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93 Cards in this Set

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cluster HA characteristics:
male, awakens during night, days-months, severe pain, lasts an hour; located directly behind one eye, lacrimation, nasal d/c; triggered by smoking, alcohol use
prophylaxis of migraines?
beta-blocker: propanolol
acute tx of migraine in pt with angina?
ibuprofen
migraine pain characteristics?
pulsatile
tx for cluster HA?
NSAID's, O2, tryptans
drawback of Fioricet?
Fioricet = butalbital + APAP + caffeine; frequent use can lead to rebound HA
drawback of neuoleptic prochlorperazine / Compazine and promethazine / Phenergan frequent use for migraine?
extrapyramidal movement risk
first line for prophylaxis of TTH:
nortriptyline
things to consider in patient with acute HA:
hx of identical HA?, intact cognition, supple neck, normal neuro, sx improvement during observation and tx
Primary HA:
NOT associated with other diseases; it is likely the interplay of genetic, developmental, environmental
Examples of Primary HA:
TTH, migraine, cluster
Secondary HA:
associated with or caused by other conditions, no resolution until specific cause is diagnosed and addressed
Examples of Secondary HA:
intracranial issue such as brain tumor, bleeding, inflammation, or any condition causing ICP
m/c type of migraine:
w/o aura = 80% of migraines
aura
from cerebral cortex / brainstem; lasts 5-20mins; accompanied / followed by a migraine
TTH abortive tx:
APAP, NSAIDs, combinations with caffeine
cluster HA
AKA migrainous neuralgia; only primary HA more common in men than women; "suicide HA"
TTH characteristics:
30mins-7days; pressing, non-pulsatile pain, bilat; could present with N, photo-, or phono-phobia
migraine without aura characteristics:
4-72hours with:
unilateral, pulsating quality; aggravated by normal activity; N/V, photo and phonophobia
migraine with aura characteristics:
focal dysfunction of cerebral cortex / brainstem causes >=1 sx: dread / anxiety, unusual fatigue, nervousness / excitement, GI upset, visual / olfactory alteration; NO aura sx should last > 1 hour - if so, choose different dx; + fhx in 70-90%
cluster HA characteristics:
occur daily in clusters; the clusters can last weeks to months and disappear for a time; can occur at equinoxes; 1-8x/d at the same time of day; common 1 hour into sleep session; unilateral behind the eye; like "hot poker"; crescendo pattern 15 min-3hours; ipsilateral lacrimation, conjunctival injection, ptosis, stuffiness; female:male 1:3-1:8!
HA red flags:
S:systemic sx: fever, weight loss, secondary HA RF's
N:neurologic sx: confusion, impaired conciousness, nuchal rigidity, HTN, papilledema, CN dysfunction, abnl motor function
O:onset: sudden, abrupt; with exertion, sex, cough, sneeze (suggests subarachnoid hemorrhage, increased ICP)
Onset, age: >50y/o or <5y/o
Previous: HA hx: 1st HA in >=30y/o; new onset of different HA
HA red flags mnemonic:
S - systemic
N - neuro
O - onset
O - onset, age of
P - previous HA hx
dietary triggers of migraine:
ripened cheese, sour cream, processed or smoked meats, organ meats, MSG, yeast products, chocolate, caffeine, nuts, onions, dried fruits, citrus, bananas, alcohol, artificial sweeteners
Triptans MOA:
act as selective serotonin receptor AGONISTs and act at the 5-HT1K serotonin receptor; increased uptake of serotonin; vasoconstrictor effect (avoid in high risk for CAD, pregnancy, pts with recent use of ergots); caution with MAOIs or high-dose SSRI; may benefit severe TTH
Ergotamines MOA:
5-HT1A and 5-HT1D receptor agonists; don't alter cerebral blood flow; avoid in CAD and pregnancy
Onset of IBU; onset of naproxen and naproxen sodium
IBU: rapid onset (within 30 minutes)
Naproxen / Naprosyn: slow onset (60 minutes)
Naproxen sodium / Aleve, Anaprox: 30 minutes
Fioricet benefits:
caffeine enhances the analgesics of APAP, butalbital (barbiturate) enhances NT action; use infrequently to avoid rebound
dietary triggers of migraine:
ripened cheese, sour cream, processed or smoked meats, organ meats, MSG, yeast products, chocolate, caffeine, nuts, onions, dried fruits, citrus, bananas, alcohol, artificial sweeteners
Triptans MOA:
act as selective serotonin receptor AGONISTs and act at the 5-HT1K serotonin receptor; increased uptake of serotonin; vasoconstrictor effect (avoid in high risk for CAD, pregnancy, pts with recent use of ergots); caution with MAOIs or high-dose SSRI; may benefit severe TTH
Ergotamines MOA:
5-HT1A and 5-HT1D receptor agonists; don't alter cerebral blood flow; avoid in CAD and pregnancy
Onset of IBU; onset of naproxen and naproxen sodium
IBU: rapid onset
Naproxen / Naprosyn: slow onset
Naproxen sodium / Aleve, Anaprox: more rapid onset
Fioricet benefits:
caffeine enhances the analgesics of APAP, butalbital (barbiturate) enhances NT action; use infrequently to avoid rebound
Midrin contains ___ and is for ___.
