Neuro Chapter 5, Medical Diagnosis Flashcards
1
Q
One of the most common medical complaints
Effects 12-16% of the North American Population
A
Headache
2
Q
How many work days are lost each year from headaches?
A
150 Million
3
Q
Headaches are rarely caused from what kind of strain?
A
Rarely caused by refractive error (eyestrain) alone
4
Q
“Thunderclap” Headache is an Indication of what condition?
A
Subarachnoid Hemorrhage (SAH)
5
Q
What are some reasons to refer for imaging in regards to a headache?
A
Visual changes, Auras or orbital bruits (turbulence), onset of headache after age 40, history of trauma, hypertension, fever
6
Q
Absence of headaches similar to the present headache indicates:
A
CNS Infection
7
Q
Headache with a fever could be an indication of what?
A
Meningitis
8
Q
A headache with rapid onset associated with exercise could be indictative of what?
A
Intracranial Hemorrhage associated with a brain aneurysm
9
Q
A headache with nasal congestion could be associated with what?
A
Sinusitis
10
Q
A headache with Papilledema (Optic Disc Swelling)
A
Increased Intracranial Pressure
11
Q
Most prevalent headache
- “Vice-like”
- Often exacerbated by emotional stress, fatigue, noise, glare
- May be associated with hypertonicity (tightness) of neck muscles
A
Tension Headache
12
Q
What are the treatments for a tension headache?
A
Ibuprofen 400-800 mg q 4-6 hours: Max 2400 mg daily
Naproxen 250-500 mg PO q 12 hours
Acetaminophen 325-1000 mg PO 1 4-6 hrs, max 4g/24 hours
13
Q
What type of headache is associated with:
- Intense unilateral pain that starts around the temple or eye
- Duration: 15 minutes to 3 hours
- Usually occurs “seasonally”
- Usually affects middle aged men
A
Cluster Headache
14
Q
Patient presents with ipsilateral congestion, rhinorrhea, lacrimation, redness of the eye or Horner Syndrome. What are they experiencing?
A
Associated symptoms of a Cluster Headache
15
Q
What is the initial treatment of choice for a Cluster headache?
A
Inhaled 100% Oxygen for 15 minutes
16
Q
What are the recommended medications for treating a Cluster Headache?
A
Sumatriptan: 6mg Subq, repeat as need for up to an hour after the intial dose
Zolmitriptan: 2.5 mg Oral, may repeat as needed for up to 2 hours after initial dose
17
Q
What diagnosis presents with gradual build up of a throbbing headache, may be unilateral or bilateral, duration of several hours, an Aura may or may not be present, postive family history, may have associated nausea and vomiting?
A
Migraine
18
Q
What is the treatment for an acute migraine headache?
A
rest in a quiet, darkened room until symptoms subside
19
Q
What is the abortive treatment for a migraine?
A
Simple NSAIDS: Ibuprofen, Naproxen, Aspirin or Acetaminophen
Sumatriptan: Oral. 25, 50, or 100 mg taken with fluids
* 50 and 100 mg have been shown to be the most effective
Zolmitriptan: 2.5mg, may repeat as needed up to 2 hours after inital dose
20
Q
When would you prescribe someone beta blockers, Propranolol or MOA’s, antidepressants or anticonvulsants to treat a Migraine?
A
When migraines occur more than 2-3 times per month or associated significant disability
21
Q
What is the treatment for concurring symptoms associated with a migraine?
A
Promethazine: 12.5 to 25mg PO/IM/IV/Rectal every 4-6 hours as needed
22
Q
What diagnosis is associated with:
- headache within 1-2 days of an injury and subsides after 7-10 days
- Often accompanied by impaired memory, poor concentration, emotional instability and increased irritability?
A
Post-Traumatic Headache
23
Q
What is the recommended treatment for a Post-Traumatic Headache?
A
- No special treatment required
- Simple analgensics are appropriate first line therapy
24
Q
What diagnosis is associated with:
- Present in 50% of patients with chronic daily headaches
- Chronic pain
- Complaints of headache unresponsive to medication?
A
Medication Overuse Headache
25
What is the treatment for a medication overuse headache?
Withdraw medications
| - Expect improvement in months, not days
26
What percentage of the population will have at least one seizure?
5-10%
27
What age has the highest occurrence of seizures?
