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Clin med exam 2 > Neurological distress > Flashcards

Neurological distress Flashcards

1
Q

Primary headache disorders

A

most common cause of pain

tension and vascular (migraine)

recurrent
similar episodes- if different or worst (or first one)–> CT or LP for eval

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2
Q

Do not miss headaches include what signs and symptoms?

A

“worst headaches of my life”
abrupt onset with strenuous activity (valsalva)
photophobia
neck stiffness
fevers
pain with eye movement
focal neurological findings (aphasia, diplopia)
vomiting
dizziness
new onset of headache over 50yo or immunocompromised

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3
Q

SAH (subarachnoid hemorrhage)

A

CT needed within 6 hours of start of pain
if not LP- assess CSF for blood or xanthochromia (yellow color from hgb breakdown)

often a SAH will have a small bleed before a rupture of the aneurysm= sentinel bleed

Have a bad headache- gets better- complete rupture

No MRI, unless MRA

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4
Q

Who needs a CT?

A 
first time presenters
>50/55yo
confusion/ altered 
focal neurological findings complaints 
hx consistent with vertebral art dissection- head and neck CT
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5
Q

Who needs a LP?

A

fever
clinical suspicion of meningitis (photophobia, neck stiffness)
suspicion of SAH but normal CT
idiopathic intracranial hypertension (pseudotumor cerebri)

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6
Q

Cluster headaches

A

males
pain behind eye
tearing of the eye relief with high flow oxygen and NSAIDS

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7
Q

Temporal arteritis

A

vasculitis of the major vessels including:
external and internal carotid

can affect ophthalmic causes decreased blood flow retina associated with blindness

initial study= ESR

  • if high treat pt on assumed dx
  • follow up biopsy of temporal artery to make dx
  • steroids
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8
Q

Idiopathic intracranial hypertension

A

female, obese
LP is diagnostic and therapeutic opening pressures are elevated

taking off fluid= relief

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9
Q

Cavernous sinus thrombosis

A

CN 3, 4, 5, v1, v2, 6 pass through here

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10
Q

Headaches in pregnancy

A

concern as they develop:

eclampsia
cavernous sinus thrombosis
SAH
Posterior reversible encephalopathy syndrome (PRES)

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11
Q

Headaches in AIDS population

A

Need CD4 count (t cell)

They can develop:
opportunistic infections by Toxoplasma gondii infection (abscess formation) small cystic structures found on CT head

cryptococcal meningitis (fungal) dx by LP and India ink stain

bacterial meningitis-
may lack fever, meningismus and present only with headache

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12
Q

Encephalitis

A

rapidly progressing fever
headache
altered mental status

consider: Herpes simplex encephalitis= most common type

others:
west nile
eastern equine

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13
Q

Herpes simplex encephalitis

A

= necrotizing, hemorrhagic infection that results in brain tissue destruction and require early aggressive treatment with antiviral therapy

LP + PCR testing of CSF for herpes simplex

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14
Q

Meningitis and encephalitis tx

A

get an LP ASAP

administer abx.antivirals ASAP (do not delay for LP)

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15
Q

Migraine

A

more than 3 headaches in 6 months

common- aura
complicated- neurological complains and findings (vision and motor)

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16
Q

Tx headache general

A
  1. dopaminergic agonist
    - compazine
    - reglan
  2. serotonin agonist
    - erogtamine
  3. NSAIDS
  4. steroids
    - dexamethasone: decadron
  5. sphenopalatine ganglion block (CN5)
    - lidocaine on a cotton swab in the back of nose
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17
Q

CVA pathophysiology

A

ischemic- 80%

  • thrombosis in situ
  • emboli

lacunar stroke- in situ thrombus or emboli

hemorrhagic- 20%

  • hemorrhagic sub arachnoid bleeds (SAB)
  • HTN bleeds
  • AV malformations
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18
Q

Thrombosis

A

plaque in artery (atherosclerosis)

large vessels with thrombosis- from rupture of plaques

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19
Q

Embolic

A

cardioembolic event (recurrent and high mortality rate)
OR
dissections of carotid or vertebral artery where a clot embolizes
OR
atherosclerotic plaque

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20
Q

small vessel obstruction is called

A

lacunar strokes= pure motor or sensory

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21
Q

Hemorrhagic

A

subarachnoid hemorrhage

intracranial hemorrhage

(HTN, anticoagulants, use of sympathomimetics)

22
Q

Initial exam is a

A

FAST exam

Face
- abnormal- one side does not move 
Arms
- one arm drifts compared to other 
Speech 
- slurred or inappropriate words or mute  
Time 
- time of onset

if + in any then consider CVA until proven otherwise

23
Q

What to obtain if CVA suspicion ?

A

blood glucose
non-contrast CT of head
- assess for blood which is a contradiction to receiving thrombolytics

24
Q

What are some stroke mimics?

