1
Q
Gold standard for diagnosing sleep apnea
A
Polysomnogram (PSG)
2
Q
Sleep apnea definition
A
Collapsing of upper airways during sleep that causes cessation of breathing (apnea) or inadequate breathing (hypopnea) and sleep fragmentation
3
Q
Apnea definition
A
Cessation of breathing that lasts more than 10 seconds
4
Q
Hypopnea definition
A
Respiration that declines more than 10 seconds but does not necessarily stop, determined by measurements of nasal pressure which leads to consequences such as o2 desaturation
5
Q
Arousal (sleep study) definition
A
Brief sudden change in sleep state that can be detected on the EEG caused by a drop in O2 and increased CO2 following an apnea or hypopnea episode that then moves to a sympathetic response to compensate which stirs the patient awake slightly resulting in a lack of deep sleep
6
Q
apnea-hypopnea index (AHI) and what are the range of values
A
- Average number of apneas + hypopneas per hour of sleep of a patient, most common used
- Normal is <5 events per hour, mild is 5-14, moderate is 15-29, severe is 30 events per hour or more
7
Q
3 types of sleep apnea
A
- Obstructive (most common, airway is blocked by nocturnal muscle done decrease or anatomic obstructions)
- Central (brain fails to signal muscles in order to breath, rib and abdominal motion ceases)
- Mixed/complicated (central and obstructive, hard to diagnose)
8
Q
Common anatomic obstructions in obstructive sleep apnea (4) and which is most common in children
A
- muscle relaxation
- obesity
- nasal obstruction
- enlarged tonsils/adenoids (most common in children)
9
Q
Mallampati scoring for obstructive sleep apnea
A
Used in anasthesia to predict ease of intubation, can be used to predict whether a patient might have obstructive sleep apnea based on whether soft palate or uvula can be visualized (class 1-4 going from able to see soft palate and uvula, only partial of soft palate, only uvula, or nothing)
10
Q
2 nasal anatomic obstructions that can contribute to obstructive sleep apnea
A
- enlarged turbinates
- deviated septum
11
Q
Pierre Robin Sequence definition
A
Congenital condition present at birth that results in a smaller than normal lower jaw, tongue being placed back further than normal, and opening in roof of mouth (cleft palate) predisposing to obstructive sleep apnea
12
Q
Treacher Collins syndrome definition
A
Varies in severity of presentation but due to underdeveloped facial bones with downward slanting eyes and a cleft palate as well as malformed ears
13
Q
Most common risk factor for obstructive sleep apnea
A
Obesity
14
Q
New onset of A-fib if acute MI is ruled out is likely to be from…
A
….Obstructive sleep apnea
15
Q
Common presentation of sleep apnea (5)
A
- Sleepiness (inability to remain awake and alert but not fatigue (lack of physical or mental energy))
- Snoring
- Choking sounds
- awaken feeling unrested
- morning headaches
16
Q
Epworth sleepiness scale
A
Useful screening tool for sleep apnea
17
Q
CPAP vs BiPAP
A
CPAP is one constant level of pressure to passively open the upper airway, while BiPAP has 2 pressure settings, one prescribed for inhalation and a lower one for exhalation (can be easier to exhale)
18
Q
Oral appliance therapy
A
2nd line treatment for sleep apnea including mandibular advancement devices to adjust position of mandible during sleep or tongue retaining devices that prevent tongue from obstructing
19
Q
Acute stress disorder vs PTSD
A
Acute stress disorder begins immediately and lasts 3 days to 1 month, PTSD is > 1 month
20
Q
PTSD definition
A
Disorder characterized by intrusive thoughts, nightmares, and flashbacks of past traumatic events, avoidance of reminders of trauma, hypervigilance, and sleep disturbance, all of which lead to considerable social, occupational, or interpersonal dysfunction
21
Q
5 major symptom clusters of PTSD
A
- Re-experiencing traumatic event
- Avoidance and emotional numbing
- increased arousal during sleep
- Social or occupational impairment
- > 1 month
22
Q
PTSD treatment options (2)
A
- Exposure therapy first line
- SSRI (paxil/zoloft) if not successful
23
Q
Trazodone (deseryl) for PTSD and what is one big ADR?