Early Childhood and late adulthood
28
What is an abnormal, excessive, hypersynchronous discharge from an aggregate of CNS neurons?
Seizure
29
What are the most common reasons for young adults ( 18-35) to experience a seizure?
- Trauma
- Metabolic Disorders (Alcohol withdrawal, uremia, hyper/hypoglycemia)
- CNS Infection
30
Seizures in older adults (>35) are caused from?
- Cerebrovascular Disease (Stroke)
- Brain Tumor
- Metabolic Disorders
- Degenerative Disorders (Alzheimer)
- CNS Infection
31
What type of seizure is associated with the following symptoms?
- Auras that are associated with an onset of
seizure
- Focal seizure with retained awareness
- Only one side of the brain is affected
Partial Seizure
32
What type of seizure is associated with the following symptoms?
- One part of the brain is affected
- Patient appears to be awake, but not in contact with the environment, doesn't respond normally
- Patients often have no memory of what occurred during the seizure
Focal Seizure with impaired awareness
33
What type of seizure is associated with the following symptoms?
- Involves the entire brain
- May or may not lead to alteration of consciousness
- Most common type is Tonic-Clonic seizure (grand mal)
Generalized Seizure
34
Which seizure phase is characterized by sudden muscle stiffening?
Tonic
35
Which seizure phase is characterized by rhythmic jerking?
Clonic
36
What phase of seizure is a patient most likely to bite their tongue?
Clonic
37
Which type of seizure is characterized by a sudden loss of muscle strength?
Atonic Seizure
38
What phase of seizures is characterized by somnolence, confusion or headache that may occur for several hours or "Todd Paralysis"?
Postictal Phase
39
What phase of seizures are associated with auras that are associated with an onset to seizures?
Preictal Phase
40
What is "Todd Paralysis"?
Weakness of the limbs
41
What ancillary testing is used to diagnose a seizure?
Video EEG monitoring
42
What labs should be run after a seizure has occured?
- Electrolytes
- LFT
- CBC
- Finger Stick Glucose
43
what is the treatment for an active seizure?
- Diazepam 5mg IV/IM Q 5-10 minutes (do not exceed 30mg)
| - MEDEVAC Immediately
44
What is the diagnosis for a seizure that lasts more than or equal to 5 minutes or is associated with 2 or more seizures with an incomplete recovery of consciousness?
Status Epilepticus (EMERGENCY)
45
What is the treatment for Status Epilepticus?
- Diazepam 5-10 mg IV/IM do not exceed 30 mg
- Valproic Acid 30mg/kg
- Intubation
46
What type of seizure is associated with the following symptoms?
- Not associated with abnormally excessive neuronal activity
- Eyes are closed and episodes last longer than 2 minutes
- Usually there is no postictal phase
- incontinence is less common
Psychogenic nonepileptic seizure (PNES)
47
What is the treatment for a Psychogenic nonepileptic seizure (PNES)?
Psychotherapy with cognitive behavioral therapy or interpersonal therapy
48
Which lobe is affected when a patient is having a seizure with VISUAL phenomenons (colors, flashes, scotoma)?
Occipital Lobe
49
Which lobe is affected when a patient is having a seizure with PARESTHESIA (tingling, pain, temperature)?
Parietal Lobe
50
Which lobe is affected when a patient is having a seizure with hallucinations, epigastric rising, emotions, automatisms, Deja vu?
Temporal Lobe
51
What lobe is affected when a patient is having a seizure with head and neck movements, Jacksonian march, posturing?
Frontal Lobe
52
What are the two major branches that make up the internal carotid arteries?
1. Anterior Cerebral Artery (ACA)
| 2. Middle Cerebral Artery (MCA)
53
When the two vertebral arteries fuse they become what?
The Basilar Arteries
54
What are the branches of the Basilar Artery?
Right Posterior Cerebral Artery (PCA)
| Left Posterior Cerebral Artery (PCA)
55
What artery supplies the Cerebellum and the Brainstem with blood?
Basilar Artery
56
What interconnects the internal carotid and vertebral basilar arteries?
Circle of Willis
57
What is an acute neurologic injury that occurs as the result of the interupted blood flow to the brain?
Stroke
58
What is a rupture of a blood vessel causing bleeding into the brain and lack of cerebral blood flow leading to ischemia?
Hemorrhagic Stroke
59
What is a blockage of blood vessels causing a lack of cerebral blood flow leading to ischemia?
