Unit 3 Flashcards
Bacterial Meningitis Subjective Signs
Headache Photophobia Neck Pain/Stiffness Stiffness (Nuchal) N/V Myalgia
Bacterial Meningitis - Objective Symptoms
Fever (103+) w/chills, tachycardia, & tachypnea
Brudzinski’s sign
Kernig’s sign
Opisthotonus
Change in mental status (confusion, lethargy, stupor, coma)
Cranial nerve dysfunction (unilateral) ->diploplia, facial weakness, pupillary abnormalities
Seizures
Rash (petechial)
Posturing (decorticate/decerebrate)
Kernig’s Sign
Inability to fully extend the legs
Brudzinski’s Sign
Hip & knee flexion when the neck is flexed
Opisthotonus
Severe back spasm, causing arching of the back
Bacterial Meningitis causes cranial nerve abnormalities (unilateral). What are the symptoms?
diploplia, facial weakness, pupillary abnormalities (dilated/nonreactive)
Post-polio - Subjective Signs
Muscle weakness (progressive) Fatigue (generalized & muscular) Joint pain
Post-polio - Objective Symptoms
Muscle atrophy (gradual) Increasing skeletal deformities (scoliosis-curvature of the spine)
Who is risk for Post-Polio Syndrome
Polio is a contagious (viral) disease. Only a polio survivor can develop Post-Polio Syndrome. An estimated 25-40% of polio survivors develop PPS.
What causes Post-Polio Syndrome
The new weakness appears to be related to the degeneration of individual nerve terminals and the muscle fibers it activates. Body compensates by creating new nerve-end terminals. Over time motor neurons lose the ability to maintain the increased work demands.
How is Post-Polio Syndrome diagnosed
Diagnosed after a comprehensive medical history & physical exam, and by excluding other disorders. No specific labs
Criteria for a Post-Polio diagnosis
[] Prior paralytic poliomyelitis (w/motor neuron loss)
[] A period of partial or complete functional recovery after acute infection. (15+ years)
[] Slow progressive & persistent new muscle weakness or decreased endurance, with or without generalized fatigue, muscle atrophy, or muscle/joint pain
[] Symptoms persist at least 1 year
[] Exclude other causes (neuromuscular, medical, or skeletal abnormalities)
True or False:
Progressive scoliosis causing breathing insufficiency can occur years after polio but is not an indicator of Post-Polio Syndrome
True
How is Post-Polio Syndrome treated
[] No effective Rx that can stop deterioration or reverse the deficits.
[] Non-fatiguing exercises may improve muscle strength & reduce tiredness.
What is the role of exercise in the treatment of Post-Polio Syndrome
[] Exercise is safe & effective (medical supervision.
[] More likely to benefit those muscle groups that were least affected by polio.
[] Cardio better than strengthening
[] Frequent breaks
[] No muscle should be exercised to the point of ache, fatigue, or weakness
Can Post-Polio Syndrome be prevented
No
How is Progressive Supranuclear Palsy (PSP) different from Parkinson’s Disease
PSP:
[] Usually stand straight or occasionally tilt their heads backward.
[] Speech & swallowing problems are more severe and present earlier in disease process.
[] Abnormal eye movements
[] Tremor rare
[] Respond poorly to levodopa
Parkinson's: [] Usually bend forward [] Normal eye movements [] Tremor common [] Respond will to levodopa
How is Progressive Supranuclear Palsy (PSP) similar from Parkinson’s Disease
[] Both PSP & Parkinson’s cause stiffness, movement difficulties, & clumsiness.
[] Age of onset: late middle age
[] Bradykinesia (slow movement)
[] Muscle rigidity
Most common neurodegenerative disease
Alzheimer’s Disease
Second most common neurodegenerative disease
Parkinson’s Disease
Parkinson’s Disease - general definition
Chronic, progressive, degenerative disorder of the basal ganglia in the CNS
Parkinsonism is divided into 4 categories
[] Idiopathic (most common)
[] Symptomatic
[] Parkinson-plus syndromes (known cause, ie CVA, drugs, infection, trauma, toxin exposure)
[] Other herododegenerative diseases (ie Huntington’s)
Cause of Parkinson’s Disease
Unknown
Pathophysiology of Parkinson’s Disease
[] A degenerative disease of the motor systems of the brain.
