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171 Cards in this Set
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- Back
Parkinson's Disease -
What is it When does it start Life expectancy |
ACh and dopamine must be
in balance for normal, balanced movement dec. levels of dopamine in substantia nigra idiopathic hypokinetic usu. starts ~50-60 y/o life expectancy ~ 9 yrs. |
|
Parkinson's Disease -
Insults that lead to "parkinsonism" |
Most cases are idiopathic
insults dec. dopamine - postencephalitic toxic insults - (carbon disulfide manganese MPTP) bihemispheric ischemic traumatic iatrogenic (neuroleptic meds) |
|
Parkinson's Disease -
History/PE |
Tremor at rest (pill rolling)
cogwheel rigidity bradykinesia festinating gait stooped posture unstable posture masked facies memory loss micrographia shy-dragger- any autonomic dysfunction |
|
Parkinson's Disease -
Tx |
1st -
is it from a secondary cause that can be reversed? then - how does pt. function daily? tremor but functioning - > 60 y/o - amantidine < 60 y/o - anticholinergic if can't function - l-dopa-carbidopa most effective but most side effects "response fluctuations" Tx fluctuations - COMT or selegiline list of meds - L-dopa/carbidopa - mainstay bromocriptine selegiline entacapone (COMT inhib) amantadine & anticholinerg - limited efficacy If meds fail & dis. advanced- deep brain stimulation of GPi and subthal nucleus, or pallidotomy - ablation of GPi (posteroventral GP) rarely done now |
|
Huntington's -
What is it |
Hyperkinetic
AD atrophy of caudate lose GABA CAG triple repeats on C4p anticipation - prog. expansion > 39 repeats - mutant genes |
|
Huntington's -
History/PE |
Presents ~30-50 y/o
gradual onset of - chorea dementia altered behavior depression |
|
Huntington's -
Dx |
Clinical
CT MRI molecular genetic testing |
|
Huntington's -
Tx |
No cure
disease cannot be halted genetic counseling haloperidol - psychosis reserpine - minimize unwanted movements |
|
Alzheimer's -
What is it |
MCC of dementia in elderly
• senile plaques - B amyloid • neurofibrillary tangles - abnorm phosphorylated tau protein • loss of ACh in cortex - basal nucleus of Meynert • amyloid angiopathy => lg lobar hemorrhage • hippocampus affected early |
|
Alzheimer's -
Risk factors |
Age - most important
family history Down's (> 35 y/o) female gender chromosomes 21, 14 chromosome 1 - younger age chromosome 19 - older homozygous for ApoE4 - high rate of Alzheimer's |
|
Alzheimer's -
History/PE |
Amnesia usually 1st sign
then language deficits acalculia depression agitation apraxia |
|
Alzheimer's -
Evaluation |
Dx of exclusion
def. Dx only on autopsy MRI or CT - diffuse cortical and subcortical atrophy Neuropsych testing - distinguish between dementia and depression |
|
Alzheimer's -
Tx |
Supportive therapy
Cholinesterase inhibitors - first-line therapy donepezil rivastigmine galantamine Vit E (a-tocopherol) - may slow cognitive decline |
|
Alzheimer's -
Complications |
Survival is 5-10 yrs from
onset of sxs death usually secondary to aspiration pneumonia or other infections |
|
Delirium -
What is it caused by Timing of onset Course |
Caused by acute illness,
infection or drug toxicity Sudden onset Reversible (usually) impairment of consciousness - dec. awareness of your envi can't maintain attention |
|
Dementia -
What is it caused by Timing of onset Course |
Caused by anatomic changes
in the brain Slow, gradual onset Irreversible |
|
Subarachnoid Hemorrhage -
What is it |
Due to bleeding
from ruptured aneurysm MCC - head trauma (Circle of Willis) (considered separate d/o) spontan - ruptured aneurysm usually congenital berry associated with APKD, coarctation of aorta other cause - AV malformation ~50-60 y/o high mortality |
|
Subarachnoid Hemorrhage -
History/PE |
Sudden-onset headache
"worst headache of my life" loss of consciousness fever n/v neck stiffness seizure CN3 palsy - if berry aneurysm may be preceded by milder sentinel headaches weeks earlier |
|
Subarachnoid Hemorrhage -
Dx |
CT without contrast immed.