A
- Sedative antidepressant that has been very efficient in PTSD patients who are also suffering form insomnia
- Priapism
24
Q
Reactive attachment disorder definition and presentation
A
- Psychologic result of significant social neglect in childhood between child and caregiver
- Failure to thrive, poor hygiene, withdrawal from another person avoiding eye contact and disliking being held
25
Disinhibited social engagement disorder definition
-Lack of shyness approaching and interacting with unfamiliar adults, often due to exposure to extreme insufficient care
26
Dissociative Identity disorder (Dissociative disorders type 1)
Characterized by 2 or more personality states that have incorporated possession of an individual
27
Depersonalization/derealization disorder (Dissociative disorders type 2)
Experiences of unreality or detachment with respect to ones self or surroundings, acute transient stress related dissociative reactions
28
Antipsychotic drugs uses (5)
- Schizophrenia
- schizoaffective disorder
- delusional disorder
- manic phase of bipolar disorder
- major depression in combo with other antidepressants
29
Psychosis definition
Condition of mental disorder characterized by marked thought disturbance and perception of reality, loss of contact from reality
30
Theory of schizophrenia cause
Theorized to be due to overactive dopaminergic pathways in brain areas such as the limbic system
31
Atypical antipsychotics are...
...2nd generation agents
32
First vs second gen antipsychotics
1st gen cause strong blockade of dopamine in CNS causing higher risk side effects such as extrapyramidial movement symptoms, 2nd gen have moderate dopamine receptor blockade and serotonergic blockade as well and have lower risk of extrapyramidal symptoms but greater risk of metabolic effects, but both are ultimately are very efficient at treatment of psychosis
33
Examples of 1st gen antipsychotics (3)
- chorpromazine (thorazine)
- haloperidol (haldol)
- thiothixene (navane)
34
1st gen antipsychoics ADR's (6)
- Extrapyramidal reactions
- Hyperprolactinemia
- Weight gain
- Dry mouth
- Sedation
- Orthostatic hypotension
35
Extrapyramidal reactions and treatment (and one treatment to avoid
- Movement disorders caused by dopamine blockade presenting very similar to parkinsons with late stage presenting as tardive dyskinesia
- Only way to temporarily stave off tardive dyskinesia is to increase dose of antipsychotic but this will long term worsen condition, it is irreversible even upon cessation of drug, can give anticholinergic drugs
- Avoid levadopa
36
Clozapine (clozaril) Drug class, indication, ADRs (2)
Powerful 2nd gen antipsychotic indicated only for patients with schizophrenia who have not responded to traditional agents or who cannot tolerate extra pyramidal side effects, large ADR is agranulocytosis that can be fatal requiring mandatory weekly monitoring of blood counts and highest incidence of weight gain
37
Receptor blockade and side effects of antipsychotic agents (D2, H1, muscarinic cholinergic, and a1 adrenergic)
D2 - extrapyramidal reaction
H1 - weight gain and sedation
muscarinic cholinergic - dry mouth and urinary retention
a1 adrenergic - orthostatic hypotension
38
Long acting injectible antipsychotics function and one problem
- Prevent relapse and maintain highest possible level of functioning for patients and promote adherance for those who need long term treatment
- Effects are long term and cannot be reversed if toxicity or pregnancy occurs
39
OBRA '87 regulations
Require that an individual on an antipsychotic must be necessary and should be discontinued if not needed and given at the lowest effective dose, particularly important in elderly care facilities up to governmental regulation
40
Tardive dyskinesia definition
Side effect of antipsychotic medications causing facial behavior such as tongue protrusion or puffing out of cheeks
41
Pica definition and what 3 groups is it most often seen in?
Persistent eating of non-nutritive substances for a period of at least one month inappropriate for given individual's developmental level (not including teething babies), not accounted for by ethnic/social norm, highest among pregnant women, children, adults with iron deficiency
42
Complications of pica (3)
- Heavy metal toxicity
- GI symptoms and complications
- bowel obstruction
43
Rumination disorder definition
Repeated regurgitation of food for >1 month that is either re-chewed, re-swallowed, or spit out not due to a medical condition and not exclusive to anorexia, bulimia, binge eating, etc.
