Neuro Cases 1 & 2 Flashcards
For tension-type HA, Location? Characteristics? Duration? Pt appearance? Associated sx?
Location: bilateral
Characteristics:pressure or tightness, wanes
Duration: 30 minutes-7 days
Pt appearance: pt may remain active or need rest
Associated sx: none
What specific hx should be taken for HA?
–presence of aura and prodrome –frequency, intensity and duration of attack –# of HA per month –time and mode of onset –quality, site and radiation of pain –associated sx and abnormalities –family hx of migraines –precipitating and relieving factors –age of onset –exacerbation or relief with position change –effect of activity on pain –relationship w/ for alcohol –response to previous tx –review current meds –recent vision changes –recent trauma –changes in sleep, exercise, weight or diet –state of general health –change in work or lifestyle –change in method of birth control –environmental factors –menstrual cycle
Discuss vestibular migraines
–central cause
–episodic vertigo in pt with hx of migraine
–most common cause of vertigo in kids
–3x more common in women than men
–most common in 20-50YO
–family hx
–tx: stress relief, sleep, exercise, medications
What type of dizziness if common to both peripheral and central causes?
Dizziness that increases with motion
What specific hx should be taken for dizziness?
–hx of trauma
–frequency, intensity, duration of attack
–severity (how it affects life)
–associated sx (blurry vision, syncope, N/V, hearing loss)
–personal and family hx of similar problems
–review of meds
For cluster HA, Location? Characteristics? Duration? Pt appearance? Associated sx?
Location: unilateral, around eye or temple
Characteristics: begins quickly reaching a crescendo within minutes, deep pain, continuous, excruciating and explosive
Duration: 15 minutes-3 hours
Pt appearance: pt remains active
Associated sx: ipsilateral lacrimation and redness of eye, stuff nose, rhinorrhea, pallor, sweating, Horner’s, facial neuro sx, restlessness or agitation, sensitivity to alcohol
For migraine HA, Location? Characteristics? Duration? Pt appearance? Associated sx?
Location: unilateral in most adults, bilateral in most teenagers and kids
Characteristics: gradual onset, crescendo pattern, pulsating, moderate or severe intensity, aggravated by routine PA
Duration: 4-72 hours
Pt appearance: prefers to rest in a dark, quiet room
Associated sx: nausea, vomiting, photophobia, photophobia, aura
Differentiate between Parkinson’s tremor and essential tremor: body parts
Parkinson’s: hands and legs
Essential: hands, head, voice
Discuss continuous vestibular sx and possible dx
=dizziness lasting days to weeks
–classic sx: continuos dizziness or vertigo with N/V, nystagmus, gait instability and head motion intolerance
–often related to trauma or toxin
–if not trauma or toxin exposure, consider vestibular neuritis or central etiologies
What does TiTrATE stand for?
Timing of the sx
Triggers of the sx
And a Targeted Examination
Discuss resting tremors
–occurs in body part that is relaxed and supported against gravity
–enhanced by central stress or movement of another body part
–diminished voluntary movement of that body part
Discuss essential tremors
–most common pathological tremor –kinetic is most common –common in hands and wrists but can also effect head, LE and voice –usually bilateral –can be inherited –progresses with age –can cause social embarrassment and early retirement –exacerbated by caffeine and fatigue –lessened by alcohol
What would you include in a targeted exam for CC of dizziness?
–HEENT
–CV
–Neuro including Romberg
–Dix-Hallpike maneuver to dx BPPV
What is a tremor?
=involuntary, rhythmic, oscillatory movement of a body part; most common movement disorder seen in primary care practices
Discuss vestibular neuritis,
Presentation and sx?
Tx?
–Peripheral cause
–2nd most common cause of vertigo
–May be cause by virus
–Most commonly affects 30-50YO
–Sx: rotatory vertigo with movement of objects in the visual field
–Horizontal nystagmus to non affected side
–Abnormal gait with tendency to fall to affected side
–Lasts a few days, less severe sx can linger
–Tx: anti-emetic, anti-histamine, benzos
Discuss enhance physiologic tremors
–everyone has an asymptomatic physiological tremor
–low ampliytude, high frequency at rest and during activity
–enhanced by anxiety, stress, certain medications and metabolic conditions
–if pts have tremors that come and go with anxiety, med use, caffeine intake or fatigue, they don’t need further testing
Differentiate between Parkinson’s tremor and essential tremor: distribution
Parkinson’s: asymmetrical
Essential: symmetrical
Discuss psychogenic tremors
–can be difficult to differentiate from organic tremor
–some features are consistent incl. abrupt onset, spontaneous remission, changing tremor characteristics, ↑with attention and extinction with distraction
–more frequently seen in patients in allied health progressions
What sx of a headache would require an emergency evaluation?
