Week 5 6 & 7 Flashcards
nociceptive pain
pain due to mechanical, thermal or chemical activation of receptor to noxious stimuli
neuropathic pain
pain due to damage to neuronal pathways involved in sensory processing
hyperalgesia
abnormal increase in sensitivity to painful stimuli (may occur after injury)
allodynia
perception of normal stimuli as painful
paresthesia
spontaneous sensations without generating stimuli
deafferentation pain
from interruption of afferent nerve impulses of spinothalamic tract
A-delta fibers
fast, sense pain
C fibers
slow, sense itch, temp and pain
gate control theory
interplay between fibers in dorsal horn such that activation of surrounding fibers (mechanical, shaking, pressure) can suppress pain signal (and TENS can also block)
pain inhibitory descending pathways (4)
o Locus coeruleus – noradrenergic o Dorsal raphe – serotonergic, GABAergic o Endogenous opioids - Endorphins, enkephalins, dynorphin o Cannabinoids, adenosine
central wind up pain
intensity increases over time for a given stimulus delivered repeatedly above critical rate
has greater firing, decreased threshold, increased or abnormal VGNaC
3 major opioid receptor subtypes
- Endorphins – MOR – Mu
- Enkephalins – DOR – delta
- Dynorphin – KOR – kappa
what does MOR do
Gi protein that inhibits adenyl cyclase and VGCC to increase K+ that leads to analgesia sedation, euphoria (reward, want MOR), antitussive (cough, codeine)
intracranial pain sensitive areas
venous sinuses, basal arteries, dura of fossae
red flags for headaches
change in pattern, progressive worsening, neurological dysfunction, fever, stiff neck, vomiting, confusion, LOC, character/personality change, post-trauma
tension headache
nagging, pressure, vice grip, band like
bilateral
migraine headache
unilateral, throbbing, worse with activity, aura, allodynia, triggers
migraine w/o aura diagnostic criteria
at least 5 attacks, 4-72 hours long, unilateral, pulsating, moderate to severe pain, aggravation by physical activity, associated with nausea, vomiting, photophobia or phonophobia
migraine w/ aura diagnostic criteria
At least 2 attacks fulfilling “without aura” criteria plus aura
Aura – visual disturbance like lines, lights flashing, color changes
retinal migraine
monocular visual disturbance, with scintillations, scotomata, blindness, and migraine headaches and normal optho exam
cluster headache
30-90 min
comes and goes in waves
one side, behind eye/temple, like a hot poker, eye redness and tearing, nasal discharge, drooping of eyelid, agitated, pacing, wakes at night (~1hr of sleep)
in elderly patients on BZDs, use ___________ to prevent ____________
1/2 dose to prevent falls
MS symptoms
Changes in sensation in arms, legs or face
Optic neuritis, nystagmus, diplopia
Weakness, spasms
Fatigue, cognitive impairment, depression
MS pathology
BBB breakdown allows T-cells to enter CNS and destroy myelin sheath
MS imaging
Gad enhancing lesions on T1 with plaques in white matter
MS labs
elevated IgG
oligoclonal bands
Neuromyelitis optica / Devic’s disease
demyelination and necrosis of optic nerves and spinal cord often preceded by viral illness and associate with systemic autoimmune diseases
Neuromyelitis optica / Devic’s disease symptoms
optic neuritis
myelitis
agoraphobia
distress from excessive worry in two or more situations: public transportation, open spaces, enclosed spaces, in line, in crowds or outside of the home alone
biomarkers for EtOH abuse (3)
γ-glutamyltransferase (GGT), carbohydrate-deficient transferrin (CDT) – better for recent heavy drinking/relapse
ethylglucuronide (EtG) – detects any drinking w/i 72 hours
Wernicke-Korsakoff syndrome
due to vitamin B1 deficiency
• Wernicke – encephalopathy, ataxia and ophthalmoplegia; Medical emergency – give B1 and Mg
• Korsakoff – anterograde amnesia, “stories”
what two drugs are not on a regular drug screen (2)
fentanyl, clonazepam
opioid drug testing
Natural derivatives – morphine -> test +
Semi-synthetics – hydrocodone -> test + or –
Synthetics – methadone -> test –
hallucinogen persisting perception disorder