44
Complications of rumination disorder (3)
- malnutrition
- esophageal ulceration
- tooth decay
45
Pica and rumination disorder treatment (2)
- Pharmacologic treatment for comorbid conditions
- Psychotherapy
46
Avoidant restrictive food intake disorder (ARFID) definition
An eating or feeding disturbance manifested by persistent failure to meet appropriate nutritional and or energy needs associated with significant weight loss, nutritional deficiency, and marked interference with psychosocial functioning NOT*** due to disturbance in perception of body weight and shape (not anorexia or bulimia)
47
Binge eating disorder (BED) definition
Recurrent episodes of binge eating episodes characterized by both eating in a discrete period of time (such as 2 hours) an amount of food that is definitely larger than what most would normally eat AND individual has lack of control over eating (cannot stop eating or control what or how much one is eating), associated with eating rapidly, alone, and feeling disgusted with oneself (ego dystonic) not associated with compensatory behaviors
48
Bing eating disorder treatment (3)
- Psychotherapy
- group therapy in or outpatient
- pharmacotherapy for psychiatric comorbidities
49
Anorexia nervosa definition and epidemiology
- Persistent restriction of energy intake leading to significantly low body weight and intense fear of gaining weight or becoming fat regardless of own weight as well as disturbance in way ones body weight or shape is experienced
- 90% of cases of females primarily affecting adolescent girls and young women
50
Anorexia nervosa 2 subtypes
1) Restrictive - restricted food and compulsive exercise
2) binge eating/purging - restricts food with intermittent episodes of binging OR** purging
51
Bulimia nervosa definition
Recurrent episodes of binge eating episodes characterized by both eating large portions of food in discrete period of time and a sense of lack of control as well as reucrrent inappropriate compensatory behavior in order to prevent weight gain such as self induced vomiting, laxatives, diuretics, fasting, etc.
52
Bulimia nervosa 2 subtypes
1) purging - use of vomiting or misuse of laxatives, diuretics, etc
2) non purging - person has used other inappropriate compensatory behavior but has not engaged regularly in self induced vomiting, diuretics, laxatives, etc. but rather things like excessive exercising and fasting
53
Atypical anorexia nervosa
All criteria met despite significant weight loss, individuals weight is within or above normal range
54
Most deadly psychaitric disease
anorexia nervosa
55
Red flags on physical exam for eating disorder (5)
- Bradycardia
- hypotension
- low BMI
- lanugo
- russel's sign (abrasions on knuckles of hand from purging)
56
Refeeding syndrome definition
Significant risk in malnourished patients with anorexia nervosa because patients are in an adjusted homeostatic state (catabolic), too rapid of refeeding can upset this balance putting at risk of edema/CHF as well as abdominal pain because of decreased motility of gut as well as profound reduction in serum phosphate that enters cells upon refeeding to be used as ATP putting at risk of hypophosphatemia
57
3 categories of disruptive behavior disorders
- oppositional defiant disorder
- conduct disorder
- ADHD
58
Oppositional defiant disorder definition
Consists of pattern of negative, hostile, and defiant behavior especially toward authority figures lasting at least 6 months, behaviors must occur more frequently than typically observed in children of comparable age/development causing significant impairment in social, academic, or occupational functioning
59
Cornerstones of treatment for oppositional defiant disorder (2)
- Individual or family therapy
- parent child interaction therapy
60
Conduct disorder definition
Repetitive and persistent pattern of behaviors that violate the basic rights of others or age appropriate norms or rules of society directed at people, animals, or property
61
Antisocial personality disorder definition
Pervasive pattern of impaired personality (self and interpersonal) functioning with the presence of impaired self functioning (ego-centrism or failure to conform to law) and impaired interpersonal functioning (lack of remorse, failure of intimacy)
62
Treatment of antisocial personality disorder (3)
- often legal system is first to recognize
- psychotherapy
- medical treatment
63
Impulse control disorders definition
Failure to resist impulsive act or behavior that is potentially harmful or dangerous to oneself or others characterized by a sense of tension or arousal prior to he act and experience of pleasure or relief upon committing the act either ego syntonic (behavior acceptable to patient's personality) or ego dystonic (remorse and guilt)
64
Intermittent explosive disorder
Several discrete episodes of failure to resist aggressive impulses resulting in serious assaultive acts, destruction of property, verbal aggression, out of proportion to psychosocial pressures, diagnosis of exclusion, may or may not see guilt about behavior following event
65
Kleptomania definition
Failure to resist stealing objects which are not generally needed or without monetary value caused via sense of tension prior to act and pleasure at time of threat followed by regret (ego dystonic***)
