not syndrome
- If someone is taking cortisol in hospital for weeks it would be syndrome?
27
Q
Cushing’s Syndrome
A
- Too much cortisol can produce some of the hallmark signs of Cushing’s syndrome — a fatty hump between your shoulders, a rounded face, and pink or purple stretch marks on your skin. Cushing’s syndrome can also result in high blood pressure, bone loss and, on occasion, diabetes.
- Treatments for Cushing’s syndrome can return your body’s cortisol production to normal and noticeably improve your symptoms. The earlier treatment begins, the better your chances for recovery
*Any cause of too much cortisol often times iatrogenic which is an illness caused?
28
Q
Cushing’s Syndrome common s/s
A
- Common signs and symptoms involve progressive obesity and skin changes, such as:
- Weight gain and fatty tissue deposits, particularly around the midsection and upper back, in the face (moon face) and between the shoulders (buffalo hump)
- Pink or purple stretch marks (striae) on the skin of the abdomen, thighs, breasts and arms
- Thinning, fragile skin that bruises easily
- Slow healing of cuts, insect bites and infections
- Acne
- A moon face (systemic edemic)
- Osteoporosis causes bone thinning
- Increased facial hair especially in females
29
Q
Cushing’s Syndrome for women and other s/s
A
- Women with Cushing’s syndrome may experience:
Thicker or more visible body and facial hair (hirsutism)
Irregular or absent menstrual periods - Other signs and symptoms include:
- Fatigue
- Muscle weakness
- Depression, anxiety and irritability
- Loss of emotional control
- Cognitive difficulties
- New or worsened high blood pressure
- Glucose intolerance that may lead to diabetes
- Headache
- Bone loss, leading to fractures over time
- Glucose intolerance
- Patients on long term steroid treatment (from rheumatoid arthritis, Chron’s disease) watch out for cushing’s syndrome
Easiest thing to keep an eye on from labs is to watch their blood sugar
30
Q
Acromegaly
A
- Acromegaly (ak-roh-MEG-uh-lee) is a rare hormonal disorder that develops when your pituitary gland produces too much growth hormone, nearly always as a result of a noncancerous (benign) tumor. The excess hormone causes swelling, skin thickening, tissue growth and bone enlargement, especially in your face, hands and feet.
- Because acromegaly is uncommon and physical changes occur gradually, it often isn’t recognized right away. Although untreated acromegaly can lead to serious illness and premature death, available treatments can reduce your risk of complications and significantly improve your symptoms.
- Big head and bid hands or feet due to thickening of the skull
31
Q
Acromegaly
A
- Growth Hormone oversecretion continues after epiphyseal plates have closed
- Occurs in adults
- Bones of hands face and feet are enlarged
- Due to the release of growth hormone
32
Q
Hypertension
A
- BP > 140/90
- Pre-hypertension = 120-139/80-89
- Causes
- Atherosclerosis
- Explain this process
- Anxiety/Stress
- Increased Na > ?
- Kidney disorders >
- Aldosterone, Renin
- Atherosclerosis
- Signs and Symptoms
- Asymptomatic
- HA, blurred vision, arrhythmias/chest pain, nose bleed
- Risks for> atherosclerosis, aneurysm, heart failure, stroke, vision loss (hypertensive retinopathy), metabolic syndrome (next slide), cognitive function
- Testing
- Clinical
- R/O above disorders
- Silent killer
- Understand NO antihypertensive drug indicated on the chart under initial drug therapy
Thiazide-type diuretics works on the loop of Henle - ACEI works on angiotensin converting enzymes
- ARB is angiotensin II receptor blocker
- BB is a beta block, the beta 1 receptor on the heart
- CCB is calcium channel blocker
- Review ace inhibitors, beta inhibitors, CCB,
33
Q
Essential And Secondary HTN
A
1) Essential
- Abnormally elevated BP in which the exact cause cannot be defined
- At-risk population: + FHX, Age, Obesity, Sedentary lifestyle
2) Secondary
- The result of an identifiable abnormality
- Essential means it just happens and you don’t know why
Secondary means you can say this is causing your blood pressure
34
Q
Secondary HTN Causes
A
1) Increase Cardiac output
- Hypervolemia
* renal artery stenosis
* renal disease
* hyperaldosteronism
* hypersecretion of ADH
* aortic coarctation
* pregnancy (preeclampsia)
- Stress
* sympathetic activation
- Pheochromocytoma
* increased catecholamines
2) Increased systemic vascular resistance
- Stress
* sympathetic activation
* athrerosclerosis
* renal artery disease- increased angiotensin II
* Pheochromocytoma- increased catecholamines
* Throid dysfunction
* diabetes
* cerebral ischemia
- Some of the causes
- There are two different main reasons
- Stress, heart rate increases & contractility so that eventually lead to an increase in cardiac output
- Stenosis is narrowing
- Low blood flow to the kidney which releases renin,
- Know how each of these lead to hypertension
- If you fix the problem you fix the high blood pressure
35
Q
Metabolic Syndrome (Syndrome X)
A
- An association between certain factors and cardiovascular disease.