blood appears white if CT neg - LP immediately ck for xanthochromia no LP if inc. ICP - sudden dec. in CSF pressure can cause further bleeding 4-vessel angiography to pinpoint location |
|
Subarachnoid Hemorrhage -
Tx |
Prevent 2nd rupture -
most likely in 1st 48 hrs obliterate aneurysm IV fluids keep BP OK nimodipine -prevent vasospasm phenytoin lower ICP - raise head of bed, hyperventilation pain meds - no NSAIDs surgery - clip aneurysm IR (stent-assisted) coiling |
|
Subarachnoid Hemorrhage -
Complications |
2nd rupture -
esp. with aneurysm extend into brain parenchyma- esp. with AVM arterial vasospasm obstructive hydrocephalus |
|
Epidural Hematoma -
What is it |
Often due to blunt trauma
usually lateral skull fracture tear of Middle Meningeal Art. |
|
Epidural Hematoma -
History/PE |
Lucid interval - min. to hrs.
then headache progressive obtundation hemiparesis "blown pupil" |
|
Epidural Hematoma -
Dx |
CT -
lens-shaped convex hyperdensity close observation and serial neuro exams before surgery |
|
Epidural Hematoma -
Tx |
Neurosurgical evacuation
|
|
Subdural Hematoma -
What is it |
Usually after head trauma
rupture of bridging veins cortex to dural sinuses esp. elderly & alcoholics |
|
Subdural Hematoma -
History/PE |
Headache
change in mental status - days to weeks can present as dementia in elderly contralateral hemiparesis may have remote h/o fall |
|
Subdural Hematoma -
Dx |
CT -
crescent-shaped concave hyperdensity |
|
Subdural Hematoma -
Tx |
Neurosurgical evacuation
blood may regress spontan- eously if chronic corticosteroids phenytoin |
|
Parenchymal Hemorrhage -
Causes |
HTN (usually in basal ganglia)
tumor amyloid angiopathy - elderly vascular malformations - AVM cavernous hemangiomas |
|
Parenchymal Hemorrhage -
History/PE |
lethargy
headache focal mtr & sensory deficits some obtundation |
|
Parenchymal Hemorrhage -
Dx |
CT without contrast
check for mass effect or edema |
|
Parenchymal Hemorrhage -
Tx |
Raise head of bed
antiseizure prophylaxis neurosurgical evacuation - if mass effect esp. in posterior fossa |
|
Coma -
What is Rule of 4 |
1. Thiamine, D50, naloxone
coma cocktail 2. 2 mechanisms bilateral hemisphere or RAS 3. 3 general dis. processes structural metabolism seizures 4. 4 key aspects to exam |
|
Coma -
General Processes: Structural |
Hematoma
Infarction Abscess Tumor Abnormal imaging lesion that occupies space |
|
Coma -
General Processes: Metabolism |
Electrolyte, endocrine or
metabolic functions substrate deprivation - O2, glucose vitamin deficiency organ failure - kidney toxins - meds etoh drugs infections inflammatory dis. Normal imaging |
|
Coma -
General Processes: Seizures |
Status epilepticus
postictal |
|
Coma -
4 aspects of exam |
Pupils
eye movement motor response ventilation pattern - acid-base status |
|
Coma -
Tx |
Stabilize the patient -
Airway Breathing Circulation Reverse the reversible - coma cocktail O2 ID and tx underlying cause Prevent further damage |
|
Broca's Aphasia -
What is it What part of brain affected |
D/o of language production
motor broken speech comprehension is intact expressive or nonfluent aphasia post. inferior frontal gyrus |
|
Broca's Aphasia -
Features |
Repetition is impaired
frustration - cuz aware associated with - arm and face hemiparesis hemisensory loss apraxis of oral muscles often secondary to left superior MCA stroke |
|
Broca's Aphasia -
Tx |
Speech therapy
tx underlying condition wide range of outcomes intermediate prognosis |
|
Wernicke's Aphasia -
What is it |
D/o of language comprehension
nonsensical production Wernicke's is wordy left post. superior temporal receptive or fluent aphasia |
|
Wernicke's Aphasia -