Ischemic Stroke
60
What subtype of stroke are TIA's and CVA's?
Ischemic Stroke
61
1. What percentage of strokes are ischemic?
| 2. What percentage of strokes are hemorrhagic?
1. 80%
| 2. 20%
62
What is the 3rd leading medical cause of death and the 2nd most frequent cause of neurological morbidity
Stroke
63
What are some risk factors associated with stroke?
HTN, atherosclerosis and age
64
What is an obstruction of an artery due to a blockage that forms in the vessel?
Thrombotic
65
What is an obstruction of an artery due to a blockage from debris that has broken off from a distal area?
Embolic
66
What is a lack of brain blood flow due to decreased systemic blood flow?
Systemic Hypoperfusion
67
What is defined as a transient episode of neurologic dysfunction casused by focal brain, spinal cord, or retinal ischemia without acute infarction?
Transient Ischemic Attack (TIA)
68
What is defined as neurological dysfunction caused by focal brain, spinal cord or retinal ischemia with infarction (tissue death) of central nervous system tissue?
Cerebral Vascular Accident (CVA) or Stroke
69
What is the only way to tell the difference between a TIA vs a CVA?
MRI
70
What are the two subtypes of Hemorrhagic Strokes or Intracranial Hemorrhage (ICH)?
Intracerebral Hemorrhage
| Subarachnoid Hemorrhage
71
What is the difference between a Intracranial hemorrhage and a Subarachnoid hemorrhage?
Intracranial: Bleeds directly into the brain tissue
| Subarachnoid; Bleeds into the subarachnoid space
72
What diagnosis is a patient describing when they state the "worst headache of my life"?
Subarachnoid hemorrhage (SAH)
73
What is the initial treatment for Ischemic Stroke?
Maintain oxygenation > 94%
| Elevate head of bed to 30 degrees
74
What labs are required for Ischemic Stroke?
EKG, CBC, FBG, O2 sat
75
What imaging is utilized for diagnosing a stroke?
Non-contrast CT
| MRI
76
What should be done with a patient's blood pressure in regards to a Ischemic Stroke?
1. Do not lower it acutely
2. Unless pressure is above systolic 220 and or diastolic of 120, in this case the blood pressure should be lowered by 15%
77
What medication should be utilized to lower an ischemic stroke patient's blood pressure?
Labetalol, 10-20 mg IV, may give same or double dose every 10-20 mins to max of 150mg
78
What is the treatment for a patient with an ischemic stroke?
```
Aspirin 325mg (Consult Medical Officer First)
MEDEVAC
```
79
What resource would you look at when determining a patient's overall disposition in regards to a TIA or Cerebrovascular disease?
MANMED 15-106
80
What diagnosis is associated with an uncomfortable "creeping", "crawling" sensation or "pins and needles feeling" in the limbs, especially in the legs?
Restless Leg Syndrome
81
During deep sleep a patient may or may not experience what symptom?
Periodic Limb Movements of sleep (PLMS)
82
What are considered some causes of Restless Leg Syndrome?
- CNS and PNS abnormalities
- Reduced iron stores in the CNS
- Alterations in dopaminergic systems
- Circadian Physiology
- NT imbalances of glutamate and GABA
83
What is a PNS abnormality associated with RLS?
Patients with RLS have been found to have static hyperalgesia (Increased sensitivity to pain)
84
What level of sensation do patients with RLS experience?
Deep Sensation
85
What are some factors that can exacerbate RLS?
Antihistamines
Dopamine Receptor Antagonists
Antidepressants like SSRIs and SNRIs
86
What can cause a patient to have volitional movements like foot tapping, bouncing or leg rocking?
Lack of Circadian Rhythm Pattern
87
What is Akathisia?
An intense desire to move
88
What are disorganized spasms of muscles that are associated with palpable muscle contractions?
Nocturnal Leg Cramps
89
What levels of Serum Ferritin indicate low iron?
< 45 to 50 mcg/L
90
What is the treatment for RLS caused by low iron levels?
Ferrous Sulfate 325mg, 3 times a daily for 3-6 months
| Supplement with a stool softener/laxative
91
In patients with an altered mental status, what is it called when they only respond to repeated vigorous stimuli?
Stuporous Patient
92
What are some medical situations that can lead to a Coma?
