1
Q
causes of syncope
A
- neuro-cardiogenic (vasovagal, carotid sinus syndrome, valsalva)
- vasomotor (inability to maintain peripheral tone)
- cardiac
- other- seizure, TIA, psychogenic
2
Q
seizure- generalized vs partial
A
- generalized- complete loss of consciousness
- partial- altered consciousness but wakefulness is retained
3
Q
seizure- potential causes in adults
A
- metabolic
- drug induced
- drug withdrawal
- CNS pathology (CVA, head trauma, space occupying lesion, infection)
- endocrine- hypo/hyperthyroidism
- systemic conditions
4
Q
seizure- drug induced
A
-Tramadol and Bupropion lower seizure threshold!!
5
Q
seizur- drug withdrawal
A
-alcohol and benzodiazepines- abrupt withdrawal!!
6
Q
CNS infectious etiologies in pts with HIV/AIDs
A
- toxoplasmosis
- HSV encephalitis
- CMV
- Cryptococcus neoformans
- JC polyomavirus (PML)
- CNS tb
- neurosyphilis
- neurocysticercosis (T solium)
7
Q
CD4 count <200- what infection, treatment?
A
- Pneumocystis jiroveci
- TMP/SMX
8
Q
CD4 count <100- what infection, treatment?
A
- toxoplasmosis
- TMP/SMX
9
Q
CD4 count <50- what infection, treatment?
A
- mycobacterium avium
- Azithromycin
10
Q
TST (tb skin test) > 5 mm induration- what infection, treatment?
A
- TB
- isoniazid
11
Q
Toxoplasmosis- caused by?
A
Toxoplasmosis gondii (obligate intracellular parasite)
- reproduces in intestinal tract of CATS- oocytes in their feces
- fecal-oral route!- humans acquire thru ingestion
12
Q
Toxoplasmosis- presentation, Diagnosis, Tx
A
- symptomatic when immunocompromised host acquires a primary infection or reactivation of latent infection
- altered mental status, fever, headaches, seizures, focal neuro deficits
- clinical sx, IgG anti-toxoplasma, MRI RING ENHANCED LESIONS!!
- sulfadiazine + pyrimethamine + leucovorin
13
Q
Toxoplasmosis- prophylaxis when??
A
- CD4 count <100
- TMP-SMX!!
14
Q
long term use of methadone- does what?
A
inc risk of long QTC- at risk for torsade de pointes, cardiac death
- risk inc when used with other 3A4 substrate medications
- antiviral medications to treat HIV/AIDS are 3A4 substrates!
15
Q
treatment for cerebral edema
A
(main goal- pressure < 20mmHg)
- osmotic diuretics
- IV mannitol
- induced hyperventilation (causes resp alkalosis- aid in buffering post-injury acidosis)
- head elevation
- invasive- decompressive craniotomy, ventriculostomy
16
Q
IV mannitol
A
- draws water out of cells/tissues- excreted by kidneys
- also causes vasoconstriction- dec intracranial blood flow
- can cause hypernatremia and acute tubular necrosis!
17
Q
CSF in bacterial infection- opening pressure, WBC, %PMN, glucose, protein, gram stain, cytology
A
- pressure >300 mmHg
- WBC >1000
- PMN >80%
- glucose <40
- protein >200
- gram stain- positive!!
- cytology- neg
18
Q
CSF in viral infection- opening pressure, WBC, %PMN, glucose, protein, gram stain, cytology
A
- pressure <300 mmHg
- WBC <1000
- PMN 1-50%
- glucose >40
- protein <200
- gram stain- neg
- cytology- neg
19
Q
CSF in neoplastic infection- opening pressure, WBC, %PMN, glucose, protein, gram stain, cytology
A
- pressure 200 mmHg
- WBC <500
- PMN 1-50%
- glucose <40
- protein >200
- gram stain- neg
- cytology- POSITIVE!
20
Q
CSF in fungal infection- opening pressure, WBC, %PMN, glucose, protein, gram stain, cytology
A
- pressure 300 mmHg
- WBC <500
- PMN 1-50%
- glucose <40
- protein >200
- gram stain- neg
- cytology- POSITIVE!
