Lecture 12: Neuro Flashcards
(196 cards)
1
Q
Neurologic Exam in the ED
* Neuro Exam should include what?
A
- Mental Status Testing
- Higher Cerebral Function
- Cranial Nerves/Brainstem testing
- Sensory Exam
- Reflexes
- Gait (if possible)
- Cerebellar testing
2
Q
Brain Box
* What are the parts of cerebral hemispheres?
* What are the parts of diencephalon?
A
Cerebral Hemispheres (Cortex)
* LEFT HEMISPERE IS DOMINANT FOR ALL RIGHT-HANDED AND 80% OF LEFT-HANDED POPULATION
Diencephalon (Pituitary, Optic Chiasm)
* Thalamus
* Hypothalamus/Subthalamus
3
Q
Brain Box
* Brain Stem parts?
* What structure is for movement?
A
Brain Stem (M/P/M) – cranial nerve nuclei are there
* Medulla (lower part of brainstem/respiratory center etc.)
* Oculovestibular (cold water testing)/Oculocephalic Reflex (doll’s eyes movement)
Cerebellum
4
Q
Where is broca’s and wernicke’s area?
A
- Broca: Frontal lobe
- Wern: Temporal Lobe
5
Q
What sign is for cerebellum?
Confirmed by getting what?
A
- Cerebellum – romberg sign: positive when the patient is unable to maintain balance with their eyes closed
- Confirm by getting CT
6
Q
Higher Cerebral Function
* What happens when dominant hemisphere involvement?
A
Language and Dysphasia or Aphasia
* If Dominant Hemisphere involvement
7
Q
What the two types of dysphasia?
A
- Receptive: does the patient understand what’s being said (wernicke area – temporal lobe)?
- Expressive: Can understand but cant speak (Broca – frontal lobe).
8
Q
Define:
* Nonfluent aphasia –
* Fluent aphasia –
* Paraphrasic –
A
- Nonfluent aphasia – halting, slow speech
- Fluent aphasia – gibberish (vocabulary lost)
- Paraphrasic – choice of incorrect words
9
Q
Cranial Nerves:
* What is teh corneal reflex?
* What is the pupillary response?
A
Corneal Reflex
* CN 5,7
Pupillary Response
* CN 2,3
* About 20% of population has anisocoria
10
Q
Cranial Nerves
* Why is VII important?
* EOM cranial nerves?
A
VII important in emergency neuro exam
* Face Drooping to one side/forehead spared (central)
* Bells palsy will involve the entire face
EOM’s
* CN 3,4 AND 6 (and even 2)
11
Q
Cranial Nerves
* What do you do for bells palsy?(3)
A
Bells palsy – admit, get steroids and get a CT to r/o tumor. Its probably a viral cause
12
Q
Motor Exam
* Note what?
* What type of drift?
* Quantify what?
* Why do you do relexes?
A
Note atrophy, contractures – chronic process, not acute
Pronator drift (Frontal Lobe) – contralateral frontal lobe
Quantify weakness
Reflexes: (Pathologic) – All are UMN.
* Important to note Babinski, Clonus
* CNS/Cord
13
Q
Cerebellar
* How do you test it?
* What are the two types of vertigo?
A
RAHM, Finger to Nose, Nystagmus (noted with CNs)
* Central Cause Vertigo – Vertical Nystagmus (Pathologic)
* Peripheral Cause Vertigo – Horizontal Nystagmus
14
Q
Cerebellar
* What is an important finding?
* Coordinated what?
* Consider what with cerebellar dysfunction
A
- Gait: Ataxia is very important finding
- Coordinated fine muscle movement
- Consider posterior circulation (posterior cerebral vessels) issues with cerebellar dysfunction
15
Q
- How can you if the HA is a primary or secondary HA?
- How can you tell who needs to get worked up for a HA?
A
- HA with facial pain-> Sinusitis and without facial pain-> can be anything
- Anyone with chronic HA with any focal changes (muscle weakness, vision changes, AMS), hx of vascular issues, abnormal hx
16
Q
HA
* When is imaging not recommended? How do you treat it?
A
No imaging in primary headaches isindicated with normal neurovascularexam and without atypicalfeatures/redflags.
* Treat supportive with NSAIDs or combination medications (Fioricet)
* I like triple cocktail: Metoclopramide, diphenhydramine, ketorolac
17
Q
HA
* Primary or secondary headache work-up rarely requires what? What is the exception?
* What may be useful depending on hx or clinical presentation?
A
Primary or secondary headache work-up rarely requires CT imaging unlessthey have Hx of hypertension and new neuro deficits
* Excludes hemorrhage only (angiogram)
MRI with perfusion maybe usefuldepending on history or clinicalpresentation
18
Q
ACEP clinical policy
* In general, they recommend CT scan for what?
* All patients with what need to have a CT and possible LP?
A
- In general, they recommend CT scan for new focal deficits, acute sudden onset of headache, worsening off-baseline headache, in HIV-positive patients (toxoplasmosis, viral enceph), patients older than 50 with a new headache (CAD) , and most traumatic headaches (Canadian head CT rules).
- ALL PTS WITH HYPERTENSIVE HEADACHE PRESENTATION NEED CT; IF CT IS NORMAL STRONGLY CONSIDER AN LP
19
Q
Critical secondary causes of HA
* What should you think about when “worst HA of my life”
* What are two other causes?
A
SAH, “worst headache of my life”, thunderclap headache
* Aneurysm 90%
* A-V Malformation <10%
Meningitis
Brain Tumor with increased ICP (Increased Cranial Pressure)
20
Q
Other critical secondary causes
* Vascular:
* CNS:
* Ophthalmic:
A
- Vascular (SDH, EDH, CVA, Temporal arteritis, carotid or vertebral artery dissection, ICH)
- CNS (encephalitis, cerebral abscess)
- Ophthalmic (glaucoma)
Subdural – venous origin
Epidural – arterial.
21
Q
Other critical secondary causes
* Toxic:
* Endocrine:
* Metabolic:
A
- Toxic (carbon monoxide poisoning)
- Endocrine (pheochromocytoma)
- Metabolic (hypoxia, hypoglycemia, hypercapnia, high altitude cerebral edema)
22
Q
What NIHSS score that does not get TPA
A
If less than 5 (very minor or TIA) or more than 20 (too severe and tpa wont improve anything) – not a TPA candidate
23
Q
Venous Cavernous Thrombosis
* What are the sxs?(5)
* What is a risk factor?
A
- Headache and Facial pain
- Vision Loss
- Focal neurologic symptoms
- Change in consciousness
- Seizures
- RF: After getting J&J Covid vaccine
24
Q
Venous Cavernous Thrombosis
* What is the txt?