66
Pyromania definition
Irresistible impulse to set fire without any motive beyond fire itself with tension arousal before event and gratification or relief upon witnessing aftermath commonly ego syntonic***
67
OCD definition
Clinical syndrome with excessive anxiety evoking thoughts and compulsive behaviors generally recognized as unreasonable by the patient (ego dystonic), can cause significant distress and impairment, either uncomplicated when seen alone or complicated when co-occurring with other disorders
68
Hoarding disorder definition
Persistent difficulty discarding or parting with possessions regardless of actual value associated with distress associated with discarding items that ultimately substantially compromises living area use
69
Trichotillomania definition
Condition of repeated urge to pull hair resulting in induced alopecia from preceding tension followed by relief when pulling, unable to stop even after developing thinned area of hair, interferes with function at work/school, brings emotional distress (ego dystonic)
70
Trichobezoars definition
Complication from trichotillomania and ingestion of pulled hair resulting in potentially forming a bowel obstruction
71
ADHD pathophysiology
Exact etiology of ADHD is unknown but multiple genetic factors have been implicated, 50% of children have parents who have the disorder,often see right prefrontal cortex/caudate nucleus/globus pallidus are smaller suggesting lack of connectivity of regions of brain that modulate attention and impulsivity
72
2 neurotransmitters implicated in ADHD
Dopamine
norepi
| Norepi
73
Potential environmental influences on ADHD (4)
- Dietary influences controversial (red dye, FDA says no but can't hurt if patients want to try)
- prenatal to alcohol, smoking, valproate
- head trauma
- foster care
74
ADHD diagnostic criteria
Persistent pattern of inattention and or hyperactivity/impulsivity that interfere with functioning or development, typically some symptoms before age of 12*** in 2 or more settings**** that is not explained by other disorders (substance abuse in teens for example)
75
ADHD diagnostic workup (4)
- Lab tests and neurological testing not needed except for differential
- Standardized behavior rating scale
- Very thorough evaluation about history
- physical exam usually normal unless something on differential
76
The action potential generated from painful stimuli is the same from person to person, however what differs is how they...
....interpret it
77
Pathway of pain sensation
- "injury" of some kind (change in homeostasis
- Reflex arc initiated as well as
- spinal cord sends message upward
- thalamus relays message to different systems including limbic (interpretation of sensation), somatosensory cortex (what and where is stimulus) and frontal cortex (applies meaning)
78
First steps for working with patients with chronic pain
Assess for underlying disease thru labs and workups for possible alternatives
79
NSAIDS + acetaminophen have been proven to be ___ effective as opioids regarding pain reduction
just as effective
80
Pediatric patients under 12 should never get ___ products because of ____, preferred agents are ___ and ____
codeine, variability of metabolism into morphine in patients causing potentially fatal outcomes, hydrocodone and morphine
81
Complications of chronic opioid use (4)
- constipation (prescribe a laxative with it)
- allodynia (pain in response to nonpainful stimulation)
- hyperalgesia (excessive response to pain not related to their original pain)
- opioid induced androgen deficiency (infertility, decreased sexual function)
82
Neonatal abstinence syndrome (NAS)
Refers to recommendation against withdrawing from drugs such as opioids in pregnancy to ensure better prenatal care in 1st trimester when already at elevated risk, 2nd semester is better to withdrawal but best is to wait until after delivery, child may be delivered in withdrawal depending on mother's last dose, infant treated with morphine and methadone
83
Addiction definition
Treatable chronic medical disease involved in complex interactions among brain circuits (dopamine bursts), genetics, the environment (vietnam vets example), and an individuals life experiences, people with addiction use substances or engage in behaviors that become compulsive and continue despite harmful consequences, argued to be a disease due to a lack of human connection
84
Substance abuse disorder diagnostic criteria (only 2 criteria need to be met for mild)
- substance taken in larger amounts than intended
- persistent desire or can't cut down
- time is spent obtaining, using, recovering
- craving
- failure to fufill obligations
- withdrawal
85
Converting to morphine miligran equivalents (MME)
Take daily dose of med in mg/day, convert using conversion factor to MME, then lower dose by 25% to prevent overshooting mark
86
Drugs most responsible for overdose death involving opioids
- synthetic (fentanyl, tramadol)
- Heroin
- oxycodone
- hydrocodone
- RARELY methocodone (not euphoric)
87
Tolerance definition
The need for increasingly larger or more concentrated dosage of substance in order to achieve desired effect
88
Withdrawal from ___ and ___ can be fatal, while withdrawal from ___ is not