- Seizures
- Hypothermia
- Metabolic Disturbances
- Bilateral Cerebral hemispheric dysfunction
- Disturbance of the brainstem reticular
activating system
- Mass lesion involving one cerebral hemisphere
that compresses the brainstem
93
What are some medical situations that can cause an abrupt onset of Coma?
Subarachnoid Hemorrhage (SAH)
Brainstem Stroke
Intracerebral Hemorrhage
94
What medical situation would cause a slow onset of coma?
Structural or Mass Intracranial Lesions
95
What does a purposeful withdrawal to painful stimuli suggests?
Sensory and Motor Pathways are Intact
96
A Unilateral absence of responses to painful stimuli despite application of stimuli to both sides of the body suggests?
A Corticospinal Lesion
97
A Bilateral absence of painful stimuli responses suggests?
Brainstem involvement
Bilateral pyramidal tract lesions
Psychogenic unresponsiveness
98
Posturing that can occur with lesions of the internal capsule and rostral cerebral peduncle is called what?
Decorticate (Flexor)
99
Posturing that may occur with dysfunction or destruction of the midbrain and rostral pons is called what?
Decerebrate (extensor)
100
Unilateral absence of corneal reflex implies damage to what?
Ipsilateral Pons or a Trigeminal Nerve Deficit
101
A Bilateral absence of the corneal reflex can be seen with?
Large Pontine lesions or in a deep pharmacologic coma
102
Ipsilateral hemispheric lesion, contralateral pontine lesions or ongoing seizures from the contralateral hemisphere can cause what kind of eye movement?
Conjugate Deviation
103
What diagnosis is associated with episodes of deep breathing alternating with episodes of apnea that can occur with bi-hemispheric or diencephalic disease or in metabolic disorders?
Cheyne-Stokes Respiration
104
What occurs with lesions of the brainstem tegmentum?
Central Neurogenic Hyperventilation
105
What causes prominent end-inspiratory pauses and suggests damage at the Pontine level?
Apneustic Breathing
106
What causes a completely irregular pattern of breathing with deep and shallow breaths occurring randomly and is associated with lesions of the lower pontine tegmentum and medulla?
Ataxic Breathing
107
What is the maximum score on the Glasgow coma Scale?
15
108
What is the lowest score on the Glasgow Coma Scale?
3
109
What do you do with a coma patient who scores less than 8 on the Glasgow Coma Scale?
Intubate
110
What is the Glasgow Coma Scale graded for an intubated patient with verbal response?
1T
111
What Glasgow Coma scale suggests a minor brain injury?
13 - 15
112
What Glasgow Coma Scale suggests moderate brain injury?
9 - 12
113
What Glasgow Coma score suggests severe brain injury?
3 - 8
114
What is the drug of choice for Opioid Reversal?
Naloxone (NARCAN)
115
What is the dosage for Narcan?
0.4 to 2mg IV,IM, Sub Q may repeat the dose every 2 to 3 minutes
116
What should be considered when administering Narcan to an opioid dependent patient?
Avoid acute withdrawal syndrome
| Use a lower dose (0.1 to 0.2mg)
117
What is the diagnosis for someone who experiences a sudden deceleration or acceleration of the head that leads to an impact of the brain against the cranium?
Concussion
118
What diagnosis is considered a subset of traumatic brain injury (TBI) and may occur with or without loss of consciousness?
Concussion
119
How many TBI related medical visits were seen in 2013?
2.8 Million
120
What is the leading cause of Concussions?
Falls (47%)
121
What is the 2nd leading cause of Concussions?
Being struck by or against an object (15%)
122
What is the 3rd leading cause of Concussions?
Motor Vehicle Accidents (MVA)
123
Which age range is the most prone to concussions?
Young (15-34 year old) Males and drunk
124
When a TBI injury is present at the site of impact as well as the opposite side from rebound motion, what is this called?
Coup-Contrecoup
125
What are hallmark symptoms of a TBI?
Confusion and Amnesia
126
What are early symptoms of a TBI?
Headache, Dizziness, Vertigo, Imbalance, Nausea and Vomiting
127
What are some delayed symptoms (hours to days) of a concussion?
Mood/Cognitive disturbance, light/noise sensitivity, sleep disturbance
128
What is a less common sign of a TBI?
Seizures within a week of head injury
| Occurs in 5% of TBI Patients, more common with severe injury
129
When should a MACE exam be completed?
Within 48 hours of head injury
130
How should a patient with a Concussion be managed?