Features |
Neologisms
word substitutions unaware - no comprehension secondary to left inf./post MCA stroke |
|
Wernicke's Aphasia -
Tx |
Speech therapy
tx underlying condition poorer prognosis than Broca's |
|
Brain Neoplasms -
Mets vs. Primary |
Benign usually > 65 y/o
Metas - Lots of Bad Stuff Kills Glia Lung Breast Skin Kidney GI metas > primary supratentorial at junction of gray and white matter Primary (1o) - MC primary in adults - glioblastoma and meningioma most 1o are supratentorial MC primary in kids - medulloblastoma & astrocytoma most 1o are infratentorial |
|
Brain Neoplasms -
Dx |
CT with contrast
MRI with gadolinium CT-guided Bx Bx during surgical tumor debulking |
|
Brain Neoplasms -
General Principles of Tx |
Resection (if possible)
radiation chemo palliative tx corticosteroids - reduce vasogenic edema type of therapy depends on - type of tumor histology progression site |
|
Brain Neoplasms:
Glioblastoma - Characteristics and Presentation |
Grade IV astrocytoma
MC primary brain tumor prognosis grave < 1 year to live can cross corpus callosum progresses fast headache ICP |
|
Brain Neoplasms:
Glioblastoma - Tx |
Surgical resection
radiation and chemo have variable results |
|
Brain Neoplasms:
Meningioma - Characteristics and Presentation |
2nd MC primary
often incites osteoblastic reaction in overlying cranial bones orig from dura or arachnoid good prognosis incidence inc. with age |
|
Brain Neoplasms:
Meningioma - Tx |
Surgical resection
radiation for unresectable |
|
Brain Neoplasms:
Acoustic Neuroma (Schwannoma) Characteristics and Presentation |
Derived from schwann cells
bilat schwannoma in NF2 Ipsilateral hearing loss tinnitus vertigo signs of cerebellar dysfunction facial weakness facial sensory loss |
|
Brain Neoplasms:
Acoustic Neuroma (Schwannoma) Tx |
Surgical removal
|
|
Brain Neoplasms:
Astrocytoma - Characteristics and Presentation |
Grades 1 - pilocytic,
mainly kids grade 2 - diffuse grade 3 - anaplastic grade 4 - glioblastoma multif headache inc. ICP can cause unilat paralysis in CN 5-7 & CN10 |
|
Brain Neoplasms:
Astrocytoma - Tx |
Resection if possible
radiation |
|
Brain Neoplasms:
Medulloblastoma - Characteristics and Presentation |
Highly malignant
arises from cerebellum and 4th ventricle can compress 4th ventricle may seed subarachnoid space inc. ICP morning headaches |
|
Brain Neoplasms:
Medulloblastoma - Tx |
Surgical resection
coupled with radiation and chemo |
|
Brain Neoplasms:
Ependymoma - Characteristics and Presentation |
Common in kids
arises from ventricles and spinal cord commonly found in 4th ventricle can cause hydrocephalus |
|
Brain Neoplasms:
Ependymoma - Tx |
Surgical resection
radiation |
|
Neurofibromatoses -
What are they |
NF1 -
von Recklinghausen AD chromosome 17 NF2 chromosome 22 |
|
Neurofibromatoses -
Hx/PE |
NF1 -
2 or more of: neurofibromas (2) cafe-au-lait spots (6) freckling - axillary or inguinal optic glioma lisch nodules (2) osseous abnorm 1st degree relative with NF1 NF2 - bilat acoustic neuromas or 1st deg. relative with NF2 and unilat acoustic neuroma or 1st deg. relative with NF2 and neurofibroma, meningioma, glioma or schwannoma |
|
Neurofibromatoses -
Dx |
MRI -
brain brain stem spine derm exam ophthal exam family Hx hearing test |
|
Neurofibromatoses -
Tx |
No cure
tx symptoms surgical removal for acoustic neuromas |
|
Tuberous Sclerosis -
What is it |
Seizures - start as infant
mental retardation skin and eye lesions small benign tumors - brain face eyes kidney other organs very variable clinical course AD chromosome 9 |
|
Tuberous Sclerosis -
Hx/PE |
Infantile spasms
