Neurological Disorders Flashcards
Example of 5HT-1 agonist
Sumatriptan (Imitrex)
Sumatriptan is contraindicated with
History of CVD
Sumatriptan can interact with
- SSRI/SNRI –> risk of serotonin syndrome
- ergots
Side effects of Sumatriptan
- flushing
- tingling
- chest/neck/sinus/jaw discomfort
Ergotamine/caffeine
- Cafergot
- potent vasoconstrictor
- do not use with other vasoconstrictors
- s/e: nausea
Antiemetics for abortive therapy
- Trimethobenzamide (Tigan)
- Metoclopramide (Reglan)
Contraindications to vasoconstricting drugs
- known or suspected CVD
- Known or suspected CVA and/or TIA
- HLD
- males >40
- menopausal females
- uncontrolled HTN
- Complex migraine
New onset headache in a middle/older adult is usually ___
secondary
Most common cause of stroke
Hemorrhagic
Risk factors for stroke
- HTN
- afib
- stimulants (cocaine)
- aneurysms
TIA resolves within
24 hours
Treatment for TIA
- 911
- oxygen asap
long-term treatment for embolic stroke
- anticoagulation with warfarin
- keep INR between 2-3
Long term teatment for hemorrhagic stroke
-avoid heparin, coumadin, aspirin
Cluster headache acute treatment
- 100% oxygen at 12 L/minute
- intranasal 4% Lidocaine or intranasal sumatriptan
Cluster headache concerns
-may become suicidal
Cluster headache symptoms
- severe “ice-pick”
- behind one eye and temple
- tearing, rhinorrhea, ptosis, miosis (Horner’s syndrome)
Horner’s syndrome
- ptosis
- miosis
- facial anhidrosis
Gold standard diagnosis for GCA
-temporal biopsy
Plan for GCA
-STAT referral to optho or ED
First line treatment for GCA
- High dose steroids
- Prednisone 40-60 mg PO daily
Persons with ___ are at high risk for GCA
polymylagia rheumatica
Patients with polymyalgia rheumatica present with
- bilateral morning stiffness and aching
- lasts 30 minutes or longer
- usually a recent onset
Tension headache presentation
- bandlike bilateral headache
- dull and constant
- tensing of neck muscles
- reports increased life stressors
Tension headache treatment
- NSAIDs,
- analgesics
- Combination OTC of analgesics,asa, caffeine
- stress reduction and relaxation
Rebound headache
- daily headaches
- irritability, depression, insomnia may be present
- caused by overuse of abortive medications
- discontinue or slowly taper
Bacterial meningitis presentation
- acute onset high fever
- severe headeache
- stiff neck
- meningisimus
- purple-colored petechial rash
- N/V
- photophobia
Is bacterial meningitis a reportable disease
yes
Romberg test; what system
cerebellar system
Romberg test procedure
stand with arms/hands straight on each side with feet together
-positive: excessive swaying, falls down, keeps feet apart to keep balance
Tandem gait procedure
walk in straight line with heel to toe
-positive: unable to perform tandem walking
Coordination cerebellar tests
- Rapid alternative movements
- heel-to-shin testing
Sensory system cerebellar tests
- vibration sense
- sharp-dull touch
- temperature
Stereogenesis
ability to recognize familiar objects through sense of touch only
what system does stereogenesis test
cerebellar
Graphesthesia
ability to identify figures “written” on skin
Motor exam components
- Gait
- pronator drift
- gross leg and fine motor movements of hands
Normal reflex
+2
Sustained clonus reflex grade
+4
No reflex grade
0
Positive Babinski reflex
toes spread like a fan
Kernig’s sign
flex patient’s hips one at a time, then attempt to straighten the leg while keeping hip flexed at 90
-Positive: resistance to straightening because of painful hamstring and/or complains of back pain
Brudzinski’s sign
- passively flex/bend the neck toward’s chest
- Positive: patient reflexively flexes hips and knee to relieve pressure and pain
Nuchal rigidity
- tell patient to touch chest with chin
- positive: unable to touch chest secondary to pain
Offending bacteria for bacterial meningitis
- Streptococcus pneumoniae
- Neisseria meningitidies
- Haemophlius influenzae
Labs for bacterial meningitis
- Lumbar puncture: CSF with large WBCs
- elevated opening pressure
- CT or MRI
- gram stain and C&S of CSF before antibiotics
Bacterial meningitis infants medications
-ampicillin or 3rd generation ceph
Bacterial meningitis adults medications
-3rd generation ceph plus chloramphenicol
Bacterial meningitis >50 medications
-amoxicllin plus 3rd gen ceph
Prophylaxis coverage for bacterial meningitis close contacts
rifampin
ceftriaxone
Complications of bacterial meningitis
-patients who recover usually have permanent neurologic sequelae
Trigeminal neuralgia aka
Tic Douloureux
Most common cause of carpal tunnel
-repetitive wrist/hand motion
Which nerve is compressed in CTS
median
Risks for CTS
- hypothyroidism
- pregnancy
- obesity
CTS presentation
- numbness/tingling on thumb, index finger, middle finger areas
- hand grip weakened
Tinel’s sign
- tap anterior wrist briskly
- positive: pins and needles sensation
Phalen’s sign
- full flexion of wrist for 60 seconds
