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F15 Clinical and Physical Diagnosis > Week 1 'The Head' (HA's and TBI's) > Flashcards

Week 1 'The Head' (HA's and TBI's) Flashcards

1
Q

Listed are some lab tests one might take for someone with head pain/injury when appropriate:

ESR, CRP, CBC, CMP

What does each stand for and what does it test?

A

ESR (Erythrocyte Sedimentation Rate): A sed rate test isn’t a stand-alone diagnostic tool, but it may help your doctor diagnose or monitor the progress of an inflammatory disease. When your blood is placed in a tall, thin tube, red blood cells (erythrocytes) gradually settle to the bottom. Inflammation can cause the cells to clump together.

CRP (C-reactive protein) is a substance produced by the liver that increases in the presence of inflammation in the body. An elevated CRP level is identified with blood tests and is considered a non-specific “marker” for disease.

CBC (complete blood count) is a blood test used to evaluate your overall health and detect a wide range of disorders, including anemia, infection and leukemia. A complete blood count test measures several components of your blood, including erythrocytes.

CMP (comprehensive metabolic panel) is a blood test that measures your glucose level, electrolyte and fluid balance, kidney function, and liver function.

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2
Q

Mild Traumatic Brain Injury (mild concussion)

1. How is its severity graded?

A
  1. Grade 1=confusion, sx last 15min, no LOC

Grade 3=LOC for seconds to minutes

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3
Q

Mild TBI

  1. What are some of the immediate signs and sx?
  2. Longer lasting sx?
A
  1. none-to-brief loss of consciousness, dilated pupils, breathing stops, muscles flaccid, heart slows. Recovery in seconds to minutes.
  2. May have giddiness, anxiety, poor concentration, Headaches, and sleep disturbance for weeks
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4
Q

What is a Moderate Diffuse TBI?

1. Signs and Sx?

A

LOC lasting for up to an hour with slower recovery of orientation and behavior
1. Lethargic for 1-7 days, agitation and anxiety.

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5
Q

Moderate Diffuse TBI

2. What might show up on a CT scan?

A
  1. CT may be normal or may show scattered petechia in brain. Possible hematoma at contra-coup position
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6
Q

Define petechia:

A

a small red or purplish spot caused by a hemorrhage

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7
Q

what does hematoma at “contra-coup” position mean?

A

hematoma: a localized collection of blood outside the blood vessels, usually in liquid form within the tissue

Contra-coup position: In head injury, a coup injury occurs under the site of impact with an object, and a contrecoup injury occurs on the side opposite the area that was hit

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8
Q

Moderate Diffuse TBI

  1. What are the RED Flag symptoms of a Moderate Diffuse TBI?
  2. Tx?
A
  1. LOC, altered mental status, convulsions, persistent HA, weakness of the extremities, bleeding from the ears, loss of hearing
  2. hospitalization to watch for complications; rest (cognitive and physical), no alcohol or drugs
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9
Q

Moderate Diffuse TBI

5. What’s the prognosis and how does it vary with age?

A
  1. Complete recovery within days to weeks for those 40 may have permanent psychological and intellectual effects.
    Worse prognosis in alcohol and drug users.
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10
Q

Severe Diffuse TBI

  1. Categorized by injury or patient response?
  2. signs and sx?
  3. Tx?
A
  1. patient response
  2. deep loss of consciousness from start, severe brain edema, ischemic infarction, hemorrhages immediate or delayed several hours
    Respiratory obstruction due to vomit or saliva
    Brain stem damage shown by bilateral pupillary fixation, slow responses to light, or anisocoria
  3. Tx: emergency hospitalization
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11
Q

Define Ischemic Infarction

A

Ischemic: decrease of blood supply
Infarction: the occlusion of a blood vessel usually by an thrombus or embolus

Ischemic Infarction: Decrease of blood supply (ischemia) due to the obstruction of a blood vessel (infarction)

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12
Q

Define anisocoria

A

Anisocoria: a condition characterized by unequal size of the eyes

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13
Q

What is Bilateral Pupillary Fixation?

