Clinical Medicine II-Spring 2012
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| What are extracranially causes of HA’s | skin, muscle, BV’s, periosteum
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| Intracranially causes of HA’s | Venous sinuses/arteries, Dura, Falk cerebri
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| Does the actual brain tissue (parenchyma) itself cause pain | no
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| When do migraines usually start | adolescence or young adulthood, possible childhood. Rare to start in adulthood, suspect other causes.
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| Epidemiology of migraine HA’s | runs in families, starts in childhood, MC in women (menstruation)
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| Two types of migraine HA’s | Common (MC) and Classic
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| Characteristics of a common migraine | 4-72hrs, unilateral, pulsating, mod-sev pain, aggravated by PA, N/V, Photophobia/phonophobia
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| How many attacks until can probably make the dx | at least 5 attacks to dx w/ migraine HA’s
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| What is a classic migraine | same as common but have an aura gradually prior to HA lasting <60min
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| What are the three types of aura | visual (MC), sensory (unilateral paresthisias/numbness), Motor (unilateral weakness, speech difficulty)
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| Does the aura resolve prior to HA | yes, will resolve than “Boom” hit by HA
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| What can cause a Migraine HA | Must be susceptible but common onset by menstration, sleep, fasting, PA, stress, Tyramine foods (red wine, hard cheeses, herring), phenylethlamine (chocolate), Nitrates (processed meats), Caffeine withdrawal/excess, MEDS: OCP’s antiHTN’s
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| What is the primary pathophysiology behind migraines | start by vasoconstriction followed by abnl vasodilation
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| Common prophylaxis for migraines | BB’s CCB’s, SSRIs, TCA’s, Anti-sz meds
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| Common abortive tx of migraines | OTC analgesics, Vasoconstrictors/Ergots, Anti-emetics, serotonin agonists, IV/IM NSAIDS: ketorolac, narcs, steroids
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| Cluster HA’s | serious of HA’s over a period of 2-3m every 1-2 years M>F, onset late 20’s
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| What can trigger cluster HA’s | alcohol, nitroglycerine, histamine
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| Clinical features of cluster HA’s | pain always unilateral, excruciating, penetrating, not throbbing, around the trigeminal n. distribution, behind eye, autonomic sxs
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| What are the autonomic features w/ cluster HA’s | lacrimation, conjunctival injection (unilateral), nasal congestion/rhinorrhea, ptosis: eyelid dropping/miosis:pupil constriction
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| Tx cluster HA | high flow O2 inhalation 5-8L/m for 10 mins, effective ~70%, same as migraines
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| Proposed mechanism of cluster HA’s | dilation of retroorbital blood vessels and inflammation of trigeminal n. branches
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| Most common type of HA | tension headache, band like constriction around head, 30m-7days, PA unaffected, some photo/phonphobia, no N/V usually
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| Tx tension HA’s | Mild analgesics, stress reduction, relaxation techniques
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| 5 Extra-cranial sources of HA | sinusitis, acute glaucoma, temporal arteritis, TMJ, trigeminal neuralgia
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| HA: worse w/ bending forward, coughing, better w/ supine, usually stabbing/aching | Sinusitis: pain over sinuses, URI sx
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| Orbital pain w/ N/V, unilateral, visual disturbances in that eye | acute glaucoma, cornea is often edematous, cunjunctiva is injected,
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| Dx of acute glaucoma | tonometry (measuring the intra-ocular pressure)
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| Jabbing excrutiating pain over the temple, unilateral or can be bilateral, visual loss may be present, often w/ other systemic sxs | Temporal arteritis
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| Why is temporal arteritis so important to dx | inflammation can also be happening at ophthalmic a. →blindness
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| Epidemiology of temporal arteritis | >50yo, 4xF>M
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| Dx of temporal arteritis | labs: elevated ESR, biopsy,
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| What is tic doloureux | trigeminal neuralgia: brief, severe attacks in distribution of branch of trigeminal n. pain is lancinating “electric shop”
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| Cause and triggers of tic doloureux | D/t partial demylinization of trigeminal n. possible d/t n. compression, triggered by eating, talking, washing face
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| Tx of tic doloureux | analgesics, narcs, anti-sz
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| Name 5 life threatening HA’s | SAH, meningitis, brain tumor, subdural/epidural hematoma, HTN HA
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| What is a diagnostic feature of a SAH | pt states “Worst HA of my life” very acute
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| Signs of a SAH, dx | LOC, focal neuro signs, sz, nuchal rigidity, CT, -? Then do LP!
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| Where do most of the cerebral aneurysms occur | around the Circle of Willis
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| What does acute blood look like on a CT? | white
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| Tx once dx has been made of SAH | Nimodipine (CCB); vasodilator, phenytoin, and urgen neurosurgical consultation
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| Sxs Dx and tx of Meningitis | HA, fever, nuchal rigidity, toxicity, D:LP, Tx: bacterial: IV, abx, steroids, viral: supportive
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| Difference b/w CT of subdural and epidural hematoma | S: sickle, H: lenticular shaped, like a lense
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| Story of a subdural hematoma | HA w/ confusion, obtundation, in elderly often w/ minor head injury, DX: CT
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| Difference b/w epidural and subdural hematoma | E: artery bleed: more serious, S: venous bleed
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| Story of an epidural hematoma | trauma, brief LOC, HA when awake, deteriorating mental status, URGENT neurosurg
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| What classifies a HTN HA | Diastolic BP >130, will be alleviated by BP control
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| Progressively worsening HA over days to weeks, often worse in the morning w/ a.m. vomiting | brain tumor HA
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| Complaints of a brain tumor | HA, weakness, paralysis, sensory deficits, cranial n. palsie, visual distrb, ataxia, AMS, sz’s
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| Study of choice to dx a brain tumor | MRI, or CT w/ contrast (acute setting), EEG w/ sz’s
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| 4 types of brain tumors | astrocytoma (gliomas), meningioma, acoustic neuroma, metastasis (2nd brain tumor)
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| MC brain tumor and location | astrocytoma, in cerebral hemispheres
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| Histopathological grading of a astrocytoma | low-grad astrocytoma (6-8yr), anaplastic astroycytoma (5ys), glioblastoma multiforme (<1yr)(biopsy to grade)
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| RF’s of astrocytoma | radiation, some genetics,
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| Tx astrocytoma | surgery (debulking), radiation, chemotherapy, stroids if edema present, anticonvulsants
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| Second MC type of brain tumor | meningioma, on surface of brain in concavity of skull, mostly benign
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| Tx meningioma | managing sxs, observation, surgical if easily accessible, radiation
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| Acoustic neuroma, RF’s | tumor that rises from schwann cell sheath around vestibule-chochlear n. RF’s: radiation, neurofibromatosis type II
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| Unilateral HL MC complaint | Acoustic neuroma, have tinnitus, vertigo, disequilibrium, HA, or facial n. compression: weakness or numbness
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| TX acoustic neuroma | surgical excision to preserve hearing, If not surgical candidate: gamma knife to reduce size, maybe just observe in elderly or if sm
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| Complication of surgical excision | facial n. paralysis
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| MC sources of 2nd cerebral metastases | Lung, Breast, Genitourinary, Osteosarcoma, Melanoma, GI
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| When do we consider the brain tumor is a metastases | when there are more than one tumor in the brain, check other sources
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| Tx cerebral metastases | avoid surgery, whole-brain radiation therapy, gamma knife: but subclinical lesions are most likely present, chemo
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| What are surgical indications for brain mets | solitary lesion >3cm, in an accessible area of brain, or if only ONE lesion is symptomatic
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