- Insulin resistance
- Hypertension
- Cholesterol abnormalities
- Increased risk for clotting
- Abdominal obesity
- Approximately 20%-30% of the population in industrialized countries have metabolic syndrome.
- Syndrome is a constilation of s/s
36
Q
Metabolic Syndrome (Syndrome X)
A
- central obesity
- high blood pressure
- high triglycerides
- low HDL-cholesterol
- insulin resistance
37
Q
Dizzy vs. Vertigo
A
- Dizzy = disorientation in space, unsteady, lightheadedness, confused (weakness with “about to faint” feeling)
- Dizzy S/S: vertigo, lightheaded, disequilibrium
- Vertigo (subtype of dizziness) = illusion of movement (either patient or environment)
- Sensation that YOU ARE spinning = subjective vertigo
- Sensation that the room is spinning = objective vertigo
- Dizzy is any type of unstable, broad classification
- Vertigo is the spinning type of sensadtion
- Vertigo is a subtype of dizziness
38
Q
Vertigo
A
- Illusion of movement (you or surroundings)
- Causes:
- Main Cause: Benign Paroxysmal Positional Vertigo
BPPV Video Clip - Dehydration, hypotension
- Motion sickness
- Ear infection/labrynthitis
- MS
- Head trauma
- Migraine
- Main Cause: Benign Paroxysmal Positional Vertigo
- Signs and Symptoms
- Dizzy, unbalanced, lightheaded, “spinning”, N/V
- Testing
- CT, EKG, glucose, particle repositioning
- Main cuase is benighn paroxysmal positional vertigo
- Easily correctable
- Area of inner ear that deals with balance vestibule
- How to hair cells lead to vertigo? Know how
- EKG because of arrthmias that could lead to dizziness because not enough blood flow to brain
- Glucose because if you forget to eat you can get hyperglycemic and get dizzy
39
Q
Meniere’s Disease
A
- Inner ear disorder that causes vertigo and hearing changes
- Triad > Vertigo, Tinnitus, Hearing loss
- 90% of cases – only one ear is affected
- Hearing loss tends to recover between attacks
- Causes
- Fluid changes/imbalance in inner ear
- Some relation to trauma, infection, allergies, anxiety/stress
- Signs and Symptoms
- Sudden onset, severe N/V
- Testing
- Clinical, Balance, CT/MRI
- Tx
- Low-salt diet, medication, diuretics?, surgery? (remove vestibular n. 95% success in removing vertigo and retaining hearing)
- Dizzy all the time, couldn’t eat or sleep, nausious all the time
- Vestibulocochlear nerve what is this role?
- Vestibul is for balance cochlear is for hearing
40
Q
Arrhythmias
A
- Irregular cardiac rhythm
- Causes
- Electrolyte or hormonal imbalances
- Na and K, Thyroid hormone
- Stress Heart > Heart disease, HTN
- Caffeine, Drugs
- Postural Orthostatic Tachycardia Arrhythmia
- Lack of blood entering heart when you stand up
- Signs and Symptoms
- “skipped” beat, “fluttering” sensation, chest pain, dizziness, syncope, asymptomatic
- Testing
- EKG
- 24 hour Holter monitor
- Chemistry panel
- Hormones
- Palpitation can feel like your heart is skipping a beat
- Know cardiac conduction system (how a action potential spreads to the heart)
- Where should your heart beat originate? SA nodes
- Many diff. types of arrhythmias
- SA node regulates heart beat
- Sometimes you can have a piece of ectopic tissue anywhere in the heart
- Sometimes the AV node can take over which is not good, their heart beat will drop. Know why
- Electrolyte imbalance is pretty common
- Everyone has a skipped beat once in a while
- Drugs that activate sympathetic nervous system
- EKG is least invasive test
- EKG
- AV node slows down, delays repolarization
- Know what each component of ekg
- St segment is normal so no stemi
- What is faster? Depolarization from SA node to AV node and so on is faster
- If ventricles depolarize
- What is the slurring from for a delta wave? Its depolarizing spreading through the cardiac muscle itself
- Great vessels coming out of your heart is aorta and pulmonary trunk
- With WPW conduction still goes down normal pathway
- AV node is gatekeeper. Someone with WPW the problem is a accessory pathway that doesn’t go through AV node
- AV node normally slows down conduction but with the accessory pathway it allows action potential to get to ventricles early called pre-exciation
- Pre excited ventricles you get delta wave
- Supraventricle means above
41
Q
Pheochromocytoma
A
- Tumor of the adrenal medulla with excess secretion of catecholamines (epi and norepi)
- Signs and Symptoms
- HTN (paroxysmal) – episodic HTN
- Classic triad: diaphoresis, episodic HA, tachycardia
- Other s/s: anxiety, chest/abdominal pain, pallor, orthostatic hypotension, hyperglycemia, wt loss
- Testing
- CT
- Urine Analysis
- Tx
- Surgery
- Why the hyperglycemia?