21
Q
weakness/fatigue/tremor/falls- etiologies
A
- neurologic- parkinson’s, alzheimers, lewy body dementia, benign familial tremor
- cardiac- arrhythmia, valvular
- metabolic- anemia, electrolyte disturbance, thyroid, EtOH use
- musculoskeletal- DJD, OA, joint laxity
22
Q
resting tremor
A
- skeletal m activation is not necessary
- enhanced by cognitive tasks or motor tasks with other body parts
23
Q
postural tremor
A
-occurs in an attempt to hold a body part motionless against gravity
24
Q
action tremor
A
- occurs during voluntary contraction of skeletal m
- finger-to-nose, heel-to-shin, reaching, drawing, etc
- isometric tremor- m contraction against a rigid stationary object
25
Parkinson tremor (vs benign essential tremor)- age of onset, gender, fam hx, asymmetry, character, where, assoc features
- >50
- M>W
- >25%
- +++
- at rest, supination-pronation
- hands, legs, chin, tongue
- bradykinesia, rigidity, gait difficulty, postural instability, micrographia
26
benign essential tremor (vs parkinson dz)- age of onset, gender, fam hx, asymmetry, character, where, assoc features
- 2nd and 6th decade
- M=W
- >50%
- +
- postural, kinetic
- hands, head, voice
- deafness, dystonia, parkinsonism
27
parkinson's triad
- tremor (pill-rolling, resting)- starts in arm, progresses to contral arm; alcohol improves tremor
- bradykinesia- unsteady gait
- rigidity (resistance to passive movement)
28
parkinsons- clinical diagnosis
- triad (tremor, bradykinesia, rigidity)
- response to L-DOPA
- order CT or MRI to ensure no underlying structural abnormalities!!
29
parkinsons- treatment
- levodopa- inhibits peripheral DA decarboxylation, crosses BBB, precursor for DA in CNS
- dopamine agonist (younger pts or in advanced PD)
30
parkinson's- improve quality of life
- PT/OT consult
- exercise regimen
- changes to diet
- therapy (pyschologic components in PD!!!)
- support groups
- family counseling
31
indications for use of warfarin, INR target
- atrial fibrillation- 2-3
- DVT/PE- 2-3
- bioprosthetic valve- 2-3
- mechanical valve- 2.5-3.5
32
most common cause of supratherapeutic INR
-interactions with warfarin and its metabolism!!
33
elevated INR- risk? management of supratherapeutic INR
bleeding!
- >5- lower dose of warfarin
- 5-9- omit 1-2 doses of warfarin, could admin vit K
- >9- hold warfarin, admin vit K
- if bleeding present- hold warfarin, admin vit K by IV infusion, supplement with prothrombin conc or fresh frozen plasma
34
pt who has fallen and on blood thinner- why use a non-contrasted CT head?
- contrast will obscure blood
| - make sure pt doesnt have a brain bleed!!
35
mini-mental state exam- questions?
- orientation
- registration
- attention and calculation
- recall
- language
36
mini-mental state exam- score
- normal- 24-30
- mild dementia- 18-23
- moderate dementia- 10-17
- severe dementia- <10
37
pediatric H&P- do what?
- esta their developmental baseline
- ask about pregnancy, delivery, nursery course
- any sick child that prefers to be left alone and doesnt want to be moved- be concerned!!!
- high fever with tachycardia cn cause flow murmur
- urine for culture- obtained via catheterization!!
38
CBC- what is included?
- WBC
- RBC
- Hg
- hematocrit
- MCV
- MCHC
- platelet
39
CBC with differential- what is included?
-neutrophil, lymphocyte, monocyte, eosinophil, basophil
40
CBC- left shift- indicates what?
-elevated white count + left shift= infection!
41
what is a left shift?
-immature neutrophils (bands) are pushed out of marrow to fight an infection
42
I/T ratio
- immature neutrophils/total neutrophils
| - >0.2- infection!
43
causes of meningitis- birth-2 months old
- Group B strep
- E coli
- L monocytogenes
44
causes of meningitis- 2 months- 12 yrs
- S pneumoniae
- N meningitides
- H influenza (dec b/c of vaccination)
45
causes of meningitis- adolescents
-N meningitidis
46
causes of meningitis- >60 age
- S pneumoniae
| - L monocytogenes
47
CSF protein can be artificially elevated by what?
presence of RBCs
- intracranial hemorrhage
- traumatic taps
48
careful consideration in when doing a LP
suspicion of
- inc intracranial P
- coagulation abnormalities
- spinal epidural abscess
49
consider a CT prior to LP in pts with
- altered mentation
- focal neurologic signs
- papilledema
- hx of seizure within previous week
- impaired cellular immunity
50
typical signs of meningitis
-headache, fever, nausea, vomiting, nuchal rigidity, photophobia
51
tests for meningitis
- kernig sign
- brudzinski's sign
- nuchal rigidity
- fontanelle check if pt <2 yo
52
kernig sign
- flex pts leg at both hip and knee, try to straighten/extend the knee
- positive- extension of knee- pain!!!
53
brudzinski's sign
- flex neck, watch hip and knees
| - positive- reflex flexion at hips!
54
empiric treatment for bacterial meningitis
-vancomycin + ceftriaxone
P3.2
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