ashleaf lesions - hypopigmentation trunk and extremities shagreen patch - lumbosacral sebac. adenoma - nose, cheeks mulberry tumors phakomas |
|
Tuberous Sclerosis -
Dx |
CT -
calcified tubers periventricular areas can => astrocytomas (rare) Wood's UV lamp - skin lesions EKG renal US |
|
Tuberous Sclerosis -
Tx |
Clonazepam or valproic acid
inc. ICP - may indicate a tuber obstructing Foramen of Munro surgery |
|
Von Hippel-Lindau -
What is it |
AD
deletion of VHL gene on ch 3 hemangioblastoma - cerebellum medulla retinal angioma RCC pheochromocytoma |
|
Von Hippel-Lindau -
Hx/PE |
Headache
N/V cerebellar Sxs retinal angiomas - usu. periphery can => retinal detachment |
|
Von Hippel-Lindau -
Dx |
CT - head, abdo
MRI - post. fossa emphasis serpentine signal voids angiography - vascularity CBC - polycythemia VMA levels in urine ophthal US |
|
Von Hippel-Lindau -
Tx |
Surgical resection
or radiation |
|
Osler-Weber-Rendu -
What is it |
AD
also called - Hereditary Hemorrhagic Telangiectasia (HHT) telangiectasia and AVM in lungs, GI, brain recurrent epistaxis |
|
Osler-Weber-Rendu -
Hx/PE |
Recurrent epistaxis
painless bleeding in bowel hepatic AV fistula - (hepatomegaly RUQ pain pulsatile mass palpable thrill audible bruit high-output CHF liver failure) hep. enceph - portosys shunt neuro complications rt-to-left shunt - (cyanosis clubbing hypoxemia 2ndary polycythemia exertional dyspnea) |
|
Osler-Weber-Rendu -
Tx |
Iron
folate symptomatic tx of epistaxis ASA - contraindicated embolization, surgical excision or ligation of AV fistulas |
|
Closed-Angle Glaucoma -
What is it |
Med emergency
usu older pts. and Asians iris root plugs opening of trabecular meshwork acutely pupillary dilation anterior uveitis dislocation of lens |
|
Closed-Angle Glaucoma -
Hx/PE |
Intraocular pressure inc.
very fast extreme periocular pain acute red eye blurred vision |
|
Closed-Angle Glaucoma -
Dx Tx |
Best diagnostic test -
tonometry Tx - acetazolamide pilocarpine - when P drops laser iridotomy - curative |
|
Open-Angle Glaucoma -
What is it |
Most common form
almost always bilateral risk factors - > 40 y/o Black diabetic myopic family Hx diseased trabecular meshwork obstructs proper drainage => intraoc P inc. gradually progressive vision loss vision loss - moves periph to central => blindness |
|
Open-Angle Glaucoma -
Hx/PE |
Asymp initially
suspect if pt. - > 35 y/o freq. lens changes mild headaches vision disturbances impaired adaptation to dark earliest defect - periph nasal fields cupping of optic disk |
|
Open-Angle Glaucoma -
Dx |
Tonometry
ophthalmic exam of optic n. central field testing eval on long-term basis can be hard to Dx until advanced stages |
|
Open-Angle Glaucoma -
Tx |
Prevention
> 40 y/o - exam every 3-5 yrs inc. risk factor - annually timolol, betaxolol pilocarpine acetazolamide laser trabeculoplasty - if meds fail |
|
Macular Degeneration -
What is it |
MCC of permanent bilat
vision loss in elderly vision loss - central do not lose periph atrophic - gradual loss exudative - faster damage more severe |
|
Macular Degeneration -
Hx/PE |
painless loss of
central vision atrophic - irreg pigmentation of macular region exudative - hyperpigmentation pimple-like elevation of macula - from hemorrhage |
|
Macular Degeneration -
Tx |
Laser photocoagulation -
may delay loss of central vision in exudative |
|
Retinal Artery Occlusion -
What is it Hx/PE |
From emboli or thrombi
sudden painless unilat blindness pupil accommodates but reacts sluggishly to direct light cherry-red spot on fovea artery may look bloodless retinal edema |
|
Retinal Artery Occlusion -
Tx |
Thrombolysis within
8 hrs of onset of Sx dec. intraoc P - drain ant. chamber IV acetazolamide |
