Rheum and Neuro Flashcards
3-step screening tool for inflammatory arthritis (RA)
- discomfort with squeezing the MCP and MTP joints
- 3 or more swollen joints
- More than 1 hour of morning stiffness
key labs for RA
RF: may be pos or neg - but positive = more severe dz
Anti-CCP: confirmatory test for RA
RA: poor prognostic indicators
- Functional limitations
- RF + or Anti-CCP +
- Erosions on x-rays
- Extra-articular disease: Interstitial lung disease, vasculitis, scleritis, rheumatoid nodules
Guidelines for bone densitometry - who should get a DEXA scan
Women > 65 years and men > age 70 - ALL
Younger postmenopausal women and men aged 50-69 years with a risk factor (must document):
• Prior fragility fracture (before age 50)
• Use of a high risk medication
• Family history of osteoporosis
• Rheumatoid arthritis or condition associated with increased bone loss
• Glucocorticoids > 5mg daily for > 3 months
• Current smoker
• Low body weight (<127 lbs)
Guidelines for using pharmacotherapy for osteoporosis
Applicable population: postmenopausal women and men age 50+
• Previous hip or vertebral fx
• T-score -2.5 or less at femoral neck, total hip, or spine
• T-score b/t -1.0 and -2.5 at femoral neck, total hip or spine and 10yr FRAX of >3% at hip or >20% for major osteoporosis-related fxs (humerus, forearm, hip, clinical vertebral fx)
Central findings - indicates lesion in CNS (brain and spinal cord - upper motor neurons)
Horizontal axis:
- Hyper-reflexia
- Spasticity: velocity-dependent “catch” with rapid passive extension of joint
- Sensory changes: often harder to localize
- Weakness (flexor posturing in UE; extensor posturing in LE)
Vertical Axis:
- if unilateral, think cortex / brainstem
- if bilateral, think subcortical, brainstem, or spinal cord
Peripheral Findings
Horizontal axis:
- Hypo-reflexia
- Atrophy/Fasciculation
- Sensory changes: dermatomal, sensory-nerve dist, glove/stocking (polyneuropathy)
Vertical Axis:
- reflexes: biceps: C5/6, triceps: C7/8, patella: L3/4, achilles: S1/2
- dermatomes
- muscle innervation
aphasia - definition and likely location pf lesion
language disorder
Brocas: impaired production
Wernickes: impaired comprehension
lesion: left side – frontal and temporal regions
agnosia - definition and likely location pf lesion
inability to process sensory information despite adequate sensory input
• Tactile agnosia
• Prosopagnosia (“face blindness”)
lesion: occipital/parietal lobe
apraxia - definition and likely location of lesion
disorder of planning motor tasks, perform learned motor tasks
lesion: posterior parietal lobe
amnesia - definition and likely location pf lesion
deficit in memory
lesion: medial temporal lobe, hippocampus, dienceohalon
Headache - red flag sxs that suggest secondary cause
SSNOOP Systemic symptoms (fever, weight loss, vomiting, vision loss)
Secondary risk factors (HIV, cancer, immuno-supressive drugs)
Neurologic symptoms (confusion, impaired alertness)
Onset: sudden, abrupt, pain induced by exertion, wakes from sleep, subsides w/ emesis
Older: new onset and progressive (worsening) HA, esp age > 50 (or < 5yr)
Previous HA history or HA progression: pattern change, first HA, or different (change in quality, frequency or severity)
Headache - red flag signs that suggest secondary cause
Abnormal neurologic exam: focal signs
Neck stiffness and especially meningismus
Papilledema (inc. ICP)
Temporal artery palpation
AMS
common HA triggers (tension and migraine)
Diet / EtOH Hormones Sensory stimuli: light/odor Stress Change of environment/habit
migraine HA treatment
mild: anti-inflammatory
- acetaminophen/aspirin/caffeine (Excedrin Migraine)
- NSAIDs (Ibuprofen/Naproxen)
Failed analgesics: 5-HT recepto agonists (ergotamines and triptans) - no CV dz
Dopamine receptor antagonists
migraine HA prophylaxis - indications
- HA > 2 times weekly
- Contraindications or intolerance to abortive meds
- HA that severely limits quality of life despite abortive therapy
- Presence of uncommon migraine conditions: hemiplegic or basilar migraine, or migraine with prolonged aura
migraine prophylaxis - medications
beta-blockers (propranolol, timolol)
tricyclics (amitriptyline, nortriptyline)
anti-convulsants (topirimate, valproate, gabapentin)
tension HA - treatment
Simple analgesics (acetaminophen, Aspirin, NSAIDs)
Behavioral approaches: relaxation techniques
cluster HA - treatment
First line abortive therapy is oxygen (10-12L via nasal cannula for 15 min)