alcohol and benzos, opioids
89
Maintenance therapy vs controlled environment
Maintenance therapy refers to an individual on medication such as methadone or buprenorphine or naltrexone and no criteria for SUD met, while controlled environment is where they have access to alcohol and controlled substances is restricted and no criteria for SUD are met (jails or rehab)
90
10 substance classes in substance related and addictive disorders
- alcohol
- caffeine
- cannabis
- hallucinogens
- inhalent
- opioid
- sedative
- stimulants
- tobacco
- other
91
Alcohol acute withdrawal treatment gold standard (3)
- diazepam (valium)
- carbamezapine (tegretol)
- thiamine/folate/magnesium
92
Naloxonevs naltrexone
Naloxone is an antagonist used to treat opioid overdose, naltrexone is an agonist that prevents cravings (withdrawal assistance)
93
__% of people who die by suicide did not have a mental health condition, what age group has highest suicide rate, majority are performed via...
54%, young adults attempt most often but elderly white men with chronic illness have greatest rate, ...firearm
94
Nonsuicidal self injury (NSSI)
Self injurious behavior that places patients at high risk for suicide
95
302 procedure
Causes a patient to be admitted to inpatient unit for 5 days against their will for observational purposes based on past 30 days of information requiring a petitioner, medical practitioner, and county delegate, if they leave facility then warrant for arrest can be issued
96
No harm contract
Clinical practice used tool where patient promises provider they will get specific help if do become suicidal - not shown to protect against suicide
97
__% of people grieve without need for professional intervention
90%
98
Stress definition
Nonspecific response of the body to any demand placed on it to adapt, good when short term and at mild to moderate level as it is essential for life
99
There are __ cervical vertebrae and ___ cervical nerve roots
7, 8 (remember they exit above except for C8 nerve root which exits below C7 and then T1 onward they exit below as well)
100
Recall the annulus fibrosis and nucleus pulposis
Annulus fibrosis is the outer portion of the intervertebral disk (type 1 collagen) and the nucleus pulposis (type 2 collagen) is the shock absorbing gel that is inside
101
What is normal space available for the spinal cord in an adult? What is considered true nerve compression?
>17mm. <14mm
102
Spondylosis treatment options (6)
- NONSURGICAL first line****
- NSAIDS
- short term narcotics for acute flare such as tramadol
- facet injections
- PT/OT
- surgical treatment for instability (not for isolated neck pain, that won't help)
103
Cervical radiculopathy definition
Clinical symptom of nerve root compression resulting in sensory/motor symptoms of the upper extremity caused by things such as cervical spondylosis, disc herniation, etc, typically will complain of dermatomal unilateral upper extremity pain
104
How would you test for C5 radiculopathy? (sensory and motor and reflex)
- The upper anterior shoulder
- Deltoid/biceps
- biceps reflex
105
How would you test for C6 radiculopathy? (sensory and motor and reflex)
- the middle shoulder down the arm straight to the thumb
- Biceps/wrist extension
- brachioradialis reflex
106
How would you test for C7 radiculopathy? (sensory and motor and reflex)
- The posterior shoulder down the arm straight to the 2nd and 3rd digits of the hand
- Triceps/wrist flexion
- triceps reflex
107
How would you test for C8 radiculopathy? (sensory and motor and reflex)
- The corner of the axilla down the arm straight tot he 4th and 5th digits of the hand
- finger flexion
- no specific reflex
108
How would you test for T1 radiculopathy? (sensory and motor and reflex)
- The back heading toward the axilla just below the corner from where the arm leaves and the most medial aspect of the arm going down
- finger abduction
- no specific reflex
109
Spurlings maneuver/cervical compression test
Provacative test to reproduce cervical radiculopathy radicular pain pattern, maximally extend and rotate at the neck toward the involved side then apply vertical force downward
110
Cervical myelopathy presentation (3)
- subtle clumsiness of hands and gait imbalance in early manifestations
- dropping things, inability to manipulate small objects
- physical weakness upper extremity early and lower extremity late stage (either severe or coexistent lumbar stenosis)
111
Cervical myelopathy definition
Caused by spinal CORD compression rather than a specific nerve root from wear and tear of aging
112
Cervical myelopathy causes (5)
- ossification of posterior longitudinal ligament
- congenital stenosis
- tumor/abscess
- spondylosis
- trauma
113
Lhermitte's sign
Electric shock like sensations down spine or legs with certain positions of the neck, indicating MS, cervical spondylosis, cervical disk herniation, etc
114
finger escape test, also known as Wartenberg's sign
a physical exam to check for nerve damage or cervical cord dysfunction. A positive test is when a patient's little finger (and sometimes other fingers) drifts into an abducted (outward) position when they try to keep them extended and adducted (together). This indicates weakness in certain hand muscles due to an ulnar nerve or cervical spinal cord issue.
