Clin Med 4

Question 1

challenges of txing pain

Answer 1

disparities in minorities/women/elderly/cog impair; undertx ca or end of life care; pain –> loss productivity or QOL; stigma for pain med seekers

Question 2

what’s chronic pain?

Answer 2

> 3mo; from underlying dz/condition/injury or idio

Question 3

addiction. 5 C’s? vs pseudoaddiction

Answer 3

primary, chronic, neurobio dz w/ genetic, psychosocial, environ factors. chronic, compulsive, no ctrl, cont despite harm, craving vs iatrogenic syndrome from misinterpreting relief-seeking behaviors for drug-seeking behaviors

Question 4

physical dependence vs tolerance

Answer 4

both nml physio conseq d/t extended opioid for pain. adaptation manifested by w/drawal d/t abrupt cess, rapd dose reduction, dec blood drug lvl, antag admin; NOT addiction vs reduced effect from constant dose –> inc dose to produce desired effect

Question 5

effective nonpharm vs nonopioid therapies. opioid OD depends on what? factors that inc risk for harm?

Answer 5

OMM, exer, cog behav therapy vs APAP, NSAID, anticonvul, anti dep. dose-dependent. preg, mental health d/o, old age, sleep breathing d/o

Question 6

nociceptive vs somatic vs visceral pain

Answer 6

src –> periph n –> dorsal horn spinal cord –> decussate @ spinal cord –> ascend spinal cord via lat spinothal tract –> thal –> sensory cortex vs dull/achy pain from body surface or MSK tissue d/t inflamm, stretch, ctx/spastic; better w/ rest, worse w/ activity vs vague/diffuse internal organ pain

Question 7

referred vs neuropathic pain

Answer 7

primary aff nociceptors –> DRG –> spinal cord –> mult sensory nn converge into ascending spinal nn of spinothal tract –> thal –> orig pain but along dermatome vs complex chronic pain w/ shooting/burning like phantom limb syndrome

Question 8

APAP vs NSAIDs & corticosteroids vs antidep vs anticonvul vs LA w/ examples

Answer 8

noninflamm pain, Tylenol vs acute pain, flare ups w/ chronic pain; oral prednisone or cortisone injections vs TCA, cymbalta for fibromyalgia & neuropathy vs nerve pain; gabapentin for post herpetic neuralgia, pregabalin for fibromyalgia & diabetic neuroapthy

Question 9

key things to consider for ER opioids

Answer 9

methadone should not be first choice for ER, do transdermal fentanyl, ER/long acting opioids should not be used for acute or intermittent pain

Question 10

key things to consider when doing Morphine Milligram Equivalent

Answer 10

use mg dose & calculate w/ conversion factor; use lowest dose possible, avoid >50 MME/d (or else reeval, inc f/u, give naloxone), consider pain mgmt referral w/ doses >90-120 MME/d

Question 11

how to rx opioids for acute pain not related to surgery or trauma?

Answer 11

start lowest dose & don’t give >3d worth (ie. don’t give more just in case); reeval pts w/in 1-4wks starting long term opioids or >q3mo; determine if opioids meet tx goals, cause AE, benefits > risks, dose can be taper to discont

Question 12

tapering opioids sxs vs how to do it

Answer 12

drug craving, anxiety, tachy, insomnia, mydriasis vs taper 10-50% wkly or 2-3wks if AE

Question 13

rx naloxone w/ opioids if:

Answer 13

h/o OD or substance use d/o, taking CNS depressants like benzos, >50 MME/d

Question 14

how to tx OUD?