A

Bilateral Pupillary Fixation: both eyes’ pupils are fixated (won’t adjust to changes in light)….this is a guess

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14
Q

Post concussion syndrome

A

Some people will experience symptoms lasting from weeks to years, including anxiety, fatigue, dizziness, HA, memory problems, attention problems, sleep disturbance, irritability

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15
Q

Define normocephalic, microcephalic, and macrocephalic

A

Normocephalic: head and all major organs of the head are in normal condition without significant abnormalities

Microcephalic: condition where the head (circumference) is smaller than normal. Microcephaly may be caused by genetic abnormalities or by drugs, alcohol, certain viruses, and toxins that are exposed to the fetus during pregnancy and damage the developing brain tissue

Macrocephalic: the head is abnormally large

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16
Q

How can TBI lead to secondary injury?

A

further swelling of brain tissue can lead to secondary brainstem damage and death – from hypotension, hypoxia, infection, hematoma

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17
Q

With headaches there are two main ways of classifying them:

A
  1. Primary or Secondary

2. Vascular or nonvascular

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18
Q

What is a primary headache? Give some examples of types of headaches that fall into this category most often.

A

Any headache not caused by an underlying medical diagnosis (90% of all headaches)
Main Examples: Migraine, Tension-type cluster

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19
Q
  1. List some of the qualities of a vascular headache.
  2. How do vascular HA’s come about?
  3. List examples of HA’s in this category.
  4. How does it differ from a non-vascular HA?
A

Vascular HA: 1. quality of pain=throbbing or pounding,

  1. Caused when various triggers lead to rapid changes in artery size; from spasm/constriction. Other arteries in brain and scalp then dilate.
  2. Ex: migraine, cluster, fever, hypertension, exertion, hangover
  3. Non-vascular HA: steady, dull pain.
    Ex: tension-type, TMJ, brain tumor, sinus or dental infection, ear problem
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20
Q

History taking on patient complaint of Headache:

A

99% of info needed will be covered in the LMNOPQRST questions

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21
Q

What do the LMNOPQRST history taking questions stand for?

A 
L- Location
M-Management of Disease
N- New or Old
O-Onset
P-Precipitating Factors
Q- Quality
R- Relieving Factors
S- Severity 
T- Treatment/Timing
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22
Q

List some RED flags that should be taken very seriously if they come up during history taking

A

Onset after age 50 (temporal arteritis, intercranial mass)
Incr. frequency and severity (subdural hematoma, mass, medication overuse)
Sudden onset of HA (subarachnoid hemorrhage, vascular malformation, mass)
Pain moves to lower neck and thoracic spine (meningitis, meningial irritation)
First or worst HA (intracranial hemorrhage, CNS infx)
History of head trauma (intracranial hemorrhage, subdural hematoma, epidural hematoma)
History of HIV or cancer (meningitis, brain abscess, metastasis, opportunistic infx)
Changes in Mental status

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23
Q

PE for HA includes:

A 
Vital signs (esp BP, temp)
head and neck-carotid and temporal artery pulsations, cervical ROM, tenderness of muscles, palpate cranium, jaw, neck, sinus, perform oral and ear exam
Neurological exam (cranial nerves, motor/sensory, reflexes, coordination)
HEENT (fundoscopic exam extremely important to check for papilledema)
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24
Q

Papilledema

A

Papilledema (or papilloedema) is optic disc swelling that is caused by increased intracranial pressure. The swelling is usually bilateral and can occur over a period of hours to weeks.

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25
Q

What are some RED flags on PE of a patient with a HA?