A
Treated with Steroids/Antibiotics/Heparin.
* Sometimes stem from sinusitis
25
Homonymous Hemianopia
* What is it?
* Eyes look where?
* Left vs Right MCA?
Homonymous Hemianopia (loss of sight in ½ of visual field)
* Blindness in the same field of vision in each eye
* Eyes look toward the side of the stroke
* Left MCA: Right HH (looks to left)
* Right MCA: Left HH (looks to right)
26
27
HH Examples:
* What happens for damage site #1 and #2?
* Damage at site #1: this would be like losing sight in the left eye. The entire left optic nerve would be cut and there would be a total loss of vision from the left eye.
* Damage at site #2: partial damage to the left optic nerve. Here, information from the nasal visual field of the left eye (temporal part of the left retina) is lost.
28
HH Examples:
* What happens for damage site #3 and #4?
* Damage at site #3: the optic chiasm would be damaged. In this case, the temporal (lateral) portions of the visual field would be lost. The crossing fibers are cut in this example.
* Damage at site #4 and #5: damage to the optic tract (#4) or the fiber tract from the lateral geniculate to the cortex (#5) can cause identical visual loss. In this case, loss of vision of the right side.
29
Homonymous Hemianopia
* Differs from what?
30
Ischemic stroke
* What do you give?
* What are the two types? What do they require? Imaging?
Ischemic (80-85%) tPA patient pool within window
* Thrombosis: Develops gradually over minutes or hours. Most have *Hx of Afib*
* Requires anticoagulation
* A CT is 58% sensitive for infarction within the first 24 hours. MRI is 82% sensitive.
* If the patient is imaged greater than 24 hours after the event, both CT and MR are greater than 90% sensitive.
* Embolic (A-Fib Hx)
* Anticoagulation outside of the window especially with LMWH increases risk of Sentinel Bleeds; and tends to cause distal occlusion not accessible by IR
* Should still give ASA
31
Hemorrhagic stroke:
* What do they not get?
* What are the types and causes?
* No tPA
* ICH
* SAH
* Berry Aneurysm 1st
* AVM (rare)
32
Stroke, TIA, Focal Conditions
* What do you have to get before giving treatment?
Have to get CT before giving any TPA.
33
What are the nonmodifiable and modifiable (well and less well documented)
34
Stroke Syndromes
* What resolves quickly?
* What happens with anterior cerebral artery?
TIA resolves quickly (certainly within 24 hours, usually much less)
Anterior Cerebral Artery
* Contralateral LE weakness greater than UE
35
Stroke Syndromes
* What are the sxs of middle cerebral artery?
* What are the sxs of posterior cerebral artery?
Middle Cerebral Artery (90%)
* Contralateral UE numbness; weaker UE than LE
* Aphasia(Dominant Hemisphere)
* Homonymous Hemianopsia (looks toward lesion)
Posterior Cerebral Artery
* Motor involvement is minimal/Cortical Blindness
36
Stroke Syndromes
* What is Vertebrobasilar Syndrome? What are the sxs? What are the crossed deficits?
Vertebrobasilar Syndrome – posterior circulation (vertebral/basilar arteries involved)
* Dizziness, vertigo, diplopia, dysphagia, ataxia, dysdiadochokinesia
* Crossed deficits: ipsilateral CN deficits with contralateral motor weakness/sensory loss
37
Stroke Syndromes
* What are the sxs of basilar artery occlusion?
Quadriplegia, “Locked-In” Syndrome” (complete muscle paralysis except upward gaze) – can only move eyes up
38
Stroke Syndromes
* What are the sxs of cerebellar stroke?
* Drop Attack – Sudden inability to stand
* Vertigo, headache, nausea, vomiting, neck pain
* Within 6-12 hours, cerebral edema, increased brainstem pressure, decreased consciousness, herniation, death
## Footnote
Get a CT to see a big bleed.
39
Stroke Syndromes
* Lacunar: What vessels are affected? What are the sxs?
Lacunar (Chronic Hypertension)/Pia vessels
* Pure Motor
* Pure Sensory
* Arterial Dissection
* Severe headache or neck pain for hours to days prior to onset of deficits
## Footnote
LONG-STANDING HX OF HYPERTENSION
40
IV Thrombolytic Tx in Ischemic CVA
* When can you give TPA normally? over 80 yo?
* When can you give TPA if large defect?
* How old must the patient be to given be able to recieve tPA?
* Onset is well established to be (4.5 hrs)
* 3hrs >80yo
* IR if large enough defect <24hrs
* Patient older than 18
41
IV Thrombolytic Tx in Ischemic CVA
* What are the exclusions?
* What NIHSS score is excluded?
* Multiple exclusions – minor symptoms, rapid improvement, prior ICH, seizure at onset, recent bleeding, recent MI, recent surgery, hypertension, previous recent stroke or head injury, current use of anticoagulants, recent use of heparin, low platelet count, blood glucose parameters
* Exclude NIHSS score of <5 or >20 because No benefit/>risk of bleed (6%)
42
IV Thrombolytic Tx in Ischemic CVA
* What must you get before tPA administration?
* What is the cutoff of INR?
* Must obtain CT brain w/o contrast to screen for hemorrhage prior to tPa administration
* Don’t give ASA until CT is done either
* INR: 7
43
Treatment:
* Patients with ischemic strokes who do not get thrombolytics and those with TIAs:
* TIA:
* Patients with ischemic strokes who do not get thrombolytics and those with TIAs: Give antiplatelets such as aspirin, dipyridamole, clopidogrel (plavix)
* TIA: consider need for endarterectomy if greater than 70% stenosis
44
Hemorrhagic Strokes: ICH
* Clinically looks like what?
* Cerebellar hemorrhage needs what?
* What are the sxs? What needs to be done?
* Clinically looks like cerebral infarction, may involve ventricles
* Cerebellar Hemorrhage (NEED Surgical Decompression)
* Sudden onset of dizziness, vomiting, truncal ataxia, unable to walk, gaze palsies, increasing stupor, progressing rapidly to coma and herniation without surgery – Get CT (look for white) and Sx ASAP
45
Hemorrhagic Strokes: SAH
* May have what on hx?
* What can happen earlier on and present as what?
* See blood where?
* Get what labs?
* May have what? (2)
* May have sentinel event elicited on history
* Small bleed earlier – could present as headaches
* Could be a sentinel bleed but within 6hrswhere you will be able to see blood in LP (yellow – Xanthochromia) or pink).
* Get CBC to make sure its not a traumatic LP – look at WBC in CSF (for every WBC there should be 700-800RBC’s).
* May have vomiting
* May have been precipitated by cough, intercourse
46
* CEREBELLAR BLEED IS TREATABLE WITH what?