- Direct Observation for 24hrs
- Awaken the patient every 2 hrs to ensure normal alertness
- SIQ for 24hrs
- no alcohol, sedatives or pain relievers other than NSAIDS should be given for 48 hrs
131
When should a patient diagnosed with a concussion, be considered for a MEDEVAC?
- Inability to waken patient
- Severe or worsening headaches
- Somnolence or Confusion
- Restlessness, unsteadiness or seizures
- Difficulties with vision
- Vomiting, fever or stiff neck
- Urinary or bowel incontinence
- Weakness or numbness involving body parts
132
What diagnosis occurs when a symptomatic patient from the 1st concussion sustains a 2nd concussion?
Second Impact Syndrome (can be fatal)
133
What happens to a patient with repeated concussions?
- Can lead to neuropsychologic deficits
- Behavior changes, personality changes, depression, increased suicidality
- Parkinsonism
- Speech and Gait Abnormalities
134
What is the diagnosis for a patient with repeated concussions?
Chronic Traumatic Encephalopathy (CTE)
135
What is the percentage of Linear fractures associated with Cranial Trauma?
75%
136
Where are the thinnest areas of the skull?
- Temporal Region
| - Nasal Sinuses
137
The following signs are associated with what diagnosis?
- Battle Signs
- " Raccoon Eyes"
- Hemotympanum
- CSF rhinorrhea/otorrhea
- Cranial nerve deficits
Basilar Skull Fracture
138
Bradycardia + Hypertension + Respiratory Irregularity = ?
Cushing's Triad
139
If a patient shows signs of increased Intracranial Pressure (ICP) or brain herniation, what treatment should be provided?
- Secure and maintain an open airway
- Elevate head of bed (25-30 deg): Reverse Trendelenburg
- Ventilate to maintain oxygenation and avoid hypercarbia (increased CO2 in the blood)
140
What fluids should be avoided with patients who have ICP?
- Glucose Containing Solutions
- Hypotonic Solutions
(these fluids raise blood pressure)
- Avoid over hydration
141
Which osmotic therapies can be used on a patient with ICP?
- Mannitol: 1g/kg IV as 15-20% solution
| - Hypertonic NaCI 7.5%, 250cc bolus
142
What is the last resort considered for a patient with ICP?
Hyperventilation
143
What are the different types of Intracranial hemorrhage (ICH) locations?
- Epidural
- Subdural
- Subarachnoid
- Intracerebral Bleed
144
Which artery is most commonly affected in an epidural hematoma?
Middle Meningeal Artery (MMA)
145
What is the treatment for a epidural hematoma?
- Immediate neurosurgical consutlation
- Operation is likely required: Trephination, Burr hole
- Head CT
146
What percentage of time does a skull fracture lead to an arterial injury?
85%
147
Which hemorrhage is more common than epidural hemorrhages?
Subdural Hemorrhage (makes up 20% of severe head injuries)
148
Which group(s) of patients are most likely to have a subdural hemorrhage?
- Elderly
- Alcohol Abusers
- Anticoagulated at risk
149
Hematoma that Tears binding veins which drains blood from the brain to the dural sinuses
- May tamponade, gradual progression
- May be chronic
Subdural Hematoma
150
How many days after onset does an Acute subdural hematoma present itself?
1-2 days
151
How many days after onset does a Chronic subdural hematoma present itself?
15 days or more
152
Which medical diagnosis defines the following symptoms?
- Usually a rupture of a blood vessel aneurysm
- Sometimes due to trauma or congenital anomaly
- Bleeding is high pressure and into the subarachnoid space which normally carries CSF
Subarachnoid Hemorrage (SAH)
153
How does a Subarachoid Hemorrhage (SAH) present itself?
"Thunder Clap Headache" Or "Worst Headache of My Life"
154
What activities can increase the risk for a Subarachnoid Hemorrhage?>
- Druge Use (Cocaine, amphetamines), smoking, hypertension, alcohol use
155
What is the treatment for a SAH?
- Bedrest
- Analgesia with Tylenol
- Avoid drugs that can lead to anticoagulation
- MEDEVAC
156
When should a MACE exam be completed?
As soon as possible for any patient invovled in a potential concussive event
157
How much rest is recommended for a service member involved in a potentially concussive event?
24 hours
158
Who is required to have a minimum of 24 hrs of recovery unless the results of the clinical evaluation indicate a longer period is needed?