Midrin contains isometheptene mutate (vasocostrictor), APAP (analgesic) and dichloralphenazone (relaxant) ansd is used at onset of migraine or TTH.
Neuoroleptic examples
aka 1st gen. antipsychotics: prochlorperazine / compazine and promethazine / phenergan; also are antiemetics; highly sedating; limit to 3 d / w d/t risk of extrapyramidal sx
other anti emetics used in migraineurs:
ondansetron / zofran (non-sedating, $$$), metoclopramide / reglan (prokinetic, well-tolerated - not for daily use d/t EPM risk)
Systemic corticosteroids for intractable / severe migraine and in cluster HA
not for >1xm; use prednisone 20mg 4xdx2d or a Medrol Dosepak
opioids: hydrocodone, oxycodone, codeine in relation to HA:
migraine rescue; sedating, habituating
goal of migraine prophylaxis:
50% reduction in # in 2/3 of pt's; with easier-to-control HA
method of migraine prophylaxis drugs action:
blockade of the 5HT2 receptor; needs 1-2m use; look out for HA producing meds: estrogen, progesterone, vasodilators
HA of increased ICP characteristics:
worst on awakening, less intense as day passes; Must find ETX!
findings in CSF of pt with bacterial meningitis?
glucose about 30% of serum levels
findings in CSF of aseptic or viral meningitis?
predominance of lymphocytes
PE findings in papilledema:
optic disk bulging
Neisseria is:
G- diplococcus
during an outbreak of meningococcal meningitis, what to use for prophylaxis?
1dose ceftriaxone, mult. doses of rifampin, 1dose of MCV4 or Menactra
common pathogens in bacterial meningitis:
strept. pneumo (G+ diplococci), neisseria (G- diplococci), staphylo (G+ cocci), haemophilus influ (G- coccobaccili); seeding is usually via hematogenous spread, likely from asx nose and throat bacteria
clinical presentation for an adult with bacterial meningitis:
fever, HA, nuchal rigidity; in elderly, the fever and rigidity are often absent; encephalitis is more likely Viral and with fewer meningeal signs
define pleocytosis:
WBC count of more than 5 cells/mm3 of CSF; expected in meningitis caused by bacterial, viral, TB, fungal, or protozoan; elevated CSF opening pressure in almost all cases
in bact. meningitis CSF exam findings include:
WBC median of 1200cells/mm3 of CSF with 95% neutrophils; also decrease CSF glucose to about 40% of plasma concentration
in viral meningitis, what happens to glucose, protein, lymphocytes?
glucose: nml
nml to slight elevated protein
lymphocytosis; Head CT or MRI before lumbar puncture
pailledema - optic disk bulging -
absence of venous pulsations on fundoscope = increased ICP
neissereria menigitidis, extra characteristics:
purpuritic or petechial rash in 50% of pt's
N. meningitidis is seen in ___% of people.
5-10% healthy adults; 60-80% of those in closed populations
incubation of n. meningitis:
3-4d average, communicable at that time
MCV 4 vaccine recommendation for:
children 2-10y/o; >=55y/o
tx for suspected bacterial meningitis?
