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2015-09-14 07:28:21

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  1. Multiple Sclerosis
    General, Symptoms, Types, Diagnose, Treat
    Autoimmune, myelin breaks down. Females more likely than males, living in north, sunlight, Vit D. Genetic possibly. Related to female hormones


    • Optic neuritis
    • cognitive and mood
    • weakness
    • dysesthesia- abnormal sensation
    • paresthesia- pins and needles
    • spasticity


    • Relapsing remitting: symptoms come and go, most common
    • Secondary progressive: symptoms come and go but get worse over time
    • Primary progressive: generally no remission, symptoms get worse, 15% of people, men just as likely
    • Progressive relapsing: relapse of symptoms but right from onset it is progressive


    • MRI gold standard, need 3 lesions usually
    • LP for cell count and proteins, but similar to viral meningitis
    • Mcdonald diagnostic criteria for clinical diagnosis
    • Oligoclonal ummunoglobulin bands positive in CSF, negative in serum


    • Avoid triggers
    • Acute attacks: glucocorticoids for functionally disabling symptoms.
    • 1st line: interferon beta- prevents leukocytes from entering CNS, decreases inflammation, RRMS is best. ADR- infection site necrosis, flu, liver, decrease immune system
    • Glatiramer acetate- synthetic protein mimics myelin, blocks t cells, "copaxone", ADR- site reaction, chest pain, flushing, dyspnea
    • 2nd line: have high side effects
  2. Methylprednisolone

    • used to treat acute attacks of MS
    • no more than 3 courses of steroids in year
    • R/o infection prior to steroids
    • ADRs: mental status changes, GI disturbance, increased infection
  3. Interferon beta
    • 1st line for MS treatment
    • decreases CNS inflammation by blocking leukocytes, unknown MOA
    • works best for RRMS
    • injected
    • ADR: infection site necrosis, flu, liver, decreases immune system
  4. Glatiramer acetate
    • 1st line drug for MS
    • mimics structure of myelin, blocks T cells, decreases inflammation
    • works best on RRMS
    • ADR: injection site reaction, chest pain, flushing, pain, nausea
    • sub q injection
  5. Tension- Type Headache
    Headache with 2 of the following

    • Mild to moderate pain
    • pressing/tightening - nonpulsating quality
    • Bilateral
    • Not aggravated by physical activity

    Accompanied by both no N/V and no photophobia/phonophobia

    After NSAID treatment, beta blockers (faster acting, low side effects), then TCA's (more long term use).
  6. Sinus headache
    Commonly misdiagnosed

    Have symptoms of acute sinusitis

    • viral URI with symptoms
    • nasal congestion
    • thick, nasal discharge
    • pressure over sinus cavities
    • not usually recurrent
    • does not usually switch sides
  7. Cluster headache
    Symptoms and treatment
    • More prevalent in men
    • genetics
    • severe unilateral pain, orbital/frontal
    • lasts 15-180 mins, 1-8x daily, 2-3 weeks
    • lacrimation, congestion, rhinorrhea, swelling, ptosis, miosis, eyelid edema
    • autonomic features


    • acute: sumatriptan injection, 100% O2
    • suppressive: verapmil and prednisone
  8. Migraine
    Symptoms, treatment
    Any 2 of the following

    • moderate or severe
    • worsened by routine physical activity
    • unilateral (can be bilateral)
    • throbbing