* What happens if they are pregnant?
* If you think theres a stroke – can’t do what? Just do what?
* CEREBELLAR BLEED IS TREATABLE WITH SURGICAL DECOMPRESSION AND HEMATOMA EVACUATION
* Pregnant – get a CT with covered fetus in lead.
* If you think theres a stroke – can’t do LP (disqualifies them from getting TPA therapy). LP is done rarely to eval headache if CT is negative. **Just do a CT.**
47
Management of stroke
* What is important to know?
* What do you need to stabilize?
* What is stroke alert? What is important about CT with different strokes?
## Footnote
Family said normal at bedtime: no tPA because need a clear time frame
48
Hemorrhagic stroke:
* Control what?
* Elevate what?
* What can you give?
* What about cerebellar hem stroke?
49
Subarachnoid Hemorrhage (SAH)
* high risk for what?
* Maintain what?
* What reduces vasospasm? VASOSPASM OCCURS WHEN?
High risk for re-bleeding within 24 hours
Maintain MAP 110
Nimodipine (CCB) reduces vasospasm
* VASOSPASM OCCURS WHEN FREE BLOOD CONTACTS VESSEL WALL ( CONSTRICTION ) DECREASED BLOOD FLOW WORSENS
50
Subarachnoid Hemorrhage (SAH)
* Prophylax against what?
* Consider what?
Prophylax against vomiting and seizures with phenytoin (to keep ICP down)
Consider
* Angiography
* NEUROSURGERY CONSULT
51
Heat stroke
* Altered what?
* What is abnormal?
* Elevated what?
* What can be initally present? Hx what is present?
* Altered LOC
* Neurologic abnormality
* Elevated temperature (104)
* Initially sweating can be present but becomes absent if the disease process is allowed to progress. Historically anhidrosis is present.
52
Heat Stroke
* What is not present with heat exhaustion?
* May appreciate what?
* Highest documented core temperature in survivor was what?
* Upon what?
* No CNS involvement/AMS with Heat exhaustion
* May appreciate dilutional hyponatremia
* Highest documented core temperature in survivor was 46.5C (115.7 F)
* **Upon cooling**, cannot let them shiver
53
Contributing Medications-heat stroke
* Reduce the ability to do what? Examples?
* Decrease what? Examples?
* Increase what? Examples?
54
AMS, Coma
* What do you need to get?
* **What cocktail?** (3)
* Labs for what?(2)
* AMS
* ABC’s
* Vital signs, accucheck
* Cocktail (thiamine-alcohol, dextrose-DKA, narcan-OD)
* Labs for electrolytes, drug screens
55
AMS, Coma
* History and physical exam for clues of what?
* Pinpoint Pupils =
* Can pupils be dilated in opiate intoxication?
* History and physical exam for clues consistent with various etiologies (hepatic encephalopathy, uremia, CO2 narcosis, etc)
* Pinpoint Pupils = caused by Narcotic OD or Pons Bleed
* Can pupils be dilated in opiate intoxication? Yes because of benzo
56
Ataxia, gait disturbances
* What is the issue with romberg?
* Wide differential of etiologies and will need to sort through them:
Romberg
* unsteady with eyes open and eyes closed cerebellum
* worse with eyes closed – posterior column
Wide differential of etiologies and will need to sort through them: **those that are caused by CNS problems and those that are not**
## Footnote
Get CT if dizzy and some neuro abnormalities. Don’t if just dizzy.
57
Central Vertigo
* What are the causes? (4)
* Cerebellar CVA and Hemorrhage
* Lateral medullary CVA
* Vertebrobasilar Insufficiency
* Vertebral Artery Dissection
58
Central Vertigo
* What do you need to get?
image(CT) those whom you think may have central vertigo
59
Acute Vestibular Syndrome
* what are the sxs?
* May last how long?
* 25% are due to what?
* Rapid onset of vertigo, N/V, gait unsteadiness combined with head-motion intolerance and nystagmus
* May last days/weeks
* 25% are due to posterior circulation infarcts
60
HINTS Exam for Vertigo
* Stands for what?
* Differentiate between what?
* can only be performed when?
* Specificity is 96%, r/o what?
* Stands for Head Impulse-Nystagmus Test of Skew
* Differentiate between peripheral or central causes
* Can only be performed in a continuously symptomatic patient, not intermittent like BPPV
* Specificity is 96%, r/o stroke better than MRI in the first 48hrs.
61
HINTS Exam for Vertigo
* Involves testing of what? (3)
* Contraindicated in what?
Involves testing of
* Head Impulse (VOR): Vestibulo-ocular reflex function
* Nystagmus: fast component correlates to same direction gaze
* Skew: Cover/uncover of the eye
Contraindicated in trauma of head/c-spine, cervical dissections
62
What is the difference between head impulse in central and peripheral vertigo?
* Normal VOR can be seen in Central Vertigo when eyes move smoothly
* Abnormal VOR = presence of OR significant lag of corrective saccades = peripheral vertigo
63
Nystagmus
* What is the difference in peripheral and central?
* Unidirectional nystagmus and gaze is likely peripheral
* Bidirectional or rotary or vertical, all are likely central
64
Skew
* What is it?
Deviation of eye upon covering of contralateral eye, which corrects with uncovering
65
HINTS EXAM
66
Seizures: generalized
* Usually involves what?
* What are the two types?
Generalized (usually involves loss of consciousness)
* Grand Mal Tonic-clonic
* Absence (petit mal
67
Seizures: Partial (focal)
* What is present?
* Simple partial (no alteration of consciousness)
* Focal motor, sensory, visual, olfactory auras
* Complex partial (impaired consciousness)
68
Seizures
* Need to get what?
* Check for what?
* Need to get a good history from an observer
* CHECK FOR INCONTINENCE AND TONGUE LACERATION due to seizures
69
What are the causes of etiologies of reactive seizures?
70
Brief Discussion
* What do you give for active seizure in ED?
* What does a first seizure need?
* Febrile seizure in who?
Active Seizure in ED-> give benzo or atavan or in TB give B6
First Seizure (full work-up)
* Identify etiology (head trauma, underlying medical problem, ETOH, CNS infection)
* Admit for all of above as well as for persistent AMS, new focal abnormality, new intracranial lesion, acute head trauma, status epilepticus
Febrile Seizure usually in kids <5yo
71
Status Epilepticus
* What is it?
* The longer they contiune, what will happen?
72
Status Epilepticus
* What do you need to do for stabilization?
* What do you start with? Progress to what? Risk of what in children?
* Give what if eclamptic?