115
Grip/release test
Test for cervical myelopathy asking patients to make fist 20 times in 10 seconds, if fail then positive for cervical myelopathy
116
positive babinski sign in an adult pt can indicate this condition...
...cervical myelopathy
117
Hoffmans sign
Test used for cervical myelopathy where involuntary flexion of index and or thumb occurs when snapping the middle finger distal phalanx downward
118
Waddell signs (5)
Signs of nonorganic (kinda sorta faking it) back pain, clinically significant if 3 positive signs are present
- superficial and nonanatomic tenderness
- pain with axial compression or simulated rotation
- negative straight leg raise while patient is distracted
- nondermatomal regional pain pattern
- overreaction on physical exam
119
Lumbar disc herniation is more common in what gender? What is the most common level? What happens over time with most?
Men, L5-S1>L4-5, Macrophages reabsorb and diminish size over time
120
How would you test for an L1-3 radiculopathy? (sensory and motor and reflex)
- Hip to groin and inner thigh
- Hip flexion
- No reflex
121
How would you test for L4 radiculopathy? (sensory and motor and reflex)
- anterior thigh going down to front of knee
- Knee extension/foot dorsiflexion
- patellar reflex
122
How would you test for L5 radiculopathy? (sensory and motor and reflex)
- anterior shin going down to the toes
- Great toe extension
- trendelenberg gait
123
How would you test for S1 radiculopathy? (sensory and motor and reflex)
- outer shin down to the pinky toe
- Foot planterflexion/eversion
- achilles reflex
124
Lumbar disc herniation treatment options (2)
- NSAIDS and PT
- Partial discectomy surgery within 3-4 months if not resolving, absolutely indicated in cauda equina or progressive neurologic deficit
125
Lumbar spinal stenosis symptoms (3)
- leaning forward alleviates symptoms
- Extension of spine decreases space worsening symptoms
- pain, paresthesias, subjective weakness or heaviness in back, buttock, and lower extremities
126
Spondylosis vs spondylitis vs spondylolysis vs spondylolithesis
- Degeneration of intervertebral disks
- Inflammation of the vertebrae
- fracture of pars interarticularis without vertebral transfer
- fracture of pars interarticularis with vertebral transfer
Professional Development
flashcards
Decks in class (62)
# Cards
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Part 1122
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Part 2123
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Part 3120
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Part 4150
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Part 5124
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Part 6125
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Part 7148
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Part 8160
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Part 9198
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Part 10119
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Part 11131
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Part 12119
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Part 13126
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Part 14123
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Part 15133
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Part 16142
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Part 17124
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Part 18135
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Part 19127
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Part 20108
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Part 21160
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Part 22125
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Part 23145
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Part 24160
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Part 25170
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Part 26120
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Part 27130
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Part 28153
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Part 29124
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Part 30144
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Part 31181
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Part 32121
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Part 33165
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Part 34133
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Part 35116
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Part 36175
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Part 37170
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Part 38191
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Part 39222
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Part 40150
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Part 41124
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Part 42154
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Part 43183
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Part 44132
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Part 45103
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Part 46125
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Part 47165
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Part 48126
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Part 49114
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Part 50155
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Part 51151
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Part 52101
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Part 53128
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Part 54151
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Part 55130
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Part 56132
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Part 57149
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Part 58131
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Part 59151
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Part 60151
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Part 61136
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Part 62111