Follow with same tx as migraine HA
medication OD headache - dx and tx
Hx of analgesic use averaging more than 2 - 3 days per wk in association with chronic daily HA supports the diagnosis of MOH
Treatment:
- stop all the overused med
- bridge therapy: long acting NSAID (Naproxen 550 mg BID) or prednisone
- preventative med and revisit triggers (diary)
stroke - modifiable risk factors
- HTN (most important risk)
- CV dz - CHF, previous MI, aortic valve disease and atrial fibrillation
- Cigarette smoking
- Carotid Artery Disease: can limit blood flow to the brain, act as a potential source for cerebral emboli
- Diabetes
Dyslipidemia
Obesity
Lack of Exercise
Use of OCP, Hormone Therapy
stroke - non-modifiable risk factors
- Family History: stroke or CAD
- Age: risk doubles every 10 yrs after age 55
- Gender: <55 (men more likely to have stroke); >55 risk same for males and females
- History of Prior Stroke, TIA or Heart Attack
- Race: African Americans - higher incidence and risk of death from stroke; Asian Americans – high risk of hemorrhagic stroke
symptoms not likely to be a stroke or TIA (non-focal)
Generalized weakness or numbness (bilateral)
Faintness or syncope
Incontinence
Isolated symptoms (occurring alone)
- Vertigo or loss of balance
- Double vision
- Slurred speech or difficulty swallowing
Confusion / reduced LOC
- reduced conscious level is more important predictor of non stroke pathology
ABSD2 score
Helps to determine disposition following TIA:
Age [A]: >60 (1 pt) Blood pressure [B]: >140/90 (1 pt) Clinical features [C] - Unilateral weakness (2 pts) - Dysphasia (difficult swallow) w/out weakness (1 pt) Duration of symptoms [D] - >60 min (2 pts) - 10-59 min (1 pt) Diabetes [D]: 1 pt
TIA - indications for hospital admit
o Crescendo symptoms o Symptom duration > 1 hour o Internal carotid stenosis > 50% o Known Afib or other cardiac source o Known hypercoagulable state o ABCD2 Score >3
stroke - imaging
CT (non contrast): fast, available, cheap
- R/O hemorrhage
- verify cerebrovascular cause to sxs
- identify abnormal findings that contradict tPA
- goal: door to CT 25 min; 45 min interpretate
MRI: higher sensitivity for ischemic stroke (also detects hemorrahage)
4 proven interventions for acute ischemic stroke (aka tx for acute ischemic stroke)
SCUs: stroke care units
Thrombolysis (tPA): IV alteplase w/ in 3 hrs
Aspirin (ASA): 300 mg QD for 14 days (initiate after 24 hrs if using thrombolytics)
Decompressive hemicraniectomy
- reduces mortality in pts < 55 years with malignant brain swelling after large infarction
- make decision w/ neurosurgeon
acute tx for hemorrhagic stroke
Management in SCU
Regulate BP (not yet found to improve outcome)
Control brain edema (not yet found to improve outcome)
Neurosurgical consultation: pts at risk for obstructive hydrocephalus
acute tx fort TIA
Note: usually not admitted
confirm not stroke (imagine - CT/MRI)
pt education and good RTC precautions: 10.5 % have stroke w/in 3 mo)
Primary prevention measures:
- anticoagulants
- antiplatelets
- carotid endarterectomy
thrombolysis alteplase)
can improve recovery following ischemic stroke, but also carries a risk of a brain bleed (so there are several contraindications)
- > 3 hrs since stroke onset
- bleeding or bleeding risks
- meds that cause bleeding / reduced clotting
- blood glucose < 50 mg/dl
- seizure w/ post-ictal neural impairment
Primary Prevention for Stroke or TIA (never had one before)
Anti-coagulation (Warfarin): for patients with atrial fibrillation (CHA2DS2-VASc score)
Antihypertensives: for the tx of hypertension
Lipid reduction with statins: pts w/ pre-existing ischaemic heart disease
Aspirin in women 45 years or older (but not men)
Modification of risk factors such as diabetes, moderation of EtOH, reduction in smoking
Secondary Prevention for Stroke or TIA (had one before)
Anticoagulants (Warfarin): for pts w/ atrial fibrillation reduces RR of recurrent stroke by about 70% (CHA2DS2-VASc Score)
Antiplatelet agents: ASA and extended-release dipyridamole (Persantine)
Carotid endarterectomy: pets who have at least 70% stenosis of the symptomatic carotid artery
CHA2DS2-VASc Score
used to determine whether to recommend anticoagulants to patients with Atrial Fibrillation
- estimate risk of pt having a thromboembolic event if no anti-coagulation medication is used
O = low risk: possibly DO NOT use Warfarin / Coumadin
1 or greater = moderate to high risk: recommended to use Warfarin / Coumadin