* AB(intubation)C, accucheck, IV, labs (electrolytes, tox screen)
* **Valium or Lorazepam** to start with, progress to fosphenytoin (15-20 mg/kg)/ keppra/ phenobarbital/ propofol if needed after benzos are given, should consider pyridoxine
* risk of respiratory depression in pediatrics (be cautious)
* Magnesium if eclamptic
73
Peripheral Lesions: Botulism
* Esp in what?
* What are the sxs?
* Paralysis?
* Normal what?
* What do you give?
74
Peripheral Lesions: Guilain barre syndrome
* What type of paralysis
* Antecedent wjhat?
* What are the ssxs?
* No what?
* Can develop what?
* What does LP show?
* ascending paralysis
* Antecedent viral illness (gastroenteritis)
* Numbness, tingling , followed by weakness (legs, thighs, arms) – Ascending – admit to ICU and intubate
* No deep tendon reflexes and no sensations
* Can develop respiratory failure
* LP shows high protein in CSF
75
Focal neuropathies LMN
* There are many common entrapment neuropathies that are reversible with appropriate treatment such as what? (2)
* Carpal Tunnel Syndrome (Median Nerve)
* Ulnar Nerve Entrapment
76
Focal neuropathies LMN: Bell's palsy
* What is a common cause?
* Differentiate btw what?
* Clinically see what? In CVA, what is spared?
* What is and is not affected? What do you need to image?
* Treat with what?
77
Chronic Neurologic Disorders: Amyotrophic Lateral Sclerosis
* Widespread what?
* Degeneration of what?
* Widespread motor and respiratory dysfunction within weeks to months/Normal sensation
* Degeneration of Upper/Lower Motor Neurons
78
Chronic Neurologic Disorders: Myasthenia gravis (diplopia, ptosis)
* What are the sxs?
* What is impaired?
* What test needs to be done? What are the results?
79
CNS Infections: bacterial meningitis
* Encapsulated organisms invade through what?
* Classic fulminant:
* What is common?
* What are late signs?
* Careful example for what?
80
If you are thinking bacterial menigititis, what do you need to do?
If you are thinking bacterial menigititis – delay/skip CT and get them IV dexamethazone (stops inflammatory reaction from toxins released from dying bacteria) and immediate IV ABX.
## Footnote
Strep,pneumonia, H.flu and Neisseria are all encapsulating
81
82
Meningitis
* What is it?
* Sxs depend on what?
* What is the time course?
* What is the highest incidence?
83
Management of meningitis
* _
* Full what?
* What is the empiric txt? Before ehat?
* Consider what?
* ABCs
* Full septic work up with cultures
* IV Empiric antibiotics based upon presumed agent (ROCEPHIN AND VANCOMYCIN)
* Even before L-P done
* Consider IV Dexamethasone prior to antibiotics (Pneumococcus)/lysis of bacterial cell wall toxins released by antibiotic
84
Management of meningitis
* High risk contacts should be prophylaxed with what?
High risk contacts (family esp females) should be prophylaxed with rifampin (deactivates birth control)
85
86
What do you give for empiric treatment of bacterial meningitis?
## Footnote
Pneumococcal mostly. H.flu is very infrequent. Get 2 ABX – Vanco for G+ and anaerobes + Ceftriaxone.
87
Meningitis Prevention
* The following groups should consider vaccination with a meningococcal conjugate (MenACWY) vaccine? (4)
* What groups of people need more vaccine?
88
Viral Meningitis:
* MCC?
* What is encephalitis?
* Also transmitted by what?
* Enteroviruses – 80%
* Encephalitis – infection of brain parenchyma with an inflammatory response (HSV-1)
* Also transmitted by mosquitoes and ticks or the bite of an infected animal (as in Rabies) – worry about Dengue fever
## Footnote
* Meningitis – not as serious
89
Brain Abscess
* What type of infection?
* What is necessary?
* What groups of people are at risk?
Focal pyogenic infection
* Mortality 30-65%
* Biopsy is necessary to r/o tumor and to culture organism
Uncommon
* Immunocompromised: fungal and parasitic (Toxoplasma, Entamoeba, Aspergillus, and Candida)
90
Brain Abscess
* How does it spread?
* 10% is what?
* What is needed ASAP?
* Consider what?
* Paranasal sinus, mastoid, sources by hematogenous or continuous spread
* 10% direct implantation by penetrating trauma or surgery
* Antibiotics needed ASAP
* Consider Neurosurgery drainage
91
Syncope
* What is it?
* Usually does what?
* What is common? No what?
* A symptom, not disease
* Sudden transient loss of consciousness
* Usually resolves without intervention
* Brief myoclonic jerking is common – NOT a seizure
* No postictal state and no loss of bowel or bladder
92
Syncope
* What are the 5 most common nontraumatic causes?
* Everyone Must get what?
5most common nontraumatic causes
* Hypoglycemia
* Hypoxia
* CVA
* MI
* PE
Everyone MUST receive EKG
93
Syncope
* What is the DDX list?
* Hyponatremia (<110)
* Complex headache with aura
* Psychogenic: Panic Attack, hysteria, conversion reaction
* Hypovolemia
* Drug reaction: Viagra/NTG, Antiarrhythmic, BP meds, Cocaine, ETOH
* Vasovagal/Vasomotor
94
Syncope: Vasovagal/Vasomotor
* Triggering stimulus resulting in what?
* Acute what?
* What type of syndrome?
* What is situational?
* Triggering stimulus resulting in simultaneous enhancement of parasympathetic nervous system (vagal) tone and withdrawal of sympathetic nervous system tone.
* Acute Blood Loss (>750ml-2000ml)
* Barber Syndrome – carotid sinus hypersensitivity
* Situational: Micturition, defecation
95
Syncope: DDX list
* What are some other casues?
* PE
* Arrhythmia
* Valvular heart disease: AS/MS
* Brugada Syndrome
96
Brugada Syndrome
* What is it?
* Common in who?
* What is it tx by?
* Incomplete RBBB
* STE V1-V2
* T wave inversion V1-V2
* Adult males in 30s-40s of Mediterranean origin
* Tx by AICD
97
Syncope Work-up
* Get what?
* UA?
* CBC?
* What other labs?
* EKG (WPW, Brugada, AMI, prolonged QT/QRS/blocks etc)
* UA Spec Gravity: Defines state of Hydration
* 1.010/normal
* >1.010/more concentrated
* CBC: to evaluate anemia
* Glucose & Lytes
98
Syncope Work-up
* What test?
* Depending on what?
* Most will require what?
* Pregnancy test: yes (blood loss from ectopic)
* Depending on initial findings, may consider Echo, Holter, stress test
* Most will require admission and 24hr observation
* In patients >45yo, 1 year mortality rate is 15%-30%
99
Dementia vs Delirium
* What is dementia vs delirium?