[] Progressive cell loss is noted in the substantia nigra, which carry major connections to the basal ganglia.
[] Also kills dopaminergic neurons, noradrenergic neurons, & cholingergic neurons. This produces a cellular abnormality called Lewy Bodies inside the neurons.
Parkinson’s Disease - Subjective Signs
6 cardinal signs: [] tremor at rest [] rigidity [] bradykinesia or hypokinesia [] flexed posture [] loss of postural reflexes [] freezing phenomenon
Parkinson’s Disease - Objective Symptoms
[] tremor
[] weak & clumsy limb
[] a stiff, achy limb
[] gait disorder
Constipation, orthostatic hypotension, dysarthria (slurred speech), hypophonia (soft speech), hypomimia (mask-like face) are also common.
Parkinson’s Disease - Diagnostic Tests
H&P usually leads to diagnosis
CT or MRI to r/o structural brain lesions
Ca2+ level to exclude hypoparathyroidism
PET scan can detect changes in striatal dopamine & subclinical nigral pathology
Parkinson’s Disease - Management
Control symptoms Levodopa Add Seleginine (MAO-B inhibitor) if Levodopa produces fluctuation in response
Parkinson’s Disease - Differential diagnosis
Essential tremor Medication induced Infarct or tumor of the basal ganglia Wilson's disease Huntington's disease
Parkinson’s disease - Differential Dx
Essential tremor Medication induced Progressive Supranuclear Palsy Infarcts or tumors in the basal ganglia Wilson's disease Huntington's disease
Levodopa. Drug class = ________
Dopaminergic
Drug class = MAO Inhibitor
Name 2 examples
Used to treat ________
Selegiline (Eldepryl L-deprenyl)
Rosagiline (Azilect)
Parkinson’s disease
Drug class = Dopaminergic
Used to treat _________
2 examples
Parkinson’s disease
Carbidopa/Levodopa (Sinemet, Atamet)
Amantadine (Symmetrel)
Drug class = Dopamine Agonist
4 examples
Used to treat _______
Bromocriptine (Parlodel)
Pergolide (Permax)
Pramipexole (Mirapex)
Ropinirole (Requip)
Parkinson’s disease
Drug class = Anticholinergics
2 examples
Used to treat _______
Trihexyphenidyl (Artane)
Benzotropine (Cogentin)
Parkinson’s disease
Drug class = Peripheral catechol-O-methyltransferase (COMT) Inhibitors
2 examples
Used as adjunctive therapies to ______ for the treatment of ______
Tolcapone (Tasmar)
Entacapone (Comtan)
Adjunctive therapy to levodopa for the treatment of Parkinson’s disease.
Parkinson’s disease - Treatment options for patients with severe symptoms that are refractory to meds.
Thalamotomy (for intractable tremors and drug induced kinesias
Pallidotomy (for bradykinesias, tremor, and dyskinesias
Deep brain stimulation to suppress rest tremor
Stroke - Differential diagnosis
[] Subarachnoid hemorrhage (severe HA w/ \/ LOC
[] Subdural hematoma (HA-generalized & bitemporal
[] Brain abscess (HA, altered LOC, hemiparesis, NV, fever)
[] Idiopathic intracranial HTN (pseudotumor) (papilledema, diplopia, HA, normal CT)
[] Arterial dissection (cephalic pain, sudden HA ->retinal or hemispheric ischemic symptoms)
[] Carotid dissection (Occipital HA or acute neck pain -> ischemic symptoms of diplopia, syncope, and amaurosis fugax, unilateral neck pain that is sudden and radiates to the ipsilateral face or eye)
[] Encephalitis (general, sudden HA w/ confusion, altered LOC, seizures)
Amaurosis Fugax
A temporary blindness that may result from transient ischemia caused by an insufficiency of the carotid artery or exposure to centrifugal force
Mini-mental exam - definition
When is it used
Tool to assess mental status or cognition.