|
Retinal Vein Occlusion -
What is it Hx/PE |
Sudden
painless retinal hemorrhages cotton wool spots edema of fundus elderly MCC - HTN can => macular dis., glaucoma |
|
Retinal Vein Occlusion -
Tx |
Laser photocoagulation
|
|
Inc. ICP -
Causes |
Blood -
EDH, SDH, SAH, ICH spontaneous or traumatic CSF - hydrocephalus idiopathic intracranial HTN brain mass - tumor trauma -cerebral contusions edema - trauma tumors |
|
Inc. ICP -
Signs in approx. order of appearance |
N/V and headache
altered mental status in kids - bulging fontanelles papilledema CN palsies - esp. CN6 Cushing's Triad - (HTN brady irreg breathing) endstage - cerebral herniation |
|
Inc. ICP -
Tx - in order |
Make sure BP and resp. good
sedation elevate head of bed IV mannitol hyperventilate to CO2 30-35 ventriculostomy surgery - removal of hematoma decompressive craniectomy |
|
Herniation -
What is it Types Dx |
Endpoint of untreated masses
or inc. ICP specific signs and Sxs depends on type of hernia and mass lesion uncal herniation - CN3 compression: ipsilat dilated pupil midbrain compression: ipsilat hemiplegia tonsillar herniation - resp. compromise Dx - CT without contrast - r/o mass lesion or hemorrhage |
|
Guillain-Barre -
What is it |
Acute
rapidly progressive acq. demyelinating autoimmune d/o of periph nerves recent C. jejuni infection viral infection recent vaccination |
|
Guillain-Barre -
Hx/PE |
Rapidly progressive
ascending paralysis involves trunk, diaph and CN autonomic Sxs areflexia |
|
Guillain-Barre -
Dx |
Diffuse demyelination on -
EMG & nerve conduction studies albuminocytologic dissociation CSF prot. > 55 mg/dL |
|
Guillain-Barre -
Tx |
ICU -
risk of respiratory failure plasmapheresis or IVIG aggressive rehab |
|
MS -
What is it |
Acq. demyelinating dis.
may have T cell-mediated autoimmune pathogenesis environmental and genetic female-to-male 2:1 20-40 y/o inc. prev. with gtr distance from equator risk - related to where lived the 1st 15 yrs. of life subtypes - benign relapsing/remitting 2o progressive chronic progressive |
|
MS -
Hx/PE |
Mult. neuro complaints
sep. in time and space can't be explained by a single lesion limb weakness optic neuritis paresthesias diplopia internuclear ophthalmoplegia urinary retention vertigo Sxs wax & wane or progress exacerbations - stress infections heat trauma vigorous activity |
|
MS -
Dx |
Multiple, asymmetric periven-
tricular lesions in white mtr corpus callosum lesions - pathognomonic active lesions enhance with Gado on MRI inc. CSF IgG oligoclonal bands |
|
MS -
Tx |
Acute - steroids
treat Sxs - spasticity: baclofen or zanaflex pain: phenytoin fatigue: amantadine or provigil depression avoid hot climates prophylaxis: immunomodulators reduce no. of attacks, disability Avonex - once wkly IM Betaseron- every other day subq Copaxone - daily subq |
|
Stroke -
Types |
Ischemic - 80%
emboli thrombi systemic hypoperfusion hemorrhagic |
|
Stroke -
Risk Factors |
Age
male race HTN diabetes obesity smoking hypercholesterolemia AF carotid stenosis coke alcohol IV drug user |
|
Stoke -
Hx/PE MCA |
Aphasia
neglect gaze preference homonymous hemianopsia contralateral hemiparesis - arm/face > leg |
|
Stoke -
Hx/PE ACA |
Amnesia
personality changes foot drop gait dysfunction cognitive changes contralateral hemiparesis - leg > arm/face |
|
Stoke -
Hx/PE PCA |
Homonymous hemianopia
memory deficits dyslexia/alexia |
|
Stoke -
Hx/PE Basilar |
Coma
CN palsies apnea visual Sxs drop attacks dysphagia |
|
Stoke -
Hx/PE Lacunar |
Unilat pure motor or sensory
dysarthria - clumsy hand syndrome ataxic hemiparesis |
|
Stoke -
Hx/PE TIA |
Transient neuro deficits