## Footnote
May be very difficult to differentiate in the elderly
Demented pat can have delirium
BA-52 – involuntary
BA-40 – voluntary (BA-32 is extension after 72hrs)
100
Dementia vs Delirium
* What are the labs, imaging and other tests?
101
Dementia vs Delirium
* What is the txt?
* Patient with dementia or delirium may be unable to alert you to what?
* Demented patient can have what?
* Underlying problems if possible
* Support and safety
* Patient with dementia or delirium may be unable to alert you to trauma or physical illness because of impaired ability to perceive or describe their symptoms
* Demented patient can have delirium
102
Depression
* What is it?
* What would be some important questions that you would ask of a patient presenting with Depression?
* With your eye on liability issues, what would be the most important question?
* Is a state of intense sadness, melancholia or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living.
* Are you feeling stuck, thoughts of suicide, do you have a plan or have you tried?
* Have you had thoughts of suicide?
103
Schizophrenia - characteristics
* What are the signs?
* Do not realize what?
* loosening of what?
* Disheveled appearance, bizarre behavior, poor judgment, unusual gestures, respond to internal stimuli
* Do not realize that thoughts & perceptions are abnormal – lack insight
* Loosening of associations (vague, rambling, nonsensical)
104
Schizophrenia - characteristics
* What are the sxs?
* Brought to the ED because of what?
* Symptoms such as disorganized thinking, auditory hallucinations, delusions, and echolalia/echopraxia
* Brought to the ED because of drug abuse, suicidal behavior, paranoid violence or worsening of hallucinations
105
Schizophrenia
* What are delusions?
**A false belief based on incorrect inference about external reality** that is firmly sustained despite what almost everybody else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person's culture or subculture
106
Schizophrenia
* What are hallucinations
* seeing lines or squares, hearing voices.
* is a sensory perception experienced in the absence of an external stimulus, as distinct from an illusion, which is a misperception of an external stimulus
107
Schizophrenia
* no what?
* What is the mainstay treatmetn?
* No cure – minimize or control symptoms
* The mainstay of treatment for schizophrenia is an antipsychotic medication, but the need for chemical restraints in an ER setting may include a benzodiazepine (lorazepam) and a neuroleptic sedating agent (haloperidol) via ETO.
## Footnote
ETO - Absent more appropriate interventions, an emergency treatment order for immediate administration of rapid response psychotropic medications or physical restraints to a person to expeditiously treat symptoms, that if left untreated, present an immediate danger to the safety of the person or others.
108
Schizophrenia
* Physical restraints may be utilized after what?
* Acute exacerbation or psychosis will meet what?
Physical restraints may be utilized after chemical for violent behavior toward themselves or others.
* Physical restraints don’t improve mental state.
Acute exacerbation or psychosis will meet baker act criteria
109
Restraint Types
* What are the different restraints? Must have what?
* Physicians/PAs/APRNs are authorized by FL state law to do what?
* Restraints: Mittens, soft wrist, and 4 point restraints all require an order and specific assessment documentation.
* Must have a good reason for it.
* Physicians/PAs/APRNs are authorized by FL state law to order/renew restraints, unless specifically excluded by a particular facility.
110
Restraint Types
* Nonviolent restraints:
* Violent Restraints: (what is the hour limits?)
Nonviolent restraints: Order may not exceed 24 hours.
Violent Restraints: Must be time limited and must specify clinical justification for the restraint
* Four hours for adults, aged 18 years and older
* Two hours for children and adolescents aged nine to 17 years, or
* One hour for children under nine years.
111
Mood Disorders: bipolar disease
* Characterized by what?
* Elated moods can quickly deteriorate to what? The manic episodes may demonstrate what?
* Complications include what?
* Characterized by recurrent, cyclic episodes of manic and depressive symptoms
* Elated moods can quickly deteriorate to hostility. The manic episodes may demonstrate a decreased need for sleep, poor impulse control, pressured speech with grandiose ideas.
* Complications include suicide and substance abuse.
112
Panic Disorder
* Sudden what?
* Dx of what? Must r/o what?
* What is the txt?
## Footnote
Panic disorder – have to r/o thyroid storm or AMI
113
What are some other Anxiety Disorders?
* Phobias
* Obsessive-Compulsive Disorder (OCD) and
* Posttraumatic Stress Disorder (PTSD)
* Not usually ER problems unless they develop into severe anxiety or panic attacks.
114
Suicidal patient
* What are the risk factors?
115
Suicidal patient
* A high percentage of suicide attempts involve what? MC completed suicide is from what?
* Gender prevalence?
* Lethargy and confusion may make the assessment more what?
* A high percentage of suicide attempts involve medication overdose (females>males), but the most common completed suicide is from firearms (males>females).
* Males have the highest rates of completed suicide.
* Lethargy and confusion may make the assessment more difficult, but a suicidal patient is often forthcoming about their intentions for self-harm – so ASK.
116
Suicidal patient
* Approach the patient in what way?
* Get a what? R/O what?
* Get what consult?
117
Suicide
* Keep the suspicion of what?
* What are two facts about suicide?
118
Homicidal and Suicidal Ideation (HI/SI)
* Any Baker Act patient, whether voluntary or not, has to be what?
* You must get what?
* Who could have exceptions?
* Any Baker Act patient, whether voluntary or not, has to be medically cleared and various facilities require different things
* You must get EKG, chemistry, pregnancy test (if applicable), ASA, Acetaminophen, UDS, and ETOH levels
* Young children who are under Baker act could have exceptions
119
Baker Act (Florida statute, 1971/72)
* Involuntary examination refers to what?
Involuntary examination refers to psychiatric intake (done by psychiatrist), not an ER note
## Footnote
Baker act – involuntary commitment to a mental department (48-72hrs) - Florida
120
PAs may do some assessment of Florida Mental Health Act (HB573)
* The legal conditions requires what?
* According to section 458.347, Florida Statutes, the supervising physician may only do what?
* The legal conditions require that a practitioner have experience in the diagnosis and treatment of mental and nervous disorders.
* According to section 458.347, Florida Statutes, the supervising physician may only delegate such tasks as are within the supervising physician's scope of practice.
## Footnote
AG opinion only allows a PA to initiate an involuntary examination, not to perform any of the other duties permitted to a physician. Has to be based on information within the last 48hrs.
121
PAs may do some assessment of Florida Mental Health Act (HB573)
* According Per Bill McCollum Attorney General?