re-experiencing of symptoms from hallucinogens like:
afterimages, trails, color flashes, lights and halos
what can you treat opioid addicted pregnant patient
methadone
can add buprenorphine
neonatal abstinence syndrome
high-pitched crying, yawning, sneezing, tremors, ↑ muscle tone, feeding difficulties, diarrhea, tachypnea or apnea, seizures
disinhibited social engagement disorder
o Child has experienced extremes of insufficient care (social neglect, deprivation, changes, unusual)
o After age 9 months, child develops pattern of disinhibited behavior (not just impulsivity) towards unfamiliar adults
acute stress disorder
o Exposure to trauma involving threat of death or injury or repeated exposure to details of trauma
o Leads to 9 or more of: Intrusive symptoms, negative mood, dissociative symptoms, avoidance or arousal problems (sleep, emotion, concentration)
o Lasting for 3 days to 1 month
self induced emesis causes _________
metabolic alkalosis
laxative and diuretic abuse cause ______
metabolic acidosis
difference between bulimia and anorexia
BN patients tend to experience their eating symptoms as more ego-dystonic (distressing) & thus they more readily seek treatment, compared to AN
Lhermitte sign
what is it and what does it suggest
electrical sensation runs down limbs when neck is bent forward
dorsal column lesion
Uhthoff phenomenon
worsening of symptoms of demyelinating diseases when body gets overheated by weather, exercise, fever, sauna, hot tub etc
difference between delirium and dementia
delirium will have an organic cause that can be seen on labs or imaging
potential underlying causes of mental disorders
TIT v DID
tumor, infection, trauma, vascular, degenerative, intoxications, developmental
delusional disorder
more than 1 delusion for at least one-month duration, function not markedly impaired or bizarre
positive symptoms of schizophrenia
hallucinations, delusions, disorganized speech, bizarre behavior, poor affect
negative symptoms of schizophrenia
alogia (poverty of speech), affective blunting (↓emotional range), apathy, anhedonia-asociality (inability to experience pleasure or enjoy activities)
pathophysiology of schizophrenia
dopamine hypothesis and glutamate hypothesis
hypofunction of NMDA receptors
schizophrenia co-morbidities risk
13x suicide rate, cardiovascular disease, weight gain, diabetes, metabolic syndrome, pulmonary disease, medications, lifestyle, SUDs
schizoaffective disorder
period with a major depressive or manic episode with Criterion A for schizophrenia
- Bipolar type – if the disturbance includes a manic or a mixed episode
- Depressive type – if only includes major depressive episodes
cataonia
psychomotor disturbance with stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, echolalia, echopraxia
mesolimbic dopamine pathway - blockage causes what and comes from where
Block of this pathway treats positive symptoms like delusions/hallucinations
From midbrain (ventral tegmentum to nucleus accumbens)
mesocortical dopamine - blockage causes what and comes from where
Block of this pathway may exacerbate the negative symptoms
From ventral tegmentum to PFC
nigrostriatal dopamine pathway - blockage causes what and comes from where
Block of this pathway can lad to EPS (dyskinesia, parkinsonism, akathisia)
From substantia nigra to basal ganglia
tuberoinfundibular dopamine pathway - blockage causes what and comes from where
Block of this pathway can lead to hyperprolactinemia (sexual dysfx, amenorrhea)
From hypothalamus to anterior pituitary
acute dystonic reaction
abrupt, distressing, painful, sustained contraction/spasm of the muscles of the neck, eyes, mouth, tongue, trunk or extremities; within first 4 days of treatment with antipsychotics
treatment of acute dystonic reaction
IM Benztropine or diphenhydramine
tardive dyskinesia
From chronic dopamine blockade via nigrostriatal pathway (super-sensitivity to DA)
Lip smacking, sucking, puckering, choreoathetoid-like movements of fingers and toes and slow, writhing movements of the trunk
neuroleptic malignant syndrome