- CT you can see it
- Can look for breakdown products in UA
- Know what norepinephrine and epinephrine do
42
Q
Epinephrine & Norepinephrine function
A
Epinephrine and norepinephrine are released during the flight/fight response, causing vasoconstriction of blood vessels in the kidney.
- Epinephrine, produced by the adrenal medulla, causes either smooth muscle relaxation in the airways or contraction of the smooth muscle in arterioles, which results in blood vessel constriction in the kidneys, decreasing or inhibiting blood flow to the nephrons.
- Norepinephrine, produced by the adrenal medulla, is a stress hormone that increases blood pressure, heart rate, and glucose from energy stores; in the kidneys, it will cause constriction of the smooth muscles, resulting in decreased or inhibited flow to the nephrons.
- Together, epinephrine and norepinephrine cause constriction of the blood vessels associated with the kidneys to inhibit flow to the nephrons
43
Q
Anxiety
A
- “A state of being uneasy, apprehensive, or worried about what may happen.”
- Anxiety is a normal emotion
- Anxiety will set off an alarm reaction in our body
- “Fight or flight”
- Adrenalin released
- Typically symptom subsides
- When anxiety persists to interfere with day-to-day activities and relationships then it may be classified as a disorder
44
Q
Statistics and Facts About Anxiety Disorders
A
- Anxiety disorders are the most common mental illness in the U.S.
- affecting 40 million adults in the United States age 18 and older (18.1% of U.S. population)
- cost the U.S. more than $42 billion a year, almost one-third of the country’s $148 billion total mental health bill, according to “The Economic Burden of Anxiety Disorders,” a study commissioned by ADAA and published in The Journal of Clinical Psychiatry, Vol. 60, No. 7, July 1999.
45
Q
Generalized Anxiety Disorder (GAD)
A
- 6.8 million, 3.1%
- Women are twice as likely to be affected than men.
46
Q
Obsessive-Compulsive Disorder (OCD)
A
- 2.2 million, 1.0%
- Equally common among men and women.
- One-third of affected adults first experienced symptoms in childhood.
47
Q
Panic Disorder
A
- 6 million, 2.7%
- Women are twice as likely to be affected than men.
- Very high comorbidity rate with major depression
48
Q
Posttraumatic Stress Disorder (PTSD)
A
- 7.7 million, 3.5%
- Historically women are more likely to be affected than men
- Childhood sexual abuse is a strong predictor of lifetime likelihood for developing PTSD.
49
Q
Social Anxiety Disorder (SAD)
A
- 15 million, 6.8%
- It is equally common among men and women
50
Q
Specific Phobias (i.e. scared of doctors)
A
- 19 million, 8.7%
- Women are twice as likely to be affected as men.
51
Q
Know chronic/acute subdural hematoma
A
.
52
Q
Generalized Anxiety Disorder (GAD)
A
-Chronic anxiety that tends to focus on real-life issues
* Work problems
* Finances
* Relationships
* Health
- >6 months
- Signs and Symptoms
* “Can’t stop worrying”, tension headaches, muscular tension and body aches, bruxism (teeth grinding)
* Fight or Flight S/S: ↑HR, SOB, shakiness
- Testing
* Clinical
* R/O physical causes > diseases
(Pheochromocytoma, hyperthyroidism)