Answer 14

offer Medication Assisted Tx –> bupo + waiver, methadone, naltrexone

Question 15

12 guidelines for opioids for chronic pain

Answer 15

1. nonpharm/opioid therapy for chronic pain
2. est realistic tx goals before opioid therapy for chronic pain
3. discuss risks & benefits before opioid therapy, talk abt tapering
4. rx IR, not ER/long acting for chronic pain
5. rx lowest dose & inc slowly prn
6. rx no greater quantity than needed for pain duration (3d = suff)
7. eval benefits/harm w/in 1-4wks of starting opioid therapy
8. eval risk factors for opioid-related harms (give naloxone based on hx)
9. review pt hx & PDMP
10. do urine test before opioid therapy
11. don’t rx opioids w/ benzos –> taper off benzos first
12. give evidence-based tx for pts w/ opioid use d/o like bupo & methadone

Question 16

how to inform pt abt urine drug test

Answer 16

don’t test for substance that doesn’t affect pt mgmt; explain to pts that test is to improve safety, explain expected results, ask if there are “unexpected” results

Question 17

risk factors vs etio of neonatal sz

Answer 17

premature, low birth wt, HIE vs asphyxia/hypoxia/ischemia encephalopathy, hypo/ernatremia, ICH, CNS malform, infxn

Question 18

benign neonatal familial convulsion vs pyridoxine dependency/biotinidase defic vs benign neonatal sleep myoclonus

Answer 18

dom chrm 20, 2/3rd day of life, clonic/apneic sz w/o EEG marker vs various sz types vs EEG & PE nml, good prognosis

Question 19

how to dx vs tx neonatal sz

Answer 19

observation +/- EEG vs determine cause of sz & give vent + glu, phenobarbital, phenytoin

Question 20

simple vs complex febrile szs. how to tx?

Answer 20

b/w 6mo-5yo, can happen w/ common illnesses or vax; EEG nonspecific. <15min, lack focality –> generalized, tonic-clonic vs >15min, focal manifestations, recur w/in 24h. avoid prophylactic AEDs but can give oral diazepam; rectal diazepam for mult or prolonged attacks

Question 21

benign partial epilepsy w/ centrotemporal spikes. tx? vs w/ occipital paroxysms. tx? assoc?

Answer 21

childhood; partial sz going to sleep affecting face, oropharynx, limbs; spikes = hallmark. first-line AED vs 4-12yo; visual halluc/distort, hemianopsia, amaurosis. first line AED. idio occipital epi, celiac dz, occipital calcifications

Question 22

childhood absence epi. tx?

Answer 22

4-8yo, absence sz w/ 3Hz spike wave + hypervent, can have tonic-clonic in adulthood. valproate, ethos, lamto, levet, topiramate

Question 23

west syndrome. tx?

Answer 23

3-8mo; triad: infantile spasm, Hypsarrhythmia EEG, psychomotor delay. pre/perinatal brain injury, metab d/o, degen d/o, neurocut d/o, cerebral malform; focal cortical dysplasia. benzos, val, corticosteroids/corticotropin, vigabatrin

Question 24

lennox-gastaut syndrome. tx?

Answer 24

1-7yo; mult sz types (a/tonic, atypical absence, tonic-clonic > myoclonic), mental retard, slow spike-wave EEG. corticosteroid, ketogenic diet, val+lamot, felbamate but more AE

Question 25

juvenile myoclonic epi. tx?

Answer 25

tonic-clonic after waking exac by sleep depriv or alc w/drawal; >4Hz polyspike wave; can be triggered by strobe lights or absence sz. val > lamot, topiramate

Question 26

temp lobe epi. tx? vs front lobe epi vs par lobe epi vs occ lobe epi

Answer 26

most common form of focal onset epi –> higher risk of mem & mood difficulties. temp lobe surg vs brief recurring sz from frontal lobe while sleeping vs focal sz w/ awareness –> somatosens disturbance, visual halluc. somatosens sz –> pain, mostly in face/hand/arm, Jacksonian march. somatic illusions –> from nonlang dom cerebral hemi, can’t move 1 extremity, contralat hand wkness vs visual –> halluc, illusion, blind, palinopsia. oculomotor –> tonic eye dev, oculoclonic/nystagmus, eyelid fluttering

Question 27

sz precipitants vs sz risk factors

Answer 27

metabl/electrolyte imbal, stimulant/convuls intox, sedative/EtOH w/draw, sleep deprive, stress, hormones, infxn vs fhx, h/o febrile sz/head trauma/meningitis/stroke/lesion

Question 28

how to dx epi sz v pseudo sz? what are pseudo szs?