last < 24 hours most last < 1 hour |
|
Stoke -
Dx |
CT without contrast -
ischemic vs. hemorrhagic MRI EKG echocardiogram vascular studies - carotid US MRA transcranial doppler or MRA screen for hypercoagulability PE |
|
Stoke -
Tx Preventive and Long-Term |
* Vigilance for signs of -
brain swelling inc. ICP herniation * tPA - ischemic stroke if admin within 3 hrs. of onset of Sxs * ASA - ischemic stroke presenting within 48 hours * no hypotension, hypoxemia, hypoglycemia * tx aspiration pneumonia, UTI or DVT Preventive & long-term Tx - * ASA, clopidogrel or dipyridamole/ASA * carotid endarterectomy * anticoags * management of HTN, DM and hypercholesterolemia |
|
Carpal Tunnel Syndrome -
What is it Risk factors |
Median n. compression where
passes thru carpal tunnel women 30-55 Risk factors - repetitive use injury pregnancy DM hypothyroidism acromegaly RA obesity |
|
Carpal Tunnel Syndrome -
Hx/PE |
Wrist pain
numbness & tingling of 3 1/2 weak grip dec. thumb opposition thenar atrophy nocturnal pain & paresthesias Sxs may awaken pt. at night relieved by shaking wrist |
|
Carpal Tunnel Syndrome -
Workup |
Tinel's sign -
tap tingle Phalen's sign - ph-lex (flex) paresthesias EMG - to confirm NCV - to confirm eval for risk factors |
|
Carpal Tunnel Syndrome -
Tx |
Neutral wrist splint
modify activity create ergonomic work envi NSAIDs corticosteroids - direct injection surgery if Sxs persist - carpal tunnel release |
|
Myasthenia Gravis -
What is it |
Autoimmune
Ab that bind to postsynaptic Ach receptors (nicotinic) block receptors lose receptors young adult women can be associated with - thymoma thyrotoxicosis |
|
Myasthenia Gravis -
Hx/PE |
Muscle weakness inc. in
periods of activity dec. after rest Sx come and go onset can be sudden fluctuating fatigable ptosis diplopia (double vision) dysphagia (swallowing) dysarthria (speech) Sxs worsen throughout day myasthenic crisis - so severe, resp. failure and aspiration secondary to weakness often secondary to infection (resp. muscles compromised) ocular myasthenia - common variant if doesn't spread in 2-3 yrs, probably won't |
|
Myasthenia Gravis -
Dx |
Edrophonium (tensilon test) -
diagnostic abnormal single-fiber EMG dec. response to repetitive n. stimulation antistriatal ab if thymoma chest CT - eval for thymoma |
|
Myasthenia Gravis -
Tx |
* Neostigmine (treat Sx)
* pyridostigmine (treat Sx) * prednisone * plasmapheresis or IVIG - temp relief (wks) if severe * thymoma resection |
|
Amyotrophic Lat. Sclerosis -
What is it |
Progressive neurodegen. dis
unknown etiology degeneration of motor neurons UMN and LMN degenerate => resp. failure and death |
|
Amyotrophic Lat. Sclerosis -
Hx/PE |
Slowly progressive weakness
may have fasciculations init UMN and LMN |
|
Amyotrophic Lat. Sclerosis -
Dx |
Clinical presentation
EMG and n. conduction studies CT/MRI - cervical spine check for lesions r/o systemic causes - CBC TSH SPEP UPEP Ca2+ PTH PFTs urine for heavy metal - (if h/o exposure) |
|
Amyotrophic Lat. Sclerosis -
Tx |
Supportive
pt. education pulmonary specialist riluzole |
|
Thiamine (B1) Deficiency -
What are Signs/Sxs |
Wernicke's
inadeq intake or absorption excessive alcohol interferes with GI absorption and liver storage acute onset - confusion opthalmoplegia - nystagmus lat. rectus palsy conjugate gaze palsy abnormal pupils ataxia - vestibular dysfunction cerebellar dysfunction |
|
Thiamine (B1) Deficiency -
Pts. |
Alcoholics
dialysis hyperemesis starvation cancer AIDS can be triggered by large-dose glucose admin if deficient |
|
Thiamine (B1) Deficiency -
Tx |
Reversible almost immediately
with thiamine admin |
|
Korsakoff's Psychosis -
What is it |