    Either or both N/V and sound and light sensitive

    • Treatments
    • Acute: Triptans or ergots (serotonin agonists lead to vasoconstriction), NSAIDS
    • dopamine blockers for N/V
    • Prophylactic: beta blockers, TCA's, anticonvulsants (TCA's best)
  9. Sumatriptan
    • Serotonin (5-HT) agonist, stimulates b and d receptors
    • treat at first sign of migraine
    • Injectable, PO, or tablet. 
    • CI- hx of hemiplegic or basilar migraine, ischemic cardiac disease, peripheral vascular disease, uncontrolled HTN
    • SE- dizziness, fatigue, HTN, tingling, warm/hot, tightness
    • metabolized by liver
  10. Rizatriptan
    • Similar to sumatriptan
    • SE: chest pain, dizziness, fatigue, nausea
    • Don't take while pregnant (C)
  11. Ergotamines (dihydroergotamine)
    • Do not administer with CYP3A4 inhibitors
    • CI- vascular disease, liver or kidney impairment, coronary artery disease, HTN, pregnancy
    • cause vasoconstriction
  12. TCA's
    • Prophylactic migraine treatment
    • Most reliable for chronic migraines, amitriptyline
    • make sure to dose correctly
    • Usually inhibits serotonin and norepinephrine reuptake
    • CI: MI
    • SE: sedating, weight gain
    • metabolized in liver
  13. Beta blockers
    • work well for migraine prophylaxis when combined with TCA
    • CI: asthma, sinus bradycardia, heart block, diabetes
    • SE: fatigue, raynauds, CNS effects, sexual dysfunction (males)
    • start low, take before attacks usually occur
    • rifkin uses nadolol or atenolol
  14. Calcium channel blockers
    • Verapamil (main one), diltiazem, dihydropyridine, flunarazine
    • low success rate, preferred for prophylaxis of migraine with aura or prolonged aura
  15. Topiramate
    • "Topamax is dopamax"
    • anticonvulsant, and sometimes used for chronic migraines
    • blocks sodium channels, augments GABA, antagonizes glutamate
    • May be related to actions at GABA
    • Grand mal, partial seizures, mostly 2nd line
    • SE: cognitive impairment, paresthesias, weight loss, depression, fatigue
    • Can combine with TCA's
    • Affects oral contraceptives
  16. Mechanical mononeuropathy/radiculopathy
    • Radiculopathy: Lesion at the nerve root. Usually spondylyotic compression or herniated disc, will have sharp shooting pain
    • Mononeuropathy: usually paresthesias, pain, or numbness.
    • Commonly see sensory abnormalities first

    Most get better on their own

    TCA's can be used for neuropathic pain in small doses

    Numbness, paresthesias, pain, sometimes deficit of dermotome and/or myotome

    • Ulnar: when it's bad see claw hand
    • weakness in opponens digiti mini me
    • atrophy in hypothenar muscles, possibly all intrinsic muscles
    • decreased sensation in 5 throughhalf of 3
    • positive tenels sign, percussion brings about symptoms
    • can be entrapment in cubital tunnel
    • Radial: wrist drop
    • Saturday night palsy - nerve wraps around back of humerus
    • decreased brachioradialis reflex
    • grip can be weak but stronger when wrist is extended

    • L4: pain lower back, hip, posterolateral thigh, anterior leg.
    • Weakness or atrophy in quads, left knee jerk diminished
    • L5: above SI joint, hip, lateral thigh and leg, first three toes, weakness in dorsiflexion of big toe and foot, foot drop
    • S1: Over SI joint, hip, posterolateral thigh, and leg to heel, back of calf, lateral heel, and toe.
    • weakness in planter flexion
    • atrophy in calf
    • ankle jerk dimished or absent
  17. Bell's Palsy
    Symptoms and treatment
    • Ideopathic facial neuropathy - CN VII, LMN lesion
    • Usually gets better on it's own
    • Subacute onset, typically preceded by virus
    • Affects one whole side of the face. stroke will be fine in the upper face b/c UMN from both side still work
    • Ear pain because CN VII innervates stapedius muscle


    • Treat early with prednisone to decrease nerve inflammation
    • Artificial tears to keep eyes from drying
  18. Vestibular schwannoma
    • Slow growing tumor on vestibulocochlear nerve
    • progressive unilateral hearing loss
    • rarely other symptoms
  19. trigeminal neuralgia
    • episodic unilateral facial pain of variable time
    • unclear cause
    • often triggered by somatosensory stimuli
    • rarely structural cause, may be loop of artery bumping CN V
    • responds well to AED's
  20. Guillain Barre Syndrome
    • Acute/subacute inflammatory demyelinating polyradiculopathy with symmetric lower to upper extremity weakness, ascending
    • Increased incidence with campylobacter or other respiratory or GI infections