All service members diagnosed with a TBI/Concussion
159
What is the treatment for a service member who has been diagnosed with a 2nd TBI/concussion within 12 months?
Return to duty is delayed for an additional 7 days following symptom resolution
160
What is the treatment for a service member who has been diagnosed with three TBI/concussions within 12 months?
Return to duty is delayed until a recurrent concussion evaluation has been completed
161
What domains can be affected by a concussion and should be evaluated?
- Attention
- Memory
- Processing Speed
- Executive Functioning
162
Red flags for a concussion
Lack of recall or repetitious questioning
163
Early symptoms of a concussion (minutes to hours)
Headache, dizziness, vertigo, imbalance, nausea, vomiting
164
Delayed symptoms of a concussion (hours to days)
Mood/cognitive disturbance, light/noise sensitivity, sleep disturbance
165
If seizures occur within what time frame it's more related to TBI than epilepsy?
One Week
166
How many people each year are affected by a spinal cord injury?
40 million
167
What is the breakdown of accidents that cause spinal cord injuries?
- MVA (41%)
- Falls (23%)
- Violence (14%)
- Sports (9%)
168
What is the pathophysiology for severe spinal cord injuries?
- Injuries occur with injury to vertebral column which leads to mechanical compression of the spinal cord
- Mechanical Compression can lead to ischemia and inflammation
169
What is the presentation of a spinal cord injury?
Depends on the spinal cord level affected
170
What antiflammatory medication is used on patients with spinal cord injuries to help reduce inflammation?
- After consulation with a Medical Officer
| - Methlyprednisolone (Solumedrol) 125 mg IM/IV q 4-6 hours prn
171
What nemonic is used for C-Spine X-ray?
NSAID
- N: Neurological Deficit
- S: Spinal Tenderness
- A: Altered mental status
- I: Intoxicated
- D: Distracting injuries
172
What is the usual cause of Lumbar Disk Herniation?
- Bending or heavy loading with the back in flexion
173
Which part of the spinal cord are most commonly affected in patients with radiculopathy?
L5-S1 disk is affected in 90% of cases
174
What is the clinical presentation of Radiculopathy?
- Pain with back flexion or prolonged sitting
- Radicular pain into the leg due to compression of neural structures
- Lower extremity numbness and weakness
175
What is the presentation of Sciatica?
- Electrical Shock
| - Pain radiating down the posterior aspect of the leg often to below the knee
176
Which spinal herniation causes numbness, weakness, including weakness with plantar flexion of the foot?
(L5/S1)
177
Which spinal herniation causes dorsiflexion of the toes?
(L4/L5)
178
What spinal herniation causes pain, paresthesia and sensory loss in the inguinal region
L1
179
What spinal herniation location is classified as acute back pain that radiates around the anterior aspect of thigh to knee and may have weakness of hip flexion, knee extension and hip adduction?
L2 - L4
180
What spinal herniation has pain radiating down the lateral aspect of the leg into the foot and decreased strength in foot dorsiflexion, toe extension, foot inversion, foot eversion?
L5
181
Spinal herniation resulting in pain radiating down posterior aspect of leg into the foot, weakness in plantar flexion due to gastrocnemius
S1
182
What is the name for a presence of worsening of Radicular pain with straight leg testing?
Lasegue's Sign
183
What is a bundle of nerves that spread out from the bottom of the spinal cord?
Cauda Equina
184
What are the causes of Cauda Equina Snydrome?
- Herniated disc
- Infection or Inflammation
- Cancer
- Spinal Stenosis
185
What is the clinical presentation of Cauda Equina Syndrome?
- Pain, numbness or tingling in the lower back and spreading down 1 or both legs
- "Foot Drop"
- Problems with bowel or bladder control
- Problems with sex
186
What is the treatment for Cauda Equina Sydrome?
- It's a medical emergency
- Likely needs an MRI
- Treatment of whatever is affecting the nerves causing the symptoms
187
What is an entrapment neuropathy caused by compression of the median nerve between the carpal ligament and other structures within the carpal tunnel?
Carpal Tunnel Syndrome
188
Carpal Tunnel Syndrome is commonly seen in what types of patients?
- Pregnancy
- Diabetes mellitus
- Rheumatoid arthritis
189
What is the clinical presentation for Carpal Tunnel Syndrome?