A

Fever: infx (intercranial, systemic or local)
Neck stiffness/rigidity: meningitis
Papilledema: meningitis, mass, pseudotumor cerebri, increased intracranial pressure
Focal neurological signs
Signs of systemic illness or infection: meningitis, encephalitis, lyme dz, systemic infx, collagen vascular disease

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26
Q

List the types of HA’s

A

Migraine
Tension-type HA (TTH)…very common
Cluster HA ….neurovascular
Trigeminal Neuralgia
Giant Cell Arteritis (temporal arteritis)
Hemicrania Continua
SUNCT syndrome (shortlasting Unilateral Neuralgiform ha attacks w/ Conjunctival injection and Tearing)
Medication overuse HA
HA from inflammation and infx in skull/brain
Intracranial Masses
Subarachnoid Hemorrhage

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27
Q

Migraine HA’s
Epidemiology:
Frequency, Sex, Age of first migraine

A

Frequency: Second most common type of HA (tension-type is most common)
Sex: F:M 3:1
Age: First attack often is in childhood, incidence incr. in adolescence (age of onset >55 is strong predictor for intracranial path)

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28
Q

What are the theories/pathophysiology explaining what causes migraines?

A

neurovascular, vasoactive neuropeptide (substance P), cortical spreading depression, role of serotonin? genetics? (definitely familial)

29
Q

What does poly-factoral mean?

A

multiple vectors of treatment approaches

30
Q

List some common triggers for migraines:

A

Stress (emotional and physical)
Hormones in women (PMS, use of BCP or HRT)
Hypoglycemia (skipped meals)
Poor sleep
Changing weather conditions
Odors, light, smoke
Food intolerances/allergies (possibly account for 30-93%; cows milk, eggs, chocolate, wheat, MSG….esp. TYRAMINE-containing foods like cheese, cured or processed meats)

31
Q

What classifies a Migraine?

A

At least five attacks with the following:
HA lasting 4-72hrs
At least 2 of the following characteristics
-unilateral location
-pulsating quality
-moderate to severe pain
-worse with routine activity
During HA at least one of the following occurs, nausea, vomiting, photophobia, phonophobia
History, PE, and neuro exam show no evidence of organic dz.

32
Q

What is phonophobia?

A

Fear of loud sounds

33
Q

What classifies a migraine with aura?

A

Aura includes at least 1 of the following (during at least two attacks):
visual scintillating scotoma (area of loss of vision, irregular luminous patch)
sensory paresthesia on face, numbness, unilateral weakness, olfactory hallucinations
Dysphasic- speech disturbance (aphasia)

-Aura develops over 5-20 min, usu lasting

34
Q

paresthesia

A

sensation of tingling, tickling, pricking, or burning of a person’s skin with no apparent and obvious long-term physical effect.

35
Q

What are the 3 questions you ask if you suspect a Migraine?

A
  1. Has a HA limited your activities for a day or more in the last 3 months?
  2. Are you nauseated or sick to your stomach when you have a HA?
  3. Does light bother you when you have a HA?
36
Q

Tension-type HA (TTH)
Epidemiology:
Sex, age, triggers

A

sex: F:M, 2:1
age: all ages, but most are young adults
triggers: stress and mental tension, head or neck movement

37
Q

What are the diagnositic criteria for a TTH?

A

At least 2 of the following:

  • location of pain is bilateral in head or neck
  • quality of pain is steady (pressing/tightening), non-throbbing
  • Intensity is mild to moderate
  • HA pain not aggravated by normal activity

ALso, duration of pain btwn 30 min-7days, no evidence of organic dz

38
Q

Cluster HA epidemiology
Sex, frequency, age, mortality/morbidity, genetics

What triggers cluster HA’s?

A

Sex: M:F, 4.3:1 (more males get this than females!)
Age: mean age of onset 30 yrs for men, later for women
Genetics: autosomal dominant gene may play a role
Frequency: .4-1% of all males get this!