Idiosyncratic reaction to dopamine antagonists that causes severe muscle rigidity, elevated temperature plus diaphoresis, confusion, coma, tachycardia, HTN, leukocytosis, elevated CK
Exposed to DA agonist within 72 hours, but can be up to 30 days
treatment for neuroleptic malignant syndrome
muscle relaxant dantrolene, dopamine agonist bromocriptine, or ECT
paroxysmal depolarization shift
Intense depolarization of epileptic neurons because the opening of the voltage gated potassium channels is not enough to bring the membrane down to baseline
most typical EEG wave
alpha
8-13 Hz
Benign Rolandic Epilepsy (Benign Epilepsy with Central Temporal Spikes)
Twitching, numbness, or tingling of the child’s face or tongue (a partial seizure), which often interferes with speech and may cause drooling
genetics related to Janz Syn (myoclonic epilepsy of childhood)
6p EF, GABRA1
genetics related to astrocytoma (4)
IDH1, EGFR, ATRX, and TERT
genetics related to oligodendroglioma (2)
1p and 19p co-deletions
genetics related to medulloblastoma (1)
MYCN amp
genetics related to Temozolomide treatment response
MGMT
type of edema seen with brain tumors
vasogenic
children with brain tumors often present with ____________
early morning headache and vomiting
children often have brain tumors located in _________
midline
leading to loss of coordination and spasticity due
features of glioblastoma (4)
worst adult tumor
angiogenesis/ neovascularization
prominent palisading necrosis
ring enhancing lesion on imaging
features of pilocytic astrocytoma (4)
benign
biphasic cystic pattern
elongated cells and Rosenthal fibers
features of oligodendroglioma (3)
round nuclei with halos, fried egg appearance
chicken wire vascularization
calcifications
features of ependymoma (2)
rosettes
4th ventricle
features of medulloblastoma (4)
grade 4 tumor of children
small blue cells
homer wright rosettes
radio-sensitive
medulloblastoma genetics
- Wnt pathway has best prognosis
* Myc pathway has worse prognosis
delirium treatment options
haloperidol
atypical antipsychotics
BZDs
neurofibromatosis I
o NF1 on Chr 17q AD
Peripheral neuromas, optic glioma
Café-au-lait spots, subQ nodules
Developmental delay, visual issues, painful neuromas, scoliosis
neurofibromatosis II
o NF2 on Chr 22 AD
Bilateral acoustic neuromas, earing and balance issues
Tuberous Sclerosis
o TS C-1 (hamartin) and TS C-2 (tuberin) AD to inhibit mTOR kinase
Developmental delay, seizures, adenoma sebaceous
Ash leaf spots, Pial hemagiomatosis, calcification, seizures
Giant Cell Astrocytoma
sturge weber syndrome
o GNAQ Chr 9:21 sporadic
Development delay, ADHD, headache, seizures, Pial hemagiomatosis, calcification, Port wine stain, buphthalmos
von hippel lindau
o VHL tumor suppressor gene 3p25-26 AD
Polycythemia, cystic lesions, tumors, telangiectasias, hemangioblastomas
Ataxia Telengectasia
o ATM AR
IgA and IgG deficiency that can lead to sinus and lung infections
Telangiectasias, cerebellar dysfunction, gait abnormalities
Osler Weber Rendu (Hereditary hemorrhagic telangiectasia)
o ALK-1, ENG, and SMAD4 genes AD
Ocular and nail related telangiectasias
Brain arteriovenous malformations, seizures/headaches/ataxia, visual
Klippel Trenauny syndrome
o PIK2CA gene
Overgrowth of bone and tissues, pain, bleeding, port-wine stains
Spinal cord arteriovenous malformations, paralysis (Coup de Poignard)
acute meningitis bugs
- Viral – enterovirus
- Bacteria – many (Neisseria, group B strep in newborns)
- Naegleria fowleri
subacute meningitis bugs
- Mycobacteria – Mycobacterium tuberculosis
- Spirochetes – Treponema pallidum, Borrelia burgdorferi
- Fungi – Cryptococcus neoformans, Candida spp. Coccidio, Aspergillus
CSF changes in meningitis
low glucose, increased protein
acute encephalitis bugs
- Viral – arthropod borne (West Nile), HSV, HIV, CMV, polio, rabies
- Other – listeria, rickettsia, mycoplasma, toxoplasma
chhonic encephalitis bugs
Tuberculous tuberculoma, neurosyphilis
malignant hyperthermia
rapid onset of tachycardia, muscle rigidity, HTN, hyperthermia, hyperkalemia, hypercapnia and metabolic acidosis