    • Weakness and parasthesias, usually symmetric
    • Decreased reflexes***
    • Affects face, other polyneuropathies usually don't
    • Autonomic - tachycardia, hypo/hypertension, dyspnea
    • Concerned about respiratory failure

    • Diagnose: High protein with normal WBC in CSF
    • Treat: Plasmapheresis removes harmful autoantibodies
    • IV Ummune glublin (IG)

    Most recover, some have persisiting disability

    Prednisone contraindicated***
  21. Charco-Marie-Tooth disease
    • Gradual polyneuropathy
    • usually onset in children, by gene mutation
    • demyelination, not autoimmune though

    • Stork legs (atrophy)
    • high arches and hammer toes
  22. Duchenne muscular dystrophy
    • Gradual myopathy
    • onset in young boys
    • gene mutation, x linked

    • Starts with weakness in shoulders and hips
    • lumbar lordosis
    • big calves from fibrous fatty tissue
    • gowers sign is pushing on legs to get up
  23. Myasthenia gravis
    • Neuromuscular junctionopathy
    • Usually affects ocular muscles with or without general weakness
    • fluctuates with muscle use
    • caused by autoantibodies blocking Ach receptor**
    • drooper upper eyelid
    • bad episode can lead to respiratory failure
    • nerve conduction studies
    • Can treat with Ach esterase inhibitors or immunosuppresion with steroids
  24. Parkinson's Disease
    • Loss of dopamine receptors in substantia nigra
    • 40-65 yr most common
    • tremors, bradykinesia, rigidity, postural instability
    • loss of smell, masked face
    • micrographia
    • depression

    • Clinical diagnosis
    • MRI to rule out other casues
    • PET with radionuclide glucose
    • DaT scan - shows density of healthy dopamine neurons, shows function, not anatomy. Does not definitively diagnose


    • Levodopa/carbidopa (sinemet): most effectiv tx
    • L-dopa converted to dopamine in brain
    • SE- N/V, hypotension, dyskinesia*** can wear off
    • PO, needs carbidopa to avoid peripheral decarboxylation
    • Dopamine agonist: not as effective
    • bromocriptine, pramipexole, ropinirole, apomorphine
    • typically used for younger pts
    • metabolized by liver
    • SE- orthostatic hypotension, N, headache, spleepiness, confusion, hallucinations
    • can be combined with L dopa or MOAB
    • start low, go slow
    • MOA-B inhibitors: blocks breakdown of dopamine by monoamine oxidase B
    • selegiline, rasagiline, zydis selegiline
    • Often used first line
    • may be neuroprotective, not always significant symptomatic improvement
    • Liver*
    • CI- SSRI's, potential for serotonin syndrome
    • Slegiline metabolizes to amphetamines
    • SE- headaches, insomnia, joint pain, edema*, dyskinesias
    • Catechol-O-Methyl Transferase inhibitors: used with L-dopa, not for monotherapy
    • Tolcapone, entacapone, stalevo (comtan with carbidopa/ldopa in one tab)
    • extends active time of L dopa
    • processed in liver
    • SE: inscreased dyskinesia, discoloration urine/saliva, N/V/D, cognitive, liver failure
    • Misc: amantadine -usually for flu, can treat dyskinesias, SE - hallucinations, edema, sedation
    • trihexyphenidyl, benztropine
  25. Essential/familial tremor
    • Action tremor
    • upper/lower extremities, head and chest
    • more rapid than PD
    • due to abnormal oscillatory activity in basal ganglia or abnormal in thalamic gaba receptors
    • EtOH usually helps


    • Beta blockers: most effective
    • Propanolol
    • SE- bradycardia, hypotension, fatigue, depression
    • CI- asthma, heart block/failure, diabetes
    • Anticonvulsants: list
    • Primidone- SE - mood swings, irritable, N, malaise. affects CYP 450
    • Gabapentin - limited effectiveness, SE - sleepiness, mood, restless
    • Topiramate- enhances GABA, SE - cognitive, somnolence
    • Benzodiazepines- may decrease anxiety that fuels tremor. SE - sedation, dependance, falls in elderly
  26. Restless Legs
    • Dopamine loss, may be precursor to PD
    • can be present during day
    • painful, bugs crawling
    • relieved by walking
    • work up for iron level, ferritin, iron binding capacity