ceftriaxone with or without vancomycin or ampicillin or both; acyclovir is an option in viral (aseptic) meningitis
tx for MS, includes:
interferon beta-1b or 1a (reduces exacerbations); mitoxantrone / Novantrone (immunosuppression); natalizumab / Tysabri (MAB; potential for progressive multifocal leukoencephalopathy)
tx for Parkinson's:
levodopa, ropinirole, pramipexole
surgical indication for Parkinson's:
when meds aren't tolerated or helpful
findings on a PE with Parkinson's:
resting tremor and bradykinesia
MS characteristics:
recurrent, chronic demyelinating disorder, focal neuro deficits, relapsing and remitting; weakness or numbness of a limb, monocular vision loss, diplopia, vertigo, facial weakness or numbness, sphincter disturbed, ataxia, nystagmus
CSF characteristics in a pt with MS:
pleocytosis, predominance of monocytes, abnl protein, markedly increased gamma-globulin, high IgG level, increased myelin basic protein
other tx mainstays of MS exacerbations:
systemic high-dose coritcosteroids (shortens exacerbations)
Parkinson characteristics:
progressive movement disorder caused by alteration in dopamine-containing neurons of pars compacta of the substantial nigra; onset usually in 6th decade; possible in young adults
Dx of Parkinson's via clinical traits includes:
resting tremor, riiidity, bradykinesia, flexed posture, loss of postural reflexes, masklike facies; at least one aside from resting tremor must be present to dx
Parkinsonian gait looks like:
arms held rigid at sides, forward falls common, rapid, small steps, forward/backward small steps to turn
Tx for Parkinson's:
dopamine agonists: ropinirole / Requip, pramipexole / Mirapex; levodopa still used but increased SE's (after 5-10y develop dyskinesia) - Levodopa + Carbidopa = Sinemet
other Tx for Parkinson's:
amantadine / Symmetrel (an antiviral) - less than 1 y, can also be used later against the dyskinesias;
COMT inhibitors (increase t1/2 of levodopa): tolcapone Tasmar, entapone / Comtan
MAO-B inhibitors: selegiline (also increases the t1/2)
Apomorphin / Apokyn: injectible dopamine agonist for rescue;
benztropine (anticholinergic, help with tremor, however causes dry mouth, urinary retention, altered mentation)
pt presentation during absence / petit mal seizure:
blank staring lasting 3-50 seconds with impaired conciousness
pt presentation for simple partial seizure:
awake state with abnl motor behavior lasting seconds
pt presentation of tonic-clonic / grand mal seizure:
rigid extension of arms and legs, followed by sudden jerking movements with LoC
pt presentation with myoclonic seizure:
brief, jerking contractions of arms, legs, trunk, or all of these
adult seizure tx includes:
carbamazepine, phenytoin, gabapentin, valproic acid / Depakote, lamotrigine, topiramate
drug interactions when taking phenytoin (and carbamazepine) and ____.
theophylline; pheny and carbs are narrow therapeutic index drugs; other NTI drugs are warfarin, theophylline, digoxin; many NTI drugs have high levels of protein binding / cytochrome
risk factors for TIA:
a-fib, carotid artery disease, OC use
TIA can last:
24 hours or less
in recent TIA, consider:
LT antiplatelet therapy is indicated
m/c etx of stroke:
cerebral ischemia
presentation of acute stroke:
partial visual field loss, unilat hearing loss, facial muscle paralysis, vertigo, diplopia, HA, ataxia
RF's for TIA include:
a-fib, carotid artery disease, OCP
TIA =
reversible neurologic sx that can last up to 24 hours
in care of pt with recent TIA:
LT antiplatelet therapy is indicated
m/c etx of CVA:
cerebral ischemia
presentation of acute CVA:
partial loss of visual field, unilat hearing loss, facial mm paralysis, vertigo, diplopia, HA, ataxia
RF's for CVA:
atherosclerosis, cardiac problems, hyper coagulable states (OCP use), HTN, dyslipidemia, DM, hx of TIA or ischemia
secondary prevention for CVA:
antiplatelet therapy with ASA or (if ASA not tolerated or if PAD or other atherosclerosis) clopidogrel / Plavix
if TIA or stroke originates from cardiac embolus, care includes tx with:
warfarin PO with INR goal 2.0-3.0
m/c etiologies of delirium and dementia:
delirium: acute infection
dementia: Alzheimer disease
m/c etx of delirium mnemonic:
D: drugs
E: emotional, E for electrolyte
L: low PO2
I: infection - UTI and CAP
R: retention of urine or feces, Reduced sensory input
I: ictal (alc. withdrawal is a common reason for isolated 1st seizure in elderly)
U: undernutrition
M: metabolic, Myocardial problems
S: subdural hematoma, can be from trivial trauma
Eval of pt with mental status change, labs:
BUN, Cr, glucose, calcium, sodium, LFTs, b12/folate, TSH, RPR, CBC with WBC diff., UA, U C&S, ECG
m/c etx of dementia:
Alzheimer's and multi-infarct / vascular dementia
tx for dementia:
cholinesterase inhibitors: donepezil/ Aricept, tacrine / Cognex, rivastigmine / Exelon - these have clear, minor, time-limited benefits; NMDA-receptor antagonists: memantine / Namenda