- Pain, Burning, Tingling in the distribution of the median nerve
190
Which nerve innervates the thumb, pointer, middle and half of the ring finger?
Median Nerve
191
What is used for determining a diagnosis of Carpal Tunnel?
- Tinal Or Phalen's Sign exacerbates neuropathic symptoms
| - Ultrasound and Nerve Conduction Studies
192
What is the treatment for Carpal Tunnel Syndrome?
- Affected wrist should be splinted in the neutral position for 3 months
- NSAIDS
- If pain persists after 3 months, then a referral for surgery
193
What is the name of the surgery used to treat Carpal Tunnel Syndrome?
Carpal Tunnel Release Surgery
194
What diagnosis is associated with the following signs and symptoms?
- Acute facial palsy (paralysis) of a specific pattern
- Lower motor neuron disease affecting CN VII
- Rare (34/200,000 people), slightly more common in pregnancy
- Idiopathic paresis of lower motor neuron type
- Associated with Herpes Simplex Virus, Lyme Disease or HIV
Bell's Palsy
195
What are the specific symptoms of Bell's Palsy?
- Abrupt onset of unilateral facial paralysis
- Pain about the ear precedes or accompanies the weakness, can last for a few days
- Face feels stiff and pulled on one side
- May be Ipsilateral restriction of the eye
- May have changes in taste
- Tearing (68%) or dryness of the eye (16%)
- Bell's Phenomenon (upward rolling of th eye on attempted lid closure)
196
How do we determine the difference between Bell's Palsy vs Stroke?
- Stroke, there is no paralysis of the forehead
- Intact forehead muscle tone suggests stroke not BELL's Palsy
- Look for other abnormalities or neurological deficits
197
What is the treatment for Bell's Palsy?
- Evaluate Eye Closure
- If inadequate eye closure, protective measures should be implemented
- Oral Steroids can shorten duration of symptoms
- Prednisone is used for mild to moderate Bell's Palsy (60 mg Po daily X 7 days, then 5 day taper
- Valacyclovir 1000mg 3 times daily for 7 days
198
What percentage of Bell's Palsy patients recover completely without treatment/
60%
199
What percentage of Bell's Palsy patients remain disfigured?
10%
200
In a patient with Bell's Palsy, how would you treat them to avoid corneal ulcerations?
Artificial tears, Lubricating ointment and possibly an eye shield
201
What diagnosis is associated with the following?
- Inflammation of the coverings of the brain (meninges)
Meningitis
202
What are the common bacterial causes of meningitis?
- Streptococcus Pneumonia
- Neisseria Meningitides
- Listeria Monocytogenes
203
What are the common viral infections associated with Meningitis?
- Enterovirus
- Herpes Simplex Virus (13-36% of patients with genital herpes)
- West Nile Virus
204
What is the classic triad of acute bacterial meningitis?
- Fever
- Nuchal Rigidity
- Change in Mental status
205
Meningitis symptoms with a RASH is associated with what bacterial infection?
Neisseria Meningitides
206
How do you differentiate between Meningitis and Encephalitis?
- Distinguishing feature is degree of brain function disturbance
- Meningitis Cerebral Function Usually Remains normal
- Encephalitis brain function is more abnormal leading to altered mental status, motor and sensory deficits, altered behavior, speech or movement disorders, speech changes
207
What sign involves, Spontaneous flexion of hips during flexion of neck?
Brudzinski sign
208
What sign involves, Inability or reluctance to allow full extension of knee when hip is flexed at 90 degrees?
Kernig Sign
209
What is the treatment for Meningitis?
- Medical Emergency
- Need antibiotics that can cross the blood brain barrier
- Ceftriaxone (rocephin) 2g IV Q 12hrs
- Dexamethasone: 0.15 mg/kg IV Q 6 hrs (decreases inflammation)
210
What is the prophylaxis for exposed crew members?
- Ciprofloxacin (500mg PO X 1)
| - Mask patients and medical personnel in close proximity
211
What are the 3 categories of chronic pain?
- Nociceptive Pain
- Neuropathic Pain
- Centralized Pain
212
Pain caused by stimuli that threaten or result in bodily tissue damage
Nociceptive pain
213
Pain resulting from maladaptive response to damage or pathology of the somatosensory nervous system
Can occur in absence of active stimuli or as exaggerated response to minor or moderate stimuli
Neuropathic pain
214
Reduced ability of the CNS to diminish responses to peripheral stimuli
Centralized pain
215
An acutely painful condition that persists beyond the usually expected 6-12 week time course for healing
Chronic pain
216
What is characterized by what we traditionally recognize as pain that is caused by a noxious stimuli?
