Neurologic Disorders

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cluster HA characteristics:

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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

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prophylaxis of migraines?

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beta-blocker: propanolol

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acute tx of migraine in pt with angina?

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ibuprofen

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migraine pain characteristics?

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pulsatile

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tx for cluster HA?

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NSAID's, O2, tryptans

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drawback of Fioricet?

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Fioricet = butalbital + APAP + caffeine; frequent use can lead to rebound HA

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drawback of neuoleptic prochlorperazine / Compazine and promethazine / Phenergan frequent use for migraine?

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extrapyramidal movement risk

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first line for prophylaxis of TTH:

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nortriptyline

Front 9

things to consider in patient with acute HA:

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hx of identical HA?, intact cognition, supple neck, normal neuro, sx improvement during observation and tx

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Primary HA:

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NOT associated with other diseases; it is likely the interplay of genetic, developmental, environmental

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Examples of Primary HA:

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TTH, migraine, cluster

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Secondary HA:

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associated with or caused by other conditions, no resolution until specific cause is diagnosed and addressed

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Examples of Secondary HA:

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intracranial issue such as brain tumor, bleeding, inflammation, or any condition causing ICP

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m/c type of migraine:

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w/o aura = 80% of migraines

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aura

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from cerebral cortex / brainstem; lasts 5-20mins; accompanied / followed by a migraine

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TTH abortive tx:

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APAP, NSAIDs, combinations with caffeine

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cluster HA

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AKA migrainous neuralgia; only primary HA more common in men than women; "suicide HA"

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TTH characteristics:

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30mins-7days; pressing, non-pulsatile pain, bilat; could present with N, photo-, or phono-phobia

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migraine without aura characteristics:

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4-72hours with:
unilateral, pulsating quality; aggravated by normal activity; N/V, photo and phonophobia

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migraine with aura characteristics:

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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%

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cluster HA characteristics:

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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!

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HA red flags:

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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

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HA red flags mnemonic:

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S - systemic
N - neuro
O - onset
O - onset, age of
P - previous HA hx

Front 24

dietary triggers of migraine:

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ripened cheese, sour cream, processed or smoked meats, organ meats, MSG, yeast products, chocolate, caffeine, nuts, onions, dried fruits, citrus, bananas, alcohol, artificial sweeteners

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Triptans MOA:

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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

Front 26

Ergotamines MOA:

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5-HT1A and 5-HT1D receptor agonists; don't alter cerebral blood flow; avoid in CAD and pregnancy

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Onset of IBU; onset of naproxen and naproxen sodium

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IBU: rapid onset (within 30 minutes)
Naproxen / Naprosyn: slow onset (60 minutes)
Naproxen sodium / Aleve, Anaprox: 30 minutes

Front 28

Fioricet benefits:

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caffeine enhances the analgesics of APAP, butalbital (barbiturate) enhances NT action; use infrequently to avoid rebound

Front 29

dietary triggers of migraine:

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ripened cheese, sour cream, processed or smoked meats, organ meats, MSG, yeast products, chocolate, caffeine, nuts, onions, dried fruits, citrus, bananas, alcohol, artificial sweeteners

Front 30

Triptans MOA:

Back 30

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

Front 31

Ergotamines MOA:

Back 31

5-HT1A and 5-HT1D receptor agonists; don't alter cerebral blood flow; avoid in CAD and pregnancy

Front 32

Onset of IBU; onset of naproxen and naproxen sodium

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IBU: rapid onset
Naproxen / Naprosyn: slow onset
Naproxen sodium / Aleve, Anaprox: more rapid onset

Front 33

Fioricet benefits:

Back 33

caffeine enhances the analgesics of APAP, butalbital (barbiturate) enhances NT action; use infrequently to avoid rebound

Front 34

Midrin contains ___ and is for ___.

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Midrin contains isometheptene mutate (vasocostrictor), APAP (analgesic) and dichloralphenazone (relaxant) ansd is used at onset of migraine or TTH.

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Neuoroleptic examples

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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

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other anti emetics used in migraineurs:

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ondansetron / zofran (non-sedating, $$$), metoclopramide / reglan (prokinetic, well-tolerated - not for daily use d/t EPM risk)

Front 37

Systemic corticosteroids for intractable / severe migraine and in cluster HA

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not for >1xm; use prednisone 20mg 4xdx2d or a Medrol Dosepak

Front 38

opioids: hydrocodone, oxycodone, codeine in relation to HA:

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migraine rescue; sedating, habituating

Front 39

goal of migraine prophylaxis:

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50% reduction in # in 2/3 of pt's; with easier-to-control HA

Front 40

method of migraine prophylaxis drugs action:

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blockade of the 5HT2 receptor; needs 1-2m use; look out for HA producing meds: estrogen, progesterone, vasodilators

Front 41

HA of increased ICP characteristics:

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worst on awakening, less intense as day passes; Must find ETX!

Front 42

findings in CSF of pt with bacterial meningitis?

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glucose about 30% of serum levels

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findings in CSF of aseptic or viral meningitis?

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predominance of lymphocytes

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PE findings in papilledema:

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optic disk bulging

Front 45

Neisseria is:

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G- diplococcus

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during an outbreak of meningococcal meningitis, what to use for prophylaxis?