[Accordingly, I am of the view that a physician assistant licensed pursuant to Chapter 458 or 459, Florida Statutes, may refer a patient for involuntary evaluation pursuant to section 394.463, Florida Statutes, provided that the physician assistant has experience regarding the diagnosis and treatment of mental and nervous disorders and such tasks as are within the supervising physician's scope of practice.]
122
Baker Act (FS 394.455)
* What is it?
* Patient must have what? What is not?
* Emergency psychiatric commitment for unstable individual.
* Patient must have a mental illness
* Drug or ETOH abuse or Dementia are NOT mental illness
123
Baker Act (FS 394.455)
* What is the criteria?
Must meet criteria (1 + (2 or 3) + 4)
1. Reason to believe that the person has a mental illness;
2. The person refuses voluntary examination;
3. The person is unable to determine whether examination is necessary
4. AND the person has a substantial likelihood that without care or treatment the person will cause serious bodily harm in the near future.
124
Baker Act
* What are the different kinds?
Different kinds in Florida
* BA-52 – involuntary
* BA-40 – voluntary
* BA-32 is extension after 72hrs (done by court)
125
Baker Act
* 394.455(18)“Mental illness” means what?
394.455(18)“Mental illness” means an impairment of the mental or emotional processes that exercise conscious control of one’s actions or of the ability to perceive or understand reality, which impairment substantially interferes with a person’s ability to meet the ordinary demands of living, regardless of etiology. For the purposes of this part, the term does not include retardation or developmental disability as defined in chapter 393, intoxication, or conditions manifested only by antisocial behavior or substance abuse impairment.
126
Baker Act
* Senate Bill 7012 as of 7/1/20 - also excludes what?
Dementia and traumatic brain injury
127
Baker Act
* Under Chapter 393: Developmental disability means what?
Under Chapter 393: Developmental disability means a disorder or syndrome that is attributable to intellectual disability, cerebral palsy, autism, spina bifida, Down syndrome, Phelan-McDermid syndrome, or Prader-Willi syndrome; that manifests before the age of 18; and that constitutes a substantial handicap that can reasonably be expected to continue indefinitely.
128
Baker Act
* Suicidal and homicidal ideation cannot be determined when a patient is what?
* Once the intoxicated patient is sober, they should be what?
* Suicidal and homicidal ideation cannot be determined when a patient is intoxicated (there is a condition referred to as mood disorder 2/2 intoxication/substance use/abuse).
* Once the intoxicated patient is sober, they should be re-evaluated and if still suicidal/homicidal, a Baker Act should be placed at that time or if you are uncertain, the consult to [tele]psychiatrist should be placed at that time to evaluate for same. That is when the 72-hour clock will start.
129
Baker Act
* Many providers have been pressured by families to do what?
* This is NOT the proper route for what?
* Improper Baker Acts can result in what?
* Many providers have been pressured by families to Baker Act patients with developmental issues or dementia due to their inability to take care of these patients when their behavior becomes more aggressive.
* This is NOT the proper route for placement in a long-term care facility and is specifically EXCLUDED by the Baker Act.
* Improper Baker Acts can result in litigation- civil (i.e., medical malpractice) and criminal penalties for false imprisonment of the patient.
130
Marchman Act (FS 397.311)
* What is this for?
* Usually initated by who?
* Considering the exclusions of Baker Act on previous slide, any patient with what?
* A PA cannot do what?
* For those struggling with substance abuse issues
* Usually initiated by law enforcement or a judge
* Considering the exclusions of Baker Act on previous slide, any patient with acute intoxication should be Marchman Acted as they do NOT meet criteria for a Baker Act even if they make suicidal or homicidal statements
* A PA cannot release BA or MA in Florida, must be done by physician/psychiatrist
131
Marchman Act Clinical Pearl
* Documenting with as much as detail that patient is what? Why?
Documenting with as much as detail that patient is clinically sober and no longer meets criteria for the Marchman Act (ie is not so impaired by their addiction as to be a direct harm to self or others) and is able to pursue outpatient care and follow up is a good strategy when charting and that you are providing them with outpatient detox resources.
132
Acute psychosis
* What are delusions?
* What are hallucinations?
* What are other issues?
* Most will require what?
* But you have to r/o what?
* Delusions – lose touch with reality due to increased dopamine
* Hallucinations – sensory perceptual distortion
* Flight of ideas/Tangentiality
* Mutism/Animation
* Most will require psychiatric stabilization
* But you have to r/o organic etiology
133
Anorexia Nervosa
* What is it?
* What are the criteria?(4)
An eating disorder that most commonly affects girls 14-18yo.
* Weight loss >15% of ideal body wt. (IBW)
* Fear of becoming fat (when actually underweight)
* Distorted body image
* Absence of 3 consecutive menstrual cycles
134
Anorexia Nervosa
* What is the assessment?
135
Anorexia Nervosa
* What is the management?
* Correction of metabolic abnormalities, electrolyte imbalances
* Institute a gradual refeeding regimen
* Psychiatric evaluation
* Outpatient treatment if patient is compliant and has good family support
136
Anorexia Nervosa
* Admission is indicated on case-by-case basis if what? (4)
1. Malnutrition (<75% of IBW)
2. Persistent vomiting
3. Metabolic complications (dehydration, hypotension, hypothermia, electrolyte imbalance)
4. Comorbid medical or psych conditions (diabetes, arrhythmias, depression)
137
Bulimia
* What is it?
* usually follows what?
* What is the criteria?
138
Anorexia and Bulimia
* Difficult to what?
* Combo of what?
* Significant what?
* Difficult to treat
* Combination of multiple metabolic derangements along with psychological implications
* Significant long-term morbidity and mortality
139
Conversion Disorder
* A person may unconsciously and acutely produce what?
* Seen in those that do what?
* A person may unconsciously and acutely produce a symptom suggestive of a physical disorder that results in a change or loss of physical functioning –
* paralysis, pseudoseizures, blindness, numbness.
* Seen in those doctor shopping for primary or secondary gain and/or malingering
## Footnote
Have to r/o all neuro problems and any organic etiologies.
140
Conversion Disorder
* Must r/o what?
* Many patients (25%-50%) who are diagnosed with this disorder are ultimately found to have what?
* Must rule out organic etiology first (with labs and imaging)
* Many patients (25%-50%) who are diagnosed with this disorder are ultimately found to have true organic etiologies. So, it should be a part of your differential diagnosis, but only after extensive testing.
141
Conversion Disorder
* Techniques that distinguish neuro deficits from Conversion Reactions: What are the bowles and currier test?
Bowles and Currier test – have the patient extend his arms, crossing them at the wrists, so the palm are facing each other; then have him interlock the fingers and rotate the hands inward toward the chest. In this position, false responses to sensory testing are difficult.
142
Conversion Disorder
* What is the hoover test and arm drop?