Answer 28

pre-sz sxs = aura
during-sz sxs = tonic, clonic, incont, tongue injury
post-sz sxs = disorient, confusion, Todd’s paralysis. psychogenic sz = sx of conversion or somatization d/o, no changes in EEG, rare motor loss & post ictal confusion

Question 29

cell mechanisms of sz

Answer 29

excitation –> glu, asp, inward Na+/Ca2+. inhib –> GABA, inward Cl-, outward K+

Question 30

AED doing Na+ inactivation vs GABA activation vs Ca2+ inactivation

Answer 30

carbam, phenytoin, lamot, val, topiramate vs benzos, phenobarb, gabapentin, vigabatrin, val, topira, tiagabine vs ethos

Question 31

P450 inducing vs inhibiting AED

Answer 31

carbam, phenytoin, barbs vs depakote; sulfonamides, isoniazid, cimetidine

Question 32

AE of carbam vs phenytoin vs val vs ethos, lamot

Answer 32

aplastic anemia, agranulocytosis, diplopia, hepatotox vs gingival hyperplasia, hirsut, teratogen, ataxia vs neutropenia, thrombocytopenia, teratogen, hepatotox vs SJS (bullous in mucous mem)

Question 33

tx options for drug resistant epi

Answer 33

VNS therapy (mild pulse to L vagus n), brain surg (resection, corpus callostomy, subpial transsection, stereotactic ablation, RNS), diet (keto, modified Atkins, low glycemic index)

Question 34

status epilepticus

Answer 34

> 30min of continuous sz, >2 sequential sz w/o full recovery

Question 35

trauma to skul = based on mech vs morphology vs severity

Answer 35

blunt, penetrating vs fx, lesion, DAI, diffuse brain injury vs GCS

Question 36

traumatic vs nontraumatic subarach hem

Answer 36

intense cerebral vessel vasospasm, sm cerebral vessels sheared –> bleed vs “worst HA of life”, thunderclap; PCKD, berry aneurysm

Question 37

exertional HA = caused by cough vs sex vs exer

Answer 37

assoc w/ chiari if >30min –> tx w/ cough suppressants or NsAIDs vs more common in middle aged –> tx w/ beta blockers? vs bil & throbbing –> avoid strenuous exer or pretx w/ NsAIDs

Question 38

cytotoxic vs vasogenic cerebral edema

Answer 38

intracellular process from membrane pump failure –> posttraumatic ischemia vs failure of tight jxns of endothelum for BBB from trauma or hem

Question 39

cerebral vasoconstrict vs dil = promoted by?

Answer 39

hyperoxia/tension, alkalemia, hypocarbia vs hypoxia/tension, acidemia, hypercarbia

Question 40

CBF autoreg. TBI dec cerebral blood flow by?

Answer 40

brain vasculature maintain mean BP 50-160mmHg. dec CBF by 50%

Question 41

cingulate vs transtentorial vs uncal vs cerebellar tonsillar hern go where?

Answer 41

under falx cerebri vs downward vs under tent cerebelli vs foramen magnum

Question 42

risk factors for subdural hematoma

Answer 42

trauma, antithrombotic therapy; brain atrophy & alc

Question 43

cerebral contusion vs intracerebral hematoma

Answer 43

in front & temp lobes; from hours to day coalesce to cerebral hematomas vs in deep front & temp lobes; d/t brain thrust against irreg surfaces of fossa –> small hem coalesce or deep arterioles sheared

Question 44

how to deal w/ mild vs mod vs severe head injury?

Answer 44

GCX 13-15: all CT/labs neg –> admit or send home w/ f/u vs GCX 9-12: confused, follow simple commands –> ABCs, CT/labs, neurosurg vs GCX 3-8: can’t follow commands –> ABCs, CT/labs, neurosurg; intub, vent, elevate head 30deg mannitol for ICP