A

hypoglycemia

seizure with Todd’s paralysis

complicated migraines

25
Q

What are some major contradictions to thrombolytic therapy? (break up or dissolve blood clots)

A

hx of stroke or other serious head injury in preceding 3m

hx of intracranial bleed

hx of tumor

hx of GI bleed

received heparin past 48 hrs, and elevated PTT

previous surgery within 14 days

significant acute hypertension

26
Q

tPA (for ischemic strokes)

A

activate plasminogen to plasmin which breaks up the fibrin of the clot- give within 3 hours!

IV- will break up clot anywhere in the body
- 6% will have ICB- of this 45% will die

27
Q

Anterior cerebral circulation

A

can’t move legs, contralateral to vascular lesion

if edema- difficult to determine vascular territory

28
Q

Middle cerebral circulation

A

can’t move face & arms (contralateral to lesion), gaze towards defect, homonymous hemianopsia

if edema- difficult to determine vascular territory

29
Q

Post circulation

A

can have LOC

vision and thought process visual agnosia, 3rd nerve palsy

dizziness
coordination problems

if edema- difficult to determine vascular territory

30
Q

Tx regardless of tPA admin

A

manage hypoxia, hypoglycemia, and hypertension

pass swallowing study to eat

hob 30

31
Q

Chronic tx options

A

aspirin (nonsteroidal anti-inflammatory drug and blood thinner)

stroke despite asa use started on oral anticoagulant (clopidigel)

32
Q

Admit patients with

A

acute neurological findings even if no evidence of CVA found

33
Q

Transient ischemic attacks (mini stroke)

A

10% move on to full CVA in first 24 hours

need a workup to exclude causes of embolic stroke, admitted

will need aspirin for acute and long term use- reduce mortality

34
Q

What are the higher risks for a TIA to become a CVA?

ABCD2 scale

A 
age>60 
blood pressure > 140/90 
clinical feature- unilateral motor symptoms 
duration >60 
diabetic
35
Q

What does a workup for TIA include?

A

doppler US of the carotid arteries
study of vasculature with MRA (magnetic resonance arteriogram)
neurological consult

36
Q

Tonic clonic seizures & others (2)

A

include the whole body
change in mental status

absence- brief episodes of unresponsiveness usually with no motor activity

partial- awake and symptoms don’t cross the midline of the body

37
Q

Seizure ddx

A

SICK DRIFTER

Substrate (glucose and o) 
Infection 
Cation's (Na, Ca, Mag) 
Kids (eclampsia) 
Drugs (CRAP- cocaine..) 
Rum, alcohol 
Illness (chronic sz disorder) 
Fever 
Trauma 
Extra toxins
Rat poising
38
Q

PE findings- seizure

A

lateral tongue biting
confusion
Todd’s paralysis is unilateral and resolves within hours

39
Q

What does workup for first time seizures include?

A

not started on antiseizure med after one
no driving, alcohol, recreational meds for 6 m

neuro ref for EGG and start on meds after 2

40
Q

Seizure and fever?

A

consider infection

41
Q

What meds are used for seizures?

A

Benzodiazepines

  • lorazepam (4 doses) then
  • Dilantin

then other meds like
-gabapentin

42
Q

Intractable seizures that are not responding to meds may need ____

A

phenobarbital and control of airway

43
Q

Consider a cause for seizure tx

A

hypoglycemia can cause seizures

44
Q

Intractable seizures are also known as ___ and is defined as ____

A

status epilepticus

defined as multiple seizures with no return to baseline in between seizures

45
Q

Differentiation from a syncopal episode:

A

is there hypoxia, cardiac arrhythmia, or signs of seizure such as loss of urination or tongue biting?

if there is a quick recovery (syncope) verses a post ictal period where there is confusion

46
Q

Febrile seizure

A

ages 6 m- 5 yrs

lasts less than 15 min

child is otherwise without significant medical problems

requires supportive care only

47
Q

Febrile seizure difficult ages and why

A

6 m to 1 y

fevers in this age can indicate serious bacterial infection

work up initiated

if does not meet febrile seizure criteria- a workup should be started

48
Q

Seizure like activity or seizure in neonates is high risk for serious pathology and should be treated with

A

glucose (hypoglycemia)
pyridoxine (inborn errors of metabolism)
abx (meningitis/ encephalitis)- get a LP ASAP

49
Q

Guillian bare

A

ascending paralysis
peripheral weakness with no tendon reflexes

preservation of sensory

50
Q

Idiopathic facial n palsy (CN)

A

differentiation from a central cause like stroke which has preservation of forehead muscles vs peripheral causes where the entire face is weak

51
Q

Botulism (CN 3, 4, 6)

A

due to spore infection or premade toxin found in unpasteurized foods such as honey or garlic

careful with cheese sauce at gas stations!

Clin med exam 2 (12 decks)

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