    • Iron replacement
    • low dose dopamine agonist (ropinirole, pramipexole)
    • carbodopa/Ldopa
    • Gabapentin
    • Opiods (for pain/sleep)

    Treatment may augment condition, especially with doaminergic meds. watch dosing
  27. Myoclonus
    Sudden jerk

    • Causes: hypoxic brain damage
    • neurodegenerative disease
    • electrolyte imbalances
    • adverse effects of medications


    • Stop offending drug
    • Anti-convulsants or neuroleptics: list
    • valproic acid, levetiracetam, primidone
    • Benzodiazepines: clonazepam
  28. Huntington's Disease
    • Degenerative changes in caudate, putamen, globus pallidus, temporal, frontal lobes
    • MRI may show atrophy in caudate head
    • onset 25-40 yrs
    • dianose usually with chorea (jerky movements)
    • GABA and Ach levels decrease
    • cognitive and behavioral changes
    • clumsiness, fidgety, dance like movements
    • depression

    Treat (the choreiform movements)

    risperidone, olanzapine, tetrabenazine, ldopa if akinetic
  29. Seizures
    • Simple partial- consciousness maintained
    • complex partial- consciousness impaired
    • Generalized: both hemispheres, associated with LOC
    • absence- brief impairment, unaware of attack, staring, no post-ictal phase, childhood and ceases by 20
    • tonic-clonic (grand mal) - LOC, rigidity, arrest of respiration followe by jerking, to post ictal phase
    • Myoclonus- sudden, brief, sporadic involuntary twitching, no LOC, 1 or more group of muscles
    • atonic- drop attack, sudden loss of postural tone