Late complication of
untreated pts. with Wernicke's can be triggered by severe or repeated DTs can be triggered by SAH and thalamic injuries immediate memory affected confabulation |
|
Korsakoff's Psychosis -
Tx |
Prognosis good -
head injury and SAH irreversible - others |
|
B12 deficiency -
What are Signs/Sxs |
Subacute combined degen
|
|
B12 deficiency -
Pts. |
Pts with pernicious anemia
|
|
B12 deficiency -
Tx |
B12 injections or
large oral doses |
|
Folate Deficiency -
What are Signs/Sxs |
Irritability
glossitis diarrhea depression neural tube defects |
|
Folate Deficiency -
Pts |
Alcoholics - alcohol
interferes with absorption Pts. with pernicious anemia |
|
Folate Deficiency -
Tx |
Reversible if corrected early
|
|
Seizures -
General Evaluation |
. Epilepsy -
seizure d/o 2+ seizures not related to reversible stressors . was seizure epileptic - Hx inc. prolactin = epileptic . VITAMINS seizure caused by - vascular infection trauma autoimmune metabolic idiopathic neoplasm sychiatric (faking it) . anticonvulsant therapy indicated? 1st seizure not treated when underlying cause unknown |
|
Partial Seizures -
What are they |
Arise from focus
limited to one side consciousness usually not lost can progress to generalized simple partial & complex part |
|
Partial Seizures -
Hx/PE |
Simple partial -
consciousness not impaired motor - Jacksonian march sensory - parietal autonomic - BP, HR, PVR psychic - fear, deja vu postictally - Todd's paralysis resolves in 1-2 days Complex partial - consciousness impaired temporal lobe auditory or visual hallucinat deja vu automatisms postictal - confusion amnesia |
|
Partial Seizures -
Workup |
EEG
r/o systemic causes - CBC electrolytes Ca2+ fasting glucose LFTs tox screen RPR renal panel ESR r/o mass - MRI or CT with contrast |
|
Partial Seizures -
Tx |
Tx underlying cause
recurrent partial - phenytoin oxcarbazepine tegretol phenobarbital valproic acid kids - phenobarbital intractable temporal lobe - WADA testing ant. temporal lobectomy |
|
Generalized Seizures -
What are they |
Begin diffusely throughout
both sides consciousness always lost postictal confusion most common types - tonic-clonic (grand mal) absence (petit mal) |
|
Tonic-Clonic Seizures -
Hx/PE |
Start suddenly
with tonic extension of back and extremities rep. symm. clonic movements incontinence tongue biting may look cyanotic consciousness slowly regained may complain of - muscle ache headache |
|
Tonic-Clonic Seizures -
Tx |
Tx underlying cause
idiopathic - valproate - 1st line lamotrigine - adjunctive topiramate - adjunctive symptomatic - same therapy as partial sz. |
|
Absence (Petit Mal) Seizures-
What are they |
Begin in childhood
subside before adulthood often familial |
|
Absence (Petit Mal) Seizures-
Hx/PE |
Brief, often unnoticeable
episodes of impaired consciousness lasts 5-10 seconds have 100's of times/day amnestic during and immediately after eye flutters or lips smack can be precipitated by hyperventilation |
|
Absence (Petit Mal) Seizures-
Evaluation |
EEG -
3 Hz per sec. spike & wave discharges |
|
Absence (Petit Mal) Seizures-
Tx |
Ethosuximide - 1st line
valproic acid zonisamide |
|
Infantile Spasms
(West Syndrome) - What is it Tx |
Syndrome -
. infantile spasms (generalized seizures) symmetric tonic 5-10 at a time while drowsy or upon awakening . abnorm interictal EEG . arrest of psychomotor dev. at age of onset starts at 3-12 months usu male MR Tx - ACTH prednisone clonazepam valproic acid |
|
Status Epilepticus -
What is it Common Causes |
Brain in persist. state of Sz