Useful for gross screening of dementia. It is the initial test done when trying to diagnose Alzheimer’s Disease.
Agitation Dementia - Non-Pharm Management
Reduce 5 common triggers: fatigue change in routine Misleading or inappropriate stimulus Demands to perform beyond abilities Physical stressors (pain)
Meaningful activities Validation therapy Social contract Animal0assisted behavior Exercise, Reminiscence, Music Relaxation
Agitation Dementia - Pharm Management
Atypical antipsychotics (1st line) Quetiapine (Seroquel)
Anticonvulsants and acetylcholinesterase inhibitors (2nd line)
Benzodiazepines
Suicide Stats
Males successfully complete suicide (gun) 3:1 vs. females (OD).
Risk /\ w/age; 65+ more likely to commit suicide.
Older adults are less likely to voice intent
Caucasians are at the greatest risk
Higher risk: unemployed, single, divorced, widowed, EtOH/drug problems, Chronic/life-threatening/painful illness.
Chronic alcoholism & substance abuse = 25% of all completed suicides
Major depression and bipolar disorders = 50% al all suicides.
White men with mild depressive disorder are 5X more likely to commit suicide than the general pop.
Know causes of bacterial meningitis.
What age group at risk
Neisseria meningitis (children/young adults) Heamophilus influenza type B (infants/children) Streptococcus pneumonia (adults)
Screening tools for chemical dependency
CAGE
TACE (alcoholism in pregnant woman)
CRAFFT(adolescent alcohol problem)
C
A
G
E
Alcohol use assessment:
Have you ever tried to Cut back?
Have you ever been Annoyed/Angered when questioned about use?
Have you ever felt Guilt about use?
Have you ever had an Eye-opener to get started in the AM?
T
A
C
E
How many drinks does it Take to make you feel high?
Have people Annoyed you by criticizing your drinking?
Have you felt you ought to Cut down on your drinking?
Have you ever had to have an Eye-opener?
C R A F F T
Have you ever ridden in a Car w/someone high/drunk?
Do you drink/take drugs to Relax, feel better about yourself, or to fit it?
Do you drink/take drugs while you are Alone?
Do you ever Forget things you did while drinking/taking drugs?
Does a Family member or Friend tell you to cut down?
Have you ever gotten into Trouble because of drinking/drugs?
Stress Incontinence - management
Kegel exercises Weight loss Electrical stimulation Alpha-adrenergics agonists ( ) No diuretics Surgical correction of hypermobile bladder neck & periurethral bulking agents
Urge incontinence - management
Scheduled toileting Fluid management Treat UTI if needed Topical estrogen Anticholinergics Smooth muscle relaxants Tricyclic antidepressant Sx-stones, tumors OAB-antimuscarinics to block parasympathetic stimulation of detrusor muscle
Overflow incontinence - Management
Tx underlying problem Scheduled toileting Crede's maneuver Alpha-blockers Catheters/pads
Functional incontinence - Management
Remove barriers Education Scheduled toileting PT/OT Vaginal cone Kegel exercises Pads
Rx - overactive bladder
Anticholinergics Oxybutynin (Ditropan) Tolterodine (Detrol) Trospium chloride Darifenacin Solifenacin Fesoterodine fumarate (Toviaz)
What can cause “the worst headache of my life”
*Traction/Inflammatory headache
Temporal arteritis
Subdural hematoma
Immediate referral to neurosurgeon
Describe a traction/inflammatory
Acute New onset Increasing intensity Medical emergency Constant progressive pain
TIA treatment
Hospitalization should be considered for patients seen within 72 hours of the attack, when they are at increased risk for early recurrence
Most common drugs that cause delirium
Tricyclic antidepressants Lithium Sedative hypnotics (benzos) Anticonvulsants (barbiturates) Anti-Parkinson's (benztropine, trihexyphenidyl) Narcotics Anticholinergics Beta blockers Steroids NSAIDs Digoxin Cimetidine Fluoroquinolones Skeletal muscle relaxants
Potential causes of new onset seizures
In most newly diagnosed cases, no specific cause is identified. Many implicating factors: Head trauma CNS infection CVA Hyponatremia Hypocalcemia Hypoglycemia Hypoxia Drug OD/withdrawal
New onset seizures - testing that should be done
CBC Glucose CMP LFTs Serum Ca2+ UA Drug screen Blood alcohol Blood levels of anti-seizure meds EEG CT MRI lumbar puncture EKG
Dementia associated with Parkinson’s disease
Pathophysiology
Degenerative disorder of the basal ganglia involving the Dopaminergic nigrostriatal pathway. It involves the loss of pigmented neurons in the substantia nigra -> Formation of Lewy bodies
Parkinson’s disease dementia may affect multiple cognitive domains including:
Attention Memory Visuospatial Constructional Executive functions
How to handle confusion in a NH patient who has a psych diagnosis.