Triggers: Season (spring or autumn), often mistakenly associated with allergies, common in cigarette smokers

39
Q

Diagnostic criteria for cluster HA’s:
Episodic Cluster HA:
Chronic cluster headache:

A

Episodic cluster HA: at least 2 cluster periods lasting 7 days to 1 year, are separated by pain-free periods lasting >1month

Chronic Cluster HA: attacks occur for >1 year w/out remission or with remission of

40
Q 
Describe the general characteristics of cluster HA's
Onset:
Pain Quality:
Location:
Duration:
Frequency:
Concomitant symptoms:
A

Onset: sudden pain, peaks in 10-15 min; typically awakens a person from sleep “alarm clock HA”

Pain Quality: boring, constant, searing, “knife cutting through head”, scalp may be tender, pulsing in arteries felt

Location: Unilateral facial, temple, periorbital region (trigeminal V1 or V2), remains on same side during cluster period

Duration: 10minutes - 3hrs per episode

Frequency: 1-3 but up to 8 episodes per day for up to 12 months

Concomitant symptoms: nausea, restlessness, agitation and at least one of the following on ipsilateral side-
conjunctival injection, lacrimation, miosis, ptosis, eyelid edema, facial sweating, nasal congestion, rhinorrhea

41
Q

miosis

A

excessive constriction of the pupil of the eye

42
Q

ptosis

A

drooping of the upper eyelid

43
Q

In cluster HA’s, some patients experience symptom-free intervals lasting an average of

A

In cluster HA’s, some patients experience symptom-free intervals lasting an average of 2 yrs (2months-20yrs)

44
Q

DDX for cluster HA’s:

A

paroxysmal hemicrania, trigeminal neuralgia, HA with intracranial lesion, SUNCT syndrome

45
Q

Trigeminal Neuralgia
Mortality/morbidity:
Sex:
Age:

A

Mortality/morbidity: severity of pain may lead to suicide
Sex: M:F = 1:1.5
Age: in 90%, begins >40 yrs

46
Q

Trigeminal Neuralgia

Diagnostic criteria:

A

Paroxysmal attacks of facial or frontal pain occur, lasting a fraction of a second to 2 minutes. Pain has at least one of the following charcteristics:
sudden, intense, sharp, superficial, stabbing, burning in quality, precipitation from trigger areas

47
Q

Trigeminal Neuralgia
Location:
Duration:
Triggers:

A

Location: right side > left , most commonly V2 or V3

Duration: paroxysms from few secs to few minutes, bouts from few days to months, with remission from weeks to years

Triggers: touching, heat, cold, wind, chewing, yawning, grimacing, talking, shaving, washing, brushing teeth, etc….

48
Q

Trigeminal Neuralgia

Work up: head CT or MRI is indicated in patients with:

A

head CT or MRI is indicated in patients with trigeminal sensory loss (light touch), patients with bilateral symptoms, under age 40

49
Q

DDX of trigeminal Neuralgia:

A

SUNCT syndrome, cluster-tic syndrome, jabs and jolts syndrome, post herpetic neuralgia (varicella zoster virus) and other neuralgias

50
Q

Work up for Cluster HA’s

A

CT or MRI is warranted to rule out brain or pituitary pathology

51
Q

Workup for Tension-Type HA

A

Assess triggers/stressors

PE: Neurologic and musculoskeletal exams- typically all findings will be normal

52
Q

Workup for Migraine patients:

A

Medical Hx
HA diary
Screening test for Migraine (the three questions)

53
Q

Hemicrania Continua, what is it? What causes it? How is it different from cluster HA’s?

M:F?
What is one effective treatment?

A

A type of trigeminal autonomic cephalagia, HA of unknown origin. Differs from CLuster HAs in higher frequency/shorter duration of attacks;

higher incidence in women, 2:1

indomethacin is effective treatment

54
Q

FYI diagnostic criteria and work up for hemicrania is left out

A

B/c not too important

55
Q

SUNCT syndrome

What does it stand for?

A

Short lasting, Unilateral Neuralgia ha attacks w/ Conjunctival injection and Tearing

56
Q

What is conjunctival injection?