–thunderclap HA –acute or subacute neck pain with Horner syndrome and/or neuro deficit –suspected meningitis or encephalitis –neuro deficit or papilledema –orbital or periorbital sx –possible CO exposure
Discuss cerebellar tremors
–low frequency
–slow-intension or postural tremor
–d/t MS with cerebellar plaques, stroke or brainstem tumors
Differentiate between Parkinson’s tremor and essential tremor: course
Parkinson’s: progressive
Essential: stable or slowly progressive
Differentiate between Parkinson’s tremor and essential tremor: writing
Parkinson’s: micrographia
Essential: tremulous
Discuss resting tremors
–most common type of tremor
–occur with voluntary muscle contraction
–postural: maintaining position against gravity (i.e. arm elevation)
–isometric: muscle contraction against right stationary object (i.e. making a fist)
–kinetic: associated with voluntary movements, includes intention tremors (i.e. reaching for a pen)
What are some low risk features for HA complaint?
–≤50YO –primary HA –hx of similar hx –no abnormal neuro findings –no concerning changes –no high-risk comorbid conditions
What are the danger signs of a HA?
SNOOP
–systemic sx (i.e. fever, weight loss, cancer, pregnancy)
–neuro sx
–onset is new
–other associated conditions
–previous HA hx with progression or change
How does occipital neuralgia present? Dx? Tx?
Presentation: unilaterally, starts where neck meets skull and moves forward to involve ear and forehead; pain caused by trauma to nerves including pinching of the nerve by overly high neck muscles and compression of the nerve as it leaves the spine
Dx: via occipital nerve block
Tx: massage, NSAIDS, muscle relaxants
Differentiate between Parkinson’s tremor and essential tremor: other neuro sx
Parkinson’s: bradykinesia, rigidity, loss of postural reflexes
Essential: none
Discuss spontaneous episodic sx for dizziness and possible dx
=dizziness lasting seconds to days; no triggers
–unilateral hearing loss→Meziere dz
–sx of migration HA→vestibular migraine
–continulus, associated with psych disorder→psych dx
What is the most frequent headache? What is the most common dx for pts who present to clinicians with HA complaints?
Most frequent: tension HA
Most common dx: migraine
Differentiate between Parkinson’s tremor and essential tremor: frequency
Parkinson’s: 3-6 Hz
Essential: 5-12 Hz
Differentiate between Parkinson’s tremor and essential tremor: family hx
Parkinson’s: less common
Essential: often
What are the three clinical scenarios for dizziness?
–episodic triggered sx
–spontaneous episodic sx
–continuous vestibular sx
Differentiate between Parkinson’s tremor and essential tremor: tremor type
Parkinson’s: at rest, ↑with walking, ↓with posture holding or action
Essential: posture holding or action
Discuss BPPV,
Cause?
Presentation?
Tx?
Cause: peripheral cause; loose canaliths get stuck in semicircular canals; no obvious cause in older individuals, head trauma in younger individuals
Presentation: most commonly in individuals 50-70YO
Tx: EPley maneuvers, Brandt-Daroff exercises, no pharm tx
Discuss Parkinsonism tremors
–various meds cause Parkinsonism by blocking or depleting DA
–most common form is idiopathic PD
–classic tremor starts as a pill-rolling motion of the fingers
–bradykinesia includes difficulty rising from a seated position, ↓arm swing while walking, micrographia
–70% of PD pts have a resting tremor which can get better with action
Discuss Meneire dz
–peripheral cause
–vertigo with hearing loss
–most common from 20-60YO but can affect any age
–severe vertigo, requires bedrest
–unknown cause
–can have BPPV too so Dix-Hallpike test may be positive
What should you do during a PE for a HA CC?
–BP and P –listen for bruit at neck, eyes and head –palpate head, neck and shoulder regions –check temporal and neck arteries –examine spine and neck muscles –neuro exam (mental status, CN, funduscopy and otoscope, symmetry on motor reflex cerebellar sensory etc., gait, station)
Discuss episodic triggered sx for dizziness and possible dx
=brief episodes of intermittent dizziness lasting seconds to hours; common triggers include head motion or change in body position
Most likely BPPV
What hx should be taken for tremor CC?
–family hx of neurologic dz (genetic component especially for essential tremors)
–tremor in older pts with gradual onset is more likely PD or essential tremor
–sudden onset more likely to be psychogenic, related to medications or toxins or in rare cases, a brain tumor