Treatment consists of
identifying the underlying cause,
correction of precipitating factors, &
symptom mgmt.
Interventions for the confused NH pt.
Restore fluid and electrolyte balance Environmental changes Support techniques (ie eliminate unnecessary stimuli, safe environment, reduce anxiety)
If the underlying cause of confusion (in the NH pt.) is a psych diagnosis ___________ may be helpful.
Pharmacotherapy such as sedatives and neuroleptics.
Drugs prescribed for delirium
Haloperidol Thioridazine Chlorpromazine Ativan Midazolam Risperidone Zyprexa
Early symptoms of Alzheimer’s Disease
Difficulty remembering names and recent events Difficulty expressing oneself with words Spatial cognition problems Impaired reasoning and judgment Apathy Depression
Later symptoms of Alzheimer’s Disease
Impaired judgment
Disorientation
Behavior changes
Difficulty speaking, swallowing, walking
Management of Alzheimer’s Disease
First line of treatment: Cholinesterase inhibitors
ie: Donepezil, Galantamine, & Rivastigmine
Dementia with Lewy Bodies - common symptoms
Visual hallucination
Muscle rigidity
Tremors
Dementia with Lewy Bodies - Management
Avoid neuroleptic drugs
Social interaction
Daily exercise
Low dose atypical antipsychotic (Quetiapine)
Frontotemporal dementia - Symptoms
Change in personality and behavior and difficulty with language.
Pick’s disease is characterized by Pick’s bodies in the brain. It is a form of _____
Frontotemporal dementia
Normal pressure hydrocephalus - Symptoms
Difficulty walking (ataxic gait)
Memory loss
Incontinence
Chronic Rx Management of Dementia
Rivastigmine L-dopa Selective serotonin reuptake (depression) Clonazepam or melatonin (sleep) Midodrine Memantine (hallucination or delusions)
Potential causes of seizures
Head trauma Tumors or lesions Alzheimer's Dis. CNS infection CVA Atherosclerosis Parkinson's Dis. Intracranial Hemorrhage Metabolic Disorders Substance withdrawl
Characteristics of Essential Tremor
Enhanced by emotional stress
Bilateral, begins in fingers and hands
Spreads to jaws, lips, & head
Treatment of Essential Tremor
Often unnecessary
If tremor is disabling, then propranolol
Primidone, if propranolol is ineffective
If Rx’s are not effective, then high frequency thalamic stimulation or subdural motor cortex stimulation
Cerebellar tremor occurs during…
movement and increases toward the end of purposeful act.
Cerebellar tremor - Associated s/s
Ataxia Nystagmus Incoordination Muscle weakness Atrophy
MS (multiple sclerosis) tremors - Associated s/s
Intermittent
Nystagmus Paralysis Constipation Muscle weekness Impotence
Work up for CVA
CBC PT/PTT Electrolytes BUN, Creatinine Glucose Ca 2+ Magnesium Sed rate EKG CXR MRI/CT head (no contrast) to exclude a nonvascular lesion, and to determine if the CVA is ischemic infarction or an intracranial hemorrhage.
CVA symptoms with decreased platelets and prolonged PT/PTT may indicate
hemorrhagic stroke