    Some treatments

    • Absence- ethosuximide 1st line, valproic acid 2nd line, lamotregine
    • grand mal- valproic acid, phenytoin, carbamazepine, lamotrigine, topiramate, 
    • status epilepticus - lorazepam or diazepam and then IV phenytoin (fosphentyoin?)
    • myoclonus- valproic acid, clonazepine
  30. Phenobarbital
    • Don't use
    • Barbituate- binds to GABA receptor, agonist
    • SE- permanent neurologic deficit if injected into or near peripheral nerve, depression, osteoporosis*, irritable, cognitive impair
    • IV/PO, metabolized by liver, slow onset
    • induces P450***
    • CI - pregnancy, renal disease
  31. Phenytoin
    • Reduces ion currents across neuronal membranes
    • treats all seizures EXCEPT absence
    • seizure prophylaxis
    • SE- gingival hyperplasia, drowsiness, N/V, rash, ataxia
    • CI- pregnancy, liver/renal disease, alcohol
    • use fosphenytoin instead
    • PO, IV, IM metabolized in liver, INDUCER, slow onset. should be oral only because toxic to tissue, fenytoin is ok IV though
  32. Carbamezapine
    • Reduces ion currents, also antidiuretic effect
    • All types of seizures except absence
    • 1st line for simple/complex partial
    • add on for tonic clonic, elderly partial
    • also for trigeminal neuralgia
    • SE- agranulocytosis, vertigo, N/V, hyponatremia, Steven Johnson****
    • PO, induces own metabolism
    • CI - MOAB****
  33. Valproic Acid/divalproex
    • 1st line in absence, tonic clonic
    • divalproex 1st for atonic and myoclonic
    • increases GABA, inhibits glutamate
    • SE- hepatotoxicity, pancreatitis, GI problems, menstrual cycle changes
    • CI- liver problems, pregnancy
    • PO/IV, metabolized in liver, enzyme inhibitor
    • can be add on drug
  34. ethosuximide
    • 1st line for absence
    • blocks calcium channels motor cortex depression
    • SE- drowsiness, headache, N, GI upset, weight gain
    • CI- liver or kidney problems, pregnancy
    • Monitor blood levels
    • increases phenytoin levels
  35. Gabapentin
    • Used a lot with pain, partial seizures
    • related to GABA
    • SE- somnolence, ataxia, dizziness
    • PO
    • Watch dose with kidney failure
    • decreased risk for pregnancy but lacks efficacy
  36. lamotrigene
    • 1st line for partial and tonic clonic, atonic, myoclonic
    • SE- dizziness, headache, N, blurred vision, STEVEN JOHNSON RASH, double vision
    • PO, neither inducer/inhibitor
    • CI- liver/kidney, decreased risk in pregnancy
    • titrate slowly
    • 2 forms of BC in women
  37. Oxcarbazepine
    • 1st line partial seizures
    • 2nd line/add on tonic-clonic
    • Caution in elderly, kidney impairment, pregnancy
    • SE- dizziness, drowsiness, headache, N/V
    • enzyme inducer
  38. levetiracetam
    • 1st line for partial, tonic clonic, atonic, myoclonic, add on/2nd line for others
    • SE- agitation, aggression, rash
    • titrate slowly, PO, rapid absorption
    • CI- carbamezepine
  39. Lorazepam/diazepam
    • enhance gaba mediated Cl influx
    • benzodiazepene
    • status epilepticus, anxiety, chemo-related N/V
    • SE- drowsiness, ataxia, CNS depression, depression***
    • IV/PO, metabolized in liver
  40. Celexocib
    • selective for cox-2, do not affect platelet function
    • still affect kidney, and CV
    • take with food
    • interacts with warfarin
    • sulfonamide
    • PO
  41. morphine
    • severe pain
    • pure alkaloid, opiate receptor agonist, mu receptor
    • SE- respiratory deression, constipation, hypotension, cholestasis, N/V
    • IM/PO/SC/IV, poorly absorbed, cleared by kidneys
    • tolerance develops
    • enhances other CNS depressants
  42. codeine
    • moderate to severe pain, also cough suppression
    • sched 2 alone but sched 3 with APAP
    • avoid in children!
    • least potent of opiods
  43. hydrocodone
    • moderate to severe pain
    • vicodin when combined with APAP
  44. tramadol
    • moderate to severe pain
    • better oral absorption than morphine
  45. meperidine
    • only used when patient has shivers as well
    • dirty drug
    • may cause CNS excitation
    • does not suppress cough
  46. fentanyl
  47. methadone
    • similar to morphine, weaker sedative
    • detoxification of narcotic addiction
    • secreted more slowly than morphine
    • prolongs QT interval, torsauds
    • don't dose alone
    • IM/SC/PO
  48. oxycodone
    • better oral absorption than morphine
    • moderate to severe pain
    • percocet when combined with APAP
  49. hydromorphone
    • moderate to severe pain
    • semisynthetic
    • more potent than morphine
    • tablets, IV, SC
  50. oxymorphone
    • semisynthetic
    • take 1-2 hrs after food/alcohol when oral
  51. tramadol
    • opioid that works with mu receptor in CNS
    • inhibits reuptake of norepinephrine and serotonin
    • secreted by kidneys
    • only partially antagonized by naloxone
    • CI- seizures
    • caution with SSRI's for serotonin syndrome
  52. Stroke
    • Ischemic: most common
    • atherothrombotic- clot in carotid
    • embolic- usually cardiac in origin
    • lacunar- penetrating arteries of brain get blocked, not always symptomatic

    • Hemorrhagic: less common
    • intracerebral- hypertension, mycotic aneurysm, tumor, vasculitis
    • subarachnoid- aneurysm, trauma (most common)
  53. Stroke location
    • TACS: Total anterior circulation syndrome
    • typically from middle cerebral artery
    • hemiparesis, global aphasia, hemineglect
    • 40% mortality at 1 month, 60 at 1 year
    • PACS: partial anterior circulation syndrome
    • usually localizes somewhere
    • LACS: lacunar syndrome
    • have good recovery
    • POCS: posterior circulation syndrome
    • can either be benign or most deadly depending where

    • supratentorial is brain and subtentorial is cerebellum and brain stem
    • cortical is brain tissue in function, subcortical is wires to get there (mainly branching arteries)
  54. Stroke treatment
    thrombolysis: for ischemic