1 cont. seizure or recurrent w/o regaining cons. > 30 min. med emergency - 20% mortality common causes - anticonv. withdrawal/noncomp anoxic brain injury alcohol withdrawal metab disturb (hypoNa+) trauma infection usual cause - subtherapeutic or noncompliance |
|
Status Epilepticus -
Evaluation |
Airway, breathing, circulation
labs - electrolytes anticonvulsants get Hx look for etiology if no prior Hx (tumor, encephalitis, SAH) (EEG, CT only when stable) |
|
Status Epilepticus -
Tx |
Diazepam or lorazepam
if continues - phenytoin or fosphenytoin if continues - phenobarbital if continues - midazalom or propoful |
|
Headache -
Things to think about (Evaluation) |
Headache new or old
characteristics any associated Sxs any neurological Sxs SAH suspected? |
|
Migraine Headache -
What is it |
More commonly affects women
and those with family Hx vascular & 5HT abnorm triggers - menses OCP chocolate fasting stress bright lights |
|
Migraine Headache -
Hx/PE |
Throbbing > 2 hrs
usually lasts < 24 hrs n/v photophobia sensitive to noise "classic" migraine - visual aura precedes unilat "common" migraine - 80% can be b/l, periorbital |
|
Migraine Headache -
Dx |
Hx
if have focal neuro deficits- CT or MRI Sxs acute in onset - r/o meningitis or SAH |
|
Migraine Headache -
Tx |
Avoid known triggers
aspirin/NSAIDs sumatriptan prophylaxis - beta-blockers TCAs Ca2+ channel blockers valproic acid |
|
Cluster Headache -
What is it |
Men
~ 25 y/o - age of onset |
|
Cluster Headache -
Hx/PE |
Unilat, periorbital
30 min. - 3 hrs. attacks in clusters - same part of head same time of day same time of year can be precip by alcohol or vasodilators ipsilat tearing of eye |
|
Cluster Headache -
Dx |
Hx
|
|
Cluster Headache -
Tx |
Acute therapy with
high-flow O2 (100% nonrebreather O2) sumatriptan corticosteroids prophylaxis - Ca2+ channel blockers valproic acid methylsergide prophylaxis important - by the time abortive meds take effect, has already resolved methylsergine (sansert) - need drug holiday every several months to avoid risk of retroperitoneal fibrosis |
|
Tension Headache -
What is it |
MC type diagnosed in adults
chronic |
|
Tension Headache -
Hx/PE |
Tight, bandlike pain
occipital and neck exacerbated by - noise bright lights stress fatigue |
|
Tension Headache -
Dx |
Dx of exclusion
|
|
Tension Headache -
Tx |
Avoid exacerbating factors
NSAIDs - 1st line prophylaxis - Ca2+ channel blockers alpha blockers TCAs |
|
Benign Paroxysmal
Positional Vertigo - What is it |
Peripheral vertigo
otoliths dislodge from usual position migrate over time into semicircular canals abnorm fluid displacement => vertigo |
|
Benign Paroxysmal
Positional Vertigo - Hx/PE |
Sudden onset of severe
vertigo and nystagmus vertigo with head movement in direction of affected ear happens turning head in bed 5 sec. - 1 min. n/v Sxs dec. with repetitive tests usu h/o recent trauma |
|
Benign Paroxysmal
Positional Vertigo - Dx |
Nylen-Barany Maneuver
(Dix-Hallpike) |
|
Benign Paroxysmal
Positional Vertigo - Tx |
Usually subsides spontan.
in wks to months Epley Repositioning Maneuver |
|
Meniere's Disease
(Endolymphatic Hydrops) - What is it |
Peripheral vertigo
from buildup of endolymphatic fluid in inner ear = V and P change risk factors - head trauma syphilis |
|
Meniere's Disease
(Endolymphatic Hydrops) - Hx/PE |
Sudden attacks of vertigo
lasts up to 24 hours attacks can last hrs to days n/v ear fullness tinnitus hearing loss signif permanent hearing loss can occur over period of yrs |
|
Meniere's Disease
(Endolymphatic Hydrops) - Dx |
Audiometry -
low-freq. pure tone hearing loss |
|
Meniere's Disease
(Endolymphatic Hydrops) - Tx |
Low-salt diet
acetazolamide acute - antihistamines antiemetics benzos if refractory - surgical decompression |