A

a non-specific term to describe an eye that appears red due to illness or injury. The term usually refers to injection and prominence of the superficial blood vessels of the conjunctiva, or sclera, which may be caused by disorders of these or adjacent structures.

57
Q

SUNCT syndrome: common or rare? what causes it? What is it?

Nature of the HA:

A

rare.
unknown cause.
A type of trigeminal autonomic cephalagia.

Sudden brief attacks of severe UNILATERAL head pain in orbital, periorbital, or temporal areas, with concomitant ipsilateral cranial automonic symptoms (last 5sec-2min, with 3-200/day, 1-2 bouts per year, remission lasting months

58
Q

FYI triggers and workup for SUNCT are left out

A

adfda

59
Q

Medication Overuse HA
Define: (what type of medication?)
____% of patients with chronic HAs and most with daily HAs have analgesic overuse HAs

A

“rebound HA”
Definition: worsening of head pain in chronic HA sufferers due to frequent and !excessive use of analgesic!

20%

60
Q

Medication overuse HA’s typically occur in this age group:

M:F ratio?

A

30-40 yos

M:F = 1:5

61
Q

FYI Criteria, characteristics, and DDX for med overuse HA’s is left out

A

adfasf

62
Q

HA from inflammation and Infx in skull/brain

Main cause:

A

meningitis

63
Q

Meningitis
Etiology:
Organism: (try to list 4)

A

microbial infx/inflammation (often in young folks in close living quarters)

Organism: Streptococcus pneumoniae, Neisseria meningitidis, staphylococci, Haemophilus influenza type B (in those not vaccinated), Mycobacterium tuberculosis
Also, viral, fungal, parasitic, and non-infectious cases

64
Q

Meningitis onset: rapid or gradual?

SSxs:
what is the triad to look for?

A

yes, it can be rapid or gradual

SSxs: generalized HA, throbbing, very severe, they will just look really sick
TRIAD: nuchal rigidity, change in mental status, fever (not all have all 3)

65
Q

Meningitis
PE:
Associated sx and signs:

A

PE:
Kernig’s sign = guarding in hamstrings to prevent traction of spinal cord
Brudzinski’s sign = involuntary flexion of hip/knee and neck pain
fundoscopic exam to check for papilledema
Mental status exam
dermatologic exam to assess for rash (later stage sign)

Associated sx and signs: seizure, collapse, loss of consciousness, vomiting, petechial rash

66
Q

Meningitis

How is it diagnosed?

A

Diagnosis by lumbar puncture, blood culture/gram stain

67
Q

Intracranial Masses:
Give an example:
Pain is where? bilateral or unilateral?

As tumor gets bigger, what will you see?

How would you diagnose one of these?

A

Any intracranial tumor
Ex: pituitary tumor (compressing on sella turcica)

Signs and Sxs: pain is referred to frontal and temporal regions (bilateral), or vertex or occiput

As tumor gets bigger it will compress optic chiasm or nerves and hypothalamus leading to:

  • visual field defects (bilateral or unilateral)
  • Associated signs of pituitary hormone deficits

DX: CT or MRI of cranium

68
Q

Subarachnoid Hemorrhage

A

Bleeding is due to head trauma or spontaneous rupture of a congenital intracranial aneurysm

Onset: sudden, followed by chronic, persistent intense HA (worst and worsening)

SSxs: see meningitis

69
Q

subdural hematoma

A

Wiki: is a type of hematoma, usually associated with traumatic brain injury. Blood gathers between the dura mater, and the brain. Usually resulting from tears in bridging veins which cross the subdural space, subdural hemorrhages may cause an increase in intracranial pressure (ICP), which can cause compression of and damage to delicate brain tissue. Subdural hematomas are often life-threatening when acute.

Class: Onset gradual, steady aching, gradual personality changes, altered consciousness, hemiparesis

F15 Clinical and Physical Diagnosis (5 decks)

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