- positive: tingling sensation of median nerve
Which headache is treated with high-dose anticonvulsants
trigeminal neuralgia
Only bilateral headache
tension
Which headache is seen more in middle-aged males
cluster
Peripheral vertigo
involves vestibular system
central vertigo
involves brainstem or cerebellum
Benign paroxysmal vertigo is reproduced by which maneuver
Dix-Hallpike
Meniere disease characteristics
- recurrent
- minutes to hours
- acute onset
- unilateral decrease/loss inhearing
Antihistamin medications for vertigo
Meclizine (antivert)
Dimenhydrinate (Dramamine)
Diphenhydramine (Benadryl)
When to refer vertigo
most cases except BPV
Patients on ___ are at risk for B12 deficiency
- metformin
- increased after 4 years
Rest tremors
-occurs when tremulous body part is supported by gravity and not engaged in activity
Action tremor
occurs when body part is being used
Most common rest tremor
Parkinson’s disease
Cardinal features of Parkinson’s
- rest tremor
- Bradykinesia
- rigidity
PD treatment
MAOI
Doapmine agonists
anticholingergic medications
doapmine replacement
MAOI
Rasagiline (Azilect)
Selegiline
Dopamine agonist
Pramipexole (Mirapex)
Anticholinergic medications for PD
Benztropine mesylate (Cogentin)
Dopamine replacement
-Carbidopa/levodopa (Sinemet)
How is PD diagnosis made
assessing response to dopaminergic therapy
Most common action tremor
essential tremor
When is essential tremor more common
older age
Where does essential tremor occur
bilateral action tremor of hands, forearms, head, voice, chin, lip
-leg tremor is unusual
Clinical features of essential tremor
- apparent when arms are outstretched
- more apparent at end of goal-directed movements (glass closer to lips)
- no other neuro deficits
Eessential tremor treatment
- Propanolol
- primidone
Dementia diagnostic criteria
- at least 1 cognitive decline in these domains
- learning and memory
- language,
- executive function
- complex attention
- perceptual-motor
- social cognition
- cognitive deficits must be severe enough to interfere with daily function
Most common dementia
Alzheimer’s
Cognitive testing for dementia
- MMSE
- Montreal Cognitive Assessment (MoCA)
Delirium
acute onset
AD treatment
- acetylcholinesterase inhibitors
- Memantine (Namenda)
Acetylcholinesterase inhibitor examples
- donepezil (Aricept)
- rivastigmine (Exelon)
- galantamine (Razadyne)
Multiple sclerosis patho
demyelinating and dysmelinating
- cause unknown
- inflammation of nerves
MS presentation
- relapse and remissions
- 15-50 years
- optic neuritis
- fatigue
- bowel and bladder dysfunction
- cognitive impairment
- depression
- eye movement abnormalities
Imaging for multiple sclerosis
MRI
Acute attack of MS treatment
-IV methylprednisolone with short prednisone taper
CN 1
olfactory
CN 2
optic
-Snellen chart
CN 3
oculomotor
- eye movements
- pupillary constriction
- accomodation
CN 4
trochlear
-movement of superior oblique muscle
CN 5
Trigeminal
- sensation to face, nasal and buccal mucosa, and teeth
- motor division for mastication
CN 6
Abducens
-movement of lateral rectus muscle
CN 7
Facial
-innervates facial muscles and supplies taste to anterior 2/3 of tongue
CN 8
Vestibulocochlear
-hearing, balance, position
CN 9
Glossopharyngeal
-sensation to pharynx, posterior 1/3 of tongue, TM
CN 10
Vagus
-gag reflex, rise of uvula at midline
CN 11
Spinal accessory
-motor nerve supplying sternocleidomastoid and trapezius muscles
CN 12
Hypoglossal
- Motor fibers to muscles of tongue
- tongue sticks out at midline
What test treats BPPV
Epley maneuver
Acetylcholinesterase inhibitor mechanism
-prevents breakdown of acetylcholinesterase
Acetylcholinesterase side effects
- nausea
- vomiting
- diarrhea
- decreased appetite
- weight loss
- bradycardia
- hypotension
Vertical diplopia cranial nerve
-CN 4
Horizontal diplopia cranial nerve
CN 6
Both vertical and horizontal diplopia
CN 3
older adult concerned about misplacing items, is it concerning?
No, patient is able to self-report memory loss and continue working
Best antieplipetic for generalized seizures
valproate
Valproate serum levels
50-100
Status epilepticus
- seizure more than 5 minutes
- transfer to ER
NMDA receptor antagonist for dementia
Memantine
Migraine prophylaxis for pregnancy
-Riboflavin (B vitamin)
Acute angle glaucoma presentation
- one eye with pain
- blurred vision
- N/V
- cornea hazy
- pupil dilated midway
Acute angle glaucoma treatment
ED
Chronic subdural hematoma
-gradual and symptoms may not show until a few weeks after injury
Subarachnoid hemorrhage
- severe sudden headache
- photophobia
- N/V
- meningeal irritation (stiff neck, positive Brudzinski, Kernig)
- sentinal headache: sudden severe ehadache that resolves before major hemorrhage happens
Patients who experience TIA are at higher risk for stroke
True
up to 20% will have stroke within 90 days
First line treatment for trigeminal neuralgia
carbamazepine