* Hoover test – cup your hands under the heels of the patient and ask him to raise his normal leg. With pseudoparalysis, the other leg will push downward.
* Arm drop – Pick up arm and drop above the head area. The arm will not hit the patient in the face.
143
AMS Presentation Summary: consider intox with
* GBH?
* Lithium?
* Barbiturates?
* Metals?
144
AMS Presentation Summary: consider intox with
* Opioids?
* Insulin?
* _
145
Hyperactive Presentation Summary
* Cocaine and Amphetamines: What are the sxs? No what? Consider what?
* Sympathomimetics: mydriasis/hyperpyrexia/constriction and formication
* NO Beta-Blockers
* Consider intralipid infusion
146
Hyperactive Presentation Summary
* What are the sxs of Meth/LSD/MDMA/PCP/BathSalts and mushrooms?
Meth/LSD/MDMA/PCP/BathSalts
* Nystagmus, agitation, seizures
Mushrooms
* Most have GI symptoms and hepatitis
147
Hyperactive Presentation Summary
* Most can be managed by what?
* Most can be managed by what?
* Most can be managed by observation if mild, benzodiazepines if moderate to severe symptomatology
* Evaluate for capacity prior to dc
148
Intoxication
* Impairment of what?
* Intoxication” should be included in what?
* Question competency?
* Impairment of judgment, perception, emotional control and psychomotor activity produced by recent ingestion of alcohol or drugs (cocaine, opioids, benzos, amphetamine)
* “Intoxication” should be included in the differential diagnosis of patients with an altered state of consciousness
* Question competency-FDLE Basis (under 0.08)
149
Intoxication
* If chemical restraint is necessary, what should you use? Should get what?
* A thorough history is crucial for what?
* If chemical restraint is necessary, an antipsychotic (haloperidol) is a safer choice than a sedative-hypnotic to avoid respiratory depression
* Get an EKG and be put on cardiac monitor because haloperidol causes prolong QT
* A thorough history is crucial for discovery of the possibility of need for prophylaxis for withdrawal
150
What is withdrawal? What are standard sxs?
* Withdrawal – a syndrome that is induced by the cessation of the use of a substance that the body has become dependent upon
* Standard symptoms (nausea, tremor, hypertension, tachycardia, hyperreflexia, sleep disturbances, anxiety) usually occur within 6-24 hrs
151
Withdrawal
* What substances can be serious?
An alcoholic, however, is at risk for severe complications and death. (as is a chronic benzodiazepine user)
152
Alcohol Withdrawal
* More severe what? What score can be used?
* May resemble what?
* More severe hyperactivity with accompanying diaphoresis, fever, disorientation and hallucinations may occur about 24 hours after the last intake of alcohol
* CIWA score (look up on MDCalc)
* May resemble psychosis, anxiety or septicemia
153
Alcohol Withdrawal
* What can occur from ETOH withdrawl? Requires what?
Delirium Tremens and subsequently Seizures may occur in 1-5 days from ETOH stop
* Substantial mortality and requires ICU admission
154
Alcohol Withdrawal
* What is the management?
155
Alcohol Withdrawal
* What is the discharge criteria?
* If patient is in early withdrawal and is willing to be managed in an outpatient setting or inpatient detox center
* There are no underlying medical conditions or trauma
156
Alcohol Withdrawal
* What is the admission criteria?
* Seizure activity
* Delirium tremens or Hallucinations
* Wernicke’s encephalopathy
* Underlying medical or surgical problems
157
Alcohol Withdrawal
* Wernicke’s encephalopathy is characterized by what?
Wernicke’s encephalopathy is characterized by ataxia, confusion, impairment of short-term memory, and paralysis of one or more of the EOM’s (ophthalmoplegia). It is caused by lesions in the brain, often resulting from inadequate intake or absorption of thiamine (Vit. B1)
158
Wernicke’s encephalopathy
* What are the hallmark of the disease?
* What may be the presenting feature ?
* Cannot give what? Why?
* Ocular signs are the hallmark of the disease, including horizontal nystagmus, bilateral abducens palsy, complete ophthalmoplegia, and pupillary abnormalities
* Apathy, impaired awareness, disorientation, mental sluggishness, and restlessness characterize the encephalopathy. In extreme cases, coma may be the presenting feature
* No D5W/dextrose in these patients: may precipitate WE due to glucose oxidation being a thiamine-intensive process that may drive the insufficient circulating vitamin B-1 intracellularly
159
Alcohol Withdrawal
* What is korakoff's syndrome?
* What are the sxs?
* What is confabulation?
* Korsakoff's syndrome is a brain disorder caused by inadequate intake of thiamine
* Symptoms: severe memory loss, confabulation, lack of insight , meager content in conversation, indifference to surroundings
* Confabulation is invented memories which are then taken as true due to gaps in memory sometimes associated with blackouts (know smth that happened during their blackout).
160
Neuromuscular(leptic) Malignant Syndrome
* Most commonly associated with what?
* Etiology?
* What are the sxs?
* What is the DDX?
* What is the txt?
* Most commonly associated with the use of antipsychotic drugs.
* Etiology is speculative
* Hyperthermia (102.2F to 107.6F), muscle rigidity, ANS instability including tachycardia, and AMS
* Rhabdomyolysis, metabolic acidosis, renal insufficiency
* DDx includes serotonin syndrome, malignant hyperthermia and list of others
* Treatment: **Dantrolene (malignant Hyperthermia), carbidopa, amantadine**
## Footnote
* ANS – Autonomic Nervous System
* High fever, Altered LOC, Metabolic acidosis.
* CT and LP to r/o menigntis. Give them Vanco or ceftriaxone until labs come back to prevent development if it is meningitis. .
161
Serotonin Syndrome-SSRI’s/MAOI’s Overdose
* What are the clinical features?
* What is the management?
## Footnote
* SS and NMS are the same thing in terms of clinical presentation, but are different physiologically.
* If see fever and HyperTN and confusion – think meningitis too. Get a CT and then LP.
* If SS – give Benzos.
* Alprazolam comes PO only.
162
Benzodiazepines Overdose
* What type of presentation?
* Serious toxicity and death tends to occur with what?
* See what?
* Progressive what?
* What management?
* Nonspecific presentation
* Serious toxicity and death tends to occur with co-ingestions (especially alcohol)
* **See pupillary dilation**, not constriction (similar to ETOH)
* Progressive decrease of LOC
* General supportive management
163
Benzodiazepines Overdose: Flumazenil (Romazicon)
* Contrainidicated in who?
* Do not use if what? What may it cause?
* Withdrawal can be what?
164
Synthetic Marijuana abuse
* What is it?
* Sold legally where?
* What is main concern?