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1dose ceftriaxone, mult. doses of rifampin, 1dose of MCV4 or Menactra

Front 47

common pathogens in bacterial meningitis:

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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

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clinical presentation for an adult with bacterial meningitis:

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fever, HA, nuchal rigidity; in elderly, the fever and rigidity are often absent; encephalitis is more likely Viral and with fewer meningeal signs

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define pleocytosis:

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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

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in bact. meningitis CSF exam findings include:

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WBC median of 1200cells/mm3 of CSF with 95% neutrophils; also decrease CSF glucose to about 40% of plasma concentration

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in viral meningitis, what happens to glucose, protein, lymphocytes?

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glucose: nml
nml to slight elevated protein
lymphocytosis; Head CT or MRI before lumbar puncture

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pailledema - optic disk bulging -

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absence of venous pulsations on fundoscope = increased ICP

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neissereria menigitidis, extra characteristics:

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purpuritic or petechial rash in 50% of pt's

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N. meningitidis is seen in ___% of people.

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5-10% healthy adults; 60-80% of those in closed populations

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incubation of n. meningitis:

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3-4d average, communicable at that time

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MCV 4 vaccine recommendation for:

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children 2-10y/o; >=55y/o

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tx for suspected bacterial meningitis?

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ceftriaxone with or without vancomycin or ampicillin or both; acyclovir is an option in viral (aseptic) meningitis

Front 58

tx for MS, includes:

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interferon beta-1b or 1a (reduces exacerbations); mitoxantrone / Novantrone (immunosuppression); natalizumab / Tysabri (MAB; potential for progressive multifocal leukoencephalopathy)

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tx for Parkinson's:

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levodopa, ropinirole, pramipexole

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surgical indication for Parkinson's:

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when meds aren't tolerated or helpful

Front 61

findings on a PE with Parkinson's:

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resting tremor and bradykinesia

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MS characteristics:

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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

Front 63

CSF characteristics in a pt with MS:

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pleocytosis, predominance of monocytes, abnl protein, markedly increased gamma-globulin, high IgG level, increased myelin basic protein

Front 64

other tx mainstays of MS exacerbations:

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systemic high-dose coritcosteroids (shortens exacerbations)

Front 65

Parkinson characteristics:

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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

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Dx of Parkinson's via clinical traits includes:

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resting tremor, riiidity, bradykinesia, flexed posture, loss of postural reflexes, masklike facies; at least one aside from resting tremor must be present to dx

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Parkinsonian gait looks like:

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arms held rigid at sides, forward falls common, rapid, small steps, forward/backward small steps to turn

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Tx for Parkinson's:

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dopamine agonists: ropinirole / Requip, pramipexole / Mirapex; levodopa still used but increased SE's (after 5-10y develop dyskinesia) - Levodopa + Carbidopa = Sinemet

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other Tx for Parkinson's:

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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)

Front 70

pt presentation during absence / petit mal seizure:

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blank staring lasting 3-50 seconds with impaired conciousness

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pt presentation for simple partial seizure:

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awake state with abnl motor behavior lasting seconds

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pt presentation of tonic-clonic / grand mal seizure:

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rigid extension of arms and legs, followed by sudden jerking movements with LoC

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pt presentation with myoclonic seizure:

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brief, jerking contractions of arms, legs, trunk, or all of these

Front 74

adult seizure tx includes:

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carbamazepine, phenytoin, gabapentin, valproic acid / Depakote, lamotrigine, topiramate

Front 75

drug interactions when taking phenytoin (and carbamazepine) and ____.

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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

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risk factors for TIA:

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a-fib, carotid artery disease, OC use

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TIA can last:

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24 hours or less

Front 78

in recent TIA, consider:

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LT antiplatelet therapy is indicated

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m/c etx of stroke:

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cerebral ischemia

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presentation of acute stroke:

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partial visual field loss, unilat hearing loss, facial muscle paralysis, vertigo, diplopia, HA, ataxia

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RF's for TIA include:

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a-fib, carotid artery disease, OCP

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TIA =

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reversible neurologic sx that can last up to 24 hours

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in care of pt with recent TIA:

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LT antiplatelet therapy is indicated

Front 84

m/c etx of CVA:

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cerebral ischemia

Front 85

presentation of acute CVA:

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partial loss of visual field, unilat hearing loss, facial mm paralysis, vertigo, diplopia, HA, ataxia

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RF's for CVA:

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atherosclerosis, cardiac problems, hyper coagulable states (OCP use), HTN, dyslipidemia, DM, hx of TIA or ischemia

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secondary prevention for CVA:

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antiplatelet therapy with ASA or (if ASA not tolerated or if PAD or other atherosclerosis) clopidogrel / Plavix

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if TIA or stroke originates from cardiac embolus, care includes tx with:

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warfarin PO with INR goal 2.0-3.0

Front 89

m/c etiologies of delirium and dementia:

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delirium: acute infection
dementia: Alzheimer disease

Front 90

m/c etx of delirium mnemonic:

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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

Front 91

Eval of pt with mental status change, labs:

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BUN, Cr, glucose, calcium, sodium, LFTs, b12/folate, TSH, RPR, CBC with WBC diff., UA, U C&S, ECG

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m/c etx of dementia:

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Alzheimer's and multi-infarct / vascular dementia

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tx for dementia:

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cholinesterase inhibitors: donepezil/ Aricept, tacrine / Cognex, rivastigmine / Exelon - these have clear, minor, time-limited benefits; NMDA-receptor antagonists: memantine / Namenda