BMB 3

Question 1

Which patients have a high risk of overdosing

Answer 1

Those taking opioids WITH benzos

Question 2

If pt has to take opioids, what else should be inv in tx?

Answer 2

non opioid tx like EXERCISE, snri’s, etc. ESTABLISH CLEAR GOALS with pt, discuss risks, and reassess pt every 90d -perscribe shorter acting, immediate release bc have less opiate amt (eg oxycodone + acetominophen (APAP))

Question 3

what dose of opioids should be given for chronic vs acute pain?

Answer 3

-chronic: lowest dose possible, or <50mg morphine per day (def under 90), 4-6 hr -acute: same as above, 3-7d plan (NO er-la tabs)

Question 4

when do you follow up w/ pt on new opiate program

Answer 4

4 wk (bc accidentally overdose is highest w/i first month)

Question 5

risk factors for opiate OD?

Answer 5

sleep disorders, pregnant women, renal/hep insuff, 65+, mental health issues, substance abuse issues, past OD

Question 6

what can you rx pt in case of OD?

Answer 6

Naxalone/Narcan to “wake up” pt (opioid antag)

Question 7

what should you do before you rx opioids?

Answer 7

-review PDMP to make sure rx is being given to pts in other states (lists any controlled substance eg benzos) -give urine drug test to avoid interaxn with drugs (not necessary for acute pain, only need annually)

Question 8

what combo should you not rx with opiate?

Answer 8

benzos! high risk of OD

Question 9

if pt has opiate abuse disorder, what do you give them?

Answer 9

give tx with buprenorphine or methadone in conjxn with behavioral tx

Question 10

What is a major risk factor for both types of stroke (most are ischemic)? (lack of blood O2 to brain causing cell death)

Answer 10

HTN!

Question 11

what is subarach hemm usually due to?

Answer 11

aneurysm rupture, oftentimes ACA or MCA in circle of willis

Question 12

who do subdural hemorrhages usu occuur in

Answer 12

elderly pt with brain atrophy or vol loss, so brain pulls away from dura w torsion of bridging vv, may see midline shift when crescent compresses

Question 13

which pts do epidural hem usu occur in

Answer 13

young pt with severe trauma to side of head, unlike subdural it doesnt cross suture lines

Question 14

Sx of stroke

Answer 14

subacute focal neuro deficit, eg left hemisphere infarct may have speech changes and right sided weakness, ischemic may be painless and would NOT inv unconsciousness

Question 15

if pt has stroke sx and goes unconscious, where may stroke be present?

Answer 15

midline structure such as pons or thalamus, or from bleed that incr intracranial pressure overall, will also show a structural lesion

Question 16

If pt experiences painless clumsiness on one side, what should they do?

Answer 16

not sleep it of, go to dr within 4.5 hr and get tpa tx

Question 17

what other things may lead to focal neuro deficit and mimic stroke?

Answer 17

seizure, migraine, re-expression during illness of past stroke sx, conversion disorder (NOT malingering bc thats rare)

Question 18

How much total body O2 does brain consume?

Answer 18

20%!

Question 19

What happens when CBF (cerebral blood flow) drops?

Answer 19

eg from necrosis, brain will decr metabolic rate and shunt blood to that region, may be areas of infarction with penumbra– penumbra can be resolved with reperfusion (reperfusing infarct can cause free radicals however)

Question 20

What is CT perfusion imaging

Answer 20

imaging to detect whether tissue is dead or viable in brain, takes adv of autoregulation wihihc brain ppts in– looks at vessel diameter changing (as BP drops, vessel dilates etc), if tissues arent responding it means they cant autoregulate meaning dead tissue

Question 21

Which part of circle of willis accounts for most of blood flow to brain?

Answer 21

anterior division! 80%

Question 22

Which branch of anterior circ are most strokes related to?

Answer 22

MCA!

Question 23

What are the divisions of the MCA in which stroke can occur, and what type of stroke does each lead to?