* Typically seen what?
165
166
Alcohols
* Ethanol: What are the examples? What is the txt?
* Isopropyl alcohol: What is the example? Potent? Metabolized by what?
Ethanol (beer, wine and whiskey)
* Thiamine, ABCs, glucose, dialysis
Isopropyl alcohol (rubbing alcohol)
* Twice as potent as ethanol
* Metabolized by alcohol dehydrogenase to acetone
167
Alcohols
* Methanol: What is the example? What is the sx? How is it metabolized? Treat with what?
* Ethylene Glycol: What is the example? What is the sxs? What is the txt?
Methanol (wood alcohol – commercial use paint thinner)
* Blind Drunk with wide anion gap
* Alcohol dehydrogenase converts methanol to formaldehyde (Optic papillitis) and formic acid
* Treat with Ethanol or fomepizole and dialysis if necessary
Ethylene Glycol (coolants – antifreeze)
* Sweet breath odor with wide anion gap and calcium oxalates crystals in urine
* Treatment same as methanol: Thiamine, ethanol, dialysis
168
Aspirin Ingestion
* Found in what?
* Acute mild ingestion leads to what? What is useful for novel ingestion only?
* Moderate and higher ingestion (>150-300mg/kg) leads to what?
* Treatment geared towards what?
169
Hemodialysis & Hemoperfusion
* What are Specific toxins that are life-threatening and that are dialyzable?
* Ethylene glycol/Methanol
* Lithium
* ASA>100 mg/dL
* Theophylline (xanthine)
170
Enhanced Elimination- ASA
* Urinary what? Contraindicated in who? Only useful in what?
* What is rarely used and what is not effective?
171
Tylenol Ingestion
* Toxic when?
* What is used to track?
* What is the DOC with GIT decontamination?
* Toxic when ingested >140mg/kg or 7-10 gm single dose
* Rumack-Matthew Nomogram to track within 4 hours of ingestion
* Acetylcysteine (Mucomyst) is drug of choice with GIT decontamination
172
Beta-Blocker Ingestion
* What are the sxs? Why does this happen?
* Consider what?
* What is the txt? (3)
173
Calcium Channel Blockers
* What are the sxs? Why?
* What is the txt?
* How much is lethal to toddler?
174
Coumadin (Warfarin) Toxicities
* How does it occur?
* Can cause what?
* What can be used to reverse the effects?
* Typically patients mislabel bottles and take too much or not according to schedules
* Can cause spontaneous bleeding if high
* Vit K can reverse the effects
175
176
Anticholinergic(toxicity)(Dry Manifestations)
* What are the examples of drugs? What are the sxs?
177
Anticholinergic(toxicity) (Dry Manifestations)
* Fatalities associated with what?
* _
* Consider what?
* What is used for wide QRS complexs?
* What is other management?
* Ask for what?
178
Antidotes
* Call who?
179
Common Antidotes Summary
* acetaminophen?
* CCB?
* Cyanide?
180
Common Antidotes Summary
Deferoxamine –
Dextrose –
digoxin (yellow-green Halos)
Ethylene glycol and methanol OD
Methanol, ethylene glycol
Beta blockers, calcium channel blockers
181
Common Antidotes Summary
* Methylene blue –
* Naloxone (narcan) –
* Physostigmine –
* Pralidoxime (2-PAM) –
182
Common Antidotes Summary
* Protamine –
* Pyridoxine B6 –
* Thiamine B1 –
* Vitamin K/FFP -
* Andexxa –
* Praxibind –
183
184
Abuse and Assault
* What is child maltreatment?
185
Neglect
* What are the types?
* Failure to provide what?
* Early infancy presents as what?
* What does the PE show?
* Physical and emotional neglect
* Failure to provide adequate clothing, shelter, food, health care, schooling
* Early infancy: presents as FTT
* PE: longstanding malnutrition, poor hygiene, very little SQ fat, protruding ribs, skin hanging from buttocks, alopecia over a flattened occiput
## Footnote
* FAILURE TO THRIVE – see Ht gain but NO Wt gain.
186
Failure To Thrive
* What is it?
* Body mass index is what?
* May have what?
* Why should you admit to the hospital?
* Do what type of survey?
187
Factitious Disorder Imposed on Others
* What is it?
* Covert video surveillance helps what?
* Biologic mother reports serious symptoms, requests multiple tests (even surgeries)
* Covert video surveillance helps documents parental (typically mother) invasive actions
188
Factitious Disorder Imposed on Others
* What are different ways this can occur? (5)
* Parent suffocating child = Apnea
* Parent placing blood in child’s urine
* Parent injecting fecal matter into IV to cause bacteremia
* Request testing that is invasive and sometimes dangerous
* Requests excessive lab testing
189
Child Sexual Abuse
* Child is usually brought in because of what?
* Usual disclosure by who? when?
* The child knows what?
* Collect what?
* What is an evidence of abuse?
* Child is usually brought in because of a disclosure made by the child
* Usual disclosure by a child is often several years later, average of 20 years
* The child knows the assailant more than 90% of the time
* Collect Evidence, report to authorities
* STD is evidence of abuse
190
Child Physical Abuse
* History does not what?
* Discrepancy between what?
* What type of parent?
* What is present?
* Often child is what?
* Protect who?
191
Burns
* What are different types of burns?
* Scald Burns (immersion)—no “splash” configuration
* Glove and stocking pattern or donut type burn to buttocks
* Cigarette burns leave small circumferential scab-covered areas
192
Skeletal Survey
* What should get done if needed?
* X-ray of what? What does it show?
193
Elder Abuse
* Under what?
* Socially isolated from who?
* Many live with who?
* Patient may be hesitant to do what?
* Under recognized and underreported
* Socially isolated from their families
* Many live with their abusers
* Patients may be hesitant to disclose the abuse for fear of embarrassment, abandonment, retaliation or nursing home placement.
194
Female & Male Alleged Sexual Assault
* What is a violent crime?
* Rape consist of what?
* What must be addressed?
* Always notify who?
* Prophylaxis for what?
195
Prophylaxis STDs
* Gonorrhea?
* Chalmydia?
* HIV?
196
Intimate Partner Violence (IPV)
* Replaces what term?
* Includes what?
* What are the characterisitc injuries?
* Must do what? Offer what?
* Replaces term “domestic violence”
* Includes physical abuse, psychological abuse, sexual assault, progressive social isolation, stalking, intimidation, threats
* Characteristic Injuries: fingernail scratches, bite marks, cigarette burns, bruises consistent with strangulation, rope burns. Forearm bruises or fractures suggesting defensive posture
* Must report to authorities, pt may later refuse to press charges.
* Offer shelter referral