Nociceptive Pain
217
What pain is most commonly described as tingling, pins and needles, burning and shooting electric like shocks?
Neuropathic Pain
218
What is the initial treatment for chronic pain management?
- Non-Pharmacologic Therapies
- Home Exercise Program
- Physical Therapy
219
What are some meds that inhibit pain transmissions?
- Tylenol
- NSAID
- Capsaicin
220
What medications inhibit descending pain modulation?
- Gabapentin
- Tricyclic Antidepressants
- SNRI's
221
How many stages are there in NREM (quiet sleep)?
THREE
- 1st stage: Beginning of sleep Cycle, transition between wakefulness and sleep
- 2nd stage: less aware of surroundings, breathing and heart rate becomes more regular (people spend 50% in this stage)
- 3rd stage: Deepest sleep stage, muscles relax and people are less responsive to noise and activity (delta wave sleep)
222
What stage of sleep is associated with dreams, brain is more active, eyes move rapidly ("paradoxical sleep")
REM
223
How may REM periods are there during the night?
4-5 REM periods accounting for 1/4 of the total night's sleep (1.5 - 2 hours)
224
When does the first REM period begin?
80-120 minute after onset of sleep and last 10 mins
225
How long are later REM periods?
15-40 mins and occur mostly in the last several hours of sleep
226
What characteristics are impaired by loss of sleep?
- Creativity
| - Rapidity of Response to unfamiliar situations
227
What diagnosis is associated with difficulty initiating or maintaining sleep?
Insomnia
228
What are the risk factors that lead to sleep issues?
- Alcohol Abuse
- Stimulant Abuse
- Tobacco Abuse
- Psychiatric Comorbidities
229
How is insomnia diagnosed?
- Chronic diagnosis established by history and patient report
- Sleep history for 1 week
230
Which 4 criteria have to be met for insomnia
| ?
- Difficulty Initiating Sleep, maintaining sleep or waking up to early
- Sleep difficulties occur despite adequate opportunity for sleep
- Patient has daytime impairment that is attributable to sleep difficulty
- Sleep difficulty is not better explained by another sleep disorder or substance abuse
231
What is the treatment for Insomnia?
- Educate on sleep hygiene
| - For chronic insomnia, a referral for cognitive behavior therapy
232
What is considered short term insomnia and what is it usually caused by?
- Less than a month in duration
| - Usually occurs from psychologic or physiologic stress
233
Which medications can assist with insomnia?
- Melatonin
- Trazodone
- Vistaril
- Diphenhydramine
234
What does either a sensation of motion when there is no motion or an exaggerated sense of motion in response to movement cause for someone?
Vertigo
235
What is peripheral vertigo?
- Onset is sudden
- Associated with tinnitus and hearing loss
- Horizontal nystagmus May be Present
236
What is Central Vertigo?
- Onset is gradual
- No associated auditory symptoms
- Often presents with other neurological signs and symptoms like ataxia, dysarthria, dysphagia, focal or lateralized weakness
237
What is the Etiologies for Peripheral Vertigo?
- BPPV
- Herpes Zoster
- Otitis Media
- Aminoglycoside Toxicity
238
What is the Etiologies for Central Vertigo?
- Brainstem Ischemia
- Multiple Sclerosis
- Vestibular Migraine
239
What test involves quickly lowering the patient to the supine position with the head extending over the edge and placed 30 degrees lower than the body, turned either to the left of right
Dix-Halpike Testing
240
Patients with benign paroxysmal positioning vertigo (BPPV) will elicit what response after a Dix-Hallpike test?
Delayed onset (~10 seconds) of fatigable nystagmus
241
If after performing the Dix-Halpike test there is non-fatigable nystagmus, what does this indicate?
CNS Disease
242
What is the treatment for Vertigo?
Anti-vertigo:
- Meclizine 25-50mg q 6-12 hours PRN for Dizziness
- Diazepam 1mg PO q 12 hours PRN for Dizziness
Antiemetic:
- Ondansetron 4mg PO/IV q 8 hours PRN
- Promethazine 12.5 to 25mg every 4-6 hours PRN