    • Some exclusion factors: seizure at onset, any hemorrhage, aneurysm, neoplasm, uncontrolled hypertension at time of treatment, known bleeding problems, improving symptoms
    • Must be treated within 4.5 hours of onset

    intraarterial thrombolysis

    • TPA given through catheter at site
    • has longer time window but takes longer to do, used for bigger clots

    • For hemorrhagic strokes look into surgery
    • Must be careful with BP for both strokes, if too low you risk ischemia

    Aspirin has some benefit, given within 24-48 hours of stroke onset
  55. Pseudotumor cerebri
    • Headaches, visual changes, papilledema with no tumor
    • FFO: Fertile (females), Forty, Obese

    • Diagnose with LP or intracranial monitor to find elevated ICP
    • Reduction of symptoms with CSF drainage


    • Acetazolamide to reduce CSF
    • CSF diversion (shunt)
  56. Cavernous sinus
    • Carotid artery
    • CN III, IV, V1, V2, VI
    • Sympathetics
  57. Brain metastases
    • Multiple lesions, with edema
    • Primary: examples
    • Men- lung, melanoma, GI, GU, lymphoma
    • Women- lung, breast, " " "


    • Small number that are accessible: surgery and whole brain radiotherapy
    • stereotactic radiosurgery and WBRT
    • Large number: not easily accessible
    • WBRT, sterotactic radiosurgery
  58. fluoroscopy
    • "real time" imaging
    • Gold standard for vascular stenosis/atheroosclerosis or vasculitis
    • good for aneurysms, AV malformations
    • disadvantages- cost, stroke risk, radiation
  59. Meningitis
    • Most common symptoms headache, neck stiffness, fever
    • Others include altered mental status, neurologic findings, papilledema, rash

    • Kernig's sign- flex leg at hip and knee, then try to extend leg with hip flexed. pain and spasm in hamstring resisting extension indicates meningeal irritation
    • Brudzinski's sign- flexion of neck causes legs to be drawn up

    • CSF: >1000 WBC for bacterial, >100 for viral. Normal up to 5
    • Cell differential- lymphocytes viral, PMN's bacterial
    • Gold standard for bacterial is culture
    • Neisseria mengitidis (-?meningococcus) is common bacteria and streptococcus pneumonia (+, pneumococcal)


    bacterial- vancommycin, ceftriaxone if not penicillin
  60. Lumbar puncture
    • Indications: subarachnoid hemorrhage (gold standard for ruling this out)
    • infection
    • disorders of nervous system
    • types of brain cancer
    • excess CSF

    • Contraindications: for LP
    • infection near puncture site
    • increased ICP (papilledema)

    Rare occurence is herniation syndrome- brain stem herniation when lumbar pressure is lowered. pts at risk can be identified with history and neuro exam, or CT

    • opening pressure- >250mmH20 not normal
    • glucose should be 2/3 of serum, low may be bacterial, viral usually normal

    xanthocrhomia is yellow, orange or pink supernatant, from subarachnoid hemorrhage or high bilirubin

    Traumatic tap usually has 1:700 WBC:RBC
  61. apraxia
    inability to perform particular purposeful actions
  62. aphasia
    loss of ability to understand or express speech
  63. dysarthria
    difficult or unclear speech that is otherwise linguistically normal
  64. dyphonia
    difficulty in producing sound because of physical disorder of mouth, tongue, throat, etc
  65. Dorsal column lesion
    • loss of light touch, vibration, position, generalized blow lesion
    • ipsilateral*
  66. fasiculus cuneate
    • nerve tract primarily to arms. 
    • ipsilateral at spinal cord level
  67. lateral corticospinal tract
    • Ipsilateral at spinal cord leve
    • UMN- signs would be weakness, hyperreflexia (+babinski, clonus) hypertonia
  68. lateral spinothalamic tract
    • pain and temperature
  69. Transection of right half of spinal cord
    • right dorsal column causes absence of light touch, vibration, position sense in right leg
    • lateral corticospinal tract causes upper motor neuron signs in right leg
    • lateral spinothalamic absence of pain and temp in LEFT leg