Answer 23

-stroke to superior division of MCA (which goes frontal), causes broca’s aphasia (cant speak) -stroke to inferior division of MCA (which goes temporal) causes wernicke’s aphasia (cant understand)

Question 24

Where do lenticulostriate aa branch off of and what can stroke there cause?

Answer 24

lenticulostriates branch of ACA and strokes to them can cause sensory and motor isseus (would cause internal capsule issues but not necessarily show cortical signs, may just cause limb weakness on one side etc)

Question 25

What vessels are part of post circ?

Answer 25

vertebral AA giving off PICA, AICA, basilar/pontine aa, PCA (?) (see img)

Question 26

What might L hemisphere stroke (cortical signs) cause?

Answer 26

language loss

Question 27

R hemisphere stroke may cause?

Answer 27

hemineglect, attn deficits

Question 28

Deficit in leg vs arm/face may occur where?

Answer 28

medial (ACA, which is more midline), vs lateral (MCA)!

Question 29

Posterior circulation stroke may show signs of…

Answer 29

Vertigo, N/V from basilar occlusion Pure heminopsia maybe from PCA issue

Question 30

What might strokes to thalamus, brainstem, and cerebellum show?

Answer 30

thalamus- lots of stuff! good mimicker brainstem- midbrain may show disconj of eyes, pons nonspecific, medulla CN 3/6/12

Question 31

What might clumsiness/weakness on left side mean?

Answer 31

right side sided UMN in internal capsule issue

Question 32

What if person experiences numbness on one side (sensory sx only) replaced by burning pain? (what syndrome is this, and what structure is affected?)

Answer 32

This is thalamic pain syndrome! (dejerine-roussy), where there is lesion to thalamus (VPL/VPN), hemisensory loss/pain (sensory only, no motor or cortical sx)

Question 33

where can pure motor stroke occur?

Answer 33

• lacunar infarct to posterior limb of internal capsule (most common)
• lacunar infarct to pontine aa

Question 34

If there’s an eye deviation issue, which structure is likely involved and which circulation is this?

Answer 34

CN III, so brainstem (midbrain) thus issue with post circ

Question 35

Weber’s syndrom involves?

Answer 35

IPSILATERAL CN III palsy, with contralateral weakness

Question 36

What might alien hand phenomena indicate?

In addn with neglect to one side?

Answer 36

alien hand- ACA stroke

neglect- issue with one side of parietal lobe (issue is same side as gaze preference???) (ACA and MCA)

Question 37

What might fhx of Rheumatoid arthritis and multiple miscarriages indicate?

Answer 37

hyercoagulable state

Question 38

What is Todd’s paralysis

Answer 38

After a seizure, pt gets flaccid weakness on one side (post-seizure paralysis where brain wont respond for 1-3d, brain has shut off on one side to prevent more depol)

Question 39

papilledema and pain that worsens when lying down may indicate which process?

Answer 39

increased ICP

Question 40

Ok so: clogged dural sinus, miscarriages/autoimmune RA hypercoagulability, and incr in ICP (papilledema and progressive pain when lying down) indicates which process?

Answer 40

there’s a DURAL SINUS THROMBOSIS due to hypercoagulable state, which increases ICP, its progressive over time (unlike subarach hemm which would be immediate v painful thunderclap headache)

Question 41

Alexia without agraphia and homo heminopsia means which structure and circ?

Answer 41

Cortical issue (lobe?), heminopsia means occip issue, supplied by PCA

Question 42

LATERAL MEDULLARY SYNDROME (of Wallenberg)

What is the TRIAD?

Other sx?

What vessel is affected, and which branch?

Answer 42

Triad: NAUSEA, VOMITING and VERTIGO!

Sx: roller coaster or sudden head movements causing dissection

Vessel: dissection of vertebral artery, eg PICA branch

Question 43

What cerebral artery is affected with
-total motor loss

• complete global aphasia
• occipital lobe issues?

Answer 43

ACA, MCA, and PCA! internal carotid artery issue would affect both ACA AND MCA (lenticulostriate aa branch off MCA)

***create diagram with all this info!